diff options
| author | nfenwick <nfenwick@pglaf.org> | 2025-02-04 07:12:02 -0800 |
|---|---|---|
| committer | nfenwick <nfenwick@pglaf.org> | 2025-02-04 07:12:02 -0800 |
| commit | d7437e1a3927ed773a89227aeb8dbb9a8093c08f (patch) | |
| tree | 1ec4f4c2e513d91209039b7de3c00eb72dcdf6ae | |
| parent | 9ee85c4cf0829168b9c8bd145fbffcd3cfbfdb53 (diff) | |
| -rw-r--r-- | .gitattributes | 4 | ||||
| -rw-r--r-- | LICENSE.txt | 11 | ||||
| -rw-r--r-- | README.md | 2 | ||||
| -rw-r--r-- | old/63313-0.txt | 19016 | ||||
| -rw-r--r-- | old/63313-0.zip | bin | 333906 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h.zip | bin | 6075276 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/63313-h.htm | 24089 | ||||
| -rw-r--r-- | old/63313-h/images/cover.jpg | bin | 254626 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_024.jpg | bin | 124503 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_038a.jpg | bin | 225207 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_038b.jpg | bin | 225177 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_040a.jpg | bin | 89461 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_040b.jpg | bin | 129608 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_040c.jpg | bin | 151262 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_044.jpg | bin | 160917 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_045.jpg | bin | 144258 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_052a.jpg | bin | 132778 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_052b.jpg | bin | 106666 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_052c.jpg | bin | 149103 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_080.jpg | bin | 146408 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_083.jpg | bin | 141619 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_088.jpg | bin | 152612 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_116a.jpg | bin | 26249 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_116b.jpg | bin | 12595 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_116c.jpg | bin | 41053 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_116d.jpg | bin | 40422 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_116e.jpg | bin | 56429 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_116f.jpg | bin | 55606 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_138.jpg | bin | 133161 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_158.jpg | bin | 192799 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_160.jpg | bin | 137139 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_206.jpg | bin | 208189 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_218a.jpg | bin | 180685 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_218b.jpg | bin | 124432 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_218c.jpg | bin | 190585 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_220a.jpg | bin | 226024 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_220b.jpg | bin | 258569 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_221.jpg | bin | 165016 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_272.jpg | bin | 123751 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_306.jpg | bin | 135858 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_311.jpg | bin | 152222 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_326.jpg | bin | 173706 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_330.jpg | bin | 147205 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_332.jpg | bin | 142267 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_336a.jpg | bin | 206340 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_336b.jpg | bin | 213794 -> 0 bytes | |||
| -rw-r--r-- | old/63313-h/images/i_frontis.jpg | bin | 115449 -> 0 bytes |
47 files changed, 17 insertions, 43105 deletions
diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..f7c236a --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #63313 (https://www.gutenberg.org/ebooks/63313) diff --git a/old/63313-0.txt b/old/63313-0.txt deleted file mode 100644 index 0c655b3..0000000 --- a/old/63313-0.txt +++ /dev/null @@ -1,19016 +0,0 @@ -The Project Gutenberg EBook of Neurosyphilis, by -Harry Caesar Solomon and Elmer Ernest Southard - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Neurosyphilis - Modern Systematic Diagnosis and Treatment Presented In One - Hundred And Thirty-Seven Case Histories - -Author: Harry Caesar Solomon - Elmer Ernest Southard - -Release Date: September 27, 2020 [EBook #63313] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK NEUROSYPHILIS *** - - - - -Produced by Richard Tonsing, Bryan Ness, and the Online -Distributed Proofreading Team at https://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive/Canadian Libraries) - - - - - - - - - - THE - CASE HISTORY SERIES - - - CASE HISTORIES IN MEDICINE - BY - RICHARD C. CABOT, M.D. - Third edition, revised and enlarged - - - CASE HISTORIES IN PEDIATRICS - BY - JOHN LOVETT MORSE, M.D. - Second edition, revised and enlarged - - - ONE HUNDRED SURGICAL PROBLEMS - BY - JAMES G. MUMFORD, M.D. - Second Printing - - - CASE HISTORIES IN NEUROLOGY - BY - E. W. TAYLOR, M.D. - Second Printing - - - CASE HISTORIES IN OBSTETRICS - BY - ROBERT L. DENORMANDIE, M.D. - Second Edition - - - CASE HISTORIES IN DISEASES OF WOMEN - BY - CHARLES M. GREEN, M.D. - - NEUROSYPHILIS - MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT - Presented in one hundred and thirty-seven Case Histories - BY - E. E. SOUTHARD, M.D., SC.D. - AND - H. C. SOLOMON, M.D. - - Being Monograph Number Two of the Psychopathic Hospital, Boston, - Massachusetts. (Monograph Number One was A Point Scale for Measuring - Mental Ability by Robert M. Yerkes, James W. Bridges and Rose S. - Hardwick. Published by Warwick and York. Baltimore 1915.) - -[Illustration: METCHNIKOFF WASSERMANN EHRLICH SCHAUDINN NOGUCHI] - - - - - NEUROSYPHILIS - MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT - PRESENTED IN ONE HUNDRED AND THIRTY-SEVEN CASE HISTORIES - - - BY - - E. E. SOUTHARD, M.D., Sc.D., - - Bullard Professor of Neuropathology, Harvard Medical School; - Pathologist, Massachusetts Commission on Mental Diseases; Director, - Psychopathic Department, Boston State Hospital; Vice-President, American - Medico-Psychological Association - - AND - - H. C. SOLOMON, M.D., - - Instructor in Neuropathology and in Psychiatry, Harvard Medical School; - Special Investigator in Brain Syphilis, Massachusetts Commission on - Mental Diseases; Acting Chief-of-Staff, Psychopathic Department, Boston - State Hospital - - - WITH AN INTRODUCTION BY - - JAMES JACKSON PUTNAM, M.D., - - Professor Emeritus of Diseases of the Nervous System, Harvard Medical - School - - - BY VOTE OF THE TRUSTEES OF THE BOSTON STATE HOSPITAL - - MONOGRAPH NUMBER TWO - - OF THE - - PSYCHOPATHIC HOSPITAL BOSTON, MASSACHUSETTS - - - BOSTON - - W. M. LEONARD, PUBLISHER - - 1917 - - - - - _Copyright, 1917. - By W. M. Leonard_ - - - - - =In= - - MASSACHUSETTS - - A STATE THAT - - BOTH TOLERATES AND FOSTERS - - RESEARCH - ------------------------------------------------------------------------- - - - - - PREFACE - - -This book is written primarily for the general practitioner and -secondarily for the syphilographer, the neurologist, and the -psychiatrist. Our material is drawn chiefly from a psychopathic -hospital, that modern type of institution in which the mental problems -of general medical practice come to a diagnostic head weeks, months, or -years before the asylum is thought of. - -It is this peculiar nature of psychopathic hospital material—a -concentrated essence of the most difficult daily problems of general -practice—that brings together such an apparent _mélange_ of cases as are -here described, ranging from mild single-symptom diseases like -extraocular palsy up to genuine magazines of symptoms as in general -paresis; from feeblemindedness, apparently simple, up to apparently -simple dotage, both feeblemindedness and dotage really syphilitic; from -the mind-clear tabetic to the maniacal or deluded subject who looks -physically perfectly fit; from the early secondaries to the late -tertiaries or so-called quaternaries; from peracute to the most chronic -of known conditions; from the most delicate character changes to the -profoundest ruin of the psyche. - -Although the bulk of our case-material is drawn from general practice -through the thinnest of intermediary membranes, the psychopathic -hospital, yet we have tried to depict the whole story by presenting -enough autopsied cases from district state hospitals to show exactly -what treatment has to face. Nor have we hesitated to insert cases in -which treatment has failed. - -In addition to (_a_) the Psychopathic Hospital, Boston, group of -incipient, doubtful, obscure, or complicated cases (the early clinical -group) and (_b_) the Danvers State Hospital, Hathorne, group of -longer-standing, committed, fatal cases (the finished or autopsied -group) we present (_c_) a miscellaneous group of cases, including many -from private neurological or psychiatric practice. No doubt those -familiar with Boston medicine will see traces of the teaching of our -former chiefs, notably Professors James Jackson Putnam and Edward Wyllys -Taylor. We are obliged to them for some well-observed cases. - -We have dedicated our work to the Commonwealth, but perhaps we should -more specifically ascribe to the Massachusetts Commission on Mental -Diseases (formerly the State Board of Insanity) the spirit that -permitted our special study of neurosyphilis treatment. To these -authorities, who have countenanced and encouraged a somewhat costly -piece of special work since 1914, we offer our thanks, hoping that other -states will be one by one stimulated to the state-endowment of research. -States doing full duty by research can be counted on one hand. - -To our Psychopathic Hospital colleagues and the internes, and especially -to Drs. Myrtelle M. Canavan and Douglas A. Thom of the Commission’s -Pathological Service, we also offer our best thanks. - -The Danvers traditions are tangible here: cases of Drs. A. M. Barrett, -H. A. Cotton, H. W. Mitchell, H. M. Swift, and others are presented. We -have been especially aided by the more recent work of Dr. Lawson G. -Lowrey. - -Nor should we have been able to present our samples of brain correlation -without drawing on the collection arranged and analyzed by Dr. Annie E. -Taft, Custodian, Harvard Department of Neuropathology. The photographs, -part of a collection of brain photographs now numbering over 10,000 -representing 700 brains of all sorts, were made by Mr. Herbert W. -Taylor. - -The Wassermann testing work has been done by Dr. W. A. Hinton of the -State Board of Health. Dr. Hinton himself wrote out the text description -of the Wassermann method. The method of his laboratory is held to the -standards of control set by previous chiefs, viz. by Professor F. P. -Gay, who brought immunological methods direct from the laboratory of -Bordet (whose method the Wassermann method essentially is), Prof. W. P. -Lucas, and the late Dr. Emma W. D. Mooers, who had assisted Plaut in his -first work with the Wassermann method in Kraepelin’s Munich Clinic. - -The material combed by us to secure this illustrative series amounts to -over 2000 cases of syphilis of the nervous system, including over 100 -autopsies in all types of case. We have presented these with very -varying fulness, chiefly to illustrate the contentions at the heads of -the case-descriptions. - -In using the book, we suggest early reference to the Summary and Key, -where for convenience are placed numerous cross-references permitting -extended illustration of almost every proposition from several cases. - -We have not made a large feature of the Medicolegal and Social section. -This kind of thing well deserves a volume by itself, with all the legal -and social-service implications drawn out in their amazing richness and -detail. The social service slogan, “A paretic’s child is a syphilitic’s -child” has already accomplished a great deal of good in our local world. -Some day we may not be compelled to _drive_ the paretic’s spouse and -offspring to the Wassermann serum test! The general practitioner must -help here. - -A note on the Treatment section. This is manifestly not the last word or -even, we hope, our own last word, since the systematic work of the -Massachusetts Commission must be kept up for some years to get a -reliable verdict. Some of the results give rise to greater optimism than -has prevailed in asylum circles, especially re general paresis. We are -confident that _no one can now successfully make a differential -diagnosis between the paretic and the diffuse non-paretic forms of -neurosyphilis in many phases of either disease_, even with all -laboratory refinements. If this be so, it is _improper not to give the -full benefits of modern treatment to all cases in which the diagnosis -remains doubtful_ between the paretic and the diffuse non-paretic forms -of neurosyphilis. We ourselves advocate modern treatment, not only in -the diffuse, but also in early paretic forms of neurosyphilis. - -It would have been out of place in a book in this Case History Series to -have dealt extensively with the history of our topic. We have -compensated inadequately for this lack by a few remarks at the head of -the Summary and Key. We are, like all others in the field, under the -inevitable obligation to Nonne of Hamburg, whose great work has gone -into three editions, the second of which has appeared in English -translation (Nonne’s Syphilis of the Nervous System, C. R. Ball, -translator). Mott’s work, embodied in a large volume of the Power-Murphy -System of Syphilis, has also been attentively consulted, as well as the -various systematic works on neurology and psychiatry. The topic of -Neurosyphilis is getting wide and appropriate attention in this country -through special journals, both those dealing with nervous and mental -diseases, and those dealing with syphilis. Syphilis is in a sense the -making of psychiatry and will go far to pushing psychiatry into general -practice. - -At the last moment we have been led to deviate from our plan of -presenting only local cases familiar and accessible to us. In a section -on Neurosyphilis and the War, we present excerpts and digests of -English, French, and German cases of neurosyphilis that have appeared in -association with the war. Our own country has not suffered greatly as -yet either from the lighting up of neurosyphilis under martial stress or -from the immediate or remote effects of syphilis obtained in the unholy -congress of Mars and Venus. Space forbids a large collection of these -martial cases, but, as will be seen, a fair sample of problems is -presented. - -Speaking for the moment as the senior author of this book, I wish to say -that, were it not for the energy, industry, and ingenuity of the junior -author, Dr. H. C. Solomon, the book would not have been written. Nor, in -all probability, would the systematic work of the Commonwealth on -neurosyphilis and its treatment ever have been begun. I can also accord -the highest praise to Mrs. Maida Herman Solomon for her social-service -work in this new field. - -Perhaps, in closing, we owe an apology to John Milton for our borrowings -from the two Paradises. Had he known much about syphilis, Milton might -have written still stronger mottoes for us. - - E. E. SOUTHARD - - 74 FENWOOD ROAD - _Boston, Massachusetts_ - - - - - TABLE OF CONTENTS - - - PAGE - - SECTION I. THE NATURE AND FORMS OF SYPHILIS OF THE NERVOUS SYSTEM - (NEUROSYPHILIS). CASES 1 TO 8 17 - - CASE - - 1. Paradigm: protean symptoms, nervous and mental. Autopsy, with - meningeal, parenchymatous, and vascular lesions. 17 - - 2. Tabes dorsalis (tabetic neurosyphilis). Autopsy 31 - - 3. General paresis (paretic neurosyphilis). Autopsy 37 - - 4. Cerebral thrombosis (vascular neurosyphilis). Autopsy 42 - - 5. Juvenile paresis (juvenile paretic neurosyphilis). Autopsy 45 - - 6. Extraocular palsy (focal meningeal neurosyphilis). Autopsy 50 - - 7. Gumma of brain (gummatous neurosyphilis). Autopsy 53 - - 8. _Meningitis hypertrophica cervicalis_ (gummatous - neurosyphilis). Autopsy 56 - - - SECTION II. THE SYSTEMATIC DIAGNOSIS OF THE FORMS OF NEUROSYPHILIS - CASES 9 TO 38 63 - - CASE - - 9. Neurasthenia _versus_ neurosyphilis 63 - - 10. Paretic neurosyphilis _versus_ manic-depressive psychosis 68 - - 11. Neurosyphilis _versus_ manic-depressive psychosis 71 - - 12. Dementia praecox _versus_ neurosyphilis. Autopsy 74 - - 13. Neurosyphilis: negative Wassermann reaction (W. R.) of serum 77 - - 14. Diffuse neurosyphilis: six tests apt to run mild 80 - - 15. Paretic neurosyphilis: six tests strong 85 - - 16. Taboparesis (tabetic neurosyphilis): tests like those of - paresis 92 - - 17. Paretic _versus_ diffuse neurosyphilis: confusion _re_ tests 97 - - 18. Vascular neurosyphilis: positive serum, negative fluid W. R. 101 - - 19. Seizures in diffuse neurosyphilis 103 - - 20. Seizures in paretic neurosyphilis 106 - - 21. Aphasia in paretic neurosyphilis 111 - - 22. Aphasia in paretic neurosyphilis 115 - - 23. Remission in paretic neurosyphilis 117 - - 24. Remission in diffuse neurosyphilis 122 - - 25. _Paresis sine paresi_ 126 - - 26. Paretic neurosyphilis. Autopsy 131 - - 27. Gummatous neurosyphilis. Operation 137 - - 28. Extraocular palsy (cranial neurosyphilis) 140 - - 29. Tabes dorsalis (tabetic neurosyphilis): six tests apt to run - mild 141 - - 30. Tabetic neurosyphilis, clinically atypical 143 - - 31. Cervical tabes 146 - - 32. Erb’s syphilitic spastic paraplegia 147 - - 33. Syphilitic muscular atrophy 149 - - 34. Neurosyphilis of the secondary period 151 - - 35. Juvenile paretic neurosyphilis: optic atrophy 154 - - 36. Juvenile paretic neurosyphilis 157 - - 37. Simple feeblemindedness, syphilitic 159 - - 38. Juvenile tabes 161 - - SECTION III. PUZZLES AND ERRORS IN THE DIAGNOSIS OF NEUROSYPHILIS - (INCLUDING NON-SYPHILITIC CASES). CASES 39–82 165 - - CASE - - 39. Paretic _versus_ diffuse neurosyphilis. Autopsy 165 - - 40. Paretic _versus_ vascular neurosyphilis, cerebellar. Autopsy 169 - - 41. Paretic _versus_ vascular neurosyphilis, cerebellar. Autopsy 172 - - 42. Tabetic combined with vascular neurosyphilis. Autopsy. 175 - - 43. Tabetic neurosyphilis: mental symptoms, non-paretic. Autopsy 177 - - 44. Cerebral gliosis. Autopsy 180 - - 45. Neurasthenia _versus_ neurosyphilis 183 - - 46. Hysteria. Neurosyphilis of the secondary period 185 - - 47. Manic-depressive psychosis _versus_ paretic neurosyphilis 187 - - 48. Cerebral tumor 190 - - 49. Early post-infective paretic neurosyphilis 192 - - 50. Atypical paretic neurosyphilis, hemitremor. Autopsy 197 - - 51. Paretic neurosyphilis. Autopsy 199 - - 52. Manic-depressive psychosis _versus_ paretic neurosyphilis 202 - - 53. Syphilitic(?) exophthalmic goitre. Autopsy 205 - - 54. Argyll-Robertson pupils 209 - - 55. Argyll-Robertson pupils: pineal tumor. Autopsy 212 - - 56. Neurosyphilis(?) with negative spinal fluid 216 - - 57. Disseminated syphilitic encephalitis, seven months - post-infective. Autopsy 218 - - 58. “Pseudoparesis” 222 - - 59. Syphilitic paranoia? 225 - - 60. Paretic neurosyphilis _versus_ alcoholic pseudoparesis 227 - - 61. Alcoholic pseudoparesis _versus_ paretic neurosyphilis 231 - - 62. Alcoholic neuritis and paretic neurosyphilis 234 - - 63. Chronic alcoholism _versus_ paretic neurosyphilis 236 - - 64. Neurosyphilis, diabetic pseudoparesis, or brain tumor 238 - - 65. Neurosyphilis and diabetes 240 - - 66. Neurosyphilis: hemianopsia 242 - - 67. Paretic neurosyphilis _versus_ syphilis and cerebral malaria 245 - - 68. Paretic neurosyphilis: gold sol test “syphilitic.” Autopsy 247 - - 69. Lues maligna 250 - - 70. Neurosyphilis _versus_ multiple sclerosis 253 - - 71. Atypical neurosyphilis 256 - - 72. Huntington’s chorea _versus_ neurosyphilis 258 - - 73. Senile arteriosclerotic psychosis _versus_ neurosyphilis 262 - - 74. Hysterical fugue _versus_ neurosyphilis 264 - - 75. Tabetic neurosyphilis _versus_ pernicious anemia 267 - - 76. Congenital neurosyphilis 270 - - 77. Congenital _versus_ paretic neurosyphilis 272 - - 78. Juvenile paretic neurosyphilis 275 - - 79. Epilepsy _versus_ juvenile neurosyphilis 277 - - 80. Addison’s disease and juvenile paretic neurosyphilis. Autopsy 279 - - 81. Neurosyphilis of the secondary period 283 - - 82. Taboparetic neurosyphilis and typhoid meningitis. Autopsy 284 - - - SECTION IV. NEUROSYPHILIS, MEDICOLEGAL AND SOCIAL. CASES 83–98 289 - - CASE - - 83. A public character, neurosyphilitic. Autopsy 289 - - 84. Debts, neurosyphilitic 295 - - 85. Suicidal attempt by a neurosyphilitic 296 - - 86. Neurosyphilis and juvenile delinquency 298 - - 87. Neurosyphilis in a defective delinquent 300 - - 88. _Paresis sine paresi_ in a forger 303 - - 89. Trauma: juvenile paretic neurosyphilis 306 - - 90. Trauma: paretic neurosyphilis 308 - - 91. False claim for trauma: neurosyphilis 309 - - 92. Traumatic exacerbation? in neurosyphilis 310 - - 93. Trauma: cranial gumma at the site of injury 311 - - 94. Occupation-neurosis _versus_ syphilitic neuritis 312 - - 95. Character change: neurosyphilis 314 - - 96. A neurosyphilitic family 316 - - 97. A neurosyphilitic’s normal-looking family 318 - - 98. The neurosyphilitic’s marriage 319 - - - SECTION V. THE TREATMENT OF NEUROSYPHILIS. CASES 99–123. - - (CASES 99–103 SHOW THE VARIETY OF STRUCTURAL LESIONS THAT - TREATMENT HAS TO FACE) 323 - - CASE - - 99. An incurable spastic paresis in paretic neurosyphilis. - Autopsy 323 - - 100. A theoretically curable case. Autopsy 328 - - 101. A highly meningitic case, theoretically amenable to - treatment. Autopsy 332 - - 102. A highly atrophic case, theoretically not amenable to - treatment. Autopsy 335 - - 103. Paretic neurosyphilis with markedly focal lesions. Autopsy 338 - - (CASES 104 TO 123 ARE EXAMPLES OF TREATMENT INCLUDING - SUCCESSES AND FAILURES.) - - 104. Diffuse neurosyphilis: treatment successful after nine months 342 - - 105. Atypical neurosyphilis: treatment successful 346 - - 106. Argyll-Robertson pupil not necessarily of bad prognosis: - treated case an insurance risk 350 - - 107. Spinal fluid cleared: symptoms persistent 355 - - 108. Arteriosclerosis does not contraindicate treatment 359 - - 109. Symptoms of intracranial pressure relieved by treatment 362 - - 110. Therapeutic improvement in tabetic neurosyphilis 366 - - 111. W. R. rendered negative in tabetic neurosyphilis 367 - - 112. Example of successful treatment of paretic neurosyphilis 370 - - 113. Another example 372 - - 114. Clinical recovery but tests persistently positive in treated - paretic neurosyphilis 375 - - 115. Improvement delayed in treated paretic neurosyphilis 377 - - 116. Non-neural syphilis in treated paretic neurosyphilis 380 - - 117. Partial recovery in treated paretic neurosyphilis 382 - - 118. Laboratory signs improved: clinical situation stationary: - treated paretic neurosyphilis 384 - - 119. Another example 386 - - 120. Failure of treatment 388 - - 121. Treatment, at first mild, later intensive 390 - - 122. Intensive treatment 392 - - 123. Syphilitic feeblemindedness improved by treatment 395 - - - SECTION VI. NEUROSYPHILIS AND THE WAR. - - CASES A TO N FROM BRITISH, FRENCH, AND GERMAN WRITERS - (1914–1916) 399 - - CASE - - A. Tabes “shell-shocked” into paresis? (Donath) 401 - - B. Latent syphilis “shell-shocked” into tabes? (Duco and Blum) 403 - - C. Aggravation of neurosyphilis by service? (Weygandt) 404 - - D. Aggravation of neurosyphilis _by_ service? (Todd) 406 - - E. Aggravation of neurosyphilis _on_ service? (Todd) 409 - - F. Duration of neurosyphilitic process important. (Farrar) 411 - - G. Latent syphilis lighted up to paresis by war stress without - shell-shock. (Marie) 412 - - H. Paresis lighted up by “gassing”? (de Massary) 414 - - I. Epilepsy in a neuropath lighted up by syphilis acquired at - war. (Bonhoeffer) 415 - - J. Syphilitic—after Dixmude epileptic. (Bonhoeffer) 417 - - K. Syphilitic root-sciatica in a fireworks man. (Dejerine, Long) 418 - - L. Paresis lighted up in civilian by domestic stress of the war. - (Percy Smith) 420 - - M. Shell-shock pseudoparesis. (Pitres and Marchand) 421 - - N. Shell-shock pseudotabes. (Pitres and Marchand) 424 - - - SECTION VII. SUMMARY AND KEY 427 - - APPENDICES: - - A. The six tests 471 - - B. Common methods of treatment 486 - - - - - INTRODUCTION - - -It is a privilege to be allowed to write a word of introduction to a -textbook which so richly fulfils its function as does this volume on the -manifold disorders classified under Neurosyphilis, a subject of which -the importance for the welfare of society is found to loom the larger -the more deeply its mysteries are probed. - -The case histories with which its pages are so amply stocked are -carefully analyzed in accordance with a broadly chosen plan, and the -generalizations that precede and follow them are obviously based on a -wide and varied personal experience such as alone could render a -familiarity with the literature of the subjects treated adequate to its -best usefulness. Both writers were indeed well adapted for this task. -Dr. Southard, as everyone is aware, has long been a highly -conscientious, ardent and productive worker in the department of -pathological anatomy, and of late years a careful student of clinical -diagnosis and methods, both at the Danvers State Hospital and still -more, at the Psychopathic Hospital which he worked so hard to found; -while Dr. Solomon’s researches, in the special field of neurosyphilis, -have been of the highest order. - -Undoubted as are the merits of the case-system of instruction that has -been so much in vogue in recent years, and excellent as is the modern -supplementation of this method by the use of published records, the -danger is still real that the student will have presented to him a -picture of nature in disease that is too diagrammatic, too concise, with -the result that while the task of memory is lightened through simplified -formulation, the training of the doubting and inquiring instincts is -often given too little stimulus and scope. In this book this danger is -deliberately met through the casting of emphasis rather on the -pluralistic aspects of the processes at stake than (primarily) on their -unitary aspects. - -The student who utilizes this volume cannot but emerge from his study a -more thoughtful person than he was at the period of his entry. He will -have seen that clinical rules of thumb cannot be followed to advantage, -and that, on the contrary, surprises are to be expected and prepared -for. Let the recognition of this fact, if it seems to increase the -difficulties in the way of diagnosis, not lead to pessimism in that -respect, or to hopelessness in therapeutics. On the contrary the -writers’ bias is towards the worth-whileness of clinical efforts and an -increased respect for accuracy and thoroughness in the utilization of -modern methods of research. The chance is indeed held open that even the -gaunt spectre of “General Paresis” may prove to be less terrible than it -seems, and for this hope good grounds are given. - -It is in this way made clear, on the strength of anatomical evidence of -much interest, that even if in the treatment of a given patient, the -time arrives when a fatal or unfavorable result seems manifestly -foreshadowed, it may be still worth while to renew the treatment with -fresh zeal, for the sake of combatting some symptom or exacerbation, for -which a locally fresh process furnishes the cause. - -Another noteworthy principle here emphasized and illustrated is that the -relationship between “functional” (hysterical, neurasthenic, migrainoid) -symptoms and the signs (or symptoms) of organic processes is clinically -important and worthy of much further study. This is a matter which, in a -general sense, has interested me for many years. Above and over the -“organic” hovers always the “functional,” as representing the first -indication of the marvelous tendency to repair, or substitution, for -which the resources of nature are so vast. Yet this functional tendency -also has its laws, of which, in their turn, the organic processes -display the action in quasi diagrammatic form. Hysteria, neurasthenia, -migraine, etc., do not arise _de novo_ in each case, but conform to -typical, though not rigid, formulas, susceptible of description. I have -recently had the opportunity to study in detail an analogous series of -transitions between the movements (and emotions) indicative of -apparently purposeless myoclonic movements (on an epileptoid basis) and -the movements of surprise, engrossment, purposeful effort, the -excitement and joy by which the former were excited and into which they -shaded over. - -Taken altogether, this book represents work and thought in which, for -amount and kind, the neurologists of Boston may take just pride. - - JAMES J. PUTNAM. - - ST. HUBERT’S, KEENE VALLEY, NEW YORK. - _August, 1917._ - - - - - Me miserable! which way shall I fly - Infinite wrath and infinite despair? - Which way I fly is Hell; myself am Hell; - And, in the lowest deep, a lower deep - Still threatening to devour me opens wide, - To which the Hell I suffer seems a Heaven. - - Paradise Lost, Book IV, lines 73–78. - - - - - I. THE NATURE AND FORMS OF SYPHILIS OF THE NERVOUS SYSTEM - (NEUROSYPHILIS) - - - PARADIGM to show possible abundance and variety of symptoms and - lesions in DIFFUSE NEUROSYPHILIS (“cerebrospinal syphilis”). - Autopsy. - - -=Case 1.= Mrs. Alice Morton[1] was in the hands of at least five -well-known specialists in different branches of medicine and surgery -during the nineteen years of her disease. It appears that she acquired -syphilis upon marriage at the age of 23 to a man who later became -tabetic and acknowledged syphilitic infection previous to marriage. Mrs. -Morton remained without children and there were no miscarriages. - -At the age of 27, she developed iritis, paresis of the left eye muscles, -and ulceration of the throat, with destruction of the uvula. The -syphilitic nature of her disease was at once recognized and the -classical treatment was given, although, through numerous shifts in -consultants, this treatment was never pushed to the limit. At 28 Mrs. M. -began to suffer from severe headaches resembling migraine and -accompanied by attacks of paræsthesia; at 35, came severe pains in the -back and difficulty in walking. - -At 36, the migraine attacks began to be accompanied by blurring of -vision and dizziness. The difficulty in walking became extreme, -affecting particularly the right foot. The legs became spastic, there -were pains and hyperæsthesia of the chest, and severe cramps of the -legs. Antisyphilitic treatment at this time yielded marked improvement. - -During her thirty-sixth year, Mrs. M. sustained curious transient losses -of vision and of hearing. She was also irritable, and at this time -developed her first pronounced mental symptoms, namely, delusions -concerning her relatives. There were also a few seizures of an -epileptiform nature. - -At 38 there was a spell of total deafness, followed by improvement. The -eye muscles were also subject to a variable involvement with intervening -spells of improvement. The _knee-jerks were lost, but after a time -returned_ in less pronounced form. Shortly, an absolute paralysis and -extensive decubitus developed, and death occurred at 39. - -The autopsy is briefly summarized below, but it is important in the -understanding of Mrs. M.’s case (particularly some of the sensory -symptoms and the transiency of certain symptoms) to consider the -pre-infective history. Although there seems to be no doubt that the -patient acquired syphilis at about 23 years of age from a syphilitic -husband, who himself later became tabetic, yet it is of note that the -patient was the only child of parents, both of whom also suffered from -mental disease. Mrs. M.’s father died of what was called softening of -the brain (one should avoid terming _all_ old cases of _so-called_ -“softening of the brain” syphilitic, since the older diagnosticians did -not always distinguish between non-syphilitic arteriosclerotic effects -and syphilitic disease). Mrs. M.’s mother also died insane (confusion -and emotional depression). It is clear, then, that we do not need to -suppose that every symptom shown by Mrs. M. is directly due to -destructive or irritative lesions immediately due to the spirocheta -pallida. The case is, in fact, an excellent lesson as to the association -of structural and functional effects in neuropathological cases. - -Mrs. M. as a child had shown talent, but was somewhat nervous and -eccentric. At one time, she had an attack of hysterical dysphasia; at -another time, an attack of hysterical dyspnea; during another period, an -apparent obsession (kicking the mopboard at regular intervals). -Moreover, she had for years suffered from migraines of a severe and -unusual type. Both the hysterical tendency and the migrainous tendency -became mingled with the results of the neurosyphilis in later stages of -the disease in such wise that it was hard to tell exactly where the -structural phenomena left off and the functional phenomena began. - -For example, at the age of 32, nine years after infection and four years -after the earliest nerve symptoms traceable to syphilis, and at about -the time of the onset of spinal cord symptoms, an attack was described -as follows: - - The patient had a very severe attack of migraine (?) yesterday, - preceded and accompanied by paraphasia, so severe that for three - hours she was unable to make herself understood, and indeed felt “as - if her ideas were getting away from her.” This attack was ushered in - by a numbness of the forefinger and thumb of the right hand, which - lasted for about three hours, though the earlier attacks had lasted - for only about ten minutes. During this period the hand felt as if - it had been frozen and the loss of muscular power was so great that - she was unable to hold objects in the hand. In some of the attacks - this paræsthesia has affected the entire left half of the body, and - occasionally the right half. Sometimes the seizures come on with - great suddenness, so that once, when she was attacked while in the - middle of the street, she had considerable difficulty in reaching - the sidewalk. After the worst part of the attack is over a certain - amount of paraphasia may persist for some days, together with - awkwardness in the use of the right hand and numbness. She has had a - great deal of nausea and vomiting, without reference to the taking - of food.[2] - -Bearing in mind the mingling of structural with functional symptoms in -this case, let us consider the autopsy findings. - - - =ANATOMICAL= - - =FORMS OF NEUROSYPHILIS= - - AUTONOMIC (SYMPATHETIC) NEUROSYPHILIS? - - PERIPHERAL NEUROSYPHILIS - - CENTRAL NEUROSYPHILIS - MENINGEAL - VASCULAR - PARENCHYMATOUS - MENINGOVASCULAR - VASCULOPARENCHYMATOUS - DIFFUSE ( = MENINGOVASCULOPARENCHYMATOUS) - - GUMMA - - CHART 1 - - - =CLINICAL FORMS OF NEUROSYPHILIS= - - =HEAD AND FEARNSIDES, 1914= - - SYPHILIS MENINGOVASCULARIS - CEREBRAL FORMS - HEMIPLEGIA - AFFECTION OF THE CRANIAL NERVES - MUSCULAR ATROPHY - LATERAL AND COMBINED DEGENERATIONS - EPILEPSY - - SYPHILIS CENTRALIS - DEMENTIA PARALYTICA - TABES DORSALIS - MUSCULAR ATROPHY - OPTIC ATROPHY - GASTRIC CRISES - EPILEPTIC MANIFESTATIONS - - CHART 2 - - -=Peripheral neurosyphilis=: The lesions of the cranial nerves were -characteristically asymmetrical. Whereas the left third nerve looked -entirely normal, the =right third nerve= had its diameter reduced -two-thirds. On the other hand, the fourth nerves were equal and -apparently normal. The sensory portion of the left fifth nerve was -normal; the right fifth nerve was normal. The =right sixth nerve= agreed -with the right third nerve in being atrophic, and was in fact reduced to -a mere thread without contained nerve fibres at a point 2 mm. from its -superficial origin. Although the right third nerve was atrophic, it was -the =left seventh and eighth nerves= which had become atrophic; the -process had spared the right seventh and eighth nerves. The remainder of -the cranial nerves were grossly normal, except that the =optic nerves= -had an outer zone of a translucent nature. So far, no spirochetes have -been demonstrated in any portion of the nervous system of this case, but -such asymmetrical and focal cranial nerve lesions are perhaps due to -local spirochetal infection, punctuating (as it were) the diffuse -process. - -How much of the transient blindness, deafness, and ocular paralysis can -be explained on the anatomical findings in these nerves? Possibly a -portion of the phenomena can be so explained. Thus, the mechanical -conditions of pressure inside and outside these nerves, both in their -peripheral course and in their passage through the membranes, can be -readily understood to differ during the acute and subacute inflammation, -during the process of repair in the pial tissues, and during the process -of overgrowth of neuroglia tissue about the superficial origins of the -nerves. Of course, the majority of lesions of these nerves were entirely -extinct at the time of the autopsy, and their history could be surmised -only from the appearances in the _left eighth nerve_. Here occurred a -sharply marked focal area of gliosis with apparently total destruction -of nerve fibres and related with a _lymphocytosis_ of the investing -membrane (one of the few areas of lymphocytosis found anywhere in this -case). - -If it were not for the pre-infective history, the hysterical dysphasia -and dypsnea, the youthful obsessions, the migrainous tendency, and the -psychopathic inheritance, we might be tempted to try to explain the -transient blindness, the deafness, and ocular palsies on the basis of -mechanical and toxic variations in the conditions of the peripheral -cranial nerves. The existence of a trace of lymphocytosis in the left -eighth nerve leads to the hypothesis that treatment might still be -effective in this particular region (see below in discussion of spinal -symptoms). - -=Spinal neurosyphilis:= Not only the spinal cord but also the posterior -and anterior nerve roots exhibited severe lesions. These lesions were -both meningeal and parenchymatous. The meningeal process differed in its -intensity in different parts of the spinal cord, being severest in the -thoracic region. At one point in this region, the dura mater was so -firmly attached to the pia mater that the line of demarcation between -the two membranes was hard to make out. In fact, it seems clear that -there could have been no free intercommunication between the spinal -fluid above these adhesions of dura to pia mater and the spinal fluid -below the adhesions. Accordingly, it seems that _lumbar puncture_, had -it been practised in this case, _would have failed to show features -representative of the whole cerebrospinal fluid system_. Moreover, since -at no point in this region of adhesions or in the pia mater of the -spinal cord below this point, were found any lymphocytes, it seems clear -that the ordinary lumbar puncture would have failed to reveal a -pleocytosis. Whether this fluid would have yielded a positive globulin -and excess albumin test, it is now impossible to say; but it appears -that the process in the lower part of the spinal cord was to all intents -and purposes extinct. - -However, there was one region of more severe inflammatory involvement. -The _spinal cord in the cervical region showed a lymphocyte -infiltration_ of its vessels amounting to a mild myelitis (meaning, -thereby, an inflammatory process of the spinal cord remote from the pia -mater). Moreover, in this region, there was, besides the perivascular -infiltration of the substance, also an infiltration of the overlying -membranes themselves, especially in and near the posterior root zones. - -The lessons of this finding are several: The inflammatory process in -this case does not appear to have been entirely extinct! Can we not -suppose that treatment might still have benefited this local -inflammation (perivascular infiltration of the cervical spinal cord -substance and overlying lymphocytic meningitis)? Can we not also picture -the gradual ascent of the inflammatory lesions from lower segments to -higher segments and possibly conceive of the gradual elevation of the -zone of hyperæsthesia manifested in this case as following the gradual -displacement upward of the lymphocytic process? Are there spirochetes in -this tissue? So far none have been discovered, possibly through -inaccuracies of available technique. To the neuropathologist, however, -the lesion looks like a local reaction to organisms. - -In addition to the spinal meningitis, chronic and acute, as above -described, there were extensive parenchymatous spinal lesions. - -In the first place, the meningitis had affected practically all the -posterior roots so that the explanation of the posterior column -sclerosis of this case is clear. The meningitis had apparently been so -marked, also, that all the fibres anywhere near the periphery of the -spinal cord had been likewise destroyed. The posterior columns and the -posterior root zones were markedly sclerotic; or as we say (having -reference to the overgrowth of neuroglia tissue) gliotic. But there was -as much sclerosis (gliosis) of the lateral columns (particularly in the -posterior two-thirds) as there was in the posterior columns and root -zones. In fact, the entire posterior half or two-thirds of the spinal -cord markedly outstripped the anterior portions of the cord in the -severity of the gliosis (sclerosis) shown. - -But although we can explain the posterior column sclerosis, the -sclerosis of the posterior root zones and the marginal sclerosis -(_Randsklerose_) round the entire periphery of the cord, on the basis of -long-standing effects of old meningitis, we cannot thus explain another -finding, namely, the destruction of the fibres in the lateral columns. -This, in fact, is explained through lesions (mentioned below) that -affected the encephalon. The net result of all these lesions of the -spinal cord was to leave only the gray matter and a small amount of -surrounding fibres (belonging to short tracts uniting nearby segments) -intact. Briefly stated, =every long tract in the spinal cord appeared -upon examination to be extensively degenerated=. The genesis of this -parenchymatous loss was, however, double, being in part due to a local -meningeal process (sometimes known as “perimeningitis”) and in part due -to a cutting off of the pyramidal tract fibres on both sides by lesions -higher up in the nervous system. - -[Illustration: - - CASE I. SPINAL CORD (THREE LEVELS) SHOWING: - - A. Marginal sclerosis—effect of old meningitis now extinct. - B. Posterior column sclerosis—effect of meningitis about posterior - roots also now extinct. - C. Bilateral pyramidal tract sclerosis—effect of cerebral thrombotic - lesions. - - Note distortion of tissues in B and C, partly artificial (tissues in - places diffluent). -] - - - =ANATOMICAL FORMULAE= - - =MENINGOVASCULOPARENCHYMATOUS INVOLVEMENT= - - M, V, P, or Combinations Applied to the Classification of Head and - Fearnsides - - I. SYPHILIS MENINGOVASCULARIS - CEREBRAL FORMS M or V or MV[3] - HEMIPLEGIA V - AFFECTION OF THE CRANIAL NERVES M - MUSCULAR ATROPHY M - LATERAL AND COMBINED DEGENERATIONS M - EPILEPSY M or V - - II. SYPHILIS CENTRALIS - DEMENTIA PARALYTICA MVP or VP - TABES DORSALIS MP - MUSCULAR ATROPHY P - OPTIC ATROPHY P - GASTRIC CRISES (M? or) P? - - EPILEPTIC MANIFESTATIONS P? - - CHART 3 - - -Can we offer any explanation of the =partial return of knee-jerks= after -their temporary total loss at a certain period of the disease? We may -assume that the knee-jerks were functionally lost about a year before -the death of the patient through the partial or even almost complete -destruction of the entering posterior root fibres at that level of the -spinal cord which is directly related with the knee-jerk. The later -partial return of the knee-jerks apparently requires us to suppose the -maintenance of some fibres and collaterals by which a functional -connection can be effected between the fibres of the posterior roots and -the anterior horn cells which innervate the quadriceps femoris. Let us -now suppose that _pari passu_ with the actual return of the knee-jerks, -the destructive processes that are affecting both pyramidal tracts high -up in the nervous system are now advancing. It is clear that, whatever -inhibitory influence these pyramidal tracts have been exerting up to -this time upon the knee-jerk reflex arc, that influence is now to be -decidedly reduced in amount and possibly absolutely lost. Upon the loss -of such inhibitory influences exerted from above, the few persisting -connections of the posterior roots and anterior horn cells are now -permitted to resume their functions. - -=Encephalic neurosyphilis=: The lesions mentioned above as causing -destruction of the pyramidal tracts of the spinal cord were -symmetrically destructive and atrophic lesions of the gray matter of -both corpora striata with atrophy of the anterior segments of the -internal capsules. There was a degenerative process of the corpus -callosum especially affecting the forceps minor of the tapetum. The -ventricles were largely dilated, indicating a considerable destruction -and atrophy of the white matter in general. - -After the above discussion of the possible effects of pyramidal tract -lesion in this case, it is unnecessary further to discuss the paraplegia -produced by the cystic lesions of the corpora striata. The theorist -might inquire how these cystic lesions are produced: whether by vascular -blocking or by toxic effects of the accumulations of spirochetes. -Evidence is lacking which would completely sustain either hypothesis. -Still, we do know that lesions almost identical in appearance may be -produced by the necrosis consequent to the plugging of nutritive vessels -in an organ like the brain supplied with end arteries. Therefore, it is -probable that most pathologists would believe these lesions of the -corpora striata to be produced by vascular plugging of the nature of -thrombosis. - -It is worth while to note that there was a suggestion of foci of -encephalitis made out upon the gross examination. The cortex in general -showed strikingly few lesions. However, the convolutions did show in -places numerous ill-defined areas of hyperemia and slight swelling. -These areas were of irregular distribution and only a few mm. or cm. in -diameter. No gross vascular lesions were demonstrable in connection with -these focal areas. Microscopically, however, venous plugs of -polymorphonuclear leucocytes were found, and the local hyperemias were -found to be largely due to venous congestion. However, very few -polymorphonuclear leucocytes were found outside the blood vessels. - -The white matter of numerous convolutions showed microscopically certain -pale spots suggestive of an early atrophic process. Very possibly these -represent a general tendency in the cerebrum to the same process of -parenchymatous loss which had proceeded to such a marked degree in the -spinal cord. - -There was a single large so-called cyst of softening in the cerebellum -(1.5 mm. across by 0.5–7.5 cm. in depth). - -How far can we explain the symptoms of this case on the basis of these -encephalic lesions? We can offer no correlation with the cerebellar -lesion; and possibly this lack of correlation is to be expected on -account of its failure to affect the vermis. As to the cystic lesions of -the corpora striata, their effect in producing paraplegia at the close -of life is obvious, and their possible relation to the partial return of -knee-jerks has been discussed. Literally amazing was the comparative -integrity of the cortical gray matter of this case when the spinal cord -and the interior structures of the encephalon had been subjected to such -severe and numerous lesions. The only mental symptoms noted in the case -were sundry delusions directed against the patient’s relatives and a -certain optimism which led the patient to cling as if with an obsession -to the belief that in the end she would get well. - - - =VARIOUS FORMS OF NEUROSYPHILIS COLLECTED FROM SEVERAL SOURCES= - - =MENINGEAL NEUROSYPHILIS (M)= - - GUMMA OF DURA MATER M - GUMMATOUS MENINGITIS (PIAL) M - SYPHILITIC MENINGITIS (PIAL) M - SYPHILITIC CRANIAL NERVE PALSIES (PRIMARILY PIAL) M - SYPHILITIC BULBAR PALSY M - SYPHILITIC ROOT NEURITIS M - SYPHILITIC TRANSVERSE MYELITIS M - SYPHILITIC NEURITIS (SOME CASES BY EXTENSION) M - SYPHILITIC EPILEPSY (SOME CASES) M - SYPHILITIC MUSCULAR ATROPHY (SOME CASES) M - - =VASCULAR NEUROSYPHILIS (V)= - - SYPHILITIC ARTERIOSCLEROSIS V - SYPHILITIC CEREBRAL THROMBOSIS V - SYPHILITIC APOPLEXY V - ANEURYSM V - SYPHILITIC EPILEPSY V - - =PARENCHYMATOUS NEUROSYPHILIS (P)= - - GUMMA P - CEREBROSPINAL SCLEROSIS P - SYPHILITIC PARANOIA P? - SYPHILITIC CHOREA P - SYPHILITIC EPILEPSY P - TABETIC PSYCHOSIS P? - SYPHILITIC MUSCULAR ATROPHY P - SYPHILITIC NEURITIS P - - CHART 4A - - - =MENINGOVASCULAR NEUROSYPHILIS (MV)= - - CEREBRAL SYPHILIS MV - CEREBROSPINAL SYPHILIS MV - SYPHILITIC EPILEPSY MV - - =MENINGOPARENCHYMATOUS NEUROSYPHILIS (MP)= - - CEREBRAL SYPHILIS MP - CEREBROSPINAL SYPHILIS MP - TABES DORSALIS MP - ERB’S SYPHILITIC SPASTIC SPINAL PALSY MP - - =VASCULOPARENCHYMATOUS NEUROSYPHILIS (VP)= - - CEREBRAL SYPHILIS VP - CEREBROSPINAL SYPHILIS VP - PARETIC NEUROSYPHILIS (GENERAL PARESIS) VP - LISSAUER’S GENERAL PARESIS VP - - =MENINGOVASCULOPARENCHYMATOUS NEUROSYPHILIS (MVP)= - - CEREBRAL SYPHILIS MVP - CEREBROSPINAL SYPHILIS MVP - PARETIC NEUROSYPHILIS MVP - TABOPARESIS MVP - - =DOUBTFUL (TOXIC?, IRRITATIVE?) NEUROSYPHILIS (?)= - - “PARESIS SINE PARESI” - SYPHILITIC NEURASTHENIA - TABETIC PSYCHOSIS - SYPHILITIC PARANOIA - SYPHILITIC POLYURIA, POLYDIPSIA - SYPHILITIC NEURALGIA - - CHART 4B - - -=Summary:= We have here dealt at length with a long-standing DIFFUSE -NEUROSYPHILIS affecting to some extent the entire =meninges= and -producing a destruction of posterior column fibres and numerous other -fibres of the spinal cord (=tabetiform= portion of the neurosyphilis -=picture=). We have also found central lesions of the corpora striata -affecting the destruction of both pyramidal tracts (=paraplegic= portion -of the neurosyphilis =picture=). We have found evidences of acute -inflammation (=lymphocytosis=) in the cervical region of the spinal cord -and in the left eighth nerve (=progressive inflammatory= neurosyphilis -=picture=). In short, we have presented a case of =diffuse= -(meningovasculoparenchymatous) =neurosyphilis= characterized by an -ascending character in a course of at least 16 years; we have indicated -a number of possible clinical correlations, not only with the major -portion of the clinical course (symptoms of myelitis and pyramidal tract -destruction), but we have also mentioned, merely for their suggestive -value, a number of finer correlations between histological findings and -certain clinical features (notably transient losses of vision and -hearing, and a partial return of the lost knee-jerks). Bearing in mind -the clinical and anatomical findings of this case, we shall be able to -discuss the cases that follow in a briefer and more condensed fashion. - - - =TABETIC NEUROSYPHILIS (“tabes dorsalis,” “locomotor ataxia”) - complicated by vascular neurosyphilis (hemiplegia). Autopsy.= - - -=Case 2.= Francis Garfield had been a successful lumberman and had -enjoyed good health until his forty-fifth year. Suddenly one day, while -walking on the street, Garfield lost the use of his legs and for a time -was quite unable to walk. However, he recovered locomotion and after a -time there was nothing wrong with his leg movements except a slight -ataxia. - -At the age of 52 Garfield had to give up work. It appears that he had -been becoming cranky, sometimes, for example, shouting, whistling and -slamming doors, apparently to annoy the family. His intellectual -capacity seemed to be maintained, although his memory was slightly -impaired. - -At 67 years there was an ill-defined seizure, followed a few days later -by another seizure with aphasia (wrong words used and lack of -understanding of things said). - -For years Garfield had been totally deaf in the right ear (following -explosion of a gun?). Now, however, the left ear also showed a sensory -impairment. Slight slurring of speech had been noticed first in the -sixty-sixth year. - -=Physically= there was a slightly enlarged heart with accentuated second -aortic sound and irregular rhythm. =Neurologically=, inability to stand -or walk; marked ataxia in his leg movements; upper extremities quite -well controlled; the pupils were small and unequal, the left being -larger than the right; although the reactions were difficult to test, -the pupils seemed to react slightly to direct light stimuli; the -knee-jerks were absent; tests for sensibility so far as could be -determined did not show any abnormalities; there was much complaint of -sharp pains in the legs. - -There is no doubt that we are here dealing with a case of TABES DORSALIS -plus certain complications due to VASCULAR LESIONS. The case went on to -death from rupture of =aortic aneurysm= (also doubtless a syphilitic -complication). The death occurred at 71, four years after admission to -Danvers Hospital. - - - =MAIN FORMS OF NEUROSYPHILIS= - - =(CLASSIFICATION OF THIS BOOK)= - - DIFFUSE NEUROSYPHILIS - (non-vascular forms of “cerebral,” “spinal” and “cerebrospinal - syphilis”) - - VASCULAR NEUROSYPHILIS - (“cerebral arteriosclerosis,” “cerebral thrombosis”) - - PARETIC NEUROSYPHILIS - (“general paresis”) - - TABETIC NEUROSYPHILIS - (“tabes dorsalis”) - - GUMMATOUS NEUROSYPHILIS - (“gumma of membranes, of brain”) - - JUVENILE NEUROSYPHILIS - (paretic, tabetic, diffuse) - - CHART 5 - - - =POSSIBLE INVOLVEMENT= - - =BRAIN AND CORD SYPHILIS= - - [M]embranes, [V]essels, [P]arenchyma - - [MVP] EARLY, LATENT?, SYMBIOSIS?, ATTENUATION?.... - MVP CEREBRAL, CEREBROSPINAL SYPHILIS, PARESIS MVP - [M]VP PARESIS; SYPHILITIC ARTERIOSCLEROSIS VP - M[V]P ?SYPHILOTOXIN FROM MENINGITIS MP - MV[P] SYPHILITIC MENINGITIS; CEREBRAL OR CEREBROSPINAL SYPHILIS MV - [MV]P SYPHILOTOXIC ATROPHY OR SCLEROSIS P - M[VP] SYPHILITIC MENINGITIS M - [M]V[P] SYPHILITIC ARTERIOSCLEROSIS V - - M, V or P in brackets [] means not involved. - - CHART 6 - - - =NEUROSYPHILIS= - - =SIX TESTS= - - BLOOD WASSERMANN - SPINAL FLUID WASSERMANN - SPINAL FLUID CYTOLOGY - SPINAL FLUID GLOBULIN - SPINAL FLUID ALBUMIN - SPINAL FLUID GOLD SOL - - CHART 7 - - -This case has been especially worked up and published by Dr. A. M. -Barrett on account of the fact that the vascular lesions of the brain -had produced a condition of pure word-deafness. Reference is made to the -Journal of Nervous and Mental Disease, Vol. 37, 1910, for a complete -description of the brain findings and an analysis of the word-deafness, -a summary of which is as follows: - - “Reaction to Words and Sounds.—Total deafness to words spoken, but - gives attention to sounds; no ability to recognize meaning of sounds - heard; no ability to repeat words heard. Spontaneous - Speech.—Retained ability to speak spontaneously, with rare - paraphasic utterances; occasional inability to speak readily the - word desired, but later always giving the correct reaction; - calculation fair; spelling good except for occasional paraphasia; - spelling good for words pronounced. Reaction to Things Seen.—Objects - correctly recognized and named except for an occasional paraphasic - reply; mistakes in pronunciation not recognized; correct color - recognition. Reaction to Things Felt.—Good for familiar objects; an - occasional paraphasic reply. Reaction to Words Seen.—Reads printing - and writing understandingly; unimpaired reading except for an - occasional paraphasic reply; meaning of familiar signs recognized; - slight difficulty in readily understanding meaning of arithmetical - signs. Writing.—Spontaneous writing and drawing ability retained; - ataxia (tabetic) in writing movements; no ability to write from - dictation. Internal language.—No evidence of impairment.” - -The brain post mortem showed severe atheromatous degeneration of the -arteries at the base of the brain. Both middle cerebral arteries showed -scattered atheromatous patches. The pia mater was transparent and -delicate, except in the regions of both Sylvian fissures. There were -residuals of old softening in both temporal lobes. In the fresh brain -the regions of the right and left first temporal convolutions were -sunken inward, and the pia intimately adherent to the softened areas. -The limits and more exact localizing of these softenings were worked out -from serial sections. - -Barrett found in his serial sections that, although the transverse -temporal convolutions of the left hemispheres were intact, these -convolutions were undermined throughout their entire extent by -degenerations in the fibres of the center of the first temporal -convolution. Barrett, accordingly, regarded his case as essentially a -case of subcortical tissue destruction. He agrees with various authors -that the pure word-deafness of his case is the result of an isolation of -the receiving station in the transverse convolutions of the left -hemisphere. The tissue destruction produced by the vascular lesion had -cut off the transverse convolutions from the internal geniculate body. - -We are here, however, not considering the origin and relations of pure -word-deafness but present the case as one of =tabes dorsalis= of 20 -years standing, terminated by two characteristic syphilitic -complications, first, an extensive destruction of brain tissue through -=cerebral thrombosis= and secondly, =fatal aortic aneurysm=. - -=Summary=: We have here dealt briefly with a long-standing case of -NEUROSYPHILIS of the TABETIC type: A characteristic but not necessary -complication of the case is the LATE CEREBRAL VASCULAR INVOLVEMENT. The -=posterior column sclerosis= is virtually the only spinal change. Spinal -meningeal changes are absent (although it is to be assumed that chronic -inflammatory changes in the posterior roots were at one time present in -some quantity and although the spinal fluid characteristically shows -lymphocytosis in tabetic neurosyphilis). - -Whether the spirochetes produce special toxic components able to cause -tabes or whether special kinds of spirochete are the tabes-making kinds -is hard to say. Special qualities of individual tissue may be involved. - -The =cerebral lesions= of a =cystic= nature are of vascular origin, like -the differently localized encephalic lesions of Case 1 (Alice Morton). -Vascular syphilis is not a special property of the vessels of the -nervous system. In fact this very case died of =aortic aneurysm=. - - - =PARETIC NEUROSYPHILIS (“general paresis,” “dementia paralytica,” - “softening of the brain”). Autopsy.= - - -=Case 3.= James Dixon, 44, was first seen at the Danvers Hospital, -reciting verses in a dramatic and noisy way. He remained good-natured -and jolly; nor was there any change in his euphoria until he had become -physically weaker and more generally demented. In fact, Dixon appeared -to become more and more expansive as he became physically weaker. He was -in the habit of describing himself as “O. K., No. 1, Superfine.” - -=Physically= the patient was gray and bald on vertex, had a dusky -complexion, was very thin (6 ft. in height, weight 155 lbs.); the mucous -membranes were pallid; the teeth rather poorly preserved; the heart was -somewhat enlarged; the pulse irregular in rhythm, of poor volume and -tension. - -=Neurologically=, the patient showed a characteristic Romberg sign and -ataxia in walking a straight line. The tremulous tongue was protruded to -the left, and there was a coarse tremor of the extended fingers. The -knee-jerks were absent, and the Achilles jerks could not be obtained; -the plantar reactions were slight; the arm reflexes were present. The -pupils were stiff to light. There was a marked vocal tremor. The -sensations could not be tested on account of the patient’s mental state. - -It appears that Dixon had left school at about 16, at about 22 had gone -into the provision business, and later had become a hotel clerk. He had -married at 28; there had been two miscarriages, at three months and six -weeks respectively; one child was stillborn; four children were living. - -The patient was not very alcoholic. The patient’s wife thought the -symptoms had been coming on since his forty-first year when irritability -set in, but he was not discharged from work until about a year since. He -was taken back again after his wife’s pleas, and remained at work about -three months; but for ten months before admission to the hospital, Dixon -had done practically nothing, had shown a marked memory failure and -speech defect, at the same time claiming to be a person capable of doing -and accomplishing everything. He had become careless of his personal -appearance, collected a drawer-full of stumps of cigars, carried lumps -of coal in his pocket, laughed causelessly, and spat on the carpet. - -We here deal with a case of unknown duration from the initial infection, -but with symptoms lasting about three years and three months. Aside from -the cause of death (empyema of left pleural cavity associated with acute -hemorrhagic splenitis, acute ileitis, and bronchial lymphnoditis), the -body showed a number of other lesions outside the nervous system. There -was the usual sclerosis of the aorta, though perhaps less marked than -usual. There was a curious acute arteritis with fusiform dilatation of -the arteria profunda femoris, with an edema of the thigh muscles and -blebs of the overlying skin. There were also multiple chronic caseating -lesions of the liver, without evidence of fibrosis. The explanation of -these liver lesions is not yet clear. There was a cloudy swelling of the -kidney. - -The calvarium was dense and the dura mater thick and adherent. There was -a chronic leptomeningitis, which, however, was rather unusual in being -most marked in the posterior cisterna and along the sulci of the -cerebellar hemispheres. There was a general cerebral sclerosis, with a -question of atrophy of the superior temporal gyri (suggesting the -so-called Lissauer’s paresis). There was a marked cerebellar sclerosis -with a consequent sclerosis (grossly palpable) of the commissural fibres -of the pons. There was a generalized slight spinal sclerosis. As a fair -sample of the variety of head findings in paretic neurosyphilis, the -details of the =head examination= are presented. - -[Illustration: - - A. Normal postcentral cortex. (Compare B.) -] - -[Illustration: - - B. Nerve cell losses. Perivascular deposits of mononuclear cells, - amongst which are numerous plasma cells. Note decrease in number of - nerve cells. Note irregular disposition of nerve cells. From paretic - neurosyphilis. -] - - Crown bald, with a slight fuzzy growth of short hairs. Scalp - slightly adherent to calvarium; latter of usual thickness but denser - than normal. Dura adherent to calvarium in region of vertex; dura - not remarkable. Sinuses normal. Arachnoid villi moderately - developed. Pia mater a trifle thickened and rather evenly throughout - the cerebral portion. Linear sulcal markings are remarkable for - their absence. The wall of the cerebellomedullary cisterna is thick - and opaque. The most prominent pial thickenings are over the - cerebellum. These are linear or may show feathery out-growths and - are seated over the sulci, particularly in the neighborhood of the - fissure and about the great cerebellar notch. They correspond fairly - well with the focal variation in consistence of underlying tissues - noted below. - - =Brain= weight, 1265 grams. Consistence somewhat increased - throughout and somewhat evenly increased. The prefrontal region - shows the maximal increase of consistence but the remainder of the - frontal region and corresponding occipital region are much firmer - than normal. The two superior temporal gyri appear to be firmer than - adjacent gyri and are possibly slightly diminished in superficial - diameter. The hippocampal gyri are fairly firm. The substance on - section is a trifle more moist than normal. The gray and white - matter cut quite evenly. Diminution in depth of gray matter, if - existent, could not be demonstrated. The ventricles show a moderate - sanding throughout, best marked in the fourth ventricle. The basal - ganglia are not remarkable except for the development of numerous - dilated perivascular spaces about the lenticulostriate vessels. The - =pons= is atrophic, but more so on the right side. The pons, like - the prefrontal cortex, shows on section a distinct increase of - consistence immediately beneath the pia mater. The white bands of - the pons on section are distinctly firmer than the intervening - substance. The olives are of equal consistence. Weight of - cerebellum, pons, and medulla, 155 grams. The =cerebellum= shows an - obvious atrophic and gliotic process of a symmetrical character. The - superior surface, including both vermis and hemispheres, shows a - consistence above normal and general reduction of the depth measured - from the white matter. The reduction in depth gives rise to a - visible depression as compared with tissue posterior to the - postclival sulci. The lobus cacuminis, though slightly raised from - the surrounding lobes, is equally firm, if not firmer. The superior - and inferior surfaces show practically an equal increase of - consistence. The dentate nuclei are not especially increased in - consistence. The flocculi are reduced in size about one-third. - - There was slight universal increase in consistence of =spinal cord=, - best marked in lumbar region. - - =Microscopic findings= are here presented merely in sufficient - detail to establish the diagnosis. The left superior frontal gyrus - shows extensive and somewhat irregular cellular and fibrillar - gliosis of the plexiform layer, together with an increase of - thickened vessels having lymphocytes and plasma cells in their - sheaths. - - The perivascular infiltrations are most extensive in the lower - layers of the cortex. The lamination is in places thoroughly - obscured, except that representatives of the layer of large external - pyramids are almost always demonstrable. - - The layer of medium-sized pyramids has undergone more numerical loss - of elements than have the other layers. - - Gliosis of white matter. - - Specimens from the cerebellum show a destructive process of great - severity, but a little irregular in extent, affecting chiefly the - Purkinje cell belt. The Purkinje cells are often absent throughout - one side of a given lamina, and there has ensued a dense - accumulation of neuroglia cells along a former Purkinje cell belt, - together with a considerable gliosis of the molecular layer. - Considerable gliosis of the white matter, both diffuse and - perivascular in distribution. - - Perivascular plasma cell infiltrations as in cerebrum, but largely - meningeal or in the white matter. - - Sections from the corpora striata demonstrate a mild and early - granular ependymitis, considerable subependymal gliosis of cellular - type, considerable perivascular gliosis in the white portions of the - tissue, and a moderate infiltration of perivascular sheaths with - pigmented cells, lymphocytes, and plasma cells. There is little - evidence of alteration in the nerve cells. Some are unevenly - pigmented. - -=Summary=: We here present a case with numerous and widespread -neurosyphilitic lesions. However, the gross cerebral vascular -complications of Case 1 (Alice Morton) and of Case 2 (Francis Garfield) -are notably absent in James Dixon. Rather atypical (there seems to be -_always something atypical in cases of neurosyphilis!_) are the liver -lesions and arteritis of the leg, atypical, that is to say, for PARETIC -NEUROSYPHILIS. Highly typical of paretic neurosyphilis and almost -constant therein is the aortic sclerosis. - -[Illustration: - - Apparent new formation of small blood vessel. Photographed by Dr. A. - M. Barrett. -] - -[Illustration: - - Rod cells (Stäbchenzellen) in paretic neurosyphilis. Photographed by - Dr. A. M. Barrett. -] - -[Illustration: - - Granular ependymitis—microscopic appearance of a marked example of - “sanding” of ventricle. -] - -Characteristic and constant in paretic neurosyphilis is the -=Plasmocytosis and Lymphocytosis, Perivascular= in distribution about -small cortical vessels. There is also a characteristic (though -characteristically less prominent) =Plasmocytosis and Lymphocytosis, -Meningeal= in distribution. The pleocytosis of the spinal fluid, almost -constant though variable in amount in life, is an indicator of the -meningeal picture and less directly of the parenchymatous picture. - -=Granular Ependymitis= (“sanding” of ventricle floors) is characteristic -and may be regarded as part of the parenchymatous picture. This -ependymitis is an indicator how chemical changes could be readily -produced at least in the ventricular fluids, since the limiting -membranes of the nerve tissue are here subject to multiple breaks. The -“sanding” is a neuroglia reaction to these multiple small breaks -(Weigert’s explanation). - -Parenchymatous losses have led to =Atrophy and Sclerosis=, of very -varying extent in different parts of the encephalon. The atrophy is -characteristic in paretic neurosyphilis, but by no means constant. -Numerous cases have come to autopsy without clearly defined gross -atrophy. Sclerosis is also characteristic and even more frequent than -atrophy, doubtless because sclerosis represents an earlier phase of a -process eventuating in gross atrophy. - -A =Tabetiform Picture= characterizes the spinal cord, but in this case -the tabetic clinical picture did _not_ precede the paretic clinical -picture. We are consequently to regard the tabetic spinal process as -incidental and on all fours with the =Cerebellar and Pontine Atrophy=. - - - =VASCULAR NEUROSYPHILIS (“syphilitic cerebral thrombosis”). - Autopsy.= - - -=Case 4.= James Pierce was an almshouse transfer to the Danvers Hospital -in his fiftieth year. He died three years later. The accompanying brain -pictures demonstrate so extensive a lesion of the left hemisphere that -it is of great interest to determine if possible the genesis and course -of his disease. It appears that syphilis had been acquired somewhere -about the age of 38 or 40, so that the total duration of the process was -between 13 and 15 years. In Pierce’s forty-third or forty-fourth year, -he had a shock while walking in the streets of his native city, -whereupon he was subsequently transferred to the Danvers Hospital, whose -data have been summed up as follows (we are obliged to Dr. Charles T. -Ryder for these data): - - =Neurological examination:= Neuromuscular condition: Barely able to - walk or stand without assistance; hemiplegia of right side; swings - foot out and drags toe out and around in attempting to walk. Right - hand held by side, flexed at right angle; fingers contracted and - thumb thrown across palm. Can lift arm from side; practically no - movements of forearms or fingers; atrophy of deltoid, arm, forearm, - and hand. Muscular movements of left upper extremities fairly well - performed; good strength. - - =Cranial nerves:= Refuses to respond to any tests to determine - hearing or vision, but evidently hears what is said to him, and in - his movements gives no evidence of deafness. Right corner of mouth - droops; tongue protrudes straight. - - =Reflexes:= Pupils dilated; margins irregular; left pupil larger; - they vary in size but it is impossible to determine whether the - variation is due to light or accommodation reflex. Reflexes of right - side extremely exaggerated throughout; there is little ankle clonus; - Babinski is not obtained, patient holding his toes in flexed - position in resisting attempts to elicit reflexes. - - =Sensations:= Reaction to pain stimuli on either side. Evidently - some anesthesia on right side, but pressure is apparently very - painful. There is considerable spasticity of limbs on right side on - passive motion. Too demented to make accurate tests. - - The above examination was made on May 6, 1904. On May 20th the - record states: - - There is almost complete sensory aphasia with word-deafness; some - paraphasic circumlocution. Many of his words are very well - enunciated but have no meaning. Is apparently unable to recognize - objects or their uses. - - Brother stated that he was always supposed not to be over bright. - Physician’s certificate states that he is epileptic, averaging two - attacks per week. On the 15th of May he had a general convulsion; - was unconscious for half an hour, and dull and drowsy for two hours - afterwards. On the 19th, he had a similar attack in the afternoon, - the convulsion lasting a minute, and he was stuporous for an hour. - - On November 8th he had a severe epileptic convulsion. His body was - curled up to the right. The convulsive seizure lasted for two - minutes and was followed by complete unconsciousness for an hour, - when the patient roused and appeared as usual in a few minutes. From - that time to December 15th he had five epileptic convulsions; he was - much more feeble, and unable to help himself as much as formerly. - - Nov. 7, 1905: Patient has had occasional convulsions since last - note, but none during the last three months. He is confined to bed, - has become very much demented, and shows very marked speech defect, - so that he is almost unintelligible. He understands only the - simplest directions. Legs are considerably contracted and knees are - flexed. Arm and hand on the right are paralyzed and show some - atrophic changes; partially flexed. Left elbow jerk is very lively. - On May 23, 1906 he was reported as having Achilles on right side - only, and Babinski on right side. He died January 5, 1907. - - =The autopsy findings= were as follows: - - =Head:= Calvarium of moderate thickness; diploë present; dura - slightly adherent over bregmatic region. Longitudinal sinus contains - cruor clot. Dura is somewhat thickened and slightly more opaque than - normal. Pacchionian granulations, small but fairly numerous. Pia - contains throughout a considerable excess of clear serous fluid. The - convolutions in general are of good breadth and proportion. There is - an atrophic area roughly circular in outline and about 2 cm. in - diameter in the posterior part of the right third frontal - convolution corresponding to Broca’s area on the opposite - hemisphere. The space thus formed is filled with edema held by the - pia. On the left side is a similar subpial collection which covers - the site of the posterior portions of all of the third frontal - convolutions, parts of the lower end of the precentral convolution, - and the whole of the first temporal convolution, which have - disappeared entirely. The basal vessels show slight changes. - - Cerebellum and basal ganglia are grossly normal. - - The spinal membranes are negative. The regions of the pyramidal - tracts in the cord are firm, project slightly from surface of - section, and are china white. - -=Summary:= Here is a picture made up almost purely of VASCULAR -NEUROSYPHILIS, with SECONDARY SPINAL (PYRAMIDAL TRACT) CHANGES. -Doubtless the genesis of this picture is allied to that of Case 1 (Alice -Morton) and to that of the terminal vascular complications in a tabetic, -Case 2 (Francis Garfield). - -The absence of meningeal and parenchymatous (i.e., outside the region of -necrosis produced by the vascular disease) lesions is characteristic of -an important group of neurosyphilitic diseases. It is clear that the -case, although one of _extensive_ lesions, is _not_ one of _diffuse_ -lesions in the sense of Case 1 (Alice Morton). - -The spinal fluid picture in life may nevertheless show (as other cases -amply demonstrate) a certain amount of lymphocytosis and possibly -plasmocytosis, together with a variety of other changes. Treatment might -be expected to keep down these associated changes, although obviously -the effects of the necrosis are final and definite. Franz in Washington -has succeeded in “reeducating” some of these hemiplegics, employing -lower mechanisms of the nervous system. - -[Illustration: - - Vascular neurosyphilis—effects of syphilitic thrombosis of Sylvian - artery 10 years before death. (Case 4.) -] - -[Illustration: - - =Case 4.= (See previous figure for brain lesion.) Three levels of the - spinal cord showing unilateral pyramidal tract sclerosis, 10 years - after cerebral thrombosis. -] - - - =JUVENILE PARETIC NEUROSYPHILIS (“juvenile paresis”). Autopsy.= - - -=Case 5.= John Lawrence was an under-sized negro, who came under -hospital observation when he was 23 years of age. There was some -evidence that the patient’s father was a neurosyphilitic although -accurate data were out of the question. At all events, John had -Hutchinsonian teeth, a forward bowing of the tibiae, and -Argyll-Robertson pupils. These findings together with a history of -backwardness at school seem to stamp the diagnosis. It seems that there -had been a change for the worse from the age of 18, though the boy had -been able to sell newspapers and black shoes up to within a year of his -arrival at the hospital. During the last months of his life, he showed a -general incoördination, with false movements suggesting those of a -drunken person. There were numerous tremors, the glance was shifting, -and there was a tendency to nystagmus. Some of these phenomena (taking -into account that the Hutchinsonian teeth were not entirely typical and -there was even at times some doubt as to whether the pupils were -actually stiff) led to a question of the diagnosis multiple sclerosis. - -There was, however, little doubt that the case was one of juvenile -paresis. Among the symptoms found at various times in this case are the -following: disorientation for time, place and persons, confusion, with -coarsely irrelevant replies to questions, ill-defined and transitory -delusions of persecution, auditory, tactile, and visual hallucinations, -and defective memory. - -Early in life, the patient had had a habit of falling asleep in school -hours, and had experienced a number of falls at various times. During an -attack of measles he had had a number of spasms, each of which lasted -ten minutes or more. - -The =autopsy= showed death to be due to an early bronchial pneumonia. -The thymus was persistent, measuring 3 × 2 × .5 cm. The marrow of the -femur was red. - -There was a moderate degree of =sclerosis of the aorta= confined to a -few plaques in the arch (not a characteristic syphilitic scarring of the -aorta). The spleen was small and had a thickened capsule. - -The majority of the lesions, however, were in the =nervous system=, and -the following description is taken from the routine hospital records to -exemplify the findings in a fairly characteristic case of JUVENILE -PARESIS. - - =Head:= Scalp closely adherent to =calvarium=. Calvarium heavy - without diploë. =Dura= adherent to calvarium in bregmatic region. - Sinuses contain liquid blood. Arachnoidal villi in considerable - quantity. =Pia mater= contains considerable clear fluid and shows - diffuse haziness and focal thickenings. The diffuse haziness is - almost universal and is best marked over the superior surface of the - cerebellum. The focal thickenings are of general distribution over - the veins of the sulci on the superior surface of the brim and are - heaped up to form considerable linear mounds near the region of the - arachnoidal villi. The superior surface of the cerebellum is - traversed by similar linear mounds of fibrous tissue running at an - angle to the laminæ. There is no notable increase of fibrous tissue - at the base. - - =Brain:= Weight 965 grams. The sulcation is roughly symmetrical - except in the occipital poles where there is unusually rich and - complex but shallow sulcation. The cortical substance is everywhere - firmer than normal, but the sulci fail to flare notably. In a few - places there is a focal increase of consistence of still greater - degree with apparent local hypertrophy (or gliosis with increase of - substance). These foci are in the right second temporal gyrus (3 cm. - in diameter) and in the left first temporal gyrus (of same size but - somewhat less firm) and are of a whitish, waxen appearance, being - visible several feet away by reason of their color and apparent - encroachment upon the adjacent sulci. The foci are sharply limited - by the sulci laterally, but pale out gradually before and behind. - - The convolutions of the vertex show another type of lesion. The - tissue of the greater part of the vertex resembles that of the - flanks and base in being firmer than normal and of a grayish pink - color. Behind the fissure of Rolando on the right side and behind - the anterior limits of the ascending frontal region on the left side - the brain tissue of the vertex becomes suddenly still firmer and of - a yellowish gray color. This lesion disappears gradually into the - occipital microgyria behind and the gyri gradually lose their - yellowish tint. The lesion fades away gradually so that it fails to - involve the temporal convolutions. - - The cerebral tissue cuts firmly and smoothly. The tissue of the - frontal region is a little edematous. The white matter is of a - normal appearance. The ependyma of all the ventricles is somewhat - sanded. The fourth ventricle is most affected. - - The =cerebellum= is not edematous and is as firm as the normal - olivary bodies. The cerebellar hemispheres are symmetrical and of a - normal appearance, save that the laminæ are slightly narrower than - usual and very compactly set. The color, where not obscured by the - haziness of the pia mater, is of a grayish pink somewhat suggestive - of freshly tanned shoe leather. The substance cuts smoothly and - firmly. The dentate nuclei are unusually firm. The =pons= is small, - but of the usual color. Lower structures normal except the =cord= - which is small and shows curious deviations from the normal - markings. The posterior horns and gray commissure are at many levels - the only structures to preserve the normal gray appearance, so that - the H or butterfly appearance is replaced by a crescent. At these - levels, traces of gray matter often stand out in the loci of the - anterior horns. - -The important =anatomical diagnoses= in the nervous system are as -follows: - -Atrophy of cerebrum, 965 grams (there is of course a question whether we -are not dealing with a degree of cerebral hypoplasia). - -Focal scleroses of cerebrum, suggesting the tuberous scleroses of -Bourneville. - -Occipital microgyria. - -Cerebral and cerebellar gliosis. - -Chronic ependymitis. - -Gliosis of the gray matter of the spinal cord. - -Chronic diffuse and focal leptomeningitis. - -The =microscopic examination= confirmed the diagnosis of paresis. The -hypertrophic nodules were of special interest. They were found to be -overlain by a characteristic though thin exudate of lymphocytes and -plasma cells, together with pigmented cells. The nodules appeared to be -supplied with an unusual number of vessels of small calibre, about which -were a few lymphocytes. The large vessels and those with well developed -adventitiæ were surrounded by more numerous lymphocytes and by more -focal accumulations of pigmented cells. The cortex in the middle of a -nodule had almost lost its characteristic cortical layering. The cortex -was here reduced (specimen from temporal lobe) to about one-quarter of -its normal thickness, and was found to be composed largely of expanded -neuroglia cells and vascular tissue, with a few nerve elements, small, -shrunken, and dark-staining. The destructive process appeared to have -borne hardest on the layer of internal large pyramids and the fusiform -layer. There was, however, nowhere any evidence of focal necrosis such -as ought to characterize a true gumma. The sections stained by the -Marchi method failed to show evidence of fatty degeneration within the -focus, although there was a marked diffuse accumulation of fatty -granulations along the nerve fibres in the underlying white matter. A -special study of the cerebellar material was made by one of the -authors.[4] Occasional Purkinje cells showed the characteristic -binucleate condition, which has frequently been noted in recent -literature. - -The cerebellum of this case was perhaps the most markedly diseased of -all portions of the nervous system. As noted, the cerebellar tissue was -exceedingly firm. How far the notable incoördination of the case (he was -observed on staff rounds characteristically curled up in a heap, showing -quite an unusual degree of general incoördination) was due to the -cerebellar lesions, it is perhaps not possible to say. - -=Summary=: John Lawrence, JUVENILE PARETIC NEUROSYPHILIS, is a foil to -Case 3 (James Dixon), paretic neurosyphilis due to acquired syphilis. - -Both showed =Cerebral Atrophy=, but Lawrence the more markedly because -of hypoplasia incidental to the congenital origin of his condition. - -Whereas Dixon gave little or no sign of =stigmata=, Lawrence (besides -being under-sized, having suspicious teeth, and showing at autopsy a -persistent thymus) showed a =Hydromyelia= and curious trefoil shape to -the spinal cord. Dixon on the other hand had liver lesions and arterial -lesions of the leg. - -The suggestion of =Tuberous Sclerosis= in Lawrence is not found in -Dixon; but we have not found it elsewhere. Bourneville did not describe -tuberous sclerosis as syphilitic. - -Binucleate Purkinje cells emphasize the congenital source of the lesions -in Lawrence. - -=Plasmocytosis and Lymphocytosis=, =Perivascular=, and (less marked) -=Meningeal=, are found in both the congenital and the acquired cases, as -also parenchymatous changes, both =nerve cell losses= and =gliosis=. -Both also show granular =ependymitis=. - -It is clear that, over and above the factors of destruction evident in -both Lawrence and Dixon, the congenital case, Lawrence exhibits also the -effects of arrest (in brief not merely atrophy but also hypoplasia). -Early treatment is, therefore, theoretically indicated in the juvenile -group, which means early diagnosis. Early diagnosis and treatment are -still more to be recommended because these juvenile cases progress often -very slowly at first. - - - =FOCAL BASILAR MENINGEAL NEUROSYPHILIS (“syphilitic extraocular - palsy,” plus other symptoms). Autopsy.= - - -=Case 6.= Flora Black, a housewife of 43 years, had been tired out for a -year but had been apparently in fair health. She awoke one day with -double vision due to a left internal strabismus. The visual difficulty -gradually passed away so that five months after the sudden seizure she -was apparently quite well again. There was one exception: about three or -four months after the attack of diplopia, Mrs. Black had begun to feel a -kind of weakness in various parts of the face and there were also fairly -definite paresthesiæ. In the sixth month after the initial attack, the -patient began to be unable to chew and was fain to support the lower jaw -with a bandage to aid in mastication. Deglutition was, however, quite -unaffected and there was never any regurgitation of food. There were -pains in the face, the forehead and the back of the neck. - -Upon =physical examination= at entrance to a general hospital, no -changes in the body at large were discoverable. There was a slight edema -of the ankles, otherwise no sign of bodily disease. - -Conditions in the =head= were as follows: The facial lines were (notes -by courtesy of Dr. E. W. Taylor) smoothed out; both upper and lower -eyelids and the corners of the mouth drooped slightly and more markedly -on the left side. There was slight photophobia and considerable -lachrymation. The patient was unable to pucker forehead, nose or mouth. -The unsupported lower jaw fell and the patient was unable to open the -mouth widely. The movements of the tongue were normally performed. -Speech was mumbling. Sensations of touch, heat and cold were preserved -all over the face except that the left cheek below the level of the -mouth yielded a less accurate registration of tactile sensations. A hot -test tube did not feel as hot in the lower left cheek as elsewhere. -Quinine and sugar could not be tasted over the left half of the tongue -in front. Smell and hearing were also diminished on the left side. It -appeared that there was a complete paralysis of the 5th and 7th nerves -and a partial paralysis of the 8th, 11th and 12th, as well as a defect -in smell. - -The patient died suddenly, three weeks after admission, running a slight -temperature during her stay. The autopsy showed (rather surprisingly) a -double ovarian carcinoma with metastases into the retroperitoneal -glands. Both kidneys were found to be riddled with nodules of carcinoma. -The pelvic veins were thrombosed and there was a complete occlusion of -the pulmonary artery. There was a riding embolus in the foramen ovale -and there was coronary embolism. - -The striking nature of these complications and the interest of the case -neurologically would warrant its publication in complete detail. We here -present the case with utmost brevity as an example of a SYPHILITIC -CRANIAL NEURITIS by extension from the meninges. - -The =brain= was in general without change but there was a considerable -exudate over the entire =pontine region= which had involved several -cranial nerves. The 5th nerves, especially the left, showed gross -effects of the inflammatory lesion. There seems to be little or no doubt -that this neuritis was of syphilitic origin despite the complication of -the case with carcinoma of the ovary and despite the fact that the case -was observed and came to autopsy before the modern methods of systematic -diagnosis could be applied. It is the best case available to us for the -demonstration of a focal cranial nerve lesion of the type characteristic -of neurosyphilis. We may well suppose that similar conditions would have -been found at various stages in the development of Case 1 (Alice -Morton). The pontine region of Case 1 was entirely free from lymphocytic -exudate at the time of the autopsy. Possibly the clearing up of the -pontine pia mater in Case 1 was a therapeutic effect of the thorough -treatment therein used. Whether a case like Mrs. Black’s could be cured -(aside from the ovarian carcinoma and its complications) by the -institution of vigorous systematic treatment is a matter of doubt. -Still, in a general way, these cases of focal syphilitic neuritis are -among the most favorable cases for treatment. - -=Summary=: We present the case of Flora Black to emphasize how slight in -extent and theoretically curable neurosyphilis may be. We fear that Case -1 (Alice Morton) may present too unrelieved and pessimistic a picture. -The extensive vascular lesions and complications of Alice Morton, of -Case 2 (Francis Garfield), of Case 4 (James Pierce) arrest attention by -the incurability of their residual effects (if we omit modern attempts -at reeducation of lower arcs). On the other hand the unrelenting -progress to destruction of important parenchymatous structures, as shown -in the paretic James Dixon (Case 3) and his juvenile replica John -Lawrence (Case 5), as well as in Alice Morton (Case 1) and the tabetic -Francis Garfield (Case 2), lead to a certain justifiable pessimism. For -it is only the meningeal and fine vascular infiltrations of these cases -that we can theoretically hope to combat, probably by destroying the -spirochetes in these meningeal and perivascular loci. We seem -theoretically less able to stop the progress of the often highly -systemic and symmetrical, parenchymatous lesions of the tabetic and -paretic group. - -The condition in Flora Black is clearly much more hopeful, both being -more focal and being almost purely meningeal and therefore accessible to -therapy. - -The two cases which conclude our general survey of neurosyphilis are -also focal cases, one of gumma (Lecompte) and one of focal dural lesion -(Wyman). - -[Illustration: - - 1. Pons, normal except for focal infiltration of left fifth nerve. -] - -[Illustration: - - 2. Higher power view of infiltrated left fifth nerve. -] - -[Illustration: - - 3. Detail of infiltrated left fifth nerve, showing: 1, diffuse - infiltration with mononuclear cells; 2, perivascular infiltration; - 3, strands of relatively unaffected nerve fibers. -] - -Microscopic appearances in Case 6. Extraocular palsy (focal meningeal -syphilis, especially of left fifth nerve). Illustrates exquisite -focality of the syphilitic process sometimes found, as well as its -unilaterality (giving rise to asymmetrical symptoms and signs). Process -in itself probably curable. - - - =GUMMATOUS NEUROSYPHILIS (“gumma of brain”). Autopsy.= - - -=Case 7.= Mrs. Lecompte was a woman of middle age, who, according to the -history given by her son, had been entirely well until her final -illness, which began approximately two years before admission to Danvers -Hospital. The beginning of her trouble seemed to be chiefly headaches, -which would last continuously for several days, or more than a week at a -time. These headaches lasted throughout the course of the disease. In -the morning, on arising, she would feel very dizzy, but this would pass -away during the day. She had had a number of spells of unconsciousness, -lasting about fifteen minutes. In these attacks she would breathe -heavily, there was frothing at the mouth, twitching of the hands, and -the eyes would roll about. Her memory failed gradually, her disposition -changed and she became very irritable. Vomiting occurred almost every -day, and at times was of a projectile character. She became -hallucinated; the hallucinations were chiefly of a visual nature. - -About four months before admission to the hospital, after one of her -seizures, the entire right side was found to be completely paralyzed, -and she complained that it was numb. At this time, she had difficulty -with her speech. In a few days, however, she was able to talk correctly -again, and in a week she was back at work, although the right side was -weak and awkward. She continued to grow worse, and then began to have -spells lasting several days, so that it became necessary to have her -placed in a hospital. - -On admission to the hospital, aside from obesity, the general viscera -showed no points of special interest, and there was no evidence of any -new growth outside of the nervous system. She was unsteady on her feet, -standing with them wide apart. The gait was quite ataxic; the whole -right side was weaker than the left and used more awkwardly. There was a -paralysis of the right side of the face; the right angle of the mouth -drooped; the right eyelid could not be closed but remained continuously -open; nor could the right side of the forehead be wrinkled. Vision and -hearing were not affected. She miscalled tastes and smells; whether this -was due to aphasic difficulties or to cranial nerve involvement could -not be divined. There seemed to be some difficulty in deglutition. The -knee-jerks were markedly exaggerated; slight clonus was obtained but was -not always present. Both pupils reacted well to light and distance and -consensually. Sensation could not be readily tested. There was marked -ataxia, especially with the eyes closed. The speech was thick and -mumbling. The patient was unable to write or copy. Mentally the patient -was quite dull; at times, stuporous; when aroused, was found to be -entirely disoriented. Memory almost entirely absent. In general she -showed herself to be very much confused. - -She remained practically in this condition, even gaining in weight, for -the following two years, when suddenly one morning, she had an epileptic -seizure, vomited, coughed a great deal, with bleeding from the mouth and -ears, and died in a few hours. - -The symptoms in this case pointed to brain tumor. The only inconsistent -thing was the long-continued life,—four years,—after the symptoms were -observed. As she lived before the W. R. and spinal fluid tests were -known, no light was gained in these ways. The post mortem examination -showed the patient had a GUMMA OF THE BRAIN. - -The =summary of the anatomical diagnoses= at autopsy was: - -Decubitus. - -Lymphadenitis of the mesenteric nodes. - -Chronic fibrous peritonitis. - -Chronic fibrous myocarditis. - -Pulmonary hypostasis. - -Thrombosis of vein in right adrenal, with hemorrhage. - -Syphilitic leptomeningitis. - -Gumma of left hemisphere. - -Focal softenings in the pons. - -The =anatomical description of the head= (Dr. A. M. Barrett) is as -follows: - - The sutures in the =calvarium= are well outlined; diploë large in - amount. The =dura= is diffusely but lightly adherent to the - calvarium; it is very dense, especially over the left hemisphere. - The meningeal arteries are thickened but not atheromatous. The - sinuses contain a small amount of fluid blood and post mortem clot. - The inner surface shows nothing abnormal. There is a great - flattening of the convolutions of the left hemisphere, which is not - the case on the right side. Over the convexity, the =pia= is thin - and not abnormal except for some slight adhesions between the - frontal lobes and the two lips of the Sylvian fissures. The pia at - the base over the cisterna, pons, and medulla is thick, cloudy, and - of a grayish gelatinous appearance. It is so thick that it is easily - removable in a large piece. - - The surface of the left hemisphere is dry, and the whole brain is - flabby and bulges as if from internal pressure. A section through - the hemispheres at the region of the optic chiasm shows a hard, firm - area in the left hemisphere deep down in the white substance. It is - about 2½ cm. in diameter, with a wavy border. The central part is of - a silver-gray gelatinous-like appearance, with red spots and whitish - streaks radiating from the centre. In the pons on the right side, in - a plane passing through the posterior corpora quadrigemina, are two - pinhead size softenings among the pyramidal fibres. The ependyma of - the fourth ventricle is granular. - - =Microscopic examination of the tumor=: The area evidently contains - several central necrotic foci surrounded by zones of infiltration - and proliferation, with bordering areas of nervous tissue showing - secondary reactions. The necrotic area stains poorly. From the edge - there are projections of reddish homogeneous bands, some intermixed - with well-differentiated fibrillæ, probably glia fibrils. The - bordering zone is densely infiltrated with lymphoid, plasma, and a - few epithelial cells. The nerve tissue outside of this zone is - spongy and infiltrated with lymphoid and plasma cells. There are a - few scattered, shrunken nerve cells. In this zone and in the zone of - infiltration near the necrotic area, there are scattered cells - resembling giant cells. There are many obliterated vessels in the - area, and other vessels show many infiltrating lymphoid and plasma - cells in the walls. The examination of the specimen stained by the - methods for bacilli of tuberculosis are negative. The growth is a - classical gumma. - - - =GUMMATOUS NEUROSYPHILIS (gumma of spinal meninges, “meningitis - hypertrophica cervicalis of Charcot?”). Autopsy.= - - -=Case 8.= John Wyman was first seen in his thirty-sixth year by Dr. -James J. Putnam. He denied syphilitic infection and stated that the -first symptoms had come four months before. He had begun to notice a -numbness of the fingers, at first of the right hand and shortly -thereafter of the left hand. After a few weeks there had been difficulty -in walking, and a few weeks later headaches, especially on the right -side, developed. Two weeks before he was first seen medically, he had -begun to have a feeling of tightness or constriction in his arms. - -It appears that micturition had been impaired early, that is to say, a -few weeks after the initial sensory disorder had begun. A catheter was -used for a time and improvement followed. Shortly before consultation -retention of urine developed again, this time associated with rectal -incontinence. The feet began to feel heavy and dead. Then the legs began -to be increasingly weak so that the patient was almost bedridden. Vision -appeared to be normal except that reading was followed by fatigue. The -speech was also slow but the slowness could be attributed to fatigue. - -Notes of Dr. Putnam’s =physical examination= are as follows: The patient -lay in bed on the left side, without motion, and almost incapable of -motion. The tongue was protruded, and there was no paralysis of facial -muscles, or of the eye muscles (the right pupil had been reported to be -slightly larger than the left). There seemed to be a disinclination to -move the head, but with some effort it could be moved, and without pain. -The arms and hands were held rigidly in median positions; many movements -were possible, but all were imperfect and of slight amplitude. The -fingers were flexed to a moderate degree, and could not easily be -straightened, and there was, in fact, a general rigidity of most of the -muscles of the body below the neck, and even, in some degree, of the -neck. The immobility was so great that the general impression made was -almost that of a patient with fracture of the spine in the cervical -region. Even the breath, and especially the inspiration, was imperfect. -The legs were more freely movable than the arms, but still the motions -were very stiff and awkward, and of slight amplitude; with effort the -whole leg could be lifted from the bed, and flexed or extended with -moderate force. The right leg was rather stronger than the left, but the -left hand and arm were stronger than the right. The sensibility was -almost absent over the hands and lower part of the arms, and was -impaired over the entire head and neck, except the forehead, the middle -part of the face, and the nose. It is interesting to compare the -conditions of the sensibility here present with those seen in cervical -syringomyelia. The sensibility of the upper part of the forehead was -less good than of the lower part, and there was slight impairment even -over portions of the lower jaw. The sensibility of the left (stronger) -arm was rather more impaired than that of the right arm, while on the -contrary the sensibility of the left leg was better than that of the -right leg, though the difference between them was not great. These -statements apply to sensory tests by contact, heat, cold, and pricking. -Knee-jerks were highly exaggerated, and likewise the wrist-jerks. All -forced attempts at movements were attended by a high degree of muscular -tremor, especially when the patient was fatigued or under emotional -strain. The fingers especially were the seat of coarse tremor. - -The remainder of this clinical description (courteously supplied us by -Dr. Putnam) may be quoted. A second examination which included also a -few facts not given in the first examination was made on the following -March 28, 1905. This report says “the ends of the fingers became numb -about June 1, 1904. Work was given up on July 3, and at that time the -patient was walking very badly. No treatment was used and no -satisfactory diagnosis made. In the course of July he improved somewhat, -and during August he was able to ride out a little (these spontaneous -improvements are of interest for the diagnosis). He went away from home -for a short time, but from the time of his return, about the last of -September, he grew worse rapidly, and fell into the condition above -described, in which he was wholly unable to help himself, even to -turning in bed. At times he had a great deal of pain in the neck and -forehead. Antisyphilitic treatment was recommended, and for a time -potassium iodid and other iodid preparations were given, but at first in -relatively small doses (grs. 75 daily). Under this treatment the -excretion of urine rose to four quarts daily as a maximum though -sometimes the quantity was not so great.” - -Under this treatment the patient began soon to improve, and continued -doing somewhat better till about five months later. He became able to -walk downstairs and out of doors, and regained considerable use of his -hands. The quantity of urine passed became greatly increased by the use -of the iodid. - -About the middle of March he became worse again. A careful examination -of the sensibility showed that in general the condition was much the -same as that previously reported. The iodid treatment, with perhaps some -mercurial, was resumed; the potassium iodid was given in doses which -were increased up to 850 grains daily, although this maximum dose was -taken only for about one week. This large quantity gradually impaired -the sense of taste for the time being, and blurred his vision, but -otherwise did him no harm. Under this he improved, so that he became -able to run more or less, and went about freely, and attended to his -business, though still retaining some stiffness in his movements. - -This improvement continued until about two years later, when he again -had a relapse, and was seen medically once more. His condition at this -time was still a pretty good one, but the movements were stiff and -awkward. The bin-iodid of mercury was advised, which was taken in doses -of 9⁄25 grain daily. It will be remembered that this was long before the -days of salvarsan treatment. - -This was toward the end of June, 1907. Contrary to expectation, there -was no material gain from this treatment, and the patient died early in -October, without being seen again. - -The =autopsy= was limited to the =nervous system= and the findings were -as follows (Dr. A. R. Robertson): - - =Head=: Hair abundant, fair, of fine texture and rather curly. Scalp - of medium thickness and strips readily from calvarium. The latter - appears normal and upon removal is of about the normal thickness. It - lifts readily from the dura mater, except for the numerous - attachments of Pacchionian granulations. - - =Meninges=: The dura is smooth, moderately injected and shows no - areas of thickening; it lifts readily from the pia-arachnoid. The - pia-arachnoid shows discrete and in many places diffuse areas of - opacity. There is a moderate amount of subpial clear fluid and the - vessels are moderately injected. Over the anterior surface of the - medulla and lower portion of the pons and largely confined to the - right side there is a very marked thickening of the pia-arachnoid to - which the dura is densely adherent. This thickening extends down - anteriorly and laterally on the right side over the upper part of - the cervical cord. The thickened meninges over the upper part of the - medulla completely surround the right vertebral artery, shortly - before it joins its fellow of the opposite side to form the basilar. - Dissection of the arteries shows them to be patent and thin walled. - Over the =cerebrum= and cerebellum the pia-arachnoid strips readily - leaving a smooth surface. Section of the cerebral cortex, basal - nuclei, pons and cerebellum show no gross lesions. The ventricles - are moderately distended with fluid. The ependyma contains numerous - small cysts. Section of the =pons= shows no lesions of the nervous - tissue, but very marked thickening of the surrounding meninges as - noted above. - - =Cord=: Throughout the cervical and dorsal region the dura is quite - tensely distended with an abundance of clear, light, straw-colored - fluid. Upon snipping the dura this fluid escapes with a small spurt, - as if under considerable pressure. The cord within, for the most - part, lies free, but over the upper three or four centimeters of the - cervical portion it is densely adherent to the dura anteriorly and - laterally on the right side. Cross sections were made through the - upper three or four centimeters of the cord, and over this area the - cord is constricted by very marked thickening of all the meninges. - The meninges here average from one to three millimeters in - thickness. On the right side and somewhat anteriorly opposite the - junction of the atlas and axis there is a single nodular, firm mass - which on section shows a yellowish, firm center surrounded by very - dense, pearl-gray tissue. The demarcation between the homogeneous - yellowish centre and its surrounding gray tissue is very sharp. This - nodule measures about 0.75 to 1 cm. in diameter. The adjacent cord - is deeply indented by it. Below this nodule there is a translucent, - grayish appearance of both posterior sensory columns which extends - downwards and diminishes in intensity until it finally disappears in - the upper dorsal region. This same appearance is well marked on the - right outer margin of the upper cervical cord corresponding to the - crossed pyramidal tract, and extends downwards diminishing in - intensity until it disappears about the mid-dorsal region. The left - pyramidal tract appears to be similarly but very slightly involved; - section of the lower dorsal cord entirely negative. - =Microscopically=, characteristic GUMMA. - -It is a question whether this case is one of the group described in 1871 -by Charcot under the name of _pachymeningitis cervicalis hypertrophica_. -Charcot did not regard his new disease as syphilitic, and it is very -probable that syphilis is not responsible for all cases. Charcot, -however, noted that his new disease was not incurable: he noted that the -resulting paraplegia, although it might be very marked and accompanied -by flexion of the leg on the thigh and although the paraplegia might -have lasted a very long time, might end in recovery. Charcot thought -that surgical intervention was necessary. He described three periods in -the disease, the first or neuralgic (pseudo-neuralgic) was characterized -by sharp pains in the neck and by the sensation of constriction in the -upper part of the thorax. The second phase of the disease was, according -to Charcot, the paralytic phase, in which a cervical paraplegia -accompanied by muscular atrophy developed. Sometimes cases were found to -remain in this paralytic phase and even to end spontaneously in cure. If -the muscular atrophy was degenerative, then the atrophy was never -replaced; but, according to Charcot, some cases of atrophy were simple -and accordingly curable. If, however, the spinal cord itself became -involved in the meningeal inflammation, then phenomena of transverse -myelitis set in with a spastic paraplegia and involvement of the bladder -and rectum. Muscular atrophy never developed in the legs, at least in -typical cases. - -Among the causes of this condition the following have been mentioned: -cold, overexertion, alcoholism, tuberculosis and syphilis. Syphilis -undoubtedly plays the major part. Even before the days of the W. R., -observers, among whom may be mentioned Dejerine-Tinel and Pförringer, -discovered syphilis in nearly all sufferers from _pachymeningitis -cervicalis hypertrophica_. - -It should be differentiated from caries of the spine and cord and -meningeal tumors. The spinal fluid examination makes this somewhat easy. - -Antisyphilitic remedies are indicated, and should be tried even when the -etiology is obscure, if only as a therapeutic test. - - - But what have been thy answers? What but dark, - Ambiguous, and with double sense deluding, - Which they who asked have seldom understood, - And, not well understood, as well not known? - - Paradise Regained, Book I, lines 434–437 - - - - - II. THE SYSTEMATIC DIAGNOSIS OF THE MAIN FORMS OF NEUROSYPHILIS - - - =PARETIC NEUROSYPHILIS (“general paresis”) sometimes persistently - receives the diagnosis NEURASTHENIA simply through omission to apply - approved diagnostic methods.= - - -=Case 9.= Greeley Harrison, a man of 46, certainly looked like a -neurasthenic. He wanted aid for nervous indigestion of years’ standing, -headache, insomnia, nervousness, failing memory, and deafness. He -volunteered, in fact, that he had neurasthenia, and that he had been -treated for this by hypophosphites. - -During the practically negative =physical examination=, Harrison -complained of headache and throbbing in the head, and during examination -of the abdomen felt much nauseated and proceeded to vomit rather -persistently. There were hemorrhoids. - -=Neurological examination= showed that the left pupil was smaller than -the right, was irregular, failed to react consensually, and reacted very -slowly to direct light. For the rest, however, the neurological -examination was negative. On account of the nausea and vomiting, special -examination of the gastric contents was made, but nothing abnormal was -found. - -=Mentally=, it was rather striking that the patient’s memory was quite -inaccurate both for remote and for recent events. His school knowledge -was very meagre. As for delusions, the only approximation thereto was -the patient’s continually dwelling upon his bodily symptoms. -Emotionally, he varied between depression and a sanguine attitude. - -Although there was no symptom directly suggesting syphilis in the -Harrison case, the slightly abnormal pupillary reactions and the amnesia -warranted the suspicion of syphilis. The blood and spinal fluid both -proved positive to the W. R.; the gold sol reaction was of the “paretic” -type; there were 18 cells per cmm.; there was considerable globulin, and -an excess of albumin. On the whole, therefore, we felt entitled to make -the diagnosis GENERAL PARESIS. Why should not a careful observer have -considered syphilis seriously? Yet in our experience such cases are -frequently diagnosticated neurasthenia, thus entailing dangerous delay -in treatment (in this case, five years’ delay). - -Going over the history of the case with still greater detail, we learned -that for a number of years past, there had been symptoms of a -neurological nature. For instance, five years before, at the age of 41, -the patient had been apparently overcome when working near a stove, and -went upstairs talking incoherently, but recovered shortly. Thereafter, -such spells occurred almost every month; later, more frequently; still -later, the attacks were associated with unconsciousness and amnesia. -Occasionally preceding the attack there would be twitching of the mouth, -jerking of the arms, and incoherent talk. Throughout these last five -years, in point of fact, the patient had been unable to do regular work, -had been given to much complaining, and had been far less efficient than -formerly. In short, it would seem that, with the improved technique now -in the possession of medical science for the diagnosis of general -paresis, cases like that of Harrison will be diagnosticated earlier and -earlier. - - 1. How typical is the insidious onset of symptoms in the case of - Harrison? The onset of symptoms in neurosyphilis is ordinarily - considered to be sudden, and this statement is generally true - despite the fact that after the diagnosis is established a number - of mild prodromal symptoms can be remembered by the relatives. - However, some cases, of which Harrison is an example, have an - exceedingly insidious onset without sudden access of striking - symptoms. Joffroy and Mignot remark that with the improvement of - clinical methods, the course of paretic neurosyphilis must now be - stated to take some six or seven years for completion. In point of - fact, there were early episodic symptoms (seizures almost monthly) - which should not have escaped medical attention. They did escape - medical attention, however, and Harrison was wont to say “Why - wasn’t I told that my disease was syphilis five years ago?” - - 2. Is there such a disease as syphilitic neurasthenia? According to - Kraepelin, syphilitic neurasthenia has been described as occurring - shortly after infection and in the first stages of syphilis. There - are milder and severer forms; the milder forms show discomfort, - difficulty in thinking, irritability, insomnia, cephalic pressure, - indefinite variable, uncomfortable sensations, and pains. The - severer cases acquire anxiety, more pronounced emotional disorder, - dizziness, disorder of consciousness, difficulty in finding the - right word, transient palsies, pronounced sensory disorders, - nausea, and increase of temperature. Kraepelin is in doubt whether - there is any definite clinical picture of this sort, and whether - there is any causal relation between the syphilitic infection and - such symptoms as those described. If the effect of knowledge - concerning infection is a merely psychic effect, then it is - improper to term the neurasthenia in question a syphilitic - neurasthenia. For the relation of hysteria to the acquisition of - syphilis, see below the case of Alice Caperson (46). In point of - fact, modern work has shown even in the primary and secondary - stages of general syphilis more or less pronounced neurosyphilitic - phenomena in the shape of the so-called meningitic irritation of - French authors. (Besides the case of Caperson (46), see the case - of Fitzgerald and the discussions under these cases.) - - 3. What is the relation of the early symptoms of this case to the - so-called preparesis of Dana? The case might well have been an - example of Dana’s preparesis. For a discussion of this, see Case - of William Twist (13). - - 4. What is the classical differential diagnosis between paretic - neurosyphilis and neurasthenia? The testing of the blood by the W. - R. is unconditionally necessary. If the W. R. is negative, the - diagnosis of paretic neurosyphilis is extremely improbable. (It - must be borne in mind that a number of cases of paretic - neurosyphilis have been shown to have a negative W. R. in the - serum, and receive a proper diagnosis only after spinal fluid - examination.) Next to the serum W. R. stand the pupillary and - aphasic symptoms. In the presence of Argyll-Robertson pupil or - even a slight speech defect, the diagnosis of neurasthenia must - certainly be made with caution if at all. Kraepelin remarks: The - sudden occurrence of neurasthenic disorders in a male of middle - age without any evident cause therefor is always suspicious. Yet - it must be emphasized that a complaint of occasional dizziness, - slight speech defect, tremor of tongue, and a moderate increase of - tendon reflexes do not possess any marked diagnostic significance. - Clear insight and understanding of the nature of the disease - phenomena, a persistent search for recovery, reasonableness in - conversation, progressive improvement under appropriate treatment, - speak for neurasthenia. - - Joffroy and Mignot differentiate what they call preparetic - neurasthenia from other neurasthenic states, not only on the basis - of its etiology but on the basis of its symptoms. They also call - attention to the fact that neurasthenia, being a pure neurosis, - develops either on a manifestly hereditary basis or upon some - physical injury, weakening disease, or moral shock. The pure - neurotic suffers a great deal more than the patient who is - destined to become a victim of paresis. The character change in - neurasthenia does not amount to that entire transformation of - personality (even to the performance of criminal acts) that we - find in paretic neurosyphilis; at the most, the neurasthenic shows - minor emotional disturbances and a certain pathological egoism. - The psychotherapeutic test also rather readily dissipates many of - the neurotic, hypochondriacal fears and feelings. Although both - pure neurasthenia and the paretic pseudoneurasthenia are - characterized by sexual weakness, the sexual anæsthesia of the - preparetic is practically always preceded by a stage of sexual - over-excitement. These finer clinical indications, however, fade - into insignificance beside the data that can and should be - obtained from laboratory tests. - - 5. How exceptional is such a case as that of Harrison? We have in - our experience seen many patients with a similar course and - configuration of symptoms, although the majority of these cases in - a community advanced enough to provide easy access to a Wassermann - laboratory are now diagnosticated far earlier than was the case of - Harrison. - - 6. What attitude shall we take toward so-called syphilophobia? It - seems to us that resort to a serum W. R. is indicated, both from - the standpoint of the community and still more importantly from - the standpoint of the patient. We are even inclined to suggest for - a case of persistent syphilophobia, when the serum W. R. has - proved negative, a lumbar puncture. Syphilophobia must be - considered, not as a syphilitic psychosis, but as a phobia to be - classified among the psychoneuroses. It becomes a difficult - question to decide at times whether a patient who has had - syphilis, has had a considerable course of treatment and shows the - symptoms of a syphilophobiac should be further treated for - syphilis or merely for his phobia. We have seen recently such a - patient who gave a certain history of syphilis and who was greatly - disturbed lest he should be developing paresis. This fear bothered - him greatly. Examination showed irregular pupils, but no other - signs of syphilis. The W. R. in blood and spinal fluid was - negative as were the other spinal fluid tests. It was considered - wise to treat him only for his phobia and under this treatment he - was given some relief. - - - =PARETIC NEUROSYPHILIS (“general paresis”) may look precisely like - MANIC-DEPRESSIVE PSYCHOSIS.= - - -=Case 10.= The mental picture in Lyman Agnew, an architect, 58 years of -age, was wholly characteristic of manic-depressive psychosis. In the -first place, there had been (at 55) a previous attack of depression, -lasting a few months, from which Agnew had completely recovered. He had -remained entirely well up to four months before consultation. -(Manic-depressive psychosis is, at least in a majority of cases, -hereditary. There had been mental disorder in one maternal cousin, and -mental impairment in the patient’s mother some time before her death -from cerebral hemorrhage. There was no other report of mental disease in -the family.) - -It appears that in the interval between attacks, Agnew had been working -very hard and had been fairly successful in paying off a mortgage on his -house. A marked elation, somewhat natural, followed this success and -continued to an abnormal degree. Agnew labored under considerable -excitement, was over-fussy, and at times showed a flight of ideas. His -mania or hypomania gradually diminished and depression set in, in which -depression he arrived for consultation. He had marked ideas of -self-accusation, was emotionally unstable, wept much, and showed a -characteristic retardation of activities and unrest. - -=Physically=, there was no neurological disorder. The patient appeared -rather under-nourished. The heart borders lay 2 cm. to the right and at -11½ cm. to the left of the mid-sternal line. The aortic second sound was -very loud. There was a moderate radial arteriosclerosis. Systolic blood -pressure was 210, diastolic 155. - -The high blood pressure suggested nephritis, possibly of -arteriosclerotic origin, but urine examination and blood-nitrogen tests -yielded no evidence of kidney disease. Moreover, it is our experience -that a manic-depressive psychosis in persons past middle life is not -infrequently complicated by high blood pressure. In point of fact, some -authors insist upon a relation between manic-depressive psychosis and -the arteriosclerosis which rather frequently sets in in this disease. - -Routine examination of the blood serum, however, yielded a positive W. -R. Following the approved rule of making an examination of the spinal -fluid in all mental cases having a positive serum W. R., we proceeded to -lumbar puncture. The fluid was clear and contained 35 cells per cmm., -the albumin was in excess, and there was a positive globulin reaction. -The gold sol reaction was of the “paretic” type; the W. R. was strongly -positive. - -On this basis, it seems worth while to consider the diagnosis of GENERAL -PARESIS or that of some form of non-paretic neurosyphilis. The former is -the diagnosis which we prefer. - - 1. What is the classical differential diagnosis between - manic-depressive psychosis and neurosyphilis? The laboratory tests - have naturally supplanted the older purely clinical methods of - differential diagnosis. The difficulties lodge, in the first - instance, in depressive states. It would appear to be impossible - on purely clinical grounds in certain cases to tell the depression - of neurosyphilis from the depression of manic-depressive - psychosis, since the slightly greater interest in the outer world - taken by manic-depressive patients and their greater - responsiveness to diagnostic threats (suggestion that patient is - to be pinched or cut) are of no special value in the individual - case. Identical considerations hold for the maniacal phases of - manic-depressive psychosis, for these maniacal phases may even - develop delusions (Kraepelin) of precisely the same nature as the - characteristic expansive delusions of the excited paretic. - - 2. If the clinical symptoms are insufficient in differential - diagnosis, are not the pupillary signs and the speech defect of - greater value? They are of value if present, but as in the case of - Agnew, the victim of neurosyphilis may show no pupillary or speech - disorder. Instances are familiar, also, in which the pupillary and - speech signs are absent in very advanced cases of non-paretic or - even of paretic neurosyphilis. - - 3. Would not a circular course or recurrence of attacks be decisive - for manic-depressive psychosis? Paretic neurosyphilis sometimes - exhibits the same circular or recurrent course. We conclude that - neither the clinical symptoms, the classical pupillary and speech - signs, nor the ups and downs of a particular disease, are at all - decisive as between manic-depressive psychosis and paretic - neurosyphilis. Resort must be had to laboratory tests. - - 4. What is the significance of the high blood pressure in paretic - neurosyphilis? Work from our laboratory (Southard and Canavan) has - shown plasma cells in the kidneys in 17 out of 30 paretics (56%), - and in 16 of these 17 paretics with renal plasmocytosis, the - plasma cells were found in the periglomerular region. What the - relation of these findings may be to heightened blood pressure is - as yet unknown. The severe syphilitic involvement of the aorta so - characteristic in paretic neurosyphilis, as in other forms, may - possibly have a bearing on blood pressure. - - - =A POSITIVE SERUM WASSERMANN REACTION associated with mental - symptoms (even with grandiosity) does NOT prove the EXISTENCE OF - PARETIC NEUROSYPHILIS (“general paresis”).= - - -=Case 11.= Juliette Lachine came to a general hospital with pain in the -right upper quadrant of the abdomen, wherein was found an enlarged -liver. This liver was regarded as syphilitic on the ground that the -patient had a positive serum W. R. and that her two elder children were -clearly suffering from congenital syphilis. The liver mass was promptly -reduced by antisyphilitic treatment of the classical sort. When, -however, the patient was given an injection of salvarsan, she shortly -began to develop marked mental symptoms, whereupon she was removed to -the Psychopathic Hospital. - -The =mental picture= at the Psychopathic Hospital was as follows: Lack -of orientation for time, marked distractibility of attention, with a -certain jumping from one subject to another, delusions of a religious -nature, claims of wonderful powers possessed by the patient, moods -variable, though as a rule of a euphoric and elated nature, with -laughing and singing. The activity seemed to be of a mental rather than -a peripheral nature. The patient did not regard herself as mentally -abnormal. The liver was still 4 cm. below the costal margin in the -nipple line. We found the W. R. to be positive in the serum but negative -in the spinal fluid. In fact, the spinal fluid was entirely negative. - -So far as we are aware the picture presented by this case is one of -MANIC-DEPRESSIVE PSYCHOSIS. We regard the disease as merely complicating -the syphilis, although it is entirely possible that some visceral -condition incidental to the syphilis might be proved (in a higher stage -of psychiatric science) to have produced the mania. - -In any event, the patient quite recovered from her mental symptoms in a -month. She was then able to tell us of a previous attack of depression -some 12 years previously, namely, at the age of 26. It appears that she -had at that time been committed to a hospital for the insane. - - 1. In this case, in which the diagnosis of manic-depressive - psychosis and not paretic neurosyphilis was made, are we sure that - the symptoms that we term manic-depressive psychosis were not - actually produced by syphilotoxins? In other words, in the absence - of spinal fluid signs of inflammation or chemical change, might it - not be possible for generalized syphilis outside the nervous - system to produce manic-depressive symptoms? There is so far in - the literature no experimental or other evidence of syphilotoxins. - The existence of products and substances permitting the W. R. and - the gold sol reaction is not of course evidence of syphilotoxins. - Although there is no evidence of soluble syphilotoxins, it is - thought that in the so-called Järisch-Herxheimer reaction (the - intensification of clinical symptoms after salvarsan injection) - effects may be due to the liberation of products from the killed - bodies of spirochetes. Such endotoxins are not here in question. - - 2. Is visceral syphilis, such as gumma of the liver, able to produce - characteristic syphilitic reactions in the spinal fluid? We have - had an autopsied case in which there was a “paretic” gold sol - reaction of the fluid (though without other signs). The autopsy - showed gummata of the liver. However, the finer anatomy of the - nervous system showed a mild but definite meningo-encephalitic - process, which was doubtless responsible for the gold sol - reaction. - - 3. What is the value of grandiose ideas? Ballet distinguishes two - groups of grandiose ideas: (_a_) ideas of self-satisfaction, - including ideas concerning extraordinary capacity, strength, - power, and wealth on the part of the patient; and (_b_) ideas of - ambition; the latter being of a more exact, constant, uniform and - systematizing nature. The more vague and less systematized ideas - of self-satisfaction rest in a phase of contentedness and - optimism; the more definite ideas of pride and ambition are - responsible for striking transformations of personality. General - paresis shows, according to Ballet, these ideas of - self-satisfaction in their most developed form. A certain - variability, absurdity, incoherence, and contradictoriness - characterize these ideas and the patient has little or no insight - into their nature. When such ideas occur at the outset of the - disease, they naturally may be of medicolegal interest. Cotard - explains these ideas of megalomania on the part of paretics on the - ground that they are essentially motor or will disorders and rest - upon a sort of hyperbulia, exhibiting itself in exuberant - activity. Régis has thought that the delusional generosity and - liberality of the paretic, and his willingness to lend his wealth - and talents to social progress, is helpful for diagnosis when - contrasted with the more personal egoism of the victim of - manic-depressive psychosis. The self-satisfaction of the - manic-depressive patient often does not reach a delusional stage, - but remains a mere feeling of pathological well-being or euphoria. - The maniacal patient may compare himself with some great man but - he does not identify himself with him. It must be remembered that - these ideas of self-satisfaction occur also in alcoholism, but - according to Ballet they occur only in the dementing phase of - chronic alcoholism, and have no special diagnostic value. They may - be a clinical stumbling-block for a time in the cases of alcoholic - pseudoparesis. As for the ideas of ambition in which the patients - believe themselves to be princes, emperors, divine messengers, and - the like, these are less characteristic of paretic neurosyphilis - than of delusional psychoses of a non-syphilitic nature. At all - events, such ideas if definite, of long-standing, and systematized - by the patient to form a thorough-going portion of his life, are - not characteristic of neurosyphilis. The victim of paretic - neurosyphilis can as a rule be persuaded out of his delusions, at - least for the time being. These distinctions, it must be added, - are hardly of value in the early cases of any of the psychoses in - question, and cannot be made as a rule in either private or - psychopathic hospital practice. Typical examples of grandiosity, - although not so frequent as might be thought from textbooks, are - always on display in institutions for the chronic insane. - - - =PARETIC NEUROSYPHILIS (“general paresis”) may look precisely like - DEMENTIA PRAECOX. Autopsy.= - - -=Case 12.= Henry Phillips remains a striking case in the memory of those -who knew him and his medical findings. Phillips came to the hospital -voluntarily at 42 years of age from the bank where he worked as a clerk; -he came at the suggestion of his employer. It seems that he had been -annoying his associates because he had fallen into a habit of -continually scratching himself. Phillips was entirely sure that he was -the victim of what he called the “Scotch itch,” and explained off-hand -that this itch had been put upon him by the Free Masons as a matter of -revenge because he would not join their order. He said once, for -example: “At times I feel like raising Hell; then I get a psychic -intimation; and then I get to using a foot-rule on my back and to -slapping my face.” He explained this psychic intimation as coming from -the order of Scottish Rites. Another example of talk is as follows: “My -father is a fighting man; that is part of it. They mean to throw me -down. I am through now trying for membership in the Free Masons. They -have good cause, they must fight. They do not want me for some personal -matters. I can go just so far in agreeing and seconding their advances, -but in the end it fails. I have no strength nor endurance.” - -Aside from these delusions, there was little abnormality to be found, -though his recollection for minor events of the immediate present was -inaccurate. He was rather abnormally impulsive, gesticulating a good -deal while talking, and was of the appearance that the laity call -“nervous.” It appears that he had always been peculiar, subject to -violent fits of temper, in which fits he might throw things at other -members of the family. He always had pronounced likes and dislikes which -he never concealed. He had never had friends, had always been secretive; -and he was often termed a great student. For some five years he had been -studying Japanese from time to time, associating himself with a -Japanese. - -It never does to jump at the diagnosis dementia praecox. However, the -picture seemed characteristic enough for the paranoid form of this -disease. Physically, Phillips had no particular abnormality; the -knee-jerks were a little lively, and the pupils reacted a little -sluggishly. However, the routine W. R. of the serum proved to be -positive. Examination of the spinal fluid was resorted to,—as in all -cases with a positive serum W. R.—and it also proved to be positive and -strongly so; the globulin and albumin were increased, and there was a -pleocytosis. A diagnosis of neurosyphilis was hardly avoidable. Phillips -later admitted a chancre, which he claimed was located on the mucous -membrane of the cheek and acquired by using the same utensils as his -Japanese friend, which friend, he stated, had active syphilis. - -Antisyphilitic treatment of considerable intensiveness was begun, with -intravenous injections of salvarsan and intraspinous injections of -salvarsanized serum, but the patient grew steadily worse. His mental -symptoms became more marked, although not especially characteristic of -general paresis. =Neurologically,= he did develop signs more suggestive -of general paresis, and 18 months later died. - -The =autopsy= showed features of GENERAL PARESIS. It is not necessary to -enter into the question of the details of histological correlation at -this time. - - 1. What conclusion can be drawn from lively knee-jerks? Lively - knee-jerks are of very little significance. Not only certain - neurosyphilitics but also a variety of neurotic persons, victims - of dementia praecox and hysteria, are very prone to have active - tendon reflexes. Of course, extreme degrees of exaggeration are of - importance, and especially an association of the hyperreflexia - with the Babinski reaction, the Gordon, or Oppenheim reflexes, - ankle clonus, and the like. - - 2. Is there any special or differentiating factor in an extragenital - chancre as against a genital chancre? Probably this question - should be answered in the negative. Some have claimed that - chancres draining by lymphatic channels of the head are more - likely to lead to cerebral syphilis. This idea cannot be said to - be established. - - 3. Is there any significance in the story, if true, that Phillips - acquired his syphilis from a Mongolian? It seems to be fairly well - established that syphilis of the nervous system is extremely rare - in China and Japan, whereas bone syphilis is very frequent there. - It has been held that this has to do (_a_) with strains of - spirochetes, (_b_) with the state of civilization, or (_c_) with - the degree of “syphilization.” Apparently when a race is first - infected with syphilis the lesions are chiefly of the cutaneous - and osseous systems; only in later generations the vascular and - nervous systems suffer. However, involvement of the nervous - systems of Mongolians resident in this country is no rarity, a - point possibly in favor of the theory of special strains affecting - the nervous system as prevalent in western countries. Little or - nothing is known as to the effect of transmission from one race to - another, as from Mongolian to Caucasian in Phillips’ story. - - - =NEUROSYPHILIS is NOT to be entirely ruled out by a negative serum - Wassermann Reaction; for the fluid Wassermann Reaction may be - positive.= - - -=Case 13.= William Twist is a case of note in the matter of the -so-called preparetic period (the idea of Charles L. Dana which was -scoffed at when first proposed by him in 1910). The patient, a very -successful traveling salesman, 35 years of age, was admitted to the -Psychopathic Hospital showing a typical picture of general paresis. - -Thus, =mentally=, the patient showed elation, grandiosity (millions of -dollars to give away), intellectual weakness, disorder of memory, lack -of judgment, rambling talk, speech defect, omission of letters in -writing and spelling. - -=Neurologically=, there was tremor of the lips, slight irregularity of -the pupils, which however reacted well, and lively knee-jerks. - -Mr. Twist had sought advice at our out-patient department in his -thirty-third year. The records show that at that time he was somewhat -depressed, and his speech was even then, according to his own statement, -stammering. However, we found the W. R. at that time to be negative in -the blood serum. It appeared that his mother had died of consumption; -his father was said to have committed suicide. A brother had once -recovered from an attack of depression, presumably an attack of -manic-depressive psychosis. Accordingly, we thought at the time that the -case was probably one of manic-depressive psychosis. Moreover, our -routine serum W. R. failed to indicate any syphilitic process. As for -the so-called stammering of speech, this appeared to be a matter of the -patient’s own recollection rather than of our observation. In any event, -the patient had gone into the country and appears to have entirely -recovered; falling, again, however, into mental difficulties after a -short period, and finally arriving at the hospital in the -above-mentioned classical condition. - -The W. R. in the blood serum proved again negative. The test was -repeated a number of times; also, after salvarsan had been given. The -salvarsan did not act provocatively, and the blood serum has remained -consistently negative. - -In cases of syphilis the W. R. is at times negative. Swift claims that -in such cases an injection of salvarsan will often produce a positive W. -R. if the blood is tested on several days following the injection. - -The spinal fluid, however, did show a positive W. R. as well as a gold -sol reaction of a “paretic” type. There were at the first examination -194 cells per cmm., there was a moderate excess of albumin, and a -positive globulin test. In short, there was no question of any other -diagnosis than GENERAL PARESIS. - - 1. How can the negative W. R. of the blood serum be explained? It is - difficult or impossible to explain this. Figures differ as to the - percentage of cases of general paresis with negative blood serum; - perhaps 3 to 5% of these cases yield a negative serum W. R. - - It is important to note the long preparetic period: at least a year - and a half. Could our diagnostic methods be sharpened a trifle, - such cases as these could be obtained early in this preparetic - period and it might then be safe to promise good therapeutic - results. - - 2. What is the nature of the preparesis of Dana? When Dana’s brief - paper on preparesis was written, there was of course hardly any - idea that cases of paretic neurosyphilis could be cured or would - recover, except possibly vanishingly few _curiosa_ about which - there would always rage a diagnostic question. Accordingly, Dana, - having found certain cases that seemed to him to have early signs - of paresis but had apparently been cured by treatment, proposed to - call them cases of preparesis. His idea was that he would thereby - not offend those who held that general paresis was theoretically a - fatal disease. With modern work and the display of more and more - atypical cases of neurosyphilis, and the observation of relatively - numerous cures or remissions under treatment, the designation of - preparesis for a separate entity, or even for a sub-form of - neurosyphilis, becomes superfluous. - - 3. What is the percentage of cases of paretic neurosyphilis that - show a negative serum W. R.? Among the best figures are those of - Müller, who found that of 386 examples of paretic neurosyphilis, - 379 showed all reactions positive, or 98.5%. - - 4. What is the meaning and value of the so-called provocative - salvarsan injection? In practice, there may be a series of - negative W. R.’s in the blood serum before a positive reaction is - finally obtained, owing to technical difficulties or biological - peculiarities. Where intensive work is being done upon the - neurosyphilis problem, it is beyond question desirable to make the - W. R. test upon at least three separate samples of blood drawn at - intervals, for the second or third test may prove positive. This - situation makes the interpretation of the so-called provocative - salvarsan injection exceedingly doubtful; that is, the reaction - might have been positive on repetition without the injection of - salvarsan. The present case, as above stated, failed to yield a - serum W. R. even after repeated tests and the “provocative.” - - 5. What is the significance of the irregular pupils in this group? - Paretic neurosyphilis shows inequality of the pupils in a high per - cent of cases. Irregularity of outline of the pupils is commonly - thought to be an important sign and to suggest neurosyphilis. It - is true that many cases of pupillary irregularity are syphilitic, - but the sign is of little or no differential value since - congenital malformations and relics of old injuries and adhesions - may produce effects identical with those of neurosyphilis. - - - =DIFFUSE (that is, meningovasculoparenchymatous[5]) NEUROSYPHILIS is - typically associated with six positive tests (serum Wassermann - reaction, fluid Wassermann reaction, spinal fluid gold sol reaction, - pleocytosis, positive globulin, excessive albumin); but one or more, - and frequently several, of these tests are likely to run mild as - compared with the tests in PARETIC NEUROSYPHILIS (“general - paresis”). The clinical course of the diffuse (and especially the - meningovascular) cases is likely to be protracted, with a good - prognosis as to life (barring fatal vascular insults).= - - -=Case 14.= We shall present the case of John Jackson, a surveyor, 31 -years of age, suffering from a left hemiplegia, with this in mind: To -exhibit difficulties in diagnosis in the presence of an embarrassment of -symptomatic riches. - -The patient arrived at the hospital, in the first place, because he had -been threatening a woman who lived next door to him. He believed that -this neighbor had been talking about him and circulating reports against -him. Excited by these ideas, he had threatened to cut her throat. - -Now the occurrence of hemiplegia in adult life before the approach of -senium is always suspicious of syphilis, and this suspicion we naturally -entertained from the beginning. However, there was upon the scalp a -crooked linear furrow about six inches long, running from the vertex to -the right parietal eminence. Another furrow about an inch long was -present upon the forehead. These furrows appeared to be of a bony nature -and were not tender. There was evidence of an old decompression -operation on the right side of the head; there were also large scars on -both sides of the neck, evidently the result of old operations; and -there were numerous palpable glands—the largest about the size of a lima -bean—all firm and not tender. - -[Illustration: - - Station in syphilitic hemiplegia. Syphilitic pigmentation of skin. -] - -It seems that at the age of eight, according to the patient’s mother, -Jackson had received a head injury and had remained unconscious for -three weeks. Upon recovery, he had to relearn both to walk and to talk; -however, he was able to begin school where he left off. He became more -nervous and irritable after the accident than previously. Nothing -further had developed until, at about 25 years of age, a tubercle was -discovered in his eye (the right pupil was smaller than the left, -reacting more slowly; right iris bound down by adhesions, with white -opacity of anterior chamber). For two years, 25 to 27, the patient was -under medical treatment for tuberculosis, and at the conclusion of this -period numerous glands were removed from the neck and diagnosticated -tuberculous. However, the neck did not heal and he carried bandages upon -it for two years. - -At 28, the patient’s mother described the occurrence of a slight shock, -with head retraction, for a minute or two, and inability to speak. -Thereafter there had been five or six similar attacks, less severe, and -without loss of speech. The attacks were never accompanied by convulsive -movements. Then occurred a paralytic stroke, leaving the patient with a -left hemiplegia, which had somewhat improved. Mentally, the patient had -gone down hill, becoming less alert and more apathetic, and to some -extent amnestic. One had to consider, accordingly, the somewhat doubtful -possibility of post-traumatic and post-operative conditions, and the -question of tuberculosis (possibly errors in diagnosis; the lungs showed -no evidence of tuberculosis). - -=Physically,= the signs of a left hemiplegia were appropriate. -Spasticity on the left side was found; there were Babinski, Gordon, -Oppenheim reflexes and ankle clonus on the left side (all absent on the -right). Speech defect was present. =Mentally,= aside from the delusions -noted at the beginning of our analysis, a striking feature was the -patient’s childishness. While reciting delusions, the patient was -overactive and evinced a somewhat childish interest. Arithmetically, -Jackson had preserved a fair ability but his apathy and lack of interest -interfered with tests, and possibly also with the exercise of memory. As -above noted, we were compelled to maintain the suspicion of syphilis -throughout despite the attractive hypotheses of traumatic and -post-decompressive effects and cerebral tuberculosis. A history of the -acquisition of syphilis an unknown number of years before admission -entered to strengthen the suspicion of the syphilitic nature of the -mental symptoms. - - - TYPICAL LABORATORY FINDINGS IN NEUROSYPHILIS (NONNE, 1915) - ─────────────┬─────────┬─────────┬─────────┬───────────────┬─────────── - DIAGNOSIS │ W. R., │ W. R. │ SPINAL │ PHASE I, │PLEOCYTOSIS - │ BLOOD │0.22 CC. │ FLUID, │ GLOBULIN │ - │ SERUM │ BLOOD │ 1.0 CC. │ │ - │ │ SERUM │ │ │ - ─────────────┼─────────┼─────────┼─────────┼───────────────┼─────────── - PARESIS OR │POSITIVE │POSITIVE,│POSITIVE,│POSITIVE, │POSITIVE, - TABOPARESIS│ IN │ 85–90% │ 100% │ 95–100% │ ABOUT 95% - │ ALMOST │ │ │ │ - │ 100% │ │ │ │ - │ │ │ │ │ - TABES (not │POSITIVE,│POSITIVE,│POSITIVE,│POSITIVE, │POSITIVE, - combined │ 60–70% │ 20% │ 100% │ 90–95% │ 90% - with │ │ │ │ │ - paresis) │ │ │ │ │ - │ │ │ │ │ - CEREBROSPINAL│POSITIVE,│POSITIVE,│POSITIVE │POSITIVE almost│POSITIVE - SYPHILIS │ 70–80% │ 20–30% │ ALMOST │ always; │ ALMOST - │ │ │ ALWAYS │ NEGATIVE only│ ALWAYS - │ │ │ │ EXCEPTIONALLY│ - ─────────────┴─────────┴─────────┴─────────┴───────────────┴─────────── - CHART 8 - - -[Illustration: - - Syphilitic thrombosis. Contours of brain preserved. -] - -The W. R. proved positive in blood and spinal fluid. The gold sol -reaction was of the syphilitic type; 37 cells were found per cmm.; there -was a slight amount of globulin and a slight excess of albumin. - -We made a diagnosis of CEREBROSPINAL SYPHILIS rather than general -paresis on account of, first, the slow course of the disease; second, -the vascular type of the cerebral insult, hardly typical of paresis; and -third, the mild spinal fluid reaction. Treatment will hardly cure the -hemiplegia, at least so far as restoration of cerebral tissues lost in -the insult is concerned. We were perhaps entitled to consider that, as -in the cases of Petrofski (17), O’Neil (19), Robinson (45), the -meningitic process could be arrested. Unfortunately, our treatment of 20 -injections of salvarsan over a period of 10 weeks, followed by a number -of months of bi-weekly injections of mercury salicylate, proved -incapable of making any change in the mental and physical picture or in -the laboratory findings. - - 1. Can we explain the apparently poor reaction to treatment of the - cerebrospinal syphilis in the case of Jackson by supposing a more - deep-seated involvement than the meningovascular involvement - indicated by the hemiplegia and the signs in the fluid? Autopsied - cases in our experience show focal parenchymatous involvements - that have not caused obvious clinical symptoms at any time during - the course of the disease. These symptomatically silent lesions - may have been present. - - 2. What is the comparative prognostic value of seizures in paretic - neurosyphilis and in such a meningovascular case as that of - Jackson? Paretic seizures are often and indeed characteristically - recovered from. Moreover, autopsies in paretic neurosyphilis - characteristically show no gross focal destructive lesions to - correspond with the seizures. The paretic seizures are apparently - more irritative than paralytic. However, the seizures of the - meningovascular group of neurosyphilis are also, though less - commonly, recovered from, so that the differential diagnosis on - the basis of the outcome of seizures is not safe. Rarely paretic - neurosyphilis itself also develops seizures from which no recovery - is made. - - 3. What is the relation of neuropathic heredity to neurosyphilis? - The family history of John Jackson is undoubtedly poor, since his - father died of diabetes and a paternal uncle was insane; and on - the mother’s side, the grandmother died of tuberculosis and an - aunt died insane. This general question was more interesting in - the days before the syphilitic nature of general paresis and of - allied diseases was known. However, we may still hold perhaps that - not only syphilis but also various intoxications, especially - alcoholism, do flourish upon a neuropathic soil. This question, - like that of Krafft-Ebing’s celebrated claim of the relation - between syphilization and civilization, needs revision in the - light of more extensive applications of the W. R. in larger and - larger groups of persons under various community conditions. - - - =The SIX TESTS (serum Wassermann reaction, fluid Wassermann - reaction, pleocytosis, gold sol reaction, globulin, excess albumin) - are likely to run STRONGER in PARETIC NEUROSYPHILIS (“general - paresis”) than in DIFFUSE (especially meningovascular) - NEUROSYPHILIS; in particular, the gold sol reaction is likely to - prove “paretic” rather than “syphilitic.” The clinical course of - paretic neurosyphilis (“general paresis”) is likely to terminate in - death within a few years.= - - -=Case 15.= Pietro Martiro was a well developed and nourished man, 30 -years of age, who had been doing erratic things and acting peculiarly -for a few weeks before entering the hospital. In the hospital, Martiro -proved to be very excitable and given to violence. He had marked -delusions of grandeur, saying he was worth many millions of dollars, was -the greatest singer in the world, the greatest athlete in the world, and -the like. - -=Physically=, there was no disorder except overactivity of some -reflexes. The diagnosis of GENERAL PARESIS offered no difficulties, and -it was confirmed by the laboratory tests (positive serum and fluid W. -R., “paretic” gold sol reaction, 42 cells per cmm., an excess of -albumin, and a positive globulin test). - -=Treatment=: The perfect physique of this case and the extremely brief -clinical duration (a few weeks) would naturally suggest a probably -favorable outcome. However, cases with marked delusions of grandeur have -very frequently proved to be cases with extensive brain tissue loss as -shown in certain studies with Danvers material. - -In any event, the treatment in this case proved unavailing. Enormous -doses of salvarsan, twice a week, aided by mercury and potassium iodid, -were given. Although other cases had been helped by such intensive -treatment, Martiro went steadily downhill, nor was there the slightest -diminution in the intensity of any of the spinal fluid reactions. After -50 injections of salvarsan over a period of 30 weeks without -improvement, treatment was discontinued. A few months later, the patient -died. - - - =PARETIC NEUROSYPHILIS (GENERAL PARESIS)= - - =PHYSICAL SYMPTOMS= - - EARLY HEADACHE - VISUAL DISORDER - HYPALGESIA - ADIADOCHOKINESIS - ATAXIA - NASOLABIAL FLATTENING - VOCAL CHANGE - SPEECH DISORDER - WRITING DISORDER - LOSS OF MANUAL DEXTERITY - PUPILLARY CHANGES - REFLEX CHANGES - SEIZURES - LATE: PARALYSIS, CONTRACTURE - - CHART 9 - - - =PARETIC NEUROSYPHILIS (GENERAL PARESIS)= - - =MENTAL SYMPTOMS= - - INTAKE IMPAIRED - CONSCIOUSNESS CLOUDED - FATIGUABILITY INCREASED - HALLUCINOSIS RARE - AMNESIA—RECENT! CHRONOLOGY AND STORAGE IMPAIRED. FABULATION - OVER-SUGGESTIBILITY - JUDGMENT IMPAIRED - FANTASTIC DELUSIONS - INSIGHT INTO ILLNESS NIL - EARLY IRRITABILITY OR HEBETUDE - QUICK SHIFTING EMOTION - CHARACTER CHANGE - CONDUCT SLUMP - - CHART 10 - - - 1. What is the duration of paretic neurosyphilis (“general - paresis”)? If we omit the doubtful, early, and prodromal stages - and count the beginning of the disease with the occurrence of - definite symptoms, we find (Kraepelin) that almost half the - patients with pronounced paretic signs die within the first two - years of their disease. Kraepelin’s observations upon 244 cases - are as follows: - - Year: 1 2 3 4 5 6 7 8 9 10 14 - Cases: 51 63 52 41 22 4 5 2 2 1 1 - - The average duration of the disease in months has been calculated - as varying from 24 to 32 months. Juvenile paresis runs a slower - and more insidious course. The duration of paresis, according to - many observers, diminishes with the increasing age of the patient. - It is now held that a combination of tabes with paresis does not - prolong the duration of the paresis. As noted above in the - discussion of Case Harrison (9), our conceptions of the - characteristic duration of paretic neurosyphilis must alter with - the increase of our knowledge due to the early application of - laboratory tests. - - 2. What is the significance of the term _general paresis_? The case - of Martiro is, of course, a good instance to show that the term is - sometimes a misnomer. The characteristic generalized motor - incapacity denoted by the term _general paresis_ is shown in - patients in the institutions for the chronic insane in their last - few months of life. The term _paresis_ is perhaps to be preferred - to the term _paralysis_ because the paralysis is not complete but - partial; but perhaps the best reason is that the word _paresis_ is - a shorter word. When the mental side is to be emphasized, the term - _paralytic dementia_ is employed. In this book we have used the - term _paretic neurosyphilis_ to mean a more precise statement of - the etiology of general paresis (general paralysis, paralytic - dementia). The lay term, _softening of the brain_, like the terms - _metasyphilis_ and _parasyphilis_ is in the present phase of our - knowledge to be eschewed. - -[Illustration: - - Euphoria in paretic neurosyphilis (“general paresis”). The head, arms - and trunk were shaking with mirth; hence, the indistinct outlines of - the photograph. -] - - 3. If this fatal case be typical of general paresis (for more - favorable results, see Part V), what is the toll of deaths from - this disease in the community at large? A striking statement may - be quoted from Dr. Thomas W. Salmon’s “Analysis of General - Paralysis as a Public Health Problem:” - - “With the information in our possession at the present time, we - are able to state that not fewer than 1000 persons in whom general - paralysis is recognized die in New York State every year. Let us - compare this with the lives lost from some other important - preventable diseases. It means that _one in nine_ of the 6909 men - who died between the ages of 40 and 60 in New York last year died - from recognized general paralysis and that _one in thirty_ of the - 5299 women who died in the same age-period died from this disease. - - “The number of deaths from general paralysis in New York last year - about equalled the number of deaths from typhoid fever. The - following table gives the number of deaths due to the ten most - important specific infectious diseases. Of course, deaths in - measles, typhoid fever and scarlet fever will be found also under - the names of some of the complications of these diseases, but it - should be remembered that these primary diseases are not - invariably fatal as general paralysis is. Many of the patients - with measles who died from bronchopneumonia would have recovered - but for this complication, while the paretics with - bronchopneumonia would have died even if this complication had not - arisen. No attempt is being made to compare the _prevalence_ of - general paralysis with that of other diseases—we are trying only - to estimate its share in the _mortality_. - - “1. Tuberculosis (all forms) 16,133 - 2. Pneumonia 9,302 - 3. Bronchopneumonia 7,217 - 4. Diphtheria and croup 1,854 - 5. Influenza 1,381 - 6. Measles 1,071 - 7. Typhoid Fever 1,018 - _General paralysis (recognized)_ 1,000 - 8. Scarlet fever 837 - 9. Whooping cough 818 - 10. Syphilis 782” - - - =PARETIC NEUROSYPHILIS (GENERAL PARESIS)= - - =CHARACTERISTICS= - - AMNESIA - QUICK SHIFTING EMOTIONS - CHARACTER CHANGE - CONDUCT SLUMP - NERVOUS DISORDERS - SPEECH DISORDERS - PUPILLARY CHANGES - REFLEX CHANGES - SEIZURES - CEREBROSPINAL FLUID PICTURE - - CHART 11 - - - =SYPHILITIC PSYCHOSES= - - SYPHILITIC NEURASTHENIA - GUMMA - SYPHILITIC PSEUDOPARESIS - APOPLECTIC CEREBRAL SYPHILIS - SYPHILITIC EPILEPSY - SYPHILITIC PARANOIA - TABETIC PSYCHOSIS - HEREDITARY - PARESIS - - KRAEPELIN, 1910 - - CHART 12 - - - =TABOPARETIC NEUROSYPHILIS (“taboparesis”) is CLINICALLY a - combination of the symptoms of TABES DORSALIS and those of GENERAL - PARESIS. The COURSE of TABOPARESIS is likely to be from a - characteristic tabes dorsalis (often of years’ standing) to a - characteristic general paresis; the ultimate paretic picture is - likely to retain various characteristics of tabes. The LABORATORY - TESTS in the paretic phase are characteristic of ordinary - (non-tabetic) general paresis. The PROGNOSIS, after the paretic - phase has arrived, is apt to be that of general paresis.= - - -=Case 16.= Joseph Sullivan, a waiter, 50 years of age, sought assistance -at the Psychopathic Hospital voluntarily. His complaint of severe and -lancinating pains in the legs, difficulty with his gait, and a feeling -of constriction about the waist, was forthwith suggestive of tabes -dorsalis. He was a rather poorly nourished, white-haired man, with a -drooping of the left side of the face. The pupils reacted sluggishly to -light, the right somewhat better than the left. A marked Romberg -reaction could be demonstrated. Ataxia in walking was marked. There was -some incoördination of the hands, considerable tremor, and writing was -poorly performed. The ankle-jerks and knee-jerks were absent. On the -whole, the diagnosis of TABES DORSALIS was clear enough. - -The most appealing situation was =mental=. Sullivan was exceedingly -apprehensive about his condition on the ground that it was growing -progressively worse; if it was to get worse, Sullivan feared he would -commit suicide. From his own account, he had become irritable, -quick-tempered, and often unreasonable. As usual in these cases, the -question arose whether the depression was psychopathic or natural. - - - =TABETIC SYMPTOMS AND SIGNS IN ORDER OF THEIR FREQUENCY= - - =ANALYSIS OF 250 CASES= - - PER CENT - - 1. ROMBERG SIGN 96.4 - 2. ABSENT KNEE-JERKS 90.0 - 3. LANCINATING PAINS 88.4 - 4. STAGGERING GAIT 87.2 - 5. ARGYLL-ROBERTSON PUPIL 80.0 - 6. ATAXIA IN UPPER EXTREMITIES 68.2 - 7. SPHINCTER DISTURBANCES 67.6 - 8. SENSORY DISTURBANCES 58.2 - 9. VISUAL DISTURBANCES 43.6 - 10. PARESTHESIA AND NUMBNESS OF FEET AND LOWER EXTREMITIES 42.8 - 11. GIRDLE SENSE 31.2 - 12. PTOSIS OF EYE-LIDS 23.2 - 13. PARESTHESIA OR NUMBNESS IN HANDS OR UPPER EXTREMITIES 13.6 - 14. STRABISMUS 12.0 - 15. VISCERAL CRISES 12.0 - 16. LOSS OF SEXUAL DESIRE 11.5 - 17. CHARCOT JOINTS 9.2 - 18. VERTIGO 4.0 - 19. MAL PERFORANS 3.2 - 20. PAIN IN JOINTS 2.8 - 21. RECTAL TENESMUS 2.8 - 22. MENTAL DEGENERATION (other than paresis) 2.4 - 23. HEMIPLEGIA 2.4 - 24. VESICAL TENESMUS 2.0 - 25. DIFFICULTY IN ARTICULATION 2.0 - 26. DEAFNESS 1.2 - 27. ANOSMIA 0.8 - - BALDWIN LUCKE. - - CHART 13 - - -While in the hospital things shortly came to a crisis. In the midst of a -fit of depression, Sullivan attempted suicide by beating his head -against the wall. Whether this attempt could be regarded psychopathic, -however, remained in question. Sullivan had been drinking very heavily -although he had stopped about six weeks before admission, fearing that -the alcohol was causing a development of symptoms. The remedy was almost -worse than the disease because he then became more nervous, lost his -appetite, and had a marked insomnia. - -According to the patient’s own history, he had had several attacks of -gonorrhœa and a syphilitic infection at the age of 19; that is, some 31 -years before admission to the hospital. However, the first -_neurological_ symptoms of which the patient was aware came about 27 or -28 years after infection, namely, 3 or 4 years before admission, when -facial paralysis developed. At that time, he had suddenly felt a -peculiar sensation in the throat and became unable to swallow for a -time. His voice remained hoarse and low for some time, and his face -began to droop. The lancinating pains and the ataxia also dated back -several years. - - 1. How shall we evaluate the mental symptoms? The prognosis of tabes - dorsalis is relatively good so far as life is concerned, and it - might even be possible for Sullivan by training to remain capable - of being a waiter. The manual incoördination was not marked, and - possibly the manual tremor was in part due to alcohol. - Accordingly, the mental symptoms, such as emotional lability and - memory defect, were in the foreground of attention. In point of - fact, the laboratory examinations showed positive W. R. in the - serum and the spinal fluid, which latter also contained 60 cells - per cmm., positive globulin, and an excess of albumin. THE - DIAGNOSIS MADE WAS THAT OF TABOPARESIS, meaning thereby a tabes - associated with appropriate symptoms of a mental nature. - - 2. How shall the term _taboparesis_ be used? Some use the term, as - we feel erroneously, for instances of general paresis which happen - to show crural areflexia (absence of knee-jerks). We feel that the - best usage of the term is for instances in which well-defined - symptoms of tabes (as well as of paresis) are present, namely, - characteristic ataxia, lightning pains, and the like. If the term - is used more loosely, as above mentioned, then practically every - case of general paresis might perhaps be termed _taboparesis_, - since almost every case of paresis does show involvement of the - cord as well as of the cerebrum. Such involvement may lead to - hyperreflexia, hyporeflexia, or areflexia according to the - localization of the process. In true taboparesis, in which there - is a commingling of the features of tabes with those of paresis, - we should find the posterior roots of the spinal cord affected. - The spinal lesions of paresis itself are more apt to be - intraspinal; that is, confined to the nervous system within the - pial investment. - - 3. Bearing in mind that Sullivan was a waiter, what shall be said - about the infectivity of these cases? It is counted as a rule as - negative, since there are no open spirochete-bearing lesions. The - longer the period since infection the less, as a rule, is the - chance of contagion in syphilis; and as tabes and paresis occur - fairly late in the disease, the infectiousness at this stage is - practically negligible. - - 4. Of what differential value is the insight shown by Sullivan into - the nature of his symptoms? Kraepelin remarks that a genuine - insight into the nature of the disease does not as a rule occur in - paresis. At the beginning of the disease, there may sometimes be a - correct understanding of the nature of the disease and of its - probable outcome; but the presence or absence of insight into the - fact of mental disease is by no means a differential sign of - practical value. - - 5. What is to be said of the occurrence of depression and excited - states in paretic neurosyphilis? A variety of classifications of - sub-forms of paretic neurosyphilis have been propounded. - Kraepelin, for example, deals with four: the demented, depressive, - expansive, and agitated forms, but remarks that the division is - merely convenient for exposition. The institutional intake does - not accurately represent the distribution of cases. Under - psychopathic hospital conditions with the relatively easy resort - to such institutions, the number of quiet cases increases; under - the less advanced conditions in Heidelberg, Kraepelin took in 53% - demented paretics as against 56% at Munich (73% women) under the - easier conditions of admission. The admissions of demented - paretics varied from 37 to 56%. The variations depend much upon - the facility with which the cases can be brought to institutions. - Where admission is beset with various legal restrictions, the - quiet and demented cases are more apt to be treated for long - periods at home. The depressive type of paretic neurosyphilis - forms a much smaller group, according to Kraepelin, as only about - 12% of his Heidelberg admissions were of this type, and still - fewer of his Munich admissions. Other authors give percentages as - high as 16 and 19. The so-called expansive group is larger, - Kraepelin finding 30% of his Heidelberg cases to be of this group, - and 21 to 22% of his Munich cases. The rarest sub-form of paretic - neurosyphilis is the agitated form: 6% of Kraepelin’s Heidelberg - admissions; 14% among males and 5% among females in his Munich - admissions, where the diagnosis of agitated paresis was entered on - somewhat broader lines. French authors (Sérieux and Ducaste) have - enlarged the number of sub-forms of paretic neurosyphilis as - follows: Expansive 27%; sensory 24%; demented 24%; persecutory 3%; - depressive 2%; circular 7%; hypochondriacal 7%; and maniacal 6%. - - - =DIFFUSE (meningovasculoparenchymatous) NEUROSYPHILIS may look - precisely like PARETIC NEUROSYPHILIS (“general paresis”) at certain - periods of clinical and laboratory examination.= - - -=Case 17.= The police found Gregorian Petrofski crouching on his knees -on a Boston sidewalk, attempting to take pickets off a fence. Petrofski -knew little English; he said that he had slept in Poland the night -before. He did not appear to be alcoholic. - -When he was examined, through an interpreter, he told how he had been in -America two days, and in Boston two years; that he was at the present -time in Poland, and that his brother had brought him to the hospital and -left him there. - -The =physical examination= showed Petrofski to be well developed and -nourished. His pupils were somewhat dilated and reacted somewhat slowly -to light and accommodation. =Neurologically,= there was nothing else -abnormal found upon systematic examination although, through lack of -coöperation, sensory and coördination tests proved difficult if not -impossible. There was a large ulcer on the under surface of the glans -penis, with several small smooth scars on the upper surface. There was a -purulent discharge from the external meatus. There were exostoses of -both tibiae. - -The initial diagnosis had to consider uremia and diabetes, which could -be easily excluded on examination. Alcoholism was excluded through -absence of alcohol on the breath. There remained such diagnoses as -epilepsy, some post-traumatic condition, or meningitis, to say nothing -of the hypothesis of syphilis raised by the tibial exostoses and the -lesions of the penis. The hypothesis of trauma was given up, as well as -epilepsy and meningitis upon the data of the lumbar puncture. The spinal -fluid proved to be clear but with enormous amounts of globulin and -albumin, 80 cells per cmm., a “paretic” gold sol reaction, and a -positive spinal fluid W. R. (the serum W. R. was also positive). -Accordingly, it was clear that the case was one of neurosyphilis. - -Treatment was instituted with injections of mercury salicylate, a grain -and a half twice a week, and potassium iodid. After some weeks, -diarrhoea and salivation with marked symptoms of mercury poisoning set -in; the treatment was suspended, but later re-instituted. In a few weeks -Petrofski was apparently quite well, the spinal fluid tests had all -become negative, as had the serum W. R. - -Petrofski now began to pick up a good deal of English, and gave a -consistent narrative of his past life, although the period just prior to -and during his early stay in the hospital has remained blank. Without -further treatment Petrofski has remained well for over a year. - - 1. Does the “paretic” gold sol reaction mean general paresis? In - connection with this general question, a brief summary of the - significance of the gold sol reaction in this group may be made. - (1) Fluids from cases of general paresis in the vast majority of - cases will give a strong and fairly characteristic reaction, - especially if more than one sample is tested. (2) Very rarely - general paresis fluid will give a reaction weaker than the - characteristic one. (3) Fluids from cases of syphilitic - involvement of the central nervous system other than general - paresis often give a weaker reaction than the paretic, but in a - fairly high percentage of cases give the same reaction as the - paretics. (4) Non-syphilitic cases may give the same reaction as - the paretics; these cases are usually chronic inflammatory - conditions of the central nervous system. (5) When a syphilitic - fluid does not give the strong “paretic reaction” it is - presumptive evidence that the case is not general paresis, and - this test offers a very valuable differential diagnostic aid - between general paresis, tabes, and cerebrospinal syphilis. (6) - The term “syphilitic zone” is a misnomer, as non-syphilitic as - well as syphilitic cases give reactions in this zone, but no fluid - of a case with syphilitic central nervous system disease has given - a reaction out of this zone, so that the finding may be used - negatively; and any fluid giving a reaction outside of this zone - may be considered non-syphilitic. (7) Mild reactions may occur - without any evident significance, while a reaction of no greater - strength may mean marked inflammatory reaction. (8) Tuberculous - meningitis, brain tumor, and purulent meningitis fluids - characteristically, though not invariably, give reactions in - higher dilutions than syphilitic fluids. (9) The unsupplemented - gold sol test is insufficient evidence on which to make any - diagnosis, but used in conjunction with the W. R., chemical and - cytological examinations, it offers much information, aiding in - the differential diagnosis of general paresis, cerebrospinal - syphilis, tabes dorsalis, brain tumor, tuberculous meningitis, and - purulent meningitis. (10) We believe that no cerebrospinal fluid - examination is complete for clinical purposes without the gold sol - test. - - - =FREQUENT SYMPTOMS IN DIFFUSE AND VASCULAR NEUROSYPHILIS= - - =(“CEREBRAL” AND “CEREBROSPINAL SYPHILIS”)= - - PUPILLARY DISORDER - HEADACHE - VERTIGO - INSOMNIA - DROWSINESS - CHANGE IN DISPOSITION - Irritability Slow thinking - SEIZURES - PARALYSES - Permanent Transient - APHASIA - HEMIANOPSIA - SENSORY DISTURBANCES - GASTRIC CRISES - SPHINCTER DISTURBANCES - INTRACRANIAL PRESSURE SYMPTOMS - POLYURIA, POLYDIPSIA, GLYCOSURIA - MÉNIÈRE’S SYNDROME - NYSTAGMUS - - CHART 14 - - - See Appendix B for technical details. - - 2. What is the relation of the tibial exostosis to neurosyphilis? - The syphilographers have always stressed the tibial lesions in the - diagnosis of syphilis. Although not so much attention has been - paid to these and kindred osseous lesions in neurosyphilis, yet we - have frequently found such lesions and they afford an important - auxiliary means of diagnosis. - - - =A POSITIVE SERUM Wassermann reaction with a NEGATIVE FLUID - Wassermann Reaction may be found in NEUROSYPHILIS, particularly in - VASCULAR NEUROSYPHILIS: the remaining signs in the fluid, although - frequently positive, may even be negative.= - - -=Case 18.= Frederick Wescott was a promoter, an elderly looking man of -60 years. His health had been failing for 18 months. There had been -shortness of breath, dizziness, a tired feeling, inability to “get the -words he wanted,” and forgetfulness of names. About eight weeks before -examination, Wescott had had a convulsion, following which he had been -unable to express himself at all well. This convulsion was not -accompanied by loss of consciousness. Besides a marked motor aphasia, -there was agraphia. - -=Physically=, Wescott showed arteriosclerosis and a blood pressure of -135 systolic, but, except very lively knee-jerks, no other reflex -disorders or anomalies were discovered. In particular, the pupils -reacted fairly well. - -There was, perhaps, no special reason to implicate syphilis in the case, -yet Wescott gave a history of syphilis at 35 years. The W. R. of the -blood serum proved positive; that of the spinal fluid was negative, and -the albumin was but slightly increased; there was a very slight amount -of globulin, and there were 16 cells per cmm. in the fluid. The gold sol -reaction suggested syphilis. - -We felt entitled to make a diagnosis of SYPHILITIC CEREBRAL -ARTERIOSCLEROSIS, regarding the convulsion or seizure eight weeks before -as due to a vascular insult. The laboratory picture in the spinal fluid -in Wescott’s case seems to be rather characteristic of this group of -syphilitic arteriosclerotics. - - 1. What is the reason for the negative spinal fluid W. R.? The - theory would be that the syphilitic lesion is localized in the - vascular system and that the parenchyma is only secondarily, if at - all, involved. The W. R. producing bodies are accordingly not - found in the fluid. - - 2. How frequently are several of the spinal fluid tests negative, - while others are positive? Whereas, clinically speaking, the five - tests in the spinal fluid (W. R., globulin reaction, excess - albumin, pleocytosis, and gold sol reaction) are each indicative - of a pathological condition in the central nervous system, yet a - specially intensive study of the distribution of these tests has - shown that they are prone to occur independently. Consequently, we - must concede that they do not all represent the same inflammatory - products and chemical conditions. The W. R. producing bodies, the - gold sol reaction producing bodies, as well as the globulins and - albumins, have been proved to be separate. Special work has also - shown that _these tests disappear under treatment at different - rates_. There is, unfortunately, no doubt that the rate and - intensity, presence or absence, and the order of disappearance of - these tests in either treated or untreated cases, do not at all - parallel the clinical conditions of the patients. - - 3. What is the prognosis in vascular neurosyphilis, such as in the - case of Wescott? The prognosis is identical with that of cerebral - arteriosclerosis in general, that is to say, bad, but with - frequent periods of improvement. In the neurosyphilitic type of - arterial disease thromboid formation is frequent. Where the lesion - is chiefly perivascular infiltration, rather than disintegration - of the vessel wall, improvement may very well occur as a result of - treatment. Wescott showed slight improvement under treatment. He - has already lived two years since his first convulsion, and three - and a half years since the onset of symptoms. - - - =DIFFUSE NEUROSYPHILIS (so-called “cerebrospinal syphilis”) is often - marked by SEIZURES.= - - -=Case 19.= Agnes O’Neil, an unmarried woman of 28 years, was first -examined five weeks after the initial symptoms. It appears that she had -had certain seizures, with unconsciousness and twitching of the limbs -(otherwise not well described), followed by confusion of mind and -sometimes by a weakness of the left side and a difficulty in speaking. -Headache had been almost constant, as well as pains in the arms and -legs. - -=Physically=, both in general and =neurologically=, there were no signs -or symptoms; mentally, we could discover no symptoms. Syphilis was -denied, although possible exposure to syphilis was admitted. - -The =diagnosis= of some form of organic brain disease was clear with the -picture of convulsions followed by slight aphasia with headaches and -limb pains. With onset at 28, the most frequent cause for such -epileptiform seizures is certainly syphilis. Examination of the blood -and spinal fluid showed a positive W. R., in both. The albumin was also -somewhat increased. The clinical picture suggested a fairly generalized -meningitic involvement. - -The =prognosis= in such cases of generalized meningitic involvement is -in general good, and this principle was illustrated in the O’Neil case, -in which the symptoms soon disappeared under intensive antisyphilitic -treatment. In fact the spinal fluid W. R. became negative in the course -of four weeks. The blood serum W. R., however, has remained positive -despite eight months of active treatment. - - - =CONDITIONS IN WHICH CONVULSIONS OCCUR= - - NEUROSYPHILIS - HYSTERIA - EPILEPSY MAJOR (GRAND MAL) - EPILEPSY MINOR (PETIT MAL) - DEMENTIA PRAECOX - TOXIC CONDITIONS: - Asphyxia, Uremia, Alcohol, Absinthe, Lead, Mercury, etc. - ORGANIC BRAIN LESIONS - Apoplexy, Meningitis, Intracranial Growths - STOKES-ADAMS DISEASE - MALINGERING - DISSEMINATED SCLEROSIS - - CHART 15 - - - 1. Are certain cases of syphilitic epilepsy really cases of - Jacksonian epilepsy? As a matter of nomenclature, Jacksonian - cortical epilepsy is usually the result of a focal and - circumscribed irritative lesion in the cortex. Gumma, local - syphilitic meningitis, and syphilitic vascular lesions, as well as - scars consequent upon the latter, are among the causes of - Jacksonian epilepsy, along with such other focal lesions as - trauma, tumor abscess, tubercle, and the like. Even non-syphilitic - Jacksonian epilepsy has been observed from time to time in cases - of diffuse intracranial pressure. Jacksonian attacks also have - been found in so-called genuine epilepsy. Accordingly, we must not - conclude from the occurrence of Jacksonian convulsions, even - though in a proved syphilitic case, that the convulsions in - question are surely due to a focal lesion, for they may be due to - diffuse syphilitic lesions. - - 2. What is the significance of aphasia in Agnes O’Neil? Aphasia is - not a characteristic symptom in ordinary Jacksonian epilepsy, but - the aphasia is another sign of focal lesion and forms an added - argument against the diagnosis of genuine or idiopathic epilepsy. - See also discussion of aphasia in paretic neurosyphilis under Case - Levenson (22). - - 3. What is the behavior of the serum W. R. and the spinal fluid W. - R. under systematic treatment? Sometimes, as in this case, the - serum W. R. remains positive and the fluid W. R. becomes negative; - but in other equally well-defined cases, the reverse holds true, - and the serum W. R. reaction becomes negative whereas the spinal - fluid reaction remains positive. The obvious conclusion is that we - cannot always be sure even by faithful tests of either the serum - or the fluid alone, whether the treatment has succeeded in - abolishing the laboratory signs. - - 4. Can this case be regarded as one of cure? Not by the definition - adopted in this book or by the syphilographers who take into - account not only the nervous system but the body which contains - it. To be sure, the spinal fluid of Agnes O’Neil is now entirely - negative and she is clinically free from symptoms; yet from the - broad standpoint of syphilis therapy in general, this patient is - not cured, as is evidenced by the positive serum W. R. - - - =PARETIC NEUROSYPHILIS (“general paresis”) is often marked by - SEIZURES.= - - -=Case 20.= Lester Crane, a plumber, 37 years of age, came to the -hospital with a slow and defective speech. Moreover, there seemed to be -some mental disorder since his answers to questions were not always -relevant. It appeared that he was seeing bugs on the wall. - -=Physically=, Crane was a well developed and nourished man, with -overactive knee-jerks and a Babinski reaction on the left side. - -It developed that there was an impairment in hearing. The pupils reacted -well both to light and to distance. The patient was very restless and -smiled in a silly fashion. His memory was decidedly defective in all -spheres, and he was very slow in the intake of ideas. - -The plumber’s wife said that, at about the age of 23 or 24, he had a -spell of confusion lasting two or three days, with peculiar conduct, -unintelligible talk, and a good deal of weeping. The medical diagnosis -at that time took into account the fact that Crane was a plumber and was -“lead encephalopathy.” - -However, according to his wife, Crane had acquired chancre at about 26 -years, was treated mercurially for about three years and declared well. -He had remained well up to about 18 months before entrance, when, -without previous warning, the patient had a convulsion with the -continuous movements for about half an hour. He was semi-conscious for -about 18 hours and vomited continuously. There was amnesia for the whole -affair on regaining consciousness. In a week’s time, Crane was entirely -well. But six weeks later there was another convulsion. Upon removal to -a hospital, the diagnosis of general paresis was made, and the patient -was given the Swift-Ellis intraspinous treatment. This seemed to be very -successful, and the patient discontinued treatment after 14 weeks -(during which time there had been seven treatments) on the ground that -he was entirely well. - -However, after discontinuing treatment, there was another convulsion in -about a month, and further convulsions occurred once a month. For six -months, however, the patient took no treatment, but finally returned to -the hospital and was given mercury. This treatment appeared to suspend -convulsions again for three months, but at the expiration of six months, -the patient had three convulsions in one day, and several more during -the following days. After the last of these convulsions, there had been -numbness on the right side of the body and considerable headache. - -The diagnosis of PARETIC NEUROSYPHILIS (“general paresis”) is borne out -by the laboratory tests. The W. R. of the blood serum was, to be sure, -negative, but the W. R. of the spinal fluid was positive, and there was -a “paretic” type of gold reaction, together with other laboratory signs. - -The case well demonstrates that group of paretic cases in which -convulsions periodically occur, leaving the patient worse after each -convulsion. Treatment with salvarsan was instituted, and mercury and -iodid was given by mouth. During the period of eight months which have -now elapsed since the beginning of this treatment, there have been no -convulsions; there has been a great improvement in the memory, the -hearing has improved, the W. R. in the spinal fluid is much less -intense, the gold sol test has become negative, and the other tests are -all less intense. - -The patient, however, has not been entirely well, for in place of the -generalized convulsions, he has had minor seizures, beginning as a rule -with a tingling sensation in the right hand, extending up the arm, down -the trunk and leg, and through the right side of the face, with a bitter -sensation on the right half of the tongue. The patient maintains that -this sensation is absolutely confined to the right half of the body (in -this connection we may recall case Morton (1), in which there was also a -hemiplegia together with other apparently hysterical symptoms at several -times during the long course of a disease with abundant structural -correlations). During these minor seizures, the patient is unable to -talk, although he does not lose consciousness and is entirely aware of -everything going on about him. These attacks have of late been growing -somewhat less frequent. - - - =LOSS OF DEEP REFLEXES= - - NEUROSYPHILIS - NEURITIS - (alcohol, diabetes, diphtheria, lead, arsenic, tubercle, - cachexia, etc.) - Peripheral nerves sensory or motor - PERIPHERAL NERVE PALSIES - TEMPORARILY FROM COMPRESSION BY TOURNIQUET - FRIEDREICH’S ATAXIA - SUBACUTE COMBINED DEGENERATION OF POSTERIOR AND LATERAL COLUMNS - Posterior column disease - FOCAL LESION IN GRAY MATTER OF CORD - INFANTILE PARALYSIS (ACUTE ANTERIOR POLIOMYELITIS) - PROGRESSIVE MUSCULAR ATROPHY - (chronic anterior poliomyelitis) - Anterior cornua of cord - AMYOTROPHIC LATERAL SCLEROSIS - SYRINGOMYELIA - THROMBOSIS OF ANTERIOR SPINAL ARTERY - LANDRY’S PARALYSIS - Anterior cornua and peripheral motor nerves - MYOPATHIES - (pseudohypertrophic and atrophic types) - MuscLe itself - AMYOTONIA CONGENITA - FAMILY PERIODIC PARALYSIS - (during attacks) - INCREASED INTRACRANIAL PRESSURE - (especially hydrocephalus and tumors of posterior fossa) - PNEUMONIA - IMMEDIATELY AFTER ATTACK OF MAJOR EPILEPSY - (post-epileptic coma) - TOXIC COMA - (uremia, morphine, etc.) - DURING SPINAL ANESTHESIA - COMPLETE TRANSVERSE LESION OF CORD - - PURVES STUART - - CHART 16 - - - 1. What is the cause of the negative serum W. R.? It is claimed that - 3 to 5% of all cases of general paresis yield a negative blood - serum. In this particular case, there had been considerable - treatment, including some Swift-Ellis treatment, so that it may be - that this treatment had reduced a formerly positive blood serum W. - R. to a negative one. - - 2. What is the nature of the typical seizures of general paresis? - The most frequent seizures are epileptiform and bear a general - resemblance to cortical epilepsy; but more rarely these seizures - resemble the ordinary epileptic attack or consist of a violent - general shaking of the whole body. A variety of initial minor - disorders usher in the attacks: the temperature is often - increased. The attacks are over after one or at most after a few - hours. Kraepelin speaks of one that lasted 14 days. Sometimes a - _status paralyticus_ develops, suggestive of the _status - epilepticus_. Another rarer form of characteristic seizure is the - apoplectiform, which can hardly be told from an ordinary stroke, - and may be followed by the usual post-apoplectic phenomena. A good - many of the strokes leading to sudden death in middle life are - probably cases of neurosyphilis although often set down as early - arteriosclerosis of a non-syphilitic nature. Besides the - epileptiform and apoplectiform seizures, there are certain - seizures of a less definite and complete nature, ranging from - simple fainting spells, dizzy spells and petit mal attacks, to - various special forms of irritative muscular contractions and - temporary speech disorders. Sometimes these attacks occur with - complete preservation of consciousness. Transient paresthesias, - visual field defects, and especially attacks of vomiting, which, - according to Kraepelin, may precede paresis by years (of course in - this connection gastric crises of tabes must be thought of), may - be counted as sensory seizures. - - 3. What is the proportion of paretic cases developing seizures? - Figures vary from 30 to 90%. According to Kraepelin, seizures - occurred in 30 to 40% of his cases at Heidelberg; he was of the - impression that treatment in bed had reduced the number of - seizures. 65% of paretics admitted to Munich (under very free - conditions of admission) were determined to have shown seizures - before their admission to the hospital. Seizures are said to be - somewhat more frequent in men than in women. These paretic - seizures are not due to either hemorrhages or vascular plugging—at - least in the vast majority of cases—and must be ascribed to the - effects of microscopic injuries. - - 4. What is the effect of seizures upon the future course of paretic - neurosyphilis? The current idea as expressed, for example, by - Mercier, is that “immediately after each crisis the patient is - much worse than he was before it, and thereafter there is some - improvement, but he never improves up to the point at which he was - before the occurrence of the crisis.” That is, “The course of the - disease is one of sudden plunges, each deeper than the last, each - followed by a gradual recovery that is less complete than the - recovery from the previous plunge.” - - 5. During what period of the disease are seizures most common? Late - in the disease many cases have convulsions, even though there were - none for the first year or two. In other cases the convulsion is - the first indication of paresis. - - - =DIFFUSE (non-paretic) NEUROSYPHILIS (“cerebrospinal syphilis”) is - often marked by APHASIA.= - - -=Case 21.= Martha Bartlett, a woman of 40 years, was brought to the -Psychopathic Hospital aphasic, or at least unable to talk distinctly -enough to be understood, or even to give name and address. The police -had found her wandering aimlessly about the streets. Although she was -well-dressed, she was mud-bespattered and apparently had not changed her -garments for several days. It shortly developed that the patient, -although unable to express herself either in words or by writing, could -understand everything that was said to her and could indicate by the -monosyllables _yes_ or _no_ whether she agreed or disagreed with -statements made. It was thus determined that she was pretty well -oriented. She was able to understand both speech and printed words. -Although she approximated more than is at all common a pure type of -_motor aphasia_, it appeared that there was a slight involvement on the -sensory side, especially in the sphere of visual imagery. - -=Neurologically=, the patient showed moderate strabismus, slight -deviation of the tongue to the right, and considerable tremor on -protrusion of the tongue. The right side of the palate hung lower than -the left. The ankle and arm reflexes were possibly more active on the -left side, and the left grasp was somewhat better than the right. Both -knee-jerks were active, but again the reflex on the left side was more -active than the right. No other abnormalities of reflex were determined. -There was no Rombergism but the gait was somewhat ataxic. For the rest, -the physical examination was normal. The blood pressure was 120 -systolic, 85 diastolic. - - - =CONDITIONS IN WHICH SPEECH DEFECT IS FOUND= - - NEUROSYPHILIS - HYPOGLOSSAL PARALYSIS - FACIAL PALSY - PARALYSIS OF PALATE (POST-DIPTHERITIC) - BULBAR PALSY - PSEUDOBULBAR PALSY - MYOPATHY—FACIO-SCAPULO-HUMERAL TYPE OF LANDOUZY AND DEJERINE - MYASTHENIA GRAVIS - FRIEDREICH’S ATAXIA - LARYNGEAL TABES - ALCOHOLIC INTOXICATION - POST HEMIPLEGIC - LENTICULAR DISEASE - BILATERAL ATHETOSIS - MULTIPLE SCLEROSIS - DEAF MUTISM - PARALYSIS AGITANS - CHOREA - STAMMERING - TICS - HYSTERICAL APHONIA - - CHART 17 - - -The ready suspicion was that the case was one of apoplexy of slight -degree with post-apoplectic phenomena. Upon investigation, this -suspicion was confirmed since it appeared that Mrs. B. had been -apparently quite well until about six months before admission, when -without particular warning she began to act strangely and promptly fell -into a series of convulsions. These convulsions would begin with -twitchings of the face, and then spread throughout the body. There would -be a period of unconsciousness for two or three hours. It is not certain -how many of these convulsive seizures the patient had. At all events she -is reported to have recovered therefrom completely, remaining well for -three months; whereupon, suddenly, while visiting a friend, she suffered -a paralysis of the left side of the body. She remained dazed and had -hospital treatment for about a week. Ever since this left-sided -paralysis, the aphasic condition above described has persisted. - -Such a phenomenon has often been dismissed in the past as due to an -early arteriosclerosis, but most neurologists and internists of today -would look beyond the diagnosis of mere arteriosclerosis and consider -syphilis. The only suggestive feature in the case, aside from the -post-apoplectic reflex disorder and spastic phenomena, is the -irregularity and diminished light reaction of the pupils. Our suspicions -were confirmed by the positive serum W. R. The W. R. of the spinal fluid -proved, however, to be negative. There was a moderately strong gold sol -reaction of the syphilitic type. There was a slight excess of albumin, -and there was an exceedingly slight amount of globulin. There was but -one cell per cmm. - -On the whole, it would seem best to consider the case of Mrs. Bartlett -to be one of CEREBRAL ARTERIOSCLEROSIS OF SYPHILITIC ORIGIN, and a case -in which there is no evidence of meningitis or meningoencephalitis. - - 1. What is the explanation of the negative spinal fluid W. R.? It - may be that none of the W. R. producing bodies have gone over into - the spinal fluid. It has been shown by the work of Weston that the - W. R. producing body is not identical with the bodies responsible - for the other tests in cerebrospinal syphilis. Moreover, it has - been clearly shown that these several tests of the spinal fluid do - not run at all parallel with one another. Especially is it true - that the chemical tests do not correspond at all with the degree - or nature of the pleocytosis. On the whole, when involvement of - the nervous system is entirely vascular, it is not only - theoretically proper but also practically common, to find a spinal - fluid negative to several tests. - - 2. Omitting consideration of the syphilitic gold sol of this case, - what conclusion could be drawn from the albumin and globulin - findings? It would not be warrantable to assume syphilis since it - is a common finding after cerebral hemorrhage due to - non-syphilitic arteriosclerosis to find excess albumin and also - globulin in the spinal fluid. Occasionally, also, pleocytosis - occurs in cases of cerebral hemorrhage even when the hypothesis of - an active meningitis can be excluded. We may recall in this - connection the pleocytosis in so-called meningitis sympathica of - certain brain tumors. (See also the case of Milton Safsky (48), a - case of brain tumor in which there was an excess of albumin, a - large quantity of globulin, and a pleocytosis of 146 cells per - cmm.) - - 3. What can be expected from treatment in these cases of vascular - cerebral syphilis? The condition offers very little opportunity - for therapeutic results. However, antisyphilitic therapy is - indicated to prevent if possible further progress of the lesions. - Since the lesions are, however, vascular, and since it must remain - a question how far these vascular lesions are due directly to - spirochetal action, and since in any event it may be difficult to - reach the spirochetes thus active, perhaps it is best to place - most reliance on potassium iodid. In any event, potassium iodid - should be given. Salvarsan and mercury are also indicated. It is - common to warn against administration of large doses of salvarsan - in this type of case on the ground that further vascular ruptures - may be produced. (See Friedberg, 108.) - - 4. If we conclude that the aphasia of the Bartlett case is due to - vascular disease, can we conclude a relation between this vascular - disease and vascular tension? It is not safe to draw such a - conclusion. The Bartlett case itself showed low blood pressure. To - be sure, some cases of neurosyphilis show high blood pressure from - which one draws the _à la mode_ clinical conclusion to the effect - that the kidneys are probably involved in the arteriosclerosis; - but other cases do not show a high blood pressure but may in fact - show a low blood pressure. The vascular disease doubtless - responsible for the aphasia in the Bartlett case is probably not - at all an effect of blood pressure conditions, but is, on the - contrary, an effect of local syphilitic vascular lesions. - - - =PARETIC NEUROSYPHILIS (“general paresis”) is often marked by - APHASIA.