CHAPTER VII. VARIETIES OF GENERAL PARESIS. (Part 2)

not go out of doors. He feared that something was going to happen to himself and family and refused food. His pulse was 120, with no physical symptoms to account for it; no nervous phenomena; pupils natural in size and out- line, but sluggish ; tongue protruded* a little to the right side ; his general condition, pallor, want of muscular tone and anemia. A curious fact was that his despondency came on towards evening and had disappeared by morn- ing. He did not sleep well, was fidgety, restless and would not keep in bed. He was sent to work in the garden, became more cheerful, less restless and appeared convalescent, but two weeks later was nervous, frightened and tried to get out of the window at night. Nervous twitchings were now observed around eyelids and mouth ; his voice, at first melancholic, was now emotional and trem- ulous ; he was facile, easily diverted from one subject to another, but peculiarly sensitive in his feelings. Later the depression disappeared, he showed temper and impatience ; he was now reported as gaining strength, and improved in his mental condition, but twitching around eyes and mouth was still present. He was discharged much improved and again admitted in three months. He is now decidedly paretic, soon gets tired in walking and staggers ; his words are interrupted ; there is a quivering of the lower lip, even when the mouth is closed. Pupils normal, except that they remained dilated for two or three months. He is now MELANCHOLIC FORM. 85 violent and abusive. (Abstract, Campbell Clark, Mental Diseases, p. 217.) General Paresis of the Melancholic Form. — One of the types of general paresis, first described by Baillarger, is that with symptoms of melancholia and hypochon- dria. In the place of the symptoms of elation in the first stage, there is a feeling of anxiety and forebod- ing. In these cases it is more than a passing feeling of depression of spirits, which is so frequent in the prodromal stage. The symptoms are so like those of a true melancholia that the history presented by the friends of the patient must greatly influence the diagnosis, until such time as a congestive attack, or some somatic sign, occurs to give assurance as to the nature of the malady. After a time, in some cases, the ordinary course of the disease is followed, in others the symptoms of mental depression persist to the end. The hypochondriacal form of the disease is marked by headache, defective circulation, vaso-motor dis- turbances and various abnormal sensations, referred chiefly to the internal organs. Associated therewith are the mental conditions of despondency, languor, inattention and distress about unimportant matters. Actual pain in the epigastric region may be com- plained of for some time, indicating, as some believe, an involvement of the great sympathetic nerve. Hal- lucinations and illusions of a disagreeable character are sometimes added to the other symptoms. Clouston believes that almost all of these patients suffer from some organic visceral disease, or func- tional disturbance, which transmits sensations that are disagreeable and depressing. In examining his pathological register, he found that nearly all of his cases of general paresis who had had tubercular disease had been melancholic. 86 VARIETIES OF GENERAL PARESIS. A CASE OF THE MELANCHOLIC FORM WITH TUBERCULAR DISEASE. G. K.9 a man, had the fixed melancholic delusion that a man was inside of him, who annoyed him constantly and thus made him depressed. Death showed tubercular dis- ease of the intestines. (Abstract, Clouston, Mental Dis- eases, p. 400.) A CASE OF THE MELANCHOLIC FORM WITH BRONCHITIS. A cabman who was very happy in the supposed posses- sion of thousands of pounds suddenly became melancholic, declared himself a beggar and cried bitterly. Upon exam- ination he was found to be suffering from bronchitis. Reflex action was so dulled that he had no cough and felt no pain. As he improved his delusions of grandeur re- turned ; upon relapse the melancholy state at once came back, but at last he recovered from the bronchitis and was again the happy possessor of his thousands (Clouston). The author adds: ** Whenever I see a general paretic dull, now I always search for an organic visceral cause and usually find it." GENERAL PARESIS OF THE MELANCHOLIC FORM. The patient never presented symptoms of excitement or exhilaration before admission, and since then the mental state has been one of depression ; he sees people at night climbing into the window or door of his room ; they are his enemies and try to take pictures of him. At other times, they pound his feet black and blue and, in evidence, he begs you to examine them for yourself. At other times, he hears them shouting to him to come out and de- fend himself if he can. He believes they are the attend- ants, who disguise themselves at night, and says he would kill them if he could, and, in fact, he tries to whenever he gets a chance. He had an epileptoid seizure soon after admission and was in a partial hemiplegic condition for nearly three weeks. (Abstract, Stearns, Mental Diseases, p. 484.) MELANCHOLIC FORM. 87 A CASE OF GENERAL PARESIS OF THE MELANCHOLIC TYPE. John C, married, aged 47, merchant ; no insane relatives. First attack of insanity, which had lasted six weeks, caused by loss of money, and anxiety, and began with the loss of identity. He refused to take food because he believed he could not afford it, and