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At the other end a demodulator reconverted the sound into ECG with a good gain accuracy. This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrhythmia. This technique helped medical aid reach in remote areas.
In addition, electronic stethoscopes can be used as recording devices, which is helpful for purposes of telecardiology. There are many examples of successful telecardiology services worldwide. Three hub stations through were linked via the Pak Sat-I communications satellite, and four districts were linked with another hub.
These 12 remote sites were connected and on average of 1, patients were treated per month per hub. The project was still running smoothly after two years. Wireless ambulatory ECG technology , moving beyond previous ambulatory ECG technology such as the Holter monitor , now includes smartphones and Apple Watches which can perform at-home cardiac monitoring and send the data to a physician via the internet. Telepsychiatry, another aspect of telemedicine, also utilizes videoconferencing for patients residing in underserved areas to access psychiatric services.
It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical programs, diagnosis and assessment, medication therapy management, and routine follow-up meetings. As of , the following are some of the model programs and projects which are deploying telepsychiatry in rural areas in the United States:.
There is an independent comparison site of current technologies. Links for several sites related to telemedicine, telepsychiatry policy, guidelines, and networking are available at the website for the American Psychiatric Association.
In April , a Manchester-based Video CBT pilot project was launched to provide live video therapy sessions for those with depression, anxiety, and stress related conditions called InstantCBT  The site supported at launch a variety of video platforms including Skype, GChat, Yahoo, MSN as well as bespoke  and was aimed at lowering the waiting times for mental health patients.
This is a commercial, for-profit business. In the United States, the American Telemedicine Association and the Center of Telehealth and eHealth are the most respectable places to go for information about telemedicine.
For this reason, most companies provide their own specialized videotelephony services. The momentum of telemental health and telepsychiatry is growing. In June the U. Veterans Administration announced expansion of the successful telemental health pilot. Their target was for , cases in There is an independent comparison site that provides a criteria-based comparison of telemental health technologies. The COVID pandemic has been associated with large increases in telemedicine visits in the United States for various behavioral and psychiatric conditions such as anxiety, bipolar disorder, depression, insomnia, opioid use disorder, and overactivity.
During the first two quarters of January to June , office-based visits decreased as telemedicine visits increased for these six conditions according to data from IQVIA. The most typical implementation are two computers connected via the Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes.
Sometimes the receiving computer will have a printer so that images can be printed for convenience. The teleradiology process begins at the image sending station. The radiographic image and a modem or other connection are required for this first step.
The image is scanned and then sent via the network connection to the receiving computer. Today’s high-speed broadband based Internet enables the use of new technologies for teleradiology: the image reviewer can now have access to distant servers in order to view an exam. Therefore, they do not need particular workstations to view the images; a standard personal computer PC and digital subscriber line DSL connection is enough to reach Keosys’ central server. No particular software is necessary on the PC and the images can be reached from anywhere in the world.
Telepathology is the practice of pathology at a distance. It uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis , education , and research. The use of ” television microscopy “, the forerunner of telepathology, did not require that a pathologist have physical or virtual “hands-on” involvement is the selection of microscopic fields-of-view for analysis and diagnosis.
A pathologist, Ronald S. Weinstein, M. In an editorial in a medical journal, Weinstein outlined the actions that would be needed to create remote pathology diagnostic services.
A number of clinical telepathology services have benefited many thousands of patients in North America, Europe, and Asia. Telepathology has been successfully used for many applications including the rendering histopathology tissue diagnoses, at a distance, for education, and for research. Although digital pathology imaging, including virtual microscopy , is the mode of choice for telepathology services in developed countries, analog telepathology imaging is still used for patient services in some developing countries.
Teledermatology allows dermatology consultations over a distance using audio, visual and data communication, and has been found to improve efficiency, access to specialty care, and patient satisfaction. Teleophthalmology is a branch of telemedicine that delivers eye care through digital medical equipment and telecommunications technology.
Today, applications of teleophthalmology encompass access to eye specialists for patients in remote areas, ophthalmic disease screening, diagnosis and monitoring; as well as distant learning. Teleophthalmology may help reduce disparities by providing remote, low-cost screening tests such as diabetic retinopathy screening to low-income and uninsured patients. These patients were examined by ophthalmic assistants locally but surgery was done on appointment after the patient images were viewed online by eye surgeons in the hospital 6—12 hours away.
Instead of an average five trips for say, a cataract procedure, only one was required for surgery alone as even post-op care like removal of stitches and appointments for glasses was done locally. There were large cost savings in travel as well. In the United States, some companies allow patients to complete an online visual exam and within 24 hours receive a prescription from an optometrist valid for eyeglasses, contact lenses, or both.
Some US states such as Indiana have attempted to ban these companies from doing business. Remote surgery also known as telesurgery is the ability for a doctor to perform surgery on a patient even though they are not physically in the same location.
It is a form of telepresence. Remote surgery combines elements of robotics , cutting-edge telecommunications such as high-speed data connections, telehaptics and elements of management information systems. While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery.
Remote surgery is remote work for surgeons, where the physical distance between the surgeon and the patient is immaterial. It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital. Remote surgery or telesurgery is performance of surgical procedures where the surgeon is not physically in the same location as the patient, using a robotic teleoperator system controlled by the surgeon.
The remote operator may give tactile feedback to the user. Remote surgery combines elements of robotics and high-speed data connections. A critical limiting factor is the speed, latency and reliability of the communication system between the surgeon and the patient, though trans-Atlantic surgeries have been demonstrated. Telemedicine has been used globally to increase access to abortion care, specifically medical abortion , in environments where few abortion care providers exist or abortion is legally restricted.
Clinicians are able to virtually provide counseling, review screening tests, observe the administration of an abortion medication, and directly mail abortion pills to people. An abortion care provider communicates with the person located at another site using clinic-to-clinic videoconferencing to provide medical abortion after screening tests and consultation with clinic staff. Rebecca Gomperts. It offers a similar service as Women on Web in the United States, but the medications are prescribed to an Indian pharmacy, then mailed to the United States.
Food and Drug Administration FDA , aims to increase access to medical abortion care without requiring an in-person visit to a clinic. The medications necessary for the abortion, mifepristone and misoprostol , are mailed directly to the person and they have a follow-up video consultation in 7—14 days. A systematic review of telemedicine abortion has found the practice to be safe, effective, efficient, and satisfactory. In the United States, eighteen states require the clinician to be physically present during the administration of medications for abortion which effectively bans telehealth of medication abortion: five states explicitly ban telemedicine for medication abortion, while thirteen states require the prescriber usually required to be a physician to be physically present with the patient.
Telemedicine can facilitate specialty care delivered by primary care physicians according to a controlled study of the treatment of hepatitis C. In light of the ongoing COVID pandemic, primary care physicians have relied on telehealth to continue to provide care in outpatient settings. Telemedicine has also been beneficial in facilitating medical education to students while still allowing for adequate social distancing during the COVID pandemic. Many medical schools have shifted to alternate forms of virtual curriculum and are still able to engage in meaningful telehealth encounters with patients.
Telehealth is a modern form of health care delivery. Telehealth breaks away from traditional health care delivery by using modern telecommunication systems including wireless communication methods. Consequently, since telehealth is a new form of health care delivery that is now gathering momentum in the health sector, many organizations have started to legislate the use of telehealth into policy.
This illustrates that the medical council has foreseen the importance that telehealth will have on the health system and have started to introduce telehealth legislation to practitioners along with government.
Traditional use of telehealth services has been for specialist treatment. However, there has been a paradigm shift and telehealth is no longer considered a specialist service. For individuals living in rural communities, specialist care can be some distance away, particularly in the next major city.
Telehealth eliminates this barrier as health professionals are able to conduct medical consultations through the use of wireless communication technologies.
However, this process is dependent on both parties having Internet access. Telehealth allows the patient to be monitored between physician office visits which can improve patient health. Telehealth also allows patients to access expertise which is not available in their local area. This remote patient monitoring ability enables patients to stay at home longer and helps avoid unnecessary hospital time. In the long-term, this could potentially result in less burdening of the healthcare system and consumption of resources.
