'Fournier, Alfred: Treatment and Prophylaxis of Syphilis, translated by C. F. Marshall, Rebman Co., New York.

10

Gregg, Donald: Boston Med. & Surg. Jour., Dec. 16, 1915.

"The Social Evil in Chicago: Gunthorp-Warren Printing Co., Chicago, 1911, p. 241.

12 Bazeley, J. H. and Anderson, H. M.: Boston Med. & Surg. Jour., Dec. 23, 1917.

13

'Williams, Frankwood E.: The Relation of Alcohol and Syphilis to Mental Hygiene, Am. Jour. of Public Health, Boston, Mass., Vol. vi, No.

12.

"Osler, William: Annual Oration on the Campaign against Syphilis, Lancet, May 26, 1917, p. 787.

15

'Sullivan, E. A. and Spaulding, E. R.: The Extent and Significance of Gonorrhoea in a Reformatory for Women, Jour. Am. Med. Assn., Jan. 8, 1916.

16

1912.

Neisser, Quoted by Mullowney, J. J.: The China Med. Jour., March,

17 Norris: Gonorrhoea in Women, W. B. Saunders Co., 1913, p. 128. 18 Ibid., p. 96.

19 Southard and Solomon: Neurosyphilis, William Leonard, Boston, 1917, p. 300.

20

21

Reid, G. Archdall: Lancet, Vol. ccxii, No. 4914, p. 694.

Editorial, Boston Med. & Surg. Jour., Vol. clxxvii, p. 740.

22 Gaucher and Bizard: Jour. Am. Med. Assn., Feb. 3, 1917, p. 384.

23 Bloch, Iwan: System of Syphilis, Vol. 1, p. 19.

24 Watson, David: Gonorrhoea and Its Complications in Male and Female, Paul B. Hoeber, New York, 1916, p. 2.

25 Lyster, William: Venereal Disease and the New Army, Jour. Am. Med. Assn., Oct. 13, 1917.

26 Method of Attack on Venereal Disease, Am. Social Hygiene Assn., New York.

"Exner, N. J.: Prostitution and its Relation to the Army on the Mexican Border, Am. Soc. Hygiene Assn., New York City, p. 10.

28 Ibid., p. 15.

29 Editorial, Lancet, Oct. 13, 1917.

80 Revised Laws of Mass., 1902, I, Chap. 75, Sec. 48.

31 Martin Edward: The Control of Venereal Disease in the Army, Jour. Am. Med. Assn., 1xix, 18, p. 1537.

Boston Med. & Surg. Jour., Dec. 9, 1915.

Third Great Plague, W. B. Saunders Co., Phila

Mobilizing the Brains of the Nation, Mental

Syphilis in Relation to Mental Disease

WILLIAM C. SANDY, M.D.

(Assistant Superintendent, Connecticut Hospital for Insane,
Middletown, Conn.)

Syphilis has long been recognized as an important etiological factor in mental disease. With the refinement of diagnostic methods by the addition of the precise laboratory tests for syphilis, the etiological significance of syphilis in mental disease has become more firmly established. The relationship between syphilis and insanity cannot be emphasized too strongly. Here the cause is clearly a preventable one and in prophylaxis largely rests the hope of the future in combating the increasing problem of the insane.

The limits of this paper will not admit an extended discussion of the different clinical manifestations of the syphilitic infection in the psychoses. It is purposed, however, to outline the types of psychoses and to direct the attention to the importance of taking widespread prophylactic measures against syphilis, with some suggestions as to ways and means from the standpoint of mental hygiene.

That the syphilitic infection is prevalent to a startling degree in the community at large is undoubtedly true, but estimates as to the actual number of cases vary too greatly to be conclusive. Moreover, even though the number of syphilitics were known it would be impossible to estimate accurately the percentage of nervous and mental cases liable to develop, as there appear to be many other factors such as race, individual susceptibility, possibly the influence of associated habits such as alcoholism and other conditions, which seem to have a bearing in determining whether the nervous system is involved, which portion, and to what extent it is attacked. The results of Wassermann surveys of communities, institutions or other groups of individuals undoubtedly represent to a certain degree the percentage of luetic infection among these persons. Here again, however, no generalization

can be made and marked variations will be found due to differences of technique, the personal equation of the examiner, racial or community peculiarities of those examined and so on. For instance, in the matter of racial difference alone, in Southern communities the prevalence of syphilis in the negro is so marked that it is customary to regard each individual as syphilitic until proved otherwise. But even in the negro race, the percentage of positive Wassermanns reported by different writers varies greatly depending apparently upon the examiner and his methods. In any case one should remember that in the psychoses as well as in other conditions a positive Wassermann does not always mean that syphilis is the most important causal agent. It may be merely incidental.

