Pastoral Medicine A Handbook for the Catholic Clergy ALEXANDER E. SANFORD, M.D NEW EDITION REVISED, AND ENLARGED BY A CHAPTER ON THE MOMENT OF DEATH BY THE REV. WALTER M. DRUM, SJ. AND BY CHAPTERS ON "THE FIFTH COMMANDMENT" AND " NEURASTHENIA IN ITS PASTORAL- PSYCHIATRIC ASPECTS" NEW YORK JOSEPH F. WAGNER r^WFTWONY'S, SEMtNiM^L SANTA BARBARA. CAJU& il 45bjftat REMIGIUS LAFORT, S.T.L. Censor Librorum imprimatur ^.JOHN M. FARLEY, D.D. Archbhhop of New Tork NEW YORK, November 17, 1905. COPYRIGHT, 1905, BY JOSEPH F. WAGNER, NBW YORK CONTENTS A* PAGE INTRODUCTION 5 FIRST PART. HYGIENE. I. AIR GENERAL REMARKS 11 AIR AS A CAUSE OF DISEASE 14 WEATHER AND CLIMATE 17 II. SOIL AND DRINKING WATER 23 III. NUTRITION AND FOOD 28 FASTING AND ABSTAINING 32 FOOD 34 IV. DWELLING AND CLOTHING 47 CLOTHING 60 V. HYGIENE OF SCHOOLS 63 VI. THE INFIRMARY 71 VII. DEATH ASPHYXY SIGNS OF DEATH MANNERS OF DEATH BURIAL 74 SECOND PART. PASTORAL MEDICINE THE RELATION OF MAN IN His BODILY CONDITIONS TO RELIGION AND MORALITY 87 I. PROCURATIO ABORTUS 88 II. BIRTH, CARE OF THE CHILD 92 THE CHILD AT SCHOOL AGE 97 III. MATRIMONY 98 IMPEDIMENTUM CONSANGUINITATIS 99 IV. CELIBACY 101 PAGE MAN IN SICKNESS 107 I. SOMATIC DISEASES 108 TUBERCULOSIS 117 DIPHTHEBIA 118 CHOLERA 119 CHILDBED FEVER 120 APOPLEXY 121 DISEASES OF THE RESPIRATORY ORGANS 122 DISORDERS OF THE HEART 123 ABDOMINAL DISEASES 123 ACCIDENTS 124 II. MENTAL DISEASES 124 MELANCHOLY 132 MANIA 134 RAVING MADNESS 135 MORBIDITY OF IMAGINATION 135 NERVOUS DISORDERS 141 EPILEPSY 141 HYSTERIA 144 III. DISEASES DUE TO OCCUPATIONS 149 IV. HYPNOSIS AND SUGGESTION 155 V. ALCOHOLISM 163 VI. MORPHINISM 172 THIRD PART. FIRST AID TO THE INJURED. I. HEMORRHAGE AND ITS TREATMENT 175 II. WOUNDS AND THEIR TREATMENT 180 III. SPRAINS, DISLOCATIONS, FRACTURES 184 IV. ARTIFICIAL RESPIRATION AND THE TREATMENT OF ASPHYXIA 187 V. POISONS AND THEIR TREATMENT 194 VI. INSENSIBILITY AND FITS 208 VII. BURNS, SCALDS, ELECTRIC SHOCK, REMOVAL OF FOREIGN BODIES FROM EYE, EAR, AND NOSE 215 VIII. THE TRANSPORT OF SICK AND INJURED 219 APPENDIX. THE MOMENT OF DEATH, by the Rev. W. M. Drum, S.J. . 223 THE FIFTH COMMANDMENT 236 NEURASTHENIA IN ITS PASTORAL-PSYCHIATRIC ASPECTS. . . . 266 INTRODUCTION. HpHE purpose of Pastoral Medicine is to present to the practical theologian facts of physical science, as de- veloped by the medical profession, for the purpose of ap- plying them in pastoral functions and in explanation and support of the teachings of faith and morals. Pastoral Medicine has for its object the treatment of some branches of the scope of pastoral labors, which, as a rule, are but sparingly, if at all, included in the clerical student's plan of studies. In the intimate connection between body and soul, it seems necessary that the clergyman should have some knowledge of the conditions of the body, if he wishes to fill with best results the office of administrator to the soul. He requires this knowledge, furthermore, for the purpose of applying it to the proper care of his own body, and also to enable him to render judicious advice and practical as- sistance in cases of serious accident, when he may be on hand before the physician, and to offer counsel in the rational treatment of sickness where, in cases of emer- gency, a medical man is not immediately at hand. There must, therefore, be numerous instances when the knowl- edge gained from a course in Pastoral Medicine will be applicable to best advantage. Anthropology is a science of modern times. It teaches the history of man, his origin and his place among living beings, the structure and functions of his body. The theologian, for the reasons referred to, is bound to be interested in the results of this field of research. The relationship existing between medicine and the- ology also exists between the former and the science of law. When applied to jurisprudence, medicine teaches the aspect and influence of medical and physical facts for 6 PASTORAL MEDICINE. the purpose of the administration of justice. In both instances medicine stands in the position of an auxiliary science. Medicine does not undertake to render a verdict in judicial matters, and Pastoral Medicine does not decide in points of faith and morals. Its task is merely to furnish material for the formation of a correct judgment. Nor has Pastoral Medicine anything to do with the heal- ing of diseases as practised by the medical profession, though undoubtedly it may greatly help in the prevention of sickness and in establishing of proper hygienic con- ditions for the welfare of mankind. The priest is, to a considerable degree, the teacher of the people. The people, as experience teaches, turn often to the priest for help and advice, not only in matters ecclesiastical, but also in questions of physical welfare. To be able to give the advice proper in such instances the priest should be familiar, at least, with the funda- mental principles of hygiene. The objection may be raised that hygiene does not properly belong to the scope of Pas- toral Medicine, and that the necessary knowledge in this field might be obtained from popular scientific works. If this be true, it is also true that works of this kind are not always readily accessible, and that for various reasons the young ecclesiastic can not be expected to take up ex- tensively this field of study. In this country, moreover, some knowledge of hygiene is almost indispensable for the priest, who, for instance, is likely to be called upon to arrange for the building of a school, church, or other public edifice, with proper re- gard for hygienic conditions. When treating of any branch of science or art we in- quire into its development ; its history. The development of Pastoral Medicine, in the sense as it is taken in this book, is of modern date. The connection between the INTRODUCTION. 7 clerical and medical professions, however, is as old as the history of man. Health is the highest of worldly possessions. It is, therefore, not surprising that mankind, when deprived of this possession, have at all times endeavored to regain health by all known and available means. In ancient times, when sickness was considered solely in the light of punishment from the deity, the priest, as mediator between the deity and the mortals, was called upon to combat the affliction by prayers, sacrifices, and conjurations. But soon the treatment of physical ills was made a profession and physicians appeared upon the scene. Among the Egyptians, the oldest civilized nation, the science of medi- cine was very early developed by their priests. Phy- sicians were not allowed to depart from established meth- ods of treatment. Each form of sickness had its special physicians. " Medical science with them," says Hero- dotus, " meant a physician was a healer only of one par- ticular form of ailment and not for others, and there were plenty, and for all kinds of diseases. They had physicians for the eyes, for the head, for the teeth, for the stomach, and for other diseases." Egyptian physicians gained con- siderable reputation not only at home, but also in foreign countries, until the physicians of Greece proved to be their superiors. The most renowned among Greek physicians was Hippocrates, 460-364 B. C. It was he who first taught the observation of nature, the study and examination of the sick person. He also wrote books on medical and hygienic subjects. Soon after him philosophy regained the upper hand and medicine walked hand in hand with the systems and theories of the philosophers. Finally the science of medicine sank so low that in Greece as well as in Rome its practice was left to slaves. We must linger for a moment with the Israelites. 8 PASTORAL MEDICINE. Among the chosen people priests and Levites possessed much medical knowledge. It was their duty to pass judg- ment upon the cause and healing of leprosy, to undertake the religious treatment for the purification of women after childbirth, and to watch over the proper observance of the rules and regulations prescribed by the health authori- ties. The Israelites very early had also a lay medical pro- fession, who took payment for their services : " If men quarrel, and the one strike his neighbor with a stone, or with his fist, and he die not, but keepeth his bed : if he rise again and walk abroad upon his staff, he that struck him shall be quit, yet so that he make restitution for his work, and for his expenses upon the physicians" (Exod. xxi. 18, 19)- Let us now throw a glance upon the conditions existing at the time when Christianity appeared upon the scene. The Lord Himself performed many wonderful cures upon the afflicted, and always exercised His charity upon the sick and the weak. The first Christians, from the bishop down to the new convert, vied in their efforts to follow His example in taking care of the sick, the helpless, and the victims of persecutions. As soon as Christianity was allowed a free field, there arose before the eyes of astonished heathenism an activity of Christian charity. There rose up in all large cities hospitals, where the sick were taken care of and the pil- grims found a home. Many holy Fathers, such as St. Basil, St. Ambrose, and St. Augustine, were founders of such institutions. Medicine was practised in the spirit of Christian charity by clerics and monks. (J. Chrys. de Sacerdot. L. 3, c. 6.) The Augustinian monks were particularly renowned for their knowledge and skill in medicine. Also the Benedic- INTRODUCTION. 9 tines of Monte Cassino practised medicine according to the doctrines of Hippocrates and Galenus. To these zeal- ous clerical physicians we owe the preservation of many ancient manuscripts on medical science and practice, as the works of Hippocrates, Galenus, Celsius, and others. In the early Middle Ages medicine was a favorite study of numerous ecclesiastics. Many of them made practical application of the results of their studies in convent, mon- astery, and at the sickbed, and as a consequence the pur- suit of this work brought some of them into conflict with the dignity of their office. Referring to this state of affairs the Cistercian monk Helinand (1227) complains: " Ecce quaerunt clerici Parisiis artes liberates, Aureliani auctores, Bononiae codices, Salerni pyxides, Toleti daemones et nusquam mores." We must not omit to mention the celebrated medical school of Salerno, where Greek, Roman, and even Arabian doctors obtained their knowledge. Desiderius, Abbot of Monte Cassino, who later became Pope Victor III., was a physician and instructor at this school toward the end of the eleventh century. Digressions from studies proper to their vocation, by priests, finally caused the Church to proceed in a dis- ciplinary manner. The council of Rheims (1131) forbade monks and priests to study and practise medicine for the purpose of revenue. Two councils at Montpellier (1162 and 1195) made this interdiction more severe. In the Decrt. Greg. lib. iii., tit. 4, we read, " Sententiam san- guinis nullus clericus dictet out proferat, nullus quoque clericus ruptariis vel ballistariis aut hujusmodi viris san- guinum praeponatur, nee ullam chirurgiae artem, Sub- diaconus, Diaconus, vel Sacerdos exerceat, quae adus- tionem vel incisionem inducit." io PASTORAL MEDICINE. Pope Innocent III., at the General Council of 1215, con- firmed the prohibition of the practice of chirurgy by monks and clerics. A further proceeding, partly caused by the clerical occupation with medicine, is taken in the well known bull of Boniface VIII. (1300), in which excom- munication is pronounced upon all those who undertook the dissection of a human body or the boiling of human bones. On account of these and similar severe measures, clerical physicians gradually became extinct. Notwithstanding these misemployments, it was at all times a recognized fact that the ecclesiastic who devotes his work to the care of the soul, should take into considera- tion its habitation: the body, and, consequently, should not be without certain amount of medical knowledge. It is not the purpose of Pastoral Medicine to teach or to induce the priest to take upon himself the task of the practising physician ; it merely undertakes to enable him to advise and caution, to protect by hygienic and dietetic measures, himself and his flock against disease. FIRST PART. HYGIENE. TT YGIENE is that branch of medical science which oc- * * cupies itself with the preservation and furtherance of health and sanitary conditions. In our own days hygiene has received considerable attention and advance- ment. It is clearly the fact that the prevention of sick- ness is more easily accomplished than its cure. Therefore great attention to this matter is being paid in all well regulated communities. England took the lead over all other countries in the diffusion of knowledge concerning hygienic conditions. Disraeli (Lord Beaconsfield) at a meeting in Manchester (England) maintained the import- ance of hygiene in the following language : " In my opin- ion, the establishing of sanitary conditions among our peo- ple is the one social question which stands above all others and which must command the primary attention of all statesmen and politicians irrespective of party. By pro- viding wholesome habitations, pure drinking water, un- adulterated food, and pure air we shall be enabled to secure the happiness and welfare of our people." I. AIR. i. General Remarks. The 7one of gas which enwraps our terrestrial globe, and which moves with the globe's surface around its axis, we call the atmosphere. The layer of air nearest to the earth's surface is the most compressed, and, therefore, the heaviest. Farther removed from the earth the air be- comes thinner and lighter. Since the atmosphere sur- / ii 12 PASTORAL MEDICINE. rounds all objects upon the surface of the earth uni- formly and penetrates all vacuities, we do not feel its pressure. The instruments with which we measure the pressure of the air are called barometers. The ordinary mercury barometer contains in its sealed long glass tube a column of mercury about thirty inches long. The air pressure upon the short, open arm of the barometer tube prevents the mercury from flowing out. If water were to be sub- stituted for mercury, the column of water to hold the bal- ance with the pressure of air would be greater in propor- tion as water is lighter than mercury. Putting the specific weight of water at = I, that of mercury will be 13.59. By a simple computation we will find that the height of the column of water would have to be about 36 feet. In other words, air pressure will raise water about 36 feet. (As demonstrated in an ordinary pump.) We further learn from these physical laws that the atmospheric air of ^ square inch has a pressure of about 2.27 pounds. The force of atmospheric pressure diminishes with increas- ing elevation above the level of the sea. At an elevation of 17,000 feet the barometer will indicate hardly half the pressure that it will show at sea level. Besides the mercury barometer, there are also used metal or aneroid barometers for the measurement of air pressure. The action of aneroid barometers depends on the varying pressure of the atmosphere upon the elastic top of a metallic box (shaped like a watch) from which the air has been exhausted. An index shows the varia- tion of pressure. Though as regards the handier form, the greater durability and convenient carrying the aneroid barometer are preferable, yet it remains necessary for the purpose of correct measurements to compare it with the mercury barometer. AIR. 13 The temperature of the air is ascertained by ther r mometers. Atmospheric air, the prime necessity of all organic life upon earthj has been shown to be essentially a mixture of nitrogen (79%), oxygen (20.96%), carbon dioxide (0.04%), some vapor of water and traces of ozone. This mixture is considered the pure, wholesome air, and re- mains nearly always the same under normal conditions. Of these component gaseous substances nitrogen is the least important in relation to hygienic considerations. It has no functions in the animal body and is merely a medium for diluting the oxygen. Oxygen is the gas in- dispensable for breathing and, therefore, for life. With each respiration oxygen mixes with the blood in the lung- cells and makes it bright red, arterial. The arterial stream of blood charged with oxygen penetrates into all, even the most remote parts of the body, and is active in all functions of life. Ozone is a peculiar modification of oxygen. The most remarkable property of this agent is its oxidizing power. Pigments are easily destroyed by ozone, metals rust under its influence, moreover organic corpuscles of all kinds, contained in dust, in the air, as well as disease germs, are all oxidized and thereby rendered innocuous. Just as sure as you will find ozone in a fragrant pine forest, you will look for it in vain in the lanes of manufacturing towns or in crowded habitations. Of the greatest influence upon hygienic conditions is the percentage of carbon dioxide in the air. The principal cause for the existence of carbon dioxide is the respiration of human beings and animals. As ex- plained above, oxygen enters into the blood with the air which we take into our lungs through the action of breath- ing, At the same time we expel in the reverse action of i 4 PASTORAL MEDICINE. the respiratory organs air laden with carbon dioxide. An adult emits by respiration carbon dioxide to the extent of about 25 quarts hourly. A second cause for the presence of atmospheric carbon dioxide is the process of decomposition and decay, which takes place especially in manure and fertilized soil. In the third place, the consumption of fuel in industrial centres furnishes a great amount of carbon dioxide. Fi- nally there are subterranean stores of carbon dioxide which feed the atmosphere through the fissures of rocks and volcanoes. This ceaseless supply of carbon dioxide is counter- balanced by a proportionate absorption. In regard to this point we must mention, first, the wonderful inter- change between the animal and vegetable kingdoms. Green plants consume in daylight carbon dioxide, applying the same for the building of cells. Atmospheric precipitations (rain) also absorb carbon dioxide, and, lastly, carbon dioxide is removed by the acids of salt water and by dispersing winds. The result is, that we find, as a rule, an equal percentage of carbon dioxide in the atmosphere (0.03-0.04%) 1. Air as a Cause of Disease. Experience teaches that air in the open, containing 0.05% of carbon dioxide, as is often the case in industrial centres, is hard to breathe for a length of time. In rooms air must be considered as bad and unfit for a continued stay for human beings, which, as a consequence of the breathing process of its occupants, contains more than 0.10% of carbon dioxide. To many people even a short stay in such rooms causes headaches, dizziness, or nausea. A continued stay in such rooms will cause poorness of blood and inclination to lung diseases. Good air in living AIR AS A CAUSE OF DISEASE. 15 rooms, such as not to impair health, must not contain more than 0.07% of carbon dioxide. The clergyman in his everyday life comes into frequent contact with air in closed rooms where many persons are breathing, such as churches, schoolrooms, and meeting rooms. It is, therefore, necessary that such rooms, after having been vacated, be properly aired, and that free access should be given to the outer air while the rooms are oc- cupied. In closed rooms, where many people congregate, and where fresh air is prevented from entering, there soon arises an unwholesome condition not only by over- charge of carbon dioxide, but also by excretion of the skin and the nature of the exhalation. The nose in normal con- dition is the best agent to discover such conditions. Apart from the danger from gaseous substances, the air may also cause disease by being charged with dust and bacteria. In our towns the atmosphere is greatly defiled by the enormous mass of soot emitted from flues and chim- neys. Smoke and soot consist of dense masses of carbon dioxide mixed with small particles of coal, which escape into the flue from the flames on account of incom- plete combustion. In industrial centres this admixture becomes so con- siderable as to make the air detrimental to the state of general health. Inflammation of the lungs often takes a fatal turn under such conditions. These impurities of the air are particularly injurious to those whose respira- tory organs are delicate or already affected. Such indi- viduals should, if possible, change their place of abode. Especially the clergyman whose lungs are subjected to a great strain in the discharge of his duties should be careful, where such conditions prevail. 16 PASTORAL MEDICINE. Microscopic growths, called bacteria, which in our time have been discovered to be the cause of infectious diseases, form a very considerable part of the impurity of the air. These microorganisms stick to mineral dust particles and to minute fragments from clothing fabrics mixed with the air. It has been known for some time that the agents which cause fermentation and decomposition are also micro- organisms. If the development of these microorganisms is checked by the introduction of substances which are poison to them, then decomposition does not occur. These bacteria destroyers are known as conserving or antiseptic agents. The best known of them are carbolic acid, acetic acid, sublimate, salt in large quantities, etc. The careful and proper employment of such antiseptic agents serves to preserve articles of food in daily life. We stated above that bacteria are the origin and cause of contagious diseases. If a wound, infected with microorganisms or bacteria, as is the case with wounds due to accident, is treated with such antiseptic agents, festering of the wound and feverish conditions may be avoided. If not so treated suppuration and fever are the consequences. These malignant results of infection may also be avoided by the use of sanitary bandages after the wound has been properly cleansed and disinfected. The bandages will filter the air before it reaches the wound. Upon these principles rests the modern antiseptic treatment of wounds. The least number of microorganisms are found in the air of the open country, entirely or almost free from hu- man habitation, on high mountains, and also on the sea a distance from the shore. But even in populous districts the constant motion of the air causes such a dispersion of infectious microorganisms that the danger of catching disease by mere contact of air is only remote. WEATHER AND CLIMATE. 17 The deposition of these infectious microorganisms by the air is various. In the quiet air of the sick-room they settle upon the floor and the furniture. Infection by con- tact with air in the sick-room would be made more likely if dust was there allowed to gather, which through the moving about of patients, or through handling of beds, clothes, or furniture would rise and through inhalation enter the systems of those present. 3. Weather and Climate. The physical processes in the atmosphere produced by passing changes in temperature, air pressure, and lower or greater humidity of the air we call weather. By climate we understand the average condition of a certain territory in regard to temperature, moisture, etc. Weather and climate have always had a great influence upon the state of human health. Daily experience teaches, for instance, the influence of weather and climate upon catarrhal, pulmonary, rheumatic, digestive, and nervous ailments. We also know the healing power of some cli- mates for certain diseases, for instance, of the mountain air for consumption. On the other hand, it must be men- tioned that the benefit of climatic conditions is often greatly exaggerated for commercial purposes. Let us now consider what connection there is between the temperature of the air and the state of our health. The human body, by the functions of life, produces warmth. For the purpose of health the own warmth of the body must not be below a certain degree. The blood heat of a healthy person is about 98 Fahrenheit. This warmth, produced by functions of the body, digesting of food, muscle and nerve activity, etc., is counterbalanced by certain causes of decrement, such as exudation, ab- sorption by contact with cold objects, etc. i8 PASTORAL MEDICINE. The natural factors producing warmth of the body are not always sufficient to keep it in normal condition. For this purpose clothing and dwelling are needed. Excessive heat of the air causes an accumulation of heat in the body, which may call forth dangerous and sometimes acute manifestations of health disturbances, as observed in cases of heat prostration and sunstroke. In the first stage of heat prostration the face has a flushed appearance, the eyes are glassy; headache, dry- ness of skin, a burning sensation in the throat and hoarseness make their appearance. Soon dizziness, rapid action of the heart, trembling and fainting follow, until finally the afflicted collapses completely. Treatment for persons prostrated from heat is as fol- lows. Such a person should be taken quickly to an airy, cool place; tight clothing should be removed; face and head freely washed and cooled with cold water and ice bandages ; refreshing and strengthening drink should be sparingly given. In serious cases, medical aid must im- mediately be summoned, because treatment will differ according to individual conditions. It should be remembered that for the production of heat-prostration the high temperature of the air alone is not decisive. In dry and breezy air, no matter how high the temperature, or where abundant perspiration is obtained (Turkish or Russian baths), prostration will not result from great heat. It is most likely to happen in calm air of high temperature charged with a great amount of humidity, especially in a prolonged term of such wea- ther. Such conditions are met with in the tropics, at the beginning of the rainy season, and also in some moderate climates during summer time. The crowding of human beings in closed rooms, such as churches, classrooms, etc., is conducive to heat prostra- WEATHER AND CLIMATE. 19 tion, which, under such conditions, often appears in form of fainting spells. Light airy clothing, avoidance of strenuous exercise, the free drinking of pure water and other wholesome beverages, with absolute exclusion of all alcoholic liquids, are the best preventives against heat prostration. Sunstroke, properly so called, differs from ordinary heat prostration by the fact that it is directly caused by the rays of the sun. It occurs in the tropics, and to guard against it travelers in those parts usually wear light, porous cork helmets, to which a linen cloth, pro- tecting the neck, is fastened. Besides these forms of disease directly due to high atmospheric temperature, there are others indirectly caused by the latter; for instance, cholera morbus, which affects the digestive organs and results not infrequently in death, especially among children. It is advisable to call in a physician for this ailment. Regarding hygiene for hot days, Dr. Brouardel, hon- orary dean of the Paris faculty and former president of the Consulting Committee of Public Hygiene, has issued certain counsels of dietetic prudence for the dog days which may not be without their interest for American readers. He advises a sufficiency of solid food, with light vegetables, not highly seasoned, and avoiding fats and farinaceous diet. In liquids he urges hot as against cold drinks, and especially tea or coffee. If, however, cold drinks are insisted upon, coffee, wine diluted with water, and lemonade are best. Ice and alcohol are both tabooed. Apparently all the doctors in Paris were engaged in giv- ing their views of " what to eat, drink, and avoid " during the heat wave. The opinions are various, but when they are collated, it is possible to arrive at some general con- clusion. Lean meat not much of it fresh vegetables, 20 PASTORAL MEDICINE. tea and coffee in any quantities, but no spirits on any pre- tence, as few iced drinks and as little alcohol generally as possible, seem to be about the regimen favored by the French medical men during hot weather, and common sense supports it. The influence of low temperature upon the human body is, as a rule, without injurious consequences, if the body is properly protected and cared for. If this, however, is not the case, very low temperature may cause directly serious disturbances of health. Extremities become frost- bitten and gangrenous. In more aggravated cases the blood is forced into the brain and lungs, causing headache and difficulty of breathing. In the extreme stages of freezing there follow unconsciousness and death by paralysis of the vital organs. It is commonly known that frozen parts of the body must not be treated in warm rooms and by warm applications, but by rubbing with snow and ice water, in a cool place. Ordinary variations of air pressure have not, as a rule, a direct influence upon human health. Indirectly these variations are of consequence, because upon them depend winds and precipitations, and the latter are in many ways the cause of disturbances of health, such as colds, etc. Artificially increased air pressure, such as found in pneumatic caissons and in other apparatus used in bridge building, etc., causes a retarding and deepening of respira- tion ; the blood is driven from the periphery to the inner organs of the body, and the hearing, speaking, and use of muscle are greatly impaired. The change from com- pressed to ordinary air should be very carefully made, as bleeding from nose and lungs may ensue, and even sudden death may result. Diminished air pressure, as met with in high altitudes, WEATHER AND CLIMATE. 21 causes acceleration of respiration and pulse. In dimin- ished air pressure in higher altitudes veins near the surface of the skin, for instance, of the nose, lips, and gums, may burst and cause bleeding of those parts. In very high altitudes dryness of the throat, difficulty in swallow- ing, thirst, dizziness, and headache are liable to occur. These diseased conditions are mostly observed in indi- viduals not used to the living in high altitudes, and are generally called mountain sickness. The variable humidity of the air has an influence upon our health, especially in connection with high temperature. The danger resulting from this connection has been demonstrated in our remarks on heat prostration. Moist, cold air is a powerful heat conductor, and takes much heat from the body. From this fact arises the uncomfortable feeling which we experience in air of that kind. In new buildings, not thoroughly dried, there is present a damp, cold air, causing rheumatism and diseases of the respira- tory organs and kidneys. Mentioning briefly the sanitary aspect of the various climates of the earth, we have to state that the climate in the polar regions is subjected to pronounced changes in accordance with the seasons of the year. During the win- ter the sun's rays are entirely absent ; extreme cold pre- vails. Toward May the temperature rises, and attains its greatest warmth during July and August. Winter, with its death-like numbness of nature, its dreadful monotony, in connection with the prevailing dusk, produces, accord- ing to polar travelers, in most human beings an apathetic feeling and great depression of mind. Where a variety of food is lacking scurvy is of frequent occurrence a sick- ness always accompanied by decomposition of the blood. Otherwise the sanitary conditions are comparatively favorable. Pulmonary consumption is hardly ever found 22 PASTORAL MEDICINE. in Iceland, the Faroe Islands, and the northern part of Norway. Malignant diseases of the bowels and inter- mittent fever are almost unknown. The climate of the temperate zone is, as a rule, free from excessive heat and a great degree of cold in its regular change of seasons. A difference must be made there, however, between the inland climate and the climate of the coast. There are also various conditions that have influence upon the climate of parts in the temperate zone, so that it greatly varies. The tropical climate is distinguished by the regularity of its seasons. They do not differ there so much in de- grees of temperature, but rather by conditions of drought, wind and precipitation (the rainy season). The sanitary conditions of tropical regions are of in- creased interest to our clerics on account of the fact that a great number of their brethren are active as missionaries in tropical countries. The prevalent diseases of the tropics are tropical anemia, diarrhea, dysentery, intermittent fever, and malaria. The latter is a most dangerous malady in trop- ical regions. The name itself, mal-aria (bad air), stamps the sickness as the product of the surrounding atmosphere. This bad air producing malaria is principally found in marshy grounds, low-lying river banks, and the mouths of rivers with brackish water. In spite of all dangers from the hot climate, there are found among northern peo- ple many individuals who successfully and continuously overcome these conditions. Lean, but healthy, men of normal quantity and quality of blood will, in the tropics, have the advantage over bloodless, inflated, fleshy and freely perspiring individuals. SOIL AND DRINKING WATER. 23 II. SOIL AND DRINKING WATER. The soil, on which the human being lives, has a direct bearing upon the condition of the health. It has at all times been a well known fact that cer- tain localities have, for instance, been particularly favor- able to the development of malaria. As shown before, these conditions always exist where stagnant water gathers on the surface of the ground, and where at the same time decaying organic, especially vegetable, matter is deposited. By the process of decomposition there are formed several kinds of gases which, heavier than the atmosphere, remain resting upon the surface. In such districts, it is, therefore, especially dangerous to lie down upon the ground to rest or to sleep. Intermittent fever is almost sure to be the result. A person resting on or near such ground is also exposed to the danger of being inoculated with malaria germs by the sting of insects. The health menacing condition of malarial soil may be amelio- rated by drainage. The mechanical properties of certain soil (clay and sand) have a faculty of absorbing and burying decom- posed matter. With this faculty of the soil must be men- tioned another fact, which plays a great part in the house- hold of nature it is the activity of microorganisms in the soil. Through them the carbon and nitrogen of organic matter become mineralized, i. e., they are changed into carbon dioxide and nitric acid. These again furnish in- dispensable food for the vegetable world. The pores of the earth's surface are entirely, or to some extent, filled with air. This air in the soil is a continuation of the atmosphere, although it shows in its chemical com- position a difference from atmospheric air. The air in 24 PASTORAL MEDICINE. the ground is mixed with aqueous vapors; it contains larger quantities of carbon dioxide than atmospheric air and less oxygen. In deep wells, in burial vaults, etc., there occurs some- times a dangerous accumulation of carbon dioxide gases, which, upon sudden, incautious entering, cause poisoning. The best means for finding out whether a sufficient amount of breathing air is present in vaults, etc., is the lowering of a burning light. If the light dies away, it will be dangerous to go down without previously intro- ducing a sufficient amount of fresh air. In sewers, tan- pits, and similar places, there is often present besides the carbon dioxide an accumulation of poisonous, sulphurated hydrogenic gases. Workmen who enter such places in- cautiously sometimes collapse, as if struck by lightning. Ground air may enter dwellings if the cellar floor is not solidly cemented. This transmission becomes more likely when the pressure of the atmospheric air diminishes, the barometer falls, also when strong winds press upon the surface of the earth. The surface of the earth cov- ered by houses is then not subject to the wind pressure and offers an escape for the compressed ground air. Dur- ing the period of heating there is a further opportunity for the entering of ground gases into dwellings. The air in rooms becomes heated, and also lighter, and thus allows the cold ground air to rise. This efflux of ground gases may become extremely dangerous, when, owing to leak- ing pipes, illuminating gas has been allowed to saturate the soil. Under such conditions the gases penetrate the dwellings, unnoticed by the occupants, and cause poison- ing. Of much more hygienic interest than the underground air is the underground water. By underground water we understand those extensive accumulations of water which SOIL AND DRINKING WATER. 25 constantly fill the pores and cavities of the earth. In porous soil an accumulation of water can only occur there, where a substratum of rock, clay, or lime prevents the water from penetrating into lower depths. If underground water remains at certain seasons of the year near the surface, it causes a marshy condition con- ducive to malaria. If it rises to the surface only tem- porarily it will endanger the foundations of dwellings, penetrate into the basements, and, after abating, leave an abnormal moisture of the air, causing mold and offensive odor. If the underground water, however, is located at too great a distance from the surface of the earth, there arises a difficulty of obtaining water for drinking and other purposes. In most cases it is this underground water which sup- plies us with the indispensable necessity of life, i. e., drinking water. If the underground water rises and emerges in a steady flow from the ground it is called spring water. Spring water is, as a rule, considered the best drinking water. The geological conditions in most places are not such as to cause the underground water to emerge from the sur- face. The most usual way of providing drinking water is to sink a shaft well. The sinking of a well is of the utmost sanitary importance to households and institutions. Before we state, therefore, the hygienic demands, which must be made upon good drinking water, we have to ex- plain the sanitary principles which should be followed in the sinking of a well. The pure ground water of the well should be free from influxes of all foreign admixtures. To obtain this it is necessary to wall the well shaft with solid masonry. The opening of the well at its surface should be so ar- ranged that no impure water can flow into it. For the FRANCISCAN 26 PASTORAL MEDICINE. same reason the top should be well covered. A ventila- tion of the shaft for the purpose of maintaining the sa- lubrious quality of the water is not necessary. If the shaft is left open there is the danger of all kinds of injurious matter falling into it. In the neighborhood of the well there must be no sewer- canals, dung heaps, or privies. The question as to the distance that a well should be removed from a graveyard may sometimes present itself to the clergyman. As a general thing it is, from a hy- gienic standpoint, considered necessary to leave a distance of fifty yards between well and cemetery, particularly if the watercourse of the ground water comes from the di- rection of the latter. The formation of the soil into which the well is to be sunk is also worthy of earnest considera- tion if a cemetery is near. If the soil be porous limestone, then it is certain that there will not be good drinking water. If sunk in clay perforated with veins of sand, these veins are liable to carry dangerous matter from the cemetery into the well. It must, however, be mentioned that the danger from burial places for ground water is often exaggerated, not only through ignorance, but in our times also for the purpose of making propaganda for cremation. Only to the above mentioned extent would there be any danger. In cities water should be provided from a natural or artificial reservoir and led through pipes into the houses. This system of providing water is of very high sanitarial importance, because the people are, through a liberal supply of water, induced to cleanliness. Besides, danger of contagion from infected water is removed and the ref- use is effectively washed away through the sewers. From an economical standpoint, the centralized water supply in cities has the advantage of saving a great deal of man- SOIL AND DRINKING WATER. 27 ual labor and making the extinguishing of fires more feasible. If leaden pipes are used, as is commonly the case, there is danger of lead poisoning, and such actually occurs very frequently. The danger of metallic poisoning from drink- ing water exists particularly where the pipes are at times only partly filled, and where, consequently, air has access. Water which stands overnight in the pipes takes up a good deal of lead. In the morning this water should, therefore, be allowed to run off unused before water for drinking purposes is drawn from the pipes. Water containing lime or iron is not deteriorated by leaden pipes. Finally we have to settle the question: What is good drinking water? The first hygienic condition is that drinking water should not become a cause of sickness. There is danger of this when the water has a too high degree of hardness, which impairs digestion. Such water can not be used for cooking many kinds of food, such as pulse, tea, coffee, because of the indissoluble combinations which take place between the salts of lime in the water and the ingredients of these articles of food. The hardness of water is caused by a considerable per- centage of lime and magnesia. The possibility of lead poisoning by pipe water has been already mentioned. Good drinking water should contain no trace of lead when it comes from the pipes. Chemical analysis will give information in both cases. Drinking water should further be, as far as possible, free of bacteria, as well of those that cause decomposition as of those which cause sickness. Microscopical as well as bacteriological examination carried out by experts will procure the necessary information. The second hygienic demand to be put to good drink- ing water is that it should taste well and be appetizing. 28 PASTORAL MEDICINE. Water will be satisfactory if it is without smell, colorless, and clear. Even harmless admixtures to drinking water will soon cause nausea and make the water unfit for use. The taste of the water should be refreshing ; every trace of a foul, moldy, and stale taste must be absent. These bad qualities are often discovered by the taste only after the water has been warmed. The temperature of good drinking water should be from 45 to 55 Fahrenheit, throughout the whole year. Water of a higher temperature is not refreshing, and of a lower, injurious to the channels of digestion. Finally, good drinking water should be obtainable in sufficient quantity. It is deemed sufficient if about seventy- five quarts per day and head of the population are avail- able for all purposes. The minimum for consumption, by drinking and the preparation of food, has been found on ships to be two quarts per day and head, III. NUTRITION AND FOOD. To keep our body in a healthy condition it is necessary to replace in our body the matter absorbed by the func- tions of life and exertions of labor. To cover the de- ficiency caused by these processes we take foods. Foods are divided into two main groups, nitrogenous, or proteid foods, i. e., those which contain nitrogen, and non-nitro- genous, i. e., those which do not contain nitrogen. Nitrogenous foods (meat, milk, eggs, pulse) replace the consumption of the most important ingredient of the body albumen. Non-nitrogenous foods embrace fats and carbohydrates, collectively called heat producers or respiratory foods. Fat is found in both the animal and the vegetable kingdom. All fat contained in the body is there in a liquid state. NUTRITION AND FOOD. 29 Therefore, only such fats are acceptable for nutrition which become liquid at a degree of less than 105 Fahren- heit. Stearine, for instance, is absolutely indigestible, be- cause it melts only at a much higher degree. Carbohy- drates are organic compounds, containing carbon, hy- drogen, and oxygen. They belong mostly to the vegetable kingdom, although also found in animals. To carbohy- drates belong the various kinds of sugar and the starch in cereals. Besides aliments, our body requires for the maintenance of its healthy condition a supply of water and salts in a chemical sense. Water performs in the household of the body a number of important functions. As an agent of solution and for the moving of soluble substances it is of the greatest im- portance. It also plays a great part in the regulation of the heat of the body. Our body needs between four and five pounds of water every twenty-four hours, supplied partly by beverages, partly by solid food containing a percentage of water. For all tissues, for all processes of diffusion, for the proper acting of the gastric juices a certain amount of salts must be an ingredient of our food -phosphates, sul- phates, chlorides, and carbonates. Food consisting only of albumen, fat, carbohydrates, water, and salts, would, however, be taken only with dis- like. To overcome this there must be added a savoring. Under this designation we understand partly the relish- able substances contained in the food or subsequently added to it (the relishable state of roasted meat, the flavor of fruit, of wine, of lemon, seasoning spices, such as pepper, mustard, etc.), partly articles indulged in for their stimulating effect upon the nervous system, like coffee, tea, alcohol, tobacco. 30 PASTORAL MEDICINE. The importance of relishable food is found principally in the fact that it creates a desire to take nourishment. Human beings are most sensitive in this respect. Not only does the appearance of the food sometimes cause them to detest it, but their appetite is very easily dulled by a prolonged diet of the same food, prepared in the same manner. Man requires a variety in his food. This necessity has been discovered especially in educational and other institutions. Nothing is more abhorred, for in- stance, by the inmates of prisons than the monotonous bill of fare there prevailing. To the clergyman who may be called to act as a member of the Board of Administration of some hospital, orphan asylum or similar institution, the knowledge of this fact is of interest. Among inmates of orphan or similar asylums a disease is frequently met with in which food plays an important part, namely, scrofula, a sister sickness of tuberculosis. In children of the tenderest age it is the cereal food which causes this disease, either by disturbing the process of transformation of matter in the body, or by creating con- ditions favorable to the disease, if an inclination to the same has been inherited. In larger children a cereal and potato diet favors a further development of scrofula. In the diet of orphanages milk and meat should, there- fore, play an important part. In the diet of the sick we must make a distinction be- tween the nourishment of patients in feverish condition and those who are convalescent. There is also a diet for people inclined to obesity, etc. In former times the principle prevailed to prescribe diet- ing for every sick person. By this was understood the nourishing of the patients with thin, weak soups. The partaking of nourishing foods was considered harmful for patients. In our days, we know that the fever patient, NUTRITION AND FOOD. 31 for instance, suffers an increased and accelerated change of matter in his body. Through the increased secretion of important substances during the fever, the weight of the body decreases rapidly. The nourishment of fever pa- tients has for its task to give compensation for this waste, or to restrain it as much as possible. In such diseases the use of fine flour, rice, and maltose is to be strongly recommended. By employing carbo- hydrates the decomposition of albumen will be greatly prevented. As the fever abates, albumen in easily di- gestive form, such as peptone, finely minced meat, or beef tea may be given. As mentioned before, a healthy person needs between four and five pounds of water daily. The fever patient with his increased temperature needs even more, and it is a great comfort to him. After the crisis of the sickness has passed the convalescent needs more albumen for the production of muscle. As the digestive powers become stronger more carbohydrates and albumen should care- fully and gradually be added to the food, and it may be given more frequently. Overloading of the stomach should be avoided, as it is an erroneous idea that a frail child or feeble patient can speedily be brought back to normal strength by the consumption of concentrated and rich food. In contrast to the forms of diet having in view the main- tenance or recovering of normal condition of the human body, there is the reducing diet for obese persons. The nutrition of our body does not intend the accumulation of fat. If such accumulation occurs in individuals, owing to predisposition or a faulty mode of life, it may easily be- come the cause of serious maladies. Excessive depositions of fat hinder the activity of the muscles, particularly of the muscles of the heart. They cause shortness of breath, 32 PASTORAL MEDICINE. deterioration of the blood, and finally dropsical secretions into the cells and cavities of the body. A consumption of fat and carbohydrates, accompanied by sedentary habits, are most favorable for obesity. The oldest and best known cure for obesity is the one prescribed by the English phy- sician Hardy for a patient of his, named Banting, hence called Banting cure. Under this cure there are omitted from the food all substances of fat and carbohydrates. Only nitrogenous food is allowed, meat and little bread; beverages only in small quantity. Enforced exercise is an important part of the cure. This cure soon causes a distressing feel- ing of hunger, the digestion becomes impaired, the body becomes poor in albumen, and a general weakness fol- lows. Attempts to cure obesity by radical means, includ- ing diet, are always dangerous. A prudent, regular, and frequent exercise, and avoiding of luxurious food and drink are the most rational and safest cure. Like many other evils, obesity is more easily prevented than cured. Fasting and Abstaining. In sketching the physiologic-chemical aspect of the nutrition of the human body it will not be amiss to throw a side glance from a hygienic standpoint upon the law of the Church concerning fasting and abstaining. It is well known that the interpretation of this law is a very mild one, and one which takes in its enforcement considerable account of individual conditions. The reproach made against the Church for the enforcement of this law, there- fore, arises more from a general disinclination to obey her laws than from other reasons. It is apparent that the observing of the law concerning the nutrition of the body must vary with the climate. Every ecclesiastical ordinary FASTING AND ABSTAINING. 33 in charge will, therefore, before publishing an order of fasting, take into consideration local as well as social con- ditions among the people of his diocese. From fasting are excused working people who, in the performing of their daily labor, are obliged to exacting bodily exertion. Exacting exertion is not only that accom- plished by manual labor, but also that which requires great mental strain, for instance, close study. To this class should be counted especially theological students. For these young men there is great danger that their great zeal for observ- ing the laws of fasting, while engaged in arduous studies, will lay a seed of physical infirmity, and, therefore, the superior of the institution should restrain them with a loving hand. While considering the status of the clerical profession, we must not forget to mention the orders and religious societies which have the nursing of the sick for their object. The nursing of the sick makes such heavy demands upon physical strength that any restriction in the matter of food is usually out of the question, if the in- dividual is to perform his or her duties satisfactorily and without injury to self. Besides, a body with an empty stomach is exposed in an increased degree to the danger of infection. The abstaining from flesh meat is of less importance for nutrition. It can be accomplished by almost everybody at the times when the Church demands it. Only the sick and convalescent, especially those suffering from stomach complaints and to whom fish and farinaceous food cause indisposition, may be entitled to dispensation. From a hygienic standpoint the rule in the interpreta- tion of the law of the Church should be : Liberality with regard to the law of fasting and strict observance of the law of abstaining. 34 PASTORAL MEDICINE, Food. After this diversion we now turn to the different kinds of food, and we will endeavor to state briefly the demands which hygiene makes upon them. The first demand is that food must not become a source of disease; furthermore, it must be put upon the market unadulterated. We will first take under consideration food obtained from the animal kingdom, i. e., meat, milk, and eggs. Meat, for our food, we obtain from domestic animals, also from wild fowl, game, and fish. Cattle furnish the prin- cipal supply, the foremost in value being the meat of beef. Particularly tender, free from fat and easily digestible is the flesh of young fowl, wild or domestic. To soften the tough meat of wild fowl it should be soaked for some time in sour milk. Veal contains more water and lime than beef. Taste and nutritious value depend upon the age of the animal and of the quality of its feed. Pork contains considerable fat and is harder to digest, yet it is a popular and favorite food among all nations. Horseflesh has a sickening, sweet- ish taste. The meat of fish is mostly free from fat and, therefore, easily digestible ; exceptions are the eel and salmon, which have large deposits of fat, and for that reason their meat is harder to digest. It is well known that the quality of the flesh of cattle varies in accordance with the food they receive. The consumption of meat is, under certain conditions, accompanied by considerable danger to human health, for instance, owing to animal parasites, as trichinae and tape- worms. FOOD. 35 Trichinae are small, slender worms which in the larval state are parasitic in the muscles of the hog. If intro- duced, by the eating of raw or insufficiently cooked pork, in the human stomach the trichinae are liberated and rap- idly become adult, producing large numbers of young, which find their way into the muscles and bowels, produc- ing the disease called trichinosis. Another parasite may be acquired by the consumption of meat from a hog affected with pork measles. Such meat is filled with larvae of tapeworms, which will thus enter the human body and grow there. By eating raw beef another tapeworm may be acquired, larger and stronger than the one found in pork. Pork strongly affected by pork measles is of offen- sive appearance and unfit for use. But it is not only from the parasites of the flesh of warm-blooded animals that we may acquire tapeworms; there is the same danger in the consumption of some kinds of fish, as, for instance, salmon, pickerel, etc. Besides these parasites, certain diseases of cattle may be transferred into the human system by eating contam- inated flesh. Such diseases are murrain, rabies, festering sores, and tuberculosis. Particularly the latter, occurring in cattle and hogs, is deserving of the closest attention in hygiene. This disease is not at all scarce in cattle. An investigation, conducted in the state of Saxony, proved that over eleven per cent, of the cattle killed there in pub- lic slaughtering houses were infected with tuberculosis. The flesh and milk of tuberculous animals are doubtless more or less dangerous. The products from the milk of such animals, such as cream, butter, and cheese, retain the contagious qualities. Slaughtered meat may be considered as dangerous to health if instead of a fresh bright red color it has a brownish, greenish, or very pale red color, or if, when 36 PASTORAL MEDICINE. squeezed, there flows from it freely a discolored juice; if the fat, instead of hard and solid, is flabby and jelly- like ; when the marrow of the hindquarter is not firm and of roseate hue, but soft and of a brownish color. Spoiled and tainted meat, moreover, emits an offensive smell. Sellers of meat, however, know how to remove this smell. It may, nevertheless, be detected by thrusting a knife, which has previously been dipped in hot water, into the meat. The knife when removed will retain and be- tray any bad smell that there may be in the meat. The quality of smoked ham may be proved in a similar man- ner by driving a clean nail into the meat right down to the bone. If, withdrawn quickly, the nail has a foul smell, the quality of the meat is suspicious. To avoid the injury to which human health is exposed by the consumption of meat, special laws and regulations for the slaughtering of animals have been enacted since the earliest times. Moses and the writers of the Talmud allowed their people to slaughter only certain species of animals for the purpose of consumption, declaring all others unclean. The slaughter of animals was, moreover, subject to certain regulations. Freshly slaughtered meat is not suitable for immediate consumption. It is tough and has a sickly, sweetish taste. After being properly kept for two or three days it de- velops an acid which renders it tender and fit for use. Fresh meat is usually kept in ice houses. This mode of keeping meat is not as beneficial as it would first appear. The surface of the meat under ice treatment becomes thoroughly moistened and softened and offers in this con- dition a favorable place for the settlement of bacteria of decomposition. Meat kept in this manner, therefore, spoils very quickly after it is removed from the ice box and if not immediately used. FOOD. 37 Much more rational is the hanging of meat in cold, moving air. Under this treatment a dry layer is formed on the surface and the bacteria of decomposition do not find a favorable place for settling. Experts in hygiene, therefore, recommend for the magazines of abattoirs the use of iced but dry air, kept in circulation by suitable means. Care must also be taken to protect meat from flies, which cause maggots to develop in the meat, and may con- vey other infection dangerous to human health. Since, under certain circumstances, a constant supply of fresh meat is difficult or impossible, methods had to be found to make it retain its good quality for a length of time, i. e., to preserve it. The principal requirements of the proper preserving of meat are that no injurious sub- stances are brought into contact with it and that the nour- ishing properties and the flavor are not impaired. The methods most universally in use are salting, smoking, and canning. By impregnating meat with a strong solution of salt (8-12%) the bacteria of decomposition are prevented from settling and spreading. If meat thus salted is then dried in well ventilated rooms, and afterward smoked over a smoldering wood-fire, good results will be ob- tained and there will be no danger of infection by para- sites (smoked ham, sausage). In contrast with this time-honored method of thoroughly smoking the meat, the modern method of rapid smoking is to be deprecated. By this method the meat is dipped into a compound of water, wood-vinegar, and juniper oil and afterward dried. This process does not kill certain parasites and bacteria, ' and the flavor of the meat is impaired. The food next in importance to meat obtained from the animal kingdom is milk. Milk is principally obtained from cows and goats. Goat 38 PASTORAL MEDICINE. milk as a popular food is of great importance. It con- tains more fatty substances than cows' milk, but has less sugar. It should receive particular consideration. Its availability is increased by the fact that goats are easily and inexpensively obtained, their maintenance costs next to nothing, and they are hardly ever affected with disease. The greatest supplier of milk is the cow, and the feed- ing and keeping of this animal are of great influence upon the quality of its milk. Insufficient feeding of milk- ing cows, either with dry or green fodder, has as a con- sequence the production of watery milk, devoid of fatty substances. The kind of fodder itself is of equal im- portance. Poisonous herbs, such as meadow saffron or ranunculus, render the milk of animals, devouring them while grazing, detrimental to health, particularly to infants. Milch cows should be kept scrupulously clean, in well ventilated stables. Their bodies should be carefully cleaned every day, because experience teaches that a well groomed animal furnishes a superior quality of milk. Furthermore, proper care should be taken in the handling of the milk until it is put to use. Soon after it has been drawn from the udder it should be poured through a fine sieve to cleanse it of impurities, and should then be kept in cool rooms. Milk should not be kept in vessels of copper, brass or tin, nor in jars covered with cheap glazing or made of cast iron and lead enamel^ as the milk easily absorbs in- jurious matters. The place where milk is stored should not be in close vicinity to sleeping or sick rooms, and persons who are nursing patients afflicted with contagious diseases should not be allowed to handle milk. Milk is preeminently fitted to be a vehicle of the germs of contagious diseases. Cholera, typhoid, and scarlet fever have often been spread by infected milk. A mother who has just been attending FOOD. 39 her child sick with scarlet fever, may convey germs of the disease to the milk handled by her and given to her other healthy children, who will imbibe these disease germs and very likely get the disease. Milk may also in other ways be the cause of the spread of contagious diseases. If the milk cans are washed with impure water containing disease germs they will adhere to the sides of the vessels, get into the milk and through it reach the consumer. The spreading of cholera and typhoid fever has been traced to this source. Unscrupulous milk dealers injure the consumer's health by selling adulterated milk. The ordinary way of adulter- ating milk is by the adding of water. The defective quality of such milk is detected by the milk scale or by chemical analysis. The most important ingredient of milk, cream, appears on the surface if the milk is allowed to stand without dis- turbance for about twenty-four hours. By the buttering process butter is obtained from the cream, the quality of which corresponds directly with the quality of the milk from which it is obtained, and with the care employed in its handling. After removing the butter there remains in the churn the buttermilk, which, in its fresh state, is a wholesome, cooling drink, containing considerable nour- ishment. Skimmed milk, though not as nutritious as un- skimmed milk, is of no little value as a food and for household purposes. Cheese, also a dairy product, is an excellent and rich food, containing much nitrogen, but not always easy to digest. To the articles of animal food belong also the eggs. The component parts of an egg are about two-thirds wa- ter and for the rest pure albumen and fat in nearly equal portions. The fat is in the yolk, and gives it its yellow 40 PASTORAL MEDICINE. color. Eggs contain none of the sugar principles, and should be eaten with bread or vegetables that contain them. Hard-boiled or fried eggs require longer time to digest than soft-boiled. The latter are, therefore, more wholesome. We will now turn to the food obtained from the vege- table kingdom. In the first place, we must place under this head the food which is the most indispensable and most universally used food of all, i. e., bread. Bread is obtained from the flour of cereals mixed with water, with an addition of leaven or yeast, into a dough. Fermenta- tion then takes place in the dough, changing part of the starch contained in the flour into sugar, alcohol, and car- bonic acid. This latter causes the rising of the dough and gives to the bread its spongy condition, which alone makes it digestible. The kneaded and molded dough is then baked in the oven. Good flour should be yellowish-white, and not of a red or bluish tint. It should have a dry, smooth, yet solid touch, and there should be no lumps in it. If a quantity is pressed together in the hand, it should give a crunching sound, and when released should readily fall apart. The flavor of the flour must not be moldy. Its taste should be sweet, not sour or offensively bitter. A grating sound of flour when taken between the teeth shows that it contains sand. Flour becomes detrimental to health if the cereal from which it is obtained is tainted by certain fungous diseases. Rye bread often contains spawn of ergot, kernels of dark color a little larger than rye grain. Ergot is a fungus which settles as a parasite on the young rye grain, par- ticularly in very wet seasons. If the flour contains as much as 1-2% of ergot its use will cause a sickness called raphany. This sickness FOOD. 41 caused in former times great loss of life, especially toward the end of the sixteenth and at the beginning of the seventeenth century. Even in our own time small epi- demics due to ergot occur occasionally in damp regions, for instance, in the department of Sologne, in France. If rye flour thus contaminated is mixed with pure wa- ter in a dish of white china, it will show a peculiar reddish- brown color, while pure rye flour will, under the same treatment, remain purely white. The impurity can also be detected by chemical analysis. Another health-disturber, also of parasitic origin, is sometimes found in the flour of maize, or Indian corn. It causes a disease named pellagra and occurs frequently in northern Italy. The fruit of leguminous plants, such as peas, beans, and lentils, are particularly rich in albumen. Potatoes con- tain principally starch-flour and water, with very little albumen. They are a favorite and indispensable food of the people, meeting adequately the demands of the body for hydrates of carbon. Some meat should neces- sarily be taken with them, because if albumen is not sup- plied from some source, a potato-diet will soon cause dis- turbed digestion. Green vegetables are very valuable, owing to their palatableness and on account of the salts which they sup- ply to the body. Their actual nutritious value is small, but they contribute to the easy digestion of other food, and they are a great help in the maintenance of good health in the organic body. Fresh fruit is wholesome on account of its agreeable taste and of the change in the diet which it offers. It is also of some nutritious value, which is determined by its contents of sugar. The agreeable taste is caused by fruit acids. As explained before, civilized man craves for his nutri- 42 PASTORAL MEDICINE. tion besides the actual means of sustenance also stimu- lants and articles to gratify the taste. The first consideration among stimulants must be given to alcoholic beverages. The active principle of these beverages is alcohol, an odorless liquid, which mixes freely with water under all conditions. Its effect upon the human organism, when taken moderately, is stimulating the action of the heart is increased and the nervous system becomes animated. Taken in large quantities it causes stupor and prostration, and even sud- den death. Alcohol, besides, works upon the gastric juices of the stomach and appeases the feeling of hunger. An undesirable ingredient accompanying many alcoholic liquors is fusel oil. Fusel oil has a penetrating, offensive odor. Its presence in liquor can be discovered by rubbing some of the liquor between the two hands, when the odor will be noticeable. The fusel oil of potatoes is more dan- gerous to health than that of rye. Fusel oil is the principal agent to cause a detrimental effect upon health by a mis- use of alcoholic drinks, although excess in the use of alco- holic drink will, also for other reasons, injure health. The misuse of alcohol, and inebriation, will be given further attention in another chapter. Some of the best known alcoholic drinks are : (i) Liquors. They are produced from the starch of rye, barley, potatoes, etc., by transforming it by mashing into fermentable sugar. Through fermentation there are de- veloped alcohol, carbonic acid, glycerine, and small quanti- ties of other organic acids. By a distilling of this fer- mented matter the alcohol is secured, which, through the mixing with water, is made into the drinkable liquor. Of alcoholic drinks it is principally liquor which contains fusel oil. To prevent danger to health, this ingredient must not amount to more than 1-10%. Rum is manufac- STIMULANTS. 