During the COVID pandemic, there were large increases in the use of telemedicine for primary care visits within the United States, increasing from an average of 1. The technological advancement of wireless communication devices is a major development in telehealth.
Furthermore, patients are more willing to stay on their treatment plans as they are more invested and included in the process as the decision-making is shared.
Technological developments in telehealth are essential to improve health care, especially the delivery of healthcare services, as resources are finite along with an ageing population that is living longer. Restrictive licensure laws in the United States require a practitioner to obtain a full license to deliver telemedicine care across state lines. Typically, states with restrictive licensure laws also have several exceptions varying from state to state that may release an out-of-state practitioner from the additional burden of obtaining such a license.
A number of states require practitioners who seek compensation to frequently deliver interstate care to acquire a full license. If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. In , the U. State medical licensing boards have sometimes opposed telemedicine; for example, in electronic consultations were illegal in Idaho, and an Idaho-licensed general practitioner was punished by the board for prescribing an antibiotic, triggering reviews of her licensure and board certifications across the country.
In , Teladoc filed suit against the Texas Medical Board over a rule that required in-person consultations initially; the judge refused to dismiss the case, noting that antitrust laws apply to state medical boards.
Telehealth allows multiple, varying disciplines to merge and deliver a potentially more uniform level of care, using technology. As telehealth proliferates mainstream healthcare, it challenges notions of traditional healthcare delivery. Some populations experience better quality, access and more personalized health care. Telehealth can also increase health promotion efforts. These efforts can now be more personalised to the target population and professionals can extend their help into homes or private and safe environments in which patients of individuals can practice, ask and gain health information.
There has been a particular push toward mHealth applications as many areas, even underdeveloped ones have mobile phone and smartphone coverage. In a article reviewing research on the use of a mobile health application in the United Kingdom,  authors describe how a home-based application helped patients manage and monitor their health and symptoms independently.
The downside of using mHealth applications is that not everyone, especially in developing countries, has daily access to internet or electronic devices. In developed countries , health promotion efforts using telehealth have been met with some success.
The Australian hands-free breastfeeding Google Glass application reported promising results in This application made in collaboration with the Australian Breastfeeding Association and a tech startup called Small World Social , helped new mothers learn how to breastfeed. When the trial ended, all participants were reported to be confident in breastfeeding. A scientific review indicates that, in general, outcomes of telemedicine are or can be as good as in-person care with health care use staying similar.
Advantages of the nonexclusive adoption of already existing telemedicine technologies such as smartphone videotelephony may include reduced infection risks,  increased control of disease during epidemic conditions,  improved access to care,  reduced stress and exposure to other pathogens   during illness for better recovery, reduced time  and labor costs, efficient more accessible matching of patients with particular symptoms and clinicians who are experts for such, and reduced travel while disadvantages may include privacy breaches e.
Theoretically, the whole health system could benefit from telehealth. There are indications telehealth consumes fewer resources and requires fewer people to operate it with shorter training periods to implement initiatives.
Telemedicine also can eliminate the possible transmission of infectious diseases or parasites between patients and medical staff. This is particularly an issue where MRSA is a concern.
Additionally, some patients who feel uncomfortable in a doctors office may do better remotely. For example, white coat syndrome may be avoided. Patients who are home-bound and would otherwise require an ambulance to move them to a clinic are also a consideration. However, whether or not the standard of health care quality is increasing is debatable, with some literature refuting such claims.
Although health care may become affordable with the help of technology, whether or not this care will be “good” is the issue. Major problems with increasing adoption include technically challenged staff, resistance to change or habits  and age of patient. Focused policy could eliminate several barriers.
A review lists a number of potentially good practices and pitfalls, recommending the use of “virtual handshakes” for confirming identity , taking consent for conducting remote consultation over a conventional meeting, and professional standardized norms for protecting patient privacy and confidentiality. Due to its digital nature it is often assumed that telehealth saves the health system money.
However, the evidence to support this is varied. When conducting economic evaluations of telehealth services, the individuals evaluating them need to be aware of potential outcomes and extraclinical benefits of the telehealth service. In a UK telehealth trial done in , it was reported that the cost of health could be dramatically reduced with the use of telehealth monitoring. Telemedicine can be beneficial to patients in isolated communities and remote regions, who can receive care from doctors or specialists far away without the patient having to travel to visit them.
While many branches of medicine have wanted to fully embrace telehealth for a long time, there are certain risks and barriers which bar the full amalgamation of telehealth into best practice.
For a start, it is dubious as to whether a practitioner can fully leave the “hands-on” experience behind. The benefits posed by telehealth challenge the normative means of healthcare delivery set in both legislation and practice. Therefore, the growing prominence of telehealth is starting to underscore the need for updated regulations, guidelines and legislation which reflect the current and future trends of healthcare practices. When a clinician and patient are in different locations, it is difficult to determine which laws apply to the context.
As it stands, telehealth is complex with many grey areas when put into practice especially as it crosses borders. This effectively limits the potential benefits of telehealth. An example of these limitations include the current American reimbursement infrastructure, where Medicare will reimburse for telehealth services only when a patient is living in an area where specialists are in shortage, or in particular rural counties.
The area is defined by whether it is a medical facility as opposed to a patient’s’ home. The site that the practitioner is in, however, is unrestricted. Medicare will only reimburse live video synchronous type services, not store-and-forward, mhealth or remote patient monitoring if it does not involve live-video.
Some insurers currently will reimburse telehealth, but not all yet. So providers and patients must go to the extra effort of finding the correct insurers before continuing. Again in America, states generally tend to require that clinicians are licensed to practice in the surgery’ state, therefore they can only provide their service if licensed in an area that they do not live in themselves.
More specific and widely reaching laws, legislations and regulations will have to evolve with the technology. They will have to be fully agreed upon, for example, will all clinicians need full licensing in every community they provide telehealth services too, or could there be a limited use telehealth licence? Would the limited use licence cover all potential telehealth interventions, or only some?
Who would be responsible if an emergency was occurring and the practitioner could not provide immediate help — would someone else have to be in the room with the patient at all consult times? Which state, city or country would the law apply in when a breach or malpractice occurred? A major legal action prompt in telehealth thus far has been issues surrounding online prescribing and whether an appropriate clinician-patient relationship can be established online to make prescribing safe, making this an area that requires particular scrutiny.
Telehealth has some potential for facilitating self-management techniques in health care, but for patients to benefit from it, the appropriate contact with, and relationship, between doctor and patient must be established first.
Without a focus on the doctor-patient relationship and on the patient’s understanding, telehealth cannot improve the quality of life of patients, despite the benefit of allowing them to do their medical check-ups from the comfort of their home. The downsides of telemedicine include the cost of telecommunication and data management equipment and of technical training for medical personnel who will employ it.
Virtual medical treatment also entails potentially decreased human interaction between medical professionals and patients, an increased risk of error when medical services are delivered in the absence of a registered professional, and an increased risk that protected health information may be compromised through electronic storage and transmission.
Another disadvantage of telemedicine is the inability to start treatment immediately. For example, a patient with a bacterial infection might be given an antibiotic hypodermic injection in the clinic, and observed for any reaction, before that antibiotic is prescribed in pill form. We must also be wary of equitability.
Many families and individuals in the United States, and other countries, do not have internet access in their homes. Not to mention they may lack the necessary equipment to access telehealth services, such as a laptop, tablet, or smart phone. Informed consent is another issue — should the patient give informed consent to receive online care before it starts?
Or will it be implied if it is care that can only practically be given over distance? When telehealth includes the possibility for technical problems such as transmission errors, security breaches, or storage issues, it can impact the system’s ability to communicate.
