SPECTRUM Journal of Student Research at Saint Francis University
Volume 4 (1) Fall 2013
SPECTRUM
4 (1)
2
SPECTRUM: Journal of Student Research at Saint Francis University Faculty Editors: Balazs Hargittai Professor of Chemistry bhargittai@francis.edu
Grant Julin Assistant Professor of Philosophy gjulin@francis.edu
Student Editorial Board: Shannon Adams Cathleen Fry Daniel Hines ’13 Paul Johns ’07 Timothy Keith Cecelia MacDonald Gabrielle McDermott Jonathan Miller ’08 Morgan Onink Aaron Rovan ‘09
Cover photo by Balazs Hargittai
Allison Bivens ’12 Sean Gdula ‘13 Eric Horell ’13 Amanda Johnson Jennifer Kirchner Lauren McConnell ’12 Sarah McDonald Steven Mosey Rebecca Peer Jennifer Yealy ‘13
SPECTRUM
4 (1)
3
SPECTRUM Table of Contents Medical Device Excise Tax: An Economic Review Conor S. Norris; Edward Timmons
4
Keeping One’s Head or Heart? Exploring Popular Reaction to Henry VIII’s Seccession from Rome Julie L. Cashdollar; Lori Woods
13
Urinary Incontinence: The Silent Embarrassment of Female Athletes Lauren S. Wingard; Heather R. Kindel; Stephen M. LoRusso
24
Contents of SPECTRUM Volumes 1 – 3
34
Call for papers
36
(Student authors’ names underlined.)
SPECTRUM
4 (1)
4
Medical Device Excise Tax: An Economic Review Conor S. Norris School of Business csn100@francis.edu
Edward Timmons, Ph.D. School of Business etimmons@francis.edu
In the passage of the Patient Protection and Affordable Care Act, Congress included a provision instituting an excise tax on medical devices. The goal of this paper is to examine the effects of the excise tax on the medical device industry. Within my paper, I discussed the general effects of excise taxes and the effects such a tax would have on the industry. In order to quantify the potential effects, I examined estimations of other economists along with my own arguments. A difference-in-difference table comparing the medical device industry revenues to the pharmaceutical industry revenues augments my arguments. Although the new tax provides the revenue to cover the increased costs of expanded health insurance coverage, it will increase the price and affect the sales of the medical device industry. Because of the high paying jobs for American workers and the benefit of those jobs to the economy, any move to decrease the sales of medical device manufacturers would hamper economic growth. I found the excise tax detrimental to the success of the medical device industry. Health care industries can provide substantial benefits to its consumers, and any regulation or tax that can negatively impact their usage presents potential problems. Introduction In 2010, Congress passed the Patient Protection Affordable Care Act (PPACA), expanding health insurance coverage for all Americans. In order to finance the law, they included a 2.3 percent excise tax on medical devices, taxing the revenue of firms. Because firms’ revenues are much greater than their profits, the excise tax will raise more revenue than an equal corporate tax. Medical device firms face the highest corporate tax rates for any industry, paying 40-45 percent of profits in taxes, before the bill.1 The excise tax mostly affects firms domiciled in the United States by taxing devices sold in the United States, placing American firms at a disadvantage to foreign competitors. Because the excise tax focuses on revenue, when firms lose money in the short term due to the expenses of research and development, they still are required to pay the tax. This hurts firms involved in the
1
Michael Ramlet, Robert Book, and Han Zhong. “The Economic Impact of the Medical Device Excise Tax,” American Action Forum. June 4, 2012, 2
research and development stage of products, thereby discouraging innovation. The seminal piece on the effects of the excise tax is “Employment Effects of the New Excise Tax on the Medical Device Industry,” by Diana and Harold Furchtgott- Roth. They discuss the effects of the bill on the industry as a whole, before examining the effects on employment within the field, and finally on the macro-economic level. Furthermore, shorter articles such as “The JobKilling Medical Device Tax,” “Obamacare’s Tax on Medical Devices: Cuts R&D by $2 Billion a Year,” and “The Economic Impact of the Medical Device Excise Tax” discuss some details of the provision within the PPACA and its effects on employment or research or development. Articles like the piece by the Office of the Actuary and the “Medicare Auctions for Durable Medical Equipment” delve into the costs of the program and tax. Taken together, these sources paint a picture of the harmful nature of the medical device excise tax within the healthcare law. Although the purpose of the PPACA is to help to decrease the cost and increase the quality of
SPECTRUM
4 (1)
health care, the medical device excise tax provision harms the industry. The purpose of the other excise taxes focus on internalizing externalities and decreasing a product’s consumption to the optimum level of society, rather than to raise revenue. This tax increase the cost of research and development for medical device firms, who must pay this tax even if they lose money in a given year, which often is the case. Adding a cost to research and development decreases the investment for firms who are in the R and D phase, because their profits decrease with the new tax. Moreover, American firms are disadvantaged compared to foreign firms, who sell more devices in other countries, decreasing their exposure to the tax. Employment within the industry will fall as companies’ costs rise as demand falls. The economy as a whole suffers, as increased unemployment decreases the demand for other goods and services and the inputs and complementary goods’ demands fall. The increase in revenue of $2.7 billion the first year does help the government pay the increased cost of the new law; however, the drawbacks outweigh the benefits. Although the medical device excise tax represents a responsible plan by Congress to fund a large program, the tax harms the industry, increasing costs, decreasing employment, and hampering future research and development. Its effects on the economy are far-reaching, harming other related industries and the well-being of patients who may not be able to afford the higher costing medical devices. Tax on Medical Devices Within the Patient Protection and Affordable Care Act (PPACA), Congress passed a 2.3 percent excise tax on medical devices. Congress included this measure to help defray the cost of increasing Medicaid coverage to all individuals up to 133 percent of the poverty line.2 This tax will be levied against the manufacturers of the medical devices. The Food and Drug Administration considers a 2
Richard S. Foster. “Estimated Financial Effects of the ‘Patient Protection and Affordable Care Act,’ as Amended.” Center for Medicare and Medicaid Services, April 22, 2010., 6
5 medical device to be any sort of instrument implanted to diagnose or treat a disease, or affect function of body parts. Medical devices do not achieve their primary purpose through chemical reactions.3 In other words, a medical device constitutes any artificial object used in order to treat a patient, whether it be something simple like bandages or casts, or something more complex like pacemakers or stents, without using chemical reactions for treatment. The FDA breaks down medical devices into three groups, referred to as Class I, II, and III. Class I devices require the least amount of regulation, because they cause the least amount of risk. They can be found in any drug store or pharmacy and are intended for use by individuals. On the other hand, Class II devices require more regulation by the FDA, and include patient monitors, diagnostic imaging machines, and laboratory equipment. Life sustaining devices and implanted objects are considered Class III devices. Examples of these are pacemakers, stents, and artificial joints. Many of the Class I items are exempt from the tax. The bill explicitly removes the following: contact lenses, hearing aids, and eyeglasses, along with devices purchased by consumers for use outside of care provider’s premises.4 Before Congress introduced the excise tax, the Medical device industry operated with high tax rates. For profitable firms, federal corporate taxes totaled 35 percent of profit. State taxes on corporate income added another 5 to 10 percent on top of that. In addition to the 40 to 45 percent paid in taxes, Congress has now added the 2.3 percent excise tax. Unlike the corporate taxes, this tax takes a percentage of the firms’ revenue, regardless of its profitability. According to Diane FurchtgottRoth, former Chief Economist for the U. S. Department of Labor, the total tax burden of the 3
Daniel McLain, “Conducting Medical Device Safety and Performance Assessments using Embase as a Tool for Completing the Clinical Evaluation Report.” Downey & Associates, Inc. September 12, 2012., 5 4 Joint Committee on Taxation, Description of H.R. 436, the “Protect Medical Innovation Act of 2011” (JCX-45-12), May 29, 2012 , 2
SPECTRUM
4 (1)
6
field will effectively double, making it one of the highest tax rates for any industry in the world.5 The total taxable revenue of medical device firms equals $13.7 billion dollars, $3.1 billion of which is paid in taxes. 6 Unlike other industries, because of the focus on innovation in the medical device field, firms involved in research and development often operate with low profits margins or outright losses. Profits from products are not realized for years after introduction. The tax would still require these firms to pay the excise tax, despite their lack of profits caused by the increase in expenditures and a stable cash flow. Start-ups and small firms, which make up roughly 91 percent of the medical device industry, will disproportionately suffer the burden of the excise tax. Over 13,300 medical device companies employ fewer than 50 workers, categorizing them as small and exposing them to the tax. Medical device manufacturing comprises a major source of exports for the United States economy. One third of medical devices manufactured in the United States are exported for sale in other countries, which outpaces nearly all other manufacturing fields.7 While most manufacturing products enter the United States as imports from other countries, medical devices are primarily produced in the United States. Careers in medical device manufacturing and sale provide well-paying jobs to American workers. The excise tax threatens the success of these American firms, as they must pay higher taxes relative to foreign competitors. Excise Taxes The government places companies in other industries. gasoline industry faces excise into a fund for the repair 5
excise taxes on For example, the taxes, which pays and addition of
Diana Furchtgott- Roth and Harold Furchtgott- Roth. “Employment Effects of the New Excise Tax on the Medical Device Industry.” September 2011, 2 6 Devon Herrick. “The Job-Killing Medical Device Tax,” National Center for Policy Analysis No. 106. February 2012, 2 7 “Employment Effects of the Medical Device Excise Tax,” 5
infrastructure. Alternatively, excise taxes cover so called sin products, such as tobacco and alcohol. In these cases, the tax attempts to discourage consumption and reduce the externalities that the products impose on society as a whole. The provision in the PPACA does not attempt either of these; rather the measure exists solely to raise revenue. This tax will still decrease consumption of medical devices, despite the fact those devices provide positive effects for the economy. Without the medical device tax, the supply and demand of medical devices can be represented by the lines S and D, respectively in Figure 1 below. The quantity demanded at the point of equilibrium is Q, while the price is at P. When we consider the excise tax, the supply curve shifts up, showing a decrease in the supply of medical devices. This moves the equilibrium price to Pexcise tax and the quantity to Qexcise tax. The price of the medical devices increases, while the quantity produced and sold decreases. However, the companies themselves receive less money per product, as the money received by companies decrease by 2.3 percent per product because of the tax.
Figure 1. Effect of the excise tax for medical device manufacturers.
In order to determine whether the consumers or the firms would bear more of the increased cost from the excise tax, we can estimate the elasticity of demand and supply. Elasticity refers to the ability of supply and demand to adjust to changes in the price of the good or service. Medical devices
SPECTRUM
4 (1)
typically have no substitutes, although treatments can substitute for actual devices on occasion. Furthermore, most medical devices constitute a need rather than a luxury, reducing elasticity. Some devices such as artificial joints may be more discretionary, but most including pacemakers and stents are necessities. Finally, because of the third party payer system, the person typically pays only a fraction of the price of the medical device, elasticity is low. Overall, demand is relatively inelastic. On the other hand, businesses can increase their production in order to meet a rise in demand. Although supply is more inelastic in the short term, the elasticity increases elastic as the firms can add more resources and labor as the time period lengthens. Overall, the elasticity of supply is greater than demand. Because of the greater elasticity of demand, the consumers would bear more of the excise tax burden than the producers. Although the tax affects both producers and consumers, the consumers will pay more than the producers, as they are less capable of adjusting to the price change. The consumers pay the increase in the price, which is represented by the highlighted by the yellow section B and C. Companies pay the remainder, which is shown by section E and F. Depending on the elasticity of the supply and demand of medical devices, section B and C may be larger or smaller than section E and F. In this case, because of the relative inelasticity of demand, the section B and C are larger than section E and F. The two sections labeled D and G represent the dead weight loss to the economy because of the tax. Fewer transactions take place, resulting in D and G being completely lost from the economy. Both the consumer surplus and the producer surplus are diminished as a result of the tax. Consumer surplus is the difference between the maximum price that a consumer is willing and able to pay and the actual price they pay for a good or service. A consumer will buy a product up until the point when the marginal benefit of the good is equal to its price. The consumer surplus equals the area above the equilibrium price and under the demand curve, shown as sections A, B, C, and D.
