important that those who are close to the patient should have some
realisation of the possibility of its occurrence. There are usually
some signs beforehand of the possibility of the crime. Many of these
early suicides have distinct tendencies to and stigmata of hebephrenic
melancholia. The best known symptoms of this condition are those
described by Dr. Peterson, the present president of State Commission
of Lunacy of New York in his book on mental diseases. The symptoms
noted are extraordinarily rapid and paradoxical changes of
disposition. Depressed ideas intrude themselves in the midst of
boisterous gaiety, and untimely jocularity in the deepest depression,
or at solemn moments. Then there is the paradoxical facial expression,
the so-called paramimia, that is, a look of joy and pleasure when
really mental depression is present, or a look of depression when
joyful sentiments {310} are being expressed. The existence of such
rather noticeable peculiarities may lead to the suspicion of mental
disequilibration in young people.
The most important warning may well be the occurrence of suicide in
any other member of the family for several generations before. The
tendency of suicide to repeat itself in families is now well known and
recognised. During the year 1901 in New York City, in one case other
members of the immediate family had committed suicide in six
instances. The subject has taken on additional interest because of the
suicide of a well-known gambler who was the fourth of his family in
two generations to take his own life. In another case, reported within
the last five years, the suicide was the last of a family of nine
children, every one of whom had committed suicide. There is the record
in the German army of four generations of a noble family, the eldest
son of which committed suicide during the 5 years from 50 to 55.
In these cases the tendency to suicide is not directly inherited, but
there is a mental weakness that makes the individual incapable of
withstanding the sufferings life may entail. In the later members of
the family there is also a suggestibility that the frequent
contemplation of the idea of suicide finally leads to the putting off
of the natural abhorrence at the thought of its commission. In such
families, therefore, it is particularly important to warn medical
attendants and members of the family of the possibilities of
unfortunate acts so as to prevent if possible the execution of any
impulse to self-murder.
JAMES J. WALSH.
{311}
XXVIII
VENEREAL DISEASES AND MARRIAGE
Syphilis is a disease that is contagious, inoculable, and
transmissible by heredity. It may be acquired innocently, and it is so
acquired in about 4 per centum of cases according to good authority,
but the other 96 per centum is venereal. The disease attacks any part
of the body within and without from the soles of the feet to the hair
and finger-nails. The first evidence, where the case is not
hereditary, is a hardened sore called a chancre; next the lymphatic
glands swell, and many forms of skin-eruption occur; then follows a
chronic inflammation of the cellulo-vascular tissues and the bones,
and small tumours, called gummata, may develop in almost any part of
the body. The disease may vary from a light attack to malignancy.
There are periods in the course of the disease.
1. The period of primary incubation, or the time from infection to the
appearance of the chancre. This is commonly three weeks.
2. The primary stage: the chancre forms and the neighbouring glands
are affected. This stage lasts from three to ten days.
3. The secondary incubation, or the time between the appearance of the
chancre and the development of what are called the secondary
symptoms,--usually about six months.
4. The secondary stage. Here occur fever, anaemia, neuralgic pains,
and the eruptions on the skin and the mucous membranes. This period
lasts from twelve to eighteen months in the majority of cases.
5. The intermediate period. During this time there may be no symptom,
or slighter recurrence of the secondary {312} symptoms. This period
lasts from two to four years. It may end in recovery of health or be
followed by tertiary symptoms.
6. The tertiary stage. In this period gummata form, or there may be
diffuse infiltration of various parts of the body, chronic
inflammation and ulceration of the bones, skin and other tissues,
nervous diseases, and so on. The tertiary stage commonly begins from
three to four years after the primary infection.
The three chief divisions, which are apt to blend one into the other,
are the primary, secondary, and tertiary periods.
The affections of the secondary stage are often severe. There may be
fever associated with weakness, headache, general malaise and pain,
and this may be marked or rather light. In this stage iritis is liable
to occur, and if it is not properly diagnosed and treated it will
result in blindness.
The lesions of the tertiary stage may cause great destruction of
tissues and very grave consequences. Cerebral syphilis, if unchecked,
will inevitably cause paralysis or paresis. There may be loss of
speech, epilepsy, coma, paralyses, apoplectic hemiplegia, and so on.
The pain is harassing and often it amounts to great anguish. Whatever
part of the brain substance is destroyed will not be restored.
In syphilitic affections of the spinal cord, if the inflammation is
acute death ensues in a few days or weeks. _Tabes dorsalis_, or
locomotor ataxia, is caused in about 93 per centum of cases of this
disease by syphilis, and it is an incurable and dreadful malady.
