CHAPTER XV. ETIOLOGY. (Part 3)

reduction of the limit of the age of development of the disease has occurred within recent years and is due to the strain of modern life. The same condition exists, especially in the cities of all countries, where there is excitement and mental strain in business life. Mickle, in speaking of this feature of the disease in Europe, says : " The lowering of the average age speaks ill for the vitality of Western Europe, in as much as general paresis is the result of exaggerated expense of vital force and premature senility." The cases found in early life are infrequent but occasional, and are called sometimes " developmental general paresis." For details see section under par- ticular symptomatology. 18 2o6 ETIOLOGY. Among women the disease is much less common, as stated more fully elsewhere, develops from three to five years earlier, and runs its course more mildly, requiring greater length of time. A CASS OF GBNBRAL PARBSIS IN AN OLD MAN. S. B., set. 6i, but looking 70, married, an artist, no in- sane relatives, no previous attack of insanity. Present one dates back six months, due to pecuniary losses, showing itself with forgetfulness of small things. He became inco- herent and childish, lost himself in his own house ; mistak- ing his relatives ; neglecting the decencies of society ; restless, fidgety, and rubbing his head with his hands. On admission he had tremulousness of lips and tongue, with hesitation of speech ; he became more restless and in- terfering and lost mental power. A month after admission he had a series of convulsive seizures from which he re- covered, but was left weaker in mind ; at the end of three months he had a further series of fits and again recovered. Mental and physical weakness increased and he died; pachymeningitis was found post mortem. These cases are often difficult to differentiate from those of senile dementia. (Abstract, Savage, of. cit.^ p. 311.) GBNBRAL PARBSIS IN A MAN SBVENTY-FIVB YBARS OLD. Mr. Y., aet. 75 ; four children ; a retired merchant, gave up business five years ago. He had become erratic, had grown unusual and peculiar ; he had had for some years •* nervous dyspepsia." His mental vigor, however, seemed to increase. He became interested in social reform and took up hobbies which he rode for a while and then dropped ; horses, dogs, poultry, etc. After the novelty had worn off, he would forget his fads entirely. He had attacks of depression, with tendency to seclude himself and to lose consciousness of his surroundings. Two weeks before admission he was more excited and erratic, trying to carry out absurd schemes and being violent when opposed. On admission, his physical condition AGB. 207 was excellent. Pupils contracted and immobile ; tongue slightly tremulous, but not facial muscles ; patellar reflex exaggerated ; he was constantly moving about and talking about his plans. He had grandiose delusions about himself and his wealth. He was dictatorial, easily angered, and would not brook opposition ; appetite good and bowels reg- ular ; he slept well at night ; during the first three days re- sented restraint and sent telegrams for aid to many promi- nent people. He attacked his attendant frequently ; and insisted that every one should obey because he was such a great man. The next day he said he had the greatest intellect in the world, could acquire any language in three weeks, no one could compare with him, etc. Three days later he was quieter and disclaimed all ill-feeling towards others. He was full of schemes for the material advance- ment of his friends in the ward ; said he had been put in the institution by mistake and that his friends didn't know where he was. He addressed the envelope of a letter to ** Mrs. R. two, three to fifty without the five ; living there a long time, but the cry is coming, push along, better hearken, it is a loud cry especially in New York." His pupils were very contracted and did not react to light; marked tremor of tongue ; no difficulty in articulation ; marked arteriosclerosis; pulse 90 and incompressible. Said he was worth ten thousand millions and would buy the institution and make it a home for little girls from the city. His memory failed rapidly ; appetite good ; says he is very strong ; the management of large affairs is noth- ing to him, etc. All his delusions were becoming more expansive. In a letter, he says: *In a recent invest- ment, I have made a great deal of money; I was rich before and will soon be embarrassed with riches. I have bought Mrs. S.'s house just as it is, beautifully furnished for you and Mr. C. and would like to have you come here and live as long as you live, in the greatest plenty. Mr. C. will not have to work at all except for his pleasure. You will have your carriages and horses and everything like a rich woman. I have bought all the houses in Irish- town, cheap as dirt, but I will tear them down and have 2o8 ETIOLOGY. rows of fine stores put up in their place. I send you $50 to-day and will send you plenty more soon. Oh, if I ain't a happy man ! Come quickly, I have all the money . you will ever need. You can have miles of hot-houses and millions of roses and chrysanthemums." Two weeks later, he was so rapt up in his ideas that he rarely spoke to any one ; sometimes he did not eat. He thinks his food is prepared by a French cook and he constantly magnifies the quality of his food; his possessions include all of England and Ireland. He has risen to the formation of a new government and a reorganization of society. Finally he came to own Africa and then the world. The next month, his physical strength failed and he became more excited. His memory was gone