Part 13

For the great majority of those that are susceptible to the {131} hypnotic condition, there is very little danger. We now have on record the experiences of men who have seriously devoted many years to the study of hypnotic phenomena. There is entire agreement among these men that the possible dangers of hypnotism have been exaggerated. Indeed, it may be as well to say at once that most of what has been written with regard to the dangers of hypnotism has come from those who have least practical experience with the condition. Dr. Milne Bramwell, who, for a quarter of a century, has had a very extensive experience with hypnotism in its many phases, in his recent book on hypnotism, deliberately speaks of the "so-called dangers" of hypnotism. He has never seen any evil effects, though he has been practising hypnotism very freely on all kinds of patients for over twenty years.

It is on the experience of such serious, disinterested observers that we must rely for our ultimate conclusions as to hypnotism, rather than on the claims of pseudo-experts who like to magnify their own powers, or on popular magazine articles, or still less the Sunday newspapers, the writers for which are mainly interested in producing a sensation. It seems probable that in the next few years hypnotism will occupy a less prominent place in popular interest than it has in the recent past. Interest in hypnotism runs in cycles, reaching a maximum about once a generation, and we are on the downward swing of the last wave of popular attention to this subject.

A subject that has attracted much attention, whenever hypnotism has been under discussion, has been the possibility of crime being committed under the influence of hypnotic suggestion. The best authorities in hypnotism seem to be agreed that subjects can not be brought by hypnotic influence to perform actions that are directly contrary to their own feeling of right and wrong. The supposed exceptions to this rule are rather newspaper sensations than real compelled crimes. There is no doubt, however, that a tendency to the performance of certain wrong actions, so that the normal disinclination to their performance becomes much less than before, may be cultivated by a series of hypnotic as well as by waking suggestions. Where the individual influenced is {132} already characterised by weakness of will in certain directions, the added weight of the motives furnished by hypnotic suggestion may prove sufficient to turn the scale of responsibility. It is probably because of such influence that a recent case in France has attracted world-wide attention.

In general, however, it may be said that normal individuals can not be brought to the commission of crime by hypnotic suggestion, and the plea of irresponsibility, for this reason, is not worthy of consideration. There are phases of this important problem, however, which require further careful study. Undoubtedly some of the so-called inherited tendencies to the commission of crime are really instances of the influence of auto-suggestion that has kept the possibility of some criminal act constantly before the mind. Some of the cases of hereditary dipsomania are almost surely of this character. Persons whose parents have been the subject of inebriety lose something of their own will power to keep away from intoxicating drink by the reflection that it is hopeless for them to struggle against an inherited tendency.

A series of cases have been reported in which suicide has occurred in successive generations in the same family at about the same time of life. There seems no doubt that suggestion must have great influence in such cases. In one well-authenticated report, mentioned in the chapter on suicides, the members of the family were officers in the German army, and the eldest son, the family representative, committed suicide within the same five years of life, in four successive generations. The last member of the family had refused to marry, because of this doom hanging over the house, and had often referred to the possibility of suicide in his own case. In his early years he seemed to have the idea that he might escape the family fate, but after middle life he settled down irretrievably to the persuasion that he would inevitably go like the others.

Here, in America, a rather striking example of this has recently been the subject of sensational newspaper reports. A notorious gambler, whose career had seen many ups and downs, finally found himself in a condition where, strange as it may seem, legal restriction made it impossible for him to {133} continue his usually lucrative profession. Three members of his immediate family, two brothers and his mother, had committed suicide. To friends he had sometimes spoken of this sad history of family self-murder, but always with a calm rationality which seemed to indicate that he hoped to avoid any such fate. When well on in years, however, with his means of livelihood taken from him, he, too, took the family path out of difficulties and shot himself at the door of the man who had been most instrumental in taking away from him his occupation. It seems not unlikely, from the circumstances of the case, that a double crime, homicide, as well as suicide would have been reported, only for the fortuitous circumstance that the other man was not in at a time when usually he was to be found at his office.

In such cases as these it seems reasonably clear that long-continued familiarity with a given idea produces an auto-suggestion which finally overcomes the natural abhorrence even of suicide. Something can be done for such unfortunates by suggestion in the opposite direction, and by taking care that as far as possible they are not allowed to brood over the fate they consider impending. At times of stress and emotional strain, relatives and friends must be particularly careful in their watch over them. It is never advisable that they should take up such professions as those of broker or politician, or speculator, since the emotional states connected with such occupations are likely to prove too much for their mental equilibrium.

