ItsCAUSESapparently lie in prolonged mental exhaustion and inattention to bodily health. I have been led to suspect syphilis as at least a predisposing cause.
TheCOURSE AND DURATIONof katatonia are tedious, and even if there is apparent recovery from the first attack, the tendency is to relapses and to slowly-advancing dementia and death from those causes of which dements in hospitals die, especially phthisis. I have never seen a complete and permanent recovery.
TheMORBID ANATOMYof katatonia suggests a deep-seated neurosis, the precise nature of which we do not understand. In terminal stages there are atrophy and degeneration and all that goes with them.
TheCLINICAL HISTORYof katatonia is so characteristic that it need be confused with the other diseases already mentioned as simulating features of it, and with the early stage of general paralysis, only through insufficient observation or too hasty diagnosis.
It is difficult to treat katatonia without the conveniences of a hospital.
PRIMARYCONFUSIONALINSANITYis a term recently introduced for a form of mental disease of which the most marked features are moderate fever rapidly developed, confusion, incoherence, and mild delirium. The onset of the disease is rapid. In some of the cases which I have seen the diagnosis was made of typhoid fever, although the clinical marks of that disease were absent, the general appearance of the patient in the two diseases being quite similar.
There is no real melancholia or exaltation, no rapid flow of ideas, and no dementia. Hallucinations of the special senses are common; there is a consciousness of illness; the delusions are unsystematized, and the confusion of ideas frequently goes to the point of not being able to recognize persons and places. The usual signs of fever are present for a few days, but the temperature rarely exceeds 102° F., and soon drops to nearly or quite the normal.
TheCOURSEof the disease is quite rapid, and if recovery does not take place in several weeks or a few months, chronic insanity with delusions or dementia of various degrees may be expected.
TheMORBID ANATOMYis not distinctive of this condition in the early stage, and we cannot yet differentiate it from simple fevers by the post-mortem. If ending in incurability, the atrophic and degenerative changes of chronic mental disease are found.
As regards removal from home, the considerations already referred to should be the guide. It is a good rule to keep the patient at home if a suitable one for the purpose, and to resort to the asylum in case of chronicity or troublesome complications.
PRIMARYDELUSIONALINSANITY(Folie systematisée, Verrücktheit20) differs from secondary delusional insanity in the facts that the disease arises primarily, and not secondarily to other mental diseases; that there is little or no mental enfeeblement in the early stage; and that the delusions, although fixed and systematized, are limited. It has the advantage of allowing the avoidance of the misleading terms monomanie of the French and monomania of English and American writers, the narrower forms of which may be included under the term primary insanity (primäreVerrücktheit), including the further developments of the neuropathic constitution, especially those with the physical marks of degeneration described by Sander as originäre Verrücktheit, and those marked by imperative conceptions and such delusions of self-importance, suspicion, etc. as seem to some people evidence of insanity, while by others they are considered as simply false beliefs not indicating mental disease. Unlike primary insanity, which is one of the states of mental defect and degeneration, and incurable, primary delusional insanity may occur in persons of healthy mental organization, and may end in recovery,21although it is one of the most distinctly hereditary forms of insanity, generally speaking.
20Called also by some writers Wahnsinn, although they use the term for secondary delusional insanity also.
21Some writers include both diseases under the term monomania, and make both incurable degenerative states, which is contrary to my experience. Clouston also has seen cures in what he calls monomania (primary delusional insanity) without the neuropathic taint.
There are several subdivisions of primary delusional insanity, according to the character of the delusions: (1) with delusions of unseen agency, suspicion, and persecution; (2) with delusions of personal exaltation; (3) with delusions transformed from sensations.
Delusions of unseen agency, suspicion, and persecution appear either acutely and expand very rapidly in a few weeks, or from a very insidious beginning so gradually that they may exist for months or years before they are detected. The general indications of illness consist in impaired sleep, slight loss of flesh, some reserve or shyness in relations with other people, and diminished ability to concentrate the mind in the usual occupations. The mental impairment at first is very slight, and shows itself (1) in the readiness with which the absurd delusions are believed and the fixedness of their hold on the mind, and (2) in the diminished general power of judgment and self-control in the little matters of daily life, at first so slight that it is not seen except in matters requiring some effort to maintain the customary equilibrium. Hallucinations, especially of hearing, appear. In the progress of the disease the mind loses power of self-control more and more, the delusions become more fixed, concealment is no longer possible, and the patient is so annoyed or angered that he repeatedly seeks relief from the courts (Querulantenwahnsinn) or commits some act of violence in self-defence. The common delusions are of marital infidelity, attempts at poisoning, mesmerism, electricity, influence through telegraphs, telephones, poisoned air, etc., signs of which are evolved directly from the consciousness or transformed from common sights and sounds, such as ringing of bells, striking of clocks, simple ordinary motions, etc. The delusions in time produce a state of mental depression.
