On the classical assumption that PARETIC NEUROSYPHILIS (“general paresis”) is a fatal disease, is there a disease PSEUDOPARETIC NEUROSYPHILIS (“pseudoparesis”) which may recover or pursue a long course like that of a case of diffuse neurosyphilis (“cerebrospinal syphilis”)?
Case 58. Peter Burkhardt had been an efficient highway inspector, but in his forty-fifth year he had begun to be unable to do his work satisfactorily. His wife had become somewhat afraid of him. He had had somnolent spells in his chair and had squandered money. The mental symptoms had lasted for some six months, but had become more marked during the month preceding admission. Burkhardt would at times fail to recognize his friends.
The general physical condition of Burkhardt was very good. The pupils were irregular and reacted sluggishly both to light and to accommodation. The knee-jerks and ankle-jerks were absent. There were no other neurological disorders upon systematic examination. There was a speech defect. Mentally, little could be determined except a certain sluggishness.
History and physical examination at once suggested general paresis. The serum W. R. was doubtful, but the spinal fluid reaction was positive, as was the gold sol reaction (which was “paretic”); the globulin and albumin were greatly increased; there were 48 cells per cmm. Antisyphilitic treatment, consisting of salvarsan twice a week and potassium iodid by mouth, was followed by a rapid mental improvement. After two months, Burkhardt was discharged apparently normal, with all the blood and spinal fluid tests negative. He has been taken back into the highway service.
1. What is the proper definition of pseudoparesis? Fournier termed pseudoparesis certain cases that looked like paresis but were not syphilitic in origin. Of these cases the most characteristic group is that of alcoholic pseudoparesis. It is clear that there will be no difficulty in the definition of a disease pseudoparesis whose entity is presented in the adjective that precedes the term (e.g., alcoholic pseudoparesis). According to this usage, a case of pseudoparesis would be one in which the symptoms and possibly some of the signs somewhat resemble the symptoms of paresis itself but for which another etiology could be fairly established.
2. Are there any cases of syphilitic pseudoparesis? We are of the opinion that the term should be dropped. It is true that there are cases which clinically look like general paresis and exhibit the appropriate laboratory signs of general paresis but seem to differ from paresis in their course even when they receive no treatment whatever. In the present phase of doubt as to the classification of paretic and non-paretic forms of neurosyphilis, it seems to us of doubtful utility to characterize a case as pseudo simply because it differs in its course, particularly as the literature has always duly recognized that a number of cases of general paresis have had long courses and sometimes very long remissions.
There is also another group of cases that have been termed cases of pseudoparesis, namely: certain cases of neurosyphilis which clinically look like general paresis and seem to be following its classical course but are interrupted by treatment. Here again it seems to us doubtful whether the designation pseudo should be attached to this group of cases, particularly while the whole therapeutic question in the paretic group of neurosyphilis cases remains sub judice. Accordingly we are tempted to include in the group of paretic neurosyphilis cases that either get well of themselves, or get well under treatment, or pursue a very long course, or are subject to very long remissions. But we make this decision in terminology without prejudice to the therapeutic question and it is open to any critic to throw these cases into an atypical non-paretic group of neurosyphilis cases.
3. How shall we explain the absence of ataxia of case Burkhardt when knee-jerks are absent and when, therefore, we are entitled to conclude a certain degree of spinal disease? As stated in connection with case Sullivan (16), the absence of knee-jerks is not a warrant for terming a case—paresis of the tabetic form. The fact is that the lesion in paresis tends to be intraspinal, just as the higher brain lesions tend to occur within the brain substance. The meninges are relatively spared both within the cranium and within the spinal canal. The characteristic degeneration of posterior nerve roots which we find in tabes dorsalis is not necessarily found in general paresis even when there are somewhat extensive spinal lesions. Accordingly the absence of sensory returns by way of the posterior nerve roots which characterizes tabes dorsalis is not necessarily a phenomenon of general paresis. The mechanism by which the knee-jerks are lost depends upon histological detail. They may be lost when under tabetic conditions the posterior roots are severely diseased and when under paretic conditions only intraspinal collaterals or a small portion of fibres are affected. The whole question hinges upon where and to what degree the various reflex arcs are cut in the disease. The tabetic phenomena are, as so commonly stated, intradural; that is, the sensory or gangliospinal neurones at certain levels are affected all the way in from the points at which they pierce the dura mater. The affection of these and other neurones in general paresis is an intraspinal and parenchymatous affection.
Neurosyphilis; auditory hallucinations; ideas of persecution; attacks of excitement. SYPHILITIC PARANOIA (Kraepelin)?
Case 59. Bridget Curley was a case that was discharged from the Psychopathic Hospital, recovered, after 26 days in hospital. The symptoms so resembled those of alcoholic hallucinosis that the diagnosis was made despite the fact that the patient consistently denied the use of intoxicants. There was, in fact, no proof that she drank alcohol. The case was, however, not clearly one of alcoholic hallucinosis or of any other well-defined form of mental disease. A provisional diagnosis of manic-depressive psychosis, manic phase, had, in fact, also been made.