certain conditions, call in an experienced physician, leave the
treatment to him, and pay no attention to her. Do not make light of
the disease, do not speak of it at all. There are attacks that may be
cured by the razor-strop or a bucket of cold water, but these are
exceptional. They are new cases or old professional offenders. Rough
treatment is not so good as patient tact, but at times roughness is
the only cure.
AUSTIN OMALLEY.
{240}
XX
MENSTRUAL DISEASES
Menstruation is a periodic discharge of blood from the uterus and the
Fallopian tubes. It occurs every twenty-eight or thirty days, and it
lasts from puberty to the menopause, or the cessation of the
menses,--about the forty-fifth year of age.
There is a connection between menstruation and the production of the
human ovum. During the first stage of menstruation the mucous membrane
lining the uterus swells to twice or thrice its normal thickness, and
this growth is a preparation for the reception of the ovum, which, as
a rule, is given off by one of the ovaries at this time and passes out
into the uterus. Menstruation and ovulation ordinarily occur
simultaneously, but they may be independent and take place at
different times. If, during this stage, the ovum is impregnated,
pregnancy begins, and menstruation ceases until some time after
childbirth. In married women conception is more likely to be effected
during the first stage of menstruation than during the interval of
quiescence; the contrary is almost the exception. Impregnation,
however, is likely to occur in the spring more than at other seasons,
and this fact coincides with the advent of spring in various
latitudes.
If the ovum is not impregnated, the material that made the uterine
mucous membrane thick during the first week of menstruation
degenerates and passes off, constituting the menstrual flow. This
stage lasts about five days. A reparative period of about four days
follows, and then a period of quiescence until the next menstruation
commences.
Menstruation is first observed about the fourteenth year, but it may
start earlier or later. In general, it comes on {241} earlier in warm
climates, and later in the extreme north. The menstruation, too, is
likely to show sooner in the labouring classes than in girls who do
not work.
Even in normal menstruation there is often a marked physiological
excitation which affects the entire person. Very commonly a nervous
disturbance and sensitiveness are observed, and in women that are not
robust there may be mental depression and irritability. The
temperature will rise a half degree, and drop to the normal height on
the day preceding the flow.
There are derangements of menstruation which are symptoms of various
diseases. Amenorrhoea is an absence of menstruation in conditions
other than pregnancy or lactation. Absolute amenorrhoea is a complete
absence of menstruation for several months; relative amenorrhoea is
delayed, scant menstruation.
Amenorrhoea is common during convalescence from acute diseases; it is
also a result of chronic diseases of the liver, stomach, intestines,
kidneys, and especially of the lungs; it complicates anaemia, malaria,
rheumatism, and other general pathological conditions. Fright, grief,
great anxiety, mental shock cause amenorrhoea; so do homesickness and
many forms of insanity.
There are also local causes of this condition: imperfect development
of the uterus or the organs connected therewith, and inflammations of
these organs or of the pelvic wall.
Opposed to amenorrhoea is menorrhagia, or an excessive menstrual flow.
Metrorrhagia, or hemorrhage from the uterus at any time, is a term
confounded with menorrhagia, which is an inordinate menstrual loss of
uterine blood, but the distinction is not important. Menorrhagia and
metrorrhagia commonly have an identical cause and they frequently
coexist. They are found in chronic diseases of the heart, lungs,
liver, and other organs; they are an outcome of prolonged lactation,
and of local affections of the uterus and its appendages. Any
condition also that deranges the blood may cause menorrhagia or
metrorrhagia; so do malignant tumours of the uterus, uterine
displacements, lacerations that {242} occur in childbirth, and
psychical influences, as fright, anxiety, and other strong emotions.
Dysmenorrhoea, difficult or obstructed menstruation, is a term used
for menstruation accompanied by pain. This is a common menstrual
derangement, and it may be neuralgic or inflammatory in origin, or it
may be caused by obstruction to the menstrual flow. There is another
variety of dysmenorrhoea, called membranous, in which the superficial
layer of the uterine lining is cast off partly or wholly.
In the neuralgic form the uterus and its appendages are normal in
appearance, but the pain recurs monthly, and it may have degrees from
mere discomfort to agony. This form is characterised by reflex
headache, sympathetic nausea or vomiting; and the pain may not be
confined to the uterus and its appendages. The irritation often brings
out latent hysterical phenomena, spinal irritation, and neurasthenia.
Rheumatism and gout are predisposing causes, so are indolence, lack of
physical exercise, light clothing in cold weather, forced school work
and similar depressing agents.
In the neurotic variety of dysmenorrhoea pain often persists after the
menstrual flow has set in, but in inflammatory dysmenorrhoea the flow
relieves the pain or removes it. Marriage commonly removes the
neurotic form of dismenorrhoea.
