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

by Unknown

Maniacal excitement is a late symptom in the demented, hypochondriacal, and melancholic forms of general paralysis; and it rarely occurs in them except in the final months of the disease, unless as a direct sequence of congestive, epileptiform, or apoplectiform attacks, and then it lasts usually from a few hours to several days. These attacks may occur at any time without any warning whatever, and may be attended with fury or stupor also. As a matter of fact, they are very rare at an early stage except in the excited form of general paralysis, of which they are a pretty constant symptom until marked dementia has appeared, and they may continue to the end. The fury of these maniacal attacks is of the most furious and maddest kind, blind, the most utterly regardless of consequences of any kind of insane excitement, and without the intelligence even of the acute maniac.

The ability to recognize his own mental state is sometimes retained by the patient, at certain times at least, to a quite late stage in the disease, so that he learns to call his visions hallucinations and his strange fancies delusions. He may even agree that his illusions are all nonsense, that the disease is in his brain. The so-called lucid intervals are not uncommon until the final stage of absolute dementia, when attention, memory, judgment, conception, connection of ideas, imagination, desires, the exercise of the senses, general sensibility, after becoming more and more imperfect are at last completely suspended. The moral sense and finer feelings had gone long before.

Although the story of the mind's decay in general paralysis is a comparatively short one, from a few weeks to four or five years for the prodromal period, and then an average of two or three years for the rest, but varying from a few weeks to a rare extreme of twenty years, there may be at any stage of the disease, except at the very end, a more or less complete remission lasting from a few months to ten years. It is dangerous to say, therefore, that there is any degree of dementia which may not be temporarily at least, or in some part, recovered from. Most of the reported cures of general paralysis have been at last proved to be simply remissions, which may be partial or so complete as to leave no trace to the most practised observer. It is not uncommon to see a remission of six months or a year or two, in which the patient can lead a quiet life; it is seldom that he undertakes responsibilities without bringing the remission rapidly to an end. There are a few cases where active business has been resumed and followed successfully for several years. But there is apt even then to be some deterioration in character, which may amount to an actual moral insanity. An arrest in the downward progress, so that the symptoms remain for a considerable time without essential change, is not very uncommon, and may occur at any stage of the disease.

The physical symptoms of general paralysis consist in impaired control over the muscles, diminished power of co-ordinating them, followed at once by progressive muscular enfeeblement ending in complete paralysis.

The ataxia first shows itself in the finer muscles—of the eye, of the fingers, of articulation. There is a little hesitancy or rather deliberateness of speech, the voice loses its fine quality, the intonation may be slightly nasal. Instead of contracting smoothly and evenly as in health, the muscles show a hardly noticeable jerkiness; an irregular fibrillary tremor is seen when they are exerted to their utmost and held in a state of extreme tension for several moments. In attempts to steady the handwriting the patient forms his letters slowly, makes them larger than usual, or tries to hurry over the letters, making them smaller. The coarser muscles show ataxic symptoms much later. It is observed by the patient or his friends that he does not walk off with his usual rapid gait, and the effort to co-ordinate his muscles produces an early or unusual fatigue, which may be associated with general muscular pain. Extreme soreness and pain, following the course of some one or more of the main nerve-trunks, may be most persistent and obstinate to treatment, lasting for several years, limiting the motion of the limb, sometimes beginning a year or two before other symptoms are observed. Sooner or later, especially after a little weariness or excitement, there are observed at times, not constantly, indistinctness or an occasional trip in enunciating linguals and labials, a tremor in the handwriting, a slight unsteadiness in the gait. When the tongue is protruded as far as possible, when the hands and arms are stretched out, when the muscles of facial expression are exerted, in standing with feet together with closed eyes, a decided muscular tremor and unsteadiness are remarked. These muscular symptoms soon become constant, although they may be so slight as to be well marked only by some unusual test, such as prolonged use after excitement or fatigue, and the ataxia may diminish, the gait, speech, or handwriting may improve, while muscular power is growing progressively less.

In walking the feet are not raised as usual, the steps are shorter, the legs are kept wider apart; turning about is accomplished in a very deliberate way, such as to suggest an insecure feeling; movements like dancing are impossible. Going up and down stairs is difficult; the whole foot is rested carefully on each step, and the head and shoulders are held stiffly, so as to maintain the balance. The muscular movements are generally uneven and tremulous, and yet the strength may not be so very much impaired, although perhaps available only for short periods at a time. Even these symptoms may so improve by a few days' quiet, or even by a night's rest, as to quite throw the physician off his guard unless a thorough examination is made. The patient, too, on an even floor or sidewalk may walk so as not to attract attention, and yet in a new place, over a rough surface, or in the attempt to perform difficult or rapid movements, exhibit striking ataxia and feebleness of gait. In starting off with a definite purpose he may for a short distance walk quite well, as he may do under the influence of a glass of wine.

From this point the progress is usually rapid. The handwriting becomes more and more tremulous, unsteady, full of omissions of letters and words, disjointed, disconnected, and finally illegible; the articulation more thick, stammering, hesitating, indistinct, unintelligible; the gait staggering, shuffling, straddling, uncertain, unsteady, even to causing frequent falls. There may be still a considerable degree of strength for a single short effort, but the co-ordination is so imperfect as to make it avail little. The voice, for instance, may be loud and forcible, but the co-ordination sufficient for only a short explosive utterance of one syllable, and then quite an interval before the force can be concentrated for the next. Progressive muscular paresis becomes finally absolute paralysis.

Remissions in the physical symptoms follow the same general laws as in the mental symptoms, but are not so complete, and there may be an arrest in their progress also.

In all stages of the disease, especially the later, there may be almost any of the symptoms observed which occur in the various functional and organic diseases of the nervous system. The hyperæsthesia, local or general, may be most absolute, or the anæsthesia so complete that acts of self-mutilation ordinarily causing exquisite pain are performed without apparent suffering. Any motor ganglia, any nerve, any tissue, may degenerate, giving rise to various degrees of impairment up to total destruction of function—of the optic nerve, causing blindness; of the auditory, deafness; of the olfactory, glosso-pharyngeal, or any of the cranial or spinal nerves.

The pupils may be of normal size. They may be of normal or sluggish accommodation to light and distance, or there may be dilatation or contraction of either or both pupils and no response to light or accommodation. The pinhole pupil is not uncommon. There may be neuro-retinitis, atrophy of the disc, neuritis, nystagmus, diplopia, amblyopia, hemianopsia, color-blindness, ptosis, conjugate deviation of both eyes, or paralysis of any of the ocular muscles. The paralysis of one of the muscles of the eyeball may be one of the earliest and most persistent symptoms. The optic neuritis or atrophy may also occur early, but seldom appears in time to aid in a doubtful diagnosis.