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Syphilis and Insanity.
SYPHILIS AND INSANITY.
935
think, the former. Indeed, it is probable that the spirochæte itself, and not the mere idea, plays a AN address was delivered recently to the Fellow- real part in the production of the mentality of the ship of Medicine by Sir GEORGE SAVAGE, in which syphilophobe, when the need for diagnosis on a the relations between syphilis and insanity were pathological basis is urgent. For if there are
Syphilis
and
Insanity.
detail from the clinical and some cases which fall within the province of the setiological points of view. This discourse contained psycho-analyst, there are others which need intellimany lessons of interest and importance, not only gent, careful, and conscientious specific treatment Moreover, danger point is reached by to the general practitioner, but to some of those by drugs. younger specialists whose positivist inclinations in not a few in this distressing and distressed condition, who, fearing and believing that others know pathology may well, perhaps, be corrected by due the source of their misery, avoid society, and in consideration of an elder’s weighty words ; we extreme instances may seek escape in suicide. therefore look forward with interest to their fuller But there are also certain cases in which mental, in the columns of a contemporary. publication One of the more important of these lessons is moral, and physical degeneration may ensue, rapidly that experience shows the practical unwisdom and progressively, in the years or months closely of the prevailing mental habit of insistence consequent to infection. Perhaps such are less However common than they once were, but they do occur, on the doctrine of the " single cause." necessary for teaching purposes, or for the sys- and a neuronic rather than a vascular pathological tematic classification and delimitation of clinical basis may be suspected. Possibly these cases can entities, this imputation of single causes of be regarded as analogous to the acute myelitis disease may be, clinical experience and careful and nephritis sometimes seen during the late thought alike impress us with the obligation secondary stages of syphilis. The association of recognising the complexity of the causation between what, in a generic sense, may be called but its importance of disease. Herein Sir GEORGE SAVAGE, as a " fits " and syphilis, is complex, " clinician of unrivalled authority and experience, is evident. Undoubtedly, fits which are truly ranges himself beside the late Dr. MERCIER, who, epileptic are common in children the subject of in one of the most valuable of his essays-that on congenital syphilis, or, what is not quite the " Causation "-declared repeatedly that what we same thing, whose parents have been syphilitic; call " the cause of a disease is that in which, for while, in the juvenile form of general paralysis, our purposes, we are most interested. The position less familiar to the practitioner than it should is now accepted-and Sir GEORGE SAVAGE does not be, " fits" of various clinical form occur. But, dispute it-that without antecedent syphilis there apart from the irregular " fits," or seizures of is no general paralysis of the insane. In consequence, classical general paralysis, slight "fits " or faints non-syphilitic clinical forms, apparently closely sometimes happen under stress or strain to those resembling general paralysis of the insane, are who have been infected ; and they are apt to be differentiated therefrom, and are placed in followed by progressive mental enfeeblement, different categories by the application of patho- although the course of classical general paralysis tests. We therefore consider syphilis as is not pursued. Sir GEORGE SAVAGE, while suslogical " the " cause of general paralysis. Nevertheless, as pecting local vascular change, in such cases, as Sir GEORGE SAVAGE points out, and not for the the underlying anatomical factor, points out how first time, we do not know why some persons, and, frequently the diagnosis of general paralysis is indeed, some races of mankind, though sodden wrongly made. The ultimate outcome, however, is with syphilis, should yet escape general paralysis certainly bad; feeblemindedness generally results. of the insane. Moreover, some persons already A valuable and practical distinction is to be made, infected seem only to become the victims of "G.P.I." moreover, between " general paralysis of the after the intervention of an accidental or incidental insane beginning as " locomotor ataxy" and factor. Thus, Sir GEORGE SAVAGE has noted many locomotorataxy accompanied by manifestations of insanity. The recognition of the distinccases in which indications of general paralysis became first noticeable after influenza, contracted tion is important, and difficulty is thereby during prevalence of that disease ; and, like French lessened. With respect to one important matter, namely the observers, he has seen groups of cases, serially infected by syphilis, and all, or several of them, relation between imbecility, idiocy, and parental developing general paralysis. Some have believed syphilis, Sir GEORGE SAVAGE accepted the positive " that there are strains" of spirochaetes specially results of the Wassermann test, when applied to so prone to producegeneral paralysis, andWiEDERSHElM, many idiots and imbeciles who do not display 30 or more years ago, in his " Structure of Man," specific characters of congenital syphilis, as hinted that even such pathological changes as evidence that parental infection has played a those of tabes may be indirectly due (under the part in the production of the mental and phyaction of the spirochæte, it must now be claimed) sical arrest, even when no further evidence of to the occurrence of morphological variations in parental syphilis can be obtained; and, from the lumbar cord. Wider approaches are thus opened garnered wisdom he produced clinical evidence which sustains the confidence of the laboratory up to the one goal of all physicians. Syphilophobia is too often dismissed impatiently. workers. Yet he insisted, and rightly, that the Sir GEORGE SAVAGE devoted some attention to a children of syphilitics, more often than others, group of cases’ wherein the subjects, without having apart from all question of syphilis, are the offspring. run any real risk of contagion, are yet obsessed by of the less desirable type of parent; while their dread of syphilis ; and he observed, with truth, that surroundings, more often than those of others, the youthful masturbator and the ascetic celibate are apt to be unfavourable or degrading. The alike may become so obsessed-the one during note of caution in respect of the attribution of Ufels evolution, theother during its decay. Classic certain effects to a single cause was thus sounded, syphilophobia, on the other hand, follows actual at the conclusion as well as at the beginning, of a infection or serious risk-more commonly, we vigorous and progressive lecture.
discussed in
some
"
"
"
"
.
936
STATE AID TO THE UNIVERSITIES OF OXFORD AND CAMBRIDGE. THE
Annotations.
MEMORIAL.
Two tablets in memory of Baron Lister of Lyme were unveiled on Tuesday, Nov. llth : the one, a marble portrait in bas-relief, to be a permanent memorial of Lister’s work in University College Hospital; the other, similar but smaller, Sir George to be erected in University College. Makins, in unveiling the former, traced the development of Lister’s great principle which revolutionised the practice of surgery in his time and asserted itself in every ramification of the science of preventive medicine. Sir Joseph Thomson spoke of Lister’s association with the Royal Society, of which he became a Fellow at 33 years of age. Both tablets have been worthily executed by Professor Havard Thomas.
Regis
" Ne quid nlmlø."
STATE AID TO THE UNIVERSITIES AND CAMBRIDGE.
LISTER
OF
OXFORD
BOTH the ancient Universities have applied for financial assistance to the State, and as a matter of course it has followed that Royal Commissioners have been appointed to inquire into the financial resources of the Universities and their constituent colleges and halls, as well as into the relations of the affiliated foundations to any central administration. Mr. Asquith is the chairman of the Commission, which forms one body of three committeesnamely, a Committee for the University of Oxford, a Committee for the University of Cambridge, and a Committee on Estates Management. The Secretary of the Commission is Mr. C. L. Stocks, an Assistant Secretary to the Treasury. The following is the personnel :-
Oxford Committee. The Right Hon. H. H. Asquith (chairman). Professor W. G. S. Adams, Gladstone Professor of Political Theory and Institutions, Oxford. Professor W. H. Bragg, C.B.E., F.R.S., Quain Professor of ,
___
TUBERCULOUS MENINGITIS AND LETHARGIC ENCEPHALITIS.