In some cases the primary delusion is of personal exaltation, attended with persecution and mental depression. The individual thinks himself some great personage unjustly deprived of his rights.
Delusions of grandeur or of personal exaltation develop in the same way, usually subacutely from what might seem a foolish fancy rather than an insane belief. The Napoleons, kings, queens, greatest financiers, gods, etc. of the insane asylums are those who reason correctly if one concedes the truth of their false premises, until the progress of the disease produces such general brain-enfeeblement that their premises and theirreasoning from them are both insane. The delusions lose their fixedness, and their force too, in the general lowering of the mind's strength, and complaints and boasts and acts of anger become fewer, and finally cease.
TheCOURSEof the disease is nearly always subacute in the beginning and chronic to the end in the two forms of primary delusional insanity—that is, with (1) delusions of persecution and mental depression, and (2) delusions of grandeur. A few cases with acute development result in recovery, most of which relapse. The course is for the most part to chronic delusional insanity attended with moderate dementia.
TheMORBID ANATOMYis not known, except that atrophic and degenerative changes—not distinctive, however—are found in the terminal stages.
The patient is rarely willing to be treated as an ill person, for he is sure of the correctness of his delusions. If during the first attack he can be entirely removed from his daily associations by change of scene and travel, or, if that is not possible, by admission or commitment to an asylum, before the delusions become fixed and while it is still safe for him to be at large, there is reasonable chance of recovery. Second or third attacks very seldom end in recovery unless they arise from alcoholic excess, when entire abstinence for a sufficient length of time affords fair hope of a favorable result, except in cases of long-standing drunkenness.
TREATMENT, when the delusions have become fixed, involves, chiefly, safety to society or its comfort. The patients rarely commit suicide, driven to desperation by their delusions of persecution when they are particularly horrible. The more common tendency is to acts of violence toward others, so that seclusion in an asylum is usually the only safe course to pursue for delusions which one week may be directed against certain persons who can easily be gotten out of the way, the next week may be directed against others, and so on indefinitely. Delusions of grandeur may be only a nuisance or annoyance, but may at any time become sources of danger. The course is, for the most part, to slowly-advancing dementia. Asylum treatment offers no chances of recovery in cases not depending upon alcoholic excess, but becomes necessary for the protection of society.
Transformed delusions (sensorielle Verrücktheit) arise usually in some anomaly of sensation, which probably directs the delusions already forming in a mind in the early stage of disease rather than causes the disease. The causes lie in a deep-seated exhaustion of the nervous system, especially in the neuropathic constitution and profound hysteria. Various anomalous sensations give rise to a belief in delusions as to their being caused by individuals for a purpose, or to their being an indication of all sorts of impossible and most extraordinary changes in the part: the chest is of stone, the leg of brass, the head on fire, the hand ice, and so on indefinitely. Hallucinations and a cataleptiform state are common. The variety of delusions which may arise is almost endless, and they may have their origin in the unhealthy action of any organ in the body: one of the most troublesome forms, called ovarian insanity by Skae, causes single women of severely continent lives to imagine all sorts of impossible marital relations with men whose lives are equally beyond scandal and above suspicion.
Without proper care theCOURSEof the disease is to slowly-advancingdementia; and this may be expected when there is organic disease of any important organ of the body.
Before the delusions are fixed, diversion, change of scene, travel under agreeable circumstances and judiciously regulated, may be of great benefit. In the later stage of firmly-fixed delusion asylum treatment offers more chances of success.
In all the forms of primary delusional insanity the whole history of the case is difficult to get at, and there may be, and usually is, so strong a tinge of possibility at least, if not of actual probability, in the delusions, in the early stage of the disease, that a correct diagnosis cannot be arrived at until the time and opportunity for a cure have passed.