43 tured from sugar sirups, brandy by distilling of grape wines, arrack from malted and fermented rice. It may be mentioned that these three kinds of liquors are generally sold in an adulterated state, and are but seldom genuine. (2) Beers and ales are obtained by a yeast fermentation, without distillation, of a mixture of malt, hops, and water. They contain relatively little alcohol. A considerable amount of hop resin contained in new beer may cause a violent and painful irritation of the bladder. Good beer is wholesome and nutritious, owing to its contents of hy- drates of carbon and salts. Taken in small quantities it may prove of benefit to convalescents and individuals of poor condition of the blood, owing to its stimulating effect upon the appetite. It retards digestion if taken in large quantities. Persons inclined to obesity should take beer very sparingly or better avoid it altogether. In moderate quantities it is of benefit also to nervous persons. It calms their nerves and induces sleep. (3) Wine. Ripe grapes are crushed, and the juice so obtained is kept for some days, with the skin and seed- kernels left in the same, so as to thoroughly absorb the substances which give wine its peculiar flavor. White wine is then pressed out of this mass, while red wine is not pressed until after fermentation, as only the acids of fermentation will extract color from the grapes. Good wine is of great benefit if taken moderately. To aged peo- ple, in whom the functional energy is weakened, wine is of great consequence. Of course, an excessive consumption of wine can not help but be injurious. Chronic alcoholism is found with the habitual drinker of wine as well as with the drinker of strong liquor. Gout is generally the result of the con- tinued drinking of heavy wines. 44 PASTORAL MEDICINE. Children should not take alcoholic drinks of any kind, unless prescribed in case of sickness. Other stimulating beverages, gratifying to the taste, are coffee, tea, and chocolate. The drink we call coffee is an infusion of the seeds of the coffee tree. Before being put to use, the coffee beans are roasted. By this process the wooden fiber is carbonated and the aroma is developed. The action of coffee upon the nervous system is stimulat- ing it produces energetic action of the heart and kindles the mental and physical powers. Coffee is adulterated in many ways. The meal of wheat and Indian corn are used to produce artificial coffee beans, which are so like the genuine bean that only a microscopic or chemical analysis can tell the difference. A simpler method, however, of detecting adulteration is the following: If put in ether, the artificial bean will at once sink to the bottom, while the genuine bean, on ac- count of its fatty substance, will float for some time. Roasted and ground coffee offers a great opportunity for adulteration. Ground coffee especially is largely adulterated with shavings of iron, with sand, clay, etc. Tea is the infusion of the leaves of the tea shrub after they have been prepared by heating, roasting, or slight fermentation. Tea is adulterated by the admixture of leaves of various kinds. From the fruit of the cocoa tree there is obtained cocoa, which, with an admixture of sugar and spices, is made into chocolate. Cocoa differs from tea and coffee in that respect that, if properly prepared, it furnishes a very nourishing bever- age. The nourishing ingredients of cocoa are dissolved if the powdered cocoa, mixed with eight parts of milk, is boiled for ten minutes under constant stirring. Ingredients used in the preparation of food either to STIMULANTS. 45 give taste or to aid digestion are called spices or condi- ments. Their importance is found in their effect upon the digestive channels in exciting an increased secretion of the gastric juices. Such spices are cloves, black pepper, red pepper, mustard, horseradish. The most indispensable spice for foods is table salt. It plays a very important part in the household of the body. The great natural craving for it sufficiently indicates its importance. We must not conclude this chapter without mentioning the use of tobacco, which first was found in use among the natives of America. It was from there taken to Europe. Since that time the use of tobacco has been con- stantly growing, although ecclesiastical as well as worldly authorities have at various times endeavored to suppress or at least restrict the use of it. At the present time the world's consumption of tobacco amounts to from six to seven hundred million pounds. The most prominent ingredient of the tobacco plant is nicotine, a narcotic poison. Nicotine is a powerful nerve stimulant, which, if used in excess, will cause palsy or paralysis. Tobacco is used in three different ways. The use least detrimental to health is to snuff it. Ac- cording to a medical authority 500 grains of this form of tobacco contain only 0.062% of nicotine. The snuffing of tobacco is, therefore, not so detrimental to health as the use of it in other forms, although in the form of snuff fraudulent admixtures to it would be more difficult to de- tect. When packed in tinfoil, it has often been the cause of lead poisoning. The chewing of tobacco is largely in favor with persons who have outdoor employment, such as soldiers, sailors, men employed in the building trades, etc. The sanitary influence of chewing tobacco has, like the 46 PASTORAL MEDICINE. use of any kind of stimulant, been judged in various ways. Anybody who has had occasion to examine a large num- ber of tobacco chewing men will have to acknowledge that, as a general rule, they are healthy individuals, possessed especially of healthy, strong teeth. At any rate, the use of tobacco in this form does not seem to have detrimental effects. The smoking of tobacco is the most common form of using it. The smoking of cigars is more liable to be detri- mental to health than the smoking of pipes, because in the latter the smoke has to pass through a certain distance before it reaches the mouth, thus losing some of its irritating qualities. The effects of the smoking of tobacco upon the human body are local as well as general. If done to excess, it will cause a chronic catarrh of the membrane of the throat and secretion of a mucous phlegm, causing irritation; the tongue becomes coated and the sense of taste dulled. The eyes become inflamed by the smoke. The irritation of the delicate skin of the lips, caused by the continual carrying in the mouth of a short pipe, should also be considered. Cancer of the lips is sometimes the consequence. It is stated by medical authority that a moderate use of tobacco increases the activity of the brain and combats the inclination for sleep; it has a soothing, but not an exhilarating, influence. It always causes a slight weaken- ing of the muscles. The secretion of saliva is increased by smoking tobacco, which thereby becomes an aid to diges- tion; it also stimulates the action of the bowels and the secretion of urine. Smoking is to be avoided in all forms of chronic catarrh of the various membranes, even in catarrh of the bladder. In suppuration of the ear it is particularly harmful. It DWELLING AND CLOTHING. 47 should also be avoided in cases of sleeplessness produced by mental exertion, in weakness of the heart, and neuralgic afflictions. Any one of the three ways of consuming tobacco becomes detrimental to health if used to excess. Proper consideration of fellow beings, moreover, should make us careful not to offend decency by tobacco use. Chew- ing of tobacco especially is distasteful and insufferable among people of refinement. IV. DWELLING AND CLOTHING Our climate, our morals, our habits of living, our oc- cupations, and incidents of our daily life cause us to spend only a comparatively small part of our time in the open air. Most human beings spend the greater part of their time in closed rooms, either at home, or accord- ing to their calling, in schools, churches, hospitals, manu- facturing plants, or offices. It is, therefore, apparent that the dwelling must have an important influence upon the condition of human health, because detrimental influences in this connection are liable to be of lasting effect. From a hygienic point of view we are interested in dwelling in three different ways : I. The location ; 2. The soil upon which the dwell- ing is erected ; 3. The material used in its construction. The location is the healthier the more free access at- mospheric air and sunlight have to all parts of the dwell- ing. If houses are built too closely together, if the court- yards or airshafts are reduced to the smallest space, the air in the living rooms of such buildings will be seriously impaired. Consequently, in large cities, squares and open places, particularly if planted with" trees and shrubbery, are of great hygienic value. Dwellings are made un- 48 PASTORAL MEDICINE. healthy by improperly constructed drains, sewers, or by the proximate location of latrines and dunghills. This topic will be treated more fully in another chapter of this work. Of great influence upon health are the surroundings of dwellings in industrial centres. Through injurious gases, smoke from factory chimneys, continuous loud noises, manufacturing districts become unsuitable for dwelling. The soil upon which a house is erected may be con- sidered healthy if it is dry sand or rock, and if it does not contain decaying matter or stagnant water. The building materials generally used are wood and brick. The mortar used in stone buildings contains a large part of water, so that, in the just finished building, there is contained a con- siderable quantity of water. In the foundation and walls of a newly erected ordinary brick dwelling there are con- tained many thousand quarts of water, which will evap- orate. From a sanitary point of view it is, therefore, ad- visable that newly erected brick buildings should not be occupied until thoroughly dried. Damp walls, such as in new buildings, are of a twofold consequence in regard to health. In the first instance, there is no air circulation, because air can not penetrate the pores of the bricks if filled with water. Furthermore, damp walls absorb heat in a much greater degree than dry walls. Dwellers in houses with damp walls lose a great amount of bodily heat by a one-sided radiation. Hence the uncomfortable, chilly feeling that one experi- ences in such houses. Further consequences of a pro- tracted stay in damp rooms are rheumatism, catarrh of the respiratory organs, kidney trouble, with resulting dropsy. Dampness in dwellings may also be due to the soil upon which they are erected. We have said above that the ground should be dry. But it is natural that this DWELLING. 49 precaution can not always be observed. Therefore, in order to prevent the ascending of dampness through the pores of the bricks, etc., it is advisable to cover the cellar floor with an impenetrable layer of cement. If water from rains or floods has flowed into the cellars or basements of dwelling houses, it should be pumped out as soon as possible, because such water is sure to be im- pure and to contain a great deal of decaying matter. After the water has been removed as thoroughly as possible, the remaining moisture should be disinfected by an applica- tion of a mixture of carbolic acid and water, or of chlo- ride of lime and water. Walls are treated with the disinfectant by brushes or mops ; floors are cleaned by scrubbing with it. Public institutions, such as schools, orphan asylums, prisons, and hospitals, should be most carefully attended to in the described manner when they have suffered an inundation. We will now take under consideration those parts of a dwelling which are in constant use as living rooms. Rooms with southern exposure are preferable to those of northern exposure, because they offer a free access to sunlight. They are drier, more cheerful, warmer in the cold season, and benefited by the southern breezes in sum- mer time. Special consideration is due to the sanitary conditions of the modern flat and apartment houses in large cities. Ac- cording to the late Professor Virchow and other authori- ties, living-rooms situated on the fourth or fifth story are more detrimental to the health of their inhabitants than even the rooms in the basement. To mention only one fact, it has been ascertained that the greatest percentage of miscarriages happen among women living on the upper floors. 50 PASTORAL MEDICINE. Care should be taken, whenever possible, to have sep- arate rooms for the members of a family, because the air of overcrowded rooms soon becomes vitiated by the pro- cess of respiration. The overcrowding of living rooms does not only take place in large cities, but also happens frequently in the country, especially in winter time. It is an accepted fact that, per person and hour, thir- teen cubic feet of fresh air are necessary. The air of the atmosphere gains access through the cracks of windows and doors, and also through the pores of walls, especially at a time when dwellings are heated. Under any circum- stances this access of air has largely to be assisted by the opening of windows. It has been found lately that the filling between ceiling and flooring is frequently injurious to health. It is ap- parent that the slightest defect in the flooring is sufficient to allow the space under floors to become, in the course of years, an accumulation of dirt and decaying matter which is bound to breed sickness. This is essentially the case in rooms that are used as sick rooms. There is, therefore, also great danger from this source in new buildings con- structed of old building material. By microscopic ex- amination it has been found that old material used for filling in between floor and ceiling contained germs of consumption, typhus, and membranous croup. The saf- est material for this purpose is sand or ashes. To make our living-rooms comfortable we require light- ing and heating, both of which are of the greatest im- portance for our health. Great progress has been made in the manner of light- ing. Starting from the old fashioned candle or oil lamp, there has come into use, at first kerosene oil, then gas, and now electric light. Let us now inquire into the sanitary conditions of the various modern ways of illuminating. LIGHTING AND HEATING. 51 Kerosene is found in the bowels of the earth, deposited there by a decomposition of vegetable and animal matter. The raw kerosene^ or petroleum, is made available for use by distillation. Properly distilled kerosene will not develop a dangerous amount of explosive gases, even if exposed to a high degree of heat. One of the most widely used materials for lighting pur- poses is illuminating gas, usually obtained from coal. Illuminating gas obtained from coal requires a com- plicated process of purification to remove obnoxious and noncombustible matter. The most important element of illuminating gas as regards human health is carbonic acid gas, because it is well known as a deadly poison if inhaled in considerable quantity. By the process of burning it is changed completely into carbonic acid. If illuminating gas saturates the air to the extent of from 10-25% the mixture then becomes highly explosive. Accidents due to such explosions are quite frequent. In our times electric light is largely taking the place of illuminating gas. There are two kinds of electric light, the arc light and the incandescent light. The first is produced by two pieces of carbon, which represent the positive and negative pole of a current and consist of a stream of glowing particles of carbon. The incandescent light is formed by heating a thin car- bon wire in a vacuous glass bulb until it glows. In regard to health we have to consider in this connec- tion principally the eyes, which are greatly affected by artificial light. The principal requirement is that the light should be steady and not flickering. Lamp shades are of great importance in the universally accepted mode of lighting. They prevent the rays of the light from fall- ing directly into the eyes, from causing a strong dazzling and preventing the eyes from distinguishing objects. Such 5* PASTORAL MEDICINE. shades also reflect and concentrate the light upon the working table. The evenness of the flame is of im- portance, for the reason that a flickering or wavering light is very injurious to the eyes. All illuminating materials, excepting the incandescent light, contaminate the air of living-rooms by the process of burning. Besides, they create a considerable amount of heat. A burning kerosene lamp emits about twelve times the amount of carbonic acid which a human being does by respiration, and about eight times more of heat and vapor. Kerosene and gas are about equal in this respect. By a comparison of gas and electric light the con- clusion is reached that both kinds of illumination have, from a hygienic standpoint, their advantages and disad- vantages. In favor of electric light are the enhancing of the sense of color and the keenness of vision, the trifling production of heat, and the lack of corruption of the air; against it are its vivid dazzling qualities and the danger from the operation of a strong electric current. The disadvantages adduced against gas light are its great production of heat and corruption of the air, as well as the dangers of explosion, and of poisoning by inhalation. The advantages of the electric light, from a sanitary point of view, according to this, are almost entirely lack- ing in gas. In order to make living comfortable in dwelling places in our latitudes during the cold part of the year, heating arrangements are indispensable. The first object of every heating apparatus in dwellings is to keep the air always at a temperature agreeable and advantageous to the organism, i. e., of from 64 to 70 degrees Fahrenheit. The quicker the heating results, the easier to regu- late it, the less contamination of the air is caused by the HEATING. 53 products of combustion, so much the more perfect are the heating arrangements, if they, furthermore, require little time for attendance and are as economical and cheap as possible. We distinguish between local and central heating arrangements. In local heating arrangement the heat-dispenser is found in the rooms to be warmed. To this class belong the stove and the fireplace. The construction of a stove is such that the fuel must either be continually put on, as in the ordinary stove, or emptied into it to serve for a longer time, as in the self- feeding stove. Ordinary stoves allow of a quick warming of rooms, but require continual attention lest the fire should as quickly go out. The handling of the fuel gives rise to a troublesome development of dust and thereby to the deterioration of the air in the room, when a dust-pro- ducing substance like coal is used. The common material of which stoves are made is iron. By great heat the thin sides of the stove easily become red hot, and in this condition permit the poisonous car- bonic oxide gas to pass from the fire chamber to the room. To guard against this the sides of the stove are re- inforced by the inserting of a fire pot in the fire chamber, which, however, does not prevent the side of the stove from becoming red hot. Ordinary stoves provide, to a certain extent, for a re- newing of the air of the room, because the air necessary for combustion is drawn from the room to be heated. There results a current of air from the room through the fire chamber to the chimney, and fresh air from the out- side enters through the cracks of the doors and windows. The self-feeding stove is supplied with fuel for a longer period. But this must be of a kind that will not cake, 54 PASTORAL MEDICINE. so that spaces may be left through which the air nec- essary for combustion can pass. By means of a regulating shutter in front of the stove, below the fire chamber, the entrance of air, and with it the intensity of the combustion, can be regulated at will. The self-feeding stove permits of the easy regulation of uniform warmth to a room, as required by the tem- perature outside. On the other hand, it should not be overlooked that the more completely such stoves allow of shutting off the draft, the greater becomes the possi- bility of fire-damp (carbonic oxide) penetrating into the room. Many a perfect and patented self-feeding stove has had to be removed because of the appearance, among the occupants of a room, of illness resulting from chronic poisoning by carbonic oxide gas. Carbonic oxide gas, which has already been mentioned as a poisonous ingredient of illuminating gas, is a color- less and odorless gas of a nature extremely poisonous for the human organism. It results from the incomplete combustion of carboniferous bodies, and especially from the process of combustion in a stove. This gas is also commonly called fire-damp. But this designation is not intended to apply to the smoke and vapor which arise from a fire. These last-mentioned products of combustion are intolerable to the senses and the breathing organs, and people, therefore, get rid of them as speedily as pos- sible. Carbonic oxide also emanates from glowing coals after the smoke has passed away. If at this stage of combus- tion the draft of the chimney is interrupted by means of a valve or shutter, the poisonous gas enters the room and is most deadly for the unwary occupants, especially in sleep. The gas is breathed by the lungs, and then enters into combination with the blood, so that the latter HEATING. 55 can no longer absorb the oxygen, which is indispensable to life. Death follows painlessly. If the quantity of gas breathed is not fatal, or the victim is resuscitated, there often remains behind a per- manent impairment of health (mental debility, diabetes). It is not stoves alone that in everyday life cause car- bonic oxide poisoning, but also portable coal-burners, which sometimes through inexcusable carelessness are used to heat closed rooms. We have, in our practice, many times met with cases where servant girls, who had taken with them into their bedroom an iron pot filled with red hot anthracite and charcoal, were, on the following morning, found dead or dying. In order to prevent injury to health, caution is also necessary in the use of apparatus for heating or cooking by gas. The gaseous products of combustion must be sufficiently diverted and fresh air must be allowed to enter, otherwise a considerable accumulation of danger- ous carbonic oxide and a lessening of oxygen will re- sult. Heating by means of a fireplace is effected by the maintenance of an open fire in a niche in the wall, with a direct draft of the products of combustion into the chim- ney. Fireplaces are not very common in this country. In England and France they are much in use. How- ever homelike a fireplace makes a room, it is not a practical method of heating, because a far too little part of the warmth produced by the fire is secured for the room. On the other hand, however, its great value as a ventilator for the room must be acknowledged. As to central-heating apparatus, the heat producer is not in the room itself, but in another part of the house, commonly in the cellar, from which the distribution of warmth in the building is effected by means of a system 56 PASTORAL MEDICINE. of pipes. Belonging to this class of apparatus are the heating by hot air, by steam, and by hot water. A description of the construction of these apparatus would be too much of a digression here, but space may be given to a few remarks on their advantages and dis- advantages, since it will be of interest for thoughtful people to be generally posted on these points. These heat- ing arrangements are also ordinarily used in large estab- lishments, like hospitals, orphan asylums, schools, con- vents, etc. Heating by hot air can be installed cheaply, it com- bines rapidity of warming with a certain continuity. Its greatest advantage consists in assuring of a constant change of air in rooms, in which, as far as sanitation is concerned, it excels all other modes of heating. The disadvantages of the hot air system are : Some dif- ficulty of regulating the supply of warmth, great con- sumption of fuel, and the danger of leakage or over- heating of the apparatus, and a consequent deterioration of the quality of the air. Great care must be taken to restore to the heated air a sufficient degree of moisture, and this is accomplished by the placing of water within the heater, so that its steam mixes with the air distributed through the pipes. Steam heating admits of wide distribution, and is, therefore largely in use in big buildings. It is easy to regulate. Disadvantages of steam heat are : Costliness of installa- tion, danger connected with the management of the boiler, the conductors easily become leaking and then cause an annoying noise. Special contrivances are necessary to secure moisture to the air, and also for the changing of air. Steam heating can only exceptionally be specially in- VENTILATION. 57 stalled in smaller dwellings; while for larger structures for example, the heating of hospitals and institutions steam heating will always have the preference. Hot water heating works very rapidly, is simple to manage, and can be easily introduced at a moderate cost in buildings already existing. Its disadvantages are the great rapidity with which it cools off, the danger of freezing, the singeing of the par- ticles of dust that settle on the pipes, the dependence of the heating of different rooms on each other, and hence the difficulty already mentioned of obtaining the tem- perature wished for ; lack of change of air. This method of heating is not to be recommended for dwelling houses, but, on the other hand, it is good for heating single subordinate parts for example, enclosed staircases and corridors as well as for single large rooms that have to be used daily, such as halls of all kinds and restaurants. VENTILATION. Regarding this subject, it has already been many times mentioned that change of air is necessary for the maintenance of good health, while living in closed rooms. Fresh air must be introduced and the air already used must be expelled. This renewing of the air in closed rooms we call ventilation. In dwelling rooms the natural circulation of air through doors and windows usually suffices. In warm weather the windows are frequently open, and during the season of heating, the cooler, fresh air penetrates through the cracks of doors and windows, while the used-up, warmer, and therefore lighter, air is carried off through cracks of the upper parts of windows or through opened transoms. Air also escapes through the stove. Tn larger rooms, however, where many people are gathered, the natural circulation is often not sufficient for 58 PASTORAL MEDICINE. a renovation of the air. In these cases the heating ap- paratus is combined with a ventilating arrangement, or special ventilating shafts are installed, or other mechan- ical contrivances are resorted to. The latter are usually circular fans, placed in windows, and set in rapid revolu- tion. They are so constructed that one captures fresh air for the room to be ventilated, while another expels the used-up air in another place (ventilation by means of aspiration and expulsion). PRIVIES. A discussion of hygienic requirements for a perfect dwelling can not be dismissed without touching upon the removal of human excrement. Every properly erected house ought to have a conve- nient and well-arranged privy. An inappropriate or faultily constructed privy renders the finest residence un- comfortable and dangerous to health. The privy, where there are no sewers, ought to be situated on the side of the house, where wind and sun have access. The room itself ought to be sufficiently spacious. The floor, walls, and ceiling must be smooth and easy to clean. There should be no living-room above it. The opening of the hole in the seat must be closed with a lid. The better installations are those that have in the opening a funnel-shaped trap of enameled iron, closed underneath by a movable valve. The cleansing of the trap is accomplished by an arrangement of running water. The excremental matter falls into a cavity or a remov- able receptacle (barrel, etc.). This cavity must be made watertight on the bottom and sides. For greater safety it is recommended that a layer of rich clay be pressed hard around the sides, on the bottom of the pit, and also its enclosing walls, in order that the surrounding soil may not become infected. The conduit to the pit DRAINAGE. 59 must be on the outside of the building, well closed, and should receive an additional cover of earth. In order to ventilate the cavity, or cistern, for the purpose of averting an accumulation of ill-smelling gases and their entrance into the dwelling, it is recommended that an air- drain be arranged by leading a pipe from the cistern to a point above the top of the house, or at least above the highest windows. This pipe, however, only accomplishes its object if the air in it is warmed, and so is kept cir- culating. Therefore, this drain pipe is placed, where pos- sible, near a chimney. In order to keep a privy odorless, it is flushed with water, where running water is available, or from time to time dry earth is thrown into the pit. The cisterns, as well as removable receptacles, require to be emptied and cleaned from time to time. The use of chlorides is recommended to dispel gases and destroy germs. In large cities the refuse of the privies is removed by sewers. The drainage of cities consists of a subterranean net- work of pipes, connecting with the water closets and sinks of the houses, discharging their contents into larger pipes and sewers, and, by means of a natural descent, into a great central reservoir or into some large river near by. If there is no suitable large stream at hand, the sewage is removed by pumps and used for agricultural purposes. Sometimes it is destroyed by cremation. Drainage and running water secured by aqueducts are hygienic arrangements of large cities that go hand in hand. 60 PASTORAL MEDICINE. Clothing. In considering clothing from a hygienic standpoint, its first object is the regulation of the warmth of the body. To accomplish this in our climate we need a considerable amount of clothing. The materials of our clothing are woven either out of vegetable fiber (cotton, linen), or out of the hair of ani- mals (wool), or out of silk thread. They are, therefore, porous, with interstices between the individual fibers. The air contained in these pores and between the gar- ments plays an important role, the effect of the clothing being the hindering of the escape of warmth generated by the body. The prevention of the escape of warmth from the body becomes essentially lessened if the clothes are wet. Wet clothes, in which the air in the pores of the material is dislodged by water, conduct warmth much more readily than dry clothes containing air in their pores. Further- more, the evaporation of the water in the clothes pro- duces cold, very perceptible to the skin. For the maintenance of bodily well-being, however, the warming effect of clothing is not alone decisive. There must also be a circulation of air, from the surface of the body through the clothing. Unobstructed exhala- tion of the body is quite as important for the health as the free breathing through the lungs. In this regard, there- fore, earnest consideration must be given to the porosity of clothing. An obvious example is rubber clothing. While retaining a great deal of heat, it is quite unsuitable, because circulation of air is not permitted. A third task of clothing is the protection of the surface of the body against the direct rays of heat, whether CLOTHING. 61 caused, in the open air, by the sun, or by artificial sources of heat. Light colored, white or yellow, goods afford the best protection against the sun's rays. If the absorbing power of heat by white material be placed at 100: that of light yellow will be 102; of dark yellow, 140; of light green, 152; of red, 168; of light blue, 168; of black, 208. Thus the clergyman with his black clothes is, in this respect, most unfavorably situated, a misfortune which can be somewhat compensated by lightness of material. Different parts of the body demand special considera- tion in respect to clothing. So the head, as was mentioned above in our remarks on sunstroke, must be protected by an airy and light cov- ering against the rays of the sun. The wearing of heavy head covering, which permits no ventilation to the skin of the head, causes dizziness, perspiration of the head and consequent wetting of the hair, injures the growth of the latter and causes it to fall out. The neck, on account of its important blood vessels and nerves, must be free from tight-fitting clothing. Other- wise there will result congestion of the blood, rush of blood to the head, causing headache and injury to the eyes. People should be especially warned against the use of thick shawls. They effeminate the neck and render the organs situated in this part (tonsils, upper part of the throat, larynx) unable to resist the influence of weather. The lower part of the body, in times of epidemic ill- nesses of the digestive organs (intestinal catarrh, diar- rhea, cholera), should be protected by a body band. The clothing of the feet requires particular care. Wet stockings, for instance, for the reasons already mentioned, cause colds. Furthermore, the style of the leather foot- covering must be one fitting the structure of the foot. 62 PASTORAL MEDICINE, Tight shoes are not only a torment for the wearer, but they also hinder the natural growth and the circulation of blood of the foot, and may cause very painful and annoying corns and ulcers. Besides interrupting the regulation of warmth, when in a wet condition, clothes can also cause illness in other ways. It is especially harmful to wear too many layers of clothes. When a man wears four or five different clothes, one over the other, there can hardly be said to be a normal skin exhalation. Colored garments, for instance, stockings and under- clothes, can give rise to skin diseases when the coloring matter is poisonous (aniline dyes, colors made of lead). Particular danger lurks in second-hand clothes, such as bought from old clothes dealers. Many diseases, con- sumption among others, can be spread by the wearing of second-hand clothes. Where the use of such clothing must be resorted to, as in asylums for the poor, etc., it should be worn only after a thorough disinfection in a steam disinfection apparatus. In connection with a discussion of the hygienic purpose of clothing,. the care of the surface of the body the skin must receive attention. Warm baths open the pores of the skin, by expelling dirt that gathers in them through the mixing of perspira- tion with small particles shed by the skin and minute fibers from the underclothing. Only then can an evapora- tion through the skin or the breathing through the skin, as physiologists say take place in a normal manner. The importance of this operation for the maintenance of a healthy body has been shown. Washing with cold water, and cold baths, stimulate and harden the skin, so that the body becomes able to resist without injury the in- clemency of weather. HYGIENE OF SCHOOLS. 63 A special obligation, also of particular importance to clergymen, is the care of the teeth. The importance of good teeth for public speaking is known ; everybody who has to use his organ of speech in public is aware of this, and, above all, the one who has defective teeth. Besides, good teeth are needful for a normal digestion all of which is sufficient reason for taking particular care of the teeth, without considering the esthetic side of the question. The chief enemy of the teeth is a fungous growth which is developed between them by spittle mixing with remains of food. It corrodes the enamel of the teeth, and grad- ually the substance of the teeth is destroyed. To prevent this, a regular cleansing of the teeth with a good tooth brush is necessary. As a tooth powder, one made out of carbonate of lime and an evanescent oil (as the oil of peppermint) may be recommended. The cleansing of the teeth takes place most advantageously before going to bed, because decomposition in the uncleansed cavities of tfie mouth sets in most easily during the night. The tooth brush should be used not alone in a horizontal direc- tion, but also vertically, so that the interstices between the teeth may be cleaned. In order to remove the tartar that gathers on teeth and the dark color that the teeth of many smokers acquire, a cleansing of the teeth by a skilled dentist, from time to time, is recommended. V. HYGIENE OF SCHOOLS. Owing to the close connections that exist between the clergyman and the school, it is evident that the former must be desirous to know of the perils to health that the schools may bring. Mens sana in corpore sano. The influence exerted on the child by the school will 64 PASTORAL MEDICINE. have its effect, also in relation to his body, not seldom last'ing all through life. At no period of life can external pernicious influences result in greater harm than at the time when man, though most capable of training, is still undeveloped in his organism and of little force of re- sistance. It can not be denied that the perils to health of the school are often exaggerated by parents and phy- sicians. On the other hand, unprejudiced observation shows that many forms of illness occur exclusively among children of school age, for the origin of which the school itself must be held responsible. We may, therefore, speak very well of school diseases. These diseases are con- tracted partly through the stay in school rooms, partly through the deportment of the body during tuition. Here belong congestion of the head, headache in fore- head and back part of the head, nose-bleeding, pulmonary diseases, indigestion, liver complaints, curvatures of the spine (sections), the latter especially frequent among girls. Ordinary scoliosis lateral bending of the spine : one shoulder becoming consequently higher than the other Professor Virchow characterizes directly as an arrest in development of the body due to the school. The spread of contagious diseases through the school should also not be overlooked. Hygiene of the school concerns itself, first of all, with the school building. The schoolhouse, like the dwelling house, must be erected on healthy soil. It should have an open space all around and be situated as quietly as possible. The struc- ture must be solid, the material without defect, and the new structure sufficiently dry before occupation. The corridors must be light and well ventilated. The stairs must not be steep or winding (no spiral staircases) and must be provided with guard railings. HYGIENE OF SCHOOLS. 65 In the installation of the water closets the general sani- tary requirements mentioned in the case of dwelling houses are to be observed. In the privies a seat should be pro- vided for each twenty-five to thirty children. Seats should be suitable, not too high nor too low. They should be separated by solid board partitions. The cleanliness of privies and urinals should be severely insisted upon. As an indispensable requisite, every schoolhouse must have a playground. To every two hundred children there should be a quarter of an acre. Furthermore, the attention of those concerned in hy- giene is directed to the schoolroom and its disposition. The first and most important condition for a good schoolroom is its adequate size, which alone makes pos- sible the preservation of good air. There may be no fault to be found with all other arrangements, yet when the requisite size of the room is lacking, all other precautions are in vain and the health of the scholars and teachers will unavoidably be undermined. Not more than eighty scholars should be taught in one class. The suitable ratio of length to breadth of a school- room is considered to be 3 to 2. For classes with less than fifty scholars a space approaching square size is allowable. The length of the room ought not to be more than thirty yards, its width not more than twenty yards. A clear height of less than ten yards or of more than four- teen yards for the schoolroom is to be avoided. The flooring of the ground floor, where there is no cellar, must be at least a foot and a half above the ground. Underneath should be placed a layer of dry sand, or sifted coal ashes, eight inches thick. The floor should be of oak planks, closely joined, and resting upon supporting beams laid near together. Walls and ceiling must be trimmed smooth. The PAST 66 PASTORAL MEDICINE. former should be painted in a light blue, or grayish blue, shade ; the latter may be calcimined. Wall papers should not be tolerated in school buildings. The doors of the schoolroom must be at least forty inches wide, must be in plain sight of the children (not on a back wall) and must open outward. The light should always fall on the children from the left side; the windows, therefore, must be placed as suit- ably as possible for this purpose in one of the side walls. The wall back of the teacher's chair, the opposite side wall, and the wall back of the children, should have no windows. The ratio of size of the surface of glass in the windows, to the surface of the floor in the room should be I to 5 or I to 6. Direct sunlight must be kept off by means of shades of unbleached linen or something similar. These requirements regarding the light are of decisive importance for the prevention of short-sightedness. A renowned oculist found in the schools of a city, where they were situated in wide streets, 1.8 to 6.6% of the chil- dren afflicted with short sight; in other schools, shut in by high buildings and in narrow streets, tHe proportion was as large as 7.4 to 15.1%. In providing school benches care should be taken that they afford to each scholar a seat in accordance with re- quirements of health. As a rule, a stable connection of desk and bench, affording each scholar a width of seat of about two feet, is recommended. In each class there are likely to be scholars of generous build, requiring corresponding styles of seats, and for all classes the availability of four different sizes of benches is recommended. Besides these stable school benches, there are con- structed such with independent desks or with seats to fold up, etc. The position of the pupils on their benches, for writ- HYGIENE OF SCHOOLS. 67 ing or reading, is of great importance for the prevent- ing of bending of the spine. In the ordinary faulty position of pupils the right shoulder is raised and pushed forward ; the left hand rests on the edge of the desk ; the left arm is drawn back ; the left shoulder and head are inclined toward the left side; the vertebrae are turned about their axis toward the right. As a result, the head rests no longer on the spinal column, but, hanging forward and to the right, it is at first sup- ported by exertion of the muscles of the neck ; then, when these become tired, it supports itself by leaning against the chest, which latter will rest on the edge of the desk. Thus the eyes are brought within only a few inches of the writing. That such a position must injure the spine, and likewise the eyes, goes without saying. In an examina- tion of the children of a certain school it was found that, out of one hundred and sixty-two girls examined, only ninety-two were entirely erect; while in fifty-four there were found the first stages of curvature of the spine. In other children the trouble was found to have already progressed further, and several of them proved to be in- curable. The important progress of general hygiene, which has introduced reforms relative to all our functions of life, and in particular regarding the care of the body, directs attention to all those circumstances of school life from which proceed influences upon the health of pupils, and it is to be hailed as a gratifying result that the care of the health of school children now finds active attention in ever-widening circles. Of course, many a desirable improvement must, for the present, be dispensed with on account of some insurmount- able difficulty, which, however, makes it an only more pressing duty to painfully and conscientiously take all 68 PASTORAL MEDICINE. such measures which circumstances may allow to be car- ried out. Another important factor in the care of health in schools, important also from an educational point of view, is cleanliness. Especially injurious is the dust in school- rooms. It spreads the bacilli and causes the infection of diseases of the eye, as proven by medical authorities. The schoolroom, with its furniture, must, therefore, be dusted often and thoroughly. For this purpose it is not sufficient to sweep the schoolrooms twice weekly with a dry broom, but they must be cleaned each week at least once with a wet mop. The dust every time must be carefully removed with a moist rag. Moreover, where there is room enough it should be arranged that wet overshoes and coats are discarded before entering the schoolroom. Finally, it may be pointed out that out of regard for the eyesight of the pupils slates should be used as little as possible. In the absence of a better and more practical medium, they can not be entirely dispensed with. Their use, however, in schools with more classes than one, should in future be confined to the first two years. In one-class and half-day schools, frequented primarily by children of the poorer country population, it may, of course, not be possible to restrict the use of the slates in a like manner. When heating the schoolrooms during the cold spell by means of stoves a pail of water should be placed on each stove to keep the air moist. The stoves ought to be in good condition and provided with a fire pot. HYGIENE OF SCHOOLS. 69 Protection Against Contagion. Furthermore, the school plays an important part in the spreading of contagious diseases prevalent with children, especially measles and scarlet fever. Under the following points we gather some information as to how to protect as far as possible the children against contagion : 1. Diseases which, since easily contracted, render neces- sary special rules for schools include : (a) Cholera, dysentery, measles, rubeola, scarlet fever, diphtheria, smallpox, spilosis, and relapsing fever. (b) Abdominal typhus, contagious inflammation of the eye, scabies, and whooping cough if acute and accom- panied by spasm. 2. Children stricken with one of the diseases enumerated under (a) or (&) are to be excluded from frequenting the school. 3. The same applies to children in whose homes one of the sicknesses in I under (a), mentioned, occurs, even if the children themselves be in perfect health. An excep- tion may only be granted upon a physician's testimony, that the child by reason of thorough isolation is rendered safe from infection. 4. Children excluded from school for reasons set forth in 2 or 3 may only be readmitted upon a physician's attest that all danger of infection has passed away, or after the lapse of such certain time, which by experience is con- sidered as the normal duration of the sickness. 5. The normal duration of smallpox and scarlet fever is six weeks ; for measles and rubeola, four weeks. The child, and his clothes, should be thoroughly cleansed before he is readmitted. 70 PASTORAL MEDICINE. For the enforcing of the rules 2-4 the head of the school (principal, first teacher, director, or rector) is re- sponsible. 6. In boarding-school, seminaries, and the like, if there occurs a case of contagious disease, inmates may, during its course or immediately thereafter, be allowed to go home, provided this may be done, according to the opinion of a physician, without danger of infection, and all nec- essary measures of precaution, as laid down by physicians, must be complied with. Under the same conditions, chil- dren may be discharged on demand by their parents, guardians, or foster-parents. 7. If a person dwelling in the schoolhouse be stricken with one of the diseases named under (a) and (b), or if a person living in the same house with one of the school- teachers be stricken with one of the diseases as named in i (a), the head of the family must immediately inform the school board. The patient must be placed in quaran- tine. The civil authorities are to decide whether or not the school is to be closed, and what sanitary measures should be taken. This rule applies also to boarding schools. 8. If several cases, as in I, appear in the locality of the school or its environs, principal and teachers have to pay particular attention that the schoolhouse is kept clean and that the rooms are well ventilated. Especially the class- rooms and the toilets must be thoroughly cleaned every day, which work must not be performed by school chil- dren. The classrooms must be constantly ventilated, also after school hours; and the closets must be regularly disin- fected. 9. The closing of schools or single classes is decided upon by the civil authorities in consultation with the of- THE INFIRMARY. 71 ficial physician. In case of imminent danger, the school board and the local police have the power to close on the strength of any physician's opinion. 10. The reopening of a school or class, closed on account of a contagious disease, must be preceded by a thorough cleaning and disinfecting of the schoolrooms. The re- opening can only be ordered by the civil authority, the official physician concurring. VI. THE INFIRMARY. Another public institution which offers a field for the clergyman is the hospital. As pointed out in the preface, hospitals and hospices were founded in the first Christian centuries by the Church. General epidemics (pestilence, black death, pox, lep- rosy) led to the erection of numerous plague-houses. The Church at all times, through its servants, has maintained and supported such institutions wherever she was able. Even to-day there are many places where the clergyman is a member of the board of managers of an infirmary, and it behooves him to know the principal sanitary re- quirements. It goes without saying that a building, wherein patients are to regain their health, must stand on dry, clean soil and be provided with good drinking-water. It ought to be situated in an open and quiet neighborhood. In man- ufacturing towns the vicinity of factories and shops ought to be avoided. The dimensions of the site depend on the number of patients for whom the hospital is destined. If possible, the estimate should include the laying out of a garden. Wherever possible hospital and ground space should allow two hundred square yards, or at least one hundred square yards, for each patient. 72 PASTORAL MEDICINE. To each bedstead is to be allotted a space of eight to ten square yards, an air space of thirty to sixty cubic yards, and a light space (in windows) of one and a half to two and a half square yards. Length, width, and height of rooms, also the number of windows, may be calculated from the foregoing dimensions. For the supply of direct sunshine, which every sick man greatly needs, is of importance not only the number and the size of the windows, but also their location. They must be placed so advantageously that they are reached by the sun through the greater part of the day and the most part of the year. They are to be provided with blinds. All rooms in the hospitals, especially the sick-rooms, ought to be well provided with good fresh air, which can be achieved by ventilation and good mechanical cleans- ing. Should the natural ventilation prove insufficient to replenish the air, then air pumps are to be used. Of material importance is the prompt removal of excretion and sputum, and the sweeping away of the dust with a moist mop or rag. In preserving good air the mode of heating and lighting plays no small part. Steam heat is preferable to the ordinary stove, and the electric light to gas or kero- sene, for the latter consume oxygen and produce car- bonic acid. In order to meet all exigencies for a hospital, the builder of a hospital has the choice of three systems: the corridor, the pavilion, and the barrack systems. The corridor system, representing the uniform hospital, is especially adapted for small infirmaries with from ten to one hundred beds. The sick-rooms are all adjacent, and have only one window-wall ; the doors open into the corridor, which ought to be lighted by numerous win- dows. THE INFIRMARY. 73 Apart from the main building, and only connected with it by a passageway leading from the ground floor, is the building containing kitchen, laundry, etc. Only in this way can the patients be spared the vapor and odor from these places. As far apart as possible from the other sick-rooms, are the rooms for delirious and insane patients; also an isolated room for contagious diseases, if a special building for such diseases can not be obtained. Every hospital should have a morgue, for the dead bodies should, for various reasons, not be kept within the institution itself. In the morgue building may be located the disinfecting room likewise indispensable for every hospital. There the disinfecting apparatus, worked by steam, may be placed. In contrast with the corridor system, which assembles all patients in one building, are the barrack and the pavilion systems, which scatter them. The barrack contains a large sick room, room for the nurses, isolating rooms, the scullery, baths, and water- closets. The beds, as a rule, are placed in two rows, separated by a spacious passageway. The ceiling is formed by slanting roofing, the ridge of which is raised and provided with window-blinds, which let the bad air escape and admit fresh air. The plan of sick room and outbuilding is the same in the pavilion system as in the barrack. In the former system, however, there is no ridge ventilation, and there must be special ventilating appliances. On the other hand, it admits of the erection of two or three story build- ings. In larger institutions these sick rooms barracks or pavilions are linked to a central building containing the offices, kitchen, laundry, etc. 74 PASTORAL MEDICINE VII. DEATH. ASPHYXY. SIGNS OF DEATH. MANNERS OF DEATH. BURIAL. When all the organs of the human body have definitely ceased to work, then death has set in. The transition from life to death may be sudden, even in people of good health; for instance, in case of death by lightning, by sunstroke or apoplexy, by crushing or laceration, by bullet wounds, during childbirth or con- finement, while undergoing difficult operation, in some cases of poisoning, or through grave interior hemor- rhages, of the brain for instance, or of the lungs. In such cases of death pose and facial expression of the dead remain exactly as they were in his last moments; whereof every battlefield furnishes proof, likewise the inquest over suicides. Generally, however, death comes more or less gradually, and is heralded by preceding signs. The stage in which these signs occur is called death- struggle or agony. The last phase of life of a person has been called a struggle, because it often shows symptoms of excitement, particularly of pains and spasms, and because it was taken to be the last stand of the principle of life against the threatening annihilation. On the other hand, many peo- ple, especially those of advanced age, pass away very quietly and without pain. The strength of the body has nothing to do with the agony. The strongest apoplectic may die without struggle, while the most emaciated con- sumptive suffers for hours and days, so that the ancients said of these afflicted, " Non moriuntur, sed extinguuntur sicuti elychnium deficiente oleo." The agony in all cases presents a mixture of the symptoms of the death-causing malady and of the signs DEATH. 75 of the progressing paralysis of the nerves and muscles. The different organs of the body die off in a certain almost regular order. Consciousness, if present in agony, survives the senses. It seems as if scent and taste disappear first. Then vanishes the sight. Dying people complain frequently of a fog in front of their eyes, or cry for light. Their hear- ing, however, is responsive to impressions even after the eye is already surrounded by darkness. The attention of the bystander should be called to this fact, lest any in- cautious remarks be made. The faculty of feeling re- mains sometimes to the last moment. The dying feel the cold, which gradually extends from the periphery of the body to the inner parts. The exterior muscles are the ones to first lose the faculty to obey the will. The sinews contract, but are un- able to move the limbs. The body slides downward in the bed; the limbs, obeying the law of gravitation, fall down powerless if raised. The features begin to appear drawn, the underjaw drops, the eyelids sink, but do not close. In prolonged agony, the coat of the eye becomes red. The patient is unable to fix the eye upon an object ; the cornea loses its luster and becomes dull. The temples shrink. The nose becomes pointed and seems elongated. The nostrils are caved in. The whole face seems longer. The outlines of the jawbones stand out sharply, owing to the relaxed muscles. The chin is pointed and protruding. The lips are dry, the complexion yellowish or bluish ; the skin is cool, covered with cold, sticky perspiration. The picture sketched is called fades Hippocratica. Breathing is slow, with long intervals and difficult. The respiration is uneven. After some superficial drafts, the patient breathes deeply. The tracheas are filled with phlegm, which no longer can be expectorated by coughing. 76 PASTORAL MEDICINE. The air, breathed in and out, produces in the phlegm of the bronchia a rattling sound, that can be heard at a dis- tance the death-rattle. The contraction of the heart be- comes weaker, there is less blood in the arteries ; the pulsa- tion grows smaller; the beats can no longer be counted, nor, finally, felt. Has a sick person offered the foregoing symptoms, one is justified to pronounce him dead after respiration ceases entirely. Asphyxy, or apparent death, is a condition in which the functions of life, while not entirely ceasing, fail to manifest themselves outwardly. Loss of consciousness, of feeling, even of the animal heat, are incidents ; only the faculty of hearing is sometimes normally retained. This death-like state may endure for hours, even for a few days. That a minimum of animation suffices to protect organic matter from decay, is proven by the plants in winter time, by insects while in the state of chrysalis, particularly by animals in their winter sleep. From its causes there are distinguished different kinds of asphyxy : 1. Asphyxy from interior illness: A deep swoon after exhaustion by a fatiguing and prolonged march, after a difficult delivery, after prolonged starvation (as in the case of shipwrecked and insane persons), from vehement spasms, in cases of hysteria, epilepsy, and eclampsy, from Asiatic cholera in asphyctic stage, from some forms of yellow fever, typhus, tetanus, children's cramps, from asthma and asthmatic spasms, from poisoning by opium, prussic acid, chloroform. 2. Asphyxy from exterior troubles: From extensive and heavy contusions received by heavy corporal punish- ment (whipping post), grave concussions of the brain, ASPHYXY. 77 particularly after an explosion, from dangerous and numerous wounds resulting in a large loss of blood, large loss of blood by women in childbed, and by little children. 3. Asphyxy from specific causes. Asphyxy from irre- spirable gases (inhalation of sulphuric and sulphurous vapors, of nitric acid and muriatic vapors, of ammonia and chloric gases); asphyxy of new-born babies; asphyxy from drowning, hanging, strangulation, from stroke of lightning, from heat, from rarefaction of air (lack of oxygen), from suffocation or being buried under wreck- age, etc., from foreign substances in mouth or larynx. Asphyxy is entitled to particular attention because of the possibility of burying alive an only apparently dead person. Although the burying alive of a person is stated by the ignorant, and in sensational literature, to be of not rare occurrence, it must be admitted that the instances in which this has been proved are exceedingly rare. The safest way to avoid any mistake as to death hav- ing set in is to wait for the sure sign of death. The prema- ture burial of corpses, even aside from legal reasons, is a practice to be condemned. The means by which asphyxy can be distinguished from real death, some of which will at the same time serve for reviving purposes, are as follows: i. Respiration and the movements of the heart con- tinue in asphyxy, though in a minimal degree; whereas they cease entirely if death has really set in. To ascertain their presence a small feather or a lighted candle should be held under the nose, or a small vessel filled with water is placed in the cardiac region and its movement observed, or a cooled looking-glass held close to the mouth to see whether it shows any moisture from breath. Furthermore, the muscle activity is stimulated by smell- 78 PASTORAL MEDICINE. ing-salts (spirits of sal-ammoniac), by tickling the nose, by irritating the skin with spirits of mustard, dropping burning sealing wax on the skin, sprinkling with cold water or pouring it over the body. 2. Apply mustard plasters or rub the skin sore in some places with a wet flannel or with brushes, till the epidermis is removed; if death has set in, the places whereon the poultice has been applied do not become red, nor do the parts rubbed show any exudation, but dry up soon and assume, after six to twelve hours, a yellow-brownish color of a horny and somewhat transparent appearance. 3. Spots of a bluish red hue (livores mortis) appear generally eight to twelve hours after death, first on the lower surface of the corpse, i. e., if it lies on its back, then on the back ; if face down, on the face, the chest, and the abdomen. 