Slightly more than a third of the cases encountered in his clinic showed the symptom-complex which he describes as syphilitic pseudo-paresis. As a rule these cases are of the simple demented type with a general mental deterioration. The patients show some disturbance of apprehension and attention, tire easily and are quite forgetful and dull. Delirious states may supervene, with clouding, confusion and disorientation, as well as hallucinations of sight and hearing. Memory is markedly impaired and confabulation may be noted. Judgment is not so much interfered with as in paresis. The patients have some insight into their condition and complain of headache, difficulty of thought, etc. Occasional delusions are observed. These may be of a hypochondriacal type or grandiose in character. As a rule the mood is cheerful, but it may be depressed, anxious or fearful, with suicidal tendencies. Sleep is disturbed and there is considerable restlessness, usually at night. With all of these symptoms there are the physical signs of a severe cortical involvement, dizziness, fainting spells, twitchings, seizures or frank convulsions, occasional paralyses, etc. Disturbance of sensation and motion may appear with a perfectly clear consciousness at times. Aphasic symptoms are not uncommon. The eye muscles are affected in many cases, with ptosis, double vision, strabismus, etc. The pupils are usually immobile or sluggish, frequently only one being involved. The field of vision is narrowed and choked disc is common. Speech is affected, as well as writing. All kinds of paralyses occur and they persist for some time. The gait may be spastic or ataxic. The reflexes are usually increased and often different on the two sides. Romberg's sign often appears. A Babinski reflex and ankle clonus may be found. The patients are usually untidy in their habits. Blood pressure is increased in some cases and the pulse slow. There may be variations in temperature. Often there are evidences of old syphilitic processes on the skin surface, enlarged glands, residuals of choroiditis, etc. Usually Kraepelin found a positive Wassermann reaction in the blood, but not in the spinal fluid, which showed a slight cell increase, often from fifteen to twenty per cubic millimeter, rarely in larger numbers. He found the course of the disease rapid, but with occasional remissions. There may be a sudden collapse and death. It usually terminates, however, in a profound dementia, often with a hemiplegia and epileptiform seizures. There are other conditions suggesting general paresis. Marcus, for instance, has described a delirious, confusional state occurring usually in the first year after the infection, sometimes later, but as a rule developing suddenly. The patients become sleepless, confused, anxious and disoriented. Numerous hallucinations appear, both of hearing and vision, usually of a very unpleasant type. The patients often become excited and violent or even suicidal. Physical signs more or less similar to those already described are to be expected. According to Marcus, these cases always respond to syphilitic treatment.
A small group of cases, as pointed out by Westphal, shows excitements strongly simulating the expansive type of general paresis. This form begins ordinarily with a depression, sometimes appearing suddenly, followed by irritability, marked restless excitement, headache, and fainting attacks. Usually there are hallucinations, and delusional ideas of a grandiose type. Above all there are pupillary disturbances, increased or decreased reflexes, seizures, paralyses, etc., strongly resembling paresis. All of these symptoms may disappear under syphilitic treatment in time. Some cases, however, last for years, dying as a rule in a seizure. Kraepelin also describes at some length a group showing the Korsakow complex. He suggests that the fact that this condition usually develops in alcoholics is not without significance.
Kraepelin is of the opinion that the mental picture is the conspicuous and characteristic feature of general paresis standing out more prominently than the physical evidences of the disease. In syphilitic pseudo-paresis, on the other hand, there is a clearer sensorium without such marked disorientation, and memory is not usually so much affected. 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. In these cases the physical signs drop somewhat into the background. There are, nevertheless, stationary cases of general paresis which can be differentiated with great difficulty if at all. The development of pseudo-paresis is slower and more irregular. After a seizure and a paralysis there may be a long remission. The disease, furthermore, does not, like general paresis, always terminate in death.
Kraepelin finds the apoplectiform type of brain syphilis very common. After a few premonitory symptoms such as headache, dizziness, irritability, weakness of memory, etc., a typical apoplexy takes place, leaving a hemiplegia with or without a speech defect. This sometimes occurs without any loss of consciousness. The patient presents the appearance of an ordinary hemiplegic with increased reflexes on one side and ankle clonus followed by a Babinski reflex, etc. Writing is usually affected as well as speech. There may not be another attack for some years. There is, however, a progressive mental deterioration. Occasional confusional states or excitements may be met with. In the meanwhile, numerous physical signs appear, papillary changes, disturbances of the reflexes, ptosis, tremors, hemianopsia, etc. Epileptiform attacks may occur. The blood pressure is usually quite high. There is an increase in the cells in the spinal fluid, often with a negative Wassermann, although the blood serum is positive. Death usually results from a seizure. Three-fourths of Kraepelin's cases developed before the age of forty-five, which, of course, assists materially in the diagnosis.