because he thought people were trying to poison him; after admission, he was reported as silent and obstinate, refusing his food, negligent of his person and sleepless ; he had to be fed arti- ficially ; and he had a convulsive seizure in the early part of his illness. He slowly lost strength, but remained per- verse and melancholy. The cause of his physical deteri- oration and of the difficulty in breathing which came on, was unknown. Died in about three months. (Abstract, Savage, op, cii,^ p. 314.) AN ODD CAPRICE IN A MELANCHOLIC PARETIC. A patient, prevented from suicide by his wife, drew dia- grams of his tombstone, whose inscription recited all his achievements, and sang the praises of his wife for saving the life of so valuable a citizen. (Abstract, Spitzka on Insanity, p. 199.) A PECULIAR DELUSION OF ONIONS AND SARDINES, IN THE HYPOCHONDRIACAL TYPE. A patient who could not eat or digest, and who had not a penny, according to his statements made during the hy- pochondriacal period, awoke one morning with the project to get up a monopoly of the entire sardine and Bermuda onion trade in the world, and having, as he alleged, se- cured it, proposed to eat all the sardines and onions him- self. (Abstract, Spitzka, op, cit.^ p. 200.) A CASE OF GENERAL PARESIS OF THE MELANCHOLIC TYPE. One patient who had many of the commonest delusions of melancholia, thought he was going to be arrested, that people were going to injure him, that they were malign- SPINAL GENERAL PARESIS. 89 replaced by spastic paraplegia. (3) The group of spastic cases in which symmetrical descending scle- rosis of the lateral columns is early apparent and continuous; usually as the sequel of convulsive seizures and especially frequent in those subjects who have been addicted to alcoholic excess. The best observers have invariably failed to find that the great Wallerian law of degeneration applies to the pathological reductions of general paresis.^ IMPLICATION OF THE LATERAL COLUMNS. Francis R., single, aged 30, medical student, no history of insanity, first attack, lasting six months; said to have followed excesses and to have had former attack of syphilis. The first symptoms were, change in disposition, oddness in behavior and absence of mind. He had always been vain about his appearance and powers and this developed into extreme exaltation ; he thought himself a perfect para- gon, although he had not passed even his preliminary exam- ination. On admission he was of medium height, squarely built, with bright malar capillary congestion, his walk jerky, patellar reflexes exaggerated, pupils unequal, the right one larger, both reacting to accommodation, but slightly only to light. For twelve months he slowly devel- oped weak-mindedness, great hesitation in speech, extreme facial and lingual tremor, a nervously irritable appear- ance ; no control over bladder and rectum ; indifferent to One of the earlier views of paretic dementia, when it was the termi- nation clinically of posterior sclerosis, was that the degenerative conditions in the spinal cord continued through the motor tracts all the way to the cerebrum and to the cerebral cortex. This is certainly not the correct view. A number of years ago I had for several years a case of posterior sclerosis under my care in private practice. The patient became paretic and went to the Pennsylvania Hospital for the Insane, and subsequently to Danville, where he died. The body was sent to Philadelphia, and a post-mortem was made, and twenty or thirty sections from the cord, and all the way to the cortex, were examined under the microscope. Similar cases have been recorded. The disease perhaps ascends so far as the cord is concerned; but the cerebral condition is only a localized expression of a general condition. The disease does not usually extend anteriorly beyond the oblongata and pons. (Mills, C. K., Nervous and Mental Diseases, Vol. 18. p. 85-) 8 90 VARIETIES OF GENERAL PARESIS. his surroundings, neither reading nor associating. One 3'ear after admission he was unable to walk alone, could not articulate a single word, very wet and dirty, legs be- coming contracted. He died in about three years after onset of disease. (Abstract, Savage, op. cii.j p. 319.) GENERAL PARESIS WITH LATERAL SCLEROSIS IN A WOMAN. Edith C, married, aet. 35, printer's wife, no history of insanity, first attack, of six weeks' duration, had no chil- dren. When admitted the first symptoms were accusations ac^ainst her husband. She became incoherent and restless, wandering about in her night-dress, saying her husband wanted to poison her ; she was excited, had exalted ideas about riches ; thought there was chloroform in her hus- band's brain, that he was mad ; that she was a duchess. On admission she had hallucinations of taste, pupils small but equal, slept badly, walk shaky, reflexes greatly exag- gerated, no change in optic discs. After admission, she steadily got more feeble in gait, more tremulous in speech, with difficulty in swallowing, and loss of power over rec- tum and bladder. In about two months she had an epi- leptiform attack with general convulsions, but the symp- toms were most marked on right side ; she lost power and sank. (Abstract, Savage, op. cit.y p. 320.) IMPLICATION OF POSTERIOR COLUMNS. GENERAL PARESIS PRECEDED BY LOCOMOTOR ATAXIA. G. A., a man of 50, who had had locomotor ataxia for seven years, began to be maniacal, sleepless, and to have delusions of grandeur. Imagined he was an earl with millions ; wrote fifty letters a day, ordering everything imaginable ; and invited the Q^een to dinner. His speech was affected by the characteristic tremble of the lips, the shuffie and thickness in the articulation of long words and sentences. He passed through the second and third stages of the disease and died in eighteen months from the time of the beginning of the mental symptoms. (Abstract, Clouston, op. ct't.y p. 389.) SPINAL GENERAL PARESIS. 