CHAPTER XVI. GENERAL PARESIS FOLLOWING ORDINARY INSANITY. (Part 2)

508.) GENERAL PARESIS IN WHICH MARKED IMPROVEMENT FOLLOWED ABSCESSES. A man had passed through the early stages and his friends were awaiting his death. It was a question whether to let him die as he was or to evacuate three or four ab- scesses which he had. It was decided to evacuate them. 234 GENERAL PARESIS. and he at once improved and has remained in a somewhat weak-minded condition for about six years. He can now play tennis well. (Abstract, Savage, Journal of Mental Science, Vol. 37, p. 488.) A CASE OF GENERAL PARESIS IN WHICH A MARKED RE- MISSION OCCURRED AFTER AN EXTENSIVE SLOUGH. Male, aet. 40 ; married ; native of Michigan ; formerly hotel proprietor and of average business capacity. His mother was intemperate and her family subject to phthisis. He was also intemperate, reckless in his expenditures and led a fast life. After marriage, he reformed but did not suc- ceed in business. There was no history of syphilis. After two years of mental infirmity, he was admitted to asylum. At first, he had been depressed and indifferent to business. After a year, he developed delusions of grandeur. His bodily health improved, while his mind grew weaker. Pre- vious to admission, he had remained in bed for several weeks and had shown a great tendency to sleep. On admission, he weighed one hundred and seventy-seven pounds ; height medium ; bodily health fair ; pupils contracted and right larger than left ; skin dry ; articulation thick and in- distinct ; temperature 99^ ; great ataxia ; expression dull and heavy ; fine facial lines absent ; replied to questions in a drawling way and often his replies were irrelevant ; he had delusions of grandeur and he thought himself in perfect health. One month after admission, he was depressed, and sat quietly alone, apparently reading. He showed stupidity and torpor, was dull, anxious to go to bed and would fall asleep even while eating. Extreme debility and paresis were present. He required constant personal attention. His articulation was clumsy and his voice weak. His condition passed into elation. He became mischievous, threw clothing from the window, appropriated others' property. On January 6th, about a year after ad- mission, he had an apoplectiform seizure, with choreiform movements of the head, twisting of the mouth, protrusion of the tongue and tossing of the arms. The axillary tem- perature was 103^ ; pulse rapid ; pupils contracted. Tenth, I REMISSIONS. 235 continues fairly comfortable in bed, with no convulsive move- ments. He is eating well and feeling ** first rate." Four- teenth, he sits up and pretends to read a paper. Twenty- first, he does not recognize an old acquaintance. He is very untidy. February, he is able to be about ; quiet ; very feeble in mind ; inclined to sit alone ; inappreciative of what is said to him ; gait feeble. He has sudden im- pulses to do violence. His handwriting is totally illegible. March, he is again elated and extravagant ; he forms strange intimacies and promises feeble-minded patients work at immense wages. During April, he had rheumatoid affec- tion of the joints. He was confined to bed and grew de- bilitated. There was tendency to engorgement of the right lung. May, he is able to be about. June, he is better mentally than at any time since coming under treatment ; quiet, appreciative, and able to care for himself ; attends chapel and entertainments ; he is neat in dress ; he shows a disposition to assist in work ; he can remember names. The improvement followed the formation of a large gan- grenous slough on the left heel. His articulation and gait are much better. He can write legibly. He is able to write letters ; mind is quite clear ; he is contented and cheerful ; he has no delusions. August, he thinks himself well enough to be discharged but is not strenuous about going away. His writing improves. September, he is industrious and pleasant; enjoys the freedom of the grounds ; plays croquet. On November 25 he was re- moved by his wife on trial. She regards him as well. His mind is not strong but the progress of the disease seems arrested. After his return home, he took care of horses. He had limited endurance, but could contribute materially to his family's support. Thirteen months after his dis- charge, he was in good flesh and seemed as well mentally as when he left the asylum. He has been working more or less ; he shows a pleasant interest in the institution ; re- cently he has experienced pain in the heel on which the slough appeared. Present condition about two and a half years after discharge — he has improved mentally ; he has been out of employment but a few months since he left the 236 GENERAL PARESIS. asylum ; except for catarrh, he is in good bodily health ; weight 165 pounds ; no paresis in speech or gait ; hand- writing regular ; he has full control of a livery stable and earns good wages ; he keeps his books accurately ; and he has good memory for remote and recent events. His dis- position has changed. He used to be irritable and quick- tempered, but is now always good-natured. His habits are temperate and regular. (Abstract, Burr, C. B., Ameri- can Journal of Neurology and Psychology, 1884.) Duration. — It is difficult to mark a general average in the duration of this affection, for many factors combine to effect its progress. The special form taken by the disease in any case has probably the greatest influence as to the length of time required for it to run its course. The so-called ascending form, /. e.y when the spinal cord is affected first, is slow. If brain and cord are attacked at the same time the duration is usually short. Cases with expansive or exciting delusions proceed with greater rapidity than those of the depressed form. Again the average course of the disease is longer in women than in men, in those who have lived a life of comparative comfort than in the poor, and in hereditary cases than in those not hereditary. All factors of a violently disturbing nature hasten the end, while all quieting influences such as the environment of isolation, cessation of business trials, and absence from home cares tend to prolong the life. Perhaps there is no factor which modifies the duration so largely as remissions, which may vary in length from a few weeks to many months. One of the difficulties of determining the duration is frequently the impos- sibility of fixing the time at which the disease actu- ally began. The prodromal stage may run but a few months, sometimes a few years, and it is said in very exceptional cases that it may last nearly a life- DURATION. 