Mental shocks of various kinds, excessive emotional strain with mental exhaustion, and injuries to the brain, are the commonly reported exciting causes of general paralysis, but it is not certain that—in many cases, at least—they do more than hasten the pathological process and call attention to the symptoms. So far as my observation goes, the injury to the head, supposed to be the cause of general paralysis, often has appeared to probably come from an accident due to the impaired physical strength and to the vaso-motor disturbance in the brain incident to the early stage of the disease and while it was still unrecognized. Cases are observed in which no predisposing or exciting cause is found by the physician. I have seen it following diphtheria and other debilitating diseases, after long exposure to malaria, and apparently due simply to prolonged mental strain in persons otherwise living in moderation under circumstances exceptionally favorable to health.
SYMPTOMATOLOGY AND COURSE.—As a rule, to which the exceptions are few, the early symptoms of general paralysis are obscure. Their appearance and progress are so gradual and insidious that they are usually overlooked for a period varying from several weeks to a year or more, sometimes for four or five years, perhaps even longer. There is a slight change in character, which is frequently attributed to wilfulness or perverseness arising from some disagreeable circumstance; to want of a reasonable attention to the little affairs of daily life; to indifference, temper, carelessness, or recklessness; to a want of aptitude and receptivity having an ethical rather than medical significance; to an impaired moral sense. The patient may be observed to be simply more quiet and heavy; inclined to be depressed rather than distinctly melancholy; a little heedless; unusually indifferent, and indisposed to worry over things that formerly would have disturbed him; drowsy or dropping off to sleep at work or in the theatre; disturbing the household by his restlessness at night—in and out of bed, up and down stairs, for trivial and yet not seemingly insane reasons. He may become easily disturbed by trifles, and yet careless to more important matters. He begins to overlook, perhaps rather than forget, recent little things. His power of attention is diminished, his will weakened, his self-control impaired. He becomes less careful of the niceties and proprieties of life, less interested in his family and all that is nearest to him—self-absorbed, egotistic, indulging in inconsequent stories and remarks. Although the memory is not distinctly at fault, fresh impressions do not make their usual imprint on the mind. His moods are unnaturally changeable. A certain slovenliness in habits or carelessness in dress, an inattention to customary little courtesies and attentions, slight yet noticeable, are not uncommon early symptoms of general paralysis. There is soon observed, often noticeable to the patient, a lack of endurance, an early sense of fatigue from exertion, a sense of muscular prostration, physical discomfort, or general pains which may be attributed to malaria or rheumatism. Commonly, not always, there is disturbed sleep or restlessness. There may or may not be headache, slight or severe, transient or persistent. There may be a sense of pressure or an uncomfortable feeling about the head, especially the forehead, or it may be the seat of no pain or discomfort whatever. There may be a slight or severe local or general sensation of distress or uneasiness in the head after mental effort only. There is often pain, anæsthesia, hyperæsthesia, paræsthesia affecting any sensitive nerve, often none at all, or impaired muscular sense.
The average daily temperature is higher in general paralytics than in health. It is sometimes lower, and the range is greater than the normal. In the only extremely rapid case which I have seen (two months in all) it was 97° F., and thereabouts for a number of days, and then rapidly rose to 103° and 104°, where it remained until near death. After the congestive, epileptiform, and apoplectiform attacks it rises from two to seven degrees, and remains high for a considerable time, while in pure epilepsy it quickly falls. This difference, however, is not sufficient, as between epilepsy proper and epilepsy as an early symptom of general paralysis, to establish the differential diagnosis with certainty in all cases.
The vaso-motor disturbances in the brain are indicated by transient congestions or local anæmia, dizziness, faintness, temporary outbursts of anger, excitement, or confusion, and rapid changes in the mental and emotional state. Convulsive attacks are not common in the early stage of the disease, except in those cases due to syphilis, but may occur, and may so resemble hysteria, petit mal, epilepsy, and apoplexy as to be confidently diagnosticated for those diseases. The emotional state is of indifference, despondency, gloom, melancholia, elation, a feeling of self-satisfaction, or mania.
The symptoms thus far are not clear except on minute examination. The family and most intimate friends of the patient observe that he is changed, but cannot tell how, and are apt to say that he is not the same man that he was, that his troubles have been too much for him, that he does foolish things as never before, etc. Sometimes he estimates his symptoms correctly, sees the downward change himself, and is oppressed by it; oftener he is indifferent to it, or still oftener quite well satisfied with his condition and prospects, or even mildly elated. He may squander his fortune, ruin his reputation, become addicted to drink. His sexual appetite, not held back by his normal power of self-control or exaggerated with a general physical and intellectual erethism, may lead him into all sorts of improprieties and immoralities or to exhausting excesses, which are perhaps more common among the married than among the unmarried; and yet his disease is not recognized, because the later symptoms of general paralysis—namely, grand delusions, staggering gait, tremor, and marked dementia—have not yet appeared.
The pianist loses his skilled touch; the actor fails to learn a 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 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: