CHAPTER XL PARTICULAR SYMPTOMATOLOGY (^Continued). After the onset of the established disease many of the patients are subject to episodes of cerebral origin. These attacks comprise apoplectic, convulsive and paralytic seizures. Lewis designates them as follows : Syncopal or quasi-synco- pal attacks. Petit mal, or, exception- ally, grand mal. Limited, or unilateral, twitching. Epileptiform discharges. Apoplectiform, or true congestive, attacks. Hemiplegia and mono- plegia. Syncopal Attacks. — Vertigo, or "slight faintness," is often the first indication recognized by the patient and his friends, at the onset of the disease. The pa- tient does not lose consciousness, but feels disposed to sit down to rest for a few minutes. These attacks are referable to a spasm of the vaso-constrictor nerves of the pial vessels, with subsequent damming back of the returning blood, with irritation of the nervous ele- ments. Syncopal attacks are by no means uncommon, dur- ing the course of general paresis, and often are the first signs of a failing circulation. A patient, after eating, suddenly blanches and falls forward; his pu- pils are dilated, his pulse feeble, his skin becomes cold and damp; no convulsions follow and shortly he rallies and recovers his former condition.
<Callout type="important" title="Important">Syncopal attacks can be the first sign of a failing circulation.</Callout>
A VARIETY OF CEREBRAL SEIZURE IN WOMEN SIMULAT- ING KATATONIC SYMPTOMS. Naecke observed three paretic women who had repeated attacks of stupor with muscular tension. They became speechless, head bent forward, face pale and expression- less, eyes wide open, staring into vacancy ; they seemed without comprehension, had to be fed and forced to move. Both stupor and muscular tension usually disappeared in a few hours.
<Callout type="warning" title="Warning">Women may experience severe symptoms that mimic catatonic behavior.</Callout>
GENERAL PARESIS DEVELOPING IN A MAN SUBJECT TO SYNCOPE FROM INFANCY. A patient, 42 on admission, had syncope from his infancy, on the least annoyance ; he became pale, fell down and lost consciousness, and on coming to, he would have severe headache. He conducted an important business and had three children. His mother and brother presented the same symptoms. While in asylum, he had no syncopal attack.
<Callout type="risk" title="Risk">Syncopal attacks can be a precursor to more serious conditions.</Callout>
APOPLECTIFORM ATTACKS. Apoplectiform Attacks. — It is not always possible to separate sharply in clinical work the various forms of cerebral seizures, but there is an apoplectic type, which maybe associated with slight convulsive move- ments, although not so necessarily. These attacks are less frequent than the epileptiform seizures. Pre- monitions may be present or absent, while the attacks vary in degree from the slightest symptoms to those of the most extreme type. The symptoms are as follows : There is generally a precedent rise of tem- perature, expressed in a congestion of the face with heated skin. The pupils may be dilated. Paralysis, especially of the unilateral form, follows, with pos- sibly conjugated deviation of the eyes with rotation of the head. The condition simulates pathologically the physiological action of the nitrite of amyl. The patient has observed for some time that his head feels dull and heavy, he experiences sudden rushes of blood to the head, his temporals beat violently and for the moment he is unable to speak or even think. These attacks may occur at anytime; they may be so slight as to cause scarcely any interruption of the flow of ideas, or they may resemble apo- plexies, due to extensive hemorrhage. Tetanoid seizures may occur, with tonic spasm of the muscles of the chest and neck, resembling epilep- tiform seizures. Pleurothotonos and even opisthotonos may be present. Hysteroid waves occur, chiefly in women, but in men there may appear un- controlled emotional outbreaks.
