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ACUTE GENERAL PARALYSIS
961 for
dealing
with such failure before
operation, &c.,
will have to be considered.
greatly indebted to Prof. Samson Wright permission to work in his department and for constant help and criticism. I
am
for his
REFERENCES 1. 2. 3. 4. 5. 6. 7.
8. 9. 10. 11.
12. 13. 14. 15. 16.
17.
18. 19.
Moncrieff, A.: THE LANCET, 1932, ii., 665. Loewy, A.: Pflügers Archiv, 1894, lviii., 416. Siebeck, R. : Deut. Arch. f. Klin. Med., 1911, cii., 390. Douglas, C. G., and Haldane, J. S.: Jour. of Physiol., 1912, xlv., 235. Haldane, J. S. : Amer. Jour. Physiol., 1915, xxxviii., 20. Krogh, A., and Lindhard, J.: Jour. of Physiol., 1913, xlvii., 30. Henderson, Y., Chillingworth, F. P., and Whitney, J. L.: Amer. Jour. Physiol., 1915, xxxviii., 1. Campbell, J. M. H., Douglas, C. G., and Hobson, F. G.: Jour. of Physiol., 1914, xlviii., 303. Pearce, R. G., and Hoover, D. H.: Amer. Jour. Physiol., 1917, xliv., 369, 391; Ibid., 1920, lii., 472. Haldane, J. S.: Respiration, New Haven, 1922, p. 33. Liljestrand, G.: Handbuch d. Normalen u. Path. Phys. Berthe, A., and Bergmann, G. U., Berlin, 1925, vol. ii., p. 198. Hess, W. R.: Die Regulierung der Atmung, Leipzig, 1931, p. 19. Aitken, R. S., and Clark-Kennedy, A. E.: Jour. of Physiol., 1928, lxv., 389. Arsenijevic, M. S., and Knipping, H. W.: Zeitsch. f. Exp. Med., 1930, lxxiv., 787. Knipping, H. W., and Moncrieff, A.: Quart. Jour. Med., 1932, n.s., i., 17. Moncrieff, A., and Wilson, A. T. : Jour. of Physiol. (Proc. Phys. Soc., March, 1933). In the press. Hasselbach, K. A., and Lindhard, J.: Skand. Arch. f. Phys., 1911, xxv., 361. Dreyer, G.: The Assessment of Physical Fitness. London, 1920. Treadgold, H. A.: THE LANCET, 1932, ii., 813 (and personal communication).
20. Briscoe, G.: Med. Research Council Spec., Rep. Series No. 53, 1920, p. 203. 21. Meakins, J. C., and Davies, H. W.: Respiratory Function in Health and Disease, Edinburgh, 1925. 22. Means, J. H.: Dyspnœa, Baltimore, 1924, p. 37.
Clinical
and Laboratory Notes
ACUTE BY E. R.
GENERAL
PARALYSIS
SORLEY, M.B., D.P.H. ABERD.
SURGEON
LIEUT.-COMMANDER, R.N.
P. Schmierer1 has recorded ten cases of acute general paralysis in patients aged 36 to 58. He states that in some cases the disease runs a fulminating course, death taking place a few days or weeks after admission to a mental hospital without any intercurrent complication to explain it. The clinical is acute delirium. Schmierer conone of syndrome siders that the duration of the disease ranges from 7 to 18 days, and he estimates its frequency as 1 per cent. of all cases of general paralysis. As an example of this condition the following case may be of interest. A man, aged 35, was admitted to the Royal Naval Hospital, Bermuda, on June 29th, 1932, as a case of cerebral syphilis. He gave a history that for about a week prior to admission he had been feeling nervous and shaky ; his messmates and others in his ship stated that he had been acting strangely for several weeks. There was a history of syphilis dating from 1922. A Kahn test was positive early in June, 1932. On admission he complained of shakiness and unsteadiness, and said that he felt a pricking sensation in the soles of his feet. Temperature was 103’4° F. and
The patient seemed to be rational, slow and speech halting. The pupils were irregular, the right being larger than the left’; both were sluggish to light but accommodated
pulse-rate
90.
but cerebration
was
1 Thèse de Paris, 1932. (Epitome, p. 113).
See Brit. Med. Jour., 1932, i.
well. limbs was the limbs.
fairly
A very
coarse
There
present.