7 Once taking the effect of the excise tax into consideration, the consumer surplus reduces to just section A. Similarly, the producer surplus is the difference between the price received for a good or service and the cost of producing it. The Producer Surplus is sections E, F, G, H, and I, encompassing the region below the equilibrium price and the demand curve. After the tax, the producer surplus falls to only H and I. Because of the excise tax, the medical device industry loses a portion of the producer and consumer surplus, along with decreasing the supply and increasing the costs. Most of the losses go to the government as revenue, while the remainder is a deadweight loss, caused by the disequilibrium of the market. Effects on Innovation The most immediate effect on the medical device industry is the disincentive for research or development. When firms engage in research and development, their profit margins fall, as mentioned earlier. All but the largest firms will be able to sustain such loses while still paying the excise tax, thus reducing innovation to the largest few firms. Additionally, with the diminishing profitability resulting from the tax, venture capitalism decreases. Estimates of the reduction in investment in the industry start at $2 billion per year, conservatively. The decreased yields on investments into the medical device industry will likely cause investment to move into other fields where the returns are greater. The excise tax will harm innovation within the industry. Furchtgott-Roth, called the tax, “an unintentional tax on innovation,” because companies who lose profit margins from research and development are still taxed at the 2.3 percent rate.8 Even companies that can withstand losses from innovation may instead focus on cost effective research and development, in order to maintain some profitability. Although this may be able to prevent an exodus of investors, the National Venture Capitalism Association states that studies based on cost effectiveness yields lower quality 8
“Employment Effects of the New Excise Tax on the Medical Device Industry.”, 6
SPECTRUM
4 (1)
results, as companies base success on costs rather than effectiveness.9 Effects on Prices Although the excise tax will be placed on the manufacturers, due to the greater ability of supply to adjust to changes in price, much the tax will pass on to consumers. Prices will certainly rise, increasing the costs of purchasing medical devices for treatment. Furchtgott-Roth estimates that at the minimum one half of the excise tax will be passed on to consumers. In addition, the Chief Actuary Richard S. Foster predicts that “these fees and excise tax would generally be passed through to health consumers in the forms of higher drug and device prices.”10 Accordingly, the number of medical devices purchased will decline as the higher costs discourage consumption. By decreasing the usage of medical devices and increasing the burden of buying them, the government is restricting the treatment options for patients and harming both them and the companies who produce the devices in the process. Effects on Employment Once demand for the medical devices decreases, the companies that manufacture those devices will find themselves with decreased revenue. Faced with this event, they will have lay off workers to meet the lack of demand and remain profitable. Based on the elasticity of supply and demand of medical devices, Furchtgott- Roth estimates the between 2,300 and 23,000 jobs will be lost in the industry due to the excise tax, assuming that none of the firms relocated employment overseas. Although the tax does not come into effect until the beginning of 2013, the company Stryker announced layoffs of 1,000 workers in order to reduce costs in advance of the tax. Covidien Plc also announced a 200 employee
8 layoff and plans to move some production offshore to Mexico and Costa Rica.11 Assuming that firms do transfer production facilities overseas, the employment losses appear even bleaker. Many medical device companies already operate small plants overseas, reducing the cost and easing the process for future movement overseas. Companies have two main choices of how to offshore their production. First, they can close the plants in the United States, moving all production to foreign countries. This results in the loss of jobs for American workers involved in the manufacturing process. Companies can instead keep the American manufacturing plants operational, while offering all new job growth opportunities in their overseas operations. This keeps some American jobs, but eliminates future growth potential. Once considering the movement of jobs to offshore locations, the jobs losses increase substantially. If only 15 percent of production shifts offshore, according to Furchtgott-Roth’s model, the United States’ industry employment will fall by between 63,000 and 84,000 workers.12 Overall, industry compensation would decline by $5 to $7 billion with the loss of workers. With production spread across the country, nearly every state would experience some job losses. However, the states who would be greatest effected are California, Florida, Illinois, Indiana, Massachusetts, Minnesota, New Jersey, New York, Ohio, Pennsylvania, Tennessee, Texas, Utah, and Wisconsin.13 Michael Ramlet, Robert Book, and Han Zhong estimate that up to 47,100 employees, or 10 percent of the industry, could lose their job as a result of the medical device tax, if the companies would absorb the cost entirely. From their models, they find that for every $1 million of revenue lost, 1.247 jobs within the industry are lost. Basing their estimates on the Joint Committee on Taxation’s projections, they predict 14,500 jobs within the medical device industry to be lost by 2022 as a
9
“Impact of Health Reform on Life Sciences Innovation,” NVCA, June 2010, 7 10 “Estimated Financial Effects of the ‘Patient Protection and Affordable Care Act,’ as Amended.”, 5
11
“Job-killing Medical Device Tax”, 3 “Employment Effects of the New Excise Tax,” 9 13 Ibid., 9 12
SPECTRUM
4 (1)
result of the tax.14 The job reductions increase to 2.210 per million dollars of revenue when considering the indirect jobs that also disappear as less demand for devices cause firms with related products and services to need fewer workers. By subtracting the total revenue of the industry from the value added by the industry, we can derive the value of inputs provided by other industries. Using this figure, Ramlet, Book, and Zhong then find the effects of the excise tax on indirect jobs related to medical device production. Effects on Demand Regardless of the government’s actions, demand for medical devices should increase because of the aging of the Baby Boomer generation and the increase of obesity and its related diseases.15 The provision within the PPACA that expands the Medicaid to 133 percent of the poverty line coverage would grant health insurance to an estimated 15.9 million people, who previously would not purchase medical devices.16 However, the increased prices resulting from the excise tax will serve to decrease demand, as insurance companies and people will seek to find less expensive alternatives. Given these various factors affecting the demand of medical devices, an accurate estimation is impossible without further study. Effects on Government Revenue The purpose of the medical device excise tax is to increase revenues to help defray the cost of increasing the Medicaid provision of the PPACA.17 In 2010, the Joint Committee on Taxation projected between $2.7 and $3.1 billion annually to be raised
14
“The Economic Impact of the Medical Device Excise Tax,”, 4 15 Han Zhong, “Primer: The Medical Device Industry,” American Action Forum, 2012, 3 16 John Holahan and Irene Headen, “Medicaid Coverage and Spending in Health Reform: National and State‐by‐State Results for Adults at or Below 133% FPL,” Urban Institute, 2011, 4 17 “Estimated Financial Effects of the ‘Patient Protection and Affordable Care Act,’ as Amended,” 21
9 from 2014 to 2019, as shown in Figure 2.18 In total, the Joint Committee on Taxation projects $29 billion in revenue from 2013 to 2022.19 This provides much needed tax revenue to the government; however, it reduces the growth potential and even may shrink the medical device industry.
Figure 2.
Effects on Medical Device Companies American based firms will struggle to compete with the foreign competitors. With the excise tax in place, foreign-domiciled firms’ profits will increase relative to American firms. Foreign firms primarily sell medical devices in foreign markets, where there is no excise tax. Domestic based firms will continue to introduce medical devices in Europe before the United States, in order to avoid the costs of the excise tax. Small companies (with sales of less than $100 million), who comprise 95% of the industry, will be hardest hit by the tax. However, even large multinational American firms sell a majority of their devices in the United States, keeping them exposed to a tax increase.20 Start-up companies, who often lose money early, will increasingly form in other countries without the excise tax. As Figure 3 shows below, in 2011 the number of venture capital agreements in the U.S. fell by 50 18
Description of H.R. 436, the “Protect Medical Innovations Act of 2011”, 4 19 Ibid., 4 20 “Employment Effects of The Medical Device Excise Tax,” 5
SPECTRUM
4 (1)
percent from the previous few years, and his decrease looks should continue with the excise tax. Falling revenues and profits decrease the return on investments, causing demand for investing in medical device companies to fall. Investors will only invest in a company if they believe that the future returns will exceed the current cost. As uncertainty of the upcoming excise tax looms over the industry, investors believe that there is a higher risk for investing in medical device companies. Because the tax will decrease the revenues, and the profits, of medical device companies, they have become a less attractive investment opportunity. Already, this lack of investment decreases the capital available for research and development of new and improved products.
10 based pharmaceutical manufacturers in a difference in difference table. Figure 4 and 5 display the revenues on a company level for the medical device industry and pharmaceutical industry, respectively. Similarities between the pharmaceutical industry and medical device industry include well-paid employees, the strong position of U. S. manufacturers, and a stable demand. After finding their revenues from company yearly reviews, the growth in revenue from year to year in dollars and percentage was calculated (Figure 6).
Figure 4. Medical Device Industry.
Figure 3. Venture Capital Agreements in the Medical Device Industry.
Although the medical device excise tax did not come into effect until January 1, 2013, it impacted the industry before its institution. Firms have begun reducing costs in research and development and employment ahead of the tax. The entire industry will soon be forced to follow Stryker and Covidien’s suit and lay off workers in order to survive, except the largest companies, such as Johnson and Johnson, who have diversified in other areas. In order to determine the effect of the medical device excise tax on companies, the revenues of nine major medical device manufacturers were examined against the revenue of the 9 largest U.S.-
Figure 5. Pharmaceutical Industry. 2008-2009 2009-2010 difference growth growth Medical Device 3.9% 3.4% 0.5% Industry ($3.87 bn) ($3.53 bn) Pharmaceutical 5.1% 4.1% 1.0% Industry* ($19.72 bn) ($10.13 bn) difference 1.2% 0.7% 0.5% *2008-2009 growth estimated by the IMS Figure 6.
SPECTRUM
4 (1)
From 2008 to 2009, the medical device manufacturers’ revenue grew by 3.9 percent, continuing its growth pattern of the 2000s.21 After the announcement of the excise tax portion of the PPACA, the growth slowed to 3.4 percent. Over the same period, the pharmaceutical industry’s revenue grew by 5.1 percent, then fell to 4.1 percent. The pharmaceutical industry’s growth in 2008-2009 had to be estimated because of the acquisition of Schering-Plough by Merck. Medical device revenue continued to increase in 2010; however, its pace reduced, departing from the trend of recent years. Pharmaceutical growth fell by 1 percent, while the Medical Device growth fell by .5 percent. Pharmaceutical companies’ growth had fallen in previous years, due largely to the increased use of the less expensive generic drugs.22 These generic drugs sell at a much lower price, thereby reducing the profits for a pharmaceutical company. Many of the medical device firms experience decreased revenue growth from 2009 to 2010, which negatively impacted those firms. Results include firms laying off or outsourcing workers in advance of the tax. St. Jude Medical, Medtronic, and Boston Scientific announced layoffs this year totaling over 2,000 employees, in addition to the moves by Stryker and Covidien.23 These labor reductions aim at minimizing costs before the tax comes into effect, in order for the companies to sustain their profitability. Johnson and Johnson and Medtronic did continue their revenue growth in 2010; however, they are the two largest revenue earning firms in the field, with profits high enough to withstand the short-term losses of the tax during research and development. Companies will increase profits by reducing costs or maximizing revenue. As a result, companies will either decrease labor costs, by reducing the size of their labor force, or increase the price. 21
Han Zhong. “Primer: The Medical Device Industry.” American Action Forum. June 2012, 3 22 IMS Health, Press Release: “IMS Health Reports U.S. Prescription Sales Grew 5.1 Percent in 2010,” 4-1-10 23 Erin McBride. “Medical Device Manufacturers to Lay Off Thousands of Employees.” Beta.fool.com. November 15, 2012
11 The difference in difference chart shows a decrease in the revenue growth in the medical device industry, while a similar industry experienced the same slowing growth for reasons specific to the industry. If the recession would have a serious effect on the medical device industry revenue, it would have occurred in 2008-2009 change in revenue, not 2009-2010. Rather, we can trace the decrease to the PPACA, which disrupted the typical conditions of the health care market. The medical device industry does not sell generic devices like the pharmaceutical industry, so we should expect that their growth would not fall like the pharmaceutical firms. The excise tax will not take effect until 2013, so we cannot determine its true effect until then. However, the responses of the medical device companies, their decreasing revenue growth, and the lack of capital from investors demonstrate its already detrimental effects. Conclusion In addition to the high corporate tax rates already in place on the medical device industry, Congress has instituted a 2.3 percent excise tax on the revenues of medical device companies. Although this move is aimed at funding the expansion of Medicaid in the Patient Protection and Affordable Care Act, the harm it causes to medical device industry hampers the economy overall. The tax raises the cost of medical devices, most of which passes directly to the consumer, raising the cost of medical treatments. This is antithetical to one of the goals of the new healthcare law, to stabilize and eventually reduce the costs of health care. Rising costs will decrease consumption of medical devices, which as a whole would harm the health care delivered to individuals. Employment within the industry will fall, as will the quantity of devices demanded fall and the firms will have to decrease costs in order to remain profitable. Many firms have and will continue to send jobs to overseas production facilities. Operating in these markets without the tax will allow them to manufacture the devices near where they will sell their products. Furthermore, innovation will suffer
SPECTRUM
4 (1)
as the process of research and development often requires operating at a loss in the first years. Excise taxes have been used by the government in order to reduce consumption of a good or service that causes adverse effects for society. In this case, Congress aims at raising revenue, but they will decrease the consumption of these devices, which negatively impacts the well-being of people. Moreover, the worsening condition of the medical device industry spreads to other related industries, which provide valuable inputs for medical devices. Higher unemployment within the industry also harms unrelated industries, which are patronized by the high earning medical device employees. The excise tax will provide a projected $29 billion through 2022, but the cost of that revenue far outweighs the benefit. By passing the medical device excise tax, Congress limits people’s ability to afford potentially life-saving medical devices. Firms will decrease their employment of American workers, moving production overseas or simply reducing
12 output. Neither scenario benefits the American economy or health care recipients. The disincentive to innovate also reduces future profits, preventing companies from prospering off of a future invention that can save lives. Not only do medical devices provide a high quality source of employment, but also it improves the quality of life of the consumers. For this reason, Congress must consider carefully any attempt to influence the industry. The medical device excise tax harms the United States’ economy with far-reaching effects, only rectifiable by a removal of the tax.
