CHAPTER XIV. DIFFERENTIAL DIAGNOSIS. (Part 1)

CHAPTER XIV. DIFFERENTIAL DIAGNOSIS. The symptoms manifested in a typical case of general paresis are so well defined that it is not diffi- cult, even for an inexperienced observer, to come to a definite determination; especially is this true of the intermediate stages of the disease. If a patient is first seen in the latest months of his illness, without a his- tory of the previous course and symptoms, it may be impossible to distinguish the condition in which he is found from that due to other organic lesions. Again, at the earliest onset of the trouble, when the symptoms are slight and undecided in character, there is often a difficulty in diagnosis, which in some instances can be surmounted only by an acuteness of observation that comes to one of experience in the signs of men- tal and nervous disease. The difficulty in diagnosis arises from the fact that the pathological condition is a general and indetermi- nate invasion of the nervous system, appearing often indiscriminately in any of its divisions. This gives rise to much irregularity and variety in the sympto- matology, both psychic and physical, and a conse- quent simulation of various simpler organic disorders. As Spitzka remarks: "Among the individual signs may be found almost any and every focal and general symptom known to the neurologist." According to the predominating character of its manifestations the disease has been divided into a number of types, and it is in the rarer and more obscure of these types that we find the greatest difficulty. Thus there are cases 17a CHRONIC ALCOHOLIC INSANITY. 1 73 in which melancholia and hypochondria form the pre- vailing phase, those in which maniacal excitement predominates, and those where dementia exists alone without the characteristic excitement. Spinal symp- toms of either a spastic or tabetic nature may obscure the diagnosis and a predominance of the epileptiform and apoplectiform attacks may closely simulate con- ditions of a more localized origin. ' The symptoms upon which we chiefly rely in mak- ing a diagnosis of general paresis are: affection of speech, pupillary anomalies, muscular tremor, and uncertain gait, accompanied, on the mental side, by intellectual weakness, and, in many cases, by delus- ions of grandeur. When these exist in combination, one needs no further assistance in the recognition of the disease. We will touch briefly upon the principal conditions which may be mistaken for general paresis, mention- ing the salient points which enter into the determina- tion of a correct diagnosis in each case. Chronic Alcoholic Insanity. — Closely allied in some of its phases with general paresis is the form of in- sanity due to chronic alcoholism. In considering this we must bear in mind its etiological connection with the disease in question, as well as the fact that the two conditions may exist in combination. It is the type of paresis in which the mental state is most marked by melancholic depression and hypo- chondriasis which most closely resembles brain dis- turbance due to alcohol. The delusions of a perse- cutory nature and the general attitude of dread and suspicion which mark this latter disorder are very unlike the exhilarated fancies and contented calmness of mind found in a typical case of paresis. The speech, though slurred and tremulous like that of the general paralytic, shows a thicker enunciation 15 174 DIFFERENTIAL DIAGNOSIS. and is without the characteristic vocal defects of that disease, so significant to the practiced ear. The tre- mor in alcoholism is more universally distributed, and not first noticed in certain special muscle groups. The sensorial disorders of various kinds are much more prominent; the motor symptoms, including muscular ataxia, on the other hand, are decidedly less in extension and are not of the steadily progress- ive order found in general paresis. In certain cases of chronic alcoholism, which symp- tomatically closely resemble some types of general paresis, judgment may have to be suspended for a time. Where the excessive use of alcohol is the only factor involved, the removal of the stimulant and the eflfect of treatment will probably, in time, determine the diagnosis. There are also cases of acute alco- holic mania, which so closely resemble paresis of the maniacal form, that time alone can definitely settle the question. Syphilitic Insanity. — Another affection, produced by an indeterminate invasion of the whole system is that form of mental disease which is due to syphilis. Most readily confounded with it are those cases of general paresis in which dementia is the chief, or an early symptom, and in which the exaltation is but slightly marked, or entirely absent, the mental state being tinged with depression and fear. This form of insanity is characterized by mental excitement and motor restlessness, passing on through stages of mental enfeeblement, with muscular inco- ordination and paresis, into a complete dementia and motor paralysis. An early and rapid decline of memory is common in this disease, as is also the occurrence of epileptiform and apoplectiform attacks. Except in the early and undefined stages of either disease, the diagnosis should not be attended with PARALYTIC INSANITY. 