,transcriber's notes ,this is derived from the ,internet ,archive3 http3_/_/www4archive4org_/details_/essay sinpastora#jjwalsgoog ,page numbers in this book are indicated by numbers enclosed in curly braces1 e4g4 #ii4 ,they have been located where page breaks occurred in the original book4 ,obvious spelling errors have been corrected but inventive and inconsistent spelling is left unchanged4 ,end ,transcriber's notes iii ,,essays ,,in ,,pastoral ,,medicine ,,by ,,austin ,,omalley1 ,m4,d41 ,ph4,d41 ,,ll4,d1 ,,pathologist ,,and ,,ophthalmologist ,,to ,,saint ,,agnes',s ,,hospital ,,philadelphia and ,,james ,j4 ,,walsh1 ,m4,d41 ,ph4,d41 ,,ll4,d4 ,,adjunct ,,professor ,,of ,,medicine ,,at ,,the ,,new ,,york ,,polyclinic ,,school ,,for ,,graduates ,,in ,,medicine2 ,,professor ,,of ,,nervous ,,diseases ,,and ,,of ,,the ,,history ,,of ,,medicine ,,fordham ,,university1 ,,new ,,york ,,longmans1 ,,green1 ,,and ,,co4 #ia ,,and #ic ,,fifth ,,avenue1 ,,new ,,york ,,london ,,and ,,bombay #aijf iv ,copyright1 #aijf ,by ,longmans1 ,green1 and ,co4 ,all rights reserved4 ,,the ,,university ,,press1 ,,cambridge1 ,u4 ,s4 ,a4 v ,,preface ,the term ,pastoral ,medicine is somewhat difficult to define because it comprises unrelated material ranging from disinfection to foeticide4 ,it presents that part of medicine which is of import to a pastor in his cure1 and those divisions of ethics and moral theology which concern a physician in his practice4 ,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 quality1 and it also explains to the pastor1 who must often minister to a mind diseased1 certain medical truths which will soften harsh judgments1 and other facts1 which may be indifferent morally but which assist him in the proper conduct of his work1 especially as an educator4 ,pastoral medicine is not to be confused with the code of rules commonly called medical ethics4 ,the material of pastoral medicine requires constantly renewed discussion1 because medicine in general is progressive enough frequently to devise better methods of diagnosis and treatment1 and thus the postulates of the moral questions involved are changed4 ,this discussion1 however1 is not easily made4 ,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 decisions4 ,the moralist1 on the other hand1 is commonly a poor counsellor to the physician1 because long training in medicine is needed before the physical data of the moral decisions is comprehended4 ,the physician1 therefore1 is at a loss to determine what he may or may not do in vi cases that involve the greatest moral responsibility1 and the priest is a hesitating guide because the moral theologies do not convincingly present the doctrine in these cases4 ,now and then such subjects have been proposed for discussion to a group of physicians and moralists1 but usually no practical conclusion has been reached because one side did not understand the other4 ,in #ahih there was a series of articles on ectopic gestation in the ,american ,ecclesiastical ,review1 in which moralists like ,lehmkuhl1 ,sabetti1 ,aertnys1 and ,holaind1 and some of the leading gynaecologists of ,america considered the questions but arrived at no decision4 ,the physicians did not understand certain questions1 other questions were on obsolete medical practice1 essential questions were omitted1 and from the data the moralists came to opposed conclusions4 ,we find also in moral theologies deductions drawn from false medical sources4 ,reasons are given1 for example1 to justify the use of a large quantity of alcoholic liquor at a dose in cases of great pain1 typhoid fever1 snake-poisoning1 and other diseases1 in the supposition that such doses will benefit or cure the patient1 whereas the physician that would follow that treatment would be guilty of malpractice4 ,there was recently in ,america a discussion on the relation of oeophorectomy to the impedimentum impotentiae4 ,one side held that a lack of ovaries constitutes impotence2 the other side1 that it does not4 ,the discussion was useful because it incidentally gathered the full doctrine of the moralists on this subject1 but from the medical point of view there is no connection whatever between these conditions4 ,a small number of books on pastoral medicine have been written by clergymen that were not physicians1 and a few ,german books by physicians that were also moralists4 ,those by the physicians draw conclusions from antiquated medical practice1 or they are mere popular treatises on hygiene2 those by the clergymen have some value on the ethical side1 but they are incomplete because the authors had not the necessary medical knowledge4 ,the essays offered in this book by no vii means cover the entire field of pastoral medicine1 but as far as they go we have endeavoured to offer the medical doctrine of the present day on the questions considered1 and that as completely as is necessary to draw the moral inferences4 ,since1 then1 so many of the questions of pastoral medicine are not defined1 physicians are likely to follow the doctrine of the standard medical books1 which without exception advise them to take the life of a dangerous foetus almost as unconcernedly as they might prescribe an active drug1 or in any case to put utility before justice4 ,there is1 therefore1 an urgent necessity that competent men fix that shifting part of ethics and moral theology called pastoral medicine1 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 causeway4 ,some may think that the authors are inclined toward an exaggerated charity in suggesting the measure of responsibility for many human actions1 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 marred4 ,responsibility is dependent entirely upon free will2 and while the great principle of free will remains solid in truth1 no two men are free in exactly the same manner4 ,physical conditions have not a little to do with modifications of freedom of the will4 ,to point out this fact to the clergyman and the physician has been our intention1 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 misjudgment4 ,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 them4 viii ix ,,contents ,the ,authorship of the respective ,essays is indicated by the signature at the end of each ,essay4 ,chapter ,page ,i4 ,ectopic ,gestation #a ,,ii4 ,pelvic ,tumours in ,pregnancy #dj ,,iii4 ,abortion1 ,miscarriage1 and ,premature ,labour #dh ,,iv4 ,the ,caesarean ,section and ,craniotomy #ee ,v4 ,maternal ,impressions #fj ,,vi4 ,human ,terata and the ,sacraments #fi ,,vii4 ,social ,medicine #hh ,,viii4 ,some ,aspects of ,intoxication #aje ,,ix4 ,heredity1 ,physical ,disease1 and ,moral ,weakness #abj ,x4 ,hypnotism1 ,suggestion1 and ,crime #abi ,,xi4 ,unexpected ,death #ace ,,xii4 ,unexpected ,death in ,special ,diseases #aej ,,xiii4 ,the ,moment of ,death #afd ,,xiv4 ,the ,priest in ,infectious ,diseases #afh ,,xv4 ,infectious ,diseases in ,schools #ahg ,,xvi4 ,school ,hygiene #bjb ,,xvii4 ,mental ,diseases and ,spiritual ,direction #baa ,,xviii4 ,neurasthenia #bcj ,,xix4 ,hysteria #bce ,,xx4 ,menstrual ,diseases #bdj ,,xxi4 ,chronic ,disease and ,responsibility #bde x ,,xxii4 ,epilepsy and ,responsibility #bea ,,xxiii4 ,psychic ,epilepsy and ,secondary ,personality #bei ,,xxiv4 ,impulse and ,responsibility #bff ,,xxv4 ,criminology and the ,habitual ,criminal #bga ,,xxvi4 ,paranoia1 a ,study in ,cranks #bhb ,,xxvii4 ,suicides #cjf ,,xxviii4 ,venereal ,diseases and ,marriage #caa ,,xxix4 ,social ,diseases #cag ,,xxx4 ,de ,impedimento ,matrimonii ,dirimente ,impotentia #cbf ,,appendix4 ,bloody ,sweat #cdg ,,index #ceg #a ,,essays ,,in ,,pastoral ,,medicine ,i ,,ectopic ,,gestation ,ectopic gestation is gestation in the uterine adnexa1 the peritoneal cavity1 or the horn of an abnormal or rudimentary uterus4 ,it is opposed to natural uterine gestation1 and1 since it includes pregnancy in an abnormal uterus1 it is a more comprehensive term than extrauterine pregnancy4 ,in this article the morality involved in the surgical treatment of ectopic gestation is considered2 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 foetus2 to explain the varieties1 effects1 diagnosis1 and treatment of ectopic gestation2 to present the cases of this condition1 or rather this disease1 as they occur in medical practice2 to set forth some of the moral principles or laws that govern medical practice1 especially where there is question of life and death2 and finally to apply these principles to the cases offered for investigation4 ,the uterus is in the pelvic cavity1 between the bladder and the rectum and above the vagina1 into which it opens4 ,it is a hollow1 pear-shaped1 muscular organ1 somewhat flattened1 and about three inches long1 two inches broad1 and one inch thick4 ,the base or fundus is upward1 and the neck is downward4 ,passing out horizontally from the corners or horns of the uterus1 which are at its base1 are the two ,fallopian ,tubes1 one on either side4 ,these are about five inches in length and somewhat convoluted4 ,they are true tubes1 opening into the uterus1 and they are about one-sixteenth of an inch in diameter along the greater part of their extent ,the ends farthest #b from the uterus are fringed and funnel-shaped2 and this funnel-end1 called the ,infundibulum or the ,fimbriated ,extremity1 opens into the abdominal or peritoneal cavity4 ,near the ,fimbriated ,extremity of each tube is an ,ovary1--an oval body about one and a half inches long by three-quarters of an inch in width4 ,illustration ,the ,uterus and its ,adnexa ,f ,u1 ,fundus or ,base of the ,uterus4 ,f ,t1 ,p ,t1 ,fallopian ,tubes4 ,on the left of the reader the ,fimbriated ,extremity of the tube is lifted up to show it4 ,o1 ,o1 ,ovaries4 ,b ,l1 ,b ,l1 ,broad ,ligament4 ,r1 ,rectum4 ,b1 ,bladder4 ,for convenience in description1 each tube is divided into four parts3 7#a7 the ,uterine ,portion1 which is that part included in the wall of the uterus itself2 it extends from the outer end of the horn into the upper angle of the uterine cavity1 and its lumen is so small it will admit only a very fine probe2 7#b7 the ,isthmus1 or the narrow part of the tube which lies nearest the uterus2 it gradually opens into the wider part called 7#c7 the ,ampulla2 7#d7 the ,infundibulum1 or the funnel-shaped end of the ,ampulla4 ,this part is fimbriated1 as has been said1 and one of the fimbriae--the ,fimbria ,ovarica--which is longer than the others1 forms a shallow gutter which extends to the ovary4 #c ,the uterus1 tubes1 and ovaries lie in a septum which reaches across the pelvis from hip to hip4 ,this septum is called the ,broad ,ligament4 ,if a man's soft felt hat1 of the kind called a ,fedora hat1 is held crown downward with one hand at the front and the other at the back of the rim1 it will represent the pelvic cavity1 and the fold along the crown of the hat coming up into this cavity is very like the ,broad ,ligament4 ,as the crown is held downward1 the uterus would be in the middle1 its fundus upward1 and1 of course1 altogether outside the hat1 but in the crown fold4 ,the tubes and ovaries would also be outside the hat and in the crown fold1 and the fimbriated extremities would open by holes into the hat's interior4 ,the ovum breaks through the surface of the ovary1 passes1 probably on a capillary layer of fluid1 into the fimbriated extremity of the tube1 and then is moved along slowly through the tube into the uterus4 ,ovulation and menstruation occur about the same time1 but often one antedates the other a few days4 ,in exceptional cases they may occur independently4 ,if the ovum produced is not fecundated1 it gradually shrivels up1 and passes off through the uterus and the vagina4 ,fecundation of the ovum rarely occurs in the uterus1 but ordinarily in the ,fallopian tube1 according to the general opinion of physiologists4 ,after fecundation the ovum is pushed on into the uterus in from five to seven days1 where it fastens to the wall and develops4 ,hyrtl 7,kollmann's ,lehrbuch der ,entwickelungsgeschichte des ,menschen1 ,jena1 #ahih7 speaks of a case in which the ovum appeared to reach the uterus in three days4 ,if the fecundated ovum is blocked or held in the ,fallopian tube1 the embryo grows where the ovum stops1 and we have a case of ,ectopic ,gestation4 ,the average time of normal human gestation is ten lunar months or forty weeks4 ,at the moment the pronucleus of the spermatozoon fuses with the pronucleus of the ovum in the ,fallopian tube and makes the segmentation nucleus1 in my opinion1 the soul of the child enters1 and personality exists as absolutely as it does in a child after birth4 ,it is as much a murder1 as such1 to unjustly destroy this microscopic fecundated ovum as it is to kill the child after birth4 ,this is the opinion of every embryologist ,i have consulted on the #d subject1 with the exception of one who said he did not know when the soul enters4 ,technically the product of conception is called the ,ovum for the first two weeks of pregnancy2 during the third and fourth weeks it is called the ,embryo1 and after the fifth week the ,foetus4 ,during the fourth week the embryo begins to draw nourishment from the maternal blood through its umbilical vessels1 but before that time it obtains nourishment by osmosis4 ,the foetus at the end of the eighth week is about one inch in length2 at the end of the fourth lunar month it is from four to six inches long1 and its sex may be distinguished4 ,at the end of twenty-four weeks1 if the normal foetus is born it will attempt to breathe and to move its limbs1 but it dies in a short time4 ,at the end of twenty-eight weeks of gestation if it is born it moves its limbs freely and cries weakly4 ,it is nearly fifteen inches in length and weighs about three pounds4 ,such an infant might be deemed viable1 but its chances for life are extremely precarious1 even in most expert hands and with the help of an incubator4 ,at the end of thirty-two weeks of gestation a foetus if born may be raised with skilful care1 but the chances are not promising4 ,it is viable4 ,at the end of forty weeks the child is at term4 ,in #ahgf ,parry collected #ejj cases of extrauterine pregnancy from medical literature1 but when ,tait in #ahhc first operated on a case of ruptured tubal pregnancy attention was called to the subject4 ,it was better understood as coeliotomies 7opening the abdomen7 became common1 and in #ahib ,schrenck collected #faj cases that had been reported during the preceding five years4 ,kuestner alone has operated on #aje cases in five years4 ,there has been much discussion among physicians as to the causes that arrest the fertilized ovum in the tube1 but whatever these causes may be they do not affect the moral questions which come up in this article4 ,there may be mechanical obstruction from peritoneal adhesions1 or abnormal conditions resulting from inflammatory diseases of the tubes1 ovaries1 and the pelvic peritoneum1 but no general cause that will explain all cases can be ascribed4 #e ,tait denied the possibility of ,ovarian ,pregnancy1 or a pregnancy where the ovum fastened to the ovary itself and developed there1 but five fully established cases of this kind have been reported4 ,dr4 ,j4 ,whitridge ,williams1 professor of ,obstetrics at the ,johns ,hopkins ,university1 in his textbook on ,obstetrics 7,new ,york1 #aijc71 collects twenty-five cases of ovarian pregnancy1 where five cases are certain diagnoses1 thirteen highly probable1 and seven fairly probable4 ,in these twenty-five cases ten foetuses reached full term1 but four of the five certain cases ruptured at early periods4 ,it was formerly thought that primary abdominal pregnancy is quite common2 that is1 that the ovum is implanted on some organ within the abdomen itself1 apart from the uterine adnexa4 ,this is now looked upon as very doubtful1 and such cases are probably secondary2 that is1 secondary to a pre-existing tubal pregnancy which has ruptured without great maternal hemorrhage and let the foetus grow within the peritoneal cavity4 ,the common form of extrauterine pregnancy is the ,tubal ,pregnancy4 ,the ovum may be stopped in any one of the three parts of the tube1 and we find ,interstitial1 ,isthmic1 or ,ampullar ,pregnancy4 ,from these primary types1 by rupture1 secondary forms sometimes arise1--,tubo-abdominal1 ,tubo-ovarian1 and ,broad-ligament ,pregnancy4 ,the interstitial form1 that is1 where the ovum is arrested in that part of the tube which passes through the wall of the uterus itself1 is the rarest of the tubal pregnancies4 ,rosenthal 7,ein ,fall intranturaler ,schwangerschaft4 ,centralbl4 f4 ,gyn4 #abig-acje7 found it in only three per centum of #acbd cases of tubal pregnancy4 ,some deem the ,isthmic variety the commonest4 ,dr4 ,howard ,kelly 7,operative ,gynaecology7 says he never met a case of ,interstitial or ,ovarian pregnancy in his practice4 ,the interstitial form is especially liable to rupture with suddenly fatal hemorrhage4 ,about one-fourth of the cases of tubal pregnancy end within the first twelve weeks by rupture of the ,fallopian tube4 ,if the embryo is implanted in the interstitial end of the tube1 the rupture 7into the uterus1 or into the abdominal cavity1 or into the broad ligament7 takes place later1--about the fourth month1 or even considerably after that time4 ,the reason for #f the delay here is that the uterus grows with the foetus4 ,if the foetus breaks into the uterus 7a very rare occurrence71 it is either expelled through the vagina almost immediately or it goes on like a normal pregnancy4 ,tait was of the opinion that every case of tubal pregnancy results in a rupture of the tube not later than the twelfth week1 but this opinion is no longer held4 ,very rarely a tubal pregnancy goes on without rupture to full term1 as in the cases reported by ,williams1 ,saxtorph1 ,spiegelberg1 ,chiari1 and a few others4 ,three-fourths1 about seventy-eight per centum1 of the cases of tubal pregnancy result in what is technically called tubal abortion instead of rupture4 ,in tubal abortion the connection between the embryo and the tube-wall is broken by effusion of blood4 ,if the separation is complete the effused blood pushes the embryo out through the fimbriated end of the tube into the abdominal cavity1 and then the hemorrhage of the mother commonly ceases4 ,such an extrusion of the foetus is called a complete tubal abortion4 ,if the connection between the foetus and the tube-wall is only partly severed1 the ovum remains in the tube1 and the maternal hemorrhage goes on4 ,this is called incomplete tubal abortion4 ,in incomplete tubal abortion the maternal blood may slowly trickle from the fimbriated extremity of the tube into the abdominal cavity1 become encapsulated1 and thus form an haematocele4 ,if the fimbriated extremity of the tube is blocked1 the blood accumulates in the tube and makes an haematosalpynx4 ,in complete tubal abortion the foetus dies2 in incomplete tubal abortion the viability might depend on the injury done the placenta1 but in almost every case of even incomplete tubal abortion the foetus dies as a result of its separation from the tubal wall1 or from compression after the bleeding4 ,in cases of rupture of the tube in extrauterine pregnancy1 if the foetus with its attachments is expelled from the tube into the peritoneal cavity or into the broad ligament1 the embryo dies4 ,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 tube1 the foetus may #g possibly live1 provided the mother does not die from hemorrhage4 ,if the foetus goes on growing in this case1 we have an abdominal pregnancy4 ,one such case is reported by ,both where a fully developed foetus was found in the abdominal cavity even lacking all its membranes1 which had been left in the tube1 but a foetus will not live apart from its membranes within the maternal body4 ,when an embryo or foetus ruptures the tube and goes into the broad ligament1 it may live or die according to the injury done its attachments to the tubal wall1 but it ordinarily dies4 ,sometimes such a broad-ligament pregnancy ruptures again into the abdominal cavity4 ,because the bleeding is more likely to be confined within the folds of the broad ligament1 the immediate danger of maternal death from hemorrhage is less in this than in other forms of rupture4 ,concerning tubo-abdominal pregnancy the only remark to be made is that1 owing to adhesions1 it is often surgically difficult to remove such a growth4 ,if the foetus is expelled after rupture into the peritoneal cavity it dies1 and if the hemorrhage does not kill the mother the dead foetus if small is absorbed2 if large it becomes mummified1 or it hardens into a lithopoedion1 or it turns into a yellowish greasy mass called adipocere1 or it putrefies4 ,a lithopoedion may be carried for years4 ,there are more than thirty cases reported which were carried from twenty to thirty years in the abdomen1 and one case where a lithopoedion was carried for fifty years4 ,if the foetus putrefies it causes fatal septicaemia in the mother1 or a perforating abscess1 unless it is successfully removed4 ,there are various abnormalities of the uterus1 and in these pregnancy resembles in effect extrauterine pregnancy4 ,an abnormal uterus may be unicornis1 didelphys1 pseudodidelphys1 bicornis duplex1 bicornis septus1 bicornis subseptus1 bicornis unicollis1 or bicornis unicollis with a rudimentary horn4 ,the impregnated ovum may fasten in the rudimentary horn and be blocked there2 then the usual result is rupture within the first four months1 with fatal hemorrhage unless the bleeding is immediately checked by coeliotomy and ligation4 #h ,as to diagnosis in ,ectopic ,gestation1 ,williams 7op4 cit471 one of the authorities at present on the subject1 says3 ,a positive diagnosis is occasionally made before rupture1 but in the vast majority of cases the condition escapes recognition until symptoms of collapse point to the probability of rupture or abortion4 ,in advanced cases careful examination will usually disclose the real condition of affairs1 and when full term has been passed the history is so characteristic that mistakes should hardly occur4 ,in the ,american ,ecclesiastical ,review for ,january1 #ahih 7vol4 ix41 n4 i71 ,father ,rene ,i4 ,holaind1 ,s4 ,j41 published the answers of many physicians to six questions concerning extrauterine pregnancy4 ,among these physicians were ,thomas ,addis ,emmet1 ,barton ,cooke ,hirst1 ,howard ,a4 ,kelly1 ,w4 ,t4 ,lusk1 ,t4 ,galliard ,thomas1 ,mordecai ,price and his brother ,joseph ,price1 ,william ,goodell1 and ,lawson ,tait1--all eminent authorities on this subject4 ,the second question submitted was3 ,during pregnancy1 at what time and by what means can a differential diagnosis be made between intra and extra-uterine pregnancy1 and between abnormal gestation and pelvic or other tumour8 ,in answer to this question ,dr4 ,emmet said3 ,there can be no absolute certainty as to the existence of pregnancy in any case until the pulsation of the foetal heart can be detected4 ,after the eighteenth or twentieth week of gestation4 4 4 4 ,a diagnosis is difficult in all cases of abnormal pregnancy1 but an expert can1 within a reasonable degree of certainty1 arrive at a knowledge of the existing conditions between the second and third month4 ,dr4 ,hirst said3 ,in almost all cases of advanced gestation the differential diagnosis can be made4 ,in early cases it is not always possible unless conditions be favourable4 ,dr4 ,howard ,a4 ,kelly said3 ,the differential diagnosis between intra and extrauterine pregnancy can usually be made from the sixth week up to the end of pregnancy4 ,it is more easily made from the tenth to the twelfth week on4 ,writing in the ,american ,text ,book of ,obstetrics 7,philadelphia1 #ahif71 he says3 ,in the atypical cases1 on the contrary1 a positive diagnosis is often difficult or even impossible4 4 4 4 #i ,the diagnosis of ectopic gestation after the death of the foetus is largely dependent upon the clinical history2 if this be deficient1 the diagnosis is frequently impossible4 ,dr4 ,lusk said3 4444 ,the frequent discovery of the dead ovum in a tube when there has been no suspicion of pregnancy shows the difficulty of a diagnosis4 ,in his text-book 7,the ,science and ,art of ,midwifery1 ,new ,york1 #ahij7 is this remark3 ,sometimes the diagnosis can only be decided by the introduction of the sound or a finger into the uterus1 the physician assuming the risk of premature labour1 should he find his supposition of extrauterine pregnancy an error4 ,this means that sometimes the diagnosis is impossible without running the risk of causing abortion of a normal uterine pregnancy4 ,dr4 ,thomas said1 ,after the second month the diagnosis is perfectly possible4 ,this was also the opinion of ,dr4 ,mordecai ,price2 and ,dr4 ,joseph ,price holds that the diagnosis can be made after the third month1 by exclusion4 ,dr4 ,john ,f4 ,roderer1 quoting ,lawson ,tait1 says that the diagnosis between intra and extrauterine pregnancy can not be made with certainty before rupture1 nor can it be determined exactly whether an enlargement of the tube is either an ectopic pregnancy or some form of tumour4 ,dr4 ,goodell's opinion was1 ,a differential diagnosis can rarely be made positively at any stage of extrauterine pregnancy4 ,the diagnosis1 then1 is difficult2 and for the ordinary practitioner1 the average physician1 who does perhaps ninety-five per centum of the medical work of the world1 the diagnosis is often impossible4 ,there is no greater expert than ,dr4 ,thomas ,addis ,emmet1 and he says the diagnosis is difficult4 ,others hold that the diagnosis can be clearly made1 and they speak truly as regards themselves1 but ordinary skill finds the diagnosis almost impossible in many cases4 ,mordecai ,price 7,the ,pennsylvania ,medical ,journal1 vol4 viii4 p4 #bbc7 in one year saw four cases which he and other physicians diagnosed as ectopic pregnancies with rupture of the tube4 ,when the abdomen had been opened1 uterine pregnancy was discovered with a ruptured tube in each case1 and all the women died4 #aj ,the first positive diagnosis of unruptured tubal pregnancy was made by ,veit in #ahhc1 and the first one made in ,america was by ,janvrin in #ahhf1 eight years before ,father ,holaind's article was written4 ,before #ahhc1 only eleven years in advance of the same article1 when ,lawson ,tait performed the first coeliotomy for the purpose of checking hemorrhage from a ruptured tubal gestation1 extrauterine pregnancy was as mysterious as the old inflammation of the bowels1 which turned out afterward to be appendicitis4 ,hence common skill in the difficult diagnosis of ectopic gestation can not be looked for4 ,the doctrine given in all the leading medical works at present concerning the treatment of extrauterine pregnancy is this3 #a4 ,as soon as an extrauterine pregnancy is discovered remove the foetus through an opening made in the mother's abdominal wall4 ,do not use electricity or the injection of poisons into the foetal sac1 or the incandescent knife4 ,emmet and a few others approved of the use of electricity at times1 but this is against the teaching of the great majority of writers at present4 ,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 effective4 #b4 ,in a case of rupture with free hemorrhage and collapse the only operation advised is an immediate coeliotomy to stop the bleeding by ligatures4 ,the rupture should not be approached through the vaginal wall according to the common doctrine1 but through the abdominal wall4 #c4 ,if there is a rupture in which the bleeding is confined and there is no collapse1 do not operate at once unless the haematocele increases steadily or shows signs of suppuration4 ,sometimes evacuation of the haematocele through the vaginal wall is possible4 #d4 ,in the later months of an extrauterine pregnancy1 whether the case is intraligamentous or abdominal1 perform coeliotomy as soon as the diagnosis has been made1 and remove the foetus1 because there is always danger of sudden and fatal hemorrhage before the surgeon can reach the source of the bleeding4 ,what is to be done in a case where the surgeon is certain before operating that the foetus is #aa dead1 has interest only for the physician1 and it involves no moral question4 ,operating for extrauterine pregnancy maybe a simple coeliotomy1 if any coeliotomy is really simple1 but it commonly is the most dangerous operation for the mother that the gynaecologist is called upon to perform4 ,the discussion of the moral questions that arise in cases of ectopic gestation which began in volume ix4 of the ,american ,ecclesiastical ,review was very valuable1 but as the moralists had not full data to work on their decision as a whole is not satisfactory4 ,the original cases presented are in part obsolete in the medical practice of to-day1 and important physical conditions were not disclosed in some of the other parts of the cases4 ,father ,holaind tentatively agreed with ,father ,lehmkuhl in one decision1 ,fathers ,eschbach and ,sabetti directly attacked ,father ,lehmkuhl's reasons1 and ,father ,aertnys indirectly opposed ,father ,sabetti's chief argument4 ,these men are all eminent authorities1 but as each1 except ,father ,holaind1 was dissatisfied with the arguments advanced by the others1 and as their data were incomplete1 we can not rest the case on their decision4 ,in ,father ,holaind's fifth question1 if ,i understand it correctly1 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 removal4 ,he mentions antiseptic precautions in the baptism1 which would have no meaning if the foetus were out of the abdomen4 ,baptism would not be possible in that case3 the priest could not get at the foetus1 he ordinarily could not even see it1 and certainly no surgeon would permit the attempt4 ,there would be no time for the attempt in a rupture case1 even if the foetus could be seen2 and there would be no advantage gained by baptizing the foetus in the abdominal cavity where the conditions gave time to do so4 ,if it is alive it will live long enough for baptism after removal from the abdomen1 provided1 of course1 it is baptized immediately in the operating room4 ,that it does not breathe is no proof of immediate death4 ,it is not unusual for a full-term child not to breathe for even an hour or longer after birth4 #ab ,if ,father ,holaind had not in view baptism within the abdominal cavity1 the question has this meaning3 ,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 baptism8 ,the best method is to slit the membranes with a scalpel or scissors as quickly as possible4 ,the envelopes1 cord1 and placenta are essential parts of the foetus itself1 and they grow from itself1 not from the mother4 ,they take the place of the lungs and the alimentary tract1 which do not come into action until after normal birth4 ,it would be worth discussing whether a baptism on the intact foetal envelopes is valid1 were it not that we may not apply probabilism in such a case4 ,the remaining matter brought out in ,father ,holaind's questions will be considered in the course of this article4 ,before presenting the cases of ectopic gestation that occur in medical practice1 the fundamental ethical principles that are to be applied in judging the morality of the surgeon's interference should be given4 ,the morality of any action is determined1 7#a7 by the object of the action2 7#b7 by the circumstances that accompany the action2 7#c7 by the end the agent had in view4 #a4 ,the term object has various meanings1 but here it means the deed performed in the action1 the thing which the will chooses4 ,that deed by its very nature may be good1 or it may be bad1 or it may be indifferent morally4 ,in themselves to help the afflicted is a good action1 to blaspheme is a bad action1 to walk is an indifferent action4 ,some bad actions are absolutely bad1 they never can become good or indifferent 7blasphemy or adultery1 for example72 others1 as stealing1 are evil because of a lack of right in the agent3 these may become good by acquiring the missing right4 ,others are evil because of the danger necessarily connected with their performance1--the danger of sin connected with them1 or the unnecessary peril to life4 ,an action to have the moral quality must be voluntary1 deliberate2 and mere repugnance in doing an act does not in itself make the act involuntary4 #b4 ,circumstances sometimes1 though not always1 can add a #ac new element of good or evil to an action4 ,the circumstances of an action are the agent1 the object1 the place in which the action is done1 the means used1 the end in view1 the method observed in using the means1 the time in which the deed is done4 ,if a judge in his official position tells a sheriff to hang a criminal1 and a private citizen gives the same command1 the actions are very different morally because of the circumstances of the agent giving the command4 ,the object--it changes the morality of the deed if a man steals a cent or a thousand dollars4 ,the place--what might be merely a filthy action in a house might be a sacrilege in a church4 ,the means--to support a family by labour or by thievery4 ,the end in view--to give alms in obedience to divine command or to give them to buy votes4 ,the method observed in using means--kindly1 say1 or cruelly4 ,the time--to do manual labour on ,sunday or on ,monday4 ,some circumstances aggravate the evil in a deed1 some extenuate it4 ,others may so colour a deed that they specify the deed1 make the action some special virtue or vice4 ,the circumstance that a murderer is the son of the man he kills specifies the deed as parricide4 ,the end also determines the morality of an action 7see ,st ,thomas1 ,sum4 ,theol4 ,i4 #b41 q4 xviii41 a4 #d and #g74 ,since the end is the first thing in the intention of the agent1 he passes from the object wished for in the end to choosing the means for obtaining it4 ,without the end the means can not exist as such4 ,there are occasions when an end is only a circumstance3 for example1 if it is a concomitant end4 ,when an end is a1 finis extrinsecus operantis1 when it is in keeping with right reason or discordant thereto1 it may become a determinant of morality4 ,in every voluntary1 or human1 act there is an interior and an exterior act of the will1 and each of these acts has its own object4 ,the end is the proper object of the interior act of the will2 the exterior object acted upon is the object of the exterior act of the will2 and as this exterior act specifies the morality1 so does the interior object--which is the end--specify it1 and even more importantly than the exterior object does4 ,the will uses the body as an instrument on the external #ad object1 and the action of the body is connected with morality only through the will4 ,we judge the morality of a blow1 not by the physical stroke1 but from the intention of the striker4 ,the exterior object of the will is1 in a way1 the matter of the morality1 and the interior object of the will1 or the end1 is the form4 ,aristotle 7,ethics1 lib4 v41 cap4 #b7 says3 ,he that steals that he may commit adultery1 is1 absolutely speaking1 more an adulterer than a thief4 ,the thievery is a means to the principal end1 and it is this principal end that chiefly specifies or informs the action4 ,the means used to obtain an end are very important in a consideration of the morality of an act4 ,there are four classes of means1--the good1 the bad1 the indifferent1 and the excusable4 ,good means may be absolutely good1 but commonly they are liable to become vitiated by circumstances1--almsgiving is an example4 ,some means are bad always and inexcusable1--lying1 for example4 ,the excusable means are those which are bad1 but justifiable through circumstances4 ,to save a man's life by cutting off his leg is an excusable means4 ,the existence of excusable means whereby some good actions are effected does not establish the assertion that the end justifies the means4 ,the end sometimes may incriminate or sanctify indifferent means1 but it does not in itself justify all means4 ,the means1 like other circumstances1 are accidents of an action1 but they are in an action just as much as colour is in a man4 ,colour is not of a man's essence1 but you can not have a man without colour4 ,the effect of an action1 the result or product of an effective cause or agency1 may in itself be an end or an object or a circumstance1 and it has influence in the determination of morality4 ,sometimes an act has two effects1 one good and the other bad2 and that such an action be lawful it is necessary 7#a7 that the action itself be good or indifferent2 7#b7 that the good effect be intended and the evil effect be not intended 7chosen7 but only reluctantly permitted2 7#c7 that the evil effect be not a means to secure the good effect2 7#d7 that there be present a motive sufficiently grave to excuse or counterbalance the bad effect4 #ae ,st4 ,thomas 7,sum4 ,theol4 #b4 #b4 q4 #fd1 a4 #g7 ,speaking of killing a man in self-defence1 says3 ,nihil prohibet unius actus esse duos effectus1 quorum alter solum sit in intentione1 alius vero sit praeter intentionem4 ,morales autem actus recipiunt speciem secundum id quod intenditur1 non autem ab eo quod est praeter intentionem1 cum sit per accidens4 ,that an act1 therefore1 be morally good1 or justifiable1 7a7 the whole train of the tendency of the will must be good2 that is1 7#a7 the object1 7#b7 the end1 7#c7 and the circumstances must be good2 or 7b7 the intention should be good1 and the remaining elements in the train of will-tendency are to be indifferent4 ,that an act be morally bad it is enough that the object1 the end1 or the circumstances be inexcusably bad4 ,there may be honest doubt as to the existence of evil in the circumstances or the end1 and here enters the matter of probability2 but apart from this1 some general rules of morality that govern all cases may be formulated3 #a4 ,an intention or end which is gravely evil always makes the entire action evil and unjustifiable4 #b4 ,an intention or end which is slightly evil1 if it is the entire end of an action1 makes the whole action evil but not gravely evil--makes it1 say1 a venial sin and not a mortal sin4 #c4 ,if an intention or end which is venially evil accompanies secondarily a good intention or end1 and is rather a motive than the real effective agent in attracting the will1 this venial evil does not vitiate the whole goodness or righteousness of the main action4 ,compare the remarks made above in discussing an action that has a double effect1 partly good and partly bad4 #d4 ,circumstances that are gravely evil practically vitiate the entire action1 but circumstances which are venially evil do not always vitiate the entire action4 ,much might be said here concerning conscience as a judge of the morality in an act1 but this discussion is not necessary for our present purpose4 ,like other men1 physicians often confuse conscience with inclination1 or at best with unfounded opinion4 ,when conscience is to be a rule of action it must #af have at the least moral certitude2 or1 what is different but practically the same thing1 the opinion of conscience must be at the least genuinely probable4 ,the term probable is used here in a technical sense1 and it will be so used throughout the remainder of this article4 ,the doctrine of ,probabilism is connected with the promulgation of law4 ,a law1 according to ,st4 ,thomas 7op4 cit4 ,i4 #b41 q4 #ij1 a4 #d7 is3 ,ordinatio rationis ad bonum commune ab eo qui curam habet communitatis promulgata4 ,sometimes it is not evident whether or not a law binds in a particular case1 and in such a condition1 that is1 in which there is question solely of the existence1 interpretation1 or application of a law1 we may follow a probable opinion which assures us the act is licit1 although the opinion which says the act is illicit may be just as probable or even more probable4 ,this is the fundamental proposition of ,probabilism1 which is the doctrine especially of ,st4 ,alphonsus ,liguori1 but it was held centuries before his time4 ,as the church has never condemned this doctrine1 but rather tacitly approved of it1 ,catholics may safely follow it1 and those that are not ,catholics will find it very reasonable4 ,a law which is doubtful after honest and capable investigation has not been sufficiently promulgated1 and therefore it can not impose a certain obligation because it lacks an essential element of a law4 ,when we have used such moral diligence of inquiry as the gravity of a matter calls for1 but still the applicability of the law is doubtful in the action in view1 the law does not bind2 and what a law does not forbid it leaves open4 ,probabilism is not permissible when there is question of the worth of an action as compared with another1 or of issues like the physical consequences of an act4 ,if a physician knows a remedy for a disease that is certainly efficacious and another that is probably efficacious1 he may not choose the probable cure1 at the least in a grave illness4 ,probabilism has to do with the existence1 interpretation1 or applicability of a law1 as ,i said1 not with the differentiation of actions4 ,the term probable means provable1 not guessed at1 or jumped at without reason4 ,there must be sound reason #ag adduced to constitute probability4 ,the doubt must be founded on a positive opinion against the existence1 interpretation1 or application of the law4 ,it must be more than mere negative doubt1 more than ignorance1 more than vague suspicion1 especially must it be more than a sentimental impression4 ,there is a mental condition1 which easily passes over into disease1 wherein a man habitually can not make up his mind4 ,this flabbiness has nothing to do with ,probabilism4 ,the opinion against a law to constitute ,probabilism must be solid4 ,it must rest upon an intrinsic reason from the nature of the case1 or an extrinsic reason from authority1--always supposing the authority cited is really an authority4 ,many men sitting upon the supreme bench in the ,court of ,science and called authorities by friends and newspapers1 are only fools in good company4 ,the probability must also be comparative4 ,what seems to be a very good reason when standing alone may be very weak when compared with a reason on the other side4 ,when we have weighed the arguments on both sides1 and we still have good reason left for standing by our opinion1 our opinion is probable4 ,the probability is1 moreover1 to be practical4 ,it must have considered all the circumstances of the case4 ,the principles presented here have been arranged1 as we said1 with a view toward application in judging the morality of actions that may occur in cases of ectopic gestation1 and we shall apply the doctrine of probabilism in the question1 does the commandment ,thou shalt not kill bind in certain cases of ectopic pregnancy8 ,it is also necessary to add the principles underlying our duty to preserve human life4 #a4 ,it is never lawful directly or indirectly to kill an innocent man4 ,insontem et justum non occides 7,exod4 xxiii4 #g74 ,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 life4 ,directly means to kill either as an end1 say1 for revenge1 or as a means toward an end4 ,a man is a person1 an intelligent being1 therefore free1 and autocentric2 he belongs to no one except to ,god1 who made #ah him2 he is by that very fact distinguished from brutes or things which may belong to another4 ,now1 if you kill a man1 you destroy his human nature by separating his soul and body1 you subordinate and sacrifice him wholly to yourself1 make him entirely yours1 which is unjust4 ,even the state has no right to kill an innocent man4 ,a foetus in the womb1 only a few hours old1 is as much a human being as a man fifty years of age1 and this natural law holds for the foetus as for the man4 #b4 ,it is1 however1 lawful indirectly to kill a man provided this man is an unjust aggressor4 ,cardinal de ,lugo 7,de ,just4 et ,jure1 #aj1 #adi7 and others hold you may even directly kill an unjust aggressor4 ,indirectly here means incidentally4 ,an effect happens indirectly when it is neither intended as an end nor a means1 but happens as a circumstance unavoidably attached to the end or means intended4 ,we may not1 however1 kill an innocent man even indirectly1 because no end is proportionate to the sacrifice of an innocent man's life1 but the case of an unjust aggressor differs from that of an innocent man4 ,by an unjust aggressor is meant some one that outside the due course of law threatens your life or the equivalent of your life1 or the life of some one you should or may protect4 ,you may stop such an aggressor1 and if you happen to kill him while trying to stop him1 there is no moral wrong involved4 ,this aggressor may be formally or only materially unjust3 he may be a normal man with a formal intention to kill you or your ward1 or a murderous lunatic that tries to kill you or your ward1 but he must be unjust either formally or materially4 ,it is natural for every being to maintain itself in existence1 to resist destruction4 ,this is a primary law of nature4 ,as ,father ,holaind well said 7,amer4 ,eccl4 ,rev41 ,january1 #ahid73 ,the ethical foundation of self-defence is this3 ,justice requires a sort of moral equation1 and if a right prevails it must be superior to the right which it holds in abeyance4 ,at the outset both the aggressor and his intended victim have equal rights to life1 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 latter4 ,if we may be #ai allowed so to express it1 the moral power of the aggressor is equal to his inborn right to life1 less the unrighteous use which he makes of it1 whilst the moral power of the intended victim remains in its integrity and has consequently a higher juridic value4 ,when the person assailed cannot defend himself1 his right can and sometimes must be exercised by those who are bound in justice or charity to protect the innocent4 ,at the dawn of human life the physician or surgeon stands as the natural protector both of the mother and of the child2 he is beholden to both4 ,the right of self-defence is not annulled by the fact that the aggressor is irresponsible4 ,the absence of knowledge saves him from moral guilt1 but it does not alter the character of the act1 considered objectively and in itself2 it is yet an unjust aggression1 and in the conflict1 the life assailed has yet a superior juridic value4 ,the right of killing in self-defence is not based on the ill will of the aggressor but on the illegitimate character of the aggression4 ,now1 an aggressor is at least materially unjust whenever he perpetrates an act destructive of the right of another4 ,mark the words right of another1 at the end of the quotation4 ,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 mother1 supposing there were no artificial means of delivering her1 but such a child is not an aggressor even materially unjust4 ,the child itself is normal1 it has a natural right to be where it is1 it did not put itself where it is2 the mother's contracting uterus crushing the child against her narrow pelvic arch is the direct agency that kills the woman1 and the child is only an inert instrument used by the contracting uterus4 ,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 aggressor4 ,lehmkuhl 7,compendium ,theologiae ,moralis1 #ahia1 p4 #bch7 says3 ,medicus graviter peccat 444 si media abortus procurat3 nisi quando ad salvandam matrem ex probabili opinione liceat4 ,on page #ahh he says3 ,ex consulto abortum inducere1 etiam liceri videtur in praesenti vitae #bj maternae discrimine1 quod per solam foetus immaturi ejectionem avert6 possit 4 4 4 ,idque videtur applicari posse ad matrem quae tarn arcta est ut tempus praematuri partus exspectare non possit4 ,by foetus immaturus here he means an unviable foetus1 as is evident from the context4 ,if this probabilism of ,father ,lehmkuhl's stands 7but it does not71 a decision in most of the cases that occur in ectopic gestation would be easily made1 but even he himself would not take responsibility in the matter1 and that before the decision of the ,holy ,office which defined abortion4 ,since this decision1 made ,july #bd1 #ahie1 ,lehmkuhl has entirely withdrawn his opinion4 ,on ,may #d1 #ahih1 the ,holy ,office published the following decree1 which was approved by the ,pope3 ,,beatissime ,,pater1--,episcopus ,sinaloen4 ad pedes ,s4 ,v4 provolutus1 humiliter petit resolutionem insequentium dubiorum3 ,i4 ,eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore8 ,,ii4 ,et si mulieris arctitudo talis sit1 ut neque partus prematurus possibilis censeatur1 licebitne abortum provocare aut caesariam suo tempore perficere operationem8 ,,iii4 ,estne licita laparotomia quando agitur de pregnatione extra-uterina1 seu de ectopicis conceptibus8 ,feria iv1 die #d ,mali1 #ahih4 ,in ,congregatione habita1 etc 4 4 4 ,,ee4 ac ,,rr4 ,patres rescribendum censuerunt3 ,ad ,i4 ,partus accelerationem per se illicitam non esse1 duromodo perficiatur justis de causis et eo tempore ac modis1 quibus ex ordinariis contingentibus matris et foetus vitae consulatur4 ,ad ,,ii4 ,quoad primam partem1 negative1 juxta decretum1 ,feria iv41 #bd ,julii1 #ahie1 de abortus illiceitate4--,ad secundam vero quod spectat3 nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur4 ,ad ,,iii4 ,necessitate cogente1 licitam esse laparotomiam ad extra-hendos e sinu matris ectopicos conceptos1 dummodo et foetus et matris vitae1 quantum fieri potest1 serio et opportune provideatur4 ,in sequenti ,feria vi41 die #f ejusdem mensis et anni 4 4 4 ,s,smus responsiones ,,ee4 ac ,,rr4 ,patrum approbavit4 #ba ,the third question proposed by the bishop is3 ,is laparotomy licit when performed for extrauterine pregnancy or ectopic gestation8 ,the approved answer of the ,holy ,office to this question is3 ,in a case of necessity1 laparotomy for the purpose of removing an ectopic foetus 7conceptus7 from the abdomen of the mother is licit1 provided the lives of both the foetus and the mother1 as far as is possible1 are carefully and fitly guarded4 ,the expression1 dummodo et foetus et matris vitae1 quantum fieri potest1 serio et opportune provideatur1 is capable of various translations and interpretations4 ,the words might have this meaning3 ,in a case of necessity you may do laparotomy and remove an ectopic gestation1 provided you do not kill either the mother or the foetus4 ,if that is the interpretation1 the decree means that we may never remove an unviable ectopic foetus when we know that the foetus is alive1 because removal will kill it4 ,the sentence can also be translated in this sense3 ,in a case of necessity1 you may do laparotomy and remove an ectopic foetus from the mother1 provided you take full care to save mother and child if that is possible4 ,if that is the signification1 it is evidently very different from the first interpretation4 ,it would mean3 do the laparotomy1 remove the foetus1 and if you possibly can save both mother and foetus do so1 but if you can not1 take the best means you can to save one or the other4 ,if the decree refers only to cases in which the foetus is viable1 it would appear to be unnecessary--we need no decree of the ,holy ,office to let us do a laparotomy to remove a viable foetus4 ,if it does not refer to a viable foetus1 it refers to an unviable foetus1 but to remove an unviable foetus is to either kill it or to hasten its death4 ,genicot 7,institutiones ,theologiae ,moralis1 ,louvain1 #aijb1 vol4 i4 p4 #ceh7 has this interpretation of the decree3 ,in conceptione extra-uterina licebit sane recurrere ad laparotomiam similemve operationem1 quando aliqua etiam tenuissima spes affulget salvandi infantem1 simul ac mater fere certo liberabitur4 4 4 4 ,ubi vero nulla spes hujusmodi #bb affulget1 neque in hoc casu licebit abortum directe inducere1 etiamsi foetus certo moriturus sit antequam in lucem edatur1 et baptismum recipere nequeat4 ,etenim ,s4 ,inqu41 dum provocat ad responsum #ai ,august1 #ahhh1 satis indicat abortus inductionem a se haberi tamquam operationem directe occisivam foetus ideoque semper illicitam4 ,there is no question of an abortion in a laparotomy for extrauterine gestation2 abortion is altogether a different operation in method and nature4 ,secondly1 the other decree of the ,holy ,office to which he refers speaks of a direct killing of the foetus1 but there is no direct killing of the foetus in the operation for ectopic gestation1 nor is the indirect hastening of the foetus's death a means to an end4 ,the decree on abortion is so clear it leaves no room for doubt4 ,cardinal ,monaco1 in the ,epistola ad ,archiepiscopum ,camarcensem1 ,august #ai1 #ahhi1 says the ,holy ,office decreed that ,in scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellant1 sicut declaratum fuit die #bh ,maii1 #ahhd1 et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis4 ,note the words directe occisivam4 ,craniotomy is a direct killing1 and a direct killing used as a means to an end2 moreover it is an altogether unnecessary killing4 ,artificial abortion in the case of an unviable foetus is also a direct killing as a means to save the mother's life1 but the removal of an unviable ectopic foetus is neither a direct killing1 nor is it a means toward any end4 ,since the meaning of the decree concerning laparotomy in extrauterine pregnancy is by no means clear1 we may discuss the question until the law has been fully promulgated1 ready to conform to the real meaning of the decree whenever it is explained4 ,in that spirit we may now consider the cases that occur in ectopic gestation4 ,case ,i4 ,a surgeon is called in to treat a woman and he finds her in a state of collapse4 ,he makes a diagnosis of tubal pregnancy1 which has gone on to rupture with hemorrhage1 and the bleeding will evidently be fatal to the mother unless it is checked4 ,practically the only chance of saving the #bc mother's life is coeliotomy and the ligation of her open arteries4 ,dr4 ,howard ,kelly 7,operative ,gynaecology1 vol4 ii4 p4 #dcg7 says3 ,when the hemorrhage is sudden and excessive the patient falls in collapse2 but1 in spite of these alarming symptoms1 she may survive a succession of similar attacks and the foetus and sac may continue to develop4 ,this exception complicates the case slightly4 ,if the surgeon were absolutely certain that the only possible chance to save the woman's life is coeliotomy and haemostasis1 the case would be somewhat different from one in which there is some chance of escape by spontaneous haemostasis4 ,that chance1 however1 is so slight1 and so far beyond any means we have for forecasting1 that it is mere luck1 and it is to be neglected4 ,the surgeon may safely consider the patient in the gravest actual danger4 7a7 ,before he opens the abdomen he can not tell whether the foetus is alive or not2 but the stronger probability is that it is not1 and the certainty is that it has no chance at all to remain alive more than a few minutes or hours1 unless the surgeon is willing to trust to sheer luck in the expectation that he may happen to have one of ,dr4 ,kelly's exceptions before him4 7b7 ,the operation to save the mother is this3 as quickly as possible he makes a vertical slit from four to six inches long through the woman's belly-wall4 ,then commonly the free blood begins to run out1 or it may even spurt out some feet into the air4 ,the surgeon can see nothing for the blood and the presence of the entrails4 ,if the blood is not freshly welling up he bails it out with his hands or a ladle2 if it is spurting he at once thrusts in his hand1 feels for the foetal sac1 lifts it up1 and puts on clamps near the uterus on one side and near the pelvic brim on the other4 ,this stops the hemorrhage1 and he can then work more leisurely1 but unfortunately this also stops the flow of blood to the foetus4 ,he can not first examine the foetus and then stop the hemorrhage4 ,he can not back out even if he finds a live foetus without letting the mother die on the table4 7c7 ,if the placenta is already loose from the ,fallopian tube the child is dead or it will die in a few seconds or minutes4 ,if it was not loose the lifting out may tear it loose1 and this #bd tearing loose will hasten the death of the foetus a few minutes 7but give a chance for baptising it74 7d7 ,if the lifting out does not tear loose the supposedly fixed placenta1 the foetus either will die anyhow if the mother dies1 or it will die if the mother lives1 because to save her the surgeon must put ligatures just where the flow of blood will be shut off from the foetus4 ,commonly there is no time to even look for the foetus until after the maternal arteries have been closed4 7e7 ,the same conditions could exist in the rupture of a pregnancy in a rudimentary uterine horn as in a rupture in tubal gestation4 ,what is the surgeon to do in a case like this8 ,fathers ,holaind 7,amer4 ,eccl4 ,rev41 ,january1 #ahid1 in a note on p4 #ci71 ,lehmkuhl and ,sabetti say3 do coeliotomy1 ligate the mother's arteries1 remove and baptise the foetus4 ,the analysis of the case is this3 7i7 ,the action is the stopping of a fatal hemorrhage in a woman1 and possibly1 though not certainly1 an indirect incidental hastening of a foetus's inevitable death4 7#b7 ,the object of the action is the haemostasis1 which is good1 and the possible indirect hastening of the foetus's death1 which is evil1 but1 as we shall see1 excusable evil4 7#c7 ,the end of the action is to save the mother's life--a good end4 7#d7 ,the circumstances are3 7a7 that possibly1 through mere luck1 the woman's condition is not necessarily hopeless3 a few women have escaped in this seemingly imminent peril--but that chance of escape is not soundly probable2 the stronger probability by far is on the side of a fatal issue2 therefore the chance for escape may be neglected1 and the woman's case may be regarded as hopeless if operation is foregone4 7b7 ,the quickest possible work on the surgeon's part is necessary1 and there is no time or chance to examine the foetus's condition before tying the maternal arteries4 ,before he opens the mother's abdomen he can tell nothing whatever of the foetus's condition1 but the probability is all in favour of the fact that the foetus is already dead or moribund4 7c7 ,the means are coeliotomy1 and the ligation of the #be uterine and ovarian arteries to stop the mother's bleeding4 ,this ligation1 in the contingency that the foetus is still attached to the ,fallopian tube1 will also shut off the blood from the foetus1 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 indirect1 but it is an evil circumstance associated with the action which may hasten the foetal death--even here the hastening is uncertain4 7#e7 ,the action has two effects1--one1 the saving of the mother1 is directly intended and evidently good2 the other1 the possible indirect hastening of the foetus's death1 may or may not be evil4 ,the moral centre of the whole case is this possible hastening of the foetus's death4 ,if that possible hastening is licit the whole action is licit2 if it is not permissible it will vitiate the entire action4 ,suppose that there is no doubt that the ligation of the maternal arteries in this case really hastens the foetus's death some minutes3 it would still be an indirect volition4 ,father ,lehmkuhl also calls it indirect and licit4 ,father ,sabetti denied that it is indirect1 but he held that it is licit for another reason4 ,sabetti said 7,aner4 ,eccl4 ,rev41 ,august1 #ahid73 ,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 it4 ,that is true1 but the minor proposition in a syllogism drawn from that statement is to be emphatically denied4 ,the cutting off of the foetal blood is a fact associated with the means1 not a means direct or indirect toward the end1 which is to save the mother--the means to save the mother is the stopping of her bleeding4 ,this is not hair-splitting in the opprobrious sense of that term4 ,the bases of all sins are absolutely abstract principles1 and because abstract principles can not be pinched or weighed1 they have often little meaning for the opposition in an argument4 ,there is only the width of a hair between ,heaven and ,hell at many places along the frontier1 and there is only the difference between a direct or an indirect volition separating murder and a good deed4 ,the best ethics frequently consists in delicate hair-splitting2 and despite the protests of sentimentalists1 one of the most valuable benefits of ,moral ,science is #bf to show us how to handle moral poisons for good purposes1 as a physician uses the material poisons1 opium and aconite4 ,if the foetus in this case of rupture in ectopic gestation were a materially unjust aggressor on the mother's life1 the indirect hastening of its death would be justifiable according to all moralists1 and the direct hastening would be licit according to ,cardinal de ,lugo1 who was1 in the opinion of ,st4 ,alphonsus1 post ,d4 ,thomam inter alios theologos facile princeps 7,th4 ,mor41 lib4 #d4 n4 #eeb74 ,sabetti held that the foetus is a materially unjust aggressor4 ,his reason for this opinion is that the extrauterine foetus is not in a position in which it has a right to be4 ,if it were in the uterus1 its natural position1 it would have a right to its position4 ,ectopic gestation is a disease1 not a physiological condition4 ,father ,aertnys 7,amer4 ,eccl1 ,rev41 ,july1 #ahic7 denies that the foetus is an aggressor materially unjust4 ,he says3 ,nequaquam enim mortem intentat matri1 sed actione1 quam non ipse sed corpus matris producit1 conatur ad lucem pervenire1 et iste conatus non nisi ex naturali concursu rerum fit matri causa mortis4 ,infans ergo non est aggressor et multo minus est aggressor injustus4 ,hinc nego paritatem cum homine mente capto1 qui delirans alteri mortem intentat2 hic enim agit motus a sua voluntate1 licet absque culpa1 et ponit actiones in se injustas1 utpote ad necandum directe intentas4 ,in the same periodical 7,january1 #ahid7 while repeating this statement he says3 ,sive in utero existat sive alibi reconditus sit sc4 foetus1 nequaquam mortem intentat matri1 siquidem non ipse actione propria conatur egredi1 sed corpus matris infantem expellit et haec expulsio a matre emanans fit matri causa mortis4 ,what ,father ,aertnys says in these two passages is true of an intrauterine foetus1 but it is altogether erroneous when applied to an extrauterine foetus1 of which alone there is question here4 ,in extrauterine pregnancy the uterus or any other part of the maternal body does not try to expel the foetus2 the uterus has nothing at all to do with the case--the very name of the condition is extra-uterine pregnancy4 ,if an ectopic gestation #bg goes on to term 7a very rare happening71 there will be false labour and uterine contractions1 and these cease after a time without effect one way or the other2 but in all cases of rupture and the like the uterus is outside the question and the mother is passive4 ,there is no attempt by the mother in extrauterine pregnancy at expulsion either before rupture or at any other time unless the dead foetus putrefies1 and the maternal tissues try to expel it as a foreign body by breaking down into an abscess4 ,the foetus simply grows1 and its bulk bursts the tube4 ,if it were in the uterus1 the uterus would enlarge synchronously with the foetus and there would be no rupture1 but the tube will not give beyond a certain point1 therefore it bursts4 ,in normal uterine pregnancy at term the uterus and other maternal muscles are the active factors in expelling the foetus--the foetus is passive4 ,in ectopic gestation the foetus is active1 the mother is passive1 and there is no attempt at expulsion from either side4 ,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 7it may even move its arms and legs if advanced71 and this rupture tears open arteries wherethrough the mother bleeds1 commonly to death4 ,this is evidently material aggression4 ,father ,aertnys says the foetus differs from the murderous lunatic in this1 that the madman is moved by his will1 although blamelessly1 in doing unjust actions directly intended as homicidal4 ,the fact that the lunatic uses his will has no weight whatever in permitting me to defend my life against him1 it is an accidental thing outside the question2 but ,father ,aertnys in mentioning the madman's will means solely1 if ,i understand him1 that the madman is really an active aggressor4 ,the foetus1 however1 is also an active aggressor without using its will4 ,i might fall from a height toward a man and certainly endanger his life while ,i was not using my will at all1 not conscious of the man's presence under me1 or even while ,i was using all the power of my will against the result4 ,in any of these cases ,i should be a materially unjust aggressor2 and if in trying to prevent my body from killing him the man killed me1 he would be blameless4 #bh ,now1 in the first place1 the tubal foetus is an aggressor2 and since1 secondly1 its position is unnatural1 monstrous1 a disease1 a thing not intended by nature1 it has no right to its position1 and it is therefore a materially unjust aggressor4 ,since it is an aggressor on the very life of the mother in a place where it should not be1 the surgeon therefore may at the least stop the fatal bleeding it causes4 ,if the foetus dies as an unwished for1 though permitted1 consequence of this haemostasis1 the surgeon may lament this result1 but he is blameless4 ,the foetus was blocked in its unnatural position through a defect in the mother1 nevertheless it remains a materially unjust aggressor4 ,if ,i by an accidental blow had made a man insane1 and later this lunatic tried to kill me1 ,i1 or my legitimate protector1 might lawfully kill the lunatic in defence of my life4 ,this is an exact parallel to the case of the mother and the extrauterine foetus4 ,the extrauterine foetus is not like a foetus in a craniotomy case4 ,where there might be question of craniotomy the foetus is not an unjust aggressor even materially1 as has been said3 first1 because it is not an aggressor in any manner1 it is altogether passive2 secondly1 it has a perfectly natural right to be where it is4 ,in ectopic gestation with fatal rupture the foetus is1 first1 an active aggressor2 secondly1 it has no right to be where it is4 ,in craniotomy the foetus is killed as a direct means toward the end that its head may be reduced and extracted and the mother saved2 in extrauterine gestation with fatal rupture the foetus is incidentally killed as a consequence of the haemostasis1 and not as a means in any sense of the term4 ,in craniotomy the child is wantonly killed since there are other means of saving the mother2 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 mother4 ,in ,case ,i41 therefore1 we have an action that has an object partly good and partly1 very probably1 not evil2 the end intended is good2 the circumstances are justifiable or indifferent2 consequently in ,case ,i4 the surgeon may do coeliotomy1 tie the uterine and ovarian arteries1 and if the foetus #bi happens to be alive he may reluctantly and indirectly permit the hastening of its death after attempting to baptise it4 ,case ,,ii4 ,the conditions presented in ,case ,i4 are the ordinary and most common that the surgeon meets with in treating ectopic gestation1 but other conditions may be found4 ,suppose the surgeon1 before operation1 diagnoses a case of ectopic gestation1 but that he can not tell whether or not the foetus is alive4 ,the probability leans toward the side that the foetus is alive1 because there is no indubitable history1 as physicians say1 of maternal symptoms that indicate rupture4 ,medical authorities tell him to do coeliotomy at once1 ligate the uterine and ovarian arteries1 and remove the foetus4 ,would he certainly or probably be justified in following out this medical doctrine8 ,the mother is in actual1 very probable danger of death1 but not in actual1 certain danger of death4 ,she may possibly escape if operation is deferred2 she has a negligible chance of escape if no operation is performed after the death of the foetus2 coeliotomy and ligation of the uterine and ovarian arteries give her by far the surest chance of escape1 so sure an opportunity for escape when performed early that it can scarcely be called a mere chance4 ,if operation is deferred the chances for rupture are about #bb per centum1 say1 one and a half in five chances1 and all ruptures are not necessarily fatal4 ,the chances of the mother's death1 however1 are much higher than that1 because death can come in ectopic pregnancy from causes other than rupture4 ,from #fc4a to #fh4h per centum 7say1 #ff4c per centum7 of ectopic gestations treated by the expectant method result in death to the mother--just two-thirds of the women die4 ,a4 ,martin in a series of #bfe cases of ectopic gestation where the expectant treatment was employed found a maternal mortality of #fc4a per centum2 ,parry in #ejj similar cases found a mortality of #fg4b per centum2 and ,schauta in #bda cases a mortality of #fh4h per centum4 ,in the #hg years between #ahji and #ahif1 #gg cases of coeliotomy for the delivery of viable ectopic foetuses were reported #cj in all medical literature with a maternal mortality of about #eh4c per centum4 ,between #ahji and #ahhh there were #cg coeliotomies with a maternal mortality of #hf4e per centum4 ,between #ahhi and #ahif there were #dj such operations1 with a maternal mortality reduced to #cb4e per centum by modern surgical methods4 ,the results as regards the children were almost the same in the two series1 and perhaps a little better in the latter series4 ,in the first series the #cg children were alive at delivery3 the length of time in which three of these children lived is not given2 three more were alive but they did not breathe2 the others lived from a few seconds to days1 weeks1 months or years4 ,one was well at six months1 another at one year1 another at seven and a half years1 another in its fourteenth year1 another in its fifteenth year4 ,in the second series the results as regards the children were1 as has been said1 almost the same4 ,the #dj cases that were reported from #ahhi to #ahif are the standard for this phase of ectopic gestation1 because they come under the diagnosis and treatment of the present day4 ,they represent closely all such cases that occurred in the entire world between #ahhi and #ahif1 because physicians report these operations to medical societies1 and active physicians are almost without exception members of such societies--outside the civilised world these operations do not take place4 ,in the seven years there were annually less than six cases of coeliotomy for ectopic gestation at term in the world1 therefore operations at term may be neglected in discussing ,case ,,ii41 and the argument may be confined to the ordinary cases of expectant treatment4 ,schrenck in #ahib collected #faj cases of ectopic gestation which had been reported between #ahhg and #ahib2 during the same time there were #bc cases 7less than #d per centum7 of operations for the delivery of viable foetuses4 ,if the physician that has made the diagnosis in this ,case ,,ii4 leaves the patient1 she may have a fatal hemorrhage at any moment4 ,dr4 ,howard ,kelly reports 7,operative ,gynaecology1 vol4 ii4 p4 #dch7 a fatal hemorrhage in two days from rupture where the foetus was only as large as a ,lima bean4 ,the hemorrhage may be so suddenly fatal that the woman drops #ca to the floor unconscious just as if she had been shot4 ,dr4 ,harris 7,international ,cyclop4 of ,surgery1 vol4 vi4 p4 #ghd7 tells of a case where three of the best obstetricians in ,philadelphia met in consultation daily for #af days expectantly watching development1 but the woman died from hemorrhage in thirty minutes before any of these physicians could be called to her aid4 ,death may be brought about by anaemia after repeated hemorrhages4 ,some hemorrhages can be mistaken for colic by the physician1 and this error will defer until too late the treatment for hemorrhage4 ,if the woman is living in a hospital where there is a resident surgeon with instruments ready1 she has a better chance than if she is in her own house4 ,even if she has a surgeon within call the outcome of the case for her will depend largely on his skill1 his presence of mind1 the preparedness of his instruments1 the general condition of the patient1 and many other circumstances4 ,the instruments1 ligatures1 gauzes1 solutions1 dressing1 etc41 for coeliotomy are multitudinous1 and all must be sterile1 or the woman will be killed by septicaemia even if the hemorrhage is stopped4 ,it is almost impossible to keep a set of instruments and the other things used in a coeliotomy always sterile and ready for instant use4 ,the skin surface of the patient's abdomen must be sterilised1 or pus infection will get into the peritoneum through the wound4 ,in all ordinary coeliotomies this surface is carefully sterilised by a long process the night before the operation1 a protective dressing is put on1 and the sterilisation is repeated the next day just before the operation4 ,this is so important that its voluntary omission is malpractice4 ,in the hurried operation for tubal rupture there would be no time for sterilisation of the abdominal skin surface1 and probably no time to sterilise the instruments and other things used1 especially the surgeon's hands4 ,the surgeon to do any coeliotomy needs assistant physicians--one to anaesthetise the patient1 and at the least one other to work with him in the operation4 ,he should have three or four physicians and one or two nurses4 ,he can not do a coeliotomy alone4 ,hence the patient in a ruptured #cb extrauterine pregnancy must have at the very least two physicians within call4 ,the woman1 then1 in ,case ,,ii4 before operation has one chance in three of life if no operation is done until the child is viable1 and if she remains alive till the child is viable 7when she must be operated upon7 her chances for life will be no better1 judging from modern statistics4 ,at any moment1 therefore1 she is in actual peril of death by two chances in three1 and probably more if all special circumstances are considered4 ,the foetus is a materially unjust aggressor in this case before rupture or other similar mishap1 as it was in ,case ,i41 but not to the same extent4 ,in ,case ,,ii4 it is a materially unjust aggressor as two is to three2 in ,case ,i4 it is a materially unjust aggressor as three is to three4 ,if a lunatic is just about to fire three cartridges at me1 ,i may know the chances are only two in three1 or even only one in three1 that he will hit me fatally1 nevertheless ,i may licitly kill him to stop the firing and save my life4 ,the mother in ,case ,,ii4 is in exactly similar danger of life4 ,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 nunc1 is not of any weight4 ,she is in actual danger hic et nunc1 even while the surgeon is in the room examining her4 ,moreover1 the matter of time here is accidental4 ,if you give a man a poison that may kill him in ten hours1 or one that may kill him in ten days1 the action is essentially the same4 ,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 family1 and if immediate operation were insisted upon he should withdraw from the case4 ,nevertheless1 as far as ,i can see1 he has sound probabilism on the side that operation is justifiable4 ,but1 it may be objected1 in ,case ,i4 the surgeon ligated the uterine and ovarian arteries to stop an actual hemorrhage1 and he permitted the death of the foetus2 in ,case ,,ii4 there is no hemorrhage yet1 there may possibly be none at all4 ,i answer #cc that in ,case ,,ii4 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 off1 and to forestall sepsis by leisurely and proper precautions1 and exactly as in the first case he permits the death of the foetus1 he indirectly kills an unjust aggressor4 ,if the lunatic is aiming at me ,i do not have to wait until he begins firing to licitly shoot at him4 ,the sooner ,i shoot1 servato moderamine inculpatae tutelae1 the more prudent my action4 ,to put it in another form--in ,case ,,ii4 the surgeon is standing before a dam 7the stretched ,fallopian tube7 that is threatening to break at any moment and cause death to a woman below it1 because there is a lunatic 7the foetus7 behind it tearing away the masonry4 ,if the surgeon shunts off the water just above the dam 7the ligation of the arteries71 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 killed4 ,may he let the lunatic fall8 ,certainly he may4 ,but perhaps the lunatic will not succeed in tearing away the masonry4 ,he is well provided with tools to do so2 the chances are even two in three that he will succeed4 ,is he or the woman to be given the benefit of the doubt8 ,the woman1 by all means2 she has a doubt worth in juridic value at the least twice as much as that which the lunatic has4 ,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 employed4 ,we have seen that between ,november #ahji and ,november #ahif there were reported #gg cases of operation for the delivery of viable foetuses4 ,eleven of these children survived1 #fg died within a few months1 and many of these died just after delivery4 ,still1 probably all might have been baptised4 ,judging1 however1 from the geographical distribution of the cases 7see ,kelly's ,operative ,gynaecology1 vol4 ii4 p4 #deh7 and the names of the operators1 only about #ad of these children received baptism4 ,now1 since ,schrenck found #faj ectopic gestations reported in five years1 this indicates that the average number of cases of ectopic gestation which occur in the civilised world is at the least #abb a year1 for many more 7twice as many1 at the lowest #cd estimate7 are not diagnosed or not reported when diagnosed4 ,in the #hj years1 then1 between #ahji and #ahif there were at the least #igfj cases of ectopic gestation in the civilised world2 in the uncivilised countries there were certainly as many more with not a child saved1 or even brought out of the pelvic cavity4 ,to be sure1 by rejecting perhaps a third of the cases through bad diagnoses and neglect of reports1 there were #bj1jjj cases2 and in all these hardly #bj children baptised--one in a thousand4 ,modern surgical methods and improved diagnosis will do little to better the condition1 from the nature of the disease4 ,between #ahic and #ahif there were #ba cases of operation for the delivery of viable foetuses reported1 and this list is approximately correct1 because the surgeons that operate on such material are men that as a rule report their work even when it is to their discredit4 ,in these #ba cases1 #f mothers1 #bh per centum died1 #gb per centum recovered4 ,even if modern surgery should save all the mothers who had escaped until the foetus was viable1 and should bring all the children to baptism1 there would not be more than about #g such cases in the world annually4 ,increased skill in diagnosis would raise the number of children brought to baptism1 but it would more than proportionately raise the whole number of ectopic gestations discovered4 ,if #aj foetuses were brought from the pelvic cavity alive in the #acj cases of ectopic gestation of the year1 the chances for an extrauterine foetus to only reach baptism at a viable age 7not to live after baptism7 are only #g in #ajj at a most liberal estimate4 ,statistics are unreliable1 of course1 but ,i am giving odds of two to one4 ,the foetus has a much better chance for baptism if the coeliotomy is done as early in the pregnancy as possible1 but it has a negligible chance of life in any case4 ,since the creation of man there have been less than #ae extrauterine children saved1 and of these #ae four were less than a year old when reported1 and three under five years of age3 the oldest was fifteen years of age1 and all were weaklings4 ,the practical rule1 then1 is that the ectopic foetus will die anyhow1 and operation only indirectly 7mark the word7 accelerates the inevitable death of a materially unjust aggressor1 #ce while it gives the mother the best chance for her life1 which is in very grave peril4 ,case ,,iii4 ,the surgeon before operation diagnoses with the help of consultors extrauterine pregnancy1 but he or they can not tell whether the foetus is alive or not4 ,what should he do8 ,in my opinion he may operate with much more solid probability than that which exists in ,case ,,ii4 ,if the argument is more for the death of the foetus than for its life1 this1 of course1 strengthens the permissibility of the operation4 7#a7 ,the danger to the mother is exactly the same1caeteris paribus1 as in ,case ,,ii42 7#b7 the foetus is only probably alive4 ,an actual danger to life is opposed to the probable life of a materially unjust aggressor2 therefore the surgeon may probably operate at once4 ,probable here is used in the technical sense of the term4 ,case ,,iv4 ,the following case is given because a similar one was proposed in the articles in the ,american ,ecclesiastical ,review1 but it is not a practical case4 ,the surgeon1 after consultation1 does not know whether the growth in a woman's pelvis is a malignant tumour or a sac containing an extrauterine foetus4 ,if the growth is a malignant tumour1 the woman is in actual and certain danger of life1 her death is a mere matter of time if a malignant tumour is not removed1 and the sooner the tumour is removed the better4 ,if operation is deferred1 metastases of the tumour will have occurred1 and operation will be too late4 ,the indication when we find a malignant tumour is1 if it is not already too late to operate1 to take it out at once4 ,if the surgeon thinks that the growth may possibly be a foetus1 and he puts off the operation until a time when certain signs of pregnancy should be present to establish a diagnosis of gestation1 or their lack to establish a diagnosis of tumour1 it would almost surely be too late to operate in the event the growth turned out to be a malignant tumour4 ,as has been said1 the case is not practical1 because malignant tumours of the tube are so very rare that they are not to be looked for1--only one or two have been observed4 #cf ,malignant tumours about the tube should be diagnosed4 ,supposing1 however1 the case to stand1 it offers in favour of operation a probabilism stronger than that in any case except ,case ,i41 because the mother's danger is graver1 and the argument concerning the foetus is the same as that in ,case ,,iii4 ,case ,v4 ,suppose a doubtful case like ,case ,,iii4 or ,case ,,iv41 but after the surgeon has opened the abdomen he finds a foetus evidently alive4 ,this is an improbable but a possible case4 ,case ,v4 then becomes like ,case ,,ii4 with the addition of another grave danger to the lives of both the mother and the foetus1 which is the coeliotomy already performed4 ,the suggestion that the surgeon can leave the woman1 back out of the case1 is absurd4 ,if he closes the abdomen1 the coeliotomy may cause tubal abortion1 the wound might have to be opened again in a few hours or a few days1 and the mother would be left in much greater peril than she was in ,case ,,ii4 ,for the reasons already given1 he should go on with the operation4 ,case ,,vi4 ,suppose a case like ,case ,v4 in every particular except that when the surgeon finds the foetus he can not tell whether it is alive or not4 ,he should1 a fortiori1 finish the operation4 ,case ,,vii4 ,a case of ectopic gestation is diagnosed1 the conditions are explained to the woman1 and she refuses to be operated upon4 ,is she justified8 ,the probability is one to two that she will escape death if she waits1 and much less than one to two if she finally refuses operation4 ,the moralists would tell her she may refuse operation4 ,case ,,viii4 ,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 uterus2 or1 secondly1 that the gonorrhoeal infection has completely shut the tube1 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 side4 ,in either case an ectopic gestation begins4 ,the first case is improbable from a medical point of view1 #cg and the second is barely possible4 ,gonorrhoeal infection of the tubes is common enough1 but when it occurs it usually shuts the tube up permanently4 ,in chronic salpingitis at times the ovarian end of the tube is not wholly closed at once1 and since the body of the ovary is very rarely affected by gonorrhoea1 there is a possibility worth considering of a tubal pregnancy through migration to occur4 ,in such a condition the woman might have been infected with gonorrhoea1 first1 before her marriage through fornication or accident2 second1 after her marriage through adultery or accident2 third1 after the marriage by her husband4 ,if she had been infected through fornication or adultery1 she is accountable for the foreseen consequences of her sin1 and she has put an impediment for which she is responsible before the embryo4 ,suppose the physician knows these facts4 ,then the excuse for indirectly hastening the death of the foetus does not1 at first sight1 seem to exist1 because the foetus is apparently not a materially unjust aggressor4 ,it could easily happen that a surgeon's refusal to operate in a case like this would cause the death of the mother and foetus4 ,should he let both perish8 ,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 egg8 ,it is not a useless embryo the size of a pigeon's egg1 but a human being1 the most important thing on earth1 and a human being shut off from life and baptism as a direct consequence of that woman's brutal sensuality4 ,but the woman may be the mother of other helpless children4 ,what is to be done8 ,let us recur to the example of the homicidal maniac4 ,if ,i accidently by a blow make a man insane and that insane man afterward tries to kill me1 ,i or my protector may permit his death to save my life4 ,if ,i maliciously make a man insane and he afterward tries to kill me1 may ,i or my protector kill him in my defence8 ,some may say that ,i may not because ,i have lost all juridic superiority over the madman as a consequence of my sin against him4 ,that position1 however1 does not seem to be correct4 ,if it is correct1 parity makes the assertion true that the foetus in the case supposed above may not be indirectly #ch killed to save the mother4 ,if it is not true1 the foetus may be indirectly destroyed4 ,does my sin against the insane man give him a right to kill me8 ,by no means4 ,nothing but defence of life or its equivalent gives any private individual the right to kill another4 ,the man might kill me before this aggression of mine1 in defence of his sanity1 but after the fact such a killing would be mere revenge1 or an actus hominis1 not a right4 ,the woman1 we suppose1 has maliciously put the foetus in its position of material aggressor1 but has the foetus the right to kill her8 ,no2 the foetus is an individual not acting in self-defence1 it is merely growing4 ,has the woman or the surgeon1 her protector1 the right to permit the death of the foetus to defend the woman's life8 ,i think they have1 because the foetus here also is1 from its unnatural position1 a materially unjust aggressor4 ,but1 you say1 this is a vicious circle4 ,you justify the permitted death of the foetus in ,case ,i4 because it is a materially unjust aggressor1 and it is a materially unjust aggressor because it is in an unnatural position where it has no right to be2 but in the present case the mother put it in the unnatural position1 and it therefore has a right to be where it is4 ,no3 the consequence does not follow4 ,the fact that the mother put the foetus in its unnatural position does not give the foetus a right to be in that position1 although it constitutes a ground for her punishment by proper authority4 ,you object again1 if this woman has a right to permit the death of the foetus to save her own life1 how may she be punished for that death8 ,she will not be punished for the actual coeliotomy which indirectly caused the death of the foetus1 but she will be punished for the sin of putting that child in a position in which it had to be killed4 ,this seems to be a distinction without a difference4 ,as far as the mother is concerned1 transeat 2 but it is a real distinction as far as the surgeon is concerned4 ,if the woman's condition is a result of accidental infection before or after marriage1 the case goes into the class of those discussed above1 and operation is justifiable4 ,if her infection comes after her marriage adulterously1 her #ci sin is the greater1 but the operation is justifiable for the reasons which were given in the case of culpable infection before marriage4 ,if she had been infected by her husband1 the operation is justifiable--the father is accountable for the foetus's death4 ,fortunately the entire case is so nearly hypothetical that it is little more than mere words4 ,,austin ,,omalley4 #dj ,,ii ,,pelvic ,,tumours ,,in ,,pregnancy ,tumours of the uterus and its adnexa at times1 though rarely1 complicate pregnancy1 and they may involve certain moral questions that have been little discussed4 ,the tumours that cause difficulty are ovarian and uterine4 ,cystic ovarian tumours commonly do not prevent