Patient was then committed to Washington Asylum Hospital, and from there transferred to the Government Hospital for the Insane. His polygamous activities then came to light. I shall not attempt to picture the distress of his latest wife when she learned of his career, except to say that the spectacle was pitiable. The patient here showed the physical and mental signs of general paresis, and his subsequent history is unimportant for our purpose. It is hardly necessary to comment on these two cases. The first showed an onset which resembled neurasthenia and, later, melancholia. The delayed diagnosis fortunately caused no especial harm. In the second case the disease was probably present for about six years, judging by the history. Of course, there were almost certainly remissions during that time. It strains our credulity to suppose that this second patient was not seen one or more times by physicians since the onset of his disease. Several innocent families could have been saved from grief, social injury, and possibly hereditary taint if the condition had been recognized earlier. SUMMARY To recapitulate: Early paresis, if unrecognized, may cause suffering to the families and friends of the patient, owing to the fact that its victim is often in a position to control large sums of money. The usual age of incidence is somewhere between thirty and fifty, and the family physician should be on his guard against suddenly-developing physical or mental diseases during this period of life, especially in syphilitics. When the disease is suspected the diagnosis should be confirmed immediately; when it is positive he should lose no time in restricting the patient's activities. He should be familiar with the early physical signs, the eye symptoms, the disturbances of the knee-jerk, Romberg's sign, the speech defect, and the diminished sensibility to pain. He should likewise be thoroughly aware that grandiose delusions (megalomania) are not apt to be present in the early stages. He should look rather for memory defects, faulty judgment, lack of attention and retention, and change in habits. He must exclude tabes, cerebral syphilis, and alcoholic pseudoparesis. In all doubtful cases the blood and cerebrospinal fluid should be examined by the best pathologist in the community. A positive Wassermann in the spinal fluid, increased protein content of the latter, and pleocytosis mean, as a rule, general paresis. In mental disorders of children juvenile paresis should be excluded. In conclusion, it might be well to keep in mind that with every incipient case of general paresis the family physician diagnoses and causes to be committed he performs a service to society in general and to the patient's family in particular, and he may be the means of preventing the destitution of families or even murder itself. REFERENCES 1. GLUECK, BERNARD, "Paresis in General Practice," Charlotte Medical Journal, July, 1911. 2. GORDON, ALFRED, "Early Paresis," Jour. Amer. Med. Assoc., February 1, 1913. 3. JELLIFFE, SMITH ELY, "Treatment of Syphilitic Diseases of the Nervous System," Chapter viii of "The Modern Treatment of Nervous and Mental Diseases," vol. ii (Edited by White and Jelliffe). 4. KING, EDGAR, "Mental Disease and Defect in U. S. Troops," Washington, 1914. 5. KRAEPELIN, EMIL, "General Paresis," New York, 1913. Mental and Nervous Disease Monograph Series, No. 14. 6. WHITE, WILLIAM A., "The Early Diagnosis of General Paresis," Medical News, New York, 1904. 7. WHITE, WILLIAM A., "Outlines of Psychiatry," 4th Ed., 1913. Mental and Nervous Disease Monograph Series, No. 1. THE HEART IN SYPHILIS BY HARLOW BROOKS, M.D. Professor of Clinical Medicine, University and Bellevue Hospital Medical College; Visiting Physician to the City Hospital and to the Montefiore Home and Hospital for Chronic Diseases; Consulting Physician to the Ossining Hospital and to the Union Hospital, New York City IN presenting this résumé of the work which we have done in regard to this subject I wish to point out that I do not propose to discuss syphilis of the heart, but rather the condition of the heart in syphilis, just as, for example, we would consider the heart in scarlet fever, not scarlet fever of the heart. The point which I thus raise is that the changes in the heart due to syphilis may not necessarily be indelibly luetic in themselves; thus fatty degeneration, brown atrophy, or ischemia of the heart frequently develops as a result of lues, yet we could not correctly speak of these lesions in themselves as syphilitic. Doubtless one of the chief reasons that this subject has been so long neglected and misunderstood is because pathologists in particular have long considered only those lesions of the heart as syphilitic which are stamped with the hall-mark of the gumma or which present unmistakable evidence of active luetic change. As a result of this false position, appreciation of the very important rôle which the heart plays in this protean infection has been in the past mostly underestimated and underconsidered. In nearly all the older discussions of this subject the statement is made or the impression given that syphilis does not affect the heart until late in the disease. Yet one of the first and most striking findings of our study