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symptom of the prodromal stage. An analysis of the knee-jerk of sixty-three paretics admitted to the Eastern Asylum during the past five years gives fifty-seven per cent with an active or exaggerated kneejerk, sixteen per cent with knee-jerk absent, twenty-seven per cent with knee-jerk present but showing qualitative changes. I have purposely refrained from a consideration of all the physical stigmata of the disease, as it is my intention to allude to only a few of the cardinal physical symptoms which could be easily ascertained by the attending physician.

As a summary of the principal physical signs in the initial stage, I would give them in their order of importance, as follows: ArgyllRobertson, immobile or contracted pupils, exaggerated or perverted. knee-jerk, facial tremor, slurring or halting speech, defective innervation of the face, and cerebral seizures. These physical symptoms should always be looked for in all suspected cases, and carefully considered with the mental history of the patient. It is from the coexistence of the mental and physical symptoms, that we make a diagnosis. of paretic dementia.

To recapitulate we have in paretic dementia a disease in many cases which can be diagnosed in the early stages, by reference to the pupillary reflex, the knee phenomena and the characteristic progressive dementia.

(2) Prognosis and Termination.-General paralysis of the insane is a progressive and fatal disease attended with steady mental and physical failure. As is well known, the course of the disease is often interrupted by remissions which assume a more or less favorable appearance. This improvement is more apparent than real, as can be very easily determined. It is said with considerable truth, that "if a diagnosis of paretic dementia is once made, the outlook is a gloomy one.' Unquestionably treatment in an institution may to some extent secure an improvement; that is, by surrounding such a patient with hygienic influences and improving his physical state, there often results an improvement in the mental condition although this improvement may be only of a temporary nature. Recently some authorities have said that the duration of the disease has been lengthened, while others incline to the opposite opinion.

An analysis of over four hundred fifty cases admitted to the Eastern Michigan Asylum since the opening of the institution gives the following facts: Thirty per cent have terminated fatally within two years, ninety per cent within five years, ninety-eight per cent within six years. For the purpose of comparison these cases have been divided into periods. It was not found that at any time the course of the disease showed any material change, nor was the duration of the disease affected by any particular line of treatment.

(3) The Causation of Paretic Dementia.-In a recent discussion before the Philadelphia Neurologic Society, Doctor Charles K. Mills said that he had come to the conclusion that tabes dorsalis and general paralysis in their pure forms are essentially the same; that is, pathologicly and pathogeneticly; although he acknowledges that the tabetic

patients after many years may become demented, and that this demential is not of a paretic tabetic type. He further states that it is the localization and the diffusion of the lesion which gives us the clinic type; spinal in the one case, cerebral in another, cerebrospinal in a third. This theory is accepted by many psychiatrists and explains many debatable points regarding etiology. Unquestionably the two diseases have an etiology which may be similar in many respects.

During the past four or five years much has been written regarding the predisposing and active causes of paretic dementia. Although the subject considered in detail is of particular interest to the alienists, it is believed by the writer that a presentation of a few facts may not be without interest to the physician not engaged in asylum work. Not the least interesting feature regarding the etiology of paresis is the attempt which has been made during the past year to ascribe it to an inherited taint; that is, it is claimed by some authorities that the predisposition to general paralysis is inherited, and that other causes are merely exciting agents.

Mott, in his paper on "Observations Upon the Etiology and Pathology of General Paralysis" (Archives of Neurology, London County Asylum, 1899), gives reasons for supposing that general paralysis of the insane is a primary degeneration of the neuron, with secondary inflammatory changes. His conception of the disease briefly expressed, is as follows:

General paralysis is primarily a parenchymatous degeneration due to loss of durability of the nerve cells and a premature decay of tissue in which inherited and acquired conditions take part, with the result that progressive death of the last and most highly developed nervous structure ensues as soon as their initial energy is unable to cope with the antagonistic influences of environment.

