The principal forms of general paralysis are: (A) Demented form; (B) Expansive form;

(C) Excited form;

(D) Depressed form;

(E) Spinal forms

tabetic;

spastic.

A. Demented Form

This form constitutes from the psychic standpoint the pure type of general paralysis, free from accessory symptoms.

The onset is marked chiefly by indifference and loss of memory.

When the disease is fully established the symptoms are those of profound mental deterioration, which we have already described, associated with the characteristic physical disorders.

This form is frequent; its evolution is rapid and not interrupted by remissions.

B. Expansive Form

Also frequent. Special features:

Euphoria, often very marked.

Effusive benevolence, interrupted by transitory outbreaks of anger.

Ideas of self-satisfaction and ideas of grandeur (hallucinations are very rare).

Excitement, loquaciousness.

The disease begins with a morbid activity and slight excitement, which, associated with disorders of judgment, often lead the patient to ruinous deeds, misdemeanors, and even crimes. Unnecessary purchases, absurd enterprises, violations of decency, rape, and swindling are common. It is this stage that constitutes chiefly the medico-legal period of general paralysis.

The evolution of this form is slow. The duration of the illness quite frequently exceeds three years. Remissions are frequent.

C. Excited Form

This sometimes begins with a state of excitement and confusion resembling mania or acute confusion.

Its special features are:

Complete loss of orientation in all its forms;

Incoherent delusions, usually associated with numerous hallucinations;

Violent reactions with very marked motor excitement;

Profound disturbances of general nutrition.

It may run one of two possible courses: the excitement may persist and death supervene within a few months or even weeks (galloping general paralysis); or the excitement may subside and the disease may pass into one of the other forms - demented, expansive, or depressed.

D. Depressed Form

The onset is marked by a state of depression, so that the trouble may be mistaken for involutional melancholia or for a manic-depressive attack.

The special features of this form are: Psychic inhibition;

Psychic pain;

Melancholy delusions;

Attempts of suicide that are frequently childish and ineffective;

Peripheral vaso-constriction, impairment of general nutrition;

Refusal of food.

All these disorders, however, harmonize less perfectly with each other than in the constitutional depressive affections.

The evolution is very rapid. Death supervenes early, and is due to cachexia or to some complication (infection favored by the impaired nutrition and diminished resistance of the tissues).

E. Spinal Forms. Tabetic Form

This form has at the beginning the aspect of ordinary tabes. The signs of general paralysis appear much later.

Its special features are:

Lightning, lancinating pains; girdle sensation;

Marked ataxic symptoms;

Abolition of the patellar reflexes;

Romberg symptom;

Argyll-Robertson pupils.

The symptomatology of this form of general paralysis is, however, not identical with that of pure tabes. The pains are less severe, the urinary troubles less frequent (Joffroy). A curious fact difficult to explain is that as the symptoms of general paralysis become more pronounced, those of tabes (at least the subjective symptoms) seem to disappear.

Spastic Form. (Form with Lateral Sclerosis.) - This form is characterized by muscular rigidity, exaggeration of reflexes and epileptoid trembling. The Babinski sign is almost constant. "These symptoms are sometimes bilateral and symmetrical, at other times unilateral, and still at other times, at the onset of the disease, mobile and variable." (Dupre.)

The different forms above described may follow each other, or they may be associated in the most varied ways.

Course And Prognosis

The course of general paralysis is progressive, and has been schematically divided into three stages, not including the prodromal stage: (1) stage of onset; (2) stage of complete development; (3) stage of cachexia.

The symptoms at the stage of onset are very variable. Generally mental symptoms are the first to attract attention and even to suggest the diagnosis: disorders of memory and orientation; the patient loses his way in the streets with which he is most familiar, forgets on leaving the house what he started out for; there are also irritability, outbursts of anger, attacks of depression or of excitement with elation; more or less active delusions. These symptoms are not incompatible with a certain degree of mental activity; hence the anomalies of conduct leading to antisocial consequences which are at times very grave and which have led some (Legrand du Saulle) to designate this stage of the disease as its medico-legal period. The patient forgets the most common conventionalities and makes use of obscene language in public and in the presence of his own children. He enters upon foolish, ruinous enterprises, buys dozens of umbrellas, cases full of jewelry, hundreds of copies of the same book. One patient, formerly a notary, ordered in one day twelve tigers from Bengal, "tamed" in Hamburg, five thousand pounds of tar from Paris, and five hundred pounds of coffee from Port-au-Prince. Often a paretic will commit thefts and frauds, so childish in character as to suggest at once serious mental disturbance.

