CHAPTER XV. ETIOLOGY. (Part 4)

Angiolla, that general paresis is a toxic affection produced by auto-intoxication, either directly or indirectly, through an interference with nutrition. It is in this malign way that lead (Kierman et al^ and tobacco (Guis- lain et al.) are supposed to act in the few cases that now and then are ascribed to these agencies as the ex- citing cause. According to these observers the bane- ful influence of alcoholic abuse and licentiousness, as well as mental overstrain, is to be sought also in these nutritional defects that contaminate the blood with poisonous products, which induce the degener- ative changes in the nervous tissues. Injury to the Head. — Trauma of the head is recog- nized as a cause of general paresis. In the four thou- sand two hundred and eighty-four cases collected by Mickle two hundred and eighty were attributed to such injury. Probably a large number of the cases with little mental derangement, found for the most part in general hospitals, are those which result from this cause. INJURY TO THE HEAD. 215 Dercum^ gives this theory in explanation: "Con- cussion of the brain seems to lessen its power of resistance, perhaps affects directly the vaso-motor control of its larger vessels and thus predisposes it more readily to attacks of congestion. It is very probable that sunstroke acts very much as does con- cussion of the brain, namely by predisposing the organ to hyperemia and by lessening its power of resistance.*' In ninety-seven of the above cases given by Mickle, sunstroke was the assigned cause. In cases of trauma paresis may follow at once, but more frequently, it is years before the disease appears and then it is a gradual development. GENERAL PARESIS FROM INJURY TO THE HEAD. One was a man in the dock yards, the other a butler. Both immediately developed general paresis. A predis- position already existed, the blow being an exciting cause. (Abstract, Rayner, Journal of Mental Science, Vol. 37, p. 488.) A CASE OF GENERAL PARESIS FROM A BLOW ON THE HEAD. An engine-driver at the Hullborough Asylum six years before admission had a fall on the back of his head ; he had not been the ** same man " afterward. He became irritable, especially with his children ; threw knives at them and tried to stick needles into their eyes. When he came to the asylum he was unsteady in his walk, which he attributed to ** a stroke." Fifteen months afterwards he was far advanced in general paresis ; his gait was bad ; his articu- lation drawling; pupils unequal. He said he was *^all right," but thought that some one had taken him out of bed during the night and set fire to it. (Abstract, Bucknill & Tuke, Psych. Med., p. 313.) > Nervous Diseases, p. 670. 2l6 ETIOLOGY. A CASE OF GENERAL PARESIS RESULTING FROM FALL ON HEAD. C. H., aet, 56 ; fall on vertex some time before admission ; insane immediately on receipt of injury, lasting four weeks with maniacal excitement. Present attack six months pre- vious to admission. He was intemperate ; pupils irreg- ular ; he showed ataxic articulation and expansive ideas, and general tremor with characteristic physical condition ; apoplectic seizures seven months after admission ; death from exhaustion fifteen months from onset of disease. (Abstract, Neff, American Journal of Insanity, Vol. 53, p. 41.) A CASE DUE TO INJURY OF HEAD. L. T., 53, moderate drinker, injury to head four months before development of disease ; unconsciousness for a few hours ; acute delirium for ten days. Immediately after- wards mental confusion, loss of memory, mental enfeeble- ment, apprehension, expansive ideas, ataxic gait, occipital headache, paresis of arms and legs, aphasic and hesitating speech ; he had a fair realization of his condition ; psychical symptoms increased. One month after admission, he had general clonic convulsions, terminating in paresis affecting arms and legs. Respiration embarrassed ; patient died of asphyxia. (Abstract, Neff, loc. cit,^ p. 41.) INJURY TO HEAD THE PREDISPOSING CAUSE OF GENERAL PARESIS. A man who had an injury to his head, became insen- sible, recovered and remained well for two years before symptoms of paresis set in. (Abstract, Mickle, vide Sankey.) PARESIS FOLLOWING INJURY TO HEAD OF LONG STANDING. The history of a case of general paresis showed that the patient had had an injury to his head many years before, and he bore the marks of cicatrices. (Abstract, Sankey, op. cit.^ p. 287.) INJURY TO THE HEAD. 217 GENERAL. PARESIS CAUSED BY THE FIRING OF A LARGE GUN. A case of paresis was caused by the firing of a twenty- five-ton gun close to which he was standing. He had ex- alted delusions on admission, declaring that when he shook his fingers, gold dropped from them. After becoming quieter, more rational and his memory having improved, he fell into a state resembling catalepsy. About 6 A. M. of each day, he would pass into a condition of perfect stillness, lying flat on his back, not moving a muscle ; this con- tinued until 3 A. M. the following morning, when he gave signs of life by speaking to the attendant and swallowing food placed into his mouth. At 6 A. M. when the stage of stillness was coming on, he would perspire profusely, this gradually diminishing as the day wore on. His morning and evening temperature rose during this period and once or twice slight twitches were observed. He was apparently quite unconscious, pupils sluggish, sensation and motion suspended. When this periodic