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 by {174} indecent
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.
The TREATMENT is 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.
SENILE DEMENTIA is 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.
The TREATMENT consists 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.
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 close {175} alliance 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.
Insanity from Specific Poisons.
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.
The TREATMENT consists 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.
ALCOHOLIC INSANITY includes 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.
The PROGNOSIS is 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.
TREATMENT is rarely successful outside of some asylum.
SYPHILITIC INSANITY does 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 as {176} depend 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.
The PROGNOSIS is rendered much less favorable from the fact of the
syphilitic cachexia.
In addition to the usual means of TREATMENT for the several forms of
insanity, the appropriate measures for syphilis should also be tried,
except where there is evidence of diffuse organic disease.
Organic Mental Diseases.
GENERAL PARALYSIS OF THE INSANE is 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 his _Maladies 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 has {177} rapidly 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;[23] it 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.
[Footnote 23: _Journal 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 general
{178} paralysis 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 AND COURSE.—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
not {179} distinctly 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.