9I GENERAL PARESIS FOLLOWING LOCOMOTOR ATAXIA. A chaplain in a Welsh prison had locomotor ataxia of very marked and progressive character. He kept his ap- pointment in the prison for several years. After ten years, he showed signs of exaltation. These became progres- sivCt he began to run down rapidly, went into general paralysis and died eighteen months after the latter symp- ^ ' '' toms developed. (Abstract, Down, Transactions of Ninth International Medical Con- gress, Vol. 5, p. 405.) OBNBRAL PARESIS FOLLOWING LOCOMOTOR ATAXIA. A patient having locomotor ataxia finally showed mental symptoms in the form of ex- citement and delusions of gran- deur. No mental symptoms had appeared until a year after the motor symptoms, but there had been mental weakness for some time prior to the appear- ance of the more pronounced mental symptoms. (Abstract, Steams, op. cit., p. 513.) OBNBRAL PARESIS OF THE TABETIC FORM. C. 6., set. 39, married, sol- « dier, father was insane for g^^^i^ "dtnc'iiT^Mr-eTteiiii d three months. History of oflhekiieejoint; ntclUig sid of bolh present attack: Unsettled, and " "" ""''P"" '° """""' '""■ could not fix attention on his work, did stupid things in the house; although wife and children were starving, spent what money he had in useless articles and gave large orders for things for which he could not pay. On admis- sion, imagined he was very wealthy. He was restless, 92 VARIETIES OF GENERAL PARESIS. talkative and excited ; he could not sleep at night, owing to imaginary insects annoying him (hallucination of touch). His left pupil larger than right, both reacting to light; tongue tremulous ; sensation normal ; reflexes not im- paired ; special senses healthy. Progress of case : Exal- tation well marked, says he is a magnificent writer, while in reality he can barely write his own name. There is considerable mental enfeeblement, articulation correct, tongue tremulous ; left pupil sometimes larger and some- times smaller than the right ; outline sometimes irregular. There are tabic symptoms. Standing with feet together and eyes shut, he sways about and tends to fall. A year after admission : Mild exaltation, showing itself in con- tented expression, and not in well-marked delusions ; no excitement or depression. Enfeeblement is well marked, seen in being easily controlled, in want of self-assertion, in absence of mental vigor; memory is impaired, espe- cially for names of places. The symptoms of locomotor ataxia are well marked. With his eyes open, has difficulty in walking and cannot stand unsupported ; his lower limbs little better than arti- ficial limbs ; coordination of arms and hands not impaired. Sensation to pain and touch impaired in lower extremities, much less so in upper; plantar reflex impaired, tendon reflex abolished, right pupil larger than left, contract to accommodation but not to light. (Abstract, Campbell Clark, op, cit.y p. 219.) A CASE OF GENERAL PARESIS FOLLOWING LOCOMOTOR ATAXIA OF SYPHILITIC ORIGIN. Alfred S., single, 45 ; no neurotic history; syphilis six- teen years ago, but no serious secondary troubles. Six years ago locomotor ataxy developed and was treated. Symptoms of mental disorder have appeared during the past week. He had been exposed to wet and cold a good deal recently. He became excitable and irritable and sleepless and noisy at night. He wrote endless letters, tore up books ; was going to reform the world, to suppress the House of Commons, to blow up everything with dyna- SPINAL GENERAL PARESIS. 93 mite. He has had hallucinations of hearing for a month, and shooting pains in his legs. He had frequent erec- tions and emissions ; pupils at times equal, small at others, the left larger. Six years ago he had convergence and diplopia, cured by the use of mercury ; general and color vision normal ; pupils reacting both to light and accommo- dation; patellar reflexes absent; walk ataxic. On ad- mission, he had all the most marked symptoms of ataxia and of general paralysis of the insane and no treatment seemed in any way to affect him. (Abstract, Savage, Transactions of Ninth International Medical Congress, Vol. 5, p. 939.) TWO JUVENILE CASES IN WHICH THE FIRST MANIFESTA- TIONS OF THE DISEASE WERE IN THE CORD. Female, aet. 23, ill two years, in a helpless condition, unable to walk or stand up, with violent tremors, marked affection of speech, inequality of pupils and Argyll-Rob- ertson phenomenon, demented, loss of control of bladder and rectum, marked general anesthesia and slow re- flexes, suggesting medullary lesion. Also a youth, aged 19, ill on and off for four years, finally went under Char- cot with paraplegia, leading to a diagnosis of ' organic lesion of cord." Under ergot and actual cautery, the para- plegia disappeared, but later there was anesthesia of the face and arms. Then, rapidly appeared, weakness of legs, emaciation, affection of speech, tremor of lips, un- equal and inactive pupils, wet and dirty habits, etc., and early death with post-mortem evidence of general paralysis (Joffroy).