CHAPTER XV. ETIOLOGY. (Part 2)

light. A few hours later, decubitus acutus formed over sacrum. He was unable to answer questions or comprehend directions ; very weak, temperature 100.6^, pulse 90. Mentally apa- thetic. Two days later general spastic rigidity, marked twitching of all muscles, most pronounced on vastus ex- ternus ; increased hyperesthesia over spine, temperature 102°, pulse 97. Next day, November 4th, rigors, deep flush on cheek, cardiac action feeble and excited, pulse no, temperature 104°. He grinds teeth and makes masti- catory efforts. November 5th, pupils regular and brisker reaction. Increase of patellar and cremasteric reflexes, temperature 100^, pulse 90. November 12th, slight im- provement, temperature between 100° and loi^, pulse about 90 ; he is excited and destructive. November 17th, SYPHILIS. 197 several petechial spots appeared on chest, arms and legs and large purpuric extravasations over buttocks and abdo- men. He became very prostrate, refused food and medi- cine, and gradually collapsed ; temperature falling to 97° on the 20th. He died on the 21st, death being preceded by slight convulsive seizures. (Abstract, Norman, Journal of Mental Science, Vol. 39, p. 218.) A CASE OF JUVENILE GENERAL PARESIS OF HEREDITARY SYPHILITIC ORIGIN WITH SPECIFIC VASCULAR CHANGES. A young man, who died aged 21, had been healthy and had shown normal intelligence until his fifteenth year. At this time he had cramps and twitchings, apparently epi- leptic in nature and with a distinct aura. His intelligence rapidly diminished, speech became imperfect and vision failed. The pupils were dilated and unresponsive, knee- reflexes exaggerated, and there was some spasticity of the muscles. The patient was completely demented and could recognize no one except his mother. His father was syph- ilitic, a drunkard and a paranoiac. (Abstract, Von Rad, Philadelphia Medical Journal, Vol. i, p. 634.) A CASE OF GENERAL PARESIS OF SYPHILITIC ORIGIN. A man, who had contracted syphilis seventeen years before and had been under careful medical treatment, recovered and was considered fit to marry. He married and lived a perfectly healthy life, free from worry or anxiety. But, when only a little over forty, he began to consider himself an old man. His writing was not so good as formerly. His memory failed and his energy and will power were wanting. A leading physician found, how- ever, no signs of danger; but within a fortnight there were marked symptoms of acute general paralysis. (Ab- stract, Savage, of, cit.y Vol. 5, p. 394.) A CASE OF GENERAL PARESIS IN FEMALE WITH HISTORY OF SYPHILIS. I. M., aet. 32, insane two weeks, and died in one year from that time. She has had several miscarriages and the 17 198 ETIOLOGY. children living, as well as the patient, show signs of syph- ilis ; the husband's history confirms this conclusion. She had melancholic excitement for a short time during lacta- tion ; threatened to poison herself, to throw herSelf out of the window and kill her children ; she had a strong animus towards her husband and entertained delusions regarding his relations with the nurses. In a few weeks she became quite demented, restless and destructive, tearing clothing, bed clothes, etc. Her speech became paralyzed, pupils unequal, which did not respond readily to light. In the eighth month of her disease she had an attack of hemi- plegia, then became bed-ridden and at last sank rapidly and died. (Abstract, Campbell Clark, Mental Diseases, p. 220.) A CASE OF GENERAL PARESIS OF SYPHILITIC ORIGIN WITH A REMISSION AFTER ANTISYPHILITIC TREATMENT. Case of a gentleman who had been treated in the best possible way for the primary sore and subsequent stages of syphilis. About two and a half years after he was sup- posed to be cured of syphilis he had a very severe hemi- crania for which he went south without benefit. When he returned, in addition to hemicrania, he had the usual initial symptoms of general paralysis. Under large doses of potassic iodid he apparently made a complete recovery, returned to his previous occupation and worked as well as ever. A few years later the writer found that the symp- toms had nevertheless made regular progress, and he had no doubt as to what the result would be. (Abstract, Fol- soitij/oc. ci'Ly p. 26.) A CASE OF GENERAL PARESIS FROM ACQiJIRED SYPHILIS. A. B., aet. 41, van driver, no hereditary history of in- sanity, married twenty-five years, industrious, of anxious temperament, moderate sexual appetite, remarkably tem- perate. Six years ago he contracted syphilis and gave it to his wife. All active symptoms of it disappeared three years ago. Thirteen months prior to admission, his wife noticed that he could no longer perceive any odor and he SYPHILIS. 