In obstructive dysmenorrhoea the menstrual fluid is retained by narrow
or tortuous outlets, flexions of the uterus, and similar causes. The
prognosis is good in all forms of dysmenorrhoea, but frequently long
and skilful treatment is required to cure such conditions, especially
the membranous form. Inflammatory, obstructive, and membranous
dysmenorrhoea are commonly made worse by marriage.
At the end of the childbearing period menstruation gradually ceases.
In temperate climates this menopause occurs about the forty-fifth
year, but it may come earlier or considerably later. Work that keeps a
woman in a heated atmosphere, as cooking, washing, and baking,
disturbs menstruation and tends to advance the menopause. Workers in
chemical factories, in badly ventilated rooms, or women that do heavy
labour in the open air, are apt to age prematurely, and have {243} an
early menopause or "change of life." This premature climacteric is
found also in women that bear many children in rapid succession.
At the menopause there may be various physical or mental disturbances
which are probably due more to the somewhat abrupt advent of old age,
at the cessation of the childbearing part of life, rather than to the
menopause itself. It is a fact, however, that often profound
disturbances coincide with the climacteric, and we know no sufficient
cause for them if the menopause itself may not be deemed such.
There are numerous disorders of the nervous system in women which are
dependent directly or indirectly upon a derangement of the pelvic
organs. Distant parts of the body are affected pathologically through
sympathetic irritation when the primary disease is in the pelvic
organs, and direct treatment of the pelvic trouble alone cures these
reflex conditions. The very common disorders of pregnancy, the marked
physiological changes in women at the beginning of menstruation with
puberty, and its cessation with the menopause, are among the first
proofs of this assertion that occur. Menstruation may aggravate
goitre, uterine fibroid tumours, skin diseases, and affections of the
blood vessels. Disordered menstruation causes sleeplessness,
melancholy, dementia, and mania, by affecting the brain; it may bring
on local paralysis; start up latent epilepsy; excite reflex cough and
difficulty in breathing; make the heart irritable; cause nausea,
vomiting, dyspepsia, flatulence, diarrhoea, skin-inflammations, pain
in the joints, and many other symptomatic phenomena.
Chorea ("St. Vitus's Dance") is caused by various irritatations, and
dysmenorrhoea can be such a cause. If a person is disposed to hysteria
by neurotic inheritance, idleness, sedentary habits, vicious
practices, excessive development of the emotions, any affection of the
uterus or its appendages will greatly aggravate the outbreaks. The
same is true in neurasthenia; and uterine disorders can directly cause
neurasthenia, a condition described in another chapter. Migraine is an
extremely severe form of headache which arises from various
excitations, and uterine disturbances are among the causes.
{244}
Insanity frequently appears in women at puberty, soon after marriage,
during pregnancy or lactation, and at the menopause; at these periods
disposed women are especially prone to outbreaks of insanity.
Irritation and exhaustion from diseases of the pelvic organs are
potent factors in bringing on insanity, although these conditions may
coexist independently of each other. Symptoms should not be mistaken
for causes, but pelvic diseases at least aggravate a tendency toward
mental unbalance.
In an article like this it is not expedient to speak of treatment, but
the conditions are described in outline so that the spiritual adviser
may recognise the need of medical aid and suggest its employment. A
woman suffering from pelvic disorders should be relieved from a
labourious or responsible office until she has been cured of her
disease, in her own interest and especially in the interest of those
affected by her condition.
AUSTIN OMALLEY.
{245}
XXI
CHRONIC DISEASE AND RESPONSIBILITY
It is often of great practical importance to bear in mind that a
number of affections, commonly not serious in themselves at the
beginning, and sometimes giving very few external symptoms, may make
the mental condition of the individual suffering from them utterly
incapable of meeting grave responsibilities. This is especially true
with regard to such positions as that occupied by the Superior of a
religious community who may, during the course of an ailment that has
a tendency to affect the mental condition, do things that involve the
community financially, or make life so uncomfortable for their
subjects as to cause them to abandon the religious life. Some of these
ailments are very insidious and may develop utterly apart from all
anticipation in persons that were previously healthy. The weight of
responsibility itself may, by impairing the general health, bring on
an aggravation of a previously mild chronic condition that will cause
distinct mental deterioration, yet without the absolute production of
such disturbance of intellection as will be readily recognised by
those that are not brought intimately in contact with the individual.
