Mr. ——, age 52, married, a clergyman: his mother died of apoplexy; two of his four brothers are insane. He had the usual illnesses of childhood in mild form, diphtheria of the worst type in 1869, and in recent years, according to his belief, malaria, as he had lived in a malarial region eleven years. As a young man he was of robust frame and vigorous health, brought up on a farm. He overworked, denied himself, and overtaxed, in getting his education, a brain not trained from early years to exacting labor. Eight years ago, for the first time, and at intervals since then, he has had attacks of mental confusion, dimness in sight, and indistinct articulation lasting from a few moments to several minutes. Three years ago, after great emotional strain, people began to notice that his preaching had lost in animation and force, and they complained that he had suddenly become more radical in his views. Great mental worries occurred soon after. There had been no alcoholic or other excess, except of mental overwork, and there could be no reasonable possibility of syphilis, unless we adopt Hebra's dogma, “Jeder Mensch kann syphilitisch sein”—that the means of innocently acquiring that disease are so widespread that no one can be said to be free from the danger of it. Nearly two years ago, in the dark, while feeling tired mentally and physically, but not ill or dizzy, in alighting from a coach he missed the step and came to the ground on his feet with great force. He walked to the house of a friend, and was found by one of the family on their entry floor groaning, but not unconscious. He could not stand or talk, vomited incessantly, and complained of a horrible pain in the back and top of his head. Two days later, and each succeeding Sunday, he preached, obstinately and unlike him refusing to listen to advice to keep quiet; but he remained in bed between Sundays for three weeks, when the striking symptoms disappeared; but he had never felt entirely well since then—never had the same animation. He was supplying various pulpits, and found, wherever he had preached before, that people complained that there was a general lack of vigor in his preaching. Two years ago he observed that his right leg had less life in it than was natural, and soon after that both legs seemed heavy—that it was less easy to run up and down stairs, which his wife also noticed several months later. He also has had for a year a strange feeling, a sort of numbness, in his legs. He thought that his handwriting and speech have continued as good as ever, but has observed that he has had to change to a stub pen, as he found difficulty in writing with the old sharper-pointed kind; that his voice had grown less clear; and that he has rapidly become farsighted. He has never had any dizziness, pain, ache, or uncomfortable feeling about his head, except during the attacks already referred to. There have been no thoracic or abdominal symptoms, no neuralgia or rheumatism. Appetite and digestion have been faultless. He has lost about ten pounds in flesh. He has slept soundly, but is often restless, getting in and out of bed. He says that he was depressed for lack of employment; that he is not irritable, but that his family would say that he is not as tractable as he was, not as patient, less easily satisfied; that his son and wife would say that he is not what he once was—that his memory is not as clear and vivid as it was. He is conscious that within the last two years he has had violent, uncontrollable passionate outbreaks from trivial causes. He preaches his old sermons, because he thinks they are too good to be lost, and because he takes pleasure in rewriting them, in doing which he remarks that the handwriting becomes progressively worse toward the end of each sermon. He says that he can write still better sermons, but does not like to make the effort. When he went into the pulpit a week ago he was told not to announce a second service, but everybody seemed to him so pleased with his preaching that a week later he gave word that there would be an evening service, to which, he laughingly said, only one person came. In standing with his eyes closed and feet together there was a little unsteadiness. On attempting to turn around or to stand on one foot with eyes closed there was some, not very great, ataxia. In these trials the unsteadiness and ataxia soon became very striking on prolonging the muscular effort a few moments. His hands had a powerful grasp, each marking 74 with the dynamometer, and on being stretched to their full extent, with fingers spread, immediately thereafter the fibrillary tremor could be seen only on close examination. There was no marked tremor of the muscles of the lips or face, except in movements which placed them at extreme tension. The tongue was quite tremulous on being protruded to its full length and held there. In walking in a rather dark entry the steps seemed to me shortened and the feet wider apart than in his natural gait, and he did not raise his feet as much, which he noticed also. In going up stairs he placed the whole foot, heel and all, on each step to keep his balance. He turned very deliberately, keeping the feet near together and not raised from the landing. On coming down he evidently steadied himself by a muscular effort extending to his head and shoulders. The knee-jerk was well marked and alike in both legs, but I could not say that it was exaggerated. There had been no change in the sexual function.
His general mental state seemed to me to be of a quite superficial kind of despondency at his prospects, and yet absence of a corresponding degree of anxiety for the future; of satisfaction with his ability and worth; of a feeling that his family are unduly anxious about him; and of a prevailing state of inappreciation of the whole situation, and of a general state of happiness which was abnormal—an opinion which his wife afterward corroborated. He was quite emotional, and easily and rapidly moved to smiles, and from them almost to tears.
In explaining his restlessness at night he stated that he was taking quinine for his malaria, and that it acted on the liver so as to increase the flow of urine, which he repeated several times, but laughingly said, “Of course; how foolish!” when I suggested that he meant the kidneys. In removing his clothes for a physical examination I found that he had two starched shirts on—the one in which he went from home, and that in which he preached, in order not to rumple the second one. When I asked why he could not take home a soiled shirt in his valise after having brought a clean one in it, the idea struck him that he, after all, had done something foolish.
The examination of chest, abdomen, and of the urine was negative. I could not find anywhere evidence of anæsthesia, hyperæsthesia, or paræsthesia, general or local. The reaction of the muscles to the faradic current seemed normal. By ophthalmoscope and otherwise the eyes showed only the emmetropia already referred to. Hearing was also normal, as well as the other special senses. In a close examination I could at first not discover anything about his speech more than an extreme deliberation in articulation, which might perhaps have been natural to some scholarly men, but which I afterward learned had been only of recent origin, and increasing. It was more pronounced after the patient became a little wearied, and then I found that he could not articulate a long word with several labials and linguals without manifest difficulty. I gave him a sheet of paper and asked him to write from top to bottom. He could not think of anything to write. When I told him to put down the text of his sermon of the previous day, he could not possibly remember it; no more could he call to mind a sentence or a sentiment from it. What he wrote is marked No. 1. His normal handwriting, No. 2, is of the date of 1881. Nos. 3 and 4 were copied from an old sermon a few weeks previous to his visit to me, and are taken respectively from the first page and the next to the last of the copy. The facts may be observed that the old handwriting is quite free, with an easy sweep of the pen. In the copy of the sermon the first page shows that the pen is held stiffly and tightly, and that the lines are not made with as steady a movement of the hand as in the old handwriting. The lower lines on the first page are a trifle worse than the upper, and pretty much like the second and third pages, from which there is progressive deterioration to the end. The page written in my office was very carefully done, and, under the circumstances, is marked by such muscular unsteadiness and evidence of mental impairment and enfeebled memory as to be almost, if not quite, of itself pathognomonic of general paralysis.
FIG. 15.
I purposely made no remark to the patient, and he made no inquiry, about diagnosis or treatment. He would have missed his train, although there was a clock in my office, had I not reminded him of the late hour, whereupon he made all his arrangements with care, good judgment, and accuracy, and reached his home safely. As he walked briskly down the even sidewalk I doubt whether any one, even a physician, would have remarked any unsteadiness or anything abnormal about his gait. If he had been followed a few blocks, until the idea of catching his train had ceased to stimulate him, and after he had reached the crowded thoroughfares of the city, especially as he stepped up and down curbstones or walked slowly to avoid teams at crossings, a close examination would undoubtedly have shown the defects in gait already pointed out.