THE difficulty in diagnosing between these two conditions is well illustrated by a case of tuber. culous meningitis recently reported by Loyguein a man, aged 27, in whom this diagnosis was
discarded, not only during life, but even on nakedeye examination post mortem, which did not appear to contradict the hypothesis of lethargic encephalitis suggested by the patient’s symptoms. It was only after microscopical examination, which
Physics, London. Lord Chalmers, G.C.B., late Secretary to the Treasury. showed an absence of the lesions character. Mr. Albert Mansbridge. Sir H. A. Miers, F.R.S., Vice-Chancellor of Manchester istic of lethargic encephalitis described by Marie University. and Trétiakoff in the locus niger and gray Miss Emily Penrose, O.B.E., Principal of Somerville nuclei, and the presence of tubercle bacilli College. The that a correct was established.
diagnosis symptoms presented by the patient closely resembled Cambridge Committee. those of a group of patients previously observed by The Right Hon. G. W. Balfour (chairman). Toygue, in which the clinical picture, epidemioDr. H. K. Anderson, F.R.S., Master of Gonville and Caius logical character, and macroscopical appearances of College. the nerve centres post mortem excluded the diaMiss B. A. Clough, Vice-Principal of Newnham College. of tuberculous meningitis, the existence of gnosis Sir Horace Darwin, K.B.E., F.R.S. lethargic encephalitis being confirmed by the fact Sir Walter M. Fletcher, K.B.E., F.R.S., Fellow of Trinity The three of the five cases recovered. that College. in were The Right Hon. Arthur Henderson, M.P. Loygue’s patient symptoms torpor and Dr. Montagu R. James, LL.D., Provost of Eton. somnolence, disturbance of speech, subfebrile Mr. G. M. Trevelyan, O.B.E. temperature, and rapid and progressive loss of Professor Arthur Schuater, Fellow and Secretary of the flesh, followed by sphincter disorders, characRoyal Society. terised first by incontinence and then by retention Conzuzittee on Estates Management. of urine, doubtful meningeal symptoms and, towards Lord Ernle (chairman). the close, paresis of the levatores palpebrarum, Mr. H. M. Cobb, Fellow and Member of the Council of the ocular convergence, and dysphagia. The absolutely Surveyors’ Institution. clear cerebro-spinal fluid, its scanty albumin content, Sir Howard Frank, K.C.B. Sir John A. Simon, K.C.V.O.
Sir J. H. Oakley, Past-President Institution. The Hon. Edward Strutt.
of
the
Surveyors’
Undoubtedly the public support of Oxford and Cambridge bears no proportion whatever to the value of their public work. Now and again we learn of benefactions to both, though these are generally in the form of bequests to the particular college of which the testator had been a member and not to the Universities themselves, whose benefit is consequently only indirect. Again, neither Oxford nor Cambridge can expect to receive from local generosity large sums of money; the huge benefactions to the American universities, which owe their existence to local spirit, can have no counterpart here. The ancient Universities having approached the State will recognise that the State, in return for any grants made, will expect to have some reasonable responsibility in the allocation of the grants; but probably the day is gone by when the authorities of Oxford and Cambridge shudder at the thought of State interest in their affairs.
and absence of a cellular reaction were in favour of excluding both cerebro-spinal and tuberculous meningitis. Subacute syphilitic meningo-encephalitis was excluded by a negative Wassermann reaction in the blood and cerebro-spinal fluid. The autopsy showed a diffuse congestion of the brain without any obvious lesions on the convexity or base, apart from an cedematous and infiltrated appearance of the region between the inferior surface of the cerebellum and the posterior surface of the pons and medulla, and slight adhesions in the fissure of Sylvius. There was no trace of any granulations. Examination of the thoracic and abdominal organs was negative and there was no bony or glandular tuberculous focus. On microscopical examination lesions of meningo-encephalitis were found in the region of the medulla, pons, cerebral peduncles and lower part of the Sylvian fissure, with numerous tubercle bacilli scattered throughout the inflammatory tissue.
1
Bulletins et Mémoires de la Société Médicale des Hôpitaux de
Paris, 1919, 3e série, xliii., 769-775.