Finally the patient's impulsiveness may lead to acts of violence, murder, and, when combined with genital excitation, as is often the case, to violations of decency and to rape.

In this stage the physical signs are generally not fully developed; yet it is rare for them to be entirely wanting.

The second stage, that of complete development, is the one in which the fundamental symptoms are well marked and the delusions, if they exist, are in full bloom; yet the patient is still able to walk around and to eat and dress without assistance. There is in this stage as yet no loss of sphincter control except, perhaps, for occasional brief periods.

The stage of cachexia is characterized by complete physical and mental dilapidation, by the appearance of pressure-seres, and by permanent loss of sphincter control.

The prognosis is fatal. Death occurs from cachexia, from some complication, or as the result of an apoplectiform or epileptiform seizure.

The average duration, of the disease is two or three years. There is, however, no fixed rule with regard to this. In exceptional cases the disease lasts but several months or weeks (galloping general paralysis); in other cases, on the contrary, it is prolonged for ten or more years.

The progress of the disease may be interrupted by remissions. Rarely, except at the beginning, are the remissions complete. Almost always the persistence of a certain degree of mental deterioration, or at least of a neurasthenic condition and of physical signs exclude any idea of true recovery.

Diagnosis

The fundamental elements of diagnosis are progressive mental deterioration en masse and the characteristic physical signs.

General paralysis may, especially at the beginning, when neither the mental deterioration nor the somatic signs are well marked, simulate many other psychoses.

Lumbar puncture is here of great service. An increase in the number of lymphocytes in the cerebro-spinal fluid is almost constant in general paralysis, especially at the onset.

It is known that lymphocytosis of the cerebro-spinal fluid always indicates a meningeal inflammatory lesion. Though its existence does not point positively to general paralysis, yet it excludes all affections in which there are no meningeal lesions. Thus are eliminated: dementia praecox, involutional melancholia, manic-depressive psychoses, epileptic psychoses, alcoholic psychoses, and exhaustion psychoses. Further, affections with a basis of a simple process of atrophy, like senile dementia, or with a basis of a central lesion without meningeal involvement (tumors of the centrum ovale, hemorrhages, cerebral softening), are also eliminated.

The cerebro-spinal fluid and the blood may also be examined for the Wassermann reaction, and a positive result will further narrow down the diagnosis to some syphilitic disorder.

Lange's colloidal gold test, applied to the cerebro-spinal fluid, gives a very characteristic reaction in general paralysis: complete precipitation in the first two, three, or four tubes, partial precipitation in the next two or three, and no precipitation at all in the rest, 5555432100. (See Appendix I.)

Noguchi's butyric acid test, the Ross-Jones ammonium sulphate test and Pandy's phenol test usually give a positive result in cases of general paralysis and a negative result in other psychoses. All forms of meningitis, however, also give a positive result.

In the great majority of cases in which general paralysis is suspected its existence can be either established or excluded with complete certainty with the aid of spinal fluid examination. There are, however, two groups of cases which may present extraordinary difficulties of differentiation; the first consists of psychoses essentially of a non-syphilitic nature occurring in combination with tabes: here one must rely mainly on the mental symptoms for the differentiation, although it has been said that the colloidal gold test here gives but seldom the typical reaction described above;l the second group consists of cases of cerebral syphilis: the differentiation of these has already been considered in the chapter devoted to that condition.

1 D. M. Kaplan. Serology of Nervous and Mental Diseases. Philadelphia and London, 1914. - Swalm and Mann. The Colloidal Gold Test on Spinal Fluid in Paresis and Other Mental Diseases. N. Y. Med. Journ., Apr. 10, 1915.