Conor Norris ('14) is an Economics major with a minor in History and Finance. He is the President of the Phi Kappa Theta fraternity and a member of the Sigma Beta Delta honor society. He is interested in free market economics and libertarianism politics.
SPECTRUM
4(1)
13
Keeping One’s Head or Heart? Exploring Popular Reaction to Henry VIII’s Secession from Rome Julie L. Cashdollar History/Political Science Department School of Arts & Letters jlc102@francis.edu
Lori Woods, Ph.D. History/Political Science Department School of Arts & Letters lwoods@francis.edu
The purpose of this project was to see how common people reacted to Henry VIII’s decree to acknowledge himself as Supreme Head of the Church of England halfway through his reign. Henry had been a devout Catholic, but when the Pope refused to annul his marriage with Catherine of Aragon, he decided to take matters into his own hands. This topic was narrowed down by focusing on the dissolution of the religious houses, one of the movements Henry made with his newfound authority. England was predominately Roman Catholic during this time, and many people were very devout. The Catholic Church also provided many services through these religious houses that were essential to the survival of those who needed them. Was it a hard choice for the people to follow their king’s orders, despite the physical and spiritual connections they felt toward those institutions? The King’s word was law, so anyone who chose to go against it would face severe consequences. Despite that, there were some brave souls who wanted to stand up for what they felt was right. This project was done through examining the works of British historians who focused on the impact of religion in sixteenth-century England and religious uprisings that protested Henry VIII’s orders. Upon the examination of these sources, there is indication that common people were involved with these movements because they lost the services the religious houses provided for them. Introduction “You think you know a story, but you only know how it ends. To get to the heart of the story, you have to go back to the beginning.”1 These were the opening lines to every episode of “The Tudors,” the popular Showtime series chronicling the reign of King Henry VIII, from about 1520 to his death in 1547. Although some parts were historically inaccurate and over dramatized, the show’s four seasons chronicled the reign of one of the most volatile monarchs in British history. This is one of the many attempts of the television and film industry to portray the Tudor dynasty within the last decade. British historical fiction novelist Philippa Gregory has written several novels about the Tudor period, her most famous being The Other
1
The Tudors, directed by Michael Hisrt (2007-2010), (Canada: Showtime Networks, 2010), DVD.
Boleyn Girl2 about Henry VIII’s romance with the sisters, Anne and Mary Boleyn. This book was adapted into a BBC television film in 2003,3 as well as a feature film in 2008, The Other Boleyn Girl.4 Despite these television series, novels, and films, Henry VIII is not always the most recognizable historical figure. While presenting my idea in Thesis Prep, I received many blank looks from the other students when I said my project was going to be about Henry VIII of England. Some recognized him when prompted with particular facts, the most obvious being his six wives, two of whom met their end on the executioner’s block. An 2
Philippa Gregory, The Other Boleyn Girl, (New York: Scribner, 2001). 3 The Other Boleyn Girl, directed by Philippa Lowthorpe, United Kingdom: BBC, 2003. 4 The Other Boleyn Girl, directed by Justin Chadwick, Culver City, CA: Columbia Pictures, 2008.
SPECTRUM
4 (1)
even lesser-known fact was Henry VIII’s responsibility for formally severing England’s ties from the Roman Catholic Church. Little do students realize the impact this action had on the people of England. In present-day United States, we enjoy the freedom of religion under the First Amendment of the U.S. Constitution; people can choose to practice whichever religion they wish without persecution or punishment from the government. People did not have that luxury under the reign of an absolute monarch in sixteenth-century England. Religious uniformity was what made a state strong in the early modern era, and religion was an integral part of daily life for people of that time. To change something so fundamental and personal could be detrimental. Moreover, we must keep in mind that living conditions were harsher and life expectancy was much shorter five hundred years ago. Men died in battle while fighting against other countries, childbirth fatalities were a common thing among mothers and infants, and few people escaped the ravages of disease and illness, especially the plague. With so many adverse events that could affect their lives, people looked to find comfort somewhere, and often that place was within the Catholic Church. When Henry declared himself to be the “Supreme Head of the Church of England,” a royal maneuver that symbolized his severing ties with the Papacy in Rome, how did his own subjects react, particularly the common people? In this thesis, I will explore reactions of the common people because they made up the majority of the English population. Recovering the voices of common folk is not an easy task. Sources are very limited because they were not literate, and so they were unable to leave records behind. Research professor Michael Bush acknowledges the challenge of trying to differentiate the goals of upper class rebels, who used their social class to influence the turn of events in their favor, from those of the common people. As they were more likely to be literate, upper class individuals were the ones who wrote complaints to Henry VIII. Given the challenges of finding historical sources that would provide direct
14 insight to the perspectives of common people – telling a history “from below” – I have decided to approach the question from an oblique angle by questioning how common folk reacted to Henry VIII’s dissolution of the monasteries. One of the actions he took as Supreme Head of the Church of England was to dissolve the monasteries of England; all 578 monasteries and 130 convents were gone by 1540. That action displaced 8,000 monks, canons, friars, and nuns, and affected at least 80,000 dependents. According to H. Maynard Smith, “it was the poor who suffered most from the dissolution of the monasteries.” They were cast adrift with no pensions, and faced severe hardship because they were unable to support themselves. Fewer staff was employed to take care of the former religious houses because the new masters of the land had other properties; therefore, the houses were not occupied as frequently. The plundering of the monasteries also destroyed reverence for sacred objects and, consequently, precipitated the loss of a popular or traditional religion whose origins extend back to the Early Middle Ages. Moreover, when holy shrines were pillaged and devastated, most of which were housed in great monasteries, there was also a loss of art and craftsmanship from the holy images. Monasteries, nunneries, and chantries played an important religious role in English society. To get rid of them, or “dissolve” them as Henry did, would have wide-ranging repercussions because of the services these holy places provided for pilgrims and worshippers, the means of employment they afforded locals, and the alms they provided to the poor and needy. Common people were inclined to look to religious institutions for solace and support during times of need. Dissolving monasteries could hardly have rested well with them. Yet, they were caught between a “rock and a hard place.” Henry VIII’s word was law, and to go against him was treasonous. Did people simply follow the will of the king in order to save their necks? Or did they protest for what they felt was right or what benefited them? Throughout history, there have been instances where individuals or groups are
SPECTRUM
4 (1)
brave enough to stand up for the beliefs that they hold close. England was no different, and Henry’s subjects, especially in the northern part of the country, as I discovered in my research, voiced their disapproval and banded together to protest the dissolution of the monasteries in the “Pilgrimage of Grace.” Nevertheless, doing so put their very lives in jeopardy. Historians who have studied this period have given us reason to believe that the prevailing conditions in pre-Reformation England were different from those in Germany, where Martin Luther challenged the Pope and the Catholic Church with his writings, and would become a key figure in the Protestant Reformation. Parish life was very vibrant in sixteenth-century England. The relationship which English people had with the Church was different from that of Germany, which was influenced by the teachings of Martin Luther. Historian Francis Aidan Gasquet, D.D., O.S.B., examines English parishes shortly before the Protestant Reformation started to really take hold. He focuses on the poor parish of Morebath and observes that, even here, parishioners made regular contributions to their church. For example, they endeavored to replace a stolen silver chalice and a new cope, which is a liturgical vestment. Moreover, they made these contributions out of free will. Likewise, Eamon Duffy, professor of the History of Christianity at the University of Cambridge, shows that the Catholic Church was not as corrupt as reform propaganda would have us believe. His work emphasizes the health and vibrancy of Catholicism in England in the years leading up to Henry VIII’s secession from Rome. Looking at the post-Reformation period, historian Michael Bush focuses on the “Pilgrimage of Grace” a mass protest against Henry VIII’s religious policies that reflected the social, political, and religious attitudes of northerners in England. As Bush observes, one of the primary reasons for this popular protest was Henry VIII’s dissolution of the religious houses. Bush writes about uprisings that specifically involved the common people. Before examining the effects of the dissolution of the English monasteries, one must first examine
15 the events leading up to this decision midway through King Henry VIII’s reign, from the late 1520s into the 1530s, as well as the religious practices of the English common people of that time period. These two areas of history will help explain the impact of Henry’s decision. I. The Tudor Dynasty and Henry VIII’s Marriages The Tudor line started with Henry VIII’s father, King Henry VII, when he took the English throne in 1485, putting an end to the War of the Roses and power struggle between the Houses of York and Lancaster. Henry had two sons, Arthur and Henry. Arthur, the Prince of Wales, was married to Catherine of Aragon, daughter of Ferdinand and Isabella of Spain. He died shortly after their marriage in 1502. The younger Henry became heir and ascended the throne at the age of seventeen in 1509 to become Henry VIII. He married his brother’s widow with a Papal dispensation from Pope Julius II.5 Staying true to his ideas of chivalry, he treated her with respect and genuine affection.6 However, this marriage only produced one surviving child, their daughter Mary, as his heir. A female ruler threatened England’s newfound stability. If Mary were to become Queen of England, she would either marry a foreigner, who could lead to intervention from abroad, or she could marry an English nobleman, which could lead to a second War of the Roses if the groom’s family eyed the throne for themselves.7 Henry also had an illegitimate son, Henry, Duke of Richmond, but the duke could not inherit the throne. In 1525, it became known that Henry VIII was infatuated with Anne Boleyn, one of Catherine’s ladies-in-waiting. Anne held sway in Henry’s court and was admired for her grace and sharp wit. She was also in her early to mid-twenties, young enough to bear sons. However, Anne would not enter Henry’s bed until she was his lawful wife and 5
Ibid, 30. Alison Weir, The Six Wives of Henry VIII, (New York: Grove Press, 1991), 105. 7 C.R.N. Routh, Who’s Who in Tudor England, (London: Shepeard-Walwyn, 1990), 28. 6
SPECTRUM
4 (1)
16
Queen of England.8 To consummate his relationship with her, he would need an annulment from the Pope. In 1527, Henry had a revelation that his marriage to Catherine was invalid because he took his brother’s wife. According to the book of Leviticus, “If a man marries his brother’s wife and thus disgraces his brother, they shall be childless because of this incest.”9 Henry believed that he was being punished because of this sin: “God’s wrath at the sin had manifested itself in the deaths of the fruits of the union.”10 However, the Pope was not willing to grant an annulment. The Catholic Church responded to Henry’s Leviticus argument with a passage from Deuteronomy: “If brothers are living together and one of them dies without a son, his widow must not marry outside the family. Her husband’s brother shall take her and marry her and fulfill the duty of a brother-in-law to her.”11 As the years began to stretch, Henry decided to take matters into his own hands. Shortly after the New Year in 1533, Anne became pregnant, so they married in a small, private ceremony on January 25, 1533. Thomas Cranmer, Archbishop of Canterbury, pronounced Henry and Catherine’s marriage to be null and void and contrary to divine law, despite the Pope’s objections. Cranmer also declared Henry and Anne’s marriage to be good and valid.12 Shortly after his announcements, Anne was crowned Queen of England. To the royal couple’s bitter disappointment, Anne gave birth to a daughter on September 7, 1533, who was named Elizabeth. Shortly afterwards, in November of that year, Parliament made Henry the “Supreme Head of the Church of England,” imposing the death penalty upon anyone who dared to call the King a heretic or usurper. Henry was now absolute ruler over the
church as well as state.13 His next course of action was to make Anne Boleyn regent for her children if anything were to happen to him. On March 23, 1534, Parliament passed the Act of Succession, which “vested the succession to ‘the imperial crown of England’ in the children of Henry and Anne.”14 If anyone said or wrote anything that was derogatory against the royal family, the ultimate punishment was high treason, as well as the forfeiture of the perpetrator’s property to the Crown. All subjects of the realm were to swear an oath to recognize the King’s supremacy. “Most people, including members of the religious orders, took the oath required by the Act of Succession without demur.”15 As loyal subjects, they had to obey his laws because he was the ultimate figure of authority in England. After miscarriages and stillborn births, Henry’s frustrations about a male heir began to mount yet again. He soon set his sights on Jane Seymour, a former maid of honor under Catherine of Aragon, just as Anne had been before her marriage and coronation. Jane had a sweet, modest disposition, which he considered to be a welcome change from Anne’s sharp temper. His way of disposing of Anne was permanent: execution. On May 19, 1536, she was beheaded on charges of adultery, allegedly with four men, including her own brother.16 Henry and Jane married a week later. On October 12, 1537, Jane gave birth to Henry’s longawaited heir, Edward, and died of infection about two weeks after delivering her son. King Henry VIII would go on to be married three more times before his death in 1547. He was responsible for Britain’s religious shifts as well. When the Pope refused to grant Henry an annulment from his first marriage, Henry decided to go ahead with the procedures to dissolve the marriage anyway. He declared himself Supreme
8
13
G.R. Elton, Reform and Reformation: England, 1509-1558, (Cambridge, MA: Harvard University Press, 1977), 105. 9 Lev. 20:21. 10 G.R. Elton, Reform and Reformation: England, 1509-1558, (Cambridge, MA: Harvard University Press, 1977), 106. 11 Deut. 25:5. 12 Alison Weir, The Six Wives of Henry VIII, (New York: Grove Press, 1991), 248.