DOUBTINGINSANITY(Folie du doute, Maladie du doute, Grübelsucht) is classed by Régis22as a form of melancholia (mélancolie délirante), on the ground that it has the three elements of melancholia—namely, fixed ideas (délire) of a sad nature, general mental depression, and tendency to suicide. The melancholia is secondary, however, rather than primary, and doubting insanity belongs more properly under the head of a psycho-convulsive mental disease closely allied to delusional insanity, like which it is more commonly a manifestation of psychoneurotic heredity, appearing for the most part among the cultivated classes. It consists in an uncontrollable doubt and indecision, unanswerable by any degree of rational explanation, regarding the occupations, duties, or events of the day, religion, a future life, the commonest acts, or the most abstruse problems of life. Doubting insanity essentially depends upon an anomalous action of the will, with imperative conceptions and impulses. It is classed by some writers as a monomania of the degenerative type. Schüle calls it Verrücktheit sensu strictiori, using the term Verrücktheit also for the three forms of primary delusional insanity just described.
22Manuel pratique de Médecine mentale.
Délire du toucher, an insane dread of touching certain objects, and the morbid fear of defilement, called by Hammond mysophobia (similar names may be multiplied indefinitely), belong in the same category.
There are mild cases of all these forms of disease, which seem like simple weakness of character, others requiring for treatment the conveniences of the retreat for nervous and mental diseases, with a fair prospect of recovery, and still others tending to chronicity in which hallucinations, delusions, and dementia appear only as a further development into another form of insanity. They may, in mild degrees, be symptoms in the course of other mental diseases, especially melancholia, like many other manifestations of morbid mental energy, such as Doctor Johnson's inability to enter a room with his left foot first or to pass a lamp-post without striking it with his cane, etc.
PRIMARYMENTALDETERIORATIONor PRIMARYBRAINATROPHYis a term suggested for a curable impairment of the mind arising from brain-exhaustion in persons, usually men, between the ages of from fifty-five to sixty-five. I have found it in some cases associated with interstitial nephritis and with degenerative disease of the walls of the heart, and have suspected atheroma of the cerebral arteries or possibly endo-arteritis of specific or other origin. It occurs at a time when atrophy of the brain is naturally taking place. There are the usual indications of physical wear and such marked deterioration of the mental powers as toseriously interfere with the capacity to attend to customary business and every-day duties, and to closely simulate the early stage of paralytic dementia. There occur also, in a certain proportion of cases, epileptiform convulsions, slight attacks of dizziness, petit mal, and always disappearance of sexual power and desire. There may or may not be headache. The patient recognizes his condition, his mental depression does not far exceed the physiological limit, and there is no reasonable risk of suicide, except from reasons which would impel a sane man to it.
Under the influence of rest, if begun early, tonics, and a strict regard to the laws of health the symptoms commonly disappear if there is no organic disease. I have never seen the brain recover its tone to the extent of making it safe or even possible to resume the previous kind and amount of work. In a certain proportion of cases there is striking mental impairment, even dementia, and the primary atrophy of the brain sometimes makes rapid progress to unconsciousness and death.
It is not possible to say, by the degree of atrophy found post-mortem, whether there was or was not primary mental deterioration during life.
TheTREATMENTconsists in entire freedom from care, rest from work, travel, tonics, etc.
As mental disease is more than a brain disease, and is a disease of the intellect, each age from infancy up (and each individuality) impresses its peculiar mark upon it, and there are certain terms in common use to express insanity associated with certain physiological processes whose meaning should be explained.
INSANITY OFCHILDHOODis for the most part only a further development of a congenital state of mental defect. I have seen, however, well-marked mania, melancholia, primary dementia, and primary delusional insanity before the age of puberty. Typical acute mania I have seen twice in children two years old, apparently arising in normal brains after severe injuries to the head. This is quite uncommon, and the number of cases thus far observed is too few to make me feel sure that my own experience of a favorable result as to recovery in uncomplicated cases will be generally confirmed. At best, after a cure there is a more or less decided arrest of brain development.
