Original Communications. Notes on Syphilis in the Insane.-By W. JULIUS MICKLE, M.D., PART I. Intracranial Syphilis and Insanity. In dealing with a considerable number of men suffering from cerebral affections, or other nervous diseases, the question of the existence of syphilis as a cause or as a concomitant often arises, and is one of extreme interest, as well as of great practical importance for the direction of therapeusis. It may not, therefore, be out of place to put on record some of the cases observed by the writer, and especially so as the recent discussion on syphilis at the Pathological Society of London indicates that clinical observations, bearing upon the syphilitic nervous affections and their relations to other diseases of the nervous system, may not be without their uses. The notes which follow relate to syphilis as it has been studied in the military class of the insane patients under my care, and attention will be confined to the experience of the last three years. The class of insane private gentlemen is excluded from consideration in this investigation. The daily average number of insane soldiers under care here during the period just mentioned has been between three and four hundred, and the total number about six hundred; but I do not state any per-centage, either of the occurrence of ordinary constitutional syphilis or of syphilitic affections of the nervous system among them, as it is thought that such statistics would prove fallacious. That they would prove fallacious is probable for these reasons: (1.) It is often difficult to obtain a history of the patient's antecedents. (2.) Being insane, many of the patients are mentally unfitted to give the desired information, their memory is apt to be treacherous, their inattention and self-neglect extreme, and the reports of some are based upon delusions. (3.) It is particularly in instances where syphilis affects the nervous system that its evolution is sometimes insidious; that its later lesions are not preceded by its usual characteristic development on the exterior of the body, or by only a partial, or slight, or transitory development; and that the 115-LVIII, 11 a diagnosis is surrounded by obscurity. This is the opinion of several writers on the subject, and more than once the fact has forced itself upon my attention. The difficulty and obscurity which arise from this cause reach their height in dealing with the insane, partly for the first two of the reasons just mentioned, and partly because syphilis, though frequently the cause of nervous symptoms, is often in them the accidental associate of grave disorders of the nervous system, having an origin independent of syphilis, complicating its effects, or even overriding them. But the vital importance of the recognition of the syphilitic element when it holds place as a cause, and of tracing the effects of the virus and of the sequelae, reaches its acme in these very cases, and one must attempt to read them by the light of observations made on the more simple examples occurring among the sa ne. Almost every day it is necessary to decide whether or not active or smouldering syphilis is present in the system, and, if present, whether it is the cause, or one of the causes of mental aberration and of nervous lesion; or whether it modifies these; or, finally, is a comparatively innocuous and accidental complication. In some quarters a considerable variety of clinical symptoms have been fathered upon syphilis where the affiliation might well be disputed, in others the pathological anatomy of syphilitic affections has been extended too widely. It will probably be thought that in practice I have under-estimated the importance of the syphilitic element rather than the reverse, when we recur to the fact that the instances of syphilis-cerebral or other—about to be mentioned, were derived from about six hundred insane soldiers, who have been under care here during one part or other of the period previously mentioned. These men, for the most part celibate, in the vigour of masculine life, many of them careless, reckless, and comparatively ignorant of consequences, and usually drawn from a class in whose untrained minds the passions have but little control, are notoriously liable to contract the specific lues. Many are the victims of Bacchus, and not a few suffer from the wounds of Venus, while some veterans carry in their bodies the effects of both. About forty cases will be mentioned. In a still larger number of other cases more or less evidence of syphilis existed, but for various reasons they will not be detailed here. The cases will be described in three parts, of which the present communication forms Part I. It contains cases in which organic syphilitic lesions affected the brain, meninges, or intracranial nerves. In the second part will be found; (1), a résumé of the various 1 Broadbent, Lettsomian Lectures' (I), "On Syphilitic Affections of the Nervous System.' Buzzard, Syphilitic Nervous Affections,' p. 42. In deciding as to the continuance of constitutional syphilis, the persistent multiple indolent bubo has not been found, in these cases, to have the diagnostic importance assigned to it by Surgeon Venning, 'Clin. Soc. Trans.,' vol. viii, p. 62. instances of insanity in syphilitics, with reference to the varieties of so-called "syphilitic insanity; (2), instances bearing on the etiology of acute forms of insanity intercurrent in secondary syphilis; and (3), cases which bear upon the alleged connection between aortic endarteritis and syphilis. The third part will refer to the relations existing between brain syphilis and general paralysis. 66 PART I. Cases of Intracranial Syphilis. Two quotations embody all that need be said in preface to these cases; one, that the whole group of syphilitic nervous affections are primarily non-nervous; " the other, that "it is not in individual symptoms, or in any arbitrary and unexplained difference in the phenomena that we shall find the distinctive characters of syphilitic affections of any part of the nervous system."2 CASE 1.