Joseph Allen Matter, Rule by King or Rule by Law: Famous British State Trials and Executions Under Henry VIII, (New York: Vantage Press, Inc., 1979), 15. 14 Alison Weir, The Six Wives of Henry VIII, (New York: Grove Press, 1991), 264. 15 Ibid, 265. 16 C.R.N. Routh, Who’s Who in Tudor England, (London: Shepheard-Walwyn, 1990), 44.
SPECTRUM
4 (1)
Head of the Church of England in defiance of Papal authority. Henry did not present himself as a spiritual leader, but he controlled the legislation and administration, as well as defining doctrine and regulating rituals of the Church of England.17 Some of the Catholic traditions were kept intact, while others were altered or done away with completely. II. From Defender of the Faith to Dissolver of the Monasteries In the early 1500s, England appeared to be pretty stable in a religious sense. “England was Catholic England…early sixteenth-century England seemed unfertile ground for a successful revolt against the Church.”18 Henry VIII was a very devout Catholic early in his reign. Indeed, he received the title, “Defender of the Faith,” Fidei Defensor, from Pope Leo X in 1521 because of his efforts towards refuting supposed heretics. Furthermore, Henry attacked Martin Luther’s theology by writing, Assertio septem Sacramentorum, or Defense of the Seven Sacraments, and dedicated this piece to the Pope.19 During this time period, English citizens who spoke out against the Catholic Church were labeled as heretics and endured the ultimate punishment of being burned alive at the stake. However, in the middle of his reign, Henry VIII’s religious perspectives began to shift, and he no longer accepted some of the ways of Catholicism. These changes occurred because of changes in his personal and political relationships. Henry’s desire for a divorce helped drive him away from the Catholic Church because, at the time, his word was not supreme over Rome. In the 1520s, his closest political advisors and allies were his wife, Catherine of Aragon; Cardinal Thomas Wolsey, Lord Chancellor; and Sir Thomas More, a close advisor who eventually became Chancellor after Wolsey, all of whom were devout Catholics. 17
Ibid, 34. Peter Marshall, Reformation England 1480-1642, (London: Arnold, 2003), 1. 19 H.A.L. Fisher, The Political History of England Vol. V, (New York: Greenwood Press Publishers, 1906/reprinting 1969), 235. 18
17 When Anne Boleyn came into the picture, she brought reformist religious ideas into Henry’s inner circle. Along with her father and brother, she was “addicted to the new learning; and the whole influence of the queen’s circle was thrown into the scale of rebellion from Rome.”20 When Henry’s divorce was not going through, Cardinal Wolsey was blamed for the failure because he was not able to obtain the annulment from the Pope. Wolsey died on November 24, 1530, shortly after his arrest on charges of Praemunire, an English law that prohibited the assertion of Papal authority.21 Sir Thomas More replaced Wolsey as Lord Chancellor, but resigned after two years because of his sympathy towards the Catholic Church. His refusal to swear that Henry was the new Supreme Head of the Church of England led to his execution in 1534. More protested that he was, “the king’s good servant, but God’s first.”22 Henry’s new officials, such as the Archbishop of Canterbury, Thomas Cranmer, and chief minister, Thomas Cromwell, helped promote reform. “The ‘new learning’ was a minority faith with a limited geographical diffusion. But in early Tudor England, not all persons or places were of equal weight: early evangelical converts were often people of influence in positions of importance.”23 Guidelines needed to be established, and an attempted compromise was made by bishops of the old and new ways of learning; so the Ten Articles of Convocation were published in 1536. These acts addressed the questions regarding, “Images, the Saints, their Invocation, Ceremonies and Purgatory, and defend traditional practice with reasonable explanations and safeguards to placate the Liberals.”24 One group of more liberal thinkers was the Lollards, a group that was eventually absorbed 20
H.A.L. Fisher, The Political History of England Vol. V, (New York: Greenwood Press Publishers, 1906/reprinting 1969), 383. 21 C.R.N. Routh, Who’s Who in Tudor England, (London: Shepheard-Walwyn, 1990), 64. 22 Ibid, 99. 23 Peter Marshall, Reformation England 1480-1642, (London: Arnold, 2003), 35. 24 H. Maynard Smith, Henry VIII and the Reformation, (New York: Russell & Russell Inc., 1962), 157.
SPECTRUM
4 (1)
into the Protestant movement. These followers believed that the Catholic Church was corrupt and based their beliefs strictly from Scripture. “One preacher said ‘all goods should be common’; another that ‘priests and churches were unnecessary’; a third that ‘the singing and saying of mass, matins, and evensong is but a roaring, howling, whining, murmuring, conjuring, and juggling’; ‘and the playing of organs a foolish vanity.’”25 Another preacher did not believe in the idea of worshipping saints. “‘It is as much available,’ said one preacher, ‘to pray unto saints as to hurl a stone against the wind.’”26 Other groups acknowledged the spread of Lutheranism, but were not entirely committed to that particular sect. They adhered to some Catholic teachings, but wanted to get rid of other aspects of Catholic traditions such as the pageantry of the Mass or worshipping saints. They believed that “‘Justification’ in the eyes of God came through faith alone, formed by reading and hearing the scriptures.”27 Within that same time frame, 1535-1536, another change was underway. Thomas Cromwell gathered officials to act as “visitors” to examine the monasteries of England. Reformers believed that “monasteries, chantries, masses, vows, pilgrimage, veneration of saints, confession to priests—the Church’s elaborate mechanisms for sanctifying humans in this world, and aiding their souls in the next—were either a distraction, or, more likely, a damnable delusion.”28 Yet, Cromwell had another motive in mind as well. He wanted to have these religious houses suppressed in order to take their wealth and turn it over to the Crown.29 There had been some closures before Cromwell’s time. Wolsey closed approximately thirty small and decaying monasteries, and their revenues were 25
H.A.L. Fisher, The Political History of England Vol. V, (New York: Greenwood Press Publishers, 1906/reprinting 1969), 389. 26 Ibid, 389-90. 27 Peter Marshall, Reformation England 1480-1642, (London: Arnold, 2003), 27-8. 28 Alec Ryrie, “The Strange Death of Lutheran England.” Journal of ecclesiastical History, 53 (2002). 29 H. Maynard Smith, Henry VIII and the Reformation, (New York: Russell & Russell Inc., 1962), 75.
18 redirected for educational purposes, such as the establishment of a grammar school in Ipswich and a new Oxford college.30 Under Cromwell’s direction, monasteries of all sizes in England were closed by 1540. In 1536, the movement started with the smaller monasteries, but then moved to the larger houses. This decision created quite a stir among the people of England; some areas resisted these closures more than others. People of the lower echelons of society had a strong sense of Catholicism, and the religious houses played a central role in the religious and social life of the nation.31 Nevertheless, as mentioned before, the individuals with the highest influence over society wanted to institute the new religious teachings and break away from the Catholic traditions and influence. What about the beliefs of the majority of the population? Religious beliefs and practices were integral to daily life in sixteenth-century England. This was especially true for people of humble social stations. Their beliefs brought them a sense of comfort as they toiled under the harsh challenges of life. Religious houses offered a variety of services, as well as provided a sense of community among fellow parishioners. Despite social inequalities, rich and poor would both meet in church: “All, poor and rich, high and low, noble and simple, have sprung from a common stock and are children of a common father, Adam.”32 People received their baptism and Holy Communion, confessed their sins, celebrated marriages, made contributions with tithes, allowed their children to receive the same sacraments and services, and were finally buried in the churchyard when they died. The reputation for formal piety among the English people was a wellknown fact.33 Observations were made by foreigners who spent time in England. In The Eve of the Reformation, Francis A. Gasquet notes that a Venetian traveler witnessed and responded to the 30
Peter Marshall, Reformation England 1480-1642, (London: Arnold, 2003), 12. 31 Ibid, 42. 32 Francis Aidan Gasquet, The Eve of the Reformation, (Port Washington, New York/London: Kennikat Press, 1900), 354. 33 G.R. Elton, Reform and Reformation: England, 1509-1558, (Cambridge, MA: Harvard University Press, 1977), 8.
SPECTRUM
4 (1)
influence of religion on English people in the beginning of the sixteenth century: They all attend mass every day, and say many Paternosters in public. The women carry long rosaries in their hands, and any who can read take the Office of Our Lady with them, and with some companion recite it in Church verse by verse, in a low voice, after the manner of churchmen. On Sundays they always hear Mass in their parish church and give liberal alms, because they may not offer less than a piece of money of which fourteen are equivalent to a golden ducat. Neither do they omit any form of incumbent on good Christians.34 People seemed to be content with their ways of practicing their faith in the Catholic traditions. England did not have the same religious problems as did many regions of the continent at this time. One of the forms of popular religious piety that was attacked by the reformers was the worship of saints. People offered prayers to saints along with their prayers to God. People journeyed to pray at holy sites where the remains or relics of saints were laid to rest. Thomas Becket’s shrine at Canterburyhe was also known as Saint Thomas of Canterburywas a popular place for traveling pilgrims in England. These were places of hospitality for any travelers, pilgrims or non-pilgrims. When Cromwell’s men circulated through the religious locations, reports were sent back to Cromwell about the contents of monastic reliquaries. His associates convicted the monks of superstition, and eventually moved on to remove the relics from the religious houses. Examples of these relics included various girdles and the finger of Saint Stephen, which were used to assist pregnant women: “At Westminster was Our Lady’s girdle ‘which women with chield were wont to girde with’…At Newburgh, the lying-in girdle was called after St Salvator…while at Kelham the finger of St Stephen was sent to ‘lying-in women.’”35 Relics were also
19 used to pray for good crops or to cure ailments. The reformers believed this to be the large-scale exploitation of simple believers.36 Despite the skepticism from Cromwell and his followers about these superstitions, other people put stock into these traditions because religion was the only way they could address their fears. Other reform measures were taken. In August of 1536, an injunction was set to enforce religious conformity. It demanded obedience to legislation which had abolished the Pope’s jurisdiction. Bibles were provided in Latin and English, and commanded parishioners to read them without contention. Clergy had to preach the Ten Articles. Parents and masters were obliged to teach the Creed, Lord’s Prayer, and Ten Commandments in English, as opposed to the traditional Latin. Not everyone was excited to have an English Bible. Those in the country villages were not as enthusiastic compared to those in the more heavily populated areas, such as London, East Anglia, and other large towns. For example, in the neighborhood of Westbury-on-Trym, not everyone could afford to buy a Bible or even read it for that matter. Ordinary Englishmen, especially middleclass and middle-aged, linked the new English Bible with German propaganda because their beliefs tended to be conservative.37 Pilgrimages were likewise frowned upon by the reformers. They believed that the people should look only to God for help. Instead of spending money on pilgrimages, they should focus on providing for their own families as well as alms for the poor.38 Despite these decisions, most common people saw pilgrimage as a viable way to repent sins. Moreover, because religious houses were often a focus of worship for pilgrims, they continued to contribute to them because of the benefits they received from them.
36 34
Francis Aidan Gasquet, The Eve of the Reformation, (Port Washington, New York/London: Kennikat Press, 1900), 325. 35 Eamon Duffy, The Stripping of the Altars, (New Haven and London: Yale University Press, 1992), 384.
