A Case of General Paresis 
of Fourteen Years’ 
Standing, 
BY 
WHARTON SINKLER, M. D„ AND 
EDWARD N. BRUSH, M.D., Ls' 
Philadelphia, Pa. 
FROM 
American Journal of Ensamtn, 
July, 1889. 
UTICA, N. Y\ CLINICAL CASE. 
A CASE OF GENERAL PARESIS OF FOURTEEN YEARS’ 
STANDING.* 
BY WHARTON SINKLER, M. D., AND EDWARD N. BRUSH, M. D., 
Philadelphia, Pa. 
The history of this case has been so fully detailed by Dr. 
Sinkler that it is unnecessary for me to narrate the facts which 
were obtained on his admission to the Pennsylvania Hospital for 
the Insane on October 4th, 1888. 
He was in a complacent state, appeared pleased with everything 
and showed no correct appreciation of his surroundings, or of the 
fact of his commitment to the hospital. He was talkative and 
extremely incoherent. There was much disturbance of speech to 
such an extent indeed that he could not make himself understood. 
He spoke in a jerky, explosive fashion, and slurred over his words 
after the manner of a general paretic. His pupils were small and 
the left seemed the larger, but the difference was quite slight. They 
responded slowly to light; the response to accommodation was not 
tested. There was marked fibrillary twitching about the mouth, 
and the tongue showed considerable tremor. It was protruded 
slowly and with some effort withdrawn suddenly. 
A note in the case book three days after admission states that 
his gait is somewhat ataxic, and that there is considerable lack of 
control in coordinating the movements of the upper extremities. 
His disposition, the same note states, “ is very happy,” he laughs, 
whistles and attempts to sing. His usual response to inquiries 
concerning his health was the one word “healthy ” pronounced in 
a sudden, explosive manner and made to sound like “ helly.” He 
remained without material change until October 21, seventeen 
days after admission, when he became late in the evening suddenly 
very much excited. He appeared under the control of delusions 
of fear, repeated the word “poison” several times, gesticulated 
wildly and pointed repeatedly to his throat. This stage of intense 
excitement passed away before morning, but for a few days he 
remained disturbed, appeared angry at some thing, and when 
unable, from speech disturbance, to make himself understood, 
became excited. He gradually became quiet and resumed his old 
complacent happy mood. When it was possible to understand 
* These notes are the sequel to an article of like title in the April Journal and 
form Dr. Brush’s portion of the joint production. The MS. failed to reach us in 
time to secure publication with Dr. Sinkler’s.—Eds. 2 
him, he talked about machinery and inventions, and appeared to 
have extravagant delusions in that line. 
Eaily in the morning of the 13th of November he became quite 
excited and noisy, but soon becamo quiet again. At 0 a. m. he 
was observed to be in a semi-comatose state, which was followed 
by a series of convulsive seizures six or seven in number. These 
seizures were confined to the left side, and after their cessation he 
had left hemiplegia for a few hours. On the day following he was 
restless and noisy. During the day he had one convulsion, and 
during the twenty four hours ending on the morning of the 16th 
of November he had twenty convulsive seizures. His pulse on 
the 16th was 110, temperature 101J in the morning, and but 
slightly higher in the evening. 
The convulsions always commenced on the left side by extreme 
flexion of the thumb upon the hand, closing of the fingers, flexion 
of the forearm upon the arm which was then drawn across the 
chest in rapid and somewhat rhythmic movement. The leg then 
became involved, the head was drawn extremely to the left, and 
there was conjugate deviation of the eyes. After a series of con- 
vulsions of this kind the movements became general, involved the 
right side and followed no general order, but each series com- 
menced as above described. 
He continued to fail steadily from this time and was almost 
continuously confined to bed. On one or two occasions he becamo 
quite excited, and was the subject of hallucinations of sight and 
hearing, judging from his conduct. His attempts at speech were 
wholly unintelligible, except that an occasional word could be 
understood. When restless at night the hypodermatic adminis- 
tration of l-200th of a grain of hyoscine hydrobromate secured a 
quiet night’s sleep. 
On the 4th of January, just three months after admission, he 
had a renewal of the convulsive seizures which were of the same 
character as those previously described. He continued to have 
convulsions at irregular intervals, some of which were quite 
severe, the majority being slight for the next five days. During 
some of the intervals he could be aroused, attempted to speak, 
and w’as able to swallow liquid food. On the 10th of January he 
was quiet but in a semi-comatose state, during the night he had 
several slight convulsions, but was lree from them after seven 
a. m. of the ilth. At 10.30 a. m. on the 11th, his features became 
suddenly blanched, his respiration became embarrassed, and before 
I could reach his bedside, though in the ward at the time, he was 
dead. 3 
Autopsy twenty-four hours after death. Cadaveric rigidity 
marked. Examination of brain. Calvaria thick and compact, 
diploe almost obliterated; dura not adherent to calvaria, somewhat 
thickened and discolored along longitudinal sinus. Pacchionian 
bodies very prominent, adhesions between dura and pia-arachnoid 
in vicinity of Pacchionian bodies and along the entire longitudinal 
fissure; pia-arachnoid opaque, opacity most marked along lines of 
vessels. Meningeal vessels much distended, much serum in meshes 
of arachnoid. Pia-arachnoid adherent to entire brain, tearing up 
cortex when efforts at separation were made. Adhesion between 
hemispheres and along the fissure of Sylvius very marked. 
Patches of yellow atheroma in basilar and Sylvian arteries, and to 
a less extent in other cerebral vessels. Lateral ventricles dis- 
tended with serum, ependyma granular and containing calcareous 
particles. Choroid plexus contained minute serous cysts, and 
calcareous deposits. White matter of brain generally softened 
and disposed to break down. 
Heart.—Right side distended with blood deposits, atheroma, 
at base of aortic and mitral valves. Large patch of atheroma in 
arch of aorta and atheroma of large vessels generally. Several 
old yellow cicatrices on surface of liver. Kidneys somewhat 
congested. The spinal cord presented no microscopic evidences of 
pathological changes beyond some slight opacity and thickening 
of membranes. 
Unfortunately the specimens retained for examination were by 
accident spoiled during the process of hardening, but the gross 
appearances were such as would bear out the diagnosis of general 
paresis.