-Dementia; physical signs simulating general paralysis; headache; epileptiform attacks; transitory hemiplegia; recurrence of epileptiform convulsions, assuming an excessively violent form, and occurring in rapid succession; death in the "status." Syphilitic disease of the brain, cerebral arteries. Spleen, liver, skin, and testis. A private in the 11th Regiment was admitted in October, 1874, age 41, service 16 years; previously under treatment at Devonport and Netley. The cause was stated to be uncertain. The history received with him was to the effect that mental disease was insidiously developed about July, 1874, but that his conduct had been reported as being peculiar for some time previously, and that the symptoms partook of the nature of dementia from the first. The medical certificates from Netley testified to his incoherence in conversation, confusion of thought, and failing comprehension. Further, that memory was almost lost, that he was inclined to be destructive and filthy, and was restless at night, fancying then that the men of his regiment were about him; and that he suffered from increasing general paralytic disability. Secondary dementia and paralysis of insanity are both mentioned as the form of his mental disease. On admission. Physical state: Height 6 ft., weight 12 st. 2 lbs. There is some fibrillary tremor of the tongue when protruded, pupils ordinary, except that the left one is at times slightly irregular in shape, facial capillaries dilated, features full and the lines of expression partially obliterated, speech deliberate and at times faintly hesitating, but not accompanied by facial tremors. The left cheek is covered by depressed, irregular, whitish cicatrices lying in an ele 1 J. Hughlings Jackson, Journ. Mental Science.' ་ 'W. H. Broadbent, Lettsomian Lectures' (II). vated, dull red, vascular area of the skin, which at one point assumes rather a tubercular appearance. Similar, but smaller, patches exist on both temples and on the right cheek. He says he has no headache now, but has suffered much from frontal pain, and feels pain around both thighs, especially when he gets warm in bed. Writes legibly but with a little shakiness. Is slow and inactive in all his movements, and there is just perceptible a slight dragging of the left foot. There are some rounded, whitish superficial cicatrices on the right forearm, and a dull purplish irregularly depressed one just above the left elbow. These he attributes to "venereal." Two pale little tubercles are seen on the nape, there is a slightly indurated scar on the skin of the prepuce and traces of other sores. Inguinal and cervical glands rather well marked. Chronic indolent enlargement of the right testicle. Passes urine and fæces involuntarily during the examination. Mental state. Is highly amnesic and emotional. Is slow in comprehending and answering any question. The loss of memory is so great that he utterly confuses times and places, sometimes forgets that he has been at Netley, and speaks of the occurrences of several months ago as having happened yesterday, and says he "saw his regiment on parade last week." He was received here without any history of syphilis, but from the general physical and mental condition, as noted above, the diagnosis was made that he was the subject of cerebral disease of syphilitic origin, and he was placed on ten grains of iodide of potassium, with six of carbonate of ammonia, three times a day. Recently I have been able to ascertain the fact that he contracted syphilis while serving in the army, but the date and place are not ascertained. On December 10th he had two severe convulsive attacks-7.30 and 10 a.m., and at 1.30 p.m. there was slight spasmodic action on the right side of the face, the pulse being 100 and the temperature 102°. Bromide of potassium was added to his mixture and nothing further of a special nature occurred at that period. After four months and a half of treatment the above mixture was temporarily discontinued on April 14th, 1875. At this date he had improved greatly in mental condition, was bright and far more intelligent than on admission, and had regained his memory to a considerable extent. He was cheerful and took pleasure in joining in the occupations and amusements of his fellow patients. He also wrote long coherent letters to his friends containing many scriptural quotations. He had grown much stouter. The tongue was still a little tremulous on protrusion; the purplish discoloration of the cicatrix above the elbow had faded away. He continued in this condition until May 12th, when he was found to be confused and stupid, the articulation was impaired and mumbling, and there was incomplete left hemiplegia, especially of the face and upper extremity. It was not known that any convulsion had occurred. The mixture was resumed and was given every three hours, so that he took eighty grains of the iodide daily. Next day, the hemiplegia, though not quite so decided, was still very evident, and the saliva was dribbling from the left side of the mouth. He was still confused and was rather obstinate and impatient. For two or three days after this he improved, but had several slight epileptiform attacks. On the morning of May 17th, excessively severe convulsions came on in rapid succession. For several hours he had as many as twenty in each hour, lying perfectly unconscious in the epileptic status, with swollen livid purple face, and eyes deeply injected and red. The fits were quick both in their onset and in their subsidence. The course of each fit was mostly as follows. It began with tonic spasm of the right side of the face and mouth, which were drawn thereby towards the right. The head and eyes turned to the right, the right orbicularis palpebrarum partially closed in tonic spasm, and the right forearm was raised and drawn forward. Then immediately clonic spasm came on and affected in rapid succession the right side of the face, the mouth, and orbicularis palpebrarum, the eyeballs were convulsively jerked and clonic convulsion extended to the right upper, and to the right lower, extremity. The left side of the face and the left eyelids became involved also, and there was a good deal of working of the jaws. In the upper extremity there was, at the very first, flexion of the forearm which was drawn upwards, and the elbow was thrown out from the side. In the clonic spasm which followed, and was most marked at the upper arm, the elbow was held flexed at right angles and was jerked backwards, the thumb was kept straight and the fingers were flexed rather firmly on the palm. Three things occurred almost simultaneously at every onset : the mouth and face were drawn towards the right, the head and eyes turned to the right, and the arm was drawn upwards and outwards, the forearm upwards and forwards. Then almost instantly clonic spasm came on, and in the later fits was seen first on both sides of the face. When the convulsion was fully developed the face and mouth continued drawn towards the right, the right side of mouth being the more widely open, the head and eyes still turned to the right; the convulsive action was more marked in the right than in the left orbicularis palpebrarum but was always equally developed in the two sides of the occipito-frontalis. It was seen also in the left face; the muscles of both sides of the trunk were implicated in the more severe fits, and in them the left thigh jerked also. In the short intervals between the fits there was sometimes twitching about the right angle of the mouth. After seven hours the fits ceased but the pulse still rose in frequency (90 to 110), respiration was heavy, laboured, and stertorous, and the lividity and congestion of the surface marked. The perfect coma, also, continued after the fits had |