{292}
Ordinarily erotic paranoia manifests itself by the patient imagining himself or herself to be beloved by some one of superior station. This love is of rather a platonic character and the "lover" cranks are prone to pick out as the object of their attention and annoyance some young woman rather prominently in the public eye, but whose reputation is of the very highest. Mary Anderson was the subject of a good deal of this sort of persecution. At the present moment the well and favourably known daughter of a great millionaire is the subject of many such attentions.
These paranoiacs are apt to become dangerous if they are prevented from paying what they consider suitable attention to the object of their affection. In hospitals they have to be carefully watched, and more than one accident has taken place as the result of relaxation of vigilance on the part of their attendants. If kept from the object of his affection, delusions of persecution become prominent in the amorous paranoiac, and he may become a persecutor in turn and thus a dangerous lunatic. He can not be made to understand that the sending of flowers and photographs and letters is entirely distasteful to the chosen one. Fortunately, after a time, in many of these cases, a state of dementia sets in, and then the patients become mild-mannered imbeciles whom it is not at all difficult to manage.
As a rule where the patient has passed through the various stages of paranoia, dementia, with symptoms of imbecility, closes the scene. The paranoia may not always follow the course mapped out for it. Stages may be skipped, several forms of delusions may become prominent in the life of the individual at about the same time. The main feature of the disease is its progressive character, and its diagnosis depends on the queerness exhibited all during the course of life, as well as on the presence of hereditary neurotic influences.
Special Forms of Paranoia.—There are besides the two types described a number of special forms of paranoia, some of which aroused attention first under the form of monomanias, that seem to merit brief treatment by themselves. In their extreme forms they are easy of recognition. Milder types, however, may easily escape classification under the{293}head of paranoia, because they are considered to be individual oddities and not due to any physical or mental incapacity. Undoubtedly, however, the study of these peculiar "types," as the French call them, from the standard of the alienist or expert in mental diseases, will serve to make clearer the real significance of many otherwise almost unaccountable actions. There is no doubt, that the consideration of these eccentrics as paranoiacs makes the charitable judgment of many of their acts much easier, and at the same time is of service in managing them. They are likely to be of much less harm to the community and to their friends, when it is realised that they are not to be taken too seriously, but that, on the contrary, there is ample justification for a benevolent combination of interests to keep them from injuring themselves and their friends.
Paranoia Querulans.—One of the most important and familiar forms of the special types of paranoia is what is known scientificallyparanoia querulans, that is, the peculiarity of those who insist on going to law whenever there is the slightest pretext. It is pretty generally recognised that a goodly proportion of the civil suits that crowd our law courts are due to the peculiarities of these people who insist on having their rights, or what they think their rights, vindicated for them by a court of justice. There are very peculiar characters in this line, some of whom make themselves very much feared and detested by their neighbours. There are some individuals to whom the slightest injury or show of injury means an immediate appeal to the law.
Not infrequently these patients, for such they are in the highest sense of that word, waste their own substance and even the means of support of wife and children, on their foolish law schemes. When their queerness reaches a certain excessive degree its pathological character is readily recognised. In a less degreeparanoia querulansmay be a source of very serious discomfort to friends and neighbours without exciting a suspicion of its basis in mental abnormality. Not infrequently such patients become more irrational at times when their physical condition is lower than normal, and a return to their ordinary health makes them{294}more amenable to reason and less prone to appeal to expensive litigation.
It is evident that the irrationality of frequent appeals to expensive and bothersome litigation should arouse suspicion. Such patients need to be cared for quite as effectually as those who have tendencies to gamble away their substance or to waste it in the midst of inebriety. Unfortunately it is extremely difficult to frame laws so as to meet such conditions. Severer forms of the affliction are readily recognised and the sufferer is properly restrained. I remember once seeing a patient in Professor Flechsig's clinic in Leipzig, who had been sent to the asylum because of his tendency to go to law on the smallest possible pretext. This patient's incarceration in the asylum was due to a very striking manifestation of hisparanoia querulans. He answered an advertisement for a clerk, published by one of the large commercial houses. He found himself one of a row of applicants for the position, and as the member of the firm whose duty it was to engage the clerk was at the moment busy, he had to wait several hours before his application was heard and refused. He tried to secure a warrant for the firm in order to have them indemnify him for the time he had spent while waiting for his application to be heard, at the rate of wages they would have been bound to pay him had he obtained the vacant clerkship; only as they had spoiled a day he claimed a full day's wages.