In younger individuals usually, cerebral syphilis may manifest itself in the form of an epilepsy. Kraepelin is of the opinion that these conditions usually result from endarteritic involvements. In their development they show nothing differing in any way from an ordinary epilepsy. The attacks are usually mild at first, gradually increasing in severity, and are much aggravated by alcohol. There are, however, the usual physical signs of brain lues and later speech defects appear. There is eventually an emotional and intellectual deterioration. The changes in the spinal fluid are those described as characteristic of the other form of syphilis.
Kraepelin describes the paranoid forms as very uncertain in type and not so well defined. Hallucinations and delusions play the principal part with physical disturbances in the background. They become more or less prominent, however, eventually. The patient is usually anxious, restless, suspicious and develops delusions with characteristic ideas of jealousy on a sexual basis. Full-fledged persecutory trends also appear, usually with numerous hallucinations. Occasionally delusions of sin and self-accusation are noted, although ideas of grandeur mixed with complaints of persecution are more common. Consciousness remains undisturbed as a rule and there is no disorientation. The mood is changeable, at times depressed, tearful, anxious, irritable, complaining, but often cheerful and self-satisfied. There is usually more or less emotional dulness, with an indifference to the surroundings. The emotional life is shallow and superficial. Sudden excitements may occur at times with outbursts of anger. There are usually no striking conduct disorders. There may be occasional seizures of a mild form, fainting attacks, dizziness, rarely epileptiform attacks or slight apoplectiform symptoms. Sooner or later the physical signs of brain syphilis develop. The course of the disease is slow. Similar pictures are noted in tabes. The therapeutic test is not to be relied upon too strongly in making a diagnosis or differentiating between paresis and syphilis. It must be remembered that after all we are dealing here with one disease process. It has been found that in many syphilitics, even in recent cases, a positive Wassermann reaction, an increase in the cell count or in the protein content may occasionally be demonstrated in the spinal fluid.
In a study of 428 cases of neurosyphilis treated in Boston, Raeder[187] reported that 129, or practically thirty per cent, showed definite improvement, both physical and mental. He did not make any extravagant claims as to final results to be expected. "The therapia praesens of neurosyphilis is but a transition state in rational syphilography. Medical science has discovered several good clues which must be followed up; and others ferreted out and run down before the solution of the problem is complete. Indeed the successful treatment of paresis and tabes, as well as general vascular syphilis and visceral tertiaries, such as the crippling cradio-pathia, etc., may ultimately be realized in the field of preventive medicine. With chemotherapy, however, Ehrlich has doubtless found the most vulnerable approach to the treponemiatic diseases, but further research is necessary and other combinations must be found before the life of this anthropophagus pest is successfully snuffed out."
Warthin[188] at autopsy found evidences of active syphilis in a series of forty-one inactive or "cured" cases investigated by him. Eleven of these had been treated, were supposed to have recovered and showed no syphilitic manifestations at the time of death. Five had received an extended course of salvarsan therapy and in twenty-five there was no history of syphilis at all. Spirochaetes were demonstrated by the Levaditi method in thirty-six of the forty-one cases—in the aorta in thirty-two, in the testes in thirty-one, in the liver in four, in the adrenals in six, in the pancreas in six, in the spleen in one and in the nervous system in five. In some of these cases the Wassermann reaction was reported as negative. Warthin concluded that cured syphilis in many if not all instances is in a latent condition, spirochaetes of a low virulence still remaining active.
For purposes of statistical study the American Psychiatric Association has not attempted any clinical differentiation of the various types of this disease, a procedure which was felt to be inadvisable at this time. The following suggestions appear in the manual as to the classification of psychoses due to cerebral syphilis:—
"Since general paralysis itself is now known to be a parenchymatous form of brain syphilis, the differentiation of the cerebral syphilis cases might on theoretical grounds be regarded as less important than formerly. Practically, however, the separation of the non-parenchymatous forms is very important because the symptoms, the course and therapeutic outlook in most of these cases are different from those of general paralysis.