Part 43

Various characteristic physical symptoms, depending upon the seat of the cerebral lesion, are met with in the course of this form of insanity. These consist of paraplegias, hemiplegias and muscular contractures. Speech defects are very common, being due either to the enfeebled mental condition, to paralysis of the nerve supplying the muscles of the face and tongue, or to aphasia caused by implication of those parts of the cortex which are intimately associated with the faculty of speech. Mental symptoms vary considerably in different cases and in accordance with the seat and extent of the lesion. There is almost always present, however, a certain degree of mental enfeeblement, accompanied by loss of memory and of judgment, often by mental confusion. Another very general mental symptom is the presence of emotionalism which leads the patient to be affected either to tears or to laughter upon trifling and inadequate occasions.

Cerebral tumours do not necessarily produce insanity. Indeed it has been computed that not one half of the cases become insane. When insanity appears it is met with in all degrees varying from slight mental dulness up to complete dementia, and from mere moral perversion up to the most intense form of maniacal excitement. On the physical side the various symptoms of cerebral tumour such as coma, ataxia, paralysis, headache, vomiting, optic neuritis and epileptiform convulsions are met with. All forms of so-called moral changes and of changes of disposition are met with as mental symptoms and all the ordinary forms of insanity may occur in varying intensity; but by far the most common mental change occurring in connexion with cerebral tumour is a progressive enfeeblement of the intelligence, unattended with any more harmful symptoms than mental deterioration which ends in complete dementia.

Insanity due to Arterial Degeneration.

(b) _Arterial Degeneration._--Arterial degeneration is a common cause of mental impairment, especially of that form of mental affection known as "Early" dementia. It also predisposes to embolism and thrombosis, which often results in the paralytic and aphasic groups of nerve disturbance, and which are always accompanied by more or less marked interference with normal cerebral action.

The commonest seat for atheroma of the cerebral vessels is the arteries at the base of the brain and their main branches, especially the middle cerebral. As a general rule the other arteries of the cerebrum are not implicated to the same extent, although in a not inconsiderable number of cases of the disease all the arteries of the brain may participate in the change. When this is so, we obtain those definite symptoms of slowly advancing dementia commencing in late middle life and ending in complete dementia before the usual period for the appearance of senile dementia. The same appearances are met with in certain patients who have attained the age in which senile changes in the arteries are not unexpected. As a rule atheroma in the cerebral vessels is but a part of a general atheroma of all the arteries of the body. Atheroma is common after middle life and increases in frequency with age. The chief causes are syphilis, alcoholism, the gouty and rheumatic diatheses and above all Bright's disease of the kidneys. Perhaps certain forms of Bright's disease, owing to the tendency to raise the blood pressure, are of all causes the most common.

It is not easy to say to what extent, alone, the arteriosclerosis is effectual in inducing the gradual failure of the mental powers, and to what extent it is assisted in its operation by the action on the brain-cells of the general toxic substances which give rise to the arterial atheroma. In any case there can be no question that the gradual mechanical diminution of the blood-supply to the cortex caused by the occlusion of the lumen of the arteries is a factor of great importance in the production of mental incapacity.

General Paralysis.

GENERAL PARALYSIS OF THE INSANE (syn. General Paralysis, _dementia paralytica_, progressive dementia) is a disease characterized by symptoms of progressive degeneration of the central nervous system, more

## particularly of the motor centres. The disease is almost invariably

fatal. Apparent recoveries do very occasionally occur, though this is denied by the majority of alienists. The disease is in every case associated with gradually advancing mental enfeeblement, and very frequently is complicated by attacks of mental disease.

General paralysis, which is a very common disease, was first recognized in France; it was identified by J. E. D. Esquirol, and further described and elaborated by A. L. J. Bayle, Delaye and J. L. Calmeil, the latter giving it the name of _paralysie générale des aliénés_.

As first described by the earlier writers the disease was regarded as being invariably associated with delusions of grandeur. At the present day this description does not apply to the majority of cases admitted into asylums. The change may be explained as being either due to an alteration in the type of the disease, or more probably the disease is better understood and more frequently diagnosed than formerly, the diagnosis being now entirely dependent on the physical and not on the mental symptoms. This latter may also be the explanation why general paralysis is much more common at the present day in British asylums than it was. The total death-rate from this disease in English and Scottish asylums rose from 1321 in 1894 to 1795 in 1904.

General paralysis attacks men much more frequently than women, and occurs between the ages of 35 and 50 years. It is essentially a disease of town life. In asylums which draw their patients from country districts in Scotland and Ireland, the disease is rare, whereas in those which draw their population from large cities the disease is extremely common.