<Callout type="tip" title="Tip">Apoplectiform attacks can range from mild to severe, with potential for extensive hemorrhage.</Callout>
GENERAL PARESIS WITH REPEATED ATTACKS OF CEREBRAL SEIZURES. Mr. X., set. 41; single; grocer. His father died, set. 83, of urethral fever; his mother, act. 50, of cancer. One half brother has had a systematized hypochondriacal delu- sibn for some years. A half sister has been neurotic and her husband, a second cousin, committed suicide while suf- fering from nervous depression. A daughter of this sister has been hysterical for some years and has been almost insane for some time. Another half sister, by another wife, and born after the father was sixty years old, is neu- rotic with intense egotism and slight intellectual imperfec- tion in the form of inertia and absence of ambition. The only brother of the patient is sound, mentally and physic- ally. His paternal grandfather was a confirmed alcoholic. His maternal grandparents were healthy. Mr. X. was not peculiar during childhood and youth except morbidly sen- sitive to criticism and would seclude himself if offended or disappointed. He was successful at business and very much liked. His business was destroyed by fire and he became very poor. He disappeared for a year, and when found he was penniless and very much run down. He would not tell anyone what he had been doing. His rela- tives found him employment. Twenty-two years ago he was under treatment for the alcohol habit ; for two years before admission he indulged in sexual excess and has suffered from nocturnal incontinence of urine, and recently from imperfect control of the vesical sphincter during the day. A year ago in July, he had an attack of numbness in the left side and has had over ten similar attacks since, result- ing in a paresis of that side ; also he began to have difficulty in articulation, especially if fatigued or excited. Within the last six months, his spelling has become worse ; he omits words in writing or dates letters wrongly ; his penmanship varies : part of it is in a fair round hand and part of it is a dragging scrawl ; some words, begun well, end in a con- fused blur. The letter is not signed. He is unable to add a considerable column of figures in his accounts and often drops an important item. Within three months, his ideas have become confused and he cannot think clearly ; he lost his way in Boston where he is perfectly at home. At a junc- tion, he got out of a car and then got into it again, thinking k APOPLECTIFORM ATTACKS. I31 he had made the change. He cannot relate facts as they occurred or as they were told him. He severely hurt his foot by a fall, a few months ago, during a paretic attack. Recently, his temper has been excited violently by trivial things ; in speech and manner only, however, and he has never threatened injury to anyone. His statements are usually wholly unreliable. The night before admission, he was found sitting on the front steps with nothing on but a shirt, having thrown his pantaloons into the street. On admission, well nourished ; appetite good ; bolts his food ; bowels constipated ; urine negative ; heart action regular but weak ; pulse 96 ; tongue edematous, fissured, with- out coating, very tremulous when protruded ; speech hesi- tating ; linguals pronounced with difficulty ; facial muscles brought into play in talking ; pupils react to light but there is commencing atrophy of the retina. There is quanti- tative electrical change in the muscular system generally and in the left leg especially. He is very self-conscious, irritable and suspicious. During the first month's residence his general condition improved but he became very hypo- chondriacal, thinking the various paresthesias were or- ganic complaints in the parts. He had a slight apoplecti- form attack in the early part of the month ; during the latter part, he developed modified delusions of grandeur concerning his own identity and his possessions. During the next month, he had two apoplectiform attacks, one of them with motor aphasia lasting an hour. His incontin- ence was present night and day : gait more ataxic ; failure of memory more marked. During the next month he was exalted, showing explosive and boisterous mirth, or anger for trivial causes. During the next three months he had three paretic attacks, each one leaving the left side weaker and his ataxia more marked. He heard voices at night ridiculing him. With the last paretic attack, there was ptosis of left eyelid, with anesthesia and absence to response to either electrical current on the left side. There was progressive physical failure, rapid mental reduction, loss of memory for recent events and great confusion of thought. At the end of the period he could not get up or 132 DOWN. down, dress or undress : he could walk in a straight line if started, but fell if he attempted to turn. In the morning, he could articulate fairly well and write connected sen- tences, but his ability decreased during the day, so that by evening he could do neither. He also had temporary paresis of the vocal cords, making his voice husky for a day or two. At times, there was complete aphonia. Dur- ing the next two months there was no change except that he thought there was some one in his room impersonating him. He could see and hear some one. He said that this strange man put him out of bed and was trying to steal his clothes. This delusion persisted for a long time, gradually merging into the idea of dual personality, with whom he kept up an almost continuous conversation. This idea disappeared only when the mental reduction had reached the degree necessary to abolish it. At the end of the next two months, he was eating heartily but carelessly, bolting his food ; not sleeping well ; no change in the motor par- esis, can walk fairly well but cannot get up. A week later, his mirror had to be removed to prevent his breaking it in efforts to get at the person who was disturbing him. During the day, he is in constant communication with his double, who tells him he is going to die of starvation. The lingual and laryngeal paralysis is progressing, so that he speaks only in a low monotone. In a year and a half, he was entirely demented and helpless. The left side was entirely paralyzed.
