new part; the ready salesman no longer has his great facility of
selling; the singer does not see that his notes have become false and
harsh; the engraver's fine lines are no longer possible to him; the
preacher reads the same hymn three times in his Sunday service; the
man of promptness fails to keep his appointments; the speech seemingly
clear to others becomes indistinct to a deaf wife; the eye trained to
close, exact work loses its capacity of fine distinctions of form or
color; the expert accountant can no longer add up his three columns of
figures at a time; the doctor writes prescriptions showing unwonted
carelessness or impaired judgment to the extent of injuring his
practice; a banker loses his property by foolish ventures; the saving
business-man buys quantities of useless articles; the moral man
becomes licentious or the temperate a drunkard; the respected father
of a family goes to the State prison for running off with a pretty
servant-girl; the lawyer ruins his client's cause; the considerate
husband shows unwonted harshness and violence to his wife; the
industrious worker becomes a tramp or a vagabond; the amiable friend
becomes irritable, disagreeable, perverse, hard to please, easily
excited, cranky. These are some of the facts I have known to occur in
the early stage of general paralysis without giving rise to the
suspicion of cerebral disease, the conduct of the individual generally
not suggesting insanity. In one case the cerebral vaso-motor
disturbance caused marked intoxication from a small amount of wine,
previously taken habitually without showing it, for several weeks
before the most careful examination revealed other indications
suggesting general paralysis. In the upper walks of life, wherever a
nice intellectual adjustment or fine muscular co-ordination is
required in the daily duties, symptoms to put the physician at least
on his guard against general paralysis will rarely be overlooked in
this early stage of the disease if they are sought for with sufficient
care and appreciation of their import. In proportion as the employment
is coarser, and not requiring much mental or muscular exactness, the
symptoms are more difficult of correct apprehension, until we get to
the day-laborers, in whose dull nervous organizations quick reactions
do not occur, and in whose simple labor, requiring little thought and
only muscular co-ordination of a low grade, a partially demented brain
and muscles considerably impaired in strength serve their purpose so
well that an early diagnosis is next to impossible. Routine work, to
which he is long accustomed, is often done well by a general
paralytic, provided it does not require exact mental or muscular
co-ordination, when the disease has so far advanced that any new work
except of the simplest kind could not be performed.
It is seldom that general paralysis, in its early stage, receives
careful enough attention to be recognized or to create a suspicion of
its existence until exhaustion, a long period of sleeplessness,
perhaps a violent shock, a strong emotion, a fall or a blow, a
congestive attack, an epileptiform seizure, an apoplectiform
convulsion, or some unknown cause—probably a vaso-motor disturbance in
the brain—hastens the progress of the disease, and the previously
slight or obscure symptoms (at least some of them) are suddenly so
aggravated as to make them of unmistakable signification. It is usual
in such cases to date the appearance of general paralysis from this
point, and to overlook its previous existence for the weeks, months,
or it may be years, of its prodromal period. It is {181} especially
easy to overlook the period of invasion of general paralysis of the
insane, as the symptoms may, and generally do, have that temporary,
transient, and variable character which is common to diseases or
stages of disease in which vaso-motor disturbances predominate;
inasmuch, also, as the individual character has to be taken so much
into account in estimating the import of particular symptoms, and as
few or many of the leading indications of general paralysis may be
present in a particular individual, while the physician might happen
to make several examinations of his patient at times when the symptoms
did not appear at all. For now and then all symptoms absolutely
disappear in a time which may be short or long. In two cases of
general paralysis in the period of invasion, where the moral
perversion was said by the other members of the family to be a source
of great trouble, I sent both patients to an insane asylum entirely
upon the statements of their wives, without being able myself to see
any evidence of insanity, but where the clinical history of general
paralysis in its early stage was so accurately given that I was sure
there could be no mistake; and a few days' continuous observation in
the hospital showed the diagnosis to be correct.
The dementia, ataxia, and muscular impairment of the prodromal period
of general paralysis of the insane may be masked by the prominence of
almost any of the symptoms of nearly all the mental diseases; and many
of the indications of the prodromal period are symptoms of disease
only as they are departures from ordinary customs and habits, although
in other persons they might be quite the reverse and natural to their
daily life. Much that might be done by a general paralytic with great
care in the early stages may quite resemble the careless work of the
same person in health.