199 became sleepless, dull and very forgetful. Later com- plained of a fixed pain in the right antero-lateral cephalic region, which increased until it invaded the whole right side of the cranium and was extremely severe, especially at night. Apathy, insomnia and amnesia increased daily and taste hallucinations became prominent. His action became purposeless, movements uncertain, general tremor set in, he began to lose sexual power and desire, which latter had before been very strong. He had distressing dreams, that he had made a post-mortem on his wife and had removed all her viscera ; he became violent, threatening and obstinate ; and was annoyed and excited by visual halluci- nations. Diagnosis, syphilitic tumor of brain with paretic dementia. On admission he had cachexia which had re- sulted in advanced marasmus ; gait tottering, limbs ataxic in their movements, marked general tremor, fibrillar twitch- ing of muscles of expression, which were also flattened ; patellar, plantar and cremasteric reflexes exaggerated, well-marked ankle clonus. Cutaneous sensibility much in- creased. Tongue clammy and ataxic, in voluntary move- ments tremulous, indented and flabby when at rest ; pupils small, irregular and unequal, sluggish to direct consensual and light stimuli and fixed to the sympathetic reflex. The movements for accommodation were spasmodic and ill- directed ; pupillary reaction being slow and incomplete. Absolute loss of smell ; he could not hold a pen or button his clothes ; respiration quick and shallow, pulse small and feeble, tongue furred ; pronunciation blurred and chippy. Voice resembled a hoarse whisper. His attitude was that of rapt attention, gazing into space, with a want of ex- pression; he avoided conversation, and was very de- spondent — "I am done," etc. When put to bed after ad- mission, he had a slight epileptiform convulsion, during which he passed urine involuntarily. For twelve days following, there was rapid mental and physical deteriora- tion. He sat all day in one place, with limbs flexed, neck forward, gazing into the distance, and expression of intent listening. It was difficult to arouse him from this state ; he talked of imaginary events. In two weeks, on March 200 ETIOLOGY. 12, he had a violent epileptiform seizure, the convulsions throwing him out of bed. Afterwards, an increase of dementia ; he could not answer questions or fix his attention. He lay in bed in a state of general flexion ; rigidity of the limbs, tendency to bed-sores, spasmodic masticatory and swallowing movements, constant grinding of the teeth ; reflexes more exaggerated, and general hyperes- thesia well marked. After a sinus on the foot, leading down to the bone, had healed (early April), he became bright, answered questions readily and volunteered re- marks. But gradually his expression became more and more '* wiped out," general and facial tremor increased, although on April 26 he spoke more intelligently than usual. Control over bladder was impaired. On April 30 he had slight but frequent epileptiform seizures after which expression was very fatuous ; he would not speak, tongue protruded to right. On May i and 5 he had several seiz- ures and became very weak ; he was mute, fearful and emotional. He remained in this state till 8 P. M. on the 7th, when he was seized with epileptiform convulsions ; left side became rigid, right relaxed, lower jaw drawn down and back, tongue directed to right, pupils dilated and insensible to light, plantar reflexes absent, tempera- ture rose suddenly from normal to 102^, pulse 80, con- jugate deviation of head and eyes to left and he died the same night. (Abstract, Norman, loc. cit.y p. 221.) Temperament. — The idea has gained recognition that a temperament of general paresis exists, and certainly the reasons are credible. The temperament most frequently found among paretics is the intensel)^ sanguine. It is found in those vv^ho are inordinately ambitious for w^ealth, fame or station, vv^ho lack self- control and are prone to excesses, who are restless and changeable in disposition; also among the fiery, choleric, and those with an obstinate disposition. Naturally these conditions tend to nerve irritation and exhaustion. SEX. 20 1 This extreme