CHAPTER XVI. GENERAL PARESIS FOLLOWING ORDINARY INSANITY. (Part 1)

CHAPTER XVI. GENERAL PARESIS FOLLOWING ORDINARY INSANITY. General paresis seldom occurs in ordinary insan- ity, yet, as pointed out by Mickle, the operation of new agencies, or the aggravation of old ones, may light up general paresis in a chronic case of insanity. general paresis with PERIODS OF MANIACAL EXCITE- MENT ALONE FOR SEVERAL YEARS. G. G., aet. 36. Irish, drunken and hard-working, mar- ried. He had an attack of ** acute mania" in 1876, was sent to the asylum and ** recovered" in five weeks. No evidences of general paralysis were noted. Again in 1878 he had a similar attack, but no diagnosis was made, al- though some suspicion of the disease was excited, and it was only after his third admission in 1879, that the disease was fully manifest. He died with it in 1882. His wife showed that he was weakened intellectually after his first attack. (Abstract, Clouston, Mental Diseases, p. 393.) GENERAL PARESIS WITH MANIACAL EXALTATION ALONE FOR MONTHS. G. H. was acutely maniacal, very dangerous, homicidal, impulsive, strong-willed and unmanageable for twelve months, before there were any motor symptoms that en- abled Clouston to diagnose general paralysis. From the state of his pupils and the expression of his face, he sus- pected it, but he could not say definitely it was any other condition than acute mania for the first year. (Abstract, Clouston, of^ cit.j p. 394.) 224 PARESIS FOLLOWING ORDINARY INSANITY. 225 GENERAL PARESIS DEVELOPING IN AN IMBECILE. M. Christian relates a case of general paresis in a man who, born in 1824, was under treatment from 1855 to i860 by Calmeil as an imbecile. His friends assumed the care of him until 1878, when he again became disturbed, having delusions of persecution and manifesting marked mental enfeeblement. Cerebral congestions became frequent and general paresis appeared and followed a usual course. (Abstract, American Journal of Insanity, Vol. 37, p. 449.) DEVELOPMENTAL GENERAL PARESIS IN A CONGENITAL IMBECILE. Margaret C, first admission, aet. 17, had no relatives to tell her history, but was regarded as a case of congenital imbecility. She was said to have been insane for at least three years ; she was undersized, badly developed, with considerable mental enfeeblement. There was mild ex- altation ; when spoken to she usually smiled foolishly, said she felt fine, memory much impaired, no delusions, no motor symptoms. While in the asylum, she picked up a little, was slow in her movements, occasionally quarrel- some, liable to fits of rage or slight excitement, but gen- erally happy. After sixteen months, she was transferred to lunatic wards of poorhouse and then boarded out in the country. Readmitted to asylum three years after dis- charge. During this time, almost nothing could be learned of her condition. She remained fairly quiet and manage- able, but mental enfeeblement had steadily progressed ; she became very weak in body, could not stand, some paresis of right side and considerable difficulty in swallowing. Her mind was almost a complete blank ; she seldom spoke, voice monotonous and tremulous, lips and hands tremulous. The disease had reached a very advanced stage. She died ten days after admission of pneumonia in a phthisical lung. The case was not thought to be general paresis until post- mortem. (Abstract, Middlemass, Journal of Mental Science, Vol. 40, p. 37.) 226 PARESIS FOLLOWING ORDINARY INSANITY. A CASE OF GENERAL PARESIS RAPIDLY FATAL. THE PATIENT HAD RECOVERED FROM AN ATTACK OF INSANITY SEVEN YEARS BEFORE. E. G., married, set. 33 ; grandfather melancholy, parents healthy. The supposed cause of this attack was anxiety about money matters. There was a history of a previous attack of insanity, seven years before, with complete re- covery. This attack began with hesitation in speech, great incoherence, sleeplessness, and refusal to take food. He fancied his shop assistants were being starved, and that people were removing goods without payment. He was found on admission to be weak, nervous and restlessly ex- citable. In three months, he was very feeble on his legs and hard to understand due to thick speech. Later he had a convulsive fit, from which he recovered, but remained in a half dazed condition. There was no special paralysis but great exaggeration in reflexes four months after admis- sion. He was found one morning, unconscious, head turned to right, conjugate deviation of the eyeballs to right ; pulse 170, respiration 55, temperature 105^; right pupil slightly larger than left ; loss of power of rectum and bladder ; Cheyne-Stokes breathing ; he sank into deep unconscious- ness and died. (Abstract, Savage, of. cit.