Ibid, 385. H. Maynard Smith, Henry VIII and the Reformation, (New York: Russell & Russell Inc., 1962), 343. 38 Eamon Duffy, The Stripping of the Altars, (New Haven and London: Yale University Press, 1992), 398. 37
SPECTRUM
4 (1)
III. Northern Uprisings Religious houses were considered to be more important in northern England than in the south because they provided not only a focus for popular piety, but also a semblance of order in sparsely populated areas.39 They were also further away from London’s influence and propaganda that had been spread against the Catholic Church. Many people were dismayed and angered by the pillaging of monasteries.40 These houses had offered sacramental services and moral guidance to people living in areas where parish churches and secular clergy were few and far between, as well as maintained a public display of saintly objects for local inhabitants and pilgrims from far away to pray before. This set an example of Christian virtue through the charity and hospitality that the houses habitually dispensed.41 With the closure of the religious houses, clergy and common folk were put out of work. Common people were also employed as workers at religious houses. For example, landlords enclosed farmland for grazing sheep, which displaced the peasants who had worked the land as farmers because the land was free for all to use under the religious houses. The poor lost the benefactions, money that the monks distributed, as well as other sources of charity. Those who had fed and helped the poor now needed help as well, and the commonwealth did not have the means to support everyone. In addition, there were rumors of more taxation, and even back in the sixteenth century, no one liked to hear that their taxes had gone up. All of the frustration led to an outbreak in Lincolnshire in October of 1536. The chancellor of the bishop of Lincoln was taken from his bed and beaten to death because he was accused of being Cromwell’s agent. A few others were hanged as well. Demands were sent to the King, calling for the punishment of “heretic bishops,” mainly
20 Cranmer and Latimer. Recruits of approximately 40,000 to 60,000 gathered at Lincoln. The king’s troops were sent to help the nobles who remained loyal to Henry and persuade the rebels to disperse. Thirty-three of the leaders were hanged, seven of them were priests and fourteen were monks. The rest were freed.42 The rising in Lincolnshire led to another rebellion, known as the Pilgrimage of Grace, under the leadership of Robert Aske. He received help from noble families, such as Lords Darcy and Hussie, and had 40,000 men supporting him. The group wanted to maintain order and loyalty towards the king, the church and the commonwealth. Another one of their goals was to reopen the monasteries. When Aske marched to York, the citizens compelled the mayor to surrender the city to the group. Aske went on to capture more cities without any bloodshed and sent demands to the king. While all of this was going on, Henry was dealing with several issues abroad: there were troubles with Ireland, as well as threats of invasion from France and the Holy Roman Empire. Now half the country was in arms against his policies. To combat these internal pressures, he sent the Duke of Norfolk north with 10,000 troops with a promise of “pardon to all, a free Parliament, and a safe conduct for Aske to London with a conference with the king” if they dispersed.43 Aske believed Henry’s promises and returned home, urging his followers to do the same. One man, however, did not trust the king’s word: Francis Bigod formed a new rebellion in Cumberland and Westmorland. Henry retaliated and arrested all of the leaders, including Aske, even though he had nothing to do with this rebellion. Nearly two hundred rebels were executed. The monks involved were hanged from the steeples of monasteries. Aske was tried, convicted, and hanged in chains from the church steeple in York. Lords Darcy and Hussie were tried for
39
H. Maynard Smith, Henry VIII and the Reformation, (New York: Russell & Russell Inc., 1962), 85. 40 Joseph Allen Matter, Rule by King or Rule by Law: Famous British State Trials and Executions Under Henry VIII, (New York: Vantage Press, Inc., 1979), 20. 41 Michael Bush, The Pilgrims’ Complaint, (London: Ashgate Publishing Co., 2009), 75-6.
42
Joseph Allen Matter, Rule by King or Rule by Law: Famous British State Trials and Executions Under Henry VIII, (New York: Vantage Press, Inc., 1979), 20-1. 43 Joseph Allen Matter, Rule by King or Rule by Law: Famous British State Trials and Executions Under Henry VIII, (New York: Vantage Press, Inc., 1979), 21.
SPECTRUM
4 (1)
complicity by their peers in the House of Lords, found guilty, and executed.44 Among the thousands of people involved in the revolts at Lincolnshire and the Pilgrimage of Grace, the common people were in the thick of it. They wanted to prevent the “decay of the commonwealth by ending the misrule of evil ministers, notably Thomas Cromwell.”45 Supporters of the pilgrimage declared their grievances by restoring religious houses in Richmondshire, for instance, while rebels revived Coverham Abbey on the very day the community rose in revolt. Other houses were restored without the Pilgrim’s direct involvement; the religious simply re-entered during the political disruption caused by the northern uprisings.46 The Pilgrims also disrupted church services, refused to pay taxes, rents, and tithes, pulled down enclosures, sported badges and banners, and placed priests with crosses at the head of their armies.47 The rebels drafted the Lincolnshire Petitions, which consisted of six articles; two of those six dealt with spiritual matters. The first article addressed the opposition to the suppression of monasteries because the service of God is diminished by this act.48 The Pilgrims condemned it because they thought it was part of the government’s plan, which was carried out by individuals who were driven by heresy and greed, to appropriate the wealth of the church, as indicated by the transfer of monastic property to the crown. The other spiritual issue opposed the late promotion of the bishops who supported the reform because the rebels thought that they undermined the faith of Christ. The other articles were material complaints, objecting to the taxes that were placed on the commonwealth and the clergy, and placing the blame upon Thomas Cromwell and Richard Riche, one of Cromwell’s associates.49 When the rebels met, sometimes they met in one general council, with all social classes, like in York. In 44
Ibid, 22. Michael Bush, The Pilgrims’ Complaint, (London: Ashgate Publishing Co., 2009), preface. 46 Ibid, 62. 47 Michael Bush, The Pilgrims’ Complaint, (London: Ashgate Publishing Co., 2009), 1. 48 Ibid, 2. 49 Ibid, 3.
21 other places, like Pontefract, the Pilgrim delegates met in three separate assemblies, “respectful of the formal distinctions integral to the society of orders.”50 The lords, knights, esquires, and gentlemen, of the estate of chivalry, met in the castle, while the clerical estate met in the priory, and the commons met in an open space within the town’s boundaries. Robert Aske’s petition was read to the gentlemen, article-by-article, allowing room for some argument. Once an agreement was reached, those articles were then presented to the commons. However, their response, Aske claimed “wholly condescended to every article.”51 The clergy responded in a similar manner, but then Aske gave the impression that the petition sailed through the three assemblies. This series of events and reactions in the north of England have led some to question whether or not it is possible to get a good sense of the reaction of the common people if the gentry or clergy-level classes were the ones calling the shots. This was a rising of the commons, but who were the ones more likely to have the ability to write the declarations? Despite the questions about who wrote the declarations, the commoners still found a way to act. As mentioned before, they were moved to try to restore the religious houses, disrupt church services in attempts to force the clergy’s recognition of abolished saints’ days and to restore the traditional order of prayer, refuse to pay taxes, rents and tithes, remove enclosures, spoil the property of gentlemen, indulge manorial lords to accept generous occupancy agreements, respect the relic-bearing banner of St Cuthbert, and impose oaths to be true to God, the king, and the commons.52 The momentum of the movement depended on the people’s willingness to take up arms and form federations. “They did so not as the loyal tenants, servants and dupes of dissident gentlemen, monks and friars but as an independent and self-willed force.”53 An example of action
45
50
Ibid, 28. Ibid, 29. 52 Michael Bush, The Pilgrims’ Complaint, (London: Ashgate Publishing Co., 2009), 43. 53 Ibid, 42. 51
SPECTRUM
4 (1)
involved Harry Sais, servant of Christopher Askew. He was captured by a band of rebels who were common people, “undirected by gentlemen or clerics.”54 Sais said he would swear to God and the king, but was confronted when a rebel commoner asked, “And not to us?”55 Sais was threatened to lose his head if he did not swear to God, king, and commons, so he took the oath. This act was impressive because it showed that the common people could take actions upon themselves without having the authority of the higher social classes over them. The people petitioned the issue of supremacy because they believed that the Pope’s authority maintained the unity of Christendom: “How could enactments made by English parliaments and convocations annul internationally made laws, it asked, rejoining that it surely went against the law of God for a part of Christendom to abolish rules created by and for the whole.”56 They believed this opened the door to heresy because the reformers who held high political positions were using their religious beliefs to influence the actions of Henry VIII, promoting the use of his authority as King and new Supreme Head of the Church of England to make changes to religious traditions that had been established for centuries. Rhymes circulated around northern England to protest these new laws. One objected to the Crown’s plundering of the monasteries because it went against the commandment, “thou shall not steal,” and reduced the clergy’s ability to serve the spiritual and material needs of the people, particularly the poor. The other was “Pickering’s Song and it was based on two Biblical stories: the book Maccabees and the book of Esther. The people of northern England drew similarities to the plight of the Jews, who faced persecution in both stories. In Maccabeus, the story focused on the success of military force against the government could be justified by the will of God. The book of Esther showed how someone could use the power of persuasion to rid
22 the country of an evil minister, as Queen Esther pleaded with King Antiochus to save the Jews from his evil minister, Haman. The English people compared Thomas Cromwell to Haman and wanted to get rid of him.57 IV. The Aftermath By 1540, all of the monasteries, nunneries, and monastic properties, except the cathedral abbey churches, were in the king’s possession. This included 578 monasteries and 130 convents. Eight thousand monks, canons, friars, and nuns were dispossessed, and at least 80,000 dependents were affected. Cromwell did introduce a bill concerning the disposal of the monastic property. This was written by the king, having “represented not only his justifications for suppression of the monasteries, but also his good intentions.”58 Eighteen new dioceses were to be formed along with collegiate churches. The universities were to benefit with exhibitions provided for poor students. New schools would be established to educate the poor children, as well as new hospitals and almhouses for the poor. Money was to be spent on fortifications, roads, and bridges. Unfortunately, not all of Henry’s good intentions were achieved. Some money did go towards building ships, forts, and ports, and repairing highways; however, a portion of it helped finance militant pursuits, particularly against France. Funds were also used to build and expand his palaces. Only six bishoprics were founded, one of which only lasted for ten years, Westminster. They were not lavishly endowed because they were assigned the tithes of those livings which had earlier been appropriated by the monasteries. Trinity College and Cambridge were founded, and King’s College was finally completed nearly a hundred years after it was founded during the reign of Henry VI. Few professorships were founded, but instead of endowing scholarships, rectors with good livings were compelled to educate one or more boys at the university.
54
Ibid, 43. Ibid, 43. 56 Michael Bush, The Pilgrims’ Complaint, (London: Ashgate Publishing Co., 2009), 53-4. 55
57
Ibid, 12-3. H. Maynard Smith. Henry VIII and the Reformation. (New York: Russell & Russell Inc., 1962), 117. 58
SPECTRUM
4 (1)
The almonry schools of the abbeys died out because they were not very efficient. More free schools were closed than founded. This was unfortunate for the poorer class because the only remaining source of education would be from the basic grammar schools that were close to home. It was unlikely for most to be able to afford to attend a university and live away from home, and many considered working hands to be a greater contribution to daily survival than idle hands. Unfortunately that cost them the chance of an education. While small amounts were earmarked to continue most urgent charities, basically nothing more was done for the poor. The new landlords were ordered to maintain the hospitality which the religious houses had offered to travelers in the past; however, it was difficult to enforce when so many of the new men did not maintain a permanent residency at that property. 59 Most of Henry’s ideas were unfulfilled because of his “own wasteful expenditure and the importunity of his grasping courtiers.”60 The value of the land was a considerable amount. There were jewels, gold, silver, lead, vestments, and furniture of considerable worth. Within ten years, two-thirds of that revenue had been exhausted, with a larger part of the wealth dispersed.61 The land was sold to loyal members of Henry VIII’s court and supporting officials. For example, Cromwell received six pieces of property that once contained abbeys while his nephew obtained seven. It also helped keep nobility from leaning towards Catholic restoration.62 Some of the Catholic sympathizers who received such benefits were Norfolk, who helped settle the Pilgrimage of Grace, Wriothesley, and Sir Anthony Browne.63 Without the religious houses, many lost the sense of community and of sacredness that had
23 become associated with them: “The next generation grew up largely indifferent to religion because they no longer believed in divine sanctions, and because religion had become something apart and was no longer intimately associated with their everyday lives.”64 Nevertheless, there were instances where people were brave enough to try to take a stand for what they believed in. One of the most striking features of the pro-Papalism movement of the Pilgrimage of Grace was the weight of support it received from the people of northern England, which appeared to be independent of clerical manipulation.65 These people acted out of their own free will. Julie Cashdollar ('13, B.A., Political Science) works for the Pennsylvania House of Representatives as a Legislative Assistant. She was a member of the Saint Francis University Honors Program, Delta Sigma Epsilon Catholic Honors Society, Pi Sigma Alpha, the National Political Science Honor Society, the Saint Francis University History Club, and played clarinet for the Saint Francis University Marching/Pep bands.
59
H. Maynard Smith, Henry VIII and the Reformation, (New York: Russell & Russell Inc., 1962), 117-18. 60 Ibid, 117. 61 Ibid, 118. 62 Joseph Allen Matter, Rule by King or Rule by Law: Famous British State Trials and Executions Under Henry VIII, (New York: Vantage Press, Inc., 1979), 22-3. 63 H. Maynard Smith, Henry VIII and the Reformation, (New York: Russell & Russell Inc., 1962, 118.