It may be wise to obtain informed consent in person first, as well as having backup options for when technical issues occur. In person, a patient can see who is involved in their care namely themselves and their clinician in a consult , but online there will be other involved such as the technology providers, therefore consent may need to involve disclosure of anyone involved in the transmission of the information and the security that will keep their information private, and any legal malpractice cases may need to involve all of those involved as opposed to what would usually just be the practitioner.
Projections for the growth of the telehealth market are optimistic, and much of this optimism is predicated upon the increasing demand for remote medical care.
According to a recent survey, nearly three-quarters of U. In the UK, the Government’s Care Services minister, Paul Burstow, has stated that telehealth and telecare would be extended over the next five years — to reach three million people.
In the United States, telemedicine companies are collaborating with health insurers and other telemedicine providers to expand marketshare and patient access to telemedicine consultations.
The U. A team of doctors answered around anonymous inquiries annually, usually within 24 to 48 hours. The team consisted of up to six physicians who are specialists in clinical telemedicine at the USZ and have many years of experience, particularly in internal and general medicine.
In the entire period, inquiries were sent and answered. However, in the course of time, considerably more men and older people began to use the service. The diversity of medical queries covered all categories of the International Statistical Classification of Diseases and Related Health Problems ICD and correlated with the statistical frequency of diseases in hospitals in Switzerland.
Most of the inquiries concerned unclassified symptoms and signs, services related to reproduction, respiratory diseases, skin diseases, health services, diseases of the eye and nervous systems, injuries and disorders of the female genital tract.
As with the Swedish online medical advice service,  one-sixth of the requests related to often shameful and stigmatised diseases of the genitals, gastrointestinal tract, sexually transmitted diseases, obesity and mental disorders.
By providing an anonymous space where users can talk about shameful diseases, online telemedical services empower patients and their health literacy is enhanced by providing individualized health information. The Clinical Telemedicine and Online Counselling service of the University Hospital of Zurich is currently being revised and will be offered in a new form in the future.
For developing countries, telemedicine and eHealth can be the only means of healthcare provision in remote areas. For example, the difficult financial situation in many African states and lack of trained health professionals has meant that the majority of the people in sub-Saharan Africa are badly disadvantaged in medical care, and in remote areas with low population density, direct healthcare provision is often very poor  However, provision of telemedicine and eHealth from urban centers or from other countries is hampered by the lack of communications infrastructure, with no landline phone or broadband internet connection, little or no mobile connectivity, and often not even a reliable electricity supply.
India has broad rural-urban population and rural India is bereaved from medical facilities, giving telemedicine a space for growth in India. Deprived education and medical professionals in rural areas is the reason behind government’s ideology to use technology to bridge this gap. Remote areas not only present a number of challenges for the service providers but also for the families who are accessing these services.
Since , telemedicine has expanded in India. It has undertaken a new way for doctor consultations. This sector is at an ever-growing stage with high scope of development. This service crossed five million tele-consultations within a year of its launch indicating conducive environment for acceptability and growth of telemedicine in India. Sub-Saharan Africa is marked by the massive introduction of new technologies and internet access. Population in remote areas however, still lack access to healthcare and modern technologies.
Some people in rural regions must travel more between 2 and 6 hours to reach the closest healthcare facilities of their country. SAHEL was started in in Kenya and Senegal, providing self-contained, solar-powered internet terminals to rural villages for use by community nurses for collaboration with distant health centers for training, diagnosis and advice on local health issues.
This VSAT terminal equips remote regions allowing them to alert the world when there is a medical emergency, resulting in a rapid deployment or response from developed countries.
The development and history of telehealth or telemedicine terms used interchangeably in literature is deeply rooted in the history and development in not only technology but also society itself. Humans have long sought to relay important messages through torches , optical telegraphy , electroscopes , and wireless transmission.
In the 21st century, with the advent of the internet , portable devices and other such digital devices are taking a transformative role in healthcare and its delivery. Although, traditional medicine relies on in-person care, the need and want for remote care has existed from the Roman and pre-Hippocratic periods in antiquity.
The elderly and infirm who could not visit temples for medical care sent representatives to convey information on symptoms and bring home a diagnosis as well as treatment. That version of Telehealth was far different from how we know it today. During that time, they were communicating by heliograph and bonfire.
Those were used to notify other groups of people about famine and war. As technology developed and wired communication became increasingly commonplace, the ideas surrounding telehealth began emerging.
The earliest telehealth encounter can be traced to Alexander Graham Bell in , when he used his early telephone as a means of getting help from his assistant Mr. Watson after he spilt acid on his trousers. Another instance of early telehealth, specifically telemedicine was reported in The Lancet in An anonymous writer described a case where a doctor successfully diagnosed a child over the telephone in the middle of the night.
As the s came around, radio communication played a key role, especially during World War I. It was specifically used to communicate with remote areas such as Alaska and Australia.
During the Vietnam War, radio communication had become more advanced and was now used to send medical teams in helicopters to help. This then brought together the Aerial Medical Service AMS who used telegraphs, radios, and planes to help care for people who lived in remote areas.
From the late s to the early s the early foundations of wireless communication were laid down. The use of radio to deliver healthcare became accepted for remote areas. In the inventor Hugo Gernsback wrote an article for the magazine Science and Invention which included a prediction of a future where patients could be treated remotely by doctors through a device he called a “teledactyl”.
His descriptions of the device are similar to what would later become possible with new technology. In order to monitor their astronauts in space, telemedicine capabilities were built into the spacecraft as well as the first spacesuits.
Engineers for NASA created biomedical telemetry and telecommunications systems. After the technology was created, it then became the base of telehealth medicine for the public.
Massachusetts General Hospital and Boston’s Logan International Airport had a role in the early use of telemedicine, which more or less coincided with NASA’s foray into telemedicine through the use of physiologic monitors for astronauts. Due to the extreme complexity of trying to get all the medical personnel out from the hospital, the practical solution became telehealth. The clinic addressed the fundamental problem of delivering occupational and emergency health services to employees and travellers at the airport, located three congested miles from the hospital.
Clinicians at the hospital would provide consultation services to patients who were at the airport. Consultations were achieved through microwave audio as well as video links.
They performed a workup at the airport, took her to the telehealth suite where Dr. Raymond Murphy appeared on the television, and had a conversation with her. While this was happening, another doctor took notes and the nurses took vitals and any test that Dr. Murphy ordered. In , the Nebraska Psychiatric Institute began using television links to form two-way communication with the Norfolk State Hospital which was miles away for the education and consultation purposes between clinicians in the two locations.
In the Department of Health, Education and Welfare in the United States approved funding for seven telemedicine projects across different states. This funding was renewed and two further projects were funded the following year. In March , the San Bernardino County Medical Society officially implemented its Tel-Med program, a system of prerecorded health-related messages, with a log of 50 tapes.
Telehealth projects underway before and during the s would take off but fail to enter mainstream healthcare. Florida first experimented with “primitive” telehealth in its prisons during the latter s. Boultinghouse and Michael J. Davis, from the early s to ; Glenn G.
The first interactive telemedicine system, operating over standard telephone lines, designed to remotely diagnose and treat patients requiring cardiac resuscitation defibrillation was developed and launched by an American company, MedPhone Corporation, in Twelve hospitals in the U.
As the expansion of telehealth continued in Maritime Health Services MHS was a big part of the initiation for occupational health services. They sent a medical officer aboard the Pacific trawler that allowed for round-the-clock communication with a physician. MedNet is a video chatting system that has live audio and visual so the physician on the other end of the call can see and hear what is happening. MetNet can be used from anywhere, not just aboard ships. This has created a demand for at-home monitoring.
At-home care has also become a large part of telehealth. Doctors or nurses will now give pre-op and post-op phone calls to check-in. There are also companies such as Lifeline , which give the elderly a button to press in case of an emergency. That button will automatically call for emergency help.
If someone has surgery and then is sent home, telehealth allows physicians to see how the patient is progressing without them having to stay in the hospital. TeleDiagnostic Systems of San Francisco is a company that has created a device that monitors sleep patterns, so people with sleep disorders do not have to stay the night at the hospital. It was attached to them so when they wandered off it notified the staff to allow them to go after them. All these devices allowed healthcare beyond hospitals to improve, which means that more people are being helped efficiently.
