While in the hospital things shortly came to a crisis. In the midst of a fit of depression, Sullivan attempted suicide by beating his head against the wall. Whether this attempt could be regarded psychopathic, however, remained in question. Sullivan had been drinking very heavily although he had stopped about six weeks before admission, fearing that the alcohol was causing a development of symptoms. The remedy was almost worse than the disease because he then became more nervous, lost his appetite, and had a marked insomnia.
According to the patient’s own history, he had had several attacks of gonorrhœa and a syphilitic infection at the age of 19; that is, some 31 years before admission to the hospital. However, the first neurological symptoms of which the patient was aware came about 27 or 28 years after infection, namely, 3 or 4 years before admission, when facial paralysis developed. At that time, he had suddenly felt a peculiar sensation in the throat and became unable to swallow for a time. His voice remained hoarse and low for some time, and his face began to droop. The lancinating pains and the ataxia also dated back several years.
1. How shall we evaluate the mental symptoms? The prognosis of tabes dorsalis is relatively good so far as life is concerned, and it might even be possible for Sullivan by training to remain capable of being a waiter. The manual incoördination was not marked, and possibly the manual tremor was in part due to alcohol. Accordingly, the mental symptoms, such as emotional lability and memory defect, were in the foreground of attention. In point of fact, the laboratory examinations showed positive W. R. in the serum and the spinal fluid, which latter also contained 60 cells per cmm., positive globulin, and an excess of albumin. The Diagnosis made was that of Taboparesis, meaning thereby a tabes associated with appropriate symptoms of a mental nature.
2. How shall the term taboparesis be used? Some use the term, as we feel erroneously, for instances of general paresis which happen to show crural areflexia (absence of knee-jerks). We feel that the best usage of the term is for instances in which well-defined symptoms of tabes (as well as of paresis) are present, namely, characteristic ataxia, lightning pains, and the like. If the term is used more loosely, as above mentioned, then practically every case of general paresis might perhaps be termed taboparesis, since almost every case of paresis does show involvement of the cord as well as of the cerebrum. Such involvement may lead to hyperreflexia, hyporeflexia, or areflexia according to the localization of the process. In true taboparesis, in which there is a commingling of the features of tabes with those of paresis, we should find the posterior roots of the spinal cord affected. The spinal lesions of paresis itself are more apt to be intraspinal; that is, confined to the nervous system within the pial investment.
3. Bearing in mind that Sullivan was a waiter, what shall be said about the infectivity of these cases? It is counted as a rule as negative, since there are no open spirochete-bearing lesions. The longer the period since infection the less, as a rule, is the chance of contagion in syphilis; and as tabes and paresis occur fairly late in the disease, the infectiousness at this stage is practically negligible.
4. Of what differential value is the insight shown by Sullivan into the nature of his symptoms? Kraepelin remarks that a genuine insight into the nature of the disease does not as a rule occur in paresis. At the beginning of the disease, there may sometimes be a correct understanding of the nature of the disease and of its probable outcome; but the presence or absence of insight into the fact of mental disease is by no means a differential sign of practical value.
5. What is to be said of the occurrence of depression and excited states in paretic neurosyphilis? A variety of classifications of sub-forms of paretic neurosyphilis have been propounded. Kraepelin, for example, deals with four: the demented, depressive, expansive, and agitated forms, but remarks that the division is merely convenient for exposition. The institutional intake does not accurately represent the distribution of cases. Under psychopathic hospital conditions with the relatively easy resort to such institutions, the number of quiet cases increases; under the less advanced conditions in Heidelberg, Kraepelin took in 53% demented paretics as against 56% at Munich (73% women) under the easier conditions of admission. The admissions of demented paretics varied from 37 to 56%. The variations depend much upon the facility with which the cases can be brought to institutions. Where admission is beset with various legal restrictions, the quiet and demented cases are more apt to be treated for long periods at home. The depressive type of paretic neurosyphilis forms a much smaller group, according to Kraepelin, as only about 12% of his Heidelberg admissions were of this type, and still fewer of his Munich admissions. Other authors give percentages as high as 16 and 19. The so-called expansive group is larger, Kraepelin finding 30% of his Heidelberg cases to be of this group, and 21 to 22% of his Munich cases. The rarest sub-form of paretic neurosyphilis is the agitated form: 6% of Kraepelin’s Heidelberg admissions; 14% among males and 5% among females in his Munich admissions, where the diagnosis of agitated paresis was entered on somewhat broader lines. French authors (Sérieux and Ducaste) have enlarged the number of sub-forms of paretic neurosyphilis as follows: Expansive 27%; sensory 24%; demented 24%; persecutory 3%; depressive 2%; circular 7%; hypochondriacal 7%; and maniacal 6%.
DIFFUSE (meningovasculoparenchymatous) NEUROSYPHILIS may look precisely like PARETIC NEUROSYPHILIS (“general paresis”) at certain periods of clinical and laboratory examination.
Case 17. The police found Gregorian Petrofski crouching on his knees on a Boston sidewalk, attempting to take pickets off a fence. Petrofski knew little English; he said that he had slept in Poland the night before. He did not appear to be alcoholic.
When he was examined, through an interpreter, he told how he had been in America two days, and in Boston two years; that he was at the present time in Poland, and that his brother had brought him to the hospital and left him there.