Part 29

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 ÓMALLEY.

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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.

At times locomotor ataxia begins with very severe pain seizures, known as crises. These may occur in the legs or arms or in the stomach or sometimes in other organs. Occasionally they are the first symptoms of the disease that are noticed, and they may continue for months or even years before other symptoms manifest themselves. This sometimes makes it difficult to recognise the disease for what it really is. The pains are usually most excruciating, are tearing or boring in character, and are sometimes described by the patient as being similar to the sensation that would be felt if a red hot iron were forced into them, or if a knife were inserted and then twisted round. Hence the descriptive name which has been applied to them of "lightning pains" which describes the suddenness of their onset and the intensity of their character. {322} Most of the ordinary anodyne or pain-killing medicines fall to influence them, and the patient is one of the most pitiable of objects while they last.

It is now conceded on all sides that at least 75 per centum of the cases of tabes are directly due to syphilis. Indeed this affection and paresis are sometimes spoken of as parasyphilitic affections. Unfortunately the ordinary treatment for syphilitic manifestations does not affect them in the least. So far as we know at the present time, there is nothing that will hinder the course or prevent the progress or alleviate the symptoms or have any curative action on either of these dreadful diseases. They are much more common in Europe than they are in this country, but have been seen here with quite sufficient frequency in recent years to make physicians, at least, realise the necessity for having young men appreciate the dangers they invite in thoughtlessly yielding to the temptations of great city life.

There are other affections which can be traced directly to the social diseases. One of the most important of these consists of certain brain tumours which may even cause death if not properly treated. These syphilitic brain tumours frequently cause paralysis and may lead to permanent changes in the nervous system with consequent loss of motor power. Whenever the symptoms of brain tumour occur, careful inquiry is made as to the previous existence of syphilis in the case, in order to determine, if possible, if this is the morbid agent at work. If there is a history of syphilis it is usually said to be fortunate, for brain tumours due to syphilis may be made to disappear by the proper use of mercury and the iodides. If the treatment of the case is delayed, however, alterations in the nerve substance take place which can not be improved.

This disease affects especially the blood vessels and, as a consequence of the thickening of the coats of the arteries, blood may be shut off from certain portions of the brain entirely. This will, of course, produce symptoms of paralysis. Indeed, whenever paralytic symptoms manifest themselves under forty years of age, the physician's first thought is sure to be that there is syphilis in the case. This is not always {323} true, for by heredity and very hard work occasionally arteries become so degenerate that they rupture before a patient has reached many years beyond forty, but the case is always suspicious. In this, as in the corresponding instance of brain tumour, treatment, if applied sufficiently early, may not only give relief of all the symptoms, but produce a complete cure. That is, at least the symptoms are relieved for the time, though there may be relapses. Usually these relapses are quite amenable to treatment, but sometimes they get beyond the control of the physician and death ensues. It is almost the rule where there have been serious nervous symptoms once, that recurrences of them must be feared, and they will eventually shorten the patient's life.

Syphilitic manifestations of serious character develop, however, not only in the nervous system, but also in certain of the important internal organs. The liver may become so much affected as to refuse to do its work. Solid tumours may develop in the stomach, or along the course of the intestines, resembling cancer so much that occasionally operations are performed for their removal. As a rule, however, these yield quite promptly to proper antisyphilitic treatment. Whenever an obscure intraabdominal tumour is present, accordingly, it has become the custom among physicians and surgeons not to make an absolute diagnosis nor to perform any serious operation until antisyphilitic treatment has been tried. The surprises of such treatment constitute a very interesting chapter in obscure diseases in medicine.

As we said at the beginning, it is perfectly possible to have contracted the disease innocently, and indeed, the first manifestations may be so mild as to fail to attract the patient's attention. In these cases there will be no history of syphilis, yet the test of antisyphilitic treatment will demonstrate that the disease has been present. Not a few physicians have died from these serious manifestations of syphilis after having contracted the disease through a cut on the finger or the prick of an infected needle in the ordinary course of their professional work. Some of these cases in young men prove to be especially malignant and fail to react to treatment, so that a fatal issue takes place within a few years.