<Callout type="important" title="Important">Apoplectiform attacks can lead to progressive physical failure and mental decline.</Callout>
GENERAL PARESIS BEGINNING WITH CONGESTIVE SEIZURE. Robert M., aet. 34, stupid, mentally clouded, had hallu- cinations of hearing, heard people telling him to do things ; tongue tremulous ; left pupil larger than right ; plantar and knee reflexes exaggerated. Mentally the patient cleared up and was discharged ; a few months later he returned with marked motor symptoms of rapidly advancing signs of general paresis. He probably had had a congestive attack and was recovering from it before admission.
<Callout type="warning" title="Warning">Congestive seizures can lead to rapid progression of general paresis.</Callout>
EPILEPTIFORM ATTACKS. Epileptiform Attacks. — Cerebral congestion may appear at the outset of the disease, as well as ter- minate it in its later stages. It may be looked for at any time in the course of the disease. One of the most serious forms of congestion is the epileptiform attack. There is a sudden loss of consciousness with the typical warning cry, pallor followed by flushing, foaming at the mouth and convulsions. These con- vulsions may be general, or limited to one side, or even one limb. The temperature usually rises, even to the height of 103° to 104°. These attacks, as a rule, are not isolated, but occur in sequence, separated by longer or shorter periods of coma, even amounting to a regular status epilepticus. Mental deterioration invariably follows; the condi- tions are aggravated and death often occurs in the at- tack. The prolonged rise of the temperature points to this contingency. Some complication is generally left behind, such as hemiplegia, aphasia, paresis, if death does not actually ensue. It is a grave condition, which must always be at- tended with the gloomiest forebodings. It is re- garded rather as a symptomatic epilepsy than true epilepsy, although clinically it shows no essential difference. These attacks may occur early in the disease, but generally not until a year has elapsed. According to Newcombe, out of one hundred general paretics, fifty-one had epileptiform seizures, but only one had convulsions within three months of the onset. Lewis, who has studied this condition carefully, believes that the onset of the attack is almost invari- ably hemispheric, /., that the convulsions begin unilaterally and may, or may not, spread to the op- posite side; that they are often preceded by a well- marked tonic stage, as the rapid primary discharges occur; that the clonic stage, being often long pro- tracted, becomes more and more broken up into in- tervals of comparative rest, until at last an occasional convulsive jerk of the limb, or separate muscular contractions alone prevail.
<Callout type="risk" title="Risk">Epileptiform attacks can lead to death if not managed properly.</Callout>
GENERAL PARESIS BEGINNING WITH CONVULSIONS. A porter had been promoted to a position where greater responsibilities and labors of a mental character were thrown on him ; in the midst of apparent health, having been slightly worried, he was seized with a convulsion, lasting several hours with partial consciousness and later these convulsions occurred in status-like succession at intervals of a week for some months. Eighteen months after, the convulsions having been absent for a year, he died with the quiet type of paresis.
<Callout type="tip" title="Tip">Convulsive seizures can be a sign of impending general paresis.</Callout>
GENERAL PARESIS BEGINNING WITH CONVULSIONS. One of my patients had many epileptic-looking fits for a year, and was treated for epilepsy by eminent physicians during that time before the usual mental and motor signs of general paralysis appeared.
<Callout type="important" title="Important">Convulsive seizures can precede the onset of general paresis.</Callout>
GENERAL PARESIS WITH CONVULSIONS. A DESCRIPTION OF THE EPILEPTIFORM SEIZURE. J. F., seized with convulsions which occur every ten or fifteen minutes, are identical with epileptic seizures, except that the convulsions are chiefly unilateral, involve the chest muscles but slightly ; no lividity of face or obstructed breathing ; each attack lasts for about thirty seconds. The convulsive phenomena in their sequent stages were as fol- lows : (i) No pallor, but head and eyes deviate to right, a broken inarticulate cry, pupils dilate widely, brow is raised ; (2) mouth drawn to right, lips twitch strongly and EPILEPTIFORM ATTACKS. I35 uncover the canines ; (3) right arm flexed, with forefinger extended, then raised and convulsively jerked at shoulder, brow twitches violently ; (4) in certain seizures, the dis- charge spread to right leg also, but did not involve the left. After the fit, there was paralytic deviation of head and eyes to the left, and helplessness of right arm, left pupil large, but slowly regained former size, champing movements of the jaw, no exaggeration of patella reflex, no ankle clonus. At the onset of each attack, the heart, previously beating strongly, became imperceptible during the tonic stage. The cry always precedes each attack.
