General paresis

“ In the majority of instances repetitions will give a strong positive reaction.
2. Is the case of Forest to be regarded as one of general paresis? Sometimes such cases are termed in the literature syphilitic pseudoparesis (see case Burkhardt (58) ) . The differential diagnosis of this group is entirely therapeutic. There are, unhappily, no laboratory tests which will suffice in the present stage of knowledge to differentiate a case of so-called pseudoparesis from general paresis. We are inclined to term the case one of General Paresis, with recovery, or, at all events, with remission. ”

“ The food, already poor enough, is no better, when the meat of a half-rotten cow comes twice to the table.” This patient was, according to Kastan, a victim of general paresis.
Re general paresis and delinquency, Gilles de la Tourette long ago maintained that there was a medicolegal period in paresis. Lépine in his work on Troubles Mentales de la Guerre speaks of the unexpected frequency of general paresis in the army, and calls attention at the outset to the medicolegal period. ”

“ There are clinical suggestions of general paresis, not confirmed by the laboratory findings.
1. Are we dealing with a case of diabetic pseudoparesis? Is the pain in the legs of like origin, and has a neuritic process led to the absence of the knee-jerks? The Allen treatment appears to have had no beneficial result in this case.
2. Is there a tumor of the sella region, which could account for the mental symptoms and the glycosuria? The spinal fluid albumin might be regarded as consistent with a variety of psychoses, including that of brain tumor. ”

“ For instance, it is now very generally conceded that paresis, or what is sometimes called general paralysis of the insane,—a progressive mental and nervous disease, which invariably ends fatally in from three to seven years,—is always due to one of the so-called social or venereal diseases. How important this affection has become in modern life can be best appreciated from the fact that in Europe nearly one in four of those who die in the insane asylums are sufferers from paresis. In this country the disease is not so frequent, the proportion being less than one in five or even one in six. ”

“ It is, of course, a well-known fact that the disease may progress rapidly to a termination in two or three years or may continue for an almost indefinite period of time. It may manifest itself, furthermore, in various ways. The physical signs show much greater constancy than the mental symptoms.
Kraepelin [174] describes demented, depressed, expansive and agitated forms of general paresis. The "demented" form he finds to be much more common than the others. This is characterized by a progressive mental deterioration with "paralysis." ”

“ What is the definition of a remission in general paresis? Remissions form a foil to seizures; just as seizures mark a sudden advance in the severity of the disease or may even lead to death; so remissions may cause a sudden cessation of both mental and nervous phenomena in the disease. Whereas the seizures occur most often, according to Kraepelin, in the demented types of paresis, the remissions occur in all cases except in the terminal phase. Kraepelin quotes Hoppe as observing pronounced remissions of long duration in 17% of male and 15% of female paretics. ”

“ The reason why the aged, the very young, and the subjects of general paresis show but few symptoms of disease is that in senility the brain is deteriorated, while in infancy the brain is so undeveloped that the mechanism of association is inactive, hence pain and tenderness, which are among the oldest of the associations, are wanting. Senility and infancy are by nature normally narcotized. The senile are passing through the twilight into the night; while infants are traversing through the dawn into the day. ”

“ That a paretic process can be started up after trauma is admitted on all sides; but we here suppose actual physical or chemical brain disturbance permitting increased spirochetosis or inflammatory reaction. In the case of psychic shock, or what might be called psychogenic general paresis, our best resort will be to the indirect effects of hormone action, or of vasomotor and other autonomic disturbances produced directly or indirectly by emotion. We are clearly here dealing with material too speculative to be of practical service at this time. ”

“ While it is true that we have not had any great amount of success as yet with the treatment of general paresis with salvarsan, the positive knowledge that the disease is of syphilitic origin should encourage us in our efforts to solve the problem of curing it. Histological, pathological, bacteriological, chemical, clinical and psychological researches must be pushed vigorously if psychiatry is to keep pace with the general progress shown by modern medicine in other fields. ”

“ At the same time, the physical signs are relatively more prominent, although the speech difficulty and writing defects may not be so marked. The pupils sometimes show no changes. Hemiplegias with ankle clonus and a Babinski reflex are, however, disproportionately common. The eye muscles are much more often involved than they are in general paresis. Loss of pain sense is not so noticeable. An advanced form of deterioration of many years standing is against a diagnosis of paresis and favors cerebral syphilis. ”

“ The parietal region may be involved, but not to any such extent as in general paresis. There may be localized areas of atrophy. Pachymeningitis and hemorrhagic membranes are often found. The microscope shows a proliferation of the glia cells and there is often some disturbance of the layering of the cortex. Cell alterations appear, with fatty degeneration, some neurones showing little more than a darkly colored nucleus. The glia cells are enlarged. There should be no marked changes in the vessels. Fatty changes in the ganglion cells are very noticeable. ”

“ Haslam in 1798. These were followed by the researches of Bayle, Delaye and finally Calmeil, which definitely established the integrity of that disease as a clinical entity. Even then its specific origin was only a matter of conjecture. When Esmarch and Jessen suggested that general paresis was a syphilitic disease in 1857, their views were rejected by men as prominent as Charcot and Déjerine. Although paranoia is a term which has appeared in the literature of medicine for centuries, it has only had the significance now attached to it since the latter part of the nineteenth century. ”

“ There are other conditions suggesting general paresis. Marcus, for instance, has described a delirious, confusional state occurring usually in the first year after the infection, sometimes later, but as a rule developing suddenly. The patients become sleepless, confused, anxious and disoriented. Numerous hallucinations appear, both of hearing and vision, usually of a very unpleasant type. The patients often become excited and violent or even suicidal. ”