The following case is quite typical of the development of general
paralysis of the insane:
Mr. ——, age 52, married, a clergyman: his mother died of apoplexy; two
of his four brothers are insane. He had the usual illnesses of
childhood in mild form, diphtheria of the worst type in 1869, and in
recent years, according to his belief, malaria, as he had lived in a
malarial region eleven years. As a young man he was of robust frame
and vigorous health, brought up on a farm. He overworked, denied
himself, and overtaxed, in getting his education, a brain not trained
from early years to exacting labor. Eight years ago, for the first
time, and at intervals since then, he has had attacks of mental
confusion, dimness in sight, and indistinct articulation lasting from
a few moments to several minutes. Three years ago, after great
emotional strain, people began to notice that his preaching had lost
in animation and force, and they complained that he had suddenly
become more radical in his views. Great mental worries occurred soon
after. There had been no alcoholic or other excess, except of mental
overwork, and there could be no reasonable possibility of syphilis,
unless we adopt Hebra's dogma, “Jeder Mensch kann syphilitisch
sein”—that the means of innocently acquiring that disease are so
widespread that no one can be said to be free from the danger of it.
Nearly two years ago, in the dark, while feeling tired mentally and
physically, but not ill or dizzy, in alighting from a coach he missed
the step and came to the ground on his feet with great force. He
walked to the house of a friend, and was found by one of the family on
their entry floor {182} groaning, but not unconscious. He could not
stand or talk, vomited incessantly, and complained of a horrible pain
in the back and top of his head. Two days later, and each succeeding
Sunday, he preached, obstinately and unlike him refusing to listen to
advice to keep quiet; but he remained in bed between Sundays for three
weeks, when the striking symptoms disappeared; but he had never felt
entirely well since then—never had the same animation. He was
supplying various pulpits, and found, wherever he had preached before,
that people complained that there was a general lack of vigor in his
preaching. Two years ago he observed that his right leg had less life
in it than was natural, and soon after that both legs seemed
heavy—that it was less easy to run up and down stairs, which his wife
also noticed several months later. He also has had for a year a
strange feeling, a sort of numbness, in his legs. He thought that his
handwriting and speech have continued as good as ever, but has
observed that he has had to change to a stub pen, as he found
difficulty in writing with the old sharper-pointed kind; that his
voice had grown less clear; and that he has rapidly become farsighted.
He has never had any dizziness, pain, ache, or uncomfortable feeling
about his head, except during the attacks already referred to. There
have been no thoracic or abdominal symptoms, no neuralgia or
rheumatism. Appetite and digestion have been faultless. He has lost
about ten pounds in flesh. He has slept soundly, but is often
restless, getting in and out of bed. He says that he was depressed for
lack of employment; that he is not irritable, but that his family
would say that he is not as tractable as he was, not as patient, less
easily satisfied; that his son and wife would say that he is not what
he once was—that his memory is not as clear and vivid as it was. He is
conscious that within the last two years he has had violent,
uncontrollable passionate outbreaks from trivial causes. He preaches
his old sermons, because he thinks they are too good to be lost, and
because he takes pleasure in rewriting them, in doing which he remarks
that the handwriting becomes progressively worse toward the end of
each sermon. He says that he can write still better sermons, but does
not like to make the effort. When he went into the pulpit a week ago
he was told not to announce a second service, but everybody seemed to
him so pleased with his preaching that a week later he gave word that
there would be an evening service, to which, he laughingly said, only
one person came. In standing with his eyes closed and feet together
there was a little unsteadiness. On attempting to turn around or to
stand on one foot with eyes closed there was some, not very great,
ataxia. In these trials the unsteadiness and ataxia soon became very
striking on prolonging the muscular effort a few moments. His hands
had a powerful grasp, each marking 74 with the dynamometer, and on
being stretched to their full extent, with fingers spread, immediately
thereafter the fibrillary tremor could be seen only on close
examination. There was no marked tremor of the muscles of the lips or
face, except in movements which placed them at extreme tension. The
tongue was quite tremulous on being protruded to its full length and
held there. In walking in a rather dark entry the steps seemed to me
shortened and the feet wider apart than in his natural gait, and he
did not raise his feet as much, which he noticed also. In going up
stairs he placed the whole foot, heel and all, on each step to keep
his balance. He turned very deliberately, {183} keeping the feet near
together and not raised from the landing. On coming down he evidently
steadied himself by a muscular effort extending to his head and
shoulders. The knee-jerk was well marked and alike in both legs, but I
could not say that it was exaggerated. There had been no change in the
sexual function.