tremor- of was
some
tongue and spasticity in
The knee-jerks were increased. No the neck was and of present, rigidity Kernig’s sign No sensory abnormality was noted. was absent. Nothing abnormal was found in the heart or lungs. On the skin there was a dark red papular rash, chiefly centrifugal in distribution. On June 30th the patient had acute delirium ; he was very restless and difficult to manage, repeatedly trying to get out of bed, and refusing food and medicine. He had retention of urine. Lumbar puncture was done and 30 c.cm. of cerebro-spinal fluid was withdrawn ; it was clear and definitely under pressure. The findings on the fluid were : cells 297 per c.mm., lymphocytes 60 per
cent., globulin increased. For a few days the patient’s condition improved. He became quieter, being only stupid and fatuous instead of delirious and emotional. The skin condition cleared up. This improvement lasted until when he 10th, July suddenly became restless. He had periods of delirium, and his speech degenerated into a mere mumbling of syllables. Coma, with fsecal and urinary incontinence, was present on July 13th. The patient died early on the 15ththat is, on the seventeenth day after admission to
hospital. Post mortem.-Examination of brain only. The dura mater was not adherent to the skull. There were thickening of the dura, arachnoid, and pia, and definite adherence of the pia to the surface of the brain. The surface of the brain showed some flattening of the convolutions and some engorgement of the blood-vessels. The pathological report on section of the brain was: A meningo-encephalitis is present. The meninges are infiltrated with lymphocytes and plasma cells, and there is an infiltration of less degree in the sheaths of the vessels in the brain substance. The microscopic appearances are consistent with the diagnosis of acute general paralysis. The case is noteworthy for its sharp differentiation from the clinical appearances usually associated with general paralysis. It corresponds closely in duration and clinical findings to the descriptions given by Schmierer, who mentions lesions of meningoencephalitis, discoverable post mortem. He also describes intense necrotic cell changes, which, however, were not found in the case recorded above. I
am
indebted to
Surgeon
Commander P. L. Gibson
for permission to publish this TWO
CASES
BY W. N.
OF
case.
HÆMATOCOLPOS
SEARLE, M.B. N.Z., F.R.C.S. EDIN.
RESIDENT MEDICAL OFFICER, CHELSEA HOSPITAL FOR WOMEN
THE first case was a married woman, aged 32, who attended the out-patient department of the Chelsea Hospital for Women with the history of having had increasing difficulty in passing urine over a period of two years. To start the flow of urine she now found it necessary to’ press on the lower abdomen. She had been married 14 years, and neither she nor her husband apparently had tho slightest suspicion that marital relations were other than normal. The periods had never been present, and she stated that at the age of 17 she had attended the out-patient department of a London hospital owing to the non-appearance of menstruation. There she was told that she would never have children and
dealing
with such failure before
operation, &c.,
will have to be considered.
greatly indebted to Prof. Samson Wright permission to work in his department and for constant help and criticism. I
am
for his
REFERENCES 1. 2. 3. 4. 5. 6. 7.
8. 9. 10. 11.
12. 13. 14. 15. 16.
17.
18. 19.
Moncrieff, A.: THE LANCET, 1932, ii., 665. Loewy, A.: Pflügers Archiv, 1894, lviii., 416. Siebeck, R. : Deut. Arch. f. Klin. Med., 1911, cii., 390. Douglas, C. G., and Haldane, J. S.: Jour. of Physiol., 1912, xlv., 235. Haldane, J. S. : Amer. Jour. Physiol., 1915, xxxviii., 20. Krogh, A., and Lindhard, J.: Jour. of Physiol., 1913, xlvii., 30. Henderson, Y., Chillingworth, F. P., and Whitney, J. L.: Amer. Jour. Physiol., 1915, xxxviii., 1. Campbell, J. M. H., Douglas, C. G., and Hobson, F. G.: Jour. of Physiol., 1914, xlviii., 303. Pearce, R. G., and Hoover, D. H.: Amer. Jour. Physiol., 1917, xliv., 369, 391; Ibid., 1920, lii., 472. Haldane, J. S.: Respiration, New Haven, 1922, p. 33. Liljestrand, G.: Handbuch d. Normalen u. Path. Phys. Berthe, A., and Bergmann, G. U., Berlin, 1925, vol. ii., p. 198. Hess, W. R.: Die Regulierung der Atmung, Leipzig, 1931, p. 19. Aitken, R. S., and Clark-Kennedy, A. E.: Jour. of Physiol., 1928, lxv., 389. Arsenijevic, M. S., and Knipping, H. W.: Zeitsch. f. Exp. Med., 1930, lxxiv., 787. Knipping, H. W., and Moncrieff, A.: Quart. Jour. Med., 1932, n.s., i., 17. Moncrieff, A., and Wilson, A. T. : Jour. of Physiol. (Proc. Phys. Soc., March, 1933). In the press. Hasselbach, K. A., and Lindhard, J.: Skand. Arch. f. Phys., 1911, xxv., 361. Dreyer, G.: The Assessment of Physical Fitness. London, 1920. Treadgold, H. A.: THE LANCET, 1932, ii., 813 (and personal communication).
