A Case of General Paresis 
of Fourteen Years’ 
Standing. 
BY 
WHARTON SJNKLBR, M. D., AND 
EDWARD N. BRUSTf, M.Q., 
Philadelphia, Pa. 
FROM 
American Journal of Xnsamts, 
April, 1889. 
UTICA, N. Y. A CASE OF GENERAL PARESIS OF FOURTEEN 
YEARS’ STANDING. 
BY WHARTON SINKLER, M. 1)., AND EDWARD N. BRUSH, M. D., 
Of Philadelphia, Pa. 
On September 1st, 1885, I was consulted by Mr. A. B., who was 
referred to me by mv friend, Dr. C. A. Oliver. I obtained the 
following history : 
Mr. A, B. was thirty-eight years of age, and had been married 
for several years; his wife had had no children or miscarriages. 
He had syphilis some years prior to his marriage. He had always 
enjoyed good health and had been actively engaged in business as 
a broker for many years. 
Two or three years before I saw him he had failed in business, 
and since then had had no regular employment. This want of 
occupation seems to have made him restless and unsettled, and he 
talked constantly about the hardship of having no business, and 
he said if his friends would only purchase a seat for him in the 
Board of Brokers, he could soon become wealthy. He had no 
other expansive delusions at this time; but his wife told me that 
for ten years he had had somewhat extravagant ideas as to his 
powers of money-making, and that he had been more or less 
erratic. He was irritable at times, and he would occasionally give 
way to violent temper. 
Several members of his family—three brothers were, or had 
been, insane, and also one of his uncles had suffered from some 
form of mental trouble. 
On August 5th, 1S85, he wakened in the morning with violent 
pain in the eyes—most severe in the right eye. A day or two 
later, he noticed that he had double vision, and he then consulted 
Dr. Oliver. When I saw him he had almost constant pain in the 
right brow, and paroxysms of more acute pain in the same loca- 
tion. He was annoyed by the diplopia. He was otherwise in 
good health, with the exception of attacks of abdominal pain 
which were apparently always due to imprudence in diet. He was 
a large and indiscriminate eater. I used electricity the Faradic 
current—to the external rectus; gave him iodide of potassium 
internally and regulated his diet. In a few weeks the pain was 
relieved and the double vision had disappeared. I did not see the patient again until September 4th, 1887, when I 
was sent for to see him, and found him suffering from the effects 
of two epileptiform convulsions which he had had the previous 
day. 1 found that he had had three or four fits in the few months 
previous to this time. When I saw him, he was only partially 
conscious. When roused, his speech was incoherent and thick. 
He was unable to express his wants. There was no paralysis. In 
twenty-four hours after this time, he had recovered consciousness 
completely, and was able to speak distinctly, but with some 
hesitancy. He was given bromide of sodium—15 grs. three times 
a day—and in a few days he was about and apparently as well as 
usual. 
September 11th, he had a slight attack, which was more like a 
faint, and was not followed by speech difficulty. 
September 25th, he had an attack of extreme excitement brought 
on without sufficient provocation; mind much disturbed for some 
hours; he has some delusions; he talks incessantly of the hard' 
ships he is enduring at the hands of his friends, who will not buy 
him a place in business. He thinks he still has great opportunities 
for money-making if he only had a chance. Most of the time he 
is in good spirits, laughing and talking, and appears well satisfied 
with himself. 
November 22d, 1887, he had another attack in which he was 
unconscious, followed by severe pain in the head and sense of 
general fatigue. His mental condition is becoming worse; his 
memory is bad. 
January 7th, he had four convulsive attacks, after which he was 
violent and abusive to those about him. When seen by me— 
January 11th,— he was aphasic, and had been so since the date of 
the last spasms. There is ptosis of the right eye, but no loss of 
power in the arm or leg. 
January 24th, aphasia has almost disappeared ; except when he 
is excited he occasionally misapplies a wTord. He was ordered 
iodide of potassium, 20 grs. three times a day. 
March 20th, he has had no attack since last note until one week 
ago, when he had an attack following a long walk through the 
snow. He came into the house with expressionless face; stood for 
a few minutes looking blankly about; and was then seized with 
convulsive movements. Both arms shook violently and were 
drawn upwards; the face was drawn to the left; the attack lasted 
ten minutes. He afterwards slept heavily for some hours but was 
restless the remainder of the night. He was not aphasic the next 3 
day, but to-day he is, markedly ; is readily excited, and talks 
incessantly. Dynamometer, first effort—right hand 190; left, 160; 
next effort—right hand 160; left, 140. 
March 31st, he had another attack, followed by temporary 
aphasia. 
April 13th, and April 18th, two more attacks. 
May 1st, 1888, he is still very aphasic. He talks incessantly; but 
continually uses the wrong word and mispronounces words of many 
syllables. The dynamometer—right hand 180-160-120; left hand 
150-120-120. (It will be noticed that the strength of the right 
hand becomes quickly impaired.) 
May 20th, 1888, he has had no more attacks, but continues very 
aphasic: talks incessantly; beginning to have expensive ideas— 
talks of going into “ big transactions ;” says he is going to make 
“ big money.” In speaking, there is considerable mouth-tremor; 
great tremor of tongue when protruded. 