His general mental state seemed to me to be of a quite superficial
kind of despondency at his prospects, and yet absence of a
corresponding degree of anxiety for the future; of satisfaction with
his ability and worth; of a feeling that his family are unduly anxious
about him; and of a prevailing state of inappreciation of the whole
situation, and of a general state of happiness which was abnormal—an
opinion which his wife afterward corroborated. He was quite emotional,
and easily and rapidly moved to smiles, and from them almost to tears.
In explaining his restlessness at night he stated that he was taking
quinine for his malaria, and that it acted on the liver so as to
increase the flow of urine, which he repeated several times, but
laughingly said, “Of course; how foolish!” when I suggested that he
meant the kidneys. In removing his clothes for a physical examination
I found that he had two starched shirts on—the one in which he went
from home, and that in which he preached, in order not to rumple the
second one. When I asked why he could not take home a soiled shirt in
his valise after having brought a clean one in it, the idea struck him
that he, after all, had done something foolish.
The examination of chest, abdomen, and of the urine was negative. I
could not find anywhere evidence of anæsthesia, hyperæsthesia, or
paræsthesia, general or local. The reaction of the muscles to the
faradic current seemed normal. By ophthalmoscope and otherwise the
eyes showed only the emmetropia already referred to. Hearing was also
normal, as well as the other special senses. In a close examination I
could at first not discover anything about his speech more than an
extreme deliberation in articulation, which might perhaps have been
natural to some scholarly men, but which I afterward learned had been
only of recent origin, and increasing. It was more pronounced after
the patient became a little wearied, and then I found that he could
not articulate a long word with several labials and linguals without
manifest difficulty. I gave him a sheet of paper and asked him to
write from top to bottom. He could not think of anything to write.
When I told him to put down the text of his sermon of the previous
day, he could not possibly remember it; no more could he call to mind
a sentence or a sentiment from it. What he wrote is marked No. 1. His
normal handwriting, No. 2, is of the date of 1881. Nos. 3 and 4 were
copied from an old sermon a few weeks previous to his visit to me, and
are taken respectively from the first page and the next to the last of
the copy. The facts may be observed that the old handwriting is quite
free, with an easy sweep of the pen. In the copy of the sermon the
first page shows that the pen is held stiffly and tightly, and that
the lines are not made with as steady a movement of the hand as in the
old handwriting. The lower lines on the first page are a trifle worse
than the upper, and pretty much like the second and third pages, from
which there is progressive deterioration to the end. The page written
in my office was very carefully done, and, under the circumstances, is
marked by such muscular unsteadiness and evidence of mental {184}
{185} {186} impairment and enfeebled memory as to be almost, if not
quite, of itself pathognomonic of general paralysis.
[Illustration: FIG. 15. Six handwritten examples.]
I purposely made no remark to the patient, and he made no inquiry,
about diagnosis or treatment. He would have missed his train, although
there was a clock in my office, had I not reminded him of the late
hour, whereupon he made all his arrangements with care, good judgment,
and accuracy, and reached his home safely. As he walked briskly down
the even sidewalk I doubt whether any one, even a physician, would
have remarked any unsteadiness or anything abnormal about his gait. If
he had been followed a few blocks, until the idea of catching his
train had ceased to stimulate him, and after he had reached the
crowded thoroughfares of the city, especially as he stepped up and
down curbstones or walked slowly to avoid teams at crossings, a close
examination would undoubtedly have shown the defects in gait already
pointed out.