20. Briscoe, G.: Med. Research Council Spec., Rep. Series No. 53, 1920, p. 203. 21. Meakins, J. C., and Davies, H. W.: Respiratory Function in Health and Disease, Edinburgh, 1925. 22. Means, J. H.: Dyspnœa, Baltimore, 1924, p. 37.
Clinical
and Laboratory Notes
ACUTE BY E. R.
GENERAL
PARALYSIS
SORLEY, M.B., D.P.H. ABERD.
SURGEON
LIEUT.-COMMANDER, R.N.
P. Schmierer1 has recorded ten cases of acute general paralysis in patients aged 36 to 58. He states that in some cases the disease runs a fulminating course, death taking place a few days or weeks after admission to a mental hospital without any intercurrent complication to explain it. The clinical is acute delirium. Schmierer conone of syndrome siders that the duration of the disease ranges from 7 to 18 days, and he estimates its frequency as 1 per cent. of all cases of general paralysis. As an example of this condition the following case may be of interest. A man, aged 35, was admitted to the Royal Naval Hospital, Bermuda, on June 29th, 1932, as a case of cerebral syphilis. He gave a history that for about a week prior to admission he had been feeling nervous and shaky ; his messmates and others in his ship stated that he had been acting strangely for several weeks. There was a history of syphilis dating from 1922. A Kahn test was positive early in June, 1932. On admission he complained of shakiness and unsteadiness, and said that he felt a pricking sensation in the soles of his feet. Temperature was 103’4° F. and
The patient seemed to be rational, slow and speech halting. The pupils were irregular, the right being larger than the left’; both were sluggish to light but accommodated
pulse-rate
90.
but cerebration
was
1 Thèse de Paris, 1932. (Epitome, p. 113).
See Brit. Med. Jour., 1932, i.
well. limbs was the limbs.
fairly
A very
coarse
There
present.
tremor- of was
some
tongue and spasticity in
The knee-jerks were increased. No the neck was and of present, rigidity Kernig’s sign No sensory abnormality was noted. was absent. Nothing abnormal was found in the heart or lungs. On the skin there was a dark red papular rash, chiefly centrifugal in distribution. On June 30th the patient had acute delirium ; he was very restless and difficult to manage, repeatedly trying to get out of bed, and refusing food and medicine. He had retention of urine. Lumbar puncture was done and 30 c.cm. of cerebro-spinal fluid was withdrawn ; it was clear and definitely under pressure. The findings on the fluid were : cells 297 per c.mm., lymphocytes 60 per
cent., globulin increased. For a few days the patient’s condition improved. He became quieter, being only stupid and fatuous instead of delirious and emotional. The skin condition cleared up. This improvement lasted until when he 10th, July suddenly became restless. He had periods of delirium, and his speech degenerated into a mere mumbling of syllables. Coma, with fsecal and urinary incontinence, was present on July 13th. The patient died early on the 15ththat is, on the seventeenth day after admission to
hospital. Post mortem.-Examination of brain only. The dura mater was not adherent to the skull. There were thickening of the dura, arachnoid, and pia, and definite adherence of the pia to the surface of the brain. The surface of the brain showed some flattening of the convolutions and some engorgement of the blood-vessels. The pathological report on section of the brain was: A meningo-encephalitis is present. The meninges are infiltrated with lymphocytes and plasma cells, and there is an infiltration of less degree in the sheaths of the vessels in the brain substance. The microscopic appearances are consistent with the diagnosis of acute general paralysis. The case is noteworthy for its sharp differentiation from the clinical appearances usually associated with general paralysis. It corresponds closely in duration and clinical findings to the descriptions given by Schmierer, who mentions lesions of meningoencephalitis, discoverable post mortem. He also describes intense necrotic cell changes, which, however, were not found in the case recorded above. I
am
indebted to
Surgeon
Commander P. L. Gibson
for permission to publish this TWO
CASES
BY W. N.
OF
case.
HÆMATOCOLPOS
SEARLE, M.B. N.Z., F.R.C.S. EDIN.
RESIDENT MEDICAL OFFICER, CHELSEA HOSPITAL FOR WOMEN
THE first case was a married woman, aged 32, who attended the out-patient department of the Chelsea Hospital for Women with the history of having had increasing difficulty in passing urine over a period of two years. To start the flow of urine she now found it necessary to’ press on the lower abdomen. She had been married 14 years, and neither she nor her husband apparently had tho slightest suspicion that marital relations were other than normal. The periods had never been present, and she stated that at the age of 17 she had attended the out-patient department of a London hospital owing to the non-appearance of menstruation. There she was told that she would never have children and