size to render delivery possible. The skull is perforated and the
brain is broken up and removed or crushed out. Embryotomy is a similar
operation wherein the viscera of the child are removed through an
incision made in its thorax or belly (evisceration), or the head of
the child is cut off (decapitation). There are numerous instruments
and methods for performing craniotomy and embryotomy, but they all
open the skull or belly, remove the brain or viscera, and then extract
the child's body.

If the infant is hydrocephalic and is alive, the advocates of the
operation warn us to be careful after opening the head to push the
perforator into the base of the skull and stir it around well, so as
to be sure the child will not be born alive. Pernice has recently
reported a case of hydrocephalus which was delivered by craniotomy,
but the operator did not work his perforator efficiently, and the
child recovered, and grew up an idiot. A similar case occurred in
Baltimore.

The indications for craniotomy among those that advocate its
occasional use (and they are many) is in those cases in which the
woman is so infected that caesarean section is dangerous, or where a
child is hydrocephalic, or where an after-coming head is jammed (in
this case even a caesarean section will not effect delivery), or in
the case of a narrow pelvis and a moribund child, or finally in the
practice of a country physician, who can not in an emergency get an
assistant to do a caesarean section. One man can do craniotomy, but it
requires three to perform the caesarean section. If the woman's narrow
pelvis has a conjugata vera of five or more centimetres, craniotomy,
if properly done, is not dangerous to the mother. With a conjugata
vera less than 5 centimetres it is more fatal than the caesarean
section. If the women are septic, the mortality in {59} craniotomy is
from 10 to 15 per centum; in caesarean section about 25 per centum.

As to the morality of craniotomy on the living or moribund child, it
is not permissible under any possible circumstances: a consideration
of the ethical principles set forth in the article on Ectopic
Gestation will make this assertion clear.

The Congregation of the Holy Office on August 19, 1888, decreed that
"In scholis catholicis tuto doceri non posse licitam esse operationem
chirurgicam quam Craniotomiam appellunt." They gave a similar decision
May 28, 1884, and they repeated the prohibition, with the papal
approbation, on July 24, 1895. The text of these decrees may be found
in the article on abortion, miscarriage, and premature labour.

The Porro operation consists essentially in a removal of the uterus
after caesarean section to prevent further conceptions. As a means to
prevent conception it is altogether unjustifiable, because repeated
caesarean sections in the same woman, if the surgeon is at all
competent, are practically no more dangerous than normal labour.

AUSTIN ÓMALLEY.

{60}

V

MATERNAL IMPRESSIONS

There is a wide-spread persuasion that a child, while carried in the
womb of its mother, may be marked as the result of incidents that
produce violent impressions upon her nervous system. This is so old a
conviction in the human race and would seem to be substantiated by so
much evidence that it is extremely difficult to convince people that
there is no scientific basis for it. As a matter of fact, however,
there is something mysterious about the way in which certain things
that happen to the mother seem to affect the child _in utero_. As the
result of the common belief in the truth of maternal impressions,
mothers sometimes are prone to blame themselves for not having been
sufficiently circumspect during the time of their pregnancy, and
accordingly they may seek advice and consolation in the matter from
clergymen. Women sometimes become very much depressed as a consequence
of an unfortunate event of this kind, and as the simple truth is the
best possible source of consolation, it would seem that a special
chapter should be given to the subject in a work of this kind.

The evidence for the truth of the theory of maternal impression is
almost entirely due to peculiar coincidences. James I. of England, the
son of Mary Queen of Scots, could never stand, according to Sir Walter
Scott, the sight of a drawn sword with equanimity, and it is said even
that he nearly fainted at his coronation because of an unexpected
glimpse of some naked blades in the hands of courtiers. This
peculiarity was attributed to the fact that his mother, while carrying
him _in utero,_ had witnessed the violent death of her secretary, the
unfortunate David Rizzio. There have been, however, any {61} number of
men who paled at the sight of a drawn sword before and since James I.,
with regard to whom no such circumstantial story could be told to
account for it. There have been any number of women that have
witnessed bloody murders under circumstances quite as heartrending as
those surrounding Mary Queen of Scots and her secretary, and yet their
offspring, though at the time _in utero_, have not been disturbed at
the sight of drawn swords, nor of blood or any other circumstance
connected with the deep impression that must have been produced on
their mothers.

There is, of course, a striking instance related in the Old Testament,
which seems to make it very clear that a belief in maternal
impressions existed from the very earliest times among the Israelites.
The story of Jacob is well known: "Jacob took him rods of green poplar
and of the hazel and chestnut tree and pilled white streaks in them
and made the white appear which was in the rods, and he set the rods
which he had pilled before the flocks in the watering troughs when the
flocks came to drink, and the flocks conceived before the rods and
brought forth cattle, ring-streaked, speckled and spotted." In this
case it seems evident that Jacob was not looking for a miracle, but
was expecting that a law of nature would be fulfilled in the matter,
the influence of the unusual sight upon the animal mothers proving
sufficient to have a definite effect upon their unborn offspring. The
most ardent advocates of the power of maternal impressions would
scarcely concede the existence of as much influence as this of the
mother's mind over the child unborn, otherwise there would surely be a
very absurd collection of anomalous births in the race.

On the other hand, it is generally conceded that the mother's habitual
temper of mind and the thoughts with which she occupies herself may
influence her unborn offspring to a most marked degree. The story is
told of a child-murderer who delighted in fiendish deeds of cruelty
and had murdered many people in cold blood, that his mother, the wife
of a butcher, had delighted in watching the operation of slaughtering
during the course of her pregnancy. There are any number of women,
however, who have, by the necessities {62} of their occupation, had to
witness the shedding of animal blood under such circumstances and yet
without any special effect being noticeable in their offspring. It has
been said that the opposite is also true, and that if a woman occupies
herself with high and lofty thoughts, with noble deeds and unselfish
devotion to others and if she occupies her mind and senses with the
great works of art, a correspondingly beneficial effect will be noted
upon the character of the foetus. These are, however, abstruse
speculations leading to conclusions not founded upon actual
observation, but upon theorising over the supposed fitness of things.

Coincidence plays such a large part in the matter of supposed maternal
impressions that it is impossible to decide how much there is of fact
and of consequence in the many stories that are told. Most women are a
little afraid, as the time of their labour approaches, lest something
or other--usually of an indefinite nature--that has happened during
their pregnancy, may cause the marking of their child. When they find
that the child is perfectly normal, they breathe a sigh of relief and
forget all about it. If any anomaly is noted, however, then they are
sure to connect it with some incident during pregnancy, and
imagination is apt to lend details that confirm the supposed
connection. On the other hand, there are not a few cases in which such
anomalies have occurred, and good, sensible mothers have been unable
to recall anything that might possibly serve to account for the
peculiarity noticed in the child, though corresponding peculiarities
in other children were supposed to be readily traceable to maternal
impression. Even where there has been no foreboding of evil results,
something or other that has occurred during the pregnancy will often
be magnified enough by memory to account for the supposed maternal
impression.

Doctors are very familiar with this tendency to make up stories to
account for various deformities. It used to be considered that
hip-joint disease and Pott's disease were the result of injuries in
early life. They are now known to be due to tuberculous processes not
necessarily and indeed only very seldom connected with injuries of any
kind. Mothers are {63} nearly always able to account in some way,
however, for the beginnings of the disease in some accident that has
happened. Young children are apt to have so many falls that some one
of them is picked out as the probable cause of the disease that
subsequently manifests itself in the joints. It is just this state of
affairs that occurs with regard to supposed maternal impression. Some
incident that would be otherwise unthought of is magnified into an
accident that caused a serious nervous shock, and consequently led to
the marking of the child.

In general it may be said for the clergyman's direction, that if women
have, as is sometimes the case, a morbid sense of their guiltiness
with regard to some maternal impression that has set a mark upon their
child, such a state of feeling may very well be rendered less poignant
by a frank statement of the present attitude of mind of most
physicians with regard to the possible effects of maternal
impressions. Scepticism is much more the rule than it used to be, and
as time goes on fewer and fewer of the cases that used to be
considered so inexplicable in the direct relationship that seemed to
exist between maternal impression and deformity in the child are
reported. Fifty years ago nearly all the authorities on this subject
were agreed in considering that maternal impressions did play some
part, though they could not explain just how, in the production of
certain deformities. Now we venture to say that most of the thinking
physicians who have occupied themselves with this subject would
scarcely hesitate to say that they were utterly incredulous of any
such effects being produced. The lack of any direct nervous or blood
connection between mother and child is the basis for such disbelief,
and is of itself the best argument against the old tradition.

With regard to mental defects, as a rule, not so much is said as for
bodily defects. Bodily deformities are noted at once after birth, and
then the mother recalls some incident of the pregnancy to account for
them. Mental defects are, however, noticed much later, and are not so
likely to be considered as connected with incidents of the puerperal
period. There is no doubt that if the mother has had to pass through a
series of emotional strains, or has suffered from severe {64} shocks,
children are likely to be born with diminished mental capacity. This
is, however, not difficult to understand, since such incidents produce
disturbances of the nervous system of the mother, and consequently
also of her nutrition, and this is prone to be reflected in the
child's condition, especially in that most delicate part of the
child's organism, the brain. Hence it is that children born during the
siege of Paris, or shortly after, were defective to such a marked
degree that they were spoken of as "children of the siege," and this
was considered to be quite sufficient explanation of nervous
peculiarities later in life.

Baron Larrey, the distinguished French surgeon, made a report with
regard to the children born after the siege of Landau in 1793. Of 92
children, 16 died at birth, 33 died within ten months, 8 showed marked
signs of mental defects, most of them to the extent of idiocy, and two
were born with several broken bones. In this case, however, it is well
known that besides the shock of the danger consequent to the siege and
the fear and distress of the women with regard to their husbands and
relatives, there were added many privations and physical sufferings.
The nutrition of the mothers was seriously disturbed by these, and it
might well be expected that the children should suffer severely. The
statistics of such events are not available in general, and when an
effort is made to establish a cause for idiocy under other
circumstances, none is usually found. Out of nearly five hundred cases
of idiots whose histories were carefully traced in Scotland, in only
six was there any question of maternal impressions having been the
cause of the condition.

Of course there are many very wonderful coincidences that seem to
confirm the idea that impressions made upon the mother's mind are
sometimes communicated to the child in her womb. That they are not
more than coincidences, however, is rather easy to demonstrate in most
cases, since, as a matter of fact, at the time when the incident
occurred which is supposed to have caused the deformity in the foetus,
the stage of development of the intrauterine child has passed long
beyond the period when formative defects could occur. For instance, it
sometimes happens that the child-bearing woman {65} sees an accident
especially to the father of the child involving the loss of a limb.
If, by chance the child should be born with a missing member, as
sometimes happens, then there would seem almost to be no doubt of a
direct connection between the accident witnessed, the effect produced
upon the mother's mind, and the consequent deformity.

We know now that the formation of the limbs of the foetus is complete
by the end of the third month. At this time the woman is scarcely more
than conscious of the fact that she is pregnant, and it is not during
this early period, as a rule, but during a much later period, that
maternal impressions are supposed to have their influence. It is only
such maternal impressions as occur very early in pregnancy, before the
tenth week as a rule, that could possibly have any effect in the
production of such deformities. It is by no means infrequent, however,
to have children born lacking one or both limbs. Sometimes nothing but
the stumps of limbs remain. In such cases it is now well known that
intrauterine amputation has taken place. Some of the membranes that
surround the child, especially the amnion, become separated into bands
which surround tightly the growing members of the foetus and by
shutting off the blood supply through constant pressure, lead to the
dropping off of all that portion of the member lying below the band.

Not infrequently it happens that when a child is born thus deformed,
the mother, by carefully searching her memory, can find some dreadful
story that she has read, some accident that she has seen or heard of,
and that has produced a seriously depressing effect upon her at the
time, to which she now attributes the deformity that has occurred.
Until the unfortunate appearance of her child was reported to her, she
had no idea of any possible connection between the story and the
bodily state of her intrauterine child. In not a few cases, however,
the most faithful searching of the memory fails to show anything which
could, by any possible connection, be made accountable for the
deformity; and these cases, we may say at once, are in a majority.

Not a little of a popular notion with regard to the influence of
maternal impression is due to the repetition of certain {66} village
gossip which by no means loses its point or effectiveness passing from
mouth to mouth. On the other hand, maternal impressions have been
exploited by novelists, who have found that the morbid curiosity of
women particularly with regard to this subject may make their stories
more widely read. Lucas Malet, who, in spite of the apparently
masculine pseudonym, is really the late Rev. Charles Kingsley's
daughter, has recently called renewed attention to this subject by her
novel "Sir Richard Calmady." In this the hero is born with both his
lower limbs missing from just below the knees. The author has been
careful, however, with regard to the details of the supposed maternal
impression to which this deformity is attributed. A young married
woman in the early part of her first pregnancy has her husband, whom
she loves very dearly, brought back to her with both his limbs taken
off by a shocking accident which resulted fatally. It is not
impossible, some physicians might think, to consider that so severe a
shock could produce a very deleterious effect upon the foetus. That
the result should so exactly copy the scene which was brought under
the eyes of the young mother is, however, beyond credence.
Occasionally such stories, supposedly on medical authority, find their
way into the newspapers, usually from distant parts of the country.
Certain parts of Texas particularly seem to be a fruitful source of
such stories for newspaper correspondents when there is a dearth of
other news. Farmers in thinly settled parts of the country lose a foot
in a reaping machine or a hand in the hay-cutting machine when there
is no one near to help them but their wives, with the result that the
shock to their wives proves the occasion of a similar deformity in an
as yet unborn child. Careful investigation of such cases, however, has
invariably shown that either they were completely false or that the
details showed that whatever had happened was at most a coincidence
and never a direct causative factor in the subsequent deformity.

