On General Paresis
99 Art. V.? * :Author: A. E. MACDONALD, M.D., New York.
Gentlemen,?We are to consider to-day the fourth and last of the forms of insanity embraced in the classification which we agreed at our first meeting to accept, and it is not alone the last, but, to my thinking, the most important of those forms, and I have more than one reason for thinking so. In the first place, it is more recent, at least in its recognition, if not, indeed, in its origin, than the forms which we have discussed. Our knowledge of its course and causes and symptoms is much more limited and much less positive; and there is the further reason, which may increase the importance of the present opportunity of study to many of you, that, though prevalent enough in this neighbourhood, it is comparatively unknown to those localities to which you may propose, after the completion of your studies, to remove.
I speak of paresis as a comparatively newly discovered form of insanity, and you will remember that we found its name to be a comparatively recent addition to the three forms of insanity of which Pinel’s ” natural system” of classification was originally composed. Now that the disease is recognised, and that opportunities for its study are ample, we see that its symptoms were observed and recorded long since ; but so rarely were they observed that they were not held to constitute an individual form, but were simply regarded as accidental compli- cations of one or other, indifferently, of the forms already recognised. Indeed, the date of its promotion abroad to the dignity of a distinct disease is within the present century, while in this country but little over thirty years have elapsed since its first appearance or identification ; and although, since that time, the number of cases presenting its characteristics has in this neighbourhood greatly increased, its extension toward the interior has been gradual, and there are still many localities, especially in the west and south, where it has not yet appeared. That it will do so the history of the disease and its geographical progress can leave no doubt, and hence my belief that it is especially important that you should study it here where it is common, in order that you may recognise it if you go where it is now unknown but will surely follow.
I speak to you of the disease by the name commonly applied * Read before the Commissioners of Charities anil Correction at the New York City Asylum for the Insane.
to it in this country?” General Paresis.” English writers, as a rule, use the longer term?” General Paralysis of the Insane “? while individual authors have each their own designation, ” Paralytic Dementia,” ” General Incomplete Paralysis,” ” Pro- gressive Paralysis,” among the number.
The use of the word ” progressive ” in one of these designa- tions is a happy one, for progression is a principal characteristic of the disease, exaltation being another. In effect, general paresis may be defined to be a form of insanity in which there is an association of mental and physical evidences of which pro- gression and exaltation are the leading characteristics. As the patients in the different stages of the disease are presented to you, you will observe how constant and uniform these charac- teristics are. You will see, first, that they are?at least those in whom the disease is of relatively recent development?men of apparently strong frame and vigorous health. Paresis does not find its victims, as do commonly the other forms of insanity, among those who are weakened by constitutional defect or by disease, but selects them from among the active and vigorous. Nor does it go to the extremes of age, but to the prime of manhood.
I will anticipate the appearance of the patients by giving you a brief summary of the leading symptoms of the disease and of its course, and as the patients are brought before you, you will recognise these symptoms and others which are less uniform in their presence.
As a rule, then, paresis makes its appearance in a man of middle age who has apparently been possessed of a strong con- stitution and of robust health. It is quite possible?probable, indeed?that he has been somewhat inclined to dissipation or excess in various ways; but it has not gone to the point of per- ceptibly affecting his health, or appearance, or business capacity. The change which comes over him is rather a more sudden one than in most forms of insanity, excepting acute mania, and it is somewhat of a question whether the mental or the physical symptoms have precedence. Generally, in the statements of friends, the first place is assigned to the former, but they are plainer and more likely to attract the attention of the laity; and it is probable that if all cases could be carefully observed and the two sets of symptoms appreciated, they would be found to appear and advance coincidently. As regards the mental evidences, as in the approach of other forms of insanity, a period of irritability and depression may be expected ; but it may be but slight and transient, and attract no attention. Then the element of exaltation asserts itself; the patient is lively and excited ; he feels well in body, happy in spirits, hopeful and coe- fident in business. He is disposed to enjoy life, to eat, drink, and be merry, and to make his companions and acquaint- ances share in his enjoyments. He becomes speculative and reckless in his transactions, extravagant and wasteful in his expenditures and his bounties ; and before his condition is fully recognised and his property protected, he is apt to hopelessly embarrass his affairs. Increase in these tendencies, loudness in speech and manner, eccentric dress, indecency of language and demeanour, and possibly acts of violence, pave the way for posi- tive delusions, and, as I have said, the main feature of these is their exaltation or exaggeration. In whatever field the patient’s fancies may wander, they carry him far above his fellows. He is the richest, or the most powerful, or the most learned; or if, as sometimes happens, a melancholy tinge is imparted to his thoughts, he is the most abused and the most wretched.
