Progressive paralysis and syphilis of the brain. Mental disorders in syphilis. Mental disorders in brain syphilis. Forensic psychiatric assessment

A syphilitic infection can lead to severe brain damage many years after infection. There are early forms of the lesion - syphilis of the brain and later - progressive paralysis.

Progressive paralysis

Manifestations of this disease begin 10-15 years from the moment of infection. The clinical picture unfolds in three stages.

First stage progressive paralysis is called pseudoneurasthenic, since the patients’ complaints resemble neurotic symptoms. Patients report persistent and frequent headaches, weakened memory, decreased performance, and irritability. They sometimes commit unethical acts that contradict their upbringing. The first neurological symptoms appear, dysarthria occurs. Serological and immunological reactions turn out to be positive. The first stage of progressive paralysis lasts about a year.

Second stage progressive paralysis (the stage of developed signs of the disease) is determined by the leading psychopathological syndrome. Most common expansive(manic) form. Delusions of grandeur, absurd in content, disinhibition of drives, and cynicism are observed.

Depressed a form of progressive paralysis characterized by sharp decline mood, ideas of self-blame, fear of impending death, an abundance of hypochondriacal complaints, reaching the scale of Cotard’s nihilistic delirium (the assertion that the entire body has rotted).

Agitated - form of the disease is manifested by severe psychomotor agitation. Patients sing, scream, dance, suddenly aggressively attack others, tear their clothes; They throw food around and swear cynically.

At demented form, along with a weakening of intellectual capabilities, patients experience absurd and cynical forms of behavior, the sense of distance disappears when communicating with others; they are annoying in their requests, unceremonious with people of any age and social status.

Usually the pathological process is localized in frontal lobes brain If other parts are also affected, there may be additional symptoms : aphasia, agnosia, apraxia, incoordination.

Progressive paralysis can begin (if infected through domestic contact) at 12-15 years of age. This form of the disease is called youthful; It proceeds like dementia, but is characterized by a malignant course, leading to profound dementia within one year.

Third stage various forms of progressive paralysis manifest themselves in the same way and are called the stage of physical and mental insanity. Dystrophy progresses rapidly, non-healing trophic ulcers form. Mental regulation of behavior becomes impossible.

Syphilis of the brain

Develops 5-10 years after infection. It affects the vessels of the brain, accompanied by repeated hemorrhages in the brain with an increase in dementia, or proceeds with the formation of syphilitic gummas in the brain. Patients experience frequent headaches, disorders of consciousness such as stupor or twilight states, psychosensory disorders, delusions and hallucinations; Paralysis, paresis, speech, hearing, and vision disorders may occur, and epileptiform seizures may occur.

Depending on the prevailing symptoms, the following forms of brain syphilis are distinguished:: neurasthenic, apoplectiform, epileptiform, syphilitic hallucinosis and hallucinatory-paranoid.

Treatment mental disorders due to syphilis must begin with the prescription of antisyphilitic drugs - bijoquinol, novarsenol, miarsenol, sodium iodide ; antibiotics - penicillin, rifampicin.

See mental disorders in infectious and somatic diseases

Saenko I. A.

Sources:

1. Bortnikova S. M., Zubakhina T. V. Nervous and mental illnesses. Series "Medicine for you". Rostov n/d: Phoenix, 2000.
2. Directory nurse care/N. I. Belova, B. A. Berenbein, D. A. Velikoretsky and others; Ed. N. R. Paleeva. - M.: Medicine, 1989.
3. Kirpichenko A. A. Psychiatry: Textbook. for honey Inst. - 2nd ed., revised. and additional - Mn.: Higher. school, 1989.

Cerebral syphilis in children is predominantly a congenital disease. Acquired syphilis is very rare, mainly due to non-sexual transmission - the so-called “household syphilis”.

It should be pointed out that the number of patients with cerebral syphilis in the USSR has decreased significantly over the past two decades and this disease is very rare in children.

The presentation of the clinical picture of mental disorders in congenital syphilis is somewhat simplified by the fact that here we are talking about a disease with a clear etiology. The basis of all mental disorders in cerebral syphilis is the same reason - infection with a pale spirochete. It is controversial whether there are special types spirochetes in cerebral syphilis and progressive paralysis, resolved. It has been established that there are no specific spirochetes for individual forms of neurosyphilis, and the various morphological types represent only different biological stages of development or degenerative forms of the same spirochete (M. S. Margulis).

Data establishing the unity of the cause of all syphilitic diseases of the central nervous system, undoubtedly, facilitate both the study of the clinical picture of this disease and the implementation of therapeutic measures. However, the presentation of the clinic of this disease presents some difficulties, which is explained by the extreme polymorphism of the clinical and anatomical picture, determined by the diversity of the morphological substrate (vascular, inflammatory, granulomatous changes). Mesodermal forms of neurosyphilis include syphilitic diseases of the membranes, vascular lesions and gummous forms, ectodermal forms include progressive paralysis, tabes dorsalis and some other forms of syphilis of the spinal cord.

In pediatric practice, where we are dealing with congenital syphilis, the grouping is further complicated by the fact that pathological changes are often presented in the form of a delay in development

development and deformities of individual parts of the central nervous system (incorrectly located cells, heterotopias, multinucleated Purkinje cells).

The age-related characteristics of the child’s brain also matter. Thus, M. S. Margulis believes that with congenital syphilis in children, the pathological process proceeds according to the type general infection, internal organs and the central nervous system are overrun with spirochetes. The tissue reaction is predominantly proliferative in nature - most often it is a diffuse mesenchymal reaction, in contrast to adults, in whom focal proliferative phenomena are predominantly observed.

The next points that determine the diversity of the clinical picture of congenital syphilis are the features of the localization and prevalence of the lesion. But here it is necessary to emphasize that the correct determination of the topic of the lesion is possible only on the basis of a careful study of the features of cortical dynamics, because with any local lesion the activity of the cortex as a whole is disrupted.

