Essays In Pastoral Medicine Part 27

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 a.s.sociated 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 hara.s.sing 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 interst.i.tial 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 s.h.i.+vering, 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 cla.s.sed 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 cyst.i.tis, 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 prost.i.tutes 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.

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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 att.i.tude 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 pa.s.sing 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. .h.i.therto 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 p.r.o.nunciation 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 a.s.surance, 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.