has been that involvement of the heart appears very early in the infection, quite as one should expect to be the case in a septicæmia such as lues is. Carrol and I have observed twenty-four cases in which cardiac involvement occurred during the secondary stage of syphilis. Of this series, two died of cardiac failure, both verified at autopsy, and the remaining twenty-two entirely cleared up as to cardiac disturbances under specific medication alone. A twenty-fifth case, to be mentioned later, entirely failed to respond to treatment. In by far the most frequent instance,—that is, in two hundred and seventy-six of the three hundred cases analytically studied by us,the lesions did not come under observation until late in the third stage and long after the time of primary infection, for the most part. In one of our fatal cases death took place just as the secondary rash began to appear and before the diagnosis had been made. The immediate lethal cause was a perforation of an aneurismal dilatation of one of the aortic sinuses. It thus appears that, in so far as involvement of the heart is concerned, it begins among the early indications of the general septicemic condition, and danger from involvement of this organ persists from this time on until actual cure or death has taken place. Of two hundred cases analyzed in this regard, thirtythree occurred in females and one hundred and sixty-seven in men. We believe, however, that these figures only correspond to the relative entrance percentages of women as compared to men. Among women the average age of reporting for treatment was 38.1 years, and of the men, 44.75. Our impression would corroborate this apparently greater susceptibility on the part of women, though it may well be due to the fact that nearly all the men have not so generally neglected the early treatment of the primary infection as is probably the case with women. It is interesting to note, in passing, that fifty-three of the two hundred cases examined as to this particular showed postinfection fertility. It is evident, as we have noted elsewhere, that in the past clinicians have probably overestimated sterility as a result of lues. As to the character of the lesions found in these cases: My anatomical data have been derived from the analysis of the lesions found in fifty consecutive cases of syphilis which came to autopsy in my service. By far the most frequent heart tissue involved was the myocardium, which was found to be diseased in forty-four of the fifty cases. The most frequent myocardial change (out of forty-four cases) was a fatty degeneration. In five instances this was associated with fibrous lesions; parenchymatous changes were associated in six cases; probably, however, this last change was due not to luetic disease, but to subsidiary or terminal conditions. In most cadavers the fatty and fibroid alterations were apparently dependent on coronary disease. Brown atrophy was found alone in seven cases, and this, too, was believed almost, if not always, due to changes in the coronary arteries. Pure fibroid changes were found in four instances, but associated with fatty degeneration and infiltration in five others, so that a total of nine out of the fifty cases is recorded. This was associated three times with cardiac aneurism, due to the fibrosis, and in all these this was the direct cause of death. Study of this important lesion led me to conclude that the fibrosis originates in one of two manners. may result from a coronary fibrosis or an obliterative endarteritis which has brought about a myomalacia with consequent fibrous replacement, or it may follow from an elemental syphilitic inflammatory process which has its acute origin as a true syphilitic myocarditis, six instances of which were studied in my series. The frequency of this change in the papillary muscles in particular and its consequent effect on the mechanism of the heart valves is obvious. It True gumma of the heart muscle was found in but five of my autopsy cases, though Mracek found it present in ten of his fifty. Buschke and Fisher1 and Simmons 2 were apparently the first to demonstrate the presence of the spirochetæ in the heart-muscle lesions, but the most conclusive work of this nature has been that of Warthin, who showed the almost universal presence of these organisms in the heart-muscle lesions, even where the microscopic changes were otherwise very slight. 3 Pericardial changes were found in seventeen of the fifty cases. Contrary to Billings, however, I do not believe that syphilis in itself acts as a determining factor to any very considerable degree in regard to pericarditis. My opinion as to the significance of certain lesions of the epicardium is quite different, however. The most frequent epicardial change appears to consist of the formation of white, slightly raised, opalescent round or oval areas which are microscopically made up of hyperplastic endothelial cells and connective-tissue fibrils more or less infiltrated by lymphocytes. This was found in twenty-eight of the fifty cases. In some instances slight calcification takes place in these lesions, and in nearly all a definite relationship between them 'Deutsche med. Wochenschr., Nr. 19, 1906. 2 Münch. med. Wochenschr., 1906, p. 1550. |