Although the uncertainties of statistical studies are apparent and care must be taken in making general applications from the conclusions reached, yet the findings are suggestive and should always receive due consideration. Some time ago, Dr. Thomas W. Salmon cited the investigations conducted in the records of the Austrian army. Between 1880 and 1890, 4,134 officers had contracted syphilis, and in 1912 it was found that of this number about 4.9 per cent had developed general paralysis. In a recent edition of Nonne's work, it is stated that 15 to 25 out of every 1000 cases of syphilis develop cerebral manifestations.

At the Connecticut Hospital for the Insane, Middletown, the Wassermann test is made upon the blood serum of every patient admitted. During the past year, about 20 per cent have been found to be positive. Upon the other hand, a survey of the entire patient population of the New Jersey State Hospital at Trenton in 1911 and 1912, consisting of 1,583 individuals, resulted in only 7 per cent positive, a figure thought by the one who made the survey to represent approximately the prevalence of syphilis in the population of that portion of New Jersey from which the hospital drew its patients. The low percentage of positive reactions may be partially accounted for by the fact that a large proportion of those examined had been in the hospital for some years.

The statistical findings of the New York State Hospitals as to the number of cases showing a syphilitic etiology may be taken

as fairly representative. There was a total patient population under treatment in 1914 of 41,403, the number of first admissions for the year being 6,265, all of which were thoroughly and uniformly examined by a prescribed method and a diagnosis reached at a staff meeting in accordance with a recognized classification. Of the first admissions, 14.4 per cent were found to have syphilitic etiology. Besides these, 12.7 per cent resulted from arterio-sclerosis, of which syphilis is an important causal agent.

During 1914, in the New York State Hospitals, 16.6 per cent of the deaths were due to general paralysis, a disease of syphilitic origin. Salmon called attention to the fact that in New York state in 1913, there were 1,000 deaths from well recognized general paralysis (about as many as died from typhoid fever), there being a strong probability of there having been many more which were recorded as something else.

Further statistics of a similar nature might be cited almost without end but the foregoing should be sufficient to convince anyone of the importance of syphilis in relation to mental disease.

By far the most common type of psychosis due to syphilis is general paralysis of the insane or paresis as it is frequently called. Often insidious in onset and protean in clinical manifestations, paresis may be unsuspected until the attention is forcibly directed to the unfortunate individual by some scandalous action, marked change in habits or disposition or conduct entirely foreign to his ordinary mode of living. The disease is apt to make its appearance around 35 to 40, usually some ten years or more after the initial infection, the ordinary course being a progressive deterioration with death in from two to five years. The mental symptoms are so varied that one should always suspect paresis in an individual in whom any psychosis begins for the first time in middle life. While the expansive type with megalomanic features is perhaps popularly believed to be "classical," yet as a matter of fact, the demented form is much more common. In general the mental symptoms may be characterized briefly as a progressive loss of memory, change and dilapidation of personality, disposition and behavior, variable emotionality, euphoria

and absurd delusions, profound judgment defects. Physically found irregular, sluggish or Argyle-Robertson pupils, tremors, difficulty in coördination, exaggeration or (in tabetic type) absence of tendon reflexes, a characteristic speech and writing defect. From time to time, there occur the so-called paretic attacks which may be epileptoid in character. These paretic attacks may be followed by focal symptoms which, however, are only temporary and quite regularly disappear. The blood serum and spinal fluid should always be examined. In most cases the Wassermann reaction will be found to be positive in both blood and spinal fluid. In the latter, there will be a pleocytosis, the presence of more than ten cells per c.m.m. being diagnostic. The gold chloride reaction and globulin test will both be positive.

From a pathological standpoint, general paralysis is a chronic inflammatory and degenerative process. In the words of Dunlap, it is "essentially a generalized infection with the spirochete pallida, in which the central nervous system stands out more prominently than any other part." There is a general diffuse atrophy of the brain cortex, most pronounced in the frontal region. The pia is infiltrated and there is periarteritis. In the cortex, there is an irregular but active proliferation of new blood vessels, with marked infiltration about the same, consisting of lymphocytes, plasma cells and mast cells. There are cell degenerative changes, neuroglia replacement and new glia formation, especially in frontal regions. Noguchi and Moore first demonstrated the spirochete in the brain substance in paresis, a final confirmation of the syphilitic etiology.

Theoretically, cerebral syphilis is to be sharply distinguished from paresis, but clinically the differentiation may be an extremely difficult matter. Cerebral syphilis may be said to be more on the surface as contrasted with the parenchymatous changes of paresis. There are three types which may be combined to a certain degree, the gummatous, which is rarest, the meningeal, and the vascular, the latter consisting of a progressive, girdling, obliterating endarteritis. From the very nature of cerebral syphilis, it will be seen that symptoms of a focal