CHAPTER XII. PARTICULAR SYMPTOMATOLOGY (continued). (Part 1)

CHAPTER XII. PARTICULAR SYMPTOMATOLOGY (continued). Sleep. — Insomnia is one of the earliest disturbances of the disease, but usually it is not looked upon with anxiety by the patient. Frequently there is drowsi- ness through the day, or a tendency to sleep after eating. The nights are passed in much sleepless- ness, or the sleep is light and not invigorating, troubled by dreams, or nightmares or startings. In some cases there is found a special type of res- piration occurring in sleep. It is carried on by short inspirations that hardly raise the chest walls and there are frequent long and plaintive expirations. This mode of breathing is found at times in all stages of the disease. Pains. — The patient complains very frequently in the prodromal stage of sharp pains like neuralgia, or sharp rheumatic pains in the limbs, and sometimes through the body. Usually they are not localized, and for that reason seem to the patient the more un- accountable. At times, or in some cases, the pain may be localized, but comes and goes, causing the most intense agony for the time. It may continue as a neuralgic pain in the head, or in some part of the body, and attacks of hyperesthesia of parts sometimes cause intense suffering. The pains are described as sharp, lancinating, or flashing, and frequently are but momentary. Occasionally girdle pains are com- plained of, and sometimes, also, an intense burning pain over a certain spot on the knee or foot. These pains usually disappear as the disease makes its true motive apparent. 146 PARTICULAR SYMPTOMATOLOGY. Headache. — Among the prodromal symptoms is headache. The headache is sometimes neuralgic in character, at other times accompanied by tenderness, or feeling of lightness in the head (Shaw). Severe frontal headache is present in almost all cases suffering from the tabetic form; and the patient frequently rubs the hair from the frontal region, or from one entire side of the head in his attempt to rid himself of the constant pain; or he may knock his head against the wall in his desire for relief. In all forms the headache disappears as the disease ad- vances. Precedent migraine, says Mickle, often dis- appears at the development of general paresis. Sensory Disturbances. — Sooner or later in the dis- ease, later, according to Clouston, there is loss of special sensations and impairment of the cutaneous sensibilities. The latter are noticeable in very defi- nite regions. Macpherson states, " As a rule, they are most pronounced in the following order: on the chest in front, in the lower limbs, the upper limbs, and the face and hands." This applies both to ther- mal sense and the loss of feeling of pain. A curious symptom noted by Giannone is that of analgesia of the ulnar nerve. This author states that if the ulnar nerve be pressed upon as it passes over the groove in the humerus, the arm in the flexed position, it will be found, pain is absent in 53 per cent, of the cases and diminished in 25 per cent. In addition to the anesthesia of the skin, loss of special senses occurs. That of the eye has already been considered in detail. Deafness, aphonia, loss of control of the muscles of deglutition, are all fre- quent sensory disturbances. Not infrequently the patient may strangle from a bolus of food, or a stom- ach tube may reach the trachea or bronchi without any sign on the part of the patient. The sense of SENSORY DISTURBANCES. 1 47 taste may become so deranged that the patient can- not distinguish between substances placed in the mouth; and the olfactory sense, also, may be so deficient that no odor however bad gives annoyance, or is noticed by him. This loss of sensation is pro- gressive, and is believed by Clouston to be due to primary degeneration in the cortical centers of spe- cial sense and their terminal nerve apparatus. As already noted under the ocular symptoms, visual im- perfections, color-blindness, or visual hyperesthesia may be present. TWO CASES OF GENERAL PARESIS IN WHICH THERE WAS BLOOD SWEATING. Severes describes two cases of general paresis in the latter stages of which blood sweating about the face was observed. They were cases of long standing, in which the power of articulation was almost lost and muscular paralysis complete. There was observed a great multitude of coagulated blood drops about the face. After being wiped away, other drops appeared in about two hours, appearing as though the face had been picked all over with a fine needle. At the same time, the temperature of the head was increased, pulse 120 and weak. After two days this curious symptom disappeared, leaving rose- colored spots where the sweating had been most extensive. (Abstract, American Journal of Insanity, Vol. 20, p. 356.) GENERAL PARESIS WITH SENSORY PERVERSIONS. A patient believed that his skin was tucked in, another that it was hung up to dry, another was continually pick- ing off ** gold leaf" from his bodily surface. (Abstract, Spitzka, on Insanity, p. 202.) A CASE OF GENERAL PARESIS IN WHICH THE KINES- THETIC SENSE WAS LOST. A patient had conducted a large business and had accumulated considerable property. Yet after his ad- 148 PARTICULAR SYMPTOMATOLOGY. mission, he never referred to the past or inquired for his friends. When his relatives called to see him, he replied to their inquiries at times correctly and at others incorrectly. He never expressed pleasure or displeasure at their visits or requested them to come again. He never wrote or took interest in letters written to him. He was accustomed to spend the time looking out of the window, or walking up and down the hall. Two or three months after ad- mission, he lost his personal identity and insisted that he should be called Johnson. After a residence of sixteen months, during which he never expressed a regret or pleasure, he had an epileptiform seizure from the effect of which he