Circulatory disorders (hemo- and hydrodynamic) also play an important role, as well as toxic effect, associated with the decay of spirochetes and changes in metabolism in the body.

Especially great importance This last (toxic) moment has for congenital syphilis, since, in addition to the direct influence of spirochetes penetrating the placenta, the toxins of the infected mother’s body also act on the fetus, changing the metabolism of the fetus and causing malformations of its development. In such cases, one cannot talk about syphilis infection in the real sense of the word; these are dystrophic forms, what is usually referred to as “dystrophic syphilis.” Syphilitic toxins can affect not only the formed fetus, but also the germ - the germ cells of the parents. Then they talk about damage to the rudiment.

The variety of clinical and anatomical pictures depends on the stage of the process, intensity, rate of its development and duration of the course.

And finally, the last thing to keep in mind is the characteristics of the soil, the general and local reactivity of the nervous system and the whole organism. But first of all, the features of cortical reactivity must be taken into account. The latter is not constant and undergoes changes during the course of the disease with neurosyphilis.

Thus, we see what a large number of factors determine the clinical picture of the mental disorders that we encounter with congenital syphilis, and how difficult it is to present the existing variety of clinical forms in the form of any diagram. This explains the current lack of a unified classification of mental disorders in cerebral syphilis.

The only generally accepted division is into early forms, syphilis of the brain in the real sense of the word, and later - progressive paralysis and tabes. There is also no specific grouping for clinical manifestations of cerebral syphilis. Most psychiatry manuals distinguish the following forms: syphilitic neurasthenia, syphilitic meningitis, gumma, pseudoparalytic form, apoplectiform syphilis, epileptiform, paranoid and hallucinatory forms. M. O. Gurevich and N. I. Ozeretsky also accept this grouping for children’s forms.

Regarding congenital syphilis, there is a slightly different classification (into two groups). The first group includes gross symptoms of cerebral and spinal disorders and manifestations of mental insufficiency of varying degrees, which is given the name of a true syphilitic brain process. The second group with predominant disorders of the intellectual and emotional-volitional sphere as a result of more subtle trophic changes in tissues and disruption of their development by syphilitic toxin is classified as general lesions of the rudiment. M. O. Gurevich, in his work on congenital syphilis in children, distinguishes two forms: 1) progressive, fitting into the group adopted for adults, where he includes pseudoparalytic dementia, epileptiform syphilis, apoplectiform syphilis, etc.; 2) stationary (residual and associated with damage to the rudiment).

In our practice, we also divided congenital syphilis in children into progressive and stationary forms. This grouping seems to us the most correct, since it best reflects the complex interaction of two factors - the infectious agent and the reactivity of the organism.

In this lecture we will talk mainly about progressive forms of congenital syphilis. Let's start with a clinical example of cerebral syphilis with mild symptoms, which is of interest for the problem of early diagnosis.

Boy 11 years old. He was admitted to the clinic with complaints of paroxysmal headaches, increased fatigue, irritability, tendency to cry. The family has a caring attitude towards the boy. ABOUT early development he knows the following: the mother had a difficult pregnancy

(suffered from pneumonia), urgent, long labor with forceps; the mother does not remember whether there was asphyxia; the child was artificially fed. Early physical development is normal. IN infancy suffered from dysentery chicken pox, at 4 years old - measles. The illnesses were easy.

In infancy it was noted restless sleep. Mental development correct. By nature he is a sociable, affectionate, somewhat cowardly, impressionable, irritable child. I was healthy until I was 7 years old. From the age of 7 he began to complain of pain in knee joints. Surgeons suspected tuberculosis, but the diagnosis was not definitively established. The boy received spa treatment three times, but without effect. The patient was lagging behind in physical development. Despite good care, he was always pale, weak, and easily tired. At the age of approximately 10 years, paroxysmal headaches appeared, accompanied by fever, photophobia, general weakness, lack of appetite. The duration of attacks is from 3 to 10 days. At the same time, changes in character and decreased ability to work began to be noted. The boy became more irritable, whiny, and restless; During classes he often complained of increased fatigue. With these complaints he was admitted to the clinic.

The face is meaningful and expressive. The speech is correct. The vocabulary is normal for this age. The boy willingly enters into conversation and discovers a sufficient supply of information. Oriented to his surroundings. Memory for words and numbers is satisfactory, retention of what was learned in the past is weaker. The patient is conscious of his illness. He stayed in the clinic willingly, quickly got used to the environment, and obeyed all the rules of the regime. The outer covers are pale, with a slight yellowness; the subcutaneous fat layer is poorly developed, the nails are thin, brittle, The lymph nodes increased. There are no deviations from the norm from the internal organs. The neurological status shows unevenness of the pupils - the left one is wider; reaction to light is sluggish; slight asymmetry in innervation facial nerve, increased tendon reflexes, mild Kernig's sign on both sides; autonomic syndrome sharply expressed. The fundus is normal. Serological blood tests give a positive Wasserman reaction. The Sachs-Georgi reaction is positive, Kahn's is weakly positive. In the cerebrospinal fluid, protein is 0.33‰, cytosis is 43/3; positive reactions of Pandi and Nonne-Apelt, weak positive reaction Wasserman. Anamnestic data indicate that the father suffered from syphilis shortly before the birth of the child. The mother has a sluggish reaction of the pupils to light, tearfulness, and headaches.

Diagnosis of this disease as a syphilitic lesion of the central nervous system is not difficult. The clinical picture is dominated by a neurasthenic syndrome: decreased performance, increased irritability, tearfulness, headaches, dizziness, and easy fatigue. According to the above classification, we can talk about syphilitic neurasthenia. According to D. A. Eingorn (material children's department Hospital named after Kashchenko), neurasthenic syndrome is often a prodrome to a subsequent, more severe illness or, conversely, an echo of former severe disorders.