64
Ibid, 124. Michael Bush, The Pilgrims’ Complaint, (London: Ashgate Publishing Co., 2009), 57. 65
SPECTRUM
4 (1)
24
Urinary Incontinence: The Silent Embarrassment of Female Athletes Lauren S. Wingard Physical Therapy Department School of Health Sciences lsw100@francis.edu
Heather R. Kindel, MSPT Physical Therapy Department School of Health Sciences hkindel@francis.edu
Lindsay Ross-Stewart, Ph.D. Psychology Department School of Arts and Letters lross-stewart@francis.edu
Stephen M. LoRusso, Ph.D. Physical Therapy Department School of Health Sciences slorusso@francis.edu
The purpose of this study was to determine the extent of urinary incontinence among a group of Division I female athletes and to determine if a correlation exists between the presence of incontinence and the athlete’s sport. Surveys were distributed to each team either electronically or personally at the team’s practice. The sports that participated in this study included basketball, bowling, cheerleading, field hockey, lacrosse, soccer, softball, swimming, tennis, track, and volleyball. Overall, 36.4% of the athletes surveyed experienced stress urinary incontinence when participating in their given sports. Athletes who reported the greatest incidence of urinary incontinence while participating in their sport were those athletes whose sports involved the greatest amount of high impact activity. Stress incontinence was evidenced by the report of incontinence while walking, running or exercising, as well as with coughing, laughing, sneezing and lifting heavy objects. As a whole, the majority of the athletes surveyed did not practice pelvic floor strengthening exercises and were not well informed on how to complete said exercises. Urinary incontinence does occur in Division I female athletes in the population surveyed. We suggest that during conditioning, pelvic floor exercise be included in order to prevent stress urinary incontinence in female athletes. Introduction In 2000, a questionnaire study revealed that 47% of women between the ages of twenty and forty-nine experienced urinary incontinence. This percentage rose to 53.2 when women from fifty to eighty years of age were included (Culligan and Heit 1). Ten percent of middle-aged women have reported urinary incontinence on a daily basis. On a weekly basis, this figure rises to one third of women who report urinary incontinence. These high percentages exist even though more than half of the women suffering from urinary incontinence do not report their condition (Rogers 1). Not only is urinary incontinence a major medical discomfort, but this condition is also a major economic burden, costing the United States $10.3 billion in the
community and $3.3 billion in nursing homes annually as of 1994 (Flynn 53). Urinary incontinence occurs when there is an involuntary leakage of urine. There are six classifications of incontinence: urge, stress, mixed, functional, overflow, and neurogenic incontinence. When a sudden increase in abdominal pressure results in leakage, this is defined as stress urinary incontinence (Bá´“ 452), which occurs because bladder pressure exceeds urethral resistance (Rogers 1). Stress urinary incontinence is often caused by a weakness in the pelvic floor muscles, as well as low urethral resistance (Flynn 54). Many women experience incontinence due to weakness of the muscles that compose the pelvic floor. Specifically high-impact activities can increase the prevalence of stress urinary
SPECTRUM
4 (1)
incontinence, which may contribute to this medical problem in female athletes, especially those involved in high-impact sports. However, many women are often embarrassed to report cases of urinary incontinence. In this project, an anonymous survey was used to assess the prevalence of urinary stress incontinence among a group of Division I female. The hypothesis for this study is that female athletes involved in high impact sports, such as running and jumping, will report cases of stress urinary incontinence more than those involved in low-impact activities, such as bowling. This is important because urinary stress incontinence may be preventing many women from participating in sports in which they wish to be involved, which may be lowering their quality of life, and setting the stage for future incontinence. Pelvic Floor Muscles In order to determine the cause of the urinary incontinence in a female, the pelvic floor needs to be examined; the responsibility of supporting the bladder, uterus, and bowel falls to these muscles (Hulme 38). The pelvic floor muscles consist of two parts: the pelvic and the urogenital diaphragm (Bᴓ 454). When stress incontinence occurs, it is a result of a malfunction in either the urethral support system or the sphincter enclosure system, which is made up of the urethral smooth muscle, the urethral striated muscle, and the vascular elements. The urethral support system includes the endopelvic fascia, anterior vagina, arcus tendineus fasciae pelvis, and the pelvic floor muscles (Bᴓ 453). The pelvic floor muscles create a three-layer muscular plate that is approximately one centimeter thick and stretches from the pubic symphysis toward the coccyx and along the frontal sidewalls of the ileum. These are the only muscles that support the pelvic organs (Bᴓ 454) -- bladder, prostate gland in men, uterus and vagina and women, bowel, rectum, and anus -- (Hulme 41) -- and the pelvic openings -vagina, urethra, and anus (Bᴓ 454). The skeletal muscles that are important in the prevention of urinary incontinence are the
25 adductors, abdominals, obturator internus (hip rotators), external sphincter, urogenital diaphragm/perineum, levator ani/pelvic diaphragm, and the breathing diaphragm. The adductor muscles function to lengthen the obturator internus, assist with the muscle tone of the urogenital and pelvic diaphragm, and bring the legs inward toward the midline of the body. The abdominal muscles are contracted during many motions of the body, including pushing, lifting, and maintaining a postural stance. When the pelvic muscles contract, the transverse abdominus also contracts automatically. There are two obturator internus muscles found in the human body, which act as a pulley system to lift the urethra and bladder when it contracts. They are also involved in rotating the legs out from the midline, lengthening the adductors, and allowing the urogenital and pelvic diaphragm to maintain their muscle tone. The sphincter muscles consist of the internal and external urinary and anal sphincters. The external sphincters are under voluntary control and are naturally closed at rest. The bladder angle in females and the internal urinary sphincter, which is found only in males, also assist in holding urine in the bladder; however, these are not under voluntary control. The urogenital diaphragm consists of the following three muscles that exhibit a triangular shape: the bolbospongeosus/bulbocavernus, the ischiocavernus, and the transverse perineal. The primary function of these muscles is to assist with urethral sphincter action and sexual function. The pelvic diaphragm is also composed of three muscles, which are the following: the iliococcygeus, pubococcygeus, and ischiococcygeus/puborectalis. These muscles function to stabilize the internal organs and keep the bladder and bowel outlets closed until the individual uses the restroom. Finally, the breathing diaphragm is responsible for an increased intraabdominal pressure that increases during inhalation (Hulme 50-61). These muscles, vital to preventing urinary incontinence, can be classified as either slowtwitch or fast-twitch fibers. The 35% of the
SPECTRUM
4 (1)
muscles that can be classified as fast-twitch are involved when there is a sudden, unexpected increase in pressure on the urethra, such as that caused by a cough or a sneeze. One example of muscles that consist of fast-twitch fibers are those of which the urogenital diaphragm is composed. By contrast, the 65% of these muscles that can be classified as slow-twitch fibers provide postural support. The pelvic diaphragm consists primarily of slow-twitch muscle fibers. During physical activity or when delaying the need to use the restroom, the resting tone of these muscles increases in order to prevent leakage (Hulme 55). Urinary incontinence can be caused by a dysfunction of the pelvic and urogenital diaphragms. In addition, bladder control can be affected by the abdominal muscles, breathing diaphragm, hip rotator, and gluteal muscles. Therefore, pelvic, back, or hip pain may be associated with urinary incontinence, and treating one symptom may lead to improvements in the other (Hulme 38). The bladder is anterior and can be found behind the pubic symphysis. The uterus is located directly behind the bladder, and both structures are tilted anteriorly, which creates an angle between the bladder and the urethra. Acting like a bend in a straw, this angle is necessary for holding urine in the bladder (Hulme 44). The urinary system is composed of two kidneys, two ureters, the bladder (detrusor muscle), and the urethra. The urine is initially produced in the kidneys. The ureters then carry the urine from each kidney into the bladder, which expands with the increased fluid until it contracts to expel the urine through the urethra during voiding. The smooth muscle of the urethra is naturally contracted to keep the urine in the urethra. When this muscle lining relaxes, the individual is able to void. Coaptation, which is a sticky substance produced by mucous glands and blood vessels, also helps the urethra to remain closed by causing the surfaces to stick and the urethra to have a collapsed appearance during rest (Hulme 46-48). The muscles that make up the pelvic floor contain fibers that run in different directions.
26 During a voluntary contraction of the pelvic floor, the muscles work together to produce one simultaneous contraction that causes the pelvic floor muscles to lift inward and the urethra to close and stabilize because the muscles resist downward movement. If a co-contraction of the pelvic floor muscle occurs or if the contraction is weak or delayed, a number of problems can result. These problems include the following: cystocele (prolapse of the anterior vaginal wall), rectocele (prolapse of the posterior vaginal wall), enterocele (vaginal apex and uterus), pain and sexual dysfunction, and incontinence (Bᴓ 369). When stress incontinence occurs, the muscle tone of the urogenital and pelvic diaphragm is not taut enough to counter an increased intra-abdominal pressure; therefore, urine is pushed from the bladder with the increased pressure (Hulme 71-72). Some studies have shown that only 49% of women are able to correctly contract their pelvic floor muscles in order to increase urethral pressure; more than 30% of women are not able to correctly contract these muscles even when given instruction on how to perform this contraction. Commonly, the abdominal, gluteal, and adductor muscles are contracted instead (Bᴓ 454). Athletes The relationship between athletes and the prevalence of stress urinary incontinence is a controversial topic at present. In order for an athlete to be capable of competing at the optimal level, the athlete’s pelvic floor must be much stronger than that of the general population (Bᴓ 452). There is some evidence that suggests there is no relationship between athletics and stress urinary incontinence. For example, in one study, Olympic athletes were studied twenty years after they had competed. The results showed that stress incontinence and urge incontinence in the athletes were associated only with their current BMI rather than their parity, age, or the Olympic sport in which they competed (Bᴓ 373). In a third study, Nygard et al looked for incontinence among college varsity athletes. They found that there was no significant correlation between hormonal
SPECTRUM
4 (1)
therapy, weight, or duration of physical activity and the presence of incontinence or amenorrhea in the athlete (Bᴓ 457). “Although the prevalence is high”, they concluded, “most athletes do not leak during strenuous activities and high increases in abdominal pressures” (Bᴓ 458). Currently, there is no conclusive evidence that strenuous exercise causes stress urinary incontinence (Bᴓ 458). Although there is no conclusive evidence that athletics causes urinary incontinence, some researchers believe that participation in athletics may exaggerate an underlying condition in women at risk, such as those with benign hypermobility joint syndrome. Therefore, the underlying causes of stress urinary incontinence may be present while the symptoms may not be as prevalent in sedentary women (Bᴓ 458). Eliasson et al measured urinary leakage in all trampolinists that confessed leakage problems during performance. Their studies revealed that after fifteen minutes on a trampoline, participants leaked an average of twenty-eight grams (Bᴓ 455). The older trampolinists who had been training the longest and most frequently experienced greater difficulty when attempting to voluntarily contract their pelvic floor muscles in order to cease the flow of urine (Bᴓ 373). When athletes experience incontinence while performing, the leakage may cause embarrassment and result in the athlete’s cessation of his or her sport. In the end, “Athletes reported that the leakage was embarrassing, affected their sport performance, or was a social or hygienic problem” (Bᴓ 455). Methods: In this study, Division I female athletes were asked to complete an anonymous survey regarding their experience with urinary incontinence. The surveys were distributed either electronically or personally at the respective team’s practice. Thirteen female athletic teams participated in this study for a total of 122 subjects. The athletic teams that participated include the following: cheerleading, cross country, basketball, bowling, field hockey, golf, lacrosse, soccer, softball, swimming, tennis, track, and volleyball. The results from the track team were discarded due to
27 the fact that the athletes participated in multiple events and could not be divided specifically into one group for analysis. The survey responses were divided into jump, continuous running, burst, and low impact activities. The jump group consisted of the volleyball, basketball and cheerleading team; the continuous running group consisted of the lacrosse, field hockey, soccer, and cross country teams; the burst group contained the softball and tennis teams; and the low impact group consisted of the bowling, golf, and swim teams. The data were also analyzed in the generalized form of high impact and low impact activities. High impact athletes were those involved in the jumping and continuous running sports, while low impact athletes were those that were involved in the burst and low impact sports. Results: The list of questions used in the survey with the total number of positive responses to each question,and the percent of the total positive responsesis displayed in Table 1. The results of group members with a positive response and percentages are displayed in Table 2. Table 3 shows the number and percentage of athletes that responded to the survey from each team. Overall, 36.4% of the athletes surveyed reported stress urinary incontinence when participating in their given sports. As displayed in Table 2, the results suggest a direct relationship between the amount of impact that the athlete experiences during their sport and the incidence of urinary incontinence. This can be seen by the fact that the high impact group reported almost two times more urinary incontinence than the low impact group when participating in their sports with 43.4% and 21.1% respectively. Athletes involved in jumping sports experienced the most stress urinary incontinence when participating in their sport at 65.4% while 13.6% of the athletes that participate in low impact sports reported stress urinary incontinence during their sport. The continuous running group and the burst group both contained the middle ground with 33.3% and 31.3% positive
SPECTRUM
4 (1)
28
Number
Percentage
Total Participants: Total
121
Percentage of High Impact Aerobics Participation
109
90.1
Question #1 Experienced Stress Urinary Incontinence While Participating In Your Sport
44
36.4
Question #2 Experienced S.U.I. while Coughing, Laughing, or Sneezing
58
47.9
Question #3 Leak Urine When Has Strong Urge to Urinate
35
28.9
Question #4 Leaks Urine When Seeing, Hearing, or Feeling Running Water
13
10.7
Question #5 Leak Urine When Moving from Sitting to Standing
6
5
Question #6 Leak Urine when Lifting Heavy Objects
8
6.6
Question #7 Leak Urine when Walking, Running, or Exercising
19
15.7
Question #8 Urine Dribbling out after Going to the Bathroom
30
24.8
Question #9 Wear a Sanitary or Incontinence Pad to Catch Urine when Not Participating in Sport
1 2
0.8 1.7
Question #10 Wear a Sanitary or Incontinence Pad to Catch Urine when Participating in Sport Question #11 Limit Fluid Intake to Avoid Urine Leakage with Activity
5
4.1
Question #12 Educated on How to Perform Pelvic Floor Strengthening Exercises Question #13 Perform Pelvic Strength Exercises 3 or More Times Per Week Question #14 Perform Quick Holds (1-3 sec.) as Well as Long Holds (10 sec. or more)
16 4 4
13.2 3.3 3.3
Question #15 Confident On Knowing How to Prevent Stress Urinary Incontinence
39
32.2
Table 1. Questions asked and the Total number of positive responses and the percent of the total positive responses.