= - - -=Case 22.= Meyer Levenson, a traveling salesman of 36 years, had for the -last two or three years been undergoing a change of disposition, quite -interfering with his work. He had begun to take unreasonable aversions -to people, had become irritable and emotionally depressed, and often -fell to weeping without cause. - -About nine months before hospital observation, it seems that a -trunk-cover had fallen on Levenson’s head, and there is some question as -to whether he did not have a convulsion at that time. However, a month -later he had a definite seizure, followed by speech disorder, a slight -paralysis, and a staggering gait. Four weeks later, however, he had -gotten over these post-convulsive difficulties and had gone back to -work. - -At his work, he became tired easily, his gait and speech did not seem -entirely normal, and there was a considerable memory disorder. After -five more months, another attack of a convulsive nature, with twitching -of hands and face and tongue-biting occurred, and the attending -unconsciousness remained for two days. Again improvement followed, -though without ability to return to work. Four (?) months later there -were several severe convulsions and Levenson would remain unconscious -for a day or two at a time. Restlessness, irritability, and irrational -talking followed. - -=Physically=, the patient was fairly well developed and nourished; blood -pressure 168 systolic, 68 diastolic; pupils reacted very sluggishly to -light. There was a marked motor aphasia, which the patient recognized as -a speech difficulty. On the whole, however, Levenson was very euphoric -and was entirely sure that he was improving and would surely get well. - -Shortly after entrance, Levenson had a severe convulsion, with -unconsciousness. The movements were mainly on the right side of the -body, and there was a post-convulsive weakness of the right side for -several days, followed by a slow recovery of strength. - -The course of the disease—convulsions followed by improvement—is very -characteristic of a paretic onset. The =laboratory findings= were in all -respects confirmatory. It was rather striking that a permanent _motor -aphasia_ followed the convulsions in this case, since the seizures of -paresis do not in the vast majority of cases leave permanent paralyses. -The course of the disease continued to show convulsions, which would in -each instance leave him at a lower terrace of capacity than had been -before shown. The patient died four years after the onset of symptoms of -a general asthenia. With the exception of the permanent motor aphasia, -this case might be regarded as a fairly typical one of general paresis. - - 1. What is the general nature of speech disorder in paretic - neurosyphilis? Speech disorder is, along with the pupillary - changes, one of the most important clinical symptoms in paretic - neurosyphilis. There are aphasic and articulatory disturbances. - The aphasia that accompanies paretic seizures is of a transient - nature as a rule. A case with such long-standing motor aphasia as - shown by Levenson is not common. Paraphasia, with incorrect naming - of objects, may last longer. The so-called “sticking” phenomenon - is often observed. - - Word-deafness is said to be rarer but is difficult to test on - account of the patient’s dementia. Agrammatism (incapacity to form - correct sentences) is sometimes observed. But the most - characteristic disorder is in the syllabic composition of words. - Syllables are left out (“medaltricity” for medical electricity), - or fused (“exity”), or doubled (“electricicity”). Besides the - central speech disorders of which the above are examples, there - are disorders in articulation, which at first occur as a - consequence of paretic seizures or in states of excitement, but - later become permanent. These are divided into paretic and ataxic - disturbances. - - 2. What is the structural basis of these forms of aphasia? It is - believed that they are due to microscopic changes, not to coarse - destructive lesions. - -[Illustration: - - BROOKLINE, MASS. -] - -[Illustration: - - BROOKLINE, MASS. - - Mss. of Levenson, case 22. Paretic neurosyphilis. Tremor, misspelling. - Metathesis of letters (Bk, not Br) omission of letters (Book). -] - -[Illustration] - -[Illustration: - - God save the Commonwealth of Massachusetts - - Mss. of Safsky, case 48, brain tumor. Tremor not marked. Misspelling, - omission of letters. Wrong letters (h in hweth). -] - -[Illustration: - - Mss. of Halleck, case 31, cervical tabes. No brain disorder. - Pen-holding and bearing on difficulties. Crowding of phrases result - of ataxia. -] - -[Illustration: - - Mss. of Collins, case 61, paretic neurosyphilis. One misspelling - (-chussetts); not psychopathic? Characteristic tremor. -] - - - =REMISSIONS of identical appearance occur in PARETIC and in DIFFUSE - (non-paretic meningovascular) NEUROSYPHILIS.= - - -=Case 23.= Thomas Donovan, a merchant 44 years of age, acquired syphilis -according to his own story at the age of 31, and he was at that time -treated at a well-known watering-place with mercurial injections. Later -he continued treatment under his family physician, and at 34 was -pronounced cured. However, four years later—that is seven years after -his initial infection and in his 38th year—he had his blood examined and -it proved positive. He was accordingly treated by salvarsan and his W. -R. became negative. The story did not end there, however, for at 43, -mental symptoms appeared of the nature of depression and a diagnosis of -paresis was made. He was released from the institution against advice at -that time, and without treatment, made a partial recovery. - -A sudden outburst of violence brought Mr. Donovan to the Psychopathic -Hospital; he was very surly, combative, and difficult to manage, -standing 6′ 2″, and weighing 210 pounds. He was oriented only fairly -well and his surliness was streaked with humor. He facetiously said that -the Psychopathic Hospital was the largest hospital in the country, and -that it was, in fact, a horse hospital; that he had come because he -liked the surroundings, not to make money; that he was the healthiest -man in the world, never having been sick; that the Psychopathic Hospital -was a club, for which you have to get somebody to propose your name. -There was amnesia and no knowledge of current events. He regarded the -food as poisoned, refused to eat, and was very irritable and untidy. - -=Physically=, there were few abnormalities, but the pupils failed to -react either to light or accommodation, and the knee-jerks and -ankle-jerks were absent. There was a slight Rombergism. There was a -marked speech defect to test phrases. Both serum and spinal fluid W. -R.’s were positive; the fluid showed 41 cells per cmm., there were large -amounts of globulin and albumin, and the gold sol reaction was of the -“paretic” type. - - - =ATAXIA OR INCOÖRDINATION= - - NEUROSYPHILIS - LESION OF PERIPHERAL SENSORY NERVES - DIVISION OF POSTERIOR ROOTS - TUMORS OR CHRONIC SCLEROSIS OF POSTERIOR COLUMNS - SUBACUTE COMBINED DEGENERATION - VESTIBULAR ATAXIA - FRIEDREICH’S ATAXIA - FAMILY PROGRESSIVE HYPERTROPHIC NEURITIS - THROMBOSIS POSTERIOR INFERIOR CEREBELLAR ARTERY - MARIE’S HEREDITARY CEREBELLAR ATAXIA - LESIONS OF CEREBELLUM, TUMORS, ETC. - WRITERS’ CRAMP - PREHEMIPLEGIA - MULTIPLE SCLEROSIS - PSEUDO-SCLEROSIS - HYSTERIA - - CHART 18 - - - =CONDITIONS IN WHICH VERTIGO IS FOUND= - - NEUROSYPHILIS - HEAD TRAUMA - CEREBRAL ANEMIA AND HYPEREMIA - MENOPAUSE - ARTERIOSCLEROSIS - RENAL DISEASE - CEREBRAL HEMORRHAGE AND THROMBOSIS - INTRACRANIAL TUMORS - MULTIPLE SCLEROSIS - EPILEPSY (AURA) - TOXIC CONDITIONS: - alcohol, tobacco, constipation - PSYCHONEUROSIS - OCULAR DISTURBANCES - EAR DISEASE - MÉNIÈRE’S DISEASE - MIGRAINE - - CHART 19 - - -Salvarsanized serum was injected intraventricularly through a trephine -opening in the right frontal region. Injections were made through the -corpus callosum into the third ventricle. There was progressive -symptomatic improvement after each of four injections. In fact, after -the fourth injection the patient was allowed to leave the hospital -despite the fact that there was only a slight improvement in the spinal -fluid findings. The speech defect had entirely disappeared. (Speech -defect, according to many authorities, including Kraepelin, is of very -grave diagnostic significance.) His memory returned. Mr. Donovan is now -able to handle figures rather extraordinarily well. He now has a good -insight into his delusions and tells stories about them with great -humor. - - 1. What is the definition of a remission in general paresis? - Remissions form a foil to seizures; just as seizures mark a sudden - advance in the severity of the disease or may even lead to death; - so remissions may cause a sudden cessation of both mental and - nervous phenomena in the disease. Whereas the seizures occur most - often, according to Kraepelin, in the demented types of paresis, - the remissions occur in all cases except in the terminal phase. - Kraepelin quotes Hoppe as observing pronounced remissions of long - duration in 17% of male and 15% of female paretics. Gaupp observed - marked improvement in less than 10%, and very marked improvement - indeed in only 1% of his cases. Kraepelin states that such - improvements are most frequent in agitated and especially in - expansive forms of paresis, and that they are rarer and less - complete in the depressive and demented forms. Sometimes the - improvement occurs over night, although the full extent of the - remission becomes complete only gradually, perhaps in the course - of months. The sensorium clears, the disorientation disappears, - the delusions retreat, and the former delusions are treated as - dreams and imaginations. There is often a good deal of persistent - uncertainty as to events during the height of the disease. The - nervous disorders are far more obstinate than the mental. Still, - both speech and writing may often greatly improve. - - Cotton in New Jersey found, among 127 cases of paresis - diagnosticated by modern methods during seven years, that - remissions occurred in but five, or about 4%, lasting from a half - to three years. - - 2. Does a remission ever amount to a cure? The classical case quoted - in this connection is one observed by Tuczek. This case developed - a picture of paresis in 1876, at the age of 36; and a remission, - or cessation, of symptoms, occurred in 1878; but in 1883, at 43 - years, the patient developed a tabes without any trace of mental - disorder, which tabes gradually advanced. By the middle of 1898, - when the patient was 58, certain symptoms of excitement and - confusion occurred, which led to death with dementia, 22 years - after the beginning of the disease. Nissl pronounced the cortex to - be undoubtedly the characteristic cortex of a paretic. This - observation seems to indicate that a clinical remission tantamount - to a clinical recovery may occur without the death of the - spirochetes engaged. This observation is to be held in mind in - connection with all therapeutic work with neurosyphilis. - - Nonne states that during his clinical experience of 19 years he - had followed 10 cases of paresis with apparent recovery; but of - these ten cases, four had to be thrown out by Nonne because the - apparent recoveries turned out to be only long and almost complete - remissions, finally issuing in characteristic dementia. Of the - remaining six cases, perhaps two should hardly be counted as - paretic and Nonne rather preferred to term them cases of - syphilitic dementia in the sense of a non-paretic cerebral - syphilis. At the end, therefore, of his review of observations, - Nonne found himself with four cases of true recovery from paresis. - - Spielmeyer holds that there is no theoretical reason why paresis - might not be cured, since all the different changes that have been - described in the disease can be halted, and many of them can be - repaired. In particular, he reminds us that the acute infiltrative - process, the neuroglia reaction, and the phagocytic action of the - large mononuclear cells are distinctly removable processes. (See - discussion below under Section V, for apparent cures and - remissions occasionally secured under treatment.) - - - =REMISSIONS of identical appearance occur in PARETIC (“general - paresis”) and in DIFFUSE (non-paretic) NEUROSYPHILIS.= - - -=Case 24.= Michael O’Donnell, a laborer of 48 years, came home, one day, -at 5:30, complaining of severe headache. His wife told him he should lie -down and, taking him by the arm, tried to help him to the bed. At this -moment, O’Donnell lost control of both left arm and left leg, and fell, -unable to move but with consciousness preserved. The wife noted that the -left side of his face was drawn up and that he drooled. He was at once -carried to a general hospital, remaining there for about three weeks, -talking at random in a delirious manner and tied in bed. Two -intraspinous injections of salvarsan were given, and O’Donnell showed -considerable improvement and went home. - -However, upon his return from the hospital, he became very wilful, would -not remain in bed, and on one occasion actually took the mattress from -the bed, carried it to another room, and then returned to his own room -and slept upon the springs. He became irritable and emotional, insisted -upon going to the hospital, did not go there but upon returning home -insisted that he had been there. That night, O’Donnell left the house -only partly dressed. - -It appears that O’Donnell had been excessively alcoholic, but that -before August 15, when he sustained the left-sided hemiplegia above -mentioned, there had been no symptoms except that in February he had -once been very dizzy. It appears that there had been another dizzy -spell, three nights before the paralysis, accompanied by a fall and -unconsciousness for about 15 minutes. - - - =TRANSIENT OR FLEETING PARALYSES= - - NEUROSYPHILIS - MYASTHENIA GRAVIS - MYOTONIA CONGENITA (THOMSEN’S DISEASE) - PARAMYOTONIA CONGENITA - MYOTONIA ATROPHICA - INTERMITTENT CLAUDICATION - OCCUPATION NEUROSES - FAMILY PERIODIC PARALYSES - ETANY - EPILEPSY MINOR - HYSTERIA - MULTIPLE SCLEROSIS - APOPLEXY - CEREBRAL THROMBOSIS - - CHART 20 - - -O’Donnell was brought to the Psychopathic Hospital some six weeks after -the paralysis, complaining merely of a slight headache and desirous of -treatment. There were no mental symptoms of any sort. =Physically=, -O’Donnell was in general not abnormal (there was a slight pre-systolic -murmur and a blood pressure of 190 mm. systolic). The pupils were -slightly irregular, the left larger than the right; both reacted -sluggishly. Both ears were moderately deaf; the tendon reflexes of the -left arm and leg were somewhat more lively than those on the right. The -systematic =neurological= examination otherwise revealed no -abnormalities. The urine was negative. The serum W. R. was positive but -the spinal fluid reaction was negative. There were but 2 cells per cmm., -and there was a very slight trace of albumin. - - 1. How shall we account for O’Donnell’s transient paralysis? We - might invoke brain tumor, alcoholic pseudoparesis, or some form of - neurosyphilis. The diagnosis of brain tumor seems quite untenable - in view of the absence of premonitory symptoms and in the absence - of intracranial pressure. As for alcoholic pseudoparesis it is - true that the patient was excessively alcoholic. - - However, against these two diagnoses and in favor of the diagnosis - of NEUROSYPHILIS, are the positive serum W. R. and the pupillary - reactions (although these are short of the true Argyll-Robertson - phenomenon). Dizziness with retention of consciousness and - associated with the paralyses mentioned suggests rather a - subcortical than a cortical lesion. We are inclined to regard this - lesion as probably THROMBOTIC, and to place it possibly in the - region of the internal capsule. We are inclined to regard the - phenomenon as purely vascular and as not in this case associated - with an encephalitis. We are, however, not entirely satisfied with - the diagnosis. - - 2. What shall be said as to treatment? A full-blown left-sided - hemiplegia may be produced even when the thrombotic lesion is - itself exceedingly small. It is common to explain this on the - basis that there is an area of collateral edema about the small - necrotic, thrombotic, or hemorrhagic area responsible for the - lesion. In short, numerous neurones are functionally rather than - structurally affected, or at all events capable of early - restitution of function. - - 3. What is the prognosis in such cases? It appears that now and - again patients run for several years without further trouble, both - with and without treatment. We are inclined, however, to advocate - treatment rather than absence of treatment for a variety of - reasons. In the first place, vascular lesions may at any time - become associated with meningitic lesions, and treatment by - salvarsan may perhaps be counted on to head off this process; - secondly, the treatment with iodids may possibly aid in the - resolution of a local thrombotic process. - - 4. What are the prodromal symptoms of cerebrospinal syphilis? - According to Nonne, headache, dizziness, sleeplessness, mental - symptoms of the irritability group, loss of capacity as to mental - work, whether severe or not, and loss of capacity for difficult - thinking; also impairment of memory. Nonne does not regard these - phenomena as characteristic of syphilitic vascular disease, and - calls attention to the fact that in every organic disease the same - subjective symptoms occur. The triad—headache, dizziness, and - impairment of memory—is for example now counted as a prodromal - symptom complex for arteriosclerotic apoplexy (Cramer). Of course, - apoplectic attacks occur without such preliminary symptoms: - particularly, according to Nonne, the nocturnal attacks. - - 5. Can the fleeting paralysis be of service in differentiating the - diffuse from the paretic form of neurosyphilis? Probably not. In - both forms transient paralyses occur as well as the permanent - ones. In general, however, the transient paralyses are more - frequent in paretic neurosyphilis, whereas the permanent ones - occur more often in diffuse neurosyphilis. - - - =There are cases of NEUROSYPHILIS in which the laboratory signs are - positive but in which there are no clinical signs or symptoms - (PARESIS SINE PARESI?).= - - -=Case 25.= Richard Lawlor[6] was admitted to the Psychopathic Hospital, -October 29, 1914, being sent there from a general hospital where he had -gone on account of a self-inflicted wound of the wrist, apparently made -in a period of depression with suicidal intent. Routine notes follow. - -=Family History.= Paternal grandparents both died of heart disease. -Maternal grandfather died at seventy-two of dropsy. Moderately -alcoholic. Maternal grandmother died of shock at fifty-six. Father died -at age of forty, after an illness of eight years, from heart disease. -Father all his life was subject to fainting spells and headaches. The -only paternal cousin died at thirteen months of brain fever. Mother, -aged forty-seven, is, to say the least, eccentric. Says “she has several -times been given up from tuberculosis.” Two maternal uncles died of -tuberculosis, one from rupture, one from heart disease. One uncle who -“doesn’t know anything after he has a teaspoonful of liquor.” Several -other uncles and aunts whose history is not obtained. Patient is -mother’s only child. Mother was twice married. There were several -miscarriages by both husbands; patient child by first marriage. - -=Past History.= Patient born thirty-two years ago, full term, normal -delivery and development. Measles, mumps, and chickenpox in childhood. -Subject to headaches since seven or eight years old. Kicked in the face -by horse at seventeen or eighteen, not considered serious. Hit by a -baseball three or four years ago, leaving him hard of hearing on left -side. Married ten years ago; no children because he says his wife needed -an operation. He denies venereal disease by name and symptoms. For past -ten years has had attacks of depression lasting but a short time, but -quite severe. Never caused him to quit work as a barber and he felt -better when working. His married life he says was fairly happy except -for his wife’s extravagances, and on this account he left her a little -over a year ago, and she has applied for a divorce, which he is willing -that she should have, but does not wish to give her alimony. He admits -moderate alcoholism. - -=Present Trouble.= Patient states that since he left his wife a year ago -he has felt sorry a number of times. He has wished he had her back. He -has felt lonely. He has had six or eight periods of depression in that -time similar to those he has had for many years, lasting two or three -days, and sometimes a week. These were always precipitated by some cause -for worry. In these attacks he feels nervous, sleeps poorly, has little -or no appetite, sweats during his work and everything looks black. -Several times in these attacks he has had suicidal ideas. Ten months ago -he considered taking corrosive sublimate. For a little over a week -before entrance to hospital he had been out of work and had been -“sporting.” The day before entrance he had a telephone message from his -lawyer which upset him somewhat and he walked the floor all night. He -had just been shaving when the idea of suicide came to him. He sat down -a minute when suddenly the thought “to hell with the world” came to him; -he took the razor and slashed his wrist. He does not remember drawing -the razor across his wrist. As soon as he saw the blood he felt sorry, -called his mother, and was taken to an emergency hospital and then sent -to the Psychopathic Hospital. - -=Physical Examination.= Patient is a well developed and nourished man -thirty-two years of age. Head is normal as to size and shape; there are -no scars or marks of injury. Hair and skin not remarkable in any way. -Ears negative to external examination. Teeth well kept; two missing, -several gold fillings. Tongue very slightly coated. Throat negative. -Tonsils easily visible without evidence of inflammation or exudation. -Neck, no thyroid enlargement, no abnormal pulsations, no adenopathy. -Chest, symmetrical, expansion good, resonant throughout. Breath sounds -transmitted normally. No râles or rubs heard. Heart, no enlargement or -cardiac dulness. Sounds of good quality, no murmurs heard. Rate regular. -Pulses equal, regular and synchronous, and of good volume and tension. -Systolic blood pressure 130, diastolic 65. Abdomen, flat, soft and -tympanitic throughout; no masses; no tenderness. Liver edge not felt, -below costal margin. Spleen not palpable. Extremities negative, except -for incised wound on left wrist. - -=Neuromuscular Examination.= Pupils are large, round, regular, equal and -react readily to light and accommodation. No nystagmus, strabismus or -ptosis. No weaknesses or paresis of facial muscles. The tongue projects -medially and shows no tremor. The triceps and biceps reflexes are -readily elicited, and are quite active, as are the knee-jerks and -ankle-jerks. On one occasion it was thought that the tendon reflexes -were slightly more active on the left than on the right. This was never -confirmed; always afterwards found equal. There was no tremor of -extended hands. Abdominal reflexes not elicited. Cremasteric present on -both sides. The plantar response is flexor. There is no Babinski, Gordon -or Oppenheim. No Romberg. Coördination tests well performed. No speech -defect. No sensory disturbances. Urine examination negative. - -Wassermann reaction in the serum: Positive, with cholesterinized -antigen; negative, with syphilitic fetal liver antigen. - -Wassermann reaction in fluid positive on two occasions. Examination of -spinal fluid, November 4: globulin +++, albumin ++, 100 cells per cubic -millimeter; large lymphocytes, 8 per cent; small lymphocytes, 90 per -cent; plasma cells, 0.7 per cent; endothelial cells, 1.3 per cent. -November 11, globulin +++, albumin +++, cells 18 per cubic millimeter. -November 26, globulin ++, albumin ++, cells 92 per cubic millimeter; -large lymphocytes, 13.1 per cent; small lymphocytes, 82.1 per cent; -plasma, 1.2 per cent; endothelial, 3.6 per cent. - -Gold sol, November 4, 5555432100. - -Gold sol, November 26, 3332100000. - -=Mental Examination.= On entrance to hospital patient seemed slightly -depressed and a bit irritable. This condition lasted two days, after -which he was agreeable and apparently entirely over his depression. Even -during his mild depression, however, he talked freely. There was no -evidence of retardation. He told his story readily. Orientation was -intact. Memory excellent. Educational knowledge well retained. There was -no evidence of any hallucinations or delusions. - - 1. Was Richard Lawlor insane? - - There was, then, on the mental and physical examination nothing to - make a definite suggestion of a psychosis, and the most one could - think of was a psychoneurosis or a cyclothymia of at least ten - years’ duration. The findings in the cerebrospinal fluid and the - Wassermann reactions, however, give us material for thought. - Certainly one cannot call the man insane; all who saw him agreed - on this point. - - 2. If Richard Lawlor should some day develop mental symptoms, what - would be the genesis of the new psychosis? Though writers such - as Fildes and McIntosh, and Swift, have suggested an - anaphylactic or hyperallergic explanation for the development of - symptoms after a normal interval; such a hypothesis could hardly - obtain in the present case. The hyperallergic hypothesis for the - development of tertiary neurosyphilis would run to the effect - that in the secondary stages there had been a definite disease - of the nervous system, which, however, absolutely cleared up, - leaving no inflammatory vascular or parenchymatous relics of its - existence. Nothing would on this hypothesis remain except a - hypersensitisation of the tissues. In some later period of the - now clinically normal person, one or more spirochetes from a - lesion outside the nervous system are carried into the nerve - tissues and there set up an anaphylactic or hyperallergic - reaction. It is obviously difficult to prove the correctness or - incorrectness of the hyperallergic theory without numerous - examinations of the spinal fluid, in clinically normal persons - after the secondaries have passed. The present case, so far from - demonstrating a normal fluid, demonstrates a highly pathological - fluid, even though there are absolutely no clinical symptoms - which could be regarded as of nervous origin. The burden of - proof at the present time would seem to lie with those who claim - hyperallergy in neurosyphilis. We prefer on present evidence to - think that at the conclusion of the secondaries a disease - process often remains in the nerve tissues despite clinical - quiescence. - - 3. What is the prognosis in the case of Richard Lawlor? The - prognosis _re_ neurosyphilis is doubtful. We have, however, boldly - termed the condition _PARESIS SINE PARESI_, meaning thereby to - suggest that the patient is in considerable danger of the - efflorescence of a true diffuse or paretic neurosyphilis. We have - no means of telling, however, whether the positive symptoms would - be those of a paretic or a non-paretic neurosyphilis. As data - accumulate regarding these cases of _paresis sine paresi_, we may - be able finally to come upon some case in which trauma shall bring - out the clinical symptoms of neurosyphilis. For discussion of this - matter, see the case of Bessie Vogel (52) in Part III of this - book. - - 4. Should Lawlor have been brought to a psychopathic hospital? It is - a safe working rule to have any person who attempts suicide - observed. A large percentage of suicides occur in psychotic - individuals and a suicidal attempt is not infrequently the first - recognized abnormality. Immediate observation is a necessary - safeguard against another more successful attempt. - - - =Demonstrates SYMPTOMS and LESIONS of PARETIC NEUROSYPHILIS - (“general paresis”). Autopsy.= - - -=Case 26.= John Morrill, 49, an operative in a mill town in Essex -County, Mass., was described as a “Saturday night and Sunday drinker,” -with a history of very serious long sprees at the age of 43. It seems -that he had had what was called “sciatica” at 35, and was treated in -hospital for seven weeks at that time. The nature of this sciatica is in -doubt, but there was a history of syphilitic infection at 36 years (scar -of glans). - -Morrill had been married twice, and two of the children were dead; one -daughter was described as “very nervous,” but there were four children -under ten years of age, all regarded as perfectly healthy. - -Morrill had been a mill operative of average capacity, was industrious, -and had supported his family despite alcoholism. The syphilis had been -treated with reasonable thoroughness. - -Aside from alcoholism, there had been no symptoms up to two months -before admission to Danvers Hospital. Then there had been insomnia, -fatigue, agitation, eruption on foot, loss of ten pounds in weight, -hypochondriacal fears, apprehensiveness for the future of the children, -incoherent talk; and just before admission, his talk was described as -foolish. He had taken to running away and hiding in bushes by a pond and -in the cellars of other people’s houses. - -The patient was of medium height and weight, with thin grayish hair and -grayish irides; musculature was slender. The face was blank in -expression, the teeth poorly preserved with atrophy of gums, the tongue -coated, and the breath foul. There was a gummy secretion of the eyelids, -an area of brownish branny eruption over both clavicles, a number of -depressed scars over the limbs and back, and another area of scaly -eruption on the right heel and the sole of the foot. The heart area was -increased, and the sounds were faint at the base, with the first sound -accentuated at the apex. The urine showed a trace of albumin. - -=Neurologically=, the Romberg position was maintained with a general -tremor and fluttering of the eyelids. In complicated movements, the -patient was slightly ataxic. The pupils were irregular, the left being -much larger than the right. There were no light reactions to be obtained -in window light. The reaction to accommodation was present, though -slight. Vision was poor, ¼-inch capitals could not be read by left eye -at reading distance. The knee-jerks were diminished equally; the -Achilles jerks were absent; the other reflexes were normal. Upon the -sensory side, the patient gave a history of pains in the legs at -irregular intervals for several years. These pains he described as of a -darting character. There was little or no sensory disorder, although the -outer surface of the right leg required a deeper pressure to elicit -sensation. There were no disorders of muscle sense. - -If Morrill was to be trusted, he had been born in Ireland, and had come -to the United States at the age of 17. He married at 18; there had been -seven pregnancies by the first wife, with one stillborn child; one child -had died at five weeks. The four children by the second wife were -healthy. The first signs of neuritis had occurred at 45 and had received -the diagnosis neuritis, although no connection between the neuritis and -the syphilis had been noted. - -The patient entered the hospital July 26, 1904, and was discharged, -improved, January 5, 1905. He returned a little more than a year later, -January 15, 1906, and died March 21, 1906. The total duration of the -disease from the onset of mental symptoms may therefore be stated as -somewhat under two years. When the patient appeared at the hospital the -second time, he showed a positive Romberg sign, an unsteady gait, an -ataxia that still was moderate, and somewhat more marked tremors, -involving fingers, tongue, and face. He was now unable to read ½-inch -type with the left eye. The knee-jerks, formerly diminished, were both -exaggerated, the left slightly more so. The Achilles reaction, not -obtained formerly, now appeared on the right side. The pupils reacted as -before. The sensory loss had become more marked, since sharp and dull -points could hardly be distinguished. Deep pinpricks were not felt in -the leg, and heat could not be told from cold. - -The speech in 1904 had been somewhat defective (“truly rural” rendered -as “tooly lualal,” “sifted soft thistles” as “thoft thsistles”), and -there had been little further development of the speech defect. The -handwriting had lost appreciably in legibility and had become much more -tremulous. During the first period of hospital observation Morrill had -what might possibly have been visual hallucinations, but it was -impossible to tell whether his story of seeing his wife and children -trying to get in through the window was hallucinatory or a matter of -fabrication. Memory was decidedly imperfect and few details of recent -events could be produced. The association of ideas was almost a -so-called “flight” of apprehensive, fearful ideas, loosely connected, -incoherently expressed, and dealing chiefly with his work and his -children. Judgment was imperfect; the height of the room was estimated -as 24 feet, but the height and weight of persons were estimated with -fair accuracy, and also the length of small objects, whose lengths were -doubtless remembered rather than estimated. The estimate of time -elapsing during a medical examination was accurate, but the estimate of -longer durations involving over-night memories was hopelessly imperfect. -Emotionally, there was a dulling of sensibility, an appearance of -suspicion and apprehensiveness; the patient fancied himself to be in a -hopeless condition as a result of syphilis, but at the same time -accompanied his statement of his hopelessness with laughter. A sample of -his hypochondriacal ideas: “I am all gone; I am good for nothing; I am -all gone now; I can’t drink now; can’t write or talk at all; worse than -when you saw me first; nothing in my inside; all wrong through me again; -I aint got no swallow now; I can’t die even; my heart aint much good; I -can’t hear it beat; I don’t think it flutters; no life in these hands; -they are all cold and dead” (pointing to his arms and moving them -about). During such a portrayal the patient laughed in a silly way. - -During the second hospital stay, Morrill was at first restless, -sleepless, profane, imperfectly oriented for time, possibly for place, -and also for the attendants. A few weeks later he became stuporous and -confused, and his feebleness and physical exhaustion were finally ended -by death, March 21, 1906. Death was preceded by a semi-comatose -condition; a left otitis media had developed. - -At the =autopsy=, it appeared that death was due to an early -bronchopneumonia associated with acute splenitis and doubtless related -to the otitis media of the left side. The body at large showed, aside -from these acute lesions, a few chronic lesions, including slight scars -of the left apex, and chronic adhesive pleuritis, chronic diffuse -nephritis, and aortic and coronary syphilis. The aorta showed slight -linear and nodular markings, with a single small dark ulcer in the upper -thoracic region, but the aorta did not show the characteristic scarring -which syphilitic aortas often show. The femoral marrow was of a dark red -chocolate color. The thyroid appeared to be smaller than normal. A -slight sacral decubitus had developed. - -The description of the head (E.E.S.) is given in full on account of the -encephalitic lesions shown. These encephalitic lesions may be summed up -as follows: - - Local cerebral =atrophy= and =sclerosis= of the frontal, orbital, - and central regions, especially of the left operculum and left - supramarginal gyrus. - - Extension of sclerosis to hippocampal gyri with effacement of - substantia reticularis alba. - - Slight chronic internal =hydrocephalus=. - - Granular =ependymitis= (especially of floor of 4th ventricle). - - Compensatory edema of frontal and central pia mater. - - Cerebellar sclerosis (culmen monticuli, lobus culminis, lobus - cacuminis). - - Spinal sclerosis (grossly evident in the posterior columns of the - upper thoracic region and of the lumbar enlargement). - -The details are as follows: - - Head:—Bald on top. Hair =gray=. Scalp normal. Calvarium thin, deeply - excavated by arachnoidal villi to right of vertex. Diploë absent. - Dura closely adherent in bregmatic region. Dura of usual thickness. - Sinuses contain cruor clot. Arachnoidal villi slight. Pia mater hazy - and over sulcal veins porcelain white over all of vertex except - occipital poles and over flanks (notably left). Thickened also - around circle of Willis, over culmen monticuli and in posterior - cerebellar notch. Edema of pia corresponding to atrophy of frontal - and central regions. Cerebral atrophy most marked in orbital - surfaces of both frontal lobes, in left area of Broca, and in left - supramarginal region. The ascending branch and the ascending ramus - of the posterior limb of the left Sylvian fossæ both readily admit - the thumb by reason of atrophy of adjacent substance. Induration - corresponds closely with atrophy, but is not more marked about the - left Sylvian fossa. There is sclerosis of both hippocampal gyri, - with loss of the substantia reticularis alba. The culmen monticuli - and lobus culminis are firmer than the clival regions, and the lobus - cacuminis is again slightly firmer than the clival region. - Cerebellum a little softer than usual. Pia strips with usual - readiness from all regions. The subpial region of the frontal lobes - is a trifle grayer than that of the rest of cerebrum. Ventricles - slightly dilated. Surfaces evenly sanded. Floor of fourth ventricle - shows numerous coarse, closely set granules. Brain wt. 1200 grms. - Cord shows a slight increase of consistence over one or two upper - thoracic segments and in lumbar enlargement corresponding with a - slight graying out of posterior columns. In places there is a - suggestion of graying out also in lateral columns. A few calcified - plaques in posterior lumbar pia. - -Analysis of these details shows a number of lesions that characterize -paretic neurosyphilis (among others, granular ependymitis, frontal -atrophy, chronic leptomeningitis), but the lesions are more than merely -frontal, extending as they do back as far as the postcentral regions on -both sides, and even as far as the left supramarginal gyrus. The -cerebellar involvement although frequent, can hardly be said to be -characteristic in paretic neurosyphilis. The spinal involvement is -characteristic of a case which is probably to be regarded as one of -taboparesis; that is, of paretic neurosyphilis following a number of -years after the establishment of tabetic neurosyphilis. The aorta is -almost constantly affected by sclerosis in paretic neurosyphilis. The -absence of diploë in the skull is not infrequent and the adherent dura -mater is often found. - -Microscopically, the tissues showed the characteristic lesions of -PARETIC NEUROSYPHILIS; nerve cell destruction, fibrillar and cellular -gliosis, lymphocytic and plasma cell deposits about the small vessels. - - 1. What are the clinical evidences of syphilis outside the nervous - system? The brownish branny eruptions of the skin, the depressed - scars and the scaly eruption on right heel and sole are very - suggestive of syphilis. Such clinical evidences of syphilis are - very important in systematic examination. Although the laboratory - tests are of the utmost assistance in the diagnosis of syphilis, - the clinical signs should not be neglected, and no physician - should rest satisfied with laboratory signs alone. X-ray diagnosis - of bone conditions sometimes succeeds when all other methods have - failed. - - - =GUMMA of cerebral cortex verified by operation; death.= - - -=Case 27.= The presenting picture in the case of David Tannenbaum was -that of deep dementia, in which condition the patient was brought to the -hospital. There was a meagre history to the effect that about four -months before admission, he had lost his job in a hotel through lack of -further work. We heard that at this time he had begun to suffer with -excruciating pains in the head; at first, worse at night, later, worse -by day. It appeared that this pain, though it came and went, was chiefly -localized on the left side of the head. For a fortnight, Tannenbaum had -been dragging his legs, until finally he had become unable to walk at -all. - -_Pari passu_ with these developments, Tannenbaum had become mentally -confused and irritable, and his memory had become untrustworthy. For -several days before admission, an appearance of marked dementia was -presented, with slow incoherent, or at all events, irrelevant words, and -a complete disorientation for person. However, his vision had become so -poor that it would have been hard for him to have recognized any one. - -It appeared that the family history was entirely negative; that the -patient was without education but had been physically very strong, and -had been fairly successful at first in the junk business, and later in -the clothing business; but latterly he had been less fortunate in the -clothing business, and finally had to resort to work as a laborer around -a hotel. - -His wife had had eleven pregnancies with but one miscarriage. -Nevertheless, out of the eleven pregnancies, there were now but four -living children. - -=Physically=, Tannenbaum was a rather small man; he was flabby and -looked as if he had recently lost weight. The skin showed areas of -pigmentation on the face and sides of the neck, and some dark -copper-colored circular areas, marble-size, in the neck (syphilitic?). -There was a slight radial arteriosclerosis. The heart was slightly -enlarged with distant and indistinct sounds. There was a small -pedunculated growth on the right side of the abdomen. - -The pupils failed to react to flash-light but they reacted to sunlight. -They both were slightly irregular but were equal in size, and reacted in -accommodation. There was apparently almost complete blindness and -extreme deafness. Arm-jerks and knee-jerks were absent; there was an -occasional slight response of the left ankle-jerk, but the right -ankle-jerk was absent; the left abdominal reflex was very feeble; the -right absent; the cremasteric reflexes were absent, but there were no -other abnormalities in the systematic examination. Hand grips weak; gait -awkward, with right leg held somewhat flaccidly. - -It was significant that percussion over the left frontal and parietal -regions was able to elicit great pain. Either through the patient’s -deafness or through sensory aphasia, spoken language was not understood. -The serum W. R. was positive, the fluid W. R. negative. - -=Diagnosis=: The clinical symptoms seem clearly to indicate syphilis. -The local skull tenderness and impairment of vision might well suggest -intracranial pressure. Uniting these suggestions, we might automatically -arrive at a diagnosis of cerebral gumma. We have learned to be rather -cautious of making a diagnosis of gumma of the brain through its mere -rarity. - -Decompression was suggested and executed. A deep growth resembling a -GUMMA, in the view of the surgeon, was discovered. No attempt could be -made to remove it. The patient died without recovering consciousness. - - 1. What is the significance of the negative fluid W. R. in this case - of cerebral gumma? The W. R. producing substances not infrequently - fail to appear in the spinal fluid from a gumma of the brain. The - serum W. R. was positive in this case, but even the serum W. R. - may be negative in cases of gumma, both of the brain and of the - body at large. It must be remembered that the serum W. R. may be - negative in paretic neurosyphilis (general paresis); the serum W. - R. is even more apt to be negative in cases of gumma. - -[Illustration: - - Gummatous meningitis. Compression of hemisphere. Tissue destruction of - underlying cortex. -] - - 2. Is operative procedure to be advised in cerebral gumma? There are - cases in which the acute and threatening symptoms of heightened - intracranial pressure require operative treatment simply because - the therapeutist cannot wait for the effect of antisyphilitic - treatment. Moreover, antisyphilitic treatment of cerebral gumma is - not always as successful as that of most syphilitic lesions. - - 3. Could the intracranial pressure be caused by other syphilitic - lesions than gumma? A heavy meningitis may cause symptoms such as - produced by an intracranial tumor. In such a case one will usually - find evidences of inflammation in the spinal fluid. Cysts caused - by syphilitic lesions may also produce identical symptoms. - - 4. What is the significance of cranial tenderness? Where - sensitiveness to cranial percussion is not due to a scalp lesion - it is very suggestive of a tumor underlying this point. A - gummatous lesion of the cranium itself, may occur without causing - pain or increased sensitiveness. - - - =CRANIAL NEUROSYPHILIS (focal syphilitic extraocular palsy) without - mental symptoms.= - - -=Case 28.= A chef, Paolo Marini, 28 years of age, reported that on -awaking one morning, everything appeared double to him and that his -right eyelid had begun to drop. In the following month Marini had begun -to feel weak and to have difficulty in swallowing, as well as at times -difficulty in breathing. The diplopia was found to develop when Marini -looked to the right. Mentally, the patient was in all respects normal, -and no other physical signs were found except the diplopia and ptosis -above mentioned. The W. serum test was positive, but the tests of the -spinal fluid were negative. - -=Diagnosis=: “CEREBRAL SYPHILIS.” - - 1. What is the anatomical cause of this condition? It is thought to - be due in a number of cases to a small diffuse gummatous lesion at - the _basis cerebri_. In the case of Marini this lesion appears to - have been a little more extensive and to have interfered with the - tenth and twelfth nerves also. - - 2. Why is the spinal fluid negative in such a case as that of - Marini? Head and Fearnsides believe that intracerebral lues is - characterized by a negative spinal fluid, under which circumstance - one has always to consider the possibility of brain tumor or - migraine in addition to the suspicion of syphilis. - - 3. What other causes besides syphilis should one consider for the - sudden diplopia? Brain tumor, multiple sclerosis, cerebral - arteriosclerosis, tuberculous meningitis, trauma and migrainous - ophthalmoplegia, are not infrequently at the bottom of this - condition. Cases also occur in which the etiology remains obscure, - even at autopsy. - -Under antisyphilitic treatment, Marini slowly improved. - - - =The SIX TESTS in TABETIC NEUROSYPHILIS (“tabes dorsalis”) may run - milder than in paretic neurosyphilis (“general paresis”) and - characteristically run somewhat like those of diffuse - (meningovascular) neurosyphilis; in particular, the fluid Wassermann - Reaction and the gold sol reaction are apt to run milder. The - clinical course of tabes dorsalis is protracted and the prognosis as - to life is good.= - - -=Case 29.= Mario Sanzi, 55 years of age, had been having what he called -rheumatism since his 43d year. This rheumatism affected only the hips -and legs, had at times been very severe, and for two years past had been -almost constant. Before that time, pains had come at intervals, lasted a -variable period, and suddenly disappeared. They were of knife-thrust -character, and could probably be called “lancinating.” In a given -attack, these pains would come at intervals of seconds or more. There -was also a certain unsteadiness in locomotion and inability to control -the vesical sphincter. - -=Physically=, the patient was entirely normal so far as could be made -out except =neurologically=. Argyll-Robertson pupils, absence of -knee-jerks, and ankle-jerks, Romberg sign, and characteristic gait, left -no cause for doubting the diagnosis of TABES DORSALIS. The blood and -spinal fluid both proved positive to the W. R., though the W. R. in the -fluid gave a negative reaction with 0.1 cm. and became positive with 0.3 -cm. or more. The globulin was somewhat increased though less markedly so -than in paresis. The gold sol reaction was “syphilitic” but weak. It is -to be noted that the disease had run a 12–years’ course before a doctor -had been consulted. The primary infection occurred at 32 years, namely, -11 years before the symptoms began. At the time of his primary -infection, Sanzi had received several years of treatment, chiefly in the -form of mercury by mouth. - - 1. What is the value of mercurial treatment of syphilis in the - prevention of tabetic or other forms of neurosyphilis? “Fournier - strove for many years to convince the medical profession that a - syphilitic patient should be treated for at least two years after - his infection, whether the syphilis seemed latent or patent. The - method of treating only the symptoms he characterized as the - opportunist method; treatment in the absence of definite symptoms - the preventive method, as preventing the later manifestations. - That prolonged treatment does prevent is shown by Fournier’s - figures analyzing 2396 cases presenting tertiary signs. These he - divides into three groups: Group I, comprising 1878 cases, or 78 - per cent of the whole number, having no treatment or inadequate - treatment—that is mercury for less than one year; Group 2, - comprising 455 cases, or 19 per cent, having moderate - treatment—that is, mercury for one to three years; and Group 3, - comprising the remaining 19 cases which represent only 3 per cent - of the whole number, having treatment for more than three - years.”[7] - - In the light of what we now know concerning latent neurosyphilis, - it would seem well for patients to be followed from time to time - with the W. R. on blood and spinal fluid after the supposed - completion of the treatment of primary and secondary syphilis. The - examination of the spinal fluid is not superfluous, as our - experience with the so-called _paresis sine paresi_ abundantly - shows. At the present day it is not good practice to assure a - patient that he is cured after two years of ordinary mercurial - treatment without resort to frequent spinal fluid tests, even - though the serum W. R. be negative. - - - =TABETIC NEUROSYPHILIS (“tabes dorsalis”) is often quite ATYPICAL - clinically and may even show no single symptom warranting the old - clinical name “locomotor ataxia.”= - - -=Case 30.= Stephen Green is a case of TABES DORSALIS with active -knee-jerks and without locomotor or muscle-sense disorder. When observed -at the age of 45, it appeared that there were but two complaints: lack -of control of the vesical sphincter and shooting pains in the legs. It -appeared that the urinary disorder dated back ten years, when there had -been difficulty in passing the urine. Sounds had been passed at the -time; occasionally there had been incontinence during after years, -ascribed by Mr. Green to the passing of the sound. However, the -physician at that time stated that the incontinence was a symptom of -tabes dorsalis. The incontinence had recently become worse, especially -marked at night, though also occurring in the day; much worse during -excitement, and very much worse after taking alcoholic drinks. Besides -incontinence, there is also difficulty at times in passing the urine, as -well as dysuria. - -As for the pains in the legs, they had been first noticed some three or -four years ago and considered to be mild rheumatic effects. Now, -however, they have grown progressively worse and have been the effective -cause of giving up business. The pains are sharp, darting, pinching, and -burning, and last, say, about a second with an interval of about the -same length. The attack will continue sometimes for many hours. - -There is a strabismus of the left eye, ascribed by the patient to an -accident with an umbrella (there had been operation without relief). The -pupils showed the Argyll-Robertson effect and were markedly irregular. -Despite the divergent strabismus with diplopia, the eye movements were -well performed although not in parallel axes. Ankle-jerks could not be -obtained even on reinforcement, but the knee-jerks were lively, and the -other deep and skin reflexes proved normal. The blood and spinal fluid -tests were characteristic of tabes dorsalis. - -It appears that the syphilis was acquired by this patient 15 years -before; that is, 5 years before neurological symptoms began. Three -courses of treatment had been taken at a well-known watering-place, and -mercury pills had been taken for two years by mouth. The patient is -married; has no children; there have been no pregnancies. - - 1. What causes may be assigned for the absence of children in the - family of a tabetic? There may be lesions of the genital apparatus - (orchitis, or more specialized toxic lesions). But impotence such - as characterized the present case must also be taken into account. - - 2. What is the therapy for tabetic pains? Pyramidon is nowadays much - in favor; morphine may be used; some authors recommend that the - patients be instructed to chloroform or etherize themselves - slightly for relief of the pain. Surgery of the nerve roots may be - resorted to in extreme cases. Intraspinous therapy, suggested by - various authors, seems to exert beneficial effect in many cases. - - 3. Is the lack of control of the vesical sphincter an unusual - initial symptom? On the contrary, the more careful the clinical - observation, according to some observers, the more likely is the - examiner to find that vesical symptoms were the earliest or among - the earliest complaints of the patient. Baldwin Lucke found - sphincter disturbances to be initial in 8¼% of his long Blockley - series. He found sphincter disturbance to occur in some stage of - the disease in 67.6%, being exceeded in frequency only by - staggering gait (87.2%) and lancinating pain (71.6%). According to - Lucke, the most frequent _initial_ symptom is lancinating pain in - the lower extremity, which, it will be noticed, occurred also in - our case of Stephen Green as an initial symptom along with vesical - disturbance. Lucke’s figures show that paresthesia of the lower - extremities (17.6%) and weakness of the extremities (16.4%) are - the next initial symptoms in frequency. - - 4. Could the early treatment in the case of Stephen Green be - considered as adequate? No better answer can be given to this - question than by quoting from Dr. Joseph Collins,[8] who probably - has done more than any other one man in this country in insisting - on the need of proper treatment of syphilis. As to the adequate - treatment of syphilis he says: - - “It consists in the proper use of salvarsan and mercury begun at - the earliest possible moment after infection and kept up till all - biochemical evidence of the disease has ceased, while the - metabolism of the individual is maintained as nearly normal as - possible. But the physician does not do his whole duty when he has - accomplished this. He must solicitously watch the individual to - see that no evidence reappears for months and even years after the - apparent cure. As an index of such reappearance the Wassermann - test of the blood serum and of the cerebrospinal fluid is the - safest guide. - - “Until there is a definite unanimity of belief among physicians as - to when the treatment of syphilis shall be begun, and some concert - of action as to what constitutes the adequate treatment of - syphilis, we cannot hope to make any considerable progress in the - prevention of syphilis of the nervous system, save by educating - the individual toward infection.” - - - =TABETIC NEUROSYPHILIS may produce symptoms chiefly if not entirely - in the region supplied by the CERVICAL plexus (“cervical tabes”).= - - -=Case 31.= Paul Halleck, 35, was a salesman who had begun to find it -hard to carry his sample case, since he was unable to tell whether or -not he had it in his hand. There was not only an anesthesia of the -hands, but they felt numb and there was often a tingling sensation. Of -late it had become hard for Halleck to dress himself or to write, and -these symptoms had been slowly growing worse. There was no other -complaint. There was, however, a history of a chancre about 7½ years -before, which had been followed by a rash and a sore throat. There had -been treatment with mercury and potassium iodid alternating for a period -of two years. - -=Physically=, there was no evidence of disease except =neurologically=. -The pupils were unequal (the right larger than the left) and reacted -slowly to accommodation and not at all to light. A marked ataxia of the -hands was shown in coat-buttoning. The finger-to-nose test showed a -marked dysmetria. Arm-jerks as well as knee- and ankle-jerks were -absent. There was a slight swaying in the Romberg position but no true -Romberg sign. There was no difficulty in locomotion. Both blood and -spinal fluid proved positive to the W. R.; globulin and albumin were -increased. The gold sol reaction was syphilitic, and there were 85 cells -per cmm. - -This case is probably not a pure example of CERVICAL TABES, since the -knee-jerks are also absent, and we may suppose a degree of lumbar spinal -cord changes in addition to the cervical changes. It well illustrates, -however, that the tabetic involvement of the cord may be quite -generalized and that it may strike high as well as low. - - - =ERB’S SYPHILITIC SPASTIC PARAPLEGIA.= - - -=Case 32.= Margaret Neal, a maid-of-all-work, 36 years of age, was -committed to a home for inebriates on account of her excessive -alcoholism, but she was shortly transferred to the Psychopathic Hospital -on account of difficulty with locomotion. We found a very marked -spasticity in walking, with a characteristic scissors gait. The pupils -were somewhat irregular, and although both reacted to light, the left -reacted far more slowly than the right and the reaction failed to hold -well. The arm reflexes were very active, and the knee-jerks and the -ankle-jerks were particularly exaggerated. There was a double Babinski -reaction, as well as Oppenheim and Gordon reflexes and a bilateral ankle -clonus. There seemed to be tenderness over the nerve trunks in the back -of the leg, below the knee. There was no evidence of incoördination, no -Rombergism, no disturbance of sensation, no disorder of the special -senses, and not even a tremor of the tongue or hands. - -=Mentally=, the patient was entirely negative. - -=Diagnosis=: Symptomatically, it is entirely clear that the patient was -suffering from SPASTIC PARAPLEGIA. One would have to consider besides -spinal syphilis, also amyotrophic lateral sclerosis, syringomyelia, and -spinal cord tumor. However, there appeared to be no definite wasting of -muscles, and the fact that the sensations were intact seems to rule out -also syringomyelia. There was none of the characteristic pain associated -with a cord tumor. There was, in fact, a strong clinical premonition -that the case was one of spinal syphilis, simply because syphilis is the -most common cause of spastic paraplegia in the adult. The pupillary -anomalies were also highly suggestive. - -The serum W. R. proved to be weakly positive, as was also the gold sol -reaction in the zones characteristic of syphilis. The spinal fluid -examination yielded 14 cells per cmm. There was a positive globulin test -and a moderate increase in albumin. The W. R. of the spinal fluid was -negative. - - 1. Why was the spinal fluid W. R. negative in this case of spinal - syphilis? The explanation of negative W. R.’s in spinal syphilis - is not easy. Possibly, however, in the course of years the - intensity of the process has been reduced and possibly the W. R. - has been one of the first tests to disappear. - - 2. How shall we explain the nerve trunk tenderness? We might - consider this to be due possibly to an inflammation about the - posterior roots. On the whole, partly on account of the situation - of the pains below the knee, it seems probable that the nerve - trunk tenderness of this case is the residuum of an alcoholic - neuritis. - -=Treatment=: Under injections of mercury salicylate, there was a rapid -improvement. In fact, in the course of several months, the patient -regained an ability to walk long distances. There still remains a -certain spasticity, but the abnormal spinal reflexes above mentioned are -no longer present. - - - =SYPHILITIC MUSCULAR ATROPHY, probably due either to spinal - parenchymal lesions, or to root neuritis, or to both.= - - -=Case 33.= Joseph Graham, now 50 years of age, seemed no longer to be -able to do good work as a teamster. His arms had become weak and the -muscles had become tremulous and apparently wasted. There was also pain -in the left leg and hip. It appears that this latter symptom had been -thought to be rheumatism, having begun about 8 years before with a -sudden sharp shooting pain in the left hip, about the region of the -sciatic notch. Graham had rubbed the hip with liniment, but without -reducing the so-called rheumatism. The trembling of the hands had begun -some years later, but no wasting had been noticed except during the past -year. The pain in the leg had suddenly become so severe that a month -before medical observation he had quit work. The question immediately -arose whether Graham was not suffering from some familial form of -muscular atrophy; but according to his representations, there was -nothing of the sort in the family. - -=Physically=, there was little to note. =Neurologically=, there was -more. The pupils were somewhat irregular in outline, and the right was -larger than the left. The left pupil failed to react to light, and the -right pupil reacted very slowly and with but a slight excursion. There -was no tremor of the tongue and no evidence of facial palsy nor was -there smoothing of the nasolabial folds. It was somewhat remarkable, -that in the absence of these signs, there was a marked speech defect. -The atrophy of arms, forearms, and hands was well marked, especially the -atrophy of the thenar and hypothenar eminences of the right hand. The -extended hands, especially the right, showed a marked coarse tremor. -Fibrillation was found in the muscles of the hands, forearms, arms, and -pectoral muscles. There was no dysmetria, and the diadochokinesia was -normal. Strength was diminished (dynamometer right hand, 32 kg., left 31 -kg.). There was little or no atrophy of the legs, although the left -thigh was perhaps slightly atrophic and the gluteal muscles of the left -side were somewhat flabby. The patellar and Achilles reflexes were -absent on both sides. There was a slight swaying in Romberg position. -Gait was normal. There was a marked tenderness on the left side of the -sciatic notch, as well as over the entire distribution of both external -and internal popliteal nerves. This area of skin was also hyperesthetic. -There were no other neurological signs on systematic examination. - -=Diagnosis=: The sensory disorder, the speech defect, and the pupillary -abnormalities seem to render the diagnosis of progressive muscular -atrophy doubtful. Nor was there any dissociation of sensations to -suggest a syringomyelia. Under such circumstances, one must fall back -upon the question of syphilis. Both blood and spinal fluid proved to be -positive to the W. R.; the globulin was increased and the albumin -markedly so; there were 61 cells per cmm., and the gold sol reaction -read 4 4 4 4 3 2 1 0 0 0. - - 1. Is there a relation of SYPHILITIC MUSCULAR ATROPHY to amyotrophic - lateral sclerosis? Spiller, some years since, claimed such a - relation, and it would seem with some justice. - - 2. How shall the present case be classified? There is evidence of - root pains (left hip). We may naturally suppose that these root - pains are reasonably good clinical evidence of a meningitic - lesion, of which the spinal fluid clinically gave a confirmation. - The fibrillation in this case somewhat suggests, however, a - central origin for the muscular atrophy. Accordingly, it would be - difficult to definitely classify the present case as either one of - meningovascular syphilis or one of central syphilis. It will be - remembered that Head and Fearnsides classify muscular atrophy - under both these headings. - - - =The period of SECONDARY SYPHILIS is frequently (over a third of all - cases?) MARKED BY approved signs of NEUROSYPHILIS precisely like - those of full-blown paretic or diffuse (meningovascular non-paretic) - neurosyphilis. These signs occur sometimes in association with - severe clinical symptoms, sometimes without clinical symptoms.= - - -=Case 34.= John Bennett, 28, was brought to the Psychopathic Hospital -much confused. His brother, who came with him, said that he had been a -very heavy drinker but had given up drinking about four months before. -He had recently had a cold but was otherwise in good health up to the -night before admission. On this night, Bennett had become suddenly -excited and went into his mother’s room, at the common home, and began -to curse her. However, he was put to bed safely, but on the next morning -began to moan continuously. After some hours of moaning, he was brought -to the hospital. Here he remained difficult to manage, being irritable, -noisy, and resistive. Questions he either would not or could not answer, -and there was even no evidence that he understood questions. However, -within a few hours, it was clear that he was slowly coming out of the -confused state. On the following day, it was possible even to rouse him -and get his name. The confusion gradually cleared still further and, by -the end of three days, he had become mentally absolutely well so far as -could be determined. - -He then informed us that he had had a chancre about five or six months -before, followed by a secondary skin eruption; that he had received four -injections of salvarsan (the last, a month before admission) and three -injections of mercury. At about the time of the last injection of -salvarsan, he had developed headache with pain and slight stiffness in -the back of his neck; and a fortnight later, he began to have dizzy -spells, followed during the last week by difficulty in hearing. There -was amnesia for everything that happened after his spell of sudden -excitement on the evening before admission, and this amnesia was never -lifted for the four days that followed. - -=Physically=, Bennett was very well built and muscular. Nor were there -any evidences of disease outside the nervous system. There was some -slight stiffness of the neck and slight pain on movement of the head, -which probably ought to be attributed to meningitis. The =neurological -examination= showed tendon reflexes all normal, and normal sensations. -There were, in fact, no neurological signs except that both pupils were -dilated; the left was larger than the right. Both pupils reacted to -light but reacted very poorly. They reacted much better to -accommodation. - -The W. R. proved to be positive, as might well be expected in a man -whose infection had taken place less than six months before. The -globulin and albumin of the cerebrospinal fluid were in great excess, of -a degree which we clinically express by ++++. The W. R. of the fluid -also was strongly positive down to 0.1 of a cmm. The gold sol reaction -was the “paretic” type, and there were 228 cells per cmm. - - 1. How early may clinical evidence of neurosyphilis set in after - infection? Craig found one case of “brain syphilis” occurring one - month after infection. Frye claims a case of tabes dorsalis - developing six weeks after infection. Craig states that he has had - three cases of brain syphilis occurring within six months, and six - within a year of infection. - - 2. What effect did the salvarsan injections have in causing or - preventing the symptoms in this case? Nonne sums up the - neurorecidive question as follows: Since the introduction of - salvarsan therapy for neurosyphilis, paralyses of various cranial - nerves are seen more frequently. This higher frequency is in part - only apparent since more attention has been paid of late to - auditory and labyrinthine disorders. On the whole, however, it - must be considered that salvarsan does mobilize spirochete foci - which without salvarsan therapy would perhaps have remained - latent. Probably we are here dealing in some instances with fresh - infections of neurosyphilis, in other cases with a Herxheimer - reaction. Ehrlich believed that these latent foci occur - particularly in places with stagnant blood current; as, for - instance, in the narrow bony canals. This hypothesis, sufficient - in some instances, is less satisfactory for cases of peripheral - neuritis, for example. - - 3. What treatment is indicated? Intensive antisyphilitic treatment - is strongly indicated. Whatever may be the truth concerning the - production of neuro-recurrences (“neurorecidives”) it is certain - that the symptoms usually vanish with a continuance of salvarsan - therapy. The important point is to give efficient treatment, and - in a case like Bennett’s improvement is fairly certain unless some - serious insult occurs before the remedial efforts have been given - time. It is still an open question whether intraspinous treatment - is more efficient in such cases than intensive intravenous - injections of salvarsan. In Bennett’s case diarsenol was injected - intravenously twice a week in 0.6 gm. doses, reënforced with - intramuscular injections of mercury salicylate and potassium iodid - by mouth. Under this treatment improvement began slowly and in a - few months he was symptomatically well and after three months his - tests were practically negative. - - - =JUVENILE PARETIC NEUROSYPHILIS (“juvenile paresis”) with OPTIC - ATROPHY.= - - -=Case 35.= Mary Coughlin, a blind girl of 16 years, was brought to the -hospital in a state of great excitement, laughing and crying -alternately. The neurologist is entitled to think of blindness, and -particularly of the optic atrophy which Mary showed, as probably due to -syphilis. However, there was no history of syphilis in the father, who -died in an accident at the age of 40, or the mother, who died at 45, of -heart trouble. An elder sister was married and well; two younger sisters -were living and well. The fifth sibling, a boy, had died in infancy. -There had been no miscarriages. In fact, the only point in favor of -syphilis was the somewhat far-fetched point that the younger brother of -the patient had died in infancy. - -The patient’s history was rather suggestive of some other diagnosis. Her -birth had been normal, she walked and talked at 13 months, was at school -from six to twelve, reaching the seventh grade, and was considered -bright. At three years of age, she had been run down by a car and -dragged under the fender for a considerable distance. Her head was hurt -but the patient did not lose consciousness in the accident. Fainting -spells began at 11, in which spells the patient would lose consciousness -for a minute or two. About this time, the patient’s eyesight had begun -to fail, and for some four years she had been entirely blind. Headaches -had come on of late. - -The Coughlin case, except for the above-mentioned suspicion of -syphilitic optic atrophy, might be regarded as an unusual example of a -post-traumatic disease. - -We found her to be fairly well developed and nourished; there was a -deformity of the lower half of the sternum and of the third and fourth -ribs on the right side. There were no other physical phenomena found -upon systematic examination. The left pupil still reacted to light; the -right failed to react, but this lack of reaction could not be regarded -as of Argyll-Robertson nature on account of the finding of optic atrophy -with the ophthalmoscope. - -=Mentally=, it appeared that the patient’s retention of school knowledge -was poor, though her blindness for four years had doubtless given her -little opportunity to keep such information fresh. Rather strangely, -Mary gave utterance to many delusions: first, expecting to receive her -sight by an operation on the head; second, to write a book of her -doings; third, to buy a house for the children; fourth, would pay $3000 -for the house, earning the money by working at a tailor’s or as a -trained nurse; fifth, to go on the stage to earn money by dancing; -sixth, will have lots of money. - -One of Mary’s characteristic statements is as follows: “Won’t it be -lovely when I can see Dr. H.’s face in heaven or some other lovely -place? Dr. H. was a grand doctor to me, and when we get together again -we are going to Tremont Temple and keep us together. I am going to do -some dancing and play the piano. I am going to graduate at the high -school and go to Trinity College in Washington, and I hope I shall be a -faithful keeper of mother’s tomb.” - -The patient was at times euphoric and expansive. - -At this stage, what with optic atrophy, euphoria, and expansive -delusions, we should perhaps be entitled, had Mary been an adult, to -offer the diagnosis GENERAL PARESIS. In fact, on the whole, any other -than a syphilitic cause for the optic atrophy was exceedingly doubtful. -Brain tumor of a nature to produce optic atrophy might very improbably -last so long as five years. There was no evidence of any intoxication at -the time when the blindness occurred. - -The W. R. was positive in the blood and spinal fluid; there was a -positive globulin test, and an excess albumin as well as 15 cells per -cmm. - - 1. What is the significance of Mary’s trauma at three years? So far - as we are aware, none. - - 2. What light could be thrown by a W. R. study of the family? In - some instances, much light is thrown; in the present case all - three living sisters of the patient have been examined and their - serum W. R.’s have been found negative. - - 3. What is the prognosis of juvenile general paresis? Death within a - few years, as in general paresis in adults. The patients live - rarely more than four or five years after the onset of symptoms. - Mary Coughlin died a year and a half after the above examination, - namely, in her eighteenth year, some seven years after the onset - of symptoms. - - 4. What can be said of treatment? A few favorable results have been - reported after intraspinous therapy (Swift-Ellis). Too little work - has been done with systematic treatment of juvenile neurosyphilis, - both paretic and non-paretic, to permit important conclusions at - this time. - - 5. How can we explain the infection of this sibling whereas the - others, both younger and older, escaped? It would seem that we - would have to discard the hypothesis of a congenital infection and - consider that it was acquired accidentally during the lifetime of - the patient. Considering the prevalence of syphilis it is rather - to be wondered that more such cases of “innocent” infection do not - occur in children. We may recall how many instances of juvenile - gonorrhea occur. In a case as this where the symptoms calling - attention to syphilis necessarily occur so long after the original - infection it is practically impossible to trace the origin of the - infection. - - - =The diagnosis of JUVENILE PARESIS is often easy.= - - -=Case 36.= Theresa Mullen, an under-sized girl of 12 years, presented a -remarkable appearance due to congenital amputations of the fingers and -toes. She lay in bed, drivelling and making unintelligible cries. It -appeared that the patient weighed about 12 pounds at birth and was very -fat; that she had been fed on condensed milk, had survived cholera -infantum, whooping cough, and, as the parents said, “two kinds of -measles.” - -Theresa had gone to school at 5 years, reaching the third grade at the -age of 9; but at this time, she began to lose ground and was put in a -class for backward children. Moreover, at about this time, the teachers -noticed spells of causeless laughter and meaningless twisting back and -forth. Theresa would also scream at night, looking about the room; once, -rising and crying, “Take him away, that black thing,” though no -appropriate object was present. There had been little or no complaint of -headache. Theresa had been deteriorating for some time, and for a year -past had been having increased difficulty in walking. For two months the -child had not spoken intelligible words; for the last week, she had been -incontinent. - -The =diagnosis= was almost obvious from the manual and pedal deformities -taken in connection with the saddle-back deformity of the nose. It was -interesting in connection with the contentions of W. W. Graves, that the -scapulae were scaphoid in type. - -Accordingly, the history given by the parents seemed consistent enough. -The parents were both 36 years of age, having married at 23. The first -pregnancy was a miscarriage at two months, of unknown cause. Theresa -came next; thirdly, came a miscarriage at three months; fourthly, a -girl, who is not strong or well physically, has suffered much from -headaches and sore throat, but is fairly bright. The fifth pregnancy -resulted in a boy, who is bright but of under-size. Three more -pregnancies resulted in miscarriage. - -Taking into account the above-mentioned physical characteristics, the -personal history, and the family history of Theresa, the diagnosis could -hardly be in doubt even in the absence of a lack of pupillary reaction -to light on the right side, infantilism of genitalia, positive W. R.’s -of serum and spinal fluid, positive globulin, and excess albumin, 34 -cells per cmm. and the paretic type of gold sol reaction which were -found. - -The =prognosis= of this case appears to be rapid deterioration, -terminating in death within a few months. Now and again, however, some -such cases spontaneously improve. Such a case as that of Theresa Mullen -is always disheartening in itself but suggests the social value of -Wassermann tests in the other members of the family. The other children -of the Mullen family proved to be suffering also from syphilis, since -their blood sera all showed a positive W. R. - - 1. What is the characteristic age of onset in JUVENILE PARESIS? An - impression has prevailed in some quarters that the typical onset - of juvenile paresis is in the adolescent years, and Clouston’s - first case (1877) developed in a boy of 16. Thierry’s 58 cases, - developing from the 8th to the 20th year, averaged 14 years of age - at onset. Mott’s 22 cases from the 8th to the 23d year, averaged - 17 years at onset. According to Clouston, juvenile paresis - develops most often at puberty (15 to 17 years). It is sometimes - claimed that cases developing symptoms early live longer, and that - juvenile cases developing symptoms after the 20th year run a short - course. For a case developing in the 5th year, see John - Friedreich, Case No. 77. - - 2. What may be concluded from the physical signs (congenital - amputations) present in this case before the development of mental - symptoms? Some cases of juvenile paresis appear to show no - physical signs whatever in childhood. While these amputations - might be the accidental result of a difficult delivery, it is more - probable that they are due to a syphilitic process. - -[Illustration: - - Juvenile paresis—congenital amputation of digits. This case reached - fourth grade in school before deterioration. -] - - - =CONGENITAL SYPHILIS is apparently capable of producing simple - FEEBLEMINDEDNESS (that is, a form of disease non-paretic, - non-tabetic, without special tendency to progression, and without - tendency to vascular insults).= - - -=Case 37.= Isaac Goldstein was a small boy of six years and seven -months, with a father known to be suffering from general paresis. The -child was very irritable and nervous and very difficult to manage, but -would hardly have been the subject of medical attention except in a -family study suggested by the paresis of the father. - -The child had been born at term and had apparently undergone a normal -development. Physically, he showed no definite signs of congenital -syphilis. In fact, the physical examination was to all intents and -purposes negative. The W. R. of the serum, however, proved to be -positive. Mental tests showed that his mental age was that of a child of -a little over five years. Taking all things into account, it is probable -that he should be regarded, therefore, as somewhat retarded mentally. - - 1. Is syphilis answerable for the mental retardation in this case? - Provided that the family is free from feeblemindedness and mental - disease, it would seem that the retardation of a congenital - syphilitic should perhaps be regarded as syphilitic in origin. Of - course, the institutions for the feebleminded have not shown - exceedingly high percentages of syphilitic children in various W. - R. surveys; still, the percentage of positive reactions in - institutions for the feebleminded is clearly higher than the - incidence of congenital syphilis shown in the population at large. - Hence, we may conclude that syphilis is one of the etiological - factors in the production of feeblemindedness. Dr. W. E. Fernald, - of the Waverley School for the Feebleminded, has recently pointed - out that the syphilitic cases belong rather in the lower grades - (idiots and imbeciles) of feeblemindedness than in the higher - (morons). - - 2. Can we guess what the pathological anatomy and histology of the - brain may be in such cases? The Waverley studies now in process - seem to indicate that some cases have little or no gross - alterations, but show a few slight traces of lymphocytic - accumulations discovered upon extended search, and a certain - tendency to the appearance of rod cells in various foci. But the - whole matter is still _sub judice_. It is a question whether these - traces of chronic inflammation are the residuals of a more active - process or the beginnings of a process that is about to be more - active. - - 3. How characteristic is a positive W. R. in the serum of a child - without physical stigmata of congenital syphilis? If we limit the - term _stigmata_ to the major and more important signs, we must - reply that it is not unusual to find positive W. R.’s in sera of - physically normal-looking children. Except in family studies, such - cases will often escape notice, either because there are no - stigmata whatever, or because such stigmata as exist are of a - minor nature and regarded as unimportant anomalies. Some of these - cases occur in the clinics later in life as so-called _syphilis - hereditaria tarda_. If one wishes to discover these cases with - late development of symptoms before their full bloom, the most - obvious method is to examine carefully the children of known - syphilitics. - -[Illustration: - - Scaphoid Scapulae. -] - - - =JUVENILE TABETIC NEUROSYPHILIS (“juvenile tabes”); TREATMENT.= - - -=Case 38.= The point in presenting Archibald Sherry, a JUVENILE TABETIC -of 12 years on admission, is perhaps to exhibit pride in therapeutic -results. - -There was little or no doubt of the diagnosis; in an adult, the -phenomenon would be called tabes dorsalis with a question of general -paresis. The right pupil was larger than the left and reacted neither to -light nor to distance. There was a slight tremor of the tongue and of -the outstretched hands. The knee-jerks and ankle-jerks could not be -obtained, nor could the periosteal reflexes in the legs. There was a -slight unsteadiness in the gait and in various finer movements, and a -slight ataxia of the legs. There was not a classical Romberg sign but -there was slight swaying in Romberg position. The teeth were -Hutchinsonian. For the rest, the physical examination was practically -negative. - -The family history was of interest. On the paternal side there was -nervousness as well as alcoholism and degeneracy. The maternal -grandmother had cancer. Archibald’s father was immoral and alcoholic. -There was a girl four years older than Archibald, who, though nervous -and unstable, has shown no signs or symptoms of syphilis and does not -yield a W. R. in blood or spinal fluid. - -Archibald himself was born at term, a large child, who, however, lost -weight rapidly, developing a marked skin eruption on head and back three -weeks after birth. This skin disease lasted for a month and a half and -then spontaneously disappeared. Archibald remained weak and sickly, not -walking until three years of age. However, he did well in school up to -the end of his 11th year, when he failed to keep up with the children. -He had been an amiable child and had gotten on well with his playmates. -Some time in his 10th year physical disability had begun; there was -numbness in the legs with weakness; at times, actual inability to walk. -The right pupil was noticed by the mother to have increased in size; the -eyelashes had turned white. There was pain over the left eye and a -feeling of weight on top of the head. Speech became difficult or even -confused. - -Consistently enough, the W. R. both in blood and spinal fluid was -positive. Globulin and albumin were present in large amounts; there were -150 cells per cmm. - -Granting that this be in some sense a case of juvenile tabes we may -raise a doubt whether the case is one of congenital syphilis. The W. -R.’s of the blood of both father and mother are negative. Syphilis is -denied by them. The nervous and unstable older sister failed to show -definite symptoms of syphilis or a positive W. R. There had been no -miscarriages or stillbirths. The question arises whether the -Hutchinsonian teeth do not indicate congenital syphilis. It appears, -however, that it is possible to develop Hutchinsonian teeth if syphilis -is acquired before the teeth are formed. We have no data as to how or -why this particular baby should have acquired syphilis, if he did so -acquire it, at the age of three weeks. On the whole, sceptics may doubt -our suggestion that the case is one of acquired juvenile tabes. Possibly -the question is academic so far as treatment is concerned. - -=Prognosis=: The rarity of juvenile tabes is such that little can be -said as to prognosis. Three and a half years have passed since a few -injections of salvarsan were made. The pains above mentioned rapidly -disappeared, the gait became steadier, the attacks of confusion ceased, -and the speech improved. Unfortunately, on account of a lack of -coöperation on the part of Archibald’s mother, we have been unable to -continue treatment. However, we have from time to time followed the -patient in his home and he seems to have shown no falling back after the -initial improvement. It would be of great value could we know the -situation in the spinal fluid at the present time. - - 1. Is there any explanation why paresis should occur in some - juveniles and tabes in others? There is no available explanation - for this difference nor any for the characteristic early optic - atrophy of juvenile tabetics. - - - - - Be frustrate, all ye stratagems of Hell, - And, devilish machinations, come to nought! - - Paradise Regained, lines 180–181 - - - - - III. PUZZLES AND ERRORS IN THE DIAGNOSIS OF NEUROSYPHILIS - - -This part of the case collection, dealing with puzzles and errors, is -ushered in by six cases (39–44) drawn from a group of errors in -diagnosis made some years since at the Danvers Hospital. These six are -autopsied cases. Attention is called to the fact that modern methods of -diagnosis might have prevented the errors. - - - =DIFFUSE NEUROSYPHILIS (“cerebrospinal syphilis”) versus PARETIC - NEUROSYPHILIS (“general paresis”). Autopsy.= - - -=Case 39.= Caroline Davis, dead at 49 years, was a case of error in the -diagnosis of general paresis. Like Cases 40 to 44, Case 39 was -diagnosticated by the full Danvers staff as a case of general paresis; -however, it must be added, before the days of the W. R. and the modern -methods of systematic diagnosis. As will transpire in the sequel, there -is a large question whether Case 39 is not after all really a case of -neurosyphilis, possibly not of the paretic group. The details are as -follows: - -Caroline Davis was a normal school girl till 15, apt in studies, mill -worker till marriage at 18; one child, dead (cause unknown). Habits -good. Moderate deafness set in in the forties and in 1901 patient became -completely deaf in three months’ time. In 1905 she became unable to take -care of her house and had a shock in which the right leg was affected. - -On commitment patient showed good development and nutrition with slight -enlargement of capillaries of cheeks, redness and roughening of skin of -right ankle. Teeth absent. Slight radial and brachial arteriosclerosis. -Urine negative. Sluggish pupil reactions to light both directly and -consensually. Deafness absolute, bone conduction defective. Arm reflexes -brisk, knee-jerks equal, brisk. Bilateral Babinski reaction more marked -on the right side, tremor of tongue, Romberg’s sign, gait defective. -Speech stumbling, writing clear, without tremor. - -Communicated by writing only. Consciousness normal, disorientation for -day of month, for place (misnames hospital) and for persons (recognizing -nurses, not patients). - -Patient wrote many letters complaining of pain, headaches and especially -of pain in the abdomen and side. The patient was thought to show a -slight defect of memory, but her deafness rendered diagnosis difficult. -The patient died suddenly on May 23, 1908, shortly after supper, falling -backwards, and dying in five minutes with marked respiratory distress. - -=Post Mortem Findings.= The =cause of death= was not clear. The heart’s -blood and cerebrospinal fluid were sterile. There was a small hemorrhage -in the anterior part of the right ventricle derived from a small artery -of the caudate nucleus. There was about 400 cc. of blood between the -dura mater and the pia mater. There was a slight sclerosis of the basal -and Sylvian arteries. The brain substance was uniformly softer than -normal. - -It is possible that the hemorrhage had taken place some time before the -patient’s fall and that the brain substance had swollen in consequence. -Just before the fall she had a weeping spell. - -The =anatomical diagnoses= were as follows: - -Obesity, unequal pupils, fresh wound near left ear, edema of legs, -slight focal adhesive pleuritis, hypostatic congestion of lungs, chronic -endocarditis, chronic myocarditis, congestion of kidneys, congestion of -pancreas, subacute splenitis, chronic adhesive pelvic peritonitis, -hematoma and cystic condition of Fallopian tubes, =calvarium dense= and -thick, subdural hemorrhage, slight =chronic leptomeningitis=, general -=cerebral atrophy=, marked in tips of =frontal lobes=, old =cyst of -softening= between left corpora albicantia and optic chiasm, small -punctures of left ear drum, drums opaque, =chronic spinal -leptomeningitis=; brain weight, 1190 grams. - -There were marked firm interadhesions between dura and pia throughout. A -lumbar puncture soon after admission in 1907 had shown: - - Per cent - Endothelial cells 10 - Lymphocytes 30 - Plasma cells 0 - Phagocytes 0 - Polymorphonuclear cells 51 - Unclassified 9 - Fibroblasts 0 - Cells in 100 fields 125 - -It will be noted that the lumbar puncture yielded no plasma cells and -yet showed 30% of lymphocytes. Alzheimer, in 1904, attempted to -distinguish the histology of the cerebral syphilitic from that of the -general paretic, maintaining that _lymphocytosis was the characteristic -feature of the ordinary neurosyphilitic_, _whereas plasma cells were -associated with the lymphocytes in the paretic_. This case showed -=lymphocytic= deposits. To be sure, they were decidedly subordinate in -the cerebral cortex, cerebellum, and basal ganglia, to the marked -evidences of nerve cell destruction, although there were perivascular -infiltrations about a few of the larger vessels in the white matter of -the cerebral cortex. - -The spinal cord, however, showed a most severe infiltration, especially -in the gray matter, where the infiltration accompanied severe nerve cell -changes and arterial changes. The pia mater of the spinal cord was also -packed with mononuclear elements, among which, however, no plasma cells -could be found. - -But although the inflammatory changes in the shape of lymphocytosis were -relatively more prominent in the spinal cord than in the cortex, yet the -cortex yielded evidence of an exceedingly marked destructive process. -Perhaps no layer of any of the areas of the cortex examined failed to -show some atrophic alteration. The upper layers of the cortex were -everywhere more severely diseased than the lower layers. Here we are -dealing with an instance of an active meningomyelitis and subcortical -encephalitis. It is, of course, probable that the W. R., had it been -performed, would have been positive in this case. On the basis of the -histology, we are inclined to regard the clinical picture in this case -as belonging among cases of NON-PARETIC DIFFUSE NEUROSYPHILIS. - -This case, as also the next several, is especially instructive in -teaching the difficulty in differentiating paretic and non-paretic -neurosyphilis. Not only is this difficulty met in clinical diagnosis, -but in pathological diagnosis as well. - -The histological diagnosis depends in large part on the work of the -Nissl-Alzheimer school, which has received great recognition. At the -present time, however, there is beginning to be considerable doubt as to -the entire validity of this teaching. At any rate there are many -borderline cases in which the differentiation is well nigh impossible. -In this case note chronic meningoencephalitis, with cortical -degeneration, in the absence of plasmocytosis. - -From the clinical standpoint the intensity of the W. R., the character -of the gold sol reaction, and the result of therapy have added new -points in differentiation. Much more work controlled by autopsies is -still needed, however, to put us on sure ground in borderline cases. - - - =VASCULAR NEUROSYPHILIS(?) versus PARETIC NEUROSYPHILIS (“general - paresis”). Autopsy.= - - -=Case 40.= Case 40 like Case 41 was an error in the diagnosis of general -paresis which might be regarded as academic rather than practical. Both -were cases of arteriosclerotic brain disease with severe cerebellar -involvement. Case 40 had a spinal cord that was not quite normal. There -was a tabetiform lesion in the cervical spinal cord (not elsewhere), -together with a unilateral degeneration suggesting in some respects a -radicular origin. The most striking feature, however, of Case 40 as in -Case 41, was a lesion of the cerebellum. In Case 40 the dentate nuclei -were in large part destroyed by cysts of softening, although the -cerebellar cortex was fairly well preserved on both sides. The details -of Case 40 are as follows: - -H. F., male, gear maker, born 1850. - -=Heredity.= Maternal grandmother insane. Mother insane at 52, became -demented and lost use of limbs, died at 71. Aunt insane. - -=Personal History.= Common school education. Capable workman till within -a few months. Early in life alcoholic. Drunk almost every week until -1899 or 1900. Irritable, nervous, selfish, loose in relations with -women. Venereal disease denied by wife. Married in 1883. Three frail -children. No miscarriages. Neuralgia in 1901 or 1902. - -January, 1904, patient left carriage shop on account of mistakes in -work, became more pleasant, childish, fearful, talkative, did funny -things, later became vagrant, stole from fruit stores, smoked cigarettes -picked up in the street, and became restless and irritable. - -Committed to Danvers, June 24, 1904, with slightly enlarged heart, -somewhat heightened blood pressure, and a slight sediment of epithelial -cells in urine. - -Romberg’s sign was present, but there was little or no demonstrable -incoördination otherwise. Very slight tremor of fingers. Left knee-jerk -absent, right obtained on reinforcement. Achilles jerk absent. Triceps, -wrist and normal plantar reflexes present. Pupils react to -accommodation, but very slightly, if at all, to light. Sensations normal -except in legs. The legs show preservation of tactile and temperature -senses, but abolition of pain sense except over dorsum of foot. - -Speech showed slurring of syllables and “brigrade” for “brigade.” -Disorientation for time, place and in part for persons. Admitted that -his work had been deficient but regarded himself as well. Emotionally -variable, crying at times and suddenly becoming jocular. Eloped July 3 -and somehow reached his wife’s house in a neighboring city. - -Euphoria persisted. The pupils continued Argyll-Robertson, and the -knee-jerks remained absent. Became oriented for place and partially as -to time (month and day of week correct). - -During 1905 failure became rapid, with ataxia of legs, persistent -euphoria, and loss of weight. - -Convulsions, regarded as general paretic, developed in 1906. Death -sudden, December 7, 1906. - -=Post Mortem Findings.= The =cause of death= was streptococcus -septicemia, probably derived from a gangrenous bronchopneumonia or -related with a small thrombus of the right auricular appendix. There was -also an acute purulent otitis media, mastoiditis and sphenoidal -sinusitis, as well as extensive decubitus. From this decubitus or from -the intestinal tract may have been derived the numerous colonies of -_bacillus coli communis_ which developed on plates from the -cerebrospinal fluid. - -=Arteriosclerosis= was little in evidence, being confined to the -coronary, right vertebral and carotid arteries (slight in all). _Cysts -of softening existed in the posterior part of each dentate nucleus_ and -may probably be interpreted as indicating vascular disease. - -=Chronic disease outside the nervous system= was prominent and in part -suggestive of senile findings; milky patches of pericardium, adhesions -about liver and gall-bladder, adhesions about spleen, adhesions and -fibrous thickening of parietal peritoneum, adhesions in both pleural -cavities, chronic diffuse nephritis, hypertrophy of bladder wall, dense -calvarium, dural adhesions. - -The =nervous system= showed several unexpected features. The _absence of -chronic leptomeningitis_ was striking: the pia mater was everywhere -delicate and transparent except that the walls of the cerebellar and -chiasmal cisternæ were thickened and that there were slight opacities -along the sulcal veins of the convexity. Brain weight 1090 grams. There -was a generalized =sclerosis and pigmentation of the cerebral cortex=. -The sclerosis varied in degree and was most marked in the prefrontal -regions, the anterior halves of the superior frontal gyri, the middle -third of the right precentral gyrus, the region of the splenium on the -left side, and the sagittal rami. If the _bacillus coli communis_ found -in the cerebrospinal fluid had any effect upon the consistence of the -brain, obviously hard to prove in a brain of leathery consistence at the -outset, it was shown only in the right Rolandic area in the vicinity of -the sclerotic part of the precentral gyrus. =Granular ependymitis= of -all ventricles. Weight of cerebellum, pons and bulb, 135 grams. - -Perhaps the most remarkable feature of all in the case was the -occurrence of =cysts of softening= in the posterior part of each -=dentate nucleus=. For discussion, see Case 41. - - - =VASCULAR NEUROSYPHILIS (?) versus PARETIC NEUROSYPHILIS (“general - paresis”). Autopsy.= - - -=Case 41=, like Case 40, was one of arteriosclerotic brain disease with -severe cerebellar involvement. Here is another case in which the Danvers -staff made a diagnosis of general paresis without dissenting voice. -There were some tabetic symptoms, and the spinal cord at autopsy did -show a moderate lymphocytic infiltration of the meninges, entirely -consistent with the picture in the spinal fluid. In this case, the -dentate nuclei of the cerebellum were not destroyed as in Case 40, but -were affected by cell atrophies of variable degree in different parts of -the nuclei. There was also a severe gliosis of the cerebellar cortex. -The left hemisphere of the cerebellum was more severely diseased than -the right. The cortex showed far more marked and generalized cell -atrophies throughout the layers than did Case 40. The details of this -case, which was that of a colored coachman, Samuel North, are as -follows: - -He was born in 1871. Learned to read and write at school. Stableman and -coachman. Alcoholic till 1902. Took much quinine, possibly impairing -hearing thereby. Memory impaired and growing worse since 1902. Gait -unsteady for a longer but unknown period. August 13, 1907, wandered -about, instead of attending boot-black stand, muttered, talked -incoherently. In the next few days talked about religion and apparently -had hallucinations of hearing. Committed August 16, 1907. - -On commitment stoop-shouldered, flat-chested. Gait staggering. -Unsteadiness in Romberg’s position. Incoördination of arms and fingers. -Coarse tremor of tongue. Tremor of lower jaw. Exaggeration of left -knee-jerk and diminution of right. Exaggerated Achilles jerks. Spurious -left ankle clonus. Questionable Babinski reaction of left side. -Abdominal and epigastric reflexes present but cremasteric absent. Left -pupil smaller than right and fails to react to light. Reaction of right -pupil sluggish. Moderate defect of hearing of both sides. - -During the first week the patient developed hallucinations of sight and -hearing, but of no other senses. Disorientation for time, place, and -persons. Answers to arithmetical problems given with assurance but as a -rule incorrectly (as 17 and 32 are 90; 18 divided by 3 is 88). -Handwriting scarcely legible. Memory poor, especially for recent events -(recalled a lumbar puncture as an exercise in baptism). Impressibility -and attention poor. Euphoria. - -Death after gradual failure July 29, 1908. - - Lumbar puncture showed: Per Cent. - Endothelial cells 9 - Lymphocytes 81 - Plasma cells 6 - Phagocytes 0 - Polymorphonuclear cells 4 - Unclassified 0 - Fibroblasts 0 - Cells in 100 fields 700 - -=Post Mortem Findings.= The cerebrospinal fluid showed a pure culture of -_Bacillus coli communis_, and the heart’s blood showed many colonies of -an unidentified bacillus. Culture from mesenteric lymph nodes sterile. - -The =cause of death= is somewhat in doubt. There was an early pneumonic -process with fibrinous pleurisy, and there was an early acute -hemorrhagic ileitis with a very slight overlying peritonitis and slight -corresponding enlargement of mesenteric lymph nodes. There was an -infection of the meninges with _Bacillus coli communis_. - -Evidences of =chronic disease outside the nervous system= were: coronary -and pulmonary arteriosclerosis, chronic fibrous endocarditis, mitral -sclerosis, aortic sclerosis with calcification, chronic splenitis, -chronic interstitial nephritis, hepatic atrophy (wt., 900 grams), -thickening of cartilaginous portion of right auricle (old trauma), scars -of apices of lungs. - -The =calvarium= was dense and the =dura mater= everywhere adherent. The -=arachnoidal villi= were but slightly developed, but there was one small -focus of cortical herniation through the dura mater of the left middle -cranial fossa. The =pia mater= was delicate except for slight opacities -along sulci. There was some pial thickening over the region of the -interparietal sulci on both sides. There was pial pigmentation -anteriorly and superiorly. - -There is no gross evidence of intracranial arteriosclerosis, except (1) -that afforded by the lesions of the dentate nuclei of the cerebellum -mentioned below and (2) the swerving to the right of the basilar artery, -possibly due not to arteriosclerotic lengthening of the artery but to an -unusual shape of the pons (see below). - -The =brain= weighed 1245 grams (cerebellum and pons 165 grams). =The -anatomical diagnoses of central nervous system= were: - -Slight general encephalomalacia (post mortem imbibition of fluid, 31 -hours). Slight gliosis of right prefrontal and frontal gyri. Slight -gliosis of right optic thalamus. Generalized granular ependymitis, -especially near fornix and about foramina of Monro. Anomaly of pons (not -gliotic, but possessing far more white matter on the left side than the -right). Severe arteriosclerosis confined to the dentate nuclei of the -cerebellum. - -As we now look over the data in Cases 40 and 41 we are inclined to ask -the question, whether modern systematic diagnosis would not have shown -these cases to be NEUROSYPHILITIC? One is inclined to answer this -question in the affirmative, on the basis that Case 40 showed somewhat -questionable Argyll-Robertson pupils, and Case 41 showed unilateral -Argyll-Robertson effect. Both cases showed Romberg sign, but the dentate -nucleus and other cerebellar disease in each case may in some way have -contributed to or imitated this phenomenon. Whether Case 40 was a -tabetic must remain a question, but Case 41 must be regarded as a case -with spinal and meningeal changes highly characteristic of syphilis. - - - =VASCULAR NEUROSYPHILIS plus TABETIC NEUROSYPHILIS (“tabes - dorsalis”) simulating paretic neurosyphilis (“general paresis”). - Autopsy.= - - -=Case 42.= The case of Elizabeth Brown was at one time carefully studied -by Dr. A. M. Barrett in his work on mental diseases associated with -cerebral arteriosclerosis and, like Case 43, was one in which tabes -dorsalis was a factor. Elizabeth Brown’s maternal grandfather and mother -were insane; there had also been insanity in a sister. Mrs. Brown was -struck on the head at 44, and was unconscious for an hour, but there -were no sequelae to this accident. At 48, there was a shock, or -apoplectiform attack, followed by unconsciousness for two hours and by -left hemiplegia, right ptosis, and thick speech. Mrs. Brown began to -walk again after two weeks, but was found to be forgetful and -fabulatory. She seemed at times to be hearing music, and somewhat -repeatedly became helpless and unable to walk. She could not remember -from day to day, showed incontinence of urine and feces, and was brought -to the Danvers Hospital. The physical and mental deterioration was -progressive. There were some signs of organic brain disease. The -musculature was especially flabby on the left side. The left angle of -the mouth drooped, and the left nasolabial fold was smoothed out. The -arm movements were ataxic, the tongue protruded to the left, the right -pupil reacted but slightly to light (eye blind from cataract), the -knee-jerks, Achilles, wrist, and elbow reflexes, were absent. The -patient was unable to stand, and there was a marked tremor of the hand, -tongue, and lips. There was a zone of anesthesia for pain and tactile -stimulation extending round the body, from the 3d to the 6th rib, and -there were symmetrical areas of anesthesia on the inner surface of the -forearms and the legs. - -The =autopsy= showed a =general arteriosclerosis= with =chronic= and -=acute meningitis=. The brain weighed 1110 grams; the =pia mater= was -moderately thickened; the basal vessels were highly arteriosclerotic. -The brain itself, however, normal externally, upon dissection, showed a -number of small cysts irregularly scattered in the white substance. The -basal ganglia were porous, and there were several small cysts in the -pons. =Microscopically=, there was evidence of severe vascular disease, -involving not only the arteries but also the veins. It was the -superficial rather than the deep arteries that were more often attacked. -There was a marked =perivascular gliosis=. Extensive search yielded _no -evidence of lymphocyte infiltrations_, either in the brain or in the -spinal cord. - -The spinal cord showed degenerations in both the lateral and posterior -columns, of which the explanation may possibly be like that in our -paradigm, Case 1. - -Is the case of Elizabeth Brown one of neurosyphilis? We cannot -definitely say on account of the non-availability of the modern -systematic tests, but it may well be that the case, although certainly -not one of paretic neurosyphilis, was one of TABES WITH VASCULAR -COMPLICATIONS. - - - =TABETIC NEUROSYPHILIS (“tabes dorsalis”) with symptoms of cerebral - origin producing a picture resembling taboparetic neurosyphilis - (“taboparesis”). Autopsy.= - - -=Case 43.= Robert Allen was the fifth case of error in the diagnosis of -general paresis analyzed some years since from the staff meeting records -of the Danvers Hospital. The Allen case resembles the case of Elizabeth -Brown in that there was a combination of tabetic phenomena with cerebral -lesions of a non-paretic character at autopsy. But although there seemed -to be an utter absence of inflammatory cells (lymphocytosis) in the case -of Elizabeth Brown (42), there were some slight perivascular cell -accumulations in the Allen case, with a few mononuclear cells suggestive -of lymphocytes. The cerebrum, however, failed to show plasmocytosis. It -was seriously diseased, showing a marked neuroglia proliferation about -the atrophic nerve cells. - -Robert Allen was a printer coming from a long-lived race. The following -are the main facts: - -Married in 1875 (two children, healthy); again married in 1893 (one -child, healthy). Compositor from 1890. In 1898 and 1899 girdle and -lancinating pains. Thereafter for several years gait was unsteady. -During 1904 and 1905 freedom from pains and improvement in gait but -gradually increasing irritability and nervousness. Stopped work on last -of March, 1905, owing to sudden increase of irritability, emotionality, -boastfulness, expansive schemes, and ataxia. - -Habits: no tobacco, very little alcohol at long intervals. No drug -habits, no sexual irregularity known. - -Committed to Danvers April 3, 1905, with slight muscular development, -poor nutrition, acne, irregular, poorly preserved teeth, gingivitis, -flat-foot, slight radial arteriosclerosis, slight arcus senilis, a few -hyaline casts, leucocytes, epithelial cells, and trace of albumin in the -urine, scar in sulcus, and enlarged inguinal lymph nodes. - -Ataxic gait, Romberg’s sign, fibrillary twitching of chest, abdominal -and facial muscles when standing; right pupil slightly larger than left, -pupillary margins irregular, light reactions (electric bulb test) both -consensual and direct absent, slight pupillary reaction in -accommodation; biceps, triceps and wrist reflexes lively and equal; -abdominal, cremasteric and plantar reflexes normal, knee-jerks, Achilles -and front taps negative even on reinforcement. - -The patient himself stated that his ataxia began in 1904, that he had -been under treatment for swelling of legs and feet and pain in limbs -since 1903, and that there had been some trouble with limbs since 1895. -He had been told that his disease was lead-poisoning. About three weeks -before commitment patient said he had had an attack of unconsciousness. - -The patient’s speech showed considerable defect. Words were pronounced -slowly with slurring and tripping especially of the labials. Orientation -perfect. School knowledge well retained. The easier arithmetical -problems were accurately performed. Memory imperfect for minor recent -events. Estimations of space and time often very imperfect. Variability -of mood, sometimes euphoric, sometimes tearful and irritable. Occasional -expansive estimates of personal powers (“Can lift three five-hundred -pound weights with one finger”). Indistinct expansive financial ideas. - -The patient continued oriented, euphoric, expansive, untidy, till -October, 1905, but on October 12 developed an infection at the site of a -callus on the sole of the foot and died with pyemic symptoms, October -17. - -=Post Mortem Findings.= The =cause of death= was streptococcus -septicemia with acute ulcerative colitis, acute splenitis, bilateral -purulent pleuritis, multiple infarctions of lungs. - -There were no signs of =chronic disease outside the nervous system= -except a moderate thickening of the mitral valves, and slight dural -adhesions. - -The brain weighed 1450 grams. The vessels at the base showed a slight -degree of sclerosis. There was a slight opacity of the frontal, -parietal, and temporal pia overlying slightly atrophied convolutions, -whose surfaces showed in a few places slight cuppings. The ependyma over -the thalami and the floor of the fourth ventricle was finely roughened. -The spinal cord showed a typical TABES DORSALIS. - -Although we probably cannot regard either Case 42 or Case 43 as a case -of paretic neurosyphilis, and although it must remain doubtful whether -they are cases of any form whatever of neurosyphilis (in the absence of -the modern tests), yet it seems clear that both these cases may very -well have been cases of neurosyphilis on account of the existence of a -definite tabetic process in each. The symptoms of these cases, like -those of Cases 38 to 41, suggest how difficult it must be _to make a -clinical diagnosis of general paresis safely without employing available -laboratory tests_. Yet how frequently in the past have neurologists -brought data concerning various phenomena in long series of so-called -paretics in which the error of diagnosis was certainly between 5 and 15% -and frequently still greater. The entire question of the symptomatology -of paretic and non-paretic neurosyphilis, therefore, needs re-opening -and revision. - - - =CEREBRAL GLIOSIS (probably non-syphilitic) producing the clinical - picture of paretic neurosyphilis (“general paresis”). Autopsy.= - - -=Case 44.= John Hughes was a hostler, and later assistant with a -wholesale drug company, with which he remained for 32 years. He had been -moderately but constantly alcoholic all his adult life up to 50 years of -age, and at 45 had had an attack of so-called nervous prostration, in -which his head had troubled him and he had been seclusive. At 49, he had -a serious attack of otitis media, associated with delirium, swelling of -the feet, and what was called rheumatism. After this attack of otitis -media, Hughes appears to have been not altogether right. - -At 53, after a quarrel with his employer, Hughes quit work, began to -trade a little in hens and pigs, became forgetful, especially of recent -events, and did “a variety of peculiar things.” He was a married man but -he had no children. There had been miscarriages but of unknown origin; -venereal disease was denied. At 55, a week before admission, Hughes had -a spell of unconsciousness for several hours, after which his speech was -thick, and restlessness, insomnia, and a wandering tendency set in. -Visual hallucinations, fabulation, tremors, “excited-looking” eyes, are -described. He would sweep things from the dining-room table, pulled a -hot stove into the middle of the floor, attempted to sweep paint off the -floor, and cut up a carpet with a knife. - -The patient on commitment November 5, 1904, was well developed and -nourished. The mucous membranes were rather pale. Bruises and -excoriations of limbs. Harsh breathing at the base of each lung. -Enlargement of heart; sounds irregular. Accentuation of aortic second -sound; tension fair, rate 80. Slight brachial arteriosclerosis. Abdomen -slightly distended. The urine contained a faint trace of albumin and -many hyaline casts. - -Moderate tremor of extended hands. Slight tongue tremor. Romberg’s sign -absent (slight swaying). Considerable ataxia of extremities (inability -to stand with foot on opposite knee). Vision poor. Hearing could not be -tested accurately. Prompt pupil reactions with direct light. Slight -consensual reaction in left pupil, absent in right. Deep reflexes equal -and lively. - -Quiet and orderly at first. Later restless and noisy. Questions were -answered at times relevantly, more often irrelevantly. Patient -irritable, intractable. Required repeated urging to take nourishment. -Consciousness clouded. Orientation imperfect. Attendants are possibly -“officers.” Date September, 1995. Slight errors in repeating alphabet. -Mistakes in Lord’s Prayer with rhyming tendency. Simple arithmetical -tests answered automatically with many mistakes. More complex -combinations incorrect. Handwriting tremulous (noted as “typical of -general paresis”). Auditory hallucinations (answering invisible -persons), “All right, I’m coming.” Amnesia and confabulation. Q. “Have -you had breakfast?” A. “No,” (later) “Yes, I had a very light -breakfast.” Q. “What did you have?” A. “Anything that came along. A few -green peas and beans that were left, bread and butter and pie. I had a -good breakfast. Guess feed is very high.” Q. “Give names of your sisters -and brothers.” A. “There are three or four I never see. I will have to -think them up.” (Later)—“Lillie, Abbie, Julia, George.” On repetition of -question, “Elizabeth, Julia, Annie and Lizzie.” - -Delusions somewhat doubtful. At no time euphoria. - -The patient remained only nine days in the hospital, developing diarrhea -a week after admission. - -=Post Mortem Findings.= The =cause of death= was bilateral -bronchopneumonia of hypostatic distribution, accompanied by bronchitis -and acute splenitis. The intestinal tract was normal (despite the -diarrhea). No cultures. The heart showed acute myocarditis. - -The vessels in general showed no sclerosis, except that the aorta showed -a few patches with calcification near bifurcation. There was a moderate -degree of mitral sclerosis. The kidneys showed a moderate degree of -chronic interstitial nephritis. The heart weighed 530 grams and there -was moderate dilatation of all the valves. - -There were some evidences of chronic disease outside the nervous system, -namely, an obliterative pleuritis on the right side, chronic -perisplenitis, and chronic external adhesive pachymeningitis. - -The =nervous system= showed a pia mater thin and transparent, with a -moderate congestion of larger and smaller vessels. No noteworthy change -of the brain substance or of the ventricles was found, except that the -cerebral substance was of unusual firmness (autopsy twelve hours after -death). - -It is clear that the brain was not wholly normal, exhibiting a general -induration due in part to subpial gliosis and in part doubtless to -perivascular gliosis. =Microscopically= the tissues showed features of -great interest, especially multiple focal neuroglia cell proliferations -of a perivascular distribution, considerable subpial fibrillar gliosis -of an unusually focal type, and a rather general subpial cellular -=gliosis=. Histologically, it seemed that this chronic progressive -process had started, not so much in relation with dying nerve cells, as -in relation with blood vessels. The =perivascular= deposits of neuroglia -cells were confined almost exclusively to the infragranular cortex -layers. It seems plain that the diagnosis of general paresis was not -justified. It is probable that the diagnosis of neurosyphilis is not -justified. The explanation may be that now and then cases of cerebral -sclerosis may clinically imitate the neurosyphilitic process. It must be -borne in mind that the diagnosis in this case was made, like the other -cases at head of Part III, without the advantage of modern systematic -methods. Clinically speaking, of course, there was no definite -Argyll-Robertson pupil, although the consensual reaction, slight on the -left side, was absent in the right pupil. The general picture appeared -to be one of the so-called demented form of paretic neurosyphilis. - - - =Differential diagnosis between NEUROSYPHILIS and NEURASTHENIA.= - - -=Case 45.= Albert Robinson, a man of 28 years, was shipwrecked on one of -the Great Lakes. The ship was on the rocks for eight days, and Robinson -was under a great strain. Ever after the wreck, Robinson had felt severe -pain in the head, neck, and back, and a feeling of great weakness -whenever he exerted himself physically or mentally, and seven months -after the wreck, he had several attacks of fainting. - -For a number of weeks he had worried a good deal about his inability to -make money, especially as money was badly needed on account of his -wife’s approaching confinement. A few days before entrance, Robinson had -become very forgetful, and was unable to recall, the night before -entrance, where he had been during the day. On the whole, however, on -mental examination no actual evidence of memory defect could be shown to -exist. - -=Physically=, Robinson was entirely negative, except for some hard -glands in each groin. =Mentally=, there was little to show except -depression, worry over his financial condition, and his inability to -work. The serum W. R. proved negative. - -=Diagnosis=: On the whole, the diagnosis of psychoneurosis (see case -Harrison (9)) due to the shock at the time of the shipwreck seemed to be -proper. To be sure, the patient gave a history of a chancre at 25, -treated for two years, after which he was declared cured. - -However, following up the clue of admitted syphilis, rigorous -questioning elicited the fact that a few months before there had been -diplopia, lasting part of a day. - -=Lumbar puncture= seemed desirable. The fluid was clear but contained -125 cells per cmm. with appropriately increased amounts of albumin and -globulin. The spinal fluid W. R. was positive. The diagnosis of -CEREBROSPINAL SYPHILIS seemed established. - -The lesson of this case appears to be that perhaps we should never -exclude syphilis until we have made an examination of the cerebrospinal -fluid. The W. R. of the blood in meningovascular (non-paretic syphilis) -is negative in many cases (the figure is sometimes set as high as 40%). - -=Treatment=: After a half dozen injections of salvarsan, all symptoms -disappeared and Robinson went back to work, claiming to be in a better -condition than for some time past. - - 1. How shall we explain such a symptom as the transient diplopia? - This diplopia is probably an example of a neurorecidive, but it - will be observed that it occurred without salvarsan therapy. See - discussion above under the case of Bennett (34), where the general - result of the neurorecidive inquiry launched by Ehrlich early in - the history of salvarsan therapy showed that precisely similar - phenomena had always occurred in neurosyphilis, whether under - treatment or not. The anatomical and histopathological explanation - of such phenomena is, of course, doubtful, but a review of the - findings in the case of Alice Morton (1) will show how many - apparently serious symptoms in neurosyphilitics are actually - irritative or at least due to lesions which are entirely - recoverable. We may suppose, first, a local proliferation of - spirochetes; second, a local over-formation of toxic substances, - directly or indirectly the product of spirochetosis; thirdly, a - local exudation; fourthly, a local proliferation; fifthly, a - combination of these phenomena, any or all of which may be - regarded as but transient. We have sometimes found at autopsy very - little exudate except in small areas; sometimes not more than a - few mm. or cm. in superficial extent. Note, for example, the small - areas of lymphocytosis demonstrable in but two foci in the case of - Alice Morton, the paradigm placed at the beginning of this book. - - - =NEUROSYPHILIS(?) in the SECONDARY STAGE of syphilis. HYSTERICAL - symptoms. Diagnosis?= - - -=Case 46.= Alice Caperson was a colored girl of 18 years. She had -acquired syphilis five months before admission to the hospital, and the -secondary symptoms of this syphilis had just disappeared before -admission. - -Very shortly after acquiring syphilis, the young negress began to act -peculiarly. She describes herself as having a sort of nightmare, both -when asleep and also when awake. For instance, she saw her dead -grandmother. It appeared at first like a seraph; then it came nearer to -her and seemed to fill out; and then was dressed precisely as her -grandmother had been. This seraph appeared as though trying to tell her -something, but she could not make out what the something was. The vision -had appeared on two or three occasions. - -Our examination detected little beyond instability and irritability of -mood with some depression. The patient readily fell to weeping. She soon -made friends in the wards, however, and got on well. =Physical -examination= was entirely negative but the W. R. of the blood serum was -positive. The W. R. of the spinal fluid was negative, as was the gold -sol reaction; there was an excess of albumin and a positive globulin -test; there were seven cells per cmm. - -The psychiatric diagnosis of a case like that of Alice Caperson would -waver between hysteria and dementia praecox. However, as for dementia -praecox there are hardly any typical symptoms. There is insight into the -hallucinations, which are hypnagogic. There are, however, no hysterical -stigmata. - -The spinal fluid reaction is typical of the secondary stage of syphilis. -It is commonly said that in every case of syphilis the nervous system is -involved at some period, if only to the degree shown in the present -case. However, such involvement tends to disappear both with and without -antisyphilitic treatment, just as do the secondary skin symptoms. So far -as syphilis is concerned, the prognosis under radical treatment is as -good as usual. We are inclined to regard the case as one of the -HYSTERICAL or PSYCHOPATHIC group and inasmuch as cases occurring in the -developmental stage of a patient’s life are of fairly good general -prognosis, we are inclined to regard the prognosis in this particular -case as good under proper therapy and hygiene. - - 1. What is the relation of neuroses to syphilis? Neurasthenia, - chorea, hysteria, and epilepsy are often grouped (for example, by - Nonne) as neuroses bearing at times important relations to - neurosyphilis. (For the relations of neurasthenia, chorea, and - epilepsy, see cases of Greeley Harrison (9), Margaret Green (72), - and David Borofski (49), respectively.) As for the hysteria shown - in Caperson, Charcot enumerated syphilis among _agents - provocateurs_ of hysteria along with alcohol, lead, arsenic, and - the like. Fournier has also considered the problem. It is clearly - necessary to show that before infection there were no hysterical - symptoms, and that the hysteria developed during the operation of - the syphilitic process, and it is probably necessary to show that - the symptoms will clear up under antisyphilitic treatment, if we - are to concede the existence of a syphilitic hysteria. - - 2. What are the evidences of neurosyphilis in the secondary and - primary stages of syphilis? As above stated, the findings in - Caperson are typical enough. Wile and Stokes at first stated that - 60 to 70% of the secondary syphilitics show changes in the spinal - fluid; in a further article they maintain that probably every case - shows such changes and that clinical symptoms of neurosyphilis of - the secondary period can probably be determined. They claim that - it is probable also that the same holds for primary syphilis - itself. The importance of these claims lodges partly in the - relation of these early signs of neurosyphilis to the whole - question of latency and to the question of _paresis sine paresi_. - For a discussion of _paresis sine paresi_ see cases Lawlor (25), - Vogel (52). - - - =Differential diagnosis between NEUROSYPHILIS and MANIC-DEPRESSIVE - PSYCHOSIS.[9]= - - -=Case 47.= As in other instances (compare Martha Bartlett (21) and Annie -Monks (85)) so also in the case of Ethel Hunter, a woman 61 years of -age, there was no initial suspicion of neurosyphilis. Mrs. Hunter was -brought to the hospital stuporous as a result of an overdose of -paraldehyd. The paraldehyd had been administered by a physician to -combat insomnia and agitation. As soon as Mrs. H. had recovered from the -drug stupor, this agitation appeared once more, and it was clear that -she was suffering from marked depression. There was tremendous worry -over the sickness of a woman with whom the patient lived. The patient -was very self-accusatory, blaming herself for many things that had -happened in the household. Besides her agitation, depression, -self-accusations, and insomnia, the patient showed a good deal of the -symptom frequently termed “retardation”—a kind of lagging of all mental -processes found, according to Kraepelin, in manic-depressive psychosis. - -Accordingly, the diagnosis of manic-depressive psychosis might well have -been rendered. The fact that the psychosis so far as known began in the -involution period was not against the diagnosis since the so-called -involution-melancholia of this period is at least in a certain fraction -of cases nothing more or less than a form of manic-depressive psychosis. -However, the =physical examination= made the diagnosis of -manic-depressive psychosis a little doubtful. There was a superficial -thickening of the arteries (blood pressure: systolic, 170; diastolic, -104), which thickening would not in itself be against the diagnosis of -manic-depressive psychosis. (In point of fact, arteriosclerosis is -rather common late in this disease and previous attacks could not be -excluded on the basis of available history.) The contracted pupils were -irregular and both reacted sluggishly to light, although better to -accommodation; the right pupil was larger than the left. The arm -reflexes were pretty active. The left knee-jerk could not be obtained, -nor was the right knee-jerk more than very sluggish. The Achilles -reflexes could not be obtained. Although there was not a positive -Romberg sign, there was a considerable swaying in Romberg position. -There was no speech defect. The other reflexes showed nothing abnormal. -On the whole, we had to conclude that, although Mrs. Hunter might be an -instance of manic-depressive psychosis, still there was much of -neurological interest in the case. - -This conclusion was emphasized when the W. R. of the blood serum was -found to be positive. The spinal fluid W. R. was also positive, and the -gold sol index was of the “paretic” type. There were 74 cells to the -cmm. Globulin stood at ++++, and albumin at ++++. - -This case, therefore, again illustrates, as well the protean nature of -GENERAL PARESIS (the diagnosis rendered), as the doubtful value of -making a psychiatric diagnosis without due consideration of the physical -examination and laboratory findings. How easy might it have been, at -least some years ago, to consider that this patient of 61 years had -suffered a slight shock at some previous time (left knee-jerk absent), -but was as a matter of fact a case of manic-depressive psychosis with a -vascular complication! - -Note: We must again duly insist that the merely sluggish light reactions -of the pupils in such a case as this do not especially point to general -paresis. The literature seems to establish that sluggishness of light -reaction precedes the classical Argyll-Robertson pupil. Yet it does not -do to say that, if the Argyll-Robertson pupil pretty conclusively points -to neurosyphilis (for exceptions see cases Falvey (55), Murphy (60)), -then a sluggish pupillary reaction to light looks in the same direction. -Sluggishness may precede stiffness in many, or perhaps all, cases, but -sluggishness of pupils is a frequent phenomenon outside the syphilitic -group of cases. - - 1. What part is played by emotional shock and psychic causes in the - starting up of general paresis? The answer to this question cannot - be definite. That a paretic process can be started up after trauma - is admitted on all sides; but we here suppose actual physical or - chemical brain disturbance permitting increased spirochetosis or - inflammatory reaction. In the case of psychic shock, or what might - be called _psychogenic general paresis_, our best resort will be - to the indirect effects of hormone action, or of vasomotor and - other autonomic disturbances produced directly or indirectly by - emotion. We are clearly here dealing with material too speculative - to be of practical service at this time. - - 2. Was the depressive drug therapy in the case of Hunter - justifiable? The paraldehyd had been administered by a physician - apparently on purely symptomatic grounds to combat the insomnia - and agitation of this woman of 61 years. With all due - acknowledgment of the difficulties of private practice, we must - insist that when ordinary measures in the relief of insomnia and - agitation are insufficient to curb these conditions, then a - positive danger ensues with the larger doses. As a rule, with - these larger doses and with the withdrawal of sensory stimulation, - the patients relapse into a stupor of grave moment. We need only - recall the situation in delirium tremens where adequately - depressive drugs often tend to kill the patient. - - - =Case for diagnosis. Errors in the diagnosis of NEUROSYPHILIS are - possible even when abundant clinical and laboratory data are - available.= - - -=Case 48.= The first error chosen for demonstration is that in the case -of the machinist, Milton Safsky. - -Safsky, about 8 months before his entrance to the hospital in the 42d -year of his life, had begun to lose strength, to grow thin and pale, and -to suffer from an extreme and continuous thirst. He was said to have -drunk as much as 6½ gal. in a day, and passed appropriately large -quantities of urine. After a time, his management at a general hospital -became difficult, as Safsky became confused, cried “hysterically,” and -was at times very noisy. He sustained a marked memory loss, seemed to -show visual hallucinations, and complained of headache, both frontal and -occipital, and of pain about the eyes. Sometimes the patient was very -euphoric and expressed what seemed to be delusions of grandeur, saying -he was wealthy and owned many machine shops. - -Some symptoms, e.g., polydipsia and polyuria amounting to a diabetes -insipidus, associated with headache and arrested attention, suggested -possibly a new growth in the pituitary region. The mental symptoms might -naturally be supposed to be due to some infiltration or pressure effect -of intracranial growth. After admission to the Psychopathic Hospital, -the patient was found difficult to arouse, although he could eventually -be aroused. His orientation proved to be as poor as his memory. From -time to time, the patient became a bit more intelligent and able to -execute requests. - -The =physical examination= was in general almost entirely negative. -=Neurologically=, the pupils were markedly contracted and reacted slowly -to light, though they were otherwise normal. The deep reflexes were all -somewhat lively, though equal. The umbilical and cremasteric reflexes in -particular were present. Systematic examination revealed no other reflex -disorder, nor any disturbance of sensation. There was a coarse tremor of -the extended hands. There were no phenomena of importance in the visual -fields. - -As against the diagnosis of growth, pituitary or extrapituitary -(diabetes insipidus and headache), a hypothesis of neurosyphilis had to -be considered. Not only were the contracted, slowly-reacting pupils and -the active deep reflexes suggestive, but the euphoria with grandiose -ideas looked entirely consistent. As for the polyuria, one had to think -of the so-called syphilitic polyuria of the textbooks, which is regarded -as a more or less characteristic result of syphilitic involvement of the -_basis cerebri_. Moreover, the W. R. in the spinal fluid proved to be -slightly positive; 146 cells per cmm. were found therein; there was a -large quantity of globulin, and a very marked increase in albumin. These -observations seemed to be exceedingly suggestive of a cerebral syphilis. - -However, as the case progressed, the diagnostic situation changed. The -W. R. upon a second puncture fluid proved negative. After some weeks, -characteristic symptoms of intracranial pressure developed; the -diagnosis of BRAIN TUMOR had to be taken as established, and there is no -doubt of its correctness. - - 1. What is the explanation of the weakly positive W. R. in Safsky’s - spinal fluid? An explanation is not easy to find. Possibly we may - regard the reaction as an example of error in technique. It is - even possible that it may have been produced by exudative products - in the spinal fluid. - - 2. What precautions may be taken against an error in diagnosis such - as was first made through the positive spinal fluid Wassermann in - the case of Safsky? First, repetition of the W. R.; secondly, it - is very unusual to find a weakly positive W. R. in a case with - such marked excess of albumin and such very marked increase of - globulin as was shown by this case. - - 3. How can we explain the inflammatory products in the puncture - fluid? Superficial brain tumors are frequently associated with a - so-called _meningitis sympathica_. The products of such meningitis - are exhibited: _viz._, globulin, albumin, and pleocytosis, exactly - as shown in Safsky. - - - =Can PARETIC NEUROSYPHILIS (“general paresis”) appear clinically - EARLY (e.g., two years) after the initial syphilitic infection?= - - -=Case 49.= David Borofski, a street car conductor, 27 years of age, -suddenly had a convulsion while at work in his car. For four months -Borofski continued to have rather numerous convulsions, was finally -compelled to discontinue work, and resorted to the Psychopathic -Hospital. It appears from his own story that, about two years before, he -had had a chancre, for which he had been treated at a general hospital -syphilis clinic, and of which he was told he was cured. With a -progressive loss of memory and with convulsions, Borofski became much -concerned about himself, and was finally persuaded by his fellow-workers -to come to the Psychopathic Hospital. - -The convulsions were described as follows: The patient gives a short -cry, has convulsive movements for about ten minutes, remains unconscious -for perhaps half an hour, and wakes with headache, dizziness, and a -feverish appearance. Sometimes the attacks were more severe, with -frothing at the mouth, biting of lips, and loss of sphincter control. -There were also slight attacks, occurring almost every day, without loss -of consciousness; these latter attacks consisted of dizziness, inability -to speak for a few seconds, and some arm twitching. - -=Physically=, Borofski was well developed and nourished, with a blood -pressure of 160. The only abnormal phenomena =neurologically= were -absent knee-jerks and ankle-jerks, sluggish pupillary reactions, and -slight tremor of the hands. - -=Mentally=, despite suggestive complaint of amnesia, the memory was -found to be fairly good but knowledge of current events and school -knowledge was poor. The simplest problems in arithmetic Borofski gave -up. - -The first diagnosis in such a case would naturally be epilepsy. However, -when an epileptic or epileptiform attack occurs for the first time in -adult life, the chances are probably against an idiopathic epilepsy. -(This is not a universal rule but will serve.) Borofski himself, -moreover, gave a history of syphilis. And the very nature of the -attacks, with arm twitching and without loss of consciousness, would not -readily fit into the frame of the idiopathic group. The absence of -certain reflexes and the sluggish pupils are naturally also suggestive -of syphilis, although not convincing. - -The W. R. of the serum proved positive, as did that of the spinal fluid. -The gold sol reaction was characteristically “paretic”; there was an -excess of albumin and a positive globulin, and there were 15 cells per -cmm. There could be little or no doubt of the diagnosis of some form of -neurosyphilis. The laboratory picture was consistent either with general -paresis or with cerebrospinal syphilis. So far as we are aware in the -present stage of knowledge, the two conditions can hardly be -differentiated unless we choose to rely on therapeutics. However, it is -exceedingly rare for general paresis to occur only two years after the -original infection. If we can trust this statistical fact, we shall -perhaps be wiser to term the case of Borofski one of DIFFUSE -CEREBROSPINAL SYPHILIS, and not one of paresis. - -=Treatment=: Borofski was put on antisyphilitic treatment consisting of -0.6 gram of salvarsan twice a week and potassium iodid, together with -intramuscular injections of mercury salicylate. The convulsions then -ceased. After four months Borofski returned to work, and he has remained -at work for a year. He has never regained his former health. - -Fifteen months after beginning of treatment the laboratory tests were -again made (there had been more than 60 injections of salvarsan), and -the cell count and gold sol reactions were found to be negative. -Globulin and albumin were also in smaller amounts than in the original -examination. However, the W. R. of the serum and the spinal fluid -remained positive. - -Head and Fearnsides state that cases of cerebrospinal syphilis should -return negative spinal fluid tests after six months of treatment. Upon -this criterion of Head and Fearnsides, Borofski would not be a case of -cerebrospinal syphilis; but it is probably impossible to separate -various forms of neurosyphilis into categories on any such grounds. - - 1. Shall case David Borofski be regarded as one of paretic - neurosyphilis (“general paresis”)? He has returned to work and has - remained at work, though without regaining his former health. In - any event, however, he does not offer the typical picture of - inevitable decline and death presented by the typical case of - Pietro Martiro (15) presented in our discussion of systematic - diagnosis. However, we could not upon laboratory grounds, or even - upon the ground of clinical observation, distinguish Borofski from - Martiro; Borofski has greatly improved; Martiro is dead. Borofski - developed his obvious neurosyphilis only two years after the - original infection. The conservative syphilographer might, - accordingly, reply that David Borofski is not a typical case of - paretic neurosyphilis (“general paresis”) either in the length of - the incubation period for his neurosyphilitic symptoms, or in his - outcome. - - 2. What is the cause of such convulsions as those developed by David - Borofski? Evidence from clear cases of general paresis with - convulsions leads to the hypothesis that such convulsions as those - developed by Borofski are not necessarily based upon frank - destructive lesions such as would be produced by the plugging of - terminal arteries. They may well be produced through the - activities of minor lesions, only demonstrable by microscopic - methods, either through properly disposed cell losses or by the - pressure of exudate, or even by endotoxins or other substances - derived from the bodies of dead or living spirochetes. - - 3. Aside from the well-known syphilitic epilepsy due to meningitis, - is there a non-meningitic epilepsy (such a disease as Fournier - formerly described under the term parasyphilitic epilepsy)? We - dismiss from discussion the so-called symptomatic epilepsies which - are the result of a gross organic disease of the brain substance - or its membranes, and which do not differ so far as we are aware - from organic epilepsy produced by other gross lesions of an - identical size and structure. These symptomatic epilepsies may be - partial, or even may present the appearance of generalized - epilepsy. We may also leave out of account those epileptic - pictures which are produced in general paresis itself, and which - may be viewed as nothing but partial phenomena of general paresis. - The kind of so-called “parasyphilitic” epilepsy that Fournier - described is a kind of epilepsy that cannot be distinguished from - genuine epilepsy, in which the sole disease-phenomenon throughout - a long period of time consists of epileptic convulsions. It - appears that these “parasyphilitic” imitations of genuine epilepsy - occur in individuals with a very long post-infective “incubation - period,” but that there are some cases in which the epilepsy - appears, on the contrary, in the very earliest stages of syphilis. - The attacks are a little less common than those of idiopathic - epilepsy; they have the same apparently causeless beginning; are - associated with complete amnesia; and are followed by - characteristic dazed states. The patient’s intelligence, however, - suffers little. Now and then a case reacts well to antisyphilitic - treatment energetically pushed. (Spontaneous long remissions in - non-syphilitic epilepsy must be remembered.) Petit mal attacks - occur sometimes between the more severe attacks. In short, it - would appear that there is a group of syphilitic epilepsies in - which the brain shows no gross structural lesions, which - accordingly do not exhibit any Jacksonian appearances, and which - last a comparatively long time without changing their character, - and often without being especially altered for the better by any - form of antisyphilitic treatment. This condition is sometimes - known as a post-syphilitic epileptic neurosis. Nonne had been able - to collect up to 1902 some 12 cases from his own service. - - 4. Would it be proper to call Borofski a case of taboparesis? Absent - knee-jerks in a victim of paretic neurosyphilis should not be used - to suggest a diagnosis of taboparesis. This question of - terminology has been discussed above, under Sullivan (16). - - 5. What is the mechanism by which the amnesia of a case like - Borofski is produced? The answer runs in the same terms as the - answer to the questions concerning the cause of convulsions. The - amnesia in general paresis has surprising functionality. A study - of autopsied cases of general paresis has shown that amnesia is - practically as common in cases without marked destruction of brain - tissue as in cases with atrophy of classical extent and depth. The - clinical recovery in this case was practically complete in respect - to memory. We must regard the amnesia as not due to the - destruction of storage cells bearing the so-called neurograms - (Morton Prince). - - 6. What is the explanation of the persistently positive W. R.’s of - the serum and spinal fluid associated with diminished globulin and - albumin tests, a negative gold sol reaction, and normal cell - count? See discussion under Case Martha Bartlett (21). - - 7. How atypical is the early development of paretic symptoms in - David Borofski? C. B. Craig has collected, in 100 cases of brain - syphilis (a list including both paretic and non-paretic cases), - some data on this point. The shortest period reported by Craig was - in a case in which the neurosyphilitic symptoms appeared one month - after infection. Craig found three cases where symptoms appeared - in six months, and six cases within a year. The longest - post-infective period of Craig’s list was thirty years. Our case - of Chatterton (73) developed symptoms 33 years after infection and - Washington (66), forty years after infection. Nonne casts some - doubt on statements to the effect that tabetic symptoms may occur - three to four months after infection. It seems to be admitted that - pupillary anomalies and reflex changes may occur in the early - secondaries and may recover under antisyphilitic treatment. - Nonne’s case of longest post-infective interval, like that of - Craig, was one of 30 years. - - Myerson has reported a 20–year old patient who acquired chancre - April 1, 1911 (spirochetes demonstrated); salvarsan was - administered April 20th. There were no secondary symptoms, but in - May, headache, visual disturbance, vertigo, and other symptoms - developed (neurorecidive). Upon June 20th, that is, 11 weeks after - development of the chancre, aphasia and astasia developed, with - numbness of the left side. At this time, the pupils were slightly - irregular and unequal but reacted normally. The signs in the fluid - were positive. Upon this question see our cases of Bright (121) - and Bennett (34). - - - =Hemitremor following hemiplegia in PARETIC NEUROSYPHILIS (“general - paresis”). Autopsy.= - - -=Case 50.= Achilles Akropovlos, 39 years, had symptoms six months before -commitment to Danvers Hospital. There were attacks of confusion, -difficulty in walking, and speech defect, resulting in an entire -incapacity to work and eventual commitment. Rather unusual and striking -was a very marked tremor, apparently limited to the right side of the -body. =Physically=, Akropovlos was normal, but =neurologically= he -showed, in addition to the marked right-sided tremor, a marked speech -defect, and a degree of ataxia. The tendon reflexes were very active, -but there were no abnormal reflexes, and the pupils reacted normally. -According to the history, the difficulty had followed a slight attack of -apoplexy. =Mentally=, there was a marked confusion. The blood serum and -the spinal fluid were both positive to the W. R.; globulin was present, -and albumin was increased; there were 43 cells per cmm. There was hardly -any diagnosis to make except general paresis. - -Death followed 18 months later, or two years after onset of symptoms. -Increasing weakness, emaciation, and dementia preceded death. Autopsy -confirmed the diagnosis of PARETIC NEUROSYPHILIS. - - 1. What is the usual cause of death in general paresis? Intercurrent - disease very frequently occurs in general paresis, and such - intercurrent disease is then given as the cause of death. As a - matter of fact, however, one feels that in many of these cases the - intercurrent pneumonia or infection—frequently of the - bladder,—bedsores, sepsis, and the like, are merely accidental - incidents in a condition that is leading to death, and which has - caused a lowered resistance to infection. In certain instances - where nursing is exceptionally good and where no such infection - occurs, the patient continues to grow weaker and weaker, paralyses - of all the muscles follow and finally paralysis of deglutition or - respiration may lead to death. The emaciation and paralyses may be - of such a grade that the patient is entirely devoid of fat and - unable to move at all. Not infrequently vascular crises occur, and - one of these may be responsible for death. - - 2. What was the cause of the hemitremor? The hemitremor suggested an - irritative or destructive lesion in the motor path. Delving into - the history it was learned that the patient had had a shock - followed by a right hemiparesis. This had cleared up leaving the - tremor as a residuum. The autopsy disclosed a reddish-brown - pigmentation and fibrous thickening of the pia over the left motor - area, confirming the idea of a previous hemorrhage. As a rule the - shock phenomena occurring in paresis clear up more completely and - no gross lesion is visible post mortem. However, cerebral - hemorrhage must be expected in any person suffering from syphilis, - and is no rarity in paretic neurosyphilis. - - - =PARETIC NEUROSYPHILIS (“general paresis”) with NORMALLY REACTING - PUPILS. History of trauma. Autopsy.= - - -=Case 51.= Daniel Wheelwright, a barber of English extraction, 57 years -of age, had had a sunstroke at 15. At 42, there had been pneumonia, -after which an attack of rheumatism was said to have kept the patient -from work for a year. There was trauma of head (falling wrench) at 44. -This blow on the head was the assigned cause of the mental disease, -symptoms of which, however, did not develop until about the first of -September, 1905, about three months before entrance, January 9, 1906, -and about six months before death, March 20, 1906. - -It seems that the patient had begun to change in manner; he had become -despondent and apathetic, silent, and somnolent. Two weeks later, he -stopped working, began to read the papers once more, and became somewhat -more cheerful. - -About Thanksgiving, Wheelwright got up at midnight, and remained up, -lighting all the fires and talking continuously. During the next two -weeks, he talked much to himself, laughing out at times. About two weeks -before Christmas he went out and started to make a sidewalk of old -boards, working in his shirtsleeves, without a hat. He would work until -midnight making screens for windows. During the day, he would go out and -give money to passing children; would offer to pay the grocer twice as -much as articles were worth. - -On the day before Christmas, he put out all the fires and lights in the -house, sent all the family to bed, and opened all the doors. Christmas -morning, he rose early and got the washtubs ready. He helped his -compliant wife to do the washing, then put out all the fires and opened -the windows. After Christmas, he began to tell how rich he was going to -be through starting a garden and by making butter. He bought six or -seven quarts of milk daily, and procured carrots and oranges, grinding -them up to color the milk. January 9th he was committed to Danvers -Hospital. - -=Physically=, there were few symptoms. =Neurologically=, there was a -tremor of tongue, fingers, and face. The knee-jerks were lively. The -pupils reacted normally; the patient was restless, pacing up and down. -There was a speech defect demonstrable with test phrases. Orientation -was imperfect for time and for place. Handwriting was poor, memory -impairment was marked, but the patient was given to fabrication as to -past events. A characteristic sample of statements: - -“Do you know that this is an insane hospital?” “Yes; there are two or -three men here out of their heads. I could cure them with my hands but -they won’t let me. I could get all the sick men on their feet just by -rubbing them. I can do anything with my hands. I can build a house by -just sitting down and thinking about it. I can whip all the men in this -place. I have better sense now than I ever had in my life.” - -Again, “How long have you been here?” “Over three months; they have put -me in heaven three times since I have been here. They killed me, crushed -my heart, and turned my blood to water. I am all right now. I let the -sun shine on my heart and it brought it together. I can whip every man -in here as fast as they come up.” - -Again, “I will make a million dollars on my garden when I get it. I can -make a million dollars on half an acre. I can do anything. I can move -this house by just thinking of it.” - -During a special examination, the patient told how he had fastened wings -on his hands and feet, and how he had gone to heaven; he told how he had -soared high above the earth, and how differently the stars look when up -near heaven than they do from the earth. He spoke of seeing angels and -of the beauties of heaven. - -The diagnosis of PARETIC NEUROSYPHILIS was confirmed at autopsy. - - 1. What is the significance of the normally reacting pupils? While - it is usual to find pupillary anomalies in neurosyphilis, these - changes are not an essential part and it is not rare to find - normal pupils in all forms of neurosyphilis. It is less frequent - to find a normal pupil in tabetic than in diffuse or paretic - neurosyphilis. In paretic neurosyphilis it is the rule to find - pupillary changes during some stage of the disease, but not - necessarily early. At times the pupillary sign may be one of the - earliest signs of neurosyphilis—again it may occur only as a late - symptom, if at all. One of the most important of the pupillary - signs is irregularity of contour. While this does not always mean - neurosyphilis it is highly suggestive and certainly indicates - careful examination even though the W. R. in the blood be - negative. - - 2. What was the relation of trauma to the development of the - neurosyphilitic symptoms? It is, of course, the rule in all forms - of mental disease to have some factor offered by the patient or - relatives as the cause of the psychosis. Often these assigned - causes are minor events thought of only after the later appearance - of symptoms. In this case it was not thought that the trauma had - any causal effect. For a discussion of trauma and neurosyphilis - see cases Joseph O’Hearn (90), Levi Sussman (91), and Joseph - Larkin (92). - - - =NEUROSYPHILIS, probably PARETIC, with symptoms highly suggestive of - MANIC-DEPRESSIVE PSYCHOSIS.= - - -=Case 52.= Bessie Vogel[10] was admitted to the Psychopathic hospital -New Year’s day, 1915, in a very much excited condition. The family -history is very meagre, and all that is of significance is that mother -has always been very “nervous.” The records in part: - -=Past History.= Very healthy as a child, and except for occasional -throat trouble and headache had no physical ailments until eight years -ago, when she had an operation for appendicitis, and two and one-half -years ago was operated upon for hernia and adhesions. Following this she -began to show a lack of energy, neglected her housework, was much -depressed, wept frequently, complained constantly of pain in various -places, and was ill-tempered. In about five months she improved, and -then after a couple of weeks at the shore seemed entirely well. - -=Present Illness.= In November, 1914, that is, about seventeen months -after the recovery from the previous depression, she again began to show -practically the same symptoms. She was depressed, could not sleep, and -would get up in the night and sew; was self-centered and hypersensitive, -then became restless and nervous; wanted to go shopping and out for -dinner; went to New York and then to New Bedford. Symptoms became more -marked; she became very ill-tempered, threatened her husband when angry -over trifles, threatened suicide, then began to get active and spent -money extravagantly. At the end of two months, that is, Jan. 1, 1915, -she was admitted to the hospital. - -=Physical Examination.= A small, thin woman, appearing to be about 45 -years old (actual age 37). Aside from the absence of teeth and the -operation scars, the general examination is negative. =Neuromuscular -system=: The pupils are round, regular, equal, and react to light and -accommodation, but do not hold very well. Extraocular movements well -performed, no palsies of facial muscles, tongue protruded medially -without tremor. Uvula is raised symmetrically. Biceps and triceps and -supinator reflexes are present and brisk. Patellar and Achilles reflexes -are equal on the two sides and brisk. Abdominal skin reflexes not -obtained. Plantar reflex active and flexor in type. No Babinski, Gordon, -or Oppenheim. No tremors. - -Wassermann reaction serum positive. Examination of spinal fluid: clear, -globulin ++++, albumin ++++; cells, 130 per cmm.; small lymphocytes, -79.9%; large lymphocytes, 14.1%; polymorphonuclear leucocytes, 4.6%; -plasma cells, 0.7%; endothelial cell, 0.7%. W. R. positive. Gold sol -reaction, 55555522 +-. - -=Mental Examination.= On admission patient showed great psychomotor -activity, was very playful, marked flight of ideas, was expansive, very -emotional, very erotic. She slept very little, appetite was poor, and -she lost weight rapidly. Orientation and memory intact. No -hallucinations elicited. In about three weeks improvement began, and at -the end of eight weeks she appeared practically recovered. On April 9, -1915,—that is, 13 weeks after admission,—she was allowed home on visit. -On leaving, she appeared normal in every way. There was no evidence of -psychotic symptoms, she had good insight, and physically there was -absolutely nothing of a neurological nature that was abnormal. - -This case, with the history of a previous depression and its clinical -picture during the acute stage, and its recovery, is certainly in every -respect typical of manic-depressive insanity, and only the positive -result of the six tests causes us to put it in the group of GENERAL -PARESIS. Only the further course will shed any light as to the correct -significance of these findings, and even then we shall not be too sure -that we had not been dealing with a manic-depressive psychosis in a -latent neurosyphilitic. We would strongly emphasize the point that at -the present time this patient presents no mental or physical signs of -cerebrospinal syphilis or general paresis; but the six tests are still -positive. This case differs from the ordinary general paresis remission -in that there is not a single physical sign of paresis present. - -There are many transitional cases between this case which shows no -symptoms or signs of neurosyphilis except the laboratory tests, and the -typical case of general paresis. Thus we have cases with slight -character change and no physical signs except rare “seizures.” On the -other hand, in many cases the presence of abnormal neurological -phenomena without definite mental signs is first noted. Certain remitted -cases show only some slight pupillary or reflex abnormality. We believe -we have here added the last link in the chain between the primary and -quaternary symptoms. - -This case is illustrative of several which we have published elsewhere -under the name of _paresis sine paresi_ or latent neurosyphilis to -illustrate how all the laboratory signs of neurosyphilis may be present -in a patient without any physical or mental symptoms that may be -correlated with these findings. - -We summarize our discussion of this as follows: - -1. There is a group of cases showing the laboratory signs characteristic -of central nervous system syphilis: (_a_) positive W. R. in the serum, -(_b_) positive W. R. in the spinal fluid, (_c_) pleocytosis, (_d_) -excess of albumin, and (_e_) of globulin in the spinal fluid, (_f_) gold -sol reaction of central nervous system syphilis, and which show no sign -or symptom of neurosyphilis. - -2. We believe these cases represent a form of chronic cerebrospinal -syphilis, probably paretic in type. - -3. They have the greatest theoretical and practical significance in the -consideration of the life history of neural syphilis, in the concept of -_Allergie_, in regard to results of treatment, and finally as to the -evaluation of the laboratory tests. - -4. Here is perhaps offered the last link to form a complete chain -between the symptoms of the primary stage of syphilis and its final -termination of life as the result of the diseases cerebrospinal syphilis -or general paresis. - - - =SYPHILIS (?); EXOPHTHALMIC GOITRE; neurosyphilitic old lesion of - optic thalamus; unilateral induration and atrophy of left cerebral - cortex. Autopsy.= - - -=Case 53.= Carrie Pearson, a housewife 25 years of age, died at Danvers -Hospital less than a week after admission, and it was at first stated -that her symptoms had lasted but two weeks before admission. In point of -fact, a further investigation showed an important succession of -symptoms, lasting some four years. - -Carrie had been considered a healthy child, going to school at the usual -age, and progressing well with her studies. She however, left school in -the ninth grammar grade, at the age of 15, and went to work in a -milltown. She married a worthless person at the age of 18, and lived -with her husband for three years. There was one child born a year after -marriage. Two years later, however, a tremendous goitre had developed -such that her neck was described as “out square with the face,” and at -the same time the patient’s eyes had become prominent. - -About two weeks before admission, she had gone to a neighboring town to -take care of a sick woman, but during her endeavor to be a nurse, she -had broken out into a mania, tearing up furniture and bedding, and -talking irrelevantly for a period of four days. She also showed insomnia -and continually tore off her clothing from her body. - -Upon =examination=, the marked enlargement of the thyroid gland together -with the prominent eyeballs, husky voice, and pulse rate of 150 per -minute, were entirely consistent with the diagnosis of exophthalmic -goitre. The patient described herself as “Carrie Nation.” Asked to write -her name, she took the pen and tried to spatter ink, wrote hurriedly and -carelessly her maiden name and several words without apparent meaning. -Asked to write, “God save the Commonwealth of Massachusetts,” she wrote: -“God save the common pal U S Spe Manor Gen, or til pat. Since Lord, or -no prime in Hear to the God Tel. Ho. n and or Mabel, or gal.” After -this, she took paper and wrote meaningless scrawls, saying that it was -Japanese writing. There was much motor restlessness with -distractibility, pointing and grimacing, mimicking the actions of those -about her. - -Death occurred from exhaustion, and the case might not have been -regarded as unusual except for the autopsy, which showed a peculiar -brain lesion, described below. The point of greatest interest in the -case was the fact that syphilis is, although not proved to exist by -laboratory tests, beyond question a factor in the case. Although the -woman had given birth to a normal child, who is still alive, yet in the -period of a few years her breasts had atrophied, her hair had -disappeared from the axilla and from the pubes; varicose veins had -developed in both legs. Whereas there was little or no fat over the -chest or back, the omentum and mesentery were very plentifully supplied -with fat. It is probable, then, that we are dealing with a case of -exophthalmic goitre somehow of syphilitic origin. The brain lesion is -consistent with this hypothesis. - - =Autopsy=, March 3, 1907. Four hours post mortem. - - Body length, 165 cm. Body of a well developed and well nourished - young woman. Lividity in dependent parts. Purplish discoloration of - left thigh to knees. Skin rough and scaly. Petechial eruption over - chest. Neck thick, protrudes anteriorly. Varicose veins over upper - parts of calves on both legs. Eyes protruding, not covered entirely - by lids. Pupils equal, dilated. Subcutaneous fat very deep over - lower part of body. Very little fat over chest and back. Breasts are - very small, apparently atrophied. Normal amount of hair on head, - slight amount over pubes. Axillary hair absent. Fat on section of a - light yellow color. Omentum extends to pubes, plentifully supplied - with fat. Large amount of mesenteric fat. Appendix normal. - Intestines smooth and glistening. Slightly injected. No fluid in - peritoneum. Uterus small, retroverted. - -[Illustration: - - Cortical hemiatrophy—A, relatively normal right precentral (“motor”) - cortex; B, atrophic left precentral. - - Note in B: - - 1. Absence of giant pyramids of Betz (corticospinal, upper motor - neurones). - - 2. Superficial (subpial) condensation of tissues with sclerosis - (gliosis). The tissues in all areas examined _on the left side_ - yielded this effect. -] - - HEAD: HAIR in good quantity. SCALP normal. CALVARIUM shows diploë. - DURA MATER over left cerebral hemisphere inseparably adherent to - calvarium, over right hemisphere normal. Arachnoidal VILLI - moderately developed. PIA MATER shows injected veins, notably in the - sulci of the right hemisphere. Pia mater everywhere thin and clear. - VESSELS at base of normal appearance. - - BRAIN weight 1180 grams. Spread on a board, the right hemisphere - tends to flatten so that it measures 1.5 cm. more from side to side - than its fellow. Besides more marked venous injection, the right - hemisphere shows also flatter and slightly more plastic - convolutions. The posterior poles of the hemispheres are a little - firmer than the parts anterior. The orbital and hippocampal gyri on - the right side are a little firmer than the surrounding parts. On - section the gray and white matter shows no lesions, excepting the - slight plasticity of the tissues at large on the right side and a - well marked induration, with retraction under the knife, of the - occipital and hippocampal white matter. The basal ganglia of the - left side are normal. On the right side a sagittal section - demonstrates a rounded area of induration, with ill-defined borders, - measuring perhaps 1.5 cm. from above downwards by 2 × 2 cm., - situated largely in the lenticular nucleus and involving the greater - portion of the globus pallidus, a small segment of the putamen below - and behind and the regionary part of the anterior commissure with - surrounding tissues. The most striking feature of this lesion is the - occurrence in the middle of a cluster of vacuoles or cystic clefts, - with smooth pale interiors, ranging from pinhead to 0.25 cm. or even - 0.5 cm. in greatest diameters. There are six to eight clefts to a - surface of section. The color of the lesion differs little from that - of the globus pallidus itself, but the tissue is a trifle - translucent. It is impossible to demarcate the lesion with the eye. - Induration is demonstrable several mm. beyond the visible part of - the lesion. The consistence of the lesion slightly surpasses the - usual consistence of the olivary bodies. - - CEREBELLUM, PONS and BULB weight 165 grams. Cerebellar tissue a - trifle more plastic than usual. The right olive is not so prominent - as usual. - - =Note.= THYROID: Weight 125 grams. Both lobes and isthmus enlarged. - One lobe more than the other; lobe on one side measuring 6 × 4 cm. - - Anatomical Diagnoses - - Enlargement of thyroid gland. - - Exophthalmos with dilated pupils. - - Fatty degeneration of thoracic muscles. - - Slight aortic sclerosis. - - Dilatation of right heart. - - Hypertrophy of left ventricle. - - Slight tricuspid endocarditis. - - Bicuspid aortic valve. - - Hypostatic pneumonia. - - Acute and chronic splenitis. - - Fatty liver (central necroses?). - - Acute nephritis. - - Chronic gastritis. - - Small breasts. - - Axillary hair absent. - - Petechial eruption of chest. - - Varicose veins. - - Chronic external adhesive pachymeningitis of left side. - - Moderate swelling of right hemisphere with venous injection. - - Slight occipital gliosis of both sides. - - Slight gliosis of orbital and hippocampal gyri of right side. - - Sclerosis with atrophy of occipital and hippocampal white matter of - right side. - - Gliotic lesion (1.5 × 2 × 2 cm. of right lenticular nucleus - involving anterior commissure). - - 1. Was the exophthalmic goitre in Carrie Pearson due to syphilis? - Unfortunately we have no clear proof that Carrie Pearson was - syphilitic. She was stated to have been syphilitic by the - physician who treated her before her commitment to Danvers - Hospital. There is, however, no proof of syphilis, inasmuch as the - patient died in the pre-Wassermann period. - - 2. Is the thalamic lesion probably syphilitic? No lymphocytosis or - plasmocytosis characterizes the lesion, which is the only lesion - of the sort in the Danvers collection. It would not do to call a - lesion syphilitic just because it is _sui generis_. In any event, - the clinical analysis of the case faced the claim of syphilis as - an actual factor in the patient’s life and as a possible factor in - the goitre. - - - =It is well known that the ARGYLL-ROBERTSON PUPIL is characteristic - of the so-called “PARA-SYPHILITIC DISEASES” (“general paresis” and - “tabes”); does this sign occur in other neurosyphilitic conditions?= - - -=Case 54.= Julius Kantor was a shoemaker of 35 years, who came to the -hospital for treatment because his family physician had found a positive -W. R. in Kantor’s blood serum. He had had a cough for a number of years, -and during the last year a little blood had been found in the sputum; -whereupon Kantor had been placed under active anti-tuberculosis -treatment. The enterprising family physician had found the positive W. -R. in the first days of his treatment for tuberculosis. There was, in -fact, a history of a chancre nine years before, which had not been -followed by any secondary or tertiary symptoms, and which had been but -scantily treated. - -There were no mental symptoms. - -Kantor was =physically= fairly well developed and nourished. There were -a few piping râles in the left upper chest, both in front and back, and -also a slight dulness with increased vocal and tactile fremitus. No -tubercle bacilli, however, could be found on repeated sputum -examination. - -=Neurologically=, the pupils were myotic and both showed the -Argyll-Robertson reaction. There were no abnormal reflexes whatever, and -there was neither ataxia nor speech defect. Not only the blood but also -the spinal fluid W. R. proved to be positive; there was a marked -increase in the albumin and globulin; there was a gold sol reaction of -the syphilitic type, and there were but three cells per cmm. - - 1. In view of the headache in case Kantor, what other causes of - headache are to be considered? It is certain that irritations of - the dura mater can produce headache, and the physiological - observation of the sensitiveness of the membranes and the - non-sensitiveness of the brain substance is an ancient and - classical observation. Internal hemorrhagic pachymeningitis - produces severe headache. The relations of this disease to trauma, - to arteriosclerosis, and possibly to syphilis (alcohol perhaps - should also be considered) in certain instances have not been - entirely cleared up. Syphilitic headaches are, according to - Lewandowski, dependent also upon a dural affection or upon a - periosteal affection. The headaches of brain tumor are also - commonly related to dural conditions, either directly due to the - pressure of the tumor itself, or indirectly to the heightened - intracranial pressure consequent upon the tumor. It is clear that - the tension under which the dura mater lies is not always - localized in the region of a brain tumor or a syphilitic lesion. - Head has claimed that brain tumor produces headaches of two kinds, - according to whether the disease affects the dura mater or is - dependent upon an increase of pressure in the brain. It does not - appear that the pia mater has any relation to headaches, but - meningitis, in which the inflammation is confined to the pia - mater, is nevertheless associated with headache; the headache is - here supposed to be due to the increase in brain pressure, and - thus actually to an effect wrought upon the dura mater. Vasomotor - disorders and various types of cephalic hyperemia are thought to - produce a kind of headache, but Lewandowski calls this kind of - headache somewhat in question. Reflex headaches are stated to be - produced indirectly by a process of radiation from interior - lesions in the brain. There are certain headaches called nodal - headaches (_Schwielen-Kopfschmerz_). Hypermetropia, caries of the - teeth, adenoids, and diseases of the nose and axillary cavities, - to say nothing of thoracic and abdominal diseases, are also - counted among conditions that may produce headaches. In this - connection, Head has claimed differential zones of headache - corresponding to certain diseases. - - The brain itself may produce headache through intoxications, - through conditions produced by a variety of diseases; may follow - neuroses. Alcohol may produce headaches in some persons even when - it is taken in very small doses. Certain uremic cases yield - headaches, as do also gouty and chlorotic conditions. According to - Lewandowski, the headaches of arteriosclerotics are due possibly - to vasomotor disturbances in the membranes, or one may think of - nutritive cerebral disorders. A peculiar form of headache is that - of fatigue after mental work, allied to which is the neurasthenic - headache; constitutional headaches have been assumed to occur, to - say nothing of hysterical headaches. There remains also the - important question of migraine, for which a vasomotor explanation - has been proposed. - - 2. Was Kantor suffering from tuberculosis of the lungs? The - hypothesis of lung syphilis ought certainly to be very seriously - considered. Upon repeated sputum examination, no tubercle bacilli - have yet been found. - - 3. Is Kantor a case of general paresis? In the absence of mental - symptoms, and in consideration of the mildness of the reactions, - it is certainly not easy to make the diagnosis of general paresis. - However, the diagnosis of tabes dorsalis is not justified either. - Accordingly, we may answer our question: whether the - Argyll-Robertson pupil occurs in other neurosyphilitic diseases, - by pointing out that in the case of Julius Kantor, as in the case - of Henri Lepère (105) and Frederick Stone (106), the - Argyll-Robertson pupil has been found in syphilitic conditions - that are neither typically paretic nor typically tabetic. - - - =Does the Argyll-Robertson pupil necessarily indicate - neurosyphilis?= - - -=Case 55.= Daniel Falvey, 44 years of age, was an almshouse transfer to -the Danvers State Hospital in the year 1904, when the principle of state -care was adopted in Massachusetts. As in most of the almshouse transfers -of that day, little could be discovered as to antecedents. He had been a -mill-worker from the time of his immigration in 1890, at 30 years of -age. He had been somewhat alcoholic. There was a shock some 17 months -before his death, which occurred about seven weeks from the date of -transfer. - -Not only was he unable to walk unsupported, but when supported there was -a slight dragging of the left leg and the gait was noted to be somewhat -propulsive. The tongue and hands were tremulous, and the left grasp was -somewhat weaker than the right. Both knee-jerks were increased although -neither more than the other. There was no sensory disorder. - -Although but 44 years of age, Falvey presented the appearance of a much -older man. His heart was somewhat enlarged and there was a degree of -peripheral arteriosclerosis. On the whole, no special attention was -attracted to this case clinically and he was regarded as an example of -arteriosclerotic dementia, like many another among the transfers. -However, we owe to Dr. H. M. Swift the important observation of the -Argyll-Robertson pupils. The case was studied long before the Wassermann -method was available, and is here reported merely to call attention to -the fact that the stiff pupils may have other neural origin than -neurosyphilis. - -The autopsy material in the case was worked up by one of the -authors.[11] The autopsy had been performed by Dr. A. M. Barrett, who -found on section through the brain stem at the anterior border of the -pons a mass springing from and continuous with the pineal gland, lying -in the third ventricle and the aqueduct of Sylvius. Upon further study, -this mass was found to begin posteriorly in the pineal body itself, from -which the mass could hardly be told in the gross except by an injected -border. - -This mass proved upon microscopic examination to be a psammoma, which -histologically resembled a glioma rather than a sarcoma. Throughout the -mass there was a variable content of fibrillary intercellular substance -having the histological reactions of neuroglia fibrillæ. The -histological details (mitosis, large giant cells with multiple nuclei, -etc.) do not here concern us. We deal with a neoplasm springing from the -pineal gland growing on the posterior half of the third ventricle, the -anterior orifice of the aqueduct of Sylvius, and the space between the -velum interpositum as far back as the posterior corpora quadrigemina. -There is no evidence in the body of old syphilis; although it is -possible that the stiff pupils were neurosyphilitic, it seems probable -that they were related to the pineal tumor. At all events, there are in -the literature evidences that the pineal-quadrigeminal group of tumors -and other lesions may bring about pupillary disturbances. On this -account, we here include the case. The tumor hardly led to an error in -diagnosis since neither neurosyphilis nor brain tumor was at all -expected clinically. - - 1. Can alcoholism produce identical results? See Case Murphy, (60), - one of alcoholic pseudoparesis. - - 2. What is the nature of stiff pupils? A pupil is called stiff in - the sense of the Argyll-Robertson pupil if it fails to react to - illumination either of itself or of the other eye and at the same - time if it reacts properly in convergence and accommodation. Of - course the stiffness of a blind eye must not be regarded as an - Argyll-Robertson pupil. In a case of right-sided Argyll-Robertson - pupil, therefore, the left pupil reacts properly both to direct - illumination of itself and to illumination of the right eye, but - the right eye fails to react to illumination of either eye. Such - an Argyll-Robertson right pupil will remain of the same width both - in darkness and in light. Clinicians agree that the - Argyll-Robertson is diagnosticated rather too frequently than too - seldom, and this by reason of the fact that a sluggishness of - light reaction is interpreted as stiffness. The sign, as is well - known, has come to be regarded as almost pathognomonic of tabetic - or paretic neurosyphilis. Nonne, however, has found among 510 - cases of alcoholism, nine instances of Argyll-Robertson pupil and - 19 cases of sluggish light reactions. The pathological anatomy of - this sign is still doubtful although a number of schematic - accounts are available; among hypotheses, one may think of an - elective effect of the tabetic or paretic degeneration upon reflex - collaterals. The explanation would then resemble that for absent - knee-jerks and kindred reflex disorders. We should then - hypothesize a loss of the finer processes of the terminal - arborizations about the cells of the nucleus of sphincter nucleus - iridis. However, the situation of the sphincter iridis has not yet - been absolutely determined. - - When a pupil is said to be entirely stiff it means that it reacts - neither to light nor accommodation. This condition not - infrequently follows the partial stiffness or Argyll-Robertson - reaction. - - 3. Is the Argyll-Robertson pupil more tabetic than paretic? This has - been claimed at times, but in point of fact, the Argyll-Robertson - pupil is very frequent in paresis, and so also are posterior - column changes. According to statistics of Bumke, 36% of tabetics - fail to show the Argyll-Robertson pupil, and 38% of paretics. - When, however, finer methods, such as those standardized by - Weiler, with photographic records, are employed, the number of - cases without at least a tendency to the Argyll-Robertson pupil - becomes much smaller. - - In connection with the important question as to the classical - Argyll-Robertson pupil and pupillary sluggishness to light, it may - be inquired what are the ocular signs in neurosyphilis? Joffroy - has tabulated the signs in 300 general paretics as follows: - - Sign. No. of Per - cases. cent. - Alterations of light reflex 235 78 - Inequality 205 68 - Abolition of light reflex (bilateral or unilateral) 156 52 - Abolition of light reflex (bilateral) 133 44 - Irregularity of pupil 117 39 - Irregularity of both pupils 109 36 - Diminution of light reflex 108 36 - ditto (bilateral) 79 26 - Alteration in accommodation reflex 79 26 - Diminution of accommodation reflex 52 17 - Mydriasis 41 13 - Myosis 40 13 - Diminution of light reflex (unilateral) 35 11 - Abolition of accommodation reflex 35 11 - Diminution of accommodation reflex (bilateral) 29 9 - Abolition of accommodation reflex (bilateral) 26 8 - Diminution of accommodation reflex (unilateral) 23 7 - Fundus changes 21 7 - Vascular changes 16 5 - Abolition of accommodation reflex (unilateral) 12 4 - Paresis of the third nerves 10 3 - Ptosis 9 3 - Irregularity of one pupil 8 3 - Nystagmus 7 2 - Visual acuity lost 7 2 - Atrophy of disc 6 2 - Total blindness 5 2 - Paralysis of the fourth nerves 1 1 - - - =Can neurosyphilis exist in the absence of positive findings in the - spinal fluid?= - - -=Case 56.= There was no great difficulty in setting up a diagnosis of -general paresis in the case of James Burns, a mechanic of 31 years of -age, who came voluntarily to the Psychopathic Hospital for treatment. -The point in Burns’ case was that the spinal fluid proved entirely -negative in all respects despite the fact that the serum W. R. was -positive, and despite the following facts of history and mental -examination. - -The patient claimed syphilitic infection seven years before, namely, at -24 years of age, and also claimed that he had infected his wife, who was -in fact at the time undergoing antisyphilitic treatment. He complained -of insomnia, worry, depression, hypersensitivity to noises (such as -those made by his own children), thoughts of suicide, and amnesia. The -amnesia, however, might be regarded as subjective since our tests failed -to show amnesia. Nor was there any diminution in arithmetical ability. -Despite the patient’s claim that he had been “way off in his way of -thinking,” there appeared to be no delusions. Beyond a certain -flightiness in conversation, we could hardly get any evidence of -psychosis unless of the neurasthenic order. - -=Physically=, however, the left pupil failed to react to light though it -was found to react to distance, and the right pupil exhibited a -diminution of its reaction to light. There was no ataxia of gait, yet -there was a complete Romberg reaction. There was a moderate tremor of -the hands and of the tongue. Otherwise there were no reflex disorders -upon systematic examination, nor was there any demonstrable disorder in -the rest of the physical examination. - - 1. What is the diagnosis in the case of James Burns? On the whole we - agree with Nonne, that negative spinal fluid findings (of course, - in the absence of treatment) preclude the diagnosis of general - paresis. The symptoms might possibly be explained, however, by - means of a localized syphilitic involvement of the cerebrum, no - cells or products of inflammation having penetrated to the spinal - fluid. According to Head and Fearnsides, this condition may be - found especially in the anterior or middle fossa. Accordingly, - going upon these views of Nonne and of Head and Fearnsides, we - should be entitled to make, perhaps, a diagnosis of cerebral - syphilis. - - 2. What is the significance of the Argyll-Robertson pupil in James - Burns? Nonne states that if one follows cases with - Argyll-Robertson pupil over a sufficient period of years, they one - and all eventuate in active symptoms of cerebrospinal syphilis - (not necessarily of the cortical type), and this despite the fact - that the pupillary change may have been present a number of years - before any other symptom had developed. - - - =Neurosyphilis (“DISSEMINATED ENCEPHALITIS”) within seven months of - initial infection. Autopsy.= - - -=Case 57.= We borrow the main features of a remarkable case examined at -the Danvers State Hospital clinically by Dr. H. W. Mitchell and reported -elaborately by Dr. A. M. Barrett. This case, whom we shall call John -Summers, acquired syphilis at about the end of the third week in May, -1902, and consulted a physician on June 12, at which time a -characteristic initial lesion of syphilis was plain. Summers was -excessively alcoholic at times and was not seen by a physician again -until July 2, just after an alcoholic debauch. At this time there was -ulceration of the primary lesion, and a papillary eruption had developed -over the arms, chest, abdomen, and legs. Mercurial treatment and mixed -treatment were given. Arthritis occurred but disappeared with increased -dosage. - -About six months after infection, the patient developed severe -headaches, hardly controllable by treatment. Amnesia and a certain -stupidity, with neglect of personal habits, and even of eating, -developed, whereupon Summers was admitted to the Danvers Hospital, -December 11, 1902. He weighed 124 pounds, was extremely feeble, with -dull and expressionless face, coarse purposeless movements of arms; left -pupil larger than right; right external strabismus and ocular ptosis; -increased knee-jerks, crossed adductor reflex, coarse tremors of arms -and hands; and extreme clouding of consciousness. It was doubtful -whether the pupils were stiff to light or not. - -The patient died on the ninth day, December 18, in a state of coma. -After admission, his stupor had become more marked; there had been -incontinence of urine and fæces, and the patient could be aroused only -by loud tones. Difficulty in swallowing had developed; the right-sided -ptosis had become more marked, and muscular twitchings had developed on -the right side. When the left leg was pinched, there was twitching of -the left leg and arm. There was slight spasticity of the right arm and -leg. An examination upon the day of death definitely showed a lack of -reaction of the pupils to light. - -[Illustration: - - 1. Exudate in pia mater—mononucleosis. -] - -[Illustration: - - 2. Superficial (subpial) cellular reaction of neuroglia tissue - (expanded cell bodies). -] - -[Illustration: - - 3. Cellular gliosis of deeper layers of cortex. Apparent increase in - capillary supply, possibly relative to loss of neural elements. -] - - Case 57. Neurosyphilis (“disseminated syphilitic encephalitis” of A. M. - Barrett), fatal seven months from initial infection. (Photographs by A. - M. Barrett.) - -Dr. Barrett was able to find in the literature a case of Bechterew which -histologically resembled his own case, but though in the instance -reported by Bechterew the first symptoms developed within the year -following infection, death did not occur until two years later. - -In view of a total duration of symptoms clearly not over seven months, -it is interesting to inquire how far microscopic brain changes could -have proceeded. Neither calvarium nor dura mater showed changes. There -was a slight haziness of the pia mater over the convexity, but the pia -mater over the base (especially below the cisterna and from thence -spreading out over the pons and into the fissure of Sylvius) was not -only hazy but definitely thickened and hyperæmic. The thickening was -most marked about the root of the right third nerve (corresponding with -the eye findings in life). There was also a macroscopic thickening of -the left Sylvian artery. Section of the brain showed nothing abnormal -except a small area among the pyramidal fibres of the right side of the -pons, where there was a single hemorrhagic area about 7 mm. in diameter -around which there were small punctiform hemorrhages. (Compare -twitchings of left leg and arm upon stimulation of left leg, and note -also the muscular twitchings and slight spasticity of right leg and arm -noted just before death.) This case was examined and reported upon in -1905. We learn from Dr. Barrett that a re-study of the case with modern -methods has failed to demonstrate a spirochetosis. - -The meninges show infiltration and destructive and proliferative changes -of the blood vessels. Condensed extracts from Dr. Barrett’s full report -follow: - - There were local variations in the severity of the meningitis. The - sulci showed the most marked infiltration. The slighter degrees of - exudation were made up largely of lymphocytes with a few plasma - cells, occasionally large mononuclear cells, and rarely a - polymorphonuclear leukocyte. Where the exudation was more extensive, - the large mononuclear cells became more common and the - polymorphonuclear leukocytes increased in number. The large - mononuclear cells were often phagocytic, containing from one to six - leukocytes. The exudate was always most abundant about the blood - vessels. The plasma cells were always most numerous in the - adventitia of the veins, here greatly outnumbering the leukocytes. - The polymorphonuclear leukocytes were relatively infrequent except - where there were necrotic areas, which areas were usually continuous - with an infiltration of a vessel wall. - - As to vascular changes, the media was not often involved, nor was - the adventitia so often affected as the intima. Such lesions as - appeared in the intima and adventitia were infiltrative rather than - proliferative. The elastica of the blood vessels proved to show but - slight changes. - - A characteristic change was the endarteritis,—of a focal nature with - a few large mononuclear and lymphocytic cells pushing the intima - inward at the edge of a lesion. In the more marked portion of the - focal process, the thickness of the intima was greatly increased by - proliferation. Great numbers of large mononuclear cells could be - seen between the intima and the elastica. About these cells and - interlacing among the other elements of the proliferating tissue was - an excess of connective tissue fibres. - - The meningeal veins were more often diseased than the arteries; - there was adventitial infiltration with lymphoid and plasma cells; - sometimes the vein walls had become necrotic and infiltrated with - polymorphonuclear leukocytes. - - It will be remembered that the left Sylvian artery was grossly - thickened, and microscopic section of this vessel showed a partial - thrombosis. - - The brain showed diffuse and focal changes. The _diffuse_ process - was one of nerve cell degeneration and proliferative changes in the - neuroglia and blood vessels, and no section of the many examined - proved to be free from such changes, although in the majority of - instances, these diffuse changes were slight. The cortical layers - showed more of these diffuse changes than did the white substance. - Barrett considered that the glial cell changes were more delicate - indicators of the cortical changes than the nerve cell changes. He - found rod cells, satellitosis, superficial gliosis, and a large - gamut of changes in the neuroglia. There were two rather - characteristic nerve cell changes: a shrinkage change going on to - almost complete destruction, and a type of cell swelling, also - apparently proceeding to complete destruction. - -[Illustration: - - 4. Arteritis of pia mater. -] - -[Illustration: - - 5. Focal vascular lesions. - - Case 57. Seven months from infection. “Disseminated syphilitic - encephalitis,” Barrett. (Photographs by Barrett.) -] - -[Illustration: - - Paretic neurosyphilis (“general paresis”)—cerebral atrophy, _without_ - meningitis. Therapeutics cannot hope to restore lost tissue. - - Duration. 