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 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.
These muscular defects and mental inefficiencies, when slight, may be hardly detected after the patient has had a prolonged rest and is quiet and calm. After some emotional irritation, weariness, sleeplessness, vaso-motor disturbances, or congestive attacks they become very pronounced. After several weeks of absolute rest, with the patient still at rest, it may be impossible for a time to find any trace of mental defect or muscular deficiency until the patient has again been put to the strain following some effort. They are very much increased after epileptiform or apoplectiform attacks, which, however, are uncommon so early in the case.
In the progress of the disease, as the mental impairment increases, the reaction of the nervous system to external conditions becomes less active, the mind weakens, the loss of flesh may be, at least in part, regained, a great portion of the irritability and active symptoms disappears, and as the patient grows worse he may seem for a while to his friends to improve.
The leading symptoms of general paralysis of the insane are—(1) vaso-motor, (2) mental, (3) physical.
The vaso-motor symptoms consist in a progressive paresis or lessened power, which in the progress of the disease advances to complete arterial paralysis—at first a functional disorder of impaired innervation, and finally organic. They are marked early by rapid changes in the cerebral circulation, a diminished arterial tension, with occasional or frequent attacks of vertigo, dizziness, or faintness, confusion and incoherence that may amount to a transient dementia, localized and general elevation or depression of the bodily temperature; frequent attacks of congestion or at long intervals, with a flushed face or transient cerebral anæmia, may be marked by sharp emotional disturbances, fits of temper, irritability, maniacal excitement, loss of self-control, etc., or by epileptiform and apoplectiform seizures of various degrees of severity, with or without temporary or transient loss of muscular power, local or of the monoplegic, hemiplegic, or paraplegic nature, of a much less severe character than similar attacks later in the disease, due in part also to organic changes. The circumscribed loss of power of the vessels of the skin leads to various functional disturbances, and finally to paralysis, involving bed-sores, etc. Cyanosis, neuroparalytic hyperæmia of the lungs, bladder, and intestines, cold feet, œdema of the skin, local sweatings, etc. are final evidences of vaso-motor paralysis. Throughout the disease, at least nearly to the end, this vaso-motor paresis and paralysis causes marked variations in the mental state which are too rapid to be accounted for by organic changes.