Part 28
From a theoretic standpoint, it would not be easy to state all that the physician considers necessary to enable him to make his decision as to individual responsibility. Perhaps, however, the consideration of a series of cases that have attracted widespread attention, and which have been most carefully investigated in all their circumstances, may present the methods of responsible determination better than any set of rules. Three presidents of the United States have been murdered within forty years. The murderers were native-born {303} Americans. In none of the three cases was there any adequate motive for the commission of the crime. The assassin in President Lincoln's case might, it is true, be presumed to have a sufficient political motive, but no entirely sane man could have thought for a moment that any good would be accomplished at that time for the South by the removal of Lincoln. A man of known erratic tendency, with the craving for theatrical effects deeply ingrained in his nature, with a personal history not entirely free from even more serious manifestations of mental disequilibration, and with a family history of more than suspicious character as regards the mental qualities of his ancestors, committed the crime. He met his death at the hands of pursuing soldiers. Such was the temper of the time, that had he been captured alive he would surely have suffered the formal legal death penalty. Even as it was, public sentiment clamoured for legal victims and unfortunately they were found.
It seems clear, beyond all doubt, that in this case complete responsibility for his action was not present in the assassin himself. The courts decided later that there had been a conspiracy, but there has always been the feeling that justice was misled by over-zeal to find scapegoats for injured public sentiment. There is no doubt that it is an extremely difficult matter to say what shall be done to the assassin in such a case. The unfortunate result is as much an accident as the fatal consequences of any other perverted natural force. An earthquake may kill its thousands and the inevitable must simply be accepted. Society may protect itself from the further manifestations of such perverse individuals by confining the unfortunate murderer for life, but capital punishment, in the sense of a sanction for broken law, can scarcely be considered to have a place in the given conditions.
With regard to the murderer of our second assassinated President we had the farce of a long-drawn-out public trial of a man who was evidently not in his right senses. Once more a victim had to be found to satisfy injured public feeling. Guiteau was condemned to death and suffered the death penalty. Any one who reads the proceedings of the trial and who realises the significance of the motive that Guiteau {304} himself gave for his act, will appreciate that the court had to do with an irresponsible doer of a material but not a moral wrong. There were many signs of mental disequilibration in Guiteau's previous career. It is on these eventually that the expert in mental diseases must depend in order to enable him to obtain a proper estimate of the extent of the mental disturbance in any given individual. It may seem that many real criminals can be defended on this same principle of finding an inadequate motive for their crimes. There are, however, certain signs of irrationality not difficult to detect if the previous life of the individual be carefully scrutinised and these must form the ultimate criterion as to criminal responsibility.
With regard to the third murderer of a President the case is clear. He was an ignorant, somewhat conceited individual, but he presented none of the signs of true mental disequilibration that can ordinarily be depended on to indicate such a disturbance of the physical basis of mind as impairs responsibility. He was not entirely without a motive, which in the mind of a brooding, conceited individual, might seem to be adequate for the commission of the crime. His sentence of the death penalty was then in accord with the judgment of the best mental experts. How society shall protect itself, and especially its high officials, against such notoriety seekers is hard to say.
The consideration of these cases gives a clear idea of how a physician endeavours to fill up gaps in his knowledge of the character of the man, his heredity and environment, as well as his previous actions at various times in life when under the stress of emotion. It may be considered that such a weighing of circumstances will serve to excuse many genuine criminals who eminently deserve to be punished. This is, however, the assumption of the older generation who considered that if a man did a material wrong he must be punished for it. It is a heritage of the day, when even accidental killing was considered to demand some punishment. At the present time the tendency is rather to consider only the moral wrong, that is, to calculate responsibility only for such actions as are committed with due {305} deliberation, intention, and the knowledge of right and wrong as well as the freedom to perform the action. The old English legal opinion which declared a man responsible if he knows that what he is doing is wrong has now given way in most judicial proceedings to the principle that the man must not only know that he is doing wrong, but that he must also realise that he is free not to do that which he knows to be wrong. That is to say, if he feels himself compelled to the commission of crime, there is surely an impairment of responsibility. Such impulses to do wrong without adequate motive occur not infrequently among those whose mental condition is not perfectly normal, and this must always be taken into consideration in the ultimate decision as to their responsibility for their action.
JAMES J. WALSH.
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XXVII
SUICIDES
It is a very difficult problem at times to explain just how a suicide is due to mental alienation in a person whose intellectual powers appeared previously unimpaired, yet in most of the cases a knowledge of all the circumstances and of the individual himself would lead inevitably to this more charitable view. Most suicides are persons that have been recognised as paranoiacs and likely to do queer things for a long time beforehand. Indeed, some of the melancholic qualities on which the unfortunate impulse to self-murder depends are likely to have exhibited themselves in former generations. Not long since it was argued that the regular occurrence of a certain number of suicides every year--varying in various places, always on the increase, but evidently showing a definite relationship to certain local conditions --demonstrate that the human will is not free, since from a set of statistics one can foretell about how many cases of suicide would take place in a given city during the next year. As a matter of fact, suicides are not in possession of free will as a rule, but are the victims of circumstances and are unable to resist external influences.