The advent of high-speed Internet , and the increasing adoption of ICT in traditional methods of care, spurred advances in telehealth delivery. In , Dr. In the s, integration of smart home telehealth technologies, such as health and wellness devices, software, and integrated IoT , has accelerated the industry.
Healthcare organizations are increasingly adopting the use of self-tracking and cloud-based technologies, and innovative data analytic approaches to accelerate telehealth delivery. In , Mercy Health system opened Mercy Virtual , in Chesterfield, Missouri, the world’s first medical facility dedicated solely to telemedicine.
With the pandemic, telehealth has become a vital means of medical communication. It allows doctors to return to humanizing the patient. Some researchers claim this creates an environment that encourages greater vulnerability among patients in self disclosure in the practice of narrative medicine. Universities are now ensuring that medical students are coming out of school with proficient telehealth communication skills.
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The Health Resources and Services Administration. Cardiopulmonary Physical Therapy Journal. In Journal of the Statistical Society, Under no circumstances can the hypothesis be dismissed unconsidered. We shall examine these two sets of factors successively, to see 1 Bibliography.
XXXIV, p. Lunier, De la production et de la consommation des boissons alcooliques en France, Paris, I The annual rate of certain diseases is relatively stable for a given society though varying perceptibly from one people to another. Among these is insanity. Falret5 and Moreau de Tours use almost the same terms. Bourdin, in a brochure which at once created a stir in the medical world, had enunciated the same opinion even more unreservedly.
Suicide itself is either called a disease in itself, sui generis, a special form of insanity; or it is regarded, not as a distinct species, but simply an event involved in one or several varieties of insanity, and not to be found in sane persons.
Actually it is partly a social phenomenon. We shall return to this point. VII, p. From considering suicide as a disease sui generis, general propositions have been set up which are belied by experience. The other proof, however, if obtainable, would be conclusive. If suicide can be shown to be a mental disease with its own characteristics and distinct evolution, the question is settled; every suicide is a madman.
But does suicidal insanity exist? In traditional terminology of mental pathology these restricted deliria are called monomanias. At times, for example, he has an unreasonable and absurd desire to drink or steal or use abusive language; but all his other acts and all his other thoughts are strictly correct.
Therefore, if there is a suicidal mania it can only be a monomania, and has indeed been usually so called. In short, monomania is merely one extreme emotion in the order of impulses, one false idea in the order of representations, but of such intensity as to obsess the mind and completely enslave it. Thus, ambition, from being normal, becomes morbid and a monomania of grandeur when it assumes such proportions that all other cerebral functions seem para- lyzed by it. A somewhat violent emotional access disturbing mental equilibrium is therefore enough to cause the monomania to appear.
Moreover, many suicides are completely indistinguishable from other men except by the particular act of self-destruction; and there is therefore no reason to impute a general delirium to them. This is the reasoning by which suicide, under the appellation of monomania, has been considered a manifestation of insanity. But, do monomanias exist? For a long time this was not questioned; alienists one and all concurred without discussion in the theory of partial deliria.
Today however this opinion has been universally discarded. Clinical experience has never been able to observe a diseased mental impulse in a state of pure isolation; whenever there is lesion of one faculty the others are also attacked, and if these concomi- tant lesions have not been observed by the believers in monomania, it is because of poorly conducted observations.
He declares himself div- inely inspired; entrusted with a heavenly mission he brings a new religion to the world. This idea will be said to be wholly insane; yet he reasons like other men except for this series of religious thoughts.
He believes himself called upon to reform not only religion but also to reform society; perhaps he will also imagine the highest sort of destiny reserved for himself. If you have not discovered tendencies to pride in this patient, you will encounter ideas of humility or tendencies to fear. Preoccupied with religious ideas he will believe himself lost, destined to perish, etc. Finally, apart from these special manifestations, there always exists in these supposed monomaniacs a general state of the whole mental life which is fundamental to the disease and of which these delirious ideas are merely the outer and momentary expression.
Its essential character is an excessive exaltation or deep depression or general perversion. There is, especially, a lack of equilibrium and coordination in both thought and action.
The patient reasons, but with lacunas in his ideas; he acts, not absurdly, but without sequence. It is incorrect then to say that insanity constitutes a part, and a restricted part of his mental life; as soon as it penetrates the understanding it totally invades it. Moreover, the principle underlying the hypothesis of monomania contradicts the actual data of science. The old theory of the faculties has 9 Maladies mentales, p. They are too completely interconnected for insanity to attack certain of them without injury to the others.
With yet greater reason it is totally impossible for insanity to alter a single idea or emotion with- out psychic life being radically changed. For representations and impulses have no separate existence; they are not so many little sub- stances, spiritual atoms, constituting the mind by their combination.
They are merely external manifestations of the general state of the centers of consciousness, from which they derive and which they express. Thus they cannot be morbid without this state itself being vitiated. The apparently local disturbances given this name always derive from a more extensive perturbation; they are not diseases themselves, but particular and secondary mani- festations of more general diseases. If then there are no monomanias, there cannot be a suicidal monomania and, consequently, suicide is not a distinct form of insanity.
III It remains possible, however, that suicide may occur only in a state of insanity. If it is not by itself a special form of insanity, there are no forms of insanity in connection with which it may not appear.
It is only an episodic syndrome of them, but one of frequent occurrence. Per- haps this frequency indicates that suicide never occurs in a state of sanity, and that it indicates mental alienation with certainty? The conclusion would be hasty. To be sure, alienists state that most of the suicides known to them show all the indications of mental alienation, but this evidence could not settle the question, for the reviews of such cases are much too summary. Besides, no general law could be drawn from so narrowly specialized an experience.
From the suicides they have known, who were, of course, insane, no conclusion can be drawn as to those not observed, who, moreover, are much more numerous.
The only methodical procedure consists of classifying according to their essential characteristics the suicides committed by insane persons, thus forming the principal types of insane suicide, and then trying to learn whether all cases of voluntary death can be included under these systematically arranged groups.
In general, specialists have paid little heed to classifying the suicides of the insane. The four following types, however, probably include the most important varieties. Maniacal suicide. The patient kills himself to escape from an imaginary danger or disgrace, or to obey a mysterious order from on high, etc. The quality characteristic of this condition is its extreme mobility. It is a constant whirlwind. One state of mind is instantly replaced by another. Such, too, are the motives of maniacal suicide; they appear, disappear, or change with amazing speed.
If it is later repeated it will be for another motive. The most trivial incident may cause these sudden transformations. One such patient, wishing to kill himself, had leaped into a river—one that was generally shallow. The man went peaceably home at once, no longer thinking of self-destruction. Melancholy suicide. Pleasures no longer attract; he sees everything as through a dark cloud.
Life seems to him boring or painful. From that moment she contracts an extreme disgust, a def- inite desire for solitude and soon an invincible desire to die. Firmly resolved to throw herself into the river, she seeks the remotest places to prevent any rescue. But after a year the inclina- tion to suicide returns more forcefully and attempts recur in quick succession. Hallucinations and delirious thoughts often associate themselves with this general despair and lead directly to suicide.
However, they are not mobile like those just observed among maniacs. The fears by which the patient is haunted, his self-reproaches, the grief he feels are always the same. If then this sort of suicide is determined like its predecessor by imaginary reasons, it is distinct by its chronic character. Patients of this category prepare their means of self-destruction calmly; in the pursuit of their purpose they even display incredible persistence and, at times, cleverness. Obsessive suicide.
He is obsessed by the desire to kill himself, though he perfectly knows he has no reasonable motive for doing so. But throughout this resistance he is sad, depressed, with a constantly increasing anxiety oppressing the pit of his stomach.