This neurasthenic syndrome is based on progressive syphilitic brain process. Judging by the symptoms (paroxysmal headaches with fever, Kernig's sign, cerebrospinal fluid data), it can be assumed that the boy has light form syphilitic lesion of the meninges.

Syphilitic meningitis and meningo-encephalitis are one of the most common forms manifestations of congenital syphilis in children. They usually start early childhood and occur with a more pronounced picture. Symptoms of syphilitic meningitis are as follows: headaches, dizziness, vomiting, stiff neck, slow pulse, Kernig's sign, and sometimes epileptiform seizures. Usually all these phenomena occur with increased temperature, but in some cases the temperature remains normal.

When examining the fundus, a stagnant nipple is detected. Neurological symptoms vary. The most frequently observed phenomena are related to the cranial nerves, which is explained by the predominant localization of the lesion at the base of the brain. In more severe cases, paresis and paralysis are observed.

From mental symptoms syphilitic meningitis the most common are: stupor, lethargy, sometimes delirious state; in young children there is a “causeless” cry (M.B. Zucker). In more sluggish forms of the process, encephalo-asthenic syndrome predominates.

Cases of syphilitic meningitis respond well to specific therapy, so it is important to recognize the disease in a timely manner. The diagnosis is greatly facilitated by serological tests of blood and cerebrospinal fluid, which in these cases usually reveal pleocytosis, elevated protein, and a positive Wasserman reaction.

In more severe and especially untreated cases, syphilitic meningitis and meningo-encephalitis can leave severe consequences in the form of paralysis, epileptiform seizures, and the development of the child may also be delayed. One of the severe consequences of syphilitic meningitis is syphilitic hydrocephalus. Here is a description of the medical history of a girl suffering from a severe form of syphilitic brain disease.

Girl 13 years old. Complaints of seizures that appeared 2 years ago. At the beginning they were rare, then they became more frequent - four times a month. Seizures occur mainly at night; they begin with muttering in sleep, spasms of the oral muscles, tonic spasms of the limbs, loss of consciousness and involuntary urination. The duration of the attack is from 5 to 15 minutes, followed by amnesia and sleep. Anamnesis data indicate that the father and mother suffered from syphilis several years before the birth of the child. The mother had 16 pregnancies and three healthy children were born before contracting syphilis. Of the remaining children, five died in early childhood from unknown causes; one miscarriage, the rest abortions.

Our patient is in her sixth pregnancy. During pregnancy, the mother received antisyphilitic treatment. The girl was born at term and breastfed until she was one and a half years old. Physical development was delayed:

She began to walk and talk by the age of 4. A weak child from birth, strabismus and weakness of the right limbs were already noted in early childhood. Among the illnesses she suffered were measles and pneumonia. She developed poorly mentally and could not learn to read and write. At the age of 11 years, convulsive seizures began.

A girl of irregular physique; the skull is irregularly shaped - high, asymmetrical; the face is also asymmetrical; the palate is high, narrow, vaulted; the teeth are irregularly shaped, widely spaced, and the incisors have faintly defined semilunar notches (Hutchinsonian teeth). The chest is irregular in shape, there is scoliosis and lumbar lordosis. The skin is pale, with yellowness. Lymph nodes are enlarged. Thyroid not palpable. There are no deviations from the norm from the internal organs. Neurological status: pronounced anisocoria, the left pupil is larger than the right, divergent strabismus, nystagmoid movements, spontaneous and sharp at extreme positions of the eyeballs; Convergence paralysis. When researching upper limbs there is a slight restriction of movements on the right, muscle strength is reduced on the right. Tendon reflexes are increased, more on the right; Babinski's sign on the right.

There is no light reaction of the pupils on the left, and very sluggish on the right. Examination of the fundus revealed specific chorioretinitis. The Wasserman reaction in the blood is positive. Examination of the cerebrospinal fluid showed no deviations from the norm. The Wasserman reaction in liquid is negative. The girl has obvious signs of mental retardation: she does not distinguish between a pencil and a pen, and cannot even count within five (2+2=3). Her behavior in the clinic is monotonous: she is friends with small children, treats older children kindly, obeys the regime, is always passive, inactive. At first I was somewhat euphoric and persistently asked the same question. Epileptic seizures in the clinic occur once every 2-3 days. The specific therapy carried out did not produce results.

The diagnosis of congenital syphilis of the brain in this case is undoubted. The girl was born with residual symptoms of early intrauterine syphilitic brain disease. This explains the delay and disproportion of its development, dementia of the type of oligophrenia. The appearance of epileptic seizures coincides with an exacerbation of the process in prepubertal age. Cases such as this are sometimes incorrectly interpreted as lesions of the bud, based on the dysplasticity of these patients. The prognosis for this sick girl is significantly worse than that of the previous patient. Specific therapy in such cases is ineffective. Differential diagnosis of syphilitic oligophrenia with other forms of congenital dementia in the absence of positive serological data is difficult, therefore we will dwell in more detail on the criteria for diagnosing congenital cerebral syphilis in children.

Somatic signs. Newborn children have a runny nose with purulent and bloody discharge, cracked lips, wrinkled skin with a dirty gray tint, hair and eyebrow loss, enlarged liver and spleen. Especially characteristic as a symptom of congenital syphilis is the Hutchinsonian triad: a) semilunar notches on the upper

Hutchinson's teeth in the incisors, b) keratitis (parenchymatous), c) otitis. Various deformations of the skull are also important (lumpy, oblique, saddle-shaped, tower-shaped, etc.); deformation of the nasal bones (saddle nose). However, the diagnostic value of these signs cannot be overestimated. Most of them, taken individually, are not pathognomonic for syphilis. What is important is their combination in the same patient. Their absence also does not speak against syphilitic lesions.

The second criterion for diagnosing syphilitic brain damage is serological data. In addition to the positive Wasserman reaction in the blood and cerebrospinal fluid, positive protein reactions in the cerebrospinal fluid, an increase in the number of formed elements (pleocytosis), and increased amount squirrel. But negative serological and globulin reactions, especially in long-standing diseases, do not contradict the diagnosis of congenital syphilis of the brain.

