CHAPTER II.
GENERAL PARESIS.
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Synonyms. — General Paresis, Paresis ; General Paralysis, General Paralysis of the Insane; Paretic Dementia, Dementia Paralytica (Krafft-Ebing), Para- lytic Dementia; Progressive Paralysis of the Insane.
Other Titles: Progressive General Paralysis ; Pro- gressive General Paresis ; Paralytic Insanity; Progres- sive Paralysis; Diffuse Interstitial Periencephalitis; Paralysie Generale des Alienes; Folic Paralytique; Periencephalo-Meningitis Diffusa Chronica (Cal- meil); Paralyse der Irren; Paralytischer Blodsinn; Allgemeine Paralyse der Geisteskranken; Psicopatia Paralitica (Morselli).
Definition. — General paresis is a subacute, or chronic, degenerative disease of the brain, often extending to the spinal cord and the large nerve trunks. It is marked chiefly by progressive en- feeblement of the mind and concomitant paresis of the entire body. Mentally, there is moral and intel- lectual perversion, with an abnormal sense of well- being, or actual delusions of exaltation, followed by slow dementia, to which is generally superadded insanity of the maniacal, melancholic, or confusional type; physically, there is gradual development of tremor, pupillary changes, loss of coordinating power, especially of speech and gait, trophic complications, occasional epileptiform or apoplectiform seizures, and finally paresis.
The Mode of Commencement. — The very early indica- tions of general paresis are frequently so ill defined as to
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STAGES OF GENERAL PARESIS. 23
escape recognition, and their true import, even by a competent observer, cannot always be estimated, the difficulty being less when they are more or less sig- nificant, and the ensemble receives due consideration.
There are two accepted forms of onset — the grad- ual and the sudden. In the latter, there is nothing to warn before " the storm has broken." A sudden attack of acute mania may be the precursor; or a variety of cerebral seizure, such as an epileptiform, or apoplectiform attack. Some writers believe that in these attacks and, also, in the cases where a violent shock or an accident appeared to be the beginning, the real beginning was much earlier and to be sought in some of the vague warnings enumerated in the prodromes. According to these observers, and with plausibility, the beginning of the disease is seldom sudden in onset.
It should be kept in view that the changes at first are inconsequential when taken by themselves, but grow gradually more distinct in the progress of the invasion. The course of the disease depends, also, on its type, whether (a) depressive, (d) expansive, or (c) demented ; many cases are early tinged with a slightly somber or melanchol}' aspect, which may pass unnoticed.
Stages of General Paresis. — It has been customary for authors to divide this disease into stages, but there is considerable variation in these classifications; some writers make only two or three divisions, others four or five. It may be seen, therefore, from this diversity that these divisions are merely artificial and that the demar- cations are not readily discerned in practice. There is, too, not much utility in this classification, excepting as it may be of aid in the study of its evolution, and for purposes of clinical description. But here even this separation of the disease into stadia may be accounted
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by some as of limited value, because of the wide diversity of its course. In some cases no distinct stage can be traced; in some the physical symptoms are prominent from the beginning, in others not; sometimes the course is rapid, at other times it is slow; and so too with the epiphenomena, they may be present or absent in varying degree.
In these pages, for the reasons above mentioned, the plan has been chosen, of making four typical divisions, which correspond to the following order:
A prodromal stage, or period of moral and mental alteration.
A stage of decided mental alienation, or of dementia only.
A stage of chronic mental disorder.
A stage of fatuity (Mickle). Or thus expressed :
A prodromal stage.
That of fibrillar tremblings and slight incoordi- nation of the muscles of speech and facial expression, and of mental exaltation with excitement.
That of muscular incoordination and paresis, with mental enfeeblement.
That of advanced paresis, with little power of progression, almost inarticulate speech, and at last paralysis, with mental extinction (Clouston).
A HYPOTHETICAL CASE OF GENERAL PARESIS IN THE PRO- DROMAL STAGE.