The greatest difficulty in the mind of the medical man, with regard to
the possibility of maternal impression being communicated in any way
to the foetus, is, as we have said, his knowledge of the anatomy of
mother and foetus. While it is {67} generally supposed that the mother
is very intimately connected with her child _in utero,_ the actual
connection is by no means so direct as might be expected from the
popular impression. It is usually considered that the mother's blood
flows in the child's veins; but this is absolutely false. The child's
blood is formed independently of the mother's blood quite as is that
of the chick in the egg. At all times the blood of the child remains
quite different in constitution to that of its mother. It contains
many more red cells than does her blood and differs in other very
easily recognisable ways. Mother and child are connected by means of
an organ known as the placenta, which is attached very closely to the
uterine wall and from which through the cord the blood of the foetus
circulates. This placenta constitutes the so-called afterbirth. The
mother's blood flows in one portion of it, that of the child in
another, and they always remain distinct and separate from each other.
The gases necessary for the child's life diffuse through the membrane
which separates the two different bloods, and the salts and soluble
proteids necessary for the child's nutrition, as well as the water
necessary for its vital processes, all pass through this membrane, but
at no time is there any direct blood connection between mother and
child. Indeed, for a large part of the formative period of the foetus
life, that is, during the first two months of its existence, the ovum
is not very closely attached to the uterus at all, but grows by means
of the vital power which it has within itself.

Nor is there any direct nervous connection between mother and child;
indeed, there are no nerves at all in the placenta, and none in the
cord through which all communications between mother and child must
pass. It seems impossible to explain, then, how maternal impressions
can so effectively pass from mother to child; and indeed, the whole
subject, when looked at in this way, is apt to be considered
legendary, and the facts adduced in support of the theory of maternal
impressions are practically sure to be thought mere coincidences. A
little knowledge here might seem to justify many things that more
complete knowledge fails to be able to find any reasons for.

{68}

There is no doubt, however, that the mother's environment during
pregnancy is in general very important for the perfect development of
the intrauterine child. Many more deformed births are reported after
times of stress and trial, as, for example, after the sieges of great
cities, notably the siege of Paris in 1871, and such scenes of
desolation as occurred during the thirty years' war in Germany. These
are, however, not direct, but indirect effects of maternal
impressions. The development of the human being _in utero_ is an
extremely complicated process. Any disturbance of it, however slight,
is sure to be followed by serious consequences. Disturbances of
nutrition, such as are consequent upon the deprivation that has to be
endured in times of war or during sieges, is of itself sufficient
seriously to disturb even the uterine life of the child. In these
cases, however, there will be no traceable connection between the form
of the maternal impression and the type of deformity that occurs. This
is, however, the essence of the old theory of the direct effect of
maternal impressions, and consequently that theory must fall to the
ground.

From all that has been said, however, it becomes very clear that as
far as possible women should be shielded from the effect of various
nervous shocks during their pregnancy, and that they owe it to
themselves and their offspring to be careful with regard to any morbid
manifestations of feeling that they may detect in themselves.

JAMES J. WALSH.

{69}

VI

HUMAN TERATA AND THE SACRAMENTS

Teratology ([Greek text], a monster) is a part of biology that treats
of deviation from a normal development in man and the lower animals.
The name was adopted in 1822 by the elder Saint-Hilaire, who then
attempted to separate the results of modern exact methods of research
from the myths and loose descriptions of monsters found in the
writings of old authors. Cicero (_De Divinatione_) derives the term
monster from the proper preternatural signification looked for in the
occurrence of these abnormal beings: "Monstra, ostenta, portenta,
prodigia appellantur, quoniam monstrant, ostendunt, portendunt et
predicunt."

At the end of the seventeenth century Malpighi and Grew discovered
that plant tissue is entirely made up of microscopic spaces enclosing
fluid; they called these spaces _cells_. Different investigators found
that animal tissue is also composed of cells; and between 1835 and
1839 Schwann and Schleiden formulated the law that every metazoic
organism is made of cells, and starts from a cell.

In 1672 de Graaf discovered the mammalian ovum, in 1675 Ludwig Ham
found spermatozoa, in 1827 von Baer recognised the human ovum, but not
until 1875 was the important fact established that fertilisation is
effected by the fusion of the male and female pronuclei. This was
demonstrated by Oscar Hertwig from observation of the ova of
starfishes.

Mammalian ova, owing to an almost complete lack of yolk, are all
small. The egg of a whale is about the size of a fern-seed, but the
yolked eggs of birds are large--that of the great auk was 7.5 inches
long. In man the ovum is from 0.18 to 0.2 mm. in diameter, scarcely
visible to the {70} naked eye, and the spermatozoon is extremely
minute. The human spermatozoon is only fifty-four thousandths of a
millimetre in length, and from forty-one to fifty-three thousandths of
a millimetre are taken up by its flagellum. The essential part is from
four to six thousandths of a millimetre in length (Dr. L. N. Boston,
_Journ, of Applied Microscopy_, vol. iv. p. 1360). A line of 18 human
spermatozoa would reach only across the head of an ordinary pin. These
spermatozoa have the power of locomotion in alkaline fluid. Henle
found they can travel one centimetre in three minutes.

  The human ovum and spermatozoon are single cells, and the principal
  parts of a typical cell are the cytoplasm (called also the
  protoplasm), and, within this, the nucleus and centrosome. The
  centrosome is efficient in the process of cell-division. A few cells
  have also an outer envelope or membrane, and this part is well
  developed in the ovum.

  The nucleus is the centre of activity in a cell. In the resting
  state it is surrounded by a membrane, and within the membrane is an
  intra-nuclear network made up of chromatin and linin--the chromatin
  is an important element. The meshes of this network are probably
  filled with fluid.

  During the stages preparatory to the mitotic, or indirect, division
  of a cell into two cells (one of the methods of reproduction) the
  chromatin segregates in typical cases into two groups of loops, and
  each group has equal portions of the chromatin. When the chromatin
  is in this shape, a loop is called a chromosome.

  The chromosomes are very important. They occur in constant definite
  numbers in the somatic cells of the various species of many animals
  and plants, and it is probable that each species of plant and animal
  has its own characteristic number of chromosomes. Wilson (_The Cell
  in Development and Inheritance,_ New York, 1890) gives a list of 72
  species in which the number has been determined. Man has probably 16
  chromosomes in the somatic cell, and the mature male and female germ
  cells in man contribute eight chromosomes each to the nucleus of the
  impregnated ovum.

The chromosomes transmit the physical bases of heredity from one
generation to the next, and the heritages from the two parents are
equal except in cases of prepotency. Every cell {71} in the human body
is derived from the father and the mother equally. The fact that the
woman carries a child for months in her womb means only that she
employs a peculiar method of feeding and protecting it. After its
birth she feeds it from her breasts, before birth through its
umbilical vessels, but she originally gives only the eight chromosomes
as the father does, and the child's vital principle builds up the body
from this foundation. The popular notion that the foetus in the womb
is formed through some process of literal abstraction from the
maternal tissues is no more true than that the infant is so built up
while it is suckling; both processes are merely different methods of
feeding.

All the chromosomes from the fathers of at least 200 men could fit
simultaneously on the head of one pin, yet virtually, not merely
potentially, half the bodily substance of that multitude, and all the
physical characteristics derived from the 200 fathers, are indubitably
contained in those chromosomes and nowhere else, unless by a special
creation they are infused with the new soul, which seems to be an
altogether unreasonable alternative. This statement concerning the
minuteness of the chromosomes is not speculation--they can readily be
seen and measured with the aid of the microscope.

A human being, then, obtains eight microscopic chromosomes from his
father and eight from his mother, positively nothing more except food;
yet he develops into a man with a body made up of countless millions
of cells which expand into more than 200 bones in the skeleton and
over 200 muscles,--into the fascias, ligaments, tendons, the great and
small glands, the lymph and blood systems, the respiratory and
alimentary tracts, the skin and its appendages, and a nervous system,
which alone furnishes material for years of study if we would learn
its anatomy fully. Not only all this, but the man commonly closely
resembles his father or his mother, or some other ancestor, in
personal appearance, in certain physical tendencies, in graces or
blemishes; and furthermore, he shows inherited racial characteristics.

If a father is prepotent, he may have a greater effect in producing
the formed child than the mother has, and _vice versa,_ as when a son
closely resembles his father or his mother. {72} Prepotency, moreover,
may extend down through generations and centuries. In the streets of
Palermo to-day typical Normans may be seen, despite the intermarriages
of centuries, who are the descendants of those male Normans that went
down to Sicily with Tancred. There are Romans there, too, and
Saracens. When the Belgae--a race of tall, red-bearded men, with
elliptical skulls--went from the continent of Europe to Ireland,
probably six centuries before our era, they conquered the aborigines,
a gentle, brune race of lower stature. These Belgae became the
ancestors of the chieftain class, and their physical type persists
until to-day; so does that of the Pictish aborigines. Daniel O'Connell
had a typical Belgic body. Other big, blond Irishmen are Norse or
Danish in remote origin.

  How is the extremely complex human body with its various physical
  characteristics built up from the nucleus of a fecundated cell, the
  ovum? The endeavour to answer this question has brought out most
  ingenious speculation from nearly all the great biologists of modern
  times. The question is the foundation of the theories of heredity,
  and it is also fundamental in the theories of evolution.

  The human ovum is a flattened spherical cell, made up of a very
  delicate cell-wall, called the vitelline membrane; outside this is a
  comparatively thick membrane, the zona pellucida, which is properly
  not a part of the cell. Within the vitelline membrane is a granular
  cytoplasm, the vitellus (yolk), and in this lies the nucleus, which
  in the old text-books was called the germinal vesicle. This nucleus
  contains a nucleolus.

  The human spermatozoon consists of a flattened head which has a thin
  protoplasmic cap extending down two-thirds of its length. In the
  head is the nucleus with the chromatin. Beyond the head is the neck,
  which contains the anterior and posterior centrosomes. Behind the
  neck is the tail, or flagellum, in three parts,--the middle piece,
  the principal part, and the end piece. From the neck to the end of
  the tail centrally runs a bundle of fibrils, the axial filament. In
  the middle piece these fibrils are wrapped within a single spiral
  filament which winds from the neck down to the annulus at the
  beginning of the principal part, and lies in a clear fluid. Without
  the spiral filament, along the middle piece, is the mitochondria, a
  finely granular protoplasmic layer. The principal part of the tail
  consists of the axial {73} filament enclosed in an involucrum, and
  the end piece is made up of this filament without the involucrum.

  The head and neck of the spermatozoon, which contain the nucleus and
  centrosomes, are the essential parts, and the middle piece and the
  remainder of the tail appear to be used solely for locomotion and
  penetration. When the head penetrates the ovum, the tail is detached
  and rejected.

  Our knowledge of the initial stages in the development of a human
  embryo is derived indirectly from the observation of other mammals.
  There are nine early human embryos reported, and the average
  probable age of these is twelve days. Breuss' specimen was probably
  ten days old (_Wiener med. Wochenblatt,_ 1877). Peters (_Einbettung
  des mensch. Eies,_ 1899) found a smaller embryo than this. The
  Breuss ovum was 5 mm. in length; Peters' was 3 by 1.5 by 1.5 mm.,
  but the probable age was not given. There have been numerous embryos
  more than twelve days old observed, and since the process after the
  twelfth day is identical in man and the higher mammals, there is no
  doubt that the first stages are also the same.

  The segmentation that makes new cells is complicated, and the
  outcome of the division is a ball of cells. In eggs which have a
  large yolk, like those of birds, the cells form a round body resting
  on the surface of the yolk, but in mammalian ova a hollow ball of
  cells, or a _Morula,_ results, which lines the internal surface of
  the cellular envelope. The ovum absorbs moisture by osmosis and
  enlarges, and about the twelfth day after the germ-nuclei have begun
  to divide, the Morula, or hollow ball of cells, called also the
  _Blastodermic Vesicle,_ is formed.

  The next stage in development is the establishment of two primary
  germinal layers, called together the _Gastrula_, The outer layer is
  the _Ectoderm_ or the _Epiblast,_ and the inner layer is the
  _Endoderm_ or _Hypoblast_. In a Morula the smaller cells, which
  contain less yolk-material, gradually grow around the larger
  yolk-containing cells to form the Gastrula.

 Between the Ectoderm and the Endoderm a layer of cells called the
 _Mesoderm_ or _Mesoblast_ is next formed, and from these three layers
 all the parts of the embryo are built up. From the outer Ectoderm and
 the inner Endoderm those organs arise which are in the body, outer
 and inner,--as the nervous system and the outer skin from the
 Ectoderm, the inner entrails, the lungs and liver, from the Endoderm.
 From the Mesoderm come the inner skin, the bones and muscles.