Practically all physicians that have given any attention to the subject are convinced that not a few of the suicides, which are now so alarmingly on the increase in this country, are due to the frequent reading in newspapers of the accounts of suicides. As we have said elsewhere, brooding over the details of these is very likely to lessen the natural abhorrence of self-murder in persons that are predisposed, by melancholic dispositions, to such an act. The publication of cases of suicide can do no possible good, while it undoubtedly does, in this way, work incalculable harm. This is especially true with regard to suicides among young people, that is, individuals under twenty-five years of age. The saddest feature of recent {134} statistics with regard to suicide is that this crime has become proportionately much more frequent among young men and young girls, and even children, than it was two or three decades ago. It has been noted, too, in many cases that a previous suicide in the family seems to have familiarised the young mind with the idea of self-destruction and thus suggested its commission.

On the other hand, among young people especially, it has been noted that there is frequently an imitative element in suicides. Three or four suicides, practically with the same details, will occur, within a few days of each other. Suicides at all ages are especially likely to occur in groups, and are often cited to exemplify the truth of the old axiom that evils never come singly. It is especially among young people, however, that this relationship to previous suicides can be traced, and there is no doubt that it is the unfortunate publicity given to suicide, with the consequent suggestive influence, which constitutes the most important factor in these cases. All the influence that clergymen can exert, then, must be wielded to suppress this, as well as the many other evils which flow from sensational journalism.

JAMES J. WALSH.

{135}

XI

UNEXPECTED DEATH

Unexpected death and its problems constitute the principal reason why there should be a pastoral medicine, and why the clergyman must keep himself in close touch with advances in medicine. To have an ailing member of a congregation die unexpectedly, that is, without the rites of the Church, when perhaps there has been some warning as to the possibility of such an accident, can not but be a source of the gravest concern in pastoral work. Sudden death can be anticipated in many diseases that are acute, while in chronic forms of disease the sufferer can be prepared for its possibility by the administration of the sacraments at regular intervals. There is, however, an old proverb which says that death always comes unexpectedly; and even with all the modern advance in medicine, this still contains a modicum of truth. As an unprepared death is an occasion of the most poignant regret to the friends of the deceased and to the attending clergyman, it is with the idea of furnishing some data by which the occurrence of death without due anticipation may be rendered more infrequent, that the following medical points on the possibilities of a fatal termination in certain diseases have been brought together. Unfortunately, even with all our progress in modern medicine, they must be far from adequate for all cases.

Needless to say, the only rational standpoint in this matter must be that it is better to be sure than to be sorry. The impression is very prevalent now that at least the sacraments of Penance and the Holy Eucharist should be administered to the sick whenever there is even the possibility of a fatal termination of the illness. Extreme Unction is more usually delayed until there is some positive sign of {136} approaching dissolution. Delay in its administration, however, not infrequently leads to this sacrament being given when the patient is unable to appreciate its significance. This would seem to be very far from the intention of the Church. The idea has been constantly kept in mind, then, so to advise the clergyman with regard to the liability of a fatal termination as to secure, if possible, the administration of Extreme Unction while the patient is still in the full possession of his senses.

Assured prognosis, that is, positive foresight as to the course of any disease, is the most difficult problem in medicine. Nearly 2400 years ago, when Hippocrates wrote his chapter on the progress of diseases, he stated that the hardest question to answer in the practice of medicine is, will the patient live? That special chapter of his book remains, according to our best authorities, down even to our own day, a valuable document in medical literature. It can be read by young or old in medical practice with profit. While our knowledge of the course of disease has advanced very much, the wise old Greek physician anticipated most of the principles on which our present knowledge of prognosis is founded. This fact in itself will serve to show how unsatisfactory must be any absolute conclusion as to the termination of any given disease. Our forecasts are founded on empirical data,--that is, they are the result of a series of observations,--and the underlying basis of all the phenomena is the individual human being, whose constitution it is impossible to know adequately, and whose reaction to disease it is impossible, therefore, to state with absolute certainty.

With this warning as to the element of doubt that exists in all prognosis, we may proceed to the consideration of certain organic affections which make sudden death frequent.

At the beginning of the present century, Bichat, a distinguished French physician who revolutionised medical practice, said that health and the favourable or unfavourable termination of disease depends on the condition of three sets of organs--the brain, the heart, and the lungs. This was what he called the vital tripod. It was not until nearly thirty years after Bichat's death that Bright, an English {137} physician, taught the medical profession to recognise kidney disease. Since his time we have learned that even more important than Bichat's vital tripod, as regards health and the termination of disease, is the condition of the kidneys. We shall consider affections of these four organs, and their influence on the human system and intercurrent disease, in the order of their importance.