All this time the physical symptoms have been appearing and progressing, depending upon increasing loss of power of co- ordination in the voluntary muscles. The muscles of the tongue and lips, as those most delicate in their functions, are the first to suffer or to show it, and there are, as a consequence, altera- tions of speech. At first it is but a slight hesitancy or catching, but it becomes thicker and more drawling, and the enunciation is indistinct and halting, despite the patient’s manifest efforts to speak with distinctness and deliberation. At the same time the muscles of the lips are tremulous, and the patient has diffi- culty in protruding the tongue, and while it is out it quivers and jerks, and may be suddenly withdrawn without his volition. There is evident failure, too, in the co-ordinating power of the muscles of the extremities; but these, as well as characteristic alterations in the conditions of the pupil, can be better shown to you from the patients themselves.
From this beginning the patient goes on surely, but more or less rapidly, through increasing exaggeration of delusions mentally and increasing paralysis physically, to the end. I may say now, before the patients come, that they may not hear me, that this end is death. The list of therapeutic agents has been ransacked, the pathological appearances studied, but as yet to no useful purpose. It is true that recoveries have been re- corded, but they are at best insignificant in number, as well as doubtful in authenticity. Nor is the inevitable end long of being reached when once the disease is fully established. Three years is a long limit for most cases, though some have passed it. The longest period elapsing between development and death, in a case coming under my own care, has been short of six years. In these cases death occurs from the disease uncom- plicated, and may either result from the gradual increase of tbe paralysis and its extension to the muscles concerned in degluti- tion and respiration, or from the convulsive seizures which come on in its course. In other instances, pulmonary complications arise and end the patient’s life.
Phthisis is a not uncommon complication of general paresis, as indeed of other forms of insanity, and when it is present it seems to have an effect in shaping and colouring the delusions. It is in such cases that you will find the tendency towards depression that I have spoken of as occasionally existing. It stops short of the depression of true melancholia, however, and only modifies without supplanting the delusions of greatness or wealth. The patient may tell you that, through the machina- tions of his enemies he has lost his kingdom or his fortune ; but he will tell you, too, that his loss is but a temporary one, and that he will soon be more powerful or wealthier than before, and as, at any time the ravages of the pulmonary disease may be tem- porarily arrested, the original delusions will return.
Case I.?The patient whom I first present to you will show excellently the physical marks of the disease. In his case the progress of the malady has been rapid, but seven months hav- ing elapsed since its appearance. He is thirty-two years of age, and has evidently been a man of fine physique. You do not get many mental symptoms from him, for he has already passed from the lively and talkative into the dull and stupid stage ; and besides his speech is so stammering and incoherent that his answers to our questions are scarcely intelligible. You see very plainly here the tremulousness of the lips and tongue of which I spoke. He can only protrude the latter with the greatest difficulty, and has little or no control over it. His hands and limbs are equally independent of his will; the former tremble and jerk about, and his gait is so unsteady and tottering that he seems in constant danger of falling.