3 years from beginning of well marked symptoms; 6 years from - beginning of obvious symptoms; 12 years from a so-called “nervous - prostration.” -] - - Among _focal_ changes, there were four main types: Areas of - encephalitis, having the general appearance of granulation tissue, - areas of simple necrosis or softening, apparently directly related - to vascular changes near by, hemorrhages, and certain foci regarded - as gummatous. - - Save for pial infiltration and a few vascular changes, there was - very little change in the medulla and spinal cord. There was a - hypertrophic gliosis of the margin of the medulla and cord - throughout, and a focal lesion of well marked gliosis at one point - in the bulb. There were no fibre degenerations in the medulla or - cord, nor were there any coarse fibre degenerations in the cortex - itself except in one locus, the left gyrus rectus. This case is of - peculiar value in showing to what extent lesions may proceed in a - period of six to eight months after primary infection. - -Of course the case is in one sense entirely atypical. The lesions were -not confined to the nervous system. Aside from the maculo-papular -eruption and ecchymosis of the skin, there was a diffuse hemorrhage of -the inner half of the conjunctiva of the left eyeball, a small -hemorrhagic focus in the mitral valve, a caseous nodule, one cm. in -diameter, in the apex of the left lung whose tuberculous or syphilitic -nature is left in doubt; a broad milk-colored patch of thickening of the -capsule of the liver. It is to be noted that there were no gross lesions -of the aorta. - - - =On the classical assumption that PARETIC NEUROSYPHILIS (“general - paresis”) is a fatal disease, is there a disease PSEUDOPARETIC - NEUROSYPHILIS (“pseudoparesis”) which may recover or pursue a long - course like that of a case of diffuse neurosyphilis (“cerebrospinal - syphilis”)?= - - -=Case 58.= Peter Burkhardt had been an efficient highway inspector, but -in his forty-fifth year he had begun to be unable to do his work -satisfactorily. His wife had become somewhat afraid of him. He had had -somnolent spells in his chair and had squandered money. The mental -symptoms had lasted for some six months, but had become more marked -during the month preceding admission. Burkhardt would at times fail to -recognize his friends. - -The general =physical condition= of Burkhardt was very good. The pupils -were irregular and reacted sluggishly both to light and to -accommodation. The knee-jerks and ankle-jerks were absent. There were no -other neurological disorders upon systematic examination. There was a -speech defect. =Mentally=, little could be determined except a certain -sluggishness. - -History and physical examination at once suggested general paresis. The -serum W. R. was doubtful, but the spinal fluid reaction was positive, as -was the gold sol reaction (which was “paretic”); the globulin and -albumin were greatly increased; there were 48 cells per cmm. -Antisyphilitic treatment, consisting of salvarsan twice a week and -potassium iodid by mouth, was followed by a rapid mental improvement. -After two months, Burkhardt was discharged apparently normal, with all -the blood and spinal fluid tests negative. He has been taken back into -the highway service. - - 1. What is the proper definition of pseudoparesis? Fournier termed - pseudoparesis certain cases that looked like paresis but were not - syphilitic in origin. Of these cases the most characteristic group - is that of alcoholic pseudoparesis. It is clear that there will be - no difficulty in the definition of a disease pseudoparesis whose - entity is presented in the adjective that precedes the term - (_e.g._, alcoholic pseudoparesis). According to this usage, a case - of pseudoparesis would be one in which the symptoms and possibly - some of the signs somewhat resemble the symptoms of paresis itself - but for which another etiology could be fairly established. - - 2. Are there any cases of syphilitic pseudoparesis? We are of the - opinion that the term should be dropped. It is true that there are - cases which clinically look like general paresis and exhibit the - appropriate laboratory signs of general paresis but seem to differ - from paresis in their course even when they receive no treatment - whatever. In the present phase of doubt as to the classification - of paretic and non-paretic forms of neurosyphilis, it seems to us - of doubtful utility to characterize a case as pseudo simply - because it differs in its course, particularly as the literature - has always duly recognized that a number of cases of general - paresis have had long courses and sometimes very long remissions. - - There is also another group of cases that have been termed cases - of pseudoparesis, namely: certain cases of neurosyphilis which - clinically look like general paresis and seem to be following its - classical course but are interrupted by treatment. Here again it - seems to us doubtful whether the designation pseudo should be - attached to this group of cases, particularly while the whole - therapeutic question in the paretic group of neurosyphilis cases - remains _sub judice_. Accordingly we are tempted to include in the - group of paretic neurosyphilis cases that either get well of - themselves, or get well under treatment, or pursue a very long - course, or are subject to very long remissions. But we make this - decision in terminology without prejudice to the therapeutic - question and it is open to any critic to throw these cases into an - atypical non-paretic group of neurosyphilis cases. - - 3. How shall we explain the absence of ataxia of case Burkhardt when - knee-jerks are absent and when, therefore, we are entitled to - conclude a certain degree of spinal disease? As stated in - connection with case Sullivan (16), the absence of knee-jerks is - not a warrant for terming a case—paresis of the tabetic form. The - fact is that the lesion in paresis tends to be intraspinal, just - as the higher brain lesions tend to occur within the brain - substance. The meninges are relatively spared both within the - cranium and within the spinal canal. The characteristic - degeneration of posterior nerve roots which we find in tabes - dorsalis is not necessarily found in general paresis even when - there are somewhat extensive spinal lesions. Accordingly the - absence of sensory returns by way of the posterior nerve roots - which characterizes tabes dorsalis is not necessarily a phenomenon - of general paresis. The mechanism by which the knee-jerks are lost - depends upon histological detail. They may be lost when under - tabetic conditions the posterior roots are severely diseased and - when under paretic conditions only intraspinal collaterals or a - small portion of fibres are affected. The whole question hinges - upon where and to what degree the various reflex arcs are cut in - the disease. The tabetic phenomena are, as so commonly stated, - intradural; that is, the sensory or gangliospinal neurones at - certain levels are affected all the way in from the points at - which they pierce the dura mater. The affection of these and other - neurones in general paresis is an intraspinal and parenchymatous - affection. - - - =Neurosyphilis; auditory hallucinations; ideas of persecution; - attacks of excitement. SYPHILITIC PARANOIA (Kraepelin)?= - - -=Case 59.= Bridget Curley was a case that was discharged from the -Psychopathic Hospital, recovered, after 26 days in hospital. The -symptoms so resembled those of alcoholic hallucinosis that the diagnosis -was made despite the fact that the patient consistently denied the use -of intoxicants. There was, in fact, no proof that she drank alcohol. The -case was, however, not clearly one of alcoholic hallucinosis or of any -other well-defined form of mental disease. A provisional diagnosis of -manic-depressive psychosis, manic phase, had, in fact, also been made. - -The illness had begun with depression and inactivity, Bridget’s friends -accounted for these conditions on the ground that a lover had departed -for Ireland. A few days after the depression began, Bridget became dizzy -and refused to give a boarder his breakfast, stating that she had lost -her memory and had begun to hear bells ringing and people talking. She -then became greatly excited and was brought to hospital, where the -prolonged baths quieted her. - -It seems that Bridget had had stomach trouble and headaches at the top -of her head or sometimes in her temples. =Physical examination= showed -the left pupil to be larger than the right, a slight tremor of the lips, -a slight systolic murmur at the apex, slightly irregular pulse, and -moderate edema of ankles. The blood serum was negative to the W. R., but -lumbar puncture was executed and the fluid showed a positive W. R. - -The patient was tested by the Binet and other methods, and although 35 -years of age, seemed to be by the mental tests hardly over 11 years old. -She was inclined to be feverish, somewhat restive, and pugnacious; -rather slow of speech, sometimes refusing to answer and grimacing. Her -pugnacity was, however, easily controllable, and the excitement was -largely at night. This excitement subsided rapidly in the course of a -few days. - - 1. What is the diagnosis in this case? The following diagnoses and - suggestions for diagnosis were made at the staff meetings: - - Unclassified mania. - Manic-depressive psychosis, manic phase. - Toxic delirium. - Dementia praecox. - Bacterial infection of the brain. - Unclassified delirium. - Acute delirium. - Infectious psychosis. - Acute confusional psychosis. - Psychopathic personality by use of alcohol. - Mental deficiency with atypical mental state. - Syphilitic paranoia. - - 2. Is this a case of syphilitic paranoia? The so-called syphilitic - paranoia of Kraepelin is a rare and uncertain type of syphilitic - mental disease. Delusions and hallucinations are prominent. As a - rule, the onset is stated to be slow and insidious, or at any rate - there are a variety of indefinite prodromata. Jealousy is a - prominent feature, sometimes attended with marked sexual - excitement. Auditory hallucinations and ideas of persecution are - particularly in evidence. The most striking feature in Kraepelin’s - group was a sudden occurrence and equally sudden disappearance of - violent excitement, with or without external cause. Thus, an - excitement would be produced by a few words spoken, and - immediately after, the phase of excitement would pass and the - patient would become entirely friendly and accessible once more, - as if nothing had happened. About half of Kraepelin’s cases showed - a positive serum W. R. He does not report lumbar puncture - findings, and grounds the existence of disease upon certain - autopsied cases. The speech and writing disorder of paresis as - well as the characteristic disorientation for time and muscular - weakness of general paresis were absent in the group. It appears - that most cases of the group have hitherto been placed in dementia - praecox. - - - =The clinical symptoms of CHRONIC ALCOHOLISM are sometimes largely - identical with those of PARETIC NEUROSYPHILIS (“general paresis”): - differentiation by means of the laboratory findings.= - -To demonstrate this proposition, the cases of Francis Murphy (60) and -David Collins (61) are in point, being sharp foils to one another. - - -=Case 60.= A laboring man about 44 years of age was brought to the -Psychopathic Hospital one summer day, in a stupor. This patient, Francis -Murphy, had been at his regular work as axeman in the Park Service, when -he suddenly fell in a heavy convulsion. He was carried to a general -hospital, still in convulsions, and ether was administered to quiet the -movements. The convulsions shortly ceased, but the patient’s -consciousness failed to clear; hence his transfer to the Psychopathic -Hospital. - -Here he remained much disturbed and was placed in a room with a mattress -on the floor. On this mattress he would crouch on all fours for a -considerable time, looking fixedly downward as if at an object on the -floor, unresponsive to questions but compliant with efforts to place him -on his back. He gave the impression of daze and either disorientation or -confusion. - -Within twenty-four hours the patient became more tranquil and -consciousness became clearer, but the patient was at a loss to bring to -memory either recent or remote events. However, he replied to questions, -giving some different story each time he was approached. Curiously -enough, the patient seemed very contented and good-natured and would -even laugh foolishly at times, saying that he felt fine and all ready to -go out to work. - -The general impression conveyed by Francis Murphy at once suggested the -possibility of neurosyphilis. Convulsions, perhaps initial in middle -age, with a post-convulsive stupor, followed by a partial clearing up, -with persistent amnesia and a suggestion of fabrications with euphoria, -bore out the suggestion. - -The =physical examination= strengthened the impression of neurosyphilis. -Well developed and nourished, florid, with a manual tremor and sweating -of the palms, the patient was in general without physical symptoms. -=Neurologically=, however, whereas the left pupil was larger than the -right and reacted properly to light, the right pupil was a bit -contracted, somewhat irregular, and either reacted not at all to light -or very slightly so (reacting perfectly to accommodation). The -knee-jerks could be obtained only with reinforcement, and several other -reflexes could not be elicited (triceps, radial, ulnar, periosteal, -Achilles, umbilical). Moreover, the heel-to-knee test was poorly -performed; some of the common tests phrases were very poorly repeated; -there was marked tremor in writing; and the paragraphia seemed to be not -merely peripheral, for syllables were left out in words and ordinary -words spelled incorrectly (psychographic disturbance). - -We do not care here to insist that the right pupil was really an example -of the Argyll-Robertson phenomenon since the slightest tinge of doubt is -important if a positive diagnosis is practically equivalent to asserting -syphilis. Practically, however, the right pupil was regarded as an -Argyll-Robertson pupil under hospital conditions (flash-light reaction). -Argyll-Robertson pupil, areflexia, speech disorder, writing disorder, -memory disorder, conduct disorder, and euphoria, all with a history of -convulsions, certainly warranted the tentative diagnosis of -neurosyphilis. - -As usual, resort was made to the W. R. in the serum and in the spinal -fluid. One of the first results to come through from the laboratory was -the absence of globulin, normal albumin, negative gold sol reaction, and -a cell count of two cells per cmm. in the spinal fluid. Later the _W. -R.’s_ were returned _negative_ for blood and spinal fluid. - -In the meantime, an illuminating change had occurred in the patient, for -two days later,—three days after the first convulsion in the park,—the -patient had apparently quite recovered; his consciousness became nearly -clear; he could remember every event up to the time of the convulsion, -and his memory came back in appropriate degree for both remote and -recent events. - -The patient, it appeared, had for some time been drinking more and more -heavily. In recent days, he had been taking five or six whiskeys and a -half dozen beers daily on the average, and often much more. About ten -years before, the patient narrated, there had been a convulsion at a -ballgame, and this convulsion the patient himself called a “rum fit.” - -Here, then, is a case of ALCOHOLIC PSEUDOPARESIS. Without the W. serum -test and without the spinal fluid examination, it is probable that the -diagnosis of general paresis might have clung to the patient for some -time on account of the apparent Argyll-Robertson pupil, which had to be -accepted as such on the flash-light data. In point of fact, in this case -the pupil later reacted more normally to light, and the speech and -writing disorders measurably cleared up. - - 1. Can alcohol produce the Argyll-Robertson pupil? The majority of - neurologists would today answer, Yes. - - 2. If in the case of Francis Murphy, the W. R. in the blood had - happened to be positive on account of a non-neural syphilitic - infection (spinal fluid negative), would the diagnosis _general - paresis_ be warranted? Probably the diagnosis _general paresis_ - would have been made. If the patient had been lost to observation, - he might well have been regarded as an atypical paretic with - prodromal convulsions. - - 3. Would positive globulin and excess albumin in the spinal fluid - alone or in association with a positive serum W. R. warrant the - diagnosis _general paresis_ or _neurosyphilis_? The chances are - that most neurologists would advocate proceeding to treatment in - any case of positive serum reaction, whether or not there was - globulin or excess albumin; but the positive globulin and excess - albumin would probably not warrant the diagnosis _general paresis_ - or _neurosyphilis_ in the absence of excess cells and the - characteristic gold sol reaction and W. R. in the fluid. - - 4. Is the case of Francis Murphy one of alcoholic epilepsy (as - suggested by Murphy’s own phrase, “rum fits”)? It must be - remembered that epileptics become alcoholic and that epileptic - convulsions increase or become more severe with alcoholism. On the - other hand, the literature indicates that alcoholism can produce - convulsions, as can many other factors. The literature also - indicates that there is a condition of epilepsy in which the - convulsive tendency sets in as a result of alcoholism in a patient - not previously disposed to epilepsy; it appears also that - sometimes, though very rarely, the epilepsy continues after - withdrawal of alcohol, and even after giving up the habit. Francis - Murphy appears to have had but two spells of convulsions, both of - them following heavy bouts with alcohol. There is so far, then, no - warrant for calling Francis Murphy’s case one of alcoholic - epilepsy. - - 5. Does the use of alcohol by a subject destroy the value of the - W.R.? It has been held by some that alcoholism interferes with the - accuracy of the W. R. This has not been our experience and for the - present we are of opinion that the results have the same value in - alcoholics as in non-alcoholics. The next case (Collins, 61) is - one in which a positive W. R. occurred in an alcoholic. When - dealing with paretic neurosyphilis it is especially true that the - W. R. is disturbed very rarely, if at all, by toxins or drugs, - except antisyphilitic drugs. - - - =Alcoholism may cloud the diagnosis of NEUROSYPHILIS. - Differentiation by laboratory tests.= - - -=Case 61.= David Collins was a steamfitter of about 43 years of age, -picked up at 6.45 a.m. in the midst of convulsions and talking -incoherently, in a state apparently of fairly clear consciousness. On -arrival at the hospital, the patient was able to tell how he had always -been a hard drinker, and how during the past week of unemployment he had -taken large quantities of poor whiskey,—perhaps an average of a pint a -day. Collins also told how he had had delirium tremens several times, -but he said the present spell was quite unlike delirium tremens. There -was no disorientation or impairment of memory, and the patient did not -in any wise suggest a mental case a few hours after admission. - -It appears, according to Collins, that he had obtained some work the -night before, and had quit work about 6.30, whereupon he stepped into a -barroom, took one drink of whiskey, left the barroom, walked down the -street, and suddenly lost track of the world, coming to consciousness in -a carriage with two policemen, but remaining, as he said, “dopy,” -inattentive, and confused. After a meal, however, the patient began to -feel better and soon felt quite all right. - -The =physical examination= was quite negative except that -=neurologically= there was lingual and manual tremor, a speech defect, -apparent only with test phrases, unsteadiness of handwriting, left -knee-jerk greater than right, a left-sided Babinski reflex, and a -difficulty in executing rapid successive movements (dysdiadochokinesis). -This degree of neurological disorder in our experience warrants lumbar -puncture as well as a serum test. The lumbar puncture shortly disclosed -a positive globulin and excess albumin, and the returns from the W. R.’s -were positive for both spinal fluid and blood serum. The data of the -gold sol reaction were not available on account of technical -difficulties. However, it appears that the diagnosis of neurosyphilis -could hardly be avoided in this case. - -David Collins differs from Francis Murphy, then, in showing a positive -blood and spinal fluid reaction for syphilis as well as a positive -globulin and excess albumin. As above remarked, it is probable that the -positive globulin and excess albumin would not warrant more than a -suspicion of neurosyphilis taken by themselves. - -Unfortunately, we were unable to persuade the patient to submit to -treatment, and from the patient’s point of view possibly his decision, -not to submit to treatment, was a good one since he has had no symptoms -of any sort for a period of 18 months since his episode. However, as -abundantly elsewhere demonstrated, we feel that the patient is wrong, -and that the physicians are right in urging treatment. - - 1. Is not the convulsive episode an alcoholic phenomenon in David - Collins entirely separate from the patient’s general and - neurosyphilis? Possibly; however, an outbreak of neurological - symptoms with spontaneous recovery is not only consistent with the - diagnosis of syphilis, but somewhat characteristic of - neurosyphilis. We suspect that another attack will occur in David - Collins.[12] We shall from time to time make use of the social - service to suggest his going under treatment, and shall employ his - record of contact with a public institution to drive in our - suggestion. Still it is clear that there are numerous cases in the - community that are not accessible to social service initiated from - a public institution. Accordingly, educational propaganda is - necessary for salvage of the middle- and upper-class victims of - syphilis. It is a little unfortunate that the ethics of the - private practitioner make such salvage of middle- and upper-class - persons not very likely. Might it not be that an extension of - state medicine to this field would incidentally increase the - amount of successful private practice? - - 2. What may be the cause of such a convulsive episode as that of - David Collins? It would appear that the convulsions of general - paresis and of neurosyphilis in general often occur without gross - structural lesions of the brain. It may be suggested that vascular - irritation or parenchymal irritation by spirochetes, acting in - appropriate parts of the central nervous system, can produce such - convulsions. - - 3. What is the significance of the unilateral phenomenon in David - Collins (left knee-jerk greater than right; left-sided Babinski)? - The current explanation of hyperreflexia is that somehow - inhibitory impulses from upper portions of the nervous system have - ceased to influence the local arcs that mechanize reactions like - the knee-jerk and the normal plantar reflex. The phenomena are - commonly found in cases with pyramidal tract disorder, and in the - case of David Collins one may suspect, therefore, that there was a - central disorder affecting the right pyramidal tract above its - decussation. One might suspect that the convulsions were initiated - by a lesion (whether gross or microscopic in range) in the right - side of the cerebrum; but whether in the white matter or in the - gray matter must be left doubtful. The clearing up of all symptoms - suggests either that the lesion was microscopic in range or that - the phenomena were transient and functional. - - 4. Can the dysdiadochokinesis be used to indicate cerebellar lesion - in David Collins? Possibly; but it does not appear that the - difficulty in executing successive movements was unilateral. It - seems impossible to bring into close topographical relation the - basis for the Babinski and left-sided hyperreflexia, and the basis - for the dysdiadochokinesis. Alcohol is sometimes asserted to exert - an especial effect upon the cerebellum. - - 5. Must we suppose structural lesions, either (a) of the nature of - cell losses demonstrable microscopically, or (b) of the nature of - secondary degenerations demonstrable by Weigert myelin sheath - methods, in the case of David Collins? It appears that we do not - need to assert the existence of such lesions. - - 6. Could the hyperreflexia and the Babinski reaction be due to local - spinal cord disease? Possibly; but the existence of other - neurological symptoms (lingual and manual tremor, speech defect to - test phrases, ataxic handwriting, and dysdiadochokinesis) makes it - probable that there were lesions, or at any rate disordered - functions, within the cranium; and there appears to be no basis - for asserting local spinal cord disease. - - - =Differential diagnosis between NEUROSYPHILIS and ACUTE ALCOHOLIC - PSYCHOSIS.= - - -=Case 62.= Joseph Buck was a chef of 60 years who came in, seeking -advice because his memory was getting poor; he was unable to remember -names and what he was about to do. He was tremulous and had much pain in -his limbs. He had been drinking heavily for weeks,—probably ten weeks; -in fact, he described himself as having had “the shakes” and as having -lately seen animals and people that were unreal. He had had the shakes -before and the condition had lasted for two to three days after alcohol -was discontinued. - -=Physically=, Buck was tall, well developed, although poorly nourished, -with a skin suggesting alcoholism. There was a slight acne over the back -and chest; there was a slight enlargement of the heart, with blood -pressure, systolic, 180, diastolic, 120. There was a corneal opacity of -the left eye, which the patient said was the result of syphilis -following a chancre, which he had acquired at the age of 27. There was -also a ptosis of the upper lid of the left eye. The right pupil was -irregular and reacted to light sluggishly, and with a very small -excursion. The patient was slightly deaf in both ears. The deep reflexes -were all lively and equal. The tremor was most marked in finely -coördinated movements. There was a slight swaying in the Romberg -position but the sign could not be said to be present. The gait was -unsteady. There was a marked tenderness over the nerve trunks. - -So far as =mental examination= went, it seemed that the patient’s claim -of amnesia was subjective. There was certainly no more amnesia than a -slight difficulty in recalling details. The diagnosis of alcoholism with -convalescence from delirium tremens would certainly seem to have been -sufficient for the phenomena, and the suggestion of alcoholic neuritis -only confirmed the picture. To be sure, one might expect a diminution or -absence of deep reflexes; still, these reflexes may be overactive in an -irritative stage of the disease. - -Naturally, however, the history of syphilis and the pupillary phenomena -and ptosis, made the consideration of neurosyphilis necessary. Both -serum and fluid W. R.’s proved positive; there was an excessive amount -of albumin and globulin, the gold sol reaction was typically “paretic,” -and there were 377 cells per cmm. - -The patient improved upon a rest treatment and was given injections of -mercury for his syphilis. After a few months he felt well enough to -return to work, and continued at work throughout a season, receiving -mercurial treatment throughout this time. A spinal fluid examination -fifteen months later showed a weaker gold sol reaction, reduction in the -amount of globulin and albumin, and but 26 cells to the cmm. The W. R.’s -had remained positive. - - 1. What are the forms of syphilitic neuritis? According to Nonne, - syphilitic neuritis and polyneuritis have at last acquired - standing in neuropathology. The older claims depended upon - findings on palpation and recovery after antisyphilitic treatment. - Since the introduction of salvarsan, cases of ophthalmoplegia, - facial, acoustic, and optic nerve disease, as well as neuritis of - the extremities, have been reported in large numbers. These - phenomena are to be regarded as neurorecidives in the modern sense - of that term. The neurorecidive is not a salvarsan effect, but is - an effect of the syphilitic process itself, settling in the - peripheral nerves. Paresthesias are especially prominent in - peripheral mono- or polyneuritis, and this point is of some value - in differentiating the syphilitic peripheral neuritis from root - neuritis. Root neuritis is more often characterized by neuralgic - attacks. Objective hyperæsthesia of neuromuscular origin is also - found in these cases, demonstrated by pressure on the nerves. The - motor phenomena consist in a flaccid paresis or paralysis, - especially affecting the radial, ulnar, and peroneal nerves. Nonne - states that it is rare for syphilis to affect a single nerve - region, and he regards cases in which a single region alone is - affected as usually due to a local gummatous process. - - 2. What is the significance of 377 cells per cmm.? See discussion of - Washington (Case 66). - - - =Differential diagnosis between NEUROSYPHILIS and CHRONIC - ALCOHOLISM.= - - -=Case 63.= Albert Fielding, 46, was an insurance broker, who was brought -to the hospital for excessive alcoholism. Indeed, he showed all the -signs, both of chronic and acute intoxication, except that there was no -nerve trunk tenderness. Fielding was very loquacious though his speech -was rather thick. He showed tremor of hands and an alcoholic skin. -Physical and neurological examination proved entirely negative. - -Fielding claimed that he had had a nervous breakdown at about 36 years -of age, after disappointment in love. He had the drinking habit and -began to drink more and more. He had now become nervous and tremulous -and had to drink in order to brace himself. After a few days, the -patient began to be much better, having recovered from acute alcoholism. -=Mental examination= now showed good memory with orientation intact. -There was a certain tendency to reminiscence and to somewhat childish -actions. He had attempted to stop drinking but had been unable to quit. -As a matter of fact, his mother and father had been excessive drinkers -and he had inherited the tendency, etc. - -The =diagnosis= seemed to be plain. The routine W. R. upon the blood -serum was negative. However, the patient had remarked during the history -taking, that he had had a chancre and secondary symptoms of syphilis. -Accordingly, lumbar puncture was resorted to. The fluid showed a -slightly positive W. R.; the gold sol reaction was of the syphilitic -type; there was a considerable increase in albumin and globulin, and -there were 20 cells per cmm. The diagnosis of neurosyphilis seemed -clear. - -=Course=: The patient received six months’ treatment in a sanatorium but -the symptoms remained almost as before, and the patient showed the same -childishness and inability to take care of himself. Since the symptoms -continued six months after the withdrawal of alcohol, it might well be -suspected that the condition was more than a merely alcoholic one. -However, in a number of purely alcoholic cases, such long-standing -effects are found: even as long as six months or longer after the -withdrawal of the alcohol, and one might conclude therefore that -Fielding was actually a victim of alcoholic dementia. The spinal fluid -after these six months (during which period antisyphilitic treatment was -given) showed no change, and the prognosis was offered that the case -would probably develop into one of paresis. - -A year later, after six months sanatorial care and six months life in -the community, the patient returned to the Psychopathic Hospital in an -alcoholic condition. The lumbar puncture showed all signs negative -except the W. R. which was slightly positive. The W. R. of the blood was -negative. - -In connection with this case, see the case of _paresis sine paresi_ -(25). - - 1. What is the relation of the syphilitic and alcoholic process in - Robert Fielding? One does not like to break the so-called rule of - parsimony in diagnosis, but it would seem that the effects in - Fielding are the combined effects of syphilis and alcoholism. - - - =Differential diagnosis between NEUROSYPHILIS, DIABETIC - PSEUDOPARESIS and BRAIN TUMOR.= - - -=Case 64.= A large and imposing person, Calvin Hall, 55, had been -employed as a doorkeeper and guard, in which position he was on duty for -12 to 14 hours daily. Eventually, however, he had begun to have a good -deal of pain in the legs and a few months before observation, one day, -his legs gave way and he fell to the floor. There was, however, no loss -of consciousness, and he was carried to a general hospital. The result -of an examination there was that his family was informed that he had -some nervous trouble. - -Hall now began to be melancholy and wept a good deal. His appetite and -sleep remained intact. He felt too weak to walk. At the end of about a -year, he began to improve and again became able to do a little light -work. About a month before coming to the Psychopathic Hospital, about -two years after the onset of symptoms, Hall suddenly began to talk -excessively, in a rambling and rather senseless way. A fortnight later, -he began to suffer from insomnia and restlessness. - -Some medical facts were available: It seems that at 25 years this -patient had become infected with syphilis though there had never been -any secondary signs. He was married four years later but there had not -been any children. Moreover, for four years past, the patient had been -treated for glycosuria. - -Upon admission, the patient’s sensorium was clear, but his orientation -was only partial. He could give a fair account of his life, but it -appeared that his memory was somewhat impaired. There were auditory -hallucinations (voices of relatives). He often mistook the identity of -persons about him. He talked in a grandiose fashion of his great -strength and especially of a God-given power to read minds. His flow of -thought was rapid, rambling, circumstantial, and with traces of -irrelevance. He was rather continuously busy and at times restive. There -was a good deal of emotional agitation and apprehensiveness, and again -the patient would become suspicious and tearful. - -=Physically=, there was a discharging sinus connected with the right -humerus, close to the elbow. The pupils, though equal and regular, were -sluggish in reaction to light. The knee-jerks and ankle-jerks were -absent. There was no Romberg sign but there was some swaying in the -Romberg position. There was a moderate ataxia in walking. Glycosuria to -a moderate degree was determined. There were no casts or albumin in the -urine. The W. R. of the blood and of the spinal fluid was negative. The -albumin of the fluid, however, was considerably increased. X-ray -examination of the skull yielded a suggestion of absorption of the -posterior clinoid processes of the sella turcica. The X-ray examination -of the arm in the region of the sinus showed a chronic osteomyelitis, -possibly syphilitic (or diabetic?). - -The diagnostic problems in the case of Calvin Hall are extremely -intricate. There are clinical suggestions of general paresis, not -confirmed by the laboratory findings. - - 1. Are we dealing with a case of diabetic pseudoparesis? Is the pain - in the legs of like origin, and has a neuritic process led to the - absence of the knee-jerks? The Allen treatment appears to have had - no beneficial result in this case. - - 2. Is there a tumor of the sella region, which could account for the - mental symptoms and the glycosuria? The spinal fluid albumin might - be regarded as consistent with a variety of psychoses, including - that of brain tumor. We have to remember the definite history of - infection, the sterile marriage and the possibly syphilitic - osteomyelitis. - - - =DIABETES AND NEUROSYPHILIS, relations?= - - -=Case 65.= Donald Barrie, a man of 61, diabetic for several years, had -begun to worry about the diabetes, feeling that he was about to die, and -had gone so far as to make several threats of suicide. Hence he was -brought to the Psychopathic Hospital for observation. - -Barrie was rather well developed and nourished, although he looked far -older than he was. There was a marked arcus senilis; the skin was dry -and rough; the radial and other accessible vessels were markedly -sclerosed; abdomen obese; right testicle very low with thickened and -hard epididymis. - -=Neurologically= there was little abnormal to discover. The pupils were -irregular; both reacted fairly well to light. There was a slight tremor -of the extended hands, and still less of the tongue. The voice was -slightly thick and the patient stumbled somewhat on test phrases. Urine: -specific gravity, 1029; sugar; no acetone; no diacetic acid. Sugar 2 to -11 grams for 24 hours on ordinary diet. It proved impossible to get the -patient sugar-free, either by cutting down the carbohydrates or by using -the Allen method. - -=Mentally=, the depression with reiteration of wrong-doing and -self-accusation because of the contraction of syphilis, were the -striking features. There was, to be sure, a slight imperfection of -memory for remote events; memory for recent events and knowledge of -current events was very poor. Barrie claimed that his condition was -entirely hopeless, that his memory was exceedingly bad, and that he was -no longer capable of supporting his family. - - 1. What shall be said as to diagnosis in a man of 61 with - glycosuria, depression, amnesia, sluggish pupil, slight tremor, - slight speech defect, and a history of syphilis? The W. R. of the - serum proved positive, and also the W. R. of the spinal fluid. The - gold sol reaction of the fluid was of the syphilitic type. There - were 112 cells per cmm., there was an excess of albumin, and a - large amount of globulin. Accordingly, the diagnosis of PARETIC - NEUROSYPHILIS (“general paresis”), especially in view of the - laboratory findings, seems necessary. - - 2. What is the cause of the glycosuria? First: possibly it has no - relation with the syphilis; secondly: it may possibly be due to a - syphilitic involvement of the pancreas; thirdly: it is barely - possible that it is due to syphilitic disease of the fourth - ventricle or of the base of the brain, involving the pituitary - region. Perhaps our case is too complex for analysis. At all - events, the case brings up the possibility of a syphilitic - glycosuria. - - 3. Can the diabetes in the case of Barrie be explained as - syphilitic? Warthin of Ann Arbor has recently described somewhat - remarkable spirochete findings in his autopsy material. The order - of organic infection according to frequency is: aorta, heart, - testis, adrenal, pancreas, nervous system, liver, and spleen. - Warthin has called attention to the relation of pancreatitis and - spirochetosis to diabetes in a recent review[13] of findings in 41 - autopsied cases from the University Hospital in Michigan. Warthin - found active luetic lesions in the pancreas in 6 cases. - - - =Hemianopsia in a case of neurosyphilis.= - - -=Case 66.= Lawrence Washington, a colored cabman, 58 years of age, began -to forget addresses given him by his fares. Moreover, he could no longer -see as well as before, especially on looking toward the right side. He -himself states that the visual trouble dated back as long ago as his -39th year, at which time he had a terrific pain in both temples, leading -back from the eyes. Washington thought that his vision had been getting -slowly but steadily worse ever since. - -We got the impression that the amnesia claimed by Washington was more or -less subjective and he was found to be well informed. This association -of amnesia and impairment of vision naturally suggests syphilis. The -patient himself stated that he had had a chancre at the age of 18. - -We found the W. R. of the serum to be appropriately positive. The W. R. -of the spinal fluid was also positive though weakly so. There was an -excess of albumin; globulin appeared in large amount; the gold sol -reaction was of the syphilitic type; there were 186 cells in the spinal -fluid. - -Is this case one of paresis or of some other form of cerebrospinal -syphilis? Let us consider the data of the =physical examination=. On the -whole, the patient was well preserved. There was a slight radial -arteriosclerosis, but on the whole the cardiovascular system was almost -negative. The blood pressure was 100 systolic, 65 diastolic. -=Neurologically= the visual field of the left eye was somewhat limited, -and there was a temporal hemianopsia of the right eye. The -ophthalmoscopic examination showed a disseminated choroiditis on both -sides. The right pupil failed to react to light. The left pupil reacted -slowly. Both pupils reacted properly to accommodation. - -The knee-jerks could be obtained only on reinforcement, and when -obtained, the right was apparently more active than the left. The left -Achilles was absent; the right present. There were no other abnormal -reflexes. - -The motility of the facial muscles was somewhat impaired. -Finger-to-finger and finger-to-nose tests were rather poorly done. The -muscle sense was good; there was no swaying in Romberg position; and -there was no speech defect. - -We are unable to decide whether the case is one of the =parenchymatous= -type (paretic) or of the =meningovascular= type of =neurosyphilis=. It -is certainly rather unusual to find hemianopsia in a paretic. - -We have been unable to get definite results from the treatment of this -case, since the patient would not return for months after getting an -injection or two of salvarsan, on the ground that he was improved enough -and did not require further treatment. - - 1. What conclusion can be drawn from the 186 cells per cmm. in the - spinal fluid? Ordinarily this finding would indicate an active - process. Some writers have claimed that a cell count running above - 100 per cmm. was an indicator of diffuse non-paretic - neurosyphilis. It does not appear that this claim has been - substantiated. It is remarkable that this case shows an interval - of 40 years between infection and the occurrence of definite - clinical symptoms. With respect to the cell count, both in - untreated and in treated cases, the following conclusions from a - recent article (Solomon and Koefod)[14] are in point: - - 1. The number of cells found in the fluid of untreated cases - offers no definite information of prognostic value. - - 2. One is not justified in drawing any conclusions as to whether - the case is cerebrospinal syphilis or general paresis, nor the - time the process has been active, nor the severity of it, from the - cell count. - - 3. The cell count may vary greatly from month to month, or when - the interval is but several days, while at other times it may - remain very nearly the same after an interval of months. - - 4. Cases showing natural remissions may show no reduction in the - cell count, or other spinal fluid findings. - - 5. Cases treated with salvarsan, either intraspinously or - intravenously, tend to show a more or less rapid fall in the cell - count. This count will, as a rule, remain low during treatment, - but is likely to rise when treatment has been discontinued, but - may rise during treatment after having first fallen. - - 6. Cases may show remissions during treatment and still have a - pleocytosis. - - 7. Treated cases having the cell count fall to normal may at the - same time become very much worse and develop more marked paralytic - symptoms. - - 8. In general paresis the cell count in no way parallels the other - spinal fluid findings. - - 9. In cases in which the other tests show an improvement, for - instance cerebrospinal syphilis, the cell count also readily and - early drops to normal. At times it may drop to normal before other - spinal fluid tests become negative; again it may be last to reach - normal. - - 10. The change in cell count seen in syphilitic disease untreated - is also found in non-syphilitic diseases, as brain tumor. - - 11. The cell count offers nothing of prognostic importance in - syphilis of the nervous system unless accompanied by improvement - of the other laboratory signs. - - 12. The cell count is not an index to the predominance of - irritative or degenerative changes. - - - =Case of CEREBRAL MALARIA and SYPHILIS: simulation of PARETIC - NEUROSYPHILIS (“general paresis”).= - - -=Case 67.= Joseph Temple, 45, who had been a sea-going steamboat -steward, was brought to the hospital in a semi-stupor. He was entirely -uncoöperative, often resistive, attempting to bite the physician’s -fingers, and for the most part lying curled up. He was incontinent and -tube-fed. This phase, it seems, had begun the night before entrance to -the hospital. Twenty-four hours later, an extraordinary change was -noted. Temple became alert and attended to his wants, began to eat well, -and began to behave as normally as probably he ever behaved. - -He was now able to give a coherent history. It was now January. In the -previous September, he had left for Mexico; he was returning when he -suddenly fell to the deck, unconscious. After this fall, he had not been -well, having had chills and fever. At the Marine Hospital, he had been -diagnosed as suffering from malaria, and was given quinine. He had been -delirious a short time in the hospital, not being able to recognize his -wife, who called. He shortly improved so that his wife was able to take -him home. Nevertheless, headache, gastric distress, and intermittent -vomiting continued. A spell of confusion took place, two days before -admission. The patient tossed about, moaned, and failed to recognize -anyone. Malaria of the æstivo-autumnal type was demonstrated in the -hospital. The temperature always remained at normal. He was somewhat -emaciated and pale. The pupils were small, somewhat unequal, and reacted -though poorly to light and distance. The tendon reflexes were lively. - -The W. R. of the serum was positive, and information from the patient’s -physician runs to the effect that there was a syphilitic infection some -seven or eight years ago, followed by secondary symptoms, but the -patient had refused to take any protracted treatment. The spinal fluid -examination was practically negative. - -=Mentally=, the patient was euphoric, expansive, boastful, and showed a -marked emotional instability and considerable memory defect. - - 1. Can the diagnosis of general paresis be made in Joseph Temple? - Certainly the acute confusion and the syncope are consistent - enough with the diagnosis, yet the severe malaria makes it seem - likely that the phenomena were due to a cerebral attack of - malaria, and such occurrences are found in the æstivo-autumnal - form of malaria. Yet malaria would hardly explain the euphoria, - memory defect, and the pupillary findings, to say nothing of the - irritability and the active tendon reflexes. Even if we regard the - active tendon reflexes and the irritability as malarial, the other - phenomena remain outstanding as exceedingly suspicious of paresis. - - On the other hand, if we try to support forcibly the diagnosis of - general paresis, we are hardly able to explain the negative - findings in the spinal fluid. - - In point of fact, a study of the patient’s past life revealed a - story that the mental traits of euphoria, irritability, and memory - defect had been characteristic of the patient for many years. In - fact, there is some question whether the patient is not really to - be regarded as a moron of high grade. - - Upon this basis, if we regard the confusional phenomena as - malarial and the persistent mental phenomena as characteristic of - a moron and somewhat exaggerated by the disease, we have merely to - explain the suggestive pupils. As to these, it must be remembered - that though they reacted poorly to light, still they reacted - somewhat, so it is not a question of explaining an - Argyll-Robertson pupil, but only an impaired pupillary reaction. - Of course, some workers are of the opinion that pupillary changes, - perhaps even the Argyll-Robertson pupils, may occur in syphilitic - cases that are not neurosyphilitic, or at all events are not - victims of central neurosyphilis. Finally, we must remember that - there are cases of neurosyphilis of a vascular type which yield - negative spinal fluids. The case leaves many questions unanswered. - - - =Can paretic and non-paretic neurosyphilis be differentiated by - means of the gold sol reaction? The gold sol reaction in this case - was an extremely mild one and would not at all have warranted the - diagnosis GENERAL PARESIS, yet the discovery of a heavy meningeal - exudate including an unusually heavy deposit of plasma cells even in - the spinal pia mater will perhaps warrant us in making a final - retrospective diagnosis of paretic neurosyphilis. Autopsy.= - - -=Case 68.= We would like to give the full effect of our surprise at the -outcome of the case of Margaret O’Brien, a school-teacher, 26 years of -age. To be sure, Miss O’Brien developed symptoms at 22 or 23 which we -can now explain consistently with the outcome of the case; for at that -time, she began to complain of severe pain in the head, especially in -the forehead and temples, and also became nervous, unable to remain -quiet, and given to insomnia. She was markedly depressed at the time and -would refuse to talk at times. However, only the headache in this -prodromal period could be regarded as particularly suggestive of -syphilis, and headache in an over-worked school-teacher is not uncommon. - -In fact, the picture presented by the patient was one of catatonic -dementia praecox. The patient was admitted to the hospital after a -sudden onset of excitement. At first she was very restless, continually -looking about and getting up and walking away from the examiner, giving -the impression of understanding all questions but preserving an air of -indifference. A few days later, the patient was gotten to answer more -coöperatively. She remarked that the hospital was heaven although in -Boston; that it was summer time (correct) and that her memory was -greatly impaired. The physician was a messenger of God (delusion later -corrected). The patient had not done God’s will; her breath was leaving -her; God’s voice was heard from time to time, and Miss O’Brien had heard -it for a long time. God tells her to do His will. However, as Miss -O’Brien remarked, “I must think all this nonsense, turning against God.” - -The patient frequently attitudinized and would remain in an apparently -catatonic condition for many minutes. For the most part, she was -resistive and mute and non-coöperative as to examination. From time to -time, she made impulsive suicidal attempts. So far as a somewhat -inadequate =physical examination= was concerned, nothing abnormal could -be made out; in particular, the pupils reacted normally to light and -were otherwise normal. The routine W. R. of the blood serum, however, -returned positive, and in accordance with the policy of the Psychopathic -Hospital, the patient was subjected to a lumbar puncture. The lumbar -puncture yielded a positive W. R., 109 cells per cmm., a positive -globulin and a considerable excess of albumin, and an exceedingly mild -gold reaction—syphilitic type. - -Ten days after admission, the patient had a convulsion. She never -regained consciousness, continued to have convulsions for a few hours, -and died, apparently from paralysis of respiration. The heart continued -to beat for a short period after respiration ceased. The =autopsy= was -consistent with the diagnosis which had been rendered after the -surprising results of the W. R. in the blood and the laboratory findings -in the spinal fluid had been learned. There was a generalized -encephalitis with congestion of all the smaller cerebral vessels and -petechial areas in the meninges and upon the cortical surfaces. We -regard the case as one of syphilitic encephalitis. - -The brain weighed 1265 grams, indicating a loss of 79 grams by Tigges’ -formula (8 times the body length in centimetres). The pia mater was, in -the gross, quite normal within the cranium; nor were any cells found in -a smear from this pia mater; but the pia mater over the spinal cord was -visibly edematous, and a smear from the spinal pia mater showed great -numbers of lymphocytes and especially of plasma cells—a finding which -was confirmed in stained section, by which a remarkable display of -plasma cells was found plastered somewhat generally over the entire pia -mater of certain segments. The brain substance was softer than normal, -but displayed no differences of consistence. The stripping of the pia -mater of the temporal lobes on both sides yielded the so-called -“decortication” (that is, the adhesion of small bits of brain substance -to the pia mater). The optic nerves were somewhat thinner than normal. -No other gross lesions of the brain were found. - -The dura mater, although dense and injected, was not otherwise abnormal. -There was an early visible sclerosis of the middle meningeal arteries, -more marked on the left side. - -The cause of death, so far as the autopsy revealed it, was bronchial -pneumonia. There was a diffuse nephritis. - - 1. Are the hallucinations in the case of O’Brien characteristic? - Hallucinations are regarded as playing a minor rôle in general - paresis. In fact, earlier workers sometimes denied that - hallucinations occurred at all, and this denial has been made once - more of late by Plaut,[15] but Kraepelin quotes Obersteiner as - observing hallucinations in 10%, and regards that figure as - approximately corresponding with his own experience. Junius and - Arndt are cited as finding 17% of their cases hallucinated. - Auditory hallucinations are somewhat more frequent than those of - vision (alcoholic psychosis must be considered). The visual - hallucinations of paresis are thought by Kraepelin to be related - with atrophy of the optic nerves, and he states that they occur by - preference in patients having such atrophy. Hallucinations though - not common are more frequent in non-paretic neurosyphilis than in - paretic neurosyphilis. - - 2. What was the cause of death in Margaret O’Brien? The autopsy, as - above stated, indicated pneumonia. In point of fact, this patient - developed convulsions and ceased respiration, the heart continuing - to beat for some time after respiration had ceased. It may be that - the death should be counted as one of neurosyphilitic seizure. - - - =Tonsillar abscess associated with neurosyphilis (Lues Maligna?).= - - -=Case 69.= Frank Mason, 49 years, a rectifier of spirits, was admitted -to the Psychopathic Hospital in a tremulous, mentally confused, -depressed, and unhappy state. He was particularly concerned because he -could not give an accurate account of his past life and because he found -that he was continually contradicting himself. - -Superficial examination shortly discovered the pupils to be much -contracted, irregular, and non-reactive either to light or distance. -Although these pupils showed more than the Argyll-Robertson phenomenon, -yet the suspicion of syphilis was important. - -Throat examination showed a large area of ulceration involving the whole -of the right tonsil and extending even to the left side of the median -line so that the whole of the faucial pillar was involved. In the midst -of this ulcerative area was a mass of purulent necrotic tissue, about -which the edges of the ulcer stood out sharply. There was, however, very -little acute reaction about the margin of the area. - -The association of pupillary changes (especially stiffness to light), -what looked like tonsillar gumma, and mental disorder (including memory -disturbance) heightened the impression of syphilis. - -However, the remainder of the examination was not especially -confirmatory of the diagnosis. The man was well developed and obese, -with a slightly enlarged heart, with sounds of poor quality and the -aortic second sound accentuated. The systolic blood pressure was 130; -the diastolic, 90. There was no disorder of reflexes except that the arm -reflexes were very lively. - -After a time, a few facts concerning the patient’s life became -available. Although a rectifier of spirits, Mason could not be found to -have over-indulged in alcohol. It appears that some five months before -his admission to the hospital, a wisdom tooth had been extracted. About -four months before admission, the ulceration of the faucial pillar had -begun, and this ulceration was immediately laid to infection from the -wisdom tooth cavity. Mason then had to discontinue work and a depression -followed. But the account of this depression led us to think that he was -a victim more of natural sadness than psychopathic depression. There was -much worry and insomnia. To meet the insomnia, large amounts of -hypnotics were administered. The sequence of these hypnotics was a -tremendous disturbance and continual crying out by the patient. In fact, -Mason became so excited that he was removed to the Psychopathic Hospital -for temporary care in the condition above mentioned. - -We naturally awaited the outcome of the serum W. R. The return was -negative. However, the typical position of the ulcerative lesion and the -non-reacting pupils,—to say nothing of the mental symptoms and the -associated tremors, with incoördination (this incoördination was -non-characteristic and apparently due largely to the tremor),—led to -lumbar puncture. - -The spinal fluid yielded a weakly positive W. R. There was a slight -positive albumin, the globulin test was slightly positive, there were 14 -cells per cmm., and the gold sol reaction was of the syphilitic type. We -were, then, probably entitled to conclude that syphilis was active not -only in the body at large but also in the nervous system. Looking back -upon the case, we considered that large doses of morphine and hyoscyamus -might well have produced the marked mental confusion and possibly the -tremors that characterized Mason on his arrival at the hospital. - -Improvement followed after a few days of rest; the confusion disappeared -and the tremors diminished; the pupils returned to their normal size and -reaction; depression persisted, and the patient was very properly much -concerned about the tonsillar lesion. However, further improvement did -not take place under antisyphilitic treatment and patient died after -several weeks from what was believed to be an embolus from the tonsil. - - 1. What was the true interpretation of Frank Mason’s pupillary - changes? They were probably due to the opiates, despite the fact - that, taken in association with the gummatous lesion of the - faucial pillar, we had regarded them as possibly syphilitic. - - 2. How shall the negative serum W. R. be explained? Such a reaction - is consistent with the diagnosis _gumma_. It is, however, a little - surprising that with active neurosyphilis and a relatively active - non-nervous syphilitic lesion like that in this case, the serum W. - R. should have been negative. Possibly a repetition of the test at - various times would have shown a positive serum W. R. In any - event, the fluid reaction was positive. - - 3. Could the tonsillar ulceration be due to dental infection? The - chances are against this on account of the interval (2 months) - between extraction of the wisdom tooth and the ulceration, which - itself seems to be of a tertiary syphilitic nature. In point of - fact, the patient admitted a syphilitic infection 21 years - previously namely, at 28 years of age. At that time he took large - quantities of mercury and potassium iodid by mouth. - - 4. Relation of the case of Frank Mason to the so-called _lues - maligna_? The case closely resembled the cases reported by Bly. - Frank Mason showed great destruction of tissue, toxemia, failure - to react to antisyphilitic treatment. In both of Bly’s cases, the - tonsil was the starting point of the illness; and in both cases - there was a trauma of the tonsil or peri-tonsillar structures - (tonsillectomy and application of caustic). In our case there not - only had been extraction of a wisdom tooth, but the tonsil had - been cauterized. - - - =Neurosyphilis versus multiple sclerosis.= - - -=Case 70.= Annie Kelly is a young Irish woman, 21 years of age, who was -perfectly well until three months before her admission to the -Psychopathic Hospital, when suddenly one evening she became very dizzy. -This was followed by a chill and vomiting. The next day she had a sore -throat but was able to be about and do her work. The dizziness, however, -continued and she began to feel rather queer. Gradually it became -difficult for her to walk on account of staggering. - -A little later she noticed a weakness of the left side, involving face, -arm, and leg; then she began to find it difficult to talk. Finally the -right leg became weak, making walking practically impossible. All these -symptoms grew worse and the dizziness increased. At times her vision -would be blurred; there were somewhat frequent attacks of diplopia. -Finally she had to take to her bed, and at last she lost control of her -sphincters. - -At no time did she suffer any pain. She was taken to a hospital, and -after a time improved somewhat; but she was told she had a brain tumor -and had better be in a large city, where she could have surgical aid if -this became necessary; consequently, she was brought from Montana to -Boston. - -On admission to the hospital, the examination disclosed no important -symptoms outside of the nervous and locomotor systems. She was unable to -walk unless assisted. The pupils were large but reacted well to both -light and accommodation, were equal in size, and regular. Slight -nystagmus was present; there was no ptosis or strabismus; vision in the -left eye was poor. The other cranial nerves showed no involvement. The -tendon reflexes were all present and very lively; Babinski, Gordon, and -Oppenheim signs were present on either side. The ataxia was marked, -especially of the lower arms, and she had some difficulty in the -alignment of the fingers. The sense of position of the limbs was very -poor. There was some tremor, which was not of the intention type. The -writing showed some incoördination. The speech showed nothing abnormal. -=Mental examination= disclosed nothing of note objectively, but patient -stated she could not think so clearly as she could formerly. - -The =diagnosis= would seem to lie between brain tumor,—which had been -suggested to the patient by her physician,—multiple sclerosis, and -neurosyphilis. The numerous neurological symptoms without any definite -evidence of intracranial pressure were sufficient to rule out for the -moment the consideration of brain tumor. The syndrome of multiple -sclerosis is not complete, but the race, age, and onset, with the -increasing and decreasing intensity of symptoms are very suggestive of -this diagnosis. The symptoms, of course, are all consistent with -neurosyphilis also, and while the patient denied any knowledge of -syphilitic involvement, the examination of the blood and spinal fluid -was made. The W. R. was negative in both the blood serum and spinal -fluid. Further examination of the spinal fluid showed presence of -globulin and an increase in the albumin content, 43 cells per cmm. and a -“paretic” type of gold sol reaction. With the negative W. R. of both -blood serum and spinal fluid, and with so much in favor of MULTIPLE -SCLEROSIS, this diagnosis was made. - - 1. What is the relation of multiple sclerosis to syphilis? There is - no definite relationship between multiple sclerosis and - syphilis,—that is, multiple sclerosis is not a syphilitic disease; - but the complete syndrome of multiple sclerosis is often given by - a syphilitic involvement of the central nervous system (see case - Lauder, 71). - - 2. Is the spinal fluid finding in this case consistent with multiple - sclerosis? According to Nonne, about 19% of the cases of multiple - sclerosis show globulin and pleocytosis in the spinal fluid. As a - rule, the number of cells ranges between 10 and 20 per cmm. and - the globulin is not present in large amounts. In this case, the - amount of globulin, which was given as 2+, is only a moderate - amount,—less than is usually found in cases of general paresis. - There are not very many cases of multiple sclerosis in the - literature in which a gold sol reaction has been performed, but in - the majority of those tested, the reaction is reported as mild. - However, cases of multiple sclerosis giving a typical paretic - curve have been described by a number of observers, among whom may - be mentioned Kaplan and Solomon. - - 3. How frequently is it necessary to make a differential diagnosis - between multiple sclerosis and neurosyphilis? Before the days of - the W. R. this differentiation was much more difficult than at - present. But we, however, still have to face a not very rare - difficulty in separating the two conditions. Syphilis is prone to - cause small localized lesions in the nervous system. The changes - in the patient’s condition, with improvements and regressions are - equally characteristic of both diseases. How closely the - symptomatology of neurosyphilis may simulate that of typical - multiple sclerosis is shown in the next case (Lauder, 71). When - the sclerotic area of multiple sclerosis occurs in appropriate - parts of the cerebrum, symptoms of mental disturbances will occur. - In its histological picture multiple sclerosis is at times highly - suggestive of syphilis, even showing mononucleosis and meningitis. - - - =Optic atrophy; nystagmus; spasticity; intention tremor. Diagnosis: - ?= - - -=Case 71.= James Lauder began to lose his eyesight at 32 years, and was -shortly determined to be suffering from primary optic atrophy. In the -course of a year, he had become completely blind. No mental symptoms had -developed. - -=Physically=, Lauder was in very good condition. =Neurologically=, there -was a complete optic atrophy with paralysis of the internal rectus -muscle, marked nystagmus, and absent pupillary reactions. All the tendon -reflexes were exceedingly lively, though the right arm reflexes were -more lively than the left, and the left leg reflexes more lively than -the right. There was an ankle clonus on both sides. The abdominal and -cremasteric reflexes were lively. There was a slight intention tremor. -There was, however, no ataxia and no speech defect. - -=Diagnosis=: The nystagmus, optic atrophy, and the reflex disorder -suggested multiple sclerosis, although the liveliness of the superficial -reflexes, especially the abdominal reflexes, was a point somewhat -against any advanced degree of multiple sclerosis. It would appear that -the absence of pupillary reaction to accommodation is also rather -unusual in multiple sclerosis. - -The serum and spinal fluid W. R.’s proved positive. There were 25 cells -per cmm., albumin was in excess, and there was a positive globulin -reaction. - - 1. What is the significance of optic atrophy and other optic changes - with respect to neurosyphilis? Canavan, from our laboratory, has - reported that she found that 40 of 58 unselected cases of mental - disease exhibited obvious and undeniably important changes in the - optic nerve. She found that optic nerve changes were even more - frequent than chronic spinal cord changes as detectable by the - same method (Weigert myelin sheath method); there were only 34 of - the 58 cases which showed chronic spinal cord changes. Eighteen - cases very probably syphilitic (although the clinical evidence was - not in all cases supported by the W. R.) failed to show optic - nerve changes in but three instances. The 15 syphilitic cases that - did show optic nerve changes showed them in but one eye in three - cases, in both eyes in 12 cases. Canavan incidentally demonstrated - a spirochetosis in the pial sheath of the optic nerve in a case of - neurosyphilis, possibly paretic. - - 2. What is the frequency of eye changes in neurosyphilis? Posey and - Spiller (“The Eye and the Nervous System,” 1906) quote Kéraval as - finding 42 instances of fundus change in 51 cases of paresis. - Clifford Allbutt found 41 cases of atrophy in 53 of paresis; other - authors have found far fewer. Optic atrophy sufficiently marked to - cause blindness is relatively rare in paresis. Compare table of - eye changes from Joffroy under Case Falvey (55). - - As for optic atrophy in tabes, Posey and Spiller record statistics - as so various as to be on the whole unsatisfactory. The highest - percentages found appear to be those of Mott, 80%, and Gross, 88%. - It is evident that the standards for measuring optic atrophy must - differ very much. - - - =Atypical case of neurosyphilis. Picture of Huntington’s chorea.= - - -=Case 72.= Margaret Green, 28, was received at Danvers State Hospital in -an excited and frightened state. She was very talkative and said that -she was being bitten by snakes and serpents. She thought every one -approaching her was the devil, and sprinkled what she called “holy -water” about her for protection. It was clear that she was hallucinated. -She heard her child crying, and she saw a woman carrying it away. - -After a few weeks, Mrs. Green grew quiet and more rational except for a -few spells of violence and noise; she gave the impression of a rather -pleasant and agreeable, though somewhat demented, patient. Physically, -beyond a tremor of fingers and tongue and lively knee-jerks and some -evidence of enlargement of the heart, there was nothing to be found. - -Margaret Green is still in the Danvers Hospital, being now 48 years of -age. During the twenty years, she has presented,—besides the mental -picture of impairment of memory—occasional spells of confusion, a -variety of delusions based, at least in part, upon auditory and vivid -visual hallucinations, a certain irritability and psychomotor -excitement, and a picture of Huntington’s chorea. The diagnosis of -Huntington’s chorea has always been in doubt by reason of the lack of -any evidences of hereditary taint; it has, however, not been possible to -secure a properly intensive account of her relatives. - -It appears that the choreic movements were first observed—in the -hospital at least—about 16 years ago. The patient has always been -decidedly mixed upon dates. From internal evidence derived from her -obviously in part erroneous statements, it may be that the chorea began -at the age of 23. It appears that she had been often termed a victim of -St. Vitus’ dance, and had had to leave her work in the mill on account -of the disease. From one source of information, it would appear that the -patient began to have what was called St. Vitus’ dance when she was 14 -or 15 years of age; so far as this informant knew, no other member of -the family had had the affliction. - -The first movements observed in the hospital were irregular, jerking -movements, more marked in the left arm but also occurring in the other -extremities, as well as in the face, wherein were produced peculiar -grimaces. The twitching movements would become decidedly worse during -spells of irritability. Observation in the patient’s early thirties left -the question in doubt whether the left pupil reacted to light or not. In -1904, when the patient was 36, both pupils failed to react to light -either directly or consensually. At this time, the jerky movements -continued, especially in the left hand and forearm, the tongue was -tremulous, test phrases were poorly pronounced, the knee-jerks were -exaggerated (especially the left), and both wrist-jerks were -exaggerated. The systematic examination, however, revealed no other -neurological disorder. Within a year, slight spurious ankle clonus -developed on both sides; the eyes, especially the left, gave the -appearance of developing cataracts. A slight consensual light reaction -was demonstrable on the right side, but all light reactions were absent -in the left eye. - -At the age of 42, the patient was still disoriented for time, place, and -persons and subject to a deep amnesia; was tidy, tranquil, and of a -pleasant demeanor, but many of her muscles were in continual motion. -There were chewing movements and both hands and feet were rarely still. -There were no longer any spells of irritability or violence; and once -when found crying on the piazza, Mrs. Green, on being asked the reason, -replied that a gray cat had come and looked at her so hard it made her -cry. There were other crying spells at times for equally good reasons, -or for no reason. - -More recently, the patient has become fairly well oriented for time and -place, and has acquired a fairly good insight into her condition and a -good memory for past events. She has had occasionally auditory -hallucinations, as of water running. In 1914, it was reported that the -pupils reacted to light, and the rest of the systematic neurological -examination was negative except that the knee-jerks were exaggerated; -and a re-examination in 1916 showed the pupils still reacted to light. -At present, the patient is disoriented for time, stating that her age is -about 25; she is no longer subject to auditory hallucinations; she has a -marked difficulty in enunciation, emphasized by the lack of teeth and in -part due to continual movements of the tongue; the movements appear to -be part of a generalized chorea. - -In a systematic review of the Wassermann findings in the hospital -population, the blood of Margaret Green was examined and found to be -positive. Lumbar puncture forthwith performed showed a positive W. R. in -the fluid; there was a positive globulin and an excess of albumin; the -gold sol was characteristic of paresis; there were, however, but three -cells per cmm. - - 1. Are the choreiform movements related to the demonstrable syphilis - of the nervous system? Neither the fluid W. R. nor the gold sol - reaction should be regarded as necessarily an indicator of tissue - loss. The fluid W. R. is commonly thought to signify merely that - the fluid contains substances which are somehow due to the - presence of spirochetes in some region pretty closely related with - the fluid. The gold sol reaction, although well established to be - characteristic of neurosyphilis, is perhaps not so strong an - evidence of the existence of spirochetes in the region from which - fluid constituents are derived. There is no pleocytosis. However, - the positive globulin test and the excess of albumin do indicate a - certain amount of destructive process somewhere in the neural - tissues. Are we to suppose that these substances have been - continually found during the course of this disease? This question - cannot be answered with the data in hand, and we can only suspect - that these positive tests for albumin and globulin are an effect - of tissue destruction caused by neurosyphilis. It must be admitted - that the argument here is a little tenuous. The lesson is plain: - that in the present stage of our knowledge the W. R. should not be - omitted even in cases which present a fairly convincing picture of - some well-known entity. Thus, a disease, which looks like - Huntington’s chorea, as well as a disease suggestive of multiple - sclerosis, requires investigation by the methods of the - syphilographer. - - 2. How shall we explain the changes in pupillary reaction in this - case? They cannot yet be explained. A few observers have reported - changes in pupillary reflexes in the direction of normality. In - our experience such changes have not been noted. It cannot be too - strongly emphasized that it is very easy to make errors in judging - pupillary reaction if care is not used. For instance, if the - patient is accommodating for near vision, light will probably not - cause contraction. A frequent cause of error in testing the light - reflex arises from using a weak electric light. An electric - flash-light is much less efficient than daylight. Probably the - most satisfactory method is to take the patient to a window, ask - him to look at a distant object, shade the eye with the hand, - remove hand, and observe. - - 3. What is the chief triad of symptoms in Huntington’s chorea? (1) - Choreiform movements associated with (2) progressive mental - enfeeblement, (3) occurring in a patient whose family history - shows a similar condition in a preceding generation. - - - =Differential diagnosis between NEUROSYPHILIS and SENILE - ARTERIOSCLEROTIC PSYCHOSIS.= - - -=Case 73.= Marcus Chatterton was a retired sea captain, 75 years of age. -At the age of 71, he had had a seizure with a slight right hemiplegia -and inability to talk. He had been slightly confused for a short time -but had rapidly recovered. During the intervening four years, there had -been three similar attacks, and the last one had caused him to come to -the hospital. He was, in fact, confused upon admission but had become -perfectly clear by the next day. There was a considerable memory defect, -which the patient himself did not entirely appreciate. Possibly his -judgment had been deteriorating slightly. He had been irritable of late -and sometimes sleepless. - -=Physical examination= showed a rather well preserved man with but -slight senile changes. The pupils were equal and reacted readily to -light and accommodation. There was no sensory disorder and no -disturbance of coördination. There were no tremors. The systolic blood -pressure was 205, the diastolic 135. The arteries were sclerotic upon -palpation. A sufficient diagnosis would have seemed to be -arteriosclerosis, and the hypothesis of syphilis would hardly have been -raised off-hand by most practitioners. The W. R. of the serum was -negative. What led to lumbar puncture in this case was the fact that the -sea captain’s wife had died 15 years before of general paresis. The -lumbar puncture was rewarding since the W. R. was positive. There was an -increase of albumin and globulin, a “paretic” type of gold sol reaction, -and 56 cells per cmm. - -Accordingly, we must regard the condition as one of neurosyphilis. -Perhaps the arteriosclerosis was of syphilitic origin. If this is a case -of general paresis as we suppose, it is one of very long-standing -syphilis. - - 1. Do delusions of grandeur in the senile period suggest syphilis? - Not necessarily; it appears that there is a small group of senile - cases which might be called cases of senile pseudoparesis in which - extravagant delusions of grandeur are entertained, and in which - frontal atrophy is found although entirely without evidence of - chronic inflammation. It has not been proved that these cases are - of syphilitic origin. It is suggestive that the site of the most - extensive lesion is precisely the site of the most extensive - lesion classically found in paretic neurosyphilis, viz., in the - frontal regions. - - 2. Is neurosyphilis frequently found in both mates? It can hardly be - said that this is a usual finding. However, it is far from rare, - and it occurs frequently enough to be used in support of the - theory that there is a special strain of spirochete that has a - predilection for nervous tissue. It must be remembered, however, - that the wives of syphilitics are frequently infected without - being aware of it. In such cases they receive no treatment and - consequently have a larger chance of developing neurosyphilis. It - is a good rule to consider the mate of every syphilitic a - candidate for neurosyphilis. - - - =An atypical case of recurrent dazed states resembling HYSTERICAL - FUGUES. Probably an instance of NEUROSYPHILIS.= - - -=Case 74.= Abel Bachmann, a man of 40 years, remains doubtful and -perhaps belongs to the still unresolved group of mental cases due to -syphilis that cannot be placed in any of the well-known categories. -Bachmann had been found by the police, working in front of a cowbarn -without the consent or even the knowledge of the owner. Bachmann had, in -fact, spent the night in the cowbarn and was working with the idea of -paying for his night’s lodgings. The situation struck the police as so -peculiar, and Bachmann was so confused and irresponsive, that he was -brought to the Psychopathic Hospital. The afternoon of his admission, -however, he entirely cleared up and was able to give a good account of -himself. - -His story was that he had been worrying a good deal about a divorce -suit, and the morning of his episode he had awakened with peculiar -feelings. He walked from Boston to Cambridge, feeling that he was in a -strange city. He recognized the places he passed, yet they all seemed to -be changed. Upon reaching Harvard Square, he determined to return to -Boston and walked and walked, failing to reach Boston. All day he had -eaten nothing; when night fell he stole into a field and dug out -radishes. A postman stopped and said, “Hello, Bill,” which awakened him -as by an electric shock. A barn presented itself, in which he spent the -night. In the morning, the barn looked different. In fact, his entire -surroundings appeared mysterious. As he felt like working, he went to -work in front of the barn. - -It seems that in his life there had been two other episodes of a similar -nature; in fact, Bachmann had been in a state hospital for six weeks -after the first episode. The first episode had lasted a few days only, -and followed worry when he learned that the girl with whom he was in -love was married. The second attack followed the death of his mother, -whereupon he was taken to a state hospital although the total duration -of symptoms was only three days. Bachmann had had a chancre or some -other form of genital disease at 26, and had at that time been treated -with mercury. - -Except for irregular and absolutely rigid pupils, reacting neither to -light nor to accommodation, Bachmann showed no physical and especially -no neurological disease whatever. Moreover, the W. R. in the blood serum -was negative. - -As to diagnosis, one might consider hysteria, of which, however, there -are no visible stigmata. It would not appear that brain tumor would be -likely to have lasted so long as eight or nine years, even if we should -attempt to make the hypothesis of tumor cover both the non-reacting -pupils and the episodes. Bachmann was non-alcoholic, and there was no -sign of any other form of intoxication. The spinal fluid showed a -negative gold sol reaction, there were no cells in the fluid, there was -no globulin; albumin was normal. However, the W. R. was strongly -positive. - -The situation, then, in this case is that we have somewhat peculiar -psychopathic episodes, pupils rigid to light and accommodation, a -positive W. R. in the spinal fluid, and extremely little else to permit -a diagnosis. We are ignorant as to the course and pathology of such -cases. However, we cannot resist the temptation of the diagnosis of -neurosyphilis, although further classification is not ventured. - - 1. What is the significance of stiff pupil as an isolated symptom? - Nonne finds that in the end, after years of observation, the - Argyll-Robertson pupil turns out to be an advance courier of other - more functionally serious signs and symptoms of neurosyphilis. We - can confirm this experience and regard it as an established - clinical proposition that the Argyll-Robertson pupil cannot be - neglected. In this connection, refer to the case of alcoholic - pseudoparesis (Murphy, 60), and also to the case of pineal tumor - (Donald Falvey, 35). Enthusiastic reports have occasionally been - made upon apparent restoration of the true syphilitic - Argyll-Robertson pupil to normal light reaction. The difficulties - in rendering the symptomatic diagnosis of Argyll-Robertson pupil - in a given case are so great, and the chances of complication so - numerous, that we are inclined to attach little significance at - present to these claims. - - It may not be amiss to mention a somewhat humorous incident familiar - to some local neurologists. A case was reported by the interne for - a number of months as a victim of a pupil stiff to light and - accommodation, and the entirely adequate cause of this phenomenon - was actually only discovered at autopsy by the triumphant medical - examiner, who demonstrated that the patient in question was - possessed of a =glass eye=. - - - =TABETIC NEUROSYPHILIS (“tabes dorsalis”) versus PERNICIOUS ANEMIA - with spinal symptoms.= - - -=Case 75.= Mrs. Brown was a woman of 56, who for the past eight or ten -years had been complaining of trouble in her legs. As she described it, -at times her legs were so weak she could hardly stand; at other times -there was considerable pain and numbness. She has always been considered -“high strung”; that is, she had a very bad temper and lost control of -herself almost entirely when she became excited. Her legs had been -growing progressively worse, and for about a month prior to admission -she had been unable to stand or walk. She had also lost control of her -bladder. On account of her temper, it had been almost impossible to -nurse her; no nurse would stay with her because of her scolding and -fault-finding. Recently, she had been having fits of the blues. - -Her husband, who was seen before Mrs. Brown, was an old gentleman, over -70, who was chiefly remarkable from the fact that he had unequal, -irregular pupils, which reacted neither to light nor accommodation; -there was also a speech defect. - -The patient herself proved to be extremely irritable, as had been -stated,—so much so that at times it seemed almost impossible to do -anything for her. She was very querulous, constantly complaining, and -not satisfied with anything that was done. Aside from this, her =mental -examination= proved to be entirely negative; that is, there were no -psychotic symptoms. - -The systematic =physical examination= gave the following significant -findings: blood pressure, 160 systolic, 90 diastolic; no evidences, -however, of peripheral arteriosclerosis. Patient was unable to walk or -stand, and had no control over her bladder. The knee-jerks and -ankle-jerks absent on both sides; ataxia in the leg movements; loss of -sense of localization, with no tenderness over the nerve trunks; no -atrophy, paralyses, or muscular asymmetry of the parts. The vibratory -sense was maintained. Subjectively, the patient thought that the -vibratory sense differed in the legs from that in the arms. -Localization, touch, pain, heat, and cold responded to correctly. The -arms showed nothing abnormal; there was no incoördination, dysmetria, or -dysdiadochokinesis. Her pupils were equal, regular, and both reacted -normally to light and accommodation. - -=Diagnosis=: The first consideration in the case is naturally tabes -dorsalis, especially when one considers that the husband had signs which -suggested syphilis of the nervous system. The rapid onset of the acute -symptoms in this case, and the absence of the characteristic signs of -pain were at least atypical for this diagnosis, as was the absence of -any pupillary signs. Further, the W. R. was negative in the blood and -spinal fluid; there were no definite signs of inflammatory reaction as -shown by the other spinal fluid tests. These findings made a diagnosis -of tabes entirely improbable. After tabes, the most frequent cause of -the symptoms above enumerated is perhaps to be found in pernicious -anemia. Examination of the blood showed that the patient had 2,500,000 -erythrocytes per cmm. The hemoglobin by Tallquist scale was 80%. The -smear was practically negative; no blasts could be seen. Although this -picture is not a typical one for pernicious anemia, at least it is -significant in the low number of red cells to be found, and as no causes -for anemia were to be found, it seemed probable that we were dealing -with a primary anemia. The diagnosis in the case, therefore, is spinal -sclerosis of primary anemia. The mental picture was not uncharacteristic -of PERNICIOUS ANEMIA. - - 1. Could the diagnosis be rendered in this case without a lumbar - puncture? In the first place, the emaciation is not entirely - characteristic. The pupils react normally to light. Probably such - a case might well have been regarded as one of tabes dorsalis in - former days, or even at the present time, if a lumbar puncture had - not been resorted to. - - 2. Could this case possibly have been one of tabes dorsalis with - negative spinal findings? Such cases have been reported - frequently, but, unlike the present case, are apt to be of - long-standing and non-progressive, in which the active - inflammation is no longer present. The negative findings would not - be consistent with tabes, in which the symptoms are of short - duration and of sudden onset. - - 3. If the serum W. R. had been positive would the diagnosis have - been neurosyphilis? We are loath to make the diagnosis of spinal - syphilis when the spinal fluid is normal. Syphilis may produce a - marked anemia, however, and thus produce symptoms such as shown by - Mrs. Brown. It is even possible that such is the explanation of - this case, taking into consideration the suggestive findings in - the husband. However, there is insufficient evidence to make such - an hypothesis rock firm, and we do not more than suggest it. - - - =Atypical case of CONGENITAL NEUROSYPHILIS—peculiar mental state.= - - -=Case 76.= James Seabrook, 20 years of age, obviously showed a number of -signs of congenital syphilis. The =physical examination= disclosed an -old scar and indentation in the right mastoid region, another on the -right side of the neck, another on the posterior surface of the right -forearm, and two on the outer surface of the right upper arm. The -lesions were about the size of half a dollar. There was a saddle-shaped -nose and a perforation of the palate and uvula; there were palpable -cervical and axillary glands, small but numerous. There was a dulness in -the region of the right scapula, and slight dulness on both sides -behind. There were loud whispering and piping râles and bronchial -breathing throughout the chest, more marked on the left; there was much -coughing, and the sputum was at times blood-stained. The pupils were -irregular but reacted perfectly. The left knee-jerk was slightly more -active than the right. The W. R. in blood and fluid was negative; the -gold sol, globulin and albumin tests were negative. There were, however, -56 cells per cmm. in the fluid. - -We learned that the patient had had several spells of great excitement, -with pounding on the door and a desire to fight bystanders. There were -spells of headache and vertigo. =Mentally= the tests showed him to be -subnormal. - -The =diagnosis= Of CONGENITAL SYPHILIS seems established; possibly the -pulmonary condition is syphilitic. The mental subnormality as well as -the abnormal traits and episodes are probably to be accounted for on the -basis of syphilitic involvement of the brain. - - 1. Are the headache and vertigo connected with syphilis? This is - perhaps suggested by the pleocytosis in the spinal fluid. - - 2. How shall we explain the negative W. R.? This patient had - received, shortly before his entrance to the hospital, salvarsan - and mercury. Possibly the drug treatment has little or nothing to - do with the negative W. R.’s since they not infrequently grow - weaker as congenital syphilitics grow older. - - 3. What is the explanation of the spells of excitement? Compare the - spells of excitement in a form of neurosyphilis described by - Kraepelin, namely: syphilitic paranoia, discussed in the case of - Bridget Collins (59). - - 4. Is treatment indicated considering the W. R.’s to be negative in - blood and fluid? Despite the negative W. R.’s in this case - treatment is strongly indicated on account of the pleocytosis. - This would seem to indicate that there is an active inflammatory - process in the cerebrospinal axis, and it is more than probable - that this process is syphilitic. How much real improvement of the - symptoms would result from antisyphilitic treatment it is - impossible to prophesy. Every case is a special problem, and this - case is very unusual in showing a pleocytosis in the absence of - other indications of syphilitic nervous disease, _viz._, globulin, - albumin and W. R.’s. - - - =CONGENITAL NEUROSYPHILIS resembling an undifferentiated case of - FEEBLEMINDEDNESS—actually PARETIC.= - - -=Case 77.= John Friedreich, a 7–year old boy, was brought to the -Psychopathic Hospital by agents of a charitable society, who found him a -neglected child and quite evidently a subnormal one. - -The dominance of syphilis in the situation was clear. The boy’s father -had died but a few months before of syphilitic heart disease, from which -he is said to have suffered for five years. The boy’s mother (the -parents were first cousins) had also been treated for syphilis and was -excessively alcoholic. The first child of this union—a girl—had died at -6 years, of a disease diagnosticated spinal meningitis. The history -indicates that syphilis was acquired after the birth of this first -child; but in any event it is possible that the meningitic condition of -which the first child had died was syphilitic. The second pregnancy -terminated in a stillbirth; the third issued in a girl, who died two -weeks after birth of what was termed “inward convulsions.” The fourth -pregnancy resulted in a miscarriage; the fifth in our patient, John -Friedreich. The sixth pregnancy resulted in a girl, now 5 years of age, -who is apparently normal. (Her W. R. was negative and she shows no -stigmata of syphilis.) - -The patient, John Friedreich, at some very early age had a rash on his -body diagnosticated as syphilis. He also had many seizures called -fainting spells. Ever since birth he had been taking mercury pills. He -had not learned to talk until his third year, and was able then to say -only a few disconnected words. In fact, John has never been able to talk -in complete sentences, mumbling much that is quite unintelligible. -However, he walked at 15 months in a normal fashion and nothing peculiar -in his gait was noted until he was 5 years old, when he began walking on -his toes, particularly those of his left foot. Shortly thereafter, the -seemingly inevitable trauma appeared; John fell out of a window and -severely injured his left leg, whereupon the peculiarity of toe-walking -became more pronounced and associated with a limp. - -[Illustration: - - Juvenile paresis. 7 years. -] - -The patient strikes one =physically= as having the development of a -child of about five years (actual age, 7). There are a few lymph nodes -palpable in the anterior triangles of the neck. The dilated and slightly -unequal pupils react neither to light nor accommodation. There is -practically complete deafness; loud sounds are not at all noticed. - -Withal, the child in a general way presents a somewhat attractive -appearance, being very playful and mischievous, lying about on the floor -and playing with whatever comes to hand, talking to himself or making a -few indistinct remarks to the bystanders. He walks awkwardly, on the -toes of the left foot. He pays little or no attention to his toilet and -needs to be dressed and cared for in all ways. He is quick-tempered and -at times very difficult to manage. - -There was, of course, little doubt of the =diagnosis= of CONGENITAL -SYPHILIS and of FEEBLEMINDEDNESS. The W. R. was positive both in the -blood and in the spinal fluid. The gold sol reaction of the fluid was of -the “paretic” type; there were 44 cells per cmm. and there was a large -excess of albumin and much globulin. - -As to prognosis, there is doubt. - - 1. Is, or is not, this a case of juvenile paresis? - - 2. Is it, perhaps, a relatively permanent case of feeblemindedness - due to congenital syphilis? On the whole, on account of the spinal - fluid symptoms, we should be inclined to give the case a - relatively poor prognosis, namely, of death in a few years. - However, we may perchance be later surprised to learn that the - patient has lived on, at least into early adult age. - - Note: Mercury tablets in some cases of congenital syphilis do not - seem effective. John Friedreich was treated most intensively by - syphilographers from birth. - - Dr. W. E. Fernald in a personal communication stated that - syphilitic cases of feeblemindedness are rather those of the - imbecile and idiot groups than of the higher levels. This - statement emphasizes again that the true hereditary cases of - feeblemindedness are rather those of the higher group, whereas the - cases in which special causes have operated in the uterus or in - early life eventuate in idiocy and imbecility. However, such a - case as that of Friedreich shows that now and then a case of - feeblemindedness without evidence of neurological disorder and - looking in almost all respects like an hereditary case may be at - times produced by syphilis. - - 3. How often is the central nervous system involved in hereditary - syphilis? An interesting table bearing on this point is presented - by Veeder.[16] The table concerns the lesions in various parts and - systems of the body in 100 cases of late syphilis. It appears that - in 47, or approximately one-half of Veeder’s series of 100 late - cases, the infection developed some form of lesion of the nervous - system. As Veeder remarks, this result runs counter to the common - statements of pediatricians, notably of Holt. - - Bones: - Periostitis tibia 4 - Periostitis skull 1 - Osteomyelitis 1 - - Joints: - Acute arthritis knee 8 - Acute arthritis ankle 1 - - Skin: - Macular eruption 1 - Condyloma anus 3 - Gummata 3 - Alopecia 3 - - Eye: - Interstitial keratitis 24 - Choroiditis 1 - - Ulcerations: - Nasal 2 - Laryngeal 1 - Pharyngeal 1 - - Central Nervous System: - Mental deficiency 23 - Cerebrospinal syphilis 14 - Hemiplegia 6 - Epilepsy 5 - Spastic paraplegia 4 - Chorea 2 - Hydrocephalus 2 - - Miscellaneous Conditions: - Ozena 1 - Enlarged spleen (only symptom) 1 - Torticollis 1 - Aortitis 1 - Obscure abdominal pain 1 - Obscure pain in legs 2 - Endarteritis obliterans 1 - Paroxysmal hemoglobinuria 1 - Raynaud’s disease 1 - Hutchinson’s teeth 4 - - - =Juvenile paretic neurosyphilis. Quadriplegia.= - - -=Case 78.= Gridley Ringer, 15 years of age, had the facies of a -congenital syphilitic, including Hutchinsonian teeth, rhagades of the -face, and the so-called Olympic brow. No secondary sexual -characteristics had developed. There was a marked speech defect. -=Mentally=, Ringer was a low-grade imbecile. He had been born at full -term, and delivery had been normal. There had never been other -pregnancies. He had never developed normally. - -The father admitted syphilis 23 years before, namely, 8 years before the -birth of his son, but the father had been treated for several years and -had been declared cured. - - 1. What would be expected in the spinal fluid of this case? Without - the history, it would perhaps be impossible to say whether the - case was one of a quiescent imbecility or one of juvenile paresis. - The spinal fluid of the juvenile paretic gives a picture identical - with that in the adult. The spinal fluid in this case showed a - positive W. R. (as did also the serum), a marked increase of - albumin and globulin, 115 cells per cmm., and a “paretic” gold sol - reaction. Accordingly, the diagnosis of GENERAL PARESIS was made. - - 2. What is the prognosis? The prognosis of juvenile paresis is - currently regarded as entirely grave. There is probably less hope - for improvement in juvenile paresis than in the acquired paresis - of adult life, since it seems to be a general principle that - congenital syphilis is always more difficult to cure than acquired - syphilis. - - This case had seizures a few months after initial observation, and - the seizures were followed by a transient right hemiplegia. This - right hemiplegia was shortly followed by a left hemiplegia, which - remained permanently. Moreover, a few weeks later, a right - hemiplegia again developed, leaving the patient with complete - paralysis and aphasia. Death followed in six weeks. - - 3. What effects were shown in the parents? Following up the parents - was rewarded by the discovery that the mother was suffering from - nerve deafness, probably of syphilitic origin, and that the father - had recently begun to suffer from what he considered rheumatism, - but which on examination was shown to be tabetic neurosyphilis - (“tabes dorsalis”). This family again supports the hypothesis that - there is a strain of spirochetes especially prone to attack the - nervous system. Here it would seem that the syphilis acquired by - the father had infected the mother and been transmitted to the - son. In all three infected by the same strain or strains of - organisms the nervous system was involved. It is difficult, - nevertheless, to explain on this hypothesis why in one case the - disease took the form of tabes dorsalis, in the second, eighth - nerve involvement and in the third, paresis. This question of - strains is really more than academic because it enters deeply into - the question of treatment, as well as that of the suggested - increased viability of the neural strain. - - - =Is there a relation between epilepsy and juvenile neurosyphilis?= - - -=Case 79.= John Doran fell off the rear of an ice-wagon, at six years of -age, and shortly afterward developed fits. It appears that John was not -unconscious at the time of his fall, but that he complained of headache. -Although the convulsions were fairly frequent at first, it appears that -they later became rare and occurred only when the patient got into a -temper. At the stage of exhaustion after violent excitement, John would -fall. - -=Physically=, at 9 years a fair development and nutrition were evident. -There was a great exaggeration of the frontal bosses; the nose could not -be said to be typically saddlebacked, yet there was a suggestion of a -sinking of the bridge. The teeth slightly suggested the Hutchinsonian -type, but only slightly. There was a slight roughening of the tibia, and -there was a slight scar over either knee. The patient graded according -to the Binet scale at 9 years, and he was regarded as definitely -feebleminded. - -The family physician states that, according to his information, the -father contracted syphilis when the child was between three and four -months of age, and that the mother also was infected at this time. -However, the child had not been suckled except immediately after birth, -and there had been no evidences, according to the family physician, that -John had acquired syphilis. - -Ordinarily, one might content himself regarding the case of John Doran -as one of idiopathic epilepsy with mental defect or deterioration. -However, the frontal bosses, suggestive teeth, the flattened bridge of -the nose, the roughened tibiae, and the old scars, though singly not of -great significance, collectively make one suspicious. Despite the family -physician’s belief that John could not have acquired syphilis from the -parents, the infection seems entirely possible despite the fact that no -symptoms developed early thereafter. - -The W. R. in this case proved positive in both blood serum and spinal -fluid. - - 1. What is the relation of trauma to this case of JUVENILE - NEUROSYPHILIS? Probably none. - - 2. What would be the effect of treatment? For a number of years John - Doran was lost sight of. He was, however, treated, according to - our information, with intraspinous injections of salvarsanized - serum, whereupon his convulsions shortly ceased. He has been - recently examined mentally once more, and still grades as - feebleminded. He still has violent outbreaks of temper. - - 3. Is such a case as Doran typical? Shanahan has investigated - conditions at Craig Colony. There were 22 out of 886 epileptics - (at Craig Colony) or 2½%, who showed a positive W. R. Nine of - these cases were regarded by Shanahan as cases of epilepsy - actually caused by syphilis. Viet had found 7%, and Bratz and Lüth - 5% of constitutional epileptics to be syphilitic, but the data of - these German authors were obtained before the era of Wassermann - tests. - - - =Adrenal tuberculosis complicating juvenile paretic neurosyphilis - (“juvenile paresis”). Autopsy.= - - -=Case 80.= When James Arnold appeared at the Danvers Hospital in his 22d -year, he looked as if he were but 12 or 14 years of age. He was -excessively fat but of fair muscular development. The left eye diverged -outward, and the left pupil was smaller than the right. An odd feature -was a high degree of pigmentation of the skin of the genitalia and the -groins (the axilla, the mammillary areas, and the oral mucosæ were free -from pigmentation). =Physically= speaking, the patient was practically -normal. =Neurologically=, however, there was much of interest, in the -light of which the clinical history was of value. - -It seems that after an apparently normal early childhood, the boy had -begun, at the age of 11, to experience difficulty in carrying out -every-day school tasks; and after this his mental capacity had slowly -but progressively deteriorated. The deterioration was not merely -intellectual, but the boy became dishonest and untrustworthy and -developed a number of untidy and uncleanly habits, behaving at the age -of 16, as the parents stated, like a child of six. - -In his seventeenth year, the boy had been taken with a severe attack of -what was regarded as an “attack of indigestion.” This attack ushered in -a gradually developing muscular weakness, especially involving the -limbs. By the age of 21 he had become irritable and the paresis was so -extreme that the patient was unable to get in or out of a carriage. - -This generalized muscular weakness was plain upon admission to the -hospital though there seemed to be no actual paralysis. The patient was -unable to walk in a straight line and Romberg’s position could not be -maintained. Marked tremor was present in the hands and lips. There was -bilateral impairment of vision and nystagmus. Reflexes and sensations -normal. Speech was markedly affected, all syllables being very much -slurred. School knowledge and memory for both recent and remote events -very poor. The patient’s habits were very untidy. He was very emotional, -easily made to laugh or cry; and in behavior, extremely childish. - -Two months after his admission to the hospital, the weakness suddenly -became extreme. He was constantly nauseated, refusing food. The face and -hands were cyanosed and the heart’s action rapid, weak, and irregular. -This attack lasted for a week and was followed by a period of -improvement, during which, however, he still remained very weak and -apathetic. - -One month later he again became so feeble that he was unable to raise -himself in bed. He complained persistently of feeling very “sick.” His -temperature was elevated and there occurred the same train of -circulatory symptoms observed previously, _viz._, rapid and tumultuous -action of the heart, with cyanosis of face and extremities. He soon -became unconscious, remaining so until his death, which occurred on the -seventh day of the acute attack. - -This case was under observation before the days of the W. R., yet -clinically the case had been diagnosticated JUVENILE PARESIS. There was -no history of the acquisition of syphilis or any likelihood of its -acquisition. Considered clinically, many of the classical features -described by Addison were present, _viz._, marked asthenia and apathy; -severe and frequent gastro-intestinal symptoms (the disease probably -commencing with the attack of so-called “acute indigestion” six years -prior to patient’s death); attacks of extreme cardiac weakness with the -characteristic small, low-pressure pulse. On the other hand, -pigmentation of the skin (usually the most striking clinical feature) -was limited to the external genitalia, these being colored a deep brown. - -The most striking feature found at autopsy was a bilateral adrenal -tuberculosis (caseation, giant cells, lymphocytosis, tubercle bacilli). -The thymus gland was persistent (7×5×.5 cm.), whereas the thyroid gland -was smaller than usual. The brain showed macroscopic and microscopic -features entirely consistent with the diagnosis of general paresis, -including lymphocytosis, plasmocytosis, irregular degrees of nerve cell -destruction, and gliosis, with an especially characteristic microscopic -picture in the frontal regions. - -It may be of note to consider the degree of change undergone by a brain -in 11 years or more of deterioration, and the following description of -the head findings is therefore included: - - =Head=: Hair abundant, dark. Scalp normal. Calvarium, weight 435 - gm., transparent in bregmatic region only, elsewhere thick and - dense. The average thickness of the vertical plate of the frontal - bone is 7 mm. The frontal bone shows a moderate thickening and - hardening of the inner table with obliteration of diploë. Dura mater - moderately adherent to the bregmatic region of calvarium. - Arachnoidal villi moderately developed. Sinuses not remarkable. Pia - mater shows a moderate focal thickening with opacity, especially - along sulci. Vessels well injected. =Brain=: Weight, 1200 gm. The - brain shows marked focal variations in sulcation and consistence. - Spread on a board, the right hemisphere is obviously somewhat bigger - than the left. There is a difference of only 0.5 to 0.75 cm. on - measurement of the greatest circumference of the cerebrum, taken - from the median line superiorly to the median line inferiorly, but - the right hemisphere is throughout slightly more convex than the - left. Both postcentral gyri are much narrowed in their superior - portions, and the sulci posterior thereto are deeper than the other - sulci of the hemispheres. The sulci of the orbital surfaces are - asymmetrical and, on the left side, show a tendency to microgyria. - The cerebral hemispheres as a whole show a remarkable tendency to - slight protrusion of the border gyri; especially those of the two - poles, of the free edges along the great fissure, and most - strikingly the gyri at the boundary line between the inferior and - lateral surfaces. This _marginal prominence_ is slight but obvious - and is emphasized by a slightly paler color in some regions. The - cerebrum shows a general induration which is greatest in the frontal - tips and along the inferior borders of the lateral surfaces of the - hemispheres, especially right. The orbital surfaces are firm, - especially anteriorly and externally (prefrontal); the tips of the - temporal lobes are firm, and the superior temporal gyri are firmer - than adjacent gyri. The postcentral gyri are indurated more than the - other gyri of the superior surface. The hippocampal gyri are - likewise firmer than adjacent gyri. - - =Cerebellum and pons=: Weight, 145 gm. The inequality of the two - hemispheres is more marked than in the case of the cerebrum. - - Greatest lateral diameter; left, 4.5 cm., right, 5.5 cm. - - Anteroposterior diameter adjacent to notch: Left, 5.8 cm., right, - 5.5 cm. - - There is no appreciable difference in depth. The diminution in - volume appears to be chiefly at the expense of the right clivus. The - inferior surface is firmer than the superior. The laminæ adjacent to - the horizontal fissure are firmer than the remainder of the - cerebellum. The pons is small. - -There was also a lateral curvature of the spinal column, as well as -characteristic adhesions between spinal dura and pia mater which are -always suggestive of syphilis. For the rest, there were few findings of -note: some adhesions of the left pleura, hypostatic congestion of the -lungs, tracheitis, and chronic gastritis. There were four lobes of the -right lung but it is doubtful whether this should be regarded as a -stigma. - - 1. Can we separate the symptoms of Addison’s disease from those of - paresis in this case? The extreme cardiac weakness with a - characteristic, small low-pressure pulse is in point. The asthenia - and apathy are consistent enough with Addison’s disease as well as - with paresis itself. It would also be possible to ascribe the - gastro-intestinal symptoms to either disease. - - 2. Of what significance is the persistent thymus? Persistent thymus - has been observed in a few cases of Addison’s disease, but that it - plays any part in the symptomatology thereof is a matter of doubt. - - 3. How can the obesity be explained? It is of course of note that - the thyroid gland was small, but microscopically there were no - peculiar features in this gland. - - 4. Was the adrenal tuberculosis actually primary? Minute search - failed to reveal evidences of tuberculosis elsewhere unless we - regard the few adhesions binding the lower half of the lung to the - chest wall as indicative of an old tuberculosis. In particular, - the mesenteric lymph nodes were normal. - - - =Neurosyphilis? Secondary stage of syphilis.= - - -=Case 81.= Florence Fitzgerald, a woman 25 years of age, applied at the -police station to be taken care of. She said she had been a prostitute -for the last few months, was now ill, and wanted to reform. She appeared -physically ill and was sent to the Psychopathic Hospital, where she -remained at first almost mute, making answers chiefly by nodding the -head. She gave the impression of daze or stupor, and in fact her -condition was at first regarded as catatonic. This reaction, after a few -days, changed and Florence became quite normal, giving a full account of -her condition. - -It seems that four months before going to the police station, she -developed a chancre, which was locally treated. A careful physical -examination showed a fine red macular eruption which was without much -question a syphilitic roseola. The spinal fluid yielded a positive W. R. -although other tests of the fluid were negative. Curiously enough, no -physical sign of involvement of the nervous system could be discovered. -We were inclined to regard the mental symptoms as partly due to the -syphilitic intoxication, and partly due to a psychic reaction of the -nature of defense. As for the positive W. R. in the spinal fluid, in -early secondaries various observers differ as to the frequency both of -the W. R. and of other changes, percentages being given that range from -25 to 90%. See case Caperson (45). It is of note that clinically there -were symptoms referable to a syphilitic involvement of the nervous -system; namely, marked headache and malaise. The headaches of the -secondary period are frequently the result of meningeal involvement. - - - =TABOPARETIC NEUROSYPHILIS (“taboparesis”); death from TYPHOID - MENINGITIS. Autopsy.= - - -=Case 82.= Frederick Estabrook was a salesman, who, be it noted, had -never had typhoid fever or any disease remotely resembling typhoid -fever. He had acquired syphilis at 19; had married at 22; was the father -of two healthy children (no miscarriages); had had a certain disturbance -of bladder and rectum, but remained a successful salesman to the age of -28, when advancing tabes confined him to bed for a time. At 30, mental -signs of PARETIC NEUROSYPHILIS developed, and death followed at 32, -after an acute illness of a week. - -The details of the history after the first symptoms at 28 are as -follows: - -At twenty-eight patient lost control of limbs and was confined to the -house about two months, under medical care. Three months later he had -regained partial control of his limbs but had lost all control of his -sphincters. After another month he had returned to work, but did not -work steadily and seemed to have lost ambition. In the summer of 1905, -his mind became obviously altered. He grew indolent and extravagant and -given to buying expensive and useless articles. Loss of interest in -things followed, together with loss of memory for recent events, lack of -insight into illness, delusions of persecution by wife, irascibility -followed quickly by crying. Before admission to hospital, he was -euphoric, drawling and tremulous in speech, sprawling in penmanship, -alternately depressed and exalted in manner. Knee-jerks were absent, -gait ataxic, pupils stiff to light. - -The family history was negative with respect to insanity. All the family -were reported as nervous. A brother died of peritonitis at twenty-eight, -a sister of pneumonia under twenty. Another brother and sister are -living. Father and mother died of heart trouble at about sixty-seven and -sixty respectively. - -The patient was at high school one year and was a fair student. -Considerable tobacco was used, and some alcohol. Intoxication denied. -There was no history of typhoid fever or other acute disease. - -The patient on admission was sallow, poorly nourished, and flat-chested, -with a slight lateral curvature. There was slight dulness over right -apex in front and in right upper back. Voice sounds were increased over -right apex in front and over whole right back. The right chest showed -bronchial respiration throughout. The respiration in front of right -chest was of an interrupted character. The liver seemed moderately -enlarged. The urine showed a very faint trace of albumin. There were a -few small nodes in right groin and a scar on dorsum of penis. - -=Neurological Examination.= Slight swaying in Romberg position. Slight -tremor of protruded tongue and extended fingers. Pupils irregular, left -slightly larger than right. Left pupil reacted to light consensually, -but not directly. Right pupil reacted very slightly to direct light, not -consensually. Knee-jerks and Achilles jerks absent. Ankle clonus absent, -abdominal and cremasteric reflexes brisk. Sharp and dull points were -recognized in the legs with numerous mistakes. Vocal and facial tremor. -Speech slow and drawling. Test phrases repeated well if care was taken. -Consciousness clear. Orientation perfect. Calculating ability preserved. -Many words omitted in writing. Penmanship clear but shaky. - -Hallucinations absent. Memory of recent events poor. Associations of a -logical or defining type. Patient denied various statements in -commitment papers and had little or no insight into the mental side of -his disease—slight euphoria. - -After a month’s observation the patient was removed to a quiet ward and -set to work a few days in the scullery. One night he began to yell as if -assaulted and said later that he had an idea that he was going to die. -Before three months had passed he had become untidy, disorderly, and -imperfectly oriented. - -The general degeneration continued rapidly. One week before death the -temperature rose to 103 degrees F., and the patient succumbed to what -seemed clinically like a bronchopneumonia. Unconsciousness two days -before death. - -Note with respect to history of typhoid.—Inquiries of his physicians, -wife, employer, and brother tend to show conclusively that the patient -never had a disease even remotely resembling typhoid fever. - -The =autopsy= findings were as follows: - -Acute conditions: - -Hypostatic pneumonia, with early serofibrinous pleuritis and without -lymph node swelling; =enlargement of mesenteric lymph nodes=; =acute -cerebrospinal leptomeningitis=; multiple small hemorrhages of spleen. - -Other findings: - -=Scar of penis=; =sclerosis of aortic arch= (Heller’s type?) and slight -coronary arteriosclerosis; =calvarium= thin and =dense=; =dura mater -thickened= and adherent to calvarium; calcified arachnoidal villi; -=chronic= cerebral and cerebellar =leptomeningitis=; =atrophy of frontal -lobes=; =granular ependymitis=; =sclerosis of posterior columns= of -spinal cord; emaciation; unequal pupils; slight parietal fibrous -endocarditis, slight mitral sclerosis; gastro-intestinal atrophy; -chronic cystitis; chronic abscess of prostate. - - The description of the head findings is as follows: - - Skin exceedingly loose, and the whole skull cap thinned. The diploë - are absent. Adhesion with dura easily separated. The dura somewhat - thickened, but not distended. Along the longitudinal sinus extensive - calcareous granulations adhere to it. The longitudinal sinus does - not contain blood, and the inner surface is normal in color. The pia - is extensively thickened and opaque and a general subpial exudate - exists which is more marked over the vertex where it lifts the pia - from the brain surface to the extent of three centimeters in - Rolandic, superior frontal, intraparietal, and mesial precentral - sulci on each side. The arteries at base are free from atheroma. The - temporal lobes are much bound down by adhesions, as is the - cerebellum. Post mortem softening is evident. The hemispheres show - no asymmetry, but the frontal convolutions are markedly atrophic. - The corpus callosum is united to the cortex by old adhesions and has - to be dissected away from it. Lateral ventricles contain some slight - amount of cloudy fluid, and the pia along the vessels is opaque. - Some granulations in ependyma. Brain weight, 1305 grams. Pons and - cerebellum, 195 grams. - - Cord.—Dura much thickened, and the pia corresponds to its appearance - in brain with a like exudate. Cross sections of cord show sclerosis - of posterior columns. - - Bacteriologically the _typhoid bacillus_ was cultivated _from the - meninges and from the swollen mesenteric lymph nodes_. The blood was - negative; the intestines were negative so far as lesions were - concerned. - -The microscopic examination confirmed the clinical diagnosis of GENERAL -PARESIS and of TABES, since there was not only an extensive chronic -encephalitis, with the usual lymphocytic and plasma cell deposit and -irregular gliosis, but also a well marked posterior column sclerosis, -not unusual save in its extreme degree. - -It might be surmised that some difficulty would arise in distinguishing -the effects of paretic meningoencephalitis from those of the more recent -typhoidal process. The well-known tendency of typhoidal processes to -escape polynuclear exudation, at least until frank necrosis has set in, -gave rise to the idea that the two mononuclear pictures—that of general -paresis and that of typhoidal processes—might be confusing. - -The picture presented by the meninges was scarcely what might be -expected. Although numerous mononuclear phagocytic cells are everywhere -found, yet the predominant picture is that of a polynuclear exudation. - -The polynuclear leucocytes occur in greatest numbers in the tissue -spaces, especially in the meshes of the lumbar arachnoid and in the -spaces of the frontal and paracentral pia mater. In the lumbar region of -the spinal arachnoid wide fields occur in which the cells are almost one -hundred per cent polynuclear leucocytes. In places phagocytic cells -occur, and in a few fields, even in the open tissue spaces, the number -of phagocytic cells may arise to fifty per cent. Edema is a considerable -feature in the meninges. Fibrin is found chiefly in the cerebral -meninges and appears in numerous delicate strands in the tissue spaces. - - - Moloch, horrid king, besmeared with blood - Of human sacrifice, and parents’ tears; - Though, for the noise of drums and timbrels loud, - Their children’s cries unheard that passed through fire - To his grim idol. - - Paradise Lost, Book I, lines 392–396 - - - - - IV. MEDICOLEGAL AND SOCIAL - - - =Neurosyphilis in a public character: eloquence, reformatory - efforts, notoriety.= - - -=Case 83.= Major Isaac Thompson, M.D., was a character. He had been -regarded as eccentric for many years prior to his death at 63. In fact, -it seems that there had been more or less definite symptoms and signs -about his fortieth year. The doctor himself had a ready explanation for -his Argyll-Robertson pupils; he explained that he had had a peculiarly -heavy smallpox at about the age of 27 (which would be about 1872). - -The doctor had a good secondary education, he had gone through the Civil -War as a hospital steward, went into business after the war, married, -and then went to the medical school, graduating at the age of 34. He -continued in practice for a dozen years, and then gave it up. For years -he had been especially interested in certain literary lines and he had -published any number of pamphlets, all of a somewhat striking -description, often with a political color and intended to stir up reform -measures. The doctor never bore a very good reputation, and years later -it was recalled that certain books disappeared from libraries and their -loss was almost certainly traced to Dr. Thompson. In general, however, -he was considered to be a rather worthy local figure. - -It is possible that a fall on the ice in his 61st year actually started -the fatal process, since after that time the patient had difficulty in -walking, and a few months later developed periods of excitement with -peremptory insistence on obedience to his wishes. Whereas formerly the -doctor had finished up one literary piece of work after another, he now -began to do very scattering work. He appeared in public to denounce -certain financial schemes with great force and unusual eloquence. His -eloquence was greatly complimented, and these compliments induced the -doctor to a remarkable crusade against a certain corporation; there was -so much truth mixed with the fiction of his eloquence that he obtained a -considerable following in his campaign. He wanted to start a bureau of -information for the instruction of the public on these matters, and he -planned to put up a building adjoining his own home for the -accommodation of the various clerks and writers in this bureau. However, -before the building had been actually started, an outbreak occurred. - -One morning the doctor was very excitable and noisy over the telephone, -ordering typewriters and giving directions to mechanics. He repaired to -Boston in connection with certain resources that he supposed (and gave -others reason to believe) had been supplied by the Government and by a -large newspaper. One evening he returned very late. It appeared that he -had had a fracas at a hotel and had knocked down one or two colored -porters, acting as though drunk. Upon being put to bed, the doctor -talked incessantly of religious matters, proposing to undertake a Sunday -School class. His interlocutor did not exhibit a particular interest in -this scheme, whereupon Dr. Thompson threatened him with violence. Police -and doctors were called in and a constant stream of conversation lasted -for hours. The patient was finally brought to Danvers Hospital upon -representation by physicians, to whom he told that his luck had turned, -that he was about to be made senator from the district, and that he and -Roosevelt were going to break up the trusts, and that, as a matter of -fact, he was a relative of Mr. Roosevelt. - -Upon admission, the patient was a well preserved and well groomed man -with gray hair and beard. He was somewhat pallid but his teeth were well -preserved and well cared for, and there was little or no physical change -except a slight hypertension. He claimed that he had suffered from -kidney disease for some years, and there was in fact a trace of albumin -in the urine. - -=Neurologically=, the plantar and Achilles reactions could not be -obtained, but there were no other reflex disorders except the bilateral -Argyll-Robertson pupil. The doctor’s explanation for these stiff pupils, -which he described as existing for many years, was frank and -circumstantial, so that the unlikelihood of Argyll-Robertson pupils due -to smallpox was rather frowned upon by him. Without entering upon a -detailed description of the clinical symptoms and course of the disease -which led to death a little over a year after admission, it may be said -that the differential diagnosis lay between the expansive form of -general paresis and a maniacal condition, presumably the maniacal phase -of manic-depressive psychosis. From the data of a special staff meeting -held upon the case, we learn that the diagnosis of manic-depressive -psychosis was entertained more strongly than that of general paresis. -Thus, for general paresis alone was the somewhat gradual onset with -increasing excitement, accompanied by expansive delusions concerning -unlimited finance, personal over-importance, and Argyll-Robertson -pupils. Dismissing the Argyll-Robertson pupils from consideration, the -diagnosticians were led to see in the constant motor activity displayed -in conveying an enormous number of thoughts on paper, inconsistent -talking with digressions, a manic-depressive psychosis. There was no -amnesia and no other sign of mental deterioration. There was a certain -improvement early in the hospital stay of the patient. Consciousness was -clear and orientation perfect. The delusions themselves, though -extravagant, were not inconsistent or fantastic. The hallucinatory -disorder was hardly characteristic either of manic-depressive psychosis -or of paresis. - -The patient might be described as “interesting.” A good preliminary -training with years of travel and variety of occupation, furnished him -with a fund of knowledge. An excellent memory, prompt replies and -repartee, endless digressions with voluntary return to the original -topic, caused him to be an amusing and even instructive interlocutor. -However, his commitment and confinement in the institution seemed always -entirely wrong, and he expressed mixed feelings about the family, now -being bitter against them, and again condoning their mistakes. The -patient’s conduct was good and he was tidy in habits, and tried as far -as possible to conform to the requirements of the hospital. The doctor -showed a marked antipathy toward a certain male attendant, who had -removed articles from his clothing upon admission and had reclaimed a -book on rules and regulations. The doctor prepared a list of 327 -different acts of abuse, lack of care, and insubordination which he said -he had observed in the hospital. - -In the last weeks of the patient’s illness, his ideas became more -expansive and extravagant, dealing with a grapevine system of wireless -communication and delusions of unlimited wealth. He would at times keep -his room flooded with urine and water for the purpose of keeping down -the plague which he said was infecting the hospital. Later he mixed food -with urine and other ingredients, claiming that he was constructing an -elixir of life. - -The =autopsy= showed few changes of the calvarium or of the dura mater, -nor was the pia mater more than slightly thickened and milky over the -frontal poles, along the longitudinal fissure and over the sulci. There -were fairly firm adhesions of the pia mater to the dura mater along the -longitudinal fissure and over the frontal poles and at the temporal -tips. The hemispheres were firmly interadherent, and the -cerebello-pontine tissues were covered with a firm leptomeningitis. The -floors of the ventricles were smooth and the basal vessels showed little -beyond a few spots of sclerosis. There was a generalized increase of -consistence. The frontal gyri were rather prominent with wide sulci, but -upon section no very marked atrophy of the gray matter could be shown. -The rest of the brain failed to show any flaring of sulci or any special -evidence of cortical atrophy. The brain weighed 1250 grams; a possible -diminution of 100 grams, considering the patient’s body length. However, -it must be remembered that he was at this time 63 years of age. - -=Microscopically=, the diagnosis of GENERAL PARESIS was confirmed on the -basis of plasmocytosis, lymphocytosis, gliotic changes and nerve cell -destruction. There was an unusual variation in the degree of the -destructive process, which picked out, for example, certain regions of -the right side for maximal lesion (cornu ammonis, gyrus rectus, and -superior frontal gyrus). - -If the patient’s own estimate of 35 years’ duration for his -Argyll-Robertson pupils can be trusted (and in general his memory was -extremely good), we may well conceive an unusual duration for the -process in his case. There was, however, in the body at large no very -marked degree of changes. There was a slight old tuberculosis. There was -a slight interstitial nephritis, with cardiac hypertrophy and fibrous -myocarditis. There was also a sclerosis of the mitral and aortic valves; -there were chronic changes in the spleen, liver, and bladder; there was -generalized arteriosclerosis of mild degree; there were two round -gastric ulcers near the pylorus. The liver weighed but 800 grams, and -its left lobe was somewhat rough. - -This case is placed among the medicolegal and social cases because the -phenomena that ushered in his last illness were mistaken by the local -public for meritorious social reform measures. They were regarded as not -markedly different from the variety of steps taken by the very active -doctor in previous years; indeed the public eloquence that he displayed -a year before his death was quite in line with previous habits, despite -the suspicious over-brilliance of language. It is an important question, -how far the eccentricity and literary overactivity of the latter half of -the doctor’s total life can be explained on the basis of a mild -syphilitic irritation of the nervous system. In this connection we are -tempted to recall the suggestions of Mœbius concerning a portion of the -literary products of Nietzsche. Our doctor was by no means so brilliant -an exemplar of syphilitic literature as was Nietzsche, if we grant the -hypothesis of Mœbius to cover our doctor’s case as well as that of -Nietzsche. In the future, important studies of character change under -the influence of syphilis will doubtless be made. With modern diagnostic -methods, of course, the diagnosis would have been rendered almost at -once in the case of Major Isaac Thompson, M.D., and much of his past -life would have been brought under special review in connection with the -syphilis which doubtless the blood serum or at any rate the -cerebrospinal fluid would have shown. - -This case illustrates but one of the many social complications arising -as the result of paresis. When one recalls that the onset is often -insidious and not correctly understood for a period of time, it is -readily seen that many unfortunate acts may be committed by a patient. -As hypersexual desire is not an infrequent early symptom and as judgment -is early disturbed, loose morals may ruin the patient’s reputation. The -poor judgment and expansive delusions often lead to foolish business -deals wherein the patient’s family is left destitute. At other times the -onset is sudden and then the danger of false commands or acts by a -person in a responsible position, as a steamship captain, an engineer or -chauffeur, may lead to loss of life and property. - - - =Sudden grandiosity: debts. PARETIC NEUROSYPHILIS (“general - paresis”): Question of liability.= - - -=Case 84.= Lester Smith was a salesman, 31 years of age, who, while on a -business trip, accompanied by his wife, suddenly developed grandiose -ideas. He originated a scheme of cornering the phonograph market. His -prospects seemed so certain to him, that he hired an expensive suite of -rooms in a hotel at something over $35 a day. As at the first -presentation of his bill it was found that he had no money to meet these -charges, he was taken into custody and at once transferred to a hospital -for the insane, where it was discovered that he was suffering from -GENERAL PARESIS. - - 1. What is the patient’s responsibility for these debts? Legally the - patient or his estate is responsible for debts accruing from - services rendered or goods received. As he is adjudged _non compos - mentis_ contracts entered into would not hold, and he would not be - considered liable for criminal acts. - -Note: This case shows how dangerous paresis may be not only to the life -and usefulness of a patient, but further how it may ruin a family -financially. Mr. Smith’s little escapade used up all the money that he -had been able to save in his life and when he was taken to a hospital -his wife was left destitute. - - - =Suicidal attempt (?) by a neurosyphilitic.= - - -=Case 85.= At first Mrs. Annie Monks, a widowed seamstress, 50 years of -age, did not particularly suggest syphilis. Mrs. Monks was sent to us -from a general hospital. She had been found unconscious in her room, -with gas turned on, and a diagnosis of gas poisoning was made. Mrs. -Monks remained unconscious for 24 hours, and her apparent suicidal -attempt seemed to warrant her being sent to the Psychopathic Hospital. -Mrs. M., however, scoffed at the idea of any attempt at suicide, and -claimed to have had no recollection of any such affair. On the contrary, -she had gone to mass the morning of the day on which she was taken to -the hospital, remembered well enough returning to her room but nothing -of what followed until she woke up. - -Mrs. Monks was not coöperative and would reveal few facts about her -history. For years, she had had edema of the feet and palpitation of the -heart (the heart was somewhat enlarged, with a double murmur in the -aortic area, systolic louder, and a blood pressure of 160 systolic and -85 diastolic; clubbed fingers; palpable liver). She had been treated in -the out-patient department of a general hospital for a number of months. -We could obtain no evidence of mental impairment, particularly none of -memory. - -Aside from the heart lesions above indicated, the patient was fairly -well nourished, with a slight enlargement of superficial glands, and was -otherwise normal. - -=Neurologically=, the slightly irregular pupils reacted poorly to light; -the right knee-jerk could not be obtained, whereas the left knee-jerk -was very active. Systematic examination revealed no other disorder -except that the abdominal reflexes could not be obtained. - -Here we have, in a cardiac patient, a possibly or probably accidental -gas poisoning, and little to go upon for a profounder diagnosis than the -sluggish irregular pupils and unilateral absence of knee-jerk. - -The routine serum W. R. came through as positive. Following custom, we -examined the spinal fluid, finding the W. R. here again to be moderately -positive (strongly positive to 1 cc., moderately to 0.7 cc., and -negative to 0.5, 0.3, and 0.1 cc.). The gold sol index was 1 2 2 1 0 0 0 -0 0 0, which must be interpreted as syphilitic. There were 16 cells to -the cmm., the albumin was 1+, and the globulin stood at 2+. - -Here, then, we seem to have evidence of an inflammatory process of the -central nervous system, and it is natural forthwith to be sceptical as -to the accidental nature of the gas poisoning. Perhaps there was an -attempt at suicide based upon a passing impulse, or perhaps there was a -period of confusion in which the cock was not turned off. - -In any event, we feel justified in making the diagnosis of cerebrospinal -syphilis on the basis of the neurological and laboratory findings. On -the whole, we are inclined to make a diagnosis of VASCULAR NEUROSYPHILIS -with a moderate involvement of the MENINGES. - - 1. What is the outcome in such cases as that of Annie Monks? The - case somewhat resembled that of Martha Bartlett, who still - survives. The case of Annie Monks illustrates another outcome. A - few days after her admission, she became unconscious once more, - and upon recovery remained very much confused and aphasic, - moaning, and unable to handle herself well, although without - definite paralysis. Three weeks later the patient died, although - in the meantime strenuous antisyphilitic therapy was practised. - Death was sudden. We thought death due to cerebral embolism. - - - =Early delinquency and neurosyphilis in a juvenile.= - - -=Case 86.= Frank Johnson was 21 years of age when he was taken up by the -police for threatening his sister with a revolver. The police thought he -deserved an examination at the Psychopathic Hospital. The patient -protested that he had threatened his sister only to frighten her -because, he said, she nagged him and made him nervous. In fact, they had -always had trouble as she had always nagged him and they had always -fought together. Moreover, their mother always took the sister’s part. -They had been troubling him for days, and at last Frank could stand it -no longer. His sister had complained of the way he treated her dog. -Moreover, Frank said he had not been feeling well; there had been some -trouble with his stomach; and after one of the nagging attacks, he had -taken out an old empty pistol to scare his mother and sister. - -In these cases, it is good practice to consult the sister also. She said -that Frank had always been very difficult to manage, unwilling to work, -preferring to loaf about, spending every obtainable cent; he was once in -a reformatory for several years, but not reformed thereby; recently -given to drinking; at times acting somewhat peculiarly (sitting at the -window with his hat on, refusing to move). - -Further =mental examination= of Frank showed that he was properly -oriented and in possession of a good memory, although he was quite -obviously a liar. He lay about in bed at the hospital, saying that he -was too weak to be up. He was a bit dull, at times not readily grasping -ordinary questions. - -=Physically=, Johnson was rather thin; the teeth were somewhat -peg-shaped although far from typically Hutchinsonian. The pupils were -unequal and irregular, and failed to react to light or even to -accommodation when tested. The deep reflexes of arms and legs could not -be obtained, though the superficial reflexes were present. For the rest -systematic examination proved negative. Serum W. R. negative. - -The first thought in such a case would be that the criminological -diagnosis of delinquency would be sufficient. However, the pupillary -disorder and the areflexia are suggestive despite the negative serum W. -R. Resort was naturally had to lumbar puncture, whereupon a positive W. -R. was found, a characteristically “paretic” gold sol reaction, -globulin, excess albumin, and 134 cells per cmm. In short, it would -appear that we must consider a diagnosis of JUVENILE PARESIS, and, in -point of fact, the patient deteriorated rapidly from this time, becoming -demented at the end of a few months. - - 1. How far are the early difficulties of management (leading to a - reformatory) due to syphilis? We should not dogmatically say that - there is a relation between the early delinquency and syphilis. - Still, it is not unusual to find emotional disorder and - instability as well as delinquency in congenital syphilitics. - - 2. What suggestion, if any, should be made to the patient’s - intelligent and seemingly normal sister, two years older? We - prevailed upon Miss Johnson to submit to the W. R. of the serum, - which was found, as in the case of Frank, to be negative. Frank’s - sister should undoubtedly submit to a lumbar puncture; but in the - present phase of mental hygiene, she would be difficult to - persuade. - - 3. How is it possible to find such a marked evidence of congenital - syphilis in a younger sibling with no evidence of syphilis in the - elder? In the first place, there may be a history of entrance of - syphilis into the lives of the parents between the pregnancies. - However, in other instances, there is no evidence of such - intercurrent syphilis, and contrary to the prevailing opinion it - is not so infrequent to find congenital syphilis in the younger - brother or sister of a normal person. - - 4. What can be said of treatment in such cases? In the first place - it is clear that delinquent cases should be tested far earlier for - the possibility of syphilis. Had this case been examined by a - neurologist or alienist many years earlier, it is probable that - the same pupillary signs and the peg-shaped teeth would have been - found, and that the hypothesis of syphilis might have been raised. - There is no good evidence as yet that these cases can be markedly - benefited by treatment. - - - =Neurosyphilis in a “defective delinquent.”= - - -=Case 87.= Vivian Walker, 22 years of age, was arrested on the streets -of Boston for drunkenness. Upon arrival at the jail, she developed a -series of convulsions, each lasting a very brief time, with loss of -consciousness, frothing at the mouth, and jerky movements of the arms -and legs. - -The Walker family was known to the police, since there were police -records in two generations on the maternal side. The father was regarded -as of rather low-grade mentality; a sister had committed suicide. Vivian -herself had been irregular at school, was regarded as vicious, and had -been hysterical. She had been committed to a reformatory at the age of -15 years. In the reformatory she had a number of excited outbreaks, with -resentment of discipline, and these outbreaks presented hysterical -traits. After each outbreak Vivian was depressed. It was during her stay -at the reformatory that her sister committed suicide. Vivian attended -the funeral, and the idea of suicide appears to have taken hold of her -mind, as she constantly spoke of suicide, threatened suicide, and made -several attempts. She claimed at this time to see visions and to hear -her sister’s voice. On that ground she had been committed to a hospital -for the insane at 16. - -At the hospital there were many fluctuations in mental condition. Vivian -professed discouragement on account of poor home influences, telling how -her mother had often been in prison, allowing Vivian to come under the -influence of bad girls. Now and then Vivian had outbreaks of profanity -and glass-breaking, and she also made at the hospital for the insane -several half-hearted attempts at suicide. At the age of 19 she was -returned to the reformatory, whence she was placed out on probation and -allowed to return home. - -However, she was shortly re-committed to the insane hospital in a phase -of excitement, talking continuously of men and sex relations, and also -of imaginary illicit sex relations with any man whom she happened to -see. Again from time to time she made attempts at suicide. However, she -was allowed to go out on visit, returned to her habits, and at the time -of her arrest was living as a prostitute. - -After her convulsions in jail, she was admitted to the Psychopathic -Hospital. At first obstinate and stubborn, later she became tractable. -Special mental tests left her in the subnormal class, but we could -hardly class her as feebleminded. We were able to observe her in a -number of seizures, during which she would drop to the floor, apparently -lose consciousness, writhe about, and assume the position of -opisthotonos, the whole attack lasting but a minute or two. - -There was pelvic tenderness, with gonococci in the urethral smear. -Salpingectomy had to be performed, but after the operation Vivian -insisted upon getting up and running about on the second day, tearing -the bandages from her abdomen, and infecting the wound. Outbreaks of -excitement also followed the operation. - -In the diagnosis of this case, we must probably separate the convulsive -phase from the remainder of the phenomena. The conduct disturbance, -emotional outbreaks, and suicidal attempts date from early youth, and no -doubt the diagnosis defective delinquent would fit Vivian from the -beginning. The hereditary taint is characteristic enough. The sundry -phenomena in the insane hospital, and particularly the hallucinations, -lead one to wonder whether Vivian is not possibly even suffering from -dementia praecox. - -As to the convulsions, it would hardly appear that they are typically -epileptic, although certainly epileptoid. Their onset at 22 is somewhat -unusual. Several features of the seizures together with the opisthotonos -and the previous history of hysteria, lead one to think of making the -diagnosis hysteria. - - 1. Can cerebrospinal syphilis cause the symptoms? We found the serum - W. R. to be positive though Vivian denied syphilitic infection. - (She also denied gonorrhœal infection despite the clinical and - laboratory findings.) We found that the spinal fluid yielded a - gold reaction of a typical syphilitic nature, showed an excess of - albumin, a slight amount of globulin, and 130 cells per cmm. Even - these findings, however, would perhaps not justify stating that - the convulsive seizures are of syphilitic nature. The seizures - disappeared under the administration of antisyphilitic remedies. - It would seem, therefore, that the seizures should be regarded as - of syphilitic nature. In any event, the diagnosis of cerebrospinal - syphilis is justifiable. This syphilis, however, is of an active - nature and probably of recent production. We should be at a loss - to explain the earlier mental features in Vivian as syphilitic and - are therefore fain to associate the two psychoses, PSYCHOPATHIC - PERSONALITY and DIFFUSE CEREBROSPINAL SYPHILIS. - - - =NEUROSYPHILIS (“paresis sine paresi”) in an habitual criminal, a - forger.= - - -=Case 88.=[17] —— was brought to the hospital by the police. He was -charged with having forged a check, and on account of the crudeness of -the work his mental condition was suspected. - -=Family History.= The paternal grandfather was considered fast, drank a -great deal and was said to be a thief. The father is said to have been -forced to leave the State when a young man in order to avoid the -reformatory. Paternal cousin murdered a man; the sisters of this cousin -said to have been wild and one brother married a prostitute. Nothing -known of maternal relatives. - -=Past History.= Medical history is unimportant. He denies syphilis. His -early childhood is of little significance. He was somewhat dull in -school. At about the age of twelve he began to lie and steal, and has -continued this ever since. His attempts have all been very crude, it is -said, and when confronted he would strenuously deny his deeds, even when -the evidence was overwhelming. He forged checks, borrowed money from all -his friends, and charged things at stores to the family. The family paid -the bills for a time, and then later had him sent to a reform school. He -was married at nineteen, but wife has left him and obtained a divorce. -He has been excessively alcoholic for years, and is suspected also of -taking drugs. He was discharged from the navy dishonorably. He later -joined the army and was discharged therefrom on account of “rheumatism,” -according to his account, but in reality deserted. He had finished a -jail sentence of thirteen months for forgery a little over a year before -entrance. - -=Physical examination= shows a well developed and nourished man. The -general physical examination is negative. The lungs show nothing -abnormal. The heart is not enlarged, there are no murmurs or -irregularities; blood pressure, 145 systolic. The alimentary system is -negative. No palpable lymph glands. =Neurological examination=: pupils -equal and react to light and accommodation. Extraocular movements well -performed. Tongue projects in the median line, with no tremor. There is -no evidence of facial paresis or weakness of the muscles. The biceps, -triceps, knee-jerks and ankle-jerks are present and equal on the two -sides. There is no Gordon, Babinski or Oppenheim; no ankle clonus. There -is no tremor of the extended hands. No Romberg sign. There is a little -difficulty in the finger-to-finger test. There is no sensory disturbance -either subjective or objective. No tenderness over nerve trunks. - -=Mental examination= shows nothing of a psychotic nature. Patient is -well oriented; memory for remote and recent events is well preserved, -school knowledge well retained, grasp on current events good; no -delusions or hallucinations elicited. Patient is not feebleminded, -according to the intelligence tests of Binet and Simon and -Yerkes-Bridges, but shows poor attention and gives evidence of weakness -in volitional spheres; is very suggestible. - -To summarize the case, then, we have a man of thirty years of age who -has shown criminalistic and anti-social tendencies since childhood, -whose general physical and neurological examination is negative -(excepting the laboratory tests), whose mental examination shows no -psychotic symptoms, and who seems not feebleminded. In other words, with -the exception of the serological and chemical findings in the blood and -cerebrospinal fluid, there is nothing to suggest that he is more than a -“criminal type.” - -Wassermann reaction in blood serum positive. - -Wassermann reaction in cerebrospinal fluid positive. Examination of -cerebrospinal fluid: globulin ++, albumin ++, cells 55 per cubic -millimeter; large lymphocytes, 9.1 per cent; small lymphocytes, 90 per -cent; plasma, 90 per cent. Gold sol reaction, 3321000000. - - 1. Can the criminalistic tendencies be condoned in this case on the - ground of neurosyphilis? As a matter of fact the delinquencies in - this patient reach back to early childhood and as there is no - evidence of congenital syphilis it cannot be held that syphilis - had any bearing in the causation of symptoms. Even were the - delinquencies only of recent date it is doubtful if the court - would take cognizance of the laboratory findings in the absence of - definite mental symptoms. In this connection it may be stated that - the court takes cognizance only of the acts of a patient at time - of examination, and not of the history or laboratory findings, in - committing a person. We have had several patients who from - history, physical signs and laboratory tests made the diagnosis of - paretic neurosyphilis easy and yet who could not be committed - because they were mentally clear at the time. Such patients may be - of grave potential danger to themselves and families, and present - numerous social problems. See case of Joseph Wilson (95). - - - =JUVENILE PARETIC NEUROSYPHILIS (“juvenile paresis”) with initial - trauma.= - - -=Case 89.= Margaret Tennyson was a small girl of six years, described as -having been normal until run down by a double-runner sled about 13 -months before her arrival at the hospital. The change was stated to be -remarkable. “She was as unlike her own self as darkness and daylight.” -Once fat and sunny, talkative and demonstrative with her toys, now -Margaret had become silent, sullen, worried, and of a violent temper, -stubborn and unmanageable. It does not appear that the patient was -seriously injured by the double-runner, as she was able to walk a short -distance home. Shortly, however, she began to have trouble with her feet -(diagnosed at the time as flat-foot), and thereafter her whole character -and disposition changed. Upon arrival at the hospital, the patient -walked with a typical scissors gait of spastic paraplegia. - -=Physical examination= was very difficult through lack of coöperation -and a screaming and kicking resistance upon every attempt. There was a -suggestion of hydrocephalus in the protrusion of the forehead. The -pupils reacted readily to light and accommodation. The knee-jerks were -active, but there was otherwise no disorder of reflexes. The patient had -great difficulty in getting up from the floor, and for the most part -insisted upon lying in ventral decubitus on the floor, crying when -attempt was made to raise her. An attempt was made to test her by the -Binet scale, by which she was found to rate at 2⅘ years although a -portion of this low-rating was thought to be due to a failure of -coöperation. - -The =family history= threw little or no light upon the case. The parents -were living and well; a brother of 16 years was at work in the market -district; two of the other siblings are in the first and second grades -at school and regarded as exceptionally bright by their teachers. The -fourth was the patient, Margaret; a fifth had died at 9 weeks of heart -trouble; the sixth, seventh, and eighth, of 3, 1½ years and 3 months -respectively, appeared entirely well. There were no miscarriages or -stillbirths. - -[Illustration: - - Juvenile paresis—spastic paraplegia. 5 years. -] - -The scissors gait and spasticity seem to point undoubtedly to organic -disease of the nervous system, along with which the mental deterioration -seemed to suggest an active progressive involvement of the cerebrum. The -history seemed to be convincing that the child was not an instance of -congenital feeblemindedness. - -A neurologist’s clinical diagnosis would naturally be syphilis. In point -of fact, this diagnosis was borne out by the laboratory tests, which -showed a positive W. R. in the serum and spinal fluid, positive -globulin, a slight excess of albumin, and a syphilitic gold sol -reaction. - - 1. What is the significance of the trauma in the case of Margaret - Tennyson? The trauma seemed to the family the precipitating cause. - We find cases of general paresis in adults very definitely - following trauma, yet neurosyphilis, both in adults and in younger - patients, mainly occurs without trauma. On the whole, in this - case, it is perhaps safer to regard the trauma as mere - coincidence. A sister older than Margaret was found upon - examination to have a positive W. R. The other children could not - be examined. - - - =Traumatic form of PARETIC NEUROSYPHILIS (“general paresis”).= - - -=Case 90.= The point about Joseph O’Hearn was his entire mental -soundness up to the time of an injury at work, when he was blown through -a double window in an explosion, badly bruising his head. Shortly after -the accident, although not immediately, the patient began to show signs -of mental disorder, doing very foolish things, losing his memory, and -becoming unable to work. - -It was eight months after the explosion when O’Hearn, at the age of 36, -was admitted to the hospital with general mental impairment. O’Hearn was -confused and disoriented for time and place, although he seemed to -understand that he was in a hospital. He was given to foolish laughter -and a silly manner. There was considerable emotional disorder; judgment -was clearly impaired, and memory was poor. - -=Physically=, there was little to be found except upon =neurological -examination=. The right knee-jerk was greater than the left; the tongue -and fingers showed marked tremor, there was a speech defect and writing -disorder. - -On the whole, it seemed impossible not to make the diagnosis GENERAL -PARESIS, especially in view of the laboratory tests, with positive W. R. -in both serum and fluid, a “paretic” type of gold reaction, 59 cells per -cmm., excess albumin, and a large amount of globulin. - - 1. What is the relation of the trauma to the paresis? Trauma is - regarded as a precipitating cause, and Industrial Accident - Commissions have been known to allow damages in such cases. Mott - believes that the symptoms of a post-traumatic paresis must not - develop until after a week’s interval of freedom from symptoms, - since he believes that time is required to destroy or irritate the - brain to the point of producing the paretic picture. Our data are - in agreement with those of Mott. Mott also points out that gumma - sometimes occurs at the site of the trauma. - - - =False claim for compensation in neurosyphilis.= - - -=Case 91.= The facts in the case of Levi Sussman can be brought out by -the following extracts from a report to the Industrial Board: A claim -was made to the Board that the symptoms had developed after a fall from -a building, some _nine months before hospital observation_. No -connection could be found between this accident and the PARETIC -NEUROSYPHILIS found. We introduce the case to emphasize the possibility -that irrelevant accidents may be regarded by ignorant or unscrupulous -persons as setting up a mental disorder for which damages are claimed. -If symptoms are already in existence before the accident and are not -especially increased thereafter, naturally no damages should be -recovered. Unscrupulous persons may falsify about the pre-traumatic -history and claim the development of symptoms immediately after the -accident. Such claims are beyond question to be viewed with the greatest -suspicion. Some days or weeks should elapse before definite symptoms in -post-traumatic paresis appear. Just how long an interval may elapse -between trauma and paretic symptoms and shall entitle the case to be -regarded as one of traumatic paresis, is perhaps a matter of doubt. It -would seem, however, on general grounds that three months is the longest -period in which the post-traumatic effects are likely to be delayed. - -The question of traumatic paresis is of great interest on account of the -war. The great strain under which the men at the front live and the -physical injury due to being “buried” is probably responsible for an -increasing number of cases of neurosyphilis. Such at least is the -impression of Canadian medical officers with whom we have spoken. See -Section VI, Neurosyphilis and the War. - - - =Traumatic exacerbation(?) in PARETIC NEUROSYPHILIS (“general - paresis”).= - - -=Case 92.= The case of Joseph Larkin was of note from the point of view -of the Industrial Accident Board. This Irish teamster was said to have -been injured in his head two or three months before coming up for -examination at the age of 45. For a week Larkin had had frontal -headaches, had been sleeping poorly, and had been somewhat worried. In -fact, he had stopped work. The W. R. of the serum was positive and a -diagnosis of PARESIS could be made. The case did not come up for -consideration by the Industrial Board until two years after his initial -appearance. - -The =physical examination= showed irregular pupils, sluggish pupillary -reactions, Achilles absent, swaying in the Romberg position, enlargement -of the heart to the left, positive W. R. of the blood and of the spinal -fluid. - -=Mentally=, the patient’s orientation for place was poor and his memory -defective. Emotionally he was depressed or apathetic and was -apprehensive. His flow of thought was slow, and his insight into his -condition poor. - -It is interesting that a variety of causes have been assigned in this -case for the condition: such as, his work, anemia, unhygienic -surroundings, and arteriosclerosis. - -This case is not a sharply-defined case of post-traumatic general -paresis, since there had undoubtedly been a variety of mental changes -before the accident. Accordingly, recovery of damages to a full amount -could hardly be expected as in certain cases in which the phenomena of -paresis appear only after the trauma. - -[Illustration: - - Post-traumatic cranial gumma—developing 13 months after local injury - of skull. -] - - - =Trauma: syphilitic lesion of skull at site of injury.= - - -=Case 93.= The medicolegal interest of Richard Marshall is extreme, as -may be seen from the following brief report by the Psychopathic Hospital -to the Industrial Board. - - “As to the case of Richard Marshall, a patient under the provisions - of the temporary care act from December 1 to December 10, inclusive, - this case has proved unusually interesting in that the patient has - proved to be syphilitic by the Wassermann reaction of the blood. - There is no evidence of syphilis in the examination of the - cerebrospinal fluid. The X-ray examination of the skull, taken in - connection with the Wassermann reaction of the blood, warrants the - diagnosis of syphilitic osteitis of the skull at the site of the old - injury. We regard his present condition as shown by the X-ray as a - syphilitic bone condition predisposed to by the injury. We do not - find that the patient has any features of traumatic neurosis. - - “Mentally, having an actual age of 30, patient grades at 11.2 years. - It may be that patient has always been a moron. He has earned about - $8.30 a week. - - “We regard the patient as deserving treatment and feel that - responsible parties in the case would do well to have such treatment - instituted.” - -The principal symptom of which Marshall complained was headache chiefly -felt in the region of the osteitis. There was marked sensitiveness to -percussion in this area. It is of course difficult to decide whether the -headache was entirely due to the gummatous lesions or whether the trauma -had caused contusions of the brain as well. It is also possible that the -dura underlying this area was involved. - - - =OCCUPATION-NEUROSIS in a granite-cutter: SYPHILITIC NEURITIS?= - - -=Case 94.= David Fitzpatrick was a case referred to the Psychopathic -Hospital by the Industrial Accident Board. He was a granite-cutter of 52 -years of age, and had begun to complain of pain in the forearm, -extending back from the elbow, about six months before admission. It -seems that the patient had been growing progressively worse and had -thought he would have to quit work because of difficulty in grasping the -hammer. A physician had told him that he must stop his work at -granite-cutting or else he would entirely lose the use of his arm. He -was in point of fact laid off because of slackness of work and had been -unable to get work again. The pain in the arm, however, had continued -and at times was very severe. Sometimes the pain and the worry led to -insomnia. Fitzpatrick wanted the insurance company to pay certain -accumulated bills, and maintained that he would be able to do work at -$15 a week if work could be found for him. The general situation in this -case can be gathered from the following abstract from the report to the -Industrial Accident Board. - - “Secretary Industrial Accident Board, - “Dear Sir: - “_In re_ David Fitzpatrick - - referred to us with a copy of an impartial report filed by the - Massachusetts General Hospital,—we concur with said impartial report - that there is now no evidence of paralysis of the arm. We do not - find that the positive Wassermann reaction, although it indicates a - history of syphilis, has affected the patient other than possibly to - have reduced his general mental capacity. Our special tests yielded - a percentage of 62% of what a patient of his age and station should - possess. There seems, however, to be no connection between this - reduction of mental capacity and the difficulty with the arm. We - cannot connect the history of alcoholism with the arm trouble. - - “There is some evidence that other stone workers have at times shown - such effects. - - “The patient’s fairly circumstantial account of his difficulty seems - to point to a degree of myalgia or muscular pain in the region of - the forearm when held in a certain position and a feeling of - numbness in the third and fourth fingers. Whether these phenomena - are due to local pressure upon nerves in the upper part of the - forearm due to neuritis, or whether we are dealing with a functional - neuralgic phenomenon is a question. - - “We have applied some special tests for faradic sensibility to all - the fingers of both hands and have found that the fingers of the - right hand are still less sensitive than those of the left, - particularly the thumb and the little finger. This test has not yet - been applied in a sufficiently large number of cases to prove any - difficult point, nevertheless the findings are in line with the - patient’s own circumstantial account of former feelings of numbness - in the third and fourth fingers of the right hand. - - “Obviously, then, our opinion is that there is still to be found - some effect of the disease, whatever it was, which caused the - patient to knock off work. If we had more experience with such cases - and more data with the new test which we have applied, we should - perhaps be inclined to admit the diagnosis of _occupation neuritis_ - and to suppose structural alterations in the nerve trunks - corresponding with the location of the muscular pain and the - anesthesia of fingers and the dulling of electric sense, but in the - present stage of our experience, it is probably wiser to call the - case one of _occupation neurosis_.” - -It is clear that the W. R. in this case was of peculiar value in at -least partially clearing up the findings, yet it must be remembered that -it is a principle of the modern administration of industrial accident -boards and similar organizations that it is the employer’s lookout -whether the employee has syphilis. Recovery can be made as if the injury -were due wholly to an accident. It was not possible however definitely -to prove or disprove a relation of syphilis in the form of a syphilitic -neuritis to the condition in this case. - -The special tests above referred to are the electric sensory threshold -tests of E. G. Martin. - - - =Character change: neurosyphilis.= - - -=Case 95.= Joseph Wilson offered a very serious social problem. He was -the father of two children, and his wife was pregnant at the time of his -admission to the Psychopathic Hospital. He was a husky-looking man of 33 -years of age, but for the past four years he had been deteriorating in -his work; he had been drinking heavily, and finally had stolen to obtain -money for liquor. It was on account of his alcoholism and delinquency, -which were taken as an indication of change of character, that he was -sent to the hospital. - -Examination on his arrival disclosed at once that there was more to the -case than alcoholism, for the =neurological examination= showed that the -pupils were irregular, the right being larger than the left, both -reacting sluggishly to light, and there was an inequality in the -reaction of the two eyes, the left being better than the right. The -tendon reflexes were exaggerated, with ankle clonus on both sides, more -marked on the right. There was also a marked speech defect. Otherwise -the =physical examination= showed nothing of importance. - -The W. R. of the blood and spinal fluid was strongly positive. The -globulin test was strongly positive, the albumin was markedly increased, -there were 74 cells per cmm., and a gold sol reaction of the “paretic” -type. - -A formal =mental examination= did not show very much of consequence; his -memory showed no marked impairment, he was not deluded or hallucinated, -and he had a pretty good insight into his failings. However, he was -somewhat childish, and his irritability was quite marked. Were one to -rely upon the mental signs alone, it is probable that a diagnosis of -chronic alcoholism with deterioration would be made; but in the presence -of the physical findings and the laboratory tests, the diagnosis of -neurosyphilis had to be given. It is obvious that, while the patient was -suffering from a progressive brain disease, and while he did show mental -symptoms, there was not sufficient ground on which to commit him, and -therefore he had to be turned out into the community. As a matter of -fact, he was not prosecuted on account of his theft, because, although -legally responsible, it was felt that his disease was at the basis of -the character change which had led him into difficulties. Further -developments of his relations with society had to be considered, -however. It was possible to get him to discontinue the use of alcohol -altogether, and for nearly a year he has taken no alcoholic liquor and -has been self-supporting. However, his irritability has been very great, -making it very difficult for his wife to live with him, and causing his -sister to break off all relations with him. - -Here, then, is a man with a marked CHARACTER CHANGE as the result of -neurosyphilis, so that it is difficult for him to maintain the usual -social relations. It does not seem possible to remove him from the -community. - - 1. May one speak of general paresis without mental symptoms? If one - considers general paresis a mental disease, of course it cannot - exist without mental symptoms. However, if one considers the - disease as a chronic syphilitic meningoencephalitis characterized - by its pathological anatomy, then one may readily speak of general - paresis although no real evidence of mental symptoms can be - discovered. It would seem that we must take this attitude with our - present conception of brain localization, for it is easy to - conceive of a general paretic process affecting areas which do not - definitely relate to psychic function. And further, such a process - may exist but not be of such a grade as to cause mental symptoms. - - - =The neurosyphilitic’s family should not be forgotten in diagnosis - and treatment.= - - -=Case 96.= The Bornstein family is remarkable. Let us hang the story on -Becky, the mother, an Austrian woman of 43 years, who appears to have -been perfectly well up to within a year. About a year ago, Mrs. -Bornstein began to suffer from severe headaches, which were treated with -apparent success by an osteopath: at all events, Mrs. Bornstein -recovered therefrom in about six months. However, two months later, she -had a convulsion, with foaming at the mouth, blueness of face, and -general muscular stiffening. The convulsion lasted for several minutes. -Again, a fortnight before admission, the patient had five convulsions of -an identical nature in a single night. - -Moreover, since the first convulsion, Mrs. Bornstein’s =mental -condition= has altered and become variable, so that at times she is -excited, at times depressed. She would assert inaccurately that there -was some one in the house, and that she had at different times committed -crimes of a heinous nature. Now and then she would seem to see moving -pictures. Her memory was poor and she seemed to believe that events of -five or six years ago had just happened. - -The pupils were sluggish, the knee-jerks and ankle-jerks were absent, -there was slight ataxia, and there was speech defect. The suspicion of -neurosyphilis was so strong that it seemed surprising that the W. R. of -the blood serum, even after repeated tests and after the provocative -injection of salvarsan, proved negative. However, the spinal fluid -yielded a positive W. R., and a gold sol reaction of the “paretic” type, -together with 12 cells per cmm., and a marked increase of albumin, with -positive globulin. It would seem warrantable to make a diagnosis at -least of syphilis of the nervous system in this case, but it is a -question whether we should be warranted in making the diagnosis general -paresis. - -That the diagnosis is doubtful may perhaps be seen from the variety of -diagnoses in the rest of the family. In the first place, Mrs. -Bornstein’s husband admits syphilitic infection many years before. He -states also that his wife after marriage showed signs of syphilis and -received some treatment, although limited. It is stated also that the -husband himself at this time has a positive W. R. and has stiff pupils -and petit mal attacks. The oldest son, 22 years of age, is confined in -an institution with juvenile paresis. The second son has recently died -at the age of 20 years, receiving a diagnosis of rupture of the aorta. A -third son, 19 years of age, has the appearance of having achondroplasia, -although the proportions of his limbs do not quite correspond with those -of an achondroplast. The fourth son, 17 years of age, is suffering from -caries of the spine. A fifth son, 14 years old, is neurotic and has the -so-called Olympic forehead. The sixth and last son died shortly after -birth of unknown cause. - - - =Neurosyphilitic’s normal-looking family proved syphilitic.= - - -=Case 97.= Walter Heinmas was a draughtsman 33 years of age when he was -brought to the Psychopathic Hospital suffering from mental disease. This -was diagnosed as general paresis, both on account of the clinical -symptomatology and on account of the laboratory findings. In fact, it -was a case of the classical type with marked euphoria and grandiosity. - -As is the routine procedure at the Psychopathic Hospital, in the case of -all syphilitic patients, the family was sent for. This consisted of the -wife and two daughters, aged 9 and 7 respectively. The patient denied -any knowledge of a syphilitic infection. The wife, also, gave no history -of any primary, secondary, or tertiary symptoms; there had been no -abortions, miscarriages, or stillbirths; both children had been born at -term and had been entirely healthy. Examination showed that the mother -had no signs referable to syphilis, and that both the children were -mentally well endowed, with good physique and showing no stigmata of -congenital syphilis. Still the W. R. of all three (the mother and the -two children) was positive in the blood serum. These tests were repeated -several times on the children, with and without injections of salvarsan, -and they remained consistently positive. - - 1. Are these children to be considered congenital syphilitics - despite the absence of stigmata or symptoms? We must consider - these children as congenital syphilitics and candidates for the - group frequently spoken of as _syphilitis hereditaria tarda_. - - 2. What is the frequency of syphilitic involvement in the mate and - children of paretics? In our series, we have found that about 15% - of the marriages where one member develops paresis, result in - sterility; that in 18% abortions, miscarriages and stillbirths - occur; and that in 15% positive W. R. is obtained. We have adopted - the motto: “=The families of paretics are the families of - syphilitics.=” - - - =Neurosyphilis: question of marriage.= - - -=Case 98.= Mr. Jacobs’ wife was admitted to the hospital with a -diagnosis of general paresis. A few weeks after her admission, she died -as a result of her disease. According to our routine, her husband and -the children were examined for evidences of syphilis. - -Mr. Jacobs’ blood serum was found on repeated tests to be positive. He -resolutely denied any knowledge of a syphilitic involvement, but it was -later learned from his brother that about two years before his -marriage—that is, more than 25 years before we saw him—he had acquired -syphilis and had had a very small amount of treatment. - -Mr. Jacobs was put upon antisyphilitic treatment in the form of -injections of .3 gram of salvarsan every two weeks with occasional -intramuscular injections of mercury salicylate. After seven months of -treatment, the blood serum still remained positive. At about this time, -the patient came to us to ask about getting married again. He said that -he was living with his sister, who kept telling him that he was the -cause of his wife’s death, and this was so unpleasant that he desired to -start a home for himself again! - - 1. What advice should be given? It is a general opinion that the - longer the period after the initial infection, the less the - chances of infecting a partner. This chance is further reduced - under antisyphilitic treatment, of which a considerable amount had - been given in the case of Mr. Jacobs. However, when one considers - the trickiness of syphilis and the fact that there is some chance - of infection, which we would apparently overlook if we gave him - permission to marry at this time, the only possible course was to - tell the patient that he should not consider marriage until his - Wassermann had become negative and remained so for some time. The - children in this case were negative. - - 2. What is the physician’s duty to the family of a syphilitic - patient? It is our firm conviction that it is the duty of every - physician to his syphilitic patient, to the patient’s family, and - to the community, to examine the mate and the children for - evidence of syphilis acquired or congenital and to offer treatment - if it is found to be needed. This is one of the chief means at our - disposal today to prevent the late disasters of syphilis, acquired - or congenital, for by such examinations the syphilitic condition - is discovered before lesions have occurred which are irreparable. - We know that the mate and children of a syphilitic patient have - been exposed to syphilitic involvement, and it is our duty as - physicians in possession of such knowledge, and as guardians of - the public health, to investigate such cases, so that if they be - found to have syphilis, steps may be taken to treat them early. - - 3. How much danger is there of causing unhappiness and breaking up - families by this procedure? This question offers a chance for many - theoretical answers. The facts are, however, that in doing this as - a routine for nearly three years and examining several hundred - families, there has been no instance to our knowledge in which a - family has been broken up or grave difficulties have been - encountered by this procedure. - - 4. In what percentage are the mates or children of neurosyphilitics - found to show definite symptoms of syphilis? It is our opinion - that the situation in regard to neurosyphilitics is the same as - for syphilitics in general: That the same laws of attenuation of - virus, and of chance occur here as elsewhere. - -Just as this book is going to press, we have learned that the distraught -Mr. Jacobs, still desirous of starting a home for himself and feeling -entirely well, consulted a physician. This physician took a sample of -blood and had it tested at a competent laboratory, which reported the -blood negative. - -On the strength of this test, the physician felt himself warranted in -recommending, or at least not advising against, Mr. Jacobs’ marriage, -which has probably now taken place. - -Although there is some doubt what ethical relation a state institution -shall maintain with physicians in private practice, we took occasion to -call the attention of our patient’s new counsellor to the fact of the -patient’s neurosyphilis. We noted that the man’s serum had been -constantly positive (Massachusetts State Board of Health findings) in a -score or more of observations. We called attention to the fact that -lumbar puncture had shown positive signs of neurosyphilis, including a -positive W. R., globulin, excess albumin, pleocytosis, and positive gold -sol. These facts, according to a letter received from the private -practitioner in question, have not altered his opinion in the slightest -to the effect that our patient is completely normal and entirely -suitable for marriage. It is clear that he regards the patient as not a -victim of General Paresis. - - 5. What is the significance o the negative observation eventually - obtained in Jacobs’ serum? One’s first thought is to impugn the - accuracy of the laboratory work, but against this suspicion is the - excellent reputation of the laboratory in question, and the - agreement in the majority of its findings with those of the State - Board of Health. It is more likely, as we assured the private - practitioner at whose request the observation was made, that this - negative test was an exceptional and isolated observation such as - is not infrequent in long series of observations, particularly - those made under therapeutic conditions. In so important a matter, - we are inclined to feel that the physician in question should have - resorted to two more observations at intervals before running - counter to the position taken by the hospital. - - - ——many a hard assay - Of dangers, and adversities, and pains. - - Paradise Regained, Book IV, lines 478–479. - - - - - V. SOME RESULTS OF TREATMENT - - -Cases 99–103 show the Variety of Structural Lesions that Treatment has -to face. - - - =SPASTIC HEMIPLEGIA in PARETIC NEUROSYPHILIS (“general paresis”), - showing marked degenerative changes, a condition in which therapy - could be theoretically of very little avail. Autopsy.= - - -=Case 99.= James McDevitt arrived at the Danvers Hospital, July 20, 1906 -(saying that he came to be “thawed out”), and died less than six months -later: January 12, 1907. He was 34 years of age. He had been a -shoe-worker after leaving school, had worked eight years with the -General Electric Co., and had then become a bartender. He had, however, -stopped work in September, 1905, and we may safely say that mental -symptoms had begun insidiously at about that time. His symptoms, if -there were any, had been masked by a heavy alcoholism, but an obvious -change had appeared in November, 1905. The patient lost ambition, smoked -and loafed about his room, and developed speech disorder. He denied -venereal disease, nor was there any superficial evidence of such. - -=Physically=, the patient showed little or no disorder except acne of -the trunk, patches of eczema on the left lower chest, and numerous -brownish scars along both tibiae. - -=Neurologically=, the Romberg position was maintained, but the gait was -very unsteady on attempts to walk a straight line; fingers, tongue, and -face were tremulous, and finer movements were performed with marked -incoördination. No direct or consensual light reactions could be -obtained in the pupils, which were dilated and irregular. - -The condition of the reflexes is important on account of the autopsy -findings. The abdominal and cremasteric reflexes were prompt, and the -knee-jerks equal and very lively. Achilles and normal plantar reactions -were present; there was no clonus; the arm reflexes were very brisk. - - - =COMMON THERAPEUTIC CONCEPTION= - - [M]VP = TYPICAL PARESIS - - MV[P] = TYPICAL CEREBROSPINAL SYPHILIS - - [M]V[P] = TYPICAL SYPHILITIC ARTERIOSCLEROSIS - - (M = Membranes, V = Vessels, - P = Parenchyma, [] = not involved) - - CHART 21 - - -The =mental symptoms= need not detain us. Consciousness was clear; -orientation for time, place, and to some extent for persons, was -imperfect. Arithmetic had been largely forgotten. Handwriting was -irregular and scrawling, and in places unintelligible. Although the -patient claimed that his memory was intact, it was decidedly imperfect. -He remarked that John D. Rockefeller, a Chicago king, was President; the -General Electric Works had almost 50,000 people at work; and in fact -Lynn was one of the largest cities in the state, having over 12,000 -people. The height of patient’s room was estimated at 25 feet. There was -a slight euphoria. There was never any doubt of the =diagnosis= of -PARETIC NEUROSYPHILIS (“general paresis”). - -Five months after admission, slight convulsions developed, after which -the patient was more dull and demented; he became bedridden. More -convulsions followed, leaving the right arm and hand useless. There were -clonic spasms of the muscles of both lower legs. Decubitus developed and -death occurred. - -We may set the total duration of symptoms in the case of James McDevitt -at a little over a year; nor is there any evidence of previous or -prodromal symptoms beyond a total period of about 15 months, unless we -may regard his leaving the General Electric Works to become a bartender -some nine years before death, as a symptomatic change of character. In -any event, it is of note that the =autopsy= showed singularly few -lesions. Death was due doubtless to complications following decubitus, -and there was a slight acute splenitis. The kidneys showed some -parenchymal change. The aorta showed many patches of sclerosis, with -calcification or ulceration throughout its length. These changes were -not characteristic of syphilitic disease. There was considerable -coronary arteriosclerosis and a slight mitral valvular sclerosis. There -was a brown atrophy of the heart muscle, somewhat surprising in a man of -34 years. The =brain= was practically normal, weighed 1200 grams, and -showed convolutions normal in size, relation, and arrangement. There was -no sclerosis grossly evident in the blood vessels. The pia mater -appeared to contain a considerable excess of clear fluid. The calvarium -was of normal thickness and showed diploë and the dura mater failed to -show adhesions. There were no macroscopic signs of lesion in the spinal -cord. - -=Microscopically=, the lymphocytosis, plasmocytosis, and phagocytosis of -the perivascular spaces, (relative?) increase in blood vessels, the -gliosis, and evidence of nerve cell destruction, taken together -warranted the diagnosis of PARETIC NEUROSYPHILIS. It was plain that the -nerve cell destruction was best marked in the _inner layers of the -cortex_. The microscopic study of the spinal cord showed that there was -very possibly a slight sclerosis of the posterior columns in the lumbar -region, but this was so slight that it could hardly be noted in the -myelin sheath stains (Weigert). Very sharply marked, on the other hand, -were the _bilateral pyramidal tract lesions_ in the lumbar and thoracic -regions, less marked at the cervical levels. - -Without attempting to analyze carefully all these findings, it is -interesting to note in this case a foil to the usual spinal cord picture -of paretic neurosyphilis. The spinal cord, ordinarily normal, or perhaps -more usually affected by a degree of posterior column sclerosis, in this -case showed such well marked pyramidal tract sclerosis that we may -perhaps place the case in a subordinate group of SPASTIC PARETIC cases -of NEUROSYPHILIS. The source of the pyramidal tract disease lodges, -however, in the cortex cerebri itself, being part and parcel of the -lesions mentioned above as affecting more directly the inner layers of -the cortex. Many of the so-called giant, or Betz, cells had undergone a -complete destruction. It will be remembered that clonic spasms of the -muscles of the legs appeared in the fortnight preceding death, and that -there had been convulsions for about six weeks before death. There was -no evidence at the autopsy why the right arm and hand should have become -useless, whereas the left upper extremity remained normal. This case, -then, forms an exception to the ordinary paretic neurosyphilis group in -that the brunt of the microscopic process was borne by the inner layers -of the cortex. The cells of origin of the pyramidal tract fibres had -been cut in this lesion, and had become subject to partial or complete -destruction. Note, however, that the lesion remained a microscopic one -and that the marked convulsions were not related to gross lesions, -thereby following the rule for paretic seizures. - -[Illustration: - - Bilateral pyramidal tract sclerosis, secondary to destruction of large - motor (Betz) cells of motor (precentral) cerebral cortex—paretic - neurosyphilis. -] - -From the standpoint of possible treatment, it is of course true that few -organs of the body showed grave lesions save in the calcified and -ulcerated aorta, which conceivably might have become quiescent under -appropriate treatment. But, although the brain was almost if not quite -normal in the gross, and although its membranes showed practically no -lesion, treatment would not have been very promising. To be sure, the -exudate might have been cleared away if the spirochetes responsible -therefor had been destroyed by treatment. Yet the destruction of the -giant cells of origin of the pyramidal tract fibres to such an extent as -in this case could hardly have been compensated for by any known -process. So far as we are aware, the destruction of considerable numbers -of the smaller association elements of the brain is subject to the -compensation of other elements of the nervous system, which conceivably -might be re-educated or newly educated to perform certain processes. The -histological picture in a case like that of McDevitt accordingly leads -to the hypothesis that so well marked a spastic paresis, even in the -presence of otherwise favorable signs, would be of especially baneful -portent therapeutically. - - - =NEUROSYPHILIS with total duration of symptoms twenty-two days. The - comparatively MILD BRAIN LESIONS, INFLAMMATORY AND NOT DEGENERATIVE - in type, suggest the possibility that therapy might have been - successful. Autopsy.= - - -=Case 100.= Jacob Methuen, 35, was a carpenter from Newfoundland. He was -working upon a certain Thursday with his brother, who noticed that Jacob -was lifting the tools about in an unusual manner and talking strangely -to his fellow workmen. He fell asleep, going home in the street car, and -said afterward that he felt dazed and peculiar. He talked all kinds of -nonsense to his wife upon arrival. Methuen remained in bed next day, -fancying he was going to die, calling his family together, and saying -good-bye to them. He remained in bed all through the next day, but on -Sunday appeared better,—more active, and in fact quite natural. He slept -only an hour Sunday night, calling to his wife that it was time to get -up. On Monday he began to be irritable to his wife, and accused her of -flirting with his brother and intending to elope with him. He struck his -wife several times, and when two brothers came to watch him, accused -them both of trying to steal his wife, and struck them. Tuesday he -remained in bed until late at night, when he arose and tried to assault -the family. - -It seems that another brother of the patient had died but eleven days -before his admission to the hospital and five days before the onset of -Jacob’s symptoms. Since his brother’s death he had been dwelling upon -religious matters, and in fact the day after his brother’s death, he -waked up during the night, saying that he was too happy to sleep, that -he heard the Master’s voice, and at times the devil’s voice; that there -was to be a modern miracle and his spiritual life from now on would be -different. - -Eleven days after admission to the hospital, Methuen died, making a -total duration of symptoms, beginning at his brother’s death, of 22 -days. - - - =NEUROSYPHILITIC LESIONS= - - =LESIONS OF THE SECONDARY PERIOD= - - (1) INTERSTITIAL ENCEPHALITIS OR MYELITIS - (“meningitis”) - (2) PARENCHYMATOUS ENCEPHALITIS OR MYELITIS - (“encephalitis,” “myelitis”) - - =LESIONS OF THE TERTIARY PERIOD= - - (1) CHRONIC INTERSTITIAL ENCEPHALITIS OR MYELITIS - (“gummatous meningitis”) - (2) CHRONIC PARENCHYMATOUS ENCEPHALITIS - (“dementia paralytica”) - (3) CHRONIC PARENCHYMATOUS MYELITIS - (“tabes dorsalis”) - - “We have shown that the central nervous system is affected by - syphilis at the same periods and in the same manner as are other - internal organs. In addition the ‘parasyphilitic’ lesions are also - of a typically syphilitic nature, being directly comparable to the - parenchymatous affections found elsewhere in the body. They are - ‘tertiary’ lesions differing only from the so-called ‘gummatous’ - processes in the central nervous system in that their localization - is in the parenchyma while that of the latter is in the - interstitial tissues.” - - McIntosh and Fildes, 1914 - - CHART 22 - - -=Physical examination= showed a man 5′ 9″ tall, weighing 149 pounds, -rather pale and poorly nourished, with a somewhat enlarged heart and no -evidence of venereal disease. - -=Neurologically= there was a slight facial and digital tremor, but -otherwise no symptom or reflex disorder except that the tendon reflexes -were generally increased; the knee-jerks especially were very vigorous. -There was no speech defect. His handwriting was fairly legible. - -The patient was very noisy and uncontrollable, tearing clothing and -biting, striking the attendants, refusing food, talking rapidly, loudly, -and incoherently. His manner suggested auditory hallucinations but no -positive evidence of these was obtained. His clothes could not be kept -on him. The following is a sample of his reactions: As the examiner -entered, the patient stood stark naked and glaring. He started to talk -as follows: “Methuen,—I, Saviour, come to life and ought to die—— Now I -lay me—— Now I die—— The heart beats—— No, I ain’t going to die—— I am -going out soon. I want my clothes—— You can’t hold me; I am strong.” -(Struggles violently with the attendants.) “I am God. God. I know you, -you can’t fool me.