impregnation1 if there has been an absence of inflammation4 ,when these cysts are small they may not disturb pregnancy or delivery2 large cysts can1 however1 become a source of danger4 ,they may sink into the pelvis and block the channel of delivery needed by the child at term2 they may have their pedicles twisted1 and thus become gangrenous and septic4 ,big cysts of the ovary may during the growth of the pregnant uterus press upon the portal vein1 or the diaphragm1 or they may burst or cause sepsis4 ,litzman1 in #ef cases of ovarian tumours complicating pregnancy1 had only #aj normal deliveries2 and ,remy held that #bc per centum of these cases1 when left untouched1 result in death to the mothers4 ,stratz says the mortality is #cb per centum1 and it has gone as high as #dj per centum4 ,some physicians teach that any ovarian cyst found complicating pregnancy should be removed surgically4 ,other authorities hold that they should all be treated expectantly3 if they threaten the life of the mother1 they should be tapped by a trocar through the belly-wall or the vagina1 and removed only after labour4 ,this second operation is safe1 and ,i think it should prevail4 ,such cysts have often been removed during pregnancy4 ,orgler reported #adf ovariotomies 7removal of the ovaries7 performed during gestation with only four maternal deaths--#b4g per centum4 ,if the operation had not been performed #da about #cb per centum of these women would have died4 ,the chance against saving the child in such an operation is the crux4 ,if there is no operation #ag per centum of the cases result in abortion and the loss of the child1 as ,remy found from a consideration of #cba cases4 ,in ,orgler's series of #adf ovariotomies1 where he lost only #b4g per centum of the mothers1 and saved about #cj per centum that would have died 7#ig per centum in all72 he lost #cb children through abortion caused by the ovariotomies1 or #bb4e per centum2 whereas by the expectant method 7without tapping7 only #ag per centum of the children were lost4 ,bovee of ,washington1 however1 reported #ch cases of removal of the ovaries during pregnancy with one maternal death and only four abortions1 or #ab4f per centum4 ,that is considerably less than the loss by the expectant method without tapping4 ,as ,bovee succeeded1 other men now do1 but it would be far better to attempt tapping first4 ,the earlier in the pregnancy either tapping or removal is done the better4 ,fibroid tumours of the uterus1 complicating pregnancy1 occur in about #j4f per centum of pregnancies1 and they usually go on without causing trouble2 but again these tumours may block the pelvic outlet1 they may dangerously press upon abdominal viscera and the diaphragm2 some writers hold they may become inflamed and degenerate with sloughing and gangrene1 and thus bring about sepsis and death to the mother and child4 ,that they become gangrenous must very rarely happen2 the increased blood supply should prevent gangrene1 but cause an increase in the size of the fibroma4 ,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 separated4 ,this operation1 of course1 kills the foetus4 ,at times the child is viable1 and a precedent caesarean section will save it4 ,surgeons do not remove fibromata merely as a precaution1 as they sometimes do in the case of ovarian cysts4 ,other surgeons say it is safe to wait4 ,if the channel of delivery is blocked1 these men wait till term and then do caesarean #db section2 in other cases the tumour will often be lifted up out of the way during the later stages of gestation or labour4 ,in those very rare cases where it is necessary to remove the uterus wholly or in part before the child is viable1 and thereby also to kill the foetus1 the operation at first glance seems in no wise to differ in nature from a craniotomy upon a living child4 ,the condition1 however1 is commonly worse than one in which a craniotomy is indicated1 because in the latter condition we have a viable child1 and the caesarean section to solve the difficulty1 but in the former we have a child not viable1 and therefore the caesarean section would be useless1 except for the opportunity it might give for baptism of the child4 ,in such a case must the surgeon let the mother die lest he hasten the death of a non-viable child8 ,the action reduces to this1 that the surgeon by operating would permit a hastening of the inevitable death of the foetus while saving the mother's life1 but the child is not an unjust aggressor1 not even a materially unjust aggressor4 ,it has a right to be where it is4 ,the only excuse for hastening its death is to save the mother's life1--there is no question of self-defence2 but deliberately to hasten the death of a human being a second of time1 except it be done by an individual in self-defence against an unjust aggressor1 or by the state for legitimate cause1 is murder4 ,it seems probable1 however1 that there is something to be said in favour of the unavoidable hysterectomy 7removal of the womb7 in a pregnancy complicated with uterine fibromata that undoubtedly endanger life4 ,such cases differ from craniotomy1 or the direct killing of a foetus 7which were formally forbidden by the ,holy ,office on ,may #bh1 #ahhd1 and ,august #ai1 #ahhh1 and always forbidden by the natural law7 in several factors3 first1 in craniotomy the child is directly killed1 although it is not an aggressor1 in the hysterectomy it is permitted to die1 it is indirectly killed2 secondly1 in craniotomy there is a viable child1 in the hysterectomy1 an unviable child2 thirdly1 in craniotomy there is a killing that is a means toward the end of saving the mother's life1 in the hysterectomy there is a permitted hastening of the foetus's death1 and this is only a circumstance inseparably joined to the act2 fourthly1 in craniotomy the killing is utterly #dc uncalled for1 because the caesarean section1 or symphyseotomy 7a temporary dividing of the pubic joint to get more room7 will do instead1 in the hysterectomy1 because the child is not viable1 there is no alternate way out of the difficulty2 fifthly1 formal judgment has been pronounced by the ,holy ,office in craniotomy1 no formal judgment has been made as regards this hysterectomy4 ,suppose ,a and ,b are on a boat hoisting a weighty object to a ship2 the tackle breaks1 the falling weight mortally hurts ,b1 and wedges him fast to the wrecked boat4 ,the boat is about to sink and drown both men1 but if ,a tips off the weight1 and with it unavoidably the entangled ,b1 ,a can float to safety4 ,a will indirectly hasten the inevitable death of ,b by throwing off the weight which will drag him down4 ,may ,a do so8 ,very probably he may4 ,two swimmers1 ,a and ,b1 are trying to save ,c1 who dies in the water1 and as he dies he grips ,a and ,b so tightly they can not shake the corpse off4 ,a is weak1 and he will soon sink and drown owing to the weight of the corpse2 ,b also will later go down with ,a and ,c4 ,a1 however1 cuts his clothing loose from the grip of the corpse 7or some one in a boat does so who can do no more7 and ,a is saved2 but thus immediately ,b is drowned1 owing to the fact that the full weight of the corpse is upon him4 ,is ,a1 or the man in the boat1 justified8 ,probably they are4 ,a is the mother1 ,b the foetus1 ,c the diseased uterus1 the man in the boat is the surgeon4 ,the mother has herself cut away from the uterus and the foetus's death is hastened4 ,again1 take an example used by ,father ,ricaby in his ,moral ,philosophy1 p4 #bje 7,london1 #aija74 ,he supposes a visitor to a quarry to be standing on a ledge of rock which a quarryman had occasion to blast1 and the quarry man saw that unless that piece of rock where the visitor stood were blown up instantly1 a catastrophe would happen elsewhere1 which would be the death of many men1 and if there were no time to warn the visitor to clear off who could blame him if he applied the explosive8 ,the means of averting the catastrophe would be1 not that visitor's death1 but the blowing up of the rock4 ,the presence or absence of the visitor1 his death #dd or escape1 is all one to the end intended3 it has no bearing thereon at all4 ,if these examples of indirect killing are allowable1 why may not the surgeon in the rare example presented here remove the uterus and indirectly permit the hastening of the foetus's death8 ,that hastening of death is not an end1 nor a means toward an end1 but a circumstance only reluctantly and indirectly willed4 ,the end is to save the mother's life1 and the means is the removal of a septic or impacted uterus4 ,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 death1 but there is a difference3 in abortion the removal of the foetus is the means whereby the end is attained1 in the hysterectomy the removal of the tumour is the means whereby the end is attained4 ,this argument is advanced only tentatively and with diffidence1 that the matter may be discussed and settled by authority4 ,sometimes carcinoma 7a cancer7 complicates pregnancy--once in #bjjj cases is above the average4 ,a carcinoma is a malignant tumour1 and the malignancy is made much worse by the stimulus of pregnancy with its increased blood supply4 ,the maternal deaths from carcinoma of the uterus during pregnancy is1 according to the latest and most favourable statistics1 #cj per centum4 ,the mortality of the children is from #ej to #fc per centum4 ,now1 first1 if an artificial abortion is induced while the foetus is unviable1 the foetus is lost and the mother's condition is not materially improved4 ,secondly1 if curettement 7a scraping away with a sharp spoonlike instrument71 cauterization1 or amputation of the uterine cervix are performed1 the mother is helped very little1 if at all1 and consequent abortion is frequent4 ,thirdly1 if caesarean section is done at term the child has a good chance 7,sanger saved #af of #ah children thus in one series3 over #hh per centum71 but this operation nearly always kills the mother when cancer is present1 unless the entire uterus can be removed1 and often it can not be removed2 that #de is1 the case is inoperable and removal is useless owing to extension of the cancer into the surrounding tissues4 ,fourthly1 if the mother's condition is hopeless1 a caesarean section gives the child a chance for life1 but the operation will hasten the mother's death in nearly every case4 ,the first and second cases here are not practical4 ,if the surgeon can remove the uterus at term after a caesarean section1 that is the most reasonable operation for the mother and child1 and it offers no moral difficulty4 ,if the mother's condition is so bad that the uterus may not be removed1 the chances are that her death will be hastened by caesarean section1 but if caesarean section is not done1 from #ej to #fc per centum is the ratio against the saving of the child4 ,i do not think a general rule can be given as regards the certainty of hastening the maternal death3 the reckoning is to be made to meet the particular condition4 ,it seems1 however1 probable that in every case of inoperable carcinoma of the uterus complicating pregnancy a caesarean section would hasten the maternal death4 ,she will die anyhow from the cancer1 but in certain cases she may live longer if the section is not done4 ,if1 again1 a carcinoma of the uterus is inoperable at term1 the delivery of the child may be impossible without caesarean section1 from uterine inertia1 or the opposition of the dense inflamed tissues1 or the friability of these tissues4 ,in such a case without the section she would die1 and die probably sooner than with it4 ,the operation would possibly slightly prolong her life1 by1 say1 a few hours or days1 and it certainly would give the child a very good chance for its life4 ,she may1 of course1 die upon the operating table1 but she would die in childbed without the section4 ,the case is different from the ordinary caesarean section done because of a narrow pelvic bony girdle4 ,in the latter condition the chances that the mother will live are very high if the surgeon is competent1 but in the carcinoma case she will die no matter who the surgeon may be1 and very probably1 or almost certainly1 her death will be hastened by the operation in the majority of cases4 ,if the condition is such that the woman can not be delivered #df without the section1 ,i see no difficulty against operation1 because the surgeon can not1 as far as ,i know1 say positively whether he will hasten the maternal death or not1 and in the circumstances he may take advantage of the doubt4 ,if the woman with an inoperable carcinoma uteri may be delivered without section1 should such a delivery be chosen although it raises the chances of mortality as regards the child from about #ab per centum to at the least #ej per centum8 ,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 section1 and1 say1 seven chances in eight with the section4 ,the operation is far preferable as regards the child alone1 but not preferable as regards the mother alone4 ,is it then allowable8 ,in the hysterectomy for fibroma already considered1 the mother is saved and the child's inevitable death is certainly hastened2 in the caesarean section the child is most probably saved1 and the mother's inevitable death is most probably hastened2 we might say1 in some cases1 that her death is undoubtedly hastened4 ,if in the carcinoma case here the child had no chance whatever for delivery except by the caesarean section1 while the mother's death would be probably or certainly hastened1 she might legitimately consent to the operation or she might legitimately refuse the operation4 ,the child1 however1 has1 as we said1 one chance of delivery in two without the section1 while the mother's death will very probably be hastened4 ,if the mother's death would certainly be hastened by the section1 her death1 although it would be a circumstance and indirect1 not an end nor a means1 would not have counterbalanced against it necessarily the saving of the child's life1 because the child has one chance in two in any event4 ,in such an hypothesis the operation seems to be unjustifiable4 ,if1 however1 the hastening of the mother's death is only probable and not certain1 may we oppose that probability to the advantage that must accrue to the child through the section8 ,if the doubt that her death will be hastened is soundly probable1 the woman may consent to the operation4 ,she risks through charity the hastening of her own death for a great #dg advantage to the child1 but she may risk legitimately immediate death in major surgical operations for an advantage less than the saving of life itself4 ,she may have her skull opened for the removal of a depressed bone that is causing paralysis1 she may have her knee-joint opened for the wiring of a patella to prevent lameness1 but both these operations always immediately endanger life4 ,she may go into a burning house1 jump into a river1 and so on1 to save her child from possible injury4 ,,austin ,,omalley4 #dh ,,iii ,,abortion1 ,,miscarriage ,,and ,,premature ,,labour ,if pregnancy ends in the emptying of the uterus before the sixteenth week of gestation1 the condition is called an abortion2 if this happens between the sixteenth and the twenty-eighth weeks1 it is miscarriage2 if the child is born after the twenty-eighth week but before full term1 the birth is premature4 ,the term abortion in the popular mind carries with it the notion of criminal interference1 and the word miscarriage is used for both abortion and miscarriage by the laity2 physicians1 on the other hand1 commonly use the term abortion for both abortion and miscarriage4 ,these conditions may occur spontaneously or they may be induced artificially4 ,spontaneous abortions are very frequent2 perhaps one in every five or six pregnancies is the proportion3 the writer has known a single physician1 not a specialist in obstetrics1 to be called to three in one day and that in private practice4 ,from #aej to #bjj children in every #ajjj that are conceived never get a chance for baptism4 ,in the early months of pregnancy the foetus is usually dead before expulsion takes place4 ,twisting of the cord1 hydramnios1 syphilis1 an acute infectious disease in the mother1 poisonings of the mother by metals and the like substances1 maternal cardiac and renal diseases1 chronic inflammations and displacements of the womb1 and violent emotions are some of the causes of abortion4 ,in certain women a slight exertion1 a misstep1 a fall1 a ride over a rough road1 the debitum conjugale1 and similar causes bring on abortion2 in other women almost no shock is enough to make them miscarry4 ,inflammations and displacements of #di the womb cause most of the abortions in the first four months1 and after that time syphilis and ,bright's disease are the chief forces at work4 ,if a woman in early pregnancy begins to lose blood from the uterus1 and has pain in her back and lower abdomen1 abortion is threatened2 if this hemorrhage is marked1 and the cervix is dilated1 the abortion will very probably occur2 and the escape of the liquor amnii renders the abortion unavoidable4 ,in this latter case the vagina and the cervical canal are packed with sterile gauze to check the hemorrhage1 and after twenty-four hours it is removed4 ,then commonly the entire ovum comes away with the gauze1 or what remains of it is taken out with a curette4 ,valvular lesions of the heart in pregnancy make a maternal mortality of about #bh per centum1 according to ,guerard1 and when compensation is lost the mortality may run from #dh to even #ajj per centum with different physicians and different cases4 ,the prognosis is good as long as compensation is retained1 but very bad if this fails4 ,in the latter condition premature labour is indicated1 or the early removal of the viable child4 ,catholic physicians may not induce artificial abortion of an unviable foetus4 ,the decree of the ,holy ,office concerning this matter is as follows3 ,beatissime ,pater1--,stephanus 4 4 4 ,archiepiscopus ,cameracensis 4 4 4 ,quae sequuntur humiliter exponit3 ,titus medicus1 cum ad praegnantem graviter decumbentem vocabatur1 passim animadvertebat lethalis morbi causam aliam non subesse praeter ipsam praegnationem1 hoc est1 foetus in utero praesentia1 una igitur1 ut matrem a certa atque imminenti morte salvaret1 praesto ipsi erat via1 procurandi scilicet abortum seu foetus et ejectionem4 ,viam hanc consueto ipse inibat1 adhibitis tamen mediis et operationibus1 per se atque immediate non quidem ad id tendentibus1 ut in materno sinu foetum occiderent1 sed solummodo ut vivus1 si fieri posset1 ad lucem ederetur1 quamvis proxime moriturus1 utpote qui immaturus omnino adhuc esset4 ,jamvero lectis quae die #ai ,augusti1 #ahhh1 ,sancta ,sedes ad ,cameracenses ,archiepiscopos rescripsit3 tuto doceri non posse licitam esse quamcumque operationem directe occisivam foetus1 etiam si hoc necessarium foret ad matrem salvandam3 dubiis haeret ,titius circa #ej liceitatem operationum chirurgicarum1 quibus non raro ipse abortum hucusque procurabat1 ut praegnantes graviter aegrotantes salvaret4 ,quare ut conscientiae suae consulat supplex ,titius petit3 utrum enuntiatas operationes in repetitis dictis circumstantiis instaurare tuto possit4 ,feria iv1 die #bd ,julii1 #ahie4 ,in ,congregatione generali ,s4 ,romanae et ,universalis ,inquisitionis 4 4 4 ,emi ac ,rmi ,domini ,cardinales 4 4 4 respondendum decreverunt3 ,negative1 juxta alias decreta1 diei scilicet #bh ,maii1 #ahhd1 et #ai ,augusti1 #ahhh4 4 4 4 ,sanctissimus ,dominus noster 4 4 4 approbavit4 ,other documents referring to the same matter are the following3 ,epistola ad ,archiepiscopum ,cameracensem4 4 4 4 ,anno #ahhf1 ,amplitudinis tuae ,praedecessor dubia nonnulla hinc supremae ,congregationi proposuit circa liceitatem quarumdem operationum chirurgicarum craniotomiae affinium4 ,quibus sedulo perpensis1 ,eminentissimi ac ,reverendissimi ,patres ,cardinales una mecum ,inquisitores ,generales1 feria iv1 die #ad currentis mensis1 respondendum mandaverunt3 ,in scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellant1 sicut declaratum fuit die #bh ,maii1 #ahhd1 et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis4 ,idque notum facio ,amplitudini tuae1 ut significes professoribus facultatis medicae ,universitatis catholicae ,insulensis4 4 4 4 ,romae1 die #ai ,augusti1 #ahhi4 4 4 4 ,r4 ,,card4 ,,monaco4 ,the date of this response here is #ahhi1 but in the preceding decree it is given as #ahhh4 ,in the ,acta ,sanctae ,sedis the date is #ahhi4 ,another letter from ,cardinal ,monaco is this3 ,eme et ,rme ,dne1--,emi ,,pp4 mecum ,inquisitores generales in ,congregatione habita feria iv1 die #bh labentis ,maii1 ad examen revocarunt dubium ab ,eminentia tua propositum--,an tuto doceri possit in scholis catholicis licitam esse operationem chirurgicam1 quam ,craniotomiam appellant1 quando scilicet1 ea omissa1 mater et infans perituri sint1 ea e contra admissa1 salvanda sit mater1 infante pereunte8 #ea --,ac omnibus diu et mature perpensis1 habita quoque ratione eorum quae hac in re a peritis catholicis viris conscripta ac ab ,eminentia tua hinc ,congregationi transmissa sunt1 respondendum esse duxerunt3 ,tuto doceri non posse4 ,quam responsionem cum ,s,smus ,d4 ,n4 in audientia ejusdem feriae ac diei plene confirmaverit1 ,eminentiae tuae communico4 4 4 4 ,r4 ,,card4 ,,monaco4 ,romae1 #ca ,mail1 #ahhd4 ,emo ,archiepiscopo ,lugdunensi4 ,another decree concerning abortion is in part as follows3 ,beatissime ,pater1--,episcopus ,sinaloen4 ad pedes ,s4,v4 provolutus1 humiliter petit resolutionem insequentium dubiorum3 ,i4 ,eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore8 ,,ii4 ,et si mulieris arctitudo talis sit1 ut neque partus praematurus possibilis censeatur1 licibitne abortum provocare aut caesaream suo tempore perficere operationem8 4 4 4 ,feria iv1 die #d ,mail1 #ahih4 ,in ,congregatione habita1 etc4 4 4 4 ,,ee4 ac ,,rr4 ,patres rescribendum censuerunt3 ,ad ,i4 ,partus accelerationem per se illicitam non esse1 dummodo perficiatur justis de causis et eo tempore ac modis1 quibus ex ordinariis contingentibus matris et foetus vitae consulatur4 ,ad ,,ii4 ,quoad primam partem1 negative1 juxta decretum ,feria iv1 #bd ,julii1 #ahie1 de abortus illiceitate4 ,ad secundum vero quod spectat2 nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur4 4 4 4 ,in sequenti ,feria vi1 die #f ejusdem mensis et anni 4 4 4 ,s,smus responsiones ,,ee4 ac ,,rr4 ,patrum approbavit4 ,pyelonephritis 7an inflammation of the kidney where pus is present71 from the pressure of the pregnant uterus1 is a condition which sometimes obliges the physician to bring about premature labour to save the mother4 ,the symptoms usually appear in the latter half of gestation4 ,chorea 7,st4 ,vitus' ,dance71 when it develops during pregnancy1 has a maternal mortality of from #ag to #bb per centum4 ,it may cause death before the child is viable1 and to empty #eb the uterus will stop the symptoms4 ,here the decrees of the ,holy ,office will occasionally prevent the ,catholic physician from interfering4 ,if a grave surgical operation is imperatively indicated during pregnancy1 and may not be put off until after delivery1 it should be undertaken in many cases1 because modern technique commonly does not bring about an abortion2 but1 in general1 no rule can be given--each case must be judged separately4 ,if a pregnant woman has at the same time considerable albumen in her urine and a low excretion of urea1 her condition is very dangerous4 ,to empty her uterus will1 in most cases1 relieve the renal trouble1 but in any case premature labour is not to be induced rashly3 many women escape1 when by all the rules they should die4 ,eclampsia is a very grave complication of pregnancy1 and it was formerly supposed to be uraemia4 ,the disease is characterized by convulsions1 loss of consciousness1 and coma4 ,it occurs1 commonly1 in the second half of gestation1 but it has been observed as early as the third month4 ,about #gj to #hj per centum of the cases are in primiparous women4 ,the convulsions may come on altogether unexpectedly1 but commonly the attack begins with symptoms of toxaemia4 ,eclampsia may occur before1 during1 or after parturition4 ,when it comes before term it usually ends in spontaneous or artificial abortion1 but at times the woman dies undelivered4 ,now and then she may recover and be delivered at term4 ,the kidneys are usually affected1 even in those cases in which albuminous urine is not found4 ,there is also a hemorrhagic inflammation of the liver2 and oedema and congestion of the brain1 with or without apoplexy1 are other symptoms of the disease4 ,there are other lesions1 but the chief are in the kidneys1 liver1 and brain4 ,the aetiology of the disease is not yet known1 and there are very many theories offered to explain it4 ,the prognosis is always serious1 and the condition is one of the most dangerous found in pregnancy4 ,the mortality varies1 but it is about from #bj to #be per centum in the women1 and from #cc to #ej per centum in the children4 ,it is impossible to determine #ec the prognosis in particular cases1 but a large number of quickly recurring convulsive seizures1 with a weak1 thready pulse1 and a high temperature usually indicate a fatal ending4 ,apoplexy1 oedema of the lungs1 and paralysis also1 as a rule1 end in death4 ,if the uterus is emptied during the convulsions1 these cease either immediately or soon after delivery1 in from #ff to #ic per centum of the cases1 and the maternal mortality then is about #aa per centum4 ,with the expectant treatment1 in convulsive cases1 about #bh per centum of the women die1 although a use of aconite in these cases may better the prognosis4 ,pernicious vomiting 7hyperemesis gravidarum7 is another complication of pregnancy1 which sometimes results fatally if the uterus is not emptied4 ,there are cases1 especially those with high fever1 which end in death despite all treatment4 ,here1 again1 the aetiology of the disease is not known4 ,there is commonly an element of hysteria in the condition1 and in such a case moral suggestion often has a curative effect ,any bodily irritation is to be removed4 ,eye-strain alone is enough to cause persistent vomiting4 ,it is very difficult to decide when premature labour is absolutely indicated1 because some very bad cases recover spontaneously when all hope is lost4 ,hydramnios1 or an excessive quantity of liquor amnii1 may so distend the uterus as to cause grave danger to maternal life1 and if the child is viable the uterus should be emptied4 ,intrauterine hemorrhage brought on by a premature separation of the placenta is a very dangerous condition3 #cb to #ej per centum of the mothers die1 and #he to #id per centum of the children4 ,in a marked hemorrhage the only way to save the mother is to empty the uterus1 so that it may contract and thus close the patulous vessels4 ,placenta praevia is a placenta implanted in the neighbourhood of the internal os of the uterine neck4 ,this is a very perilous condition1 calling for the induction of premature labour4 ,the medical treatment is artificial abortion as soon as the condition is diagnosed in any stage of gestation2 but this is1 of course1 in conflict with the decrees of the ,holy ,office4 ,under expectant treatment about #dj per centum of #ed the mothers die1 and #ff per centum of the children4 ,those children that are born alive commonly die within ten days after delivery4 ,the great foetal mortality is due to premature birth and asphyxiation4 ,skilful obstetricians get much better results1 but skilful obstetricians are unfortunately rare4 ,when the grave complications enumerated above occur in the early months of pregnancy1 before the foetus is viable1 the ,catholic physician1 since by the natural law and the decisions of the ,holy ,office he is forbidden to induce artificial abortion1 must withdraw from the case4 ,if there is no other physician to attend to the woman1 he must let her die4 ,he can not withdraw without explanation1 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 abortion1 no matter how reputable he may be4 ,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 anything4 ,this is looked upon as legitimate abortion by the very best men that do not recognise the authority of the ,holy ,office3 they deem the position of the ,catholic physician in these cases as altogether erroneous1 or even criminal4 ,the position of the ,catholic moralists on craniotomy has turned the attention of many non-,catholic physicians to the immorality of the act1 which formerly was deemed entirely permissible4 ,probably the same good result will be effected in the matter of abortion4 ,,austin ,,omalley4 #ee ,,the ,,caesarean ,,section ,,and ,,craniotomy ,in the caesarean section the infant is delivered through an incision in the abdominal or uterine walls4 ,the operation1 according to one opinion1 takes its name from ,caius ,julius ,caesar1 who1 it is said1 was brought into the world in this manner1 a caeso matris utero2 this1 however1 is a myth4 ,up to #ahgf the maternal mortality from the operation was about #eb per centum4 ,between #aghg and #ahgf in the city of ,paris there was not one successful caesarean section as far as the mothers were concerned4 ,at present on an average less than #aj per centum of the women are lost1 and expert surgeons have better results4 ,up to about #aijb ,zweifel had made #gf such sections with only one death1 and ,reynolds1 #bc with no death4 ,leopold has performed the operation four times on the same woman1 and ,ahlfeld and ,birnbaum have reported instances where the same woman has had five caesarean sections performed upon her4 ,the operation is1 of course1 capital1 and always most serious1 even in city hospitals4 ,the indication for the operation is chiefly a narrow pelvis1 which blocks the delivery of the child4 ,there are no reliable statistics as to the frequency of narrow pelves in the ,united ,states2 but ,dr4 ,williams1 of the ,johns ,hopkins ,university ,hospital1 in a series of #bacc cases found #f4i per centum in white women and #ah4hb in negroes4 ,normally the average female pelvis1 at its narrowest diameter1 is #aa centimetres wide4 ,this part is called the conjugata vera1 and it is the diameter from the promontory of the sacrum behind to a point on the inner surface of the symphysis pubis in front4 ,in delivery much depends upon the size of the child1 and in each case the obstetrician waits until he sees that delivery #ef is impossible by natural means before he resorts to the caesarean section or other operative interference4 ,of two women with pelves of the same contraction one may require the section and the other may have a normal labour4 ,a bisischial diameter at the outlet of the parturient canal of #g centimetres or less is an indication for section2 so are certain tumours that block the delivery of the child4 ,when the conjugata vera is less than #g centimetres in flat pelves1 or #g4e centimetres in generally contracted pelves1 the treatment varies in the customary medical practice according as the child is alive or dead1 and it varies as the condition of the mother4 ,the common medical doctrine will first be given here before the moral questions that may be involved are mentioned4 ,if the deformity is diagnosed during pregnancy1 the woman is sent to a hospital1 the caesarean section is performed1 and thus all the children1 and nearly all the mothers1 are saved4 ,when the narrowness of the pelvis is discovered only during labour1 the treatment varies with the condition4 ,if the woman is not septic1 and has not been repeatedly examined by the vagina1 and if the surroundings are favourable1 caesarean section is done2 if she is septic1 the indications are for the section1 or symphyseotomy or craniotomy4 ,where the conjugata vera is below #e centimetres in length1 the caesarean section is the only method to get the child out1 dead or alive1 and after the child has been delivered1 the uterus1 if septic1 is removed4 ,if the conjugata vera is at the least #g centimetres long1 symphyseotomy may be done2 if the conjugata vera is above #e centimetres1 the mother septic1 and the child dead or dying1 craniotomy is indicated4 ,even if the child is not dying1 some obstetricians will do craniotomy4 ,in cases where the conjugata vera is above #g centimetres in flat pelves and #g4e centimetres in generally contracted pelves1 the treatment can not be reduced to general rules4 ,delivery without operation occurs in many of these cases1 but commonly the condition is obscure to the physician for some time4 ,we can measure the pelves1 but the size of the child's head is not satisfactorily measurable4 ,if the conjugata vera is from #aj to #i centimetres1 or from #eg #i4e to #h4e centimetres1 labour without operation is the rule1 and the child can usually be delivered by forceps4 ,should the child die during labour in these cases1 it is best delivered by craniotomy1 unless the longer diameter of its head has already passed the narrowest part of the pelvis4 ,when the conjugata vera is from #h4i to #g4e centimetres1 about #ej per centum of the women will be delivered with forceps1 but the other half will not4 ,after about two hours of the second stage of labour delivery by forceps is tried1 but prolonged traction is not applied4 ,occasionally delivery will come when least expected1 but often it will not4 ,if the head sticks1 caesarean section is done in favourable circumstances1 and craniotomy in unfavourable circumstances4 ,if there is ground for supposing that septic infection of the mother has begun1 the conditions are explained1 and if she wishes to have the caesarean section done the risk is left to her4 ,when the breech or face of the child presents in contracted pelves1 the condition is especially unfavourable for the child4 ,there are very many varieties of deformed pelves1 but the same rules apply to them as to those already mentioned1 except that the caesarean section is oftener indicated4 ,difficulty also not seldom occurs in women with normal pelves from an excessive size in the child through prolonged pregnancy1 bigness of one or both parents1 or the advanced age or multiparity of the mother4 ,the child's head alone may be of excessive size4 ,some monsters offer difficulty in delivery from size or shape1 but1 of course1 they are human beings1 and are to be considered as such in delivery4 ,the technique of the caesarean section has only a medical signification1 and it need not be described here4 ,symphyseotomy is an operation in which the joint of the pelvis at the symphysis pubis is cut1 and the pelvis is allowed to gape so as to let out the child4 ,the operation has fallen into disrepute4 ,the mortality as regards the mother is about the same as in the caesarean section1 but the mortality of the children is higher4 ,in symphyseotomy the infantile mortality is about #i per centum1 while in the caesarean section it is practically nothing4 ,if in symphyseotomy an error is made in estimating the size of the pelvis or the child's head--and #eh such an error is often possible--the child will be killed1 but in the caesarean section these errors make no difference4 ,after the caesarean section the woman recovers promptly2 after the symphyseotomy she recovers very slowly1 and she may receive permanent injury4 ,craniotomy is an operation wherein the head of the child is reduced in size to render delivery possible4 ,the skull is perforated and the brain is broken up and removed or crushed out4 ,embryotomy is a similar operation wherein the viscera of the child are removed through an incision made in its thorax or belly 7evisceration71 or the head of the child is cut off 7decapitation74 ,there are numerous instruments and methods for performing craniotomy and embryotomy1 but they all open the skull or belly1 remove the brain or viscera1 and then extract the child's body4 ,if the infant is hydrocephalic and is alive1 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 well1 so as to be sure the child will not be born alive4 ,pernice has recently reported a case of hydrocephalus which was delivered by craniotomy1 but the operator did not work his perforator efficiently1 and the child recovered1 and grew up an idiot4 ,a similar case occurred in ,baltimore4 ,the indications for craniotomy among those that advocate its occasional use 7and they are many7 is in those cases in which the woman is so infected that caesarean section is dangerous1 or where a child is hydrocephalic1 or where an after-coming head is jammed 7in this case even a caesarean section will not effect delivery71 or in the case of a narrow pelvis and a moribund child1 or finally in the practice of a country physician1 who can not in an emergency get an assistant to do a caesarean section4 ,one man can do craniotomy1 but it requires three to perform the caesarean section4 ,if the woman's narrow pelvis has a conjugata vera of five or more centimetres1 craniotomy1 if properly done1 is not dangerous to the mother4 ,with a conjugata vera less than #e centimetres it is more fatal than the caesarean section4 ,if the women are septic1 the mortality in #ei craniotomy is from #aj to #ae per centum2 in caesarean section about #be per centum4 ,as to the morality of craniotomy on the living or moribund child1 it is not permissible under any possible circumstances3 a consideration of the ethical principles set forth in the article on ,ectopic ,gestation will make this assertion clear4 ,the ,congregation of the ,holy ,office on ,august #ai1 #ahhh1 decreed that ,in scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam ,craniotomiam appellunt4 ,they gave a similar decision ,may #bh1 #ahhd1 and they repeated the prohibition1 with the papal approbation1 on ,july #bd1 #ahie4 ,the text of these decrees may be found in the article on abortion1 miscarriage1 and premature labour4 ,the ,porro operation consists essentially in a removal of the uterus after caesarean section to prevent further conceptions4 ,as a means to prevent conception it is altogether unjustifiable1 because repeated caesarean sections in the same woman1 if the surgeon is at all competent1 are practically no more dangerous than normal labour4 ,,austin ,,omalley4 #fj ,v ,,maternal ,,impressions ,there is a wide-spread persuasion that a child1 while carried in the womb of its mother1 may be marked as the result of incidents that produce violent impressions upon her nervous system4 ,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 it4 ,as a matter of fact1 however1 there is something mysterious about the way in which certain things that happen to the mother seem to affect the child in utero4 ,as the result of the common belief in the truth of maternal impressions1 mothers sometimes are prone to blame themselves for not having been sufficiently circumspect during the time of their pregnancy1 and accordingly they may seek advice and consolation in the matter from clergymen4 ,women sometimes become very much depressed as a consequence of an unfortunate event of this kind1 and as the simple truth is the best possible source of consolation1 it would seem that a special chapter should be given to the subject in a work of this kind4 ,the evidence for the truth of the theory of maternal impression is almost entirely due to peculiar coincidences4 ,james ,i4 of ,england1 the son of ,mary ,queen of ,scots1 could never stand1 according to ,sir ,walter ,scott1 the sight of a drawn sword with equanimity1 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 courtiers4 ,this peculiarity was attributed to the fact that his mother1 while carrying him in utero1 had witnessed the violent death of her secretary1 the unfortunate ,david ,rizzio4 ,there have been1 however1 any #fa number of men who paled at the sight of a drawn sword before and since ,james ,i41 with regard to whom no such circumstantial story could be told to account for it4 ,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 secretary1 and yet their offspring1 though at the time in utero1 have not been disturbed at the sight of drawn swords1 nor of blood or any other circumstance connected with the deep impression that must have been produced on their mothers4 ,there is1 of course1 a striking instance related in the ,old ,testament1 which seems to make it very clear that a belief in maternal impressions existed from the very earliest times among the ,israelites4 ,the story of ,jacob is well known3 ,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 rods1 and he set the rods which he had pilled before the flocks in the watering troughs when the flocks came to drink1 and the flocks conceived before the rods and brought forth cattle1 ring-streaked1 speckled and spotted4 ,in this case it seems evident that ,jacob was not looking for a miracle1 but was expecting that a law of nature would be fulfilled in the matter1 the influence of the unusual sight upon the animal mothers proving sufficient to have a definite effect upon their unborn offspring4 ,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 unborn1 otherwise there would surely be a very absurd collection of anomalous births in the race4 ,on the other hand1 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 degree4 ,the story is told of a child-murderer who delighted in fiendish deeds of cruelty and had murdered many people in cold blood1 that his mother1 the wife of a butcher1 had delighted in watching the operation of slaughtering during the course of her pregnancy4 ,there are any number of women1 however1 who have1 by the necessities #fb of their occupation1 had to witness the shedding of animal blood under such circumstances and yet without any special effect being noticeable in their offspring4 ,it has been said that the opposite is also true1 and that if a woman occupies herself with high and lofty thoughts1 with noble deeds and unselfish devotion to others and if she occupies her mind and senses with the great works of art1 a correspondingly beneficial effect will be noted upon the character of the foetus4 ,these are1 however1 abstruse speculations leading to conclusions not founded upon actual observation1 but upon theorising over the supposed fitness of things4 ,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 told4 ,most women are a little afraid1 as the time of their labour approaches1 lest something or other--usually of an indefinite nature--that has happened during their pregnancy1 may cause the marking of their child4 ,when they find that the child is perfectly normal1 they breathe a sigh of relief and forget all about it4 ,if any anomaly is noted1 however1 then they are sure to connect it with some incident during pregnancy1 and imagination is apt to lend details that confirm the supposed connection4 ,on the other hand1 there are not a few cases in which such anomalies have occurred1 and good1 sensible mothers have been unable to recall anything that might possibly serve to account for the peculiarity noticed in the child1 though corresponding peculiarities in other children were supposed to be readily traceable to maternal impression4 ,even where there has been no foreboding of evil results1 something or other that has occurred during the pregnancy will often be magnified enough by memory to account for the supposed maternal impression4 ,doctors are very familiar with this tendency to make up stories to account for various deformities4 ,it used to be considered that hip-joint disease and ,pott's disease were the result of injuries in early life4 ,they are now known to be due to tuberculous processes not necessarily and indeed only very seldom connected with injuries of any kind4 ,mothers are #fc nearly always able to account in some way1 however1 for the beginnings of the disease in some accident that has happened4 ,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 joints4 ,it is just this state of affairs that occurs with regard to supposed maternal impression4 ,some incident that would be otherwise unthought of is magnified into an accident that caused a serious nervous shock1 and consequently led to the marking of the child4 ,in general it may be said for the clergyman's direction1 that if women have1 as is sometimes the case1 a morbid sense of their guiltiness with regard to some maternal impression that has set a mark upon their child1 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 impressions4 ,scepticism is much more the rule than it used to be1 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 reported4 ,fifty years ago nearly all the authorities on this subject were agreed in considering that maternal impressions did play some part1 though they could not explain just how1 in the production of certain deformities4 ,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 produced4 ,the lack of any direct nervous or blood connection between mother and child is the basis for such disbelief1 and is of itself the best argument against the old tradition4 ,with regard to mental defects1 as a rule1 not so much is said as for bodily defects4 ,bodily deformities are noted at once after birth1 and then the mother recalls some incident of the pregnancy to account for them4 ,mental defects are1 however1 noticed much later1 and are not so likely to be considered as connected with incidents of the puerperal period4 ,there is no doubt that if the mother has had to pass through a series of emotional strains1 or has suffered from severe #fd shocks1 children are likely to be born with diminished mental capacity4 ,this is1 however1 not difficult to understand1 since such incidents produce disturbances of the nervous system of the mother1 and consequently also of her nutrition1 and this is prone to be reflected in the child's condition1 especially in that most delicate part of the child's organism1 the brain4 ,hence it is that children born during the siege of ,paris1 or shortly after1 were defective to such a marked degree that they were spoken of as children of the siege1 and this was considered to be quite sufficient explanation of nervous peculiarities later in life4 ,baron ,larrey1 the distinguished ,french surgeon1 made a report with regard to the children born after the siege of ,landau in #agic4 ,of #ib children1 #af died at birth1 #cc died within ten months1 #h showed marked signs of mental defects1 most of them to the extent of idiocy1 and two were born with several broken bones4 ,in this case1 however1 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 relatives1 there were added many privations and physical sufferings4 ,the nutrition of the mothers was seriously disturbed by these1 and it might well be expected that the children should suffer severely4 ,the statistics of such events are not available in general1 and when an effort is made to establish a cause for idiocy under other circumstances1 none is usually found4 ,out of nearly five hundred cases of idiots whose histories were carefully traced in ,scotland1 in only six was there any question of maternal impressions having been the cause of the condition4 ,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 womb4 ,that they are not more than coincidences1 however1 is rather easy to demonstrate in most cases1 since1 as a matter of fact1 at the time when the incident occurred which is supposed to have caused the deformity in the foetus1 the stage of development of the intrauterine child has passed long beyond the period when formative defects could occur4 ,for instance1 it sometimes happens that the child-bearing woman #fe sees an accident especially to the father of the child involving the loss of a limb4 ,if1 by chance the child should be born with a missing member1 as sometimes happens1 then there would seem almost to be no doubt of a direct connection between the accident witnessed1 the effect produced upon the mother's mind1 and the consequent deformity4 ,we know now that the formation of the limbs of the foetus is complete by the end of the third month4 ,at this time the woman is scarcely more than conscious of the fact that she is pregnant1 and it is not during this early period1 as a rule1 but during a much later period1 that maternal impressions are supposed to have their influence4 ,it is only such maternal impressions as occur very early in pregnancy1 before the tenth week as a rule1 that could possibly have any effect in the production of such deformities4 ,it is by no means infrequent1 however1 to have children born lacking one or both limbs4 ,sometimes nothing but the stumps of limbs remain4 ,in such cases it is now well known that intrauterine amputation has taken place4 ,some of the membranes that surround the child1 especially the amnion1 become separated into bands which surround tightly the growing members of the foetus and by shutting off the blood supply through constant pressure1 lead to the dropping off of all that portion of the member lying below the band4 ,not infrequently it happens that when a child is born thus deformed1 the mother1 by carefully searching her memory1 can find some dreadful story that she has read1 some accident that she has seen or heard of1 and that has produced a seriously depressing effect upon her at the time1 to which she now attributes the deformity that has occurred4 ,until the unfortunate appearance of her child was reported to her1 she had no idea of any possible connection between the story and the bodily state of her intrauterine child4 ,in not a few cases1 however1 the most faithful searching of the memory fails to show anything which could1 by any possible connection1 be made accountable for the deformity2 and these cases1 we may say at once1 are in a majority4 ,not a little of a popular notion with regard to the influence of maternal impression is due to the repetition of certain #ff village gossip which by no means loses its point or effectiveness passing from mouth to mouth4 ,on the other hand1 maternal impressions have been exploited by novelists1 who have found that the morbid curiosity of women particularly with regard to this subject may make their stories more widely read4 ,lucas ,malet1 who1 in spite of the apparently masculine pseudonym1 is really the late ,rev4 ,charles ,kingsley's daughter1 has recently called renewed attention to this subject by her novel ,sir ,richard ,calmady4 ,in this the hero is born with both his lower limbs missing from just below the knees4 ,the author has been careful1 however1 with regard to the details of the supposed maternal impression to which this deformity is attributed4 ,a young married woman in the early part of her first pregnancy has her husband1 whom she loves very dearly1 brought back to her with both his limbs taken off by a shocking accident which resulted fatally4 ,it is not impossible1 some physicians might think1 to consider that so severe a shock could produce a very deleterious effect upon the foetus4 ,that the result should so exactly copy the scene which was brought under the eyes of the young mother is1 however1 beyond credence4 ,occasionally such stories1 supposedly on medical authority1 find their way into the newspapers1 usually from distant parts of the country4 ,certain parts of ,texas particularly seem to be a fruitful source of such stories for newspaper correspondents when there is a dearth of other news4 ,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 wives1 with the result that the shock to their wives proves the occasion of a similar deformity in an as yet unborn child4 ,careful investigation of such cases1 however1 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 deformity4 ,the greatest difficulty in the mind of the medical man1 with regard to the possibility of maternal impression being communicated in any way to the foetus1 is1 as we have said1 his knowledge of the anatomy of mother and foetus4 ,while it is #fg generally supposed that the mother is very intimately connected with her child in utero1 the actual connection is by no means so direct as might be expected from the popular impression4 ,it is usually considered that the mother's blood flows in the child's veins2 but this is absolutely false4 ,the child's blood is formed independently of the mother's blood quite as is that of the chick in the egg4 ,at all times the blood of the child remains quite different in constitution to that of its mother4 ,it contains many more red cells than does her blood and differs in other very easily recognisable ways4 ,mother and child are connected by means of an organ known as the placenta1 which is attached very closely to the uterine wall and from which through the cord the blood of the foetus circulates4 ,this placenta constitutes the so-called afterbirth4 ,the mother's blood flows in one portion of it1 that of the child in another1 and they always remain distinct and separate from each other4 ,the gases necessary for the child's life diffuse through the membrane which separates the two different bloods1 and the salts and soluble proteids necessary for the child's nutrition1 as well as the water necessary for its vital processes1 all pass through this membrane1 but at no time is there any direct blood connection between mother and child4 ,indeed1 for a large part of the formative period of the foetus life1 that is1 during the first two months of its existence1 the ovum is not very closely attached to the uterus at all1 but grows by means of the vital power which it has within itself4 ,nor is there any direct nervous connection between mother and child2 indeed1 there are no nerves at all in the placenta1 and none in the cord through which all communications between mother and child must pass4 ,it seems impossible to explain1 then1 how maternal impressions can so effectively pass from mother to child2 and indeed1 the whole subject1 when looked at in this way1 is apt to be considered legendary1 and the facts adduced in support of the theory of maternal impressions are practically sure to be thought mere coincidences4 ,a little knowledge here might seem to justify many things that more complete knowledge fails to be able to find any reasons for4 #fh ,there is no doubt1 however1 that the mother's environment during pregnancy is in general very important for the perfect development of the intrauterine child4 ,many more deformed births are reported after times of stress and trial1 as1 for example1 after the sieges of great cities1 notably the siege of ,paris in #ahga1 and such scenes of desolation as occurred during the thirty years' war in ,germany4 ,these are1 however1 not direct1 but indirect effects of maternal impressions4 ,the development of the human being in utero is an extremely complicated process4 ,any disturbance of it1 however slight1 is sure to be followed by serious consequences4 ,disturbances of nutrition1 such as are consequent upon the deprivation that has to be endured in times of war or during sieges1 is of itself sufficient seriously to disturb even the uterine life of the child4 ,in these cases1 however1 there will be no traceable connection between the form of the maternal impression and the type of deformity that occurs4 ,this is1 however1 the essence of the old theory of the direct effect of maternal impressions1 and consequently that theory must fall to the ground4 ,from all that has been said1 however1 it becomes very clear that as far as possible women should be shielded from the effect of various nervous shocks during their pregnancy1 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 themselves4 ,,james ,j4 ,,walsh4 #fi ,,vi ,,human ,,terata ,,and ,,the ,,sacraments ,teratology 7,greek text1 a monster7 is a part of biology that treats of deviation from a normal development in man and the lower animals4 ,the name was adopted in #ahbb by the elder ,saint-,hilaire1 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 authors4 ,cicero 7,de ,divinatione7 derives the term monster from the proper preternatural signification looked for in the occurrence of these abnormal beings3 ,monstra1 ostenta1 portenta1 prodigia appellantur1 quoniam monstrant1 ostendunt1 portendunt et predicunt4 ,at the end of the seventeenth century ,malpighi and ,grew discovered that plant tissue is entirely made up of microscopic spaces enclosing fluid2 they called these spaces cells4 ,different investigators found that animal tissue is also composed of cells2 and between #ahce and #ahci ,schwann and ,schleiden formulated the law that every metazoic organism is made of cells1 and starts from a cell4 ,in #afgb de ,graaf discovered the mammalian ovum1 in #afge ,ludwig ,ham found spermatozoa1 in #ahbg von ,baer recognised the human ovum1 but not until #ahge was the important fact established that fertilisation is effected by the fusion of the male and female pronuclei4 ,this was demonstrated by ,oscar ,hertwig from observation of the ova of starfishes4 ,mammalian ova1 owing to an almost complete lack of yolk1 are all small4 ,the egg of a whale is about the size of a fern-seed1 but the yolked eggs of birds are large--that of the great auk was #g4e inches long4 ,in man the ovum is from #j4ah to #j4b mm4 in diameter1 scarcely visible to the #gj naked eye1 and the spermatozoon is extremely minute4 ,the human spermatozoon is only fifty-four thousandths of a millimetre in length1 and from forty-one to fifty-three thousandths of a millimetre are taken up by its flagellum4 ,the essential part is from four to six thousandths of a millimetre in length 7,dr4 ,l4 ,n4 ,boston1 ,journ1 of ,applied ,microscopy1 vol4 iv4 p4 #acfj74 ,a line of #ah human spermatozoa would reach only across the head of an ordinary pin4 ,these spermatozoa have the power of locomotion in alkaline fluid4 ,henle found they can travel one centimetre in three minutes4 ,the human ovum and spermatozoon are single cells1 and the principal parts of a typical cell are the cytoplasm 7called also the protoplasm71 and1 within this1 the nucleus and centrosome4 ,the centrosome is efficient in the process of cell-division4 ,a few cells have also an outer envelope or membrane1 and this part is well developed in the ovum4 ,the nucleus is the centre of activity in a cell4 ,in the resting state it is surrounded by a membrane1 and within the membrane is an intra-nuclear network made up of chromatin and linin--the chromatin is an important element4 ,the meshes of this network are probably filled with fluid4 ,during the stages preparatory to the mitotic1 or indirect1 division of a cell into two cells 7one of the methods of reproduction7 the chromatin segregates in typical cases into two groups of loops1 and each group has equal portions of the chromatin4 ,when the chromatin is in this shape1 a loop is called a chromosome4 ,the chromosomes are very important4 ,they occur in constant definite numbers in the somatic cells of the various species of many animals and plants1 and it is probable that each species of plant and animal has its own characteristic number of chromosomes4 ,wilson 7,the ,cell in ,development and ,inheritance1 ,new ,york1 #ahij7 gives a list of #gb species in which the number has been determined4 ,man has probably #af chromosomes in the somatic cell1 and the mature male and female germ cells in man contribute eight chromosomes each to the nucleus of the impregnated ovum4 ,the chromosomes transmit the physical bases of heredity from one generation to the next1 and the heritages from the two parents are equal except in cases of prepotency4 ,every cell #ga in the human body is derived from the father and the mother equally4 ,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 it4 ,after its birth she feeds it from her breasts1 before birth through its umbilical vessels1 but she originally gives only the eight chromosomes as the father does1 and the child's vital principle builds up the body from this foundation4 ,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 suckling2 both processes are merely different methods of feeding4 ,all the chromosomes from the fathers of at least #bjj men could fit simultaneously on the head of one pin1 yet virtually1 not merely potentially1 half the bodily substance of that multitude1 and all the physical characteristics derived from the #bjj fathers1 are indubitably contained in those chromosomes and nowhere else1 unless by a special creation they are infused with the new soul1 which seems to be an altogether unreasonable alternative4 ,this statement concerning the minuteness of the chromosomes is not speculation--they can readily be seen and measured with the aid of the microscope4 ,a human being1 then1 obtains eight microscopic chromosomes from his father and eight from his mother1 positively nothing more except food2 yet he develops into a man with a body made up of countless millions of cells which expand into more than #bjj bones in the skeleton and over #bjj muscles1--into the fascias1 ligaments1 tendons1 the great and small glands1 the lymph and blood systems1 the respiratory and alimentary tracts1 the skin and its appendages1 and a nervous system1 which alone furnishes material for years of study if we would learn its anatomy fully4 ,not only all this1 but the man commonly closely resembles his father or his mother1 or some other ancestor1 in personal appearance1 in certain physical tendencies1 in graces or blemishes2 and furthermore1 he shows inherited racial characteristics4 ,if a father is prepotent1 he may have a greater effect in producing the formed child than the mother has1 and vice versa1 as when a son closely resembles his father or his mother4 #gb ,prepotency1 moreover1 may extend down through generations and centuries4 ,in the streets of ,palermo to-day typical ,normans may be seen1 despite the intermarriages of centuries1 who are the descendants of those male ,normans that went down to ,sicily with ,tancred4 ,there are ,romans there1 too1 and ,saracens4 ,when the ,belgae--a race of tall1 red-bearded men1 with elliptical skulls--went from the continent of ,europe to ,ireland1 probably six centuries before our era1 they conquered the aborigines1 a gentle1 brune race of lower stature4 ,these ,belgae became the ancestors of the chieftain class1 and their physical type persists until to-day2 so does that of the ,pictish aborigines4 ,daniel ,o',connell had a typical ,belgic body4 ,other big1 blond ,irishmen are ,norse or ,danish in remote origin4 ,how is the extremely complex human body with its various physical characteristics built up from the nucleus of a fecundated cell1 the ovum8 ,the endeavour to answer this question has brought out most ingenious speculation from nearly all the great biologists of modern times4 ,the question is the foundation of the theories of heredity1 and it is also fundamental in the theories of evolution4 ,the human ovum is a flattened spherical cell1 made up of a very delicate cell-wall1 called the vitelline membrane2 outside this is a comparatively thick membrane1 the zona pellucida1 which is properly not a part of the cell4 ,within the vitelline membrane is a granular cytoplasm1 the vitellus 7yolk71 and in this lies the nucleus1 which in the old text-books was called the germinal vesicle4 ,this nucleus contains a nucleolus4 ,the human spermatozoon consists of a flattened head which has a thin protoplasmic cap extending down two-thirds of its length4 ,in the head is the nucleus with the chromatin4 ,beyond the head is the neck1 which contains the anterior and posterior centrosomes4 ,behind the neck is the tail1 or flagellum1 in three parts1--the middle piece1 the principal part1 and the end piece4 ,from the neck to the end of the tail centrally runs a bundle of fibrils1 the axial filament4 ,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 part1 and lies in a clear fluid4 ,without the spiral filament1 along the middle piece1 is the mitochondria1 a finely granular protoplasmic layer4 ,the principal part of the tail consists of the axial #gc filament enclosed in an involucrum1 and the end piece is made up of this filament without the involucrum4 ,the head and neck of the spermatozoon1 which contain the nucleus and centrosomes1 are the essential parts1 and the middle piece and the remainder of the tail appear to be used solely for locomotion and penetration4 ,when the head penetrates the ovum1 the tail is detached and rejected4 ,our knowledge of the initial stages in the development of a human embryo is derived indirectly from the observation of other mammals4 ,there are nine early human embryos reported1 and the average probable age of these is twelve days4 ,breuss' specimen was probably ten days old 7,wiener med4 ,wochenblatt1 #ahgg74 ,peters 7,einbettung des mensch4 ,eies1 #ahii7 found a smaller embryo than this4 ,the ,breuss ovum was #e mm4 in length2 ,peters' was #c by #a4e by #a4e mm41 but the probable age was not given4 ,there have been numerous embryos more than twelve days old observed1 and since the process after the twelfth day is identical in man and the higher mammals1 there is no doubt that the first stages are also the same4 ,the segmentation that makes new cells is complicated1 and the outcome of the division is a ball of cells4 ,in eggs which have a large yolk1 like those of birds1 the cells form a round body resting on the surface of the yolk1 but in mammalian ova a hollow ball of cells1 or a ,morula1 results1 which lines the internal surface of the cellular envelope4 ,the ovum absorbs moisture by osmosis and enlarges1 and about the twelfth day after the germ-nuclei have begun to divide1 the ,morula1 or hollow ball of cells1 called also the ,blastodermic ,vesicle1 is formed4 ,the next stage in development is the establishment of two primary germinal layers1 called together the ,gastrula1 ,the outer layer is the ,ectoderm or the ,epiblast1 and the inner layer is the ,endoderm or ,hypoblast4 ,in a ,morula the smaller cells1 which contain less yolk-material1 gradually grow around the larger yolk-containing cells to form the ,gastrula4 ,between the ,ectoderm and the ,endoderm a layer of cells called the ,mesoderm or ,mesoblast is next formed1 and from these three layers all the parts of the embryo are built up4 ,from the outer ,ectoderm and the inner ,endoderm those organs arise which are in the body1 outer and inner1--as the nervous system and the outer skin from the ,ectoderm1 the inner entrails1 the lungs and liver1 from the ,endoderm4 ,from the ,mesoderm come the inner skin1 the bones and muscles4 ,by this time the embryo is a minute longitudinal streak at the #gd surface of one pole of the ovum4 ,the ,primitive ,trace is like a long inverted letter ,u1 the legs of which are in apposition4 ,the ,primitive ,trace becomes a circular flattened disc2 and it grows into a cylindrical body by the juncture of the free margins which fold downward and inward and meet in the median line1 and this closes in the pelvic1 abdominal1 thoracic1 pharyngeal1 and oral cavities4 ,the legs and arms bud from this cylinder later4 ,while the ventral cylinder is growing1 another longitudinal cylinder is formed along the upper surface of the embryo1 which will contain the brain and the spinal column4 ,the subsequent development of the embryo and foetus need not be known for an understanding of the material considered in treating here of terata4 ,human terata occur in certain rather definite1 types of erroneous development1 and the classification of ,hirst and ,piersol 7,human ,monstrosities1 ,philadelphia1 #ahia71 which is a combination and change of the classifications of ,geoffrey ,saint-,hilaire1 ,klebs1 and ,foerster1 is the most satisfactory4 ,there are four great groups of abnormally developed human beings3 7#a7 ,hemiteratic2 7#b7 ,heterotaxic2 7#c7 ,hermaphroditic2 7#d7 ,monstrous4 ,hemiterata are giants1 dwarfs1 persons showing anomalies in shape1 in colour1 in closure of embryonic clefts1 in absence or excess of digits1 or having other defects4 ,this group does not come under discussion here1 but attention should be called to the fact that women who are dwarfs are to be warned before marriage that they cannot be delivered normally1--that the caesarean section or symphyseotomy will be necessary1 or that certain physicians will practise craniotomy in delivering them4 ,the ,heterotaxic group comprises persons whose left or right visceral organs are reversed in position through abnormal embryonic development2 the liver is on the left side1 the heart points to the right1 and so on4 ,of the next group1 the ,hermaphroditic1 it may be said that a true hermaphrodite1 in the full sense of the term1 has not been found2 but there have been several examples of individuals who had an ovary and a testicle1 and other rudimentary sexual organs that belonged to both male and female4 ,forms of apparent doubling are common1 and in case of doubt as to sex the probability leans toward the #ge masculine side4 ,as to marriage in such cases1 questions may arise that are to be settled by the anatomist4 ,in dealing with double monsters it is sometimes difficult or impossible to determine whether we have to do with one or two individuals1 and this difficulty has serious weight1 especially in the administration of baptism4 ,it is improbable that there is a doubling of personality in hermaphrodites4 ,a striking characteristic of compound terata is that the individuals are always of the same sex2 moreover1 the embryonal development of reproductive organs in general is such as almost to preclude a question of duality of personality4 ,terata1 more properly so called1 are divided into single1 double1 and triple monsters4 ,single monsters may be autositic1 or independent of another embryo or foetus2 or they may be omphalositic1 that is1 dependent upon another embryo or foetus1 which is commonly well developed1 and which supplies blood for both through the umbilical vessels4 ,when an omphalosite exists1 the other foetus is called1 in this case also1 the autosite4 ,the first order of autositic single monsters contains four genera with eight species1 and under these species are thirty-four varieties4 ,they may have imperfect limbs1 no limbs1 one eye in the middle of the forehead 7cyclops71 fused lower limbs 7siren71 and so on4 ,some of these monsters show a strong resemblance to lower animals1 but there is no record that is in any degree scientific of a hybrid between a human being and a lower animal4 ,there are two genera of the omphalositic single monsters1 with four species4 ,one of the twins1 the autosite1 is commonly a normal child2 the other1 the omphalosite1 may be as small as a child's fist1 and be very much deformed4 ,of these omphalosites the paracephalus has an imperfect head1 commonly no heart1 and the lungs are absent or rudimentary4 ,the acephalus has no head1 and commonly no arms2 the asomata is a head more or less developed1 with a sac below containing rudiments of the trunk organs4 ,the ,acephalus is very rare--the rarest of all monsters except the ,tricephalus4 ,there is a fourth kind--the foetus anideus4 ,this is a shapeless mass of flesh covered with skin4 ,there may be a #gf slight prominence with a tuft of hair on it at one end of the mass to indicate the head4 ,in this monster there are more traces of bodily organs than might be expected4 ,these four kinds of omphalosites are either dead when born1 or they die as soon as the placental circulation is cut off4 ,if there is any probability of life1 the physician should give them baptism before the placental circulation is stopped4 ,nothing satisfactory is known concerning the etiology of single monsters4 ,landau1 and other authorities as great as he is1 reject the theory that maternal impressions from fright or exposure to the sight of hideous deformity are the cause of terata4 ,i think the father is accountable for terata as often as the mother is4 ,barnes1 an ,english physician1 and others claim they find that terata are frequent in consanguineous marriages1 but ,i have not been able to verify the assertion4 ,it seems a theory may be offered to explain the single terata4 ,in #ahhh ,roux of ,breslau by puncturing one blastomere of a frog's egg in the two-cell stage killed the punctured blastomere without affecting the other4 ,the punctured blastomere remained inactive1 but the other developed into a complete half embryo4 ,crampton by separating and isolating the blastomeres in the two-cell stage obtained a half embryo2 and ,zoja by isolating blastomeres of the medusae1 ,clytia and ,laodice1 got dwarfed larvae4 ,wilson succeeded by the separation through shaking of the blastomeres in the two-cell and four-cell stages in developing ,amphioxus larvae1 which were half the natural size for the two-cell blastomeres1 and commonly half the normal size from the four-cell blastomeres1 yet in the latter some of the larvae were of the normal size but imperfect ,from the eight-cell stage he got only imperfect4 larvae4 ,similar results were obtained by other operators with various eggs4 ,driesch and ,morgan by removing part of the cytoplasm from a fertilized egg of the ctenophore1 ,beroe1 produced imperfect larvae showing certain defects which represent the parts removed4 ,in these cases of injured and isolated blastomeres we have1 it seems to me1 a plausible theory for the etiology of single terata4 ,the blastomeres in the human ovum may perhaps be injured in part by toxins from the mother1 or they may be defective through disease in the ovum or the spermatozoon4 ,they also may possibly be displaced traumatically1 but this seems to be doubtful4 ,there are three theories concerning the origin of omphalositic #gg terata4 ,ahlfeld 7,missbildungen des ,menschen1 ,leipsic1 #ahhb7 holds that the autosite is stronger than the omphalosite1 and as a consequence the foetal circulation in the omphalosite is reversed1 and development is thus checked4 ,dareste 7,production artificielle des monstruosites1 ,paris1 #ahgf71 ,panum 7,beitrag zur ,kenntniss der physiol4 ,bedeut4 der angeboren ,missbildungen1 ,virchow's ,archiv41 #ahgh71 ,perls 7,lehrbuch der allgem4 ,pathologie7 and ,breus 7,wiener med4 ,jahrbuch1 #ahhb7 maintain there is an inherent original defect in the omphalositic child which prevents development of the blood-vessels1 and that ,ahlfeld's theory of an indirect umbilical connection of the omphalosite to the placenta is not probable2 if it were1 omphalosites would be very common1 because one of twins is nearly always stronger than the other4 ,hirst and ,piersol 7op4 cit7 combine these theories4 ,this kind of monster is certainly an imperfectly developed human individual1 and even the ,foetus ,anideus should receive at the least conditional baptism4 ,the next group comprises the composite monsters4 ,normal twins may arise from the fertilisation of one ovum and of two distinct ova4 ,in #ejf cases examined by ,ahlfeld he found that #ff twin births came from single ova4 ,twins from a single ovum are always of the same sex1 and they are not easily distinguished one from the other4 ,triplets may arise from one1 two1 or three ova4 ,the elder ,saint-,hilaire thought that composite monsters arise from the fusion of two impregnated ova1 but this opinion is now generally rejected4 ,composite terata in every instance arise from a single ovum4 ,there is a divergence of opinion1 however1 as to the origin of a composite monster in the single ovum4 ,some authorities maintain that these monsters arise from the union of two originally separate primitive traces4 ,this supposes primitive duality followed by fusion 7,verwachsungstheorie74 ,other writers hold that there is originally one primitive trace1 and that composite terata are the product of a more or less extensive cleavage of this single blastoderm4 ,this supposes primitive unity followed by fission 7,spaltungstheorie74 ,here1 as in the case of normal development1 the argument is founded on analogy4 ,the earliest stage in the development of a human double monster observed was at the fourth week after fertilisation--,ahlfeld's case4 ,b4 ,schultze 7,u4 anomale ,duplicitaet der ,axenorgane1 ,virchow's ,archiv47 and ,panum and ,dareste 7op4 cit47 hold the fusion theory-- #gh the fusion of two separate blastoderms in one ovum4 ,panum and ,dareste have seen two separate normal blastoderms on one ovum4 ,allen ,thompson in #ahdd 7,london and ,edinburgh ,monthly ,journal of ,medical ,science71 ,wolff1 von ,baer1 and ,reichert also observed two embryos in one ovum4 ,dareste is of the opinion that the fusion of two separate ova is impossible4 ,the fission theory--the fission of a single blastoderm to make a composite monster--is supported by ,wolff1 ,j4 ,f4 ,meckel1 von ,baer1 ,j4 ,mueller1 ,valentine1 ,bischoff1 and others1 especially by ,ahlfeld4 ,ahlfeld says that this single blastoderm is split by pressure4 ,gerlach also 7,die ,entstehungsweise der ,doppelmissbildungen1 etc41 ,stuttgart1 #ahhb7 admits fission1 but he contends that it is not so simple a process as ,ahlfeld thinks it is4 ,it is not a passive cleavage1 but a result of a force in the cell-mass existing before differentiation4 ,gerlach calls fission at the anterior or head-end of the single blastoderm1 bifurcation2 and he has actually observed such bifurcation in a chick embryo of sixteen hours 7,u4 d4 ,entstehungsweise der vorderen ,verdoppelung4 ,deutsche ,archiv4 f4 klin1 ,med41 #ahhg74 ,in this case the first change noticed was a broadening of the anterior end of the primitive streak2 next a forked divergence appeared1 and this became more pronounced2 until by the twenty-sixth hour the bifurcation was half as long as the undivided posterior part4 ,from each anterior end of the diverging branches a distinct head-process extended4 ,allen ,thompson 7loc4 cit47 in #ahdd saw a goose-egg1 which had been incubated for five days1 in which was a double monster divided to the neck4 ,beyond this observation by ,gerlach we have the fact1 which seems to make for the fission theory1 that no matter how unequally nourished or how variable in extent1 the union between the halves of double monsters is always symmetric--exactly the same parts of each twin are joined4 ,this seems to exclude a fortuitous growing together of dissimilar areas or cell-masses1 for non-parasitic double terata at the least4 ,born 7 ,u4 d4 ,furchung des ,eies bei ,doppelbildungen1 ,breslauer ,aerztl4 ,zeitschr41 #ahhg71 in a study of fish ova1 found that ova which produce double monsters begin with a segmentation like that of the single normal ovum4 ,if fission is complete homogeneous twins are the result2 these twins are of the same sex and very similar in appearance4 ,incomplete fission1 as has been said1 gives rise to double or triple terata4 ,if one of the teratic twin embryos is stronger than the other1 the various combinations of enclosure and parasitism may result1 although the origin of parasitic double terata is not convincingly clear4 ,a triple #gi monster1 according to the fission theory1 arises from a double incomplete cleavage of the primitive trace4 ,dr4 ,ephraim ,cutter has observed teratic composite spermatozoa which1 he thinks1 probably have influence in producing composite monsters4 ,there are three orders of the double autositic monsters3 ,terata ,katadidyma1 in which the embryonal fission was at the cerebral end2 the ,terata ,anadidyma1 divided below2 the ,terata ,anakatadidyma1 divided above and below1 but joined at the middle of the body4 ,there are four genera of the ,terata ,katadidyma with many species4 ,the first genus is the ,diprosopus1 the double-faced4 ,the doubling varies from the finding of two complete faces to a slight trace of duplex formation in one head4 ,foerster in #ejj human monsters observed #bi cases of diprosopi4 ,there are six species of diprosopi3 #a4 ,d4 ,diophthalmus1 which has only two eyes1 but there is a doubling of the nose4 #b4 ,d4 ,distomus1 which has two mouths1 two lower jaws1 two tongues1 one pharynx1 and one oesophagus4 #c4 ,d4 ,triophthalmus1 which has three eyes1 and the doubling of the face is more complete4 ,there are only two ears4 #d4 ,d4 ,tetrophthalmus1 which has four eyes and two well-separated faces4 #e4 ,d4 ,triotus is like the last1 but it has three ears4 #f4 ,d4 ,tetrotus has four ears1 four eyes1 and there is some doubling at the pharynx4 ,two oesophaguses enter one stomach in this species commonly4 ,d4 ,tetrotus is rare--only one example in man is known4 ,in all diprosopi there is only one trunk1 one pair of arms1 and one pair of legs4 ,sir ,james ,paget had a photograph1 made in #ahef1 of a living diprosopus1 the second face of which had a mouth1 nose1 eye1 part of an ear1 and a brain 787 of its own4 ,the two faces acted simultaneously1 suckled1 sneezed1 yawned together4 ,are diprosopi twins8 ,an answer to this question will be clearer after a description of other composite terata4 ,the second genus of the ,terata ,katadidyma is the ,dicephalus4 ,this genus comprises five species1 which have in each case two heads1 with separate necks commonly4 ,there are two vertebral columns1 which usually are separate down to the sacrum1 and they converge at the lower end4 #hj ,in the interior organs doubling will be found corresponding to the degree of separation of the trunks4 ,in all the species of this genus there are one umbilicus and one cord4 ,the first species of the ,dicephalus is the ,dicephalus ,dibrachius--a two-armed1 double-headed monster4 ,in this species most of the viscera are single1 but the right and left halves of each viscus are supplied by the respective foetuses1 and the entrail does not become indistinguishably single until near the lower end of the ileum4 ,there may be two ordinary kidneys and a third smaller one1 two pancreatic glands1 and two gall-bladders4 ,such a monster may be monauchenous or diauchenous4 ,the next species is the ,dicephalus ,tribrachius ,dipus--two heads1 three arms1 and two legs4 ,there is also a ,dicephalus ,tribrachius ,tripus 7three arms and three legs71 ,d4 ,tetrabrachius ,dipus 7four arms and two legs71 and ,d4 ,tetrabrachius ,tripus 7four arms and three legs74 ,in all these cases there is no doubt of the presence of twins1 unless there might be some doubt as to dual personality in the ,dicephalus ,dibrachius4 ,in the ,dicephalus ,tetrabrachius ,dipus and the ,dicephalus ,tetrabrachius ,tripus there is almost complete duplication of the internal organs1 and the halves of the composite body belong evidently to individuals distinct in thought1 volition1 and character4 ,each brain controls only its own half of the body4 ,there are four lungs1 two hearts 7sometimes in one pericardium71 two stomachs1 two intestinal canals down to the colon or lower1 two livers 7sometimes joined71 four kidneys 7or three1 one of which is small71 two bladders1 emptied at different times through a common urethra4 ,dicephali are somewhat common4 ,foerster found #adj among #ejj specimens of monsters4 ,they are rarely born alive4 ,the best known cases of dicephali that lived for any length of time are3 #a4 ,peter and ,paul1 of ,florence1 born in #acaf1 lived thirty days4 #b4 ,the ,scotch ,brothers1 born in #adij1 lived twenty-eight years4 ,they were at the court of ,james ,,iii4 ,above the point of union the twins were independent in sensation and action1 but below the point all sensation and action were #ha common4 ,one died before the other1 and the second succumbed to infection from putrefaction a few days later4 #c4 ,the ,wuertemberg ,sisters1 born in #adih4 #d4 ,the twins1 ,justina and ,dorothea1 born in #afbg1 lived six weeks4 #e4 ,boy twins at ,padua1 born in #afia1 lived to be baptised4 #f4 ,rita-,cristina1 born at ,sassari in ,sardinia in #ahbi4 ,they lived eight months4 ,these children had a common trunk below the breast1 one pelvis1 and one pair of legs4 ,rita was feeble and quiet1 ,cristina vigorous and lively4 ,they suckled at different times2 and sensation in the heads and arms was individual1 but below the junction it was common4 ,rita died of bronchitis1 and during ,rita's final illness ,cristina was healthy2 but when ,rita died1 ,cristina1 who was suckling at the time1 suddenly expired4 ,they had two hearts in one pericardium1 the digestive tracts did not fuse until the lowest third of the ileum was reached4 ,the livers were fused1 the vertebral columns were distinct throughout4 ,these twins were baptised separately4 #g4 ,marie-,rose ,drouin1 born in ,montreal in #ahgh4 ,they lived seven months4 ,marie died of cholera infantum2 and ,rose then died1 although she had not been directly affected by the disease4 ,these twins were like ,rita-,cristina anatomically except that they had no legs4 ,the respirations and heart-pulsations differed1 and one child slept while the other child cried4 #h4 ,the ,tocci boys1 born in ,turin in #ahgg4 ,in #ahhb they were strong and healthy1 and they may be living still4 ,they resembled ,rita-,cristina anatomically in every respect4 ,each boy had control of the leg on his own side1 but not of the other leg1 consequently they could not walk4 ,their sensations above the juncture were distinct1 and their thoughts and emotions differed4 ,in the ,paris ,l'union medicale there is an account of a bicephalic still-born monster1 born at ,alexandria in #ahdh1 which1 according to the report1 had on one side a typical negro head and on the other side a typical ,egyptian fellah head4 ,this report is probably not authentic2 but if it is1 it would be difficult to reconcile it with the fission theory4 #hb ,supposing the report true1 the case would have to be one 7#a7 of superimpregnation wherein 7#b7 a spermatozoon from each source penetrated the same ovum1 7#c7 a bicephalic monster resulted1 with 7#d7 distinct racial characteristics4 ,all this is extremely improbable4 ,superimpregnation has happened4 ,there are cases where negresses have given birth to twins1 one of which was a negro and the other a mulatto4 ,instances are cited in books on ,legal ,medicine like those of ,tidy and ,beck4 ,in ,flint's ,physiology a case is recorded in which a mulatto woman in ,kent ,county1 ,virginia1 married to a negro1 gave birth to twins1 in #ahfg1 one of which was a negro much blacker than the mother1 and the other a white child1 with long1 light1 silky hair1 and a brilliant complexion4 ,the white child's nose was shaped like the mother's1 but there was no other resemblance4 ,even supposing this to be a case of superimpregnation1 that does not fully explain the extreme whiteness of one child and the extreme blackness of the other4 ,superfoetation is also possible4 ,tidy 7,legal ,medicine7 gives a case3 ,mary ,anne ,bigaud1 at thirty-seven1 on ,april #cjth1 #agdh1 gave birth to a full-term mature boy1 which survived its birth two and a half months1 and to a second mature child 7girl7 on ,september #afth1 #agdh1 which lived for one year4 ,the second child was born four and a half months after the first1 and both were nine-months children4 ,it was proved after death in this case that the mother had not a double uterus1 and the report is vouched for by ,professor ,eisenman1 and by ,leriche1 surgeon-major of the ,strasburg ,military ,hospital4 ,several other cases of superfoetation are given by ,bonnar 7,edin4 ,med4 ,journ41 ,january1 #ahfe74 ,the third genus of ,terata ,katadidyma is the ,ischiopagus4 ,these twins are divided so much from above downward that the heads are at almost opposite ends of the double body4 ,they are joined at the coccyges and sacra1 and the spinal columns have nearly the same axis4 ,the trunk organs are complete and separate1 except that they are commonly fused in the pelvis4 ,there may be two1 three1 or four legs1 given off at right angles to the pelvis4 ,this kind of monster is not rare4 ,foerster collected twenty cases1 and nine new examples #hc were reported in the ,index ,medicus between #ahgi and #ahic4 ,ischiopagic twins were born in ,county ,roscommon1 ,ireland1 in #ahbg1 and baptised separately4 ,the ,jones ,twins1 born in ,typhon ,county1 ,indiana1 in #ahhi1 lived for about two years2 they were ischiopagi1 and they had the very unusual quality1 it is said1 that they differed in complexion and the colour of eyes and hair4 ,a case was reported in ,american ,medicine1 ,september1 #aijc4 ,classed with the ,katadidyma is the genus ,pygopagus1 although it has four legs4 ,this form is very rare4 ,the twins are joined only by the latero-posterior aspects of the sacra and coccyges1 so that the two individuals are placed almost back to back4 ,the trunk organs are independent1 except for some fusion near the point of juncture4 ,examples of this class are the ,hungarian ,sisters1 born at ,szony in #agja1 who lived to womanhood2 the negresses ,millie-,christine1 born in #ahea1 and who were recently living in ,north ,carolina2 and the ,blazek ,sisters of ,bohemia4 ,the negresses had common sensation in the legs1 but ,millie could not localise what part of ,christine's legs was touched1 and vice versa4 ,the second group of the double autositic monsters are ,terata ,anadidyma--terata divided from below upward4 ,the first genus is the ,dipygus4 ,this has a single body above1 but a double pelvis with double lower extremities in the typical cases4 ,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 #gbg of this era4 ,the chronicler says in that year on ,dalkey ,island near ,dublin1 ,there was a cow seen which had one head and one body as far as her shoulders1 two bodies from her shoulders hindward1 and two tails4 ,she had eight legs1 and she was milked three times a day4 ,a perfect human ,dipygus with two equally developed pairs of legs is unknown4 ,catherine ,kaufmann1 who was born in #ahgf1 and who died in #ahgh1 had a double pelvis with double pelvic organs in part1 but she had only one pair of legs4 ,there is a similar anomaly said to be living in ,philadelphia at present4 ,blanche ,dumas1 born in #ahfj1 had a double pelvis1 double pelvic organs1 and three legs4 ,mrs4 ,b41 born in #ahfh1 #hd had four legs--the two inner ones were smaller than the outer pair4 ,her spinal column was divided up to the third lumbar vertebra4 ,her double pelvic organs acted independently4 ,there are living male examples of this form of monster4 ,the next genus is the ,syncephalus1 called also ,janus and ,janiceps4 ,its lower body is double up to the umbilicus1 the trunk single above that point2 the head shows signs of doubling1 and there are four legs and four arms2 the bodies grow front to front4 ,the head usually is large1 therefore this monster is born dead4 ,another genus is the ,craniopagus--twins joined only by the skull or scalp4 ,there are three species1 named from the place of union--,craniopagus ,frontalis1 ,c4 ,parietalis1 and ,c4 ,occipitalis4 ,a third group of double autositic monsters are the ,terata ,anakatadidyma1 which are divided above and below1 but joined from the navel to the head4 ,there are three genera4 ,the first1 the ,prosopothoracopagus1 is joined at the upper abdomen1 the chest1 and the faces2 the spinal columns are separate4 ,the faces are imperfect1 the jaws are united2 there is a broad neck with one oesophagus1 and there is one stomach and one duodenum4 ,this is a rare form1 and it can not exist out of the uterus4 ,a second genus1 the ,thoracopagus1 has a thorax in common1 and the inner legs may be united4 ,it is1 as a rule1 still-born4 ,the next genus is the ,omphalopagus1 in which the twins are joined from the navel to the bottom of the chest4 ,this double monster has the slightest union of all1 and it is very rare4 ,the ,siamese ,twins were omphalopagi4 ,they quarrelled2 one became a drunkard and the other remained temperate4 ,they married two women1 and ,chang had ten children1 and ,eng twelve4 ,chang died while ,eng was asleep1 and the latter died two hours after he had waked and learned of his brother's death4 ,there is a genus1 the ,rachipagus1 the examples of which are joined behind like the class ,terata ,anakatadidyma that are joined in front4 #he ,four known attempts have been made to separate double monsters surgically1 but all failed owing to crude surgery2 modern methods might be successful in some cases4 ,the second order of double monsters comprises the parasitic class4 ,there are three genera of these terata1 with five species and seventeen varieties4 ,the chief of these only will be mentioned4 ,the ,heterotypus is a parasitic child which hangs from the abdominal wall of the principal subject4 ,varieties of this species are the ,heteropagus1 which is a parasite with head and arms2 the ,heterodelphus1 which has no head2 the ,heterodymus1 which has a head1 neck1 and thorax4 ,the ,heteralitis is a second species1 in which the parasite is inserted at a distance from the navel of the autosite4 ,the ,epicomus is the only example1 and it consists of a parasitic supernumerary head4 ,the ,polypnathus is a parasite attached to the jaw of the autosite4 ,when fastened to the upper jaw1 it is an ,epignathus2 at the lower jaw it is an ,hypognathns4 ,another group is made up of terata having parasitic legs which are attached to different parts of the autosite1--to the pelvis1 the head1 the abdomen1 and so on4 ,finally1 there is the ,endocyma1 which is a parasite enclosed within the body of an autosite4 ,parasites are nourished through the blood supply of the autosite1 and the parasites usually are incapable of motion4 ,the autosite can feel when the parasite is touched1 and in some cases the autosite can localise the touch4 ,in ,india1 in #aghc1 a child was born which had a supernumerary head attached to the autositic head1 crown to crown2 it lived four years4 ,the parasite's eyes were always partly open1 but they appeared to be incapable of intelligent vision4 ,they contracted under strong light1 and when the autosite was suddenly awakened both sets of eyes moved4 ,gould and ,pyle 7,anomalies and ,curiosities of ,medicine7 give an account of an ,italian boy1 aged eight years1 who had a small parasitic head protruding from near the left third rib4 ,sensibility was common4 ,each of the heads received baptism 7one was called ,john and the other ,matthew71 and there was question as to whether extreme unction should be administered to the parasitic head4 ,a similar case occurred in #hf ,england in #ahhj 7,british ,med4 ,journal71 and the parasitic head could be pinched without attracting the attention of the autosite4 ,teratologists now exclude ,dermoid ,cysts from the lists of terata4 ,the hair1 teeth1 and particles of bone found in these cysts are looked upon as the development of abnormal ectodermic and endodermic cells1 rather than as evidence of a separate personality4 ,there is only one well-authenticated case of a triple monster1 and this happened in ,italy in #ahca4 ,the monster had a single broad body with three distinct heads and two necks4 ,it was killed in delivery4 ,in ,katadidyma 7terata divided from above downward71 when we have dicephali1 ischiopagi1 or pygopagi1 there are evidently two individuals present4 ,is the ,diprosopus1 however1 the two-faced monster1 possessed of one or two souls8 ,the cases vary1 as we said1 from examples with two distinct faces and four ears to cases that have merely two noses4 ,what portion of a human body is required to contain a new soul8 ,that is an interesting question for the psychologist and a very practical one for the moralist1 and no moralist has yet attempted to solve it4 ,the presence of a brain is not essential1 because acephalous monsters develop without brain1 and they are born alive2 they have a vital principle which is identical with the soul4 ,among the ,terata ,anadidyma 7divided from below upward7 the ,syncephalus and the ,craniopagus are unquestionably two persons4 ,is the ,dipygus 7single down to the navel1 double below7 one or two persons8 ,mrs4 ,b41 the example already given1 was as double below the navel as any ,dicephalus is above that point4 ,she had features so well ordered in unity that she was a pretty woman1 but that unity ceased at her waist4 ,was her husband unknowingly a bigamist8 ,i think he was4 ,after a consideration of the fission of terata1 and the non-essential quality of the brain1 why should fission that started at the feet differ from fission that started at the head8 ,in the ,rituale ,romanum ,pauli ,v4 7tit4 ii4 cap4 i4 nn4 #ah1 #ai1 #bj1 #ba71 the following directions for the baptising of terata are given3 #hg #ah4 ,in monstris vero baptizandis1 si casus eveniat1 magna cautio adhibenda est1 de quo si opus fuerit1 ,ordinarius loci2 vel alii periti consulantur1 nisi mortis periculum immineat4 #ai4 ,monstrum1 quod humanam speciem non praeseferat1 baptizari non debet2 de quo si dubium fuerit1 baptizetur sub hac conditione3 ,si tu es homo1 ego te baptizo1 etc4 #bj4 lllud vero1 de quo dubium est1 una ne1 aut plures sint personae1 non baptizetur1 donec id discernatur3 discerni autem potest1 si habeat unum vel plura capita1 unum vel plura pectora2 tunc enim totidem erunt corda et animae1 hominesque distincti1 et eo casu singuli seorsum sunt baptizandi1 unicuique dicendo3 ,ego te baptizo1 etc ,si vero periculum mortis immineat1 tempusque non suppetat1 ut singuli separatim baptizentur1 potent minister singulorum capitibus aquam infundens omnes simul baptizari1 dicendo3 ,ego vos baptizo1 in nomine ,patris1 et ,filii1 et ,spiritus sancti4 ,quam tamen formam in iis solum1 et in aliis similibus mortis periculis1 ad plures simul baptizandos1 et ubi tempus non patitur1 ut singuli separatim baptizentur1 alias numquam1 licet adhibere4 #ba4 ,quando vero non est certum in monstro esse duas personas1 ut quia duo capita et duo pectora non habet distincta2 tunc debet primum unus absolute baptizari1 et postea alter sub conditione1 hoc modo3 ,si non es baptizatus1 ego te baptizo in nomine ,patris1 et ,filii1 et ,spiritus sancti4 ,,austin ,,omalley4 #hh ,,vii ,,social ,,medicine ,the influence of the clergyman or the charitable visitor in matters of health and sanitation can scarcely be overestimated4 ,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 duty4 ,there is no doubt that if this influence be properly directed1 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 observed4 ,as this amelioration of sanitary conditions will affect mainly the poor1 lessening their suffering and adding to their possibilities of happiness1 its accomplishment becomes a great ,christian duty1 obligatory on all those who are interested in the uplifting of the poorer classes4 ,professor ,virchow1 the distinguished ,german pathologist1 used to say that popular medicine was in all ages at least fifty years behind scientific medicine4 ,he had himself discovered the principles of cellular pathology nearly half a century before his death1 yet he declared that the popular mind still believed in the old doctrines of humoral pathology1--that is1 that the conditions of health and disease depended on the constitution of the fluids of the body 7the blood1 the bile1 the mucus1 and so forth71 and had not generally accepted modern advances in medical knowledge of the underlying basis of disease in the solid tissues4 ,there is no doubt that many old-fashioned notions long since discredited by physicians are still very generally accepted by the popular mind1 and even the intelligent classes sometimes harbour convictions with regard to the good or evil effects of habits #hi of life1 diet1 and the operation of drugs of various kinds that are entirely contrary to present-day medical knowledge4 ,it is extremely important1 then1 that the clergyman or charitable visitor1 in giving views on medical matters1 which are sure to have much more weight than he perhaps attributes to them himself1 should be careful not to make statements for which he has not good authority in modern medical science4 ,it is very easy1 in a matter of this kind1 to state principles that are not the result of education1 properly so called1 but are gleaned from early false impressions obtained one knows not how or where1 entirely without definite consciousness as to their real origin4 ,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 medicine4 ,it is perhaps not so surprising1 then1 to hear physicians complain often that clergymen instead of being a help are sometimes a hindrance to the enforcement of modern hygienic rules1 because they still cling to old-fogy notions of hygiene and sanitation retained from a defective early training4 ,owing to the influence that the clergyman is sure to exert1 this becomes an extremely important matter4 ,great harm may be done and the physician discredited1 almost without a realisation1 on the part of the clergyman1 that he is interfering in another's department4 ,sympathetic coordination of clerical and medical efforts would accomplish much good that is now unfortunately left undone4 ,there is no doubt that for the important crusade against tuberculosis1 for instance1 the aid of the clergyman will accomplish much for the reduction of the death rate from this disease4 ,what is needed at the present moment is a universal conviction that tuberculosis is not an hereditary but a communicable disease4 ,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 generally2 but it does mean that careful precautions must be taken with regard to the disposal of sputum1 with the enforcement of the most exacting cleanliness on the part of consumptives themselves4 #ij ,it also means that the person suffering from the disease should not sleep with those as yet unaffected1 nor be allowed to live in very close contact1 especially with children or susceptible individuals4 ,the persuasion that tuberculosis is not hereditary will do much to encourage patients suffering from the disease to feel that they are not hopelessly doomed4 ,at the present time it is not unusual to find patients so discouraged1 when told that they have tuberculosis1 that it is almost impossible to secure a favourable reaction to any mode of treatment4 ,they have seen members of families die one after another1 or they have heard stories of the inevitable way in which consumption wiped families out of existence1 and they give up hope and become quite cast down4 ,needless to say1 while in this condition any treatment is practically hopeless4 ,on the other hand1 the conviction that tuberculosis is only an infectious disease1 quite curable in the majority of cases if taken in time1 is of itself a most important aid in the treatment of the disease1 since courage and faith are the principal requirements for successfully combating the affection4 ,we have had any number of newly invented remedies for consumption in the last twenty-five years4 ,scarcely a year has passed in which some new form of treatment1 often eventually proved to be the resuggestion of an old therapeutic method1 has not been heralded as a positive cure for consumption4 ,in every case the first patients treated by the discoverer of the new remedy have rapidly improved under his care4 ,in the hands of others1 however1 such results have not been obtained1 or only for a very short time at the beginning of the treatment4 ,after a time the new remedy failed in its inventor's hands4 ,the true reason for the improvement was then seen to be1 not the remedy suggested1 but the favourable influence on the mind of consumptives produced by the faith of the inventor in his remedy1 and their reaction to this powerful suggestion when they were put under proper conditions of an abundance of fresh air and a plentiful diet4 ,this shows1 too1 the reasonableness of the modern treatment of consumption1 which consists not in the giving of #ia drugs1 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 food4 ,most of the much advertised remedies for consumption are really harmful rather than beneficent4 ,many of them are ordinary cough mixtures containing considerable opium1 which lessens the cough1 it is true1 but also lessens the appetite and locks up the bowels4 ,besides1 the cough is nature's method of removing material from the lungs which has become disintegrated1 and if allowed to remain will certainly bring about the spread of the infection in the pulmonary tissues4 ,cough is a natural protective reaction to be encouraged1 and is not in itself a source of evil needing to be suppressed4 ,if cough is bothering the patient so much at night as to cause loss of sleep1 then it is necessary to make a choice between two evils and somewhat to suppress the cough1 even though it involves certain other inconvenience to the patient4 ,all these so-called consumption cures contain materials that are almost sure to disturb the appetite and upset the stomach4 ,the fate of a consumptive patient absolutely depends on his stomach2 just as little1 then1 of medicine must be employed as possible4 ,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 years4 ,many a patient delays an appeal to medical aid so long1 as the result of trusting to such medicines1 that a curable case of consumption becomes incurable1 or else develops to such a condition as to require years of treatment on the fresh-air1 abundant-food plan1 where months would have sufficed before4 ,a very interesting phase of social medicine is the ease and confidence displayed by people1 often of more than ordinary intelligence1 in recommending various proprietary medicines of which they know nothing except the fact that someone says he1 or more often she1 was cured of something or other by their use4 ,a chance remark like this to a sufferer becomes a high recommendation4 ,the hardest problem the doctor has before him is to find out what is really the matter with his patients4 ,not infrequently people having apparently the same set of symptoms are suffering from quite different #ib ailments4 ,a symptom like a sore throat1 for instance1 may very well be due to any one of at least a half-dozen of causes1 most of which require their own peculiar treatment4 ,when the affection under consideration is as indefinite as a tired feeling1 or indigestion1 or some one of the many ailments included under the term biliousness or kidney trouble1 from which people are supposed to suffer1 then the diagnosis problem becomes by far the most serious question in the case1 and is often very difficult4 ,the trained physician prudently hesitates1 but the inexpert in medicine steps in and quite volubly announces what the ailment is in his opinion1 and what will probably do it good4 ,a little knowledge is indeed a dangerous thing in medical matters4 ,if it be remembered that there is a very general impression among medical men now1 as the result of recent acquisitions of scientific information with regard to the origin1 pathological basis1 and course of disease1 that very probably more harm than good has been done by the administration of medicines in the past1 not only the futility of lay 7or clerical7 prescribing will be manifest1 but also somewhat of the amount of harm that may be done4 ,it is often a matter for painful surprise1 then1 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 nothing1 for a disease of which they know less1 if possible4 ,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 matters4 ,the remedies most often recommended are the so-called tonics4 ,these are best represented by the sarsaparillas1 and by various cures for catarrh1 indigestion1 and kindred indefinite ills1 of which there are a great many on the market4 ,these are not secret remedies1 since their composition is well known by those of the medical profession who care to secure the information4 ,some six years ago an analysis of most of them was made by the ,massachusetts ,state ,board of ,health4 ,footnote #a ,footnote #a3 #bhth ,annual ,report ,mass4 ,board of ,health2 food and drug inspection1 #ahig4 ,the principal active agent in all of these remedies was #ic found to be alcohol4 ,in most of them it exists in a proportion about equal to that in which it is supposed to occur in ordinary whiskey4 ,some of them are even stronger in alcoholic contents than the whiskey usually sold in our large cities4 ,this matter has seemed so important that we give the official figures of the ,board of ,health4 ,,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 each4 ,some of them have been recommended as temperance drinks6 ,per cent1 of ,alcohol 7by volume74 ,best ,tonic #g4f ,carter's ,physical ,extract #bb4j ,hooker's ,wigwam ,tonic #bj4g ,hoofland's ,german ,tonic #bi4c ,hop ,tonic #g4j ,howe's ,arabian ,tonic1 not a rum drink #ac4b ,jackson's ,golden ,seal ,tonic #ai4f ,liebig ,company's ,coca ,beef ,tonic #bc4b ,mensman's ,peptonized ,beef ,tonic #af4e ,parker's ,tonic1 purely vegetable1 recommended for inebriates #da4f ,schenck's ,sea ,weed ,tonic1 entirely harmless #ai4e ,atwood's ,quinine ,tonic ,bitters #bi4b ,l4 ,t4 ,atwood's ,jaundice ,bitters #bb4c ,moses ,atwood's ,jaundice ,bitters #ag4 #a ,baxter's ,mandrake ,bitters #af4e ,boker's ,stomach ,bitters #db4f ,brown's ,iron ,bitters #ai4g ,burdock ,blood ,bitters #be4b ,carter's ,scotch ,bitters #ag4f ,colton's ,bitters #bg4a ,copp's ,white ,mountain ,bitters1 not an alcoholic beverage #f4j ,drake's ,plantation ,bitters #cc4b ,flint's ,quaker ,bitters #ba4d ,goodhue's ,bitters #af4a ,greene's ,nervura #ag4b #id ,hartshorn's ,bitters #bb4b ,hoofland's ,german ,bitters1 entirely vegetable and free from alcoholic stimulant #be4f ,hop ,bitters #ab4j ,hostetter's ,stomach ,bitters #dd4c ,kaufmann's ,sulphur ,bitters1 contains no alcohol4 ,as a matter of fact1 it contains #bj4e per cent1 of alcohol and no sulphur #bj4e ,kingsley's ,iron ,tonic #ad4i ,langley's ,bitters #ah4a ,liverpool's ,mexican ,tonic ,bitters #bb4d ,paine's ,celery ,compound #ba4j ,pierce's ,indian ,restorative ,bitters #f4a ,puritana #bb4j ,porter's ,stomach ,bitters #bg4i ,pulmonine #af4j ,rush's ,bitters #ce4j ,richardson's ,concentrated ,sherry ,wine ,bitters #dg4e ,secor's ,cinchona ,bitters #ac4a ,shonyo's ,german ,bitters #ba4e ,job ,sweet's ,strengthening ,bitters #bi4j ,thurston's ,old ,continental ,bitters #aa4d ,walker's ,vinegar ,bitters1 contains no spirit #f4a ,warner's ,safe ,tonic ,bitters #ce4g ,warren's ,bilious ,bitters #ba4e ,wheeler's ,tonic ,sherry ,wine ,bitters #ah4h ,wheat ,bitters #ac4f ,faith ,whitcomb's ,nerve ,bitters #bj4c ,dr4 ,williams' ,vegetable ,jaundice ,bitters #ah4e ,whiskol1 a non-intoxicating stimulant1 whiskey without its sting #bh4b ,colden's ,liquid ,beef ,tonic1 recommended for treatment of the alcoholic habit #bf4e ,ayer's ,sarsaparilla #bf4b ,thayer's ,compound ,extract of ,sarsaparilla #ba4e ,hood's ,sarsaparilla #ah4h ,allen's ,sarsaparilla #ac4e ,dana's ,sarsaparilla #ac4e ,brown's ,sarsaparilla #ac4e ,corbett's ,shaker ,sarsaparilla #h4h ,radway's ,resolvent #g4i ,the dose recommended upon the labels of the foregoing preparations varies from a teaspoonful to a wineglassful1 and the frequency also varies from one to four times a day1 increased as needed4 ,many so-called tonics not on this list are also known to contain alcohol1 #ie though not as yet officially analysed so as to give exact figures4 ,most of the cure-alls for women's ills contain alcohol in noteworthy amounts1 this being in fact usually the only active ingredient in them4 ,as the analyst of the ,state ,board of ,health of ,massachusetts is a thoroughly competent chemist1 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 remedies1 though it is evident how undesirable the truth of the matter is from an advertising standpoint1 there can no longer be any question as to the authoritativeness of the proportions of the alcohol in the remedies as given4 ,it is rather sad to think of mothers giving these remedies to their children1 hopeful of the good they may accomplish1 when1 as a matter of fact1 it would be so much simpler and just the same in the end1 to give them1 instead of a tablespoonful of the favourite sarsaparilla1 whatever it might be1 a tablespoonful of dilute whiskey4 ,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 problem1 not a few prominent total abstinence advocates have put themselves on record as recommending these remedies1 though there can be no possible doubt of the great harm likely to arise from their use4 ,there are many physicians who feel sure that some of the alcoholic habits in women1 whose origin it has been hard to account for1 were really contracted during this secret tippling process under the form of a tonic remedy4 ,everyone knows that any tonic1 in order to be effective1 has to be gradually increased1 so it is not surprising that in many cases physicians have heard of patients taking six to ten tablespoonfuls of some tonic remedy every day4 ,this would be the equivalent1 in some cases1 of from three to five ounces of whiskey--a rather liberal allowance even for a confirmed whiskey drinker4 ,as noted by the ,massachusetts ,board of ,health1 the dose recommended upon the labels varies considerably1 but practically all agree in suggesting that the amount of the remedy taken shall be increased as needed4 ,a simple presentation of this subject will surely be sufficient to arouse clergymen #if to a proper sense of their duty in this matter4 ,senators1 judges of ,supreme ,courts1 ,congressmen1 and even university professors and teachers may be so benefited by dilute whiskey1 taken early and often1 as to be tempted to furnish testimonials for them 7for a due consideration usually71 but clergymen should at least know something of the consequences of their act before committing themselves4 ,an almost precisely similar state of affairs obtains with regard to another class of favourite popular remedies4 ,a number of so-called blood-purifying remedies have been recommended at various times1 and here1 as in other things1 it is surprising to find how many intelligent people lend themselves to the exploitation of the public in the interests of the proprietary vender1 who cares only to sell1 and cares very little what effect his remedies may produce4 ,most of the sarsaparillas are said to be blood purifiers4 ,it is surprising what vogue this word sarsaparilla has obtained4 ,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 boiling1 and that form excellent remedies for atonic and anaemic conditions4 ,this announcement was received by the medical profession very kindly1 and immediate tests as to the efficacy of the new remedy were made4 ,as a result of these tests1 within a few years the inefficacy of sarsaparilla became very clear4 ,it is almost entirely without effect upon the human system4 ,in the meantime1 however1 the word sarsaparilla was one to conjure with for the popular mind1 and the sarsaparilla remedies began to be manufactured4 ,millions have been made on them and out of the public4 ,the only active agent as regards tonic qualities which they contain is1 as we have said1 alcohol4 ,most of them however1 contain at least one other well-known drug likely to be at least as harmful as alcohol4 ,this is iodide of potash4 ,very few of the so-called sarsaparillas are without a notable proportion of this strong mineral salt1 as the ,massachusetts ,board of ,health said4 ,with but few exceptions they contain a considerable percentage of a very active and powerful remedy1 the iodide of potassium4 ,the sale of such an article in unlimited #ig quantities by druggists1 grocers1 and others is censurable4 ,more than this1 the method of its sale is dishonest1 since the unwary purchaser is led to believe that he is purchasing a harmless vegetable remedy1 namely1 sarsaparilla4 ,it may be seriously questioned whether the blood of persons who take iodide of potassium continuously is not decidedly impoverished1 instead of being purified1 as is claimed by the manufacturers4 ,it is not uncommon to find persons who have used continuously six1 eight1 or ten pint bottles of one of these preparations4 ,unlike sarsaparilla1 the iodide of potassium is classed among poisons by nearly every writer upon toxicology4 ,practically all the proprietary remedies have their most potent principle in the supposed mystery of their composition4 ,as a matter of fact1 all are simple prescriptions1 well known to physicians1 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 contain4 ,no important remedy has ever been put on the market by advertising methods4 ,exposure of the charlatanry of such methods will not1 however1 cause an interruption of their sale4 ,long ago ,barnum said that people wish to be humbugged1 and there is no doubt that they have been1 are1 and will be humbugged just to the extent to which they lay themselves open to the alluring methods of the advertiser4 ,it does seem too bad1 however1 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 evil4 ,alcohol and iodide of potash are not the only drugs likely to do harm that are incorporated in proprietary medicines4 ,great complaints have recently been made with regard to the spread of the cocaine habit in this country4 ,not a few of the remedies that are supposed to give immediate relief to colds in the head contain cocaine in dangerous amounts2 and there seems no doubt that in many cases the drug habit for this substance has been acquired innocently and #ih unconsciously at first by the use of such preparations4 ,these are only the more notable evils likely to result from the indiscriminate employment of medicines of whose composition there is complete ignorance1 and of whose effect there can be only the judgment dependent upon the subjective feelings of the patient4 ,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 ailment1 though making the patient less sensitive to any symptoms from which he was suffering2 but in the end doing positive harm1 because of the contraction of the alcohol or some drug habit1 or because the suppression of symptoms may be the very worst thing for the patients1 since it allows the underlying ailment to progress to a serious stage without forcing them to have it treated in radice4 ,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 contents4 ,the present writer has had one example of how utterly disingenuous1 though one feels much more like calling it rascally1 the manufacturers of so-called patent medicines or proprietary remedies may be4 ,one of the remedies widely advertised for the cure of epilepsy1 or fits1 is announced always as containing no harmful drugs1 no bromide of potash4 ,the manufacturer of the remedy was asked how he could say any such thing1 since it was very evident even to the taste that the remedy contained bromides4 ,oh1 he said1 yes1 it contains sodium bromide1 but not bromide of potash4 ,almost needless to say1 sodium bromide is at least as harmful as potassium bromide1 and the advertisement is entirely for purposes of deception4 ,the poor epileptics have been a source of revenue for quacks and charlatans as long as history runs4 ,at the present time one not infrequently finds testimonials from convents1 asylums1 reformatories1 and the like1 asserting the value of some particularly advertised remedy for this disease4 ,all these remedies contain bromides4 ,the treatment of epilepsy is now better understood by physicians and it is generally recognised that the two things that epileptic #ii patients need are outdoor air and as far as possible all freedom from responsibility4 ,bromides will1 for a time1 control the number and frequency of the attacks1 but if used indiscriminately1 and especially if employed without any proper realisation of their possibilities for harm1 these salts are almost sure to make the condition of the patient much worse than before1 to bring on a state in which mental symptoms predominate over physical1 and in which the patient may go into dementia1 or some form of mental alienation4 ,especially is this true with regard to epileptic children4 ,continuous dosing with drugs of any kind is sure to do them harm rather than good4 ,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 treatment4 ,the poor children have to suffer many things from many people4 ,people hesitate1 as a rule1 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 matter4 ,almost any suggestion1 however1 with regard to the dosing of their children is likely to be followed by loving but indiscreet mothers4 ,it is well known now1 and in many cases is admitted1 that the so-called soothing syrups so often given to children contain opium in quite appreciable quantities4 ,needless to say1 nothing much worse than this could possibly be given to children4 ,the child soon becomes accustomed to its daily dose of opium and craves the repetition of it4 ,it will not sleep without it1 and as this adds to the sales of the remedy1 this special ingredient continues to put money in the pockets of the manufacturers1 but at the expense of the nervous stability of the child1 and lack of resisting power later in life4 ,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 life2 but undoubtedly this evil has had much to do with the noticeable increase in the nervousness of our people4 ,the more nervous the heredity of the child1 the more it must be guarded against such mistaken methods of inducing sleep1 or the result is sure to be serious4 #ajj ,scarcely too much can be said in condemnation of most of the proprietary remedies for constipation1 though it is in this department of medication that the non-medical are freest with their advice4 ,first1 the cheapest possible drugs are selected by the manufacturers of such remedies4 ,secondly1 those drugs especially are employed which1 while producing the desired immediate effect1 are always followed by a reaction which requires further use of the medicine4 ,one finds testimonials1 however1 from all classes of the community1 even from clergymen1 with regard to such remedies1 though at the last international medical congress it was confidently asserted1 by three of the most prominent specialists in digestive diseases in the world1 that the modern problems in digestive disturbances are so much more intricate than they used to be1 and the affections which develop are so much more difficult of treatment1 because of the use of these unsuitable remedies1 and the consequent habituation to drugs1 which has been acquired during the prolonged period of their employment4 ,in recent years catarrh has become the word that is supposed to attract popular attention most1 and accordingly is the watchword of the proprietary medicine manufacturer4 ,a long time ago1 that is1 about half a century ago1 catarrh was supposed really to mean something in medicine4 ,those were the days of humoral pathology1 when disturbances of secretion were supposed to be the basis of all disease4 ,accordingly1 whenever there was an excessive discharge from the nose1 a patient was said to be suffering from catarrh1 and as the nasal secretion was supposed to be connected in some way with the brain1 it is easy to understand how significant such a pathological condition might well be thought4 ,in more recent years1 the word catarrh has still been employed by physicians who thoughtlessly employ terms that they think will be better understood by the laity1 owing to their familiarity with them1 though they have been outlived in medicine4 ,from representing an affection of the nose1 catarrh1 as a consequence1 has come to be employed for an excess of secretion from any mucous membrane4 ,accordingly we hear of catarrh of the stomach1 catarrh of the bladder1 or catarrh of the #aja bile-ducts1 and there has come to the general public a notion that catarrh is an all-pervading affection whose ravages must be prevented1 at all hazards1 and whose beginning must be the signal for prompt medical treatment4 ,as a matter of fact1 catarrh1 when it means anything1 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 hyperaemic1 that is1 due to an increase of blood in the part4 ,it is rather easy to understand that if more blood flows through a mucous membrane1 there will be greater secretion from it than would normally be the case4 ,this is what happens in the production of catarrh4 ,as a rule1 it is only a passing congestion without any lasting changes in the tissue4 ,catarrh may1 however1 continue to be present if the irritation1 which originally caused the congestion1 be allowed to continue4 ,it is this irritation1 however1 which needs to be treated1 and not the catarrhal inflammation1 which is only a symptom of it4 ,the three most used words in popular medicine1--catarrh1 rheumatism1 and gout1--when traced to their etymological signification1 mean the same thing4 ,catarrh means a flowing down1 rheumatism a state of flowing1 both being formed from the ,greek verb ,greek text1 to flow1 while gout is derived from the ,latin word gutta1 a drop1 which hints at the excess of fluid that is supposed to be the basis of the disease4 ,for these three diseases1 however1 the most varied remedies have been proposed1 and practically entirely without success1 when tested1 in a large number of cases4 ,as a matter of fact1 under the two words catarrh and rheumatism1 there is grouped a series of affections very different from one another1 and requiring very different treatment4 ,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 pain4 ,when the exact cause can be found1 it is usually not so difficult to succeed in preventing the recurrence of the troublesome symptoms4 ,it is with regard to these two diseases1 however1 that in non-medical circles even intelligent men are ready to give advice4 ,they constitute #ajb the most puzzling problem that the physician has to deal with1 but the non-medical mind waives the difficulty and suggests the remedy4 ,in this matter one is forcibly reminded of a famous expression of ,josh ,billings1 who used to say1 ,it is not so much the ignorance of mankind that makes them ridiculous as the knowing so many things that are not so4 ,clergymen1 lawyers1 members of ,congress1 and of various state legislatures1 all permit their portraits to appear1 advertising the merits of some trumped-up cure for catarrh or rheumatism4 ,it is interesting to realise1 then1 that in most cases1 according to expert testimony1 the remedy they recommend so highly consists of nothing more than diluted alcohol flavoured so as to taste like medicine4 ,the only real effect is the alcoholic exhilaration which follows its ingestion and gives the sense of well being1 because of which the testimonials are provided4 ,as one of the medical journals said recently1 it would be very interesting to make a list of the men and women throughout the country who1 by permitting their portraits and recommendations to be used in the advertisements of various patent medicines1 have practically confessed that they like to take their whiskey rather dilute but mixed with a little bitters4 ,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 profession4 ,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 money4 ,it is sometimes said that long years have been spent in the preparation of a remedy4 ,this not only is never true1 but never has been true in the history of proprietary medicines4 ,some one who has an eye to business gets hold of a prescription of which he knows nothing1 but of which his advertising agents are able to say much1 and the result is sometimes a fortune for the advertiser4 ,there is always a pretence of philanthropy1 but it is the mask of heartless hypocrisy4 ,unfortunately many of our religious journals are tempted by the promptly paid bills of such manufacturing concerns to print their advertisements4 ,they are aiding in a #ajc deliberate swindle1 and if this were better understood there would be much less suffering and fewer vain hopes4 ,the best-managed newspapers and magazines in the country are now absolutely refusing all medical advertisements4 ,this is the only proper attitude in the matter1 for there is a place to advertise medicines1 if they are worthy1 and that place is the medical journals4 ,if the popular advertising could be reduced1 we should soon have much less of the proprietary medicine evil4 ,there are many ways in which clergymen by their example1 their advice1 and their influence can be of great assistance to practitioners of medicine4 ,it is very sad1 then1 to find that some of them1 having elabourated theories of their own on certain subjects1 or having taken up with peculiar notions1 are in opposition to the accepted medical teaching of the world4 ,occasionally they are found among the ranks of the anti-vaccinationists1 though if there is anything that has been demonstrated to a certainty1 it is that vaccination has practically eradicated smallpox1 considering the frequency of the disease a century ago1 and that it would absolutely eradicate it1 if the practice could be made universal4 ,statistics are at hand to demonstrate this beyond all possibility of doubt4 ,there are a certain number of people1 however1 who apparently1 out of a desire for singularity as much as anything else1 refuse to accept the evidence4 ,it is very unfortunate to find clergymen among them1 for it tends to bring the clerical judgment into disrepute4 ,nearly the same thing might be said of antitoxin for diphtheria4 ,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 not4 ,if they have once committed themselves to the expression of the opinion that antitoxin is of no value1 then no amount of evidence will succeed in changing their opinion4 ,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 on4 ,if such clergymen would only realise that the clergyman has1 as a rule1 much less right to express #ajd opinions on medical subjects than has the physician to air views with regard to theological principles1 there would be much less friction1 and it would be better for patients in the end4 ,there are certain sanitary regulations that clergymen should not only not oppose1 but endeavour1 by every means in their power1 to have those who respect their opinions follow out as carefully as possible4 ,such sanitary regulations have in the past twenty-five years practically cut down the death rate of our large cities a half4 ,there is no greater source of alleviation for the physical evils1 at least those which afflict the lower classes1 than the due enforcement of modern sanitation4 ,there are prejudices1 however1 that must be overcome1 and the clergyman should be found beside the doctor1 helping him rather than opposing him1 as is sometimes the case4 ,,james ,j4 ,,walsh4 #aje ,,viii ,,some ,,aspects ,,of ,,intoxication ,there are various drugs that1 through acute or chronic poisoning from their use1 cause mental disturbance1--alcohol1 chloral1 cannabis indica1 somnal1 sulphonal1 paraldehyde1 ether1 chloroform1 antipyrin1 phenacetin1 trional1 chloralamid1 iodoform1 atropine1 hyoscyamus1 salicylic acid1 quinine1 lead1 arsenic1 mercury1 opium and morphine1 the bromides1 cocaine1 and others4 ,of these intoxicants alcohol always has been most commonly used by western nations1 but the moral aspects of alcoholism have not been shown with sufficient insistence4 ,there are many sots in human society much less reprehensible than to the unskilled observer they appear to be2 others are more blameworthy4 ,morality1 as far as the agent is concerned1 apart from the nature and circumstances of the deed1 supposes1 first1 voluntary acts1 or acts that proceed from the will with a knowledge of the end toward which the acts tend2 and1 secondly1 free acts1 or acts that under given conditions may or may not be willed4 ,if by unavoidable chance one stumbles against a man standing at the edge of a wharf1 knocks him into the water1 and drowns him1 the act has no element of morality in it1 because it is not voluntary and free4 ,if a mind is diseased1 and1 impelled by a mad notion of persecution1 it brings about a like killing1 there is no question of morality1 because the agent is not free1 and when fully analysed his action is not voluntary4 ,an act is more or less voluntary and free1 and therefore more or less moral1 as the agent is affected by ignorance1 passionate desire1 fear1 or disease4 ,ignorance1 fear1 and disease may be such as to remove all quality of morality from an act4 #ajf ,certain diseases or pathological conditions1 especially of the nervous system1 can take out of an act the elements of voluntariness and freedom that are necessary to make the act moral or immoral1 provided1 however1 these pathological conditions are not brought on through the fault of the subject in which they exist4 ,if a man voluntarily becomes drunk with alcohol1 or some other drug1 he is1 of course1 accountable for the evil he may unconsciously do while under the influence of that drug1 and if he begets an idiot or a criminal imbecile in his drunkenness1 he must atone somewhere for the blinded soul of his child4 ,here1 again1 there are certain extenuating circumstances1 because very few drunkards are fully conscious of the extent of the evil in alcoholism4 ,apart from the other requirements that go to make an act moral1 the agent must be sane2 that the act be immoral1 he must be sane or insane1 either temporarily or permanently1 through his own fault2 that it be devoid of morality an act must be a mere actus hominis1 or it must be the act of a person blamelessly insane4 ,if a man knows that an alcoholic is liable to beget a criminal imbecile solely because of the alcoholism1--and most men are aware of that fact1--this father or grandfather is more or less accountable for every larceny1 rape1 and murder done by the imbecile4 ,the law1 therefore1 should put the imbecile into safe keeping1 then seek out the father and hang him4 ,insanity is a common condition1 but it has not been satisfactorily defined4 ,it supposes an appreciable unsoundness of the will1 memory1 and understanding1 or of one or two of these faculties1 but no alienist has given a short differentiation of that unsoundness4 ,where shall we draw the line between the weak but responsible will and the insane will8 ,what degree of opacity between intellect and the world separates the ignorant man from the lunatic8 ,the extremes of sanity and insanity are readily recognisable1 but the intermediate degrees are not clear4 ,there is no test to apply to all cases2 each must be diagnosed from its peculiar symptoms1 but the will of an insane man is always weak4 ,it can not deny or defer the gratification of a desire1 nor can it keep up an effort4 ,even in its lightest forms insanity is selfish and #ajg impolite1 because it lacks the force of will necessary to take trouble4 ,it foregoes great future benefit for slight present gratification4 ,the insane man is idle1 or busy only in work that he likes1 in pleasurable activity4 ,a marked quality of sanity is the capacity for sustained work1 and the man that shirks work merely because he does not like it is gratifying himself dangerously4 ,these defects are found commonly in sane persons1 but the lunatic can not rise from them1 and he adds to the defects of will a warped intellect4 ,he can not adjust himself to his surroundings1 and the fault is in himself1 not in the circumstances4 ,his intellect may be brilliant1 but it sooner or later shows a taint4 ,the insane man is not a free1 rational agent4 ,alcoholism readily passes over into unmistakable insanity1 and it almost always is the cause of nervous degeneration in the children born within its influence4 ,this1 is a phase of the evil not sufficiently insisted upon by those that plead for total abstinence4 ,chronic poisoning by alcohol induces hardening and calcification in the walls of the arteries1 degeneration of the nerve cells and dendrites1 wasting or overgrowth of the heart muscle1 and fatty degeneration of the liver and kidneys4 ,the nerve centres that control the circulation of the blood are paralysed by it1 and1 as a sequence1 the arteries and capillaries are diminished in calibre4 ,this state in turn obstructs the flow of the blood1 and the body is not nourished1 nor are the waste and poisonous results of metabolism carried off as they should be4 ,alcohol prevents the haemoglobin of the blood from doing its office1 which is to supply oxygen and remove carbon dioxid4 ,it absorbs the necessary water from the tissues1 and thus it acts as a corroding poison4 ,it is also a functional toxin1 because it depresses the activity of organs by injuring the innervation4 ,the poison affects the brain1 and as the cerebral gray matter1 especially its pyramidal cells1 are the physical instruments of thought1 will1 and memory1 or the means of communication between the soul and the outer world1 the exercise of these spiritual functions is checked or inhibited by it4 ,a tendency to excess in the use of alcohol commonly #ajh manifests itself before the thirtieth year1 and in some cases it may be removed at the alcoholic climacteric1 which is from the fortieth to the sixty-fifth year4 ,those that become drunkards are usually of a neuropathic constitution1 through inheritance or abuse4 ,severe diseases1 like influenza1 syphilis1 typhoid2 injuries to the head1 sunstroke1 shock1 worry2 the disturbance that may accompany puberty1 pregnancy1 lactation1 and so on1--cause a nervous depression which is soothed by alcohol1 and thus a habit is fixed4 ,the reckless prescription of alcohol by some physicians is another cause of the habit1 and the use of proprietary medicines is a still more prolific source of drunkenness and the consequent misfortune4 ,cider1 beer1 ale1 and porter contain from #d to #f per centum of real alcohol2 light wines1 red and white1 and natural sherry1 #aj to #ab per centum2 strong sherry and port1 #af to #ah per centum2 brandy1 #ci to #dg per centum by weight1 or #df to #ee per centum by volume2 and whiskey1 #dd to #ej per centum by weight1 or #ej to #eh per centum by volume4 ,the effect of these liquors on the body is due primarily to alcohol1 and secondarily to ethereal derivatives of alcohol4 ,some owe a part of their effect to non-volatile substances1--beer from which all alcohol has been boiled can still affect the body in a marked degree4 ,the chemist of the ,massachusetts ,state ,board of ,health 7,document ,no4 #cd7 gives the percentage of alcohol in the common proprietary medicines1 and these percentages will be found in the article on ,social ,medicine4 ,the weakest of these compounds are twice as strong in alcohol as beer1 and they treacherously bring about the habit of drunkenness in disposed persons who may be very desirous to avoid such a calamity4 ,some men and women are quickly destroyed by alcohol2 others resist it more or less successfully for a lifetime1 as far as mere existence is concerned4 ,alcoholism is one of the commonest causes of insanity1 but it is often an effect of insanity4 ,it may be an early symptom of paresis1 or a part of the maniacal stage of circular insanity4 ,in poisoning by alcohol the higher nerve centres are first affected and the #aji lowest last4 ,the sense of human dignity and of morality1 the exercise of the intellect1 are more or less inhibited before the motive muscles are affected4 ,the usual effect of alcoholic poisoning is boisterous exaltation of mind1 but there is a depressed type of drunkenness which weeps4 ,some patients at once are subjected by hallucinations and delusions1 others are so depressed that they have a suicidal tendency1 others may have a maniacal frenzy that is destructive or homicidal4 ,in these neuropathic conditions muscular co-ordination is commonly well preserved--the patient is drunk in the head and sober in the legs4 ,in alcoholism the mental changes are gradual and progressive4 ,the intellect is blunted1 the judgment becomes foolish1 the moral sense is dulled4 ,the drunkard is always a liar4 ,delusions not infrequently occur1 and it is one of the common symptoms of alcoholic insanity to suspect a wife or husband of conjugal infidelity4 ,if a man that is a drunkard accuses his wife of infidelity1 the chances are fifty to one that she is innocent and that he is in the first stages of insanity4 ,this symptom is characteristic also of cocaine intoxication4 ,another mental disturbance of acute alcoholism is delirium tremens1 which is inexactly called mania a potu by some writers4 ,delirium tremens is not a form of mania1 but an acute hallucinatory confusion1 in which the consciousness is much more impaired than it is in a mania4 ,mania a potu is a real mania1 and it is transient commonly1 although it may leave permanent mental weakness with delusions4 ,in chronic alcoholism a paranoid condition may occur1 and this often is incurable4 ,this psychosis may come on suddenly or gradually4 ,in true paranoia the delusions are systematised1 but in this alcoholic pseudoparanoia the enfeebled intellect can not build up coherently even a delusion4 ,the alcoholic hallucinations are visual and auditory1 and we find delusions of persecution1 especially of a sexual nature4 ,the patient hears all kinds of insulting remarks made by voices4 ,these voices often come from his own belly4 ,his enemies send poisonous or foul odours into his room at night1 and the groundless suspicions of his wife's infidelity take most outrageous forms of expression4 ,he will swear #aaj he has seen her misdeeds4 ,often the baseless suspicions of his wife begin before any other noticeable impairment of intellect1 and are not recognised as delusions4 ,the first step a priest should take in investigating accusations of conjugal infidelity is to find out whether the accuser is a tippler or not4 ,the delusions of persecution lead to attacks on the supposed enemies which often are homicidal4 ,occasionally alcoholic insanity takes on a paretic form1 or it may be epileptic4 ,ten per centum of alcoholics are epileptic4 ,when the children of alcoholics are epileptic1 the convulsions begin in these children about four years earlier than in children that are epileptics from other causes4 ,if epilepsy is latent1 alcoholism will start it into action4 ,alcoholism sometimes produces a condition of waking trance followed by amnesia 7lack of memory74 ,in such a state the drunkard may transfer property1 carry out complicated professional actions1 commit crime1 take long journeys1 travel for days1 and so act that no one notices his disordered mental condition4 ,then suddenly he awakens and he has no recollection whatever of what has happened during this trance4 ,he appears to be conscious1 but to have no memory of his consciousness4 ,there is another alcoholic amnesia1 found especially in those that drink much during the morning hours1 where there is instantaneous forgetfulness4 ,if you ask one of these men to shut a door1 for example1 he will forget between his chair and the door what he started to do4 ,this condition is difficult to cure even after the use of alcohol has been relinquished4 ,dipsomania is a form of impulsive degenerative insanity1 and it is probably epileptic in origin4 ,after a few days of insomnia and loss of appetite for food1 there is an irresistible impulse to drink alcoholic liquor and to indulge in other excess4 ,the patient drinks until all means of getting alcohol are exhausted4 ,he will take crude alcohol1 bay rum1 cologne1 the alcohol that is about pathologic specimens in a hospital museum4 ,the attack lasts from one to two weeks1 and is followed by depression and a feeling of remorse4 ,the onsets are irregular in occurrence1 and between them the patient may #aaa be temperate or have even an extreme distaste for alcohol4 ,this form of disease is not infrequent among professional men and clergymen1 and it is impossible to find out just how far the patient is responsible for his condition4 ,if bishops would investigate the alcoholic tendencies of the families of candidates for seminaries1 and reject all that have this taint1 there would be much less scandal4 ,it is a serious error of judgment to ordain a seminarian that has even once been under the influence of alcohol1 and those seminarians that cover up the tippling of a companion1 because he is a good fellow1 are guilty of far-reaching crime4 ,the fact is worth investigation whether or not a liquor dealer who never drinks alcohol1 but who lives for years in the presence of volatilised alcohol1 has much of the alcoholic degeneracy and a tendency to beget neurotic children4 ,certainly the fumes of wood alcohol have killed workmen that went down only once into a vat containing these fumes1 and other alcohols in the form of vapour should have deleterious effects4 ,fere produced monsters in chickens by exposing eggs to the vapour of alcohol4 ,in judging a drunkard1 it must be remembered that in many forms of alcoholism1 after the condition is well established1 the patient has little more freedom of will than a brute has4 ,if he is accountable for the habit1 he is blamable for the crime that follows4 ,if he is not accountable1 and it is often very difficult to prove that he is1 he is to be treated as a blamelessly insane man4 ,in proper surroundings1 and with skilful direction1 a child born with a tendency1 or more exactly a temptation1 to dipsomania or other alcoholic neurosis can be saved1 but commonly the circumstances of such a child's life are the worst imaginable4 ,these children must never take alcohol1 even as a medicine1 and they must not be pushed in school to nervous exhaustion4 ,a tendency to unchastity can run in families1 like a disposition toward alcoholism1 but the disgrace in yielding to this vicious bias keeps many such unfortunates clean4 ,it is to be regretted that public opinion can not give the same aid in alcoholic predisposition4 ,a confirmed alcoholic should be prevented1 if possible1 from marriage1 because his sins will be visited upon his posterity4 #aab ,the first children of an alcoholic may be mentally sound1 the younger children are more or less mentally weak1 the youngest are not uncommonly imbeciles1 or idiots1 or under shock they grow insane4 ,fortunately many of the children of alcoholics die at an early age1 and the family of a drunkard very seldom lasts beyond four generations4 ,in the first generation moral depravity and alcoholic excess are found2 in the second1 chronic drunkenness and mania2 in the third1 melancholia1 hypochondria1 impulsive and homicidal ideas2 in the fourth1 idiocy1 imbecility1 and extinction of the family4 ,the lower the social caste of the drunkard1 the greater the liability of meeting these blights4 ,priests should take a deep interest in societies established for the promotion of temperance1 and the only temperance for most persons is total abstinence4 ,no man knows what latent tendency to alcoholism he may have1 especially in ,america1 where great grandfathers are unknown and the climate and life are trying on the nervous system4 ,the adulterated liquors sold everywhere at present make the danger greater than it ever was4 ,whatever may be the truth as regards heredity1 there is no doubt concerning the strong influence of environment2 therefore get into the temperance societies the children of alcoholic parents1 of parents that are shiftless1 hysterical1 irritable4 ,if a man has a violent temper or if he is unchaste1 get him and his children into the society to check the downward drift4 ,a bad temper is a neurotic taint1 and it commonly is a first step toward alcoholism4 ,do not forget to warn the people against patent medicines that contain alcohol4 ,if you go over the list of the families in a parish1 it is startling to find how few there are without one or more black sheep4 ,the human black sheep1 in a good environment1 is always physically imperfect1 and never so black as the gossips paint him4 ,he may be a powerful football player1 but there is something wrong with his gray matter4 ,he is morally deaf1 he was born so1 and he is to be excused if he can not always hear the still1 small voice4 ,this may sound like lax doctrine1 but it is true1 nevertheless4 ,we must recognise that moral weakness is very often1 #aac partly at least1 a physical defect1 and there is no such state as moral insanity where the intellect is normal4 ,now1 ,i do not wish to be quoted as holding that all moral depravity has a physical basis2 most of it is the unalloyed stuff2 the ,lombroso criminal is not a scientific fact2 but there is a moral condition very frequently met with which is largely physical in origin4 ,given so many grains of cocaine or morphine or so many ounces of alcohol1 and you can make a liar of a man once on the way toward sanctity4 ,given an attack of hysteria in a holy nun1 and she at once becomes a liar1 an altogether blameless liar1 but no influence that does not remove the physical cause will cure the lying4 ,the morally weak do not at present obtain enough religious instruction4 ,their religion is more a matter of inheritance and habit than of positive energy4 ,it is in the bones1 sometimes in the fists1 rather than in the soul4 ,they prefer the ,sunday newspaper to the ,sunday sermon4 ,the remedy here seems to be in making the ,sunday school solidly interesting and its teaching impressive4 ,alcoholism in the parents1 especially drunkenness at the moment of conception1 is one of the chief causes of idiocy in children4 ,fere1 as was said before1 by injecting a few drops of alcohol beneath the shell of hens' eggs1 or by exposing the eggs to the vapour of alcohol1 could produce monsters almost invariably4 ,in #ajjj cases of idiocy at the ,bicetre1 ,bourneville found a history of alcoholism in #fbj1 or #fb per centum3 in the fathers of #dga1 in the mothers of #hd1 in both parents of #fe2 and in one-half of the remaining #ch per centum no history was obtainable--probably most of these also had the alcoholic taint4 ,the administration of alcohol to infants1 of gin and whiskey1 of essences of peppermint and anise1 to relieve colic or induce sleep1 and the dosing with opiates like paregoric1 are also well-established causes of idiocy4 ,the idiot is practically dead1 except for the trouble he gives in caring for him2 but another unfortunate1 the imbecile1 most commonly the offspring of alcoholics1 is often capable of great mischief4 ,the higher grades of imbeciles1 those nearest the normal1 are almost invariably criminals4 ,not all criminals1 of course1 are imbeciles1 but a vast number of petty and brutal #aad criminals are imbeciles4 ,we keep these unfortunates most of their lives in jail1 while we fine their drunken fathers1 the cause of the imbecility1 five dollars and costs4 ,imbecility has grades1--from marked lack of intellectual power1 a stage little beyond idiocy1 up to the presence of a mind capable of fair education1--but in all cases there is real defect1 either of intellect or of will4 ,sometimes1 where the will is so weak that the patient becomes a criminal in spite of all training1 the intellect is practically normal to the superficial observer4 ,the grades of imbecility can not be clearly marked off from one another1 but1 roughly speaking1 there are three4 ,the lowest grade of imbeciles understands simple commands1 and has a slight manual dexterity4 ,they express themselves by signs and in monosyllables4 ,they can not concentrate attention upon anything1 nor can they be taught to read or write4 ,careful training can advance them so far that they may do rough1 menial work1 and they are industrious when directed by a present superior4 ,they are inclined to masturbation4 ,if they are not teased1 they are quiet2 if annoyed1 they may become dangerous4 ,imbeciles of the middle grade can converse in a narrow vocabulary1 and they commonly stammer4 ,they may be taught to read monosyllables2 they can not do even the simplest sum in addition1 yet they show a certain shrewdness4 ,they are irritable and quarrelsome1 inclined to lying and stealing1 and they have no sense of shame4 ,they will not do any regular work1 but change from one occupation to another4 ,they may have sexual instincts and cause trouble on that account4 ,they are slow to understand1 their memories are defective1 and they are always very vain4 ,their belly and what they shall wear are the chief things in their lives4 ,they are less criminal than the highest grade of imbeciles4 ,the third class1 the high-grade imbecile1 is the most important1 because he is commonly a criminal4 ,his intellect is below the average1 and his will is very flabby4 ,he learns little at school1 and what he does learn is acquired slowly4 ,he reads and writes badly and he may be able to add simple #aae columns of numbers1 but he can not multiply or divide4 ,sometimes such an imbecile has a remarkable facility in getting a speaking knowledge of two or three languages1 and he may learn a trade4 ,there is a high-grade imbecile that is cunning and shrewd1 but he has no will1 and he is a criminal4 ,as imbeciles approach the normal in intellect they recede from it in abnormality of will4 ,autopsies on imbeciles show an infantile development of the forebrain4 ,imprisonment does no good in these cases4 ,they are not taught anything in prison1 not even a trade1 because the labour organisations and the protected industries will not permit prison labour4 ,they should be confined so that they will not pervert youth and propagate their kind4 ,it is impossible to say how far a given imbecile is morally accountable for what he does1 but the accountability is not full in the best cases4 ,a neurasthenic1 however1 is not to be mistaken for an imbecile4 ,a neurasthenic person may have a tender conscience1 an imbecile has no conscience4 ,in imbecility the fault is in the will1 rather than in the intellect1 in the middle and highest grades4 ,many women1 especially1 that are hopeless fools intellectually have strong wills1 but an imbecile never has a strong will except in the sense that stubbornness is strength4 ,stubbornness is perverted strength4 ,morphine and ,cocaine ,intoxication1--,morphine1 an alkaloid of opium1 is used very extensively as an intoxicant4 ,since #ahij the importation of opium into the ,united ,states has increased fourfold1 although physicians are now using less opium than they formerly did4 ,the insomnia1 worry1 moral distress1 which bring on the alcoholic habit in some persons1 lead to morphinism in others4 ,some physicians1 by carelessly prescribing morphine for neuralgia1 migraine1 dysmenorrhoea1 or any pain1 make their patients slaves of this drug4 ,the degenerative effects of morphine are not so great nor so rapid as those of alcohol4 ,it does not shorten life so much as alcohol does1 nor are the children of a person addicted to the use of the drug so liable to idiocy and imbecility4 ,the mind is enfeebled--slowly in some cases1 rapidly in others4 ,the patient will resort to almost any means to obtain the #aaf drug1 if he is deprived of it4 ,authorities hold that he will lie without reason1 merely for the perverse pleasure in deceiving1 that he is uncertain and treacherous1 with a dull conscience and morbid impulses4 ,there are exceptions to this in cases where the drug is easily obtained by the patients4 ,opium and morphine diminish the sexual appetite in males1 even to impotence4 ,the bodily changes are slow but profound4 ,when a user of morphine has been deprived of the drug for from ten to fifteen hours1 he becomes so weak he can not stand2 he gets diarrhoea with cramps2 he sweats1 trembles1 and collapses4 ,later1 mental disturbance comes on4 ,he grows delirious1 sees insects and small animals1 as the delirium tremens patient does1 and his suffering is very great4 ,it is extremely difficult1 and commonly impossible1 to cure the morphine disease after it has been firmly established1 and a deliberate acceptance of the habit is evidently a grave vice4 ,where a patient has become addicted to the use of the drug1 through the fault of a physician1 or through ignorance1 the treatment from the social point of view of such a patient is commonly cruel4 ,cocaine intoxication is much worse than morphinism4 ,it is a new excess1 which was unknown before #ahhf4 ,many users of morphine can carry on business1 but the cocaine habitue can not do so4 ,he is always extremely busy doing nothing4 ,he writes long letters which are never finished4 ,he changes from work to work1 and even his conversation wanders4 ,his bodily weight decreases rapidly1 even one-third of his whole weight may be lost within a few weeks4 ,the skin hangs in folds and is of a dirty yellow colour1 the facial appearance is that of extreme distress1 and the muscles are feeble4 ,fainting1 irregular cardiac action1 sweating1 and insomnia are other symptoms4 ,insanity is an occasional sequence1 with hallucinations1 especially of hearing4 ,such a patient hears roaring noises and voices2 his secret thoughts are shouted out1 he thinks1 to crowds2 loud screams1 shrieks of murder1 and similar noises appall him4 ,again1 he sees swarms of flies1 ants1 roaches1 which cover him and crawl into his mouth1 nostrils1 #aag and ears4 ,he feels bugs crawling under his skin1 and he has a multitude of similar interesting experiences4 ,such patients grow homicidal4 ,like alcoholics1 they are jealous and suspicious of their wives1 but1 unlike the alcoholic1 the cocaine user is commonly reticent2 he is not willing to talk of his troubles4 ,the prognosis is always bad1 even in the best cases4 ,this drug can be withdrawn from a patient more rapidly than is possible in chronic poisoning from morphine1 but a relapse is to be expected4 ,in dipsomania1 morphinomania1 and other drug habits1 and in the cases of vicious and degenerate children1 many encouragingly good results have been reported from the use of hypnotism4 ,forel1 ,voisin1 ,ladame1 ,tatzel1 ,hirt1 ,nielson1 de ,jong1 ,liebeault1 ,bernheim1 van ,eeden1 van ,renterghem1 ,hamilton ,osgood1 ,wetterstrand1 ,schrenck-,notzing1 ,kraft-,ebbing1 ,francis ,cruise1 ,lloyd ,tuckey1 ,kingsbury1 ,woods1 and others have undoubtedly cured dipsomania by hypnosis4 ,wetterstrand alone cured #cg of #ea cases of morphinism by hypnosis4 ,one of these patients had been using morphine for fourteen years and morphine with cocaine for an additional four years4 ,all his cases except one were treated at home--they were not obliged to go to a hospital or sanitarium4 ,as to vicious children3 ,liebeault in #ahhg recorded #gg cases1 #de of whom were boys and #cb girls4 ,by hypnosis #ef of these were cured1 #i improved1 #ab were not affected4 ,as to the so-called dangers of hypnotism in the hands of skilled physicians1 there are none4 ,forel said3 ,liebeault1 ,bernheim1 ,wetterstrand1 van ,eeden1 de ,jong1 ,i myself1 and the other followers of the ,nancy school1 declare absolutely that1 although we have seen many thousands of hypnotised persons1 we have never observed a single case of mental or physical harm caused by hypnosis4 ,travelling mountebanks that hypnotise in public can do harm1 and they should be prevented from so doing4 ,on the continent of ,europe only physicians are permitted to use hypnosis4 ,for a bibliography of hypnosis as a curative agent1 see ,allbutt's ,system of ,medicine1 vol4 viii4 p4 #dbh 7,the ,macmillan ,co474 #aah ,in ,genicot's ,theologiae ,moralis ,institutiones1 vol4 i4 p4 #afb 7,louvain1 #aijb71 is the following passage3 ,videtur licitum ebrietatem inducere ad morbum depellendum1 si quando practicum est1 ex gr4 ad typhum depellendum1 vel ad coercendam vim veneni quod e serpentis morsu haustum sit 7,sabetti4 ,n4 #adi74 ,similiter1 per se licebit sensus sopire ope ebrietatis ad magnos dolores levandos3 nullum enim discrimen morale videtur inter hoc medium et alia1 ex gr4 chloroformium1 quae adhiberi solent4 ,that is1 ,father ,genicot permitted alcoholic intoxication to cure typhus or typhoid 7typhoid is called typhus abdominalis in ,europe7 and snake bite1 or to quiet great pain1 as chloroform is used1 in his opinion4 ,this doctrine would be correct morally if from a medical point of view alcoholic intoxication cured typhus1 typhoid1 or snake bite1 but it does not4 ,alcoholic liquors are necessary in some stages or forms of typhus and typhoid1 and they must be administered skilfully2 but to induce alcoholic intoxication in any pathological condition is always to add a grave poison to the disease already at work4 ,the very name of the condition is intoxication1 poisoning4 ,you can end a toothache by removing a man's jaw1 but the practice is not to be encouraged4 ,in ,america1 when a person is bitten by a rattlesnake or copperhead1 the first aid to the injured is commonly a pint of whiskey4 ,you might better rub milk on the patient's bootheels1 because the milk is harmless1 but the pint of whiskey is anything but harmless2 and one is as good as the other as far as curing the snake bite is concerned4 ,whiskey is popularly supposed to be a good medicine in all the ills of humanity4 ,it is a good medicine in certain cases and a very bad medicine in others4 ,a snake bite is a startling evil1 and while far from a physician the early settlers gave the patient the only medicine they had1 whiskey1 and if a little is good a great deal is better4 ,as the bite of the ,north ,american snakes is frequently not fatal1 some early victims grew well in spite of the snake venom and the added whiskey poisoning2 therefore a pint of whiskey cured them1 post hoc ergo propter hoc4 ,thus the cure became fixed in the popular ignorance1 and some moral theologians1 without investigating the #aai matter1 fixed it deeper4 ,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 ,kentucky4 ,the only hope in such cases1 is in ,calmette's antitoxin1 administered within an hour or two after the poisoning4 ,snake venom paralyses the muscles of respiration1 and the patient ceases to breathe4 ,a little whiskey may do good--whiskey pushed to intoxication is very injurious4 ,artificial respiration1 if needed1 as in a case of attempted resuscitation after partial drowning1 with skilful stimulation by a physician1 and the use of an antitoxin1 are the main parts of the treatment in snake poisoning2 but to pour a pint of whiskey into the victim is cruel ignorance4 ,patients often come into dispensaries showing bitten wounds which are stuffed with hair from the dog that did the biting2 whiskey causes a man to see snakes1 therefore use hair from the dog that bit you4 ,this may be good homoeopathy1 but it is not medicine4 ,the making a man drunk with alcohol to remove great pain is a treatment not used by reputable physicians3 there are many correct medical methods of removing pain1 but a big draught of whiskey is not one of them4 ,even in a case where a physician can not be found1 it is usually questionable whether the effect of alcoholic intoxication would not be worse than the irritation of the pain2 and if it were not1 where is the line to be drawn8 ,some male and female old ladies can work up great pain from a colic4 ,the bigger and stronger a man is1 especially if he has never been ill before1 the greater his agony when he is having a tooth filled4 ,,austin ,,omalley4 #abj ,,ix ,,heredity1 ,,physical ,,disease1 ,,and ,,moral ,,weakness ,heredity is a very vexed question1 with regard to which most varied opinions are held even by those apparently justified in having opinions1 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 imagined4 ,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 ,austria1 done about forty years ago1 which has lain utterly unrecognised ever since1 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 century4 ,father ,gregor ,mendel's work ,footnote #b was done with regard to the pea plants in his monastery garden1 and it revolutionised all the supposedly scientific thinking with regard to heredity that has been current in biology for half a century4 ,footnote #b3 ,see ,american ,ecclesiastical ,review1 ,jan4 #aijd2 ,walsh1 ,a ,new ,outlook in ,heredity4 ,this serves very well to show how far in advance of observed facts theories of heredity have gone4 ,there is undoubtedly a very significant influence exerted over life and its functions by the special powers that are transmitted by heredity4 ,how far this influence extends1 however1 and how much it may be said to rule details of existence1 of action and in human beings1 that complex of elements we call character1 is entirely a matter of conjecture1 and the #aba belief in its extent1 or limitation1 depends absolutely on the tendency of the individual mind to accept or discredit certain theories in heredity which have had great vogue4 ,until within a very few years it was considered a matter of common experience and observation that under some circumstances1 at least1 acquired characteristics were transmitted by heredity4 ,that is to say1 it has been definitely asserted as probable1 and by many even intelligent people considered absolutely certain1 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 ways4 ,it was not1 of course1 thought that if a man lost an arm and subsequently begot a child1 the child would be born without an arm1 but slighter modifications of the organism were somehow supposed to be transmissible2 and1 on the other hand1 modifications which affect important organic structures of the body were somehow thought to have a definite effect1 by transmission1 upon corresponding portions of the progeny4 ,when this theory is stated thus baldly1 very few people confess their belief in it1 yet how many there are who find ample justification for such expressions as1 ,his father suffered from rheumatism and it is not surprising then that he should have it2 ,her mother had heart trouble and we've always been afraid she would suffer in the same way4 ,we are only just beginning to get beyond the period in which consumption was thought to be directly and almost inevitably inherited4 ,with regard to mental ailments this was frankly conceded by nearly every one4 ,if the direct ancestry suffered from mental disease of some kind1 then it is not considered surprising that the immediate descendants should be mentally affected in some way4 ,physicians are quite as prone as those without medical training to make loose statements of this kind4 ,of course there is a reason for the confusion that exists in this matter4 ,oliver ,wendell ,holmes once said that he could cure any patient that came to him for treatment1 if he but applied to him in time4 ,for proper success1 however1 he considered that many of his patients would have had to come to him in the persons of their great grandfathers4 ,as #abb a matter of fact1 many of the supposed hereditary influences that are traced only to a father or a mother are family conditions that have existed many generations1 and that were probably originally acquired1 but the moment of whose acquisition cannot be definitely determined4 ,we know that the ,hapsburg lip has been a distinguishing feature1 a persistently recurring peculiarity1 in some of the members of the ,austrian ruling family in nearly every generation for seven centuries4 ,how much farther back than that it goes we have no way of determining4 ,it is a family affair1 a characteristic which became a matter of heredity perhaps ten centuries ago1 but the mode of its original acquisition is a mystery4 ,there is no really great scientist in biology at the present moment who teaches the hereditary transmission of acquired characteristics4 ,modifications of the organism that become matter for heredity have existed for many generations and we cannot tell just how they began4 ,there is no doubt that there is some hereditary influence1 for insanity in the same family is likely to keep recurring in successive generations4 ,more than this1 affections of certain less important organs are evidently a common trait in certain family strains4 ,there is no doubt that in some families stomach affections are the rule in successive generations4 ,it is very hard to say1 however1 just when such defective organisation became a family trait4 ,the tendency to nervous affections is undoubtedly a similar family affair4 ,certain affections have been hereditary traits for many generations4 ,an excellent example of this is the so-called ,huntingdon's chorea1 which several generations of ,american doctors1 of the name of ,huntingdon1 by following carefully the history of certain families on ,long ,island1 succeeded in tracing through four generations4 ,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 order1 or in the moral order of withstanding trials and temptations1 and the allurement to abuse of nervous excitement to which they may be subjected4 ,that some acquired pathological condition1 however1 as stomach trouble1 or heart #abc trouble1 or affection of the liver or of the brain1 should be directly transmitted1 is quite as nonsensical as that the loss of an arm should be a subject for hereditary transmission4 ,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 generations4 ,the possibility of inheritance must therefore always be borne in mind4 ,we are utterly unable as yet to understand how such family traits are originally developed1 since1 in ordinary experience1 at least1 acquired characteristics are not the subject of inheritance or transmission1 and consequently it becomes difficult to understand how they ever became impressed upon the family constitution4 ,notwithstanding this general principle with regard to heredity1 there are a number of striking observations which show that even unimportant peculiarities may occur from generation to generation1 though it is not always easy to decide where the peculiarity originated4 ,the well-known example of the occurrence of six toes has already been mentioned1 and is an oft-quoted bit of evidence as regards hereditary transmission4 ,an extra finger on the hand1 or some portion of an extra finger1 at least1 comes in the same category4 ,not long since it was pointed out that harelip is another of these peculiarities that readily lends itself to hereditary transmission4 ,recently there was the report of a family into which there were born four girls with harelip and cleft palate1 and three boys not showing any trace of these deformities4 ,often when in such cases there is no definite history of harelip1 it is found that in either one of the parents there is a very high arched palate and a thin upper lip1 showing that the normal occlusion of the cleft which exists here during foetal development is not quite perfect1 and this peculiarity may be traced for several generations back1 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 cleft4 ,an even more striking manifestation of a physical anomaly1 as a family trait1 is the condition known as hemophilia4 ,this #abd tendency to bleed easily1 so that a slight scratch1 or the pulling of a tooth1 may give rise to fatal hemorrhage1 occurs1 as a rule1 only in males1 but is transmitted through the female line4 ,it is in the mother's male relatives that the history of its previous occurrence is found1 and the tendency usually can be traced through several generations1 until it is lost in vague tradition4 ,it is no wonder1 with such examples before them as six-toedness1 harelip1 and hemophilia1 that physicians have been ready to accept heredity of qualities in the moral order1 traits of character and disposition1 and pathological tendencies to crime or passion or indulgence4 ,one of the most frequently discussed conditions of supposed pathological inheritance of this order is dipsomania4 ,everyone has heard it said1 ,poor fellow1 how can he help it2 his father was a drunkard before him4 ,as we have already said1 in such direct cases inheritance is absolutely unproven4 ,an alcoholic father may transmit a very weak physical constitution to his children1 and this may prove inadequate to enable them to withstand the emotional strain and worry of modern great city life1 and1 as a consequence1 they may take to alcohol for consolation until the habit is formed1 and then the craving for stimulants supplies the place of any hereditary influence that may be supposed to be needed4 ,of course there are cases of the drink habit in which1 after a number of generations of family history of alcoholism1 an individual seems to have the craving for stimulants born in him4 ,in such cases it is not unusual to find that the patient1 for such he must be considered1 is able to avoid indulgence in liquor entirely1 except at certain times4 ,every physician of any large experience has had under his care dipsomaniacs who had no difficulty in keeping away from liquor for weeks1 or even months1 but who had regularly recurring periods1 sometimes as far apart as every three months1 when they had an irresistible craving for stimulants come over them4 ,the regularity of the interval in these cases is often very remarkable4 ,here1 of course1 we may be in the presence of some as yet not well-understood periodical law of cell life1 with consequent depression1 and then the irresistible craving for stimulation4 #abe ,as a rule1 however1 it would seem that in most of these cases suggestion has great influence4 ,as we have said elsewhere1 with regard to suicide1 when a man has constantly before his mind's eye the fact that a father1 perhaps a grandfather1 or other members of the family1 have committed suicide1 he is likely to be much more easily led to the thought of this way of escaping hard conditions in life than are other individuals4 ,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 depression1 or for friendship's sake1 though he realises that it so weakens his will power over himself that he is likely to take too much before he stops4 ,the passage in ,julius ,caesar 7,act4 ,i4 sc4 #b7 in which ,cassius says3 ,the fault1 dear ,brutus1 is not in our stars1 but in ourselves1 illustrates one phase of the subject4 ,there are1 of course1 many other things besides the drink habit1 with regard to which men are prone to find excuses in heredity1 and to consider that somehow their ancestral tendencies make them not quite responsible for actions commonly considered the result of malice or passion1 rather than hereditary influence1 and our great ,english poet1 knowing men so well1 has stated the truth forcibly4 ,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 qualities3 ,this is the excellent foppery of the world1 that1 when we are sick in fortune1--often the surfeit of our own behaviour1--we make guilty of our disasters the sun1 the moon1 and the stars2 as if we were villains by necessity2 fools by heavenly compulsion2 knaves1 thieves1 and treachers by spherical predominance2 drunkards1 liars1 and adulterers by an enforced obedience of planetary influence2 and all that we are evil in1 by a divine thrusting on2 an admirable evasion of whore-master man1 to lay his goatish disposition to the charge of a star6 #abf ,one phase of the question of hereditary tendencies to inebriety is extremely interesting from a physiological and sociological point of view4 ,as the result of carefully gathered statistics1 there seems to be no doubt now that when children are conceived while the parents1 or either of them1 is in a state of drunkenness1 the offspring is very likely to be of low-grade physical constitution and often of very neurotic tendencies4 ,in ,france1 particularly in the case of a number of insane children and idiots1 histories of this nature have been obtained in confirmation of this unfortunate factor as an element in degeneracy4 ,in general it may be said that about one-third of the admissions to homes for children of low intelligence1 as well as to insane asylums1 are due to this cause4 ,there is in this1 of course1 an added motive for temperance1 and it would seem that parents should be warned of the danger to which they are subjecting their offspring by excessive indulgence in alcohol1 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 future4 ,this phase of alcoholic excess has never been taught as insistently as its importance would demand1 perhaps because of the delicacy of the subjects which it involves2 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 knowledge4 ,footnote #c ,footnote #c3 ,the present conditions that obtain with regard to the celebration of marriages are very prone to have a certain amount of intoxication as their result4 ,perhaps1 then1 it is a fortunate thing1 as has often been said1 that the first child is not born until some considerable time after it might normally be expected4 ,it has been said more than once1 however1 that first children are a little more likely to have certain degenerative defects than are others1 and a connection has been found between certain abuses of stimulants and incidental exhaustion to account for this4 ,one of the most amusing things to ,li ,hung ,chang1 on his travels through our country1 was the curious publicity we give to everything connected with marriage1 while presumably our ,christian ideas should rather counsel a veiling of the mysteries1 religious and physical1 connected with it4 ,certain it is that the present tendency towards farewell dinners at clubs1 and other festivities of various kinds1 are not at all likely to result in benefit to the presumably hoped-for offspring4 ,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 observations4 #abg ,de ,vries1 the professor of botany at the ,university of ,amsterdam1 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 generation4 ,these plants breed true1 that is1 maintain their own peculiarities4 ,to begin with1 they are quite different from the parent plants1 and the difference is perpetuated by inbreeding4 ,so far the problem of the origin of species has been supposed to depend upon the normal variation that is noticed in plants and animals4 ,all living things differ from one another1 even though they may belong to the same species1 and differ sometimes in remarkable degrees4 ,this continuous variation was supposed to account for the origin of new species when it became excessive4 ,it has become well recognised now1 however1 that such differences gradually disappear in the course of the normal multiplication of plants and animals4 ,the tendency is much more towards the disappearance than the maintenance of peculiarities4 ,there are certain discontinuous variations1 however--sports1 as they are called--in plants which differ very markedly in some quality from others1 and these have the tendency to perpetuate themselves4 ,just why these sports occur is not known1 nor how4 ,they occur in a certain small percentage of all normal plants1 but may die out1 though it takes but little encouragement to succeed in helping them to maintain themselves4 ,it is this that ,de ,vries has done1 and thus has succeeded in raising what would be called new species of plants4 ,this same thing would seem to occur in human beings4 ,some definite variation occurs as a consequence of a peculiar embryologic process4 ,this becomes stamped upon the genital material and appears in the subsequent generations4 ,it does not occur as a consequence of pathological changes nor of mere embryonic faults2 it is almost as if it were something introduced from without4 ,once having found an entrance1 however1 it affects the germinal material and thus perpetuates itself4 ,with regard to plants1 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 nature1 and that it is thus that evolution is intentionally #abh brought about4 ,this is1 of course1 a scientific reversion to teleology once more1 but the question of teleological influences has been discussed more seriously in the last few years in biological circles than ever before4 ,unfortunately for the coincident evolution argument involved in human beings1 the peculiarities introduced1 which become the subject of inheritance1 do not make for the development1 but rather for the degeneracy1 of the race4 ,even such peculiarities as six toes can scarcely be said to add any special feature of advantage to man in his struggle against his environment4 ,it is agreed by many of our best authorities in biology1 zoology1 and botany1 by such men as ,professor ,wilson of ,columbia ,university1 ,professor ,thomas ,hunt ,morgan of ,bryn ,mawr1 ,professor ,castle of ,harvard ,university1 ,professor ,bailly of ,cornell ,university1 ,professor ,michael ,guyer of the ,university of ,cincinnati1 ,professor ,spillmann1 who is the ,agrostologtst of the ,united ,states ,government1 and ,professor ,bateson of the ,university of ,cambridge1 ,england1 that these principles of heredity enunciated by ,father ,mendel will undoubtedly revolutionise the modern knowledge of the subject4 ,in the meantime1 however1 all the old theories are in abeyance4 ,darwin's work and ,weissmann's brilliant theories and observations must give way1 while the application of these new laws is being worked out to their fullest extent4 ,while the influence of heredity can not be denied1 there is undoubtedly a tendency to overestimate the influence on the physical being of the power of hereditary transmission1 and1 on the other hand1 to underestimate the influence of this same force as regards disposition and character4 ,there is no doubt now that the physical basis influences the exercise of the will1 and that consequently responsibility is not infrequently modified by the hampering influence of unfortunate physical qualities4 ,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 pitied1 while its failure of recognition by the unco guid not only causes suffering1 but in the end adds to the amount of evil4 ,,james ,j4 ,,walsh4 #abi ,x ,,hypnotism1 ,,suggestion1 ,,and ,,crime ,in recent years a quasi-unconscious state1 induced by suggestion and called the hypnotic trance1 has come to occupy a very important place in the popular mind4 ,hypnotism1 as the general consideration of this state is known1 has attracted not a little attention1 as well from physicians as from those interested in psychology4 ,the hypnotic 7,greek1 ,greek text1 sleep7 trance is a condition in which voluntary brain activity is almost completely in abeyance1 though the mind is able passively to receive many impressions from the external world4 ,there are very curious limitations in the effect of the hypnotic state upon the various senses4 ,while visual sensations1 and1 as a rule also1 impressions from the tactile sense1 lose their significance1 or are translated according to the will of the person active in producing the hypnotic state1 or of some person present making suggestions1 auditory sensations are quite normally perceived4 ,the patient has all the appearance of being asleep1 though motions1 and even locomotion1 are often possible1 and are performed as if the patient were walking in sleep4 ,the hypnotic state is a partial sleep1 then1 of the motor side of the nervous system and of portions of the sensory nervous system4 ,certain of the higher intellectual powers1 however1 are entirely awake1 and capable of being impressed through the hearing1 and thus hypnotic suggestion has a place4 ,for a time1 under the influence of ,charcot and his disciples1 there was a very generally accepted opinion that the hypnotic trance was a pathological condition1 somewhat allied to the cataleptic phase of major hysteria4 ,it is well known that persons suffering from severe attacks of hysteria #acj may1 while apparently unconscious1 yet receive suggestions through the hearing4 ,on the other hand1 the production of cataleptic and other strained attitudes1 in the maintenance of which fatigue seems to play no part1 is possible by means of hypnotic suggestion in susceptible individuals4 ,further investigation1 however1 seems to have shown that the hypnotic state is rather to be considered as a quasi-physiological condition1 somewhat related to sleep1 all the mystery of which is not as yet understood4 ,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 physiologists4 ,hypnotism is recognised now as having a certain limited power for good1 though the benefit derived from it is apt to be temporary1 and the operator loses his power after a time1--not so much failing to produce the hypnotic condition1 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 trance1 it is now generally considered that something less than #dj per centum of ordinary individuals can be brought under its influence4 ,much has been said of the dangers of hypnotism4 ,there seems no doubt that very nervous persons are likely to be hurt by repeated recourse to the hypnotic condition4 ,after a time they are likely to live most of their lives in a half-dreamy condition1 in which initiative and spontaneous activity becomes more difficult than before4 ,where persons have been hypnotised by means of the flash of a bright object1 or by some other special means1 it sometimes happens that accidentally some similar object may send them into hypnotic trance4 ,after a time1 too1 auto-hypnotism becomes possible1 and much of the individual's waking time is occupied with efforts to keep himself from going into the hypnotic trance4 ,these are1 however1 very extreme cases1 likely to occur only in those who are not of strong mentality in the beginning4 ,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 charlatans4 ,for the great majority of those that are susceptible to the #aca hypnotic condition1 there is very little danger4 ,we now have on record the experiences of men who have seriously devoted many years to the study of hypnotic phenomena4 ,there is entire agreement among these men that the possible dangers of hypnotism have been exaggerated4 ,indeed1 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 condition4 ,dr4 ,milne ,bramwell1 who1 for a quarter of a century1 has had a very extensive experience with hypnotism in its many phases1 in his recent book on hypnotism1 deliberately speaks of the so-called dangers of hypnotism4 ,he has never seen any evil effects1 though he has been practising hypnotism very freely on all kinds of patients for over twenty years4 ,it is on the experience of such serious1 disinterested observers that we must rely for our ultimate conclusions as to hypnotism1 rather than on the claims of pseudo-experts who like to magnify their own powers1 or on popular magazine articles1 or still less the ,sunday newspapers1 the writers for which are mainly interested in producing a sensation4 ,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 past4 ,interest in hypnotism runs in cycles1 reaching a maximum about once a generation1 and we are on the downward swing of the last wave of popular attention to this subject4 ,a subject that has attracted much attention1 whenever hypnotism has been under discussion1 has been the possibility of crime being committed under the influence of hypnotic suggestion4 ,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 wrong4 ,the supposed exceptions to this rule are rather newspaper sensations than real compelled crimes4 ,there is no doubt1 however1 that a tendency to the performance of certain wrong actions1 so that the normal disinclination to their performance becomes much less than before1 may be cultivated by a series of hypnotic as well as by waking suggestions4 ,where the individual influenced is #acb already characterised by weakness of will in certain directions1 the added weight of the motives furnished by hypnotic suggestion may prove sufficient to turn the scale of responsibility4 ,it is probably because of such influence that a recent case in ,france has attracted world-wide attention4 ,in general1 however1 it may be said that normal individuals can not be brought to the commission of crime by hypnotic suggestion1 and the plea of irresponsibility1 for this reason1 is not worthy of consideration4 ,there are phases of this important problem1 however1 which require further careful study4 ,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 mind4 ,some of the cases of hereditary dipsomania are almost surely of this character4 ,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 tendency4 ,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 life4 ,there seems no doubt that suggestion must have great influence in such cases4 ,in one well-authenticated report1 mentioned in the chapter on suicides1 the members of the family were officers in the ,german army1 and the eldest son1 the family representative1 committed suicide within the same five years of life1 in four successive generations4 ,the last member of the family had refused to marry1 because of this doom hanging over the house1 and had often referred to the possibility of suicide in his own case4 ,in his early years he seemed to have the idea that he might escape the family fate1 but after middle life he settled down irretrievably to the persuasion that he would inevitably go like the others4 ,here1 in ,america1 a rather striking example of this has recently been the subject of sensational newspaper reports4 ,a notorious gambler1 whose career had seen many ups and downs1 finally found himself in a condition where1 strange as it may seem1 legal restriction made it impossible for him to #acc continue his usually lucrative profession4 ,three members of his immediate family1 two brothers and his mother1 had committed suicide4 ,to friends he had sometimes spoken of this sad history of family self-murder1 but always with a calm rationality which seemed to indicate that he hoped to avoid any such fate4 ,when well on in years1 however1 with his means of livelihood taken from him1 he1 too1 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 occupation4 ,it seems not unlikely1 from the circumstances of the case1 that a double crime1 homicide1 as well as suicide would have been reported1 only for the fortuitous circumstance that the other man was not in at a time when usually he was to be found at his office4 ,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 suicide4 ,something can be done for such unfortunates by suggestion in the opposite direction1 and by taking care that as far as possible they are not allowed to brood over the fate they consider impending4 ,at times of stress and emotional strain1 relatives and friends must be particularly careful in their watch over them4 ,it is never advisable that they should take up such professions as those of broker or politician1 or speculator1 since the emotional states connected with such occupations are likely to prove too much for their mental equilibrium4 ,practically all physicians that have given any attention to the subject are convinced that not a few of the suicides1 which are now so alarmingly on the increase in this country1 are due to the frequent reading in newspapers of the accounts of suicides4 ,as we have said elsewhere1 brooding over the details of these is very likely to lessen the natural abhorrence of self-murder in persons that are predisposed1 by melancholic dispositions1 to such an act4 ,the publication of cases of suicide can do no possible good1 while it undoubtedly does1 in this way1 work incalculable harm4 ,this is especially true with regard to suicides among young people1 that is1 individuals under twenty-five years of age4 ,the saddest feature of recent #acd statistics with regard to suicide is that this crime has become proportionately much more frequent among young men and young girls1 and even children1 than it was two or three decades ago4 ,it has been noted1 too1 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 commission4 ,on the other hand1 among young people especially1 it has been noted that there is frequently an imitative element in suicides4 ,three or four suicides1 practically with the same details1 will occur1 within a few days of each other4 ,suicides at all ages are especially likely to occur in groups1 and are often cited to exemplify the truth of the old axiom that evils never come singly4 ,it is especially among young people1 however1 that this relationship to previous suicides can be traced1 and there is no doubt that it is the unfortunate publicity given to suicide1 with the consequent suggestive influence1 which constitutes the most important factor in these cases4 ,all the influence that clergymen can exert1 then1 must be wielded to suppress this1 as well as the many other evils which flow from sensational journalism4 ,,james ,j4 ,,walsh4 #ace ,,xi ,,unexpected ,,death ,unexpected death and its problems constitute the principal reason why there should be a pastoral medicine1 and why the clergyman must keep himself in close touch with advances in medicine4 ,to have an ailing member of a congregation die unexpectedly1 that is1 without the rites of the ,church1 when perhaps there has been some warning as to the possibility of such an accident1 can not but be a source of the gravest concern in pastoral work4 ,sudden death can be anticipated in many diseases that are acute1 while in chronic forms of disease the sufferer can be prepared for its possibility by the administration of the sacraments at regular intervals4 ,there is1 however1 an old proverb which says that death always comes unexpectedly2 and even with all the modern advance in medicine1 this still contains a modicum of truth4 ,as an unprepared death is an occasion of the most poignant regret to the friends of the deceased and to the attending clergyman1 it is with the idea of furnishing some data by which the occurrence of death without due anticipation may be rendered more infrequent1 that the following medical points on the possibilities of a fatal termination in certain diseases have been brought together4 ,unfortunately1 even with all our progress in modern medicine1 they must be far from adequate for all cases4 ,needless to say1 the only rational standpoint in this matter must be that it is better to be sure than to be sorry4 ,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 illness4 ,extreme ,unction is more usually delayed until there is some positive sign of #acf approaching dissolution4 ,delay in its administration1 however1 not infrequently leads to this sacrament being given when the patient is unable to appreciate its significance4 ,this would seem to be very far from the intention of the ,church4 ,the idea has been constantly kept in mind1 then1 so to advise the clergyman with regard to the liability of a fatal termination as to secure1 if possible1 the administration of ,extreme ,unction while the patient is still in the full possession of his senses4 ,assured prognosis1 that is1 positive foresight as to the course of any disease1 is the most difficult problem in medicine4 ,nearly #bdjj years ago1 when ,hippocrates wrote his chapter on the progress of diseases1 he stated that the hardest question to answer in the practice of medicine is1 will the patient live8 ,that special chapter of his book remains1 according to our best authorities1 down even to our own day1 a valuable document in medical literature4 ,it can be read by young or old in medical practice with profit4 ,while our knowledge of the course of disease has advanced very much1 the wise old ,greek physician anticipated most of the principles on which our present knowledge of prognosis is founded4 ,this fact in itself will serve to show how unsatisfactory must be any absolute conclusion as to the termination of any given disease4 ,our forecasts are founded on empirical data1--that is1 they are the result of a series of observations1--and the underlying basis of all the phenomena is the individual human being1 whose constitution it is impossible to know adequately1 and whose reaction to disease it is impossible1 therefore1 to state with absolute certainty4 ,with this warning as to the element of doubt that exists in all prognosis1 we may proceed to the consideration of certain organic affections which make sudden death frequent4 ,at the beginning of the present century1 ,bichat1 a distinguished ,french physician who revolutionised medical practice1 said that health and the favourable or unfavourable termination of disease depends on the condition of three sets of organs--the brain1 the heart1 and the lungs4 ,this was what he called the vital tripod4 ,it was not until nearly thirty years after ,bichat's death that ,bright1 an ,english #acg physician1 taught the medical profession to recognise kidney disease4 ,since his time we have learned that even more important than ,bichat's vital tripod1 as regards health and the termination of disease1 is the condition of the kidneys4 ,we shall consider affections of these four organs1 and their influence on the human system and intercurrent disease1 in the order of their importance4 ,when kidney disease exists the individual's resistive vitality is much lowered4 ,the kidneys are the organs which serve to excrete poisons that find their way into the circulation4 ,when the kidneys fail to act1 these poisons are retained4 ,as a result other important organs1 notably the nervous system and the heart1 suffer severely because of the irritating effect of the retained poison4 ,a patient with kidney disease runs a very serious risk in any infectious fever1 no matter how mild1 and such patients should always be completely prepared for a fatal termination when they acquire any of these diseases4 ,nephritic patients bear operations very badly4 ,the shock to the nervous system incident upon operation always throws a certain amount more than usual of excrementitious material into the circulation4 ,diseased kidneys do not fulfil their function of removing this at once1 and the result is an irritated and fatigued nervous system4 ,anaesthetics1 that is1 chloroform and ether1 are not well tolerated when nephritis exists1 and this adds to the danger of operation in such patients4 ,no matter how simple or short the operation that is to be performed on a person suffering from kidney disease1 if an anaesthetic is to be administered it would be well to prepare the patient for an untoward event that may occur4 ,kidney disease is often extremely insidious4 ,it may develop absolutely without the patient's knowledge1 even though he might be deemed to be in a position to have at least some suspicion of its existence4 ,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 urine1 only to find to his painful surprise that albumen was present and that he was the subject of latent ,bright's disease4 ,in these cases it is #ach impossible to foresee results4 ,they constitute a large number of the cases in which patients1 seemingly in good health1 succumb rather easily and unexpectedly to some simple disease1 like grippe or dysentery4 ,it is well to take the precaution1 then1 to ask the attending physician what the condition of the kidneys is in such cases4 ,if there are anomalous symptoms1 this precaution becomes doubly necessary4 ,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 excretion4 ,an important class of cases for the clergyman are those which are picked up on the street4 ,as a rule1 these patients are comatose because of the presence of kidney disease4 ,a certain proportion of them are unconscious because of apoplexy4 ,very often the patients have had some preliminary symptoms of their approaching collapse1 though these were not sufficient to make them think that any serious danger threatened4 ,as a consequence1 they will not infrequently have had recourse to some stimulant4 ,it seems unfortunately to be almost a rule1 when such cases are picked up1 if there is the odour of alcohol on their breath1 to consider that the condition is due to alcoholism4 ,every year1 in our large cities1 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 breath4 ,needless to say1 then1 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 alcoholism4 ,patients suffering from kidney disease bear extremes of cold and heat very badly4 ,in cold weather the fact that the blood is driven from the surface of the body lessens the excretory function of the skin1 and this throws the work of this important organ1 so helpful an auxiliary in excretion1 back upon the kidneys4 ,besides1 congestions of internal organs are not infrequent during cold1 damp seasons1 and these bring on exacerbations of previously existing ailments that may make fatal complications4 ,in summer intense heat leads to many more changes in the tissues1 and so provides more material to #aci be excreted than in temperate weather4 ,patients picked up on the street1 then1 at such time1 will usually be found to be suffering from kidney disease4 ,though in profound coma1 such patients seldom die without recovering consciousness4 ,not infrequently1 after the primary stroke of the coma1 there is1 in an hour or two1 a period in which the patient becomes almost completely rational4 ,this period of consciousness does not last long1 in many cases1 and should be taken immediate advantage of1 yet without unduly disturbing the patient4 ,there is a well-known tendency in kidney disease to the production of oedema1 that is1 to the outflow of the watery constituents of the blood into certain loose tissues of the body4 ,this is easily recognised1 and constitutes a valuable sign of kidney disease in the swelling of the eyelids and of the feet1 that occurs so often in patients suffering from kidney trouble4 ,the usual rule is1 if the oedema begins in the face1 it is due to the kidneys2 if in the feet1 to the heart4 ,the cause in the latter case is the sluggish circulation due to the weakness of the heart muscle1 which delays the blood so long in the extremities that its watery elements find their way out into the tissues4 ,in kidney disease this tendency to oedema constitutes a distinct danger that may involve sudden death in certain affections4 ,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 glottis4 ,this is often fatal in a very short time4 ,the glottis is the opening between the vocal cords through which respiration is carried on4 ,this opening is but small1 and swelling of the surrounding tissues readily encroaches upon it1 and soon causes difficulty of breathing4 ,if the swelling is not relieved without delay1 death takes place from asphyxiation4 ,this was probably the cause of death in ,george ,washington4 ,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 lungs4 ,the outflow of serum from the blood vessels into the loose tissues of the lungs so encroaches upon the space available for breathing1 and at the same time so reduces the elasticity of lung tissue1 that #adj respiration becomes impossible1 and death takes place in a few hours4 ,this is often the cause of unexpected death after operations4 ,the kidney affection in the patient is so slight as to have been unsuspected1 or to have been considered of not sufficient importance to render the operation especially dangerous4 ,after kidney disease the most important factor in the production of unexpected death is heart disease4 ,in about #fj per centum of the patients who die suddenly1 in the midst of seemingly good-health1 death is due to heart disease4 ,all forms of heart disease may be considered under two heads--the congenital and the acquired4 ,the congenital form of heart disease usually causes death in early years4 ,if such patients survive the fourth or fifth year1 they are usually carried off by some slight intercurrent disease shortly after puberty4 ,a few cases of congenital heart disease1 however1 live on to a good old age and seem not to be seriously inconvenienced by their heart trouble4 ,most of the acquired heart disease1 that is1 at least #fe per centum of it1 is due to rheumatism4 ,all of the infectious fevers1 however1 may cause heart disease1 and scarlet fever especially is prone to do so2 heart complications occurring in about one out of every ten cases4 ,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 is4 ,most of the cases of sudden death occur in disease of the aortic valves1 that is1 of the valves that prevent the blood from flowing back from the heart after it has been pumped out4 ,diseases of the other side of the heart1 the mitral valve1 cause lingering illness until the heart muscle becomes diseased1 when sudden death usually closes the scene4 ,diseases of the aortic valves of the heart cause visible pulsations of the arteries1 especially of those in the neck4 ,this readily attracts attention if one is on the lookout for it4 ,deaths in heart disease1 whether sudden or in the midst of apparent health1 or as the terminal stage after confinement to bed because of weak heart1 are apt to occur particularly during continued cold or hot spells4 ,each of the blizzards that we have had in recent years has been the occasion for a #ada markedly increased mortality in all forms of heart disease4 ,the cold itself is exhaustive1 and the heavy fall of snow1 by delaying cars and modes of conveyance generally1 is very apt to give occasion for considerably more exertion than usual4 ,besides1 cold closes up the peripheral capillaries and makes the pumping work of the heart much harder than before4 ,at times of continued cold1 in our large cities particularly1 the ordinary arrangements for heating the house fail to keep it at a constant temperature1 and this proves a source of exhaustion to cardiac patients4 ,heated spells1 if prolonged1 always cause an increased mortality in such patients1 because heat is relaxant and this leads to exhaustion4 ,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 ,june4 ,the deaths that occur during the hot spells of ,july and ,august are more looked for and accordingly prove not so unexpected4 ,the warning symptom in heart disease that the patient is giving out is the development of irregularity and rapidity of the pulse4 ,on the other hand1 when a pulse has been running rapidly for weeks and then drops to below the regular rate1 to #ej or #fj1 a fatal termination may be looked for at almost any time1 though1 of course1 the patient may rally4 ,the prognosis of heart cases is extremely difficult4 ,confined to bed and evidently seriously ill1 they may continue in reasonably good condition for months1 and then some indiscretion in diet1 which causes a dilation of the stomach with gas1 pushes the diaphragm up against the heart1 adds a mechanical impediment to the physical difficulties the organ is already labouring under1 and a sudden termination may ensue4 ,as a rule1 lingering heart cases terminate suddenly and often with little warning of the approach of death4 ,an interesting set of heart symptoms1 for the physician as well as the clergyman1 are those which occur in what is called angina pectoris1 heart pang1 or heart anguish4 ,serious angina pectoris occurs in elderly people whose arteries are degenerate4 ,its main symptom is a feeling of discomfort which develops in the praecordia1--the region over the heart4 #adb ,this discomfort may often increase to positive cutting pain4 ,the pain is often referred to the shoulder1 and runs down the left arm4 ,this set of symptoms is accompanied by an intense sense of impending death4 ,when the patient's arteries are degenerated1 this train of symptoms must always be considered of ominous significance4 ,a readily visible sign of arterial degeneration can sometimes be noted in the tortuous prominent temporal artery just above the temple4 ,heberden1 an ,english physician1 a little over a century ago1 pointed out that there existed in cases of true angina pectoris a degeneration of the coronary arteries4 ,these are the arteries which supply the heart itself with blood4 ,as might naturally be expected1 their degeneration seriously impairs the function of the heart muscle4 ,the first patient in whom the condition was diagnosed during life was the distinguished anatomist1 ,john ,hunter4 ,hunter was of a rather irascible temperament1 and after he had had several of these attacks1 and a consultation with ,heberden convinced him of their significance1 he is said to have remarked1 ,i am at the mercy of any villain who rouses my temper4 ,sure enough4 ,hunter died in a sudden fit of anger within the year after making the remark4 ,charcot1 the distinguished neurologist1 suffered from attacks of angina pectoris1 and was asked by his family to consult a distinguished heart specialist for them4 ,he said3 ,either ,i have degenerated heart arteries1 or ,i have not4 ,i believe that ,i have not1 and that my attacks are due to a nervous condition of my heart4 ,if ,i should consult the physician you mention1 and he were to tell me that my attacks are due to degeneration of the heart1 he would advise my giving up work4 ,that ,i am not ready to do1 and so ,i prefer to take my own assurance in the matter4 ,a few years later he was found one morning dead in bed4 ,in many of the cases of death in bed1 especially where some complaint of pain has been heard during the night1 death is due to that condition of the heart arteries which causes angina pectoris1 though it may be the first attack which proves fatal4 ,there is a condition similar to angina pectoris1 sometimes called pseudo-angina1 or false heart pang1 which occurs in individuals from fifteen to thirty years of age4 ,it is often a #adc source of great worry4 ,it occurs in young persons of a nervous temperament who have been overworked or overworried and have run down in weight4 ,there are always accompanying signs of gastric disturbance4 ,the casual factor of the symptoms seems to be a more or less sudden dilation of the stomach with gas4 ,as the stomach lies just below the heart1 only separated from it by the comparatively thin layer of diaphragm1 the heart is pushed up and its action interfered with4 ,in healthy individuals this causes no more than a passing sense of discomfort and some heart palpitation4 ,that it is which sends so many young patients to physicians with the persuasion that they have heart disease1 when they have nothing more than indigestion4 ,in nervous individuals1 however1 this interference with the heart action disturbs the nervous mechanism of the heart1 which is very intricate and delicate1 and gives rise to the symptoms of false heart pang4 ,one of these symptoms is always1 as in true angina pectoris1 an impending sense of death4 ,this can not be shaken off1 and is not merely an imagination of the patient4 ,pseudo-angina is1 however1 not a dangerous affection4 ,patients can usually be assured that there is no danger of death4 ,this assurance is not absolute1 however4 ,for some of these cases have congenital defects in their coronary arteries1 and the nervous system of the heart itself1 which make them liable to sudden death4 ,it is sometimes impossible to differentiate such cases of organic heart defects from the ordinary functional heart disturbance due to indigestion1 which causes simple curable pseudo-angina4 ,young patients may usually be disabused of their nervousness in the matter1 but absolute assurance can not be given until the case has been under observation for some time4 ,after the heart1 the head is the most important factor in sudden death4 ,the most frequent form of death from intra-cranial causes is apoplexy4 ,apoplexy1 as the name indicates--a breaking out--is due to a rupture of one of the arteries of the brain1 and a consequent flowing out of blood into the brain tissue4 ,the presence of the exuded blood causes pressure upon important nerve tracts1 and so gives rise to unconsciousness1 to paralysis1 and to the other symptoms which are #add noted in apoplexy4 ,there are a number of symptoms that act as warnings of the approach of apoplexy4 ,first1 it occurs only in those beyond middle life1 that is1 in individuals over forty-five1 and in these only where there is marked degeneration of arteries4 ,the degeneration of the arteries can be easily noted1 as a rule1 in other parts of the body4 ,the condition known as arterio-sclerosis1 that is1 arterial hardening1 can be detected by the finger at the wrist1 or by the eye in the branch of the temporal artery1 which can so frequently be seen to take its sinuous course on the forehead behind and above the eye4 ,at the wrist the thickened artery is felt as a cord that can be rolled under the finger4 ,it is not straight as in health1 but is tortuous1 because the overgrowth in the walls1 which makes it thick1 has also made it longer than normal1 thus producing tortuosity4 ,besides these objective signs1 as they are called1 there are certain subjective signs1 that is1 signs easily recognised by the patient himself1 which should put him on his guard1 and at the same time serve as a warning to the clergyman1 should he hear of their presence4 ,these signs are recurring dizziness1 or vertigo1 not clearly associated with gastric disturbance2 tendency of the limbs1 and especially the fingers and toes1 to go to sleep easily1 and when there is no external cause for this condition2 tendency to faintness and to dizziness when the patient rises in the morning1 especially if he assumes the erect position suddenly2 tendency to vertigo when the patient stoops1 as to tie a shoe1 or pick up something from the floor1 and the like2 finally1 certain changes in the patient's disposition1 with a loss of memory for things that are recent1 though the memory may be retained for the happenings of years before4 ,when several of these symptoms occur1 patients who are well on in years should take warning of the fact that they are liable at any time to have a stroke4 ,needless to say1 this has no reference to the cases of young nervous persons who may readily imagine that they have some or all of these symptoms4 ,apoplexy is typically the disease of those over fifty years of age4 ,there may even occasionally be slight losses of power in the hand or foot that point to the occurrence of small hemorrhages in the brain1 that is1 slight preliminary strokes4 #ade ,patients that have had these symptoms should not1 as a rule1 be allowed to leave home unattended4 ,if the apoplexy occurs in the street they are liable to be mishandled by those ignorant of their true condition4 ,the clergyman is usually summoned at once in these cases and may reach the stricken individual before the physician4 ,some words1 then1 with regard to the general management of such patients will not be out of place4 ,as a rule1 when a patient is taken with some sudden illness which causes him to fall down unconscious1 the first thing done is to dash water in his face1 force a stimulant down his throat1 put his head low down1 and loosen the clothing around his neck4 ,most of these proceedings are the very worst things that could be done for a patient suffering from apoplexy4 ,the rough handling1 particularly1 and the administration of a stimulant1 will surely do harm4 ,the water on the face will certainly do no good4 ,apoplectic patients can be recognised from those who are merely in a fainting fit1 first1 by the fact that they are usually old1 while the fainters are young2 and secondly1 by the manner of the breathing4 ,in a faint the breathing is shallow and faint1 not easily seen4 ,in apoplexy it is apt to be deep and long4 ,it may be irregular1 and it is always accompanied by a blowing outward and inward of the cheeks1 and especially of the side of the face which is paralysed1 as a consequence of a hemorrhage into the brain4 ,the lips are forced outward and drawn inward during the respiration4 ,in such cases the patient should be moved as little as possible2 stimulants should be avoided1 and the head should be placed higher than the rest of the body1 so as to make the hemorrhage into the brain as small as possible1 by calling in the assistance of gravity to keep the heart from sending too much blood into the head4 ,besides this placing the head high1 there is only one other helpful measure that even the physician can practise1 except in rare cases1 that is1 to put an ice-bag on the head4 ,for this a cloth dipped in cool water may be used in an emergency4 ,of course1 as soon as the doctor arrives1 the patient should be left entirely to his care4 ,the artery that ruptures in the brain1 in cases of apoplexy1 #adf is practically always the same4 ,its scientific name is the lenticulo-striate artery1 but it is oftener called by the name given it by ,charcot--the artery of cerebral hemorrhage4 ,the reason why arteries in the brain rupture rather than arteries in other organs is that in the brain1 in order to avoid the demoralising effect of too sudden changes of blood pressure upon the nervous substance1 the cerebral arteries are terminal1 are not connected directly with a network of finer arteries as in the rest of the body1 but gradually become smaller and smaller1 and end in the capillary network which is the beginning of the venous vascular system4 ,this special artery ruptures1 because it is almost on a direct line from the heart1 and so blood pressure is higher in it than in other brain arteries4 ,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 it1 though not near so much as is often claimed for it4 ,another predisposing element to apoplexy is undoubtedly heredity4 ,families have been traced in which1 for five successive generations1 there have been attacks of apoplexy between fifty-five and sixty years of age4 ,short-necked people1 with any history of apoplexy in the family1 should especially be careful1 if they have any of the symptoms--dizziness1 sleepy fingers1 etc4--that we have already noted4 ,there is a tradition that the third stroke of apoplexy is always fatal4 ,this is without foundation in experience1 though of course the liability of death increases with each stroke1 and few patients survive the third attack4 ,i remember seeing in ,mendel's clinic1 in ,berlin1 a man who was suffering from his seventh stroke and promised to recover to have another4 ,each successive stroke is much more dangerous to life than the preceding one1 however4 ,in general1 the prognosis of an apoplexy1 that is to say what the ultimate result will be1 is impossible4 ,the patient may come to in an hour or two1 and may not come out of the coma at all4 ,there is no way of deciding how large the artery is that is ruptured1 nor how much blood has been effused into the brain1 nor how much damage has been done to important nerve centres4 ,nor is there any #adg effective way of stopping the effusion1 though certain things seem to be of some benefit in this matter4 ,we can only wait1 assured that1 in most of the cases1 the patient will have a return of consciousness1 at least for a time4 ,next to apoplexy1 injuries of the head are most important4 ,the symptoms presented by the patient will often be nearly the same as those of apoplexy4 ,if the skull is fractured1 and the depressed bone is exerting pressure upon the brain substance1 there is a similar state of affairs to that which exists in apoplexy4 ,any return to consciousness must be taken advantage of for the administration of the ,sacraments4 ,as a rule1 it is impossible to tell the extent of the injury or to forecast the ultimate result4 ,a very characteristic set of symptoms develops sometimes after injuries in the temporal region or just above it4 ,for a short time up to an hour or two after the injury1 the patient is unconscious4 ,then he comes to for a while1 but relapses into unconsciousness1 from which he will usually not recover except after an operation4 ,the explanation of this succession of symptoms is that the primary unconsciousness is due to shock--concussion or shaking up of the brain4 ,the injury has1 however1 also caused a rupture of an important artery which occurs in one of the membranes of the brain in this region1 the middle meningeal artery4 ,during the state of shock blood pressure is low and hemorrhage is not severe4 ,when consciousness is regained1 blood pressure goes up and the laceration of the middle meningeal artery1 already spoken of1 provides an opening for the exit of considerable blood1 which clots in this region and presses upon the brain1 causing the subsequent unconsciousness4 ,as a rule1 the patient's only hope is in operation with ligature of the torn artery4 ,the condition is always very serious1 and complete precautions as to the possibility of fatal termination should be taken1 as soon as consciousness is regained after the blow1 in any case where the head injury has been severe enough to cause more than a momentary loss of self-possession4 ,no one can tell whether there may be further change or not1 and if this happens it will be in the form of an unconsciousness gradually deepening until relieved by operation or ended by death4 #adh ,tumours of the brain often produce death1 but usually give abundant warning of their presence4 ,the symptoms by which the physician diagnoses the presence of a brain tumour are vertigo1 headache1 vomiting1 usually some eye trouble1 and frequently some interference with the motion of some part of the body1 because of pressure exerted upon the nerve centres which preside over its motions4 ,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 syphilis4 ,where patients are known to have either of these diseases and present any two of the symptoms of brain tumour that ,i have mentioned1 it is well to suggest at least the preliminary preparation for a fatal termination4 ,sometimes states of intense persistent pain1 or of mental disturbance1 develop in these cases and make the administration of the ,sacraments unsatisfactory4 ,meningitis is a fatal affection which sometimes causes sudden death1 but more frequently produces unconsciousness without very much warning1 and the unconsciousness lasts until the death of the patient4 ,meningitis is seen much more frequently in children than in the adult4 ,ordinarily it is due to tuberculosis4 ,sometimes1 however1 there are epidemics of cerebrospinal meningitis--spotted fever1 as it used to be called4 ,in about one-half the cases this affection is fatal4 ,unfortunately this disease gives very little warning of its approach in many cases before unconsciousness sets in4 ,we have had renewed epidemics of the disease in the eastern part of the ,united ,states in recent years1 and the affection is likely to occur more frequently for some time to come4 ,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 ,church4 ,of late years we have learned that the pneumococcus1 that is1 the bacterium which causes pneumonia1 may produce a fatal form of meningitis4 ,the first symptom of meningitis is usually a stiffness of the muscles at the back of the neck4 ,if this stiffness becomes very marked in a patient suffering from tuberculosis1 or who has1 or has recently had1 pneumonia1 or at a time when there is any reason to suspect that epidemic cerebrospinal meningitis exists in a neighbourhood1 the #adi prognosis of the case is always very serious4 ,every precaution should be taken to prepare the patient for the worst4 ,unconsciousness may ensue at any moment and no opportunity for satisfactory administration of the consolations of religion be afterwards afforded4 ,while ,bichat put the lungs down as one of the vital tripod on which the continuance of life depends1 affections of these organs very seldom lead to sudden or unexpected death4 ,pulmonary affections usually run a very chronic course4 ,acute bronchitis1 however1 occurring in a patient with kidney trouble1 may lead to the development of oedema of the lungs1 and death will usually ensue in a few hours4 ,it may be well to note here that individuals who have what are called clubbed fingers1 or as the ,germans picturesquely put it1 drumstick fingers1 that is1 fingers with bulbous ends1 the finger beyond the last joint being larger than the preceding part1 nearly always have some chronic affection within the thorax4 ,this means that there is some organic affection of the heart or lungs which has lasted for many years4 ,the existence of such condition makes them distinctly more vulnerable to any serious intercurrent disease1 and this sign alone may be enough to put the attending physician on his guard as to the possibility of fatal complications in the case4 ,,james ,j4 ,,walsh4 #aej ,,xii ,,unexpected ,,death ,,in ,,special ,,diseases ,besides the general systemic conditions in which sudden death may occur without anticipation1 there are certain specific diseases of which unexpected death is sometimes a feature4 ,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 ,sacraments1 or their enforced administration in haste1 when the recipient is in a very unsatisfactory condition of mind and body4 ,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 age1 provided he does not meet with an accident or catch typhoid fever or pneumonia4 ,pneumonia is an extremely important affection as regards its prognosis4 ,from #ae to #bj per centum of sufferers from the disease die2 that is to say1 about one in six of those attacked by the disease will not recover4 ,it is a little more fatal in women than in men4 ,it is especially serious for the very young and the old4 ,healthy adults in middle life very rarely die from the disease4 ,the prognosis of any individual case1 it has been well said1 depends on what the patient takes with him into the pneumonia4 ,serious affections of important organs nearly always cause fatal complications4 ,if the heart is affected before the pneumonia is acquired1 then the prognosis is very unfavourable1 and a fatal termination is almost inevitable4 ,if the kidneys are seriously diseased beforehand1 death is almost the rule4 ,pneumonia developing during the course of pregnancy is fatal in more than one-half of the cases4 ,at one time it was suggested that premature delivery of pregnant #aea pneumonia patients might save at least the mother's life4 ,experience in ,germany1 however1 has shown that1 far from making the prognosis more favourable1 the induction of premature labour makes the outlook a little worse for the patient4 ,previous affections of the lungs1 emphysema1 or tuberculosis1 are prone to make the prognosis of pneumonia much more unfavourable than under ordinary circumstances4 ,deteriorated conditions of the blood1 anaemia1 chlorosis--such as occurs so commonly in young women--is prone to make the outlook in pneumonia more serious4 ,pneumonia of the upper lobes of the lungs is more apt to be followed by complications1 and is therefore more serious than pneumonia of the lower lobes4 ,secondary pneumonia--that is1 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 health4 ,the amount of lung involved is of course a serious factor in the prognosis4 ,if the whole of one lung is consolidated1 or if considerable portions of both lungs are thus affected1 the prognosis becomes extremely unfavourable4 ,in persons of alcoholic habits the result of pneumonia is always to be dreaded4 ,the more liberal has been the consumption of alcohol1 as a rule1 the less hope is there of a prompt1 uncomplicated recovery4 ,stimulants are of the greatest importance in pneumonia1 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 comes4 ,the less the alcohol that has been taken habitually before the development of pneumonia1 the more surely will it do the work expected of it during the course of the pneumonia4 ,it must be borne in mind that cases of pneumonia that occur in institutions1 asylums1 hospitals1 and the like1 and in crowded quarters in tenement houses or lodging houses1 have a distinctly worse prognosis than those treated in private houses1 and the priest must accordingly be more on his guard and give the ,sacraments early4 ,in pneumonia1 as in typhoid fever1 so-called walking cases always have a serious prognosis4 ,they occur in very strong patients who resist1 not the invasion of the disease1 but its #aeb weakening influence1 and keep on their feet for several days1 despite the presence of symptoms that require them to be in bed4 ,when a patient walks into a doctor's office in the third or fourth day of a pneumonia with most of one lung consolidated1 exhaustion of the heart and of the nervous system1 under these unfavourable conditions1 will usually have made his resistive vitality very low4 ,such cases should be given the ,sacraments early1 while in the full possession of their senses4 ,conditions sometimes develop rather unexpectedly in which the administration of the ,sacraments becomes unsatisfactory1 because of the collapsed state of the patient4 ,this same advice holds with regard to walking cases of typhoid fever4 ,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 affection1 the prognosis becomes very unfavourable4 ,complications1 such as hemorrhage or perforation of the intestine1 occur about the beginning of the third week1 and often prove fatal4 ,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 week1 even though they may seemingly be in excellent condition4 ,when typhoid fever is fatal the complications occur suddenly1 often without much warning2 and if intestinal perforation1 for instance1 takes place1 the peritonitis which develops makes the patient's condition very unsuitable for the reception of the ,sacraments in a proper state of mind4 ,typhoid fever patients sometimes die suddenly in collapse when they are convalescent4 ,the toxine of the typhoid bacillus often affects the heart1 and causes what is called cloudy swelling of its muscular fibres4 ,this decreases very notably their functional ability4 ,any sudden exertion1 even sitting up in bed1 may cause the heart to stop under such circumstances4 ,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 brain4 ,priests must be careful1 then1 when they call to see convalescent typhoid patients1 not to permit them to sit up #aec to greet them4 ,the doctor's directions in this matter should be followed very carefully4 ,this sudden fatal collapse may occur after any of the infectious diseases4 ,it is seen not infrequently after diphtheria4 ,it occurs more rarely after scarlet fever1 and even after some of the milder children's diseases4 ,in rheumatism1 especially where a heart complication has occurred1 this rule with regard to sudden movements is extremely important ,rheumatism is itself not a fatal disease1 yet there are certain cases in which very high temperature sets in1 causes delirium1 and death ensues at times before the patient recovers consciousness4 ,where rheumatic patients show a tendency to run high temperatures1 that is1 #ajd deg4 or higher1 it is well to be prepared for this emergency4 ,appendicitis is very much talked about in our day2 but the fatal affection represented by the new word is no more frequent than it was half a century ago1 or1 for that matter1 twenty-five centuries ago4 ,people died of inflammation of the bowels and peritonitis then2 and as the appendix was not known as the origin of the trouble1 the fateful name was not the spectre that it is now4 ,practically all abdominal colic--and this means #ij per centum of all the acute pain which follows gastro-intestinal disturbance in young or middle-aged adults--is due to appendicitis4 ,it comes on1 as a rule1 in the midst of good health4 ,it is very treacherous1 and when the patient is apparently but slightly ill1 a sudden turn for the worse may assert itself1 and an intensely painful and prostrating condition develop4 ,where symptoms of appendicitis are present1 it is the part of safety to have the patient receive at least the ,sacraments of ,penance and the ,holy ,eucharist4 ,when peritonitis develops1 vomiting is the rule4 ,hence the advisability of prompt administration of ,holy ,communion4 ,extreme ,unction can be given with some satisfaction1 even during the disturbed period which follows a beginning peritonitis4 ,for the peritonitis that sometimes results from appendicitis there is no hope of recovery except by operation4 ,operation1 to be successful1 must follow the perforation of the appendix not later than by a few hours4 #aed ,early pregnancy1 that is1 the first eight to ten weeks of gestation1 is sometimes complicated by a set of symptoms the most prominent of which are sudden very acute pains in the lower part of the abdomen1 followed by intense prostration1 and then by the symptoms of internal bleeding1--namely1 a soft pulse1 pallor with cold extremities1 sighing respiration1 and marked tendency to faintness4 ,when symptoms like these occur during the first three months of pregnancy1 they signify1 almost without exception1 rupture of an extrauterine gestation-sac4 ,except where operation can be performed at once1 these cases are almost invariably fatal4 ,extrauterine pregnancy occurs with greatest frequency in women who1 having had one or more children1 then have a period of five or more years without children1 followed by pregnancy4 ,undoubtedly1 extrauterine pregnancy1 the knowledge of which is the result of medical advance in very recent years1 and appendicitis1 which is the growth of the last twelve years1 were prominent factors in the production of many inexplicable deaths in history4 ,these were not infrequently set down as due to poison4 ,acute indigestion in elderly people is sometimes followed by sudden death4 ,observations in this matter have somehow become much more frequent of late years1 and many of the so-called cases of heart failure belong to this group4 ,the important nerve trunk that carries nervous fibres to the heart bears fibres to the digestive tract1 the oesophagus1 the stomach1 the intestines1 the liver as well1 and also to the larynx and lungs4 ,there is a certain intercommunication between the impulses which pass along these various nerve fibres4 ,intense irritation of the nerve endings in any one of these organs may be reflected back upon the heart4 ,curiously enough the nerve fibres to the heart that run in this trunk are many of them inhibitory2 that is to say1 they lessen the function of the heart or cause it to stop beating entirely4 ,if an intense nervous irritation is set up in the stomach1 reflex nervous impulses may cause the heart to stop completely and never resume its work4 ,typical cases of this kind often occur during the first cold days of the winter time4 ,elderly people come to their meals cold and chilly1 yet with appetite increased by the bracing air4 ,they sit down at once1 take a larger meal than usual1 and then develop severe gastritis during the night4 ,this is #aee relieved by purging and vomiting1 and the pain yields to the administration of morphine4 ,their condition improves and all danger seems past1 when1 on sitting up suddenly the next day1 or1 if left alone1 getting up to get something for themselves1 they collapse and are dead before help can come to them4 ,deaths like this sometimes occur in dysentery also1 the reason being the intense nervous reflex from the irritated intestinal nerve endings which exerts its influence upon the heart nerves4 ,certain diseases practically always end in sudden death and must be taken special care of by the priest for this reason4 ,aneurism1 for instance1 is one of these4 ,an aneurism is a widening or dilatation at some point of an artery4 ,the most important aneurisms occur in the arch of the aorta1 that is1 in the large curved artery which comes directly from the heart itself and of which all the other arteries are branches4 ,aneurisms develop1 according to the expression of a distinguished ,american physician1 in the special votaries of three heathen divinities1 ,vulcan1 ,bacchus1 and ,venus1--that is1 in those who have worked too hard1 in those who have drunk too hard1 and in those who have devoted themselves too much to the pleasures of the flesh4 ,the most important factor of all is1 however1 the contraction of venereal disease1 especially of that form known as syphilis4 ,the termination of aneurism cases is usually by rupture with profuse hemorrhage4 ,death takes place in a moment or two4 ,aneurisms often cause intense pain1 which is sometimes thought to be rheumatic in origin4 ,if the aneurism1 in its enlargement1 meets with bony structure1 it produces absorption of the bone by pressure upon it and so finds a way even through the bone to the overlying skin4 ,this process is always intensely painful1 and shortly after the aneurism appears at the surface the pressure upon the skin causes it to become thin and the aneurism may rupture externally4 ,addison's ,disease always ends suddenly4 ,this is a rare affection1 described by ,addison1 an ,english physician1 some fifty years ago1 which develops in individuals whose suprarenal capsules are degenerated4 ,the suprarenal capsules are little bodies of half-moon shape which lie above the kidneys4 #aef ,their degeneration produces a great lowering of blood pressure4 ,the patient becomes intensely weak1 muscular movement becomes impossible1 intellectual processes cause great fatigue1 and finally blood pressure becomes so low that fatal collapse ensues from lack of blood in the brain4 ,the external symptoms of these cases is a pigmentation1 that is1 a very dark discolouration of the skin1 which develops rather early in the disease4 ,the tongue especially becomes a very dark brown4 ,areas of pigmentation also occur where the skin is irritated1--at the wrists from the irritation of the coat sleeves1 at the edge of the hair from the irritation of the hat4 ,dr4 ,s4 ,weir ,mitchell1 in his ,autobiography of a ,quack1 has described one of these cases very strikingly4 ,the hero of the tale is found dead one morning by the nurse in the hospital1 after he has been feeling quite as well as usual for some time4 ,it must not be forgotten that patients who are burned extensively very frequently die shortly after the accident4 ,a burn that involves more than one-half of the body1 no matter how superficial the burning may be1 will always have a fatal termination4 ,deep burns in one part1 unless it is some very vital part1 are not so serious as extensive superficial burns4 ,patients with extensive burns frequently remain in encouragingly good condition for several days1 and then have a sudden change for the worse4 ,sometimes death takes place in coma4 ,sometimes it takes place as the result of a perforation of the duodenum4 ,these perforations of duodenal ulcers may take place as late as a week to ten days after the burn4 ,they are always followed by symptoms of peritonitis and the condition of intense prostration which this brings on4 ,such cases need to be prepared for the worst after the first acute symptoms of the burn have subsided1 when a certain amount of peace of mind is restored4 ,cirrhosis of the liver not infrequently causes sudden death4 ,cirrhosis is an affection in which a large part of the liver substance proper degenerates1 and its place is taken by connective tissue4 ,it is typically a disease of people of alcoholic habit4 ,it occurs in those who are engaged in the sale of spirits1 though the alcoholic absorption does not take place #aeg through the skin1 but in a much more direct way4 ,it is most frequent in people who take strong spirits on an empty stomach4 ,those who are much exposed to changes of temperature are especially liable to form such habits4 ,it is found most frequently in the drivers of wagons and cars1 in policemen1 and in sea-captains1 sailors1 and the like4 ,when cirrhosis causes sudden death1 it is nearly always by hemorrhage4 ,the hemorrhage takes place from the oesophagus1 some of the large veins of which have become dilated until the thin walls are unable to retain the blood4 ,the dilatation is due to interference with the venous circulation in the liver4 ,of late years pathologists and medical men1 especially those who are interested in children's diseases1 have devoted considerable time to the study of certain cases of sudden death1 which have long been very mysterious4 ,infants often die while in apparent good health without any adequate reason that can be found1 even on the most careful autopsy4 ,children of an older growth sometimes die suddenly as the result of some slight shock or fright1 or they die after the administration of a few whiffs of chloroform1 given to help in the performance of some simple surgical operation1 or they die at the beginning of some infectious fever which they ought to be able to withstand without any difficulty4 ,a distinguished pathologist at ,vienna1 ,professor ,paltauf1 who was the coroner's physician of the city and had a large number of these sudden deaths to investigate1 found that in most of the cases one abnormal condition was constantly present4 ,this consisted in an enlargement of the lymph glands all over the body4 ,the lymph glands in the neck were involved1 also the tonsils and lymphoid tissue at the back of the throat1 the series of lymph glands in the groin1 and1 finally1 there was a hypertrophy of the lymphoid tissue that occurs all along the intestinal tract4 ,this condition of hypertrophy of lymphoid tissue has come to be known as the lymphatic diathesis or constitution4 ,it is nearly always accompanied by a distinct hypertrophy of the thymus gland4 ,the thymus gland is an organ which occurs in the upper part of the thorax of the child1 but which atrophies and practically disappears after the age of two years4 ,in these cases it is from twice to three #aeh times its normal size in the infant1 and in older children it is persistent--that is1 retains its primary size1 though in the ordinary course of nature it should atrophy4 ,this lymphatic diathesis undoubtedly has considerable to do with the sudden deaths which occur in these patients4 ,what the exact connection is we do not as yet definitely know4 ,unfortunately1 moreover1 this lymphatic constitution gives no sure sign of its existence before the occurrence of the fatal termination4 ,enlargement of the glands of the neck and of the groin1 with some enlargement of the tonsils1 occurs in delicate children without necessarily being symptoms of the lymphatic diathesis4 ,the enlargement or persistence of the thymus can be better recognised1 and doctors now seldom fail to notice it4 ,where any suspicion of such a condition exists in children of from eight to sixteen or seventeen years of age1 proper precautions must be taken to prevent sudden fatal termination of any even mild disease without due preparation4 ,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 diathesis4 ,diseases1 like tuberculosis and cancer1 that run a long but assuredly fatal course1 usually terminate unexpectedly4 ,the tuberculous patient particularly will almost surely be planning for next year the day before he dies4 ,this condition of euphoria1 that is1 of sense of well being1 was recognised as associated with tuberculosis as far back as we have any history of the disease4 ,hippocrates pointed out as one of the symptoms of consumption the spes phthisical or consumptive hope4 ,if the patient has been very much run down1 death may take place from thrombosis of some of the arteries4 ,if the thrombosis takes place in the brain1 consciousness will be lost1 and the patient will often die without recovering it4 ,patients often develop tubercles in their brain as the result of a spread of the disease beyond the lungs1 and then1 as a rule1 death will take place in the midst of a paralysis1 which may be accompanied by loss of consciousness that lasts for several days or a week or more4 ,cancer patients also die suddenly1 or at least unexpectedly1 at the end4 ,very often in them1 as in tuberculosis1 #aei thrombosis plays an important role in the fatal termination4 ,in cancer of the stomach1 peritonitis from perforation of the stomach may close the scene4 ,the fatal termination in cancer of the uterus is often brought about by the development of uraemic symptoms4 ,the new growth in the pelvis involves the ureters1 prevents the free egress of urine1 and so causes the retention in the system of poisonous substances that should be excreted4 ,cancer in other parts of the body often causes death by metastatic cancers1 that is1 offshoots of the original cancer which occur in other organs4 ,usually these are in the liver1 but sometimes they are in the brain1 and sometimes in the bones that surround the spinal cord4 ,in the course of their growth they cause pressure symptoms upon the nervous system1 and this leads to death4 ,if patients become very much weakened1 as is not infrequently the case1 thrombosis occurs1 and portions of the clots may be shot into the pulmonary veins1 and cause death in this way4 ,two affections which are quite common1 one of them usually involving no danger at all1 sometimes cause sudden death4 ,they are varicose veins and a discharging ear4 ,varicose veins are the enlarged veins which occur on the limbs of a great many elderly people4 ,if these people become run down in health and then exhaust themselves by overwork1 the circulation through these enlarged veins is sometimes so impeded that clotting--thrombosis1 as it is called--occurs4 ,if a portion of the clot becomes detached1 and is carried off into the circulation1 a so-called embolus1 this may cause sudden death1 either by its effect upon the heart1 or more usually upon the lungs4 ,middle-ear disease causes death1 either by producing an abscess of the brain1 or by causing thrombosis of some of the large veins within the skull4 ,the dangers involved in a discharge from the ear are now well recognised4 ,insurance companies refuse to take risks on the lives of persons affected by chronic otitis media1 as it is called scientifically4 ,such persons may run along in perfect good health for years without accident1 but a sudden stoppage of the flow may be the signal for the formation of the brain abscess1 with almost inevitable death4 #afj ,certain severe forms of the infectious fevers are very often fatal4 ,these forms are popularly known as black fevers1 that is1 black measles1 black scarlet fever1 etc4 ,these fulminant forms occur especially in camps1 barracks1 orphan asylums1 jails1 and the like1 where the hygienic conditions of the patients have been very poor1 and where the resistive vitality has1 as a consequence1 become greatly lowered4 ,the black spots that occur on such patients are really due to small hemorrhages into the skin4 ,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 vessels4 ,where such cases occur1 patients should be fully prepared for the worst ,as a rule1 the mortality is from #dj to #gj per centum4 ,acute pancreatitis is a uniformly fatal disease1 though fortunately it is rare4 ,it occurs much more frequently1 however1 than used to be thought4 ,it occurs in persons over thirty who have been for some years addicted to the use of alcohol4 ,the symptoms of the disease are severe pain in the upper left zone of the abdomen1 that is1 above and to the left of the umbilicus4 ,this is accompanied by nausea and vomiting4 ,collapse ensues and death takes place on the second to the fourth day of the affection4 ,this disease may have important medico-legal bearings4 ,some slight injury in the abdomen1 as from a blow or a kick1 may precipitate an attack in predisposed individuals4 ,accusation of murder may result4 ,the mental attitude of the physician and the clergyman with regard to such cases must be very conservative4 ,no opinion as to possible culpability should be ventured4 ,cholelithiasis1 that is1 stone in the bile duct1 may not only cause severe pain1 but may lead to rupture of the duct and a rapidly fatal termination4 ,owing to the practice of wearing corsets1 gall-stones occur much more commonly in women than in men4 ,twenty-five per centum of all women over #fj years of age are found to have gall-stones4 ,while these cases suffer from intense pain they are very seldom fatal4 ,but it must not be forgotten that a fatal issue can take place either from collapse and stoppage of the heart1 because of the intensity of the pain1 or from perforative peritonitis4 #afa ,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 unsatisfactory4 ,gastric ulcers occur especially in young women1 usually in those who follow some indoor occupation4 ,its favourite victims are cooks1 though laundresses1 seamstresses1 and even clerks in stores1 suffer from it much more than those engaged in other occupations4 ,it occurs by preference in anaemic or chlorotic women4 ,sometimes1 however1 as in the case of cooks1 the patients may seem to be in good health4 ,acute pain in the stomach region1 followed by symptoms of collapse1 should in such persons be a signal for the administration of all the ,sacraments4 ,fatal peritonitis soon brings on a state of painful uneasiness ill adapted to the proper dispositions for the ,sacraments4 ,two diseases that are fortunately very rare1 but which are almost uniformly fatal1 deserve to be mentioned here4 ,in both of them the symptoms of the disease are manifested through the nervous system4 ,they are tetanus and hydrophobia4 ,tetanus occurs as a consequence especially of a wound which has been contaminated by the street dirt of a large city1 or the refuse of a farm4 ,it follows deep wounds such as are made by a hayrake or a pitchfork2 or seared wounds1 such as are made by a toy pistol4 ,a serum for the treatment of the disease has been discovered1 but unfortunately the first symptom of tetanus is not the first symptom of the disease1 but the preliminary symptom of the terminal stage of the disease1 the affection of the nervous system4 ,practically all cases of acute tetanus terminate fatally4 ,as soon as a patient exhibits the characteristic symptoms1 the lockjaw1 the stiff neck1 and the rigid muscles1 all the ,sacraments should be administered4 ,in tetanus1 as a rule1 consciousness is preserved until very late in the disease4 ,in severe cases1 however1 a convulsive state of intense irritability develops in which the slightest sound or effort brings on a series of spasmodic seizures4 ,patients must be prepared1 then1 early in the disease1 if possible4 ,rabies or hydrophobia is a disease which claims a certain number of victims every year in our large cities4 #afb ,its symptoms are the occurrence of fever and disquietude1 with spasmodic convulsions of the muscles of the throat whenever an attempt is made to swallow4 ,these symptoms come on from three to fifteen days after the bite of a mad dog4 ,unless the ,pasteur treatment has been taken shortly after the bite of the animal was inflicted1 no treatment that present-day medicine possesses is able to affect the course of the disease1 and patients nearly always die4 ,their preparation1 then1 is a matter of necessity as soon as the first assured symptoms of the disease show themselves4 ,footnote #d ,footnote #d3 ,one cannot help but add a word here as to the cause of the disease1 because clergymen can by their advice do something to remedy the evil which lies at the root of the infliction4 ,hydrophobia is due to stray dogs4 ,in practically every case the fatal bite is inflicted by some animal that no one in the neighbourhood claims4 ,bites by pet dogs are rarely fatal4 ,if clergymen would use their influence to suppress the dog nuisance we would soon have an end of hydrophobia4 ,alcoholic subjects are very liable to unexpected death from a good many causes4 ,patients suffering from delirium tremens1 for instance1 may die suddenly in the midst of a paroxysm of excitement4 ,such a termination is not frequent1 but it has occurred often enough to make it the custom1 at asylums for inebriates1 to warn friends who bring patients of the liability of such an accident4 ,it is not so apt to happen during a first attack of delirium tremens as during subsequent attacks4 ,it is most frequent among those whose addiction to alcohol for years has caused repeated paroxysms of delirium tremens4 ,the cause of the sudden death is usually heart failure4 ,this term means nothing in itself1 but it expresses the fact that a degenerated heart finally refuses to act4 ,alcoholic poison in the circulation has led to fibroid degeneration of the muscular elements of the heart and made them incapable of proper function1 or at least has greatly hampered their action1 and the heart ceases to beat4 ,it must be borne in mind that chronic alcoholism makes a number of serious organic diseases run a latent course4 ,the patient is apt to attribute his symptoms to the after effects of the abuse of alcohol4 ,unless the doctor who is called in makes a very careful examination1 serious kidney disease or even advanced pneumonia may not be discovered4 ,alcoholic subjects bear pneumonia very badly1 and the preliminary #afc symptoms of the disease are often completely concealed by the symptoms due to the patient's alcoholism4 ,other infectious diseases1 as typhoid fever1 tuberculosis1 and even various forms of meningitis1 may run a very insidious course and give but very slight warning of their presence4 ,the result is that these diseases are very frequently fatal in alcoholic subjects4 ,old inebriates bear operations badly1 and the mortality after any operation in such subjects is distinctly higher than in normal individuals4 ,one reason for this is that considerably more ether or chloroform is required to produce narcosis in alcoholic subjects than in ordinary individuals4 ,ether and chloroform are very irritant to the kidneys4 ,the kidneys are prone to be affected more or less in old alcoholic subjects4 ,death from oedema of the lungs or from some form of pneumonia is not infrequent in these post-operative cases1 and gives as a rule but little warning of its approach4 ,it is clear1 then1 that alcoholic subjects must be prepared with special care whenever disease is actually present or an operation is to be performed4 ,too great care can scarcely be exercised in their regard4 ,what would seem overcaution will save many a heartburn to friends and priest1 for it is in alcoholic subjects especially that some of the saddest cases of unexpected death without preparation occur4 ,,james ,j4 ,,walsh4 #afd ,,xiii ,,the ,,moment ,,of ,,death ,it not infrequently happens that a priest reaches a patient who has just died4 ,conditional absolution1 baptism1 or other spiritual ministration might have been offered if there were signs of life1 but the heart and lungs are still1 the patient is dead1 and the priest leaves the place without doing anything4 ,yet the patient may not really be dead4 ,our knowledge of the precise time the soul leaves the body is very imperfect4 ,there is1 we are aware1 a close connection between the vital functions of the body1 taken together or singly1 and cellular activity4 ,if the cells are not destroyed1 a vital function sometimes may be restored after its cessation1 but if the cells are destroyed up to a certain extent1 the vital function is not recoverable4 ,for example1 if the various bodily cells of a patient dead from diphtheria are examined microscopically1 it will be found that the diphtheria toxin has disintegrated the nuclei of these cells4 ,what number of cells proportionate to the whole in1 say1 the heart should be destroyed before the vitality of that organ is lost1 is not clearly known4 ,where the cells are intact1 or nearly so1 mere absence of respiration1 or of even the heart movement1 are not absolute proof of death4 ,numerous cases are found in medical records of persons that had been lying under water for many minutes1 up to even an hour1 but who were restored to life by patient and skilful efforts2 and of late remarkable restorations after what was practically death1 under anaesthesia and otherwise1 have been reported4 ,the technique consists chiefly in rhythmical compression of the heart1 commonly after surgical exposure of that organ1 with artificial respiration1 and1 in ,crile's method1 peripheral resistance is #afe employed to raise the blood pressure4 ,ludwig in #ahdb1 experimented in cardiac massage1 and ,professor ,schiff at ,florence was the first to apply the method to human subjects4 ,kemp and ,gardner1 in the ,new ,york ,medical ,journal1 ,may #g1 #aijd1 described various methods used in attempting resuscitation4 ,professor ,w4 ,w4 ,keen of ,philadelphia has collected the records of the chief cases of resuscitation after apparent death 7see ,the ,therapeutic ,gazette1 ,april1 #aijd71 and some of these are the following3 ,dr4 ,christian ,igelstrud of ,tromsoe1 ,norway1 in #aija1 was operating upon a woman1 #dc years of age1 for cancer4 ,during the operation1 which was a coeliotomy1 she collapsed and her heart ceased beating4 ,after the usual means for resuscitation had been ineffectively tried1 her heart was laid bare4 ,igelstrud took hold of the heart with his hand and made rhythmic pressure upon it4 ,in about one minute the heart began to pulsate4 ,the patient was discharged from the hospital five weeks afterward4 ,tuffier 7,bull1 et mem4 soc4 de chir41 #ahih1 p4 #icg7 in #ahih had a patient whose heart stopped after an operation for appendicitis4 ,the surgeon had left the operating room1 but he returned1 laid bare the heart1 pressed it rhythmically1 and after two minutes it began to move again4 ,the patient breathed regularly1 his eyes opened1 the dilated pupils contracted1 and he turned his head4 ,after the opening over the heart had been closed1 however1 he died4 ,prus 7,wiener klin4 ,woch41 no4 #ba1 #aijj1 p4 #dhf7 by the same method started contractions of the heart after #ae minutes in a man that had hanged himself4 ,the effort at resuscitation was made two hours after the suicide had been discovered1 but the recovery did not go beyond imperfect movements of the heart1 which gradually ceased4 ,maag 7,centralbl4 f4 ,chir41 #aija1 p4 #bj7 reports the case of a man who under chloroform anaesthesia ceased breathing and whose heart stopped4 ,after #aj minutes the patient was pulseless1 without respiration1 cyanotic1 and cold4 ,the heart was exposed and compressed rhythmically2 it was restored to action1 and he began to breathe4 ,he remained alive for #ab hours1 seemingly asleep2 then he died4 #aff ,starling and ,lane 7,lancet1 ,nov4 #bb1 #aijb1 p4 #acig7 were operating upon a man #fe years of age4 ,the heart and respiration ceased4 ,lane put his hand into the abdominal incision and squeezed the heart through the diaphragm4 ,after twelve minutes of artificial respiration the lungs and heart began to act4 ,the patient afterward was discharged from the hospital cured4 ,sick 7,centralblatt f4 ,chirurgie1 ,sept4 #e1 #aijc1 p4 #iha7 reports a very remarkable case4 ,a boy of #ae years of age died upon the operating table4 ,three quarters of an hour after the heart had ceased to beat it was laid bare4 ,the flaps did not bleed1 the pericardium was bloodless1 the heart was motionless1 relaxed1 and cold4 ,after a quarter of an hour1 during which the heart was compressed1 and artificial respiration was kept up1 that is1 one hour after what any physician would call death1 the heart was beating and respiration was restored4 ,two hours later the boy became conscious and complained of great thirst and dyspnoea4 ,he remained in this condition for twenty-seven hours1 and during that time his speech was indistinct but intelligible4 ,he then died4 ,dr4 ,george ,w4 ,crile1 of ,cleveland1 ,ohio1 reports the case of a woman whose heart movement and respiration had ceased for six minutes4 ,she was restored completely1 even without exposing the heart4 ,dr4 ,crile uses an inflated rubber suit on the patient to raise the blood pressure by peripheral resistance--he does not expose the heart4 ,he had another case1 a man #ch years of age1 who died during operation1 was resuscitated1 and died again two hours later4 ,two ,hungarian labourers1 whose skulls had been crushed in the same accident1 were brought into ,dr4 ,crile's clinic in a dying condition4 ,the heart of one of these men ceased beating as he was brought into the operating room4 ,after nine minutes the surgeons began to work upon him to resuscitate him4 ,they succeeded1 but he lived for only #bh minutes4 ,they then examined the other man and found him dead4 ,just #de minutes after this second patient had been brought into the operating room the effort to resuscitate him began4 ,as he had not been observed while the physicians had been engaged with the first man1 they do not know when his heart #afg had ceased to beat1 but he certainly was dead in the opinion of skilled observers4 ,they resuscitated him so well that he moved his head away from the operator who was relieving the depression of the skull1 but he died again in #cd minutes4 ,these cases are not what is commonly called conditions of suspended animation4 ,all the patients would have been pronounced dead by any physician1 and if they had been left untouched1 they surely never would have been revived4 ,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 present4 ,four of these attempts resulted in complete success1 others in a partial recovery1 and many were without positive result4 ,the number of complete and partial resuscitations1 however1 are enough to justify a priest in giving conditional absolution or baptism within an hour1 or even two hours1 after a patient has to all appearance died1 especially in accident cases4 ,we do not know when the soul enters the body1 and there is the same doubt as to the moment when the soul leaves the body4 ,in these latter cases we should give the patient the benefit of the doubt4 ,,austin ,,omalley4 #afh ,,xiv ,,the ,,priest ,,in ,,infectious ,,diseases ,the subject of infection is complicated1 and the medical doctrine concerning it is far from certainty despite the multitude of facts presented by bacteriologists1 chemists1 pathologists1 and clinicians4 ,before the days of bacteriology the term ,infectious commonly was applied to diseases produced by no known or definable influence of any person on another1 but wherein common climatic or other widespread conditions were thought to be chiefly instrumental in the diffusion4 ,the contagious disease was one transmitted by contact with the patient1 either directly by touch1 or indirectly through the use of the same articles4 ,now we know that many diseases called infectious are caused by micro-organisms1 and we group others under this class because we hold theoretically that they have their origin in microbes not yet isolated4 ,hence we define an infectious disease as one which is caused by a living pathogenic micro-organism1 which enters the tissues from without1 and is capable of multiplying therein4 ,these micro-organisms have a time of incubation during which a poison is made in the tissues1 and this brings about the intoxication we call the disease4 ,infection is a general term that includes contagion2 and contagious diseases are infective diseases that may be transmitted directly or indirectly from patient to patient4 ,the pathological micro-organisms with which we shall deal in this article are 7#a7 the ,schizomycetes or ,fission-,fungi1 which are microscopical organisms that multiply by fission1 and are commonly known as ,bacteria2 and 7#b7 a few ,protozoa1 which are animal micro-organisms4 ,the bacteria are classed with plants because1 like plants1 #afi they derive nourishment from both organic and inorganic material4 ,they have no seeds or flowers1 but many of them are reproduced by spores4 ,they consist of cells1 single or grouped1 which when spherical are called cocci1 when rod-shaped1 bacilli1 when spiral1 spirilla4 ,there are various subdivisions of these groups4 ,we do not know whether bacterial cells have nuclei or not4 ,a micro-organism is a parasite when it can live in animal tissues4 ,it is a saphrophyte when it can exist outside animal tissues4 ,if a parasite cannot exist outside animal tissues1 it is an obligatory parasite2 if it can1 it is a facultative saphrophyte4 ,similarly the saphrophytes are classed as obligatory saphrophytes and facultative parasites4 ,pathological micro-organisms have very complicated products which are in large part poisonous4 ,bacteriologists require seven conditions to prove a micro-organism the specific cause of a given disease1 and all these conditions have been fulfilled for anthrax1 diphtheria1 and tetanus4 ,the specificity has been satisfactorily settled for glanders1 malaria1 tuberculosis1 actinomycosis1 gonorrhoea1 and malignant oedema4 ,it has been practically settled for typhoid1 influenza1 the ,madura disease1 and the bubonic plague2 and incompletely defined for leprosy1 relapsing fever1 and ,malta fever4 ,there are certain diseases which are not called specific1 because they may be produced by various micro-organisms4 ,these are pneumonia1 osteomyelitis1 septicaemia1 pymaeia1 endocarditis1 meningitis1 erysipelas1 angina ,ludovici1 broncho-pneumonia1 and similar maladies4 ,cholera and dysentery also might be grouped with these1 as cholera appears to be produced by various vibrios and dysentery by different amoebae4 ,there are other infective diseases1 in which we have not yet found the causative micro-organism1 but we presume its existence4 ,these are3 rabies1 syphilis1 yellow fever1 dengue1 typhus1 mumps1 whooping-cough1 smallpox1 measles1 scarlet fever1 and others among the exanthemata4 ,malaria and similar diseases are caused by plasmodia1 which are protozoa and not bacteria4 #agj ,the priest is almost as frequently exposed to the danger arising from contagion as the physician is1 and a priest that often ministers to the sick is liable to grow imprudently indifferent to danger4 ,for one priest that is too much afraid of disease we find a hundred that have not sufficient dread4 ,no matter what medical science may say to the contrary1 many priests hold that they have often left smallpox cases1 for example1 without disinfecting themselves1 and that they have not spread the disease4 ,this is a very rash assertion4 ,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 street4 ,the number of persons that will not take smallpox when exposed to it is very large4 ,in ,washington in #ahie1 during an epidemic of smallpox1 #ahg persons1 to my personal knowledge1 were exposed to one group of #ci smallpox patients without taking the disease4 ,the unharmed had been present in sick-rooms or had even nursed the patients1 not knowing that the disease was smallpox4 ,in this epidemic eight persons lived in the same rooms with1 or visited frequently1 two patients that afterward died of virulent smallpox1 and none of the eight took the disease4 ,one of these eight1 however1 went into a dramshop1 had one glass of beer and left immediately1 and in fourteen days afterward 7the average time of incubation7 we took the barkeeper to the smallpox hospital4 ,this barkeeper had not been exposed to smallpox except by contact with the man mentioned here4 ,there were about #fj cases of smallpox in that epidemic1 and we traced every one to direct or indirect contact with one initial case4 ,if we were infected by every exposure to contagious disease the world would be depopulated4 ,it is true that you cannot give some persons diphtheria if you actually put the ,klebs-,loeffler bacillus into their mouths1 and nurses and physicians in consumptive wards have the tubercle bacillus in their nostrils without ill effect4 ,so for many diseases2 but it unfortunately remains true that there are susceptible persons everywhere who will at once take a disease when they are exposed to it4 #aga ,immunity changes in the same person4 ,starvation1 fatigue1 loss of blood1 unsuitable diet1 exposure to heat1 cold1 and moisture1 and other influences lessen the power of resistance to infection4 ,men vary almost as do the lower animals as regards infection4 ,the quantity of tetanus toxin that will kill #djj horses will not bother a hen2 ,algerian sheep and the white rat are not affected by anthrax1 but other sheep and the brown rat are very susceptible2 a hog will not take glanders1 man and a horse will2 men1 cattle1 and monkeys have tuberculosis1 dogs and goats do not2 white men with few exceptions are susceptible to yellow fever and malaria1 negroes are practically immune2 negroes readily succumb to the fatal sleeping sickness1 white men are almost immune2 and similar differences are observable in the same race or family4 ,the question of immunity to infectious disease is very difficult to make clear because it is so technical1 and it is only a theory at best4 ,the poison of an infectious disease kills by splitting and destroying the nuclei of the body's cells4 ,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 molecules4 ,according to ,erlich's theory there are other molecules in cells which neutralise toxic molecules1 and when the