  By this time the embryo is a minute longitudinal streak at the {74}
  surface of one pole of the ovum. The "Primitive Trace" is like a
  long inverted letter U, the legs of which are in apposition. The
  Primitive Trace becomes a circular flattened disc; and it grows into
  a cylindrical body by the juncture of the free margins which fold
  downward and inward and meet in the median line, and this closes in
  the pelvic, abdominal, thoracic, pharyngeal, and oral cavities. The
  legs and arms bud from this cylinder later. While the ventral
  cylinder is growing, another longitudinal cylinder is formed along
  the upper surface of the embryo, which will contain the brain and
  the spinal column. The subsequent development of the embryo and
  foetus need not be known for an understanding of the material
  considered in treating here of terata.

Human terata occur in certain rather definite, types of erroneous
development, and the classification of Hirst and Piersol (_Human
Monstrosities_, Philadelphia, 1891), which is a combination and change
of the classifications of Geoffrey Saint-Hilaire, Klebs, and Förster,
is the most satisfactory. There are four great groups of abnormally
developed human beings: (1) Hemiteratic; (2) Heterotaxic; (3)
Hermaphroditic; (4) Monstrous.

Hemiterata are giants, dwarfs, persons showing anomalies in shape, in
colour, in closure of embryonic clefts, in absence or excess of
digits, or having other defects. This group does not come under
discussion here, but attention should be called to the fact that women
who are dwarfs are to be warned before marriage that they cannot be
delivered normally,--that the caesarean section or symphyseotomy will
be necessary, or that certain physicians will practise craniotomy in
delivering them.

The Heterotaxic group comprises persons whose left or right visceral
organs are reversed in position through abnormal embryonic
development; the liver is on the left side, the heart points to the
right, and so on.

Of the next group, the Hermaphroditic, it may be said that a true
hermaphrodite, in the full sense of the term, has not been found; but
there have been several examples of individuals who had an ovary and a
testicle, and other rudimentary sexual organs that belonged to both
male and female. Forms of apparent doubling are common, and in case of
doubt as to sex the probability leans toward the {75} masculine side.
As to marriage in such cases, questions may arise that are to be
settled by the anatomist. In dealing with double monsters it is
sometimes difficult or impossible to determine whether we have to do
with one or two individuals, and this difficulty has serious weight,
especially in the administration of baptism. It is improbable that
there is a doubling of personality in hermaphrodites. A striking
characteristic of compound terata is that the individuals are always
of the same sex; moreover, the embryonal development of reproductive
organs in general is such as almost to preclude a question of duality
of personality.

Terata, more properly so called, are divided into single, double, and
triple monsters. Single monsters may be autositic, or independent of
another embryo or foetus; or they may be omphalositic, that is,
dependent upon another embryo or foetus, which is commonly well
developed, and which supplies blood for both through the umbilical
vessels. When an omphalosite exists, the other foetus is called, in
this case also, the autosite.

The first order of autositic single monsters contains four genera with
eight species, and under these species are thirty-four varieties. They
may have imperfect limbs, no limbs, one eye in the middle of the
forehead (_cyclops_), fused lower limbs (_siren_), and so on. Some of
these monsters show a strong resemblance to lower animals, but there
is no record that is in any degree scientific of a hybrid between a
human being and a lower animal.

There are two genera of the omphalositic single monsters, with four
species. One of the twins, the autosite, is commonly a normal child;
the other, the omphalosite, may be as small as a child's fist, and be
very much deformed. Of these omphalosites the _paracephalus_ has an
imperfect head, commonly no heart, and the lungs are absent or
rudimentary. The _acephalus_ has no head, and commonly no arms; the
_asomata_ is a head more or less developed, with a sac below
containing rudiments of the trunk organs. The Acephalus is very
rare--the rarest of all monsters except the Tricephalus. There is a
fourth kind--the _foetus anideus_. This is a shapeless mass of flesh
covered with skin. There may be a {76} slight prominence with a tuft
of hair on it at one end of the mass to indicate the head. In this
monster there are more traces of bodily organs than might be expected.
These four kinds of omphalosites are either dead when born, or they
die as soon as the placental circulation is cut off. If there is any
probability of life, the physician should give them baptism before the
placental circulation is stopped.

  Nothing satisfactory is known concerning the etiology of single
  monsters. Landau, and other authorities as great as he is, reject
  the theory that maternal impressions from fright or exposure to the
  sight of hideous deformity are the cause of terata. I think the
  father is accountable for terata as often as the mother is. Barnes,
  an English physician, and others claim they find that terata are
  frequent in consanguineous marriages, but I have not been able to
  verify the assertion.

  It seems a theory may be offered to explain the single terata. In
  1888 Roux of Breslau by puncturing one blastomere of a frog's egg in
  the two-cell stage killed the punctured blastomere without affecting
  the other. The punctured blastomere remained inactive, but the other
  developed into a complete _half_ embryo.

  Crampton by separating and isolating the blastomeres in the two-cell
  stage obtained a half embryo; and Zoja by isolating blastomeres of
  the medusae, Clytia and Laodice, got _dwarfed_ larvae.

  Wilson succeeded by the separation through shaking of the
  blastomeres in the two-cell and four-cell stages in developing
  Amphioxus larvae, which were half the natural size for the two-cell
  blastomeres, and commonly half the normal size from the four-cell
  blastomeres, yet in the latter some of the larvae were of the normal
  size but imperfect From the eight-cell stage he got only _imperfect_.
  larvae. Similar results were obtained by other operators with
  various eggs.

  Driesch and Morgan by removing part of the cytoplasm from a
  fertilized egg of the ctenophore, Beroe, produced imperfect larvae
  showing certain defects which represent the parts removed.

  In these cases of injured and isolated blastomeres we have, it seems
  to me, a plausible theory for the etiology of single terata. The
  blastomeres in the human ovum may perhaps be injured in part by
  toxins from the mother, or they may be defective through disease in
  the ovum or the spermatozoon. They also may possibly be displaced
  traumatically, but this seems to be doubtful.

  There are three theories concerning the origin of omphalositic {77}
  terata. Ahlfeld (_Missbildungen des Menschen_, Leipsic, 1882) holds
  that the autosite is stronger than the omphalosite, and as a
  consequence the foetal circulation in the omphalosite is reversed,
  and development is thus checked. Dareste (_Production artificielle
  des monstruosités_, Paris, 1876), Panum (_Beitrag zur Kenntniss der
  physiol. Bedeut. der angeboren Missbildungen, Virchow's Archiv.,_
  1878), Perls (_Lehrbuch der allgem. Pathologie_) and Breus (_Wiener
  med. Jahrbuch_, 1882) maintain there is an inherent original defect
  in the omphalositic child which prevents development of the
  blood-vessels, and that Ahlfeld's theory of an indirect umbilical
  connection of the omphalosite to the placenta is not probable; if it
  were, omphalosites would be very common, because one of twins is
  nearly always stronger than the other. Hirst and Piersol (_op. cit_)
  combine these theories. This kind of monster is certainly an
  imperfectly developed human individual, and even the Foetus Anideus
  should receive at the least conditional baptism.

The next group comprises the composite monsters. Normal twins may
arise from the fertilisation of one ovum and of two distinct ova. In
506 cases examined by Ahlfeld he found that 66 twin births came from
single ova. Twins from a single ovum are always of the same sex, and
they are not easily distinguished one from the other. Triplets may
arise from one, two, or three ova. The elder Saint-Hilaire thought
that composite monsters arise from the fusion of two impregnated ova,
but this opinion is now generally rejected. Composite terata in every
instance arise from a single ovum.

  There is a divergence of opinion, however, as to the origin of a
  composite monster in the single ovum. Some authorities maintain that
  these monsters arise from the union of two originally separate
  primitive traces. This supposes primitive duality followed by fusion
  (_Verwachsungstheorie_). Other writers hold that there is originally
  one primitive trace, and that composite terata are the product of a
  more or less extensive cleavage of this single blastoderm. This
  supposes primitive unity followed by fission (_Spaltungstheorie_).
  Here, as in the case of normal development, the argument is founded
  on analogy. The earliest stage in the development of a human double
  monster observed was at the fourth week after
  fertilisation--Ahlfeld's case.

  B. Schultze (_U. anomale Duplicität der Axenorgane, Virchow's
  Archiv._) and Panum and Dareste (_op. cit._) hold the fusion
  theory-- {78} the fusion of two separate blastoderms in one ovum.
  Panum and Dareste have seen two separate normal blastoderms on one
  ovum. Allen Thompson in 1844 (_London and Edinburgh Monthly Journal
  of Medical Science_), Wolff, von Baer, and Reichert also observed
  two embryos in one ovum. Dareste is of the opinion that the fusion
  of two separate ova is impossible. The fission theory--the fission
  of a single blastoderm to make a composite monster--is supported by
  Wolff, J. F. Meckel, von Baer, J. Müller, Valentine, Bischoff, and
  others, especially by Ahlfeld. Ahlfeld says that this single
  blastoderm is split by pressure.

  Gerlach also (_Die Entstehungsweise der Doppelmissbildungen, etc.,_
  Stuttgart, 1882) admits fission, but he contends that it is not so
  simple a process as Ahlfeld thinks it is. It is not a passive
  cleavage, but a result of a force in the cell-mass existing before
  differentiation. Gerlach calls fission at the anterior or head-end
  of the single blastoderm, _bifurcation_; and he has actually
  observed such bifurcation in a chick embryo of sixteen hours (_U. d.
  Entstehungsweise der vorderen Verdoppelung. Deutsche Archiv. f.
  klin, Med.,_ 1887). In this case the first change noticed was a
  broadening of the anterior end of the primitive streak; next a
  forked divergence appeared, and this became more pronounced; until
  by the twenty-sixth hour the bifurcation was half as long as the
  undivided posterior part. From each anterior end of the diverging
  branches a distinct head-process extended. Allen Thompson (_loc.
  cit._) in 1844 saw a goose-egg, which had been incubated for five
  days, in which was a double monster divided to the neck.

  Beyond this observation by Gerlach we have the fact, which seems to
  make for the fission theory, that no matter how unequally nourished
  or how variable in extent, the union between the halves of double
  monsters is always symmetric--exactly the same parts of each twin
  are joined. This seems to exclude a fortuitous growing together of
  dissimilar areas or cell-masses, for non-parasitic double terata at
  the least. Born ( _U. d. Furchung des Eies bei Doppelbildungen,
  Breslauer Aerztl. Zeitschr._, 1887), in a study of fish ova, found
  that ova which produce double monsters begin with a segmentation
  like that of the single normal ovum.

  If fission is complete homogeneous twins are the result; these twins
  are of the same sex and very similar in appearance. Incomplete
  fission, as has been said, gives rise to double or triple terata. If
  one of the teratic twin embryos is stronger than the other, the
  various combinations of enclosure and parasitism may result,
  although the origin of parasitic double terata is not convincingly
  clear. A triple {79} monster, according to the fission theory,
  arises from a double incomplete cleavage of the primitive trace. Dr.
  Ephraim Cutter has observed teratic composite spermatozoa which, he
  thinks, probably have influence in producing composite monsters.

There are three orders of the double autositic monsters: _Terata
Katadidyma,_ in which the embryonal fission was at the cerebral end;
the _Terata Anadidyma_, divided below; the _Terata Anakatadidyma_,
divided above and below, but joined at the middle of the body. There
are four genera of the Terata Katadidyma with many species. The first
genus is the _Diprosopus,_ the double-faced. The doubling varies from
the finding of two complete faces to a slight trace of duplex
formation in one head. Förster in 500 human monsters observed 29 cases
of diprosopi.

There are six species of diprosopi: 1. _D. Diophthalmus,_ which has
only two eyes, but there is a doubling of the nose. 2. _D. Distomus_,
which has two mouths, two lower jaws, two tongues, one pharynx, and
one oesophagus. 3. _D. Triophthalmus_, which has three eyes, and the
doubling of the face is more complete. There are only two ears. 4. _D.
Tetrophthalmus_, which has four eyes and two well-separated faces. 5.
_D. Triotus_ is like the last, but it has three ears. 6. _D. Tetrotus_
has four ears, four eyes, and there is some doubling at the pharynx.
Two oesophaguses enter one stomach in this species commonly. D.
Tetrotus is rare--only one example in man is known. In all diprosopi
there is only one trunk, one pair of arms, and one pair of legs. Sir
James Paget had a photograph, made in 1856, of a living diprosopus,
the second face of which had a mouth, nose, eye, part of an ear, and a
brain (?) of its own. The two faces acted simultaneously, suckled,
sneezed, yawned together.

Are diprosopi twins? An answer to this question will be clearer after
a description of other composite terata.

The second genus of the Terata Katadidyma is the _Dicephalus_. This
genus comprises five species, which have in each case two heads, with
separate necks commonly. There are two vertebral columns, which
usually are separate down to the sacrum, and they converge at the
lower end. {80} In the interior organs doubling will be found
corresponding to the degree of separation of the trunks. In all the
species of this genus there are one umbilicus and one cord.