condition finally passed off after a month's duration, he was comparatively rational and had lost his more prominent delusions. Four months after, these delusions returned and the disease steadily pro- gressed. On awakening to consciousness in the morning he was evidently under the influence of hallucinations of hearing. (Abstract, Bucknill & Tuke, op. cit.y p. 315.) CASES OF PARESIS FOLLOWING DEAFNESS, MOTOR NERVE ATROPHY AND TRAUMATISM OF BRAIN. (i) G. B. A. became stone deaf in one ear several years before he developed general paralysis. Clouston believed the case was one of propagation, though he had no patho- logical proof of it. The patient was a medical man and thought that the symptoms of general paralysis which fol- lowed were due to the extension of the disease of his in- ternal ear into the brain. (2) Professor Laycock used to quote a case of his where the disease had spread upwards from a Wallerian atrophy of one of the motor nerves of one of the fingers. (3) G. D., a woman of 36, passed gradu- 2l8 ETIOLOGY. ally into quiet non-delusional general paralysis after a small punctured wound due to a pitch-fork in the top of her head) penetrating for about an inch into the brain. After death 9 all the convolutions of the cortex were affected, especially around the wound. (Abstract, Clouston, Mental Diseases, p. 390.) Epilepsy. — Epilepsy is not a common predisposing cause of paresis, but its action on the brain, inducing intense cerebral congestion, does undoubtedly result in paresis at times, and the clinician should be aware of this occasional mode of development. Epilepsy which may be the cause of paresis, must not be confounded with the epileptiform attacks which are episodic in nature. Mendel gives two cases of paresis, one of a man of thirty-five, who had been epileptic from fourteen to twenty years of age, and the other of twenty-eight years of age, who had been epileptic from his eighth to his thirteenth year. GENERAL PARESIS IN AN EPILEPTIC. A commercial employ^, 33, had been an epileptic. He lost his wife soon after marriage, causing him deep grief. He died of paresis in asylum three years after admission. He did not have an epileptiform attack in the asylum. (Abstract, Christian, American Journal of Insanity, Vol. 44, p. 498.) GENERAL PARESIS DEVELOPING IN AN EPILEPTIC. J. N., male, act. 32; native of Ireland; inmate of the asylum for nearly five years ; had been formerly epileptic, but not so latterly. His head was very large and, phren- ologically, well formed. He was very quiet and childish ; his general health feeble. Three weeks before death he complained of pain in various parts of his body and was confined to bed. On the day before his death, he had a fit of syncope, from which he soon rallied but showed .NEHAI. F'AKESrs FOLlOWINd ITI'lLIil'SY. EPILEPSY. 219 difficulty in breathing and depression. A few hours after he complained of pain in the lower part of his chest and died on the following morning. (Abstract, Workman, loc. cit.^ Vol. 13, p. 18.) GENERAL. PARESIS IN WOMAN. — HISTORY OF EPILEPSY. DURATION TWO AND A HALF YEARS. K. W., a mistress, set. 28, fair education, formerly a lady's maid. Admitted in August. She had been sub- ject to epilepsy from the age of 9 to 12 ; father and uncle epileptic, and died imbecile; ^^ on the fits leaving her she became altered in disposition," probably at puberty. She was always of a haughty, ambitious character ; left service and was kept in luxury by a gentleman for some years ; afterwards was left for six months, but still supplied with means ; supposed to have become addicted to drink, became invalided and for a time was ill, nature of illness uncer- tain, had to part with all her goods ; was maintained by her female companions ; drank more and was at times muddled for a whole week together. Gradually became affected in mind, excited at times, talked to herself, when addressed would not reply, restless, would dress and undress repeat- edly during the day, slovenly in her person, was taken to workhouse, where she was described as indecent in behavior, frequently exposing herself, talking to imagi- nary people, restless, said she had large property. On admission to asylum, not noisy, restless, answers questions in a whisper, talks to herself. Slept well, expression of vacancy and confusion, frowns and knits her brows, pupils equal and act well, does not know how long she has been in the asylum (came yesterday) ; cannot tell the day of the week, has no headache, very untidy in dress, tongue tremulous and clean, bowels not open since admission, no chest symptoms. Nothing peculiar in gait, pulse 80, she 18 pale, in fair bodily condition. First month, right pupil large ; she is occasionally violent ; walks with firm step. Second month, good bodily health, pupils un- equal; she cannot understand what is said, right ear swollen. Sixth month, drawling tone, violent at times 220 ETIOLOGY. and very noisy, walks well, but frequently falls as though her knees gave way. Ninth month, one morning she appeared to have lost use of left side, in afternoon walked with limp on left leg. Fifteenth month, more paralyzed, mind very imbecile, mutters unintelligibly, wet and dirty, swallows with difficulty, dejections passed unconsciously, sordes collected on teeth. Sixteenth month, pupil dilated ; she is unable to stand, rallied a little in mind, swallows rather better, conjunctiva injected, failed slowly to eighteenth month; both pupils became contracted. Death by exhaustion. (Abstract, Sankey, o^. cit.