Considerable diversity of opinion exists at present regarding the causation of general paralysis. Hereditary predisposition admittedly plays a very small part in its causation. There is, however, an almost universal agreement that the disease is essentially the result of toxaemia or poisoning, and that acquired or inherited syphilitic infection is an important predisposing factor. A history of syphilitic infection occurs in from 70 to 90% of the patients affected. At first it was held that general paralysis was a late syphilitic manifestation, but as it was found that no benefit followed the use of anti-syphilitic remedies the theory was advanced that general paralysis was a secondary auto-intoxication following upon syphilitic infection. The latest view is that the disease is a bacterial invasion, to which syphilis, alcoholism, excessive mental and physical strain, and a too exclusively nitrogenous diet, only act as predisposing causes. This latter theory has been recently advanced and elaborated by Ford Robertson and McRae of Edinburgh.

Whatever the cause of general paralysis may be, the disease is essentially progressive in character, marked by frequent remissions and so typical in its physical symptoms and pathology that we regard the bacterial theory with favour, although we are far from satisfied that the actual causative factor has as yet been discovered.

For descriptive purposes the disease is most conveniently divided into three stages,--called respectively the first, second and third,--but it must be understood that no clear line of demarcation divides these stages from one another.

The onset of general paralysis is slow and gradual, and the earliest symptoms may be either physical or mental. The disease may commence either in the brain itself or the spinal cord may be primarily the seat of lesion, the brain becoming affected secondarily. When the disease originates in the spinal cord the symptoms are similar to those of locomotor ataxia, and it is now believed that general paralysis and locomotor ataxia are one and the same disease; in the one case the cord, in the other the brain, being the primary seat of lesion. The early physical symptoms are generally motor. The patient loses energy, readily becomes tired, and the capacity for finely co-ordinated motor acts, such as are required in playing games of skill, is impaired. Transient attacks of partial paralysis of a hand, arm, leg or one side of the body, or of the speech centre are not uncommon. In a few cases the special senses are affected early and the patient may complain of attacks of dimness of vision or impairment of hearing. Or the symptoms may be purely mental and affect the highest and most recently acquired attributes of man, the moral sense and the faculty of self-control. The patient then becomes irritable, bursts into violent passions over trifles, changes in character and habits, frequently takes alcohol to excess and behaves in an extravagant, foolish manner. Theft is often committed in this stage and the thefts are characterized by an open, purposeless manner of commission. The memory is impaired and the patient is easily influenced by others, that is to say he becomes facile. In other cases a wild attack of sudden excitement, following upon a period of restlessness and sleeplessness may be the first symptom which attracts attention. Whatever the mode of onset the physical symptoms which characterize the disease come on sooner or later. The speech is slurred and the facial muscles lose their tone, giving the face a flattened expression. The muscular power is impaired, the gait is straddling and the patient sways on turning. All the muscles of the body, but particularly those of the tongue, upper lip and hands, which are most highly innervated, present the symptom of fine fibrillary tremors. The pupils become irregular in outline, often unequal in size and either one or both fail to react normally to the stimuli of light, or of accommodation for near or distant vision.

As the disease advances there is greater excitability and a tendency to emotionalism. In classical cases the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant acts, such as purchases of large numbers of useless articles, or of lands and houses far beyond his means, numerous indiscriminate proposals of marriage, the suggestion of utterly absurd commercial schemes, or attempts at feats beyond his physical powers. The mental symptoms, in short, are very similar to those of the elevated stage of manic-depressive insanity.

Delusions of the wildest character may also be present. The patient may believe himself to be in possession of millions of money, to be unsurpassed in strength and agility, to be a great and overruling genius, and the recipient of the highest honours. This grandiose condition is by no means present in every case and is not in itself diagnostic of the disease. But mental facility, placid contentment, complete loss of judgment and affection for family and friends, with impaired memory, are symptoms universally present. As the disease advances the motor symptoms become more prominent. The patient has great difficulty in writing, misses letters out of words, words out of sentences, and writes in a large laboured hand. The expression becomes fatuous. The speech is difficult and the facial muscles are thrown into marked tremors whenever any attempt at speech is made. The voice changes in timbre and becomes high-pitched and monotonous. The gait is weak and uncertain and the reflexes are exaggerated. In the first stage the patient, through restlessness and sleeplessness, becomes thin and haggard. As the second stage approaches sleep returns, the patient lays on flesh and becomes puffy and unhealthy in appearance. The mental symptoms are marked by greater facility and enfeeblement, while the paralysis of all the muscles steadily advances. The patient is now peculiarly liable to what are called congestive seizures or epileptiform attacks. The temperature rises, the face becomes flushed and the skin moist. Twitchings are noticed in a hand or arm. These twitchings gradually spread until they may involve the whole body. The patient is now unconscious, bathed in perspiration, which is offensive. The bowels and bladder empty themselves reflexly or become distended, and bedsores are very liable to form over the heels, elbows and back. Congestive seizures frequently last for days and may prove fatal or, on the other hand, the patient may have recurrent attacks and finally die of exhaustion or some accidental disease, such as pneumonia. In the second stage of the disease the patient eats greedily, and as the food is frequently swallowed unmasticated, choking is not an uncommon accident. The special senses of taste and smell are also much disordered. We have seen a case of general paralysis, in the second stage drink a glass of quinine and water under the impression that he was drinking whisky.

