As the disease advances there is greater excitability and a tendency to emotionalism. In classical cases the general exaltation of ideas becomes so great as to lead the patient to the commission of insanely extravagant acts, such as purchases of large numbers of useless articles, or of lands and houses far beyond his means, numerous indiscriminate proposals of marriage, the suggestion of utterly absurd commercial schemes, or attempts at feats beyond his physical powers. The mental symptoms, in short, are very similar to those of the elevated stage of manic-depressive insanity.
Delusions of the wildest character may also be present. The patient may believe himself to be in possession of millions of money, to be unsurpassed in strength and agility, to be a great and overruling genius, and the recipient of the highest honours. This grandiose condition is by no means present in every case and is not in itself diagnostic of the disease. But mental facility, placid contentment, complete loss of judgment and affection for family and friends, with impaired memory, are symptoms universally present. As the disease advances the motor symptoms become more prominent. The patient has great difficulty in writing, misses letters out of words, words out of sentences, and writes in a large laboured hand. The expression becomes fatuous. The speech is difficult and the facial muscles are thrown into marked tremors whenever any attempt at speech is made. The voice changes in timbre and becomes high-pitched and monotonous. The gait is weak and uncertain and the reflexes are exaggerated. In the first stage the patient, through restlessness and sleeplessness, becomes thin and haggard. As the second stage approaches sleep returns, the patient lays on flesh and becomes puffy and unhealthy in appearance. The mental symptoms are marked by greater facility and enfeeblement, while the paralysis of all the muscles steadily advances. The patient is now peculiarly liable to what are called congestive seizures or epileptiform attacks. The temperature rises, the face becomes flushed and the skin moist. Twitchings are noticed in a hand or arm. These twitchings gradually spread until they may involve the whole body. The patient is now unconscious, bathed in perspiration, which is offensive. The bowels and bladder empty themselves reflexly or become distended, and bedsores are very liable to form over the heels, elbows and back. Congestive seizures frequently last for days and may prove fatal or, on the other hand, the patient may have recurrent attacks and finally die of exhaustion or some accidental disease, such as pneumonia. In the second stage of the disease the patient eats greedily, and as the food is frequently swallowed unmasticated, choking is not an uncommon accident. The special senses of taste and smell are also much disordered. We have seen a case of general paralysis, in the second stage drink a glass of quinine and water under the impression that he was drinking whisky.
The third stage of the disease is characterized by sleeplessness and rapid loss of body weight. Mentally the patient becomes quite demented. On the physical side the paralysis advances rapidly, so that the patient becomes bedridden and speechless. Death may occur as the result of exhaustion, or a congestive seizure, or of some intercurrent illness.
The duration of the disease is between eighteen months and three years, although it has been known to persist for seven.
No curative measures have so far proved of any avail in the treatment of general paralysis.
Insanity Associated with Epilepsy.—The term “epileptic insanity,” which has for many years been in common use, is now regarded as a misnomer. There is in short no such disease as epileptic insanity. A brain, however, Epileptic Insanity. which is so unstable as to exhibit the sudden discharges of nervous energy which are known as epileptic seizures, is prone to be attacked by insanity also, but there is no form of mental disease exclusively associated with epilepsy. Many epileptics suffer from the disease for a lifetime and never exhibit symptoms of insanity. The majority of patients, however, who suffer from epilepsy are liable to exhibit certain mental symptoms which are regarded as characteristic of the disease. Some suffer from recurrent attacks of depression, ill-humour and irritability, which may readily pass into violence under provocation. Others are emotionally fervid in religious observances, though sadly deficient in the practice of the religious life. A third class are liable to attacks of semi-consciousness which may either follow upon or take the place of a seizure, and during these attacks actions are performed automatically and without consciousness on the part of the patient.
When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal.
Epileptic patients who suffer from recurrent attacks of delirious mania are liable to certain nervous symptoms which indicate that not only are the motor centres in the brain damaged, but that the motor tracts in the spinal cord are also affected. The gait becomes awkward and laboured, the feet being lifted high off the ground and the legs thrown forward with a jerk. The tendon reflexes are at the same time exaggerated. These symptoms indicate descending degeneration of the motor tracts of the cord.
If the mental attacks partake of the character of elevation or depression the mental functions suffer more than the motor. These patients, in course of time, become delusional, enfeebled and childish, and in some cases the enfeeblement ends in complete dementia of a very degraded type.