Hence, this sort of suicide has sometimes been called anxiety-suicide. I perform my regular duties satisfactorily but like an automaton, and when spoken to, the words sound to me as though echoing in a void. My greatest torment is the thought of suicide, from which I am never free. It is as though the patient had voided this impulse. Impulsive or automatic suicide. In the twinkling of an eye it appears in full force and excites the act, or at least its beginning. This abruptness recalls what has been mentioned above in connection with mania; only the maniacal suicide has always some reason, however irrational.
The sight of a knife, a walk by the edge of a precipice, etc. Rescued immediately and asked for the motives of his behaviour, he knows nothing of them, he has yielded to irresist- ible force.
In short, all suicides of the insane are either devoid of any motive or determined by purely imaginary motives. Now, many voluntary deaths fall into neither category; the majority have motives, and motives not unfounded in reality. Not every suicide can therefore be considered insane, without doing violence to language. Of all the suicides just characterized, that which may appear hardest to detect of those observed among the sane is melancholy suicide; for very often the normal person who kills himself is also in a state of dejection and depression like the mentally alienated.
Thus, suicide has been so closely associated with insanity only by arbitrarily restricting the meaning of the words. Falret likewise refuses to consider Curtius, Codrus or Aristodemus as suicides. All cases of death resulting from an act of the patient himself with full knowledge of the inevitable results, whatever their purpose, are too essentially similar to be assigned to separate classes.
This leaves at least a group of suicides uncon- nected with insanity. Once exceptions are admitted, it is hard to stop. For there is only a gradual shading between deaths inspired by usually generous feelings and those from less lofty motives. An imperceptible gradation leads from one class to the other. If then the former are suicides, there is no reason for not giving the same name to the latter. There are therefore suicides, and numerous ones at that, not con- nected with insanity.
This often debated question may therefore be solved without requiring reference to the problem of freedom. To learn whether all suicides are insane, we have not asked whether or not they act freely; we have based ourselves solely on the empirical characteristics observable in the various sorts of voluntary death. IV Since the suicides of insane persons do not constitute the entire genus but only a variety of it, the psychopathic states constituting mental alienation can give no clue to the collective tendency to suicide in its generality.
But between mental alienation properly so-called and per- fect equilibrium of intelligence, an entire series of intermediate stages exist; they are the various anomalies usually combined under the common name of neurasthenia.
Let us therefore see whether they, in cases devoid of insanity, do not have an important role in the origin of the phenomenon we are studying. The very existence of insane suicide suggests the question. It is also a much more widespread condition than insanity; it is even becoming progressively more general.
The total of abnormalities thus termed may therefore be one of the factors with which the suicide-rate varies. It is well known that pain, in general, results from too violent a shock to the nervous system; a too intense nervous wave is usually painful. But this max- imum intensity beyond which pain begins varies with individuals; it is highest among those whose nerves have more resistance, less in others.
The painful zone begins earlier, therefore, among the latter. On the other hand, it is true that the zone of pleasure itself also begins at a lower level; for the excessive penetrability of a weakened nervous system makes it a prey to stimuli which would not excite a normal organism.
Due to this extreme sensitivity of his nervous system, his ideas and feelings are always in unstable equilibrium. It is always in process of becoming. For living means responding appropri- ately to outer stimuli and this harmonious correspondence can be established only by time and custom. It is a product of experiments, sometimes repeated for generations, the results of which have in part become hereditary and which cannot be gone through all over again everytime there is necessity for action.
If, however, at the moment of action everything has to be reconstructed, so to speak, it is impossible for this action to be what it should be. This is what the neuropath lacks. His state of disturbance causes him to be constantly taken by surprise by circum- stances. Unprepared to respond, he has to invent new forms of con- duct; whence comes his well-known taste for novelty. When, however, he has to adapt himself to traditional situations, improvised contriv- ances are inadequate against those derived from experience; and they therefore usually fail.
This psychological type is therefore very probably the one most commonly to be found among suicides. What share has this highly individual condition in the production of voluntary deaths? Can it alone, if aided by circumstances, produce them, or does it merely make individuals more accessible to forces exterior to them and which alone are the determining causes of the phenomenon?
To settle the question directly, the variations of suicide would have to be compared with those of neurasthenia. Unfortunately, the latter has not been statistically studied.
Since insanity is only the enlarged form of nervous degener- ation, it may be granted without risk of serious error that the number of nervous degenerates varies in proportion to that of the insane, and consideration of the latter may be used as a substitute in the case of the former.
This procedure would also make it possible to establish a gen- eral relation of the suicide-rate to the total of mental abnormalities of every kind. It seems to increase and decrease like insanity, a fact which might make it seem dependent on the latter. The latter hypothesis is the more plausible in that the social causes of suicide are, as we shall see, themselves closely related to urban civilization and are most intense in these great centers.
The following facts show that the opposite is the rule: 1. All statistics prove that in insane asylums the female inmates are slightly more numerous than the male. The proportion varies by coun- tries, but as appears in the table below, it is in general 54 or 55 for the women to 46 or 45 for the men.
Among , insane of both sexes, he found 78, men and 88, women, or 1. In France, certainly, of every insane who die in asylums, about 55 are men. The larger number of women recorded at a given time would therefore not prove that women have a greater ten- dency to insanity, but only that, in this condition as in all others, they outlive men. It is none the less true that the actual insane population includes more women than men; if, then, as seems reasonable, we apply the argument from the insane to the nervous, more neur- asthenics must be admitted to exist at a given moment among females than among men.
So, if there were a causal relation between the suicide-rate and neurasthenia, women should kill themselves more often than men. They should do so at least as often. But far from their aptitude for voluntary death being either higher or equal to that of men, suicide happens to be an essen- tially male phenomenon. To every woman there are on the average four male suicides Table IV, p. But the intensity of this tendency does not vary at all in propor- tion to the psychopathic factor, whether the latter is estimated by the number of new cases registered annually or by that of census subjects at a given moment.
Nevertheless, the tendency to suicide among the Jews is very slight. We shall even show later that it is least prominent in this religion. Doubtless this does 20 See below, Bk. II, Chap. If Catholics alone are compared with Protestants, the inverse propor- tion is less general; yet it is very frequent.
It will be shown later see Table IX, p. If it occasionally retrogresses after the age of 70 or 80, the decrease is very slight; it still remains at this time of life from two to three times greater than at maturity.
On the other hand, insanity appears most frequently at maturity. If the suicide-rate at each age is compared, not with the relative frequency of new cases of insanity appearing during this same period, but with the proportional number of the insane population, the lack of any parallelism is just as clear. The insane are most numerous in rela- tion to the total population at about the age of The proportion remains about the same to approximately 60; beyond that it rapidly decreases.
It is minimal, therefore, when the suicide-rate is maxi- mal, and prior to that no regular relation can be found between the variations of the two. True, statistics of mental alienation are not compiled accurately enough for these international compari- sons to be very strictly exact. Thus the countries with the fewest insane have the most suicides; the case of Saxony is especially striking.
In his excellent study on suicide in Seine-et-Marne, Dr. Leroy had already observed the same fact. However these two maxima may be completely distinct. I should even be inclined to believe that, side by side with some countries fortunate enough to have neither mental diseases nor suicides. Far from predisposing to suicide, idiocy seems rather a safeguard against it; for idiots are much more numerous in the country than in the city, while suicides are much rarer in the country.
But even by combining them no regular parallel- ism is found between the extent of mental alienation and that of sui- cide. On the whole it appears that there are many suicides where the 23 Op. They are too high to represent cases of insanity only.
Morselli has evidently given the total of the insane and the idiots. In short, as insanity is agreed to have increased regularly for a century28 and suicide likewise, one might be tempted to see proof of their interconnection in this fact.
But what deprives it of any conclusive value is that in lower societies where insanity is rare, suicide on the contrary is sometimes very frequent, as we shall show below. If in fact, as we have shown, neurasthenia may predispose to suicide, it has no such necessary result. Both his muscular weakness and his excessive sensitivity, though they disqualify him for action, qualify him for intellectual functions, which themselves demand appropriate organs.
