CHAPTER XII. PARTICULAR SYMPTOMATOLOGY (continued). (Part 2)

to defective eyesight seemed unfounded. No heat, pain or tenderness over scalp or spine. Articu- lation distinct, skin greasy. Temperature normal, urine neutral, sleep and appetite good. He was exalted and jolly ; said he would do great good to the patients around him almost involuntarily, by the magnetic power which he felt permeating his whole system ; said he had made his fortune in a day, that he was going to stand for Parliament, etc. ; his handwriting was unintelligible, due to misspellings, omitted words, etc. ; memory was so bad that he misstated his age by ten years. He was clean, stuck a feather in his hat and fraternized with the most demented patients and was fanciful and hysterical. The case seemed to be one of general paresis supervening on tabes dorsalis. For first twenty-four hours he spoke only in a whisper, but the un- interrupted current applied to the outside of the larynx, restored his full voice, to his great delight. General health improved, but he lost physical power. There were many grandiose delusions and much emotional instability. After eight months, he complained greatly of weakness and often fell down in dancing. Twelve months from admission he had two slight convulsive seizures, chiefly affecting the right side, followed in two weeks by frantic, destructive mania. Physical degeneration set in, catheter often needed ; he had albuminuria. Cellulitis appeared in both feet and spread, on which treatment made no impression. In a short time, the muscles of the legs were almost in ribbons and every TROPHIC CHANGES, 1 55 part of his body exposed to pressure assumed an inflamma- tory tint which deepened rapidly into a slough. The mania left great exhaustion, unaffected by stimulants. His physical condition hourly degenerated and no one thought he could live another day. His friends, not wish- ing him to die in an asylum, had him removed in a carriage, one mass of mortifying corruption. From 'that time he began to mend and was soon well in body but somewhat silly in mind. (Extract, Fox, B. B., Journal of Mental Science, Vol. 37, p. 394.) GANGRENE OF THE LIP IN A PARETIC, FROM SUCTION. A man in the last stage of general paresis was discovered holding his lower lip firmly between his teeth ; he had not held it there over four and a half hours. The lip was swollen, discolored and black in places. The greater part of the lip sloughed away ; the wound healing without diffi- culty. (Abstract, Arch, de Neurol., Sept., 1892.) A CASE OF GENERAL PARESIS IN WHICH MARKED IM- PROVEMENT OCCURRED AFTER EXTENSIVE SLOUGHS. Male, at. 37 ; lawyer ; no insane heredity ; no history of syphilis. He used tobacco excessively and had been licen- tious ; disposition genial ; temperament sanguine. He was an able attorney and was moderately successful financially. On admission, he had been breaking down for a year, but had made a show of practicing his profession up to within a few weeks. He first showed inordinate sexual desire and extravagant delusions. Shortly before admission, he be- came violent. He believed he could make gold and dia- monds and that he had been commanded to " raise Jesus and to be a Joseph." On admission, he was anemic and untidy ; temperature was normal ; pulse 96, small, irregu- lar and feeble ; bodily health apparently reduced, though he was as well as for several months before ; pupils equal and contracted ; speech drawling and thick ; gait ataxic. He entertained impracticable business schemes of great magnitude. His manner was dull and preoccu- 156 PARTICULAR SYMPTOMATOLOGY. pied and his expression indicated mental impairment. He remained bewildered several days after admission ; he was inclined to lie down, j>ound on doors, injure furniture and remove his clothes. A few weeks after admission, July 24, he is still restless. August 4, he is less confused and quieter, and has a ravenous appetite. He says he has a great invention for tubular locomotion, consisting of two glass balls. One ball is fastened to a pole ; the other is •' a solid globe, with the exception of four little holes for the admission of air and water where the friction occurs." The ** capacity" of this apparatus is one thousand miles a minute. His conversation is incoherent and he speaks of going •♦to the end of the universe at the end of a spark." During the passage of the electrical current through the negative pole in the auriculo-maxillary fossa to the ver- tex, he complained of haziness of vision, as though he were looking through steam. After two electrizations, his pupils were a trifle larger, and his skin cooler. August 15, tendon reflex cannot be obtained owing to muscular rigidity ; tongue deviates to the right and is coated ; pulse 90 and somewhat feeble ; skin cool and pupils contracted ; temperature 98^.5 ; mental action more feeble ; he cannot follow the simplest directions. August 27, he has steadily lost ground ; very noisy and mis- chievous and greatly disturbed at night. September, he is prone to remove all his clothing ; believes he is Jesus Christ; no decline in bodily health. October i, he has had retention of urine recently. On the second he had a mild paretic attack. He became pale, weak, and momentarily unconscious. On the third he had an in- flamed testicle ; he took food poorly and was feeble. Fifth, cystitis developed ; much muco-pus in the urine. Seventh, he is very low and does not take food well ; pulse weak and rapid ; he passes all his urine in bed and is in a wretched condition. Tenth, he is much better and takes food well. The orchitis is subsiding, no abdominal tenderness; says he is in perfect health and is taking solid food. Fourteenth, his urine is intensely alkaline, contains pus and is of a horrible odor. From the six- TROPHIC CHANGES. I57 teenth to the twenty-first he was in a highly critical condi- tion. An abscess formed in the right side of the scrotum ; there was constant dribbling of urine ; genitals and thighs were excoriated. Twenty-fourth, there is a constant dis- charge of pus and induration of the testicle ; dribbling of urine continues ; he has a bed-sore over the sacrum which developed very rapidly. Until November, he seemed to have acute pain in the back, although he said he felt none ; he took very little solid food and required constant atten- tion ; his bed-sore became very large and he constantly lost ground physically. November i, he requires the utmost personal attention and is slowly failing. The bed-sore is becoming deeper. Death at an early date is apprehended. Fifth, the destructive crisis has been arrested. The slough has separated, except in the center. A portion shows suppurative action. Eighteenth, bed-sore better; general health improved but not his personal habits. January following : He is more quiet and less irritable ; appetite good ; is gaining flesh ; bed-sore no larger than a silver dollar ; he is able to sit up and take his meals in the dining room ; gait feeble. Thirtieth, he reads much and is glad to be out of bed. April 3, he steadily improves ; quiet, or- derly, and usually pleasant ; he does not appreciate his past or present mental condition and often asks to be ex- amined and sent home ; he has no extravagant delusions ; he addresses an envelope in a business-like style. May 18, he sits quietly in a room by himself ; he is given to ges- ticulating. Nineteenth, he converses coherently; his statements are plausible ; no difiiculty in articulation ; he can stand erect with his eyes shut and shows little ataxia ; he executes fine movements with considerable precision. June 3, removed from the hospital on trial. March of the next year, he has tried to practice law, but could not accomplish much. He was reported as having seemed **out of balance." He has made himself a great annoy- ance in the courts by issuing fictitious papers and institut- ing law suits against one person and another. He also insisted upon his right to address the court in season and out of season. On his return, he was irritable and spoke 158 PARTICULAR SYMPTOMATOLOGY. to no one. He remained for about a fortnight moody and preoccupied, talking little and taking a very small quan- tity of food. May 21, he converses but little but scolds the superintendent for his detention, and uses profane language. He sits alone with bowed head and does not speak. November 8, he is at times menacing and threaten- ing ; he spends much time in writing and is cross when asked to exhibit his manuscript. December 14, a table knife is found on his person. He replies evasively when questioned as to what he purposed doing with it. March following, his bodily health is as good as at any time since his return. He is pleasant unless annoyed but denounces the officers for his detention. His clumsiness of articula- tion may be natural and it is not thick and indistinct. He shows no incoordination of muscular movement and takes long walks daily ; he will not let the physician examine him ; pulse 98 ; he can walk backwards and forward with closed eyes, and does it easily. His printing and writing are distinct. (Abstract, Burr, C. B., American Journal of Neurology and Psychology, 1884.) Bones. — Fractures of bones are found more fre- quently in general paresis than in any other form of insanity. The long bones, as well as the ribs, some- times become very brittle, due to the absorption of the organic constituents; while the impairment of nerve force leaves the patient deprived of the reflex guard to protect him from danger. Lacking judg- ment to protect himself, he is usually liable to serious accidents of this nature. Not only is there delayed reaction, in dulled reflex movement, but frequently an absence of sensitiveness to pain, so that severe fractures may occur without a sign of suflfering. Again, spontaneous fractures have been known; but not infrequently do the fractures of paretics unite naturally, and bed-sores and abscesses heal rapidly. Clouston, in accounting for the fact that the largest number of rib fractures in asylum practice is in cases i \ BONfiS. 159 of paresis, states that, when the chest is struck, or the weight of another patient or of an attendant is thrown on it, the laryngeal muscles do not act in time to close the lungs and make them resistive, by being filled with air that cannot be driven out. He gives an instance of a patient admitted with nine ribs broken on one side and four on the other, and in spite of such injury he shouted, fought and rushed about wildly, regardless of anything like inconveni- ence, and with an absence of ordinary feeling, show- ing clearly a condition of dulness of sensation; and concludes that this very dulness of sensibility is at the foundation of these fractures. It is in the second stage, when the patient is free and unprotected, that accidents and resulting frac- tures often occur. Sankey says that too frequently fractures are explained to the detriment of the at- tendant, and advises asylum physicians to be espe- cially watchful for this complication in the examina- tion for admission. He adds the case of " Leather- Coated Jack," who, reinforcing his ribs by the erection of the intercostal muscles, would allow a cart to be driven over his chest, and shows that a general paretic has no such forethought, and even if he had, the reflex movements would be too slow in their action to be of avail. A CASE OF GENERAL PARESIS IN WHICH MUSCULAR ACTION CAUSED FRACTURE OF LEG. A male with general paresis, aet. 42, in asylum for over two years ; paresis due to specific disease, and he had been out of health for two years before admission. Ataxia was a prominent feature ; gait clumsy and uncertain ; pupils sluggish, tendon reflex absent ; he was extremely appre- hensive with extravagant delusions ; mental excitement of a furious and purposeless character. Afterwards he was in a quiescent stage when one day, while out walking, he l6o PARTICULAR SYMPTOMATOLOGY. attempted to turn and fell and broke the tibia and fibula in the lower third of his leg. The fracture united promptly and convalescence went on uninterruptedly. (Abstract, Burr, C. B., American Journal of Insanity, Vol. 46, p. 75.) A CASE OF GENERAL PARESIS IN WHICH MUSCULAR ACTION CAUSED FRACTURE OF LEG. A female, aet. 34. The patient had been suffering in mind five months before admission. She had a paretic seizure six weeks after admission. She was noticed to be ataxic, and had difficulty m rising from her chair. The pain and ataxia in the legs were soon followed by incoordi- nation in the movements of the arms ; she had difficulty in feeding herself; she had frequent severe headaches and muscular incoordination was not noticeable at these times. In the following month she was more confused and de- structive of clothing ; ataxia increased and mental powers rapidly failed. In the February following admission, she showed inequality of pupils, and then had a second paretic seizure, with difficulty of respiration, high temperature and choreiform movements. On April 17th she had a severe fall in turning quickly and could not rise ; she had frac- tured right femur in lower third ; no evidence of any con- tusion of the soft parts and it was thought that the turning and not the fall had produced the fracture. She appeared to have no pain and never complained during the dressing of the fracture. In fourteen days dressing was renewed, the limb was in excellent position and showed no shorten- ing ; there was much callus. Forty-one days after injury she could lift her leg easily and unconsciously. (Abstract, Burr, C. B., loc. cit.^ p. 73.) A CASE OF GENERAL PARESIS IN WHICH SPONTANEOUS FRACTURES OCCURRED. A man, aet. 43, presented himself as an out-patient, with a fracture of both bones of the left forearm. Three days before, on lifting a shovelful of dirt, he felt a slight pain in his arm and heard a slight cracking, but continued his work. The manipulations necessary for putting the arm HEMATOMA AURIS. l6l in a plaster dressing caused him no pain. He returned five weeks later to have the plaster removed ; union was complete. At the same time, he showed his right arm and examination showed that the two bones of the fore- arm were broken. He had slipped on a flight of stairs and in falling struck the back of his hand, not very strongly, on some coal in a basket that he was assisting in carrying. In this case also, he did not know he had broken any bones. The clinical history leaves no doubt that he was a general paretic. The points of interest are : 1. In a paretic, whose disease had existed over six months, two spontaneous fractures occurred at intervalsof fiveweeks. 2. These fractures caused no pain to the patient at the mo- ment of their production, nor at the time of their reduction. 3. The union was rapid, as has already been noted for this class of fractures. (Abstract, Froelich, American Journal of Psychology, Vol. 5, p. 84.) Hematoma^ Auris. — The " insane ear," hematoma auris, found also in other forms of insanity, is partic- ularly frequent in general paresis. It occurs occa- sionally in sane persons, especially in those engaged in boxing, playing foot-ball, or wrestling, but under these circumstances it heals quickly. In all forms of insanity the prognosis is bad after the development of hematoma auris. Clouston has seen but four or five cases recover out of over eighty, who had fully developed hematoma auris; and four others, who partially recovered after slight threaten- ings of hematoma, which might not have developed fully, or were stopped by blistering fluid. Savage has seen but one case in which a patient was dis- charged well, after having marked hematoma. None of these cases of recovery, of course, were paretics. It consists of a rapidly developed extravasation of blood into an intracartilaginous cyst of the auricle of the ear. It fills the pavilion of the ear, but does l62 PARTICULAR SYMPTOMATOLOGY. not afFect~the lobe ; it grows to the size of an egg, sometimes in a few hours, more frequently in a few days. It is of a dark, reddish-blue color, rarely lighter in shade and is filled with a gelatinous sub- stance consisting in part of broken-down blood. Difference of opinion existed as to where the disease is situated, Foville saying it occurred under the peri- chondrium, Mabille that it was between the cartilage and the skin, and Vallon that it was in the body of the cartilage. The latest exposition is by Ford Robert- son.' His views may be thus expressed: Hematoma auris, to which the insane are particularly predis- posed, is due to the occurrence of certain morbid changes in the ear cartilage. They consist in the degeneration of the cells, loss of the elastic fibers, ■ Path. Meat. DIs., p. 4S. HEMATOMA AURIS. 163 and breaking down of a portion of the hyaline basis of the cartilage, so that a cyst is formed. New capil- laries develop in the walls of these cysts. The new capillaries are very prone to degenerative changes, probably identical with the hyaline fibroid degenera- tion so common in the intracranial vessels. From rupture of these new capillaries hemorrhage into one of these intracartilaginous cysts results. The rupture may be spontaneous, but usually a traumatism, more or less severe, initiates the effusion. The tumor heals in time by reabsorption, but if left untreated