neutralising molecules appear in excess the patient recovers4 ,these neutralising bodies are called antitoxins4 ,some antitoxins are always present in cells1 and where the normal quantity of these is used up in neutralising toxins1 other antitoxic bodies are formed1 until finally the excess of these is thrown off into the blood serum4 ,after they are called into being by the excitation of some toxic products1 like those of the typhoid bacillus for example1 the antitoxins remain in the blood for years1 ready to neutralise at once any influx of fresh infection4 ,in other diseases1 like diphtheria and pneumonia1 they are soon lost1--hence the recurrence of such diseases4 ,the acquired antitoxin lasts after smallpox1 vaccinia1 yellow fever1 scarlet fever1 measles1 typhoid1 mumps1 and whooping-cough2 it is very transient after pneumonia1 influenza1 diphtheria1 erysipelas1 and cholera4 #agb ,in serum therapy antitoxins are artificially excited into being in the blood of beasts4 ,this artificially prepared antitoxin is injected into the blood of1 say1 a diphtheria patient1 and the poison is at once neutralised1 instead of leaving the patient to make his own antitoxin and letting him perhaps fail in the effort4 ,the antitoxin produced in the contest of the body cells against some diseases will not only neutralise the toxin of a particular disease1 but it will also neutralise the toxin of a second disease4 ,by vaccinating a person we inoculate him with vaccinia or cowpox4 ,his body cells make an antitoxin which neutralises the toxin or virus of cowpox1 he recovers from this light disease1 and the antitoxin now remaining in his body prevents for years another successful inoculation with cowpox4 ,it does more3 in #ij per centum of cases it will prevent successful infection with smallpox4 ,smallpox 7the pocks1 pokes or pockets of matter1--opposed to the great pox or syphilis7 has been known from very early times--probably even from #abjj ,b4,c4 ,the name small pokkes was first used in ,england in #aeah4 ,the disease was brought to ,america in #aejg4 ,it may be communicated from the sick to the healthy 7#a7 by persons suffering with the disease2 7#b7 by bodies of persons that have died of smallpox2 7#c7 by infected articles2 7#d7 by healthy third persons2 7#e7 by the air1 to persons living even at some distance2 7#f7 by inoculation4 ,the poison enters the body by the mucous membrane of the nose1 mouth1 or respiratory tract1 and probably through the mucous membrane of the stomach and through the broken skin4 ,patients can communicate the disease probably during the period of incubation 7from #e to #bj days after exposure to the disease--commonly about #ad days72 and certainly from the initial stage until no trace is left of the final skin-desquamation4 ,the infection is most active during the formation and duration of the pocks4 ,the mildest smallpox in one person can cause malignant smallpox in another1 and vice versa4 ,the mortality in the unvaccinated is between #dj and #ej per centum4 ,a typical case of confluent smallpox at its height is the #agc ugliest disease in appearance and stench and almost in substance1 known to medicine4 ,anyone liable to infection by it1 or likely to carry it to others1 who says he is not afraid of it1 has either never seen it and he is talking childish nonsense1 or he has seen it and he is a fool4 ,the face is a bloated mass of corruption2 the eyes are swollen shut2 the nose1 cheeks1 lips1 and neck are puffed out enormously2 the mouth is a large sore1 ulcerous1 and spittle trickles from it ceaselessly4 ,the fever is up to #ajc or #aje degrees2 there is an unquenchable thirst1 a vile stench1 sleeplessness2 often delirium is the only relief1 and there is one chance in two of a disfigured recovery4 ,tobacco1 alcoholic liquor and a walk in the fresh air will not disinfect the visitor to such a disease4 ,years ago ,i investigated in the laboratory the popular notion that tobacco is a disinfectant4 ,i found that bacteria1 the diphtheria bacillus and swarms of others more delicate1 will grow as well in the presence of a large piece of ,navy ,plug1 as when tobacco is absent4 ,chewing tobacco1 whiskey1 a walk in the fresh air as disinfectants1 the ,sioux medicine-man's powwow1 the hind leg of a rabbit as a charm1 are all in the same category4 ,the first and chief protection against smallpox is vaccination4 ,vaccination does not always prevent infection by smallpox1 but it does prevent it in more than #ij per centum of exposures to the disease4 ,welch reported in #ahid that the death-rate in one series of #e1jjj cases of smallpox was #eh per centum in the unvaccinated1 and #af per centum in the vaccinated1 but the vaccinated took the disease in less than #aj per centum of the exposures4 ,during the ,franco-,german ,war in #ahgj-ahga1 the ,germans who had a million vaccinated men lost #deh soldiers from smallpox while a great epidemic of smallpox was existing in ,germany2 the ,french1 who were indifferent to vaccination1 during the same time lost #bc1djj men from this disease alone4 ,in the ,united ,states1 where there is no compulsory vaccination except such attempts as school boards make1 there were between ,july and ,december1 #aijc1 #ac1gci cases of smallpox2 in ,germany1 where there is a compulsory #agd vaccination law1 there was no smallpox at all1 during the same time1 except #ad cases in two seaports1 ,bremen and ,kiel1 whither the infection had been brought from without4 ,before #ahgd there had been no compulsory vaccination law in ,germany except for the army4 ,in #ahga1 #adc1jjj ,germans died of smallpox4 ,since the law went into effect in #ahgd the disease has been stamped out1 until there was between ,july and ,december1 #aijc1 only one death from smallpox in ,germany4 ,the chart on page #age will show very graphically the effect of vaccination upon smallpox4 ,in ,october1 #ahih1 smallpox was endemic in ,puerto ,rico2 in ,december1 #ahih1 it was epidemic2 in ,january1 #ahii1 it was all over the island and spreading rapidly4 ,in ,february1 #ahii1 compulsory vaccination was begun and carried out for only four months1 when #hfj1jjj vaccinations had been made in a population of about #ifj1jjj people4 ,the death-rate from smallpox dropped from #fba a year to #b4 ,during the century preceding ,jenner's discovery of vaccination1 according to ,neimeyer's calculation #djj1jjj people died of smallpox each year in ,europe4 ,bernouilli1 a trustworthy statistician1 says that during that same century1 ,fully two-thirds of all children born in ,europe were1 sooner or later1 attacked by smallpox1 and on an average one-twelfth of all children born succumbed to the disease4 ,early in the sixteenth century #c1ejj1jjj people in ,mexico had smallpox 7,prescott's ,conquest of ,mexico74 ,in #agjg1 in ,iceland1 #ah1jjj of the population of #ej1jjj died of smallpox2 and in #ahia1 #be1jjj persons in ,guatemala died of this disease4 ,in #ahge there were anti-vaccination riots in ,montreal1 and as a consequence most of the younger inhabitants of that city were not vaccinated4 ,in #ahhe1 smallpox was brought in from ,chicago2 #c1afd persons died of the disease2 of these #b1gag were children under ten years of age1 and thousands had the disease4 #age ,illustration3 ,,prussia4--,with compulsory vaccination and compulsory revaccination at the age of #ab4 ,,holland--,with compulsory vaccination of children before entering a school4 ,,austria4--,without compulsory vaccination4 #agf ,vaccination may render one immune to smallpox for many years1 but if the disease is epidemic it is well to renew the vaccination after about eight years4 ,in normal vaccination1 where the lymph has been derived from a reliable source1 on the third or fourth day pale red papules develop at the point of inoculation1 and about the tenth day these have become pustules4 ,the vesicles dry gradually1 and between the fourteenth and twentieth days the scab falls off1 leaving a pitted scar4 ,about the fifth day an aureola of inflammation forms around the pocks1 from a quarter of an inch to two inches in extent1 and the inflamed area may be somewhat sore4 ,a shield should be kept over the vaccination spot for two days1 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 area4 ,sometimes hives and other rashes occur in vaccination1 but they are unimportant4 ,where there is a very sore arm or other trouble1 the cause may be a pre-existing unhealthy condition1 like scrofula for example1 or the patient has scratched the pocks1 or infected them from his clothing1 or the vaccine lymph was unsterile4 ,a careless and dirty vaccinator might infect an arm with pus organisms4 ,if good glycerinated lymph1 not too fresh or too old1 is used1 there is seldom any trouble2 but in any case all the annoyance that may come from vaccination is infinitesimal when compared with the smallpox it averts4 ,we may take a smallpox case as a typical contagious disease in which the priest is to give the last ,sacraments2 and the disinfection and other precautions observed in such a visit will serve for any other very contagious disease4 ,for only typhus and one or two other maladies are the precautions so elaborate as those needed in smallpox4 ,there is a dress1 called ,dr4 ,hawes' ,antiseptic ,suit1 and in time of epidemics a priest should have one of these suits1 or one made after it as a pattern--they can be obtained in the shops for two or three dollars4 ,they cover the entire person1 even the shoes1 and they make unnecessary the changing of clothing and the disinfection of the exposed parts of the body4 ,the hands of the priest may be left bare after fastening the sleeves of the suit about the wrists1 or he may wear surgeon's thin rubber gloves4 ,in visiting a patient that has any of the contagious diseases mentioned in this chapter1 the priest should never touch #agg his own face with his hands after he has entered the sick-room until he has washed them in a bichloride of mercury solution4 ,a ritual should not be taken into a smallpox room1 because a book cannot be disinfected without rendering it useless4 ,the priest should memorise the prayers and ceremonial1 or write them out on paper which can be burned in the hospital or the patient's house4 ,the priest may be obliged to administer baptism1 to hear confession1 to give the ,viaticum and ,extreme ,unction4 ,before going to visit a smallpox patient let him find out from the physician in attendance whether the patient can receive the ,viaticum1 whether he can swallow it or not1 whether he can open his mouth enough to take it4 ,ask also about the possibility of vomiting4 ,only a very small particle is to be brought in the pyx4 ,the leather cover for the pyx should not be taken into a smallpox room4 ,set the pyx inside a corporal1 wrap the corporal in paper1 and put this package into the pocket of the ,hawes suit before entering the room4 ,as to the use of a stole1--the moralists say graviter peccatur ab eo qui sine urgente necessitate sine ulla sacra veste unctionem administrat4 ,there is a grave necessity here for doing away with the stole because of the difficulty in disinfecting it1 unless you have one made that can be put into boiling water for ten minutes before you leave the patient's house4 ,the oil-stocks should contain only as much oil as is necessary for the single occasion1 because what remains1 with the cotton1 should be burned in the patient's house4 ,do not remain in the room longer than you must unless you have had smallpox4 ,if there is any prayer or ceremonial that can be omitted1 by all means leave it out4 ,lehmkuhl says that the penitential psalms and the litanies may be omitted4 ,baptise by the short form4 ,st4 ,alphonsus ,liguori 7,theol4 ,mor41 lib4 #e1 tr4 #e1 n4 #gaj7 tells us there is no obligation to anoint both eyes and both ears1 si adsit periculum infectionis1 but danger of infection is not materially increased by anointing both sides4 #agh ,lehmkuhl adds1 excepta dispensatione ,sedis ,apostolicae addatur unctio pedum4 ,when the feet are to be anointed do not touch the bed-clothing1--tell the nurse to uncover the feet4 ,st4 ,alphonsus 7loc4 cit41 n4 #gbi7 speaking of extreme unction has these words3 ,pastor ratione officii tenetur sub mortali dare lis qui petunt1 nisi justa causa excuset3 etiam tempore pestis1 modo possit absque periculo vitae2 cum eo non teneri docent ,tann4 ,dian41 etc4 ,if you have not had smallpox you certainly risk your life by going into the room of a smallpox patient1 and the danger of infection is greater in typhus2 but suppose a pastor were inclined to take advantage of the excuse1 he would be obliged at any risk to go into such a room to hear confession or to baptise1 and if he hears confession he may as well stay for the anointing4 ,if you anoint a patient that has confluent smallpox you probably can not wipe away the oil1 because the skin will be pustular4 ,wipe the oil-stock carefully2 then all cotton used should be wrapped in paper and burned in the paper before you leave the house4 ,after anointing1 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 vessel4 ,wash your hands thus before you leave the sick-room4 ,if the patient can receive the ,viaticum let him lie on his back1 and you should drop the ,host into his mouth without touching him with your hand4 ,st4 ,alphonsus says3 non licet tempore pestis porrigere ,eucharistiam medio aliquo instrumento 4 4 4 sed manu danda est ,there is no need of an instrument4 ,if there are any crumbs left in the pyx make the patient take them4 ,st4 ,alphonsus says this may be done1 and it would be almost certain infection to take them yourself if you have not had smallpox recently4 ,let as little ablution water as possible be given to the patient4 ,when you leave the room1 put the pyx1 oil-stocks1 corporal1 and stole in a pan of water and boil them for ten minutes4 ,this will disinfect them thoroughly and will not injure them in any way4 ,then take off the ,hawes suit as near the street-door as possible and wet it with bichloride #agi solution4 ,wash your hands again in the bichloride solution and rinse off the bichloride2 take the pyx1 oil-stocks1 corporal1 and stole and leave immediately4 ,do not touch the door-knob when going out--let some one open the door for you--and do not shake hands with any one4 ,typhus fever is now rare in ,america1 but there was an outbreak in ,new ,york ,city in #ahha4 ,this was the fever that killed multitudes of ,irish emigrants about the middle of the nineteenth century4 ,it is called also spotted fever1 camp1 jail1 ship1 and hospital fever1 and it has many other names4 ,the name typhus is from ,greek text1 a smoke or fog1 and it indicates the befogged1 stuporous condition of the patient4 ,typhoid fever is so called because it has some resemblance to typhus4 ,the specific cause of typhus is unknown1 but the contagion develops and reproduces itself in the body of the patient4 ,it is thought that the contagion exists in the secretions and excretions of the body and in the exhalations from the lungs and skin4 ,the infection can certainly be carried by clothing1 dust1 furniture1 conveyances of all kinds1 and dead bodies1 and it remains active for months4 ,it may be transmitted through the air for short distances1 not nearly so far as the air will carry the contagion of smallpox4 ,in well-ventilated rooms there is less danger of infection1 and a typhus patient should have at least #a1ejj cubic feet of air space4 ,the contagion may be transmitted in all stages of the disease and during convalescence4 ,physical weakness1 anxiety and worry1 improper food1 and poverty1 are disposing conditions for infection by typhus4 ,the mortality is about #aj per centum--much less than that of smallpox4 ,in giving the last ,sacraments to a typhus patient exactly the same method should be followed as that observed for a smallpox patient4 ,keep as far from the patient as possible4 ,after you touch him in anointing or in giving other ,sacraments step away from him to say the necessary words4 ,do not stand between him and an open fireplace1 window1 door1 or ventilator4 ,relapsing fever1 or famine fever1 caused by ,obermeier's #ahj spirillum1 is sometimes associated with typhus4 ,it has a mortality that can go up to #ad per centum in unfavourable circumstances1 but the disease is not more contagious than typhoid under hygienic surroundings4 ,wash the hands in bichloride solution after visiting a case1 and do not touch the door-knob or things in the room4 ,rabies 7called also hydrophobia in man7 is a rare disease4 ,it is communicable by inoculation1 but it is very doubtful that the disease has been communicated from man to man4 ,the saliva from a person suffering with rabies if injected into a warm-blooded animal will cause rabies1 and on that account it is prudent to use care in touching such a patient in administering the last ,sacraments4 ,the virus might enter through an abrasion on the priest's hand4 ,there is a false hydrophobia observed in excitable persons that have been bitten by a dog thought to be mad4 ,the dog that has genuine rabies grows sullen1 it hides in comers1 and it snaps at everything presented to it ,a sticky1 frothy mucus drivels from its mouth and its eyes become red4 ,it will run straight ahead1 snapping at anything it meets2 it swallows small stones1 chips1 and similar objects2 it does not avoid water4 ,it howls1 grows lean1 and its hind legs and lower jaw become paralysed4 ,in man there is a premonitory stage2 a furious stage1 which lasts from about a day to three days2 then a final paralytic stage4 ,it is well to wait for the paralytic stage before anointing the patient1 because in the other stages the slightest touch causes violent spasms4 ,confessors should note that the virus of rabies excites the sexual centres4 ,scarlatina or scarlet fever first appeared in ,north ,america in ,massachusetts in #agce4 ,it is especially an ,april disease here4 ,one attack commonly makes the person immune for life4 ,it is a disease of children1 but it attacks adults1 and it is fatal among children old enough to receive the last ,sacraments4 ,some epidemics are very malignant2 and in such times all the precautions mentioned in speaking of the visitation of smallpox patients should be observed4 ,the contagion is spread just as that of smallpox is spread1 except that it is not carried through the air so far4 #aha ,diphtheria is a disease of children1 but it also can be fatal to adults and to children old enough to receive the last ,sacraments4 ,it is caused by the ,klebs-,loeffler bacillus1 and it most frequently attacks the throat and nostrils4 ,it can start in a cut in the skin1 or on any mucous surface1 as the inside of the eyelid4 ,the contagion is not in the breath1 but it can be coughed out4 ,it is in the saliva of the patient and it gets on his hands and on what he and the nurse touch4 ,it is not nearly so infectious as smallpox and scarlet fever4 ,in visiting such a patient the priest should be careful not to touch anything in the room1 and he should wash his hands in the bichloride solution after a visit4 ,he must also wet the soles of his shoes with the solution4 ,he should be very careful lest a child suddenly cough fine sputum containing the bacillus into his eyes4 ,diphtheria in the eyes would destroy sight1 and ,i have seen a pair of spectacles save a man in a case like that4 ,a detailed description of the disinfection in diphtheria is given in the chapter on ,infectious ,diseases in ,schools4 ,glanders is sometimes transmitted from beasts to man1 and it is almost always fatal in the human subject4 ,the disease is caused by the glanders bacillus4 ,horses1 asses1 dogs1 cats1 goats1 and sheep are susceptible to the disease2 pigs are somewhat susceptible2 cattle and birds are immune4 ,the infection is in the discharge from the nose of the patient and on the skin eruptions4 ,the same precautions are to be taken as are needed in a diphtheria case4 ,influenza1 called popularly the grippe1 is caused by the bacillus influenzae1 which was isolated by ,pfeiffer in #ahia4 ,the bacillus is found in the nasal secretions and in sputum2 it dies in from twelve to twenty-four hours when dried4 ,the disease is contagious1 and it is often fatal in alcoholics1 the overworked and harassed1 and in those that have chronic diseases4 ,in any case it is a serious malady4 ,disinfect the hands after visiting a case4 ,dengue becomes epidemic at times1 especially in the ,southern ,states4 ,the disease is very severe1 painful1 and depressant1 but the mortality is quite low except in complication with other maladies4 ,its cause is not known4 ,it is #ahb very contagious and has symptoms which belong to the class of disease in which are scarlatina and measles4 ,the priest should act as in a case of scarlatina4 ,there is a form of pneumonia which spreads so widely and rapidly that it is called epidemic pneumonia4 ,in visiting patients afflicted with this disease the priest should act as in a diphtheria case4 ,epidemic cerebrospinal meningitis is a very fatal disease at times in ,america4 ,even those patients that survive are frequently made blind or deaf1 or are left injured otherwise4 ,the malignant type is nearly always fatal4 ,in some epidemics the mortality is as high as #ge per centum4 ,the visiting priest should act as in a case of diphtheria1 although the danger of direct infection is not great4 ,tuberculosis is a chronic febrile disease1 caused by the bacillus tuberculosis1 a parasitic micro-organism discovered by ,koch in #ahhb4 ,one-seventh of mankind die by this disease4 ,the bacillus remains virulent a long time after it leaves the human body1 but it is soon killed by sunlight4 ,tuberculosis of the lungs is spread especially through sputum4 ,in the room occupied by the patient1 the clothes1 furniture1 walls1 doors1 and floor are infected by the bacilli coughed out1 even when the consumptive is careful to disinfect the sputum1 and1 by the way1 he rarely is careful4 ,when the priest visits a consumptive's room he should disinfect his hands with bichloride4 ,leprosy is caused by the lepra bacillus1 discovered by ,hansen in #ahga4 ,it is present in many parts of the body1 especially in the glands and nervous tissues1 and it is found in the mucosa of the mouth and in the nasal secretions4 ,it is very profusely distributed in the corium of the skin4 ,the name comes from ,greek text1 scaly4 ,leprosy is present here and there along the ,mississippi valley from ,minnesota and ,wisconsin to ,louisiana4 ,it is found also in ,california1 ,florida1 and the ,dakotas1 in the ,philippines1 the ,west ,indies1 and the worst infected part of the world is the ,hawaiian ,islands4 ,the bacillus has not been found in rooms used by lepers1 nor in the soil of their graves4 ,inoculation by leprous #ahc material has failed so far undoubtedly to cause leprosy4 ,there is much dispute concerning the contagiousness of this disease4 ,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 disease4 ,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 infected4 ,father ,damien1 however1 in ,molokai1 and ,father ,boglioli1 in ,new ,orleans1 did contract the disease4 ,there have been cases of infection from man to man1 but ordinarily it seems that some unknown factor must be present to insure infection4 ,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 much4 ,he may wash his hands in bichloride solution after anointing a leper1 but it is scarcely necessary to do even that4 ,actinomycosis 7,greek text1 ray-fungus7 is a disease caused by actinomyces1 a micro-organism that partly resembles a bacterium and partly a fungus4 ,the disease can be fatal4 ,it is very improbable that it ever passes from man to man1 but as a matter of prudence the priest should wash his hands in bichloride after anointing such a patient4 ,septicaemia1 or blood-poisoning1 can be brought about by different pyogenetic bacteria1--the varieties of the staphylococci 7irregularly grouped cocci71 streptococci 7chain-cocci71 pneumococci1 and others4 ,the danger of infection is so slight that it may be neglected4 ,erysipelas can be fatal1 especially in alcoholics1 the aged1 and in chronic diseases4 ,erysipelas is contagious1 especially if the bacteria get into an abrasion in the skin4 ,patients having this disease sometimes grow delirious and violent1 and the priest should be careful how he handles them4 ,disinfect the hands after anointing such a patient4 ,tetanus1 or lockjaw1 is not communicable except by inoculation4 ,the bacillus1 which was isolated by ,kitasato1 the ,japanese bacteriologist1 in #ahhi1 is found everywhere in soil1 hay dust1 floors1 on old nails1 especially on the floors of old wooden slaughter-houses4 ,it grows best in deep wounds #ahd where it is shut off from the oxygen of the air4 ,hence the danger of treading upon a nail that has been lying near the ground4 ,beriberi1 a disease observed especially among seamen1 appears at times in our coast towns4 ,it is always a very serious malady and sometimes it is rapidly fatal4 ,the infective agent1 which is not known1 is not undoubtedly communicable from man to man1 but it is carried from place to place1 and it clings to ships and buildings2 it thrives in hot1 moist1 crowded places4 ,the priest should disinfect his hands after visiting a case4 ,anthrax1 called also wool-sorter's disease and splenic fever1 is a very fatal disease1 and the bacillus is communicable to any one through an abrasion of the skin1 through the intestines by swallowing it1 or through the lungs by breathing it in in dust4 ,disinfect the hands and the shoes after visiting a patient4 ,be careful not to touch anything in his room4 ,the bacteria that cause typhoid fever1 ,asiatic cholera 7which has been epidemic in ,america7 and epidemic dysentery must get on the hands1 or on food1 or in water1 and thus reach the mouth and be swallowed before they produce these diseases4 ,act in cholera as in anthrax1 and disinfect the hands after visiting a case of typhoid4 ,the bubonic plague1 the most fatal of all epidemic diseases1 has already appeared in ,california and ,mexico4 ,it is caused by a specific bacillus isolated by ,kitasato and ,yersin in #ahid4 ,the disease is communicated by contact and it is seemingly also miasmatic4 ,the terrible plague of the ,black ,death that swept over ,europe from #acdg to #acej was a malignant form of the bubonic plague4 ,over #a1bjj1jjj people died in ,germany1 and ,italy suffered much more4 ,in ,vienna for some time about #ajjj people a day died and were buried in great trenches4 ,venice lost #ajj1jjj inhabitants1 and ,london lost more than that4 ,in both ,padua and ,florence only one-third of the inhabitants were left alive2 at ,avignon the ,rhone was consecrated so that bodies might be thrown into it for burial2 and ships drifted about the coasts of ,europe #ahe with dead crews4 ,hecker1 in his study of this plague1 says that nearly one-fourth of the population of ,europe died in that visitation4 ,civilisation was wellnigh overthrown in the panic4 ,in ,germany1 ,italy1 and ,france the ,jews were accused of poisoning the wells and thus causing the plague1 and they were slaughtered by thousands4 ,at ,strasburg #bjjj ,jews were burned to death in one holocaust2 at other places1 as at ,eslingen1 in despair the ,jews set fire to their synagogues and destroyed themselves4 ,the ,great ,plague of ,london in #affe1 in which #gj1jjj persons died1 was also the bubonic plague4 ,the mortality is about #ij per centum in some epidemics4 ,the bacillus leaves the body in the faeces1 flies carry it to food1 it thus gets to rats and mice1 and it is carried from place to place4 ,rats1 however1 are commonly infected as if by a miasm before the disease appears in man4 ,there is dispute as to the communicability of the plague from man to man by contact with fomites1 but it is practically certain the disease can be thus transmitted4 ,kitasato once succeeded in producing the disease in animals by inoculation with dust taken in an infected house4 ,merely touching a patient does not apparently convey infection1 yet some authorities hold that in time of epidemic the contagion is transmitted even through the air1 especially on the ground floor of houses4 ,perhaps mosquitoes are the medium of infection1 as they are inclined to fly low4 ,in visiting a case of bubonic plague the priest should be as cautious as if he were attending a smallpox patient4 ,after death by smallpox1 plague1 typhus1 cholera1 scarlatina1 diphtheria1 and measles the funerals should be private and the bodies should not be taken to the church4 ,malta ,fever1 or bilious remittent fever1 is found in some of the islands taken from ,spain4 ,it has a low mortality and is not contagious4 ,bruce in #ahhg isolated the bacterium that causes it4 ,we do not know the cause of yellow fever despite the claims of ,sanarelli that he has isolated the specific micro-organism4 ,recently ,american physicians discovered that it is transmitted from man to man by mosquitoes that belong #ahf to the genus ,stegomyia1 the ,stegomyia ,fasciata especially4 ,if a yellow fever patient is put into a room in which the mosquitoes have been killed and the doors and windows are screened1 he is as harmless1 as far as contagion is concerned1 as a man with a broken leg4 ,the disease is not spread by fomites4 ,malaria is caused by plasmodia1 which are protozoa1 not bacteria1 and it is carried from case to case by mosquitoes of the genus ,anopheles4 ,so certain are we that this is the mode of infection that the expression no anopheles1 no malaria has almost become a medical axiom4 ,a bite from an anopheles mosquito does not cause malaria unless the particular mosquito has previously bitten a malaria patient4 ,the stegomyia flies and bites in the early afternoon and again at night1 the anopheles flies and bites after sunset4 ,in visiting a case of pernicious malaria or one of yellow fever avoid the bites of mosquitoes by gloves and a piece of netting1 and there is no danger whatever4 ,the stegomyia mosquitoes are tropical and subtropical1 but they can live as far north as ,philadelphia and even farther4 ,the anopheles is especially a northern insect4 ,the ordinary culex mosquito1 when it alights upon a wall1 stands with its body parallel to the wall1 as a house-fly stands2 the anopheles mosquito stands with its tail raised from the wall at an angle4 ,a mosquito lays its eggs in any pool of still water1 and the wrigglers seen in an open rain-barrel are the larvae from these eggs4 ,the larvae come to the surface of the water to get air1 and they may be smothered with petroleum2 but the only effective way to get rid of malaria and yellow fever is to drain or fill pools of water and marshes4 ,mosquitoes will breed also in the small still bights along the edges of running streams2 in old tomato cans that contain rain water2 in any still water1 fresh or salt4 ,,austin ,,omalley4 #ahg ,,xv ,,infectious ,,diseases ,,in ,,schools ,cases of diphtheria1 scarlet fever1 measles1 and even smallpox are not seldom found in schoolrooms1 and much anxiety can be averted and the spread of infection can be wholly or in great part averted by a knowledge of disinfection4 ,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 physicians1 therefore a preliminary explanation of methods for the prevention of infection in the family will be advantageous2 prevention in the family is also intimately connected with prevention in the school4 ,methods useful in the family are useful also in convents and boarding-schools4 ,as regards diphtheria1 the chief causes of the spread of this disease are mistaken diagnosis1 imperfect isolation1 incomplete disinfection1 and1 paradoxical though it may seem1 a lack of susceptibility to the disease in a large number of children4 ,many physicians are still under the grave error that diphtheria can always be recognised without the aid of the microscope1 and that membranous croup commonly kills4 ,all scientific writers upon diphtheria agree that it is caused by the ,klebs-,loeffler bacillus4 ,they also hold that there is a disease called membranous croup1 as distinct from diphtheria as typhoid is1 but that membranous croup is a comparatively harmless and non-contagious disease4 ,two per centum is a liberal mortality in membranous croup1 yet a certain class of physicians are constantly reporting deaths from this disease4 ,in a series of #bhf cases 7not deaths7 diagnosed as membranous croup by physicians of ,new ,york #ahh ,city a few years ago1 ,park found the diphtheria bacillus in #bbi1 or #hj per centum4 ,i have never examined the throat of a child dead from so-called membranous croup in which ,i did not find the diphtheria bacillus4 ,this is the experience of almost every bacteriologist who has had to do with diphtheria4 ,some men report deaths from diphtheria as thrush6 ,these deaths might just as truthfully be attributed to the wearing of linen collars4 ,on the other hand1 according to ,baginsky of ,berlin1 ,martin of ,paris1 ,park of ,new ,york1 and ,morse of ,boston1 from #bj to #ej per centum of the cases admitted even to diphtheria hospitals have not diphtheria at all4 ,bacteriologists find that about #ce per centum of the cases reported by physicians to be diphtheria are really nothing but tonsilitis or pharyngitis1 with now and then a case of membranous croup4 ,without a bacteriological diagnosis1 therefore1 #ce families in each #ajj quarantined 7where quarantine laws exist7 are unjustly quarantined and subjected to the trouble and expense of useless disinfection4 ,the suffering this can cause to a poor family1 whose small business is often ruined by quarantine1 is a matter for very serious consideration4 ,again1 no matter what experience a physician may have had1 he can not in many cases differentiate diphtheria in its early stages1 or in children of good resisting power1 from comparatively harmless throat affections4 ,the extraordinary resisting power against diphtheria shown by some children and adults has been described by ,wassermann 7,zeitschrift f4 ,hyg41 #ai ,b41 #c ,h474 ,he found one series of #ag children1 from one and a half to eleven years of age1 and #cd adults1 in which #aa children and #bh adults were not only immune to diphtheria1 but some of them had enough antitoxin in their blood to neutralise a tenfold fatal dose of diphtheria toxin4 ,this explains many mysterious outbreaks of diphtheria3 such immune persons are infected and they carry about the disease unconsciously because they are not ill themselves4 ,i have seen a mother kiss a child dying of malignant diphtheria and the woman did not get even a sore throat1 but ,i know of another case exactly like this in which the mother died from the infection4 #ahi ,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 throat1 but the lighter cases that are dangerous are not easily recognised4 ,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 house4 ,the cases of these two children would never even suggest diphtheria if that first child had not had the disease4 ,both these patients died within ten days of syncope without the formation of any membrane1 but the diphtheria bacillus was present microscopically4 ,to the moment of death there was nothing in the symptoms of these two children to show diphtheria to the naked eye4 ,from a personal experience with more than #hjj cases of diphtheria in hospitals and as a medical inspector1 ,i feel certain that light attacks of diphtheria can not be diagnosed without the aid of the microscope4 ,the immunity mentioned above explains the fact that the ,klebs-,loeffler bacillus is sometimes found in healthy throats1 and the person that has such a throat is really more dangerous than a patient that is ill with diphtheria1 because we cannot guard ourselves against him4 ,school-children at times have what appears to be mere sore throat but which is really diphtheria in the naturally immune4 ,all cases of sore throat in school-children should be examined bacteriologically1 but unfortunately the bacteriological examination for diphtheria is a complicated process which requires an expert bacteriologist and a laboratory4 ,the cost of a laboratory fitted for this diagnosis alone is not great1 but it is not easy to persuade small city governments that they need such plants4 ,the only resource1 then1 is to treat every suspicious case of sore throat as if the disease were really diphtheria1 until a diagnosis is established as near the truth as possible4 ,children that are afflicted with throat inflammations should be kept from school4 ,the people should be taught the necessity of isolation and disinfection2 they should be warned against patent disinfectants1 and told to ask competent physicians to advise them in disinfection4 #aij ,diphtheria is not directly caused by unhygienic surroundings4 ,a disregard for hygiene disposes a child for infection if the child is exposed to the bacillus4 ,the specific germ must be introduced into the patient's mouth or nostrils4 ,when a child is infected with diphtheria the breath is not a medium of contagion4 ,the sputum1 spat out or coughed out1 is a means whereby the disease is spread4 ,the bacillus is in the patient's mouth and nostrils2 it gets upon his hands by contact1 upon eating utensils1 upon whatever touches the mouth of the sick person4 ,the bacillus does not float in the air of even the sick-room1 except in those cases where dried sputum is stirred up by sweeping or attrition of other kinds4 ,in a boarding-school or family when a diphtheria patient is found1 select a room set off as far as possible from the rooms commonly used1 and before putting the patient into this room remove all curtains1 upholstered furniture and carpets from it that are not so cheap or so worn that they may be destroyed after the patient's convalescence1 or which are of such texture that they will not be destroyed by water or disinfection by heat4 ,in any case the less there is in the room the easier the disinfection will be4 ,use the mattress upon which the patient had slept before you discovered the nature of the disease4 ,books should be removed1 because an infected book can not be disinfected except upon the outside4 ,the room is not to be swept while the patient is in it1--dust may be wiped up with a damp cloth4 ,the cloth is to be disinfected before it is sent out of the room4 ,the popular notions regarding sulphur as a disinfectant after diphtheria are erroneous4 ,sulphur fumes in certain definite quantities will disinfect after smallpox1 scarlet fever1 measles1 and some other diseases2 these fumes will also kill the diphtheria bacillus1 if the bacillus is wet and exposed directly2 but if it is buried in sputum or in clothing the fumes will have no effect whatever upon it4 ,the disinfectants to use are acid bichloride of mercury and heat4 ,formaldehyde does not penetrate well enough to be reliable in diphtheria4 #aia ,when the patient is taken to the room prepared1 let a mixture of one ounce of bichloride of mercury in the powdered form1 in two ounces of common hydrochloric acid 7not the dilute hydrochloric acid used in medicine71 be obtained4 ,this is a violent poison1 and it must be kept out of the reach of children and careless persons4 ,two teaspoonfuls of this solution in an ordinary wooden bucket filled with water to within two inches of the rim makes the disinfecting mixture4 ,a wooden washtub nearly filled with this disinfectant1 mixed in the bucket as directed1 should be kept near the door of the room1 and all towels1 sheets1 and soiled linen must be soaked in this tub for twenty-four hours4 ,after that any one may handle these articles with perfect safety4 ,the articles that have been soaked for twenty-four hours should be rinsed in ordinary water to remove the acid1 and they may then be washed4 ,the nurse should not touch the outside of the tub with infected articles while putting these in the disinfectant4 ,do not make the disinfectant stronger than directed here1 or it will destroy the articles soaked in it1 and for the same reason do not leave them in it longer than twenty-four hours4 ,if the attendant can be kept isolated with the patient there will be less liability of carrying the infection through the house4 ,in a majority of cases in families1 however1 the mother is obliged to care for the patient and to attend also to her household duties4 ,in the last case1 let her keep near the door of the room a cotton wrapper which can be put on over her dress whenever she enters the room4 ,she had better tie a towel over her hair4 ,in the room a china-stone basin should be kept1 containing a gallon of water1 in which there is a teaspoonful of the acid bichloride4 ,every time the attendant touches the patient let her wash her hands in this mixture1 using no soap4 ,she should remove her finger rings or they will be blackened4 ,the patient should not be handled except when absolutely necessary1 to avoid needless exposure to infection2 it is also injurious to a child ill with diphtheria to lift it up4 ,the nurse's covering wrapper should be soaked in the tub as often as possible4 ,some ignorant persons give as an excuse for a lack of care in #aib handling patients having contagious diseases like diphtheria1 that they are not afraid of the infection4 ,fear has nothing to do with the matter4 ,food is to be taken to the door of the sick-room by some one other than the attendant4 ,the tray should not be carried into the room4 ,after the meal1 take to the door a pan containing water1 and let the attendant set the dishes1 knives and forks1 and the food handled by the child1 under the water without touching the rim or sides of the dish-pan4 ,then any one may carry the pan to the kitchen1 where it is to be set upon the stove1 and the water holding the dishes and the rejected food is boiled for an hour4 ,after that process the contents of the pan are safe1 and they may be handled for washing4 ,cloths used in wiping the mouth of the patient are to be wrapped in paper and burned4 ,dejecta should be covered with fresh chlorinated lime1 one part to two of water4 ,after the patient begins to convalesce the danger of infection grows greater4 ,when the membrane has disappeared1 and the child is able to run about the room1 the attendant ceases commonly to use the throat-spray because the process is troublesome4 ,in such cases the diphtheria bacillus remains in the patient's mouth for some time--from a few days to weeks4 ,during the most of this time the child is as dangerous to others as it was while it was ill4 ,in one case in my own experience1 the bacillus remained present for eleven weeks from the date of diagnosis1 and ,i then lost sight of the child4 ,in the tenth week the bacillus present when in pure culture killed a guinea-pig in thirty-six hours4 ,this is1 of course1 an exceptional occurrence2 but the routine practice is to keep the patient isolated for three weeks after the membrane has disappeared1 unless a bacteriological examination shows that the bacillus is absent4 ,the bacillus remains after the use of antitoxin just as if antitoxin had not been used4 ,when a child is to be released from the sick-room1 bathe it carefully with soaped warm water1 washing out the hair and under the finger-nails carefully4 ,then wet a towel with the disinfectant 7the acid bichloride of mercury1--a #aic teaspoonful to a gallon of water7 and go over the body with it2 afterward rinse with ordinary water4 ,do not let the disinfectant enter the child's mouth or eyes4 ,next1 without allowing the child to touch anything in the room1 especially avoiding the door-knob1 send it to another room and dress it in clothing that has not been near the sick-room4 ,if1 after this process1 other children are infected1 the explanation is that the child had been released too soon--before the bacillus had disappeared4 ,it commonly happens that a child has been going about the house for some days before a physician has been called in4 ,in that event you have the house to disinfect4 ,you must then wet with bichloride everything the child has touched1 and boil all eating utensils4 ,as to the disinfection of the room and its contents3 the irritation of diphtheria causes a large quantity of saliva to flow from the patient's mouth2 this infected saliva runs down upon the pillows and soaks into them4 ,it may also soak into the mattress4 ,if a town has a steam disinfecting plant1 there is no trouble in dealing with bedding and carpets after diphtheria and other contagious diseases2 such a plant1 however1 costs at the least #fjjj4 ,it is safer1 in the absence of steam disinfection1 to destroy pillows by fire2 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 safe4 ,the ticking in this case should be boiled in a wash-boiler1 and the filling is to be rinsed before drying4 ,the mattress is less liable to infection but it may be infected4 ,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 disease1 the filling of the tick will most probably be not infected4 ,the loss of a good feather or hair mattress is considerable in the house of a poor man1 and these often may be saved4 ,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 #ejj cc4 of formalin for each #ajjj cubic feet of air-space in the room or closet--multiply the length by the height by #aid the width of the room or closet to get the cubic feet of air-space4 ,leave the room or closet shut tightly for twenty-four hours4 ,the ,trenner-,lee formaldehyde disinfector is a good apparatus for disinfecting4 ,the smaller size costs twenty-five dollars4 ,if anything is to be sent out of a room to be burned1 spread a piece of old carpet1 bagging1 or similar useless cloth outside the room door1 set on this the articles to be destroyed1 wrap them carefully in the fabric1 tying all with cords2 then take the bundle outside the town in a covered wagon1 pour kerosene oil on the package without opening it1 and set it afire4 ,afterward wash the wagon with the acid bichloride4 ,wet the furniture and floors of the room with the acid bichloride4 ,do not merely sprinkle the solution about1 flood everything with it1 because the germ is killed only by direct contact2 and remember that a diphtheria bacillus magnified #hjj times is not larger than the eye of a needle4 ,the bichloride will spoil gilt picture-frames1 therefore use a #aj per centum solution of pure carbolic acid on these and all other metallic surfaces4 ,coins should be boiled1 and paper money should be dipped in the #aj per centum carbolic acid solution and dried at a stove4 ,money is frequently found in smallpox rooms under the patient's pillow4 ,formalin is the best disinfectant for wall-paper unless the child has spat upon it--then use the bichloride4 ,sometimes the bichloride will not injure the wall-paper1 but if there are gilt figures upon it these will be blackened4 ,sulphur fumes are no better than formalin--not so good1 and they injure and blacken tinted and gilded wall-paper1 silks1 satins1 and other fabrics4 ,if you determine to have the room repapered1 wet it with bichloride before you bring in the workmen4 ,it is difficult to disinfect a carpet except by steam1 and on this account the carpet should be removed from the room before the patient is brought into it4 ,if it has been kept in the room1 wet it thoroughly with the bichloride1 when you are disinfecting1 if you can not have it disinfected by hot steam4 ,the wetting commonly spoils the carpet1 consequently it may be necessary to bum it4 #aie ,keep cats1 dogs1 and especially kittens1 out of a diphtheria room4 ,kittens will take the disease easily1 and cats and dogs will carry about the contagion4 ,if a valuable dog should get into the room1 disinfect its hair thoroughly with the acid bichloride and then rinse the hair4 ,be careful to disinfect its feet4 ,while using the bichloride do not forget the window-panes1 the door-knobs1 and that part of the chair-legs which touches the floor4 ,after you have used the bichloride expose the room to the gas from formalin4 ,hang up sheets wet with #ejj c4c4 of formalin for each #ajjj cubic feet of air-space1 and close all keyholes and cracks2 then leave the room shut for twenty-four hours4 ,as to the use of antitoxin as a preventive and cure for diphtheria1 too much praise cannot be given to that wonderful discovery4 ,reliable diphtheria antitoxin1 used in proper quantity and early enough1 is almost an absolute cure4 ,where it fails it has been used too late or not in the proper dose4 ,in any case its only evil effect may be an attack of nettle-rash or hives4 ,the few deaths that have occurred in its use were caused by an ignorant use of the syringe4 ,if you find a physician opposed to the use of antitoxin this simply means that he is a quack4 ,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 it4 ,the membrane often will disappear in twenty-four hours where antitoxin has been used1 and the child will be playing about the floor4 ,then the mother will say the child never had diphtheria2 she will not disinfect1 and she will let the child run about the house4 ,the free book system that prevails in some schools is a prolific source of infection4 ,books are infected at home or by children from infected houses1 and mixed with other books in the school4 ,the diphtheria bacillus will cling to a book for at least a year4 ,if books are given to the children1 give them outright2 do not let the books be mixed in the schoolroom4 ,drinking-cups used in common are another source of #aif infection4 ,let each child have its own tin cup4 ,the clothes-rack in a school also spreads infection4 ,room enough should be given to each hook to keep the hat and coat of one child from touching those of another1 and a wooden partition standing out from the wall about eight inches should separate hook from hook4 ,the janitor should wash the clothes-racks with the acid bichloride solution every time he sweeps4 ,suppose a child having diphtheria is found in school1 or one is discovered as coming from a house where he was in contact with diphtheria4 ,the discovery is made commonly after the child has been spreading infection for some days4 ,do not frighten the youngster1 but find out from him what parts of the school-building he has been visiting4 ,then send him and the other children home4 ,rooms in which the child has not been are not infected1 and only that which he has touched is infected in any case4 ,wet everything in the building and outhouses with which he possibly could have come in contact with the acid bichloride4 ,burn his books and papers1 or1 if this action may cause difficulty with parents1 let him take his books home and inform the health officer of that fact4 ,when he returns to school be sure of the history of his books4 ,use formalin or sulphur in the infected rooms1 and classes may be begun again the next day4 ,if within the week any child shows signs of sore throat send it home immediately4 ,sulphur must be burned when used as a disinfectant1 and to be effectual four pounds should be burned for every #ajjj cubic feet of air-space in the room4 ,a teaspoonful of sulphur when burned will fill a house with choking1 dangerous fumes1 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 disease4 ,sprinkling disinfectants about a house1 and setting saucers containing disinfectants in rooms is nonsense--the quantity must be sufficient and be in actual contact with the contagion4 ,a deodorant does not disinfect because it removes a stench4 ,to burn sulphur set a coal-hod or an old tin pan on two bricks in the middle of the room1 but see that there are no #aig holes in the bottom of the hod or pan through which burning sulphur could drip to the floor4 ,for a like reason see that the pan is not too narrow nor too shallow4 ,it is safer to set the bricks in a tub filled with water up to the top of the bricks4 ,use powdered sulphur in preference to the cakes sold by the druggists1 and fire this sulphur with a red coal4 ,the room should be moist with steam when the sulphur is set afire so that the fumes will act effectually4 ,leave it shut tightly for twenty-four hours4 ,in the ,northern ,states diphtheria is most prevalent in ,october1 ,november1 and ,december2 scarlet fever is an ,april disease1 but it may occur at any time4 ,it is easier to spread the infection of scarlet fever and measles than that of diphtheria1 but it is not so difficult to disinfect after scarlet fever and measles as after diphtheria4 ,the contagion of scarlet fever does not resist the fumes of sulphur or formalin4 ,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 room4 ,eruptive contagious diseases like scarlet fever1 smallpox1 and measles so affect the skin that during convalescence the cuticle scales off4 ,in severe cases of smallpox and scarlet fever the entire outer skin of the hand may peel off like a glove4 ,the contagion is always found in the scaling skin4 ,as the patient grows stronger the scales become finer1 until at last they lie as mere mealy dust in the hollows of the elbows or other parts of the body4 ,down to the very last these scales are infectious1 and they will retain the infection for months1 probably for a year or more4 ,the scales float in the air of a sick-room1 fall on the clothing of visitors1 are carried away by the shoes of those that leave the room4 ,the scaling may continue for three weeks--it commonly does4 ,these three diseases are infectious before the scaling begins1 sometimes before the rash is well out4 ,a very light attack of any of these diseases in one child may infect another fatally4 ,insist upon keeping a scarlet fever or measles patient out of school until all scaling has ceased4 ,chickenpox is almost a harmless disease1 but it is more infectious than even measles4 ,be cautious with it because #aih nearly every epidemic of smallpox begins through some one mistaking smallpox for chickenpox1 although there is little or no similarity between the diseases4 ,a child with tuberculosis of the lungs or a child infected with acute syphilis should not be permitted to go to school under any circumstance4 ,in the chapter on ,the ,priest in ,infectious ,diseases will be found an account of the necessity of vaccination as a precaution against smallpox4 ,tinea ,favosa1 or favus1 is a contagious and a very stubborn disease of the skin1 caused by the fungus ,achorion ,schoenleinii4 ,it produces yellowish crusts about the hairs of the scalp and other parts of the body1 and it destroys the hair4 ,it attacks also the finger-nails and the skin that is without hair4 ,in the later stages of the disease there is a foul odour4 ,it is one of the most difficult of the scalp-diseases to cure2 months and sometimes years are required to get rid of it4 ,a child with tinea should be kept away from school2 and his desk and what he touches should be washed with the bichloride of mercury solution4 ,burn his books and papers4 ,ringworm is a kind of tinea1 and it is caused by various mould fungi4 ,tinea ,tonsurans is ringworm of the scalp2 ,tinea ,circinata is ringworm of the body2 ,barber's ,itch is another form2 there is also a ringworm of the finger-nails2 and ,pityriasis ,versicolor is still another form4 ,all are contagious1 and some are difficult to cure because the parasite gets down between the skin and the hair-follicles and an antiseptic can not reach it4 ,children affected with these diseases should be kept away from school until they have been cured4 ,the presence of lice and of the ,acarus ,scabiei can bring about acute and severe skin eruptions4 ,the ,acarus ,scabiei causes itch1 but fortunately it is rare in ,america4 ,these parasites go from person to person1 hence a child having either should be kept from school until he is clean4 ,a thorough washing will remove lice if they have not yet inflamed the skin1 but itch requires a more vigorous #aii treatment4 ,the desks of such patients should be disinfected and their clothing should be baked4 ,they will probably be reinfected at home if the treatment is not applied to other members of the family4 ,contagious ,impetigo1 or porrigo1 as it was formerly called1 is a skin disease common among children1 and it may affect adults4 ,it appears to be of parasitic origin1 but the specific organism that causes it has not been isolated4 ,the lesions in this disease are commonly discrete--separate one from another--but they may be crowded together4 ,they are vesico-pustular and they are sunken at the top in the typical form4 ,if they are not broken by scratching1 they dry into a yellowish crust4 ,the disease affects only the skin1 but as it is contagious a child affected with it should be kept from school until cured4 ,the desk and articles used by the child should be disinfected1 and his books are to be burned4 ,whooping-cough is very infectious1 and1 contrary to the popular opinion1 it is frequently a fatal disease4 ,there is a period of incubation for from seven to ten days1 then a catarrhal stage follows in which the child has the symptoms of an ordinary cold4 ,in about another week the dry cough becomes paroxysmal with the characteristic whoop when the air is drawn in after the fit of coughing4 ,when there is an epidemic of whooping-cough1 children with colds should be sent home from school4 ,the objects used by a child that has whooping-cough should be disinfected1 and its books and papers are to be burnt4 ,mumps can be a serious and a very painful disease and it is infectious to a marked degree4 ,the specific organism is not known4 ,boys are more liable to this disease than girls are1 and recurrence is rare4 ,after a period of incubation1 which lasts from two to three weeks1 there is fever1 pain under one ear1 and the parotid gland swells4 ,the disease is commonly mild1 but it may affect a child seriously4 ,the patient is to be quarantined1 what it has touched should be disinfected1 and its books are to be burnt4 ,there are a number of infectious eye diseases that occur among school-children4 ,acute ,contagious ,conjunctivitis1 #bjj or pink eye1 is one of the most important4 ,one form of acute ,contagious ,conjunctivitis is caused by the ,koch-,weeks ,bacillus2 it is pink eye1 properly so called1 and it is very infectious4 ,objects handled by the patient can infect others and spread the disease4 ,the attack is severe1 but the prognosis for full recovery is good4 ,the child should be strictly quarantined until all secretion from the eyes has ceased1 and whatever he has touched is to be carefully disinfected4 ,another form of ,acute ,infectious ,conjunctivitis1 less contagious than that caused by the ,koch-,weeks bacillus1 is brought about by the introduction into the eye of the bacteria that give rise to pneumonia4 ,commonly the pneumonia bacteria do not cause conjunctivitis unless the patient is susceptible in a special manner4 ,as it is difficult to differentiate this second form from the first1 the same precaution should be used4 ,trachoma1 called also granular conjunctivitis1 ,egyptian ophthalmia1 and military ophthalmia1 is a very serious inflammatory disease of the external eye which has of late years become prevalent in ,american cities1 whither it has been brought by immigrants from eastern and southeastern ,europe4 ,persons that have this disease on landing in the ,united ,states are deported1 but despite this precaution it has crept in and is now endemic4 ,it is contagious1 and when well established it is extremely difficult to cure4 ,if untreated it lasts for years and it may destroy the cornea and consequently the sight4 ,a trachomatous child should be kept from school until it has been cured1 and that cure will take a very long time4 ,the ,gonococcus can be carried into the eye by handling objects like soap1 towels1 wash-basins1 which have been used by persons afflicted with gonorrhoea4 ,the infection of the eye is very severe and dangerous1 and the usual quarantine is to be observed4 ,the ophthalmia of the new-born is gonorrhoeal4 ,the ,diphtheria ,bacillus also may get into the eye1 and set up a primary infection there4 ,a membranous conjunctivitis1 too1 is at times induced by pus organisms4 #bja ,xerosis ,epithelialis1 tuberculosis1 leprosy1 and syphilis may affect the eye primarily1 and additional forms of eye-diseases are found that are infectious4 ,the general rule1 then1 is that children with any inflammation of the eyes are to be kept out of school until a physician pronounces them harmless4 ,,austin ,,omalley4 #bjb ,,xvi ,,school ,,hygiene ,priests have to put up buildings for parochial schools1 colleges1 seminaries1 orphan asylums1 convents1 and the like1 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 plumber4 ,the physical welfare of youth is almost as important as its mental training1 and there are many factors beside sewer-traps involved in the effort to sustain it4 ,if there is freedom of choice as regards the site of a schoolhouse or similar building1 the top of a small elevation is to be selected4 ,such a position affords the best natural drainage1 removes dampness1 avoids inundations1 gives full sunlight and the purer air4 ,the top of a high hill may be too exposed to the wind4 ,next to the top of a knoll1 the southerly slope of a hill is to be chosen4 ,the building should not be overshadowed by a hill1 especially on the western side4 ,trees are not to be planted close to a building in which children live1 and ivy and similar plants should not be permitted to cover the walls4 ,if a building is set in a hollow it will be surrounded with chill air and mists in the cold seasons1 even if a costly drainage system keeps the cellar and basement dry4 ,a gravelly or sandy soil beneath a building is the best1 provided this soil is not already saturated with organic matter1 or is not close above a dense layer of clay or rock4 ,clay1 marl1 peat1 and made soils should be avoided if possible1 because they are full of organic matter2 they are cold1 and they infect the ground air4 ,rock does not make a good building site--its seams carry water4 #bjc ,the subsoil should be drained four or six feet below the cellar floor1 and this floor is to be laid in concrete and cement4 ,at the level of the ground there should be a course of hollow vitrified brick to exclude dampness and to give ventilation4 ,limestone walls conduct more heat in and out than an equal thickness of glass1 bricks1 plastering1 and wainscoting4 ,the porosity of the building material determines the interchange of the air through the walls1 and it affects the temperature of the rooms4 ,if there is water in the pores of the walls heat is conducted rapidly1 but air is not permitted to pass4 ,brick as a building material has many disadvantages1 but on the whole it is best for schools1 and it resists fire better than most stones4 ,the harder the brick the better it is--vitrified brick is the best4 ,hard-pressed brick of a light colour makes an excellent outer wall-surface4 ,it is very doubtful that sewer gas escaping into a house will directly carry the micro-organisms of diseases like typhoid and diphtheria1 but such gas is poisonous1 depressant1 and it renders the inmates of a house liable to disease2 lessens their power of resistance4 ,the typhoid bacillus and other bacteria can1 of course1 be carried into a cellar by the seeping in of drainage water4 ,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 floors1 but here the weakening agent is heat4 ,tuberculosis1 scrofula1 rheumatism1 neuralgias1 bronchial1 and kidney affections are made worse in damp houses4 ,the chief defects in plumbing and drainage are the following3 7#a7 ,earthen pipe drains become broken or their joints leak1 and they saturate the ground under a house with sewage4 7#b7 ,tree roots break and clog drain pipes4 7#c7 ,the pipes sometimes have not fall enough4 7#d7 ,drains without running traps admit sewer gas4 7#e7 ,rats burrow along a drain pipe from the sewer into the house and admit sewer gas4 7#f7 ,when the soil pipe from a water-closet is exposed in cold weather it may freeze up or be clogged by urinary deposits4 7#g7 ,rats gnaw through lead pipes and joints4 7#h7 ,two or more closets or sinks with unventilated #bjd traps on the same pipe will siphon back sewage4 7#i7 ,overflow pipes sometimes have no traps and they let in gas4 7#aj7 ,ash pits near a house carry moisture to walls1 7#aa7 ,cesspools leak through the soil4 ,in planning a school-building the classrooms and the study-halls are the first things to be considered4 ,the classrooms should be oblong1 with the aisles running lengthwise4 ,each child should have at the least #ae square feet of floor space and #bjj cubic feet of air space4 ,a room #cj by #be feet with a ceiling #ac feet from the floor will serve for #dh pupils and no more4 ,this is the best size for a room when blackboards and maps are used in teaching1 because a larger room sets the children in the back seats too far away to see without eye-strain4 ,dormitories should have at the least #cjj cubic feet of air space for each child1 and great care is to be taken in the ventilation4 ,children about #aj years of age require #aa hours of sleep2 under #ac years1 #aj-a_/b hours2 under #ae years1 #aj hours2 under #ag years1 #i-a_/b hours2 under #ai years1 #i hours4 ,do not make children get out of bed before seven o'clock in the morning2 do not let them study before breakfast1 and do not force them to work after half-past eight or nine o'clock at night until they are at the least #ag years of age4 ,the hours for work should be3 ,ages ,hours of work a week ,from #e to #f #f #f to #g #i #g to #h #ab #h to #aj #ae #aj to #ab #bj #ab to #ad #be #ad to #ae #cj #ae to #af #ce #af to #ag #dj #ag to #ah #de #ah to #ai #ej ,work given for punishment must be included in these hours4 ,no one1 even an adult1 should study for more than two hours at a time without an intermission for a few #bje minutes4 ,in a boarding-school no one under any pretext1 even on rainy days1 should be permitted to study during recreation hours1 and the deprivation of recreation to make up lessons is a relic of barbarism4 ,if a teacher can not get class work done except by shutting up children during recreation hours1 remove the teacher or expel the pupil4 ,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 room1 and this must be increased if the light is obstructed by neighbouring houses or trees4 ,the light is to be admitted on the left side of the pupils1--all other windows should be counted as ventilators only4 ,windows facing the children or the teacher are to be avoided4 ,in rooms fourteen feet high a desk twenty-four feet from a window is insufficiently lighted4 ,the larger the panes of glass the better1 and the external appearance of windows is to be sacrificed to good lighting4 ,if screens are used to protect the glass from stone-throwing1 allowance is to be made for the light the screens cut off4 ,if a room can not have enough light from the left side alone1 put the additional windows on the right so that their lower sills will be eight feet from the floor2 and be careful in this case that the light from the right is not brighter than that from the left4 ,windows should have as little space as possible between them to avoid alternate bands of shadow and light4 ,set them up as near the ceiling as possible1 since the higher they are the better the illumination2 and they should not be arched at the top4 ,the lower window sills may be about four feet from the floor4 ,when window shades are used to cut off direct sunlight1 they should be somewhat darker in colour than the walls4 ,if artificial light is used in boarding-schools in the study-halls1 the best light is one that is as near in colour as possible to the white light of the sun1 and ample1 but not glaring4 ,it should be steady1 and it should not give out great heat nor injurious products of combustion4 ,hence the electric light is the best2 after that1 gas through ,welsbach #bjf or ,siemens burners4 ,well refined kerosene oil gives a good light1 but it is always dangerous4 ,acetylene gas is now used in a safe apparatus1 and it also is an excellent light4 ,no colour that absorbs light should be used on the walls4 ,pale greenish gray1 nearly white1 is the most satisfactory colour4 ,there should be no wall paper1 curtains1 or hangings of any kind in a school or college building4 ,the wall decorations should be as plain as possible1 with no roughened places to catch dust4 ,stairways are to be well lighted2 they should be at the least five feet wide1 and have landings half-way between each story4 ,diagonal or spiral stairways are dangerous4 ,steps with six-inch risers and eleven-inch treads are the easiest for children1 but six-and-a-half-inch risers may be used in high schools and colleges4 ,carbonic acid in the air of a classroom is an index of impurity4 ,external air has about three parts of carbonic acid in #aj1jjj parts of air1 and above seven parts in #aj1jjj is injurious4 ,each person exhales about fourteen cubic feet of carbonic acid gas in an hour4 ,there is no easy method of determining the quantity of carbonic acid gas present in a room1 and we must therefore arrange the ventilation so that about #cjjj cubic feet of fresh air an hour will be supplied to each person in the house4 ,beside carbonic acid there are other impurities in house air1 as dust1 micro-organisms of disease1 exhalations from bodies1 sewer gas1 and the like1 which accumulate and do injury when the ventilation is defective4 ,if every person in a house has #ajjj cubic feet of air space1 natural ventilation will suffice ordinarily1 but artificial ventilation is needed in schoolrooms and dormitories4 ,the subject of ventilation can not be satisfactorily discussed in a short article1 and those that are interested in school building should leave the matter to a competent architect1 or study books and articles like ,j4 ,s4 ,billings' ,ventilation and ,heating1 ,pettenkofer's ,ueber ,luft in den ,schulen1 and ,kober's article on ,house ,sanitation in the ,reference ,handbook of the ,medical ,sciences4 #bjg ,the proper heating of a schoolroom is a matter so generally understood that there is no need for special remark here1 except this1 that provision for proper humidity in the heated air is commonly neglected4 ,cheap water-closets do not save money--they get out of order too easily4 ,the pan1 valve1 and plunger hoppers are not to be tolerated4 ,the only kind to use are short-hopper closets with a trap that opens into the soil-pipe above the floor4 ,these may have valve-lifters attached to the seats1 because children forget to flush the hoppers4 ,the ventilation of the water-closets should be separate from that of the main building4 ,in country places where vaults are used1 there should be a supply of dry loam kept1 and enough of this to cover the fresh contents should be thrown into the vaults every evening4 ,children are seemingly always thirsty1 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 matter4 ,common cups are an abomination1 and a prolific cause of contagious diseases4 ,each child should have its own cup4 ,the rules for desks and seats for children are these3 #a4 ,the height of the seat should be about two-sevenths of that of the body4 #b4 ,the width of the seat should be about one-fifth of the length of the body1 or three-fourths the length of the thigh4 ,do not keep unfortunate little children's feet dangling all through their school years to save a few pennies on school furniture4 #c4 ,the seat should slope downward a little toward the back1 be slightly concave1 and have rounded edges in front4 #d4 ,there must be a back-rest4 #e4 ,the child1 when sitting erect1 should be able to place both forearms on the desk without raising or lowering the shoulders4 ,this is a very important rule4 #f4 ,the seat must be correctly placed as regards the distance of its front edge from the corresponding edge of the desk4 #g4 ,the desk slope should be #ae degrees4 #bjh ,badly constructed desks cause eye-strain and marked distortions of the spine4 ,desks should be adjustable in height1 especially for growing children4 ,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 least4 ,if a child is moved to another desk an adjustment is to be made at once4 ,to counteract the bad effect of long sitting1 even at properly adjusted desks1 children should be frequently sent to blackboards1 and at regular intervals a few minutes are to be given to setting up exercises4 ,great attention should be paid to the eyesight of children4 ,those that complain of headache should have their eyes examined4 ,the lines in school books should be not more than four inches in length1 and they are to be printed in clear1 well-leaded type4 ,slates are dirty and unsanitary3 let the children write on paper that has a dull finish4 ,teachers should prevent lounging positions at desks1 especially stooping4 ,they are not1 however1 to try to make children under fifteen years of age sit still4 ,the youngsters can not remain immovable1 and the effort to make them do so is irritating to no purpose4 ,nervous children need outdoor exercise more than anything else4 ,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-sense1 because there is a nervous scrupulosity which is much more frequently met with than the purely spiritual form4 ,aridity in prayer1 a loss of sensible devotion1 and similar troubles have to do with advance in the spiritual life1 but they more commonly have to do with the liver in persons that are not nearly so important spiritually as they fancy they are2 and in these cases the cook is the particular devil at fault1 if they have exercise enough4 ,one of the chief sanitary evils in our boarding-schools1 convents1 and similar institutions1 is the stupid sameness in the food which may be otherwise unobjectionable4 ,the meat1 for example1 may be good1 but the college and seminary cook sends it into the refectory chilled and clammy1 or hot and overdone4 ,in any case it is everlastingly the #bji same4 ,children can predict a dinner's ingredients a month in advance4 ,give children meat twice a day2 white flour in their bread1 because it is digested better than whole flour2 all the sugar they want at meals2 milk rather than tea1 and tea rather than coffee2 but let it be tea1 not a dose of tannic acid4 ,the physical education of girls is neglected4 ,their general education is effeminate rather than feminine4 ,if a convent faculty grows bold and modern it hires a teacher of gymnastics1 puts an extra on the bill of expense1 and ten or twelve wealthy girls play at gymnastics if they are not too lazy4 ,even if the whole school is obliged to attend the club-swinging and posturing and the other nonsense1 little good is done4 ,girls should be kept out of doors for their exercise1 and fresh air is much cheaper than a gymnastic teacher4 ,if school-girls were forced into the open air more1 they would not have time for munching caramels over the erotic spasms of ,araminta and ,reginald in the popular novel1 and there would be advantage in the change4 ,the absence of daily1 regular1 and sufficient exercise renders girls listless1 anaemic1 sallow1 foul-breathed1 melancholy1 stooped1 irritable4 ,do not permit boys under eighteen years of age to go into regular training for college track-teams4 ,their hearts are not strong enough for the strain4 ,boys should not use tobacco in any form1 but it is useless to try to make them believe this statement4 ,tobacco stunts a boy1 causes dyspepsia1 and renders his mind dull4 ,the measurements made for years at ,yale1 ,amherst1 and other colleges1 by physical directors1 show remarkable reduction in the height and chest expansion in tobacco users as compared with boys that do not smoke4 ,cigarette smoking would not be different from other smoking if it did not so readily tend to excess4 ,cigarette smoke is inhaled more than the smoke from cigars and pipes1 and thus more of the injurious ingredients of tobacco are absorbed4 #baj ,if a boy will smoke let him use a good long-cut tobacco which has little or no ,perique tobacco in it1 in a ,remington1 ,edison1 or similar wooden pipe4 ,these are pipes with stems of large calibre1 and in the stem there is a roll of absorbent paper or pith which keeps the pipe clean4 ,cigars1 no matter how costly they may be1 are too strong for a boy and for most men4 ,a poor cigar irritates the throat aside from the regular effect of the tobacco1 especially if there is much nitre in the wrapper4 ,meerschaum pipes are dirty and too strong4 ,the tongue is irritated by a pipe that has a small bore in the mouthpiece3 use a mouthpiece that has as large a bore as possible4 ,cigar smokers should1 after cutting off the end of a cigar1 blow the dust out of it from the lighting end to avoid inhaling this irritating dust4 ,,austin ,,omalley4 #baa ,,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 sentiment4 ,an unaccountable increase in piety is sometimes the first warning of approaching mental deterioration4 ,it is not hard to understand why this should be1 since religious feelings occupy so prominent a place in the minds of the majority of people1 and the removal of proper control over mental operations of all kinds leads to an exaggeration1 especially of those that have meant most for the individual before4 ,supposed religious vocations1 especially when of sudden development1 are sometimes no more than an index of disturbed mentality4 ,every confessor of lengthy experience has had some examples of this4 ,this makes it important that clergymen should have a knowledge of at least the first principles on which the diagnosis of mental diseases is made4 ,superiors of religious communities1 and especially those that have to decide as to the suitability of those applying for entrance to1 or already in probation for1 the religious life1 need even more than others a definite knowledge of the beginning symptoms of the various mental diseases1 and of the types of individuals that are most prone to suffer from them4 ,besides1 confessors and religious friends and advisers often gain the confidence of the mentally diseased much more fully than any one else4 ,it is to them especially that the earliest symptoms of beginning mental disturbance are liable to be first manifested4 ,after all1 a pastor's and a #bab confessor's duty is bound up with the welfare of his spiritual children in every sense2 and it would be supremely serviceable to the patients themselves and to their friends1 if these earliest symptoms could be recognised and properly appreciated1 and due warning thus given of the approach of further mental deterioration4 ,the mental diseases that are of special interest in this respect are the so-called idiopathic insanities4 ,idiopathic is a word we medical men use to conceal our ignorance of the cause of disease4 ,idiopathic diseases are those that have come of themselves1 that is1 without ascertainable cause4 ,as a matter of fact1 the most important group of mental diseases develop without presenting any alteration of the brain substance1 so far as can be detected by our present-day methods of examination4 ,the initial symptoms of these diseases1 then1 are of great importance1 and not readily recognisable unless looked for especially4 ,there is no physical change to attract attention1 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 patient4 ,it is in these idiopathic insanities1 then1 that the careful observation of the clergyman is of special significance4 ,needless to say1 powers of observation to be of service must be trained4 ,while there are no known changes in the brain tissues in these diseases1 it seems not improbable that the development of our knowledge of brain anatomy1 which is especially active at the present time1 will very soon demonstrate the minute lesions that are the basis of these mental disturbances4 ,it seems not unlikely that the underlying cause of so-called idiopathic insanity is usually some change within the brain cells4 ,hints of the truth of this conjecture are already at hand4 ,meantime the actual observation of this class of patients in asylums and institutions1 private and public1 and the collation of the observations of authorities in psychiatry from all over the world1 have thrown a great deal of light on these forms of mental disease4 ,we know much more of the initial symptoms and of incipient conditions that threaten the development of mental #bac disequilibration than we did twenty-five years ago4 ,with regard to prognosis especially1 recent publications have added considerably to our knowledge1 although it must be confessed that they have rendered our judgment of such cases much less hopeful4 ,the ordinary forms of mental diseases have sometimes been considered as passing incidents in the lives of patients suffering from such disorders4 ,while it was generally understood that severe cases were apt to have recurrences1 and that after persistence of mental symptoms for a certain length of time the outlook as regards eventual absolute cure is rather dubious1 yet the general prognosis of such simple states as melancholia or simple mania was not considered to be distinctly unfavourable4 ,patients might very well recover their mental sensibility after even a severe attack1 and never have a relapse4 ,it was something of an unpleasant surprise to the medical world1 a few years ago1 when one of the most distinguished authorities in ,europe on the subject of mental diseases1 ,professor ,kraepelin1 of the ,university of ,heidelberg1 stated in his text-book of psychiatry1 that among a thousand cases of acute mania he has observed only one in which the symptoms did not recur4 ,professor ,berkley1 of ,johns ,hopkins ,university1 ,baltimore1 a conservative ,american authority1 in discussing this subject of relapses after single occurrences of mania1 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 conditions4 ,simple mania1 he says1 is1 according to the statistics now at hand1 an exceedingly rare form of mental disease1 and the physician should therefore be cautious in making a prognosis of final recovery4 ,relapses after a number of years1 when stability is apparently assured1 are frequent1 as every one interested in mental medicine knows only too well4 ,the more experience the specialist in mental diseases has1 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 mentality4 ,while this is true in mania1 #bad it is almost more generally admitted with regard to melancholia4 ,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 ideas4 ,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 conditions4 ,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 depression4 ,the careful investigation of the history of these cases showed that they had suffered from previous attacks of depression1 though sometimes these were so slight as not to have attracted any special attention from the medical attendant1--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 living4 ,the most frequent form of idiopathic insanity is melancholia4 ,the disease is characterised by depression of spirits4 ,professor ,berkley's definition1 besides being scientifically exact1 is popularly intelligible4 ,according to him1 ,melancholia is a simple1 affective insanity in persons not necessarily burdened by neuropathic heredity1 characterised by mental pain which is excessive1 out of all adequate proportion to its cause1 and accompanied by a more or less well-defined inhibition of the mental faculties4 ,this latter part of the definition is extremely important4 ,in extreme cases patients are able to accomplish no other mental acts beyond those which concern the supposed cause of their depression4 ,their lack of attention to other things is the measure of the mental disturbance4 ,their minds constantly revolve about one source of discouragement4 ,they become absolutely introspective and their surroundings fail utterly1 in pronounced cases1 to produce any reaction in them4 ,in milder cases this involves an increasing neglect of whatever occupation the patient may have1 solely for the purpose of giving up time to the contemplation of the cause of his depression4 ,it is not easy always to recognise the limits between a #bae depression of spirits that is not entirely abnormal and a corresponding state of mind that is manifestly due to insanity4 ,when misfortunes occur1 individuals will be mentally depressed4 ,sorrow has in it necessarily no element of mental alienation4 ,it is only when it becomes excessive that observers realise that there is disturbance of the mental faculties1 causing the undue persistence and the exaggeration of the grief4 ,for example1 a mother loses an only son in the prime of manhood and at the height of his career4 ,it will not be surprising if1 for a considerable period1 she is unable to take up once more the thread of life where it was so rudely interrupted4 ,for weeks she may react very little to her surroundings and may prove to be so moody as to arouse suspicion of her mental condition4 ,after a time1 however1 she begins to have some of her old interest in affairs around her4 ,her depression of spirits may not entirely disappear for long years1 perhaps never2 but her affective state does not go beyond a simple sorrow4 ,on the other hand1 under the same circumstances1 a mother may give way to transports of grief that after a while settle down into a persistent state of dejection4 ,every thought1 every word1 every motive1 has a sorrowful aspect to her4 ,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 wickedness4 ,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 matter4 ,this state of mind is distinctly abnormal1 and if it persists for some time must lead to the patient's being kept under careful surveillance4 ,the immediate cause of the development of such a melancholic state is always some unfortunate event in the course of life4 ,worry and sorrow are important causative factors4 ,mostly1 however1 these causes are only capable of producing their serious effects upon the mental state of predisposed individuals1 or at times when the health of the subject is decidedly below the normal4 ,emotional disturbances are not liable to have such serious effects1 except when anaemia1 or continued dyspepsia1 or some serious nutritive drain upon #baf the system1 like frequently continued hemorrhages1 persistent dysenteric conditions1 or too prolonged lactation1 have brought the system into a condition of lowered vital resistance4 ,unfortunately1 in ordinary life these run-down physical conditions are prone to be associated with the worry and overwork that precede disaster4 ,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 relative1 father or mother1 or even more frequently husband or wife1 or child1 is found in the clinical history of the patient shortly before the development of the mental disturbance4 ,serious business troubles1 however1 loss of property1 actual want of proper nourishment1 failure to succeed in some project on which the mind has been set1 and similar conditions1 so common in our modern hurried life1 are also capable of producing the mental depression that assumes an insane character in certain individuals4 ,for the development of melancholia a predisposition seems to be necessary4 ,most people can suffer the reverses of fortune1 the accidents of life1 and the griefs of loss of friends and relatives1 without mental disequilibration4 ,certain predisposing factors are well known4 ,heredity1 for instance1 is extremely important4 ,melancholic conditions are frequently found in successive generations of the same family4 ,while heredity is not as prominent a feature in melancholia as in other forms of insanity1 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 insanity4 ,women are more often the subjects of melancholia than are men4 ,this is especially true in the earlier and in the later periods of life4 ,in the years between twenty and thirty-five the proportion of cases in each sex is more nearly equal4 ,the two conditions1 the establishment of the sexual functions1 that is1 the important systemic changes incident to puberty1 and the obliteration of the sexual function at the menopause1 with its consequent physical disturbances1 are especially important in predisposing to the occurrence of #bag melancholia in women4 ,their mental functions are less stable naturally1 and are subject to greater physical strains and stresses4 ,childbirth and lactation are also important factors in the causation of the condition4 ,long-continued lactation--that is1 beyond the physiological limit of about nine months--is especially a frequent cause4 ,the development of the mental disturbance in this case is always preceded by a state of intense anaemia1 in which the skin assumes a pasty paleness1 and other physical signs give warning of the danger4 ,lactation is sometimes prolonged for no better reason than the hope to avoid pregnancy4 ,usually we may say this method fails of its purpose and pregnancy and lactation together work serious harm4 ,in young people particularly1 homesickness is a not uncommon cause of melancholia4 ,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 unsuitable1 or when disturbances of their digestive systems make it impossible