1 75 great difficulty. In general, the much longer duration of syphilitic insanity, the irregularity of occurrence and the capricious grouping of the various symptoms are characteristic distinctions, in addition to the effect obtained by specific treatment. The principal symptoms of syphilitic insanity, which should prevent confusion, are the intense and persist- ent caphalalgia, worse at night; the early well-defined apoplectiform and epileptiform attacks, with their pro- nounced and permanent after-effects; the tendency to local spasm, followed by contractions and rigidity; the optic neuritis; the early failure of the special senses, complete rather than gradual ; the early and localized anesthesiae. In this disease the purely nervous symp- toms precede the mental signs. The state of mind is one of great irritability and depression and the delu- sions, if they exist, are of a suspicious or persecutory nature. In syphilis we find paralysis of the cranial nerves, complete and not necessarily preceded by convulsion, unlike the more incomplete and transitory effects of the convulsive attack of general paresis. The motor impairment is paralytic rather than paretic. It is apt to be localized and unilateral, and it is stationary or retrogressive in its course. The ocular symptoms are often intense, being an extreme double optic neuritis, or a severe form of choroiditis, followed frequently by sudden blindness. The affection of speech, so characteristic in general paresis, is not found in syphilis, nor is the impairment of facial, lingual and pharyngeal muscles so common, and when found, it is almost always distinctly paralytic in character. Paralytic Insanity, or Organic Dementia. — In this form of disease there is a progressive enfeeblement and diminution of mental power, generally complicated 176 DIFFERENTIAL DIAGNOSIS. with some form of motor paralysis. The mental symptoms usually begin as a mild depression, super- seded by a mildly exalted condition and combined with a childish emotionalism. The final state is one of complete forgetfulness and helpless torpidity. This being not a primary disease, but secondary to brain tumor and other lesions, the symptoms are irregular and vary with the nature of the lesion. The various symptoms are non-progressive in course and remain stationary for years, the duration of the disease being in some instances many years. The majority of the cases occur at a later period of life than is common with general paresis. The enunciation is thick and paretic, but it has not the trcmulousness found in general paresis, nor the same peculiarities. Every word is slurred, or im- perfectly pronounced, and there is no greater hesi- tancy over words that are long, and made up of con- sonants, than over the shorter vocal sounds. If, however, the primary condition be an apoplexy, involving the cerebral convolutions, the speech symptoms may more closely resemble those of the paretic. Various epileptiform and apoplectiform at- tacks may occur during the course of the disease, and their effects are more persistent than the sequelae of similar attacks, occurring in the course of the con- trasted disease. Among the motor signs are various spasms and paralyses, or paretic affections, both local and general. In many cases the mental symptoms are slight, and obscured by the much more prominent sensory com- plications. Where the primary lesion is a brain tumor, the marked and characteristic symptoms of that affection come to our aid. But certain cases of cerebellar tumor, with a general impairment of mus- cular power, a swaying, staggering, tottering gait. APOPLEXY. 177 with, possibly, some incoordination of muscular movement, may give rise to great difficulty in diag- nosis. In such cases the determination must rest upon the prominence of headache, vertigo, the char- acteristic vomiting and ocular defect. Epilepsy. — The cases of paresis in which the con- vulsive seizure is a frequent prominent and early symptom, may have to be distinguished from cases of genuine epilepsy, but this should not be difficult. The easily irritated temper of an epileptic, with the strong impulsive tendency to acts of violence, is very different from the disposition which is found in the general paralytic, although there are cases which are markedly of this opposite nature. The chief points of difference will be found in the stationary condition of the physical and mental state between the attacks, and the transitory and inconstant nature of any effects which may be produced by the convulsions. The tendency to sleep, or semi-stupor, following the epileptic fit, differs from the complete stupor remaining after a convulsion, occurring in the course of general paresis. In this latter disease, each fit is followed by a permanent increase in mental symptoms, out of all proportion to the severity of the spasm, which is generally unilateral, and may occur in a limited group of muscles only. Whereas, the spasmodic twitching, in an epileptic attack, is more generally universal. The speech of an epileptic is slow, and in long-con- tinued chronic cases may be thickened and tremulous, accompanied by a jerky tremor of the lips and face during speech; but the mental and physical state of the patient, between the attacks, should clear up any doubt. Apoplexy. — There are several points which serve to separate the congestive attack, occurring during the course of general paresis, from that due, primarily, 178 DIFFERENTIAL DIAGNOSIS. to cerebral hemorrhage. As, for instance, the ab- sence of stertorous breathing and the characteristic puffing out of the cheeks. After the attack, the para- lyzed limbs are left rigid and frequently in a state .of violent action, not flaccid and relaxed, as in apo- plexy. The transitory congestive symptoms quickly pass away, leaving a permanent aggravation of the diseased condition, in its physical or mental aspect, or in both. The customary rise of temperature, during or pre- ceding the attack, is in marked contradistinction to the subnormal temperature of a true apoplexy; the paralyses, resulting from which, are of much longer duration and more strictly limited in extent and dis- tribution. Acute Mania with Delusions. — There are cases of acute mania marked by false ideas of personal grandeur, power or wealth, which, especially when complicated with some defect in speech, or tremulousness of the facial muscles, may be, for a time, exceedingly diffi- cult to distinguish from those cases of general paresis, in which maniacal delirium, and outbursts of fury, play a prominent part. It may be impossible to make a definite diagnosis, until after the subsidence of the acute outburst. The brief duration and sudden cessation of such an attack in general paresis, leaving the various delusions still prominent, together with a marked amnesia and mental weakness, is in strong contrast to the slow and gradual recovery of true mania, with the lucidity of mind and extraordinary acuteness of memory, that mark the convalescent period. The gusts of rage and suspicious aversion are transitory and easily diverted in general paresis, and there is not that tendency to violence and malicious acts, as an essential part of mania per se. SENILE INSANITY. 