The third stage of the disease is characterized by sleeplessness and rapid loss of body weight. Mentally the patient becomes quite demented. On the physical side the paralysis advances rapidly, so that the patient becomes bedridden and speechless. Death may occur as the result of exhaustion, or a congestive seizure, or of some intercurrent illness.

The duration of the disease is between eighteen months and three years, although it has been known to persist for seven.

No curative measures have so far proved of any avail in the treatment of general paralysis.

Epileptic Insanity.

INSANITY ASSOCIATED WITH EPILEPSY.--The term "epileptic insanity," which has for many years been in common use, is now regarded as a misnomer. There is in short no such disease as epileptic insanity. A brain, however, which is so unstable as to exhibit the sudden discharges of nervous energy which are known as epileptic seizures, is prone to be attacked by insanity also, but there is no form of mental disease exclusively associated with epilepsy. Many epileptics suffer from the disease for a lifetime and never exhibit symptoms of insanity. The majority of patients, however, who suffer from epilepsy are liable to exhibit certain mental symptoms which are regarded as characteristic of the disease. Some suffer from recurrent attacks of depression, ill-humour and irritability, which may readily pass into violence under provocation. Others are emotionally fervid in religious observances, though sadly deficient in the practice of the religious life. A third class are liable to attacks of semi-consciousness which may either follow upon or take the place of a seizure, and during these attacks

## actions are performed automatically and without consciousness on the

part of the patient.

When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal.

Epileptic patients who suffer from recurrent attacks of delirious mania are liable to certain nervous symptoms which indicate that not only are the motor centres in the brain damaged, but that the motor tracts in the spinal cord are also affected. The gait becomes awkward and laboured, the feet being lifted high off the ground and the legs thrown forward with a jerk. The tendon reflexes are at the same time exaggerated. These symptoms indicate descending degeneration of the motor tracts of the cord.

If the mental attacks partake of the character of elevation or depression the mental functions suffer more than the motor. These patients, in course of time, become delusional, enfeebled and childish, and in some cases the enfeeblement ends in complete dementia of a very degraded type.

Where insanity is superadded to epilepsy the prognosis is unfavourable.

Toxic Insanity.

INSANITY ASSOCIATED WITH OR CAUSED BY ALCOHOLIC AND DRUG INTOXICATION.--The true rôle of alcoholic indulgence in the production of insanity is at present very imperfectly understood. In many cases the alcoholism is merely a symptom of the mental disease--a result, not a cause. In others, alcohol seems to act purely as a predisposing factor, breaking down the resistance of the patient and disordering the metabolism to such an extent that bodily disorders are engendered which produce well-marked and easily recognized mental symptoms. In others, again, alcohol itself may possibly act as a direct toxin, disordering the functions of the brain. In the latter class may be included the nervous phenomena of drunkenness, which commence with excitement and confusion of ideas, and terminate in stupor with partial paralysis of all the muscles. Certain brains which, either through innate weakness or as the result of direct injury, have become peculiarly liable to toxic influences, under the influence of even moderate quantities of alcohol pass into a state closely resembling delirious mania, a state commonly spoken of as _mania a potu_.

_Delirium Tremens._--Delirium tremens is the form of mental disorder most commonly associated with alcoholic indulgence in the lay mind. Considerable doubt exists, however, as to whether the disease is directly or secondarily the result of alcoholic poisoning. Much evidence exists in favour of the latter supposition. Delirium tremens may occur in persons who have never presented the symptom of drunkenness, or it may occur weeks after the patient has ceased to drink alcohol, and in such cases the actual exciting cause of the disease may be some accidental complication, such as a severe accident, a surgical operation, or an attack of pneumonia or erysipelas.