^ p. 296.) GENERAL PARESIS PRECEDED BY ACUTE MANIA IN YOUTH. G. H. A. had an attack of mania in youth, recovered, kept well, and performed his ordinary business, and at the age of 44 became a general paralytic. (Abstract, Clous- ton, op. ctt.y p. 395.) HYSTERICAL INSANITY FOLLOWED BY GENERAL PARESIS. Woman, 33, an ordinarily violent, maniacal patient, somewhat hysterical ; duration of insanity given as two years. The symptoms commenced by hysterical crying and agitation. Only motor signs, exaggerated reflexes and hysterical shaking ; she gradually quieted down ; paretic symptoms some months later, were typical during her decline and death ; she died after one year and ten PARESIS FOLLOWING ORDINARY INSANITY. 227 months. (Abstract, Phelps, American Journal of Insanity, Vol. 53, p. 59.) GENERAL PARESIS SUPERVENING ON CHRONIC MANIA OF LONG DURATION. Jane M., aet. 40, Irish, occupation, domestic ; duration of insanity, many years ; diagnosis, chronic mania. History on admission, she had delusions of poison, and had haunted the Supreme Court for years, thinking she had a suit there. She improved physically, mentally she re- mained the same ; she was removed to almshouse. Read- mitted to asylum June, 1881, age 50, single. Excitable, very talkative, disconnected ; thinks she has been poisoned by a certain doctor, who would put her out of the way if he could, that he might not be found out ; that she has recovered a large amount of money from him on a suit ; that the British Government has given her $15,000 to-day, that she was to be married to a lawyer last night and that another gave $2,000 to have her arrested because he wanted to marry her himself. She is below medium height and thin ; right pupil small and inactive to light, left one more dilated, also inactive. Previous history : Always considered eccentric, not ordinarily intelligent; limited education, temperate habits, cheerful and frank. It is believed that a disappointment in marrying first caused her alienation. First decided symptoms observed twelve years ago ; delusion that she was going to marry some rich man ; she has grown thin and more demented, always harmless, happy and neat. October, 1881, marked delusions of hearing. She listens at the ventilators to peo- ple whom she thinks are talking to her. She says that her people are here ; she is quiet, tractable, neat. April, 1882, she continues to hear devils at times, and is noisy; she scolds incoherently and breaks glass. November, 1884, she walks the floor, listening to voices which come from below ; she is much demented. She says she has five gifts in her eye, that she must walk all the time and be fed on bread and water ; left pupil large and immobile, lens cloudy. March, 1892, no great change, except that she is more 228 PARESIS FOLLOWING ORDINARY INSANITY. demented and senile. December, 1892, she had two epi- leptic convulsions, and has become untidy. January, 1894, she has had a few epileptic convulsions, usually at night ; she is much demented. April, 1895, she is very demented and weak ; she walks about and often falls and hurts her- self ; she is good-natured, very untidy. No convulsions lately. April, 1895, she had convulsions two days ago and another last night ; she has been in bed for three days in a weak, confused way. August, 1895, pupils unequal, left dilated, both inactive to light ; articulation indistinct, knee-jerks absent, walk feeble. She stands without sway- ing with eyes closed ; feeble circulation, extremities blue and cold ; she is getting gradually weaker and more de- mented ; she died in October, 1895. (Abstract, Worcester, American Journal of Insanity, Vol. 52, p. 319.) THREE CASES OF GENERAL PARESIS AND CHOREA. In the first case, the patient had many attacks of chorea from infancy up to the beginning of his paresis at 33. In the second the paretic symptoms only partially aSected the choreic ones. In the third case, the choreic move- ments were rhythmic or localized in a member in the form of paroxysmal attacks like the movements and contractions of Jacksonian epilepsy. (Abstract, Vallon and Marie, American Journal of Insanity, Vol. 51, p. 233.) Remissions. — In some cases remissions occur, usu- ally in the first or second stage of the disease, lasting from a few weeks to several months; even after a lapse of many years the disease has been known to return, but the average duration of a remission is from two to four months. A remission marks a ces- sation of active disease for the time, and many of the S3^mptoms disappear, but the disease is not eradi- cated, only quiescent, and is certain to reappear, usu- ally in a more active form. Some patients during a remission ^improve in mind and body equally; in REMISSIONS. 