May 28th, had another attack; for eight hours the right side 
was paretic. The mental condition continued to grow worse; 
periods of excitement more frequent and at intervals he was sus- 
picious of every one and every thing, although there was no 
paralysis. The bodily weakness increased; he could make no 
physical exertion without being greatly exhausted. Most of the 
time, however, he was in good spirits and talked incessantly, but 
incoherently—the aphasia remaining about the same. 
Finally, in October, his condition was such that it became neces- 
sary to transfer him to the Pennsylvania Hospital for the Insane, 
where he was placed under the care of Dr. Brush, whose report 
of the subsequent progress of the case you will see below. 
I append the report of the eye-examination made by Dr. Charles 
A. Oliver: 
Mr. A. B. first consulted me in August of 1885, with the history 
of sudden pain in the right eye, which had come on seven days 
previously. Patient said that he had been myopic for a long while, 
for which he had used -S. 3. D. in each eye for distance alone. 
Vision of right eye equaled which was brought up to -^2? 
by -S. 3. D. 
Vision of left eye equaled which was brought up to 
by -S. 3. D. 
Accommodation of right eye equaled type O. 50D. 13cm. to 
33cm. 4 
Accommodation of left eye equaled type O. 50D. 11cm. to 
41cm. 
Ophthalmoscopic examination without the use of a mydriatic, 
showed dirty gray discs without any other pathological changes 
except those ordinarily found in cases of compound myopic 
astigmatism. 
With both eyes, vertical diplopia of ten degrees, gave a homon- 
ymous diplopia of live degrees at twenty-six centimetres. Careful 
estimation of refraction by the use of Atropine, showed O. D. 
-S. 3. I). C -C. O. 75 D. axis 180°, and O. S. -S. 2. 50D. C -C. 
O. 50D. ax. 180°. This correction gave full vision in each eye. 
Study of the excursions of the extra-ocular muscles showed a 
slight paresis of the right internus. 
Diagnosis: paresis of right externus with compound myopic 
astigmatism. 
Two days before receiving correction, the patient returned 
complaining of double vision for distance which had come on a 
few days previously. Examination showed nearly five degrees of 
homonymous diplopia for five metres, and seventeen degrees for 
twenty-six centimetres. Patient referred to Dr. Wharton Sinkler 
for general treatment. 
Two days later, lull correction ordered for distance, and the 
cylinders for near work; a plain ground glass being substituted 
for the correction on the left side during the persistence of the 
double images. 
In five weeks’ time alter this treatment, the paresis had decreased 
to five degrees for the twenty-six centimetre distance, and double 
vision tor distance had become quite infrequent. 
Four weeks after this all diplopia hard ceased, and none could be 
obtained by testing. The ground glass was now removed. 
In January of 1887, at Dr. Sinkler’s request, an ophthalmic 
re-examination was made. Central vision for black type on white 
ground, with the ametropia corrected, was found to be normal. 
Central color preception proved to be good in each eye. Fields of 
vision were normal, though those of the left eye were probably 
somewhat reduced in area. The accommodative near points had 
slightly receded, but not more than could be expected for the lapse 
of time between the two examinations. The eye-grounds however, 
gave marked evidences of regressive neuro-retinitis, this being 
• more pronounced upon the left side. Upon individual exposure, the 
left pupil was the larger, though conjoinedly, both became equal. 
In associated action, the irides were freely mobile to light stimulus and accommodative action. In monocular action, the left iris was 
not so freely responsive. A slight paresis of the right externus 
could be made out. 
R'esum'e — Paresis of the right externus, which promptly yielded 
to treatment in a little more than two months’ time, followed in 
eighteen months’ time by post-neuritic changes, (incipient 
degeneration,) more marked on the left side, with slight paresis of 
the external rectus of the opposite side. 
Remarks.—There are two points of special interest in this case 
to the neurologist: First, the slow progress of the disease—the 
history of mental disturbance extending over a period of ten or 
eleven years —and secondly, the question of diagnosis. 
The case seemed to me to be one either of br.ain tumor—that is, 
a gummatous growth in the left frontal lobe; or general paresis. 
I was, at first, disposed to adopt the former view on account of 
the localizing symptoms, namely: the epileptiform convulsions, 
affecting chiefly the right side and followed by aphasia, which was 
at first transient, but afterwards became permanent; and the 
ophthalmoscopic examination of Dr. Oliver, in which he found 
neuro-retinitis, confirmed this view. Later on, however, the symp- 
toms of general paresis became more manifest, and as a report of 
the autopsy shows, the only lesions found were those of general 
paresis. It is unfortunate that portions of the brain which were 
preserved for microscopic examination decomposed before they 
could be examined. In a case like this where there was such 
distinct aphasia one would surely expect to find some microscopic 
changes in Broca’s convolution even if there were no gross lesion. 
The patient had the benefit of full anti-syphilitic treatment. 
The iodide of potassium was given up to one hundred and fifty 
grains a day, and mercury was given steadily for fully two 
months.