did not recover. This case was unusual in the almost total absence of emotional expression or desire. (Abstract, Stearns, Mental Diseases, p. 488.) A CASE OF PARESIS WITH MARKED SENSORY SYMPTOMS. In this case, affection of sight from optic atrophy was among the earliest symptoms of the disease. Three months before admission the patient had consulted Dr. Swanzy at the National Eye and Ear Infirmary who found optic atrophy, also Argyll-Robertson pupil and at times slight affection of speech and he diagnosed general par- alysis. The ocular lesions determined the form of the delusions. In the earlier stages he saw spiders, white skeletons, moving objects, crabs and different colored mosses, later he complained of fluff, flies and worms being thrown into his eyes and then of buildings being erected at the back of his eyes, which blocked out his vision. He was depressed and suspicious. There was no history of syphilis or alcoholism. (Abstract, Dawson & Rambaut, Journal of Mental Science, Vol. 45, p. 620.) A CASE OF GENERAL PARESIS WITH MARKED SENSORY SYMPTOMS. P. T., at. 36, army pensioner. History of syphilis and sexual excess ; he has two healthy children. Two years ago the patient began to suffer with convulsions, treated as idiopathic epilepsy. He was admitted in February, then he TROPHIC CHANGES. 1 49 had slight tongue tremor and flattening of face, arliculatory slurring, and very exaggerated patellar reflex ; pupillary reactions and fundus oculi were normal, also common and special sensibility. He had mild exaltation but no delusion. There was no change till April, when he had several attacks of petit mal, preceded by darting pains in the legs, and fol- lowed by a temporary accentuation of the physical signs. With the onset of these attacks optimism disappeared and he had persecutory ideas, attributing his sufferings trf drugs in his food, etc. When the attack passed oS the exaltation returned and it was more marked ; God had touched and cured him, etc. In May, a more severe con- gestive attack was succeeded by temporary aphasia and right brachial paresis, the mental state being depressed. A remission of mental and physical symptoms followed this until September, when another similar attack occurred, with no sensory disturbances except the darting pains at the outset. Near the end of November, he had a severe congestive seizure, preceded by intense darting pains and leaving a condition of left hemiparesis, also a mental state of panic terror ; he seized the paretic arm with the sound hand and shrieked, '* Take it away, the big serpent is bit- ing me." Furor was too great to allow observation of sen- sory condition. This excitement subsided after some hours and the paretic symptoms passed off, leaving patient very dull and confused ; he said a big serpent had bitten him on left side, but God had saved him because of his holiness. Sensibility to pain and touch were not lessened on left side. On December 9th there was a revival of the furor with the former delusion, but without motor paralysis. On December 25th another congestive attack was fol- lowed by left hemiplegia and hemianesthesia ; patient was happy, fondled affected arm, calling it the little son that God had brought to him. In a day or two localized motor and sensory paralysis passed off, but dementia became profound. The patient died of cardiac paralysis in January following. (Abstract, Sullivan, W. C.) Trophic Changes. — One of the most interesting con- ditions, prevailing in the later stage of the disease, »3 150 PARTICULAR SYMPTOMATOLOGY. IS the trophic changes. These are numerous and varied, and for the most part are real trophoneuroses. For instance the tendency to sacral decubitus is due not to the wet habit alone, but to a certain degree of trophic trouble which is always present. Other changes to be expected at times are the loss oi teeth and nails, the latter becoming extremely brittle and fissured. The hair likewise suffers: it gets dark, brittle, and scant and occasionally it be- comes almost white. The knees, elbows, and other points of the body, are prone to ulceration, even though there be but the weight of very light bed- clothing, such as a sheet. These regions, as well as large areas of the skin, occasionally break down and slough, from no other cause than trophic alter- ation. Abscesses, erythematous eruptions, perforat- ing ulcers of the foot, have been described, due to the same cause. Progressive muscular atrophy is not uncommon. This may take the pseudo-hypertrophic form and the muscles seem to increase in size, because of the fatty infiltration and subsequent deposit (with wasting) of fibrous tissue. The bones likewise suffer, becoming infiltrated with fat, which is deposited in the Haversian canals. This is associated with progressive increase in the amount of organic and a consequent decrease in the amount of inorganic material. This process may go on to such an extent that the bones become very brittle, a condition closely approaching osteomalacia, and fracture of them is then a very simple matter. Trophic changes in the joints, as well as of the bones, occur at times. These arthropathies are similar to those found in locomotor ataxia and like them are found in cases of the "ascending type" of paresis, in which the spinal precede the cerebral symptoms. TROPHIC CHANGES. 