CHAPTER VII. VARIETIES OF GENERAL PARESIS. (Part 1)

CHAPTER VII. VARIETIES OF GENERAL PARESIS. In attempting to classify cases of general paresis, considerable difficulty is experienced at once. There seems to be no very clearly cut divisions at present, based either on therapeutics, pathology or clinical history into which these cases can be separated. The varieties are divided by Spitzka simply into two types; in the first of which the affection is the ordinary type; the second is that in which the mental symptoms appear after serious evidence of a spinal or axial affec- tion of the nervous system, and hence this author terms this form the " ascending affection." Savage divides the cases into acute and chronic and then into those in which the symptoms are pri- marily maniacal with exaltation of ideas; next the melancholic and hypochondriacal cases; and lastly those in which dementia is more or less pronounced from the onset. He states that it will be seen in tracing the history of cases that nearly all end in dementia sooner or later. In another division he con- siders whether the brain or cord symptoms are most marked, or come on earliest. In considering the latter, he divides the cases into those in which the posterior columns of the cord are most affected, and those in which the lateral columns are chiefly involved. Folsom, in Pepper's System of Medicine, states that well-marked general paresis can be divided into four distinct types, as follows: (i) The demented and paralytic; (2) the hypochon- driacal; (3) with melancholia; (4) with exaltation and 73 74 VARIETIES OF GENERAL PARESIS. mania. There are mixed cases in which some or all of these forms occur. Folsom also believes that the period of invasion or prodromal period, be it short or long, has, as a rule (not always), gone by when the disease has arrived at a point in its progress to be definitely placed in any of these four types. B. Lewis ^ goes into the varieties of general paral)^sis in greater"detail and produces a plan of clinical group- ings in which he feels that all forms of general paral- ysis may be included; this scheme is based upon the predominance of the cerebral, bulbar or spinal symp- toms, their early or late onset and the clinical course pursued. Group I. — Paralytic m)7driasis; a partial reflex iridoplegia (light). Increased myotatic irritability. Excessive facial tremor and speech troubles. Great optimism with profound dementia. Group 2. — Mydriasis with associated iridoplegia rapidly passing into the cycloplegic form — an early symptom. Frequent myotatic excess, but no con- tractures. Late speech troubles. Acute excitement with frequent convulsions. Very rapidly fatal course (preponderance of syphilitic history). Groups J. — Spastic myosis; a complete reflex iri- doplegia. Absent or greatly impaired knee-jerk. Failure of equilibration; locomotor ataxy, defective sensibility. Very defective articulation. Much opti- mism and excitement. Group 4. — Late eye symptoms : paralytic mydria- sis, a partial reflex iridoplegia (for light only). Ataxic paraplegia confined to lower extremities (arms do not participate). Great facial ataxy with extreme troubles of speech. Epileptiform seizures ushering in pro- nounced mental enfeeblement. ^Mental Diseases, ad ed., p. 336. VARIETIES. 75 Group 5. — No oculo-motor symptoms beyond oc- casional inequality. No contractures, but notable myotatic excess. No disturbance of equilibration, locomotion, or sensation. Speech troubles not pro- nounced. Epileptiform seizures very rare, but from the first progressive deepening dementia. The French writers, according to Sankey,^ divide the disease into four varieties as follows: 1. A congestive variety. 2. A paralytic variety. 3. A melancholic variety. 4. An expansive variety. M. Baillarger insisted upon a hypochondriacal, a melancholic, a monomaniacal, and a simple form. It is therefore abundantly evident that the cases of gen- eral paresis show certain deviations in the course of the disease, but, nevertheless, Sankey believes that there will be found running through the whole of each case more or less pronounced general symptoms. Every writer upon the disease admits that such variation, also, in the advent of the various phe- nomena, is not uncommon. As regards the order of occurrence of the mental and motor symptoms, for instance, Sankey^ states that there are described three modes of invasion as possible. Firstly, the case may commence by some disorder of the mental faculties — usually by delirium, or maniacal excitement — but in some cases with depres- sion or melancholy, and on the subsidence of these symptoms the peculiar indications of general paresis, particularly those connected with the motor functions, manifest themselves. This is admitted by most authors to be the most frequent order of invasion. Both Parchappe and Calmeil agreed also that the ^Mental Diseases, p. 277. • o/. ci/..:p. 377. 