Paresis

“ Another nervous disease, corresponding in some of its features to paresis and indeed sometimes spoken of as a spinal form of paresis, is locomotor ataxia. This affection {321} begins usually with loss of sensation in the soles of the feet so that the patient thinks that he is walking on carpet all the time. Before this there may have been some disturbance of vision. The pupils may fail to react to light. Occasionally the first symptoms are motor, that is, the man notices that he is not able to walk as readily as before. He staggers easily. ”

“ Among the symptoms denoting paresis of motor-centres of cranial nerves, together with sympathetic ganglia, the first and most noteworthy is the early dilatation of the pupil. This truly pathognomic condition is never absent, and becomes intense when paresis becomes intensified into paralysis. The most glaring light, in immediate proximity to the eyeball, has then no effect whatever on the pupil. ”

“ 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. ”

“ Without further treatment Petrofski has remained well for over a year.
1. Does the “paretic” gold sol reaction mean general paresis? In connection with this general question, a brief summary of the significance of the gold sol reaction in this group may be made. (1) Fluids from cases of general paresis in the vast majority of cases will give a strong and fairly characteristic reaction, especially if more than one sample is tested. (2) Very rarely general paresis fluid will give a reaction weaker than the characteristic one. ”

“ 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. ”

“ The paresis and the atrophy of the voluntary muscles, the œdema of the connective tissue, and the serous effusions are, as a rule, not very serious matters at all events as affecting life. But it is very different when paresis and degeneration seriously implicate the heart and the muscles of respiration. In nearly all beriberics there is heart trouble, arising, doubtless, from implication of the pneumogastric nerve and the cardiac plexus. In some patients the degree of implication is slight; but in others it is sufficient so to weaken the heart that death is inevitable. ”

“ 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 average duration of the disease in months has been calculated as varying from 24 to 32 months. Juvenile paresis runs a slower and more insidious course. The duration of paresis, according to many observers, diminishes with the increasing age of the patient. It is now held that a combination of tabes with paresis does not prolong the duration of the paresis. As noted above in the discussion of Case Harrison (9) , our conceptions of the characteristic duration of paretic neurosyphilis must alter with the increase of our knowledge due to the early application of laboratory tests. ”

“ 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. ”

“ May one speak of general paresis without mental symptoms? If one considers general paresis a mental disease, of course it cannot exist without mental symptoms. However, if one considers the disease as a chronic syphilitic meningoencephalitis characterized by its pathological anatomy, then one may readily speak of general paresis although no real evidence of mental symptoms can be discovered. ”

“ 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. ”

“ 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. ”

“ There may be a feeling of tingling and numbness in the lower extremities, with anæsthesia or hyperæsthesia of the skin and more or less paresis. A feeling of constriction around the waist or the chest is sometimes complained of. In slight effusions the symptoms may be limited to numbness and formication of the extremities, with slight paresis. There is rarely fever in the early stages, unless the amount of blood is [p. 755] sufficient to give rise to inflammatory conditions of the cord or membranes. ”

“ Medicolegally speaking, Froissart, quoted by Rayneau, states that a victim of traumatic paresis may or may not have presented mental disorders before the accident, that is, that the paretic symptoms may develop out of a clear sky as a result of the accident. The accident itself must be of a serious nature. The accident must be followed by phenomena pointing to brain injury of traumatic nature. These phenomena need not be characteristic symptoms of general paresis at the outset. ”

“ Paralysis or paresis is of course one of the most frequent evidences of the existence of an intracranial tumor. The palsies of cerebral tumors are chiefly unilateral, but the loss of power may be in one or both limbs, in one side of the face, or in the entire one-half of the body, according to location and extent. Tumors of the cortical motor zone usually begin their paralytic manifestations with paresis of one member or one side of the face, which goes on, as the growth increases in size, to more or less complete hemiplegia. ”

“ 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. ”

“ COURSE OF THE DISEASE.—As already stated, a period of paresis may precede all signs of hypertrophy for several weeks, months, or even years. From the time that the enlargement of the calves has once begun about a year and a half is required before the maximum of hypertrophy is attained. Then the disease usually remains stationary for two or three years before the third period is ushered in by aggravation of paralysis in the lower and by extension of paralysis, together with hypertrophy or atrophy, to the upper limbs. ”

“ 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. ”

“ Palsy from pressure, as from sleeping with the head resting upon the arm or with the arm hanging over the back of a chair, is a frequent cause of paresis or paralysis of the muscles supplied by the musculo-spiral. ”

“ All the muscles of both eyes appeared to work normally. Upon pressure on the right globus, especially pressure directed from above and behind on the internal part, the patient would raise his left eyelid, but the paresis reappeared the moment the pressure was released; a fact which the patient himself noted while a tampon was being placed upon his eye. ”

“ 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. ”

“ When the nerve roots alone are injured, sensory phenomena predominate. Formication, radiating pains, and neuralgia are present in the area of distribution of the nerves implicated. There is motor paresis or paralysis, which may disappear either suddenly or gradually, or may persist and be followed by atrophy of the muscles concerned. ”

“ That under the powerful combination of causes, each of which is in itself sufficient to endanger life, and greatly intensified as paresis gradually deepens into paralysis, the heart, even of large animals, succumbs in a comparatively short time, may be readily understood. ”

“ 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. ”

“ Some such cases are restless and in continual movement while others are dull, apathetic and indisposed to move. The precise seat of the paresis or paralysis will be determined by the seat of the lesion as in the larger animals. Thus paraplegia is most common, less frequently hemiplegia, palsy of the fore limb, palsy of a single limb, and monoplegias, about in the order named. Palsy of the tail and sphincters implies a lesion of the lumbar section of the cord and is very offensive in the incontinence of urine and fæces especially in long-haired subjects. ”

“ When the nerve going to an eye muscle, e.g., the external rectus of one side, falls into a state of paresis, the first result is that the same volitional stimulus, which under normal circumstances would have perhaps rotated the eye to its extreme position outwards, now is competent to effect only a moderate outward rotation, say of 20o. ”

“ The case is distinguishable from the paradigm in not showing the effects of vascular insults in the shape of cysts of softening. The cerebellar sclerosis of the case is fairly characteristic of paretic cases. There is even a suggestion of atrophy in the temporal region suggesting the so-called Lissauer’s paresis. ”

“ The face usually escapes entirely. In organic palsy the face is generally less severely and less permanently affected than the limbs, but paresis is commonly present in some degree. Hysterical palsies are more likely to occur upon the left than upon the right side. Embolism is well known to occur most frequently in the left middle cerebral artery, thus giving the palsies upon the right. In hemorrhage and thrombosis the tendency is perhaps almost equal for the two sides. ”

“ 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. ”