HEBEPHRENIA(insanity of pubescence and adolescence) occurs within the ages of fourteen and twenty-three or thereabouts. Like insanity in general among persons in early life, it most commonly indicates an hereditary predisposition to mental or nervous diseases or an early-developed brain defect or injury, possibly an exalted emotional state or an increased nervous sensitiveness produced by masturbation. It is a mild form of primary dementia, modified by the mental changes going on during adolescence. Indeed, it is simply an exaggeration and prolongation of the curious psychological development of that period, too well known to need description, which goes on in the most insidious way possible through months or years of what seems silliness, absurd fancies, foolish sentimentality, egotism, impaired common sense, and diminished judgment and self-control, to a slowly-advancing dementia, which even then is not always recognized as disease. The result is an arrest of brain development on various planes of intellect, and a preservation of the youth's tastes and sense and intelligence, as modified by the morbid propensities characterizing an unhealthy development of the change from boyhood or girlhood andyouth to adult life, with the adult's strength—a curious combination of intellectual brightness, it may be, with lack of mind. For this characteristic condition Westphal uses the expressive term Permanenz der Flegeljahre (permanence of the usually transitory state, which then commonly results in permanent arrest of brain development on the plane of the mind at a definite age of adolescence); and yet there may be more than that—mental deterioration, which in years may lead to pronounced dementia. Cases of primary dementia occurring within the years of puberty and adolescence are often classed as hebephrenia and conversely, so that one term, primary dementia, is thought sufficient by many writers on insanity.
In the early stage there is sadness, hardly amounting to melancholia, and it usually constitutes an important symptom to the end, although, like all the other changes in the mental state, it is superficial to the extent of at times seeming almost insincere. Masturbation is common. Occasional outbursts of violence are also common, often with mental confusion, incoherence, or stupor, and in severe cases there occur, usually, attacks of temporary fury, with distressing or agonizing hallucinations of sight and hearing, and delirium, which may all last for a very short time or for a number of days. In young women and girls these outbursts may be coincident with menstruation or in the intervals. The countenance loses somewhat in expression in all cases, and becomes almost vacant or quite so in those in which the dementia becomes well marked. A mild form of the disease is quite common, and consists in an undue intensity or a prolongation of the curious psychological phenomena commonly observed during adolescence. It is marked by aimlessness, changeability, self-assertion, exaggerated self-consciousness, with, perhaps, propensity to lie or steal or run away from home, and ending without any apparent damage to the mind, except that the individual is less of a success in life than he would have been but for his illness.
The course is slow, and although in the majority of cases mental impairment is arrested before reaching what may be properly called complete dementia, in well-marked cases the duration of the disease is long and its results last for life. In many cases progress continues with extreme slowness to extinction of the mental faculties. Oftener the individual simply, in a certain sense, fails to reach that stage of intellectual maturity and strength which he otherwise would have attained. It is not always easy to draw the line between the psychological and the pathological changes that take place during the years of adolescence, and there are many mild cases of hebephrenia in which various kinds of failure in life are due to this disease rather than to the faults or vices to which the failure may be attributed.
InTREATMENTirritability, restlessness, absence of a power and sense of responsibility, and sleepless, excitable nights, are the most difficult symptoms to combat. The restlessness and irritability often lead to refusal to be reasonably controlled and to a tendency to wander away from home with theatrical displays, so as, in the case of girls particularly, to require restraint, especially if the excitability should be so great as to amount to outbursts of violence or should lead to sexual improprieties.
The fact should be borne in mind that there is a diseased brain which needs nutrition, rest, and discipline, which must be proportioned to suit each case. Outdoor, simple life, with sea-bathing, carefully-selected diet,without too much meat, exercise, mental training limited to the requirements of each patient, are the chief reliances. Iron, cod-liver oil, and arsenic are useful tonics. Stimulants, including tea and coffee, should be avoided. Quiet nights and necessary repose can be secured by bromides, exercise, and opiates used sparingly, which also control the impulse to masturbation. A sound education, a healthy experience of the rough and tumble of youthful life, and the careful avoidance of processes and habits of indulgence will often prevent the symptoms of disease from growing into traits of character and habits of life. On the other hand, in some cases there is a half-conscious struggle between the fine traits of character and the demoralizing influences of the disease, and a most pathetic effort to keep the better nature's supremacy over the lower impulses set free or developed by the destructive tendencies of a fearful malady.
MENSTRUALINSANITYdiffers from other periodic insanity in not being necessarily a further development of an hereditary or acquired state of mental degeneration, and in being curable in a fair proportion of cases.
INSANITY OFGESTATION, PUERPERALINSANITY,ANDINSANITY OFLACTATIONdo not call for any further comment than the remark that they represent causes and conditions rather than types of disease.
