"High blood pressure, although usually present, is not essential for the diagnosis of cerebral arteriosclerosis."
In the 49,640 admissions to the New York state hospitals during a period of eight years the 2,318 cases diagnosed as psychoses with arteriosclerosis constituted 4.67 per cent of the total number. In twenty-one hospitals in other states there were 18,336 admissions, of which 492, or 2.68 per cent, were cases of arteriosclerosis. On the other hand, the Massachusetts hospitals show 9.63 per cent of their first admissions during 1919 as arteriosclerotic psychoses. There would appear to be no way to harmonize these dissimilar findings unless it is merely a question of differentiation between the senile psychoses and those due to arteriosclerosis. In a total of 70,987 admissions to all institutions, there were 3,100 cases of arteriosclerotic psychoses, a percentage of 4.36. It is worthy of note that in all of the various groups of institutions the percentage of senile and arteriosclerotic cases combined is practically the same. This would strongly suggest varying standards of diagnosis which will undoubtedly be reconciled in time. It is only recently that any great amount of attention has been given to the psychoses due to arteriosclerosis and it must be confessed that there has been entirely too great a tendency to dismiss without further interest as senile psychoses all mental disturbances occurring in persons of advanced years. On the other hand, the custom of basing a diagnosis of arteriosclerotic psychosis on the mere presence of an increased blood pressure without the existence of any of the other symptoms which characterize that condition indicates, if nothing else, the necessity of a greater uniformity in our methods of diagnostic procedure.
CHAPTER IV
GENERAL PARALYSIS
General paralysis of the insane, general paresis, or dementia paralytica, as it is variously known, from the standpoint of etiology, symptomatology and pathology, is unquestionably the most clearly differentiated and sharply circumscribed of the psychoses at this time. Its history, like its pathology, is inseparable from that of syphilis—a subject of never failing interest and importance, from the time of the first appearance of that word in a poem (Syphilidis, sive morbi Gallici) written by the Italian physician and poet Fracastoro in 1530. Guarinoni referred to epilepsies due to syphilis in the seventeenth century. Frequent allusions are made in the literature of that period to manifestations of the disease in the nervous system. Thomas Willis called attention to the association of paralysis with mental disorders as early as 1672. A form of mania due to syphilis was described by Sanché in 1777. Jelliffe found references in literature to a specific leptomeningitis in 1766 and paraplegias in 1771. Haslam, a pharmacist at the Bethlem Hospital, is said to have given a fairly accurate description of general paresis in 1798. A French writer, A. L. Bayle, is usually spoken of as having clearly differentiated the disease in 1822. The work of Calmeil, "De la Paralysie Consididérée chez les aliénés," in 1826, was, however, the first elaborate monograph ever written on this important psychosis and established its recognition as an entity. Griesinger looked upon it as a combination of different mental conditions. Esquirol is credited with having been the first to describe the speech defect now considered such an important symptom. Baillarger is said to have introduced the term dementia paralytica in 1846.
The etiology of the disease was a subject of controversy for many years. The early writers ascribed it to sexual excesses, masturbation, alcoholism, heredity, overwork, and various other causes. It was looked upon by some as one of the sequelae of syphilis and was described as a "meta syphilitic" disease by Möbius and a "para syphilitic" disorder by Fournier. It was noted by many as occurring only in the more intellectual and highly developed races and was therefore referred to by Krafft-Ebing as a disease of "syphilization and civilization." Both Bayle and Esquirol mentioned syphilis very casually in their writings. Sandras in 1852 spoke of it as one of the principal causes of general paresis. Its etiological importance was, however, first given serious consideration by Esmarch and Jessen, prominent Danish writers, in 1857. Their views were corroborated by Steenberg in 1860 and by Kjellberg in 1863. The theory of an exclusively specific origin was not generally accepted, however, for many years. Rieger published elaborate statistics in 1886 showing that the incidence of general paresis was sixteen or seventeen times as great in syphilitics as it was in healthy persons. The fact that a definite history of infection was not available in many cases led to considerable doubt. Such eminent authorities as Charcot, Binswanger and Déjerine went so far as to deny that there was any relation between the two diseases. That some uncertainty was warranted by the information at hand is shown by the fact that Kraepelin[169] found a history of syphilis in seventy-eight per cent of his cases, while Sprengeler reported 41.5 per cent, Räcke 57.3 per cent, Torkel fifty-one per cent, Marcus seventy-six per cent, Houghberg 86.9 per cent, and Alzheimer over ninety per cent. This is not at all surprising in view of the statement made by Kraepelin[170] that Hirschl could find a definite history of an initial lesion in only thirty-six per cent of his cases of tertiary syphilis. Hudovernig found that 42.3 per cent of the women suffering from syphilis did not know when they were infected. In discussing this subject in 1897 Krafft-Ebing reported the inoculation of nine paretics with syphilitic virus without the appearance of luetic symptoms in any instance, although reinfections have been mentioned by other authorities.
One of the first advances which contributed materially to the ultimate solution of the general paresis problem was the study of the cerebrospinal fluid by Widal, Sicard and others after the introduction of lumbar puncture by Quincke in 1890. This led eventually to discoveries which were of great diagnostic importance. The isolation of the spirochaeta pallidum, now known as the treponema pallidum, by Schaudinn in 1905 settled the question for all time as to the cause of syphilis. The adaptation of the principle of complement fixation, the so-called Bordet-Gengon phenomenon, to the study of syphilitic fluids by Wassermann, Neisser and Bruck in 1906 practically removed all doubt as to the relation between that disease and general paresis. The demonstration of the treponema in the cortex of paretics by Moore and Noguchi in 1913 was practically the only other contribution necessary. They have since been found in the cerebrospinal fluid. Notwithstanding the fact that general paresis must now be looked upon as being a manifestation of syphilis beyond all peradventure of a doubt, it is nevertheless true that we are unable to explain why that disease does not always yield to specific treatment. This is undeniably the case at this time. Just why this should be so cannot be explained in the light of our present knowledge. It is, however, presumably for the same reason that tabes and other diseases of the cord and nervous system, the specific origin of which cannot logically be questioned, are equally resistant to salvarsan and mercury, whatever that reason may be.
As soon as the findings of the Wassermann reaction became evident, renewed efforts on the part of clinicians to find a cure for general paresis naturally followed. One of the first suggested was the Swift-Ellis treatment. This was based on the injection of salvarsanized blood serum into the subdural space of the spinal canal. Results were exceedingly encouraging for a while, but time showed that this was not the solution of the problem. Intravenous salvarsan administration was next tried. This, too, gave excellent results at first. The cases which were apparently cured, however, eventually relapsed sooner or later in almost every instance. The intraspinous use of salvarsan in minute doses has been no more successful than the Swift-Ellis method. Intracranial subdural treatments have been tried and salvarsan has even been injected directly into the lateral ventricles. The logical conclusion is either that the destruction of the nervous tissue has already reached a stage which is beyond repair or that the treatment does not reach the site of the disease.
Clinically we are on much safer ground. In his third edition Krafft-Ebing[171] referred to dementia paralytica as "periencephalomeningitis diffusa," the term originally employed by Calmeil. "Clinically this disease is manifested as a rule as a chronic disease of the brain with vasomotor, psychic, and motor, functional disturbances, progressive in course, with a duration of from two to three years and nearly always a fatal termination."