4. One of the most decisive signs of absolute death is the rigor of the muscles. It begins in the lower jaw, in throat and neck, extends down the trunk to arm and leg, and disappears in the same order. As a rule, the rigor sets in from four to twelve hours, sometimes, but very rarely, after twenty-four hours, or already in a few minutes after death. The muscles, those that bend or stretch the limbs, become compact, shortened, and swollen, the same as when contracted in life. 5. The ending of the rigor coincides with the be- ginning of decay, which reveals itself by a cadaverous smell, by a greenish color of the skin, beginning in the lower abdominal parts, and by developing of gases in the cavities of the body and, later on, beneath the skin. Infallible signs that death has taken place, are, there- fore, in the first place, rigor and decay; in the second place, the livores (spots), the nature of preceding illness, and the agony. MANNERS OF DEATH. 79 The manner of death varies according to the organ which has caused the death. The organs through which the stimulus of life is fed to the rest of the body are: Lungs, heart, and the brain, with the spinal cord. On account of their importance for life, they were called by the ancients " Atria mortis." Generally three different manners of death are assumed : i. Death from the brain (mors per apoplexiam). 2. Death from the respiratory organs (mors per asphyxiam). 3. Death from the heart (per syncopem). It is very rarely that these modes of death occur absolutely, and then only by sudden death. Mostly, and in case of slower death almost always, a combination of the three modes has taken place; for instance, prevented respiration changes the composition of the blood and hinders its circulation in the brain and spinal cord; this again hampers the respiration and the activity of the heart. Judiciary medicine, whose chief duty it is to reveal to the criminal courts a forcible manner of death, dis- tinguishes the following modes of death : i. Suffocation by hanging, throttling, choking, drown- ing, and other ways, cutting off the breathing with cloth or by hand, etc. 2. By bleeding to death. 3. Death by starvation. 4. Death by burning or scalding. 5. Death by freezing. 6. Death from poisoning. It is beyond the scope of the present book to describe even only superficially the symptoms of these modes, especially as, though important in deciding a case, they are by no means determining, so that it is often difficult for the experts, who hold the inquest, to establish the cause of death after the autopsy. The dead human body, the corpse, according to natural laws, soon decays, decomposes, and thereby may imperil the health of the surviving. The removal and burial of 8o PASTORAL MEDICINE. corpses was, with all nations, one of the first hygienic measures ever taken. The most common kind of burial is the interment. The first mention of burying in an earthen grave is made in Gen. xxiii. 3. Abraham purchased ground from the chil- dren of Heth to bury Sarah there. Heth's children, there- fore, must have known the practice of burying the dead. All fire worshipers buried their dead; likewise the Buddhists; whereas the Brahmins practise cremation. Those of the Japanese, who are the offspring of Bud- dhists that settled there about 1200 B. C, still bury their dead ; whereas cremation is practised to this very day by the aboriginal inhabitants, who follow the teachings of Kami. The Chinese invariably bury their dead. It is known that their scattering of the graves not only is a menace to public health, but has offered the chief obstacle for the building of railroads in China. The ancient Greeks both buried and cremated. Burying seems to have been the more common practice, as indi- cated by the many terms of the Greek language for bury- ing in the soil. T m a -- O * bo - o Jf c. C ol a O v fi KINSHIP II 2 V V i| c-^au s-g 2-a =0 2^ S'sS'S o o O o Pu Cousins of third degree I* 71 42 2Q 40 8 " " second " 1 20 626 360 266 " " first " 6 TO 2QII oee TQRfi 67.2 Descendants of cousins 6l IS? 64 6c.7 Uncles and aunts with neph- ews and nieces 12 ers 16 ,n 81 i Double cousins 27 21 1^1 06. j. Incest in its full sense IO , x I 06. i IV. CELIBACY. The Catholic Church demands celibacy of her priests. Ever since the great Gregory has carried out his principle : " non liber ari potest ecclesia a servitute laicorum, nisi liberantur clerici ab uxoribus" to this very day, has this institution of the Church been vehemently assailed. The preeminent justification of celibacy, the dogmatic, is here beyond discussion. A main objection is the following: Celibacy is impossible; therefore immoral. Let it be answered by an unbiased and unobjectionable obser- ver: " We have already mentioned how essentially the sexual impulse differs from all other instincts, and how and why it lacks the unconquerable character peculiar to the rest. No other instinct, therefore, can be, and is, bridled to such an extent by reason and morality than the sexual im- pulse " (Dr. Casper). By pledging celibacy, the rule of the will becomes sup- ported and fortified by supernatural motives. The im- portance of education is, furthermore, not to be under- rated. Abstinence decreases the libido sexualis. The 102 PASTORAL MEDICINE. Church, therefore, rightly pays great attention to the training of her clergy. Professor Schreyer, of Halle, a Protestant, in his manual of Pastoral Medicine, says anent : " Without weighing the reasons for or against such a Church law, i. e., votum castitatis, it is only the question, Hew is it best kept by young teachers of religion? First of all, pains must be taken, already in the semi- naries, for raising young men for the clergy, that they may be fitted out with such physical qualities, besides re- ligious and moral, that they may be able to ply their voca- tion without hindrance, and to keep a law which to violate is offensive enough. Hence no one should be ordained a priest without having been trained to morality and in- tegrity by piety, temperance, work, and good example, or without having been subjected to extensive trials, both physical and moral." At any rate, the experience, gleaned in the centuries since this institution exists in the occidental Church, teaches that it is just the celibacy which imparts to the Catholic priest the authority and dignity indispensable for his vocation. Even the bitterest opponents of this clergy must admit that in regard to morality no stone can be thrown at it, may the stooping down to pick one up be ever so easy. Besides, there are many more reasons which speak in favor of this law. Matrimony would be a hindrance for the priest in exercising his office at the sick-bed, in the confessional, in mission work. Simply for the sake of their historical interest, not be- cause they are valid, we touch upon the objections against celibacy as being injurious to health. From Jovinianus the Monk (388) opposed by St. Je- CELIBACY. 103 rome (contra Jovinianum liber} and St. Augustine (de bono matrimonii), down to the representatives of the Sal- ernitan school and the Arabian physicians, the claim was raised during the entire course of the middle ages, of celibacy impairing health. In the era of reformation this identical claim served many a cleric who, in his heart, had already renounced celibacy, as a pretext for shaking off the cumbersome fetters. The French encyclopedists, of the second half of the eighteenth century, poured forth their jeers and sarcasms against this ecclesiastical institution, partly to have it abolished on account of detriment to health, partly to be able of transforming their slogan " ficrasez 1'infame " into deed with chances of success. Unbiased physicians of all ages never believed that celibacy would impair health, a truism taught likewise by daily experience in other professions. Of a former period may only be mentioned here Albrecht von Haller (1708- T 777)> a remarkable savant who ruled in philosophic, mathematic, and historic domains, and who is, according to Andrew Vesalius, the founder of modern anatomy and physiology. " This great man," says Hyrtl, " died with his finger upon the radial artery, and with the words, ' It pulses no more ! ' Even his last thought was physiology." Also Peter Frank (1745-1821), an eminent clinic, de- fended celibacy. Statistics also were pressed in service against the vow. They show that married people of both sexes live longer than unmarried. According to Dr. Casper, a husband enjoys the pros- pect of reaching the age of sixty years ; a bachelor must rest content with forty-five years. Whereas one-fourth of husbands attain an age of seventy years, it is only the twentieth part of bachelors that reaches that age. Among io 4 PASTORAL MEDICINE. lunatics and suicides two-thirds to three- fourths are single. The orderly and regular way of living, incidental to matri- mony, is taken to be the explanation of the above figures. However, there can be no doubt that this very cause applies, at the least in the same degree, to Catholic priests as it does to married men. The quoted statistical results, therefore, can not include the clergy. Celibates are also the members of both sexes of Cath- olic orders, who have devoted themselves to this voca- tion in obedience to the evangelical counsels for the sake of self-perfection, and to the weal of their fellow- men. Of particular interest are orders devoted to nurs- ing the sick, inasmuch as it can be proven of them by figures that their members are directly victims of their vocation. A member of those orders may eminently say of himself, Aliis inserviendo consumer. There are two contagious diseases, tuberculosis and typhoid fever, which claim numerous victims from among the members of orders devoted to nursing. In an investi- gation, by G. Cornet, of the mortality in orders that have for their object the care of the sick, regard is only paid to Catholic orders, both male and female. The inquiries made of religious communities for this investigation cover a period of twenty-five years and refer to cause of death, age, the number of years passed in cloister, duration of sickness, and occupation of the deceased; also age and number of the yearly recruitment. According to reports from thirty-eight cloisters, aver- aging yearly 4028 sisters and brothers, and an aggre- gate personal age of 87,450 years, the cases of death in 25 years numbered 2099, whereof 1320, or 62.88 per cent nearly two-thirds had been stricken with tuberculosis ; whereas, in general only the one-seventh to one-fifth part of deaths are due to tuberculosis. In one-half of the com- RELIGIOUS ORDERS. 105 munities this average two-thirds was even surpassed, and increased in some of them to three-fourths of all deaths. Remarkably great, according to returns, is the mor- tality from typhoid fever, with 8.23, and from cancer, with 2.38 per cent.; while death cases from other sick- nesses are within the normal average. Most deaths oc- curred between the ages of twenty and fifty. Most of the deceased brothers or sisters were from forty to fifty years old. With older age mortality decreases in these orders, in contrast to the fact that absolute mortality increases in general up to the seventieth year. This is explained by the avalanche-like rise of mortality in the younger years. As a consequence, but few reach a middle, to say noth- ing of an older, age, and the absolute number of those who die at an older age must necessarily be small in view of the fact that but few survive their fiftieth year. By add- ing to these 2099 deaths 162 cases of death from com- munities which reported only age, not cause of death, we arrive at an average life of 36.27 years for these 2261 death cases, which proves an increased mortality; this is the more striking because those 2261 deceased were by no means in previous bad health ; on the contrary, they must have been strong and healthful when taking the vow. In some cloisters the average age amounted even to only 30 and 28 years, and was, therefore, lower than is the case in any other profession. The reason for this great mortality among the mem- bers of orders devoted to nursing the sick is the frequency of their contracting typhoid fever by way of contagion, while following their vocation. This is illustrated by the following table of mortality in the Catholic orders de- voted to nursing. io6 PASTORAL MEDICINE. DEATHS WITHIN TWENTY-FIVE YEARS AT THE AGE OF: CAUSES OP DEATH ?5 in a) ->, in" 1 <* *& tt >no >, $z ?8 ">; *S i CO *Z *5 4) ">>> fS 9 v * *s D re >. 0* 3 "o H Tuberculosis 14 164 348 525 2OI 43 10 6 1320 Typhoid Fever... Cancer 5 41 54 2 47 12 19 15 10 ! I 7 i 177 50 Among a total num- ber of deaths of. . 23 243 472 711 347 ISO ICO 53 2099 A comparison of the general average mortality with that in orders caring for the sick yields the further result that the relative mortality in such orders at the ages from fif- teen to twenty, figured on an equal number of living persons, is four times that of those living in the world ; at the ages from twenty to thirty, three times ; at the ages of thirty to forty, double that of the others ; while from the fortieth year up, the mortality in both are about even. In considering that just such functions to which the greatest danger of contagion is attached cleaning of the sick rooms, making the beds, handling the linen and bed clothes of tuberculous, soiled with sputum and discharges are chiefly performed by sisters in the first years of their duties, because growing age is not equal to the hard work, one finds the explanation why the number of the infected decreases among sisters with progressing age, and is most frequent during the first years. In the orders included in these statistics there died, during twenty-five years, sixty-three out of one hundred nurses of tuberculosis. To the age of fifty this disease constituted never less than one-half, mostly three- fourths, of the aggregate causes of death. Tuberculosis reaches MAN IN SICKNESS. 107 the climax at the beginning of the third year of hospital work. According to the findings by Cornet, a healthy young girl, devoting herself to nursing at the age of seventeen, meets her death twenty-one and one-half years sooner than the rest of the people of the same age. A nurse at twenty-five, regarding the years of life allotted to her, stands on a par with a fifty-eight year old person outside of the cloister ; a nurse at thirty-three, with one of sixty- two. In due consideration of all conditions entering in ques- tion, the sole and only cause for the increased mortality from tuberculosis and typhoid fever can only and solely be attributed to nursing the sick. The assumption that cloister life in itself, especially on account of celibacy, entails danger to health and existence is entirely un- founded. MAN IN SICKNESS. If the well-feeling of a person is disturbed, if some organs fail to function in a proper way, and if thereto is even added a disorder in the normal form or connection of one or more organs, then the person is sick. Health and sickness are relative and conventional perceptions; they are not absolute counterparts. In olden times men were accustomed to regard sickness as something foreign to the organism, something obtruded, something isolated from the life of the other parts of the body. Some even went so far as to personify sickness. Many expressions used in ordinary life, as for instance, " Sickness attacks the body," " The body wrestles with the disease," " The physician fights sickness," " Nature proved victorious," rest upon this philosophical view of somatic (corporeal) processes. To fully perceive the error io8 PASTORAL MEDICINE. contained in this personification and detachment of sick- ness, we must consider that the sick parts continue their connection with the rest of the body, are fed by the same, and that circulation of the blood, the influence of the nerves and change of substance continue in the sick just as in the healthy parts of the body. Diseases are nothing absolute, nothing fixed, but processes wherein the single appearances run their course in the human body, one after the other, at fixed intervals. They are compound pro- cesses, like, in state of health, digestion, or nutrition. What we call sickness, is only an abstraction. In nature there exist only sick parts, sick persons, but not a tangible thing, sickness. The processes of sickness come to pass chiefly in the body somatic diseases ; or they affect his mind psychic diseases. In making this distinction between diseases, it must be mentioned that in the case of psychic disorders a part of the body is also sick the brain, the organ of spiritual life. I. SOMATIC DISEASES. Among the diseases of the body we distinguish espe- cially those which start with fever and those which run their course without fever. The most striking symptom of feverish diseases is the rise in the temperature of the body. It can be noticed from the sparkling eyes and the reddened face of the patient. The appetite is poor, the tongue cov- ered with a white, dirty, or dark substance; the patient calls for nothing but drink. By applying the back of the hand to the skin of the patient, an increased warmth can be felt. This is a subjective way of taking the heat ; the ob- jective way is by the use of a special thermometer for the sick. In taking the temperature of persons, that part of the thermometer containing the quicksilver is usually SOMATIC DISEASES. 109 put under the axilla (arm-pit) of the patient, who, to hold it fast, must press the arm against the chest. After having remained in this position for a quarter of an hour, the thermometer is taken up again and read. A maximal thermometer continues to show the indicated highest tem- perature of the patient even after having been removed from his body. This kind of thermometers must, before use, be slightly shaken in order to bring the quicksilver down to its lowest level. Of all feverish ailments, the infectious diseases attract particular interest. All infectious diseases run their course with fever, but not all fevers are due to infectious diseases. Among the infectious diseases are reckoned all those forms of sickness caused by an organic sickness-incit- ing germ (bacillus) which has entered the body of the patient from outside and propagated therein. Diseases incited by animal parasites are termed diseases by inva- sion. They are not counted among the infectious ones. It follows, from the reproduction of the bacilli in the sick human organism, that all real contagious diseases can be continuously transferred from the sick to the healthy, so that the patient constitutes a direct transmitter. The in- fectious diseases spread in this way are called contagious (tuberculosis, diphtheria). Is the infection caused by the surroundings of the patient which the bacilli infected without his cooperation, then the disease is called mias- matic (malaria). Considering the manner in which infectious diseases spread, the resisting power of their germs against outside influences are of the greatest significance. Germs of diseases of least resistance against outside influences are those of hydrophobia and of veneric diseases. An uncon- scious infection is here impossible, except in the rarest no PASTORAL MEDICINE. cases; on the contrary, only by a direct contact between sick and healthy can these diseases be transmitted. Germs of diseases of greater resistance are those of acute exanthema : Small pox, measles, scarlet fever, diph- theria, tuberculosis, typhus, and Asiatic cholera. These germs can preserve themselves in the most varied parts of our surroundings after having left a sick body. Hence, in order to prevent the last named infectious diseases, it is of utmost importance to know the ob- jects which enter most frequently into consideration in their quality as sources of infection, and also the means by which germs are transferred from the sources of in- fection to the healthy person. (a) Sources of infection. Sources of infection for con- tagious diseases are: 1. The discharges of the sick, like saliva, sputum, pus, excrements, dandruff. They constitute the sole sources of infection in the case of hydrophobia and veneric diseases. 2. Their linen soiled with discharges, bandages, beds, and clothes. 3. Eating and drinking vessels. Objects named under 2 and 3 are sources of infection in case of acute exan- thema: diphtheria, tuberculosis,, erysipelas, typhoid, cholera. 4. The sick room and its furniture. 5. The air in the house may frequently contain the inciter of acute exanthema (measles, scarlatina, etc.) ; less often that of the abdominal typhus, but never that of cholera. 6. The water which had been used in washing or bath- ing the sick, in washing their linen, and cleaning the sick room. 7. The contents of the water closets as long as they are fresh. SOMATIC DISEASES. iii 8. The upper layers of the floor, which have received the sputum and ejections of the sick. 9. The convalescent, as well as the dead, body may, under circumstances, cause contagion. Means of Transmittance. The transmittance of germs from the carriers of infec- tion to parts of the healthy body, from which it can get infected, takes place: 1. By contact. Persons in good health touch carriers of infection either with the surface of their bodies or with their mucous membrane. Nurses, physicians, clergymen, the family of the sick are most exposed. It frequently happens that these exposed persons, while not falling sick themselves, spread the disease by infecting others in good health by contact. 2. By eating and drinking substances containing germs (typhoid, cholera). Water may be infectious even if not used as a beverage, but if used to clean dishes and glasses. When suspicious, it should, therefore, be previously boiled. 3. By inhalation. The germs contained in the dust of the air may by inhalation enter the nostrils, the mouth, or the lungs, or may be swallowed with the saliva (a fre- quent means of transmitting the bacilli of tuberculosis). 4. Another means of transmitting these germs of in- fection are insects. Stinging insects transmit the germ from the patient, or from an infectious source, directly into the blood of the healthy; thus, bedbugs in case of recurrent typhus ; mosquitoes in case of malaria ; and flies in the case of blood poisoning. Non-stinging insects play also an important part in transmitting germs, by transferring tiny parts of an infec- tious source either to the body of the healthy or to his food. These contagious objects are thus embodied in the iia PASTORAL MEDICINE. organism, concentrated, not diluted by air or water. Hence flies should, as far as possible, be kept out of the sick room of a patient afflicted with an infectious disease, and care should be taken lest such insects descend upon his discharged matter. For a long time it has been observed that of a number of healthy persons which had come in the same contact with sources of contagion, only part of them fell sick; others remained well, even in continued danger of infec- tion. The former are called predisposed or susceptible for some particular infectious disease ; the latter are called immune or unsusceptible. Negroes, for instance, are immune against yellow fever and are less predisposed for malaria than the white race. Little is known as to the conditions that cause the stated immunity or predisposition. One kind of immunity is acquired by safely passing through an infectious disease. Conquering an attack from cholera, as a rule not always affords protection for months or years against a repetition of the attack. A de- cided immunity for a long period results after one thor- ough contagion of the body by pox, scarlet fever, measles, spotted typhus, and typhus of the abdomen. Basing on this experience, many parents expose their children intentionally to a thorough contagion by measles or scarlet fever, at a time when the named infectious diseases prevail in a mild form. By escaping from the light disease a protection is acquired against possible graver forms of the identical disease. Immunity against infectious diseases is, furthermore, obtained by vaccination. It affords protection, inasmuch as the body is rendered unsusceptible against the re- spective infectious disease in its grave form, by hav- ing been inoculated with a modified and weak germ of VACCINATION. 113 the disease and passed through the subsequent lighter form of that disease. The widest known example of precautionary inoculation is that by vaccine pox. Vac- cine pox have their origin in the transfer of genuine (human) pox to the udder of cows (while milking), or by vaccination of the animals. An English physician, Edward Jenner, made the discovery, in 1796, that per- sons that had been vaccinated with the contents of vaccine pox were unsusceptible against contagion by the genuine virus. The injection of the genuine virus a process termed variolation was, at that time, frequently used to gain an immunity against pox in its graver form, by passing through the injected disease, which gen- erally was milder than one caused by infection. Jenner showed, furthermore, that vaccine pox could be trans- ferred from person to person, and that this humanized vaccine matter afforded the same powerful protection against genuine pox as the animal vaccine matter. The protective power of inoculation with vaccine mat- ter is certified to by the result of experiments, by Jenner and his contemporaries, on several thousand persons, who were subsequently variolated. It is, furthermore, proven by exact statistics that dur- ing the century reckoned from that date, mortality from pox has been reduced to a minimum in countries where vaccination was made obligatory ; whereas, in equally cul- tured countries, but without compulsory vaccination, the mortality remained stationary. If vaccination is to benefit the general state of health, it must be made compulsory, else many will shirk vaccination owing to carelessness or prejudice. Com- pulsion, however, seems only justified if the dangers re- sulting from vaccination are not considerable enough to overbalance the gained immunity from smallpox. ii4 PASTORAL MEDICINE. Experience has shown that heretofore diseased condi- tions have resulted from vaccination to some extent. The small wound received by the vaccinated has often led to grave traumatic diseases, especially to erysipelas. Furthermore, it nas been found that germs may be trans- ferred from one inoculated person to another by vaccina- tion. Especially was this observed in a number of unfor- tunate cases where syphilis had been infected in this man- ner, owing to inattention in vaccinating. That it is pos- sible to transfer tuberculosis in a like manner must also be admitted. Reckoning with these results of experience, only com- petent physicians should be permitted to vaccinate, and only with the application of antiseptics. Only the lymph of animals is permissible. Animal lymph is now produced in institutes belonging to the government, and conducted with special precaution. After the lymph is taken from the calf, the animal is slaughtered and thoroughly ex- amined. The vaccine matter taken out is only used if the examination has failed to disclose any traces of tuber- culosis or erysipelas. A transport of syphilis is rendered impossible by animal lymph. A second kind of inoculation on persons, to protect them against infectious disease, is a process invented by Pasteur, of Paris, against hydrophobia. This inocula- tion is only used on persons bitten by an animal suspected of rabies. For purposes of this inoculation there is used a dilu- tion of the poison contained in the spinal marrow of rabbits stricken with rabies. An elaborately and carefully made preparation is made from that marrow, small par- ticles of which are dissolved and administered by sub- cutaneous injections to the person in danger. In the case of an impending epidemic, the larger ma- EPIDEMICS. 115 jority of the people can not be assumed to be immune from the threatening disease. Inasmuch as we know of but one preventive inoculation, the vaccination against smallpox, other measures must be taken to prevent an epidemic from spreading. The simplest preventive is to exclude the sources of in- fection ; but in most cases the task is to keep those already infected from contact with people yet free from infection. The history of all great epidemics, from the pestilence during the Peloponnesian war, described by the eye- witness Thucydides, and from the plagues which devas- tated the Occidental Empire, under Mark Aurel, and the Oriental Empire, under Justinian, down to the black death of the Middle Ages and the cholera ravages in our days, history teaches that contagion spreads along the tracks of traffic and the highways of commerce. The cognizance of this fact led to the shutting off of districts where epidemics such as pestilence, cholera, and yellow fever prevailed. This was formerly done by mili- tary cordons along the border, and all intercourse with persons and objects was cut off. For traffic on water similar measures of precaution were taken. In the eleventh century the Venetians, in order to prevent the plague from being imported, quar- antined every ship arriving from ports suspected of being infected with the epidemic, for a space of forty days (quarantina) . This quarantine is used even to-day as a guard against malignant, contagious diseases. If the danger of infec- tion from ship and her crew is passed, she receives a certificate, with permission to hold intercourse or trade with the city or harbor. In view of the increased and fast traffic of to-day an ex- amination of the passengers has been instituted at the n6 PASTORAL MEDICINE. terminal stations along the border and at seaports, in order to prevent infection. Every person suspected of a contagious disease is restrained from traveling further, and is placed in a hospital erected for that purpose, where he is put under surveillance and cared for. If, in spite of all precaution, an epidemic breaks out, every infected should be isolated'as far as this is possible. Isolation within the home of the patient being mostly inefficient, his removal to a well-regulated hospital is by far preferable. Germs of contagion, as reproduced by the sick, are destroyed by appropriate disinfecting. In larger cities private residences, etc., are disinfected by persons espe- cially trained in this important work. Disinfecting during a case of contagious disease is done as follows : The discharges of the infected are received in suitable vessels, partly filled with a disinfecting liquid. Soiled linen and bedcloth are put in tubs, in the sick room, satu- rated with a disinfectant and kept there for some hours. After this they are taken out for further cleansing . If the infected has left the room, his bed, mattress, and clothes are enveloped in a sheet, moistened with a disinfectant and disinfected by steam in a disinfecting apparatus.* All varnished furniture in the sick room is rubbed well with a dry rag; other objects are cleaned with a liquid dis- infectant. If the wall paper is to be preserved, it is rubbed with slices of newly baked bread, in the direction from ceiling to floor. The crumbs that fall down are swept together and burned. In the same manner all objects of little value coming in contact with the sick are burned up. * Disinfectors with steaming water are to be found in almost any hospital. TUBERCULOSIS. 117 Lime water is spread over the floor. After two hours it is removed by scrubbing with soft soap, dissolved in hot water. Thereupon the room to be disinfected is fumigated by the burning of sulphur candles ; it remains unoccupied for one week and is exposed to the air. After this space of time it can be used again without danger. For liquid disinfectants are used: 1. Lime water. To obtain the same, one quart of un- adulterated, burnt lime, in small pieces, is mixed with four quarts of water in the following manner: About three-quarters of a quart of water is poured into a pail and the pieces of lime added thereto. After the lime becomes dissolved, the rest of the water is poured in and the mix- ture stirred. 2. Solution of soft soap. One pound of soap is dis- solved in seventeen quarts of hot water. 3. A solution of carbolic acid. The proper mixture is held for sale by all drug stores. Let us illustrate our directions by applying them to the most important infectious diseases. Tuberculosis. Tuberculosis (consumption) is, in temperate zones, the most widespread infectious disease, amounting to fifteen per cent, of all causes of death. The original germ of consumption is invariably Koch's bacillus. Sources of infection are, in the first place, the sputum of consumptives, their soiled laundry and clothes, and the air in the room, infected by sputum. Most dangerous for the surroundings of the consumptive is his use of hand- kerchiefs to spit in. The sputum dries up easily, is rubbed into particles and ascends with the cotton fibrils of the handkerchief in the air. n8 PASTORAL MEDICINE. The preventive means must begin with the careful re- moval of the sputum of consumptives. They should only depose their sputum in spittoons filled with water or a so- lution of carbolic acid. Handkerchiefs, or spittoons filled with sand or ashes, must not be tolerated. Linen and clothes of deceased consumptives are only to be used after having been most minutely disinfected in the steam apparatus. The sick room must be thor- oughly disinfected, especially the bedstead and its con- tents. Experience shows that germs easily remain and adhere to the bed, whence they mingle with the dust.* The drinking of raw milk is not advisable, since it is claimed that pulmonary consumption, very frequent in cows, is transmitted by milk to the human system. Diphtheria. This ravaging disease of children, up to twelve years, is engendered by LoerHer's bacillus. Sources of infection are the coughed-up parts of the growths in the throat, the sputum, and the saliva of the sick. Infection takes place by directly coughing in the face of * A farmer had within two years three death cases from consumption in his family. After the last case everything that had come in contact with the deceased was disinfected accord- ing to the above rules. I ordered the bed straw to be burned, because some of the sputum had repeatedly got into it. How- ever, the straw was not burned, but removed to the stable as a litter for two cows. After four or five months one cow fell away perceptibly, and proved thoroughly phthisical when killed. The second cow, in good condition, was sold to a butcher. Upon killing, two phthisical knots were found to be in the lungs. None of the other organs were infected. The theory that the animals were infected by the bed straw of the consumptive suggests itself. CHOLERA. 119 another person, or by contact of sources of contagion with the mouth of a hitherto healthy person; children, for instance, are prone to put all kinds of things in their mouths and thus easily catch the disease. Preventive measures consist in thoroughly disinfecting the sputum and all objects which diphtheritic persons put to their mouths, particularly dishes and glasses. When in danger of contagion by having been coughed at, the face must be washed at once with warm soap water; mouth and throat must be rinsed with boric acid water, or, if this is not on hand^ with a strong solution of com- mon salt in boiled water, Cholera (Asiatic Cholera). The home of cholera is the Delta of the Ganges, and Bengal, from whence it is imported into Europe by land or sea. The germ of this murderous plague is the cholera bacillus discovered by Koch in 1883. The contagious matter is contained in the stool of the diseased, and from there may get on or into other persons and into the most various objects, and be disseminated by them still further. The transmission of this bacillus occurs through laun- dry, soiled clothes, food, milk, and other beverages, fruit, vegetables, and fresh cheese. To prevent the cholera it is mandatory to avoid the intercourse with persons and things coming from places where the disease prevails. In times of cholera one should get accustomed to regular habits, and take pains to avoid indigestion, as the cholera bacillus easily settles in a sick intestinal canal. It is best to boil the water destined for drinking and household purposes, before it is put to use. 120 PASTORAL MEDICINE. The stool of the patient, likewise his soiled linen and bed clothes, must be disinfected immediately, while yet in the sick room. Persons who, by reason of their profession, come in touch with cholera infected, must, before leaving the sick room, thoroughly disinfect their hands with a solution of carbolic soap, after previously having washed them thor- oughly with soft soap. Not until then can they safely take food or touch their mouth again. Neither by the air in the sick room, nor by the evapora- tion of the sick, can cholera be transferred. Childbed (Puerperal) Fever. This murderous disease takes away numberless mothers from their families every year. It is prompted by de- cayed matter (cocchi) coming in contact with the genitals after a recent parturition. These bacilli stick to the hands, cloth, and instru- ments of persons who render professional aid to women in labor, as midwives and physicians. To prevent this dangerous disease, midwives must be made to clean their hands with utmost care before lending help to the lying-in. They must be severely enjoined not to treat at the same time women in labor that have fallen sick and others, re- cently delivered. Beds occupied by women with puerperal fever must be disinfected with utmost care ; the bedstead is to be taken apart and washed with a liquid disinfect- ant. The large space devoted here to infectious diseases seems justified in view of how important it is to prevent them, particularly as in many cases the clergyman is the first one able to take measures against a further spread of a contagious disease. 'APOPLEXY. 121 It is not our task to furnish a pathological sketch of all human diseases. However, as it must be of interest to the priest, in many grave cases, to know the probable course of a disease, some of the principal symptoms may be stated here, which will enable even the unprofessional to form a rough estimate of the situation. The general signs which indicate the approaching death of the patient were already described in the chapter on " Death." Let us now review the symptoms of a few diseases residing in the three big pits of the body. Apoplexy. A relatively frequent case of sickness with persons be- yond the middle age is apoplexy. This sickness is caused by an artery bursting in the brain, followed by the effluence of the blood from the cerebrum. The stricken falls suddenly dead if the efflux of the blood has destroyed vital cerebral centres. If the shock is less violent, then consciousness disappears partly or entirely, and there appear signs of paralysis of one portion of the face or of the limbs of one side. The paralysis of limbs is on the side opposite to that where the cerebrum is injured ; for instance, in case of a paralyzed right arm or right leg, then the effusion of blood comes from the left side of the brain. Those stricken suffer in some cases from a suspension of speech; the brain is still active, yet they are unable to find the expressions for their thoughts. Common belief assigns to the third day after the first stroke of apoplexy a particular tendency to bring a repeti- tion of the attack. This is corroborated by pathology, in so far as at that time a reaction begins in the brain by tHe surrounding parts against the suffered injury, 122 PASTORAL MEDICINE. which may lead to inflammation, more pressure of the blood, and hence to renewed effusions. Resulting from an apoplectic effusion of blood, or an exudation from cerebral inflammation, or an effusion of blood caused by exterior violence directed against the skull, a crowding of the space within the skull is effected, and the brain is subjected to increased pressure. This pressure manifests itself outwardly by vomiting or by a more or less pronounced stupor, and by a noticeably retarded pulse. The number of beats in cases of grown persons decreases from seventy-two a minute to sixty or fifty a minute. An acceleration of the pulsation, while the rest of the grave symptoms continue, is a sign mali ominis, an indica- tion of the beginning of cerebral paralysis. Diseases of the Respiratory Organs. Affections of respiratory organs, which stop the inflow of the indispensable oxygen into the air-cells of the lungs, manifest themselves by the painful breathing of the patient, whose countenance drops, his lips assume a bluish hue, while his forehead is covered with cold, adhesive perspiration. If the obstacle to free breathing (asthma, bronchitis, pneumonia) is not removed at an early stage, then a dire result is to be apprehended. If pneumonia takes a favorable turn, the dangerous conditions, as a rule, pass away within a few hours, dur- ing the so-called crisis. The patient falls into a deep sleep, from which he awakes substantially improved. If this common disease takes an unfavorable turn, then no improvement is manifest after the elapse of a week ; the fever continues, rattling in the throat begins, paralysis of the lungs sets in. DISORDERS OF HEART AND ABDOMEN. 123 Disorders of the Heart. The various disorders of the heart are betrayed mostly by a panting of the heart, short breath, even in repose, and more pronounced when moving about ; sometimes face and lips are of a bluish-red hue; in advanced cases dropsy ensures, the pulse is low and accelerated. With all serious heart trouble the danger of a sudden death is imminent, particularly so with a disorder of that organ prompted by a calcination of its arteries, causing vehement, oppressing spasms about the heart and the entire thorax (angina pectoris). This disease particularly threatens persons with little exercise. Yet workingmen, steadily in motion, have also suffered from a calcination of the arteries, as proved by the dissecting table. Among the working class, however, the graver effects, especially sudden death, occur less frequently. Abdominal Diseases. A serious disease of the abdominal pit is presented by the inflammation of the bowels, an inflammation of the membrane of the abdomen and the surface of the viscera. The symptoms are severe pains, a disposition to vomit, and inflation of the alvine. Pulsation is small, weak, quickened in fatal cases, hardly perceptible to the touch. The body being inflated by gases, the diaphragm can not fall, the lungs in consequence can not expand, and the patient suffers from lack of breath. It will be perceived from the foregoing that it is quite important for diagnose and prognose to observe the pulse of the sick in a competent manner, a mode of examination particularly favored by physicians of old, while modern 124 PASTORAL MEDICINE. disciples of Aesculapius are only too prone to look on it with contempt. Accidents. It is of the greatest importance for the priest to know how to render first aid to the injured. Not only will this knowledge be useful in accidents where he is summoned to administer the sacraments to the stricken, but it will be almost indispensable in the school, where instances call- ing for immediate aid are not infrequent. We refer our readers to the Third Part of this volume, which contains a very complete chapter on FIRST AID TO THE INJURED. II. MENTAL DISEASES. The term mental disease is applied to deviations from a person's normal mental activity. Their contrast to somatical diseases is conventional rather than essential, for in mental disorders, too, there is one part of the body ill : the brain, the organ of the soul. This is proven by the results of autopsy on the corpses of monomaniacs; it is taught by a history of the origin of these diseases, and by their symptoms taken all together. The latter especially lead to the deduction that the disease is by no means confined to disturbances of merely psychical functions, but that it indicates morbid changes in the body besides a deviation from mental normality. Historical Remarks. The recognition of the fact that mental disorder and affected brain are synonyms has been arrived at by observations of nature, by watching the persons afflicted with sickness. For a long time error, cruelty, and superstition ruled supreme in the domain of mental disorders. The Old Testament already tells us of psychical mor- MENTAL DISEASES. 125 bidity. The Holy Scripture tells us of Saul, that the spirit of the Lord had deserted him, that Saul was much disturbed by an evil spirit, and that he found relief, when suffering from attacks of melancholy, in David's playing of the harp. The book of Daniel narrates of Nabuchodonosor, king of Babylon, how he imagined himself to have been trans- formed into a beast, how he was turned out by his people, how he devoured grass like cattle. An example of madness having also been simulated, even in ancient times, is offered by David's pretending to be insane, thereby escaping from the apprehended ire of King Achis. Cunning Ulysses, too, simulated madness, lest he be pressed into service for the Trojan war. That insanity also took epidemical form is proven by the tale of the Scythes, who, thinking themselves trans- formed into women, donned the garb and performed the work of women. In conformity with the view taken in early times of abnormal conditions of mind, the diseased were either worshiped as favorites of the gods, or they were taken to the temples of an idol to be religiously influenced there by priests. In Egypt those suffering from melancholy were sent to the temples devoted to Saturn. It is only since the advent of Hippocrates that thera- peutics for lunatics, as well as for the rest of human diseases, received attention. According to the teachings of Hippocrates, the brains are the seat of mental activity, and are, therefore, like the rest of the organs, subject to natural causes of diseases. Mental disorders have their origin in abnormalities of the brain. Actaeus (60 B. C.) and Galenus took the same view. The latter already distinguished between a primary cerebral disorder as causing the disease, and a secondary i26 PASTORAL MEDICINE. origin of the latter, due to a morbid state of abdominal organs. Coelius Aurelianus, a contemporary of Trajan and Hadrian, emphasizes that diseases of the mind are noth- ing else but cerebral disorders with prevalent psychical symptoms ; therefore, they belong in the province of the physician, and not in that of philosophers. His method to cure is precise, correct, free from all coercive measures. After him an utter decadence of this science must be recorded. The notion that the lunatic be possessed of the devil was, for centuries, everywhere in full play, par- ticularly since such belief was supported by the utterings of these unfortunates. The Middle Ages have produced hardly any other treatises on this subject but on de- moniacs. The numerous trials for witchcraft furnish sufficient evidence of the treatment which real or imaginary lunatics had to undergo in later centuries, when ignorance and superstition were rampant. Such was mostly the lot of melancholies. Those raving mad were kept fettered in dark dungeons until they perished in filth and misery. Gentle lunatics were sometimes granted refuge in cloisters. It is known how in Europe the mischief of trials for witchcraft was combated by the Jesuit von Spec, of Paderborn (died August 7, 1653, at Treves), especially by his book : Cautio criminalis s. Liber de processu contra sagas. Up to the middle of the eighteenth century the lot that fell to lunatics was very sad indeed, although sensible physicians had an idea that the real trouble with these unfortunates was a disordered action of brains and nerves. The fact of these disorders being curable by timely recog- nition and correct treatment was not then known. MENTAL DISORDERS. 127 The initiative in reforming and humanizing the treat- ment of the insane was assumed exclusively by the Eng- lish and French. Esquirol was the first French clinic to lecture on psychical therapeutics. In Germany the one- sided metaphysical and psychological course taken there by philosophy proved an obstacle to an improvement in psychiatry. A particularly unfavorable influence was ex- ercised in this direction by the doctrines of Kant and the natural philosophy of Schelling. This one-sided conception of mental disorders was shared by the directing physician in the ward for insane at the Charite at Berlin, Carl Wilhelm Ideler (1795- 1860), who, with expert dialectics and ample subtlety, pro- claimed them to be nothing else but morbid exuberances of passions. The reaction against this spiritualistic, eth- ical, and psychological course emanated from the illus- trious clinical authority Professor Nasse, of Bonn, a rep- resentative of the school of natural science, who, in 1818, founded a periodical for psychological physicians. Since then the knowledge of mental disorders pro- gressed also in Germany with rapid strides. Well man- aged institutes for the treatment and care of the insane were established in all parts of the country. The study of psychological therapeutics became compulsory in medi- cal faculties. Soon the existing institutions proved inadequate for the ever-increasing number of insane persons. It became necessary to found special homes for the care of incur- ables which could not be intrusted to their families. In this way institutions devoted primarily to the treatment and cure of insane patients were relieved. In our own United States the care for the insane is excellent. The increase of mental diseases within the last decades is unmistakable, the growth of certain forms of mental 128 PASTORAL MEDICINE. disorders simply frightful. Special mention among the latter deserve the general paralysis, or palsy, of the brains, and the mental disorders originating from drunkenness. Descendants from progenitors that had suffered from psychical or nervous diseases possess a considerable disposition for mental disorders. The one burdened with that inheritance must not necessarily become diseased, but he may more easily become diseased than a fellow-man not so inclined by heredity. The reasons which particularly favor an increase of in- sanity are social conditions and the aggravated struggle for existence. These conditions begin with mental over- work in youth, and remain a companion to the craftsman or brain-worker for future years, in the shape of priva- tions, struggles and cares, sensuality, dissatisfaction with his circumstances, and other things, of which our fathers knew nothing, or, at least, but little. It is the aggravated struggle for existence which enters into consideration, particularly in regard to men, as one of the prime causes for one of the most wretched forms of mental disease, the paralysis of the brain or progressive paralysis. The increase of insanity engendered by drunkenness is emphasized by all writers dealing with alcoholism and its effects. The vast importance of the abuse of alcoholic beverages in regard to moral, social, and sanitary condi- tions will have to be dwelt upon later on. At present only a few expressive figures may be given. Dr. Gamier, in the January number (1890) of Annales d'Hygiene Publique, proves by statistics that within the last fifteen years the number of insanes from alco- holism has doubled. The number of females in Paris whose insanity was caused by alcohol has increased seventy-three per cent, within the past fifteen years. Ac- INHERITED INSANITY. 129 cording to the same observer, the cases of paralysis of the brain have also doubled in fifteen years. The women, in this respect too, suffer from this disease to an extent out of all proportion with former times. As already stated before, an inherited disposition favors particularly the breaking out of a mental disease. " By far the most important cause of insanity is the transferability of psychopathic disposition, and of cerebral infirmities in general, by way of procreation " (Krafft- Ebing). Next to tuberculosis there is hardly another domain in the realm of pathology where heredity plays such an important part than in that of psychical maladies. The hereditary burden is most particularly made evident where many intermarriages between blood relatives have taken place, for social or religious reasons. In circles of nobility, in isolated groups of populace, or in exclusive, religious, communities, like Hebrews, Dis- senters, Quakers, the percentage of heredity is larger than in a floating population. In inquiring after a suspected inherited disposition for insanity, one would go wrong to merely take the parents of the patient in account. On the contrary, the law of Atavism prevails here to a large extent. The disposition for sickness can be inherited by the third generation from the first without the intermediate second evincing any moments of infirmity. The developed disease (innate in- sanity) is transferred only in rare cases ; as a rule only the propitious soil is communicated, upon which psy- chosis, favored perhaps by additional causes, may shoot up. Thus it happens that individual members of an onerated family escape. It is, therefore, of frequent occur- rence to find abnormalities of a mental or nervous nature in the side relations (uncle, aunt) of an insane person. 130 PASTORAL MEDICINE. Furthermore, it must be considered that only in excep- tional cases the descendants are stricken with the identical disease from which the ascendants suffered. On the con- trary, the law of transmutation rules here. The variability of inherited morbidities sometimes takes the following course : Nervous diseases, as megrim, hys- teria, epilepsy, prevailed in the ascendancy ; the descend- ancy develops mental diseases up to idiocy: the gravest form of inherited degeneration. Another kind of transmutation is shown by the progeny of pathological characters, which almost always are pre- disposed to insanity. Certain fanatics, cranks, hypochon- driacs, queer and eccentric persons, not only have quite frequently ascendant and collateral relatives afflicted with mental and nervous diseases, but also nervous or in- sane, and even idiotic descendants. In general it may be said anent the inherited predis- position to nervous and mental diseases, that if two hered- itarily onerated individuals join in procreation, or if the unpropitious constitution of one of the generators is ag- gravated by an exterior or interior inducement, then the burden of the progeny becomes always heavier. Nervous diseases then develop into mental diseases, at first toler- ably harmless, which, however, in following generations or in branch sides assume a more and more severe form, till idiocy finally ensues. Then nature amortizes the patho- logical family, which loses the physiological faculty of procreation. In this respect the sentence of the Holy Scripture, " I shall avenge the sins of your fathers to the third and fourth generation," has a most earnest significance. To a large extent the way of living, fortunes of life, and selection of partners of the ascendants determine the hap- piness of future generations. HALLUCINATIONS. 131 Next to the organization of his brain, man owes the properties of his psychical being to the kind and manner of education received in his youth. At times infirmities in his brain organization cooperate with education in calling forth a disposition to mental morbidities. It is not only by procreation that parents leave to their descendants an afflicted organic constitution. Psychopathically predis- posed progenitors, if affected with morbid passions, with vices, or with eccentricities, communicate their oddities and moral failings to their children by bad example, or by giving them a faulty education. Of corporeal conditions predisposing for mental diseases particular stress is to be laid upon the stages of puberty and of the climacteric. It may be of importance to the priest to know the chief symptoms of psychical morbidities, inasmuch as he, in general, is among the first to notice changes in this sphere. Hence let us draw a brief outline of the more important mental morbidities. One of the momentous symptoms incidental to many forms of mental disease must be mentioned right at the outset : delusions in the organs of sense, and such arising from sensual perceptions, which occur in mental aberra- tion : namely, hallucinations and illusions. The difference between the two processes consists therein that in hallucination the sensual perception of the patient is not caused by an extraneous irritation of the senses; whereas in illusion such an irritation on its way to the organ of apperception becomes perversed. Hallucination, i. e., the actual apparition of an image of subjective origin, such as sounds, words, impressions of light, bad odors, abnormal sensations of taste, is, there- fore, a sensual deception, while illusion is an error in dis- cernment of the senses. 13* PASTORAL MEDICINE. According to the experience of specialists, insanity, in a majority of cases, manifests itself by the sensitive part of the mind. There are two distinct morbid conditions of this sensitive part : melancholy and mania. In MELANCHOLY the principal symptoms are a dole- ful mood, dejection of spirits. It is distinguished from a physiological depression by the absence of any, or of a sufficient, motive. Hence neither the patient nor those around him can explain his morbid state. Most apparent is the gloom at the beginning of the disease. It manifests itself by ill-humor, dejection, de- pression, sorrow. The patient complains of oppression, a feeling of pain and anguish of the heart: precordial anguish. All outward impressions cause pain to the patient, even those that are relished in normal state: in- appetency. Hence he has lost the faculty of enjoying anything; everything appears to him colorless, dismal, hopeless, monotonous; nothing interests him; in short, all contrasts are wanting in his mind. His imagination, which only gyrates around dismal ob- jects, is likewise hampered. The slow, labored, one-sided thinking process creates a feeling of stupidity, a weak memory, mental barrenness, and gives rise to further painful impressions. The will power is decreased by the gloom, by hampered imagination, by a feeling of a slight bodily fatigue, and by a want of energy ; there is an unfounded lack of self- confidence. Attempting to explain his morbid state, the patient then often recurs to previous sins, perhaps long since atoned for. Self-accusation follows and self-impeachment. He imagines himself forsaken by God ; he can not find mercy because of his sin; he is condemned to perdition. Are there corporeal conditions (indigestion, constipation) MELANCHOLIA. 133 which may serve as an explanation for the depression, then the patient is full of hypochondriac fancies. Out of the feeling of incompetency grows the illusion that his family must perish, that his children will have to starve soon. Of course, quite an influence is exerted, in developing melancholy, by corporeal conditions and by the different stages of age. Children onerated by inheritance or feeble health fall, at the period of puberty, in a melancholy mood, which is particularly in striking contrast to the otherwise cheerful disposition of their age. Suicides by children find explanation in this morbid condition. Girls in the stage of development, when away from the parental home, often become homesick, and, in no rare instances, under compulsion of the depression, driven by fancied dismay and coercion, commit incendiary. The frequent melancholic depression of woman during gravidity or lactation is well known. In aggravated in- stances she does violence to herself or the infant. During women's change of life, from the forty-sixth to the fiftieth year, the general psychical tuning down of the system, due to bodily mutations, often causes mel- ancholy to develop. Persons afflicted with deep melancholia are dangerous to themselves and their fellow beings ; they are a public danger. If the patient looks for the reason of his morbid condition within himself he is apt to mutilate himself in various cruel ways,* or to refuse food persistently. Because of the self-accusations he com- * From my own observation I know of a melancholic who, be- cause of taedium vitae, and as a result of self-accusations, cut his feet with a dull tree-saw up to the bones, then jumped into a deep well, where he attempted to hang himself with the sus- pended chain. 134 PASTORAL MEDICINE. mits deeds to impose just punishment upon himself, that he may suffer. To escape from his unpropitious existence, to flee from a base, sinful world, he commits suicide with greatest circumspection, deceiving most cun- ningly those near him. He is driven to murder his most beloved family because they might fall into need, or be- cause he has the best intention to spare them a life of cares. The patient is still more prone to commit such dire deeds while enwrapped in hallucinations, hearing voices ex- horting him to act, reproaching him, etc. It is altogether incorrect for those around to attempt to divert the patient, to dissuade him from his fancied troubles. He only becomes still more embittered by being contradicted. No one seems to understand him, no one knows the sorrow of his soul. Even the priest, who at the beginning has been molested by the patient in his self- accusation, at confession, even he has lost all influence over the melancholic. The melancholic must be removed as early as possible from his accustomed surroundings and must be placed in an insane asylum. MANIA offers a picture of a frame of mind opposite to that of the melancholic an unwarranted cheerful- ness, an increased and accelerated run of imagination, a heightened aspiration. The patient is more active, he carries himself more erect, he talks much and fast, he sings, whistles, and is in the mood for mischievous, inordinate, hasty actions. He produces striking thoughts, acute epigrams, witty re- marks and sarcastic comments. A notion of enlarged capability he manifests by praising his health, his strength, his courage, his self-confidence. His condi- tion, as a whole, is like that of one slightly intoxicated, the more so, as his taste for stimulants of all kinds, especi- MANIA. 135 ally for alcohol, has been whetted, and because alcohol ex- ercises a more detrimental effect upon his morbid brains than upon the brains of a normal person. The maniac's humor turns often into heated anger if he is contradicted. As long as the patient is master of his temper he avoids conflicts with the outer world. Soon his power of re- straint gets lost by dint of his lessened resistance to liquors. By his exaggerated and easily hurt self-esteem, he is driven to rioting, slander, insults, to disturbing the peace, causing damage and injury, and to sexual debauches. Raving madness is the highest degree of maniacal ex- citement. The mood is revealed by wild merriment or irate frenzy, by impetus for activity, by ceaseless noise, singing, shouting, by destroying things. His thoughts are chasing one another ; they can not be brought to an issue, and become hopelessly entangled. His sexual pro- pensity is increased and manifests itself in disgraceful acts. Mania, when unmixed, is seldom accompanied by hallucinations. It is self-evident to any layman that patients of this sort must be put in an asylum. MORBIDITY OF IMAGINATION. Physicians have been of the opinion that any disorder of the mind begins with a morbidity of the seat of affection and they inter- preted the deceptive visions as attempted declarations of the changed mood. Recent exact investigation and a thor- ough observation of the patients, however, have led to the conclusion that it is the imagination that first becomes af- fected. This disorder of the mind is called primary in- sanity, madness (paranoia). The characteristic of the malady is the developing of fancies and visions without a previous alteration of the mood. Cogitation is formally correct ; it links the fancied impressions together and develops them. As the patient 136 PASTORAL MEDICINE. can not convince himself that he has altered, but adheres to the opinion that the outer world maintains toward him a different attitude from before, his false relation to the outer world changes consequently his standard as against the world ; he is insane. Most of such patients are oner- ated by heredity ; already at an early stage they have been possessed of peculiar traits of character, eccentric moods, etc. Any one of the numerous casual causes effects the breaking out of the psychical malady, of which, at first, there are only indications ; often the patient dissembles his fancies. According to the character of the fancies the following distinctions are made : (a) Imagination of persecution. The patient imagines his health, his property, his honor, etc., to be threatened. Not perceiving the change in his own mind, the patient conceives the idea some injury to him is being planned ; in reading the newspaper he discovers allusions to him- self and his family, and insists that some harmless re- marks are meant for him. Next in order he shuns people, is irritable, uncommunicative ; he complains of being mo- lested by the police, by neighbors, freemasons, socialists. Delusions which appear in the course of his disease tend to confirm his opinion. For he hears the jeers and threats of his pursuers, he smells and tastes poison destined for him in the food, he feels magnetic and electrical operations on his body; ultimately he sees his pursuers before his eyes. A species of this insanity is that of the litigious. It is characterized by a faulty conception of the law, the in- ability to perceive being wrong, unmeasured positiveness and egotism. If their case is dismissed or decided against them, then these persons imagine themselves injured and persecuted. RELIGIOUS INSANITY. 