——I am here——I can do you all. How many doctors are -there here?” (Struggles violently. Looks at examiner.) “He is writing -something. Sir, you can’t fool me in a million years. Do you understand -that, doctor? You can’t fool me. Write all the prescriptions you want -to. Ten thousand years; you hear that, doctor? Ten thousand years. You -can’t fool me; ten thousand years. Ten thousand years are but a day for -the spirit of the Lord,” etc., etc. - -The excitement continued unabated. The patient became entirely -disoriented, and finally almost unable to move. He lay in bed trying to -talk and muttering broken gibberish, still attempting to struggle to the -extent of his limited strength. - -The =autopsy= showed no sign of lesion (brain weight 1380 grams), -unless, perhaps, the occipital regions were slightly firmer than the -rest of the brain. Death was apparently due to a bilateral pneumonia, -bronchial type. There was an acute splenitis. The only chronic lesions -of the body were a bilateral chronic adhesive pleuritis and a slight -sclerosis of the arch of the aorta. - -[Illustration: - - Paretic neurosyphilis (“general paresis”) macroscopically normal, - microscopically characteristic. Treatment does not have to face - massive destructive processes already complete. -] - -=Microscopically= there was a distinct though mild degree of -lymphocytosis of the perivascular spaces in many regions. Somewhat -extended _search failed to reveal plasma cells_, and it is certain that -if plasma cells existed, they must have occurred in very small numbers. - -Here, then, was a case of DIFFUSE NEUROSYPHILIS (with brain picture -consistent) with symptoms lasting but 22 days and with an appearance of -acute mania. It is to be noted that this case arrived at the hospital on -the eleventh day of his symptoms. The case occurred long before the -development of the temporary care system in Massachusetts. It is -probable, or at any rate possible, that he would have been brought to -the hospital far earlier, say, upon the sixth day, had the modern -temporary care system been installed at that time. The routine W. R. -examination would then have been made. With more effective hydrotherapy, -it is possible that the patient’s life might have been prolonged and -that treatment might have been effective. So far as we can see, the case -would have been a singularly good one for treatment despite the -practical unmanageability of the case under ordinary home treatment, and -even under hospital conditions where modern hydrotherapeutic appliances -are not available. - - - =PARETIC NEUROSYPHILIS showing very MARKED MENINGITIS, suggesting - that therapy might have produced improvement. Autopsy.= - - -=Case 101.= We report the case of John Baxter, a boat tender of 48 -years, because this particular victim of PARETIC NEUROSYPHILIS seems to -have had the most markedly thickened and altered meninges in our whole -series. Of course, the therapeutic theory upon which we now proceed in -the treatment of non-paretic and possibly even of paretic neurosyphilis -is that, other things being equal, the meningitis can be removed by -treatment, or in the course of treatment, so that the degree of ultimate -recovery rather depends upon the condition of the brain substance itself -than upon the condition of the meninges. Here, at all events, is an -example of the most highly meningitic neurosyphilis that we have seen. - -Curiously enough, two of Baxter’s brothers were also patients at the -hospital at which Baxter died, and a number of the other members of the -family are reported as “nervous.” It seems that at 35 Baxter began to -drink heavily and had never given over the habit of alcoholism. - -Upon admission to the hospital, in fact, he showed a sufficiently -typical picture of delirium tremens. His consciousness was clouded, he -had vivid visual hallucinations and was very apprehensive. - -His heart was enlarged to the left; the pulse, 120, was of increased -tension and irregular; there was peripheral arteriosclerosis; the teeth -were poor; the tongue coated; and the mouth foul. The urine showed a -trace of albumin and rare hyalin casts. - -=Neurologically=, the gait was somewhat unsteady, there was an extreme -tremor of the whole body, including the tongue and fingers. The Romberg -sign was negative although there was marked swaying. The pupils were -equal and reacted normally; the knee-jerks were markedly exaggerated, -the arm reflexes somewhat exaggerated. The remainder of the reflexes -upon systematic examination were negative. - -[Illustration: - - A high degree of chronic leptomeningitis. Pia mater thick, opaque, - concealing brain. In paretic neurosyphilis (“general paresis”). -] - -Upon arrival, Baxter was put to bed, but he barricaded his door and -fought with the attendants. The tremor increased, the hallucinations -were both visual and auditory. After a few days, Baxter became so weak -that he could not move. He refused to eat for a period of two days, -explaining in whispers that he did not wish to be poisoned; a voice had -told him the food was to be poisoned. The voice was of agreeable tones, -probably belonging to a lady; it did not speak, but sang to him. The -clouding of consciousness failed to clear up, as in delirium tremens, so -that, though patient was admitted March 3d, it was hardly possible to -speak freely with him until more than a month later, April 9th. A -good-natured conversation would run as follows: - - “What is your name?” “Baxter.” - “First name?” After long pause, “Don’t know.” - “John?” Pause of 7 seconds, “Yes, I think it is.” - “How old are you?” “There are legs——there is a body——up to here——” - “Say the alphabet.” Term not understood. - “Say the _a_, _b_, “Oh yes; a, b, c, d (long pause), e, f; I cannot - _c_.” say it, I did not have much education; I am not - intelligent.” (In point of fact, the patient had - a good grammar-school education, and had long - worked as a clerk in a grocery store, with good - wages.) - There was some - speech defect. - -Soon the hallucinatory phase passed, and the patient remained in a -cloudy and disoriented state, inaccessible, rarely speaking, and -gradually failing physically. Death occurred about three months after -admission (pulmonary symptoms). - -In estimating the duration of the process in John Baxter, we must take -into account that he left the grocery business and became a hard-working -but poorly-paid boat tender at about 35 years, at the same time that the -alcoholic habit began. - -The =autopsy= showed that death was due to bronchopneumonia with -pleurisy. There were in the body a variety of chronic lesions, such as -gastritis, colitis, epididymitis, splenitis, parietal and valvular -endocarditis, prostatitis, chronic appendicitis, and some mesenteric -lymphnoditis. The heart was somewhat hypertrophied. There was a slight -diffuse nephritis with cysts, emaciation, and decubitus. The calvarium -was thick and somewhat dense. The dura was thickened and adherent, and -the pia mater,—as above stated, the most thickened and altered pia mater -in our series,—is described as everywhere thickened, of a brownish gray -and white color, especially over the vascular lines, and as showing -small white areas of deeper thickening scattered over the surface, but -most markedly over the sulci, and not as a rule over the crowns of the -gyri. There were also yellowish brown spots with a suggestion of fibrin -over the lateral aspects of both hemispheres. The vessels at the base -were not remarkable in the gross. The brain weighed 1220 grams, and -appeared to be of darker color than usual. - - - =Some cases of PARETIC NEUROSYPHILIS (“general paresis”) have so - much BRAIN ATROPHY that it is not possible to expect much - improvement through antisyphilitic therapy.= - - -=Case 102.= Theodosia Jewett, dead at 58 years, showed the most -remarkably wasted brain in a long series of victims of paretic -neurosyphilis. We present her case to emphasize what therapy must face -in certain instances, but would recall the fact that exceedingly few -such wasted brains have come to our attention in cases dying in the -institutions of Massachusetts. - -Mrs. Jewett, a housewife, whose parents died of shock, and one of whose -two brothers also died of shock, was a normal child and schoolgirl, and -worked as dressmaker until she was married, at 24, to a grocer, by whom -she had two children. At the age of 46, Mrs. Jewett began to suffer from -so-called “nervous prostration.” The attack lasted some two years, but -there were no psychotic symptoms beyond worry and insomnia. The -menopause occurred at 52, at which time the first signs of psychosis -appeared, namely, a forgetfulness concerning familiar matters, such as -sewing, cooking, and the like. At 55, this amnesia had become so marked -that Mrs. Jewett could neither write nor tell time. She, however, was a -perfectly quiet and easily manageable patient, often subject to -drowsiness in the day. - -Six months before her admission to the hospital, she began to suffer -from insomnia, failed to recognize her surroundings, and had a number of -crying spells. Restlessness had begun a month before admission; auditory -hallucinations developed in the form of imaginary conversations with -dead persons. A certain loquacity set in, and for a week before -admission, Mrs. Jewett became somewhat resistive. - -=Physically=, the patient was sallow, poorly nourished, with pale mucous -membranes, peripheral arteriosclerosis, no teeth, muscular feebleness, -tremor of hands and tongue, and active knee-jerks. =Mentally=, the -patient was depressed, talked to herself, assumed a supplicating -position, suddenly altered her attitude, and was very tremulous. Her -talk was low, mumbling, and incoherent, for the most part composed of -answers to her own questions. Sometimes there was a curious difficulty -in speaking, such that the lips moved but no sound emerged; but for the -most part there was no difficulty in uttering words. The patient either -could or would not write. Only when the attention was secured by -speaking to her sharply was she apparently able to understand questions, -and the answers to these sharp questions came spasmodically and as if -interrupting her own thoughts. Nor was it ever possible to obtain a -repetition of the same answer. - -The patient died in exhaustion, with pulmonary symptoms three weeks -after admission. - -The =autopsy= which was performed 3½ hours after death showed the -following points of interest: - -The heart weighed 210 grams. There was marked thickening of the aortic -valve. The coronaries were slightly thickened. - -The lungs were slightly adherent to the chest wall at the apices and -posteriorly. The right lung was consolidated in the lower two lobes -posteriorly and the bronchi exuded pus; the left lung was not -remarkable. There was a chronic splenitis. - -The liver showed fibrous changes, was a brownish-red in color, mottled -with yellow. - -Combined weight of the kidneys 195 grams. The capsules were adherent, -tearing the cortex when stripped. - -The diploë were well marked. The dura was not adherent. The pia was -slightly thickened and raised from the cortex by a large amount of -subpial fluid (showing atrophy of the cortex). The pial vessels were -injected, more markedly so on the left side. The arachnoid villi were -reported as moderately developed, especially along the longitudinal -fissure. - -The brain was rather soft in all regions. The weight was 1045 grams. -According to Tigges’ formula the weight of the brain should be -approximately 8 times the body length in centimeters. The length in this -case was 158 cm., therefore, according to this formula the weight of the -brain should have been 1464 grams. The difference of more than 400 grams -is evidently a loss to be accounted for by atrophy, a very heavy loss. - -[Illustration: - - Perivascular exudate (low power) in atrophic cortex from case of - general paresis. -] - -[Illustration: - - Markedly atrophic cortex, but without local perivascular exudate. -] - - 1. Was the “nervous prostration” at 46 of syphilitic origin? One - cannot give a categorical answer to this question. The high - incidence of shock in the family suggests poor stock in which a - psychoneurosis is not an unusual phenomenon. The presence of - syphilis might act as a debilitating factor or _agent - provocateur_, if it were not to cause any demonstrable brain - lesion. As pointed out in the case of Harrison (9), however, it is - not unusual in neurosyphilis to find a history of symptoms - occurring years before the final breakdown and symptoms frequently - not recognized as of neurosyphilitic nature. - - 2. Does the fairly long duration of the psychosis (at least 3 years) - explain the marked atrophy? Cases having symptoms even much longer - than three years at times show relatively very little atrophy, so - that this factor in itself cannot be said to explain the - tremendous destruction of tissue. - - - =The THERAPY OF NEUROSYPHILIS has to face not merely variations in - the degree of brain wasting and in the degree of meningitis, but - also variations in the topographical distribution of lesions. - Autopsy.= - - -=Case 103.= To bring out this point we may instance the case of Alfred -Weed, a victim of PARETIC NEUROSYPHILIS, dying at the age of 48 years -after a course of about seven years. The following is an abstract of the -clinical history: - -A. W. suffered from lues some 24 years before his death at Danvers -Insane Hospital in 1907. There is no account of insanity in his family. -The patient had been undergoing mental changes for six years before -death. At the age of 42 began to take interest in socialism and -spiritualism. Would become excited at times and was observed to talk to -himself. At times it seemed that he was reacting to visual -hallucinations. After eight months he became depressed and apprehensive -and developed delusions of poisoning. - -On admission to the Danvers Insane Hospital in June, 1902, the subject -was found to be ataxic, falling in the Romberg position. Pupils were -equal but of pin-point size. There was tremor of the facial muscles. The -knee-jerks were absent. Speech was ataxic. Memory defective. Depressed. -Thought he was to be punished. Refused to eat. - -Later in the year of admission, patient became more negativistic. He -refused to have his clothes brushed. His answers were slow. Mental -arithmetic was correctly but slowly done. During January, 1903, the -patient was apt to be active and talkative for a time, and then his -attitude would suddenly change to one of silence, resistivement and -untidiness. From time to time he would be querulous and sulky. In -August, 1903, the patient became weaker and could walk with assistance -only. Paralysis developed in the left facialis region and in the left -external rectus. Pupils were still small, but the left had become -smaller than the right. Light reaction tests unsatisfactory. Knee-jerks -could not be obtained. - -In December, 1903, the patient was untidy and helpless, lying with his -thighs and legs flexed. The limbs were spastic on passive motion. In -1905, the pain sense of the legs was found lost and the pupils were -small and stiff. The protruded tongue was deflected to the right. The -right labial fold was more prominent than the left. Knee-jerks remained -absent. Ataxia was extreme. - -The =Neurological Findings= may be summed up as follows: - - 1. Ataxia of the legs. - - 2. (Probable) Diminished sensibility in the legs. - - 3. Pupils small and stiff. Left smaller than the right. - - 4. Paralysis of left facialis. - - 5. Paralysis of left external rectus. - - 6. Tongue protruded to right. - - 7. Right elbow jerk greater than left. - - 8. Knee-jerks absent. - -The cause of death was bronchopneumonia. The walls and valves of the -heart showed a few chronic changes. There was a marked splenitis and an -atrophy of the liver. The kidneys showed numerous depressed scars. The -arch of the aorta was somewhat sclerotic. The following is a full -description of the head findings which we present by way of comparison -with other cases. Note especially the cerebellar, dentate, and olivary -changes. Note also the fact that palpable sclerosis is demonstrable over -a far larger area than atrophy, so that we may almost safely conclude -that the process of induration sometimes precedes that of atrophy. One -gets the impression from the extent of visible atrophy and tangible -induration in this case, that a possible therapy would have not merely -to clear the perivascular spaces of cells and spirochetes, but would -also need to arrest the indurating and wasting process. Nor could any -therapy deal effectively with the superior frontal and upper central -atrophy of the cerebrum of this case, or with the olivary and cerebellar -lesions. - -=Head=: Hair thin at vertex. Scalp normal. Calvarium thin and dense. -Dura mater slightly adherent to calvarium at vertex. Sinuses normal. -Arachnoidal villi well developed. Pia mater of anterior and central -regions contains an excess of fluid. The pial veins well injected. - -The =pia mater= exhibits one unusual lesion: Faintly yellowish brown -spots of miliary and slightly larger size are scattered irregularly in -clusters over the vertex. These miliary pial macules are observed -especially over the posterior third of the left superior frontal gyrus -(a group of twelve or more). Two are seen in the pia mater of the right -superior frontal gyrus. One is seen in the upper part of the left post -central gyrus. The upper end of the right postcentral gyrus contains -three macules. - -Besides these brownish macules, the pia mater also shows focal white -thickenings which resemble the more frequent appearances of chronic -fibrous leptomeningitis. The white thickenings are of irregular size but -are, as a rule, larger than the macules above mentioned. They occur, as -a rule, over the sulcal veins and are most frequent in the anterior -region. - -The vessels at the base are normal. There is no evidence of pial -thickening at the base of the brain. =Brain= weight, 1265 grams. There -is visible atrophy of both superior frontal gyri and of the upper -two-thirds of both central gyri. The extent of palpable sclerosis -surpasses that of visible atrophy. Palpable increase of consistence is -shown by the prefrontal, orbital (more marked on left side), frontal, -central, hippocampal and occipital regions. The temporal cortex is of -normal or slightly reduced consistence. - -Section of the cerebral cortex shows everywhere preservation of the -cortical markings. The sclerosed areas show a diminution in depth of the -cortex, which is more marked in the left prefrontal region. The white -matter of the centrum semiovale of the prefrontal and occipital regions -on both sides shows an increase of consistence. The cerebellar cortex -also shows variations in consistence. The clivus and lobus cacuminis and -the posterior half of the inferior surfaces of both cerebellar -hemispheres are firmer than normal. The laminæ of the left clivus are a -trifle narrower than those of the right. There is visible extensive -atrophy of the laminæ on both sides of a fissure in the middle of the -left lobus cacuminis. In the coördinate portion of the right cacumen -there is a similar process which is less marked. The dentate nuclei are -firm. The olives show an increase of consistence, equal on both sides. -The left olive shows on section a crowding together of its folds in the -middle part of the upper limb. - -Spinal cord was not remarkable. - -=Summary=: - - Adhesive pachymeningitis - Chronic fibrous leptomeningitis - Miliary pial macules - Cerebral atrophy - Cerebral sclerosis - Cerebellar atrophy and sclerosis - Bronchopneumonia - Chronic splenitis - Nephritis - Aortitis - - - =It is generally recognized that DIFFUSE NEUROSYPHILIS - (“cerebrospinal syphilis”) frequently is cured through - antisyphilitic therapy. Example. Mental improvement, in one month; - recovery from paralysis, ten months.= - - -=Case 104.= John Edwards, a man of 28 years, well developed and -nourished, with general enlargement of glands and skin lesions, came to -the hospital in a stuporous condition, with evidences of a complete -hemiplegia. - -According to the wife, Edwards had had a chancre of the lip about a year -before, for which he had been treated with an intravenous injection, -presumably of salvarsan, and also presumably with mercury. The lip -lesion had then disappeared. For a month before admission, Edwards had -had headache and dizziness, for which he was given pills and drugs. -There had also been difficulty with speech and numbness of the left arm -as far up as the elbow, but this paresthesia had quickly disappeared. -The hemiplegia was of only a few days’ duration. After a feeling of -nausea and vomiting, the patient had fallen with left-sided paralysis. -Afterwards, he had shown mental peculiarities, eventually becoming -noisy, hard to manage, and appropriate for hospital care. - -The =physical examination= showed a variety of increased reflexes, -including ankle clonus on the left side. - -The question might arise whether this case was one of hemorrhage or -thrombosis, and the facts about the onset of the hemiplegia are -inadequate for a decision. However, at so early an age, the probability -of syphilis is large and the history of labial chancre was quite -suggestive. If we may conclude neurosyphilis, the diagnosis of -thrombosis rather than rupture of blood vessel is likely. The laboratory -tests bore out the diagnosis since the W. R. of serum and fluid both -proved positive; the gold sol reaction was syphilitic; there were 176 -cells per cmm.; there was excess albumin, and a positive globulin -reaction. - - - =NON-PARETIC NEUROSYPHILIS= - - =DIFFUSE NEUROSYPHILIS, - MENINGOVASCULAR PARENCHYMATOUS, - CEREBROSPINAL SYPHILIS= - - CASES SYSTEMATICALLY TREATED 13 - CLINICAL RECOVERY, C.S.F. NEGATIVE 11 - UNIMPROVED 1 - UNIMPROVED, BUT C.S.F. NEGATIVE 1 - - MASSACHUSETTS COMMISSION ON MENTAL - DISEASES, - _November, 1916_ - - CHART 23 - - -The outcome in such a case is dubious. If death does not occur soon, -recovery is not impossible under treatment. At all events, a -considerable improvement is likely. - -Edwards was given bi-weekly injections of salvarsan, intramuscular -injections of mercury salicylate, and doses of potassium iodid, -averaging 100 grains, three times a day. Under this treatment, he slowly -recovered and became mentally clear after a few weeks. The paralysis -seemed complete and permanent. Even after three or four months, there -was absolutely no change in the condition, and Edwards was quite unable -to move either arm or leg. Meanwhile, the spinal fluid had become -practically negative to all tests. - -_Treatment_ was somewhat optimistically continued and was _rewarded at -the end of ten months_ with marked improvement such that the patient was -able to stand on the paralyzed leg and move the arm to a certain degree. -This improvement is still continuing. The spinal fluid and the serum -have remained negative to laboratory tests. - -Note: A period of six months is commonly regarded as that period in -which improvement in paralysis is to occur if there is to be any -improvement. There was certainly not the slightest improvement in the -paralysis of this case before eight or nine months of treatment had -elapsed, and it took ten months to secure the marked improvement -mentioned. - - 1. What is the significance of the prodromal symptoms? The headache - and dizziness should have been viewed with great gravity. They are - characteristic in MENINGOVASCULAR NEUROSYPHILIS. - - Moreover in this case there had also been difficulties with speech - and other transient symptoms which should have called attention - far earlier to the possibility of neurosyphilis. - - 2. What is the significance of the high cell count: 176 per cubic - millimeter? Such high cell counts are frequent enough in diffuse - neurosyphilis, but low cell counts are frequent also. But although - the high cell count taken alone is of lesser significance, the - fact that the high cell count in this case is associated with a - “syphilitic” gold sol reaction is of far greater significance for - diagnosis. These associated findings are characteristic of - meningovascular neurosyphilis. - - 3. What kind of recovery may be expected in successful examples of - treatment in meningovascular cases? Recovery with defect. It will - be noted that ten months elapsed before any marked improvement - occurred on the paralyzed side. We could not expect a complete - recovery from this paralysis. - - 4. Was inadequacy of treatment following the chancre responsible for - the early cerebrospinal involvement? In this connection one must - remember that such neural involvements occur occasionally even - during active treatment (neurorecidives). The discontinuance of - treatment after a short period, in this case less than a year, is - always a risk to say the least. And this is true even though the - W. R. becomes negative, for trouble of a neurosyphilitic nature - may occur later; this when both blood and spinal fluid have - previously been found negative. The old rule of following and - treating a syphilitic for several years despite the disappearance - of symptoms is still a good rule. - - - =The results of systematic, intensive, intravenous salvarsan therapy - in atypical neurosyphilis (cases not certainly paretic, tabetic or - the common types of meningovascular neurosyphilis) may be in our - experience as good as the results of treatment in common - meningovascular cases: example.= - - -=Case 105.= Henri Lepère, a machinist, 48 years of age, came voluntarily -to the Psychopathic Hospital for a gradually failing memory and -inability to work. He had had indigestion for four years (epigastric -distress, nausea, no vomiting). He was still suffering from epigastric -distress and from headaches. At times he had had difficulty in walking. - -=Physically=, Lepère looked older than he was; he was very poorly -developed and nourished, and seemed very weak. There was a slight -visceroptosis. - -=Neurologically=, there was considerable speech defect, particularly -well marked in test phrases. The pupils were contracted and gave the -Argyll-Robertson reaction. Neurologically there were no other signs. - -=Mentally=, there was a depression with worry; but it was a question -whether these phenomena were not entirely natural. The special complaint -was of failing memory. - -The Argyll-Robertson pupil also _prima facie_ signifies neurosyphilis. -Lepère, in fact, admitted syphilitic infection at 23. The gastric -symptoms at once suggested tabes. The knee-jerks and ankle-jerks were, -to be sure, preserved; however, this is not very unusual in tabes. The -amnesia and aphasia naturally suggested paresis. Without resort to -laboratory findings, accordingly, the diagnosis of taboparetic -neurosyphilis (“taboparesis”) was suggested. - - - =EFFECT OF EARLY TREATMENT ON THE DEVELOPMENT OF NEUROSYPHILIS= - - TOTAL CASES 4134 - DEVELOPED GENERAL PARESIS 198 = 4.8% - DEVELOPED TABES DORSALIS 113 = 2.7% - DEVELOPED CEREBROSPINAL SYPHILIS 132 = 3.2% - ——————————— - 443 = 10.5% - - =EFFECT OF TREATMENT= - Repeated - None 1 course energetic - NUMBER OF CASES 100 134 924 - DEVELOPED G.P. 25 = 25% 31 = 23.1% 30 = 3.2% - DEVELOPED TABES 11 = 11% 16 = 11.9% 25 = 2.7% - DEVELOPED C.S.S. 3 = 3% 21 = 15.6% 71 = 7.6% - - Poorly Better - treated treated - 1880–84 1895–99 - NUMBER OF CASES 617 1139 - DEVELOPED G.P. 60 = 9.7% 37 = 3.2% - DEVELOPED TABES 22 = 3.5% 16 = 1.4% - DEVELOPED C.S.S. 15 = 2.4% 28 = 2.4% - - MATTAUSCHEK AND PILCZ - - CHART 24 - - -The serum W. R. proved positive, but the spinal fluid W. R. very -slightly so (yielding only moderate reaction with 1 cc., 0.7 and 0.5 -cc., and a negative reaction with 0.3 and 0.1 cc.). Globulin was -moderate, and albumin was found in only moderate excess. There were 21 -cells per cmm. in the spinal fluid. The gold sol reaction was that which -we regard as typical of syphilis or tabes. If we were to rely upon the -weakness of the fluid W. R. and the nature of the gold sol reaction, we -should be inclined to favor the diagnosis of DIFFUSE NEUROSYPHILIS -(“cerebrospinal syphilis”) rather than resort to the diagnosis of -paretic neurosyphilis. - -Salvarsan treatment was attended by the rapid disappearance of headaches -and gastric symptoms and by a rapid gain in weight and feeling of -well-being. Salvarsan was continued twice a week for two months, -whereupon Lepère returned to work. He has been successfully at work now -for seven months without return of symptoms. Four months after beginning -of treatment, the spinal fluid was examined and found entirely negative. -Nevertheless, the serum W. R. has remained positive despite eight months -of salvarsan treatment. - - 1. What is the meaning of the titrations in the spinal fluid - Wassermann reaction? When Plaut originally applied the Wassermann - reaction to spinal fluids, he used 0.2 of a cc. of spinal fluid. - With this amount of fluid he found that cases of general paresis - gave a positive reaction in about 100% of the cases while this - positive reaction was only given by 40 to 60% of the cases of - cerebrospinal syphilis and tabes dorsalis, hence he promulgated a - differential point that a negative reaction in spinal fluid - indicated that the case was not general paresis. Hauptmann later - showed that if 1 cc. of spinal fluid were used, a positive - reaction would occur in practically 100% of the cases of general - paresis, cerebrospinal syphilis and tabes. Therefore, at present, - we use the different titers of spinal fluid from which we draw the - following conclusions: If the reaction in the untreated case is - negative with 0.1 and 0.3 of a cc. and positive with the 0.5, 0.7 - and 1 cc. dilutions as in the case of Lepère, we are probably - dealing with non-paretic neurosyphilis. With this method of - titration we are also better able to watch the progress of - treatment as the dilutions of 0.1 and 0.3 cc. become negative - first. - - 2. How soon can one expect improvement after commencement of - salvarsan therapy in cases of diffuse neurosyphilis? The time - relation of results in treatment varies with each individual case. - In the case of Lepère gastric symptoms that had been present for a - number of months disappeared as if by magic after the first - injection of salvarsan. As a rule, it is true that the more acute - the symptoms the quicker their disappearance but this does not - hold for all cases, as in this particular instance the - long-standing symptoms disappeared very rapidly. The symptoms - often disappear very much more rapidly than the laboratory, tests - change. - - 3. How can the mental symptoms (depression and failing memory) of - which patient complained be explained? In the first place, as has - been stated, it is doubtful if these are more than subjective and - the result of the patient’s feeling of discomfort and pain. - However, it is also possible that there may be intracranial - involvement of the meninges or of the brain itself. And, if such - were the case, the improvement might be the result of the - treatment. - - - =The Argyll-Robertson pupil should not be used as a basis for a - necessarily bad prognosis if treatment can be given.= - - -=Case 106.= Frederick Stone was a business man of large interests. He -had been in the hands of physicians for several years for a variety of -disorders such as renal, respiratory, cardiovascular, and so on. No -suspicion of syphilis had apparently been uttered by the physicians -despite the fact that Mr. Stone readily stated that he had had a chancre -thirty years before, and that he had received several years’ treatment -of mercury and potassium iodid by mouth. - -It appeared that a few years ago he had begun to have trouble with his -nose, which was cauterized and operatively interfered with without -satisfactory results. This nasal condition had later been diagnosticated -as gummatous, and had improved considerably under a mild antisyphilitic -treatment. However, this nasal condition had been considered and treated -quite separately from the remainder of Mr. Stone’s troubles. - -What brought him to attention was a sudden diplopia with ptosis. There -was a paralysis of the external rectus of the left eye, as well as a -drooping of the lid on this side. The left eye was much inflamed. The -diplopia greatly bothered the patient, and there was also considerable -pain in the left frontal region, confined chiefly to the distribution of -the first division of the trigeminal nerve. According to the patient -this headache was periodic. There was considerable tenderness to -pinprick over the area and a diminution of sensory discrimination of -fine touch. Both the pupils failed to react to light. - -The remainder of the neurological symptomatic examination was -surprisingly clear of disorder, nor was there anything in the history -suggestive of tabes. There was ozena as well as evidence of the -operative work upon nares and throat. Possibly the arteries were -slightly hardened; blood pressure was 165 systolic. There was a large -trace of albumin, and there were numerous hyalin casts in the urine. - - - =PARETIC NEUROSYPHILIS= - - =(GENERAL PARESIS)= - - Cases systematically treated 50 - - CLINICAL REMISSIONS 34 68% - C.S.F. ALTERED TO NEGATIVE 4 8% - C.S.F. ALTERED TO WEAKER 16 32% - C.S.F. UNALTERED 14 28% - - CLINICALLY UNIMPROVED 16 32% - C.S.F. WEAKER 7 14% - C.S.F. UNALTERED 9 18% - - MASSACHUSETTS COMMISSION ON MENTAL DISEASES - NOVEMBER, 1916 - - CHART 25 - - -=Mentally=, there was a degree of depression and worry hardly out of -keeping with the general situation. Despite the preservation of memory, -Mr. Stone failed to do rather simple arithmetical calculations; this was -the more remarkable as in his business he had to handle figures a great -deal and had been doing so until recently. There was a slight tremor in -his writing, as well as a certain difficulty in enunciating test -phrases. Insomnia, irritability, and a feeling of nervousness and of -being tired out, completed the picture. - -A suggestion for diagnosis would be classically offered by the -Argyll-Robertson pupils. Should not a patient with the Argyll-Robertson -pupils have either tabes or paresis? However, in favor of tabes, besides -the pupil, are to be counted merely the troubles with the eyes. In the -direction of paresis we have to consider speech defect, to say nothing -of less definite symptoms such as insomnia and increased irritability. - -We are inclined to think, however, that the disease in this case is -meningovascular. This diagnosis is suggested by the cranial nerve -palsies and by the headache. Headache is much more rarely a phenomenon -in the paretic type of neurosyphilis than in the meningovascular type. - -In point of fact, the spinal fluid phenomena bore out the diagnosis of -MENINGOVASCULAR NEUROSYPHILIS inasmuch as the globulin, albumin, -cellular content, gold sol, and W. R.’s were all weakly positive. - - 1. How far can we regard the cardiorenal defects as syphilitic? - Perhaps we may do so on the general principle of parsimony in - scientific interpretation. - -The diagnostic lumbar puncture led to an extremely severe exacerbation -of the pains on the left side of the head. In fact, these pains could -not be held in check by the exhibition of pyramidon. Mr. Stone regarded -the pain as due to the lumbar puncture. However, there was no -improvement in the pain in the prone position,—a feature characteristic -of lumbar puncture pains. Upon administration of salvarsan, this local -pain rapidly disappeared. In fact, there was a startling improvement; -the ocular palsies disappeared in a few weeks, although these palsies -had been present for several months before the administration of -salvarsan. The blood pressure was reduced; the urine became negative. -Perhaps the most startling feature of all (although of this we are not -sure) was that the patient states he was accepted by a life insurance -company although he had been twice refused previously. - -=Note= in this case the 30–year interval between infection and -generalized neurosyphilitic involvement. Note also the amenability of -the process despite this duration. We are perhaps entitled also to note -that a neurological examination careful enough to detect an -Argyll-Robertson pupil should have been made by a number of examiners -long before the particular crisis which we have sketched. It is also -permissible to note that the rhinological work should not have been -carried out independently of all other medical work. - - 2. What are the untoward results of lumbar puncture? It is true that - there is always a possibility of setting up a septic meningitis by - lumbar puncture, but this is a very remote possibility and with - any reasonable care it is not to be considered. Lumbar puncture - also has a considerable danger in cases of increased intracranial - pressure. In cases of brain tumor where the tumor is located in - the posterior fossa, sudden death may occur from withdrawal of - spinal fluid. This is supposed to be due to the medulla being - pressed down into the foramen magnum and causing paralysis of - respiration. Therefore lumbar puncture should never be performed - except with the greatest caution in a case in which brain tumor is - suspected. - - However, aside from these remote serious consequences which play - very little rôle in the ordinary procedure of lumbar puncture, - certain unpleasant symptoms do frequently arise. These symptoms - are chiefly headache and nausea, but, however, may go as far as - vomiting. These symptoms occur almost entirely in the cases in - which there is no abnormal condition producing increased spinal - fluid pressure. Such unpleasant symptoms may last as long as four - or five days; as a rule, however, last only for a period of a day - or two. - - 3. What is the treatment of discomfort following lumbar puncture? It - is a rule well worth observing that the patient after lumbar - puncture should remain flat on his back without a pillow for 24 - hours in order to avoid any unpleasant symptoms. If any symptoms - do occur, it will be almost certainly when the patient arises, and - in nearly every instance they will be overcome if the patient - again assumes the prone position. Raising the foot of the bed so - as to lower the head also helps. Veronal or bromides may be given - but as a rule are not very satisfactory. - - 4. How permanent is the improvement obtained in the case of Mr. - Stone likely to be? As a matter of fact, the patient discontinued - treatment as soon as he felt well again, but after two months the - pain returned to be again quickly dispelled by salvarsan. This - improvement must be considered as only temporary. Under continued - treatment there may be no further relapse. There is, however, - evidence that much damage has been done to the body by the - spirochetes, much of which is irreparable. It is even possible - that further disintegration might occur even while undergoing - treatment. Still treatment offers much in such a case and is to be - highly recommended. - - - =In DIFFUSE NEUROSYPHILIS, rendering the spinal fluid negative by - treatment may mean neither cure nor disappearance of symptoms.= - - -=Case 107.= Greta Meyer, a widow, 51 years of age, came voluntarily to -the hospital, seeking medical aid for a marked depression. She was also -suffering from a right hemiplegia. It appeared, according to Mrs. Meyer, -that she was married at 16, and lived with her husband until 29, -whereupon she left him on account of his alcoholism, his abuse of her, -and the discovery through his physician that he was suffering from -venereal disease. She had had two healthy children and there never had -been miscarriages or stillbirths. Six years after the separation, namely -at 35 years of age, and 16 years before resort to the Psychopathic -Hospital, Mrs. Meyer developed certain red areas on her hand, and -learned at a hospital that these were due to syphilis. She kept up -treatment for these lesions for a year, until she seemed perfectly well. - -She had, in fact, remained perfectly well for some 14 years, until at -49, a small tumor had appeared on the right side of the forehead, near -the hair line. This tumor was firm and not sore. Medical treatment -reduced it, leaving, however, a depression in the bone. One day, about a -month after the appearance of the tumor, the patient lay down for a nap, -and upon awaking found she could only with difficulty move her right arm -and leg. Her face was not affected; she was not in pain; and there was -no disorder of speech. In a few days she got much better and she had -been improving for some time past through the administration of further -medicine. - -However, since the onset of the hemiplegia Mrs. Meyer had been very -despondent. There had been ups and downs but she had rarely felt well. -The depression was a mild one and in point of fact may perhaps be -regarded as non-psychopathic, since at her age with her disability, -there might well be a degree of sadness and unhappiness concerning the -future. =Mentally=, there was no other disorder of note, and in -particular no disorder of memory. - - - =METHODS OF TREATMENT= - - I. BY MOUTH. - 1. MERCURY - 2. IODIDES - 3. ARSENIC - - II. INTRAMUSCULAR INJECTIONS - 1. MERCURY - 2. SALVARSAN, NEOSALVARSAN, OTHER ARSENIC PREPARATIONS - 3. SODIUM NUCLEINATE - 4. ANTIMONY - - III. INTRAVENOUS - 1. MERCURY - 2. MERCURIALIZED SERUM - 3. SALVARSAN, NEOSALVARSAN, ARSENIC - 4. IODIDES - - IV. SPINAL INTRADURAL - 1. SALVARSANIZED SERUM (IN VIVO—SWIFT-ELLIS) - 2. SALVARSANIZED SERUM (IN VITRO—MARINESCO-OGILVIE) - 3. MERCURIALIZED SERUM (BYRNES) - - V. CEREBRAL SUBDURAL AND INTRAVENTRICULAR - 1. SALVARSANIZED SERUM (IN VIVO) - 2. SALVARSANIZED SERUM (IN VITRO) - 3. MERCURIALIZED SERUM - - CHART 26 - - -=Physically=, the patient showed a right-sided hemiplegia with excessive -right knee-jerk, but without Babinski or other abnormal reflex -phenomena. The extraocular movements were somewhat restricted in range -but there was neither strabismus nor nystagmus. - -The question arose whether the hemiplegia was of hemorrhagic or -thrombotic origin. After all, at 51 years, hemiplegia is rather unlikely -to be of a non-syphilitic arteriosclerotic origin; moreover, we had a -clear history of syphilis. The serum W. R. proved positive as well as -the spinal fluid W. R. The finding of 77 cells per cmm., excess albumin, -and positive globulin test, taken in connection with the entire picture -seems to warrant a diagnosis of CEREBROSPINAL SYPHILIS. If we proceed on -statistical grounds, it might be regarded as more probable that the -hemiplegia is THROMBOTIC in origin rather than hemorrhagic. It appears -that syphilitic cerebral thrombosis rather characteristically occurs -without preliminary symptoms, despite the fact that many cases do show -headache, dizziness, and restlessness as prodromal symptoms. - - 1. What is the treatment indicated in the case of Mrs. Meyer? - - It would appear that little or nothing can be done for the - hemiplegia unless the claims of Franz with respect to - reëstablishment of a degree of function in certain hemiplegics are - substantiated. However, the indication of meningitic process as - shown by the spinal fluid, suggests that the case is not a purely - vascular one but may be regarded as meningovascular. (Possibly, - also, we should regard the left frontal depression and scar as - indicative of a non-parenchymatous and non-vascular process.) - Accordingly, antisyphilitic treatment should be theoretically of - some value. - - In point of fact, the patient was given injections of mercury - salicylate, mercury by mouth, and potassium iodid. Her - psychopathic depression under this treatment, supported by proper - hygiene and rest, diminished. However, six months later, the - patient slipped on a wet floor and fell. Though the impact seemed - hardly sufficient to cause a fracture, the pelvis was somewhat - severely fractured. Very probably there was a syphilitic - rarefaction of the bone. Six months later the patient’s depression - was still in evidence, though somewhat less than upon admission. - The blood serum remained positive but the spinal fluid had become - entirely negative, both in respect to the W. R. and in respect to - the other findings. - - 2. How may one explain the continuance of the depression after the - spinal fluid had become entirely negative under treatment? It may - be that while the active process had been stopped, as seems - probable from the negative spinal fluid, that a permanent - destruction of brain tissue may account for the depression. We - recognize this readily in instances of vascular disturbance where - (as also in this case) the active process being stopped, a - residual defect remains. - - 3. Should treatment have been discontinued on reduction of the - gumma? It cannot be too often emphasized that the disappearance of - symptoms in cases of syphilis can not be considered as evidence of - cure. The neurologist and psychiatrist see only too often cases of - neurosyphilis occurring in patients who have been declared cured - at some time previous because the symptoms then present had - cleared up and remain in abeyance for years. - - - =Contrary to various warnings, arteriosclerosis by no means - absolutely contraindicates intensive salvarsan therapy.= - - -=Case 108.= Victor Friedberg, 42 years of age, gave the following -history. He acquired syphilis at 22 years. He had “adequate” medical -treatment for two years with inunctions of mercury and mercury by mouth -and potassium iodid. The only secondary symptoms were skin lesions of -the legs; these disappeared upon treatment. Married, Friedberg has one -child, apparently normal. There had been no miscarriages or stillbirths. - -At about 34 years, there began to be shooting pains in the legs, -occurring at first about once in three months, but later much more -frequently. These pains were severe, lightning in character, lasting -several days at a time, at which period his head would feel heavy; but -there were no disturbances, crises, or difficulty in locomotion. - -At 36 years of age, Friedberg waked up with pain one night, and found he -was unable to move his left leg or hand, and he felt his mouth drawn to -the left. Upon trying to get out of bed, he fell to the floor. In five -hours, however, he was entirely recovered, able to get up and walk -about, and to use his left arm quite normally. He went to sleep, but -upon waking up after an hour, discovered that his left side was again -paralyzed. After two weeks in a hospital, he was able to walk with a -crutch. The arm remained helpless for about a year. Both arm and leg -improved slowly for two years, after which time his condition had -remained stationary. For four years past, there had been no more pain, -but at 42—about two years before admission—the pains returned in his -legs, back, and side. At that time he received four injections of -salvarsan, mercury tablets, and potassium iodid. Three weeks before -admission to the hospital, Friedberg again began having headaches, very -much worse than formerly. At first these headaches were frontal, then -occipital, and there was a feeling as if something were growling inside -of the head. There was a feeling of pressure in front on the head and at -the base of the nose. - -=Physically=, Friedberg appeared somewhat older than his assigned age. -There was a degree of general peripheral arteriosclerosis, but in -general the physical examination was negative. _Neurologically_, there -was a left hemiplegia with appropriate increase of the reflexes on that -side, spasticity, Babinski reflex, and an Oppenheim; the pupils reacted -properly; there was no Romberg reaction. - -_Mentally_, Friedberg was entirely negative. - -The W. R. of the blood serum was doubtful, as was that of the spinal -fluid. There were but two cells per cmm. and there was neither globulin -nor excess albumin in the spinal fluid. - -The =differential diagnosis= might lie between cerebral hemorrhage and -syphilitic thrombosis. Thrombosis is much more common as a result of -syphilis than is hemorrhage. The occurrence of the thrombosis during -sleep without premonitory symptoms is also characteristic in syphilis. -Possibly there was a low-grade spinal meningitis at the bottom of the -lancinating pains. Whether the headache is an arteriosclerotic effect or -due to a meningitis not shown in the cerebrospinal fluid is doubtful. -However, the absence of inflammatory products in the cerebrospinal fluid -rather indicates that the headache is of arteriosclerotic origin. -Autopsies, however, warn us that we may have a localized meningitis in -various parts of the cranial cavity without the determination of any -inflammatory products in the spinal fluid. - - 1. How shall we explain the doubtful (slightly positive) W. R. in - the spinal fluid if the case is one of VASCULAR BRAIN SYPHILIS? - The finding is not unusual in these cases. The W. R. producing - body is recognized to be of a separate nature from the globulin - and albumin bodies, and is probably also separate from the gold - sol reaction producing bodies. - -Treatment: The theory of treatment is that any spirochetes that may be -still active in the body should be destroyed. Accordingly, although -salvarsan can certainly have no effect in reproducing nerve tissue, it -nevertheless seems indicated. It is frequently stated, however, that -salvarsan is dangerous in cases of this group. We have not found this -statement correct. In this case, there was a symptomatic improvement, as -far as pain and discomfort went, under salvarsan and iodids. - - 2. What precautions should be taken in intensive salvarsan treatment - of syphilitic arteriosclerosis? Treatment should be begun with - very small doses of salvarsan, that is, about 0.1 of a gram and - then the amount slowly increased. The injection should be given - slowly so as not to put too great a load upon the cardiovascular - system. - - 3. What rôle does the mental attitude of the patient play in a case - like that of Friedberg? It was quite evident that Friedberg was - neurotic and that he had a syphilophobia. Consequently some of the - symptomatic improvement may have been more results of assurances - offered by the physician and knowledge that he was being treated, - than results of salvarsan. In some cases mental anguish suffered - by the patient is of more importance than the actual symptoms of - the disease and this point must be always borne in mind in - handling syphilitic patients. - - - =Symptoms of intracranial pressure cured by antisyphilitic - treatment.= - - -=Case 109.= Mrs. Annie Rivers, a housewife 36 years of age, sought -advice and treatment for severe convulsions which she had had during a -period of several weeks. She left the hospital before being properly -examined, and had several more convulsions, after which she was brought -back in a state of marked confusion. The confusion shortly disappeared -almost completely, and a good history was obtained. - -It appears that the patient led a normal life and had had six children, -the last of whom was born about four months before her coming to the -hospital. The first symptoms appeared about a month after the birth of -the child, when, one afternoon, Mrs. Rivers suddenly fell unconscious -while ironing. She remained unconscious for nearly three hours. During -this attack there were no convulsive movements or tongue-biting; and -after the spell, she felt neither lame nor sore, but merely tired. This -was Mrs. Rivers’ statement; but her daughter stated that the patient -really did have convulsive movements. A week later came a second -convulsion, followed by daze and stupor. This second attack lasted two -hours. - -About a week before entrance, the patient had remained in bed on account -of dull grinding pain in the left side of the head, below the ear, and -upon this day the patient vomited twice. In addition to the dull -grinding pain, there were pains referred to the ear itself and to the -left side of the head, especially over the left eye; there were no pains -on the right side of the head. The next day the patient was better, but -the day thereafter again remained in bed. The only other symptoms were -cold feelings at times and bright spots in the field of vision. - -No =mental symptoms= were observed in Mrs. Rivers except a bit of -depression after her hasty retreat from the hospital the first time. -Upon her second admission, however, after a week or ten days’ residence, -apathy developed together with considerable amnesia for the same facts -she had quite readily remembered a few days previously. Along with the -apathy and amnesia developed considerable headache; and there were -attacks of vomiting. - - - =UNTOWARD SYMPTOMS OF THERAPEUTIC AGENTS= - - =A. SALVARSAN= - - CYANOSIS MALAISE - RAPID PULSE - PERSPIRATION - RESPIRATORY DIFFICULTIES - FEVER - NAUSEA, VOMITING, DIARRHOEA - DERMATOSES - EDEMA - KIDNEY IRRITATION - LIVER IRRITATION - INTENSIFICATION OF SYMPTOMS - COLLAPSE - - =B. MERCURY= - - SALIVATION - FETID BREATH - EXCESS FLOW OF SALIVA - TENDERNESS OF TEETH—LOOSENING AND FALLING OUT - SPONGY GUMS—EROSION - METALLIC TASTE - NECROSIS OF BONES OF JAW - SORENESS OF PARETIC AND MAXILLARY GLANDS - SWELLING AND EROSION OF TONGUE AND MUCOUS MEMBRANES - GASTRO-INTESTINAL SYMPTOMS - ANEMIA - PAIN IN JOINTS - NEPHRITIS - - =C. IODINE= - - SKIN LESIONS - METALLIC TASTE - SALIVATION - CORYZA - URTICARIA (EVEN TO GRADE OF ANGIONEUROTIC EDEMA) - PAINS - CONSTIPATION - INVOLVEMENT OF JOINTS - FEVER - SOFTENING AND BLEEDING OF GUMS - EROSION OF MUCOUS MEMBRANES - GASTRO-INTESTINAL SYMPTOMS - ANOREXIA - WEAKNESS - - CHART 27 - - -On the =physical= side, it is interesting to note that the -ophthalmoscopic examination upon Mrs. Rivers’ first admission to the -hospital was entirely negative, whereas a week later, pronounced -difficulty with vision appeared so that in a few days she was able to -make out only very large type. The fundi now showed hazy and indistinct -disc outlines, with small yellowish areas of fatty degeneration above -the disc, reduction of arterial calibre, and dilated and somewhat -tortuous veins (no projection of papillæ), so that the ophthalmological -diagnosis was chronic neuritis. - -The physical examination otherwise was mostly negative. The skin -presented irregular areas covered with silvery scales over the arms and -chest, back, abdomen, and legs (the patient had had psoriasis several -years before). Both pupils reacted to light and distance, though the -right was slightly larger than the left and somewhat irregular. There -was a slight tremor of the tongue and extended fingers. The reflexes -were active, especially the knee-jerks; no abdominal reflexes could be -obtained. The serum W. R. was positive, but the spinal fluid W. R. was -negative. The spinal fluid showed but 3 cells per cmm., but there was a -positive globulin test and an excess of albumin. - -=Diagnosis=: After the symptoms had fully developed, it became clear -from the optic neuritis, headaches, and vomiting that a condition of -intracranial pressure existed. In view of the positive serum W. R., it -is natural to conceive that the agent producing the intracranial -pressure was a gumma. - -It is, of course, possible that a marked degree of meningitis might be -so localized as to produce the same symptoms. The diagnostician would -crave a pleocytosis of the spinal fluid if a diagnosis of meningitis is -to be made; and there was no such pleocytosis. On the whole, we do not -feel that it is possible to make a diagnosis either of MENINGITIS or of -GUMMA. - -=Treatment=: Treatment, however, caused a disappearance of all symptoms. -The treatment consisted of but one injection of 0.3 gram of salvarsan, -followed by a few injections of mercury; whereupon Mrs. Rivers became -much brighter, recovered her vision, lost her headaches, ceased to have -convulsions or vomiting spells. - - 1. Is salvarsan contraindicated in cases with involvement of the - optic or auditory nerves? Such a contraindication exists according - to prevailing opinion. In this particular case, a hemorrhagic - retinitis occurred after the injection of salvarsan, but this - retinitis disappeared along with the other symptoms. On the whole - we believe that in many cases of optic or auditory nerve - involvement salvarsan should be used. However, one should never - lose sight of the possibility of untoward results and should - advise such treatment only when other treatment seems inefficient. - - - =TABETIC NEUROSYPHILIS (“tabes dorsalis”) may show very marked - improvement as a result of intraspinous therapy.= - - -=Case 110.= Mr. McKenzie[18] was a retired merchant of 42 years whose -complaint was that he tired very easily, could not make his legs go -where he wished, was unsteady and felt a numbness in his legs. These -symptoms had been in progress for a few months only when the examination -was made. This disclosed Argyll-Robertson pupils, absent knee-jerks and -ankle-jerks, Romberg sign, unsteady gait, moderate ataxia and dysmetria. -The W. R. was negative in the blood serum but positive in the spinal -fluid with 0.2 cc., and there were 107 cells per cmm. With the symptoms -and signs it was therefore easy to make the diagnosis of TABETIC -NEUROSYPHILIS (“tabes dorsalis”). - -The patient was given five intraspinous injections of mercuric chloride -in blood serum (mercurialized serum) according to the method of Byrnes. -The dose was 0.001 gm. of mercury. Two weeks after the first injection -the cell count was 58 cells per cmm., the Wassermann was positive only -with 0.4 cc. After the fourth injection there were but 18 cells and the -Wassermann reaction was negative even with 1½ cc. of spinal fluids. The -symptoms had improved to such a degree that the patient had no complaint -whatsoever and considered himself cured. - - 1. What are the unpleasant results of intraspinous therapy? - Frequently there is an exacerbation of symptoms and pain may be - quite severe after intraspinous injections. This, however, lasts - only a short period, that is, as a rule less than 24 hours. There - may be other symptoms of cord irritation as retention of urine or - lack of sphincter control. A rise of temperature is not unusual. - - - =Treatment may alter the W. R. to negative in blood and spinal fluid - in TABES DORSALIS.= - - -=Case 111.= Ivan Rokicki was a baker, 43 years of age, who came -complaining of exceedingly severe attacks of abdominal pain with -vomiting. He described these attacks as having occurred periodically for -a number of years, lasting sometimes as long as a week, during which -time Rokicki could not eat or get relief short of large doses of -morphine. - -Upon his arrival, Rokicki was seen in one of his attacks; he was curled -up with excruciating pain, and the abdomen was rigid, though it was -impossible to produce additional pain by external pressure. There was -spasmodic vomiting, frequently followed by slight relief from the pain, -which however shortly recurred and caused the patient to cry out in his -suffering. The condition was controlled by opiates but lasted a full -week. The leucocytes remained normal and there was no rise of -temperature. The attack ceased spontaneously. - -Save for the pain, Rokicki’s =mental examination= proved entirely -negative. =Physically=, Rokicki was fairly well developed and nourished. -His pupils were slightly irregular: the left markedly larger than the -right; both pupils failed to react to light, and the left pupil also -failed to react in accommodation. There were no other reflex disorders -evident to systematic examination, nor was there sensory disturbance or -speech defect. The heart seemed somewhat enlarged but there were no -murmurs; blood pressure: systolic 150; diastolic 110. - -The correct symptomatic diagnosis in Rokicki’s case proved to be gastric -crises, and this diagnosis must perforce be the first to entertain in -view of the chronicity, the periodicity, the non-relation to diet, and -the spontaneous cessation of the seizures. The observation of -Argyll-Robertson pupils was naturally held to substantiate the diagnosis -of TABES DORSALIS. - -The possibility of abdominal inflammation could be shortly dismissed on -account of the absence of tenderness (the rigidity in this case was not -accompanied by tenderness), fever, and other characteristic signs. There -was no diarrhoea, such as is found in lead colic, and there was no other -sign of plumbism. Jaundice was absent and there was no special radiation -of pain from the abdomen. One had to think of gastric ulcer and -hyperchlorhydria, and possibly malaria or gastroenteritis. - -The pupillary reactions pointed to a syphilitic condition despite the -fact that the lack of reaction to accommodation (over and above the -Argyll-Robertson phenomenon) in the right pupil is not entirely typical. -Accordingly, although there was no areflexia, Romberg sign, or ataxia, -resort was had to the W. R. This however proved negative, in blood and -spinal fluid; nor was there any globulin or excess albumin; there were 5 -cells to the cmm., in the spinal fluid. - -We are left, accordingly, with characteristic gastric crises; -Argyll-Robertson pupils, slightly irregular; and a somewhat enlarged -heart. - -Upon investigation, it appeared, however, that a year before the attack -above described, the patient had been examined and both blood and spinal -fluid found positive to the W. R. At that time, treatment, consisting of -intravenous injections of salvarsan and intraspinous injections of -salvarsanized serum (Swift-Ellis), had been instituted. Whereupon the -laboratory tests had become negative, as above stated, and there had -been no alleviation of the symptoms. - - 1. How can Rokicki’s normal deep leg reflexes be explained? The - abolition of the deep reflexes is of course due to lesions - properly localized. It is probable that this particular case of - tabes dorsalis is more truly “dorsal” than most cases; for most - cases exhibit lesions involving regions lower than the dorsal. - Both in these dorsal cases and in certain rare cases of cervical - tabes, the deep leg reflexes are preserved. (See cases Green (30) - and Halleck (31).) - - 2. What is the mechanism by which a characteristic gastric crisis is - produced? The mechanism is unknown. Some endeavors have been made - to meet gastric crises by surgery of the posterior roots, on the - assumption that the irritation causing the pain was located either - in the posterior ganglion or in the passage of the nerve through - the meninges. In only a few instances, however, has the result - been what was desired. In many instances the gastric crises and - pain continued uninterrupted and in addition came discomfort due - to the lack of sensation in the part supplied by the severed - nerve. At present this treatment is seldom carried out. - - 3. Should antisyphilitic treatment be continued in such a case? As - far as our present knowledge of syphilis goes one would hesitate - to suggest further antisyphilitic treatment, feeling that the - active process had been entirely stopped as suggested by the - absence of any positive findings either in the blood serum or in - the spinal fluid. We should perhaps conclude that there was no - more activity in this case and that the crises were due to the - changes that had already taken place in the nerve tissue and which - could no longer be changed. - - - =The literature is in doubt concerning (in fact is preponderantly - against) the success of treatment in PARETIC NEUROSYPHILIS (“general - paresis”). Our experience has yielded a number of apparently - successful results through systematic intensive intravenous - salvarsan therapy. Example.= - - -=Case 112.= Albert Forest had always been a successful salesman, but in -the middle of March, in his 46th year, he was arrested for grabbing a -purse from a woman in front of a theatre and running down the street -with it. In court, Forest acted strangely and he was sent to the -Psychopathic Hospital for observation. Upon investigation, it appeared -that his wife thought he had been showing mental changes for about a -year. For example, he would embrace his wife on a street car, or refuse -to pay her fare. He once attempted to hit his son on the head with a -red-hot poker. Now and then he would become sleepy and stupid. He looked -rather older than his age and had a coarse tremor of the hands. -Otherwise, no change could be detected in the physical examination, -either neurologically or otherwise. As for the manual tremor, Forest’s -wife gave a history of considerable alcoholic indulgence on his part. - -For several days, nothing abnormal could be detected in the man; and in -particular, his memory for both remote and recent events was very good -and his knowledge of current events was good. Simple arithmetic was easy -to him. - -One evening his temperature was found to be 104° F. and no cause could -be discerned for this. The next morning, Forest was discovered in a -stupor, with a complete right hemiplegia. The Babinski reflex, the -Oppenheim reflex, and ankle clonus had appeared on the right side, and -the right arm was spastic. - -However, all symptoms of this paralysis had disappeared by four o’clock -in the afternoon, and the paralytic phenomena were replaced with -violence. The patient fought with the attendants and for some time -remained extremely difficult to manage, being confused and subject to -outbreaks of violence with destruction of furniture and other property -about the ward. - -=Diagnosis.= At first we were naturally inclined to dismiss the case -with a diagnosis of alcoholism. The transient hemiplegia at once raised -a considerable question of brain syphilis or of brain tumor. - -The W. R. of the serum was doubtful. The spinal fluid yielded, besides -marked excess of albumin and much globulin, also a “paretic” gold sol -reaction and 75 cells per cmm. The W. R. was positive. - -=Treatment.= The patient was given injections of salvarsan, 0.6 gram, -twice a week, with potassium iodid. After a few weeks improvement -followed, and after several months all the laboratory tests became -negative, the patient was apparently perfectly normal mentally and was -discharged from the hospital, and has remained well for 18 months -without further treatment. The serum W. R. has continued to be negative. - - 1. What is the significance of the so-called “doubtful” W. R.? Where - there is not a complete uniformity the results of the strong and - weak antigens (see appendix on technique of Wassermann reaction) - the result is reported as doubtful. In the majority of instances - repetitions will give a strong positive reaction. - - 2. Is the case of Forest to be regarded as one of general paresis? - Sometimes such cases are termed in the literature _syphilitic - pseudoparesis_ (see case Burkhardt (58)). The differential - diagnosis of this group is entirely therapeutic. There are, - unhappily, no laboratory tests which will suffice in the present - stage of knowledge to differentiate a case of so-called - pseudoparesis from general paresis. We are inclined to term the - case one of GENERAL PARESIS, with recovery, or, at all events, - with remission. - - - =The literature is in doubt concerning (in fact is preponderantly - against) the success of treatment in PARETIC NEUROSYPHILIS (“general - paresis”). Our experience has yielded a number of apparently - successful results through systematic intensive intravenous - salvarsan therapy. Example.= - - -=Case 113.= We present the case of Gussie Silverman, a housewife, 35 -years of age, among other reasons, for its social interest. The case is, -on the whole, sufficiently typical of GENERAL PARESIS. =Physically=, for -example, the pupils failed to react to light and accommodation and were -unequal, the right being larger than the left. The knee-jerks were -sluggish though equal. The ankle-jerks could not be obtained. The -abdominal reflexes were not obtained. Otherwise, there was no reflex -disorder. - -From the =laboratory= point of view, the W. R. was positive in the blood -and in the spinal fluid. There were 80 cells per cmm. and there were an -appropriate globulin and albumin reactions. Mrs. Silverman was rather -poorly nourished and had a slight edema of the ankles. - -=Mentally=, she was found on admission to be markedly depressed. It -appeared that during a recent pregnancy, terminated by the birth of a -7–months child, she had fainted several times a day, that since the -confinement she had been very nervous, that she had been asking her -husband not to send her away, that she had refused to leave the house, -that she had become excited even to the point of injuring herself, -especially at night, and that she would go so far as to scratch her -husband, shortly afterward being very sorry for her performances. Before -this last pregnancy there had been four others and the resulting -children were all apparently in good health. Except for the fainting -spells during the pregnancy, it would not appear that the story just -told is at all characteristic of paresis. - -However, in the hospital Mrs. Silverman could hardly be got to answer -questions, continually saying, “You know what it is; I don’t have to -tell you.” She claimed so marked a degree of confusion as not to know -where she was and what she was doing. She would beg despondently that -something be done for her, and iterate and re-iterate these claims. -There appeared to be a marked degree of amnesia. Some one, she felt, had -controlled her thoughts and made her do things she did not want to do -and say things she did not want to say, things she did not know she was -about to say. She said, “I feel like jumping around. I couldn’t believe -myself as if I am me. Some one is making me jump around. I used to hear -him talking. I don’t know who it is. I used to keep my eyes open and I -couldn’t move. I feel only I would like to talk, and talk, and talk, and -talk all the time. It seems to me that some one talks in me. I couldn’t -sleep for five minutes. My God, I wish I could sleep! I used to feel -something in my heart. I used to faint. It seems to me I used to see a -funny thing. What it was I can’t tell. It used to talk to me, make me -get out of bed, throw me about, make me do things. O, I don’t know what -it was.” - -These not entirely characteristic mental symptoms, together with the -suggestive physical signs and the laboratory examination, caused -treatment to be instituted; under which treatment (intravenous -injections of salvarsan) she improved rapidly. Mental symptoms -disappeared under the administration of 12 injections of salvarsan -within two months. Moreover, the spinal fluid became entirely negative. -Two and a half years have now elapsed since her discharge and she has -shown no return of symptoms. The serum W. R. has always remained -negative although there has been no treatment since leaving the -hospital. There has, however, been no change in the reflexes, which -remain as on admission. The 7–months baby has continued to be perfectly -healthy. Its W. R. is negative, as are the W. R.’s of the husband and -the other three children. It must seem surprising that a healthy child -could have been born from a mother with generalized syphilis as in this -case. However, perhaps there are more instances than we imagine like the -case of baby Silverman. - - 1. May a patient be considered permanently cured although there has - been no recurrence of symptoms for 2½ years and although the - Wassermann has remained negative? One would hesitate to give a - definite statement that the patient was cured until more time had - elapsed. It is quite possible that spirochetes may be lurking in - some portion of the body without causing the production of - symptoms or Wassermann bodies and yet ready to break out at any - time. This hypothesis has added weight from the recent work of - Warthin already quoted. We advise examination of this patient at - intervals of not longer than six months for a good many years. - - 2. Should the course under treatment cause us to change the - diagnosis? It has often been stated that a differential point - between cerebrospinal syphilis and general paresis is the reaction - to treatment, that is, that a case which recovers could not be - general paresis. Head and Fearnsides state that if six months - after beginning of treatment the spinal fluid has become negative, - the case should be considered as one of cerebrospinal syphilis and - not general paresis. We do not feel ready to concur in this view - as we know of no similar logic in medicine. We have many cases in - which a spinal fluid has remained positive for six months and - later become negative, so that where the symptoms shown are those - of paretic neurosyphilis, we are inclined to consider the case - such until such time as more definite evidence checked by post - mortem examination causes us to change this point of view. - - 3. Do the reflexes change under treatment? The signs of spasticity - often do disappear under treatment and also when there is no - treatment. A few instances have been reported in the literature - where Argyll-Robertson pupils are said to have altered to normal. - It has never been our good fortune to see such a change nor have - we seen an absent knee-jerk become normal, as has also been - reported, except where it is the result of pyramidal tract disease - superimposed upon the posterior column sclerosis causing a return - of reflex. This, of course, is not to be considered as a return of - the normal. (See Case 1.) - - - =Some RESULTS of systematic intravenous salvarsan therapy are - PARTIAL (_e.g._, clinical recovery and persistence of positive - laboratory tests).= - - -=Case 114.= Walter Henry was an undertaker in a small town. He was -married and the father of two healthy children. In May, 1914, he began -to lose his appetite. He felt restless and seemed to be losing his grip, -and in August he repaired to a sanatorium, where he remained for two -months. Shortly after leaving the sanatorium, he fainted one day, while -digging a grave, during a spell of great heat. Since that time there had -been numerous “weak spells,” with headaches and general debility, -insomnia, and loss of weight. - -In February, 1916, Mr. Henry came to the hospital for advice, but the -trip from a distant part of the state was apparently such a strain for -him that shortly after admission he collapsed. There were no convulsive -movements in this collapse, but the patient was confused and his -breathing was rapid and stertorous. The semi-stupor lasted for about 48 -hours. Upon recovery from the stupor, Henry was found entirely -disoriented, much confused, and laboring under the belief that he was -digging a grave. After a time he again fell into a stupor and his -temperature rose to 103° F. - -The emaciation of this man was striking and unusual, but systematic -=physical examination= showed no special disease. =Neurologically=, -there were marked tremors, and there were purposeless movements of the -arms. There was a marked speech defect. The pupils were dilated, -regular, and equal, and reacted, though slightly, to light. Nothing -abnormal was noted upon systematic examination of the reflexes. - -The W. R. was strongly positive in the blood and in the spinal fluid; -the gold sol reaction was typically “paretic”; there were 16 cells per -cmm., globulin was present, and albumin was greatly increased. - -The =diagnosis= GENERAL PARESIS was accordingly made, and treatment -instituted. Intravenous injections of arsenobenzol, at first, and later -of diarsenol, were given, as a rule twice a week (usual dose, 0.6 of a -gram). Mercurial injections and potassium iodid were also given. This -treatment was continued as the patient began to improve. The improvement -was of such a degree that at the end of four months, Mr. Henry returned -to his home and his work. He had had 30 intravenous injections of -salvarsan substitutes. Despite the treatment and the clinical -improvement, the laboratory tests remained essentially unchanged. The W. -R.’s of the blood and spinal fluid remained strongly positive, as well -as also the globulin and albumin; the gold sol reaction was still -“paretic”; the cells stood at one per cmm. The patient has continued -antisyphilitic treatment since leaving the hospital, and has remained -apparently well, with good insight into his condition. - - 1. What is the significance of a temperature of 103° in a paretic - without signs of infection and a normal leucocyte count? - Temperatures of this type are not infrequent in the course of - general paresis. They are usually spoken of as “paretic - temperatures.” Their meaning is not understood, but they are often - stated to be due to a disturbance of the heat-regulating - mechanism. Such temperatures may remain elevated for a - considerable period of time, but the elevation may be very - transitory. At times they vary, like septic temperatures. - - 2. What can be argued from the fact that the cell count became - normal? If thorough antisyphilitic treatment is vigorously given, - it will be found that in the vast majority of cases of - neurosyphilis the cell count will return to normal. It matters not - whether the treatment be intravenous or subdural. It is very - difficult, however, to obtain this result in general paresis by - the use of mercury alone. It cannot, however, be urged that this - finding has any great prognostic significance as it occurs in the - cases which do poorly as well as in those which recover - symptomatically. - - 3. Is it safe to give large doses of salvarsan to a patient in a - stupor? It is not a good plan to give a large dose to such a - patient on account of the danger of sudden death. This is probably - due as much to the strain put on the heart as it is to any effect - on the nervous system, or specific arsenic effect. In this - particular instance, a dose of 0.15 gm. was the initial injection - and this was increased five centigrams per injection. - - - =IMPROVEMENT IN PARETIC NEUROSYPHILIS (“general paresis”) may become - evident only after several months of intensive treatment.= - - -=Case 115.= Henry Ryan was a shipping clerk, 54 years of age, who was -brought to the hospital following a convulsion. For a few months -preceding this period, Mr. Ryan had been failing in his abilities. He -had been very forgetful, showed no energy, and had become very -irritable. He also complained of insomnia and of feeling nervous. - -On admission to the hospital, the most striking feature in the mental -situation was that he claimed that he had not slept a wink for three -months, and each day he would solemnly affirm that he had not slept at -all the preceding night, although the records might show that he had -slept eight hours. Argument was of no avail against this conviction. In -addition, his memory was very poor; he showed little knowledge of -current events, and had no ability with arithmetical problems. - -=Neurologically= viewed, the points of chief significance were -contracted immobile pupils and a speech defect, especially noticeable on -the repetition of test phrases. The whole picture was suggestive of -general paresis, and this diagnosis was confirmed by the laboratory -findings. It was found that the W. R. was positive in the blood and -spinal fluid, that there was a pleocytosis, positive globulin reaction, -excess of albumin, and a “paretic” gold sol reaction. Consequently, the -diagnosis of GENERAL PARESIS seemed justified, although the patient -denied any knowledge of a syphilitic infection. - -Treatment in this case consisted of intravenous injections of salvarsan, -diarsenol, or arsenobenzol, whichever drug was most easily obtainable, -given twice a week in doses of 0.6 gram each. In addition, he was given -occasional injections of mercury salicylate as well as potassium iodid -by mouth. Once or twice a week, 40 to 60 cc. of spinal fluid were -withdrawn. Under this treatment for a period of three months, the -patient showed no improvement whatsoever, either in his mental condition -or in the laboratory findings. However, treatment was faithfully -persevered in, and shortly after the three months, improvement began to -be noticed. At first, the patient began to admit that possibly he may -have slept a few winks some time during the previous six months, for he -said he realized it was not possible for a man to live without sleep for -that period. Then he began to admit that he might have slept a few hours -during the night, and later that he was sleeping pretty fairly. His -memory also showed improvement. His general attitude showed alertness, -and he began to interest himself in his surroundings and in the events -of the world, and finally he gained complete insight into his condition. - -In the meantime, that is after three months of treatment, the laboratory -findings began to grow weaker. The gold sol reaction was the first to -decrease in strength, and after four months of treatment, it vacillated -between negative and a mildly positive “syphilitic” reaction. Then the -globulin and albumin became less in amount, and the W. R. began dropping -off in the 0.1 and 0.3 cc. dilutions. As is usually true in those cases -of neurosyphilis that receive adequate treatment, the cell count early -dropped to normal. The W. R. in the blood serum, however, remained -positive. - -As the patient’s condition seemed so much better, he was allowed to -leave the hospital at the end of five months. He took things easily for -the following seven months, and then, after being out of employment for -the period of a year, as his health continued good, he decided to return -to work. Before doing so, he entered the hospital again for a lumbar -puncture. At this time, it was found that the cell count was normal, -there was a very faint trace of globulin, possibly a slight increase -above normal albumin content, and a very mild gold reaction. The W. R. -in the spinal fluid was negative including the 1.0 cc. dilution; the -blood serum remained positive. - -The patient then returned to his old position and has done -satisfactorily for the past six months. During this entire time, he has -been coming to the hospital for treatment: during the major portion of -the time, about once in two weeks; of late, once in four weeks. - -The significant point in this case is that improvement did not show -itself until after more than three months of intensive treatment, and -then the improvement was synchronous with a weakening of the spinal -fluid tests. - -It is further significant that his mental and physical condition was -good before the tests had reached anything like normal; and that under -treatment, these tests continued to grow weaker and weaker, until at the -end of a year, they were practically negative. - -The case further illustrates the enormous number of injections of -salvarsan preparations that may be given to a patient without causing -any appreciable damage to the general health or to the kidney function. -Mr. Ryan has had more than 60 injections. - - 1. How soon after treatment is instituted does improvement usually - occur in paretic neurosyphilis? In our experience improvement - usually shows itself in from two or three months of treatment. - Occasionally the improvement may be very marked shortly after - treatment is commenced, that is, after three or four injections of - salvarsan. This is not, however, the rule and as in the case of - Ryan, it may be only after more than three months that improvement - is seen. This means that in the treatment of these cases patience - must be exercised and much work done. - - 2. What is the point of withdrawing large amounts of spinal fluid as - in the case of Henry Ryan? It has been stated that the withdrawal - of 40 or more cc., of spinal fluid while the patient is under - treatment has the effect of reducing the intraspinous and - intracranial pressure and thereby allowing the drug to diffuse - into the nervous tissue better than it would do under ordinary - conditions. How much truth there is in this contention it is - difficult to say and there is as yet no experimental evidence to - confirm this contention. As a matter of fact, the spinal fluid in - cases of paresis is usually under increased pressure and it is at - least plausible to conceive that a reduction of this pressure may - give some symptomatic relief. - - - =Evidence of the activity of syphilis outside the central nervous - system may be seen in cases of neurosyphilis despite intensive - treatment.= - - -=Case 116.= William Rosetti was a speculator, 43 years of age, when he -was brought to the Psychopathic Hospital on account of an outbreak in -which he smashed a showcase at the store where his sweetheart was -employed; he caused so much commotion that he was arrested. - -On admission, he was very excited, talking loudly and at length. For -some days it was very difficult to manage him, he was so active. At any -moment, he would insist upon undressing and taking physical culture -exercises. He was very euphoric and expansive, and had no insight into -his condition. - -=Physically=, he was a powerfully-built man and in very good physical -condition except for an iritis and moderate thickening of the peripheral -arteries. The =neurological signs= of importance were Argyll-Robertson -pupils, and absent knee-jerks and ankle-jerks. With these findings in -mind, a tentative diagnosis of GENERAL PARESIS was made, and this was -substantiated by the laboratory tests, which gave positive W. R.’s in -blood and spinal fluid, globulin, excessive albumin, slight pleocytosis, -and a “paretic” gold sol reaction. - -When the patient’s mental condition was somewhat better, he gave a -history of syphilitic infection 15 years before, for which he had had -almost continuous treatment. As a matter of fact, treatment had been -pretty strenuous because he had recurring skin lesions and iritis. It -was practically impossible to get the skin lesions to heal with mercury, -and it was not until salvarsan was introduced that a good result was -obtained in this respect. After one or two injections of this drug, the -skin lesion disappeared and has never returned. However, at least once a -year, he has had attacks of iritis, and for this reason was still being -treated for syphilis at the outbreak of his psychosis. - -He was at once placed on more strenuous antisyphilitic treatment in the -form of diarsenol, semi-weekly, aided by mercury injections. After a few -months of this treatment, his mental condition improved so much that he -seemed to be entirely normal. Treatment was continued, however, without -any abatement, and it was of great interest to note at the end of five -months of such treatment that, although mentally he seemed entirely -well, he had an attack of iritis, which was considered as a sign of -active syphilis. This would appear to indicate the great difficulty of -getting results in certain cases of syphilis with any drugs at our -command at present, as in the iritis we are dealing with a condition -which as a rule reacts fairly readily to antisyphilitic remedies. - - 1. Are there different strains of spirochetes showing various - degrees of malignancy? This question has been discussed at length - in the literature but there is no satisfactory answer at the - present time. We must always consider the reaction of the organism - and the host; and it is true in syphilis, as in every other - disease, that in some individuals it is more difficult to get any - therapeutic results than in others. - - 2. Was the failure to obtain results by long years of treatment due - to “drug fastness” of the spirochetes? It has been held that the - organism of syphilis will develop an immunity after a time to - mercury and arsenic preparations. This led Fournier to recommend - intermittent treatment as more efficient than continuous - treatment. Noguchi has shown that in test tube experiments, the - spirochetes develop a tolerance to increasing doses of arsenic. It - must be emphasized, however, that this finding has not been - established for the conditions _in vivo_. Another explanation of - the failure of treatment in certain instances has been offered by - McDonagh, who describes a life cycle of the organism of syphilis - under the name of _cytorrhyctes luis_, of which he believes the - spirochete to be merely one form, the other forms not being - affected by arsenic or mercury. - - - =Some results of systematic intravenous salvarsan therapy in PARETIC - NEUROSYPHILIS (“general paresis”) are partial in the sense that with - clinical recovery the laboratory tests remain partially or less - strongly positive.= - - -=Case 117.= Annie Martin was a charwoman, 37 years of age. She had -applied for relief at a general hospital, to which she was admitted on -the suspicion of nephritis; but upon admission she became markedly -excited and noisy, and spoke of seeing angels and hearing God speak to -her. As the attendants were unable to quiet her, she was promptly -transferred to the Psychopathic Hospital. She maintained that she had -been sent to the Psychopathic Hospital through the spite of the general -hospital doctors, and she claimed that other people were also attempting -to work her harm for the purpose of taking her children from her. Visual -and auditory hallucinations were marked, as was the patient’s loquacity, -irritability, and flight of ideas. However, she seemed entirely oriented -and her memory appeared to be intact. She was able to explain somewhat -clearly her supposed condition. The voices told her that somebody was -after her and that her soul belonged to the devil; that she was to be -married but that her soul was to be damned. These voices probably -belonged to priests. She was under the impression that she was going to -be sent to an electric chair and said, “I think I am coming to the end -and I want a pair of rosary beads before the end comes.” - -This patient’s pupils were markedly unequal and entirely stiff to light -and accommodation. =Neurologically=, however, there were no other -symptoms. There was a slight trace of albumin in the urine and there -were no casts. - -The psychiatric =diagnosis= in this case would off-hand undoubtedly be -dementia praecox. Yet the stiff pupils are almost proof positive of -neurosyphilis. If further proof were necessary, it is found in the -laboratory tests, which showed a positive W. R. of the serum and fluid, -with a “paretic” gold sol reaction; there were 22 cells per cmm., there -was excess albumin, and a positive globulin reaction. - -Under intensive antisyphilitic treatment, there was a slow improvement. -After several months, the patient was entirely free from mental -symptoms; the spinal fluid tests became entirely negative except that -the gold sol reaction has remained strongly positive. - - 1. Should treatment be continued in the case of Annie Martin in - spite of the clinical recovery and the negative tests except the - gold sol? We would again emphasize that it is unreasonable to - suppose that a long-standing case of syphilis can be cured in a - period of a few months of treatment and while the tests may become - negative, it would seem foolhardy to stop treatment on this - account. We do know that in many cases a Wassermann reaction - remaining negative for many months may again become positive, - indicating that the negative reaction did not mean cure but rather - the absence of the Wassermann bodies in the circulation at the - time the test was made. - - 2. What is the significance of the paretic gold sol reaction when - the other tests have become negative? As previously stated, the - gold reducing substance in the spinal fluid seems to be different - from the substances which give the other pathological reactions. - We should feel in this case that the process which was producing - these gold reducing bodies had not been stopped, in other words, - cure was not complete. - - 3. Should one make a diagnosis on the “paretic” gold sol reaction - alone? The so-called paretic gold sol curve is not always - indicative of general paresis or even of syphilis but may occur in - non-syphilitic conditions as brain tumor, multiple sclerosis, etc. - In our experience we have seen no case of _untreated_ - neurosyphilis in which the gold sol alone was positive, that is, - in cases in which therapy has not changed the findings in the - spinal fluid. In our experience the gold sol reaction has been - fortified by one or several of the other tests as the W. R., - globulin test, pleocytosis. - - - =Some effects of systematic intravenous salvarsan therapy in PARETIC - NEUROSYPHILIS (“general paresis”) are limited to the laboratory - findings without clinical improvement.= - -Two examples of such limitation are offered: William Roberts (118) and -John Silver (119). - - -=Case 118.= A bank teller, William Roberts, 39, was sent to the -Psychopathic Hospital for a depression so marked that he had become -entirely unable to work or care for himself. The story was that some -money had been left him by his uncle, that Roberts could not prove his -right to the money, and that depression, insomnia, and occasional -periods of confusion had followed during a period of about five months. - -On admission, Roberts appeared wholly disoriented and unable even to -give his correct age. Attention could not be held, and the patient would -slide off into statements like: “Oh, I made a mistake, I fooled a lot of -people, I have a terrible disease, they are going to get it, they are -going to get me,” etc., etc. There was great difficulty in thinking, and -a marked reaction of fear. This cluster of phenomena certainly suggested -very strongly the diagnosis of manic-depressive psychosis. - -=Neurologically=, Roberts proved quite negative except that the tendon -reflexes were very active and the pupils reacted somewhat sluggishly to -light. The blood serum W. R. was negative. No history of syphilis could -be obtained; nevertheless, Roberts kept dropping remarks about the -terrible disease from which he was suffering. It seemed best to proceed -to lumbar puncture, and the spinal fluid disclosed a positive W. R., -globulin, increased albumin, pleocytosis, and “paretic” gold sol -reaction. - -The =diagnosis= of GENERAL PARESIS was accordingly made. During the next -year and a half, no improvement was made; a slight speech defect was -developed, and tremors of the hand and tongue appeared. - -The effect of treatment is particularly instructive. Only after 18 -months in the hospital was intensive antisyphilitic treatment -instituted; but after a few months of this treatment the W. R. of the -spinal fluid had become negative, the cells normal in number, globulin -absent, albumin present only in normal amount. Only the gold sol -reaction remained positive. It is still of a paretic type. Treatment, -however, did not succeed in altering the patient’s mental condition in -the slightest. At the end of many months of treatment, we still confront -a man showing marked psychic symptoms and a “paretic” gold sol reaction -without other laboratory signs. - - 1. What is the significance of the practically negative tests in - this case without clinical improvement? One must believe that the - tests became negative as the result of treatment, and that this - change in the tests was due to the clearing up of some - inflammatory reactions which were present. This may mean that the - syphilis had been reduced to inactivity or latency if not cured, - or at least that there was no activity sufficient to cause a - positive W. R. in the blood serum, whereas whatever activity was - present in the brain was in such a region that it did not cause - any reacting substances to be cast into the spinal fluid. This - would not mean that there would necessarily be any return of - function already lost, because this may be considered as a - permanent loss which cannot be compensated for. As to these tests, - we now feel that the case should remain stationary; that is, that - no new symptoms will be added. However, we believe that it is - somewhat premature with our present knowledge to make this claim - very forcibly, and would rather suggest that this case be - considered as demonstrating an interesting fact, the meaning of - which can be learned only after a period of years. - - 2. Why does the gold sol reaction remain strongly positive when all - the other tests become negative? As already pointed out, above - (Case Martin (117)) there is no known rule about the disappearance - of one or other of the abnormal findings in spinal fluid under - treatment, and we can at present offer no explanation of this - phenomenon. It does, however, illustrate how careful we must be in - drawing any conclusions from tests in cases that are being - treated. - - - =Diminution in the spinal fluid tests may occur in treated cases of - neurosyphilis without clinical improvement.= - - -=Case 119.= John Silver, a man 29 years of age, presented classical -symptoms of GENERAL PARESIS: He had a convulsion shortly before his -admission to the Psychopathic Hospital, his memory was poor, he was only -partially oriented, he was very euphoric and expansive—thought he had -millions, that he was the Czar of Russia, and so on. His tendon reflexes -were very much increased and there was a marked speech defect. The W. R. -of both blood and spinal fluid were strongly positive; the spinal fluid -showed globulin, increased albumin, pleocytosis, and a “paretic” gold -sol reaction. There was, therefore, no question about the diagnosis, and -the patient was at once put under antisyphilitic treatment. This was -continued for five months; slowly the intensity of the reactions in the -spinal fluid diminished. At the end of the five months, there was the -very slightest possible trace of globulin, with a doubtful increase in -albumin, one cell per cmm., and a mild syphilitic gold sol reaction. The -W. R.’s in the blood and spinal fluid, however, remained strongly -positive. There was no mental improvement coincident with the weakening -of the spinal fluid tests, and at the end of the five months, the -patient had a series of convulsions in which he died. - -This case is given as a contrast to Case Henry (114) in which clinical -improvement occurred without diminution in laboratory tests; in the case -of John Silver, marked diminution in the intensity of these tests had no -prognostic significance. This was in keeping with the condition as shown -in Case Roberts (118) where, while the gold sol was the only test to -remain positive, the patient did not improve mentally. - - 1. What is the explanation of the lessening of the pathological - elements in the spinal fluid under treatment? We have seen that - the various findings may occur independently of one another, and - we must admit that we do not know definitely what it signifies, or - why one may be present or absent. It has been held by Head and - Fearnsides that the findings in the spinal fluid represent - conditions in the spinal cord and spinal meninges, or at the base - of the brain only, and not conditions elsewhere. This is in - keeping with our finding that the gold sol reaction in the spinal - fluid post mortem very often differs from that in the ventricular - fluids or cerebral, subdural, and subpial fluids. And further, we - have found that during life the findings in paresis in the spinal - fluid may differ markedly from those in the third ventricle, and - that the change in the fluid in these two areas under treatment - may not occur simultaneously. - - - =Systematic intensive treatment of PARETIC NEUROSYPHILIS (“general - paresis”), including intraventricular injections of salvarsan, may - entirely fail.= - - -=Case 120.= James McGinnis, aged 39, came to the hospital on a -stretcher, semi-conscious, moaning, unable to reply to questions; there -were signs of a right hemiplegia. - -The next day, McGinnis cleared a little and became able to utter a few -words. His wife said that he had been entirely well up to four years -ago. At that time he was struck in the eye by the head of a hammer that -flew off the handle. Diplopia had developed, but disappeared. - -Only two years later did a marked change appear. McGinnis became -careless as to personal appearance. Seemed absent-minded, apathetic and -drowsy; he would fall asleep in his chair or while at work. He lost his -position and became apprehensive, making not very strenuous efforts to -find work, and finally consulted a physician. The physician told him -that he had a sluggish liver and gave him calomel. - -Six months later, McGinnis was restored to his position as foreman, and -his work remained satisfactory for some six months. Then (about six -months before coming to hospital), his speech became slow and somewhat -unintelligible. He quit work, saying that his speech was going from him -and that he might be considered to be drunk. His memory grew rapidly -worse. There was improvement after a vacation and he returned to work, -but continued to be ataxic, complained of vertigo, and fell down several -times, though without loss of consciousness. On the very day of his -admission to the hospital, in attempting to get out of bed, he fell, and -psychotic symptoms at once appeared. There was slight improvement again -with entire disappearance of all paralysis after a few days, a slow -clearing up of the speech disturbance, and a certain return of memory. - -=Physically=, there was little to note. =Neurologically=, the left pupil -failed to react to light. The tendon reflexes were all very active, and -more active on the left side. Other abnormal reflexes were absent. -Improvement continued for a number of weeks, but the patient never -recovered from his speech defect, and his memory remained impaired. -Irritable at times, McGinnis was for the most part very happy and sure -he would get well. The W. R. of the blood serum was negative, but the -spinal fluid reaction was strongly positive, even down to 0.1 cc. The -globulin and albumin amounts were excessive. There was a “paretic” gold -sol reaction. There were 7 cells per cmm. The diagnosis of GENERAL -PARESIS was made. - -Intravenous injections of salvarsan, arsenobenzol or diarsenol were -made, and intramuscular injections of mercury, and potassium iodid by -mouth were given. No real improvement occurred after a certain initial -betterment; the spinal fluid yielded no changes. Diarsenolized serum -according to the Swift-Ellis technique was then injected into the third -ventricle. Under this treatment also there was no change for the better -over a period of several months. The patient died suddenly after a -series of convulsions, apparently from paralysis of respiration. - - 1. What are the causes of hemiplegia and confusion or - unconsciousness? We must consider epilepsy, brain tumor, cerebral - thrombosis, cerebral hemorrhage, multiple sclerosis, cerebral - spinal syphilis, and general paresis. - - - =MILD TREATMENT, often thought “adequate,” MAY FAIL, WHEN INTENSIVE - TREATMENT PROVES SUCCESSFUL.= - - -=Case 121.= Arthur Bright, a printer, had acquired syphilis in his 49th -year, some six months before examination. He had been treated during -these six months by three injections of salvarsan, injections of -mercury, and mercury by mouth. He had been apparently cured until about -a month before admission. He had fallen without warning from his chair -in a convulsion accompanied by unconsciousness, which lasted about two -hours. The patient had since been feeling rather peculiar. For instance, -time seemed to flow too rapidly. Sometimes the patient had had -difficulty in talking. - -=Physically=, nothing abnormal could be found either in general -condition or =neurologically=. The patient was, however, incontinent. -=Mentally=, he was apathetic and unalert, even paying no attention to -his outside physician when he came to visit him. - -The =diagnosis= of cerebrospinal syphilis already suggested by his -history was confirmed by the laboratory tests, which showed a positive -serum and spinal fluid W. R., paretic gold sol reaction, 41 cells per -cmm., an excess of albumin, and a positive globulin test. - - 1. What is the prognosis in cerebrospinal syphilis in the early - secondary stage? The prognosis appears very good provided that - intensive treatment be given and provided that no vascular insult - or other focal destructive lesion occurs before treatment has had - time to do its work. - - 2. Why did not the “effective” (?) treatment for the syphilis, - dating from the primary lesion, succeed in staving off the - cerebrospinal syphilis? It remains a question whether the - treatment by three injections of salvarsan was efficient in this - particular case. Of course, it may prove true that no treatment - whatever in the present stage of knowledge will stave off - cerebrospinal symptoms in certain cases. - -=Treatment=: Bright was given intravenous injections of diarsenol twice -a week, with occasional injections of mercury salicylate. After two -weeks, the patient seemed markedly improved, and continued to improve -rapidly. He was symptomatically well at six weeks. The spinal fluid had -then become negative, although the serum W. R. had remained positive. - -After discharge from the hospital, Bright returned to his work, but -continued to take the diarsenol treatment weekly, and two months later -the serum W. R. became negative. - -Small injections of diarsenol at intervals of a month were continued, -and Bright remained perfectly well for four months, when a peculiar -seizure developed and lasted for several hours. This seizure consisted -in a sort of somnambulism in which Bright stood up at a table, making -marks on paper, and could not be persuaded to desist. After this -seizure, Bright re-entered the hospital, again showed no mental or -physical symptoms and no abnormalities of blood or spinal fluid. - - 3. What is the explanation of this seizure? It is possibly due to a - small vascular insult, for which potassium iodid may be suggested - with precautions as to hygiene and continued observation. He has - since remained entirely well. - - - =Another example where MILD MEASURES (though conceived to be - “adequate”) SEEMED TO BE LEADING TO FAILURE; INTENSIVE THERAPY - SUCCESSFUL.= - - -=Case 122.= Levi Morovitz, a waiter, 39 years of age, came to the -hospital with evidences of an old left hemiplegia, including the left -side of the face (there was a left-sided Babinski, Gordon, and -Oppenheim, and all the reflexes were fairly active; sluggish pupil -reactions, Rombergism, and speech defect). Morovitz was much depressed, -very slow in thinking processes, had a marked memory disturbance in -general and apparently much deterioration mentally. - -A history was obtained to the effect that Morovitz had acquired syphilis -at about 33, but that he had received practically continuous treatment -ever since at a dispensary. He had, in fact, received four injections of -salvarsan a year before coming to the hospital. Of late, Morovitz had -become much more cheerful and talkative, imagining he could do great -things if he had money. He had begun to eat very rapidly and to be very -nervous. His feet had begun to drag; a distinct speech defect developed, -but from this he had recovered. About six weeks before entrance, -Morovitz had a shock, which left him with the left hemiplegia above -mentioned and with considerable headache. - -Even while the preliminary examination was being performed, Morovitz -developed a minor seizure without loss of consciousness. First came -severe pain over the frontal region, which grew in severity so that the -patient held his head in his hands. A bit later, twitching movements -began in the thumb and in the fingers of the left hand, and the small -muscles of the extensor group of the thumb and third finger showed -contractions. These contractions grew more general and the excursions of -the fingers greater, until finally every finger of the left hand became -involved, whereupon movements of the same sort, though of smaller -amplitude, began in the other hand. Finally the left arm began to jerk -with alternate contractions of the biceps and triceps. The whole seizure -lasted more than five minutes. During the seizure there was dizziness -and pain in the head, chiefly on the right side. - -=Diagnosis=: The attention is at once arrested by the data of the -seizures described. It appeared that we had to assume an irritation of -the right side of the brain, possibly due to vascular disease, or to -brain tumor, or perhaps to syphilis. The shock with residual hemiplegia -would be consistent enough with any of these diagnoses. However, the -history seemed somewhat long for brain tumor. Nor were there any -definite symptoms of intracranial pressure. “Adequate” treatment -unfortunately does not rule out syphilis. The comparatively early age -(39) of the patient makes it difficult to explain the vascular disease -except on the basis of syphilis. Add to the hemiplegia the euphoria and -grandiose ideas of a year’s duration, and we arrive at a diagnosis of -neurosyphilis, probably PARETIC NEUROSYPHILIS. - -The laboratory tests showed the W. R. of the serum and spinal fluid -positive, 80 cells per cmm. in the fluid, large amounts of globulin and -albumin, and a “paretic” type of gold sol reaction. - -To be sure the Jacksonian seizure is not especially characteristic of -paretic neurosyphilis, and even suggests a local irritation in the motor -area, such as a localized meningitis, possibly of a diffuse gummatous -nature. - -This patient was put on intensive antisyphilitic treatment, namely, -salvarsan twice a week and injections of mercury. He recovered rapidly. -After a few months he left the hospital, and after treatment had -continued for a year, he resumed his work by which time both blood and -spinal fluid had become negative. - -It must be recalled that this patient had from the time of his infection -what has been considered good antisyphilitic therapy, in spite of which -he developed after a period of years, the symptoms and signs of -neurosyphilis in its most dangerous form. The conclusion must be drawn -that however good such treatment is for the majority of cases, it was -insufficient for Morovitz. That the early failure to cure was not due to -any “drug fastness” of the spirochete or to any peculiarity of strain is -proved by the result of more vigorous antisyphilitic treatment which -caused an apparent if not a real cure. With our modern methods of -treatment checked by Wassermann reactions and spinal fluid examinations, -treatment is given according to the _needs of the individual patient_ -rather than according to general preconceptions. We have reason to -believe that under these conditions there will be fewer cases developing -late symptoms on account of insufficient treatment given even to -patients who are willing to co-operate to the last degree. - -The fact that Morovitz had no apparent symptoms for several years led to -rather desultory treatment chiefly in the form of mercury by mouth. -Previous to the time when the W. R. and lumbar puncture were available, -the physician had no exact means of determining cure except the -non-appearance of symptoms. But a period of years of quiescence before -the outbreak of symptoms referable to the involvement of the nervous -system is characteristic of syphilis. With this knowledge in mind it is -evident that today the care of a syphilitic patient must be guided, in -part at least, by examinations of the spinal fluid and W. R. - - - =Salvarsan treatment may even occasionally be of value in simple - FEEBLEMINDEDNESS due to congenital syphilis.= - - -=Case 123.= The somewhat unattractive Robert Matthews was brought, at 5 -years of age, to the hospital for backwardness of mind. It appears that -the patient was born at term, with instruments, that he began to talk at -a year, and to walk at 13 months, but that in point of fact, he had not -talked intelligibly to date. Robert had never played with other children -and is regarded by his parents as backward. In fact, Robert’s sister—a -year his junior—is much brighter. Robert had had scarlet fever but -without sequelae. - -Examination by the Binet scale showed that, although he is actually 5½ -years, he graded by the Binet scale at 4 and was regarded as -feebleminded. - -The =physical examination= showed a general adenopathy and prominent -frontal bosses. In the study of the family history in the search for an -etiology for the evident feeblemindedness, little or none could be -found. There were no miscarriages or stillbirths; the parents were -living and well. There was only the one sister above-mentioned, who is -brighter than Robert. - -The advantage of a routine W. R. is here well shown, for the W. R. in -the serum was positive. - - 1. What is the prognosis of cases of syphilitic feeblemindedness? It - would appear that every case is an individual problem. - - 2. What is the effect of treatment? Robert Matthews was given - mercury protoiodid ⅛ gr., three times a day, by mouth, for three - months. The protoiodid was followed by ten injections of - salvarsan, average: 0.15 gram, during six months. At the end of - this period, the W. R. in the blood had become negative. A - re-examination by the Binet scale, when Robert was 6–5⁄12 years of - age, showed him to grade at 5⅖, so that one might conclude that - Robert had shown more mental progress in a year than he had - previously. - -Note: The patient’s sister, 4 years of age, is attractive and bright, -measuring beyond her actual age according to the intelligence tests. -However, the girl was found to have a positive W. R. It may be that -Robert and his sister illustrate the hypothesis of Mott: that the -syphilitic virus becomes less potent as the years go on, and that the -younger children in the family are less affected than the older. -However, in our series, there are a number of instances in which this -hypothesis is not substantiated. - - 3. What is the share of syphilis in the production of - feeblemindedness? The percentage of syphilitic cases found in - institutions is not high. A variety of cases have been proved to - be congenitally syphilitic in the absence of a positive serum W. - R. - -Fernald[19] has charted a comparison of cases diagnosticated “moron” -(that is, feeblemindedness proper, in the narrower English sense) and -“imbecile.” Fernald says that the morons have, as a group, many more bad -family histories than have the imbeciles, to quote—“Only 70% of the -[imbecile] group have bad family histories. This at first seems -surprising, but when we consider that more of our syphilitic, traumatic, -and sporadic cases tend toward the lower end of the feebleminded group, -and when we remember that with such cases there is often a seemingly -normal family tree, the drop in the curve appears logical.” - -The situation with the idiots, of whom only 38 came into Fernald’s -study, was similar; 12 out of 38, or 32%, of idiots, had good family -histories. On these figures, how unfortunate it would be to dub -feeblemindedness hereditary! It is true, however, that 68–70% of the -idiots and imbeciles, judging by W. E. Fernald’s intensive study, do -have bad family histories. - -Goddard[20] states that of all the causes of feeblemindedness, there is -perhaps none for which there is less evidence than syphilis. Goddard -found syphilis in 27 of his intensively charted cases of -feeblemindedness, that is, in 9% of all his charts. He finds the -majority of the syphilis cases occurring in relatives of the -feebleminded to be in the hereditary group; for example, of 164 charts -in the hereditary group, 17, or 10%, showed syphilis. In 34 charts in a -group termed “probably hereditary” 3, or 9%, showed syphilis. Of 37 -charts in the group termed “neuropathic” 4, or 11%, showed syphilis, -whereas in 57 “accident” and 8 “no cause” groups, there were but 2 (4%), -and one, or 13%, showing syphilis. However, Goddard concedes that much -more careful studies are necessary if we are to give an exact evaluation -of syphilogenic feeblemindedness. - -The first ten of the Waverley Anatomical Series are shortly to be -described in a forthcoming publication.[21] Of these ten cases, four -showed some slight evidence of chronic inflammatory changes, indicating -the possibility of a syphilitic or similar infectious condition. These -cases, be it remembered, were not cases of juvenile paresis, but cases -of what, for the lack of a better name, may be called “ordinary” -feeblemindedness. - -If all or any of these processes are syphilitic, the syphilis is -virtually extinct. The cases had not been treated for syphilis and were -not regarded as syphilitic, though several of them showed a few stigmata -somewhat suggestive of syphilis. The anatomical conclusion at this time -is still doubtful. - -As in the text case, the hypothesis of syphilis as a direct cause for -simple feeblemindedness must be entertained for a few cases. In any -event, it would not seem logical to let any institution for the -feebleminded run without a Wassermann analysis of the population. In -addition to the Wassermann data from the blood serum, osteological data -from the X-ray have proved of occasional value for syphilis diagnosis in -this as in other groups. - - - “Within the gates of Hell sat Sin and Death.” - - Paradise Lost, Book X, Line 230. - - - - - VI. NEUROSYPHILIS AND THE WAR - - -Although the American toll of war syphilis has not yet begun and -although the crop of neurosyphilis due to war infections may not arrive -until the mid or late twenties of the century (witness German experience -in the eighties of the last century), it seems proper here to give a -number of abstracts _re_ neurosyphilis as it has developed in the war. -Available reports from English, French, and German sources have been -levied upon for the years 1914–16. - -It is clear that all the armies have had their share of -neurosyphilitics, some clearly diseased before enlistment, some -developing symptoms as a result of training, stress, or shock, others -hastened or made worse by war conditions. - -There are important questions of pension, retirement, and compensation -for neurosyphilitics. No previous war has had the benefit of the -Wassermann reaction and other exact tests bearing upon the nature, -progress, and curability of neurosyphilis. - -That we shall have our fill of pension and other problems can already be -seen from continental reports. Thibierge,[22] for example, states that -syphilis has become a real epidemic among the French soldiers and -mobilized munition workers. - -Hecht[23] of Austria claims that no less than an equivalent of 60 army -divisions have been temporarily withdrawn from fighting on the Teutonic -side for venereal diseases. He commends Neisser’s idea that salvarsan -and mercury should be given in the trenches. While hundreds or thousands -of Austrians are sick with syphilis, sound and healthy men are being -shot down in their stead. The diagnosis of syphilis, according to Hecht, -ought to be a signal for sending the men to the front. He makes even the -somewhat bizarre suggestion that special companies of syphilitics should -be formed, for convenience of treatment, on the firing line. - -Not only is the syphilis problem in the army of importance to the -military authorities, but also to the civil population, and perhaps to -them a greater problem. With the great increase of venereal disease that -is the result of the conditions of army life in war time, there will be -a considerable percentage of cases developing neurosyphilis a number of -years after discharge from the army, but caused by the infection -acquired during service. In addition many men will bring the disease -back to America in an infectious stage and spread it. We would advocate -that the names of all soldiers who had acquired syphilis and were not -considered cured at time of discharge should be given to health -organizations in their home states that they may be given further care. - -These practical and several theoretical questions are raised by the -following fourteen cases which we have condensed from their sources. - - - =A tabetic lieutenant “shell-shocked” into paresis? Case from Donath - of Vienna.= - - -=Case A.=[24] An apparently competent German professor in an -intermediate school, a lieutenant of infantry reserves, 33 years old, on -the 17th August, 1914, was stunned for a while by the shock of a -cannon-firing 25 feet away. Urination became difficult. Headaches and -limb pains ensued, with paralysis of fingers, gastric troubles, -forgetfulness especially for names, insomnia, and general scattering of -mental faculties. - -=Neurologically=, the pupils were irregular, left larger than right; -Argyll-Robertson reaction. Right knee-jerk livelier than left. Achilles -reactions absent. Slow and dissociated pain reactions in feet, lower -thighs and lower quarter of upper thighs, with hypalgesia or analgesia. -Station good; gait steady. Mentally depressed, slow of thought. Speech -poor and of indistinct construction (mild dementia). Calculation ability -poor. No pleasure in work. - -Wassermann reaction of serum weakly positive. - -It seems that for a year the patient had been subject to spells of -anger. He was irritated by his wife who had been nervous since an -earthquake. - -_On the occasion of the earthquake_, 1911, the patient himself had had a -spell of _difficulty with urination_. The spell had lasted two or three -months. The patient had had a chancre in 1902, “cured” in four or five -weeks with xeroform. In 1908, when about to marry, he had had six -mercurial inunctions. - - 1. Is this a case of traumatic paresis? From the somewhat meagre - account it would appear that Donath’s lieutenant should rather be - termed “shell-shock paresis,” in the sense of a paretic - neurosyphilis liberated by shell-shock (using shell-shock in the - sense of a shock _without_ direct brain injury). - - 2. What compensation is due such a man as Donath’s lieutenant? The - ordinary principles applicable to traumatic paresis are not here - in point, since no symptoms pointing to trauma of brain ever - supervened. See discussion under Case G. - - 3. How frequent is paresis in armies? R. L. Richards in White and - Jelliffe’s Treatment of Nervous and Mental Diseases writes as - follows (of course concerning peace times): - - “The French estimate that paresis cases are 7 per cent of all - their military cases. The German estimate is 6.6 per cent. In our - own army at the Government Hospital for the Insane, of 490 cases - of mental diseases among officers and enlisted men, 37, or 7 per - cent, were paresis. During the Russo-Japanese War, in the Russian - Psychiatric Hospital at Harbin, the percentage of paresis was 5.6 - per cent among the cases developing at the front.” - - - =A French soldier “shell-shocked” (also burial) into incipient tabes - dorsalis? Case from Duco and Blum of Paris.= - - -=Case B.=[25] A French soldier was buried by effects of shell explosion -September 8th, 1914. He sustained no wound or fracture. - -Incontinence of urine developed. Anesthesia of penis and scrotum. -Reflexes absent; pupils sluggish. Wassermann reactions suspicious. - -The diagnosis =tabes dorsalis incipiens= was made (hematomyelia of conus -terminalis eliminated). - -The patient was estimated to be “40% incapacitated,” according to the -French “_échelle de gravité_” of conditions. A full pension would not be -justified in the opinion of the French authors. - - 1. Is there evidence of an increase or exacerbation of tabes - dorsalis in the war? Birnbaum,[26] reviewing German war neurology, - quotes Weygandt as believing that the war has probably had to do - with the production of both tabes and paresis in many instances. - Other cases, however, have merely been made worse by the war - stress. Thirdly, there are cases in which the war stress has done - no harm whatever. Westphal has seen both tabes and paresis develop - in men who had never before shown any mental or physical symptoms - whatever, and accordingly, Westphal must be counted among those - who regard war stress as a liberating factor for these diseases. - Redlich and Donath are cited in the same connection. (The case of - Donath is the case presented above as Case A.) - - A very interesting claim was made by Cimbal to the effect that he - found many examples of paresis developing in the early period of - the war, particularly in November and December, 1914. Later, - according to Cimbal, cerebrospinal syphilis and tabes became more - prevalent. - - - =Neurosyphilis in a German recruit, possibly AGGRAVATED ON military - SERVICE. Pension not allowable. Case from Weygandt.= - - -=Case C.=[27] A German, long alcoholic and thought to be weakminded, -volunteered, but shortly had to be released from service. He began to be -forgetful and obstinate, cried, and even appeared to be subject to -hallucinations. The pupils were unequal and sluggish. The uvula hung to -the right. The left knee-jerk was lively, right weak. Fine tremors of -hands. Hypalgesia of backs of hands. Stumbling speech. Attention poor. - -It appeared that he had been infected with syphilis in 1881 and in 1903 -had had an ulcer of the left leg. - -The military commission denied that his service had brought about the -disease. In the phrase of the Canadian Pension Board the German -commission would probably have rendered a report “aggravated on -service,” not “by service.” (See Canadian cases D, E, and F.) - - 1. Has paresis increased in the war? Both French and German figures - controvert the claim. Marie, for example, found not a single - paretic amongst the skull injury cases at the Salpétrière. Most - authors are found demonstrating cases which they clearly regard as - in some way produced or unfavorably influenced by the war. There - seems, therefore, to be a little inconsistency between the general - statement that paresis has not increased in the war and the - somewhat frequent cases described as occurring in and modified by - the war. However, Bonhoeffer, on the basis of nine months’ war - experience, also holds it to be probable that paresis is no more - frequent in the field than in the home population. - - 2. Is the old syphilitic especially liable to break down under war - conditions? According to Richards, Shaikewicz says that in the - Russo-Japanese war paresis was noted especially among the officers - and non-commissioned officers, and that it was undoubtedly - hastened in its development by war conditions. Steida says that - while ordinarily we find paresis developing twelve to twenty years - after the primary sore of syphilis, in these cases it developed in - five to ten years after the primary sore. Some of the cases - progressed with unusual rapidity. It was also noticed that among - soldiers from the front, under treatment, evidences of syphilis - were present in 20%, while among the other soldiers under - treatment, evidences of syphilis were present in 1.6%. Undoubtedly - the old syphilitic is especially liable to break down under war - conditions. - - But, on the whole, the German authors in this war find no evidence - favoring Steida’s claim of the hastened post-infective outbreak. - - 3. How did it come about that the efficient German system - permitted this alcoholic and weakminded syphilitic to enter the - army? As will be seen, he was a volunteer. In general, the German - system has been supplied with army surgeons who have been trained, - not by brief and “brush-up” courses, but by longer periods, - sometimes two years in duration. - - - =Syphilis contracted before enlistment, “AGGRAVATED BY SERVICE.” - Canadian case, courtesy of Dr. J. L. Todd, Canadian Board of Pension - Commissioners.= - - -=Case D.= A laboring man, 42, who always strenuously denied syphilitic -infection, proceeded to France eight months after enlistment. He had not -been in France three weeks when he dropped unconscious. He regained -consciousness, but remained stupid, dull in expression, and with memory -impaired. His speech was also impaired. There was dizziness and a -right-sided hemiplegia. - -He was confined to bed four months and was then “boarded” for discharge. - -=Physically=, his heart was slightly enlarged both right and left; -sounds irregular; extra systoles; aortic systolic murmur transmitted to -neck; blood pressure 140:40. Precordial pain, dyspnea. - -=Neurologically=, there was a partial spastic paralysis of the right -thigh which could be abducted, could be flexed to 120°, and showed some -power in the quadriceps. There was also a spastic paralysis of the right -arm, but the shoulder girdle movements were not impaired. There was a -slight weakness on the right side of the face. There was no anesthesia -anywhere. - -The deep reflexes were increased on the right side, Babinski on right, -flexor contractures of right hand, extensor contractures of right leg, -abdominal and epigastric reflexes absent, pupils active, tongue -protruded in straight line. - -Fluid: slight increase in protein. W. R.+++ - -The Board of Pension Commissioners ruled that the condition had been -aggravated _by_ service. (See Case E, “aggravated _on_ service.”) - - 1. In view of the fact that the majority of the cases here - abstracted happen to be in common soldiers, is there any evidence - bearing on relative incidence in officers and men? Quoting R. L. - Richards: - - “The percentage of paresis cases among officers alone is variously - estimated from 50 per cent in the German army (Stier) to 58.9 per - cent in the Austrian army (Drastich). Since paresis is a disease - of more advanced life, it is but natural that the percentage of - paresis among officers, non-commissioned officers, and older - soldiers should be higher than among the whole military body, - where the average age is, as we have seen, well below thirty - years. Hence the above figures do not mean a greater prevalence of - syphilis among those classes, but that we have no means of knowing - how many of the others develop paresis. If anything it shows that - these ‘soldiers by calling,’ have a more stable mental make-up, - since they succumb chiefly to an exogenous toxin.” - - Rayneau at the 19th Congress of French Alienists and Neurologists - at Nantes in 1909, discussing the insane of the army from a - medicolegal point of view, states that the most frequent mental - disease amongst officers and soldiers is general paresis. At - least, this disease is the most frequent basis of invaliding, - retirement, or placing in the inactive list. He states that French - and foreign statistics are at one upon this matter, quoting - Christian as finding 32% among the soldiers interned at Charenton; - Gamier at Dijon, 59%; Meilhon at Quimper, 42% and Talon at - Marseilles, 33.8%. Grilli found 31 of 40 officers interned in - Florence, Sienna and Milan victims of general paresis. Stier’s - German statistics indicate about 50%. Rayneau himself found 16 of - 20 officers paretic and 17 out of 27 subalterns and _gendarmes_. - - The Neurological Society of Paris held a conference December 15, - 1916, with the chiefs of the neurological and psychiatric military - centres of France, and discussed a variety of questions concerning - invaliding, incapacity, and compensation in neuroses and psychoses - of war. Dupré dealt especially with the psychoses of war as caused - by trauma, strain, infection, and intoxication. General paresis is - regarded by Dupré as the most important of the dementias found in - the army. The medicolegal point of view is, of course, that - general paresis is necessarily related to an old syphilis, but its - late development leads to misinterpretations as to its probable - cause, both by the family and friends and even by magistrates. The - war acts in the French nomenclature as an _agent revélateur_ or as - an _agent accélérateur_. Although its cause is prior and exterior - to the war, general paresis in a majority of cases is brought out - (_revélé_) by the lack of adaptability of the general paretic to - the novelty and difficulties of his surroundings and duties in - war. Trauma, strain, and alcohol in a certain number of cases - accelerate the progress of a general paresis. The aggravation of - paresis is produced by these same factors, but especially by - violent cerebral trauma. According to Dupré, the Val-de-Grace - statistics show that the number of paretics has not been increased - by the war. Medicolegally, the victim of general paresis, like the - victim of traumatic or infectious chronic mental disorder, may be - assigned an incapacity of from 50 to 100%, and these patients are - invalided under _Réforme No. 1_,—a permanent invaliding. - - Lépine of Lyons also discusses the compensation question in - general paresis. Lépine thinks that, although syphilis is - indispensable in paresis, yet the truth is that syphilis plus - something else unknown to us is responsible for general paresis. - This something else is neither a special kind of virus nor is it a - particular kind of prepared soil alone. Trauma, physical, - intellectual, and moral strain, and insomnia are the factors to - which he calls special attention as adjuncts in the production of - general paresis. As to the responsibility of the State for the - production of general paresis, according to Lépine, the maximal - responsibility should be 40% on account of the very considerable - predisposition to paresis created by pre-existent syphilis. - - Marie remarked that, although there had been thousands of head - cases at the Salpétrière, there had not been a single case of - general paresis. Dupré agreed with Marie that trauma was not a - frequent etiological factor; strain and alcohol were more - important. The Society agreed that in exceptional cases, where an - encephalic trauma could be regarded as accelerating or aggravating - the disease, the degree of incapacity might be set at from 10 to - 30 per cent. - - - =Syphilis contracted before enlistment, “AGGRAVATED ON SERVICE.” - Canadian case, courtesy of Dr. J. L. Todd, Canadian Board of Pension - Commissioners.= - - -=Case E.= A laboring man, 44, acquired syphilis at a time unknown. Ten -months after enlistment this man developed symptoms on the firing line. -He was inattentive, irrational, incoherent. The diagnosis was then -“mania.” - -There were, however, scars at angle of mouth and on lower lip. Occipital -glands were palpable, fine tremor of hands. The W. R. was +++. - -Later the patient became violent, destructive, untidy, disoriented. -Auditory hallucinations are recorded. - -He was “boarded” for discharge five months after the first symptoms. The -board agreed that these symptoms would have appeared in civil life. In -view of a difference of opinion as to the part played by stress of -service, his condition was set down as “_aggravated on service_” (not, -it will be noted, _by_ service, see Case D). - - 1. Under what conditions should pensions be awarded for disability - resulting from venereal diseases? According to a personal - communication from Dr. J. L. Todd, Chairman of the Board of - Pension Commissioners for Canada, pensions are awarded for all - disabilities appearing _during_ service, unless they can be shown - certainly to be due to the men’s own fault and negligence. It - would appear that _during_ service covers both aggravations _by_ - and _on_ service. There remains some doubt as to whether - contraction of venereal disease constitutes negligence. - - 2. What have been conditions in the small inactive American army of - the past? Richards has made a study of statistics at the - Government Hospital for the Insane, Washington. - - “The leading features of this mental disease were well exemplified - in our cases the past year. They formed 7.5 per cent of the total - number. They averaged forty years of age, and Ziehen says 80 per - cent of all cases are in the fourth or fifth decade of life. They - averaged ten and a half years’ service, which would indicate that - the military life was their calling. Only one had any serious - hereditary defect. Stigmata of degeneration were infrequent, - averaging only two for each case. 66 per cent had good schooling, - considering their opportunities. Physical signs were frequent in - each case. Only one showed normal light reaction. Ziehen says the - light reaction is retained in only 20 per cent of the cases. - Patellar reflex was absent in one case and normal or exaggerated - in five. The speech defect was slight in four cases. Other - physical signs were present in the usual proportions. Memory - defects existed in all the cases. In four the onset was with - excitement. One began with a character change as the most marked - feature. In only two were the transfer diagnoses correct. One, - beginning as a quiet dementia, was diagnosticated paralysis - agitans, because of a marked tremor. One was excited and euphoric - and was called a manic-depressive psychosis. One with an obscure - onset was diagnosticated as a neurasthenic. The other one was - first observed in this hospital. The physical signs should have - led to a correct diagnosis in each of these cases.” - - - =Duration of neurosyphilitic process important _re_ compensation. - Canadian case, courtesy of Dr. C. B. Farrar, Psychiatrist, Military - Hospitals Commission.= - - -=Case F.= A Canadian of 36 enlisted in 1915, served in England, and was -returned to Canada in February, 1917, clearly suffering from some form -of neurosyphilis (W. R. positive in serum and fluid, globulin, -pleocytosis 108). - -There is no record of any disability or symptom of nervous or mental -disease at enlistment. The first symptoms were noted by the patient in -May, 1916, six months or more after enlistment. The case was reviewed at -a Canadian Special Hospital, October 11, 1916, by a board of examiners. -This board reported that: - -“The condition could only come from syphilitic infection of three years’ -standing” (a decision bearing on compensation); but the general -diagnosis remained: - -“Cerebrospinal lues, =aggravated by service=.” - -The picture which the medical board regarded as of at least three years’ -standing was as follows: - -History of incontinence, shooting pains, attacks of syncope, general -weakness, facial tremor, exaggerated knee-jerks, pupils react with small -excursion. Speech and writing disorder, perception dull, lapses of -attention, memory defect, defective insight into nature of disorder, -emotional apathy. - - 1. Was the conclusion “aggravated by service” sound? On humanitarian - grounds the victim is naturally conceded the benefit of the doubt. - But it is questionable how scientifically sound the conclusion - really was. - - 2. Could the condition come only from syphilitic infection of at - least three years’ standing? Hardly any single symptom in this - case need be of so long a standing; yet the combination of - symptoms seems by very weight of numbers to justify the conclusion - of the medical board. - - - =Can PARETIC NEUROSYPHILIS (“general paresis”) be lighted up by the - stress of military service without injury or disease? A possible - example from P. Marie, Chatelin and Patrikios of Paris.= - - -=Case G.= In apparently good health a French soldier repaired to the -colors, in August, 1914, being then 23 years old. - -Two years later, August, 1916, symptoms appeared: speech disorder with -stammering, change of character (had become easily excitable), stumbling -gait. He became more and more preoccupied with his own affairs, grew -worse, and was sent to hospital in October, 1916. - -He was then foolish and overhappy, especially when interviewed. There -was marked rapid tremor of face and tongue. Speech hesitant, monotonous, -and stammering to the point of unintelligibility. His memory, at first -preserved, became impaired so that half of a test phrase was forgotten. -Simple addition was impossible and fantastic sums would be given instead -of right answers; handwriting tremulous, letters often missed, others -irregular, unequal, and misshapen. - -Excitable from onset, the patient now became at times suddenly violent, -striking his wife without provocation. After visit at home, he would -forget to return to hospital. Often he would leave hospital without -permission (of course the more surprising in a disciplined soldier). - -No delusions were found. - -The serum and fluid W. R. were positive, albumin in fluid, -lymphocytosis. - -=Neurological examination.= Unequal pupils, slight right-side mydriasis, -pupils stiff to light, weakly responsive in accommodation, reflexes -lively, fingers tremulous on extension of arms. - -The patient had, December 5, 1916, an epileptiform attack with head -rotation, limb-contractions and clonic movements. - - 1. Should this soldier recover for disability obtained in service? - Marie was inclined to think military service in part responsible - for the development of the paresis. Laignel-Lavastine thought so - also, but that the amount assigned should be 5%–10% of the maximum - assignable. - - 2. What is the duty of the military authorities relative to so - called traumatic paresis? Medicolegally speaking, Froissart, - quoted by Rayneau, states that a victim of traumatic paresis _may - or may not_ have presented mental disorders before the accident, - that is, that the paretic symptoms may develop out of a clear sky - as a result of the accident. The accident itself must be of a - serious nature. The accident must be followed by phenomena - pointing to brain injury of traumatic nature. These phenomena need - not be characteristic symptoms of general paresis at the outset. - The period elapsing between the trauma and the supervening - condition of paresis must be occupied without notable - interruption, at first by phenomena of a purely traumatic nature, - later by signs indicating the onset and evolution of general - paresis. - - The French invaliding process called _Réforme No. 1_ with pension - is granted according to the governmental instructions only to - officers, subalterns, and soldiers whose disease is due to trauma. - In view of this governmental regulation, the military surgeon must - write out certificates describing every cranial trauma, however - slight, which might have a bearing on the development of paresis. - However, he should not too readily admit trauma as a cause of - paresis. If a long period of quietude, a period in which the - trauma itself seems to have undergone a complete recovery, - supervenes, then general paresis should not be reported by the - surgeon. - - Lépine has recently noted the following features as desirable in - board reports concerning paretics: nature of trauma, length of - service, fatigue endured, insomnia, date of infection, treatment, - W. R. - - - =Can “gassing” light up a paresis? Example from de Massary of - Issy-les-Moulineaux.= - - -=Case H.= A soldier, 35, was sent to the _Centre Neurologique_ with a -hospital ticket reading: - -“Neurasthenia, general weakness following intoxication by gas.” - -The soldier was thought at first to be a neurasthenic. But he soon -showed signs of more pronounced mental trouble. The voice was -suspicious. There was a slight irregularity of pupils. - -An epileptiform attack occurred, followed by aggravation of symptoms. - -Lumbar puncture showed pleocytosis. The W. R. of the serum proved -positive. - -Yet the evident =neurosyphilis=, possibly =paretic= (de Massary’s -diagnosis), was preceded by a neurasthenia and the neurasthenia was -preceded by “gassing.” - -De Massary believes the patient _and his family_ would perhaps be -justified in believing the condition produced by the injury. De Massary -is not clear as to the financial deserts of the patient. It is not a -manifest case of aggravation of antebellum symptoms, even if it be -neuropathologically an instance of acquired loss of resistance to -pre-existent spirochetes in body or brain. - - 1. What adjuvant factors have been recognized in military paresis? - Aside from syphilis, Rayneau finds that alcoholism, malaria, - sunstroke and various intoxications serve as causes for paresis. - Rayneau points out that the apparent integrity of the mind in - general paresis may be such that they last in the army some time - and have their oddities ascribed to misconduct or breaches of - discipline. In fact the Legrande du Saulle called this early - period in general paresis the _medicolegal period_, showing, as it - so often does, thefts, outrages against decency, frauds, assaults, - exhibitionism and the like. To be sure these acts are absurd and - infantile and not difficult to recognize as of psychotic origin. - - - =Syphilis may bring out epilepsy in a subject having taint. Case - from Bonhoeffer, 1915.= - - -=Case I.=[28] A man of 35 in the _Landwehr_ acquired syphilis some time -in the summer of 1914. He was a good soldier, passed through several -clashes, and was promoted to _Unteroffizier_. - -To understand what followed it must be stated that he had been a -bed-wetter to 11, had been practically a teetotaler (Bonhoeffer’s point -is perhaps that otherwise epilepsy might have developed sooner?), and, -when he did drink, vomited almost at once, and had amnesia for the -period of drunkenness. His father had been somewhat of a drinker. His -sister had suffered from convulsions as a child. - -February, 1915, the _Unteroffizier_ lost appetite, got headaches, and -went to hospital for a time. Upon getting better, he was sent on service -to Berlin. In a Berlin hotel he had his first convulsions and -unconsciousness, biting his tongue. He was confused for several days, -and, when he had become clear, had a pronounced retrograde amnesia -together with a tendency to fabricate a filling for the lost period. - -This retrograde amnesia is uncommon in epilepsy and suggests organic -disease. No sign of organic disease was found on neurological -examination. The patient had no signs of the epileptic make-up. The -serum W. R. was negative. On the whole, Bonhoeffer regards the epilepsy -as “reactive” to the syphilis, as a syphilogenic epilepsy. - -As to the amnesia, it is of interest that alcohol should long before -have been able to cause amnesia in this man in the same way as does now -the syphilitic epilepsy. - - 1. In view of the fact that this _Landwehr_ man appears to have - acquired syphilis while on campaign, what is the responsibility of - the government for treatment? The Canadian authorities, as stated - under Case E, are in doubt whether contraction of venereal disease - constitutes negligence on the part of the soldier. It would appear - to us that where a government does not take suitable steps to - prevent the acquisition of syphilis by the soldiers, the - government must assume a measure of responsibility for the - syphilis incurred. The government’s responsibility would be still - greater in equity, it would appear, if commercial opportunities - for the acquisition of syphilis are maintained under more or less - close government supervision or (even as has been claimed for - certain encampments on our own Mexican border) if shelter for - illicit sex relations is afforded within the limits of a military - camp. In a certain community, “E,” for example, it is claimed by - Exner,[29] the district for prostitutes was “situated within the - lines of military camps and protected and ‘regulated’ by the - military authorities.” - - But even if the government has no legal responsibility in this - regard, it would be well to consider the ultimate results of the - syphilis that will probably be acquired by great numbers of - soldiers under campaign conditions. Aside from the ravages of - syphilis outside the nervous system, it is well known, as Weygandt - intimates for German conditions, that the aftermath of war will be - a high proportion of cases of neurosyphilis. - - Weygandt remarks in his review of the influence of the war upon - psychiatry, that the opportunity for syphilitic infection in the - campaign is considerable. In the war of 1870, the conditions in - this regard were extremely unfavorable, and writing in 1915, - Weygandt remarks that at present there should be a prophylaxis - against syphilitic infection by the soldiers, which prophylaxis - should be the most energetic possible. Continence on the part of - the soldiers and the isolation of infected women, with examination - by specialists, have been advocated by Neisser and by Mendel. In - the ’80’s a great number of cases of locomotor ataxia developed in - Germany, which were due to syphilis acquired by the soldiers and - officers in the war of 1870. - - - =Syphilis in a psychopathic subject. Convulsions 5 days after - Dixmude. Case from Bonhoeffer, 1915.= - - -=Case J.=[30] A soldier in the reserves, 23, was, subsequently to his -being brought to hospital, described by his wife as a rather -over-sensitive fellow, who could hardly look at blood and was meticulous -about the household. He had always been subject to headaches, especially -after hard work. However, he had passed through his military training -well in 1910, not even having been _bestraft_. - -He began service in October and fought at Dixmude on the 19th. On the -24th in the trench and while being carried back, he had several spells -of pallor, falling stiff, and then having convulsions. Brought finally -to the Charité in Berlin, he had more spells of sudden pallor, collapse -with brief convulsions, tossings in bed, and absences, post-convulsive -headaches, and mild bad humor. - -There were numerous attacks several days apart in the first seven weeks. -The patient was not of an “epileptic” disposition, though he was rather -readily dissatisfied. Headaches also occurred without relation to -convulsions. - -The serum W. R. was positive. Treatment by mercurial inunctions. No -further convulsions. Prognosis as to the possibility of a constitutional -epilepsy unknown. - - - =SYPHILITIC ROOT-SCIATICA (lumbosacral radiculitis) in a fireworks - man with a French artillery regiment. Case presented from Dejerine’s - clinic by Long.= - - -=Case K.= No direct relation of this example of root-sciatica to the war -is claimed nor was there a question of financial reparation. - -There was no prior injury. At the end of March, 1915, the workman was -taken with acute pains in lumbar region and thighs, and with urgent but -retarded micturition. - -Unfit for work, he remained, however, five months with the regiment, and -was then retired for two months to a hospital behind the lines. He -reached the Salpétrière October 12, 1915, with “double sciatica, -intractable.” - -There was no demonstrable paralysis but the legs seemed to have “melted -away,” _fondu_, as the patient said. Pains were spontaneously felt in -the lumbar plexus and sciatic nerve regions, not passing, however, -beyond the thighs. These pains were more intense with movements of legs; -but coughing did not intensify the pains. Neuralgic points could be -demonstrated by the finger in lumbar and gluteal regions and above and -below the iliac crests (corresponding with rami of first lumbar nerves). -The inguinal region was involved and the painful zone reached the -sciatic notch and the upper part of the posterior surface of the thigh. - -The sensory disorder had another distribution objectively tested. The -sacral and perineal regions were free. Anesthesia of inner surfaces of -thighs, hypesthesia of the anterior surfaces of thighs and lower legs. -The anesthesia grew more and more marked lower down and was maximal in -the feet, which were practically insensible to all tests, including -those for bone sensation. There was a longitudinal strip of skin of -lower leg which retained sensation. - -Position sense of toes, except great toes, was poor. There was a slight -ataxia attributable to the sensory disorder—reflexes of upper -extremities, abdominal, and cremasteric preserved, knee-jerks, Achilles -and plantar reactions absent. - -The vesical sphincter shortly regained its function, though its disorder -had been an initial symptom. - -Pupils normal. - -The “sciatica” here affects the lumbosacral plexus. Signs of disorder at -one time or other affected the first lumbar distribution of the third -lumbar and first and second sacral nerves. - -As to the syphilitic nature of this affection, there had been at -eighteen (22 years before) a colorless small induration of the penis, -lasting about three weeks. There was now evident a small oval pigmented -scar. The patient had married at 20 and has had three healthy children. - -The lumbar puncture fluid yielded pleocytosis (120 per cmm.). Mercurial -treatment was instituted. - -The treatment has not reduced the pains. Long thinks it was undertaken -too long (six months) after onset. The warning for early diagnosis is -manifest. There was somehow a delay under the medical conditions of the -army. - - - =Can the “lighting up” of NEUROSYPHILIS IN CIVIL LIFE be induced by - the domestic stress of war? A possible example from Dr. R. Percy - Smith, London.= - - -=Case L.= A German Jew in London passed into the PARETIC form of -NEUROSYPHILIS shortly after the outbreak of war under conditions -suggesting that the stress of emotions directly or indirectly lighted up -the neural process. - -The man was a bank-officer, 52 years old, and married. He had lived many -years in England and was in fact a naturalized citizen. He had been -under treatment for syphilis by Sir Jonathan Hutchinson, 29 years -before, namely, at the age of 23. Subsequently, Sir John had given him -permission to marry. - -It proved that for years the man had had fixed pupils, absent -knee-jerks, and a perforated ulcer of the foot. However, there had been -no other mental or nervous symptoms preventing bank-officer’s work. - -At the outbreak of war the man was discharged from the bank. He grew -worried and sleepless. He began to charge himself with sex irregularity. -He went down to the city and burned trust documents belonging to others. - -From worry and self-accusation he passed into depression and agitation. -He developed a belief that not only he but also his German wife were to -be executed. He thought he was a criminal and was to be hanged. - -The depression then altered to a condition of hilarity and loquacity. - -In addition to the fixed pupils and absent knee-jerks, a speech disorder -shortly developed. - -The patient was placed under care, but quickly (a few months?) passed -into an advanced stage of paretic neurosyphilis and died. - - - =SHELL-SHOCK PSEUDOPARESIS (non-syphilitic). Recovery. Case from - Pitres and Marchand of Bordeaux.= - - -=Case M.= June 19, 1915, a shell exploded some distance from Lieutenant -R. He remembers the gaseous smell, the bursting of several shells nearby -and a sensation of being lifted into the air. When he recovered -consciousness, he was in hospital at Paris-Plage, covered with bruises -and scratches. They told him he had been delirious and had vomited and -spat blood. - -June 24, his wife came to see him, but this visit he could not remember. -Nor could his wife at first recognize him, he was so thin. He roused a -few moments and recognized his wife, but relapsed into torpor again. -Speech was difficult and ideas confused. - -A few days later he was able to rise; but his mental status grew worse, -especially as to speech and writing; the latter quite illegible. There -was insomnia, or, if he slept, war dreams. - -August 7, he began a period of five months’ convalescence passed with -his family, depressed, given to spells of weeping, confined to bed or -couch, unable to “find words,” conscious of his state and troubled about -it, speaking of nothing but the war, and afraid to go out for fear of -ambuscade. There was at first a slight lameness of the right leg. -Although he could walk, he felt pain in the knee on flexing the right -leg on the thigh. He walked holding this leg in extension. - -On going back to the colors, he was immediately evacuated to the _Centre -Neurologique_ at Bordeaux, January 20, 1916. - -Examination found a bored, impatient, irritated man, vexed that a man -who was not sick should be sent up “_comme fou_.” - -Omitting negative details, =neurological examination= showed slight -lameness as above, body stiff and movements jerky; difficult, unsteady -gait. The lieutenant could stand for some time on either leg, tongue and -face tremulous during speech. Limbs moderately tremulous, especially in -the performance of test movements. - -Knee-jerks and Achilles jerks absent. Other reflexes, including -pupillary, normal. Segmentary hypalgesia of right leg, especially about -knee. Tremulous speech and writing. Patient would stop short in speaking -for lack of words. - -Malnutrition. Appetite good, but a bursting feeling after meals. - -Skin dry, scaly on legs, fissured on fingers. - -Serum W. R. negative. Fluid not examined. - -=Mental examination.= Conscious and complaining of his troubles, -Lieutenant R. claimed persistently that he was not sick. Memory for -recent events was in general poor. Errands easily forgotten. Lost in the -street. Complaint of corpse odors round him. Everybody is looking at him -and making fun of him. He was apt to insult bystanders. He was afraid of -German spies. Things in shops angered him as they seemed to him to be of -German manufacture. - -There were frequent periods of depression, with pallor and no -spontaneous speech for some hours to a half-day. Headaches coming on and -stopping suddenly. - -As to diagnosis, the first impression, say Pitres and Marchand, was that -of general paresis. The progress of symptoms after the shock was -consistent with this diagnosis. The mental state and the physical -findings seemed consistent, although the pupils were normal. His partial -insight into his symptoms was not inconsistent with the diagnosis. He -had a characteristic self-confidence. There had been four stillbirths -(two twins) two children are alive, 11 and 13. Typhoid fever at 30. -Syphilis denied. No mental disease in the family. - -The patient had never done military duty, having been invalided for -“right apex.” But he had volunteered and been accepted in September, -1914. - - 1. Was this diagnosis, general paresis, at any time justified? The - spinal fluid should of course have been examined. The peculiar - lameness of the right leg was certainly not characteristic of - general paresis, and was perhaps hysterical. (There was no - limitation of visual fields or any other definite sign of - hysteria.) Presumably some quality of speech defect, the amnesia, - and the euphoria, together with absent knee-jerks, led to the - diagnosis general paresis. By the 20th of March, 1916, the - knee-jerks had become lively; the Achilles jerks normal. At this - time the patient had gained in weight, could walk though stiffly, - had headache (especially right frontal) and a feeling of lead in - head, less tremor, lack of desire to undertake anything. He still - wanted to go back into service. He still saw spies about. Dreams - terrible; devoured by spiders, leggins instruments of torture. - Skin still atrophic. June 4 there was no more tremor of speech or - face. Symptoms largely disappeared except a few ideas of - persecution. Recovery October, 1916. - - 2. How was Lieutenant R. cured? Apparently by rest in the _Centre - Neurologique_. Pitres and Marchand do not speak of the subtle - relation between mental state and the idea of non-return to - military service. This motive might still work even if Lieutenant - R. kept protesting quite sincerely that he wanted to go back into - military service. - - - =SHELL-SHOCK PSEUDOTABES (non-syphilitic, serum W. R. positive). - Improvement. Case from Pitres and Marchand of Bordeaux.= - - -=Case N.= Innkeeper B., 36, a shell-shock and burial victim June 20, -1915, was looked on by a number of physicians as a case of genuine -tabes. - -Even eight months after the episode, he still showed (when observed by -Pitres and Marchand, February 3, 1916) absence of knee-jerks and -Achilles jerks, a slight swaying in the Romberg position, pupils -sluggish to light, incoordination, delayed sensations. There was also a -history of pains in the legs, compared by the patient to those of -sciatica. These pains came in crises, the longest of which had lasted 30 -hours. - -It seems that this soldier’s troubles began the day after his shock with -a feeling of swollen feet and of cotton wool under them. He stayed on -service, however, walking with increasing difficulty. - -At the time of his evacuation, July 10, he could walk with great -difficulty. “Strips of lead were between his legs.” He could hardly -control movements in the dark, or descend stairs. Often his legs would -bend under him. Vesical function sluggish. - -After a few months the patient could walk better. On February, 1916, he -walked thrusting his legs forward trembling, and dragging toes a little. -He could not support himself on either leg. Jerkiness and incoordination -in extension or flexion of leg on thigh. - -The muscular weakness was decidedly against tabes or at all events a -pure tabes. The incoordination proved to be due, not to loss of position -sense (which was intact) but to unsteady muscular contractions. Deep -sensibility was intact. - -There were no mental symptoms. There was a slight hesitation in speech -and doubling of syllables, but nothing demonstrable with test phrases. - -The serum W. R. was positive. Syphilis denied. - - 1. What is the cause of these phenomena? Pitres and Marchand lean to - the hypothesis of slight internal traumatism. They believe that - there is either (a) slight internal hemorrhage in the nervous - system, or possibly (b) what they call “nerve cell contusion,” or - perhaps (c) caisson-disease-like phenomena from aerial - decompression. Some authors incriminate (d) the gases. It has been - reported by certain French authors that shortly after shell-shock - injury or burial there is a pleocytosis in the spinal fluid as - well as evidence of hemorrhage. The pleocytosis is said to last - only a short time; hence when patient arrives at a base hospital - lumbar puncture usually discloses nothing. - - - Baalim and Ashtaroth - - Paradise Lost, Book I, line 422. - - - - - VII. SUMMARY AND KEY - - -No more important human problem now exists than syphilis. Syphilis of -the nervous system or, briefly, neurosyphilis is a highly important -fraction of the total problem. The few outstanding dates and items which -we present on the following page give but a faint idea of the amount of -observation and thinking which the medical aspects of neurosyphilis -alone have required. The present work deals with but a small fraction of -the results of this work, nor can we more than glance at the scientific -history of syphilis and neurosyphilis—a history that would form an epoch -in itself. - -It is only in the most recent years that syphilology and the narrower -science of neurosyphilology have threatened to become separate -disciplines boasting full time specialized workers. Up to recent years -the contributions to the theory of syphilis have been largely -by-products of work in larger sciences and arts. Thus, the cellular -pathology of syphilis as worked out by Virchow and the more special -vascular features as worked out by Heubner were incidental in the -progress of pathological anatomy and histology. The bold procedure of -Quincke in proposing lumbar puncture also had its more general ground in -the extension of clinical medicine,—an interpretation likewise true of -the French achievements in the cyto-diagnosis and chemical diagnosis of -the lumbar puncture fluids. The careful histological definitions of the -Nissl-Alzheimer group were incidental to the application of approved and -classical pathological methods to neurological and psychiatric material. - -Again, the work of Schaudinn, as well as that of Metchnikoff and Roux, -was ingenious work with the methods of parasitology and experimental -pathology. The great work of Schaudinn in establishing the constancy of -the spirocheta pallida in syphilis may be said to have started -syphilology as something approaching a special discipline. The ideas of -one of the greatest of immunologists, Bordet, were almost immediately -applied to the serum diagnosis of syphilis by Wassermann and the further -application of this method to the problems of neurosyphilis was almost -immediate, with the spirocheta pallida as an object of attack. The -commanding intelligence of Ehrlich could at once seek application of -long incubated ideas of chemotherapy with the startling outcome, -salvarsan. - - - =DATES, NEUROSYPHILIS= - - VIRCHOW PATHOLOGY 1858 - HEUBNER ENDARTERITIS 1874 - QUINCKE LUMBAR PUNCTURE 1891 - RAVAUT, SICARD, NAGEOTTI, WIDAL CYTODIAGNOSIS, C.S.F. 1901 - WIDAL, SICARD, RAVAUT ALBUMIN, C.S.F. 1903 - METCHNIKOFF AND ROUX TRANSMISSION TO APES 1903 - ALZHEIMER HISTOPATHOLOGY, BRAIN SYPHILIS 1904 - SCHAUDINN AND HOFFMANN SPIROCHETA PALLIDA 1905 - WASSERMANN, NEISSER AND BRUCK SERUM DIAGNOSIS 1906 - PLAUT WASSERMANN REACTION, C.S.F. 1908 - EHRLICH SALVARSAN 1909 - SWIFT AND ELLIS SALVARSANIZED SERUM 1912 - NOGUCHI AND MOORE SPIROCHETES, BRAIN TISSUE, 1913 - PARESIS - LANGE GOLD SOL TEST 1913 - - CHART 28 - - -The history of syphilis and neurosyphilis was now to be thickly sown -with ideas and results growing from the achievements of Schaudinn and -Ehrlich. The positive reactions in the blood and spinal fluid in the -most striking of mental diseases, general paresis, led to the impression -that general paresis itself might at last be proved to be what Mœbius -had suspected, namely, 100% syphilitic. We know how difficult is the -technical proof of spirochetosis in the brains of general paretics both -post mortem and ante mortem, but no one doubts the certainty of the -syphilitic hypothesis concerning the origin of general paresis. - -The data of the gold sol reaction ultimately obtained from the ideas of -Thomas Graham concerning colloids, as developed by Szigmondi and -effectively applied by Lange, have broadened and solidified the whole -plane of attack. - -The ingenious suggestions of Swift and Ellis (salvarsanized serum) and -the notable work of Noguchi and Moore (spirochetosis in paretic brains) -indicate to us as Americans what the establishment of scientific -institutes may do to permit the rapid application of new ideas to -branches of inquiry that are opened out. Scientific institutes do not -manufacture a Virchow, a Metchnikoff, a Schaudinn, a Bordet or an -Ehrlich but they directly permit such men to work and indirectly -stimulate the development of more. - -The series of 137 cases here at least presented does not touch -systematically the problems of the neuropathology of syphilis, which -would themselves require a textbook of respectable size. We have, -however, presented in Part I, cases 1 to 8, some indication of the -protean nature of the material and from time to time in the remainder of -the book somewhat fuller accounts of the pathological anatomy and -histology have been presented than are strictly necessary in the -demonstration of the principles of modern systematic diagnosis and -treatment. - -Our work may be said to represent psychopathic hospital practice as -available to us in our official capacities at the Psychopathic -Department of the Boston State Hospital. A word is necessary concerning -the nature of this practice. The dispensary and ward practice of a -modern state psychopathic hospital, such as the Boston institution -(founded in 1912) and the Ann Arbor institution (founded in 1906), is to -be sharply distinguished from asylum practice. Those who have not -followed the evolution of the modern psychopathic hospital with the -lowering of bars to the admission of patients and the extension of its -benefits to a group of sick persons far removed from the medicolegal -concept “insanity” may not soon grasp the general nature of psychopathic -hospital material. Psychopathic hospital practice stands, in fact, -almost midway between asylum practice in the classical sense and private -practice. This has come about through the great extension of the -so-called voluntary relation under which hundreds of patients now resort -to the beds and out-patient rooms of a psychopathic hospital, who would -formerly have remained untreated or inadequately treated. Moreover, the -broadening of the concept of mental diseases as a whole has permitted in -some parts of the world the establishment of laws under which -psychopathic and psychotic patients may be brought to psychopathic -hospitals and even to asylums under the easiest possible conditions and -restrictions, omitting court procedure altogether. The operation of the -voluntary and temporary care provisions of law has accordingly yielded -us, in the Boston institution, a great group of cases formerly not at -all accessible to hospital diagnosis and treatment. Needless to say, as -always under such conditions, we have been able to show not merely that -hospital diagnosis or treatment is of importance to a new group of -cases, but also that home treatment, especially home treatment under -supervision, is possible and even ideal for a large group of cases about -which utter darkness or profound misgivings ruled in the not very -distant past. - -Accordingly, we are fain to insist that our material is of importance in -new programs of community organization for the stamping out of disease. -The work in psychopathic hospitals upon neurosyphilis in particular is -essentially a part of the public health program, although our special -work will not soon be taken over by the public health officers, so -complicated are the ramifications of medical and social diagnosis and -treatment in the neurosyphilis group. - -We have tried in Part IV (medicolegal and social cases) to give a few -examples to illustrate the part played by neurosyphilis in society; but -we regard this part of our work as the least satisfactory and the least -representative in the total work. Our colleagues in social service, in -mental hygiene, in psychopathology and in criminology will easily in the -next few years provide a far more adequate basis for a full account of -the public and social aspects of neurosyphilis. One point we should -emphasize here. The psychopathic hospital worker, whether physician or -social worker, must shortly decide upon and consolidate a program with -relation to the families of neurosyphilitics. - -The syphilographers of the dermatological and special syphilis clinics -have their identical problems with the families of syphilitics; but the -dispensaries for mental cases and in particular the psychopathic -hospital and asylum out-patient departments tap another reservoir of -syphilitic families at a stage when the memory of the initial horrors of -syphilitic infection is dimmed or erased. Any program for the diagnosis -and treatment of syphilis of the innocent must take into account not -only the skin, syphilis, and internal medicine clinics but also the -clinics for mental and nervous diseases wherein neurosyphilitics are not -infrequent. Whether the ultimate percentage will stand at 10, 15 or 20% -for the neurosyphilitics in mental clinics, is of no importance to the -principle. There are enough neurosyphilitics having economical -importance and humanly precious families to warrant definite steps. - -The Massachusetts Commission for Mental Diseases has in the last few -years employed the services of two medical workers whose time has been -largely devoted to the applications of our recent knowledge in -neurosyphilis and has gone so far as to establish a neurosyphilis ward -in one of the district state institutions (Summer Street, Worcester, -under the Grafton Hospital Board). Special social workers in the field -of neurosyphilis have also been available from time to time. These -social workers are enabled with the support of the medical profession to -do a great deal of good, for example, with the slogan THE CHILD OF A -PARETIC IS THE CHILD OF A SYPHILITIC. - -The nature of the intake of patients into psychopathic hospital wards -and out-patient clinics is such that great numbers of non-mental -syphilitics arrive for diagnosis and possible treatment. Moreover, the -existence of syphilis in non-suspects is a fact picked up by the way in -routine Wassermann serum diagnosis. - -The mental clinic in the modern sense with the medicolegal bars lowered -or well nigh removed, turns rapidly into a clinic for neurological cases -as well. The German models for mental and nerve clinics are rapidly -being imitated. The result of this administrative novelty in our -hospital procedure has incidentally yielded us many representative cases -of entirely non-psychotic and even non-psychopathic neurosyphilis. Our -impression grows and deepens that _the neurosyphilitic is seldom merely -a spinal syphilitic_. The neurosyphilitic is nearly always the victim -not merely of spinal disease but also of intracranial disease. Per -contra, the victim of intracranial neurosyphilis is almost always more -or less importantly affected by spinal neurosyphilis. - -The net result of the modern work on neurosyphilis has been to bring the -neurologist and the psychiatrist together upon one platform in diagnosis -and more and more upon one platform in treatment. But aside from the -clinical evidence that the neurosyphilitic is apt to be a victim of both -brain syphilis and cord syphilis, the autopsy evidence is stronger -still. Even the victim of tabetic neurosyphilis (“tabes dorsalis”) -himself is rarely found at autopsy without more or less evidence of -significant encephalic disease of a chronic inflammatory or degenerative -nature. Aside from tabes dorsalis and Erb’s paraplegia, the rule is -almost universal that neurosyphilis is a matter of the entire nervous -system. - -In view of the generalization of neurosyphilitic process, one might -question the advantage of any topical grouping of neurosyphilitic -disease. Practically speaking, however, as we have shown in Chart 5, it -seems advisable to separate the neurosyphilitic diseases into six -roughly distinguishable groups. First, there is the great group that we -have chosen to term =diffuse neurosyphilis=, including many of the cases -of so-called cerebral or cerebrospinal syphilis of the neurological -clinics and the group of cases that have been treated in private -practice by internists and neurologists without recourse to -institutions. These cases have lived at home and have not been socially -hard to manage until the late phases of their disease when the victims, -if poor, are sent to almshouses and infirmaries under municipal or state -care. These are the cases which have been in the past regarded as most -amenable to the classical iodid and mercurial treatment. Indeed there is -record of numerous therapeutic successes in the group. - -Whereas the lesions in diffuse neurosyphilis are chiefly chronic -inflammatory and degenerative changes of a diffuse nature (with vascular -changes incidental or subordinate to the inflammation and the -degeneration), there is an important and large group of cases that we -have termed =vascular neurosyphilis= in which the factors of -inflammation and degeneration are subordinate to vascular insults. These -are cases of syphilitic arteriosclerosis and the best examples are -victims of cerebral thrombosis. The clinical symptoms of the immediate -attacks (of apoplectiform, epileptiform or other acute nature) are not -in themselves distinguishable from the immediate effects of -non-syphilitic vascular disease; nevertheless the establishment of their -syphilitic etiology is of the utmost importance on account of the -possibilities of treatment of the underlying syphilis. For, as the -neuropathologist must always insist, the immediate effects of vascular -insults whether syphilitic or non-syphilitic are much more extensive -than the ultimate paralytic or residual irritative effects; and by -consequence a greater optimism is justifiable in the confronting of -these cases than the nihilistic observer is likely to entertain. - -Physicians dealing with chronic disease in general are apt to be -somewhat nihilistic, but this nihilism is increased a hundred fold in -disease of the nervous system. How important then is any work which -shall demonstrate partial or even complete recovery from serious looking -apoplectic and other seizures, besides all of which the point of -syphilitic treatment naturally lies in the prevention of future insults -of the same sort. Therapeutic experience in this vascular group has -almost as good a toll of successes as in the diffuse neurosyphilis group -above mentioned, that is to say, the modern systematic treatment and -even the old pre-salvarsan treatments have succeeded fairly well in -removing the products of inflammation from the membranes of the nervous -system and in abolishing vascular disease. - -The old principle that the dead neurone in the central nervous system -cannot be regenerated remains a perfectly firm principle; but there are -any number of neurones and even neurone systems that are not essential -to life or to the pursuit of happiness. We accordingly have just as good -a theoretical therapeutic outlook in many instances of chronic -neurosyphilis as we have in chronic diseases of many other organs. Add -to this the fact that a great number of the most sharply-defined and -grave symptoms are probably not due to destruction of neurones but to -irritation and functional disability of neurones, and the conclusion is -compelled that, as hinted above, an entirely unjustifiable pessimism and -nihilism have prevailed in some quarters. Of course, the recoil from -such pessimism with the onset of salvarsan treatment led various -enthusiasts to an undue optimism. - -Another great group distinguished by the existence of spinal cord -disease is the group we have termed =tabetic neurosyphilis=, which group -contains the classical tabes dorsalis or locomotor ataxia and its -congeners. - -The question of therapeutic optimism comes up most forcibly in the field -of tabes. It is hard, however, at this time to give a proper and -scientifically founded estimate of the therapeutic outcome in tabetic -neurosyphilis with modern methods. So much can be said: namely, that the -alleviation of pain and the palliation of other symptoms can be -successfully claimed as a result of the renewed interest in the -treatment of this affection. What was said above concerning the finality -of the death process in a dead neurone is very strikingly true, of -course, of some of the neurones of the posterior columns in tabes -dorsalis. Still only portions of these neurones (namely, those which run -an intradural course) are strikingly altered in a great many cases. Now -and again one is greatly astonished to observe the restoration of the -lost knee-jerk in cases of neurosyphilis (see for instance the case of -Alice Morton (1), with discussion). In short, the relation of several -tabetic symptoms to irritative conditions and functional disability of -neurones may be considered established. Naturally, moreover, if therapy -can stop the upward course of the affection as it passes from lower to -higher nerve roots (according to reasonably well-established ideas of -the genesis and progress of this affection), we are entitled to a -further degree of optimism. - -The question of therapeutic optimism _versus_ pessimism is forced upon -attention in the fourth great group of neurosyphilitic diseases which we -have chosen to distinguish, namely, the group of =paretic neurosyphilis= -including the disease formerly known as general paresis, paralytic -dementia, softening of the brain and the like. - -Of course, no one can gainsay there is a group of cases having in the -natural course of events a prognosis of fatality within a term of years, -say three to five years, and we have cases in our series which go to -show that even with the modern intensive treatment the characteristic -down-grade symptomatic progress and ultimate fatality occur. Still, we -have other cases diagnostically on all fours with the fatal cases that -have seemed to get either entirely well with the laboratory tests -returning to normal and without further mental symptoms, or else lose -mental symptoms on the one hand or laboratory signs on the other. We -should strongly object to any account of paretic neurosyphilis which -should insist that its necessary outcome is fatality within a term of -years. Of course, viewing our knowledge of the affection in the past, we -should be compelled to object to the generalization “_paresis fatal_” on -the evidences of the universally recognized remissions. If nature can -stop a paretic process, why cannot man do as much? Can it be alleged -that our own apparent therapeutic successes and those of others are -merely curious examples of coincidences, namely, that remissions have -chosen to occur precisely when therapy was systematically applied? The -percentage of therapeutic successes with modern intensive treatment, -wherever it may ultimately stand, is already too high for this -hypothesis of fortuitous remissions.[31] - -Moreover, we believe that the details of the clinical progress of some -of the reported cases are convincing on this point. What, however, is -the distinguishing feature of paretic neurosyphilis? It is in one sense -a particular kind of diffuse neurosyphilis. The tissues are apt to show -not only encephalic but also spinal changes. There is apt to be a more -or less well-defined meningitis, but the characteristic feature, without -which the diagnosis of paretic neurosyphilis would hardly be rendered, -is the existence of disease of the cerebral cortex. This disease is -parenchymatous in the sense of showing nerve cell destruction. There is -also an interstitial reaction in the shape of a neuroglia overgrowth, -but the striking and pathognomonic feature is the infiltration of the -sheaths of the small vessels in the cortex, giving evidence of an -inflammation very intimately affecting the cellular mechanisms of the -nervous system. It is striking how often a smaller or larger share of -the cells found in the vessel sheaths are plasma cells. It does not -appear, however, that the diagnosis of paretic neurosyphilis as against -diffuse non-paretic neurosyphilis can be made in the stained sections -with complete safety on the basis of plasmocytosis in the former and -lymphocytosis in the latter. Whatever the results of careful -histological differentiation by future neuropathologists may yield, it -is at all events true that we cannot yet make an important -differentiation clinically on the basis of the differential count of -plasma cells and lymphocytes in the puncture fluids. However this may -be, there is an important distinction between diffuse neurosyphilis of -the non-paretic type and paretic neurosyphilis in that paretic -neurosyphilis rarely if ever fails to show important degrees of -intracortical perivascular inflammation with larger or smaller numbers -of plasma cells. - -What has the therapeutist to face in this matter? The answer, as -elsewhere, depends somewhat upon what the future may decide as to the -habitat and toxic or antitoxic activities of the spirocheta pallida. The -early claims that the spirocheta pallida was extravascular and lay for -the most part in the parenchyma and not in the vessel sheaths were -perhaps overbold, since other workers have found the spirochete in the -vessel sheaths also (Mott). - -Aside from the spirochete and its accessibility to spirochetocidal -drugs, there seems to be no reason for supposing that the perivascular -sheaths cannot be cleansed of their inflammatory contents. There is, -again, no reason why the phagocytic cells should not continue to perform -their scavenger function until such time as the degenerative process in -the parenchyma (a process not necessarily progressive in the absence of -the spirochete or its products) ceases. There is every reason to suppose -that a great many of the clinical phenomena are not necessarily due to -permanent destruction of neurones and neuronic organs (dendrites, -axis-cylinders, nets and the like) but are due to various microphysical -conditions of pressure, intoxication and the like. - -The inflammatory conditions in the spinal cord of poliomyelitis, which -conditions are precisely as striking as those of the paretic cortex, are -beyond a question cleared away in the progress of the affection. -Reference to the paradigm case (1) will show the type of our argument. -There is no manner of doubt that in this paradigm case almost every -portion of the nervous system had been sometime swept by spirochetosis -and many of its small vessel sheaths stuffed with chronic inflammatory -products. As for paretic neurosyphilis itself, a great many of its most -striking clinical phenomena, such as loss of memory and disorientation, -as well as great degrees of apparent dementia, are found virtually as -often in cases with very slight anatomical changes as in cases with -marked cortical devastation. The inference is plain, that these -phenomena are to a degree functional rather than structural. - -In brief, we conclude not only from therapeutic experience but also on -_a priori_ grounds that the histological conditions in paretic -neurosyphilis are not entirely hopeless, and certainly not more hopeless -than conditions in many chronic diseases outside the nervous system. -Accordingly, we plead for a temperate optimism as to therapeutic results -in general paresis. - -A fifth group of neurosyphilitic cases bulking rather largely in -textbooks of pathology is the group of the =gummata=. For a variety of -reasons (therapeutic and otherwise) the actual number of gummata of the -nervous system available for clinical or even for anatomical study is -much smaller than the books might lead one to infer. - -The sixth and last of the main groups of neurosyphilitic diseases is -that of the =juvenile forms=, among which we find not only diffuse forms -without a special and well-defined course, but also characteristic -examples of paretic and tabetic neurosyphilis. The distinction of a -juvenile or congenital group of neurosyphilitics is, on theoretical -grounds, perhaps hardly defensible. On practical grounds, however, the -juvenile neurosyphilitics do form a group having special relations to -feeblemindedness, epilepsy and the like. - -We must be clearly understood as to the rough, six-unit classification -just given. It is practical merely. For comparison we have given in -other charts more expanded lists of the diagnostic entities in -neurosyphilis among which that of Head and Fearnsides is of special -interest, see Chart 2, page 21. - - -We shall now proceed to a brief analysis of the findings in our chosen -series of 137 cases. We shall not reproduce the case headings of these -cases, but expand their statements where necessary and tie them together -so far as possible into a reasonable and systematic statement of the -situation in neurosyphilis. The footnotes will contain references to -other cases in which identical points are illustrated as in the leading -cases. The leading cases will in all instances be placed first in the -footnotes. - -The paradigm[32] shows meningeal, vascular and parenchymatous lesions -and thus illustrates our definition of the term DIFFUSE which means -precisely meningeal, vascular and parenchymatous. The meningeal lesions -gave rise to two prominent sets of lesions, first, the marked tabetic -lesions of the spinal cord (due to the spinal root neuritis incidental -to the spinal meningeal inflammation), secondly, the characteristic -asymmetrical and focal atrophy of cranial nerves incidental to a now -largely extinct meningeal process at the base of the brain. The vascular -lesions are responsible for another important and characteristic factor -in the case, namely, the bilateral pyramidal tract sclerosis; the -bilateral cysts of softening of the corpora striata are characteristic -effects of old syphilitic cerebral thromboses. The parenchymatous -disease in our paradigm is everywhere obvious, less so perhaps in the -cortex itself than elsewhere, although here also evident in the shape of -lesions suggesting an early phase of tissue atrophy. - -The paradigm is of interest in demonstrating what in broad lines must be -taken as an ascending disease proceeding not only from spinal cord to -encephalon but also traceable as proceeding from lower parts of the -spinal cord to upper parts thereof and from the lower encephalon to the -higher structures of the cerebral cortex itself. - -The paradigm insistently calls attention to the advantage of persistent -therapy not only in its display of remarkable successive recoveries from -permanent looking symptoms but also histologically from the remnants of -inflammatory process to be found in an otherwise almost wholly -dismantled nervous system with extinct lesions. - -TABETIC NEUROSYPHILIS[33] (“tabes dorsalis”), of course, often proceeds -to death without special complications of syphilitic nature. We have -chosen a case, however, to demonstrate a terminal complication with -vascular insult. Incidentally the case shows another complication -inasmuch as the cause of death was rupture of aortic aneurysm. It is -important to bear in mind these complications in tabes dorsalis which go -to prove that the spirochetosis of tabetic neurosyphilis is not limited -to the region of the spinal roots or to the spinal region in general. -Tabetic neurosyphilis is apt to be only a part of a total picture of -neurosyphilis just as neurosyphilis itself is only a part of the general -syphilitic process. - -Our case of PARETIC NEUROSYPHILIS[34] (“general paresis”) is a -characteristic one in duration (three years and three months). The -aortic sclerosis almost constantly found in neurosyphilis and especially -in paretic neurosyphilis is here also shown. The spinal cord showed -lesions which are also almost always found in paretic neurosyphilis. The -characteristic frontal emphasis of the atrophic and indurative lesions -is shown. There is also a display of gross changes in the pia mater. The -characteristic so-called granular ependymitis or sanding of the -ventricular surface is shown. The case is distinguishable from the -paradigm in not showing the effects of vascular insults in the shape of -cysts of softening. The cerebellar sclerosis of the case is fairly -characteristic of paretic cases. There is even a suggestion of atrophy -in the temporal region suggesting the so-called Lissauer’s paresis. -Clinically the case belongs in the classical grandiose group of paretics -(“O. K. No. 1 superfine”). - -VASCULAR NEUROSYPHILIS[35] is illustrated in a fourth autopsied case. It -may be noted that the pia mater in this case is practically normal. The -tissues outside the area of softening due to the syphilitic thrombosis -of nutrient vessels are practically normal. The case was one of almost -complete sensory aphasia with word-deafness. The clinical picture is -accordingly quite distinct from those of the paradigm (1) and of the -case of general paresis (3) just discussed. - -JUVENILE PARESIS[36] is illustrated by a case with exceedingly extensive -lesions, largely meningeal and parenchymatous. The cerebral lesions are -atypical since in places they suggest the tuberous sclerosis of -Bourneville. The brain atrophy is extreme (965 grams) and it is possible -that this apparent brain atrophy was in part hypoplasia, since the -spirochetosis of this case was doubtless congenital. However, clinically -the patient was fairly normal up to the age of 18. - -A case of so-called SYPHILITIC EXTRAOCULAR PALSY[37] demonstrates a -characteristic meningeal process more extensive than the clinical -symptoms would have indicated. In fact, focal clinical nerve palsies are -as a rule, if not constantly, partial phenomena of a far more extensive -process of neurosyphilis. They are far more limited clinically than -anatomically and histologically. It seems at first sight improper to -term them cases of diffuse neurosyphilis in view of their clinical -focality, yet they are best described as partial cases of diffuse -neurosyphilis. - -A case of GUMMA[38] of the left HEMISPHERE is presented which appears to -have led to death in about four years from onset. This case, like many -others, is not an example of purely focalized syphilitic process -inasmuch as cysts of softening indicating slight vascular insults are -present elsewhere (pons). There is also a degree of leptomeningitis, -particularly basal. - -Our discussion of the nature and forms of neurosyphilis is completed by -a rare case probably belonging in the so-called _cervical hypertrophic -meningitis of Charcot_ but actually due to a GUMMA OF THE SPINAL -MENINGES.[39] The importance of therapeutic optimism is emphasized in -this case as in the paradigm. Theoretically the meningeal inflammation -of neurosyphilis ought to be almost entirely if not entirely removed by -therapy, and these two cases, like several others in the series, seem to -illustrate this possibility. - - -Neurosyphilis sometimes receives the clinical diagnosis neurasthenia -simply through omission to apply proved diagnostic methods. An instance -is given in which the PARETIC form of NEUROSYPHILIS (“general paresis”) -received the diagnosis _neurasthenia_[40] for a period of five years, at -any time during which period it would doubtless have been possible to -render the correct diagnosis and apply treatment. - -Neurosyphilis may imitate not only the psychoneuroses but also the -psychoses themselves. We present a case of an architect, which looked -almost precisely like _manic-depressive psychosis_[41] and had a history -of attacks, but in which the positive serum W. R. led (in accordance -with hospital rules) to an examination of the spinal fluid. The spinal -fluid tests proved the case to be one of PARETIC NEUROSYPHILIS. - -However, a positive serum W. R., even when associated with mental -symptoms, and when those mental symptoms include grandiosity, does not -prove the existence of neurosyphilis either in its paretic or -non-paretic form. Our instance seems to be one of MANIC-DEPRESSIVE -PSYCHOSIS.[42] The spinal fluid tests were entirely negative. The course -of the disease was also that of manic-depressive psychosis. In the -absence of positive spinal fluid tests, the diagnosis neurosyphilis was -excluded. - -Neurosyphilis and even PARETIC NEUROSYPHILIS may result in symptoms that -would ordinarily lead to the diagnosis _dementia praecox_.