You notice that there is a decided inequality of his pupils, the left being much dilated and failing to respond to light, while the right is about normal in size, and does so respond. This is a lesion which is almost characteristic of general paresis, and which, when associated with the mental evidences of which we have spoken, may be taken as settling the question of diagnosis. It is true that unequal pupils may be found in other cases, and even in sane people; but in the latter a history of mechanical injury, or of strain by excessive use of one eye, as in the case of engravers, may generally be found to account for it. In the case of paretics, at the inception of the disease, there is usually intense and equal contraction of the pupils?” pin-hole ” pupils, as we call them?but subsequently they dilate, and dilate un- equally. They are apt to* lose their shape, too, and become irregular, from lapping over of the edge of the iris. In some cases the right pupil is the more dilated, in others the left; and a curious fact in this connection, first recorded by Dr. Austin, in England, and verified by observations in this asylum, deserves to be mentioned. This is that where there is any tendency toward melancholy or depression, the left pupil will be found to be the larger, while where the opposite tendency exists, as it does in the great majority of cases, the right pupil will be the more dilated. I do not venture to account for this relation, but it certainly seems to exist, as you will see, I think, from the patients before you.
I may speak to you now, as well as at another time, of the probable causes of paresis. Of the general type of persons from which its victims are selected we have already spoken, and it will prepare you for what follows. The assigned cause in the case of the patient before you is excessive sexual indulgence, and in my experience it is the assigned or assignable cause in the great majority of cases. There is the source of error to be feared in this case which affects all attempts to ascribe causes to attacks of insanity of any kind?the doubt as to the real relations of cause and effect. Hence, if we get concerning a paretic the history of excessive venery, we may, especially if the history is only of recent indulgence, suspect that the excess is due to the disease and not the disease to the excess, and we may admit at once that we do have cases of paresis where there is not only no reason to suspect over-indulgence, but where the negative evidence is so conclusive that we have to seek for other causes. But in the great majority of cases, at least of those coming to this asylum, there is a straight history of inordinate venery, and strong corroborative evidences and appearances. With this we get too, in most cases, a history of hereditary tendency to insanit}’, and of intemperance in the use of stimulants; but this is true, too of the admissions generally, and not alone of those suffering from paresis. Other assigned causes are sunstroke, syphilis, and injuries to the head; but, as compared with the cause I have cited, they are infrequently advanced, and this leads me to say a word regarding the question of sex in the matter of liability to this special form of insanity. It is an undoubted fact that excessive sexual indulgence is less disastrous in its effect upon the female than upon the male, and, therefore, it it is really the principal factor in the production of paresis, we should find that disease much more prevalent among men than women, and this is exactly what we do find. In this asylum, which, as you know, receives males exclusively, there are now probably a hundred cases of paresis. In the correspond- ing asylum of the department devoted to the care of females. although the entire number of patients is much greater than here, there are, according to the report of the Superintendent, not more than three or four; and, by way of further confirming the theory advanced, it is recorded that, where women suffer from paresis, they are generally those who have led dissolute lives as professional prostitutes.
It is noticeable that, when paresis first makes its appear- ance in a given locality, its victims are exclusively males. As time passes on, a few cases are found among females, and there- after their proportion increases as the disease spreads. Case II.?This is also a comparatively recent case of paresis, the invasion of the disease dating back only five months. He is a younger man than the other, about 27, and you see that the physical disturbances are by no means so far advanced. In fact, at first glance, as he sits there, he appears a well-nourished, healthy young man. But as he rises and comes towards us we see that his gait is perceptibly affected, that his hand is tremulous, and that his pupils are unequal, the right being this time the larger. When he speaks, the diffi- culty of articulation is marked; but we can understand him distinctly enough, and learn the drift of his delusions. They are, as is commonly the case, at least in the commencement of the disease, connected with his former pursuits in life; they are limited in number, and are by no means as exaggerated as those shown by some, or as they are themselves likely to become as the disease advances. He was, prior to his admission, a professional billiard player, a champion in one branch of the game, and but recently engaged in a tournament in this city. Accordingly he accounts for his residence here by telling us that this is a large hotel, that he has charge of the billiard- room, with a fabulous number of tables, from which he derives a large income, and that the only feature of the establishment to which he objects is the fact that the door of the bar-room is always kept locked, and that he cannot get access to it. As it happens, there is another patient in his ward, a paretic also, who was likewise a billiard champion, or thinks he was, and these two worthies spend much of their time in discussing the preliminaries of a grand championship match which is to settle the question of supremacy between them. It is needless to say that the stakes are something enormous, and that each is sublimely confident of his ability to win them.
