The Early Diagnosis of Paresis.’

THE EARLY DIAGNOSIS OF PARESIS.’ B F. X. DERCUM, M. D., Professor of Nervous and Mental Diseases, Jejferson Medical College, Philadelphia. It is with much hesitation that I attempt to discuss so difficult a subject as the early recognition of paresis, for here we are confronted with borderland conditions and overlapping states. I know of no subject which is so important and no subject con- cerning which error is more frequently made both on account of the gradual invasion and also because of the generalized character of the symptoms. The recognition of the disease in its early stage is especially difficult because, in the average case, general disturbances for a long time precede the appearance of special symptoms indicative of organic change. In cases in which a satisfactory and detailed history of the very early period can be obtained, we usually receive an account of general ill-health, an ill-health evidenced both by complaints on the part of the patient, as well as by the observations of his friends. As a rule, we find that the patient has not been well for some time,-usually months. If during this preliminary period of ill-health, the patient visit his physician, the case is not infre- quently mistaken for one of neurasthenia, and yet when the symptoms presented are closely analyzed, it is found that they resemble those of neurasthenia only superficially. It is true we have quite commonly the symptom of ready fatigue and in addi- tion inability to maintain the attention for any length of time Upon affairs of business or other every-day matters. Notwith- standing, the typical fatigue syndrome of neurasthenia is want- ing, as an analysis of the early symptoms will show. The friends of the patient often maintain that his appearance and manner Read before the Medical Society of the State of New York, at Albany, January 28, 1902. 576 THE EARLY DIAGNOSIS OF PARESIS [April have changed, that he no longer attends to his business as carefully or no longer does his work as well as formerly. He may look somewhat tired or perhaps a little sleepy. At times he is pale and at times, again, his face may be unusually flushed; it often lacks its former vigor of expression. His attitude, his movements, his walk may suggest general loss of tone. Some- times he is troubled with various vague distressing sensations about the head, such as fulness, pressure or constriction, or again he may complain of ringing in the ears, sparks before the eyes, and muscae volitantes. Attacks of giddiness and vertigo may also occur and some patients suffer from a dazed or stunned feeling in the head. Occasionally there are rheumatoid pains referred to the arms, legs and to the back of the neck or trunk. More often, when pain is present, it assumes a distinctly tabetic character, is lightning-like and darting, or now and then may suggest neuralgia. Pain in the head of great severity and simu- lating migraine is not very infrequent. At times the headache is referred to the supraorbital and adjacent regions and especi- afly to the eye-ball of one side, the attack then suggesting oph- thalmic migraine. In the neurasthenic patient, the symptoms are almost exclu- sively subjective. He begins by describing to us how he feels, and complains actively of various symptoms. He tells us that he is nervous, is easily excited and upset, that he gets very tired at his work, that his head aches, his heart palpitates, that he has indigestion, that his bowels are constipated. He complains of various diffuse aches or pains which suggest the sensations of simple or exaggerated fatigue. He suffers from occipital headache, from backache, from aching in the limbs and perhaps tend- erness over the spine. He presents also quite characteristic signs of atony of digestion or of gastric catarrh and constipation; and very commonly with a history of palpitation of the heart is associated that of coldness and dampness of the extremities. While there are some superficial resemblances between the symptoms which he details and those found in the early begin.- ning of paresis, we cannot help but note certain striking differ- ences. First, the patient in the early beginning of paresis, if he appears before the physician at all, is generally brought by friends or relatives. Rarely does he come of his own mi- 1902] F. X. DERCUM 577 tiative. Secondly, it is the friends or relatives who detail the symptoms. They give an account of changes which they have noted in the patient and of which he himself may not be cogni- zant or to which he has paid no attention. The signs of ill- health are first observed by those about him, notby the patient himself, who, as a rule, does not actively complain, unless there are present tabetic or neuralgic pains or attacks of the migraine- like headache. His conduct is in marked contrast to that of the neurasthenic patient, who not only seeks the physician’s advice himself, but also has at his tongue’s end a long list of complaints with which we are all very familiar. Frequently he comes with memoranda written upon small pieces of paper. Further, the physical appearance of the neurasthenic is rarely changed, or in any case, is not altered in the same manner as is the appearance of the paretic. He may be pale, perhaps, or a trifle thin, but certainly he is not somnolent and his features lack none of their accustomed force. Often the anxiety with re- gard to his condition causes an accentuation of the facial lines; certainly never an effacement of folds and wrinkles; his face may have an anxious or a worried look, but there is no change of quality in its expression. It is still the same face to friends or relatives. It has not become altered so as to suggest that the patient is a changed man. The friends are never the ones to first discover that the patient is ill and indeed frequently listen to his compl.arnts with impatience and incredulity. No one has noted marked change either in his appearance or manner. Least of all does anyone tell us that the patient attends to his business less carefully or less well than formerly. Further, when we analyze the symptoms which are detailed by the neurasthenic, we find that they are those of chronic fatigue, of occipital headache, of backache, of limbache. There is no account of darting or lightning-like pains. The headache is quite characteristic and there is no occurrence of one or two attacks of terrible neuralgia or migraine-like headache so often met with in the early paretic. Again, the motor phenomena of neurasthenia are those of simple weakness and ready fatigue. There is never a loss of precision in movement, never a loss of accuracy of coordination. It is not observed, for instance, in the neurasthenic mechanic, that his work is done less accurately or in the neurasthenic clerk or book- 578 THE EARLY DIAGNOSIS OF PARESIS [April keeper that his hand-writing is changed. In the mechanic in the early stage of paresis, inaccuracy and change in the quality of his work are among the first symptoms observed. Further, the deterioration is observed not by himself, but by those about him. The sleep disturbances of neurasthenia are radically different from those of paresis. The neurasthenic on going to bed as a rule falls asleep readily, but is disturbed at intervals during the night or awakens early in the morning and leaves his bed in an exhausted and depressed condition. After he has taken food, and as the day progresses, his condition steadily improves until the evening, when he is in a relatively good condition. By this time his fatigue symptoms have largely disappeared and many a neurasthenic patient in the evening is in such good condition that he himself will declare that he is no longer ill. In paresis, in the early stage, the opposite condition, as a rule, obtains. Though the patient may suffer from insomnia, dreams or disturbed sleep, he is usually at his best in the morning, but as the day progresses, becomes more and more drowsy until toward evening somnolence may be very marked. Vague and sug- gestive symptoms, absent in the morning, may be present in the evening and be so pronounced as to attract the attention of those about him. The speech which may have been clear in the morning, may be distinctly thick and blurred in the evening. The face, which has had a relatively normal expression in the morning, may be dull and heavy in the evening; the gait and the ges- tures may be cumbrous and awkward. Slight disarrangement of the clothing, indifference to the niceties and proprieties, un- wonted profanity, coarseness and irritability may also be noted at this time. The neurasthenic is not only at his best in the evening, but qualitative mental changes are at no time present; in the paretic, on the other hand, qualitative mental changes, although possibly in very slight degree, are noticeable almost at the outset. The mental phenomena of the neurasthenic are essentially quantita- tive. We have first a marked and characteristic symptom in the diminution of the capacity for intellectual effort. The attempt to do mental work sooner or later brings on symptoms of ex- haustion. The task may be properly begun, but soon the patient 1902] F. X. DERCUM 579 experiences difficulty in keeping the attention upon it and if the attempt be persisted in, painful sensations about the head arise, such as a feeling of constriction, headache and giddiness.

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