This patient had been in the asylum several times before because of his tendency to go to law. He always gained in weight while in the asylum, became much more tractable and less querulous as his physical condition improved, and usually after some months could be allowed to leave the institution. He was, however, one of the inept. With the help of asylum influence he usually obtained some occupation more or less suitable, but was not able to retain it for long. When out of a situation he worried about himself, usually did not take proper food, and then soon his litigious peculiarities began to manifest themselves once more in such form that if he could get the money to retain an attorney, or if he could persuade one to take his case on a contingent fee, and he was very ingenious at this, he soon became a veritable nuisance to{295}those around him. When in poor health he was never contented unless he had at least one lawsuit on his hands, and only really happy when he had several.
The Gambler Paranoiac.—A form of paranoia that inflicts almost more of human suffering on the friends of the patient than any other is that in which the sufferer is possessed of the idea that he can, by luck or by ingenious combinations, succeed in winning money at gambling. Milder forms of this paranoia are so common that it is the custom not to think of even the severer forms of the gambling mania as a manifestation of irrational mentality. When a man thinks, however, that he can beat a gambler at his own game, or when by long lucubration he comes to the conclusion that he has invented a system by which he can beat a roulette wheel, he is, on this subject at least, as little responsible as the man who thinks that he has discovered perpetual motion.
This form of paranoia inflicts suffering mainly on the near relatives of the patient. There is no doubt that when extreme manifestation of the gambling mania becomes evident, patients should be legally restrained from further foolishness. One difficulty with regard to the proper appreciation of gambling has been an unfortunate tendency to class gambling among the malicious actions. There are many people for whom only two sins seem to have any special importance, drunkenness and gambling. As a rule, there is not the least spirit of malice in the ordinary gambler; not meaning, of course, by this the sharpers, who try to make money at the expense of others, but the man who believes that, somehow, chance and fate are going to conspire to enrich him at the expense of others, though it must be confessed that he does not usually even think of this latter part of the proposition which he accepts so readily.
We have had in recent times so many manifestations of the practical universality of the gambling spirit, the belief by people that brokers and banking concerns are ready to make them rich quick, that we have in it perhaps the best illustration of the partial truth of the proposition that "half the world is off, and the other half not quite on."
The "Phobias."—Sometimes the special form of queerness{296}takes on a very harmless aspect. Patients are worried because of the fact that they can not keep themselves clean. They want to wash their hands every time they touch any object that has been handled by others, whether that object seems to be specially dirty or not. Such patients may wear the skin off their hands washing them forty or fifty times a day. They almost absolutely refuse to touch a door-knob, because it is handled by so many people. They will consent to take only perfectly new bills. It is almost amusing to see the efforts they make to avoid shaking hands with people, without giving direct offense. When it comes to shaking hands with their physician, they are apt candidly to declare that he must not ask them to do so, because they can not overcome their feelings as to the possibility of contamination from hands that come in contact with so many patients. This fear of dirt has received the name Misophobia.
There are a number of other "phobias," and the patient's fears are manifested at the most peculiar objects. Agoraphobia, for instance, is the fear of crossing an open place. These patients begin to tremble as soon as they get away from the line of buildings in a street, in their way across the square. This trembling becomes actual staggering, with a sense of oppression over the heart that makes locomotion almost or quite impossible. Claustrophobia, the opposite of Agoraphobia, is the fear of narrow places, and prevents some people from going through a narrow street with high buildings. Many of these "phobias" have a physical basis in some organic or nervous heart affection.
The Tramp.—One of the striking manifestations of paranoia in our modern life is the tramp. Most people are inclined to consider that the cause for the wandering life of these unfortunates is rather what a distinguished physician euphemistically called by the scientific name,pigritia indurata, that is, chronic laziness, than any pathological condition of mind. Most tramps, however, will be found, on that close acquaintanceship which alone will justify judgment of their actions, to have many other peculiarities of mind besides the shiftlessness which prompts them to wander more or less aimlessly from place to place. After all, it will hardly be denied that the calm{297}acceptance of the notion that it is more satisfactory to indulge in laziness and wander without home or fireside, suffering the many privations and hardships, especially from the weather which these creatures do, rather than work and be respected and comfortable among their fellows, is of itself irrational.