Among our patients, a positive Wasserman reaction in the blood for congenital syphilis of the brain was present in 66%. It is believed that normally in children the amount of protein in the cerebrospinal fluid ranges from 0.016 to 0.024%. The number of cells can in rare cases be higher than in adults, for which the maximum is 8/3. However, these higher numbers (9/3 - 10/3) only occur in children under 6 years of age. The Nonne-Apelt and Weichbrodt reactions in normal cerebrospinal fluid are always negative; the Pandi reaction can be positive in 5% of cases.

The next series of signs that serve for the differential diagnosis of oligophrenia and congenital syphilis of the brain are found in neurological symptoms, which are extremely polymorphic. We encounter damage to the cranial nerves, hemi- and paraparesis, but especially characteristic are changes in the pupils, their shape, weakening or absence of light reaction. Changes in the fundus of the eye are frequent; paleness of the nipples, sometimes pronounced atrophic phenomena, chorioretinitis, etc.

Of the mental symptoms, we cannot name those specific to congenital syphilis. In differential diagnosis with congenital dementia of another etiology, syphilis of the brain is indicated by severe memory impairment, attention disorder, greater exhaustion, and a more pronounced impairment of performance with a relatively intact ability to judge. The presence of limited phenomena of loss (agnostic, aphasic and apractical disorders), passivity, adynamia, euphoria, weakness, impaired focus are often signs of syphilitic dementia rather than mental retardation. But

It should be noted that all these symptoms lose their significance with a deep degree of dementia. Early syphilitic lesions of the brain (especially intrauterine) usually lead to phenomena of mental underdevelopment.

Epileptic seizures are one of the common symptoms in the clinic of congenital syphilis of the brain in children. On this basis, a special type of epileptiform syphilis has been identified. However, the question of the pathogenesis of syphilitic epilepsy has not yet been finally resolved. Many authors believe that the basis of the pathogenesis of these forms is syphilitic endarteritis of small vessels of the brain.

In children, syphilitic epilepsy of a double type is observed: in one group of cases, an epileptic seizure is only a symptom in clinical picture, characteristic of syphilis of the brain. In relation to such patients, it is more correct to talk not about syphilitic epilepsy, but about epileptiform syndrome in cerebral syphilis. But there are forms in which epileptic seizures and epileptic changes in the psyche are the main part of the disease picture. In such cases, it must be assumed that the specific agent caused changes in the brain that favor the development of a new disease process similar to an epileptic disease. Specific therapy in these patients is often ineffective.

As a clinical example, we describe the following observation.

Boy 11 years old. Poor academic performance, behavioral difficulties and epileptic seizures are noted. The mother suffers from syphilis and is whiny and irritable by nature; a year ago she had visual hallucinations and seizures of unknown origin after unpleasant experiences. The boy's father is in a psychiatric hospital; he has rare epileptic seizures.

The boy was born from the first pregnancy; full term birth; asphyxia. Early physical development is correct; up to one year, a calm, lethargic, indifferent child. At 9 months of age, after suffering from measles, the boy had his first seizure; Since then the seizures have been recurring. In preschool and school age, he is annoying, hot-tempered, touchy, and angry. He has been studying at school since he was 7 years old. His academic performance was poor: he spent 3 years in the first grade of a public school, then was transferred to an auxiliary school. Reads poorly; cannot do work that requires intelligence. Accurate, efficient, thrifty. Behavioral difficulties at school are explained by his motor restlessness and affective outbursts. Among the illnesses he suffered were whooping cough (in a mild form), chicken pox, and scarlet fever. During his month-long stay at the clinic, the boy developed behavioral difficulties. He is rude, excitable, prone to affective outbursts, sometimes lethargic and gloomy. He is quarrelsome with children, at the slightest misunderstanding he begins to scream loudly, throws chairs, and does not calm down for a long time. At school he works concentratedly, carefully, and the pace of work is slow. New material learns with difficulty.

In this case, there is also a reason (anamnestic data - syphilis in the mother, the presence of neurological changes -

opinions - pupillary reactions, anisoreflexia) suggest syphilitic brain damage. However, in this case, unlike the previous one, we can assume that on the basis of the transferred syphilitic brain process, the development of an epileptic disease occurs with certain patterns of clinical manifestations and course.

This assumption is confirmed by the presence of mental changes characteristic of epilepsy: viscous affect with a tendency to outbursts, anger, importunity, pedantry. The patient’s intellectual activity is undoubtedly disturbed, but rather of an epileptic type. He works with concentration, accuracy, and is capable of prolonged exertion; the pace of work is slow, while patients suffering from a progressive form of cerebral syphilis are characterized by rapid exhaustion, fatigue, and inability to exert themselves for long periods of time. In such cases, we also use specific therapy, but combine it with systematic treatment with antiepileptic drugs.

To complete the description of the various forms of congenital syphilis of the brain, we present two more clinical examples, of which the first represents one of the most common psychopathological forms of congenital syphilis in children, and the second is relatively rare.

1. A 15-year-old girl whom we observed for the first time 8 years ago. Her father suffers from progressive paralysis, and her sister and brother have epileptic seizures. The patient’s physical development was timely, with the exception of speech, which developed very slowly. Already at the age of 4 years, the girl was loud, restless, cruel, angry and affective; at the age of 6 she began to disappear from home for the whole day; on country trains she begged, stole things from the house, built fires anywhere, tortured animals, beat children, who ran away when she appeared.

When examined at the clinic, the girl was found to have the following: infantile, dysplastic, senile face, hoarse voice. Anisocoria and sluggish pupillary response to light; Convergence paresis. A study of blood and fluid for the Wasserman reaction gave positive result. During observation in the clinic, severe motor restlessness was noted, she commits unexpected actions, is impulsive, and emotionally dull. She is quarrelsome with children, pugnacious, does not show affection to anyone, is aggressive, and deceitful. Systematic treatment did not produce results. The patient was discharged from the clinic without improvement.