Likewise, if too rigid a social environment can only irritate his natural instincts, he has a useful role to play to the extent that society itself is mobile and can persist only through progress; for he is superlatively the instrument of progress. Precisely because he rebels against tradition and the yoke of custom, he is a highly fertile source of innovation. And as the most cultivated societies are also those where representative functions are the most necessary and most developed, and since, at the same time, because of their very great complexity, their existence is conditional upon almost constant change, neurasthenics have most reason for existence pre- cisely when they are the most numerous.
They are therefore not essen- tially a-social types, self-eliminating because not born to live in the environment in which they are put down. Other causes must super- vene upon their special organic condition to give it this twist and 27 Op cit. Neurasthenia by itself is a very general predisposition, not necessarily productive of any special action, but capable of assuming the most varied forms according to circumstances. Disgust with life and inert melancholy will readily germinate amongst an ancient and dis- oriented society, with all the fatal consequences which they imply; contrariwise, in a youthful society an ardent idealism, a generous pros- elytism and active devotion are more likely to develop.
Although the degenerate multiply in periods of decadence, it is also through them that States are established; from among them are recruited all the great innovators. V But there is a special psychopathic state to which for some time it has been the custom to attribute almost all the ills of our civilization.
This is alcoholism. Rightly or wrongly, the progress of insanity, pauperism and criminality have already been attributed to it. A priori the hypothesis seems unlikely, for suicide has most victims among the most cultivated and wealthy classes and alcoholism does not have its most numerous fol- lowers among them. But facts are unanswerable. Let us test them. If the French map of suicides is compared with that of prosecu- tions for alcoholism,31 almost no connection is seen between them.
In the writers of both nations, in fact, one perceives a morbid delicacy of the nervous system, a certain lack of mental and moral equilibrium. Thus a single organic state may contribute to almost opposite social ends. See Appendix I. From the point of view of suicide, on the other hand, the Rhone is not above the average, most of the Norman departments are below it and Brittany is almost immune.
The same result is obtained by comparing suicide not with criminal intoxication but with the nervous or mental diseases caused by alcohol- ism. After grouping the French departments in eight classes according to their rank in suicides, we examined the average number of cases of insanity due to alcoholism in each class, using Dr.
Whereas suicides increase six- fold and over, the proportion of alcoholic insane barely increases by a 32 De la production et de la consommatian des boissons alcooliques en France, p. Indeed most alcohol is drunk in the northern departments and it is also in this same region that suicide shows its greatest ravages.
The maximum of one appears in Normandy and the North and diminishes as it descends toward Paris; that of alcoholic consumption. The other is most intense in the Seine and neighboring departments; it is already lighter in Normandy and does not reach the North.
The former tends westward, and reaches the Atlantic coast; the other has an opposite direction. It ends abruptly in the West, at Eure and Eure-et- Loir, but has a strong easterly tendency. Moreover, the dark area on the map of suicides formed in the Midi by Var and Bouches-du-Rhone does not appear at all on the map of alcoholism. In short, even to the extent that there is some coincidence it proves nothing, being random.
Leaving France and proceeding farther North, for example, the consumption of alcohol increases almost regularly without the appearance of suicide. Whereas only 2. And yet whereas, in the corresponding periods, suicides per million inhabitants occurred in France, Belgium had only 68, Great Britain 70, Sweden 85, Russia very few.
Even at Saint Petersburg from to the average annual rate was only Denmark is the only northern country where there are both many suicides and a large con- sumption of alcohol The conjunction is accidental. Genuine contrasts are even found in certain details: the 35 The consumption of wine indeed varies rather inversely to suicide.
Most wine is drunk in the Midi where suicides are least numerous. Wine is, however, not to be regarded as a guarantee against suicide for this reason. From another standpoint, if sui- cide occurs there less than in the rest of Germany, this is because its population is either Catholic or contains large Catholic minorities. A society does not depend for its number of suicides on having more or fewer neuropaths or alcoholics. Admittedly, under similar circum- stances, the degenerate is more apt to commit suicide than the well man; but he does not necessarily do so because of his condition.
But in Sweden alcoholism has diminished also and proportionately, while suicide has continued to increase cases per million in —88, instead of 63 in — The situation is the same in Russia. To give the reader all sides of the question we must add that the proportion of suicides ascribed to occasional or habitual drunkenness by French statistics rose from 6. Finally, it will be shown later why no great value can be attached to the information thus given by statistics concerning the presumptive causes of suicide.
It might consist of purely psychological phenomena without necessarily being associated with any perversion of the ner- vous system. Why should there not occur among men a tendency to renounce existence, which is neither a monomania nor a form of mental alienation or neurasthenia? It might even be considered an established fact if, as several writers on suicide have declared,1 each race had a characteristic suicide-rate of its own.
If then suicide really varied with races, it would be established that it is closely connected with some organic disposition. But does this relation exist? Recently race has been understood to mean an aggregate of indi- viduals with clearly common traits, but traits furthermore due to der- ivation from a common stock. In this sense M. Unfortunately, if this formula is accepted, the existence and area of a race can be established only by historical and ethnographic research, the results of which are always uncertain; for only very uncertain prob- abilities can be determined in questions of origin.
Without any other cri- terion being given, it would therefore be very hard to discover the relations of the various races to suicide, for no one could say with accuracy where they begin and end. Besides, M. Paris, Felix Alcan. This is contested by a whole school of anthropology that has taken the name of polygenists.
Only two characteristics are left to mark race. First, it is a group of individuals who resemble one another. But so do members of a single faith or profession. The distinguishing characteristic is that the resemblances are hereditary. It is a type which, however originally formed, is now hereditarily transmissible. It no longer represents merely the most general branches of the species, the natural and relatively unchangeable divisions of humanity, but every sort of type.
In fact, from this point of view each group of nations the members of which, due to their centuries-long intimate mutual relations, show partially hereditable similarities, would consti- tute a race. Only in this sense indeed can races still be regarded as con- crete, living factors of historical development. If they have not totally disappeared, at least only vague features and scattered traits are found in imperfect combination with one another, forming no characteristic physi- ognomies.
The more specialized and smaller types called races in the broad sense of the word are more clearly marked and necessarily have an historical role, since they are less the products of nature than of history.
Indeed, on the one hand, the original races have only a paleonto- logical interest, and on the other the narrower groups so designated today seem to be only peoples or societies of peoples, brothers by civilization rather than by blood. Thus conceived, race becomes almost identical with nationality.
II Yet let us agree that there are certain great types in Europe the most general characteristics of which can be roughly distinguished and among whom the peoples are distributed, and agree to give them the name of races. We mention the last only by courtesy, since it has too few representatives in Europe for its relations to suicide to be ascertainable. In fact only the Hungarians, the Finns and the people of some Russian provinces can be assigned to it.
The hypothesis would be plausible if each group of peoples thus combined under a single name had an equally strong tendency to suicide. While in general the Slavs have little inclination to self- destruction, Bohemia and Moravia are exceptions. The former has suicides per million inhabitants and the second , while Carniola has only 46, Croatia 30, Dalmatia Similarly, of all the Celto-Roman peoples, France stands out by the size of its contribution, suicides per million, while in the same period Italy had only about 30 and Spain still fewer.
Among the Germanic peoples the variety is yet greater. Of the four groups associated with this stock, three of them are much less inclined to suicide than the Slavs and Latins. These are the Flemish, numbering only 50 suicides per million , the Anglo-Saxons with only 70;5 as for the Scandinavians, Denmark, to be sure, has the high number of suicides, but Norway has only If then the terms were strictly used, it would be a question not of race but of nationality.
Yet, since the existence of a German type in part, at least, hereditary, has not been disproved, the sense of the word may be stretched to the extreme extent of saying that suicide is more developed among the peoples of German race than among most Celto-Roman, Slavic or even Anglo-Saxon and Scandina- vian societies. To attribute the German inclination to suicide to this cause, it is not enough to prove that it is general in Germany; for this might be due to the special nature of German civilization.