Such cases are not uncommon in history. A distinguished specialist in
mental diseases called attention, in the London _Lancet_ not long ago,
to the case of Nicias, the Greek general who was in charge of the
Athenian expedition against Syracuse. Nicias undoubtedly had a genius
for war and for politics when in normal health. Some of the mistakes
committed by him, though, are of an order that indicate a lapse of
mental control at certain times. Details given by a number of Greek
historians point to the existence in Nicias of {246} symptoms of
chronic nephritis, which at periods of great responsibility became
exacerbated with consequent interference with normal intellection. The
same authority points to certain otherwise inexplicable political
mistakes in the life of Napoleon III. as due to the existence in him
of a low-grade nephritis, consequent upon the presence of stone in the
kidney. After his abdication, during his life in England, he had to be
operated upon for this condition, and the calculi found had manifestly
been in existence for many years.
Even more important for the sake of the individual himself than for
those he is in contact with is the recognition of his pathological
condition. Nothing is more likely to cause kidney disease to grow
rapidly worse than responsibilities heavier than the individual is
accustomed to. When, then, there are symptoms of nephritis it is
inadvisable for the patient to be made Superior, and if the symptoms
develop after his appointment or election he should be relieved of his
responsibilities, at least to a considerable degree. There are a
number of cases on record in which failure to realise the necessity
for this mode of action has been a cause of great unhappiness in
religious communities, and not infrequently a shortening of a very
precious life that might otherwise have been spared for long years of
usefulness in some less demanding position. It is not impossible that
paresis should develop in the Superior of a religious community. The
disease is extremely rare among clergymen generally, and the
statistics of asylums show that it is rarest of all among Catholic
clergymen. Should it occur, however, it must constitute a quite
sufficient reason either for a change of Superiors, or for the
institution of such other safeguards as may, according to the special
religious institute, be provided in order to prevent serious evil.
In the religious communities of women, particularly, it has seemed to
us that the occurrence of Graves' disease (the affection is three
times more frequent in women than in men) in a Superior should always
be the signal for relieving her of the responsible duties of her
position. This action is quite as necessary for the patient's own
health as for the peace and happiness of the community. The disease
may exist in a {247} latent form and only develop strikingly after the
assumption of the serious responsibilities of the position of
Superior. When, however, the eyes are prominent, the pulse rapid, and
the goitre, or swelling of the front of the throat, characteristic of
the disease, is present, there are practically always mental symptoms
that make it extremely inadvisable for her continuance in a position
of serious responsibility. Professor Church of Chicago (Professor of
Nervous and Mental Diseases and of Medical Jurisprudence, in the
Northwestern University Medical School), in the last edition of his
book on _Nervous and Mental Diseases_, [Footnote 5] has this to say
with regard to the mental disturbances of Graves' disease:
[Footnote 5: Nervous and Mental Diseases. Church and Peterson, 4th
edition. Saunders, Phila., Pa., 1903.]
"From the beginning, and often for a long period antecedent to the
appearance of cardiac symptoms, the subjects of Graves' disease
present a considerable mental erethism. There is an indefinable and
tormenting agitation, marked by mental and motor restlessness and an
imperative and impulsive tendency to be doing. Their emotions are too
readily excited, and they are unusually impressionable and irritable,
reacting in an exaggerated manner to all the incidents of daily life.
In more pronounced cases they become voluble and manifest the greatest
mobility of ideas, but have no persistent concentration of logical
order. Their affections are likely to undergo modifications, and they
become irascible, fault-finding, inconsiderate, ungrateful, and hard
to live with. In some instances this disturbance of mentation carries
them over the border into active mania, marked, perchance, by
delusions of fear, due to the cardiac symptoms of sensations of heat.
Insomnia is often added and the fitful sleep is disturbed by
horrifying dreams that are likely to be projected into the waking
moments and woven into delusions which are usually unsystematised, and
constantly changing, furnishing the analogue of the motor
restlessness. Hallucinations of sight and hearing are not uncommon.
"The mental perturbance only rarely reaches the degree of actual
mania, and then is, perhaps, equally dependent upon numerous other
causes acting in a neurotic individual. But {248} a condition of
abnormal mental stimulation is characteristic of the malady, and is as
important an index as any of the cardinal triad." [Footnote 6]
[Footnote 6: Of physical symptoms, namely, the rapid heart, the
prominent eyes, and the enlargement of the thyroid gland in the
neck.]
Dr. Church considers, then, that the mental symptoms of the disease
are as important a concomitant, and as little likely to be absent in
any given case, as are any of the three or four well-known physical
symptoms characteristic of the disease. Under these circumstances the
necessity for the exercise of care in permitting such a patient to
continue in the office of Superior must be manifest. It is a question
not for religious authorities to decide but for physicians, and they
are to be experts in mental diseases. There are many physicians who
have had experience with cases in which Graves' disease has been a
source of unfortunate conditions in religious life, owing to the
failure to understand the relations of the physical affection to
mental disturbances. At times unfortunate consequences follow that are
irretrievable in the destruction of vocations and the impairment of
the religious spirit in communities.