Follow-up data over the past years show that the girl’s behavior continues to deteriorate. Despite all the efforts of the mother, the girl has not adapted socially, still often runs away from home, does not attend school (starts arson, breaks windows, is sharply impulsive, greedy).

The clinical picture in this patient is similar to that encountered with chronic forms epidemic encephalitis. Patients experience disinhibition of drives and a pathological passion for arson and vagrancy. Such patients, like those suffering from epidemic encephalitis, are not amenable to pedagogical influence; they have no feelings

They have no fear, no sense of responsibility, they are not attached to anyone, they are not interested in anything for a long time.

Diagnosis of congenital syphilis in our case is established on the basis of anamnesis, neurological examination of the patient and serological data. In the absence of a positive Wasserman reaction, differential diagnosis of such cases with psychopathy and mental consequences of epidemic encephalitis is very difficult.

The second patient has a form of syphilitic brain disease that is rare in children and somewhat more common in adolescents and is sometimes incorrectly diagnosed as schizophrenia.

2. Boy 12 years old. Over the last 3-4 months, he has been getting tired of schoolwork more quickly, is in a depressed mood, is whiny, does not want to go out, is touchy, irritable, is at times inhibited, has auditory hallucinations, hears a man’s voice of an imperative nature: “go for a walk.” He talks to himself, to his shadow.

According to the anamnesis, it is known that the boy’s father suffered from syphilis before his birth, his mother suffers from headaches; she had two miscarriages. My paternal aunt was mentally ill. The boy grew up sickly; in childhood he had some rashes. In the period from 3 months to a year, convulsive seizures were noted two to three times a week. In infancy he was loud and slept little. He didn’t speak until he was 3 years old; he grew up whiny, withdrawn, passive, and indecisive.

The patient is accessible, willingly talks about himself, considers himself sick. 3-4 months ago he began to hear “rumors”, voices ordering him to go somewhere, close to his ear - a whisper, a male voice. He treats this as a painful phenomenon, critically, and is always aware that it only “seems” to him. Denies visual hallucinations. Believes that he has become more irritable lately. He often finds it difficult to do his homework.

From the very first days of his stay in the clinic, the boy suffered from irritable weakness syndrome. During school hours, he constantly spins in his chair, looks around, works fussily, with tension. In his free time from classes, he cannot do anything on his own initiative. Affective, angry outbursts easily occur, but calms down quickly. Very suggestible, easily influenced by other children. In school classes, there is an inability to distinguish the essential from the unimportant; attention is unstable and easily distracted. Attention span is narrow, memory is reduced. Associations are poor and monotonous. Concrete thinking, the processes of definition and generalization are difficult. Quickly becomes exhausted in work. The patient’s physical condition shows an abnormal physique, an asymmetrical skull, asymmetrical ears, enlarged lymph nodes, and traces of keratitis on the left eye. No deviations from the norm were found in the internal organs. A neurological examination reveals anisocoria, weakened light reaction, especially on the right, weakening of the facial nerve on the left, hyperkinesis, and pronounced autonomic syndrome. Serological examination of blood and cerebrospinal fluid gave negative result. An examination of the fundus revealed the following: the veins are dilated, the arteries are narrowed, and there are many atrophic spots on the retina. The boy underwent a course of antisyphilitic treatment, after which he became calmer and more cheerful.

This disease should be attributed to that variant of cerebral syphilis, which has been described as syphilitic hallucinosis.

There is still much that is unclear in the pathogenesis of these forms of cerebral syphilis. The sluggish protracted course gives reason to assume that we are talking about syphilitic endarteritis of the cerebral vessels.

Differential diagnosis with schizophrenia in many cases of syphilitic hallucinosis is not easy, especially if paranoid syndrome subsequently develops. Emotional instability, suggestibility, superficiality of affect, characteristic disorders of intellectual activity, memory loss, severe attention disorder, inability to exert stress, fast fatiguability- all these characteristic symptoms more severe organic brain disease easily excludes the diagnosis of schizophrenia. The patient's critical attitude towards hallucinations as something extraneous is also more characteristic of syphilitic hallucinosis. Features of neurological disorders - anisocoria and sluggish reaction of the pupils to light, changes in the fundus, epileptic seizures in childhood - make us suspect that in this case we are talking about an organic process of a specific nature. Anamnestic information indicating a syphilitic disease in the father confirms the diagnosis.

Psychosis with cerebral syphilis of the brain is observed very rarely in children. A.I. Vinokurova described several cases of syphilitic psychoses in children with a schizophrenic picture. The author calls them “paraschizophrenia.” In adolescents, syphilitic psychoses are observed much more often.

Here is one such clinical observation.

Girl 15 years old. The disease began with confusion, disorientation in the environment, visual hallucinations, and fears. For 3 months, hallucinatory and delusional phenomena remained quite persistent in the clinical picture. The neurological status showed unevenness of the pupils with a sluggish reaction to light. Wasserman reactions in blood and cerebrospinal fluid are sharply positive. After a course of specific therapy, the patient was discharged from the hospital in a state of improvement.

When re-admitted a year later, the patient has difficulty thinking, is slow, copes poorly with school assignments (which were easy for her before the illness), and there is great lability and impoverished emotions.

The syphilitic origin of psychosis in this patient seems to be completely proven. But at the height of the attack, when the picture was dominated by hallucinations and delirium, it was necessary differential diagnosis with schizophrenia.

In hallucinatory and paranoid forms of cerebral syphilis, diagnostic errors in favor of schizophrenia often occur. This happens especially often in cases where they lose sight of the basic rule that recognition of a disease should not be based on individual symptoms, which is fundamental

The main thing that determines the diagnosis is disturbances in thinking and affect typical for schizophrenia.