Mr. ——'s wife had noticed that her husband did not raise his feet as
of old in walking—that he walked as if they were heavy, but under the
influence of coca wine or a decided mental stimulus he walked
apparently as well as ever for a short distance. She had noticed a
slight impairment in memory, an increased fractiousness, a diminished
ability to appreciate things in their proper light, a changeability in
his moods and mental state, a scarcely-observed but noticeable neglect
or oversight of little customary duties, occasional passionate
outbreaks from trifling causes, a disposition to laugh and cry easily;
and that often he did and said unwonted foolish little things, like
attributing increased flow of urine to his liver, wearing two starched
shirts, announcing the Sunday evening service; but she had not
considered any of the symptoms as evidence of disease, especially as
he kept accounts, attended to his preaching, etc., and showed no
manifest indications of a disturbed or impaired mind. She had remarked
a decided change in the character of his handwriting, also an unusual
deliberateness in speech, but no indistinctness or hesitation,
although his voice had become less clear. He had had no delusions,
illusions, hallucinations, or unreasonable ideas. It was for the
weakness in his legs that she asked my advice.
I found that the mental and cerebral symptoms in this case had been
overlooked, and that the weakness in the legs had been attributed to
spinal concussion, for which a favorable prognosis had been given.
I examined the patient after he had been away from home nine days,
preaching two Sundays, and making many new acquaintances in the mean
while, besides having travelled nearly two hundred miles by rail, so
that he was fatigued. After three weeks' complete rest I saw him at
his house. The knee-jerk was increased as compared with the previous
examination. Otherwise the symptoms had so ameliorated that some of
them could be brought out only after a long and patient examination,
and the rest had to be accepted as a matter of history of the case. I
had his photograph taken, and by comparing it with another taken three
years previously his family noticed what was quite obvious in that
light, but what had thus far been overlooked—namely, that the facial
muscles had lost very much in expression.
The specimen of handwriting marked 5 is of a gentleman in whom the
paralytic speech is quite evident after a half hour's talk, but quite
masked in the beginning of a conversation, when rested. It is written
{187} with care, after a long rest, and, as compared with his former
writing when done with equal care, there is seen only a wider
separation of the letters. Its general appearance, on casual
inspection, is better than that of his ordinary writing before his
illness, as that was hurried and careless. But the second or third
page brings out the ataxia distinctly. It shows how well a general
paralytic, under the influence of rest and quiet, may control certain
groups of muscles—how completely the ataxia may be concealed under an
ordinary examination; and yet the symptoms in his case may be clearly
brought out by the method just described. The tongue was quite
tremulous.
The writer of No. 6 was more advanced in general paralysis, but had
been thought not to be ataxic, from the fact that he had been able to
write a single word pretty well. His few lines are quite
characteristic of a general paralytic. Although he was in my office in
Boston, he dated his statement from his home, and wrote the word
Lawrence not badly for a man not in the habit of writing much. Seeing
me for the first time, he addressed me as Friend Folsom, and he signed
his name by his old army title of nearly twenty years before—corporal.
The characteristic writing in advanced general paralysis, irregular,
distorted, full of omissions of letters and words, and finally
illegible, may be seen in the textbooks on insanity.
It very rarely happens that the onset and early progress of general
paralysis are so sudden and rapid that there is no prodromal period or
that it is very short.
The symptoms of well-marked general paralysis include four tolerably
distinct types, as follows: (1) The demented and paralytic; (2) the
hypochondriacal; (3) with melancholia; (4) with exaltation and mania.
There are mixed cases in which some or all of these forms occur. 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 or several of these four
types.
The demented form of general paralysis is the most common, and is also
that in which the greatest increase has been noticed during the last
decade, whether from more accurate diagnosis or by reason of an
actually greater proportion, probably to a certain extent due to both
causes. It consists in a very slowly-advancing mental impairment,
making progress side by side with muscular loss of control and power,
which may continue several months or years before their importance is
appreciated, the vaso-motor disturbances not being so marked as in
more acute forms of the disease, and the changes in the mental state
and bodily strength from week to week being so slight as to escape
observation. Attacks of dizziness, petit mal, and epileptiform
seizures are quite common in this type of general paralysis. In one of
my cases a lawyer in the third year of the disease was retained as
counsel in a will case involving over a million dollars, when he fell
repeatedly in the streets, and when his occasional, indeed frequent,
mental lapses were so apparent to his partners that they did not allow
any of his business letters to leave the office without being first
inspected by them. Mental excitement, maniacal symptoms, and delusions
of grandeur rarely occur, except as transient attacks, until the final
stages. The patient commonly realizes that something is the matter
with him until he becomes quite demented, and can often describe his
{188} mental state and general symptoms quite intelligently, although
rarely with a full appreciation of their extent and import. He easily
persuades himself that it is not worth while to take steps for medical
treatment, and keeps on with his work until some distinct failure in
his mental or physical powers, usually a sense of malaise, muscular
pains, a feeling of exhaustion, convinces him and his friends that a
physician should be consulted. Perhaps he goes to some health-resort
or water-cure, or tries rest and recreation in travel, still thinking
his case not an important one, until he seeks medical advice to please
his family or friends. He may say that he is only tired mentally and
physically.