Many of these tramps prove on close acquaintance to be interesting pathological characters. Various stages of outspoken paranoia will be found to exist among them. It is not unusual to find that certain among them have acquired the idea not so uncommon now among large classes of humanity, that the world is so unjust in its treatment of the labouring man, that work seems to them almost a persecution that must be undergone for the sake of the pittance derived from it. Sometimes there is the actual extrinsic idea of personal persecution for some fancied wrong done to a large corporation during a strike, or labour troubles, which they cherish as the reason for which they have had to give up a fixed habitation, and resign the idea of supporting themselves honestly and respectably. This persecution stage of paranoia easily turns to the second phase of this affection as already described, that in which the fancied victim of persecution becomes in turn the persecutor. Tramps thus readily give way to even organised attempts at revenge upon social order, and are led to believe themselves justified in attempts to burn and otherwise destroy property because of their enmity towards property holders and employers generally. Not infrequently the third stage of paranoia, in which there are delusions of grandeur, may be observed.
Personally I have known two tramps who wandered about the country with these grandiose ideas. One of them thought that he had in his possession immense wealth in the shape of large checks, signed supposedly by various important capitalists, and even foreign rulers. These checks were actually signed in the names of these personages, at the tramp's own request, by any chance passer-by or acquaintance. This patient died in a country insane asylum in the demented stage of paranoia, having gone through all the usual phases of the disease. Another tramp was confident that each recurring election he was to be elected to one of the highest offices in{298}the state, or even to be made President of the United States. Not every one was taken into his confidence in this matter, however. The simplest declaration after the election from any chance acquaintance would assure him of his success at the polls, and on more than one occasion he turned up at the Capitol to claim exalted office, but was generally inoffensive in his ways, and was rather readily persuaded that his term of office did not begin for some time. It is easy to understand that a person might come into the possession of the idea that the official holding office in his stead should be removed; the result might very well be one of the sad tragedies supposedly due to anarchism, but really to paranoia.
Of course as with criminals, so with tramps; not a few of them take up this manner of life without any sufficient justification in their mental state to lessen our worst opinion of them. I do not think I should hesitate to say, however, that the majority of these unfortunates present distinct signs of physical and mental degeneration and are rather deserving of pity and care than of condemnation. They need, as a rule, very special environment to enable them to lead ordinary, respectable lives, because they were not originally endowed with sufficient initiative and independence of spirit to enable them to carry on the struggle for life in the midst of the hurry and bustle of our modern civilisation. As the pressure of the time becomes severer, more of these unfit come into evidence. They arc examples of the lowered mental states, unable to stand the rivalry with fellowmen, and ready to give up the struggle whenever the example of others who have already given it up is brought prominently to their notice.
It is not a little surprising how many of these tramps belonged originally to excellent, respectable families. Careful investigation of their personal history, however, will show that they have been, as a rule, backward children at school, always a little awkward in the way they took hold of things early in life, unsuccessful in the rivalries of school competitions, and in their first efforts at labour after school days were over. They always needed the encouragement of those whom they loved and respected, to keep them at their unsatisfactorily fulfilled tasks. They were the predestined failures{299}in life, and have found out their uselessness early in their careers. This is the view of tramp life that is coming to be realised as true by all those who have studied the question, not from the standpoint of theory, but of practical experience with it.
So-called Monomania. The old term for paranoia employed for a long time was monomania, a word coined by Esquirol at the beginning of the nineteenth century. This word has dropped out of the terminology of mental diseases because there is no such thing as a patient suffering from a single symptom of mental disturbance, that is, being mentally perturbed on but one line of thought. There are always others, though they may be hidden except from the careful investigator. When Esquirol introduced the term he applied it to the most prominent symptom of the patient's mental alienation, but did not intend it to be taken as excluding other symptoms by which the essential nature of the patient's insanity could be diagnosed. Careful study will always disclose the fact that other symptoms are present. The word monomania has been an unfortunate one for scientific psychiatry, because it has been abused to shield criminals. The plea is often heard that a person under charge of crime is really subject to some mania that brought about the commission of the crime.
We often hear of kleptomania as a defence for persons who have failed to recognise the distinction betweenmeumandtuum, and are haled before the court because of the detection of infringements of this distinction. True kleptomaniacs there are, but there are always other symptoms of their mental disturbance besides the tendency to steal. Their queerness in other ways has usually been recognised by their friends and by their family physician before the incident which calls attention to this special form of disequilibration occurs. Kleptomaniacs, too, are usually prone to take things of little value, or not especially suited to their wants and for which they have practically no use.
It is true collectors, that is, those who have a hobby for gathering curiosities of one kind or another to make a collection, may become so interested in additions to their collection{300}as to be tempted to appropriate to themselves articles of which they can not otherwise obtain possession. Such actions may easily go beyond the bounds of reason. It must be remembered however, that the collection mania itself is often so pronounced as to be a little beyond the bounds of ordinary rationality.