This theory is not out of harmony with our present views regarding some forms of brain and cord degenerations. It is more likely that the fact that in paretic dementia there are demonstrable brain changes leads to the conclusion that the mental symptoms are entirely dependent upon the actual loss of brain cortex. We now know that the variation in mental symptoms which is so frequently seen in general paralysis is not dependent on any particular pathologic brain lesion, but is due to the influence of organic stimuli. We presume that when the organic stimuli which make up the coanesthesias are normal, the emotional tone is optimistic; when, on the other hand, of disordered function, the emotional tone is pessimistic. This theory has been applied to other insanities and is a rational explanation of the variation in the symp

toms.

Mickle thinks that in the entire group of mental diseases taken together, heredity is really more prominent than it is in paretic dementia taken separately. Even when insanity in the family can be traced, he claims that it is not paresis which is inherited; but a tendency to organic or functional nervous diseases, as epilepsy, paralysis, et

cetera.

Müller seems to think that heredity, especially nervous diseases in parents, bears an important relation. He found hereditary taint in forty-six per cent of men and sixty per cent of women.

Krafft-Ebing has demonstrated a rather curious fact; namely, that an inherited taint is found more often in women. As supplementing this hereditary influence, it is interesting to refer to the studies of Macke, who found the stigmata of degeneration in these cases, showing large preponderance as compared to normal man.

Manam, after investigating the antecedents of two hundred fifty patients with general paralysis, came to the conclusion that an insane heredity is the most common morbid antecedent, twenty-five per cent of his cases showing this inherited predisposition. He also believes that neuropathic antecedents are quite frequently found and constitute a hereditary predisposition.

A review of the recent text-books on mental diseases is corroborative of these conclusions. The subject has also received much discussion at the various congresses of alienists, and it is acknowledged quite generally that heredity may play an important part in the development of the disease, although this is, as yet, debatable.

An analysis of four hundred consecutive cases of general paralysis admitted to the Eastern Michigan Asylum certainly would seem to indicate that the hereditary element is a strong predisposing factor to the disease. Heredity, neuropathic or insane, was present in forty per cent of the cases. During the past twelve years cases of cerebral syphilis and other brain degenerations have been carefully differentiated from general paralysis. The following statistics may be taken to bear entirely on cases of paretic dementia:

The number of cases admitted from January 1, 1890, to January I, 1902, with a family history determined, one hundred ninety. Of these heredity, neuropathic or insane, was present in eighty cases, or forty-two per cent; direct heredity existed in fifty-five, or thirty per cent; indirect heredity in twenty-five, or twelve per cent. It would appear as above stated that the large number of writers are in accord with this view; namely, that hereditary predisposition is present in a variable number of paretics. This inherited predisposition is either a tendency to organic cerebral disease similar to the inheritance seen in organic cerebral affections other than paresis; or it is a transmitted tendency to insanity from neuropathic or insane ancestors.

SYPHILIS. The great mass of literature concerning syphilis and its relation to paretic dementia is with difficulty sifted. Much diversity of opinion still exists and the matter is, as yet, in an unsettled state, although it would appear that we are gradually approaching some uniformity. All manner of arguments have been advanced by investigators to prove their claims, and statistics involving thousands of cases have been brought forward. It would appear that the argument depends on the question whether syphilis is an active factor in the production of paresis, or whether it is merely a predisposing cause. It is conceded that syphilis can cause the disease, but whether it is

due to a late action of the toxin, or whether the disease develops from some other cause in a system weakened by syphilis, is as yet undetermined. The fact that syphilis can cause a train of symptoms resembling in many respects those found in paretic dementia and with pathologic lesions distinct and showing marked differences adds to the existing confusion. We would seem to be justified in formulating the following conclusions:

(1) Syphilis has existed in fifty to seventy-five per cent of paretics. Statistics of the Eastern Michigan Asylum give sixty-one per

cent.

(2) The subjects of syphilis are from sixteen to seventeen times more likely to contract the disease than those not similarly affected. (3) The anatomic change found in the nervous system, while not distinctive of syphilis, may be related to the action of the syphilitic toxin.