137 They resort to never ending demurrers and appeals up to the highest court. The judges are declared corrupt, their decisions rendered in bad faith; all are in conspiracy against them ; libels and contempt of court ensue ; they are fined or imprisoned, whereupon new litigations arise. They draw up numerous voluminous documents ; in court they deliver endless harangues, excelling in repartee and in a faithful memory; they study the code, interpreting the laws according to ideas of their own, become shysters and champions of the " oppressed." (&) Religious Insanity. In this form of madness, like the subsequent one, the imaginations of the morbid have the character of favored connections. They have an exaggerated notion about their own importance. They are mostly hereditarily onerated, and betray from early youth a " queer " disposition. However, non-oner- ated persons may also become diseased under the impulse of violent, physically and mentally debilitating forces, es- pecially after religious revivals. At the beginning of the morbidity there appear hallucinations in nearly every sphere of sensual activity. The patient has the sensation of a divine breath permeating his body; a sensation of transfiguration takes hold of him. Women frequently reveal excitement. Sneers and raillery by the surrounders are received by the patient as " trials " to prepare them for the vocation of a Redeemer of the world, of a Prophet. In, by no means rare, cases they attempt to ply their pre- sumed call by reforming and converting, and are quite willing to use force in their missionary attempts. Arrived at this stage, the patient must no longer remain among his usual surroundings, from which he should have been removed sooner. (c) Insanity with erotic visions. The patient fancies himself loved by a person in a higher position. His love 138 PASTORAL MEDICINE. to this person is overflowing, romantic, but platonic throughout. From looks and deportment of that very person the patient gleans that he is not indifferent to her. Adver- tisements in the newspapers, concerning other people, he believes to emanate from the beloved and to be intended for himself. A communication is soon established by means of frequent hallucinations of hearing and vision, and the intercourse is promoted by illusions. Conversations by others contain for him communications which refer to the presumed love affair. Finally the patient becomes un- bearable by his acting according to his fancy. He disturbs the domestic peace, assaults imagined rivals, etc. (d) Insanity with paralysis (progressive paralysis of insane, dementia paralytica) is a disease of man at his best age. Women are not so often attacked by this disease. A deterioration of all psychical performances is the forerunner of this malady. Forgetfulness, absentminded- ness, laziness, irritability, lack of will power, are notice- able. The altered character is evinced in tastes foreign to his former views. He exhibits a desire for drink, is inclined to be extravagant and to indulge in sexual debauches. Soon corporeal symptoms are added, the patients walk un- steadily, they write a different hand, they are of slow speech, their tongue falters, the expression of the face changes on account of a paralysis of the moving nerves. Blood rushes to the head, followed eventually by apo- plectic attacks, which at first, however, quickly disappear, without leaving paralysis of the limbs. Soon arises in the psychical sphere one of the most marked symptoms of this disease : (e) The delusion of illustriousness. The delirious notion of grandeur by paralytics differs from a similar PARALYSIS. 139 fancy by maniacs therein that in a paralytic brain all spheres of possibility are by far transgressed, all bounds of time and space overleaped. The patient is God, higher than God ; he has millions, owns castles of diamonds ; he is, all at once, Napoleon, Julius Caesar, Washington. No rea- sons are advanced for his fancies. They are not connected, because of the impending psychical infirmity. What the imagined greatness consists of, depends entirely upon the education and social position of the diseased. Finally the patient becomes more and more idiotic, be- cause of progressing disease of the brain. He either suc- cumbs to a stroke of apoplexy, or dies of aseptic blood poisoning, which often sets in if the skin has been made sore by lying. Having been made acquainted with some morbidities of mental life in the sphere of feeling and thinking, let us glance at the disorders of the will and of the propensities. Physiological life knows but an impulse of self-preser- vation and a sexual impulse. Morbid life does not create new impulses, as formerly falsely assumed. The doctrine of morbid impulses culled by psychiatry from French works defied all laws of morality and of society. If a person under somewhat striking circumstances committed a crime against life or property of his fellow-beings, then, according to that doctrine of monomania, he was not to be impeached for the deed ; he was suffering from a mor- bid impetus to a criminal act, for which ne could not find any restraint in his powers. The following morbid im- petuses were fixed: To steal, kleptomania; to lust, aidoio- mania; to suicide, monomaniacal suicide; to murder, monomaniacal homicide. A morbidity in psychical life can only decrease, increase, or pervert already existing natural impulses. Anomalies of the appetite. An increase of this impulse 1 40 PASTORAL MEDICINE. can be caused by bulimia, a voracious appetite, which ap- pears shortly after meals and alternates with inappetency. This morbidity is found in hysterics and maniacs. It is different from the want of feeling of satiety common with idiots, which leads to overloading the stomach. A decrease of appetite is found with melancholies, hypochondriacs, hysterics. Maniacs often refuse to take food, because of some fancy, for instance, not being worthy to partake of food, because they are sinners, or because they can not pay for it, have no longer a body, because stomach and guts are constipated, because they are dead, or have putrefied intestines. Or they suffer from hallucina- tions. Voices command them to fast, or the food tastes like poison, like having been polluted. The perversions of appetite occur, as it is known, also in some corporeal morbidities, where the psychical life remains intact. So the desire of anaemic girls to stealth- ily eat lime, salt, sand ; the preference of the hysterical for offensively smelling and tasting substances, like valerian, asafetida; the hankering of pregnant women after most peculiar things to eat ; and other aberrations of taste. A revolting perversion of this propensity in grave psychical disorders is the coprophagy, the impulse to eat their own excrements. Anent the anomalies of the sexual impulse it suffice here to remark that with neuropathic, hereditarily predisposed persons the sexual impulse manifests itself at an abnor- mally early age, leading to sexual excesses. More im- portant for the priest, as teacher of morals and as psy- chologist, are the perversions of the sexual impulse, since he must there distinguish between morbidity and moral depravity. Any act of sexual gratification contrary to the inten- tion of nature, to propagation, must be declared perverse. EPILEPSY. 141 It is to be noted that not every perverse sexual act is a morbid one. From the pool of moral depravity spring the sexual aberration of profligates, widely spread in the days of the ancient Greeks and Romans, and to be met with even in our days. For obvious reasons this is not the place to further discuss this particular chapter. The free exercise of the will is interfered with by any form of mental disorder. Christian morality and the criminal codes of all civilized nations acknowledge this fact. Free exercise of the will in one insane is impossible : 1. Because in consequence of the morbid alteration of the brain, the organ of the soul, there arise impulses to deeds which fail to be restrained by moral and ethical countermotives, lacking by reason of that very morbidity. 2. Because the consciousness of the ego and the per- ception of the outer world have been displaced by decep- tive fancies and hallucinations Although the punishable deed has been committed by that very person under juris- diction, he was psychologically an entirely different being, Nervous Disorders. Let us now turn to two nervous diseases, which as such can exist by themselves, but which also frequently cause a psychical disorder to root on their soil and which are en- countered many times by the priest in everyday life. They are epilepsy and hysteria. EPILEPSY. Epilepsy is a chronic disease which in its developed form consists in frequent attacks from general spasms, with complete suspension of sensation and of con- sciousness, and lasting from a few seconds to some minutes. These spasms are, in many instances, preceded by warn- 142 PASTORAL MEDICINE. ings. The patients feel a pricking or a twinge in leg or arm, or a pressure rising to their head. The epileptic, sometimes with a piercing cry, falls to the ground, losing sensation and consciousness. During the first moments after the fall the patient's muscles are rigidly contracted. The breath is drawn in, the eyes are wide open, arms and legs stretched and straight. After a few minutes this rigidity ceases, and is superseded by violent convulsions of all muscles. Respiration is blocked by the cramp of the thoracic muscles employed in breathing. Hence the face assumes a bluish hue, becomes swollen. The agitation of the lingual muscles forces the saliva out, which escapes in bubbles. Frequently it is mixed with blood, the epi- leptic having bitten his tongue. During the fit it is necessary to guard the patients against injuring themselves ; especially must their faces be kept from falling into liquids, as they may thus be easily asphyxiated. In case of attacks recurring for years, there develops a certain grade of dullness, which in grave cases may de- generate into idiocy. In most patients the so-called epi- leptic alteration of character can be noticed in the inter- vals between fits. It is an abnormal irascibility, a peevish mood, which fluctuates with increased capricious- ness between psychical depression and exaltation. To this undulating mood corresponds a pathological religious- ness. They are religiously either exalted without any reason, or abnormally contrite. Many epileptics evince a tendency to sanctimony and asceticism, which offers a striking contrast to their usual fretfulness and incom- patibility. These traits are especially noticeable in asy- lums. It is only in rare cases that the mental faculties are left entirely intact by epilepsy. EPILEPSY. 143 The classical attacks, indicated by general spasms, may be substituted in epilepsy by equivalent nervous attacks which at first sight have nothing in common with the falling sickness. Such psychical equivalents are: 1. Conditions of unconsciousness, lasting frequently for a few seconds only. The patient suddenly interrupts his speech; if walking, he stops; he drops anything held previously in his hand. If this morbid attack continues for some time, the patient commits acts in violation of common sense, of morals, and of laws. Such mental absence either follows epileptic fits, or initiates them, or the whole attack consists merely of a short suspension of consciousness. 2. Greater disturbances of consciousness, accompanied by awful visions (blood, fire, etc.) ; these follow at times grave attacks (postepilectic madness), and end in sleep, with a subsequent recovery of consciousness without any recollection of what has happened. While in that delirious state the epileptics are likely to commit the most violent assaults upon other persons. 3. Epileptic vertigo. The invasion is by light con- vulsions. The head is swimming, objects appear sud- denly to circle about the patient, consciousness is only sus- pended for the briefest time, hardly noticeable. The patient himself declares after a few seconds, " It's over." It is self-evident that the deplorable epileptics are not only ill at the time when visited from an attack of their grave malady, but that there prevails an endur- ing morbid condition of the brain, the attack or its equivalents representing merely a temporary discharge. On account of the continuous morbidity, the removal of these patients into an asylum is opportune if they fail to be attended at home with expert care. Many patients, whose condition at home is pitiable, improve when cared for in 144 PASTORAL MEDICINE. an asylum. The attacks can be made milder, the incidental danger for the patient is minimized by the watchfulness of the nurses. His spirits are revived. His depression gives room to confidence if he perceives how he can find an occupation and be useful notwithstanding his sickness ; whereas this was impossible for him while at home. HYSTERIA. This term applies to a nervous disease marked by an abnormal irritability in those nervous spheres which bring about sensation and motion, but which also and particularly appears in the psychical do- main, when no evidence can be found of anatomical changes in the central organ of the nervous system, brain and spinal marrow. The word hysteria indicates the assumption in former times that the disease was confined to the female sex and that it initiated from the sexual organs. Both assumptions are erroneous. Neurotic hysteria is also a disease of men, although, by far, more seldom than of women. The fact that hysteria is frequent in women who suffer of a disease of the sexual organs only indicates that this is one of the ways in which like disturbances of the nervous system may arise. The abnormally increased irritability of the sexual nerves is characterized by various sensations of pain. Their peculiarities are a steady change in the seat, extent and duration of the pain, want of a traceable original cause, a sudden disappearance of pain or its leap to other nervous spheres previously unaffected. In place of an oversensitiveness, an insensibility of single corporeal regions has been observed in grave cases. Of perverse sensations peculiar to hysteria may be men- tioned clavis hystericus: the sensation of a nail piercing the brain ; globus hystericus: the sensation of a ball tak- ing its course from the heart to the larynx and causing HYSTERIA. 145 oppression. The nerves of the organs of senses are like- wise at times in an oversensitive condition. The eye is painfully affected by the ordinary irritation of the sun- light. Noises which never molest a normal ear are un- bearable to hystericals. Odors, not disagreeable to others, greatly annoy these patients, whereas smells which are not pleasing to most persons, for instance, the odor from burning feathers, of the valerian weed, etc., agree with them. In the nervous realm of motions convulsions and cramps take place in hysterical persons. Even complete spasmodic attacks, as in epilepsy, may occur, preceded at times by shrieking, howling, barking, laughing, or crying. During these spasms consciousness is mostly not alto- gether suspended. After the attack has run its course the patients soon recover entirely without being the worse. These attacks occur only when the hysterical is awake, in daytime, never at night, in contrast to epilepsia nocturna. Just as oversensitiveness in some cases is re- placed by insensibility, so we meet here, besides a height- ened irritability expressed by convulsions and by cramps, with a paralysis of single groups of muscles. Even the whole body is sometimes in a state approaching paralysis, which prompts many hystericals to remain in bed for months and to scrupulously avoid any exercise. Of greater import than the physical condition of hys- terics is to the clergyman their psychical mood. Hys- terical people are not only a crux medicorum, but are tor- mentors of the priest, in and out of the confessional. Affections are called forth with ease. The patients are easily frightened, easily overwhelmed by everything un- expected, sensitive to pain and easily offended. Any trifle puts them out of humor and causes excitement, never ending until some new irritation occurs, which is 146 PASTORAL MEDICINE. apt to call forth the opposite mood, and just as strong as the previous one. The dismal mood, during which the patients are an- noyed and pained by everything, and feel unhappy and incompetent for anything, may be followed immediately by a most cheerful, often also playful and mischievous humor, wherein they see everything in a roseate hue and are often capable of performing astonishing feats. The whimsical temper is the proverbial trait of hystericals. It manifests itself in a perpetual attempting and abandon- ing, in spasmodic, hasty actions without enduring energy. At the same time the patient endeavors to impress her people with the idea that her condition be something utterly pitiable, grand and extraordinary, her heated imagination often violating the truth. The border line be- tween this abnormal psychical conduct and a genuine mental disease can hardly be drawn. The degree of psychical change is less decisive in this respect than the duration of the morbid psychical symptoms. Only after enduring alterations of the imaginative activity have de- veloped, accompanied by hallucinations, only then is it a case of hysterical mental disorder. The objects of the fancies by morbid hysterical changes according to the intelligence of the patient. Frequently the object is a religious one the patients see the gates of heaven opened, have divine apparitions, have inter- course with saints, they hear and proclaim all sorts of prophecies, with or without sense. The attacks of demonism, which have played a promi- nent part particularly in the hysterical epidemics of former centuries, and which yet occur even to-day, have their roots likewise in religious fancies. The patients believe to house the devil, or various evil spirits, within their body, to be driven by them to contortion and HYSTERIA. 147 paroxysm, and to be compelled to utter unholy, shame- ful remarks, speaking for the unclean spirits and against their own volition. Many vary even the pitch of voice, according to whether one or the other evil spirit com- pels them to speak. An erotic trait is seldom missed in those cases. It is most undisguised in cases where de- lirious patients imagine to have been abused by persons about them. The details are often told with such vivid- ness, and deviate so little from the possible, that at various times such charges have led to trials, and, in some in- stances, to convictions. In touching upon a few prime causes of hysteria, we meet, like in all nervous morbidities in a wider sense, as most important cause the hereditary oneration. Par- ticularly occurs here immediate communication in this manner. Hysteria of parents, or ancestors in general, re- sults in hysteria of the children. Especially the communi- cation of this sickness from the mother to the daughter occurs extraordinarily often. The most essential influence upon both, the suppression and the development of hysterical predisposition, is exercised by education. It is possible by a fitting influence upon body and mind to smother the existing predisposition to hysteria; but also, vice versa, a non-existing predisposition, or one in a slight degree, may be developed artificially. All in- fluences favoring corporeal feebleness operate in the lat- ter respect ; therefore, a too effeminate education, whereby the body does not obtain the necessary degree of resist- ance, is just as detrimental as one too strenuous, which exacts efforts beyond capability. Both extremes are also detrimental in moral respects. By too much yielding a lack of will and a capricious- ness are favored, which furnish auspicious conditions fo r 148 PASTORAL MEDICINE. the appearance of hysteria. Too much severity and in- timidation are apt to call forth so violent an agitation that it causes increased irritability of the entire nervous sys- tem, paired with weakness of character, a result which promotes the disease. The greatest danger, however, lies in an unsteady, whimsical education, wherein immoder- ately now one, now the other course is pursued. Particularly dangerous are excessive demands from the mental capability, the overburdening with objects of instruction and inciting ambition at the same time. Want of sufficient exercise is, as a rule, another inciter. The influence of a faulty education on the develop- ment of hysteria can not be appreciated thoroughly with- out taking account of a cooperating lesser circumstance, which is found, even at a higher age, to be one of the causes of hysteria the stimulation of the impulse of imitation. Hysterical mothers not only communicate the germ of the disease to their children, they also favor its development by the education they give and by their example. First of all the symptoms of these attacks, especially paroxysm, incite imitation.* But even the entire way of feeling and of thinking is communicated with continued intercourse. This so-called imitative in- fection is found to operate at times on nurses, having attended hysterical patients for a long time, in a similar way as it does upon children. Also other patients, having been in the same room with hystericals, or casual wit- nesses of hysterical paroxysms, become frequently in- fected. * Professor Hirt, of Breslau, reports that in a village school of Silesia there were twenty girls out of a total of thirty-eight who became ill with hysterical spasms. Professor Hirt positively declares that the spreading of the morbidity among these chil- dren was caused by the impulse to imitate. DISEASES DUE TO OCCUPATIONS. 149 This imitative infection has no small bearing upon the spread of hysteria in public and boarding schools. It has been a matter of observation that, after the first case of spasms in the presence of other pupils, there soon ensued several similar cases in girls previously healthy. III. DISEASES DUE TO CERTAIN OCCUPATIONS. SAFETY DEVICES FOR WORKINGMEN. SOCIAL LEGISLATION A group of diseases is caused by the nature of a man's calling, the daily occupation, as is particularly the case with workingmen. In the majority of cases the disease is caused by the material handled, for instance, mercury in plate glass factories, phosphorus in match factories, lead in making lead paints, etc. But also non-poisonous materials are apt to cause diseases if they pulverize too much in the course of their handling. The dust particles of the working ma- terial are absorbed by the lungs and incite certain morbid changes of that organ, which are termed dust inhalations. Not only dust particles of the working material are inhaled, also different gases which develop in many in- dustrial processes. Diseases from gas inhalation form an- other class of such diseases. Furthermore, many diseases of workingmen are caused by physical overexertion, be it that the work itself taxes the muscles too much, be it that the body is not developed sufficiently, or strong enough, to perform a certain work (children and women). In some trades certain organs of the body or certain i5o PASTORAL MEDICINE. groups of muscles must be particularly exerted, and, therefore, are more exposed to injury. A fixed attitude of the body long maintained during work leads finally likewise to disease. I assume that this class of diseases is of interest to the priest because his vocation brings him quite often in touch with the industrial workman. This intercourse seems to make it desirable for the clergyman to obtain a general outline of the dangers threatening the health of his parishioners. It is self-evident that the handling of poisonous ma- terials in the course of his work must entail grave dangers for the workingman's health. The doors by which these poisonous substances enter the system are lungs, stomach, and skin of the workingman. The handling of mercury entails many dangers to health, both at the place where it is produced : at the quicksilver mines, and in the different manufactories where it is used, in silvering mirrors, in hat factories, etc. Ulcers in mouth and throat, convulsions, and finally general cachexy ap- pear if the workingman relaxes in his caution. Therefore, the workingman must be in perfect health before starting work, and must be constantly on his guard during work. Preventive measures are embodied in detail in factory rules. They relate to the workshop and the clothes of the men at work. In rooms where mirrors are silvered, special clothes must be worn. Every workingman must wash himself carefully before and after work and rinse his mouth with a prescribed solution. Meals must be taken in a different room. A workingman must not be em- ployed in the dangerous silvering room longer than four hours a day and not oftener than three times a week. The trade wherein chiefly the poisonous phosphorus is used are the match factories. The handling of phos- DISEASES DUE TO OCCUPATIONS. 151 phorus in this industry entails many dangers for the workingman's health. The disease which workingmen in match factories chiefly acquire is an affection of the jaw- bones, which leads to sores and to the decay of the bones. Persons with bad teeth are particularly in danger. In view of the incidental danger this industry, at its begin- ning, was forbidden in some countries. Only gradually sanitary measures preventing injury became known. Another most poisonous metal for the handling worker is lead. It is variously used, for glazing in potteries, for paints, etc. The most widely known disease of persons working with lead-containing matter is lead colic. It consists of attacks of vehement gripings in the bowels, especially about the navel, and persistent constipation. At a higher degree of lead poisoning there appear pains in the joints similar to rheumatic aches, without, however, changing their seats. Next paralysis sets in and atrophy of muscles, in the highest grades even deliriousness, mental depression, and epileptic spasms. The sanitary rules in lead works, and in shops where lead is handled, should be very stringent. Especially the raising of dust in the shop, or at the machines which crush the lead-containing material, is severely to be guarded against. Youthful workingmen are to be excluded from employment or from staying in works where lead paints or white lead are manufactured. Aniline factories which use arsenic are dangerous both for the workingmen and for the neighborhood, arsenic being one of the strongest mineral poisons, as is well known. Among the kinds of dust inhaled with the air in the shop by workingmen, coal dust occupies first place beyond all doubt. A deposit of coal dust in the lungs anthra- i5 PASTORAL MEDICINE. cosis pulmomim is met everywhere where the lungs are compelled to breathe smoke and coal dust with the air. This is the case in the air laden with tobacco smoke in crowded saloons, in collieries and mines. The inhaled dust incites the respiratory organs to frequent coughing in order to get rid of the foreign substances. Therefore, we frequently meet miners afflicted with cough and mucus. A prolonged inhaling of coal dust seldom fails to produce short-windedness in a considerable degree, caused by chronic inflammation in the lungs. The pale color of many coal dust inhaling workingmen is not only caused by the lack of oxygen in the working place (for instance, in coal mines), but also by the deposited dust contracting the capillary vessels in the delicate pul- monary tissue, and thus rendering them unfit for inhaling or expelling air. On the other hand, all observers emphasize the fact that genuine pneumonia is a rare disease among workers who inhale coal dust. Therefore, there is a tendency to ascribe to coal dust a specific operation against tubercu- losis and pneumonia. Regarding the various kinds of coal dust and the trades in which they are inhaled by workingmen, there work in an atmosphere containing the dust of the charcoal, the charcoal burners, the coal dealers, the firemen, and the workingmen in ultramarine and powder factories. Anthracite coal dust is inhaled by miners, trimmers, fire- men ; soot by chimney sweepers and miners ; graphite by smelters and molders. According to investigations by Hirt and Lewin, of all coal-inhaling trades it is among the chimney sweepers where the best health conditions prevail. Another kind of dust inhaled by some industrial work- ingmen is iron dust. Its deposit in the lungs is termed DISEASES DUE TO OCCUPATIONS. 153 siderosis pulmonum. The symptoms perceived in these workingmen resemble partly those found in coal workers. On the other hand the effects of metal dust are far more destroying for the pulmonaric tissue than coal dust. The number of consumptives in these trades is extraordinarily large. Of trades where metal dust is breathed are next in order the factories which prepare the peculiar paper used for the reception of gold leaf. Peroxid of iron is rubbed into this paper with a piece of dry felt, whereby an enormous amount of dust is raised. " The vitality of the girls employed at this trade," says Merkel, " is so low that it is only astonishing why not more of them perish and why, again and again, girls are found who heedlessly brave the very same danger." Particularly detrimental to the lungs of the worker is the dust developed in grinding steel wares. It is a mix- ture of iron and sandstone. This most noxious species of dust is raised in grinding scissors, knives, forks, pens and needles on fast rotating grindstones, with 2000 to 3000 revolutions in one minute. No less detrimental to the lungs of the workers is the influence of stone dust, particularly of quartz, as its small- est particles are extraordinarily hard, splintery, pointed, hence hurting in the highest degree. Two classes are especially exposed to this kind of dust : the workmen in the founding mills of glass factories, where the raw material for manufacturing glass is crushed to a dry powder, and the millwrights, who grit the mill- stones. The age average of these workers does not even reach that of the English needlemakers thirty-five years. Nor do workingmen exposed to tobacco dust present any favorable conditions of health. The likely cause is not only the dust inhaled, but other competing noxious i54 PASTORAL MEDICINE. influences: the sitting attitude, want of fresh air, prema- ture and excessive smoking in leisure hours, and lastly, the fact that frequently workingmen of feeble health look for employment in cigar and tobacco factories. These unsanitary conditions prevail, to a greater extent, where tobacco is worked up as a home industry. Then the work- room is often used as dwelling-room for the family, and as kitchen. The atmosphere therein is hardly breathable if the lungs are not accustomed to it. Among the poisonous gases inhaled by the industrial workingmen when at work claims our attention the car- bonic gas, in everyday life called merely gas. It has been dealt with in the first part of this work. The natural and most important symptoms of poisoning by carbonic gas are affections of the brain. They start in with a dull headache; then the eyes grow dim, dizziness sets in, fol- lowed soon by a total and long unconsciousness. Has the poisonous gas been inhaled for some time, then the poi- soned expires without having regained consciousness. To the danger of breathing carbonic gas are exposed the workers in gas plants, on conduits, and those employed at blast and coke furnaces. Closely related to carbonic gas is carbonic acid, both in regard to its chemical composition and in regard to its operation on the human organism. Gaseous carbonic acid, or the mixture of gases wherein it is prevalently con- tained, develops during fermentation, in distilling liquors, in breweries, in the fermentation of wine. The deadly gas mixtures in old tombs or in wells that have been closed for a long time contain a preponderance of car- bonic acid besides small quantities of sulphuretted hydro- gen. Exposed to the danger of inhaling the last named poisonous gas are the workmen in sewers and canals and the tanners. The poisoning, as a rule, appears suddenly, HYPNOSIS AND SUGGESTION. 155 as that from gas in wells. The worker collapses as if struck by lightning, and he will be past rescue if not re- moved at once from the operation of the poisonous gases. It is quite natural to expect a particular benefit in all unsanitary occupations from preventive measures. But prejudice and ignorance, heedlessness and lack of knowl- edge, want and poverty are competing with lack of con- science and with greediness, to render prevention here as difficult as possible. As there will be little success from the instruction of either workingmen or employers in regard to the preven- tion of diseases, we must arrive at the conclusion that it is necessary for the government to frame general rules for the sanitary safety of the worker, and that the fulfilment of these laws should be supervised by government of- ficials. This demand for the workingmen's safety by legal pro- vision has been complied with more or less by all civilized governments. England, in this respect, is ahead of them all. Next to that country, Switzerland has enacted the most satisfactory factory laws. IV. HYPNOSIS AND SUGGESTION. By hypnosis* is understood a sleep-like state of the nervous system, at which a person arrives through the agency of another person, the hypnotizer. The hypno- tizer's method with the susceptible person medium consists either of the command to stare at a glittering object, a glass button, for instance, or of passes with his hands over the medium's forehead and extremities, or even in the hypnotizer's simple command, "You are tired; close your eyes. Now you're sleeping." f, sleep. 156 PASTORAL MEDICINE. The hypnotized, upon entrance of hypnosis, continues in the attitude last assumed before falling asleep. He is like a statue. His senses are suspended, barring the hear- ing. Upon the hypnotizer's proposing (suggestion) any part of the central nervous system may be set in action and any psychical act made possible. The auto- matic mechanical performance ceases as soon as the sug- gested order has been executed. The retransfer from the hypnotic into the lucid state is easily accomplished by the hypnotizer, either by breathing at the medium or by the mere command to wake up. Upon awakening the hyp- notized has no recollection of what has occurred during his hypnosis. Commands by the hypnotizer may continue their effect upon the awakened, e. g., to move a limb that had been previously stiff, that it be no longer paralyzed ; not to feel pain in a certain part of the body which had ached before. As a matter of course, this applies ex- clusively to such state of paralysis not due to any anatomically traceable lesion of the nerves, for instance, to hysterical paralysis. No hypnotizer would have the power to revoke by suggestion the paralysis due to a stroke of apoplexy. To the extent of the observations mentioned, hypnosis is employed as a remedy. It was this striking condition of the nervous system whereby one person becomes the helpless tool of another, which raised, some twenty-five years ago, a storm of excitement in Austria and Germany on occasion of the exhibitions by the noted hypnotizer Hansen. A stream of believing* and unbelieving, of edu- cated and ignorant, persons poured forth every night to witness the performance. The programme of the show was always one and the same. Hansen invited to the platform a number of the spectators willing to be experi- mented with, placed them on chairs, their backs turned to HYPNOSIS AND SUGGESTION. 157 the audience, and handed a glass button to each. Each one was told to fix his eyes, and stare immovably, at the button raised close to the forehead. Hansen himself went from one object to the other, making a few strokes and passes in front of each face. Within five or ten min- utes one or the other among the objects fell into a hyp- notic state. The muscles of the object became so rigid that it was possible to place his head on one chair, his heels on another, keeping the rigid body thus suspended. A few passes by the hypnotizer's hand removed the rigor of the muscles the medium woke up. Another hypnotized object was handed a potato, and was told it was an apple. To the great amusement of the audience the object ate the raw potato with perceptible relish. It would be beyond our scope to dilate upon every number on the programme of a kindred exhibition. First of all, it should be pointed out that Hansen brought noth- ing new to the surface. His manipulations rest on ob- servations gleaned, in part, from the practices of uncivil- ized nations. In order to create a proper susceptibility of nervous activity by concentrating the entire attention on one ob- ject, Hansen made use of a glass button. The Yogies in India provoke an ecstatic condition by Trataka, i. e., by gazing upwards, the priests of the Viti Islanders by fixing their eyes silently and calmly on an ornament made of fish teeth; after an elapse of a few minutes, they begin to convulse and to tremble; they mumble and groan the spirit is supposed to possess them; in full paroxysm, with rolling eyes bulging out, with pale and contorted features, the hierophant proclaims the revelations received, in a loathsome voice. In similar fashion are inspired the oracles of spirits on Sandwich Islands, Tahiti, and other isles in the Pacific Ocean. 158 PASTORAL MEDICINE. Apparitions quite similar to those produced by Hansen were called forth by Mesmer toward the end of the eighteenth century with the aid of big so-called magnetic bathtubs, by passes, etc. Mesmer ascribed his suc- cesses to his discovery of a mysterious fluid, the so-called animal magnetism, or magnetism of life. Existing as mov- ing agency everywhere in space, this fluid was thought to be communicated as a healing power from the magnetizer to the object, through the appliances mentioned. This novel theory, clothed with much unsound mysticism, gained ground rapidly, but also was vehemently antago- nized in medical academies and societies, which sharply condemned, time and again, Mesmer's conduct. Dr. James Braid, of Manchester, in 1841, propounded an entirely novel theory of animal magnetism, whereby he became the real discoverer of hypnotism. Braid proved by his experiments that the magnetizer does not communicate to the object a mysterious force which emanates from him- self, but that the object by himself can assume a strange sleep-like, sometimes somnambulic, state wherein he thinks to have a distinct sensation not only of spontaneously oc- curring presentations, but also of those which were called forth suggested by the hypnotizer. This con- dition, produced by staring at an object, is really due to qualities and faculties innate to his nervous sys- tem. Braid's discoveries gave rise to all sorts of erroneous and barren speculations, as was the case with Mesmer's findings. Again and again the facts of hyp- notism were overhung with certain mystic accessories born by superstition and humbug. In his work " Du someil et des etats analogues/' Lie- bault, of Nancy, furnished the proof that the strange sleep-like condition, termed hypnosis, is not called forth by a mechanical-physical process, like the tiring of the HYPNOSIS AND SUGGESTION. 159 eyes from staring, or by the soothing effect of a gentle stroke upon the nerves of the skin, or similar manipula- tions, but only and solely by the idea produced in the medium that it must sleep; furthermore, that all other seemingly natural effects of hypnosis, as the rigor of muscles or the insensibility of the skin, are caused solely by suggestion, which the one experimenting, expressly or implied, communicates to the object. Where no direct words are uttered in suggesting, then the object guesses from certain circumstances or hints, or from previous ex- periences, what the hypnotizer expects. If, for instance, he lifts the medium's arm, it will in most cases fall down again. If, however, the arm is lifted a second time, then the medium rightly assumes that the hypnotizer de- sires the arm to remain in the given position. Sugges- tion, whether communicated directly or indirectly, is the kernel and the hinge of all effects caused by hypnosis, and hypnotism itself is nothing else but a condition of en- hanced suggestibility, caused by suggestion. To employ hypnotism, respectively suggestion, for medical purposes, should only be allowed to an expert physician who conscientiously takes all corporeal and mental conditions of the patient into account. It is evident that such a variation of a person's nervous life at the hands of impostor, or an ignoramus, may cause great injury, personal and general. This applies especially to public experiments and shows. The persons used as objects in such demonstrations are impaired in their corporeal and mental health by negligent, unsuitable, careless and too frequent hypnotizing. An authority on the matter remarked in a discourse on origin and cure of hypnotic diseases : " The state of hypnosis con- sists in an expressly provoked loosening, even in partly unfastening, the normally fast ties between psychical and 160 PASTORAL MEDICINE. corporeal events. But if loosened once, or even fre- quently, this tie undoubtedly loses its enduring security, hence persons repeatedly hypnotized are in danger that similar conditions may occur for some reasons not con- templated or foreseen by the hypnotizer. The very state of hypnosis must unconditionally be looked upon as some- thing abnormal, something morbid. Exactly the same symptoms, as expressly provoked in hypnotizing, are known to the physician as primary symptoms, by no means rare, of morbid conditions, caused naturally by a mental disorder, which he terms hysteria. Hypnotic conditions and symptoms of hysteria in their inner nature are most closely related. Hypnosis is nothing else but an artificially provoked hysteria. . . . Hypnotism remains ever a double-edged sword, which can do much harm, especially if not altogether judiciously used. This has been shown by experience time and again." The sense for decency and propriety disappears by public exhibitions, or becomes, at least, greatly impaired. Those present during the experiments run the risk of ac- quiring morbid nervous conditions, by looking at the mediums who lend themselves for these demonstrations. De La Tourette reports that after the public exhibition by the Magnetizer Donate, in the winter of 1880-1881, in French Switzerland, a real magnetic epidemic, "magnetism mania," made its appearance. The very same was noticed in Breslau after Hansen's seances, especially among young people. At the fifty-third convention of German scientists and physicians, at Danzig, 1880, the case of an artillery officer was related who was so susceptible that he could not attend a seance without running the risk of becoming hypnotized. As a result of these consequences public exhibitions of hypnotizers are prohibited in many countries. HYPNOSIS AND SUGGESTION. 161 The fact, finally, that while in hypnotic state a person may be exposed to assaults should not be overlooked. Attention has furthermore been directed to alleged crim- inal possibilities of hypnotism, which are quite fallacious. This, furthermore, is equally the case with another excres- cence which has shot up on French soil. Since these crini- inal possibilities will be of interest to the priest in the con- fessional, we shall here devote some attention to them. The French physicians Bernheim and Liegois asserted that a hypnotized person can be commanded by sugges- tion to commit a crime, and that upon awakening from the hypnotic state the person in question can not help com- mitting the ordered deed. Hence that person can evi- dently not be charged with the crime, neither by the crim- inal judge nor by his own conscience. These and kindred views of men who had made of hypnotism a particular study, incited, when first pub- lished, a widespread dispute, and disturbed the peace of the minds to a large extent. Searching investigation and unbiased weighing of the alleged facts, however, soon disclosed that the originators of these views were en- meshed in the most flagrant contradictions, and that they were unable to produce even a single attested case from real life to support their " laboratory theory," if it is per- missible to use this term. At the sixty-first Congress of German Physicians, at Cologne, this heresy of Bernheim was refuted as " in no ways borne out by fact, and belonging to the realm of visions." Bernheim's teachings in which he sees the ef- fects of suggestion everywhere: all our thoughts, deeds, and actions are suggested were even refuted by his own fellow-countryman, Dr. Gilles de la Tourette. In concluding, suggestion incites also our interest inas- much as it was brought forward as an explanation for PASTORAL MEDICINE. many extraordinary cures, which occurred at places of pil- grimage, for instance, at Lourdes. The above mentioned student of hypnotic conditions, Professor Bernheim, of Nancy, who, of course, is prone to trace back all psychical processes to suggestion, has this to say anent the miracu- lous cures at Lourdes : " It is not my intention to attack religion or to hurt the feelings of the faithful in ex- amining these credible reports of cures at Lourdes and in trying to disrobe them in the name of science of their character of miracle. My object in view is merely to bring about a comparison between religious suggestion and hypnotic suggestion. " There is no doubt that all these reports were collected in a spirit of truth and were tested by honorable men. The facts are correct; their explanation may have been erroneous." Charcot, one of the most famous French neurologists, every year sent many of his patients to the spring of grace. According to an article in " Archives de Neurologic" he had no doubt that even wounds, sores, cancer, etc., can be cured at those places of pilgrimage ; but he believes that these processes are founded on hysteria, and that the morbid symptoms may appear and disappear upon sugges- tion. But, finally, he honestly admits that even to-day there are many things on earth which can not be ex- plained by our philosophy. Leaving out entirely the mor- bidities of the nervous system, it is not difficult for the unbiased observer, who has been at the sick bed and the dissecting table, to decide the question where the greatest sacrifice of intellect comes in : if he is to assume a cancer, a caries, a fungus, has been made to come and go by sug- gestion, or that it has been cured by a miracle. Reviewing the above, we arrive at the following con- clusions : 'ALCOHOLISM. 163 1. The striking mutation of the nervous system, termed hypnosis, rests on natural proceedings and lacks all those mystic-spiritistical trimmings, with which the rep- resentatives of animal magnetism (mesmerism, braidism) tried to clothe it. 2. The exhibition in public of hypnotic experiments on persons is decidedly to be prohibited, for the sake of morality and public health. 3. Hypnotizing for the purpose of effecting cures should only be permitted to expert physicians. 4. Hypnotic state exposes persons to the danger of assaults. 5. The doctrine, propagated in some quarters, that sug- gestion abolishes the free agency of a person, inasmuch as an irresistible impulse to a deed, especially a crime, may be suggested to the hypnotized, is erroneous. 6. While suggestion may play a part in allaying mor- bid conditions, as an explanation of miraculous cures it is entirely inadequate. V. ALCOHOLISM. By alcoholism (abusus spirit uosorum) those aggre- gated morbid signs and tokens are understood which are the effects of long continued abuse of liquors. The his- tory of the abuse of alcoholic beverages is part of the history of civilization of mankind. True, the ancients and our forefathers certainly did practise riotous libations in honor of Bacchus, yet this insobriety never exercised that destroying influence upon the corporeal and mental welfare of the broad masses of the people as does the vice of drunkenness in modern times. Our ancestors i6 4 PASTORAL MEDICINE. quaffed nothing worse than wine and beer ; moreover, of low alcoholic grade. The abuse of spirits only became a general vice with the introduction of spirituous liquors. Its production is to be traced back to the Moors in Spain, as its name (al-cohol) indicates. The Arabian physician Abdul Kasim, of Cordova (died in 1106), speaks posi- tively of liquor obtained by distillation. Drunkenness makes a person ill, bodily and mentally, and acts destructively in ethical and social direction. (a) Somatic effects of Drunkenness. Persons given to the abuse of liquors fall more easily sick and die at an earlier age than moderate drinkers and abstainers. Habitual and excessive use of alcohol de- teriorates the entire constitution of the body. Hence vitality and resisting power to morbid agents is lowered. In times of epidemics (cholera, dysentery, pox) drunkards are among the first to fall sick and succumb to the attack in a large number. Furthermore, a drinking man falls a prey to an acute febrile disease more easily than the non-drinker. This fact is proven by statistics compiled from reports of certain individual life insurance companies in England, which have two divisions : one for insured total-abstainers from liquor, the other for non-abstainers. The death list in the abstinence section, for a space of ten years, amounted to but seventy-one per cent, of the anticipated death cases ; in the second section, however, the percentage was ninety- seven. Hence the number of deaths in the former division was twenty-six per cent, less, i. e., over one-quarter less than in the second. According to recent experiences of an assurance com- ALCOHOLISM. 165 pany in Scotland there occurred among 862 insured tavern and innkeepers 215 death cases, while, according to the mortality list of the company, only 142 death cases were to be expected. Hence this trade evinces an over- mortality amounting to fifty per cent. The following remarkable statistics anent the effects of the abuse of liquor were compiled by the Revue Sanitaire de Bordeaux. The annual mortality in England among males between the ages of twenty-five and sixty-five years reaches : Among Per cent. Priests 8.05 Farmers 9.78 Farm laborers 1 1.86 Inhabitants of the most healthy sections. . 12.46 Carpenters and joiners 12.71 Coal miners 13.81 Bricklayers *4-9 2 Lead workers, glaziers, painters 18.63 Brewers 21.09 Innkeepers 2 3-57 Help in public houses 34- I 5 Hence, hard labor, by which a man earns his daily bread, proves less detrimental than the abuse of liquors. Bad food, poor clothes, foul air, unsound dwellings are less harmful than alcohol. Even leadworkers, while handling poisonous material, are better off than brewers, tavern keepers, and the help in public houses. Taking the aggregate years of life reached by 14,176 male per- sons, who, in their capacity as restaurant, tavern, and inn- keepers, brewers, waiters, etc., had been more or less ad- dicted to the abuse of intoxicating beverages, and compar- 1 66 PASTORAL MEDICINE. ing this total with the total of years attained by per- sons taken from the general population, and from trades injurious to health, all these persons having died at a corresponding age, Baer has come to the conclusion that " the vitality of persons of the first-named callings at the age of thirty is less than that of an ironworker, and at thirty-five about equal to that of a filecutter. This pro- portion bears testimony of how the habitual use of alcohol impairs health and shortens life, even when not used to excess." The intemperate use of spirits affects a person in an acute manner thus^ that upon the stimulation at first of physical and mental capacity, there follows a paralysis of voluntary muscles and of the cerebral functions (intoxica- tion, poisoning by alcohol). At the highest degrees of intoxication, death by apoplexy is nothing uncommon. The chronic effects of alcoholic abuse are made evident in the first place in the digestive organs, where the pituitaries are directly brought in contact with the stimu- lating liquid. Catarrhal affections of throat and stomach are soon in order, appetite decreases, thirst increases. With empty stomach, especially in the morning, a chok- ing and heaving sensation is felt. Next, the liver is attacked, gathering a morbid layer of fat. With pro- gressed drunkenness, this organ shrinks, which is espe- cially the case with whisky drinkers. In most cases the kidneys, too, are affected, and form, together with the diseased condition of the liver, the foundation for dropsy. This malady, and pneumonia, constitute equally often the last tableau in the course of a body ruined from sottish- ness. Drunkenness not alone undermines the health of the drunkard, its detrimental effects extend also to the issue of drunkards. ALCOHOLISM. 167 First of all, it has been established by expert scientists that children begotten in a state of intoxication either are vastly predisposed to mental disorders, or are born idiots, or perish soon of a weak vitality. According to Darwin, the family of drunkards becomes extinct in the fourth generation. Demme compiled the following evidence of the in- fluence exercised by parent-drunkards upon vitality and health of their issue : He took ten hard drinking families and contrasted them with ten others of unquestionable sobriety. The direct issue of the ten drinking families amounted to fifty-seven children. Of these, twenty-five died within their first weeks or months of life, six were idiots, five children were noticeably slow in growing, five suffered from epileptic fits, five from innate diseases. One boy became afflicted with St. Vitus' dance and ended as an idiot. Hence, of the fifty-seven children by drunkards there were only ten, or 17.5 per cent., in whom normal faculties and developments were noticed. The ten temperate families produced sixty-one children, of whom but five died off within the first weeks, four suf- fered from curable affections of their nervous systems; only two children evinced innate defects. The remaining fifty, 81.9 per cent., presented normal faculties and devel- opment. Effects of drunkenness in the psychical sphere. Abuse of alcohol is preeminently detrimental to the organ of the mental life : to the brain, both in regard to its structure and to its functions. The drunkard's powers of 1 68 PASTORAL MEDICINE. perception and of reasoning become blunted, the will power abates. Drunkenness plays a predominant part in diseases of the mind. One-quarter of all inmates of insane asylums are drunkards, according to the concurring observations by all specialists of experience. In many instances a par- ticular psychosis grows upon the soil of chronic alco- holism, the origin of which is simply due to drunkenness. Where there is a predisposition to mental morbidity, the abuse of liquors promotes the development of the lurking disease. Such persons are strikingly susceptible for the effects of liquors. Small quantities suffice to produce symptoms of heavy intoxication (pathological in- toxication). One of the most frequent intercurrent mal- adies due to chronic alcoholism is the delirium tremens potatorum. As implied by the name itself, its fundamental signs are deliriousness and shaking, accompanied by in- somnia and hallucinations. As casual causes for the outbreak of the delirium must be considered all debilitations, which further enfeeble the drunkard's already impaired and unresisting brain. The principal casual causes are frequent debauches (a potu nimio), deprivation of liquor for the habitual stimulation of the nerves (a potu inte rmissio ) , insufficient food, acute febrile diseases, particularly pneumonia, external injuries, fractured bones. Preceded by forerunners, such as irrita- bility, oppression about the cardiac region, restless sleep, headache, dizziness, the real malady, delirium, breaks out a few days later. Dullness of mind is followed by delusions, hallucinations, at first only after dark, later also in daylight. They consist chiefly of visions of ani- mals. The patients imagine themselves surrounded and beset by rats, mice, dogs, horses, in masses. They lack sleep entirely. ALCOHOLISM. 169 (c) Effects of drunkenness in ethical respects. Experience teaches that habitual drunkenness at first decreases in a specific way the moral qualities of man, and destroys them gradually. The drunkard's sense of honor, duty, decency, and manner becomes, by and by, extin- guished. Self-control of the intoxicated is impaired ; lusts and impulses rise, stronger and more commanding; re- straint by will and reflection is utterly out of question. Enlarged self-esteem makes the intoxicated quarrelsome and more sensitive ; the latter quality again prompts him to act hastily, to take prompt revenge for an offered insult, real or imaginary. Hence criminal courts, judges, and prosecutors, are well aware of drunkenness and crime being cause and effect, and find this truism borne out, over and over again, by their daily experience. An authority, Dr. Krohne, director of a penitentiary, describes the connection between drunkenness and crime as follows: " Of the criminal assaults upon body and life, the resulting simple or grave injuries are entirely, those not deliberate in the assault, but merely accidental, are almost entirely, manslaughter, voluntary or involuntary, with but few exceptions due to liquor. In many murder cases the courts find liquor to be the cause for the crime. Crimes against morality, be they rape, malpractice with children or adults, etc., are almost exclusively due to liquor." The same authority arrives at the result that seventy per cent, of all crimes and misdemeanors com- mitted are originally more or less connected with liquor. 170 PASTORAL MEDICINE. (tf) Social effects of drunkenness. Drunkenness is the most prevalent cause of pauperism. As the French physician Picard says, " Poverty and misery follow everywhere in the wake of insobriety, like a shadow follows the body. On the very day when drunk- enness shall have vanished, the larger half of pauperism will also have disappeared." In 1885 62 per cent, of all persons supported by public charities in Germany had been pauperized by drinking. This connection between pecuniary distress and drunk- enness need astonish no one who stops to consider that some workingmen spend four-fifths or more of their daily earnings for liquor or beer. How much remains, then, for rent, clothes, and food? Drunkenness undermines family-life. The drunkard can not find recreation at home with his family, at least, none that satisfies him. He must go into the saloon. By staying in the saloon, he neglects his duties toward his family. His craving for liquor soon absorbs all his means. His folks are put in want and misery. Upon returning home, the drunkard, still under the influence of liquor, possibly somewhat conscience-stricken, is easily irritated, and only too often gives vent to his irri- tability in dealing with his family. The sufferings of wife and children of a drunkard deserve, in many instances, a crown of martyrdom. Sometimes these family members, through despair and bad example, are also driven to drink. In view of these pernicious effects of drunkenness upon the populace, clergymen, lawyers, physicians, and social economists have maintained unanimously at all times that something must be done to curb drunkenness. " In recent times," to quote from Paulsen's System of Ethics, " among earnest and thinking men the conviction gains ALCOHOLISM. 171 more and more ground that in intemperance there lies an extraordinary danger for the entire further development of life among civilized nations. How shall we meet it? " As a preventive it has been justly recommended to begin early, with the growing young people. They should be warned of drunkenness as being a vice noxious to body and soul. A powerful influence in this direction can especially be exerted by the Catechist in school. Looking around, first of all, among working-people, in our search for preventives, we note that all such associa- tions that have for their object the saving of money, as for instance building and loan associations, are efficient antidotes against the poison of drink. Considerable influence in the same direction must be attributed also to the working-girls' associations, where working-women receive tuition and training in house- keeping and in female handicraft. Well-trained, domestic wives keep their husbands to sobriety and thrift. Proofs of the opposite can be found in abundance in everyday life. An indispensable armament in the war against drunk- enness are the temperance societies. They were founded at the end of the eighteenth and the beginning of the nineteenth century, at first in America and England. The abuse of liquors in both countries had assumed such proportions that something had to be done to curb the evil. The members of these societies abstain altogether from spirituous liquors and endeavor by word and ex- ample to gain additional converts to the cause of ab- stinence. In combating against the abuse of alcohol it became the duty of the government to reduce the opportunity to obtain liquor. The plan of limiting the production of alcohol, as ad- 172 PASTORAL MEDICINE. vocated formerly, is to be dismissed for political eco- nomical reasons. On the other hand, government has an effective means of reduction at its disposal limiting the selling places, restricting the sale of liquor to certain hours of the day, and by a large prohibitive tax. Finally, it is the duty of the government to provide that only pure and unadulterated liquors are sold. Par- ticularly should only those spirits be allowed to be sold for drinking purposes which are free from fusel oil. To liberate the drunkard from his pernicious passion there is usually no other means than his stay in a drunk- ard's asylum. Here, apparently, lies yet an open field for the activity of the religious orders, which might be en- tered not without success. VI. MORPHINISM. Morphinism is the term applied to the passion of a person for morphine as a stimulant or a relish, because they are unable to forego the medicament without disturb- ing their condition or well feeling. The term is also used to express the state of sickness engendered by the mis- use of that medicine. Morphia is the most important con- stituent of the milky juice of the white poppy, papaver somniferum. Its effect upon the human body is ex- pressed in the ominous words: It mitigates pain and brings sleep. These effects are quickened if the medicine is not introduced in the stomach, but injected subcu- taneously with a hypodermic syringe. The beneficial influence of subcutaneous injections of morphia on wounded and sick became especially apparent in Germany during the war of 1866. Since then it has MORPHINISM. 173 been ever more widely used. The technique of injection being easy to acquire, the physician soon lost control of the remedy, which fell in the hand of the laity, the patient. Thus the fatal step was done. For injected morphia not only abates insomnia and bodily pain ; it transforms at the same time the whole person, producing a state of agreeable excitement which is analogous only to the effect of alcohol. The mood changes, the gloomy, through morphia-in- jection, becomes cheerful; it imparts force to the faint, energy to the weakling, in brief, self-consciousness, con- fidence in one's own power and ability is heightened. With the excernment of morphia from the body there follows, however, a state of deep depression. There is no other saving clause to lead out of this wretched state but the helpful syringe, to which the morphia fiend has recourse, as the sot to the liquor flask, to raise his de- pressed spirits, to sharpen his wits, and to steady his trembling limbs. To achieve the longed-for result it is necessary to steadily increase the doses, because the organ- ism gets used to the poison. Thus, the morphia fiend is compelled to put always larger, frightening large, quan- tities into his body, till he becomes a mental and physical wreck. The morphia habit recruits its victims almost exclu- sively from the more cultured and higher circles of so- ciety. The impecunious who only learn to know morphia at the hand of the physician or at the hospital are in no position to obtain the medicine after their discharge as cured. Persons that acquire the morphia habit are preponder- antly physicians ; then follow druggists and army officers. The female sex is also disposed, in a high degree, to the misuse of morphia injections. 174 PASTORAL MEDICINE. The sole curative against the habit is to deprive the victims .of their accustomed stimulant. Such a cure is, however, only possible in a well managed institution, and it is accompanied by violent pains, both corporeal and psychical. Many persons cured of the morphia habit develop a desire for alcohol, and thus encounter a new danger. THIRD PART. FIRST AID TO THE INJURED.