[43] - -It is important not to rule out neurosyphilis on the ground of a -_negative serum_ W. R. The fluid W. R. may turn out positive. We present -a case (of a salesman)[44] in which the serum W. R. was repeatedly -negative (even salvarsan did not act provocatively) yet the spinal fluid -W. R. proved positive. The case was clinically one of classical PARETIC -NEUROSYPHILIS (“general paresis”). It is a good rule to proceed to -lumbar puncture, even when the serum W. R. is negative, if there are -suspicious symptoms (e.g., speech defect and memory impairment, -grandiosity) or signs (e.g., marked reflex disorder, especially -pupillary disorder). - -DIFFUSE NEUROSYPHILIS was above defined as -“meningovasculoparenchymatous.” This disease is typically associated -with six positive tests (positive serum W. R., positive fluid W. R., -pleocytosis, gold sol reaction, positive globulin reaction and excess -albumin). One or more and frequently several of these six tests are -likely to run mild in diffuse neurosyphilis; that is to say, these tests -are apt to run milder than the identical tests in paretic neurosyphilis -(“general paresis”). The clinical course of the diffuse, and especially -the meningovascular cases, is likely to be protracted. The prognosis as -to life is good, barring fatal vascular insults. The illustrative -case[45] was a case with slow course. There was a series of attacks -followed by a paralytic stroke, a finding highly typical of the diffuse -form of neurosyphilis. The spinal fluid reactions were mild, suitable to -the general principle above stated. - -These tests are likely to run stronger, as above stated, in paretic -neurosyphilis (“general paresis”), than in the diffuse form. In -particular, the gold sol reaction is likely to be shown in what is -termed “paretic” form rather than in what is termed “syphilitic” form. -The clinical course of PARETIC NEUROSYPHILIS is likely to be brief. A -characteristic case[46] with very heavy globulin and albumin tests is -presented. - -TABOPARETIC NEUROSYPHILIS[47] (“taboparesis”) is clinically a -combination of the symptoms of tabetic (“tabes dorsalis”) and those of -paretic neurosyphilis (“general paresis”). First comes the tabes -dorsalis lasting often for many years. Afterward follows a -characteristic general paresis. The ultimate paretic picture is likely -to retain, however, various characteristics of tabes. The laboratory -tests in the paretic phase of taboparesis are characteristic of general -paresis and not of tabes dorsalis. The prognosis after the paretic phase -has arrived is that of general paresis. - -The diagnosis of the neurosyphilitic forms would be easy if these -principles were always carried out to the letter. The important fact is -as follows: diffuse (that is, meningovasculoparenchymatous -neurosyphilis) may look like paretic neurosyphilis (“general -paresis”)[48] at certain periods of the clinical and laboratory -examination. This fact is of obvious importance. The general prognosis -of diffuse neurosyphilis is regarded as good _quoad vitam_. The general -prognosis of paresis is bad. If, however, the differential diagnosis -cannot be rendered at particular phases of a given case, then no safe -prognosis can be offered in the individual case. In particular no -prognosis affecting the administration or non-administration of modern -systematic treatment can or should be offered in these doubtful phases. - -It is not always safe to exclude neurosyphilis even when the _fluid_ W. -R. is _negative_.[49] Particularly in vascular neurosyphilis the fluid -W. R. and even all the other laboratory signs in the spinal fluid may -sometimes be negative. A positive serum W. R. yields the correct pointer -to diagnosis. Of course, also in many cases of vascular neurosyphilis -one or more of the laboratory signs may be suggestive even when the -fluid W. R. is negative. Theoretically there may be cases in which all -the six tests are negative and yet the diagnosis neurosyphilis be the -correct one. - -A clinically important sign in neurosyphilis is the so-called -_seizures_. These occur both in DIFFUSE NON-PARETIC NEUROSYPHILIS[50] -and in PARETIC NEUROSYPHILIS.[51] - -_Aphasia_ is likewise a symptom in both these forms of neurosyphilis, -namely, in the DIFFUSE non-paretic[52] and in the PARETIC form.[53] - -The literature contains reference not only to seizures and aphasia as -characteristically paretic but also to _remissions_. Remissions like -seizures and aphasia are found in both the PARETIC[54] and NON-PARETIC -forms of neurosyphilis.[55] They have important bearings on prognosis in -all forms of neurosyphilis and are of especial significance in the -evaluation of treatment. (Remissions coincident with apparent cure.) - -So far we have been dealing with cases of neurosyphilis in which there -was no doubt of the existence of mental symptoms. There are cases, -however, in which although the laboratory signs of neurosyphilis exist, -proving beyond doubt the existence of a chronic inflammatory reaction -and allied pathological conditions in the cerebrospinal axis, there are -no mental symptoms of neurosyphilis. We have called some of these cases -PARESIS SINE PARESI[56] and present examples. - -To illustrate complications we give a case of PARETIC NEUROSYPHILIS with -autopsy in which there were ante mortem signs of HERPES ZOSTER[57] or, -at all events, of a skin eruption limited to the area of a thoracic -nerve. - -A case of GUMMA of the brain[58] in which decompression was warranted -and performed is presented. The fluid W. R., as in many such cases, was -negative; serum positive. - -A case of CRANIAL NEUROSYPHILIS (extraocular palsy[59] without mental -symptoms) showed a positive Wassermann serum test and a negative spinal -fluid. - -The laboratory reactions in TABETIC NEUROSYPHILIS[60] (“tabes dorsalis”) -run somewhat like those of diffuse non-paretic neurosyphilis and are -accordingly milder than those of paretic neurosyphilis. The fluid W. R. -and the gold sol reaction in particular are apt to run mild. The -clinical course of tabes dorsalis is well known to be protracted and the -prognosis _quoad vitam_ is good except that we must always bear in mind -the possibility of vascular insults and complications of a syphilitic -origin in the rest of the body. - -It is important to remember that TABETIC NEUROSYPHILIS is often quite -atypical[61] clinically and may even show no single symptom warranting -the old clinical name locomotor ataxia. - -There are even cases in which the name tabes dorsalis is not warranted -in view of the fact that the lesions are not low in the cord but are -higher up (TABES CERVICALIS[62]). - -A rare form of neurosyphilis is ERB’S SYPHILITIC SPASTIC PARAPLEGIA[63] -against which one needs to consider a number of non-syphilitic spinal -cord diseases. Our case showed a weakly positive serum W. R., a negative -fluid W. R., and the other tests of the spinal fluid were moderately -positive. - -SYPHILITIC MUSCULAR ATROPHY[64] is classified by Head and Fearnsides -both in their meningovascular group and in their group of the so-called -syphilis centralis. Our case affecting in large part the small muscles -of the hands in a teamster, may be due either to spinal parenchymal -lesions or to root neuritis or to both. - -It is a little extraordinary and very important that the _laboratory -signs_ are apt to be positive even in the SECONDARY period of SYPHILIS. -Perhaps a third of all cases of syphilis in the secondaries would, if -tested, yield positives precisely like those of full-blown paretic or -diffuse neurosyphilis. Strangely enough, these signs may occur without -clinical symptoms. The illustrative case,[65] a mechanic, yielded -various mental symptoms. The cases of secondary syphilis with laboratory -signs of neurosyphilis but without clinical symptoms are of the greatest -theoretical importance in relation to the problem above mentioned of -_paresis sine paresi_. It may well be inquired whether in some instances -the neurosyphilis of the secondaries does not persist until the -exhibition of mental or physical symptoms of neurosyphilis years later. -It must be remembered that this conception is hardly more than a -hypothesis at the present time. That such signs of chronic inflammation -could exist without symptoms is not so surprising when one thinks of the -startling immediate improvement seen after treatment or even in -remissions without treatment. One is reminded of the crisis in pneumonia -wherein clinical improvement takes place entirely independent of the -mechanical conditions in the lung which just after the crisis remain as -suppurative as before. - -The diagnosis of JUVENILE NEUROSYPHILIS is made upon the same lines as -that of neurosyphilis in the adult. We present two cases, one with optic -atrophy[66] and the other with signs of congenital syphilis antedating -the symptoms of paresis.[67] - -Congenital syphilis is also apparently capable of producing a simple -form of FEEBLEMINDEDNESS,[68] that is to say, a form of disease -non-paretic, non-tabetic, and without special tendency to vascular -insults. - -We present a case of JUVENILE TABETIC NEUROSYPHILIS (“juvenile -tabes”).[69] The tests were all positive. - -The line of separation between typical and atypical cases of -neurosyphilis is vague and indistinct and some of the cases classified -by us amongst puzzles perhaps belong under systematic diagnosis and vice -versa. The section on PUZZLES AND ERRORS in the diagnosis of -neurosyphilis is introduced by six cases of error in the diagnosis of -the paretic form of neurosyphilis.[70] These errors were made known by -autopsy. Aside from the sixth case, whose etiology must remain in doubt -and which was a unique case of PERIVASCULAR GLIOSIS, there is ground for -the belief that the other five cases in this Danvers Hospital study of -diagnostic errors were perhaps actually syphilitic though not of the -paretic form of neurosyphilis. At all events, the brain tissues in these -cases failed to show the plasma cell deposits which are characteristic -in the sheaths of the intracortical vessels in paretic neurosyphilis. - -A case illustrates the complication of TABES by _arteriosclerotic -symptoms_, in which case the arteriosclerosis may naturally have been of -syphilitic origin. Two cases especially illustrate the possibility of -confusing the ataxia of general paresis with CEREBELLAR ATAXIA. These -cases showed lesions of the cerebellar structures, notably of the -dentate nucleus. No one can read these cases or any of the autopsied -cases in our series, without perceiving how fundamental and even -critical is the demand for autopsies in fatal cases of neurosyphilis. -The practitioner who can secure an autopsy in a fatal case of -neurosyphilis and have the tissues worked up by approved -neuropathological methods is almost bound to add his bit to neurological -theory. Even cases of classical tabes dorsalis are often signally -important to the theorist on account of the relations of the neural to -the non-neural complications. - -We then proceed to a group of cases without special order in which a -variety of diagnostic questions arose. - -A case of questionable neurosyphilis in the secondary stage of syphilis -brings up the problems of syphilitic _neurasthenia_.[71] - -Syphilis may act as _agent provocateur_ of HYSTERIA as Charcot -insisted.[72] - -A case illustrative of difficulties in diagnosis between neurosyphilis -and manic-depressive psychosis follows.[73] - -A case for diagnosis is given which shows that errors in the diagnosis -of neurosyphilis are entirely possible even when abundant clinical and -laboratory data are available. A case with a weakly positive Wassermann -reaction in the spinal fluid finally turned out to be one of BRAIN -TUMOR.[74] - -Some questions as to the diagnosis of NEUROSYPHILIS _versus Idiopathic -Epilepsy_ are brought up by a case in which phenomena of paresis seemed -to have occurred very early, about two years after the initial -syphilitic infection.[75] - -A case of PARETIC NEUROSYPHILIS is offered in which _hemiplegia_ and -_hemitremor_ strongly suggested _vascular_ lesions; but the autopsy -showed no coarse lesions and merely confirmed the diagnosis paresis -microscopically.[76] - -An autopsied case of PARETIC NEUROSYPHILIS is given, in which the pupils -persisted in reacting normally. Herpes zoster-like lesions in life -yielded no special signs at autopsy (all root-ganglia looked alike above -and below zone of “shingles.”)[77] - -An example of NEUROSYPHILIS, probably PARETIC, yielded symptoms highly -suggestive of _manic-depressive psychosis_.[78] An interesting feature -in this case was the birth of a healthy child nine months after the -onset of the psychotic attack. - -An example of _exophthalmic goitre_[79] following the acquisition of -SYPHILIS showed at autopsy a heavy scarring of the optic thalamus and -unilaterally atrophic process in the cerebral cortex. - -We come to some questions concerning the _Argyll-Robertson pupil_. It is -agreed on all hands that the Argyll-Robertson pupil is characteristic of -the paretic and tabetic forms, but the sign occurs also in other -neurosyphilitic conditions;[80] in fact the sign does not necessarily -indicate neurosyphilis as an instance of PINEAL TUMOR demonstrates.[81] - -The question raised above as to the possibility that neurosyphilis may -exist in the absence of positive findings in the spinal fluid is -illustrated in a man, a mechanic, who claimed syphilitic infection and -showed an _Argyll-Robertson pupil_ on one side.[82] The serum W. R. was -positive; the _fluid tests_ were _negative_. - -An extraordinary case is given in some detail in which NEUROSYPHILIS in -the form termed DISSEMINATED ENCEPHALITIS[83] proved fatal within seven -months of the initial infection. - -We have frequently mentioned the classical assumption that paretic -neurosyphilis (“general paresis”) is a fatal disease. Some have -suggested that there is another form clinically almost identical with -general paresis except that it pursues a long course and the suggestion -has been made that these cases be termed _pseudoparesis_.[84] We are of -the opinion that this term should be dropped and advocate the use of the -word pseudoparesis only for non-syphilitic disease looking like paresis, -such as alcoholic pseudoparesis and the like. - -The question whether there is a form of mental disease SYPHILITIC -PARANOIA[85] is raised by a case with auditory hallucinations, ideas of -persecution and attacks of excitement. The diagnosis of alcoholic -hallucinosis was actually made although there is no proof that the -patient ever drank alcohol. - -Alcohol may cause symptoms identical with those of paretic -neurosyphilis, including seizures, Argyll-Robertson pupils, speech -defect and mental symptoms. The differentiation is readily made by the -negative laboratory findings. An illustration is given in our case of -the alcoholic teamster. Cases such as this bear the name ALCOHOLIC -PSEUDOPARESIS.[86] - -However, when the clinical picture is the same as in the case of our -teamster, the alcohol may only be a complicating factor in -neurosyphilis, as shown by our next case of the _alcoholic_ steamfitter -who in fact was shown to have NEUROSYPHILIS.[87] - -Sometimes cases of apparently frank _alcoholism_, even with apparently -characteristic delirium tremens and neuritis, prove to be essentially -neurosyphilitic.[88] On the other hand, true combinations of ALCOHOLISM -and NEUROSYPHILIS occur which it would be proper to classify under -either heading and in which therapy must take serious account of both -conditions.[89] - -As above stated, we elect to use the term pseudoparesis only for -non-syphilitic cases. There are other forms of pseudoparesis than -alcoholic pseudoparesis. The question of _Diabetic Pseudoparesis_ is -raised by an exceedingly complicated case of which our best -interpretation is that the patient, a proved syphilitic (with syphilitic -osteomyelitis (?)), a huge doorkeeper, was perhaps suffering from an old -SYPHILITIC scarring of the PITUITARY body.[90] Neither this case nor a -second case, one of PARETIC NEUROSYPHILIS with _glycosuria_ is actually -entitled to the diagnosis diabetic pseudoparesis. The second case of -paretic neurosyphilis with glycosuria brings up some unanswerable -questions as to the pancreatic or basal meningitic or other origin for -the glycosuria.[91] - -_Isolated symptoms_ are often presented by neurosyphilitics (e.g., -hemianopsia);[92] but we tend to regard these cases as due to focal -lesions that are merely part and parcel of DIFFUSE LESIONS. - -A neurosyphilitic case (a steward) with the rather unusual complication -(for our northern region) of severe MALARIA producing cerebral -thrombosis is reported.[93] - -The diagnosis _Dementia Praecox_[94] was actually made in the case of a -young school-teacher in whom the laboratory findings proved conclusively -that the condition was one of NEUROSYPHILIS. The gold sol reaction in -this case was mild. The chief lesion at autopsy was a fresh looking, -gelatinous pial exudate over the spinal cord which turned out to contain -an almost pure display of very numerous plasma cells. - -The question of LUES MALIGNA[95] is brought up in a rectifier of spirits -in whom the characteristic tremendous destruction of tissue, toxemia and -failure to react to antisyphilitic treatment were illustrated. Moreover, -this case had a trauma (cautery) to the tonsil, as in other cases of -lues maligna. - -A case somewhat suggestive of _brain tumor_, of _neurosyphilis_ and of -_multiple sclerosis_[96] turned out to be MULTIPLE SCLEROSIS (the fluid -showed a pleocytosis and a moderate amount of globulin with a paretic -type of gold sol reaction). - -As a foil to this case that we regard as multiple sclerosis, we present -a second case with nystagmus, optic atrophy and spasticity in which the -suspicion of _multiple sclerosis_ might well be raised but which the -tests demonstrated to be NEUROSYPHILITIC.[97] - -An even stranger imitation of well-defined non-syphilitic entities was -presented by a case apparently of _Huntington’s chorea_[98] (except for -absence of the hereditary taint) which case, however, proved to the -surprise of all diagnosticians to be one of NEUROSYPHILIS. - -Frequent errors of diagnosis must occur in the field of the senile -psychoses. We present a case that would at first blush warrant the -diagnosis of _senile arteriosclerotic psychosis_[99] in a sea captain of -75 years (wife dead 15 years before of general paresis) who turned out -to be a characteristic case from the laboratory standpoint of -NEUROSYPHILIS. - -The Protean nature of the symptomatology of neurosyphilis is -sufficiently established. Still, a case that might fit into textbooks -concerning DISSOCIATION OF PERSONALITY[100] is certainly a clinical -oddity, as illustrated by a fugacious musician. - -A case with strong suspicions of _neurosyphilis_ of _tabetic_ type -turned out to be more probably one of neural complications in PERNICIOUS -ANEMIA.[101] - -NEUROSYPHILIS IN JUVENILES presents puzzling conditions. - -One case was marked clinically by _attacks of excitement_.[102] It is -impossible to place this case among the main groups of juvenile -neurosyphilis. - -Another case of FEEBLEMINDEDNESS,[103] also NEUROSYPHILITIC in origin, -presented physical symptoms and laboratory signs of paretic -neurosyphilis; yet this case had been considered one of _simple -feeblemindedness_. - -A case apparently of JUVENILE PARETIC NEUROSYPHILIS in a 15 year old boy -presented the rather unusual complication of shocks with -quadriplegia,[104] a _vascular complication_ not usually expected in the -paretic type of neurosyphilis in adults. - -Epileptic phenomena[105] are rare as the effect of JUVENILE -NEUROSYPHILIS, but occur as demonstrated in a case which slipshod -methods of diagnosis might well have regarded as one of _idiopathic -epilepsy_. - -A case of JUVENILE PARETIC NEUROSYPHILIS with the complication of -ADDISON’S DISEASE[106] is given (autopsy confirmation). - -The puzzle in diagnosis offered by syphilis in the secondary stage[107] -is illustrated by a case which showed the characteristic NEUROSYPHILITIC -complications of the SECONDARY STAGE of syphilis. This patient may well -have been a moron at the outset and exhibited some reactions (refusal to -talk) explicable on the basis of feeblemindedness. She was a -neurosyphilitic only in the sense of the neural complication that we -find in the secondary stage of syphilis. As stated above, we do not yet -know what the fate of these neural complications of secondary syphilis -is to be. The frequency of this finding in secondary syphilis is -probably too great to warrant the hypothesis that it must always go on -to a chronic neurosyphilis; but we certainly are warranted in regarding -these cases as potential chronic neurosyphilitics. - -A case of TABOPARETIC NEUROSYPHILIS in which the heavy exudate -characteristic of paresis became a soil for a growth of the typhoid -bacillus is presented with autopsy.[108] This fatality with TYPHOID -MENINGITIS is merely a concrete example of the many complications which -syphilitics and especially neurosyphilitics have to sustain. - - -The case series then goes on to illustrate, though quite inadequately, a -variety of MEDICOLEGAL AND SOCIAL complications of neurosyphilis. It is -well known that many social complications with grave moral, economic and -even political difficulties occur. - -Our series starts with a “public character”[109] whose eloquence and -reformatory efforts led to a considerable notoriety. The autopsy in this -case showed singularly few lesions despite the fact that the case was -microscopically one of wholly characteristic PARETIC NEUROSYPHILIS. The -question might arise how far we are entitled to correlate the -reformatory efforts of this always eccentric character with syphilis. -The man himself a physician, was aware of the doubt which his -Argyll-Robertson pupils threw upon his medical situation. He explained -them on the basis of an old smallpox! We are inclined to think that the -whole of this man’s life, from his giving up of medical practice to live -as a kind of literary and political hack, was due to subtle changes of -neurosyphilitic origin. The fact that there was a certain delinquent -streak in the man is not inconsistent with this idea. Interestingly -enough, a fall on the ice in the man’s 61st year actually started up the -fatal process, a condition of affairs amply illustrated in cases of -neurosyphilis, brought out by trauma that come to the attention of the -Industrial Accident Board in connection with claims for compensation. - -A case of sudden _grandiosity_[110] illustrates an episode of -NEUROSYPHILITIC origin. Such a person might well be regarded by the lay -newspaper reader as a crank or a grafter but the neurosyphilitic -possibility should always be entertained in cases of this order. - -As against the social difficulties that look in the direction of the -classical paretic grandeur, we present a case of apparent _suicidal -attempt_ by gas, which attempt was followed by a period of amnesia that, -taking into account the laboratory findings, was probably -NEUROSYPHILITIC.[111] - -Vistas of extraordinary interest are opened out by studies of the -relation of neurosyphilis to _delinquency_. The case of the psychopathic -reformer (Case 83) above mentioned was one in which the delinquency may -possibly have been related to acquired syphilis. We present also a case -of juvenile neurosyphilis, a young man of reform school type[112] in -which JUVENILE PARETIC NEUROSYPHILIS was established. This patient, in -fact, deteriorated very rapidly to a condition of considerable dementia -a few months after the diagnosis was established. - -A striking case of so-called DEFECTIVE DELINQUENCY is presented, an -alcoholic prostitute of the reformatory group.[113] The NEUROSYPHILIS in -this case was a complication rather than an original factor in the -delinquency. - -One case of PARESIS SINE PARESI was that of an habitual criminal[114] -and forger who, without showing mental or physical symptoms of -neurosyphilis, yielded the laboratory signs of paretic neurosyphilis. -Again, as in the case of the prostitute just mentioned, the -CRIMINALITY[115] seems to have antedated the neurosyphilis and even to -have been hereditary. - -By way of introducing the next group of Industrial Accident Board cases, -we present a case of JUVENILE PARESIS with initial TRAUM. - -The Industrial Board group is of note in that the signs of the traumatic -form[116] of paretic neurosyphilis do not occur immediately upon the -accident. Some time elapses in which the physical, chemical or -parasitological changes have time to work themselves out in the injured -tissues. Many hypotheses may be raised as to the reason why a trauma -lights up a syphilitic process. Of course, =false claims=[117] =may be -made for compensation by neurosyphilitics= in whom the symptoms were -already in existence before the accident and in whom they may not even -be markedly exacerbated by the accident. The false claimants can -probably not readily frame a story which the expert psychiatrist cannot -discredit if he is allowed to perform laboratory tests and give the -patient the benefit of thorough examination. However, some cases of -established PARETIC NEUROSYPHILIS are perhaps truly subject to -_exacerbations_[118] of the clinical process and it may well be held -that such exacerbations warrant partial compensation. - -The fact that a trauma may light up a syphilitic process is illustrated -in a case that came to the Psychopathic Hospital, in which a SYPHILITIC -LESION developed in the skull AT THE SITE OF SKULL INJURY.[119] - -A case of OCCUPATION-NEUROSIS[120] that might be interpreted as a -_syphilitic neuritis_ is presented. The case is still in doubt as to its -scientific evaluation. - -The workmen’s compensation group of syphilitic cases is of extraordinary -general interest since it indicates that employers may well be on the -lookout not to employ known syphilitics unless fortified by special -insurance arrangements. Whether in future employers may desire =to -employ only W. R. negative workmen= is one of the highly complicated -questions _re_ workmen’s compensation and health insurance. - -But the problems of neurosyphilis are not merely medicolegal and broadly -public or social. The most appealing difficulties lodge within the bosom -of the family. Now and then a case of INCOMPATIBILITY OF TEMPERAMENT, -perhaps complicated by _alcoholism_, occurs which tests prove to be -NEUROSYPHILITIC.[121] - -Special attention should be drawn to a certain NEUROSYPHILITIC -FAMILY[122] in which both parents and five children showed a variety of -syphilitic diseases, including syphilis without apparent neural -complications, paretic neurosyphilis, juvenile paresis, aortic aneurysm, -achondroplasia and caries of the spine, and an as yet indefinite -neurosis. There was a sixth child that died shortly after birth, as well -as three stillborn. - -One =cannot conclude= from the normal[123] look of a neurosyphilitic’s -family =that the normal-looking members are not syphilitic=, as -illustrated by the family of our draughtsman. - -The most =intricate social complications= may arise. We present a case -of a syphilitic man (a well-to-do merchant) who was apparently being -goaded into a second marriage[124] because he was continually being -charged with having caused his first wife’s death. This he had actually -done in a certain sense because his wife had died of general paresis, -having contracted syphilis from him. - - -In the fifth section on THERAPY, we have attempted to outline some of -the principles and problems that arise in the treatment of -neurosyphilis. Enough has probably been said concerning the attitude of -optimism or pessimistic nihilism that may be adopted toward the whole -subject. It must be borne in mind, however, that a great deal of the -work on treatment of neurosyphilis is still in the experimental stage. -As a rule, each case must be considered separately and individually and -the prognosis can be made satisfactorily only after treatment has been -given. This section contains a group of cases that have been treated -rather intensively and the results of this treatment are indicated. The -section is introduced by _five untreated cases_, the brains and cords of -which have been studied post mortem. These illustrate the pathological -conditions which we have to meet, and from these examples we can draw -the theoretical conclusion that some cases are beyond the aid of therapy -on account of the brain destruction. Others, in which the symptomatology -bespeaks just as grave a situation, turn out on autopsy to have very -little actual damage to the brain tissues and therefore should -theoretically at any rate be amenable to antisyphilitic therapy. - -In order to get any adequate conception of the possibilities of -therapeutic results in cases of neurosyphilis, one must consider the -pathological changes that occur and how far these changes are reparable. -In cases in which the destruction of tissue is marked, it is, of course, -out of the question to expect to get any marked clinical improvement. A -case of spastic hemiplegia[125] in paretic neurosyphilis is given with -the autopsy findings as an illustration of irreparable damage that may -occur to the parenchymatous structure, thus precluding any chance of -functional recovery. - -On the other hand, there is a group of cases in which the symptoms may -be exceedingly severe and yet the actual destruction of tissue be almost -nil. This point is illustrated by a case[126] in which _total duration -of symptoms_ terminating in death was _only 22 days_. At autopsy there -was very little in the way of macroscopical lesions, and microscopically -there was no marked evidence of destruction in the parenchymatous -tissue. The lesions were represented chiefly by perivascular -infiltration. According to all our modern ideas, this type of reaction -is resolvable under antisyphilitic treatment. Though this case was one -of very short duration, similar pathological pictures may be obtained in -cases of considerably longer standing. It is also of great importance to -remember that symptomatically such a case may be in no way distinguished -from a case with marked atrophy. - -Another autopsied case is given which shows an exceedingly =marked -meningitis=.[127] The meningitic processes according to the literature -and experience react very readily to antisyphilitic treatment in the -form either of mercury and iodid or in combination with salvarsan. The -lesion here present would probably have improved had intensive treatment -been given. Clinically the diagnosis of general paresis was made and, as -has been the rule in the past, treatment was not given on the ground -that it had no value in paresis. While this is an extreme case of -meningitis, it is to be remembered that the vast majority of cases of -paretic neurosyphilis show some degree of meningitis. Just as in the -marked meningitis of the diffuse neurosyphilis, so with the meningitis -of the paretic form, improvement is expected under treatment. As a part -or even the whole of the symptomatology in a given case may be due to -this meningitic process, we have reason occasionally to expect marked -improvement as the result of antisyphilitic treatment. - -As a contrast to this case with marked meningitis, another case of -=marked atrophy=[128] is given. Here the atrophy was very perceptible on -macroscopical examination and the mere view of the brain at once -indicated that in such a case important results from treatment were not -to be expected. - -The =topographical variation= of the lesions in neurosyphilis must be -remembered when treatment is to be instituted. Thus very marked lesions -may exist in portions of the brain which do not give any very definite -localizing symptoms. As a result, one may be led to believe from -clinical evidence that the case is a very mild one though the lesions -may really be very extensive. The topographical distribution must, -therefore, be taken into consideration in trying to estimate the damage -done. This point of topographical distribution of the lesions is -illustrated by a case.[129] - -It has been generally recognized that =clinical improvement=, if not -cure, may be =readily obtained in the group of diffuse neurosyphilis=, -i.e., so-called cerebral and cerebrospinal forms of syphilis. These are -cases in which the parenchyma is very slightly, if at all, affected and -in which the lesion is chiefly in the meninges and blood vessels, -irritative rather than degenerative. A case[130] is given to illustrate -this point. In our experience systematic intravenous salvarsan therapy -associated with mercury and iodid gives remarkably good results in the -vast majority of this group of cases. - -It is generally conceded that antisyphilitic treatment, particularly -salvarsan, has a very satisfactory result applied to diffuse -neurosyphilis. But the same good results may be obtained in cases which -are not so typically of the diffuse type. An illustration is given in -the case of a machinist in which the diagnosis was in doubt between -paretic, tabetic or diffuse neurosyphilis.[131] The result of treatment -was as satisfactory as could be expected in any type of neurosyphilis -and this in a case of several years’ duration with Argyll-Robertson -pupils. - -As a rule, the Argyll-Robertson pupil is taken as a grave omen for -treatment, an idea based upon a conception that the Argyll-Robertson -pupil so frequently represents the old so-called “parasyphilitic” cases, -which, in the past were taught as being incapable of improvement by the -ordinary antisyphilitic methods. - -A second case[132] with Argyll-Robertson pupil shows again that the -=prognosis may be very good despite the Argyll-Robertson sign=. - -But even in the diffuse neurosyphilis, the symptomatic results of -treatment may not be entirely happy. Under treatment it may be possible -to reduce the spinal fluid tests to negative without, however, as in the -case of our hemiplegic lady,[133] making the physical or mental symptoms -disappear. In other words, it may be possible to stop the active -progress of the disease without removing the symptoms. - -One is always warned of the danger of intravenous salvarsan therapy in -hemiplegic cases due to arteriosclerotic conditions. While this warning -is well justified, it does not mean that the most intensive treatment is -contraindicated, as shown in the case of our hemiplegic machinist.[134] -Such may be given over long periods of time with the most satisfactory -results. - -A case[135] is given which illustrates the value of antisyphilitic -treatment in cases showing symptoms of intracranial pressure due to -syphilitic disease. In the case of the woman which we cite, we believe -that the symptoms of intracranial pressure were probably due to a -gummatous new growth, although it is possible that they were due to a -marked meningitic process. However, the results of a limited amount of -antisyphilitic treatment in this case were very brilliant. Similar -results may often be obtained in gumma of the brain. This is not always -true, however, and it may become necessary to use surgical procedure in -order rapidly to overcome the effects of intracranial pressure. - -While it has always been conceded that treatment would greatly help -cases of diffuse and vascular neurosyphilis, the utmost pessimism has -existed concerning the results to be obtained by treatment in cases of -tabetic and paretic neurosyphilis. Only in the last five or six years, -due to the stimulus of Ehrlich’s discovery of salvarsan and the -introduction of the intraspinous methods of therapy, have intensive work -and study been given to the treatment of these cases. And though it has -been by no means settled in the minds of the various workers in this -field, as to what the ultimate results of such treatment will be and -though some do not believe that there is any good to be expected from -our present methods, still the majority of men who are treating these -cases systematically feel very much encouraged. - -=At times very brilliant results= are to be obtained by intraspinous -treatment =in tabetic neurosyphilis= (“tabes dorsalis”). A very striking -illustration is given of a case of this sort in which the symptoms dated -only a few months but which had all the classical symptoms, signs and -laboratory tests. Five intraspinous injections of mercurialized serum -were sufficient to cause the disappearance of the subjective symptoms -and to reduce the spinal fluid test to negative.[136] - -It must be emphasized that the best results in cases of tabetic -neurosyphilis are usually to be expected in cases in which the symptoms -are of short standing. Where the process is of long duration and much -destruction of spinal cord tissue has occurred, the best one can expect -is that the activity and progress may be halted. This is illustrated by -our case of a baker, 43 years of age, who had been suffering from the -symptoms of tabes for some years. Under treatment it was possible to get -an entirely negative serology of the blood and spinal fluid.[137] -Despite this evidence that the activity of syphilis had ceased, the -symptoms continued unabated. We are ready to believe, however, that much -good was accomplished. For the patient should not have any further -untoward developments or the appearance of any new symptoms. These, -without such treatment, might well be expected. At times excellent -clinical results are obtained in long-standing cases. - -The results of treatment in paretic neurosyphilis (“general paresis”) -have been considered even less hopeful than in tabetic neurosyphilis -(“tabes dorsalis”); indeed, it has often been stated that the patients -are made worse by treatment. Recent work, however, supports a much more -optimistic viewpoint. We feel that =intensive treatment has been of the -greatest value in a number of cases of paretic neurosyphilis=. Two cases -are given which show the most satisfactory and brilliant results of -intensive intravenous salvarsan therapy in cases diagnosed as general -paresis. The first case, an excellent salesman, 46 years of age, with -most aggravated mental symptoms, recovered symptomatically and all his -tests were rendered negative.[138] He has now remained entirely well and -economically efficient for about two years without further treatment. -The other case,[139] a housewife, also with very marked symptoms -suggestive in all ways of general paresis, also recovered rapidly under -treatment and her tests became negative. Her remission has now lasted -for nearly three years without further treatment. - -At times it is not possible to get the spinal fluid tests to become -negative in cases of paretic neurosyphilis under the most intensive -salvarsan therapy. In spite of this, the clinical condition of the -patient may improve so greatly that the patient can be considered -=clinically recovered=. An illustration is given of an undertaker[140] -who was brought from a condition of the greatest cachexia and mental -confusion to a condition of robust appearance and mental efficiency -under intravenous salvarsan therapy, in spite of the fact that his tests -were very slightly if at all reduced in intensity. He has been able to -resume his former occupation and his former life with great satisfaction -to himself and his family. - -Improvement in paretic neurosyphilis under treatment is not to be -expected very early. =Two or three months of active treatment= may -elapse before one sees signs of improvement. Indeed, as illustrated by -our case of the shipping clerk, this improvement may begin to make its -appearance only after more than four months of intensive treatment -consisting of two injections of salvarsan per week.[141] In spite of the -long delay in this case, complete clinical recovery occurred and the -tests became almost negative at the end of a year of treatment. - -It is not only in the central nervous system that the syphilitic process -may resist the most intensive treatment. In the case of the speculator, -a victim of paretic neurosyphilis, which we cite, a perennially -recurrent iritis appeared after several months of the most intensive -salvarsan treatment which was apparently sufficient to reduce the -symptoms of the paretic neurosyphilis,[142] but not of non-neural -syphilis. - -We give the case of a charwoman having the diagnosis of paretic -neurosyphilis, who, under intensive treatment, made a symptomatic -recovery. The interesting point in her findings is that all the tests in -the spinal fluid became negative except the gold sol reaction which -remained of the “paretic” type.[143] There is no general rule as to the -reaction of the spinal fluid tests under treatment. At times one test is -the first to disappear under treatment; again it is another. We have -seen many cases in which the gold sol was the first test to become -negative and others, as the case given, in which it is the last to show -any change. As in our undertaker, symptomatic clinical improvement may -be practically complete without any change in the spinal fluid tests. - -One must remember that it is the condition of the patient that is of -first importance; not so much the laboratory tests. Having shown the -clinical recoveries with the tests remaining positive, we now have to -report two cases in which there was =improvement= as shown =by the tests -but no clinical improvement=. The first patient, a bank teller[144] of -39 years, with a diagnosis of paretic neurosyphilis, received intensive -intravenous salvarsan for several months. Under this treatment all the -tests became negative except the gold sol which remained of the paretic -type. In spite of this, there was not the slightest improvement in his -mental condition. - -The second case, a young man of 29 years in whom the symptoms of -neurosyphilis had recently appeared, under treatment showed a marked -diminution in the intensity of the spinal fluid tests, notwithstanding -which the patient became more and more demented and died after a series -of convulsions.[145] - -Of course, good results indicated above in some of our cases of paretic -neurosyphilis are not to be expected in every case no matter how -intensive the treatment. We give a case of paretic neurosyphilis in -which the most intensive intravenous salvarsan therapy gave no -satisfactory results. This was followed by several intraventricular -injections of salvarsanized serum. The results of this combined -treatment, however, were still not satisfactory, and the patient -died.[146] - -In order to emphasize as strongly as possible what we believe is a great -=advantage of systematic intensive treatment= for neurosyphilis, we -offer two cases in different time periods of neurosyphilis. The first is -a printer with the symptoms of diffuse neurosyphilis six months after -the appearance of his chancre.[147] These symptoms appeared despite -three injections of salvarsan, injections of mercury and mercury by -mouth. Under intensive treatment (meaning injections of salvarsan twice -a week and continued injections of mercury), complete recovery occurred -in a few weeks. - -The second case is that of a waiter with signs and symptoms of -neurosyphilis in whom the diagnosis lay between the diffuse and paretic -forms.[148] This patient developed his symptoms in spite of continuous -antisyphilitic treatment during the six years since his infection. This -treatment had been comparatively mild, consisting in great part of -mercury by mouth. However, he had had courses of injections of mercury -and several injections of salvarsan. Under a systematic course of -intravenous injections of salvarsan twice a week for a number of months, -all symptoms disappeared and the spinal fluid tests became negative as -well as the W. R. in the blood serum. - -A final case is offered which indicates that antisyphilitic treatment -may occasionally be of service in improving the mentality of a -FEEBLEMINDED CONGENITAL SYPHILITIC.[149] - -No attempt has been made in this section to give a per cent evaluation -of the results of treatment in any one group of neurosyphilis. Two -charts (charts 25 and 26), however, are appended which give an -indication of some of our results. It seems to us, however, that it is -too early to make any definite statements as to how far treatment will -take us in the groups of neurosyphilis. We do feel decidedly, however, -that many patients, in whatever group of neurosyphilis the diagnosis may -place them, will respond to intensive systematic antisyphilitic -treatment. =It is unfair to give an entirely grave prognosis in any case -of neurosyphilis until the effect of treatment has been tried.= - - -In a separate section, entitled NEUROSYPHILIS AND THE WAR, we have -presented fourteen cases selected from British, French and German -writers in the war literature of 1914–16. Most of these cases were -naturally somewhat inadequately reported under the critical conditions -of literature made in the war. We present the cases for what they are -worth: at all events they draw attention to the extraordinary interest -of the neurosyphilis problem in relation to the war. - -Such cases as A, one of tabes dorsalis apparently developing paresis by -a process akin to shell-shock, is of value in the interpretation of the -development of paresis in civil life. By “shell-shock” we commonly refer -to a condition in which there is no actual traumatic injury of the -brain. The hypothesis must be then that the explosion in some way -indirectly caused an alteration of living conditions of the spirochetes, -permitting the development of paresis. - -Case B similarly seems to be a case in which a latent syphilis has -turned shell-shock into tabes dorsalis. - -Cases C, D, E bring up the question of aggravation of neurosyphilis _by_ -service and _on_ service, respectively. - -Case F likewise shows how, in the determination of amount of pension, -the probable duration of the neurosyphilitic process is important. - -Case G seems to show that war stress alone, without the emotional or -physical effects of shell-shock, may kindle a latent syphilis into -paretic neurosyphilis. - -Case H similarly suggests that the “gassing” process may effect the same -result. - -Case I seems to show that the neuropathically tainted person may have -latent epilepsy brought out through syphilis, the syphilis in this case -having been acquired during the first summer of the war. - -Case J was an interesting case of a syphilitic who, after the stress of -the Battle of Dixmude, became an epileptic. - -Syphilitic root-sciatica was developed in Case K at work in the war -zone. - -Case L is one of a civilian who apparently would not have developed -paresis at precisely the moment when he did, if he had not been -discharged as a German Jew from his long-held bank position in London. - -Two cases, M and N, are cases of shell-shock, non-syphilitic; yet the -picture of paresis in the one case and of tabes in the other was for a -long time almost convincing to the examiners. They are better termed -cases of pseudoparesis and pseudotabes, using the prefix “pseudo”, as -usual, to signify a non-syphilitic imitation of the disease in question. - -To sum up in the most general way the lessons of this book, we may -emphasize again (1) _the unity-in-variety of the phenomena of -neurosyphilis_, (2) _the value of a hopeful approach to the therapy of -all cases of neurosyphilis_, _even the paretic form_, and (3) _the value -of applying syphilis tests to every case of neurosis or psychosis_. - -(1) RE _unity-in-variety of neurosyphilitic phenomena_. - -The unity of these phenomena is confirmed, theoretically, by the common -factor of spirochetosis: practically, by the Wassermann reaction, -positive in serum or spinal fluid! Almost at this point the unity of -phenomena ceases. Neither chronicity, nor evidence of mononuclear cell -deposits, nor evidence of serious structural damage to the nervous -system, nor presence of other positive tests than the W. R.,[150] nor -existence of mental or nervous symptoms or signs, is a common feature of -neurosyphilis. Sometimes the nervous system appears to harbor -spirochetes in the most cordial manner as guest-friends (_paresis sine -paresi_.) Again, perhaps as an expression of elaborate processes of -immunity, the spirochetes take effect in relatively huge gummata. -Sometimes the neurosyphilitic process rises as if by a regular process -of siege from spinal nerve-root to spinal nerve-root (tabes dorsalis and -diffuse neurosyphilis). Again, the nervous system is taken by storm, as -it were (disseminated encephalitis). Very frequently the neurosyphilis -is simply an indirect effect of blood-vessel disease, and huge masses of -tissue are scooped out in necrosis with dependent secondary -degenerations; and later the extinct lesions of vascular origin may or -may not betray evidence of their syphilitic origin. Sometimes diffuse -processes run on, apparently, with perfect fatalism to a mortal issue in -a few years both with and without treatment. Again treatment appears to -accomplish much (see fuller discussion under 2). The laws governing the -preference of processes to lodge in membranes, vessels, and parenchyma, -and in all combinations of these, have not been worked out. Hardly a -case of neurosyphilis, properly studied ante mortem and post mortem, but -would throw important light on our medical approach to one of the great -problems of civilization, the problem of syphilis as a whole. - -(2) RE _value of a hopeful approach to the therapy of neurosyphilis_. - -The prognosis of neurosyphilis is not worse than that of the chronic -diseases in general. In fact, the prognosis of neurosyphilis _quoad -vitam_ is either good or dubious, certainly not bad. The surprising -reversals of form which the spirochete shows in certain remissions are -always to be awaited. Treatment of neurosyphilis has certainly effected -amazing results, not so much by way of Ehrlich’s _therapia sterilisans -magna_ as by means of systematic intensive treatment. Even paretic -neurosyphilis (general paresis) seems to have been cured. Preparetic -phases are theoretically hopeful. Nor is it so certain that paretic -neurosyphilis will ultimately prove a perfectly distinct species of -neurosyphilis. General paresis seems to us at least to be more closely -related to diffuse neurosyphilis than is tabes dorsalis to diffuse -neurosyphilis. In any particular case, moreover, =during a good part of -the early months or years=, =it is difficult or impossible to tell the -paretic from the non-paretic forms of diffuse neurosyphilis by any -combination of clinical observations and tests=. In the instance of more -protracted neurosyphilis, e.g., tabetic, the outlook for vascular -complications is such that antisyphilitic treatment directed at -prevention of these complications is scientifically warrantable, even if -the tabetic process itself proves unassailable. The old distinction of -syphilis and parasyphilis, so striking and apparently satisfactory when -introduced by Fournier, seems to be a false distinction which should be -dropped. Therapeutically, we should approach all cases of neurosyphilis -without bias or nihilistic prejudgments. - -(3) RE _universal applicability of syphilis tests in nervous and mental -cases_. - -The importance of putting every neurosis or psychosis through syphilis -tests is not based alone on the frequency of neurosyphilis, though -neurosyphilis is surely frequent enough. The importance of universally -applying these tests is established by the experience of lingering -doubts both in the physician’s mind and (nowadays increasingly) in the -patient’s and friends’ minds, so long as these tests are not applied. -Nor should the positive serum Wassermann reaction fail to be followed by -lumbar puncture and appropriate tests. The general practitioner -confronting neuroses or psychoses—and what practitioner does not?—must -not expect valuable results from consultation with neurologists and -psychiatrists when he does not carry to these specialists the results of -at least the serum W. R. in his patient. Not only are practitioners, -specialists, and patients subject to discomfiture on the eventual and -delayed proof of syphilis or neurosyphilis, but valuable time has been -lost to treatment. How often the physician of yore (and really not so -long since) had to be regarded as an eccentric virtuoso if he tested -urine as routine! Well, for routine use in nervous and mental diseases, -the Wassermann serum reaction is at least as important as urinalysis. -Nor would we cease our homily with the general practitioner. We know -neurologists and psychiatrists who use the Wassermann test _only when it -is likely to be positive_! But they are dying out. - - - - - APPENDIX A - - -In appendix A a brief outline is given of the six tests (W. R. on blood -serum and spinal fluid, cell count, globulin test, albumin test, gold -sol test). This is not intended as a complete working manual but rather -as indicating the methods used in diagnosis in the cases presented -herein. For more complete details the reader may be referred to -textbooks on the subject of serology, among which may be mentioned -Kaplan: “Serology of the Nervous System”; Plaut, Rehm and Schottmüller: -“Leitfaden zur Untersuchungen der Zerebrospinalflüssigkeit”; Kolmer: -“Infection, Immunity and Specific Therapy,” and, for the Wassermann -technique, an article by Dr. W. A. Hinton in M. J. Rosenau’s “Preventive -Medicine and Hygiene.” - -Our own W. R’s. have been performed at the Wassermann laboratory of the -Massachusetts State Board of Health (formerly the Neuropathological -Testing Laboratory, Harvard Medical School), under the supervision of -Dr. W. A. Hinton. The other tests are performed at the Psychopathic -Hospital. It is very important that a close relationship should exist -between the clinician and the Wassermann laboratory if the most is to be -obtained from the reactions. This relationship has been effectively -close between the authors and the above-mentioned laboratory; and has -enabled us to get very much clearer ideas about certain cases than could -otherwise have been obtained. - -=Cell Count.= In order to obtain the number of cells per cmm., the -examination should be made of the fresh fluid as soon as possible after -this is withdrawn. The most convenient counting chamber for this purpose -is the so-called Fuchs-Rosenthal counting chamber, the ruled spaces of -which contain slightly over 3 cmm. (an ordinary blood cell counting -chamber may be used). According to the method used by us the cells are -stained in a pipette with Unna’s polychrome methylene blue. Using a -white-counting pipette, stain is drawn up to the first or second marking -and the remainder of the pipette filled with spinal fluid. This makes no -change in the dilution for practical purposes. After two or three -minutes the staining is satisfactory and the counting may be done. With -this stain a differential count may be made. Plasma cells stain a -lavender as contrasted to the blue of the lymphocytes. The -characteristic halo surrounding the eccentric nucleus is visible. The -blood cells do not assume color with this stain; hence it is unnecessary -to add any acetic acid. - -For permanent preparations, and more accurate differential counts of the -spinal fluid, the Alzheimer method may be used. The technique is given -in a paper by H. A. Cotton and J. B. Ayer as follows:[151] - -1. Lumbar puncture in the usual manner. - -2. 96% alcohol, in proportion to twice the amount of cerebrospinal -fluid, is added drop by drop and well mixed. - -3. Centrifuge the mixture for one hour at high speed in a glass tube -with conical end. (An ordinary electric urinary centrifuge apparatus can -be employed, the tube to be well stoppered to prevent evaporation.) - -4. The supernatant fluid is poured off, leaving a small coagulum in the -bottom of the tube. - -5. Add absolute alcohol—alcohol and ether—ether, each separately for one -hour, to dehydrate and harden coagulum. - -6. The coagulum can now be gently loosened from the bottom of the tube -by a long needle. The tube is then inverted, and the coagulum allowed to -fall into the hand by a quick tap on the end of the tube. Care must be -taken not to squeeze or handle the coagulum. The hand is placed over a -small homeopathic vial, containing thin celloidin, and the coagulum -allowed to drop into the celloidin, where it remains over night (twelve -hours usually). - -7. Coagulum is placed in thick celloidin which is allowed to evaporate -slowly. It is then mounted on blocks and sections cut 14µ in thickness. - -8. The sections are stained and mounted according to the following -procedure: - -(_a_) Remove celloidin by absolute alcohol and ether. - -(_b_) 80% alcohol. - -(_c_) Water. - -(_d_) Sections are carried on glass or platinum needle into a dish of -Pappenheim’s pyronin-methyl green stain and kept in a water bath at 40° -C. five to seven minutes. - -(_e_) Quickly cool dish in running water. - -(_f_) Wash off superfluous stain in plain water. - -(_g_) Absolute alcohol to differentiate—until no more stain comes away -from section. - -(_h_) Clear in Bergamot oil. - -(_i_) Mount in balsam. - - -The normal cell count may be stated as being up to 6 cells per cmm.; -from 6 to 12 cells may be considered as suggestive of pathological -condition and more than 12 cells per cmm. as definitely pathological. -The type of cell in syphilitic diseases is preponderantly the small -lymphocyte. A low percentage, that is, very rarely over 20%, of large -lymphocytes, endothelial phagocytic cells, polymorphonuclear leucocytes -and plasma cells may also be found. The finding of plasma cells in any -number in the spinal fluid is suggestive although not conclusive -evidence for the diagnosis of paretic neurosyphilis. - -=Globulin= is an albumin which is precipitated by half saturation with a -salt. A very simple and satisfactory test is known as the Nonne-Appelt -test, which has been modified by Ross-Jones. Into a test tube of small -diameter, run 1 cc. of spinal fluid. Place under this fluid with a -pipette, 1 cc. of a saturated solution of ammonium sulphate -((NH_{4})_{2}SO_{4}). If any globulin is present a white, -sharply-defined ring will form at the junction of the two fluids. -According to our readings, a ring that is just visible with the aid of a -black background is called 1+, a ring that is just visible without the -black background, 2+; a ring easily perceptible, 3+ and a relatively -very heavy ring, 4+. On shaking the tube, if globulin is present, the -fluid will show turbescence. - -Another simple globulin test used in our laboratory as a check on the -Nonne-Appelt test is the Pandy test. A few cc. of a clarified 10% -solution of phenol are placed in a watch glass. One drop of spinal fluid -is run into this solution. A milky turbescence indicates globulin. - -The presence of globulin in the spinal fluid is always an indication of -abnormality of the cerebrospinal axis. There is nothing differential in -this finding as it occurs in all inflammatory processes. However, it is -characteristically present in most cases of neurosyphilis (exception to -the rule: the pure vascular type does not show globulin in a very high -per cent). - -=Albumin Test.= Albumin in small quantities is present in all spinal -fluids. Increase over the normal amount occurs in pathological -conditions such as most cases of neurosyphilis, especially in those in -which globulin is found. Any albumin precipitant may be used for rough -clinical calculation, comparing the amount of precipitate with that from -the normal fluid. Our method is to place 1 cc. of spinal fluid in a -small test tube of about 5 mm. diameter and to precipitate the albumin -by the addition of 3 drops of 33⅓% of trichloracetic acid. This test has -its chief value as confirmatory of the globulin test, since in the vast -majority of instances where globulin is found there will also be found -an increase in albumin. - -The =Gold Sol Reaction= is an empirical test discovered by Carl Lange in -the utilization of the work of Zsigmondi with solutions of colloidal -gold and albumins. Briefly the details of the test are as follows: - -Ten tubes are set up in a rack. To the first tube 1.8 cc. of a 0.4% of -salt solution is added and to each of the following tubes 1 cc. of this -solution. Then to the first tube containing 1.8 cc. of salt solution one -adds 0.2 cc. of the spinal fluid to be tested. This gives a dilution of -1 to 10. From this tube 1 cc. is pipetted into the second tube and this -process continued through the ten tubes. This gives dilutions of spinal -fluid of 1 to 10, 1 to 20, 1 to 40, etc., to 1 to 5120 in the last tube. -Then 5 cc. of colloidal gold solution is added to each tube. A positive -reaction is indicated by the precipitation or throwing down of the -colloidal gold into its metallic form. This produces a change in color. -This precipitation may be partial or complete and the amount of -precipitation is indicated by the color and is read as follows: - -The unchanged fluid is called 0; a slight change giving a red-blue as 1; -a further change giving a blue-red as 2; a straight blue as 3; a -lavender or violet as 4; and the colorless fluid representing complete -precipitation as 5. The numbers are placed in a row, indicating the tube -in which the color occurs. The fluid from a case of paretic -neurosyphilis will give a complete precipitation beginning in the first -tube and running through a number of tubes and then grading off. It may -be indicated 5 5 5 5 4 3 1 0 0 0. The characteristic reaction of fluids -from tabetic and diffuse neurosyphilis is less strong than from the -paretic. The greater part of the reaction will take place, however, in -the first five tubes, but as a rule it will not begin very strongly in -the first two. A characteristic reaction is 1 2 3 3 2 1 0 0 0 0. Another -reaction that may be considered characteristic of the tabetic or diffuse -form is 3 3 3 2 1 0 0 0 0 0. Fluids from non-syphilitic cases as a rule -give a reaction having its greatest intensity beyond the fifth tube, -that is, in the high dilutions. - -A reaction characteristic of brain tumor or tuberculous meningitis is 0 -0 0 0 1 3 3 2 1 0. - -The conclusions that may be drawn from the gold sol reaction have been -summarized by one of the authors as follows: - -1. Fluids from cases of general paresis will give a strong and fairly -characteristic reaction, especially if more than one sample is tested, -in the vast majority of cases. - -2. Very rarely a general paresis fluid will give a reaction weaker than -the characteristic one. - -3. Fluids from cases of syphilitic involvement of the central nervous -system other than general paresis often give a weaker reaction than the -paretic, but in a fairly high percentage of cases give the same reaction -as the paretics. - -4. Non-syphilitic cases may give the same reaction as the paretics; -these cases are usually chronic inflammatory conditions of the central -nervous system. - -5. When a syphilitic fluid does not give the strong “paretic reaction,” -it is good presumptive evidence that the case is not general paresis; -and this test offers a very valuable differential diagnostic aid between -general paresis, tabes and cerebrospinal syphilis. - -6. The term “syphilitic zone” is a misnomer, as non-syphilitic as well -as syphilitic cases give reactions in this zone; but no fluid of a case -with syphilitic central nervous system disease has given a reaction out -of this zone (test thus valuable negatively). Any fluid giving a -reaction outside of this zone may be considered non-syphilitic. - -7. Light reactions may occur without any evident significance, while a -reaction of no greater strength may mean marked inflammatory reaction. - -8. Tuberculous meningitis, brain tumor and purulent meningitis fluids -characteristically, though not invariably, give reactions in higher -dilutions than syphilitic fluids. - -9. The unsupplemented gold sol test is insufficient evidence on which to -make any diagnosis, but used in conjunction with the Wassermann -reaction, chemical and cytological examinations, it offers much -information looking toward the differential diagnosis of general -paresis, cerebrospinal syphilis, tabes dorsalis, brain tumor, -tuberculous meningitis, purulent meningitis. - -10. We believe that no cerebrospinal fluid examination is complete for -clinical purposes without the gold sol test. - - -The =Wassermann reaction= as carried out in the Wassermann Laboratory is -based on the principles of the original method—the only essential -modification consists in the employment of cholesterinized alcoholic -extracts of human hearts as antigen instead of aqueous extracts of -foetal livers from cases of congenital syphilis. Experience has shown -that properly standardized antigens made from human hearts are much more -sensitive in the detection of true cases of syphilis. - -=Antigens.= Three antigens are used, each being an alcoholic extract of -human heart which is saturated at room temperature with cholesterin. -These antigens differ slightly in their sensitiveness. Before the test -is made each antigen is diluted with 0.85% salt solution in the -proportion of four parts of the cholesterinized antigen extract to -sixteen parts of 0.85% salt solution. The amount to be used, the dosage, -is carefully determined by testing each antigen against a large number -of known positive and known negative specimens of blood. The dosage of -the antigens employed is less than one-half the amount which inhibits -hemolysis when the antigen is incubated for one hour with the hemolytic -system which consists of complement, amboceptor and cells in the proper -proportions. These antigens are designated as A, B, and C. Antigen A is -the most sensitive. B and C are very similar to each other -quantitatively and qualitatively. - -=Specimens to be tested.= The serum which separates from the clot is -withdrawn, centrifugalized if necessary, and then heated at 55 degrees -for thirty minutes. 0.1 cc. of serum is used in the test and 0.2 cc. of -each specimen is used as a control to exclude the presence of -anti-complementary substances. Spinal fluids are tested in two ways. As -a routine 0.5 cc. of the spinal fluid is used in the test and 1.0 cc. is -used in the control; or when especially requested spinal fluids are -titrated by using respectively 1.0, 0.7, 0.5, 0.3, and 0.1 cc. of the -spinal fluid for each test and 1.0 cc. of spinal fluid for the control. -Spinal fluids are not inactivated. - -=Complement.= The complement is obtained from the serum of guinea pig’s -blood. No complement is used when older than eighteen hours. A 10% -solution and 0.85% salt solution is used in the test. The amount used is -twice the minimum quantity necessary to hemolyze the sensitized cells. - -=Sheep’s Corpuscles.= A 5% suspension of sheep’s corpuscles in 0.85% -salt solution is prepared from defibrinated sheep’s blood. The -corpuscles are washed three times and for each washing four to five -times as much 0.85% salt solution is used as the original volume of the -defibrinated blood. - -=Amboceptor.= The amboceptor is prepared by injecting sheep’s corpuscles -into a rabbit. The serum of this rabbit which contains amboceptor is -diluted with 0.85% salt solution so that 0.25 cc. will hemolyze 0.5 cc. -of a 5% suspension of sheep’s corpuscles. In the test twice the quantity -or 0.5 cc. of amboceptor is used. - -=Sensitized Cells.= The sensitized cells consist of equal parts of -washed sheep’s corpuscles and diluted amboceptor. This mixture is -incubated in a water bath at 37° C. for a half hour to effect the -sensitization of the cells. - -=Technique of the Wassermann Test.= One-tenth cubic centimeter of each -inactivated specimen of serum and 0.5 cc. of each uninactivated specimen -of spinal fluid is pipetted into a separate tube. A mixture is freshly -prepared in salt solution, each cubic centimeter of which contains the -proper amount of antigen A (the most sensitive antigen), and two units -of a 10% solution of guinea pig serum (complement). One cubic centimeter -of this mixture is pipetted into each test tube. These tubes are then -incubated for forty minutes in a water bath at 37° C. At the end of this -period, sensitized cells are added, and the tubes are again incubated in -a water bath at 37° C. for one hour. Each specimen which shows any -degree of inhibition of hemolysis is retested in the afternoon. For this -second test antigen A is again used and in addition antigens B and C. A -control is also made for each specimen retested to eliminate any -possibility of the inhibition of hemolysis being due to -anti-complementary substances in the serum or spinal fluid tested. The -technique of the second test differs in no wise from that of the first, -except for the use of a control in each retested specimen and the -employment of three antigens instead of one. The degree of positiveness -is noted for each retested specimen and compared with the degree of -positiveness obtained for the corresponding specimen with the same -antigen-complement-salt solution mixture in the morning’s test. The -specimen is retested on the next day when discrepancies occur between -the morning reading for antigen A and the afternoon reading for antigen -A. From the above description it will be noted that the negative -specimens have but a single test with one antigen only, while the -positive specimens are retested, thus permitting a confirmation of any -positive reaction. In this way attention is focalized on the positive -specimens. - -=Interpretation of Results.= Antigen C (the weakest of the three -antigens) is used entirely for diagnostic purposes and any specimen -showing the slightest degree of inhibition with this antigen and -stronger degrees of inhibition with the other antigens is reported as -positive. The specimens which are strongly or moderately positive with -antigens A and B and negative with antigen C are reported as doubtful. -In testing spinal fluids by the titration method, antigen C is used and -the readings are based upon the degree of inhibition of hemolysis noted. -The intensity of this inhibition is indicated by Arabic numerals: “5” -indicates complete inhibition, while “1” means a faint cloudiness, hence -a weak reaction. Intermediate numbers show relative intensity varying -between complete inhibition “5” (strong positive) and slight inhibition -“1” (weak positive); “—” equals no inhibition (negative). - -Although it is commonly believed that the recent administration of -antisyphilitic treatment will affect the reaction by making it negative, -this is not our experience, and it is, therefore, not necessary that -treatment be withdrawn for a short period before the specimen is -submitted for examination. - -The reaction as carried out in this laboratory has the following -diagnostic significance: =Positive indicates syphilis=, except very -rarely in acute febrile conditions such as malaria and pneumonia. -=Negative does not exclude syphilis.= In obscure conditions a series of -less than three negatives has little diagnostic significance. =Doubtful -suggests syphilis.= It is therefore advisable to submit three or more -specimens in such a case, and interpret a persistently or -predominatingly doubtful reaction as indicative of syphilitic infection. - -=Bruck Test.= A new serum test for syphilis has recently been described -by C. Bruck.[152] Following are recent results in our laboratory with -this test.[153] - -This new test for the diagnosis of syphilis by C. Bruck has aroused much -interest. The scientific standing of Bruck and the simplicity of the -technique led us to overcome our prejudice, that has been the offspring -of the numerous tests that have been offered of late. Bruck states that -since the discovery of the complement fixation test for syphilis by -Wassermann, Neisser and himself in 1906, he has been trying to find a -simple chemical reaction that would take the place of the complicated -technique of the Wassermann reaction. This method, as he has published -it, was worked out and is being used at the front, in the present war, -where complete laboratory equipment is not available. - -Commencing our experiments with a great deal of scepticism, we were much -surprised at the results obtained, which are given below. Whatever may -be the final status of the test in the determination of syphilis, we -feel that there is a great deal of interest in the fact that this simple -chemical reaction does pick out certain differences in the composition -of blood sera and that apparently a large number of syphilitic sera -differ in their chemical composition percentage from the majority of -non-syphilitic sera. - -The technique, while exceedingly simple, offers many chances for errors -and individual variations so that we have thought it well to give -directions and cautions at some length. - -Bruck’s[154] technique is described as follows: “The test is made with -0.5 cc. clear serum in a test tube, to which is added 2 cc. of distilled -water, and the whole shaken. Then, with a precision pipette, 0.3 cc. of -the ac. nitr. purum of the German pharmacopeia is added and the whole -thoroughly shaken and then set aside at room temperature for ten -minutes. Then 16 cc. of distilled water at room temperature is added, -and closing the tube with the finger, it is shaken up and down three -times carefully, not vigorously enough to make it foam. This is repeated -ten minutes later, and the tube is then set aside for half an hour. By -this time the precipitate is entirely dissolved in the tube with the -normal serum, while the syphilitic serum shows a distinct, flocculent -turbidity. In two or three hours, or better still, in twelve hours, the -gelatinous and characteristic precipitate is piled up on the floor of -the test tube.” - -The acid is prepared by diluting the Acidum nitricum of the U. S. P. -(Sp. gr. 1.403) with distilled water until the hydrometer shows the -specific gravity 1.149, which corresponds to the nitric acid of the -German pharmacopeia, but since this requires a special hydrometer, a -simpler method is to make a 25 per cent solution of the Acidum nitricum, -which will give about the proper specific gravity. - -The serum is obtained by allowing 10 cc. of blood to stand at room -temperature for an hour, and then centrifuging. Serum that has stood for -some time may be used as well as the fresh, and even bloody serum does -not seem to confuse the results to any great degree. The serum gives the -same results with or without inactivation. Post mortem blood gave -results as constant as that obtained during life, in the few cases that -we had in this series. But the reaction may be influenced markedly by -the size of the test tubes. We have found that the 13×1.9 cm. is the -most favorable size. - -When one first thinks of this test it appears very simple and probably -somewhat crude as a chemical reaction, but there are certain precautions -that must be observed, and several hundred normal and syphilitic sera -should be tried before the investigator can feel that he has a refined -routine technique. There is the personal equation which must be watched, -for here is probably the greatest source of error, and readily explains -why two different persons get widely varying results with the same sera -if they have done only a few dozen tests. We must take it for granted -that the reaction is a quantitative one, where some positive reactions -may differ only slightly from the normal non-syphilitic, and, -furthermore, any normal serum may be made to give a positive reaction, -and almost any positive serum be made to give a negative by improper -manipulation at some point in the test. There are as many places for -error to creep in as there are steps in the process. Bruck has omitted -many details in his publication, which allow personal variations, and so -we have tried to develop a routine process that will eliminate as many -of these as possible. - -We shall here attempt to explain the methods which we have found most -satisfactory and at the same time indicate the places where error is -likely to occur. The 0.5 cc. of serum is added to 2 cc. of distilled -water, and shaken thoroughly. Now add slowly exactly 0.3 cc. of acid -from a precision pipette, care being taken it does not flow down the -side of the tube. The tube should be shaken gently while the acid is -being added, for this prevents the formation of a flocculent precipitate -in normal serum which is difficult to dissolve later. After the acid is -added shake each tube gently to make sure that these flakes do not -persist. It is difficult to shake each tube in exactly the same manner, -as must be done if we expect uniform results. - -The first 250 tests of this series were made by allowing the tubes to -stand for ten minutes as Bruck advocates. Then we found that practically -all sera gave a positive reaction if allowed to stand 15–20 minutes, and -so in the other tests of the series an attempt was made to make the -reaction more sensitive by allowing the tubes to stand only 6–7 minutes. -During this time the tubes should be shaken gently once or twice. The -manner in which the 16 cc. of water is added also influences the -reaction. If allowed to flow freely in upon the precipitate, the -positive may be forced into solution as well as the negative. Both -pipette and tube should be slanted and the water allowed to flow down -the side of the tube without disturbing the precipitate. If all has gone -well up to this point, we may see a marked difference between the normal -and syphilitic precipitates, in that the normal will begin to go into -solution at once, thus clouding the water, while a positive precipitate -will be composed of large flakes which show little or no tendency to go -into solution or cloud the water above. It must be remembered that the -most flocculent positive precipitate will go into solution if the fluid -is splashed or shaken too hard while the tube is being inverted. If any -doubt as to the character of the precipitate now exists, it may be -allowed to stand ten minutes longer, and again inverted as before, or -even repeated several times during the next hour or two. We see no -reason why the tubes should be left to stand over night, for during this -time a precipitate usually settles in the normal tubes. This, however, -differs from the syphilitic precipitate in that it is still finely -granular and goes back into solution readily when the tubes are -inverted. - -In view of these possible grounds for error, it is only logical to run -controls of known positive and known negative sera along with each group -of unknown bloods, and even then certain tubes will seem doubtful, in -which event the test should be repeated with added precaution to see if -a definite positive or negative reaction may be obtained. - -In the last tests of this series we seemed to aid the reaction by -rendering the serum-water solution alkaline by one or two drops of 10 -per cent potassium hydroxide before the acid was added. The positive -sera have a larger precipitate, while the normal seem to dissolve more -readily. - - TABLE I - - Syphilis: nervous system involved. - - General Paresis Wassermann and Bruck agree positively 47 - Wassermann and Bruck agree negatively 7 - Wassermann and Bruck at variance 10 - - Tabes Dorsalis Wassermann and Bruck agree positively 3 - - Cerebrospinal Wassermann and Bruck agree positively 8 - Wassermann and Bruck agree negatively 3 - - Juvenile Paresis Wassermann and Bruck agree positively 1 - - Summary: Wassermann and Bruck agree positively 59 - Wassermann and Bruck agree negatively 10 - Wassermann and Bruck at variance 10 - - TABLE II - - Syphilis: nervous system not involved. - - Syphilis Wassermann and Bruck agree positively 12 - Wassermann and Bruck at variance 5 - - Congenital Syph. Wassermann and Bruck agree positively 3 - Wassermann and Bruck agree negatively 2 - - Summary: Wassermann and Bruck agree positively 15 - Wassermann and Bruck agree negatively 2 - Wassermann and Bruck at variance 5 - - TABLE III - - Non-syphilitic: Wassermann reaction negative. - Doubtful or positive Bruck 86 - Bruck test negative 216 - - Total for three groups: - Wassermann and Bruck agree positively 74 - Wassermann and Bruck agree negatively 230 - Wassermann and Bruck at variance 101 - -The tests here reported were made on blood sera obtained from patients -admitted to the Psychopathic Hospital and its Out-Patient Department. As -a routine Wassermann test is made on each patient who enters the -hospital, it was only necessary to take another tube of blood from each -patient, and check the results in each instance with the Wassermann -reaction. As it takes several days to get the report from the Wassermann -laboratory of the State Board of Health, there was no chance of being -prejudiced by a previous knowledge of the Wassermann reaction. The cases -for the most part were those of mental disease; the majority in good -general physical health. - -A comparison of the total number with the Wassermann reaction shows that -there was a general agreement of 304 of the 405 cases tested, or a -percentage agreement of practically 75%. In considering the cases of -syphilis of the central nervous system in a group by themselves, we find -that the agreement is closer, since 69 of the 79 cases tested, or 87% -agreed without any question of doubt. It will be noted that in several -cases of general paresis, the Wassermann reaction, which was repeated at -intervals, was negative, and in most of these cases the Bruck test was -negative also. Our few cases of congenital and latent syphilis also -checked very closely with the Wassermann test. In the various groups of -mental cases in this series, no factor of interference was discovered. -It is also of interest that in the cases where the blood was obtained -post mortem, the Bruck test agreed with the Wassermann result obtained -on ante mortem blood serum. Further work on post mortem sera will be -reported. Some of the patients not included in the syphilitic groups -that have a negative Wassermann and no clinical signs of syphilis, give -a history of previous infection at some time, which might partly account -for the variations in the two tests. - -CONCLUSIONS - - 1. We present results of the Bruck sero-chemical test in 405 cases. - In 101 of these cases there were definite clinical manifestations - of syphilis, in which the Wassermann and Bruck tests agreed - positively in 74 or 75%. The two tests agreed negatively in 12 - instances, and were at variance in 15. - - 2. In the group which showed syphilis of the nervous system we had - 64 cases of clinically certain general paresis, of which the - Wassermann and Bruck tests agreed in 54 instances, or practically - 85%. In other forms of central nervous system involvement the - agreement was 100% in the 15 cases tested. - - 3. In the cases with no apparent involvement of the nervous system - the agreement was somewhat less, being 76%. This may be in keeping - with the fact that the Wassermann test was not so strongly - positive in these cases. - - 4. The advantages of the test are: (1) the short time required to do - the test; (2) the limited amount of apparatus necessary, and (3) - the simplicity of the technique. - - 5. The disadvantages of the test seem, for the most part, to be - bound up in the personal variations that are apt to occur. - - 6. We are here dealing, most probably, with a quantitative chemical - difference in the protein content of syphilitic and non-syphilitic - sera, the nature of which is not understood by us. It is our hope - that this may be brought to light in the near future in the field - of chemistry. - - - - - APPENDIX B - COMMON METHODS OF TREATMENT USED IN CASES OF NEUROSYPHILIS - - -The =treatment for neurosyphilis= according to the viewpoint of the -authors =is treatment for syphilis=. It is necessary in order to cure a -case of neurosyphilis to cure the syphilis in the patient. Accordingly, -the methods of treatment best adapted for the cure of syphilis are -indicated in the treatment of neurosyphilis. As experience shows that it -is often more difficult to cure the neurosyphilitic cases, treatment -will have to be pushed with greater intensity than in some non-nervous -system syphilis. In general, then, the methods that have been applied by -the syphilologist will be used in the treatment of cases of -neurosyphilis. In addition, methods attempting to bring the drug into -local contact with the central nervous system have been devised. The -methods of treatment have been in part indicated in Chart 27. - -The method chiefly used in treatment of the cases of this book is what -we have called =intensive systematic intravenous treatment=. The -treatment consists of intravenous injections of salvarsan (or a -substitute for salvarsan, as arsenobenzol and diarsenol) given in a dose -of about 0.6 gram and repeated twice a week over a period of a number of -months. In addition, injections of mercury salicylate averaging 0.065 -gram once a week are given and potassium iodid by mouth. As indicated, -the important point is to keep up treatment for a long period of time. -This method has produced practically no untoward results, certainly no -more untoward results than are to be expected with salvarsan in smaller -quantities and it has seemed to us that the therapeutic results have -been as satisfactory as in any other form of treatment. - -Specialized forms of treatment intended to place the drug in contact -with the central nervous system may be described under the headings of -=spinal intradural treatment= and =cerebral subdural= and -=intraventricular treatment=. - -Three main therapeutic agents have been largely used. These are (1) -salvarsanized serum according to the =method of Swift-Ellis= (=in -vivo=). The serum according to this method is prepared as follows: An -intravenous injection of salvarsan is given to a patient and blood -withdrawn at the end of one-half hour. This is allowed to clot. The -serum is removed and after inactivation at 56° C. for one-half hour it -is ready for use. The average dose is 15 to 30 cc. of serum. As a matter -of fact, it is not necessary to use the blood serum from the same -patient to whom the intraspinous injection is to be given. (2) The -salvarsanized serum according to the =method of Ogilvie= (=in vitro=). -Blood serum is prepared from any patient and to it is added salvarsan in -such a strength that the amount to be injected, 10 to 30 cc. of serum, -will contain 0.0001 to 0.001 gm. (3) Mercurialized serum according to -the =method of Byrnes=. Mercury bichloride is added to blood serum in -such proportion that the amount of serum to be injected will contain -from 0.00065 gram to 0.0026 gram. - -The method of intraspinous injection is to perform lumbar puncture, -withdraw an amount of fluid approximately equivalent to the amount to be -injected; then allow the serum to be injected to run in by gravity. - -For the =cerebral=, =subdural and intraventricular= injections, the same -sera may be used as for the intraspinous. Five or six times as much -salvarsan may be given, but a smaller amount of serum may be advisable, -that is, 10 to 15 cc. To perform injections a trephine opening is made -in the calvarium about the size of a dime. The location of choice for -the opening is slightly back of the longitudinal prominence just to the -right of the median line, to avoid the frontal sinus. For subdural -injections a curved needle is thrust between the dura and the brain and -the serum allowed to flow in slowly by gravity. For the intraventricular -injections a blunted spinal puncture needle is thrust through the brain -substance into the 3rd ventricle. When the 3rd ventricle is reached the -clear cerebral fluid will flow out; then after withdrawing a sufficient -amount, the serum may be introduced by gravity. The trephining may be -done under local anesthesia but as a rule it is better to induce general -anesthesia. The subsequent injections can be made without recourse to -any anesthesia whatsoever, as they are practically painless. - -All procedures both in the injections and in the preparation of sera are -naturally to be performed under aseptic conditions. - - - - - INDEX - - - Abscess, tonsillar, associated with neurosyphilis, 250. - - Addison’s disease in juvenile paretic, 279. - - Agraphia, 101. - - Albumin test, 474. - - Allbutt, Clifford, 257. - - Alcoholism, chronic, 227. - - Alcoholic dementia, 237. - epilepsy, 229. - hallucinosis, 225. - pseudoparesis, 222, 223, 451. - - _Allergie_, 129, 204. - - Alzheimer, 428. - method, 472. - - Amboceptor, 477. - - Amnesia, 195. - - Anaphylaxis, 129. - - Anatomical formulae, 25. - - Antigens, 476. - - Aortic aneurysm, 35, 439. - - —— sclerosis, 41, 46, 135. - - Aphasia, 31, 43, 101, 262, 445. - - Apoplexy, 197. - - Argyll-Robertson pupil, 209, 212, 217, 291, 450. - as isolated symptom, 217. - in alcoholism, 214, 229. - - Arndt, Junius and, 249. - - Arsenobenzol, 375, 377, 389, 486. - - Arteriosclerosis, cerebral, 101. - not a contraindication to intensive salvarsan therapy, 359. - radial, 68. - - Ascending lesion, 23. - - Asymmetrical lesions, 19. - - Ataxia, 31, 223. - - Atheromatous degeneration, 35. - - Atrophy, cerebellar, 39. - cerebral, 47, 134, 205. - parenchymal, 41. - pontine, 39. - - Atypical case congenital neurosyphilis, 270. - - Ayer, J. B., 472. - - - Ballet, 72. - - Barrett, A. M., 54, 175, 187, 212, 218, 219. - - Bechterew, 219. - - Binet and Simon, 304. - - Binet scale, 277. - - Birnbaum, 403. - - Blood pressure, high, 70, 262, 124. - - Bly, 252. - - Bonhoeffer, 404, 415, 417. - - Bordet, 427. - - Bratz, 278. - - Bruck test, 479. - - Bruck, C., 479. - - Bumke, 214. - - - Canavan, 256. - and Southard, 70. - - Cell count, 471. - - Cerebral syphilis, see diffuse neurosyphilis. - - Cerebrospinal syphilis, see diffuse neurosyphilis. - - Cervical hypertrophic meningitis of Charcot, 56, 441. - - Chancre, extragenital, 75, 342. - - Character change, neurosyphilis, 314. - - Charcot, 60, 186. - - Choroiditis, 242. - - Christian, 407. - - Cimbal, 403. - - Civilization and syphilis, 76. - - Clinical evidences of syphilis, 131. - - Clouston, 158. - - Collins, Joseph, 145. - - Compensation in neurosyphilis, 309, 402, 456. - - Complement, 477. - - Conduct disorder, 38. - - Congenital syphilis, absence of stigmata, 318. - as cause of feeblemindedness, 159, 447. - involvement of nervous system in, 274. - - Congenital neurosyphilis, 270, 395. - resembling feeblemindedness, 272. - - Conjugal neurosyphilis, 263. - - Convulsions, 43, 101, 248, 362. - cause of in paretic neurosyphilis, 232. - in psychopathic subject with syphilis, 417. - - Corneal opacity, syphilitic, 234. - - Cotard, 73. - - Cotton, H. A., 472. - - Craig, C. B., 152, 196. - - Cramer, 125. - - Cranial neurosyphilis, 140. - tenderness, 139. - - Crises, gastric, 367. - - Cysts, ependymal, 59. - of softening, 27, 36, 54. - - Cytorrhyctes luis, 381. - - - Dana, Charles L., 65, 77, 78. - - Dazed states, 264. - - Deafness, 63. - - Decompression, 138. - - Defective delinquent—diffuse neurosyphilis, 300, 455. - - Dejerine-Tinel, 61. - - Delinquency and juvenile neurosyphilis, 298. - - Delirium tremens, 332. - - Dementia, 137. - - Dementia paralytica, see paretic neurosyphilis. - - Dementia praecox, 74, 185, 247. - - Depression, 95, 126. - - Depressive drugs, 189. - - Diabetes, and neurosyphilis, 240. - insipidus, 190. - - Diabetic pseudoparesis, 238. - - Diarsenol, 377, 389, 391, 486. - - Differential diagnosis, alcoholism and neurosyphilis, 227, 231, 234, - 236. - brain tumor, diabetic pseudoparesis and neurosyphilis, 238. - diffuse and paretic neurosyphilis, 165, 193, 247. - manic-depressive psychosis and neurosyphilis, 69. - multiple sclerosis and neurosyphilis, 253, 255. - neurasthenia and neurosyphilis, 65, 183. - senile arteriosclerotic psychosis and neurosyphilis, 262. - - Diffuse neurosyphilis, cerebrospinal syphilis, cerebral syphilis, - spinal syphilis, 17, 80, 85, 97, 103, 122, 140, 183, 193, 300, 331, - 342, 359, 433, 439, 443. - premonitory symptoms, 342. - prognosis, 80, 103, 124, 433, 443. - spinal fluid findings in, 348. - symptoms, 99. - treatment, 98, 103, 184, 302, 390. - treatment, results, 343. - - Diplopia, 50, 184, 253, 356. - causes, 140. - - Donath, 401, 403. - - Drastich, 407. - - Duco and Blum, 403. - - Dupré, 407. - - Dysdiadochokinesis, 231. - - - Ehrlich, 184, 428, 429. - - Encephalitis, 27, 248. - disseminated, 218. - - Endarteritis, 220. - - Ependymal cysts, 59. - - Ependymitis, 40, 47, 49, 134. - - Epilepsy, 192. - alcoholic, 229. - brought out by syphilis, 415. - Jacksonian, 103. - parasyphilitic, 194. - relation to juvenile neurosyphilis, 277. - syphilitic, 103, 194. - syphilogenic, 415. - - Epileptic neurosis, 195. - - Erb’s syphilitic spastic paraplegia, 147. - treatment of, 148. - - Euphoria, 73. - - Excited states, 95. - - Exner, M. J., 416. - - Exophthalmic goitre, syphilitic (?), 205. - - Extraocular palsy, 140, 441. - - Eye changes in neurosyphilis, 257. - - Eye muscles, paresis of, 17, 50. - - Facial paralysis, 53. - - Families of neurosyphilitics, 275, 316, 318, 320, 373, 431, 457. - - Family of neurosyphilitic, normal-looking, but syphilitic, 318. - - Familial syphilis, 299, 306. - - Farrar, C. B., 411. - - Fearnsides, Head and, 21, 140, 150, 193, 217, 374, 378. - - Feeblemindedness, 395. - and congenital syphilis, 159. - - Fernald, W. E., 159, 273, 396. - - Fildes, McIntosh and, 129, 329. - - Focal changes, 221. - meningitis, 50. - softenings, pontine, 54. - - Fournier, 142, 222, 186, 194, 381. - - Franz, 357. - - Froissart, 413. - - Fugue, hysterical, 264. - - - Garnier, 407. - - General paresis, see paretic neurosyphilis. - - Glands, 270. - - Gliosis, 39, 47, 49, 136, 180. - - Globulin, 229. - tests, 473. - - Glycosuria, 238, 241. - - Goddard, 397. - - Gold sol reaction, 247, 474. - in brain tumor, 100. - paretic, 85, 98. - paretic, other tests negative, 383, 385. - in purulent meningitis, 100. - syphilitic, 85, 98, 345. - - Graham, Thomas, 429. - - Grandiosity, 72, 295, 455. - - Graves, W. W., 157. - - Grilli, 407. - - Gross, 257. - - Gumma, see gummatous neurosyphilis. - - Gumma of tonsil, 250. - - Gummatous neurosyphilis, 53, 56, 137, 138, 140, 221, 362, 438. - - - Hallucinations, 53. - in paretic neurosyphilis, 249. - - Hauptmann, 348. - - Head and Fearnsides, 21, 140, 150, 193, 210, 217, 374, 387. - - Headache, 53, 63, 122, 247, 352. - causes of, 209. - - Hecht, 399. - - Hemianopsia in neurosyphilis, 242. - - Hemiplegia, 31, 45, 80, 122, 262, 360. - causes of, 389. - - Hemitremor, 197. - - Heredity, neuropathic, 84. - - Herxheimer reaction, 152. - - Heubner, 427, 428. - - Hinton, W. A., 471. - - Huntington’s chorea, 258. - - Hutchinsonian teeth, 45. - - Hydrocephalus, 134, 306. - - Hyperreflexia, explanation of, 233. - - Hypochondriacal ideas, 133. - - Hysteria, 185, 301. - - Hysterical symptoms, 18. - - - Incontinence, vesical in tabetic neurosyphilis, 144. - rectal, 56. - - Incubation period of neurosyphilis, 152. - - Infectiousness of neurosyphilis, 95. - - Insight, 95. - - Insomnia, 63. - - Intracranial pressure, 139, 362. - - Intraspinal lesions, 95. - - Intraspinous therapy, 122, 366, 486. - unpleasant results of, 366. - - Intraventricular injections, 389, 487. - - Involution-melancholia, 187. - - Iodine, untoward results, of, 363. - - Iritis, 17. - - - Järisch-Herxheimer reaction, 72. - - Joffroy, 214. - and Mignot, 64. - - Junius and Arndt, 249. - - Juvenile neurosyphilis, 438, 447. - relation to epilepsy, 277. - - Juvenile paresis, see juvenile paretic neurosyphilis. - - Juvenile paretic neurosyphilis, juvenile paresis, 45, 154, 157, 272, - 275, 298, 306, 440. - age of onset, 158. - and Addison’s disease, 279. - and delinquency, 298. - prognosis, 156, 158, 162, 273, 275. - treatment, 154, 161, 278, 299. - - Juvenile paretic neurosyphilis, with initial trauma, 306. - congenital amputation of toes in, 158. - - Juvenile tabetic neurosyphilis, 161, 447. - - - Kaplan, 255, 471. - - Kéraval, 257. - - Key, 427. - - Knee-jerks, absence of, 223. - lively, 75. - return of, 24. - - Koefod, Solomon and, 243. - - Kolmer, 471. - - Kraepelin, 65, 66, 69, 88, 91, 95, 187, 225, 249. - - Krafft-Ebing, 84. - - - Laignel-Lavastine, 413. - - Lange, C., 428, 429, 474. - - Lancinating pains, 92, 141. - - Lépine, 408, 413. - - Leptomeningitis, 47, 54, 135. - - Lewandowski, 210. - - Liability of paretic, 295. - - Lissauer’s paralysis, 38. - - Locomotor ataxia, see tabetic neurosyphilis. - - Long, 418. - - Lucke, Baldwin, 93, 144. - - Lues maligna, 250, 452. - - Lumbar puncture, untoward effects, 352. - treatment of, 354. - - Lüth, 278. - - Lymphocytosis, 23, 30, 40, 49. - - - McDonagh, 381. - - McIntosh, Fildes and, 129, 329. - - Malaria, cerebral, simulation of paretic neurosyphilis, 245. - - Mallory and Wright, 472. - - Manic-depressive psychosis, 68, 71, 77, 187, 202, 291, 384, 442. - - Marie, Chatelin and Patrikios, 412. - - Marie, 408, 414. - - Martin, E. G., 313. - - Massary, de, 414. - - Mattauschek and Pilcz, 347. - - Medicolegal and Social, 454. - period of paretic neurosyphilis, 414. - - Meilhon, 407. - - Memory, failing, 63. - - Meningitis hypertrophica cervicalis of Charcot, 56. - sympathica, 19. - syphilitic, 103. - - Mercurialization, 98. - - Mercury, 58, 83, 85, 98, 148, 193, 235, 376, 377, 389, 391, 395, 486. - untoward results of, 363. - - Metasyphilis, 89. - - Metchnikoff and Roux, 427, 428. - - Microgyria, occipital, 47. - - Mignot, Joffroy and, 64, 66. - - Migraine, 19. - - Mitchell, H. W., 218. - - Mœbius, 429. - - Mott, F. W., 158, 257, 308, 396, 437. - - Multiple sclerosis, 253, 256. - relation of syphilis to, 254. - spinal fluid findings in, 254. - - Muscular atrophy, 149, 446. - syphilitic relation to amyotrophic lateral sclerosis, 150. - - Muscular weakness, 279. - - Myerson, A., 196. - - - Nageotti, 428. - - Nausea, 63. - - Neisser, 399. - - Nerve trunk tenderness, 148, 234. - - Nervousness, 63. - - Nervous indigestion, 63. - - Neurasthenia, 63, 183. - - Neuritis, cranial, 51. - optic, 365. - root, 235. - syphilitic, 235. - - Neurorecidive, 152, 153, 184, 196, 235. - - Neuroses, relation of syphilis to, 186. - - Neurosyphilis, 187, 238, 240, 242. - aggravated on military service, 404. - atypical, 258, 346. - atypical case resembling hysterical fugue, 264. - dates, 428. - forms of, 20, 21, 28, 29, 95. - galloping, 328. - history of, 427. - incubation period, 152. - infectiousness of, 95. - laboratory findings in, 82. - latent, 142, 203. - lesions, 303. - lighted up by stress of military service, 412. - and marriage, 319. - prevention, 320. - onset, 64. - in primary stage, 186. - in secondary stage, 185, 283, 390. - in secondary stage, prognosis, 390. - in secondary stage, treatment, 153. - spinal, 23. - and the war, 399, 466. - - Nissl-Alzheimer method, 427. - - Noguchi, 381. - and Moore, 428, 429. - - Nonne, 82, 125, 152, 186, 195, 196, 214, 216, 235, 254, 265. - -Apelt test, 473. - - Numbness, 56. - - Nystagmus, 45, 253, 256, 279. - - - Obersteiner, 249. - - Occupation-neurosis, 312. - - Ogilvie method, 487. - - Operation for gumma, 139. - - Optic atrophy, 256. - in juvenile paretic neurosyphilis, 154. - - Optic thalamus, syphilitic lesion of, 205. - - Osteitis, syphilitic, 311. - - Ozena, 350. - - - Pains, 31. - - Pandy test, 474. - - Paralysis, 123. - recovery from, 342. - of respiration, 248. - - Paranoia, syphilitic, 225. - - Paraphasia, 19, 43. - - Paraplegia, 26, 30. - - Parasyphilis, 89. - - _Paresis sine paresi_, 126, 186, 204, 303, 445. - - Paresis, see paretic neurosyphilis. - - Paretic neurosyphilis, dementia paralytica, general paresis, softening - of the brain, 37, 63, 68, 74, 78, 80, 85, 97, 131, 188, 192, 197, - 199, 202, 227, 241, 262, 289, 295, 309, 314, 323, 338, 372, 375, - 377, 382, 384, 386, 388, 392, 435, 440, 442. - adjuvant causes of, 414. - causing social complications, 289. - causes of death in, 197. - course, 85. - duration, 88. - forms, 95. - improvement, 377. - incidence among officers, 407. - incidence among soldiers, 402. - lesions of, 131. - “lighted up” by domestic stress in civil life, 420. - “lighted up” by “gassing,” 414. - mortality from, 89. - nomenclature, 88. - onset, 192. - pathology of, 436. - prognosis, 435, 444. - symptoms, 90, 131. - symptoms, mental, 87. - symptoms, physical, 86. - versus diffuse neurosyphilis, 165. - versus vascular neurosyphilis, 169, 172. - with very marked meningitis, 332. - with very marked brain atrophy, 335. - without mental symptoms, 315. - traumatic exacerbation, 310. - traumatic form, 308, 413. - traumatic, shell-shock, 401. - treatment of, 85, 370, 372, 377, 382, 384, 386, 388, 392. - treatment, results of, 351. - - Pensions for disabilities resulting from venereal disease, 409. - - Pensions for neurosyphilis, 411. - - Peripheral neurosyphilis, 19. - - Perivascular infiltration, 41. - - Pernicious anemia with spinal symptoms, 267. - - Petit mal attacks, 195. - - Pförringer, 61. - - Phobia, 67. - - Pilcz, Mattauschek and, 347. - - Pitres and Marchand, 421, 424. - - Plaut, 249, 348, 428. - - Plaut, Rehm and Schottmüller, 471. - - Plasmocytosis, 40, 49, 55. - - Pleocytosis, 23, 220, 247, 344. - effect of antisyphilitic treatment on, 244, 376. - in remissions, 243. - significance of, 243. - spinal fluid otherwise negative, 270. - - Polydipsia, 190. - - Polyuria, 190. - - Pontine hemorrhage, 219. - softening, 54. - - Posey and Spiller, 257. - - Potassium iodid, 58, 85, 98, 193, 222, 376, 377, 389, 486. - - Preparesis, 65, 77, 78. - - Prince, Morton, 195. - - Psammoma, 213. - - Pseudoneurasthenia, 66. - - Pseudoparesis, 449. - alcoholic, 222, 229, 451. - diabetic, 238. - senile, 263. - shell-shock, 421. - syphilitic, 223, 371. - - Pseudoparetic neurosyphilis, 222. - - Pseudotabes, shell-shock, 424. - - Psychogenic neurosyphilis, 189. - - Psychographic disturbance, 228. - - Psychopathic personality, 302. - - Ptosis, 350. - - Pupillary reaction, changes in, 261. - signs, 69. - - Pupils, Argyll-Robertson, see Argyll-Robertson pupils. - irregular, 79, 201. - normally reacting in paretic neurosyphilis, 199. - sluggish reaction to light, 188. - stiff as isolated symptom, 265. - - Purkinje cells, binucleate, 48. - - Putnam, James J., 19, 56. - - Pyramidal tract lesion, bilateral, 326. - sclerosis, 44. - - - Quadriplegia in juvenile paretic neurosyphilis, 275. - - Quincke, 427, 428. - - - _Randsklerose_, 24. - - Ravaut, 428. - - Ravaut, Sicard, Nageotti, Widal, 428. - - Rayneau, 407, 413, 414. - - Recovery, 77. - - Recurrences, 70. - - Redlich, 403. - - Régis, 73. - - Remissions, 122, 435, 445. - - Retardation, 187. - - Retention of urine, 56. - - Retinitis, hemorrhages, 365. - - Richards, R. L., 402, 404, 406, 409. - - Robertson, A. R., 59. - - Rod cells, 226, 297. - - Romberg sign, 141, 216, 279. - - Root-sciatica, syphilitic, 418. - - Rosenau, 471. - - Ross-Jones test, 473. - - “Rum fit,” 229. - - Ryder, Charles T., 42. - - - Saddle-shaped nose, 210. - - Salivation, 98. - - Salmon, Thomas W., 89. - - Salvarsan, 75, 83, 85, 193, 222, 377, 389, 486. - provocative, 78, 79. - untoward results of, 363. - - Salvarsanized serum, 75. - - Schaudinn, 427, 429. - - Sciatic pain in neurosyphilis, 149. - - Seizures, 31, 64, 83, 103, 444. - causes of in paretic neurosyphilis, 194. - Jacksonian, 392. - minor, 392. - - Senile arteriosclerotic psychosis, 262. - - Sensitized cells, 478. - - Sérieux and Ducaste, 96. - - Shaikewicz, 404. - - Shanahan, 278. - - Sheep’s corpuscles, 477. - - Shock, 42, 81. - - Sicard, 428. - - Six tests, 80, 85. - in tabetic neurosyphilis, 141. - - Smith and Solomon, 479. - - Social cases, 454. - service, 232. - - Solomon, 142, 255. - and Koefod, 243. - Smith and, 479. - Southard and, 202, 303. - - Somnolence, 45. - - Southard, E. E., 48, 134, 212. - and Canavan, 70. - and Solomon, 202, 303. - and Taft, 397. - - Spasms, clonic, 326. - - Spastic hemiplegia in paretic neurosyphilis, 323. - - Spastic paraplegia, Erb’s, 147, 306. - - Spasticity, 18, 256. - - Speech defect, 69, 133. - - Spiller, 150. - Posey and, 257. - - Spinal fluid findings in secondary stage of syphilis, 151, 185, 283. - in juvenile paretic neurosyphilis, 275. - negative in diffuse neurosyphilis, 140. - negative in gummatous neurosyphilis, 138. - negative in neurosyphilis, 216. - negative in tabetic neurosyphilis, 269. - in tabetic neurosyphilis, 141. - - Spinal fluid, withdrawal for therapeutic purposes, 377, 379. - - Spinal syphilis, see diffuse neurosyphilis. - - Spirochetes, “drug fastness,” 381, 394. - strains, 76, 263, 276, 381, 394. - - Steida, 405. - - Sterility in tabetic neurosyphilis, 144. - - Stier, 407. - - Stokes, Wile and, 186. - - Suicide, 92, 126, 240, 296, 301. - - Summary, 427. - - Syphilis aggravated by service, 406, 411. - on service, 409. - - Syphilis as cause of diabetes, 241. - as cause of feeblemindedness, 396. - hereditaria tarda, 160, 318. - history of, 427. - lesions in, 329. - of lung, 211. - from Mongolian, 76. - primary, 65. - secondary, 65. - tertiary, lesions in, 329. - - Syphilitic feeblemindedness, pathology of, 160. - neuritis, 312. - psychosis, 91. - - Syphilophobia, 67, 361. - - Syphilotoxins, 72. - - Swift, 129, 212. - - Swift and Ellis, 428, 429. - method, 428, 487. - - - Tabes dorsalis, see tabetic neurosyphilis. - - Tabetic neurosyphilis, tabes dorsalis, locomotor ataxia, 30, 31, 141, - 146, 366, 367, 434, 446. - associated with cerebral symptoms, 177. - atypical, 143. - cervical, 146. - course, 141. - with negative spinal fluid findings, 269. - prognosis, 94. - shell-shock, 403. - “shell-shocked” into paretic neurosyphilis, 401. - symptoms, 93. - symptoms in order of frequency, 145. - treatment, 145, 366, 367. - plus vascular neurosyphilis, 175. - with vascular insult, 30, 439. - versus pernicious anemia, 267. - - Taboparesis, see Taboparetic neurosyphilis. - - Taboparetic neurosyphilis, taboparesis, 92, 135, 195, 284, 443. - course, 92. - nomenclature, 94. - prognosis, 92, 443. - and typhoid meningitis, 284. - - Taft, A. E., Southard, E. E., and, - - Talon, 407. - - Taylor, E. W., 50. - - Temperature, paretic, 376. - - Tests, changes under treatment, 102. - changed to negative in paretic neurosyphilis without clinical - improvement, 385. - changed to less strongly positive in paretic neurosyphilis without - clinical improvement, 386. - - Therapeutic conception, 324. - - Thibierge, 399. - - Thierry, 158. - - Throbbing in head, 63. - - Thrombosis, cerebral, 36, 42, 342, 357, 360, 124. - - Thymus, persistent, 282. - - Tibial exostoses, 100. - - Tigges’ formula, 248. - - Todd, J. L., 406, 409. - - Transient deafness, 18. - blindness, 18. - paralysis, 124. - paralysis, condition in which occurs, 123. - - Trauma and juvenile neurosyphilis, 278, 306. - neurosyphilis, 456. - paretic neurosyphilis, 199, 308, 310. - syphilitic osteitis, 311. - - Treatment of neurosyphilis, 67, 75, 83, 124, 148, 184, 222, 235, 299, - 328, 332, 335, 342, 346, 350, 351, 355, 384, 390, 392, 395, 419, - 439, 457. - case in which theoretically of no avail, 323. - methods, 356, 486. - - Treatment of syphilis, effect on development of neurosyphilis, 142, - 347. - - Tremor, 197. - intention, 256 - - Tubercle, 80. - - Tuberous sclerosis of Bourneville, 47. - - Tumor, cerebral, 53, 191, 238, 253. - pineal, 213. - - - Unconsciousness, 53. - causes of, 389. - - - Vascular changes, 220. - - Vascular neurosyphilis, 31, 42, 72, 296, 359, 433, 440. - plus tabetic neurosyphilis, 175. - prognosis, 433. - versus paretic neurosyphilis, 169, 172. - - Veeder, B. S., 274. - - Vertigo, 122. - - Viet, 278. - - Virchow, 427, 428. - - Vomiting, 53, 63. - - - Warthin, 241. - - Wassermann reaction, 191. - and alcoholism, 230. - in congenital syphilis, 160, 271. - meaning of “doubtful,” 360. - negative in diffuse neurosyphilis, 184. - negative in juvenile paretic neurosyphilis, 298. - negative in spinal fluid in spinal syphilis, 148. - negative in spinal fluid in neurosyphilis, 101. - negative in neurosyphilis, 252. - negative in paretic neurosyphilis, 77. - technique, 476. - titrations in spinal fluid, 348. - - Wassermann, Neisser and Bruck, 428. - - Weiler, 214. - - Weygandt, 403, 404. - - Widal, Sicard, Ravaut, 428. - - Wiles and Stokes, 186. - - Word-deafness, 35, 43. - - - X-ray diagnosis of bone conditions, 136. - - - Yerkes-Bridges, 304. - - - Ziehen, 409. - - Zsigmondi, 429, 474. - ------ - -Footnote 1: - - The cases chosen to illustrate the propositions of the boxed headings - always illustrate several other points. See the footnotes of Section - VI for lists of cases illustrating special points. The names assigned - to the cases are fictitious and chosen to suggest race or descent. - -Footnote 2: - - Notes of Dr. James J. Putnam. - -Footnote 3: - - M = meningeal - V = vascular - P = parenchymatous - -Footnote 4: - - E. E. Southard: Lesions of the granule layer of the human cerebellum; - _Journal of Medical Research_, XVI, 1907. - -Footnote 5: - - Proof of marked parenchymatous lesions must hang on post mortem data; - the inference here as to the presence of parenchymatous lesions is a - clinical inference. - -Footnote 6: - - Reprinted from an article by Southard & Solomon: “Latent neurosyphilis - and the question of _Paresis sine paresi_.” Boston Medical & Surgical - Journal, XXIV, 1. - -Footnote 7: - - Solomon: “How Shall Latent Syphilis be Treated? The Prophylaxis of - Syphilis of the Central Nervous System.” Interstate Medical Journal, - XXIII, 8. - -Footnote 8: - - Joseph Collins: Syphilis of the Brain, _Journal American Medical - Association_, July 10, 1915, Vol. LXV, pp. 139–144. - -Footnote 9: - - A. M. Barrett has recently discussed this subject in a paper in the - _Journal of the American Medical Association_, Vol. LXVII, Dec. 2, - 1916. - -Footnote 10: - - Reprinted from an article by Southard & Solomon: “Latent neurosyphilis - and the Question of _Paresis sine paresi_.” Boston Medical and - Surgical Journal, XXIV, 1. - -Footnote 11: - - E. E. Southard. A case of glioma of the pineal region, _Am. Jour. of - Ins._, Vol. LXI, 1905. - -Footnote 12: - - Since this was written Collins has had further difficulties related to - his neurosyphilis, improving under treatment. - -Footnote 13: - - Warthin: “Persistence of active lesions and spirochetes in the tissues - of clinically inactive or ‘cured’ syphilitics,” _American Journal of - Medical Sciences_, CLII, 1916. - -Footnote 14: - - “The Significance of Changes in Cellular Content of Cerebrospinal - Fluid in Neurosyphilis,” _Boston Medical and Surgical Journal_, - CLXXIII, 27. - -Footnote 15: - - Plaut: Ueber Halluzinosen der Syphilitiker, Berlin, 1913. - -Footnote 16: - - Borden S. Veeder: Hereditary Syphilis in the Light of Recent Clinical - Studies; Am. Jour. of Med. Sc., CLII, 1916. - -Footnote 17: - - Reprinted from article by Southard and Solomon: “Latent Neurosyphilis, - the Question of _Paresis sine paresi_,” _Boston Medical and Surgical - Journal_, XXIV, 1. - -Footnote 18: - - (This case was furnished by Dr. D. A. Haller from the Peter Bent - Brigham Hospital series.) - -Footnote 19: - - Fernald, W. E. Standardized Fields of Inquiry for Clinical Studies of - Borderline Defectives. Mental Hygiene, Vol. 1, No. 2, April, 1917. - -Footnote 20: - - Goddard, H. H., Feeblemindedness, its Causes and Consequences, 1914. - -Footnote 21: - - W. E. Fernald and E. E. Southard. Waverley Research Series in the - Pathology of the Feebleminded. Proceedings of the American Academy of - Arts and Sciences, 1917. - -Footnote 22: - - Thibierge. La Syphilis dans l’armée, 1917. - -Footnote 23: - - Hecht. Wien. klin. Woch., xxix, 51. - -Footnote 24: - - Donath. Beiträge zu den Kriegsverletzungen und -er-krankungen des - Nervensystems. Wiener klin. Wehnschr., No. 27–8, 1915. - -Footnote 25: - - Duco et Blum. Guide pratique du Médecin dans les Expertises - médicolégales militaires. Paris, 1917. - -Footnote 26: - - Birnbaum. Kriegsneurosen und -psychosen auf Grund der gegenwärtigen - Kriegsbeobachtungen: Sammelbericht. Z. f. d. ges. Neurol. u. - Psychiat., Bd. XII, H. 1, 1915. - -Footnote 27: - - Weygandt. Kriegseinflüsse und Psychiatrie. Jahreskurse f. ärztl. - Fortbildung, Maiheft, 1915. - -Footnote 28: - - Bonhoeffer. Erfahrungen über Epilepsie und Verwandtes im Feldzuge. - Monatschr. f. Psychiat u. Neurol., Bd. 38, H. 1–2, 1915. - -Footnote 29: - - Exner, M. J., Prostitution in its relation to the army on the Mexican - Border, _Social Hygiene_, Vol. 3, 2, April, 1917. - -Footnote 30: - - Bonhoeffer, _loc. cit._ - -Footnote 31: - - We have recently reviewed the outcome in 300 _untreated_ cases of - paretic neurosyphilis (Psychopathic Hospital material, strictly - comparable with treated cases) finding but 5 now capable of - self-support and 10 more in normal-looking remission. This percentage - is far lower than that in treated cases (at present, July, 1917, 50 in - 200 capable of self-support). - -Footnote 32: - - Alice Morton (1). - -Footnote 33: - - Francis Garfield (2). - -Footnote 34: - - John Dixon (3). - -Footnote 35: - - James Pierce (4). - -Footnote 36: - - John Lawrence (5). - -Footnote 37: - - Flora Black (6). - -Footnote 38: - - Mrs. Lecompte (7). - -Footnote 39: - - John Wyman (8). - -Footnote 40: - - Greeley Harrison (9). _Also_ - Albert Robinson (45), - Alice Caperson (46), - Abel Bachmann (74). - -Footnote 41: - - Lyman Agnew (10). _Also_ - Ethel Hunter (47), - Bessie Vogel (52), - Isaac Thompson (83), - Juliette Lachine (11). - -Footnote 42: - - Juliette Lachine (11). _Also_ - Lyman Agnew (10), - Ethel Hunter (47), - Bessie Vogel (52), - Isaac Thompson (83). - -Footnote 43: - - Henry Philipps (12). _Also_ - Bridget Curley (59), - Margaret O’Brien (68), - Annie Martin (117). - -Footnote 44: - - William Twist (13). _Also_ - Lester Crane (20), - Thomas Donovan (23). - -Footnote 45: - - John Jackson (14). _Also_ - Martha Bartlett (21), - Paolo Marini (28), - Margaret O’Brien (68). - -Footnote 46: - - Pietro Martiro (15). _Also_ - Meyer Levenson (22), - Achilles Akropovlos (50). - -Footnote 47: - - Joseph Sullivan (16). - -Footnote 48: - - Gregorian Petrofski (17). _Also_ - Richard Lawlor (25), - John Bennett (34), - Julius Kantor (54), - Albert Forest (112). - -Footnote 49: - - Frederick Wescott (18). _Also_ - Martha Bartlett (21), - James Burns (56), - Victor Friedburg (108). - -Footnote 50: - - Agnes O’Neil (19). _Also_ - Michael O’Donnell (24). - John Edwards (104). - Arthur Bright (121). - -Footnote 51: - - Lester Crane (20). _Also_ - Greeley Harrison (9). - David Borofski (49). - David Collins (61). - -Footnote 52: - - Martha Bartlett (21). _Also_ - Agnes O’Neil (19), - Vivian Walker (87). - -Footnote 53: - - Meyer Levenson (22). _Also_ - Albert Forest (112). - -Footnote 54: - - Thomas Donovan (23). _Also_ - William Twist (13), - Bessie Vogel (52), - David Collins (61). - -Footnote 55: - - Michael O’Donnell (24). _Also_ - Alice Morton (1). - -Footnote 56: - - Richard Lawlor (25). _Also_ - Bessie Vogel (52), - —— —— (88). - -Footnote 57: - - John Morrill (26). - -Footnote 58: - - David Tannenbaum (27). - _Also_ Mrs. LeCompte (7), - Annie Rivers (109). - -Footnote 59: - - Paolo Marini (28). _Also_ - Flora Black (6). - -Footnote 60: - - Mario Sanzi (29). _Also_ - Stephen Green (30), - Paul Halleck (31). - -Footnote 61: - - Stephen Green (30). _Also_ - Paul Halleck (31), - Henri Lepère (105), - Ivan Rokicki (111). - -Footnote 62: - - Paul Halleck (31). - -Footnote 63: - - Margaret Neal (32). - -Footnote 64: - - Joseph Graham (33). - -Footnote 65: - - John Bennett (34). _Also_ - Alice Caperson (46), - Florence Fitzgerald (81), - Vivian Walker (87), - Arthur Bright (121). - -Footnote 66: - - Mary Coughlin (35). - -Footnote 67: - - Theresa Mullen (36). _Also_ - John Lawrence (5), - John Friedreich (77), - Gridley Ringer (78), - James Arnold (80). - -Footnote 68: - - Isaac Goldstein (37). - -Footnote 69: - - Archibald Sherry (38). - -Footnote 70: - - Caroline Davis (39). - H. F. (40). - Samuel North (41). - Elizabeth Brown (42). - Robert Allen (43). - John Hughes (44). - -Footnote 71: - - Albert Robinson (45). _Also_ - Greeley Harrison (9). - -Footnote 72: - - Alice Caperson (46). _Also_ - Florence Fitzgerald (81). - -Footnote 73: - - Ethel Hunter (47). _Also_ - Lyman Agnew (10), - Bessie Vogel (52), - Juliette Lachine (11). - -Footnote 74: - - Milton Safsky (48). _Also_ - Daniel Falvey (55). - -Footnote 75: - - David Borofski (49). _Also_ - Lester Crane (20). - -Footnote 76: - - Achilles Akropovlos (50). - -Footnote 77: - - Daniel Wheelwright (51). - -Footnote 78: - - Bessie Vogel (52). _Also_ - Lyman Agnew (10), - Juliette Lachine (11), - Ethel Hunter (47). - -Footnote 79: - - Carrie Pearson (53). - -Footnote 80: - - Julius Kantor (54). _Cf._ - James Burns (56). - Henri Lepère (105). - Frederick Stone (106). - -Footnote 81: - - Daniel Falvey (55). _Cf._ - Francis Murphy (60). - -Footnote 82: - - James Burns (56). _Also_ - Frederick Wescott (18), - Martha Bartlett (21), - Victor Friedburg (108). - -Footnote 83: - - John Summers (57). - -Footnote 84: - - Peter Burkhardt (58). - -Footnote 85: - - Bridget Curley (59). - -Footnote 86: - - Francis Murphy (60). - -Footnote 87: - - David Collins (61). - -Footnote 88: - - Joseph Buck (62). - -Footnote 89: - - Albert Fielding (63). - -Footnote 90: - - Calvin Hall (64). - -Footnote 91: - - Donald Barrie (65). - -Footnote 92: - - Lawrence Washington (66). - -Footnote 93: - - Joseph Temple (67). - -Footnote 94: - - Margaret O’Brien (68). _Also_ - Henry Phillips (12). - Bridget Curley (59). - Annie Martin (117). - -Footnote 95: - - Frank Mason (69). - -Footnote 96: - - Annie Kelly (70). - James Lauder (71). - -Footnote 97: - - James Lauder (71). - -Footnote 98: - - Margaret Green (72). - -Footnote 99: - - Marcus Chatterton (73). - -Footnote 100: - - Abel Bachmann (74). - -Footnote 101: - - Mrs. Brown (75). - -Footnote 102: - - James Seabrook (76). - -Footnote 103: - - John Friedreich (77). _Cf._ - Isaac Goldstein (37). - -Footnote 104: - - Gridley Ringer (78). - -Footnote 105: - - John Doran (79). - -Footnote 106: - - James Arnold (80). - -Footnote 107: - - Florence Fitzgerald (81). _Also_ - John Bennett (34), - Alice Caperson (46), - Vivian Walker (87), - Arthur Bright (121). - -Footnote 108: - - Frederick Estabrook (82). - -Footnote 109: - - Maj. Isaac Thompson, M.D. (83). - -Footnote 110: - - Lester Smith (84). - -Footnote 111: - - Annie Marks (85). - -Footnote 112: - - Frank Johnson (86). - -Footnote 113: - - Vivian Walker (87). - -Footnote 114: - - —— —— (88). _Cf._ - Richard Lawlor (25). - Bessie Vogel (52). - -Footnote 115: - - Margaret Tennyson (89). - John Lawrence (5). - Mary Coughlin (35). - Theresa Mullen (36). - John Friedreich (77). - Gridley Ringer (78). - James Arnold (80). - -Footnote 116: - - Joseph O’Hearn (90). - -Footnote 117: - - Levi Sussman (91). - -Footnote 118: - - Joseph Larkin (92). - -Footnote 119: - - Richard Marshall (93). - -Footnote 120: - - David Fitzpatrick (94). - -Footnote 121: - - Joseph Wilson (95). - -Footnote 122: - - Becky Bornstein (96). - Walter Heinmas (97). - Mr. Jacobs (98). - -Footnote 123: - - Walter Heinmas (97). - -Footnote 124: - - Mr. Jacobs (98). - -Footnote 125: - - James McDevitt (99). - -Footnote 126: - - Jacob Methuen (100). - -Footnote 127: - - John Baxter (101). - -Footnote 128: - - Theodosia Jewett (102). - -Footnote 129: - - A. W. (103). - -Footnote 130: - - John Edwards (104). _Cf._ - Henri Lepère (105), - Frederick Stone (106), - Arthur Bright (121), - Agnes O’Neil (19), - Paolo Marini (28). - -Footnote 131: - - Henri Lepère (105). _Cf._ - Julius Kantor (54). - -Footnote 132: - - Frederick Stone (106). - -Footnote 133: - - Greta Meyer (107). _Cf._ - John Jackson (14). - -Footnote 134: - - Victor Friedburg (108). - -Footnote 135: - - Annie Rivers (109). - -Footnote 136: - - Mr. McKenzie (110). _Cf._ - Ivan Rokicki (111). - -Footnote 137: - - Ivan Rokicki (111). - -Footnote 138: - - Albert Forest (112). _Cf._ - Gussie Silverman (113), - Walter Henry (114), - William Rosetti (116), - Annie Martin (117), - Levi Morovitz (122), - Peter Burkhardt (58). - -Footnote 139: - - Gussie Silverman (113). - -Footnote 140: - - Walter Henry (114). - -Footnote 141: - - Henry Ryan (115). - -Footnote 142: - - William Rosetti (116). - -Footnote 143: - - Annie Martin (117). _Cf._ - William Roberts (118). - -Footnote 144: - - William Roberts (118). - John Silver (119). - -Footnote 145: - - John Silver (119). - -Footnote 146: - - James McGinnis (120). - -Footnote 147: - - Arthur Bright (121). _Cf._ - Levi Morovitz (122), - John Bennett (34). - -Footnote 148: - - Levi Morovitz (122). - -Footnote 149: - - Robert Matthews (23). _Cf._ - Isaac Goldstein (37). - -Footnote 150: - - For cases in which, without autopsy we have risked the diagnosis - neurosyphilis _in the absence of W. R. in serum or fluid_, see William - Twist (13), Frederick Wescott (18), Martha Bartlett (21), Thomas - Donovan (23), Paolo Marini (28), Margaret Neal (32), Bridget Curley - (59), Victor Friedburg (108), Ivan Rokicki (111). - -Footnote 151: - - From Mallory and Wright: Manual of Laboratory Technique. - -Footnote 152: - - Bruck. Münch. med. Wochen. Jan. 22, 1917. - -Footnote 153: - - Smith and Solomon. Boston Medical and Surgical Jour. - -Footnote 154: - - Bruck: Journal of American Medical Association, Vol. lviii, No. 12, - March 24, 1917, p. 944. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Pg. 456, added footnote anchor for footnote A. - 2. Silently corrected typographical errors and variations in spelling. - 3. Archaic, non-standard, and uncertain spellings retained as printed. - 4. Footnotes were re-indexed using numbers and collected together at - the end of the last chapter. - 5. Enclosed italics font in _underscores_. - 6. Enclosed bold font in =equals=. - 7. Subscripts are denoted by an underscore before a series of - subscripted characters enclosed in curly braces, e.g. H_{2}O. - - - - - -End of the Project Gutenberg EBook of Neurosyphilis, by -Harry Caesar Solomon and Elmer Ernest Southard - -*** END OF THIS PROJECT GUTENBERG EBOOK NEUROSYPHILIS *** - -***** This file should be named 63313-0.txt or 63313-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/3/3/1/63313/ - -Produced by Richard Tonsing, Bryan Ness, and the Online -Distributed Proofreading Team at https://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive/Canadian Libraries) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for the eBooks, unless you receive -specific permission. If you do not charge anything for copies of this -eBook, complying with the rules is very easy. You may use this eBook -for nearly any purpose such as creation of derivative works, reports, -performances and research. They may be modified and printed and given -away--you may do practically ANYTHING in the United States with eBooks -not protected by U.S. copyright law. Redistribution is subject to the -trademark license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country outside the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - This eBook is for the use of anyone anywhere in the United States and - most other parts of the world at no cost and with almost no - restrictions whatsoever. You may copy it, give it away or re-use it - under the terms of the Project Gutenberg License included with this - eBook or online at www.gutenberg.org. If you are not located in the - United States, you'll have to check the laws of the country where you - are located before using this ebook. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm web site -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from both the Project Gutenberg Literary Archive Foundation and The -Project Gutenberg Trademark LLC, the owner of the Project Gutenberg-tm -trademark. Contact the Foundation as set forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org - - - -Section 3. Information about the Project Gutenberg Literary Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's principal office is in Fairbanks, Alaska, with the -mailing address: PO Box 750175, Fairbanks, AK 99775, but its -volunteers and employees are scattered throughout numerous -locations. Its business office is located at 809 North 1500 West, Salt -Lake City, UT 84116, (801) 596-1887. Email contact links and up to -date contact information can be found at the Foundation's web site and -official page at www.gutenberg.org/contact - -For additional contact information: - - Dr. Gregory B. Newby - Chief Executive and Director - gbnewby@pglaf.org - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without wide -spread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg Web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works. - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our Web site which has the main PG search -facility: www.gutenberg.org - -This Web site includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. - diff --git a/old/63313-0.zip b/old/63313-0.zip Binary files differdeleted file mode 100644 index 549f63c..0000000 --- a/old/63313-0.zip +++ /dev/null diff --git a/old/63313-h.zip b/old/63313-h.zip Binary files differdeleted file mode 100644 index c3db669..0000000 --- a/old/63313-h.zip +++ /dev/null diff --git a/old/63313-h/63313-h.htm b/old/63313-h/63313-h.htm deleted file mode 100644 index 41fb50f..0000000 --- a/old/63313-h/63313-h.htm +++ /dev/null @@ -1,24089 +0,0 @@ -<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" - "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> -<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> - <head> - <meta http-equiv="Content-Type" content="text/html;charset=UTF-8" /> - <title>The Project Gutenberg eBook of Neurosyphilis, by E. E. Southard</title> - <link rel="coverpage" href="images/cover.jpg" /> - <style type="text/css"> - body { margin-left: 8%; margin-right: 10%; } - h1 { text-align: center; font-weight: bold; font-size: xx-large; } - h2 { text-align: center; font-weight: bold; font-size: x-large; } - .pageno { right: 1%; font-size: x-small; background-color: inherit; color: silver; - text-indent: 0em; text-align: right; position: absolute; - border: thin solid silver; padding: .1em .2em; font-style: normal; - font-variant: normal; font-weight: normal; text-decoration: none; } - p { text-indent: 0; margin-top: 0.5em; margin-bottom: 0.5em; text-align: justify; } - sup { vertical-align: top; font-size: 0.6em; } - .fss { font-size: 75%; } - .sc { font-variant: small-caps; } - .large { font-size: large; } - .xlarge { font-size: x-large; } - .small { font-size: small; } - .lg-container-b { text-align: center; } - @media handheld { .lg-container-b { clear: both; } } - .lg-container-l { text-align: left; } - @media handheld { .lg-container-l { clear: both; } } - .lg-container-r { text-align: right; } - @media handheld { .lg-container-r { clear: both; } } - .linegroup { display: inline-block; text-align: left; } - @media handheld { .linegroup { display: block; margin-left: 1.5em; } } - .linegroup .group { margin: 1em auto; } - .linegroup .line { text-indent: -3em; padding-left: 3em; } - div.linegroup > :first-child { margin-top: 0; } - .linegroup .in1 { padding-left: 3.5em; } - .linegroup .in12 { padding-left: 9.0em; } - .linegroup .in13 { padding-left: 9.5em; } - .linegroup .in16 { padding-left: 11.0em; } - .linegroup .in2 { padding-left: 4.0em; } - .linegroup .in20 { padding-left: 13.0em; } - .linegroup .in24 { padding-left: 15.0em; } - .linegroup .in28 { padding-left: 17.0em; } - .linegroup .in36 { padding-left: 21.0em; } - .linegroup .in4 { padding-left: 5.0em; } - .linegroup .in5 { padding-left: 5.5em; } - .linegroup .in8 { padding-left: 7.0em; } - .index li {text-indent: -1em; padding-left: 1em; } - .index ul {list-style-type: none; padding-left: 0; } - ul.index {list-style-type: none; padding-left: 0; } - .dl_1 dd { text-align: left; padding-top: .5em; margin-left: 6.2em; - text-indent: -1em; } - .dl_1 dt { float: left; clear: left; text-align: left; width: 5.0em; - padding-top: .5em; padding-right: .5em; } - .dl_2 dd { text-align: left; padding-top: .5em; padding-left: .5em; - margin-left: 2.7em; text-indent: -1em; } - .dl_2 dt { float: left; clear: left; text-align: right; width: 1.5em; - padding-top: .5em; padding-right: .5em; } - .ol_1 li {padding-left: 1em; text-indent: -1em; } - @media handheld { .dl_1 dt { float: left; clear: left; text-align: left; - width: 5.0em; padding-top: .5em; padding-right: .5em; } } - @media handheld { .dl_2 dt { float: left; clear: left; text-align: right; - width: 1.5em; padding-top: .5em; padding-right: .5em; } } - dl.dl_1 {margin-left: 2.78%; margin-right: 2.78%; margin-top: .5em; - margin-bottom: .5em; } - dl.dl_2 { margin-top: .5em; margin-bottom: .5em; } - ol.ol_1 {padding-left: 0; margin-left: 2.78%; margin-top: .5em; - margin-bottom: .5em; list-style-type: decimal; } - div.footnote > :first-child { margin-top: 1em; } - div.footnote p { text-indent: 1em; margin-top: 0.25em; margin-bottom: 0.25em; } - div.pbb { page-break-before: always; } - hr.pb { border: none; border-bottom: thin solid; margin-bottom: 1em; } - @media handheld { hr.pb { display: none; } } - .chapter { clear: both; page-break-before: always; } - .figcenter { clear: both; max-width: 100%; margin: 2em auto; text-align: center; } - .figleft { clear: left; float: left; max-width: 100%; margin: 0.5em 1em 1em 0; - text-align: left; } - .figright { clear: right; float: right; max-width: 100%; margin: 0.5em 0 1em 1em; - text-align: right; } - div.figcenter p { text-align: center; text-indent: 0; } - div.figleft p { text-align: center; text-indent: 0; } - div.figright p { text-align: center; text-indent: 0; } - @media handheld { .figleft { float: left; } } - @media handheld { .figright { float: right; } } - .figcenter img { max-width: 100%; height: auto; } - .figleft img { max-width: 100%; height: auto; } - .figright img { max-width: 100%; height: auto; } - .id001 { width:30%; } - .id002 { width:15%; } - .id003 { width:15%; } - .id004 { width:60%; } - .id005 { width:30%; } - .id006 { width:50%; } - @media handheld { .id001 { margin-left:35%; width:30%; } } - @media handheld { .id002 { margin-left:42%; width:15%; } } - @media handheld { .id003 { width:15%; } } - @media handheld { .id004 { margin-left:20%; width:60%; } } - @media handheld { .id005 { width:30%; } } - @media handheld { .id006 { margin-left:25%; width:50%; } } - .ic002 { width:100%; } - .ic004 { width:100%; } - .ic006 { width:100%; } - div.ic002 p { text-align:justify; } - div.ic006 p { text-align:right; } - .ig001 { width:100%; } - .table0 { margin: auto; margin-top: 2em; } - .table1 { margin: auto; margin-top: 2em; width: 80%; } - .table2 { margin: auto; margin-top: 2em; border-collapse: collapse; } - .table3 { margin: auto; } - .bbt { border-bottom: thin solid; } - .brm { border-right: medium solid; } - .nf-center { text-align: center; } - .nf-center-c0 { text-align: left; margin: 0.5em 0; } - .c000 { margin-top: 0.5em; margin-bottom: 0.5em; } - .c001 { margin-top: 4em; } - .c002 { margin-top: 2em; } - .c003 { margin-top: 1em; } - .c004 { page-break-before: always; margin-top: 4em; } - .c005 { page-break-before:auto; margin-top: 4em; } - .c006 { margin-top: 2em; text-indent: 1em; margin-bottom: 0.25em; } - .c007 { text-indent: 1em; margin-top: 0.25em; margin-bottom: 0.25em; } - .c008 { vertical-align: top; text-align: right; padding-right: 1em; } - .c009 { vertical-align: top; text-align: left; text-indent: -1em; - padding-left: 1em; padding-right: 1em; } - .c010 { vertical-align: bottom; text-align: right; } - .c011 { vertical-align: top; text-align: left; text-indent: -1em; - padding-left: 1.5em; padding-right: 1em; } - .c012 { font-size: .9em; } - .c013 { margin-left: 2.78%; margin-right: 2.78%; text-indent: 0; margin-top: 2em; - margin-bottom: 0.25em; } - .c014 { text-decoration: none; } - .c015 { margin-left: 5.56%; text-indent: 1em; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c016 { margin-left: 2.78%; margin-right: 2.78%; text-indent: 0; margin-top: 2em; } - .c017 { margin-left: 2.78%; margin-right: 2.78%; text-indent: 0; } - .c018 { margin-left: 2.78%; margin-right: 2.78%; text-indent: 0; text-align: right; - } - .c019 { text-indent: 0; margin-top: 2em; margin-bottom: 0.25em; } - .c020 { text-align: center; } - .c021 { vertical-align: top; text-align: left; } - .c022 { text-align: right; } - .c023 { vertical-align: top; text-align: center; } - .c024 { vertical-align: top; text-align: left; padding-right: 1em; } - .c025 { vertical-align: bottom; text-align: left; } - .c026 { font-size: .9em; text-indent: 1em; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c027 { margin-left: 8.33%; text-indent: -2.78%; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c028 { margin-left: 8.33%; text-indent: 1em; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c029 { vertical-align: top; text-align: center; padding-left: .5em; - padding-right: .5em; } - .c030 { vertical-align: top; text-align: left; text-indent: -1em; - padding-left: 1.5em; padding-right: .5em; } - .c031 { vertical-align: top; text-align: right; padding-left: .5em; - padding-right: .5em; } - .c032 { margin-left: 8.33%; text-indent: -2.78%; margin-top: 2em; - margin-bottom: 0.25em; } - .c033 { vertical-align: top; text-align: right; } - .c034 { margin-left: 11.11%; margin-right: 2.78%; text-indent: 0; margin-top: 2em; - } - .c035 { margin-left: 11.11%; margin-right: 2.78%; text-indent: 0; } - .c036 { margin-left: 11.11%; margin-right: 2.78%; text-indent: 0; - text-align: right; } - .c037 { margin-left: 8.33%; margin-top: 2em; text-indent: 1em; - margin-bottom: 0.25em; } - .c038 { margin-left: 8.33%; text-indent: -2.78%; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c039 { margin-left: 5.56%; } - .c040 { vertical-align: top; text-align: center; padding-right: 1em; } - .c041 { vertical-align: bottom; text-align: center; padding-right: 1em; } - .c042 { vertical-align: bottom; text-align: center; } - .c043 { vertical-align: bottom; text-align: right; padding-right: 1em; } - .c044 { font-size: .9em; } - .c045 { margin-left: 8.33%; } - .c046 { margin-top: .5em; } - .c047 { margin-left: 5.56%; text-indent: 0; margin-top: 0.25em; - margin-bottom: 0.25em; } - .c048 { margin-left: 5.56%; margin-right: 2.78%; text-indent: 0; - margin-top: 0.25em; margin-bottom: 0.25em; } - .c049 { margin-right: 2.78%; } - .c050 { vertical-align: top; text-align: left; text-indent: -1em; - padding-left: 1em; } - .c051 { text-align: left; } - .c052 { border: none; border-bottom: thin solid; width: 10%; margin-left: 0; - margin-top: 1em; text-align: left; } - div.tnotes { padding-left:1em;padding-right:1em;background-color:#E3E4FA; - border:1px solid silver; margin:2em 10% 0 10%; font-family: Georgia, serif; - } - .covernote { visibility: hidden; display: none; } - div.tnotes p { text-align:left; } - @media handheld { .covernote { visibility: visible; display: block;} } - .figcenter,.figleft,.figright {font-size: .9em; page-break-inside: avoid; - max-height: 100%; max-width: 100%; } - p, div { clear: both; } - .footnote {font-size: .9em; } - div.footnote p {text-indent: 2em; margin-bottom: .5em; } - .section { clear: both; page-break-before: always; } - .ol_1 li {font-size: .9em; } - @media handheld {.ol_1 li {padding-left: 1em; text-indent: 0em; } } - body {font-family: serif, 'DejaVu Sans'; text-align: justify; } - table {font-size: .9em; padding: 1.5em .5em 1em; page-break-inside: avoid; } - div.titlepage {text-align: center; page-break-before: always; - page-break-after: always; } - div.titlepage p {text-align: center; text-indent: 0em; font-weight: bold; - line-height: 1.5; margin-top: 3em; } - .ph2 { text-indent: 0em; font-weight: bold; font-size: x-large; margin: .75em auto; - page-break-before: always; } - .box,.chart {border-style: solid; border-width: medium; padding: 1em; margin: 1em; - page-break-inside: avoid; max-width: 100%;page-break-before: always; } - .chart {page-break-after: always; } - @media handheld {.chart {font-size: .7em;} } - .vincula{ text-decoration: overline; } - .fraction {display: inline-block; vertical-align: middle; text-align: center; - font-size: smaller; text-indent: 0; } - .left {text-align: left; display: block; margin-left: 0em; margin-right: auto; - max-width: 50%;top: 1em; } - .right {text-align: right; display: block; margin-left: auto; margin-right: 0em; - max-width: 50%; } - </style> - </head> - <body> - - -<pre> - -The Project Gutenberg EBook of Neurosyphilis, by -Harry Caesar Solomon and Elmer Ernest Southard - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Neurosyphilis - Modern Systematic Diagnosis and Treatment Presented In One - Hundred And Thirty-Seven Case Histories - -Author: Harry Caesar Solomon - Elmer Ernest Southard - -Release Date: September 27, 2020 [EBook #63313] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK NEUROSYPHILIS *** - - - - -Produced by Richard Tonsing, Bryan Ness, and the Online -Distributed Proofreading Team at https://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive/Canadian Libraries) - - - - - - -</pre> - - -<div class='tnotes covernote'> - -<p class='c000'><b>Transcriber’s Note:</b></p> - -<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p> - -</div> - -<div class='nf-center-c0'> -<div class='nf-center c001'> - <div><span class='xlarge'>THE</span></div> - <div><span class='xlarge'>CASE HISTORY SERIES</span></div> - <div class='c002'>CASE HISTORIES IN MEDICINE</div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>Richard C. Cabot</span>, M.D.</span></div> - <div><span class='small'>Third edition, revised and enlarged</span></div> - <div class='c002'>CASE HISTORIES IN PEDIATRICS</div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>John Lovett Morse</span>, M.D.</span></div> - <div><span class='small'>Second edition, revised and enlarged</span></div> - <div class='c002'>ONE HUNDRED SURGICAL PROBLEMS</div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>James G. Mumford</span>, M.D.</span></div> - <div><span class='small'>Second Printing</span></div> - <div class='c002'>CASE HISTORIES IN NEUROLOGY</div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>E. W. Taylor</span>, M.D.</span></div> - <div><span class='small'>Second Printing</span></div> - <div class='c002'>CASE HISTORIES IN OBSTETRICS</div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>Robert L. DeNormandie</span>, M.D.</span></div> - <div><span class='small'>Second Edition</span></div> - <div class='c002'>CASE HISTORIES IN DISEASES OF WOMEN</div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>Charles M. Green</span>, M.D.</span></div> - <div class='c003'>NEUROSYPHILIS</div> - <div>MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT</div> - <div><span class='small'>Presented in one hundred and thirty-seven Case Histories</span></div> - <div><span class='small'>BY</span></div> - <div><span class='small'><span class='sc'>E. E. Southard, M.D., Sc.D.</span></span></div> - <div><span class='small'>AND</span></div> - <div><span class='small'><span class='sc'>H. C. Solomon</span>, M.D.</span></div> - <div class='c003'><span class='small'>Being Monograph Number Two of the Psychopathic Hospital, Boston, Massachusetts. (Monograph Number One was A Point Scale for Measuring Mental Ability by Robert M. Yerkes, James W. Bridges and Rose S. Hardwick. Published by Warwick and York. Baltimore 1915.)</span></div> - </div> -</div> - -<div class='figcenter id001'> -<img src='images/i_frontis.jpg' alt='METCHNIKOFF WASSERMANN EHRLICH SCHAUDINN NOGUCHI' class='ig001' /> -</div> - -<div class='titlepage'> - -<div> - <h1 class='c004'>NEUROSYPHILIS<br /> <span class='xlarge'>MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT</span><br /> <span class='large'>PRESENTED IN ONE HUNDRED AND THIRTY-SEVEN CASE HISTORIES</span></h1> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div>BY</div> - <div class='c003'><span class='large'>E. E. SOUTHARD, M.D., Sc.D.,</span></div> - <div class='c003'><span class='small'>Bullard Professor of Neuropathology, Harvard Medical School; Pathologist, Massachusetts Commission on Mental Diseases; Director, Psychopathic Department, Boston State Hospital; Vice-President, American Medico-Psychological Association</span></div> - <div class='c003'>AND</div> - <div class='c003'><span class='large'>H. C. SOLOMON, M.D.,</span></div> - <div class='c003'><span class='small'>Instructor in Neuropathology and in Psychiatry, Harvard Medical School; Special Investigator in Brain Syphilis, Massachusetts Commission on Mental Diseases; Acting Chief-of-Staff, Psychopathic Department, Boston State Hospital</span></div> - <div class='c002'>WITH AN INTRODUCTION BY</div> - <div class='c003'>JAMES JACKSON PUTNAM, M.D.,</div> - <div class='c003'><span class='small'>Professor Emeritus of Diseases of the Nervous System, Harvard Medical School</span></div> - <div class='c002'><span class='small'>BY VOTE OF THE TRUSTEES OF THE BOSTON STATE HOSPITAL</span></div> - <div class='c003'>MONOGRAPH NUMBER TWO</div> - <div class='c003'><span class='small'>OF THE</span></div> - <div class='c003'>PSYCHOPATHIC HOSPITAL BOSTON, MASSACHUSETTS</div> - <div class='c002'>BOSTON</div> - <div class='c003'>W. M. LEONARD, <span class='sc'>Publisher</span></div> - <div class='c003'>1917</div> - </div> -</div> - -</div> - -<div class='nf-center-c0'> -<div class='nf-center c001'> - <div><span class='small'><em>Copyright, 1917.</em></span></div> - <div><span class='small'><em>By W. M. Leonard</em></span></div> - </div> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c001'> - <div><strong>In</strong></div> - <div class='c003'>MASSACHUSETTS</div> - <div class='c003'>A STATE THAT</div> - <div class='c003'>BOTH TOLERATES AND FOSTERS</div> - <div class='c003'>RESEARCH</div> - </div> -</div> - -<div class='pbb'> - <hr class='pb c003' /> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_5'>5</span> - <h2 class='c005'>PREFACE</h2> -</div> - -<p class='c006'>This book is written primarily for the general practitioner -and secondarily for the syphilographer, the neurologist, -and the psychiatrist. Our material is drawn chiefly from a -psychopathic hospital, that modern type of institution in -which the mental problems of general medical practice come -to a diagnostic head weeks, months, or years before the -asylum is thought of.</p> - -<p class='c007'>It is this peculiar nature of psychopathic hospital material—a -concentrated essence of the most difficult daily problems -of general practice—that brings together such an apparent -<i><span lang="fr" xml:lang="fr">mélange</span></i> of cases as are here described, ranging from mild -single-symptom diseases like extraocular palsy up to genuine -magazines of symptoms as in general paresis; from feeblemindedness, -apparently simple, up to apparently simple -dotage, both feeblemindedness and dotage really syphilitic; -from the mind-clear tabetic to the maniacal or deluded -subject who looks physically perfectly fit; from the early -secondaries to the late tertiaries or so-called quaternaries; -from peracute to the most chronic of known conditions; -from the most delicate character changes to the profoundest -ruin of the psyche.</p> - -<p class='c007'>Although the bulk of our case-material is drawn from general -practice through the thinnest of intermediary membranes, -the psychopathic hospital, yet we have tried to depict the -whole story by presenting enough autopsied cases from district -state hospitals to show exactly what treatment has to face. -Nor have we hesitated to insert cases in which treatment -has failed.</p> - -<p class='c007'>In addition to (<em>a</em>) the Psychopathic Hospital, Boston, -group of incipient, doubtful, obscure, or complicated cases -(the early clinical group) and (<em>b</em>) the Danvers State Hospital, -Hathorne, group of longer-standing, committed, fatal cases -<span class='pageno' id='Page_6'>6</span>(the finished or autopsied group) we present (<em>c</em>) a miscellaneous -group of cases, including many from private neurological -or psychiatric practice. No doubt those familiar with -Boston medicine will see traces of the teaching of our former -chiefs, notably Professors James Jackson Putnam and Edward -Wyllys Taylor. We are obliged to them for some well-observed -cases.</p> - -<p class='c007'>We have dedicated our work to the Commonwealth, but -perhaps we should more specifically ascribe to the Massachusetts -Commission on Mental Diseases (formerly the -State Board of Insanity) the spirit that permitted our special -study of neurosyphilis treatment. To these authorities, -who have countenanced and encouraged a somewhat costly -piece of special work since 1914, we offer our thanks, hoping -that other states will be one by one stimulated to the state-endowment -of research. States doing full duty by research -can be counted on one hand.</p> - -<p class='c007'>To our Psychopathic Hospital colleagues and the internes, -and especially to Drs. Myrtelle M. Canavan and Douglas -A. Thom of the Commission’s Pathological Service, we also -offer our best thanks.</p> - -<p class='c007'>The Danvers traditions are tangible here: cases of Drs. A. -M. Barrett, H. A. Cotton, H. W. Mitchell, H. M. Swift, and -others are presented. We have been especially aided by the -more recent work of Dr. Lawson G. Lowrey.</p> - -<p class='c007'>Nor should we have been able to present our samples of -brain correlation without drawing on the collection arranged -and analyzed by Dr. Annie E. Taft, Custodian, Harvard Department -of Neuropathology. The photographs, part of a -collection of brain photographs now numbering over 10,000 -representing 700 brains of all sorts, were made by Mr. Herbert -W. Taylor.</p> - -<p class='c007'>The Wassermann testing work has been done by Dr. W. -A. Hinton of the State Board of Health. Dr. Hinton himself -wrote out the text description of the Wassermann method. -The method of his laboratory is held to the standards of control -set by previous chiefs, viz. by Professor F. P. Gay, who -brought immunological methods direct from the laboratory -of Bordet (whose method the Wassermann method essentially -<span class='pageno' id='Page_7'>7</span>is), Prof. W. P. Lucas, and the late Dr. Emma W. D. Mooers, -who had assisted Plaut in his first work with the Wassermann -method in Kraepelin’s Munich Clinic.</p> - -<p class='c007'>The material combed by us to secure this illustrative series -amounts to over 2000 cases of syphilis of the nervous system, -including over 100 autopsies in all types of case. We have -presented these with very varying fulness, chiefly to illustrate -the contentions at the heads of the case-descriptions.</p> - -<p class='c007'>In using the book, we suggest early reference to the Summary -and Key, where for convenience are placed numerous -cross-references permitting extended illustration of almost -every proposition from several cases.</p> - -<p class='c007'>We have not made a large feature of the Medicolegal and -Social section. This kind of thing well deserves a volume by -itself, with all the legal and social-service implications drawn -out in their amazing richness and detail. The social service -slogan, “A paretic’s child is a syphilitic’s child” has already -accomplished a great deal of good in our local world. Some -day we may not be compelled to <em>drive</em> the paretic’s spouse and -offspring to the Wassermann serum test! The general practitioner -must help here.</p> - -<p class='c007'>A note on the Treatment section. This is manifestly not -the last word or even, we hope, our own last word, since the -systematic work of the Massachusetts Commission must be -kept up for some years to get a reliable verdict. Some of -the results give rise to greater optimism than has prevailed -in asylum circles, especially re general paresis. We are confident -that <em>no one can now successfully make a differential -diagnosis between the paretic and the diffuse non-paretic forms -of neurosyphilis in many phases of either disease</em>, even with all -laboratory refinements. If this be so, it is <em>improper not to -give the full benefits of modern treatment to all cases in which -the diagnosis remains doubtful</em> between the paretic and the -diffuse non-paretic forms of neurosyphilis. We ourselves advocate -modern treatment, not only in the diffuse, but also -in early paretic forms of neurosyphilis.</p> - -<p class='c007'>It would have been out of place in a book in this Case -History Series to have dealt extensively with the history of -our topic. We have compensated inadequately for this lack -<span class='pageno' id='Page_8'>8</span>by a few remarks at the head of the Summary and Key. -We are, like all others in the field, under the inevitable obligation -to Nonne of Hamburg, whose great work has gone into -three editions, the second of which has appeared in English -translation (Nonne’s Syphilis of the Nervous System, C. R. -Ball, translator). Mott’s work, embodied in a large volume -of the Power-Murphy System of Syphilis, has also been attentively -consulted, as well as the various systematic works -on neurology and psychiatry. The topic of Neurosyphilis is -getting wide and appropriate attention in this country through -special journals, both those dealing with nervous and mental -diseases, and those dealing with syphilis. Syphilis is in a -sense the making of psychiatry and will go far to pushing -psychiatry into general practice.</p> - -<p class='c007'>At the last moment we have been led to deviate from our -plan of presenting only local cases familiar and accessible to -us. In a section on Neurosyphilis and the War, we present -excerpts and digests of English, French, and German cases -of neurosyphilis that have appeared in association with the -war. Our own country has not suffered greatly as yet either -from the lighting up of neurosyphilis under martial stress or -from the immediate or remote effects of syphilis obtained -in the unholy congress of Mars and Venus. Space forbids a -large collection of these martial cases, but, as will be seen, a -fair sample of problems is presented.</p> - -<p class='c007'>Speaking for the moment as the senior author of this book, -I wish to say that, were it not for the energy, industry, and -ingenuity of the junior author, Dr. H. C. Solomon, the book -would not have been written. Nor, in all probability, would -the systematic work of the Commonwealth on neurosyphilis -and its treatment ever have been begun. I can also accord -the highest praise to Mrs. Maida Herman Solomon for her -social-service work in this new field.</p> - -<p class='c007'>Perhaps, in closing, we owe an apology to John Milton for -our borrowings from the two Paradises. Had he known -much about syphilis, Milton might have written still stronger -mottoes for us.</p> - -<div class='lg-container-r'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>E. E. Southard</span></div> - </div> - </div> -</div> - -<div class='lg-container-l'> - <div class='linegroup'> - <div class='group'> - <div class='line in2'><span class='sc'>74 Fenwood Road</span></div> - <div class='line'><em>Boston, Massachusetts</em></div> - </div> - </div> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_9'>9</span> - <h2 class='c005'>TABLE OF CONTENTS</h2> -</div> - -<table class='table0' summary=''> - <tr> - <th class='c008'></th> - <th class='c009'> </th> - <th class='c010'><span class='sc'>Page</span></th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section I. The Nature and Forms of Syphilis of the Nervous System (Neurosyphilis). Cases 1 To 8</span></td> - <td class='c010'><a href='#Page_17'>17</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <th class='c008'><span class='sc'>Case</span></th> - <th class='c009'> </th> - <th class='c010'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>1.</td> - <td class='c009'>Paradigm: protean symptoms, nervous and mental. Autopsy, with meningeal, parenchymatous, and vascular lesions.</td> - <td class='c010'><a href='#Page_17'>17</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>2.</td> - <td class='c009'>Tabes dorsalis (tabetic neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_31'>31</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>3.</td> - <td class='c009'>General paresis (paretic neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_37'>37</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>4.</td> - <td class='c009'>Cerebral thrombosis (vascular neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_42'>42</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>5.</td> - <td class='c009'>Juvenile paresis (juvenile paretic neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_45'>45</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>6.</td> - <td class='c009'>Extraocular palsy (focal meningeal neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_50'>50</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>7.</td> - <td class='c009'>Gumma of brain (gummatous neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_53'>53</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>8.</td> - <td class='c009'><em>Meningitis hypertrophica cervicalis</em> (gummatous neurosyphilis). Autopsy</td> - <td class='c010'><a href='#Page_56'>56</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section II. The Systematic Diagnosis of the Forms of Neurosyphilis Cases 9 To 38</span></td> - <td class='c010'><a href='#Page_63'>63</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <th class='c008'><span class='sc'>Case</span></th> - <th class='c009'> </th> - <th class='c010'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>9.</td> - <td class='c009'>Neurasthenia <i><span lang="la" xml:lang="la">versus</span></i> neurosyphilis</td> - <td class='c010'><a href='#Page_63'>63</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>10.</td> - <td class='c009'>Paretic neurosyphilis <i><span lang="la" xml:lang="la">versus</span></i> manic-depressive psychosis</td> - <td class='c010'><a href='#Page_68'>68</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>11.</td> - <td class='c009'>Neurosyphilis <i><span lang="la" xml:lang="la">versus</span></i> manic-depressive psychosis</td> - <td class='c010'><a href='#Page_71'>71</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>12.</td> - <td class='c009'>Dementia praecox <i><span lang="la" xml:lang="la">versus</span></i> neurosyphilis. Autopsy</td> - <td class='c010'><a href='#Page_74'>74</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>13.</td> - <td class='c009'>Neurosyphilis: negative Wassermann reaction (W. R.) of serum</td> - <td class='c010'><a href='#Page_77'>77</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>14.</td> - <td class='c009'>Diffuse neurosyphilis: six tests apt to run mild</td> - <td class='c010'><a href='#Page_80'>80</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>15.</td> - <td class='c009'>Paretic neurosyphilis: six tests strong</td> - <td class='c010'><a href='#Page_85'>85</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>16.</td> - <td class='c009'>Taboparesis (tabetic neurosyphilis): tests like those of paresis</td> - <td class='c010'><a href='#Page_92'>92</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>17.</td> - <td class='c009'>Paretic <i><span lang="la" xml:lang="la">versus</span></i> diffuse neurosyphilis: confusion <i><span lang="la" xml:lang="la">re</span></i> tests</td> - <td class='c010'><a href='#Page_97'>97</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>18.</td> - <td class='c009'>Vascular neurosyphilis: positive serum, negative fluid W. R.</td> - <td class='c010'><a href='#Page_101'>101</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>19.</td> - <td class='c009'>Seizures in diffuse neurosyphilis</td> - <td class='c010'><a href='#Page_103'>103</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>20.</td> - <td class='c009'>Seizures in paretic neurosyphilis</td> - <td class='c010'><a href='#Page_106'>106</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>21.</td> - <td class='c009'>Aphasia in paretic neurosyphilis</td> - <td class='c010'><a href='#Page_111'>111</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>22.</td> - <td class='c009'>Aphasia in paretic neurosyphilis</td> - <td class='c010'><a href='#Page_115'>115</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>23.</td> - <td class='c009'>Remission in paretic neurosyphilis</td> - <td class='c010'><a href='#Page_117'>117</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>24.</td> - <td class='c009'>Remission in diffuse neurosyphilis</td> - <td class='c010'><a href='#Page_122'>122</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>25.</td> - <td class='c009'><em>Paresis sine paresi</em></td> - <td class='c010'><a href='#Page_126'>126</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>26.</td> - <td class='c009'>Paretic neurosyphilis. Autopsy</td> - <td class='c010'><a href='#Page_131'>131</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>27.</td> - <td class='c009'>Gummatous neurosyphilis. Operation</td> - <td class='c010'><a href='#Page_137'>137</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>28.</td> - <td class='c009'>Extraocular palsy (cranial neurosyphilis)</td> - <td class='c010'><a href='#Page_140'>140</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>29.</td> - <td class='c009'>Tabes dorsalis (tabetic neurosyphilis): six tests apt to run mild</td> - <td class='c010'><a href='#Page_141'>141</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>30.</td> - <td class='c009'>Tabetic neurosyphilis, clinically atypical</td> - <td class='c010'><a href='#Page_143'>143</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>31.</td> - <td class='c009'>Cervical tabes</td> - <td class='c010'><a href='#Page_146'>146</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>32.</td> - <td class='c009'>Erb’s syphilitic spastic paraplegia</td> - <td class='c010'><a href='#Page_147'>147</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>33.</td> - <td class='c009'>Syphilitic muscular atrophy</td> - <td class='c010'><a href='#Page_149'>149</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'><span class='pageno' id='Page_10'>10</span>34.</td> - <td class='c009'>Neurosyphilis of the secondary period</td> - <td class='c010'><a href='#Page_151'>151</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>35.</td> - <td class='c009'>Juvenile paretic neurosyphilis: optic atrophy</td> - <td class='c010'><a href='#Page_154'>154</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>36.</td> - <td class='c009'>Juvenile paretic neurosyphilis</td> - <td class='c010'><a href='#Page_157'>157</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>37.</td> - <td class='c009'>Simple feeblemindedness, syphilitic</td> - <td class='c010'><a href='#Page_159'>159</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>38.</td> - <td class='c009'>Juvenile tabes</td> - <td class='c010'><a href='#Page_161'>161</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section III. Puzzles and Errors in the Diagnosis of Neurosyphilis (Including Non-syphilitic Cases). Cases</span> 39–82</td> - <td class='c010'><a href='#Page_165'>165</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <th class='c008'><span class='sc'>Case</span></th> - <th class='c009'> </th> - <th class='c010'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>39.</td> - <td class='c009'>Paretic <i><span lang="la" xml:lang="la">versus</span></i> diffuse neurosyphilis. Autopsy</td> - <td class='c010'><a href='#Page_165'>165</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>40.</td> - <td class='c009'>Paretic <i><span lang="la" xml:lang="la">versus</span></i> vascular neurosyphilis, cerebellar. Autopsy</td> - <td class='c010'><a href='#Page_169'>169</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>41.</td> - <td class='c009'>Paretic <i><span lang="la" xml:lang="la">versus</span></i> vascular neurosyphilis, cerebellar. Autopsy</td> - <td class='c010'><a href='#Page_172'>172</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>42.</td> - <td class='c009'>Tabetic combined with vascular neurosyphilis. Autopsy.</td> - <td class='c010'><a href='#Page_175'>175</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>43.</td> - <td class='c009'>Tabetic neurosyphilis: mental symptoms, non-paretic. Autopsy</td> - <td class='c010'><a href='#Page_177'>177</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>44.</td> - <td class='c009'>Cerebral gliosis. Autopsy</td> - <td class='c010'><a href='#Page_180'>180</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>45.</td> - <td class='c009'>Neurasthenia <i><span lang="la" xml:lang="la">versus</span></i> neurosyphilis</td> - <td class='c010'><a href='#Page_183'>183</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>46.</td> - <td class='c009'>Hysteria. Neurosyphilis of the secondary period</td> - <td class='c010'><a href='#Page_185'>185</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>47.</td> - <td class='c009'>Manic-depressive psychosis <i><span lang="la" xml:lang="la">versus</span></i> paretic neurosyphilis</td> - <td class='c010'><a href='#Page_187'>187</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>48.</td> - <td class='c009'>Cerebral tumor</td> - <td class='c010'><a href='#Page_190'>190</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>49.</td> - <td class='c009'>Early post-infective paretic neurosyphilis</td> - <td class='c010'><a href='#Page_192'>192</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>50.</td> - <td class='c009'>Atypical paretic neurosyphilis, hemitremor. Autopsy</td> - <td class='c010'><a href='#Page_197'>197</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>51.</td> - <td class='c009'>Paretic neurosyphilis. Autopsy</td> - <td class='c010'><a href='#Page_199'>199</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>52.</td> - <td class='c009'>Manic-depressive psychosis <i><span lang="la" xml:lang="la">versus</span></i> paretic neurosyphilis</td> - <td class='c010'><a href='#Page_202'>202</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>53.</td> - <td class='c009'>Syphilitic(?) exophthalmic goitre. Autopsy</td> - <td class='c010'><a href='#Page_205'>205</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>54.</td> - <td class='c009'>Argyll-Robertson pupils</td> - <td class='c010'><a href='#Page_209'>209</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>55.</td> - <td class='c009'>Argyll-Robertson pupils: pineal tumor. Autopsy</td> - <td class='c010'><a href='#Page_212'>212</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>56.</td> - <td class='c009'>Neurosyphilis(?) with negative spinal fluid</td> - <td class='c010'><a href='#Page_216'>216</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>57.</td> - <td class='c009'>Disseminated syphilitic encephalitis, seven months post-infective. Autopsy</td> - <td class='c010'><a href='#Page_218'>218</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>58.</td> - <td class='c009'>“Pseudoparesis”</td> - <td class='c010'><a href='#Page_222'>222</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>59.</td> - <td class='c009'>Syphilitic paranoia?</td> - <td class='c010'><a href='#Page_225'>225</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>60.</td> - <td class='c009'>Paretic neurosyphilis <i><span lang="la" xml:lang="la">versus</span></i> alcoholic pseudoparesis</td> - <td class='c010'><a href='#Page_227'>227</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>61.</td> - <td class='c009'>Alcoholic pseudoparesis <i><span lang="la" xml:lang="la">versus</span></i> paretic neurosyphilis</td> - <td class='c010'><a href='#Page_231'>231</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>62.</td> - <td class='c009'>Alcoholic neuritis and paretic neurosyphilis</td> - <td class='c010'><a href='#Page_234'>234</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>63.</td> - <td class='c009'>Chronic alcoholism <i><span lang="la" xml:lang="la">versus</span></i> paretic neurosyphilis</td> - <td class='c010'><a href='#Page_236'>236</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>64.</td> - <td class='c009'>Neurosyphilis, diabetic pseudoparesis, or brain tumor</td> - <td class='c010'><a href='#Page_238'>238</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>65.</td> - <td class='c009'>Neurosyphilis and diabetes</td> - <td class='c010'><a href='#Page_240'>240</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>66.</td> - <td class='c009'>Neurosyphilis: hemianopsia</td> - <td class='c010'><a href='#Page_242'>242</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>67.</td> - <td class='c009'>Paretic neurosyphilis <i><span lang="la" xml:lang="la">versus</span></i> syphilis and cerebral malaria</td> - <td class='c010'><a href='#Page_245'>245</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>68.</td> - <td class='c009'>Paretic neurosyphilis: gold sol test “syphilitic.” Autopsy</td> - <td class='c010'><a href='#Page_247'>247</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>69.</td> - <td class='c009'>Lues maligna</td> - <td class='c010'><a href='#Page_250'>250</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>70.</td> - <td class='c009'>Neurosyphilis <i><span lang="la" xml:lang="la">versus</span></i> multiple sclerosis</td> - <td class='c010'><a href='#Page_253'>253</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>71.</td> - <td class='c009'>Atypical neurosyphilis</td> - <td class='c010'><a href='#Page_256'>256</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>72.</td> - <td class='c009'>Huntington’s chorea <i><span lang="la" xml:lang="la">versus</span></i> neurosyphilis</td> - <td class='c010'><a href='#Page_258'>258</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>73.</td> - <td class='c009'>Senile arteriosclerotic psychosis <i><span lang="la" xml:lang="la">versus</span></i> neurosyphilis</td> - <td class='c010'><a href='#Page_262'>262</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>74.</td> - <td class='c009'>Hysterical fugue <i><span lang="la" xml:lang="la">versus</span></i> neurosyphilis</td> - <td class='c010'><a href='#Page_264'>264</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>75.</td> - <td class='c009'>Tabetic neurosyphilis <i><span lang="la" xml:lang="la">versus</span></i> pernicious anemia</td> - <td class='c010'><a href='#Page_267'>267</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>76.</td> - <td class='c009'>Congenital neurosyphilis</td> - <td class='c010'><a href='#Page_270'>270</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>77.</td> - <td class='c009'>Congenital <i><span lang="la" xml:lang="la">versus</span></i> paretic neurosyphilis</td> - <td class='c010'><a href='#Page_272'>272</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>78.</td> - <td class='c009'>Juvenile paretic neurosyphilis</td> - <td class='c010'><a href='#Page_275'>275</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'><span class='pageno' id='Page_11'>11</span>79.</td> - <td class='c009'>Epilepsy <i><span lang="la" xml:lang="la">versus</span></i> juvenile neurosyphilis</td> - <td class='c010'><a href='#Page_277'>277</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>80.</td> - <td class='c009'>Addison’s disease and juvenile paretic neurosyphilis. Autopsy</td> - <td class='c010'><a href='#Page_279'>279</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>81.</td> - <td class='c009'>Neurosyphilis of the secondary period</td> - <td class='c010'><a href='#Page_283'>283</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>82.</td> - <td class='c009'>Taboparetic neurosyphilis and typhoid meningitis. Autopsy</td> - <td class='c010'><a href='#Page_284'>284</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section IV. Neurosyphilis, Medicolegal and Social. Cases 83–98</span></td> - <td class='c010'><a href='#Page_289'>289</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <th class='c008'><span class='sc'>Case</span></th> - <th class='c009'> </th> - <th class='c010'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>83.</td> - <td class='c009'>A public character, neurosyphilitic. Autopsy</td> - <td class='c010'><a href='#Page_289'>289</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>84.</td> - <td class='c009'>Debts, neurosyphilitic</td> - <td class='c010'><a href='#Page_295'>295</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>85.</td> - <td class='c009'>Suicidal attempt by a neurosyphilitic</td> - <td class='c010'><a href='#Page_296'>296</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>86.</td> - <td class='c009'>Neurosyphilis and juvenile delinquency</td> - <td class='c010'><a href='#Page_298'>298</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>87.</td> - <td class='c009'>Neurosyphilis in a defective delinquent</td> - <td class='c010'><a href='#Page_300'>300</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>88.</td> - <td class='c009'><em>Paresis sine paresi</em> in a forger</td> - <td class='c010'><a href='#Page_303'>303</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>89.</td> - <td class='c009'>Trauma: juvenile paretic neurosyphilis</td> - <td class='c010'><a href='#Page_306'>306</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>90.</td> - <td class='c009'>Trauma: paretic neurosyphilis</td> - <td class='c010'><a href='#Page_308'>308</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>91.</td> - <td class='c009'>False claim for trauma: neurosyphilis</td> - <td class='c010'><a href='#Page_309'>309</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>92.</td> - <td class='c009'>Traumatic exacerbation? in neurosyphilis</td> - <td class='c010'><a href='#Page_310'>310</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>93.</td> - <td class='c009'>Trauma: cranial gumma at the site of injury</td> - <td class='c010'><a href='#Page_311'>311</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>94.</td> - <td class='c009'>Occupation-neurosis <i><span lang="la" xml:lang="la">versus</span></i> syphilitic neuritis</td> - <td class='c010'><a href='#Page_312'>312</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>95.</td> - <td class='c009'>Character change: neurosyphilis</td> - <td class='c010'><a href='#Page_314'>314</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>96.</td> - <td class='c009'>A neurosyphilitic family</td> - <td class='c010'><a href='#Page_316'>316</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>97.</td> - <td class='c009'>A neurosyphilitic’s normal-looking family</td> - <td class='c010'><a href='#Page_318'>318</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>98.</td> - <td class='c009'>The neurosyphilitic’s marriage</td> - <td class='c010'><a href='#Page_319'>319</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section V. The Treatment of Neurosyphilis. Cases 99–123.</span></td> - <td class='c010'> </td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c009'>(<span class='sc'>Cases 99–103 show the Variety of Structural Lesions that Treatment has to Face</span>)</td> - <td class='c010'><a href='#Page_323'>323</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <th class='c008'><span class='sc'>Case</span></th> - <th class='c009'> </th> - <th class='c010'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>99.</td> - <td class='c009'>An incurable spastic paresis in paretic neurosyphilis. Autopsy</td> - <td class='c010'><a href='#Page_323'>323</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>100.</td> - <td class='c009'>A theoretically curable case. Autopsy</td> - <td class='c010'><a href='#Page_328'>328</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>101.</td> - <td class='c009'>A highly meningitic case, theoretically amenable to treatment. Autopsy</td> - <td class='c010'><a href='#Page_332'>332</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>102.</td> - <td class='c009'>A highly atrophic case, theoretically not amenable to treatment. Autopsy</td> - <td class='c010'><a href='#Page_335'>335</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>103.</td> - <td class='c009'>Paretic neurosyphilis with markedly focal lesions. Autopsy</td> - <td class='c010'><a href='#Page_338'>338</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c009'>(<span class='sc'>Cases 104 to 123 are Examples of Treatment Including Successes and Failures.</span>)</td> - <td class='c010'> </td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>104.</td> - <td class='c009'>Diffuse neurosyphilis: treatment successful after nine months</td> - <td class='c010'><a href='#Page_342'>342</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>105.</td> - <td class='c009'>Atypical neurosyphilis: treatment successful</td> - <td class='c010'><a href='#Page_346'>346</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>106.</td> - <td class='c009'>Argyll-Robertson pupil not necessarily of bad prognosis: treated case an insurance risk</td> - <td class='c010'><a href='#Page_350'>350</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>107.</td> - <td class='c009'>Spinal fluid cleared: symptoms persistent</td> - <td class='c010'><a href='#Page_355'>355</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>108.</td> - <td class='c009'>Arteriosclerosis does not contraindicate treatment</td> - <td class='c010'><a href='#Page_359'>359</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>109.</td> - <td class='c009'>Symptoms of intracranial pressure relieved by treatment</td> - <td class='c010'><a href='#Page_362'>362</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>110.</td> - <td class='c009'>Therapeutic improvement in tabetic neurosyphilis</td> - <td class='c010'><a href='#Page_366'>366</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>111.</td> - <td class='c009'>W. R. rendered negative in tabetic neurosyphilis</td> - <td class='c010'><a href='#Page_367'>367</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>112.</td> - <td class='c009'>Example of successful treatment of paretic neurosyphilis</td> - <td class='c010'><a href='#Page_370'>370</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>113.</td> - <td class='c009'>Another example</td> - <td class='c010'><a href='#Page_372'>372</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'><span class='pageno' id='Page_12'>12</span>114.</td> - <td class='c009'>Clinical recovery but tests persistently positive in treated paretic neurosyphilis</td> - <td class='c010'><a href='#Page_375'>375</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>115.</td> - <td class='c009'>Improvement delayed in treated paretic neurosyphilis</td> - <td class='c010'><a href='#Page_377'>377</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>116.</td> - <td class='c009'>Non-neural syphilis in treated paretic neurosyphilis</td> - <td class='c010'><a href='#Page_380'>380</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>117.</td> - <td class='c009'>Partial recovery in treated paretic neurosyphilis</td> - <td class='c010'><a href='#Page_382'>382</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>118.</td> - <td class='c009'>Laboratory signs improved: clinical situation stationary: treated paretic neurosyphilis</td> - <td class='c010'><a href='#Page_384'>384</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>119.</td> - <td class='c009'>Another example</td> - <td class='c010'><a href='#Page_386'>386</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>120.</td> - <td class='c009'>Failure of treatment</td> - <td class='c010'><a href='#Page_388'>388</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>121.</td> - <td class='c009'>Treatment, at first mild, later intensive</td> - <td class='c010'><a href='#Page_390'>390</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>122.</td> - <td class='c009'>Intensive treatment</td> - <td class='c010'><a href='#Page_392'>392</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>123.</td> - <td class='c009'>Syphilitic feeblemindedness improved by treatment</td> - <td class='c010'><a href='#Page_395'>395</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section VI. Neurosyphilis and the War.</span></td> - <td class='c010'> </td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c009'><span class='sc'>Cases A To N from British, French, and German Writers</span> (1914–1916)</td> - <td class='c010'><a href='#Page_399'>399</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <th class='c008'><span class='sc'>Case</span></th> - <th class='c009'> </th> - <th class='c010'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>A.</td> - <td class='c009'>Tabes “shell-shocked” into paresis? (Donath)</td> - <td class='c010'><a href='#Page_401'>401</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>B.</td> - <td class='c009'>Latent syphilis “shell-shocked” into tabes? (Duco and Blum)</td> - <td class='c010'><a href='#Page_403'>403</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>C.</td> - <td class='c009'>Aggravation of neurosyphilis by service? (Weygandt)</td> - <td class='c010'><a href='#Page_404'>404</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>D.</td> - <td class='c009'>Aggravation of neurosyphilis <em>by</em> service? (Todd)</td> - <td class='c010'><a href='#Page_406'>406</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>E.</td> - <td class='c009'>Aggravation of neurosyphilis <em>on</em> service? (Todd)</td> - <td class='c010'><a href='#Page_409'>409</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>F.</td> - <td class='c009'>Duration of neurosyphilitic process important. (Farrar)</td> - <td class='c010'><a href='#Page_411'>411</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>G.</td> - <td class='c009'>Latent syphilis lighted up to paresis by war stress without shell-shock. (Marie)</td> - <td class='c010'><a href='#Page_412'>412</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>H.</td> - <td class='c009'>Paresis lighted up by “gassing”? (de Massary)</td> - <td class='c010'><a href='#Page_414'>414</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>I.</td> - <td class='c009'>Epilepsy in a neuropath lighted up by syphilis acquired at war. (Bonhoeffer)</td> - <td class='c010'><a href='#Page_415'>415</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>J.</td> - <td class='c009'>Syphilitic—after Dixmude epileptic. (Bonhoeffer)</td> - <td class='c010'><a href='#Page_417'>417</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>K.</td> - <td class='c009'>Syphilitic root-sciatica in a fireworks man. (Dejerine, Long)</td> - <td class='c010'><a href='#Page_418'>418</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>L.</td> - <td class='c009'>Paresis lighted up in civilian by domestic stress of the war. (Percy Smith)</td> - <td class='c010'><a href='#Page_420'>420</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>M.</td> - <td class='c009'>Shell-shock pseudoparesis. (Pitres and Marchand)</td> - <td class='c010'><a href='#Page_421'>421</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>N.</td> - <td class='c009'>Shell-shock pseudotabes. (Pitres and Marchand)</td> - <td class='c010'><a href='#Page_424'>424</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Section VII. Summary and Key</span></td> - <td class='c010'><a href='#Page_427'>427</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'><span class='sc'>Appendices</span>:</td> - <td class='c010'> </td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>A.</td> - <td class='c009'>The six tests</td> - <td class='c010'><a href='#Page_471'>471</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>B.</td> - <td class='c009'>Common methods of treatment</td> - <td class='c010'><a href='#Page_486'>486</a></td> - </tr> -</table> - -<div class='chapter'> - <span class='pageno' id='Page_13'>13</span> - <h2 class='c005'>INTRODUCTION</h2> -</div> - -<p class='c006'>It is a privilege to be allowed to write a word of introduction -to a textbook which so richly fulfils its function as does -this volume on the manifold disorders classified under Neurosyphilis, -a subject of which the importance for the welfare of -society is found to loom the larger the more deeply its mysteries -are probed.</p> - -<p class='c007'>The case histories with which its pages are so amply -stocked are carefully analyzed in accordance with a broadly -chosen plan, and the generalizations that precede and follow -them are obviously based on a wide and varied personal -experience such as alone could render a familiarity with the -literature of the subjects treated adequate to its best usefulness. -Both writers were indeed well adapted for this task. -Dr. Southard, as everyone is aware, has long been a highly -conscientious, ardent and productive worker in the department -of pathological anatomy, and of late years a careful -student of clinical diagnosis and methods, both at the Danvers -State Hospital and still more, at the Psychopathic Hospital -which he worked so hard to found; while Dr. Solomon’s -researches, in the special field of neurosyphilis, have been of -the highest order.</p> - -<p class='c007'>Undoubted as are the merits of the case-system of instruction -that has been so much in vogue in recent years, -and excellent as is the modern supplementation of this method -by the use of published records, the danger is still real that -the student will have presented to him a picture of nature in -disease that is too diagrammatic, too concise, with the result -that while the task of memory is lightened through simplified -formulation, the training of the doubting and inquiring -instincts is often given too little stimulus and scope. In -this book this danger is deliberately met through the casting -of emphasis rather on the pluralistic aspects of the processes -at stake than (primarily) on their unitary aspects.</p> - -<p class='c007'><span class='pageno' id='Page_14'>14</span>The student who utilizes this volume cannot but emerge -from his study a more thoughtful person than he was at the -period of his entry. He will have seen that clinical rules of -thumb cannot be followed to advantage, and that, on the -contrary, surprises are to be expected and prepared for. -Let the recognition of this fact, if it seems to increase the -difficulties in the way of diagnosis, not lead to pessimism in -that respect, or to hopelessness in therapeutics. On the -contrary the writers’ bias is towards the worth-whileness of -clinical efforts and an increased respect for accuracy and -thoroughness in the utilization of modern methods of research. -The chance is indeed held open that even the gaunt spectre -of “General Paresis” may prove to be less terrible than it -seems, and for this hope good grounds are given.</p> - -<p class='c007'>It is in this way made clear, on the strength of anatomical -evidence of much interest, that even if in the treatment of a -given patient, the time arrives when a fatal or unfavorable -result seems manifestly foreshadowed, it may be still worth -while to renew the treatment with fresh zeal, for the sake of -combatting some symptom or exacerbation, for which a -locally fresh process furnishes the cause.</p> - -<p class='c007'>Another noteworthy principle here emphasized and illustrated -is that the relationship between “functional” (hysterical, -neurasthenic, migrainoid) symptoms and the signs -(or symptoms) of organic processes is clinically important -and worthy of much further study. This is a matter which, -in a general sense, has interested me for many years. Above -and over the “organic” hovers always the “functional,” as -representing the first indication of the marvelous tendency -to repair, or substitution, for which the resources of nature -are so vast. Yet this functional tendency also has its laws, -of which, in their turn, the organic processes display the -action in quasi diagrammatic form. Hysteria, neurasthenia, -migraine, etc., do not arise <i><span lang="la" xml:lang="la">de novo</span></i> in each case, but conform -to typical, though not rigid, formulas, susceptible of description. -I have recently had the opportunity to study in detail -an analogous series of transitions between the movements -(and emotions) indicative of apparently purposeless myoclonic -movements (on an epileptoid basis) and the movements -<span class='pageno' id='Page_15'>15</span>of surprise, engrossment, purposeful effort, the excitement -and joy by which the former were excited and into which -they shaded over.</p> - -<p class='c007'>Taken altogether, this book represents work and thought -in which, for amount and kind, the neurologists of Boston -may take just pride.</p> - -<div class='lg-container-r'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>James J. Putnam.</span></div> - </div> - </div> -</div> - -<div class='lg-container-l'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>St. Hubert’s, Keene Valley, New York.</span></div> - <div class='line in16'><em>August, 1917.</em></div> - </div> - </div> -</div> - -<div><span class='pageno' id='Page_16'>16</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c001'> - <div class='linegroup'> - <div class='group'> - <div class='line'>Me miserable! which way shall I fly</div> - <div class='line'>Infinite wrath and infinite despair?</div> - <div class='line'>Which way I fly is Hell; myself am Hell;</div> - <div class='line'>And, in the lowest deep, a lower deep</div> - <div class='line'>Still threatening to devour me opens wide,</div> - <div class='line'>To which the Hell I suffer seems a Heaven.</div> - </div> - <div class='group'> - <div class='line in20'>Paradise Lost, Book IV, lines 73–78.</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_17'>17</span> - <h2 class='c005'>I. THE NATURE AND FORMS OF SYPHILIS OF THE NERVOUS SYSTEM (NEUROSYPHILIS)</h2> -</div> - -<div class='box'> - -<p class='c013'>PARADIGM to show possible abundance and -variety of symptoms and lesions in DIFFUSE -NEUROSYPHILIS (“cerebrospinal syphilis”). -Autopsy.</p> - -</div> - -<p class='c006'><b>Case 1.</b> Mrs. Alice Morton<a id='r1' /><a href='#f1' class='c014'><sup>[1]</sup></a> was in the hands of at least -five well-known specialists in different branches of medicine -and surgery during the nineteen years of her disease. It -appears that she acquired syphilis upon marriage at the age -of 23 to a man who later became tabetic and acknowledged -syphilitic infection previous to marriage. Mrs. Morton -remained without children and there were no miscarriages.</p> - -<p class='c007'>At the age of 27, she developed iritis, paresis of the left eye -muscles, and ulceration of the throat, with destruction of the -uvula. The syphilitic nature of her disease was at once -recognized and the classical treatment was given, although, -through numerous shifts in consultants, this treatment was -never pushed to the limit. At 28 Mrs. M. began to suffer -from severe headaches resembling migraine and accompanied -by attacks of paræsthesia; at 35, came severe pains in the -back and difficulty in walking.</p> - -<p class='c007'>At 36, the migraine attacks began to be accompanied by -blurring of vision and dizziness. The difficulty in walking -became extreme, affecting particularly the right foot. The -<span class='pageno' id='Page_18'>18</span>legs became spastic, there were pains and hyperæsthesia of -the chest, and severe cramps of the legs. Antisyphilitic -treatment at this time yielded marked improvement.</p> - -<p class='c007'>During her thirty-sixth year, Mrs. M. sustained curious -transient losses of vision and of hearing. She was also irritable, -and at this time developed her first pronounced mental -symptoms, namely, delusions concerning her relatives. -There were also a few seizures of an epileptiform nature.</p> - -<p class='c007'>At 38 there was a spell of total deafness, followed by improvement. -The eye muscles were also subject to a variable -involvement with intervening spells of improvement. -The <em>knee-jerks were lost, but after a time returned</em> in less -pronounced form. Shortly, an absolute paralysis and extensive -decubitus developed, and death occurred at 39.</p> - -<p class='c007'>The autopsy is briefly summarized below, but it is important -in the understanding of Mrs. M.’s case (particularly some of -the sensory symptoms and the transiency of certain symptoms) -to consider the pre-infective history. Although there seems -to be no doubt that the patient acquired syphilis at about -23 years of age from a syphilitic husband, who himself later -became tabetic, yet it is of note that the patient was the -only child of parents, both of whom also suffered from mental -disease. Mrs. M.’s father died of what was called softening -of the brain (one should avoid terming <em>all</em> old cases of <em>so-called</em> -“softening of the brain” syphilitic, since the older diagnosticians -did not always distinguish between non-syphilitic -arteriosclerotic effects and syphilitic disease). Mrs. M.’s -mother also died insane (confusion and emotional depression). -It is clear, then, that we do not need to suppose that every -symptom shown by Mrs. M. is directly due to destructive or -irritative lesions immediately due to the spirocheta pallida. -The case is, in fact, an excellent lesson as to the association of -structural and functional effects in neuropathological cases.</p> - -<p class='c007'>Mrs. M. as a child had shown talent, but was somewhat -nervous and eccentric. At one time, she had an attack of -hysterical dysphasia; at another time, an attack of hysterical -dyspnea; during another period, an apparent obsession (kicking -the mopboard at regular intervals). Moreover, she had -for years suffered from migraines of a severe and unusual type. -<span class='pageno' id='Page_19'>19</span>Both the hysterical tendency and the migrainous tendency -became mingled with the results of the neurosyphilis in later -stages of the disease in such wise that it was hard to tell -exactly where the structural phenomena left off and the -functional phenomena began.</p> - -<p class='c007'>For example, at the age of 32, nine years after infection -and four years after the earliest nerve symptoms traceable -to syphilis, and at about the time of the onset of spinal cord -symptoms, an attack was described as follows:</p> - -<p class='c015'>The patient had a very severe attack of migraine (?) -yesterday, preceded and accompanied by paraphasia, -so severe that for three hours she was unable to make -herself understood, and indeed felt “as if her ideas were -getting away from her.” This attack was ushered in -by a numbness of the forefinger and thumb of the right -hand, which lasted for about three hours, though the -earlier attacks had lasted for only about ten minutes. -During this period the hand felt as if it had been frozen -and the loss of muscular power was so great that she -was unable to hold objects in the hand. In some of -the attacks this paræsthesia has affected the entire left -half of the body, and occasionally the right half. Sometimes -the seizures come on with great suddenness, so that -once, when she was attacked while in the middle of -the street, she had considerable difficulty in reaching -the sidewalk. After the worst part of the attack is -over a certain amount of paraphasia may persist for -some days, together with awkwardness in the use of -the right hand and numbness. She has had a great -deal of nausea and vomiting, without reference to the -taking of food.<a id='r2' /><a href='#f2' class='c014'><sup>[2]</sup></a></p> - -<p class='c007'>Bearing in mind the mingling of structural with functional -symptoms in this case, let us consider the autopsy findings.</p> - -<div><span class='pageno' id='Page_20'>20</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>ANATOMICAL</b></span></div> - <div class='c003'><b>FORMS OF NEUROSYPHILIS</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>AUTONOMIC (SYMPATHETIC) NEUROSYPHILIS?</div> - </div> - <div class='group'> - <div class='line'>PERIPHERAL NEUROSYPHILIS</div> - </div> - <div class='group'> - <div class='line'>CENTRAL NEUROSYPHILIS</div> - <div class='line in2'>MENINGEAL</div> - <div class='line in2'>VASCULAR</div> - <div class='line in2'>PARENCHYMATOUS</div> - <div class='line in2'>MENINGOVASCULAR</div> - <div class='line in2'>VASCULOPARENCHYMATOUS</div> - <div class='line in2'>DIFFUSE ( = MENINGOVASCULOPARENCHYMATOUS)</div> - </div> - <div class='group'> - <div class='line'>GUMMA</div> - </div> - </div> -</div> - -<div class='c018'> <span class='sc'>Chart 1</span></div> - -</div> - -<div><span class='pageno' id='Page_21'>21</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>CLINICAL FORMS OF NEUROSYPHILIS</b></span></div> - <div class='c003'><b>HEAD AND FEARNSIDES, 1914</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>SYPHILIS MENINGOVASCULARIS</div> - <div class='line in2'>CEREBRAL FORMS</div> - <div class='line in2'>HEMIPLEGIA</div> - <div class='line in2'>AFFECTION OF THE CRANIAL NERVES</div> - <div class='line in2'>MUSCULAR ATROPHY</div> - <div class='line in2'>LATERAL AND COMBINED DEGENERATIONS</div> - <div class='line in2'>EPILEPSY</div> - </div> - <div class='group'> - <div class='line'>SYPHILIS CENTRALIS</div> - <div class='line in2'>DEMENTIA PARALYTICA</div> - <div class='line in2'>TABES DORSALIS</div> - <div class='line in2'>MUSCULAR ATROPHY</div> - <div class='line in2'>OPTIC ATROPHY</div> - <div class='line in2'>GASTRIC CRISES</div> - <div class='line in2'>EPILEPTIC MANIFESTATIONS</div> - </div> - </div> -</div> - -<div class='lg-container-r c017'> - <div class='linegroup'> - <div class='group'> - <div class='line in36'><span class='sc'>Chart 2</span></div> - </div> - </div> -</div> - -</div> - -<p class='c019'><span class='pageno' id='Page_22'>22</span><b>Peripheral neurosyphilis</b>: The lesions of the cranial -nerves were characteristically asymmetrical. Whereas the -left third nerve looked entirely normal, the <b>right third nerve</b> -had its diameter reduced two-thirds. On the other hand, -the fourth nerves were equal and apparently normal. The -sensory portion of the left fifth nerve was normal; the right -fifth nerve was normal. The <b>right sixth nerve</b> agreed with the -right third nerve in being atrophic, and was in fact reduced -to a mere thread without contained nerve fibres at a point -2 mm. from its superficial origin. Although the right third -nerve was atrophic, it was the <b>left seventh and eighth -nerves</b> which had become atrophic; the process had spared -the right seventh and eighth nerves. The remainder of the -cranial nerves were grossly normal, except that the <b>optic -nerves</b> had an outer zone of a translucent nature. So far, -no spirochetes have been demonstrated in any portion of the -nervous system of this case, but such asymmetrical and focal -cranial nerve lesions are perhaps due to local spirochetal -infection, punctuating (as it were) the diffuse process.</p> - -<p class='c007'>How much of the transient blindness, deafness, and -ocular paralysis can be explained on the anatomical findings -in these nerves? Possibly a portion of the phenomena can be -so explained. Thus, the mechanical conditions of pressure -inside and outside these nerves, both in their peripheral course -and in their passage through the membranes, can be readily -understood to differ during the acute and subacute inflammation, -during the process of repair in the pial tissues, and -during the process of overgrowth of neuroglia tissue about -the superficial origins of the nerves. Of course, the majority -of lesions of these nerves were entirely extinct at the time of -the autopsy, and their history could be surmised only from -the appearances in the <em>left eighth nerve</em>. Here occurred a -sharply marked focal area of gliosis with apparently total -destruction of nerve fibres and related with a <em>lymphocytosis</em> -of the investing membrane (one of the few areas of lymphocytosis -found anywhere in this case).</p> - -<p class='c007'>If it were not for the pre-infective history, the hysterical -dysphasia and dypsnea, the youthful obsessions, the migrainous -tendency, and the psychopathic inheritance, we might be -tempted to try to explain the transient blindness, the deafness, -and ocular palsies on the basis of mechanical and toxic variations -in the conditions of the peripheral cranial nerves. -The existence of a trace of lymphocytosis in the left eighth -nerve leads to the hypothesis that treatment might still be -effective in this particular region (see below in discussion of -spinal symptoms).