(4) While syphilis can be proven to exist in a percentage of cases, in many instances a history of syphilis cannot be obtained. The pathologic findings in these cases are similar to the changes found in those in which there was a history of syphilis.

ALCOHOL.-Considerable stress has been placed on alcohol as a cause of the disease. However, we are now confident that many cases in which alcohol was thought to be an active cause were not typic cases, but were really forms of alcoholic insanity with organic cerebral changes. While we here also have diversified opinions, the consensus of opinion may be taken to be, first, that it has not been proved that alcohol by itself can produce paretic dementia; second, that it can prove a powerful assistance in the aggravation of symptoms by accelerating organic changes which have already begun.

SEXUAL EXCESSES.-This theory has lately been revived. Statistics have, however, failed to show that by itself it can produce the disease. Mickle's statistics ("General Paralysis," 1886) say that it is of minor importance, it then being placed as a causative agent at a fraction of over one per cent.

Statistics from the Eastern Michigan Asylum based on an analysis of four hundred cases show a similar percentage. It is difficult to conceive of such a cause producing definite organic cerebral disease. If sexual excess is suspected as a probable cause care should be taken to separate cause and effect. It is more than likely that the latter will prove to be the case.

MENTAL STRAIN.-Those who accept mental strain as an exciting cause for paresis, define its meaning to be prolonged intellectual labor attended by worry and mental strain-financial or otherwise. It is difficult to conceive of a painful emotional condition, even if prolonged, as being able to produce an organic brain disease. In justice to the advocates of this cause, it should be remembered that they regard it as an exciting cause only. It may be that it acts in a contributory way, similar to the action of the two causes mentioned above, sexual excesses and alcohol.

SUMMARY.

(1) It would appear that the clinic syndrome of paretic dementia. may be produced by several agents.

(2) An inherited tendency exists in a comparatively large number of cases and may be a strong predisposing agent.

(3) The precentage of syphilis in general paralysis is too considerable to be disregarded. In all probabilty it is an important element in the production of the disease.

(4) Other influences than syphilis may act and be productive of similar symptoms.

(5 The predilection of the disease to age, rest, occupation, et cetera, is as yet not clearly understood. It is probably referable to the idiosyncrasies of the disease.

(6) It seems probable that if an equal amount of study were given to other brain degenerations we would find the same variations in etiology.

MEDICAL MALPRACTICE.*

BY WILLIAM P. LANE, M. D., DETROIT, MICHIGAN.

MEMBER OF THE DETROIT BAR.

MEDICAL malpractice is that practice in the domain of medicine, either contrary to the law of the land or to established customs of the profession, causing either death or impairment of health. Practice of medicine contrary to the law of the land calls for the interference of the state authorities in the form of criminal procedure; that against established customs, involving as it does a lack of ordinary skill, brings the offending physician into court by civil process in an action to recover damages.

Malpractice, as recognized by the criminal courts, is confined exclusively to cases of abortion or attempted abortion, and so far as the intent is concerned, it makes no difference whether instruments be employed, or whether well-known and recognized ecbolics be administered. Conviction in the latter class of cases, however, is extremely rare on account of the therapeutic range of the different drugs that are popularly supposed to cause uterine contractions to the extent of expelling the fetus.

The intent of the physician who administers ergot, savine, borax, cotton root compound, tansy, pennyroyal, arsenic and other mineral. irritants is hard to prove, when the varied therapeutic properties of these drugs would be brought in issue. Were he a professional abortionist, even, the doctrine of "reasonable doubt" might protect him, and if he had the shadow of a reputation in his profession, it is a certainty that he would escape conviction.

Abortion by the use of instruments is more certain than by drugs and more easily proved, and the instruments vary from the crude wooden skewer or knitting needle of the ignorant midwife, or unfor*Read before the WAYNE COUNTY (Detroit) MEDICAL SOCIETY.

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