<Callout type="warning" title="Warning">Unilateral convulsions can be a sign of more serious underlying conditions.</Callout>
A CASE WITH EPILEPTIFORM SEIZURES. RAPID COURSE. John W., set. 45, first symptoms, restlessness at night, which is a frequent first warning, epileptiform fits followed. Sexual desire very strong but could not be gratified. Naturally temperate and careful of money. Slight ac- cident to left foot two years previously. Tabetic gait, weaker on left side ; grip jerky and spasmodic in left hand ; speech slow, interrupted and slurred ; absence of tendon reflex ; left eye blind from injury. Died a year after admission.
<Callout type="important" title="Important">Epileptiform seizures can indicate the rapid progression of general paresis.</Callout>
A CASE OF GENERAL PARESIS OF THE CON- VULSIVE FORM. G. E., set. 40. He was of an excitable disposition ; he has led a dissipated life in regard to drink and women ; of a fiery temper ; he had had syphilis, and much mental excitement. He had complained for some time of severe headache, and insomnia ; he was unusually irritable, and not fit to do a day's business. One day he suddenly fell down in a fit, and remained in general and severe convulsions with complete unconsciousness for about two hours and died in them. After death there were all the pathological signs of gen- eral paralysis, especially the adherence of the pia to the 136 CONVOLUTIONS OF THE VERTEX. There was no localized disease of the membranes or vessels that was recognized as syphi- litic and he had not been drinking heavily before his death.
<Callout type="warning" title="Warning">Severe convulsions can be a sign of advanced general paresis.</Callout>
Unilateral Twitching. — Limited or unilateral twitching of the muscles of the face or of certain groups of muscles, such as those of the hand, or of the thumb and fingers is not infrequent. These convulsive jerks are usually of short duration, but they are sometimes prolonged over hours, or even days. The rhythmic jerks may be on both sides but generally they are unilateral.
<Callout type="important" title="Important">Unilateral twitching can indicate the onset of general paresis.</Callout>
Key Takeaways
- Recognize syncopal, petit mal, and grand mal attacks as early signs of general paresis.
- Be aware that apoplectiform attacks can range from mild to severe with potential for extensive hemorrhage.
- Understand the risk of epileptiform seizures leading to rapid mental decline and death.
Practical Tips
- Monitor patients for syncopal episodes, as they may indicate a failing circulation.
- Look out for unilateral twitching or convulsions, which can be early signs of general paresis.
- Be cautious with patients experiencing severe headaches and insomnia, as these could signal the onset of more serious conditions.
Warnings & Risks
- Syncopal attacks can be a precursor to more serious conditions like general paresis.
- Epileptiform seizures can lead to rapid mental decline and death if not managed properly.
- Unilateral twitching or convulsions should be taken seriously as they may indicate the onset of general paresis.
Modern Application
While the historical techniques in this chapter are rooted in a bygone era, the recognition of syncopal episodes, apoplectiform attacks, and unilateral twitchings remains crucial for early detection of neurological disorders. Modern medical practices have advanced significantly, but these symptoms still serve as important indicators that require immediate attention.
Frequently Asked Questions
Q: What are some common signs of general paresis in the early stages?
In the early stages, patients may experience syncopal or quasi-syncope attacks, which involve vertigo and a feeling of faintness. These episodes can be followed by petit mal or grand mal seizures, characterized by loss of consciousness and convulsions. Unilateral twitching is also a notable sign.
Q: How do apoplectiform attacks differ from epileptiform attacks?
Apoplectiform attacks are less frequent than epileptiform seizures but can be associated with slight convulsive movements. They may include symptoms like headache, facial congestion, and unilateral paralysis. Epileptiform attacks, on the other hand, involve a sudden loss of consciousness, convulsions, and a rise in temperature.
**Q: