[Reprint from Alienist and Neurologist, St. Louis, April, 1891.J Ninety Cases of Fare tic Dementia. By G. R. Trowbridge, A. M., M. D., Bellow of the American Academy of Medicine; Assistant Physician, State Hospital for the Insane, Danville, Pa. ' I 'HE very fact that this disease was practically unrecognized in this country forty years ago, and to-day ranks among the worst forms of insanity, is suffi- cient reason to make statistics on the subject both of consid- erable interest and value. In all probability there were cases of paretic dementia before the time of Bayle, and although he is credited, I believe, with first having accurately described the signs and symptoms of it about the year 1825, it is scarcely probable that the inhabitants of this world were exempt from it though it was not recognized and under- stood as it is to-day. History is indirectly contradictory to this, and if we are to believe the facts as recorded there were certainly sufficient causes in the Middle Ages to produce a generous supply of paretic dementia, and I have not the least doubt but that it existed to a considerable extent among the so-called nobilty of France, England and other European nations, whose ideas of morality and moderation were somewhat at a discount. The same causes which are pro- ducing it to-day were in working order then, though per- haps not to as great an extent; and granting that the mental, moral and physical conditions of two centuries ago were practically the same as those of the nineteenth cen- tury, it is fair to conclude that this age is not entirely responsible for this disease. That paretic dementia is increasing in this country with alarming rapidity there is no room for doubt, as the reports of our institutions for the insane show. It is, how- ever, only another indication of the " fast " age in which we live; and this yearly increase of the disorder is not a thing of which the American citizen should be proud, but 2 G. T. Trowbridge. on the contrary, it should be looked upon as a veritable curse, as it only proves that those vices and immoralities which are the corner-stone of general paresis, are increas- ing and causing the moral, physical and mental wreck of our fellow-citizens. No one can realize the truth of this better than the medical officers in our hospitals for the insane. In a large number of cases of paretic dementia admitted to hospitals for the insane, causes for the disease are given which are ridiculous in the extreme; and though either through ignorance or unwillingness on the part of the friends, or delicacy on the part of the physi- cian, the real and true cause 'cannot be ascertained, yet in three cases out of five it would be a comparatively easy matter to guess it, as the real causes of paretic dementia can be sifted down to an extremely small number. The following statistics of ninety cases were com- piled from the registers of this hospital, and though they are more or less defective, they present some interesting points. Of the 3,518 admissions to this hospital, 90 were cases of paretic dementia ; 77 of these being males, and 13 females. This is about two and one-half per cent, of the entire number admitted. In the State Hospital for the Insane, at Independence, Iowa, of 3,700 admissions, 40, or a little over one per cent., were cases of paretic dementia.* Of 2,297 male patients at the Pauper Asylum of N. Y. City, 284, or a little over twelve per cent., were paretic dements, f We have here almost two extremes in the number of cases. This may be accounted for by the fact that in N. Y. City the opportunities, surroundings and tendencies are much more inclined toward the causes of paretic dementia than they would be in a less thickly populated district; besides, the wandering population, which is • "General Paresis of the Insane." Gershom H. Hill, M. D., Medical News, November 8, 1890. t Spitzka, "Manual of Insanity," page 180. Ninety Cases of Paretic Dementia. 3 continuously arriving in our metropolis, affects to some extent the percentage of such cases. I should say from these three records that a probable fair estimate of the cases of general paralysis in our insane hospitals was about five or six per cent. The nationalities of my 90 cases are as follows : Males, German 7, English 3, Americans 55, Welsh 2, Irish 4, Canadian 1, Negroes 2, unknown 3. Females, Americans II, Irish I, Welsh I. From these figures we see, that of the 77 males 19 were foreign-born, and of the 13 females 2 were foreigners. According to the last report of the Commission on Lunacy of the State of Pennsylvania, about one-half of the insane of the State are foreigners, and as only one- fourth of these cases are of foreign nativity, it can hardly be said that foreigners are especially responsible for it. We must consider, however, that these ninety cases are from an American institution where it is to be expected that Americans will predominate in everything, and I am sure that the same would be true of English or French institutions, as the inhabitants of these countries are as much exposed and prone to general paralysis as the American. The' one factor, however, in this country which makes us as a class more subject to this disease than other nations, is the continuous strife and struggle for the supremacy. This may not be evident in all >parts of the United States, but, nevertheless, it is a fact that the Americans as a class are living too fast, and that by this strain on the mind and body are placing themselves and their descendants in a condition where it will require but a slight exciting cause to overcome an overtaxed brain. I do not think that business or intellectual pursuits are alone often exciting causes of paretic dementia, for as a rule those affected with this disease are not from the higher stations of life, but on the contrary are from the middle, or even lower classes, where the actual business cares are the least; still, these may in a great measure act as predisposing causes. 4 G. R. Trowbridge. In the consideration of occupation, I shall only take the males, as the occupations of the females were unknown, except in two cases, and these had no bearing on the disease. Of the 77 men, there were 14 laborers, 8 farm- ers, 7 miners, blacksmiths, engineers and carpenters, 4 each; railroaders and clerks, 3 each ; plasterers, lumber- men and book-keepers, 2 each; mason, miller, iron-worker, landlord, coachman, telegrapher, waiter, insurance agent, mechanical engineer, barber, plumber, author, lawyer, grocer, shoemaker, bartender, minister, mechanic and brick- layer, 1 each ; unknown, 5. Mickle,* in regard to occupation, says: " Military and naval life, occupations exposing the workers to great heat and sweat, or to alternate heat and cold draughts, pros- titution-all favor the production of general paralysis. So do those which occasion emotional strain, constant worry and irritation, or intellectual overwork." These various occupations are those which belong to a class in middle life-at least the great majority; the largest number being day laborers; second, farmers; third, miners, etc., etc., there being a decrease in number of persons as the occupation becomes better. These figures, to a certain extent, support my statement, that seldom is general paralysis caused by mental strain alone, as the greater number of cases are those whose occupation requires very, little mental effort. Dr. Hill says:f "So far as my own observation extends, the disease is seldom brought on by purely intellectual pursuits." It seems impossible that the work of a laborer should in any way affect his mental powers, and especially to the extent of paretic dementia, yet it might be a predisposing cause, and so be the basis on which an exciting cause might obtain a foundation, and this brings us to the consideration of the exciting causes given in these cases. I shall have to leave out the thirteen females, as in * Mickle, " General Paralysis of the Insane," page 254. f Medical News, Nov. 8, 1890. Ninety Cases of Paretic Dementia. 5 only two cases were the causes given; the first being due to intemperance and heredity, the second to overwork and anxiety. Of the 77 men, 23 were due to intemperance, 7 to syphilis, 2 to syphilis and intemperance, 6 to overwork, 6 to business trouble and heredity, 2 to heredity and intemperance; rheumatism, typhoid fever, poverty, exposure and sunstroke, I each ; unknown, 26. First among exciting causes is the excessive use of alcohol. This is acknowledged, I believe, by the majority of writers to be a great producer of general paralysis. In close relation to it, both socially and as an exciting cause, is syphilis. It is claimed by some that syphilis is not an exciting cause of paretic dementia, but there are cases of general paralysis which cannot be traced to any other source, and the symptoms of this form are so iden- tical with the regular general paralysis that it is stretch- ing a point to claim another name for the disease. It is a distinction without a difference. This, however, does not mean that syphilis always produces paretic dementia to the exclusion of other insanities. Spitzka,* in regard to this matter, says : " Clinically, it is not always possible to make a sharp discrimination between syphilitic dementia and paretic dementia proper, for syphilis plays an important role in the etiology of the latter affection. * * * * * * Mendel found that of 201 patients, 117 were syphilitic, and Ripping could only detect a syphilitic element in about twelve per cent. It is to be borne in mind that the mere co-existence of a syphilitic taint does not prove a given form of insanity to be syphilitic; but the fact is significant that, of all syphilitic lunatics, one-half are paretic dements, or suffer from the allied form of disease (syphilitic dementia). " In the writer's experience, syphilis is an etiological factor in the production of various forms of progressive dementia in about one-third of the cases among the pau- per insane of New York. Its existence could be deter- * Spltzka, " Manual of Insanity," page 244. 6 G. R. Trowbridge. mined in fourteen per cent, of the paralytic patients in private practice. Of these, eighty per cent, had typical paretic dementia, and the remainder the true syphilitic form of dementia." The excessive indulgence of vicious habits, as a rule, is likely to produce some impairment of the mental facul- ties, and in the majority of cases of paretic dementia, were the truth known, alcohol and syphilis would occupy the first place as exciting causes. Here, again, the question reverts to one of social standing. Alcohol and syphilis are luxuries which are placed within the reach of everybody, from the laborer to the millionaire, but we find in my ninety cases on a close comparison, that as the number in the excitipg causes lessens the cause itself becomes more respectable. I found that intemperance was given as a cause, especially among laborers and miners, the same was true of syphilis, whereas the occupation, being a little better, the cause appeared as overwork, or was unknown. Paretic dementia, as a rule, does not attack vigorous and well-balanced minds, unless, perchance, heredity plays a part, but is found among the class whose morals are of such a low grade that regard for themselves or others is completely destroyed, and they give themselves up to immoralities and vices which are the exciting causes of the disease. Thirty-four of the seventy-seven cases were due to either alcoholism, syphilis or heredity, or a combination of two or more, and I venture to say that in the twenty-six cases in which the cause was unknown, these three factors would be in the majority. Heredity plays an important part in the causation of paretic dementia, though I do not think as important a one as alcohol and syphilis, as it acts more as a predis- posing cause. Dr. J. Z. Gerhard, Superintendent of the State Luna- tic Hospital, Harrisburg, Pa., says:* "The causes of general paralysis have not been absolutely determined, * " Thirty-ninth Annual Report of the State Lunatic Hospital, Harrisburg, Pa." Ninety Cases of Paretic Dementia. 7 but it is probable that several factors enter into its development, and that there is a close and important rela- tion between it and syphilis, although we cannot trace a history of syphilis in all cases." The disease, as a rule, does not attack either extreme age or youth, but on the contrary seems to select indi- viduals in the prime of life. In summarizing these ninety cases, I find that among the men, the youngest case when attacked was 26 years old, and the oldest 63 years ; the average of the 77 cases being 41 years and 8 months. Among the 13 females, the youngest was 21 years of age, and the oldest $6 years, the average being 41 years and 6 months. Mickle* gives the age attacked between 30 and 55, and also quotes from the statistics of the English and Welsh Asylums, showing that it is more frequent between the ages of 30 and 40, than 40 and 50. Spitzkaf also says that paretic dementia develops, as a rule, between the thirtieth and fortieth years. In regard to duration, my cases show that among the males (50 cases) the longest time for the disease to run its course was ten years ; the shortest, six months. Aver- age of the fifty cases, two years and seven months ; and among the females (8 cases), the longest was six years ; the shortest, one year and six months ; average, two years and eight months. Average of fifty-eight cases, male and female, two years, eight and one-half months. I have here only taken those cases in which the disease has completed its course, i. e., resulted in death, as some are still here, and others were, for various reasons, discharged. SpitzkaJ says that the duration of the disease is very variable, and may last any length of time, from six months to ten years; the usual time being about three years. Dr. Hill§ gives the duration in twenty-five cases as two years and six months. * Mickle, " General Paralysis of the Insane," pages 248-250. t Spitzka, "Manual of .Insanity," page 216. t Ibid., page 216. § "General Paralysis of the Insane " Med. News, November 8, 1890. 8 G. R. Trowbridge. Mickle* says it may last " from a few weeks or months to one, two or several years." I think a fair average of the course of the disease is from two and one-half to three years, though, as we have seen, the course in single cases may be varied to either extreme. The time spent in the hospital by these patients is as follows-and here, again, I shall only consider those cases resulting in death, omitting those which are still here, and those which have been discharged. Among the fifty male cases, the longest residence in the hospital was seven years, the shortest, eight days; average, one year and nine months. Among the eight female cases, the longest residence was three years and two months, short- est, three months ; average one year and six months. Average for the fifty-eight cases, one year and seven and one-half months. The average duration before admission was, males, one year and one month ; females, one year and two months. The ages at death were as follows: Males, oldest, 65 years; youngest, 29 years ; average, forty-four years, three months. Females, oldest, 58 years; youngest, 26 years; average, forty-four years and two months. I shall not draw any conclusions from these cases, as I would only repeat those of other writers, but leave that to my readers. We must realize that if this disease continues to gain ground, and go on increasing, we will have another powerful factor which will aid in the mental, moral and physical deterioration of the American people as a whole. There is room for improvement in our mode and manners of life, and the sooner we realize it the bet- ter it will be for this and future generations. * Mickle, "General Paralysis of the Insane," page 211.