“ When the syphilitic process is an extensive one with a widespread meningitis or gummatous involvement of the base, numerous focal symptoms are to be expected. Choked disc, optic tract lesions, paralysis of the ocular muscles, facial neuralgias, facial palsies, deafness, or anesthesias may occur. Mental deterioration naturally advances with the progress of the disease, but the personality is much better preserved than in general paresis. Periods of unconsciousness are not infrequent and convulsive attacks may appear. ”

“ One is not justified in drawing any conclusions as to whether the case is cerebrospinal syphilis or general paresis, nor the time the process has been active, nor the severity of it, from the cell count. ”

“ Late Syphilis of the Nervous System—General Paralysis.—General paralysis, or paresis, is a progressive mental degeneration, with relapses and periods of improvement which reduce the patient by successive stages to a jibbering idiocy ending invariably in death. Such patients may, in the course of their decline, have delusions which lead them to acts of violence. ”

“ It is in many cases associated with defective vision, weakness or loss of memory, mania, impairment of intelligence, persistent pains in the head or chronic hydrocephalus. Sometimes to one or more of these symptoms is added more or less general paresis or complete paralysis. Southhall46 mentions the case of a child two years old whose attack was followed by incomplete paralysis, and death at the end of eight months with softening [p. 820] of the brain. Gordon thus describes the conclusion of a case: "The man has gradually passed into a state of almost organic life ”

“ The senile psychoses constitute approximately ten per cent and arteriosclerosis five per cent of the total. General paresis averages about twelve per cent in the New York hospitals and from seven to ten per cent in the other states. Cerebral syphilis amounts to a little less than one per cent of the cases. It should be said that in the large cities the rate for syphilis is, in some instances at least, twice as high as that given. Brain tumor, with all other brain and nervous diseases, only constitutes about one and one-half per cent of our admissions. ”

“ Recent work, however, supports a much more optimistic viewpoint. We feel that intensive treatment has been of the greatest value in a number of cases of paretic 463neurosyphilis. Two cases are given which show the most satisfactory and brilliant results of intensive intravenous salvarsan therapy in cases diagnosed as general paresis. The first case, an excellent salesman, 46 years of age, with most aggravated mental symptoms, recovered symptomatically and all his tests were rendered negative. ”

“ Some of the Effects.—It is now known that paresis, also termed general paralysis or softening of the brain, is probably invariably due to syphilis. The work of Flexner and Noguchi on paresis and tabes dorsalis show that always in such afflictions the tissues of the central nervous system have been invaded by the parasite. The original infection, however, may have occurred so long before as to have been almost forgotten by the patient. Thus many an apparently robust man is stricken down in the prime of life. ”

“ As a rule, however, we may state in general terms that diseases of the superior laryngeal nerves produce paralysis or paresis of the external tensors of the vocal cords, the crico-thyroids, and, to a certain extent, of the constrictors of the larynx. Diseases of the recurrent nerves produce paralysis or paresis of the other muscles of the organ. If the disease of the nerve is of one side only, we have, as a rule admitting of only a very few exceptions, a unilateral impairment of the motor functions of the parts. ”

“ To the excito-motor frontal region. In the early stages symptoms of irritation predominate, the patient suffering from fits of a focal or Jacksonian type (see p. 189) , whilst, later on, paresis of a progressive type, involving the face or extremities unequally, becomes evident. In children, however, the rapid transference of impulses from one motor area to another causes the fits to soon lose their focal character, general convulsions taking their place. ”

“ This may become so extreme that the patient dies by syncope. In other cases the paresis is mainly shown in the vaso-motor system, and its centres in the medulla, the blood is delayed in the distended capillaries and veins, it becomes overcharged with carbon dioxide, the heart’s action is accelerated and feeble, the pulse rapid, weak and fluttering, perspiration breaks out on the skin, and the temperature is normal or subnormal. The muscular weakness, the flaccid condition of the facial muscles, and general depression suggest a state of collapse. ”

“ The victim will sometimes manifest incredible strength in breaking his chain and scaling high walls. Twitchings of the muscles of the face, and even general convulsions, are sometimes seen. Food is usually rejected, or if swallowed is soon vomited. In the course of two or three days the furious stage merges into the paralytic one, first shown by paresis of the hind extremities and a swaying motion in walking, then by paralysis of the lower jaw, which hangs pendent and allows the escape of a viscid saliva. ”

“ Paretic neurosyphilis, dementia paralytica, general paresis, softening of the brain, 37, 63, 68, 74, 78, 80, 85, 97, 131, 188, 192, 197, 199, 202, 227, 241, 262, 289, 295, 309, 314, 323, 338, 372, 375, 377, 382, 384, 386, 388, 392, 435, 440, 442. adjuvant causes of, 414. causing social complications, 289. causes of death in, 197. course, 85. duration, 88. forms, 95. improvement, 377. incidence among officers, 407. incidence among soldiers, 402. lesions of, 131. “lighted up” by domestic stress in civil life, 420. “lighted up” by “gassing,” 414. mortality from, 89. nomenclature, 88. onset, 192. ”

“ Unscrupulous persons may falsify about the pre-traumatic history and claim the development of symptoms immediately after the accident. Such claims are beyond question to be viewed with the greatest suspicion. Some days or weeks should elapse before definite symptoms in post-traumatic paresis appear. Just how long an interval may elapse between trauma and paretic symptoms and shall entitle the case to be regarded as one of traumatic paresis, is perhaps a matter of doubt. ”

“ There are forms of paranoia in the middle-aged which sometimes exhibit symptoms so strongly simulant of paresis as to deceive even the expert. There are forms of nervous weakness—neurasthenia—some of which are really cases of mental exhaustion or incapacity—the modern psychasthenia—which often lead even experienced physicians to think of and sometimes to diagnose paresis. ”