935
think, the former. Indeed, it is probable that the spirochæte itself, and not the mere idea, plays a AN address was delivered recently to the Fellow- real part in the production of the mentality of the ship of Medicine by Sir GEORGE SAVAGE, in which syphilophobe, when the need for diagnosis on a the relations between syphilis and insanity were pathological basis is urgent. For if there are
Syphilis
and
Insanity.
detail from the clinical and some cases which fall within the province of the setiological points of view. This discourse contained psycho-analyst, there are others which need intellimany lessons of interest and importance, not only gent, careful, and conscientious specific treatment Moreover, danger point is reached by to the general practitioner, but to some of those by drugs. younger specialists whose positivist inclinations in not a few in this distressing and distressed condition, who, fearing and believing that others know pathology may well, perhaps, be corrected by due the source of their misery, avoid society, and in consideration of an elder’s weighty words ; we extreme instances may seek escape in suicide. therefore look forward with interest to their fuller But there are also certain cases in which mental, in the columns of a contemporary. publication One of the more important of these lessons is moral, and physical degeneration may ensue, rapidly that experience shows the practical unwisdom and progressively, in the years or months closely of the prevailing mental habit of insistence consequent to infection. Perhaps such are less However common than they once were, but they do occur, on the doctrine of the " single cause." necessary for teaching purposes, or for the sys- and a neuronic rather than a vascular pathological tematic classification and delimitation of clinical basis may be suspected. Possibly these cases can entities, this imputation of single causes of be regarded as analogous to the acute myelitis disease may be, clinical experience and careful and nephritis sometimes seen during the late thought alike impress us with the obligation secondary stages of syphilis. The association of recognising the complexity of the causation between what, in a generic sense, may be called but its importance of disease. Herein Sir GEORGE SAVAGE, as a " fits " and syphilis, is complex, " clinician of unrivalled authority and experience, is evident. Undoubtedly, fits which are truly ranges himself beside the late Dr. MERCIER, who, epileptic are common in children the subject of in one of the most valuable of his essays-that on congenital syphilis, or, what is not quite the " Causation "-declared repeatedly that what we same thing, whose parents have been syphilitic; call " the cause of a disease is that in which, for while, in the juvenile form of general paralysis, our purposes, we are most interested. The position less familiar to the practitioner than it should is now accepted-and Sir GEORGE SAVAGE does not be, " fits" of various clinical form occur. But, dispute it-that without antecedent syphilis there apart from the irregular " fits," or seizures of is no general paralysis of the insane. In consequence, classical general paralysis, slight "fits " or faints non-syphilitic clinical forms, apparently closely sometimes happen under stress or strain to those resembling general paralysis of the insane, are who have been infected ; and they are apt to be differentiated therefrom, and are placed in followed by progressive mental enfeeblement, different categories by the application of patho- although the course of classical general paralysis tests. We therefore consider syphilis as is not pursued. Sir GEORGE SAVAGE, while suslogical " the " cause of general paralysis. Nevertheless, as pecting local vascular change, in such cases, as Sir GEORGE SAVAGE points out, and not for the the underlying anatomical factor, points out how first time, we do not know why some persons, and, frequently the diagnosis of general paralysis is indeed, some races of mankind, though sodden wrongly made. The ultimate outcome, however, is with syphilis, should yet escape general paralysis certainly bad; feeblemindedness generally results. of the insane. Moreover, some persons already A valuable and practical distinction is to be made, infected seem only to become the victims of "G.P.I." moreover, between " general paralysis of the after the