and he was completely self-absorbed. He said : •! am God," "I am the Law," ' Everything is according to my will." ' Announce to the world that a new world has emerged from its hiding place of love and mercy to all men and it will enter at once upon its glorious mission of peace and good will to man." Then followed elaborate plans for the gov- ernment and language of the new world, signing himself : **The Supreme Ruler of the new world, as of the old." One day, he was a loving, beneficent ruler ; the next, an avenging deity, pronouncing curses on every one who came near him. He said • I am God and no one is fit to talk with me." The next day he boasted of his muscular power and wanted to spar with every one ; said he was a second Samson. Next came an attack of depression, he being much of the time on his knees communicating with the deity. But he soon became exalted again; tried to take off his clothing, because in the new world no cloth- ing is allowed. He never spoke directly to any one or answered questions. Sexual perversion appeared. After this, he was restless and excited and he had visual and auditory hallucinations. Once, he tore his mattress to pieces because the Empress of China was sewed up in it. His delusions became transient ; that everyone who came near him meant to kill him ; sometimes talked of suicide ; thought he was a great military genius, Napoleon and RACE AND SOCIAL INFLUBNCBS. 209 Nelson combined. After this, he had an attack of ex haustion, with muttering delirium, and picking at the bed- clothes. During the next week, he failed rapidly. The arteriosclerosis increased. His pulse ran up to 120. He occasionally had an involuntary stool and passed his urine in bed. He thought his room was haunted by dogs and cats but he was generally in ecstasy. Three days before death he became stuporose and the day before he died he had right hemiplegia, without involvement of the facial muscles. (Abstract, Tomlinson, Journal of Nervous and Mental Diseases, Vol. 16, p. 772.) Race and Social Influences. — So free are some coun- tries from general paresis that for a time it was sup- posed to be confined to certain races, particularly to the Anglo-Saxon. This was based on the fact which now is well determined that it is unknown in Asia and to the savage in his native state. The disease accompanies the hurry and worry of the extreme struggle for both existence and high place in late civilized life, regardless of race or nation. For example, the Scotch Highlander is free so long as he remains in his rural surroundings, with little to fire his ambition or imagination, but when he goes into city life and his energy and determination are bent on competition, he places himself in a position that may readily end in his being a paretic. The Irishman, too, almost entirely free from the disease at home, is not at all exempt from it in American cities, or in English factories and mines, where in the latter case, his life is made up of the hardest of work and the lowest and roughest of surroundings. It is said the disease was unknown among the slaves of the Southern States and unreported among free negroes until they came to the centers of popu- lation. At present in Baltimore, as an instance, pare- sis claims the same percentage of negroes, according 2IO ETIOLOGY. to the population, that it does among Caucasians. In Norway and Sweden the disease is very rare. In France and Germany it is common among brain work- ers. In our own countr}- and in England it is found most frequently in regions where competition has been strongest for several generations. In the Western States only one or two per cent, or less, are general paretics when coming from farm life; but in the East- ern States from ten to sixteen per cent, in the populous districts. Berkley * says : " It is in the cities where rum and syphilis dwell in close fellowship, where the strife and excitement of modern civilization is ever at flood tide, that general paresis is rife." Spitzka,^ from a careful study of the subject among the indigent insane of New York City, gives the pro- portion of general paretics as follows: Anglo-Saxon, 13.29; Celts, 11.58; Germans, 11. 13; Hebrews, 10.29; Negroes, 8.82. He shows that the Anglo-Saxon race, the one of greatest speculative business tend- encies and of highest intellectual development, has the largest number; that mere business exertion is not the most fertile cause from the low percentage of the Hebrew race; that intellectual exertion, per se, is not a cause, as shown by the lesser percentage of the Germans, who stand first in the abstract and specu- lative sciences; that a libidinous life is not whollj^re- sponsible, for if such a reflection were to be cast on any race in this respect it would be the Negro race, which shows the lowest percentage of general pare- sis, and to which, living in natural conditions, not compelled to enter into competition, the disease is unknown. The writer then adds: "The conclusion will seem reasonable that general paresis is more fre- quent with races of a high than of a low cerebral or- ' Mental Diseases, p. 194. * Manual of Insanitj, p. 181. i GENERAL PARESIS IN THE NEGRO. RACB AND SOCIAL INFLUENCES. 