CLIMACTERICINSANITYin women and in men is usually a curable folie raisonnante—insanity of action or affective insanity, which may develop into secondary dementia or chronic insanity with delusions. It does not necessarily include all acute forms of insanity occurring at the climacterium, but only those slowly developing with the physiological changes going on.
The course is usually subacute, the duration a couple of years or more, and the termination in about half the cases is in recovery. Permanent change of character and further progress to incurable insanity are perhaps about equally common.
TREATMENTconsists in a sedative and fattening diet, simple, healthful conditions of life. Removal to an asylum or some form of restraint is needed where the conduct is such as to demand seclusion and control.
SENILEINSANITYarises in suspicions and a generally deluded state of mind regarding those persons whom there is every reason to trust—namely, relations and near friends—and as extraordinary credulousness of designing persons whose interest and character would naturally suggest being on the guard against them. There is impaired judgment, as shown by the mismanagement of property and diminished capacity for business, usually some perversion of the sexual instinct. The suspicions and credulousness in time amount to insane delusions, and if life lasts the end is in marked dementia. But there may be no mental impairment evident to casual observers or to ordinary acquaintances for many years. The improper relations assumed with the opposite sex, the neglect or abuse of those nearest by ties of blood, the squandering of property on strangers, and the omission to provide properly for the members of the family, are wrongly attributed to a character become bad rather than to destructive brain disease, where they belong. Not seldom senile insanity is a moral insanity, and shows itself by an entire change of character not explainable by other circumstances than disease, and is then marked byindecent exposures, loss of the fine sense of the decencies and proprieties of life, destruction of the discriminating power between right and wrong acts.
The course of senile insanity is slow, unless there be also some fatal disease with it, and evident mental impairment may be so late that the disease may be overlooked for years.
TheTREATMENTis abundant nutrition, including wine, removal from irritating conditions of life, protection of the individual against himself, and guarding the community against harm or indecencies. Small doses of morphia daily are often of great benefit, and there is no real danger of acquiring the opium habit if reasonable discretion is exercised in its use.
SENILEDEMENTIAis simply an excess of the natural mental weakness of old age out of proportion to the bodily state, an exaggerated childishness of senility to the extent of producing irresponsibility. It is in reality a subacute primary dementia modified by the peculiarities of old age. Memory fails first, and a condition of general weakness of mind follows rapidly afterward. Secretiveness, suspicions, delusions, and hallucinations of the special senses are almost always present.
It is not uncommon for the early symptoms to consist in an inhibition of the higher faculties of the mind, so that the lower impulses become prominent. The sense of right and wrong and the moral perceptions may become entirely weakened. Acts of indecency, dishonesty, injustice, depravity may follow impaired judgment, and yet so far precede strikingly perverted memory and general intelligence as to make the insanity, which is obvious to an experienced observer, entirely fail to impress itself upon the minds of the community.
TheTREATMENTconsists in caring for the comfort of the patient, which can usually be done at home or at least in a private family, unless there are persistent impulses requiring the control of an asylum. The preparations of opium are useful to control extreme restlessness, and may be given freely, avoiding narcotism. A bland diet of fattening food is best suited to the wants of the aged. A simplified life often serves every purpose, especially in the quiet of the country, although it is best not to remove them from familiar scenes unless as a matter of necessity.
Complicating insanities simply add to the usual symptoms of the special forms of mental disease many of the characteristics of the particular disease, rheumatism, gout, phthisis, organic diseases of the heart, etc. Choreic movements depend upon the same pathological changes as are found in the sane, and certain diseases are attended with such profound changes in the nutrition of the brain as to give rise to mental impairment, which amounts to almost extinction of the mind, such as myxœdema and chronic nephritis. Acute mania occurs in the last stage of Bright's disease, which may be difficult to differentiate from uræmia. Mania, melancholia, and delusional insanity occur in the course of acute febrile diseases or appear during the period of convalescence; in the latter case the prognosis is much more unfavorable than in the former. The closealliance between insanity and pulmonary consumption is a matter of frequent observation. The two diseases are interchangeable, and they often coexist. The relation between rheumatism and insanity is less close.
Maniacal symptoms have been reported from the use of various drugs, including iodoform, mercury, etc. Hasheesh dementia is not uncommon in the East. Acute delirium arises from hydrate of chloral and the preparations of opium analogous to acute alcoholic mania from excessive drinking, and chronic impairment from their prolonged use. Bromide of potassium rarely produces symptoms similar to those of mania; taken for a long time in even moderate doses, it tends to mental sluggishness, and in long-continued large quantities given uninterruptedly there is a danger of well-marked dementia.