229 others the improvement in mind is noted without corresponding motor improvement. Remissions have been known so complete that every motor symptom disappeared and the mind seemed as clear as in health; these at times have been pronounced cures, but generally it is believed that the disease does not let go its hold on the system and that it is sure to return, sooner or later. Bland- ford says of some such seeming cures: *^ These cases would be pronounced sane by any jury. They have either lost their delusions, or are able to conceal them. I have received letters from such written without a mistake. But those who had best recovered are long since dead, and I know of no one whose disease did not reappear in a longer or shorter time." Remissions may occur at any time in the progress of the malady, but they shorten in duration as the disease advances. During these periods of cessation every trace of maniacal excitement and emotional display may cease, but some delusion frequently con- tinues; or a slight tremor of the lip or hand, an inequality of pupils, some defect in speech, or in gait generally remains. If every other mental trace dis- appears, there sometimes develops some moral or esthetic eccentricity, i. e., purposeless lying, irritability of temper, extravagance in buying; or the only sign of disease may be a stolid or troubled expression. The patient is apt to grow stout in body and become more feeble in cold weather. Frequently the patient feels well; he converses intelligently, his interest in business returns and he desires to resume his former life. But if permitted to return to his occupation he soon becomes con- scious of a weakness in continued mental effort, or if it be manual work he finds the bodily vigor does not return, and in either case he soon breaks down. ao 230 GENERAL PARESIS. It IS agreed that the enfeeblement of mind is incom- patible with perfect responsibility; that under the best conditions the engaging in business should be dis- couraged; that only quiet surroundings, free from ex- citement and anxiety, should be provided. Medical care and treatment should continue during the remis- sion, and a nurse or some responsible person should keep constant supervision, for the disease will surely appear again, and frequently its reappearance is marked by an outburst of excitement or violence, or by an epileptiform seizure. GENERAL PARESIS WITH MARKED REMISSION. A commercial traveller, with a history of drink, was ad- mitted with all the physical and mental symptoms of general paresis. He went into a stage of complete paralysis and then recovered so that he took a situation again at £300 a year : he held it for eighteen months, returned to asylum and died in a short time of general paresis (Whitcombe). REMISSION OF EIGHTEEN MONTHS IN SEA CAPTAIN. A captain of a steamer came to asylum in a maniacal state. After a few months of this excitement, with exalta- tion, he quieted down and seemed to recover perfectly ; he had no tremor or other signs of general paresis, although paresis was suspected. He commanded a ship eighteen months and the only difference noticed in him was that he was more placid and complaisant than formerly. He returned to England and rapidly broke down ; he became demented, had extreme tremor and in two months died of epileptiform convulsions. (Abstract, Whitcombe, Journal of Mental Science, Vol. 37, p. 487.) A REMISSION OF THREE YEARS OR MORE. A man, act. 31 ; after some eccentricities became mani- acal, with much exaltation, extravagant boasting, letter writing to the queen, masturbation, self-decoration, etc. In two years this condition subsided and he became taciturn REMISSIONS. 