* I. HEMORRHAGE AND ITS IMMEDIATE TREATMENT. DEFINITION. Hemorrhage may be defined as the escape of blood from the heart or the blood-vessels. THE CAUSES are: (i,) Injury; (ii,) Disease. THE SITUATION. Hemorrhage may be either: (i,) External. This is most frequently the result of injury. (ii,) Internal. This is generally due to disease. THE SYMPTOMS of Hemorrhage are: The actual appear- ance of blood (which is always seen in external hemorrhage, while in internal hemorrhage blood may also reveal its presence e. g., in bleeding from the lungs, etc.), and the constitutional effects, more or less, which follow the loss of blood, i. e., the signs of syncope or fainting, which are indicated by a cold and clammy skin, a pallid and livid face, dilated pupils, feeble and irregular breathing, an irregular and almost imperceptible pulse, dizzi- ness, inclination to vomit, and loss of consciousness. These con- stitutional effects are in proportion to the suddenness of the loss of blood, i. e., the quicker the loss, the more profound the syncope. VARIETIES of Hemorrhage. The severity of the bleeding varies with the portion of the vascular circuit which is wounded, and hemorrhage presents different characteristics according to its origin from capillaries, veins or arteries respectively: 1. Capillary. This is the least dangerous form ; it is indicated by a general oozing from the whole surface of a wound, and the color of the blood is more or less brick red. 2. Venous. This is indicated by the blood flowing in a con- tinuous stream, and issuing from the cut end of the vessel furthest from the heart, i. e., in the limbs from below the wound, the color of the blood being a dark purple. Venous hemorrhage comes next in seriousness to arterial. 3. Arterial. This is the most serious form of bleeding; it is indicated by the blood flowing in a forcible pulsatile stream (which rises with each beat of the heart and falls in the interval), and issuing from the cut end of the vessel nearest the heart, i. e., in the limbs from above the wound, the color of the blood being a bright scarlet. The following embodies directions for First Aid by the English physi- cians WARWICK and TUNSTALL, both acknowledged authorities on the subject 175 176 PASTORAL MEDICINE. External Hemorrhage. 1. THE TREATMENT OF CAPILLARY HEMORRHAGE. Expose the part to the air and apply pressure to the wound to close the vessels, and prevent further escape of blood. This may be done by means of a perfectly clean finger, or a clean bit of sponge or lint. If the above means are not sufficient, encourage coagulation of blood, so that the clot may seal the cut vessels ; this may be done by the application of clean cold water, or hot water at a temperature of 100 to 120 F., or by first drying the part and then applying a styptic, such as common salt, burnt or dried alum, tincture of steel, turpentine, tannic or gallic acid, tincture of eucalyptus, etc. Note. Styptics are not to be applied too strong, otherwise they destroy the vitality of the tissues. 2. THE TREATMENT OF VENOUS HEMORRHAGE. In treating bleeding from veins, adopt the following measures, viz. : (i,) Remove all constrictions which impede the backward flow of blood to the heart, i. e., all tight clothing about the chest and neck must be loosened, garters undone, etc. (ii,) Elevate the bleeding part if possible above the level of the heart, *. e., if the bleeding is from a limb, raise it. (iii,) Apply first digital pressure (pressure with perfectly clean fingers), directly to the surface of the wound, and then place a clean pad on the wound and keep it in position by a bandage. (iv,) Keep the wounded part in an elevated position (if possible) for some hours after the bleeding has stopped. The Immediate Treatment of a Burst Varicose Vein. The superficial veins of the lower extremity are liable to become dilated or varicose, from the incompetency of their valves and the consequent undue pressure of the column of blood upon their walls; these dilated veins may burst, producing serious or even fatal hemorrhage if not promptly attended to; the measures therefore to be adopted in dealing with a condition of this description are as follows: (i,) Place the patient at once on his back, (ii,) Remove all constrictions round the limb on the heart side. (iii,) Raise the wounded leg. (iv,) Expose the bleeding surface, place a clean pad directly on the wound and fix it, by means of a triangular bandage. HEMORRHAGE. 177 (v,) If the patient has to be removed, carry him on a stretcher, lying on his back with his foot raised. (vi,) Keep the patient in a recumbent position with the foot raised for some hours after the accident. (vii,) If the bleeding has been at all excessive keep the patient warm, in order to counteract any sudden failure of the heart's action. 3. TREATMENT OF ARTERIAL HEMORRHAGE. In arterial bleeding the force of the heart's beat pumping the blood through the cut vessel prevents any chance of clotting, therefore the two main factors in stopping bleeding are: (i,) To place the bleeding part, if possible, in a proper position, i. e., above the level of the heart, at the same time expose the wound to the air, and remove all constrictions which impede the return of venous blood. (ii,) To apply pressure to the wound itself or to the main artery supplying the part. Pressure should always first be applied with the thumb and finger (digital pressure), so that no time is lost in getting appliances. To aid the above means, the patient should be kept absolutely quiet and in a recumbent position. Should there be any constitutional symptoms (syncope), these must be treated. (See page 178.) "FIRST AID" METHODS OF CONTROLLING AR- TERIAL HEMORRHAGE. The measures to be adopted will depend upon the severity of the bleeding. 1. IF THE BLEEDING is NOT EXCESSIVE, i. e., in all superficial hemorrhages apply: (i,) Firm pressure directly to the bleeding point by means of absolutely clean fingers, and when the bleeding has quite stopped place (ii,) A clean pad over the wound and keep it in position either by means of a folded triangular bandage, or by a roller bandage. In some situations, e. g., the palm of the hand, a graduated compress (made by superimposing several layers of clean lint upon each other, the smallest piece being about the size of a quarter and the largest that of a 50 cent piece) is more effective than a simple pad. 2. IF THE BLEEDING is EXCESSIVE, apply if possible: (i,) Digital Compression (compression by means of the fingers) to the main artery supplying the part with blood. This 178 PASTORAL MEDICINE. pressure is applied to the artery between the wound and the heart, and at a joint where some hard basis of support is fur- nished, against which the artery can be pressed, e. g., where the vessel passes over or along a bone. The great value of digital compression is that it can be ap- plied immediately. In digital compression the following points are to be remembered : (a,) To use the thumb to make the pressure. (&,) Having ascertained the position of the artery by its pulsation, get it fairly against the bone, and press directly upon it, using sufficient force just to stop the bleeding but not to cause the patient any pain. (c,) Compress if possible the artery only, avoiding all ad- jacent structures such as veins and nerves. Digital com- pression is only applicable in certain parts of the body, viz., the limbs, the neck, and some parts of the head and face, and it can not be effectively maintained by one per- son for more than about fifteen minutes at a time, (ii,) Replace Digital Compression by applying a hard pad upon the artery, and keeping it in position by a bandage. THE TREATMENT OF CONSTITUTIONAL SYMP- TOMS. In order to counteract syncope or fainting due to the loss of blood, the patient must be kept at absolute rest in a re- cumbent position with the feet slightly raised ; his clothes should be removed, his body should be wrapped in warm blankets, and hot-water bottles should be applied to his feet. If able to swallow, stimulants well diluted are to be given in small quan- tities, but only after the hemorrhage has entirely stopped. If the loss of blood has been very excessive, the breathing may become embarrassed, or may actually stop; artificial respiration must then be resorted to. Internal Hemorrhage. The CAUSES of internal hemorrhage are: (i,) Injury from blows, punctured wounds, severe crushes, and falls causing bruising and laceration of internal organs. (ii,) Disease producing bursting of a blood-vessel. The blood in internal hemorrhage may either escape into one of the closed cavities of the body, such as the abdomen, cranium, or thorax, or it may make its escape externally through an opening in the body, artificial or natural. HEMORRHAGE. 179 Serious hemorrhage into a closed cavity is denoted by the history of the accident and the signs of syncope or fainting. Measures to be adopted in a condition of this description are : (i,) To send at once for medical assistance. (ii,) In the meanwhile to treat the constitutional symptoms which are due to the loss of blood. When the blood makes its escape through one of the natural openings of the body, it make take the form of: (i,) Blood Spitting; (2,) Blood Vomiting; (3,) Nose Bleeding. I. BLOOD SPITTING. This may proceed from: (a,) The Mucous Membrane of the Mouth, especially the gums, or from the cavity left after the extraction of a tooth. TREATMENT. If the bleeding is slight, the patient must wash his mouth out with hot water, as hot as it can be borne, or with a solution of alum, or with a strong solution of salt and water, or small pieces of ice must be given him to suck. If the bleeding is from the socket of a tooth, plug it well with a pledget of cotton wool which has been dipped in a solution of salt and water. If the bleeding is severe, apply pressure directly to the bleeding point if possible, by means of a small pad of clean lint. (&,) The Throat, caused by injury to the wind pipe or gullet. TREATMENT. Keep the patient quiet in a reclining position, and give him small pieces of ice to suck at frequent intervals. (c,) The Posterior Surface of the Mucous Membrane of the Nose. TREATMENT. (See Bleeding from the Nose.) () If y u are in doubt as to the nature of the poison taken, adopt the general treatment applicable to a case of unknown poisoning (see below). (b,) If you are aware of the nature of the poison taken, adopt the general treatment applicable to the special poison (indicated in the table given below). THE GENERAL TREATMENT APPLICABLE TO A CASE OF UNKNOWN POISONING. Here the objects to be aimed at in treatment are: (i,) To get rid, if possible, of the unabsorbed poison from the system; this is effected, either by administering an emetic to bring the poison up, or an aperient to pass the poison through the alimentary canal. (ii,) To counteract depression and shock, by giving stimulants and nourishments, and by the application of warmth by means of poultices, hot fomentations, etc. (Hi,) To relieve pain, by administering sedatives and demul- cents. EMETICS. The following may be used : 'Sulphate of Zinc, grs. xx to xxx in half a tumbler of warm 196 PASTORAL MEDICINE. water; this is prompt and safe, but is not to be given if salt and water has been already administered. Ipecacuanha Powder, grs. xv to xxx in half a tumbler of warm water; this produces very little depression and does not irritate the stomach. Ipecacuanha Wine, I to 2 tablespoon fuls in an equal quantity of water ; this produces a good deal of depression and is not very prompt in its action. Mustard, a tablespoonful in a tumbler of warm water. Salt, two tablespoonfuls in a tumbler of warm water. This is not to be given after sulphate of zinc. Tepid Water, in large draughts, followed by irritation of the back of the throat by means of the finger or a feather. Any of the above emetics may be repeated once or twice if necessary. The action of an emetic is facilitated by giving plenty of tepid water. It is important to remember that patients suffering from narcotic poisoning are not easily made to vomit. CAUTION. Emetics are not to be given in cases of corrosive poisoning, which is indicated by stains on the fingers, the lips, in the mouth, etc. APERIENTS. The following may be given : Castor Oil, I to 2 tablespoonfuls for a dose. Sulphate of 'Magnesia (Epsom Salts), a tablespoonful in a tumbler of warm water ; to be repeated if necessary. STIMULANTS. Administer : Sal Volatile (Aromatic Spirits of Ammonia), one-half to a tea- spoonful in a tablespoonful of warm water. Spirits (Brandy or Whisky), from a tea to a tablespoonful, according to circumstances. Strong Beef Tea, Tea, or Coffee. The Hot and Cold Douche alternately. Note. It may (in cases where the patient is unable to swallow) be necessary to give spirits, beef tea, tea or coffee by an enema. SEDATIVES AND DEMULCENTS. These are non-irri- tating fluids (which soothe internal local irritation and relieve pain), such as milk, raw eggs, barley water, arrowroot, flour mixed in water, olive oil, linseed tea, gruel, etc. POISONS. 197 THE POISONS. Special Poisons Their Symptoms Their General Treatment i. THE ACIDS- Immediate burning CAUTION. Emet- CO) The strong cor- sain in the mouth, ics are not to be given. rosive ones, viz. : :hroat and stomach, Administer f r e - (i,) Acetic (Glacial, vomiting and purging quently magnesia or and Aromatic Vine- may occur. Wherever chalk dissolved in gar). the skin and mucous warm water, then de- (ii,) Hydrochloric membrane are touched mulcents, such as lime (Muriatic, Spirits of they are destroyed, water and milk, milk Salt). there is more or less and egg, olive oil, J4 (iii,) Nitric (Aqua suffocation and great pint to i pint of water, fortis). shock. thick gruel ; if there (iv,) Sulphuric is depression, give (Oil of Vitriol). stimulants. If any acid has got into the air passages, make the patient inhale the fumes of ammonia. (v,) Carbolic With the above Administer Epsom (Phenol). symptoms there is the salts, l /2 oz. in 8 ozs. of voidance of greenish warm water, then or black urine, and the white of egg mixed odor of the acid can with water in large be detected in the quantities, or large breath. quantities of milk, or olive oil, 2 to 4 ozs. in i pint of water, or castor oil, i oz. ; also give stimulants freely and apply warmth to the extremities. (vi,) Oxalic (Salts Burning pain in the Avoid giving potash, of Lemon or Sorrel). stomach, cramp in the leg, vomiting of dark colored fluid, a hack- soda, or ammonia, or their carbonates, but administer frequently ing cough with a feel- chalk and water, mag- ing of constriction in nesia and water, and the throat, the mouth lime water, and then is white and sore, there give i oz. of castor oil, is great shock, and and stimulants freely. death may rapidly supervene. 198 PASTORAL MEDICINE. Special Poisons Their Symptoms Their General Treatment (6) PRUSSIC The patient almost Administer emetics ACID (Hydrocyanic immediately after first, then stimulants Acid, Scheele's Acid), swallowing the acid freely and ad lib., and this may also occur in becomes insensible, if necessary by an oil of almonds, al- with fixed and glisten- enema, make the pa- mond flavor, peach ing eyes, the pupils are tient smell the fumes kernels, bitter almond dilated and insensitive of ammonia, apply the water, laurel water, to light, the limbs are hot and cold douche and cyanide of potas- flaccid, the skin is cold alternately, perform sium. and covered with a artificial respiration clammy perspiration. (about 20 to the min- the respirations are ute), and keep it up gasping, and occur at steadily, and at the long intervals, and same time use friction there may be convul- to the extremities. sions. NOTE. If life can be maintained for about half an hour, recovery is almost certain. 2. ACONITE There is warmth at Give emetics first, (Monkshood, Blue the pit of the stomach, then stimulants freely, Rocket) and its alka- tingling of the mouth. apply warmth to the loids; occurs in aconite lips and tongue, a lower extremities, by liniment, neuraline, feeling of constriction hot water bottles and etc. in the throat, difficulty by friction with the in swallowing, numb- warm hand. Apply a ness of the tips of the mustard poultice or a fingers, loss of sensa- mustard leaf over the tion, deafness and dim- heart, keep the patient ness of sight ; this is strictly in the recum- followed by paralysis. bent position and per- first of the lower and form artificial respira- then of the upper ex- tion if necessary. tremities, the pulse is NOTE. Stimulants irregular and almost may have to be given imperceptible, the res- by an enema. pirations are shallow, feeble and infrequent, there may be convul- sions, the pupils are generally dilated, there is great prostration, and death may take place quite suddenly after some slight ex- ertion. POISONS. 199 Special Poisons Their Symptoms Their General Treatment 3. ALCOHOL, as in Giddiness, inability Give emetics ; if the rectified, proof, and to stand or walk, the patient is insensible methylated spirit, gait is tottering, the rouse him and keep brandy, rum, whisky, expression is vacant, him awake, administer gin, etc. the face is flushed, the hot strong coffee, ap- conjunctivse are con- ply the hot and cold gested, the lips are douche alternately ; livid, the breath smells when the patient has of alcohol, the skin is sufficiently recovered, covered with sweat, wrap him up in warm the pupils are dilated blankets and put him and fixed or con- to bed. tracted, convulsions occur, stupor and coma. 4. THE ALKA- Immediate burning CAUTION. Emetics LIES, the strong pain in the mouth, are not to^ be given, caustic ones, viz. : _ throat and stomach, b" f administer vine- (i), Ammonia vomiting and purging, gar, lemon or orange (Spirits of harts- the mucous membrane juice, tartaric or citric horn, etc.), as in of the mouth is de- acid in plenty of caustic ammonia, stroyed, and there are water ; give demul- ammonia liniment, symptoms of suffo- cents and stimulants compound cam- cation and of great if required; if the phor liniment, shock. power of swallowing liquid ammonia. is lost, give inhala- (ii,) Lime, as caus- tions of acetic acid or tic lime, quicklime. vinegar from a pocket (Hi,) Potash, a s handkerchief. caustic potash. (iv,) Soda, as caus- tic soda. 5. ANTIMONY, as There is a metallic Encourage vomiting chloride or tartarated antimony (tartar emetic), occurs also in antimonial wine, and in specifics. taste in the mouth, with nausea and in- cessant vomiting, a feeling of heat, con- striction and choking in the throat, pain in by giving large draughts of tepid water, when the vomit- ing subsides admin- ister strong tea or coffee, also white of the stomach, violent egg mixed in water, purging, and cramps barley water, arrow- in the limbs, the skin root or milk. Give is cold, the head and stimulants if there is face are congested collapse. Wrap the and there is great de- patient up in warm pression and collapse. blankets and put hot water bottles to his ' feet. 20O PASTORAL MEDICINE. Special Poisons Their Symptoms Their General Treatment 6. ARSENIC (Ar- Faintness and de- Give emetics, and senious acid, White pression followed by a then large draughts of arsenic), may also burning pain in the tepid greasy or soapy occur in Aqua To- stomach, vomiting of water, or salt and fana, fly papers, brown matter mixed water, dialysed iron in mineral, Vienna and with mucus and I oz. doses, or mag- other emerald green, streaks of blood, purg- nesia in large quanti- rat paste, vermin ing, severe cramps in ties, these are to be killer, cheap ices, the calves of the legs, frequently repeated ; crayons, French constriction and dry- give olive oil Yz pint chalks, wall papers, ness of the throat, in i pint of lime water, and tinned fruits, (as great thirst, hiccough. administer d e m u 1 - an impurity of the loss of voice, cold centsj if there is de- tin). sweats, profound pression, give stimu- shock and exhaustion. lants freely, and apply warmth and friction; after the acute symp- toms have passed off, apply linseed meal poultices to the abdo- men. 7. BELLADONNA Heat and dryness of Give emetics first, (the Deadly Night- the mouth and throat, then strong hot coffee shade) and its alka- suppression of saliva, and stimulants, apply loid atropine. difficulty of swallow- mustard to the calves ing and great thirst, of the legs and hot the face is flushed, the water bottles to the eyes are prominent and feet, administer the sparkling, the vision is hot and cold douche double or indistinct. alternately, and per- the pupils are dilated form artificial respira- and insensible to light, tion. there is great excite- ment and noisy de- lirium, the gait is un- steady and staggering. there is a frequent desire to pass water, with inability to do so. the skin is dry and there may be a rash like that of scarlet fever. POISONS. 201 Special Poisons Their Symptoms Their General Treatment 8. CANTHARIDES Burning sensation in Give emetics and (Spanish Fly, Blister the throat and stom- then demulcents, es- Beetle), occurs also in ach, with pain and pecially white of egg blistering fluid. difficulty in swallow- and milk or thick ing, vomiting of mucus gruel, but avoid giv- and blood, diarrhoea ing fats and oils; with blood and slime when the acute symp- in the motions, inces- toms have been re- sant desire to pass lieved, give the pa- water, high tempera- tient a hot bath or t u r e , quick pulse, apoly hot linseed meal headache, loss of sen- poultices to the abdo- sibility, convulsions. men. 9. CAMPHOR, as Odor of the breath, Give emetics and in the essence, lini- languor, giddiness, then stimulants freely, ment and spirits of faintness, disturbance apply warmth to the camphor. of vision, noises in the extremities and ad- ears, delirium and con- minister the hot and vulsions, a cold and cold douche alter- clammy skin, weak nately. pulse and difficult breathing. 10. CAUSTIC, LU- Pain and discolora- Give common salt NAR (Nitrate of sil- tion of the mouth and dissolved in water or ver) throat, followed by milk freely, give emet- T V* / . vomiting of whitish ics (but not sulphate flaky matter which of zinc), and demul- turns black. cents. ii. CHLORAL Deep sleep, with loss Give emetics, wrap (Chloral hydrate, Syrup of chloral). of muscular power, diminished sensibility, the face is livid and the patient up in warm blankets, and apply hot water bottles to the bloated, the pulse is feet, keep the patient slow or very weak, the roused by shouting or respirations are di- flapping his face with minished, and the sur- a wet towel, give hot face of the body is strong coffee, and per- cold. form artificial respira- tion if there is the slightest failure of the breathing. 12. CHLORINE GAS, as in chloride of lime. Irritation of the throat, cough, tight- ness of the chest, diffi- culty of breathing and Admit plenty of fresh air, give inhala- tions of steam or^ of very dilute ammonia. inability to swallow. 202 PASTORAL MEDICINE. Special Poisons Their Symptoms Their General Treatment 13. CHLOROFORM The respirations are Pull the tongue for- (inhaled). arrested, the breathing ward, see that the is stertorous, and the mouth and throat are face is livid. clear, loosen every- thing tight about the chest, flap the face and chest with a wet towel. give plenty of fresh air, apply the hot and cold douche alter- nately to the chest and head, and perform artificial respiration. 14. CHLOROFORM The breath smells of Give emetics first, (swallowed). chloroform, the gait is then carbonate of soda staggering, this is fol- dissolved in plenty of lowed by insensibility. water, rouse the pa- the pupils are dilated, tient in every possible the breathing is ster- way, apply mustard to 1 torous, the skin is cold the calves of the legs and the pulse is im- and a mustard leaf perceptible. over the heart 15. COPPER, as There is a metallic First give large the sulphate (blue taste in the mouth, quantities of milk and vitriol, blue stone), or constriction in the eggs, then emetics (if the acetate (verdi- throat and gullet. there is no vomiting), gris). griping and colicky and then large pains in the abdomen, draughts of tepid nausea, vomiting and water, after that barley purging, d 5 ffi c u 1 1 water, arrowroot or breathing, quick pulse, gruel, and apply hot great weakness and linseed meal poultices thirst, cold perspira- to the abdomen. tion, coldness of the limbs, headache, gid- diness, and finally coma. 16. CROTON OIL. Great pain in the ab- Give emetics first, domen, with vomiting then demulcents, es- and purging, the face pecially white of egg is pale, the features in milk, and stimu- are pinched, the pulse lants freely, and apply is small, the skin is hot linseed meal moist, and there is poultices to the abdo- great collapse. men. POISONS. 203 Special Poisons Their Symptoms Their General Treatment 17. ERGOT O F Tingling and cramp Give emetics first, RYE and its alka- of the limbs, dizziness, then castor oil, after loids, ergotine, etc. weakness, itching that strong tea and vomiting and diar- stimulants, keep the rhoea. patient in a recumbent position, and apply warmth to the ex- tremities. 18. ETHER (in- Same as chloroform Same as chloroform haled). inhaled. inhaled. 19. FUNGI (Fly There is violent Give emetics first, fungus, poisonous colic, with vomiting then castor oil i oz., mushrooms). and diarrhoea, great then stimulants freely, excitement and then apply warmth to the coma, the pulse is extremities and hot slow, the breathing is linseed meal poultices stertorous, the pupils to the abdomen. are dilated, and the extremities are cold. 20. THE GASES, There is irritation of Remove quickly to viz., carbonic acid or the throat, with head- the fresh air, and per- carbonic oxide gas, ache, drowsiness, gid- form artificial respira- coal gas or sewer gas, diness, and singing in tion, apply smelling choke damp or after the ears, loss of mus- salts to the nostrils, damp, marsh gas, cular power, lividity, and cold to the head charcoal fumes, and hurried respirations and chest, and give acetylene. and coma. stimulants. 21. HOLLY BER- There is vomiting, Give emetics, and RIES. with pain in the head then stimulants freely. and abdomen, and apply friction and purging, the pupils are warmth to the ex- contracted, then drow- tremities. siness followed by unconsciousness and collapse supervene. 22. HYOSCYA- MUS (henbane), and its alkaloids hyoscya- mine, etc. Much the same as belladonna, i. e., thirst, dilated pupils, delir- ium, etc. Give emetics first, then stimulants mod- erately, and apply the hot and cold doudV alternately. 204 PASTORAL MEDICINE. Special Poisons Their Symptoms Their G eneral Treatment 23. IODINE and Pain and heat in Give emetics first, IODOFORM. throat and stomach. then starch and water, with vomiting and or gruel and water, purging (the vomited or white of eggs and matter yellow or water freely. blue), followed by giddiness and faint- ness with convulsions. 24. LABURNUM There is purging, Give emetics first, and its active principle vomiting, and great then stimulants in cytisine, which is also restlessness, this is moderation, and ad- present in Arnica. followed by drowsi- minister the hot and ness, insensibility and cold douche alter- convulsive twitchings. nately to head and chest. 25. LEAD as ace- There is dryness of Give emetics freely, tate (sugar of lead), the throat, with a then Epsom salts (2 lead paint or white metallic taste and great 07 in a tumbler of lead ; may occur in thirst, colicky pains in warm water), then de- crayons, French chalk the abdomen which are mulcents, and apply and hair dyes. relieved by pressure, hot linseed meal poul- constipation, cramps tices to the abdomen. in the legs, cold sweats, paralysis of lower ex- tremities, convulsions. 26. MERCURY, as If corrosive subli- First give white of corrosive sublimate, mate or the acid ni- egg mixed with water perchloride of mer- trate is taken, the lips or flour and water. cury, red and white and mouth are white then give emetics free- precipitate, red oxide and swollen, the ly, after this demul- of mercury, and the tongue is white and cents and stimulants. acid nitrate of mer- shrivelled, and there is cury. a sense of constriction in the throat ; in all cases of poisoning by mercury there is a metallic taste in the mouth, pain in the stomach, nausea, vomiting of stringy mucus mixed with blood, profuse purg- ing with bloody stools, a cold and clammy skin, difficult respira- tions, syncope and convulsions. POISONS. 205 Special Poisons Their Symptoms Their General Treatment 27. MUSSELS, also PTOMAINES (ani- mal alkaloids, poison- ous meat, poisonous fish). 28. NITROUS OX- IDE GAS (laughing gas). 29. NITRO-BEN- ZOL (nitro-benzine, artificial oil of bitter almonds, essence of henbane). Also present in aniline dyes, liqueurs, sweet- meats, pomades. 30. NUX VOMICA (St. Ignatius' bean), and its alkaloid STRYCHNIA (as in vermin killer). There is uneasiness and weight at the pit of the stomach, a sen- sation of numbness in the extremities, heat, dryness and constric- tion in the throat, thirst, shivering, diffi- culty of breathing, cramps in the legs, inflammation of the eyes, colic, vomiting and purging, itching of the skin, failure of the heart's action and collapse. Same as chloroform inhaled. There is weakness and discomfort, great nausea and anxiety, confusion of the mind, lividityof the face and body, dilated pupils and convulsions. Violent rigid con- vulsions, with lockjaw during the convulsive attack; the eyeballs are prominent, the pupils dilated, the res- pirations impeded, and the pulse feeble and very rapid. Death usually takes place either from asphyxia or from collapse dur- ing a paroxysm. Give emetics first, then castor oil I oz., then stimulants freely, apply hot water bot- tles to the feet, and wrap the patient up in warm blankets. Same as chloroform inhaled. Give emetics first, then stimulants freely, apply the hot and cold douche alternately, and perform artificial respiration. Give emetics first, then animal charcoal ad lib. mixed in water, followed by an emetic; if possible perform artificial respiration. 206 PASTORAL MEDICINE. Special Poisons Their Symptoms Their General Treatment 31. OPIUM (lau- Mental excitement, Give emetics first, danum) and its al- followed by headache, rouse and keep the kaloids (morphine, uneasiness, a sensation patient awake in every codeine, etc.), occur of weight in the limbs, possible way, by mak- in tincture and wine incapacity for exer- ing him walk about, or of opium, sedative tion, sleepiness, dim- flapping him with a solutions, C h 1 o r o - inution of sensibility, wet towel, apply am- dyne, Carminative, and contraction of the monia or sal volatile Cordial and Elixirs, pupils; at first the to the nostrils, give a Mother's Friend and patient can be roused pint of hot strong Soothing Syrups, Syr- with difficulty, but coffee, rpply the cold up of Poppies, Pare- later on he becomes douche to the head fre- goric and many kinds quite insensible, his quently, perform arti- of patent medicines. muscles are relaxed, ficial respiration and his skin is cold, the keep it up at least for pupils fail to respond two hours. Do not to light, his face and give wine or brandy. lips are cold and blue, CAUTION. In mak- the respirations are ing the patient walk slow, irregular, and about be careful not to stertorous, and the overexhaust him. as pulse is weak and with opium poisoning compressible. there is always a cer- tain amount of de- pression. 32. PARAFFIN The symptoms vary Give emetics first, OIL. very much, there may then stimulants freely, be a burning sensa- and apply warmth to tion in the mouth, the body. gullet or stomach, and great thirst ; the ex- tremities are cold, the face is pale, the pulse is feeble, the respira- tions are weak, and often there is coma. 33. PHOSPHORUS Pain in the stomach. Give emetics first. (as in matches, vomiting, the vomited then Epsom salts (^2 phosphorus paste, matter may be lumin- oz. in a tumbler of rat poison, vermin ous in the dark, odor water), stimulants if killer, rat paste). of phosphorus in the required, and demul- breath, bleeding from cents, especially milk. the nose, blood stained Avoid giving fats motions, and convul- and oils. sions. POISONS. 207 Special Poisons Their Symptoms Their General Treatment 34. TIN and its The same as in lead Give emetics first, salts. poisoning. then sal volatile in water, and white of egg in milk. 35. TOBACCO and Nausea and vomit- Give emetics first, its alkaloid, nicotine. ing, accompanied with then strong tea, and great weakness and stimulants freely, ap- Faintness, confusion of ply warmth to the ex- ideas, dimness of sight, tremities and keep the weak pulse, cold skin, patient in a recumbent covered with clammy position. perspiration, pupils at first contracted and then dilated. 36. TURPENTINE Odor in the breath, Give emetics first, (oil and spirits of tur- pentine, turps, cam- phene). intoxication, pupils contracted, breathing stertorous, coma, col- then Epsom salts (i oz. in half a tumbler of warm water), and lapse and tetanic con- demulcents. vulsions, irritability of the bladder, the urine having the smell of violets. The symp- toms of turpentine poisoning resemble somewhat those of opium. 37. ZINC, as sul- phate (white vitriol), and chloride (Disin- fecting Fluid). Corrosion of the lips and of the mucous membrane o f the mouth, pain and in- cessant vomiting, the Do not give emetics, but give first large draughts of milk and white of egg, and then bicarbonate of soda or pulse and respirations are quickened, the common soda in large quantities dissolved in pupils are dilated, the warm water, and then muscles are paralyzed, and coma supervenes. strong tea, apply lin- seed meal poultices to the abdomen. Note. The following Poisons are frequently taken either acci- dentally or for suicidal purposes, viz Carbolic acid, Oxahc acid, Prussic acid, Arsenic, Opium, Phosphorus, Strychnia (Nra vomica), Lead (Sugar of), and Mercury (Red and White Pr< cipitate). 208 PASTORAL MEDICINE. VI. THE IMMEDIATE TREATMENT OF INSENSIBILITY AND FITS. Insensibility. Loss of consciousness may be produced by the following causes: 1, Syncope, or fainting. 2, Asphyxia, or suffocation. 3, Shock and collapse. 4, Concussion of the brain. 5, Compression of the brain. 6, Apoplexy. 7, Alcoholic intoxication. 8, Narcotic poisoning, as opium poisoning. 9, Sunstroke. 10, Freezing. Unconsciousness is also present in the following: 1, Epilepsy. 2, The convulsions of infants. 3, Uraemic poisoning, which often comes on in the course of kidney disease and is due to the non-excretion (by the kidneys) of the waste material in the blood. But as convulsions form the most prominent symptom, these diseases are dealt with separately under " Fits." i, SYNCOPE, or FAINTING, may be due to mental emotion, pain, extreme exhaustion (as from hunger, fatigue, etc.), hem- orrhage, cold, heat (particularly if combined with a close atmos- phere, as in heated rooms, in large crowds, etc.), constriction of the chest (as in tight lacing, etc.), and organic disease of the heart. Symptoms. Fainting is generally ushered in by a feeling of giddiness and fluttering at the heart. This is followed by the face becoming suddenly pale and the lips white; the pulse becomes weakened and the breathing quickened ; a cold sweat appears on the brow and the palms of the hands; the patient staggers and finally falls to the ground in an unconscious state. Rarely convulsive movements of the whole body may also be present. INSENSIBILITY AND FITS, 209 TREATMENT. As fainting is caused by a diminution of the supply of blood to the brain from partial paralysis of the heart, the object to be aimed at in treatment is to restore the cerebral circulation; therefore, when a person has fainted, do not attempt to place him in a sitting or standing posture (as this will only embarrass the already weakened action of the heart, and may be fatal), but lay him flat on his back, or, better still, on his left side with his pelvis and feet slightly raised; loosen all tight clothing about his body and neck; give him plenty of fresh air; sprinkle cold water on his face, apply smelling salts to his nostrils ; when able to swallow, give him a glass of water or a little brandy, whisky, or sal volatile mixed in water, and keep him in the recumbent position for some time after he has recovered. If the faint is prolonged and consciousness does not return, send for medical assistance, but in the meanwhile apply warmth to the feet and a hot mustard plaster over the region of the heart, and if natural breathing has not returned, perform artificial respiration by the "Sylvester" method (page 187). In a crowded room a fainting fit may be prevented by placing the patient in a stooping position on a chair and bending his head between his knees. The person must be held, for if he faints in this position he dives forward on to his head, and may turn a somersault or might break his neck. If the patient has completely fainted this treatment is not to be attempted, as it only helps to obstruct the circulation and respiration. 2, ASPHYXIA. This has been dealt with on page 190. 3, SHOCK, or COLLAPSE, may be produced by severe in- juries or emotional disturbance, causing a profound depressing effect upon the central nervous system. The injuries most liable to produce shock are: (i,) Those involving large surfaces of the skin, as in burns and scalds. (ii,) Those causing crushing or tearing of the body, as ma- chinery and railway accidents. (iii,) Those affecting the abdomen and viscera. Loss of blood and exposure to cold intensify the condition of shock. Symptoms. A person in a state of shock presents the follow- ing appearance : He lies flat on his back, his limbs are flaccid, and he makes no spontaneous movements; his body is cold and clammy, his face is pale, his eyes are sunken, his pulse is small, PASTORAL MEDICINE. feeble and irregular, his respirations are shallow, feeble and sighing, his temperature falls to 97 F. or a degree or two lower, and he is semi-unconscious. Should a case of shock tend to terminate favorably, the con- dition known as that of " Reaction " comes on. This is usually ushered in by the patient vomiting, the pulse then becomes stronger, the body warmer, and color returns to the face. TREATMENT. The object to be aimed at in treatment is to bring about reaction by the application of warmth and the administration of stimulants. Therefore, to treat shock place the patient in bed between blankets as soon as possible, keeping his head quite low. Apply hot water bottles to his feet and between his thighs, and apply friction to his arms and legs. If able to swallow, give him small quantities of hot stimulants, and frequently repeat them till reaction takes place, then lessen the stimulants considerably, taking care not to over stimulate. During the state of collapse, should the breathing become embarrassed, perform artificial respiration according to the "Sylvester" method (page 187). 4, CONCUSSION OF THE BRAIN is caused usually by blows or falls upon the head, or falls upon the feet or lower end of the spine, the effect being a severe shaking up of the brain substance. Symptoms. These vary in their severity according to the force of the blow applied. The patient may present the appearance of being merely stunned, or he may be in a condition identical with that already described under " Shock." TREATMENT. The same as for shock; and at the same time apply cold in the form of ice or wet cloths to the head. Avoid alcoholic stimulants, but give instead hot beef tea or hot coffee, and keep the patient absolutely quiet in a darkened room. 5, COMPRESSION OF THE BRAIN is caused by injuries to the head producing pressure of the brain substance either by the depression of a piece of bone onto it, or by a blood clot (pro- duced by the rupture of a blood-vessel). Symptoms. Resemble those of apoplexy, which see. TREATMENT. If there is a wound on the head, dress it; otherwise adopt the same treatment as for apoplexy. 6, APOPLEXY is caused by the bursting of a diseased blood- vessel into the substance of or upon the surface of the brain, INSENSIBILITY AND FITS. an causing compression of that organ. It usually occurs in elderly persons. Symptoms. Just before the attack there are generally some premonitory symptoms, such as headache, giddiness, especially on stooping, weight and fulness in the head, noises in the ears. When the actual attack occurs, the patient is more or less un- conscious, his face is flushed, his breathing is shallow and ster- torous; his eyes are insensible to light and touch, the pupils are fixed, and are either unequally dilated, or one or both may be contracted; his pulse is full and slow, and there is paralysis more or less affecting one side of the body. TREATMENT. The object of treatment is to get the circulation quiet and the heart's action free from embarrassment; there- fore loosen all tight clothing about the neck and chest, put the patient to bed with his head raised, and apply cold to it; apply hot water bottles to his feet and mustard poultices to the calves of his legs. Be careful to give nothing by the mouth (as it may choke the patient), and send for medical assistance. 7, ALCOHOLIC INTOXICATION: Symptoms. A person in a state of stupor from alcohol presents the following picture: He is semi-unconscious, and can be partially roused, his face is flushed and bloated, his eyes are reddened and blood-shot but are not insensible to touch, his pupils are equally dilated and fixed, his lips are livid, his breathing is slow, the surface of his body is cold, and he may smell of liquor. Note. Alcoholic stupor may be hard to distinguish from apoplexy, but the state of the pupils, the sensitiveness of the eyes to touch, and the presence or absence of paralysis will help to determine the condition. TREATMENT. (See "Poisons," page IQ9-) CAUTION. If in doubt as to whether a person is suffering from drunkenness or apoplexy, treat him for the latter and be par- ticularly careful not to make him vomit. 8, NARCOTIC POISONING. (See "Opium Poisoning," page 206.) 9, SUNSTROKE is caused by exposure to the rays of the sun. Symptoms. Sunstroke is ushered in with giddiness, nausea, and weakness; this is followed by drowsiness and more or less unconsciousness. The eyes are blood-shot, the skin is hot and 2i2 PASTORAL MEDICINE. dry, the breathing is quick and noisy; the pupils are contracted at first and become dilated afterwards; the pulse may be slow or quick, and there may be convulsions. TREATMENT. Place the patient in a cool, shady spot; remove the clothing from the neck and upper part of the body and raise the head ; douche the head, neck, chest and spine with cold water, or wrap cold sheets round him, and continue these cold applications till he becomes conscious, then remove him to bed, keep the room darkened, and watch him carefully; if the unconsciousness returns, renew the application of cold. 10, FREEZING: TREATMENT. Take the patient into a room which has no fire in it, rub the body with ice-cold or snow water and restore warmth gradually. It is dangerous to apply heat too early ; as soon as the patient is able to swallow give him stimulants and hot drinks. TEST FOR INSENSIBILITY. To determine whether a person is insensible, raise the eyelid and touch the white of the eye, blinking, which can not be avoided if the person is con- scious, does not occur. HOW TO ACT IF A PATIENT IS FOUND IN A STATE OF UNCONSCIOUSNESS. Before efficient help can be ren- dered, the first thing to do, is to try and arrive at the cause which has produced the state of unconsciousness, and in order to do this a systematic examination of the patient and his sur- roundings must be made, therefore proceed as follows : (i,) Notice position of the body and its surroundings. (ii,) Notice whether the body is lying still or there are con- vulsive movements. (iii,) If possible obtain all information as to the cause. (iv,) Lay the patient on the back, inclining the head to one side (to prevent the tongue from falling back or vomited matter going down the trachea) ; if the face is flushed slightly raise the head, if the face is pale keep the head flat, place the arms by the sides and extend the legs, and loosen all tight clothing about the neck and chest. (v,) Examine the head, to ascertain whether there is a depressed wound (which would suggest compression), or a mere bruising (which would suggest stunning). (vi,) Examine the eyes to see if they are sensitive to light and touch, if there is any squinting, and the state of the pupils ; INSENSIBILITY AND FITS. 213 (a,) If sensitive to touch, no brain injuries are present, (fe), If the pupils are unequally contracted there is brain trouble. (O If the pupils are equally contracted, there is opium poisoning. (vii,) Examine the face; (a,) If it is drawn to one side, this will indicate apoplexy or compression of the brain. (&,) If it is bloated and flushed, this will suggest the excessive use of alcohol. (viii,) Smell the breath, the odor of opium or alcohol may be detected. (ix,) Examine the mouth and tongue, froth in the mouth and a bite on the tongue will indicate fits, particularly epileptic, (x,) Notice the breathing; (a,) If it is slow, it indicates great weakness as in shock. (&,) If it is snoring (stertorous), it indicates brain trouble, (xi,) Examine the pulse; (a,) If it is slow, there is brain trouble. (&,) If it is rapid, there is sunstroke or fever, (c,) If it is quick and thready, there is great weakness such as shock. (xii,) Feel the surface of the body; (a,) If the skin is abnormally cold, there is either freezing, intoxication, collapse, or fainting. (&,) If the skin is hot, there is sunstroke or high fever, (xiii,) Examine the ribs, collar bones and limbs for fractures, (xiv,) Examine the limbs to see if there is any paralysis; this is done by raising the limbs and allowing them to fall, if they do so lifelessly it suggests paralysis. (xv,) If convulsive movements are present, the patient is subject to fits of some kind (either epileptic, hysterical or uraemic in an adult, or convulsions of infants). Fits. I, EPILEPTIC FITS. The distinguishing features of these fits are convulsive movements and unconsciousness. An epileptic fit begins by the patient suddenly falling unconscious, with strained and rigid muscles ; as he is seized he may utter a sharp, shrill cry or yell. This stage of rigidity is then succeeded by 2i4 PASTORAL MEDICINE. a stage of convulsions in which the patient's body is thrown into violent twitchings and contortions with foaming at the mouth. During this stage the tongue may be bitten. After the patient has been in the convulsive stage for a few minutes, he may at once regain his consciousness or he may be more or less confused for a time, or more frequently he becomes drowsy and passes into a deep sleep or stupor, which may last several hours. TREATMENT. During the convulsive stage place the patient in a safe place to prevent him from hurting himself; put a piece of wood or other hard substance well padded between his teeth to prevent him from biting his tongue, loosen all tight clothing about the neck, chest and abdomen, and do not attempt to restrain the convulsive movements or to administer anything by the mouth. After the convulsive stage has passed off and the patient seems drowsy, encourage natural sleep. If on waking he seems ex- hausted, give him a little soup or beef tea, but do not give stimu- lants. 2, HYSTERICAL FITS. These occur more often in females than males and are ushered in with crying, sobbing or laughing without any cause; then follow jerky movements of the limbs (not truly convulsions), at the same time the breathing is quickened, the eyelids are closed, and in severe attacks the patient falls down apparently but not actually unconscious, taking care never to hurt herself. TREATMENT. The best treatment for hysterical patients is to exclude all fussy friends and let them alone. The patient will come to herself when she realizes that her condition is exciting no sympathy or alarm. 3, THE CONVULSIONS OF INFANTS. These are usually caused by teething, constipation, indigestion, worms, etc., but they may be due to fever or brain disease. Symptoms. Just before the occurrence of a fit the child is usually peevish and fretful. During the fit the body first becomes stiff, the pulse is rapid and weak, the breathing is hurried, the skin is wet with a cold, clammy perspiration, and there is complete loss of consciousness. The rigidity of the body lasts a few seconds, and is succeeded by a stage of convul- sive movements in which the muscles of the face twitch and the limbs jerk violently. As one fit passes off another may BURNS, SCALDS, ETC. 215 supervene, or the child may pass into a semi-comatose condition and then into a natural sound sleep. TREATMENT. The course to adopt is to relieve as quickly as possible the cerebral circulation, therefore place the child at once in a bath as warm as can be borne comfortably from ten to twenty minutes, or put the feet in hot water with mustard in it; at the same time apply cold sponges to the head and quickly change them, and send for medical assistance. 4, UR^MIC CONVULSIONS. In the course of Bright's disease convulsions and unconsciousness may occur. TREATMENT. The course to adopt here is to encourage the action of the skin, therefore place the patient in bed between warm blankets, pack hot water bottles round him, and send for medical assistance. VII. BURNS AND SCALDS AND THEIR IMMEDIATE TREATMENT; ELECTRIC SHOCK AND ITS IMME- DIATE TREATMENT; THE REMOVAL OF FOREIGN BODIES FROM THE EYE, EAR, AND NOSE. Burns and Scalds. BURNS are caused by the application of a fire or dry heat. SCALDS are caused by the application of hot liquids or moist heat. Burns are divided into the following degrees, according to the extent of injury inflicted, viz.: ist degree. A mere reddening of the skin. 2nd degree. The formation of blisters. 3rd degree. Charring and destruction of tissues. In addition to the actual damage caused by burns and scalds there is also present : (i,) Shock to the System. This is in direct proportion to tl superficial extent of the burn. Burns of the abdomen and chest are especially liable to produce marked shock, and children suffering from burns and scalds the shock is usually profound. (ii,) Congestion of Internal Organs.-Tbis usually comes o after the shock. 216 PASTORAL MEDICINE. TREATMENT. In the management of burns and scalds the following points have to be borne in mind : (a,) The local injury. (&,) The shock to the system. If the shock is severe it should be treated first, and the local injury afterwards, when reaction has set in. The Local Injury. In attending to a burn care should be taken that the clothing is removed with the utmost care from the burnt part, and that no blisters are broken in removing it. The clothing should therefore be cut off, and if parts adhere to the body they should be gently removed after first soaking them in oil ; if this is not sufficient, the part should first be immersed in a bath of warm water. If the burns are extensive only one portion of the body should be dressed at a time, the rest being kept covered up. To dress the Burns proceed as follows: either apply over the burnt parts pieces of lint which have been soaked in carron oil (a mixture consisting of equal parts of linseed oil and lime- water), or in carbolic oil, I in 40, or in a saturated solution of common washing soda, or spread boracic acid ointment (which has been diluted with an equal part of vaseline) upon pieces of lint and apply it to the burnt parts. Note. Strong antiseptics for dressing burns should be avoided, and the dressings should not be changed too often. BURNS FROM ACIDS. First drench the parts with water, wash them with a solution made by dissolving washing soda in water, and then treat as for an ordinary burn. BURNS FROM ALKALIES. Drench the parts first with water, then wash with a solution of dilute vinegar and water, and finally treat as for an ordinary burn. TO EXTINGUISH THE FLAMES FROM BURNING CLOTHING. Throw the person down whose clothes are on fire, and cover him up as quickly as possible with a rug, coat, shawl, blanket or other article of covering. Shock by Electricity. This may be produced by : (i,) Natural Electricity. As lightning. (ii,) Artificial Electricity As currents from telegraph, tele- phone, electric lighting and motor wires. SHOCK BY ELECTRICITY. 217 NATURAL ELECTRICITY. The effects of lightning vary according to circumstances ; there may be only slight shock with dizziness, or there may be violent convulsions, insensibility or im- mediate death. ARTIFICIAL ELECTRICITY. The danger of a current of electricity is in proportion to its intensity thus, the low tension currents of the telephone and telegraph wires would probably only produce slight shock, while the high tension currents (and especially the alternating ones), for lighting and motor purposes are extremely dangerous. The current from a dynamo may be 10,000 volts, for arc lamps the current is usually 2,400 volts, and for lighting (in houses) 100 volts. A current of 100 volts would be very dangerous, a current of from 20 to 30 volts is as much as can be comfortably borne by a strong man. When electric wires have a current passing through them, they are termed live wires, and it is from these that there is danger, as they may be exposed either by accident or for repairs. Symptoms. A person taking hold of naked live wires (. e., those that are not covered with an insulating material), with a current of high tension passing through them, would most likely be violently convulsed and be unable to let go, or there might be insensibility with suspended animation or even death. Parts of the body or clothes in contact with the wires may be scorched or burnt. TREATMENT. Here proceed as follows : (i,) Remove the sufferer from the source of danger; this must be done with the greatest care, or the person giving assistance may himself receive the shock and be rendered incapable^ " When the injured person retains his hold of the wire, it is dangerous to touch any part of him, even the parts of the body covered by clothes." A case of this kind is recorded in the Electrical Review "While a man was cleaning an electric street lamp in Boston, he received a shock and was killed, his body being suspended from the wires; a man who endeavored to remove the body came in contact with the current and was dashed to the ground with such violence that he died shortly afterwards." . . Therefore before removing the sufferer, first protect the hands 2i8 PASTORAL MEDICINE. whenever possible with india-rubber gloves (these are used in electrical works and may be at hand), if these can not be pro- cured, first wrap a mackintosh coat or a thick dry woolen cloth coat, or other dry article of clothing round the patient (damp articles of clothing are good conductors of electricity, and the sufferer's own clothes may be damp from perspiration), and then pull the sufferer away from the source of danger. (ii,) Send at once for medical assistance, but in the mean- while place the patient in a comfortable position, loosen all tight clothing round the body, and if there is any difficulty with the breathing begin at once to perform artificial respiration. Two live naked wires of which the sufferer may have hold, may be short circuited by dropping (not placing, as then the assistant might get the shock), an iron bar or other metallic tool across them, in this way carrying the current from one wire to the other instead of through the body of the sufferer. Removal of Foreign Bodies. 1. FROM THE EYE. Foreign bodies may be removed from the surface of the eye as follows. If under the upper lid, first evert the lid by placing a bodkin or match over it, and then gently pull the lid over; in this way the whole of the upper surface of the conjunctiva is exposed and may be very gently swept over with a camel's hair brush, or with a piece of soft linen dipped in warm water. If under lower lid, the whole of the conjunctiva under the lower lid may be exposed by gently pulling the eyelid down with a finger, and the foreign body removed as described above. 2. FROM THE EAR. Great care should be taken in these cases not to poke any sharp instruments into the ear, as the drum might easily be injured; warm glycerine or oil may be poured into the ear and the organ gently syringed out with warm soapy water. 3. FROM THE NOSE. The nose should either be blown forcibly, or gently syringed out with warm water, or the patient may be made to sniff pepper and sneeze. TRANSPORT OF SICK OR INJURED. tig VIII. THE TRANSPORT OF SICK AND INJURED. THE POSITION OF SICK OR INJURED PERSONS DURING TRANSPORT. Patients may be removed in any of the following positions: i. The Sitting Position. This is to be adopted for patients who are slightly injured in the upper part of the body, and are without constitutional symptoms. 2. The Semi-Recumbent Position. This is to be adopted for those who are injured about the region of the chest, and are suffering more or less from shortness of breathing. 3. The Recumbent Position. This is to be adopted in all cases where persons have been dangerously injured about the head, chest or abdomen, also in fractures of the long bones, injuries to joints of the lower extremity, and in cases of faint- ness, shock and excessive hemorrhage. Note. Before a patient is removed, the necessary " First Aid " treatment should always be rendered, and the clothes about the chest should be Loosened. Preparation for the Reception of a Case of Accident or Sudden Illness. While engaged in attending to a case of accident or sudden illness, if possible, send a messenger to the patient's house, in order that arrangements may be made for his reception. i. SELECTION AND PREPARATION OF THE ROOM. (i,) Selection of the Room. The points to attend to are: that the room should be easily accessible, it should be large and lofty with a south or southwest aspect, the windows should admit sufficient light, and should be made to open top and bottom, and there should be a fireplace with a chimney that does not smoke. (ii,) Preparation of the Room. The room should be thoroughly cleansed (if time will permit of it), well ventilated by drawing down the top windows, a fire should be lighted in it, it should 220 PASTORAL MEDICINE. be warmed to a temperature of 60 Fahr. and maintained at this, a thermometer being hung in the room for the purpose of regulating the temperature; the carpet and all superfluous furni- ture should be removed from the room. 2. THE BEDSTEAD AND BED. (i,) The Bedstead. Wide bedsteads are to be avoided, as the patient can not be easily got at ; the best kind of bedstead to use is an iron one, 3 to 3^ feet wide by 6 l / 2 feet long, it should be placed away from the wall (so that it can be approached from either side), and if possible across the room between the door and fireplace with the head facing the window. (ii,) The Bed. Feather beds and flock mattresses are to be avoided, hair mattresses are the best; the bed clothes should be light and warm, no vallances or curtains should be used, and care should be taken that the space under the bedstead is vacant. The bed should be made and the bed clothes well turned down, two stout chairs should be placed next to the bed, on which to rest the stretcher while the patient is being undressed. It may (in cases where the injuries are severe, or mud-stained clothes have to be removed or extensive dressings applied), be necessary to have a second bed or couch in the room on which to first lay the patient. Extra blankets and hot water bottles should be kept in readiness. In cases of collapse the blankets should be made hot and flannel should be wrapped round the hot water bottles. If there is any likelihood of the bedclothes being soiled, i. e., in cases of extensive injury, or where dressings have to be applied, or where the patient is unconscious or extremely weak and passes his evacuations under him, a draw-sheet should be placed on the bed. TO PUT ON A DRAW-SHEET proceed as follows: Procure a large cotton sheet, fold it lengthways into four and place it across the bed so that it will reach from just below the patient's shoulders to his knees, now place a piece of mackintosh between the draw-sheet and the under sheet, the draw-sheet being about 4 inches wider than the mackintosh ; one end of the draw-sheet is tucked in under the mattress, the other end is rolled up on the opposite side of the bed ; when the part of the draw-sheet under the patient becomes soiled it is withdrawn a little to one side by being rolled up a little more. In cases of fracture where the patient will have to lie in bed TRANSPORT OF SICK OR INJURED. 221 for several weeks, it is important to have a properly arranged bed termed a "fracture bed." THE ESSENTIALS OF A "FRACTURE BED" ARE: (i,) That there should be no sagging or giving way; (ii,) That the surface should be evenly smooth and comfort- ably elastic; (iii,) That the foot of the mattress should be a little higher than the head. The best way to arrange a fracture bed is as follows: first place a straw palliasse on the bedstead, then on the palliasse place two horsehair mattresses 3^ to 4 inches thick, and on the top mattress one blanket; to raise the bedstead place a thin board under the legs at the foot. In fracture of the lower extremity or of the spine, there should be no bolsters or pillows for the head, but only a thin cushion, and boards should be placed across the bed under the mattress. A cradle to take off the weight of the bed clothes may be necessary in fracture of the lower extremity, or sprain of the ankle joint; for a cradle, a cardboard box with the ends cut out, or a three-legged stool, may be used. 3. CARRYING THE PATIENT UPSTAIRS TO HIS ROOM. Before removing the patient to his room, the hall and staircase should be cleared so as to allow sufficient room for those carrying him to pass. The particular method to be adopted for carrying will depend in each case upon the nature and extent of the injury, and the condition of the patient. A patient may be carried upstairs by (i,) A single bearer. (ii,) By two bearers. (iii,) On a stretcher. Here the head should go first, and the stretcher should be carried in the same manner as is laid down for carrying stretchers when loading wagons, the two bearers at the foot should take care to keep the stretcher as nearly hori- zontal as possible by raising it, or (iv,) By placing the patient in a strong chair and carrying him up backwards, while a third person walks after the chair, helps to support it, and prevents the patient from falling out. 4. REMOVING THE CLOTHES. Before putting the patient 222 PASTORAL MEDICINE. to bed the clothes should be first removed, and great care should be taken in doing this ; in serious cases it is better to remove the clothes by cutting them away. In removing a coat from an injured arm, draw out the un- injured arm first, and in putting on anything put the injured arm in first. In removing trousers from an injured limb rip up the outside seam. In removing clothing in cases of burns and scalds, cut away the parts which are not adhering, and soak the adhering parts well with oil before removing them. 5. LIFTING THE PATIENT INTO BED. This may be done as follows : (i,) If the bed is narrow and there is room for the stretcher, place it on the floor with the head close to the foot of the bed, three bearers can then lift the patient head foremost over the foot of the bed. (ii,) If the bed is wide, place the stretcher close alongside the bed, the patient's head corresponding to that of the bed. Nos. I, 2 and 3 bearers place themselves on the far side of the stretcher, and No. 4 bearer on the near side ; the patient is then lifted and supported on the knees of Nos. i, 2 and 3 bearers, No. 4 bearer pulls away the stretcher and stands aside, while the other bearers lift the patient, stand up, and place him in position on the bed. 6. PREPARATION FOR SURGEON'S VISIT. When sum- moning a doctor, inform him as far as possible of the nature of the case so that he may come prepared. The following should be in readiness: Plenty of hot and cold water, clean towels and soa'p, and a receptacle for dirty water. For Burns and Scalds. A good supply of clean old linen, cotton wool, olive oil, " carron " oil and bandages. For Hemorrhage. Ice, sponges and plenty of water. For Drowning. Plenty of blankets heated before the fire and several hot water bottles, the sheets from the bed should also be removed. If poultices and fomentations are required, plenty of boiling water, linseed meal, mustard, a small basin, a large spoon, olive oil, tow, flannel, a kitchen roller and two sticks or a large towel. Appendix. THE MOMENT OF DEATH. BY THE REV. WALTER M. DRUM, S. J. COME of the leading authorities in medical science ^ now consider it an established truth that the mo- ment of death is later than it is commonly supposed to be. Fr. Ferreres SJ. asked the Catholic medical society, Academia de los Santos Cosme y Damidn, of Barcelona, to give him its opinion on the differences between real and apparent death, and last year published, in Razon y Fe, 1 the answer of that learned society and the result of his own study. We are indebted to him for most of our data. The question of the moment of death has always been of importance to the moral theologian; for while there is life in the body, there is a soul of a wayfarer to be lost or to be saved, there is a chance to turn a human soul from the road to hell and set it on the way to heaven. According to the common opinion of moral theo- logians, no matter how likely is the presence of death, the least probability of the presence of life makes it lawful that the saving sacraments be administered to a dying man; for the probability of life means a possibility of salvation, and man has a right to that which is necessary for his salvation. Sacramento, sunt propter homines, non homines propter sacramental 1 Cf. "La Muerte Real y la Muerte Aparente con Relacion a los Santos Sacramentos," by J. B. Ferreres, S. J., in Razon y Fe for January, February, March and May, 1904. 