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 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.
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 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.