Jump N Total Participants Number and Percentage of High Impact Aerobics Participation Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15
Run %
26
N
Burst %
57
N
Low Impact %
16
N
%
22
High Impact Total N
%
83
Low Impact Total N
%
38
26
100.0
54
94.7
16
100.0
13
59.0
80
96.4
29
76.3
17 18 11
65.4 69.2 42.3
19 22 18
33.3 38.6 31.6
5 8 3
31.3 50.0 18.8
3 10 3
13.6 45.5 13.6
36 40 29
43.4 48.2 34.9
8 18 6
21.1 47.4 15.8
2 1
7.7 3.8
7 4
12.3 7.0
2 0
12.5 0.0
2 1
9.0 4.5
9 5
10.8 6.0
4 1
10.5 2.6
3 4
11.5 15.4
2 13
3.5 22.8
0 0
0.0 0.0
3 2
13.6 9.0
5 17
6.0 20.5
3 2
7.9 5.3
10 0
38.5 0.0
10 1
17.5 1.8
4 0
25.0 0.0
6 0
27.3 0.0
20 1
24.1 1.2
10 0
26.3 0.0
0 0
0.0 0.0
1 4
1.8 7.0
0 0
0.0 0.0
1 1
4.5 4.5
1 4
1.2 4.8
1 1
2.6 2.6
6 2
23.1 7.7
6 0
10.5 0.0
2 1
12.5 6.3
2 1
9.0 4.5
12 2
14.5 2.4
4 2
10.5 7.7
1 13
3.8 50.0
1 17
1.8 29.8
1 4
6.3 25.0
1 5
4.5 22.7
2 30
2.4 36.1
2 9
7.7 23.7
Table 2. The total number of athletes and the percentage of athletes in each group who answered with a positive response.
SPECTRUM
4 (1)
response respectively for athletes that reported stress urinary incontinence during their given sport. More athletes reported symptoms of stress urinary incontinence when participating in their given sport than when they were simply running. The athletes in sports that seemed to promote incontinence also said they were more prone to experience symptoms when they laughed, coughed, or sneezed. Also, the activity that promoted the most incontinence in all of the groups was coughing, laughing, and sneezing. The most incontinence occurred with this activity in the jump group (65.4%). However, when comparing the athletes divided into just high impact and low impact, the percentages of prevalence were very close with high impact at 48.2% and low impact at 47.4%. Finally, in all of the groups the activity that produced the third most incontinence was when the athlete had a strong urge to urinate. As with all of the other groups, the most incontinence occurred in the jump category with 42.3% and the least occurred in the low impact category with 13.6%. When compared with high impact and low impact, the high impact (34.9%) reported almost two times more prevalence of incontinence with the strong urge to urinate than the low impact (15.8%). Team Participation Team Percentage Basketball 63% Bowling 36% Cheerleading 22% Cross Country 89% Field Hockey 67% Golf 78% Lacrosse 91% Soccer 64% Softball 53% Swimming 55% Tennis 60% Volleyball 71% Table 3. The percentage of athletes that participated in the study from each team.
Most of the athletes surveyed were approximately the same age and practiced approximately the same number of hours per week. Therefore, there were no correlations found with
29 these variables. Only 13.2% of the athletes were aware of how to perform pelvic floor strengthening exercises. Of those who were educated in these exercises, only 3.3% performed pelvic floor strengthening exercises three or more times per week, and 3.3% performed quick holds as well as long holds. Discussion: In a similar research study conducted by Carls et al, 171 surveys were distributed (86 returned) at eighteen high schools and colleges in central Illinois (Carls 23). The athletes in this survey ranged in age from fourteen to twenty-one years, with an average age of seventeen years (Carls 22). These athletes practiced from three to twenty-five hours per week within their sports of basketball, cheerleading, pom-pom dancing, softball, track, volleyball, or weightlifting. Sixty percent of these athletes competed at the collegiate level and 40% were involved in high school athletics. Twentyeight percent of the individuals who returned the survey reported symptoms of stress urinary incontinence when competing in their given athletic activities, which was lower than the 36.4% reported at Saint Francis University. Eleven point six percent reported symptoms when exercising and 9.3% reported symptoms while running, compared to the 15.7% who reported symptoms during these activities in the current study. Finally, only 2.3% reported symptoms when weightlifting (Carls 23). Weightlifting was not heavily correlated with the presence of stress urinary incontinence in the current study as well, with only 6.6% reporting symptoms when lifting. The incidences of leakage varied over a wide range for the athletes involved in the study by Carls et al. Twenty-five percent of the respondents reported leakage from two to four times per month; only 8% of the athletes reported symptoms two to four times per week. Many of the participants of that survey also reported that their symptoms affected their social lives and participation in various exercises in negative ways (16%) or caused them to avoid such activities entirely (8%). Also, 91% of the athletes reported that they had never
SPECTRUM
4 (1)
30
heard of Kegels, which are exercises for the pelvic floor muscles (Carls 23). In the current study, 86.8% reported that they were not educated in Kegels or preventing stress urinary incontinence. The percentages of athletes that reported incontinence with various activities between the study conducted by Carls et al and the current study are compared in Table 4. Carls et al
This study
28
36.4
Exercises
11.6
15.7
Coughing
11.6
47.9
Running
9.3
15.7
Sneezing Hearing Running Water with Urge
6.9
47.9
4.7
10.7
Weightlifting
2.3
6.6
Uneducated on Kegels
91
86.6
Sports
Table 4. The percentage of athletes that reported incontinence with different activities in the study by Carls et al compared to the current study.
Some obvious differences between the two studies are in the percentage of subjects reporting urine leakage during sneezing and coughing. These are activities that are sudden and intense, similar to some physical activities, and reflected in our grouping categories. The Carls et al study reported rates of 6.9 and 11.6% whereas we reported 47.9%. One might anticipate a difference between the high and low impact groups in this question, with perhaps one of the groups being closer to the levels reported by Carls, but the percent incidence between the high impact and low impact groups was 48.2 and 47.4% respectively. Still very different. So why our respondents reported such higher levels of incontinence than in the Carls et al study is not clear. Perhaps there is some relationship between the intensity of high school versus college athletes intensity levels, or their willingness to report instances of leakage. This could explain why their numbers are lower than ours in all categories. Other studies have also found a correlation between participation in athletics and symptoms of
stress urinary incontinence. For example, a study conducted by Albright, Nygaard, Svengalis, and Thompson studied 156 college students and found that 28% of these athletes experienced urine loss during their given sports. Forty percent of these athletes reported that their symptoms began in high school while 17% reported that their symptoms first occurred even earlier, in junior high school. Another study of 104 female Olympic athletes, 16.7% of whom were nulliparous, reported results of 35.8% of the athletes admitting incontinence. A third study conducted by BĂ˜ and Borgen indicated 41% of the 660 involved athletes experienced stress incontinence. Similarly, a study published by Cleven, Olesen, Thyssen, and Lose in 2002 showed that among the 291 athletes (91.4%) studied, 43% indicated urine loss while participating in their given sports. Finally, urinary incontinence has also been reported in a study of female soldiers. Thirty percent of these respondents experienced urinary incontinence when performing physical training and field duty (Carls 21-22). On average these studies indicate that 35.56% of females who participate in chronic physical activities, such as sports, report instances of stress urinary incontinence. Our 36.4% is in line with these findings. Pelvic Floor Muscles and Athletes There are two existing hypotheses regarding the relationship between athletics and the pelvic floor muscles in females: the first hypothesis is that the pelvic floor muscles of female athletes are very strong; the other hypothesis is that athletics may cause female athletes to stretch, overload, and weaken their pelvic floors. The theory behind the first hypothesis is that the increased abdominal pressure that results from extreme physical activity would result in a pre-contraction of the pelvic floor muscles. Therefore, the muscles should be trained during these activities. However, increased abdominal pressure does not result in a simultaneous or pre-contraction of the pelvic floor muscles in all women. Also, the pelvic floor muscles are not voluntarily contracted in any sport. If physical activity did strengthen the pelvic floor
SPECTRUM
4 (1)
muscles, then stress urinary incontinence should be both prevented and treated. However, female athletes leak during physical activity, especially activity involving high-impact movements. Similarly, the belief behind the second hypothesis is that pelvic organ prolapse and stress urinary incontinence have been linked to heavy lifting and strenuous work. For example, some researchers (Nicholas and Milley) have suggested that chronic damage may result in the uterosacral and cardinal ligaments, the pelvic floor muscles, and the connective tissue of the perineum due to repeated abdominal pressure from either a chronic cough or hard manual work (Bᴓ 457). Evaluation There are a variety of methods used to address living with this condition and treating the symptoms of urinary incontinence. The approach used for treatment is dependent upon the severity of the symptoms, the underlying cause, and the type of urinary incontinence (Flynn 53). The pelvic floor musculature can also be examined to determine the strength of these muscles and their potential relationship to the episodes of incontinence (Rogers 2). To accomplish this, the patient is asked to contract the pelvic floor muscles around the medical professional’s gloved fingers that are inserted into the vagina or the rectum (Hulme 38). Then, the medical professional can evaluate the strength of the patient’s muscles, as well as the patient’s ability to contract these muscles correctly (Rogers 2). While the medical professional is palpating the muscle action, the patient will be asked to tighten and release the pelvic muscles quickly six times. Then, the patient is asked to tighten the pelvic muscles and hold and relax for intervals of ten seconds and to repeat these longer contraction rest intervals six times. The muscle strength can then be assessed using a scale. During muscle contractions of the pelvic floor, biofeedback may be very beneficial to the patient in order to determine if the contractions are being performed properly. This technique can produce a visual of the recruitment patterns and endurance of the pelvic floor muscles as well as the accessory
31 muscles that are required to produce these contractions (Hulme 40). Arnold Kegel, M.D., was the first to use biofeedback in the 1940s. In the present day, biofeedback can be produced through the use of electromyography (EMG), which involves monitoring pelvic muscle activity through the use of sensors that record the electrical activity where the nerves are connected to the muscles. These measurements are then displayed on a monitor or through the use of a sound or blinking light. This allows the patient to witness visually the muscle group being activated, which quickly gives the brain more accurate information, allowing adjustments to be made in order to increase muscle strength as quickly and efficiently as possible (Hulme 113-17). In 2002, MØrkved et al. found that when biofeedback was paired with pelvic floor muscle training, there was a cure rate of 67% when subjects were exposed to physical activity (BØ 376). Treatment Once the extent and type of incontinence have been determined, a treatment plan can be developed. Typically, noninvasive methods, such as behavior techniques and physical therapy, are the first resort. If the noninvasive methods do not improve or eliminate the symptoms, more drastic treatment plans may be initiated. While behavior and lifestyle changes may be beneficial to many people suffering from urinary incontinence, these methods will not be as effective for those with stress urinary incontinence because they do not address the internal weaknesses that are the underlying cause of these symptoms. Electrical stimulation and physical therapy to strengthen the pelvic floor muscles are the most commonly used method of treating urinary stress incontinence (Haslam, Jeyaseelan, Oldham, Roe, Winstanley 632). Exercises can be used to increase the strength of the pelvic floor muscles and the urinary sphincter. These exercises, also known as Kegels, involve squeezing the muscles used to stop urination for intervals of three seconds. In order to accomplish Kegels affectively, the abdominal
SPECTRUM
4 (1)
muscles, leg muscles, and buttocks should not be contracted or moved in any manner (Mayo Clinic Staff, “Urinary Incontinence: Treatment and Drugs” 1). Another source indicates that the muscle contraction should be held for ten seconds, relaxed for ten seconds, and repeated twenty-five times twice a day (Flynn 54). The original Kegel exercises were prescribed to be completed three hundred to five hundred times per day (Hulme 73). The number of contractions that should be completed on a daily basis has been under consideration for quite some time. However, positive results have been correlated with between 30 to 50 contractions on a daily basis. (Rogers 2). Kegel exercises were first developed by Arnold Kegel, M.D. He described these exercises as contractions of the pelvic floor muscles or vagina to stop urine flow (Hulme 4), and they have been one of the main recommendations for treating incontinence since the 1940s (Hulme 73). Kegel’s theory was that if the cross-sectional area and tone of the muscles was increased and if the connective tissue was stiffened, then the pelvic floor would be raised and support the viscera at a higher level. The Kegel program theoretically would cause the pelvic floor muscles to form a stronger base and allow the individual to contract these muscles automatically (BØ 376). The pelvic floor musculature consists of two types of fibers: Type I and Type II. Type I muscle fibers, or slow twitch fibers, are used for slower, more sustained contractions and are fatigue resistant; strengthening Type I fibers would increase muscle endurance. Type I fibers make up at least 80% of the levator ani. Contrastingly, Type II fibers, or fast twitch fibers, are responsible for forceful, strong muscle contractions; exercising these fibers will result in increased muscle strength. The Type I fibers of the pelvic muscles are responsible for maintaining a general level of muscle support, while the Type II fibers are responsible for the urethral closure during sudden increased intra-abdominal pressure. Therefore, both types of fibers need to be strengthened in the case of stress urinary incontinence. Kegel exercises include “quick flicks” or 2-second contractions to
32 target the Type II muscle fibers, and longer contractions of a minimum of 5 seconds in order to increase the endurance of the pelvic floor musculature and target the Type I fibers. These exercises should be completed three times daily with at least ten seconds of relaxation between each contraction. Ideally, the exercises should be completed in the lying, sitting, and standing positions. Improvements in urinary incontinence may be seen after six to eight weeks, with optimal improvements occurring after this time (Newman 2-4). The main problem with these exercises was that many people did not know whether they were correctly performing the exercises or they did not understand how to perform the proper contractions in general. As more research was conducted on this problem, it was discovered that many other muscles in the lower pelvis and legs in addition to the pelvic floor muscles were responsible for the support of the bladder (Hulme 4). The definition of a cure rate when dealing with the amount of urine lost is two grams or less of urine leaked during a pad test. In 2001, Hay-Smith et al. found that 44% to 70% of those suffering from stress urinary incontinence had been cured after pelvic floor muscle training. Other studies conducted separately by BØ et al. and MØrkved et al. found that urine leakage could be cured during running and jumping activities through the process of training the pelvic floor muscles. Unfortunately, a randomized controlled trial has never been conducted with athletes. However, BØ found that in a study of twenty-three women, 74% were able to reduce their symptoms of urinary incontinence during running and jumping activities. Sixty-five percent of these women experienced a decrease in leakage during lifting activities (BØ 375). As indicated in this study, 13.2% of respondents indicated they were educated on Kegel’s and 39.2 % indicated they knew how to prevent urine leakage. But this knowledge did not appear to have much effect on the overall incidence of incontinence, since our numbers are still in line with those reported in the literature.