If there is neuritis from the virus it becomes intense and causes
muscular contractions, paresis, and paralysis. The optic, auditory,
and olfactory nerves may be attacked and destroyed. The nose also may
be destroyed and it commonly caves in. The bones of the face are
frequently attacked in the tertiary stage and they rot away. The tibia
is diseased more frequently than the other long bones.
The heart is rarely injured, but when it is, the prognosis usually is
bad. In a large number of cases death is sudden and unexpected. If the
arteries are involved the prognosis again is bad, because the symptoms
here do not show until {313} too late for effective treatment When the
liver is the seat of gummata these may be cured in the early stage,
but in the later stage the prognosis is unfavourable. Some forms of
renal syphilis are remediable, but others are not, especially the
interstitial kind.
Syphilis is transmitted to a child congenitally, not as a tendency or
predisposition, but as an active contagion. It may come from the
father, the mother, from both parents, or by direct infection.
The transmission from the father is the most frequent. The spermatozoa
carry the infection to the maternal ovum. Down to the end of the
secondary stage, and half through the intermediate period between the
secondary and tertiary stages of syphilis, a father or mother may
beget a child that will be infected with hereditary syphilis, a
shivering, blasted, rotten little wretch for whom a quick death is the
greatest imaginable blessing, and it usually gets this blessing. In
the acute stage of a virulent syphilis the disease is most likely to
be transmitted; but sometimes, though rarely, a father that has been
free from all symptoms of syphilis for many years may beget a child
that is born with a virulent hereditary form of the disease.
Infection by the mother is more certain and more harmful than that
from the father, because the intrauterine life of the child is
poisoned throughout its course. Two-thirds of the cases of hereditary
syphilis die either by abortion, or if they live to term they die
shortly after delivery. If the mother is infected during the first
eight months of pregnancy the child will nearly always be syphilitic,
but if she is infected after the eighth month the child may escape.
If at the moment of conception both parents have the disease the child
will almost certainly take it, and this infection will cause its
death. In a series observed by Fournier, 28 per centum of the cases
caused by paternal infections died and 37 per centum showed the luetic
taint; in the cases caused by maternal infection 60 per centum died,
and 84 per centum had syphilitic lesions; in the mixed heredity, that
is when both the father and mother were luetic, 68.5 per centum died
and 92 per centum were born syphilitic. When a child {314} is first
infected at delivery the case is not technically classed as hereditary
syphilis.
During the first year after the father or mother has taken syphilis
the probability of infecting the child is the greatest. In the third
year the liability of infecting the child is lessened, but present. In
a series of 562 cases of hereditary syphilis observed by Fournier, 60
children, over 10 per centum, were infected more than six years after
the primary parental infection. Carefully observed cases have been
exceptionally found where infection of the child has occurred in the
fifteenth and even the twentieth year after the original parental
lesion. Fournier reports the case of one woman that had nineteen
consecutive stillbirths from syphilis.
Mild parental syphilis may transmit hereditarily the most malignant
type of the disease, and very virulent parental infection may result
in a comparatively mild infection of the child, if any infection by
syphilis may be called mild. That the parent shows no symptoms from an
old infection is no proof that he or she is cured, or that the child
may not be infected.
With proper treatment of the mother the infantile mortality in
hereditary syphilis is reduced from 59 per centum to 3 per centum, and
the children that are born living are not unfrequently free from
syphilis. When a woman is infected at the conception of her child
miscarriage takes place before the child is viable, from the first to
the sixth month; later other miscarriages occur; later still, living
but syphilitic children are born, of whom one-fourth die within the
first six months; finally she may have children that are not infected.
If a syphilitic man has been properly treated he may, after four
years, beget healthy children, and he commonly does, but he may be the
father of syphilitic children. Syphilitic women properly treated may,
after about six years from infection, bring forth healthy children,
and they commonly do, but not always.
There is a wide diversity of opinion among the best authorities
concerning the curability of syphilis. Gowers (_Syphilis and the
Nervous System_. 1892) says: "There is no evidence that the disease
ever is or ever has been cured, the {315} word 'disease' being here
used to designate that which causes the various manifestations of the
malady." He means there is no absolute proof that a person who has
once been infected is ever so fully cured that he may marry without
danger of transmitting the disease.
Fournier requires, as the minimum time, four years of methodical
treatment before he deems the patient safe, but even this arbitrary
fixing of the number of years is not warranted by experience. Many
physicians hold that in the tertiary stage the disease is not
transmissible, but that statement is not true. Commonly it is,
sometimes it is not. After all symptoms have disappeared the disease
has been transmitted.
In short, a person that wittingly marries any one who has had syphilis
at any time is a fool; and if one of the contracting parties has had
syphilis within the four years preceding the marriage the marriage is
criminal, even if the syphilis has been carefully and skilfully
treated by a physician.