With cerebral syphilis in children, hallucinatory and delusional manifestations are rarely observed. The main ones are: 1) dementia syndromes, 2) epileptic, 3) cerebrasthenic, 4) psychopathic-like conditions. In other words, with cerebral syphilis in children, the same basic psychopathological syndromes are observed, which we noted as consequences of acute infectious brain diseases. This uniformity of psychopathological manifestations is reflected in the characteristics of the child’s age-related reactivity.

We have already indicated that in children the higher parts of the central nervous system, which are ontogenetically young formations, are more vulnerable to various pathogenic agents, and the regulatory and protective functions of the cerebral cortex are still characterized by insufficient stability. Therefore, younger children are more likely to experience dementia. When the functional activity of the cerebral cortex decreases and its control is weak, conditions associated with the disinhibition of the functions of the underlying sections of the subcortical region easily arise. In the clinical picture of mental illness, this is reflected in symptoms of motor agitation, impulsive acts, increased gross instincts - ultimately, in psychopathic behavior. The characteristic features of cortical dynamics in young children, their tendency to increased irradiation of the irritative process, can also explain why young children develop so easily convulsive states, epileptiform and epileptic syndromes. Thus, the predominance of certain syndromes in childhood (psychopathic-like, epileptiform, dementia syndrome) is determined by physiological age-related characteristics of cerebral dynamics and insufficient functional maturity of the cerebral cortex.

In conclusion, let us dwell on the question of the peculiarities of the course of cerebral syphilis in children.

The first signs of congenital syphilis are usually detected during the first year of life. In early childhood, these children experience anxiety, emotional instability, or excessive lethargy and passivity. Sometimes the onset of the disease is detected only in the period from 7 to 12 years and later.

Before this, the disease remains latent, the child is regarded as healthy, although even in this latent period it is often possible to detect a delay in intellectual development, various disorders behavior.

In the future, the course of the process may take various shapes: sometimes sluggish, slow, with little progression, sometimes catastrophically severe, quickly leading to a deep defect, sometimes remitting in the form of individual attacks. Often, an exacerbation of the syphilitic process coincides with some kind of infection (influenza, pneumonia, measles) or head injury. It can be assumed that in such cases, intercurrent infection or trauma activates the syphilitic process, which was previously latent.

In more favorable cases, the syphilitic process is interrupted for more or less long term(sometimes for several decades). However, even in these cases one cannot be sure that the disease will not give rise to a new outbreak.

The patterns that determine the course and outcome of congenital syphilis in each individual case seem complex and depend on a number of reasons: the severity of the process, the characteristics of its morphological substrate (vascular, inflammatory, granulomatous changes), distribution in the brain and pathophysiological characteristics . Thus, among certain forms of brain syphilis, syphilitic lesions of the meninges proceed more favorably and are better amenable to specific therapy. With syphilitic gummas, the clinical picture depends on their localization and timely therapeutic intervention

Among syphilitic lesions of the brain, two main groups of disorders are distinguished: cerebral syphilis and progressive paralysis. It is generally accepted that cerebral syphilis occurs in earlier periods after infection, and progressive paralysis in later periods, and in connection with this, various morphological changes are found in brain tissue. With syphilis of the brain, the vessels and membranes of the brain (tissues of mesodermal origin) are affected; with progressive paralysis, dystrophic changes in the brain tissue itself.

The onset of these diseases after primary infection is observed at different times: syphilis of the brain - after 4-6 years, but there may be shorter and longer incubation periods.

With progressive paralysis, this period is longer. It should be noted that in last years due to the violation of the clarity of dispensary observation and the emerging opportunity to contact a large number private doctors who do not always provide complete treatment for primary syphilis, the risk of mental disorders of a syphilitic nature may increase.

Syphilis of the brain (Lues cerebri)

With syphilis of the brain, the membranes of the brain and blood vessels are affected. With syphilitic damage to the membranes of the brain, manifestations of their irritation (meningism) are observed; headache, irritability, affective reactions, mood swings. Neurological symptoms are often observed, mainly from the cranial nerves; hearing loss, damage to the facial and trigeminal nerves, anisocoria, deformation of the pupils, changes in the reaction to light and accommodation, aphasia, hemi- and monoplegia are rarely observed. The Wasserman reaction, RIBT and RIF in the blood and cerebrospinal fluid are sharply positive (although the Wasserman reaction in the blood may be negative). The Lange reaction (with colloidal gold), which gives a typical picture of a “syphilitic tooth”, is practically not carried out in the laboratories of psychiatric and venereological institutions.

Apoplictiform form syphilis of the brain is the most common manifestation of vascular damage; is in the nature of strokes, which at first are unstable in nature with a fairly rapid restoration of functions. Subsequently, more extensive disorders are observed and recovery does not occur; persistent neurological disorders are detected, such as apraxia, agnosia, and pseudobulbar disorders.

Mental disorders are more pronounced: patients are irritable, angry, faint-hearted, there are quite clear mood swings, decreased memory and intelligence.

The clinical picture of gummous syphilis of the brain is rare and clinically resembles the picture of brain tumors. Positive Wasserman reaction and RIF in the blood and cerebrospinal fluid are clear diagnostic signs.

A hallucinatory-delusional form of cerebral syphilis may be observed, as with all exogenous organic disorders. True hallucinations predominate, delusions are often hypochondriacal or persecutory, simple and concrete. These disorders are accompanied by mood swings, depression, irritability, and anger. Neurological symptoms are not severe: anisocoria, facial asymmetry, etc. The Wasserman reaction and RIF in the blood and cerebrospinal fluid are positive.

Mental disorders with congenital syphilis

The basis of all mental disorders in cerebral syphilis is one reason - infection with a pale spirochete. In pediatric practice, when it comes to congenital syphilis, pathological changes are observed in the form of developmental delay and deformity of individual parts of the central nervous system. Matter age characteristics children's brain.

M.S. Margulis believed that with congenital syphilis in children, the pathological process occurs as a general infection, the internal organs and central nervous system are flooded with spirochetes.