^f p. 322.) Physical Overwork and Strain. — Exhausting physical labor is to a certain extent undoubtedly an exciting cause of general paresis, especially when not coun- teracted by pleasant diversion, or by intellectual ex- ercise. This is particularly true when acting upon those in whom the nervous system has lost the elas- ticity of youth and its ability to respond after fatigue. If the condition of the system has been impaired by the use of alcohol, it is then especially susceptible to the effects of steady overwork. It is not the work that kills; seldom, perhaps never, does this of itself end in general paresis; but the endless monotony, the subjection to extreme heat, sudden changes of heat and cold, tend to wear on and weaken the central nervous system, and when this condition is associated with ill-regulated passions, strain, poverty, anxiety, or extreme disappointment, the brain falls a ready prey to paresis. GENERAL PARESIS INDUCED BY EXPOSURE TO COLD. The patient, a man, reached home, having been out in the snow all night and from this time had violent pains in his limbs. Two years afterward, his pains ceased and then he began to show symptoms of paresis. (Abstract, Chris- tian, loc. cit.f Vol. 44, p. 496.) INTELLECTUAL OVERWORK. 221 Intellectual Overwork, Anxiety, Mental Shock, Etc. — Intellectual work done judiciously should never injure. Even neurasthenia claims a lower percent- age of professional and intellectual men than those of other occupations. But forced intellectual labor, carried on with imperfect training, creates anxiety and uneasiness, continually weighs down the spirits, disturbs the sleep, wears with special force on the brain, and readily predisposes to paresis. Again, the early training may have been thorough, but if one is obliged to work under keen emotional strain, or excessive anxiety, especially if fatal re- verses threaten, the constitution must be strong and the control over self sufficient, if one is to escape from the ill consequences of such conditions. Paresis is well said to be the disease of civilization — the disease of mental stress. It is the worry rather than the work that does the damage. Savage says: " General paralysis occurs mostly in the anxious- minded, conscientious man, and as far as my expe- rience among the middle classes is concerned, it is rather due to overstrain than to overwork." Excessive worry and anxiety in one case may in- duce mania or melancholia, while in another paresis. Stearns refers to a table of six hundred and thirty- four cases of paresis, of which one hundred and six were attributed to " largely reverses in fortune, grief, anxiety, and distress arising from unfortunate social relations." Of Mickle's table, fifteen per cent, were assigned to mental anxiety, adverse circumstances, worry and overwork. GENERAL PARESIS CAUSED BY MENTAL STRAIN, WORRY, AND ANXIETY. An energetic manager of a successful business prose- cuted some workmen under him for want of performance 19 222 ETIOLOGY. of their duties. He failed to get a conviction, which led to a conspiracy of the workmen, and the result was that his life was rendered miserable by a system of threatening and intimidation. Sleeplessness, worry and loss of appetite were followed by the ordinary symptoms of general pare- sis. (Abstract, Savage, of. cit.^ p. 284.) GENERAL PARESIS FOLLOWING MENTAL SHOCK. A man acquired general paresis who suddenly found that his son had forged his name for a large amount. FOLLOWING MENTAL SHOCK. A widow lost her only child by a fever in ^ ievf days while traveling abroad. GENERAL PARESIS FOLLOWING GRIEF. A man returning from India, lost his wife during the voyage and a child directly after landing. FOLLOWING LOSS IN STOCK MARKET. A speculator in the stock exchange, on losing a very large amount of money, acquired general paresis. FOLLOWING GRIEF AND DISAPPOINTMENT. A widower, left with two sons, after carefully superin- tending their youth, found, on their coming of age, that they both threw off their allegiance and launched into extravagance and vice, one of them speedily drinking himself to death. The other began to follow the same course. The father acquired general paresis on the death of the eldest. (Abstract, Sankey, op. cit., p. 291.) GENERAL PARESIS FROM OVER-JOY. A hair-dresser's wife with a family of children had been in a state of destitution all winter. One morning her husband came home with the news that he had got permanent em- ployment and gave her a sovereign which had been ad- vanced to him. In the evening, he found that she had INTELLECTUAL OVERWORK. 223 spent the sovereign wholly in buying carpet-slippers which she said she meant to sell for a large sum. In this case the exciting cause was over-joy. (Abstract, Sankey, of. cit.y p. 291.) DISAPPOINTMENT THE EXCITING CAUSE IN A CASE OF PARESIS. A navy officer became engaged to the adopted daughter of a wealthy bachelor uncle who permitted the marriage on condition that the officer should give up his profession and live near him, he making them a handsome allowance. But the uncle married his nurse and changed his will so that, on his death, his niece was deprived of all her expec- tations and her husband developed general paresis. The actual catastrophy only acted as an exciting cause probably for the husband had amaurosis at the time. (Abstract, Sankey, op. cit.j p. 290.)