intervention of an accidental or incidental insane beginning as " locomotor ataxy" and factor. Thus, Sir GEORGE SAVAGE has noted many locomotorataxy accompanied by manifestations of insanity. The recognition of the distinccases in which indications of general paralysis became first noticeable after influenza, contracted tion is important, and difficulty is thereby during prevalence of that disease ; and, like French lessened. With respect to one important matter, namely the observers, he has seen groups of cases, serially infected by syphilis, and all, or several of them, relation between imbecility, idiocy, and parental developing general paralysis. Some have believed syphilis, Sir GEORGE SAVAGE accepted the positive " that there are strains" of spirochaetes specially results of the Wassermann test, when applied to so prone to producegeneral paralysis, andWiEDERSHElM, many idiots and imbeciles who do not display 30 or more years ago, in his " Structure of Man," specific characters of congenital syphilis, as hinted that even such pathological changes as evidence that parental infection has played a those of tabes may be indirectly due (under the part in the production of the mental and phyaction of the spirochæte, it must now be claimed) sical arrest, even when no further evidence of to the occurrence of morphological variations in parental syphilis can be obtained; and, from the lumbar cord. Wider approaches are thus opened garnered wisdom he produced clinical evidence which sustains the confidence of the laboratory up to the one goal of all physicians. Syphilophobia is too often dismissed impatiently. workers. Yet he insisted, and rightly, that the Sir GEORGE SAVAGE devoted some attention to a children of syphilitics, more often than others, group of cases’ wherein the subjects, without having apart from all question of syphilis, are the offspring. run any real risk of contagion, are yet obsessed by of the less desirable type of parent; while their dread of syphilis ; and he observed, with truth, that surroundings, more often than those of others, the youthful masturbator and the ascetic celibate are apt to be unfavourable or degrading. The alike may become so obsessed-the one during note of caution in respect of the attribution of Ufels evolution, theother during its decay. Classic certain effects to a single cause was thus sounded, syphilophobia, on the other hand, follows actual at the conclusion as well as at the beginning, of a infection or serious risk-more commonly, we vigorous and progressive lecture.
discussed in
some
"
"
"
"
.
936
STATE AID TO THE UNIVERSITIES OF OXFORD AND CAMBRIDGE. THE
Annotations.
MEMORIAL.
Two tablets in memory of Baron Lister of Lyme were unveiled on Tuesday, Nov. llth : the one, a marble portrait in bas-relief, to be a permanent memorial of Lister’s work in University College Hospital; the other, similar but smaller, Sir George to be erected in University College. Makins, in unveiling the former, traced the development of Lister’s great principle which revolutionised the practice of surgery in his time and asserted itself in every ramification of the science of preventive medicine. Sir Joseph Thomson spoke of Lister’s association with the Royal Society, of which he became a Fellow at 33 years of age. Both tablets have been worthily executed by Professor Havard Thomas.
Regis
" Ne quid nlmlø."
STATE AID TO THE UNIVERSITIES AND CAMBRIDGE.
LISTER
OF
OXFORD
BOTH the ancient Universities have applied for financial assistance to the State, and as a matter of course it has followed that Royal Commissioners have been appointed to inquire into the financial resources of the Universities and their constituent colleges and halls, as well as into the relations of the affiliated foundations to any central administration. Mr. Asquith is the chairman of the Commission, which forms one body of three committeesnamely, a Committee for the University of Oxford, a Committee for the University of Cambridge, and a Committee on Estates Management. The Secretary of the Commission is Mr. C. L. Stocks, an Assistant Secretary to the Treasury. The following is the personnel :-
Oxford Committee. The Right Hon. H. H. Asquith (chairman). Professor W. G. S. Adams, Gladstone Professor of Political Theory and Institutions, Oxford. Professor W. H. Bragg, C.B.E., F.R.S., Quain Professor of ,
___
TUBERCULOUS MENINGITIS AND LETHARGIC ENCEPHALITIS.
THE difficulty in diagnosing between these two conditions is well illustrated by a case of tuber. culous meningitis recently reported by Loyguein a man, aged 27, in whom this diagnosis was
discarded, not only during life, but even on nakedeye examination post mortem, which did not appear to contradict the hypothesis of lethargic encephalitis suggested by the patient’s symptoms. It was only after microscopical examination, which
Physics, London. Lord Chalmers, G.C.B., late Secretary to the Treasury. showed an absence of the lesions character. Mr. Albert Mansbridge. Sir H. A. Miers, F.R.S., Vice-Chancellor of Manchester istic of lethargic encephalitis described by Marie University. and Trétiakoff in the locus niger and gray Miss Emily Penrose, O.B.E., Principal of Somerville nuclei, and the presence of tubercle bacilli College. The that a correct was established.
diagnosis symptoms presented by the patient closely resembled Cambridge Committee. those of a group of patients previously observed by The Right Hon. G. W. Balfour (chairman). Toygue, in which the clinical picture, epidemioDr. H. K. Anderson, F.R.S., Master of Gonville and Caius logical character, and macroscopical appearances of College. the nerve centres post mortem excluded the diaMiss B. A. Clough, Vice-Principal of Newnham College. of tuberculous meningitis, the existence of gnosis Sir Horace Darwin, K.B.E., F.R.S. lethargic encephalitis being confirmed by the fact Sir Walter M. Fletcher, K.B.E., F.R.S., Fellow of Trinity The three of the five cases recovered. that College. in were The Right Hon. Arthur Henderson, M.P. Loygue’s patient symptoms torpor and Dr. Montagu R. James, LL.D., Provost of Eton. somnolence, disturbance of speech, subfebrile Mr. G. M. Trevelyan, O.B.E. temperature, and rapid and progressive loss of Professor Arthur Schuater, Fellow and Secretary of the flesh, followed by sphincter disorders, characRoyal Society. terised first by incontinence and then by retention Conzuzittee on Estates Management. of urine, doubtful meningeal symptoms and, towards Lord Ernle (chairman). the close, paresis of the levatores palpebrarum, Mr. H. M. Cobb, Fellow and Member of the Council of the ocular convergence, and dysphagia. The absolutely Surveyors’ Institution. clear cerebro-spinal fluid, its scanty albumin content, Sir Howard Frank, K.C.B. Sir John A. Simon, K.C.V.O.
Sir J. H. Oakley, Past-President Institution. The Hon. Edward Strutt.
of
the
Surveyors’
Undoubtedly the public support of Oxford and Cambridge bears no proportion whatever to the value of their public work. Now and again we learn of benefactions to both, though these are generally in the form of bequests to the particular college of which the testator had been a member and not to the Universities themselves, whose benefit is consequently only indirect. Again, neither Oxford nor Cambridge can expect to receive from local generosity large sums of money; the huge benefactions to the American universities, which owe their existence to local spirit, can have no counterpart here. The ancient Universities having approached the State will recognise that the State, in return for any grants made, will expect to have some reasonable responsibility in the allocation of the grants; but probably the day is gone by when the authorities of Oxford and Cambridge shudder at the thought of State interest in their affairs.
and absence of a cellular reaction were in favour of excluding both cerebro-spinal and tuberculous meningitis. Subacute syphilitic meningo-encephalitis was excluded by a negative Wassermann reaction in the blood and cerebro-spinal fluid. The autopsy showed a diffuse congestion of the brain without any obvious lesions on the convexity or base, apart from an cedematous and infiltrated appearance of the region between the inferior surface of the cerebellum and the posterior surface of the pons and medulla, and slight adhesions in the fissure of Sylvius. There was no trace of any granulations. Examination of the thoracic and abdominal organs was negative and there was no bony or glandular tuberculous focus. On microscopical examination lesions of meningo-encephalitis were found in the region of the medulla, pons, cerebral peduncles and lower part of the Sylvian fissure, with numerous tubercle bacilli scattered throughout the inflammatory tissue.
1
Bulletins et Mémoires de la Société Médicale des Hôpitaux de
Paris, 1919, 3e série, xliii., 769-775.