selfishness and lamentable lack of self- control, permitted to dominate a life, sometimes reaps in this disease a very natural, but most pitiful harvest. PARESIS IN TWO INSTANCES ATTACKING BROTHERS. Twin brothers had general paralysis, the disease be- ginning and running its course in one sooner than in the other. The two had lived in different parts of the kingdom and had no symptoms of syphilis or history of that disease. Two other brothers at the same age, 32, became general paretics, though they had led utterly different lives, one being sober and industrious while the other was intemper- ate and licentious. They had inherited a tendency to break down prematurely along the nervous lines. (Ab- stract, Savage, loc. cit.^ Vol. 5, p. 393.) Sex. — Statistics uniformly agree in showing that general paresis occurs more frequently among men than women. An interesting table by Regis,* made up from 7,552 insane and 868 general paretics, gives the following data: (i) In rural populations the disease is about one and a half times more common in men, and rare in either sex. (2) Among laboring classes of large cities it is three times more common in men and it is relatively frequent in both. (3) In the higher classes it is nearly thirteen times more frequent in men, and very common among men and rare among women. The number of paretics in proportion to the whole number of the insane is estimated by the same author as follows: [a) Among men, 3 : 100, and among women 2.13 : 100. {b) In working classes of large cities, men, 23 : 100, women, 7.7 : 100. In higher classes, men, 33.3 : 100; women, 2.58 : 100. The ratio of liability, according to Sankey,^ is: (i) Males of the lower class ; (2) males of the upper * Mental Maladies, p. 457. * Ibidem^ p. 283. 20^ ETIOLOGY. class; (3) females of the lower class, and (4) females of the upper class. There is a question as to whether males of the upper or lower class pre- dominate, some authors reverse the order as given above. GENERAL PARESIS IN A YOUNG WOMAN. Marjory C, admitted, act. 18, was the third of a family of seven. The two eldest are living and healthy, the third was the patient, the fourth was still-born, the fifth is alive and well. The two youngest were twins, one of them died soon after birth with convulsions ; father was intemperate but denied syphilis. The patient's illness commenced four years before admission, as the result of a severe fall on the head. When picked up she was unconscious and blood was oozing from left ear, pus subsequently came out. Three days after the fall she suddenly became aphasic, left side of face twitched ; she did not lose consciousness, and the attack passed off in ten minutes. She remained well for three years. A year before admission, her manner and mental capacity began to change. She could not keep her situation as a servant ; she would pick up and eat crumbs of bread on the street, and could give no reason for doing so. Two months before admission she fell and was picked up unconscious, although the fall was not at all severe. She soon recovered consciousness and then it was noticed that her mouth was drawn to the left. She developed delusions ; she thought she was the mother of a large family ; she became suspicious of her relatives. When admitted the disease was well advanced. She walked with difficulty, muscular power much impaired ; she was very deficient mentally ; she seldom spoke or comprehended simple ques- tions ; memory not very good, especially for recent events, but she knew simple multiplication table ; she was rather depressed in appearance. Tongue and lips tremulous, voice quavering, pupils unequal, did not react well to light and not at all to accommodation ; knee-jerks and superficial reflexes slightly increased. She is undersized and undeveloped, and had never menstruated; no very SEX. 203 evident marks of syphilis. After admission, disease pro- gressed rapidly, she became more mentally deficient, spoke less, until she finally ceased to speak ; she became so weak that she was confined to bed. She lost flesh in spite of extra feeding ; she had most careful nursing but died of exhaustion three months after her admission. (Abstract, Middlemass, Journal of Mental Science, Vol. 40, p. 38.) OBNBRAL PARESIS IN WOMAN. CAUSE SHOCK. DIED IN THIRTY-THREE MONTHS. M. E. J., admitted in June; female; single; aet. 35; servant. She had a child when 19. Three weeks after Christmas she was disappointed in marriage, became altered in behavior, at