The first species of the Dicephalus is the _Dicephalus Dibrachius_--a
two-armed, double-headed monster. In this species most of the viscera
are single, but the right and left halves of each viscus are supplied
by the respective foetuses, and the entrail does not become
indistinguishably single until near the lower end of the ileum. There
may be two ordinary kidneys and a third smaller one, two pancreatic
glands, and two gall-bladders. Such a monster may be monauchenous or
diauchenous.

The next species is the _Dicephalus Tribrachius Dipus_--two heads,
three arms, and two legs. There is also a _Dicephalus Tribrachius
Tripus_ (three arms and three legs), _D. Tetrabrachius Dipus_ (four
arms and two legs), and _D. Tetrabrachius Tripus_ (four arms and three
legs). In all these cases there is no doubt of the presence of twins,
unless there might be some doubt as to dual personality in the
Dicephalus Dibrachius. In the Dicephalus Tetrabrachius Dipus and the
Dicephalus Tetrabrachius Tripus there is almost complete duplication
of the internal organs, and the halves of the composite body belong
evidently to individuals distinct in thought, volition, and character.
Each brain controls only its own half of the body. There are four
lungs, two hearts (sometimes in one pericardium), two stomachs, two
intestinal canals down to the colon or lower, two livers (sometimes
joined), four kidneys (or three, one of which is small), two bladders,
emptied at different times through a common urethra.

Dicephali are somewhat common. Förster found 140 among 500 specimens
of monsters. They are rarely born alive. The best known cases of
dicephali that lived for any length of time are:

1. Peter and Paul, of Florence, born in 1316, lived thirty days.

2. The Scotch Brothers, born in 1490, lived twenty-eight years. They
were at the court of James III. Above the point of union the twins
were independent in sensation and action, but below the point all
sensation and action were {81} common. One died before the other, and
the second "succumbed to infection from putrefaction" a few days
later.

3. The Würtemberg Sisters, born in 1498.

4. The twins, Justina and Dorothea, born in 1627, lived six weeks.

5. Boy twins at Padua, born in 1691, lived to be baptised.

6. Rita-Cristina, born at Sassari in Sardinia in 1829. They lived
eight months. These children had a common trunk below the breast, one
pelvis, and one pair of legs. Rita was feeble and quiet, Cristina
vigorous and lively. They suckled at different times; and sensation in
the heads and arms was individual, but below the junction it was
common. Rita died of bronchitis, and during Rita's final illness
Cristina was healthy; but when Rita died, Cristina, who was suckling
at the time, suddenly expired. They had two hearts in one pericardium,
the digestive tracts did not fuse until the lowest third of the ileum
was reached. The livers were fused, the vertebral columns were
distinct throughout. These twins were baptised separately.

7. Marie-Rose Drouin, born in Montreal in 1878. They lived seven
months. Marie died of cholera infantum; and Rose then died, although
she had not been directly affected by the disease. These twins were
like Rita-Cristina anatomically except that they had no legs. The
respirations and heart-pulsations differed, and one child slept while
the other child cried.

8. The Tocci boys, born in Turin in 1877. In 1882 they were strong and
healthy, and they may be living still. They resembled Rita-Cristina
anatomically in every respect. Each boy had control of the leg on his
own side, but not of the other leg, consequently they could not walk.
Their sensations above the juncture were distinct, and their thoughts
and emotions differed.

In the Paris _L'union médicale_ there is an account of a bicephalic
still-born monster, born at Alexandria in 1848, which, according to
the report, had on one side a typical negro head and on the other side
a typical Egyptian fellah head. This report is probably not authentic;
but if it is, it would be difficult to reconcile it with the fission
theory. {82} Supposing the report true, the case would have to be one
(1) of superimpregnation wherein (2) a spermatozoon from each source
penetrated the same ovum, (3) a bicephalic monster resulted, with (4)
distinct racial characteristics. All this is extremely improbable.

Superimpregnation has happened. There are cases where negresses have
given birth to twins, one of which was a negro and the other a
mulatto. Instances are cited in books on Legal Medicine like those of
Tidy and Beck. In Flint's Physiology a case is recorded in which a
mulatto woman in Kent County, Virginia, married to a negro, gave birth
to twins, in 1867, one of which was a negro much blacker than the
mother, and the other a white child, with long, light, silky hair, and
a "brilliant complexion." The white child's nose was shaped like the
mother's, but there was no other resemblance. Even supposing this to
be a case of superimpregnation, that does not fully explain the
extreme whiteness of one child and the extreme blackness of the other.

Superfoetation is also possible. Tidy (_Legal Medicine_) gives a case:
"Mary Anne Bigaud, at thirty-seven, on April 30th, 1748, gave birth to
a full-term mature boy, which survived its birth two and a half
months, and to a second mature child (girl) on September 16th, 1748,
which lived for one year." The second child was born four and a half
months after the first, and both were "nine-months" children. It was
proved after death in this case that the mother had not a double
uterus, and the report is vouched for by Professor Eisenman, and by
Leriche, surgeon-major of the Strasburg Military Hospital. Several
other cases of superfoetation are given by Bonnar (_Edin. Med.
Journ.,_ January, 1865).

The third genus of Terata Katadidyma is the _Ischiopagus_. These twins
are divided so much from above downward that the heads are at almost
opposite ends of the double body. They are joined at the coccyges and
sacra, and the spinal columns have nearly the same axis. The trunk
organs are complete and separate, except that they are commonly fused
in the pelvis. There may be two, three, or four legs, given off at
right angles to the pelvis. This kind of monster is not rare. Förster
collected twenty cases, and nine new examples {83} were reported in
the _Index Medicus_ between 1879 and 1893. Ischiopagic twins were born
in County Roscommon, Ireland, in 1827, and baptised separately. The
Jones Twins, born in Typhon County, Indiana, in 1889, lived for about
two years; they were ischiopagi, and they had the very unusual
quality, it is said, that they differed in complexion and the colour
of eyes and hair. A case was reported in _American Medicine_,
September, 1903.

Classed with the Katadidyma is the genus _Pygopagus_, although it has
four legs. This form is very rare. The twins are joined only by the
latero-posterior aspects of the sacra and coccyges, so that the two
individuals are placed almost back to back. The trunk organs are
independent, except for some fusion near the point of juncture.
Examples of this class are the Hungarian Sisters, born at Szony in
1701, who lived to womanhood; the negresses Millie-Christine, born in
1851, and who were recently living in North Carolina; and the Blazek
Sisters of Bohemia. The negresses had common sensation in the legs,
but Millie could not localise what part of Christine's legs was
touched, and _vice versa_.

The second group of the double autositic monsters are _Terata
Anadidyma_--terata divided from below upward. The first genus is the
_Dipygus_. This has a single body above, but a double pelvis with
double lower extremities in the typical cases. There is an exact
description of a double monster of this kind in the Gaelic _Annals of
the Four Masters_ as early as the year 727 of this era. The chronicler
says in that year on Dalkey Island near Dublin, "There was a cow seen
which had one head and one body as far as her shoulders, two bodies
from her shoulders hindward, and two tails. She had eight legs, and
she was milked three times a day."

A perfect human Dipygus with two equally developed pairs of legs is
unknown. Catherine Kaufmann, who was born in 1876, and who died in
1878, had a double pelvis with double pelvic organs in part, but she
had only one pair of legs. There is a similar anomaly said to be
living in Philadelphia at present. Blanche Dumas, born in 1860, had a
double pelvis, double pelvic organs, and three legs. Mrs. B., born in
1868, {84} had four legs--the two inner ones were smaller than the
outer pair. Her spinal column was divided up to the third lumbar
vertebra. Her double pelvic organs acted independently. There are
living male examples of this form of monster.

The next genus is the _Syncephalus_, called also _Janus_ and
_Janiceps_. Its lower body is double up to the umbilicus, the trunk
single above that point; the head shows signs of doubling, and there
are four legs and four arms; the bodies grow front to front. The head
usually is large, therefore this monster is born dead.

Another genus is the _Craniopagus_--twins joined only by the skull or
scalp. There are three species, named from the place of
union--_Craniopagus Frontalis, C. Parietalis_, and _C. Occipitalis_.

A third group of double autositic monsters are the _Terata
Anakatadidyma_, which are divided above and below, but joined from the
navel to the head. There are three genera. The first, the
_Prosopothoracopagus_, is joined at the upper abdomen, the chest, and
the faces; the spinal columns are separate. The faces are imperfect,
the jaws are united; there is a broad neck with one oesophagus, and
there is one stomach and one duodenum. This is a rare form, and it can
not exist out of the uterus.

A second genus, the _Thoracopagus_, has a thorax in common, and the
inner legs may be united. It is, as a rule, still-born.

The next genus is the _Omphalopagus_, in which the twins are joined
from the navel to the bottom of the chest. This double monster has the
slightest union of all, and it is very rare. The Siamese Twins were
omphalopagi. They quarrelled; one became a drunkard and the other
remained temperate. They married two women, and Chang had ten
children, and Eng twelve. Chang died while Eng was asleep, and the
latter died two hours after he had waked and learned of his brother's
death.

There is a genus, the _Rachipagus_, the examples of which are joined
behind like the class Terata Anakatadidyma that are joined in front.

{85}

Four known attempts have been made to separate double monsters
surgically, but all failed owing to crude surgery; modern methods
might be successful in some cases.

The second order of double monsters comprises the parasitic class.
There are three genera of these terata, with five species and
seventeen varieties. The chief of these only will be mentioned. The
_Heterotypus_ is a parasitic child which hangs from the abdominal wall
of the principal subject. Varieties of this species are the
_Heteropagus_, which is a parasite with head and arms; the
_Heterodelphus_, which has no head; the _Heterodymus_, which has a
head, neck, and thorax. The _Heteralitis_ is a second species, in
which the parasite is inserted at a distance from the navel of the
autosite. The _Epicomus_ is the only example, and it consists of a
parasitic supernumerary head. The _Polypnathus_ is a parasite attached
to the jaw of the autosite. When fastened to the upper jaw, it is an
_Epignathus_; at the lower jaw it is an _Hypognathns_. Another group
is made up of terata having parasitic legs which are attached to
different parts of the autosite,--to the pelvis, the head, the
abdomen, and so on. Finally, there is the _Endocyma_, which is a
parasite enclosed within the body of an autosite.

Parasites are nourished through the blood supply of the autosite, and
the parasites usually are incapable of motion. The autosite can feel
when the parasite is touched, and in some cases the autosite can
localise the touch. In India, in 1783, a child was born which had a
supernumerary head attached to the autositic head, crown to crown; it
lived four years. The parasite's eyes were always partly open, but
they appeared to be incapable of intelligent vision. They contracted
under strong light, and when the autosite was suddenly awakened both
sets of eyes moved.

Gould and Pyle (_Anomalies and Curiosities of Medicine_) give an
account of an Italian boy, aged eight years, who had a small parasitic
head protruding from near the left third rib. Sensibility was common.
Each of the heads received baptism (one was called John and the other
Matthew), and there was question as to whether extreme unction should
be administered to the parasitic head. A similar case occurred in {86}
England in 1880 (_British Med. Journal_), and the parasitic head could
be pinched without attracting the attention of the autosite.

Teratologists now exclude Dermoid Cysts from the lists of terata. The
hair, teeth, and particles of bone found in these cysts are looked
upon as the development of abnormal ectodermic and endodermic cells,
rather than as evidence of a separate personality.

There is only one well-authenticated case of a triple monster, and
this happened in Italy in 1831. The monster had a single broad body
with three distinct heads and two necks. It was killed in delivery.

In Katadidyma (terata divided from above downward), when we have
dicephali, ischiopagi, or pygopagi, there are evidently two
individuals present. Is the Diprosopus, however, the two-faced
monster, possessed of one or two souls? The cases vary, as we said,
from examples with two distinct faces and four ears to cases that have
merely two noses. What portion of a human body is required to contain
a new soul? That is an interesting question for the psychologist and a
very practical one for the moralist, and no moralist has yet attempted
to solve it. The presence of a brain is not essential, because
acephalous monsters develop without brain, and they are born alive;
they have a vital principle which is identical with the soul.

Among the Terata Anadidyma (divided from below upward) the Syncephalus
and the Craniopagus are unquestionably two persons. Is the Dipygus
(single down to the navel, double below) one or two persons? Mrs. B.,
the example already given, was as double below the navel as any
Dicephalus is above that point. She had features so well ordered in
unity that she was a pretty woman, but that unity ceased at her waist.
Was her husband unknowingly a bigamist? I think he was. After a
consideration of the fission of terata, and the non-essential quality
of the brain, why should fission that started at the feet differ from
fission that started at the head?

In the _Rituale Romanum Pauli V._ (tit. ii. cap. i. nn. 18, 19, 20,
21), the following directions for the baptising of terata are given:

{87}

  18. In monstris vero baptizandis, si casus eveniat, magna cautio
  adhibenda est, de quo si opus fuerit, Ordinarius loci; vel alii
  periti consulantur, nisi mortis periculum immineat.

  19. Monstrum, quod humanam speciem non praeseferat, baptizari non
  debet; de quo si dubium fuerit, baptizetur sub hac conditione: _Si
  tu es homo, ego te baptizo,_ etc.