When kidney disease exists the individual's resistive vitality is much lowered. The kidneys are the organs which serve to excrete poisons that find their way into the circulation. When the kidneys fail to act, these poisons are retained. As a result other important organs, notably the nervous system and the heart, suffer severely because of the irritating effect of the retained poison. A patient with kidney disease runs a very serious risk in any infectious fever, no matter how mild, and such patients should always be completely prepared for a fatal termination when they acquire any of these diseases.

Nephritic patients bear operations very badly. The shock to the nervous system incident upon operation always throws a certain amount more than usual of excrementitious material into the circulation. Diseased kidneys do not fulfil their function of removing this at once, and the result is an irritated and fatigued nervous system. Anaesthetics, that is, chloroform and ether, are not well tolerated when nephritis exists, and this adds to the danger of operation in such patients. No matter how simple or short the operation that is to be performed on a person suffering from kidney disease, if an anaesthetic is to be administered it would be well to prepare the patient for an untoward event that may occur.

Kidney disease is often extremely insidious. It may develop absolutely without the patient's knowledge, even though he might be deemed to be in a position to have at least some suspicion of its existence. The story is told of more than one professor of medicine who has presented his own urine to his class for examination in order that they might have the opportunity of studying normal urine, only to find to his painful surprise that albumen was present and that he was the subject of latent Bright's disease. In these cases it is {138} impossible to foresee results. They constitute a large number of the cases in which patients, seemingly in good health, succumb rather easily and unexpectedly to some simple disease, like grippe or dysentery. It is well to take the precaution, then, to ask the attending physician what the condition of the kidneys is in such cases. If there are anomalous symptoms, this precaution becomes doubly necessary. Even such simple infectious diseases as mumps or chicken-pox may cause a fatal issue where the kidneys are not in a condition to do their normal work of excretion.

An important class of cases for the clergyman are those which are picked up on the street. As a rule, these patients are comatose because of the presence of kidney disease. A certain proportion of them are unconscious because of apoplexy. Very often the patients have had some preliminary symptoms of their approaching collapse, though these were not sufficient to make them think that any serious danger threatened. As a consequence, they will not infrequently have had recourse to some stimulant. It seems unfortunately to be almost a rule, when such cases are picked up, if there is the odour of alcohol on their breath, to consider that the condition is due to alcoholism. Every year, in our large cities, some deaths are reported in the cells of the station houses because a serious illness was mistaken for alcoholism as a result of the odour of the breath. Needless to say, then, the odour of alcohol on the breath of a person in coma should not deter a clergyman from waiting for a time to be sure his ministrations may not be needed for something much more serious than alcoholism.

Patients suffering from kidney disease bear extremes of cold and heat very badly. In cold weather the fact that the blood is driven from the surface of the body lessens the excretory function of the skin, and this throws the work of this important organ, so helpful an auxiliary in excretion, back upon the kidneys. Besides, congestions of internal organs are not infrequent during cold, damp seasons, and these bring on exacerbations of previously existing ailments that may make fatal complications. In summer intense heat leads to many more changes in the tissues, and so provides more material to {139} be excreted than in temperate weather. Patients picked up on the street, then, at such time, will usually be found to be suffering from kidney disease. Though in profound coma, such patients seldom die without recovering consciousness. Not infrequently, after the primary stroke of the coma, there is, in an hour or two, a period in which the patient becomes almost completely rational. This period of consciousness does not last long, in many cases, and should be taken immediate advantage of, yet without unduly disturbing the patient.