A feature of the clinical picture of congenital syphilis is the localization and extent of the lesion. Circulatory disorders (hemo- and hydrodynamic) and toxic effects associated with the disintegration of spirochetes and changes in metabolism in the body play an important role. The variety of clinical manifestations depends on the stage of the process, the intensity and duration of the disease.

There are early and late forms of congenital syphilis.

The clinical manifestations of congenital syphilis are divided into two groups. The first includes gross symptoms of cerebral and spinal disorders and manifestations of mental insufficiency of varying degrees. The second group is characterized by a predominance of intellectual and emotional disorders.

Progressive paralysis (paralisis progressiva alienorum - progressive paralysis of the insane, Bayle's disease)

It was described as an independent disease by the French psychiatrist A. Bayle in 1822. The syphilitic nature was proven after the discovery by the Japanese scientist Noguchi (Nogushi) in 1911 of the spirochete pallidum in the brains of patients with progressive paralysis. Progressive paralysis is now rare due to active antibiotic therapy for acute forms of the disease.

From the literature of past years, it is known that men aged 35-50 years are more likely to get sick. In the clinical picture of progressive paralysis, three stages are distinguished: the initial, or asthenic, stage of the disease and the terminal type of marasmus.

First stage(asthenic, or pseudoneurasthenic): it increases gradually, weakness, headaches, fatigue appear, and performance decreases. Against this background, the patient begins to commit actions that were previously unusual for him, and shows rudeness and tactlessness. So, an intelligent man went to visit with his wife, a tram arrived, he got on and left, leaving his wife in bewilderment.

At the next stage, even more pronounced inappropriate actions appear: the person takes other people’s things without asking, goes out to guests in his underwear, and then begins to express ridiculous ideas of greatness and wealth.

There are several forms in the clinical picture of the second stage of the disease: the most frequently encountered previously expansive form with a complacent mood and ideas of greatness and wealth; Dementia with a predominance of increasing dementia; circular - characterized by mood swings; agitated and galloping - with rapid development of the disease.

Typical neurological disorders in progressive paralysis are disturbances in speech, writing and gait. Speech disorders(dysarthria) are characterized by slurred speech; they say that the patient has “porridge in his mouth”, he is unable to speak tongue twisters, subsequently he misses words, syllables, and repeats syllables several times (logoclony). The writing becomes uneven, the patient misses letters and syllables, repeats syllables, and the writing becomes increasingly illegible. The gait becomes uncertain and staggering. One of early signs Argyll Robertson syndrome is a lack of reaction to light while maintaining a reaction to accommodation. Other pupillary disorders are also possible: miosis, anisocoria and other neurological signs (deviation of the tongue to the side, ptosis, etc.).

In the somatic status, a decrease in sensitivity, increased fragility of bones, hair loss, and weight loss are quite clearly noted, despite a good appetite.

Serological changes: when examining blood and cerebrospinal fluid, positive reactions of Wasserman, RIF, etc. are detected. In the cerebrospinal fluid - an increase in the number of cells and protein, a change in protein fractions with an increase in the level of globulin. The Lange reaction with colloidal gold plays an important diagnostic role: with progressive paralysis in the first test tubes, discoloration of the solution of cerebrospinal fluid with colloidal gold is observed, the “paralytic type” of the curve.

Differential diagnosis is based on serological indicators, analysis of neurological and psychopathological symptoms.

Mental disorders as a result of syphilitic brain damage manifest themselves in various stages of the disease and tend to be progressive.
In case of syphilitic damage to the brain, separate independent clinical forms syphilis of the brain (with primary damage to the membranes and blood vessels of the brain) and progressive paralysis (with primary damage to the substance of the brain - its parenchyma). Both cerebral syphilis and progressive paralysis arise as a result of infection with the pallidum spirochete, but they differ sharply in the time of onset of the disease, in the nature and location pathological process, as well as according to the clinical picture.
Progressive paralysis has recently been extremely rare, although in accordance with the increasing incidence of syphilis at present, an increase in the number of patients with progressive paralysis can be expected in a few years.

267 Chapter 21. Disorders with syphilis of the brain

Mental disorders in brain syphilis

The psychopathological manifestations of cerebral syphilis are very diverse and are determined mainly by the stage of the disease, localization and prevalence of the pathological process.
Mental disorders with syphilis of the brain are similar to psychopathological symptoms with other organic diseases brain: encephalitis, meningitis, tumors, vascular diseases. Taking this into account, characteristic neurological symptoms, as well as laboratory results, are of great importance in their diagnosis and differentiation from other diseases.
The most common psychopathological syndrome of stages I-II of brain syphilis is neurosis-like (syphilitic neurasthenia), in which neurotic, hypochondriacal and depressive disorders are observed. Symptoms such as severe irritability, emotional lability, complaints of headaches, memory impairment, and loss of performance predominate. Lacunar (partial) dementia gradually develops.
Characteristic pupillary disorders are observed (sluggish reaction of the pupils to light), pathology of the cranial nerves, meningeal symptoms, and epileptiform seizures are noted. A positive Wasserman reaction in the blood is detected and is inconsistent. - in the cerebrospinal fluid, moderate pleocytosis (cellular shift), positive globulin reactions, pathological curves in the Lange reaction (change in the color of the liquid in the first 3-5 tubes - “syphilitic wave” 11232111000, in 5-7 tubes - “meningitis curve” 003456631100).
Stages II and III of syphilis are characterized by psychoses, which are classified according to the leading syndrome. There are syphilitic psychoses with hallucinatory-delusional, pseudoparalytic (progressive dementia) syndromes and disorders of consciousness of the delirious and twilight types.
Hallucinatory-delusional syndrome in cerebral syphilis often begins with the appearance of auditory hallucinations: the patient hears insults, abuse directed at himself, often cynical sexual reproaches, soon the patient becomes completely uncritical of these disorders, believes that he is being pursued by murderers, thieves, etc. .