76 VARIETIES OF GENERAL PARESIS. special paretic symptoms may follow the mental at any length of time, as after many years, though this is exceptional and not the usual course. Secondly, other cases occur, in which the mental symptoms, as mania, melancholia and especially a state of dementia, are manifested simultaneously with the lesion of motility. Thirdly, MM. Baillarger and Lunier asserted that, as a rule, the lesion of motility precedes the mental phenomena. Voisin, the well-known authority, has given five forms of general paresis : 1. Acute general paresis in which the course is rapid, the stages are confounded, and death occurs early as a rule. It may suddenly attack an apparently healthy person without any warning. 2. The common form of general paresis in which the mental state is generally expansive and ambitious. Often accompanied by epileptiform and apoplectiform attacks. 3. The form inwhichsymptomsof dementia predom- inate (paralytic dementia). It is the chronic form par excellence,and is accompanied by few somatic troubles. 4. The senile form connected with atheroma of the arteries. In its course it is next in rapidity to form i. It is very rare. 5. The spinal form in which the medullary troubles dominate the scene, and the intellectual are of sec- ondary importance. It is very irregular in its mani- festations. (Shaw, Epitome Mental Diseases, p. 77.) Another division of general paresis is into four forms, three of which depend on the character of the mental symptoms, and the fourth on their absence or significance: (i) the expansive form; (2) the depres- sive or melancholy form; (3) the demented form; (4) the somatic form (Shaw). VARIETIES. 77 Mickle, in his classic work, has laid down five groups into which general paresis can be divided. The first group consists of cases of a common kind, which exhibit exalted delusions, maniacal excitement and hallucinations. The duration of this condition is short; cerebral hyperemia and softening are observed with adhesion and decortication. In the second group there is found a protracted stage of dementia, the quiet self-satisfaction of the early stage being followed by peevishness or apprehension, till the personal habits become foul and brutish. The duration of this condition is lengthy, and the brain seen to be atro- phied with considerable increase of intracranial serum. The gyri of the upper surface and frontal region are wasted, adhesion and decortication are moderate, and the white substance is pale. In the third group dementia is early and predominant, and melancholic delusions are common, the latter course of the disease being one of extreme dementia. Hemiplegia is conspicuous and common, epileptiform attacks being very frequent. The duration of this condition is brief and on autopsy the left hemisphere is found more diseased than the right and more or less atrophied. In the fourth group the morbid le- sions are much more conspicuous in the right than in the left hemisphere. The outbreak begins with active delirium and maniacal agitation, the symptoms of dementia and melancholia noticeable in the third group being wanting. The duration is somewhat lengthy. The fifth group is not well defined. There is much local induration of the cortex and the inter- stitial changes tend to sclerosis; the mental symp- toms are various; epileptiform fits, hemiplegia, and spasms are frequent and the duration somewhat long. (Blandford on Insanity, p. 311.) Mickle also recognizes eight mental varieties in the 78 VARIETIES OF GENERAL PARESIS. first Stage of general paralysis. These are : (i) Symp- toms of dementia predominant, in which are found every degree of mental failure and deficiency. (2) Expansive delirium is predominant. Here grandiose ideas and a feeling of elation or quiet self-satisfaction are actively shown. (3) Mental excitement is pre- dominant, with probabl)', though not necessarily, exaltation and grandiose ideas. There'may be excite- ment, mental and motor, or merely silent restiveness, or what is described as the galloping form of general paralysis — raving, violent, sleepless, with typhoid-like symptoms. (4) Hypochondriac symptoms are prom- .inent. In such cases the essential mental state may be hypochondria, with delusions as to the viscera, and especially regarding the liver and bowels. Ac- cording to Mickle, this form is next in frequence to the expansive: according to Clark's experience the first class, the early demented, are more prevalent than the hypochondriacal. (5) Melancholic s)'mp- toms prominent. (6) Persecutory delusions prom- inent. (7) Stuporose form. (8) Circular form. (Abstract, Campbell Clark, Mental Diseases, p. 207.) According to a few writers there is no division as satisfactory as that of " Meynert's Eight," which is as follows : 1. Simple progressive dementia with the usual motor impairment which accompanies it, but except- ing hypochondrical depression, not necessarily ex- hibiting other mental symptoms than dementia. 