The most important feature of suicide in recent years is the constant increase in the number, the increase affecting disproportionately young adults. This increase in the number of suicides is no illusion; it is not due to more careful statistics. It is true that in recent years, that is to say during the last quarter of a century particularly, the unsparing investigation by the authorities of all cases of suspicious death, and their report by sensational newspapers, has added somewhat to the apparent number of suicides. {307} Families were accustomed to announce accidental death and have their story unquestioned, in a certain number of cases, where now there is no hope of concealment because of the unfortunate publicity that has crept into life. This increase, however, would account for only a small additional number of suicides, while the actual figures have more than trebled in the last thirty years.
This increase has come especially in the large cities. According to the report of the New York Board of Health, there were 1,308 suicides in New York City during the decade from 1870 to 1880. During the decade from 1890 to 1900 there were 3,944 suicides. This increase is much more than the corresponding increase in population. During the first decade mentioned there were 124 suicides per million of population. During the last decade this had risen to 196 suicides per million. The increase is nearly 60 per centum. The increase is variously distributed over the different ages. While every five years from twenty upwards shows a percentage of increase in the number of suicides committed, somewhat less than the percentage of increase for all ages, the five years between fifteen and twenty shows an increase of 106 per centum. In a word the deaths of adolescents from suicide have more than doubled in the last thirty years.
Towards the end of the last decade of the nineteenth century there was for a time a cessation of the continuous increase. This occurred during the years 1898 and 1899. Apparently it was due to the fact that the occupation of the country with other interests, the war and its problems, and the fact that an era of prosperity made material conditions better, and thus gave less occasion for depression of spirits. During the years since 1900, however, the increase has not only reasserted itself, but has more than made up for the period during which suicides were less frequent. The increase during the last four years is more than was noted during the six years from 1891 to 1897.
The same increase has been noted in European cities. The higher the scale of civilisation in a city, or at least the greater the material progress and the more strenuous the life, {308} the higher the death rate. In Dresden, for instance, the rate is 51 suicides per 100,000 every year. In Paris it is 42, in Berlin it is 36; while in Lisbon and Madrid it is lowest, being only respectively two and three per 100,000 per year. While suicides are more common among men than women in all countries, this is not true for certain ages. Between the ages of fifteen and twenty-five the suicides of women are more numerous than those of men. The suicides of women are increasing faster than those of men. Fifty years ago the proportion was five to one. Twenty years ago it had fallen from three to one. Now it is less than two and a half to one. The saddest feature of the suicide situation is the increasing number of the children who commit suicide.
Almost needless to say, children's suicides are without any serious motives and are usually due to an attack of pique because of a slight from a playmate, a reprimand at home, a rebuke from a teacher, envy of the success of a companion, disappointment over a passing love affair, sometimes a peculiar attachment in the case of weak and morbid individuals, the manifestations of which are resented by its object, or are forbidden by parents and guardians. These unfortunate accidents have become so common now that special care must be taken with regard to children of neurotic heredity. When in previous generations there have been the manifestations of lack of mental equilibrium, then children's mutterings with regard to possible recourse to suicide should be the signal for the exercise of close surveillance. As far as possible such children should be kept from the strenuous competition at school in modern life.
As has been well pointed out there is no doubt that the power of suggestion and example has much to do with the increase of suicide. Dymond, an authority in the matter, says, "The power of the example of the suicide is much greater than has been thought. Every act of suicide tacitly conveys the sanction of one more judgment in its favour. Frequency of repetition diminishes the sensation of abhorrence and makes succeeding sufferers, even of less degree, resort to it with less reluctance."
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Our modern newspapers, by supplying all the details of every suicide that occurs, especially if it presents any criminally interesting features or morbidly sentimental accessories, familiarise the mind, particularly of the impressionable young, with the idea of suicide. When troubles come lack of experience in life makes the youthful mind forecast a future of hopeless suffering. Love episodes are responsible for most of the suicides in the young, while sickness and physical ills are the causes in the old. In a certain number of cases, however, domestic quarrels, and especially the infliction of punishment on the young at an age when they are beginning to feel their independence and their right to be delivered from what they are prone to consider restriction, are apt to be followed in the morbidly unstable by thoughts of suicide.
The important practical question is the prevention of the fulfilment of the morbid impulse during these impressionable years. Many a young person has been saved from suicide at this time to realise the enormity of the act and to live without any further temptation to its commission for a long lifetime. As a rule the motive for the act is so trivial and often so insensate that it is not difficult to make patients (because patients they truly are) see the folly of their irrational impulse.
In order to forestall the putting into action of their impulse it is 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.
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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.