  20. lllud vero, de quo dubium est, una ne, aut plures sint personae,
  non baptizetur, donec id discernatur: discerni autem potest, si
  habeat unum vel plura capita, unum vel plura pectora; tunc enim
  totidem erunt corda et animae, hominesque distincti, et eo casu
  singuli seorsum sunt baptizandi, unicuique dicendo: _Ego te
  baptizo_, etc Si vero periculum mortis immineat, tempusque non
  suppetat, ut singuli separatim baptizentur, potent minister
  singulorum capitibus aquam infundens omnes simul baptizari, dicendo:
  _Ego vos baptizo_, in nomine Patris, et Filii, et Spiritus sancti.
  Quam tamen formam in iis solum, et in aliis similibus mortis
  periculis, ad plures simul baptizandos, et ubi tempus non patitur,
  ut singuli separatim baptizentur, alias numquam, licet adhibere.

  21. Quando vero non est certum in monstro esse duas personas, ut
  quia duo capita et duo pectora non habet distincta; tunc debet
  primum unus absolute baptizari, et postea alter sub conditione, hoc
  modo: _Si non es baptizatus, ego te baptizo in nomine Patris, et
  Filii, et Spiritus sancti._

   AUSTIN ÓMALLEY.

{88}

VII

SOCIAL MEDICINE

The influence of the clergyman or the charitable visitor in matters of
health and sanitation can scarcely be overestimated. The removal of
prejudices with regard to sanitary regulations for the prevention of
disease and modern advances in the treatment of disease is an
important social duty. There is no doubt that if this influence be
properly directed, sanitary measures of various kinds will be much
more readily enforced and the precautions necessary to prevent the
spread of serious infectious ailments more faithfully observed. As
this amelioration of sanitary conditions will affect mainly the poor,
lessening their suffering and adding to their possibilities of
happiness, its accomplishment becomes a great Christian duty,
obligatory on all those who are interested in the uplifting of the
poorer classes.

Professor Virchow, the distinguished German pathologist, used to say
that popular medicine was in all ages at least fifty years behind
scientific medicine. He had himself discovered the principles of
cellular pathology nearly half a century before his death, yet he
declared that the popular mind still believed in the old doctrines of
humoral pathology,--that is, that the conditions of health and
disease depended on the constitution of the fluids of the body (the
blood, the bile, the mucus, and so forth), and had not generally
accepted modern advances in medical knowledge of the underlying basis
of disease in the solid tissues. There is no doubt that many
old-fashioned notions long since discredited by physicians are still
very generally accepted by the popular mind, and even the intelligent
classes sometimes harbour convictions with regard to the good or evil
effects of habits {89} of life, diet, and the operation of drugs of
various kinds that are entirely contrary to present-day medical
knowledge.

It is extremely important, then, that the clergyman or charitable
visitor, in giving views on medical matters, which are sure to have
much more weight than he perhaps attributes to them himself, should be
careful not to make statements for which he has not good authority in
modern medical science. It is very easy, in a matter of this kind, to
state principles that are not the result of education, properly so
called, but are gleaned from early false impressions obtained one
knows not how or where, entirely without definite consciousness as to
their real origin. The physician himself finds that he is compelled to
be careful of this same tendency to put too much stress on traditions
with regard to health which he imbibed before he began to study
medicine. It is perhaps not so surprising, then, to hear physicians
complain often that clergymen instead of being a help are sometimes a
hindrance to the enforcement of modern hygienic rules, because they
still cling to old-fogy notions of hygiene and sanitation retained
from a defective early training. Owing to the influence that the
clergyman is sure to exert, this becomes an extremely important
matter. Great harm may be done and the  physician discredited, almost
without a realisation, on the part of the clergyman, that he is
interfering in another's department. Sympathetic coordination of
clerical and medical efforts would accomplish much good that is now
unfortunately left undone.

There is no doubt that for the important crusade against tuberculosis,
for instance, the aid of the clergyman will accomplish much for the
reduction of the death rate from this disease. What is needed at the
present moment is a universal conviction that tuberculosis is not an
hereditary but a communicable disease. This does not mean that it is
virulently contagious and that as a result sufferers from tuberculosis
must at once be segregated from other members of the family and from
the community generally; but it does mean that careful precautions
must be taken with regard to the disposal of sputum, with the
enforcement of the most exacting cleanliness on the part of
consumptives themselves. {90} It also means that the person suffering
from the disease should not sleep with those as yet unaffected, nor be
allowed to live in very close contact, especially with children or
susceptible individuals.

The persuasion that tuberculosis is not hereditary will do much to
encourage patients suffering from the disease to feel that they are
not hopelessly doomed. At the present time it is not unusual to find
patients so discouraged, when told that they have tuberculosis, that
it is almost impossible to secure a favourable reaction to any mode of
treatment. They have seen members of families die one after another,
or they have heard stories of the inevitable way in which consumption
wiped families out of existence, and they give up hope and become
quite cast down. Needless to say, while in this condition any
treatment is practically hopeless. On the other hand, the conviction
that tuberculosis is only an infectious disease, quite curable in the
majority of cases if taken in time, is of itself a most important aid
in the treatment of the disease, since courage and faith are the
principal requirements for successfully combating the affection.

We have had any number of newly invented remedies for consumption in
the last twenty-five years. Scarcely a year has passed in which some
new form of treatment, often eventually proved to be the resuggestion
of an old therapeutic method, has not been heralded as a positive cure
for consumption. In every case the first patients treated by the
discoverer of the new remedy have rapidly improved under his care. In
the hands of others, however, such results have not been obtained, or
only for a very short time at the beginning of the treatment. After a
time the new remedy failed in its inventor's hands. The true reason
for the improvement was then seen to be, not the remedy suggested, but
the favourable influence on the mind of consumptives produced by the
faith of the inventor in his remedy, and their reaction to this
powerful suggestion when they were put under proper conditions of an
abundance of fresh air and a plentiful diet.

This shows, too, the reasonableness of the modern treatment of
consumption, which consists not in the giving of {91} drugs, but in
securing for the patient a plenty of fresh air for many hours a day
and the encouragement to consume a liberal amount of nutritious food.
Most of the much advertised remedies for consumption are really
harmful rather than beneficent. Many of them are ordinary cough
mixtures containing considerable opium, which lessens the cough, it is
true, but also lessens the appetite and locks up the bowels. Besides,
the cough is nature's method of removing material from the lungs which
has become disintegrated, and if allowed to remain will certainly
bring about the spread of the infection in the pulmonary tissues.
Cough is a natural protective reaction to be encouraged, and is not in
itself a source of evil needing to be suppressed. If cough is
bothering the patient so much at night as to cause loss of sleep, then
it is necessary to make a choice between two evils and somewhat to
suppress the cough, even though it involves certain other
inconvenience to the patient. All these so-called consumption cures
contain materials that are almost sure to disturb the appetite and
upset the stomach. The fate of a consumptive patient absolutely
depends on his stomach; just as little, then, of medicine must be
employed as possible. This will indicate the necessity for clergymen
rather advising against than in favour of these proprietary medicines
which have been definitely known to do so much harm in recent years.
Many a patient delays an appeal to medical aid so long, as the result
of trusting to such medicines, that a curable case of consumption
becomes incurable, or else develops to such a condition as to require
years of treatment on the fresh-air, abundant-food plan, where months
would have sufficed before.

A very interesting phase of social medicine is the ease and confidence
displayed by people, often of more than ordinary intelligence, in
recommending various proprietary medicines of which they know nothing
except the fact that someone says he, or more often she, was cured of
something or other by their use. A chance remark like this to a
sufferer becomes a high recommendation. The hardest problem the doctor
has before him is to find out what is really the matter with his
patients. Not infrequently people having apparently the same set of
symptoms are suffering from quite different {92} ailments. A symptom
like a sore throat, for instance, may very well be due to any one of
at least a half-dozen of causes, most of which require their own
peculiar treatment. When the affection under consideration is as
indefinite as a tired feeling, or indigestion, or some one of the many
ailments included under the term biliousness or kidney trouble, from
which people are supposed to suffer, then the diagnosis problem
becomes by far the most serious question in the case, and is often
very difficult. The trained physician prudently hesitates, but the
inexpert in medicine steps in and quite volubly announces what the
ailment is in his opinion, and what will probably do it good. A little
knowledge is indeed a dangerous thing in medical matters. If it be
remembered that there is a very general impression among medical men
now, as the result of recent acquisitions of scientific information
with regard to the origin, pathological basis, and course of disease,
that very probably more harm than good has been done by the
administration of medicines in the past, not only the futility of lay
(or clerical) prescribing will be manifest, but also somewhat of the
amount of harm that may be done.

It is often a matter for painful surprise, then, to find that
clergymen and members of religious communities allow their names to be
used in the recommendation of remedies of whose composition they know
nothing, for a disease of which they know less, if possible. This evil
becomes especially poignant when the columns of our reputable
religious press are allowed to be used for the purpose of exploiting
the public in these matters. The remedies most often recommended are
the so-called tonics. These are best represented by the sarsaparillas,
and by various cures for catarrh, indigestion, and kindred indefinite
ills, of which there are a great many on the market. These are not
secret remedies, since their composition is well known by those of the
medical profession who care to secure the information. Some six years
ago an analysis of most of them was made by the Massachusetts State
Board of Health.   [Footnote 1]

  [Footnote 1: 28th Annual Report Mass. Board of Health; food and drug
  inspection, 1897.]

The principal active agent in all of these   remedies was {93} found
to be alcohol. In most of them it exists in a proportion about equal
to that in which it is supposed to occur in ordinary whiskey. Some of
them are even stronger in alcoholic contents than the whiskey usually
sold in our large cities. This matter has seemed so important that we
give the official figures of the Board of Health.

TABLE

From the Report of the Massachusetts Board of Health

_Tonics and Bitters_

The following were examined for the purpose of ascertaining the
percentage of alcohol in each. Some of them have been recommended as
temperance drinks!

       Per cent, of Alcohol (by volume).

  "Best" Tonic    7.6
  Carter's Physical Extract    22.0
  Hooker's Wigwam Tonic   20.7
  Hoofland's German Tonic   29.3
  Hop Tonic   7.0
  Howe's Arabian Tonic, "not a rum drink"   13.2
  Jackson's Golden Seal Tonic   19.6
  Liebig Company's Coca Beef Tonic   23.2
  Mensman's Peptonized Beef Tonic   16.5
  Parker's Tonic, "purely vegetable," "recommended for inebriates"   41.6
  Schenck's Sea Weed Tonic, "entirely harmless"   19.5
  Atwood's Quinine Tonic Bitters     29.2
  L. T. Atwood's Jaundice Bitters   22.3
  Moses Atwood's Jaundice Bitters   17. 1
  Baxter's Mandrake Bitters   16.5
  Boker's Stomach Bitters   42.6
  Brown's Iron Bitters   19.7
  Burdock Blood Bitters   25.2
  Carter's Scotch Bitters   17.6
  Colton's Bitters   27.1
  Copp's White Mountain Bitters, "not an alcoholic beverage" 6.0
  Drake's Plantation Bitters   33.2
  Flint's Quaker Bitters   21.4
  Goodhue's Bitters 16.1
  Greene's Nervura   17.2
{94}
  Hartshorn's Bitters   22.2
  Hoofland's German Bitters, "entirely vegetable and free from
          alcoholic stimulant"   25.6

  Hop Bitters 12.0
  Hostetter's Stomach Bitters   44.3
  Kaufmann's Sulphur Bitters, "contains no alcohol." As
      a matter of fact, it contains 20.5 per cent, of alcohol
      and no sulphur   20.5

  Kingsley's Iron Tonic 14.9
  Langley's Bitters   18.1
  Liverpool's Mexican Tonic Bitters   22.4
  Paine's Celery Compound   21.0
  Pierce's Indian Restorative Bitters   6.1
  Puritana   22.0
  Porter's Stomach Bitters   27.9
  Pulmonine   16.0
  Rush's Bitters   35.0
  Richardson's Concentrated Sherry Wine Bitters   47.5
  Secor's Cinchona Bitters   13.1
  Shonyo's German Bitters   21.5
  Job Sweet's Strengthening Bitters   29.0
  Thurston's Old Continental Bitters   11.4
  Walker's Vinegar Bitters, "contains no spirit"   6.1
  Warner's Safe Tonic Bitters   35.7
  Warren's Bilious Bitters   21.5
  Wheeler's Tonic Sherry Wine Bitters   18.8
  Wheat Bitters   13.6
  Faith Whitcomb's Nerve Bitters   20.3
  Dr. Williams' Vegetable Jaundice Bitters   18.5
  Whiskol, "a non-intoxicating stimulant, whiskey without its sting"   28.2
  Colden's Liquid Beef Tonic,
      "recommended for treatment of the alcoholic habit"   26.5

  Ayer's Sarsaparilla   26.2
  Thayer's Compound Extract of Sarsaparilla   21.5
  Hood's Sarsaparilla   18.8
  Allen's Sarsaparilla   13.5
  Dana's Sarsaparilla   13.5
  Brown's Sarsaparilla   13.5
  Corbett's Shaker Sarsaparilla   8.8
  Radway's Resolvent   7.9

  The dose recommended upon the labels of the foregoing preparations
  varies from a teaspoonful to a wineglassful, and the frequency also
  varies from one to four times a day, "increased as needed."

