Chronic alcoholism sometimes pre sents symptoms resembling early general paresis, but the ocular symptoms of the latter are absent. The tremor and epi leptiform attacks and mental manifesta tions are easily mistaken for the same classes of symptoms in general paresis. This is especially the case where the de lusions are of the depressive form. In alcoholic insanity, however, there are more frequently delusions of suspicion, and, in married persons, delusions of infidelity on the part of the spouse, which may lead to criminal acts.
The insomnia, loss of memory, and hypochondriac sensations of neuras thenia may be mistaken for general pare sis. In many cases it is only when the progressive character of the disease is noted that a positive diagnosis can be made. In neurasthenia delusions of grandeur do not occur, and, in place of the sense of well-being expressed by the paretic, the most minute details of physical symptoms are given. Thus, the neurasthenic can usually give an accurate account, with most wearisome details, of his gastric, abdominal, cardiac, or cere bral symptoms. The paretic, if he notices these at all, declares them of no consequence. Neurasthenia may be de fined symptomatically, as a morbid sensi tiveness, while, on the other hand, paresis is an abnormal lack of sensitiveness to morbid impressions.
A subject presenting the symptoms heretofore given, namely: persistent in somnia, with headache, a gradual change in his moral nature, loss of regard for public opinion; peculiarities in the psy chical life, coming on so gradually as not to attract attention until opinions or acts more peculiar than usual are mani fested; delusions, either of persecution, depression, or grandeur; irregular, di lated, or contracted pupils, with absence of the usual reactions to light and sensa tion; the persistence of the accommoda tion-reflex, heightened patellar reflex and attacks of faintness, attacks of uncon sciousness or epileptiform convulsions should be viewed as a beginning case of general paresis. If the usual speech defects characterizing this disease are present, the diagnosis may be regarded as reasonably certain.
In advanced cases of general paresis no difficulty should arise in diagnosis.
Causation.—General paresis — paretic dementia, general paralysis of the insane —is a disease of the middle period of life, rarely beginning before the thirty-fifth and still more rarely after the fiftieth years of life. Cases among children or in old persons are, however, not un known. It attacks by preference persons in the higher walks of life, but among these is found especially in such as have more or less irregular habits. Syphilis is regarded by many authorities as the most prominent single cause, but cases frequently occur in which no evidence of syphilitic infection can be found. Men
tal stress, especially when associated with intemperance, venereal excesses, or other irregular habits are often found as pre cedent conditions and may perhaps be re garded as etiological factors.
The two most important etiological factors in precocious general paresis are heredity and congenital syphilis. J. WMiesworth (Brit. Med. Jour., Mar. 25, '93).
Analysis of two hundred cases in Kratit-Ebing's clinic. Conclusion that syphilis is the chief cause of general paresis. Heredity seemed to be concerned in 11 per cent. of cases. Psychical causes could not be discovered. In 13 cases there was a history of traumatism, in 19 alcoholic excesses. Out of 175 cases with complete histories, 56 per cent. gave a positive history of syphilis, and 25 per cent, a probable history. In seventy eight cases the period from infection to the symptoms of paresis varied from two to twenty-nine years. Hirschl (Wien. klin. Rundschau, No. 45, '95).
In forty-one cases of paretic dementia in children, syphilis could be traced in S7.S per cent. Zappert (Therap. Woch., iv, 289, '97).
Report to the Asylums Committee of the London County Council showing that in many cases of general paralysis there was usually a history of venereal infection, particularly in those cases of the tabetic type in which the dementia in the early stage was very slight. Lewis, of Claybury Asylum, investigated this point, and found that out of a total number of 200 males suffering from all forms of mental disease admitted to Claybury in 1897, 70 had suffered from venereal infection (including both soft and hard sores). Of these 200 cases 24 were general paralytics, and in 16 of them there were certain evidences of in fection, doubtful evidence in 3, and no evidence in 5. Alcoholism was relatively infrequent as a cause. In 10 cases of juvenile general paralysis which Mott saw there were undoubted signs of con genital syphilis (Hutchinson's teeth, linear cicatrices, or interstitial keratitis) in no less than S. Again, he found that atheroma of the aorta was comparatively frequent in general paralysis. Of S6 males dying under forty-six years of age. 24 had atheroma of the aorta; 60 of these cases were general paralytics, of whom 22 had atheroma, or 1 in 3, whereas the proportion was 1 in 13 for the other eases. Of 53 females dying under forty-six, 18 had atheroma; 18 of the cases were general paralytics, and of these 10 had atheroma, or more than half. It must be remembered that emi nent authorities regard syphilis as the most important cause of atheroma of the aorta. Mott (Transactions of Asylums Committee of London County Council, '98).