for them properly to assimilate it4 ,a number of instructive examples of this condition have occurred in the last few years among our young soldiers in the ,philippines4 ,to the physical strain necessarily incident to campaigning1 especially in young men unaccustomed to the life of the soldier1 there was added the serious trial of the tropical climate and the unusual and not over-abundant or varied diet provided by the army rations4 ,autointoxication is said to play a prominent role in the causation of melancholia4 ,this supposes that there is a manufacture of poisonous materials within the system1 whose transference to the nervous tissues causes functional disturbance of these delicate organs4 ,such poisons are especially liable to be manufactured when digestive disturbances have existed for long periods of time1 or when chronic alcoholism is a feature of the case4 ,the ordinary depressed condition so familiar in our dyspeptic friends and that develops so commonly as the result of indigestion1 is an example of the depressing effect of toxic substances upon nervous tissues and mental states4 #bah ,melancholia does not develop as a rule without some warning of what may be looked for4 ,nutritive disturbances are nearly always prominent features in the case for some time before any mental peculiarities are noticed4 ,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 nourishment4 ,usually there has been distinct digestive disturbance for some months4 ,there is apt to be loss of appetite4 ,there may be some slight yellowness in the whites of the eyes4 ,commonly there has been an increasing disregard for the patient's usual habits1 especially in the matter of exercise and friendly intercourse4 ,there is a disposition to sit apart and brood by the hour1 and a well-marked tendency to avoid friends and even members of the family1 with an utter disinclination to meet strangers4 ,one of the marked features of the disease in women is a tendency to untidiness4 ,women lose all regard for their personal appearance and fail to arrange their clothes properly4 ,men who have been specially neat in their personal appearance take on slouchy1 careless habits1 allow their clothes to become soiled and dirty1 and have evidently forgotten all their old customs in this matter4 ,the symptoms are not always continuous4 ,there is often a rhythmic alteration of intensity of symptoms that corresponds more or less to the physiological rhythm of life4 ,in ordinary circumstances human temperature is highest in the afternoon and vital processes are most active at this time4 ,the lowest temperatures occur in the morning1 especially in the early hours2 and it is at this time that vital processes are least active and the general condition is most depressed4 ,it is not surprising1 then1 to find that melancholic patients are liable to suffer from deeper mental depression during the morning hours4 ,in suicidal cases it is especially in the morning hours that patients need the closest surveillance4 ,in a certain number of cases of melancholia1 instead of the quiet1 often absolute immobility of the patients1 there is a form of the disease characterised by the presence of incessant movement and an agitated state of countenance1 #bai that disclose their disturbed mental conditions4 ,in melancholia1 as a rule1 sleep is very much disturbed1 and at times patients do not sleep at all4 ,in the agitated form of melancholia1 the patient is often quiet only when under the influence of a sleeping-potion4 ,patients may tear their hair1 disarrange their clothing1 strike themselves1 hit their heads against the wall1 sigh and sob1 and repeat some phrase that indicates their deep depression4 ,they are apt to reiterate such expressions as ,i am lost1 ,i am damned4 ,this is a much more serious form of melancholia than the quiet kind4 ,the mental faculties are much more completely unbalanced1 and the prognosis of the case is more unfavourable4 ,there may be recovery within a very short time1 and this recovery may be more or less complete4 ,usually1 however1 the condition becomes chronic and runs for many years4 ,such patients may sometimes be distracted sufficiently from their state of depression to smile and manifest pleasure in other ways4 ,usually1 however1 this diversion is only temporary and they recur to their darker moods until some new and specially striking notion distracts their thoughts once more4 ,with regard to melancholia the most important feature is the tendency to suicide4 ,this is apt to be present in any case1 however mild1 and may assert itself unexpectedly at any moment4 ,where there is suspicion of the existence of melancholia1 patients must be under constant surveillance2 and1 as a rule1 they should be under the supervision of some one accustomed to the difficulties that such cases may present4 ,patients are often extremely ingenious in the methods by which they obtain the opportunities necessary for the commission of suicide4 ,for instance1 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 success4 ,in a recent case in ,new ,york ,city1 a woman under the surveillance of a new1 though trained nurse1 asked the nurse to step from the room for a moment4 ,when the nurse came back three minutes later1 the woman was crushed to death on the sidewalk seven stories below4 ,a male patient asks an attendant #bbj to step from the room for a moment for reasons of delicacy1 and takes the opportunity to possess himself of some sharp instrument or of some poison4 ,at times1 during the night1 patients rise up while attendants doze for a few minutes1 and find the means to hang themselves without the production of the slightest noise4 ,these unfortunate suicides are happening every day4 ,they are the saddest possible blow to a family4 ,only the most careful watchfulness will prevent their occurrence4 ,clergymen should add the weight of their authority to that of the medical attendant in insisting1 when such patients are kept at home1 that they shall be guarded every moment4 ,as a rule melancholic patients should be treated in an institution4 ,their chances of ultimate complete recovery1 and1 more important still1 of speedier recovery than at home are much better under the routine of institution life and the care of trained attendants4 ,nearly three-fourths of the patients who suffer from melancholia will recover from a first attack under proper care4 ,subsequent attacks make the prognosis much more unfavourable4 ,not more than one-half will recover from a second attack1 and1 although melancholia is often spoken of as a mild form of intellectual disturbance1 recurring attacks give a proportionately worse and worse outlook for the patient4 ,if the general condition of the patient1 that is1 the physical health1 is very much run down when the mental disturbance commences1 then the outlook is much better than if the mental disturbance should occur when the patient is enjoying ordinarily good health4 ,thin1 anaemic patients1 contrary to what might be expected1 usually recover and often their recovery is permanent4 ,the first favourable sign in the case is an improvement in physical health4 ,this is very shortly followed by an almost corresponding improvement in the mental condition4 ,when the patient has reached the normal physical condition1 the mental disturbance has usually disappeared4 ,it is an extremely unfavourable sign1 however1 to have run-down patients gradually improve in physical health #bba without commensurate improvement in their mental condition4 ,this is nearly always a positive index that the mental disturbance will continue for a long while1 may not be recovered from completely1 or may degenerate into a condition of dementia with more or less complete loss of mental faculties4 ,the severe forms of melancholia are apt to be associated with delusions4 ,fear becomes a prominent factor1 and the patient is afraid of every one who approaches1 or concentrates his timidity with regard to certain persons or things4 ,delusions of persecution are not unusual1 and this sometimes leads to homicidal tendencies4 ,after enduring supposed persecution for as long as he considers it possible1 the melancholic turns on his persecutors and inflicts bodily harm4 ,the simplest actions1 even efforts to benefit the patient by enforcement of the regulations of the physician1 may be misconstrued into serious attempts at personal injury1 for which the patient may execute summary vengeance4 ,at times the hallucinations take on the character of the supposition that attempts to poison them are being made4 ,the patient may conceal his supposed knowledge of these attempts until a favourable opportunity presents itself for revenging them4 ,on the other hand1 it is not an unusual thing to have melancholic patients commit homicide with the idea of putting friends out of a wicked world4 ,the stories so common in the newspapers of husbands who kill wives and children1 of mothers who murder their children1 are often founded on some such delusion as this4 ,a mother argues with herself1 that her own unworthiness is to be visited on her children1 and that they are to be still more unhappy than she is4 ,out of maternal solicitude1 then1 but in an acute excess of melancholia1 she puts them out of existence and ends her own life at the same time4 ,when the melancholia is founded on supposed incurable ills in the body1 patients are sometimes known to mutilate themselves1 or to have recourse to alcohol1 or some narcotic drug1 in order to relieve them of their pain1 which is mostly imaginary1 and make life somewhat more livable during its continuance4 ,alcoholic excesses are especially common in #bbb cases of recurrent or periodical melancholia4 ,many of the cases of so-called periodical dipsomania are really due to recurring attacks of severe depression of spirits1 in which men take to alcohol as some relief for their intense feelings of inward pain and discouragement4 ,one of the most characteristic symptoms of melancholia is the refusal to take food4 ,sometimes this refusal is the consequence of an expressed or concealed desire to commit suicide4 ,in many cases the refusal of food is associated with the patient's melancholic delusions4 ,if the patient is hypochondriac1 food is not taken because the stomach is supposed not to be able to digest it1 or because it would never pass through the system4 ,at times the delusions are in the moral sphere and the patient is too wicked to eat1 or must fast for a long period or perhaps for the rest of life1 with the idea of doing penance4 ,as a matter of fact the refusal to eat is associated with the lowered state of function all through the system1 which is the basis of the melancholic condition4 ,this causes loss of appetite and lowering of the digestive function with a certain amount of nausea even at the thought of food1 so that it is scarcely any wonder that patients refuse to take food4 ,needless to say1 they must be made to eat4 ,this often requires the insertion of a stomach tube and forced feeding4 ,and as it must be done regularly1 it is accomplished much more easily at an institution than at home4 ,the other most common type of functional mental disease is mania4 ,this is a form of insanity characterised by exaltation of spirits with a rapid flow of ideas and a distinct tendency to muscular agitation4 ,it is almost exactly the opposite of melancholia in every symptom4 ,originally1 of course1 mania meant any form of madness4 ,then it became gradually limited to those forms of insanity which differed from melancholia4 ,now it has come to have a meaning as an acute attack of mental exaltation4 ,it is necessary to remember this development of signification in reading the older literature on the subject of mental disturbance4 ,professor ,berkley calls attention to the fact that ,shakespeare's statement1 ,melancholy is the nurse of frenzy1 may have been founded upon the observation that there are #bbc few cases of mental exaltation without a forerunning stage of depression4 ,it is characteristic of the acuity of observation of the poet whose works have created so much discussion as to his early training1 that this association of mental states1 which became an accepted scientific truth only during the last century1 should have been anticipated in a passing remark in the development of a dramatic character4 ,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 preparing4 ,mania is sometimes said to break out suddenly4 ,as a matter of fact there are always preliminary symptoms2 though these are of such a general nature that they may have escaped observation4 ,the patient's history generally shows that there has been loss of appetite and consequent loss in weight1 commonly accompanied by constipation and headache with increasing inability to sleep4 ,usually these symptoms have been present at least for some weeks or a month or more4 ,then the patient brightens up4 ,instead of the brooding so common before1 there is a tendency to talkativeness2 the eye is bright2 the expression lively2 in the midst of his loquacity the patient becomes facetious and jocular4 ,the backward before become enterprising4 ,undertakings are attempted that are evidently far beyond the power1 pecuniary or mental1 of the individual4 ,active employment is sought1 and1 where this fails1 restless to and fro movement becomes the habit4 ,friends notice this change in disposition1 and also note a certain lack of connection in the ideas4 ,there is apt to be a distinct change of disposition4 ,a man who has been very loath to make friends before1 now becomes easy in his manner toward strangers and takes many people into his confidence4 ,in the severer forms motion becomes constant2 the arms are thrown around2 to and fro movement at least is kept up2 the voice becomes loud and is constantly used4 ,patients can not be kept quiet1 and1 as a consequence of their constant movement1 their temperature rises and loss of sleep makes them weaker and weaker until perhaps physical exhaustion ensues4 #bbd ,the causes of mania are not always so distinctly traceable as those of melancholia4 ,heredity is an important factor4 ,this is1 however1 not so much a question of actual direct inheritance of mental disturbance from the preceding generation1 as a family trait of mental weakness that can be traced through many generations4 ,direct inheritance of acquired peculiarities no scientific thinker now admits4 ,family peculiarities1 however1 are traceable through many generations4 ,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 family4 ,and as has been said other family traits can be traced back in the same way4 ,it would not be entirely surprising1 then1 if mental peculiarities and a predisposition to mental disturbance should be also a matter of inheritance4 ,it is well known now that the physical condition of the brain substance may have much to do with the intellectual functions4 ,injuries to certain parts of the brain may cause special changes even of personal disposition4 ,in the famous crowbar case1 in which an iron drill over four feet in length was driven through one side of the head1 it was noted that the man1 who had been somewhat morose before1 was inclined to be more amiable afterwards1 but also had a tendency to be bibulous in his habits4 ,german clinicians have recently pointed out that the existence of an excess of pressure on the frontal lobes of the brain1 such as is produced by the presence of a tumour1 may cause a tendency to make little jokes4 ,this symptom is known as ,witzelsucht4 ,it is considered of distinct significance and value in localising tumours of the brain4 ,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 observers4 ,if modifications of the brain substance can produce changes of disposition and temperament1 it is easy to understand how temperament and disposition may be a matter of inheritance4 ,if we inherit a father's nose and a mother's eyes1 #bbe the minutest conformations of brain substance may also be inherited4 ,it is on these1 to a certain extent at least1 that the general outlines of the disposition depend4 ,it would not be surprising to find1 then1 a disposition to mental unsteadiness as the result of the transmission of brain peculiarities4 ,here1 as in everything else1 there is question1 not merely of parental influence1 but of the inheritance of the family traits1 some of which are skipped in certain generations4 ,when melancholia and mania are said to be due to heredity as one of the principal causes1 the meaning intended is that in certain families the brain tissues are liable to be transmitted in somewhat impaired condition1 and that through these brain tissues the mind will either not act properly1 or under the stress of violent emotion1 the loss of friends by death1 or the loss of fortune1 or serious disappointments in life1 or a love affair1 the already tottering mental condition will be overturned4 ,in a word1 it is not the direct transmission of insanity1 but of a predisposition to the development of insanity under stresses and strains that is a matter of family inheritance4 ,this is considered true now not only of mental but of all diseases4 ,not consumption1 but the predisposition to it is inherited4 ,these considerations make clear how important this matter of heredity is4 ,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 marriage1 so as to prevent further racial degeneration4 ,under present circumstances1 any such legal regulation is probably impossible2 but it seems perfectly clear that clerical influence should be brought to bear to discourage1 as far as possible1 intermarriage among those of even slightly disturbed mental heredity4 ,especially must any such idea as the possible beneficial influence of matrimony 7for there are popular traditions to this effect7 be unhesitatingly rejected and it must not be allowed to tempt those interested to look on such intermarriage with indifference4 #bbf ,another and more serious question for the clergyman is that of the vocation in life of those who are weak mentally4 ,by vocation is meant not only religious calling1 but the occupation in life generally4 ,young people of unstable mentality and especially those of insane heredity should be advised against taking up such professions as that of actor or actress1 or broker1 or other life duties that entail excitement and mental strain4 ,as far as possible they should be discouraged from taking up city life1 and should be advised to live quietly in the country4 ,mania is apt to follow certain severe infectious diseases in delicate individuals4 ,pneumonia1 for instance1 or typhoid fever or chorea1 and sometimes consumption or rheumatism1 may be followed by a period of maniacal excitement4 ,severe injury to the brain or the pressure due to the presence of a brain tumour1 may also be a cause of mania4 ,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 disease4 ,by this is meant in persons who have some organic lesion of the valvular mechanism of the heart4 ,this leads to disturbance of the circulation and interferes with cerebral nutrition1 thus predisposing to functional brain disturbance4 ,while melancholia occurs very frequently in older people1 mania is almost essentially a mental disease of the young4 ,the vast majority of cases occur between the twelfth and thirty-fifth year4 ,the subjects of the disease are usually those who possess what is called the sanguine temperament1 that is1 hopeful1 enthusiastic people1 easily excited and aroused1 easily cast down4 ,mania is much more common in females than in males4 ,one of the important characteristics of mania is the super-excitation of the sexual faculty4 ,in many individuals the first sign of their mental disequilibration noticed by friends is a tendency to sexual excess4 ,this is true of women as well as of men1 and the extent to which this may manifest itself is almost unlimited4 ,at the beginning of the disease this symptom is often a source of serious misunderstanding1 and may be the cause of family disruption4 ,usually1 before #bbg there are any open insane manifestations1 there are definite symptoms that would point to a pathological excitement in the sexual sphere4 ,one of the most striking characteristics of maniacal patients is the anaesthesia that often develops and is maintained in spite of the most serious injury4 ,because of this1 maniacal patients should be guarded with quite as much care as those suffering from melancholia4 ,i have seen a patient who1 during an attack of acute mania1 had put her hand over a lighted gas jet1 holding it there until the tissues were completely charred4 ,the burner was behind an iron grating1 but she succeeded in reaching it4 ,neither from this dreadful burning itself1 nor during the after dressings1 did she complain of the slightest pain4 ,because of this anaesthetic condition and the consequent lack of complaint1 maniacal patients often suffer from severe internal trouble without the medical attendant having any suspicion of its existence4 ,there are few conditions that are more painful1 for instance1 than peritonitis1 yet maniacal patients have been known to suffer and die from peritonitis1 due to intestinal or gastric perforation1 without a single complaint4 ,unexpected death frequently occurs in mania because of the failure to recognise the existence of serious pathological conditions4 ,pneumonia may develop1 for instance1 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 movement1 it being utterly impossible to confine the patient to bed4 ,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 existence4 ,in the meantime1 the patient may be constantly in the wildest motion and so add to the exhausting effect of the organic disease4 ,the prognosis of acute mania is not unfavourable4 ,patients suffering from a first attack will recover completely in eight cases out of ten4 ,notwithstanding complete recovery1 relapses are prone to occur whenever the patient undergoes a severe emotional strain4 ,as a rule not nearly so much mental disturbance is required to produce a second attack #bbh as the first one1 so that patients require great care4 ,in a certain number of cases recovery is incomplete2 persistent delusions remain1 and there may even be some weakness of intelligence4 ,paranoia1 as it is called1 mild delusional insanity1 may assert itself and then may persist for the rest of life4 ,notwithstanding this1 patients may get along in life reasonably well1 though their mental condition is decidedly below the normal4 ,in a certain number of cases1 after the period of excitement disappears1 a certain amount of dementia is noticed4 ,this consists of a distinct lowering of the intelligence1 though without the presence of any special delusion4 ,this dementia progresses until finally there is a state of almost complete obliteration of the mental faculties4 ,the prognosis as to life in cases of mania is very good4 ,very few patients die during an attack of acute mania4 ,at times there is a development of tuberculosis that proves fatal1 because of the restlessness of the individual4 ,pneumonia or typhoid fever may also prove fatal4 ,besides mania or melancholia1 there is a third form of functional mental disease1 which is a combination of these two forms4 ,it is usually spoken of as circular insanity4 ,the patient has usually first an attack of melancholia1 then an attack of mania1 and then after an interval melancholia and mania once more4 ,we have said that most cases of mania develop after a distinct stage of depression of spirits1 so that successive attacks of mania take partly the character of circular insanity4 ,this latter disease1 however1 is an index of a much more degenerated mental state of the individual than is either mania or melancholia alone4 ,when it occurs1 the prognosis as to future sanity for any lengthy interval is unfavourable4 ,a series of attacks alternately of depression and excitement finally make it necessary to confine the patient to an institution4 ,as might be expected in this severer form of mental disturbance1 heredity plays an especially important part in circular insanity4 ,at least #gj per centum of the patients affected show a family history of insanity in some forms4 ,in this disease direct inheritance of this particular form of #bbi mental disturbance is noticeably frequent4 ,the patients who develop this form of insanity usually show marked signs of degeneration1 even before any attack of absolute mental disturbance has occurred4 ,wounds of the head1 alcoholism1 and epilepsy are prominent factors in the production of circular insanity4 ,this only means that the predisposition to mental disequilibration is so strong that but very little is required to disturb the intellectual equilibrium4 ,fortunately1 circular insanity is rare4 ,in #dj1jjj cases of insanity in ,new ,york ,state1 only #if cases of this form were noted4 ,mild types of the disease are not1 however1 very rare4 ,many otherwise sane people have alternating periods of hopeful excitement and of discouraging depression1 not momentary but enduring for weeks at a time1 which are really due to the same functional disturbances that in people of less stable mentality produce absolute insanity4 ,these cases are of special interest to the clergyman and to directors of consciences4 ,,james ,j4 ,,walsh4 #bcj ,,xviii ,,neurasthenia ,neurasthenia1 or nerve-weakness1 the vapours of the old novelists and dramatists1 is a very common malady1 and it gives the clergyman trouble by the turmoil it causes in families1 religious communities1 in themselves1 and elsewhere4 ,whether the condition is a distinct disease or not1 and that question has been voluminously discussed1 is not altogether an important matter1 but that there is such a group of symptoms is unfortunately a weighty fact4 ,it takes so many forms that it is bewildering1 and therefore not readily reduced to unity4 ,the cerebral form often exists independently4 ,there is such a thing as brain fag1 although many complainants may have very little material for the fag to work on4 ,often such a patient is robust1 even an athlete1 and his assertions meet with ridicule or abuse instead of treatment4 ,if the patient is a woman she is not seldom called hysterical4 ,she is not hysterical4 ,hysteria1 by the way1 is as distinct a trouble as a broken leg1 and far more serious1 and not a synonym for perverseness1 as the term is popularly used4 ,in the cerebral form1 business1 reading1 study go into one ear and out the other4 ,the patient's memory fails him temporarily just when he may need it most1 say1 in a speech or sermon2 a fly buzzing on a pane is a calamity and a source of profanity2 a flat note in the choir-singing is ample reason for doubting the divine origin of the church1 and every petty trouble that whisks its harmless tail across his floor makes him seek the table-top4 ,i have known a whole convent of nuns1 who were closely shut in1 with bad ventilation and a worse cook1 until all were more or less neurasthenic1 almost #bca disintegrated by the presence of a lamb sent in as a pet2 not because of the bleating or any ordinary reason1 but solely because of the hideous incongruity and indecency in the fact that the lamb was a male4 ,the cerebral neurasthenic makes rash1 impetuous changes in his mode of life4 ,he leaves a religious order because the coffee is weak1 he resigns an important post in a bank because the president uses snuff1 he abandons medicine for trade because the curate meddled in the treatment of two of his patients4 ,he takes on anxiety1 locks up the house six times over the same night2 meals are eaten in awed silence by his trembling children2 altogether he is an unmitigated nuisance4 ,he may get religious scruples4 ,if he is a priest he takes an hour to an hour and a half to say a low mass1 and most of that time is spent in searching the corporal for imaginary particles or in drying the dry chalice4 ,he rereads his breviary until he is exhausted4 ,because moral theologians say that certain scruples are from the devil1 he is convinced that the devil takes a particular interest in his case4 ,the devil did probably take a special interest in his father's or grandfather's lack of scrupulosity1 for his condition is commonly a result of alcoholism in an ancestor4 ,there are three chief types of neurasthenics3 in one class is the person that appears robust1 and is really so except in his nervous system1 which lacks a governor4 ,such patients have little more than a troubled appearance to draw the attention of a chance observer to their condition4 ,a second class is made up of eloquent narrators of their troubles4 ,they try all the physicians in turn1 then the homoeopaths and osteopaths and similar quacks1 and they add patent medicines prescribed by themselves4 ,they are petulant1 capricious1 and despite their apparent energy they accomplish nothing4 ,the third class are silent1 limp1 clammy-handed2 they are brought against their will to see the physician2 they are sulky2 bitter and unreasoning haters2 inclined to melancholy4 ,they may have a tendency even to suicide1 but this is somewhat rare4 ,neurasthenics are not so liable to insanity as is popularly supposed1 but such an outcome is possible in certain #bcb cases4 ,if their vague fears go on into a more or less fixed delusion there is cause for anxiety lest insanity result1 but care should be taken here to be sure the delusion is really irremovable4 ,some neurasthenics are afraid to cross an open square or a wide street1 others dread any closed apartment4 ,vertigo is common2 so is insomnia4 ,insomnia is almost a constant symptom4 ,the patient may have naps or he may have uninterrupted vigils4 ,sometimes there is a heavy but unrefreshing sleep4 ,sleepless patients are thrown into distracting rage by the barking of a neighbour's dog1 the howling of cats1 or the cackling of a successful hen1 and they haunt the magistrates' courts in efforts to suppress such noises4 ,they put cotton in their ears1 wear heavy nightcaps1 stop clocks1 board up windows in search of sleep1 which is not found4 ,these patients commonly have an enduring feeling of weight or constriction in the head1 especially at the occiput1--a headache that is not actual pain4 ,they also have vertigo1 which is independent of any aural disease1 and this is transient1 showing itself on abrupt changes of position4 ,another phase of neurasthenia is spinal4 ,these cases have pain in the back and their legs give out4 ,the back-pain is a diffuse ache1 or it manifests itself on pressure at certain spots along the spine4 ,there may be severe pain at the coccyx1 especially in women4 ,the walking may simulate paralytic forms if hysteria is mixed with the neurasthenia4 ,cardiac symptoms are often prominent1 especially palpitation1 but there is a nervous excitation of the heart rather than any definite lesion4 ,the gastro-intestinal symptoms are often important4 ,pain referred to the stomach and acidity are common1 the tongue is coated1 the faeces scybalous4 ,digestion is torpid4 ,sometimes there is nervous diarrhoea4 ,a list of the belly symptoms described by some neurasthenics is interminable4 ,we often find a sexual form1 which is the worst of all and the hardest to cure4 ,it is commonly connected with masturbation4 ,such neurasthenics are shameless in the description of their nastiness4 ,it is better to keep them from marriage unless they are cured1 and they are not to be foisted off on #bcc any one as husband or wife to effect a cure4 ,allbutt says of them3 ,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 science1 a course of conduct which is in the worst interests both of these persons themselves and of our own profession4 ,it were a curious inquiry how it comes that sexual perversions are so 'scientific' a study1 while the brutalities of the thieves' kitchen or the wiles of other pests of society lie in comparative neglect4 ,physical1 intellectual1 or emotional strain can cause neurasthenia suddenly or gradually4 ,where it comes on without obvious cause there is commonly a bad family history of nervousness or alcoholism4 ,anaemia makes it worse2 eye-strain1 too1 is a provoking factor4 ,in some cases a renal congestion is the cause4 ,in many cases a lack of restraint1 bad education1 uncontrolled passion1 are a marked influence in fixing the neurasthenic habit4 ,a sedulous parent nags at a neurasthenic child that is too weak for exertion until the child's susceptibility to correction is blunted4 ,instead of treatment and help the child receives cuffs and abuse1 and hell-fire is held up before him until he deems all religious talk dust and ashes4 ,encouragement will sometimes do more good than all the threats in the via purgativa4 ,nagging never cured anything except a tendency toward virtue1 and it always deepens neurasthenia4 ,be careful in the selection of a confessor for a neurasthenic child4 ,get one that does not believe in kicking a soul into paradise4 ,the treatment of neurasthenia is difficult4 ,traveling about in search of health is not advisable4 ,the ,weir ,mitchell ,rest ,cure is very effective in many bad cases1 but it is costly1 and if not correctly applied it is useless4 ,it is the only cure for some patients4 ,sea air helps a certain class of neurasthenics1 but it makes others worse--it is bad for the dyspeptic neurasthenic4 ,a chronic rhinitis1 a refractive error of the eyes1 a displacement of the uterus1 a congested kidney1 a floating kidney1 a tight prepuce1 and similar teasing disorders must be cured before the neurasthenia can be removed2 often the neurasthenia disappears with this cure4 ,traumatic neurasthenia is like simple neurasthenia in #bcd most details4 ,it is called also nerve shock1 spinal irritation1 railway spine4 ,there is always a causative shock or injury1 which is followed at once or after an interval by the symptoms of neurasthenia4 ,in acute traumatic neurasthenia there may be1 in addition to the symptoms observed in simple neurasthenia1 high fever1 and such a fever has been observed to go as high as #aac degrees ,fahrenheit4 ,,austin ,,omalley4 #bce ,,xix ,,hysteria ,the term ,hysteria 7,greek text uterus7 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 hysteria4 ,it is now etymologically meaningless1--men also grow hysterical4 ,briquet found #aa male to #bjd female hysterics1 and later statistics increase the number of males4 ,the disease is not readily definable4 ,the patient is usually a young emotional woman1 oftenest between #ae and #bj years of age4 ,she commonly has anaesthetic spots on her body1 concentric limitations of the field of vision1 and hystero-genetic zones1 or tender points1 which1 when pressed1 appear to inhibit the hysterical fit4 ,the symptoms enumerated here are not1 however1 found in every case of hysteria1 and it is difficult at times to diagnose the disease4 ,the various manifestations of hysteria are 7#a7 apt to come and go suddenly4 ,a severe paralysis that suddenly disappears for a time is hysterical2 7#b7 even if they last for years they may be suddenly cured2 7#c7 they are dominated more by mental and moral influences than are the symptoms of any other disease2 7#d7 we find no organic lesion with which we can connect the symptoms4 ,the conditions that bring about hysteria are hysteria in a parent1 or insanity1 alcoholism1 or some similar neurotic taint in an ancestor4 ,there is no direct connection between hysteria and the disorders of the sexual organs4 ,immediate causes are acute depressive emotions1 shocks from danger1 sudden grief1 severe revulsions of feeling1 as from disappointment in love2 and1 secondly1 cumulative #bcf emotional disturbance1 as from worry1 poverty1 ill treatment1 unhappy marriage1 or religious revivals4 ,certain diseased conditions1 as anaemia1 chronic intoxications1 pelvic trouble1 cause hysteria1 or1 more exactly1 start it into activity where it is latent4 ,it is also communicated by imitation and it may become epidemic4 ,after the great plague1 the ,black ,death1 in the fourteenth century1 there were very remarkable epidemics of imitative hysteria in ,germany and elsewhere4 ,in #acgd1 at ,aix-la-,chapelle1 crowds of men and women danced together in the streets until they fell exhausted in a cataleptic state4 ,these dances spread over ,holland and ,belgium and went to ,cologne and ,metz4 ,it is said that in ,metz there were #aajj of the dancers seen at the same time4 ,the ,dancing ,plague broke out again in #adah at ,strasburg1 in ,belgium1 and along the ,lower ,rhine4 ,viel hundert fingen zu ,strassburg an ,zu tanzen und springen ,frau und ,mann1 ,am offnen ,markt1 ,gassen und ,strassen2 ,tag und ,nacht ihrer viel nicht assen1 ,bis ihn das ,wuethen wieder gelag4 ,st4 ,vits ,tanz ward genannt die ,plag4 ,beckmann 7,historia des ,fuerstenthums ,anhalt4 ,zerbst4 #agaj7 tells of a similar outbreak in #abcg1 wherein nearly a hundred children were seized by the disease at ,erfurt1 and they went along the road to ,arnstadt1 dancing and jumping hysterically4 ,a number of these children died of exhaustion4 ,the same infection is often at work in the fury of a mob1 the panic of a beaten army1 and it probably was an element in the ,children's ,crusade4 ,the ,tarantism so common in ,italy from the fifteenth to the eighteenth century is another example of epidemic hysteria4 ,the ,bubonic ,plague ravaged ,italy sixteen times between #aaai and #acdj1 and smallpox was at work when the black death could find no fresh victims4 ,as a consequence of economic disturbance and fear the people were generally neurasthenic1 and a slight shock was enough at times to set whole villages into hysterical convulsions4 #bcg ,in #aghg1 at ,hodden ,bridge in ,lancashire1 ,england1 a girl in a cotton mill threw a mouse upon another girl that had a great dread of this animal4 ,the frightened girl was thrown into a hysterical convulsion which lasted for hours4 ,the next day three girls that had watched her were in convulsions1 the following day six more1 and two days later fourteen more girls and a man were in fits4 ,american white and negro camp-meetings result in similar outbreaks1 and the ,french ,convulsionnaires1 who did outrageous things from #agca to #agij1 were also afflicted with imitative hysteria4 ,the ,cornish ,jumpers1 founded in #agfj by ,harris ,rowland and ,william ,williams1 and the ,american ,barkers were also hysterical4 ,the ,barkers in the meetings would run about on all fours growling1 to show the degeneration of their human nature1 and they would end in almost general fits of imitative hysteria4 ,there was an epidemic of hysteria in ,tennessee1 ,kentucky1 and a part of ,virginia1 which began in #ahjj and lasted for a number of years4 ,it started at revivals4 ,the majority of the cases were in persons from #ae to #be years of age1 although it was observed in every age from #f years to #fj4 ,the muscles affected were those of the neck1 trunk1 and arms4 ,the contractions were so violent that the patients were thrown to the ground1 and their motions there exactly resembled those of a live fish thrown out of the water upon the land4 ,there are numerous theories formulated to explain hysteria2 some are ingenious1 especially that of ,janet1 but none is convincing4 ,convulsions1 tremors1 paralyses of various forms and degrees are common in hysteria4 ,in major hysteria the patient falls into a convulsion gently4 ,there is checked breathing1 up to apparent danger of suffocation4 ,then follows a furious convulsion1 even with bloody froth at the mouth1 but there is a trace of wilfulness or purpose in the movements4 ,next may come a stage of opisthotonos1 where the body is bent back in a rigid arch till the patient rests on her heels and head only1 and this is followed by relaxation and recurrence of the contortions4 ,an ecstatic phase succeeds this1 at times in the so-called crucifix position1 with outbursts of various emotions1 and a final regaining of a #bch normal state4 ,any of these stages1 however1 may constitute the whole fit4 ,in minor hysteria there is commonly a sensation of a rising ball in the throat 7the globus hystericus74 ,there may be uncontrollable laughter or weeping4 ,muscular rigidity is frequently found4 ,the patient1 especially if she is a child1 may mimic dogs and other animals4 ,the snarling1 biting1 and barking of false hydrophobia are hysterical2 these symptoms do not occur in real hydrophobia4 ,there are almost innumerable physical symptoms of the disease1 which are chiefly of medical interest1 but the mental phases are such as to involve questions of morality4 ,the hysterical character is marked by an overmastering desire to be an object of general sympathy1 admiration1 or interest1 rather than by a tendency to baser indulgence4 ,the will is weak1 the emotions explosive1 the patient is impulsive and lacking in self-control4 ,she is a giggler1 who goes from absurd laughter into floods of tears4 ,the desire for sympathy and attention makes the patient exaggerate her symptoms or simulate diseases and conditions that do not exist in her case4 ,hysterics will swallow pins or stick them into their flesh to force attention4 ,sometimes the simulation of disease is not willed4 ,if there are a number of hysterical girls in a hospital ward and one develops1 say1 a peculiar paralysis1 within two or three hours every hysterical woman in the room will have the same paralysis1--not pretended1 but real1 although temporary4 ,it must be remembered that the disease1 with all its perversity1 is as much a fact as pneumonia1 and the element of sham is only one of its symptoms4 ,some authorities go so far as to hold that a woman who will not lie is not hysterical4 ,they invent most extraordinary slanders against even their own immediate family1 and it is never prudent to believe an accusation made by an hysterical patient1 no matter how plausible the story4 ,acquired hysteria in many cases may be cured1 but the congenital condition is practically hopeless1 yet the latter kind may be kept from violent outbreaks4 ,we can not prevent drunkards1 epileptics1 and lunatics from propagating their kind1 and therefore we shall still have the #bci hysteric with us4 ,the child that has a bad ancestry and shows hysterical tendencies should be carefully reared4 ,if it has an hysterical father or mother it should1 if possible1 be removed from this evil influence4 ,keep it from long hours of mechanical work that leaves opportunity for dreaming4 ,shut out novels and art for art's sake1 especially music4 ,give it a practical education4 ,teach it obedience1 self-control1 and truthfulness4 ,harden its will by exercise at things it does not like1 and do not coddle it4 ,do not marry off an hysterical girl to cure her4 ,do not inflict her presence upon some unfortunate young man because he is a good citizen4 ,marriage will not cure hysteria1--the worst cases are married women1 and they beget other hysterics in spreading succession4 ,when the disease shows itself offer no sympathy1--do not try to put out a fire with oil4 ,when a good1 pious girl grows hysterical1 the chief obstacles to her cure are untactful and sympathetic visits from friends1 lay and clerical4 ,a visit from the pastor1 because of his importance1 is always harmful1 and if the bishop drives up in his carriage so that the neighbours may see him1 all the physicians in the city can not help her4 ,if you wish to keep an hysterical girl in her vapours1 get her a physician that will grow excited over her1 take the dear child out of school and weep above her couch1 let the family and its friends assure the unfortunate attending physician in her presence that he is heartless1 and she will stay hysterical to her soul's content4 ,if you wish to control the attack1 or even remove the disease under certain conditions1 call in an experienced physician1 leave the treatment to him1 and pay no attention to her4 ,do not make light of the disease1 do not speak of it at all4 ,there are attacks that may be cured by the razor-strop or a bucket of cold water1 but these are exceptional4 ,they are new cases or old professional offenders4 ,rough treatment is not so good as patient tact1 but at times roughness is the only cure4 ,,austin ,,omalley4 #bdj ,,xx ,,menstrual ,,diseases ,menstruation is a periodic discharge of blood from the uterus and the ,fallopian tubes4 ,it occurs every twenty-eight or thirty days1 and it lasts from puberty to the menopause1 or the cessation of the menses1--about the forty-fifth year of age4 ,there is a connection between menstruation and the production of the human ovum4 ,during the first stage of menstruation the mucous membrane lining the uterus swells to twice or thrice its normal thickness1 and this growth is a preparation for the reception of the ovum1 which1 as a rule1 is given off by one of the ovaries at this time and passes out into the uterus4 ,menstruation and ovulation ordinarily occur simultaneously1 but they may be independent and take place at different times4 ,if1 during this stage1 the ovum is impregnated1 pregnancy begins1 and menstruation ceases until some time after childbirth4 ,in married women conception is more likely to be effected during the first stage of menstruation than during the interval of quiescence2 the contrary is almost the exception4 ,impregnation1 however1 is likely to occur in the spring more than at other seasons1 and this fact coincides with the advent of spring in various latitudes4 ,if the ovum is not impregnated1 the material that made the uterine mucous membrane thick during the first week of menstruation degenerates and passes off1 constituting the menstrual flow4 ,this stage lasts about five days4 ,a reparative period of about four days follows1 and then a period of quiescence until the next menstruation commences4 ,menstruation is first observed about the fourteenth year1 but it may start earlier or later4 ,in general1 it comes on #bda earlier in warm climates1 and later in the extreme north4 ,the menstruation1 too1 is likely to show sooner in the labouring classes than in girls who do not work4 ,even in normal menstruation there is often a marked physiological excitation which affects the entire person4 ,very commonly a nervous disturbance and sensitiveness are observed1 and in women that are not robust there may be mental depression and irritability4 ,the temperature will rise a half degree1 and drop to the normal height on the day preceding the flow4 ,there are derangements of menstruation which are symptoms of various diseases4 ,amenorrhoea is an absence of menstruation in conditions other than pregnancy or lactation4 ,absolute amenorrhoea is a complete absence of menstruation for several months2 relative amenorrhoea is delayed1 scant menstruation4 ,amenorrhoea is common during convalescence from acute diseases2 it is also a result of chronic diseases of the liver1 stomach1 intestines1 kidneys1 and especially of the lungs2 it complicates anaemia1 malaria1 rheumatism1 and other general pathological conditions4 ,fright1 grief1 great anxiety1 mental shock cause amenorrhoea2 so do homesickness and many forms of insanity4 ,there are also local causes of this condition3 imperfect development of the uterus or the organs connected therewith1 and inflammations of these organs or of the pelvic wall4 ,opposed to amenorrhoea is menorrhagia1 or an excessive menstrual flow4 ,metrorrhagia1 or hemorrhage from the uterus at any time1 is a term confounded with menorrhagia1 which is an inordinate menstrual loss of uterine blood1 but the distinction is not important4 ,menorrhagia and metrorrhagia commonly have an identical cause and they frequently coexist4 ,they are found in chronic diseases of the heart1 lungs1 liver1 and other organs2 they are an outcome of prolonged lactation1 and of local affections of the uterus and its appendages4 ,any condition also that deranges the blood may cause menorrhagia or metrorrhagia2 so do malignant tumours of the uterus1 uterine displacements1 lacerations that #bdb occur in childbirth1 and psychical influences1 as fright1 anxiety1 and other strong emotions4 ,dysmenorrhoea1 difficult or obstructed menstruation1 is a term used for menstruation accompanied by pain4 ,this is a common menstrual derangement1 and it may be neuralgic or inflammatory in origin1 or it may be caused by obstruction to the menstrual flow4 ,there is another variety of dysmenorrhoea1 called membranous1 in which the superficial layer of the uterine lining is cast off partly or wholly4 ,in the neuralgic form the uterus and its appendages are normal in appearance1 but the pain recurs monthly1 and it may have degrees from mere discomfort to agony4 ,this form is characterised by reflex headache1 sympathetic nausea or vomiting2 and the pain may not be confined to the uterus and its appendages4 ,the irritation often brings out latent hysterical phenomena1 spinal irritation1 and neurasthenia4 ,rheumatism and gout are predisposing causes1 so are indolence1 lack of physical exercise1 light clothing in cold weather1 forced school work and similar depressing agents4 ,in the neurotic variety of dysmenorrhoea pain often persists after the menstrual flow has set in1 but in inflammatory dysmenorrhoea the flow relieves the pain or removes it4 ,marriage commonly removes the neurotic form of dismenorrhoea4 ,in obstructive dysmenorrhoea the menstrual fluid is retained by narrow or tortuous outlets1 flexions of the uterus1 and similar causes4 ,the prognosis is good in all forms of dysmenorrhoea1 but frequently long and skilful treatment is required to cure such conditions1 especially the membranous form4 ,inflammatory1 obstructive1 and membranous dysmenorrhoea are commonly made worse by marriage4 ,at the end of the childbearing period menstruation gradually ceases4 ,in temperate climates this menopause occurs about the forty-fifth year1 but it may come earlier or considerably later4 ,work that keeps a woman in a heated atmosphere1 as cooking1 washing1 and baking1 disturbs menstruation and tends to advance the menopause4 ,workers in chemical factories1 in badly ventilated rooms1 or women that do heavy labour in the open air1 are apt to age prematurely1 and have #bdc an early menopause or change of life4 ,this premature climacteric is found also in women that bear many children in rapid succession4 ,at the menopause there may be various physical or mental disturbances which are probably due more to the somewhat abrupt advent of old age1 at the cessation of the childbearing part of life1 rather than to the menopause itself4 ,it is a fact1 however1 that often profound disturbances coincide with the climacteric1 and we know no sufficient cause for them if the menopause itself may not be deemed such4 ,there are numerous disorders of the nervous system in women which are dependent directly or indirectly upon a derangement of the pelvic organs4 ,distant parts of the body are affected pathologically through sympathetic irritation when the primary disease is in the pelvic organs1 and direct treatment of the pelvic trouble alone cures these reflex conditions4 ,the very common disorders of pregnancy1 the marked physiological changes in women at the beginning of menstruation with puberty1 and its cessation with the menopause1 are among the first proofs of this assertion that occur4 ,menstruation may aggravate goitre1 uterine fibroid tumours1 skin diseases1 and affections of the blood vessels4 ,disordered menstruation causes sleeplessness1 melancholy1 dementia1 and mania1 by affecting the brain2 it may bring on local paralysis2 start up latent epilepsy2 excite reflex cough and difficulty in breathing2 make the heart irritable2 cause nausea1 vomiting1 dyspepsia1 flatulence1 diarrhoea1 skin-inflammations1 pain in the joints1 and many other symptomatic phenomena4 ,chorea 7,st4 ,vitus's ,dance7 is caused by various irritatations1 and dysmenorrhoea can be such a cause4 ,if a person is disposed to hysteria by neurotic inheritance1 idleness1 sedentary habits1 vicious practices1 excessive development of the emotions1 any affection of the uterus or its appendages will greatly aggravate the outbreaks4 ,the same is true in neurasthenia2 and uterine disorders can directly cause neurasthenia1 a condition described in another chapter4 ,migraine is an extremely severe form of headache which arises from various excitations1 and uterine disturbances are among the causes4 #bdd ,insanity frequently appears in women at puberty1 soon after marriage1 during pregnancy or lactation1 and at the menopause2 at these periods disposed women are especially prone to outbreaks of insanity4 ,irritation and exhaustion from diseases of the pelvic organs are potent factors in bringing on insanity1 although these conditions may coexist independently of each other4 ,symptoms should not be mistaken for causes1 but pelvic diseases at least aggravate a tendency toward mental unbalance4 ,in an article like this it is not expedient to speak of treatment1 but the conditions are described in outline so that the spiritual adviser may recognise the need of medical aid and suggest its employment4 ,a woman suffering from pelvic disorders should be relieved from a labourious or responsible office until she has been cured of her disease1 in her own interest and especially in the interest of those affected by her condition4 ,,austin ,,omalley4 #bde ,,xxi ,,chronic ,,disease ,,and ,,responsibility ,it is often of great practical importance to bear in mind that a number of affections1 commonly not serious in themselves at the beginning1 and sometimes giving very few external symptoms1 may make the mental condition of the individual suffering from them utterly incapable of meeting grave responsibilities4 ,this is especially true with regard to such positions as that occupied by the ,superior of a religious community who may1 during the course of an ailment that has a tendency to affect the mental condition1 do things that involve the community financially1 or make life so uncomfortable for their subjects as to cause them to abandon the religious life4 ,some of these ailments are very insidious and may develop utterly apart from all anticipation in persons that were previously healthy4 ,the weight of responsibility itself may1 by impairing the general health1 bring on an aggravation of a previously mild chronic condition that will cause distinct mental deterioration1 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 individual4 ,such cases are not uncommon in history4 ,a distinguished specialist in mental diseases called attention1 in the ,london ,lancet not long ago1 to the case of ,nicias1 the ,greek general who was in charge of the ,athenian expedition against ,syracuse4 ,nicias undoubtedly had a genius for war and for politics when in normal health4 ,some of the mistakes committed by him1 though1 are of an order that indicate a lapse of mental control at certain times4 ,details given by a number of ,greek historians point to the existence in ,nicias of #bdf symptoms of chronic nephritis1 which at periods of great responsibility became exacerbated with consequent interference with normal intellection4 ,the same authority points to certain otherwise inexplicable political mistakes in the life of ,napoleon ,,iii4 as due to the existence in him of a low-grade nephritis1 consequent upon the presence of stone in the kidney4 ,after his abdication1 during his life in ,england1 he had to be operated upon for this condition1 and the calculi found had manifestly been in existence for many years4 ,even more important for the sake of the individual himself than for those he is in contact with is the recognition of his pathological condition4 ,nothing is more likely to cause kidney disease to grow rapidly worse than responsibilities heavier than the individual is accustomed to4 ,when1 then1 there are symptoms of nephritis it is inadvisable for the patient to be made ,superior1 and if the symptoms develop after his appointment or election he should be relieved of his responsibilities1 at least to a considerable degree4 ,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 communities1 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 position4 ,it is not impossible that paresis should develop in the ,superior of a religious community4 ,the disease is extremely rare among clergymen generally1 and the statistics of asylums show that it is rarest of all among ,catholic clergymen4 ,should it occur1 however1 it must constitute a quite sufficient reason either for a change of ,superiors1 or for the institution of such other safeguards as may1 according to the special religious institute1 be provided in order to prevent serious evil4 ,in the religious communities of women1 particularly1 it has seemed to us that the occurrence of ,graves' disease 7the affection is three times more frequent in women than in men7 in a ,superior should always be the signal for relieving her of the responsible duties of her position4 ,this action is quite as necessary for the patient's own health as for the peace and happiness of the community4 ,the disease may exist in a #bdg latent form and only develop strikingly after the assumption of the serious responsibilities of the position of ,superior4 ,when1 however1 the eyes are prominent1 the pulse rapid1 and the goitre1 or swelling of the front of the throat1 characteristic of the disease1 is present1 there are practically always mental symptoms that make it extremely inadvisable for her continuance in a position of serious responsibility4 ,professor ,church of ,chicago 7,professor of ,nervous and ,mental ,diseases and of ,medical ,jurisprudence1 in the ,northwestern ,university ,medical ,school71 in the last edition of his book on ,nervous and ,mental ,diseases1 ,footnote #e has this to say with regard to the mental disturbances of ,graves' disease3 ,footnote #e3 ,nervous and ,mental ,diseases4 ,church and ,peterson1 #dth edition4 ,saunders1 ,phila41 ,pa41 #aijc4 ,from the beginning1 and often for a long period antecedent to the appearance of cardiac symptoms1 the subjects of ,graves' disease present a considerable mental erethism4 ,there is an indefinable and tormenting agitation1 marked by mental and motor restlessness and an imperative and impulsive tendency to be doing4 ,their emotions are too readily excited1 and they are unusually impressionable and irritable1 reacting in an exaggerated manner to all the incidents of daily life4 ,in more pronounced cases they become voluble and manifest the greatest mobility of ideas1 but have no persistent concentration of logical order4 ,their affections are likely to undergo modifications1 and they become irascible1 fault-finding1 inconsiderate1 ungrateful1 and hard to live with4 ,in some instances this disturbance of mentation carries them over the border into active mania1 marked1 perchance1 by delusions of fear1 due to the cardiac symptoms of sensations of heat4 ,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 unsystematised1 and constantly changing1 furnishing the analogue of the motor restlessness4 ,hallucinations of sight and hearing are not uncommon4 ,the mental perturbance only rarely reaches the degree of actual mania1 and then is1 perhaps1 equally dependent upon numerous other causes acting in a neurotic individual4 ,but #bdh a condition of abnormal mental stimulation is characteristic of the malady1 and is as important an index as any of the cardinal triad4 ,footnote #f ,footnote #f3 ,of physical symptoms1 namely1 the rapid heart1 the prominent eyes1 and the enlargement of the thyroid gland in the neck4 ,dr4 ,church considers1 then1 that the mental symptoms of the disease are as important a concomitant1 and as little likely to be absent in any given case1 as are any of the three or four well-known physical symptoms characteristic of the disease4 ,under these circumstances the necessity for the exercise of care in permitting such a patient to continue in the office of ,superior must be manifest4 ,it is a question not for religious authorities to decide but for physicians1 and they are to be experts in mental diseases4 ,there are many physicians who have had experience with cases in which ,graves' disease has been a source of unfortunate conditions in religious life1 owing to the failure to understand the relations of the physical affection to mental disturbances4 ,at times unfortunate consequences follow that are irretrievable in the destruction of vocations and the impairment of the religious spirit in communities4 ,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 office4 ,this is true1 however1 not only for physical disease but for the so-called neuroses4 ,these are maladies which have their basis in some disturbance of the physical constitution1 though this is not always easy to find4 ,we prefer to speak of them as neuroses rather than neurasthenia1 because this latter name has somehow come to have an unwelcome sound and to carry with it the idea of imaginary rather than real ailments4 ,a true neurasthenic1 however1 is supremely to be pitied4 ,it has often been noticed that such individuals1 while perfectly capable of judging properly for others1 are not able to form right judgments with regard to their own conditions4 ,this principle1 however1 should not be taken as a rule1 and it must not be forgotten that neurasthenics are often the subjects of compulsory ideas--so-called obsessions1 in which they are not entirely responsible for actions performed4 ,at such #bdi times they are prone to be irritated by very trivial faults1 and what is worse1 to exaggerate slight defects into serious infractions of rule or of obedience4 ,with regard to such persons1 therefore1 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 substantiation4 ,in this matter the subject is quite as likely to suffer as the ,superior1 and information obtained from them should not be acted upon without consultation with others who know the details of the case4 ,as a rule neurasthenic individuals become1 as is well known1 worse as far as the mental condition is concerned when they are asked to assume new responsibilities4 ,this physical side of the choice of ,superiors1 and of those to be elected by members of the community1 should always receive due attention1 though sometimes it is entirely lost sight of4 ,not a few communities1 however1 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 piety1 which was1 however1 rather emotional than practical4 ,the physician's view of some of these cases would add materially to the knowledge of the character of such individuals4 ,it should in general be very clear that the development of any serious nervous disease1 which is not likely to be cured by ordinary remedies or which requires freedom from responsibility as the first requisite for improvement1 should be the signal for consideration as to a change of ,superiors4 ,physicians see much more of the evil that may be worked in this way1 and realise the true significance of what is often a sad state of affairs1 much better than those who have not the secret of the cause of the unfortunate condition4 ,it is almost needless to say that the question of obedience to some one whose responsibility is not complete1 but is influenced by neurotic disturbance1 becomes an extremely difficult problem for the subject1 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 circumstances4 ,with regard to women especially1 it must be remembered that there is for them a period between the ages of forty #bej and fifty1 during which for several years they are extremely unsuited for the responsibilities and exacting duties of a ,superior4 ,these years prove even to mothers of families1 surrounded only by their own children and the ordinary circumstances of home life1 a time of worry and irritation that plays sad havoc even with the best of dispositions4 ,mothers constantly complain to their physicians of an irritability of temper which they can scarcely account for1 and which makes them do and say things which they are extremely sorry for afterwards4 ,it is easy to understand1 then1 that a ,superior with still more insistent duties when brought in contact with a number of persons1 some of whom are almost sure not to be entirely sympathetic1 is likely to suffer from irritation that is not a sign of absence of a fitting religious disposition1 but only a physical manifestation of the physical strain through which she has to pass at this time of life4 ,the years of the menopause1 to be very plain1 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 another4 ,charcot1 the distinguished ,french neurologist1 used to say that women should never be asked to assume special responsibilities during the days of their monthly period1 for their judgments are often warped by their physical condition4 ,it is doubtful whether1 in the majority of normal women1 this is quite true1 though the expression deserves to be remembered4 ,there is no doubt1 however1 that the years of the change of life do bring on very serious modifications of the character of the individual1 and occasionally these changes are lasting4 ,,james ,j4 ,,walsh4 #bea ,,xxii ,,epilepsy ,,and ,,responsibility ,from the very earliest times epilepsy has been looked upon as a mysterious and in many ways an inexplicable disease4 ,the ,romans spoke of it as the malum comitiale1 the comitial disease1 because if an attack of it occurred during the meeting of the ,roman people known as the comitia1 in which municipal officers were elected and other city business transacted1 an adjournment was at once moved1 and no further proceedings were considered valid4 ,during more modern times1 especially during the middle ages1 and almost down to our own time1 those affected by the disease frequently came to be looked upon as the subjects of possession by the devil4 ,hysterical manifestations were even more frequently considered signs of possession 7diabolical manifestations7 but even in our time it is not always easy to make the distinction between certain forms of hysteria and epilepsy4 ,many of these sufferers were considered as not responsible for their actions4 ,in this respect1 at least1 the advance of modern medical science has only served to confirm the popular impression of less sophisticated times1 and it has come to be recognised that quite a large number of the sufferers from epilepsy must be deemed lacking in responsibility4 ,there are few nervous diseases that have been more studied than epilepsy1 and yet1 because the ailment involves so intimately the relations of the nervous system and the bodily function1 there are few diseases of which less definite opinions can be given4 ,this is especially true as regards prognosis and the question of mental deterioration in any given case4 ,as a matter of fact the extension of our knowledge of epilepsy1 far from making the question of the responsibility of the #beb epileptic under trying circumstances more easy of solution1 has rather served to show how difficult this problem must ever remain4 ,there are many forms of the disease1--the frank epileptic convulsion in which patients fall down1 are seized with certain convulsive movements1 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 description4 ,there are forms of epilepsy1 however1 quite different from these4 ,in some cases1 the attacks occur only at night1 and unless the patient happens to be watched for some reason1 there may be no trace of their occurrence1 except perhaps a sore tongue where it has been bitten1 or an intense feeling of weariness and depression in the morning4 ,in still other cases1 the physical signs are lacking almost entirely4 ,there may be only a momentary loss of consciousness4 ,a distinguished professor of medicine in this country used to have a momentary attack of confusion1 during which he lost the thread of his discourse1 and always within a minute1 with a somewhat flushed face1 he was able to go on1 though he had to begin with another idea4 ,the so-called psychic epilepsy1 in which the symptoms are entirely mental and consist of some marked change of disposition for a time1 are now universally conceded as constituting well-marked phases of the disease4 ,curiously enough it is with regard to these obscure cases1 uncomplicated by serious physical manifestations1 that there is most mystery2 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 recognition4 ,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 performed1 apparently without sufficient motive1 and yet where the limits of responsibility must if possible be determined4 ,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 act1 and because the patient ordinarily understands perfectly the distinction between good and evil4 #bec 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 doing4 ,as yet the general public refuses to take the standpoint of the expert in mental diseases in many of these cases2 and only when clergymen also shall come to a realisation of the pathological elements undermining free will in these cases1 that justice will be properly tempered1 not by unworthy or misplaced charity1 but by the mercy which1 knowing all1 has learned duly to appreciate what is and what is not criminal4 ,epilepsy1 in certain of its obscurer forms1 is responsible for many conditions in which there is a sudden access of insane excitement of a violent1 often very impulsive1 character1 though sometimes of very short duration4 ,during this state the patient is practically irresponsible1 and yet he may have sufficient control over his actions to enable him to work serious harm4 ,such a stage of excitement may last not more than an hour or two2 usually all trace of it passes off in a day or two2 before and after it the patient may be in perfectly sound sense and in apparently good health4 ,one of our best authorities here in ,america1 ,berkley1 in his treatise on ,mental ,diseases1 gives the following striking opinion on this subject4 ,the subject of masked epilepsy and the consequent mania is replete with interest to the physician and the jurist1 since such patients are prone to impulsive acts of violence and automatic states in which the most complicated1 but entirely unconscious1 actions and crimes may be carried out without premeditation on the part of the sufferer1 being also out of all accord with his character during his intervals of mental health4 ,besides the irritability1 impulsiveness is an equally characteristic feature4 ,no form of insanity more frequently gives rise to assaults and murder than epilepsy1 and in no form of alienation is the physician so frequently called to the witness stand to determine the responsibility of the criminal4 ,one of the most prominent features of all epilepsy is the well known tendency to irritability that characterises sufferers from the disease4 ,this of itself is an index of the fact that #bed their responsibility is somewhat lessened1 since they are unable to withstand even the petty annoyances of life without exaggerated reaction4 ,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 usual4 ,just after the comatose condition which follows an attack of epilepsy patients are also prone to be very irritable4 ,an attack of epilepsy is really an explosion of nerve force1 for no rational purpose1 along motor nerves4 ,this same tendency to an unwarranted explosion of energy is liable to occur along other nerve tracts that rule the patient's disposition4 ,the main symptom of importance in the case1 and the one on which depends the recognition of the existence of the epileptic condition1 is the actual occurrence of typical epileptic seizures4 ,these do not always occur4 ,sometimes the periodic attacks take the form of what are called epileptic equivalents1 that is1 certain anomalous states of consciousness or disposition1 which can be accounted for only on the supposition that there is some more or less latent explosion of nerve force in progress4 ,at times even so simple a condition as migraine so nearly simulates epilepsy of the psychical type1 because of its complications and sequelae and the regularity with which it occurs1 that it has been spoken of as an epileptic equivalent4 ,there is no doubt that1 in successive generations1 epilepsy and migraine may have a relation to one another that is something more than merely a coincidence4 ,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 epilepsy4 ,this means epilepsy that develops without a direct cause1 and which is evidently dependent on some essential defect of the nervous system of the individual4 ,in asylums epileptics that have become irrational are known for their religious manifestations1 and very often for perversion of their religious tendencies4 ,as has been well said1 an epileptic may carry his ,bible under his arm1 read passage after passage from the ,scriptures1 sing psalms continuously1 and yet be so #bee ungovernable as to be a nuisance1 and so irritable towards his fellow patients and attendants as to be a constant source of worriment4 ,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 repetition1 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 injury4 ,this last is a marked feature of the disease1 for epileptics are prone to foster fancied grudges1 and to consider without due reason that they have been ill treated4 ,this is especially true with regard to their relatives or to those in attendance on them1 and must be always borne in mind when the subjects of epilepsy bring tales of woe and persecution1 which they pour out to anyone who will listen to them1 and especially to anyone whom they think will set them right4 ,these fancied wrongs are as real to the patients themselves as if they had suffered from actual maltreatment4 ,the idea of revenge may easily obtrude itself4 ,it can be kept under control1 as a rule1 during ordinary health1 between attacks1 but just preceding or after an attack it may very well become of the imperative character that sets an uncontrollable impulse at work4 ,on the other hand1 no class of patients is apt to exhibit the low cunning of the insane in so marked a degree as the epileptic4 ,not only this1 but even during ordinary health between attacks they may1 owing to their disposition1 plan cunningly to simulate some of the symptoms of an attack and then accomplish a really malicious purpose with deliberation4 ,in a word1 these patients present to the alienist the most serious problem in the calculation of responsibility that can possibly be imagined4 ,as an expert has declared1 ,it is ofttimes impossible to decide whether an assault has been committed with full consciousness1 or in a transient but blind epileptic fury4 ,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 closely1 yet are not true epilepsy4 ,these attacks are usually due to some #bef cerebral affection or perhaps to some injury of the brain4 ,chronic intoxications1 that is1 the long continued presence in the body in noxious quantities of some poisonous substance1 are especially liable to cause these attacks1 which are called from their character epileptiform4 ,characteristic epileptiform convulsions occur as the result of lead poisoning or from alcohol or syphilis4 ,lead poisoning1 for instance1 may very well occur in others than those engaged directly in the manufacture or handling of lead4 ,certain persons are extremely susceptible to the influence of lead4 ,in them such small amounts as are contained in a hair-dye1 or even in water that is being used by others without any bad effect1 may cause particularly the nervous symptoms of lead poisoning4 ,chronic alcoholism is also a relative term in this regard4 ,some persons are able to stand very large amounts of alcohol without serious consequences1 even though it is taken for long periods4 ,others succumb to its influence very rapidly2 some especially susceptible people are liable to suffer from epileptiform convulsions almost whenever they take alcohol to excess4 ,this masked epilepsy may take on an anomalous form4 ,the story is told of a student of a ,catholic college in the eastern part of this country1 who1 during one vacation1 was given as a joke by some friends a rather strong dose of liquor in a glass of ginger ale4 ,he was very thirsty at the time and did not notice the presence of the alcohol until he had swallowed the whole glass4 ,as he was well aware himself he was extremely susceptible to the influence of alcohol4 ,during the course of half an hour he became almost wildly drunk1 and going down the street with an open pocket-knife he murdered the first person whom he met1 who happened to be an entire stranger to him4 ,the occurrence took place in ,new ,jersey1 and1 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 hanged4 ,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 #beg epilepsy4 ,only one feature with regard to them is more favourable1 and that is that the ultimate prognosis is not bad4 ,the neutralisation of existing poison in the system1 and the prevention of further ingestion of the toxic material1 puts an end to the tendency to epileptiform convulsions1 as a rule1 and also to the mental symptoms associated with them4 ,epilepsy remains1 notwithstanding all the advance in modern nervous pathology1 quite as mysterious a disease as it has ever been4 ,it matters not what its cause1 or how slight it may be1 sooner or later it is almost sure to be followed by mental disturbance and deterioration of intellectual and will power4 ,at times there are periodic attacks of mental perturbation that may become true insanity4 ,even the mild form of epilepsy known as ,jacksonian epilepsy1 and consisting not of general convulsive movements1 but of convulsive movements in only one member or one side of the body1 are1 if allowed to continue1 followed by some mental disturbance4 ,it would seem as if the explosion of nerve force in the brain centres1--which1 physiologically speaking1 an attack of epilepsy evidently is1--causes eventual deterioration of the physical basis of mind and will1 so that mental operations can no longer be performed with their wonted expertness or accuracy1 nor decisions made as rationally as before4 ,in general1 it is well understood that the more serious the epilepsy the more liability there is of the development of permanent mental disturbance4 ,the earlier in life the epilepsy declares itself1 too1 the more unfavourable is the prognosis as to the enduring retention of complete mental sanity4 ,in people in whom the epilepsy commences late in life1 the process of mental deterioration does not begin to be noticeable so soon as when it occurs in younger years1 and besides1 it practically never runs a rapid course4 ,epilepsy1 however1 developing late in life1 unless for some special cause1 as injury or the development of syphilitic tumours in the brain1 is an extremely rare affection4 ,idiopathic epilepsy1 that is1 epilepsy for which no definite cause can be discovered1 is usually dependent on hereditary instability of the nervous system and is typically a disease of early years1 of childhood #beh and adolescence4 ,according to the best authorities1 about one-fourth of the cases of epilepsy make their appearance before the age of #g years4 ,over #ej per centum of all cases develop before puberty4 ,about one-third of all the cases develop between #ad and #bj4 ,and even of the remaining1 less than #bj per centum1 over #ab per centum develop between #bj and #be1 leaving scarcely more than #e per centum for all the remaining years of life4 ,of course1 even in severer forms of epilepsy1 mental disturbances do not appear at once4 ,it sometimes takes many years for the constantly recurring manifestation of explosive nerve force to produce the deterioration that gives rise to lowered rationality4 ,distinct mental deterioration is eventually inevitable1 though modern experience with epileptic colonies1 in which patients are enabled to live a quiet life1 most of it in the open air and under conditions of nutrition and restfulness especially favourable for their physical well-being1 shows that the development of insanity may be put off almost indefinitely4 ,there are many advertised cures for epilepsy4 ,none of them is successful1 and all of them may do harm4 ,the bromides have a distinct effect in lessening the number and frequency of seizures1 but if taken to excess they have a serious depressing effect upon the patient4 ,there have been more cases of mental disturbance among epileptics1 and intellectual degeneration sets in earlier1 since the introduction of the bromides1 than before4 ,it is the abuse of the drug1 however1 not its use1 that does harm4 ,more important than any drug is the care of the patient's general health4 ,the digestion must be kept without derangement2 the bowels made regular2 all sources of worry and emotional strain must be removed4 ,patients should as far as possible live in the country1 and farm life has been found especially suitable4 ,relatives are often a source of irritation rather than consolation to these patients1 and the life in epileptic colonies has been found eminently helpful4 ,,james ,j4 ,,walsh4 #bei ,,xxiii ,,psychic ,,epilepsy ,,and ,,secondary ,,personality ,one of the most interesting phases of epilepsy is the type of the disease in which1 without any significant motor symptoms1 psychical manifestations prevail very markedly4 ,a special manifestation in this affection is the occurrence of a more or less complete assertion of what is called a secondary personality4 ,apparently the individual becomes so divided in the use of the mental faculties that there are two states of consciousness4 ,in one of these the patient knows and remembers all the ordinary acts of life1 the other carries the record of only such actions as are done in a peculiarly morbid psychic or epileptic condition4 ,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 others1 and may make the problem of responsibility for apparently criminal acts that have been performed very difficult of solution4 ,undoubtedly1 however1 this set of phenomena constitutes a form of mental alienation that must be reckoned with in many more cases than might be thought possible4 ,the difficulties that may have to be encountered in the proper appreciation of the actions of such individuals is best illustrated by some cases4 ,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 circumstances4 ,the patient1 a young man of about twenty-two1 was the son of parents themselves of marked nervous heredity1 signs of which appeared in other members of his generation4 ,while in attendance at a public academy he had been quite severely maltreated during the #bfj course of an initiation into a secret society of the students--the more or less familiar processes known as hazing being employed4 ,as a result of this he had suffered from an attack of unconsciousness that lasted for several hours4 ,no other symptoms1 however1 or sequelae1 appeared for nearly a year4 ,then1 while boarding with his sister1 he became morose and difficult to get along with4 ,he quarrelled with his sister several times and generally their relations were rather strained4 ,he came home one evening very late to supper1 and because things were not to suit him on the table1 he grew violently angry4 ,he went upstairs to his room in this morose state and1 procuring a revolver1 after a short time came down and shot at his sister4 ,fortunately he missed her4 ,he at once left the house but was followed by his brother-in-law1 and1 after he began to run away1 by others whose attention had been attracted by the shot4 ,he left the country road and ran across the fields4 ,he was found at the foot of a rather high stone wall in a state of unconsciousness4 ,from this unconsciousness he did not recover until the next morning4 ,in the meantime he had been brought home and put to bed4 ,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 supper4 ,the family made no further difficulty about the matter1 and1 as nothing serious had resulted1 the boy went home to live with his father on a farm and seemed to grow much more equable in temper4 ,one day1 when very tired and out of sorts because things had not been going as he wanted them to1 he was asked to clear a potato patch of potato bugs by spreading ,paris green over it4 ,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 poison4 ,a doctor was called1 an emetic was given and he purged1 and after a time he recovered from the symptoms of poisoning4 ,he claimed that he had no recollection of what he had done1 nor did he know how he came to take the poison4 ,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 #bfa morose in temper4 ,he was not melancholic in the sense that he wanted to commit suicide1 but something seemed to come over him in spells1 and while in a state of mind of which he had no recollection afterwards1 he performed actions that seemed voluntary and yet were not4 ,he did not have very good health on the farm1 and so he was advised to try the effect of life at sea4 ,a position as assistant steward was obtained for him on a coastwise vessel4 ,in this position he gained rapidly in weight and seemed to have excellent health4 ,all tendencies to moroseness of disposition disappeared4 ,after a time he was promoted to a stewardship and later became the purser of a rather important vessel4 ,he has given excellent satisfaction and feels in every way that he is in a much more balanced condition than ever before4 ,he still insists that he remembers nothing of how the two almost fatal incidents in his life came about4 ,all his family are convinced that it was not a responsible state of mind that led him to attempt either of the crimes4 ,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 patient4 ,at times these attacks last much longer1 and the change to a secondary personality may represent a rather long interval4 ,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 press4 ,patients suffering from this form of nervous disease may wander from their homes1 and while performing automatically a number of actions1 such as buying tickets1 travelling on cars and railroad trains1 or even arranging the details of their journey for a long distance1 may yet be in a state of mind that is not their ordinary consciousness4 ,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 accustomed1 or for which their early training fitted them4 ,there seems to be an absolute division between the #bfb states of consciousness that rule the individual during the intervals of ordinary and extraordinary personality4 ,there are1 of course1 many reasons for thinking that at times such a change of personality might be feigned2 but many of the cases have been followed with too much care to allow this thought to serve as an explanation for all of them4 ,a case which serves to bring home very clearly the possibility of such a state of mind giving rise to serious complications is the following3 ,the patient was a young man in attendance at the medical school of a university in a foreign city4 ,he had been very careless in money matters1 and had aroused family suspicion that even the money sent him for tuition was being used extravagantly4 ,a friend of the family came to see him unexpectedly in order to assure himself how the boy was actually getting along4 ,the boy's accounts were in a very disordered condition2 he had not bought the books for which he pretended to want money2 he had not paid his tuition4 ,he realised that all this would come out as soon as the university authorities were consulted4 ,very naturally he was in an extremely perturbed state of mind4 ,while on the way to the university with this friend they passed a corner pharmacy1 and the young man asked to be allowed to step in for a moment for a remedy for headache4 ,the friend waited on the sidewalk for him1 and when1 after some minutes1 the young man did not come out he went in to inquire for him1 and found that after purchasing a headache powder the young man had gone out by a side door4 ,for three days nothing was heard from him4 ,then a telegram announced that he was in a hospital in a distant city and that he had been picked up on the street unconscious4 ,when he came to in the hospital he had no idea where he was1 and1 according to his own story1 no recollection of how he got to the distant city4 ,it might be very easy to think1 under such circumstances1 that this was all pretence4 ,a number of these cases of ambulatory epilepsy have been under the observation of distinguished neurologists1 however1 and there seems no good reason to doubt that some of them1 at least1 were entirely without any fictitious element4 ,in any given case the #bfc possibility of the occurrence of an attack of what is really the assumption of a secondary personality must be judged from the circumstances1 from the previous history of the individual1 from the family traits1 and from certain stigmata as narrowing of the field of vision and the like1 which go to show the existence of a highly neurotic constitution4 ,in this case the family history showed marked neurotic tendencies on both sides1 and a brother had displayed a tendency to regularly spaced attacks of alcoholism about every six weeks1 and