All of these conditions may be prolonged beyond the usual action of the particular drug or give rise to symptoms in excess of those usually observed. The characteristic indications of the particular drug, sometimes marked by the combined use of several, will be found if they are carefully looked for.
TheTREATMENTconsists in breaking off the bad habit gradually or abruptly as each case may require, and in otherwise treating the persisting symptoms in accordance with the general principles already stated in considering the various mental diseases.
ALCOHOLICINSANITYincludes mental disorder from the use of alcohol in both the acute and chronic forms.
Acute alcoholic mania may come from a single excess in drinking, which in some individuals is always attended with maniacal symptoms. It may constitute the alcoholic trance described under the head of Transitory Insanity. From long drinking and exhaustion or by withdrawal of the accustomed stimulant we may have the familiar mania-a-potu or delirium tremens.
Under the prolonged use of alcohol primary delusional insanity, melancholia, mania, and dementia occur.
From long-continued drinking of alcohol, even to slight excess, for many years, it is rare not to find some mental impairment, if only an “uncontrollable violence of the instincts and emotions,” a sort of moral insanity.
ThePROGNOSISis more favorable than in most forms of insanity uncomplicated by the abuse of alcohol, especially in the case of primary delusional insanity, if the bad habits can be effectually corrected and if the alcoholic excesses have not been continued long enough to produce organic changes in the cerebral blood-vessels. In the latter case the dementia sometimes simulates that of general paralysis so closely as to be called pseudo-paralytic dementia from alcohol.
TREATMENTis rarely successful outside of some asylum.
SYPHILITICINSANITYdoes not properly include those cases of mania, melancholia, and delusions of persecution of the ordinary type of which the exciting cause is found in the train of thought aroused and kept up by the consciousness of having contracted syphilis, but only such asdepend upon the presence of the syphilitic poison in the system. There are no diagnostic marks to distinguish it from insanity not caused by syphilis, except in a certain proportion of cases of organic syphilitic disease of the brain.
ThePROGNOSISis rendered much less favorable from the fact of the syphilitic cachexia.
In addition to the usual means ofTREATMENTfor the several forms of insanity, the appropriate measures for syphilis should also be tried, except where there is evidence of diffuse organic disease.
GENERALPARALYSIS OF THEINSANEis a disease marked by definite pathological changes in the central nervous system, chiefly in the cortex of the brain, but which may extend to any part of the cerebro-spinal tract or to the sympathetic ganglia and cranial and spinal nerves. Its constant symptoms are—(1) vaso-motor disturbance ending in vaso-motor paresis; (2) mental impairment, which makes progress, for the most part unevenly, to complete terminal dementia or extinction of mind; (3) impaired muscular control, which advances more or less uniformly to almost entire paresis or nearly total paralysis. Expansive delusions, the delirium of grandeur, megalomania (which may change suddenly to micromania), or simply a feeling of elation, happiness, self-satisfaction, or undue complacency, are found, but often not until or near the end. The other symptoms vary in individual cases within a wide range, so as to simulate almost every form of insanity; and it is quite possible that they include what a more exact pathology will hereafter recognize as several distinct diseases.
SYNONYMS.—General paralysis is also known as general paresis, progressive paralysis of the insane, paretic dementia, paralytic dementia, cirrhosis of the brain, paralysie-générale, folie paralytique, démence paralytique, periencephalite chronique diffuse, meningo-myélo-encephalite chronique interstitielle diffuse, encephalite généralisée, periencephalite chronique diffuse, encephalite interstitielle diffuse, encephalite avec proliferation sclereuse interstitielle, Allgemeine Paralyse, progressive Paralyse der Irren, chronische progressive parenchymatöse Encephalitis der Rindensubstanz, pericerebritis, periencephalo-meningitis diffusa chronica, periencephalo-myelitis chronica diffusa, encephalitis interstitialis corticalis, paralytische Blödsinn, primäre Encephalitis interstitialis mit Ausgang in Sclerose. Griesinger placed general paralysis among the complications of insanity. It is popularly known as softening of the brain (Gehirnerweichung).