237 time. Archer gives the order of duration ascending as follows: Cases marked by excitement, by depres- sion, by uniform dementia, by alternating excitement and depression, and by apoplectic attacks. The disease is progressive and if uninterrupted by remissions, or other favoring circumstances, the patient goes steadily down to death, probably before two years from the time of the established disease. It is said that more patients die under two than over five years after attacked, but cases have been pro- longed to ten, or even fourteen years or more; how- ever, a case lasting ten years is very unusual. Clous- ton says : " So far as I am aware, no case with every mental and bodily symptom of general paresis, and diagnosed by many competent and experienced specialists to be such, ever lived so long as thirty years." Blandford gives an account of a patient, who lived twenty-seven years. French authors regard the average as less than two years, and some English writers place it at twenty-two months. Dercum says : " Males generally die within two or three years, females within three or four, while the great majority of all cases die within five years. Nothing more definite can be said than that the end may come within a few weeks after inception, either from maniacal exhaustion, a cerebral seizure, or decline of vital powers, or it may be prolonged; some- times the patient is relieved by weeks of comparative freedom from disease, but it may be that he drags out weary months of continually increasing helplessness in both mind and body. A CASE OF GENERAL PARESIS OF LONG DURATION. A. B., act. 55, merchant, no history of syphilis; tem- perate ; insanity on maternal side of family. The family noticed, ten years before his death, that his speech was 238 GENERAL PARESIS. clumsy and unintelligible, his walk was uncertain and hands unsteady. He made expansive statements as to his business ; showed less restraint in the use of money ; became very social ; showed anxiety for nothing. Two years later, a diagnosis of paresis was made. The patient continued in business and, except that he began to lose in- terest in his affairs, no further mental symptoms developed. Speech was jerky and scarcely intelligible ; movements of upper and lower extremities became very ataxic so that he was scarcely able to feed himself or walk without assistance. Examination during the last five years of life showed ex- cessive tremor of tongue and muscles of face ; ataxia and tremor of arms with ataxia and exaggerated reflexes in legs ; pupils normal ; speech more unintelligible ; had maniacal and epileptic seizures several times a year. (Abstract, Fisher, E. D., Journal of Nervous and Mental Diseases, Vol. 18, p. 824.) GENERAL PARESIS OF LONG DURATION. Savage gives a case of general paresis of long dura- tion which was marked by severe convulsions, recurring during the greater part of the disease. Death occurred at the end of nine years. A CASE OF PARESIS OF FOURTEEN YEARS* DURATION. Brush and Sinkler conjointly report a case of gen- eral paresis of fourteen years' duration. It was marked throughout its course by numerous epileptiform convulsions. (Abstract, American Journal of Insanity, Vols. 45 and 46.) GENERAL PARESIS OF LONG DURATION. M. Lapointe observed a case of general paralysis of unusual duration in which the cardinal symptoms had grad- ually disappeared and had been replaced by simple de- mentia. The autopsy verified the diagnosis after the dis- ease had lasted fifteen years. (Abstract, Journal of Ner- vous and Mental Diseases, Vol. 24, p. 314.) PROGNOSIS. 239 A CASE OF GENERAL PARESIS OF LONG DURATION, A patient who had general paralysis for sixteen years was a typical case, with periodical attacks of violence, sending telegrams continually, writing in a general par- alytic style. (Abstract, Briscoe, Journal of Mental Sci- ences, Vol. 53, p. 883.) A CASE OF GENERAL PARESIS OF LONG DURATION. Lapointe related a case of general paresis lasting for twenty-five years, the diagnosis being eventually con- firmed by post-mortem examination. (Abstract, Journal of Mental Science, Vol. 43, p. 383.) A CASE OF GENERAL PARESIS WITH A LONG PRO- DROMAL PERIOD. A baronet, who had shown symptoms of brain affection and epileptiform attacks, so far back as 1856, lived until 1883. (Abstract, Blandford, op. cit.