'Cf. St. Alphonsus, L. 6, n. 124; Busembaum, S. J., De Bap- tismo, Dubium 4, Resp. 4; Gury, S. J., Compend. 2, 247; Bal- lerini, S. J.-Palmieri, S. J., 4, 75i. 223 224 PASTORAL MEDICINE. Lehmkuhl, S. J. 3 says we should administer the sacra- nents if there be any doubt whatsoever, be it never so small, in favor of the subject's being alive and in proper dispositions. Villada, S. J.* considers that, for six minutes after what seems to be the moment of death, there is a doubt in favor of the presence of life and the sacraments may be administered. Noldin, S. J. and Alberti have the same view. Genicot, S. J. 5 holds that the sacraments must be ad- ministered if the priest arrives just after the breath, pulse-beats and heart-beats have ceased. Unless there be fear of contempt of the sacrament by the bystanders, he would have Extreme Unction given to a man who has just died. In Palmieri's Ballerini, 6 we find it set down that the slenderest hope of the validity of the sacrament is enough to make it our duty to administer that sacrament to a dying man. Bucceroni, S. J., La Croix, S. J., Marc and others may be cited in favor of this common opinion of moralists. Their view is summed up in the Instruction of Eichstadt : "It is better to expose a sacrament to the danger of invalidity, than man to the danger of eternal damnation. " We leave out all question of those who are known to live ; we speak only of those whose death is apparent but not certain, whose life may have, and yet probably has not come to an end. We also leave out all question of administering the sacraments absolutely; for the absolute administering of a sacrament requires a moral certainty * Cf. Lehmkuhl, 2, n. 273. 4 Cf. Villada, Casus 3, 244. * Cf. Genicot, 2, 422. Cf. Ball-Palm. 5, 238. THE MOMENT OF DEATH. 225 that the subject lives and is in proper dispositions. Our question is only about the administration of the sacra- ments conditionally, i. e., on the condition that the sub- ject be alive and be in proper dispositions. This condition is not, of course, to be expressed in the formula of ad- ministration unless the rubrics call for such expression. To make clear to every one the importance of knowing the moment of death, we give five cases of those that may be apparently dead, and may, in the state of latent life, be brought unto eternal salvation: First. An infant unbaptized. , Second. An adult, unbaptized, who never has had the use of reason. Third. An adult, unbaptized, who has had the use of reason, but has never made an act of perfect love of God, is not in mortal sin, and has given some sign of a wish to be saved. Fourth. An adult, unbaptized, who has had the use of reason, has made an act of perfect love of God, and then has committed mortal sin for which he has attrition but not contrition, and has given a sign of a wish to be saved. Fifth. An adult, baptized, who has committed mortal sin for which he has attrition but n^c contrition, and whose life leads one to suppose that if he knew the need and could ask for absolution he would certainly ask. The possibility of these five cases must be admitted by all. Where there is need of acts of attrition and of inten- tion to receive the sacraments, these acts may at times be not only past and not retracted, but even actual. In cases of latent life the subject may have clear thought and full deliberation. The presence of a priest may arouse him to proper disposition. It is the experience of physi- cians that now and then the cerebrum is free and thought 226 PASTORAL MEDICINE. and will are unimpeded, while there is complete paralysis of the cerebellum and those parts of the nervous system that control muscular action. In the first case, baptism is the only means to salva- tion. Without baptism that infant will not go to the hell of the damned, nor yet will it ever see God. In the second case, the adult is, practically speaking, an infant ; his soul can not enter heaven unless washed with the waters of baptism. In the third case, baptism may be administered condi- tionally, and without it the man's soul may not be saved. In the fourth case, the man's soul is ticketed to hell, and baptism is the only sacrament, the only means to save him from hell. In the fifth case, conditional absolution or extreme unction is necessary to keep the soul from eternal tor- ture. 7 Attrition without a sacrament will not save this soul from hell. From a consideration of these five cases, we may con- clude how very important it is not only for the clergy, but also for the laity, to know that the moment of death is generally later than it is supposed to be. Time and again it happens that death has not yet come to the body which seems a lifeless corpse, and the conditional ad- ministration of a sacrament by us is, in God's providence, the only possible means of saving for the enjoyment of heaven a soul that otherwise would be kept from the beatific vision forever. What, then, is the moment of death ? After the receipt of the query of Fr. Ferreres, the Academia de los Santos Cosme y Damian considered our question in the society's four sessions of January 8th, I5th, 22d, and 29th, 1903. T Cf. C. Pesch, 7, 538; Suarez, De Extrema Unctione, d. 41, i, n. 15; Ballerini-Palmieri, 5, 861. THE MOMENT OF DEATH. 227 Eminent physicians entered into the discussion. The conclusion was reached that no one really dies at the moment which is ordinarily considered his last, but death comes some time later. Fr. Ferreres sets down this thesis : "Between the mo- ment of death, commonly so called, and the instant at which death really takes place, it is probable that there is always a period of latent life during which the sacra- ments may be administered." Let us first consider the case of the new-born child. It is now the common opinion of theologians that the human fetus is, from its conception, endowed with a soul. God creates the soul and unites it to the body at the very moment of conception. From that very moment the fetus is capable of salvation and of baptism. The prematurely ejected fetus and the still-born child should be baptized conditionally, so long as there is a probability of life. How long is there a probability of life in the fetus that is born before its time? The pastoral Instruction of Eichstadt answers, "So long as there is no corruption nor certain sign of death." Eschbach 8 tells us to baptize the fetus absolutely if there be in it the slightest motion, and conditionally if there be in it no motion, nor yet any cor- ruption. Berardi 9 lays down a similar rule. This wise rule is in keeping with the experience of physicians. The child of premature birth has often given signs of life after it seemed for many hours to be dead. Dr. Grau y Marti speaks of a fetus in which a slight pal- pitation was marked twenty-three hours after apparent death had begun. Dr. Ruiz Contreres brought back to life a child born in its seventh month and abandoned for ' Cf. " Quaest. Physiol.-Theol.," d. III., p. 2, c. 3, a. 3- *Cf. "Praxis Confess.," III., 845, 846. 228 PASTORAL MEDICINE. dead, put it in an incubator and kept it alive a day or two. Dr. Goodell reported to the Gynecological Society of Chicago the remarkable case of a physician who made every effort to bring three infants back to life, left them for dead, returned next day to bury them and found them alive. Icard exclaims: "How many babies have been left for dead, and later found alive by those that intended to bury them !" From these facts we may learn several practical les- sons. Physicians should do all in their power to bring to life children that seem to be still-born yet give no sign of putrefaction. Laborde, in his work, "Les Tractions Rhythmees de la Langue," gives the testimony of many physicians to show that numerous children have been given up for dead who might have been saved to life if proper efforts had been made. The faithful should be made to understand that, unless it be certain putrefac- tion has set in, the still-born child (be it never so imma- ture) should invariably be baptized sub conditione. Very many souls may in this wise be saved to life eternal. Doctors should learn to baptize in case of premature birth. If the fetus be still enveloped in the secundine, and too immature even for the possibility of incubating, it is to be baptized in that state. But there is great like- lihood that the after-birth is not part of the child. The first baptism is not certain ; hence the doctor should bap- tize a second time and sub conditione. He should im- merse the fetus in water, tear open the secundine with his fingers, pronounce the formula ("If thou art alive and art not baptized, I baptize thee," etc.), and withdraw the fetus at once. 10 If there is a period of latent life in the delicate organ- "Cf. Eschbach, 321; Capellmann "Medicina Pastoralis," 112. THE MOMENT OF DEATH. 229 ism of the child that is born before its time, there is such a period also in the stronger organism of the dying adult. How long does this period of latent life last? When does death begin ? When do the organs of the adult cease to live ? These questions have not yet been satisfactorily answered by men of science. Even in the seventeenth century, Dr. Thomassini wished the first twelve hours after apparent death to be considered as a continuation of life. Laborde thinks no doctor can be certain of the presence of death till he has used the rhythmic tractions of the tongue for three hours. All agree that there is a period of latent life even when the whole organism is wasted away by lingering disease. The length of this period is variously estimated. Dr. Coutenot puts this length at an hour ; Dr. Blanc, at from two to six hours; Capellmann, at one to twenty-four hours; Surbled, at more than three hours; Icard, at six to twelve hours. We are no surer of the moment of death than were the scientists of two hundred years ago. In the eighteenth century the Benedictine Fr. Feijoo said : "No one knows what is the soul's last influence on the body, nor in what precise condition the body must be in order to preserve its union with the soul. Hence it is impossible to know just when a man dies. Let us take a body that has so wasted away as to seem utterly lifeless ; let it be without respira- tion, without color, without feeling, without motion. We can be certain of only one thing about this body. There is in it no perceptible soul-influence. But what is to make us sure that in some one or other of the internal organs the soul does not perform some function or other? You tell me that life comes to an end when the blood ceases to flow and the heart ceases to beat. I ask you how you know this. You can be sure of no such thing unless by 230 PASTORAL MEDICINE. divine or angelic revelation. All we can be certain of is the absence of any vital action that may be perceived by the senses." " The learned monk of scholastic days also tells us that the blood may circulate so slowly and the heart may beat so softly as to suffice for life, yet not for our observation. In this idea he agrees with old Galen, who centuries ago suggested that there could be a beating of the heart and a respiration so slight as not to be notice- able, yet strong enough to keep life up awhile. Galen and Feijoo were not far from the truth; we are very little, if at all nearer. Icard claims that life ends when the heart stops beat- ing, but allows of only two ways of finding out with cer- tainty that the heart does not beat. Either the heart must be laid bare or a long delicate needle must be pushed through the body to the heart. The eye will correct the error of the ear, and will observe either the palpitation of the heart laid bare or the registration of such palpitation by the needle. Any one whose latent life is discovered by either of the above methods is not likely to outlive the discovery many minutes. Drs. Coutenot, Laborde and Blanc, and the majority of the members of the Barcelona Academy do not agree with Dr. Icard, and insist that the soul may exist in the body without exerting the greater vital functions. Our own Dr. Keane is said to have succeeded, by heart-mas- sage, in renewing palpitation two hours after the heart had ceased to beat. This dispute between Dr. Icard and others is theoretical rather than practical. All admit it is practically impos- sible to tell the exact time at which the heart stops beat- ing. Icard says there are many clinical proofs that the u Cf. "Senales de la Muerte Actual," 252. THE MOMENT OF DEATH. 231 heart may perform its function so gently that the most experienced ear can not, by auscultation, note any sound at all. He cites cases in which physicians tried a whole hour and failed either to hear a heart-beat or to observe any respiration ; yet, on opening up the breast, they found the heart still beating and the subject still alive. Various other signs of death are mentioned by physi- cians, but these signs do not give any certainty. The livid spots that appear on the body may be due to as- phyxia. 12 The change of countenance may be a result of sudden irregularity in the heart-beats. Even the rigidity of the body is no certain sign of the presence of death. It precedes the death of those attacked by spasms, lockjaw and asphyxia. The Paris Academy of Medicine offered a prize to the one who would find some other sign of death besides the rigidity and decomposition of the corpse. One hundred and two papers were handed in. None gave satisfaction ; all proposed signs which did, indeed, seem to prove that the greater functions were at an end, but did not prove that the lesser functions had ceased. We prefer to follow such a Catholic and scientific so- ciety as the Academia de los Santos Cosme y Damidn, rather than the view of one or two physicians, on this important question. We say, with Icard, that it is ex- ceedingly difficult to tell just when the greater functions of respiration and circulation come to an end. The time- honored tests of the candle or mirror placed near the nose or mouth are of little importance nowadays. We go even farther than Icard and follow, as a fairly probable opinion, the unanimous judgment of the above-named academy, that there is really no certain and universal 12 Cf. Capellman, 183. PASTORAL MEDICINE. sign of death other than decomposition of the whole body, and in a somewhat advanced stage. Decomposition that has just set in is not a sure sign of real death ; such de- composition may come from gangrene that precedes death. Death is not as sudden as it sometimes seems to be. The separation of soul from body is a slow and violent process. Death takes its grim hold on the human organs, not all at once but step by step. Most physicians now agree that the greater functions, such as respiration and circulation, first cease ; then there comes a period of latent life that varies in length according to the cause which brings death. During this period of latent life the func- tional properties of the tissues and organic elements re- main, but without external manifestation of their pres- ence ; if these functional properties are put into action by outside force, the greater of the vital functions may at times be fully restored. 18 How is it life clings to man even after the greater func- tions of respiration and circulation have ceased ? Because an organ continues to live so long as its cells and tissues are not incapacitated for their specific organic function and retain the various elements necessary for nutrition. Of course, without the greater functions of circulation and respiration, the supply of oxygen and other nutritive elements is cut off from the cells and tissues ; yet, accord- ing to many physicians, the cells and tissues may go on living for a while, even after their supply of nutrition is cut off. By what means do the cells and tissues live M Cf. Capellmann, 178. This is also Laborde's explanation. We have submitted this paper to several eminent physicians; among them was Dr. J. Taber Johnson, vice-president of the Medical School of Georgetown University. They considered our argu- ment was sound, our conclusion probable and our medical au- thorities good. THE MOMENT OF DEATH. 233 without new fuel? By virtue of the nutritive elements which past respiration and circulation have stored up. The more hale and hearty are the organs, the longer will they last on their organic reserve-store of nutritive en- ergy, the longer will the time of latent life be. Healthy cells and tissues do not break down so readily as do sickly cells and tissues. The state of apparent death lasts longer in cases of a sudden, than in cases of long expected death. During a long and painful sickness, every organ, tissue and cell has been gradually yet constantly weak- ened, and has been so impoverished as to have drained out almost completely that reserve-supply of nutrition which is always stored up within healthy organs, tissues and cells. The period of latent life is very short after such draining and impoverishment of the system; when the greater functions cease, when the lungs refuse to sup- ply oxygen and the blood no longer carries nutrition to the cells, life comes to a speedy end, the cells and tissues have no reserve-supply to fall back upon. This lengthy explanation is not a mere fancy, nor a theory that is not borne out by facts. We appeal to the facts we have given about infants. We add more facts that go to show how doubtful is the presence of death until decomposition has reached an advanced stage. First we give some facts of sudden death. Professor Wetz/of the Catholic University of Lisle, gives several cases of return to life after one and one-half to three hours of apparent death caused by lightning. Laborde for three hours applied his system of rhythmic tractions of the tongue, and brought to perfect health a person who had been ten minutes under water and was given up for dead. Sorre in this way saved one who had been an hour under water. Laborde gives 189 cases in which rhythmic tractions of the tongue revived those who 234 PASTORAL MEDICINE. seemed to have been killed by strangulation, asphyxiation and other forms of suffocation. Dr. Blanc says there are numerous cases of wounded soldiers who were restored to life after they had been from two to twelve days in the state of apparent death from hemorrhage. These cases of sudden death should suffice to prove our point. We shall add a few cases of lingering death. Even in regard to the man who seems to have died after a long sickness, Dr. Icard gives this wise advice: "It is better far to treat a dead man as if he were alive than to treat a live man as if he were dead." Dr. Icard gives such advice to the prudent physician of the body. May not the prudent physician of the soul be right in always doubting the presence of death ? Now for our examples of lingering death. Dr. Cirera tells of a woman who seemed to have died from pneumo- nia and pericarditis. After fifteen minutes of artificial respiration the heart-beats were again perceived; after two hours the woman had regained the use of her senses ; she died twenty-four hours later. Dr. Coriton gives the case of a woman who was found livid, stiff, without respiration or palpitation. She was said to have died from some tracheo-bronchial affection. The rhythmic tractions of the tongue were applied at the rate of thirty-five to forty per minute. All pallor first disappeared from the cheeks, then from the nostrils; later on there was a slight movement of the nostrils ; after five minutes a soft sigh was heard; after half an hour pulsation and respiration were regular; the woman lived three months more. The facts and authorities we have given prove, with at least some probability, that there is a period of latent life between the apparent and real moment of death of every man. Not on our own authority, but on the authority of THE MOMENT OF DEATH. 235 Fr. Ferreres and the physicians and theologians already cited, we hold that it is fairly probable that we can never be sure this period of latent life is ended till total decom- position has reached an advanced stage. So long as we have any doubt about the presence of total decomposition, it is probable that we should administer conditionally the sacraments which may be the only possible means of bringing the subject to heaven. THE FIFTH COMMANDMENT. I. ABORTION. 1 TT was reserved for Christian civilization to prohibit * artificial abortioning for therapeutic purposes and to abolish it almost wholly, until, toward the close of the last century, the English achieved the very doubtful honor of reintroducing abortion among obstetric opera- tions. The French followed suit, so did the Germans after prolonged opposition. Jaquemier* wrote, in 1867: "To-day, where there is no longer a hesitation to interrupt in its first stages a gravidity which can not run its course without jeopardizing the life of the woman in labor, no physician worthy of his name would consent to remain voluntarily an inactive witness." The operation has been reintroduced in Germany by Menden, Kiwisch and Scan- zoni. Owing to their influence, nearly all the teachers of obstetrics, and writers thereon, cite one or the other occa- sion, sometimes quite many, where artificial abortion is indicated. Abortion is the bringing forth of the fetus before its maturity. Not being developed sufficiently to live in- dependently from the womb, the fetus is doomed to cer- 1 In these chapters we reproduce, in addition to the matter on this subject in the Second Part, page 86 of this work, the state- ments of Dr. Capellmann, one of the most frequently quoted authorities on these practical questions. Those who wish to study this subject more thoroughly will find all arguments in favor of abortion ably answered and refuted by Van Oppenray, S.J., in "The Right to Life of the Unborn Child" (New York: Wagner). 1 Jaquemier, in : Dictionnaire Encyclopedique des Sciences Medi- cales. Paris, 1867. Volume VII., 575. 236 ABORTION. 237 tain death; hence the direct effect of abortion is the death of the fetus. Artificial abortion is tantamount to killing the fetus. In order to judge rightly the question whether abortion in obstetrics be permissible, it is necessary to determine what is the nature of the object in the abortion. This object is the impregnated ovum of the human female in the state of being developed. The fetus must be sup- posed to be alive until the contrary is sufficiently proven. That a dead fetus may be brought forth goes without saying. However, it is very difficult, in most instances impossible, to determine positively whether the fetus is dead or alive at the time of gravidity. Hence we have to suppose that the fetus is alive. In such case, however, it is endowed with a human soul. The homo- geneous human soul is the vital principle for the animal life of man. And there is no reason to suppose that the fetus has a specific vital principle, a specific soul, up to delivery or to a certain stage of the gravidity, the ra- tional human soul then to take its place, qua cedente as St. Thomas opines. 1 An absence of a rational soul pending the life in the womb can not be construed from the lack of the higher functions of the soul or of their manifestation. The rea- son thereof is, for one, that the perceptive and active or- gans of the embryo are not developed, or are prevented from working. This is by no means an isolated instance. In a like manner we see how, in a quiet sleep, in a swoon, 1 " Quaestiones disputatae, quaestio unica de anima art. 9. Et sie quum in embryone primo sit anima vegetativa tantum, quum perventum fuerit (sc. ab embryone) ad majorrm perfec- tionem, tollitur forma imperfecta et succedit forma perfectwr quae est anima vegetativa et sensitiva simul, et ulttma cedente succedit ultima forma completissima, qua est amma rahonahs. 238 PASTORAL MEDICINE. or in apparent death, animal life continues to functionate, although the higher actions of the soul are suspended, or at least seem suspended. It is not necessary for the soul to be ever active in all directions ; at most we may deduce from the non-manifestation of some actions of the soul, that the proper conditions for their exercise are lacking. Hence the want of higher activities of the soul is no proof for the non-presence of a rational soul ; therefore we assume that the human embryo at the moment of im- pregnation becomes endowed with a rational human soul, and that the impregnated human embryo is an inde- pendent human being. Every human being the impregnated human embryo, too has, first of all, the right to live. This right is inalienable, provided ( i ) the person has not forfeited the same by acting contrary to divine and human laws, and by transgressing natural and social order; or, unless (2) in case of assault the assaulted acquires the right to in- flict, in self-defense, bodily injury upon the aggressor; he may even kill him to preserve his own life. Ad ( i ) The child in the womb can not forfeit its right of existence by acting contrary to law, or by transgressing the ruling order, because it is by force in a wholly passive state. No one can merit punishment by remaining pas- sive, or by inaction, if he is debarred from acting without fault of his own. Ad (2) Nor can it be argued that the fetus is commit- ting an assault against the life of its mother. Without any of its own doing, without any act or volition of its own, the child has been brought into a position where it event- ually may endanger the mother's life. Hence we can not speak of an unjust assault. The qualification "unjust" is, however, essentially necessary for making the killing in self-defense permissible. But even if the child can not ABORTION. 8 39 be born without imperiling the life of its mother, it is more than doubtful whether the child can be regarded as committing the assault. In by far the largest number of cases the impediment is caused by the mother; for instance, by a too narrow pelvis, etc. Besides, the act of giving birth has not its origin with the child, but with the mother. The danger for mother and child comes from the action of the womb, which, while not controlled by the mother's will-power, emanates from her, pertains to her. Hence, if by a voluntary act on the part of the mother, by procreation, the child without any of its own doing has been placed within the mother's womb; if the dislodgment of the child from the uterus is aimed at by an activity emanating from the mother ; if, finally, this dislodgment is disturbed or prevented through impedi- ments due to the mother, as it is in most cases ; and if all these circumstances, all dut to the mother, tend to jeop- ardize the lives of mother and child, can any one possessed of a particle of justice maintain that the child has com- mitted an unjust assault or even an assault? Hence the mother, or the physician acting in her behalf, has not the excuse of self-defense on her or his side. Therefore arti- ficial abortion is to be looked upon as an unjustifiable homicide; it is tantamount to murder. Murder is prohibited by every divine and human law. Hence the artificial abortion is prohibited. 1 The ques- tion is, whether there are circumstances that make the arti- ficial abortion permissible. Here we must make a two- fold distinction. 1 Some women who have been impregnated outside of wedlock expect from the physician to save them from dishonor by pro- voking an abortion. It goes absolutely without saying that the physician must not do it. There are some physicians who ad- vise not to refuse the imputation, lest the person refused may 240 PASTORAL MEDICINE. i. Is it permissible to cause directly the artificial abor- tion, in order to rescue the mother's life from danger? 2. Is it permissible to cause indirectly the artificial abor- tion, to put the life of the mother thereby out of danger ? The answer of the moralists is, "Nunquam licet directe procurare abortum." Even the intention to preserve the life of the mother does not make the direct abortion per- missible. It will not do to plead the welfare of the mother as directly intended, the abortion only indirectly ; it mat- ters, what is being done. With the exception of a single case (stated below), the mother is only removed out of danger after and because of the abortion having taken place. Hence the saving of the mother is not directly and immediately due to the medicine which started the abortion, and which may have been indifferent in itself, but it is only due to and caused by the abortion. Now, a good effect directly intended, must not have been caused by a forbidden effect, for in that case the forbidden effect must necessarily have been intended. Abortion would be brought about indirectly by the use of remedies which are either necessary or apt to ward off the danger for the mother, but which probably, or likely, cause the not-intended abortion. It is, no doubt, permissible to use proper and safe remedies for a good purpose, even if they may produce a second for- bidden but not intended effect, on the condition that the directly intended good effect is in proportion to the loss or damage caused by the forbidden effect; that the means used are apt to directly and immediately cause find the sought-for help elsewhere. They advise to seemingly grant the request, but to prescribe some indifferent medicine, put- ting her off in that manner. Aside of the fact that this trick will mostly fail in its purpose, I hold such an apparent consent to a criminal plan to be morally unallowable, and at any rate most unworthy. ABORTION. 241 the good effect, not, however, that the good effect has its cause in the forbidden effect simultaneously brought about with it; that another means to achieve the good effect does not exist or is not known; finally, that the utmost is done to prevent the forbidden effect. Hence in treating the pregnant, even in the absence of any urgent danger, the use is allowed (see Gury, tract, de V. 402) of means and remedies which, according to med- ical science, are necessary for the cure of the mother, or which have at least a healing tendency. Their use is al- lowed, albeit they may be known to sometimes cause abor- tion. But this effect must not be a necessary sequel of the medicine, but rather a rare instance. Against the probable or certain cure of the mother as effected by that remedy, is to be taken in account an only possible endan- gering of the fetus; the directly intended good effect is therefore adequate to the possibly arising subsequent evil effect. In this category belong all medicines if ad- ministered in regular therapeutical doses, also bathing, bleeding, injections into the genitals, and so on. As a matter of course, the remedies, whether for internal or external use, must be given in such quantities only as are absolutely necessary for the cure of the mother, and the administering persons should feel themselves bound to prevent abortion as far as possible. Should the mother be in direct and immediate danger of death, then a treatment directly and immediately sav- ing her life may be adopted, although expected to cause abortion. This would be permissible, however, only in default of any other saving means, and only if the utmost care be taken to prevent abortion. As I have proved in my treatise 1 neither of the aforesaid conditions apply to 1 "De Occisione Foetus." 24* PASTORAL MEDICINE. any of the cases, with but a single exception, in which the obstetricians of our day perceive a necessity for pro- voking abortion. The one condition especially is never fulfilled : that the rescue of the mother be directly due to the remedy given. The rescue of the mother would in all cases only be resultant from the removal of the fetus, the interruption of pregnancy; hence it could not be main- tained that the abortion was brought about indirectly. On the contrary, the means of saving the mother would be found in nothing else but the abortion itself ; hence the latter would have been directly employed as a means, which is prohibited. Here I cannot possibly coincide with Lehmkuhl * when he says, in his early editions (III., 841) : Ex consulto abort tint inducere, etiam licere videtur in PRAESENTI z-itae mater nae discritnine, quod per solam foetus immaturi in- jectionem averti possit: quo in casu vix magis erit DIRECTA abortus procuratio sensu theologico, quam in jiaufragio tabulam amico cedere est directa sui ipsius oc- cisio. (Eodem modo si ejectio foetus necessaria esset ad ejus baptismum, hacc indirecta occisio, sen potius mortis acceleratio, videretur esse: sed id vix unquam occurrerit.) The explanation as given by Lehmkuhl in this sentence fails to make the matter clear. In cases of pressing danger for the mother, he pleads for the abortion, which he disclaims to be in the nature of a direct one, yet his arguments fairly apply to the latter. To begin with, the roundabout way of speaking of abortion, telling us that the mother laxatis fibris foetum ex utero elabi sinat, atque ita perire permittat. Yet he himself takes issue with that view, because the provoked abortion re- 1 "Theologia Moralis." Auctore Augustino Lehmkuhl. Friburgi Brisgoviae. Sumptibus Herder, 1883. ABORTION. 243 quires something else, a perturbatio conditions naturalis and a violentia. And then, on second thought, he shifts the question to an altogether different point: the fetus' control over its own life and its will to sacrifice its own life for the sake of its mother are pressed into service. He says r 1 Foetus, "potest renuntiare in favorem mater- nae vitae;" this will remain, necessarily, unproved. 2. Foetus, "REVERA RENUNTIARE DICENDUS EST, quia in illis circunistantiis jus illud sibi evadit inutile, quippe quod a certa morte se non defendat, imo si ad supernaturalem finem respicimus, aggravat periculum SINE BAPTISMO de- cedendi, qui, abortu secuto, foetui applicare potest." By what right are we to assume that the fetus wants to re- nounce anything? As to the christening of the fetus, after the abortion has taken place, it is a matter of experience that the fetus sur- vives the provoked abortion only in rare instances. In rejoinder to the closing sentence (I., c. 844) : "Modo tamen post foetus immaturi ejectionem baptismi con- ferendi saltern aeque certa sit spes, atque esset, si terminus naturae exspectaretur" it is to be remarked, that there are greater chances for a valid christening at the end of gravidity than after abortion, for the reason, already men- tioned, that the fetus, after being produced prematurely, will be rarely found alive, even in the case of a quick abor- tion, which, moreover, can but seldom be brought about. How Olfers (Pastoral Medicine, p. 15) can claim the reverse to be a fact I can not comprehend. I wonder how many fetuses post abortum he has seen alive? In regard to those cases where the immediate danger to the mother is due to some other malady we may add that the chances of saving the mother by bringing about the abortion are by no means great. Abortion can not 244 PASTORAL MEDICINE. be effected within a short time, it often takes several days; besides, artificial abortion itself is not without its dangers to a woman, especially in the critical condition caused by some other illness. I cling to the axiom subscribed to without dissension by all moralists : "Nunquam licet directe procurare abor- tum." If it is only the abortion (ejectio foetus}, which removes the danger of life, it follows that the abortion, the evil effect, precedes and causes the good effect. It is impossible to call this an indirect abortion. The .rules under which the indirect abortion is permis- sible, coincide, to my mind, in but one single instance when the pregnant womb becomes irremovably com- pressed into the small pelvis, as may happen by bending backward, prolapsing or inclining the gravid womb. If in this case all other means known to science for the re- placing or releasing of the womb have been tried and have failed, then I hold it permissible l to indirectly bring about abortion by puncturing the^amnion and draining off the fluid contained therein. My reasons therefor are : 1. The mother's life is in immediate danger ; but for a reposition of the uterus she and the fetus are bound to perish. 2. This is the only remedy left. 3. The draining off of the amniotic fluid is apt to re- move the danger immediately. In this case the danger for the mother does not lie in her pregnancy, in the physio- logical sense, but in a purely mechanical cause, to wit: the enlargement of the womb. By draining the amnion 1 Some theologians are taking exception even to this case of indirect abortion. Cappellmann seems to be supported in his view by some authorities; by Antonelli, for instance. His argu- ments, however, should be judged in the light of Van Oppenray's statements in " The Right to Life of the Unborn Child." MYOMA. 245 of its fluid, the uterus is made to shrink, the mechanical obstacle to the reposition of the womb is removed, and the mother thereby placed out of immediate danger, and before the abortion, which, indeed, is bound to follow, has been brought about. A necessity for resorting to a real abortion, the artificial ejection of the fetus from the womb, is not present. Happily, the compression of the womb does not, in itself, occur very frequently ; moreover, the cases where a reposition is absolutely impossible are so rare that Professor Martin, of Berlin, in fifty-seven cases, had but once occasion to take recourse to the puncturing of the amnion. Of the fifty-seven cases, fifty were righted by reposition, five abortioned spontaneously, with subse- quent reposition. The remaining case was that of a woman who, having made an unsuccessful attempt at let- ting off the fluid, went to the hospital in a critical condi- tion and died without reposition. The woman that had been punctured by Professor Martin died likewise. II. MYOMA. Within the past decade there has been frequently per- formed an operation which, being virtually an indirect abortion, ought to be noted here. I refer to the supra- vaginal operation of the gravid uterus because of Myoma. The growth of the myoms during pregnancy is at times such as to threaten imminently and directly the life of the mother. Some of these myoms cannot be removed even by laparotomy unless the uterus be removed with them. The extirpation of the diseased womb is apt to save the patient. Here, too, the danger was not caused by pregnancy, but by the growth in the uterus. It is true that with the removal of the uterus the fetus also is removed. Simultaneously with removing the 246 PASTORAL MEDICINE. danger from the mother an abortion takes place, if one wants to put it that way ; however, the abortion was not necessary to remove the danger. But all doubts, misgiv- ings and difficulties that may hitherto have existed are removed for the Roman Catholic through the decision of the Holy Office of July 24, 1895, which is, in the words of Lehmkuhl, "ejusmodi invasionem in vitale foetus elementum craniotomiae aequiparat atque pro directa occisione habet proin pro re intrinsecits illicita." In the eighth edition of his "Theologia Moralis " Lehm- kuhl retracts his former opinion, citing the text of the decisions from "Analecta Ecclesiastica," vol. iii., page 480, thus: "Stephanus Maria Alphonsus Sonnois, Archiep. Cam- eracensis, ad pedes Sanctitatis Tuae devotissime provo- lutus, quae sequuntur humiliter exponit. Titius medicus, quum ad praegnantem graviter decumbentem vocabatur, passim animadvertebat, letalis morbi causam aliam non subesse praeter ipsam praegnationem, hoc est, foetus in utero praesentiam. Una igitur, ut matrem a certa atquc imminenti morte salvaret, praesto ipsi erat via, procu- randi scilicet abortum seu foetus ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis et operationi- bus, per se atque immediate non quidem ad id tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut vivus, si fieri posset, ad lucem ederetur, quamvis proxime moriturus, utpote qui immaturus omnino adhuc esset." Jamvero lectis, quae die 19 Augusti, 1889, Sancta Sedes ad Cameracensem Archiepiscopum rescripsit. "Tuto doceri non posse licitam esse quamcunque opera- tionem directe occisivam foetus, etiam si hoc neces- sarium foret at matrem salvandam" dubius haeret Titius circa liceitatem operationum chirurgicarum, quibus non raro ipse abortum hucusque procuravit, ut praegnantes CRANIOTOMYCESAREAN SECTION. 247 graviter aegrotantes salvaret. Quare, ut conscientiae suae consulat, supplex Titius petit, utrum enuntiatas operationes m repetitis dictis circumstantiis instaurare tuto possit."-Fer. iv., die 24 Julii, 1895. "In Congreg. gen. S. R. et univ. Inquisitionis proposita supradicta in- stantia Emi et Rmi DD. Cardinales in rebus fidei et morum Inquisitores gen., praehabito Rmos D. Consul- torum voto, respondendum decreverunt: Negative, juxta alia decreta, die scil. 28 Mai 1884 et 19 Aug. 1889. Se- quenti vero feria V. die 25 Julii in audientia R. G. P. adsessori impertita SSmus D. N. relatam Sibi Em. Ta- trum resolutionem adprobavit. L. + S. I. MANCINI CAN. MAGNONI, S. R. et Univ. Inquisitionis notarius." III. CRANIOTOMY AND OTHER OPERATIONS UPON THE CHILD IN THE WOMB. CESAREAN SECTION. The various operations upon the child to bring on de- livery, such as perforation, cephalotripsy, embryotomy, embryothlasy were known, in part, already to the an- cients. Until the beginning of the nineteenth century, however, it had been the conditio sine qua non for the operation that the child was dead, and was pronounced so by experts. Within the last century, however, the occi- sion of the living child, also, has gained ground more and more, and it is generally recommended, in our time, in cases which, admitting only of the alternative between cesarean section and occision, demand the delivery of the mother who would not submit to cesarean section. Is it permitted to perforate the child? Obviously not, for it is tantamount to directly killing the child, which 248 PASTORAL MEDICINE. is always prohibited. Moreover, in an overwhelming majority of cases, occision by no means offers the only salvation for the mother, inasmuch as the cesarean sec- tion is almost always feasible. Lastly, the occision is not even a certain expedient for saving the mother, while the child is surely bound to perish by it. It has been customary to look upon the cesarean sec- tion as a deadly operation, hence moralists are prone to regard it as unefficacious for the rescue of mother and child. In former years those that died after or during this operation may have outnumbered those that sur- vived it; to-day the reverse is the case. Statistics show that of loo women which have undergone the cesarean section, the number of survivors were, according to Kaiser, 38 ; to Michaelis, 46 ; to Mayer, 46 ; to Hermann, 57; to Indes-Lacomb, 60, and to Villeneuve, 69, which makes an average of 52.6 per cent. In addition hereto, it must be noted that, according to all compilations, the mortality due to cesarean section has been reduced owing to improvement in surgery and treat- ment. This is clearly shown by a table prepared by Gar- imond from statistics by Kayser, Lauth, Gueniot and Joulain. The percentage of mothers surviving that opera- tion was : Per cent. From 1750 to 1800 32 From 1801 to 1832 37 From 1832 to 1839 51 From 1839 to 1861 60 Undoubtedly the results obtained by cesarean section have been more favorable yet since the introduction of aseptic surgery. It is to be regretted that no statistics on a larger scale have been published on this subject. Ac- cording to recent reports from maternity hospitals at CRANIOTOMYCESAREAN SECTION. 249 Leipsic and Dresden there were only four deaths in twenty-four cases, where the cesarean section had been performed after Saenger's conservative-antiseptic method. F. A. Kehrer reports 6 death cases out of 16, while ac- cording to Leopold there were out of 23 but 2 that did not survive the operation; again, Winkel estimates the mortality among the women undergoing the operation at 8.6 and 8.4 per cent. Kaltenbach even maintains that the mortality amounts to not more than from 2 to 3 per cent, if the section is performed under favorabU external conditions and according to approved surgical and anti- septic methods. Altogether there were, according to the above figures, 12 deaths out of 63 ; hence the number of survivors from the operation average 80 per cent. Another table, compiled by Struzzi, assistant to Pro- fessor Porro, covers 150 cases where hysterotomy was performed after Porro's method from 1876 to 1887, inclusive. Of these 49 died; the rest, 67 per cent., were saved. Even these small figures bear testimony of a re- duced mortality. Taking into further account the large proportion of new-born children surviving the section, which accord- ing to Scanzoni amounts to 65, according to Michaelis and Hermann to 66, to Kaiser to 70, Villeneuve to 72, Kehrer to 72.5 and to Leopold even to 87 per cent., we must recognize the cesarean section, especially in view of the fatal situation which renders its performance neces- sary, as not only not deserving the name of a savage oper- ation, but we must on the contrary praise it, as a most beneficial many-lives-saving operation. On the other hand, occision, so much-touted, in contra- distinction to cesarean section, yields altogether differ- 5 PASTORAL MEDICINE. cut results from what ought to be expected on the strength of its being so generally recommended. According to Lee there died, after the operation, 23 out of 127 mothers; according to Professor Halbertsma, of Utrecht, 39 to 39.5 per cent died out of 100 mothers. Here too the introduction of antiseptics was accompanied with a great improvement. The percentage of women dying after perforation is quoted by Spiegelberg and Winckel to be 17 per cent, respectively 14.6 per cent ; by Miiller, of Berne, and Thorn, of Halle, 12 per cent. ; Merkel, of Leipsic, 8 per cent ; and Wyder, of Berlin, 8.3 per cent According to a compilation by Kehrer the mortality among mothers who underwent perforation was, in Hessia. Nas- sau and Baden (from 1852-1888), 16.5 per cent; in 303 cases of craniotomy, 19.8 per cent ; in 12 hospital wards from 2.8 per cent to 56.5 per cent. Average, 14.6 per cent The mortality among mothers after perforation is therefore nearly as high as after the cesarean section, while by perforation every one of the children perish as a matter of course. According to the figures above, the survivors, after cesarean section, average 150 to 170 out of 200; those surviving perforation average 80 to 90 out of 200; balance in favor of cesarean section, 70 to 80 human fives. While no claim is advanced as to these figures being ab- solutely correct, yet they show sufficiently that cesarean section preserves many children's lives ; they disprove the contention that it is almost always deadly for the mother ; they show, again, that the process of perforation, which results in a sure death for the child, offers but a limited chance for saving the mother, being almost as dangerous for her as the section. This ought to con- demn the occision of the living child already on the ground of utility. Hence the killing of the child by CRANIOTOMYCESAREAN SECTION. 251 the physician cannot be sanctioned, not even in the case where nearly all obstetricians advise occision, to wit, when there is but an alternative between section and per- foration, and the mother, whose life depends on delivery, refuses to submit to the section. There is nothing left for the physician but to wait for the death of either the child or the mother. Not being able to avert the death of the latter by fair means, he must bide his time, and then use all his art in behalf of the surviving life. For the Roman Catholic this question is authoritatively decided by virtue of the decree by the Holy Office, ad- dressed to the Cardinal Archbishop of Lyon, which reads as follows: Eminentissime et Reverendissime Domine: Eminentissimi P. P. mecum Inquisitores Generales in Congregatione generali habita Feria iv., die 28 labentis Maii, ad examen revocarunt dubium ab Eminentia tua propositum: "An tuto doceri possit in scholis catholicis, licitam esse operationem chirurgicam quam cranioto- miam appellant, quando scilicet ea omissa mater et nlius perituri sint, ea e contra admissa, salvanda sit mater in- fanta pereunte?" Ac omnibus diu et mature perpensis, habita quoque ratione eorum quae hac in re a peritis catholicis viris conscripta ac ab Eminentia tua huic Con- gregatione transmissa sunt, respondendum esse duxerunt : Tuto doceri non posse. Quam responsionem, cum S. S. D. N. in audientia ejusdem Feriae et diei plene confirm- averit, Eminentiae tuae communico, tuasque manus hu- millime deosculor, humillimus ac addictissimus servus verus. Romae, 21 Maii 1884. R. CARDINALIS MONACO. 252 PASTORAL MEDICINE. IV. THE PORRO SECTION. In recent times, some operations are much spoken of which we can not pass over with silence, to wit, the cas- tration of the woman and the so-called Porro section. The castration of the woman consists in the extirpation of her ovary, for one reason or another. It is not known to me that the castration has ever been advised for the purpose of sterilization. Castration is indicated partly in the case of big sores or ulcers, in the ovary or a degenera- tion of the latter, partly in the case of certain nervous diseases, believed to originate in the ovary, which are of so lasting and violent a nature as to make life a burden to the patient ; hence the opinion that the castration is justi- fied. The question about the origin of these nervous dis- eases being by no means settled, many an error and a fail- ure may go along. However, there will be hardly any objection from a moral point of view, after it once has been more clearly defined by experience where and when that operation be indicated, provided it is not made for the sake of sterilization, or needlessly, or frivolously. In respect to Porro's operation matters lie somewhat different. Prompted by the poor results as obtained in Italy and France from cesarean section, which in his opinion were due to the frequently enormous and irrepres- sible hemorrhages; and on the other hand, encouraged by the success attained in extirpating uterus and ovary of non-pregnant women, Professor Porro, of Pavia, in 1876, gave to cesarean section a different form. In one case of unquenchable hemorrhage, after cesarean section, he successfully extirpated uterus and ovary after extracting the child. At once other surgeons in France, Germany and Austria followed suit, achieving more or DANGEROUS OPERATIONS. 253 less good results. This operation soon was performed for some cause other than perilous hemorrhage; for in- stance, because of degeneration of the tissues of the womb, or of the ovary, or because of ulcers on these parts. Later on, this operation was extended to cases where there was only a narrowness of the pelvis, without any degener- ation of the groin or dangerous hemorrhages, the purpose of the operation being to render a future conception by the patient impossible, so that she never again would have to undergo cesarean section. This, to my mind, trans- gresses the limit of what is allowed. If the pelvis is so absolutely narrow that the woman, in case of her preg- nancy, could only be delivered by means of the cesarean section, then the danger to her life is very remote indeed. To begin with, it is not at all certain whether she will ever become pregnant again; furthermore, delivery by means of the section includes but a relative danger of life, as we have shown. Now, it is proposed to stave off this remote danger by an operation almost fully as dan- gerous as the old cesarean section, making impossible thereby her fecundity, destroying the purpose of mar- riage, and committing an annihilating assault upon the natural destiny of woman. Tempting as the thought may be to spare the woman a future danger from cesarean sec- tion by Porro's operation, this process can never be coun- tenanced either if judged by natural law or by Christian morality. V. SURGICAL OPERATIONS WITH DANGER TO LIFE. They are performed to avert a probable or immediate peril, sometimes also for removing very troublesome or disfiguring growths. Grave operations performed with a view to placing the patient beyond danger of death are 254 PASTORAL MEDICINE. permitted, because they hold out promise of a probable, or at least possible, rescue, in place of an anticipated death. These operations are likewise permitted if the peril to be warded off is only probable and more re- mote, provided that, if the operation be deferred too long, the illness, and with it the peril, are apt to increase, while, at the same time, the vitality of the patient is de- creasing; hence the chances for a successful operation are continually lessened. It would be different, however, if the dangerous opera- tion were to be performed, not because the patient's life is in danger, but for the removal of some disfiguring or troublesome ailment. In this case the sanction could not be granted unqualifiedly. It would be, in the first place, for the surgeon to decide whether the operation under the prevailing conditions is permissible or not. If the ailing is too troublesome or disfiguring, then the question may be answered affirmatively. An analogous example, much mooted by moralists, may here be quoted. Supposing some one unjustly held in captivity and suffering all kinds of hardships had no way to escape except by risking his life. The attempt, if successful, would mean liberty and happiness for him ; a failure, loss of life. Preferring death to an intolerable captivity, would it be right for him to risk his life for liberty? This should be admitted, provided he has rea- sonable chances for succeeding. A dangerous operation may present a similar case. In a different situation, how- ever, when the operation cannot be sanctioned, the patient has, of course, no right to request it, and the physician must refuse to grant such a request. The decision whether the operation is permissible must depend, in each individual case, on the nature of the patient, on the seriousness of his trouble and on the DANGEROUS OPERATIONS. 255 chances for a successful performance of the operation. Happily, however, kindred cases are quite rare. Another question may be raised, namely : is the patient bound to submit to a grave operation, either because his life is surely endangered or because of a very disfiguring and offensive ailing? This, of course, is to be denied. According to reliable authorities no one is bound to un- dergo a grave operation in order to remove a certain danger to his life, even if the chances are in favor of its successful performance. "Non teneris vitae servandae causa pati amputationem cruris sive brachii, aut incisionem z'entris ad extrahendum calculum." (Liguori.) But to my mind it should not be overlooked that the above decision perhaps needs to be modified, in view of the vast progress made by both medicine and surgery, inasmuch as grave operations are performed nowadays under altogether dif- ferent circumstances, and mostly with better success, than formerly. "Non tenetur quis," says Gury, "servare vitam remediis extraord'mariis, quaeque MAXIMUM DOLOREM af- ferant; non datur enim obligatio servandae vitae, nisi me- diis ordinariis, quae magna non adducunt incommoda, . . neque dolores valde acerbos causant" Says Scavini, in his "Theologia Moralis Universa": "Cum servare vitam op- erations DOLORES NIMIS ATROCES afferente extra com- munes vires positum sit." Thus, the main stress is laid upon the pains and hardship which the operation entails. But what is to be said now, when most of the grave op- erations are almost painless, owing to the use of chloro- form and other narcotics ? Is the mere determination to submit to a likely successful and in itself painless opera- tion in order to escape an otherwise certain death likely to call for any great effort on part of the patient? The fact of the operation being rendered painless by the use of nar- cotics is well-known to the layman, hence his fear and ter- 256 PASTORAL MEDICINE. ror of the surgical knife have been greatly diminished. This must influence our decision to some extent. Granted the incision may later on cause pain to the patient, this pain generally will not be any more, mostly much less, se- vere, than the pain caused by the ailment which necessi- tates the operation, which pain the patient has to en- dure, and which he would still have to endure, if not operated upon. Aside of the pain, there is to consider, perhaps, some permanent disfigurement as a result of the life-saving operation, for instance the loss of a limb. But even this hardship is nowadays mitigated or remedied by the improved manufacture of artificial limbs, etc., which has reached a perfection not dreamed of in former times. Not only is the disfigurement done away with, but even the usefulness of the lost parts is more or less restored. All these instances ought to modify the decision of the question as it seems. However, the thesis propounded by the moralists ought well-nigh to remain unchallenged as often as a patient feels overawed by the thought of the operation, the progress in modern surgery notwithstand- ing. Natures vary in their sensitiveness. CESAREAN SECTION/ Special mention must be made at this juncture of an op- eration important in various ways, to wit, the cesarean sec- tion. According to the laws of science and morality the cesarean section is indicated after a situation has arisen where delivery in the usual way can only be rendered pos- sible by an occision of the child, or worse, where even the Decision of the child would not avail to make possible an extraction along the natural passageway. In the first case, if the section is not resorted to, the child could not be extracted until after its death, and only by dint of .1. 1 See also page 247. CESAREAN SECTION. 257 painful and always dangerous operation upon the mother. In the second case, both mother and child would be sure to perish in default of cesarean section. In considering whether or not to submit to cesarean section, the mother has not only to consider her own welfare, but also the welfare of the child, which is bound to die unless the sec- tion be performed. That the child must not be killed for the sake of its mother has been stated above; here the question will arise, "Is it permissible for the mother to let her child die when it could probably be saved by cesarean section?" In the case of the extraction of the perforated dead body of the child along the natural passageway the mother, having refused to undergo the cesarean sec- tion, will have to face the hardly smaller danger incidental to perforation. We have shown previously that the latter operation is quite as dangerous as the sec- tion, chiefly because, in waiting for the child to die, the vitality of the mother becomes more and more sapped, until finally the operation is performed under adverse circumstances. The moralists lay stress upon the hor- ror of the operation, but its damaging effect may, if necessary, be diminished to a great extent, or even nulli- fied by the use of chloroform or other anaesthetics. The "peritia medici" demanded by the moralists, is just as nec- essary in performing occision as in performing the sec- tion, hence does not affect the choice between the two op- erations. To sum up, if mother and child are physically strong enough, so that hopes for preserving both lives may be entertained in reason, then the mother should be urged to submit to the section. The aforesaid applies, with greater force still, to the second case, where even perforation would not answer the purpose of rendering extraction along- the natural 258 PASTORAL MEDICINE. passageway possible, to the therefore so-called absolute indication for the section. In this case both mother and child are confronted by certain death, and the mother should be urged, even for the sake of her own life, but, moreover, in view of a possible saving of both lives, to undergo the cesarean section. It is true, as the moralists say, this is a medium extraor dinar ium ad servandum vitam, therefore the mother who stands in too great a dread of the operation should not be bidden under penalty of com- mitting a grave sin to make the sacrifice for the sake of preserving her own temporal life or that of her child. In one, and only one, instance it is for theology to decide whether the mother is obliged to submit to the dreaded operation for the sake of the eternal salvation of her child, namely, if the child, bound to perish otherwise, could be saved with reasonable certainty by the cesarean section and if the christening of the child with the aid of instruments would be either impossible or too uncertain. From a medical point of view it may be mentioned that a number of sections are still being made without the aid of anaesthetics and I repeatedly have had occasion to convince myself of the fact that women can stand the operation without anaesthetics in spite of its painfulness. The feeling of horror before the operation is sometimes worse than the operation itself, because nothing is more dreaded by the laymen than the incisio ventris. I am con- vinced the operations necessary for the occision and sub- sequent extraction of the child are causing more pain than the section, yet they seem not so dreadful to the laymen, because they allow of the extraction along the natural passageway, and because all the cutting and lancing is made upon the child's body, not upon the mother. OTHER OBSTETRIC OPERATIONS. 259 VI. OTHER OBSTETRIC OPERATIONS. As to the question whether the rest of obstetric opera- tions be allowed, or obligatory, there is clearly no room left for doubt, provided they are properly and truly war- ranted. The use of the forceps, the operation of turning around, or the bringing about of the premature birth, if done according to the dictates of science, to wit, in due time and properly executed, serve the purpose of deliver- ing the mother for the sake of her welfare and that of her child. Premature birth, i. e., bringing on delivery before pregnancy has run its full course, yet at a time when the child is quite sufficiently developed for a separate ex- istence away from its mother, is likely to jeopardize the child's life, inasmuch as its organs are not quite per- fectly developed, hence not equal to the influences of the surroundings and the changed mode of its nutrition. This operation enters into consideration in cases where the de- livery, at the natural end of pregnancy, can positively be only effected by a grave operation, perilous for both mother and .child, or only (aside of cesarean section) by perforation of the child, while at the same time it would be reasonable to assume that by premature birth the child would be born alive and remain alive, while the mother had not been put to any considerable danger. In this case it should not be made obligatory for the mother to await the natural term of her pregnancy, and thus place herself in danger of death. Hence the artificial inducing of premature birth is allowed, and the mother may even have the obligation to choose, for her own sake, such a reasonable escape from a fatal situation, especially as she can plead against it neither great pains nor an uncon- querable horror. 260 PASTORAL MEDICINE. The above applies, to an even higher degree, perhaps, to the second order of indications for premature birth: perilous diseases of and accidents to the woman in preg- nancy, at a time when there is a probability for saving her life, by bringing on an early birth. Had the mother died before her delivery, then the child would be in utmost peril ; hence early birth, also in this case, is beneficial to mother and child. Finally, we must mention the sectio caesarea post mor- tem matris. Should her death occur after completing the twenty-eighth week of her pregnancy, then the sectio caesarea is absolutely demanded without regard to the life of the child. In view of the possible baptism of the child, it is questionable whether this limit to twenty-eight weeks is proper. I am inclined to doubt it. True, there may be small chance of extracting the fetus alive by means of the section, if the death has been in the first months of preg- nancy ; not so, however, after the completion of the fourth month. Therefore I would, in order to christen the child, perform the section unless it was proved, by weighty reason, that the child had died before or together with its mother. I would especially perform the sectio caesarea upon all pregnants that have died suddenly or after very short sickness. The section must, of course, be performed as soon as possible after death. At times this may be a difficult matter; there are some cases of sudden deaths where it is not at all easy to make sure whether death has actu- ally set in or not. This, however, is the physician's busi- ness, who may show, in such contingencies, what skill and decision may do. He will use the same care in performing upon the dead as on the living woman, and even in case of asphyxia of the mother no serious injury will have been done. OTHER OBSTETRIC OPERATIONS. 