268 Section III. Certain forms of mental illness

Against the background of hallucinatory-delusional disorders, episodes of impaired consciousness with speech and motor agitation may be observed.
Hallucinatory-delusional syndrome in cerebral syphilis must be differentiated from the corresponding syndromes of schizophrenia and alcoholic psychosis.
With syphilis of the brain, delusions and hallucinations have an ordinary content, are associated with an emotional component, and develop against the background of an organic change in personality with typical disorders of memory and thinking, while in schizophrenia they are abstract, signs of emotional impoverishment of the personality, and impaired thinking are found. In alcoholic psychosis, alcoholic personality changes occur.
In the syphilitic process there are always characteristic neurological and somatic signs of this disease, as well as relevant data laboratory research.
In pseudoparalytic syndrome against the background of dementia of the organic type (partial, lacunar), which, as it develops, increasingly acquires a global picture (complete, with a disorder of all, including criticism, manifestations of the intellect), a complacent background of mood predominates, patients are euphoric, can express delusional ideas of greatness of fantastic content.
Sometimes epileptiform seizures and strokes occur.
In addition to these important psychotic syndromes, delirious and twilight disorders of consciousness may be observed.
The variety of clinical manifestations, as already indicated, depends on the characteristics of the pathological process, its localization and prevalence, duration from the moment of infection, the severity of the syphilitic infection, and the premorbid characteristics of the body. Pathomorphological (microscopic) examination reveals a predominance of cerebral vascular lesions, predominantly of small caliber.
In the vessels and membranes of the brain, against the background of chronic pathomorphological changes, signs of an inflammatory process are observed. Pathochemical methods reveal disorders of carbohydrate (mucopolysaccharide) metabolism in the brain. Mental disorders are expressed more often in those forms of cerebral syphilis in which there were no gross focal disorders.
The whole variety of pathomorphological (under microscopic examination) changes in the brain can be reduced to

269 ​​Chapter 21. Disorders with syphilis of the brain

syphilitic gummas, which can be multiple different sizes, diffuse inflammatory process- meningitis and vascular damage with a picture of obliterating endarteritis.
For syphilis of the brain, specific therapy is carried out. All patients diagnosed with cerebral syphilis are sent for treatment to mental asylum.
Treatment. The main and most common method of treating cerebral syphilis is penicillin therapy (at least 12,000,000 units per course of treatment). Several courses are offered. For repeated courses, it is advisable to prescribe prolonged forms of penicillin - ecmonvocillin 300,000 units intramuscularly 2 times a day.
Antibiotic treatment is combined with iodine and bismuth preparations. Up to 40 g of bioquinol per course. These drugs are used in combination with vitamins, especially group B, and general strengthening treatment is also carried out.
Used to treat patients with mental disorders psychotropic drugs depending on the leading syndrome.
Forensic psychiatric examination of cerebral syphilis due to the variety of clinical manifestations should not be determined by only one diagnosis of the disease; in each case, an expert opinion is made individually, taking into account the specific manifestations of the disease.
In psychotic forms, as well as severe dementia and personality degradation, patients with brain syphilis are insane.
Currently, during forensic psychiatric examinations, patients are most often encountered who, thanks to long-term and thorough treatment of syphilis, have only minor mental disorders. Such persons are critical of their condition, retain professional knowledge and skills, and therefore, during a forensic psychiatric examination, they are recognized as sane in relation to the acts accused of them.

The term syphilitic psychosis is used to summarize all types of mental disorders caused by syphilis of the brain. Such lesions develop as a result of the impact of the disease on the brain and are divided into two large groups: progressive paralysis and cerebral syphilis itself.

Brain damage, first of all, provokes a mental disorder such as neurasthenia. The patient becomes lethargic, irritable, constantly complains of headaches and increased fatigue, and his performance decreases. When trying to explore different kinds mental activity of a person, experts note that they have remained virtually unchanged or are gradually decreasing. Neurological examination shows signs of stigmatization: the pupils react sluggishly to light, tendon reflexes are upset (more often - increased). These symptoms are similar to atherosclerosis, however syphilitic lesions start at more early age, which allows for differentiation.

Another form of mental disorder with cerebral syphilis is Plautus hallucinosis. Its manifestations are very similar to schizophrenia, but delusional disorders predominate. This form of mental disorder is characterized by deception of feelings, the occurrence of delusional ideas and hallucinations. Delusions of persecution or self-accusation of non-existent offenses are observed. The delusional ideas themselves are simple and relate either to the patient’s environment or to life situations that happened to him.

Progressive paralysis was once described as an independent disorder of the human nervous system, but at the end of the 19th century Wasserman discovered spirochetes in the blood, and a couple of decades later another scientist, H. Noguchi, isolated it in the brain. So it became clear that this disease quite often causes psychosis.

As a rule, more than 10 years pass from the moment of infection to the first manifestations of mental disorders with syphilis. All this time, the symptoms are increasing, emerging gradually. Disorders begin with the fact that a person becomes less efficient, his memory begins to fail him in elementary matters, and some processes are more difficult than usual. The mood also changes. At first the patient becomes irritable. He is enraged by moments that he has never paid attention to before, and he reacts to everything extremely inadequately. Sleep disorders begin.

Further mental manifestations of cerebral syphilis are even more serious: a personality disorder begins. The patient becomes indifferent to what he was previously interested in; he does not even care about members of his own family. He may lose his modesty, become sloppy, wasteful, and even begin to use foul language, even if he has never done this before. The next stage is dementia, expressed by serious memory disorders.

Treatment of such forms of syphilis involves antibiotic therapy, which is usual for such diagnoses. The most important thing is not to downplay the importance of symptoms that are unusual for a person - for example, signs of syphilitic psychosis are often attributed to fatigue, lack of good rest, stress. Many even try to cope with the problem by turning to a psychoanalyst, not knowing what kind of illness is developing inside them. Unfortunately, the prognosis for this disease can be completely different: it all depends on the timeliness of detection and the correctness of the prescribed treatment, of course, exclusively under strict medical supervision.