2. With the expansive delusions and the distinctive motor disturbances which appear simultaneously and are progressive, constituting the " classic " form of general paralysis. The mental state is usually of self- satisfaction and exultation,but there maybe depression. 3. Of the same type as the last, but failing its steadily progressive character through arrest of the VARIETIES. 79 active process. The remissions, which seldom last so long as a year, raise hopes of recovery, but still manifest unmistakable impairment of the reasoning faculties. The psychic disturbances are much greater than can be accounted for by the atrophy of the brain alone. 4. Cases in which the characteristic exaltation and grand delusions reach such an astounding height that manifest motor symptoms are looked for with con- fidence from day to day and yet may not appear even for a year, any slight incoordination naturally being obscured by the general muscular disturbance. Meanwhile there may be such an improvement that the patient leaves the hospital for awhile, once, rarely twice, on the responsibility of his family, but to return with marked motor, as well as mental, signs. 5. A very rare form, with alternate symptoms of exal- tation and depression of the type of circular insanity. 6. With early furious delirium, painful hallucina- tions, confusion and incoherence somewhat resemb- ling acute delirium. 7. Progressive general paralysis, in which the characteristic indications appear secondary to other forms of insanity; for instance, after paranoia or melancholia, first described by Hoestermann. 8. The combined form with sclerosis in the whole cerebro-spinal tract, the symptoms of tabes or spastic paralysis predominating, according as the posterior or lateral columns of the spinal cord are chiefly involved. The ascending type, in which the cord is first affected, is rare. Optic neuritis ending in atrophy and paraly- sis, especially of the ocular muscles, may precede marked mental symptoms. (Folsom per Hughes, Practice of Medicine, p. 472.) It is beyond the scope of this work, addressed as it is to the medical student and general practitioner, to do 8o VARIETIES OF GENERAL PARESIS. more with these elaborate classifications than to enumerate them. But there are a few special forms included in these classifications which are usually described by writers that may appropriately find men- tion at this point. The Galloping Form. — As the name suggests, the galloping form acts in such a rapid and violent man- ner that within a few months, or it may be but weeks, all resistance to the disease is overcome, and death follows after this brief time. It usually assumes a grave aspect from the first, and in some cases mani- acal outbreaks occur, from the earliest stage of the disease. Many times early exhaustion supervenes, then partial collapse and lowered temperature are speedily followed by death. These cases are similar to those of acute delirium, and with these are often confused. Berkley speaks of one case in which slight irrita- bility and alteration of disposition was followed within two weeks by excitement, in the highest degree, with delirium and fever, the malady running its course in five weeks. The same author records another case, who recovered from this attack of seeming acute delirium and was still living after four years, but much demented and showed the characteristic pupils and increase of knee-jerk. Zacher reports two cases of acutely progressive paresis, the first, after a melancholic prodromal state, ran its course in less than four weeks; the second, lasted for two and a half months. A CASE OF RAPID GENERAL PARESIS AND ATAXY DEVEL- OPING TOGETHER. Thomas J. B., married, aet. 51, clerk, no insane relatives ; first attack of insanity ; supposed to depend on intemperance, although he had been temperate for the last two years. A THE GALLOPING FORM. 8l slight attack of depression, lasting one week, occurred when he became teetotal. He has had two severe falls, with no symptoms of local head injury. The first symp- toms of this attack occurred three weeks