261 But what in the absence of the physician? What in the case of his being too far off (as is often the case in the country), or if he can not be had? Should it behoove the priest to perform the operation ? It has been done by res- olute priests, bent on soul-saving, but I am against it. I can not coincide with the worthy Vering, who holds that the priest should make himself acquainted with the sec- tion, and that it is his duty to perform it, if necessary, rather than let the child die unbaptized. That the op- eration is unbecoming to the priest need not be demon- strated. With the same right, he may be asked to study the whole of obstetrics and to play midwife in case of emergency. It would be no more unbecoming for the priest to save mother and child, in case of both being endangered by placenta praevia, by promptly delivering the mother, than to save, perhaps, the child by per- forming the sectlo caesarea. The only difference be- tween the two is that in the former case everybody would declare it absurd to demand such service from the priest, while in the second case some one has said it should be that way, because it has been done, therefore ap- pears to be feasible. This fallacy is comprehensible, because the performance of the section, to the mind of the non-physician, is a heroic deed, and we are apt to overlook and forgive the unbecoming on account of the heroic. The undertaking of the sectio caesarea by the layman, however, is not only unbecoming, but risky. Aside from the difficulty to ascertain whether the mother is really dead, the performance of the operation re- quires not only a thorough knowledge of the respective parts, but also a considerable surgical skill which the layman would lack, even if he should know by heart the most accurate description of the operation. The cesarean section on the body, warm and fresh, of a 262 PASTORAL MEDICINE. woman just deceased, is even for experts a very exacting operation, especially because it mostly must be performed without expert assistance, the time being too precious to lose it in trying to obtain such assistance. The alarming case in itself, the excitement and suspense whether or not the corpse will stir at the first incision the constant gush of warm blood all these are things which would af- fect any one but an expert, who remains calm because familiar with the operation and used to bloody surgery. Who, then, can reasonably demand that it be made man- datory of the priest to perform the section in case of emergency, when he has but a vague idea of the operation, gleaned from an aphoristic description of the same ? The little he knows of the operation, would it not become en- tirely useless in his natural trembling and hesitancy, and would not the success of the operation be thereby rendered improbable to the highest degree? I shall not allude to other evils in the wake of such a process. Who will pro- tect him from slander, given rise to by the circumstances of a proceeding uncommon for a layman? Will not the people ask, "Why did he meddle? It was not his busi- ness." Whether or not it may be permissible for the priest to perform the incisio in case of emergency, that is for the ecclesiastical authority to decide. A decree of the Holy Office for missionaries prohibits them to venture such a performance, and advises them to confine themselves to in- structing others in their duties and to keep them duti- ful. ("Ne missionarii in casibus particularibus se in- gerant in demandanda sectione, multo que minus in ea peragenda.") Of late Dr. Max Bunge advises the cesarean section upon the dying woman, an operation which heretofore has OTHER OBSTETRIC OPERATIONS. 263 only been scatteringly performed. He says: "If diag- nosis and prognosis by the physician should foretell him the certain death of a highly pregnant woman in short order ; if the fetus can be proved to be living ; if the de- livery by way of the pelvis channel should fail to offer a better prognosis; finally, if, in view of the impending exitus letalis, no success can be expected from bringing about delivery, then the cesarean section should be per- formed without delay, as soon as the woman shows cer- tain symptoms which, we know, indicate that the child, in the shortest of time, will precede its mother in death (asphyxia of the mother, decrease in the pressure of the blood combined with long agony, excessively high tem- perature, etc.). It may sometimes be possible to observe this impending danger in the palpitation of the infant's heart. That such a course be allowable, by consent of the dying, or, if she be unconscious, by her folks, is never- theless doubtful. It can not be denied that it revolts the sentiment to the utmost. Although Bunge places little value upon this objection, it will, as a rule, be the reason why relatives will refuse their consent. Besides, it will be quite difficult to select the right moment for the opera- tion. One may defer it too long or else begin it too soon. Possibly the dying mother is operated upon, only that a dead child be extracted (even if the child was seemingly alive a moment ago) ; another time a seemingly dying mother is operated upon, yet she does not die of her disease. In that case her danger from her existing mal- ady would only have been increased unnecessarily by the cesarean section. Because of these difficulties this operation is not likely to be performed, except in rare instances. 264 PASTORAL MEDICINE. VII. ECTOPIC GESTATION. CLEAR OVA. Ectopic conception and gestation take place when, by an accident, the nascent human form is lodged extra- uterine, in some recess not intended nor suited to pro- tect its early growth. The possibility of saving the fetus, i. e., the child, with- out destroying the life of the mother, seems to exist in many cases of ectopic gestation. Ectopic conceptions are not as rare as might be sup- posed, one doctor having reported fifty cases as having occurred within his own practice, another eighty-five. The fact that a diagnosis of ectopic conception and gestation is often extremely difficult, sometimes even im- possible, is of considerable importance in the matter. "A mere possibility can not be the basis of a strict moral ob- ligation ; hence a physician who has tried in vain to ascer- tain whether an ectopic growth does or does not contain a living fetus must consult the interest of the mother, without being deterred by the possibility of an abnormal conception. The physician has then the right to assume that it is not a child, because monstrosities are not to be supposed." 1 If, however, it is ascertained that the growth is really a living fetus, the case falls under the decree of the Sacred Congregation of May 4, 1898: "Necessitate cogente, licitam esse laparotomiam ad ex- trahendos e sinu matris ectopicos conceptus, dummodo et foetus et matris vitae, quantum fieri potest, serio et op- portune provideatur." In English : In a case of extra-uterine pregnancy doc- tors may, when compelled by necessity, perform lapa- rotomy to extract the extra-uterine fetus, provided proper 1 Rev. R. Holaind, S.J., in Am. Eccles. Review. ECTOPIC GESTATION CLEAR OVA. 265 and conscientious care be taken of the lives of both mother and child, as much as possible. It is an open question just how quantum fieri potest in the decree is to be construed. That the operation is law- ful when the fetus has become viable was evident before this decision and we trust the exact range of the decision will be made clear, beyond all doubt, by the Sacred Office. It can not be doubted, however, that the immortal soul of the fetus is to be safeguarded, no matter whether the fetus is in its proper place or not. CLEAR OVA are formed simply of accessories and contain no trace of life or of a fetus. In these cases the embryo dies spontaneously during the first weeks of preg- nancy, before the appearance of the bones. The dead fetus then gradually dissolves, but the strange part of this anomaly is, that the annexes, membranes and placenta continue to develop for a period more or less long, bring- ing on uncontrollable vomiting and endangering the life of the mother unless the growth is removed by operation. To the medical science of to-day no means is known to positively determine whether the ovum in the uterus is a clear or a living ovum. The living fetus is of course under all conditions en- titled to the protection which the Holy Office has pre- scribed for it. However, if the physician, in a grave case, believes he has good reason to assume that there is a clear ovum and no life present, he has probably the right to consult solely the interest of the mother, as, in the words used by Rev. Holaind, S.J. anent extra-uterine gestation, quoted above, "a mere possibility can not be the basis of a strict moral obligation." Under all circumstances the operator must be prepared to administer baptism the very moment he detects or suspects life in the fetus or ovum, even though he has not expected to find it NEURASTHENIA In Its Pastoral- Psychiatric Aspects. INTRODUCTION. WITHIN the last few decades the nervous diseases, in their thousandfold shapes, have increased to an alarming extent. The exact Joiowledge of these forms of morbidity, however, has not kept pace with their growth. Only twenty years ago decided neurasthenics were diag- nosed as hypochondriacs, and neurasthenia was looked upon as nothing else but some modification of either hypochondria, or hysteria, or melancholy. The essence of these morbid apparitions being misjudged, their rational treatment was in consequence prevented. In more recent times, some gratifying disclosures anent the various ner- vous diseases have been obtained as a result of psychiatric research. That a knowledge of morbid conditions grow- ing out of neurasthenia is not only highly valuable to the physician, but also to the educator, teacher, lawyer, and not in the least degree to the priest, goes without saying. The learned Benedictine, Rev. Anselm Ricker, verily says, in his "Pastoral Psychiatry:" "A priest, who has gained psychiatric knowledge will be kind and prudent in dealing with the mentally afflicted, and will save many a man from great misfortune." Hence it will not be amiss to deal with those of the, only too many, apparitions of mental morbidity which are of par- ticular interest for the priest, because of their many far- reaching effects upon religious life and sentiment. For it is the priest who may be in a position to learn of the most secret trend of thoughts, and who not seldom is 266 NEURASTHENIA. 267 made the confidant by persons suffering from being "not understood by a cold world," and who turn to him, in the hope that he may understand their mental condition and suffering. Such mental suffering is to be found in compulsory thoughts, compulsory notions, and in compulsory condi- tions in general. Hansjakob, a German author, has force- fully described the power exercised by the compulsory images over the morbidly irritable soul. We may believe what he tells of it in his book "Days of Sickness," for he is relating his own personal experience: "Let him who never has been afflicted with compulsory notions thank God and his good nerves for not knowing these furies, against whom will and reason are equally powerless. Com- pulsory notions are for soul and mind what lashes are for the body, only lashes are as balm compared with those illusions, because mental sufferings, mental tortures are in general more hurtful and tantalizing than physical pains." Of course, he who never has had occasion to observe this ailment in its entire depth and broadness, and to watch it in its course, will be readily at hand with a judg- ment that can only be wrong, or with advice that fails to help. At best the uninitiated will counsel the afflicted to try to banish those stupid, silly, ridiculous thoughts. The unfeeling ignoramus will make the cutting remark, "That man is crazy and ought to be in an asylum." Another will find it incomprehensible why those thoughts, together with the impulse they give to perverse actions, might not be overcome by exerting the will-power. The well-mean- ing, spiritual adviser, who, though well-meaning, is unac- quainted with this condition, will say, perhaps, "These are nothing but temptations and distractions, which ought to be despised." 268 PASTORAL MEDICINE. The latter view is the more readily formed, because these compulsory notions often present themselves in the false garb of temptations, and prove the more irri- tating, confusing and alarming the more they concern themselves with vital questions of religious life and the more they harass moral notions. The above considerations make it clear how valuable a thorough knowledge of these mental states and pro- cesses, with their so unstable border lines, will be for the priest, for the purpose of his gaining a clear insight in a given case and of his exerting a favorable influence upon the afflicted. The aphorism: "To understand all means to forgive all" contains a great deal of practical wisdom, and applying it to our subject, we may well say : He who has gained some insight into the true nature of these mental processes will arrive at a true understanding of them, and eventually will not class them any longer with mortal guilt. In order that the subsequent discourse may be better understood, some suitable cases may first be enumerated. They are taken from the book entitled, "La folie du doute," of the French author on psychiatry, Legrand du Saulle. I. CLINICAL CASES FOR ELUCIDATION. I. Case. A woman patient never could think of, talk of, or do anything at all without employing in her mind at the same time the words " cursed," " damned," or " calf." She could not get rid of the impression that everything she did would be cursed, would be damned, no matter how she struggled against it, no matter how much she was even aware of the abnormal in this mental process. This state lasted two and a half years, where- upon she regained her mental balance quite suddenly. For the next six years she was mentally and physically in good health, COMPULSORY NOTIONS DEFINED. 269 when she suddenly, while reading a newspaper, took the notion that her husband would be eternally lost She could not get rid of that notion for the next six months. 2. Case. A woman, very intelligent and educated, twenty- seven years of age, mother of two children, married for seven years, and always most fortunately situated. Upon the death of one of her friends it occurred to her that she, too, might die sud- denly. By and by her mind was filled with other delusions; for example, that she might not know how to converse in society, that people by looking at her might perceive her perverse thoughts, etc. The upshot was, she never wanted to go into society, to the theater, to church, being kept in anxiety and perturbation because of her delusions. 3. Case. Reported by Esquirol. 1 A girl of eighteen years was in constant morbid fear of having wronged somebody, and never could overcome this thought. Being a bookkeeper she always was afraid of having cheated some one by one of the bills she had written out in the course of business. Later on she had to look time and again over the bills and letters to be sure she had made no mistake or error. At a still later period she was afraid to handle coins, because a part of the metal might stick to her fingers and the coins thus be robbed of a part of their value. She said: "I know my notion is foolish and per- verse, but I can not overcome it." II. COMPULSORY NOTIONS DEFINED. Starting from the above cases, which characterize both the simple compulsory images and compulsory conditions, our first question is : What Are These Compulsory Images Really? The conception is as old as humanity, new is only the name which was coined by the well-known author on psychiatry, Krafft-Ebing, who began first to describe it in 1867. These conditions were treated, previous 1 Ebing, by Fabret, Sr., in 1866, then by Morel, Trelat and 'Traite des maladies mentales, page 331. 270 PASTORAL MEDICINE. others, and finally, more exhaustively, by Legrand du Saulle in a clever monograph entitled, "La folie du doute avec delire de toucher." The various terms chosen by the French for these morbid psychical apparitions, such as maladie du doute, delire partielle, foli avec conscience, delire emotif, show clearly their endeavor to separate these conditions from the mental diseases proper. In Germany a description of compulsory images was fur- nished chiefly by Dr. Krafft-Ebing. His definition fol- lows: "There are numerous persons with a mental or nervous ailing, who complain of not being able to get rid of certain troubling and annoying ideas, although they are perfectly aware of their silliness and impro- priety ; and that those ideas are constantly intruding upon their conscious, logical, associated conception, which cannot be brought to conclusion because of the distur- bance. As a result, these ideas cause the patient to be- come irritated, and to be impelled to corresponding ac- tions which he may find ridiculous or disgusting, accord- ing to their nature." Such notions fixed enduringly upon the conscious mind with morbid intensity are called "com- pulsory images." Krafft-Ebing emphasizes, especially, "that the idea arises, in a state of mental good health, called forth perfectly unsolicited and without provoca- tion, and that it keeps itself before*lhe conscious mind, in spite of the most energetic objection by the will, until it vanishes spontaneously. It should be well noted that these notions are bearing the character of compulsory ideas as long as the sound judgment struggles against them and perceives them as intruding upon the normal flow of the association of ideas." Moreover, these compulsory notions are followed by a lack of desire or inclination ; hence they differ essentially from another only superficially similar disturbance, to COMPULSORY NOTIONS DEFINED. 271 wit, when some single notion sticks to the mind. The characteristics of that disturbance are that some occurred notion, no matter of what description, reasserts itself time and again in the usual course of thoughts. Ordinarily no notion can remain for a long period on the surface of the flow of thoughts unless there are special causes to incite that notion always anew. New impressions and images which are constantly jamming themselves into the con- scious mind obtain the preponderance as soon as the vivid- ness of previous pictures begins to pale. The slower the train of thought progresses the easier will it be for single notions to retain their supremacy. Especially groups of ideas of a rhythmic arrangement, a verse, a melody, may so assert themselves sometimes, that we can not get rid of them, but must invariably return to them, to our discomfiture, till they finally are driven in the background by new events. Again, in our speech or writing there may involuntarily start up certain expres- sions, or figures of words, which we find impossible to avoid, try as we may. In contrast to the compulsory thinking, we many times do not notice such continual repetitions, in case of an idea simply adhering to the mind, until afterwards; it entirely lacks the feeling of compulsion, of being over- whelming despite resistance, no matter how disagreeably we may be affected by the stubbornness of the notions. Dr. Koch reports of two cases. One of a girl seven years old, whose trains of thought for a long time had always been intermingled by the ideas "eternity," "sempiternal," though there was no connection between them and the original thought; another instance that of a woman, hounded by the word "Esslingen." However, these cases should not be classed among compulsory ideas because in both instances there is extant a remembrance of the word 272 PASTORAL MEDICINE. heard or read, moreover the repetitions enter upon con- sciousness only afterward and the feeling of compulsion is lacking. In that case we have to deal with an almost unchanged sediment of prior actual impressions, whereas the subject of a compulsory notion is accidental. Compulsory Notions Defined According to Dr. Westphal and Dr. Krafft-Ebing. Prior to Krafft-Ebing, the alienist Dr. Westphal has applied the term "compulsory notions," in the sense of the former, to such notions "which, leaving the intelli- gence otherwise intact, and without being conditioned by a sentimental-like or affectionate-like state, enter and occupy the foreground of consciousness, against and con- trary to the will of the respective persons; which will not be banished ; which hinder or cross the normal train of thoughts ; which are recognized by the afflicted as being abnormal and foreign to his mind, and which he opposes with his entire consciousness." To Westphal belongs the credit of having discerned the fact that these compulsory notions are apt to appear even without any affective base (without primary melancholy) ; also that they represent a mental disease, which constitutes a class by itself, owing to their continuance, independence and certain character- istics in their course and reactions. In view of the facts of their existence, it is easier to state what compulsory notions are than to state whence they come. Krafft-Ebing says : "The origin of the com- pulsory notions is spontaneous. Either it takes the con- sciousness by sudden surprise or it has been called forth by an external event of shocking influence (murder, ex- ecution of capital punishment, conflagration, suicide of one beloved, etc.). In the former case it can not be formed COMPULSORY NOTIONS DEFINED. 273 in the usual way by association of ideas, but must be awakened and sustained by interior physiological stimula- tions upon the psychical organ. This explains why its contents are foreign to the mind and disturbing the con- scious image ; this explains also its resistance against the associating energy. In their origin they are like prim- ordial deliriums, in contradistinction to notions formed by the psychological process of association and reflection. They are spontaneous and primary creations of a brain abnormally organized or diseased, immediate mechanical productions of the unconscious mental life, the same as are most hallucinations in another field of mental mor- bidities." These compulsory notions find their analogy in physio- logical life in images which interfere with and distract calm thinking, in notions, melodious airs, which do not at all pertain to the subject, which are confound- ing, distracting and irritating, and which can only be banished by dint of a certain exertion of the will-power and by straining the mechanism of association. Later on we shall have an opportunity of pointing out many a cause for the origin and the continuance of the compul- sory notions, but for the sake of completeness Krafft- Ebing's explanation of what causes the compulsory ideas may be quoted here. Krafft-Ebing's definition contains all the marks characteristic of a compulsory notion, with- out making a distinction between notions arising spon- taneously, void of cognizable association and enduring permanently without any basis of affection, and those that have been obtained from a logically proceeding train of thought, and have been retained because of an acci- dental coincidence of their contents with the mood caused by a prevailing element of affections. However, it may- be assumed that both groups may result into com- 274 PASTORAL MEDICINE. pulsory notions, whether generated without any asso- ciation at all, or whether taken from a logical train of thought. Krafft-Ebing's remark, of the person laboring under a compulsory notion being conscious of its ab- surdity and impropriety, ought not to be interpreted that every compulsory notion is in itself absurd, for his con- sciousness of the senseless and silly may refer just as well to notions the contents of which may have originated with his prior images as with notions of a really absurd subject. For example, a person prompted by the ever-returning thought of having left the door ajar, goes every now and then to close the door, or another person is always polish- ing some metal object because the idea "verdigris" is in his mind. These may be just as silly notions as if one labors under the idea of having committed perjury, al- though he never has been in court, or if one would con- tinually ponder, what would be the result if a certain sensational thing would happen to him. III. COMPULSORY NOTIONS CAUSED BY A DIS- TURBANCE IN THE SPHERE OF EMOTION. Under what conditions can these disturbances arise? Sentiments are not decided solely by the course of notions, although the mutual relation of the notions may be able to generate sentiments; the subject of a single notion, too, may be very pleasant, or painful. The senti- ment derives its color from the object of the compulsory notion and the momentary general mood ; the accompany- ing anxiety finds its explanation in the frequent ab- surdity of the notion. Anent the relation of the no- tions, it is known that an undisturbed train of thoughts creates a feeling of gratification and inclination ; likewise it is a matter of experience that obstacles in the organism CAUSE OF COMPULSORY NOTIONS. 275 of mental life, according to the degree of intensity, are ac- companied by a feeling of uneasiness, of depression, and finally one of dread. Should the subject, of the com- pulsory notion by accident, be not an absurd one, then the cause of the annoyance lies in the stopping of the train of thoughts, in the inability to bring the notion to a satisfactory finish, in the want of power to break the com- pulsion. Just as in the physical domain the taking of nourishment awakens different feelings, according to dif- ferent circumstances, so the same is the case with the en- trance of a notion or a group of notions into conscious- ness. If that notion as a whole, is coincident with the notions which are just passing through the mind, then its effect is promoting, while its conspicuity is agreeable. In case of a non-coincidence, however, then one of two things may happen. Are the notions in progress of no particular interest; then it depends upon the subject of the new train whether they evoke a feeling of pleasure or displeasure. The dislodgment of the first notion does not evoke, in itself, a noticeable feeling. Or the notions passing through the conscious mind are commanding the interest of the person. Then the attempt of any other notion to enter into consciousness will be noticed as a dis- turbance, and therefore causes a disagreeable feeling. (This fact must be kept in mind, particularly in the case of compulsory notions of a blasphemous or salacious nature.) This is confirmed by experience. A friend is always welcome under ordinary circumstances, i. e., when the mind is occupied with notions of lesser importance, because by his appearance the train of thoughts relating to his being and doings becomes realized after having previously entered into consciousness without much diffi- culty. On the other hand, the friend may call at an inop- 276 PASTORAL MEDICINE. portune time, i. e., at a time when another powerful mass of notions holds sway in the vicinity of consciousness, so that your ideal train of thought is unable to enter con- sciousness, as may be the case, for example, if there is some important and undeferable work to do. Now the real train of thoughts which intrudes into conscious- ness with the friend's appearance does not meet anything congenial, and hence there is a disturbance and a feeling of annoyance. Naturally, the more disagreeable the in- terrupting notion, the more increased the annoyance. This notion, however, obtains its coloring from the pre- vailing sentiment of mental life. In this respect it is not to be denied, says Krafft- Ebing, that original anomalies in character help to ad- vance one or the other compulsory notion; for instance the brooding over religious questions by the bigoted, thoughts of pollution by hysterically or hypochondriacally inclined, the ruminating whether something has been done right, be in its proper place, by people conspicuous, from their early youth, for their methodical ways and their painful orderliness. As to the subject of compulsory notions it is really surprising how persons of an altogether different position, sex, education, have the same typical notions, and at sim- ilar periods, too. IV. SUBJECTS OF COMPULSORY NOTIONS. According to Westphal, the subject of compulsory no- tions is mostly absurd, without traceable connection with a previous impression, hence incomprehensible for the patient. Yet the compulsory notions are not always ab- surd, as Krafft-Ebing has pointed out; they may con- cern themselves with real, possible dangers, with philo- sophical problems or mathematical questions. Often the SUBJECTS OF COMPULSORY NOTIONS. 277 subject is silly and whimsical. Thus a certain woman, every time she met a person, drew a mental picture of that person placing his head under his arm. Others imagined all the pictures in a room were hanging crooked. A certain priest was perpetually considering what con- fusion it would be if, when in church, he would suddenly have to urinate. Often the subject is dreadful, and for the patient perfectly desperate; for instance if the sight of a knife, a rope, or an open window arouses in them the thought of some deed of violence to a person they love. Especially perturbating are ideas of a blasphemous content, which occasionally are evoked by contrast. Re- ligious souls are gravely tortured by this, especially if blasphemous, unhallowed and salacious thoughts force themselves upon them at pious exercises and holy occa- sions, at Confession and Communion, when looking at an image of the Holy Mother, or of a saint, or at the Cross, when reading religious books, or when seeing a priest, a monk, or a nun, and if they erroneously ascribe the cause for having those thoughts to a secret inner de- pravity. At prayer, for instance, may arise the contrast- ing notion "damned," instead of "hallowed," "hell," in- stead of "heaven," and it may persistently return with every attempt at reading aright the passage of the prayer ; others again, when reading a vile name, labor under the compulsory notion of having applied the same to the divine Saviour, the most blessed Virgin, or a saint. Often the subject is salacious. Thus some people can- not pray in front of an image of the Holy Mother without being tortured by the vilest salacious ideas ; at times the compulsory notions dwell even exclusively on purely sex- ual ground. A certain woman, whenever she went out, was harassed by the idea to evoke immoral thoughts in all 278 PASTORAL MEDICINE. male persons she met ; another woman, onerated and in the period of retrogradation, combined with originally simple sacrilegious thought salacious ideas referring to the divine persons; with other people everything they see, read or hear is made to bear a sexual relation, even the most tri- fling objects. Legrand du Saulle enumerates a large num- ber of relations composing the subject of compulsory no- tions. They relate to God, the divine Mother, to the crea- tion, to nature, the duration of life, to religious exercises, the eternal perdition, the construction of sexual organs, the process of cohabitation, rape, etc. In order to sketch, to some extent, the occasional subject of com- pulsory notions, which will be dwelt upon more fully in a subsequent list of clinical cases, we must mention a sub- ject which forms a link between physiological-psychologi- cal thinking and compulsory thinking, which Dr. Koch ex- emplifies as follows: "Here is classed the, by no means rare, event, when a person thinks that if he should do or omit something, said doing or omission would be of a certain consequence. For instance, one imagines that some evil would be conjured by his stepping upon the joints of the pavement of the sidewalk ; or something will happen if he does not touch a certain house, or a certain tree, at a certain spot ; or that he will die if he does not walk ten steps on a certain lawn; or that something dreadful would be in store for him if he did not count until 100 ere he met somebody on the street; or if he would not hold his breath till he has reached a certain spot. An otherwise bright young man was always tor- tured by the thought that he would commit a grave sin by not finishing a certain prayer before the clock had ceased to strike." The subject of compulsory notions is of a proteus-like variety. They are of an especially fatal effect when they SUBJECTS OF COMPULSORY NOTIONS. 279 refer to religious or moral topics. Especially sexual, re- ligious, blasphemous, homicidal and suicidal compulsory notions are important for their identification and correct judgment. Compulsory notions of sexual or blasphemous contents have been dealt with above. Here are some more clinical cases : Mrs. W., thirty-one years old; her mother suffered from nervous disease. Unhappily married eleven years; never had a child. The husband has squandered her estate. She brooded over it; was suffering a few months since from insomnia, lack of appetite, heart-throbbing, precordial pressure, paralgies in the region of the heart, faintness and weakness. One evening, while praying the Our Father, she was besieged by blasphemous thoughts ("Ass that thou art;" curse words instead of "holy Mother"). She was greatly annoyed and tried to get over these vile thoughts by praying, but it only aggravated matters. She suffered from permanent insomnia; became despondent; she felt as if her heart had changed to a stone; became restless, and was looking in vain for consolation, first by going to the priest, then to a physician. Finally, the mere sight of a holy picture sufficed to evoke sacrilegious notions. She anxiously avoided praying. Patient proved to be intelligent, neurasthenic, somewhat hysteric, very anaemic. Is thoroughly aware of her morbid condition. Beyond traces of psychical anaesthesia, she displays nothing in the sense of melancholy. The beginning of her menstruation is accompanied by headache; at that period her perturbed state is temporarily interrupted. Was admitted on February 20 to the clinic; was able to occupy herself with religious subjects again early in March; left the treatment on March 10, feeling well, and has since seemingly remained in good health. Compulsory notions of a sexual subject occur particu- larly frequently to persons who constitutionally incline to neurasthenia, and where neurosis has been caused to break out by masturbation. Krafft-Ebing says: "The appearance of compulsory notions of an erotic nature, while not rare, is only secondary in view of the multitude of other notions not touching upon the sexual sphere. In other cases where not directly due to menstrual processes, 2 8o PASTORAL MEDICINE. or temporary sexual excitement, sexual compulsory no- tions, though stable, are isolated instances. Krafft-Ebing, however, mentions a case of neurasthenia sexualis with compulsory notion, which case is most important for gauging similar cases in real life; for, as Krafft-Ebing points out, these conditions of psycho-sexual erethism, combined with erotic compulsory notions, may be mis- taken on superficial observation for chronic nymphomania. The patient is conscious of the morbidity of these condi- tions, and is most painfully annoyed by the sexual erethism. Case I. Mr. A., thirty-five years of age; business man, of onerated family. Sexual life commenced with seventeen years. Masturbated, without being seduced, but not to excess. Under close surveillance at home, and educated in extreme moral views to prudishness, he, mostly from bashfulness, abstained from intimate intercourse with women, masturbating instead with aid of obscene pictures. . . . Unhappy marriage and separation. He returned to psychical masturbation, suffered from successive pollutions and from neurasthenic troubles; after they continued for one and one-half years he fell a victim to compulsory notions. He developed a morbid sense of order. He could not stand it if books or utensils did not lie in a certain way; he was continually afraid to make a mistake in his bookkeeping and was compelled to figure unceasingly. He was constantly ascertaining whether the door was closed; whether his trousers were buttoned up, etc. After some weeks the compulsory notions assumed an almost exclusively sexual direction. Whatever he saw, even the most indifferent thing, made him think of sexual relations. Although without any libido, and although the situations disgusted him, he had to go through them ad nauseam. In vain did he seek refuge in solitude and in diligent work. Pressure in the head, disturbance of his thinking faculties, irritability and anxiety were ever on the increase. He felt nervously excited, suffered from frequent heart-throbbing; had difficulty in falling asleep because of a deluge of salacious thoughts, and dreamed invariably of lascivious situations. . . . Skull normal. No sign of degeneration. Nutrition reduced. . . . An ex- planation of his case to him, together with mental treatment, SUBJECTS OF COMPULSORY NOTIONS. 281 a mild cold-water cure, preparations of bromo, especially natrium bromatum, camphor monobramata, brought about a noticeable amelioration in a few weeks; it took, however, five months of quiet country life, with treatment in accordance! to free the patient of his compulsory notions. Years thereafter I met patient again. He was in good health, save some light neurasthenic troubles. His vita sexualis was at rest. Case 2.M., twenty-seven years of age, sewing girl ; never had known her parents; ... led a quiet and solitary life; never patronized dancing places ; badly nourished ; lost flesh ; presented symptoms of neurasthenia cerebro-spinalis after a quite severe rheumatism accompanied, eventually, by chorea. Two years ago became, without cause, afflicted with erotic excitations, which tortured her day and night. Nocturnal pollutions. In daytime she could think of nothing but of all that might happen between man and woman, which caused her much distress and fear of losing her reason. She had to draw a mental picture of situa- tions although it was nauseating to her. Her free thinking was increasingly disturbed. Whenever she read something, or looked at something, she had to associate it with salacious ideas; the same happened when she beheld men. Attempts at diverting her mind by serious reading and hard work not only failed, but ag- gravated matters. Neurasthenic troubles were also on the in- crease. Headache, irritation of the spine and the spinal marrow, restless sleep, heart-throb, etc. Ailment moved in remissions and exacerbations. Very rarely an intermission of a few days oc- curred, when patient felt as if relieved from a great weight. Ap- peared to be a most decent person, and admitted, under tears, of having masturbated now and then within the last month when tortured by erethismus genitalis, thereby increasing, however, her troubles, both physically and mentally. . . . Day and night she claimed to be tortured by filthy thoughts, always imagining being raped. Her condition often makes her raving, when she would like to tear off her clothes. She also says to be contem- plating suicide. She can not understand why she should suffer so, inasmuch as she never had been sensual, and had been leading a quiet and respectable life. Examination of the body shows de- creased nutrition, anemia, sensitiveness of the spine to pressure, patellar reflection much heightened. Bromo, antipyrin, natr. nitricum, camphor monobromatic, codein, produced temporary relief. PASTORAL MEDICINE. Homicidal and Suicidal Notions by Compulsion. Suicide notions may be awakened by contrast, like a bolt out of the blue sky, or they are called forth in imita- tion, or by a sense of disinclination arising from a bodily ill-feeling. Not infrequently these ideas force them- selves upon persons that never have felt tired of life, and whose entire disposition has been averse to such thoughts, hence an increased torture is caused thereby. The homicidal ideas are not seldom directed against the most beloved kin. A frequent cause for such thought is, according to Krafft-Ebing, the reading of murder and of sensational suicide, whereof a yellow press furnishes painstaking and graphic accounts, giving the most minute particulars of the accident, or crime, possibly with pho- tographs or drawings. The existence of such thought may cause the greatest compunction, especially to the re- ligiously inclined, Anxiety Caused by Compulsory Notions. Heretofore we have looked upon these notions more in the light of primary delirium, and we endeavored to arrive at an understanding of the psychical process, to the extent that it is conditioned by anomalous association and combination, or by a morbid mood. The strain by these compulsory notions upon the cerebral centre is so intense and lasting that other cerebral centres must become neces- sarily irradiated. The advent of the compulsory notion is followed at first by unrest and irritation, then by a feel- ing of discomfort and oppression. They increase to out- ward unrest and a feeling of dread, both of which may be transformed, by and by or suddenly, into a condition of violent, motoric agitation and of intense mental anxiety. THE MANIA OF DOUBTING 283 This feeling of anxiety is particularly favorable for a frequent return of the notions, until ultimately the entire mental life becomes governed by the morbid condition. In science these compulsory notions, as caused by neurasthe- nic anxieties, are classed together under the term "pho- bies." It may happen that a patient be finally in fear of the fear. These conditions, which are only troublesome be- cause of the indistinctness of the anxious feeling, are of no particular interest for the priest in his work; hence we turn to those conditions where clear notions, coupled with an anxious feeling, are influencing and disturbing mental life. Hereto pertain first of all The Mania of Doubting and Brooding. The mania to doubt is formed by compulsory notions, and may or may not be accompanied by an anxious feeling. In the former category we have the timid and the scru- pulous. The doubting mania develops slowly, often al- ready in childhood. The patients constantly have ex- treme misgivings; they take things too seriously and view everything from the gloomy side. This malady is, however, but one of a thousand manifestations of mental oneration. Hereditary inclination to mental disease plays here an overwhelming, governing, part. Often the malady remains unnoticed for a long time. At first the mania con- sists of exaggerated criticalness and childish timidity. The patient is not sure of himself ; he is afraid of making mistakes, of committing errors; he feels constrained to review even his most trifling actions over and over again, and to make the most careful dispositions. Here, too, the patient is fully cognizant of his condition. According to Krafft-Ebing the doubting mania is formed by notions that are produced not by any asso- 2 3 4 PASTORAL MEDICINE. ciation of ideas, but by a physiological process, by internal and direct irritations of the cerebral organs of imagina- tion, For example, a clerk who hitherto has done his figur- ing without any difficulty may, from overwork, succumb to the compulsory notion of not having added correctly the figures before him. Thereupon he finds himself immedi- ately under the compulsory incentive to test the accuracy of his addition. That this is not a simple case of an un- certainty as to the sum, easy of explanation, may be de- duced from the inexplicable anxiety accompanying the notion and also because the second addition, although agreeing with the first, fails to satisfy him entirely. He has become a victim of compulsory doubts. The same applies to the well-known oddities of some people, who never cease looking whether the doors are properly locked, the light really turned off; whether the letters have not been put in the wrong envelopes ; whether some one has not secreted himself behind the stove, under the bed or in the wardrobe. This compulsory doubting or brooding may concern indifferent, even silly or whimsical objects, but also very reasonable things, often philosophi- cal and religious questions and problems. The train of thoughts which rules the patient obtains its direction from his degree of education and from his social position. These forms of compulsory thinking are particularly torturing and perplexing for those religiously inclined, if they begin to affect questions of religious or moral order. Hereto be- longs the entire group of scrupulous people who con- stantly are scrutinizing all they think, speak or do, and who imagine a possible careless performance of a deed, or its omission, to have the most absurd consequences. Such morbid doubtfulness may have an oppressing, discouraging and depressing effect upon a timid priest, should this notion creep into his performance of holy THE MANIA OF DOUBTING. 285 functions, taking the shape of compulsory verification and recapitulation, in pronouncing certain words and for- mulas, for instance when reciting the words of absolution and consecration. In such cases matters are aggravated by the fear to jeopardize the essential value of the function by a violation of certain clear and binding regulations. Thus it may happen that the "ego," having lost all firm support, becomes swallowed up in doubt. This brood- ing and doubting generates that morbid precision which the patient uses as a staff to steady him on the shaking soil. Constant recapitulation of the daily office, growing desire for delay of the same and finally giving it up en- tirely, is not rarely the sad upshot of a like condition. To many a priest the celebration of holy Mass is most painful because he once made a mistake, and he is constantly afraid of making it over and over again, and therefore dreads the reading of the Mass because of that thought. Again, the always recurring thought, whether he had been possessed of the earnest intention to act in the sense of the Church, may transform for a clergyman the sim- plest priestly act into martyrdom. The late Ballerini used to place these timid priests in three classes: I. Mementistae, who can not get time enough to think of all the people they intend to pray for. 2. Consecristae, who are in steady fear of not having uttered the words of consecration clearly enough and pointedly enough, who therein are careful to excess. At times some suffer on that account from real fright, heart- throbs and trembling. 3. Fragmentistae, who scrape and rub, against all rhyme and reason, until not only pos- sible particles, but also the least of the numerous specks of dust, caused by their own silly manipulation, has been removed. Hereto may be added the Intentionistae, who are in difficulties because of intentio consecrandi et ap- 286 PASTORAL MEDICINE. plicandi, and the Rubricistae, who are troubled with all kinds of misgivings about the rubrics, especially about the Actio. What priest has not had experiences with penitents who are constantly afraid of not having been truthful, of having forgotten something, of not having stated suffi- ciently number and circumstances, and, finally, of not having been penitent enough ; or, after receiving the holy Eucharist, of having partaken thereof in unworthiness. Others, again, are in doubt whether they have given cor- rect evidence in court, whether they have paid a debt, ful- filled a promise, written a letter properly, or that they have said something offensive, etc. A certain judge was constantly haunted by fear of some warrant not having been revoked, by oversight ; hence time and again he had to make sure whether the prisoner had been really dis- charged. These unfortunates are aware of the silliness of their doings ; they do their best to free themselves of these troublesome intruders of the compulsory ideas; they ac- knowledge that they owe unconditional obedience to their adviser particularly where religious matters are concerned, but the one and prime idea, is, after all, that something most important might be the matter, the whole reputation may depend on it ultimately, it might be wrong after all and jeopardize salvation! This idea is more powerful than all reasonable considerations, teachings and admoni- tions. Those religiously inclined feel constrained to ac- cuse themselves because of the points in doubt ; they ask for advice, only to doubt again and more than ever. V. VARIOUS COMPULSORY CONDITIONS. The multitude of different notions filling the mind of those afflicted with the brooding and doubting mania is VARIOUS COMPULSORY CONDITIONS. 287 shown by the following classification by Ball: i. The philosophers, who occupy themselves with the great meta- physical problems and are always brooding over the con- ception of deity, universe, creation, etc. 2. The realists, who think more or less of trivial things. A certain speci- men of this type was seriously occupied with the question, Why is the stove near the wall and not in the middle of the room ? Then we have (3) the scrupulous, who are always reproaching themselves, no matter what they have done. 4. The timid, always afraid of having blundered, and (5) the morbid mathematicians, who never cease figuring, who pay attention to nothing, are interested in nothing, but the number of objects, no matter what they are. It happened with one of these counting fiends that he even kept tab of the number of sentences which he used when speaking on some subject ; others, when entering a room, count the pictures on the wall or the books on the shelves. These few examples are sufficient to show how far these compulsory ideas may go. The brooding mania appears at times in aggravated form when the intruding ideas strike the mind in the shape of useless inquiries. This kind of mental rumination may be directed either to indifferent themes or most important ones. Dr. Koch mentions the case of an educated person who constantly pondered over the following question: "The equivalent for our apple is, in Italy, the orange ; for our pear, the fig ; for our quince, the lemon ; but what is the equivalent for our prune?" Auto-mechanically, like an endless screw, a morbid motive forces itself into the thinking process by connecting and transforming all conceived notions and thoughts into interrogatory sentences. In dismal monotony questions are obtruding them- selves such as: What is God? Is there a God? What is eternity? Why does the devil exist? How was the world s88 PASTORAL MEDICINE. made ? Why am I here ? Why do people exist ? Why is there but one sun ?, etc. As we have seen above, the simple compulsory thinking may by degrees be developed into compulsory conditions, manifesting themselves in "compulsory feelings, in com- pulsory fears." The thought of having injured the life or the health of other people by dropping a match, a pin, a piece of broken glass, or by making an inkstain, compels a picture of the most absurd consequences. For example, a person was stricken with the compulsory fear of getting diarrhoea every time she would attend Mass; the upshot was that she finally stayed away from church altogether. A priest had the compulsory fear of robbing his fellow priest who paid him a visit. A man, when walking in the street was fearful to step on a child. To ward off this thought he counted: Don't crush one child, don't crush two children, etc. A case where compulsory brood- ing, mostly over religious questions, is followed by the compulsory notion of pollution by metals or animals, is, according to Krafft-Ebing, a special morbidity within the whole group of compulsory notion, but we enumerate it here for the sake of completeness and because it is proven by experience, that doubting mania and the fear of touch- ing metals, etc., may develop jointly. To the doubting mania, the folie du doute, corresponds in the emotional mania the folie de toucher. Although in the possession of his reason and clearly aware of the silliness and the mor- bidity of his fear, the patient, nevertheless, declares to be afraid of touching a coin, a doorknob, etc., because it may be poisoned or he may thereby injure his own health or that of some one else. The alienist Falret states that the variety of fears, brought to light every moment by morbid notions, is beyond any estimate. Dr. Morel tells of a sexton who for twenty-five years CAUSES OF COMPULSORY CONDITIONS.***) was afraid of touching his staff; an appellate judge, who never entered a room except with one hand in the pocket of his coat, who never suffered any one to enter his room but received his visitors in the corridor, and who never crossed the streets except on tiptoes. Some people think of hydrophobia when beholding a cat or dog; others must think of verdigris when looking at a copper vessel or a metal doorknob. The patients consider these ideas very stupid, but are unable to free themselves of the com- pulsion. Compulsorily they employ measures for pre- caution or safety that are most troublesome. A certain woman had to wash her hands more than 200 times a day. Others are continually dusting the furniture or disinfect- ing the rooms. Finally we must mention the dread of some particular place, more or less a consequence of an abnormal mental condition caused by compulsory ideas. Although the outer senses are engaged, yet the whole pro- cess is nothing but the creation of an overirritated imag- ination. Inasmuch as the mind is dependent on the offer- ings of imagination, it is inevitable that the awful subject of the thoughts evokes the feeling of fear. Thus the fol- lowing thought may occur to a person about to enter, for instance, an open square : Now I shall have an accident, I shall faint. The patient is conscious of the silliness of this fear, he tries to be reasonable, to banish his fear, all in vain. His case is like that of a person suffering from vertigo. No matter how often he may reason here is no ground for any fear, the fear remains in effect ; notwith- standing the bidding of his will, the giddy must submit to the feeling although he pronounces it to be false. VI. CAUSES OF COMPULSORY CONDITIONS. One of the main causes for the generation and continu- ance of the compulsory ideas and for their repeated re- PASTORAL MEDICINE. turn is the morbid accentuating of feeling. The reason why that mood exists lies principally in the egotism of a person, because he pays undue attention to a thought or train of thoughts which touch upon his sphere of interest ; this explains also why the compulsory notions derive their color from the position, the education, the sentiment of the patients ; this explains why the subject of the com- pulsory notion is proteus-like diversified. The feeling of anxiety, which accompanies the compulsory notion be- comes intensified by organic anomalies or by an abnormal disposition of character. These compulsory conditions, which for the most part develop on neurasthenic soil, hence may be called Neuropsychose, are favored by the morbid impressionability common to neurasthenia, the re- duced thinking power and will power, which renders it difficult to fight the compulsory idea by means of sponta- neously called forth, liberating ideas, by associating them ; the compulsory notion dealing with the welfare or the evil of one's self or of others is promoted by vivid emotions ; if of an organic case it is enhanced by physical sensations. But in particular it is the fear that the compulsory no- tions may compel the patient to do something which may compromise him, hold him up to ridicule or even incrim- inate him, it is that fear, keeping him in a permanent con- dition of emotional irritation, which is thwarting the cure of his nervous debility. This fear is essentially furthered by the simultaneous decrease of capability and power of resistance incidental to neurasthenia. Dr. Kaan points to a similar apparition in animal life, the shyness and faint-heartedness of horses. If the horse fails to move the wagon on his first efforts, it begins to tremble, to snort, and does not respond to the whip. The failure of the very first effort suffices for some horses to behave that way, CAUSES OF COMPULSORY CONDITIONS.agi others only after several trials. In the same manner does a person, aware of his lessened capability, become faint- hearted ; this result is the same whether he has been con- vinced of his inability, or lessened ability, through a real failure or only on account of his depressed mood. The compulsory notion to verify, to -constantly scruti- nize, every act, deemed, perhaps rightly, of importance, as may be the case with judges, priests, etc., is caused by a feeling of lessened energy, combined with a distrust of his memory on part of the neurasthenics. The repro- ducing power of the memory being weakened, it does not readily answer all doubts and misgivings, hence the anxious doubts are exacerbated. Worst of all if the neu- rasthenic has actually had occasion to satisfy himself of the untrustworthiness of his memory; in that case he never eases his mind, even after his hardest thinking has failed to reveal an offense which may account for his troubled conscience. The precordial pressure, a frequent symptom of neurasthenia, continues to prevail ; memory, which lied once may lie again. Herefrom develop the im- pulses to verify. One example by Dr. Kaan: The cor- responding clerk of a large business house, who had neu- rasthenia from overwork, once caught himself writing a wrong figure ; henceforth he re-read every letter innumer- able times before posting it ; but this failed to quiet him. He reviews his day's work, the least little instance which he can not exactly recall assumes in his apprehensive imagination proportions of most terrible neglect of duties, which he can not recall to his mind. Finally he spends his whole leisure time examining his conscience in this manner. A certain priest in saying his office had always to think of the said prayers, if he succeeded in remember- ing every part of them then he would continue praying, 292 PASTORAL MEDICINE. if not he would repeat. Here was present the impulse to repeat also when doing his other priestly work. To retain a prayer in his memory he hit upon the most whimsical expedients. So he imagined the words of the absolution to be printed with golden letters and grouped now in this now in another order ; he painstakingly marked the single psalms in his breviary, or he placed a certain article on a particular spot after having read a portion of his prayer. These few examples will show sufficiently how compul- sory notions are furthered by neurasthenic conditions. The more these compulsory notions, morbid fears, rule the patient's inner life, the more does his outward life present itself as a chain of morbid compulsory acts in- tended for the greater part as defense, but also as a safety means. First of all these patients, afraid of the fear, avoid any situation apt to bring those dreaded im- pulses to their attention, the pious refrain from devo- tions, the suicide candidate shuns the sight of weapons; the woman afflicted with compulsory erotic thoughts anxiously avoids being left alone with a man ; those afraid of making themselves ridiculous in society become misanthropical hermits, and finally he who thinks him- self capable of incriminating himself by writing, will be- come frightened by the sight of a piece of paper. Those afflicted with compulsory notions are prone to devise all sorts of ways and means to banish the thought. Thus a woman patient could get rid of her ideas by putting them down on paper ; it quieted her. Another patient went through certain motions with his head or with his hands or feet; another counted up to a certain number, or walked for a certain number of steps, or put his hand on a certain object a given number of times. A girl escaped her blasphemous thoughts by ex- claiming: I don't want to. A gentleman, in order to rid CAUSES OF COMPULSORY CONDITIONS.2 93 himself of blasphemous thoughts, wrote and then read innumerable times : I won't commit a mortal sin, cursed be those thoughts. A patient afflicted with blasphemous thoughts about the mother of the Lord, succeeded in banishing them by ex- claiming: Our beloved Lady of Victory at Paris, whereby the word Paris appeared to him as his salvation. A young man used to expectorate before partaking of Holy Communion in order to banish the thought of having broken his fast. These compulsory acts directed against, and emanating from, compulsory notions are on a par with compulsory omissions, refraining to read certain books, to open a letter, etc. The following interesting case may serve as an analysis of the entire morbid process. An art student, twenty-one years old, gravely onerated, ascribed a saving influence to certain words. To conjure a mis- fortune he said the words: grave, shroud, bier, etc. Not being different in acts and customs from other people he used to be in company with friends. One day they spoke jestingly about the number 13. At once the following idea passed through his mind: if 13 be really an ominous number, then it is a pity that God has created 13, that there is a period of 13 years, that there was a 13 in the beginning, and that 13 will remain in eternity. Very well, then. At the beginning 13, at the end 13, and 13 in eternity. Why shirk misfortune? He mentally formed the formula: "God 13, at the beginning 13, in eternity 13." This idea rules him, He repeats his formula every minute, hence can not think of anything else. For a brief time his formulas satisfied him, but only too soon had he to look for new conjura- tions. Sometimes he touched his dressing-case 13 times in suc- cession before going to bed, or 13 different things that were scat- tered in his room. By and by he executed these 13 touches several times in succession; ultimately he staid awake all night, running around in his room and touching things 13 times. Henceforth 13 is foremost in his thoughts. He never uses 13 words in a sentence. Has he written twelve words without finishing the sentence, then he adds at least two more words, lest the 13 would beget some misfortune. The same when he talks. In 294 PASTORAL MEDICINE. order to avoid sentences with 13 words he counts them. The following is taken from a memorandum by him : " Unable to overcome this notion by reason I make use of the number 13. Speaking unto myself, as if the world were mine, I said one evening: If I should do between to-day and to-morrow a single superstitious thing, then all stars which I behold shall be 13. At the same time I imagined all stars above my head to be transformed in the number 13, composed of innumerable particles, of which the essence was 13. I did not quite under- stand the meaning of a star 13, but I was so afraid of the 13 that I did not perform any silly acts until the other morning. The process having been successful I abused it. 'God be 13 if I do something superstitious' another time. " The notion of God 13 was not any more sensible than the notions of the stars being in their essence 13. However, sense or nonsense, I did not object. The notion of God kept me in awe which sufficed for a time to prevent my doing foolish acts." Not less queer are the means used against erotic com- pulsory ideas. A gentleman tried to correct them by counter thoughts ; he took pains to picture women to him- self as skeletons and their limbs as burned and charred. He knew very well that these means would not help, being against all reason, and the ultimate failure aggravated matters. Even in case of success, the patient gets fagged out in the degree of the expended resistance. Finally he resists no longer, he loses all his will power as against the compulsory notions, hence always the same senseless act over and over again. It is easily perceived how this peremptory compulsion tires out the mind. Bad enough to be hounded by a com- pulsory idea for a few days only, but what an unbearable burden to serve for years as football to such a tyrannical influence. A failure of these defensive efforts will exer- cise a particular hurtful and depressing effect upon a very religious and morally pure soul. By the fear of such blasphemous ideas taking root in the mind they are CLINICAL CASES. 