15I and so doubtless depend upon lesions of the spinal cord. An interesting case, involving both hip joints, was seen recently at the Philadelphia Hospital in a paretic. The sternum and ribs may become firmly united by reason of ossification of the cartilages. The thorax thereby becomes a rigid case, and breath- ing is only successfully accomplished by bringing into use the accessory muscles of res- piration. Macpherson calls atten- tion to the fact that incurving with elongation and ossification of the xyphoid portion of the sternum is quite apt to cause much pain and annoyance to'the patient in breath- ing. Among other trophic changes may be noted the absence of the general healthy appearance of the skin. A diminution of the hem- oglobin, giving a color index vary- ing from 0.5 to .85 of the normal and a lower number of red cor- puscles, are constantly to be ob- served. Herpes zoster and furun- culosis, faintly indicated at first, may become so serious as to en- danger the life of the patient. "'" uana.) Hematoma of lower bowel, diarrhea and gastric hemorrhage may supervene. Hematoma of the ear, another trophic change, is treated under separate head. GENERAL PARESIS WITH ARTHROPATHY OF KNEE JOINTS. J. D., XX. 38 ; white, admitted in July. He had suffered for some years with pain in the legSt which had been called rheumatic. Otherwise he was healthy up to a year and a half before admission when he had a swelling of 152 PARTICULAR SYMPTOMATOLOGY. the knees. Six months before admission, he began to have persecutory delusions ; he became silly and weak. Drawling speech began three months before admission. There had been no convulsions, or history of syphilis. On admission he was very demented. Both knee joints were enormously enlarged ; grating sounds could be heard in them easily. The anterior end of the condyles of the femur was enlarged. Shortly after admission, he had a maniacal episode. After this, he showed a grandiose delu- sional state ; he was more demented ; he talked incoherently about finding immense sums of money. His speech be- came more drawling and unsteady. He managed to walk about, but the joints grew more deformed. The patellae were flattened, disfigured, and increased in diameter ; the bosses on the condyles were very prominent ; no stalactites could be determined; grating sounds could always be heard ; the joints were painless and free from heat or red- ness ; there was increase of fluid within them ; no edema about them but the skin felt hard and tough; there was increased lateral movement. Very strong electrical cur- rents failed to cause contractions in the muscles of the thighs and legs, except in the peroneal group of the right leg. He died of edema of the lungs. The post-mortem findings of the knee joints are given. The right joint was as follows : The synovic membrane in front was of a steel-gray color, mottled with blue patches and covered with numerous small miliary calcare- ous nodules. The anterior edges of the condyles of the femur were greatly hypertrophied in nodular masses or rugosities. These formed bosses extending upwards and outwards about two centimeters beyond the edge of the condyle. In the anterior notch between the condyles was a triangular mass of nodules embedded in tissue and freely movable. These nodules were of stony hardness. Over the articular surface of the right condyle there was left the lining membrane of the joint considerably thickened and rough in some places, in others thin, and presenting about the center an eroded patch. Over the surface of the left condyle, the lining membrane was absent, and the bone TROPHIC CHANGES. 1 53 was worn and eroded, especially toward the periphery. There was a series of small eroded patches with nodules running along the outer border to the posterior extremity of the condyle. In brief, most of the soft structures of the joint showed destructive changes. The semilunar carti- lages were much worn and eroded, and easily displaced. The inner surface of the capsular ligament showed some pedunculated masses. The crucial ligaments were appar- ently wasted, but still held firmly. The end of the tibia was covered with thin, worn and eroded membrane ; part of the surface of the bone was bare. The joint contained a green, thick, opaque fluid. The patella was quite de- formed. It was thin and flattened, with rugous edges. The under surface was covered with shreds of membrane. The capsular ligament was much distended and the joint cavity extended to an abnormal limit upon the front of the femur. The left knee joint was rather larger and more distended than the right. The same general characteristics were to be noted — distended capsule, eroded membranes, nodular pedunculated formations, and bony bosses on the anterior edges of the condyles. (Abstract, Lloyd, J. H., Journal of Nervous and Mental Diseases, Vol. 18, p. 83.) A CASE OF GENERAL PARESIS SUPERVENING ON TABES DORSALIS, MARKED TROPHIC DISTURBANCES. C, aet. 37, male, married for six years, one child, five years old ; phthisis on both sides of the family ; his father had died of diabetes, his brothers were intemperate. He had been a medical student, drifting on for years without obtaining a qualification and had led a fast life. He was sus- pected of syphilis but denies it ; of late he has been temper- ate. Six years ago he received a blow on the head and neck and since then has been a changed man. Soon after he got married, sexual vigor much diminished. His marriage involved him in pecuniary worry, to which he was unac- customed ; felt depressed ; lightning pains in the limbs ; six to eight weeks before admission, seized with agonizing pains down his back. Similar attack affecting head a week later. A year ago he had become captious, irritable 154 PARTICULAR SYMPTOMATOLOGY. and unlike himself ; more recently he had been depressed, hysterical and high spirited by turns and occasionally vio- lent. Exaltation appeared a month before admission. On admission, June i8, he was anemic and cachectic ; pupils contracted and sluggish, the left slightly ; the larger patel- lar reflexes absent; with feet together and eyes shut, a little disposition to totter ; pains down his legs, which he said had lasted on and off since his accident six years ago, also a sense of abdominal constriction of recent origin. Said he was passing water with a less forcible stream and that there was dullness of sensation on both ulnar regions, but no anesthesia was detected on testing. His com- plaints too, as