CHAPTER XIV. DIFFERENTIAL DIAGNOSIS. (Part 2)

the symp- toms returned and with unmistakable features of the dis- order. (Abstract, Blandford, Insanity and Treatment, p. 303.) AN ILLUSTRATION OF BARLY DIAGNOSIS. Mr. , a druggist, 38 years old. Three or four years ago he began to show a want of aptitude in his work, which had been slowly increasing. He had also moderate pains in his legs and occasional headaches, for which he began to dose himself extravagantly. He attended to business closely, although he had excellent clerks, and nothing happened amiss. His clerks and family, and then customers began to notice absent-mindedness and inatten- tion in him. His father-in-law, an intelligent wholesale druggist, thought he must be taking morphine. Without giving any reason for his actions he stopped going to church and to the choir of which he was leader, and made false statements due to confusion or impaired memory and attention. He was pliant, dull, apathetic, with lessened animation in his expression and conduct, showing inertia and weariness on moderate exertion. He lost forty-seven pounds in spite of a voracious appetite and abundant nutri- tious food. There was moderate tremor of hands and tongue but no more than is often seen in neurasthenia. His articulation was slow. He readily gave up his busi- ness and went to an asylum, where he died with typical symptoms of general paresis. (Abstract, Folsom, loc. ctt.^ p. 17.) A CASE OF GENERAL PARESIS ILLUSTRATIVE OF DIAGNOSIS. A clergyman, had an exacting city parish ; with the age and physique in which general paresis prevails. After ten years' service it was found that judgment, common sense ILLUSTRATIVE OF DIAGNOSIS. 1 83 and notions of propriety were very slightly impaired; he was easily irritated, fatigued by bodily exercise, restless, inattentive, almost indifferent ; finally he called for the same hymn three times and did not notice the slip. Often he had dizziness and headache ; the more he wrote the worse his writing became. He was sent to the country to rest for two years ; he*improved somewhat, but did not regain his previous intellectual power. Gait became heavy, knee- jerk exaggerated ; face lost animation and expression. He took a small parish where the demands made upon him are light and he has preached for three years without com- plaint. If tired his gait is unsteady ; he cannot make him- self heard in a large hall ; he has less serious views of life. (Abstract, Folsom, loc. cit.^ p. 15.) A CASK OF GENERAL PARESIS EXHIBITING TYPICAL FEA- TURES IN DIAGNOSIS. Mr. Z., aet. 38 ; lawyer ; on admission he was well devel- oped ; all vital organs but stomach in good condition. He has indigestion most of the time ; he is irritable and suspi- cious ; he says he is ill-used by his family ; he has lost the power to work ; tremor of tongue when protruded with in- volvement of muscles of expression ; speech scanning ; articulation of labials difficult ; pupils normal but are very mobile and dilate widely under excitement ; reflexes nega- tive. History : He was brighter as a boy than his brothers and in good physical health. He was never on good terms with his family because they did not appreciate his intel- lectual capacity. After leaving college he had diphtheria, leaving him profoundly prostrated, from the effects of which he did not recover for more than a year. He began to practice law successfully and also entered politics, which led him into convivial habits and he became addicted to alcohol. After being defeated in an election he gave up practising law and took up other business, working from 8 A. M. till II P. M. for eighteen months. After finish- ing this he was much incensed because he thought his work was not properly valued. He left his native city and entered a Western firm where he did not get along well 184 DIFFERENTIAL DIAGNOSIS. either, always accusing them of cheating and not appreci- ating his work. Three years ago he began to show unusual irritability and a disposition to quarrel ; he would become violently angry for trivial causes; his self-consciousness was morbidly developed ; he was very egotistic and suspi- cious. Since then all these qualities have become more prominent. He thinks he is not properly Veated by his family or employers. There is no history of insanity in the family, although his father was morose and eccentric and his brother became insane on account of an accident. Mr. Z. has been conscious of a failing power to work and has resorted to alcohol to keep himself up and drown his bitter feelings. He also used tobacco immoderately. He has suffered with indigestion, with flatulence and fugitive pains in the stomach, back and head. For the first month after admission he was irritable, cynical and morose, alter- nately excited and depressed, railing at his family and friends, criticising the stupidity of every one. During the following year there was progressive mental and physical failure; impairment of memory and attention; loss of physical power ; growing paresis of facial muscles ; ex- plosive laughter and weeping with exacerbation of excite- ment ; no hallucinations or delusions ; he was constantly try- ing to excite sympathy. He applied to various lawyers to institute proceedings for his discharge. When by himself he would talk over his grievances, cursing family, doctors, etc. He was very unhappy, but never violent. He was constantly trying to induce newspapers and lawyers to expose the management of the insane asylum, but would not appear personally in the matter. His handwriting deteriorated ; sometimes a letter would be omitted or the last letter of a word would end in a scrawl. The lines became uneven and wavy and with intervals so that they looked like a series of dashes. He wrote with many flour- ishes and spoke very deliberately. Soon afterward he managed to escape and he is now in a sanatorium, from which place he is sending out letters, asking newspapers, etc., that they expose the mismanagement of insane asy- lums. (Abstract, Tomlinson, loc. ctt.^ p. 778.) ILLUSTRATIVE OF DIAGNOSIS. 185 A CASE OF GENERAL PARESIS ILLUSTRATING DIAGNOSIS IN THE EARLY STAGE OF THE DISEASE. A senior partner in successful commercial house ; strong constitution, healthy, 50 years old ; laryngologist consulted because it was thought he could not speak so clearly as formerly ; no local trouble, supposed to be nervous. He attended to his routine duties well, but became tired early in the day, and was irritable and meddling. His talk was not always to the point but there was nothing to suggest mental trouble. He could not take up new work readily, or remember recent stories ; in some small matters at home he became careless and inattentive. When giving orders across a large room his voice was raised as if in effort, and the sentences came out explosively ; was diagnosed a gen- eral paretic and advised to go to Europe. In this he was pliant, almost indifferent. He was well behaved on the steamer. In England and France he showed lack of in- terest and became dull and inactive ; articulation became less clear ; he was irritable, and easily tired. After return he went to a summer resort where he showed delirium at night with delusions and some violence ; also incoherence and thickness of speech. Diagnosis doubted because of continued business ability, but he finally presented a typ- ical case of general paresis and died in two or three years. (Abstract, Folsom, loc, cit,^ p. 9.) A CASE OF GENERAL PARESIS IN WHICH THE DIAGNOSIS AND ETIOLOGY WERE COMPLICATED AND INTERESTING. C. D., admitted, aet. 35, with symptoms of general par- esis ; he was one of a family of eight children of hard- working, steady parents. He was in school for a short time, then became a plumber, working at it very hard ; he was good looking, well-nourished and strong. In his youth he was given to alcoholic and sexual excesses. After his marriage, at 26, he was less alcoholic but sexual excess continued. He was always a busy, unrestful man, 'and a capable workman. Three months before marriage^he worked at a job for a week night and day in extreme heat : 1 86 DIFFERENTIAL DIAGNOSIS. his illness was dated from this time. Again he worked at a similar job eighteen months after marriage. After finishing the job he came home *'blue in the face" and *' fainted"; soon after he suffered from lead-poisoning. For four years he did nothing, then started a shop, b|^t soon, after much worry and chagrin, all his means were gone. Afterwards he was a successful cabman until he was thrown, breaking a leg and getting a severe blow on the head. Towards the end of his treatment in the hospital he became manifestly insane. (Abstract, Wilson, G. R., Journal of Mental Science, Vol. 38, p. 40.)