A system of practical medicine. By American authors. Vol. 5

by Unknown

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 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 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.