After there is evidence of definite atrophic and degenerative disease in the brain, as indicated by great mental impairment and muscular paralysis, the mental and physical symptoms may be subject to great changes, without any apparent cause but vaso-motor disturbances, and alternating rapidly from extreme intellectual confusion and absence of mind to a clear, even if temporary, mental state. Less extreme changes in the condition of the mind are common.
The mental symptoms, after the disease is pronounced, consist in an intensification of those already mentioned as characterizing the prodromal period—in an increase in the loss of power of control over all mental operations and in the loss of mental power, the two symptoms making progress side by side. In the form of the disease attended with maniacal excitement the prodromal period is usually shorter than in the others, but may last several years. After the prodromal period has passed the mental impairment increases, so that the judgment, memory, power of attention and expression grow progressively worse; and this impairment constitutes the only characteristic mental state universally present in all stages of general paralysis of the insane—namely, progressive dementia. The accidental symptoms may be those belonging to any type of insanity except logical systematized delusions. They very rarely simulate the states of mental defect and degeneration.
If there are delusions of persecution, they are marked by a degree of confusion or incoherence not compatible with logical inference. The state of melancholia may change rapidly to mania, and the demented form may at an hour's notice become the excited. Where the symptoms of mental exaltation and depression alternate, resembling folie circulaire, the alternation is less regular than in alternating insanity properly speaking; hallucinations of sight and hearing and of all the special senses are quite common, although, as a rule, rather late symptoms, and then confused and often only partially intelligible. There are also all sorts of illusions and delusions.
The impairment of the sense of right and wrong becomes quite marked; the patient loses the sense of property and ownership. In no other disease could the reported case occur of a man, to outward appearance well, going up to a policeman and asking his assistance in rolling off a barrel of liquor which belonged to some one else, and which he meant to appropriate. For this reason what seem to be thefts are very common, and although by that time there is striking mental impairment, it may not be obvious to every-day people. Almost every other moral obliquity occurs, particularly a tendency to drunkenness and every possible violation of the proprieties and laws regarding property and the sexual function. It is all done, too, in such a foolish way that the insanity would be apparent to almost any intelligent person before whom the facts might be fully and clearly placed. There may be a curious consciousness in the patient of the fact that something is the matter with him, and a most extraordinary unconsciousness of what an inordinate fool he is acting. If he can be made to see what folly he is committing, perhaps a few moments later he is saying that he was n-ever b-better in his life. The emotions change most rapidly, and an adroit examiner will have his patient crying over some trifle one moment, and another moment laughing over something equally inconsequent. The prevailing mental state changes as rapidly as the emotions. Violent anger, outbursts of passion, penitence, amusement do not succeed each other more rapidly than indifference, melancholy, and exaltation.
The suicidal idea is common in general paralytics before they become very demented; the suicidal impulse is rarely strong enough to result in anything more than futile attempts at self-destruction. Suicide by deliberation is also rare, for even when it is meditated the weakened, indecisive mind usually fails to prepare adequate plans for its successful issue. Homicidal attempts are not to be expected as a rule, except in the delirium of the states of maniacal excitement or in an outburst of anger for a fancied wrong or deliberately for some trifling reason. Even from suicide and homicide a practised physician or attendant will easily turn the general paralytic who is not maniacal to some amusing or silly thought. He has become credulous, simple-minded, and easily moulded to an expert's wishes, so far as his general conduct is concerned, and yet at any moment he is capable of a furious mania or a violent storm of passion, which after cerebral congestive attacks may be long and severe. Sometimes these symptoms just described may be very pronounced at night and not especially troublesome during the daytime. I have had patients who were dangerous, violent, noisy, deluded at night, and entirely quiet by day, for several months.
The mental state is of progressive impairment. The ideas flow slowly, and there is slowness or hesitation in speech in giving utterance to them, even to the degree of amnesic aphasia. Word-blindness occurs, and word-deafness and the various disturbances of speech associated with the several forms of aphasia. After the dementia is very marked there is often a most extraordinary variation in it. The patient may be confused, incoherent, and to appearance hardly capable of sustained thought, but soon quite able to perform a business transaction. The friends say of such patients, “He is crazy to-day,” or “To-day he is sane;” and this quite independent of the marked increase in the dementia which occurs from organic changes, epileptiform and apoplectiform attacks, after which the advance in the mental impairment is rapid and great. Accompanying dizzy and congestive attacks there is a temporary dementia which may be over in an hour or two.
The patient may recall many long-past events fairly well when he cannot find his way to the dinner-table without blundering, when he does not know morning from afternoon, and after he is unable to dress and undress himself without constant remindings or even actual help. Such paralytics wander off and die of exposure, are picked up by the police as having lost their way or as not knowing where their home is, or fall into some fatal danger from which they have not mind enough to extricate themselves. When the mental impairment has reached this point the lack of mind shows itself in a lack of facial expression, which is so characteristic of the disease that with a practised eye it is recognized as far as the countenance can be distinctly seen; and from this point the progress is commonly quite rapid to absolute dementia, entire inability to form or express thoughts, too little intellect to even attend to the daily natural wants, and a descent to the lowest possible plane of vegetative life, and then death.
At some time or other in the history of general paralysis delusions of grandeur, a general feeling of personal expansiveness or extreme self-satisfaction, may be confidently looked for. In the melancholic and hypochondriacal forms of the disease, as has already been mentioned, they are late symptoms; in the demented type they occur only, for the most part, near the final stage of absolute dementia; and in the excited form they are usually found from the beginning or at least developing from a general feeling of bien-être. They may vary from what would pass as inordinate, silly conceit to a wildness of delirium which stops hardly short of infinity. The patient is the greatest financier, the handsomest man, the best runner, can out-box the champion pugilist, can write the finest sermons. Delusions of this degree, especially in women, are apt to refer to the reproductive faculty or to the qualities which please the opposite sex. One man can make a million dollars a day writing poetry; another is building cities of solid gold; another owns all the railroads in the country, is king over all the earth, god over God; another is running express-trains over his bridge across the Atlantic or has a doctor who comes to see him in a balloon. There is often a depth of vulgarity and obscenity about the delusions which is rarely seen in other diseases. When the grand delusions appear in the melancholic form, they are apt to be tinged with gloom, as of a queen whose diamonds are withheld from her, a lover who is kept from his princess bride, etc. In the hypochondriacal form it may be a crystal liver, a silver stomach, a brain of solid gold, etc.
Delusions of personal belittlement, called micromania, sometimes follow or alternate with the megalomania.