Male, 40 to 45 years old, single, of robust habit and good previous general health, (in some cases a syphilitic history may be obtained) ; no distinct insane ancestry; of sanguine temperament. Mentally intelligent, more rarely accomplished or highly educated ; active, energetic, specu- lative, sanguine of success ; disposed to be changeable and fickle. Fond of society, a bon-vivant, and self-indulgent in every way with tendency to excesses in drink and sexual
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indulgences. After a sudden reverse in hopes, preceded by a period of mental strain, patient shows change in character and conduct; rarely, by great depression, usually by an unusual mental excitement, often amounting to a distinct elation. The patient's spirits are high, such as an extra glass of alcoholic stimulant would give. The patient busies himself in various matters, exhibiting a constant garrulity and an entire absence of reticence, with egotistical brag- ging ; he will button-hole persons, almost strangers, and relate to them his confidences. He exhibits very little physical change at this epoch. His elevation may lead him to social indulgences or drink, (thus, alteration in behavior is frequently ascribed to intoxication). Mental character is one of restlessness, followed by mental con- fusion ; patient makes faux 'pas of various kinds, such as shown in the following incidents. A gentleman walked into a drawing room without removing his hat and lighted a cigar. A poor woman openly stole some plants from a window. A woman coming out of a church took a hand- ful of silver from a plate held at the door without any attempt at concealment. A married woman began to un- dress herself by a country roadside. A woman ordered a pair of breeches for her husband, a bricklayer, to be made of moire antique. (Abstract, Sankey, Lectures on Mental Disease, p. 255.)
TYPICAL CASE OF GENERAL PARESIS IN A MAN.
Clarence E., married, aged 37 ; wine merchant. No in- sane relatives ; not very sober habits. Anxiety the supposed cause for this first attack of insanity. He had followed many different occupations during his life. He had had a fit before admission. On admission, he had mania with exaltation ; imagined he was the eldest son of God ; was formerly a great duke ; and had unbounded wealth ; also said that he slept twenty to sixty hours a night. Occa- sionally he would say that he had lost all his delusions, but it required only a short conversation to get evidence of their persistence. He could not appreciate facts. He lost strength and flesh rapidly during the first few months of
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his admission, and there was an increase of tremulousness in his facial and lingual muscles. He walked about rest- lessly for hours and wrote endless letters to great people. His memory was markedly affected and his sense of color was changed. Six months after admission, for a few days, his speech became affected, and there was loss of power in his extremities, but there were no distinct convulsions. He recovered from this and ate and slept well. He had pneu- monia in about a year after admission. During the next year he was much better, walked in the garden. How- ever, his handwriting was shaky, and early in the next year, two and a half years after admission, his aspect be- came dull and expressionless. He was unsteady in his gait and on several occasions fell, but his muscles were fairly well developed. His memory was failing and he was easily moved to tears. His average temperature was 98.4° in the morning and 100^ at night; he had no control over rectum and bladder, and had loss of sensibility. In May of the same year, he had a convulsive fit, from which he recovered, and for a month afterward gained flesh. In the following year, he was fat, flabby and demented, unable to stand ; reflexes very exaggerated ; appetite good ; limbs somewhat contracted ; right pupil large ; he laughed senselessly when spoken to and resisted interfer- ence. He was threatened with bed-sores. In latter part of same year, he had severe convulsion affecting right side ; he recovered, but was in every way weaker, legs becoming contracted and he ground his teeth. During the next year and as long as he lived he never regained con- sciousness ; swallowed food automatically but never artic- ulated. Optic discs were pale and atrophied, but he could hear and see a little. He remained in bed, his limbs drawn up, till August, when he had a fit which was pre- ceded by a condition of extreme reflex irritability ; head was drawn to right side ; right pupil was large ; he had clonic spasms of lower jaw and occipito-frontalis muscle. He recovered from this, but died, worn out, in March of the following year, about five and a half years after admis- sion. (Abstract, Savage on Insanity, p. 299.)
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