</p> - -<p class='c007'><span class='pageno' id='Page_23'>23</span><b>Spinal neurosyphilis:</b> Not only the spinal cord but also -the posterior and anterior nerve roots exhibited severe lesions. -These lesions were both meningeal and parenchymatous. -The meningeal process differed in its intensity in different -parts of the spinal cord, being severest in the thoracic region. -At one point in this region, the dura mater was so firmly -attached to the pia mater that the line of demarcation between -the two membranes was hard to make out. In fact, -it seems clear that there could have been no free intercommunication -between the spinal fluid above these adhesions -of dura to pia mater and the spinal fluid below the adhesions. -Accordingly, it seems that <em>lumbar puncture</em>, had it been -practised in this case, <em>would have failed to show features representative -of the whole cerebrospinal fluid system</em>. Moreover, -since at no point in this region of adhesions or in the -pia mater of the spinal cord below this point, were found any -lymphocytes, it seems clear that the ordinary lumbar puncture -would have failed to reveal a pleocytosis. Whether this -fluid would have yielded a positive globulin and excess albumin -test, it is now impossible to say; but it appears that -the process in the lower part of the spinal cord was to all -intents and purposes extinct.</p> - -<p class='c007'>However, there was one region of more severe inflammatory -involvement. The <em>spinal cord in the cervical region showed -a lymphocyte infiltration</em> of its vessels amounting to a mild -myelitis (meaning, thereby, an inflammatory process of the -spinal cord remote from the pia mater). Moreover, in this -region, there was, besides the perivascular infiltration of the -substance, also an infiltration of the overlying membranes -themselves, especially in and near the posterior root zones.</p> - -<p class='c007'>The lessons of this finding are several: The inflammatory -process in this case does not appear to have been entirely -extinct! Can we not suppose that treatment might still -have benefited this local inflammation (perivascular infiltration -of the cervical spinal cord substance and overlying lymphocytic -meningitis)? Can we not also picture the gradual -ascent of the inflammatory lesions from lower segments to -higher segments and possibly conceive of the gradual elevation -of the zone of hyperæsthesia manifested in this case as -<span class='pageno' id='Page_24'>24</span>following the gradual displacement upward of the lymphocytic -process? Are there spirochetes in this tissue? So far none -have been discovered, possibly through inaccuracies of -available technique. To the neuropathologist, however, the -lesion looks like a local reaction to organisms.</p> - -<p class='c007'>In addition to the spinal meningitis, chronic and acute, -as above described, there were extensive parenchymatous -spinal lesions.</p> - -<p class='c007'>In the first place, the meningitis had affected practically -all the posterior roots so that the explanation of the posterior -column sclerosis of this case is clear. The meningitis had -apparently been so marked, also, that all the fibres anywhere -near the periphery of the spinal cord had been likewise destroyed. -The posterior columns and the posterior root zones -were markedly sclerotic; or as we say (having reference to the -overgrowth of neuroglia tissue) gliotic. But there was as -much sclerosis (gliosis) of the lateral columns (particularly in -the posterior two-thirds) as there was in the posterior columns -and root zones. In fact, the entire posterior half or two-thirds -of the spinal cord markedly outstripped the anterior portions -of the cord in the severity of the gliosis (sclerosis) shown.</p> - -<p class='c007'>But although we can explain the posterior column sclerosis, -the sclerosis of the posterior root zones and the marginal -sclerosis (<em>Randsklerose</em>) round the entire periphery of the -cord, on the basis of long-standing effects of old meningitis, -we cannot thus explain another finding, namely, the destruction -of the fibres in the lateral columns. This, in fact, -is explained through lesions (mentioned below) that affected -the encephalon. The net result of all these lesions of the -spinal cord was to leave only the gray matter and a small -amount of surrounding fibres (belonging to short tracts uniting -nearby segments) intact. Briefly stated, <b>every long tract in -the spinal cord appeared upon examination to be extensively -degenerated</b>. The genesis of this parenchymatous loss was, -however, double, being in part due to a local meningeal process -(sometimes known as “perimeningitis”) and in part due -to a cutting off of the pyramidal tract fibres on both sides by -lesions higher up in the nervous system.</p> - -<div class='figcenter id002'> -<img src='images/i_024.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p><span class='sc'>Case I. Spinal Cord (Three Levels) Showing:</span><br /><br />A. Marginal sclerosis—effect of old meningitis now extinct.<br />B. Posterior column sclerosis—effect of meningitis about posterior roots also now extinct.<br />C. Bilateral pyramidal tract sclerosis—effect of cerebral thrombotic lesions.<br /><br />Note distortion of tissues in B and C, partly artificial (tissues in places diffluent).</p> -</div> -</div> - -<div><span class='pageno' id='Page_25'>25</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='3'><span class='large'><b>ANATOMICAL FORMULAE</b></span></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='3'><b>MENINGOVASCULOPARENCHYMATOUS INVOLVEMENT</b></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='3'>M, V, P, or Combinations Applied to the Classification of Head and Fearnsides</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>I.</td> - <td class='c009'>SYPHILIS MENINGOVASCULARIS</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>CEREBRAL FORMS</td> - <td class='c021'>M or V or MV<a id='r3' /><a href='#f3' class='c014'><sup>[3]</sup></a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>HEMIPLEGIA</td> - <td class='c021'>V</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>AFFECTION OF THE CRANIAL NERVES</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>MUSCULAR ATROPHY</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>LATERAL AND COMBINED DEGENERATIONS</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>EPILEPSY</td> - <td class='c021'>M or V</td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>II.</td> - <td class='c009'>SYPHILIS CENTRALIS</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>DEMENTIA PARALYTICA</td> - <td class='c021'>MVP or VP</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>TABES DORSALIS</td> - <td class='c021'>MP</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>MUSCULAR ATROPHY</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>OPTIC ATROPHY</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c009'>GASTRIC CRISES</td> - <td class='c021'>(M? or) P?</td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c011' colspan='2'>EPILEPTIC MANIFESTATIONS</td> - <td class='c021'>P?</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='3'><span class='sc'>Chart 3</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_26'>26</span>Can we offer any explanation of the <b>partial return of knee-jerks</b> after their temporary total loss at a certain period of -the disease? We may assume that the knee-jerks were -functionally lost about a year before the death of the patient -through the partial or even almost complete destruction of -the entering posterior root fibres at that level of the spinal -cord which is directly related with the knee-jerk. The later -partial return of the knee-jerks apparently requires us to -suppose the maintenance of some fibres and collaterals by -which a functional connection can be effected between the -fibres of the posterior roots and the anterior horn cells which -innervate the quadriceps femoris. Let us now suppose -that <i><span lang="la" xml:lang="la">pari passu</span></i> with the actual return of the knee-jerks, -the destructive processes that are affecting both pyramidal -tracts high up in the nervous system are now advancing. -It is clear that, whatever inhibitory influence these pyramidal -tracts have been exerting up to this time upon the knee-jerk -reflex arc, that influence is now to be decidedly reduced in -amount and possibly absolutely lost. Upon the loss of -such inhibitory influences exerted from above, the few persisting -connections of the posterior roots and anterior horn -cells are now permitted to resume their functions.</p> - -<p class='c007'><b>Encephalic neurosyphilis</b>: The lesions mentioned above -as causing destruction of the pyramidal tracts of the spinal -cord were symmetrically destructive and atrophic lesions of -the gray matter of both corpora striata with atrophy of the -anterior segments of the internal capsules. There was a -degenerative process of the corpus callosum especially affecting -the forceps minor of the tapetum. The ventricles -were largely dilated, indicating a considerable destruction and -atrophy of the white matter in general.</p> - -<p class='c007'>After the above discussion of the possible effects of pyramidal -tract lesion in this case, it is unnecessary further to -discuss the paraplegia produced by the cystic lesions of the -corpora striata. The theorist might inquire how these -cystic lesions are produced: whether by vascular blocking or -by toxic effects of the accumulations of spirochetes. Evidence -is lacking which would completely sustain either hypothesis. -Still, we do know that lesions almost identical in -appearance may be produced by the necrosis consequent to -<span class='pageno' id='Page_27'>27</span>the plugging of nutritive vessels in an organ like the brain -supplied with end arteries. Therefore, it is probable that -most pathologists would believe these lesions of the corpora -striata to be produced by vascular plugging of the nature of -thrombosis.</p> - -<p class='c007'>It is worth while to note that there was a suggestion of -foci of encephalitis made out upon the gross examination. -The cortex in general showed strikingly few lesions. However, -the convolutions did show in places numerous ill-defined -areas of hyperemia and slight swelling. These areas were of -irregular distribution and only a few mm. or cm. in diameter. -No gross vascular lesions were demonstrable in connection -with these focal areas. Microscopically, however, venous -plugs of polymorphonuclear leucocytes were found, and the -local hyperemias were found to be largely due to venous congestion. -However, very few polymorphonuclear leucocytes -were found outside the blood vessels.</p> - -<p class='c007'>The white matter of numerous convolutions showed microscopically -certain pale spots suggestive of an early atrophic -process. Very possibly these represent a general tendency in -the cerebrum to the same process of parenchymatous loss which -had proceeded to such a marked degree in the spinal cord.</p> - -<p class='c007'>There was a single large so-called cyst of softening in the -cerebellum (1.5 mm. across by 0.5–7.5 cm. in depth).</p> - -<p class='c007'>How far can we explain the symptoms of this case on the -basis of these encephalic lesions? We can offer no correlation -with the cerebellar lesion; and possibly this lack of correlation -is to be expected on account of its failure to affect the vermis. -As to the cystic lesions of the corpora striata, their effect in -producing paraplegia at the close of life is obvious, and their -possible relation to the partial return of knee-jerks has been -discussed. Literally amazing was the comparative integrity -of the cortical gray matter of this case when the spinal cord -and the interior structures of the encephalon had been subjected -to such severe and numerous lesions. The only -mental symptoms noted in the case were sundry delusions -directed against the patient’s relatives and a certain optimism -which led the patient to cling as if with an obsession to the -belief that in the end she would get well.</p> - -<div><span class='pageno' id='Page_28'>28</span></div> -<div class='chart'> - -<table class='table1' summary=''> -<colgroup> -<col width='95%' /> -<col width='4%' /> -</colgroup> - <tr><td class='c020' colspan='2'><span class='large'><b>VARIOUS FORMS OF NEUROSYPHILIS COLLECTED FROM SEVERAL SOURCES</b></span></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='2'><b>MENINGEAL NEUROSYPHILIS (M)</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>GUMMA OF DURA MATER</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>GUMMATOUS MENINGITIS (<span class='sc'>Pial</span>)</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC MENINGITIS (<span class='sc'>Pial</span>)</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC CRANIAL NERVE PALSIES (<span class='sc'>Primarily Pial</span>)</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC BULBAR PALSY</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC ROOT NEURITIS</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC TRANSVERSE MYELITIS</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC NEURITIS (<span class='sc'>Some Cases by Extension</span>)</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC EPILEPSY (<span class='sc'>Some Cases</span>)</td> - <td class='c021'>M</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC MUSCULAR ATROPHY (<span class='sc'>Some Cases</span>)</td> - <td class='c021'>M</td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c023' colspan='2'><b>VASCULAR NEUROSYPHILIS (V)</b></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>SYPHILITIC ARTERIOSCLEROSIS</td> - <td class='c021'>V</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC CEREBRAL THROMBOSIS</td> - <td class='c021'>V</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC APOPLEXY</td> - <td class='c021'>V</td> - </tr> - <tr> - <td class='c009'>ANEURYSM</td> - <td class='c021'>V</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC EPILEPSY</td> - <td class='c021'>V</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c023' colspan='2'><b>PARENCHYMATOUS NEUROSYPHILIS (P)</b></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>GUMMA</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c009'>CEREBROSPINAL SCLEROSIS</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC PARANOIA</td> - <td class='c021'>P?</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC CHOREA</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC EPILEPSY</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c009'>TABETIC PSYCHOSIS</td> - <td class='c021'>P?</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC MUSCULAR ATROPHY</td> - <td class='c021'>P</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC NEURITIS</td> - <td class='c021'>P</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='2'><span class='sc'>Chart 4a</span></td></tr> -</table> - -</div> - -<div><span class='pageno' id='Page_29'>29</span></div> -<div class='chart'> - -<table class='table1' summary=''> -<colgroup> -<col width='95%' /> -<col width='4%' /> -</colgroup> - <tr><td class='c020' colspan='2'><b>MENINGOVASCULAR NEUROSYPHILIS (MV)</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>CEREBRAL SYPHILIS</td> - <td class='c021'>MV</td> - </tr> - <tr> - <td class='c009'>CEREBROSPINAL SYPHILIS</td> - <td class='c021'>MV</td> - </tr> - <tr> - <td class='c009'>SYPHILITIC EPILEPSY</td> - <td class='c021'>MV</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='2'><b>MENINGOPARENCHYMATOUS NEUROSYPHILIS (MP)</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>CEREBRAL SYPHILIS</td> - <td class='c021'>MP</td> - </tr> - <tr> - <td class='c009'>CEREBROSPINAL SYPHILIS</td> - <td class='c021'>MP</td> - </tr> - <tr> - <td class='c009'>TABES DORSALIS</td> - <td class='c021'>MP</td> - </tr> - <tr> - <td class='c009'>ERB’S SYPHILITIC SPASTIC SPINAL PALSY</td> - <td class='c021'>MP</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='2'><b>VASCULOPARENCHYMATOUS NEUROSYPHILIS (VP)</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>CEREBRAL SYPHILIS</td> - <td class='c021'>VP</td> - </tr> - <tr> - <td class='c009'>CEREBROSPINAL SYPHILIS</td> - <td class='c021'>VP</td> - </tr> - <tr> - <td class='c009'>PARETIC NEUROSYPHILIS (GENERAL PARESIS)</td> - <td class='c021'>VP</td> - </tr> - <tr> - <td class='c009'>LISSAUER’S GENERAL PARESIS</td> - <td class='c021'>VP</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='2'><b>MENINGOVASCULOPARENCHYMATOUS NEUROSYPHILIS (MVP)</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>CEREBRAL SYPHILIS</td> - <td class='c021'>MVP</td> - </tr> - <tr> - <td class='c009'>CEREBROSPINAL SYPHILIS</td> - <td class='c021'>MVP</td> - </tr> - <tr> - <td class='c009'>PARETIC NEUROSYPHILIS</td> - <td class='c021'>MVP</td> - </tr> - <tr> - <td class='c009'>TABOPARESIS</td> - <td class='c021'>MVP</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='2'><b>DOUBTFUL (TOXIC?, IRRITATIVE?) NEUROSYPHILIS (?)</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>“PARESIS SINE PARESI”</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c009'>SYPHILITIC NEURASTHENIA</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c009'>TABETIC PSYCHOSIS</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c009'>SYPHILITIC PARANOIA</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c009'>SYPHILITIC POLYURIA, POLYDIPSIA</td> - <td class='c021'> </td> - </tr> - <tr> - <td class='c009'>SYPHILITIC NEURALGIA</td> - <td class='c021'> </td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='2'><span class='sc'>Chart 4b</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_30'>30</span><b>Summary:</b> We have here dealt at length with a long-standing -<span class='sc'>Diffuse Neurosyphilis</span> affecting to some extent -the entire <b>meninges</b> and producing a destruction of posterior -column fibres and numerous other fibres of the spinal cord -(<b>tabetiform</b> portion of the neurosyphilis <b>picture</b>). We have -also found central lesions of the corpora striata affecting the -destruction of both pyramidal tracts (<b>paraplegic</b> portion of -the neurosyphilis <b>picture</b>). We have found evidences of -acute inflammation (<b>lymphocytosis</b>) in the cervical region of -the spinal cord and in the left eighth nerve (<b>progressive -inflammatory</b> neurosyphilis <b>picture</b>). In short, we have -presented a case of <b>diffuse</b> (meningovasculoparenchymatous) -<b>neurosyphilis</b> characterized by an ascending character in -a course of at least 16 years; we have indicated a number -of possible clinical correlations, not only with the major portion -of the clinical course (symptoms of myelitis and pyramidal -tract destruction), but we have also mentioned, merely for -their suggestive value, a number of finer correlations between -histological findings and certain clinical features (notably -transient losses of vision and hearing, and a partial -return of the lost knee-jerks). Bearing in mind the clinical -and anatomical findings of this case, we shall be able to discuss -the cases that follow in a briefer and more condensed fashion.</p> - -<div><span class='pageno' id='Page_31'>31</span></div> -<div class='box'> - -<p class='c013'><b>TABETIC NEUROSYPHILIS (“tabes dorsalis,” -“locomotor ataxia”) complicated by vascular -neurosyphilis (hemiplegia). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 2.</b> Francis Garfield had been a successful lumberman -and had enjoyed good health until his forty-fifth year. -Suddenly one day, while walking on the street, Garfield lost -the use of his legs and for a time was quite unable to walk. -However, he recovered locomotion and after a time there -was nothing wrong with his leg movements except a slight -ataxia.</p> - -<p class='c007'>At the age of 52 Garfield had to give up work. It appears -that he had been becoming cranky, sometimes, for example, -shouting, whistling and slamming doors, apparently to annoy -the family. His intellectual capacity seemed to be maintained, -although his memory was slightly impaired.</p> - -<p class='c007'>At 67 years there was an ill-defined seizure, followed a few -days later by another seizure with aphasia (wrong words -used and lack of understanding of things said).</p> - -<p class='c007'>For years Garfield had been totally deaf in the right ear -(following explosion of a gun?). Now, however, the left -ear also showed a sensory impairment. Slight slurring of -speech had been noticed first in the sixty-sixth year.</p> - -<p class='c007'><b>Physically</b> there was a slightly enlarged heart with accentuated -second aortic sound and irregular rhythm. <b>Neurologically</b>, -inability to stand or walk; marked ataxia in his -leg movements; upper extremities quite well controlled; -the pupils were small and unequal, the left being larger than -the right; although the reactions were difficult to test, the -pupils seemed to react slightly to direct light stimuli; the -knee-jerks were absent; tests for sensibility so far as could -be determined did not show any abnormalities; there was -much complaint of sharp pains in the legs.</p> - -<p class='c007'>There is no doubt that we are here dealing with a case of -<span class='sc'>Tabes Dorsalis</span> plus certain complications due to <span class='sc'>Vascular -Lesions</span>. The case went on to death from rupture of <b>aortic -aneurysm</b> (also doubtless a syphilitic complication). The -death occurred at 71, four years after admission to Danvers -Hospital.</p> - -<div><span class='pageno' id='Page_32'>32</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>MAIN FORMS OF NEUROSYPHILIS</b></span></div> - <div class='c003'><b>(CLASSIFICATION OF THIS BOOK)</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>DIFFUSE NEUROSYPHILIS</div> - <div class='line in2'>(non-vascular forms of “cerebral,” “spinal” and “cerebrospinal syphilis”)</div> - </div> - <div class='group'> - <div class='line'>VASCULAR NEUROSYPHILIS</div> - <div class='line in2'>(“cerebral arteriosclerosis,” “cerebral thrombosis”)</div> - </div> - <div class='group'> - <div class='line'>PARETIC NEUROSYPHILIS</div> - <div class='line in2'>(“general paresis”)</div> - </div> - <div class='group'> - <div class='line'>TABETIC NEUROSYPHILIS</div> - <div class='line in2'>(“tabes dorsalis”)</div> - </div> - <div class='group'> - <div class='line'>GUMMATOUS NEUROSYPHILIS</div> - <div class='line in2'>(“gumma of membranes, of brain”)</div> - </div> - <div class='group'> - <div class='line'>JUVENILE NEUROSYPHILIS</div> - <div class='line in2'>(paretic, tabetic, diffuse)</div> - </div> - </div> -</div> - -<div class='c018'> <span class='sc'>Chart 5</span></div> - -</div> - -<div><span class='pageno' id='Page_33'>33</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='3'><span class='large'><b>POSSIBLE INVOLVEMENT</b></span></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='3'><b>BRAIN AND CORD SYPHILIS</b></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='3'>[M]embranes, [V]essels, [P]arenchyma</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c024'>[MVP]</td> - <td class='c009'>EARLY, LATENT?, SYMBIOSIS?, ATTENUATION?....</td> - <td class='c025'> </td> - </tr> - <tr> - <td class='c024'>MVP</td> - <td class='c009'>CEREBRAL, CEREBROSPINAL SYPHILIS, PARESIS</td> - <td class='c025'>MVP</td> - </tr> - <tr> - <td class='c024'>[M]VP</td> - <td class='c009'>PARESIS; SYPHILITIC ARTERIOSCLEROSIS</td> - <td class='c025'>VP</td> - </tr> - <tr> - <td class='c024'>M[V]P</td> - <td class='c009'>?SYPHILOTOXIN FROM MENINGITIS</td> - <td class='c025'>MP</td> - </tr> - <tr> - <td class='c024'>MV[P]</td> - <td class='c009'>SYPHILITIC MENINGITIS; CEREBRAL OR CEREBROSPINAL SYPHILIS</td> - <td class='c025'>MV</td> - </tr> - <tr> - <td class='c024'>[MV]P</td> - <td class='c009'>SYPHILOTOXIC ATROPHY OR SCLEROSIS</td> - <td class='c025'>P</td> - </tr> - <tr> - <td class='c024'>M[VP]</td> - <td class='c009'>SYPHILITIC MENINGITIS</td> - <td class='c025'>M</td> - </tr> - <tr> - <td class='c024'>[M]V[P]</td> - <td class='c009'>SYPHILITIC ARTERIOSCLEROSIS</td> - <td class='c025'>V</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='3'>M, V or P in brackets [] means not involved.</td></tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='3'><span class='sc'>Chart 6</span></td></tr> -</table> - -</div> - -<div><span class='pageno' id='Page_34'>34</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>NEUROSYPHILIS</b></span></div> - <div class='c003'><b>SIX TESTS</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>BLOOD WASSERMANN</div> - <div class='line'>SPINAL FLUID WASSERMANN</div> - <div class='line'>SPINAL FLUID CYTOLOGY</div> - <div class='line'>SPINAL FLUID GLOBULIN</div> - <div class='line'>SPINAL FLUID ALBUMIN</div> - <div class='line'>SPINAL FLUID GOLD SOL</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 7</span></div> - -</div> - -<p class='c019'><span class='pageno' id='Page_35'>35</span>This case has been especially worked up and published by -Dr. A. M. Barrett on account of the fact that the vascular -lesions of the brain had produced a condition of pure word-deafness. -Reference is made to the Journal of Nervous and -Mental Disease, Vol. 37, 1910, for a complete description of -the brain findings and an analysis of the word-deafness, a -summary of which is as follows:</p> - -<p class='c015'>“Reaction to Words and Sounds.—Total deafness to -words spoken, but gives attention to sounds; no ability -to recognize meaning of sounds heard; no ability to -repeat words heard. Spontaneous Speech.—Retained -ability to speak spontaneously, with rare paraphasic -utterances; occasional inability to speak readily the -word desired, but later always giving the correct reaction; -calculation fair; spelling good except for occasional -paraphasia; spelling good for words pronounced. Reaction -to Things Seen.—Objects correctly recognized -and named except for an occasional paraphasic reply; -mistakes in pronunciation not recognized; correct color -recognition. Reaction to Things Felt.—Good for -familiar objects; an occasional paraphasic reply. Reaction -to Words Seen.—Reads printing and writing -understandingly; unimpaired reading except for an -occasional paraphasic reply; meaning of familiar signs -recognized; slight difficulty in readily understanding -meaning of arithmetical signs. Writing.—Spontaneous -writing and drawing ability retained; ataxia -(tabetic) in writing movements; no ability to write -from dictation. Internal language.—No evidence of -impairment.”</p> - -<p class='c007'>The brain post mortem showed severe atheromatous degeneration -of the arteries at the base of the brain. Both -middle cerebral arteries showed scattered atheromatous -patches. The pia mater was transparent and delicate, except -in the regions of both Sylvian fissures. There were residuals -of old softening in both temporal lobes. In the fresh brain -the regions of the right and left first temporal convolutions -were sunken inward, and the pia intimately adherent to the -<span class='pageno' id='Page_36'>36</span>softened areas. The limits and more exact localizing of these -softenings were worked out from serial sections.</p> - -<p class='c007'>Barrett found in his serial sections that, although the transverse -temporal convolutions of the left hemispheres were intact, -these convolutions were undermined throughout their -entire extent by degenerations in the fibres of the center of -the first temporal convolution. Barrett, accordingly, regarded -his case as essentially a case of subcortical tissue -destruction. He agrees with various authors that the pure -word-deafness of his case is the result of an isolation of the -receiving station in the transverse convolutions of the left -hemisphere. The tissue destruction produced by the vascular -lesion had cut off the transverse convolutions from -the internal geniculate body.</p> - -<p class='c007'>We are here, however, not considering the origin and relations -of pure word-deafness but present the case as one of -<b>tabes dorsalis</b> of 20 years standing, terminated by two characteristic -syphilitic complications, first, an extensive destruction -of brain tissue through <b>cerebral thrombosis</b> and secondly, -<b>fatal aortic aneurysm</b>.</p> - -<p class='c007'><b>Summary</b>: We have here dealt briefly with a long-standing -case of <span class='sc'>Neurosyphilis</span> of the <span class='sc'>Tabetic</span> type: A characteristic -but not necessary complication of the case is the <span class='sc'>Late Cerebral -Vascular Involvement</span>. The <b>posterior column sclerosis</b> -is virtually the only spinal change. Spinal meningeal changes -are absent (although it is to be assumed that chronic inflammatory -changes in the posterior roots were at one time present -in some quantity and although the spinal fluid characteristically -shows lymphocytosis in tabetic neurosyphilis).</p> - -<p class='c007'>Whether the spirochetes produce special toxic components -able to cause tabes or whether special kinds of spirochete are -the tabes-making kinds is hard to say. Special qualities of -individual tissue may be involved.</p> - -<p class='c007'>The <b>cerebral lesions</b> of a <b>cystic</b> nature are of vascular -origin, like the differently localized encephalic lesions of Case -1 (Alice Morton). Vascular syphilis is not a special property -of the vessels of the nervous system. In fact this very case -died of <b>aortic aneurysm</b>.</p> - -<div><span class='pageno' id='Page_37'>37</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general paresis,” -“dementia paralytica,” “softening of the brain”). -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 3.</b> James Dixon, 44, was first seen at the Danvers -Hospital, reciting verses in a dramatic and noisy way. He -remained good-natured and jolly; nor was there any change -in his euphoria until he had become physically weaker and -more generally demented. In fact, Dixon appeared to become -more and more expansive as he became physically -weaker. He was in the habit of describing himself as -“O. K., No. 1, Superfine.”</p> - -<p class='c007'><b>Physically</b> the patient was gray and bald on vertex, had -a dusky complexion, was very thin (6 ft. in height, weight -155 lbs.); the mucous membranes were pallid; the teeth -rather poorly preserved; the heart was somewhat enlarged; -the pulse irregular in rhythm, of poor volume and tension.</p> - -<p class='c007'><b>Neurologically</b>, the patient showed a characteristic Romberg -sign and ataxia in walking a straight line. The tremulous -tongue was protruded to the left, and there was a coarse -tremor of the extended fingers. The knee-jerks were absent, -and the Achilles jerks could not be obtained; the plantar -reactions were slight; the arm reflexes were present. The -pupils were stiff to light. There was a marked vocal tremor. -The sensations could not be tested on account of the patient’s -mental state.</p> - -<p class='c007'>It appears that Dixon had left school at about 16, at about -22 had gone into the provision business, and later had become -a hotel clerk. He had married at 28; there had been -two miscarriages, at three months and six weeks respectively; -one child was stillborn; four children were living.</p> - -<p class='c007'>The patient was not very alcoholic. The patient’s wife -thought the symptoms had been coming on since his forty-first -year when irritability set in, but he was not discharged -from work until about a year since. He was taken back again -after his wife’s pleas, and remained at work about three -<span class='pageno' id='Page_38'>38</span>months; but for ten months before admission to the hospital, -Dixon had done practically nothing, had shown a marked -memory failure and speech defect, at the same time claiming -to be a person capable of doing and accomplishing everything. -He had become careless of his personal appearance, collected -a drawer-full of stumps of cigars, carried lumps of coal in his -pocket, laughed causelessly, and spat on the carpet.</p> - -<p class='c007'>We here deal with a case of unknown duration from the -initial infection, but with symptoms lasting about three -years and three months. Aside from the cause of death -(empyema of left pleural cavity associated with acute hemorrhagic -splenitis, acute ileitis, and bronchial lymphnoditis), -the body showed a number of other lesions outside the nervous -system. There was the usual sclerosis of the aorta, though -perhaps less marked than usual. There was a curious acute -arteritis with fusiform dilatation of the arteria profunda -femoris, with an edema of the thigh muscles and blebs of the -overlying skin. There were also multiple chronic caseating -lesions of the liver, without evidence of fibrosis. The explanation -of these liver lesions is not yet clear. There was a cloudy -swelling of the kidney.</p> - -<p class='c007'>The calvarium was dense and the dura mater thick and -adherent. There was a chronic leptomeningitis, which, however, -was rather unusual in being most marked in the posterior -cisterna and along the sulci of the cerebellar hemispheres. -There was a general cerebral sclerosis, with a question of -atrophy of the superior temporal gyri (suggesting the so-called -Lissauer’s paresis). There was a marked cerebellar sclerosis -with a consequent sclerosis (grossly palpable) of the commissural -fibres of the pons. There was a generalized slight spinal -sclerosis. As a fair sample of the variety of head findings in -paretic neurosyphilis, the details of the <b>head examination</b> are -presented.</p> - -<div class='figleft id003'> -<img src='images/i_038a.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>A. Normal postcentral cortex. (Compare B.)</p> -</div> -</div> - -<div class='figright id003'> -<img src='images/i_038b.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>B. Nerve cell losses. Perivascular deposits of mononuclear cells, amongst which are numerous plasma cells. Note decrease in number of nerve cells. Note irregular disposition of nerve cells. From paretic neurosyphilis.</p> -</div> -</div> - -<p class='c015'><span class='pageno' id='Page_39'>39</span>Crown bald, with a slight fuzzy growth of short hairs. -Scalp slightly adherent to calvarium; latter of usual -thickness but denser than normal. Dura adherent -to calvarium in region of vertex; dura not remarkable. -Sinuses normal. Arachnoid villi moderately developed. -Pia mater a trifle thickened and rather evenly throughout the cerebral portion. Linear sulcal markings are -remarkable for their absence. The wall of the cerebellomedullary -cisterna is thick and opaque. The most -prominent pial thickenings are over the cerebellum. -These are linear or may show feathery out-growths and -are seated over the sulci, particularly in the neighborhood -of the fissure and about the great cerebellar -notch. They correspond fairly well with the focal -variation in consistence of underlying tissues noted -below.</p> - -<p class='c015'><b>Brain</b> weight, 1265 grams. Consistence somewhat -increased throughout and somewhat evenly increased. -The prefrontal region shows the maximal increase of -consistence but the remainder of the frontal region and -corresponding occipital region are much firmer than -normal. The two superior temporal gyri appear to be -firmer than adjacent gyri and are possibly slightly -diminished in superficial diameter. The hippocampal -gyri are fairly firm. The substance on section is a -trifle more moist than normal. The gray and white -matter cut quite evenly. Diminution in depth of gray -matter, if existent, could not be demonstrated. The -ventricles show a moderate sanding throughout, best -marked in the fourth ventricle. The basal ganglia are -not remarkable except for the development of numerous -dilated perivascular spaces about the lenticulostriate -vessels. The <b>pons</b> is atrophic, but more so on the -right side. The pons, like the prefrontal cortex, shows -on section a distinct increase of consistence immediately -beneath the pia mater. The white bands of the -pons on section are distinctly firmer than the intervening -substance. The olives are of equal consistence. -Weight of cerebellum, pons, and medulla, 155 grams. -The <b>cerebellum</b> shows an obvious atrophic and gliotic -process of a symmetrical character. The superior -surface, including both vermis and hemispheres, shows -a consistence above normal and general reduction of -the depth measured from the white matter. The reduction -in depth gives rise to a visible depression as -compared with tissue posterior to the postclival sulci. -The lobus cacuminis, though slightly raised from the -surrounding lobes, is equally firm, if not firmer. The -superior and inferior surfaces show practically an equal -increase of consistence. The dentate nuclei are not -especially increased in consistence. The flocculi are -reduced in size about one-third.</p> - -<p class='c015'><span class='pageno' id='Page_40'>40</span>There was slight universal increase in consistence of -<b>spinal cord</b>, best marked in lumbar region.</p> - -<p class='c015'><b>Microscopic findings</b> are here presented merely in -sufficient detail to establish the diagnosis. The left -superior frontal gyrus shows extensive and somewhat -irregular cellular and fibrillar gliosis of the plexiform -layer, together with an increase of thickened vessels -having lymphocytes and plasma cells in their sheaths.</p> - -<p class='c015'>The perivascular infiltrations are most extensive in -the lower layers of the cortex. The lamination is in -places thoroughly obscured, except that representatives -of the layer of large external pyramids are almost -always demonstrable.</p> - -<p class='c015'>The layer of medium-sized pyramids has undergone -more numerical loss of elements than have the other -layers.</p> - -<p class='c015'>Gliosis of white matter.</p> - -<p class='c015'>Specimens from the cerebellum show a destructive -process of great severity, but a little irregular in extent, -affecting chiefly the Purkinje cell belt. The Purkinje -cells are often absent throughout one side of a given -lamina, and there has ensued a dense accumulation of -neuroglia cells along a former Purkinje cell belt, together -with a considerable gliosis of the molecular layer. -Considerable gliosis of the white matter, both diffuse -and perivascular in distribution.</p> - -<p class='c015'>Perivascular plasma cell infiltrations as in cerebrum, -but largely meningeal or in the white matter.</p> - -<p class='c015'>Sections from the corpora striata demonstrate a mild -and early granular ependymitis, considerable subependymal -gliosis of cellular type, considerable perivascular -gliosis in the white portions of the tissue, and a moderate -infiltration of perivascular sheaths with pigmented -cells, lymphocytes, and plasma cells. There is little -evidence of alteration in the nerve cells. Some are -unevenly pigmented.</p> - -<p class='c007'><b>Summary</b>: We here present a case with numerous and -widespread neurosyphilitic lesions. However, the gross cerebral -vascular complications of Case 1 (Alice Morton) and of -Case 2 (Francis Garfield) are notably absent in James Dixon. -Rather atypical (there seems to be <em>always something atypical -in cases of neurosyphilis!</em>) are the liver lesions and arteritis of -the leg, atypical, that is to say, for <span class='sc'>Paretic Neurosyphilis</span>. -Highly typical of paretic neurosyphilis and almost constant -therein is the aortic sclerosis.</p> - -<div class='figcenter id004'> -<img src='images/i_040a.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Apparent new formation of small blood vessel. Photographed by Dr. A. M. Barrett.</p> -</div> -</div> - -<div class='figcenter id004'> -<img src='images/i_040b.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Rod cells (Stäbchenzellen) in paretic neurosyphilis. Photographed by Dr. A. M. Barrett.</p> -</div> -</div> - -<div class='figcenter id004'> -<img src='images/i_040c.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Granular ependymitis—microscopic appearance of a marked example of “sanding” of ventricle.</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_41'>41</span>Characteristic and constant in paretic neurosyphilis is the -<b>Plasmocytosis and Lymphocytosis, Perivascular</b> in distribution -about small cortical vessels. There is also a characteristic -(though characteristically less prominent) <b>Plasmocytosis -and Lymphocytosis, Meningeal</b> in distribution. The pleocytosis -of the spinal fluid, almost constant though variable in -amount in life, is an indicator of the meningeal picture and -less directly of the parenchymatous picture.</p> - -<p class='c007'><b>Granular Ependymitis</b> (“sanding” of ventricle floors) is -characteristic and may be regarded as part of the parenchymatous -picture. This ependymitis is an indicator how -chemical changes could be readily produced at least in the -ventricular fluids, since the limiting membranes of the nerve -tissue are here subject to multiple breaks. The “sanding” -is a neuroglia reaction to these multiple small breaks (Weigert’s -explanation).</p> - -<p class='c007'>Parenchymatous losses have led to <b>Atrophy and Sclerosis</b>, -of very varying extent in different parts of the encephalon. -The atrophy is characteristic in paretic neurosyphilis, but by -no means constant. Numerous cases have come to autopsy -without clearly defined gross atrophy. Sclerosis is also characteristic -and even more frequent than atrophy, doubtless -because sclerosis represents an earlier phase of a process -eventuating in gross atrophy.</p> - -<p class='c007'>A <b>Tabetiform Picture</b> characterizes the spinal cord, but -in this case the tabetic clinical picture did <em>not</em> precede the -paretic clinical picture. We are consequently to regard the -tabetic spinal process as incidental and on all fours with -the <b>Cerebellar and Pontine Atrophy</b>.</p> - -<div><span class='pageno' id='Page_42'>42</span></div> -<div class='box'> - -<p class='c013'><b>VASCULAR NEUROSYPHILIS (“syphilitic cerebral -thrombosis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 4.</b> James Pierce was an almshouse transfer to the -Danvers Hospital in his fiftieth year. He died three years -later. The accompanying brain pictures demonstrate so -extensive a lesion of the left hemisphere that it is of great -interest to determine if possible the genesis and course of his -disease. It appears that syphilis had been acquired somewhere -about the age of 38 or 40, so that the total duration of -the process was between 13 and 15 years. In Pierce’s forty-third -or forty-fourth year, he had a shock while walking in -the streets of his native city, whereupon he was subsequently -transferred to the Danvers Hospital, whose data have been -summed up as follows (we are obliged to Dr. Charles T. -Ryder for these data):</p> - -<p class='c015'><b>Neurological examination:</b> Neuromuscular condition: -Barely able to walk or stand without assistance; -hemiplegia of right side; swings foot out and drags toe -out and around in attempting to walk. Right hand -held by side, flexed at right angle; fingers contracted -and thumb thrown across palm. Can lift arm from -side; practically no movements of forearms or fingers; -atrophy of deltoid, arm, forearm, and hand. Muscular -movements of left upper extremities fairly well -performed; good strength.</p> - -<p class='c015'><b>Cranial nerves:</b> Refuses to respond to any tests to -determine hearing or vision, but evidently hears what is -said to him, and in his movements gives no evidence of -deafness. Right corner of mouth droops; tongue protrudes -straight.</p> - -<p class='c015'><b>Reflexes:</b> Pupils dilated; margins irregular; left -pupil larger; they vary in size but it is impossible to -determine whether the variation is due to light or accommodation -reflex. Reflexes of right side extremely -exaggerated throughout; there is little ankle clonus; -Babinski is not obtained, patient holding his toes in -flexed position in resisting attempts to elicit reflexes.</p> - -<p class='c015'><span class='pageno' id='Page_43'>43</span><b>Sensations:</b> Reaction to pain stimuli on either side. -Evidently some anesthesia on right side, but pressure -is apparently very painful. There is considerable -spasticity of limbs on right side on passive motion. -Too demented to make accurate tests.</p> - -<p class='c015'>The above examination was made on May 6, 1904. -On May 20th the record states:</p> - -<p class='c015'>There is almost complete sensory aphasia with word-deafness; some paraphasic circumlocution. Many of -his words are very well enunciated but have no meaning. -Is apparently unable to recognize objects or their uses.</p> - -<p class='c015'>Brother stated that he was always supposed not to be -over bright. Physician’s certificate states that he is -epileptic, averaging two attacks per week. On the -15th of May he had a general convulsion; was unconscious -for half an hour, and dull and drowsy for two -hours afterwards. On the 19th, he had a similar attack -in the afternoon, the convulsion lasting a minute, and -he was stuporous for an hour.</p> - -<p class='c015'>On November 8th he had a severe epileptic convulsion. -His body was curled up to the right. The -convulsive seizure lasted for two minutes and was -followed by complete unconsciousness for an hour, -when the patient roused and appeared as usual in a few -minutes. From that time to December 15th he had -five epileptic convulsions; he was much more feeble, -and unable to help himself as much as formerly.</p> - -<p class='c015'>Nov. 7, 1905: Patient has had occasional convulsions -since last note, but none during the last three -months. He is confined to bed, has become very much -demented, and shows very marked speech defect, so -that he is almost unintelligible. He understands only -the simplest directions. Legs are considerably contracted -and knees are flexed. Arm and hand on the right -are paralyzed and show some atrophic changes; partially -flexed. Left elbow jerk is very lively. On -May 23, 1906 he was reported as having Achilles on -right side only, and Babinski on right side. He died -January 5, 1907.</p> - -<p class='c015'><b>The autopsy findings</b> were as follows:</p> - -<p class='c015'><b>Head:</b> Calvarium of moderate thickness; diploë -present; dura slightly adherent over bregmatic region. -Longitudinal sinus contains cruor clot. Dura is somewhat -thickened and slightly more opaque than normal. -Pacchionian granulations, small but fairly numerous. -Pia contains throughout a considerable excess of clear -<span class='pageno' id='Page_44'>44</span>serous fluid. The convolutions in general are of good -breadth and proportion. There is an atrophic area -roughly circular in outline and about 2 cm. in diameter -in the posterior part of the right third frontal convolution -corresponding to Broca’s area on the opposite -hemisphere. The space thus formed is filled with edema -held by the pia. On the left side is a similar subpial -collection which covers the site of the posterior portions -of all of the third frontal convolutions, parts of the -lower end of the precentral convolution, and the whole -of the first temporal convolution, which have disappeared -entirely. The basal vessels show slight changes.</p> - -<p class='c015'>Cerebellum and basal ganglia are grossly normal.</p> - -<p class='c015'>The spinal membranes are negative. The regions of -the pyramidal tracts in the cord are firm, project -slightly from surface of section, and are china white.</p> - -<p class='c007'><b>Summary:</b> Here is a picture made up almost purely of -<span class='sc'>Vascular Neurosyphilis</span>, with <span class='sc'>Secondary Spinal (Pyramidal -Tract) Changes</span>. Doubtless the genesis of this -picture is allied to that of Case 1 (Alice Morton) and to that -of the terminal vascular complications in a tabetic, Case 2 -(Francis Garfield).</p> - -<p class='c007'>The absence of meningeal and parenchymatous (i.e., outside -the region of necrosis produced by the vascular disease) -lesions is characteristic of an important group of neurosyphilitic -diseases. It is clear that the case, although one of -<em>extensive</em> lesions, is <em>not</em> one of <em>diffuse</em> lesions in the sense of -Case 1 (Alice Morton).</p> - -<p class='c007'>The spinal fluid picture in life may nevertheless show (as -other cases amply demonstrate) a certain amount of lymphocytosis -and possibly plasmocytosis, together with a variety -of other changes. Treatment might be expected to keep -down these associated changes, although obviously the effects -of the necrosis are final and definite. Franz in Washington -has succeeded in “reeducating” some of these hemiplegics, -employing lower mechanisms of the nervous system.</p> - -<div class='figcenter id004'> -<img src='images/i_044.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Vascular neurosyphilis—effects of syphilitic thrombosis of Sylvian artery 10 years before death. (Case 4.)</p> -</div> -</div> - -<div class='figcenter id002'> -<img src='images/i_045.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p><b>Case 4.</b> (See previous figure for brain lesion.) Three levels of the spinal cord showing unilateral pyramidal tract sclerosis, 10 years after cerebral thrombosis.</p> -</div> -</div> - -<div><span class='pageno' id='Page_45'>45</span></div> -<div class='box'> - -<p class='c013'><b>JUVENILE PARETIC NEUROSYPHILIS (“juvenile -paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 5.</b> John Lawrence was an under-sized negro, who -came under hospital observation when he was 23 years of -age. There was some evidence that the patient’s father was -a neurosyphilitic although accurate data were out of the -question. At all events, John had Hutchinsonian teeth, a forward -bowing of the tibiae, and Argyll-Robertson pupils. -These findings together with a history of backwardness at -school seem to stamp the diagnosis. It seems that there had -been a change for the worse from the age of 18, though the -boy had been able to sell newspapers and black shoes up to -within a year of his arrival at the hospital. During the last -months of his life, he showed a general incoördination, with -false movements suggesting those of a drunken person. There -were numerous tremors, the glance was shifting, and there -was a tendency to nystagmus. Some of these phenomena -(taking into account that the Hutchinsonian teeth were not -entirely typical and there was even at times some doubt as -to whether the pupils were actually stiff) led to a question of -the diagnosis multiple sclerosis.</p> - -<p class='c007'>There was, however, little doubt that the case was one of -juvenile paresis. Among the symptoms found at various -times in this case are the following: disorientation for time, -place and persons, confusion, with coarsely irrelevant replies to -questions, ill-defined and transitory delusions of persecution, -auditory, tactile, and visual hallucinations, and defective -memory.</p> - -<p class='c007'>Early in life, the patient had had a habit of falling asleep -in school hours, and had experienced a number of falls at -various times. During an attack of measles he had had a -number of spasms, each of which lasted ten minutes or more.</p> - -<p class='c007'>The <b>autopsy</b> showed death to be due to an early bronchial -pneumonia. The thymus was persistent, measuring 3 × 2 × -.5 cm. The marrow of the femur was red.</p> - -<p class='c007'><span class='pageno' id='Page_46'>46</span>There was a moderate degree of <b>sclerosis of the aorta</b> confined -to a few plaques in the arch (not a characteristic syphilitic -scarring of the aorta). The spleen was small and had a -thickened capsule.</p> - -<p class='c007'>The majority of the lesions, however, were in the <b>nervous -system</b>, and the following description is taken from the routine -hospital records to exemplify the findings in a fairly characteristic -case of <span class='sc'>Juvenile Paresis</span>.</p> - -<p class='c015'><b>Head:</b> Scalp closely adherent to <b>calvarium</b>. Calvarium -heavy without diploë. <b>Dura</b> adherent to calvarium -in bregmatic region. Sinuses contain liquid -blood. Arachnoidal villi in considerable quantity. <b>Pia -mater</b> contains considerable clear fluid and shows diffuse -haziness and focal thickenings. The diffuse haziness -is almost universal and is best marked over the superior -surface of the cerebellum. The focal thickenings are -of general distribution over the veins of the sulci on the -superior surface of the brim and are heaped up to form -considerable linear mounds near the region of the arachnoidal -villi. The superior surface of the cerebellum is -traversed by similar linear mounds of fibrous tissue -running at an angle to the laminæ. There is no notable -increase of fibrous tissue at the base.</p> - -<p class='c015'><b>Brain:</b> Weight 965 grams. The sulcation is roughly -symmetrical except in the occipital poles where there is -unusually rich and complex but shallow sulcation. The -cortical substance is everywhere firmer than normal, -but the sulci fail to flare notably. In a few places there -is a focal increase of consistence of still greater degree -with apparent local hypertrophy (or gliosis with increase -of substance). These foci are in the right second -temporal gyrus (3 cm. in diameter) and in the left first -temporal gyrus (of same size but somewhat less firm) -and are of a whitish, waxen appearance, being visible -several feet away by reason of their color and apparent -encroachment upon the adjacent sulci. The foci are -sharply limited by the sulci laterally, but pale out -gradually before and behind.</p> - -<p class='c015'>The convolutions of the vertex show another type of -lesion. The tissue of the greater part of the vertex -resembles that of the flanks and base in being firmer -than normal and of a grayish pink color. Behind the -fissure of Rolando on the right side and behind the anterior -limits of the ascending frontal region on the left -<span class='pageno' id='Page_47'>47</span>side the brain tissue of the vertex becomes suddenly -still firmer and of a yellowish gray color. This lesion -disappears gradually into the occipital microgyria behind -and the gyri gradually lose their yellowish tint. -The lesion fades away gradually so that it fails to involve -the temporal convolutions.</p> - -<p class='c015'>The cerebral tissue cuts firmly and smoothly. The -tissue of the frontal region is a little edematous. The -white matter is of a normal appearance. The ependyma -of all the ventricles is somewhat sanded. The fourth -ventricle is most affected.</p> - -<p class='c015'>The <b>cerebellum</b> is not edematous and is as firm as -the normal olivary bodies. The cerebellar hemispheres -are symmetrical and of a normal appearance, save that -the laminæ are slightly narrower than usual and very -compactly set. The color, where not obscured by the -haziness of the pia mater, is of a grayish pink somewhat -suggestive of freshly tanned shoe leather. The substance -cuts smoothly and firmly. The dentate nuclei are -unusually firm. The <b>pons</b> is small, but of the usual -color. Lower structures normal except the <b>cord</b> which -is small and shows curious deviations from the normal -markings. The posterior horns and gray commissure -are at many levels the only structures to preserve the -normal gray appearance, so that the H or butterfly -appearance is replaced by a crescent. At these levels, -traces of gray matter often stand out in the loci of the -anterior horns.</p> - -<p class='c007'>The important <b>anatomical diagnoses</b> in the nervous system -are as follows:</p> - -<p class='c007'>Atrophy of cerebrum, 965 grams (there is of course a -question whether we are not dealing with a degree of cerebral -hypoplasia).</p> - -<p class='c007'>Focal scleroses of cerebrum, suggesting the tuberous -scleroses of Bourneville.</p> - -<p class='c007'>Occipital microgyria.</p> - -<p class='c007'>Cerebral and cerebellar gliosis.</p> - -<p class='c007'>Chronic ependymitis.</p> - -<p class='c007'>Gliosis of the gray matter of the spinal cord.</p> - -<p class='c007'>Chronic diffuse and focal leptomeningitis.</p> - -<p class='c007'>The <b>microscopic examination</b> confirmed the diagnosis of -paresis. The hypertrophic nodules were of special interest. -<span class='pageno' id='Page_48'>48</span>They were found to be overlain by a characteristic though -thin exudate of lymphocytes and plasma cells, together with -pigmented cells. The nodules appeared to be supplied with -an unusual number of vessels of small calibre, about which -were a few lymphocytes. The large vessels and those with -well developed adventitiæ were surrounded by more numerous -lymphocytes and by more focal accumulations of pigmented -cells. The cortex in the middle of a nodule had almost lost -its characteristic cortical layering. The cortex was here -reduced (specimen from temporal lobe) to about one-quarter -of its normal thickness, and was found to be composed largely -of expanded neuroglia cells and vascular tissue, with a few -nerve elements, small, shrunken, and dark-staining. The -destructive process appeared to have borne hardest on the -layer of internal large pyramids and the fusiform layer. -There was, however, nowhere any evidence of focal necrosis -such as ought to characterize a true gumma. The sections -stained by the Marchi method failed to show evidence of -fatty degeneration within the focus, although there was a -marked diffuse accumulation of fatty granulations along the -nerve fibres in the underlying white matter. A special study -of the cerebellar material was made by one of the authors.<a id='r4' /><a href='#f4' class='c014'><sup>[4]</sup></a> -Occasional Purkinje cells showed the characteristic binucleate -condition, which has frequently been noted in -recent literature.</p> - -<p class='c007'>The cerebellum of this case was perhaps the most markedly -diseased of all portions of the nervous system. As noted, the -cerebellar tissue was exceedingly firm. How far the notable -incoördination of the case (he was observed on staff rounds -characteristically curled up in a heap, showing quite an unusual -degree of general incoördination) was due to the cerebellar -lesions, it is perhaps not possible to say.</p> - -<p class='c007'><b>Summary</b>: John Lawrence, <span class='sc'>Juvenile Paretic Neurosyphilis</span>, -is a foil to Case 3 (James Dixon), paretic neurosyphilis -due to acquired syphilis.</p> - -<p class='c007'>Both showed <b>Cerebral Atrophy</b>, but Lawrence the more -<span class='pageno' id='Page_49'>49</span>markedly because of hypoplasia incidental to the congenital -origin of his condition.</p> - -<p class='c007'>Whereas Dixon gave little or no sign of <b>stigmata</b>, Lawrence -(besides being under-sized, having suspicious teeth, and -showing at autopsy a persistent thymus) showed a <b>Hydromyelia</b> -and curious trefoil shape to the spinal cord. Dixon -on the other hand had liver lesions and arterial lesions of the -leg.</p> - -<p class='c007'>The suggestion of <b>Tuberous Sclerosis</b> in Lawrence is not -found in Dixon; but we have not found it elsewhere. Bourneville -did not describe tuberous sclerosis as syphilitic.</p> - -<p class='c007'>Binucleate Purkinje cells emphasize the congenital source -of the lesions in Lawrence.</p> - -<p class='c007'><b>Plasmocytosis and Lymphocytosis</b>, <b>Perivascular</b>, and (less -marked) <b>Meningeal</b>, are found in both the congenital and -the acquired cases, as also parenchymatous changes, both -<b>nerve cell losses</b> and <b>gliosis</b>. Both also show granular -<b>ependymitis</b>.</p> - -<p class='c007'>It is clear that, over and above the factors of destruction -evident in both Lawrence and Dixon, the congenital case, -Lawrence exhibits also the effects of arrest (in brief not -merely atrophy but also hypoplasia). Early treatment is, -therefore, theoretically indicated in the juvenile group, which -means early diagnosis. Early diagnosis and treatment are -still more to be recommended because these juvenile cases -progress often very slowly at first.</p> - -<div><span class='pageno' id='Page_50'>50</span></div> -<div class='box'> - -<p class='c013'><b>FOCAL BASILAR MENINGEAL NEUROSYPHILIS -(“syphilitic extraocular palsy,” plus other -symptoms). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 6.</b> Flora Black, a housewife of 43 years, had been -tired out for a year but had been apparently in fair health. -She awoke one day with double vision due to a left internal -strabismus. The visual difficulty gradually passed away so -that five months after the sudden seizure she was apparently -quite well again. There was one exception: about three or -four months after the attack of diplopia, Mrs. Black had begun -to feel a kind of weakness in various parts of the face and there -were also fairly definite paresthesiæ. In the sixth month -after the initial attack, the patient began to be unable to -chew and was fain to support the lower jaw with a bandage -to aid in mastication. Deglutition was, however, quite unaffected -and there was never any regurgitation of food. -There were pains in the face, the forehead and the back of -the neck.</p> - -<p class='c007'>Upon <b>physical examination</b> at entrance to a general hospital, -no changes in the body at large were discoverable. -There was a slight edema of the ankles, otherwise no sign -of bodily disease.</p> - -<p class='c007'>Conditions in the <b>head</b> were as follows: The facial lines -were (notes by courtesy of Dr. E. W. Taylor) smoothed out; -both upper and lower eyelids and the corners of the mouth -drooped slightly and more markedly on the left side. There -was slight photophobia and considerable lachrymation. -The patient was unable to pucker forehead, nose or mouth. -The unsupported lower jaw fell and the patient was unable -to open the mouth widely. The movements of the tongue -were normally performed. Speech was mumbling. Sensations -of touch, heat and cold were preserved all over the -face except that the left cheek below the level of the mouth -yielded a less accurate registration of tactile sensations. -A hot test tube did not feel as hot in the lower left cheek as -<span class='pageno' id='Page_51'>51</span>elsewhere. Quinine and sugar could not be tasted over the -left half of the tongue in front. Smell and hearing were also -diminished on the left side. It appeared that there was a -complete paralysis of the 5th and 7th nerves and a partial -paralysis of the 8th, 11th and 12th, as well as a defect in -smell.</p> - -<p class='c007'>The patient died suddenly, three weeks after admission, -running a slight temperature during her stay. The autopsy -showed (rather surprisingly) a double ovarian carcinoma -with metastases into the retroperitoneal glands. Both -kidneys were found to be riddled with nodules of carcinoma. -The pelvic veins were thrombosed and there was a complete -occlusion of the pulmonary artery. There was a riding embolus -in the foramen ovale and there was coronary embolism.</p> - -<p class='c007'>The striking nature of these complications and the interest -of the case neurologically would warrant its publication in -complete detail. We here present the case with utmost -brevity as an example of a <span class='sc'>Syphilitic Cranial Neuritis</span> -by extension from the meninges.</p> - -<p class='c007'>The <b>brain</b> was in general without change but there was -a considerable exudate over the entire <b>pontine region</b> which -had involved several cranial nerves. The 5th nerves, especially -the left, showed gross effects of the inflammatory -lesion. There seems to be little or no doubt that this neuritis -was of syphilitic origin despite the complication of the case -with carcinoma of the ovary and despite the fact that the -case was observed and came to autopsy before the modern -methods of systematic diagnosis could be applied. It is the -best case available to us for the demonstration of a focal -cranial nerve lesion of the type characteristic of neurosyphilis. -We may well suppose that similar conditions would have been -found at various stages in the development of Case 1 (Alice -Morton). The pontine region of Case 1 was entirely free -from lymphocytic exudate at the time of the autopsy. Possibly -the clearing up of the pontine pia mater in Case 1 was -a therapeutic effect of the thorough treatment therein used. -Whether a case like Mrs. Black’s could be cured (aside from -the ovarian carcinoma and its complications) by the institution -of vigorous systematic treatment is a matter of doubt. -<span class='pageno' id='Page_52'>52</span>Still, in a general way, these cases of focal syphilitic neuritis -are among the most favorable cases for treatment.</p> - -<p class='c007'><b>Summary</b>: We present the case of Flora Black to emphasize -how slight in extent and theoretically curable neurosyphilis -may be. We fear that Case 1 (Alice Morton) may -present too unrelieved and pessimistic a picture. The -extensive vascular lesions and complications of Alice Morton, -of Case 2 (Francis Garfield), of Case 4 (James Pierce) arrest -attention by the incurability of their residual effects (if we -omit modern attempts at reeducation of lower arcs). On the -other hand the unrelenting progress to destruction of important -parenchymatous structures, as shown in the paretic -James Dixon (Case 3) and his juvenile replica John Lawrence -(Case 5), as well as in Alice Morton (Case 1) and the tabetic -Francis Garfield (Case 2), lead to a certain justifiable pessimism. -For it is only the meningeal and fine vascular infiltrations -of these cases that we can theoretically hope to -combat, probably by destroying the spirochetes in these -meningeal and perivascular loci. We seem theoretically less -able to stop the progress of the often highly systemic and -symmetrical, parenchymatous lesions of the tabetic and -paretic group.</p> - -<p class='c007'>The condition in Flora Black is clearly much more hopeful, -both being more focal and being almost purely meningeal -and therefore accessible to therapy.</p> - -<p class='c007'>The two cases which conclude our general survey of neurosyphilis -are also focal cases, one of gumma (Lecompte) and -one of focal dural lesion (Wyman).</p> - -<div class='section'> - -<div class='figleft id005'> -<img src='images/i_052a.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>1. Pons, normal except for focal infiltration of left fifth nerve.</p> -</div> -</div> - -<div class='figright id005'> -<img src='images/i_052b.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>2. Higher power view of infiltrated left fifth nerve.</p> -</div> -</div> - -<div class='figcenter id001'> -<img src='images/i_052c.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>3. Detail of infiltrated left fifth nerve, showing: 1, diffuse infiltration with mononuclear cells; 2, perivascular infiltration; 3, strands of relatively unaffected nerve fibers.</p> -</div> -</div> - -<p class='c026'>Microscopic appearances in Case 6. Extraocular palsy (focal meningeal syphilis, especially -of left fifth nerve). Illustrates exquisite focality of the syphilitic process sometimes found, -as well as its unilaterality (giving rise to asymmetrical symptoms and signs). Process in -itself probably curable.</p> - -</div> - -<div><span class='pageno' id='Page_53'>53</span></div> -<div class='box'> - -<p class='c013'><b>GUMMATOUS NEUROSYPHILIS (“gumma of -brain”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 7.</b> Mrs. Lecompte was a woman of middle age, who, -according to the history given by her son, had been entirely -well until her final illness, which began approximately two -years before admission to Danvers Hospital. The beginning -of her trouble seemed to be chiefly headaches, which would -last continuously for several days, or more than a week at a -time. These headaches lasted throughout the course of the -disease. In the morning, on arising, she would feel very dizzy, -but this would pass away during the day. She had had a -number of spells of unconsciousness, lasting about fifteen -minutes. In these attacks she would breathe heavily, there -was frothing at the mouth, twitching of the hands, and the -eyes would roll about. Her memory failed gradually, her disposition -changed and she became very irritable. Vomiting -occurred almost every day, and at times was of a projectile -character. She became hallucinated; the hallucinations were -chiefly of a visual nature.</p> - -<p class='c007'>About four months before admission to the hospital, after -one of her seizures, the entire right side was found to be completely -paralyzed, and she complained that it was numb. -At this time, she had difficulty with her speech. In a few -days, however, she was able to talk correctly again, and in a -week she was back at work, although the right side was weak -and awkward. She continued to grow worse, and then began -to have spells lasting several days, so that it became -necessary to have her placed in a hospital.</p> - -<p class='c007'>On admission to the hospital, aside from obesity, the general -viscera showed no points of special interest, and there was -no evidence of any new growth outside of the nervous system. -She was unsteady on her feet, standing with them wide apart. -The gait was quite ataxic; the whole right side was weaker -than the left and used more awkwardly. There was a paralysis -of the right side of the face; the right angle of the mouth -<span class='pageno' id='Page_54'>54</span>drooped; the right eyelid could not be closed but remained -continuously open; nor could the right side of the forehead -be wrinkled. Vision and hearing were not affected. She -miscalled tastes and smells; whether this was due to aphasic -difficulties or to cranial nerve involvement could not be -divined. There seemed to be some difficulty in deglutition. -The knee-jerks were markedly exaggerated; slight clonus -was obtained but was not always present. Both pupils -reacted well to light and distance and consensually. Sensation -could not be readily tested. There was marked ataxia, -especially with the eyes closed. The speech was thick and -mumbling. The patient was unable to write or copy. Mentally -the patient was quite dull; at times, stuporous; when -aroused, was found to be entirely disoriented. Memory almost -entirely absent. In general she showed herself to be -very much confused.</p> - -<p class='c007'>She remained practically in this condition, even gaining in -weight, for the following two years, when suddenly one -morning, she had an epileptic seizure, vomited, coughed a -great deal, with bleeding from the mouth and ears, and died -in a few hours.</p> - -<p class='c007'>The symptoms in this case pointed to brain tumor. The -only inconsistent thing was the long-continued life,—four -years,—after the symptoms were observed. As she lived -before the W. R. and spinal fluid tests were known, no light -was gained in these ways. The post mortem examination -showed the patient had a <span class='sc'>Gumma of the Brain</span>.</p> - -<p class='c007'>The <b>summary of the anatomical diagnoses</b> at autopsy was:</p> - -<p class='c007'>Decubitus.</p> - -<p class='c007'>Lymphadenitis of the mesenteric nodes.</p> - -<p class='c007'>Chronic fibrous peritonitis.</p> - -<p class='c007'>Chronic fibrous myocarditis.</p> - -<p class='c007'>Pulmonary hypostasis.</p> - -<p class='c007'>Thrombosis of vein in right adrenal, with hemorrhage.</p> - -<p class='c007'>Syphilitic leptomeningitis.</p> - -<p class='c007'>Gumma of left hemisphere.</p> - -<p class='c007'>Focal softenings in the pons.</p> - -<p class='c007'>The <b>anatomical description of the head</b> (Dr. A. M. Barrett) -is as follows:</p> - -<p class='c015'><span class='pageno' id='Page_55'>55</span>The sutures in the <b>calvarium</b> are well outlined; -diploë large in amount. The <b>dura</b> is diffusely but -lightly adherent to the calvarium; it is very dense, -especially over the left hemisphere. The meningeal -arteries are thickened but not atheromatous. The -sinuses contain a small amount of fluid blood and post mortem -clot. The inner surface shows nothing abnormal. -There is a great flattening of the convolutions of -the left hemisphere, which is not the case on the right -side. Over the convexity, the <b>pia</b> is thin and not abnormal -except for some slight adhesions between the -frontal lobes and the two lips of the Sylvian fissures. -The pia at the base over the cisterna, pons, and medulla -is thick, cloudy, and of a grayish gelatinous appearance. -It is so thick that it is easily removable in a large piece.</p> - -<p class='c015'>The surface of the left hemisphere is dry, and the -whole brain is flabby and bulges as if from internal -pressure. A section through the hemispheres at the -region of the optic chiasm shows a hard, firm area in the -left hemisphere deep down in the white substance. It -is about 2½ cm. in diameter, with a wavy border. The -central part is of a silver-gray gelatinous-like appearance, -with red spots and whitish streaks radiating from -the centre. In the pons on the right side, in a plane passing -through the posterior corpora quadrigemina, are two -pinhead size softenings among the pyramidal fibres. -The ependyma of the fourth ventricle is granular.</p> - -<p class='c015'><b>Microscopic examination of the tumor</b>: The area -evidently contains several central necrotic foci surrounded -by zones of infiltration and proliferation, with -bordering areas of nervous tissue showing secondary -reactions. The necrotic area stains poorly. From -the edge there are projections of reddish homogeneous -bands, some intermixed with well-differentiated fibrillæ, -probably glia fibrils. The bordering zone is densely -infiltrated with lymphoid, plasma, and a few epithelial -cells. The nerve tissue outside of this zone is spongy -and infiltrated with lymphoid and plasma cells. There -are a few scattered, shrunken nerve cells. In this zone -and in the zone of infiltration near the necrotic area, -there are scattered cells resembling giant cells. There -are many obliterated vessels in the area, and other vessels -show many infiltrating lymphoid and plasma cells -in the walls. The examination of the specimen stained -by the methods for bacilli of tuberculosis are negative. -The growth is a classical gumma.</p> - -<div><span class='pageno' id='Page_56'>56</span></div> -<div class='box'> - -<p class='c013'><b>GUMMATOUS NEUROSYPHILIS (gumma of -spinal meninges, “meningitis hypertrophica cervicalis -of Charcot?”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 8.</b> John Wyman was first seen in his thirty-sixth -year by Dr. James J. Putnam. He denied syphilitic infection -and stated that the first symptoms had come four months -before. He had begun to notice a numbness of the fingers, at -first of the right hand and shortly thereafter of the left hand. -After a few weeks there had been difficulty in walking, and a -few weeks later headaches, especially on the right side, developed. -Two weeks before he was first seen medically, he -had begun to have a feeling of tightness or constriction in -his arms.</p> - -<p class='c007'>It appears that micturition had been impaired early, -that is to say, a few weeks after the initial sensory disorder -had begun. A catheter was used for a time and improvement -followed. Shortly before consultation retention of urine -developed again, this time associated with rectal incontinence. -The feet began to feel heavy and dead. Then -the legs began to be increasingly weak so that the patient -was almost bedridden. Vision appeared to be normal except -that reading was followed by fatigue. The speech -was also slow but the slowness could be attributed to fatigue.</p> - -<p class='c007'>Notes of Dr. Putnam’s <b>physical examination</b> are as follows: -The patient lay in bed on the left side, without motion, and -almost incapable of motion. The tongue was protruded, -and there was no paralysis of facial muscles, or of the eye -muscles (the right pupil had been reported to be slightly -larger than the left). There seemed to be a disinclination to -move the head, but with some effort it could be moved, and -without pain. The arms and hands were held rigidly in -median positions; many movements were possible, but all -were imperfect and of slight amplitude. The fingers were -flexed to a moderate degree, and could not easily be straightened, -and there was, in fact, a general rigidity of most of the -<span class='pageno' id='Page_57'>57</span>muscles of the body below the neck, and even, in some degree, -of the neck. The immobility was so great that the general -impression made was almost that of a patient with fracture of -the spine in the cervical region. Even the breath, and especially -the inspiration, was imperfect. The legs were more -freely movable than the arms, but still the motions were very -stiff and awkward, and of slight amplitude; with effort the -whole leg could be lifted from the bed, and flexed or extended -with moderate force. The right leg was rather stronger than -the left, but the left hand and arm were stronger than the -right. The sensibility was almost absent over the hands -and lower part of the arms, and was impaired over the entire -head and neck, except the forehead, the middle part of the -face, and the nose. It is interesting to compare the conditions -of the sensibility here present with those seen in -cervical syringomyelia. The sensibility of the upper part -of the forehead was less good than of the lower part, and there -was slight impairment even over portions of the lower jaw. -The sensibility of the left (stronger) arm was rather more impaired -than that of the right arm, while on the contrary the -sensibility of the left leg was better than that of the right -leg, though the difference between them was not great. These -statements apply to sensory tests by contact, heat, cold, and -pricking. Knee-jerks were highly exaggerated, and likewise -the wrist-jerks. All forced attempts at movements were attended -by a high degree of muscular tremor, especially when -the patient was fatigued or under emotional strain. The -fingers especially were the seat of coarse tremor.</p> - -<p class='c007'>The remainder of this clinical description (courteously supplied -us by Dr. Putnam) may be quoted. A second examination -which included also a few facts not given in the -first examination was made on the following March 28, 1905. -This report says “the ends of the fingers became numb about -June 1, 1904. Work was given up on July 3, and at that -time the patient was walking very badly. No treatment was -used and no satisfactory diagnosis made. In the course of -July he improved somewhat, and during August he was able -to ride out a little (these spontaneous improvements are of -interest for the diagnosis). He went away from home for -<span class='pageno' id='Page_58'>58</span>a short time, but from the time of his return, about the last -of September, he grew worse rapidly, and fell into the condition -above described, in which he was wholly unable to -help himself, even to turning in bed. At times he had a -great deal of pain in the neck and forehead. Antisyphilitic -treatment was recommended, and for a time potassium iodid -and other iodid preparations were given, but at first in -relatively small doses (grs. 75 daily). Under this treatment -the excretion of urine rose to four quarts daily as a maximum -though sometimes the quantity was not so great.”</p> - -<p class='c007'>Under this treatment the patient began soon to improve, -and continued doing somewhat better till about five months -later. He became able to walk downstairs and out of doors, -and regained considerable use of his hands. The quantity -of urine passed became greatly increased by the use of the -iodid.</p> - -<p class='c007'>About the middle of March he became worse again. A -careful examination of the sensibility showed that in general -the condition was much the same as that previously reported. -The iodid treatment, with perhaps some mercurial, was -resumed; the potassium iodid was given in doses which were -increased up to 850 grains daily, although this maximum dose -was taken only for about one week. This large quantity -gradually impaired the sense of taste for the time being, and -blurred his vision, but otherwise did him no harm. Under -this he improved, so that he became able to run more or -less, and went about freely, and attended to his business, -though still retaining some stiffness in his movements.</p> - -<p class='c007'>This improvement continued until about two years later, -when he again had a relapse, and was seen medically once -more. His condition at this time was still a pretty good one, -but the movements were stiff and awkward. The bin-iodid -of mercury was advised, which was taken in doses of <span class='fraction'>9<br /><span class='vincula'>25</span></span> grain -daily. It will be remembered that this was long before the -days of salvarsan treatment.</p> - -<p class='c007'>This was toward the end of June, 1907. Contrary to expectation, -there was no material gain from this treatment, -and the patient died early in October, without being seen -again.</p> - -<p class='c007'><span class='pageno' id='Page_59'>59</span>The <b>autopsy</b> was limited to the <b>nervous system</b> and the -findings were as follows (Dr. A. R. Robertson):</p> - -<p class='c015'><b>Head</b>: Hair abundant, fair, of fine texture and -rather curly. Scalp of medium thickness and strips -readily from calvarium. The latter appears normal -and upon removal is of about the normal thickness. -It lifts readily from the dura mater, except for the -numerous attachments of Pacchionian granulations.</p> - -<p class='c015'><b>Meninges</b>: The dura is smooth, moderately injected -and shows no areas of thickening; it lifts readily from -the pia-arachnoid. The pia-arachnoid shows discrete -and in many places diffuse areas of opacity. There is a -moderate amount of subpial clear fluid and the vessels -are moderately injected. Over the anterior surface -of the medulla and lower portion of the pons and largely -confined to the right side there is a very marked thickening -of the pia-arachnoid to which the dura is densely -adherent. This thickening extends down anteriorly -and laterally on the right side over the upper part of the -cervical cord. The thickened meninges over the upper -part of the medulla completely surround the right -vertebral artery, shortly before it joins its fellow of the -opposite side to form the basilar. Dissection of the -arteries shows them to be patent and thin walled. -Over the <b>cerebrum</b> and cerebellum the pia-arachnoid -strips readily leaving a smooth surface. Section of -the cerebral cortex, basal nuclei, pons and cerebellum -show no gross lesions. The ventricles are moderately -distended with fluid. The ependyma contains numerous -small cysts. Section of the <b>pons</b> shows no -lesions of the nervous tissue, but very marked thickening -of the surrounding meninges as noted above.</p> - -<p class='c015'><b>Cord</b>: Throughout the cervical and dorsal region -the dura is quite tensely distended with an abundance -of clear, light, straw-colored fluid. Upon snipping the -dura this fluid escapes with a small spurt, as if under -considerable pressure. The cord within, for the most -part, lies free, but over the upper three or four centimeters -of the cervical portion it is densely adherent to -the dura anteriorly and laterally on the right side. -Cross sections were made through the upper three or -four centimeters of the cord, and over this area the cord -is constricted by very marked thickening of all the -meninges. The meninges here average from one to -three millimeters in thickness. On the right side and -<span class='pageno' id='Page_60'>60</span>somewhat anteriorly opposite the junction of the atlas -and axis there is a single nodular, firm mass which -on section shows a yellowish, firm center surrounded by -very dense, pearl-gray tissue. The demarcation between -the homogeneous yellowish centre and its surrounding -gray tissue is very sharp. This nodule -measures about 0.75 to 1 cm. in diameter. The adjacent -cord is deeply indented by it. Below this nodule there -is a translucent, grayish appearance of both posterior -sensory columns which extends downwards and diminishes -in intensity until it finally disappears in the -upper dorsal region. This same appearance is well -marked on the right outer margin of the upper cervical -cord corresponding to the crossed pyramidal tract, and -extends downwards diminishing in intensity until it -disappears about the mid-dorsal region. The left -pyramidal tract appears to be similarly but very -slightly involved; section of the lower dorsal cord entirely -negative. <b>Microscopically</b>, characteristic <span class='sc'>Gumma</span>.</p> - -<p class='c007'>It is a question whether this case is one of the group described -in 1871 by Charcot under the name of <em>pachymeningitis -cervicalis hypertrophica</em>. Charcot did not regard his -new disease as syphilitic, and it is very probable that syphilis -is not responsible for all cases. Charcot, however, noted that -his new disease was not incurable: he noted that the resulting -paraplegia, although it might be very marked and -accompanied by flexion of the leg on the thigh and although -the paraplegia might have lasted a very long time, might -end in recovery. Charcot thought that surgical intervention -was necessary. He described three periods in the disease, -the first or neuralgic (pseudo-neuralgic) was characterized by -sharp pains in the neck and by the sensation of constriction -in the upper part of the thorax. The second phase of the -disease was, according to Charcot, the paralytic phase, in -which a cervical paraplegia accompanied by muscular atrophy -developed. Sometimes cases were found to remain in this -paralytic phase and even to end spontaneously in cure. If -the muscular atrophy was degenerative, then the atrophy -was never replaced; but, according to Charcot, some cases of -atrophy were simple and accordingly curable. If, however, -<span class='pageno' id='Page_61'>61</span>the spinal cord itself became involved in the meningeal -inflammation, then phenomena of transverse myelitis set in -with a spastic paraplegia and involvement of the bladder and -rectum. Muscular atrophy never developed in the legs, at -least in typical cases.</p> - -<p class='c007'>Among the causes of this condition the following have -been mentioned: cold, overexertion, alcoholism, tuberculosis -and syphilis. Syphilis undoubtedly plays the major -part. Even before the days of the W. R., observers, among -whom may be mentioned Dejerine-Tinel and Pförringer, -discovered syphilis in nearly all sufferers from <em>pachymeningitis -cervicalis hypertrophica</em>.</p> - -<p class='c007'>It should be differentiated from caries of the spine and -cord and meningeal tumors. The spinal fluid examination -makes this somewhat easy.</p> - -<p class='c007'>Antisyphilitic remedies are indicated, and should be tried -even when the etiology is obscure, if only as a therapeutic -test.</p> - -<div><span class='pageno' id='Page_62'>62</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c002'> - <div class='linegroup'> - <div class='group'> - <div class='line'>But what have been thy answers? What but dark,</div> - <div class='line'>Ambiguous, and with double sense deluding,</div> - <div class='line'>Which they who asked have seldom understood,</div> - <div class='line'>And, not well understood, as well not known?</div> - </div> - <div class='group'> - <div class='line in24'>Paradise Regained, Book I, lines 434–437</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_63'>63</span> - <h2 class='c005'>II. THE SYSTEMATIC DIAGNOSIS OF THE MAIN FORMS OF NEUROSYPHILIS</h2> -</div> - -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general paresis”) -sometimes persistently receives the diagnosis -NEURASTHENIA simply through omission to -apply approved diagnostic methods.</b></p> - -</div> - -<p class='c006'><b>Case 9.</b> Greeley Harrison, a man of 46, certainly looked -like a neurasthenic. He wanted aid for nervous indigestion -of years’ standing, headache, insomnia, nervousness, failing -memory, and deafness. He volunteered, in fact, that he had -neurasthenia, and that he had been treated for this by hypophosphites.</p> - -<p class='c007'>During the practically negative <b>physical examination</b>, Harrison -complained of headache and throbbing in the head, -and during examination of the abdomen felt much nauseated -and proceeded to vomit rather persistently. There were -hemorrhoids.</p> - -<p class='c007'><b>Neurological examination</b> showed that the left pupil was -smaller than the right, was irregular, failed to react consensually, -and reacted very slowly to direct light. For the -rest, however, the neurological examination was negative. -On account of the nausea and vomiting, special examination -of the gastric contents was made, but nothing abnormal -was found.</p> - -<p class='c007'><b>Mentally</b>, it was rather striking that the patient’s memory -was quite inaccurate both for remote and for recent events. -His school knowledge was very meagre. As for delusions, -the only approximation thereto was the patient’s continually -dwelling upon his bodily symptoms. Emotionally, he varied -between depression and a sanguine attitude.</p> - -<p class='c007'><span class='pageno' id='Page_64'>64</span>Although there was no symptom directly suggesting syphilis -in the Harrison case, the slightly abnormal pupillary -reactions and the amnesia warranted the suspicion of syphilis. -The blood and spinal fluid both proved positive to the W. R.; -the gold sol reaction was of the “paretic” type; there were -18 cells per cmm.; there was considerable globulin, and an -excess of albumin. On the whole, therefore, we felt entitled -to make the diagnosis <span class='sc'>General Paresis</span>. Why should -not a careful observer have considered syphilis seriously? -Yet in our experience such cases are frequently diagnosticated -neurasthenia, thus entailing dangerous delay in treatment -(in this case, five years’ delay).</p> - -<p class='c007'>Going over the history of the case with still greater detail, -we learned that for a number of years past, there had been -symptoms of a neurological nature. For instance, five years -before, at the age of 41, the patient had been apparently overcome -when working near a stove, and went upstairs talking -incoherently, but recovered shortly. Thereafter, such spells -occurred almost every month; later, more frequently; still -later, the attacks were associated with unconsciousness and -amnesia. Occasionally preceding the attack there would be -twitching of the mouth, jerking of the arms, and incoherent -talk. Throughout these last five years, in point of fact, the -patient had been unable to do regular work, had been given -to much complaining, and had been far less efficient than -formerly. In short, it would seem that, with the improved -technique now in the possession of medical science for the -diagnosis of general paresis, cases like that of Harrison will be -diagnosticated earlier and earlier.</p> - -<p class='c027'>1. How typical is the insidious onset of symptoms in the -case of Harrison? The onset of symptoms in neurosyphilis -is ordinarily considered to be sudden, and this -statement is generally true despite the fact that after -the diagnosis is established a number of mild prodromal -symptoms can be remembered by the relatives. -However, some cases, of which Harrison is an example, -have an exceedingly insidious onset without sudden access -of striking symptoms. Joffroy and Mignot remark -that with the improvement of clinical methods, -the course of paretic neurosyphilis must now be stated -<span class='pageno' id='Page_65'>65</span>to take some six or seven years for completion. In -point of fact, there were early episodic symptoms -(seizures almost monthly) which should not have escaped -medical attention. They did escape medical -attention, however, and Harrison was wont to say -“Why wasn’t I told that my disease was syphilis five -years ago?”</p> - -<p class='c027'>2. Is there such a disease as syphilitic neurasthenia? According -to Kraepelin, syphilitic neurasthenia has been -described as occurring shortly after infection and in -the first stages of syphilis. There are milder and -severer forms; the milder forms show discomfort, difficulty -in thinking, irritability, insomnia, cephalic pressure, -indefinite variable, uncomfortable sensations, and -pains. The severer cases acquire anxiety, more pronounced -emotional disorder, dizziness, disorder of -consciousness, difficulty in finding the right word, -transient palsies, pronounced sensory disorders, nausea, -and increase of temperature. Kraepelin is in doubt -whether there is any definite clinical picture of this sort, -and whether there is any causal relation between the -syphilitic infection and such symptoms as those described. -If the effect of knowledge concerning infection -is a merely psychic effect, then it is improper to term -the neurasthenia in question a syphilitic neurasthenia. -For the relation of hysteria to the acquisition of syphilis, -see below the case of Alice Caperson (46). In point of -fact, modern work has shown even in the primary and -secondary stages of general syphilis more or less pronounced -neurosyphilitic phenomena in the shape of -the so-called meningitic irritation of French authors. -(Besides the case of Caperson (46), see the case of -Fitzgerald and the discussions under these cases.)</p> - -<p class='c027'>3. What is the relation of the early symptoms of this case -to the so-called preparesis of Dana? The case might -well have been an example of Dana’s preparesis. For -a discussion of this, see Case of William Twist (13).</p> - -<p class='c027'>4. What is the classical differential diagnosis between -paretic neurosyphilis and neurasthenia? The testing -of the blood by the W. R. is unconditionally necessary. -If the W. R. is negative, the diagnosis of paretic neurosyphilis -is extremely improbable. (It must be borne in -mind that a number of cases of paretic neurosyphilis -have been shown to have a negative W. R. in the serum, -and receive a proper diagnosis only after spinal fluid -examination.) Next to the serum W. R. stand the -<span class='pageno' id='Page_66'>66</span>pupillary and aphasic symptoms. In the presence of -Argyll-Robertson pupil or even a slight speech defect, -the diagnosis of neurasthenia must certainly be made -with caution if at all. Kraepelin remarks: The sudden -occurrence of neurasthenic disorders in a male of -middle age without any evident cause therefor is always -suspicious. Yet it must be emphasized that a -complaint of occasional dizziness, slight speech defect, -tremor of tongue, and a moderate increase of tendon -reflexes do not possess any marked diagnostic significance. -Clear insight and understanding of the -nature of the disease phenomena, a persistent search -for recovery, reasonableness in conversation, progressive -improvement under appropriate treatment, speak for -neurasthenia.</p> - -<p class='c028'>Joffroy and Mignot differentiate what they call -preparetic neurasthenia from other neurasthenic states, -not only on the basis of its etiology but on the basis of -its symptoms. They also call attention to the fact that -neurasthenia, being a pure neurosis, develops either on -a manifestly hereditary basis or upon some physical -injury, weakening disease, or moral shock. The pure -neurotic suffers a great deal more than the patient who -is destined to become a victim of paresis. The character -change in neurasthenia does not amount to that -entire transformation of personality (even to the performance -of criminal acts) that we find in paretic -neurosyphilis; at the most, the neurasthenic shows -minor emotional disturbances and a certain pathological -egoism. The psychotherapeutic test also rather -readily dissipates many of the neurotic, hypochondriacal -fears and feelings. Although both pure neurasthenia -and the paretic pseudoneurasthenia are characterized -by sexual weakness, the sexual anæsthesia of the -preparetic is practically always preceded by a stage -of sexual over-excitement. These finer clinical indications, -however, fade into insignificance beside the -data that can and should be obtained from laboratory -tests.</p> -<p class='c027'>5. How exceptional is such a case as that of Harrison? We -have in our experience seen many patients with a -similar course and configuration of symptoms, although -the majority of these cases in a community advanced -enough to provide easy access to a Wassermann laboratory -are now diagnosticated far earlier than was the -case of Harrison.</p> - -<p class='c027'><span class='pageno' id='Page_67'>67</span>6. What attitude shall we take toward so-called syphilophobia? -It seems to us that resort to a serum W. R. -is indicated, both from the standpoint of the community -and still more importantly from the standpoint of the -patient. We are even inclined to suggest for a case of -persistent syphilophobia, when the serum W. R. has -proved negative, a lumbar puncture. Syphilophobia -must be considered, not as a syphilitic psychosis, but -as a phobia to be classified among the psychoneuroses. -It becomes a difficult question to decide at times -whether a patient who has had syphilis, has had a -considerable course of treatment and shows the symptoms -of a syphilophobiac should be further treated for -syphilis or merely for his phobia. We have seen recently -such a patient who gave a certain history of -syphilis and who was greatly disturbed lest he should -be developing paresis. This fear bothered him greatly. -Examination showed irregular pupils, but no other -signs of syphilis. The W. R. in blood and spinal fluid -was negative as were the other spinal fluid tests. It -was considered wise to treat him only for his phobia -and under this treatment he was given some relief.</p> - -<div><span class='pageno' id='Page_68'>68</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general paresis”) -may look precisely like MANIC-DEPRESSIVE -PSYCHOSIS.</b></p> - -</div> - -<p class='c006'><b>Case 10.</b> The mental picture in Lyman Agnew, an architect, -58 years of age, was wholly characteristic of manic-depressive -psychosis. In the first place, there had been (at -55) a previous attack of depression, lasting a few months, -from which Agnew had completely recovered. He had -remained entirely well up to four months before consultation. -(Manic-depressive psychosis is, at least in a majority of -cases, hereditary. There had been mental disorder in one -maternal cousin, and mental impairment in the patient’s -mother some time before her death from cerebral hemorrhage. -There was no other report of mental disease in the family.)</p> - -<p class='c007'>It appears that in the interval between attacks, Agnew -had been working very hard and had been fairly successful -in paying off a mortgage on his house. A marked elation, -somewhat natural, followed this success and continued to an -abnormal degree. Agnew labored under considerable excitement, -was over-fussy, and at times showed a flight of -ideas. His mania or hypomania gradually diminished and -depression set in, in which depression he arrived for consultation. -He had marked ideas of self-accusation, was emotionally -unstable, wept much, and showed a characteristic -retardation of activities and unrest.</p> - -<p class='c007'><b>Physically</b>, there was no neurological disorder. The patient -appeared rather under-nourished. The heart borders lay -2 cm. to the right and at 11½ cm. to the left of the mid-sternal -line. The aortic second sound was very loud. There -was a moderate radial arteriosclerosis. Systolic blood pressure -was 210, diastolic 155.</p> - -<p class='c007'>The high blood pressure suggested nephritis, possibly of -arteriosclerotic origin, but urine examination and blood-nitrogen -tests yielded no evidence of kidney disease. Moreover, -it is our experience that a manic-depressive psychosis -<span class='pageno' id='Page_69'>69</span>in persons past middle life is not infrequently complicated -by high blood pressure. In point of fact, some authors insist -upon a relation between manic-depressive psychosis and -the arteriosclerosis which rather frequently sets in in this -disease.</p> - -<p class='c007'>Routine examination of the blood serum, however, yielded -a positive W. R. Following the approved rule of making an -examination of the spinal fluid in all mental cases having a -positive serum W. R., we proceeded to lumbar puncture. The -fluid was clear and contained 35 cells per cmm., the albumin -was in excess, and there was a positive globulin reaction. -The gold sol reaction was of the “paretic” type; the W. R. -was strongly positive.</p> - -<p class='c007'>On this basis, it seems worth while to consider the diagnosis -of <span class='sc'>General Paresis</span> or that of some form of non-paretic -neurosyphilis. The former is the diagnosis which we -prefer.</p> - -<p class='c027'>1. What is the classical differential diagnosis between -manic-depressive psychosis and neurosyphilis? The laboratory -tests have naturally supplanted the older purely -clinical methods of differential diagnosis. The difficulties -lodge, in the first instance, in depressive states. -It would appear to be impossible on purely clinical -grounds in certain cases to tell the depression of neurosyphilis -from the depression of manic-depressive psychosis, -since the slightly greater interest in the outer -world taken by manic-depressive patients and their -greater responsiveness to diagnostic threats (suggestion -that patient is to be pinched or cut) are of no special -value in the individual case. Identical considerations -hold for the maniacal phases of manic-depressive psychosis, -for these maniacal phases may even develop delusions -(Kraepelin) of precisely the same nature as the -characteristic expansive delusions of the excited paretic.</p> - -<p class='c027'>2. If the clinical symptoms are insufficient in differential -diagnosis, are not the pupillary signs and the speech -defect of greater value? They are of value if present, -but as in the case of Agnew, the victim of neurosyphilis -may show no pupillary or speech disorder. Instances -are familiar, also, in which the pupillary and speech -signs are absent in very advanced cases of non-paretic -or even of paretic neurosyphilis.</p> - -<p class='c027'><span class='pageno' id='Page_70'>70</span>3. Would not a circular course or recurrence of attacks -be decisive for manic-depressive psychosis? Paretic -neurosyphilis sometimes exhibits the same circular -or recurrent course. We conclude that neither the -clinical symptoms, the classical pupillary and speech -signs, nor the ups and downs of a particular disease, are -at all decisive as between manic-depressive psychosis -and paretic neurosyphilis. Resort must be had to -laboratory tests.</p> - -<p class='c027'>4. What is the significance of the high blood pressure in -paretic neurosyphilis? Work from our laboratory -(Southard and Canavan) has shown plasma cells in -the kidneys in 17 out of 30 paretics (56%), and in -16 of these 17 paretics with renal plasmocytosis, the -plasma cells were found in the periglomerular region. -What the relation of these findings may be to heightened -blood pressure is as yet unknown. The severe syphilitic -involvement of the aorta so characteristic in paretic -neurosyphilis, as in other forms, may possibly have a -bearing on blood pressure.</p> - -<div><span class='pageno' id='Page_71'>71</span></div> -<div class='box'> - -<p class='c013'><b>A POSITIVE SERUM WASSERMANN REACTION -associated with mental symptoms (even -with grandiosity) does NOT prove the EXISTENCE -OF PARETIC NEUROSYPHILIS (“general -paresis”).</b></p> - -</div> - -<p class='c006'><b>Case 11.</b> Juliette Lachine came to a general hospital -with pain in the right upper quadrant of the abdomen, wherein -was found an enlarged liver. This liver was regarded as -syphilitic on the ground that the patient had a positive serum -W. R. and that her two elder children were clearly suffering -from congenital syphilis. The liver mass was promptly reduced -by antisyphilitic treatment of the classical sort. -When, however, the patient was given an injection of salvarsan, -she shortly began to develop marked mental symptoms, -whereupon she was removed to the Psychopathic Hospital.</p> - -<p class='c007'>The <b>mental picture</b> at the Psychopathic Hospital was as -follows: Lack of orientation for time, marked distractibility -of attention, with a certain jumping from one subject to -another, delusions of a religious nature, claims of wonderful -powers possessed by the patient, moods variable, though as a -rule of a euphoric and elated nature, with laughing and singing. -The activity seemed to be of a mental rather than a -peripheral nature. The patient did not regard herself as -mentally abnormal. The liver was still 4 cm. below the costal -margin in the nipple line. We found the W. R. to be positive -in the serum but negative in the spinal fluid. In fact, the -spinal fluid was entirely negative.</p> - -<p class='c007'>So far as we are aware the picture presented by this case -is one of <span class='sc'>Manic-Depressive Psychosis</span>. We regard the disease -as merely complicating the syphilis, although it is entirely -possible that some visceral condition incidental to the -syphilis might be proved (in a higher stage of psychiatric -science) to have produced the mania.</p> - -<p class='c007'>In any event, the patient quite recovered from her mental -symptoms in a month. She was then able to tell us of a -<span class='pageno' id='Page_72'>72</span>previous attack of depression some 12 years previously, -namely, at the age of 26. It appears that she had at that time -been committed to a hospital for the insane.</p> - -<p class='c027'>1. In this case, in which the diagnosis of manic-depressive -psychosis and not paretic neurosyphilis was made, -are we sure that the symptoms that we term manic-depressive -psychosis were not actually produced by -syphilotoxins? In other words, in the absence of -spinal fluid signs of inflammation or chemical change, -might it not be possible for generalized syphilis outside -the nervous system to produce manic-depressive -symptoms? There is so far in the literature no experimental -or other evidence of syphilotoxins. The existence -of products and substances permitting the W. R. -and the gold sol reaction is not of course evidence of -syphilotoxins. Although there is no evidence of soluble -syphilotoxins, it is thought that in the so-called Järisch-Herxheimer -reaction (the intensification of clinical -symptoms after salvarsan injection) effects may be -due to the liberation of products from the killed bodies -of spirochetes. Such endotoxins are not here in -question.</p> - -<p class='c027'>2. Is visceral syphilis, such as gumma of the liver, able to -produce characteristic syphilitic reactions in the spinal -fluid? We have had an autopsied case in which there -was a “paretic” gold sol reaction of the fluid (though -without other signs). The autopsy showed gummata -of the liver. However, the finer anatomy of the nervous -system showed a mild but definite meningo-encephalitic -process, which was doubtless responsible -for the gold sol reaction.</p> - -<p class='c027'>3. What is the value of grandiose ideas? Ballet distinguishes -two groups of grandiose ideas: (<em>a</em>) ideas of self-satisfaction, -including ideas concerning extraordinary -capacity, strength, power, and wealth on the part -of the patient; and (<em>b</em>) ideas of ambition; the latter -being of a more exact, constant, uniform and systematizing -nature. The more vague and less systematized -ideas of self-satisfaction rest in a phase of contentedness -and optimism; the more definite ideas of pride and -ambition are responsible for striking transformations -of personality. General paresis shows, according to -Ballet, these ideas of self-satisfaction in their most -developed form. A certain variability, absurdity, incoherence, -<span class='pageno' id='Page_73'>73</span>and contradictoriness characterize these -ideas and the patient has little or no insight into their -nature. When such ideas occur at the outset of the -disease, they naturally may be of medicolegal interest. -Cotard explains these ideas of megalomania on the part -of paretics on the ground that they are essentially motor -or will disorders and rest upon a sort of hyperbulia, -exhibiting itself in exuberant activity. Régis has -thought that the delusional generosity and liberality -of the paretic, and his willingness to lend his wealth -and talents to social progress, is helpful for diagnosis -when contrasted with the more personal egoism of the -victim of manic-depressive psychosis. The self-satisfaction -of the manic-depressive patient often does not -reach a delusional stage, but remains a mere feeling of -pathological well-being or euphoria. The maniacal -patient may compare himself with some great man but -he does not identify himself with him. It must be -remembered that these ideas of self-satisfaction occur -also in alcoholism, but according to Ballet they occur -only in the dementing phase of chronic alcoholism, -and have no special diagnostic value. They may be -a clinical stumbling-block for a time in the cases of -alcoholic pseudoparesis. As for the ideas of ambition -in which the patients believe themselves to be -princes, emperors, divine messengers, and the like, these -are less characteristic of paretic neurosyphilis than of -delusional psychoses of a non-syphilitic nature. At -all events, such ideas if definite, of long-standing, -and systematized by the patient to form a thorough-going -portion of his life, are not characteristic of neurosyphilis. -The victim of paretic neurosyphilis can as a -rule be persuaded out of his delusions, at least for -the time being. These distinctions, it must be added, -are hardly of value in the early cases of any of the -psychoses in question, and cannot be made as a rule in -either private or psychopathic hospital practice. Typical -examples of grandiosity, although not so frequent -as might be thought from textbooks, are always on display -in institutions for the chronic insane.</p> - -<div><span class='pageno' id='Page_74'>74</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general paresis”) -may look precisely like DEMENTIA -PRAECOX. Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 12.</b> Henry Phillips remains a striking case in the -memory of those who knew him and his medical findings. -Phillips came to the hospital voluntarily at 42 years of age -from the bank where he worked as a clerk; he came at the -suggestion of his employer. It seems that he had been -annoying his associates because he had fallen into a habit of -continually scratching himself. Phillips was entirely sure -that he was the victim of what he called the “Scotch itch,” -and explained off-hand that this itch had been put upon him -by the Free Masons as a matter of revenge because he would -not join their order. He said once, for example: “At -times I feel like raising Hell; then I get a psychic intimation; -and then I get to using a foot-rule on my back and to slapping -my face.” He explained this psychic intimation as coming -from the order of Scottish Rites. Another example of talk is -as follows: “My father is a fighting man; that is part of it. -They mean to throw me down. I am through now trying -for membership in the Free Masons. They have good cause, -they must fight. They do not want me for some personal -matters. I can go just so far in agreeing and seconding their -advances, but in the end it fails. I have no strength nor -endurance.”</p> - -<p class='c007'>Aside from these delusions, there was little abnormality -to be found, though his recollection for minor events of the -immediate present was inaccurate. He was rather abnormally -impulsive, gesticulating a good deal while talking, -and was of the appearance that the laity call “nervous.” -It appears that he had always been peculiar, subject to -violent fits of temper, in which fits he might throw things at -other members of the family. He always had pronounced -likes and dislikes which he never concealed. He had never -had friends, had always been secretive; and he was often -<span class='pageno' id='Page_75'>75</span>termed a great student. For some five years he had been -studying Japanese from time to time, associating himself -with a Japanese.</p> - -<p class='c007'>It never does to jump at the diagnosis dementia praecox. -However, the picture seemed characteristic enough for the -paranoid form of this disease. Physically, Phillips had -no particular abnormality; the knee-jerks were a little lively, -and the pupils reacted a little sluggishly. However, the -routine W. R. of the serum proved to be positive. Examination -of the spinal fluid was resorted to,—as in all cases -with a positive serum W. R.—and it also proved to be -positive and strongly so; the globulin and albumin were increased, -and there was a pleocytosis. A diagnosis of neurosyphilis -was hardly avoidable. Phillips later admitted a -chancre, which he claimed was located on the mucous membrane -of the cheek and acquired by using the same utensils -as his Japanese friend, which friend, he stated, had active -syphilis.</p> - -<p class='c007'>Antisyphilitic treatment of considerable intensiveness -was begun, with intravenous injections of salvarsan and -intraspinous injections of salvarsanized serum, but the -patient grew steadily worse. His mental symptoms became -more marked, although not especially characteristic of general -paresis. <b>Neurologically,</b> he did develop signs more suggestive -of general paresis, and 18 months later died.</p> - -<p class='c007'>The <b>autopsy</b> showed features of <span class='sc'>General Paresis</span>. It is -not necessary to enter into the question of the details of histological -correlation at this time.</p> - -<p class='c027'>1. What conclusion can be drawn from lively knee-jerks? -Lively knee-jerks are of very little significance. Not -only certain neurosyphilitics but also a variety of neurotic -persons, victims of dementia praecox and hysteria, -are very prone to have active tendon reflexes. Of -course, extreme degrees of exaggeration are of importance, -and especially an association of the hyperreflexia -with the Babinski reaction, the Gordon, or Oppenheim -reflexes, ankle clonus, and the like.</p> - -<p class='c027'>2. Is there any special or differentiating factor in an extragenital -chancre as against a genital chancre? Probably -<span class='pageno' id='Page_76'>76</span>this question should be answered in the negative. -Some have claimed that chancres draining by lymphatic -channels of the head are more likely to lead to -cerebral syphilis. This idea cannot be said to be -established.</p> - -<p class='c027'>3. Is there any significance in the story, if true, that -Phillips acquired his syphilis from a Mongolian? It -seems to be fairly well established that syphilis of the -nervous system is extremely rare in China and Japan, -whereas bone syphilis is very frequent there. It has -been held that this has to do (<em>a</em>) with strains of -spirochetes, (<em>b</em>) with the state of civilization, or (<em>c</em>) -with the degree of “syphilization.” Apparently when -a race is first infected with syphilis the lesions are -chiefly of the cutaneous and osseous systems; only in -later generations the vascular and nervous systems -suffer. However, involvement of the nervous systems -of Mongolians resident in this country is no rarity, a -point possibly in favor of the theory of special strains -affecting the nervous system as prevalent in western -countries. Little or nothing is known as to the effect -of transmission from one race to another, as from -Mongolian to Caucasian in Phillips’ story.</p> - -<div><span class='pageno' id='Page_77'>77</span></div> -<div class='box'> - -<p class='c013'><b>NEUROSYPHILIS is NOT to be entirely ruled out -by a negative serum Wassermann Reaction; for -the fluid Wassermann Reaction may be positive.</b></p> - -</div> - -<p class='c006'><b>Case 13.</b> William Twist is a case of note in the matter -of the so-called preparetic period (the idea of Charles L. -Dana which was scoffed at when first proposed by him in 1910). -The patient, a very successful traveling salesman, 35 years -of age, was admitted to the Psychopathic Hospital showing -a typical picture of general paresis.</p> - -<p class='c007'>Thus, <b>mentally</b>, the patient showed elation, grandiosity -(millions of dollars to give away), intellectual weakness, -disorder of memory, lack of judgment, rambling talk, speech -defect, omission of letters in writing and spelling.</p> - -<p class='c007'><b>Neurologically</b>, there was tremor of the lips, slight irregularity -of the pupils, which however reacted well, and lively -knee-jerks.</p> - -<p class='c007'>Mr. Twist had sought advice at our out-patient department -in his thirty-third year. The records show that at that -time he was somewhat depressed, and his speech was even -then, according to his own statement, stammering. However, -we found the W. R. at that time to be negative in the blood -serum. It appeared that his mother had died of consumption; -his father was said to have committed suicide. A -brother had once recovered from an attack of depression, -presumably an attack of manic-depressive psychosis. Accordingly, -we thought at the time that the case was probably -one of manic-depressive psychosis. Moreover, our routine -serum W. R. failed to indicate any syphilitic process. As for -the so-called stammering of speech, this appeared to be a -matter of the patient’s own recollection rather than of our -observation. In any event, the patient had gone into the -country and appears to have entirely recovered; falling, again, -however, into mental difficulties after a short period, and -finally arriving at the hospital in the above-mentioned classical -condition.</p> - -<p class='c007'><span class='pageno' id='Page_78'>78</span>The W. R. in the blood serum proved again negative. -The test was repeated a number of times; also, after salvarsan -had been given. The salvarsan did not act provocatively, -and the blood serum has remained consistently negative.</p> - -<p class='c007'>In cases of syphilis the W. R. is at times negative. Swift -claims that in such cases an injection of salvarsan will often -produce a positive W. R. if the blood is tested on several days -following the injection.</p> - -<p class='c007'>The spinal fluid, however, did show a positive W. R. as -well as a gold sol reaction of a “paretic” type. There were -at the first examination 194 cells per cmm., there was a moderate -excess of albumin, and a positive globulin test. In -short, there was no question of any other diagnosis than -<span class='sc'>General Paresis</span>.</p> - -<p class='c027'>1. How can the negative W. R. of the blood serum be explained? -It is difficult or impossible to explain this. -Figures differ as to the percentage of cases of general -paresis with negative blood serum; perhaps 3 to 5% of -these cases yield a negative serum W. R.</p> - -<p class='c027'>It is important to note the long preparetic period: at -least a year and a half. Could our diagnostic methods -be sharpened a trifle, such cases as these could be obtained -early in this preparetic period and it might -then be safe to promise good therapeutic results.</p> - -<p class='c027'>2. What is the nature of the preparesis of Dana? When -Dana’s brief paper on preparesis was written, there -was of course hardly any idea that cases of paretic -neurosyphilis could be cured or would recover, except -possibly vanishingly few <i><span lang="la" xml:lang="la">curiosa</span></i> about which there -would always rage a diagnostic question. Accordingly, -Dana, having found certain cases that seemed to him -to have early signs of paresis but had apparently been -cured by treatment, proposed to call them cases of -preparesis. His idea was that he would thereby not -offend those who held that general paresis was theoretically -a fatal disease. With modern work and the display -of more and more atypical cases of neurosyphilis, -and the observation of relatively numerous -cures or remissions under treatment, the designation -of preparesis for a separate entity, or even for a sub-form -of neurosyphilis, becomes superfluous.</p> - -<p class='c027'><span class='pageno' id='Page_79'>79</span>3. What is the percentage of cases of paretic neurosyphilis -that show a negative serum W. R.? Among the best -figures are those of Müller, who found that of 386 examples -of paretic neurosyphilis, 379 showed all reactions -positive, or 98.5%.</p> - -<p class='c027'>4. What is the meaning and value of the so-called provocative -salvarsan injection? In practice, there may -be a series of negative W. R.’s in the blood serum -before a positive reaction is finally obtained, owing to -technical difficulties or biological peculiarities. Where -intensive work is being done upon the neurosyphilis -problem, it is beyond question desirable to make the -W. R. test upon at least three separate samples of blood -drawn at intervals, for the second or third test may -prove positive. This situation makes the interpretation -of the so-called provocative salvarsan injection exceedingly -doubtful; that is, the reaction might have been -positive on repetition without the injection of salvarsan. -The present case, as above stated, failed to yield a serum -W. R. even after repeated tests and the “provocative.”</p> - -<p class='c027'>5. What is the significance of the irregular pupils in this -group? Paretic neurosyphilis shows inequality of the -pupils in a high per cent of cases. Irregularity of outline -of the pupils is commonly thought to be an important -sign and to suggest neurosyphilis. It is true -that many cases of pupillary irregularity are syphilitic, -but the sign is of little or no differential value since -congenital malformations and relics of old injuries and -adhesions may produce effects identical with those of -neurosyphilis.</p> - -<div><span class='pageno' id='Page_80'>80</span></div> -<div class='box'> - -<p class='c013'><b>DIFFUSE (that is, meningovasculoparenchymatous<a id='r5' /><a href='#f5' class='c014'><sup>[5]</sup></a>) -NEUROSYPHILIS is typically associated -with six positive tests (serum Wassermann reaction, -fluid Wassermann reaction, spinal fluid gold sol -reaction, pleocytosis, positive globulin, excessive -albumin); but one or more, and frequently several, -of these tests are likely to run mild as -compared with the tests in PARETIC NEUROSYPHILIS -(“general paresis”). The clinical course -of the diffuse (and especially the meningovascular) -cases is likely to be protracted, with a good prognosis -as to life (barring fatal vascular insults).</b></p> - -</div> - -<p class='c006'><b>Case 14.</b> We shall present the case of John Jackson, a -surveyor, 31 years of age, suffering from a left hemiplegia, -with this in mind: To exhibit difficulties in diagnosis in the -presence of an embarrassment of symptomatic riches.</p> - -<p class='c007'>The patient arrived at the hospital, in the first place, because -he had been threatening a woman who lived next door -to him. He believed that this neighbor had been talking -about him and circulating reports against him. Excited by -these ideas, he had threatened to cut her throat.</p> - -<p class='c007'>Now the occurrence of hemiplegia in adult life before the -approach of senium is always suspicious of syphilis, and this -suspicion we naturally entertained from the beginning. -However, there was upon the scalp a crooked linear furrow -about six inches long, running from the vertex to the right -parietal eminence. Another furrow about an inch long -was present upon the forehead. These furrows appeared to -be of a bony nature and were not tender. There was evidence -of an old decompression operation on the right side of -the head; there were also large scars on both sides of the -neck, evidently the result of old operations; and there were -numerous palpable glands—the largest about the size of -a lima bean—all firm and not tender.</p> - -<div class='figcenter id002'> -<img src='images/i_080.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Station in syphilitic hemiplegia. Syphilitic pigmentation of skin.</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_81'>81</span>It seems that at the age of eight, according to the patient’s -mother, Jackson had received a head injury and had remained -unconscious for three weeks. Upon recovery, he -had to relearn both to walk and to talk; however, he was -able to begin school where he left off. He became more nervous -and irritable after the accident than previously. Nothing -further had developed until, at about 25 years of age, a -tubercle was discovered in his eye (the right pupil was -smaller than the left, reacting more slowly; right iris bound -down by adhesions, with white opacity of anterior chamber). -For two years, 25 to 27, the patient was under medical -treatment for tuberculosis, and at the conclusion of this -period numerous glands were removed from the neck and -diagnosticated tuberculous. However, the neck did not -heal and he carried bandages upon it for two years.</p> - -<p class='c007'>At 28, the patient’s mother described the occurrence of -a slight shock, with head retraction, for a minute or two, -and inability to speak. Thereafter there had been five or six -similar attacks, less severe, and without loss of speech. The -attacks were never accompanied by convulsive movements. -Then occurred a paralytic stroke, leaving the patient with a -left hemiplegia, which had somewhat improved. Mentally, -the patient had gone down hill, becoming less alert and more -apathetic, and to some extent amnestic. One had to consider, -accordingly, the somewhat doubtful possibility of -post-traumatic and post-operative conditions, and the question -of tuberculosis (possibly errors in diagnosis; the lungs -showed no evidence of tuberculosis).</p> - -<p class='c007'><b>Physically,</b> the signs of a left hemiplegia were appropriate. -Spasticity on the left side was found; there were Babinski, -Gordon, Oppenheim reflexes and ankle clonus on the left -side (all absent on the right). Speech defect was present. -<b>Mentally,</b> aside from the delusions noted at the beginning of -our analysis, a striking feature was the patient’s childishness. -While reciting delusions, the patient was overactive and -evinced a somewhat childish interest. Arithmetically, Jackson had preserved a fair ability but his apathy and lack of -interest interfered with tests, and possibly also with the -exercise of memory. As above noted, we were compelled -to maintain the suspicion of syphilis throughout despite -the attractive hypotheses of traumatic and post-decompressive -effects and cerebral tuberculosis. A history of the -acquisition of syphilis an unknown number of years before -admission entered to strengthen the suspicion of the syphilitic -nature of the mental symptoms.</p> - -<div><span class='pageno' id='Page_82'>82</span></div> -<div class='chart'> - -<table class='table2' summary=''> - <tr> - <th class='bbt c029' colspan='6'>TYPICAL LABORATORY FINDINGS IN NEUROSYPHILIS (<span class='sc'>Nonne</span>, 1915)</th> - </tr> - <tr> - <th class='bbt brm c029'><span class='sc'>Diagnosis</span></th> - <th class='bbt brm c029'><span class='sc'>W. R., Blood Serum</span></th> - <th class='bbt brm c029'><span class='sc'>W. R. 0.22 cc. Blood Serum</span></th> - <th class='bbt brm c029'><span class='sc'>Spinal Fluid, 1.0 cc.</span></th> - <th class='bbt brm c029'><span class='sc'>Phase I, Globulin</span></th> - <th class='bbt c029'><span class='sc'>Pleocytosis</span></th> - </tr> - <tr> - <td class='brm c030'>PARESIS OR TABOPARESIS</td> - <td class='brm c030'>POSITIVE IN ALMOST 100%</td> - <td class='brm c030'>POSITIVE, 85–90%</td> - <td class='brm c030'>POSITIVE, 100%</td> - <td class='brm c030'>POSITIVE, 95–100%</td> - <td class='c030'>POSITIVE, ABOUT 95%</td> - </tr> - <tr> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='c030'> </td> - </tr> - <tr> - <td class='brm c030'>TABES (not combined with paresis)</td> - <td class='brm c030'>POSITIVE, 60–70%</td> - <td class='brm c030'>POSITIVE, 20%</td> - <td class='brm c030'>POSITIVE, 100%</td> - <td class='brm c030'>POSITIVE, 90–95%</td> - <td class='c030'>POSITIVE, 90%</td> - </tr> - <tr> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='brm c030'> </td> - <td class='c030'> </td> - </tr> - <tr> - <td class='bbt brm c030'>CEREBROSPINAL SYPHILIS</td> - <td class='bbt brm c030'>POSITIVE, 70–80%</td> - <td class='bbt brm c030'>POSITIVE, 20–30%</td> - <td class='bbt brm c030'>POSITIVE ALMOST ALWAYS</td> - <td class='bbt brm c030'>POSITIVE almost always; NEGATIVE only EXCEPTIONALLY</td> - <td class='bbt c030'>POSITIVE ALMOST ALWAYS</td> - </tr> - <tr> - <td class='c031' colspan='6'><span class='sc'>Chart 8</span></td> - </tr> -</table> - -</div> - -<div class='figcenter id004'> -<img src='images/i_083.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Syphilitic thrombosis. Contours of brain preserved.</p> -</div> -</div> - -<p class='c019'><span class='pageno' id='Page_83'>83</span>The W. R. proved positive in blood and spinal fluid. The -gold sol reaction was of the syphilitic type; 37 cells were -found per cmm.; there was a slight amount of globulin and a -slight excess of albumin.</p> - -<p class='c007'>We made a diagnosis of <span class='sc'>Cerebrospinal Syphilis</span> rather -than general paresis on account of, first, the slow course of -the disease; second, the vascular type of the cerebral insult, -hardly typical of paresis; and third, the mild spinal fluid -reaction. Treatment will hardly cure the hemiplegia, at -least so far as restoration of cerebral tissues lost in the insult -is concerned. We were perhaps entitled to consider that, as -in the cases of Petrofski (17), O’Neil (19), Robinson (45), -the meningitic process could be arrested. Unfortunately, -our treatment of 20 injections of salvarsan over a period -of 10 weeks, followed by a number of months of bi-weekly -injections of mercury salicylate, proved incapable of making -any change in the mental and physical picture or in the -laboratory findings.</p> - -<p class='c027'>1. Can we explain the apparently poor reaction to treatment of -the cerebrospinal syphilis in the case of Jackson by -supposing a more deep-seated involvement than the -meningovascular involvement indicated by the hemiplegia -and the signs in the fluid? Autopsied cases in -our experience show focal parenchymatous involvements -that have not caused obvious clinical symptoms -at any time during the course of the disease. These -symptomatically silent lesions may have been present.</p> - -<p class='c027'>2. What is the comparative prognostic value of seizures -in paretic neurosyphilis and in such a meningovascular -case as that of Jackson? Paretic seizures are often -and indeed characteristically recovered from. Moreover, -<span class='pageno' id='Page_84'>84</span>autopsies in paretic neurosyphilis characteristically -show no gross focal destructive lesions to correspond -with the seizures. The paretic seizures are -apparently more irritative than paralytic. However, -the seizures of the meningovascular group of neurosyphilis -are also, though less commonly, recovered from, -so that the differential diagnosis on the basis of the -outcome of seizures is not safe. Rarely paretic neurosyphilis -itself also develops seizures from which no -recovery is made.</p> - -<p class='c027'>3. What is the relation of neuropathic heredity to neurosyphilis? -The family history of John Jackson is undoubtedly -poor, since his father died of diabetes and -a paternal uncle was insane; and on the mother’s side, -the grandmother died of tuberculosis and an aunt died -insane. This general question was more interesting in -the days before the syphilitic nature of general paresis -and of allied diseases was known. However, we may -still hold perhaps that not only syphilis but also various -intoxications, especially alcoholism, do flourish upon -a neuropathic soil. This question, like that of Krafft-Ebing’s -celebrated claim of the relation between syphilization -and civilization, needs revision in the light of -more extensive applications of the W. R. in larger -and larger groups of persons under various community -conditions.</p> - -<div><span class='pageno' id='Page_85'>85</span></div> -<div class='box'> - -<p class='c013'><b>The SIX TESTS (serum Wassermann reaction, -fluid Wassermann reaction, pleocytosis, gold sol -reaction, globulin, excess albumin) are likely to -run STRONGER in PARETIC NEUROSYPHILIS -(“general paresis”) than in DIFFUSE (especially -meningovascular) NEUROSYPHILIS; in particular, -the gold sol reaction is likely to prove -“paretic” rather than “syphilitic.” The clinical -course of paretic neurosyphilis (“general paresis”) -is likely to terminate in death within a few -years.</b></p> - -</div> - -<p class='c006'><b>Case 15.</b> Pietro Martiro was a well developed and nourished -man, 30 years of age, who had been doing erratic things -and acting peculiarly for a few weeks before entering the hospital. -In the hospital, Martiro proved to be very excitable -and given to violence. He had marked delusions of grandeur, -saying he was worth many millions of dollars, was the greatest -singer in the world, the greatest athlete in the world, and -the like.</p> - -<p class='c007'><b>Physically</b>, there was no disorder except overactivity -of some reflexes. The diagnosis of <span class='sc'>General Paresis</span> offered -no difficulties, and it was confirmed by the laboratory tests -(positive serum and fluid W. R., “paretic” gold sol reaction, -42 cells per cmm., an excess of albumin, and a positive -globulin test).</p> - -<p class='c007'><b>Treatment</b>: The perfect physique of this case and the -extremely brief clinical duration (a few weeks) would naturally -suggest a probably favorable outcome. However, cases -with marked delusions of grandeur have very frequently -proved to be cases with extensive brain tissue loss as shown -in certain studies with Danvers material.</p> - -<p class='c007'>In any event, the treatment in this case proved unavailing. -Enormous doses of salvarsan, twice a week, aided by mercury -and potassium iodid, were given. Although other cases had -been helped by such intensive treatment, Martiro went -steadily downhill, nor was there the slightest diminution in -the intensity of any of the spinal fluid reactions. After 50 -injections of salvarsan over a period of 30 weeks without improvement, -treatment was discontinued. A few months -later, the patient died.</p> - -<div><span class='pageno' id='Page_86'>86</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>PARETIC NEUROSYPHILIS (GENERAL PARESIS)</b></span></div> - <div class='c003'><b>PHYSICAL SYMPTOMS</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>EARLY HEADACHE</div> - <div class='line'>VISUAL DISORDER</div> - <div class='line'>HYPALGESIA</div> - <div class='line'>ADIADOCHOKINESIS</div> - <div class='line'>ATAXIA</div> - <div class='line'>NASOLABIAL FLATTENING</div> - <div class='line'>VOCAL CHANGE</div> - <div class='line'>SPEECH DISORDER</div> - <div class='line'>WRITING DISORDER</div> - <div class='line'>LOSS OF MANUAL DEXTERITY</div> - <div class='line'>PUPILLARY CHANGES</div> - <div class='line'>REFLEX CHANGES</div> - <div class='line'>SEIZURES</div> - <div class='line'>LATE: PARALYSIS, CONTRACTURE</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 9</span></div> - -</div> - -<div><span class='pageno' id='Page_87'>87</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>PARETIC NEUROSYPHILIS (GENERAL PARESIS)</b></span></div> - <div class='c003'><b>MENTAL SYMPTOMS</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>INTAKE IMPAIRED</div> - <div class='line'>CONSCIOUSNESS CLOUDED</div> - <div class='line'>FATIGUABILITY INCREASED</div> - <div class='line'>HALLUCINOSIS RARE</div> - <div class='line'>AMNESIA—RECENT! CHRONOLOGY AND STORAGE IMPAIRED. FABULATION</div> - <div class='line'>OVER-SUGGESTIBILITY</div> - <div class='line'>JUDGMENT IMPAIRED</div> - <div class='line'>FANTASTIC DELUSIONS</div> - <div class='line'>INSIGHT INTO ILLNESS NIL</div> - <div class='line'>EARLY IRRITABILITY OR HEBETUDE</div> - <div class='line'>QUICK SHIFTING EMOTION</div> - <div class='line'>CHARACTER CHANGE</div> - <div class='line'>CONDUCT SLUMP</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 10</span></div> - -</div> - -<p class='c032'><span class='pageno' id='Page_88'>88</span>1. What is the duration of paretic neurosyphilis (“general -paresis”)? If we omit the doubtful, early, and prodromal -stages and count the beginning of the disease -with the occurrence of definite symptoms, we find -(Kraepelin) that almost half the patients with pronounced -paretic signs die within the first two years of -their disease. Kraepelin’s observations upon 244 cases -are as follows:</p> - -<table class='table3' summary=''> - <tr> - <td class='c024'>Year:</td> - <td class='c008'>1</td> - <td class='c008'>2</td> - <td class='c008'>3</td> - <td class='c008'>4</td> - <td class='c008'>5</td> - <td class='c008'>6</td> - <td class='c008'>7</td> - <td class='c008'>8</td> - <td class='c008'>9</td> - <td class='c008'>10</td> - <td class='c033'>14</td> - </tr> - <tr> - <td class='c024'>Cases:</td> - <td class='c008'>51</td> - <td class='c008'>63</td> - <td class='c008'>52</td> - <td class='c008'>41</td> - <td class='c008'>22</td> - <td class='c008'>4</td> - <td class='c008'>5</td> - <td class='c008'>2</td> - <td class='c008'>2</td> - <td class='c008'>1</td> - <td class='c033'>1</td> - </tr> -</table> -<p class='c028'>The average duration of the disease in months has -been calculated as varying from 24 to 32 months. -Juvenile paresis runs a slower and more insidious -course. The duration of paresis, according to many -observers, diminishes with the increasing age of the -patient. It is now held that a combination of tabes -with paresis does not prolong the duration of the -paresis. As noted above in the discussion of Case -Harrison (9), our conceptions of the characteristic -duration of paretic neurosyphilis must alter with the -increase of our knowledge due to the early application -of laboratory tests.</p> - -<p class='c027'>2. What is the significance of the term <em>general paresis</em>? -The case of Martiro is, of course, a good instance to -show that the term is sometimes a misnomer. The -characteristic generalized motor incapacity denoted -by the term <em>general paresis</em> is shown in patients in the -institutions for the chronic insane in their last few -months of life. The term <em>paresis</em> is perhaps to be -preferred to the term <em>paralysis</em> because the paralysis is -not complete but partial; but perhaps the best reason -is that the word <em>paresis</em> is a shorter word. When the -mental side is to be emphasized, the term <em>paralytic -dementia</em> is employed. In this book we have used the -term <em>paretic neurosyphilis</em> to mean a more precise -statement of the etiology of general paresis (general -paralysis, paralytic dementia). The lay term, <em>softening of the brain</em>, like the terms <em>metasyphilis</em> and <em>parasyphilis</em> -is in the present phase of our knowledge to be eschewed.</p> - -<div class='figcenter id001'> -<img src='images/i_088.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Euphoria in paretic neurosyphilis (“general paresis”). The head, arms and trunk were shaking with mirth; hence, the indistinct outlines of the photograph.</p> -</div> -</div> - -<p class='c027'><span class='pageno' id='Page_89'>89</span>3. If this fatal case be typical of general paresis (for more -favorable results, see Part V), what is the toll of deaths -from this disease in the community at large? A striking -statement may be quoted from Dr. Thomas W. Salmon’s -“Analysis of General Paralysis as a Public Health -Problem:”</p> - -<p class='c028'>“With the information in our possession at the -present time, we are able to state that not fewer than -1000 persons in whom general paralysis is recognized -die in New York State every year. Let us compare -this with the lives lost from some other important -preventable diseases. It means that <em>one in nine</em> of -the 6909 men who died between the ages of 40 and 60 -in New York last year died from recognized general -paralysis and that <em>one in thirty</em> of the 5299 women -who died in the same age-period died from this disease.</p> - -<p class='c028'>“The number of deaths from general paralysis in -New York last year about equalled the number of -deaths from typhoid fever. The following table gives -the number of deaths due to the ten most important -specific infectious diseases. Of course, deaths in -measles, typhoid fever and scarlet fever will be found -also under the names of some of the complications of -these diseases, but it should be remembered that -these primary diseases are not invariably fatal as general -paralysis is. Many of the patients with measles who -died from bronchopneumonia would have recovered -but for this complication, while the paretics with -bronchopneumonia would have died even if this complication -had not arisen. No attempt is being made to -compare the <em>prevalence</em> of general paralysis with that -of other diseases—we are trying only to estimate its -share in the <em>mortality</em>.</p> - -<table class='table3' summary=''> - <tr> - <td class='c008'>“1.</td> - <td class='c024'>Tuberculosis (all forms)</td> - <td class='c033'>16,133</td> - </tr> - <tr> - <td class='c008'>2.</td> - <td class='c024'>Pneumonia</td> - <td class='c033'>9,302</td> - </tr> - <tr> - <td class='c008'>3.</td> - <td class='c024'>Bronchopneumonia</td> - <td class='c033'>7,217</td> - </tr> - <tr> - <td class='c008'>4.</td> - <td class='c024'>Diphtheria and croup</td> - <td class='c033'>1,854</td> - </tr> - <tr> - <td class='c008'>5.</td> - <td class='c024'>Influenza</td> - <td class='c033'>1,381</td> - </tr> - <tr> - <td class='c008'>6.</td> - <td class='c024'>Measles</td> - <td class='c033'>1,071</td> - </tr> - <tr> - <td class='c008'>7.</td> - <td class='c024'>Typhoid Fever</td> - <td class='c033'>1,018</td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c024'><em>General paralysis (recognized)</em></td> - <td class='c033'>1,000</td> - </tr> - <tr> - <td class='c008'>8.</td> - <td class='c024'>Scarlet fever</td> - <td class='c033'>837</td> - </tr> - <tr> - <td class='c008'>9.</td> - <td class='c024'>Whooping cough</td> - <td class='c033'>818</td> - </tr> - <tr> - <td class='c008'>10.</td> - <td class='c024'>Syphilis</td> - <td class='c033'>782”</td> - </tr> -</table> - -<div><span class='pageno' id='Page_90'>90</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>PARETIC NEUROSYPHILIS (GENERAL PARESIS)</b></span></div> - <div class='c003'><b>CHARACTERISTICS</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>AMNESIA</div> - <div class='line'>QUICK SHIFTING EMOTIONS</div> - <div class='line'>CHARACTER CHANGE</div> - <div class='line'>CONDUCT SLUMP</div> - <div class='line'>NERVOUS DISORDERS</div> - <div class='line'>SPEECH DISORDERS</div> - <div class='line'>PUPILLARY CHANGES</div> - <div class='line'>REFLEX CHANGES</div> - <div class='line'>SEIZURES</div> - <div class='line'>CEREBROSPINAL FLUID PICTURE</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 11</span></div> - -</div> - -<div><span class='pageno' id='Page_91'>91</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>SYPHILITIC PSYCHOSES</b></span></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>SYPHILITIC NEURASTHENIA</div> - <div class='line'>GUMMA</div> - <div class='line'>SYPHILITIC PSEUDOPARESIS</div> - <div class='line'>APOPLECTIC CEREBRAL SYPHILIS</div> - <div class='line'>SYPHILITIC EPILEPSY</div> - <div class='line'>SYPHILITIC PARANOIA</div> - <div class='line'>TABETIC PSYCHOSIS</div> - <div class='line'>HEREDITARY</div> - <div class='line'>PARESIS</div> - </div> - </div> -</div> - -<div class='lg-container-r c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>Kraepelin</span>, 1910</div> - </div> - <div class='group'> - <div class='line'><span class='sc'>Chart 12</span></div> - </div> - </div> -</div> - -</div> - -<div><span class='pageno' id='Page_92'>92</span></div> -<div class='box'> - -<p class='c013'><b>TABOPARETIC NEUROSYPHILIS (“taboparesis”) -is CLINICALLY a combination of the -symptoms of TABES DORSALIS and those of -GENERAL PARESIS. The COURSE of TABOPARESIS -is likely to be from a characteristic -tabes dorsalis (often of years’ standing) to a characteristic -general paresis; the ultimate paretic -picture is likely to retain various characteristics -of tabes. The LABORATORY TESTS in the -paretic phase are characteristic of ordinary (non-tabetic) -general paresis. The PROGNOSIS, -after the paretic phase has arrived, is apt to be -that of general paresis.</b></p> - -</div> - -<p class='c006'><b>Case 16.</b> Joseph Sullivan, a waiter, 50 years of age, sought -assistance at the Psychopathic Hospital voluntarily. His -complaint of severe and lancinating pains in the legs, difficulty -with his gait, and a feeling of constriction about the waist, -was forthwith suggestive of tabes dorsalis. He was a rather -poorly nourished, white-haired man, with a drooping of the -left side of the face. The pupils reacted sluggishly to light, -the right somewhat better than the left. A marked Romberg -reaction could be demonstrated. Ataxia in walking was -marked. There was some incoördination of the hands, considerable -tremor, and writing was poorly performed. The -ankle-jerks and knee-jerks were absent. On the whole, -the diagnosis of <span class='sc'>Tabes Dorsalis</span> was clear enough.</p> - -<p class='c007'>The most appealing situation was <b>mental</b>. Sullivan was -exceedingly apprehensive about his condition on the ground -that it was growing progressively worse; if it was to get -worse, Sullivan feared he would commit suicide. From his -own account, he had become irritable, quick-tempered, and -often unreasonable. As usual in these cases, the question -arose whether the depression was psychopathic or natural.</p> - -<div><span class='pageno' id='Page_93'>93</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='3'><b><span class='large'>TABETIC SYMPTOMS AND SIGNS IN ORDER OF THEIR FREQUENCY</span></b></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='3'><b>ANALYSIS OF 250 CASES</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c009'> </td> - <td class='c010'>PER CENT</td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'>1.</td> - <td class='c009'>ROMBERG SIGN</td> - <td class='c010'>96.4</td> - </tr> - <tr> - <td class='c008'>2.</td> - <td class='c009'>ABSENT KNEE-JERKS</td> - <td class='c010'>90.0</td> - </tr> - <tr> - <td class='c008'>3.</td> - <td class='c009'>LANCINATING PAINS</td> - <td class='c010'>88.4</td> - </tr> - <tr> - <td class='c008'>4.</td> - <td class='c009'>STAGGERING GAIT</td> - <td class='c010'>87.2</td> - </tr> - <tr> - <td class='c008'>5.</td> - <td class='c009'>ARGYLL-ROBERTSON PUPIL</td> - <td class='c010'>80.0</td> - </tr> - <tr> - <td class='c008'>6.</td> - <td class='c009'>ATAXIA IN UPPER EXTREMITIES</td> - <td class='c010'>68.2</td> - </tr> - <tr> - <td class='c008'>7.</td> - <td class='c009'>SPHINCTER DISTURBANCES</td> - <td class='c010'>67.6</td> - </tr> - <tr> - <td class='c008'>8.</td> - <td class='c009'>SENSORY DISTURBANCES</td> - <td class='c010'>58.2</td> - </tr> - <tr> - <td class='c008'>9.</td> - <td class='c009'>VISUAL DISTURBANCES</td> - <td class='c010'>43.6</td> - </tr> - <tr> - <td class='c008'>10.</td> - <td class='c009'>PARESTHESIA AND NUMBNESS OF FEET AND LOWER EXTREMITIES</td> - <td class='c010'>42.8</td> - </tr> - <tr> - <td class='c008'>11.</td> - <td class='c009'>GIRDLE SENSE</td> - <td class='c010'>31.2</td> - </tr> - <tr> - <td class='c008'>12.</td> - <td class='c009'>PTOSIS OF EYE-LIDS</td> - <td class='c010'>23.2</td> - </tr> - <tr> - <td class='c008'>13.</td> - <td class='c009'>PARESTHESIA OR NUMBNESS IN HANDS OR UPPER EXTREMITIES</td> - <td class='c010'>13.6</td> - </tr> - <tr> - <td class='c008'>14.</td> - <td class='c009'>STRABISMUS</td> - <td class='c010'>12.0</td> - </tr> - <tr> - <td class='c008'>15.</td> - <td class='c009'>VISCERAL CRISES</td> - <td class='c010'>12.0</td> - </tr> - <tr> - <td class='c008'>16.</td> - <td class='c009'>LOSS OF SEXUAL DESIRE</td> - <td class='c010'>11.5</td> - </tr> - <tr> - <td class='c008'>17.</td> - <td class='c009'>CHARCOT JOINTS</td> - <td class='c010'>9.2</td> - </tr> - <tr> - <td class='c008'>18.</td> - <td class='c009'>VERTIGO</td> - <td class='c010'>4.0</td> - </tr> - <tr> - <td class='c008'>19.</td> - <td class='c009'>MAL PERFORANS</td> - <td class='c010'>3.2</td> - </tr> - <tr> - <td class='c008'>20.</td> - <td class='c009'>PAIN IN JOINTS</td> - <td class='c010'>2.8</td> - </tr> - <tr> - <td class='c008'>21.</td> - <td class='c009'>RECTAL TENESMUS</td> - <td class='c010'>2.8</td> - </tr> - <tr> - <td class='c008'>22.</td> - <td class='c009'>MENTAL DEGENERATION (other than paresis)</td> - <td class='c010'>2.4</td> - </tr> - <tr> - <td class='c008'>23.</td> - <td class='c009'>HEMIPLEGIA</td> - <td class='c010'>2.4</td> - </tr> - <tr> - <td class='c008'>24.</td> - <td class='c009'>VESICAL TENESMUS</td> - <td class='c010'>2.0</td> - </tr> - <tr> - <td class='c008'>25.</td> - <td class='c009'>DIFFICULTY IN ARTICULATION</td> - <td class='c010'>2.0</td> - </tr> - <tr> - <td class='c008'>26.</td> - <td class='c009'>DEAFNESS</td> - <td class='c010'>1.2</td> - </tr> - <tr> - <td class='c008'>27.</td> - <td class='c009'>ANOSMIA</td> - <td class='c010'>0.8</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='3'><span class='sc'>Baldwin Lucke.</span></td></tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='3'><span class='sc'>Chart 13</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_94'>94</span>While in the hospital things shortly came to a crisis. In -the midst of a fit of depression, Sullivan attempted suicide -by beating his head against the wall. Whether this attempt -could be regarded psychopathic, however, remained in question. -Sullivan had been drinking very heavily although he -had stopped about six weeks before admission, fearing that -the alcohol was causing a development of symptoms. The -remedy was almost worse than the disease because he then -became more nervous, lost his appetite, and had a marked -insomnia.</p> - -<p class='c007'>According to the patient’s own history, he had had several -attacks of gonorrhœa and a syphilitic infection at the age of -19; that is, some 31 years before admission to the hospital. -However, the first <em>neurological</em> symptoms of which the patient -was aware came about 27 or 28 years after infection, namely, -3 or 4 years before admission, when facial paralysis developed. -At that time, he had suddenly felt a peculiar sensation in the -throat and became unable to swallow for a time. His voice -remained hoarse and low for some time, and his face began to -droop. The lancinating pains and the ataxia also dated -back several years.</p> - -<p class='c027'>1. How shall we evaluate the mental symptoms? The prognosis -of tabes dorsalis is relatively good so far as life is -concerned, and it might even be possible for Sullivan by -training to remain capable of being a waiter. The -manual incoördination was not marked, and possibly -the manual tremor was in part due to alcohol. Accordingly, -the mental symptoms, such as emotional lability -and memory defect, were in the foreground of attention. -In point of fact, the laboratory examinations showed -positive W. R. in the serum and the spinal fluid, which -latter also contained 60 cells per cmm., positive globulin, -and an excess of albumin. <span class='sc'>The Diagnosis made -was that of Taboparesis</span>, meaning thereby a tabes -associated with appropriate symptoms of a mental -nature.</p> - -<p class='c027'>2. How shall the term <em>taboparesis</em> be used? Some use the -term, as we feel erroneously, for instances of general -paresis which happen to show crural areflexia (absence -of knee-jerks). We feel that the best usage of the -term is for instances in which well-defined symptoms of -tabes (as well as of paresis) are present, namely, characteristic -ataxia, lightning pains, and the like. If the -<span class='pageno' id='Page_95'>95</span>term is used more loosely, as above mentioned, then -practically every case of general paresis might perhaps -be termed <em>taboparesis</em>, since almost every case of paresis -does show involvement of the cord as well as of the -cerebrum. Such involvement may lead to hyperreflexia, -hyporeflexia, or areflexia according to the localization -of the process. In true taboparesis, in which there -is a commingling of the features of tabes with those of -paresis, we should find the posterior roots of the spinal -cord affected. The spinal lesions of paresis itself are -more apt to be intraspinal; that is, confined to the -nervous system within the pial investment.</p> - -<p class='c027'>3. Bearing in mind that Sullivan was a waiter, what shall -be said about the infectivity of these cases? It is -counted as a rule as negative, since there are no open -spirochete-bearing lesions. The longer the period since -infection the less, as a rule, is the chance of contagion -in syphilis; and as tabes and paresis occur fairly late in -the disease, the infectiousness at this stage is practically -negligible.</p> - -<p class='c027'>4. Of what differential value is the insight shown by Sullivan -into the nature of his symptoms? Kraepelin -remarks that a genuine insight into the nature of the -disease does not as a rule occur in paresis. At the -beginning of the disease, there may sometimes be a -correct understanding of the nature of the disease and -of its probable outcome; but the presence or absence of -insight into the fact of mental disease is by no means a -differential sign of practical value.</p> - -<p class='c027'>5. What is to be said of the occurrence of depression and -excited states in paretic neurosyphilis? A variety of -classifications of sub-forms of paretic neurosyphilis -have been propounded. Kraepelin, for example, deals -with four: the demented, depressive, expansive, and -agitated forms, but remarks that the division is merely -convenient for exposition. The institutional intake -does not accurately represent the distribution of cases. -Under psychopathic hospital conditions with the relatively -easy resort to such institutions, the number of -quiet cases increases; under the less advanced conditions -in Heidelberg, Kraepelin took in 53% demented -paretics as against 56% at Munich (73% women) under -the easier conditions of admission. The admissions of -demented paretics varied from 37 to 56%. The variations -depend much upon the facility with which the -cases can be brought to institutions. Where admission -<span class='pageno' id='Page_96'>96</span>is beset with various legal restrictions, the quiet and -demented cases are more apt to be treated for long -periods at home. The depressive type of paretic -neurosyphilis forms a much smaller group, according -to Kraepelin, as only about 12% of his Heidelberg admissions -were of this type, and still fewer of his Munich -admissions. Other authors give percentages as high as -16 and 19. The so-called expansive group is larger, -Kraepelin finding 30% of his Heidelberg cases to be of -this group, and 21 to 22% of his Munich cases. The -rarest sub-form of paretic neurosyphilis is the agitated -form: 6% of Kraepelin’s Heidelberg admissions; 14% -among males and 5% among females in his Munich -admissions, where the diagnosis of agitated paresis was -entered on somewhat broader lines. French authors -(Sérieux and Ducaste) have enlarged the number of -sub-forms of paretic neurosyphilis as follows: Expansive -27%; sensory 24%; demented 24%; persecutory 3%; -depressive 2%; circular 7%; hypochondriacal 7%; and -maniacal 6%.</p> - -<div><span class='pageno' id='Page_97'>97</span></div> -<div class='box'> - -<p class='c013'><b>DIFFUSE (meningovasculoparenchymatous) NEUROSYPHILIS -may look precisely like PARETIC -NEUROSYPHILIS (“general paresis”) at certain -periods of clinical and laboratory examination.</b></p> - -</div> - -<p class='c006'><b>Case 17.</b> The police found Gregorian Petrofski crouching -on his knees on a Boston sidewalk, attempting to take -pickets off a fence. Petrofski knew little English; he said -that he had slept in Poland the night before. He did not -appear to be alcoholic.</p> - -<p class='c007'>When he was examined, through an interpreter, he told -how he had been in America two days, and in Boston two -years; that he was at the present time in Poland, and that -his brother had brought him to the hospital and left him -there.</p> - -<p class='c007'>The <b>physical examination</b> showed Petrofski to be well -developed and nourished. His pupils were somewhat dilated -and reacted somewhat slowly to light and accommodation. -<b>Neurologically,</b> there was nothing else abnormal found upon -systematic examination although, through lack of coöperation, -sensory and coördination tests proved difficult if not impossible. -There was a large ulcer on the under surface of the -glans penis, with several small smooth scars on the upper -surface. There was a purulent discharge from the external -meatus. There were exostoses of both tibiae.</p> - -<p class='c007'>The initial diagnosis had to consider uremia and diabetes, -which could be easily excluded on examination. Alcoholism -was excluded through absence of alcohol on the breath. -There remained such diagnoses as epilepsy, some post-traumatic -condition, or meningitis, to say nothing of the hypothesis -of syphilis raised by the tibial exostoses and the lesions -of the penis. The hypothesis of trauma was given up, as -well as epilepsy and meningitis upon the data of the lumbar -puncture. The spinal fluid proved to be clear but with -enormous amounts of globulin and albumin, 80 cells per cmm., -a “paretic” gold sol reaction, and a positive spinal fluid -<span class='pageno' id='Page_98'>98</span>W. R. (the serum W. R. was also positive). Accordingly, it -was clear that the case was one of neurosyphilis.</p> - -<p class='c007'>Treatment was instituted with injections of mercury salicylate, -a grain and a half twice a week, and potassium iodid. -After some weeks, diarrhoea and salivation with marked -symptoms of mercury poisoning set in; the treatment was -suspended, but later re-instituted. In a few weeks Petrofski -was apparently quite well, the spinal fluid tests had all become -negative, as had the serum W. R.</p> - -<p class='c007'>Petrofski now began to pick up a good deal of English, and -gave a consistent narrative of his past life, although the -period just prior to and during his early stay in the hospital -has remained blank. Without further treatment Petrofski -has remained well for over a year.</p> - -<p class='c027'>1. Does the “paretic” gold sol reaction mean general paresis? -In connection with this general question, a brief summary -of the significance of the gold sol reaction in this -group may be made. (1) Fluids from cases of general -paresis in the vast majority of cases will give a strong -and fairly characteristic reaction, especially if more -than one sample is tested. (2) Very rarely general -paresis fluid will give a reaction weaker than the characteristic -one. (3) Fluids from cases of syphilitic -involvement of the central nervous system other than -general paresis often give a weaker reaction than the -paretic, but in a fairly high percentage of cases give -the same reaction as the paretics. (4) Non-syphilitic -cases may give the same reaction as the paretics; these -cases are usually chronic inflammatory conditions of -the central nervous system. (5) When a syphilitic -fluid does not give the strong “paretic reaction” it is -presumptive evidence that the case is not general paresis, -and this test offers a very valuable differential diagnostic -aid between general paresis, tabes, and cerebrospinal -syphilis. (6) The term “syphilitic zone” is a misnomer, -as non-syphilitic as well as syphilitic cases give -reactions in this zone, but no fluid of a case with syphilitic -central nervous system disease has given a reaction -out of this zone, so that the finding may be used negatively; -and any fluid giving a reaction outside of this -zone may be considered non-syphilitic. (7) Mild reactions -may occur without any evident significance, -while a reaction of no greater strength may mean marked -inflammatory reaction. (8) Tuberculous meningitis, -brain tumor, and purulent meningitis fluids characteristically, -though not invariably, give reactions in higher -dilutions than syphilitic fluids. (9) The unsupplemented -gold sol test is insufficient evidence on which to -make any diagnosis, but used in conjunction with the -W. R., chemical and cytological examinations, it offers -much information, aiding in the differential diagnosis -of general paresis, cerebrospinal syphilis, tabes dorsalis, -brain tumor, tuberculous meningitis, and purulent meningitis. -(10) We believe that no cerebrospinal fluid -examination is complete for clinical purposes without -the gold sol test.</p> - -<div><span class='pageno' id='Page_99'>99</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c034'> - <div><span class='large'><b>FREQUENT SYMPTOMS IN DIFFUSE AND VASCULAR NEUROSYPHILIS</b></span></div> - <div class='c003'><b>(“CEREBRAL” AND “CEREBROSPINAL SYPHILIS”)</b></div> - </div> -</div> - -<div class='lg-container-b c035'> - <div class='linegroup'> - <div class='group'> - <div class='line'>PUPILLARY DISORDER</div> - <div class='line'>HEADACHE</div> - <div class='line'>VERTIGO</div> - <div class='line'>INSOMNIA</div> - <div class='line'>DROWSINESS</div> - <div class='line'>CHANGE IN DISPOSITION</div> - <div class='line in4'>Irritability Slow thinking</div> - <div class='line'>SEIZURES</div> - <div class='line'>PARALYSES</div> - <div class='line in4'>Permanent Transient</div> - <div class='line'>APHASIA</div> - <div class='line'>HEMIANOPSIA</div> - <div class='line'>SENSORY DISTURBANCES</div> - <div class='line'>GASTRIC CRISES</div> - <div class='line'>SPHINCTER DISTURBANCES</div> - <div class='line'>INTRACRANIAL PRESSURE SYMPTOMS</div> - <div class='line'>POLYURIA, POLYDIPSIA, GLYCOSURIA</div> - <div class='line'>MÉNIÈRE’S SYNDROME</div> - <div class='line'>NYSTAGMUS</div> - </div> - </div> -</div> - -<div class='c036'><span class='sc'>Chart 14</span></div> - -</div> - -<p class='c037'><span class='pageno' id='Page_100'>100</span>See Appendix B for technical details.</p> - -<p class='c027'>2. What is the relation of the tibial exostosis to neurosyphilis? -The syphilographers have always stressed -the tibial lesions in the diagnosis of syphilis. Although -not so much attention has been paid to these and -kindred osseous lesions in neurosyphilis, yet we have -frequently found such lesions and they afford an important -auxiliary means of diagnosis.</p> - -<div><span class='pageno' id='Page_101'>101</span></div> -<div class='box'> - -<p class='c013'><b>A POSITIVE SERUM Wassermann reaction with -a NEGATIVE FLUID Wassermann Reaction may -be found in NEUROSYPHILIS, particularly in -VASCULAR NEUROSYPHILIS: the remaining -signs in the fluid, although frequently positive, may -even be negative.</b></p> - -</div> - -<p class='c006'><b>Case 18.</b> Frederick Wescott was a promoter, an elderly -looking man of 60 years. His health had been failing for 18 -months. There had been shortness of breath, dizziness, a -tired feeling, inability to “get the words he wanted,” and -forgetfulness of names. About eight weeks before examination, -Wescott had had a convulsion, following which he had -been unable to express himself at all well. This convulsion -was not accompanied by loss of consciousness. Besides a -marked motor aphasia, there was agraphia.</p> - -<p class='c007'><b>Physically</b>, Wescott showed arteriosclerosis and a blood -pressure of 135 systolic, but, except very lively knee-jerks, -no other reflex disorders or anomalies were discovered. In -particular, the pupils reacted fairly well.</p> - -<p class='c007'>There was, perhaps, no special reason to implicate syphilis -in the case, yet Wescott gave a history of syphilis at 35 years. -The W. R. of the blood serum proved positive; that of the -spinal fluid was negative, and the albumin was but slightly -increased; there was a very slight amount of globulin, and -there were 16 cells per cmm. in the fluid. The gold sol reaction -suggested syphilis.</p> - -<p class='c007'>We felt entitled to make a diagnosis of <span class='sc'>Syphilitic Cerebral -Arteriosclerosis</span>, regarding the convulsion or seizure -eight weeks before as due to a vascular insult. The laboratory -picture in the spinal fluid in Wescott’s case seems to be -rather characteristic of this group of syphilitic arteriosclerotics.</p> - -<p class='c027'>1. What is the reason for the negative spinal fluid W. R.? -The theory would be that the syphilitic lesion is localized -in the vascular system and that the parenchyma -<span class='pageno' id='Page_102'>102</span>is only secondarily, if at all, involved. The W. R. -producing bodies are accordingly not found in the fluid.</p> - -<p class='c027'>2. How frequently are several of the spinal fluid tests negative, -while others are positive? Whereas, clinically -speaking, the five tests in the spinal fluid (W. R., globulin -reaction, excess albumin, pleocytosis, and gold sol -reaction) are each indicative of a pathological condition -in the central nervous system, yet a specially -intensive study of the distribution of these tests has -shown that they are prone to occur independently. -Consequently, we must concede that they do not all -represent the same inflammatory products and chemical -conditions. The W. R. producing bodies, the gold sol -reaction producing bodies, as well as the globulins and -albumins, have been proved to be separate. Special -work has also shown that <em>these tests disappear under -treatment at different rates</em>. There is, unfortunately, no -doubt that the rate and intensity, presence or absence, -and the order of disappearance of these tests in either -treated or untreated cases, do not at all parallel the -clinical conditions of the patients.</p> - -<p class='c027'>3. What is the prognosis in vascular neurosyphilis, such as -in the case of Wescott? The prognosis is identical -with that of cerebral arteriosclerosis in general, that -is to say, bad, but with frequent periods of improvement. -In the neurosyphilitic type of arterial disease -thromboid formation is frequent. Where the lesion is -chiefly perivascular infiltration, rather than disintegration -of the vessel wall, improvement may very well -occur as a result of treatment. Wescott showed slight -improvement under treatment. He has already lived -two years since his first convulsion, and three and a -half years since the onset of symptoms.</p> - -<div><span class='pageno' id='Page_103'>103</span></div> -<div class='box'> - -<p class='c013'><b>DIFFUSE NEUROSYPHILIS (so-called “cerebrospinal -syphilis”) is often marked by SEIZURES.</b></p> - -</div> - -<p class='c006'><b>Case 19.</b> Agnes O’Neil, an unmarried woman of 28 years, -was first examined five weeks after the initial symptoms. It -appears that she had had certain seizures, with unconsciousness -and twitching of the limbs (otherwise not well described), -followed by confusion of mind and sometimes by a weakness -of the left side and a difficulty in speaking. Headache had -been almost constant, as well as pains in the arms and legs.</p> - -<p class='c007'><b>Physically</b>, both in general and <b>neurologically</b>, there were -no signs or symptoms; mentally, we could discover no symptoms. -Syphilis was denied, although possible exposure to -syphilis was admitted.</p> - -<p class='c007'>The <b>diagnosis</b> of some form of organic brain disease was -clear with the picture of convulsions followed by slight aphasia -with headaches and limb pains. With onset at 28, the most -frequent cause for such epileptiform seizures is certainly -syphilis. Examination of the blood and spinal fluid showed -a positive W. R., in both. The albumin was also somewhat -increased. The clinical picture suggested a fairly generalized -meningitic involvement.</p> - -<p class='c007'>The <b>prognosis</b> in such cases of generalized meningitic -involvement is in general good, and this principle was illustrated -in the O’Neil case, in which the symptoms soon disappeared -under intensive antisyphilitic treatment. In fact -the spinal fluid W. R. became negative in the course of four -weeks. The blood serum W. R., however, has remained -positive despite eight months of active treatment.</p> - -<div><span class='pageno' id='Page_104'>104</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>CONDITIONS IN WHICH CONVULSIONS OCCUR</b></span></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>NEUROSYPHILIS</div> - <div class='line'>HYSTERIA</div> - <div class='line'>EPILEPSY MAJOR (<span class='sc'>Grand Mal</span>)</div> - <div class='line'>EPILEPSY MINOR (<span class='sc'>Petit Mal</span>)</div> - <div class='line'>DEMENTIA PRAECOX</div> - <div class='line'>TOXIC CONDITIONS:</div> - <div class='line in4'>Asphyxia, Uremia, Alcohol, Absinthe, Lead, Mercury, etc.</div> - <div class='line'>ORGANIC BRAIN LESIONS</div> - <div class='line in4'>Apoplexy, Meningitis, Intracranial Growths</div> - <div class='line'>STOKES-ADAMS DISEASE</div> - <div class='line'>MALINGERING</div> - <div class='line'>DISSEMINATED SCLEROSIS</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 15</span></div> - -</div> - -<p class='c032'><span class='pageno' id='Page_105'>105</span>1. Are certain cases of syphilitic epilepsy really cases of -Jacksonian epilepsy? As a matter of nomenclature, -Jacksonian cortical epilepsy is usually the result of a -focal and circumscribed irritative lesion in the cortex. -Gumma, local syphilitic meningitis, and syphilitic -vascular lesions, as well as scars consequent upon the -latter, are among the causes of Jacksonian epilepsy, -along with such other focal lesions as trauma, tumor -abscess, tubercle, and the like. Even non-syphilitic -Jacksonian epilepsy has been observed from time to -time in cases of diffuse intracranial pressure. Jacksonian -attacks also have been found in so-called genuine -epilepsy. Accordingly, we must not conclude from the -occurrence of Jacksonian convulsions, even though in a -proved syphilitic case, that the convulsions in question -are surely due to a focal lesion, for they may be -due to diffuse syphilitic lesions.</p> - -<p class='c038'>2. What is the significance of aphasia in Agnes O’Neil? -Aphasia is not a characteristic symptom in ordinary -Jacksonian epilepsy, but the aphasia is another sign of -focal lesion and forms an added argument against the -diagnosis of genuine or idiopathic epilepsy. See also -discussion of aphasia in paretic neurosyphilis under -Case Levenson (22).</p> - -<p class='c038'>3. What is the behavior of the serum W. R. and the spinal -fluid W. R. under systematic treatment? Sometimes, -as in this case, the serum W. R. remains positive and the -fluid W. R. becomes negative; but in other equally -well-defined cases, the reverse holds true, and the serum -W. R. reaction becomes negative whereas the spinal -fluid reaction remains positive. The obvious conclusion -is that we cannot always be sure even by faithful -tests of either the serum or the fluid alone, whether the -treatment has succeeded in abolishing the laboratory -signs.</p> - -<p class='c038'>4. Can this case be regarded as one of cure? Not by the -definition adopted in this book or by the syphilographers -who take into account not only the nervous system but -the body which contains it. To be sure, the spinal -fluid of Agnes O’Neil is now entirely negative and she is -clinically free from symptoms; yet from the broad -standpoint of syphilis therapy in general, this patient is -not cured, as is evidenced by the positive serum W. R.</p> - -<div><span class='pageno' id='Page_106'>106</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general -paresis”) is often marked by SEIZURES.</b></p> - -</div> - -<p class='c006'><b>Case 20.</b> Lester Crane, a plumber, 37 years of age, came -to the hospital with a slow and defective speech. Moreover, -there seemed to be some mental disorder since his answers to -questions were not always relevant. It appeared that he -was seeing bugs on the wall.</p> - -<p class='c007'><b>Physically</b>, Crane was a well developed and nourished man, -with overactive knee-jerks and a Babinski reaction on the -left side.</p> - -<p class='c007'>It developed that there was an impairment in hearing. -The pupils reacted well both to light and to distance. The -patient was very restless and smiled in a silly fashion. His -memory was decidedly defective in all spheres, and he was -very slow in the intake of ideas.</p> - -<p class='c007'>The plumber’s wife said that, at about the age of 23 or 24, -he had a spell of confusion lasting two or three days, with -peculiar conduct, unintelligible talk, and a good deal of -weeping. The medical diagnosis at that time took into -account the fact that Crane was a plumber and was “lead -encephalopathy.”</p> - -<p class='c007'>However, according to his wife, Crane had acquired -chancre at about 26 years, was treated mercurially for about -three years and declared well. He had remained well up to -about 18 months before entrance, when, without previous -warning, the patient had a convulsion with the continuous -movements for about half an hour. He was semi-conscious -for about 18 hours and vomited continuously. There was -amnesia for the whole affair on regaining consciousness. In -a week’s time, Crane was entirely well. But six weeks later -there was another convulsion. Upon removal to a hospital, -the diagnosis of general paresis was made, and the patient -was given the Swift-Ellis intraspinous treatment. This -seemed to be very successful, and the patient discontinued -treatment after 14 weeks (during which time there had -<span class='pageno' id='Page_107'>107</span>been seven treatments) on the ground that he was entirely -well.</p> - -<p class='c007'>However, after discontinuing treatment, there was another -convulsion in about a month, and further convulsions occurred -once a month. For six months, however, the patient took -no treatment, but finally returned to the hospital and was -given mercury. This treatment appeared to suspend convulsions -again for three months, but at the expiration of -six months, the patient had three convulsions in one day, -and several more during the following days. After the last -of these convulsions, there had been numbness on the right -side of the body and considerable headache.</p> - -<p class='c007'>The diagnosis of <span class='sc'>Paretic Neurosyphilis</span> (“general paresis”) -is borne out by the laboratory tests. The W. R. of -the blood serum was, to be sure, negative, but the W. R. of -the spinal fluid was positive, and there was a “paretic” type -of gold reaction, together with other laboratory signs.</p> - -<p class='c007'>The case well demonstrates that group of paretic cases in -which convulsions periodically occur, leaving the patient worse -after each convulsion. Treatment with salvarsan was instituted, -and mercury and iodid was given by mouth. During -the period of eight months which have now elapsed since the -beginning of this treatment, there have been no convulsions; -there has been a great improvement in the memory, the hearing -has improved, the W. R. in the spinal fluid is much less -intense, the gold sol test has become negative, and the other -tests are all less intense.</p> - -<p class='c007'>The patient, however, has not been entirely well, for in -place of the generalized convulsions, he has had minor seizures, -beginning as a rule with a tingling sensation in the -right hand, extending up the arm, down the trunk and leg, and -through the right side of the face, with a bitter sensation on -the right half of the tongue. The patient maintains that -this sensation is absolutely confined to the right half of the -body (in this connection we may recall case Morton (1), in -which there was also a hemiplegia together with other apparently -hysterical symptoms at several times during the -long course of a disease with abundant structural correlations). -During these minor seizures, the patient is unable -to talk, although he does not lose consciousness and is entirely -aware of everything going on about him. These -attacks have of late been growing somewhat less frequent.</p> - -<div><span class='pageno' id='Page_108'>108</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><b><span class='large'>LOSS OF DEEP REFLEXES</span></b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>NEUROSYPHILIS</div> - <div class='line'>NEURITIS</div> - <div class='line in4'>(alcohol, diabetes, diphtheria, lead, arsenic, tubercle, cachexia, etc.)</div> - <div class='line in8'>Peripheral nerves sensory or motor</div> - <div class='line'>PERIPHERAL NERVE PALSIES</div> - <div class='line'>TEMPORARILY FROM COMPRESSION BY TOURNIQUET</div> - <div class='line'>FRIEDREICH’S ATAXIA</div> - <div class='line'>SUBACUTE COMBINED DEGENERATION OF POSTERIOR AND LATERAL COLUMNS</div> - <div class='line in8'>Posterior column disease</div> - <div class='line'>FOCAL LESION IN GRAY MATTER OF CORD</div> - <div class='line'>INFANTILE PARALYSIS (ACUTE ANTERIOR POLIOMYELITIS)</div> - <div class='line'>PROGRESSIVE MUSCULAR ATROPHY</div> - <div class='line in4'>(chronic anterior poliomyelitis)</div> - <div class='line in8'>Anterior cornua of cord</div> - <div class='line'>AMYOTROPHIC LATERAL SCLEROSIS</div> - <div class='line'>SYRINGOMYELIA</div> - <div class='line'>THROMBOSIS OF ANTERIOR SPINAL ARTERY</div> - <div class='line'>LANDRY’S PARALYSIS</div> - <div class='line in8'>Anterior cornua and peripheral motor nerves</div> - <div class='line'>MYOPATHIES</div> - <div class='line in4'>(pseudohypertrophic and atrophic types)</div> - <div class='line in8'>MuscLe itself</div> - <div class='line'>AMYOTONIA CONGENITA</div> - <div class='line'>FAMILY PERIODIC PARALYSIS</div> - <div class='line in4'>(during attacks)</div> - <div class='line'>INCREASED INTRACRANIAL PRESSURE</div> - <div class='line in4'>(especially hydrocephalus and tumors of posterior fossa)</div> - <div class='line'>PNEUMONIA</div> - <div class='line'>IMMEDIATELY AFTER ATTACK OF MAJOR EPILEPSY</div> - <div class='line in4'>(post-epileptic coma)</div> - <div class='line'>TOXIC COMA</div> - <div class='line in4'>(uremia, morphine, etc.)</div> - <div class='line'>DURING SPINAL ANESTHESIA</div> - <div class='line'>COMPLETE TRANSVERSE LESION OF CORD</div> - </div> - </div> -</div> - -<div class='lg-container-r c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>Purves Stuart</span></div> - </div> - <div class='group'> - <div class='line in2'><span class='sc'>Chart 16</span></div> - </div> - </div> -</div> - -</div> - -<p class='c032'><span class='pageno' id='Page_109'>109</span>1. What is the cause of the negative serum W. R.? It is -claimed that 3 to 5% of all cases of general paresis -yield a negative blood serum. In this particular case, -there had been considerable treatment, including some -Swift-Ellis treatment, so that it may be that this -treatment had reduced a formerly positive blood serum -W. R. to a negative one.</p> - -<p class='c038'>2. What is the nature of the typical seizures of general -paresis? The most frequent seizures are epileptiform -and bear a general resemblance to cortical epilepsy; -but more rarely these seizures resemble the ordinary -epileptic attack or consist of a violent general shaking -of the whole body. A variety of initial minor disorders -usher in the attacks: the temperature is often increased. -The attacks are over after one or at most after a few -hours. Kraepelin speaks of one that lasted 14 days. -Sometimes a <i><span lang="la" xml:lang="la">status paralyticus</span></i> develops, suggestive of -the <i><span lang="la" xml:lang="la">status epilepticus</span></i>. Another rarer form of characteristic -seizure is the apoplectiform, which can hardly -be told from an ordinary stroke, and may be followed -by the usual post-apoplectic phenomena. A good -many of the strokes leading to sudden death in middle -life are probably cases of neurosyphilis although often -set down as early arteriosclerosis of a non-syphilitic -nature. Besides the epileptiform and apoplectiform -seizures, there are certain seizures of a less definite and -complete nature, ranging from simple fainting spells, -dizzy spells and petit mal attacks, to various special -forms of irritative muscular contractions and temporary -speech disorders. Sometimes these attacks occur with -complete preservation of consciousness. Transient paresthesias, -visual field defects, and especially attacks of -vomiting, which, according to Kraepelin, may precede -paresis by years (of course in this connection gastric -crises of tabes must be thought of), may be counted as -sensory seizures.</p> - -<p class='c038'>3. What is the proportion of paretic cases developing -seizures? Figures vary from 30 to 90%. According to -Kraepelin, seizures occurred in 30 to 40% of his cases -at Heidelberg; he was of the impression that treatment -in bed had reduced the number of seizures. 65% of -<span class='pageno' id='Page_110'>110</span>paretics admitted to Munich (under very free conditions -of admission) were determined to have shown seizures -before their admission to the hospital. Seizures are -said to be somewhat more frequent in men than in -women. These paretic seizures are not due to either -hemorrhages or vascular plugging—at least in the -vast majority of cases—and must be ascribed to the -effects of microscopic injuries.</p> - -<p class='c038'>4. What is the effect of seizures upon the future course of -paretic neurosyphilis? The current idea as expressed, -for example, by Mercier, is that “immediately after -each crisis the patient is much worse than he was before -it, and thereafter there is some improvement, but he -never improves up to the point at which he was before -the occurrence of the crisis.” That is, “The course of -the disease is one of sudden plunges, each deeper than -the last, each followed by a gradual recovery that is less -complete than the recovery from the previous plunge.”</p> - -<p class='c038'>5. During what period of the disease are seizures most -common? Late in the disease many cases have convulsions, -even though there were none for the first year -or two. In other cases the convulsion is the first -indication of paresis.</p> - -<div><span class='pageno' id='Page_111'>111</span></div> -<div class='box'> - -<p class='c013'><b>DIFFUSE (non-paretic) NEUROSYPHILIS (“cerebrospinal -syphilis”) is often marked by APHASIA.</b></p> - -</div> - -<p class='c006'><b>Case 21.</b> Martha Bartlett, a woman of 40 years, was -brought to the Psychopathic Hospital aphasic, or at least -unable to talk distinctly enough to be understood, or even -to give name and address. The police had found her wandering -aimlessly about the streets. Although she was well-dressed, -she was mud-bespattered and apparently had not -changed her garments for several days. It shortly developed -that the patient, although unable to express herself either in -words or by writing, could understand everything that was -said to her and could indicate by the monosyllables <em>yes</em> or <em>no</em> -whether she agreed or disagreed with statements made. -It was thus determined that she was pretty well oriented. -She was able to understand both speech and printed words. -Although she approximated more than is at all common a -pure type of <em>motor aphasia</em>, it appeared that there was a slight -involvement on the sensory side, especially in the sphere of -visual imagery.</p> - -<p class='c007'><b>Neurologically</b>, the patient showed moderate strabismus, -slight deviation of the tongue to the right, and considerable -tremor on protrusion of the tongue. The right side of the -palate hung lower than the left. The ankle and arm reflexes -were possibly more active on the left side, and the left grasp -was somewhat better than the right. Both knee-jerks were -active, but again the reflex on the left side was more active -than the right. No other abnormalities of reflex were determined. -There was no Rombergism but the gait was somewhat -ataxic. For the rest, the physical examination was -normal. The blood pressure was 120 systolic, 85 diastolic.</p> - -<div><span class='pageno' id='Page_112'>112</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><b><span class='large'>CONDITIONS IN WHICH SPEECH DEFECT IS FOUND</span></b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>NEUROSYPHILIS</div> - <div class='line'>HYPOGLOSSAL PARALYSIS</div> - <div class='line'>FACIAL PALSY</div> - <div class='line'>PARALYSIS OF PALATE (<span class='sc'>Post-Diptheritic</span>)</div> - <div class='line'>BULBAR PALSY</div> - <div class='line'>PSEUDOBULBAR PALSY</div> - <div class='line'>MYOPATHY—FACIO-SCAPULO-HUMERAL TYPE OF LANDOUZY AND DEJERINE</div> - <div class='line'>MYASTHENIA GRAVIS</div> - <div class='line'>FRIEDREICH’S ATAXIA</div> - <div class='line'>LARYNGEAL TABES</div> - <div class='line'>ALCOHOLIC INTOXICATION</div> - <div class='line'>POST HEMIPLEGIC</div> - <div class='line'>LENTICULAR DISEASE</div> - <div class='line'>BILATERAL ATHETOSIS</div> - <div class='line'>MULTIPLE SCLEROSIS</div> - <div class='line'>DEAF MUTISM</div> - <div class='line'>PARALYSIS AGITANS</div> - <div class='line'>CHOREA</div> - <div class='line'>STAMMERING</div> - <div class='line'>TICS</div> - <div class='line'>HYSTERICAL APHONIA</div> - </div> - </div> -</div> - -<div class='lg-container-r c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>Chart 17</span></div> - </div> - </div> -</div> - -</div> - -<p class='c019'><span class='pageno' id='Page_113'>113</span>The ready suspicion was that the case was one of apoplexy -of slight degree with post-apoplectic phenomena. Upon -investigation, this suspicion was confirmed since it appeared -that Mrs. B. had been apparently quite well until about six -months before admission, when without particular warning -she began to act strangely and promptly fell into a series of -convulsions. These convulsions would begin with twitchings -of the face, and then spread throughout the body. There -would be a period of unconsciousness for two or three hours. -It is not certain how many of these convulsive seizures the -patient had. At all events she is reported to have recovered -therefrom completely, remaining well for three months; whereupon, -suddenly, while visiting a friend, she suffered a paralysis -of the left side of the body. She remained dazed and -had hospital treatment for about a week. Ever since this -left-sided paralysis, the aphasic condition above described -has persisted.</p> - -<p class='c007'>Such a phenomenon has often been dismissed in the past -as due to an early arteriosclerosis, but most neurologists and -internists of today would look beyond the diagnosis of mere -arteriosclerosis and consider syphilis. The only suggestive -feature in the case, aside from the post-apoplectic reflex -disorder and spastic phenomena, is the irregularity and diminished -light reaction of the pupils. Our suspicions were -confirmed by the positive serum W. R. The W. R. of the -spinal fluid proved, however, to be negative. There was a -moderately strong gold sol reaction of the syphilitic type. -There was a slight excess of albumin, and there was an exceedingly -slight amount of globulin. There was but one cell -per cmm.</p> - -<p class='c007'>On the whole, it would seem best to consider the case of -Mrs. Bartlett to be one of <span class='sc'>Cerebral Arteriosclerosis of -Syphilitic Origin</span>, and a case in which there is no evidence -of meningitis or meningoencephalitis.</p> - -<p class='c027'>1. What is the explanation of the negative spinal fluid -W. R.? It may be that none of the W. R. producing -bodies have gone over into the spinal fluid. It has been -shown by the work of Weston that the W. R. producing -body is not identical with the bodies responsible for -the other tests in cerebrospinal syphilis. Moreover, it -has been clearly shown that these several tests of the -spinal fluid do not run at all parallel with one another. -Especially is it true that the chemical tests do not correspond -at all with the degree or nature of the pleocytosis. -On the whole, when involvement of the nervous -<span class='pageno' id='Page_114'>114</span>system is entirely vascular, it is not only theoretically -proper but also practically common, to find a spinal -fluid negative to several tests.</p> - -<p class='c027'>2. Omitting consideration of the syphilitic gold sol of this -case, what conclusion could be drawn from the albumin -and globulin findings? It would not be warrantable to -assume syphilis since it is a common finding after -cerebral hemorrhage due to non-syphilitic arteriosclerosis -to find excess albumin and also globulin in the -spinal fluid. Occasionally, also, pleocytosis occurs in -cases of cerebral hemorrhage even when the hypothesis -of an active meningitis can be excluded. We may recall -in this connection the pleocytosis in so-called meningitis -sympathica of certain brain tumors. (See also -the case of Milton Safsky (48), a case of brain tumor in -which there was an excess of albumin, a large quantity -of globulin, and a pleocytosis of 146 cells per cmm.)</p> - -<p class='c027'>3. What can be expected from treatment in these cases of -vascular cerebral syphilis? The condition offers very -little opportunity for therapeutic results. However, -antisyphilitic therapy is indicated to prevent if possible -further progress of the lesions. Since the lesions are, -however, vascular, and since it must remain a question -how far these vascular lesions are due directly to spirochetal -action, and since in any event it may be difficult -to reach the spirochetes thus active, perhaps it is -best to place most reliance on potassium iodid. In any -event, potassium iodid should be given. Salvarsan -and mercury are also indicated. It is common to warn -against administration of large doses of salvarsan in -this type of case on the ground that further vascular -ruptures may be produced. (See Friedberg, 108.)</p> - -<p class='c027'>4. If we conclude that the aphasia of the Bartlett case is -due to vascular disease, can we conclude a relation -between this vascular disease and vascular tension? It -is not safe to draw such a conclusion. The Bartlett case -itself showed low blood pressure. To be sure, some -cases of neurosyphilis show high blood pressure from -which one draws the <i><span lang="fr" xml:lang="fr">à la mode</span></i> clinical conclusion to the -effect that the kidneys are probably involved in the -arteriosclerosis; but other cases do not show a high -blood pressure but may in fact show a low blood pressure. -The vascular disease doubtless responsible for -the aphasia in the Bartlett case is probably not at all -an effect of blood pressure conditions, but is, on the -contrary, an effect of local syphilitic vascular lesions.</p> - -<div><span class='pageno' id='Page_115'>115</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general paresis”) -is often marked by APHASIA.</b></p> - -</div> - -<p class='c006'><b>Case 22.</b> Meyer Levenson, a traveling salesman of 36 -years, had for the last two or three years been undergoing a -change of disposition, quite interfering with his work. He -had begun to take unreasonable aversions to people, had -become irritable and emotionally depressed, and often fell to -weeping without cause.</p> - -<p class='c007'>About nine months before hospital observation, it seems -that a trunk-cover had fallen on Levenson’s head, and there -is some question as to whether he did not have a convulsion -at that time. However, a month later he had a definite -seizure, followed by speech disorder, a slight paralysis, and a -staggering gait. Four weeks later, however, he had gotten -over these post-convulsive difficulties and had gone back to -work.</p> - -<p class='c007'>At his work, he became tired easily, his gait and speech -did not seem entirely normal, and there was a considerable -memory disorder. After five more months, another attack -of a convulsive nature, with twitching of hands and face and -tongue-biting occurred, and the attending unconsciousness remained -for two days. Again improvement followed, though -without ability to return to work. Four (?) months later -there were several severe convulsions and Levenson would -remain unconscious for a day or two at a time. Restlessness, -irritability, and irrational talking followed.</p> - -<p class='c007'><b>Physically</b>, the patient was fairly well developed and nourished; -blood pressure 168 systolic, 68 diastolic; pupils reacted -very sluggishly to light. There was a marked motor -aphasia, which the patient recognized as a speech difficulty. -On the whole, however, Levenson was very euphoric and was -entirely sure that he was improving and would surely get well.</p> - -<p class='c007'>Shortly after entrance, Levenson had a severe convulsion, -with unconsciousness. The movements were mainly on the -right side of the body, and there was a post-convulsive weakness -<span class='pageno' id='Page_116'>116</span>of the right side for several days, followed by a slow -recovery of strength.</p> - -<p class='c007'>The course of the disease—convulsions followed by improvement—is -very characteristic of a paretic onset. The -<b>laboratory findings</b> were in all respects confirmatory. It was -rather striking that a permanent <em>motor aphasia</em> followed the -convulsions in this case, since the seizures of paresis do not -in the vast majority of cases leave permanent paralyses. -The course of the disease continued to show convulsions, -which would in each instance leave him at a lower terrace of -capacity than had been before shown. The patient died -four years after the onset of symptoms of a general asthenia. -With the exception of the permanent motor aphasia, this -case might be regarded as a fairly typical one of general -paresis.</p> - -<p class='c027'>1. What is the general nature of speech disorder in paretic -neurosyphilis? Speech disorder is, along with the -pupillary changes, one of the most important clinical -symptoms in paretic neurosyphilis. There are aphasic -and articulatory disturbances. The aphasia that accompanies -paretic seizures is of a transient nature as a -rule. A case with such long-standing motor aphasia -as shown by Levenson is not common. Paraphasia, with -incorrect naming of objects, may last longer. The so-called -“sticking” phenomenon is often observed.