  Many so-called tonics not on this list are also known to contain
  alcohol, {95} though not as yet officially analysed so as to give
  exact figures. Most of the cure-alls for women's ills contain
  alcohol in noteworthy amounts, this being in fact usually the only
  active ingredient in them.

As the analyst of the State Board of Health of Massachusetts is a
thoroughly competent chemist, and as these figures have now been
before the public for over five years without any contradiction on the
part of the manufacturers of these remedies, though it is evident how
undesirable the truth of the matter is from an advertising standpoint,
there can no longer be any question as to the authoritativeness of the
proportions of the alcohol in the remedies as given.

It is rather sad to think of mothers giving these remedies to their
children, hopeful of the good they may accomplish, when, as a matter
of fact, it would be so much simpler and just the same in the end, to
give them, instead of a tablespoonful of the favourite sarsaparilla,
whatever it might be, a tablespoonful of dilute whiskey. As was noted
in the volumes on the _Physiological Aspects of the Liquor Problem_
published recently by a sub-committee of the Committee of Fifty for
the investigation of the liquor problem, not a few prominent total
abstinence advocates have put themselves on record as recommending
these remedies, though there can be no possible doubt of the great
harm likely to arise from their use. There are many physicians who
feel sure that some of the alcoholic habits in women, whose origin it
has been hard to account for, were really contracted during this
secret "tippling" process under the form of a tonic remedy. Everyone
knows that any tonic, in order to be effective, has to be gradually
increased, so it is not surprising that in many cases physicians have
heard of patients taking six to ten tablespoonfuls of some tonic
remedy every day. This would be the equivalent, in some cases, of from
three to five ounces of whiskey--a rather liberal allowance even for a
confirmed whiskey drinker.

As noted by the Massachusetts Board of Health, the dose recommended
upon the labels varies considerably, but practically all agree in
suggesting that the amount of the remedy taken shall be increased as
needed. A simple presentation of this subject will surely be
sufficient to arouse clergymen {96} to a proper sense of their duty in
this matter. Senators, judges of Supreme Courts, Congressmen, and even
university professors and teachers may be so benefited by dilute
whiskey, taken early and often, as to be tempted to furnish
testimonials for them (for a due consideration usually), but clergymen
should at least know something of the consequences of their act before
committing themselves.

An almost precisely similar state of affairs obtains with regard to
another class of favourite popular remedies. A number of so-called
blood-purifying remedies have been recommended at various times, and
here, as in other things, it is surprising to find how many
intelligent people lend themselves to the exploitation of the public
in the interests of the proprietary vender, who cares only to sell,
and cares very little what effect his remedies may produce. Most of
the sarsaparillas are said to be blood purifiers. It is surprising
what vogue this word "sarsaparilla" has obtained. A little more than
half a century ago a German chemist and pharmacist announced that the
sarsaparilla plant contained certain principles that could be
extracted by boiling, and that form excellent remedies for atonic and
anaemic conditions. This announcement was received by the medical
profession very kindly, and immediate tests as to the efficacy of the
new remedy were made. As a result of these tests, within a few years
the inefficacy of sarsaparilla became very clear. It is almost
entirely without effect upon the human system. In the meantime,
however, the word "sarsaparilla" was one to conjure with for the
popular mind, and the sarsaparilla remedies began to be manufactured.
Millions have been made on them and out of the public. The only active
agent as regards tonic qualities which they contain is, as we have
said, alcohol. Most of them however, contain at least one other
well-known drug likely to be at least as harmful as alcohol. This is
iodide of potash. Very few of the so-called sarsaparillas are without
a notable proportion of this strong mineral salt, as the Massachusetts
Board of Health said.

"With but few exceptions they contain a considerable percentage of a
very active and powerful remedy, the iodide of potassium. The sale of
such an article in unlimited {97} quantities by druggists, grocers,
and others is censurable. More than this, the method of its sale is
dishonest, since the unwary purchaser is led to believe that he is
purchasing a harmless vegetable remedy, namely, sarsaparilla.

"It may be seriously questioned whether the blood of persons who take
iodide of potassium continuously is not decidedly impoverished,
instead of being purified, as is claimed by the manufacturers. It is
not uncommon to find persons who have used continuously six, eight, or
ten pint bottles of one of these preparations.

"Unlike sarsaparilla, the iodide of potassium is classed among poisons
by nearly every writer upon toxicology."

Practically all the proprietary remedies have their most potent
principle in the supposed mystery of their composition. As a matter of
fact, all are simple prescriptions, well known to physicians, and
owing their successful treatment of many ills much more to the
printer's ink used to secure their sale than to any pharmaceutical
ingredient which they contain. No important remedy has ever been put
on the market by advertising methods. Exposure of the charlatanry of
such methods will not, however, cause an interruption of their sale.
Long ago Barnum said that people wish to be humbugged, and there is no
doubt that they have been, are, and will be humbugged just to the
extent to which they lay themselves open to the alluring methods of
the advertiser. It does seem too bad, however, that the influence of
the clergymen and of religious as well as charitable visitors--an
influence acquired because of the confidential position they occupy
and the feeling of good faith their mode of life inspires--should be
abused for the encouragement and extension of what is manifestly a
great evil.

Alcohol and iodide of potash are not the only drugs likely to do harm
that are incorporated in proprietary medicines. Great complaints have
recently been made with regard to the spread of the cocaine habit in
this country. Not a few of the remedies that are supposed to give
immediate relief to colds in the head contain cocaine in dangerous
amounts; and there seems no doubt that in many cases the drug habit
for this substance has been acquired innocently and {98} unconsciously
at first by the use of such preparations. These are only the more
notable evils likely to result from the indiscriminate employment of
medicines of whose composition there is complete ignorance, and of
whose effect there can be only the judgment dependent upon the
subjective feelings of the patient. It must not be forgotten that the
patient's feelings are for the moment often favourably influenced by
some substance that may do no good to the ailment, though making the
patient less sensitive to any symptoms from which he was suffering;
but in the end doing positive harm, because of the contraction of the
alcohol or some drug habit, or because the suppression of symptoms may
be the very worst thing for the patients, since it allows the
underlying ailment to progress to a serious stage without forcing them
to have it treated _in radice_.

These are only a few examples that show very well the inadvisability
of recommending in any way medicines of which one does not know the
exact contents. The present writer has had one example of how utterly
disingenuous, though one feels much more like calling it rascally, the
manufacturers of so-called patent medicines or proprietary remedies
may be. One of the remedies widely advertised for the cure of
epilepsy, or fits, is announced always as containing no harmful drugs,
no bromide of potash. The manufacturer of the remedy was asked how he
could say any such thing, since it was very evident even to the taste
that the remedy contained bromides. "Oh," he said, "yes, it contains
sodium bromide, but not bromide of potash." Almost needless to say,
sodium bromide is at least as harmful as potassium bromide, and the
advertisement is entirely for purposes of deception.

The poor epileptics have been a source of revenue for quacks and
charlatans as long as history runs. At the present time one not
infrequently finds testimonials from convents, asylums, reformatories,
and the like, asserting the value of some particularly advertised
remedy for this disease. All these remedies contain bromides. The
treatment of epilepsy is now better understood by physicians and it is
generally recognised that the two things that epileptic {99} patients
need are outdoor air and as far as possible all freedom from
responsibility. Bromides will, for a time, control the number and
frequency of the attacks, but if used indiscriminately, and especially
if employed without any proper realisation of their possibilities for
harm, these salts are almost sure to make the condition of the patient
much worse than before, to bring on a state in which mental symptoms
predominate over physical, and in which the patient may go into
dementia, or some form of mental alienation. Especially is this true
with regard to epileptic children. Continuous dosing with drugs of any
kind is sure to do them harm rather than good. Care for their diet and
rest and the removal of all sources of disturbance of their digestive
tract is more important than any other method of treatment.

The poor children have to suffer many things from many people. People
hesitate, as a rule, to accept recommendations with regard to the
administration of drugs to their animals when the person who gives the
recommendation is known not to be an expert in the matter. Almost any
suggestion, however, with regard to the dosing of their children is
likely to be followed by loving but indiscreet mothers. It is well
known now, and in many cases is admitted, that the so-called soothing
syrups so often given to children contain opium in quite appreciable
quantities. Needless to say, nothing much worse than this could
possibly be given to children. The child soon becomes accustomed to
its daily dose of opium and craves the repetition of it. It will not
sleep without it, and as this adds to the sales of the remedy, this
special ingredient continues to put money in the pockets of the
manufacturers, but at the expense of the nervous stability of the
child, and lack of resisting power later in life. It would be hard to
say how many of the nervous wrecks so commonly met with in young
adults now are to be attributed to this unfortunate state of affairs
early in life; but undoubtedly this evil has had much to do with the
noticeable increase in the nervousness of our people. The more nervous
the heredity of the child, the more it must be guarded against such
mistaken methods of inducing sleep, or the result is sure to be
serious.

{100}

Scarcely too much can be said in condemnation of most of the
proprietary remedies for constipation, though it is in this department
of medication that the non-medical are freest with their advice.
First, the cheapest possible drugs are selected by the manufacturers
of such remedies. Secondly, those drugs especially are employed which,
while producing the desired immediate effect, are always followed by a
reaction which requires further use of the medicine. One finds
testimonials, however, from all classes of the community, even from
clergymen, with regard to such remedies, though at the last
international medical congress it was confidently asserted, by three
of the most prominent specialists in digestive diseases in the world,
that the modern problems in digestive disturbances are so much more
intricate than they used to be, and the affections which develop are
so much more difficult of treatment, because of the use of these
unsuitable remedies, and the consequent habituation to drugs, which
has been acquired during the prolonged period of their employment.

In recent years catarrh has become the word that is supposed to
attract popular attention most, and accordingly is the watchword of
the proprietary medicine manufacturer. A long time ago, that is, about
half a century ago, catarrh was supposed really to mean something in
medicine. Those were the days of humoral pathology, when disturbances
of secretion were supposed to be the basis of all disease.
Accordingly, whenever there was an excessive discharge from the nose,
a patient was said to be suffering from catarrh, and as the nasal
secretion was supposed to be connected in some way with the brain, it
is easy to understand how significant such a pathological condition
might well be thought. In more recent years, the word "catarrh" has
still been employed by physicians who thoughtlessly employ terms that
they think will be better understood by the laity, owing to their
familiarity with them, though they have been outlived in medicine.
From representing an affection of the nose, catarrh, as a consequence,
has come to be employed for an excess of secretion from any mucous
membrane. Accordingly we hear of catarrh of the stomach, catarrh of
the bladder, or catarrh of the {101} bile-ducts, and there has come to
the general public a notion that catarrh is an all-pervading affection
whose ravages must be prevented, at all hazards, and whose beginning
must be the signal for prompt medical treatment.

As a matter of fact, catarrh, when it means anything, means only that
stage of inflammation in which there is an increased secretion and
which represents an inflammatory condition so mild as often to be
described as only hyperaemic, that is, due to an increase of blood in
the part. It is rather easy to understand that if more blood flows
through a mucous membrane, there will be greater secretion from it
than would normally be the case. This is what happens in the
production of catarrh. As a rule, it is only a passing congestion
without any lasting changes in the tissue. Catarrh may, however,
continue to be present if the irritation, which originally caused the
congestion, be allowed to continue. It is this irritation, however,
which needs to be treated, and not the catarrhal inflammation, which
is only a symptom of it. The three most used words in popular
medicine,--catarrh, rheumatism, and gout,--when traced to their
etymological signification, mean the same thing. Catarrh means a
flowing down, rheumatism a state of flowing, both being formed from
the Greek verb [Greek text], to flow, while gout is derived from the
Latin word _gutta_, a drop, which hints at the excess of fluid that is
supposed to be the basis of the disease.

For these three diseases, however, the most varied remedies have been
proposed, and practically entirely without success, when tested, in a
large number of cases. As a matter of fact, under the two words
catarrh and rheumatism, there is grouped a series of affections very
different from one another, and requiring very different treatment.
The important thing is not so much the suggestion of a remedy as the
recognition of the particular cause which in one case is producing an
excess of secretion and in the other is giving rise to the so-called
rheumatic pain. When the exact cause can be found, it is usually not
so difficult to succeed in preventing the recurrence of the
troublesome symptoms. It is with regard to these two diseases,
however, that in non-medical circles even intelligent men are ready to
give advice. They constitute {102} the most puzzling problem that the
physician has to deal with, but the non-medical mind waives the
difficulty and suggests the remedy. In this matter one is forcibly
reminded of a famous expression of Josh Billings, who used to say, "It
is not so much the ignorance of mankind that makes them ridiculous as
the knowing so many things that are not so."

Clergymen, lawyers, members of Congress, and of various state
legislatures, all permit their portraits to appear, advertising the
merits of some trumped-up cure for catarrh or rheumatism. It is
interesting to realise, then, that in most cases, according to expert
testimony, the remedy they recommend so highly consists of nothing
more than diluted alcohol flavoured so as to taste like medicine. The
only real effect is the alcoholic exhilaration which follows its
ingestion and gives the sense of well being, because of which the
testimonials are provided. As one of the medical journals said
recently, it would be very interesting to make a list of the men and
women throughout the country who, by permitting their portraits and
recommendations to be used in the advertisements of various patent
medicines, have practically confessed that they like to take their
whiskey rather dilute but mixed with a little bitters. The whole
question illustrates the tendency of the proprietary medicine man to
exploit some phase of medicine long after it has ceased to be of
interest to the medical profession.