first was depressed and would cry for hours together, soon after began to talk nonsense, said she was going to Paris, talked much of her lover who had just married another ; her mother kept her at home two months, when she became destructive and violent; she was then taken to the workhouse. On admission, mind appeared imbecile, she is noisy and violent at times, fairly nourished, gait tottering, articulation confused, says she has plenty of money, industriously inclined, offers to assist nurses. Tenth month, she has gained flesh. Symptoms of general paresis well marked, especially as regards articu- lation ; at times excited, at times cries and roars lustily. Fourteenth month, motor paresis much increased, unable to stand, falls about, wet and dirty. Seventeenth month, articulation worse, is scarcely intelligible ; she is confined to bed, muttering : you must have a million million cows to suck, thousands of dolls, beautiful cows — but she is stronger, pupils equal. Eighteenth month, able to leave bed, restless, would not remain in bed, she takes nourish- ment well. Nineteenth month, she is up and roaming about ward but gait unsteady. Twentieth month, excited, she tried to strike, articulation very indistinct, she dressed up a foot stool and carried it about as a doll. Twenty-first month, mind very imbecile, she is regardless of decency. Twenty-second month, paretic symptoms continue with restlessness, she wanders about and shows a disposition to 204 ETIOLOGY. violence. Twenty-sixth month, she is still able to be up, mind demented, gait unsteady, voice tremulous, pupils equal ; she is stronger than a month ago. Twenty-seventh month, she is stouter and well nourished, scarcely able to speak, still up and restless. Thirtieth month, general pow- ers failing, speech very drawling, imbecile laugh, says she has a beautiful fortune left her, stuffs her mouth with food in eating, some difficulty in swallowing. Thirty-third month, pupils equal, she is unable to stand, lies in bed with knees up, difficult swallowing, grinding of the teeth, mind very demented, legs gradually more drawn up ; she died from exhaustion without convulsions in the thirty- fourth month of the disease. (Abstract, Sankey, op, cit.^ P- 321.) PARESIS IN DISSOLUTE WOMEN. Among unmarried women, prostitutes seem particularly liable to paresis, a fact noted by Snell and Cullerre, who found eighteen of this class out of thirty-nine female par- etics. Of the three unmarried women paretics I have known, one was, I believe, of this class, and one of the others had been an unlegalized mother. (Abstract, Ban- nister, American Journal of Insanity, Vol. 50, p. 483.) A CASE OF GENERAL PARESIS IN A GIRL. MOTHER ALSO HAD PARESIS. A girl, set. 14, suffered with general paresis. The mother and paternal grandmother both died in asylums. The mother was a general paralytic. There was no syphilis. The patient had been healthy until at six when she became restless and very destructive. Her mental state was one of complete dementia and she died when fifteen. (Abstract, Marr, Philadelphia Medical Journal, Vol. 4, p. 704.) Age. — General paresis is a disease of middle life, much more common between the ages of thirty-five and fifty years than at an earlier or later period. It attacks men in the prime of life, when the brain and nervous system are in the highest condition of func- I AGE. 105 tional activity and at an age when the most severe strains have to be borne. In later years the fortune is made, or the business life, with its pressing duties has grown familiar and the early anxieties and cares have been relieved. The disease is very infrequent before twenty years of age and is unknown after the age of seventy-six. Its occurrence between nine and twenty years of age has been occasionally reported but the disease is then usually luetic in nature and runs its course quickly. At twenty-five it is infrequent, but the common age of occurrence is between thirty and forty. After fifty-five it is rare, but it has been known to follow late acquired syphilis and thus has "been found in a few recorded instances in men between sixty and seventy- five years of age. Hirschl, for example, gives the case of a man who contracted syphilis in his fifty- sixth year and the symptoms of paresis began at sixty. The greatest number of cases shown in the early tables occur between the fortieth and fiftieth years, but late statistics show the greatest number to occur between thirty and forty years of age. This