Syphilis and Birth Difficulties in
- Author:
Hehnry Harris, M.D., D.P.M.
I.?Method
Out of slightly over 2,000 medium- and low-grade mental defectives at Caterham Mental Hospital, 159 were selected as cases of ” combined defect,” i.e., having definite organic nervous lesions along with their mental defect. Of these 8 were excluded because their lesions were not definitely pre- natal or natal. Several were post-encephalitic, one was probably a case of Schilders disease. Several cases of hypertrophic muscular paralysis were also omitted because we have no evidence here that the nervous system is involved. Only those with unequivocal nerve lesions were included in the series. Those who have worked with idiots and imbeciles will appreciate the difficulty of a neurological examination where resistiveness, disuse contractures and so on have to be allowed for. I am indebted and grateful to Dr Kinnier Wilson, neurologist to the Metropolitan Asylums Board, for his encouragement and help with the more doubtful cases.
Of the 151 cases discussed here?comprising about 7.5% of the hospital population?a number have already been included in a paper by Dr J. L. Gordon on ” The Incidence of Congenital Syphilis in Mental Deficiency.” The present paper is the result of a further examination during 1926-1929, of the neurological cases mentioned in this paper and of other cases: of an attempt to classify the commoner neurological disorders found and to correlate them with the obstetric history and the serum Wasserman reaction.
The. Wasserman technique employed was that described by Dr J. L. Gordon in the M.A.B. annual report for 1923-4. The obstetric histories were obtained from the parents in most cases: otherwise from a questionnaire sent to the parents or in the last instance from the family history taken on admission. They are, of course, not as reliable as first-hand reports by obstetricians, but they were the best possible in the circumstances.
II.?A Clinical Classification of the Neurological Lesions Found
Among the neurological disorders that were found were the following: ? OO ^ 1. The hemi- and mono-piegias. One hemiplegia, diagnosed as post- diphtheritic by Dr Kinnier Wilson, was excluded from the series.
2. The cerebral diplegias. These form a wide and indefinite group, but for convenience are considered together. Undoubtedly, ” cerebral diplegia ” is the name of a syndrome associated with different diseases of different path- ology and due either to congenital, natal or acquired causal factors. This has been further discussed in a previous paper.
In the course of about 2^ years of work with such cases, one was unable to draw up even a tentative classification. Much work remains to be done in this respect.
The following are some of the types considered here under the term ” cerebral diplegia ” : ? a. The ordinary spastic diplegias or ” Littles disease.” b. The athetoid, choreiform and choreo-athetoid diplegias. According to Kinnier Wilson, these are related to group (a): the differentia being the varying degree and extent of decerebration present.
Foersters atonic diplegia and Hunts ataxic diplegia are not separ- ately considered here. Although 2 or 3 cases were found which might have been included in the latter group, it was not considered that they could be definitely distinguished from the spastic diplegias of group (a).
The tetraplegias: probably related to group (a).
The diplegias associated with microcephaly.
The diplegias associated with hydrocephaly.
Congenital syphilitic lesions, i.e., juvenile G.P.I., or syphilitic myelitis.
III.?The Incidence of Positive Wasserman Reactions
Of the 151 cases, 32 or 2i.2?/a had a positive Wasserman reaction. Gordon found an incidence of 16.5% in his 1913 series of about 400 cases of defectives and of 15.65% in his 1926 group of 575 cases. Within the latter group the incidence in those with ” combined defect ” was 21.6% : whereas in those without such defect it was 14%. This incidence is practically the same as in the present series with which it partly overlaps. Dayton, summarising all the previous series up to the date of his paper in 1925, concluded that the incidence of positive Wasserman reactions among mental defectives was 7.8% and among normal children 5.3%. The incidence in the different series varied widely from 1.5% to 55%. No numbers were given with regard to those suffering from combined defect. Of the 151 cases, 35 or 23.18% were hemiplegic, 113 or 75.49% were lumped in the diplegia group and there were three cases with congenital syphilitic lesions. Two of the latter had G.P.I.; one was a case of syphilitic myelitis. All three had a positive Wasserman.
Of the 35 hemiplegics, 7 or 20% were positive. Of the 113 diplegics, 22 or 19.48% were positive. The total incidence of positive reactions among combined defectives is therefore about 2/% : greater than the incidence of 14% in those of Gordon’s series who had no lesions: and still greater than Dayton’s incidence of 7.8% among defectives of all grades. The incidence among hemiplegics and diplegics was about the same and in the neighbourhood of 20%. The few cases of clinical syphilis were all positive.
IV.?The Incidence of Birth Difficulties
The criterion of birth difficulty was: either an instrumental delivery, a second and third stage of more than 24 hours’ duration in all, a premature or precipitate delivery, or an abnormal presentation: in so far as such data could be obtained from the parents, in some cases from a questionnaire submitted to them, and in the last instance from the history taken on admission. Of the 151 cases, 49 or ^2.45% had birth difficulties. This included : ?
20 Forceps delivery Prolonged labour Breech Version Premature labour Precipitate labour r7 6 2 3
Of the 35 hemiplegics, 10 or 25.57% had difficulties: of the 113 diplegics, 38 or 33-63%. The total incidence of birth difficulties among combined defectives averages therefore about 3o%0. It would be interesting to compare this with the incidence among physicallv normal defectives and among normal children. On the face of it, the present figures seem to indicate that it must be considerably greater among the combined defectives.
One cannot, however, decide?on the strength of these figures?how much the birth difficulties are the result of a pre-natal condition rather than a natal cause of defect. That birth injuries can cause mental deficiency with or without lesions seems to be generally accepted.
V.?Conclusions
1. About 20% in the present series of 151 ” combined defectives “had positive Wasserman reactions: the incidence was about the same in both the diplegic and hemiplegic groups. 2. About 30% had a history of birth difficulties: the incidence in the two sub-groups varied but little. 3. The attempt to classify the types of neurological lesions that one found, was unsatisfactory. It does not seem likely that a satisfactory classifica- tion will be elaborated until team work enables a really scientific histological examination of the anatomy of the central nervous system of large numbers of mental defectives to be correlated with the clinical findings and with routine C.S.F. and serological findings.
Birth data should also be correlated with the clinical and histological picture; and this will require the co-operation of trained social workers, of obstetricians and of general practitioners.
VI.?References
DAYTON. Mental Hygiene, 1925, October, p. 760.
GORDON, J. L. M.A.B. Annual Report, 1923, p. 177.
(3) GORDON, J. L. M.A.B. Annual Report, 1926-7, p. 290. The incidence of congenital sy-philis in mental deficiency. (4) HARRIS, H. Mental Deficiency and Maladjustment. Brit. Jour. Med. Psych. VIII, 1928. (5) WILLIAMS, A. C. Combined Defect. Mental Welfare, Oct., 1926. (6) WILSON, S. A. Kinnier. On Decerebrate Rigidity in Man and the Occurrence of Tonic Fits. Brain, XLIII, 220. 1920.
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