211 ganization, because their higher civilization induces a restless mental activity and its attendant emotional strain. General paresis, therefore, is not a penalty of high cerebral development, but the expression of a discrepancy between the instrument and its pur- pose; of the inadequacy of some brains to support the strain to which the race, as a whole, is subjected." It is generally agreed among alienists that the gen- eral conditions incident to the life of the poor predis- pose them to insanity, and it is found that a higher per cent, of these classes become insane than those of the middle and higher classes. Whether this rule applies to the distribution of general paresis is a mooted question. Some authorities, as Mickle, be- lieve that paresis is more prevalent in the lower classes, while other observers of equal rank, for in- stance Regis, find that the upper classes suffer most from it. It appears from compiled statistics of the insane, for a series of recent years, comprising the in- sane of the Atlantic seaboard in and about the large commercial centers of Boston, New York, Philadel- phia and Baltimore that the highest per cent, of gen- eral paresis among men makes its appearance in the better classes of society. Of 17,633 indigent male patients, 13.7 per cent were general paretics, and of 16,956 indigent female patients, 1.3 were general paretics ; of 3,005 private male patients the per cent. of general paretics was 16.2, and of 2,736 private female patients the per cent, was .18. The result, therefore, may be put down in the following order: (i) Men of the upper classes, (2) men of the lower classes, (3) women of the lower classes, (4^ women of the upper classes. This proportion holds good equally for the local divisions in and about the four large cities mentioned, excepting in the case of Phila- delphia; here among the women the larger per cent. 212 ETIOLOGY. was with those of the higher classes. There is no ex- planation to offer for this variation from the general rule. Whatever may be the truth in respect to the general rule, one fact is assured — the disease is on the increase. The restless pursuit of wealth and social position, the anxiety and hurry, emotional strain and intellectual overwork, the unhygienic modes of life and especially of the laboring class, the excesses in excite- ment and excitants together with syphilis, tend to fix on modern civilization a most deadly foe, unknown in former times. PARESIS IN A MULATTO WHO HAD BEEN FORMERLY A SLAVE. G. R., a mulatto, male, age 22, of large stature, and fine athletic appearance, admitted July 5, 1855. He was a native of Maryland and had been a slave. His insanity was ascribed to excitement at a religious meeting. On admission he was tranquil and very docile, but was sub- ject to short and very violent paroxysms, in which he was dangerously furious. His bowels were usually constipated before these attacks. He complained of want of feeling in his feet and the anterior surface of his legs. He had a great desire for education and often wept because he could not read. Once he escaped from the asylum grounds but was brought back and on the twenty-third day after admis- sion killed himself by jumping from the asylum roof. (Abstract, Workman, American Journal of Insanity, Vol. 13, p. 22.) Excesses. — Alcoholic and sexual excesses, indulged singly or combined, are especially potent causes of the disease. With the excessive use of alcohol the effect in some cases is direct, and the most conservative of writers say that it is prolific in its tendency when intellectual or emotional strain exists. " A mere physiological hyperemia of the brain, under the use i BXCBSSES. 213 of alcohol, may become pathological and determine the onset of paresis" (Dercum). In a table prepared by Mickle from Reports of the Commissioners in Lunacy (England), by far the highest percentage (21.4) was attributed to intemper- ance in drink. Some other statistics give as high as thirty per cent Of sexual excess, there has been some confusion as to the excess producing the disease and the excess which is a common early symptom of the disease. It is an early symptom in some cases, as are many of the irregularities of the life in the early stages of the malady, but usually this as a symptom continues only a short time, while, if the facts can be secured in very many cases, a history of earlier excesses will be found. It is recognized as an exhausting cause and in conjunction with prolonged anxiety, or exces- sive emotional strain, or even exhausting physical work, it tends to bring about the conditions of the disease. Savage sums up his researches thus : " Gen- eral paresis usually arises from a combination of causes, the most common direct cause being excesses of all kinds, whether sexual or alcoholic, which act more powerfully when associated with strain, worry and anxiety." GENERAL PARESIS IN WHICH EXCITEMENT AND EXCESSES PLAY A PROMINENT PART. A case of this nature presented expansive ideas and pro- jects, great restlessness and some excitement with moral defect, the physical symptoms being obscure. After three months an abatement of the conditions occurred, so that some of his friends insisted that a mistake had been made in diagnosis and he was set at liberty. But he soon plunged into a life of speculation, became indecent in lan- guage and lascivious in conduct, and died in less than 214 ETIOLOGY. three years of general paresis. (Abstract, Steams, of. cit.^ p. 509.) A CASB OF GENERAL PARESIS, THE RESULT OF INTEM- PERATE PARENTS. A boy, aet. 16, showed progressive paralysis, with com- plete fatuity and great emaciation, also contractures. He was in a very demented state a year before death. Father was English, mother Italian ; both very intemperate. Par- ental neglect and semi-starvation were prominent features in the case. (Abstract, Wiglesworth, Journal of Mental Science, Vol. 39, p. 367.) Toxic Agents. — Aside from the toxin of syphilis, that takes so important a role, as a causative factor in the disease, there has been of late years a tendency among many of the best neuro-pathologists to accept the theory, which was first put forth by