But the inclination would have to be shown to be connected with an hereditary state of the German organism, and that this is a permanent trait of the type, persist- ing even under change of social environment. Only thus could we regard it as a racial product. Table VII shows for each province the average suicide-rate for the quin- quennium —77 together with the numerical weight of the German elements.
The races have been distinguished by their use of language; though this is not an absolutely exact standard, it is nevertheless the surest that can be employed.
Bohemia, Moravia and Bukovina, con- taining only from 37 to 9 per cent of Germans, have a higher average of suicides than Styria, Carinthia and Silesia , where the Germans are in the great majority. The latter provinces likewise, though containing an important Slav minority, in respect to suicide exceed the only three where the population is entirely German, Upper Austria, Salzburg and Transalpine Tyrol.
The part played by the metropolis must not be attributed to race. The two races are both found in Switzerland. Fifteen cantons are wholly or in part German. Their average of suicides is To accomplish this we have compared German and French cantons of the same confession.
Facts thus concur in showing that Germans commit suicide more than other peoples not because of their blood but because of the civil- ization in which they are reared. The French people consists of a mixture of two principal races, the Celts and the Cymry, who from the beginning have been distinct from each other in regard to height.
From the times of Julius Caesar the Cymry have been known for their great stature. Thus Broca was able to determine by the height of the inhabitants how these two races are distributed today over our territory, and he found populations of Celtic origin preponderant to the South of the Loire and those of Cymric origin to the North.
But Morselli has gone further. He thought that he could prove the regular variation of French suicides according to the distribution of ethnic groups. Considering that the average stature in France has perceptibly changed within thirty years, that the number of exempt for this reason has dropped from Likewise the last three groups are on approximately the same level,9 however unequal in respect to height.
In other words, the two great regional masses found on the ethnographic map are also found on that of suicides; but the coincidence is only broadly and generally accurate.
It does not appear in the detailed variations shown by the two subjects compared. Once the coincidence has thus been reduced to its true proportions, it is no longer a decisive proof of the ethnic elements; for it is merely a curious fact inadequate to prove a law. It may well be a mere encounter of independent factors.
On the contrary, it is contradicted by the following facts: 1. It would be surprising if such a collective type as the Germans, place for even more doubt. Morphological reasons are impossible here. Anthropology may indeed determine the average stature in a given region, but not the crossings from which this average results. Now these intermediate statures may quite as well be due to crossings of the Celts with men of greater stature as to alliances of the Cymry with smaller men than themselves.
Historical arguments then remain which can only be very conjectural. We shall see below that suicide was common among the ancient Celts. Thus, if the greater aptitude for suicide of the Cymry has ethnic causes, it is 10 See below, Bk.
In that case, how- ever, suicide should be found to increase the more, even outside of France, the more the distinctive characteristics of this race have been unaltered. This is not so. The greatest statures in Europe 1. Yet the suicide-rate has not risen in the Scandinavian peninsula. The same race is said to have preserved its purity better in Holland, Belgium and England than in France,12 and yet the last-named country shows many more suicides than the other three.
But this geographical distribution of French suicides may be explained without the necessity of introducing the obscure operations of race. Our country is known to be divided morally as well as ethno- logically into two parts as yet not wholly combined.
The peoples of the Center and the Midi have retained their own temperament, a character- istic way of life, and for this reason resist the ideas and manners of the North. Now the center of French civilization is in the North; it has remained essentially northern in character. Since, on the other hand, as will be seen later, this civilization contains the principal causes which lead Frenchmen to suicide, the geographical limits of its sphere of action are also those of the zone most fertile in suicides.
Thus, if the people of the North commit suicide more than those of the Midi, it is not because they are more predisposed to it by their ethnic tempera- ment, but simply that the social causes of suicide are more specially located north rather than south of the Loire.
As for the origin and persistence of this twofold moral character of our country, this is an historical question not adequately to be solved by ethnographic considerations. There is no such antagonism between the northern and southern types that centuries of common life have not been able to overcome.
But for historical reasons the provincial spirit and local traditionalism have remained much stronger in the Midi, while in the 12 See Topinard, Anthropologie, p. And just this moral levelling, by increasing the circulation of persons, ideas and things has made the latter region the birthplace of an intense civilization.
But has the heredity of suicide been proved? The question deserves close examination because of an interest of its own besides its relation to the one just considered. But psychologists have very often spoken of heredity in quite another sense. According to this, it is the tendency to self-destruction which passes directly and wholly from parents to children and which, once transmitted, gives birth wholly automatically to suicide. It would then be a sort of psychological 13 The same remark applies to Italy.
There, too, suicides are more numerous in the North than in the South, and, on the other hand, the average height of the people of the North is slightly greater than that of the South, But present-day Italian civilization is Piedmontese in origin and, on the other hand, the Piedmontese are slightly taller than the people of the South. The maximum found in Tuscany and Venetia is 1.
In Sardinia height diminishes to 1. Thus it would depend essentially on individual causes. Does observation show the existence of such an heredity? Certainly, suicide sometimes reappears in a given family with terrible regularity.
None have misfortunes; all enjoy good health. All seven brothers committed suicide within forty years. But the example of physiologists should teach us not to draw hasty conclusions in these questions of heredity which have to be treated very carefully. Thus, there are certainly many cases where tuberculosis attacks successive generations and yet scholars still hesitate to admit that it is hereditary.
The opposite seems to be the prevalent conclusion. This repetition of a disease in the same family may indeed be due not to the hereditary character of tuberculosis itself but to that of a general temperament calculated to receive and on occasion propagate the bacillus causing the disease.
To have the right to reject the last explanation peremptor- ily, one must at least have proven that the Koch bacillus is often found in the foetus; until this has been proved the solution is doubtful.
Like caution is required in the problem before us. To solve it, therefore, it is not enough to cite certain facts favorable to the thesis of heredity. These facts must also be numerous enough not to be attributable to accidental circumstances—not to permit another explanation—to be contra- dicted by no other fact.
Do they satisfy this triple condition? To be sure, they are considered common. But to conclude that the nature of suicide is hereditary, their greater or less frequency is not enough. One must also be able to show their proportion relative to the 14 Sur les fonctions du cerveau, Paris, If hereditary antecedents were shown for a relatively high fraction of the total number of suicides, it might be admitted that a relation of causality exists between the two facts, that suicide tends to be hereditarily transmissible.
But lacking this proof it is always possible that the cases cited are due to chance combinations of various causes. Now the observations and comparisons which alone would solve this question have never been made on a large scale. Rarely is more than a certain number of interesting anecdotes adduced.
Our slight information on this particular matter is in no sense conclusive; it is even somewhat contradictory. Among 39 insane cases with a more or less pronounced tendency to suicide observed by Dr. First, almost all these observations were made by alienists and, con- sequently, among the insane. Of all diseases, insanity is perhaps the one most commonly transmitted. One may therefore question whether what is hereditary is the tendency to suicide rather than the insanity of which it is a frequent but nevertheless accidental symptom.
In this case heredity has nothing more to do with the tendency to suicide than with hemoptysis in cases of heredi- tary tuberculosis. If the unfortunate, with both insane persons and suicides in his family, kills himself, it is not because his parents had done the same but because they were insane. This primary cause, however, is not enough to explain all the facts. For it is not also proved, on the one hand, that suicide never repeats itself except among families of the insane; and on the other, the remarkable fact remains that in some of these families suicide seems to be in an endemic state, although insanity does not necessarily imply such a result.
Not every insane person is impelled to self-destruction. How does it happen, then, that there are families of insane apparently predestined to it? The abundance of such cases evidently presupposes another factor than the one just mentioned, but which may be accounted for without attributing it to heredity.
The contagious power of example is enough to cause it. In fact, we shall see in one of the following chapters that suicide is very contagious. This contagiousness is specially common among indi- viduals constitutionally very accessible to suggestion in general and especially to ideas of suicide; they are inclined to reproduce not only all that impresses them but, above all, to repeat an act toward which they have already some inclination.