With regard to all of these things clergymen may do a great
humanitarian work by protecting the poor from the efforts of
advertising remedy-makers to get their hard-earned money. It is
sometimes said that long years have been spent in the preparation of a
remedy. This not only is never true, but never has been true in the
history of proprietary medicines. Some one who has an eye to business
gets hold of a prescription of which he knows nothing, but of which
his advertising agents are able to say much, and the result is
sometimes a fortune for the advertiser. There is always a pretence of
philanthropy, but it is the mask of heartless hypocrisy. Unfortunately
many of our religious journals are tempted by the promptly paid bills
of such manufacturing concerns to print their advertisements. They are
aiding in a {103} deliberate swindle, and if this were better
understood there would be much less suffering and fewer vain hopes.
The best-managed newspapers and magazines in the country are now
absolutely refusing all medical advertisements. This is the only
proper attitude in the matter, for there is a place to advertise
medicines, if they are worthy, and that place is the medical journals.
If the popular advertising could be reduced, we should soon have much
less of the proprietary medicine evil.

There are many ways in which clergymen by their example, their advice,
and their influence can be of great assistance to practitioners of
medicine. It is very sad, then, to find that some of them, having
elabourated theories of their own on certain subjects, or having taken
up with peculiar notions, are in opposition to the accepted medical
teaching of the world. Occasionally they are found among the ranks of
the anti-vaccinationists, though if there is anything that has been
demonstrated to a certainty, it is that vaccination has practically
eradicated smallpox, considering the frequency of the disease a
century ago, and that it would absolutely eradicate it, if the
practice could be made universal. Statistics are at hand to
demonstrate this beyond all possibility of doubt. There are a certain
number of people, however, who apparently, out of a desire for
singularity as much as anything else, refuse to accept the evidence.
It is very unfortunate to find clergymen among them, for it tends to
bring the clerical judgment into disrepute.

Nearly the same thing might be said of antitoxin for diphtheria.
Clergymen seem to consider it necessary for them to have their minds
made up as to whether the use of diphtheria antitoxin is advisable or
not. If they have once committed themselves to the expression of the
opinion that antitoxin is of no value, then no amount of evidence will
succeed in changing their opinion. Under these circumstances it
becomes extremely difficult at times for physicians to succeed in
having families permit them to treat their patients after the manner
in which they are convinced the treatment should be carried on. If
such clergymen would only realise that the clergyman has, as a rule,
much less right to express {104} opinions on medical subjects than has
the physician to air views with regard to theological principles,
there would be much less friction, and it would be better for patients
in the end.

There are certain sanitary regulations that clergymen should not only
not oppose, but endeavour, by every means in their power, to have
those who respect their opinions follow out as carefully as possible.
Such sanitary regulations have in the past twenty-five years
practically cut down the death rate of our large cities a half. There
is no greater source of alleviation for the physical evils, at least
those which afflict the lower classes, than the due enforcement of
modern sanitation. There are prejudices, however, that must be
overcome, and the clergyman should be found beside the doctor, helping
him rather than opposing him, as is sometimes the case.

JAMES J. WALSH.

{105}

VIII

SOME ASPECTS OF INTOXICATION

There are various drugs that, through acute or chronic poisoning from
their use, cause mental disturbance,--alcohol, chloral, cannabis
indica, somnal, sulphonal, paraldehyde, ether, chloroform, antipyrin,
phenacetin, trional, chloralamid, iodoform, atropine, hyoscyamus,
salicylic acid, quinine, lead, arsenic, mercury, opium and morphine,
the bromides, cocaine, and others. Of these intoxicants alcohol always
has been most commonly used by western nations, but the moral aspects
of alcoholism have not been shown with sufficient insistence. There
are many sots in human society much less reprehensible than to the
unskilled observer they appear to be; others are more blameworthy.

Morality, as far as the agent is concerned, apart from the nature and
circumstances of the deed, supposes, first, voluntary acts, or acts
that proceed from the will with a knowledge of the end toward which
the acts tend; and, secondly, free acts, or acts that under given
conditions may or may not be willed. If by unavoidable chance one
stumbles against a man standing at the edge of a wharf, knocks him
into the water, and drowns him, the act has no element of morality in
it, because it is not voluntary and free. If a mind is diseased, and,
impelled by a mad notion of persecution, it brings about a like
killing, there is no question of morality, because the agent is not
free, and when fully analysed his action is not voluntary.

An act is more or less voluntary and free, and therefore more or less
moral, as the agent is affected by ignorance, passionate desire, fear,
or disease. Ignorance, fear, and disease may be such as to remove all
quality of morality from an act. {106} Certain diseases or
pathological conditions, especially of the nervous system, can take
out of an act the elements of voluntariness and freedom that are
necessary to make the act moral or immoral, provided, however, these
pathological conditions are not brought on through the fault of the
subject in which they exist. If a man voluntarily becomes drunk with
alcohol, or some other drug, he is, of course, accountable for the
evil he may unconsciously do while under the influence of that drug,
and if he begets an idiot or a criminal imbecile in his drunkenness,
he must atone somewhere for the blinded soul of his child. Here,
again, there are certain extenuating circumstances, because very few
drunkards are fully conscious of the extent of the evil in alcoholism.

Apart from the other requirements that go to make an act moral, the
agent must be sane; that the act be immoral, he must be sane or
insane, either temporarily or permanently, through his own fault; that
it be devoid of morality an act must be a mere _actus hominis_, or it
must be the act of a person blamelessly insane. If a man knows that an
alcoholic is liable to beget a criminal imbecile solely because of the
alcoholism,--and most men are aware of that fact,--this father or
grandfather is more or less accountable for every larceny, rape, and
murder done by the imbecile. The law, therefore, should put the
imbecile into safe keeping, then seek out the father and hang him.

Insanity is a common condition, but it has not been satisfactorily
defined. It supposes an appreciable unsoundness of the will, memory,
and understanding, or of one or two of these faculties, but no
alienist has given a short differentiation of that unsoundness. Where
shall we draw the line between the weak but responsible will and the
insane will? What degree of opacity between intellect and the world
separates the ignorant man from the lunatic? The extremes of sanity
and insanity are readily recognisable, but the intermediate degrees
are not clear. There is no test to apply to all cases; each must be
diagnosed from its peculiar symptoms, but the will of an insane man is
always weak. It can not deny or defer the gratification of a desire,
nor can it keep up an effort. Even in its lightest forms insanity is
selfish and {107} impolite, because it lacks the force of will
necessary to take trouble. It foregoes great future benefit for slight
present gratification. The insane man is idle, or busy only in work
that he likes, in pleasurable activity. A marked quality of sanity is
the capacity for sustained work, and the man that shirks work merely
because he does not like it is gratifying himself dangerously.

These defects are found commonly in sane persons, but the lunatic can
not rise from them, and he adds to the defects of will a warped
intellect. He can not adjust himself to his surroundings, and the
fault is in himself, not in the circumstances. His intellect may be
brilliant, but it sooner or later shows a taint. The insane man is not
a free, rational agent.

Alcoholism readily passes over into unmistakable insanity, and it
almost always is the cause of nervous degeneration in the children
born within its influence. This, is a phase of the evil not
sufficiently insisted upon by those that plead for total abstinence.

Chronic poisoning by alcohol induces hardening and calcification in
the walls of the arteries, degeneration of the nerve cells and
dendrites, wasting or overgrowth of the heart muscle, and fatty
degeneration of the liver and kidneys. The nerve centres that control
the circulation of the blood are paralysed by it, and, as a sequence,
the arteries and capillaries are diminished in calibre. This state in
turn obstructs the flow of the blood, and the body is not nourished,
nor are the waste and poisonous results of metabolism carried off as
they should be. Alcohol prevents the haemoglobin of the blood from
doing its office, which is to supply oxygen and remove carbon dioxid.
It absorbs the necessary water from the tissues, and thus it acts as a
corroding poison. It is also a functional toxin, because it depresses
the activity of organs by injuring the innervation. The poison affects
the brain, and as the cerebral gray matter, especially its pyramidal
cells, are the physical instruments of thought, will, and memory, or
the means of communication between the soul and the outer world, the
exercise of these spiritual functions is checked or inhibited by it.

A tendency to excess in the use of alcohol commonly {108} manifests
itself before the thirtieth year, and in some cases it may be removed
at the alcoholic climacteric, which is from the fortieth to the
sixty-fifth year. Those that become drunkards are usually of a
neuropathic constitution, through inheritance or abuse. Severe
diseases, like influenza, syphilis, typhoid; injuries to the head,
sunstroke, shock, worry; the disturbance that may accompany puberty,
pregnancy, lactation, and so on,--cause a nervous depression which is
soothed by alcohol, and thus a habit is fixed. The reckless
prescription of alcohol by some physicians is another cause of the
habit, and the use of proprietary medicines is a still more prolific
source of drunkenness and the consequent misfortune.

Cider, beer, ale, and porter contain from 4 to 6 per centum of real
alcohol; light wines, red and white, and natural sherry, 10 to 12 per
centum; strong sherry and port, 16 to 18 per centum; brandy, 39 to 47
per centum by weight, or 46 to 55 per centum by volume; and whiskey,
44 to 50 per centum by weight, or 50 to 58 per centum by volume. The
effect of these liquors on the body is due primarily to alcohol, and
secondarily to ethereal derivatives of alcohol. Some owe a part of
their effect to non-volatile substances,--beer from which all alcohol
has been boiled can still affect the body in a marked degree.

The chemist of the Massachusetts State Board of Health (Document No.
34) gives the percentage of alcohol in the common proprietary
medicines, and these percentages will be found in the article on
_Social Medicine_.

The weakest of these compounds are twice as strong in alcohol as beer,
and they treacherously bring about the habit of drunkenness in
disposed persons who may be very desirous to avoid such a calamity.

Some men and women are quickly destroyed by alcohol; others resist it
more or less successfully for a lifetime, as far as mere existence is
concerned. Alcoholism is one of the commonest causes of insanity, but
it is often an effect of insanity. It may be an early symptom of
paresis, or a part of the maniacal stage of circular insanity. In
poisoning by alcohol the higher nerve centres are first affected and
the {109} lowest last. The sense of human dignity and of morality, the
exercise of the intellect, are more or less inhibited before the
motive muscles are affected.

The usual effect of alcoholic poisoning is boisterous exaltation of
mind, but there is a depressed type of drunkenness which weeps. Some
patients at once are subjected by hallucinations and delusions, others
are so depressed that they have a suicidal tendency, others may have a
maniacal frenzy that is destructive or homicidal. In these neuropathic
conditions muscular co-ordination is commonly well preserved--the
patient is "drunk in the head and sober in the legs."

In alcoholism the mental changes are gradual and progressive. The
intellect is blunted, the judgment becomes foolish, the moral sense is
dulled. The drunkard is always a liar. Delusions not infrequently
occur, and it is one of the common symptoms of alcoholic insanity to
suspect a wife or husband of conjugal infidelity. If a man that is a
drunkard accuses his wife of infidelity, the chances are fifty to one
that she is innocent and that he is in the first stages of insanity.
This symptom is characteristic also of cocaine intoxication.

Another mental disturbance of acute alcoholism is _delirium tremens_,
which is inexactly called _mania a potu_ by some writers. _Delirium
tremens_ is not a form of mania, but an acute hallucinatory confusion,
in which the consciousness is much more impaired than it is in a
mania. _Mania a potu_ is a real mania, and it is transient commonly,
although it may leave permanent mental weakness with delusions.

In chronic alcoholism a paranoid condition may occur, and this often
is incurable. This psychosis may come on suddenly or gradually. In
true paranoia the delusions are systematised, but in this alcoholic
pseudoparanoia the enfeebled intellect can not build up coherently
even a delusion. The alcoholic hallucinations are visual and auditory,
and we find delusions of persecution, especially of a sexual nature.
The patient hears all kinds of insulting remarks made by "voices."
These voices often come from his own belly. His enemies send poisonous
or foul odours into his room at night, and the groundless suspicions
of his wife's infidelity take most outrageous forms of expression. He
will swear {110} he has _seen_ her misdeeds. Often the baseless
suspicions of his wife begin before any other noticeable impairment of
intellect, and are not recognised as delusions. The first step a
priest should take in investigating accusations of conjugal infidelity
is to find out whether the accuser is a tippler or not.

The delusions of persecution lead to attacks on the supposed enemies
which often are homicidal. Occasionally alcoholic insanity takes on a
paretic form, or it may be epileptic. Ten per centum of alcoholics are
epileptic. When the children of alcoholics are epileptic, the
convulsions begin in these children about four years earlier than in
children that are epileptics from other causes. If epilepsy is latent,
alcoholism will start it into action.

Alcoholism sometimes produces a condition of waking trance followed by
amnesia (lack of memory). In such a state the drunkard may transfer
property, carry out complicated professional actions, commit crime,
take long journeys, travel for days, and so act that no one notices
his disordered mental condition. Then suddenly he awakens and he has
no recollection whatever of what has happened during this trance. He
appears to be conscious, but to have no memory of his consciousness.
There is another alcoholic amnesia, found especially in those that
drink much during the morning hours, where there is instantaneous
forgetfulness. If you ask one of these men to shut a door, for
example, he will forget between his chair and the door what he started
to do. This condition is difficult to cure even after the use of
alcohol has been relinquished.