1 79 While the delusions of an acute mania may assume an exalted and self-satisfied nature, the tremendous exaggeration common to general paresis is wanting, and this is considered by some to be an important and valuable point in the diagnosis. The delusions of monomania, fixed in character and logically reasoned out, being due to a perversion of intellect, not simply the exaggerations of an imagination uncontrolled by reason, can raise no question in the mind of the care- ful observer. The tenacity with which they are held is in striking contrast to the shifting and easily diverted mental processes of the paretic. Senile Insanity. — Cases of senile insanity, which may present symptoms strongly suggestive of general paresis, are usually made clear by the advanced age at which they occur. General paresis is rarely found in subjects after sixty years of age. While, on the other hand, there have been cases of undoubted pare- sis, which have occurred in the aged; and some of unusual duration which have been found in advanced life. The cases of mild maniacal exaltation, coexisting with delusions of great possessions and power, to- gether with changes in speech, are sometimes found to be cases of general paresis in the aged. But the senile speech is not the typical defect of paresis due to convolutional decay. It is rather a combination of the loss of muscular power and mental quickness, due to failing faculty; and it is characterized by a combination of aphasic, amnesic and paretic symp- toms. This gives rise to a slight indistinctness, from imperfect muscular power and incoordination, with a difficulty in finding words, and a tendency to omit parts of a sentence, especially the nouns. There is no accompaniment of a fibrillar trembling of the facial and labial muscles. The advanced dementia found in senile cases is distinguished by the absence of l8o DIFFERENTIAL DIAGNOSIS. motor symptoms, such as tremor or paresis, and by its non-progressive and stationary character, and its comparatively long duration. Tabes Dorsalis. — In the cases where the spinal cord is involved, or is the seat of the disease, we may have a condition strongly suggestive of a tabes dor- salis. There may be an exaggeration of the deep tendon reflexes with a paralysis, spastic in type, or as frequently, a marked impairment of knee-jerk and ankle reflex, associated with a tabetic gait, and other symptoms, closely simulating this disease, but tran- sient in duration. The other and distinctive symp- toms are, however, so marked that a diflferentiation is not diflScult. Disseminated Sclerosis. — The lesion of a dissemi- nated sclerosis, being general and irregularly dis- tributed, gives rise to numerous symptoms similar in nature and localization to those of general paresis. Such are the muscular paresis, tremor, speech affec- tion, etc. But the staccato quality of the enunciation should not be confounded with the slurred drawling speech of paresis, except by observers of limited experience. Then, too, the tremulousness present is a decided " intention tremor,'' and is distinguished by its coarser quality and greater excursion. Nystag- mus is a frequent and significant symptom, in addi- tion to the bulbar paralysis and muscular rigidity and contractures. There is only a late development of mental symptoms, if any appear. Lead Poison. — The epileptic seizures and loss of memory, which often occur in cases oi lead-poison- ing, may give rise to some suspicion of a paretic con- dition, if the other symptoms and the history of ex- posure and invasion are not clear. Especially would this be so in those cases, where a delirium, either maniacal or melancholic, terminates in a dementia of PARALYSIS AGITANS. l8l an extreme degree. The occurrence of the char- acteristic wrist-drop, the discoloration of the skin and the blue line on the gums would determine the case. To these may be added the greater promi- nence of sensory symptoms, anesthesia, etc., together with a total failure of muscular response to the electric current. Paralysis Agitans. — Some cases of general paresis have a symptomatic paralysis agitans occurring in their course ; or paralysis agitans may be complicated with an affection of speech and muscular weakness, a stolidity of feature and a slowness of movement not unlike the condition seen in the former disease. The history of the case should decide it, as the paralytic tremor, when seen in paresis, always follows its more characteristic mental and motor symptoms. A CASE OF GENERAL PARESIS ILLUSTRATIVE OF DIAGNOSIS. A case remained for some time in doubt and presented in its early stages symptoms by no means characteristic of general paralysis. The patient was brought to the asylum with insanity of only a few days' duration. He had been riding on the pavement, assaulting the police, and he was incoherent and rambling. He said the sun was turned into the moon, and such things ; he had no grandiose delusions ; he was frequently taciturn, not speaking perhaps for a whole day. On alternate days his condition varied ; on one he was dull and depressed, refused his food and would not speak ; on the other, he was gay and excited. He had few delusions and he said little except that he " wanted to go." He was wet and dirty ; he had no stutter. The signs of gen- eral paralysis were mostly absent but there was irregularity of pupils and great defect in memory. In six months he got so much better that he went into the country with his wife and was reported to be quite well. When readmitted in the following year the signs of general paralysis were well i6 1 82 DIFFERENTIAL DIAGNOSIS. marked. His sons were dukes, he was worth millions, etc. At the commencement only the irregularity of pupils, defect of memory and general absent-mindedness made the prognosis unfavorable. He complained constantly of pain in the head. When said to be recovered he remained in the country idle ; the moment he resumed work