before admission, when he became strange in manner; unable to attend to his business ; sleepless, with exaltation of ideas ; believing himself a great man ; able to compose poetry and paint pictures, at least, fit for the academy. He said his father was the son of a nobleman; was restless, boastful and en- croaching ; constantly moving about, willing to race or fight with the patients. His pupils were small but equal ; memory for recent events bad ; walk unsteady, legs be- ing thrown away from the body and falling on the heels ; patellar reflexes absent, says he can't feel the ground ; falls on closing eyes ; slight tremor of lips and hesitation of speech. He continued happy and contented with his pow- ers, making many pictures and filling reams of paper. In about a month he had divergence of eyes ; marked cere- bral giddiness when left eye was closed ; no evident changes visible in his discs. Since then bodily and men- tal weakness progressed rapidly. (Abstract, Savage on Insanity, p. 318.) A CASE OF GALLOPING GENERAL PARESIS. A man of 40, who had always been healthy, was taken ill and in a few weeks developed a typical case of general paresis with well-marked expansive ideas and delusions of grandeur and power. He was removed to the asylum and died there in ten days from a series of convulsive seizures which numbered ninety-nine in twenty-four hours. (Abstract, Jelliffe, Allgem. Zeitschreift fiir Psych., 55, 99-S-) GENERAL PARESIS OF THE GALLOPING TYPE. Louis F. G., married, aet. 50; artist, no history of in- sanity in the family ; and no previous attack of insanity. He had suffered from pleurisy with delirium two years be* fore ; steady in his habits ; cheerful and intelligent. Two months before admission he was irritable, nervous and de- pressed ; he lost his artistic power and forgot to complete his 7 : ;;c died In >. cl furesif. '•: :.r.d most iVi- :;-J:ry. Tn:> .-,.' J cerra::; J:rier -o ..■■ dojbt ol' e.'a- »i««r.:(.-: OJ liic THE DOUBLE FORM. 83 form attacks supervened and he is now in last stage of the disease. (Abstract, Blandford on Insanity, p. 306.) GENERAL PARESIS OF THE DOUBLE FORM. Herbert F., single, ast. 42, accountant, no insane rela- tives, first attack of insanity, no cause known. When admitted the symptoms had existed about six weeks. They began with nervousness and twitching, followed by idepression and threats of suicide, but were soon replaced by great exaltation and extravagance. He believed himself rich and powerful and offered marriage to several ladies ; tongue tremulous, pupils equal ; hallucinations of hearing ; memory weak, sleeps well ; excessive patellar reflexes ; writing shaky. Five weeks after admission, both legs swelled and unhealthy-looking pustules formed. In two months he was variable, weaker in mind and emotional. In three months more he was melancholic and said he had offended God, but again became violent and emotional. In a year after admission he was quiet, no exaltation, looked like one suffering from melancholia with stupor ; circulation feeble, hands livid and congested. A little loss of expression, less tremor of tongue and hesitation of speech, yet he was wet and dirty. If seen for the first time now, he would hardly be recognized as a general paralytic. (Abstract, Savage, op, cit,^ p. 326.) GENERAL PARESIS IN WHICH PARETIC SYMPTOMS ALTERNATE WITH IDEAS OF PERSECUTION. A hereditary degenerative patient was attacked by gen- eral paralysis. At about the same period manifested ideas of persecution, and attempted suicide. On admission in the following year he presented classical signs of general paralysis, also ideas of persecution and hallucinations of hearing. The symptoms of meningo-encephalitis disap- peared, while delusions of suspicion increased. Psycho- motor hallucinatory delusions of general and genital sensi- bility were added and he attacked his "persecutors" with deliberate violence. Two years later he had two epilepti- form attacks and signs of general paralysis reappeared in 84 VARIETIES OF GENERAL PARESIS. a more serious form, delusions of persecution vanished. Again the paralytic symptoms retrogressed and the delu- sions revived. In three years more his mental faculties had declined in vigor and the persecutory insanity had pro- gressively lost in activity and cohesion. (Magnon, Jour- nal of Mental Science, Vol. 53, p. 381.) GENERAL PARESIS OF THE ALTERNATING FORM. J. B., a country laborer, with a history of alcoholic ex- cess and hereditary taint. On admission he was melan- choly, not inclined to conversation or to answer questions. He had the delusion that no one would employ him and was so miserable that he secluded himself and would