HISTORY.—The combination of the two series of symptoms, paralysis and dementia, was recognized by Haslam, and at the beginning of this century by French writers, who also knew their fatal import. Esquirol describes a typical case of general paralysis of the insane under the head of monomania in hisMaladies mentales. His pupils, especially Bayle and Calmeil, have studied and described general paralysis. At the time of his first visit to England, forty years ago, the late Luther Bell had never recognized a case, and there can be no doubt of the fact that it hasrapidly increased, particularly in the last dozen or twenty years, with the rapid increase in the aggregation of the population.
ETIOLOGY.—So far as heredity is concerned, general paralysis has not such close relations with mental diseases as insanity in general. It is estimated to be hereditary, in the sense of being closely related to other forms of insanity, about one-half as often, and it is nearly allied to apoplexy and epilepsy. My own experience leads me to the conclusion that in those cases of general paralysis without a previous history of syphilis (and the same statement is true in less degree of persons who have had syphilis) the vast majority occur in families in which there have been cases of insanity, epilepsy, or apoplexy. It is rare among people living simple agricultural lives, but is intimately connected with the faults and vices of civilization—specialized overwork, involving strain in the office, study, factory, mine, etc., especially if to bodily exhaustion and brain wear and worry there be added hard living and hard drinking, sexual excesses, and syphilis. The Scotch Highlander rarely has the disease until he comes to Edinburgh or Glasgow. In Ireland general paralysis is so rare that of 9271 cases of insanity in 1882, only 6 were general paralytics, as compared with 1151 out of 13,581 in England the same year; during which, in Scotland, of 238 deaths from insanity, 10 were from general paralysis; but the Irishman has no special exemption from general paralysis in American cities or in large English towns and mines and factories, where he works hard, drinks hard, and lives hard generally. It is, so far as I am able to learn, unreported thus far among our negro population until they come to the great centres of population; it is said to have been unknown among the slaves. Among the English, Scotch, and Americans it prevails most among those people who are in, or who have dropped down to, the lower strata of society. Of 2212 private patients in England, 139, or about 6 per cent., were general paralytics, while 1012, or about 9 per cent., were found among 11,359 pauper patients. French and German writers report it as most common among the brain-workers. In women of the upper class it exceedingly seldom occurs. In some of our Western asylums not more than 1 or 2 per cent., or even less, of the patients are reported as general paralytics, coming chiefly from farms. In the asylum for the centre of the manufacturing districts of Massachusetts about 9 per cent. of the patients are general paralytics. From the iron- and coal-mines of England from 14 to 17 per cent. of the insane confined in asylums are general paralytics. It is more common in cold climates than in warm, other things being equal. From one-sixth to one-tenth of the cases, varying in different localities, are women.
General paralysis not only is most frequent in the stronger sex, but it selects the strong individuals in the prime of life, between the ages of thirty-five and fifty. It is extremely rare under the age of twenty, although Turnbull has reported an unique case at the age of twelve;23it is not common under thirty or over sixty; I have seen two cases in men sixty-five years old. It is seldom seen in individuals who have been weak from childhood, unless as the probable result of syphilis.
23Journal of Mental Science, October 1881.
The excesses of the habits of the city and of mining and manufacturing centres, hard work, high living, late hours, predispose to generalparalysis in strong constitutions at the period of their greatest activity, especially if the physical strain, the violent struggle for existence, has begun early in life with insufficient food and excessive work, and if ordinary paralysis be not uncommon in the family. Alcoholic and sexual excesses are considered to be particularly common predisposing causes. Recent investigators find syphilis to be a part of the antecedent history of from one-half to three-fourths of the cases, but chiefly in those slowly advancing or subacute from the beginning. By some writers syphilis is considered to be in those cases only a diathesis, as is held by Fournier, or a debilitating antecedent, like chronic malarial poisoning. Others think that so large a proportion can be accounted for only by some specific relation between the two diseases. If the fact so often stated is true, that syphilis is rapidly increasing, perhaps part at least of the increase in general paralysis can be thus accounted for.
Mental shocks of various kinds, excessive emotional strain with mental exhaustion, and injuries to the brain, are the commonly reported exciting causes of general paralysis, but it is not certain that—in many cases, at least—they do more than hasten the pathological process and call attention to the symptoms. So far as my observation goes, the injury to the head, supposed to be the cause of general paralysis, often has appeared to probably come from an accident due to the impaired physical strength and to the vaso-motor disturbance in the brain incident to the early stage of the disease and while it was still unrecognized. Cases are observed in which no predisposing or exciting cause is found by the physician. I have seen it following diphtheria and other debilitating diseases, after long exposure to malaria, and apparently due simply to prolonged mental strain in persons otherwise living in moderation under circumstances exceptionally favorable to health.