As a rule it may be said that the development of serious disease is
almost sure to incapacitate a Superior from fulfilling the functions
of office. This is true, however, not only for physical disease but
for the so-called neuroses. These are maladies which have their basis
in some disturbance of the physical constitution, though this is not
always easy to find. We prefer to speak of them as neuroses rather
than neurasthenia, because this latter name has somehow come to have
an unwelcome sound and to carry with it the idea of imaginary rather
than real ailments. A true neurasthenic, however, is supremely to be
pitied.
It has often been noticed that such individuals, while perfectly
capable of judging properly for others, are not able to form right
judgments with regard to their own conditions. This principle,
however, should not be taken as a rule, and it must not be forgotten
that neurasthenics are often the subjects of compulsory
ideas--so-called obsessions, in which they are not entirely
responsible for actions performed. At such {249} times they are prone
to be irritated by very trivial faults, and what is worse, to
exaggerate slight defects into serious infractions of rule or of
obedience. With regard to such persons, therefore, constant care has
to be exercised to control their statements by those of others and not
to take them at their full value without due substantiation. In this
matter the subject is quite as likely to suffer as the Superior, and
information obtained from them should not be acted upon without
consultation with others who know the details of the case.
As a rule neurasthenic individuals become, as is well known, worse as
far as the mental condition is concerned when they are asked to assume
new responsibilities. This physical side of the choice of Superiors,
and of those to be elected by members of the community, should always
receive due attention, though sometimes it is entirely lost sight of.
Not a few communities, however, have suffered in their usefulness and
in the fulfilment of the design of their institute by the selection of
Superiors whose neurotic conditions sometimes seemed to proclaim a
high degree of piety, which was, however, rather emotional than
practical. The physician's view of some of these cases would add
materially to the knowledge of the character of such individuals.
It should in general be very clear that the development of any serious
nervous disease, which is not likely to be cured by ordinary remedies
or which requires freedom from responsibility as the first requisite
for improvement, should be the signal for consideration as to a change
of Superiors. Physicians see much more of the evil that may be worked
in this way, and realise the true significance of what is often a sad
state of affairs, much better than those who have not the secret of
the cause of the unfortunate condition. It is almost needless to say
that the question of obedience to some one whose responsibility is not
complete, but is influenced by neurotic disturbance, becomes an
extremely difficult problem for the subject, and one in which there is
apt to be the feeling that it was not the original intention of his
obligation of obedience to bind him under such circumstances.
With regard to women especially, it must be remembered that there is
for them a period between the ages of forty {250} and fifty, during
which for several years they are extremely unsuited for the
responsibilities and exacting duties of a Superior. These years prove
even to mothers of families, surrounded only by their own children and
the ordinary circumstances of home life, a time of worry and
irritation that plays sad havoc even with the best of dispositions.
Mothers constantly complain to their physicians of an irritability of
temper which they can scarcely account for, and which makes them do
and say things which they are extremely sorry for afterwards. It is
easy to understand, then, that a Superior with still more insistent
duties when brought in contact with a number of persons, some of whom
are almost sure not to be entirely sympathetic, is likely to suffer
from irritation that is not a sign of absence of a fitting religious
disposition, but only a physical manifestation of the physical strain
through which she has to pass at this time of life. The years of the
menopause, to be very plain, should not be allowed to make a
Superior's life miserable and to add to the difficulties that a
religious community always has to face in its relations to its
Superior and to one another. Charcot, the distinguished French
neurologist, used to say that women should never be asked to assume
special responsibilities during the days of their monthly period, for
their judgments are often warped by their physical condition. It is
doubtful whether, in the majority of normal women, this is quite true,
though the expression deserves to be remembered. There is no doubt,
however, that the years of the change of life do bring on very serious
modifications of the character of the individual, and occasionally
these changes are lasting.
JAMES J. WALSH.
{251}
XXII
EPILEPSY AND RESPONSIBILITY
From the very earliest times epilepsy has been looked upon as a
mysterious and in many ways an inexplicable disease. The Romans spoke
of it as the _malum comitiale_, the comitial disease, because if an
attack of it occurred during the meeting of the Roman people known as
the _comitia_, in which municipal officers were elected and other city
business transacted, an adjournment was at once moved, and no further
proceedings were considered valid. During more modern times,
especially during the middle ages, and almost down to our own time,
those affected by the disease frequently came to be looked upon as the
subjects of possession by the devil. Hysterical manifestations were
even more frequently considered signs of possession (diabolical
manifestations) but even in our time it is not always easy to make the
distinction between certain forms of hysteria and epilepsy. Many of
these sufferers were considered as not responsible for their actions.
In this respect, at least, the advance of modern medical science has
only served to confirm the popular impression of less sophisticated
times, and it has come to be recognised that quite a large number of
the sufferers from epilepsy must be deemed lacking in responsibility.