Gonorrhoea is always a dangerous disease. In the male, beside the
acute lesions, it can cause chronic or fatal inflammations along the
various parts of the genito-urinary tract or in different organs of
the body. When the disease becomes chronic it lasts indefinitely. It
may then cause cystitis, or so affect the kidneys as to bring about
very grave results; it may get into the circulation and induce
gonorrhoeal rheumatism of the joints, especially of the knee joint,
and result in a partly or completely stiffened joint. The heart may be
affected and endocarditis ensue; there may be meningitis or
inflammation of the cerebral membranes; the eye may be infected, and
unless it is skilfully treated blindness will follow. Strictures of
the male urethra from chronic gonorrhoeal inflammation often require
major surgical operations for relief.
The disease in women has most of these complications, and other grave
peculiar phases. All prostitutes have acute or chronic gonorrhoea, and
12 per centum, probably more, of reputable women are infected; and the
suffering caused is very great. The gonococcus remains virulent for
two or three years at the least in a man's chronic gleet, and if he
marries he infects his wife. Should her womb be infected {316} she is
seldom completely cured. If the Fallopian tubes are involved, and this
happens frequently, they suppurate, and often they must be removed by
coeliotomy. The woman suffers for a long time when the tubes are
attacked by the disease, and she becomes sterile ordinarily.
When a child is born to a woman that has gonorrhoea its eyes are
infected at delivery, and if it is not very skilfully treated it will
surely lose its sight. Because of this danger, in maternity hospitals
the eyes of all babies are treated at delivery as a precaution, and
many physicians observe the same precaution in private practice.
When, therefore, a man has chronic gonorrhoea he should not marry
until about four years after the last infection, and he should be
carefully treated in the meantime. There is a popular opinion that
gonorrhoea is a trifling disease, but the contrary is the truth: it is
a grave disease, especially in women; and the person that carelessly
infects another is certainly guilty of crime for which a long term in
jail would be a light punishment.
AUSTIN OMALLEY.
{317}
XXIX
SOCIAL DISEASES
There are certain affections not at all uncommon and as a rule
producing rather serious effects upon the social body, of which,
though their existence is well known to all, very little is said. It
is certain that what is considered the more severe of these venereal
diseases may be acquired quite innocently. Indeed, many thousands of
cases of this affection, acquired innocently, have now been reported
by medical men in this country alone. If the statistics of all the
world were gathered together, there would probably be a hundred
thousand cases of this dreadful affection, which have been acquired
without any blame on the part of the sufferer. It has become the
custom, especially in English speaking countries, to ignore the
presence of these diseases, and this has led to a multiplication of
opportunities for their spread to such a degree that now the condition
of affairs, for those who know it best, is rather alarming. It is with
the intention that a few definite ideas, given absolutely without
exaggeration and without any striving after effect, may enlist
clergymen, as well as physicians, in a crusade against these diseases,
that the present chapter is written.
It has been said over and over again at medical society meetings that
it is a very unfortunate thing that universities in these modern times
are situated in large cities. The young man just freed from the
restraints of home life, or of the seclusion of a college, is at once
without any preliminary training, exposed to all the dangers, moral
and physical, of large city life. Not only is this true, but he is
even not properly warned of the dangers that lie so close to his path.
Our prudery has gone so far that the very names of these {318}
affections are tabooed and above all must not be mentioned before the
young. As to the awful evils that such diseases may cause, as to the
lifelong suffering, even to mental degeneration and early death, that
they may involve, not even a hint is considered to be proper. The
consequence is that young men expose themselves not infrequently to
danger, absolutely unknowing the significance that such diseases have
in recent years acquired in the minds of modern physicians, and it is
usually not until a serious mistake has been made that the young man
is brought in contact with the physician who may be frank in pointing
out evils utterly unknown before.
This state of affairs has come to be considered as so irrational in
many foreign universities that now a special course of lectures is
given every year on the significance of what may be called the social
diseases. The students are told very frankly what the possibilities of
danger for them in certain excesses may be, so that at least the young
man can not say "I knew nothing about it," when the risk becomes an
actual reality of danger. At the University of Berlin the first course
of such lectures was established, and the interest aroused and the
results obtained were such as to make other universities consider the
advisability of such lectures for their students. Even here in prim
and prude America, one or two of the great universities have come to
the realisation that the physical well being of their students is
committed to their care, as well as their intellectual development,
and at least a beginning of that precious wisdom that comes from the
fear of the physical evils of sin has been acquired because of
opportunities provided by the faculty.