SYMPTOMATOLOGY ANDCOURSE.—As a rule, to which the exceptions are few, the early symptoms of general paralysis are obscure. Their appearance and progress are so gradual and insidious that they are usually overlooked for a period varying from several weeks to a year or more, sometimes for four or five years, perhaps even longer. There is a slight change in character, which is frequently attributed to wilfulness or perverseness arising from some disagreeable circumstance; to want of a reasonable attention to the little affairs of daily life; to indifference, temper, carelessness, or recklessness; to a want of aptitude and receptivity having an ethical rather than medical significance; to an impaired moral sense. The patient may be observed to be simply more quiet and heavy; inclined to be depressed rather than distinctly melancholy; a little heedless; unusually indifferent, and indisposed to worry over things that formerly would have disturbed him; drowsy or dropping off to sleep at work or in the theatre; disturbing the household by his restlessness at night—in and out of bed, up and down stairs, for trivial and yet not seemingly insane reasons. He may become easily disturbed by trifles, and yet careless to more important matters. He begins to overlook, perhaps rather than forget, recent little things. His power of attention is diminished, his will weakened, his self-control impaired. He becomes less careful of the niceties and proprieties of life, less interested in his family and all that is nearest to him—self-absorbed, egotistic, indulging in inconsequent stories and remarks. Although the memory is notdistinctly at fault, fresh impressions do not make their usual imprint on the mind. His moods are unnaturally changeable. A certain slovenliness in habits or carelessness in dress, an inattention to customary little courtesies and attentions, slight yet noticeable, are not uncommon early symptoms of general paralysis. There is soon observed, often noticeable to the patient, a lack of endurance, an early sense of fatigue from exertion, a sense of muscular prostration, physical discomfort, or general pains which may be attributed to malaria or rheumatism. Commonly, not always, there is disturbed sleep or restlessness. There may or may not be headache, slight or severe, transient or persistent. There may be a sense of pressure or an uncomfortable feeling about the head, especially the forehead, or it may be the seat of no pain or discomfort whatever. There may be a slight or severe local or general sensation of distress or uneasiness in the head after mental effort only. There is often pain, anæsthesia, hyperæsthesia, paræsthesia affecting any sensitive nerve, often none at all, or impaired muscular sense.
The average daily temperature is higher in general paralytics than in health. It is sometimes lower, and the range is greater than the normal. In the only extremely rapid case which I have seen (two months in all) it was 97° F., and thereabouts for a number of days, and then rapidly rose to 103° and 104°, where it remained until near death. After the congestive, epileptiform, and apoplectiform attacks it rises from two to seven degrees, and remains high for a considerable time, while in pure epilepsy it quickly falls. This difference, however, is not sufficient, as between epilepsy proper and epilepsy as an early symptom of general paralysis, to establish the differential diagnosis with certainty in all cases.
The vaso-motor disturbances in the brain are indicated by transient congestions or local anæmia, dizziness, faintness, temporary outbursts of anger, excitement, or confusion, and rapid changes in the mental and emotional state. Convulsive attacks are not common in the early stage of the disease, except in those cases due to syphilis, but may occur, and may so resemble hysteria, petit mal, epilepsy, and apoplexy as to be confidently diagnosticated for those diseases. The emotional state is of indifference, despondency, gloom, melancholia, elation, a feeling of self-satisfaction, or mania.
The symptoms thus far are not clear except on minute examination. The family and most intimate friends of the patient observe that he is changed, but cannot tell how, and are apt to say that he is not the same man that he was, that his troubles have been too much for him, that he does foolish things as never before, etc. Sometimes he estimates his symptoms correctly, sees the downward change himself, and is oppressed by it; oftener he is indifferent to it, or still oftener quite well satisfied with his condition and prospects, or even mildly elated. He may squander his fortune, ruin his reputation, become addicted to drink. His sexual appetite, not held back by his normal power of self-control or exaggerated with a general physical and intellectual erethism, may lead him into all sorts of improprieties and immoralities or to exhausting excesses, which are perhaps more common among the married than among the unmarried; and yet his disease is not recognized, because the later symptoms of general paralysis—namely, grand delusions, staggering gait, tremor, and marked dementia—have not yet appeared.