finally became absolutely uncontrollable4 ,there seemed good reason to think that the case was a real example of ambulatory epilepsy1 and that the lapse of memory claimed by the patient really existed4 ,in these cases it is usual for the so-called secondary personality to assert itself at moments of intense excitement1 especially if they have been preceded by days of worry and fatigue and nights of disturbed rest4 ,the secondary personality is not a complete personality1 but is a manifestation of the original ego with the memory for past events as a tabula rasa4 ,it is well known that the memory is one of the intellectual faculties most dependent on physical conditions4 ,it is the lowest in the scale of mental qualities and is shared to a very large degree by the animals4 ,injuries to the head not infrequently produce lacunae in the memory4 ,these lacunae often have very striking limitations4 ,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 years4 ,still more interesting is the fact that languages learned in youth may continue to be easily used1 when those that were learned later in life1 though perhaps known better than the previously studied languages1 are forgotten4 ,it has often been noted that people who suffer from apoplexy may have peculiar affections of their memory4 ,this may include such striking peculiarities as the forgetting of the uses of things1 though their names are retained1 or more commonly1 the forgetting of names while the knowledge of uses remains4 ,the one form of memory disturbance is called ,word ,amnesia2 the other is called ,apraxia4 ,it is on #bfd record that a person suffering from a hemorrhage in the brain has lost completely the use of a language acquired later in life1 though the memory of the native language1 long since fallen into disuse1 was perfectly retained4 ,one apoplectic woman patient who had left ,germany before she was ten years of age1 and who had lived in ,america until she was fifty1 forgot absolutely the ,english she knew so well and had to set herself to work to learn it over again1 though her ,german came back to her very naturally4 ,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 brain4 ,it is not surprising1 then1 to find that lapses of memory may occur and that1 as a consequence1 so many of the facts that ordinarily enable us to identify ourselves as particular persons may be in abeyance4 ,that apparently a secondary personality asserts itself1--though not in the sense that there is ever another ego present1 another mind or another will1--practically all experts in psychology and nervous diseases are now ready to concede4 ,there are1 however1 involved in this question a number of important problems of responsibility that have not as yet been entirely worked out1 and with regard to which prudent persons are withholding their judgment4 ,each case must be studied entirely on its own merits1 with a leaning in favour of the criminal or patient1 in case there are evidences in past life of serious disturbances of mentality1 though only of very temporary nature1 or if there is a strong nervous or mental heredity4 ,the notion of the possibility of a secondary personality asserting itself is a much older idea than it is usually thought to be4 ,when ,stevenson wrote ,dr4 ,jekyll and ,mr4 ,hyde1 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 phenomenon1 but rather to the traditional feeling1 long existent1 of the possibility of two personalities in almost any individual4 ,the other law in his members1 of which ,st4 ,paul speaks1 is an expression of this feeling1 and its recognition was not original with him since it is after all a phenomenon at least as old #bfe as the existence of conscience4 ,it is one of the basic ideas in religious feeling4 ,nearly everyone has something of the consciousness that there is in him possibilities for evil that somehow he escapes1 and yet the escape is not entirely due to his own will power4 ,there is here the mystery of temptation1 of free will and of grace as the drama of conscience works itself out in every human being4 ,at times the evil inclination seems to get beyond the power of the will and a period of irresponsibility sets in4 ,needless to say1 the adjudication of how much may be due to the habitual neglect of repression of lower instincts is extremely difficult1 and this constitutes the problem which the alienist must try to solve4 ,in the meantime there is need in many mysterious cases where secondary personality may play a role1 of the exercise of a larger ,christian charity than that hitherto practised4 ,pretenders may succeed in deceiving only too often1 but in the past not a few innocent individuals have been held to a responsibility for actions for which they were not quite accountable4 ,,james ,j4 ,,walsh4 #bff ,,xxiv ,,impulse ,,and ,,responsibility ,not unlike that condition which develops as the result of so-called psychic epilepsy1 in which patients perform apparently voluntary acts1 while the mind is really clouded by an epileptic attack1 are those states in which1 as the result of a more or less blind impulse1 acts are performed for which the responsibility of the individual is at least dubious4 ,modern experts in nervous and mental diseases have sometimes spoken of these states as obsessions4 ,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 spirit1 though his intellectual and volitional state was not as completely under the subjection of this spirit as in the condition of possession4 ,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 term4 ,as the result of obsession1 mystical writers would have conceded that responsibility is not quite complete1 though it is not entirely done away with4 ,the modern alienist is just as sure of the diminution of responsibility1 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 conditions4 ,the will is sometimes spoken of by certain of these modern psychologists as mainly an inhibitory faculty1 that is1 a faculty which prevents certain reflex acts from taking place1 though permitting one set of reflexes to have its way4 ,under the influence of an obsession or1 as the ,french call it1 une idee obsedante1 this inhibition is not #bfg exercised and as a result an action is accomplished which the agent may very shortly afterwards regret exceedingly4 ,there is no doubt that impulsions or impulsive ideas may push an individual into the performance of an action which his reason condemns4 ,uncontrollable anger is a well recognised example of this4 ,impulses of other kinds may exercise just as tyrannic a sway1 though it is harder to recognise the elements that make up the mental condition in other cases4 ,of course it may well be said that man must control his impulses4 ,it is1 however1 just such impulses as can not be controlled that lessen responsibility and sometimes seem entirely to destroy it4 ,it would1 without doubt1 be very easy to advance the uncontrollable impulse as an excuse for many criminal actions4 ,in fact1 the discussion of responsibility and its limitation by impulse would seem to be open to so many abuses as to make it advisable1 in the present indefinite state of our knowledge1 to put the subject aside entirely4 ,the argument1 however1 from the abuse of the thing1 does not hold1 and an effort must be made to get at the truth concerning certain mental conditions which modify responsibility4 ,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 perform4 ,allurements that are almost compelling for some individuals1 for others have no influence at all4 ,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 sorry4 ,this may even be the case to such an extent as to endanger their lives1 yet they are not able to control themselves4 ,many men suffering from degeneration of the arteries of the heart have been warned1 like ,john ,hunter more than a century ago1 of the extreme danger of a fit of anger1 yet1 like ,john ,hunter1 have succumbed to bursts of anger1 notwithstanding the warning1 because someone irritated them beyond their rather limited powers of endurance4 ,it is extremely difficult ever to come to any proper appreciation of the responsibility of a given individual from a #bfh single act4 ,preceding acts1 however1 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 circumstances4 ,the only way to render this clear is to illustrate such conditions by a concrete case4 ,not many years ago one of the large cities of this country was shocked1 for one twenty-four hours at least1 by the news that a business man had shot his partners and himself1 while at a consultation in which the affairs of the partnership were being settled up1 after legal dissolution had taken place4 ,the man in question had paid some debts of the firm with his own personal checks1 and without taking proper legal recognisance for the moneys paid4 ,when the partnership had been dissolved his partners insisted that instead of obtaining credit for these payments he should1 on the contrary1 pay his share of these debts once more as a partner4 ,the state of the evidence was such that his lawyers told him it would be useless to take the case before the court at all2 there was nothing to do but pay the unjust demands4 ,he went to the meeting of his partners with a certified check for the amount of their claims in his pocket4 ,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 owe1 and that his partners knew he did not owe1 and that they were evidently taking advantage of a legal quibble in order to cheat him4 ,evidently it was an extremely trying situation4 ,it was too much for his mental balance and he took a revolver from his pocket1 shot both his partners dead1 and then shot himself4 ,taken by itself it is extremely difficult to say anything about the responsibility of a man who commits an act like this4 ,in ordinary life he was known as a clever business man2 to his friends he was known to be rather irascible and impatient1 but a fairly good fellow4 ,he was known to have what is called an awful temper2 he had1 however1 never committed any violent act before4 ,it is possible1 of course1 that a man should give way to a fit of anger for the beginning of which he is responsible1 and then do violence #bfi much greater than he would justify himself for in calmer moments4 ,there was another occurrence in the man's life that seemed to throw informing light on his mental condition4 ,when he first came to live in the large city in which he died he began paying attention to a young woman1 and the young woman was informed by a friend that he probably had a wife living4 ,the young woman investigated this by putting the question directly to him4 ,he denied it at once1 wanted to know the name of her informant1 and finally laughed the whole matter out of her mind4 ,within a week after his marriage to her1 while on their wedding tour1 he was arrested1 charged with bigamy at the instance of his first wife1 and it became evident at once that the charge was well substantiated4 ,here is a man1 then1 who twice at least in life1 when put in the presence of trying conditions1 goes on to do the irretrievable1 though the act is eminently irrational4 ,with regard to the murder and suicide it is said that he had talked to friends of shooting the scoundrels who were cheating him1 but had been persuaded of the utter foolishness of any such idea4 ,he had apparently given it up entirely4 ,notwithstanding this1 he went to the last conference with his former partners with a loaded revolver1 as well as the certified check for the amount of their claim4 ,in the case of his bigamous marriage1 notwithstanding the warning that his second fiancee's questions must have been1 he followed out his preconceived idea of marrying her1 though he must have realised in saner moments that discovery of his double dealing was inevitable4 ,in a word1 he was a man who1 becoming dominated by an idea1 an obsession it may be called1 to do something1 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 idea4 ,there are many such individuals1 and only the knowledge of their previous career enables us to desume the responsibility for their acts under trying conditions4 ,that they are not responsible in the ordinary sense in which the logical1 timorous mortal is who is at once repelled from such modes #bgj of action seems very clear4 ,their lack of responsibility is manifest1 at least to a degree that makes it easy for charity to find excuses for their crimes because of fatal flaws of character1 the result of physical defects and faulty training1 which make themselves felt especially at the moments that try men's souls4 ,,james ,j4 ,,walsh4 #bga ,,xxv ,,criminology ,,and ,,the ,,habitual ,,criminal ,in recent years no little attention has been devoted to the subject of criminology1 and a supposed science of the criminal has been evolved4 ,it has been the claim of a very well known ,italian school of mental diseases1 whose leader is ,professor ,lombroso of ,turin1 that there is a criminal type in humanity1 that is1 that there is a generic human organisation not difficult of differentiation1 at least as a class1 the members of which almost necessarily develop criminal proclivities4 ,even when criminality has not actually occurred1 this is thought to be but an accident1 and criminal acts may be looked for at any time from these individuals4 ,lombroso's claims in this matter have met with decided opposition in every country of ,europe and also here in ,america4 ,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 individuals4 ,magnan1 the very well and widely known ,french authority on insane peculiarities1 especially the so-called criminal monomaniacs1 and whose opportunities for careful investigation of such cases in the ,asile ,st4 ,anne in ,paris have been very extensive1 utterly rejects the idea of a special physical conformation as characteristic of the criminal4 ,he is not the only one of the distinguished authorities in mental diseases who is in opposition to ,lombroso in this matter4 ,dr4 ,emile ,laurent1 the eminent criminologist of ,paris1 has shown that the same anomalies which are supposed to characterise criminals are to be found among those who have never committed any criminal act1 and that these supposed signs of degeneracy are not sufficient to indicate even #bgb that there are criminal tendencies4 ,manouvrier1 the distinguished anthropological authority of the ,university of ,paris1 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 classes4 ,he admits1 however1 that environment sometimes leads to the formation of habits which modify the anatomy in certain ways1 and that of course traces of hard work1 as well as of poor living1 can be found in the anatomical conformation of many habitual criminals4 ,dr4 von ,holder1 a distinguished ,german authority on the subject1 says that it is impossible to draw any conclusion from cranial asymmetries as to psychical characteristics1 and that physical signs of degeneration indicate nothing further than the possible presence of a tendency to psychic degeneration4 ,dr4 ,wines1 quoted by ,draehms in his book on ,the ,criminal1 a ,scientific ,study1 says that in a strictly scientific sense1 the existence of an anthropological criminal type has not been proved1 and it is doubtful whether it ever can be proved4 ,dr4 ,arthur ,mc,donald1 the well known ,american specialist in criminology and degeneracy1 some of whose work in connection with the ,national ,bureau of ,education at ,washington has attracted widespread attention1 says1 in his ,abnormal ,man3 ,the study of the criminal can also be the study of a normal man1 for most criminals are so by occasion or accident1 and differ in no essential respect from other men4 ,most human beings who are abnormal or defective in any way are much more like than unlike normal individuals4 ,how much the subject of criminology has been overdone because of the morbid popularity of the idea that many persons are1 as it were1 forced by their natures into the commission of crime1 can best be appreciated from some recent publications with regard to left-handed individuals4 ,a number of supposed observers1 much more anxious1 evidently1 to make out a case for a pet preconceived theory1 than to make observations that would add to the present store of truth1 have rushed into print4 ,as a result1 left-handed persons have been said to be criminals much more commonly than #bgc those who habitually use their right hand1 and have also been said to be defective in other ways4 ,they were spoken of as weaklings1 degenerates1 and the like4 ,statistics even were quoted to show a much larger proportion of criminals than might be expected1 according to the normal percentage1 between right-handed and left-handed people1 among those who use their left hand by preference4 ,as a matter of fact1 left-handed people are far from being the weaklings or degenerates they are thus proclaimed2 but on the contrary are often magnificent athletes and excellent specimens of normal development4 ,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 life4 ,this question of the criminal and the left-handed individual and their mutual relations is only a good example1 then1 of how far over zealous advocates of a theory have been led astray in their attempts to bolster it up4 ,draehms1 whose opinion on the supposed born criminal is worth while quoting1 as it is founded on his personal experiences and observations while a resident chaplain of the state prison at ,san ,quentin1 ,california1 says3 ,crime is not1 as ,lombroso and his coadjutors would have us believe1 wholly either a disease or a neurosis in the sense of a direct1 absolute1 physiological1 pathognomonic entity1 though doubtless not infrequently closely associated with physical1 anatomical1 and nerve degeneration1 as above conceded4 ,to presuppose absolute and necessary brain lesion or diseased nerve action1 or anomalous1 physiognomonical1 or anatomical diathesis1 as the inevitable precursor of any form of mental and moral deflection1 is an assumption wholly unwarranted and is nowhere substantiated by facts1 though its advocates have sought to lay their foundations deep and wide in the materialistic hypothesis4 ,most criminals present unusually sound physiological conditions1 and there is among them no unusual death rate1 considering their habits and mode of life1 as we shall hereafter see4 ,hence their moral instability can not be associated with physiological instability in the absolute sense4 ,the physical defect must be either reversionary or incidental1 rather than absolute4 #bgd ,the impetus in the study of criminals1 which came as a result of the revolutionary teaching of the ,italian school1 has not been without a good effect4 ,criminals all over the world have been studied more closely and more sympathetically1 in order to test the new ideas1 until now it is possible to draw definite conclusions with regard to certain features of the problem4 ,after a time1 ,lombroso came to admit that the so-called criminal type occurred in somewhat less than half the criminal cases4 ,criminal anthropologists1 however1 have shown that the physical conformation called by the name criminal1 is really only the result of a defective or degenerative physical constitution4 ,it is easy to understand that persons born with a defective nervous system1 or with serious degenerative lesions in other parts of the body1 which prevent the proper nutrition and functional development of the nervous system1 would perform many more materially criminal acts than the rest of the population4 ,the idiot and certain forms of the degenerative insane show this4 ,any defective development of the nervous system1 moreover1 may lead to instability of moral character1 because the free action of the soul may be hampered by the physical environment with which it is associated4 ,certain of the physical peculiarities most frequently seen in criminals have an influence of this kind and merit discussion4 ,a knowledge of them will furnish clergymen with reasons for a larger charity to those unfortunates1 and a greater tolerance for their relapses1 without allowing sentiment to play too important a role in dealing with them4 ,there are all grades of defective human beings1 from the idiot up to those little less than normal4 ,anatomical peculiarities prevent the proper functions of the nervous system1 as it is not hard to understand4 ,the will is hampered in its action by the defect of the instrument through which it must work4 ,in persons properly to be considered as degenerates usually the head is small1 though this may not be very noticeable because of over-development of the jaws4 ,a heavy lower jaw particularly1 because of the principle of bone-development that size depends on functional action and reaction1 may lead to over-thickness of the skull at the point of articulation4 ,the #bge jaw articulates with the base of the skull1 and as a consequence the cranial capacity of these individuals is distinctly less than normal4 ,besides this1 there is commonly some abnormality in the shape of the head1 or the cranium is distinctly asymmetrical4 ,it has been noted that criminals have a large orbital capacity1 that is to say1 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 tissue4 ,the bones of the skull are likely to be thicker and heavier than usual1 thus also limiting the cranial capacity4 ,the superciliary ridges often project and give the beetling brow that is sometimes so remarkable4 ,the jaws are heavy1 and especially the lower jaw is apt to be large and prognathic1 that is1 projecting4 ,this may extend even to the existence of a so-called lemurian appendix of the jaw4 ,the zygomatic process is apt to be prominent1 in keeping with the heaviness of the upper jaw4 ,the nose is usually somewhat flattened1 and may be crooked4 ,this peculiar development of the nose puts most of the internal parts of that important organ within the skull itself4 ,this further encroaches upon the cranial capacity4 ,the ears are asymmetrical1 often unevenly placed at the sides of the head1 sometimes adherent at the lobule1 sometimes very prominent4 ,the displacement of the soft tissues is due to the existence of asymmetry of the skull4 ,as may be seen1 all of the characteristics of the criminal type1 pointed out by ,lombroso1 may practically be summed up in the one expression1 there is diminished amount of intracranial space4 ,with regard to many cranial deformities1 and especially various thickenings of the cranial bones1 it must not be forgotten that they are not the expression of physical heredity1 but are often pathologically acquired4 ,certain diseases of children are accountable for many of them4 ,various disorders of nutrition in the early years of life express themselves in bony deformities1 and the skull is not spared4 ,rickets1 for instance1 is well recognised as a cause of such deformities4 ,owing to a wrong etymology of this word1 by which it is supposed to be derived from the ,greek word ,greek text1 meaning the spine1 rickets is sometimes scientifically #bgf called rachitis4 ,the connection1 then1 between the cranial deformity and some underlying nervous disturbance might be assumed4 ,it does not exist1 however4 ,rickets is an ,english word1 the derivation of which is unknown1 but probably it is wricken1 twisted1 deformed1 and its use has crept in because the disease was first described in ,england1 and is indeed often spoken of on the continent of ,europe as an ,english disease4 ,not that it is any more frequent in ,england1 however1 but was there first recognised as a distinct pathological entity4 ,as the result of this affection the children1 usually of poor parents1 suffer from gastro-intestinal disorders of various kinds1 and develop symptoms of malnutrition1 affecting especially bone tissue4 ,the ends of the long bones at the wrists and at the ankles1 where the effects of the disease can be noticed particularly1 become more thickened and nodular than usual4 ,the ends of the ribs1 where the bones join the cartilages1 also become nodular1 so that a series of beads can be seen down each of the child's sides1 a condition described as the rickety rosary4 ,in a similar way the bones of the skull become thickened1 especially at the edges of the fontanels1 that is1 the openings in the child's head before complete ossification of the skull has taken place4 ,as a consequence of this thickening these openings do not close as they should1 and the head becomes markedly deformed in some cases4 ,indeed1 as has been shown by experts in children's diseases1 many of the peculiarities that have been pointed out by over enthusiastic craniologists as indicating criminal degeneration1 are really the results of the rickety process on the skull4 ,needless to say1 however1 this does not change the character of the individual1 nor is there any good reason why such deformities should have any special connection with criminality4 ,it happens that many of the criminal classes suffer from malnutrition in their early childhood1 and as a consequence there is a faulty bony development of the skull4 ,it is observations of this kind1 particularly1 that have served to discredit craniology as an independent science4 ,with regard to habitual criminals1 the question of criminality must be discussed from the standpoint1 not of those who theorise1 but of those who know from actual #bgg observation most about the criminal classes4 ,in an article in ,the ,nineteenth ,century and ,after for ,december1 #aija1 ,sir ,robert ,anderson discusses how to put an end to professional crime4 ,sir ,robert has been ,chairman of the ,criminal ,investigation ,committee of the ,english ,parliament for many years4 ,his opinion1 then1 is worth weighing well and is very strikingly different from those of the criminologists who would find a very large proportion of criminals among mankind4 ,he says3 ,i am not turning phrases about this matter1 or dealing in rhetorical fireworks4 ,i am speaking seriously and deliberately1 and ,i appeal to all who have any confidence in my judgment and knowledge of the subject1 to accept my assurance that if not #gj1jjj but #gj known criminals were put out of the way1 the whole organisation of crime against property in ,england would be dislocated1 and we should1 not ten years hence but immediately1 enjoy an amount of immunity from crimes of this kind that it might to-day seem ,utopian to expect4 ,the criminal statistics cult blinds its votaries4 ,it is the crime committed by professional criminals that keeps the community in a state of siege4 ,the professional criminals are few and ,i may add they are well known to the police4 ,the theory that these men commit crimes under the overpowering pressure of habit1 or of impulse1 is altogether mistaken4 ,they pursue a career of crime because1 as ,sir ,alfred ,wills expresses it1 they calculate and accept its risks4 ,and just in proportion as you increase the risks you will diminish the number of those who will face them4 ,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 impulse4 ,i believe there are fewer of this class in ,england than abroad1 but ,i know that these are not the sort of criminals whose crimes perplex the police4 ,the high-class criminal is a different type of person altogether4 ,sir ,robert gives an extract from one of the morning papers of the day on which he wrote these lines1 in order to show how different is the status of every ordinary habitual criminal from that which the enthusiastic criminologist supposes it to be3 #bgh ,hewson ,patchett1 #dh1 was sentenced yesterday for obtaining seven pounds and a gold watch by false pretenses4 ,he urged it was his first offence1 but a ,london detective informed the court that there were about two hundred cases against him for housebreaking4 ,sir ,robert adds3 ,if ,patchett is a cool-headed1 deliberate criminal1 the whole proceeding is a farce4 ,and if he be one of those miserable1 weak creatures who can not abstain from crime1 the sentence is barbarous4 ,such experiences as ,sir ,robert hints at as occurring frequently in ,england1 are certainly by no means uncommon in this country4 ,within the past year in at least four cases in ,new ,york ,city1 in which a burglar1 besides committing robbery1 wounded or killed some one1 either in the commission of the crime itself or in endeavouring to avoid arrest afterwards1 there were more than two convictions registered against the criminal in his previous life4 ,there can be no doubt that criminality becomes for some men a sort of mania1 and that society must protect itself against their actions quite as it does against those of the insane by confining them under surveillance4 ,it seems very clear that while a man may1 under stress of circumstances or because of some specially tempting opportunity1 be induced to commit burglary or some other crime by violence in order to obtain money1 this will not happen a second time1 except in the case of certain individuals whose moral tone is so perverted that reformation is practically hopeless4 ,if a second conviction for burglary1 therefore1 is secured1 a longer sentence than is now the custom should be inflicted1 and the individual should not be allowed to go from under the surveillance of the authorities until he has demonstrated1 for at least five years1 his willingness and capacity to earn an honest living4 ,this may seem a drastic method4 ,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 criminals4 ,here is where ,sir ,robert ,anderson's experience is of value4 ,the confirmed criminals are not near so many in number as is usually supposed1 or as is even claimed by certain heedless #bgi statistical experts in criminology4 ,there is no doubt1 however1 that these men succeed in drawing others around them and in organising most of the crimes of violence that are committed4 ,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 withdraw4 ,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 receive1 not a definite sentence but an indeterminate sentence2 that is to say1 that on his second conviction for burglary1 he should be sent to jail until such a time as1 in the opinion of officers of the institution where he has been confined1 he shows signs of a disposition to become a worthy member of society1 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 prison1 then there would be much less need of the theoretical considerations with regard to the heredity of criminal traits1 and the supposed all powerful influence of environment in fostering criminal tendencies4 ,there is in this matter a very worthy field for the development of philanthropic qualities1 and the student of the abnormal man will find many opportunities for the exercise of a large-hearted charity1 rather than the facile condemnation which places all violations of law under the head of criminality4 ,those who have made special studies with regard to criminals have1 as a rule1 come to the conclusion that our modern method of treating those convicted of crime is eminently irrational4 ,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 crime4 ,most of the burglars have a police record4 ,pickpockets and others continue to pursue their avocations1 notwithstanding a series of convictions4 ,it is clear that a sentence of a year or two1 or even more each time that a crime is committed1 does not act as a deterrent4 ,such people are differently constituted from those who are influenced by #bhj public conviction of crime and restraint of liberty4 ,there is something radically wrong with their moral sense4 ,it would seem that the proper way to treat them is after the same fashion as the method used with those who are mentally impaired4 ,after a man has shown1 by a second conviction of a crime by violence1 that he is one of those whose moral sense can not be restored by punishment to a realisation of his action1 then an indeterminate sentence1 somewhat as in the case of the mentally unstable1 who are allowed to leave the asylum but are kept under observation1 is the only proper method4 ,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 crime4 ,there would be much less need for all machinery of the criminal law than at the present time1 and the community would be better protected4 ,this is certainly true as regards the large cities1 where crimes against property are almost without exception committed by those who have been previously convicted for such crimes1 or who at least have been in intimate association with such convicted criminals4 ,this view of the criminal1 as one against whom society must protect itself just as it does against the insane1 is comparatively modern4 ,it must be borne in mind1 however1 that insane asylums are by no means an old institution1 and that the present restraint of very large numbers of the insane is something unknown before in history4 ,it seems not unlikely that if this newer aspect of criminology could be made popular great benefit would follow1 not only to the peace of the community and the freedom of its members from fear as to such crimes1 but also a number of the weaker individuals1 who are now influenced and led astray by clever criminals1 would be saved from commission of crime and the necessity of punishment1 with the degradation and lifelong stigma that this involves4 ,this is an aspect of criminology with which the ,christian clergyman can be in sympathy1 and that does not smack of the utter materialism which was at the foundation of much of the discussion of the so-called criminal type4 ,the #bha recognition of moral perversion as a form of insanity requiring treatment and then constant observation for many years1 just as in the case of mental disequilibration would be a distinct advance over our present crude methods of dealing with criminals4 ,,james ,j4 ,,walsh4 #bhb ,,xxvi ,,paranoia1 ,a ,,study ,,in ,,cranks ,of late years the crank1 in the various forms in which he or she may occur1 has became a subject of great popular as well as scientific interest4 ,as a matter of fact1 the queernesses of people are a more absorbing study to the neurologists and psychologists than are any forms of insanity4 ,it not infrequently happens that individuals of peculiar tendencies are prone to have special affinity for religious ideas1 and strange applications of ,christian formulae of thought4 ,even when they do not become absolutely insane in their religiosity1 they may often go to extremes4 ,it must be remembered1 too1 that some cranks are mentally affected in but mild form1 and it may be difficult to determine whether their oddity is really the result of a certain amount of mental torsion1 or merely intellectual tension4 ,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 individuals4 ,they often put their confessors1 particularly1 in serious quandaries in the matter of spiritual advice4 ,a review1 then1 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 possible1 though the present state of medical knowledge1 here as elsewhere1 leaves much to be desired4 ,a distinguished authority in mental diseases once said1 half in jest though he meant it to be taken at least half in earnest1 that a great many more of us are cracked than are usually thought to be1 only that most of us succeed in concealing the crack quite well4 ,the frequency of the crank adds to the #bhc interest of his study1 which is by no means a department of medical science of recent growth4 ,while interest in this class of persons has become much more intense in recent years1 eccentric individuals have been an object of close observation and of serious study almost as far back as history goes4 ,when ,quintilian said that genius was not far separated from insanity1 he meant to record the conclusion of his time1 that men of genius are apt to seem inexplicable in their ways to those who come closely in contact with them4 ,eccentric persons1 however1 are by no means always undesirable members of a generation4 ,it has been noted by historians in all ages that to the refusal of eccentric individuals1--often thought at the beginning1 particularly1 to be little better than insane--to accept the traditions of the past1 we owe many of the privileges which we enjoy at the present time4 ,their refusal to think along old lines of thought often makes them valuable pioneers in progress4 ,definite knowledge with regard to the pathological basis of crankism1 or eccentricities1 has not yet been obtained4 ,what has been learned1 however1 has enabled the neurologist to distinguish various forms of mental perturbation1 to recognise the probable influence of certain conditions and environments on the future action of eccentric individuals1 and to foretell the probable outcome of the cases4 ,all of this information is of very practical importance to religious ,superiors and others in positions of religious confidence1 who are sure to be brought1 even more than the rest of the community1 in contact with the eccentric class4 ,it has seemed advisable1 then1 to condense some of the recent knowledge on this subject into popular form for the use of confessors1 spiritual directors1 and those in religious authority4 ,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 ,berlin1 to whom we owe the term paranoia1 the recognised scientific designation for crankism1 is yet alive and continuing his lectures on neurology at the great ,german university4 ,the term1 from the ,greek word ,greek text1 meaning alongside of1 and #bhd ,greek text1 mind1 expresses the fact that the mental faculties of individuals designated by it are beside themselves1 that is1 the mental powers are not entirely under the control of the individual1 so that they only come near voluntary intellection in its highest sense4 ,in a word1 the term contains a series of expressive innuendos by its etymological derivation4 ,professor ,berkley of ,johns ,hopkins ,university says that the word paranoia was first adapted by ,mendel from the writings of ,plato1 to indicate an especial form of mental disease occurring in individuals capable of considerable education1 at times of brilliant acquirements1 yet possessing a mental twist that makes them a class apart from the great mass of humanity4 ,professor ,peterson1 the ,president of the ,new ,york ,state ,commission of ,lunacy1 gives a very good definition of the condition which1 though couched in somewhat technical terms1 furnishes the most definite idea of the essential properties of paranoia4 ,he says3 ,paranoia may be defined as a progressive psychosis founded on a hereditary basis1 characterised by an early hypochondriacal stage1 followed by a stage of systematisation of delusions of persecution1 which are later transformed into systematised illusions of grandeur4 ,he continues3 ,though hallucinations1 especially of hearing1 are often present1 the cardinal symptom is the elabourate system of fixed delusion4 ,in a word1 the paranoiac is a crank usually descended from more or less cranky ancestors1 with an overweening interest in his health to begin with1 who later develops the idea that many people are trying to do him harm1 or at least to prevent his rise in the world1 and who finally becomes possessed of the notion that he is somebody1 even though those around him refuse to acknowledge it and pay very little attention to the claim4 ,such people not infrequently hear things that are not said4 ,that is1 not only do they hear the voices of the dead1 of spirits good and evil1 but also the voices of living persons1 who are at a distance from them and sometimes even when those living persons are present1 but have said absolutely nothing4 ,these delusions of hearing1 however1 are not so important as the self-deception forced upon them by their #bhe mental state with regard to their importance in the world and their relations to other people4 ,the most significant consideration with regard to paranoia is the fact that it is practically always hereditary4 ,krafft-,ebing said that he never saw a case of true and reasonably well developed paranoia without hereditary taint4 ,this does not imply1 of course1 that the same symptom of delusions exists in several generations1 but some serious mental peculiarity is always found to exist in the preceding generation4 ,other authorities are not quite so sweeping in their assertion of heredity for these cases1 though practically all are agreed that in over #hj per centum of the cases1 some hereditary element can be traced without overstretching the details of family history that are given4 ,paranoia occurs a little more commonly in females than in males4 ,as it is of hereditary origin1 it is not surprising to find that the peculiarities are noticed very early in life1 though they may not be sufficiently emphasised to attract the attention of any but acute observers1 who are brought closely in contact with the patients4 ,even in childhood1 patients who subsequently develop serious forms of paranoia1 usually have been shy1 backward1 inclined not to play readily1 irritable1 peculiar1 precocious1 prone to spend much time in study at an age when they ought to be interested mainly in sports1 and they are generally old beyond their years4 ,a typical example of this was ,friederich ,nietzsche1 the ,german philosopher1 who died a few years ago in an insane asylum4 ,olla ,hanssen1 ,nietzsche's biographer1 who carefully collected the family accounts of the philosopher's childhood1 said that he did not talk until much later in childhood than is usual4 ,as a boy he was retiring and solitary in his habits4 ,during his school days he was always interested in books not in sports1 in lonely walks not in young companions4 ,a history of this kind will be found in the early career of many queer folk4 ,very often these old-fashioned traits are a source of pleasure to parents and sometimes even to teachers4 ,during childhood1 however1 the sports of childhood should satisfy the child1 and abnormalities of interest in things outside of childhood's sphere are always suspicious4 ,the growing #bhf organism needs1 first of all1 muscular exercise1 and after that the freedom of mind that comes with spontaneous play4 ,it may be said1 in passing1 that the walk of a city child with its maid1 when even the child's choice in the matter of where it shall walk is not consulted and the maid's will is constantly imposed1 is the worst possible training for spontaneous action or volition in later life4 ,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 history4 ,the mother's delivery was difficult perhaps1 and the child was for some time after birth unconscious1 or infantile convulsions occurred4 ,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 child4 ,it has recently been announced1 for instance1 that so-called idiopathic epilepsy1--that is1 epilepsy without some directly immediate cause1--very seldom develops later in life in persons who have not had in childhood convulsive seizures as the result of some extreme irritation4 ,this does not imply that every child that has convulsions will suffer from some serious nervous or mental condition later2 but every child whose mental and nervous equilibrium is not stable1 because of hereditary elements of weakness1 will almost certainly suffer4 ,injuries to the head in childhood are nearly of as great importance as the actual occurrence of convulsions4 ,there are usually three stages of paranoia described by authorities in mental diseases4 ,these have been called the prodromal or initial period1 which is also1 because of the set of symptoms usually most prominent in it1 often called the hypochondriacal stage of the disease4 ,the patient occupies himself with his feelings and his sensations4 ,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 described4 ,this set of symptoms1 by itself alone1 is not an index of enduring mental disturbance1 but may be only a manifestation of a passing mental perturbation in sympathy with some slight physical ailment4 ,this state may indeed be nothing more than the result of too persistent introspection4 #bhg ,most medical students suffer from a certain amount of hypochondria during their early acquisition of a knowledge of the symptoms of disease4 ,in the true hypochondriac1 however1 every bodily sensation1 or as it is technically called1 somaesthetic sensation1 is translated to mean a significant symptom of serious disease4 ,a slight feeling of fatigue becomes to the patient's mind the tired feeling of a dangerous constitutional disorder4 ,any peculiar feeling1 such as that of the hand or foot going to sleep1 is set down at once as a symptom of a serious nervous disease1 or if the patient has heard that in old people numbness of the extremities is a forerunner of apoplexy1 he is sure to conclude that apoplexy is threatening in his own case4 ,subjective sensations of heat and cold set him to taking his temperature and his pulse1 and even slight variations in these are magnified into important physical signs of disease4 ,very often such slight symptoms as passing lapses of memory are magnified into approaching complete failure of memory1 and lassitude becomes a permanent loss of will power1 evidently due to disease in the patient's mind1 and there begins the persuasion that nothing can overcome it4 ,morbid introspection becomes1 after a time1 the favourite occupation1 and every slightest sensation or feeling sets up trains of thought that lead to far-reaching conclusions with regard to physical weakness4 ,the patient is apt to be greatly preoccupied with himself1 to neglect his duty towards others1 to be utterly selfish1 to fail to realise how much sympathy is being wasted on him4 ,some people never pass beyond this preliminary stage of the mental disorder4 ,usually1 however1 after a time the patient misinterprets not only his own sensations1 but the actions of other people in his regard2 he becomes suspicious and distrustful of everybody around him1 sometimes even of his best friends4 ,he is passing on to the second stage of the disease1 in which he is sure to feel that he is the object of persecution4 ,just as he misunderstood his physical symptoms1 so he misconstrues the actions of his friends4 ,he is sure that they look at him curiously1 that they smile #bhh ironically4 ,sometimes he thinks that they wink at one another with regard to him1 or make signs behind his back that are meant to be derisive4 ,even harmless passing observations may be morbidly perverted into severe and inimical criticism of himself and his actions4 ,the paranoiac is now apt to enter fully upon the second or persecutory stage of his mental disorder4 ,his distress and discomfort he attributes to those around him and he is sure that he is the subject of persecution4 ,at first his persecutors are not very definitely recognised4 ,no particular person is picked out and even no particular set of persons4 ,there is just a vague sense of persecution4 ,a distinguished neurologist once said that no sane person in this world1 outside of a novel or a play1 has time to make it his business to persecute anyone else4 ,when people come1 then1 with stories of persecution1 either they themselves are not in their right mind and are deluded as to the source of the persecution1 or else their persecutor is not in his right mind and the case needs seeing to from the other standpoint4 ,after a time1 longer or shorter in individual cases1 the paranoiac begins to recognise definitely who his persecutors are4 ,as a rule1 it is not some single individual1 but a combination of individuals4 ,already there is the beginning of the third state of the disease--the grandiose stage of the disease1 in which the patient feels an extreme sense of his own importance4 ,it would be derogatory to his self conceit to consider himself the subject of persecution by an individual1 and so it is usually some society1 or the government1 or its officials1 or some secret organisation that is persecuting him1 and perhaps also persecuting those who are near and dear to him4 ,sometimes it is the ,odd ,fellows1 or perhaps the ,masons1 who are the persecutors4 ,if the newspapers have recently had some account of the disappearance of ,morgan years ago1 and this subject crops up periodically in the papers1 then the ,masons become a favourite subject for paranoiacs' delusions of persecutions4 ,just after the ,cronin murder in ,chicago1 the ,clan-na-,gael became an extremely fearsome spectre for paranoiacs who thought themselves persecuted4 ,it is of some #bhi importance to know1 as a rule1 what the usual reading matter of a patient is1 and what things are likely in his past history to have impressed him1 in order to realise what the real source of his delusions of persecutions are4 ,it is curious how rational these patients may be on all other subjects except the special topic of their delusion4 ,during the past year a paranoiac has been under observation1 who is considered a reasonably rational individual by those who know him well1 who follows his daily occupation1 that of clerk1 without intermission and with business ability1 who is a faithful attendant at church1 and who is very kind to his family1 but who is sure that he is the subject of persecution by the ,clan-na-,gael4 ,he never belonged to the organisation4 ,he is not able to give any good reason why he should be persecuted1 except perhaps the fact that1 though an ,irishman1 he never did belong to them4 ,he is perfectly sure1 however1 that they are planning to poison him and his family4 ,he finds peculiar tastes in the tea and the coffee at times4 ,he throws out these materials and insists on his wife getting others at another grocery store4 ,he sometimes brings groceries home from a distance and yet finds that if he ever buys materials a second time in the same place1 they are sure to have been tampered with in the meantime by emissaries of this secret organisation4 ,he feels sure that he has seen these secret agents1 but he is only able to give vague descriptions4 ,not a little of the prejudice against these organisations is really founded on such morbid suspicions4 ,another form that the idea of persecution sometimes takes1 in this second stage1 is the delusion that the patient is neglected by those who should specially care for him or her4 ,a woman insists that she is neglected by her husband4 ,she may become intensely jealous of him and make life extremely miserable for him without there being any good reason for her jealousy4 ,these cases are not nearly so rare as might be thought4 ,on the other hand1 men suspect their wives of unfaithfulness4 ,this suspicion may go to very serious lengths in persecution at home1 though the man all the time keeps his suspicions to himself1 in order not to make a laughing stock of himself outside of the house4 ,it is this curious mixture of #bij rationality and delusion that is the characteristic feature of the disease4 ,it is for this reason that these conditions were sometimes called monomanias1 as if patients were really disturbed only on one point4 ,as a matter of fact1 however1 patients are mentally wrong on a number of points1 though there is some one mental aberration so much more prominent than other peculiarities that it overshadows the others4 ,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 persecuted4 ,the ,french have a suggestive expression for this4 ,it is persecutes persecuteurs1 that is to say1 persecuted persecutors1--patients who are trying to repay supposed persecutors by persecution on their own part4 ,such patients1 of course1 very easily become dangerous4 ,they need to be carefully watched4 ,as a rule1 the persons whom they are prone to select as the persecutors upon whom they must avenge themselves are absolutely innocent parties4 ,at times they are even dear and well meaning friends4 ,after the persecutory stage in paranoia1 comes the third1 or so-called expansive period of the disease4 ,it has been remarked that sometimes this develops as a sort of logical sequence from the patient's ideas of persecution4 ,if he has too many enemies and if important secret organisations are trying to be rid of him1 he must be a person of some importance4 ,as a consequence he evolves for himself a royal or aristocratic descent1 or hints that he is the unacknowledged son of great personages4 ,in a kingdom royalty is1 of course1 a dominant idea4 ,in a republic like our own1 he may consider himself to be the ,president or the politician to whom the ,president owes his office4 ,paranoia ,religiosa4--,not infrequently the first hint of their supposed greatness comes to such patients suddenly in a dream or in a vision2 when their expansiveness takes a religious turn1 this is especially apt to be the case4 ,they may believe themselves to be especially chosen by the ,almighty1 a new ,messiah or even ,christ ,himself1 come once more to earth4 ,such people may retain much of their rationality on most of the points relating to practical life1 and yet have this #bia hallucination as to their close relationship with the divinity4 ,not only may they retain their mental equilibrium on other points1 but they may even give decided manifestations of great genius4 ,this is1 ,i suppose1 one of the most interesting features of this form of mental disease1 but it is well illustrated in the lives of many modern founders of religious sects1 even in our own generation4 ,such religious reformers as ,mahomet and ,swedenborg seem undoubtedly to have been afflicted with this third stage of expansive paranoia4 ,in our own day there is no doubt that many of the founders of new religious sects1 many of the heaven-sent apostles or reincarnations of patriarchs and prophets1 the miraculous healers and the like1 are afflicted in this same way4 ,it is useless and entirely contrary to the known facts to put such people aside as mere imposters4 ,imposters they are1 but they have imposed on themselves as well as on their followers4 ,they are sincere as far as they go1 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 ability1 with wonderful capacity for the direction of complex affairs4 ,a prominent neurologist said1 not long ago1 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 fortunes4 ,paranoia ,erotica4--,after the paranoia religiosa1 the most common form of the disease is the paranoia erotica4 ,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 interchangeable4 ,this declaration represents1 however1 the unconscious exaggeration of a mind unsympathetic towards religious ideas4 ,but it must not be lost sight of that the two forms of excesses1 erotic and religious1 are more nearly related than would be ordinarily supposed1 and that erotic manifestations may be confidently looked for in patients who have been afflicted by a too highly wrought religious sentimentality4 ,st4 ,theresa seems to have realised this very well and has touched on the subject in one of her letters4 #bib ,ordinarily erotic paranoia manifests itself by the patient imagining himself or herself to be beloved by some one of superior station4 ,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 eye1 but whose reputation is of the very highest4 ,mary ,anderson was the subject of a good deal of this sort of persecution4 ,at the present moment the well and favourably known daughter of a great millionaire is the subject of many such attentions4 ,these paranoiacs are apt to become dangerous if they are prevented from paying what they consider suitable attention to the object of their affection4 ,in hospitals they have to be carefully watched1 and more than one accident has taken place as the result of relaxation of vigilance on the part of their attendants4 ,if kept from the object of his affection1 delusions of persecution become prominent in the amorous paranoiac1 and he may become a persecutor in turn and thus a dangerous lunatic4 ,he can not be made to understand that the sending of flowers and photographs and letters is entirely distasteful to the chosen one4 ,fortunately1 after a time1 in many of these cases1 a state of dementia sets in1 and then the patients become mild-mannered imbeciles whom it is not at all difficult to manage4 ,as a rule where the patient has passed through the various stages of paranoia1 dementia1 with symptoms of imbecility1 closes the scene4 ,the paranoia may not always follow the course mapped out for it4 ,stages may be skipped1 several forms of delusions may become prominent in the life of the individual at about the same time4 ,the main feature of the disease is its progressive character1 and its diagnosis depends on the queerness exhibited all during the course of life1 as well as on the presence of hereditary neurotic influences4 ,special ,forms of ,paranoia4--,there are besides the two types described a number of special forms of paranoia1 some of which aroused attention first under the form of monomanias1 that seem to merit brief treatment by themselves4 ,in their extreme forms they are easy of recognition4 ,milder types1 however1 may easily escape classification under the #bic head of paranoia1 because they are considered to be individual oddities and not due to any physical or mental incapacity4 ,undoubtedly1 however1 the study of these peculiar types1 as the ,french call them1 from the standard of the alienist or expert in mental diseases1 will serve to make clearer the real significance of many otherwise almost unaccountable actions4 ,there is no doubt1 that the consideration of these eccentrics as paranoiacs makes the charitable judgment of many of their acts much easier1 and at the same time is of service in managing them4 ,they are likely to be of much less harm to the community and to their friends1 when it is realised that they are not to be taken too seriously1 but that1 on the contrary1 there is ample justification for a benevolent combination of interests to keep them from injuring themselves and their friends4 ,paranoia ,querulans4--,one of the most important and familiar forms of the special types of paranoia is what is known scientifically paranoia querulans1 that is1 the peculiarity of those who insist on going to law whenever there is the slightest pretext4 ,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 rights1 or what they think their rights1 vindicated for them by a court of justice4 ,there are very peculiar characters in this line1 some of whom make themselves very much feared and detested by their neighbours4 ,there are some individuals to whom the slightest injury or show of injury means an immediate appeal to the law4 ,not infrequently these patients1 for such they are in the highest sense of that word1 waste their own substance and even the means of support of wife and children1 on their foolish law schemes4 ,when their queerness reaches a certain excessive degree its pathological character is readily recognised4 ,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 abnormality4 ,not infrequently such patients become more irrational at times when their physical condition is lower than normal1 and a return to their ordinary health makes them #bid more amenable to reason and less prone to appeal to expensive litigation4 ,it is evident that the irrationality of frequent appeals to expensive and bothersome litigation should arouse suspicion4 ,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 inebriety4 ,unfortunately it is extremely difficult to frame laws so as to meet such conditions4 ,severer forms of the affliction are readily recognised and the sufferer is properly restrained4 ,i remember once seeing a patient in ,professor ,flechsig's clinic in ,leipzig1 who had been sent to the asylum because of his tendency to go to law on the smallest possible pretext4 ,this patient's incarceration in the asylum was due to a very striking manifestation of his paranoia querulans4 ,he answered an advertisement for a clerk1 published by one of the large commercial houses4 ,he found himself one of a row of applicants for the position1 and as the member of the firm whose duty it was to engage the clerk was at the moment busy1 he had to wait several hours before his application was heard and refused4 ,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 heard1 at the rate of wages they would have been bound to pay him had he obtained the vacant clerkship2 only as they had spoiled a day he claimed a full day's wages4 ,this patient had been in the asylum several times before because of his tendency to go to law4 ,he always gained in weight while in the asylum1 became much more tractable and less querulous as his physical condition improved1 and usually after some months could be allowed to leave the institution4 ,he was1 however1 one of the inept4 ,with the help of asylum influence he usually obtained some occupation more or less suitable1 but was not able to retain it for long4 ,when out of a situation he worried about himself1 usually did not take proper food1 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 attorney1 or if he could persuade one to take his case on a contingent fee1 and he was very ingenious at this1 he soon became a veritable nuisance to #bie those around him4 ,when in poor health he was never contented unless he had at least one lawsuit on his hands1 and only really happy when he had several4 ,the ,gambler ,paranoiac4--,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 can1 by luck or by ingenious combinations1 succeed in winning money at gambling4 ,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 mentality4 ,when a man thinks1 however1 that he can beat a gambler at his own game1 or when by long lucubration he comes to the conclusion that he has invented a system by which he can beat a roulette wheel1 he is1 on this subject at least1 as little responsible as the man who thinks that he has discovered perpetual motion4 ,this form of paranoia inflicts suffering mainly on the near relatives of the patient4 ,there is no doubt that when extreme manifestation of the gambling mania becomes evident1 patients should be legally restrained from further foolishness4 ,one difficulty with regard to the proper appreciation of gambling has been an unfortunate tendency to class gambling among the malicious actions4 ,there are many people for whom only two sins seem to have any special importance1 drunkenness and gambling4 ,as a rule1 there is not the least spirit of malice in the ordinary gambler2 not meaning1 of course1 by this the sharpers1 who try to make money at the expense of others1 but the man who believes that1 somehow1 chance and fate are going to conspire to enrich him at the expense of others1 though it must be confessed that he does not usually even think of this latter part of the proposition which he accepts so readily4 ,we have had in recent times so many manifestations of the practical universality of the gambling spirit1 the belief by people that brokers and banking concerns are ready to make them rich quick1 that we have in it perhaps the best illustration of the partial truth of the proposition that half the world is off1 and the other half not quite on4 ,the ,phobias4--,sometimes the special form of queerness #bif takes on a very harmless aspect4 ,patients are worried because of the fact that they can not keep themselves clean4 ,they want to wash their hands every time they touch any object that has been handled by others1 whether that object seems to be specially dirty or not4 ,such patients may wear the skin off their hands washing them forty or fifty times a day4 ,they almost absolutely refuse to touch a door-knob1 because it is handled by so many people4 ,they will consent to take only perfectly new bills4 ,it is almost amusing to see the efforts they make to avoid shaking hands with people1 without giving direct offense4 ,when it comes to shaking hands with their physician1 they are apt candidly to declare that he must not ask them to do so1 because they can not overcome their feelings as to the possibility of contamination from hands that come in contact with so many patients4 ,this fear of dirt has received the name ,misophobia4 ,there are a number of other phobias1 and the patient's fears are manifested at the most peculiar objects4 ,agoraphobia1 for instance1 is the fear of crossing an open place4 ,these patients begin to tremble as soon as they get away from the line of buildings in a street1 in their way across the square4 ,this trembling becomes actual staggering1 with a sense of oppression over the heart that makes locomotion almost or quite impossible4 ,claustrophobia1 the opposite of ,agoraphobia1 is the fear of narrow places1 and prevents some people from going through a narrow street with high buildings4 ,many of these phobias have a physical basis in some organic or nervous heart affection4 ,the ,tramp4--,one of the striking manifestations of paranoia in our modern life is the tramp4 ,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 name1 pigritia indurata1 that is1 chronic laziness1 than any pathological condition of mind4 ,most tramps1 however1 will be found1 on that close acquaintanceship which alone will justify judgment of their actions1 to have many other peculiarities of mind besides the shiftlessness which prompts them to wander more or less aimlessly from place to place4 ,after all1 it will hardly be denied that the calm #big acceptance of the notion that it is more satisfactory to indulge in laziness and wander without home or fireside1 suffering the many privations and hardships1 especially from the weather which these creatures do1 rather than work and be respected and comfortable among their fellows1 is of itself irrational4 ,many of these tramps prove on close acquaintance to be interesting pathological characters4 ,various stages of outspoken paranoia will be found to exist among them4 ,it is not unusual to find that certain among them have acquired the idea not so uncommon now among large classes of humanity1 that the world is so unjust in its treatment of the labouring man1 that work seems to them almost a persecution that must be undergone for the sake of the pittance derived from it4 ,sometimes there is the actual extrinsic idea of personal persecution for some fancied wrong done to a large corporation during a strike1 or labour troubles1 which they cherish as the reason for which they have had to give up a fixed habitation1 and resign the idea of supporting themselves honestly and respectably4 ,this persecution stage of paranoia easily turns to the second phase of this affection as already described1 that in which the fancied victim of persecution becomes in turn the persecutor4 ,tramps thus readily give way to even organised attempts at revenge upon social order1 and are led to believe themselves justified in attempts to burn and otherwise destroy property because of their enmity towards property holders and employers generally4 ,not infrequently the third stage of paranoia1 in which there are delusions of grandeur1 may be observed4 ,personally ,i have known two tramps who wandered about the country with these grandiose ideas4 ,one of them thought that he had in his possession immense wealth in the shape of large checks1 signed supposedly by various important capitalists1 and even foreign rulers4 ,these checks were actually signed in the names of these personages1 at the tramp's own request1 by any chance passer-by or acquaintance4 ,this patient died in a country insane asylum in the demented stage of paranoia1 having gone through all the usual phases of the disease4 ,another tramp was confident that each recurring election he was to be elected to one of the highest offices in #bih the state1 or even to be made ,president of the ,united ,states4 ,not every one was taken into his confidence in this matter1 however4 ,the simplest declaration after the election from any chance acquaintance would assure him of his success at the polls1 and on more than one occasion he turned up at the ,capitol to claim exalted office1 but was generally inoffensive in his ways1 and was rather readily persuaded that his term of office did not begin for some time4 ,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 removed2 the result might very well be one of the sad tragedies supposedly due to anarchism1 but really to paranoia4 ,of course as with criminals1 so with tramps2 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 them4 ,i do not think ,i should hesitate to say1 however1 that the majority of these unfortunates present distinct signs of physical and mental degeneration and are rather deserving of pity and care than of condemnation4 ,they need1 as a rule1 very special environment to enable them to lead ordinary1 respectable lives1 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 civilisation4 ,as the pressure of the time becomes severer1 more of these unfit come into evidence4 ,they arc examples of the lowered mental states1 unable to stand the rivalry with fellowmen1 and ready to give up the struggle whenever the example of others who have already given it up is brought prominently to their notice4 ,it is not a little surprising how many of these tramps belonged originally to excellent1 respectable families4 ,careful investigation of their personal history1 however1 will show that they have been1 as a rule1 backward children at school1 always a little awkward in the way they took hold of things early in life1 unsuccessful in the rivalries of school competitions1 and in their first efforts at labour after school days were over4 ,they always needed the encouragement of those whom they loved and respected1 to keep them at their unsatisfactorily fulfilled tasks4 ,they were the predestined failures #bii in life1 and have found out their uselessness early in their careers4 ,this is the view of tramp life that is coming to be realised as true by all those who have studied the question1 not from the standpoint of theory1 but of practical experience with it4 ,so-called ,monomania4 ,the old term for paranoia employed for a long time was monomania1 a word coined by ,esquirol at the beginning of the nineteenth century4 ,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 disturbance1 that is1 being mentally perturbed on but one line of thought4 ,there are always others1 though they may be hidden except from the careful investigator4 ,when ,esquirol introduced the term he applied it to the most prominent symptom of the patient's mental alienation1 but did not intend it to be taken as excluding other symptoms by which the essential nature of the patient's insanity could be diagnosed4 ,careful study will always disclose the fact that other symptoms are present4 ,the word monomania has been an unfortunate one for scientific psychiatry1 because it has been abused to shield criminals4 ,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 crime4 ,we often hear of kleptomania as a defence for persons who have failed to recognise the distinction between meum and tuum1 and are haled before the court because of the detection of infringements of this distinction4 ,true kleptomaniacs there are1 but there are always other symptoms of their mental disturbance besides the tendency to steal4 ,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 occurs4 ,kleptomaniacs1 too1 are usually prone to take things of little value1 or not especially suited to their wants and for which they have practically no use4 ,it is true collectors1 that is1 those who have a hobby for gathering curiosities of one kind or another to make a collection1 may become so interested in additions to their collection #cjj as to be tempted to appropriate to themselves articles of which they can not otherwise obtain possession4 ,such actions may easily go beyond the bounds of reason4 ,it must be remembered however1 that the collection mania itself is often so pronounced as to be a little beyond the bounds of ordinary rationality4 ,other so-called monomaniacs have the same characteristic and are associated with related symptoms of mental disturbance4 ,pyromania is sometimes pleaded as a defense for arson4 ,it is a legitimate defense1 however1 only when the careful tracing of the patient's history beforehand shows the existence of other symptoms of mental unbalance4 ,the homicidal mania is of the same order4 ,there have been cases where men seem to have delighted in inflicting injuries or death upon fellow creatures from pure malice4 ,such cases as that of ,jack the ,ripper1 for instance1 are undoubtedly due to a special tendency to take life4 ,in these cases1 however1 associated symptoms are never lacking4 ,it is not improbable that in ,jack the ,ripper's case a sexual element was present1 because the victims were always of one low class1 and that the general character of the murderer would have revealed his irresponsibility4 ,there are several stories of children--whose mothers delighted in seeing their husbands1 who were butchers1 slaughter animals--who seem to have had a veritable mania for seeing blood flow and to have exercised it in the murder of human beings4 ,only the most careful examinations of the previous life of the patient1 the investigation of childish tendencies and habits at school1 and the incidents of boyhood and youth will sometimes enable the expert to recognise the constant existence of symptoms of mental disequilibration1 the decided manifestation of which leads to serious events in after life4 ,monomania as a defense for crime has brought expert evidence into great disrepute4 ,in this matter the greatest care is undoubtedly needed1 however1 for it is easy to do great wrong and punish the irresponsible victim of an impulse over which he has no proper control4 ,on the other hand1 it must not be forgotten that no such thing is known to exist as the perversion of the will on a single point4 ,moral insanity with regard to one special set of actions is a delusion that the #cja increase of knowledge with regard to mental diseases has erased from the text books on this subject4 ,responsibility of ,paranoiacs4--,from what has been said it is easy to understand how difficult is the determination of the responsibility of paranoiacs4 ,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 rational1 though not tempted thereto by any benefit directly accruing to themselves4 ,on the contrary1 it not infrequently happens that the mode of life adopted by the paranoiacs is of such a kind as would of itself1 because of the hardships involved or the mental trials1 deter ordinary people from following it4 ,paranoia1 at least in its severer forms1 completely justifies the plea of irresponsibility for actions committed4 ,when it is remembered1 however1 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 punishment1 some idea of the difficulty of the decision in these cases may be appreciated4 ,it is important1 of course1 that the physician should1 as far as possible1 avoid falling into the error of judging such people too harshly1 since after all on him depends the attitude of society towards them4 ,it would seem to be quite as important that the clergyman should occupy an advanced position in this matter4 ,it might seem that charity could easily be overdone2 it must never be forgotten1 however1 that it is better that ninety-nine guilty should escape rather than that one innocent person should be punished4 ,as a matter of fact1 prejudice is much more likely to be against the supposed criminal than in his favour4 ,while it is often declared that too many persons1 who have done at least material wrong1 are allowed to escape deserved punishment1 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 responsibility4 ,responsibility is1 after all1 not the same in all men1 but modified very much by the character of the individual1 by his environment and by the #cjb motives which have come to be the well-springs of his actions4 ,no two men are equal in their responsibility when there is question of certain temptations to do wrong4 ,some men find it perfectly easy to resist allurements to dishonesty which others can not resist4 ,some men are perfectly free as regards their attitude towards indulgence in spirituous liquors4 ,others find it almost impossible to resist their cravings in this direction4 ,one might go through the list of passionate actions and find this true with regard to every one of them4 ,if this must be admitted with regard to men who are considered perfectly sane and responsible1 how much more so does it become true of those who are already somewhat mentally unbalanced8 ,unfortunately1 the tendency to judge harshly1 rather than mercifully1 still continues to be one main reason for the infliction of punishment where often it is not deserved4 ,above all the clergyman must be a leader in this tendency to mercy1 and his influence should be felt in popular education in this regard4 ,it only too often happens that clergymen are found to be strenuous upholders of the opinion that right is simply right and wrong1 wrong1 and that a man who knows the difference between right and wrong must be considered as responsible for his actions1 no matter what modifying circumstances or mental conditions may enter into the problem of the decision as to his responsibility4 ,if the clergyman would but realise how difficult in any individual case must be such a decision1 and how much must be known with regard to the previous character of the individual1 then a great beginning for the modification of the present over-severe modes of thought will have been made4 ,from a theoretic standpoint1 it would not be easy to state all that the physician considers necessary to enable him to make his decision as to individual responsibility4 ,perhaps1 however1 the consideration of a series of cases that have attracted widespread attention1 and which have been most carefully investigated in all their circumstances1 may present the methods of responsible determination better than any set of rules4 ,three presidents of the ,united ,states have been murdered within forty years4 ,the murderers were native-born #cjc ,americans4 ,in none of the three cases was there any adequate motive for the commission of the crime4 ,the assassin in ,president ,lincoln's case might1 it is true1 be presumed to have a sufficient political motive1 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 ,lincoln4 ,a man of known erratic tendency1 with the craving for theatrical effects deeply ingrained in his nature1 with a personal history not entirely free from even more serious manifestations of mental disequilibration1 and with a family history of more than suspicious character as regards the mental qualities of his ancestors1 committed the crime4 ,he met his death at the hands of pursuing soldiers4 ,such was the temper of the time1 that had he been captured alive he would surely have suffered the formal legal death penalty4 ,even as it was1 public sentiment clamoured for legal victims and unfortunately they were found4 ,it seems clear1 beyond all doubt1 that in this case complete responsibility for his action was not present in the assassin himself4 ,the courts decided later that there had been a conspiracy1 but there has always been the feeling that justice was misled by over-zeal to find scapegoats for injured public sentiment4 ,there is no doubt that it is an extremely difficult matter to say what shall be done to the assassin in such a case4 ,the unfortunate result is as much an accident as the fatal consequences of any other perverted natural force4 ,an earthquake may kill its thousands and the inevitable must simply be accepted4 ,society may protect itself from the further manifestations of such perverse individuals by confining the unfortunate murderer for life1 but capital punishment1 in the sense of a sanction for broken law1 can scarcely be considered to have a place in the given conditions4 ,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 senses4 ,once more a victim had to be found to satisfy injured public feeling4 ,guiteau was condemned to death and suffered the death penalty4 ,any one who reads the proceedings of the trial and who realises the significance of the motive that ,guiteau #cjd himself gave for his act1 will appreciate that the court had to do with an irresponsible doer of a material but not a moral wrong4 ,there were many signs of mental disequilibration in ,guiteau's previous career4 ,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 individual4 ,it may seem that many real criminals can be defended on this same principle of finding an inadequate motive for their crimes4 ,there are1 however1 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 responsibility4 ,with regard to the third murderer of a ,president the case is clear4 ,he was an ignorant1 somewhat conceited individual1 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 responsibility4 ,he was not entirely without a motive1 which in the mind of a brooding1 conceited individual1 might seem to be adequate for the commission of the crime4 ,his sentence of the death penalty was then in accord with the judgment of the best mental experts4 ,how society shall protect itself1 and especially its high officials1 against such notoriety seekers is hard to say4 ,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 man1 his heredity and environment1 as well as his previous actions at various times in life when under the stress of emotion4 ,it may be considered that such a weighing of circumstances will serve to excuse many genuine criminals who eminently deserve to be punished4 ,this is1 however1 the assumption of the older generation who considered that if a man did a material wrong he must be punished for it4 ,it is a heritage of the day1 when even accidental killing was considered to demand some punishment4 ,at the present time the tendency is rather to consider only the moral wrong1 that is1 to calculate responsibility only for such actions as are committed with due #cje deliberation1 intention1 and the knowledge of right and wrong as well as the freedom to perform the action4 ,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 wrong1 but that he must also realise that he is free not to do that which he knows to be wrong4 ,that is to say1 if he feels himself compelled to the commission of crime1 there is surely an impairment of responsibility4 ,such impulses to do wrong without adequate motive occur not infrequently among those whose mental condition is not perfectly normal1 and this must always be taken into consideration in the ultimate decision as to their responsibility for their action4 ,,james ,j4 ,,walsh4 #cjf ,,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 unimpaired1 yet in most of the cases a knowledge of all the circumstances and of the individual himself would lead inevitably to this more charitable view4 ,most suicides are persons that have been recognised as paranoiacs and likely to do queer things for a long time beforehand4 ,indeed1 some of the melancholic qualities on which the unfortunate impulse to self-murder depends are likely to have exhibited themselves in former generations4 ,not long since it was argued that the regular occurrence of a certain number of suicides every year--varying in various places1 always on the increase1 but evidently showing a definite relationship to certain local conditions --demonstrate that the human will is not free1 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 year4 ,as a matter of fact1 suicides are not in possession of free will as a rule1 but are the victims of circumstances and are unable to resist external influences4 ,the most important feature of suicide in recent years is the constant increase in the number1 the increase affecting disproportionately young adults4 ,this increase in the number of suicides is no illusion2 it is not due to more careful statistics4 ,it is true that in recent years1 that is to say during the last quarter of a century particularly1 the unsparing investigation by the authorities of all cases of suspicious death1 and their report by sensational newspapers1 has added somewhat to the apparent number of suicides4 #cjg ,families were accustomed to announce accidental death and have their story unquestioned1 in a certain number of cases1 where now there is no hope of concealment because of the unfortunate publicity that has crept into life4 ,this increase1 however1 would account for only a small additional number of suicides1 while the actual figures have more than trebled in the last thirty years4 ,this increase has come especially in the large cities4 ,according to the report of the ,new ,york ,board of ,health1 there were #a1cjh suicides in ,new ,york ,city during the decade from #ahgj to #ahhj4 ,during the decade from #ahij to #aijj there were #c1idd suicides4 ,this increase is much more than the corresponding increase in population4 ,during the first decade mentioned there were #abd suicides per million of population4 ,during the last decade this had risen to #aif suicides per million4 ,the increase is nearly #fj per centum4 ,the increase is variously distributed over the different ages4 ,while every five years from twenty upwards shows a percentage of increase in the number of suicides committed1 somewhat less than the percentage of increase for all ages1 the five years between fifteen and twenty shows an increase of #ajf per centum4 ,in a word the deaths of adolescents from suicide have more than doubled in the last thirty years4 ,towards the end of the last decade of the nineteenth century there was for a time a cessation of the continuous increase4 ,this occurred during the years #ahih and #ahii4 ,apparently it was due to the fact that the occupation of the country with other interests1 the war and its problems1 and the fact that an era of prosperity made material conditions better1 and thus gave less occasion for depression of spirits4 ,during the years since #aijj1 however1 the increase has not only reasserted itself1 but has more than made up for the period during which suicides were less frequent4 ,the increase during the last four years is more than was noted during the six years from #ahia to #ahig4 ,the same increase has been noted in ,european cities4 ,the higher the scale of civilisation in a city1 or at least the greater the material progress and the more strenuous the life1 #cjh the higher the death rate4 ,in ,dresden1 for instance1 the rate is #ea suicides per #ajj1jjj every year4 ,in ,paris it is #db1 in ,berlin it is #cf2 while in ,lisbon and ,madrid it is lowest1 being only respectively two and three per #ajj1jjj per year4 ,while suicides are more common among men than women in all countries1 this is not true for certain ages4 ,between the ages of fifteen and twenty-five the suicides of women are more numerous than those of men4 ,the suicides of women are increasing faster than those of men4 ,fifty years ago the proportion was five to one4 ,twenty years ago it had fallen from three to one4 ,now it is less than two and a half to one4 ,the saddest feature of the suicide situation is the increasing number of the children who commit suicide4 ,almost needless to say1 children's suicides are without any serious motives and are usually due to an attack of pique because of a slight from a playmate1 a reprimand at home1 a rebuke from a teacher1 envy of the success of a companion1 disappointment over a passing love affair1 sometimes a peculiar attachment in the case of weak and morbid individuals1 the manifestations of which are resented by its object1 or are forbidden by parents and guardians4 ,these unfortunate accidents have become so common now that special care must be taken with regard to children of neurotic heredity4 ,when in previous generations there have been the manifestations of lack of mental equilibrium1 then children's mutterings with regard to possible recourse to suicide should be the signal for the exercise of close surveillance4 ,as far as possible such children should be kept from the strenuous competition at school in modern life4 ,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 suicide4 ,dymond1 an authority in the matter1 says1 ,the power of the example of the suicide is much greater than has been thought4 ,every act of suicide tacitly conveys the sanction of one more judgment in its favour4 ,frequency of repetition diminishes the sensation of abhorrence and makes succeeding sufferers1 even of less degree1 resort to it with less reluctance4 #cji ,our modern newspapers1 by supplying all the details of every suicide that occurs1 especially if it presents any criminally interesting features or morbidly sentimental accessories1 familiarise the mind1 particularly of the impressionable young1 with the idea of suicide4 ,when troubles come lack of experience in life makes the youthful mind forecast a future of hopeless suffering4 ,love episodes are responsible for most of the suicides in the young1 while sickness and physical ills are the causes in the old4 ,in a certain number of cases1 however1 domestic quarrels1 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 restriction1 are apt to be followed in the morbidly unstable by thoughts of suicide4 ,the important practical question is the prevention of the fulfilment of the morbid impulse during these impressionable years4 ,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 lifetime4 ,as a rule the motive for the act is so trivial and often so insensate that it is not difficult to make patients 7because patients they truly are7 see the folly of their irrational impulse4 ,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 occurrence4 ,there are usually some signs beforehand of the possibility of the crime4 ,many of these early suicides have distinct tendencies to and stigmata of hebephrenic melancholia4 ,the best known symptoms of this condition are those described by ,dr4 ,peterson1 the present president of ,state ,commission of ,lunacy of ,new ,york in his book on mental diseases4 ,the symptoms noted are extraordinarily rapid and paradoxical changes of disposition4 ,depressed ideas intrude themselves in the midst of boisterous gaiety1 and untimely jocularity in the deepest depression1 or at solemn moments4 ,then there is the paradoxical facial expression1 the so-called paramimia1 that is1 a look of joy and pleasure when really mental depression is present1 or a look of depression when joyful sentiments #caj are being expressed4 ,the existence of such rather noticeable peculiarities may lead to the suspicion of mental disequilibration in young people4 ,the most important warning may well be the occurrence of suicide in any other member of the family for several generations before4 ,the tendency of suicide to repeat itself in families is now well known and recognised4 ,during the year #aija in ,new ,york ,city1 in one case other members of the immediate family had committed suicide in six instances4 ,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 life4 ,in another case1 reported within the last five years1 the suicide was the last of a family of nine children1 every one of whom had committed suicide4 ,there is the record in the ,german army of four generations of a noble family1 the eldest son of which committed suicide during the #e years from #ej to #ee4 ,in these cases the tendency to suicide is not directly inherited1 but there is a mental weakness that makes the individual incapable of withstanding the sufferings life may entail4 ,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 commission4 ,in such families1 therefore1 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-murder4 ,,james ,j4 ,,walsh4 #caa ,,xxviii ,,venereal ,,diseases ,,and ,,marriage ,syphilis is a disease that is contagious1 inoculable1 and transmissible by heredity4 ,it may be acquired innocently1 and it is so acquired in about #d per centum of cases according to good authority1 but the other #if per centum is venereal4 ,the disease attacks any part of the body within and without from the soles of the feet to the hair and finger-nails4 ,the first evidence1 where the case is not hereditary1 is a hardened sore called a chancre2 next the lymphatic glands swell1 and many forms of skin-eruption occur2 then follows a chronic inflammation of the cellulo-vascular tissues and the bones1 and small tumours1 called gummata1 may develop in almost any part of the body4 ,the disease may vary from a light attack to malignancy4 ,there are periods in the course of the disease4 #a4 ,the period of primary incubation1 or the time from infection to the appearance of the chancre4 ,this is commonly three weeks4 #b4 ,the primary stage3 the chancre forms and the neighbouring glands are affected4 ,this stage lasts from three to ten days4 #c4 ,the secondary incubation1 or the time between the appearance of the chancre and the development of what are called the secondary symptoms1--usually about six months4 #d4 ,the secondary stage4 ,here occur fever1 anaemia1 neuralgic pains1 and the eruptions on the skin and the mucous membranes4 ,this period lasts from twelve to eighteen months in the majority of cases4 #e4 ,the intermediate period4 ,during this time there may be no symptom1 or slighter recurrence of the secondary #cab symptoms4 ,this period lasts from two to four years4 ,it may end in recovery of health or be followed by tertiary symptoms4 #f4 ,the tertiary stage4 ,in this period gummata form1 or there may be diffuse infiltration of various parts of the body1 chronic inflammation and ulceration of the bones1 skin and other tissues1 nervous diseases1 and so on4 ,the tertiary stage commonly begins from three to four years after the primary infection4 ,the three chief divisions1 which are apt to blend one into the other1 are the primary1 secondary1 and tertiary periods4 ,the affections of the secondary stage are often severe4 ,there may be fever associated with weakness1 headache1 general malaise and pain1 and this may be marked or rather light4 ,in this stage iritis is liable to occur1 and if it is not properly diagnosed and treated it will result in blindness4 ,the lesions of the tertiary stage may cause great destruction of tissues and very grave consequences4 ,cerebral syphilis1 if unchecked1 will inevitably cause paralysis or paresis4 ,there may be loss of speech1 epilepsy1 coma1 paralyses1 apoplectic hemiplegia1 and so on4 ,the pain is harassing and often it amounts to great anguish4 ,whatever part of the brain substance is destroyed will not be restored4 ,in syphilitic affections of the spinal cord1 if the inflammation is acute death ensues in a few days or weeks4 ,tabes dorsalis1 or locomotor ataxia1 is caused in about #ic per centum of cases of this disease by syphilis1 and it is an incurable and dreadful malady4 ,if there is neuritis from the virus it becomes intense and causes muscular contractions1 paresis1 and paralysis4 ,the optic1 auditory1 and olfactory nerves may be attacked and destroyed4 ,the nose also may be destroyed and it commonly caves in4 ,the bones of the face are frequently attacked in the tertiary stage and they rot away4 ,the tibia is diseased more frequently than the other long bones4 ,the heart is rarely injured1 but when it is1 the prognosis usually is bad4 ,in a large number of cases death is sudden and unexpected4 ,if the arteries are involved the prognosis again is bad1 because the symptoms here do not show until #cac too late for effective treatment ,when the liver is the seat of gummata these may be cured in the early stage1 but in the later stage the prognosis is unfavourable4 ,some forms of renal syphilis are remediable1 but others are not1 especially the interstitial kind4 ,syphilis is transmitted to a child congenitally1 not as a tendency or predisposition1 but as an active contagion4 ,it may come from the father1 the mother1 from both parents1 or by direct infection4 ,the transmission from the father is the most frequent4 ,the spermatozoa carry the infection to the maternal ovum4 ,down to the end of the secondary stage1 and half through the intermediate period between the secondary and tertiary stages of syphilis1 a father or mother may beget a child that will be infected with hereditary syphilis1 a shivering1 blasted1 rotten little wretch for whom a quick death is the greatest imaginable blessing1 and it usually gets this blessing4 ,in the acute stage of a virulent syphilis the disease is most likely to be transmitted2 but sometimes1 though rarely1 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 disease4 ,infection by the mother is more certain and more harmful than that from the father1 because the intrauterine life of the child is poisoned throughout its course4 ,two-thirds of the cases of hereditary syphilis die either by abortion1 or if they live to term they die shortly after delivery4 ,if the mother is infected during the first eight months of pregnancy the child will nearly always be syphilitic1 but if she is infected after the eighth month the child may escape4 ,if at the moment of conception both parents have the disease the child will almost certainly take it1 and this infection will cause its death4 ,in a series observed by ,fournier1 #bh per centum of the cases caused by paternal infections died and #cg per centum showed the luetic taint2 in the cases caused by maternal infection #fj per centum died1 and #hd per centum had syphilitic lesions2 in the mixed heredity1 that is when both the father and mother were luetic1 #fh4e per centum died and #ib per centum were born syphilitic4 ,when a child #cad is first infected at delivery the case is not technically classed as hereditary syphilis4 ,during the first year after the father or mother has taken syphilis the probability of infecting the child is the greatest4 ,in the third year the liability of infecting the child is lessened1 but present4 ,in a series of #efb cases of hereditary syphilis observed by ,fournier1 #fj children1 over #aj per centum1 were infected more than six years after the primary parental infection4 ,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 lesion4 ,fournier reports the case of one woman that had nineteen consecutive stillbirths from syphilis4 ,mild parental syphilis may transmit hereditarily the most malignant type of the disease1 and very virulent parental infection may result in a comparatively mild infection of the child1 if any infection by syphilis may be called mild4 ,that the parent shows no symptoms from an old infection is no proof that he or she is cured1 or that the child may not be infected4 ,with proper treatment of the mother the infantile mortality in hereditary syphilis is reduced from #ei per centum to #c per centum1 and the children that are born living are not unfrequently free from syphilis4 ,when a woman is infected at the conception of her child miscarriage takes place before the child is viable1 from the first to the sixth month2 later other miscarriages occur2 later still1 living but syphilitic children are born1 of whom one-fourth die within the first six months2 finally she may have children that are not infected4 ,if a syphilitic man has been properly treated he may1 after four years1 beget healthy children1 and he commonly does1 but he may be the father of syphilitic children4 ,syphilitic women properly treated may1 after about six years from infection1 bring forth healthy children1 and they commonly do1 but not always4 ,there is a wide diversity of opinion among the best authorities concerning the curability of syphilis4 ,gowers 7,syphilis and the ,nervous ,system4 #ahib7 says3 ,there is no evidence that the disease ever is or ever has been cured1 the #cae word 'disease' being here used to designate that which causes the various manifestations of the malady4 ,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 disease4 ,fournier requires1 as the minimum time1 four years of methodical treatment before he deems the patient safe1 but even this arbitrary fixing of the number of years is not warranted by experience4 ,many physicians hold that in the tertiary stage the disease is not transmissible1 but that statement is not true4 ,commonly it is1 sometimes it is not4 ,after all symptoms have disappeared the disease has been transmitted4 ,in short1 a person that wittingly marries any one who has had syphilis at any time is a fool2 and if one of the contracting parties has had syphilis within the four years preceding the marriage the marriage is criminal1 even if the syphilis has been carefully and skilfully treated by a physician4 ,gonorrhoea is always a dangerous disease4 ,in the male1 beside the acute lesions1 it can cause chronic or fatal inflammations along the various parts of the genito-urinary tract or in different organs of the body4 ,when the disease becomes chronic it lasts indefinitely4 ,it may then cause cystitis1 or so affect the kidneys as to bring about very grave results2 it may get into the circulation and induce gonorrhoeal rheumatism of the joints1 especially of the knee joint1 and result in a partly or completely stiffened joint4 ,the heart may be affected and endocarditis ensue2 there may be meningitis or inflammation of the cerebral membranes2 the eye may be infected1 and unless it is skilfully treated blindness will follow4 ,strictures of the male urethra from chronic gonorrhoeal inflammation often require major surgical operations for relief4 ,the disease in women has most of these complications1 and other grave peculiar phases4 ,all prostitutes have acute or chronic gonorrhoea1 and #ab per centum1 probably more1 of reputable women are infected2 and the suffering caused is very great4 ,the gonococcus remains virulent for two or three years at the least in a man's chronic gleet1 and if he marries he infects his wife4 ,should her womb be infected #caf she is seldom completely cured4 ,if the ,fallopian tubes are involved1 and this happens frequently1 they suppurate1 and often they must be removed by coeliotomy4 ,the woman suffers for a long time when the tubes are attacked by the disease1 and she becomes sterile ordinarily4 ,when a child is born to a woman that has gonorrhoea its eyes are infected at delivery1 and if it is not very skilfully treated it will surely lose its sight4 ,because of this danger1 in maternity hospitals the eyes of all babies are treated at delivery as a precaution1 and many physicians observe the same precaution in private practice4 ,when1 therefore1 a man has chronic gonorrhoea he should not marry until about four years after the last infection1 and he should be carefully treated in the meantime4 ,there is a popular opinion that gonorrhoea is a trifling disease1 but the contrary is the truth3 it is a grave disease1 especially in women2 and the person that carelessly infects another is certainly guilty of crime for which a long term in jail would be a light punishment4 ,,austin ,,omalley4 #cag ,,xxix ,,social ,,diseases ,there are certain affections not at all uncommon and as a rule producing rather serious effects upon the social body1 of which1 though their existence is well known to all1 very little is said4 ,it is certain that what is considered the more severe of these venereal diseases may be acquired quite innocently4 ,indeed1 many thousands of cases of this affection1 acquired innocently1 have now been reported by medical men in this country alone4 ,if the statistics of all the world were gathered together1 there would probably be a hundred thousand cases of this dreadful affection1 which have been acquired without any blame on the part of the sufferer4 ,it has become the custom1 especially in ,english speaking countries1 to ignore the presence of these diseases1 and this has led to a multiplication of opportunities for their spread to such a degree that now the condition of affairs1 for those who know it best1 is rather alarming4 ,it is with the intention that a few definite ideas1 given absolutely without exaggeration and without any striving after effect1 may enlist clergymen1 as well as physicians1 in a crusade against these diseases1 that the present chapter is written4 ,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 cities4 ,the young man just freed from the restraints of home life1 or of the seclusion of a college1 is at once without any preliminary training1 exposed to all the dangers1 moral and physical1 of large city life4 ,not only is this true1 but he is even not properly warned of the dangers that lie so close to his path4 ,our prudery has gone so far that the very names of these #cah affections are tabooed and above all must not be mentioned before the young4 ,as to the awful evils that such diseases may cause1 as to the lifelong suffering1 even to mental degeneration and early death1 that they may involve1 not even a hint is considered to be proper4 ,the consequence is that young men expose themselves not infrequently to danger1 absolutely unknowing the significance that such diseases have in recent years acquired in the minds of modern physicians1 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 before4 ,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 diseases4 ,the students are told very frankly what the possibilities of danger for them in certain excesses may be1 so that at least the young man can not say ,i knew nothing about it1 when the risk becomes an actual reality of danger4 ,at the ,university of ,berlin the first course of such lectures was established1 and the interest aroused and the results obtained were such as to make other universities consider the advisability of such lectures for their students4 ,even here in prim and prude ,america1 one or two of the great universities have come to the realisation that the physical well being of their students is committed to their care1 as well as their intellectual development1 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 faculty4 ,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 slight1 perhaps4 ,as a matter of fact1 nothing can be more helpful from the ethical standpoint than this knowledge of how closely may follow the wages of sin1 which is death4 ,it is for this reason that clergymen would seem to owe it1 as a duty to themselves and their position in social #cai life1 to acquire a certain knowledge of these affections4 ,a very great change has come over the attitude of the medical profession towards the so-called venereal diseases in recent years4 ,a quarter of a century ago they were considered to be not very serious after all1 and indeed in some cases to be no more serious than a cold1 a mere passing incident in life4 ,now it is well recognised that almost never do they leave their victim in the state of health in which he was before1 and that unfortunately the deterioration of tissues which has taken place is likely to be enduring4 ,even many years afterwards there may be serious complications involving health or even life4 ,for instance1 it is now very generally conceded that paresis1 or what is sometimes called general paralysis of the insane1--a progressive mental and nervous disease1 which invariably ends fatally in from three to seven years1--is always due to one of the so-called social or venereal diseases4 ,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 paresis4 ,in this country the disease is not so frequent1 the proportion being less than one in five or even one in six4 ,the disease is becoming more and more common1 however1 as large city life becomes more prominent1 and as the possibility of infection with social diseases is more widespread4 ,paresis is what is sometimes called softening of the brain1 and it attacks by preference men under thirty-five4 ,the first symptoms of it as a rule are not alarming4 ,a young man's disposition changes1 so that an individual heretofore rather stingy becomes extravagant1 while occasionally a prodigal becomes very saving and considers that he has already a large sum of money to his credit4 ,the most prominent feature of the early stage of the disease is the occurrence of delusions of grandeur1 that is to say1 the patients get the idea that they are important personages1 or that they have fallen heirs to a large sum of money1 or that they have been appointed to high salaried positions4 ,as a consequence of these delusions1 they may make expensive presents to their friends4 ,occasionally there are other changes in disposition4 ,a young #cbj man1 for instance1 who has been of genial character becomes morose and hard to live with4 ,the opposite change to greater liveliness of disposition is not unknown1 but is more infrequent4 ,sometimes there are marked excesses1 high living1 luxurious habits1 and the like1 before the existence of disease is recognised4 ,the mental stigmata of the disease at the beginning are not alarming at all4 ,there are slight lapses of memory4 ,a man who has hitherto been known as an accurate mathematician1 makes frequent mistakes in adding or multiplying4 ,the physical signs are even slighter4 ,in using long words1 syllables are omitted from them4 ,a favourite method of testing the speech of a person suspected of beginning paresis is to ask for the pronunciation of a word like ,constantinople4 ,usually a syllable will be elided1 and the reply will be ,constanople1 or something similar4 ,there is a slight tremulousness of the hands and usually a rather easily marked tremor of the lips1 especially when the tongue is protruded4 ,often in the very earliest stage of the disease1 there are changes in the pupils4 ,they may be unequal1 or may fail entirely to react to light4 ,when these signs are positive1 that is1 when there is a change in disposition and then the physical stigmata that we have gone over appear1 the diagnosis of the disease is almost certain4 ,the physician is able to say1 with considerable assurance1 that the young1 strong1 healthy-looking patient1 who has often had to be tempted to come to see the doctor by some specious reason1 because he does not consider himself that he has anything wrong with him1 will have to be confined in an asylum within a year1 or at most1 two1 and will die in a state of dementia within five years4 ,this1 of course1 is an awful picture4 ,this is the course of the disease in nearly #bj per centum of the inmates of our asylums4 ,almost without exception there is a history of syphilis in these cases1 and the medical world is now persuaded that this is the most important factor in the production of paresis4 ,another nervous disease1 corresponding in some of its features to paresis and indeed sometimes spoken of as a spinal form of paresis1 is locomotor ataxia4 ,this affection #cba 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 time4 ,before this there may have been some disturbance of vision4 ,the pupils may fail to react to light4 ,occasionally the first symptoms are motor1 that is1 the man notices that he is not able to walk as readily as before4 ,he staggers easily4 ,if he tries to turn round while walking he is apt to lose his balance4 ,if he tries to walk in the dark1 he is almost sure to have so great a sense of insecurity that he dare not go far from the wall4 ,occasionally the first sign is a sinking of the limbs on the way down stairs4 ,in certain very sad cases1 the first and only symptom is a failure of sight which goes on progressively1 until the optic nerve is completely destroyed and sight forever rendered impossible4 ,all these symptoms are traceable directly to certain changes which have been noted in the spinal cord4 ,these changes are due to disturbance of the blood and lymph supply of the nervous tissue4 ,once the changes have taken place1 there is no hope of the patient ever recovering the normal use of his limbs4 ,not infrequently he becomes bedridden and can not walk at all because he is not able to steady himself4 ,he may not suffer in his general health1 however1 to any serious extent1 and may live on for twenty years1 though usually his resistive vitality is lowered and he is carried off by some intercurrent disease4 ,at times locomotor ataxia begins with very severe pain seizures1 known as crises4 ,these may occur in the legs or arms or in the stomach or sometimes in other organs4 ,occasionally they are the first symptoms of the disease that are noticed1 and they may continue for months or even years before other symptoms manifest themselves4 ,this sometimes makes it difficult to recognise the disease for what it really is4 ,the pains are usually most excruciating1 are tearing or boring in character1 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 them1 or if a knife were inserted and then twisted round4 ,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 character4 #cbb ,most of the ordinary anodyne or pain-killing medicines fall to influence them1 and the patient is one of the most pitiable of objects while they last4 ,it is now conceded on all sides that at least #ge per centum of the cases of tabes are directly due to syphilis4 ,indeed this affection and paresis are sometimes spoken of as parasyphilitic affections4 ,unfortunately the ordinary treatment for syphilitic manifestations does not affect them in the least4 ,so far as we know at the present time1 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 diseases4 ,they are much more common in ,europe than they are in this country1 but have been seen here with quite sufficient frequency in recent years to make physicians1 at least1 realise the necessity for having young men appreciate the dangers they invite in thoughtlessly yielding to the temptations of great city life4 ,there are other affections which can be traced directly to the social diseases4 ,one of the most important of these consists of certain brain tumours which may even cause death if not properly treated4 ,these syphilitic brain tumours frequently cause paralysis and may lead to permanent changes in the nervous system with consequent loss of motor power4 ,whenever the symptoms of brain tumour occur1 careful inquiry is made as to the previous existence of syphilis in the case1 in order to determine1 if possible1 if this is the morbid agent at work4 ,if there is a history of syphilis it is usually said to be fortunate1 for brain tumours due to syphilis may be made to disappear by the proper use of mercury and the iodides4 ,if the treatment of the case is delayed1 however1 alterations in the nerve substance take place which can not be improved4 ,this disease affects especially the blood vessels and1 as a consequence of the thickening of the coats of the arteries1 blood may be shut off from certain portions of the brain entirely4 ,this will1 of course1 produce symptoms of paralysis4 ,indeed1 whenever paralytic symptoms manifest themselves under forty years of age1 the physician's first thought is sure to be that there is syphilis in the case4 ,this is not always #cbc true1 for by heredity and very hard work occasionally arteries become so degenerate that they rupture before a patient has reached many years beyond forty1 but the case is always suspicious4 ,in this1 as in the corresponding instance of brain tumour1 treatment1 if applied sufficiently early1 may not only give relief of all the symptoms1 but produce a complete cure4 ,that is1 at least the symptoms are relieved for the time1 though there may be relapses4 ,usually these relapses are quite amenable to treatment1 but sometimes they get beyond the control of the physician and death ensues4 ,it is almost the rule where there have been serious nervous symptoms once1 that recurrences of them must be feared1 and they will eventually shorten the patient's life4 ,syphilitic manifestations of serious character develop1 however1 not only in the nervous system1 but also in certain of the important internal organs4 ,the liver may become so much affected as to refuse to do its work4 ,solid tumours may develop in the stomach1 or along the course of the intestines1 resembling cancer so much that occasionally operations are performed for their removal4 ,as a rule1 however1 these yield quite promptly to proper antisyphilitic treatment4 ,whenever an obscure intraabdominal tumour is present1 accordingly1 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 tried4 ,the surprises of such treatment constitute a very interesting chapter in obscure diseases in medicine4 ,as we said at the beginning1 it is perfectly possible to have contracted the disease innocently1 and indeed1 the first manifestations may be so mild as to fail to attract the patient's attention4 ,in these cases there will be no history of syphilis1 yet the test of antisyphilitic treatment will demonstrate that the disease has been present4 ,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 work4 ,some of these cases in young men prove to be especially malignant and fail to react to treatment1 so that a fatal issue takes place within a few years4 #cbd ,on the other hand1 in general it may be said that the disease is eminently curable1 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 life4 ,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 system4 ,hence it is that paresis and locomotor ataxia are comparatively quite common among actors1 brokers1 and financiers4 ,they are also quite common among sea captains and military men who are exposed to severe hardships and have to assume weighty responsibilities4 ,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 responsibilities4 ,these diseases are very uncommon among clergymen and are less common in ,ireland than in any other country in the world1 which would serve to confirm the opinion that the venereal disease is a prominent factor in their causation4 ,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 described4 ,there are many thousands of cases of syphilis that never have any of these serious manifestations at all4 ,it is evident that some cases are completely cured and that no deleterious influence remains4 ,on the other hand1 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 time4 ,the children may suffer from the skin lesions of syphilis in their early life1 may suffer from serious eye diseases a little later1 and then eventually succumb to nervous and mental diseases resembling paresis and locomotor ataxia in early adult life4 ,in fact it is this transmission of the disease that constitutes one of its saddest pictures1 and the sins of the parents are indeed visited on the children4 ,besides this severer type of social disease1 there is what has been called sometimes a milder form4 ,it consists only of a discharge with some fever1 which is considered to last not more than a few weeks4 ,as a matter of fact1 however1 the disease may continue to exist1 though the symptoms become latent #cbe and the patient may infect others when he least suspects it4 ,this form of disease gives rise to many sad complications in family life4 ,practically all the severe eye diseases of newly born children1 the ophthalmia from which so many eyes are lost1 is due to this disease4 ,special medical care is now taken of these cases1 and the serious consequences are not so often seen as used to be the case4 ,within a score of years1 however1 about one-half of the inmates of blind asylums owed their loss of sight to this disease4 ,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 disease4 ,most of the sterility in families is due to the same cause4 ,there is an unfortunate impression that usually the woman is responsible in these cases1 and not a little sympathy is wasted on the man1 because of the absence of children in the family4 ,almost invariably1 however1 the real cause of the family misfortune is to be traced to an infectious disease in the man contracted perhaps many years before1 of whose presence he may be more or less unconscious1 the symptoms have become so slight1 but this has proved sufficient to infect the wife and bring about serious changes that preclude all possibility of the procreation of children4 ,these statements may seem exaggerated4 ,on the contrary1 they are rather understatements of actualities4 ,no one who knows the real state of the case will fail to realise this4 ,physicians themselves have only come properly to appreciate the true state of affairs in the last twenty years4 ,we need a coordination of all the forces that make for social amelioration in modern life to correct present false impressions4 ,,james ,j4 ,,walsh4 #cbf ,,xxx ,,de ,,impedimento ,,matrimonii ,,dirimente ,,impotentia ,hoc argumentum praecipue ad juris consultos ecclesiasticos et civiles pertinet2 et quamvis differentia sit inter jurisdictionem judicis civilis et ecclesiastici tamen judicium utriusque quatenus necessario pendet ab existentia conditionum physicalium in medici consilio situm est4 ,obscuritas doctrinae et quidem gravis de hoc impedimento1 libris moralistarum1 medicorum et juris consultorum perlectis1 invenitur2 et quamvis1 elapsis perpaucis annis1 fere omnis liber tractans de scientia medicinali parva fide dignus1 tamen multa ex editis physiologorum veterum tanquam vera a moralistis praesertim promulgantur4 ,hae difficultates per ignorantiam anatomiae et physiologiae genitalium non minuuntur4 ,ut auxilium1 si quid sit1 ad difficultates solvendas feram1 species et gradus ,impotentiae hie collegi tanquam medicus1 eo modo ut conditio physica clarius cognoscatur4 ,in unoquoque ,statuum ,foederatorum ,americae ,septentrionalis impotentia ratio sufficiens divortium obtenendi est1 in plurimis autem matrimonium irritum ab initio non reddit4 ,impotentia vel temporanea causa divortii esse potest si impotens intra spatium temporis rationabile remedium medicinale recuset4 ,sub lege civili ,americana contrahens qui tempore matrimonii ineundi certior erat de impotentia consortis jus divortii petendi propter abnormalitatem istam amittit4 ,procrastinatio longa et inexplicabilis divortii petendi1 et etiam inscitia culpabilis impotentiae consortis divortium impossibile coram judice civili reddunt4 ,conditio haec etiam impedimentum dirimens matrimonii sub lege canonica ,ecclesiae est4 ,si impotentia contractum matrimonii anteat et perpetua sit1 matrimonii contractus #cbg solvitur ipso facto1 quandocumque detegitur4 ,procrastinatio aut ignorantia culpabilis non excusant4 ,jurgia oriuntur ex eo quod impotentia cum sterilitate saepius confunditur4 ,juris consulti civiles infrequenter hoc modo offendunt1 medici autem et moralistae crebro in errore isto versantur4 ,juris consulti ,americani et medici de impotentia doctrinam accipiunt librorum praesertim ,on ,domestic ,relations1 auctore ,irving ,browne 7,boston4 #ahij71 ,a ,system of ,legal ,medicine1 auctore ,allen ,mac,lean ,hamilton 7,neo-,eboraci1 #ahig71 et ,a ,manual of ,medical ,jurisprudence1 auctore ,a4 ,s4 ,taylor 7,neo-,eboraci1 #ahig74 ,irving ,browne 7op4 cit47 ait3 ,ubi ,impotentia adsit nullum habetur matrimonium validum4 ,impotentia autem incapacitatem prae se fert physiciam1 non meram frigitatem1 declinationem seu repugnantiam1 neque etiam recusationem absolutam coitus sexualis4 ,neque sterilitas nec malformatio quae copulam non impediant1 neque infirmatio quaecumque sanabilis incapacitatem gignunt4 ,impotentiam tempore ineundi matrimonii exstitisse necesse est4 ,eadem est doctrina ,schouleri et ,baldwinii4 ,white et ,martin1 medici1 7,genito-,urinary and ,venereal ,diseases4 ,philadelphiae4 #ahig47 impotentiam ita definiunt3 ,inabilitas actus sexualis perficiendi4 ,non necessario cum sterilitate consociatur1 neque necesse est quod sterilis impotens sit4 ,et ita alii omnes4 ,significatio vocis ,impotentiae sub lege canonica deducitur1 7#a71 ex dijudicationibus ,pontificum ,romanorum1 aut 7#b71 ex judiciis ,congregationis ,sancti ,officii1 tribunalis ad sententias hujus generis pronuntiandas instituti1 aut1 7#c71 ex legis interpretatione a moralistis scientia praeditis4 ,sixtus ,v1 ,pontifex ,romanus1 7,const4 ,cum frequenter1 anno #aehg7 decrevit eunuchos impotentes esse sensu legis canonicae de ,impotentia1 nullum autem judicium papale totam questionem conficit4 ,congregatio etiam ,sancti ,officii in perpaucis casibus particularibus dijudicavit sed legem nullomodo distincte definiebat4 ,norma igitur a nobis sequenda ex interpretatione moralistarum est depromenda4 #cbh ,lex non est decretum mere disciplinare3 e natura ipsa contractus matrimonialis desumitur4 ,ballerini 7,theol4 ,mor41 vol4 #f1 p4 #feh7 scribit matrimonium consistere in mutua traditione potestatis ad copulam conjugalem4 ,s4 ,thomas 7,supplem4 ,sum1 ,theol41 q4 #eh1 a4 #c7 ait3 ,in matrimonio est contractus quidam1 quo unus alteri obligatur ad debitum carnale solvendum3 unde sicut in aliis contractibus non est conveniens obligatio si aliquis se obliget ad hoc quod non potest dare vel facere1 ita non est conveniens matrimonii contractus1 si fiat ab aliquo qui debitum carnale solvere non possit2 et hoc impedimentum vocatur impotentia coeundi4 ,antequam explicationem a moralistis pleniorem vocum ,impotentia coeundi dabamus1 attendendum accurate est ad definitionem matrimonii finum a ,s4 ,alphonso ,liguorio 7,theol4 ,mor41 lib4 vi41 n4 #hhb7 datam4 ,fines1 inquit1 intrinseci essentiales sc4 matrimonii sunt duo3 traditio mutua cum obligatione reddendi debitum1 et vinculum indissolubile4 ,fines intrinseci accidentales pariter sunt duo3 procreatio prolis et remedium concupiscentiae4 ,fines autem accidentales extrinseci plurimi esse possunt1 ut pax concilianda1 voluptas captanda1 etc4 ,his positis1 certum est quod si quis excluderet duos fines intrinsecos accidentales1 non solum valide1 sed etiam licite posset quandoque contrahere2 prout si esset senex et nuberet sine spe procreandi prolem1 nec intenderet remedium concupiscentiae2 sufficit enim ut salventur fines substantiales1 ut supra4 ,haec sententia ,s4 ,alphonsi magni momenti est1 et in ea solutio multarum difficultatum inveniri potest4 ,dicit hic 7#a7 fines intrinsecos essentiales matrimonii esse traditionem mutuam cum obligatione reddendi debitum1 et vinculum indissolubile1 atque illis demptis nullum matrimonium2 7#b7 procreationem autem prolis et remedium concupiscentiae abesse posse1 et tamen matrimonium esse validum si duo fines essentiales adsint4 ,sanctus hoc loco infert1 ut patet e contextu alibi 7e4 g41 lib4 vi41 n4 #ajie1 res4 #b71 traditionem mutuam potestatis ad copulam carnalem necessario potentiam coeundi supponere1 potentiam autem generandi non esse necessariam nec remedium concupiscentiae4 ,in libro vi41 n4 #ajif1 ait3 ,impotentia est illa propter quam conjuges non possunt copulam habere per se aptam ad generationem2 unde sicut validum est matrimonium #cbi inter eos qui possunt copulari1 esto per accidens nequeunt generare1 puta quia steriles aut senes1 vel quia femina semen non retinet1 ita nullum est matrimonium inter eos qui nequeunt consummare eo actu1 quo ex se esset possibilis generatio4 ,distinctio haec inter potentiam coeundi et potentiam generandi a moralistis omnibus datur2 illa autem data1 plurimi distinctionem obliviscuntur et sterilitatem simplicem cum impotentia confundunt4 ,a4 ,konings1 ,c4,,ss4,r41 7,theol4 ,mor41 ed4 #g1 vol4 #b1 p4 #bgf7 haec habet3 ,impotentia est incapacitas ad copulam carnalem1 per se aptam ad generationem4 ,in n4 #afai1 ,sec4 #e1 ait3 ,non est confundenda impotentia coeundi cum impotentia generandi4 ,hinc steriles et senes qui matrimonium consummare valent1 valide contrahunt1 item mulieres quae possunt semen excipere1 etsi illud non retineant4 ,hanc doctrinam ,s4 ,alphonso refert 7,theol4 ,mor41 lib4 #d1 n4 #ajie1 ed4 ,mech4 #ahde71 et paragraphum hoc modo complet3 ,non tamen carentes utero vel vagina4 ,hoc est1 tenet mulierem utero et vagina carentem impotentem esse4 ,unusquisque carentiam vaginae impotentiam esse admittit2 mulier autem sine utero semen excipiendi capax est1 concupiscentiam quoque maris satiare potest4 ,sterilis tantum est4 ,potentiam etiam habet coeundi1 semen excipere potest et retinere1 concupiscentiam quoque satiare potest1 etiamsi uterus1 ovaria et tubi ,fallopiani absint4 ,praeterea1 illi duo fines intrinseci essentiales matrimonii existunt4 ,augustinus ,lehmkuhl1 ,s4,j41 7,theol4 ,mor471 alius illustris discipulus ,s4 ,alphonsi est ,impotentiam definit3 ,defectus propter quern conjuges non possunt copulam habere per se aptam ad generationem4 ,alibi 7,american ,ecclesiastical ,review1 vol4 #bh1 n4 #c71 de impotentia excisioneque ovariorum scribens1 ait3 ,puto1 questionem propositam1 utrum excisio ovariorum vel uteri constituat impedimentum dirimens necne1 theoretice nondum esse plane solutam4 ,existimat autem questionem practice solutam esse judiciis ,congregationis ,s4 ,officii1 d4 #c ,februarii1 #ahhg1 et d4 #cj ,julii1 #ahij1 editis1 matrimonium mulieris ovariis carentis et mulieris utero et ovariis carentis1 permittentibus4 ,etiamsi haec judicia non edarentur tanquam leges formaliter generales1 ,lehmkuhl opinatur in #ccj casibus ejusdem generis aptari posse4 ,re quidem vera illa doctrina sequi potest practice et theoretice2 nulla enim est quaestio seria de impotentia in muliere carente ovariis4 ,joseph ,antonelli tamen 7,de ,conceptu ,impotentiae et ,sterilitatis relate ad ,matrimonium1 ,romae1 #aijj7 tenet carentiam ovariorum esse impotentiam sub lege2 et ,casacca 7,amer4 ,eccl4 ,rev41 vol4 xxvii1 n4 #f1 et alibi7 eamdem opinionem sequitur4 ,e contra1 ,marc 7,inst4 ,mor4 ,alphon47 docet carentiam ovariorum uterique non esse impotentiam4 ,joseph ,hild 7,amer4 ,ecc4 ,rev4 vol4 xxviii41 n4 #f7 optime vindicat opinionem1 nempe1 carentiam ovariorum non esse impotentiam1 et in corpore tractatus citat definitiones impotentiae a moralistis egregiis prolatas4 ,schmalzgrueber 7,theol4 ,mor41 lib4 iv41 tit #ae1 n4 #ca7 dicit3 ,sola impotentia ad copulam dirimit matrimonium1 non vero impotentia ad generationem4 ,coninck 7,de ,sacr41 vol4 ii41 d4 #ca1 dub4 #g1 n4 #hf7 ita habet3 ,steriles 444 si aliter potentes sint ad usum matrimonii1 valide contrahunt2 quia nec generatio nec potestas generandi est de essentia matrimonii4 ,mastrius 7,dis4 de ,matr41 q4 v41 n4 #aad7 ait3 ,impotentia est inhabilitas perpetua ad consummandum matrimonium 4 4 4 non est ex eo praecise quod alteruter conjugum aut uterque sint steriles1 quia impotentia ad generandum seu ad prolificandum1 dummodo adsit potentia ad copulam carnalem et seminationem1 non est impedimentum dirimens1 ut omnes passim concedunt cum ,scoto 4 4 4 et ubi est certa impossibilitas ad bonum prolis1 tunc matrimonium est ibi in remedium1 non in officium4 ,vincentius de ,justis 7,de ,dispens4 ,matr4 lib4 ii1 c4 #ag1 nn4 #a1 #b1 #c7 scribit3 ,impotentia ad matrimonium est duplex4 ,prima1 quae sterilitas dicitur1 efficit ut proles generari non possit1 ex se tamen matrimonium nec impedit nec dirimit1 ut docent ,sanchez1 ,guttier1 ,coninck4 4 4 4 ,ratio est1 quia nec generatio1 nec generandi potestas sunt de essentia matrimonii4 ,s4 ,thomas 7,supplem1 q4 #eh1 a4 #a7 in articulo de ,impotentia1 quam ,frigiditatem et ,impotentiam ,coeundi nuncupat1 nihil de sterilitate scribit1 nec de impotentia generandi tanquam quid impotentiae coeundi oppositum4 #cca ,in omnibus hisce definitionibus verba de se1 ex se1 per se1 et alia similia1 adhibentur de copula carnali qua copula4 ,amort 7,de ,matr1 q4 #aja7 de his verbis loquens ait3 ,impotentia est inhabilitas corporalis ad copulam carnalem de se ad generationem prolis idoneam4--,dicitur3 de se2 potest enim contingere per accidens1 v4 g41 ob debilitatem spirituum seminalium in viro aut femina1 vel ob indispositionem matricis in muliere1 quod copula carnalis1 etiam perfecta1 hoc est1 per effusionem seminis in vagina mulieris completa1 non sit idonea ad generationem prolis4 ,loquuntur moralistae1 ut dixi1 de copula carnali quatenus copula est sine respectu ad possibilitatem generandi4 ,hisce omnibus positis1 rogamus3 7#a71 ,quid sit impotentia sub lege in muliere8 7#b71 ,estne mulier carens ovariis1 utero vel tubis ,fallopianis impotens8 7#c71 ,quid sit impotentia sub hac lege in viro8 7#d71 ,estne vir aspermatosus impotens1 et quid de viris semen sterile habentibus8 ,i4 ,impotentia ,mulieris4 ,mulieres steriles frequentius quam viris1 viri autem impotentes frequentius quam mulieres sunt4 ,impotentia absoluta et perpetua raro in mulieribus1 in viris crebro invenitur4 ,in fundo pelvis femineae septum est a latere in latus1 rectum inter et vesicam urinariam1 et in medio hujus partitionis uterus1 qui piroformis est1 quasi ad perpendiculum jacet et cervix sua in vaginam intrat4 ,a cornibus uteri1 i4e41 ab angulis superioribus1 tubi ,fallopiani procedunt ad libellam1 et apud terminos tuborum ovarium est in utroque latere4 ,tubi aperti sunt prope ovaria1 et non substantiae ovariorum continui4 ,si unum ovarium et tubus oppositi lateris demantur1 vel si tubus iste occludatur1 ovum ex ovario manente migrare per partem exteriorem uteri et foecundari potest4 ,genitalia externa mulieris e labiis majoribus praecipue constant2 intra et inter haec labia minora seu nymphae sunt4 ,intra labia minora ad summum versus clitoris est2 infra hanc est meatus urinarius2 infra meatum1 orificium vaginae4 ,per imam partem orificii in virginibus extenditur pellicula tenuis quae hymen vocatur4 ,haec communiter in coitu primo rumpitur4 #ccb ,tempore mensium praesertim ova egrediuntur ex ovariis in tubos ,fallopianos et inde in uterum4 ,si ova non foecundentur per vaginam amittuntur4 ,foecundatio in tube ,fallopiano fit4 ,in muliere impotentia temporanea aut perpetua oriri potest e causis sequentibus3 7#a71 propter hymenem imperforabilem aut cribriformem1 aut septatum aut annularem2 7#b71 propter vaginam duplicem2 7#c71 propter vaginismum aut dolorem2 7#d71 propter uterum prolapsum aut productionem cervicis uteri2 7#e71 propter atresiam vaginae aut labia adhaerentia2 7#f71 propter orificium vaginae in loco abnormali2 7#g71 propter arctationem vaginae2 7#h71 propter tumores aut incrementum morbidum intra vel circa genitalia2 7#i71 propter ,sadismum2 7#aj71 propter ,masochismum2 7#aa71 propter ,sodomiam gradus secundi seu defeminationem2 ,sodomiam gradus tertii2 ,sodomiam cum horrore2 ,urningismum2 ,androgyniam4 #a4 ,aliquando vice hymenis normalis invenitur membrana densa seu cartilaginosa1 aut membrana continua1 aut cribro similis1 aut tanquam septum1 aut annularis1 quae impediat intromissionem4 ,operatione simplici chirurgica conditio removetur4 #b4 ,raro septum adest quod vaginam in duas partes dividit et impotentiae causa est4 ,chirurgus septum removere potest4 #c4 ,vaginismus contractio spasmodica musculorum ad orificium vaginae est1 et haec vaginam claudit4 ,frequenter inter neuroses ideopathicas includitur1 scrutinium autem diligens locum inflammationis detegit qui origo est spasmi reflexi4 ,insolenter conditio ex hyperaesthesia murorum vaginalium inducitur4 ,medicatio vaginismi examen expertum supponit et quandoque scrutinium endoscopicum vesicae urinariae4 ,fissurae in ano1 endometritis chronica1 urethritis granosa circa cervicem vesicae urinariae1 causae principales sunt vaginismi1 et istae #ccc causae sanabiles sunt4 ,inflammatio acuta vulvae1 vaginae1 uteri1 tuborum aut ovariorum1 carunculae urethrales1 urethritis1 fissurae cervicis vesicae urinariae1 haemorrhoides1 fissurae recti1 coccygodinia1 ulcera uteri et amotio uteri vel ovariorum e loco debito1 possunt tantum dolorem in coitu infligere ut mulier practice impotens fiat4 ,morbi autem isti fere omnes medicabiles sunt1 sed tamen aliqui omnino pervicaces sunt4 ,in vaginismo hysterico et in aliis casibus insanabilibus intromissio fieri potest ope chloroformi ad evitandum divortium4 #d4 ,quando uterus prolabitur vel cervix producitur ita ut copula impossibilis sit1 chirurgus mederi potest4 #e4 ,atresia vaginae est occlusio vaginae in longum perfecta vel imperfecta4 ,nullum orificium invenitur4 ,congenita esse potest1 et tunc plerumque desunt omnia organa generativa4 ,atresia etiam consequitur vulnera et inflammationes morborum1 ut diphtheritis et scarlatina4 ,ubi atresia per totam vaginam extenditur nullum datur medicamentum1 et impotentia absoluta et perpetua adest4 ,labia adhaerentia separari possunt4 #f4 ,aliquando sed perraro vagina in rectum aperit4 ,possibilitas removendi impotentiam e loco orificii vaginae pendet4 #g4 ,arctatio vaginae oritur ex causis atresiae1 et remotio conditionis quum impotentia inducat impossibilis esse potest4 #h4 ,tumores pudendi1 vaginae et recti1 hypertrophia labiorum et clitoridis1 et elephantiasis labiorum copulam impedire possunt4 ,alii tumores et hypertrophiae removeri possunt1 alii autem insanabiles sunt4 #i4 ,dantur perversitates sexuales quae viros impotentes reddunt1 et haec aliquando in mulieribus inveniuntur4 ,tales sunt ,sadismus1 ,masochismus1 et gradus ,sodomiae praeter primum4 ,isti morbi animi causae sunt impotentiae in muliere propter aversionem ejus virorum etiamsi physice potens sit4 ,vix in matrimonium iniit talis mulier1 et igitur perversitates istae parvi momenti relate ad mulieres1 relate autem ad viros magni momenti sunt4 ,de his quid infra dicendum erit4 #aj4 ,senectus nunquam reddit mulierem impotentem1 virum autem reddit4 ,etiamsi nihil ad impotentiam pertineat1 hic #ccd juvat dicere in locis temperatis terrae parturitionem maxima ex parte desinere anno a natu quadragesimo-quinto4 ,cessare potest anno vicesimo-octavo1 et perstare post annum quinquagesimum4 ,j4 ,whitridge ,williams 7,obstetrics4 ,neo-,ebor4 #aijc71 casum citat mulieris quae anno sexagesimo-tertio aetatis puerum vicesimum-secundum peperit et postea menses aderant4 ,parturitio aliquando decem vel duodecim annos post ultimos menses evenit4 ,nunc1 estne mulier ovariis carens impotens8 ,nullo modo3 sterilis tantum est4 ,nam 7#a7 ,congregatio ,s4 ,officii in matrimonium duas mulieres ovariis orbatas inire permisit4 7#b7 ,talis mulier capax est copulae carnalis aeque ac mulier habens ovaria1 et moralistae omnes concedunt nil amplius requirendum ut matrimonium validum fiat4 7#c7 ,si talis mulier impotens sit omnis mulier insanabiliter sterilis impotens esset1 et discrimen a moralistis prolatum impotentiam inter et sterilitatem nugatorium esset et puerile4 ,mulier in qua tubi ,fallopiani occludantur sterilis est perpetuo2 idem dicendum de muliere habente uterum infantilem1 vel ovaria rudimentaria1 vel ovaria morbida1 et ita porro4 ,nemo autem tales tanquam impotentes unquam tenet4 ,aliquando mulier ovariis orbata sensationem sexualem possidet1 vulgo autem non possidet4 ,in utroque casu tamen remedium idem concupiscentiae mari perstat1 et hoc sufficit pro viro ut matrimonium validum sit4 ,huc accedit1 relate tum ad mulierem tum ad virum1 quod duo fines intrinseci essentiales matrimonii1 et fines sufficientes juxta ,s4 ,alphonsum1 adsint1 scilicet1 traditio mutua cum obligatione et possibilitate reddendi debitum1 et vinculum indissolubile4 ,si in tali muliere existat sensatio sexualis1 pro ea remedium concupiscentiae habetur1 sin minus1 dantur saltem duo fines essentiales intrinseci matrimonii4 ,re quidem vera mulier carens ovariis et eodem tempore expers sensationis sexualis differt a muliere quae parturit sed sine sensatione sexuali est2 nihilominus semper manent illi ovariis carenti duo fines essentiales intrinseci matrimonii4 ,vetula communiter nequit parire et expers sensationis sexualis est1 sed licite matrimonium contrahit4 ,conditio vetulae est eadem ac conditio mulieris ovariis orbatae4 ,lehmkuhl #cce 7,amer4 ,ecc4 ,rev4 vol4 #bh1 n4 #c71 in hanc assertionem urget excisionem ovariorum esse quid positive actum contra primarium matrimonii finem1 quum senectus conditio naturalis sit ,chirurgus honestus aut inhonestus nunquam removet ovaria ut conceptio evitetur2 operatio enim nimis periculosa est4 ,removentur ovaria primario ad morbum gravem medendum1 et sterilitas consequens intenditur tantum per accidens4 ,remotio ovariorum igitur est quid per accidens actum contra primarium finem matrimonii1 7et iste non est finis essentialis intrinsecus7 seu generationem prolis2 et nihil refert etiamsi positive actum esset si non sit in fraudem legis4 ,in casu mulieris habentis ovaria rudimentaria et nullam sensationem sexualem 7casus enim quandoque contingit7 quid sit positive actum contra primarium finem matrimonii8 ,estne una lex pro ista a natura castrata et alia pro muliere a chirurgo castrata et tertia pro vetula senectute castrata8 ,inter ovaria et testiculos analogia est1 etiamsi obstet ,d4 ,bossu1 medicus ,gallicus1 a ,professore ,hild 7,amer4 ,ecc4 ,rev4 vol4 #bh1 n4 #a7 et ,eschbach citatus4 ,demptis ovariis sensatio sexualis destruitur haud secus ac quum testiculi removeantur1 sed analogia incompleta est et claudit4 ,eunuchus insuper incapax est communiter intromissionis1 et semper inseminationis4 ,moralistae vulgo docent inseminationem essentialem esse copulae carnali4 ,utcumque de inseminationis necessitate veritas sit 7de qua infra7 eunuchus nequit satisfacere primo matrimonii fini essentiali intrinseco1 mulier expers ovariis satisdare potest4 ,carentia aut occlusio tuborum ,fallopianorum sterilitatem insanabilem efficit1 sed usque adhuc nemo tenet illam carentiam vel occlusionem esse impotentiam4 ,conditio quoad potentiam generandi eadem est ac in carentia ovariorum1 sensationem autem sexualem proprie carentia tuborum non efficit4 ,idem omnino dicendum est de carentia uteri4 ,si vagina remaneat capax talis mulier copulae carnalis est4 ,mulier igitur impotens est sub lege ecclesiastica tantum in quinque casibus3 7#a71 ubi atresia vaginae aut adhaesio labiorum insanabiles sunt3 haec atresia et adhaesio raro inveniuntur2 #ccf 7#b71 in casu rarissimo in quo vagina in rectum aperit insanabiliter2 7#c71 ubi arctatio vaginae immedicabilis sit3 haec rara est2 7#d71 quando adsunt tumores maligni aut incrementa morbida quae nequeant removeri2 7#e71 in casibus defeminationis aut ,urningismi 7de quibus infra74 ,sadismus et ,masochismus et aliae perversitates sexuales ita infrequenter observantur1 in gradu saltem in quo impotentiam creant1 ut negligi possint4 ,,ii4 ,impotentia ,maris4 ,tractus genitalis viri1 a testiculis ad meatum urinarium seu orificium penis1 ad centimetra #ha 7uncias fere #cb7 extenditur4 ,ex testiculis chorda spermatica per inguen infra cutem transit1 murum abdominalem penetrat per annulum inguinalem1 et sub vesica urinaria urethram juxta cervicem vesicae intrat4 ,semen non ex uno fonte provenit4 ,secretio ista fluida est et cinerea1 partim ex testiculis qui in scroto sunt oriens et partim ex vesiculis seminalibus1 prostate1 glandulis ,cowperi1 et folliculis cryptisque urethrae1 quae omnia extra scrotum sunt4 ,elementum essentiale in semine cellulae sunt quae spermatozoa vocantur1 et haec ex testiculis proveniunt4 ,locomotionis potentiam habent spermatozoa et in foecundatione ovum penetrant4 ,secretio glandularum quae spermatozoa fert alkalina est et removet aciditatem urinae2 acidus enim spermatozoa destruit4 ,erectio penis praecedit ejectionem seminis1 et centra nervosa erectionis et ejectionis in chorda spinale apud lumbos sunt4 ,erectio effectus est dilatationis arteriarum penis et occlusionis venarum quae congestionem sanguinis efficiunt2 postea musculi perineales aliique musculi erectionem perficiunt4 ,impotentia maris in tria genera dividi potest2 videlicet3 ,impotentia ,psychica1 ,impotentia ,atonica1 ,impotentia ,organica3 ,i4 ,impotentia ,psychica4 ,species3 7#a71 ,impotentia ,psychica absoluta aut relativa2 7#b71 ,sadismus2 7#c71 ,masochismus2 7#d71 ,fetichismus2 #ccg 7#e71 ,eviratio2 7#f71 ,urningismus2 7#g71 ,sodomia cum horrore2 7#h71 ,gynandria2 7#i71 ,metamorphosis ,sexualis ,paranoica2 7#aj71 ,anaesthesia ,sexualis2 ,,ii4 ,impotentia ,atonica4 ,species3 7#a71 ,impotentia ,paralytica2 7#b71 ,impotentia e venenis2 7#c71 ,impotentia ex irritatione4 ,,iii4 ,impotentia ,organica4 ,species3 7#a71 absentia penis2 7#b71 penis multiplex2 7#c71 hypertrophia aut magnitudo penis vel praeputii2 7#d71 penis rudimentarius2 7#e71 adhaesio penis scroto1 ingueni vel abdomini2 7#f71 hypospadias et epispadias2 7#g71 distortiones penis ex podagra1 lue1 rheumatismo1 gonorrhoea2 7#h71 aneurysma corporum cavernosorum et varix venae dorsalis penis2 7#i71 frenum nimis curtum2 7#aj71 anchylosis articulamenti coxendicis et abdomen permagnum2 7#aa71 tumores et incrementa morbida circa genitalia1 sicut herniae1 hydrocele1 haematocele1 elephantiasis1 lipoma1 carcinoma1 sarcoma1 cystoma1 enchondroma et fibroma2 7#ab71 phthisis testiculorum et varicocele2 7#ac71 anorchismus et castratio2 7#ad71 prostratitis chronica2 7#ae71 senectus2 7#af71 aspermia4 ,i4 ,impotentia ,psychica4 #a4 ,impotentia psychica ea est quae ex coercitatione inhibente cerebri in centrum genito-spinale exercitata devenit4 ,impotentia ex maleficio veterum moralistarum est4 ,timor1 luctus1 gaudium magnum1 et aversio hanc impotentiam psychicam efficiunt4 ,quandoque #cch nuper maritus propter excitationem passionis ejectionem praecocem vel erectionem debilem vel nullam habet4 ,in his casibus impotentia temporanea est si medicus peritus prudensque sit4 ,haec impotentia relativa esse potest4 #b4 ,sadismus4 ,haec paraesthesia sexualis et aliae perversitates ex excessu venereo deveniunt et impotentiam gignunt4 ,sadismus nomen habet a quodem libidinoso ,gallico marchione de ,sade1 saeculo duodevicesimo vigente4 ,datur libido magna erga alium sexum sed cum crudelitate in objectum uriginis1 quae crudelitas usque ad homicidium cum mutilatione frequenter extendit1 vel saltem adesse debet humiliatio personae amatae4 ,sadistae erant ,nero et ,tiberius2 et exemplum infame erat ,giles de ,laval1 qui ,a4,d4 #addj1 supplicium capitis affectus est1 post trucidationem ,sadisticam fere #bjj liberorum inter octo annos4 ,occisiones apud ,white ,chapel ,londini probabiliter ,sadisticae fuerunt4 ,sadista impotens est exceptis casibus in quibus crudelis vel saltem contumeliosus simul esse potest4 ,haec crudelitas gradus habet a ,sadismo symbolico1 in quo crudelitas simulatur1 vel mere dramatica est1 per contumeliam veram usque ad homicidium et anthropophagiam4 ,formae etiam bestiales et sodomiticae inveniuntur4 ,sadista nullo modo tanquam semper insanus considerari debet1 species autem suae pessimae paranoicae sunt1 et degeneratio neurotica frequens est in familiis ,sadistarum4 ,sadismus maris frequens est1 sed ,kraft-,ebing 7,psycopathia ,sexualis1 ,philadelphiae1 #ahic7 tantum duos casus inter mulieres invenit4 ,fictiones antiquae de ,lamiis et ,marmolycibus ex actibus mulierum ,sadisticarum ortae sunt4 ,necrophilia1 seu libido erga cadavera cum propensione ad mutilationem1 species est ,sadismi quae vulgo paranoica est4 #c4 ,masochismus4 ,haec degeneratio nomen habet a fabularum scriptore ,sacher-,masoch4 ,conditio est ,sadismo contraria4 ,masochista uriginem habet magnam uti ,sadista1 et nulla datur potentia sexualis sine crudelitate vel humiliatione2 crudelitas autem vel humiliatio in ,masochistam ipsum vertenda est4 ,hic homicidium non intrat4 ,masochismus1 natura sua passiva1 vitium feminarum esse debet1 sed solummodo #cci casus unus in muliere inventus est a ,kraft-,ebing4 ,valde communis est inter mares4 ,masochismus ,larvatus est species hujus degenerationis in qua sordes physicae sordibus adduntur moralibus4 #d4 ,masochismus ,symbolicus seu ,fetichismus4 ,fetichista potens est tantum praesente parte vestium1 e4 g41 calccus mulieris1 vel aliud objectum seu ,fetich1 quodcumque sit4 ,aliquando mera imaginatio sufficit4 ,tonsores furtivi capillorum puellarum quandoque ,fetichistae sunt1 et in capillis longis virorum attractio sexualis quandoque est mulieribus4 ,virtus musicorum saepe in capillis ,samsoniis est plus quam arte4 ,westermarck 7,history of ,human ,marriage4 ,neo-,eboraci4 #ahia7 describit seditionem gravem mulierum in ,madagascar quum ,rex ,radama capillos longos militum tonderi jusserit4 ,relatio etiam est odores inter et passionem sexualem4 ,si nervi olfactorii catelli scindantur catellus nunquam canem femineam recognoscit4 ,meretrices gaudent odoramentis pungentibus1 e4g41 moscho4 #e4 ,eviratio4 ,haec degeneratio gradus est ,sodomiae4 ,in gradu primo ,sodomiae impotentia non necesse adest1 in gradu autem secundo semper adest4 ,in hoc secundo gradu homo ,sodomiticus meretrix masculina evadit cum maribus1 atque transformatio profunda et stabilis animi supervenit1 ita ut mas se feminam esse in actu sexuali sentit4 ,hic est effeminatio usque ad statum criminalem pregrediens4 ,gradus initialis hujus status est amicitia inordinata inter duos pueros aut duas puellas4 ,in casibus firmatis evirationis1 ,sodomista agit tanquam pellex masculina aliis ,sodomistis1 aut in vestibus femineis ut uxor se gerit4 ,coloniae sunt ,sodomistarum hujus generis in fere omne urbe magna2 se invicem cognoscunt1 societates1 choreas publicas1 et dialectum completam habent1 praesertim ,berolini1 ,lutetiae-,parisiorum1 ,neapolis et ,washingtonii4 ,impotentes sunt ad copulam carnalem naturalem4 ,sodomia cum effeminatione seu viraginitate frequens est inter mulieres4 ,hie degenerata marem mente evenit4 ,impotens vix dici potest1 nisi propter aversionem sexualem a maribus4 #f4 ,urningismus4 ,urning est vox ,germanica ab ,ulrichs inventa4 ,urningismus idem est in re ac ,sodomia primi et #cdj secundi gradus1 sed additur mollitia scriptionis poesis1 ambulationum imminente luna1 et aliorum hujusmodi4 #g4 ,sodomia cum horrore est similis evirationi et defeminationi1 sed vice frigiditatis adest horror alterius sexus4 #h4 ,gynandria et ,androgynia4 ,in istis degenerationibus transformatio ita profunda est ut ,sodomista masculinus circa pectus et in modo se gerendi feminae similis sit physice1 et virago virum evadat aspectu4 ,exempla sunt bote et mujerado inter ,sioux et ,pueblos ,indos ,americanos4 #i4 ,metamorphosis ,sexualis ,paranoica species insaniae est in qua patiens imaginat sexum suum mutatum esse4 ,insanabilis est4 ,degenerationes istae fere omnes cum masturbatione incipiunt4 ,medicatio moralis esse debet1 sed ,kraft-,ebing et von ,schrenk-,notzing sanationem obtinuerunt ope hypnosis4 #aj4 ,anaesthesia ,sexualis status est in quo vir aut mulier omnino caret sensatione sexuali4 ,illi secus habent corpora normalia4 ,conditio valde infrequens est4 ,kraft-,ebing enumerat decem casus congenitos in maribus1 et duos in feminis4 ,anaesthesia sexualis acquisita etiam invenitur4 ,,ii4 ,impotentia ,atonica4 #a4 ,impotentia ,paralytica4 ,centra nervosa sexualia in chorda spinale apud lumbos atonica esse possunt propter morbum generalem1 aut venena1 aut paralysem4 ,impotentia atonica frequens est in anaemia1 diabete mellito1 uraemia1 cholaemia1 lepra1 rheumatismo1 ataxia lumbali1 lue chordae spinalis1 myelitide1 parese1 et haemorrhagia cerebrali4 ,aliqui tumores cerebrales impotentiam gignunt1 paralysis diphtheritica causa est impotentiae temporaneae1 et conditio invenitur in cachexia alicujus morbi tabescentis4 ,phthisicus autem saepe potens est usque ad finem vitae4 ,utrum impotentia perpetua sit necne ex natura morbi dependet4 #b4 ,impotentia ex venenis4 ,potentia sexualis minuitur vel destruitur abusu venenorum vel absorbendo eadem1 uti opium1 morphina1 chloral1 potassii bromidum et iodidum1 cannabis ,indica1 carbonei sulphidum1 arsenium1 antimonium1 plumbum et iodum4 ,fabri1 ut pictores 7house-painters7 et typographi1 qui plumbo utuntur hoc modo patiuntur4 ,alcohol frequenter origo est impotentiae1 et quandoque tabacum eumdem #cda affectum habet sine alio indicio physico4 ,impotentia pervicax esse potest ex utraque causa4 #c4 ,impotentia ex irritatione4 ,irritatio chronica urethrae prostaticae e libidine1 gonorrhoea1 masturbatione1 urina acida aut neurosibus genito-urinariis impotentiam inducit4 ,neuroses centrorum sexualium sensibiles aut motoriae esse possunt1 et neuroses motoriae quandoque impotentiam creant4 ,prognosis hujusmodi impotentiae fausta est nisi adsint spermatorrhoea et genitalium atrophia4 ,prostatorrhoea quoque impotentiae causa esse potest1 et hic prognosis melior quam in spermatorrhoea est4 ,athletae1 ut pugil1 cursor1 et alii ejusdem classis temporaliter impotentes esse possunt ,,iii4 ,impotentia ,organica4 ,mas impotens esse potest propter malformationes congenitas aut acquisitas1 morbos et defectus genitalium4 #a4 ,absentia congenita aut postnatalis penis impotentiam insanabilem creat4 #b4 ,penis rudimentarius causa impotentiae est1 sed casus amplificationis post matrimonium habentur4 #c4 ,penis multiplex rarissime impotentiam creat4 #d4 ,hypertrophia penis aut praeputii1 et magnitudo relativa penis rarissime efficiunt hominem impotentem4 #e4 ,adhaesio penis scroto1 ingueni vel abdomini reddit hominem impotentem2 sanabilis autem est conditio4 #f4 ,impotentiam quandoque creat hypospadias1 seu absentia partis inferioris urethrae1 et epispadias1 seu absentia partis dorsalis urethrae2 sed conditiones a chirurgo sanari plerumque possunt1 quandoque autem nequeunt4 #g4 ,distortiones penis e podagra1 lue1 rheuraatismo1 et gonorrhoea impotentem faciunt virum quandoque immedicabiliter4 #h4 ,aneurysma corporum cavernosorum et varix venae dorsalis penis impotentiae a chirurgo sanabilis causae sunt4 #i4 ,frenum glandulae penis curtum nimis incurvat penem1 et ita vir impotens est4 ,conditio facile a chirurgo removeri potest4 #aj4 ,rarissime anchylosis articulamenti coxendicis et venter pinguedineus impotentem virum reddit4 ,anchylosis insanabilis est4 #aa4 ,tumores et incrementa morbida circa genitalia1 ut #cdb herniae1 hydrocele1 haematocele1 elephantiasis1 lipoma1 carcinoma1 sarcoma1 cystoma1 enchondroma1 et fibroma causae sunt impotentiae4 ,herniae1 lipoma1 hydrocele1 haematocele1 et quandoque elephantiasis scroti sanari possunt2 tumores benigni et maligni aliquando removentur sed vulgo amputatione penis aut testiculorum4 #ab4 ,testiculi marcescunt in varicocele et impotentia sequitur4 ,varicocele amoveri potest1 et si mature operetur chirurgus impotentia evitatur4 ,lues testiculorum destrui potest substantiam testiculorum nisi morbus mature sanetur1 et impotentia potest esse absoluta4 ,tuberculosis testiculorum destruit organum4 #ac4 ,anorchismus seu absentia testiculorum bilateralis et congenita1 idem efficit ac castratio4 ,conditio rara est ,cryptorchismus1 seu retentio testiculorum in abdomine1 plerumque sterilitatem gignit non necessario impotentiam4 ,castratio completa1 morbo vel secus1 impotentiae causa est1 sed non necessario statim post castrationem4 ,gross 7,a ,practical ,treatise on ,impotence1 ,philadelphiae4 #ahij7 citat quattuor casus in quibus erectio permanebat1 in uno homine usque ad decennium4 ,kruegelstein 7,henke's ,zeitschrift4 #ahdb4 vol4 ,i1 p4 #cdh7 dicit virum quemdam post amissionem testiculorum uxorem foecundavit4 ,si casus revera contigerit1 spermatazoa in vesciculis seminalibus permanserant4 #ad4 ,prostatitis chronica causa est impotentiae et plerumque insanabilis est4 #ae4 ,nulla regula firma dari potest de impotentia physiologica senectutis in maribus4 ,viri sexto et octogesimo anno non solum potentes inventi sunt sed etiam liberos generaverunt4 ,potentia generandi in maribus vulgo circa annum sexagesimum-secundum cessat1 exceptiones autem multae inveniuntur4 ,potentia coeundi permanere potest longe post annum sexagesimum-secundum4 ,ecclesia igitur senes cujuscumque aetatis ad matrimonium admittit2 et confessarius nihil rogat de potentia nisi ab ipso sene interrogatur4 ,si confessarius sciat senem revera impotentem esse1 non permittere debet matrimonium ejus4 #af4 ,opinio videtur esse moralistarum ad habendam copulam carnalem necessariam esse non solum erectionem et #cdc intromissionem sed ettam inseminationem plus minusve perfectam4 ,laymann 7,de ,imped4 ,matr41 cap4 #aa7 ait3 ,impotentia perpetua ad copulam perfectam dirimit matrimonium subsequens4 ,et addit3 ,dixi perfectam1 id est1 quae fit cum effusione veri seminis in vas muliebre4 ,mastrius 7loco jam citato7 tenet inseminationem esse necessariam4 ,lehmkuhl 7,theol4 ,mor47 in definitione impotentiae absolutae dicit talem esse impotentiam quae aliquem ad quamlibet copulam consummatam inhabilem reddit4 ,hic utitur vocibtis1 copula consummata1 in qua ,ballerini requirit inseminationem quasi perfectam 7op1 cit41 vol4 #f1 p4 #agh71 et ,sanchez 7,de ,matr41 lib4 #b1 disp4 #ba1 n4 #e7 inseminationem imperfectam4 ,petrus de ,ledesma quoque 7apud ,eschbach4 ,disputationes ,physico-,theologiae4 ,disp4 #bjj7 de senibus loquens ait3 ,si enim senes ita senio confecti et exhausti1 quod nullo modo semine valeant1 quamvis possint erigere membrum et penetrare vas1 non possunt contrahere1 et si contrahunt1 matrimonium est invalidum4 ,qui steriles sunt ita sunt ex tribus causis3 7#a7 ,aspermia1 seu absentia absoluta seminis2 7#b7 ,azoospermia1 seu absentia spermatozoon in semine2 7#c7 ,oligospermia1 seu carentia alicujus partis seminis4 ,aspermia vulgo efficitur occlusione urethrae vel obliteratione partis ejusdem4 ,defectus isti congeniti esse possunt vel ex morbo aut vulnere4 ,tumores tractus generativi claudere possunt aditum inter testiculos meatumque urinarium et ita aspermia efficitur4 ,spadones1 etiamsi raro potentiam habeant intromissionis1 aspermia afflictantur quoad partem seminis ex testiculis provenientem 7in qua spermatozoa sunt71 sed humor ex parte anteriori tractus generativi adesse aliquo modo potest4 ,azoospermia fere eodem modo oritur1 obstructio autem vel destructio prope testiculos est1 et ita secretio aliarum partium tractus generativi exire potest1 sed sine spermatozois4 ,in ,oligospermia spermatozoa adesse possunt1 sed quia aliud elementum seminis deest spermatozoa inertia sunt4 ,casus inveniuntur in quibus propter malformationem semen perfectum in vesicam urinariam ejactatur4 #cdd ,omnes istae conditiones insanabiles esse possunt1 raro sanari possunt4 ,estne vir aspermatosus1 seu carens semine1 impotens8 7#a74 ,affirmant multi moralistae qui inseminationem requirant talem impotentem4 7#b74 ,ejectio seminis confectio est actus sexualis viro1 et alia in actu ejectioni mere conducunt4 ,in ,azoospermia copula carnalis qua copula eadem est ac in coitu normali3 microscopium solum aut sterilitas absentiam spermatozoon detegunt4 ,in ,oligospermia coitus quoque normalis esse paret4 ,opinor virum aspermatosum impotentem sub lege esse quia nequit copulam sexualem perficere2 e contra1 virum oligo-spermatosum aut azoospermatosum steriles tantum esse4 ,impotentia igitur definiri potest1 in viro3 ,impotens est quum 7#a7 vel absolute et perpetua1 vel relative et perpetua1 incapax sit intromissionis et quasi inseminationis2 aut 7#b7 quum spado sit1 et ita sub decreto ,sixti ,v veniat4 ,impotentia in muliere definiri potest3 quum nullam vaginam vel vaginam perpetuo impenetrabilem habeat2 vel cum pathologice recuset marem4 ,impotentia coeundi potest esse 7#a7 aut antecedens aut consequens2 prout matrimonii contractum anteit aut illi supervenit2 7#b7 perpetua seu insanabilis1 aut temporanea2 7#c7 absoluta aut relativa1 in quantum aliquem ad quemlibet copulam consummatam inhabilem reddit1 aut tantummodo usum matrimonii inter duas certas personas impossibilem facit 7,lehmkuhl74 ,ut impotentia tanquam impedimentum matrimonii dirimens habeatur1 debet esse3 7#a7 impotentia coeundi2 7#b7 insanabilis2 7#c7 antecedens2 7#d7 aut absoluta aut relativa4 ,,augustinus ,,omalley4 #cde ,,appendix #cdf #cdg ,,appendix ,,bloody ,,sweat ,the bloody sweat of our ,lord mentioned in ,saint ,luke's ,gospel 7xxii41 #dd71 has given rise to not a little discussion4 ,the ,greek text is3 ,greek text4 ,the ,vulgate has this text thus3 ,et factus est sudor ejus sicut guttae sanguinis decurrentis in terram4 ,the ,douay version is3 ,and his sweat became as drops of blood trickling down upon the ground4 ,the ,king ,james translation has it3 ,and his sweat was as it were great drops of blood falling down to the ground4 ,the ,greek text and the ,vulgate and ,douay versions are the same1 but in the ,king ,james translation the words1 as it were great differ somewhat from the statement in ,greek4 ,the belief in the ,catholic ,church is that our ,lord literally sweat blood through ,his unbroken skin1 and this sweat is commonly deemed miraculous4 ,those that deny the sweat was really blood have no ground whatever for their assertion1 because apart from all miracle bloody sweat can be a purely natural occurrence4 ,dr4 ,j4 ,h4 ,pooley1 in ,the ,popular ,science ,monthly 7vol4 #bf1 p4 #ceg71 has an article on this subject in which he reported #dg cases of bloody sweat through unbroken skin4 ,he1 however1 is of the opinion that our ,lord's sweat had no real blood in it4 ,whatever his reason may be for this assertion he carefully conceals it4 ,hemorrhage through the unbroken skin is a rare occurrence2 but1 as has been said1 ,dr4 ,pooley found #dg cases reported1 and there are probably many others4 ,the discharge may be pure blood which coagulates in crusts1 or it may be blood mixed with sweat2 it may be present over the whole surface of the body or only in those parts where the #cdh skin is thin and delicate4 ,commonly1 bloody sweat is an oozing1 but ,hebra1 is his ,diseases of the ,skin1 tells of a young man that he himself observed1 from whose legs and hand blood ran1 sometimes in minute jets one-twelfth of an inch in height4 ,the skin was sound1 and the bloody sweat was not caused by any emotion4 ,the flow may be intermittent1 appearing at intervals from a few hours to months4 ,sometimes the discharge is connected with skin diseases1 but often the skin is unaffected4 ,examples have been found at every age and in both sexes1 but this sweat is commoner in women4 ,du ,gard reports an instance in a child only three months old1 and ,spolinus tells of such a sweat in a child twelve years of age4 ,bloody sweat may occur in malaria2 it may be connected with neurasthenic conditions1 and it has been caused frequently by overwhelming emotion1 as terror and anguish4 ,de ,thou tells of a ,french officer who was in command at ,monte ,maro in ,piedmont in #aeeb1 who sweated blood after he had been threatened with an ignominious execution if he did not surrender the town4 ,the same writer mentions a young ,florentine1 put to death in ,rome during the pontificate of ,sixtus ,v1 who sweated blood before execution4 ,the ,society of ,arts at ,haarlem reported the case of a ,danish sailor who sweated blood through terror in a storm4 ,this man was observed carefully by a physician on the ship4 ,the physician at first thought the man had been wounded by a fall1 but after wiping away the blood he discovered that the oozing came through uninjured skin4 ,when the storm had ceased the sailor at once regained a healthy condition4 ,in the ,french ,transactions medicales1 for ,november1 #ahcj1 is narrated the case of a young woman who had turned from ,protestantism to ,catholicism1 and after this conversion she grew hysterical because of persecution by her family4 ,during the hysterical attacks she sweat blood from the surface of her cheeks and belly4 ,before the ,christian era bloody sweat was observed by ,aristotle1 ,galen1 ,diodorus ,siculus1 and ,lucan also mention such occurrences4 ,the stigmata of some saints are authenticated cases of bleeding through the sound skin of the hands1 feet1 and side during extraordinary sympathy with our ,lord in ,his ,passion1 and deep mental concentration upon that ,passion1--the stigmata of ,saint ,francis of ,assisi1 for example4 ,such bleeding is regarded in the ,church as miraculous4 ,apart from any question of faith1 there is no reason why they may not be #cdi miraculous1 especially if the supernatural quality is supported by other facts2 but1 again1 such stigmata can be natural4 ,to prove1 in general1 that stigmata are miraculous requires commonly heroic sanctity as a background1 and even then in all cases the proof is not necessarily absolute4 ,focachon1 a chemist at ,charmes1 applied postage stamps to the left shoulder of a hypnotised subject1 and kept them in place with ordinary sticking plaster and a bandage4 ,he suggested to the patient that he had applied a blister4 ,the subject was watched1 and after twenty-four hours the bandage1 which had been untouched1 was removed4 ,the skin under the postage stamps was thickened1 necrotic1 of a yellowish-white colour1 puffy with the serum of the blood and leucocytes1 and surrounded by an intensely red zone of inflammation4 ,several physicians1 including ,beaunis1 confirmed this observation2 and ,beaunis made photographs of the blister1 which he showed to the ,society of ,physiological ,psychology1 ,june #bi1 #ahhe4 7,animal ,magnetism4 ,binet and ,fere4 ,new ,york1 #ahhi47 ,in ,ricard's ,journal de magnetisme animal1 #b;d year1 #ahdj1 pp4 #ah1 #aea1 is a similar case4 ,prejalmini1 in ,november1 #ahdj1 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 blister4 ,at the meeting of the ,societe de biologie1 on ,july #aa1 #ahhe1 ,bourru and ,burot1 professors of the ,rochefort school1 published records of epistaxis and of bloody sweat1 produced by suggestion on a male hysteric4 ,on one occasion1 after the patient had been hypnotised1 his name was traced with the end of a blunt probe on both the patient's forearms4 ,there was1 of course1 no mark of any kind left on the arms4 ,then the patient was told3 ,this afternoon1 at four o'clock1 you will go to sleep1 and blood will then issue from your arms on the lines which ,i have now traced4 ,the man was paralytic and anaesthetic on the left side4 ,he fell asleep at four o'clock1 and while he was asleep the name appeared on the sound left arm1 raised in a red wheal1 and there were minute drops of complete blood 7serum and corpuscles7 in several places4 ,there was no change on the paralysed right forearm4 ,later the patient himself commanded the arm to bleed and it did so4 ,this second occurrence was observed by ,mabille4 7,binet and ,fere4 ,op4 cit41 p4 #aii47 ,charcot and his pupils at the ,salpetriere have often produced by suggestion alone the effects of burns upon the skin of hypnotised patients4 ,the blisters in these cases did not appear at once #cej but after some hours had elapsed4 ,the blisters1 of course1 contained blood4 ,the weekly bleeding1 through the unbroken skin1 of the hands and feet of ,louise ,lateau is an example of stigmata in our own day1 which may have been supernatural or natural4 ,physicians would call it natural1 an effect of autohypnosis1 but there is no reason why it may not have been just as miraculous as the stigmata of the saints4 ,professor ,lefevre of the ,university of ,louvain1 a physician1 said her stigmata were miraculous4 ,theodore ,schwann1 the discoverer of the cell doctrine1 deemed her condition natural4 ,in the ,letters of the ,rt4 ,rev4 ,casper ,borgess1 ,bishop of ,detroit1 ,michigan1 is an account of a visit to ,louise ,lateau made in ,july1 #ahgg4 ,he says1 ,i first seated myself on the only chair in the room1 which ,i had placed at the right side1 near the head of the bed4 ,louise's two hands rested on several thicknesses of folded linen1 spread over the bed-cover1 and were covered with a folded linen cloth4 ,this ,i removed4 ,the hands were both heavily covered with blood2 in some places it had congealed1 and looked very dark2 but in the centre1 between the fore and little fingers1 on the upper part of the hand1 the blood was quite fresh and flowed freely4 ,not knowing at the time that the wiping of the hands causes her intense pain1 ,i proceeded to wipe off the hands1 for a more perfect inspection of the wound on each hand4 ,the wound1 or stigma1 on the right hand seemed more than one inch in length1 about half an inch at its greatest width1 and was of oval shape4 ,turning the hand1 ,i saw a wound of the same form in the palm of the hand1 and opposite the wound on the back of the same4 ,the blood seemed to rise in bubbles1 forming in rapid succession1 flowing in a spread stream down to the wrist4 ,examining the wound itself1 ,i was well convinced that the skin of the hand was not broken nor in any way injured2 and there was no sign of a wound made by any material instrument1 sharp or dull4 ,and1 withal1 the blood oozing out of the wound appeared a reality1 and complete in form4 ,the bishop evidently uses the term wound in a figurative sense1 because he draws attention to the fact that the skin was intact1 continuous4 ,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 ,lord4 ,while the bishop was examining her hands ,louise went into an ecstatic condition4 ,if the ,church defines that a bloody sweat or the stigmata of a saint are supernatural1 that definition1 of course1 ends the matter for ,catholics as far as the particular case is concerned2 #cea but until such a decision has been made these conditions are all to be regarded as effects of natural causes working in a natural manner4 ,in many conditions where the nervous system can have influence a miracle is very difficult of proof from the context4 ,there can1 of course1 be evident miracles in the cure of some nervous disorders1 supposing the diagnosis to be certain4 ,the sudden cure of advanced paresis would be as much a miracle as the sudden replacing of a lost femur4 ,commonly1 however1 in neuroses if there is an apparently miraculous healing or similar effect1 the supernatural quality can not be established4 ,suppose ,bernadette reported that she had seen the ,blessed ,virgin at ,lourdes3 the only safe thing to do in such a case is to deny the apparition until it has been proved4 ,suppose1 secondly1 that a patient who has been confined to bed for years by an hysterical paralysis1 believed in the reality of the vision1 had himself carried to ,lourdes1 and while at prayer there he suddenly stood up cured4 ,that effect would prove neither the reality of the vision nor the supernatural quality of the cure2 nor would it disprove either4 ,we simply can not judge the case1 because exactly the same effect has happened hundreds of times from purely natural impressions4 ,if that same paralytic were lying in his bed at home and you set the house afire he would jump up and run4 ,if the patient1 however1 had been bedridden with a paralysis caused by certain degeneration of nervous tissue1 and he were cured in the manner described1 that effect would be supernatural1 miraculous2 always provided there is no error in the medical diagnosis4 ,there is a genuine diabetes and a pseudodiabetes4 ,the latter condition may be diagnosed as true diabetes by a number of physicians1 but it is only a symptom of hysteria4 ,if the pseudodiabetes is suddenly cured1 this cure may or may not be miraculous1 but no one can say which is the truth2 the probability is a hundred to one that the cure is altogether natural4 ,there was a flourishing ,christian ,science congregation established in the west recently upon miraculous cure of a case of pseudodiabetes1 which some ignorant physicians had called true diabetes1 notwithstanding the fact that ,christian ,science does not believe in either diabetes or false diabetes4 ,we must not1 then1 call every strange event miraculous2 nor1 what is worse1 are we rashly to make the supernatural a matter to be explained away loftily by the impudence of half science4 ,a ,belgian priest named ,hahn wrote a monograph #ceb to the effect that the ecstatic conditions observed in the life of ,saint ,teresa were autohypnotic1 and he succeeded in drawing upon himself the undivided attention of the ,congregation of the ,index and a serious disturbance of his peace of mind4 ,he became a martyr to science4 ,we all like to be liberal1 impartial2 but from the religious ,mugwump libera nos1 ,domine6 ,autohypnosis is always a mark of degeneracy in the natural order1 and to call the ecstacy of a saint autohypnosis not only takes all worth from the manifestation1 but the assertion is also untrue4 ,there is a vast difference between the intense intellectual contemplation of a great saint in ecstacy1 which leaves the person unconscious of the body and its surroundings1 and the cataleptic trance of a neurotic patient who may mimic the saint4 ,hypnotic or autohypnotic stigmata1 and by stigmata here is meant bleeding from the hands1 feet1 and side1 would be degeneracy of the mind and body in the natural order4 ,moreover1 no clearly established cases are known1 because conditions like those of ,louise ,lateau are by no means certainly physical from all points of view1 as they would be if they occurred in an ordinary hysteric4 ,in hypnosis or autohypnosis the subject's mind and body are degenerate2 in sanctity1 where at times may be displayed certain effects that resemble autohypnosis1 there is always a sound mind4 ,a saint may have an unsound1 neurotic body1 but a crazy saint or an hysterical saint is no better than any other lunatic or hysteric1 and certainly anything but a saint4 ,if a saint has stigmata1 these external marks might come 7#a7 miraculously1 as a gratuitous sign of divine favour2 7#b7 as an effect of natural1 intense contemplation of the ,passion of our ,lord1 producing these bleedings in a sound body2 or 7#c7 as an effect of a rational1 intense contemplation of the same ,passion1 acting1 more easily1 on a neurotic body4 ,scientific theorising on this matter is necessarily sterile1 because such an investigation is only half material for science1--physical science4 ,science is not a bad thing in itself1 especially when it minds its own business and keeps its place below stairs2 but it never sympathises with sanctity1 and there is no deep knowledge without sympathy4 ,fact-grinding made ,darwin nauseate ,shakspere4 ,science can not see in the dark as genius and sanctity see1 and if it does see in the dark it is no longer science but genius working on a scientific object4 ,as ,professor ,william ,james said3 ,science taken in its essence should stand only for a method1 and not for any special beliefs1 yet1 as habitually taken by its #cec votaries1 ,science has come to be identified with a certain fixed general belief1 the belief that the deeper order of ,nature is mechanical exclusively1 and that non-mechanical categories are irrational ways of conceiving and explaining even such a thing as human life4 ,science should recognise its own limitations and not meddle in attempted explanations of the inexplicable4 ,therefore1 what of the stigmata of the saints from a scientific point of view8 ,there is no scientific point of view4 ,,austin ,,omalley4 #ced #cee ,,index #cef #ceg ,,index ,a ,abdominal pregnancy1 #e4 ,abortion1 #bb1 #dh2 causes of1 #dh1 #di1 #ea1 #eb1 #ec2 in puerperal pneumonia1 #aea2 tubal1 #f4 ,abortus1 #ai1 #bj1 #di4 ,acephalus1 #ge4 ,actinomyces1 visits in1 #ahc4 ,acute indigestion in the aged1 #aed4 ,addison's disease1 death in1 #aee2 symptoms of1 #aef4 ,adipocere1 #g4 ,aertnys on ectopic gestation1 #bf1 #bg4 ,aggressor1 #ah1 #ai4 ,agoraphobia1 #bif4 ,air-space1 #bjd4 ,alcohol1 effects on the mind1 #aji2 in proprietary medicines1 #ic2 in snake-poisoning1 #aah2 in typhoid fever1 #aah4 ,alcoholic amnesia1 #aaj2 climacteric1 #ajh2 delusions1 #aji1 #aaj2 insanity1 #ajg1 #aje1 #aji2 liquors1 #ajh2 poisoning1 #ajg1 #aji1 #aaj2 pseudo-paranoia1 #aji4 ,alcoholism1 #aje2 and cirrhosis of the liver1 #aef2 and coma1 #ach2 and conjugal infidelity1 #aji2 and epilepsy1 #bef2 and idiocy1 #aac2 and imbecility1 #aab1 #aad2 and marriage1 #aaa1 #abf2 and pneumonia1 #aea2 and surgical operations1 #afc2 and the will1 #aaa2 causes of1 #ajh2 children in1 #aab2 complicating disease1 #afb2 temperance societies1 #aab4 ,amateur medical advice1 #hi4 ,ambulatory epilepsy1 #bfa4 ,amenorrhoea1 #bda4 ,amnesia and epilepsy1 #bfc4 ,ampullar pregnancy1 #e4 ,amputations1 uterine1 #fe4 ,anaesthesia in mania1 #bbg4 ,anatomia genitalium mulieris1 #cca4 ,androgynia1 #cdj4 ,aneurism1 causes of1 #aee2 death in1 #aee4 ,angina pectoris1 death in1 #adb4 ,anointing in smallpox1 #agg4 ,anopheles mosquito1 #ahf4 ,anthrax1 visits in1 #ahd4 ,antitoxin1 #aga1 #aie4 ,aortic valvular disease1 death in1 #adj4 ,apoplexy1 #adc2 and fainting1 #ade2 hard arteries and1 #add2 short neck and1 #adf2 symptoms of1 #add2 the third stroke in1 #adf2 treatment in1 #ade2 vertigo and1 #add4 ,appendicitis1 peritonitis in1 #aec2 prognosis in1 #aec4 ,apraxia1 #bfc4 ,aristotle1 his determinants of morality1 #ad4 ,arteries in apoplexy1 #adf4 ,arteriosclerosis and apoplexy1 #add4 ,aspects of intoxication1 #aje4 ,aspermia1 #cdc4 ,asomata1 #ge4 ,assassins of presidents1 #cjb4 ,atresia vaginae et impotentia1 #ccc4 ,autohypnosis1 #acj4 ,autositic monsters1 #ge4 ,azoospermia1 #cdc4 ,b ,bacteria1 #afh2 kinds of1 #afi2 specific causes of disease1 #afi4 ,baptism in ectopic gestation1 #hc2 of monsters1 #hg4 ,barber's itch1 contagiousness1 #aih4 ,barkers1 #bcg4 ,beer1 percentage of alcohol in1 #ajh4 ,beriberi1 visits in1 #ahd4 ,bibliography of hypnotism1 #aag4 ,bichloride of mercury1 a disinfectant1 #aia4 ,black death1 #ahd2 mortality of1 #ahd4 ,black fevers1 #afj4 ,bleeders1 #abd4 ,blood brought out by suggestion1 #cdi4 ,bloody sweat1 #cdg2 and hypnosis1 #cdi2 cases of1 #cdh4 ,books and infection1 #aie2 disinfection of1 #aij4 ,borgess on the ,lateau case1 #cej4 ,brain tumours1 #adh2 and syphilis1 #cbb2 symptoms of1 #adh4 ,breeding places of mosquitoes1 #ahf4 ,breuss' ovum1 #gc4 #cef ,brick in buildings1 #bjc4 ,broad ligament1 #c4 ,broad-ligament pregnancy1 #e4 ,bromides and epilepsy1 #ih4 ,bubonic plague1 mortality in1 #ahe2 transmission of1 #ahe2 visits in1 #ahd4 ,building materials1 #bjc4 ,building sites1 #bjb4 ,burns1 death in1 #aef4 ,c ,caesarean section1 #da1 #db1 #ea1 #ee2 and sepsis1 #ef1 #eg2 indications for1 #ee2 statistics of1 #ee4 ,cancer complicating pregnancy1 #dd2 death in1 #aeh4 ,canonical law on impotence1 #cbf4 ,carbonic add in the air1 #bjf4 ,cardiac massage1 #afe4 ,carentia ovariorum1 #ccd4 ,carpets1 disinfection of1 #aid4 ,cases of ectopic gestation1 #bb4 ,castratio et impotentia1 #cdb4 ,catarrh and proprietary drugs1 #ajj ,cathartics1 #ajj4 ,causae impotentiae mulieris1 #ccb4 ,cats and diphtheria1 #aie4 ,cells1 #fi4 ,cellular activity and death1 #afd4 ,centrosome1 #gj4 ,cerebrospinal meningitis1 #adh1 #ahb4 ,cerebral neurasthenia1 #bcj4 ,chickenpox1 #aig4 ,children of drunkards1 #aab2 suicide of1 #cjh4 ,chorea1 #ea2 and menstrual disorders1 #bdc4 ,chromatin1 #gj4 ,chromosomes1 #gj1 #ga4 ,circular insanity1 #bbh4 ,circumstances m morality1 #ab4 ,cirrhosis of the liver1 causes of1 #aef2 death in1 #aef4 ,classrooms1 #bjd4 ,claustrophobia1 #bif4 ,clothes1 disinfection of1 #aia4 ,cocaine1 insanity from1 #aaf2 intoxication1 #aae1 #aaf1 #aag4 ,coeliotomy1 #d4 ,colelithiasis1 death in1 #afj4 ,coma and alcoholism1 #ach2 and kidney disease1 #ach4 ,composite monsters1 #gg4 ,compulsory vaccination1 #age4 ,confluent smallpox1 #agb4 ,congenital syphilis1 #cac2 statistics of1 #cac4 ,conjugata vera1 #ee1 #ef1 #eg4 ,conjunctivitis1 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