It is well admitted now by all that ignorance is not innocence and
that knowledge of the consequences of social diseases is likely to be
a very important factor in preventing young men from taking risks that
would otherwise be considered very slight, perhaps. As a matter of
fact, nothing can be more helpful from the ethical standpoint than
this knowledge of how closely may follow the wages of sin, which is
death. It is for this reason that clergymen would seem to owe it, as a
duty to themselves and their position in social {319} life, to acquire
a certain knowledge of these affections. A very great change has come
over the attitude of the medical profession towards the so-called
venereal diseases in recent years. A quarter of a century ago they
were considered to be not very serious after all, and indeed in some
cases to be no more serious than a cold, a mere passing incident in
life. Now it is well recognised that almost never do they leave their
victim in the state of health in which he was before, and that
unfortunately the deterioration of tissues which has taken place is
likely to be enduring. Even many years afterwards there may be serious
complications involving health or even life.
For instance, it is now very generally conceded that paresis, or what
is sometimes called general paralysis of the insane,--a progressive
mental and nervous disease, which invariably ends fatally in from
three to seven years,--is always due to one of the so-called social or
venereal diseases. How important this affection has become in modern
life can be best appreciated from the fact that in Europe nearly one
in four of those who die in the insane asylums are sufferers from
paresis. In this country the disease is not so frequent, the
proportion being less than one in five or even one in six. The disease
is becoming more and more common, however, as large city life becomes
more prominent, and as the possibility of infection with social
diseases is more widespread.
Paresis is what is sometimes called softening of the brain, and it
attacks by preference men under thirty-five. The first symptoms of it
as a rule are not alarming. A young man's disposition changes, so that
an individual heretofore rather stingy becomes extravagant, while
occasionally a prodigal becomes very saving and considers that he has
already a large sum of money to his credit. The most prominent feature
of the early stage of the disease is the occurrence of delusions of
grandeur, that is to say, the patients get the idea that they are
important personages, or that they have fallen heirs to a large sum of
money, or that they have been appointed to high salaried positions. As
a consequence of these delusions, they may make expensive presents to
their friends. Occasionally there are other changes in disposition. A
young {320} man, for instance, who has been of genial character
becomes morose and hard to live with. The opposite change to greater
liveliness of disposition is not unknown, but is more infrequent.
Sometimes there are marked excesses, high living, luxurious habits,
and the like, before the existence of disease is recognised.
The mental stigmata of the disease at the beginning are not alarming
at all. There are slight lapses of memory. A man who has hitherto been
known as an accurate mathematician, makes frequent mistakes in adding
or multiplying. The physical signs are even slighter. In using long
words, syllables are omitted from them. A favourite method of testing
the speech of a person suspected of beginning paresis is to ask for
the pronunciation of a word like Constantinople. Usually a syllable
will be elided, and the reply will be "Constanople," or something
similar. There is a slight tremulousness of the hands and usually a
rather easily marked tremor of the lips, especially when the tongue is
protruded. Often in the very earliest stage of the disease, there are
changes in the pupils. They may be unequal, or may fail entirely to
react to light.
When these signs are positive, that is, when there is a change in
disposition and then the physical stigmata that we have gone over
appear, the diagnosis of the disease is almost certain. The physician
is able to say, with considerable assurance, that the young, strong,
healthy-looking patient, who has often had to be tempted to come to
see the doctor by some specious reason, because he does not consider
himself that he has anything wrong with him, will have to be confined
in an asylum within a year, or at most, two, and will die in a state
of dementia within five years. This, of course, is an awful picture.
This is the course of the disease in nearly 20 per centum of the
inmates of our asylums. Almost without exception there is a history of
syphilis in these cases, and the medical world is now persuaded that
this is the most important factor in the production of paresis.
Another nervous disease, corresponding in some of its features to
paresis and indeed sometimes spoken of as a spinal form of paresis, is
locomotor ataxia. This affection {321} begins usually with loss of
sensation in the soles of the feet so that the patient thinks that he
is walking on carpet all the time. Before this there may have been
some disturbance of vision. The pupils may fail to react to light.
Occasionally the first symptoms are motor, that is, the man notices
that he is not able to walk as readily as before. He staggers easily.
If he tries to turn round while walking he is apt to lose his balance.
If he tries to walk in the dark, he is almost sure to have so great a
sense of insecurity that he dare not go far from the wall.
Occasionally the first sign is a sinking of the limbs on the way down
stairs. In certain very sad cases, the first and only symptom is a
failure of sight which goes on progressively, until the optic nerve is
completely destroyed and sight forever rendered impossible.
All these symptoms are traceable directly to certain changes which
have been noted in the spinal cord. These changes are due to
disturbance of the blood and lymph supply of the nervous tissue. Once
the changes have taken place, there is no hope of the patient ever
recovering the normal use of his limbs. Not infrequently he becomes
bedridden and can not walk at all because he is not able to steady
himself. He may not suffer in his general health, however, to any
serious extent, and may live on for twenty years, though usually his
resistive vitality is lowered and he is carried off by some
intercurrent disease.