In the hypochondriacal form of general paralysis, vaso-motor
disturbances, flushed or pale face, headache, defective circulation,
and various abnormal sensations referred to the peripheral nerves and
internal organs are associated with a hypochondriacal mental state,
which is also marked by an evident mental impairment, manifested in an
almost childish changeability of complaints. Grand delusions and great
mental and motor excitement do not, as a rule, appear until the later
stages, but the hypochondriacal form is less subacute than the
demented.
In general paralysis with melancholia the sad delusions are apt to be
associated with some form of expansive ideas or to be transformed into
them at some stages of the disease, although the classical delusions
of grandeur are a late symptom.
The maniacal form of general paralysis with the délire de grandeur is
the disease as described by Calmeil. Mental exhilaration and delusions
of personal importance are its conspicuous features. It may develop at
any time in the course of the other three forms just mentioned; its
prodromal period may be such as has been described, usually shorter,
or the symptoms may be of excitement and maniacal from the beginning.
It is the general paralysis of the books until within recent years.
It is doubtful whether these four forms of general paralysis depend
upon any pathological basis which can now be determined, but their
recognition is practically important for an early diagnosis, and they
differ from each other very little in their later and final stages.
They constitute what is known as the descending form of general
paralysis, in the majority of cases of which descending degeneration
of the lateral columns of the spinal cord or posterior spinal
sclerosis, or both, appear, secondary to the brain disease.
In the ascending form of general paralysis there are posterior spinal
sclerosis and the usual symptoms of that condition—which are described
in another article of this work—from one year to a dozen or more years
before there are indications of dementia.
In the first stage of general paralysis, although a distinct loss of
power is an early symptom, it is not so striking in its manifestations
as loss of control. The moral obliquity and the mental lapses seem
entirely out of proportion to the general mental impairment. What
seems moral perversion is often strictly so, but oftener it depends
upon a want of attention or appreciation of the facts in the case,
which can be aroused if there is opportunity for it. There is a clear
inability to use the force that the mind has. The foolish credulity
and readiness to be duped are often only a temporary condition. There
is, at the same time, an inability to co-ordinate the muscles to a
striking degree at a time when there is still {189} only slight
impairment of the muscular strength, or inversely, and the
co-ordinating power may improve up to a certain point, while the
muscular impairment goes on. This ataxia is first noticed in those
muscles requiring the nicest adjustment for their usual work, the
penman's and the pianist's fingers, the proofreader's eyes, the
singer's throat. But it may be for a long time very slight or not
easily detected.
Although this muscular ataxia may be observed, even if not constantly,
in the prodromal period of general paralysis, it is usually well
marked only when the symptoms have become well developed. There is
also a fibrillary tremor of one group of muscles or of one set of
fibres after another when these muscles are exerted, and increasing as
they become wearied, as they soon do, from the exercise. The
handwriting may show no conspicuous fault at the top of the page, and
at the bottom be full of evidences of muscular tremor and
unsteadiness, or a single word may be written without conspicuous
fault, and a few lines serve to show ataxia of the muscles used in
writing. In beginning to read there may be only the most trifling want
of clearness of tone and steadiness of articulation, noticeable only
to the most practised ear, which after a number of minutes becomes a
distinct harshness of voice or evident stumbling over linguals and
labials, or hesitation in speech, which may seem like the utterance of
a person slightly under the influence of wine or with lips cold from
frosty air. The hesitancy of speech is due partly to a slower flow of
ideas than in health, an impaired power of attention to the subject in
hand, a diminished creative power or expression of thoughts, but also
to a distinct ataxia, an inability to promptly co-ordinate the muscles
required to perform the act. The difficulty in reading is partly
mental and in part due to inco-ordination of the muscles governing the
eyes as well as those of articulation.