SPECTRUM
4 (1)
Another method to train the pelvic floor muscles that can be used by physical therapists is electrical stimulation. This procedure involves inserting an electrode into either the rectum or the vagina. This electrode will transmit an electrical current to stimulate and strengthen the pelvic floor muscles, which has been found to be effective for both urge incontinence and stress incontinence; however, this treatment process is lengthy and does not produce instant results (Mayo Clinic Staff, “Urinary Incontinence: Treatment and Drugs” 1). Summary: Stress urinary incontinence is a major problem among collegiate female athletes that needs to be addressed. In the current study, 69.2% of female division I athletes involved in sports that involved a great deal of jumping experienced urinary incontinence during their sport. Thirty-six point four percent of the total female athlete respondents reported experiencing urinary incontinence during their sport. These numbers are too high to remain unaddressed. Many athletes report that stress urinary incontinence is embarrassing, can be a hygienic problem, or may even cause them to cease participating in their given sports. Kegels or exercises that target strengthening the pelvic musculature can help to prevent some of this incontinence. Eighty-six point two percent of the respondents in the current study reported that they were not educated on how to perform these exercises. These athletes should be educated and pelvic floor strengthening should be included as part of their strengthening and conditioning requirements for their given sports. Works Cited 1. Bø, K. "Pelvic Floor Physical Therapy in Athletes." Evidence-based Physical Therapy for the Pelvic Floor: Bridging Science and Clinical Practice. Ed. Bø, K. Edinburgh: Churchill Livingstone, 2007. 369-77. 2. Bø, K. "Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport." The Norwegian University of Sport and Physical Education 34.7 (2004): 451-64. PubMed. Web. 4 Mar. 2011. <http://www.ncbi.nlm.nih.gov/pubmed/15233598>.
33 3. Carls, C. "The Prevalence of Stress Urinary Incontinence in High School and College-age Female Athletes in the Midwest: Implications for Education and Prevention." Continence Care Program, Passavant Area Hospital, Wound Ostomy Continence Services: 21-24+. PubMed. Web. 4 Mar. 2011. <http://www.ncbi.nlm.nih.gov/pubmed/17390923>. 4. Culligan, Patrick J., M.D., and Michael Heit, M.D. "Urinary Incontinence in Women: Evaluation and Management." American Family Physician. N.p., 1 Dec. 2000. Web. 10 May 2011. <http://www.aafp.org/afp/2000/1201/p2433.html>
5. Flynn, Linda. “Continence Restoration in the Homebound Elderly: Interventions and Outcomes." Home Health Care Management & Practice. Web. 04 Mar. 2011. <http://hhc.sagepub.com/content/6/3/52.full.pdf+html>. 6. Hulme, Janet A. Beyond Kegels: Fabulous Four Exercises and More – to Prevent and Treat Incontinence. 3rd ed. Missoula: Phoenix, Pub. 7. Haslam, E.J., S.M. Jeyaseelan, J.A. Oldham, B.H. Roe, and J. Winstanley. "An Evaluation of a New Pattern of Electrical Stimulation as a Treatment for Urinary Stress Incontinence: A Randomized, Double-blind, Controlled Trial." Clinical Rehabilitation 14.6 (2000): 631-40. Clinical Rehabilitation. SAGE. Web. 10 May 2011. <http://cre.sagepub.com/content/14/6/631.short>. 8. Rogers, Rebecca G. "Urinary Stress Incontinence in Women." New England Journal of Medicine 358.10 (2008): 1029-036. 9. Mayo Clinic Staff. “Urinary Incontinence: Causes” Mayo Clinic. Mayo Foundation for Medical Education and Research, 25 June 2011. Web. 25 Mar. 2012 <http://www.mayoclinic.com/health/urinaryincontinence/DS00404/DSECTION=causes>
10. Mayo Clinic Staff. “Urinary Incontinence: Treatments and Drugs” Mayo Clinic. Mayo Foundation for Medical Education and Research, 25 June 2011. Web. 25 Mar. 2012. http://www.mayoclinic.com/health/urinaryincontinence/DS00404/DSECTION=treatments-and-drugs
11. Newman, Diane K., DNP. "Kegel Exercise." Kegels (pelvic Floor Exercises). Seek Wellness, 2013. Web. 19 Mar. 2013.
Lauren Wingard (’15, DPT) is a graduate student at Saint Francis University, pursuing her Doctorate of Physical Therapy. She was the co-captain of the Saint Francis Women's Volleyball Team and the co-director of Reaching Every Door, as well as a member of SGA, Best Buddies, FCA, and the Saint Francis University Honors Program.
SPECTRUM
4 (1)
34
Contents of SPECTRUM Volumes 1 – 3 (Student authors’ names underlined)
Volume 1 Jennifer M. Sabol; Edward J. Timmons: Long-Term Recession Forecasting Using the Yield Curve Brittany H. Miller; Laura M. Stibich; Julia H. Moore; Brendon LaBuz: An Invariant of Metric Spaces Under Bornologous Equivalences Andrew R. McKee; Arthur Remillard: Running into the Unknown: The Religious Dimensions of Distance Running
Volume 2 Issue 1 Abstracts of the First Annual Saint Francis University Research Day
Issue 2 Latitia S. Lattanzio; Robin L. Cadwallader: Man’s Struggle Anthony R. Horner; Rose A. Clark; Stephen M. LoRusso; Edward P. Zovinka: Measuring Potassium in Muscle Tissue Utilizing an Atomic Absorption Spectrometer Validation of an Adaptation for a Whole-body Potassium Counting Method Lisa M. Moser; Arthur Remillard: Listening with Compassion: The benefits of storytelling in the health care setting Ethan L. Hullihen; Timothy W. Bintrim: Door 1, 2, or 3? The Monty Hall Problem KaLynn M. Kline; Heather J. Harteis; Lauren E. McConnell; Janel A. Jesberger; Michele R. Hargittai; Balazs Hargittai: The influence of multiple prolines on the folding of disulfide rich small peptides
SPECTRUM
4 (1)
35
Volume 3 Issue 1 Chelsea N. Weimert; Jill M. Cavalet: Acceptance and Use of Exercise among Physicians and Physician Assistants as a Treatment Option for Depression Agnieszka N. Marciniak; Laura E. Ritchey; Rose A. Clark: Surface pKa and Cytochrome c: How the surface pKa of a Self-Assembled Monolayer affects the Formal Reduction Potential and the Electron Transfer Rate of Adsorbed Cytochrome c Eric S. Horell; Robin L. Cadwallader: The Complex Cat and Society’s Signifiers in “Sam the Cat”
Issue 2 Abstracts of the Second Annual Saint Francis University Research Day
Issue 3 Tia M. Dudukovich; Lindsay Ross-Stewart: Gender Differences in College Athletes’ Perceptions of Group Cohesion Based on Type of Sport Kaylyn M. Oshaben; Edward P. Zovinka: Analysis for the presence of toxic metals and the effect of sunlight on tattoo pigments Elyse M. Grasser; Denise H. Damico: No Hope Without Dope – A History of the Tour de France Elizabeth A. Wheeler: Silent Praise
Issue 4 Daniel S. Valcicak; Stephen M. LoRusso: Will Women Surpass Men in the 100m Dash? A Look into the Trending Times and Physiology of Male and Female 100 Meter Sprinters
Rebecca A.M. Peer; William H.J. Strosnider: Passive Co-Treatment of Acid Mine Drainage and Municipal Wastewater: Removal of Less Commonly Addressed Metals at Cerro Rico de Potosí, Bolivia Dennis J. Ryan; Robin L. Cadwallader: Giving Voice to the Death of Dorian Gray: An Investigation of Hedonistic Suicide
Call for papers Sub m ission G uid elines The purpose of SPECTRUM is not merely to disseminate new results, but also to inform and enlighten. Our readership is a general and multidisciplinary audience who may not be an expert in your field of study. Consequently, please explain all pertinent concepts essential to understanding your article as well as any concepts that might not be common knowledge. Please submit your file in Microsoft Word format as an attachment to the following email address: spectrum@francis.edu. The text should be single spaced, using 12-point Times New Roman font. Please use italics, rather than underlining, for emphasis. O r ganiz at ion of M anuscr ip t s SPECTRUM is an interdisciplinary journal accepting submissions from the natural sciences, the humanities as well as the professional schools (health sciences and business), therefore, the structure and style of each manuscript will differ from discipline to discipline. Regardless, all submissions must provide a cover sheet, a thorough introduction of the problem your research addresses, the conclusion(s), result(s) or findings of your research, as well as some form of bibliographic citation. Below are the general guidelines for these requirements, some of which may not apply to your area of research. C ov er Sheet Title Names and departments of undergraduate researcher(s) and faculty advisor(s) Abstract (200 â&#x20AC;&#x201C; 300 words) Six key words Int r od uct ion Include general background of the relevant field and the larger problem your research addresses as well as its relevance within the field. In addition, explain what prompted your investigation, a summary of previous findings related to your research problem and what contributions your project brings (or was expected to bring) to the issue. M et hod s and M at er ials (If ap p licab le) Summarize important methods and materials used in your research. R esult s/C onclusions Give detailed report of the results and or conclusions reached through your research. Discussion Results should be evaluated in the context of general research problem, the implications of which should be explained with conclusions, predictions or suggestions (if applicable) for further study. T ab les (if ap p licab le) Create tables in Microsoft Word format and insert into general text accompanied by a table legend. Each table needs a number based on its appearance in the paper, where it is referenced. Figur es (if ap p licab le) Please submit figures at the end of the article, one image per page; we will fit these in as we organize the manuscript. Each figure needs a number (the figures shall be numbered consecutively in the order of their appearance in the paper) and a title. SPECTRUM will be printed black and white, but there will be an online version where figures submitted in color will appear in color. R efer ences You may use any referencing style you choose so long as it is a standard format or your discipline (IEE, APA, ACS, PubMed) and that you use it consistently and to the appropriate bibliographical standards.