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A hundred years ago: The diagnosis of general paralysis

By F. W. Mott, M.D., F.R.S., F.R.C.P.,

Physician to Charing Cross Hospital; and Pathologist to the London County Asylums.

Extracted from the January 1908 issue of The Practitioner

By F. W. Mott, M.D., F.R.S., F.R.C.P.,

Physician to Charing Cross Hospital; and Pathologist to the London County Asylums.

Extracted from the January 1908 issue of The Practitioner

A correct diagnosis of general paralysis in its early stages may be of very great importance, for momentous issues may arise, in relation to medico-legal questions, involving criminal responsibility, and testamentary validity. Moreover, social questions, relating to marital responsibilities and duties, professional and business capacity, may necessitate an unqualified opinion as to whether or no a patient is suffering from this fatal disease.

Perhaps the most difficult question of diagnosis obtains in cases of alcoholic pseudo-paralysis. I have seen such cases diagnosed as general paralysis, but, post mortem, none of the characteristic morbid appearances were found.

The reason why these cases are diagnosed as general paralysis is the existence of grandiose delusions of wealth, etc., associated with tremor of the lips and tongue, and perhaps, for a time, the pupils are sluggish to light. There may be some paresis, or even paralysis of the limbs with tenderness on pressure. The grandiose delusions, however, are usually only ascertained by conversation with the patient, unlike the general paralytic, who babbles of his wealth and strength unsolicited. Moreover, there is a tendency for the delusions to pass off when alcohol is withheld.

Polyneuritic psychosis, or Korsakom's syndrome, was formerly, and is sometimes even now, confounded with general paralysis, but it is a totally distinct disease. It is really a chronic form of delirium tremens, affecting mainly women, and is brought about by the effects of a microbial toxin on a chronic alcoholic subject. The symptoms are quite characteristic; there is mental confusion, loss of memory, especially of recent events, loss of orientation in time and space, illusions of personal identity, hallucinations and delusions generally of a terrifying character, or relating to marital or maternal instincts; a frequent delusion is of babies being in the bed, and of hearing the crying of babies, of burglars, thieves and detectives. The knee-jerks are absent, or sometimes exaggerated, there is weakness in the limbs, which may go on to a complete paralysis, wrist drop, and foot drop, and, if the dementia is profound, there is loss of control of the sphincter. The patient may complain of burning pains, and put insane interpretations upon them. There is tenderness on deep pressure, and not infrequently, there is a history of syphilis, or venereal disease. There may be facial paresis, ocular paresis, and sluggishly-acting pupils. Such cases may terminate in a permanent dementia; but I have seen cases, in men and women, who have been admitted to the asylum with the signs of polyneuritic psychosis, which have eventually terminated in true general paralysis.

A far more frequent occurrence is that a patient is admitted with acute mania â potu, but is really a general paralytic, who has taken to drinking heavily. How far are we to decide whether this is a case of alcoholism, or alcoholism in a general paralytic? An instance will show how difficult it is to do so:–

A man was admitted to the asylum, with a history of drink, and, shortly after admission, he had a series of fits; he was quite unconscious, and, for a few days after, he was the subject of delusions and hallucinations. A week later his mind was perfectly clear; he was a potential epileptic, in whom alcohol had induced a series of epileptic fits, followed by a post-epileptic psychosis, from which he recovered. Examination of his pupils, after he had recovered from the fits, revealed none of the signs, which I have previously described, and I was led to diagnose the case as not a general paralytic.

As another instance:–

A man, who had jumped off a tramway car, was admitted to Charing Cross Hospital. He was violently maniacal, threatening to shoot all those around, said he was followed, and persecuted by voices calling him opprobrious names and accusing him of crime.

I saw him a few days later at Hanwell; his pupils were equal, regular and reacted to light and accommodation. I came to the conclusion that it was a case of acute alcoholic hallucinosis, and that he would recover in a short time, although he had been in an asylum not long before. A week later he was perfectly rational without hallucinations or delusions.

Another case, however, turned out quite differently:–

A man, admitted to Hanwell with a history of alcohol, had the delusion that his wife, who was dead, had been taken out of her coffin, and had gone away with another man to America, that he had seen this happen. He also had a delusion that she had visited him while in the asylum. His pupils were unequal, irregular in contour, and sluggish in action to light and remained so. He subsequently developed all the typical signs of general paralysis.

Another case:–

A man was admitted to Colney Hatch Asylum in a state of acute alcoholic mania. He had hallucinations of black devils, which came and perched on his nose, and put stinking things in his nostrils; he was violent, excited, and had to be put in a padded room. A week later, when I saw him, and the effects of the alcohol had passed off, a marked euphoria had taken the place of the terrifying hallucinations. He was a king with millions, and angels now came and moistened his lips with sweet things, and put perfumes into his nostrils.

It is a remarkable fact that the hallucinations and delusions of alcohol are usually of a terrifying character, and refer to black and grey creeping, crawling, horrible insects, rats, spectres of dead persons, policemen, burglars, coffins, etc.

Delusions of infidelity by the husband on the part of the wife, or the converse, are very frequent in chronic alcoholism.

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