</p> - -<p class='c028'>Word-deafness is said to be rarer but is difficult to test -on account of the patient’s dementia. Agrammatism -(incapacity to form correct sentences) is sometimes -observed. But the most characteristic disorder is -in the syllabic composition of words. Syllables are -left out (“medaltricity” for medical electricity), or -fused (“exity”), or doubled (“electricicity”). Besides -the central speech disorders of which the above -are examples, there are disorders in articulation, which -at first occur as a consequence of paretic seizures or in -states of excitement, but later become permanent. These -are divided into paretic and ataxic disturbances.</p> - -<p class='c027'>2. What is the structural basis of these forms of aphasia? -It is believed that they are due to microscopic changes, -not to coarse destructive lesions.</p> - -<div class='figcenter id006'> -<img src='images/i_116a.jpg' alt='' class='ig001' /> -<div class='ic006'> -<p>BROOKLINE, MASS.</p> -</div> -</div> - -<div class='figcenter id006'> -<img src='images/i_116b.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p><span class='right'>BROOKLINE, MASS.</span><br /><br />Mss. of Levenson, case 22. Paretic neurosyphilis. Tremor, misspelling. Metathesis of letters (Bk, not Br) omission of letters (Book).</p> -</div> -</div> - -<div class='figcenter id006'> -<img src='images/i_116c.jpg' alt='' class='ig001' /> -</div> - -<div class='figcenter id006'> -<img src='images/i_116d.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p><span class='right'>God save the Commonwealth of Massachusetts</span><br /><br />Mss. of Safsky, case 48, brain tumor. Tremor not marked. Misspelling, omission of letters. Wrong letters (h in hweth).</p> -</div> -</div> - -<div class='figcenter id006'> -<img src='images/i_116e.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Mss. of Halleck, case 31, cervical tabes. No brain disorder. Pen-holding and bearing on difficulties. Crowding of phrases result of ataxia.</p> -</div> -</div> - -<div class='figcenter id006'> -<img src='images/i_116f.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Mss. of Collins, case 61, paretic neurosyphilis. One misspelling (-chussetts); not psychopathic? Characteristic tremor.</p> -</div> -</div> - -<div><span class='pageno' id='Page_117'>117</span></div> -<div class='box'> - -<p class='c013'><b>REMISSIONS of identical appearance occur in -PARETIC and in DIFFUSE (non-paretic meningovascular) -NEUROSYPHILIS.</b></p> - -</div> - -<p class='c006'><b>Case 23.</b> Thomas Donovan, a merchant 44 years of age, -acquired syphilis according to his own story at the age of 31, -and he was at that time treated at a well-known watering-place -with mercurial injections. Later he continued treatment -under his family physician, and at 34 was pronounced -cured. However, four years later—that is seven years -after his initial infection and in his 38th year—he had his -blood examined and it proved positive. He was accordingly -treated by salvarsan and his W. R. became negative. The -story did not end there, however, for at 43, mental symptoms -appeared of the nature of depression and a diagnosis of paresis -was made. He was released from the institution against -advice at that time, and without treatment, made a partial -recovery.</p> - -<p class='c007'>A sudden outburst of violence brought Mr. Donovan to -the Psychopathic Hospital; he was very surly, combative, -and difficult to manage, standing 6′ 2″, and weighing 210 -pounds. He was oriented only fairly well and his surliness -was streaked with humor. He facetiously said that the -Psychopathic Hospital was the largest hospital in the country, -and that it was, in fact, a horse hospital; that he had come -because he liked the surroundings, not to make money; that -he was the healthiest man in the world, never having been -sick; that the Psychopathic Hospital was a club, for which -you have to get somebody to propose your name. There -was amnesia and no knowledge of current events. He -regarded the food as poisoned, refused to eat, and was very -irritable and untidy.</p> - -<p class='c007'><b>Physically</b>, there were few abnormalities, but the pupils -failed to react either to light or accommodation, and the -knee-jerks and ankle-jerks were absent. There was a slight -Rombergism. There was a marked speech defect to test -phrases. Both serum and spinal fluid W. R.’s were positive; -the fluid showed 41 cells per cmm., there were large amounts -of globulin and albumin, and the gold sol reaction was of -the “paretic” type.</p> - -<div><span class='pageno' id='Page_118'>118</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>ATAXIA OR INCOÖRDINATION</b></span></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>NEUROSYPHILIS</div> - <div class='line'>LESION OF PERIPHERAL SENSORY NERVES</div> - <div class='line'>DIVISION OF POSTERIOR ROOTS</div> - <div class='line'>TUMORS OR CHRONIC SCLEROSIS OF POSTERIOR COLUMNS</div> - <div class='line'>SUBACUTE COMBINED DEGENERATION</div> - <div class='line'>VESTIBULAR ATAXIA</div> - <div class='line'>FRIEDREICH’S ATAXIA</div> - <div class='line'>FAMILY PROGRESSIVE HYPERTROPHIC NEURITIS</div> - <div class='line'>THROMBOSIS POSTERIOR INFERIOR CEREBELLAR ARTERY</div> - <div class='line'>MARIE’S HEREDITARY CEREBELLAR ATAXIA</div> - <div class='line'>LESIONS OF CEREBELLUM, TUMORS, ETC.</div> - <div class='line'>WRITERS’ CRAMP</div> - <div class='line'>PREHEMIPLEGIA</div> - <div class='line'>MULTIPLE SCLEROSIS</div> - <div class='line'>PSEUDO-SCLEROSIS</div> - <div class='line'>HYSTERIA</div> - </div> - </div> -</div> - -<div class='lg-container-r c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'><span class='sc'>Chart 18</span></div> - </div> - </div> -</div> - -</div> - -<div><span class='pageno' id='Page_119'>119</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>CONDITIONS IN WHICH VERTIGO IS FOUND</b></span></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>NEUROSYPHILIS</div> - <div class='line'>HEAD TRAUMA</div> - <div class='line'>CEREBRAL ANEMIA AND HYPEREMIA</div> - <div class='line'>MENOPAUSE</div> - <div class='line'>ARTERIOSCLEROSIS</div> - <div class='line'>RENAL DISEASE</div> - <div class='line'>CEREBRAL HEMORRHAGE AND THROMBOSIS</div> - <div class='line'>INTRACRANIAL TUMORS</div> - <div class='line'>MULTIPLE SCLEROSIS</div> - <div class='line'>EPILEPSY (<span class='sc'>Aura</span>)</div> - <div class='line'>TOXIC CONDITIONS:</div> - <div class='line in4'>alcohol, tobacco, constipation</div> - <div class='line'>PSYCHONEUROSIS</div> - <div class='line'>OCULAR DISTURBANCES</div> - <div class='line'>EAR DISEASE</div> - <div class='line'>MÉNIÈRE’S DISEASE</div> - <div class='line'>MIGRAINE</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 19</span></div> - -</div> - -<p class='c019'><span class='pageno' id='Page_120'>120</span>Salvarsanized serum was injected intraventricularly through -a trephine opening in the right frontal region. Injections -were made through the corpus callosum into the third ventricle. -There was progressive symptomatic improvement -after each of four injections. In fact, after the fourth injection -the patient was allowed to leave the hospital despite -the fact that there was only a slight improvement in the -spinal fluid findings. The speech defect had entirely disappeared. -(Speech defect, according to many authorities, -including Kraepelin, is of very grave diagnostic significance.) -His memory returned. Mr. Donovan is now able to handle -figures rather extraordinarily well. He now has a good insight -into his delusions and tells stories about them with -great humor.</p> - -<p class='c027'>1. What is the definition of a remission in general paresis? -Remissions form a foil to seizures; just as seizures -mark a sudden advance in the severity of the disease -or may even lead to death; so remissions may cause -a sudden cessation of both mental and nervous phenomena -in the disease. Whereas the seizures occur -most often, according to Kraepelin, in the demented -types of paresis, the remissions occur in all cases except -in the terminal phase. Kraepelin quotes Hoppe as observing -pronounced remissions of long duration in -17% of male and 15% of female paretics. Gaupp -observed marked improvement in less than 10%, and -very marked improvement indeed in only 1% of his -cases. Kraepelin states that such improvements are -most frequent in agitated and especially in expansive -forms of paresis, and that they are rarer and less complete -in the depressive and demented forms. Sometimes -the improvement occurs over night, although the full -extent of the remission becomes complete only gradually, -perhaps in the course of months. The sensorium clears, -the disorientation disappears, the delusions retreat, -and the former delusions are treated as dreams and -imaginations. There is often a good deal of persistent -uncertainty as to events during the height of the disease. -<span class='pageno' id='Page_121'>121</span>The nervous disorders are far more obstinate than the -mental. Still, both speech and writing may often -greatly improve.</p> - -<p class='c028'>Cotton in New Jersey found, among 127 cases of -paresis diagnosticated by modern methods during -seven years, that remissions occurred in but five, or -about 4%, lasting from a half to three years.</p> - -<p class='c027'>2. Does a remission ever amount to a cure? The classical -case quoted in this connection is one observed by -Tuczek. This case developed a picture of paresis in -1876, at the age of 36; and a remission, or cessation, -of symptoms, occurred in 1878; but in 1883, at 43 years, -the patient developed a tabes without any trace of -mental disorder, which tabes gradually advanced. By -the middle of 1898, when the patient was 58, certain -symptoms of excitement and confusion occurred, which -led to death with dementia, 22 years after the beginning -of the disease. Nissl pronounced the cortex to -be undoubtedly the characteristic cortex of a paretic. -This observation seems to indicate that a clinical -remission tantamount to a clinical recovery may occur -without the death of the spirochetes engaged. This -observation is to be held in mind in connection with all -therapeutic work with neurosyphilis.</p> - -<p class='c028'>Nonne states that during his clinical experience of -19 years he had followed 10 cases of paresis with apparent -recovery; but of these ten cases, four had to -be thrown out by Nonne because the apparent recoveries -turned out to be only long and almost complete -remissions, finally issuing in characteristic dementia. -Of the remaining six cases, perhaps two should hardly -be counted as paretic and Nonne rather preferred to -term them cases of syphilitic dementia in the sense of -a non-paretic cerebral syphilis. At the end, therefore, -of his review of observations, Nonne found himself -with four cases of true recovery from paresis.</p> - -<p class='c028'>Spielmeyer holds that there is no theoretical reason -why paresis might not be cured, since all the different -changes that have been described in the disease can -be halted, and many of them can be repaired. In -particular, he reminds us that the acute infiltrative process, -the neuroglia reaction, and the phagocytic action -of the large mononuclear cells are distinctly removable -processes. (See discussion below under Section V, -for apparent cures and remissions occasionally secured -under treatment.)</p> - -<div><span class='pageno' id='Page_122'>122</span></div> -<div class='box'> - -<p class='c013'><b>REMISSIONS of identical appearance occur in -PARETIC (“general paresis”) and in DIFFUSE -(non-paretic) NEUROSYPHILIS.</b></p> - -</div> - -<p class='c006'><b>Case 24.</b> Michael O’Donnell, a laborer of 48 years, came -home, one day, at 5:30, complaining of severe headache. His -wife told him he should lie down and, taking him by the arm, -tried to help him to the bed. At this moment, O’Donnell -lost control of both left arm and left leg, and fell, unable to -move but with consciousness preserved. The wife noted -that the left side of his face was drawn up and that he drooled. -He was at once carried to a general hospital, remaining there -for about three weeks, talking at random in a delirious manner -and tied in bed. Two intraspinous injections of salvarsan -were given, and O’Donnell showed considerable improvement -and went home.</p> - -<p class='c007'>However, upon his return from the hospital, he became -very wilful, would not remain in bed, and on one occasion -actually took the mattress from the bed, carried it to another -room, and then returned to his own room and slept upon the -springs. He became irritable and emotional, insisted upon -going to the hospital, did not go there but upon returning -home insisted that he had been there. That night, O’Donnell -left the house only partly dressed.</p> - -<p class='c007'>It appears that O’Donnell had been excessively alcoholic, -but that before August 15, when he sustained the left-sided -hemiplegia above mentioned, there had been no symptoms -except that in February he had once been very dizzy. It -appears that there had been another dizzy spell, three nights -before the paralysis, accompanied by a fall and unconsciousness -for about 15 minutes.</p> - -<div><span class='pageno' id='Page_123'>123</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>TRANSIENT OR FLEETING PARALYSES</b></span></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>NEUROSYPHILIS</div> - <div class='line'>MYASTHENIA GRAVIS</div> - <div class='line'>MYOTONIA CONGENITA (THOMSEN’S DISEASE)</div> - <div class='line'>PARAMYOTONIA CONGENITA</div> - <div class='line'>MYOTONIA ATROPHICA</div> - <div class='line'>INTERMITTENT CLAUDICATION</div> - <div class='line'>OCCUPATION NEUROSES</div> - <div class='line'>FAMILY PERIODIC PARALYSES</div> - <div class='line'>ETANY</div> - <div class='line'>EPILEPSY MINOR</div> - <div class='line'>HYSTERIA</div> - <div class='line'>MULTIPLE SCLEROSIS</div> - <div class='line'>APOPLEXY</div> - <div class='line'>CEREBRAL THROMBOSIS</div> - </div> - </div> -</div> - -<div class='c018'><span class='sc'>Chart 20</span></div> - -</div> - -<p class='c019'><span class='pageno' id='Page_124'>124</span>O’Donnell was brought to the Psychopathic Hospital some -six weeks after the paralysis, complaining merely of a slight -headache and desirous of treatment. There were no mental -symptoms of any sort. <b>Physically</b>, O’Donnell was in general -not abnormal (there was a slight pre-systolic murmur and -a blood pressure of 190 mm. systolic). The pupils were slightly -irregular, the left larger than the right; both reacted -sluggishly. Both ears were moderately deaf; the tendon -reflexes of the left arm and leg were somewhat more lively -than those on the right. The systematic <b>neurological</b> examination -otherwise revealed no abnormalities. The urine -was negative. The serum W. R. was positive but the spinal -fluid reaction was negative. There were but 2 cells per cmm., -and there was a very slight trace of albumin.</p> - -<p class='c027'>1. How shall we account for O’Donnell’s transient paralysis? -We might invoke brain tumor, alcoholic pseudoparesis, -or some form of neurosyphilis. The diagnosis of brain -tumor seems quite untenable in view of the absence -of premonitory symptoms and in the absence of intracranial -pressure. As for alcoholic pseudoparesis it -is true that the patient was excessively alcoholic.</p> - -<p class='c028'>However, against these two diagnoses and in favor -of the diagnosis of <span class='sc'>Neurosyphilis</span>, are the positive serum -W. R. and the pupillary reactions (although these are -short of the true Argyll-Robertson phenomenon). -Dizziness with retention of consciousness and associated -with the paralyses mentioned suggests rather a subcortical -than a cortical lesion. We are inclined to -regard this lesion as probably <span class='sc'>Thrombotic</span>, and to place -it possibly in the region of the internal capsule. We -are inclined to regard the phenomenon as purely vascular -and as not in this case associated with an encephalitis. -We are, however, not entirely satisfied with the -diagnosis.</p> - -<p class='c027'>2. What shall be said as to treatment? A full-blown left-sided -hemiplegia may be produced even when the -thrombotic lesion is itself exceedingly small. It is -common to explain this on the basis that there is an -area of collateral edema about the small necrotic, -thrombotic, or hemorrhagic area responsible for the -lesion. In short, numerous neurones are functionally -rather than structurally affected, or at all events capable -of early restitution of function.</p> - -<p class='c027'>3. What is the prognosis in such cases? It appears that -now and again patients run for several years without -further trouble, both with and without treatment. -We are inclined, however, to advocate treatment rather -than absence of treatment for a variety of reasons. -<span class='pageno' id='Page_125'>125</span>In the first place, vascular lesions may at any time -become associated with meningitic lesions, and treatment -by salvarsan may perhaps be counted on to head -off this process; secondly, the treatment with iodids -may possibly aid in the resolution of a local thrombotic -process.</p> - -<p class='c027'>4. What are the prodromal symptoms of cerebrospinal syphilis? -According to Nonne, headache, dizziness, sleeplessness, -mental symptoms of the irritability group, loss -of capacity as to mental work, whether severe or not, -and loss of capacity for difficult thinking; also impairment -of memory. Nonne does not regard these phenomena -as characteristic of syphilitic vascular disease, -and calls attention to the fact that in every organic -disease the same subjective symptoms occur. The -triad—headache, dizziness, and impairment of memory—is -for example now counted as a prodromal symptom -complex for arteriosclerotic apoplexy (Cramer). -Of course, apoplectic attacks occur without such preliminary -symptoms: particularly, according to Nonne, -the nocturnal attacks.</p> - -<p class='c027'>5. Can the fleeting paralysis be of service in differentiating -the diffuse from the paretic form of neurosyphilis? -Probably not. In both forms transient paralyses occur -as well as the permanent ones. In general, however, -the transient paralyses are more frequent in paretic -neurosyphilis, whereas the permanent ones occur more -often in diffuse neurosyphilis.</p> - -<div><span class='pageno' id='Page_126'>126</span></div> -<div class='box'> - -<p class='c013'><b>There are cases of NEUROSYPHILIS in which -the laboratory signs are positive but in which there -are no clinical signs or symptoms (PARESIS SINE -PARESI?).</b></p> - -</div> - -<p class='c006'><b>Case 25.</b> Richard Lawlor<a id='r6' /><a href='#f6' class='c014'><sup>[6]</sup></a> was admitted to the Psychopathic -Hospital, October 29, 1914, being sent there from a -general hospital where he had gone on account of a self-inflicted -wound of the wrist, apparently made in a period of -depression with suicidal intent. Routine notes follow.</p> - -<p class='c007'><b>Family History.</b> Paternal grandparents both died of -heart disease. Maternal grandfather died at seventy-two of -dropsy. Moderately alcoholic. Maternal grandmother died -of shock at fifty-six. Father died at age of forty, after an -illness of eight years, from heart disease. Father all his life -was subject to fainting spells and headaches. The only paternal -cousin died at thirteen months of brain fever. Mother, -aged forty-seven, is, to say the least, eccentric. Says “she -has several times been given up from tuberculosis.” Two -maternal uncles died of tuberculosis, one from rupture, one -from heart disease. One uncle who “doesn’t know anything -after he has a teaspoonful of liquor.” Several other uncles -and aunts whose history is not obtained. Patient is mother’s -only child. Mother was twice married. There were several -miscarriages by both husbands; patient child by first -marriage.</p> - -<p class='c007'><b>Past History.</b> Patient born thirty-two years ago, full -term, normal delivery and development. Measles, mumps, -and chickenpox in childhood. Subject to headaches since -seven or eight years old. Kicked in the face by horse at -seventeen or eighteen, not considered serious. Hit by a -baseball three or four years ago, leaving him hard of hearing -<span class='pageno' id='Page_127'>127</span>on left side. Married ten years ago; no children because -he says his wife needed an operation. He denies venereal -disease by name and symptoms. For past ten years has -had attacks of depression lasting but a short time, but quite -severe. Never caused him to quit work as a barber and he -felt better when working. His married life he says was -fairly happy except for his wife’s extravagances, and on this -account he left her a little over a year ago, and she has -applied for a divorce, which he is willing that she should -have, but does not wish to give her alimony. He admits -moderate alcoholism.</p> - -<p class='c007'><b>Present Trouble.</b> Patient states that since he left his wife -a year ago he has felt sorry a number of times. He has -wished he had her back. He has felt lonely. He has had -six or eight periods of depression in that time similar to those -he has had for many years, lasting two or three days, and -sometimes a week. These were always precipitated by some -cause for worry. In these attacks he feels nervous, sleeps -poorly, has little or no appetite, sweats during his work and -everything looks black. Several times in these attacks he -has had suicidal ideas. Ten months ago he considered taking -corrosive sublimate. For a little over a week before entrance -to hospital he had been out of work and had been “sporting.” -The day before entrance he had a telephone message from -his lawyer which upset him somewhat and he walked the -floor all night. He had just been shaving when the idea of -suicide came to him. He sat down a minute when suddenly -the thought “to hell with the world” came to him; he took -the razor and slashed his wrist. He does not remember drawing -the razor across his wrist. As soon as he saw the blood -he felt sorry, called his mother, and was taken to an emergency -hospital and then sent to the Psychopathic Hospital.</p> - -<p class='c007'><b>Physical Examination.</b> Patient is a well developed and -nourished man thirty-two years of age. Head is normal as -to size and shape; there are no scars or marks of injury. -Hair and skin not remarkable in any way. Ears negative -to external examination. Teeth well kept; two missing, several -gold fillings. Tongue very slightly coated. Throat -negative. Tonsils easily visible without evidence of inflammation -<span class='pageno' id='Page_128'>128</span>or exudation. Neck, no thyroid enlargement, no -abnormal pulsations, no adenopathy. Chest, symmetrical, -expansion good, resonant throughout. Breath sounds transmitted -normally. No râles or rubs heard. Heart, no enlargement -or cardiac dulness. Sounds of good quality, no -murmurs heard. Rate regular. Pulses equal, regular and -synchronous, and of good volume and tension. Systolic -blood pressure 130, diastolic 65. Abdomen, flat, soft and -tympanitic throughout; no masses; no tenderness. Liver -edge not felt, below costal margin. Spleen not palpable. -Extremities negative, except for incised wound on left wrist.</p> - -<p class='c007'><b>Neuromuscular Examination.</b> Pupils are large, round, regular, -equal and react readily to light and accommodation. -No nystagmus, strabismus or ptosis. No weaknesses or -paresis of facial muscles. The tongue projects medially and -shows no tremor. The triceps and biceps reflexes are readily -elicited, and are quite active, as are the knee-jerks and ankle-jerks. -On one occasion it was thought that the tendon -reflexes were slightly more active on the left than on the right. -This was never confirmed; always afterwards found equal. -There was no tremor of extended hands. Abdominal reflexes -not elicited. Cremasteric present on both sides. The -plantar response is flexor. There is no Babinski, Gordon -or Oppenheim. No Romberg. Coördination tests well performed. -No speech defect. No sensory disturbances. Urine -examination negative.</p> - -<p class='c007'>Wassermann reaction in the serum: Positive, with cholesterinized -antigen; negative, with syphilitic fetal liver antigen.</p> - -<p class='c007'>Wassermann reaction in fluid positive on two occasions. -Examination of spinal fluid, November 4: globulin +++, albumin -++, 100 cells per cubic millimeter; large lymphocytes, -8 per cent; small lymphocytes, 90 per cent; plasma cells, -0.7 per cent; endothelial cells, 1.3 per cent. November 11, -globulin +++, albumin +++, cells 18 per cubic millimeter. -November 26, globulin ++, albumin ++, cells 92 per cubic -millimeter; large lymphocytes, 13.1 per cent; small lymphocytes, -82.1 per cent; plasma, 1.2 per cent; endothelial, -3.6 per cent.</p> - -<p class='c007'>Gold sol, November 4, 5555432100.</p> - -<p class='c007'>Gold sol, November 26, 3332100000.</p> - -<p class='c007'><span class='pageno' id='Page_129'>129</span><b>Mental Examination.</b> On entrance to hospital patient -seemed slightly depressed and a bit irritable. This condition -lasted two days, after which he was agreeable and apparently -entirely over his depression. Even during his mild depression, -however, he talked freely. There was no evidence of -retardation. He told his story readily. Orientation was -intact. Memory excellent. Educational knowledge well retained. -There was no evidence of any hallucinations or -delusions.</p> - -<p class='c027'>1. Was Richard Lawlor insane?</p> - -<p class='c028'>There was, then, on the mental and physical examination -nothing to make a definite suggestion of a -psychosis, and the most one could think of was a -psychoneurosis or a cyclothymia of at least ten years’ -duration. The findings in the cerebrospinal fluid and -the Wassermann reactions, however, give us material -for thought. Certainly one cannot call the man -insane; all who saw him agreed on this point.</p> - -<p class='c027'>2. If Richard Lawlor should some day develop mental -symptoms, what would be the genesis of the new psychosis? -Though writers such as Fildes and McIntosh, and -Swift, have suggested an anaphylactic or hyperallergic -explanation for the development of symptoms after a -normal interval; such a hypothesis could hardly obtain -in the present case. The hyperallergic hypothesis for -the development of tertiary neurosyphilis would run -to the effect that in the secondary stages there had been -a definite disease of the nervous system, which, however, -absolutely cleared up, leaving no inflammatory vascular -or parenchymatous relics of its existence. Nothing -would on this hypothesis remain except a hypersensitisation -of the tissues. In some later period of the -now clinically normal person, one or more spirochetes -from a lesion outside the nervous system are carried -into the nerve tissues and there set up an anaphylactic -or hyperallergic reaction. It is obviously difficult -to prove the correctness or incorrectness of the -hyperallergic theory without numerous examinations -of the spinal fluid, in clinically normal persons after the -secondaries have passed. The present case, so far from -demonstrating a normal fluid, demonstrates a highly -pathological fluid, even though there are absolutely -no clinical symptoms which could be regarded as of -<span class='pageno' id='Page_130'>130</span>nervous origin. The burden of proof at the present -time would seem to lie with those who claim hyperallergy -in neurosyphilis. We prefer on present evidence -to think that at the conclusion of the secondaries -a disease process often remains in the nerve tissues -despite clinical quiescence.</p> - -<p class='c027'>3. What is the prognosis in the case of Richard Lawlor? -The prognosis <i><span lang="la" xml:lang="la">re</span></i> neurosyphilis is doubtful. We have, -however, boldly termed the condition <em>PARESIS SINE -PARESI</em>, meaning thereby to suggest that the patient -is in considerable danger of the efflorescence of a true -diffuse or paretic neurosyphilis. We have no means of -telling, however, whether the positive symptoms would -be those of a paretic or a non-paretic neurosyphilis. -As data accumulate regarding these cases of <em>paresis -sine paresi</em>, we may be able finally to come upon some -case in which trauma shall bring out the clinical symptoms -of neurosyphilis. For discussion of this matter, -see the case of Bessie Vogel (52) in Part III of this book.</p> - -<p class='c027'>4. Should Lawlor have been brought to a psychopathic -hospital? It is a safe working rule to have any person -who attempts suicide observed. A large percentage of -suicides occur in psychotic individuals and a suicidal -attempt is not infrequently the first recognized abnormality. -Immediate observation is a necessary safeguard -against another more successful attempt.</p> - -<div><span class='pageno' id='Page_131'>131</span></div> -<div class='box'> - -<p class='c013'><b>Demonstrates SYMPTOMS and LESIONS of -PARETIC NEUROSYPHILIS (“general paresis”). -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 26.</b> John Morrill, 49, an operative in a mill town in -Essex County, Mass., was described as a “Saturday night -and Sunday drinker,” with a history of very serious long -sprees at the age of 43. It seems that he had had what was -called “sciatica” at 35, and was treated in hospital for -seven weeks at that time. The nature of this sciatica is in -doubt, but there was a history of syphilitic infection at 36 -years (scar of glans).</p> - -<p class='c007'>Morrill had been married twice, and two of the children -were dead; one daughter was described as “very nervous,” -but there were four children under ten years of age, all regarded -as perfectly healthy.</p> - -<p class='c007'>Morrill had been a mill operative of average capacity, was -industrious, and had supported his family despite alcoholism. -The syphilis had been treated with reasonable thoroughness.</p> - -<p class='c007'>Aside from alcoholism, there had been no symptoms up to -two months before admission to Danvers Hospital. Then -there had been insomnia, fatigue, agitation, eruption on foot, -loss of ten pounds in weight, hypochondriacal fears, apprehensiveness -for the future of the children, incoherent talk; -and just before admission, his talk was described as foolish. -He had taken to running away and hiding in bushes by a -pond and in the cellars of other people’s houses.</p> - -<p class='c007'>The patient was of medium height and weight, with thin -grayish hair and grayish irides; musculature was slender. -The face was blank in expression, the teeth poorly preserved -with atrophy of gums, the tongue coated, and the breath -foul. There was a gummy secretion of the eyelids, an area -of brownish branny eruption over both clavicles, a number of -depressed scars over the limbs and back, and another area -of scaly eruption on the right heel and the sole of the foot. -The heart area was increased, and the sounds were faint at -<span class='pageno' id='Page_132'>132</span>the base, with the first sound accentuated at the apex. The -urine showed a trace of albumin.</p> - -<p class='c007'><b>Neurologically</b>, the Romberg position was maintained with -a general tremor and fluttering of the eyelids. In complicated -movements, the patient was slightly ataxic. The -pupils were irregular, the left being much larger than the -right. There were no light reactions to be obtained in window -light. The reaction to accommodation was present, though -slight. Vision was poor, ¼-inch capitals could not be read by -left eye at reading distance. The knee-jerks were diminished -equally; the Achilles jerks were absent; the other reflexes were -normal. Upon the sensory side, the patient gave a history -of pains in the legs at irregular intervals for several years. -These pains he described as of a darting character. There -was little or no sensory disorder, although the outer surface -of the right leg required a deeper pressure to elicit sensation. -There were no disorders of muscle sense.</p> - -<p class='c007'>If Morrill was to be trusted, he had been born in Ireland, -and had come to the United States at the age of 17. He married -at 18; there had been seven pregnancies by the first wife, -with one stillborn child; one child had died at five weeks. -The four children by the second wife were healthy. The -first signs of neuritis had occurred at 45 and had received the -diagnosis neuritis, although no connection between the -neuritis and the syphilis had been noted.</p> - -<p class='c007'>The patient entered the hospital July 26, 1904, and was -discharged, improved, January 5, 1905. He returned a little -more than a year later, January 15, 1906, and died March 21, -1906. The total duration of the disease from the onset of -mental symptoms may therefore be stated as somewhat under -two years. When the patient appeared at the hospital the -second time, he showed a positive Romberg sign, an unsteady -gait, an ataxia that still was moderate, and somewhat more -marked tremors, involving fingers, tongue, and face. He -was now unable to read ½-inch type with the left eye. The -knee-jerks, formerly diminished, were both exaggerated, the -left slightly more so. The Achilles reaction, not obtained -formerly, now appeared on the right side. The pupils reacted -as before. The sensory loss had become more marked, since -<span class='pageno' id='Page_133'>133</span>sharp and dull points could hardly be distinguished. Deep -pinpricks were not felt in the leg, and heat could not be told -from cold.</p> - -<p class='c007'>The speech in 1904 had been somewhat defective (“truly -rural” rendered as “tooly lualal,” “sifted soft thistles” as -“thoft thsistles”), and there had been little further development -of the speech defect. The handwriting had lost appreciably -in legibility and had become much more tremulous. -During the first period of hospital observation Morrill had -what might possibly have been visual hallucinations, but it -was impossible to tell whether his story of seeing his wife and -children trying to get in through the window was hallucinatory -or a matter of fabrication. Memory was decidedly -imperfect and few details of recent events could be produced. -The association of ideas was almost a so-called “flight” -of apprehensive, fearful ideas, loosely connected, incoherently -expressed, and dealing chiefly with his work and his children. -Judgment was imperfect; the height of the room was estimated -as 24 feet, but the height and weight of persons were -estimated with fair accuracy, and also the length of small -objects, whose lengths were doubtless remembered rather -than estimated. The estimate of time elapsing during a -medical examination was accurate, but the estimate of longer -durations involving over-night memories was hopelessly -imperfect. Emotionally, there was a dulling of sensibility, -an appearance of suspicion and apprehensiveness; the patient -fancied himself to be in a hopeless condition as a result of -syphilis, but at the same time accompanied his statement -of his hopelessness with laughter. A sample of his hypochondriacal -ideas: “I am all gone; I am good for nothing; -I am all gone now; I can’t drink now; can’t write or talk at -all; worse than when you saw me first; nothing in my inside; -all wrong through me again; I aint got no swallow now; -I can’t die even; my heart aint much good; I can’t hear -it beat; I don’t think it flutters; no life in these hands; -they are all cold and dead” (pointing to his arms and moving -them about). During such a portrayal the patient laughed -in a silly way.</p> - -<p class='c007'>During the second hospital stay, Morrill was at first restless, -<span class='pageno' id='Page_134'>134</span>sleepless, profane, imperfectly oriented for time, possibly -for place, and also for the attendants. A few weeks later he -became stuporous and confused, and his feebleness and physical -exhaustion were finally ended by death, March 21, 1906. -Death was preceded by a semi-comatose condition; a left -otitis media had developed.</p> - -<p class='c007'>At the <b>autopsy</b>, it appeared that death was due to an early -bronchopneumonia associated with acute splenitis and doubtless -related to the otitis media of the left side. The body at -large showed, aside from these acute lesions, a few chronic -lesions, including slight scars of the left apex, and chronic -adhesive pleuritis, chronic diffuse nephritis, and aortic and -coronary syphilis. The aorta showed slight linear and nodular -markings, with a single small dark ulcer in the upper thoracic -region, but the aorta did not show the characteristic scarring -which syphilitic aortas often show. The femoral marrow -was of a dark red chocolate color. The thyroid appeared -to be smaller than normal. A slight sacral decubitus had -developed.</p> - -<p class='c007'>The description of the head (E.E.S.) is given in full on -account of the encephalitic lesions shown. These encephalitic -lesions may be summed up as follows:</p> - -<p class='c015'>Local cerebral <b>atrophy</b> and <b>sclerosis</b> of the frontal, -orbital, and central regions, especially of the left operculum -and left supramarginal gyrus.</p> - -<p class='c015'>Extension of sclerosis to hippocampal gyri with -effacement of substantia reticularis alba.</p> - -<p class='c015'>Slight chronic internal <b>hydrocephalus</b>.</p> - -<p class='c015'>Granular <b>ependymitis</b> (especially of floor of 4th -ventricle).</p> - -<p class='c015'>Compensatory edema of frontal and central pia mater.</p> - -<p class='c015'>Cerebellar sclerosis (culmen monticuli, lobus culminis, -lobus cacuminis).</p> - -<p class='c015'>Spinal sclerosis (grossly evident in the posterior -columns of the upper thoracic region and of the lumbar -enlargement).</p> - -<p class='c007'>The details are as follows:</p> - -<p class='c015'>Head:—Bald on top. Hair <b>gray</b>. Scalp normal. -Calvarium thin, deeply excavated by arachnoidal villi -to right of vertex. Diploë absent. Dura closely adherent -in bregmatic region. Dura of usual thickness. -<span class='pageno' id='Page_135'>135</span>Sinuses contain cruor clot. Arachnoidal villi slight. -Pia mater hazy and over sulcal veins porcelain white -over all of vertex except occipital poles and over flanks -(notably left). Thickened also around circle of Willis, -over culmen monticuli and in posterior cerebellar notch. -Edema of pia corresponding to atrophy of frontal and -central regions. Cerebral atrophy most marked in -orbital surfaces of both frontal lobes, in left area of -Broca, and in left supramarginal region. The ascending -branch and the ascending ramus of the posterior -limb of the left Sylvian fossæ both readily admit the -thumb by reason of atrophy of adjacent substance. -Induration corresponds closely with atrophy, but is -not more marked about the left Sylvian fossa. There -is sclerosis of both hippocampal gyri, with loss of the -substantia reticularis alba. The culmen monticuli and -lobus culminis are firmer than the clival regions, and -the lobus cacuminis is again slightly firmer than the -clival region. Cerebellum a little softer than usual. -Pia strips with usual readiness from all regions. The -subpial region of the frontal lobes is a trifle grayer -than that of the rest of cerebrum. Ventricles slightly -dilated. Surfaces evenly sanded. Floor of fourth -ventricle shows numerous coarse, closely set granules. -Brain wt. 1200 grms. Cord shows a slight increase of -consistence over one or two upper thoracic segments -and in lumbar enlargement corresponding with a slight -graying out of posterior columns. In places there is -a suggestion of graying out also in lateral columns. -A few calcified plaques in posterior lumbar pia.</p> - -<p class='c007'>Analysis of these details shows a number of lesions that -characterize paretic neurosyphilis (among others, granular -ependymitis, frontal atrophy, chronic leptomeningitis), but -the lesions are more than merely frontal, extending as they -do back as far as the postcentral regions on both sides, and -even as far as the left supramarginal gyrus. The cerebellar -involvement although frequent, can hardly be said to be -characteristic in paretic neurosyphilis. The spinal involvement -is characteristic of a case which is probably to be regarded -as one of taboparesis; that is, of paretic neurosyphilis -following a number of years after the establishment of tabetic -neurosyphilis. The aorta is almost constantly affected by -sclerosis in paretic neurosyphilis. The absence of diploë in -<span class='pageno' id='Page_136'>136</span>the skull is not infrequent and the adherent dura mater is -often found.</p> - -<p class='c007'>Microscopically, the tissues showed the characteristic -lesions of <span class='sc'>Paretic Neurosyphilis</span>; nerve cell destruction, -fibrillar and cellular gliosis, lymphocytic and plasma cell -deposits about the small vessels.</p> - -<p class='c027'>1. What are the clinical evidences of syphilis outside the -nervous system? The brownish branny eruptions of -the skin, the depressed scars and the scaly eruption -on right heel and sole are very suggestive of syphilis. -Such clinical evidences of syphilis are very important -in systematic examination. Although the laboratory -tests are of the utmost assistance in the diagnosis of -syphilis, the clinical signs should not be neglected, and -no physician should rest satisfied with laboratory signs -alone. X-ray diagnosis of bone conditions sometimes -succeeds when all other methods have failed.</p> - -<div><span class='pageno' id='Page_137'>137</span></div> -<div class='box'> - -<p class='c013'><b>GUMMA of cerebral cortex verified by operation; -death.</b></p> - -</div> - -<p class='c006'><b>Case 27.</b> The presenting picture in the case of David -Tannenbaum was that of deep dementia, in which condition -the patient was brought to the hospital. There was a meagre -history to the effect that about four months before admission, -he had lost his job in a hotel through lack of further work. -We heard that at this time he had begun to suffer with excruciating -pains in the head; at first, worse at night, later, -worse by day. It appeared that this pain, though it came -and went, was chiefly localized on the left side of the head. -For a fortnight, Tannenbaum had been dragging his legs, -until finally he had become unable to walk at all.</p> - -<p class='c007'><i><span lang="la" xml:lang="la">Pari passu</span></i> with these developments, Tannenbaum had -become mentally confused and irritable, and his memory had -become untrustworthy. For several days before admission, -an appearance of marked dementia was presented, with slow -incoherent, or at all events, irrelevant words, and a complete -disorientation for person. However, his vision had become -so poor that it would have been hard for him to have recognized -any one.</p> - -<p class='c007'>It appeared that the family history was entirely negative; -that the patient was without education but had been physically -very strong, and had been fairly successful at first in the -junk business, and later in the clothing business; but latterly -he had been less fortunate in the clothing business, and -finally had to resort to work as a laborer around a hotel.</p> - -<p class='c007'>His wife had had eleven pregnancies with but one miscarriage. -Nevertheless, out of the eleven pregnancies, there -were now but four living children.</p> - -<p class='c007'><b>Physically</b>, Tannenbaum was a rather small man; he was -flabby and looked as if he had recently lost weight. The skin -showed areas of pigmentation on the face and sides of the -neck, and some dark copper-colored circular areas, marble-size, -in the neck (syphilitic?). There was a slight radial -<span class='pageno' id='Page_138'>138</span>arteriosclerosis. The heart was slightly enlarged with distant -and indistinct sounds. There was a small pedunculated -growth on the right side of the abdomen.</p> - -<p class='c007'>The pupils failed to react to flash-light but they reacted to -sunlight. They both were slightly irregular but were equal in -size, and reacted in accommodation. There was apparently -almost complete blindness and extreme deafness. Arm-jerks -and knee-jerks were absent; there was an occasional slight -response of the left ankle-jerk, but the right ankle-jerk was -absent; the left abdominal reflex was very feeble; the right -absent; the cremasteric reflexes were absent, but there were -no other abnormalities in the systematic examination. Hand -grips weak; gait awkward, with right leg held somewhat flaccidly.</p> - -<p class='c007'>It was significant that percussion over the left frontal and -parietal regions was able to elicit great pain. Either through -the patient’s deafness or through sensory aphasia, spoken -language was not understood. The serum W. R. was positive, -the fluid W. R. negative.</p> - -<p class='c007'><b>Diagnosis</b>: The clinical symptoms seem clearly to indicate -syphilis. The local skull tenderness and impairment of -vision might well suggest intracranial pressure. Uniting -these suggestions, we might automatically arrive at a diagnosis -of cerebral gumma. We have learned to be rather cautious -of making a diagnosis of gumma of the brain through its -mere rarity.</p> - -<p class='c007'>Decompression was suggested and executed. A deep -growth resembling a <span class='sc'>Gumma</span>, in the view of the surgeon, was -discovered. No attempt could be made to remove it. The -patient died without recovering consciousness.</p> - -<p class='c027'>1. What is the significance of the negative fluid W. R. in -this case of cerebral gumma? The W. R. producing -substances not infrequently fail to appear in the spinal -fluid from a gumma of the brain. The serum W. R. -was positive in this case, but even the serum W. R. may -be negative in cases of gumma, both of the brain and of -the body at large. It must be remembered that the -serum W. R. may be negative in paretic neurosyphilis -(general paresis); the serum W. R. is even more apt -to be negative in cases of gumma.</p> - -<div class='figcenter id004'> -<img src='images/i_138.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Gummatous meningitis. Compression of hemisphere. Tissue destruction of underlying cortex.</p> -</div> -</div> - -<p class='c027'><span class='pageno' id='Page_139'>139</span>2. Is operative procedure to be advised in cerebral gumma? -There are cases in which the acute and threatening -symptoms of heightened intracranial pressure require -operative treatment simply because the therapeutist -cannot wait for the effect of antisyphilitic treatment. -Moreover, antisyphilitic treatment of cerebral gumma -is not always as successful as that of most syphilitic -lesions.</p> - -<p class='c027'>3. Could the intracranial pressure be caused by other syphilitic -lesions than gumma? A heavy meningitis may -cause symptoms such as produced by an intracranial -tumor. In such a case one will usually find evidences -of inflammation in the spinal fluid. Cysts caused by -syphilitic lesions may also produce identical symptoms.</p> - -<p class='c027'>4. What is the significance of cranial tenderness? Where -sensitiveness to cranial percussion is not due to a scalp -lesion it is very suggestive of a tumor underlying this -point. A gummatous lesion of the cranium itself, may -occur without causing pain or increased sensitiveness.</p> - -<div><span class='pageno' id='Page_140'>140</span></div> -<div class='box'> - -<p class='c013'><b>CRANIAL NEUROSYPHILIS (focal syphilitic -extraocular palsy) without mental symptoms.</b></p> - -</div> - -<p class='c006'><b>Case 28.</b> A chef, Paolo Marini, 28 years of age, reported -that on awaking one morning, everything appeared double to -him and that his right eyelid had begun to drop. In the following -month Marini had begun to feel weak and to have -difficulty in swallowing, as well as at times difficulty in breathing. -The diplopia was found to develop when Marini looked -to the right. Mentally, the patient was in all respects normal, -and no other physical signs were found except the diplopia -and ptosis above mentioned. The W. serum test was positive, -but the tests of the spinal fluid were negative.</p> - -<p class='c007'><b>Diagnosis</b>: “<span class='sc'>Cerebral syphilis</span>.”</p> - -<p class='c027'>1. What is the anatomical cause of this condition? It is -thought to be due in a number of cases to a small diffuse -gummatous lesion at the <em>basis cerebri</em>. In the case -of Marini this lesion appears to have been a little more -extensive and to have interfered with the tenth and -twelfth nerves also.</p> - -<p class='c027'>2. Why is the spinal fluid negative in such a case as that of -Marini? Head and Fearnsides believe that intracerebral -lues is characterized by a negative spinal fluid, -under which circumstance one has always to consider -the possibility of brain tumor or migraine in addition to -the suspicion of syphilis.</p> - -<p class='c027'>3. What other causes besides syphilis should one consider -for the sudden diplopia? Brain tumor, multiple sclerosis, -cerebral arteriosclerosis, tuberculous meningitis, -trauma and migrainous ophthalmoplegia, are not -infrequently at the bottom of this condition. Cases -also occur in which the etiology remains obscure, even -at autopsy.</p> - -<p class='c007'>Under antisyphilitic treatment, Marini slowly improved.</p> - -<div><span class='pageno' id='Page_141'>141</span></div> -<div class='box'> - -<p class='c013'><b>The SIX TESTS in TABETIC NEUROSYPHILIS -(“tabes dorsalis”) may run milder than in paretic -neurosyphilis (“general paresis”) and characteristically -run somewhat like those of diffuse (meningovascular) -neurosyphilis; in particular, the fluid -Wassermann Reaction and the gold sol reaction -are apt to run milder. The clinical course of tabes -dorsalis is protracted and the prognosis as to life -is good.</b></p> - -</div> - -<p class='c006'><b>Case 29.</b> Mario Sanzi, 55 years of age, had been having -what he called rheumatism since his 43d year. This rheumatism -affected only the hips and legs, had at times been very -severe, and for two years past had been almost constant. -Before that time, pains had come at intervals, lasted a variable -period, and suddenly disappeared. They were of -knife-thrust character, and could probably be called “lancinating.” -In a given attack, these pains would come at -intervals of seconds or more. There was also a certain -unsteadiness in locomotion and inability to control the -vesical sphincter.</p> - -<p class='c007'><b>Physically</b>, the patient was entirely normal so far as could -be made out except <b>neurologically</b>. Argyll-Robertson pupils, -absence of knee-jerks, and ankle-jerks, Romberg sign, and -characteristic gait, left no cause for doubting the diagnosis -of <span class='sc'>Tabes Dorsalis</span>. The blood and spinal fluid both proved -positive to the W. R., though the W. R. in the fluid gave a -negative reaction with 0.1 cm. and became positive with -0.3 cm. or more. The globulin was somewhat increased though -less markedly so than in paresis. The gold sol reaction was -“syphilitic” but weak. It is to be noted that the disease had -run a 12–years’ course before a doctor had been consulted. -The primary infection occurred at 32 years, namely, 11 -years before the symptoms began. At the time of his primary -infection, Sanzi had received several years of treatment, -chiefly in the form of mercury by mouth.</p> - -<p class='c027'><span class='pageno' id='Page_142'>142</span>1. What is the value of mercurial treatment of syphilis -in the prevention of tabetic or other forms of neurosyphilis? -“Fournier strove for many years to convince -the medical profession that a syphilitic patient -should be treated for at least two years after his infection, -whether the syphilis seemed latent or patent. -The method of treating only the symptoms he characterized -as the opportunist method; treatment in the -absence of definite symptoms the preventive method, as -preventing the later manifestations. That prolonged -treatment does prevent is shown by Fournier’s figures -analyzing 2396 cases presenting tertiary signs. These -he divides into three groups: Group I, comprising 1878 -cases, or 78 per cent of the whole number, having no -treatment or inadequate treatment—that is mercury -for less than one year; Group 2, comprising 455 -cases, or 19 per cent, having moderate treatment—that -is, mercury for one to three years; and Group 3, -comprising the remaining 19 cases which represent -only 3 per cent of the whole number, having treatment -for more than three years.”<a id='r7' /><a href='#f7' class='c014'><sup>[7]</sup></a></p> - -<p class='c028'>In the light of what we now know concerning latent -neurosyphilis, it would seem well for patients to be -followed from time to time with the W. R. on blood -and spinal fluid after the supposed completion of the -treatment of primary and secondary syphilis. The -examination of the spinal fluid is not superfluous, as -our experience with the so-called <em>paresis sine paresi</em> -abundantly shows. At the present day it is not good -practice to assure a patient that he is cured after two -years of ordinary mercurial treatment without resort -to frequent spinal fluid tests, even though the serum -W. R. be negative.</p> - -<div><span class='pageno' id='Page_143'>143</span></div> -<div class='box'> - -<p class='c013'><b>TABETIC NEUROSYPHILIS (“tabes dorsalis”) -is often quite ATYPICAL clinically and may even -show no single symptom warranting the old clinical -name “locomotor ataxia.”</b></p> - -</div> - -<p class='c006'><b>Case 30.</b> Stephen Green is a case of <span class='sc'>Tabes Dorsalis</span> with -active knee-jerks and without locomotor or muscle-sense -disorder. When observed at the age of 45, it appeared that -there were but two complaints: lack of control of the vesical -sphincter and shooting pains in the legs. It appeared that -the urinary disorder dated back ten years, when there had -been difficulty in passing the urine. Sounds had been -passed at the time; occasionally there had been incontinence -during after years, ascribed by Mr. Green to the passing of -the sound. However, the physician at that time stated that -the incontinence was a symptom of tabes dorsalis. The -incontinence had recently become worse, especially marked -at night, though also occurring in the day; much worse during -excitement, and very much worse after taking alcoholic -drinks. Besides incontinence, there is also difficulty at -times in passing the urine, as well as dysuria.</p> - -<p class='c007'>As for the pains in the legs, they had been first noticed -some three or four years ago and considered to be mild -rheumatic effects. Now, however, they have grown progressively -worse and have been the effective cause of giving -up business. The pains are sharp, darting, pinching, and -burning, and last, say, about a second with an interval of -about the same length. The attack will continue sometimes -for many hours.</p> - -<p class='c007'>There is a strabismus of the left eye, ascribed by the -patient to an accident with an umbrella (there had been -operation without relief). The pupils showed the Argyll-Robertson -effect and were markedly irregular. Despite the -divergent strabismus with diplopia, the eye movements were -well performed although not in parallel axes. Ankle-jerks -could not be obtained even on reinforcement, but the knee-jerks -<span class='pageno' id='Page_144'>144</span>were lively, and the other deep and skin reflexes proved -normal. The blood and spinal fluid tests were characteristic -of tabes dorsalis.</p> - -<p class='c007'>It appears that the syphilis was acquired by this patient -15 years before; that is, 5 years before neurological symptoms -began. Three courses of treatment had been taken at a -well-known watering-place, and mercury pills had been taken -for two years by mouth. The patient is married; has no -children; there have been no pregnancies.</p> - -<p class='c027'>1. What causes may be assigned for the absence of children -in the family of a tabetic? There may be lesions of the -genital apparatus (orchitis, or more specialized toxic -lesions). But impotence such as characterized the -present case must also be taken into account.</p> - -<p class='c027'>2. What is the therapy for tabetic pains? Pyramidon is -nowadays much in favor; morphine may be used; -some authors recommend that the patients be instructed -to chloroform or etherize themselves slightly -for relief of the pain. Surgery of the nerve roots -may be resorted to in extreme cases. Intraspinous -therapy, suggested by various authors, seems to exert -beneficial effect in many cases.</p> - -<p class='c027'>3. Is the lack of control of the vesical sphincter an unusual -initial symptom? On the contrary, the more careful -the clinical observation, according to some observers, -the more likely is the examiner to find that vesical -symptoms were the earliest or among the earliest complaints -of the patient. Baldwin Lucke found sphincter -disturbances to be initial in 8¼% of his long Blockley -series. He found sphincter disturbance to occur in -some stage of the disease in 67.6%, being exceeded in -frequency only by staggering gait (87.2%) and lancinating -pain (71.6%). According to Lucke, the most -frequent <em>initial</em> symptom is lancinating pain in the -lower extremity, which, it will be noticed, occurred -also in our case of Stephen Green as an initial symptom -along with vesical disturbance. Lucke’s figures show -that paresthesia of the lower extremities (17.6%) and -weakness of the extremities (16.4%) are the next initial -symptoms in frequency.</p> - -<p class='c027'>4. Could the early treatment in the case of Stephen Green -be considered as adequate? No better answer can be -given to this question than by quoting from Dr. Joseph -<span class='pageno' id='Page_145'>145</span>Collins,<a id='r8' /><a href='#f8' class='c014'><sup>[8]</sup></a> who probably has done more than any other -one man in this country in insisting on the need of -proper treatment of syphilis. As to the adequate treatment -of syphilis he says:</p> - -<p class='c028'>“It consists in the proper use of salvarsan and mercury -begun at the earliest possible moment after infection -and kept up till all biochemical evidence of the disease -has ceased, while the metabolism of the individual is -maintained as nearly normal as possible. But the physician -does not do his whole duty when he has accomplished -this. He must solicitously watch the individual -to see that no evidence reappears for months and even -years after the apparent cure. As an index of such reappearance -the Wassermann test of the blood serum and -of the cerebrospinal fluid is the safest guide.</p> - -<p class='c028'>“Until there is a definite unanimity of belief among physicians -as to when the treatment of syphilis shall be -begun, and some concert of action as to what constitutes -the adequate treatment of syphilis, we cannot -hope to make any considerable progress in the prevention -of syphilis of the nervous system, save by educating -the individual toward infection.”</p> - -<div><span class='pageno' id='Page_146'>146</span></div> -<div class='box'> - -<p class='c013'><b>TABETIC NEUROSYPHILIS may produce symptoms -chiefly if not entirely in the region supplied -by the CERVICAL plexus (“cervical tabes”).</b></p> - -</div> - -<p class='c006'><b>Case 31.</b> Paul Halleck, 35, was a salesman who had begun -to find it hard to carry his sample case, since he was unable -to tell whether or not he had it in his hand. There was not -only an anesthesia of the hands, but they felt numb and -there was often a tingling sensation. Of late it had become -hard for Halleck to dress himself or to write, and these symptoms -had been slowly growing worse. There was no other -complaint. There was, however, a history of a chancre about -7½ years before, which had been followed by a rash and a -sore throat. There had been treatment with mercury and -potassium iodid alternating for a period of two years.</p> - -<p class='c007'><b>Physically</b>, there was no evidence of disease except <b>neurologically</b>. -The pupils were unequal (the right larger than the -left) and reacted slowly to accommodation and not at all -to light. A marked ataxia of the hands was shown in coat-buttoning. -The finger-to-nose test showed a marked dysmetria. -Arm-jerks as well as knee- and ankle-jerks were -absent. There was a slight swaying in the Romberg position -but no true Romberg sign. There was no difficulty in -locomotion. Both blood and spinal fluid proved positive -to the W. R.; globulin and albumin were increased. The -gold sol reaction was syphilitic, and there were 85 cells per -cmm.</p> - -<p class='c007'>This case is probably not a pure example of <span class='sc'>Cervical -Tabes</span>, since the knee-jerks are also absent, and we may -suppose a degree of lumbar spinal cord changes in addition to -the cervical changes. It well illustrates, however, that the -tabetic involvement of the cord may be quite generalized and -that it may strike high as well as low.</p> - -<div><span class='pageno' id='Page_147'>147</span></div> -<div class='box'> - -<p class='c013'><b>ERB’S SYPHILITIC SPASTIC PARAPLEGIA.</b></p> - -</div> - -<p class='c006'><b>Case 32.</b> Margaret Neal, a maid-of-all-work, 36 years -of age, was committed to a home for inebriates on account -of her excessive alcoholism, but she was shortly transferred -to the Psychopathic Hospital on account of difficulty with -locomotion. We found a very marked spasticity in walking, -with a characteristic scissors gait. The pupils were somewhat -irregular, and although both reacted to light, the -left reacted far more slowly than the right and the reaction -failed to hold well. The arm reflexes were very active, and -the knee-jerks and the ankle-jerks were particularly exaggerated. -There was a double Babinski reaction, as well as -Oppenheim and Gordon reflexes and a bilateral ankle clonus. -There seemed to be tenderness over the nerve trunks in the -back of the leg, below the knee. There was no evidence of -incoördination, no Rombergism, no disturbance of sensation, -no disorder of the special senses, and not even a tremor of -the tongue or hands.</p> - -<p class='c007'><b>Mentally</b>, the patient was entirely negative.</p> - -<p class='c007'><b>Diagnosis</b>: Symptomatically, it is entirely clear that -the patient was suffering from <span class='sc'>Spastic Paraplegia</span>. One -would have to consider besides spinal syphilis, also amyotrophic -lateral sclerosis, syringomyelia, and spinal cord -tumor. However, there appeared to be no definite wasting -of muscles, and the fact that the sensations were intact seems -to rule out also syringomyelia. There was none of the -characteristic pain associated with a cord tumor. There was, -in fact, a strong clinical premonition that the case was one of -spinal syphilis, simply because syphilis is the most common -cause of spastic paraplegia in the adult. The pupillary -anomalies were also highly suggestive.</p> - -<p class='c007'>The serum W. R. proved to be weakly positive, as was also -the gold sol reaction in the zones characteristic of syphilis. -The spinal fluid examination yielded 14 cells per cmm. There -<span class='pageno' id='Page_148'>148</span>was a positive globulin test and a moderate increase in albumin. -The W. R. of the spinal fluid was negative.</p> - -<p class='c027'>1. Why was the spinal fluid W. R. negative in this case of -spinal syphilis? The explanation of negative W. R.’s -in spinal syphilis is not easy. Possibly, however, in -the course of years the intensity of the process has been -reduced and possibly the W. R. has been one of the -first tests to disappear.</p> - -<p class='c027'>2. How shall we explain the nerve trunk tenderness? We -might consider this to be due possibly to an inflammation -about the posterior roots. On the whole, partly -on account of the situation of the pains below the knee, -it seems probable that the nerve trunk tenderness of -this case is the residuum of an alcoholic neuritis.</p> - -<p class='c007'><b>Treatment</b>: Under injections of mercury salicylate, there -was a rapid improvement. In fact, in the course of several -months, the patient regained an ability to walk long distances. -There still remains a certain spasticity, but the abnormal -spinal reflexes above mentioned are no longer present.</p> - -<div><span class='pageno' id='Page_149'>149</span></div> -<div class='box'> - -<p class='c013'><b>SYPHILITIC MUSCULAR ATROPHY, probably -due either to spinal parenchymal lesions, or to root -neuritis, or to both.</b></p> - -</div> - -<p class='c006'><b>Case 33.</b> Joseph Graham, now 50 years of age, seemed -no longer to be able to do good work as a teamster. His -arms had become weak and the muscles had become tremulous -and apparently wasted. There was also pain in the left leg -and hip. It appears that this latter symptom had been -thought to be rheumatism, having begun about 8 years before -with a sudden sharp shooting pain in the left hip, about the -region of the sciatic notch. Graham had rubbed the hip -with liniment, but without reducing the so-called rheumatism. -The trembling of the hands had begun some years later, -but no wasting had been noticed except during the past year. -The pain in the leg had suddenly become so severe that a -month before medical observation he had quit work. The -question immediately arose whether Graham was not -suffering from some familial form of muscular atrophy; -but according to his representations, there was nothing of -the sort in the family.</p> - -<p class='c007'><b>Physically</b>, there was little to note. <b>Neurologically</b>, there -was more. The pupils were somewhat irregular in outline, -and the right was larger than the left. The left pupil failed -to react to light, and the right pupil reacted very slowly -and with but a slight excursion. There was no tremor of the -tongue and no evidence of facial palsy nor was there smoothing -of the nasolabial folds. It was somewhat remarkable, -that in the absence of these signs, there was a marked speech -defect. The atrophy of arms, forearms, and hands was -well marked, especially the atrophy of the thenar and hypothenar -eminences of the right hand. The extended hands, -especially the right, showed a marked coarse tremor. Fibrillation -was found in the muscles of the hands, forearms, arms, -and pectoral muscles. There was no dysmetria, and the -diadochokinesia was normal. Strength was diminished (dynamometer -<span class='pageno' id='Page_150'>150</span>right hand, 32 kg., left 31 kg.). There was little or -no atrophy of the legs, although the left thigh was perhaps -slightly atrophic and the gluteal muscles of the left side -were somewhat flabby. The patellar and Achilles reflexes -were absent on both sides. There was a slight swaying in -Romberg position. Gait was normal. There was a marked -tenderness on the left side of the sciatic notch, as well as -over the entire distribution of both external and internal -popliteal nerves. This area of skin was also hyperesthetic. -There were no other neurological signs on systematic examination.</p> - -<p class='c007'><b>Diagnosis</b>: The sensory disorder, the speech defect, and -the pupillary abnormalities seem to render the diagnosis -of progressive muscular atrophy doubtful. Nor was there -any dissociation of sensations to suggest a syringomyelia. -Under such circumstances, one must fall back upon the question -of syphilis. Both blood and spinal fluid proved to be -positive to the W. R.; the globulin was increased and the -albumin markedly so; there were 61 cells per cmm., and the -gold sol reaction read 4 4 4 4 3 2 1 0 0 0.</p> - -<p class='c027'>1. Is there a relation of <span class='sc'>Syphilitic Muscular Atrophy</span> to -amyotrophic lateral sclerosis? Spiller, some years since, -claimed such a relation, and it would seem with some -justice.</p> - -<p class='c027'>2. How shall the present case be classified? There is -evidence of root pains (left hip). We may naturally -suppose that these root pains are reasonably good -clinical evidence of a meningitic lesion, of which the -spinal fluid clinically gave a confirmation. The fibrillation -in this case somewhat suggests, however, a -central origin for the muscular atrophy. Accordingly, -it would be difficult to definitely classify the present case -as either one of meningovascular syphilis or one of -central syphilis. It will be remembered that Head -and Fearnsides classify muscular atrophy under both -these headings.</p> - -<div><span class='pageno' id='Page_151'>151</span></div> -<div class='box'> - -<p class='c013'><b>The period of SECONDARY SYPHILIS is frequently -(over a third of all cases?) MARKED BY -approved signs of NEUROSYPHILIS precisely like -those of full-blown paretic or diffuse (meningovascular -non-paretic) neurosyphilis. These signs -occur sometimes in association with severe clinical -symptoms, sometimes without clinical symptoms.</b></p> - -</div> - -<p class='c006'><b>Case 34.</b> John Bennett, 28, was brought to the Psychopathic -Hospital much confused. His brother, who came -with him, said that he had been a very heavy drinker but had -given up drinking about four months before. He had -recently had a cold but was otherwise in good health up to -the night before admission. On this night, Bennett had -become suddenly excited and went into his mother’s room, -at the common home, and began to curse her. However, he -was put to bed safely, but on the next morning began to -moan continuously. After some hours of moaning, he was -brought to the hospital. Here he remained difficult to manage, -being irritable, noisy, and resistive. Questions he either would -not or could not answer, and there was even no evidence -that he understood questions. However, within a few hours, -it was clear that he was slowly coming out of the confused -state. On the following day, it was possible even to rouse -him and get his name. The confusion gradually cleared -still further and, by the end of three days, he had become -mentally absolutely well so far as could be determined.</p> - -<p class='c007'>He then informed us that he had had a chancre about five -or six months before, followed by a secondary skin eruption; -that he had received four injections of salvarsan (the last, -a month before admission) and three injections of mercury. -At about the time of the last injection of salvarsan, he had -developed headache with pain and slight stiffness in the back -of his neck; and a fortnight later, he began to have dizzy -spells, followed during the last week by difficulty in hearing. -There was amnesia for everything that happened after his -<span class='pageno' id='Page_152'>152</span>spell of sudden excitement on the evening before admission, -and this amnesia was never lifted for the four days that -followed.</p> - -<p class='c007'><b>Physically</b>, Bennett was very well built and muscular. -Nor were there any evidences of disease outside the nervous -system. There was some slight stiffness of the neck and slight -pain on movement of the head, which probably ought to be -attributed to meningitis. The <b>neurological examination</b> -showed tendon reflexes all normal, and normal sensations. -There were, in fact, no neurological signs except that both -pupils were dilated; the left was larger than the right. Both -pupils reacted to light but reacted very poorly. They reacted -much better to accommodation.</p> - -<p class='c007'>The W. R. proved to be positive, as might well be expected -in a man whose infection had taken place less than -six months before. The globulin and albumin of the cerebrospinal -fluid were in great excess, of a degree which we -clinically express by ++++. The W. R. of the fluid also -was strongly positive down to 0.1 of a cmm. The gold sol -reaction was the “paretic” type, and there were 228 cells -per cmm.</p> - -<p class='c027'>1. How early may clinical evidence of neurosyphilis set in -after infection? Craig found one case of “brain -syphilis” occurring one month after infection. Frye -claims a case of tabes dorsalis developing six weeks -after infection. Craig states that he has had three -cases of brain syphilis occurring within six months, -and six within a year of infection.</p> - -<p class='c027'>2. What effect did the salvarsan injections have in causing -or preventing the symptoms in this case? Nonne sums -up the neurorecidive question as follows: Since the -introduction of salvarsan therapy for neurosyphilis, -paralyses of various cranial nerves are seen more frequently. -This higher frequency is in part only apparent -since more attention has been paid of late to -auditory and labyrinthine disorders. On the whole, -however, it must be considered that salvarsan does mobilize -spirochete foci which without salvarsan therapy -would perhaps have remained latent. Probably we are -here dealing in some instances with fresh infections of -neurosyphilis, in other cases with a Herxheimer reaction. -<span class='pageno' id='Page_153'>153</span>Ehrlich believed that these latent foci occur particularly -in places with stagnant blood current; as, for -instance, in the narrow bony canals. This hypothesis, -sufficient in some instances, is less satisfactory for cases -of peripheral neuritis, for example.</p> - -<p class='c027'>3. What treatment is indicated? Intensive antisyphilitic -treatment is strongly indicated. Whatever may be the -truth concerning the production of neuro-recurrences -(“neurorecidives”) it is certain that the symptoms -usually vanish with a continuance of salvarsan therapy. -The important point is to give efficient treatment, and -in a case like Bennett’s improvement is fairly certain -unless some serious insult occurs before the remedial -efforts have been given time. It is still an open question -whether intraspinous treatment is more efficient -in such cases than intensive intravenous injections of -salvarsan. In Bennett’s case diarsenol was injected -intravenously twice a week in 0.6 gm. doses, reënforced -with intramuscular injections of mercury salicylate and -potassium iodid by mouth. Under this treatment improvement -began slowly and in a few months he was -symptomatically well and after three months his tests -were practically negative.</p> - -<div><span class='pageno' id='Page_154'>154</span></div> -<div class='box'> - -<p class='c013'><b>JUVENILE PARETIC NEUROSYPHILIS (“juvenile -paresis”) with OPTIC ATROPHY.</b></p> - -</div> - -<p class='c006'><b>Case 35.</b> Mary Coughlin, a blind girl of 16 years, was -brought to the hospital in a state of great excitement, laughing -and crying alternately. The neurologist is entitled to -think of blindness, and particularly of the optic atrophy -which Mary showed, as probably due to syphilis. However, -there was no history of syphilis in the father, who died in an -accident at the age of 40, or the mother, who died at 45, of -heart trouble. An elder sister was married and well; two -younger sisters were living and well. The fifth sibling, a -boy, had died in infancy. There had been no miscarriages. -In fact, the only point in favor of syphilis was the somewhat -far-fetched point that the younger brother of the patient -had died in infancy.</p> - -<p class='c007'>The patient’s history was rather suggestive of some other -diagnosis. Her birth had been normal, she walked and -talked at 13 months, was at school from six to twelve, reaching -the seventh grade, and was considered bright. At three -years of age, she had been run down by a car and dragged -under the fender for a considerable distance. Her head was -hurt but the patient did not lose consciousness in the accident. -Fainting spells began at 11, in which spells the patient would -lose consciousness for a minute or two. About this time, the -patient’s eyesight had begun to fail, and for some four years -she had been entirely blind. Headaches had come on of late.</p> - -<p class='c007'>The Coughlin case, except for the above-mentioned suspicion -of syphilitic optic atrophy, might be regarded as an -unusual example of a post-traumatic disease.</p> - -<p class='c007'>We found her to be fairly well developed and nourished; -there was a deformity of the lower half of the sternum and of -the third and fourth ribs on the right side. There were no -other physical phenomena found upon systematic examination. -The left pupil still reacted to light; the right failed to -react, but this lack of reaction could not be regarded as of -<span class='pageno' id='Page_155'>155</span>Argyll-Robertson nature on account of the finding of optic -atrophy with the ophthalmoscope.</p> - -<p class='c007'><b>Mentally</b>, it appeared that the patient’s retention of -school knowledge was poor, though her blindness for four years -had doubtless given her little opportunity to keep such information -fresh. Rather strangely, Mary gave utterance to -many delusions: first, expecting to receive her sight by an -operation on the head; second, to write a book of her doings; -third, to buy a house for the children; fourth, would pay -$3000 for the house, earning the money by working at a -tailor’s or as a trained nurse; fifth, to go on the stage to earn -money by dancing; sixth, will have lots of money.</p> - -<p class='c007'>One of Mary’s characteristic statements is as follows: -“Won’t it be lovely when I can see Dr. H.’s face in heaven or -some other lovely place? Dr. H. was a grand doctor to me, -and when we get together again we are going to Tremont -Temple and keep us together. I am going to do some dancing -and play the piano. I am going to graduate at the high -school and go to Trinity College in Washington, and I hope -I shall be a faithful keeper of mother’s tomb.”</p> - -<p class='c007'>The patient was at times euphoric and expansive.</p> - -<p class='c007'>At this stage, what with optic atrophy, euphoria, and -expansive delusions, we should perhaps be entitled, had Mary -been an adult, to offer the diagnosis <span class='sc'>General Paresis</span>. In -fact, on the whole, any other than a syphilitic cause for the -optic atrophy was exceedingly doubtful. Brain tumor of a -nature to produce optic atrophy might very improbably last -so long as five years. There was no evidence of any intoxication -at the time when the blindness occurred.</p> - -<p class='c007'>The W. R. was positive in the blood and spinal fluid; -there was a positive globulin test, and an excess albumin -as well as 15 cells per cmm.</p> - -<p class='c027'>1. What is the significance of Mary’s trauma at three years? -So far as we are aware, none.</p> - -<p class='c027'>2. What light could be thrown by a W. R. study of the -family? In some instances, much light is thrown; in -the present case all three living sisters of the patient -have been examined and their serum W. R.’s have been -found negative.</p> - -<p class='c027'><span class='pageno' id='Page_156'>156</span>3. What is the prognosis of juvenile general paresis? Death -within a few years, as in general paresis in adults. -The patients live rarely more than four or five years after -the onset of symptoms. Mary Coughlin died a year -and a half after the above examination, namely, in her -eighteenth year, some seven years after the onset of -symptoms.</p> - -<p class='c027'>4. What can be said of treatment? A few favorable results -have been reported after intraspinous therapy (Swift-Ellis). -Too little work has been done with systematic -treatment of juvenile neurosyphilis, both paretic and -non-paretic, to permit important conclusions at this -time.</p> - -<p class='c027'>5. How can we explain the infection of this sibling whereas -the others, both younger and older, escaped? It would -seem that we would have to discard the hypothesis of -a congenital infection and consider that it was acquired -accidentally during the lifetime of the patient. Considering -the prevalence of syphilis it is rather to be -wondered that more such cases of “innocent” infection -do not occur in children. We may recall how many -instances of juvenile gonorrhea occur. In a case as -this where the symptoms calling attention to syphilis -necessarily occur so long after the original infection it -is practically impossible to trace the origin of the -infection.</p> - -<div><span class='pageno' id='Page_157'>157</span></div> -<div class='box'> - -<p class='c013'><b>The diagnosis of JUVENILE PARESIS is often -easy.</b></p> - -</div> - -<p class='c006'><b>Case 36.</b> Theresa Mullen, an under-sized girl of 12 years, -presented a remarkable appearance due to congenital amputations -of the fingers and toes. She lay in bed, drivelling -and making unintelligible cries. It appeared that the patient -weighed about 12 pounds at birth and was very fat; that -she had been fed on condensed milk, had survived cholera -infantum, whooping cough, and, as the parents said, “two -kinds of measles.”</p> - -<p class='c007'>Theresa had gone to school at 5 years, reaching the third -grade at the age of 9; but at this time, she began to lose -ground and was put in a class for backward children. Moreover, -at about this time, the teachers noticed spells of causeless -laughter and meaningless twisting back and forth. -Theresa would also scream at night, looking about the room; -once, rising and crying, “Take him away, that black thing,” -though no appropriate object was present. There had been -little or no complaint of headache. Theresa had been deteriorating -for some time, and for a year past had been -having increased difficulty in walking. For two months the -child had not spoken intelligible words; for the last week, -she had been incontinent.</p> - -<p class='c007'>The <b>diagnosis</b> was almost obvious from the manual and -pedal deformities taken in connection with the saddle-back -deformity of the nose. It was interesting in connection with -the contentions of W. W. Graves, that the scapulae were -scaphoid in type.</p> - -<p class='c007'>Accordingly, the history given by the parents seemed -consistent enough. The parents were both 36 years of age, -having married at 23. The first pregnancy was a miscarriage -at two months, of unknown cause. Theresa came next; -thirdly, came a miscarriage at three months; fourthly, a -girl, who is not strong or well physically, has suffered much -from headaches and sore throat, but is fairly bright. The -<span class='pageno' id='Page_158'>158</span>fifth pregnancy resulted in a boy, who is bright but of under-size. -Three more pregnancies resulted in miscarriage.</p> - -<p class='c007'>Taking into account the above-mentioned physical characteristics, -the personal history, and the family history of -Theresa, the diagnosis could hardly be in doubt even in the -absence of a lack of pupillary reaction to light on the right -side, infantilism of genitalia, positive W. R.’s of serum and -spinal fluid, positive globulin, and excess albumin, 34 cells -per cmm. and the paretic type of gold sol reaction which -were found.</p> - -<p class='c007'>The <b>prognosis</b> of this case appears to be rapid deterioration, -terminating in death within a few months. Now and again, -however, some such cases spontaneously improve. Such a -case as that of Theresa Mullen is always disheartening in -itself but suggests the social value of Wassermann tests in the -other members of the family. The other children of the Mullen -family proved to be suffering also from syphilis, since -their blood sera all showed a positive W. R.</p> - -<p class='c027'>1. What is the characteristic age of onset in <span class='sc'>Juvenile -Paresis</span>? An impression has prevailed in some quarters -that the typical onset of juvenile paresis is in the adolescent -years, and Clouston’s first case (1877) developed -in a boy of 16. Thierry’s 58 cases, developing from the -8th to the 20th year, averaged 14 years of age at onset. -Mott’s 22 cases from the 8th to the 23d year, averaged -17 years at onset. According to Clouston, juvenile -paresis develops most often at puberty (15 to 17 years). -It is sometimes claimed that cases developing symptoms -early live longer, and that juvenile cases developing -symptoms after the 20th year run a short course. For -a case developing in the 5th year, see John Friedreich, -Case No. 77.</p> - -<p class='c027'>2. What may be concluded from the physical signs (congenital -amputations) present in this case before the -development of mental symptoms? Some cases of -juvenile paresis appear to show no physical signs whatever -in childhood. While these amputations might be -the accidental result of a difficult delivery, it is more -probable that they are due to a syphilitic process.</p> - -<div class='figcenter id001'> -<img src='images/i_158.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Juvenile paresis—congenital amputation of digits. This case reached fourth grade in school before deterioration.</p> -</div> -</div> - -<div><span class='pageno' id='Page_159'>159</span></div> -<div class='box'> - -<p class='c013'><b>CONGENITAL SYPHILIS is apparently capable -of producing simple FEEBLEMINDEDNESS (that -is, a form of disease non-paretic, non-tabetic, without -special tendency to progression, and without -tendency to vascular insults).</b></p> - -</div> - -<p class='c006'><b>Case 37.</b> Isaac Goldstein was a small boy of six years and -seven months, with a father known to be suffering from general -paresis. The child was very irritable and nervous and -very difficult to manage, but would hardly have been the -subject of medical attention except in a family study suggested -by the paresis of the father.</p> - -<p class='c007'>The child had been born at term and had apparently -undergone a normal development. Physically, he showed no -definite signs of congenital syphilis. In fact, the physical -examination was to all intents and purposes negative. The -W. R. of the serum, however, proved to be positive. Mental -tests showed that his mental age was that of a child of a -little over five years. Taking all things into account, it is -probable that he should be regarded, therefore, as somewhat -retarded mentally.</p> - -<p class='c027'>1. Is syphilis answerable for the mental retardation in this -case? Provided that the family is free from feeblemindedness -and mental disease, it would seem that -the retardation of a congenital syphilitic should perhaps -be regarded as syphilitic in origin. Of course, the -institutions for the feebleminded have not shown exceedingly -high percentages of syphilitic children in -various W. R. surveys; still, the percentage of positive -reactions in institutions for the feebleminded is clearly -higher than the incidence of congenital syphilis shown -in the population at large. Hence, we may conclude -that syphilis is one of the etiological factors in the -production of feeblemindedness. Dr. W. E. Fernald, -of the Waverley School for the Feebleminded, has recently -pointed out that the syphilitic cases belong -rather in the lower grades (idiots and imbeciles) of -feeblemindedness than in the higher (morons).</p> - -<p class='c027'><span class='pageno' id='Page_160'>160</span>2. Can we guess what the pathological anatomy and histology -of the brain may be in such cases? The Waverley -studies now in process seem to indicate that some -cases have little or no gross alterations, but show a few -slight traces of lymphocytic accumulations discovered -upon extended search, and a certain tendency to the -appearance of rod cells in various foci. But the whole -matter is still <i><span lang="la" xml:lang="la">sub judice</span></i>. It is a question whether -these traces of chronic inflammation are the residuals of -a more active process or the beginnings of a process that -is about to be more active.</p> - -<p class='c027'>3. How characteristic is a positive W. R. in the serum of a -child without physical stigmata of congenital syphilis? -If we limit the term <i><span lang="la" xml:lang="la">stigmata</span></i> to the major and more -important signs, we must reply that it is not unusual -to find positive W. R.’s in sera of physically normal-looking children. Except in family studies, such -cases will often escape notice, either because there -are no stigmata whatever, or because such stigmata -as exist are of a minor nature and regarded as unimportant -anomalies. Some of these cases occur in the -clinics later in life as so-called <em>syphilis hereditaria tarda</em>. -If one wishes to discover these cases with late development -of symptoms before their full bloom, the -most obvious method is to examine carefully the children -of known syphilitics.</p> - -<div class='figcenter id001'> -<img src='images/i_160.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Scaphoid Scapulae.</p> -</div> -</div> - -<div><span class='pageno' id='Page_161'>161</span></div> -<div class='box'> - -<p class='c013'><b>JUVENILE TABETIC NEUROSYPHILIS (“juvenile -tabes”); TREATMENT.</b></p> - -</div> - -<p class='c006'><b>Case 38.</b> The point in presenting Archibald Sherry, a -<span class='sc'>Juvenile Tabetic</span> of 12 years on admission, is perhaps -to exhibit pride in therapeutic results.</p> - -<p class='c007'>There was little or no doubt of the diagnosis; in an adult, -the phenomenon would be called tabes dorsalis with a question -of general paresis. The right pupil was larger than the -left and reacted neither to light nor to distance. There was -a slight tremor of the tongue and of the outstretched hands. -The knee-jerks and ankle-jerks could not be obtained, nor -could the periosteal reflexes in the legs. There was a slight -unsteadiness in the gait and in various finer movements, and -a slight ataxia of the legs. There was not a classical Romberg -sign but there was slight swaying in Romberg position. The -teeth were Hutchinsonian. For the rest, the physical examination -was practically negative.</p> - -<p class='c007'>The family history was of interest. On the paternal side -there was nervousness as well as alcoholism and degeneracy. -The maternal grandmother had cancer. Archibald’s father -was immoral and alcoholic. There was a girl four years -older than Archibald, who, though nervous and unstable, has -shown no signs or symptoms of syphilis and does not yield a -W. R. in blood or spinal fluid.</p> - -<p class='c007'>Archibald himself was born at term, a large child, who, -however, lost weight rapidly, developing a marked skin -eruption on head and back three weeks after birth. This -skin disease lasted for a month and a half and then spontaneously -disappeared. Archibald remained weak and sickly, -not walking until three years of age. However, he did well -in school up to the end of his 11th year, when he failed to -keep up with the children. He had been an amiable child -and had gotten on well with his playmates. Some time in -his 10th year physical disability had begun; there was numbness -in the legs with weakness; at times, actual inability to -<span class='pageno' id='Page_162'>162</span>walk. The right pupil was noticed by the mother to have -increased in size; the eyelashes had turned white. There -was pain over the left eye and a feeling of weight on top of -the head. Speech became difficult or even confused.</p> - -<p class='c007'>Consistently enough, the W. R. both in blood and spinal -fluid was positive. Globulin and albumin were present in -large amounts; there were 150 cells per cmm.</p> - -<p class='c007'>Granting that this be in some sense a case of juvenile -tabes we may raise a doubt whether the case is one of congenital -syphilis. The W. R.’s of the blood of both father and -mother are negative. Syphilis is denied by them. The -nervous and unstable older sister failed to show definite -symptoms of syphilis or a positive W. R. There had been no -miscarriages or stillbirths. The question arises whether the -Hutchinsonian teeth do not indicate congenital syphilis. It -appears, however, that it is possible to develop Hutchinsonian -teeth if syphilis is acquired before the teeth are formed. We -have no data as to how or why this particular baby should -have acquired syphilis, if he did so acquire it, at the age of -three weeks. On the whole, sceptics may doubt our suggestion -that the case is one of acquired juvenile tabes. Possibly -the question is academic so far as treatment is concerned.</p> - -<p class='c007'><b>Prognosis</b>: The rarity of juvenile tabes is such that little -can be said as to prognosis. Three and a half years have -passed since a few injections of salvarsan were made. The -pains above mentioned rapidly disappeared, the gait became -steadier, the attacks of confusion ceased, and the speech improved. -Unfortunately, on account of a lack of coöperation -on the part of Archibald’s mother, we have been unable to -continue treatment. However, we have from time to time -followed the patient in his home and he seems to have shown -no falling back after the initial improvement. It would be of -great value could we know the situation in the spinal fluid at -the present time.</p> - -<p class='c027'>1. Is there any explanation why paresis should occur in -some juveniles and tabes in others? There is no -available explanation for this difference nor any for -the characteristic early optic atrophy of juvenile -tabetics.</p> -<div><span class='pageno' id='Page_164'>164</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c001'> - <div class='linegroup'> - <div class='group'> - <div class='line'>Be frustrate, all ye stratagems of Hell,</div> - <div class='line'>And, devilish machinations, come to nought!</div> - </div> - <div class='group'> - <div class='line in28'>Paradise Regained, lines 180–181</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_165'>165</span> - <h2 class='c005'>III. PUZZLES AND ERRORS IN THE DIAGNOSIS OF NEUROSYPHILIS</h2> -</div> - -<p class='c006'>This part of the case collection, dealing with puzzles and -errors, is ushered in by six cases (39–44) drawn from a group -of errors in diagnosis made some years since at the Danvers -Hospital. These six are autopsied cases. Attention is called -to the fact that modern methods of diagnosis might have -prevented the errors.</p> - -<div class='box'> - -<p class='c013'><b>DIFFUSE NEUROSYPHILIS (“cerebrospinal -syphilis”) versus PARETIC NEUROSYPHILIS -(“general paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 39.</b> Caroline Davis, dead at 49 years, was a case -of error in the diagnosis of general paresis. Like Cases -40 to 44, Case 39 was diagnosticated by the full Danvers -staff as a case of general paresis; however, it must be added, -before the days of the W. R. and the modern methods of -systematic diagnosis. As will transpire in the sequel, there -is a large question whether Case 39 is not after all really a -case of neurosyphilis, possibly not of the paretic group. -The details are as follows:</p> - -<p class='c007'>Caroline Davis was a normal school girl till 15, apt in -studies, mill worker till marriage at 18; one child, dead -(cause unknown). Habits good. Moderate deafness set in -in the forties and in 1901 patient became completely deaf -in three months’ time. In 1905 she became unable to take -care of her house and had a shock in which the right leg was -affected.</p> - -<p class='c007'>On commitment patient showed good development and -nutrition with slight enlargement of capillaries of cheeks, -redness and roughening of skin of right ankle. Teeth -<span class='pageno' id='Page_166'>166</span>absent. Slight radial and brachial arteriosclerosis. Urine -negative. Sluggish pupil reactions to light both directly and -consensually. Deafness absolute, bone conduction defective. -Arm reflexes brisk, knee-jerks equal, brisk. Bilateral Babinski -reaction more marked on the right side, tremor of -tongue, Romberg’s sign, gait defective. Speech stumbling, -writing clear, without tremor.</p> - -<p class='c007'>Communicated by writing only. Consciousness normal, -disorientation for day of month, for place (misnames hospital) -and for persons (recognizing nurses, not patients).</p> - -<p class='c007'>Patient wrote many letters complaining of pain, headaches -and especially of pain in the abdomen and side. The patient -was thought to show a slight defect of memory, but her -deafness rendered diagnosis difficult. The patient died -suddenly on May 23, 1908, shortly after supper, falling backwards, -and dying in five minutes with marked respiratory -distress.</p> - -<p class='c007'><b>Post Mortem Findings.</b> The <b>cause of death</b> was not clear. -The heart’s blood and cerebrospinal fluid were sterile. There -was a small hemorrhage in the anterior part of the right -ventricle derived from a small artery of the caudate nucleus. -There was about 400 cc. of blood between the dura mater and -the pia mater. There was a slight sclerosis of the basal and -Sylvian arteries. The brain substance was uniformly softer -than normal.</p> - -<p class='c007'>It is possible that the hemorrhage had taken place some -time before the patient’s fall and that the brain substance -had swollen in consequence. Just before the fall she had a -weeping spell.</p> - -<p class='c007'>The <b>anatomical diagnoses</b> were as follows:</p> - -<p class='c007'>Obesity, unequal pupils, fresh wound near left ear, edema -of legs, slight focal adhesive pleuritis, hypostatic congestion -of lungs, chronic endocarditis, chronic myocarditis, congestion -of kidneys, congestion of pancreas, subacute splenitis, chronic -adhesive pelvic peritonitis, hematoma and cystic condition of -Fallopian tubes, <b>calvarium dense</b> and thick, subdural hemorrhage, -slight <b>chronic leptomeningitis</b>, general <b>cerebral atrophy</b>, -marked in tips of <b>frontal lobes</b>, old <b>cyst of softening</b> -between left corpora albicantia and optic chiasm, small -<span class='pageno' id='Page_167'>167</span>punctures of left ear drum, drums opaque, <b>chronic spinal -leptomeningitis</b>; brain weight, 1190 grams.</p> - -<p class='c007'>There were marked firm interadhesions between dura and -pia throughout. A lumbar puncture soon after admission -in 1907 had shown:</p> - -<table class='table3' summary=''> - <tr> - <th class='c024'></th> - <th class='c023'><span class='small'>Per cent</span></th> - </tr> - <tr> - <td class='c024'>Endothelial cells</td> - <td class='c033'>10</td> - </tr> - <tr> - <td class='c024'>Lymphocytes</td> - <td class='c033'>30</td> - </tr> - <tr> - <td class='c024'>Plasma cells</td> - <td class='c033'>0</td> - </tr> - <tr> - <td class='c024'>Phagocytes</td> - <td class='c033'>0</td> - </tr> - <tr> - <td class='c024'>Polymorphonuclear cells</td> - <td class='c033'>51</td> - </tr> - <tr> - <td class='c024'>Unclassified</td> - <td class='c033'>9</td> - </tr> - <tr> - <td class='c024'>Fibroblasts</td> - <td class='c033'>0</td> - </tr> - <tr> - <td class='c024'>Cells in 100 fields</td> - <td class='c033'>125</td> - </tr> -</table> - -<p class='c007'>It will be noted that the lumbar puncture yielded no -plasma cells and yet showed 30% of lymphocytes. Alzheimer, -in 1904, attempted to distinguish the histology of the -cerebral syphilitic from that of the general paretic, maintaining -that <em>lymphocytosis was the characteristic feature of the -ordinary neurosyphilitic</em>, <em>whereas plasma cells were associated -with the lymphocytes in the paretic</em>. This case showed <b>lymphocytic</b> -deposits. To be sure, they were decidedly subordinate -in the cerebral cortex, cerebellum, and basal ganglia, -to the marked evidences of nerve cell destruction, although -there were perivascular infiltrations about a few of the larger -vessels in the white matter of the cerebral cortex.</p> - -<p class='c007'>The spinal cord, however, showed a most severe infiltration, -especially in the gray matter, where the infiltration -accompanied severe nerve cell changes and arterial changes. -The pia mater of the spinal cord was also packed with mononuclear -elements, among which, however, no plasma cells -could be found.</p> - -<p class='c007'>But although the inflammatory changes in the shape of -lymphocytosis were relatively more prominent in the spinal -cord than in the cortex, yet the cortex yielded evidence of an -exceedingly marked destructive process. Perhaps no layer -of any of the areas of the cortex examined failed to show some -atrophic alteration. The upper layers of the cortex were -everywhere more severely diseased than the lower layers. -Here we are dealing with an instance of an active meningomyelitis -<span class='pageno' id='Page_168'>168</span>and subcortical encephalitis. It is, of course, probable -that the W. R., had it been performed, would have been -positive in this case. On the basis of the histology, we are -inclined to regard the clinical picture in this case as belonging -among cases of <span class='sc'>Non-paretic Diffuse Neurosyphilis</span>.</p> - -<p class='c007'>This case, as also the next several, is especially instructive -in teaching the difficulty in differentiating paretic and non-paretic -neurosyphilis. Not only is this difficulty met in -clinical diagnosis, but in pathological diagnosis as well.</p> - -<p class='c007'>The histological diagnosis depends in large part on the -work of the Nissl-Alzheimer school, which has received great -recognition. At the present time, however, there is beginning -to be considerable doubt as to the entire validity of this -teaching. At any rate there are many borderline cases in -which the differentiation is well nigh impossible. In this -case note chronic meningoencephalitis, with cortical degeneration, -in the absence of plasmocytosis.</p> - -<p class='c007'>From the clinical standpoint the intensity of the W. R., -the character of the gold sol reaction, and the result of -therapy have added new points in differentiation. Much -more work controlled by autopsies is still needed, however, -to put us on sure ground in borderline cases.</p> - -<div><span class='pageno' id='Page_169'>169</span></div> -<div class='box'> - -<p class='c013'><b>VASCULAR NEUROSYPHILIS(?) versus PARETIC -NEUROSYPHILIS (“general paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 40.</b> Case 40 like Case 41 was an error in the diagnosis -of general paresis which might be regarded as academic -rather than practical. Both were cases of arteriosclerotic -brain disease with severe cerebellar involvement. Case 40 -had a spinal cord that was not quite normal. There was a -tabetiform lesion in the cervical spinal cord (not elsewhere), -together with a unilateral degeneration suggesting in some -respects a radicular origin. The most striking feature, however, -of Case 40 as in Case 41, was a lesion of the cerebellum. -In Case 40 the dentate nuclei were in large part destroyed -by cysts of softening, although the cerebellar cortex was -fairly well preserved on both sides. The details of Case -40 are as follows:</p> - -<p class='c007'>H. F., male, gear maker, born 1850.</p> - -<p class='c007'><b>Heredity.</b> Maternal grandmother insane. Mother insane -at 52, became demented and lost use of limbs, died at 71. -Aunt insane.</p> - -<p class='c007'><b>Personal History.</b> Common school education. Capable -workman till within a few months. Early in life alcoholic. -Drunk almost every week until 1899 or 1900. Irritable, -nervous, selfish, loose in relations with women. Venereal -disease denied by wife. Married in 1883. Three frail -children. No miscarriages. Neuralgia in 1901 or 1902.</p> - -<p class='c007'>January, 1904, patient left carriage shop on account of -mistakes in work, became more pleasant, childish, fearful, -talkative, did funny things, later became vagrant, stole from -fruit stores, smoked cigarettes picked up in the street, and -became restless and irritable.</p> - -<p class='c007'>Committed to Danvers, June 24, 1904, with slightly -enlarged heart, somewhat heightened blood pressure, and a -slight sediment of epithelial cells in urine.</p> - -<p class='c007'>Romberg’s sign was present, but there was little or no -demonstrable incoördination otherwise. Very slight tremor -<span class='pageno' id='Page_170'>170</span>of fingers. Left knee-jerk absent, right obtained on reinforcement. -Achilles jerk absent. Triceps, wrist and -normal plantar reflexes present. Pupils react to accommodation, -but very slightly, if at all, to light. Sensations normal -except in legs. The legs show preservation of tactile and -temperature senses, but abolition of pain sense except over -dorsum of foot.</p> - -<p class='c007'>Speech showed slurring of syllables and “brigrade” for -“brigade.” Disorientation for time, place and in part for -persons. Admitted that his work had been deficient but -regarded himself as well. Emotionally variable, crying at -times and suddenly becoming jocular. Eloped July 3 and -somehow reached his wife’s house in a neighboring city.</p> - -<p class='c007'>Euphoria persisted. The pupils continued Argyll-Robertson, -and the knee-jerks remained absent. Became oriented -for place and partially as to time (month and day of week -correct).</p> - -<p class='c007'>During 1905 failure became rapid, with ataxia of legs, -persistent euphoria, and loss of weight.</p> - -<p class='c007'>Convulsions, regarded as general paretic, developed in -1906. Death sudden, December 7, 1906.</p> - -<p class='c007'><b>Post Mortem Findings.</b> The <b>cause of death</b> was streptococcus -septicemia, probably derived from a gangrenous -bronchopneumonia or related with a small thrombus of the -right auricular appendix. There was also an acute purulent -otitis media, mastoiditis and sphenoidal sinusitis, as well as -extensive decubitus. From this decubitus or from the -intestinal tract may have been derived the numerous colonies -of <em>bacillus coli communis</em> which developed on plates from the -cerebrospinal fluid.</p> - -<p class='c007'><b>Arteriosclerosis</b> was little in evidence, being confined to -the coronary, right vertebral and carotid arteries (slight in -all). <em>Cysts of softening existed in the posterior part of each -dentate nucleus</em> and may probably be interpreted as indicating -vascular disease.</p> - -<p class='c007'><b>Chronic disease outside the nervous system</b> was prominent -and in part suggestive of senile findings; milky patches of -pericardium, adhesions about liver and gall-bladder, adhesions -about spleen, adhesions and fibrous thickening of parietal -<span class='pageno' id='Page_171'>171</span>peritoneum, adhesions in both pleural cavities, chronic diffuse -nephritis, hypertrophy of bladder wall, dense calvarium, dural -adhesions.</p> - -<p class='c007'>The <b>nervous system</b> showed several unexpected features. -The <em>absence of chronic leptomeningitis</em> was striking: the pia -mater was everywhere delicate and transparent except that -the walls of the cerebellar and chiasmal cisternæ were thickened -and that there were slight opacities along the sulcal -veins of the convexity. Brain weight 1090 grams. There -was a generalized <b>sclerosis and pigmentation of the cerebral -cortex</b>. The sclerosis varied in degree and was most marked -in the prefrontal regions, the anterior halves of the superior -frontal gyri, the middle third of the right precentral gyrus, -the region of the splenium on the left side, and the sagittal -rami. If the <em>bacillus coli communis</em> found in the cerebrospinal -fluid had any effect upon the consistence of the brain, -obviously hard to prove in a brain of leathery consistence at -the outset, it was shown only in the right Rolandic area in the -vicinity of the sclerotic part of the precentral gyrus. <b>Granular -ependymitis</b> of all ventricles. Weight of cerebellum, pons -and bulb, 135 grams.</p> - -<p class='c007'>Perhaps the most remarkable feature of all in the case was -the occurrence of <b>cysts of softening</b> in the posterior part of -each <b>dentate nucleus</b>. For discussion, see Case 41.</p> - -<div><span class='pageno' id='Page_172'>172</span></div> -<div class='box'> - -<p class='c013'><b>VASCULAR NEUROSYPHILIS (?) versus -PARETIC NEUROSYPHILIS (“general paresis”). -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 41</b>, like Case 40, was one of arteriosclerotic brain -disease with severe cerebellar involvement. Here is another -case in which the Danvers staff made a diagnosis of general -paresis without dissenting voice. There were some tabetic -symptoms, and the spinal cord at autopsy did show a moderate -lymphocytic infiltration of the meninges, entirely consistent -with the picture in the spinal fluid. In this case, the dentate -nuclei of the cerebellum were not destroyed as in Case 40, -but were affected by cell atrophies of variable degree in different -parts of the nuclei. There was also a severe gliosis of -the cerebellar cortex. The left hemisphere of the cerebellum -was more severely diseased than the right. The cortex -showed far more marked and generalized cell atrophies -throughout the layers than did Case 40. The details of this -case, which was that of a colored coachman, Samuel North, -are as follows:</p> - -<p class='c007'>He was born in 1871. Learned to read and write at school. -Stableman and coachman. Alcoholic till 1902. Took much -quinine, possibly impairing hearing thereby. Memory impaired -and growing worse since 1902. Gait unsteady for a -longer but unknown period. August 13, 1907, wandered -about, instead of attending boot-black stand, muttered, -talked incoherently. In the next few days talked about -religion and apparently had hallucinations of hearing. Committed -August 16, 1907.</p> - -<p class='c007'>On commitment stoop-shouldered, flat-chested. Gait staggering. -Unsteadiness in Romberg’s position. Incoördination -of arms and fingers. Coarse tremor of tongue. Tremor -of lower jaw. Exaggeration of left knee-jerk and diminution -of right. Exaggerated Achilles jerks. Spurious left ankle -clonus. Questionable Babinski reaction of left side. Abdominal -and epigastric reflexes present but cremasteric -<span class='pageno' id='Page_173'>173</span>absent. Left pupil smaller than right and fails to react to -light. Reaction of right pupil sluggish. Moderate defect of -hearing of both sides.</p> - -<p class='c007'>During the first week the patient developed hallucinations -of sight and hearing, but of no other senses. Disorientation -for time, place, and persons. Answers to arithmetical -problems given with assurance but as a rule incorrectly (as -17 and 32 are 90; 18 divided by 3 is 88). Handwriting -scarcely legible. Memory poor, especially for recent events -(recalled a lumbar puncture as an exercise in baptism). -Impressibility and attention poor. Euphoria.</p> - -<p class='c007'>Death after gradual failure July 29, 1908.</p> - -<table class='table3' summary=''> - <tr> - <th class='c024'>Lumbar puncture showed:</th> - <th class='c023'><span class='small'>Per Cent.</span></th> - </tr> - <tr> - <td class='c024'>Endothelial cells</td> - <td class='c033'>9</td> - </tr> - <tr> - <td class='c024'>Lymphocytes</td> - <td class='c033'>81</td> - </tr> - <tr> - <td class='c024'>Plasma cells</td> - <td class='c033'>6</td> - </tr> - <tr> - <td class='c024'>Phagocytes</td> - <td class='c033'>0</td> - </tr> - <tr> - <td class='c024'>Polymorphonuclear cells</td> - <td class='c033'>4</td> - </tr> - <tr> - <td class='c024'>Unclassified</td> - <td class='c033'>0</td> - </tr> - <tr> - <td class='c024'>Fibroblasts</td> - <td class='c033'>0</td> - </tr> - <tr> - <td class='c024'>Cells in 100 fields</td> - <td class='c033'>700</td> - </tr> -</table> - -<p class='c007'><b>Post Mortem Findings.</b> The cerebrospinal fluid showed -a pure culture of <em>Bacillus coli communis</em>, and the heart’s blood -showed many colonies of an unidentified bacillus. Culture -from mesenteric lymph nodes sterile.</p> - -<p class='c007'>The <b>cause of death</b> is somewhat in doubt. There was an -early pneumonic process with fibrinous pleurisy, and there -was an early acute hemorrhagic ileitis with a very slight -overlying peritonitis and slight corresponding enlargement of -mesenteric lymph nodes. There was an infection of the -meninges with <em>Bacillus coli communis</em>.</p> - -<p class='c007'>Evidences of <b>chronic disease outside the nervous system</b> -were: coronary and pulmonary arteriosclerosis, chronic -fibrous endocarditis, mitral sclerosis, aortic sclerosis with -calcification, chronic splenitis, chronic interstitial nephritis, -hepatic atrophy (wt., 900 grams), thickening of cartilaginous -portion of right auricle (old trauma), scars of apices of lungs.</p> - -<p class='c007'>The <b>calvarium</b> was dense and the <b>dura mater</b> everywhere -adherent. The <b>arachnoidal villi</b> were but slightly developed, -<span class='pageno' id='Page_174'>174</span>but there was one small focus of cortical herniation through -the dura mater of the left middle cranial fossa. The <b>pia -mater</b> was delicate except for slight opacities along sulci. -There was some pial thickening over the region of the interparietal -sulci on both sides. There was pial pigmentation -anteriorly and superiorly.</p> - -<p class='c007'>There is no gross evidence of intracranial arteriosclerosis, -except (1) that afforded by the lesions of the dentate nuclei -of the cerebellum mentioned below and (2) the swerving to -the right of the basilar artery, possibly due not to arteriosclerotic -lengthening of the artery but to an unusual shape of -the pons (see below).</p> - -<p class='c007'>The <b>brain</b> weighed 1245 grams (cerebellum and pons 165 -grams). <b>The anatomical diagnoses of central nervous system</b> -were:</p> - -<p class='c007'>Slight general encephalomalacia (post mortem imbibition -of fluid, 31 hours). Slight gliosis of right prefrontal and -frontal gyri. Slight gliosis of right optic thalamus. Generalized -granular ependymitis, especially near fornix and about -foramina of Monro. Anomaly of pons (not gliotic, but -possessing far more white matter on the left side than the -right). Severe arteriosclerosis confined to the dentate nuclei -of the cerebellum.</p> - -<p class='c007'>As we now look over the data in Cases 40 and 41 we are -inclined to ask the question, whether modern systematic -diagnosis would not have shown these cases to be <span class='sc'>Neurosyphilitic</span>? -One is inclined to answer this question in the affirmative, -on the basis that Case 40 showed somewhat questionable -Argyll-Robertson pupils, and Case 41 showed unilateral -Argyll-Robertson effect. Both cases showed Romberg sign, -but the dentate nucleus and other cerebellar disease in each -case may in some way have contributed to or imitated this -phenomenon. Whether Case 40 was a tabetic must remain -a question, but Case 41 must be regarded as a case with spinal -and meningeal changes highly characteristic of syphilis.</p> - -<div><span class='pageno' id='Page_175'>175</span></div> -<div class='box'> - -<p class='c013'><b>VASCULAR NEUROSYPHILIS plus TABETIC -NEUROSYPHILIS (“tabes dorsalis”) simulating -paretic neurosyphilis (“general paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 42.</b> The case of Elizabeth Brown was at one time -carefully studied by Dr. A. M. Barrett in his work on mental -diseases associated with cerebral arteriosclerosis and, like -Case 43, was one in which tabes dorsalis was a factor. Elizabeth -Brown’s maternal grandfather and mother were insane; -there had also been insanity in a sister. Mrs. Brown was -struck on the head at 44, and was unconscious for an -hour, but there were no sequelae to this accident. At 48, -there was a shock, or apoplectiform attack, followed by -unconsciousness for two hours and by left hemiplegia, right -ptosis, and thick speech. Mrs. Brown began to walk again -after two weeks, but was found to be forgetful and fabulatory. -She seemed at times to be hearing music, and somewhat -repeatedly became helpless and unable to walk. She could -not remember from day to day, showed incontinence of urine -and feces, and was brought to the Danvers Hospital. The -physical and mental deterioration was progressive. There -were some signs of organic brain disease. The musculature -was especially flabby on the left side. The left angle of the -mouth drooped, and the left nasolabial fold was smoothed -out. The arm movements were ataxic, the tongue protruded -to the left, the right pupil reacted but slightly to light (eye -blind from cataract), the knee-jerks, Achilles, wrist, and -elbow reflexes, were absent. The patient was unable to -stand, and there was a marked tremor of the hand, tongue, -and lips. There was a zone of anesthesia for pain and -tactile stimulation extending round the body, from the 3d -to the 6th rib, and there were symmetrical areas of anesthesia -on the inner surface of the forearms and the legs.</p> - -<p class='c007'>The <b>autopsy</b> showed a <b>general arteriosclerosis</b> with <b>chronic</b> -and <b>acute meningitis</b>. The brain weighed 1110 grams; -<span class='pageno' id='Page_176'>176</span>the <b>pia mater</b> was moderately thickened; the basal vessels -were highly arteriosclerotic. The brain itself, however, -normal externally, upon dissection, showed a number of -small cysts irregularly scattered in the white substance. -The basal ganglia were porous, and there were several small -cysts in the pons. <b>Microscopically</b>, there was evidence of -severe vascular disease, involving not only the arteries but -also the veins. It was the superficial rather than the deep -arteries that were more often attacked. There was a marked -<b>perivascular gliosis</b>. Extensive search yielded <em>no evidence -of lymphocyte infiltrations</em>, either in the brain or in the spinal -cord.</p> - -<p class='c007'>The spinal cord showed degenerations in both the lateral -and posterior columns, of which the explanation may possibly -be like that in our paradigm, Case 1.</p> - -<p class='c007'>Is the case of Elizabeth Brown one of neurosyphilis? We -cannot definitely say on account of the non-availability of -the modern systematic tests, but it may well be that the case, -although certainly not one of paretic neurosyphilis, was one -of <span class='sc'>Tabes with Vascular Complications</span>.</p> - -<div><span class='pageno' id='Page_177'>177</span></div> -<div class='box'> - -<p class='c013'><b>TABETIC NEUROSYPHILIS (“tabes dorsalis”) -with symptoms of cerebral origin producing a picture -resembling taboparetic neurosyphilis (“taboparesis”). -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 43.</b> Robert Allen was the fifth case of error in the -diagnosis of general paresis analyzed some years since from -the staff meeting records of the Danvers Hospital. The -Allen case resembles the case of Elizabeth Brown in that -there was a combination of tabetic phenomena with cerebral -lesions of a non-paretic character at autopsy. But although -there seemed to be an utter absence of inflammatory -cells (lymphocytosis) in the case of Elizabeth Brown (42), -there were some slight perivascular cell accumulations in -the Allen case, with a few mononuclear cells suggestive of -lymphocytes. The cerebrum, however, failed to show plasmocytosis. -It was seriously diseased, showing a marked -neuroglia proliferation about the atrophic nerve cells.</p> - -<p class='c007'>Robert Allen was a printer coming from a long-lived race. -The following are the main facts:</p> - -<p class='c007'>Married in 1875 (two children, healthy); again married in -1893 (one child, healthy). Compositor from 1890. In 1898 -and 1899 girdle and lancinating pains. Thereafter for -several years gait was unsteady. During 1904 and 1905 -freedom from pains and improvement in gait but gradually -increasing irritability and nervousness. Stopped work on -last of March, 1905, owing to sudden increase of irritability, -emotionality, boastfulness, expansive schemes, and ataxia.</p> - -<p class='c007'>Habits: no tobacco, very little alcohol at long intervals. -No drug habits, no sexual irregularity known.</p> - -<p class='c007'>Committed to Danvers April 3, 1905, with slight muscular -development, poor nutrition, acne, irregular, poorly preserved -teeth, gingivitis, flat-foot, slight radial arteriosclerosis, slight -arcus senilis, a few hyaline casts, leucocytes, epithelial cells, -and trace of albumin in the urine, scar in sulcus, and enlarged -inguinal lymph nodes.</p> - -<p class='c007'><span class='pageno' id='Page_178'>178</span>Ataxic gait, Romberg’s sign, fibrillary twitching of chest, -abdominal and facial muscles when standing; right pupil -slightly larger than left, pupillary margins irregular, light -reactions (electric bulb test) both consensual and direct -absent, slight pupillary reaction in accommodation; biceps, -triceps and wrist reflexes lively and equal; abdominal, cremasteric -and plantar reflexes normal, knee-jerks, Achilles -and front taps negative even on reinforcement.</p> - -<p class='c007'>The patient himself stated that his ataxia began in 1904, -that he had been under treatment for swelling of legs and -feet and pain in limbs since 1903, and that there had been -some trouble with limbs since 1895. He had been told that -his disease was lead-poisoning. About three weeks before -commitment patient said he had had an attack of unconsciousness.</p> - -<p class='c007'>The patient’s speech showed considerable defect. Words -were pronounced slowly with slurring and tripping especially -of the labials. Orientation perfect. School knowledge well -retained. The easier arithmetical problems were accurately -performed. Memory imperfect for minor recent events. -Estimations of space and time often very imperfect. Variability -of mood, sometimes euphoric, sometimes tearful and -irritable. Occasional expansive estimates of personal powers -(“Can lift three five-hundred pound weights with one finger”). -Indistinct expansive financial ideas.</p> - -<p class='c007'>The patient continued oriented, euphoric, expansive, -untidy, till October, 1905, but on October 12 developed an -infection at the site of a callus on the sole of the foot and died -with pyemic symptoms, October 17.</p> - -<p class='c007'><b>Post Mortem Findings.</b> The <b>cause of death</b> was streptococcus -septicemia with acute ulcerative colitis, acute splenitis, -bilateral purulent pleuritis, multiple infarctions of lungs.</p> - -<p class='c007'>There were no signs of <b>chronic disease outside the nervous -system</b> except a moderate thickening of the mitral valves, -and slight dural adhesions.</p> - -<p class='c007'>The brain weighed 1450 grams. The vessels at the base -showed a slight degree of sclerosis. There was a slight -opacity of the frontal, parietal, and temporal pia overlying -slightly atrophied convolutions, whose surfaces showed in a -<span class='pageno' id='Page_179'>179</span>few places slight cuppings. The ependyma over the thalami -and the floor of the fourth ventricle was finely roughened. -The spinal cord showed a typical <span class='sc'>Tabes Dorsalis</span>.</p> - -<p class='c007'>Although we probably cannot regard either Case 42 or -Case 43 as a case of paretic neurosyphilis, and although it -must remain doubtful whether they are cases of any form -whatever of neurosyphilis (in the absence of the modern tests), -yet it seems clear that both these cases may very well have -been cases of neurosyphilis on account of the existence of a -definite tabetic process in each. The symptoms of these -cases, like those of Cases 38 to 41, suggest how difficult it -must be <em>to make a clinical diagnosis of general paresis safely -without employing available laboratory tests</em>. Yet how frequently -in the past have neurologists brought data concerning -various phenomena in long series of so-called paretics -in which the error of diagnosis was certainly between -5 and 15% and frequently still greater. The entire question -of the symptomatology of paretic and non-paretic neurosyphilis, -therefore, needs re-opening and revision.</p> - -<div><span class='pageno' id='Page_180'>180</span></div> -<div class='box'> - -<p class='c013'><b>CEREBRAL GLIOSIS (probably non-syphilitic) -producing the clinical picture of paretic neurosyphilis -(“general paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 44.</b> John Hughes was a hostler, and later assistant -with a wholesale drug company, with which he remained -for 32 years. He had been moderately but constantly alcoholic -all his adult life up to 50 years of age, and at 45 had -had an attack of so-called nervous prostration, in which his -head had troubled him and he had been seclusive. At 49, -he had a serious attack of otitis media, associated with -delirium, swelling of the feet, and what was called rheumatism. -After this attack of otitis media, Hughes appears to -have been not altogether right.</p> - -<p class='c007'>At 53, after a quarrel with his employer, Hughes quit -work, began to trade a little in hens and pigs, became forgetful, -especially of recent events, and did “a variety of -peculiar things.” He was a married man but he had no -children. There had been miscarriages but of unknown -origin; venereal disease was denied. At 55, a week before -admission, Hughes had a spell of unconsciousness for several -hours, after which his speech was thick, and restlessness, insomnia, -and a wandering tendency set in. Visual hallucinations, -fabulation, tremors, “excited-looking” eyes, are -described. He would sweep things from the dining-room -table, pulled a hot stove into the middle of the floor, attempted -to sweep paint off the floor, and cut up a carpet -with a knife.</p> - -<p class='c007'>The patient on commitment November 5, 1904, was well -developed and nourished. The mucous membranes were -rather pale. Bruises and excoriations of limbs. Harsh -breathing at the base of each lung. Enlargement of heart; -sounds irregular. Accentuation of aortic second sound; -tension fair, rate 80. Slight brachial arteriosclerosis. Abdomen -slightly distended. The urine contained a faint trace -of albumin and many hyaline casts.</p> - -<p class='c007'><span class='pageno' id='Page_181'>181</span>Moderate tremor of extended hands. Slight tongue -tremor. Romberg’s sign absent (slight swaying). Considerable -ataxia of extremities (inability to stand with foot -on opposite knee). Vision poor. Hearing could not be -tested accurately. Prompt pupil reactions with direct light. -Slight consensual reaction in left pupil, absent in right. Deep -reflexes equal and lively.</p> - -<p class='c007'>Quiet and orderly at first. Later restless and noisy. -Questions were answered at times relevantly, more often -irrelevantly. Patient irritable, intractable. Required repeated -urging to take nourishment. Consciousness clouded. -Orientation imperfect. Attendants are possibly “officers.” -Date September, 1995. Slight errors in repeating alphabet. -Mistakes in Lord’s Prayer with rhyming tendency. Simple -arithmetical tests answered automatically with many mistakes. -More complex combinations incorrect. Handwriting -tremulous (noted as “typical of general paresis”). Auditory -hallucinations (answering invisible persons), “All right, I’m -coming.” Amnesia and confabulation. Q. “Have you -had breakfast?” A. “No,” (later) “Yes, I had a very light -breakfast.” Q. “What did you have?” A. “Anything -that came along. A few green peas and beans that were left, -bread and butter and pie. I had a good breakfast. Guess -feed is very high.” Q. “Give names of your sisters and -brothers.” A. “There are three or four I never see. I will -have to think them up.” (Later)—“Lillie, Abbie, Julia, -George.” On repetition of question, “Elizabeth, Julia, -Annie and Lizzie.”</p> - -<p class='c007'>Delusions somewhat doubtful. At no time euphoria.</p> - -<p class='c007'>The patient remained only nine days in the hospital, -developing diarrhea a week after admission.</p> - -<p class='c007'><b>Post Mortem Findings.</b> The <b>cause of death</b> was bilateral -bronchopneumonia of hypostatic distribution, accompanied -by bronchitis and acute splenitis. The intestinal tract was -normal (despite the diarrhea). No cultures. The heart -showed acute myocarditis.</p> - -<p class='c007'>The vessels in general showed no sclerosis, except that the -aorta showed a few patches with calcification near bifurcation. -There was a moderate degree of mitral sclerosis. The kidneys -<span class='pageno' id='Page_182'>182</span>showed a moderate degree of chronic interstitial nephritis. -The heart weighed 530 grams and there was moderate dilatation -of all the valves.</p> - -<p class='c007'>There were some evidences of chronic disease outside the -nervous system, namely, an obliterative pleuritis on the right -side, chronic perisplenitis, and chronic external adhesive -pachymeningitis.</p> - -<p class='c007'>The <b>nervous system</b> showed a pia mater thin and transparent, -with a moderate congestion of larger and smaller -vessels. No noteworthy change of the brain substance or of -the ventricles was found, except that the cerebral substance -was of unusual firmness (autopsy twelve hours after death).</p> - -<p class='c007'>It is clear that the brain was not wholly normal, exhibiting -a general induration due in part to subpial gliosis and in part -doubtless to perivascular gliosis. <b>Microscopically</b> the tissues -showed features of great interest, especially multiple focal -neuroglia cell proliferations of a perivascular distribution, -considerable subpial fibrillar gliosis of an unusually focal -type, and a rather general subpial cellular <b>gliosis</b>. Histologically, -it seemed that this chronic progressive process had -started, not so much in relation with dying nerve cells, as in -relation with blood vessels. The <b>perivascular</b> deposits of -neuroglia cells were confined almost exclusively to the infragranular -cortex layers. It seems plain that the diagnosis of -general paresis was not justified. It is probable that the diagnosis of -neurosyphilis is not justified. The explanation may -be that now and then cases of cerebral sclerosis may clinically -imitate the neurosyphilitic process. It must be borne -in mind that the diagnosis in this case was made, like the other -cases at head of Part III, without the advantage of modern -systematic methods. Clinically speaking, of course, -there was no definite Argyll-Robertson pupil, although the -consensual reaction, slight on the left side, was absent in the -right pupil. The general picture appeared to be one of -the so-called demented form of paretic neurosyphilis.</p> - -<div><span class='pageno' id='Page_183'>183</span></div> -<div class='box'> - -<p class='c013'><b>Differential diagnosis between NEUROSYPHILIS -and NEURASTHENIA.</b></p> - -</div> - -<p class='c006'><b>Case 45.</b> Albert Robinson, a man of 28 years, was shipwrecked -on one of the Great Lakes. The ship was on the -rocks for eight days, and Robinson was under a great strain. -Ever after the wreck, Robinson had felt severe pain in the -head, neck, and back, and a feeling of great weakness whenever -he exerted himself physically or mentally, and seven -months after the wreck, he had several attacks of fainting.</p> - -<p class='c007'>For a number of weeks he had worried a good deal about -his inability to make money, especially as money was badly -needed on account of his wife’s approaching confinement. -A few days before entrance, Robinson had become very -forgetful, and was unable to recall, the night before entrance, -where he had been during the day. On the whole, however, -on mental examination no actual evidence of memory defect -could be shown to exist.</p> - -<p class='c007'><b>Physically</b>, Robinson was entirely negative, except for -some hard glands in each groin. <b>Mentally</b>, there was little -to show except depression, worry over his financial condition, -and his inability to work. The serum W. R. proved -negative.</p> - -<p class='c007'><b>Diagnosis</b>: On the whole, the diagnosis of psychoneurosis -(see case Harrison (9)) due to the shock at the time of -the shipwreck seemed to be proper. To be sure, the patient -gave a history of a chancre at 25, treated for two years, after -which he was declared cured.</p> - -<p class='c007'>However, following up the clue of admitted syphilis, -rigorous questioning elicited the fact that a few months -before there had been diplopia, lasting part of a day.</p> - -<p class='c007'><b>Lumbar puncture</b> seemed desirable. The fluid was clear -but contained 125 cells per cmm. with appropriately increased -amounts of albumin and globulin. The spinal fluid -W. R. was positive. The diagnosis of <span class='sc'>Cerebrospinal -Syphilis</span> seemed established.</p> - -<p class='c007'><span class='pageno' id='Page_184'>184</span>The lesson of this case appears to be that perhaps we should -never exclude syphilis until we have made an examination -of the cerebrospinal fluid. The W. R. of the blood in meningovascular -(non-paretic syphilis) is negative in many cases -(the figure is sometimes set as high as 40%).</p> - -<p class='c007'><b>Treatment</b>: After a half dozen injections of salvarsan, -all symptoms disappeared and Robinson went back to work, -claiming to be in a better condition than for some time past.</p> - -<p class='c027'>1. How shall we explain such a symptom as the transient -diplopia? This diplopia is probably an example of -a neurorecidive, but it will be observed that it occurred -without salvarsan therapy. See discussion above under -the case of Bennett (34), where the general result of -the neurorecidive inquiry launched by Ehrlich early -in the history of salvarsan therapy showed that precisely -similar phenomena had always occurred in -neurosyphilis, whether under treatment or not. The -anatomical and histopathological explanation of such -phenomena is, of course, doubtful, but a review of the -findings in the case of Alice Morton (1) will show how -many apparently serious symptoms in neurosyphilitics -are actually irritative or at least due to lesions which -are entirely recoverable. We may suppose, first, a -local proliferation of spirochetes; second, a local over-formation -of toxic substances, directly or indirectly the -product of spirochetosis; thirdly, a local exudation; -fourthly, a local proliferation; fifthly, a combination -of these phenomena, any or all of which may be regarded -as but transient. We have sometimes found at autopsy -very little exudate except in small areas; sometimes -not more than a few mm. or cm. in superficial extent. -Note, for example, the small areas of lymphocytosis -demonstrable in but two foci in the case of Alice -Morton, the paradigm placed at the beginning of this -book.</p> - -<div><span class='pageno' id='Page_185'>185</span></div> -<div class='box'> - -<p class='c013'><b>NEUROSYPHILIS(?) in the SECONDARY STAGE -of syphilis. HYSTERICAL symptoms. Diagnosis?</b></p> - -</div> - -<p class='c006'><b>Case 46.</b> Alice Caperson was a colored girl of 18 years. -She had acquired syphilis five months before admission to -the hospital, and the secondary symptoms of this syphilis -had just disappeared before admission.</p> - -<p class='c007'>Very shortly after acquiring syphilis, the young negress -began to act peculiarly. She describes herself as having -a sort of nightmare, both when asleep and also when awake. -For instance, she saw her dead grandmother. It appeared -at first like a seraph; then it came nearer to her and seemed -to fill out; and then was dressed precisely as her grandmother -had been. This seraph appeared as though trying to tell her -something, but she could not make out what the something -was. The vision had appeared on two or three occasions.</p> - -<p class='c007'>Our examination detected little beyond instability and -irritability of mood with some depression. The patient -readily fell to weeping. She soon made friends in the wards, -however, and got on well. <b>Physical examination</b> was entirely -negative but the W. R. of the blood serum was positive. -The W. R. of the spinal fluid was negative, as was the gold -sol reaction; there was an excess of albumin and a positive -globulin test; there were seven cells per cmm.</p> - -<p class='c007'>The psychiatric diagnosis of a case like that of Alice Caperson -would waver between hysteria and dementia praecox. -However, as for dementia praecox there are hardly any -typical symptoms. There is insight into the hallucinations, -which are hypnagogic. There are, however, no hysterical -stigmata.</p> - -<p class='c007'>The spinal fluid reaction is typical of the secondary stage -of syphilis. It is commonly said that in every case of syphilis -the nervous system is involved at some period, if only -to the degree shown in the present case. However, such -involvement tends to disappear both with and without antisyphilitic -treatment, just as do the secondary skin symptoms. -<span class='pageno' id='Page_186'>186</span>So far as syphilis is concerned, the prognosis under radical -treatment is as good as usual. We are inclined to regard -the case as one of the <span class='sc'>Hysterical</span> or <span class='sc'>Psychopathic</span> group -and inasmuch as cases occurring in the developmental stage -of a patient’s life are of fairly good general prognosis, we -are inclined to regard the prognosis in this particular case as -good under proper therapy and hygiene.</p> - -<p class='c027'>1. What is the relation of neuroses to syphilis? Neurasthenia, -chorea, hysteria, and epilepsy are often grouped -(for example, by Nonne) as neuroses bearing at times -important relations to neurosyphilis. (For the relations -of neurasthenia, chorea, and epilepsy, see cases of -Greeley Harrison (9), Margaret Green (72), and David -Borofski (49), respectively.) As for the hysteria shown -in Caperson, Charcot enumerated syphilis among <i><span lang="fr" xml:lang="fr">agents -provocateurs</span></i> of hysteria along with alcohol, lead, arsenic, -and the like. Fournier has also considered the -problem. It is clearly necessary to show that before -infection there were no hysterical symptoms, and that -the hysteria developed during the operation of the syphilitic -process, and it is probably necessary to show that -the symptoms will clear up under antisyphilitic treatment, -if we are to concede the existence of a syphilitic -hysteria.</p> - -<p class='c027'>2. What are the evidences of neurosyphilis in the secondary -and primary stages of syphilis? As above stated, the -findings in Caperson are typical enough. Wile and -Stokes at first stated that 60 to 70% of the secondary -syphilitics show changes in the spinal fluid; in a further -article they maintain that probably every case -shows such changes and that clinical symptoms of -neurosyphilis of the secondary period can probably be -determined. They claim that it is probable also that -the same holds for primary syphilis itself. The importance -of these claims lodges partly in the relation -of these early signs of neurosyphilis to the whole question -of latency and to the question of <em>paresis sine paresi</em>. -For a discussion of <em>paresis sine paresi</em> see cases Lawlor -(25), Vogel (52).</p> - -<div><span class='pageno' id='Page_187'>187</span></div> -<div class='box'> - -<p class='c013'><b>Differential diagnosis between NEUROSYPHILIS -and MANIC-DEPRESSIVE PSYCHOSIS.<a id='r9' /><a href='#f9' class='c014'><sup>[9]</sup></a></b></p> - -</div> - -<p class='c006'><b>Case 47.</b> As in other instances (compare Martha Bartlett -(21) and Annie Monks (85)) so also in the case of Ethel Hunter, -a woman 61 years of age, there was no initial suspicion of -neurosyphilis. Mrs. Hunter was brought to the hospital -stuporous as a result of an overdose of paraldehyd. The -paraldehyd had been administered by a physician to combat -insomnia and agitation. As soon as Mrs. H. had recovered -from the drug stupor, this agitation appeared once more, and -it was clear that she was suffering from marked depression. -There was tremendous worry over the sickness of a woman -with whom the patient lived. The patient was very self-accusatory, -blaming herself for many things that had happened -in the household. Besides her agitation, depression, -self-accusations, and insomnia, the patient showed a good -deal of the symptom frequently termed “retardation”—a -kind of lagging of all mental processes found, according to -Kraepelin, in manic-depressive psychosis.</p> - -<p class='c007'>Accordingly, the diagnosis of manic-depressive psychosis -might well have been rendered. The fact that the psychosis -so far as known began in the involution period was not against -the diagnosis since the so-called involution-melancholia of -this period is at least in a certain fraction of cases nothing -more or less than a form of manic-depressive psychosis. -However, the <b>physical examination</b> made the diagnosis of -manic-depressive psychosis a little doubtful. There was a -superficial thickening of the arteries (blood pressure: systolic, -170; diastolic, 104), which thickening would not in itself be -against the diagnosis of manic-depressive psychosis. (In -point of fact, arteriosclerosis is rather common late in this -<span class='pageno' id='Page_188'>188</span>disease and previous attacks could not be excluded on the -basis of available history.) The contracted pupils were -irregular and both reacted sluggishly to light, although better -to accommodation; the right pupil was larger than the left. -The arm reflexes were pretty active. The left knee-jerk -could not be obtained, nor was the right knee-jerk more than -very sluggish. The Achilles reflexes could not be obtained. -Although there was not a positive Romberg sign, there was -a considerable swaying in Romberg position. There was -no speech defect. The other reflexes showed nothing abnormal. -On the whole, we had to conclude that, although -Mrs. Hunter might be an instance of manic-depressive psychosis, -still there was much of neurological interest in the -case.</p> - -<p class='c007'>This conclusion was emphasized when the W. R. of the -blood serum was found to be positive. The spinal fluid W. R. -was also positive, and the gold sol index was of the “paretic” -type. There were 74 cells to the cmm. Globulin stood at -++++, and albumin at ++++.</p> - -<p class='c007'>This case, therefore, again illustrates, as well the protean -nature of <span class='sc'>General Paresis</span> (the diagnosis rendered), as the -doubtful value of making a psychiatric diagnosis without -due consideration of the physical examination and laboratory -findings. How easy might it have been, at least some years -ago, to consider that this patient of 61 years had suffered a -slight shock at some previous time (left knee-jerk absent), -but was as a matter of fact a case of manic-depressive -psychosis with a vascular complication!</p> - -<p class='c007'>Note: We must again duly insist that the merely sluggish -light reactions of the pupils in such a case as this do not -especially point to general paresis. The literature seems to -establish that sluggishness of light reaction precedes the -classical Argyll-Robertson pupil. Yet it does not do to say -that, if the Argyll-Robertson pupil pretty conclusively points -to neurosyphilis (for exceptions see cases Falvey (55), Murphy -(60)), then a sluggish pupillary reaction to light looks in the -same direction. Sluggishness may precede stiffness in many, -or perhaps all, cases, but sluggishness of pupils is a frequent -phenomenon outside the syphilitic group of cases.</p> - -<p class='c027'><span class='pageno' id='Page_189'>189</span>1. What part is played by emotional shock and psychic -causes in the starting up of general paresis? The -answer to this question cannot be definite. That a -paretic process can be started up after trauma is admitted -on all sides; but we here suppose actual physical -or chemical brain disturbance permitting increased -spirochetosis or inflammatory reaction. In the case of -psychic shock, or what might be called <em>psychogenic -general paresis</em>, our best resort will be to the indirect -effects of hormone action, or of vasomotor and other -autonomic disturbances produced directly or indirectly -by emotion. We are clearly here dealing with material -too speculative to be of practical service at this time.</p> - -<p class='c027'>2. Was the depressive drug therapy in the case of Hunter -justifiable? The paraldehyd had been administered by -a physician apparently on purely symptomatic grounds -to combat the insomnia and agitation of this woman of -61 years. With all due acknowledgment of the difficulties -of private practice, we must insist that when -ordinary measures in the relief of insomnia and agitation -are insufficient to curb these conditions, then a positive -danger ensues with the larger doses. As a rule, with -these larger doses and with the withdrawal of sensory -stimulation, the patients relapse into a stupor of -grave moment. We need only recall the situation in -delirium tremens where adequately depressive drugs -often tend to kill the patient.</p> - -<div><span class='pageno' id='Page_190'>190</span></div> -<div class='box'> - -<p class='c013'><b>Case for diagnosis. Errors in the diagnosis of -NEUROSYPHILIS are possible even when abundant -clinical and laboratory data are available.</b></p> - -</div> - -<p class='c006'><b>Case 48.</b> The first error chosen for demonstration is that -in the case of the machinist, Milton Safsky.</p> - -<p class='c007'>Safsky, about 8 months before his entrance to the hospital -in the 42d year of his life, had begun to lose strength, to grow -thin and pale, and to suffer from an extreme and continuous -thirst. He was said to have drunk as much as 6½ gal. in a day, -and passed appropriately large quantities of urine. After a -time, his management at a general hospital became difficult, -as Safsky became confused, cried “hysterically,” and was at -times very noisy. He sustained a marked memory loss, -seemed to show visual hallucinations, and complained of -headache, both frontal and occipital, and of pain about the -eyes. Sometimes the patient was very euphoric and expressed -what seemed to be delusions of grandeur, saying he -was wealthy and owned many machine shops.</p> - -<p class='c007'>Some symptoms, e.g., polydipsia and polyuria amounting -to a diabetes insipidus, associated with headache and arrested -attention, suggested possibly a new growth in the pituitary -region. The mental symptoms might naturally be supposed -to be due to some infiltration or pressure effect of intracranial -growth. After admission to the Psychopathic Hospital, the -patient was found difficult to arouse, although he could -eventually be aroused. His orientation proved to be as poor -as his memory. From time to time, the patient became a -bit more intelligent and able to execute requests.</p> - -<p class='c007'>The <b>physical examination</b> was in general almost entirely -negative. <b>Neurologically</b>, the pupils were markedly contracted -and reacted slowly to light, though they were otherwise -normal. The deep reflexes were all somewhat lively, -though equal. The umbilical and cremasteric reflexes in -particular were present. Systematic examination revealed -no other reflex disorder, nor any disturbance of sensation. -<span class='pageno' id='Page_191'>191</span>There was a coarse tremor of the extended hands. There -were no phenomena of importance in the visual fields.</p> - -<p class='c007'>As against the diagnosis of growth, pituitary or extrapituitary -(diabetes insipidus and headache), a hypothesis of -neurosyphilis had to be considered. Not only were the contracted, -slowly-reacting pupils and the active deep reflexes -suggestive, but the euphoria with grandiose ideas looked -entirely consistent. As for the polyuria, one had to think of -the so-called syphilitic polyuria of the textbooks, which is -regarded as a more or less characteristic result of syphilitic -involvement of the <em>basis cerebri</em>. Moreover, the W. R. in -the spinal fluid proved to be slightly positive; 146 cells per -cmm. were found therein; there was a large quantity of -globulin, and a very marked increase in albumin. These -observations seemed to be exceedingly suggestive of a cerebral -syphilis.</p> - -<p class='c007'>However, as the case progressed, the diagnostic situation -changed. The W. R. upon a second puncture fluid proved -negative. After some weeks, characteristic symptoms of intracranial -pressure developed; the diagnosis of <span class='sc'>Brain Tumor</span> -had to be taken as established, and there is no doubt of its -correctness.</p> - -<p class='c027'>1. What is the explanation of the weakly positive W. R. in -Safsky’s spinal fluid? An explanation is not easy to -find. Possibly we may regard the reaction as an example -of error in technique. It is even possible that it -may have been produced by exudative products in the -spinal fluid.</p> - -<p class='c027'>2. What precautions may be taken against an error in -diagnosis such as was first made through the positive -spinal fluid Wassermann in the case of Safsky? First, -repetition of the W. R.; secondly, it is very unusual -to find a weakly positive W. R. in a case with such -marked excess of albumin and such very marked increase -of globulin as was shown by this case.</p> - -<p class='c027'>3. How can we explain the inflammatory products in the -puncture fluid? Superficial brain tumors are frequently -associated with a so-called <em>meningitis sympathica</em>. -The products of such meningitis are exhibited: -<i><span lang="la" xml:lang="la">viz.</span></i>, globulin, albumin, and pleocytosis, exactly -as shown in Safsky.</p> - -<div><span class='pageno' id='Page_192'>192</span></div> -<div class='box'> - -<p class='c013'><b>Can PARETIC NEUROSYPHILIS (“general -paresis”) appear clinically EARLY (e.g., two years) -after the initial syphilitic infection?</b></p> - -</div> - -<p class='c006'><b>Case 49.</b> David Borofski, a street car conductor, 27 years -of age, suddenly had a convulsion while at work in his car. -For four months Borofski continued to have rather numerous -convulsions, was finally compelled to discontinue work, and -resorted to the Psychopathic Hospital. It appears from his -own story that, about two years before, he had had a chancre, -for which he had been treated at a general hospital syphilis -clinic, and of which he was told he was cured. With a progressive -loss of memory and with convulsions, Borofski became -much concerned about himself, and was finally persuaded -by his fellow-workers to come to the Psychopathic -Hospital.</p> - -<p class='c007'>The convulsions were described as follows: The patient -gives a short cry, has convulsive movements for about ten -minutes, remains unconscious for perhaps half an hour, and -wakes with headache, dizziness, and a feverish appearance. -Sometimes the attacks were more severe, with frothing at -the mouth, biting of lips, and loss of sphincter control. There -were also slight attacks, occurring almost every day, without -loss of consciousness; these latter attacks consisted of dizziness, -inability to speak for a few seconds, and some arm -twitching.</p> - -<p class='c007'><b>Physically</b>, Borofski was well developed and nourished, with -a blood pressure of 160. The only abnormal phenomena -<b>neurologically</b> were absent knee-jerks and ankle-jerks, sluggish -pupillary reactions, and slight tremor of the hands.</p> - -<p class='c007'><b>Mentally</b>, despite suggestive complaint of amnesia, the -memory was found to be fairly good but knowledge of current -events and school knowledge was poor. The simplest -problems in arithmetic Borofski gave up.</p> - -<p class='c007'>The first diagnosis in such a case would naturally be -epilepsy. However, when an epileptic or epileptiform attack -<span class='pageno' id='Page_193'>193</span>occurs for the first time in adult life, the chances are -probably against an idiopathic epilepsy. (This is not a -universal rule but will serve.) Borofski himself, moreover, -gave a history of syphilis. And the very nature of the attacks, -with arm twitching and without loss of consciousness, would -not readily fit into the frame of the idiopathic group. The -absence of certain reflexes and the sluggish pupils are naturally -also suggestive of syphilis, although not convincing.</p> - -<p class='c007'>The W. R. of the serum proved positive, as did that of -the spinal fluid. The gold sol reaction was characteristically -“paretic”; there was an excess of albumin and a positive -globulin, and there were 15 cells per cmm. There could be -little or no doubt of the diagnosis of some form of neurosyphilis. -The laboratory picture was consistent either with -general paresis or with cerebrospinal syphilis. So far as we -are aware in the present stage of knowledge, the two conditions -can hardly be differentiated unless we choose to rely on -therapeutics. However, it is exceedingly rare for general -paresis to occur only two years after the original infection. -If we can trust this statistical fact, we shall perhaps be wiser -to term the case of Borofski one of <span class='sc'>Diffuse Cerebrospinal -Syphilis</span>, and not one of paresis.</p> - -<p class='c007'><b>Treatment</b>: Borofski was put on antisyphilitic treatment -consisting of 0.6 gram of salvarsan twice a week and -potassium iodid, together with intramuscular injections of -mercury salicylate. The convulsions then ceased. After -four months Borofski returned to work, and he has remained -at work for a year. He has never regained his former health.</p> - -<p class='c007'>Fifteen months after beginning of treatment the laboratory -tests were again made (there had been more than 60 injections -of salvarsan), and the cell count and gold sol reactions -were found to be negative. Globulin and albumin were -also in smaller amounts than in the original examination. -However, the W. R. of the serum and the spinal fluid remained -positive.</p> - -<p class='c007'>Head and Fearnsides state that cases of cerebrospinal -syphilis should return negative spinal fluid tests after six -months of treatment. Upon this criterion of Head and -Fearnsides, Borofski would not be a case of cerebrospinal -<span class='pageno' id='Page_194'>194</span>syphilis; but it is probably impossible to separate various -forms of neurosyphilis into categories on any such grounds.</p> - -<p class='c027'>1. Shall case David Borofski be regarded as one of paretic -neurosyphilis (“general paresis”)? He has returned to -work and has remained at work, though without regaining -his former health. In any event, however, he does -not offer the typical picture of inevitable decline and -death presented by the typical case of Pietro Martiro -(15) presented in our discussion of systematic diagnosis. -However, we could not upon laboratory grounds, -or even upon the ground of clinical observation, distinguish -Borofski from Martiro; Borofski has greatly -improved; Martiro is dead. Borofski developed his -obvious neurosyphilis only two years after the original -infection. The conservative syphilographer might, accordingly, -reply that David Borofski is not a typical -case of paretic neurosyphilis (“general paresis”) either -in the length of the incubation period for his neurosyphilitic -symptoms, or in his outcome.</p> - -<p class='c027'>2. What is the cause of such convulsions as those developed -by David Borofski? Evidence from clear cases of -general paresis with convulsions leads to the hypothesis -that such convulsions as those developed by Borofski -are not necessarily based upon frank destructive -lesions such as would be produced by the plugging of -terminal arteries. They may well be produced through -the activities of minor lesions, only demonstrable by -microscopic methods, either through properly disposed -cell losses or by the pressure of exudate, or even by -endotoxins or other substances derived from the bodies -of dead or living spirochetes.</p> - -<p class='c027'>3. Aside from the well-known syphilitic epilepsy due to -meningitis, is there a non-meningitic epilepsy (such -a disease as Fournier formerly described under the term -parasyphilitic epilepsy)? We dismiss from discussion -the so-called symptomatic epilepsies which are the -result of a gross organic disease of the brain substance -or its membranes, and which do not differ so far as we -are aware from organic epilepsy produced by other -gross lesions of an identical size and structure. These -symptomatic epilepsies may be partial, or even may -present the appearance of generalized epilepsy. We -may also leave out of account those epileptic pictures -which are produced in general paresis itself, and which -<span class='pageno' id='Page_195'>195</span>may be viewed as nothing but partial phenomena of -general paresis. The kind of so-called “parasyphilitic” -epilepsy that Fournier described is a kind of epilepsy -that cannot be distinguished from genuine epilepsy, in -which the sole disease-phenomenon throughout a long -period of time consists of epileptic convulsions. It appears -that these “parasyphilitic” imitations of genuine -epilepsy occur in individuals with a very long post-infective -“incubation period,” but that there are some -cases in which the epilepsy appears, on the contrary, -in the very earliest stages of syphilis. The attacks -are a little less common than those of idiopathic epilepsy; -they have the same apparently causeless beginning; -are associated with complete amnesia; and -are followed by characteristic dazed states. The -patient’s intelligence, however, suffers little. Now and -then a case reacts well to antisyphilitic treatment energetically -pushed. (Spontaneous long remissions in -non-syphilitic epilepsy must be remembered.) Petit -mal attacks occur sometimes between the more severe -attacks. In short, it would appear that there is a -group of syphilitic epilepsies in which the brain shows -no gross structural lesions, which accordingly do not -exhibit any Jacksonian appearances, and which last -a comparatively long time without changing their -character, and often without being especially altered -for the better by any form of antisyphilitic treatment. -This condition is sometimes known as a post-syphilitic -epileptic neurosis. Nonne had been able to collect up -to 1902 some 12 cases from his own service.</p> - -<p class='c027'>4. Would it be proper to call Borofski a case of taboparesis? -Absent knee-jerks in a victim of paretic neurosyphilis -should not be used to suggest a diagnosis of taboparesis. -This question of terminology has been discussed above, -under Sullivan (16).</p> - -<p class='c027'>5. What is the mechanism by which the amnesia of a case -like Borofski is produced? The answer runs in the -same terms as the answer to the questions concerning -the cause of convulsions. The amnesia in general -paresis has surprising functionality. A study of autopsied -cases of general paresis has shown that amnesia -is practically as common in cases without marked -destruction of brain tissue as in cases with atrophy of -classical extent and depth. The clinical recovery in -this case was practically complete in respect to memory. -We must regard the amnesia as not due to the destruction -<span class='pageno' id='Page_196'>196</span>of storage cells bearing the so-called neurograms -(Morton Prince).</p> - -<p class='c027'>6. What is the explanation of the persistently positive W. -R.’s of the serum and spinal fluid associated with -diminished globulin and albumin tests, a negative gold -sol reaction, and normal cell count? See discussion -under Case Martha Bartlett (21).</p> - -<p class='c027'>7. How atypical is the early development of paretic symptoms -in David Borofski? C. B. Craig has collected, -in 100 cases of brain syphilis (a list including both -paretic and non-paretic cases), some data on this -point. The shortest period reported by Craig was in -a case in which the neurosyphilitic symptoms appeared -one month after infection. Craig found three cases -where symptoms appeared in six months, and six cases -within a year. The longest post-infective period of -Craig’s list was thirty years. Our case of Chatterton -(73) developed symptoms 33 years after infection and -Washington (66), forty years after infection. Nonne -casts some doubt on statements to the effect that -tabetic symptoms may occur three to four months -after infection. It seems to be admitted that pupillary -anomalies and reflex changes may occur in the early -secondaries and may recover under antisyphilitic treatment. -Nonne’s case of longest post-infective interval, -like that of Craig, was one of 30 years.</p> - -<p class='c028'>Myerson has reported a 20–year old patient who -acquired chancre April 1, 1911 (spirochetes demonstrated); -salvarsan was administered April 20th. There -were no secondary symptoms, but in May, headache, -visual disturbance, vertigo, and other symptoms developed -(neurorecidive). Upon June 20th, that is, -11 weeks after development of the chancre, aphasia -and astasia developed, with numbness of the left side. -At this time, the pupils were slightly irregular and unequal -but reacted normally. The signs in the fluid -were positive. Upon this question see our cases of -Bright (121) and Bennett (34).</p> - -<div><span class='pageno' id='Page_197'>197</span></div> -<div class='box'> - -<p class='c013'><b>Hemitremor following hemiplegia in PARETIC -NEUROSYPHILIS (“general paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 50.</b> Achilles Akropovlos, 39 years, had symptoms -six months before commitment to Danvers Hospital. There -were attacks of confusion, difficulty in walking, and speech -defect, resulting in an entire incapacity to work and -eventual commitment. Rather unusual and striking was a -very marked tremor, apparently limited to the right side of -the body. <b>Physically</b>, Akropovlos was normal, but <b>neurologically</b> -he showed, in addition to the marked right-sided -tremor, a marked speech defect, and a degree of ataxia. -The tendon reflexes were very active, but there were no abnormal -reflexes, and the pupils reacted normally. According -to the history, the difficulty had followed a slight attack of -apoplexy. <b>Mentally</b>, there was a marked confusion. The -blood serum and the spinal fluid were both positive to the W. -R.; globulin was present, and albumin was increased; there -were 43 cells per cmm. There was hardly any diagnosis to -make except general paresis.</p> - -<p class='c007'>Death followed 18 months later, or two years after onset -of symptoms. Increasing weakness, emaciation, and dementia -preceded death. Autopsy confirmed the diagnosis of -<span class='sc'>Paretic Neurosyphilis</span>.</p> - -<p class='c027'>1. What is the usual cause of death in general paresis? -Intercurrent disease very frequently occurs in general -paresis, and such intercurrent disease is then given as -the cause of death. As a matter of fact, however, one -feels that in many of these cases the intercurrent -pneumonia or infection—frequently of the bladder,—bedsores, -sepsis, and the like, are merely accidental -incidents in a condition that is leading to death, and -which has caused a lowered resistance to infection. -In certain instances where nursing is exceptionally good -and where no such infection occurs, the patient continues -to grow weaker and weaker, paralyses of all the -muscles follow and finally paralysis of deglutition or -<span class='pageno' id='Page_198'>198</span>respiration may lead to death. The emaciation and -paralyses may be of such a grade that the patient is -entirely devoid of fat and unable to move at all. Not -infrequently vascular crises occur, and one of these may -be responsible for death.</p> - -<p class='c027'>2. What was the cause of the hemitremor? The hemitremor -suggested an irritative or destructive lesion in -the motor path. Delving into the history it was -learned that the patient had had a shock followed by -a right hemiparesis. This had cleared up leaving the -tremor as a residuum. The autopsy disclosed a reddish-brown -pigmentation and fibrous thickening of the pia -over the left motor area, confirming the idea of a -previous hemorrhage. As a rule the shock phenomena -occurring in paresis clear up more completely and no -gross lesion is visible post mortem. However, cerebral -hemorrhage must be expected in any person suffering -from syphilis, and is no rarity in paretic neurosyphilis.</p> - -<div><span class='pageno' id='Page_199'>199</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS (“general paresis”) -with NORMALLY REACTING PUPILS. History -of trauma. Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 51.</b> Daniel Wheelwright, a barber of English extraction, -57 years of age, had had a sunstroke at 15. At 42, -there had been pneumonia, after which an attack of rheumatism -was said to have kept the patient from work for a year. -There was trauma of head (falling wrench) at 44. This blow -on the head was the assigned cause of the mental disease, -symptoms of which, however, did not develop until about the -first of September, 1905, about three months before entrance, -January 9, 1906, and about six months before death, March -20, 1906.</p> - -<p class='c007'>It seems that the patient had begun to change in manner; -he had become despondent and apathetic, silent, and somnolent. -Two weeks later, he stopped working, began to -read the papers once more, and became somewhat more -cheerful.</p> - -<p class='c007'>About Thanksgiving, Wheelwright got up at midnight, and -remained up, lighting all the fires and talking continuously. -During the next two weeks, he talked much to himself, -laughing out at times. About two weeks before Christmas -he went out and started to make a sidewalk of old boards, -working in his shirtsleeves, without a hat. He would work -until midnight making screens for windows. During the -day, he would go out and give money to passing children; -would offer to pay the grocer twice as much as articles were -worth.</p> - -<p class='c007'>On the day before Christmas, he put out all the fires and -lights in the house, sent all the family to bed, and opened all the -doors. Christmas morning, he rose early and got the washtubs -ready. He helped his compliant wife to do the washing, then -put out all the fires and opened the windows. After Christmas, -he began to tell how rich he was going to be through starting -a garden and by making butter. He bought six or seven -<span class='pageno' id='Page_200'>200</span>quarts of milk daily, and procured carrots and oranges, -grinding them up to color the milk. January 9th he was -committed to Danvers Hospital.</p> - -<p class='c007'><b>Physically</b>, there were few symptoms. <b>Neurologically</b>, there -was a tremor of tongue, fingers, and face. The knee-jerks -were lively. The pupils reacted normally; the patient was -restless, pacing up and down. There was a speech defect -demonstrable with test phrases. Orientation was imperfect -for time and for place. Handwriting was poor, memory -impairment was marked, but the patient was given to fabrication -as to past events. A characteristic sample of statements:</p> - -<p class='c007'>“Do you know that this is an insane hospital?” “Yes; -there are two or three men here out of their heads. I could -cure them with my hands but they won’t let me. I could get -all the sick men on their feet just by rubbing them. I can -do anything with my hands. I can build a house by just -sitting down and thinking about it. I can whip all the men -in this place. I have better sense now than I ever had in -my life.”</p> - -<p class='c007'>Again, “How long have you been here?” “Over three -months; they have put me in heaven three times since I have -been here. They killed me, crushed my heart, and turned -my blood to water. I am all right now. I let the sun shine -on my heart and it brought it together. I can whip every -man in here as fast as they come up.”</p> - -<p class='c007'>Again, “I will make a million dollars on my garden when -I get it. I can make a million dollars on half an acre. -I can do anything. I can move this house by just thinking -of it.”</p> - -<p class='c007'>During a special examination, the patient told how he had -fastened wings on his hands and feet, and how he had gone to -heaven; he told how he had soared high above the earth, and -how differently the stars look when up near heaven than they -do from the earth. He spoke of seeing angels and of the -beauties of heaven.</p> - -<p class='c007'>The diagnosis of <span class='sc'>Paretic Neurosyphilis</span> was confirmed -at autopsy.</p> - -<p class='c027'><span class='pageno' id='Page_201'>201</span>1. What is the significance of the normally reacting pupils? -While it is usual to find pupillary anomalies in -neurosyphilis, these changes are not an essential part -and it is not rare to find normal pupils in all forms of -neurosyphilis. It is less frequent to find a normal -pupil in tabetic than in diffuse or paretic neurosyphilis. -In paretic neurosyphilis it is the rule to find pupillary -changes during some stage of the disease, but not necessarily -early. At times the pupillary sign may be one of -the earliest signs of neurosyphilis—again it may occur -only as a late symptom, if at all. One of the most important -of the pupillary signs is irregularity of contour. -While this does not always mean neurosyphilis it is -highly suggestive and certainly indicates careful examination -even though the W. R. in the blood be negative.</p> - -<p class='c027'>2. What was the relation of trauma to the development -of the neurosyphilitic symptoms? It is, of course, the -rule in all forms of mental disease to have some factor -offered by the patient or relatives as the cause of the -psychosis. Often these assigned causes are minor -events thought of only after the later appearance of -symptoms. In this case it was not thought that the -trauma had any causal effect. For a discussion of -trauma and neurosyphilis see cases Joseph O’Hearn -(90), Levi Sussman (91), and Joseph Larkin (92).</p> - -<div><span class='pageno' id='Page_202'>202</span></div> -<div class='box'> - -<p class='c013'><b>NEUROSYPHILIS, probably PARETIC, with -symptoms highly suggestive of MANIC-DEPRESSIVE -PSYCHOSIS.</b></p> - -</div> - -<p class='c006'><b>Case 52.</b> Bessie Vogel<a id='r10' /><a href='#f10' class='c014'><sup>[10]</sup></a> was admitted to the Psychopathic -hospital New Year’s day, 1915, in a very much excited -condition. The family history is very meagre, and all -that is of significance is that mother has always been very -“nervous.” The records in part:</p> - -<p class='c007'><b>Past History.</b> Very healthy as a child, and except for occasional -throat trouble and headache had no physical ailments -until eight years ago, when she had an operation for appendicitis, -and two and one-half years ago was operated upon for -hernia and adhesions. Following this she began to show a -lack of energy, neglected her housework, was much depressed, -wept frequently, complained constantly of pain in various -places, and was ill-tempered. In about five months she -improved, and then after a couple of weeks at the shore -seemed entirely well.</p> - -<p class='c007'><b>Present Illness.</b> In November, 1914, that is, about -seventeen months after the recovery from the previous depression, -she again began to show practically the same -symptoms. She was depressed, could not sleep, and would -get up in the night and sew; was self-centered and hypersensitive, -then became restless and nervous; wanted to go -shopping and out for dinner; went to New York and then to -New Bedford. Symptoms became more marked; she became -very ill-tempered, threatened her husband when angry -over trifles, threatened suicide, then began to get active and -spent money extravagantly. At the end of two months, that -is, Jan. 1, 1915, she was admitted to the hospital.</p> - -<p class='c007'><b>Physical Examination.</b> A small, thin woman, appearing -to be about 45 years old (actual age 37). Aside from the -<span class='pageno' id='Page_203'>203</span>absence of teeth and the operation scars, the general examination -is negative. <b>Neuromuscular system</b>: The pupils -are round, regular, equal, and react to light and accommodation, -but do not hold very well. Extraocular movements -well performed, no palsies of facial muscles, tongue -protruded medially without tremor. Uvula is raised symmetrically. -Biceps and triceps and supinator reflexes are -present and brisk. Patellar and Achilles reflexes are equal -on the two sides and brisk. Abdominal skin reflexes not -obtained. Plantar reflex active and flexor in type. No -Babinski, Gordon, or Oppenheim. No tremors.</p> - -<p class='c007'>Wassermann reaction serum positive. Examination of -spinal fluid: clear, globulin ++++, albumin ++++; -cells, 130 per cmm.; small lymphocytes, 79.9%; large lymphocytes, -14.1%; polymorphonuclear leucocytes, 4.6%; -plasma cells, 0.7%; endothelial cell, 0.7%. W. R. positive. -Gold sol reaction, 55555522 +-.</p> - -<p class='c007'><b>Mental Examination.</b> On admission patient showed great -psychomotor activity, was very playful, marked flight of -ideas, was expansive, very emotional, very erotic. She -slept very little, appetite was poor, and she lost weight -rapidly. Orientation and memory intact. No hallucinations -elicited. In about three weeks improvement began, and at -the end of eight weeks she appeared practically recovered. -On April 9, 1915,—that is, 13 weeks after admission,—she -was allowed home on visit. On leaving, she appeared -normal in every way. There was no evidence of psychotic -symptoms, she had good insight, and physically there was -absolutely nothing of a neurological nature that was abnormal.</p> - -<p class='c007'>This case, with the history of a previous depression and its -clinical picture during the acute stage, and its recovery, -is certainly in every respect typical of manic-depressive insanity, -and only the positive result of the six tests causes us -to put it in the group of <span class='sc'>General Paresis</span>. Only the further -course will shed any light as to the correct significance of -these findings, and even then we shall not be too sure that we -had not been dealing with a manic-depressive psychosis in a -latent neurosyphilitic. We would strongly emphasize the -point that at the present time this patient presents no mental -<span class='pageno' id='Page_204'>204</span>or physical signs of cerebrospinal syphilis or general paresis; -but the six tests are still positive. This case differs from the -ordinary general paresis remission in that there is not a single -physical sign of paresis present.</p> - -<p class='c007'>There are many transitional cases between this case which -shows no symptoms or signs of neurosyphilis except the laboratory -tests, and the typical case of general paresis. Thus -we have cases with slight character change and no physical -signs except rare “seizures.” On the other hand, in many -cases the presence of abnormal neurological phenomena without -definite mental signs is first noted. Certain remitted -cases show only some slight pupillary or reflex abnormality. -We believe we have here added the last link in the chain -between the primary and quaternary symptoms.</p> - -<p class='c007'>This case is illustrative of several which we have published -elsewhere under the name of <em>paresis sine paresi</em> or -latent neurosyphilis to illustrate how all the laboratory signs -of neurosyphilis may be present in a patient without any -physical or mental symptoms that may be correlated with -these findings.</p> - -<p class='c007'>We summarize our discussion of this as follows:</p> - -<p class='c007'>1. There is a group of cases showing the laboratory signs -characteristic of central nervous system syphilis: (<em>a</em>) positive -W. R. in the serum, (<em>b</em>) positive W. R. in the spinal fluid, -(<em>c</em>) pleocytosis, (<em>d</em>) excess of albumin, and (<em>e</em>) of globulin in -the spinal fluid, (<em>f</em>) gold sol reaction of central nervous -system syphilis, and which show no sign or symptom of -neurosyphilis.</p> - -<p class='c007'>2. We believe these cases represent a form of chronic -cerebrospinal syphilis, probably paretic in type.</p> - -<p class='c007'>3. They have the greatest theoretical and practical -significance in the consideration of the life history of neural -syphilis, in the concept of <i><span lang="fr" xml:lang="fr">Allergie</span></i>, in regard to results of -treatment, and finally as to the evaluation of the laboratory -tests.</p> - -<p class='c007'>4. Here is perhaps offered the last link to form a complete -chain between the symptoms of the primary stage of syphilis -and its final termination of life as the result of the diseases -cerebrospinal syphilis or general paresis.</p> - -<div><span class='pageno' id='Page_205'>205</span></div> -<div class='box'> - -<p class='c013'><b>SYPHILIS (?); EXOPHTHALMIC GOITRE; neurosyphilitic -old lesion of optic thalamus; unilateral -induration and atrophy of left cerebral cortex. -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 53.</b> Carrie Pearson, a housewife 25 years of age, died -at Danvers Hospital less than a week after admission, and it -was at first stated that her symptoms had lasted but two -weeks before admission. In point of fact, a further investigation -showed an important succession of symptoms, lasting -some four years.</p> - -<p class='c007'>Carrie had been considered a healthy child, going to school -at the usual age, and progressing well with her studies. She -however, left school in the ninth grammar grade, at the age -of 15, and went to work in a milltown. She married a worthless -person at the age of 18, and lived with her husband -for three years. There was one child born a year after -marriage. Two years later, however, a tremendous goitre -had developed such that her neck was described as “out -square with the face,” and at the same time the patient’s -eyes had become prominent.</p> - -<p class='c007'>About two weeks before admission, she had gone to a -neighboring town to take care of a sick woman, but during -her endeavor to be a nurse, she had broken out into a mania, -tearing up furniture and bedding, and talking irrelevantly -for a period of four days. She also showed insomnia and -continually tore off her clothing from her body.</p> - -<p class='c007'>Upon <b>examination</b>, the marked enlargement of the thyroid -gland together with the prominent eyeballs, husky voice, and -pulse rate of 150 per minute, were entirely consistent with -the diagnosis of exophthalmic goitre. The patient described -herself as “Carrie Nation.” Asked to write her name, -she took the pen and tried to spatter ink, wrote hurriedly and -carelessly her maiden name and several words without apparent -meaning. Asked to write, “God save the Commonwealth -of Massachusetts,” she wrote: “God save the -<span class='pageno' id='Page_206'>206</span>common pal U S Spe Manor Gen, or til pat. Since Lord, or -no prime in Hear to the God Tel. Ho. n and or Mabel, or gal.” -After this, she took paper and wrote meaningless scrawls, -saying that it was Japanese writing. There was much -motor restlessness with distractibility, pointing and grimacing, -mimicking the actions of those about her.</p> - -<p class='c007'>Death occurred from exhaustion, and the case might not -have been regarded as unusual except for the autopsy, which -showed a peculiar brain lesion, described below. The point -of greatest interest in the case was the fact that syphilis is, -although not proved to exist by laboratory tests, beyond -question a factor in the case. Although the woman had -given birth to a normal child, who is still alive, yet in the -period of a few years her breasts had atrophied, her hair had -disappeared from the axilla and from the pubes; varicose -veins had developed in both legs. Whereas there was little -or no fat over the chest or back, the omentum and mesentery -were very plentifully supplied with fat. It is probable, then, -that we are dealing with a case of exophthalmic goitre somehow -of syphilitic origin. The brain lesion is consistent with -this hypothesis.</p> - -<p class='c015'><b>Autopsy</b>, March 3, 1907. Four hours post mortem.</p> - -<p class='c015'>Body length, 165 cm. Body of a well developed and -well nourished young woman. Lividity in dependent -parts. Purplish discoloration of left thigh to knees. -Skin rough and scaly. Petechial eruption over chest. -Neck thick, protrudes anteriorly. Varicose veins over -upper parts of calves on both legs. Eyes protruding, -not covered entirely by lids. Pupils equal, dilated. -Subcutaneous fat very deep over lower part of body. -Very little fat over chest and back. Breasts are very -small, apparently atrophied. Normal amount of hair -on head, slight amount over pubes. Axillary hair absent. -Fat on section of a light yellow color. Omentum -extends to pubes, plentifully supplied with fat. Large -amount of mesenteric fat. Appendix normal. Intestines -smooth and glistening. Slightly injected. No -fluid in peritoneum. Uterus small, retroverted.</p> - -<div class='figcenter id001'> -<img src='images/i_206.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Cortical hemiatrophy—A, relatively normal right precentral (“motor”) cortex; B, atrophic left precentral.<br /><br />Note in B:<br /><br />1. Absence of giant pyramids of Betz (corticospinal, upper motor neurones).<br /><br />2. Superficial (subpial) condensation of tissues with sclerosis (gliosis). The tissues in all areas examined <em>on the left side</em> yielded this effect.</p> -</div> -</div> - -<p class='c015'><span class='pageno' id='Page_207'>207</span><span class='sc'>Head</span>: <span class='sc'>Hair</span> in good quantity. <span class='sc'>Scalp</span> normal. -<span class='sc'>Calvarium</span> shows diploë. <span class='sc'>Dura Mater</span> over left -cerebral hemisphere inseparably adherent to calvarium, -over right hemisphere normal. Arachnoidal <span class='sc'>Villi</span> -moderately developed. <span class='sc'>Pia Mater</span> shows injected -veins, notably in the sulci of the right hemisphere. -Pia mater everywhere thin and clear. <span class='sc'>Vessels</span> at base -of normal appearance.</p> - -<p class='c015'><span class='sc'>Brain</span> weight 1180 grams. Spread on a board, the -right hemisphere tends to flatten so that it measures -1.5 cm. more from side to side than its fellow. Besides -more marked venous injection, the right hemisphere -shows also flatter and slightly more plastic -convolutions. The posterior poles of the hemispheres -are a little firmer than the parts anterior. The orbital -and hippocampal gyri on the right side are a little -firmer than the surrounding parts. On section the -gray and white matter shows no lesions, excepting the -slight plasticity of the tissues at large on the right side -and a well marked induration, with retraction under -the knife, of the occipital and hippocampal white -matter. The basal ganglia of the left side are -normal. On the right side a sagittal section demonstrates -a rounded area of induration, with ill-defined -borders, measuring perhaps 1.5 cm. from above downwards -by 2 × 2 cm., situated largely in the lenticular -nucleus and involving the greater portion of the globus -pallidus, a small segment of the putamen below and -behind and the regionary part of the anterior commissure -with surrounding tissues. The most striking -feature of this lesion is the occurrence in the middle -of a cluster of vacuoles or cystic clefts, with smooth -pale interiors, ranging from pinhead to 0.25 cm. or even -0.5 cm. in greatest diameters. There are six to eight -clefts to a surface of section. The color of the lesion -differs little from that of the globus pallidus itself, but -the tissue is a trifle translucent. It is impossible to -demarcate the lesion with the eye. Induration is demonstrable -several mm. beyond the visible part of the -lesion. The consistence of the lesion slightly surpasses -the usual consistence of the olivary bodies.</p> - -<p class='c015'><span class='sc'>Cerebellum</span>, <span class='sc'>Pons</span> and <span class='sc'>Bulb</span> weight 165 grams. -Cerebellar tissue a trifle more plastic than usual. -The right olive is not so prominent as usual.</p> - -<p class='c015'><b>Note.</b> <span class='sc'>Thyroid</span>: Weight 125 grams. Both lobes -and isthmus enlarged. One lobe more than the other; -lobe on one side measuring 6 × 4 cm.</p> - -<div class='nf-center-c0'> -<div class='nf-center c039'> - <div><span class='pageno' id='Page_208'>208</span>Anatomical Diagnoses</div> - </div> -</div> - -<p class='c015'>Enlargement of thyroid gland.</p> - -<p class='c015'>Exophthalmos with dilated pupils.</p> - -<p class='c015'>Fatty degeneration of thoracic muscles.</p> - -<p class='c015'>Slight aortic sclerosis.</p> - -<p class='c015'>Dilatation of right heart.</p> - -<p class='c015'>Hypertrophy of left ventricle.</p> - -<p class='c015'>Slight tricuspid endocarditis.</p> - -<p class='c015'>Bicuspid aortic valve.</p> - -<p class='c015'>Hypostatic pneumonia.</p> - -<p class='c015'>Acute and chronic splenitis.</p> - -<p class='c015'>Fatty liver (central necroses?).</p> - -<p class='c015'>Acute nephritis.</p> - -<p class='c015'>Chronic gastritis.</p> - -<p class='c015'>Small breasts.</p> - -<p class='c015'>Axillary hair absent.</p> - -<p class='c015'>Petechial eruption of chest.</p> - -<p class='c015'>Varicose veins.</p> - -<p class='c015'>Chronic external adhesive pachymeningitis of left side.</p> - -<p class='c015'>Moderate swelling of right hemisphere with venous -injection.</p> - -<p class='c015'>Slight occipital gliosis of both sides.</p> - -<p class='c015'>Slight gliosis of orbital and hippocampal gyri of -right side.</p> - -<p class='c015'>Sclerosis with atrophy of occipital and hippocampal -white matter of right side.</p> - -<p class='c015'>Gliotic lesion (1.5 × 2 × 2 cm. of right lenticular -nucleus involving anterior commissure).</p> - -<p class='c027'>1. Was the exophthalmic goitre in Carrie Pearson due to -syphilis? Unfortunately we have no clear proof that -Carrie Pearson was syphilitic. She was stated to have -been syphilitic by the physician who treated her before -her commitment to Danvers Hospital. There is, however, -no proof of syphilis, inasmuch as the patient died -in the pre-Wassermann period.</p> - -<p class='c027'>2. Is the thalamic lesion probably syphilitic? No lymphocytosis -or plasmocytosis characterizes the lesion, which -is the only lesion of the sort in the Danvers collection. -It would not do to call a lesion syphilitic just because -it is <i><span lang="la" xml:lang="la">sui generis</span></i>. In any event, the clinical analysis of -the case faced the claim of syphilis as an actual factor -in the patient’s life and as a possible factor in the goitre.</p> - -<div><span class='pageno' id='Page_209'>209</span></div> -<div class='box'> - -<p class='c013'><b>It is well known that the ARGYLL-ROBERTSON -PUPIL is characteristic of the so-called “PARA-SYPHILITIC -DISEASES” (“general paresis” -and “tabes”); does this sign occur in other neurosyphilitic -conditions?</b></p> - -</div> - -<p class='c006'><b>Case 54.</b> Julius Kantor was a shoemaker of 35 years, -who came to the hospital for treatment because his family -physician had found a positive W. R. in Kantor’s blood -serum. He had had a cough for a number of years, and -during the last year a little blood had been found in the -sputum; whereupon Kantor had been placed under active -anti-tuberculosis treatment. The enterprising family physician -had found the positive W. R. in the first days of his -treatment for tuberculosis. There was, in fact, a history -of a chancre nine years before, which had not been followed -by any secondary or tertiary symptoms, and which had -been but scantily treated.</p> - -<p class='c007'>There were no mental symptoms.</p> - -<p class='c007'>Kantor was <b>physically</b> fairly well developed and nourished. -There were a few piping râles in the left upper chest, both -in front and back, and also a slight dulness with increased -vocal and tactile fremitus. No tubercle bacilli, however, -could be found on repeated sputum examination.</p> - -<p class='c007'><b>Neurologically</b>, the pupils were myotic and both showed -the Argyll-Robertson reaction. There were no abnormal -reflexes whatever, and there was neither ataxia nor speech -defect. Not only the blood but also the spinal fluid W. R. -proved to be positive; there was a marked increase in the -albumin and globulin; there was a gold sol reaction of the -syphilitic type, and there were but three cells per cmm.</p> - -<p class='c027'>1. In view of the headache in case Kantor, what other -causes of headache are to be considered? It is certain -that irritations of the dura mater can produce -headache, and the physiological observation of the -sensitiveness of the membranes and the non-sensitiveness -<span class='pageno' id='Page_210'>210</span>of the brain substance is an ancient and classical -observation. Internal hemorrhagic pachymeningitis -produces severe headache. The relations of this disease -to trauma, to arteriosclerosis, and possibly to -syphilis (alcohol perhaps should also be considered) in -certain instances have not been entirely cleared up. -Syphilitic headaches are, according to Lewandowski, -dependent also upon a dural affection or upon a periosteal -affection. The headaches of brain tumor are also -commonly related to dural conditions, either directly -due to the pressure of the tumor itself, or indirectly to -the heightened intracranial pressure consequent upon -the tumor. It is clear that the tension under which the -dura mater lies is not always localized in the region -of a brain tumor or a syphilitic lesion. Head has -claimed that brain tumor produces headaches of two -kinds, according to whether the disease affects the dura -mater or is dependent upon an increase of pressure in -the brain. It does not appear that the pia mater has -any relation to headaches, but meningitis, in which -the inflammation is confined to the pia mater, is nevertheless -associated with headache; the headache is here -supposed to be due to the increase in brain pressure, -and thus actually to an effect wrought upon the dura -mater. Vasomotor disorders and various types of -cephalic hyperemia are thought to produce a kind of -headache, but Lewandowski calls this kind of headache -somewhat in question. Reflex headaches are -stated to be produced indirectly by a process of radiation -from interior lesions in the brain. There are -certain headaches called nodal headaches (<em>Schwielen-Kopfschmerz</em>). -Hypermetropia, caries of the teeth, -adenoids, and diseases of the nose and axillary cavities, -to say nothing of thoracic and abdominal diseases, -are also counted among conditions that may produce -headaches. In this connection, Head has claimed -differential zones of headache corresponding to certain -diseases.</p> - -<p class='c028'>The brain itself may produce headache through intoxications, -through conditions produced by a variety -of diseases; may follow neuroses. Alcohol may produce -headaches in some persons even when it is taken -in very small doses. Certain uremic cases yield headaches, -as do also gouty and chlorotic conditions. -According to Lewandowski, the headaches of arteriosclerotics -are due possibly to vasomotor disturbances -<span class='pageno' id='Page_211'>211</span>in the membranes, or one may think of nutritive cerebral -disorders. A peculiar form of headache is that of -fatigue after mental work, allied to which is the neurasthenic -headache; constitutional headaches have been -assumed to occur, to say nothing of hysterical headaches. -There remains also the important question of -migraine, for which a vasomotor explanation has been -proposed.</p> - -<p class='c027'>2. Was Kantor suffering from tuberculosis of the lungs? -The hypothesis of lung syphilis ought certainly to be -very seriously considered. Upon repeated sputum -examination, no tubercle bacilli have yet been found.</p> - -<p class='c027'>3. Is Kantor a case of general paresis? In the absence of -mental symptoms, and in consideration of the mildness -of the reactions, it is certainly not easy to make -the diagnosis of general paresis. However, the diagnosis -of tabes dorsalis is not justified either. Accordingly, -we may answer our question: whether the -Argyll-Robertson pupil occurs in other neurosyphilitic -diseases, by pointing out that in the case of Julius -Kantor, as in the case of Henri Lepère (105) and -Frederick Stone (106), the Argyll-Robertson pupil has -been found in syphilitic conditions that are neither -typically paretic nor typically tabetic.</p> - -<div><span class='pageno' id='Page_212'>212</span></div> -<div class='box'> - -<p class='c013'><b>Does the Argyll-Robertson pupil necessarily indicate -neurosyphilis?</b></p> - -</div> - -<p class='c006'><b>Case 55.</b> Daniel Falvey, 44 years of age, was an almshouse -transfer to the Danvers State Hospital in the year 1904, -when the principle of state care was adopted in Massachusetts. -As in most of the almshouse transfers of that day, -little could be discovered as to antecedents. He had been a -mill-worker from the time of his immigration in 1890, at 30 -years of age. He had been somewhat alcoholic. There was -a shock some 17 months before his death, which occurred -about seven weeks from the date of transfer.</p> - -<p class='c007'>Not only was he unable to walk unsupported, but when -supported there was a slight dragging of the left leg and the -gait was noted to be somewhat propulsive. The tongue and -hands were tremulous, and the left grasp was somewhat -weaker than the right. Both knee-jerks were increased -although neither more than the other. There was no sensory -disorder.</p> - -<p class='c007'>Although but 44 years of age, Falvey presented the appearance -of a much older man. His heart was somewhat enlarged -and there was a degree of peripheral arteriosclerosis. On the -whole, no special attention was attracted to this case clinically -and he was regarded as an example of arteriosclerotic -dementia, like many another among the transfers. However, -we owe to Dr. H. M. Swift the important observation of the -Argyll-Robertson pupils. The case was studied long before -the Wassermann method was available, and is here reported -merely to call attention to the fact that the stiff pupils may -have other neural origin than neurosyphilis.</p> - -<p class='c007'>The autopsy material in the case was worked up by one of -the authors.<a id='r11' /><a href='#f11' class='c014'><sup>[11]</sup></a> The autopsy had been performed by Dr. A. M. -Barrett, who found on section through the brain stem at the -<span class='pageno' id='Page_213'>213</span>anterior border of the pons a mass springing from and continuous -with the pineal gland, lying in the third ventricle and the -aqueduct of Sylvius. Upon further study, this mass was -found to begin posteriorly in the pineal body itself, from -which the mass could hardly be told in the gross except by an -injected border.</p> - -<p class='c007'>This mass proved upon microscopic examination to be a -psammoma, which histologically resembled a glioma rather -than a sarcoma. Throughout the mass there was a variable -content of fibrillary intercellular substance having the histological -reactions of neuroglia fibrillæ. The histological -details (mitosis, large giant cells with multiple nuclei, etc.) do -not here concern us. We deal with a neoplasm springing from -the pineal gland growing on the posterior half of the third -ventricle, the anterior orifice of the aqueduct of Sylvius, and -the space between the velum interpositum as far back as the -posterior corpora quadrigemina. There is no evidence in the -body of old syphilis; although it is possible that the stiff -pupils were neurosyphilitic, it seems probable that they were -related to the pineal tumor. At all events, there are in the -literature evidences that the pineal-quadrigeminal group of -tumors and other lesions may bring about pupillary disturbances. -On this account, we here include the case. The -tumor hardly led to an error in diagnosis since neither neurosyphilis -nor brain tumor was at all expected clinically.