^ p. 299.) Prognosis. — The prognosis is uniformly unfavorable. It is regarded as one of the most fatal of diseases. According to Ziehlen some years ago there were but a dozen cases of recovery on record. Spitzka gives an account of one, a rheumatic patient whom he treated five years after his discharge, and was unable to find any trace of general paresis in him. Another instance he records of a general paretic in Australia, who had escaped from the asylum, and five years later paid them a visit to show that he had recovered. Other authors report a few cases whose histories were followed for from six to ten years after discharge and no relapse had occurred, but one of these same authors expresses his doubt as to their having been genuine cases. It is the opinion of some writers that these and similar ones were not cases of true recovery. When death comes within two or three years after discharge the belief by them is that the patient dies 240 GENERAL PARESIS. in a period of remission, and had he lived a little longer the disease would inevitably have returned, for from its nature it is necessarily progressive and fatal. Blandford says, " patients are dying of it (paresis) in all the asylums by the hundred yet the best authorities record no recoveries." A few cases of severe injury, or intercurrent disease, have been known to cause a form of recovery but it is after all only an arrest of the progressive enfeeblement, and the mental defect in time goes on. Remissions offer a ground of hope, but in a great number of cases they are rare, and after each remission the disease re- appears in a more intense form. General paresis is thus far one of the most unfavorable forms of insanity as regards recovery and the duration of life. SUPPOSED RECOVERY. Simon cites the case of a patient who had a remission and remained well for twenty-five years. A CASE OF GENERAL PARESIS WITH MARKED REMISSION, AFTER SUPPURATION THAT RESEMBLED A RECOVERY. D. Mc, married, aet. 50, railway agent, no insane in- heritance, the first attack of insanity requiring seclusion, although he had been peculiar for years before. Cause, over-work ; sober, industrious ; no syphilis ; first symptoms were excitement, incoherent, rambling conversation, exalted ideas of wealth and station ; benevolent, thought he had a secret which would benefit the human race. On admission he talked incessantly, with wild exaltation ; he was sleepless, haggard, restless, and unable to stand still for a minute. He was treated with hyoscyamine without benefit, was in- coherent ; left pupil large ; speech hesitating ; took several hours to finish a short letter ; wet and dirty at times, mem- ory became worse. In three months he had a huge car- buncle on back of his neck ; no sugar in his urine. After the carbuncle, his symptoms improved. He was discharged TERMINATION. 24I well in five months' time. Some months later, he was al- lowed to manage his own affairs. He is now under treat- ment for anomalous paralytic symptoms, supposed to be due to syphilis, but is without mental disorder four years after discharge. (Abstract, Savage, of. cit.^ p. 322.) APPARENT RECOVERY FOLLOWING EXCESSIVE SUPPURATION. In the only case of general paralysis that Savage says he ever saw, which apparently recovered, one symptom -—cranial nerve paralysis — pointed to syphilis, though there was no other proof of the disease. The man got well and remained well for years, but died of obscure nervous disease, which was looked upon as specific. In another case with specific history prolonged remission has occurred and in both of these cases, excessive suppuration was the immediate cause of relief. (Abstract, Savage, of. cit.^ p. 322.) A CASE OF PARESIS WHICH PRACTICALLY RECOVBRBD. A patient with typical symptoms of general paralysis, after six or eight months' treatment, was discharged on leave. After a year's leave of absence he was in command of a ship and his former employers could detect no loss whatever of his faculties. (Abstract, Savage, loc. cit.^ Vol. S, p. 402.) APPARENT RECOVERY FOLLOWING A CEREBRAL SEIZURE. Recovery occurred after an apoplectiform attack in a case of Schules. (Abstract, Spitzka, op. cit.^ p. 216.) Termination. — Death may come in one of many forms to terminate the course of the disease. It may come suddenly, in an apoplectiform or an epileptoid seizure, in paralysis of the heart, or even in choking, or the end may be hastened by tuberculosis, pneu- monitis, edema of lungs, acute intestinal, renal or vesical troubles, deep bed-sores, septic infection. 242 GENERAL PARESIS. or by embolism, erysipelas, phlegmon, suicide or trauma. Extended dementia, or the alternating form of paresis, may prolong the duration, and the end come, finally, from simple exhaustion due to the general disease. Cases strongly hereditary run a longer course, and, as has been said, remissions sometimes postpone for years the fatal termination. "The dis- ease is special," says Savage, " in so far that it ends fatally in nearly all cases, and in almost always the same way; and that, whatever the earlier symptoms may have been, the later ones are similar to a re- markable degree." GENERAL PARESIS, DEATH IN THE MANIACAL STAGE ; DURATION ABOUT A YEAR. F. C, act. 40. Surgeon in Indian army; was in the massacre of Cawnpore, escaped and underwent many risks and hardships. Some time afterwards, his friends wrote that he was much altered in behavior, subsequently, that he had a sunstroke. Ten years later and a year before admis- sion he was induced to come to England ; on the voyage he behaved curiously ; also, his wife died, an event which seemed to excite him very much, and his behavior called for the interposition of the ship's authorities. On his arri- val, his youngest child died. At home, he would carry his children around on his hip in the Indian fashion, calling on acquaintances and talking in an excited manner ; he be- haved strangely to his mother's servants, whom he alarmed. He invited women whom he met at night into his mother's house. Condition on admission : Five feet ten inches high, defective vision, some obliquity of the balls, and amaurosis of left eye ; dark complexion ; he has hemorrhoids and is subject to prolapsus ; good pulse, no difficulties of digestion or chest signs. He talks incessantly about himself, his plans which he continually changes ; he talks to everyone he meets, to his servants of his own affairs, which are of Utopian character; he has marked elation of spirits and TERMINATION. 243 feebleness of intellect; he