Dipsomania is a form of impulsive degenerative insanity, and it is
probably epileptic in origin. After a few days of insomnia and loss of
appetite for food, there is an irresistible impulse to drink alcoholic
liquor and to indulge in other excess. The patient drinks until all
means of getting alcohol are exhausted. He will take crude alcohol,
bay rum, cologne, the alcohol that is about pathologic specimens in a
hospital museum. The attack lasts from one to two weeks, and is
followed by depression and a feeling of remorse. The onsets are
irregular in occurrence, and between them the patient may {111} be
temperate or have even an extreme distaste for alcohol. This form of
disease is not infrequent among professional men and clergymen, and it
is impossible to find out just how far the patient is responsible for
his condition. If bishops would investigate the alcoholic tendencies
of the _families_ of candidates for seminaries, and reject all that
have this taint, there would be much less scandal. It is a serious
error of judgment to ordain a seminarian that has even once been under
the influence of alcohol, and those seminarians that cover up the
tippling of a companion, because he is a good fellow, are guilty of
far-reaching crime. The fact is worth investigation whether or not a
liquor dealer who never drinks alcohol, but who lives for years in the
presence of volatilised alcohol, has much of the alcoholic degeneracy
and a tendency to beget neurotic children. Certainly the fumes of wood
alcohol have killed workmen that went down only once into a vat
containing these fumes, and other alcohols in the form of vapour
should have deleterious effects. Féré produced monsters in chickens by
exposing eggs to the vapour of alcohol.

In judging a drunkard, it must be remembered that in many forms of
alcoholism, after the condition is well established, the patient has
little more freedom of will than a brute has. If he is accountable for
the habit, he is blamable for the crime that follows. If he is not
accountable, and it is often very difficult to prove that he is, he is
to be treated as a blamelessly insane man. In proper surroundings, and
with skilful direction, a child born with a tendency, or more exactly
a temptation, to dipsomania or other alcoholic neurosis can be saved,
but commonly the circumstances of such a child's life are the worst
imaginable. These children must never take alcohol, even as a
medicine, and they must not be pushed in school to nervous exhaustion.
A tendency to unchastity can "run in families," like a disposition
toward alcoholism, but the disgrace in yielding to this vicious bias
keeps many such unfortunates clean. It is to be regretted that public
opinion can not give the same aid in alcoholic predisposition.

A confirmed alcoholic should be prevented, if possible, from marriage,
because his sins will be visited upon his posterity. {112} The first
children of an alcoholic may be mentally sound, the younger children
are more or less mentally weak, the youngest are not uncommonly
imbeciles, or idiots, or under shock they grow insane. Fortunately
many of the children of alcoholics die at an early age, and the family
of a drunkard very seldom lasts beyond four generations. In the first
generation moral depravity and alcoholic excess are found; in the
second, chronic drunkenness and mania; in the third, melancholia,
hypochondria, impulsive and homicidal ideas; in the fourth, idiocy,
imbecility, and extinction of the family. The lower the social caste
of the drunkard, the greater the liability of meeting these blights.

Priests should take a deep interest in societies established for the
promotion of temperance, and the only temperance for most persons is
total abstinence. No man knows what latent tendency to alcoholism he
may have, especially in America, where great grandfathers are unknown
and the climate and life are trying on the nervous system. The
adulterated liquors sold everywhere at present make the danger greater
than it ever was. Whatever may be the truth as regards heredity, there
is no doubt concerning the strong influence of environment; therefore
get into the temperance societies the children of alcoholic parents,
of parents that are shiftless, hysterical, irritable. If a man has a
violent temper or if he is unchaste, get him and his children into the
society to check the downward drift. A bad temper is a neurotic taint,
and it commonly is a first step toward alcoholism. Do not forget to
warn the people against patent medicines that contain alcohol.

If you go over the list of the families in a parish, it is startling
to find how few there are without one or more "black sheep." The human
black sheep, in a good environment, is always physically imperfect,
and never so black as the gossips paint him. He may be a powerful
football player, but there is something wrong with his gray matter. He
is morally deaf, he was born so, and he is to be excused if he can not
always hear the still, small voice. This may sound like lax doctrine,
but it is true, nevertheless.

We must recognise that moral weakness is very often, {113} partly at
least, a physical defect, and there is no such state as "moral
insanity" where the intellect is normal. Now, I do not wish to be
quoted as holding that all moral depravity has a physical basis; most
of it is the unalloyed stuff; the Lombroso criminal is not a
scientific fact; but there is a moral condition very frequently met
with which is largely physical in origin. Given so many grains of
cocaine or morphine or so many ounces of alcohol, and you can make a
liar of a man once on the way toward sanctity. Given an attack of
hysteria in a holy nun, and she at once becomes a liar, an altogether
blameless liar, but no influence that does not remove the physical
cause will cure the lying.

The morally weak do not at present obtain enough religious
instruction. Their religion is more a matter of inheritance and habit
than of positive energy. It is "in the bones," sometimes in the fists,
rather than in the soul. They prefer the Sunday newspaper to the
Sunday sermon. The remedy here seems to be in making the Sunday school
solidly interesting and its teaching impressive.

Alcoholism in the parents, especially drunkenness at the moment of
conception, is one of the chief causes of idiocy in children. Féré, as
was said before, by injecting a few drops of alcohol beneath the shell
of hens' eggs, or by exposing the eggs to the vapour of alcohol, could
produce monsters almost invariably. In 1000 cases of idiocy at the
Bicétre, Bourneville found a history of alcoholism in 620, or 62 per
centum: in the fathers of 471, in the mothers of 84, in both parents
of 65; and in one-half of the remaining 38 per centum no history was
obtainable--probably most of these also had the alcoholic taint. The
administration of alcohol to infants, of gin and whiskey, of essences
of peppermint and anise, to relieve colic or induce sleep, and the
dosing with opiates like paregoric, are also well-established causes
of idiocy.

The idiot is practically dead, except for the trouble he gives in
caring for him; but another unfortunate, the imbecile, most commonly
the offspring of alcoholics, is often capable of great mischief. The
higher grades of imbeciles, those nearest the normal, are almost
invariably criminals. Not all criminals, of course, are imbeciles, but
a vast number of petty and brutal {114} criminals are imbeciles. We
keep these unfortunates most of their lives in jail, while we fine
their drunken fathers, the cause of the imbecility, "five dollars and
costs."

Imbecility has grades,--from marked lack of intellectual power, a
stage little beyond idiocy, up to the presence of a mind capable of
fair education,--but in all cases there is real defect, either of
intellect or of will. Sometimes, where the will is so weak that the
patient becomes a criminal in spite of all training, the intellect is
practically normal to the superficial observer.

The grades of imbecility can not be clearly marked off from one
another, but, roughly speaking, there are three. The lowest grade of
imbeciles understands simple commands, and has a slight manual
dexterity. They express themselves by signs and in monosyllables. They
can not concentrate attention upon anything, nor can they be taught to
read or write. Careful training can advance them so far that they may
do rough, menial work, and they are industrious when directed by a
present superior. They are inclined to masturbation. If they are not
teased, they are quiet; if annoyed, they may become dangerous.

Imbeciles of the middle grade can converse in a narrow vocabulary, and
they commonly stammer. They may be taught to read monosyllables; they
can not do even the simplest sum in addition, yet they show a certain
shrewdness. They are irritable and quarrelsome, inclined to lying and
stealing, and they have no sense of shame. They will not do any
regular work, but change from one occupation to another. They may have
sexual instincts and cause trouble on that account. They are slow to
understand, their memories are defective, and they are always very
vain. Their belly and what they shall wear are the chief things in
their lives. They are less criminal than the highest grade of
imbeciles.

The third class, the high-grade imbecile, is the most important,
because he is commonly a criminal. His intellect is below the average,
and his will is very flabby. He learns little at school, and what he
does learn is acquired slowly. He reads and writes badly and he may be
able to add simple {115} columns of numbers, but he can not multiply
or divide. Sometimes such an imbecile has a remarkable facility in
getting a speaking knowledge of two or three languages, and he may
learn a trade. There is a high-grade imbecile that is cunning and
shrewd, but he has no will, and he is a criminal. As imbeciles
approach the normal in intellect they recede from it in abnormality of
will.

Autopsies on imbeciles show an infantile development of the forebrain.
Imprisonment does no good in these cases. They are not taught anything
in prison, not even a trade, because the labour organisations and the
protected industries will not permit prison labour. They should be
confined so that they will not pervert youth and propagate their kind.
It is impossible to say how far a given imbecile is morally
accountable for what he does, but the accountability is not full in
the best cases. A neurasthenic, however, is not to be mistaken for an
imbecile. A neurasthenic person may have a tender conscience, an
imbecile has no conscience. In imbecility the fault is in the will,
rather than in the intellect, in the middle and highest grades. Many
women, especially, that are hopeless fools intellectually have strong
wills, but an imbecile never has a strong will except in the sense
that stubbornness is strength. Stubbornness is perverted strength.

_Morphine and Cocaine Intoxication_,--Morphine, an alkaloid of opium,
is used very extensively as an intoxicant. Since 1890 the importation
of opium into the United States has increased fourfold, although
physicians are now using less opium than they formerly did.

The insomnia, worry, moral distress, which bring on the alcoholic
habit in some persons, lead to morphinism in others. Some physicians,
by carelessly prescribing morphine for neuralgia, migraine,
dysmenorrhoea, or any pain, make their patients slaves of this drug.

The degenerative effects of morphine are not so great nor so rapid as
those of alcohol. It does not shorten life so much as alcohol does,
nor are the children of a person addicted to the use of the drug so
liable to idiocy and imbecility. The mind is enfeebled--slowly in some
cases, rapidly in others. The patient will resort to almost any means
to obtain the {116} drug, if he is deprived of it. Authorities hold
that he will lie without reason, merely for the perverse pleasure in
deceiving, that he is uncertain and treacherous, with a dull
conscience and morbid impulses. There are exceptions to this in cases
where the drug is easily obtained by the patients. Opium and morphine
diminish the sexual appetite in males, even to impotence. The bodily
changes are slow but profound.

When a user of morphine has been deprived of the drug for from ten to
fifteen hours, he becomes so weak he can not stand; he gets diarrhoea
with cramps; he sweats, trembles, and collapses. Later, mental
disturbance comes on. He grows delirious, sees insects and small
animals, as the delirium tremens patient does, and his suffering is
very great. It is extremely difficult, and commonly impossible, to
cure the morphine disease after it has been firmly established, and a
deliberate acceptance of the habit is evidently a grave vice. Where a
patient has become addicted to the use of the drug, through the fault
of a physician, or through ignorance, the treatment from the social
point of view of such a patient is commonly cruel.

Cocaine intoxication is much worse than morphinism. It is a new
excess, which was unknown before 1886. Many users of morphine can
carry on business, but the cocaine _habitué_ can not do so. He is
always extremely busy doing nothing. He writes long letters which are
never finished. He changes from work to work, and even his
conversation wanders. His bodily weight decreases rapidly, even
one-third of his whole weight may be lost within a few weeks. The skin
hangs in folds and is of a dirty yellow colour, the facial appearance
is that of extreme distress, and the muscles are feeble. Fainting,
irregular cardiac action, sweating, and insomnia are other symptoms.

Insanity is an occasional sequence, with hallucinations, especially of
hearing. Such a patient hears roaring noises and voices; his secret
thoughts are shouted out, he thinks, to crowds; loud screams, shrieks
of murder, and similar noises appall him. Again, he sees swarms of
flies, ants, roaches, which cover him and crawl into his mouth,
nostrils, {117} and ears. He feels bugs crawling under his skin, and
he has a multitude of similar interesting experiences.

Such patients grow homicidal. Like alcoholics, they are jealous and
suspicious of their wives, but, unlike the alcoholic, the cocaine user
is commonly reticent; he is not willing to talk of his troubles.

The prognosis is always bad, even in the best cases. This drug can be
withdrawn from a patient more rapidly than is possible in chronic
poisoning from morphine, but a relapse is to be expected.

In dipsomania, morphinomania, and other drug habits, and in the cases
of vicious and degenerate children, many encouragingly good results
have been reported from the use of hypnotism. Forel, Voisin, Ladame,
Tatzel, Hirt, Nielson, de Jong, Liebeault, Bernheim, van Eeden, van
Renterghem, Hamilton Osgood, Wetterstrand, Schrenck-Notzing,
Kraft-Ebbing, Francis Cruise, Lloyd Tuckey, Kingsbury, Woods, and
others have undoubtedly cured dipsomania by hypnosis.

Wetterstrand alone cured 37 of 51 cases of morphinism by hypnosis. One
of these patients had been using morphine for fourteen years and
morphine with cocaine for an additional four years. All his cases
except one were treated at home--they were not obliged to go to a
hospital or sanitarium.

As to vicious children: Liebeault in 1887 recorded 77 cases, 45 of
whom were boys and 32 girls. By hypnosis 56 of these were cured, 9