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On the other hand, in general it may be said that the disease is eminently curable, though it may require great care on the part of the patient and the avoidance of all excesses either of work or indulgence for the rest of life. It has often been noted that people who live in the midst of serious emotional strain are most likely to suffer from manifestations of syphilis in their nervous system. Hence it is that paresis and locomotor ataxia are comparatively quite common among actors, brokers, and financiers. They are also quite common among sea captains and military men who are exposed to severe hardships and have to assume weighty responsibilities. In such men the previous attack of syphilis has so weakened the nervous system that it degenerates under the strain placed upon it by the subsequent responsibilities. These diseases are very uncommon among clergymen and are less common in Ireland than in any other country in the world, which would serve to confirm the opinion that the venereal disease is a prominent factor in their causation.

We would not have the idea be assumed that syphilis is an incurable disease and is bound to be followed in all cases by the awful manifestations that we have described. There are many thousands of cases of syphilis that never have any of these serious manifestations at all. It is evident that some cases are completely cured and that no deleterious influence remains. On the other hand, it must not be forgotten that the presence of this disease in the tissues of either parent during the first five years of its course are almost sure to affect offspring born at this time. The children may suffer from the skin lesions of syphilis in their early life, may suffer from serious eye diseases a little later, and then eventually succumb to nervous and mental diseases resembling paresis and locomotor ataxia in early adult life. In fact it is this transmission of the disease that constitutes one of its saddest pictures, and the sins of the parents are indeed visited on the children.

Besides this severer type of social disease, there is what has been called sometimes a milder form. It consists only of a discharge with some fever, which is considered to last not more than a few weeks. As a matter of fact, however, the disease may continue to exist, though the symptoms become latent {325} and the patient may infect others when he least suspects it. This form of disease gives rise to many sad complications in family life. Practically all the severe eye diseases of newly born children, the ophthalmia from which so many eyes are lost, is due to this disease. Special medical care is now taken of these cases, and the serious consequences are not so often seen as used to be the case. Within a score of years, however, about one-half of the inmates of blind asylums owed their loss of sight to this disease. At the present time there still remains a very notable proportion of persons blind from early childhood whose infirmity must be attributed to the sad consequences of the social disease.

Most of the sterility in families is due to the same cause. There is an unfortunate impression that usually the woman is responsible in these cases, and not a little sympathy is wasted on the man, because of the absence of children in the family. Almost invariably, however, the real cause of the family misfortune is to be traced to an infectious disease in the man contracted perhaps many years before, of whose presence he may be more or less unconscious, the symptoms have become so slight, but this has proved sufficient to infect the wife and bring about serious changes that preclude all possibility of the procreation of children.

These statements may seem exaggerated. On the contrary, they are rather understatements of actualities. No one who knows the real state of the case will fail to realise this. Physicians themselves have only come properly to appreciate the true state of affairs in the last twenty years. We need a coordination of all the forces that make for social amelioration in modern life to correct present false impressions.

JAMES J. WALSH.

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XXX

DE IMPEDIMENTO MATRIMONII DIRIMENTE IMPOTENTIA

Hoc argumentum praecipue ad juris consultos ecclesiasticos et civiles pertinet; et quamvis differentia sit inter jurisdictionem judicis civilis et ecclesiastici tamen judicium utriusque quatenus necessario pendet ab existentia conditionum physicalium in medici consilio situm est. Obscuritas doctrinae et quidem gravis de hoc impedimento, libris moralistarum, medicorum et juris consultorum perlectis, invenitur; et quamvis, elapsis perpaucis annis, fere omnis liber tractans de scientia medicinali parva fide dignus, tamen multa ex editis physiologorum veterum tanquam vera a moralistis praesertim promulgantur. Hae difficultates per ignorantiam anatomiae et physiologiae genitalium non minuuntur. Ut auxilium, si quid sit, ad difficultates solvendas feram, species et gradus Impotentiae hie collegi tanquam medicus, eo modo ut conditio physica clarius cognoscatur.