Now, here are two patients, the delusions of each of whom depends largely upon belief in the entire truth of the delu- sions held and enunciated by the other. This is a peculiarity which you often find among patients with paresis, and do not find among patients with other forms of insanity. You will remember that at our former meetings, and especially when we had the maniacal patients before us, there were often implied, and sometimes audible, expressions of dissent on the part of other patients from the views of the particular patient who happened to be addressing you, and these views were often ridiculed and laughed at. As a rule, an insane man appreciates the falsity of the beliefs of other insane men around him, while cherishing beliefs equally false himself. And this is a fortu- nate thing for the officers of asylums, for it prevents the association of patients in schemes for attack or escape. Should one patient invite the co-operation of others in a plan to escape, the chances are that they would inform upon him, believing him quite unfit to be at large, while each consi- dering for himself that his own detention is quite unwar- rantable ; and where a patient attacks an officer, it is quite common for other patients to interfere for his protection. There is, then, usually but little confidence between the insane, and but little acceptance of the delusive ideas of one by the other. But the paretics are in some measure an excep- tion to this rule. It is by no means uncommon for one of them to uphold the correctness of the assertion of his fellow-patient almost as loudly as his own, unless, indeed, those views clash with his, in which case, of course, the other man is all wrong, just as in the case of sane people.
This patient, and the other of whom I have spoken, hold each the delusion that he is going to win money from the other, because he believes the delusion of the other that he has got money to lose. Similarly, a patient who was formerly a professional gambler plays cards with his comrades industriously, cheats incorrigibly, and flatters himself that he is rapidly absorbing the millions they claim to possess; and in more legitimate business there are transactions made and copartner- ships formed that are quite dazzling in their results, and always equally productive to both parties.. Case III.?This is an exceptional patient in oneor two respects. In the first place, he is much beyond the usual age of paretics, being aged sixty-six; and in the second place, the disease has lasted an unusually long time to have reached only its present stage, for he has been an inmate here for five years. You see that he is a lively little old gentleman, fat and good-natured, very talkative, and with a disposition to assume the direction of affairs and generally assert himself. There is surprisingly little physical disturbance for one in whom the disease has endured so long, and whom it has at times affected so hardly?for he has more than once been at the point of death from the epilepti- form attacks which are incident to paresis. The affection of 106 ON GENERAL PARESIS. the speech and gait, though perceptible, are not marked, and the difference in his pupils is the only decided physical symptom present. The right pupil is again in his case the more dilated, and he feels that there is some trouble with his vision, and he is constantly asking for spectacles, which, of course, fail to correct it. But, if the physical symptoms are absent?or in abeyance, for be has shown them decidedly enough at other times?there is no lack of the mental ones. His delusions cover every conceivable subject, and reach quite inconceivable heights. There is no difficulty in eliciting them either, for he is very garrulous, and always glad to have an opportunity for speech-making. He has been brought before classes so often now that he is quite prepared for it. Often, as I pass through his ward, he asks when he is to have an opportunity of delivering himself; and he is constantly preparing discourses upon the most diverse and abstract topics. In all the insane, the delusions, as we have seen, relate to them- selves, and first to the condition of their own bodies and minds. You will remember this in the maniacal and melancholic classes, and you will discover it in this patient and in his class. He tells you that he is the strongest man in the world, that he has defeated all the noted pugilists, none of whom could strike him a blow ; and he offers you an opportunity, which we will waive, of seeing how easily he can defeat myself. His health, he tells us, is ” first-rate,” and it is a singular thing how commonly paretics will answer the same inquiry with the same expression. Sankey, an English alienist, first called attention to this curious little point; I have often, in trying it, got the answer first-rate ” from eight or nine out of ten patients addressed, and I think you will be able to verify the result if you try the experiment for yourselves when we come to pass through the wards. This feeling of well-being and health marks the paretic to the end, and his contentment and happi- ness render his disease the least trying, although the most fatal, of the forms of insanity. Up to the last moment, when the patient cannot rise in his bed or move a limb, or swallow, he will tell you that he is first-rate, that his remaining in bed is only a matter of choice, and that he could rise and take part in the most active pursuits, if he so willed it.