Other so-called monomaniacs have the same characteristic and are associated with related symptoms of mental disturbance. Pyromania is sometimes pleaded as a defense for arson. It is a legitimate defense, however, only when the careful tracing of the patient's history beforehand shows the existence of other symptoms of mental unbalance. The homicidal mania is of the same order. There have been cases where men seem to have delighted in inflicting injuries or death upon fellow creatures from pure malice. Such cases as that of Jack the Ripper, for instance, are undoubtedly due to a special tendency to take life. In these cases, however, associated symptoms are never lacking. It is not improbable that in Jack the Ripper's case a sexual element was present, because the victims were always of one low class, and that the general character of the murderer would have revealed his irresponsibility. There are several stories of children—whose mothers delighted in seeing their husbands, who were butchers, slaughter animals—who seem to have had a veritable mania for seeing blood flow and to have exercised it in the murder of human beings.
Only the most careful examinations of the previous life of the patient, the investigation of childish tendencies and habits at school, and the incidents of boyhood and youth will sometimes enable the expert to recognise the constant existence of symptoms of mental disequilibration, the decided manifestation of which leads to serious events in after life. Monomania as a defense for crime has brought expert evidence into great disrepute. In this matter the greatest care is undoubtedly needed, however, for it is easy to do great wrong and punish the irresponsible victim of an impulse over which he has no proper control. On the other hand, it must not be forgotten that no such thing is known to exist as the perversion of the will on a single point. Moral insanity with regard to one special set of actions is a delusion that the{301}increase of knowledge with regard to mental diseases has erased from the text books on this subject.
Responsibility of Paranoiacs.—From what has been said it is easy to understand how difficult is the determination of the responsibility of paranoiacs. Many classes of persons ordinarily considered to be quite responsible for their actions are yet so circumstanced that they are led into the performance of actions usually not considered rational, though not tempted thereto by any benefit directly accruing to themselves. On the contrary, it not infrequently happens that the mode of life adopted by the paranoiacs is of such a kind as would of itself, because of the hardships involved or the mental trials, deter ordinary people from following it. Paranoia, at least in its severer forms, completely justifies the plea of irresponsibility for actions committed. When it is remembered, however, that paranoiacs are often cunning enough to take advantage of their own supposed queerness voluntarily to commit crimes they might otherwise be deterred from by fear of punishment, some idea of the difficulty of the decision in these cases may be appreciated.
It is important, of course, that the physician should, as far as possible, avoid falling into the error of judging such people too harshly, since after all on him depends the attitude of society towards them. It would seem to be quite as important that the clergyman should occupy an advanced position in this matter. It might seem that charity could easily be overdone; it must never be forgotten, however, that it is better that ninety-nine guilty should escape rather than that one innocent person should be punished.
As a matter of fact, prejudice is much more likely to be against the supposed criminal than in his favour. While it is often declared that too many persons, who have done at least material wrong, are allowed to escape deserved punishment, as our knowledge of mental diseases increases there is more and more of a tendency on the part of experts to recognise that for many apparently voluntary actions men have only a modicum of responsibility. Responsibility is, after all, not the same in all men, but modified very much by the character of the individual, by his environment and by the{302}motives which have come to be the well-springs of his actions. No two men are equal in their responsibility when there is question of certain temptations to do wrong. Some men find it perfectly easy to resist allurements to dishonesty which others can not resist. Some men are perfectly free as regards their attitude towards indulgence in spirituous liquors. Others find it almost impossible to resist their cravings in this direction. One might go through the list of passionate actions and find this true with regard to every one of them. If this must be admitted with regard to men who are considered perfectly sane and responsible, how much more so does it become true of those who are already somewhat mentally unbalanced?
Unfortunately, the tendency to judge harshly, rather than mercifully, still continues to be one main reason for the infliction of punishment where often it is not deserved. Above all the clergyman must be a leader in this tendency to mercy, and his influence should be felt in popular education in this regard. It only too often happens that clergymen are found to be strenuous upholders of the opinion that right is simply right and wrong, wrong, and that a man who knows the difference between right and wrong must be considered as responsible for his actions, no matter what modifying circumstances or mental conditions may enter into the problem of the decision as to his responsibility. If the clergyman would but realise how difficult in any individual case must be such a decision, and how much must be known with regard to the previous character of the individual, then a great beginning for the modification of the present over-severe modes of thought will have been made.
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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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."
{309}
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.
{311}
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 ÓMALLEY.