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LECTURE XXV.

GENERAL PARESIS.

Synonyms — Importance—Definition—Ætiology-Sex-Age-Heredity-So

cial Position- Locality-Statistics : 1. In New England Institutions; 2. New York Institutions, Michigan Institutions—Comparison of the Different Sections, Different Nationalities, and Races-Sexual Indulgence- Table of Causes from Reports of the Commissioners of Lunacy in England Syphilis—Intemperance in the Use of Alcohol-Acquired or Inherited Tendency-Symptoms : 1. During the Initial Period— May be Those of Elation or Depression—Peculiarities of Mental and Physical Symptoms in Both These States—Duration of Initial Period.

Synonyms.-General paralysis of the insane. Paralytic insanity. Paralytic dementia. General paralysis. Paretic dementia. Progressive general paralysis.

The discovery and differentiation of no form of insanity has been attended with such important results to psychology as those of the disorder we are now to study. Concerning no form of mental disease has there been so much written during the past twenty-five years in Germany, France, and Great Britain. This has been due not only to its great intrinsic importance, but also in part at least to the fact that it is attended by, or consists in, lesions of the brain and other portions of the nervous system which are easily demonstrable. The interdependence of mind and brain have by this fact been more definitely and clearly shown than ever before. Some knowledge of this disease is of special importance

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to medical students and general practitioners in this country from the fact that it appears to be rapidly increasing, especially in large cities. This is doubtless due to the development of conditions and changes in the habits and practices of society as well as in the forms of our civilization which will hereafter be referred to and explained. Our progress in its study may be facilitated by presenting some form of definition with which to commence, and yet so multiform are its symptoms and so diverse are its anatomical lesions that it is not easy to formulate one in the compass of a few lines. I, however, suggest the following as sufficiently accurate for our present purpose.

Definition.-General paresis is a disease primarily affecting the brain and nervous system; attended by organic changes in the cortex and some of its membranes; evidenced by mental symptoms of an expansive and exalted, or in some cases of a depressive character; also by certain physical symptoms, such as paresis resulting in a peculiar affection of the speech, especially in the articulation of words; disorders of motility, incoördination of gait, and generally with disorder of sensibility, and finally with paralysis; the disease passing through a more or less definite course, ending in death within a few years after the appearance of characteristic symptoms.

Ætiology. PREDISPOSING.-1. Sex.--The statistics of all authorities agree in demonstrating that general paresis is much more prevalent among males than females. The degree of difference, however, varies considerably with different writers and in different localities. In my own statistics, hereafter referred to, relating to New England, it is found that the admissions of female paralytics stand, in proportion to that of males, almost exactly as one to ten,

in those relating to New York, as one to six and five-tenths, showing a large difference in the two localities.

Taking the two States of Vermont and Maine, in which there are no large cities, and we find the proportion of female paralytics to male is that of one to three and fivetenths, thus exhibiting a difference of six and five-tenths per cent., as compared with the numbers which cover the six New England States, and the percentage of both sexes is also lower. Among populations residing largely in the conditions of country life, therefore, exciting causes appear to affect both sexes more nearly in the same degree than in centres having a large population.

The Commissioners in Lunacy, in England, make the proportion of admissions four males to one female. In Germany the ratio is much greater in public than in private asylums, it being nine to one in the former, and only about four to one in the latter. Dr. Mickle has computed the admissions to asylums in England, amounting to 54,642, and finds that the per cent. of general paresis among males was 12.65 and among females 3.25, which would yield a proportion of about four to one.

The ratio of the sexes at the Retreat, during the past twenty years, has been eight males to one female.

2. Age.—This form of disease is much more common between the ages of thirty-five and fifty years than during an earlier or later period of life. Of the seventy-four cases which have been in the Retreat during the last twenty years, the youngest male was twenty and the youngest female was twenty-six at the time of admission. The oldest male was sixty-nine and the oldest female was sixty-one. The average age of males was forty-five, and that of females was forty-eight. I saw the case of a female patient in la Salpêtrière, Paris, several years since, who was only eighteen; and

cases are reported as occurring at a still earlier age. These extremes, however, in either direction among males or females, are the exceptions, and comprise but a very small proportion of the total number of cases. The large majority of cases, as indicated in the above average among men, occur in the prime of physical development, and when the brain and whole nervous system are in the highest state of functional activity and vigor.

The above average age among female general paretics is at variance with general statistics, which indicate that the disease appears in women from three to five years earlier than among men, instead of three years later. Modern and fuller statistics tend to show that general paresis appears within the last ten years, in a larger proportion of cases, at an earlier period of life than the statements of some authors would seem to indicate.

3. Heredity.—Hereditary influences have been regarded as one of the strongest predisposing causes of general paresis. We should predicate this from the character of the disease itself. As it appears to arise primarily in a hyperemic, or subacute, inflammatory process, which affects the cerebral cortex, we certainly are warranted in conjecturing that persons who are leading lives attended with great mental excitement, reverses in fortune, and consequent strain and disappointment, will be more likely to beget offspring who may, under the influence of exciting causes, develop general paresis. Without doubt, in this manner heredity becomes a most important factor as a predisposing cause. Indeed, there can be as little doubt that there exists a general paretic dyscrasia or diathesis, as that there is a cancerous or a tuberculous diathesis; and as both these have been evolved, in the process of time, from the influence of certain experiences which pertain to life in the conditions

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of civilization, so in like manner will a general paretic diathesis develop into a larger degree of activity, and consequent frequency of transmission, under the stimulation of the twentieth century civilization and the influence of certain diseases.

In my own cases, hereditary influence appears to have existed in nineteen per cent. of males and in 22.2 per cent. of females, this number having had parents who had suffered from some forms of mental or brain diseases. In the tables of Dr. Mickle, heredity existed in 14.3 per cent. of males and in 19.1 per cent. of females.

4. Social Position.—There exists no doubt that the general conditions incident to life in the lower ranks of society predispose to some forms of mental disease, and that a higher per cent. of these classes than of the more wealthy become insane. Does the same rule hold true in the case of general paresis? I have no information or general statistics of hospitals in this country which will shed light on this subject. Referring to those presented by Dr. Mickle, we find that out of 5454 private male patients, the per cent. of general paralytics was 9.63, and in 4173 female patients the per cent. was 1.84. Total, 5.91 per cent. of private admissions.

Of 22,113 pauper male patients, 13.38 per cent were general paretics, and of 23,811 pauper female patients, 3.5 per cent. were general paretics, yielding 8.21 per cent. of pauper admissions. This indicates nearly four per centmore of general paresis among pauper male patients than among private male patients, and 1.22 per cent. more of pauper females than of private females.

It should, however, be borne in mind that more or less of those classified as pauper cases, because in public asylums, actually have belonged to the higher classes, or at least

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