In the patient before you the delusions by no means limit themselves to his strength and prowess. He is of great beauty and strength, to be sure, and has lived for millions of years, and made millions of money, part of which is invested in the build- ing in which we are now visiting him. But it is rather upon his intellectual and artistic abilities and achievements that he prides himself. Apart from painting the works that have been ON GENERAL PARESIS. 107 erroneously ascribed to Raphael, and with the exception of the Bible, which he wrote to oblige his friend Martin Luther, the most satisfactory outcome of his genius has been a series of plays which he published under the nom de plume of ” Shakespeare.” He tells you this with all earnestness and gravity, and proceeds to quote from his works, commencing rightly enough, but soon wandering off into disconnected nonsense. It does not do to accuse him of this, however, for he demands, with great prompt- ness and some asperity, whether, having written the work in the first place, he is not privileged to alter it as he may see fit ? He is a linguist too, as well as a litterateur, and boasts a thorough acquaintance with all the known, and several of the unknown, tongues. To Grermans or Poles among the patients, lie will occasionally address himself, using the most absurd gibberish, and complacently attributing their inability to understand him to their ignorance of their own language. He has matrimonial aspirations too: offers himself and tempting settlements to any lady who visits the ward, and justifies himself to us by asserting that his first wife? Queen Victoria?is undoubtedly dead, she having been stolen from him by the Pope some centuries since. For the rest, he is now the contented, self-satisfied man that you see, though at one time he was noisy and destructive and filthy. He imagines that he leaves the asylum whenever he wants to, and gives cir- cumstantial accounts of his excursions and adventures. His imagination transforms the asylum dinner into one of many courses and ample accompaniments, and there is nothing to mar his happiness. He has the usual history of excessive venery, as, indeed, had the patient who preceded him.
Case IV. ?This is the last patient that I shall introduce to you here, for I think that it will be more to your profit to spend the time remaining in the wards, in closer examination of indi- vidual cases. I present him only that I may have a text for briefly calling your attention to a couple of points, in relation to the disease, which the other patients did not specially call out. In the first place, this man comes to us not simply as a patient committed for treatment and care, but as a prisoner under indictment. The crime charged against him is forgery, and it was not until his trial was in progress that suspicion of his insanity was suggested, and he was sent here for examination and report. He is a paretic, evidently, and his forgery, which was of a note or cheque, was, no doubt, committed under the in- fluence of delusions as to his wealth, which he now manifests plainly enough. Many of our paretic patients come to us after arrest and appearance before the courts, and some after sentence even. The evidences of paresis, as you have seen, are not greatly unlike those of drunkenness, and they sometimes lead to mistaken diagnosis upon the part of the finest police force, and even to misdirected therapeusis in the matter of clubs. “Where graver crimes have been alleged against them, they have usually been those of arson or of false pretences. The paretic is very apt to set fire to his residence with the view of replacing it by one better suited to his newly acquired wealth and position ; or he may obtain goods upon false representa- tions as to his solvency and ability to pay for them.
You will observe that this patient does not give a very definite summary of his wealth ; he indicates its extent rather by comparisons than by dollars and cents. This use of the comparative is a common thing among paretics when they are speaking of their powers, or attainments, or possessions. They are richer than Rothschild, or ” biger men than old Grant,” and they are very apt to spell it with one ” g,” too, for the evidences of their disease find their way into their letters very speedily. Apart from the alterations in the handwriting con- sequent upon the loss of co-ordinating power, there are lapses in spelling and grammatical construction, even on the part of those who were before the most accurate. This, of course, comes from the lapse of memory, upon which the delusions also largely depend.
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