There is a well-known tendency in kidney disease to the production of oedema, that is, to the outflow of the watery constituents of the blood into certain loose tissues of the body. This is easily recognised, and constitutes a valuable sign of kidney disease in the swelling of the eyelids and of the feet, that occurs so often in patients suffering from kidney trouble. The usual rule is, if the oedema begins in the face, it is due to the kidneys; if in the feet, to the heart. The cause in the latter case is the sluggish circulation due to the weakness of the heart muscle, which delays the blood so long in the extremities that its watery elements find their way out into the tissues. In kidney disease this tendency to oedema constitutes a distinct danger that may involve sudden death in certain affections. In patients suffering from kidney disease any acute sore throat involving the larynx and causing hoarseness may be followed by what is called oedema of the glottis. This is often fatal in a very short time. The glottis is the opening between the vocal cords through which respiration is carried on. This opening is but small, and swelling of the surrounding tissues readily encroaches upon it, and soon causes difficulty of breathing. If the swelling is not relieved without delay, death takes place from asphyxiation. This was probably the cause of death in George Washington. In almost the same way any acute affection of the lungs that occurs in a patient suffering from kidney disease may be followed by oedema of the lungs. The outflow of serum from the blood vessels into the loose tissues of the lungs so encroaches upon the space available for breathing, and at the same time so reduces the elasticity of lung tissue, that {140} respiration becomes impossible, and death takes place in a few hours. This is often the cause of unexpected death after operations. The kidney affection in the patient is so slight as to have been unsuspected, or to have been considered of not sufficient importance to render the operation especially dangerous.

After kidney disease the most important factor in the production of unexpected death is heart disease. In about 60 per centum of the patients who die suddenly, in the midst of seemingly good-health, death is due to heart disease. All forms of heart disease may be considered under two heads--the congenital and the acquired. The congenital form of heart disease usually causes death in early years. If such patients survive the fourth or fifth year, they are usually carried off by some slight intercurrent disease shortly after puberty. A few cases of congenital heart disease, however, live on to a good old age and seem not to be seriously inconvenienced by their heart trouble. Most of the acquired heart disease, that is, at least 65 per centum of it, is due to rheumatism. All of the infectious fevers, however, may cause heart disease, and scarlet fever especially is prone to do so; heart complications occurring in about one out of every ten cases. The probabilities of sudden death in a case of heart disease depend on what valve is affected and what the condition of the heart muscle is. Most of the cases of sudden death occur in disease of the aortic valves, that is, of the valves that prevent the blood from flowing back from the heart after it has been pumped out. Diseases of the other side of the heart, the mitral valve, cause lingering illness until the heart muscle becomes diseased, when sudden death usually closes the scene.

Diseases of the aortic valves of the heart cause visible pulsations of the arteries, especially of those in the neck. This readily attracts attention if one is on the lookout for it. Deaths in heart disease, whether sudden or in the midst of apparent health, or as the terminal stage after confinement to bed because of weak heart, are apt to occur particularly during continued cold or hot spells. Each of the blizzards that we have had in recent years has been the occasion for a {141} markedly increased mortality in all forms of heart disease. The cold itself is exhaustive, and the heavy fall of snow, by delaying cars and modes of conveyance generally, is very apt to give occasion for considerably more exertion than usual. Besides, cold closes up the peripheral capillaries and makes the pumping work of the heart much harder than before. At times of continued cold, in our large cities particularly, the ordinary arrangements for heating the house fail to keep it at a constant temperature, and this proves a source of exhaustion to cardiac patients.

Heated spells, if prolonged, always cause an increased mortality in such patients, because heat is relaxant and this leads to exhaustion. Patients who have been nursed faithfully through a severe winter will sometimes succumb to the first few successive days of hot weather that are likely to come at the end of May or the beginning of June. The deaths that occur during the hot spells of July and August are more looked for and accordingly prove not so unexpected.

The warning symptom in heart disease that the patient is giving out is the development of irregularity and rapidity of the pulse. On the other hand, when a pulse has been running rapidly for weeks and then drops to below the regular rate, to 50 or 60, a fatal termination may be looked for at almost any time, though, of course, the patient may rally. The prognosis of heart cases is extremely difficult. Confined to bed and evidently seriously ill, they may continue in reasonably good condition for months, and then some indiscretion in diet, which causes a dilation of the stomach with gas, pushes the diaphragm up against the heart, adds a mechanical impediment to the physical difficulties the organ is already labouring under, and a sudden termination may ensue. As a rule, lingering heart cases terminate suddenly and often with little warning of the approach of death.

An interesting set of heart symptoms, for the physician as well as the clergyman, are those which occur in what is called angina pectoris, heart pang, or heart anguish. Serious angina pectoris occurs in elderly people whose arteries are degenerate. Its main symptom is a feeling of discomfort which develops in the praecordia,--the region over the heart. {142} This discomfort may often increase to positive cutting pain. The pain is often referred to the shoulder, and runs down the left arm. This set of symptoms is accompanied by an intense sense of impending death. When the patient's arteries are degenerated, this train of symptoms must always be considered of ominous significance. A readily visible sign of arterial degeneration can sometimes be noted in the tortuous prominent temporal artery just above the temple.