The early symptoms are always physical. The stomach is disordered. The desire for food is absent, and there may be abdominal pain and vomiting. The hands are tremulous, and the patient is unable to sleep. At this stage the disease may be checked by the administration of an aperient and some sedative such as bromide and chloral. The mental symptoms vary greatly in their severity. In a mild case one may talk to the patient for some time before discovering any mental abnormality, and then it will be found that confusion exists regarding his position and the identity of those around him, while the memory is also impaired for recent events. Hallucinations of sight and hearing may be present. The hallucinations of sight may be readily induced by pressure upon the eyeballs. If the symptoms are more acute they usually come on suddenly, generally during the evening or night. The patient becomes excited, suffers from vivid hallucinations of sight and hearing which produce great fear, and these hallucinations may be so engrossing as to render him quite oblivious to the environment. The hallucinations of sight are characterized by the false sense impressions taking the forms of animals or insects which surround or menace the patient. Visions may also appear in the form of flames, goblins or fairies. The hallucinations of hearing rarely consist of voices, but are more of the nature of whistlings, and ringings in the ears, shouts, groans or screams which seem to fill the air, or emanate from the walls or floors of the room. All the special senses may be affected, but sight and hearing are always implicated. Delirium tremens is a short-lived disease, generally running its course in from four to five days. Recovery is always preceded by the return of the power of sleep.

The patient must be carefully nursed and constantly watched, as homicidal and suicidal impulses are liable to occur under the terrifying influence of the hallucinations. The food should be concentrated and fluid, given frequently and in small quantities.

_Chronic Alcoholic Insanity._--Almost any mental disorder may be associated with chronic alcoholism, but the most characteristic mental symptoms are delusions of suspicion and persecution which resemble very closely those of the persecution stage of systematized delusional insanity. The appearance of the patient is bloated and heavy; the tongue is furred and tremulous, and symptoms of gastric and intestinal disorder are usually present. The gait is awkward and dragging, owing to the

## partial paralysis of the extensor muscles of the lower limbs. All the

skeletal muscles are tremulous, particularly those of the tongue, lips and hands. The common sensibility of the skin is disordered so that the patient complains of sensory disturbances, such as tinglings and prickings of the skin, which may be interpreted as electric shocks. In some cases the mental symptoms may be concealed, but delusions and hallucinations, particularly hallucinations of sight and hearing, are very commonly present. The delusions are often directly the outcome of the physical state; the disordered stomach suggesting poisoning, and the disturbances of the special senses being interpreted as various forms of persecution. The patient hears voices shouting foul abuse at him; all his thoughts are read and repeated aloud; electric shocks are sent through him at night; gases are pumped into his room. Sexual delusions are very common and frequently affect marital relations by arousing suspicions regarding the fidelity of wife or husband; or the delusions may be more gross and take the form of belief in actual attempts at sexual mutilations. The memory is always impaired.

Patients who in addition to chronic alcoholism are also insane are always dangerous and liable to sudden and apparently causeless outbursts of violence.

_Dipsomania._--Dipsomania is a condition characterized by recurrent or periodic attacks of an irresistible craving for stimulants. The general bodily condition has a great deal to do with the onset of the attack, that is to say, the patient is more liable to an attack when the bodily condition is low than when the health is good. The attacks may be frequent or recur at very long intervals. They generally last for a few weeks, and may be complicated by symptoms of excitement, delusions or hallucinations.

_Treatment_ consists in attention to the general health between attacks, with the use of such tonics as arsenic and strychnine. During the attack the patient should be confined to bed and treated with sedatives.

_Morphinism._--The morphia habit is most commonly contracted by persons of a neurotic constitution. The mental symptoms associated with the disease may arise either as the result of an overdose, when the patient suffers from hallucinations, confusion and mild delirium, frequently associated with vomiting. On the other hand, mental symptoms very similar to those of delirium tremens may occur as the result of suddenly cutting off the supply of morphia in a patient addicted to the habit. Finally, chronic morphia intoxication produces mental symptoms very similar to those of chronic alcoholism. This latter condition, characterized by delusions of persecution, mental enfeeblement and loss of memory, is hopelessly incurable. The patient is always thin and anaemic on account of digestive disturbances. There is weakness or slight paralysis of the lower limbs, and the skeletal muscles are tremulous.

_Treatment._--The quantity of the drug used must be gradually reduced until it is finally discontinued, and during treatment the patient must be confined to bed.

Senile Insanity.

SENILE INSANITY.--States of mental enfeeblement are always the result of failure of development or of structural changes in the cortical grey matter of the brain. If the enfeeblement is due to failure of development or brain damage occurring in early life, it is spoken of as _idiocy_ or imbecility. Every form of insanity which occurs after a certain period of life is apt to be regarded by some observers as senile, but although the failing mental power may colour the character of the symptoms it cannot be regarded as correct to designate, for instance, a recurrent form of mania as senile merely because it necessarily manifests itself in a subject who has lived into the senile period. On the other hand, many persons first suffer from mental derangement at an advanced period of life without at the same time manifesting any marked failure of mental power, while others only manifest their insanity as a result of the decay of their mental faculties.

From this statement it will be seen that senile insanity is a complex of different conditions, some of them accompanied by dementia, others without dementia.

_Senile Dementia_ is distinguished occasionally into "senile" properly so called, and "presenile" dementia, which supervenes at middle age or even earlier.