This twofold condition is found among insane or merely neurasthenic persons whose parents have committed suicide. For their nervous weakness makes them susceptible to hyp- nosis and simultaneously predisposes them to ready reception of the idea of self-destruction. It is not astonishing then that the memory or sight of the tragic end of their kinfolk becomes for them the source of an obsession or irresistible impulse. In families where repeated suicides occur, they are often performed almost identically.
They take place not only at the same age but even in the same way. In one case hanging is preferred, in another asphyxiation or falling from a high place.
In a case often quoted, the resemblance is yet greater; the same weapon served a whole family at intervals of several years. For they must be besieged and persecuted by these memories to be persuaded to repeat the act of their predecessors so faithfully.
This explanation is made yet more probable by numerous cases of the same character where heredity is not in question and where con- tagion is the only source of the evil. They seem copies of one another. Once the hook was removed there was an end of the epidemic. Likewise, at the camp of Boulogne, a soldier blew out his brains in a sentry-box; in a few days others imitated him in the same place; but as soon as this was burned, the contagion stopped.
Furthermore, many persons feel that by imitating their parents they yield to the prestige of example. A fourth brother, a doctor, killed him- self.
Two years before, he had told me with terrifying despair that he would not escape his fate. For the past three months they have persecuted me con- stantly and I am tempted to kill myself at every moment. When she was in this sad state her father killed himself.
From that time she felt herself absolutely destined to violent death. Thus is my blood tainted! Now the man whom she thought her father was not really so. To free her from her fears her mother confessed the truth and obtained an interview for her with her real father. She at once gave up all idea of suicide; her cheerfulness steadily returned and she recovered her health. But in addition, certain stat- istical facts, the importance of which psychologists seem to have missed, are inconsistent with the hypothesis of hereditary transmission properly so called.
They are as follows: 1. Now, actually, the suicides of females are known to be very few, only a slight fraction of those of males.
What then shall one think of an heredity which remains latent in most cases, except that it is a vague potentiality of a wholly unproven reality? Speaking of the heredity of tuberculosis, M. Even supposing that a lesion existed at the beginning of life, would it not have lost its virulence after so long a time? Is it natural to accuse these fossil microbes rather than decidedly living bacilli of all the evil. This is why heredity has been called the basic cause of the special madness appearing in earliest infancy and known for this reason as hereditary insanity.
Phtisie, vol. LXXVI, p. But if the transmitted characteristic is possible at any age, it should appear at once. Thus, the longer it takes in appearing, the more clearly must heredity be con- sidered only a weak stimulus to its existence.
It is not clear why the tendency to suicide should share one phase of organic development rather than another. But the opposite actually takes place. Suicide is extremely rare among children. From —75 according to Legoyt, there were in France per million children under 16 years of age 4. But no proof exists that these extraordinary facts must be attributed to heredity. They are most numerous in large cities. This also causes the number of child-suicides to grow with pitiful regularity in civilized lands.
But in addition, not only is suicide very rare during childhood but it reaches its height only in old age, and during the interval grows stead- ily from age to age. Sweden is the only society in which the maximum comes between 40 and 50 years.
Everywhere else, it occurs only in the last or next to the last period of life and, everywhere alike, with very slight exceptions due perhaps to errors of tabulation,29 the increase to this extreme limit is continuous. The decrease observable beyond 80 years is not absolutely general and in any case is very slight.
The contingent of this age is somewhat below that of the septuagenarians, but is above the others or, at least, most of them. How therefore can one attribute to heredity a tendency appearing only in the adult and which, from that period on, continues to increase with the advance of age? For women there is a moment of pause at the same age, which is general and must therefore be real. It marks a stage in female life. The law of homochronous heredity cannot be invoked for the spe- cies.
It practically states that under certain circumstances the inherited characteristic appears among the descendants at approximately the same age as among the parents. This is not true of suicide, which, beyond 10 or 15 years, is common to all ages. This constant progression shows that its cause itself develops as a man grows older.
In short, the variation of suicide with age shows that no organic- psychic state can possibly be its determining cause. Even the decrease often observed at about 80 years of age is not only slight and not absolutely general, but only relative, since nona- genarians commit suicide as much or more than sexagenarians and, especially, more than men in full maturity.
Does not this prove that the cause of the variations of suicide cannot be a congenital and invariable impulse, but the progressive action of social life?
Just as suicide appears more or less early depending on the age at which men enter into society, it grows to the extent that they are more completely involved in it. We are thus referred back to the conclusion of the preceding chapter.
Just as the material environment at times causes the appearance of diseases which, without it, would remain dormant, it might be capable of activating the general and merely potential nat- ural apitudes of certain persons for suicide.
One important fact, however, would have been seized: that at least some of the variations connected with this phenomenon might be accounted for without reference to social causes. In Arch. I Suicides are distributed as follows on the map of Europe, according to the varying degrees of latitude: 36th—43rd degree of latitude More exactly, Morselli has stated that the space between the 47th and 57th degrees of latitude, on the one hand, and the 20th and 40th of longitude on the other, was the area most favorable to suicide.
This zone coincides approximately with the most temperate region of Europe. Morselli advanced this thesis, though somewhat hesitantly. Indeed, the relation is not readily discernible between temperate climate and the tendency to suicide; to require such an hypothesis the facts must be in unusual agreement.
Italy is today relatively exempt; but it was very frequent there at the time of the Empire when Rome was the capital of civilized Europe. It has also been highly developed at certain epochs under the burning sun of India. The area formed by it on the map is not a single, fairly equal and homogeneous strip, including all the countries having the same climate, but two distinct areas: one having Ile-de-France and neighboring departments as a center, the other Sax- ony and Prussia.
We 2 See below, Bk. In the countries outside the central zone, their regions closest to it, whether North or South, are those most stricken with suicide. Thus, it is most developed in Italy in the North, while in England and Belgium it is more so in the South.
But there is no reason to ascribe these facts to the proximity to the temper- ate climate. Until the northern provinces of Italy showed most suicides, then the center and thirdly the south. The change consists in the movement of the Italian capital to the center of the country as a result of the conquest of Rome in Suicides followed along.
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Quick Links. It gives you a constant analogue. In addition, the following functions can be accessed. Chronograph, Compass, Alarm and Thermometer. Table of Contents. Previous Page. Next Page. Swiss watches since t-touch, multifunctions 16 pages. Watch Tissot T It gives you a constant analogue time display and a variety of digital displays. Page 2 Official service centers adresses www.
The display light freee stay on for 5 seconds. Options display Beep display Activate glass Switch to sub-menus: Automatic switch to see page 4 Units display standby mode after 5 seconds Beep every second Climate zone display Back to units display At any time: exit sub-menu — This mode economises the battery when the watch is not being worn. Furthermore, the pressure indicate the weather trend.
Total cumulative loss in altitude Mean vertical speed of descent Back: Elapsed time or stopped time Start chrono Stop chrono Reset chrono a Tissot touch expert manual pdf free stop with partial b Restart the chrono time displayed, and chrono counting the elapsed time In compass mode, tisso digital screen displays the angle between 12 o’clock and the minutes hand.
Activate glass Compass display Azimuth display User compass calibration Back to compass display Turn the watch more than a complete revolution on rouch horizontal surface e. An alarm lasts 30 seconds, without repeating. Wxpert the programmed time is reached, you can stop the alarm by pressing one of the push-buttons. Stop alarm 1 sec. Activate glass Free tissot touch expert manual pdf free display Alarm 2 display Alarm rings When a function is selected and the manyal is cleared, it is probably due to a failure of the selected function’s sensor.
To activate the functions http://replace.me/2887.txt your T-TOUCH a gentle press on the push-buttons or touch on the glass is all that is required. Print tissot touch expert manual pdf free 1 Print document 14 pages. Rename the frer. Delete bookmark? Cancel Delete. Delete from my manuals? Sign In OR. Don’t have an account? Sign up! Restore password. Upload manual. Upload from disk. Upload from URL.