231 and hypochondriacal 9 with loss of expression, thickness of articulation, fibrillar tremor and incapacity, for exertion. These symptoms vanished and for three years he has been in constant and responsible employment. (Abstract, Mortimer, Alienist and Neurologist, Vol. 10, p. 489.) A MARKED REMISSION AFTER THREE YEARS' DURATION OF THE DISEASE. Man, with well-marked symptoms of general paresis. The disease went on for two years and he nearly died of general convulsions but after a time began to improve ; he remained in asylum three years, then went abroad and when heard of some years later was still well. (Abstract, Rayner, Journal of Mental Science, Vol. 37, p. 487.) A REMISSION IN A MEDICAL. MAN. A medical man had marked symptoms of general par- esis, who had taken alcohol and all kinds of drugs. Gradually the symptoms passed away, he was discharged and two or three years after, he was again a ** dispenser." (Abstract, Rayner, loc. cit.y p. 488.) GENERAL. PARESIS WITH REMISSION OF SOMATIC SYMPTOMS. A case in which, during periods of excitement and even in conditions of exaltation, the somatic symptoms, which at the best were very slightly developed, seemed wholly in abeyance. Competent experts could not be certain that it was general paresis, though it proved to be so. (Abstract, Stearns, op. cit,^ p. 512.) A REMISSION OF MORE THAN THREE YEARS. Patient, act. 32, had been very restless and talkative, boasting of his riches and adventures. His account of his life was incoherent and contradictory. At the hospital he was singing and shouting and very destructive ; eight months after admission he had a paroxysm of maniacal violence. On admission, he had numerous exalted delu- 232 GENERAL PARESIS. sionsy was king of the world, brothers were kings, could do whatever he tried, etc. ; speech thick, and articulation at times difficult; his gait very unsteady ; temperature 98^ in the morning, and 99° in the evening. He was under treatment for a year when he began to improve and the exalted delusions passed away. The thickness of speech and difficulty in articulation remained, although in a less degree, his legs still were weak. He remained under observation for another year when he was discharged. He kept well for over three years when he disappeared from observation. (Abstract, Bucknill & Tuke, Psycho- logical Medicine, p. 330.) A REMISSION OF THREE YEARS. THE PATIENT RETURNED TO BUSINESS. In one case, which has since been running rapidly a downward course, the remission lasted three years, during which time he attended to extensive commercial under- takings with fair success and took charge of several assign- ments. (Abstract, Spitzka, of. cit.y p. 215.) A REMISSION OF FIVE YEARS' DURATION. Patient admitted, supposed to have general paresis ; maniacal excitement, inequality of pupils, blurring of speech, alteration of handwriting and knee reflexes af- fected. At the end of a year he had serious convulsions, with temporary loss of power on left side. He improved very much mentally and became apparently well but re- mained as a voluntary boarder until a few weeks ago — over five years. Then he became excitable ; handwriting changed, left out words and letters. He is occasionally wet and restless ; he is unmanageable, tumbles about, and he has exalted ideas and schemes. (Abstract, Whitcombe, loc. cit.y Vol. 37, p. 487.) A CASE OF GENERAL PARESIS WITH A REMISSION OF MORE THAN NINE YEARS. The patient had usual delusions, twitches of facial mus- cles, tremor of upper lip, thick speech, and weakness of REMISSIONS. 233 the knees, and was violent and destructive. He gradually calmed down, became quite rational, and lost all abnormal symptoms, except the tremor of lip and slight thickness of speech. He was ill for three months and was kept under observation six months before he was discharged. He is still alive, nine years since discharge, and draws his pension regularly. (Abstract, Bucknill & Tuke, op. cit.^ P- 330-) A COMPLETE REMISSION OF LONG DURATION. A patient had been transferred to an asylum eleven years before, certified to be suffering from general par- alysis. There was nothing which militated against such a diagnosis except that the man gradually improved, was discharged and for years after supported himself by his handicraft. (Abstract, Blandford, of, cit.y p. 307.) A remission more or less prolonged sometimes fol- lows fracture, abscess, erysipelas or some other inter- current disease or episode. GENERAL PARESIS WITH IMPROVEMENT FOLLOWING CARBUNCLES. A man with general paralysis, who had been in the asylum three years, developed three carbuncles and was expected to die, but is now getting better. (Abstract, White, Journal of Mental Science, Vol. 37, p. 488.) REMISSION AFTER A LARGE CARBUNCLE. Hurd, H. M., has reported a case of remission after the patient had had a large carbuncle over the cervical verte- brae. (Abstract, Stearns, op, cit.y p.