295 involuntarily called into consciousness ; the upshot of that one blasphemous thought being that all objects, asso- ciated with the idea (the image of a saint, etc.), tend to reproduce the fear and with it the thought. The circle becomes larger and larger. The religiously inclined will fail like him who looks at the sun intensively. Over- straining his eyes he will see black spots for some time. To such spots may be likened the blasphemous or sala- cious thoughts. The more one cares for his salvation, the more horrified he is by an unclean thought or impulse. While the indifferent soon dismisses these thoughts, the overzealous Christian will concentrate his whole energy to fight and suppress them; but it has just the op- posite effect. His resistance against intercurring asso- ciation, and to even a greater extent his self-confidence, has been shaken by sexual neurasthenia, he enters into the fray with hesitation, his precordial pressure makes him, from the start, despair of an ultimate victory. The simple and compound notions, this conglomeration of compulsory sentiments, affections and impulses, with corresponding acts, afford a view into mental conditions that are surprising, and more prevalent than many would believe. It is of vital interest, not only for the priest, but also for the layman, to find an explanation for these con- ditions and to overcome the alarm resulting therefrom. VII. GENERAL VIEW OF COMPULSORY NOTIONS AND CONDITIONS. CLINICAL CASES. In order to gain a general view of shape, substance, development and last stage of compulsory notions and conditions, and in order to gain a basis for practical de- duction at the same time, some additional clinical cases 296 PASTORAL MEDICINE. may be enumerated, wherein are crowded together all their symptoms to an extent that it would look as if these "cases" had been especially constructed. Yet it must be admitted that these symptoms may well be found on one and the same person, as we have seen already. A ten-year-old girl, about to make a pilgrimage, was afraid she would forget to state a certain sin at Confession. To calm herself, she endeavored to memorize her sins in certain order and repeated them time and again in her mind. She went to Confession greatly perturbed and was even more excited there- after. She never could rid herself of the thought of having con- cealed, accidentally or even purposely, a sin, although both her memory and her conscience told her otherwise. She was aware of the silliness of her fear, yet she could not free herself of it, nor overcome her doubt. Patient describes her condition thus : " I went, after Confession, to Holy Communion in a state of the most awful perturbation. When the priest offered me the holy Host, the idea struck me, I should have to bite into the Host. After closing my mouth I really thought I had bitten the Host in two. I did not dare open my lips for fear I might spit out one of the parts. My perturbation was intensified by my thinking of having perhaps done all that on purpose, of having wilfully harbored these thoughts. I experienced the most terrible mortal anguish. The horrible thought of having com- mitted a sacrilege, on purpose at that, occupied my whole mind. To get rid of that thought and to find consolation, I analyzed my whole action, I pondered over it, but a moment of peace had hardly arrived when the thought recurred with renewed force : Thou hast committed a sacrilege. This train of thought per- secuted me stubbornly until I was fifteen, notwithstanding that I realized its absurdity at times it tortures me even now. This persistent and horrifying idea is sure to come back to me every time I go to Confession and Communion. Other persons, too, may become afflicted with kindred ideas upon receiving the holy sacraments, but theirs certainly do not adhere to conscious- ness with such persistency. I don't dare to read the examination of conscience in a prayer book, lest I might think of having com- mitted all the sins enumerated therein. At Confession I suffer mortal pain. Every time I answer the priest's question I must think: Now this was wrong, I denied instead of affirming; what CLINICAL CASES. 297 I said wasn't right. My scruples almost kill me. Although the priest assured me that I did say yes, I still kept on doubting that he might have misunderstood my no for yes. " At the same time I was worried with solving some questions, which took a hold on me with great intensity and persistence. How is it possible for a deceased to reach the other world? How did the world spring into existence? What is eternity? How did I spring into existence? The Scriptures would not suffice me. I pondered for years over these questions that kept worrying me. Even if I did succeed in forgetting them for a day, they were sure to return. Then my brain would surprise me all at once with angry thoughts, even calling God names, so that I acted as if in despair. I beat my head, butted it against the wall, I raised my hands, crying out, No, no, I did not want to say that I did everything to banish the thought, but what a vain effort! When writing a letter I feared of having written down some nonsense, of having made mistakes in spelling or in punctuation. Hence I would start the same letter over again, each time with other sentences, other words, and thus could never come to a fin- ish. Having quieted down I re-read the letter as I had written it first, and found it to be free of any mistakes. But as soon as I had mailed that letter, then my doubts came back to me again. Have I penned all I intended to write, would the letter be intelligible? All these queer thoughts attained a certain degree of force, and then would vanish. However, they kept me in a constant par- oxysm. " At our farm there is a chest containing cruets with altar wine, used in the adjoining chapel. I always passed that chest in a roundabout way, fearing to soil the cruets. To take some linen out of the same chest is beyond me; I might soil the linen and thereby the cruets. Motionless I remain seated in my room for hours, stiff and motionless like a statue, afraid of touching any- thing. When walking on the street I am hounded by the idea a brick may fall down from the roof and kill me. I therefore often walk in the middle of the street, or changing from right to left side, always in the greatest excitement. Once at Holy Communion I had the impression that the Host were lying on the floor and that I were to step on it with force. The most annoying job for me is to go shopping; when paying I have to count and re- count the money, to ask repeatedly, is this a dime? Is it perhaps a counterfeit? Having closed the door of the store behind me, then I again imagine of having paid too little. I go back and lay 298 PASTORAL MEDICINE. quickly down on the counter some coins to ease my conscience. My doubting was steadily gaining ground; it followed in the wake of almost every act. Once when, after the prevailing fash- ion, I wore a dress with a train, I was afraid somebody might stumble over my train, break his legs or receive fatal injury; my vanity would make me a criminal. I could not bear it any longer, so I took off that dress. The most dreadful thing for me was to wear a new dress. I would not wear it in the street lest I might soil it by brushing against something. When crossing a bridge I would keep in. the middle, fearing of otherwise pushing some one into the river. When doing kitchenwork, or when I had to shake hands with a visitor (which I always liked to avoid), then I thought my hands were soiled and dirty, and I would wash them for hours. I knew it was absurd, yet I could not turn from the wash basin. When the lights were lit I was afraid they would put my dress afire. In such a state it often seemed to me I must set my dress afire, that I may ascertain with my own eyes that something is afire and so gain peace. I can't explain this interior compulsion, this magic force. I'm very much afraid that some time it will control me to such an extent as to make me cause a great misfortune." Krafft-Ebing continues : " When I explained to her that the imagination was no fault of her own, but caused by compulsory notions and by compulsory actions, hence a pathological condi- tion, she could not find enough words to thank me. Almost always she knows in advance when a paroxysm is coming. Her mental agony is greatest when her bodily condition is not har- monious, when some parts of her body are aching. The par- oxysm is introduced by violent choking and strangulation, by an intensive strain of different muscles, a burning sensation at the crown of the head, a lasting sensation of the brain being frozen and becoming petrified. All these sensations favor the ad- vent of compulsory notions. When traveling or when in agree- able company, however, she gets a relative rest, then she has a feeling as if everything disagreeable had been removed from her brain; then she can calmly reflect on her queer condition. She is kept conscious, however, to be on her guard, for the terrible doubt and a chorus of the most horrible compulsory notions are ever lurking and lying in ambush. Patient is of intelligent appear- ance; her eyes are neuropathic. But for a certain nervous rest- lessness and awkwardness in the intercourse with others, there CLINICAL CASES. 299 is nothing to betray her grave malady. Her psychical and neuro- pathic ailments were considerably lessened after cold ablutions and bromide of potassium 3-4.0 a day. "The anamnesis being of high importance in a case of this kind, it may be added that the patient's father had always been in good health. The oldest son of his brother, however, had been a lunatic, a second son had died in an insane asylum, a son of this latter being affected with a brain trouble at the present time; the son of another brother was in an asylum because of paralysis; the patient's mother and her mother's two brothers and a sister are suffering from Tic convulsif. Patient has two brothers, both likewise ab- normal, and a sister who presents the second case, upon which we shall here dwell for the sake of a more thorough under- standing. Miss M. N., thirty-six years of age, states she has never been normal since her earliest youth; was tortured by most baneful doubts, especially on religious subjects, even when a child. " I dare say, doubt and anxious scrupulosity were growing apace with myself." She remembers of having been in constant doubt, even at the early age of ten, whether or not that what she had thought or said had not been in the nature of a sin. Frightened by the doubts which she never could banish, she wrote her thoughts down upon slips of paper, which she conveyed to her mother, with the request, to ascertain whether or not these thoughts contained anything sinful, her sister acting as go- between. Her doubts were mostly on religious topics. "Often I was harassed by this question': If I had the alternative to com- mit a sin or to go to prison, which would I choose? Thereupon if I would decide, for the sake of life, for the former, then the idea would at once strike me: Thou hast mentally committed a grave sin. This made me excited. I wrung my hands and cried out loud, No, no, I dare not do it, nor will I do it. At church I am afraid of not being attentive enough thinking of having pur- posely taken my eyes off the priest, and looked upon other people in order to disturb them in their worship, and thus give public offense in the church." When occupied with the most simple and ordinary work of every-day life, patient is in doubt whether or not she has done something sinful or whether or not she should cease to do certain work for the sake of religion. " Now, when this doubt on certain days is growing exuberantly, then I PASTORAL MEDIC/ME. CLINICAL CASES. 301 cry out, No! No! I am not afraid, I don't want to be afraid! When copying, or when paying a bill, she was constantly in doubt. " My hardest task is to pass over a threshold I always think to commit a sin thereby. I often remain standing in front of it, as if under a spell. I exert myself to step across (fast moving her lips, talking to herself) ; finally I step across, although in greatest excitement and anxiety. Many times I can only do it if one of my folks takes my hand and draws me across." She anxiously avoids to put her foot upon the joints of the floor; there might be evil thoughts therein. Her fear of fire is indescribable. After putting out the lamp in her room at night, she must make sure, time and again, whether the light has been extinguished. She is ever in fear of becoming asphyxiated through her own carelessness, although she fails to see any- thing burning or glowing. In church she is struck by the sudden idea, not to have behaved decently; of having seduced others by a glance or certain motions, to disbelieve God's Word that just has been preached from the pulpit. Everywhere in her life she is confronted by scruples, dangers, fears and obstacles. " How happy, on the contrary, are other people ! How must I be afraid to be thought crazy ! Why is it that just I am incapable to quiet myself, to think and feel like other people? The paroxysms last from one to twelve hours and are preceded by an aching of all nerves. Remissions are most pronounced when she travels, or, at times, when she is much occupied or when attending parties. Invariably she never feels better than on the first day of menstruation. Patient is intelligent and educated. No indi- cations of masturbating (neither in her sister). She sleeps well but has little appetite. Iron bromide of potassium 4.0, and cold rubbings brought relief. In winter, however, nutrition decreases, the sanguification deteriorates, whereupon nervous troubles and compulsory notions recur again. M. N. does not possess a system- building "mania"; her morbid thoughts have not altered her relations to her family and society; she is a judicious person, capable of plying her vocation and to be conscious of the mor- bidity of her compulsory thoughts. Hence we have all the significant tokens combined of the ailment called compulsory notion. Patient, conscious of her morbid ideas, endeavors to struggle against them with all her powers; she is her own e cellent observer and draws a minute and precise picture of her mental agony, as most of these unfortunates do. 302 PASTORAL MEDICINE. From this general depiction of compulsory notions, and resulting compulsory conditions, it becomes clear that it is irrelevant in what shape these thoughts appear, what course they take ; whether the patient must constantly ask himself : why does the earth revolve ? or whether he must picture to himself a fact, e. g., the unexpected death of a child, or a man who hung himself by the neck and of whom he was told, or an obscene process ; or whether the notion is followed by the corresponding act, like the pa- tient who had to read from right to left all the signs he saw, or like the woman who had to pronounce a certain number before she could do even the most trifling thing. In every case the brain labors under a compulsion. If the subject of the notion is indifferent, then the notion is apt to be considered simple foolishness of no account, simply a silly play of imagination, but if the notions are of a moral or religious nature, then they are often ascribed to satanic influences, thought to threaten the religious, moral life in a peculiar way. The true nature, however, becomes revealed by analyzing these sur- prising and compulsory processes and by a conscientious anamnesis so far as the latter be possible. Then the soil whereupon these mental maladies are growing is dis- covered. We shall not investigate in how far the devil, the fiend of any peace of soul, uses the morbidly discordant nerves as a basis for his operations, we shall on the contrary con- tent ourselves in the interest of the patient to attribute these conditions to the morbid state of the nerves. Every priest must admit that he has not solely to deal with nor- mal minds; he often meets minds wherein the disease is either developing, or progressing, though they appear out- wardly to be whole, and the number of these "sick souls" is not small. It does make a difference whether the priest COMPULSORY NOTION vs. TEMPTATION. 303 has an insight into such morbid conditions or whether he mistakes them for temptations. The afflicted, to be sure, takes them in most cases to be the product of his wicked mind. We do not maintain that temptations and enticements do not happen to entirely healthy persons, without any help of morbid influences, but it must be taken for granted that the conditions described here are caused by disease and hence need a different treatment. A parallel between compulsory notion and temptation will show us the dif- ference between whole and sick souls. The parallel will in itself solve the question as to the responsibility, because the psychiatric theory of compulsory notions and condi- tions does not remove the moral responsibility which, how- ever, in kindred cases can never wholly be determined. The responsibility will only be distributed and valued dif- ferently. The whole and the sick have different thoughts. VIII. DIFFERENCE BETWEEN COMPULSORY NOTION AND TEMPTATION. We are conscious of exceeding, in the following discus- sions, the scope of this work. Nevertheless our chapter would lose much of its usefulness should we omit to take up this part of our subject. First of all the question : What is understood by temp- tation ? As a rule, by temptation is understood any incite- ment to evil from within or from without "conatus volun- tatem pertrahendi ad peccatum." They are thoughts, ideas, sensations, appetencies, and inclinations, incited either from within, by our own nature, or from without, by the world and by the fiends that are urging us on and enticing us in order to appease our inclination to violate the law divine, and to subordinate the most holy will of 3 o 4 PASTORAL MEDICINE. God to our own disorderly volition. In general, to tempt means to try, to put to trial, to test. According to this definition temptation is in essen- tial relation to the moral law prescribed by the Lord and by nature ; hence temptation is the source of either guilt or merit, according as to whether the tempted, a perfectly free agent and possessed of full knowledge, decides for or against the temptation. Any temptation is, therefore, primarily an interior pro- cess. It may appear in its tamest form as motus primo primi, qui non solum in appetitu sensitivo, sed etiam in voluntate (c. gr. motus odii, superbiae, contra fidem, etc.) oriunter et in malum tendunt, or it may be caused from without by an opportunity or impetus. It moves in the moral sphere exclusively. The decision for or against, in asserting or declining, in committing or omitting, brings about its termination. In comparing our conception of temptation, as far as it relates to a process from within, to our conception of compulsory notion we find a surprising and deceiving similarity in the manner of appearance in their subjects and in their shape. This similarity is es- pecially deceiving, when the compulsory notions trans- gress from an indifferent into a moral and religious sphere, being possibly in the nature of contrasting no- tions. Considering the perturbating influence of these thoughts upon mind and soul, it is no wonder that many a person believes the veritable devil to be at the bottom of them. Now for the differential diagnosis : Compulsory notion is likewise a process from within, it appears just as spontaneously as the temptation, its asso- ciation can not be traced, to wit, it does not reveal itself to consciousness. However, it maintains itself perma- nently without being caused by any affection, which is never the case with temptations. Further, the compul- COMPULSORY NOTION vs. TEMPTATION. 303 sory notion, by its pathological intensity and endurance, and in respect to the actions resulting from it, may as- sume the psychological significance and the compelling power of real insanity, which is altogether impossible in the case of temptation. The latter touches only upon the ethical part of man, compulsory notion may move along in different roads. Should it likewise touch upon the ethical part of a person or upon his religious sentiment, then it is like the motus primo primi in the moral theo- logical sense, only the mind is cognizant of it, because it is morbid and inapprehensible for the critic, i. e., no judg- ment can be formed, hence it is beyond the control of the will power. Moreover, the compulsory notion in its sim- ple and complex form, as well as in its consolidation into compulsory condition, is unlike temptation because the afflicted in the resulting omissions and commissions, does not look for a gratification of his desire. On the con- trary it is in the nature of the whole process that its aim fails to satisfy. It is the daily work of the ailing nerves to transform everything disagreeable, any trivial, miserable, petty thing in everyday life, into a torturing compulsory notion, so that an ill-considered word may evoke nearly the same remorse as a parricide would. The devilishness of it all is that the nerves do only molest one with the disagreeable things, compelling the patient to think them out into the most remote, horrifying conse- quences. A characteristic sign of the compulsory notion is their typical subject, especially manifest in contrasting notions (e. g. blasphemous). The author has seen this confirmed in a number of afflicted, whose blasphemous thoughts, es- pecially those relating to the Holy Mother were of a per- fect congruity. The same applies also to notions of an in- different subject. Finally the morbid character of com- 306 PASTORAL MEDICINE. pulsory notions, and hence its contrariness to temptation, may be recognized by the fact that these thoughts as well as the accompanying anxiety and fear can be made to vanish by an operation wholesome to the nerves, such as cold baths, etc. Even a thorough cure may be, and has been, effected without the aid of religion in influencing the mood. Another difference is this, the patient may be- come weak-minded or idiotic when receiving awkward treat- ment and if the surrounding conditions are unfavorable. In contrasting temptation and compulsory notion we do not attempt to draw a sharp dividing line, the principal task being in such cases to trace the particular manifesta- tion of a person's mental life from his general condition and thus to indirectly find the right diagnosis by means of anamnesis. IX. RESPONSIBILITY OF PERSONS WITH COMPUL- SORY NOTIONS AND IN COMPULSORY CONDITION. According to the description given of the different forms of the notions, there can no longer be a doubt as to the morbidity of the condition. It is a morbid state, for the reason that the patients are, as a rule, predis- posed for their condition because of an evident psycho- neuropathical constitution, or of morbid disturbances of mood and of sentiment. Of course there are also physiologically normally constituted people, who, never- theless, are tortured by whimsical and hideous notions entirely foreign to their ethical consciousness. Who does not know that a person when standing on the brink of an abyss is easily struck by the idea, How would it be to leap down? although that person is free of any taedium vitae. Krafft-Ebing, however, maintains that the number of like persons is insignificantly small if compared to the number of cases wherein compulsory RESPONSIBILITY. 307 notions are caused by the neurasthenic disposition of the person. As stated before, the compulsory notions are es- pecially grave if they extend their perturbating influence upon the religious mood and the conscience of the patient. To sum up: the responsibility for compulsory ideas and the actions resulting therefrom must only and solely be judged by the amount of free agency, of which the pa- tient is yet possessed. Krafft-Ebing assumes a number of vastly different degrees, he thinks a morally strong mind full of will power may perhaps emerge victoriously from the struggle, yet there are also stages where the free agency has been wrecked by psychical compulsion. This might be the case even if there is but one single morbid notion, as the observer would be wrong to assume a per- son could be whole with even only one single notion. His other slight disturbances of the mind are often not perceived so easily and readily. Besides, we are never full masters over the contents of our consciousness, nor can we efface the single thoughts at will from our conscious- ness, not even if the train of notions has run its course without interruption. This explains the most manifold combinations incidental to such morbid states, because in connection therewith there may be disturbances in an- other sphere, that of the will, in view of the ultimate mu- tual relation between thinking and feeling ; in the extreme case we have no longer to deal with actions by will, but with actions by impetus, wherein reason is no longer the controlling factor, as we have seen in the cases quoted. Hence, if e. g. a person at Confession, while confessing his sins, suddenly begins to curse and to swear, and then feels most unhappy because he could not help it, then we cannot hold him responsible, because he is obeying a morbid impetus, the accompanying symptom of a violent nervous disease, as proven by anamnesis. The belief that every 308 PASTORAL MEDICINE. man can control his thoughts and his actions under any circumstances must be qualified in our cases. The tenet that man is absolutely master of his own thoughts has more or less of a limitation. People are queer creatures, a hot room, a gloomy day, lack of exercise, indigestion, often form the whole difference between happiness and misery, courage and energy. Leibnitz, the philosopher, is said to have always tested his mood before sitting down to a difficult mental work. Who has not yet suffered from the whims and the irrita- bility of persons with a liver complaint? It's a matter of common knowledge that persons whose hearts are af- fected are tortured by an anxious, scrupulous conscience, while on the other hand their ire is aroused by a mere trifle. According to Hans Jacob, Schopenhauer would never have proposed as axiom his assertion of the identity of body and will had he had knowledge of the compul- sory notions. It is commonly conceded that poor physi- cal condition makes a doubter out of man and excites a lasting discord between body and mind. If the will is often powerless against sensual affections, because by suddenly arising they arrive sooner than the act of the will, this is even more the case with compul- sory notion, when the most earnest struggle to escape the pangs of the imaginary play are in vain. Many a person would will if he only could. To arrive at a practical, suitable judgment, valuation and treatment, it is necessary to acknowledge the morbid- ity of this real alienation of mental life, which stands off from a healthy mental life. As shown by the examples it is clear that a person, whose mental life has taken a change, may have become ailing, may have become psy- chopathetical, without being of a diseased mind in the real sense. FURTHER DEVELOPMENT. 309 It is certain that this special kind of morbid formal dis- turbances of the thinking power is always developed from a neuropathic case and cannot grow in the realm of health. Sometimes the patients resemble in their de- meanor some stages of insanity, but they lack the charac- teristic productive delusion supported by a previous ex- isting weakness of the critic powers, which are a mark of all typical cases of paranoia. In most cases of paranoia the patient, even at the most advanced stages, is not aware of the morbidity of his delusions, whereas the patient afflicted with compulsory ideas knows perfectly well his mor- bid condition and he recognizes how inappropriate and silly his thoughts are. In how far the developing com- pulsory notions infect the general psychical personality of the patient depends first on the malady itself, partly also on the surrounding circumstances. Not a few per- sons afflicted with these conditions, especially the onerated of a robust constitution, continue in their responsible vo- cation, in their family and social life, notwithstanding the fact that they are handicapped by their notions. The term compulsory notion does not include delusion, except sec- ondarily when the patient who feels that he is no longer the master of his own thoughts should interpret this to be due to a strange personality that is causing these thoughts. The essential difference between delusion and compulsory notion is therefore this, the one afflicted with notions is aware of his misery, not so the real insane. People with a nervous ailing, and they are the ones mostly afflicted with compulsory notions, suffer more, by the continuance of their consciousness, than, for instance, melancholies. X. FURTHER DEVELOPMENT OF COMPULSORY CONDITIONS. The question which causes most anxiety to such pa- 3 to PASTORAL MEDICINE. tients who, overcoming their shyness, have consulted an expert, is : Is it possible for these compulsory notions and conditions, while they are not mental diseases, to develop into such? In general this is not the case, as it can be proven that in cases of insanity the compulsory thinking as such has not changed into psychosis, but that the insanity is due to another cause, and that it is immate- rial whether or not the patient has previously been afflicted with compulsory notions, also immaterial whether or not such notions continue after insanity has set in. A special- ist for nervous diseases quotes a case where the malady had continued for thirty-eight years and remained until death, without developing dementia. In view of the fact that anxiety is mostly the dominating notion, Dr. Wille comes to the conclusion that the notions develop into melancholia, especially those sets of notions that do not deal with a nonsensical absurd subject, but with one that is simply false, untrue and contrary to real condi- tion. Dr. Wille supports his view by citing the mania of self-accusation of sinning. We can only concur therein from our priestly experience, and every confessor will easily know what value to put upon those endless, minute and detailed, self-accusations, if he duly has recog- nized the fundamental cause for this self -torturing, anxious, examination of conscience. The danger of falling into a certain, though not deep, melancholia, is likely to exist, as there are "flowing transi- tions" between both maladies and because the first state may at any moment be complicated by the addition of melancholia. The possibility of a development into par- anoia, into insanity has been affirmed by Krafft-Ebing, Maynert, Wille, Schu'le and Kraepelin. However, such cases are said to be very rare. The development has been called abortive insanity. On the other hand it is main- FURTHER DEVELOPMENT. 3 1 1 tained by Dr. Koch, that the compulsory thinking never produces a psychological reaction of the mood. On the contrary he thinks that these conditions are rather a safeguard against, than favorable for, the setting in of insanity. Dr. Koch points to the fact that those afflicted with no- tions keep up a daily struggle, full of cares and anxieties for years and years, they ply their vocation, they suc- ceed in not betraying their real state; compelled to satisfy their notions they labor often in addition thereto under the fear of becoming insane ; yet none of these and similar things lead to a breaking out of insanity, which ordinarily is favored by such lasting cares and griev- ances. However, in spite of Dr. Koch's quieting declara- tion, the old tenet, that every one is to be considered men- tally sound until the contrary is proven, should be dis- carded and the view, founded upon experience, should be adopted in its stead, that there exist a large number of in- termediary links of morbid symptoms and conditions. Between people in perfect health and wholly sick peo- ple there are a great number of persons, in whom the whole and the sick is mixed and where only some single morbid traits are manifest. These elementary anomalies may have existed at the birth of the patient, for it is just in our cases where the hereditary psychopathical constitu- tion plays a baneful part. The temptation lies near to show at this juncture that the compulsory notions may be traced back to puberty and even further; one may rightfully speak of some such morbid conditions not only at early childhood, but one may speak of infantile insan- ity. According to Drs. Wille and Westphal the compulsory notions do not favor a certain sex. Griesinger says they are more prevalent among men, Schiile and Legrand du PASTORAL MEDICINE. Saulle, however, hold they are more prevalent among wo- men. No line of demarcation as to the age can be drawn ; it seems that middle aged persons are mostly afflicted ; this is the age when neurosis and psychosis mostly pre- vail. Dr. Wille observed seventeen patients as to their ages: between fourteen and twenty years, two men and two women; twenty-one to twenty-five years, one man, one woman; twenty-six to thirty years seven men, two women ; thirty-one to thirty-five years, two women ; thirty- six to forty years, two men, two women. According to my experience even men and women over seventy years are subject to compulsory notions. Better situated classes are as a rule more disposed to these notions, although nowadays there are nervous peasants, peasant women and servant girls, who may individually present some symp- toms of predisposition. It is not rare to find a coincidence of compulsory no- tions with a shy and melancholy nature, with weakness of intellect, with a painstaking sense for order and clean- liness, with an inkling of -hypochondria and with an ex- acerbating of neurasthenical symptoms. Griesinger denies that frequent pollutions are one of the causes; Krafft- Ebing, on the other hand, declares that these notions have been observed in persons predisposed by their constitu- tion for neurasthenia who have brought about neurosis by masturbating. Further etiological and occasional mo- ments are the weakening influence of childbed upon women, difficult delivery, large loss of blood and anaemia, gravidity, lactation ; with men, alteration of the mood, overexertion, acute diseases, sexual rioting, fright, anger, trouble, chronic dyspepsia. The further course of these morbid conditions is re- mitting; long intermissions are by no means rare; it frequently occurs that some compulsory idea may always TREATMENT. 313 come back occasionally. All these conditions bear a cer- tain periodical character, hence they differ very much in their course. Riots in baccho et venere may aggravate matters. Whether or not a complete cure may be hoped for is difficult to establish because the cases, even when acute, are rarely healed in asylums, hence an observa- tion of the extreme development is rendered impossible, because the private cases of an unfavorable termination remain unobserved. As far as they have been studied periodical melancholia has been observed. So Krafft- Ebing says. This malady results either in cure or in a state of mental torpor. In cases where the malady was ac- quired, where the patient had not been naturally predis- posed, a cure has been repeatedly effected, but never in other cases, although an intermission lasting for years has been accomplished. While the crisis lasts there have been observed in many instances taedium vitae, attempts at suicide, and suicide. In the later case the chief reason for it is probably pronounced melancholia. XL TREATMENT OF COMPULSORY CONDITIONS. The tracing back of these elementary psychical distur- bances to a neurothic basis, points of itself to the door of the physician. The priest who is to give advice in like cases does a meritorious act by explaining the morbidity of the condition and by advising to consult a physician. As to the treatment of the cases, theory and practice in- dicate the use of tonics and teach the value of fresh air. According to the patient's individuality the climate of the sea shore or of the mountains is to be chosen. In connection therewith a hydropathic treatment is of great advantage (ablutions, rubbing down, sponge bath, bathing in ocean or river) also a general electrization (electric massage, electric bath). Of medicines, success 3 i4 PASTORAL MEDICINE. may be expected from quinine, ergotin, zinc, arsenic, phosphates, opiates. In the case of anaemia, iron should be prescribed. In less pronounced, hysterical cases Krafft-Ebing has successfully prescribed preparations of zinc (zinc valerian, zinc bromat.). In cases of pronounced psychical hyperaesthesia, with notions of a homicidal or suicidal character, he has successfully made use of preparation of zinc with opium. The nourishment should contain much albumen and fat. Insomnia, if based on pronounced anaemia, should be treated with alcoholic bev- erages, especially beer ; otherwise, according to special in- dication with bromo preparations (4-5. o) opio quinine, paraldehyd. A priest who has gained an insight into the conditions spoken of, will understand first of all that many of these careworn people are subjects for medical treatment. He recognizes the soul-ache to be the outcome of an existing, if hidden, nervous ailment ; he can realize the agony suf- fered by these poor creatures ; he knows how burdensome their lives are. Hence he will advise to consult a physi- cian, not any physician, but an experienced, conscientious specialist. Dr. Koch does not hesitate to maintain that a physician if not thoroughly versed in the treatment of nervous diseases is apt to commit bigger blunders than the layman, for no other reason than because he lacks the faculty of analyzing critically and thoroughly the tangle of ideas and emotions especially of the scrupulous reli- gious. Unprincipled would be the advice to banish com- pulsory ideas on sexual subjects by indulging in sexual relations, especially outside of wedlock, with all its dan- gers for body and soul. Even matrimony does not offer any cure for these conditions, except in those cases where there is a lack of regularity in living and of a moral aim. Krafft-Ebing says: It bespeaks sadly for the defective THE TASK OF THE PRIEST. 315 hygienic education of the present time, when even physi- cians look forward to matrimony as a curative for ner- vous diseases, e. g. hysteria, and when they even suggest such a step to their clients. The author has known many men and women subject to compulsory notions al- though they had been married for many years. Statistics show that among a large part of hysterical persons 75 per cent, had had children and 65 per cent, had had more than three children. The same proportion may be rightfully assumed to apply to the conditions treated herein. XII. THE TASK OF THE PRIEST. Somatical treatment must, however, go hand in hand with psychical treatment and there lies for the priest a large and fertile field, though beset with difficulties. In this case the appellation "physician of souls" will not signify an empty title for him, for it takes any amount of sympathy and patience to listen with interest to the ever- recurring accusations. i. First of all the priest will have to enlighten the complainant. Often the sting of the agony is removed as soon as the patient has learned of the true nature of his malady and has been quieted by the assurance that these tormenting conditions have a pathological basis; the priest will reassure the patient, that he is in no dan- ger from insanity, albeit he at times is subject to a strange anxiety ; he will reassure him that it was not his depraved heart, that has evoked his blasphemous thoughts while at worship, but that they were due to a slight illness, a momentary fatigue from overwork or to any other in- different cause. He will tell him, that there is no occa- sion for compunction, but that he ought to take some exercise, to join pleasant company, to seek distraction. An 316 PASTORAL MEDICINE. enlightenment, to good purpose, will not burden the soul but unburden it. 2. It being a matter of experience that the onerated are already afflicted in their youth with compulsory notions and conditions, it is the duty of those conducting the edu- cation, especially in institutions, to investigate calmly, kindly, gently and with perseverance, why there are sometimes obstacles to an educational success. Many a time it will then become evident that the manifest inap- petency for work, the reduced capability, the mental palsy, plain to all, the striking absence of mind, the inattention and apathy at school, bashful and reserved ways, that slight inclination to gloominess, that wavering of the whole demeanor, that all these are not character-traits, .but a consequence of the conflict, the defensive struggle, which the poor tortured has to wage with the torturing process within, with the compulsory ideas. In dealing with his charges, teacher, educator and priest must com- bine the love of the friend, the earnestness of the master and the invincible patience of the humanitarian who feels that he is human himself and that he has to deal with a human being. Warm and intelligent sympathy, suit- able enlightenment, keeping off evil influences, advice how to strengthen the will power, will bring relief, the tendency for morbid conditions will be restrained or suppressed, at least their disastrous course mitigated and their damaging effects removed. 3. Imagination is a powerful vehicle for compulsory notions as we have seen. It can become a blessing for man or a curse. It is like the sacred fire of Vesta, glow- ing and animating while watched, but destroying when unfettered. Hence an indulging in sentiments and fan- cies must not be nourished, but carefully restrained, this applies to young and old alike. Sanguinary natures THE TASK OF THE PRIEST. 317 must be held by salubrious compulsion to regular activity or they must be made to conform severely with the order of the day. Serua ordinem et ordo te servabit, says St. Augustine. 4. The priest, as the confessor, will urge those afflicted to fully reveal themselves to him. This is neces- sary because there exists a general prejudice against psychical disturbances, even in educated circles; as a result, the patient, owing to a false shame and shyness, is loath to reveal with candor what is in his heart. It is just the candor or sincerity with which the inner misery is revealed to a friend, a kin, a husband or a wife, which furnishes the first hold for beneficial assistance. This sincerity merits a reward in the shape of unlimited pa- tience with the afflicted. 5. This patience must therefore be exercised by always listening attentively to his woes. The compulsory notions should never be denounced as craziness or nonsense, this, if ever so well meant, would only effect the reverse of the intended result. However, in listening patiently to the account of the compulsory notions, the priest must never exhibit weakness of will power or hesitancy. It would be advisable first of all, that the confessor consents to the penitent's laying bare the whole condition of his soul openly and thoroughly, but only once. Any subsequent repetitions and rehearsings of his story should be cut off earnestly and decidedly by the short remark, "Yes, I know all this already, let us talk of something else" ; thus leading the conversation into another channel. Any hes- itancy would be out of place, moreover it would be a grave error for the advising priest, to view with alarm certain striking symptoms. If the penitent e. g. should curse and swear most awfully during confession as well as at the beginning and finish, then the confessor should out- 3 i8 PASTORAL MEDICINE. wardly preserve a calm and unaffected demeanor while in- wardly taking cognizance of the malady. He knows that a psychopathical person kneels in front of him, who per- haps on account of a cold has not had her menses, and that this condition has produced that dismal but irresistible impetus. One imprudent word may put her in despair and rouse in her the delusion of her damnation, for, not knowing the true cause of her state, she will attribute her contrasting notions to her own depravity. No confessor should overlook the fact, that, the more violent struggle and defence have been, the more blasphemous become the thoughts, as in such cases there always have been such struggles. 6. Such patients, especially if their religious and moral life be the object of a vehement attack, are prone to change their spiritual advisers, which finds explanation in their hunger for consolation. Hence they should be required, like all overscrupulous, to remain with the con- fessor once chosen, to confide in him and to obey him. Else the confessor should, if feasible, communicate with the newly-chosen confessor, tell him all about the case and what advice he has given. 7. A violent struggle against these compulsory no- tions, energetic attempts to suppress them, are of evil. A good advice is to let any whimsical idea, a doubt, rest for a day, so to speak. As a rule the disagreeable thought becomes stale after a day, at least it loses its vividness, or it vanishes entirely. If possessed of the notion to verify whether this or that is done properly, let the patient not immediately follow his momentary impetus to verify, but fix a quite distant date for him to go to the root of the mat- ter. When the time fixed arrives, the doubt, etc., has lost its strength or has entirely vanished by this happy self- deceit. "The more the nerves of these patients are af- THE TASK OF THE PRIEST. 319 fected, the more prone they are to indulge in unsound religious notions and exercises. It is certain that many morbidly egotistical ideas never vanish but for the aid of religion ; it is certain that religion only is often able to induce a patient not to brood over his ailment and thereby retard an improvement ; it is certain that many a perverse and evil inclination is not suppressed by indulgence, but by invoking the power of religion against it. But just as certain it is that many a cure has been retarded by im- proper religious doings, certainly many a malady is su- premely ruled by morbid religious notions, and a person may occupy herself too much with religious mat- ters. Where the troubles and temptations themselves are morbid or intermixed with morbid religious elements, there naturally is a longing for false religious remedies and the upshot is despondence." (Dr. Koch.) And why is this so ? Because the desired success fails to be achieved, as is regularly the case when such patients are reading ascetic books about temptations, etc. It is just as impossible to remove morbid conditions by reading such books as it is impossible to cure an insane of his mania by arguments. The most convincing words of con- solation found in these books must fall flat, "because they were not written for them." Everything that is good may be wrongly applied, especially here, because the application is made from out of the morbid mood. No wonder if we hear the plaint : Now it's worse than ever. 8. It is best, first to restrict all religious demands that are only still more confusing and burdening, and there- upon to lead the afflicted into a childlike confidence in God, telling them God is aware their will is good, He rules this small world of ours and He guides those whose will is good upon roads which lead to righteousness. The peni- tent should be warned against all damaging influences. All 320 PASTORAL MEDICINE. overwork and over-stimulation, bodily or mentally, are damaging. It would be outrageous to tire those unfortu- nates out, and to burden them down with work. Again it would be damaging to use means which while they may serve for building up a Christian character, would fail to prove beneficial in this instance. Should the compulsory notions range into the religious sphere, then the afflicted are to be treated like melancholies; they should not be burdened with more religious exercises, etc., but should on the contrary be restricted therein. Are the com- pulsory notions of an indifferent nature, then a prudent adducing of comforting religious truth will certainly serve a good purpose, will divert the thought and have an elevating and easing tendency. Excessive fasting should also be warned against because the nerves if poorly nourished would lose still more of their energy, hence it should be seen that the patients be well fed. The adage modicus cibi, medicus sibi, is of great value only to the healthy. In our time when there are so many "sick nerves," the priest, too, will have occasion in his vocation to meet more morbid conditions than he likes to; however, after some diagnosis of the mental processes above described, he will be ready to judge the cases aright and to give benefi- cial advice. His own gain will be twofold ; he no longer will take his fellowmen, nor judge them or treat them, all after one pattern; by this individual-psychology he will find the road to the proper intercourse with the patient, and thus may lead many a soul to peace. INDEX OF IMPORTANT SUBJECTS. PAGE Abdominal Diseases 123 Abortion 86, 236 Abstaining 32 Accidents 124 Administration of Sacra- ment to Those Apparently Dead 223 Agony 74 Air II, 24 Air as a Cause of Disease.. 14 Albumen 29, 31 Alcohol, Poison for Children 95 Alcoholic Beverages 42 Alcoholism 43, 163 Anima rationalis 89, 237 Anomalies of Appetite 140 Antiseptics 16 Anxiety, Compulsory 282 Apoplexy I2t Apparent Death 223 Artificial Abortion 86, 236 Asiatic Cholera no, 119 Asphyxy 74, 76, 77 Atavism I 21 Bacteria 16,27, 37, ">9 Banting Cure 3 2 Baptism of the Child in the Womb 93 Baptism of the Fetus . . .90, 265 Baptism of Infants 93 Baptizing those Apparently Dead 225 Bathing 62 & PACK Bending of the Spine (in School Children) 64,67 Birth 92 Burial 74, 79 Burial Vaults 24 Burying Alive 77 Carbohydrates 29, 31 Carbonates 29 Carbonic Gas 154 Care of the Child 94 Castration 252 Celibacy 101 Cemetery 26, 82 Cesarean Section 247, 256 Cesarean Section upon the Dying Woman 262 After the Woman's Death 260 Child at School Age 97 Childbed Fever 120 Chlorides 29 Cholera 38 Cholera Morbus 19 Clear Ova 264 Climacteric Stage 131 Climate 17, 21 Clothing 47, 60 Coal Dust iSi Colored Undergarments Poi- sonous 62 Compulsory Conditions (Nervous) 286 Compulsory Notions 267 322 PASTORAL MEDICINE. PAGE Contagion, How to Protect School Children Against. 69 Craniotomy 247 Cremation 80, 81 Criminal Abortion 89 Criminal Possibilities of Hypnosis 161 Crowded Rooms 18 Damp Walls 48 Death 74, 223 Decomposition of the Buried Corpse 81 Delusions 131, 266 Diet of the Sick 30 Difference between Com- pulsory Notion and Temptation 303 Diphtheria no, 118 Diseases due to Occupations 149 Diseases of Cattle Transfer- able to the Human System 35 Diseases of the Respiratory Organs ; 122 Disinfection .^ 1 16 Drinking Water.. 23, 27, 28, 29 Drunkenness 164 Dwelling 47 Ectopic Gestation 264 Electric Light 50, 51, 72 Emotional Disturbances ...274 Epidemics 71, 114 Epilepsy 141 Extirpation of Ovary 252 Erotic Insanity 137 Fasting 32 Fever Patients 30 Fire Damp 54 PAGE Fireplace 53, 55 First Aid to the Injured: See Separate Index. Food 28, 34 Foundlings 95 Freezing 20 Fruit 41 Fuel 53 Gases 154 Gout 43 Grave 84 Ground Air 24 Growths in the Uterus ....245 Hallucinations 131 Headache 64 Healing Power of Climate.. 17 Heart Diseases 123 Heat Prostration 18 Heating 52, 72 Hemorrhages 92 Homicidal Notions 282 Hospital 71 Human Soul Present in Fetus 89, 237 Humidity of the Air 21 Hydrophobia 109, 1 14 Hygiene II Hygiene for Hot Days . . . . 19 Hygiene of Schools 63 Hygienic Requirements for Dwellings 47 Hypnosis 155 Hysteria 144 Illuminating Gas 24, 50, 51 Illusions 132, 266 Immunity 112 INDEX. 323 PAGE Impedimentum Consanguin- itatis 99 Infanticide 95 Infection Infectious Diseases 109 Infirmary Insanity i^ Iron Dust Kleptomania 139 Lead Colic 151 Leaden Pipes, Cause of Poi- soning 27 Lighting 50, 72 Liquor 42 Malaria 22, 23 Man in Sickness 107 Mania 134 Mania of Doubting 283 Manners of Death 74, 79 Marshy Soil 25 Means of Contagion in Measles no Meat 28, 30, 34 Melancholy 132 Mental Diseases 124, 266 Mentally Weak Children .. 97 Mercury 150 Mesmerism 158 Milk, Carrier of Contagion. 38 Miraculous Cures not Pos- sible by Hypnosis 162 Moment of Death 223 Monotonous Bill of Fare . . 30 Moral Depravity 14^ Morbidity of Imagination. .135 Morphinism 172 Mortality Among Religious Orders 104 PAGE Mortality Among Inebriates 165 Myoma 345 Nervous Diseases 141, 266 Neurasthenia 266 Neurasthenia Sexualis 280 Neurasthenics in the Con- fessional 315 New Buildings not to be Oc- cupied until Thoroughly Dry 48 Nursing the Sick 33 Nutrition 28, 32 Obesity 3032 Obstetric Operations . .236, 259 Origin of Man 87 Oxygen I3 Ozone 13 Paralysis due to Insanity ..138 Paranoia 135 Phosphates 29 Phosphorus 150 Playgrounds 65 Pork Measles 35 Porro Section 252 Predisposition 112 Premature Birth 227, 259 Preventive Measures 115 Privies 58, 65 Procuratio Abortus 88 Puberty 131 Pulse 27, 28 Raving Madness 135 Religious Insanity 137, 266 Religious Orders 104 Responsibility of Neuras- thenics 306 Russian Baths . . 18 324 PASTORAL MEDICINE. PAGE Safety Devices 149 Scarlet Fever 38, 110 School Benches 66 School Diseases .64, 69 Schoolhouse 64 Schoolroom 65 Scrofula 30 Short-sightedness in School Children 66 Sick Nerves 266 Sick-rooms 7 2 Signs of Death 74, 77 Smallpox no, 113 Social Legislation 149 Soil 23 Somatic Diseases 108 Sources of Infection no Still-Born Children 228 Stimulants 42 Stone Dust 153 Stoves 53 Stuttering 97 Sudden Death 233, 260 Suffocation 79 Suggestion 155 Suicidal Notions 282 Sulphates 29 Sunstroke 19 PAGE Surgical Operations 253 Syphilis 89, 109 Tapeworms 34 Teeth 63 Temperature 13 Tobacco 45 Transmutation 130 Treatment of Neuras- thenics 313 Trichinosis 35 Tropical Diseases 22 Tuberculosis 30, 35, no, 117 Tuberculous Cattle 35 Turkish Baths 18 Typhoid 38 Typhus no Underground Water 24 Vaccination 112, 113 Variety of Food 30 Veneric Diseases 109 Ventilation 50, 56, 57, 72 Water Closets in Schools.. 65 Water Supply 26 Weather 17 Wells 24, 26 Witchcraft . 126 FIRST AID TO THE INJURED. PAGE Acids, hydrochloric poison- ing 197 hydrocyanic poisoning. . .198 muriatic poisoning 197 nitric poisoning 197 oxalic poisoning 197 poisoning from 197 PAGE Acetylene poisoning 203 Acids, acetic poisoning, etc. 197 aqua fortis poisoning 197 arsenious poisoning . . . .200 carbolic poisoning 197 carbonic poisoning 203 glacial acetic poisoning. .197 INDEX. 3 2 5 PAGE Acid, prussic poisoning . . . 198 sulphuric poisoning 197 Aconite liniment poisoning. 198 Alcohol poisoning 199 for wounds 18^ Alcoholic intoxication 21 1 Alkalies, ammonia caustic poisoning 199 liniment poisoning ..199 liquid poisoning 199 lime poisoning 199 potash poisoning 199 soda poisoning 199 Almond flavor poisoning . . 198 Aniline dyes poisoning 205 Antimonial wine poisoning. 199 Antimony poisoning 199 chloride of, poisoning . . 199 tartarated, poisoning . . . 199 Aperients in poisoning .... 196 castor oil as 196 sulphate of magnesia as Apoplexy Aqua fortis poisoning .... 197 tofana poisoning 200 Arnica poisoning 204 Aromatic vinegar poisoning. 197 Arsenic, white, poisoning. .200 Artificial respiration. .178, 189 Hall's method ...187, 189 Howard's method. 187, 188 Sylvester's method ... 187 Asphyxia from blocking larynx choking drowning hanging poisonous gases 193 strangulation 193 196 2IO 193 193 191 193 PAGE Atropine poisoning 200 Bed, for accidents 220 Bed-fracture, essentials of. .221 Bedstead for accidents 220 Belladonna poisoning 200 Bites by mad dogs 184 snakes 183 Bitter almonds poisoning ..198 Bleeding from the nose 180 Blister beetle poisoning 201 fluid poisoning 201 Blood, spitting 179 Blue rocket poisoning 198 stone poisoning 202 vitriol poisoning 202 Breathing, to restore from drowning I9 1 Burning clothing, to extin- guish flames of 216 Burns and scalds 215, 222 from acids 216 alkalies 216 Camphene poisoning 207 Camphor essence poisoning. 201 liniment poisoning. .I99 2 01 spirit poisoning 201 Cantharides poisoning 201 Carbolic acid poisoning 197 Carbonic acid gas poison- ing 203 oxide gas poisoning 203 Carrying and lifting patients.22i of injured 219 Caustic, lunar, poisoning . .201 Chalks, poisonous 200, 204 Charcoal fumes, poisonous. .203 Chloral hydrate poisoning. 201 syrup poisoning 201 326 PASTORAL MEDICINE. PAGE Chloride of lime poisoning. .201 of zinc poisoning 207 Chlorine gas poisoning 201 Chlorodyne poisoning 206 Chloroform inhaled, poison- ing 202 swallowed, poisoning . .202 Choke damp poisoning 203 Choking from accident 193 Clothes, removal of, in acci- dents 221 Clothing, burning, to extin- . guish flames of 216 Codeine poisoning 206 Collapse 209 Common salt for wounds . . 182 Compound fracture, immedi- ate treatment of 187 of tibia 185 Compression of brain . . . .210 Concussion of brain 210 Convulsions 214 of infants 214 uraemic 215 Copper acetate poisoning ..204 sulphate poisoning 204 Corrosive poisons 194 sublimate poisoning ....204 Crayons, poisonous ...200, 204 Cyanide of potassium poi- soning 198 Cytisine poisoning 204 Deadly nightshade poison- ing 200 Death, appearances accom- panying in asphyxia . . 193 Demulcents in poisoning ..196 Digital compression for hemorrhage 178 PAGE Dislocations 184 Draw sheet, to put on 220 Drowning, treatment of ap- parent death from 190 what things to prepare in case of 222 Ears, removal of foreign bodies from 218 Electricity 217 Emetics, caution as to 195 for use in cases of poi- soning 195 Epileptic fits 213 Ergot of rye poisoning 203 Ergotine poisoning 203 Ether poisoning 203 Eyes, removal of foreign body from 218 Fainting 208 Fire, to extinguish in clothes.2i6 Fits 213 Fly papers, poisonous 200 Foreign bodies, removal of. 218 Fracture-bed, essentials of. 214 Fracture, immediate treat- ment of a compound. .187 signs of 186 Fractures 185 repair of 185 Freezing, treatment of 212 Fungi poisoning 203 fly poisoning 203 Gases, carbonic acid poison- ing 203 oxide poisoning 203 coal gas poisoning 203 laughing gas poisoning. .203 INDEX. 327 PAGE Gases, marsh gas poisoning.2O3 sewer gas poisoning . . . .203 Glacial acetic acid poison- ing 197 Greenstick fracture, of radius 185 Hemorrhage 175 arterial 175, 177 articles required for con- trolling 222 capillary 175 causes of 175 definition of 175 " first aid " for 177 immediate treatment . . . 175 internal 178 situation of 175 varieties of 175 venous 175, 176 Hair dyes poisoning 204 Hanging, asphyxia from . . . 193 Henbane poisoning 203 Holly berries poisoning 203 Hydrochloric acid poisoning. 197 Hydrocyanic acid poisoning. 198 Hyoscyamine poisoning . . . .203 Hysterical fits 214 Ices, cheap poisonous 200 Infants, convulsions of 214 Insects, stings of 183 Insensibility 208 test for 212 Intoxication, alcoholic 211 Iodine poisoning 204 lodoform poisoning 204 Irritant poisons 194 Laburnum poisoning 204 PAGE Laudanum poisoning 206 Laurel water poisoning 198 Lead poisoning 204 acetate poisoning 204 paint poisoning 204 sugar of, poisoning ....204 white, poisoning 204 Lightning, effects of 217 Lime, caustic, poisoning . . . 199 quick, poisoning 199 Liqueurs poisoning 205 Lungs, bleeding from 179 Matches poisoning 206 Mercury, acid nitrate, poi- soning 204 perchloride poisoning . .204 red oxide of, poisoning. .204 Monkshood poisoning 198 Morphine poisoning 206 Muriatic poisoning 197 Mushrooms, poisonous 203 Mussels, poisonous 205 Narcotic poisons 194 Neuraline poisoning 198 Nicotine poisoning 207 Nitrate of silver poisoning. .201 Nitric acid poisoning 197 Nitro-benzol poisoning 205 Nitrous oxide gas poisoning.2O5 Nose bleeding 180 removal of foreign body from 218 Oil of almonds poisoning . . 198 vitriol poisoning 107 Opium tincture poisoning . .206 wine of, poisoning 206 Oxalic acid poisoning 197 328 PASTORAL MEDICINE. PAGE Paraffin oil poisoning 206 Paregoric poisoning 206 Peach kernels poisoning . . . 198 Phenol poisoning 197 Phosphorus poisoning 206 Poisoning, classification of. .194 Poisoning, definition of .... 194 depression from 195 evidence of 194 general treatment for . . 195 how to act in 195 immediate treatment of. .194 pain, relief of, in 195 shock from 195 unknown, general treat- ment 195 Poisonous fish and meat . ..205 Poisons, acetate of copper.. 202 lead 204 acids 197 acetic 197 arsenious 200 carbolic 197 carbonic 203 hydrochloric 197 hydrocyanic 198 nitric 197 oxalic 197 prussic 198 sulphuric 197 aconite 198 liniment of 198 ether 203 after damp 203 alcohol 199 alkalies 199 ammonia 199 caustic 199 liquid 199 liniment 199 PAGE Poisons, alkalies, lime 199 caustic 199 quick 199 potash 199 caustic 199 soda 199 caustic 199 almond flavor 198 oil 198, 205 ammonia 199 aniline dyes 205 animal alkaloids 205 antimony ; 199 tartarated 199 antimonial wine 199 aperients for castor oil, sulphate of magnesia (Epsom salts) 196 aqua fortis 197 tofana 200 arnica 204 aromatic vinegar 197 arsenic 200 white 200 arsenious acid 200 atropine 200 bean, St. Ignatius' 205 belladonna 200 benzol 205 berries, holly 203 bites, mad dog and snake 183 bitter almonds 198, 205 blister beetle 201 fluid 201 blue rocket 198 stone 202 vitriol 202 brandy 199 camphene 207 INDEX. 3*9 PAGE Poisons, camphor 201 essence 201 liniment 201 spirits 201 cantharides 201 carbolic acid 197 carbonic acid 203 gas 203 oxide gas 203 caustic ammonia 109 lime 199 lunar 201 potash 199 soda 199 chalks, French 200, 204 charcoal fumes 203 choral 201 hydrate 201 syrup 201 chloride of antimony 199 lime 201 chlorine gas 201 chlorodyne 206 chloroform, inhaled 202 swallowed 202 - choke damp 203 coal gas 203 codeine 206 compound camphor lini- ment 201 copper -2O2 acetate 202 sulphate 202 corrosive acids 197 sublimate 204 corrosives IQ 4 crayons 2, 204 croton oil 2O2 cyanide of potassium . . 198 cytisine 2 4 PAGE Poisons, deadly nightshade . 200 demulcents for arrowroot, barley water, eggs (raw), flour and water, gruel, linseed tea, milk, olive oil 196 dog bites 184 emerald green 200 emetics for ipecacuanha powder, ip- ecacuanha wine, mus- tard, salt, sulphate of zinc, tepid water 195 enema for beef tea, spirits, tea (or coffee) 196 ergot of rye 203 ergotine 203 essence of camphor 201 henbane 203 ether, inhaled 203 fish poisonous 205 fly fungi 203 papers 200 French chalks 200, 204 friend and soothing syrup, mother's 206 fruits, tinned 200 fungi 203 gases 203 acetylene 203 after damp 203 carbonic acid 203 oxide 203 charcoal fumes 203 chlorine 201 choke damp 203 coal gas 203 marsh gas 203 nitrous oxide 205 33 PASTORAL MEDICINE. PAGE Poisons, gases, sewer gas. .203 gin 199 glacial acetic acid 197 hair dyes 204 hartshorn 199 henbane 203 holly berries 203 hydrate of chloral 201 hydrochloric acid 197 hydrocyanic acid 198 hyoscyamine 203 hyoscyamus 203 ices, cheap 200 Ignatius', St., bean 205 insect stings 183 iodine 204 iodoform 204 irritants 194 laburnum 204 laudanum 206 laughing gas 205 laurel water 198 lead 204 acetate 204 hair dyes 204 paint 204 sugar of 204 white 204 lime, caustic 199 quick 199 liniment, aconite 198 ammonia 199 belladonna 200 camphor 201 liqueurs 205 lunar, caustic 201 mad dog bites 184 matches 206 mercury 204 acid nitrate 204 PAGE Poisons, mercury, perchlo- ride 204 red oxide 204 red and white precipi- tate 204 methylated spirit 199 mineral green 200 monkshood 198 morphine 206 mother's friend and soothing syrup 206 muriatic acid 197 mushrooms 203 mussels 205 narcotic 194 narcotic irritants 194 neuraline 198 nicotine 207 nightshade, deadly 200 nitrate of silver 201 nitric acid 197 nitro-benzine 205 nitro-benzol 205 nitrous oxide gas 205 nux vomica 206 oil of almonds 198 bitter 198 turpentine 207 vitriol 197 opium 206 oxalic acid 197 oxide of mercury 204 paint, lead 204 paraffin oil 206 paregoric 206 paste for rats 200, 206 peach kernels 198 perchloride of mercury. .204 phenol 197 phosphorus 206 INDEX. 331 PAGE Poisons, phosphorous paste.2oo poisonous fish 205 meat 205 mushrooms 203 pomades, as 205 - poppies, syrup of 206 potassium cyanide 198 proof spirit 199 prussic acid 198 ptomaines 205 quick lime 199 rat paste 200, 206 poison 206 rectified spirits 199 red oxide of mercury . . .204 precipitate 204 rum 199 rye, ergot of 203 St. Ignatius' bean 205 salts of lemon 19? sorrel 197 sedatives for (see " de- mulcents " above) 196 sewer gas 203 silver nitrate 201 snake bite 184 soda, caustic 199 soothing syrup, mother's.2o6 Spanish fly 201 spirit, methylated 199 proof 199 rectified 199 spirits of camphor 201 hartshorn 199 salt 197 turpentine 207 stimulants for beef tea, coffee (or tea), cold and hot douches alternately, sal volatile PAGE (aromatic spirits of am- monia), spirits (brandy or whisky) 196 Poisons, stings of insects.. 183 strong acids 197 strychnine 205 sugar of lead 204 sulphate of copper 202 sulphuric acid 197 sweetmeats as 205 syrup of chloral 201 poppies 206 soothing 206 tartar emetic 199 tartarated antimony ... 199 tin 207 impurities of 200 tincture of opium 206 tinned fruits 200 tobacco 207 turpentine 207 oil of 207 spirits of 207 turps 207 verdigris 202 vermin killer . .200, 205, 206 Vienna green 200 vitriol, blue 202 oil of 197 white 207 wall papers 200 whisky 199 white arsenic 200 lead 204 precipitate 204 vitriol 207 wine of antimony 199 opium 206 zinc 207 chloride 207 332 PASTORAL MEDICINE PAGE Poisons, sulphate 207 Pomades, poisonous 205 Potash caustic poisoning . . 199 Poultices and fomentations 222 Precipitate, red, poisoning. 204 white, poisoning 204 Preparation of sick room . .219 Prussic acid poisoning .... 198 Ptomaine poisoning 205 Quick lime poisoning 199 Radial, fracture of 133 Rat paste poisoning . .200, 206 Respiration, artificial 187 Salt, common for wounds. 182 Salts of lemon poisoning . . 197 sorrel poisoning . . . .197 Scalds, immediate treatment of 215 Sedatives in poisoning 196 Shock 209 from burns 215 Sick room, selection of ... .219 Snake bites 183 Soda caustic poisoning 199 Soothing syrup poisoning . .206 Spanish fly poisoning 201 Spirits (See Poisons) Sprains 184 St. Ignatius' bean poisoning. 205 Stimulants in poisoning cases 196 Stings of insects 183 Strangulation, asphyxia from 193 Strychnine poisoning 205 Styptics 176 Sulphuric acid poisoning . . 197 Sunstroke . ..211 PAGE Sweetmeats, poisonous 205 Syncope 178, 208 Syrup of poppies poisoning . 206 Tin, salts of, poisoning . . . 207 Tinned fruits poisoning . . . .200 Tobacco poisoning 207 Transportation of injured person 186, 219 Turpentine poisoning 207 Unconsciousness, action in case of 211 Uraemic convulsions 215 Varicose vein, how to treat a burst 176 Verdigris poisoning 202 Vermin killer poison- ing 200, 205 Vienna emerald green poi- soning 200 Vitriol, blue, poisoning ....202 white, poisoning 207 Vomiting of blood 179 Wounds, bullet 181 clean cut 181 contused 183 definition of 180 immediate treatment of. . 181 incised 182 lacerated 181, 183 poisoned 181, 183 punctured 183 simple 180 stab 181 to cleanse 181 dress 182 Zinc, chloride of, poison- ing 207 THE LIBRARY UNIVERSITY OF CALIFORNIA Santa Barbara THIS BOOK IS DUE ON THE LAST DATE STAMPE1 A 000 552 274 3