PARETIC NEUROSYPHILIS (“general paresis”) sometimes persistently receives the diagnosis NEURASTHENIA simply through omission to apply approved diagnostic methods.
Case 9. Greeley Harrison, a man of 46, certainly looked like a neurasthenic. He wanted aid for nervous indigestion of years’ standing, headache, insomnia, nervousness, failing memory, and deafness. He volunteered, in fact, that he had neurasthenia, and that he had been treated for this by hypophosphites.
During the practically negative physical examination, Harrison complained of headache and throbbing in the head, and during examination of the abdomen felt much nauseated and proceeded to vomit rather persistently. There were hemorrhoids.
Neurological examination showed that the left pupil was smaller than the right, was irregular, failed to react consensually, and reacted very slowly to direct light. For the rest, however, the neurological examination was negative. On account of the nausea and vomiting, special examination of the gastric contents was made, but nothing abnormal was found.
Mentally, it was rather striking that the patient’s memory was quite inaccurate both for remote and for recent events. His school knowledge was very meagre. As for delusions, the only approximation thereto was the patient’s continually dwelling upon his bodily symptoms. Emotionally, he varied between depression and a sanguine attitude.
Although there was no symptom directly suggesting syphilis in the Harrison case, the slightly abnormal pupillary reactions and the amnesia warranted the suspicion of syphilis. The blood and spinal fluid both proved positive to the W. R.; the gold sol reaction was of the “paretic” type; there were 18 cells per cmm.; there was considerable globulin, and an excess of albumin. On the whole, therefore, we felt entitled to make the diagnosis General Paresis. Why should not a careful observer have considered syphilis seriously? Yet in our experience such cases are frequently diagnosticated neurasthenia, thus entailing dangerous delay in treatment (in this case, five years’ delay).
Going over the history of the case with still greater detail, we learned that for a number of years past, there had been symptoms of a neurological nature. For instance, five years before, at the age of 41, the patient had been apparently overcome when working near a stove, and went upstairs talking incoherently, but recovered shortly. Thereafter, such spells occurred almost every month; later, more frequently; still later, the attacks were associated with unconsciousness and amnesia. Occasionally preceding the attack there would be twitching of the mouth, jerking of the arms, and incoherent talk. Throughout these last five years, in point of fact, the patient had been unable to do regular work, had been given to much complaining, and had been far less efficient than formerly. In short, it would seem that, with the improved technique now in the possession of medical science for the diagnosis of general paresis, cases like that of Harrison will be diagnosticated earlier and earlier.
1. How typical is the insidious onset of symptoms in the case of Harrison? The onset of symptoms in neurosyphilis is ordinarily considered to be sudden, and this statement is generally true despite the fact that after the diagnosis is established a number of mild prodromal symptoms can be remembered by the relatives. However, some cases, of which Harrison is an example, have an exceedingly insidious onset without sudden access of striking symptoms. Joffroy and Mignot remark that with the improvement of clinical methods, the course of paretic neurosyphilis must now be stated to take some six or seven years for completion. In point of fact, there were early episodic symptoms (seizures almost monthly) which should not have escaped medical attention. They did escape medical attention, however, and Harrison was wont to say “Why wasn’t I told that my disease was syphilis five years ago?”
2. Is there such a disease as syphilitic neurasthenia? According to Kraepelin, syphilitic neurasthenia has been described as occurring shortly after infection and in the first stages of syphilis. There are milder and severer forms; the milder forms show discomfort, difficulty in thinking, irritability, insomnia, cephalic pressure, indefinite variable, uncomfortable sensations, and pains. The severer cases acquire anxiety, more pronounced emotional disorder, dizziness, disorder of consciousness, difficulty in finding the right word, transient palsies, pronounced sensory disorders, nausea, and increase of temperature. Kraepelin is in doubt whether there is any definite clinical picture of this sort, and whether there is any causal relation between the syphilitic infection and such symptoms as those described. If the effect of knowledge concerning infection is a merely psychic effect, then it is improper to term the neurasthenia in question a syphilitic neurasthenia. For the relation of hysteria to the acquisition of syphilis, see below the case of Alice Caperson (46). In point of fact, modern work has shown even in the primary and secondary stages of general syphilis more or less pronounced neurosyphilitic phenomena in the shape of the so-called meningitic irritation of French authors. (Besides the case of Caperson (46), see the case of Fitzgerald and the discussions under these cases.)
3. What is the relation of the early symptoms of this case to the so-called preparesis of Dana? The case might well have been an example of Dana’s preparesis. For a discussion of this, see Case of William Twist (13).