</p> - -<p class='c027'>1. Can alcoholism produce identical results? See Case -Murphy, (60), one of alcoholic pseudoparesis.</p> - -<p class='c027'>2. What is the nature of stiff pupils? A pupil is called -stiff in the sense of the Argyll-Robertson pupil if it -fails to react to illumination either of itself or of the -other eye and at the same time if it reacts properly in -convergence and accommodation. Of course the stiffness -of a blind eye must not be regarded as an Argyll-Robertson -pupil. In a case of right-sided Argyll-Robertson -pupil, therefore, the left pupil reacts properly -both to direct illumination of itself and to illumination -of the right eye, but the right eye fails to react to illumination -of either eye. Such an Argyll-Robertson right -pupil will remain of the same width both in darkness -and in light. Clinicians agree that the Argyll-Robertson -<span class='pageno' id='Page_214'>214</span>is diagnosticated rather too frequently than too -seldom, and this by reason of the fact that a sluggishness -of light reaction is interpreted as stiffness. The -sign, as is well known, has come to be regarded as almost -pathognomonic of tabetic or paretic neurosyphilis. -Nonne, however, has found among 510 cases of alcoholism, -nine instances of Argyll-Robertson pupil and -19 cases of sluggish light reactions. The pathological -anatomy of this sign is still doubtful although a number -of schematic accounts are available; among hypotheses, -one may think of an elective effect of the tabetic or -paretic degeneration upon reflex collaterals. The explanation -would then resemble that for absent knee-jerks -and kindred reflex disorders. We should then -hypothesize a loss of the finer processes of the terminal -arborizations about the cells of the nucleus of sphincter -nucleus iridis. However, the situation of the sphincter -iridis has not yet been absolutely determined.</p> - -<p class='c028'>When a pupil is said to be entirely stiff it means that -it reacts neither to light nor accommodation. This -condition not infrequently follows the partial stiffness -or Argyll-Robertson reaction.</p> - -<p class='c027'>3. Is the Argyll-Robertson pupil more tabetic than paretic? -This has been claimed at times, but in point of fact, the -Argyll-Robertson pupil is very frequent in paresis, and -so also are posterior column changes. According to -statistics of Bumke, 36% of tabetics fail to show the -Argyll-Robertson pupil, and 38% of paretics. When, -however, finer methods, such as those standardized by -Weiler, with photographic records, are employed, the -number of cases without at least a tendency to the -Argyll-Robertson pupil becomes much smaller.</p> - -<p class='c028'>In connection with the important question as to the -classical Argyll-Robertson pupil and pupillary sluggishness -to light, it may be inquired what are the ocular -signs in neurosyphilis? Joffroy has tabulated the signs -in 300 general paretics as follows:</p> - -<table class='table3' summary=''> - <tr> - <th class='c040'>Sign.</th> - <th class='c041'>No. of cases.</th> - <th class='c042'>Per cent.</th> - </tr> - <tr> - <td class='c009'>Alterations of light reflex</td> - <td class='c043'>235</td> - <td class='c010'>78</td> - </tr> - <tr> - <td class='c009'>Inequality</td> - <td class='c043'>205</td> - <td class='c010'>68</td> - </tr> - <tr> - <td class='c009'>Abolition of light reflex (bilateral or unilateral)</td> - <td class='c043'>156</td> - <td class='c010'>52</td> - </tr> - <tr> - <td class='c009'>Abolition of light reflex (bilateral)</td> - <td class='c043'>133</td> - <td class='c010'>44</td> - </tr> - <tr> - <td class='c009'>Irregularity of pupil</td> - <td class='c043'>117</td> - <td class='c010'>39</td> - </tr> - <tr> - <td class='c009'><span class='pageno' id='Page_215'>215</span>Irregularity of both pupils</td> - <td class='c043'>109</td> - <td class='c010'>36</td> - </tr> - <tr> - <td class='c009'>Diminution of light reflex</td> - <td class='c043'>108</td> - <td class='c010'>36</td> - </tr> - <tr> - <td class='c009'>  ditto (bilateral)</td> - <td class='c043'>79</td> - <td class='c010'>26</td> - </tr> - <tr> - <td class='c009'>Alteration in accommodation reflex</td> - <td class='c043'>79</td> - <td class='c010'>26</td> - </tr> - <tr> - <td class='c009'>Diminution of accommodation reflex</td> - <td class='c043'>52</td> - <td class='c010'>17</td> - </tr> - <tr> - <td class='c009'>Mydriasis</td> - <td class='c043'>41</td> - <td class='c010'>13</td> - </tr> - <tr> - <td class='c009'>Myosis</td> - <td class='c043'>40</td> - <td class='c010'>13</td> - </tr> - <tr> - <td class='c009'>Diminution of light reflex (unilateral)</td> - <td class='c043'>35</td> - <td class='c010'>11</td> - </tr> - <tr> - <td class='c009'>Abolition of accommodation reflex</td> - <td class='c043'>35</td> - <td class='c010'>11</td> - </tr> - <tr> - <td class='c009'>Diminution of accommodation reflex (bilateral)</td> - <td class='c043'>29</td> - <td class='c010'>9</td> - </tr> - <tr> - <td class='c009'>Abolition of accommodation reflex (bilateral)</td> - <td class='c043'>26</td> - <td class='c010'>8</td> - </tr> - <tr> - <td class='c009'>Diminution of accommodation reflex (unilateral)</td> - <td class='c043'>23</td> - <td class='c010'>7</td> - </tr> - <tr> - <td class='c009'>Fundus changes</td> - <td class='c043'>21</td> - <td class='c010'>7</td> - </tr> - <tr> - <td class='c009'>Vascular changes</td> - <td class='c043'>16</td> - <td class='c010'>5</td> - </tr> - <tr> - <td class='c009'>Abolition of accommodation reflex (unilateral)</td> - <td class='c043'>12</td> - <td class='c010'>4</td> - </tr> - <tr> - <td class='c009'>Paresis of the third nerves</td> - <td class='c043'>10</td> - <td class='c010'>3</td> - </tr> - <tr> - <td class='c009'>Ptosis</td> - <td class='c043'>9</td> - <td class='c010'>3</td> - </tr> - <tr> - <td class='c009'>Irregularity of one pupil</td> - <td class='c043'>8</td> - <td class='c010'>3</td> - </tr> - <tr> - <td class='c009'>Nystagmus</td> - <td class='c043'>7</td> - <td class='c010'>2</td> - </tr> - <tr> - <td class='c009'>Visual acuity lost</td> - <td class='c043'>7</td> - <td class='c010'>2</td> - </tr> - <tr> - <td class='c009'>Atrophy of disc</td> - <td class='c043'>6</td> - <td class='c010'>2</td> - </tr> - <tr> - <td class='c009'>Total blindness</td> - <td class='c043'>5</td> - <td class='c010'>2</td> - </tr> - <tr> - <td class='c009'>Paralysis of the fourth nerves</td> - <td class='c043'>1</td> - <td class='c010'>1</td> - </tr> -</table> - -<div><span class='pageno' id='Page_216'>216</span></div> -<div class='box'> - -<p class='c013'><b>Can neurosyphilis exist in the absence of positive -findings in the spinal fluid?</b></p> - -</div> - -<p class='c006'><b>Case 56.</b> There was no great difficulty in setting up a -diagnosis of general paresis in the case of James Burns, a -mechanic of 31 years of age, who came voluntarily to the -Psychopathic Hospital for treatment. The point in Burns’ -case was that the spinal fluid proved entirely negative in all -respects despite the fact that the serum W. R. was positive, -and despite the following facts of history and mental examination.</p> - -<p class='c007'>The patient claimed syphilitic infection seven years before, -namely, at 24 years of age, and also claimed that he had -infected his wife, who was in fact at the time undergoing antisyphilitic -treatment. He complained of insomnia, worry, -depression, hypersensitivity to noises (such as those made -by his own children), thoughts of suicide, and amnesia. The -amnesia, however, might be regarded as subjective since our -tests failed to show amnesia. Nor was there any diminution -in arithmetical ability. Despite the patient’s claim that -he had been “way off in his way of thinking,” there appeared -to be no delusions. Beyond a certain flightiness in conversation, -we could hardly get any evidence of psychosis unless of -the neurasthenic order.</p> - -<p class='c007'><b>Physically</b>, however, the left pupil failed to react to light -though it was found to react to distance, and the right pupil -exhibited a diminution of its reaction to light. There was -no ataxia of gait, yet there was a complete Romberg reaction. -There was a moderate tremor of the hands and of the tongue. -Otherwise there were no reflex disorders upon systematic -examination, nor was there any demonstrable disorder in the -rest of the physical examination.</p> - -<p class='c027'>1. What is the diagnosis in the case of James Burns? On -the whole we agree with Nonne, that negative spinal -fluid findings (of course, in the absence of treatment) -preclude the diagnosis of general paresis. The symptoms -<span class='pageno' id='Page_217'>217</span>might possibly be explained, however, by means -of a localized syphilitic involvement of the cerebrum, -no cells or products of inflammation having penetrated -to the spinal fluid. According to Head and Fearnsides, -this condition may be found especially in the anterior -or middle fossa. Accordingly, going upon these views -of Nonne and of Head and Fearnsides, we should be -entitled to make, perhaps, a diagnosis of cerebral -syphilis.</p> - -<p class='c027'>2. What is the significance of the Argyll-Robertson pupil in -James Burns? Nonne states that if one follows cases -with Argyll-Robertson pupil over a sufficient period -of years, they one and all eventuate in active symptoms -of cerebrospinal syphilis (not necessarily of the cortical -type), and this despite the fact that the pupillary change -may have been present a number of years before any -other symptom had developed.</p> - -<div><span class='pageno' id='Page_218'>218</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis (“DISSEMINATED ENCEPHALITIS”) -within seven months of initial infection. -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 57.</b> We borrow the main features of a remarkable -case examined at the Danvers State Hospital clinically by -Dr. H. W. Mitchell and reported elaborately by Dr. A. M. -Barrett. This case, whom we shall call John Summers, -acquired syphilis at about the end of the third week in May, -1902, and consulted a physician on June 12, at which time -a characteristic initial lesion of syphilis was plain. Summers -was excessively alcoholic at times and was not seen by a -physician again until July 2, just after an alcoholic debauch. -At this time there was ulceration of the primary lesion, and a -papillary eruption had developed over the arms, chest, -abdomen, and legs. Mercurial treatment and mixed treatment -were given. Arthritis occurred but disappeared with -increased dosage.</p> - -<p class='c007'>About six months after infection, the patient developed -severe headaches, hardly controllable by treatment. Amnesia -and a certain stupidity, with neglect of personal habits, and -even of eating, developed, whereupon Summers was admitted -to the Danvers Hospital, December 11, 1902. He weighed -124 pounds, was extremely feeble, with dull and expressionless -face, coarse purposeless movements of arms; left pupil -larger than right; right external strabismus and ocular ptosis; -increased knee-jerks, crossed adductor reflex, coarse tremors -of arms and hands; and extreme clouding of consciousness. -It was doubtful whether the pupils were stiff to light or not.</p> - -<p class='c007'>The patient died on the ninth day, December 18, in a -state of coma. After admission, his stupor had become more -marked; there had been incontinence of urine and fæces, -and the patient could be aroused only by loud tones. -Difficulty in swallowing had developed; the right-sided -ptosis had become more marked, and muscular twitchings -had developed on the right side. When the left leg was -pinched, there was twitching of the left leg and arm. There -was slight spasticity of the right arm and leg. An examination -upon the day of death definitely showed a lack of reaction of -the pupils to light.</p> -<div> - -<div class='figcenter id004'> -<img src='images/i_218a.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>1. Exudate in pia mater—mononucleosis.</p> -</div> -</div> - -<div class='figleft id003'> -<img src='images/i_218b.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>2. Superficial (subpial) cellular reaction of neuroglia tissue (expanded cell bodies).</p> -</div> -</div> - -<div class='figright id003'> -<img src='images/i_218c.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>3. Cellular gliosis of deeper layers of cortex. Apparent increase in capillary supply, possibly relative to loss of neural elements.</p> -</div> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c044'> - <div>Case 57. Neurosyphilis (“disseminated syphilitic encephalitis” of A. M. Barrett), fatal seven months from initial infection. (Photographs by A. M. Barrett.)</div> - </div> -</div> - -</div> - -<p class='c007'><span class='pageno' id='Page_219'>219</span>Dr. Barrett was able to find in the literature a case of -Bechterew which histologically resembled his own case, but -though in the instance reported by Bechterew the first symptoms -developed within the year following infection, death did -not occur until two years later.</p> - -<p class='c007'>In view of a total duration of symptoms clearly not over -seven months, it is interesting to inquire how far microscopic -brain changes could have proceeded. Neither calvarium -nor dura mater showed changes. There was a slight -haziness of the pia mater over the convexity, but the pia -mater over the base (especially below the cisterna and from -thence spreading out over the pons and into the fissure of -Sylvius) was not only hazy but definitely thickened and -hyperæmic. The thickening was most marked about the -root of the right third nerve (corresponding with the eye -findings in life). There was also a macroscopic thickening of -the left Sylvian artery. Section of the brain showed nothing -abnormal except a small area among the pyramidal fibres -of the right side of the pons, where there was a single hemorrhagic -area about 7 mm. in diameter around which there -were small punctiform hemorrhages. (Compare twitchings -of left leg and arm upon stimulation of left leg, and note -also the muscular twitchings and slight spasticity of right -leg and arm noted just before death.) This case was examined -and reported upon in 1905. We learn from Dr. Barrett -that a re-study of the case with modern methods has failed -to demonstrate a spirochetosis.</p> - -<p class='c007'>The meninges show infiltration and destructive and proliferative -changes of the blood vessels. Condensed extracts -from Dr. Barrett’s full report follow:</p> - -<p class='c015'>There were local variations in the severity of the -meningitis. The sulci showed the most marked infiltration. -The slighter degrees of exudation were -made up largely of lymphocytes with a few plasma -cells, occasionally large mononuclear cells, and rarely -<span class='pageno' id='Page_220'>220</span>a polymorphonuclear leukocyte. Where the exudation -was more extensive, the large mononuclear cells became -more common and the polymorphonuclear leukocytes -increased in number. The large mononuclear cells were -often phagocytic, containing from one to six leukocytes. -The exudate was always most abundant about the -blood vessels. The plasma cells were always most -numerous in the adventitia of the veins, here greatly -outnumbering the leukocytes. The polymorphonuclear -leukocytes were relatively infrequent except where there -were necrotic areas, which areas were usually continuous -with an infiltration of a vessel wall.</p> - -<p class='c015'>As to vascular changes, the media was not often -involved, nor was the adventitia so often affected as the -intima. Such lesions as appeared in the intima and -adventitia were infiltrative rather than proliferative. -The elastica of the blood vessels proved to show but -slight changes.</p> - -<p class='c015'>A characteristic change was the endarteritis,—of a -focal nature with a few large mononuclear and lymphocytic -cells pushing the intima inward at the edge of a -lesion. In the more marked portion of the focal process, -the thickness of the intima was greatly increased by -proliferation. Great numbers of large mononuclear -cells could be seen between the intima and the elastica. -About these cells and interlacing among the other -elements of the proliferating tissue was an excess of -connective tissue fibres.</p> - -<p class='c015'>The meningeal veins were more often diseased than -the arteries; there was adventitial infiltration with -lymphoid and plasma cells; sometimes the vein walls -had become necrotic and infiltrated with polymorphonuclear -leukocytes.</p> - -<p class='c015'>It will be remembered that the left Sylvian artery -was grossly thickened, and microscopic section of this -vessel showed a partial thrombosis.</p> - -<p class='c015'>The brain showed diffuse and focal changes. The -<em>diffuse</em> process was one of nerve cell degeneration and -proliferative changes in the neuroglia and blood vessels, -and no section of the many examined proved to be free -from such changes, although in the majority of instances, -these diffuse changes were slight. The cortical layers -showed more of these diffuse changes than did the -white substance. Barrett considered that the glial cell -changes were more delicate indicators of the cortical -changes than the nerve cell changes. He found rod -cells, satellitosis, superficial gliosis, and a large gamut -of changes in the neuroglia. There were two rather -characteristic nerve cell changes: a shrinkage change -going on to almost complete destruction, and a type of -cell swelling, also apparently proceeding to complete -destruction.</p> - -<div class='figcenter id001'> -<img src='images/i_220a.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>4. Arteritis of pia mater.</p> -</div> -</div> - -<div class='figcenter id001'> -<img src='images/i_220b.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>5. Focal vascular lesions.<br /><br />Case 57. Seven months from infection. “Disseminated syphilitic encephalitis,” Barrett. (Photographs by Barrett.)</p> -</div> -</div> - -<div class='figcenter id001'> -<img src='images/i_221.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Paretic neurosyphilis (“general paresis”)—cerebral atrophy, <em>without</em> meningitis. Therapeutics cannot hope to restore lost tissue.<br /><br />Duration. 3 years from beginning of well marked symptoms; 6 years from beginning of obvious symptoms; 12 years from a so-called “nervous prostration.”</p> -</div> -</div> - -<p class='c015'><span class='pageno' id='Page_221'>221</span>Among <em>focal</em> changes, there were four main types: -Areas of encephalitis, having the general appearance -of granulation tissue, areas of simple necrosis or softening, -apparently directly related to vascular changes -near by, hemorrhages, and certain foci regarded as -gummatous.</p> - -<p class='c015'>Save for pial infiltration and a few vascular changes, -there was very little change in the medulla and spinal -cord. There was a hypertrophic gliosis of the margin -of the medulla and cord throughout, and a focal lesion -of well marked gliosis at one point in the bulb. There -were no fibre degenerations in the medulla or cord, nor -were there any coarse fibre degenerations in the cortex -itself except in one locus, the left gyrus rectus. This -case is of peculiar value in showing to what extent -lesions may proceed in a period of six to eight months -after primary infection.</p> - -<p class='c007'>Of course the case is in one sense entirely atypical. The -lesions were not confined to the nervous system. Aside from -the maculo-papular eruption and ecchymosis of the skin, -there was a diffuse hemorrhage of the inner half of the conjunctiva -of the left eyeball, a small hemorrhagic focus in the -mitral valve, a caseous nodule, one cm. in diameter, in the -apex of the left lung whose tuberculous or syphilitic nature is -left in doubt; a broad milk-colored patch of thickening of -the capsule of the liver. It is to be noted that there were no -gross lesions of the aorta.</p> - -<div><span class='pageno' id='Page_222'>222</span></div> -<div class='box'> - -<p class='c013'><b>On the classical assumption that PARETIC NEUROSYPHILIS -(“general paresis”) is a fatal -disease, is there a disease PSEUDOPARETIC -NEUROSYPHILIS (“pseudoparesis”) which may -recover or pursue a long course like that of a case -of diffuse neurosyphilis (“cerebrospinal syphilis”)?</b></p> - -</div> - -<p class='c006'><b>Case 58.</b> Peter Burkhardt had been an efficient highway -inspector, but in his forty-fifth year he had begun to be unable -to do his work satisfactorily. His wife had become somewhat -afraid of him. He had had somnolent spells in his chair and -had squandered money. The mental symptoms had lasted -for some six months, but had become more marked during -the month preceding admission. Burkhardt would at times -fail to recognize his friends.</p> - -<p class='c007'>The general <b>physical condition</b> of Burkhardt was very good. -The pupils were irregular and reacted sluggishly both to light -and to accommodation. The knee-jerks and ankle-jerks were -absent. There were no other neurological disorders upon -systematic examination. There was a speech defect. <b>Mentally</b>, -little could be determined except a certain sluggishness.</p> - -<p class='c007'>History and physical examination at once suggested general -paresis. The serum W. R. was doubtful, but the spinal -fluid reaction was positive, as was the gold sol reaction (which -was “paretic”); the globulin and albumin were greatly -increased; there were 48 cells per cmm. Antisyphilitic -treatment, consisting of salvarsan twice a week and potassium -iodid by mouth, was followed by a rapid mental improvement. -After two months, Burkhardt was discharged apparently -normal, with all the blood and spinal fluid tests negative. -He has been taken back into the highway service.</p> - -<p class='c027'>1. What is the proper definition of pseudoparesis? Fournier -termed pseudoparesis certain cases that looked like -paresis but were not syphilitic in origin. Of these -cases the most characteristic group is that of alcoholic -pseudoparesis. It is clear that there will be no difficulty -<span class='pageno' id='Page_223'>223</span>in the definition of a disease pseudoparesis whose -entity is presented in the adjective that precedes the -term (<i><span lang="la" xml:lang="la">e.g.</span></i>, alcoholic pseudoparesis). According to this -usage, a case of pseudoparesis would be one in which the -symptoms and possibly some of the signs somewhat -resemble the symptoms of paresis itself but for which -another etiology could be fairly established.</p> - -<p class='c027'>2. Are there any cases of syphilitic pseudoparesis? We are -of the opinion that the term should be dropped. It is -true that there are cases which clinically look like general -paresis and exhibit the appropriate laboratory signs -of general paresis but seem to differ from paresis in their -course even when they receive no treatment whatever. -In the present phase of doubt as to the classification of -paretic and non-paretic forms of neurosyphilis, it seems -to us of doubtful utility to characterize a case as pseudo -simply because it differs in its course, particularly as -the literature has always duly recognized that a number -of cases of general paresis have had long courses and -sometimes very long remissions.</p> - -<p class='c028'>There is also another group of cases that have been -termed cases of pseudoparesis, namely: certain cases of -neurosyphilis which clinically look like general paresis -and seem to be following its classical course but are -interrupted by treatment. Here again it seems to us -doubtful whether the designation pseudo should be -attached to this group of cases, particularly while the -whole therapeutic question in the paretic group of neurosyphilis -cases remains <i><span lang="la" xml:lang="la">sub judice</span></i>. Accordingly we are -tempted to include in the group of paretic neurosyphilis -cases that either get well of themselves, or get well under -treatment, or pursue a very long course, or are subject -to very long remissions. But we make this decision in -terminology without prejudice to the therapeutic question -and it is open to any critic to throw these cases into -an atypical non-paretic group of neurosyphilis cases.</p> - -<p class='c027'>3. How shall we explain the absence of ataxia of case Burkhardt -when knee-jerks are absent and when, therefore, -we are entitled to conclude a certain degree of spinal -disease? As stated in connection with case Sullivan -(16), the absence of knee-jerks is not a warrant for -terming a case—paresis of the tabetic form. The fact -is that the lesion in paresis tends to be intraspinal, -just as the higher brain lesions tend to occur within the -brain substance. The meninges are relatively spared -both within the cranium and within the spinal canal. -<span class='pageno' id='Page_224'>224</span>The characteristic degeneration of posterior nerve -roots which we find in tabes dorsalis is not necessarily -found in general paresis even when there are somewhat -extensive spinal lesions. Accordingly the absence of -sensory returns by way of the posterior nerve roots -which characterizes tabes dorsalis is not necessarily a -phenomenon of general paresis. The mechanism by -which the knee-jerks are lost depends upon histological -detail. They may be lost when under tabetic -conditions the posterior roots are severely diseased -and when under paretic conditions only intraspinal -collaterals or a small portion of fibres are affected. -The whole question hinges upon where and to what -degree the various reflex arcs are cut in the disease. -The tabetic phenomena are, as so commonly stated, -intradural; that is, the sensory or gangliospinal neurones -at certain levels are affected all the way in from the -points at which they pierce the dura mater. The affection -of these and other neurones in general paresis is -an intraspinal and parenchymatous affection.</p> - -<div><span class='pageno' id='Page_225'>225</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis; auditory hallucinations; ideas of -persecution; attacks of excitement. SYPHILITIC -PARANOIA (Kraepelin)?</b></p> - -</div> - -<p class='c006'><b>Case 59.</b> Bridget Curley was a case that was discharged -from the Psychopathic Hospital, recovered, after 26 days in -hospital. The symptoms so resembled those of alcoholic -hallucinosis that the diagnosis was made despite the fact that -the patient consistently denied the use of intoxicants. There -was, in fact, no proof that she drank alcohol. The case was, -however, not clearly one of alcoholic hallucinosis or of any -other well-defined form of mental disease. A provisional -diagnosis of manic-depressive psychosis, manic phase, had, in -fact, also been made.</p> - -<p class='c007'>The illness had begun with depression and inactivity, -Bridget’s friends accounted for these conditions on the ground -that a lover had departed for Ireland. A few days after the -depression began, Bridget became dizzy and refused to give a -boarder his breakfast, stating that she had lost her memory -and had begun to hear bells ringing and people talking. She -then became greatly excited and was brought to hospital, -where the prolonged baths quieted her.</p> - -<p class='c007'>It seems that Bridget had had stomach trouble and headaches -at the top of her head or sometimes in her temples. -<b>Physical examination</b> showed the left pupil to be larger than -the right, a slight tremor of the lips, a slight systolic murmur -at the apex, slightly irregular pulse, and moderate edema of -ankles. The blood serum was negative to the W. R., but -lumbar puncture was executed and the fluid showed a positive -W. R.</p> - -<p class='c007'>The patient was tested by the Binet and other methods, -and although 35 years of age, seemed to be by the mental -tests hardly over 11 years old. She was inclined to be feverish, -somewhat restive, and pugnacious; rather slow of -speech, sometimes refusing to answer and grimacing. Her -pugnacity was, however, easily controllable, and the excitement -<span class='pageno' id='Page_226'>226</span>was largely at night. This excitement subsided rapidly -in the course of a few days.</p> - -<p class='c027'>1. What is the diagnosis in this case? The following diagnoses -and suggestions for diagnosis were made at the -staff meetings:</p> - -<ul class='index c045'> - <li class='c046'>Unclassified mania.</li> - <li class='c046'>Manic-depressive psychosis, manic phase.</li> - <li class='c046'>Toxic delirium.</li> - <li class='c046'>Dementia praecox.</li> - <li class='c046'>Bacterial infection of the brain.</li> - <li class='c046'>Unclassified delirium.</li> - <li class='c046'>Acute delirium.</li> - <li class='c046'>Infectious psychosis.</li> - <li class='c046'>Acute confusional psychosis.</li> - <li class='c046'>Psychopathic personality by use of alcohol.</li> - <li class='c046'>Mental deficiency with atypical mental state.</li> - <li class='c046'>Syphilitic paranoia.</li> -</ul> - -<p class='c027'>2. Is this a case of syphilitic paranoia? The so-called syphilitic -paranoia of Kraepelin is a rare and uncertain type -of syphilitic mental disease. Delusions and hallucinations -are prominent. As a rule, the onset is stated -to be slow and insidious, or at any rate there are a -variety of indefinite prodromata. Jealousy is a prominent -feature, sometimes attended with marked sexual -excitement. Auditory hallucinations and ideas of -persecution are particularly in evidence. The most -striking feature in Kraepelin’s group was a sudden occurrence -and equally sudden disappearance of violent -excitement, with or without external cause. Thus, -an excitement would be produced by a few words -spoken, and immediately after, the phase of excitement -would pass and the patient would become entirely -friendly and accessible once more, as if nothing had -happened. About half of Kraepelin’s cases showed a -positive serum W. R. He does not report lumbar -puncture findings, and grounds the existence of disease -upon certain autopsied cases. The speech and writing -disorder of paresis as well as the characteristic disorientation -for time and muscular weakness of general -paresis were absent in the group. It appears that -most cases of the group have hitherto been placed in -dementia praecox.</p> - -<div><span class='pageno' id='Page_227'>227</span></div> -<div class='box'> - -<p class='c013'><b>The clinical symptoms of CHRONIC ALCOHOLISM -are sometimes largely identical with those of -PARETIC NEUROSYPHILIS (“general paresis”): -differentiation by means of the laboratory findings.</b></p> - -</div> - -<p class='c007'>To demonstrate this proposition, the cases of Francis -Murphy (60) and David Collins (61) are in point, being -sharp foils to one another.</p> - -<p class='c006'><b>Case 60.</b> A laboring man about 44 years of age was brought -to the Psychopathic Hospital one summer day, in a stupor. -This patient, Francis Murphy, had been at his regular work -as axeman in the Park Service, when he suddenly fell in a -heavy convulsion. He was carried to a general hospital, -still in convulsions, and ether was administered to quiet -the movements. The convulsions shortly ceased, but the -patient’s consciousness failed to clear; hence his transfer to -the Psychopathic Hospital.</p> - -<p class='c007'>Here he remained much disturbed and was placed in a room -with a mattress on the floor. On this mattress he would -crouch on all fours for a considerable time, looking fixedly -downward as if at an object on the floor, unresponsive to -questions but compliant with efforts to place him on his back. -He gave the impression of daze and either disorientation or -confusion.</p> - -<p class='c007'>Within twenty-four hours the patient became more tranquil -and consciousness became clearer, but the patient was at -a loss to bring to memory either recent or remote events. -However, he replied to questions, giving some different story -each time he was approached. Curiously enough, the patient -seemed very contented and good-natured and would even -laugh foolishly at times, saying that he felt fine and all -ready to go out to work.</p> - -<p class='c007'>The general impression conveyed by Francis Murphy at -once suggested the possibility of neurosyphilis. Convulsions, -perhaps initial in middle age, with a post-convulsive -<span class='pageno' id='Page_228'>228</span>stupor, followed by a partial clearing up, with persistent -amnesia and a suggestion of fabrications with euphoria, bore -out the suggestion.</p> - -<p class='c007'>The <b>physical examination</b> strengthened the impression -of neurosyphilis. Well developed and nourished, florid, with -a manual tremor and sweating of the palms, the patient -was in general without physical symptoms. <b>Neurologically</b>, -however, whereas the left pupil was larger than the right and -reacted properly to light, the right pupil was a bit contracted, -somewhat irregular, and either reacted not at all to light or -very slightly so (reacting perfectly to accommodation). The -knee-jerks could be obtained only with reinforcement, and -several other reflexes could not be elicited (triceps, radial, -ulnar, periosteal, Achilles, umbilical). Moreover, the heel-to-knee -test was poorly performed; some of the common tests -phrases were very poorly repeated; there was marked tremor -in writing; and the paragraphia seemed to be not merely -peripheral, for syllables were left out in words and ordinary -words spelled incorrectly (psychographic disturbance).</p> - -<p class='c007'>We do not care here to insist that the right pupil was really -an example of the Argyll-Robertson phenomenon since the -slightest tinge of doubt is important if a positive diagnosis -is practically equivalent to asserting syphilis. Practically, -however, the right pupil was regarded as an Argyll-Robertson -pupil under hospital conditions (flash-light reaction). Argyll-Robertson -pupil, areflexia, speech disorder, writing disorder, -memory disorder, conduct disorder, and euphoria, all with a -history of convulsions, certainly warranted the tentative diagnosis -of neurosyphilis.</p> - -<p class='c007'>As usual, resort was made to the W. R. in the serum and in -the spinal fluid. One of the first results to come through -from the laboratory was the absence of globulin, normal -albumin, negative gold sol reaction, and a cell count of two -cells per cmm. in the spinal fluid. Later the <em>W. R.’s</em> were -returned <em>negative</em> for blood and spinal fluid.</p> - -<p class='c007'>In the meantime, an illuminating change had occurred in -the patient, for two days later,—three days after the first -convulsion in the park,—the patient had apparently quite -recovered; his consciousness became nearly clear; he could -<span class='pageno' id='Page_229'>229</span>remember every event up to the time of the convulsion, and -his memory came back in appropriate degree for both remote -and recent events.</p> - -<p class='c007'>The patient, it appeared, had for some time been drinking -more and more heavily. In recent days, he had been taking -five or six whiskeys and a half dozen beers daily on the -average, and often much more. About ten years before, the -patient narrated, there had been a convulsion at a ballgame, -and this convulsion the patient himself called a “rum fit.”</p> - -<p class='c007'>Here, then, is a case of <span class='sc'>Alcoholic Pseudoparesis</span>. Without -the W. serum test and without the spinal fluid examination, -it is probable that the diagnosis of general paresis might -have clung to the patient for some time on account of the -apparent Argyll-Robertson pupil, which had to be accepted -as such on the flash-light data. In point of fact, in this case -the pupil later reacted more normally to light, and the speech -and writing disorders measurably cleared up.</p> - -<p class='c027'>1. Can alcohol produce the Argyll-Robertson pupil? The -majority of neurologists would today answer, Yes.</p> - -<p class='c027'>2. If in the case of Francis Murphy, the W. R. in the blood -had happened to be positive on account of a non-neural -syphilitic infection (spinal fluid negative), would the -diagnosis <em>general paresis</em> be warranted? Probably the -diagnosis <em>general paresis</em> would have been made. If -the patient had been lost to observation, he might -well have been regarded as an atypical paretic with -prodromal convulsions.</p> - -<p class='c027'>3. Would positive globulin and excess albumin in the spinal -fluid alone or in association with a positive serum W. R. -warrant the diagnosis <em>general paresis</em> or <em>neurosyphilis</em>? -The chances are that most neurologists would advocate -proceeding to treatment in any case of positive serum -reaction, whether or not there was globulin or excess -albumin; but the positive globulin and excess albumin -would probably not warrant the diagnosis <em>general -paresis</em> or <em>neurosyphilis</em> in the absence of excess cells -and the characteristic gold sol reaction and W. R. in -the fluid.</p> - -<p class='c027'>4. Is the case of Francis Murphy one of alcoholic epilepsy -(as suggested by Murphy’s own phrase, “rum fits”)? -It must be remembered that epileptics become alcoholic -and that epileptic convulsions increase or become -<span class='pageno' id='Page_230'>230</span>more severe with alcoholism. On the other hand, the -literature indicates that alcoholism can produce convulsions, -as can many other factors. The literature -also indicates that there is a condition of epilepsy in -which the convulsive tendency sets in as a result of -alcoholism in a patient not previously disposed to epilepsy; -it appears also that sometimes, though very -rarely, the epilepsy continues after withdrawal of alcohol, -and even after giving up the habit. Francis Murphy -appears to have had but two spells of convulsions, both -of them following heavy bouts with alcohol. There is -so far, then, no warrant for calling Francis Murphy’s -case one of alcoholic epilepsy.</p> - -<p class='c027'>5. Does the use of alcohol by a subject destroy the value -of the W.R.? It has been held by some that alcoholism -interferes with the accuracy of the W. R. This -has not been our experience and for the present we -are of opinion that the results have the same value -in alcoholics as in non-alcoholics. The next case -(Collins, 61) is one in which a positive W. R. occurred -in an alcoholic. When dealing with paretic neurosyphilis -it is especially true that the W. R. is disturbed -very rarely, if at all, by toxins or drugs, except antisyphilitic -drugs.</p> - -<div><span class='pageno' id='Page_231'>231</span></div> -<div class='box'> - -<p class='c013'><b>Alcoholism may cloud the diagnosis of NEUROSYPHILIS. -Differentiation by laboratory tests.</b></p> - -</div> - -<p class='c006'><b>Case 61.</b> David Collins was a steamfitter of about 43 -years of age, picked up at 6.45 a.m. in the midst of convulsions -and talking incoherently, in a state apparently of fairly clear -consciousness. On arrival at the hospital, the patient was -able to tell how he had always been a hard drinker, and how -during the past week of unemployment he had taken large -quantities of poor whiskey,—perhaps an average of a pint a -day. Collins also told how he had had delirium tremens several -times, but he said the present spell was quite unlike delirium -tremens. There was no disorientation or impairment of -memory, and the patient did not in any wise suggest a mental -case a few hours after admission.</p> - -<p class='c007'>It appears, according to Collins, that he had obtained some -work the night before, and had quit work about 6.30, whereupon -he stepped into a barroom, took one drink of whiskey, -left the barroom, walked down the street, and suddenly lost -track of the world, coming to consciousness in a carriage with -two policemen, but remaining, as he said, “dopy,” inattentive, -and confused. After a meal, however, the patient began -to feel better and soon felt quite all right.</p> - -<p class='c007'>The <b>physical examination</b> was quite negative except that -<b>neurologically</b> there was lingual and manual tremor, a speech -defect, apparent only with test phrases, unsteadiness of handwriting, -left knee-jerk greater than right, a left-sided Babinski -reflex, and a difficulty in executing rapid successive movements -(dysdiadochokinesis). This degree of neurological disorder -in our experience warrants lumbar puncture as well as a -serum test. The lumbar puncture shortly disclosed a positive -globulin and excess albumin, and the returns from the W. R.’s -were positive for both spinal fluid and blood serum. The -data of the gold sol reaction were not available on account of -technical difficulties. However, it appears that the diagnosis -of neurosyphilis could hardly be avoided in this case.</p> - -<p class='c007'><span class='pageno' id='Page_232'>232</span>David Collins differs from Francis Murphy, then, in showing -a positive blood and spinal fluid reaction for syphilis as -well as a positive globulin and excess albumin. As above -remarked, it is probable that the positive globulin and excess -albumin would not warrant more than a suspicion of neurosyphilis -taken by themselves.</p> - -<p class='c007'>Unfortunately, we were unable to persuade the patient to -submit to treatment, and from the patient’s point of view -possibly his decision, not to submit to treatment, was a good -one since he has had no symptoms of any sort for a period of 18 -months since his episode. However, as abundantly elsewhere -demonstrated, we feel that the patient is wrong, and -that the physicians are right in urging treatment.</p> - -<p class='c027'>1. Is not the convulsive episode an alcoholic phenomenon -in David Collins entirely separate from the patient’s -general and neurosyphilis? Possibly; however, an -outbreak of neurological symptoms with spontaneous -recovery is not only consistent with the diagnosis of -syphilis, but somewhat characteristic of neurosyphilis. -We suspect that another attack will occur in David -Collins.<a id='r12' /><a href='#f12' class='c014'><sup>[12]</sup></a> We shall from time to time make use of the -social service to suggest his going under treatment, and -shall employ his record of contact with a public institution -to drive in our suggestion. Still it is clear that -there are numerous cases in the community that are -not accessible to social service initiated from a public -institution. Accordingly, educational propaganda is -necessary for salvage of the middle- and upper-class -victims of syphilis. It is a little unfortunate that the -ethics of the private practitioner make such salvage of -middle- and upper-class persons not very likely. Might -it not be that an extension of state medicine to this -field would incidentally increase the amount of successful -private practice?</p> - -<p class='c027'>2. What may be the cause of such a convulsive episode as -that of David Collins? It would appear that the convulsions -of general paresis and of neurosyphilis in general -often occur without gross structural lesions of the -brain. It may be suggested that vascular irritation or -<span class='pageno' id='Page_233'>233</span>parenchymal irritation by spirochetes, acting in appropriate -parts of the central nervous system, can produce -such convulsions.</p> - -<p class='c027'>3. What is the significance of the unilateral phenomenon in -David Collins (left knee-jerk greater than right; left-sided -Babinski)? The current explanation of hyperreflexia -is that somehow inhibitory impulses from upper -portions of the nervous system have ceased to influence -the local arcs that mechanize reactions like the knee-jerk -and the normal plantar reflex. The phenomena are -commonly found in cases with pyramidal tract disorder, -and in the case of David Collins one may suspect, therefore, -that there was a central disorder affecting the right -pyramidal tract above its decussation. One might -suspect that the convulsions were initiated by a lesion -(whether gross or microscopic in range) in the right -side of the cerebrum; but whether in the white matter -or in the gray matter must be left doubtful. The -clearing up of all symptoms suggests either that the -lesion was microscopic in range or that the phenomena -were transient and functional.</p> - -<p class='c027'>4. Can the dysdiadochokinesis be used to indicate cerebellar -lesion in David Collins? Possibly; but it does not -appear that the difficulty in executing successive movements -was unilateral. It seems impossible to bring -into close topographical relation the basis for the -Babinski and left-sided hyperreflexia, and the basis for -the dysdiadochokinesis. Alcohol is sometimes asserted -to exert an especial effect upon the cerebellum.</p> - -<p class='c027'>5. Must we suppose structural lesions, either (a) of the -nature of cell losses demonstrable microscopically, or -(b) of the nature of secondary degenerations demonstrable -by Weigert myelin sheath methods, in the case -of David Collins? It appears that we do not need to -assert the existence of such lesions.</p> - -<p class='c027'>6. Could the hyperreflexia and the Babinski reaction be due -to local spinal cord disease? Possibly; but the existence -of other neurological symptoms (lingual and manual -tremor, speech defect to test phrases, ataxic handwriting, -and dysdiadochokinesis) makes it probable -that there were lesions, or at any rate disordered functions, -within the cranium; and there appears to be no -basis for asserting local spinal cord disease.</p> - -<div><span class='pageno' id='Page_234'>234</span></div> -<div class='box'> - -<p class='c013'><b>Differential diagnosis between NEUROSYPHILIS -and ACUTE ALCOHOLIC PSYCHOSIS.</b></p> - -</div> - -<p class='c006'><b>Case 62.</b> Joseph Buck was a chef of 60 years who came in, -seeking advice because his memory was getting poor; he -was unable to remember names and what he was about to do. -He was tremulous and had much pain in his limbs. He had -been drinking heavily for weeks,—probably ten weeks; -in fact, he described himself as having had “the shakes” -and as having lately seen animals and people that were unreal. -He had had the shakes before and the condition had lasted -for two to three days after alcohol was discontinued.</p> - -<p class='c007'><b>Physically</b>, Buck was tall, well developed, although poorly -nourished, with a skin suggesting alcoholism. There was -a slight acne over the back and chest; there was a slight -enlargement of the heart, with blood pressure, systolic, 180, -diastolic, 120. There was a corneal opacity of the left eye, -which the patient said was the result of syphilis following a -chancre, which he had acquired at the age of 27. There -was also a ptosis of the upper lid of the left eye. The right -pupil was irregular and reacted to light sluggishly, and with -a very small excursion. The patient was slightly deaf in -both ears. The deep reflexes were all lively and equal. The -tremor was most marked in finely coördinated movements. -There was a slight swaying in the Romberg position but the -sign could not be said to be present. The gait was unsteady. -There was a marked tenderness over the nerve trunks.</p> - -<p class='c007'>So far as <b>mental examination</b> went, it seemed that the -patient’s claim of amnesia was subjective. There was certainly -no more amnesia than a slight difficulty in recalling -details. The diagnosis of alcoholism with convalescence -from delirium tremens would certainly seem to have been -sufficient for the phenomena, and the suggestion of alcoholic -neuritis only confirmed the picture. To be sure, one might -expect a diminution or absence of deep reflexes; still, these reflexes -may be overactive in an irritative stage of the disease.</p> - -<p class='c007'><span class='pageno' id='Page_235'>235</span>Naturally, however, the history of syphilis and the pupillary -phenomena and ptosis, made the consideration of neurosyphilis -necessary. Both serum and fluid W. R.’s proved -positive; there was an excessive amount of albumin and -globulin, the gold sol reaction was typically “paretic,” and -there were 377 cells per cmm.</p> - -<p class='c007'>The patient improved upon a rest treatment and was -given injections of mercury for his syphilis. After a few -months he felt well enough to return to work, and continued -at work throughout a season, receiving mercurial treatment -throughout this time. A spinal fluid examination fifteen -months later showed a weaker gold sol reaction, reduction -in the amount of globulin and albumin, and but 26 cells to -the cmm. The W. R.’s had remained positive.</p> - -<p class='c027'>1. What are the forms of syphilitic neuritis? According to -Nonne, syphilitic neuritis and polyneuritis have at -last acquired standing in neuropathology. The older -claims depended upon findings on palpation and recovery -after antisyphilitic treatment. Since the introduction -of salvarsan, cases of ophthalmoplegia, -facial, acoustic, and optic nerve disease, as well as -neuritis of the extremities, have been reported in large -numbers. These phenomena are to be regarded as -neurorecidives in the modern sense of that term. The -neurorecidive is not a salvarsan effect, but is an effect -of the syphilitic process itself, settling in the peripheral -nerves. Paresthesias are especially prominent in peripheral -mono- or polyneuritis, and this point is of some -value in differentiating the syphilitic peripheral neuritis -from root neuritis. Root neuritis is more often characterized -by neuralgic attacks. Objective hyperæsthesia -of neuromuscular origin is also found in these cases, -demonstrated by pressure on the nerves. The motor -phenomena consist in a flaccid paresis or paralysis, -especially affecting the radial, ulnar, and peroneal -nerves. Nonne states that it is rare for syphilis to -affect a single nerve region, and he regards cases in -which a single region alone is affected as usually due to -a local gummatous process.</p> - -<p class='c027'>2. What is the significance of 377 cells per cmm.? See -discussion of Washington (Case 66).</p> - -<div><span class='pageno' id='Page_236'>236</span></div> -<div class='box'> - -<p class='c013'><b>Differential diagnosis between NEUROSYPHILIS -and CHRONIC ALCOHOLISM.</b></p> - -</div> - -<p class='c006'><b>Case 63.</b> Albert Fielding, 46, was an insurance broker, -who was brought to the hospital for excessive alcoholism. -Indeed, he showed all the signs, both of chronic and acute -intoxication, except that there was no nerve trunk tenderness. -Fielding was very loquacious though his speech was rather -thick. He showed tremor of hands and an alcoholic skin. -Physical and neurological examination proved entirely negative.</p> - -<p class='c007'>Fielding claimed that he had had a nervous breakdown at -about 36 years of age, after disappointment in love. He had -the drinking habit and began to drink more and more. He -had now become nervous and tremulous and had to drink in -order to brace himself. After a few days, the patient began -to be much better, having recovered from acute alcoholism. -<b>Mental examination</b> now showed good memory with orientation -intact. There was a certain tendency to reminiscence -and to somewhat childish actions. He had attempted to stop -drinking but had been unable to quit. As a matter of fact, -his mother and father had been excessive drinkers and he had -inherited the tendency, etc.</p> - -<p class='c007'>The <b>diagnosis</b> seemed to be plain. The routine W. R. -upon the blood serum was negative. However, the patient -had remarked during the history taking, that he had had a -chancre and secondary symptoms of syphilis. Accordingly, -lumbar puncture was resorted to. The fluid showed a slightly -positive W. R.; the gold sol reaction was of the syphilitic -type; there was a considerable increase in albumin and -globulin, and there were 20 cells per cmm. The diagnosis -of neurosyphilis seemed clear.</p> - -<p class='c007'><b>Course</b>: The patient received six months’ treatment in a -sanatorium but the symptoms remained almost as before, -and the patient showed the same childishness and inability -to take care of himself. Since the symptoms continued six -<span class='pageno' id='Page_237'>237</span>months after the withdrawal of alcohol, it might well be -suspected that the condition was more than a merely alcoholic -one. However, in a number of purely alcoholic cases, -such long-standing effects are found: even as long as six -months or longer after the withdrawal of the alcohol, and one -might conclude therefore that Fielding was actually a victim -of alcoholic dementia. The spinal fluid after these six months -(during which period antisyphilitic treatment was given) -showed no change, and the prognosis was offered that the -case would probably develop into one of paresis.</p> - -<p class='c007'>A year later, after six months sanatorial care and six -months life in the community, the patient returned to the -Psychopathic Hospital in an alcoholic condition. The lumbar -puncture showed all signs negative except the W. R. which -was slightly positive. The W. R. of the blood was negative.</p> - -<p class='c007'>In connection with this case, see the case of <em>paresis sine -paresi</em> (25).</p> - -<p class='c027'>1. What is the relation of the syphilitic and alcoholic process -in Robert Fielding? One does not like to break the -so-called rule of parsimony in diagnosis, but it would -seem that the effects in Fielding are the combined -effects of syphilis and alcoholism.</p> - -<div><span class='pageno' id='Page_238'>238</span></div> -<div class='box'> - -<p class='c013'><b>Differential diagnosis between NEUROSYPHILIS, -DIABETIC PSEUDOPARESIS and BRAIN -TUMOR.</b></p> - -</div> - -<p class='c006'><b>Case 64.</b> A large and imposing person, Calvin Hall, 55, -had been employed as a doorkeeper and guard, in which -position he was on duty for 12 to 14 hours daily. Eventually, -however, he had begun to have a good deal of pain in the legs -and a few months before observation, one day, his legs gave -way and he fell to the floor. There was, however, no loss of -consciousness, and he was carried to a general hospital. The -result of an examination there was that his family was informed -that he had some nervous trouble.</p> - -<p class='c007'>Hall now began to be melancholy and wept a good deal. -His appetite and sleep remained intact. He felt too weak to -walk. At the end of about a year, he began to improve and -again became able to do a little light work. About a month -before coming to the Psychopathic Hospital, about two years -after the onset of symptoms, Hall suddenly began to talk -excessively, in a rambling and rather senseless way. A fortnight -later, he began to suffer from insomnia and restlessness.</p> - -<p class='c007'>Some medical facts were available: It seems that at 25 -years this patient had become infected with syphilis though -there had never been any secondary signs. He was married -four years later but there had not been any children. Moreover, -for four years past, the patient had been treated for -glycosuria.</p> - -<p class='c007'>Upon admission, the patient’s sensorium was clear, but -his orientation was only partial. He could give a fair account -of his life, but it appeared that his memory was somewhat -impaired. There were auditory hallucinations (voices of -relatives). He often mistook the identity of persons about -him. He talked in a grandiose fashion of his great strength -and especially of a God-given power to read minds. His -flow of thought was rapid, rambling, circumstantial, and with -traces of irrelevance. He was rather continuously busy and -<span class='pageno' id='Page_239'>239</span>at times restive. There was a good deal of emotional agitation -and apprehensiveness, and again the patient would -become suspicious and tearful.</p> - -<p class='c007'><b>Physically</b>, there was a discharging sinus connected with -the right humerus, close to the elbow. The pupils, though -equal and regular, were sluggish in reaction to light. The -knee-jerks and ankle-jerks were absent. There was no Romberg -sign but there was some swaying in the Romberg position. -There was a moderate ataxia in walking. Glycosuria to a -moderate degree was determined. There were no casts or -albumin in the urine. The W. R. of the blood and of the -spinal fluid was negative. The albumin of the fluid, however, -was considerably increased. X-ray examination of the skull -yielded a suggestion of absorption of the posterior clinoid -processes of the sella turcica. The X-ray examination of -the arm in the region of the sinus showed a chronic osteomyelitis, -possibly syphilitic (or diabetic?).</p> - -<p class='c007'>The diagnostic problems in the case of Calvin Hall are -extremely intricate. There are clinical suggestions of general -paresis, not confirmed by the laboratory findings.</p> - -<p class='c027'>1. Are we dealing with a case of diabetic pseudoparesis? -Is the pain in the legs of like origin, and has a neuritic -process led to the absence of the knee-jerks? The -Allen treatment appears to have had no beneficial -result in this case.</p> - -<p class='c027'>2. Is there a tumor of the sella region, which could account -for the mental symptoms and the glycosuria? The -spinal fluid albumin might be regarded as consistent -with a variety of psychoses, including that of brain -tumor. We have to remember the definite history of -infection, the sterile marriage and the possibly syphilitic -osteomyelitis.</p> - -<div><span class='pageno' id='Page_240'>240</span></div> -<div class='box'> - -<p class='c013'><b>DIABETES AND NEUROSYPHILIS, relations?</b></p> - -</div> - -<p class='c006'><b>Case 65.</b> Donald Barrie, a man of 61, diabetic for several -years, had begun to worry about the diabetes, feeling that -he was about to die, and had gone so far as to make several -threats of suicide. Hence he was brought to the Psychopathic -Hospital for observation.</p> - -<p class='c007'>Barrie was rather well developed and nourished, although -he looked far older than he was. There was a marked arcus -senilis; the skin was dry and rough; the radial and other -accessible vessels were markedly sclerosed; abdomen obese; -right testicle very low with thickened and hard epididymis.</p> - -<p class='c007'><b>Neurologically</b> there was little abnormal to discover. The -pupils were irregular; both reacted fairly well to light. -There was a slight tremor of the extended hands, and still -less of the tongue. The voice was slightly thick and the -patient stumbled somewhat on test phrases. Urine: specific -gravity, 1029; sugar; no acetone; no diacetic acid. Sugar 2 -to 11 grams for 24 hours on ordinary diet. It proved impossible -to get the patient sugar-free, either by cutting down -the carbohydrates or by using the Allen method.</p> - -<p class='c007'><b>Mentally</b>, the depression with reiteration of wrong-doing -and self-accusation because of the contraction of syphilis, -were the striking features. There was, to be sure, a slight -imperfection of memory for remote events; memory for recent -events and knowledge of current events was very poor. -Barrie claimed that his condition was entirely hopeless, that -his memory was exceedingly bad, and that he was no longer -capable of supporting his family.</p> - -<p class='c027'>1. What shall be said as to diagnosis in a man of 61 with -glycosuria, depression, amnesia, sluggish pupil, slight -tremor, slight speech defect, and a history of syphilis? -The W. R. of the serum proved positive, and also the -W. R. of the spinal fluid. The gold sol reaction of the -fluid was of the syphilitic type. There were 112 cells -<span class='pageno' id='Page_241'>241</span>per cmm., there was an excess of albumin, and a large -amount of globulin. Accordingly, the diagnosis of -<span class='fss'>PARETIC NEUROSYPHILIS</span> (“general paresis”), especially -in view of the laboratory findings, seems necessary.</p> - -<p class='c027'>2. What is the cause of the glycosuria? First: possibly -it has no relation with the syphilis; secondly: it may -possibly be due to a syphilitic involvement of the pancreas; -thirdly: it is barely possible that it is due to -syphilitic disease of the fourth ventricle or of the base -of the brain, involving the pituitary region. Perhaps -our case is too complex for analysis. At all events, the -case brings up the possibility of a syphilitic glycosuria.</p> - -<p class='c027'>3. Can the diabetes in the case of Barrie be explained as -syphilitic? Warthin of Ann Arbor has recently described -somewhat remarkable spirochete findings in -his autopsy material. The order of organic infection -according to frequency is: aorta, heart, testis, adrenal, -pancreas, nervous system, liver, and spleen. Warthin -has called attention to the relation of pancreatitis and -spirochetosis to diabetes in a recent review<a id='r13' /><a href='#f13' class='c014'><sup>[13]</sup></a> of findings -in 41 autopsied cases from the University Hospital in -Michigan. Warthin found active luetic lesions in the -pancreas in 6 cases.</p> - -<div><span class='pageno' id='Page_242'>242</span></div> -<div class='box'> - -<p class='c013'><b>Hemianopsia in a case of neurosyphilis.</b></p> - -</div> - -<p class='c006'><b>Case 66.</b> Lawrence Washington, a colored cabman, 58 -years of age, began to forget addresses given him by his fares. -Moreover, he could no longer see as well as before, especially -on looking toward the right side. He himself states that the -visual trouble dated back as long ago as his 39th year, at -which time he had a terrific pain in both temples, leading -back from the eyes. Washington thought that his vision -had been getting slowly but steadily worse ever since.</p> - -<p class='c007'>We got the impression that the amnesia claimed by Washington -was more or less subjective and he was found to be -well informed. This association of amnesia and impairment -of vision naturally suggests syphilis. The patient himself -stated that he had had a chancre at the age of 18.</p> - -<p class='c007'>We found the W. R. of the serum to be appropriately positive. -The W. R. of the spinal fluid was also positive though -weakly so. There was an excess of albumin; globulin appeared -in large amount; the gold sol reaction was of the syphilitic -type; there were 186 cells in the spinal fluid.</p> - -<p class='c007'>Is this case one of paresis or of some other form of cerebrospinal -syphilis? Let us consider the data of the <b>physical -examination</b>. On the whole, the patient was well preserved. -There was a slight radial arteriosclerosis, but on the whole -the cardiovascular system was almost negative. The blood -pressure was 100 systolic, 65 diastolic. <b>Neurologically</b> the -visual field of the left eye was somewhat limited, and there -was a temporal hemianopsia of the right eye. The ophthalmoscopic -examination showed a disseminated choroiditis on -both sides. The right pupil failed to react to light. The left -pupil reacted slowly. Both pupils reacted properly to accommodation.</p> - -<p class='c007'>The knee-jerks could be obtained only on reinforcement, -and when obtained, the right was apparently more active -than the left. The left Achilles was absent; the right present. -There were no other abnormal reflexes.</p> - -<p class='c007'><span class='pageno' id='Page_243'>243</span>The motility of the facial muscles was somewhat impaired. -Finger-to-finger and finger-to-nose tests were rather poorly -done. The muscle sense was good; there was no swaying -in Romberg position; and there was no speech defect.</p> - -<p class='c007'>We are unable to decide whether the case is one of the -<b>parenchymatous</b> type (paretic) or of the <b>meningovascular</b> -type of <b>neurosyphilis</b>. It is certainly rather unusual to find -hemianopsia in a paretic.</p> - -<p class='c007'>We have been unable to get definite results from the treatment -of this case, since the patient would not return for -months after getting an injection or two of salvarsan, on the -ground that he was improved enough and did not require -further treatment.</p> - -<p class='c027'>1. What conclusion can be drawn from the 186 cells per cmm. -in the spinal fluid? Ordinarily this finding would -indicate an active process. Some writers have claimed -that a cell count running above 100 per cmm. was an -indicator of diffuse non-paretic neurosyphilis. It does -not appear that this claim has been substantiated. -It is remarkable that this case shows an interval of 40 -years between infection and the occurrence of definite -clinical symptoms. With respect to the cell count, -both in untreated and in treated cases, the following -conclusions from a recent article (Solomon and Koefod)<a id='r14' /><a href='#f14' class='c014'><sup>[14]</sup></a> -are in point:</p> - -<p class='c028'>1. The number of cells found in the fluid of untreated -cases offers no definite information of prognostic -value.</p> - -<p class='c028'>2. One is not justified in drawing any conclusions -as to whether the case is cerebrospinal syphilis -or general paresis, nor the time the process has been -active, nor the severity of it, from the cell count.</p> - -<p class='c028'>3. The cell count may vary greatly from month to -month, or when the interval is but several days, while -at other times it may remain very nearly the same -after an interval of months.</p> - -<p class='c028'>4. Cases showing natural remissions may show no -reduction in the cell count, or other spinal fluid findings.</p> - -<p class='c028'><span class='pageno' id='Page_244'>244</span>5. Cases treated with salvarsan, either intraspinously -or intravenously, tend to show a more or less -rapid fall in the cell count. This count will, as a rule, -remain low during treatment, but is likely to rise when -treatment has been discontinued, but may rise during -treatment after having first fallen.</p> - -<p class='c028'>6. Cases may show remissions during treatment -and still have a pleocytosis.</p> - -<p class='c028'>7. Treated cases having the cell count fall to normal -may at the same time become very much worse and -develop more marked paralytic symptoms.</p> - -<p class='c028'>8. In general paresis the cell count in no way parallels -the other spinal fluid findings.</p> - -<p class='c028'>9. In cases in which the other tests show an improvement, -for instance cerebrospinal syphilis, the cell -count also readily and early drops to normal. At times -it may drop to normal before other spinal fluid tests -become negative; again it may be last to reach normal.</p> - -<p class='c028'>10. The change in cell count seen in syphilitic -disease untreated is also found in non-syphilitic diseases, -as brain tumor.</p> - -<p class='c028'>11. The cell count offers nothing of prognostic -importance in syphilis of the nervous system unless accompanied -by improvement of the other laboratory -signs.</p> - -<p class='c028'>12. The cell count is not an index to the predominance -of irritative or degenerative changes.</p> - -<div><span class='pageno' id='Page_245'>245</span></div> -<div class='box'> - -<p class='c013'><b>Case of CEREBRAL MALARIA and SYPHILIS: -simulation of PARETIC NEUROSYPHILIS (“general -paresis”).</b></p> - -</div> - -<p class='c006'><b>Case 67.</b> Joseph Temple, 45, who had been a sea-going -steamboat steward, was brought to the hospital in a semi-stupor. -He was entirely uncoöperative, often resistive, attempting -to bite the physician’s fingers, and for the most -part lying curled up. He was incontinent and tube-fed. -This phase, it seems, had begun the night before entrance to -the hospital. Twenty-four hours later, an extraordinary -change was noted. Temple became alert and attended to his -wants, began to eat well, and began to behave as normally -as probably he ever behaved.</p> - -<p class='c007'>He was now able to give a coherent history. It was now -January. In the previous September, he had left for Mexico; -he was returning when he suddenly fell to the deck, unconscious. -After this fall, he had not been well, having had -chills and fever. At the Marine Hospital, he had been -diagnosed as suffering from malaria, and was given quinine. -He had been delirious a short time in the hospital, not being -able to recognize his wife, who called. He shortly improved -so that his wife was able to take him home. Nevertheless, -headache, gastric distress, and intermittent vomiting continued. -A spell of confusion took place, two days before -admission. The patient tossed about, moaned, and failed -to recognize anyone. Malaria of the æstivo-autumnal type -was demonstrated in the hospital. The temperature always -remained at normal. He was somewhat emaciated and pale. -The pupils were small, somewhat unequal, and reacted though -poorly to light and distance. The tendon reflexes were -lively.</p> - -<p class='c007'>The W. R. of the serum was positive, and information from -the patient’s physician runs to the effect that there was a -syphilitic infection some seven or eight years ago, followed -by secondary symptoms, but the patient had refused to take -<span class='pageno' id='Page_246'>246</span>any protracted treatment. The spinal fluid examination -was practically negative.</p> - -<p class='c007'><b>Mentally</b>, the patient was euphoric, expansive, boastful, -and showed a marked emotional instability and considerable -memory defect.</p> - -<p class='c027'>1. Can the diagnosis of general paresis be made in Joseph -Temple? Certainly the acute confusion and the syncope -are consistent enough with the diagnosis, yet the severe -malaria makes it seem likely that the phenomena were -due to a cerebral attack of malaria, and such occurrences -are found in the æstivo-autumnal form of malaria. -Yet malaria would hardly explain the euphoria, -memory defect, and the pupillary findings, to say nothing -of the irritability and the active tendon reflexes. -Even if we regard the active tendon reflexes and the -irritability as malarial, the other phenomena remain -outstanding as exceedingly suspicious of paresis.</p> - -<p class='c028'>On the other hand, if we try to support forcibly the -diagnosis of general paresis, we are hardly able to explain -the negative findings in the spinal fluid.</p> - -<p class='c028'>In point of fact, a study of the patient’s past life -revealed a story that the mental traits of euphoria, -irritability, and memory defect had been characteristic -of the patient for many years. In fact, there is some -question whether the patient is not really to be regarded -as a moron of high grade.</p> - -<p class='c028'>Upon this basis, if we regard the confusional phenomena -as malarial and the persistent mental phenomena -as characteristic of a moron and somewhat exaggerated -by the disease, we have merely to explain the suggestive -pupils. As to these, it must be remembered that though -they reacted poorly to light, still they reacted somewhat, -so it is not a question of explaining an Argyll-Robertson -pupil, but only an impaired pupillary reaction. Of -course, some workers are of the opinion that pupillary -changes, perhaps even the Argyll-Robertson pupils, -may occur in syphilitic cases that are not neurosyphilitic, -or at all events are not victims of central neurosyphilis. -Finally, we must remember that there are cases of -neurosyphilis of a vascular type which yield negative -spinal fluids. The case leaves many questions unanswered.</p> - -<div><span class='pageno' id='Page_247'>247</span></div> -<div class='box'> - -<p class='c013'><b>Can paretic and non-paretic neurosyphilis be differentiated -by means of the gold sol reaction? -The gold sol reaction in this case was an extremely -mild one and would not at all have warranted the -diagnosis GENERAL PARESIS, yet the discovery -of a heavy meningeal exudate including an unusually -heavy deposit of plasma cells even in the -spinal pia mater will perhaps warrant us in making -a final retrospective diagnosis of paretic neurosyphilis. -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 68.</b> We would like to give the full effect of our surprise -at the outcome of the case of Margaret O’Brien, a -school-teacher, 26 years of age. To be sure, Miss O’Brien -developed symptoms at 22 or 23 which we can now explain -consistently with the outcome of the case; for at that time, -she began to complain of severe pain in the head, especially -in the forehead and temples, and also became nervous, unable -to remain quiet, and given to insomnia. She was markedly -depressed at the time and would refuse to talk at times. -However, only the headache in this prodromal period could -be regarded as particularly suggestive of syphilis, and headache -in an over-worked school-teacher is not uncommon.</p> - -<p class='c007'>In fact, the picture presented by the patient was one of -catatonic dementia praecox. The patient was admitted to -the hospital after a sudden onset of excitement. At first she -was very restless, continually looking about and getting up -and walking away from the examiner, giving the impression of -understanding all questions but preserving an air of indifference. -A few days later, the patient was gotten to answer -more coöperatively. She remarked that the hospital was -heaven although in Boston; that it was summer time (correct) -and that her memory was greatly impaired. The physician -was a messenger of God (delusion later corrected). The -patient had not done God’s will; her breath was leaving her; -God’s voice was heard from time to time, and Miss O’Brien -<span class='pageno' id='Page_248'>248</span>had heard it for a long time. God tells her to do His will. -However, as Miss O’Brien remarked, “I must think all this -nonsense, turning against God.”</p> - -<p class='c007'>The patient frequently attitudinized and would remain -in an apparently catatonic condition for many minutes. -For the most part, she was resistive and mute and non-coöperative -as to examination. From time to time, she -made impulsive suicidal attempts. So far as a somewhat -inadequate <b>physical examination</b> was concerned, nothing abnormal -could be made out; in particular, the pupils reacted -normally to light and were otherwise normal. The routine -W. R. of the blood serum, however, returned positive, and -in accordance with the policy of the Psychopathic Hospital, -the patient was subjected to a lumbar puncture. The lumbar -puncture yielded a positive W. R., 109 cells per cmm., a -positive globulin and a considerable excess of albumin, and -an exceedingly mild gold reaction—syphilitic type.</p> - -<p class='c007'>Ten days after admission, the patient had a convulsion. -She never regained consciousness, continued to have convulsions -for a few hours, and died, apparently from paralysis -of respiration. The heart continued to beat for a short -period after respiration ceased. The <b>autopsy</b> was consistent -with the diagnosis which had been rendered after the -surprising results of the W. R. in the blood and the laboratory -findings in the spinal fluid had been learned. There was a -generalized encephalitis with congestion of all the smaller -cerebral vessels and petechial areas in the meninges and -upon the cortical surfaces. We regard the case as one of -syphilitic encephalitis.</p> - -<p class='c007'>The brain weighed 1265 grams, indicating a loss of 79 -grams by Tigges’ formula (8 times the body length in centimetres). -The pia mater was, in the gross, quite normal -within the cranium; nor were any cells found in a smear -from this pia mater; but the pia mater over the spinal cord -was visibly edematous, and a smear from the spinal pia -mater showed great numbers of lymphocytes and especially -of plasma cells—a finding which was confirmed in stained -section, by which a remarkable display of plasma cells was -found plastered somewhat generally over the entire pia -<span class='pageno' id='Page_249'>249</span>mater of certain segments. The brain substance was softer -than normal, but displayed no differences of consistence. -The stripping of the pia mater of the temporal lobes on both -sides yielded the so-called “decortication” (that is, the adhesion -of small bits of brain substance to the pia mater). The -optic nerves were somewhat thinner than normal. No other -gross lesions of the brain were found.</p> - -<p class='c007'>The dura mater, although dense and injected, was not -otherwise abnormal. There was an early visible sclerosis -of the middle meningeal arteries, more marked on the left -side.</p> - -<p class='c007'>The cause of death, so far as the autopsy revealed it, -was bronchial pneumonia. There was a diffuse nephritis.</p> - -<p class='c027'>1. Are the hallucinations in the case of O’Brien characteristic? -Hallucinations are regarded as playing a minor -rôle in general paresis. In fact, earlier workers sometimes -denied that hallucinations occurred at all, and -this denial has been made once more of late by Plaut,<a id='r15' /><a href='#f15' class='c014'><sup>[15]</sup></a> -but Kraepelin quotes Obersteiner as observing hallucinations -in 10%, and regards that figure as approximately -corresponding with his own experience. Junius -and Arndt are cited as finding 17% of their cases hallucinated. -Auditory hallucinations are somewhat more -frequent than those of vision (alcoholic psychosis must -be considered). The visual hallucinations of paresis are -thought by Kraepelin to be related with atrophy of the -optic nerves, and he states that they occur by preference -in patients having such atrophy. Hallucinations -though not common are more frequent in non-paretic -neurosyphilis than in paretic neurosyphilis.</p> - -<p class='c027'>2. What was the cause of death in Margaret O’Brien? -The autopsy, as above stated, indicated pneumonia. -In point of fact, this patient developed convulsions and -ceased respiration, the heart continuing to beat for -some time after respiration had ceased. It may be -that the death should be counted as one of neurosyphilitic -seizure.</p> - -<div><span class='pageno' id='Page_250'>250</span></div> -<div class='box'> - -<p class='c013'><b>Tonsillar abscess associated with neurosyphilis -(Lues Maligna?).</b></p> - -</div> - -<p class='c006'><b>Case 69.</b> Frank Mason, 49 years, a rectifier of spirits, -was admitted to the Psychopathic Hospital in a tremulous, -mentally confused, depressed, and unhappy state. He was -particularly concerned because he could not give an accurate -account of his past life and because he found that he was -continually contradicting himself.</p> - -<p class='c007'>Superficial examination shortly discovered the pupils to be -much contracted, irregular, and non-reactive either to light -or distance. Although these pupils showed more than the -Argyll-Robertson phenomenon, yet the suspicion of syphilis -was important.</p> - -<p class='c007'>Throat examination showed a large area of ulceration -involving the whole of the right tonsil and extending even -to the left side of the median line so that the whole of the -faucial pillar was involved. In the midst of this ulcerative -area was a mass of purulent necrotic tissue, about which the -edges of the ulcer stood out sharply. There was, however, -very little acute reaction about the margin of the area.</p> - -<p class='c007'>The association of pupillary changes (especially stiffness -to light), what looked like tonsillar gumma, and mental disorder -(including memory disturbance) heightened the impression -of syphilis.</p> - -<p class='c007'>However, the remainder of the examination was not especially -confirmatory of the diagnosis. The man was well -developed and obese, with a slightly enlarged heart, with -sounds of poor quality and the aortic second sound accentuated. -The systolic blood pressure was 130; the diastolic, -90. There was no disorder of reflexes except that the arm -reflexes were very lively.</p> - -<p class='c007'>After a time, a few facts concerning the patient’s life -became available. Although a rectifier of spirits, Mason -could not be found to have over-indulged in alcohol. It -appears that some five months before his admission to the -<span class='pageno' id='Page_251'>251</span>hospital, a wisdom tooth had been extracted. About four -months before admission, the ulceration of the faucial pillar -had begun, and this ulceration was immediately laid to infection -from the wisdom tooth cavity. Mason then had to -discontinue work and a depression followed. But the account -of this depression led us to think that he was a victim more -of natural sadness than psychopathic depression. There -was much worry and insomnia. To meet the insomnia, -large amounts of hypnotics were administered. The sequence -of these hypnotics was a tremendous disturbance and continual -crying out by the patient. In fact, Mason became so -excited that he was removed to the Psychopathic Hospital -for temporary care in the condition above mentioned.</p> - -<p class='c007'>We naturally awaited the outcome of the serum W. R. -The return was negative. However, the typical position of -the ulcerative lesion and the non-reacting pupils,—to say -nothing of the mental symptoms and the associated tremors, -with incoördination (this incoördination was non-characteristic -and apparently due largely to the tremor),—led to lumbar -puncture.</p> - -<p class='c007'>The spinal fluid yielded a weakly positive W. R. There -was a slight positive albumin, the globulin test was slightly -positive, there were 14 cells per cmm., and the gold sol reaction -was of the syphilitic type. We were, then, probably -entitled to conclude that syphilis was active not only in the -body at large but also in the nervous system. Looking back -upon the case, we considered that large doses of morphine and -hyoscyamus might well have produced the marked mental -confusion and possibly the tremors that characterized Mason -on his arrival at the hospital.</p> - -<p class='c007'>Improvement followed after a few days of rest; the confusion -disappeared and the tremors diminished; the pupils -returned to their normal size and reaction; depression persisted, -and the patient was very properly much concerned -about the tonsillar lesion. However, further improvement -did not take place under antisyphilitic treatment and patient -died after several weeks from what was believed to be an -embolus from the tonsil.</p> - -<p class='c027'><span class='pageno' id='Page_252'>252</span>1. What was the true interpretation of Frank Mason’s -pupillary changes? They were probably due to the -opiates, despite the fact that, taken in association with -the gummatous lesion of the faucial pillar, we had regarded -them as possibly syphilitic.</p> - -<p class='c027'>2. How shall the negative serum W. R. be explained? -Such a reaction is consistent with the diagnosis <em>gumma</em>. -It is, however, a little surprising that with active neurosyphilis -and a relatively active non-nervous syphilitic -lesion like that in this case, the serum W. R. should -have been negative. Possibly a repetition of the test -at various times would have shown a positive serum -W. R. In any event, the fluid reaction was positive.</p> - -<p class='c027'>3. Could the tonsillar ulceration be due to dental infection? -The chances are against this on account of the interval -(2 months) between extraction of the wisdom tooth -and the ulceration, which itself seems to be of a tertiary -syphilitic nature. In point of fact, the patient -admitted a syphilitic infection 21 years previously -namely, at 28 years of age. At that time he took -large quantities of mercury and potassium iodid by -mouth.</p> - -<p class='c027'>4. Relation of the case of Frank Mason to the so-called -<i><span lang="la" xml:lang="la">lues maligna</span></i>? The case closely resembled the cases -reported by Bly. Frank Mason showed great destruction -of tissue, toxemia, failure to react to antisyphilitic -treatment. In both of Bly’s cases, the tonsil was the -starting point of the illness; and in both cases there was -a trauma of the tonsil or peri-tonsillar structures (tonsillectomy -and application of caustic). In our case -there not only had been extraction of a wisdom tooth, -but the tonsil had been cauterized.</p> - -<div><span class='pageno' id='Page_253'>253</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis versus multiple sclerosis.</b></p> - -</div> - -<p class='c006'><b>Case 70.</b> Annie Kelly is a young Irish woman, 21 years of -age, who was perfectly well until three months before her -admission to the Psychopathic Hospital, when suddenly -one evening she became very dizzy. This was followed by a -chill and vomiting. The next day she had a sore throat but -was able to be about and do her work. The dizziness, -however, continued and she began to feel rather queer. -Gradually it became difficult for her to walk on account of -staggering.</p> - -<p class='c007'>A little later she noticed a weakness of the left side, involving -face, arm, and leg; then she began to find it difficult -to talk. Finally the right leg became weak, making -walking practically impossible. All these symptoms grew -worse and the dizziness increased. At times her vision would -be blurred; there were somewhat frequent attacks of diplopia. -Finally she had to take to her bed, and at last she lost control -of her sphincters.</p> - -<p class='c007'>At no time did she suffer any pain. She was taken to a -hospital, and after a time improved somewhat; but she was -told she had a brain tumor and had better be in a large city, -where she could have surgical aid if this became necessary; -consequently, she was brought from Montana to Boston.</p> - -<p class='c007'>On admission to the hospital, the examination disclosed no -important symptoms outside of the nervous and locomotor -systems. She was unable to walk unless assisted. The -pupils were large but reacted well to both light and accommodation, -were equal in size, and regular. Slight nystagmus -was present; there was no ptosis or strabismus; vision in -the left eye was poor. The other cranial nerves showed -no involvement. The tendon reflexes were all present and -very lively; Babinski, Gordon, and Oppenheim signs were -present on either side. The ataxia was marked, especially -of the lower arms, and she had some difficulty in the alignment -of the fingers. The sense of position of the limbs was -<span class='pageno' id='Page_254'>254</span>very poor. There was some tremor, which was not of the -intention type. The writing showed some incoördination. -The speech showed nothing abnormal. <b>Mental examination</b> -disclosed nothing of note objectively, but patient stated she -could not think so clearly as she could formerly.</p> - -<p class='c007'>The <b>diagnosis</b> would seem to lie between brain tumor,—which -had been suggested to the patient by her physician,—multiple -sclerosis, and neurosyphilis. The numerous neurological -symptoms without any definite evidence of intracranial -pressure were sufficient to rule out for the moment -the consideration of brain tumor. The syndrome of multiple -sclerosis is not complete, but the race, age, and onset, with -the increasing and decreasing intensity of symptoms are -very suggestive of this diagnosis. The symptoms, of course, -are all consistent with neurosyphilis also, and while the patient -denied any knowledge of syphilitic involvement, the -examination of the blood and spinal fluid was made. The -W. R. was negative in both the blood serum and spinal fluid. -Further examination of the spinal fluid showed presence of -globulin and an increase in the albumin content, 43 cells -per cmm. and a “paretic” type of gold sol reaction. With -the negative W. R. of both blood serum and spinal fluid, -and with so much in favor of <span class='sc'>Multiple Sclerosis</span>, this -diagnosis was made.</p> - -<p class='c027'>1. What is the relation of multiple sclerosis to syphilis? -There is no definite relationship between multiple -sclerosis and syphilis,—that is, multiple sclerosis is -not a syphilitic disease; but the complete syndrome -of multiple sclerosis is often given by a syphilitic involvement -of the central nervous system (see case -Lauder, 71).</p> - -<p class='c027'>2. Is the spinal fluid finding in this case consistent with -multiple sclerosis? According to Nonne, about 19% -of the cases of multiple sclerosis show globulin and -pleocytosis in the spinal fluid. As a rule, the number of -cells ranges between 10 and 20 per cmm. and the globulin -is not present in large amounts. In this case, the -amount of globulin, which was given as 2+, is only a -moderate amount,—less than is usually found in -cases of general paresis. There are not very many -<span class='pageno' id='Page_255'>255</span>cases of multiple sclerosis in the literature in which -a gold sol reaction has been performed, but in the -majority of those tested, the reaction is reported as -mild. However, cases of multiple sclerosis giving a -typical paretic curve have been described by a number -of observers, among whom may be mentioned Kaplan -and Solomon.</p> - -<p class='c027'>3. How frequently is it necessary to make a differential -diagnosis between multiple sclerosis and neurosyphilis? -Before the days of the W. R. this differentiation was -much more difficult than at present. But we, however, -still have to face a not very rare difficulty in separating -the two conditions. Syphilis is prone to cause small -localized lesions in the nervous system. The changes -in the patient’s condition, with improvements and -regressions are equally characteristic of both diseases. -How closely the symptomatology of neurosyphilis may -simulate that of typical multiple sclerosis is shown in -the next case (Lauder, 71). When the sclerotic area -of multiple sclerosis occurs in appropriate parts of -the cerebrum, symptoms of mental disturbances will -occur. In its histological picture multiple sclerosis is -at times highly suggestive of syphilis, even showing -mononucleosis and meningitis.</p> - -<div><span class='pageno' id='Page_256'>256</span></div> -<div class='box'> - -<p class='c013'><b>Optic atrophy; nystagmus; spasticity; intention -tremor. Diagnosis: ?</b></p> - -</div> - -<p class='c006'><b>Case 71.</b> James Lauder began to lose his eyesight at 32 -years, and was shortly determined to be suffering from -primary optic atrophy. In the course of a year, he had -become completely blind. No mental symptoms had developed.</p> - -<p class='c007'><b>Physically</b>, Lauder was in very good condition. <b>Neurologically</b>, -there was a complete optic atrophy with paralysis -of the internal rectus muscle, marked nystagmus, and absent -pupillary reactions. All the tendon reflexes were exceedingly -lively, though the right arm reflexes were more -lively than the left, and the left leg reflexes more lively than -the right. There was an ankle clonus on both sides. The -abdominal and cremasteric reflexes were lively. There was -a slight intention tremor. There was, however, no ataxia -and no speech defect.</p> - -<p class='c007'><b>Diagnosis</b>: The nystagmus, optic atrophy, and the reflex -disorder suggested multiple sclerosis, although the -liveliness of the superficial reflexes, especially the abdominal -reflexes, was a point somewhat against any advanced degree -of multiple sclerosis. It would appear that the absence of -pupillary reaction to accommodation is also rather unusual -in multiple sclerosis.</p> - -<p class='c007'>The serum and spinal fluid W. R.’s proved positive. There -were 25 cells per cmm., albumin was in excess, and there was -a positive globulin reaction.</p> - -<p class='c027'>1. What is the significance of optic atrophy and other -optic changes with respect to neurosyphilis? Canavan, -from our laboratory, has reported that she found that -40 of 58 unselected cases of mental disease exhibited -obvious and undeniably important changes in the -optic nerve. She found that optic nerve changes were -even more frequent than chronic spinal cord changes -as detectable by the same method (Weigert myelin -<span class='pageno' id='Page_257'>257</span>sheath method); there were only 34 of the 58 cases -which showed chronic spinal cord changes. Eighteen -cases very probably syphilitic (although the clinical -evidence was not in all cases supported by the W. R.) -failed to show optic nerve changes in but three instances. -The 15 syphilitic cases that did show optic -nerve changes showed them in but one eye in three cases, -in both eyes in 12 cases. Canavan incidentally demonstrated -a spirochetosis in the pial sheath of the optic -nerve in a case of neurosyphilis, possibly paretic.</p> - -<p class='c027'>2. What is the frequency of eye changes in neurosyphilis? -Posey and Spiller (“The Eye and the Nervous System,” -1906) quote Kéraval as finding 42 instances of fundus -change in 51 cases of paresis. Clifford Allbutt found -41 cases of atrophy in 53 of paresis; other authors have -found far fewer. Optic atrophy sufficiently marked to -cause blindness is relatively rare in paresis. Compare -table of eye changes from Joffroy under Case -Falvey (55).</p> - -<p class='c028'>As for optic atrophy in tabes, Posey and Spiller -record statistics as so various as to be on the whole -unsatisfactory. The highest percentages found appear -to be those of Mott, 80%, and Gross, 88%. It is evident -that the standards for measuring optic atrophy -must differ very much.</p> - -<div><span class='pageno' id='Page_258'>258</span></div> -<div class='box'> - -<p class='c013'><b>Atypical case of neurosyphilis. Picture of Huntington’s -chorea.</b></p> - -</div> - -<p class='c006'><b>Case 72.</b> Margaret Green, 28, was received at Danvers -State Hospital in an excited and frightened state. She was -very talkative and said that she was being bitten by snakes -and serpents. She thought every one approaching her was -the devil, and sprinkled what she called “holy water” about -her for protection. It was clear that she was hallucinated. -She heard her child crying, and she saw a woman carrying it -away.</p> - -<p class='c007'>After a few weeks, Mrs. Green grew quiet and more rational -except for a few spells of violence and noise; she gave the -impression of a rather pleasant and agreeable, though somewhat -demented, patient. Physically, beyond a tremor of -fingers and tongue and lively knee-jerks and some evidence -of enlargement of the heart, there was nothing to be found.</p> - -<p class='c007'>Margaret Green is still in the Danvers Hospital, being now -48 years of age. During the twenty years, she has presented,—besides -the mental picture of impairment of memory—occasional -spells of confusion, a variety of delusions based, -at least in part, upon auditory and vivid visual hallucinations, -a certain irritability and psychomotor excitement, and a -picture of Huntington’s chorea. The diagnosis of Huntington’s -chorea has always been in doubt by reason of the lack -of any evidences of hereditary taint; it has, however, not -been possible to secure a properly intensive account of her -relatives.</p> - -<p class='c007'>It appears that the choreic movements were first observed—in -the hospital at least—about 16 years ago. The -patient has always been decidedly mixed upon dates. From -internal evidence derived from her obviously in part erroneous -statements, it may be that the chorea began at the age of -23. It appears that she had been often termed a victim -of St. Vitus’ dance, and had had to leave her work in the mill -on account of the disease. From one source of information, -<span class='pageno' id='Page_259'>259</span>it would appear that the patient began to have what was -called St. Vitus’ dance when she was 14 or 15 years of age; -so far as this informant knew, no other member of the family -had had the affliction.</p> - -<p class='c007'>The first movements observed in the hospital were irregular, -jerking movements, more marked in the left arm but also -occurring in the other extremities, as well as in the face, -wherein were produced peculiar grimaces. The twitching -movements would become decidedly worse during spells of -irritability. Observation in the patient’s early thirties left -the question in doubt whether the left pupil reacted to -light or not. In 1904, when the patient was 36, both pupils -failed to react to light either directly or consensually. At -this time, the jerky movements continued, especially in the -left hand and forearm, the tongue was tremulous, test -phrases were poorly pronounced, the knee-jerks were exaggerated -(especially the left), and both wrist-jerks were exaggerated. -The systematic examination, however, revealed -no other neurological disorder. Within a year, slight spurious -ankle clonus developed on both sides; the eyes, especially -the left, gave the appearance of developing cataracts. -A slight consensual light reaction was demonstrable -on the right side, but all light reactions were absent in the -left eye.</p> - -<p class='c007'>At the age of 42, the patient was still disoriented for time, -place, and persons and subject to a deep amnesia; was -tidy, tranquil, and of a pleasant demeanor, but many of her -muscles were in continual motion. There were chewing -movements and both hands and feet were rarely still. There -were no longer any spells of irritability or violence; and -once when found crying on the piazza, Mrs. Green, on being -asked the reason, replied that a gray cat had come and looked -at her so hard it made her cry. There were other crying -spells at times for equally good reasons, or for no reason.</p> - -<p class='c007'>More recently, the patient has become fairly well oriented -for time and place, and has acquired a fairly good insight -into her condition and a good memory for past events. -She has had occasionally auditory hallucinations, as of water -running. In 1914, it was reported that the pupils reacted -<span class='pageno' id='Page_260'>260</span>to light, and the rest of the systematic neurological examination -was negative except that the knee-jerks were exaggerated; -and a re-examination in 1916 showed the pupils still reacted to -light. At present, the patient is disoriented for time, stating -that her age is about 25; she is no longer subject to auditory -hallucinations; she has a marked difficulty in enunciation, -emphasized by the lack of teeth and in part due to continual -movements of the tongue; the movements appear to be part -of a generalized chorea.</p> - -<p class='c007'>In a systematic review of the Wassermann findings in the -hospital population, the blood of Margaret Green was examined -and found to be positive. Lumbar puncture forthwith -performed showed a positive W. R. in the fluid; there -was a positive globulin and an excess of albumin; the gold -sol was characteristic of paresis; there were, however, but -three cells per cmm.</p> - -<p class='c027'>1. Are the choreiform movements related to the demonstrable -syphilis of the nervous system? Neither the -fluid W. R. nor the gold sol reaction should be regarded -as necessarily an indicator of tissue loss. The fluid -W. R. is commonly thought to signify merely that the -fluid contains substances which are somehow due to the -presence of spirochetes in some region pretty closely -related with the fluid. The gold sol reaction, although -well established to be characteristic of neurosyphilis, -is perhaps not so strong an evidence of the existence of -spirochetes in the region from which fluid constituents -are derived. There is no pleocytosis. However, the -positive globulin test and the excess of albumin do -indicate a certain amount of destructive process somewhere -in the neural tissues. Are we to suppose that -these substances have been continually found during -the course of this disease? This question cannot be -answered with the data in hand, and we can only suspect -that these positive tests for albumin and globulin -are an effect of tissue destruction caused by neurosyphilis. -It must be admitted that the argument -here is a little tenuous. The lesson is plain: that -in the present stage of our knowledge the W. R. -should not be omitted even in cases which present a -fairly convincing picture of some well-known entity. -Thus, a disease, which looks like Huntington’s chorea, -<span class='pageno' id='Page_261'>261</span>as well as a disease suggestive of multiple sclerosis, -requires investigation by the methods of the syphilographer.</p> - -<p class='c027'>2. How shall we explain the changes in pupillary reaction -in this case? They cannot yet be explained. A few -observers have reported changes in pupillary reflexes -in the direction of normality. In our experience such -changes have not been noted. It cannot be too strongly -emphasized that it is very easy to make errors in -judging pupillary reaction if care is not used. For -instance, if the patient is accommodating for near -vision, light will probably not cause contraction. A -frequent cause of error in testing the light reflex arises -from using a weak electric light. An electric flash-light -is much less efficient than daylight. Probably -the most satisfactory method is to take the patient to -a window, ask him to look at a distant object, shade -the eye with the hand, remove hand, and observe.</p> - -<p class='c027'>3. What is the chief triad of symptoms in Huntington’s -chorea? (1) Choreiform movements associated with -(2) progressive mental enfeeblement, (3) occurring in -a patient whose family history shows a similar condition -in a preceding generation.</p> - -<div><span class='pageno' id='Page_262'>262</span></div> -<div class='box'> - -<p class='c013'><b>Differential diagnosis between NEUROSYPHILIS -and SENILE ARTERIOSCLEROTIC PSYCHOSIS.</b></p> - -</div> - -<p class='c006'><b>Case 73.</b> Marcus Chatterton was a retired sea captain, -75 years of age. At the age of 71, he had had a seizure with -a slight right hemiplegia and inability to talk. He had been -slightly confused for a short time but had rapidly recovered. -During the intervening four years, there had been three -similar attacks, and the last one had caused him to come to -the hospital. He was, in fact, confused upon admission -but had become perfectly clear by the next day. There was -a considerable memory defect, which the patient himself -did not entirely appreciate. Possibly his judgment had been -deteriorating slightly. He had been irritable of late and -sometimes sleepless.</p> - -<p class='c007'><b>Physical examination</b> showed a rather well preserved -man with but slight senile changes. The pupils were equal -and reacted readily to light and accommodation. There -was no sensory disorder and no disturbance of coördination. -There were no tremors. The systolic blood pressure was 205, -the diastolic 135. The arteries were sclerotic upon palpation. -A sufficient diagnosis would have seemed to be arteriosclerosis, -and the hypothesis of syphilis would hardly have been raised -off-hand by most practitioners. The W. R. of the serum was -negative. What led to lumbar puncture in this case was the -fact that the sea captain’s wife had died 15 years before of -general paresis. The lumbar puncture was rewarding since -the W. R. was positive. There was an increase of albumin -and globulin, a “paretic” type of gold sol reaction, and 56 -cells per cmm.</p> - -<p class='c007'>Accordingly, we must regard the condition as one of -neurosyphilis. Perhaps the arteriosclerosis was of syphilitic -origin. If this is a case of general paresis as we suppose, -it is one of very long-standing syphilis.</p> - -<p class='c027'><span class='pageno' id='Page_263'>263</span>1. Do delusions of grandeur in the senile period suggest -syphilis? Not necessarily; it appears that there is a -small group of senile cases which might be called cases -of senile pseudoparesis in which extravagant delusions -of grandeur are entertained, and in which frontal -atrophy is found although entirely without evidence of -chronic inflammation. It has not been proved that -these cases are of syphilitic origin. It is suggestive -that the site of the most extensive lesion is precisely -the site of the most extensive lesion classically found in -paretic neurosyphilis, viz., in the frontal regions.</p> - -<p class='c027'>2. Is neurosyphilis frequently found in both mates? It -can hardly be said that this is a usual finding. However, -it is far from rare, and it occurs frequently enough -to be used in support of the theory that there is a -special strain of spirochete that has a predilection for -nervous tissue. It must be remembered, however, -that the wives of syphilitics are frequently infected -without being aware of it. In such cases they receive -no treatment and consequently have a larger -chance of developing neurosyphilis. It is a good rule -to consider the mate of every syphilitic a candidate for -neurosyphilis.</p> - -<div><span class='pageno' id='Page_264'>264</span></div> -<div class='box'> - -<p class='c013'><b>An atypical case of recurrent dazed states resembling -HYSTERICAL FUGUES. Probably an instance -of NEUROSYPHILIS.</b></p> - -</div> - -<p class='c006'><b>Case 74.</b> Abel Bachmann, a man of 40 years, remains -doubtful and perhaps belongs to the still unresolved group -of mental cases due to syphilis that cannot be placed in any -of the well-known categories. Bachmann had been found by -the police, working in front of a cowbarn without the consent -or even the knowledge of the owner. Bachmann had, in -fact, spent the night in the cowbarn and was working with -the idea of paying for his night’s lodgings. The situation -struck the police as so peculiar, and Bachmann was so confused -and irresponsive, that he was brought to the Psychopathic -Hospital. The afternoon of his admission, however, -he entirely cleared up and was able to give a good account of -himself.</p> - -<p class='c007'>His story was that he had been worrying a good deal about -a divorce suit, and the morning of his episode he had awakened -with peculiar feelings. He walked from Boston to Cambridge, -feeling that he was in a strange city. He recognized the -places he passed, yet they all seemed to be changed. Upon -reaching Harvard Square, he determined to return to Boston -and walked and walked, failing to reach Boston. All day he -had eaten nothing; when night fell he stole into a field and dug -out radishes. A postman stopped and said, “Hello, Bill,” -which awakened him as by an electric shock. A barn presented -itself, in which he spent the night. In the morning, -the barn looked different. In fact, his entire surroundings -appeared mysterious. As he felt like working, he went to -work in front of the barn.</p> - -<p class='c007'>It seems that in his life there had been two other episodes -of a similar nature; in fact, Bachmann had been in a state -hospital for six weeks after the first episode. The first -episode had lasted a few days only, and followed worry when -he learned that the girl with whom he was in love was married. -<span class='pageno' id='Page_265'>265</span>The second attack followed the death of his mother, whereupon -he was taken to a state hospital although the total -duration of symptoms was only three days. Bachmann -had had a chancre or some other form of genital disease at -26, and had at that time been treated with mercury.</p> - -<p class='c007'>Except for irregular and absolutely rigid pupils, reacting -neither to light nor to accommodation, Bachmann showed -no physical and especially no neurological disease whatever. -Moreover, the W. R. in the blood serum was negative.</p> - -<p class='c007'>As to diagnosis, one might consider hysteria, of which, -however, there are no visible stigmata. It would not appear -that brain tumor would be likely to have lasted so long as -eight or nine years, even if we should attempt to make the -hypothesis of tumor cover both the non-reacting pupils and -the episodes. Bachmann was non-alcoholic, and there was -no sign of any other form of intoxication. The spinal fluid -showed a negative gold sol reaction, there were no cells in the -fluid, there was no globulin; albumin was normal. However, -the W. R. was strongly positive.</p> - -<p class='c007'>The situation, then, in this case is that we have somewhat -peculiar psychopathic episodes, pupils rigid to light and -accommodation, a positive W. R. in the spinal fluid, and extremely -little else to permit a diagnosis. We are ignorant -as to the course and pathology of such cases. However, we -cannot resist the temptation of the diagnosis of neurosyphilis, -although further classification is not ventured.</p> - -<p class='c027'>1. What is the significance of stiff pupil as an isolated -symptom? Nonne finds that in the end, after years of -observation, the Argyll-Robertson pupil turns out to -be an advance courier of other more functionally -serious signs and symptoms of neurosyphilis. We can -confirm this experience and regard it as an established -clinical proposition that the Argyll-Robertson pupil -cannot be neglected. In this connection, refer to the -case of alcoholic pseudoparesis (Murphy, 60), and also -to the case of pineal tumor (Donald Falvey, 35). Enthusiastic -reports have occasionally been made upon -apparent restoration of the true syphilitic Argyll-Robertson -pupil to normal light reaction. The difficulties -in rendering the symptomatic diagnosis of -<span class='pageno' id='Page_266'>266</span>Argyll-Robertson pupil in a given case are so great, and -the chances of complication so numerous, that we are -inclined to attach little significance at present to these -claims.</p> - -<p class='c027'>It may not be amiss to mention a somewhat humorous -incident familiar to some local neurologists. A case was -reported by the interne for a number of months as a -victim of a pupil stiff to light and accommodation, and -the entirely adequate cause of this phenomenon was -actually only discovered at autopsy by the triumphant -medical examiner, who demonstrated that the patient -in question was possessed of a <b>glass eye</b>.</p> - -<div><span class='pageno' id='Page_267'>267</span></div> -<div class='box'> - -<p class='c013'><b>TABETIC NEUROSYPHILIS (“tabes dorsalis”) -versus PERNICIOUS ANEMIA with spinal -symptoms.</b></p> - -</div> - -<p class='c006'><b>Case 75.</b> Mrs. Brown was a woman of 56, who for the -past eight or ten years had been complaining of trouble in -her legs. As she described it, at times her legs were so weak -she could hardly stand; at other times there was considerable -pain and numbness. She has always been considered -“high strung”; that is, she had a very bad temper and -lost control of herself almost entirely when she became -excited. Her legs had been growing progressively worse, -and for about a month prior to admission she had been unable -to stand or walk. She had also lost control of her -bladder. On account of her temper, it had been almost -impossible to nurse her; no nurse would stay with her because -of her scolding and fault-finding. Recently, she had -been having fits of the blues.</p> - -<p class='c007'>Her husband, who was seen before Mrs. Brown, was an -old gentleman, over 70, who was chiefly remarkable from the -fact that he had unequal, irregular pupils, which reacted -neither to light nor accommodation; there was also a speech -defect.</p> - -<p class='c007'>The patient herself proved to be extremely irritable, as -had been stated,—so much so that at times it seemed -almost impossible to do anything for her. She was very -querulous, constantly complaining, and not satisfied with -anything that was done. Aside from this, her <b>mental examination</b> -proved to be entirely negative; that is, there were -no psychotic symptoms.</p> - -<p class='c007'>The systematic <b>physical examination</b> gave the following -significant findings: blood pressure, 160 systolic, 90 diastolic; -no evidences, however, of peripheral arteriosclerosis. Patient -was unable to walk or stand, and had no control over her -bladder. The knee-jerks and ankle-jerks absent on both -sides; ataxia in the leg movements; loss of sense of localization, -<span class='pageno' id='Page_268'>268</span>with no tenderness over the nerve trunks; no atrophy, -paralyses, or muscular asymmetry of the parts. The vibratory -sense was maintained. Subjectively, the patient thought -that the vibratory sense differed in the legs from that in the -arms. Localization, touch, pain, heat, and cold responded -to correctly. The arms showed nothing abnormal; there -was no incoördination, dysmetria, or dysdiadochokinesis. -Her pupils were equal, regular, and both reacted normally -to light and accommodation.</p> - -<p class='c007'><b>Diagnosis</b>: The first consideration in the case is naturally -tabes dorsalis, especially when one considers that the husband -had signs which suggested syphilis of the nervous -system. The rapid onset of the acute symptoms in this -case, and the absence of the characteristic signs of pain were -at least atypical for this diagnosis, as was the absence of -any pupillary signs. Further, the W. R. was negative in -the blood and spinal fluid; there were no definite signs of -inflammatory reaction as shown by the other spinal fluid -tests. These findings made a diagnosis of tabes entirely improbable. -After tabes, the most frequent cause of the symptoms -above enumerated is perhaps to be found in pernicious -anemia. Examination of the blood showed that the patient -had 2,500,000 erythrocytes per cmm. The hemoglobin by -Tallquist scale was 80%. The smear was practically negative; -no blasts could be seen. Although this picture is not -a typical one for pernicious anemia, at least it is significant -in the low number of red cells to be found, and as no causes -for anemia were to be found, it seemed probable that we -were dealing with a primary anemia. The diagnosis in the -case, therefore, is spinal sclerosis of primary anemia. The -mental picture was not uncharacteristic of <span class='sc'>Pernicious -Anemia</span>.</p> - -<p class='c027'>1. Could the diagnosis be rendered in this case without -a lumbar puncture? In the first place, the emaciation -is not entirely characteristic. The pupils react normally -to light. Probably such a case might well -have been regarded as one of tabes dorsalis in former -days, or even at the present time, if a lumbar puncture -had not been resorted to.</p> - -<p class='c027'><span class='pageno' id='Page_269'>269</span>2. Could this case possibly have been one of tabes dorsalis -with negative spinal findings? Such cases have been -reported frequently, but, unlike the present case, are -apt to be of long-standing and non-progressive, in -which the active inflammation is no longer present. -The negative findings would not be consistent with -tabes, in which the symptoms are of short duration -and of sudden onset.</p> - -<p class='c027'>3. If the serum W. R. had been positive would the diagnosis -have been neurosyphilis? We are loath to make -the diagnosis of spinal syphilis when the spinal fluid is -normal. Syphilis may produce a marked anemia, -however, and thus produce symptoms such as shown -by Mrs. Brown. It is even possible that such is the -explanation of this case, taking into consideration the -suggestive findings in the husband. However, there -is insufficient evidence to make such an hypothesis -rock firm, and we do not more than suggest it.</p> - -<div><span class='pageno' id='Page_270'>270</span></div> -<div class='box'> - -<p class='c013'><b>Atypical case of CONGENITAL NEUROSYPHILIS—peculiar -mental state.</b></p> - -</div> - -<p class='c006'><b>Case 76.</b> James Seabrook, 20 years of age, obviously -showed a number of signs of congenital syphilis. The -<b>physical examination</b> disclosed an old scar and indentation in -the right mastoid region, another on the right side of the -neck, another on the posterior surface of the right forearm, -and two on the outer surface of the right upper arm. The -lesions were about the size of half a dollar. There was a -saddle-shaped nose and a perforation of the palate and -uvula; there were palpable cervical and axillary glands, small -but numerous. There was a dulness in the region of the right -scapula, and slight dulness on both sides behind. There were -loud whispering and piping râles and bronchial breathing -throughout the chest, more marked on the left; there was -much coughing, and the sputum was at times blood-stained. -The pupils were irregular but reacted perfectly. The left -knee-jerk was slightly more active than the right. The W. -R. in blood and fluid was negative; the gold sol, globulin and -albumin tests were negative. There were, however, 56 -cells per cmm. in the fluid.</p> - -<p class='c007'>We learned that the patient had had several spells of great -excitement, with pounding on the door and a desire to fight -bystanders. There were spells of headache and vertigo. -<b>Mentally</b> the tests showed him to be subnormal.</p> - -<p class='c007'>The <b>diagnosis</b> Of <span class='sc'>Congenital Syphilis</span> seems established; -possibly the pulmonary condition is syphilitic. The mental -subnormality as well as the abnormal traits and episodes -are probably to be accounted for on the basis of syphilitic -involvement of the brain.</p> - -<p class='c027'>1. Are the headache and vertigo connected with syphilis? -This is perhaps suggested by the pleocytosis in the -spinal fluid.</p> - -<p class='c027'>2. How shall we explain the negative W. R.? This patient -had received, shortly before his entrance to the hospital, -<span class='pageno' id='Page_271'>271</span>salvarsan and mercury. Possibly the drug treatment -has little or nothing to do with the negative W. R.’s -since they not infrequently grow weaker as congenital -syphilitics grow older.</p> - -<p class='c027'>3. What is the explanation of the spells of excitement? -Compare the spells of excitement in a form of neurosyphilis -described by Kraepelin, namely: syphilitic -paranoia, discussed in the case of Bridget Collins (59).</p> - -<p class='c027'>4. Is treatment indicated considering the W. R.’s to be -negative in blood and fluid? Despite the negative -W. R.’s in this case treatment is strongly indicated -on account of the pleocytosis. This would seem to -indicate that there is an active inflammatory process -in the cerebrospinal axis, and it is more than probable -that this process is syphilitic. How much real improvement -of the symptoms would result from antisyphilitic -treatment it is impossible to prophesy. -Every case is a special problem, and this case is very -unusual in showing a pleocytosis in the absence of -other indications of syphilitic nervous disease, <i><span lang="la" xml:lang="la">viz.</span></i>, -globulin, albumin and W. R.’s.</p> - -<div><span class='pageno' id='Page_272'>272</span></div> -<div class='box'> - -<p class='c013'><b>CONGENITAL NEUROSYPHILIS resembling -an undifferentiated case of FEEBLEMINDEDNESS—actually -PARETIC.</b></p> - -</div> - -<p class='c006'><b>Case 77.</b> John Friedreich, a 7–year old boy, was brought -to the Psychopathic Hospital by agents of a charitable society, -who found him a neglected child and quite evidently a subnormal -one.</p> - -<p class='c007'>The dominance of syphilis in the situation was clear. The -boy’s father had died but a few months before of syphilitic -heart disease, from which he is said to have suffered for five -years. The boy’s mother (the parents were first cousins) -had also been treated for syphilis and was excessively alcoholic. -The first child of this union—a girl—had died -at 6 years, of a disease diagnosticated spinal meningitis. -The history indicates that syphilis was acquired after the -birth of this first child; but in any event it is possible that -the meningitic condition of which the first child had died was -syphilitic. The second pregnancy terminated in a stillbirth; -the third issued in a girl, who died two weeks after -birth of what was termed “inward convulsions.” The -fourth pregnancy resulted in a miscarriage; the fifth in our -patient, John Friedreich. The sixth pregnancy resulted in -a girl, now 5 years of age, who is apparently normal. (Her -W. R. was negative and she shows no stigmata of syphilis.)</p> - -<p class='c007'>The patient, John Friedreich, at some very early age had -a rash on his body diagnosticated as syphilis. He also had -many seizures called fainting spells. Ever since birth he had -been taking mercury pills. He had not learned to talk -until his third year, and was able then to say only a few disconnected -words. In fact, John has never been able to talk -in complete sentences, mumbling much that is quite unintelligible. -However, he walked at 15 months in a normal -fashion and nothing peculiar in his gait was noted until he -was 5 years old, when he began walking on his toes, particularly -those of his left foot. Shortly thereafter, the seemingly inevitable trauma appeared; John fell out of a window -and severely injured his left leg, whereupon the peculiarity -of toe-walking became more pronounced and associated -with a limp.</p> - -<div class='figcenter id002'> -<img src='images/i_272.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Juvenile paresis. 7 years.</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_273'>273</span>The patient strikes one <b>physically</b> as having the development -of a child of about five years (actual age, 7). There -are a few lymph nodes palpable in the anterior triangles of the -neck. The dilated and slightly unequal pupils react neither -to light nor accommodation. There is practically complete -deafness; loud sounds are not at all noticed.</p> - -<p class='c007'>Withal, the child in a general way presents a somewhat -attractive appearance, being very playful and mischievous, -lying about on the floor and playing with whatever comes to -hand, talking to himself or making a few indistinct remarks -to the bystanders. He walks awkwardly, on the toes of the -left foot. He pays little or no attention to his toilet and -needs to be dressed and cared for in all ways. He is quick-tempered -and at times very difficult to manage.</p> - -<p class='c007'>There was, of course, little doubt of the <b>diagnosis</b> of <span class='sc'>Congenital -Syphilis</span> and of <span class='sc'>Feeblemindedness</span>. The W. R. -was positive both in the blood and in the spinal fluid. The -gold sol reaction of the fluid was of the “paretic” type; -there were 44 cells per cmm. and there was a large excess of -albumin and much globulin.</p> - -<p class='c007'>As to prognosis, there is doubt.</p> - -<p class='c027'>1. Is, or is not, this a case of juvenile paresis?</p> - -<p class='c027'>2. Is it, perhaps, a relatively permanent case of feeblemindedness -due to congenital syphilis? On the whole, -on account of the spinal fluid symptoms, we should be -inclined to give the case a relatively poor prognosis, -namely, of death in a few years. However, we may -perchance be later surprised to learn that the patient -has lived on, at least into early adult age.</p> - -<p class='c028'>Note: Mercury tablets in some cases of congenital -syphilis do not seem effective. John Friedreich was -treated most intensively by syphilographers from birth.</p> - -<p class='c028'>Dr. W. E. Fernald in a personal communication stated -that syphilitic cases of feeblemindedness are rather those -of the imbecile and idiot groups than of the higher levels. -This statement emphasizes again that the true hereditary -<span class='pageno' id='Page_274'>274</span>cases of feeblemindedness are rather those of the higher -group, whereas the cases in which special causes have -operated in the uterus or in early life eventuate in idiocy -and imbecility. However, such a case as that of Friedreich -shows that now and then a case of feeblemindedness -without evidence of neurological disorder and looking -in almost all respects like an hereditary case may be -at times produced by syphilis.</p> - -<p class='c027'>3. How often is the central nervous system involved in -hereditary syphilis? An interesting table bearing on -this point is presented by Veeder.<a id='r16' /><a href='#f16' class='c014'><sup>[16]</sup></a> The table concerns -the lesions in various parts and systems of the body in -100 cases of late syphilis. It appears that in 47, or -approximately one-half of Veeder’s series of 100 late -cases, the infection developed some form of lesion of -the nervous system. As Veeder remarks, this result -runs counter to the common statements of pediatricians, -notably of Holt.</p> - -<table class='table3' summary=''> - <tr> - <td class='c024'>  Bones:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Periostitis tibia</td> - <td class='c033'>4</td> - </tr> - <tr> - <td class='c024'>Periostitis skull</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Osteomyelitis</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>  Joints:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Acute arthritis knee</td> - <td class='c033'>8</td> - </tr> - <tr> - <td class='c024'>Acute arthritis ankle</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>  Skin:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Macular eruption</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Condyloma anus</td> - <td class='c033'>3</td> - </tr> - <tr> - <td class='c024'>Gummata</td> - <td class='c033'>3</td> - </tr> - <tr> - <td class='c024'>Alopecia</td> - <td class='c033'>3</td> - </tr> - <tr> - <td class='c024'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>  Eye:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Interstitial keratitis</td> - <td class='c033'>24</td> - </tr> - <tr> - <td class='c024'>Choroiditis</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>  Ulcerations:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Nasal</td> - <td class='c033'>2</td> - </tr> - <tr> - <td class='c024'>Laryngeal</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Pharyngeal</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>  Central Nervous System:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Mental deficiency</td> - <td class='c033'>23</td> - </tr> - <tr> - <td class='c024'>Cerebrospinal syphilis</td> - <td class='c033'>14</td> - </tr> - <tr> - <td class='c024'>Hemiplegia</td> - <td class='c033'>6</td> - </tr> - <tr> - <td class='c024'>Epilepsy</td> - <td class='c033'>5</td> - </tr> - <tr> - <td class='c024'>Spastic paraplegia</td> - <td class='c033'>4</td> - </tr> - <tr> - <td class='c024'>Chorea</td> - <td class='c033'>2</td> - </tr> - <tr> - <td class='c024'>Hydrocephalus</td> - <td class='c033'>2</td> - </tr> - <tr> - <td class='c024'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>  Miscellaneous Conditions:</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c024'>Ozena</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Enlarged spleen (only symptom)</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Torticollis</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Aortitis</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Obscure abdominal pain</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Obscure pain in legs</td> - <td class='c033'>2</td> - </tr> - <tr> - <td class='c024'>Endarteritis obliterans</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Paroxysmal hemoglobinuria</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Raynaud’s disease</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>Hutchinson’s teeth</td> - <td class='c033'>4</td> - </tr> -</table> - -<div><span class='pageno' id='Page_275'>275</span></div> -<div class='box'> - -<p class='c013'><b>Juvenile paretic neurosyphilis. Quadriplegia.</b></p> - -</div> - -<p class='c006'><b>Case 78.</b> Gridley Ringer, 15 years of age, had the facies of -a congenital syphilitic, including Hutchinsonian teeth, rhagades -of the face, and the so-called Olympic brow. No -secondary sexual characteristics had developed. There was -a marked speech defect. <b>Mentally</b>, Ringer was a low-grade -imbecile. He had been born at full term, and delivery had -been normal. There had never been other pregnancies. -He had never developed normally.</p> - -<p class='c007'>The father admitted syphilis 23 years before, namely, -8 years before the birth of his son, but the father had been -treated for several years and had been declared cured.</p> - -<p class='c027'>1. What would be expected in the spinal fluid of this case? -Without the history, it would perhaps be impossible to -say whether the case was one of a quiescent imbecility -or one of juvenile paresis. The spinal fluid of the juvenile -paretic gives a picture identical with that in the -adult. The spinal fluid in this case showed a positive -W. R. (as did also the serum), a marked increase of -albumin and globulin, 115 cells per cmm., and a “paretic” -gold sol reaction. Accordingly, the diagnosis of -<span class='sc'>General Paresis</span> was made.</p> - -<p class='c027'>2. What is the prognosis? The prognosis of juvenile paresis -is currently regarded as entirely grave. There is -probably less hope for improvement in juvenile paresis -than in the acquired paresis of adult life, since it seems -to be a general principle that congenital syphilis is -always more difficult to cure than acquired syphilis.</p> - -<p class='c028'>This case had seizures a few months after initial -observation, and the seizures were followed by a transient -right hemiplegia. This right hemiplegia was -shortly followed by a left hemiplegia, which remained -permanently. Moreover, a few weeks later, a right -hemiplegia again developed, leaving the patient with -complete paralysis and aphasia. Death followed in -six weeks.</p> - -<p class='c027'>3. What effects were shown in the parents? Following up -the parents was rewarded by the discovery that the -<span class='pageno' id='Page_276'>276</span>mother was suffering from nerve deafness, probably -of syphilitic origin, and that the father had recently -begun to suffer from what he considered rheumatism, -but which on examination was shown to be tabetic -neurosyphilis (“tabes dorsalis”). This family again -supports the hypothesis that there is a strain of spirochetes -especially prone to attack the nervous system. -Here it would seem that the syphilis acquired by the -father had infected the mother and been transmitted -to the son. In all three infected by the same strain -or strains of organisms the nervous system was involved. -It is difficult, nevertheless, to explain on this -hypothesis why in one case the disease took the form -of tabes dorsalis, in the second, eighth nerve involvement -and in the third, paresis. This question of strains -is really more than academic because it enters deeply -into the question of treatment, as well as that of the -suggested increased viability of the neural strain.</p> - -<div><span class='pageno' id='Page_277'>277</span></div> -<div class='box'> - -<p class='c013'><b>Is there a relation between epilepsy and juvenile -neurosyphilis?</b></p> - -</div> - -<p class='c006'><b>Case 79.</b> John Doran fell off the rear of an ice-wagon, at -six years of age, and shortly afterward developed fits. It -appears that John was not unconscious at the time of his fall, -but that he complained of headache. Although the convulsions -were fairly frequent at first, it appears that they later -became rare and occurred only when the patient got into a -temper. At the stage of exhaustion after violent excitement, -John would fall.</p> - -<p class='c007'><b>Physically</b>, at 9 years a fair development and nutrition -were evident. There was a great exaggeration of the frontal -bosses; the nose could not be said to be typically saddlebacked, -yet there was a suggestion of a sinking of the -bridge. The teeth slightly suggested the Hutchinsonian -type, but only slightly. There was a slight roughening of the -tibia, and there was a slight scar over either knee. The -patient graded according to the Binet scale at 9 years, and -he was regarded as definitely feebleminded.</p> - -<p class='c007'>The family physician states that, according to his information, -the father contracted syphilis when the child was between -three and four months of age, and that the mother also was -infected at this time. However, the child had not been -suckled except immediately after birth, and there had been -no evidences, according to the family physician, that John -had acquired syphilis.</p> - -<p class='c007'>Ordinarily, one might content himself regarding the case -of John Doran as one of idiopathic epilepsy with mental -defect or deterioration. However, the frontal bosses, suggestive -teeth, the flattened bridge of the nose, the roughened -tibiae, and the old scars, though singly not of great significance, -collectively make one suspicious. Despite the family physician’s -belief that John could not have acquired syphilis from -the parents, the infection seems entirely possible despite the -fact that no symptoms developed early thereafter.</p> - -<p class='c007'><span class='pageno' id='Page_278'>278</span>The W. R. in this case proved positive in both blood -serum and spinal fluid.</p> - -<p class='c027'>1. What is the relation of trauma to this case of <span class='sc'>Juvenile -Neurosyphilis</span>? Probably none.</p> - -<p class='c027'>2. What would be the effect of treatment? For a number of -years John Doran was lost sight of. He was, however, -treated, according to our information, with intraspinous -injections of salvarsanized serum, whereupon -his convulsions shortly ceased. He has been recently -examined mentally once more, and still grades as feebleminded. -He still has violent outbreaks of temper.</p> - -<p class='c027'>3. Is such a case as Doran typical? Shanahan has investigated -conditions at Craig Colony. There were 22 -out of 886 epileptics (at Craig Colony) or 2½%, who -showed a positive W. R. Nine of these cases were -regarded by Shanahan as cases of epilepsy actually -caused by syphilis. Viet had found 7%, and Bratz and -Lüth 5% of constitutional epileptics to be syphilitic, -but the data of these German authors were obtained -before the era of Wassermann tests.</p> - -<div><span class='pageno' id='Page_279'>279</span></div> -<div class='box'> - -<p class='c013'><b>Adrenal tuberculosis complicating juvenile paretic -neurosyphilis (“juvenile paresis”). Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 80.</b> When James Arnold appeared at the Danvers -Hospital in his 22d year, he looked as if he were but 12 or 14 -years of age. He was excessively fat but of fair muscular -development. The left eye diverged outward, and the left -pupil was smaller than the right. An odd feature was a high -degree of pigmentation of the skin of the genitalia and the -groins (the axilla, the mammillary areas, and the oral mucosæ -were free from pigmentation). <b>Physically</b> speaking, the -patient was practically normal. <b>Neurologically</b>, however, -there was much of interest, in the light of which the clinical -history was of value.</p> - -<p class='c007'>It seems that after an apparently normal early childhood, -the boy had begun, at the age of 11, to experience difficulty -in carrying out every-day school tasks; and after this his -mental capacity had slowly but progressively deteriorated. -The deterioration was not merely intellectual, but the boy -became dishonest and untrustworthy and developed a number -of untidy and uncleanly habits, behaving at the age of 16, as -the parents stated, like a child of six.</p> - -<p class='c007'>In his seventeenth year, the boy had been taken with a severe -attack of what was regarded as an “attack of indigestion.” -This attack ushered in a gradually developing muscular -weakness, especially involving the limbs. By the age of 21 -he had become irritable and the paresis was so extreme that -the patient was unable to get in or out of a carriage.</p> - -<p class='c007'>This generalized muscular weakness was plain upon admission -to the hospital though there seemed to be no actual -paralysis. The patient was unable to walk in a straight line -and Romberg’s position could not be maintained. Marked -tremor was present in the hands and lips. There was bilateral -impairment of vision and nystagmus. Reflexes and -sensations normal. Speech was markedly affected, all syllables -being very much slurred. School knowledge and memory -<span class='pageno' id='Page_280'>280</span>for both recent and remote events very poor. The patient’s -habits were very untidy. He was very emotional, easily -made to laugh or cry; and in behavior, extremely childish.</p> - -<p class='c007'>Two months after his admission to the hospital, the weakness -suddenly became extreme. He was constantly nauseated, -refusing food. The face and hands were cyanosed and -the heart’s action rapid, weak, and irregular. This attack -lasted for a week and was followed by a period of improvement, -during which, however, he still remained very weak and -apathetic.</p> - -<p class='c007'>One month later he again became so feeble that he was -unable to raise himself in bed. He complained persistently of -feeling very “sick.” His temperature was elevated and there -occurred the same train of circulatory symptoms observed -previously, <i><span lang="la" xml:lang="la">viz.</span></i>, rapid and tumultuous action of the heart, -with cyanosis of face and extremities. He soon became -unconscious, remaining so until his death, which occurred -on the seventh day of the acute attack.</p> - -<p class='c007'>This case was under observation before the days of the -W. R., yet clinically the case had been diagnosticated <span class='sc'>Juvenile -Paresis</span>. There was no history of the acquisition of -syphilis or any likelihood of its acquisition. Considered clinically, -many of the classical features described by Addison -were present, <i><span lang="la" xml:lang="la">viz.</span></i>, marked asthenia and apathy; severe and -frequent gastro-intestinal symptoms (the disease probably -commencing with the attack of so-called “acute indigestion” -six years prior to patient’s death); attacks of extreme cardiac -weakness with the characteristic small, low-pressure pulse. -On the other hand, pigmentation of the skin (usually the -most striking clinical feature) was limited to the external -genitalia, these being colored a deep brown.</p> - -<p class='c007'>The most striking feature found at autopsy was a bilateral -adrenal tuberculosis (caseation, giant cells, lymphocytosis, tubercle -bacilli). The thymus gland was persistent (7×5×.5 -cm.), whereas the thyroid gland was smaller than usual. -The brain showed macroscopic and microscopic features -entirely consistent with the diagnosis of general paresis, -including lymphocytosis, plasmocytosis, irregular degrees of -<span class='pageno' id='Page_281'>281</span>nerve cell destruction, and gliosis, with an especially characteristic -microscopic picture in the frontal regions.</p> - -<p class='c007'>It may be of note to consider the degree of change undergone -by a brain in 11 years or more of deterioration, and the -following description of the head findings is therefore -included:</p> - -<p class='c015'><b>Head</b>: Hair abundant, dark. Scalp normal. Calvarium, -weight 435 gm., transparent in bregmatic region -only, elsewhere thick and dense. The average thickness -of the vertical plate of the frontal bone is 7 mm. -The frontal bone shows a moderate thickening and -hardening of the inner table with obliteration of diploë. -Dura mater moderately adherent to the bregmatic -region of calvarium. Arachnoidal villi moderately -developed. Sinuses not remarkable. Pia mater shows -a moderate focal thickening with opacity, especially -along sulci. Vessels well injected. <b>Brain</b>: Weight, -1200 gm. The brain shows marked focal variations -in sulcation and consistence. Spread on a board, the -right hemisphere is obviously somewhat bigger than -the left. There is a difference of only 0.5 to 0.75 cm. -on measurement of the greatest circumference of the -cerebrum, taken from the median line superiorly to the -median line inferiorly, but the right hemisphere is -throughout slightly more convex than the left. Both -postcentral gyri are much narrowed in their superior -portions, and the sulci posterior thereto are deeper -than the other sulci of the hemispheres. The sulci -of the orbital surfaces are asymmetrical and, on the -left side, show a tendency to microgyria. The cerebral -hemispheres as a whole show a remarkable tendency to -slight protrusion of the border gyri; especially those of -the two poles, of the free edges along the great fissure, -and most strikingly the gyri at the boundary line between -the inferior and lateral surfaces. This <em>marginal prominence</em> -is slight but obvious and is emphasized by a -slightly paler color in some regions. The cerebrum -shows a general induration which is greatest in the frontal -tips and along the inferior borders of the lateral surfaces -of the hemispheres, especially right. The orbital surfaces -are firm, especially anteriorly and externally (prefrontal); -the tips of the temporal lobes are firm, and -the superior temporal gyri are firmer than adjacent -gyri. The postcentral gyri are indurated more than -<span class='pageno' id='Page_282'>282</span>the other gyri of the superior surface. The hippocampal -gyri are likewise firmer than adjacent gyri.</p> - -<p class='c015'><b>Cerebellum and pons</b>: Weight, 145 gm. The inequality -of the two hemispheres is more marked than in -the case of the cerebrum.</p> - -<p class='c015'>Greatest lateral diameter; left, 4.5 cm., right, 5.5 cm.</p> - -<p class='c015'>Anteroposterior diameter adjacent to notch: Left, -5.8 cm., right, 5.5 cm.</p> - -<p class='c015'>There is no appreciable difference in depth. The -diminution in volume appears to be chiefly at the expense -of the right clivus. The inferior surface is firmer than -the superior. The laminæ adjacent to the horizontal -fissure are firmer than the remainder of the cerebellum. -The pons is small.</p> - -<p class='c007'>There was also a lateral curvature of the spinal column, -as well as characteristic adhesions between spinal dura and -pia mater which are always suggestive of syphilis. For the -rest, there were few findings of note: some adhesions of the -left pleura, hypostatic congestion of the lungs, tracheitis, and -chronic gastritis. There were four lobes of the right lung -but it is doubtful whether this should be regarded as a stigma.</p> - -<p class='c027'>1. Can we separate the symptoms of Addison’s disease from -those of paresis in this case? The extreme cardiac -weakness with a characteristic, small low-pressure -pulse is in point. The asthenia and apathy are consistent -enough with Addison’s disease as well as with paresis -itself. It would also be possible to ascribe the gastro-intestinal -symptoms to either disease.</p> - -<p class='c027'>2. Of what significance is the persistent thymus? Persistent -thymus has been observed in a few cases of Addison’s -disease, but that it plays any part in the symptomatology -thereof is a matter of doubt.</p> - -<p class='c027'>3. How can the obesity be explained? It is of course of -note that the thyroid gland was small, but microscopically -there were no peculiar features in this gland.</p> - -<p class='c027'>4. Was the adrenal tuberculosis actually primary? Minute -search failed to reveal evidences of tuberculosis elsewhere -unless we regard the few adhesions binding the -lower half of the lung to the chest wall as indicative -of an old tuberculosis. In particular, the mesenteric -lymph nodes were normal.</p> - -<div><span class='pageno' id='Page_283'>283</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis? Secondary stage of syphilis.</b></p> - -</div> - -<p class='c006'><b>Case 81.</b> Florence Fitzgerald, a woman 25 years of age, -applied at the police station to be taken care of. She said -she had been a prostitute for the last few months, was now ill, -and wanted to reform. She appeared physically ill and was -sent to the Psychopathic Hospital, where she remained at -first almost mute, making answers chiefly by nodding the -head. She gave the impression of daze or stupor, and in -fact her condition was at first regarded as catatonic. This -reaction, after a few days, changed and Florence became -quite normal, giving a full account of her condition.</p> - -<p class='c007'>It seems that four months before going to the police station, -she developed a chancre, which was locally treated. A -careful physical examination showed a fine red macular -eruption which was without much question a syphilitic -roseola. The spinal fluid yielded a positive W. R. although -other tests of the fluid were negative. Curiously enough, no -physical sign of involvement of the nervous system could be -discovered. We were inclined to regard the mental symptoms -as partly due to the syphilitic intoxication, and partly due to -a psychic reaction of the nature of defense. As for the positive -W. R. in the spinal fluid, in early secondaries various -observers differ as to the frequency both of the W. R. and -of other changes, percentages being given that range from -25 to 90%. See case Caperson (45). It is of note that -clinically there were symptoms referable to a syphilitic involvement -of the nervous system; namely, marked headache -and malaise. The headaches of the secondary period are frequently -the result of meningeal involvement.</p> - -<div><span class='pageno' id='Page_284'>284</span></div> -<div class='box'> - -<p class='c013'><b>TABOPARETIC NEUROSYPHILIS (“taboparesis”); -death from TYPHOID MENINGITIS. -Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 82.</b> Frederick Estabrook was a salesman, who, be it -noted, had never had typhoid fever or any disease remotely -resembling typhoid fever. He had acquired syphilis at 19; -had married at 22; was the father of two healthy children -(no miscarriages); had had a certain disturbance of bladder -and rectum, but remained a successful salesman to the age of -28, when advancing tabes confined him to bed for a time. -At 30, mental signs of <span class='sc'>Paretic Neurosyphilis</span> developed, -and death followed at 32, after an acute illness of a week.</p> - -<p class='c007'>The details of the history after the first symptoms at 28 -are as follows:</p> - -<p class='c007'>At twenty-eight patient lost control of limbs and was confined -to the house about two months, under medical care. -Three months later he had regained partial control of his -limbs but had lost all control of his sphincters. After another -month he had returned to work, but did not work steadily -and seemed to have lost ambition. In the summer of 1905, -his mind became obviously altered. He grew indolent and -extravagant and given to buying expensive and useless articles. -Loss of interest in things followed, together with loss -of memory for recent events, lack of insight into illness, delusions -of persecution by wife, irascibility followed quickly by -crying. Before admission to hospital, he was euphoric, drawling -and tremulous in speech, sprawling in penmanship, alternately -depressed and exalted in manner. Knee-jerks were -absent, gait ataxic, pupils stiff to light.</p> - -<p class='c007'>The family history was negative with respect to insanity. -All the family were reported as nervous. A brother died of -peritonitis at twenty-eight, a sister of pneumonia under twenty. -Another brother and sister are living. Father and mother died -of heart trouble at about sixty-seven and sixty respectively.</p> - -<p class='c007'>The patient was at high school one year and was a fair -<span class='pageno' id='Page_285'>285</span>student. Considerable tobacco was used, and some alcohol. -Intoxication denied. There was no history of typhoid fever -or other acute disease.</p> - -<p class='c007'>The patient on admission was sallow, poorly nourished, and -flat-chested, with a slight lateral curvature. There was -slight dulness over right apex in front and in right upper -back. Voice sounds were increased over right apex in front -and over whole right back. The right chest showed bronchial -respiration throughout. The respiration in front of right chest -was of an interrupted character. The liver seemed moderately -enlarged. The urine showed a very faint trace of -albumin. There were a few small nodes in right groin and a -scar on dorsum of penis.</p> - -<p class='c007'><b>Neurological Examination.</b> Slight swaying in Romberg -position. Slight tremor of protruded tongue and extended -fingers. Pupils irregular, left slightly larger than right. Left -pupil reacted to light consensually, but not directly. Right -pupil reacted very slightly to direct light, not consensually. -Knee-jerks and Achilles jerks absent. Ankle clonus absent, -abdominal and cremasteric reflexes brisk. Sharp and dull -points were recognized in the legs with numerous mistakes. -Vocal and facial tremor. Speech slow and drawling. Test -phrases repeated well if care was taken. Consciousness clear. -Orientation perfect. Calculating ability preserved. Many -words omitted in writing. Penmanship clear but shaky.</p> - -<p class='c007'>Hallucinations absent. Memory of recent events poor. -Associations of a logical or defining type. Patient denied -various statements in commitment papers and had little or no -insight into the mental side of his disease—slight euphoria.</p> - -<p class='c007'>After a month’s observation the patient was removed to a -quiet ward and set to work a few days in the scullery. One -night he began to yell as if assaulted and said later that he -had an idea that he was going to die. Before three months -had passed he had become untidy, disorderly, and imperfectly -oriented.</p> - -<p class='c007'>The general degeneration continued rapidly. One week -before death the temperature rose to 103 degrees F., and the -patient succumbed to what seemed clinically like a bronchopneumonia. -Unconsciousness two days before death.</p> - -<p class='c007'><span class='pageno' id='Page_286'>286</span>Note with respect to history of typhoid.—Inquiries of -his physicians, wife, employer, and brother tend to show -conclusively that the patient never had a disease even remotely -resembling typhoid fever.</p> - -<p class='c007'>The <b>autopsy</b> findings were as follows:</p> - -<p class='c007'>Acute conditions:</p> - -<p class='c007'>Hypostatic pneumonia, with early serofibrinous pleuritis -and without lymph node swelling; <b>enlargement of mesenteric -lymph nodes</b>; <b>acute cerebrospinal leptomeningitis</b>; multiple -small hemorrhages of spleen.</p> - -<p class='c007'>Other findings:</p> - -<p class='c007'><b>Scar of penis</b>; <b>sclerosis of aortic arch</b> (Heller’s type?) and -slight coronary arteriosclerosis; <b>calvarium</b> thin and <b>dense</b>; -<b>dura mater thickened</b> and adherent to calvarium; calcified -arachnoidal villi; <b>chronic</b> cerebral and cerebellar <b>leptomeningitis</b>; -<b>atrophy of frontal lobes</b>; <b>granular ependymitis</b>; <b>sclerosis -of posterior columns</b> of spinal cord; emaciation; unequal -pupils; slight parietal fibrous endocarditis, slight mitral sclerosis; -gastro-intestinal atrophy; chronic cystitis; chronic abscess -of prostate.</p> - -<p class='c015'>The description of the head findings is as follows:</p> - -<p class='c015'>Skin exceedingly loose, and the whole skull cap -thinned. The diploë are absent. Adhesion with dura -easily separated. The dura somewhat thickened, but -not distended. Along the longitudinal sinus extensive -calcareous granulations adhere to it. The longitudinal -sinus does not contain blood, and the inner surface -is normal in color. The pia is extensively thickened -and opaque and a general subpial exudate exists which -is more marked over the vertex where it lifts the pia -from the brain surface to the extent of three centimeters -in Rolandic, superior frontal, intraparietal, -and mesial precentral sulci on each side. The arteries -at base are free from atheroma. The temporal lobes -are much bound down by adhesions, as is the cerebellum. -Post mortem softening is evident. The hemispheres -show no asymmetry, but the frontal convolutions are -markedly atrophic. The corpus callosum is united to -the cortex by old adhesions and has to be dissected -away from it. Lateral ventricles contain some slight -amount of cloudy fluid, and the pia along the vessels -<span class='pageno' id='Page_287'>287</span>is opaque. Some granulations in ependyma. Brain -weight, 1305 grams. Pons and cerebellum, 195 grams.</p> - -<p class='c015'>Cord.—Dura much thickened, and the pia corresponds -to its appearance in brain with a like exudate. -Cross sections of cord show sclerosis of posterior -columns.</p> - -<p class='c015'>Bacteriologically the <em>typhoid bacillus</em> was cultivated -<em>from the meninges and from the swollen mesenteric lymph -nodes</em>. The blood was negative; the intestines were -negative so far as lesions were concerned.</p> - -<p class='c007'>The microscopic examination confirmed the clinical diagnosis -of <span class='sc'>General Paresis</span> and of <span class='sc'>Tabes</span>, since there was -not only an extensive chronic encephalitis, with the usual -lymphocytic and plasma cell deposit and irregular gliosis, -but also a well marked posterior column sclerosis, not unusual -save in its extreme degree.</p> - -<p class='c007'>It might be surmised that some difficulty would arise in -distinguishing the effects of paretic meningoencephalitis from -those of the more recent typhoidal process. The well-known -tendency of typhoidal processes to escape polynuclear exudation, -at least until frank necrosis has set in, gave rise to -the idea that the two mononuclear pictures—that of general -paresis and that of typhoidal processes—might be confusing.</p> - -<p class='c007'>The picture presented by the meninges was scarcely what -might be expected. Although numerous mononuclear phagocytic -cells are everywhere found, yet the predominant -picture is that of a polynuclear exudation.</p> - -<p class='c007'>The polynuclear leucocytes occur in greatest numbers in -the tissue spaces, especially in the meshes of the lumbar arachnoid -and in the spaces of the frontal and paracentral pia -mater. In the lumbar region of the spinal arachnoid wide -fields occur in which the cells are almost one hundred per -cent polynuclear leucocytes. In places phagocytic cells occur, -and in a few fields, even in the open tissue spaces, the -number of phagocytic cells may arise to fifty per cent. -Edema is a considerable feature in the meninges. Fibrin is -found chiefly in the cerebral meninges and appears in numerous -delicate strands in the tissue spaces.</p> - -<div><span class='pageno' id='Page_288'>288</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c002'> - <div class='linegroup'> - <div class='group'> - <div class='line'>Moloch, horrid king, besmeared with blood</div> - <div class='line'>Of human sacrifice, and parents’ tears;</div> - <div class='line'>Though, for the noise of drums and timbrels loud,</div> - <div class='line'>Their children’s cries unheard that passed through fire</div> - <div class='line'>To his grim idol.</div> - </div> - <div class='group'> - <div class='line in28'>Paradise Lost, Book I, lines 392–396</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_289'>289</span> - <h2 class='c005'>IV. MEDICOLEGAL AND SOCIAL</h2> -</div> - -<div class='box'> - -<p class='c013'><b>Neurosyphilis in a public character: eloquence, -reformatory efforts, notoriety.</b></p> - -</div> - -<p class='c006'><b>Case 83.</b> Major Isaac Thompson, M.D., was a character. -He had been regarded as eccentric for many years prior to -his death at 63. In fact, it seems that there had been more -or less definite symptoms and signs about his fortieth year. -The doctor himself had a ready explanation for his Argyll-Robertson -pupils; he explained that he had had a peculiarly -heavy smallpox at about the age of 27 (which would be -about 1872).</p> - -<p class='c007'>The doctor had a good secondary education, he had gone -through the Civil War as a hospital steward, went into business -after the war, married, and then went to the medical -school, graduating at the age of 34. He continued in practice -for a dozen years, and then gave it up. For years he -had been especially interested in certain literary lines and -he had published any number of pamphlets, all of a somewhat -striking description, often with a political color and -intended to stir up reform measures. The doctor never bore -a very good reputation, and years later it was recalled that -certain books disappeared from libraries and their loss was -almost certainly traced to Dr. Thompson. In general, however, -he was considered to be a rather worthy local figure.</p> - -<p class='c007'>It is possible that a fall on the ice in his 61st year actually -started the fatal process, since after that time the patient -had difficulty in walking, and a few months later developed -periods of excitement with peremptory insistence on obedience -to his wishes. Whereas formerly the doctor had -finished up one literary piece of work after another, he now -began to do very scattering work. He appeared in public -<span class='pageno' id='Page_290'>290</span>to denounce certain financial schemes with great force and -unusual eloquence. His eloquence was greatly complimented, -and these compliments induced the doctor to a -remarkable crusade against a certain corporation; there was -so much truth mixed with the fiction of his eloquence that -he obtained a considerable following in his campaign. He -wanted to start a bureau of information for the instruction -of the public on these matters, and he planned to put up a -building adjoining his own home for the accommodation of -the various clerks and writers in this bureau. However, -before the building had been actually started, an outbreak -occurred.</p> - -<p class='c007'>One morning the doctor was very excitable and noisy over -the telephone, ordering typewriters and giving directions to -mechanics. He repaired to Boston in connection with certain -resources that he supposed (and gave others reason to -believe) had been supplied by the Government and by a -large newspaper. One evening he returned very late. It -appeared that he had had a fracas at a hotel and had knocked -down one or two colored porters, acting as though drunk. -Upon being put to bed, the doctor talked incessantly of -religious matters, proposing to undertake a Sunday School -class. His interlocutor did not exhibit a particular interest -in this scheme, whereupon Dr. Thompson threatened him -with violence. Police and doctors were called in and a constant -stream of conversation lasted for hours. The patient -was finally brought to Danvers Hospital upon representation -by physicians, to whom he told that his luck had -turned, that he was about to be made senator from the -district, and that he and Roosevelt were going to break up -the trusts, and that, as a matter of fact, he was a relative -of Mr. Roosevelt.</p> - -<p class='c007'>Upon admission, the patient was a well preserved and -well groomed man with gray hair and beard. He was somewhat -pallid but his teeth were well preserved and well cared -for, and there was little or no physical change except a slight -hypertension. He claimed that he had suffered from kidney -disease for some years, and there was in fact a trace of -albumin in the urine.</p> - -<p class='c007'><span class='pageno' id='Page_291'>291</span><b>Neurologically</b>, the plantar and Achilles reactions could -not be obtained, but there were no other reflex disorders -except the bilateral Argyll-Robertson pupil. The doctor’s -explanation for these stiff pupils, which he described as -existing for many years, was frank and circumstantial, so -that the unlikelihood of Argyll-Robertson pupils due to smallpox -was rather frowned upon by him. Without entering upon -a detailed description of the clinical symptoms and course -of the disease which led to death a little over a year after -admission, it may be said that the differential diagnosis lay -between the expansive form of general paresis and a maniacal -condition, presumably the maniacal phase of manic-depressive -psychosis. From the data of a special staff meeting -held upon the case, we learn that the diagnosis of manic-depressive -psychosis was entertained more strongly than that -of general paresis. Thus, for general paresis alone was the -somewhat gradual onset with increasing excitement, accompanied -by expansive delusions concerning unlimited finance, -personal over-importance, and Argyll-Robertson pupils. -Dismissing the Argyll-Robertson pupils from consideration, -the diagnosticians were led to see in the constant motor -activity displayed in conveying an enormous number of -thoughts on paper, inconsistent talking with digressions, a -manic-depressive psychosis. There was no amnesia and no -other sign of mental deterioration. There was a certain -improvement early in the hospital stay of the patient. -Consciousness was clear and orientation perfect. The delusions -themselves, though extravagant, were not inconsistent -or fantastic. The hallucinatory disorder was hardly -characteristic either of manic-depressive psychosis or of -paresis.</p> - -<p class='c007'>The patient might be described as “interesting.” A -good preliminary training with years of travel and variety -of occupation, furnished him with a fund of knowledge. -An excellent memory, prompt replies and repartee, endless -digressions with voluntary return to the original topic, -caused him to be an amusing and even instructive interlocutor. -However, his commitment and confinement in the -institution seemed always entirely wrong, and he expressed -<span class='pageno' id='Page_292'>292</span>mixed feelings about the family, now being bitter against -them, and again condoning their mistakes. The patient’s -conduct was good and he was tidy in habits, and tried as -far as possible to conform to the requirements of the hospital. -The doctor showed a marked antipathy toward a -certain male attendant, who had removed articles from his -clothing upon admission and had reclaimed a book on rules -and regulations. The doctor prepared a list of 327 different -acts of abuse, lack of care, and insubordination which -he said he had observed in the hospital.</p> - -<p class='c007'>In the last weeks of the patient’s illness, his ideas became -more expansive and extravagant, dealing with a grapevine -system of wireless communication and delusions of unlimited -wealth. He would at times keep his room flooded -with urine and water for the purpose of keeping down the -plague which he said was infecting the hospital. Later he -mixed food with urine and other ingredients, claiming that -he was constructing an elixir of life.</p> - -<p class='c007'>The <b>autopsy</b> showed few changes of the calvarium or of -the dura mater, nor was the pia mater more than slightly -thickened and milky over the frontal poles, along the longitudinal -fissure and over the sulci. There were fairly firm -adhesions of the pia mater to the dura mater along the -longitudinal fissure and over the frontal poles and at the -temporal tips. The hemispheres were firmly interadherent, -and the cerebello-pontine tissues were covered with a firm -leptomeningitis. The floors of the ventricles were smooth -and the basal vessels showed little beyond a few spots of -sclerosis. There was a generalized increase of consistence. -The frontal gyri were rather prominent with wide sulci, but -upon section no very marked atrophy of the gray matter -could be shown. The rest of the brain failed to show any -flaring of sulci or any special evidence of cortical atrophy. -The brain weighed 1250 grams; a possible diminution of 100 -grams, considering the patient’s body length. However, it -must be remembered that he was at this time 63 years -of age.</p> - -<p class='c007'><b>Microscopically</b>, the diagnosis of <span class='sc'>General Paresis</span> was -confirmed on the basis of plasmocytosis, lymphocytosis, gliotic -<span class='pageno' id='Page_293'>293</span>changes and nerve cell destruction. There was an unusual -variation in the degree of the destructive process, which -picked out, for example, certain regions of the right side -for maximal lesion (cornu ammonis, gyrus rectus, and superior -frontal gyrus).</p> - -<p class='c007'>If the patient’s own estimate of 35 years’ duration for -his Argyll-Robertson pupils can be trusted (and in general -his memory was extremely good), we may well conceive an -unusual duration for the process in his case. There was, -however, in the body at large no very marked degree of -changes. There was a slight old tuberculosis. There was -a slight interstitial nephritis, with cardiac hypertrophy and -fibrous myocarditis. There was also a sclerosis of the mitral -and aortic valves; there were chronic changes in the spleen, -liver, and bladder; there was generalized arteriosclerosis of -mild degree; there were two round gastric ulcers near the -pylorus. The liver weighed but 800 grams, and its left -lobe was somewhat rough.</p> - -<p class='c007'>This case is placed among the medicolegal and social -cases because the phenomena that ushered in his last illness -were mistaken by the local public for meritorious social -reform measures. They were regarded as not markedly -different from the variety of steps taken by the very active -doctor in previous years; indeed the public eloquence that -he displayed a year before his death was quite in line with -previous habits, despite the suspicious over-brilliance of -language. It is an important question, how far the eccentricity -and literary overactivity of the latter half of the -doctor’s total life can be explained on the basis of a mild -syphilitic irritation of the nervous system. In this connection -we are tempted to recall the suggestions of Mœbius -concerning a portion of the literary products of Nietzsche. -Our doctor was by no means so brilliant an exemplar of -syphilitic literature as was Nietzsche, if we grant the hypothesis -of Mœbius to cover our doctor’s case as well as -that of Nietzsche. In the future, important studies of -character change under the influence of syphilis will doubtless -be made. With modern diagnostic methods, of course, -the diagnosis would have been rendered almost at once in -<span class='pageno' id='Page_294'>294</span>the case of Major Isaac Thompson, M.D., and much of his -past life would have been brought under special review in -connection with the syphilis which doubtless the blood -serum or at any rate the cerebrospinal fluid would have -shown.</p> - -<p class='c007'>This case illustrates but one of the many social complications -arising as the result of paresis. When one recalls -that the onset is often insidious and not correctly understood -for a period of time, it is readily seen that many unfortunate -acts may be committed by a patient. As hypersexual -desire is not an infrequent early symptom and as judgment is -early disturbed, loose morals may ruin the patient’s reputation. -The poor judgment and expansive delusions often lead to -foolish business deals wherein the patient’s family is left -destitute. At other times the onset is sudden and then the -danger of false commands or acts by a person in a responsible -position, as a steamship captain, an engineer or chauffeur, -may lead to loss of life and property.</p> - -<div><span class='pageno' id='Page_295'>295</span></div> -<div class='box'> - -<p class='c013'><b>Sudden grandiosity: debts. PARETIC NEUROSYPHILIS -(“general paresis”): Question of liability.</b></p> - -</div> - -<p class='c006'><b>Case 84.</b> Lester Smith was a salesman, 31 years of age, -who, while on a business trip, accompanied by his wife, -suddenly developed grandiose ideas. He originated a scheme -of cornering the phonograph market. His prospects seemed -so certain to him, that he hired an expensive suite of rooms -in a hotel at something over $35 a day. As at the first -presentation of his bill it was found that he had no money -to meet these charges, he was taken into custody and at -once transferred to a hospital for the insane, where it was -discovered that he was suffering from <span class='sc'>General Paresis</span>.</p> - -<p class='c027'>1. What is the patient’s responsibility for these debts? -Legally the patient or his estate is responsible for -debts accruing from services rendered or goods received. -As he is adjudged <i><span lang="la" xml:lang="la">non compos mentis</span></i> contracts -entered into would not hold, and he would not -be considered liable for criminal acts.</p> - -<p class='c007'>Note: This case shows how dangerous paresis may be -not only to the life and usefulness of a patient, but further -how it may ruin a family financially. Mr. Smith’s little -escapade used up all the money that he had been able to -save in his life and when he was taken to a hospital his wife -was left destitute.</p> - -<div><span class='pageno' id='Page_296'>296</span></div> -<div class='box'> - -<p class='c013'><b>Suicidal attempt (?) by a neurosyphilitic.</b></p> - -</div> - -<p class='c006'><b>Case 85.</b> At first Mrs. Annie Monks, a widowed seamstress, -50 years of age, did not particularly suggest syphilis. -Mrs. Monks was sent to us from a general hospital. She -had been found unconscious in her room, with gas turned -on, and a diagnosis of gas poisoning was made. Mrs. Monks -remained unconscious for 24 hours, and her apparent suicidal -attempt seemed to warrant her being sent to the -Psychopathic Hospital. Mrs. M., however, scoffed at the -idea of any attempt at suicide, and claimed to have had no -recollection of any such affair. On the contrary, she had -gone to mass the morning of the day on which she was -taken to the hospital, remembered well enough returning -to her room but nothing of what followed until she woke up.</p> - -<p class='c007'>Mrs. Monks was not coöperative and would reveal few -facts about her history. For years, she had had edema of -the feet and palpitation of the heart (the heart was somewhat -enlarged, with a double murmur in the aortic area, -systolic louder, and a blood pressure of 160 systolic and -85 diastolic; clubbed fingers; palpable liver). She had -been treated in the out-patient department of a general -hospital for a number of months. We could obtain no -evidence of mental impairment, particularly none of memory.</p> - -<p class='c007'>Aside from the heart lesions above indicated, the patient -was fairly well nourished, with a slight enlargement of -superficial glands, and was otherwise normal.</p> - -<p class='c007'><b>Neurologically</b>, the slightly irregular pupils reacted poorly -to light; the right knee-jerk could not be obtained, whereas -the left knee-jerk was very active. Systematic examination -revealed no other disorder except that the abdominal reflexes -could not be obtained.</p> - -<p class='c007'>Here we have, in a cardiac patient, a possibly or probably -accidental gas poisoning, and little to go upon for a profounder -diagnosis than the sluggish irregular pupils and -unilateral absence of knee-jerk.</p> - -<p class='c007'><span class='pageno' id='Page_297'>297</span>The routine serum W. R. came through as positive. Following -custom, we examined the spinal fluid, finding the -W. R. here again to be moderately positive (strongly positive -to 1 cc., moderately to 0.7 cc., and negative to 0.5, 0.3, -and 0.1 cc.). The gold sol index was 1 2 2 1 0 0 0 0 0 0, -which must be interpreted as syphilitic. There were 16 -cells to the cmm., the albumin was 1+, and the globulin stood -at 2+.</p> - -<p class='c007'>Here, then, we seem to have evidence of an inflammatory -process of the central nervous system, and it is natural -forthwith to be sceptical as to the accidental nature of the -gas poisoning. Perhaps there was an attempt at suicide -based upon a passing impulse, or perhaps there was a period -of confusion in which the cock was not turned off.</p> - -<p class='c007'>In any event, we feel justified in making the diagnosis of -cerebrospinal syphilis on the basis of the neurological and -laboratory findings. On the whole, we are inclined to -make a diagnosis of <span class='sc'>Vascular Neurosyphilis</span> with a moderate -involvement of the <span class='sc'>Meninges</span>.</p> - -<p class='c027'>1. What is the outcome in such cases as that of Annie -Monks? The case somewhat resembled that of Martha -Bartlett, who still survives. The case of Annie Monks -illustrates another outcome. A few days after her -admission, she became unconscious once more, and -upon recovery remained very much confused and -aphasic, moaning, and unable to handle herself well, -although without definite paralysis. Three weeks -later the patient died, although in the meantime -strenuous antisyphilitic therapy was practised. Death -was sudden. We thought death due to cerebral -embolism.</p> - -<div><span class='pageno' id='Page_298'>298</span></div> -<div class='box'> - -<p class='c013'><b>Early delinquency and neurosyphilis in a juvenile.</b></p> - -</div> - -<p class='c006'><b>Case 86.</b> Frank Johnson was 21 years of age when he -was taken up by the police for threatening his sister with -a revolver. The police thought he deserved an examination -at the Psychopathic Hospital. The patient protested -that he had threatened his sister only to frighten her because, -he said, she nagged him and made him nervous. In -fact, they had always had trouble as she had always nagged -him and they had always fought together. Moreover, their -mother always took the sister’s part. They had been troubling -him for days, and at last Frank could stand it no longer. -His sister had complained of the way he treated her dog. -Moreover, Frank said he had not been feeling well; there -had been some trouble with his stomach; and after one of -the nagging attacks, he had taken out an old empty pistol -to scare his mother and sister.</p> - -<p class='c007'>In these cases, it is good practice to consult the sister also. -She said that Frank had always been very difficult to manage, -unwilling to work, preferring to loaf about, spending -every obtainable cent; he was once in a reformatory for -several years, but not reformed thereby; recently given to -drinking; at times acting somewhat peculiarly (sitting at -the window with his hat on, refusing to move).</p> - -<p class='c007'>Further <b>mental examination</b> of Frank showed that he was -properly oriented and in possession of a good memory, although -he was quite obviously a liar. He lay about in bed at -the hospital, saying that he was too weak to be up. He was -a bit dull, at times not readily grasping ordinary questions.</p> - -<p class='c007'><b>Physically</b>, Johnson was rather thin; the teeth were somewhat -peg-shaped although far from typically Hutchinsonian. -The pupils were unequal and irregular, and failed to react -to light or even to accommodation when tested. The deep -reflexes of arms and legs could not be obtained, though the -superficial reflexes were present. For the rest systematic -examination proved negative. Serum W. R. negative.</p> - -<p class='c007'><span class='pageno' id='Page_299'>299</span>The first thought in such a case would be that the criminological -diagnosis of delinquency would be sufficient. However, -the pupillary disorder and the areflexia are suggestive -despite the negative serum W. R. Resort was naturally had -to lumbar puncture, whereupon a positive W. R. was found, -a characteristically “paretic” gold sol reaction, globulin, excess -albumin, and 134 cells per cmm. In short, it would appear -that we must consider a diagnosis of <span class='sc'>Juvenile Paresis</span>, -and, in point of fact, the patient deteriorated rapidly from -this time, becoming demented at the end of a few months.</p> - -<p class='c027'>1. How far are the early difficulties of management (leading -to a reformatory) due to syphilis? We should not -dogmatically say that there is a relation between the -early delinquency and syphilis. Still, it is not unusual -to find emotional disorder and instability as well as -delinquency in congenital syphilitics.</p> - -<p class='c027'>2. What suggestion, if any, should be made to the patient’s -intelligent and seemingly normal sister, two years -older? We prevailed upon Miss Johnson to submit -to the W. R. of the serum, which was found, as in the -case of Frank, to be negative. Frank’s sister should -undoubtedly submit to a lumbar puncture; but in -the present phase of mental hygiene, she would be -difficult to persuade.</p> - -<p class='c027'>3. How is it possible to find such a marked evidence of -congenital syphilis in a younger sibling with no evidence -of syphilis in the elder? In the first place, there -may be a history of entrance of syphilis into the lives -of the parents between the pregnancies. However, in -other instances, there is no evidence of such intercurrent -syphilis, and contrary to the prevailing opinion -it is not so infrequent to find congenital syphilis in -the younger brother or sister of a normal person.</p> - -<p class='c027'>4. What can be said of treatment in such cases? In the -first place it is clear that delinquent cases should be -tested far earlier for the possibility of syphilis. Had -this case been examined by a neurologist or alienist -many years earlier, it is probable that the same pupillary -signs and the peg-shaped teeth would have been -found, and that the hypothesis of syphilis might have -been raised. There is no good evidence as yet that -these cases can be markedly benefited by treatment.</p> - -<div><span class='pageno' id='Page_300'>300</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis in a “defective delinquent.”</b></p> - -</div> - -<p class='c006'><b>Case 87.</b> Vivian Walker, 22 years of age, was arrested -on the streets of Boston for drunkenness. Upon arrival at -the jail, she developed a series of convulsions, each lasting -a very brief time, with loss of consciousness, frothing at the -mouth, and jerky movements of the arms and legs.</p> - -<p class='c007'>The Walker family was known to the police, since there -were police records in two generations on the maternal side. -The father was regarded as of rather low-grade mentality; -a sister had committed suicide. Vivian herself had been -irregular at school, was regarded as vicious, and had been -hysterical. She had been committed to a reformatory at -the age of 15 years. In the reformatory she had a number -of excited outbreaks, with resentment of discipline, and these -outbreaks presented hysterical traits. After each outbreak -Vivian was depressed. It was during her stay at the reformatory -that her sister committed suicide. Vivian attended -the funeral, and the idea of suicide appears to have -taken hold of her mind, as she constantly spoke of suicide, -threatened suicide, and made several attempts. She claimed -at this time to see visions and to hear her sister’s voice. -On that ground she had been committed to a hospital for -the insane at 16.</p> - -<p class='c007'>At the hospital there were many fluctuations in mental -condition. Vivian professed discouragement on account of -poor home influences, telling how her mother had often been -in prison, allowing Vivian to come under the influence of -bad girls. Now and then Vivian had outbreaks of profanity -and glass-breaking, and she also made at the hospital -for the insane several half-hearted attempts at suicide. At -the age of 19 she was returned to the reformatory, whence -she was placed out on probation and allowed to return home.</p> - -<p class='c007'>However, she was shortly re-committed to the insane -hospital in a phase of excitement, talking continuously of -men and sex relations, and also of imaginary illicit sex relations -<span class='pageno' id='Page_301'>301</span>with any man whom she happened to see. Again -from time to time she made attempts at suicide. However, -she was allowed to go out on visit, returned to her habits, -and at the time of her arrest was living as a prostitute.</p> - -<p class='c007'>After her convulsions in jail, she was admitted to the -Psychopathic Hospital. At first obstinate and stubborn, -later she became tractable. Special mental tests left her -in the subnormal class, but we could hardly class her as -feebleminded. We were able to observe her in a number -of seizures, during which she would drop to the floor, apparently -lose consciousness, writhe about, and assume the -position of opisthotonos, the whole attack lasting but a -minute or two.</p> - -<p class='c007'>There was pelvic tenderness, with gonococci in the urethral -smear. Salpingectomy had to be performed, but after the -operation Vivian insisted upon getting up and running about -on the second day, tearing the bandages from her abdomen, -and infecting the wound. Outbreaks of excitement also -followed the operation.</p> - -<p class='c007'>In the diagnosis of this case, we must probably separate -the convulsive phase from the remainder of the phenomena. -The conduct disturbance, emotional outbreaks, and suicidal -attempts date from early youth, and no doubt the diagnosis -defective delinquent would fit Vivian from the beginning. -The hereditary taint is characteristic enough. The sundry -phenomena in the insane hospital, and particularly the hallucinations, -lead one to wonder whether Vivian is not possibly -even suffering from dementia praecox.</p> - -<p class='c007'>As to the convulsions, it would hardly appear that they -are typically epileptic, although certainly epileptoid. Their -onset at 22 is somewhat unusual. Several features of the -seizures together with the opisthotonos and the previous -history of hysteria, lead one to think of making the diagnosis -hysteria.</p> - -<p class='c027'>1. Can cerebrospinal syphilis cause the symptoms? We -found the serum W. R. to be positive though Vivian -denied syphilitic infection. (She also denied gonorrhœal -infection despite the clinical and laboratory -findings.) We found that the spinal fluid yielded a -<span class='pageno' id='Page_302'>302</span>gold reaction of a typical syphilitic nature, showed an -excess of albumin, a slight amount of globulin, and -130 cells per cmm. Even these findings, however, -would perhaps not justify stating that the convulsive -seizures are of syphilitic nature. The seizures disappeared -under the administration of antisyphilitic -remedies. It would seem, therefore, that the seizures -should be regarded as of syphilitic nature. In any -event, the diagnosis of cerebrospinal syphilis is justifiable. -This syphilis, however, is of an active nature -and probably of recent production. We should be at -a loss to explain the earlier mental features in Vivian -as syphilitic and are therefore fain to associate the two -psychoses, <span class='sc'>Psychopathic Personality</span> and <span class='sc'>Diffuse -Cerebrospinal Syphilis</span>.</p> - -<div><span class='pageno' id='Page_303'>303</span></div> -<div class='box'> - -<p class='c013'><b>NEUROSYPHILIS (“paresis sine paresi”) in an -habitual criminal, a forger.</b></p> - -</div> - -<p class='c006'><b>Case 88.</b><a id='r17' /><a href='#f17' class='c014'><sup>[17]</sup></a> —— was brought to the hospital by the -police. He was charged with having forged a check, and on -account of the crudeness of the work his mental condition -was suspected.</p> - -<p class='c007'><b>Family History.</b> The paternal grandfather was considered -fast, drank a great deal and was said to be a thief. The -father is said to have been forced to leave the State when a -young man in order to avoid the reformatory. Paternal -cousin murdered a man; the sisters of this cousin said to have -been wild and one brother married a prostitute. Nothing -known of maternal relatives.</p> - -<p class='c007'><b>Past History.</b> Medical history is unimportant. He denies -syphilis. His early childhood is of little significance. He -was somewhat dull in school. At about the age of twelve he -began to lie and steal, and has continued this ever since. -His attempts have all been very crude, it is said, and when -confronted he would strenuously deny his deeds, even when -the evidence was overwhelming. He forged checks, borrowed -money from all his friends, and charged things at stores to -the family. The family paid the bills for a time, and then -later had him sent to a reform school. He was married at -nineteen, but wife has left him and obtained a divorce. He -has been excessively alcoholic for years, and is suspected also -of taking drugs. He was discharged from the navy dishonorably. -He later joined the army and was discharged therefrom -on account of “rheumatism,” according to his account, -but in reality deserted. He had finished a jail sentence of -thirteen months for forgery a little over a year before entrance.</p> - -<p class='c007'><b>Physical examination</b> shows a well developed and nourished -man. The general physical examination is negative. -<span class='pageno' id='Page_304'>304</span>The lungs show nothing abnormal. The heart is not enlarged, -there are no murmurs or irregularities; blood pressure, 145 -systolic. The alimentary system is negative. No palpable -lymph glands. <b>Neurological examination</b>: pupils equal and -react to light and accommodation. Extraocular movements -well performed. Tongue projects in the median line, with no -tremor. There is no evidence of facial paresis or weakness -of the muscles. The biceps, triceps, knee-jerks and ankle-jerks -are present and equal on the two sides. There is no -Gordon, Babinski or Oppenheim; no ankle clonus. There is -no tremor of the extended hands. No Romberg sign. There -is a little difficulty in the finger-to-finger test. There is no -sensory disturbance either subjective or objective. No tenderness -over nerve trunks.</p> - -<p class='c007'><b>Mental examination</b> shows nothing of a psychotic nature. -Patient is well oriented; memory for remote and recent -events is well preserved, school knowledge well retained, grasp -on current events good; no delusions or hallucinations elicited. -Patient is not feebleminded, according to the intelligence -tests of Binet and Simon and Yerkes-Bridges, but shows poor -attention and gives evidence of weakness in volitional spheres; -is very suggestible.</p> - -<p class='c007'>To summarize the case, then, we have a man of thirty years -of age who has shown criminalistic and anti-social tendencies -since childhood, whose general physical and neurological examination -is negative (excepting the laboratory tests), whose -mental examination shows no psychotic symptoms, and who -seems not feebleminded. In other words, with the exception -of the serological and chemical findings in the blood -and cerebrospinal fluid, there is nothing to suggest that he is -more than a “criminal type.”</p> - -<p class='c007'>Wassermann reaction in blood serum positive.</p> - -<p class='c007'>Wassermann reaction in cerebrospinal fluid positive. Examination -of cerebrospinal fluid: globulin ++, albumin ++, -cells 55 per cubic millimeter; large lymphocytes, 9.1 per -cent; small lymphocytes, 90 per cent; plasma, 90 per cent. -Gold sol reaction, 3321000000.</p> - -<p class='c027'><span class='pageno' id='Page_305'>305</span>1. Can the criminalistic tendencies be condoned in this -case on the ground of neurosyphilis? As a matter of -fact the delinquencies in this patient reach back to -early childhood and as there is no evidence of congenital -syphilis it cannot be held that syphilis had any -bearing in the causation of symptoms. Even were the -delinquencies only of recent date it is doubtful if the -court would take cognizance of the laboratory findings -in the absence of definite mental symptoms. In this -connection it may be stated that the court takes cognizance -only of the acts of a patient at time of examination, -and not of the history or laboratory findings, -in committing a person. We have had several patients -who from history, physical signs and laboratory tests -made the diagnosis of paretic neurosyphilis easy and -yet who could not be committed because they were -mentally clear at the time. Such patients may be of -grave potential danger to themselves and families, and -present numerous social problems. See case of Joseph -Wilson (95).</p> - -<div><span class='pageno' id='Page_306'>306</span></div> -<div class='box'> - -<p class='c013'><b>JUVENILE PARETIC NEUROSYPHILIS (“juvenile -paresis”) with initial trauma.</b></p> - -</div> - -<p class='c006'><b>Case 89.</b> Margaret Tennyson was a small girl of six -years, described as having been normal until run down by a -double-runner sled about 13 months before her arrival at the -hospital. The change was stated to be remarkable. “She -was as unlike her own self as darkness and daylight.” Once -fat and sunny, talkative and demonstrative with her toys, now -Margaret had become silent, sullen, worried, and of a violent -temper, stubborn and unmanageable. It does not appear -that the patient was seriously injured by the double-runner, -as she was able to walk a short distance home. Shortly, -however, she began to have trouble with her feet (diagnosed -at the time as flat-foot), and thereafter her whole character -and disposition changed. Upon arrival at the hospital, the -patient walked with a typical scissors gait of spastic paraplegia.</p> - -<p class='c007'><b>Physical examination</b> was very difficult through lack of -coöperation and a screaming and kicking resistance upon -every attempt. There was a suggestion of hydrocephalus -in the protrusion of the forehead. The pupils reacted readily -to light and accommodation. The knee-jerks were active, -but there was otherwise no disorder of reflexes. The patient -had great difficulty in getting up from the floor, and for the -most part insisted upon lying in ventral decubitus on the floor, -crying when attempt was made to raise her. An attempt -was made to test her by the Binet scale, by which she was -found to rate at 2⅘ years although a portion of this low-rating -was thought to be due to a failure of coöperation.</p> - -<p class='c007'>The <b>family history</b> threw little or no light upon the case. -The parents were living and well; a brother of 16 years was -at work in the market district; two of the other siblings are -in the first and second grades at school and regarded as exceptionally -bright by their teachers. The fourth was the -patient, Margaret; a fifth had died at 9 weeks of heart trouble; -the sixth, seventh, and eighth, of 3, 1½ years and 3 months -respectively, appeared entirely well. There were no miscarriages -or stillbirths.</p> - -<div class='figcenter id002'> -<img src='images/i_306.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Juvenile paresis—spastic paraplegia. 5 years.</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_307'>307</span>The scissors gait and spasticity seem to point undoubtedly -to organic disease of the nervous system, along with which -the mental deterioration seemed to suggest an active progressive -involvement of the cerebrum. The history seemed -to be convincing that the child was not an instance of congenital -feeblemindedness.</p> - -<p class='c007'>A neurologist’s clinical diagnosis would naturally be syphilis. -In point of fact, this diagnosis was borne out by the laboratory -tests, which showed a positive W. R. in the serum and spinal -fluid, positive globulin, a slight excess of albumin, and a -syphilitic gold sol reaction.</p> - -<p class='c027'>1. What is the significance of the trauma in the case of -Margaret Tennyson? The trauma seemed to the -family the precipitating cause. We find cases of general -paresis in adults very definitely following trauma, -yet neurosyphilis, both in adults and in younger patients, -mainly occurs without trauma. On the whole, in this -case, it is perhaps safer to regard the trauma as mere -coincidence. A sister older than Margaret was found -upon examination to have a positive W. R. The other -children could not be examined.</p> - -<div><span class='pageno' id='Page_308'>308</span></div> -<div class='box'> - -<p class='c013'><b>Traumatic form of PARETIC NEUROSYPHILIS -(“general paresis”).</b></p> - -</div> - -<p class='c006'><b>Case 90.</b> The point about Joseph O’Hearn was his entire -mental soundness up to the time of an injury at work, when -he was blown through a double window in an explosion, -badly bruising his head. Shortly after the accident, although -not immediately, the patient began to show signs of mental -disorder, doing very foolish things, losing his memory, and -becoming unable to work.</p> - -<p class='c007'>It was eight months after the explosion when O’Hearn, at -the age of 36, was admitted to the hospital with general mental -impairment. O’Hearn was confused and disoriented for -time and place, although he seemed to understand that he -was in a hospital. He was given to foolish laughter and a -silly manner. There was considerable emotional disorder; -judgment was clearly impaired, and memory was poor.</p> - -<p class='c007'><b>Physically</b>, there was little to be found except upon <b>neurological -examination</b>. The right knee-jerk was greater than -the left; the tongue and fingers showed marked tremor, there -was a speech defect and writing disorder.</p> - -<p class='c007'>On the whole, it seemed impossible not to make the diagnosis -<span class='sc'>General Paresis</span>, especially in view of the laboratory -tests, with positive W. R. in both serum and fluid, a “paretic” -type of gold reaction, 59 cells per cmm., excess albumin, -and a large amount of globulin.</p> - -<p class='c027'>1. What is the relation of the trauma to the paresis? -Trauma is regarded as a precipitating cause, and Industrial -Accident Commissions have been known to -allow damages in such cases. Mott believes that the -symptoms of a post-traumatic paresis must not develop -until after a week’s interval of freedom from symptoms, -since he believes that time is required to destroy or -irritate the brain to the point of producing the paretic -picture. Our data are in agreement with those of -Mott. Mott also points out that gumma sometimes -occurs at the site of the trauma.</p> - -<div><span class='pageno' id='Page_309'>309</span></div> -<div class='box'> - -<p class='c013'><b>False claim for compensation in neurosyphilis.</b></p> - -</div> - -<p class='c006'><b>Case 91.</b> The facts in the case of Levi Sussman can be -brought out by the following extracts from a report to the -Industrial Board: A claim was made to the Board that the -symptoms had developed after a fall from a building, some -<em>nine months before hospital observation</em>. No connection could -be found between this accident and the <span class='sc'>Paretic Neurosyphilis</span> -found. We introduce the case to emphasize the -possibility that irrelevant accidents may be regarded by -ignorant or unscrupulous persons as setting up a mental -disorder for which damages are claimed. If symptoms are -already in existence before the accident and are not especially -increased thereafter, naturally no damages should be recovered. -Unscrupulous persons may falsify about the pre-traumatic -history and claim the development of symptoms -immediately after the accident. Such claims are beyond -question to be viewed with the greatest suspicion. Some -days or weeks should elapse before definite symptoms in -post-traumatic paresis appear. Just how long an interval -may elapse between trauma and paretic symptoms and shall -entitle the case to be regarded as one of traumatic paresis, -is perhaps a matter of doubt. It would seem, however, on -general grounds that three months is the longest period in -which the post-traumatic effects are likely to be delayed.</p> - -<p class='c007'>The question of traumatic paresis is of great interest on -account of the war. The great strain under which the men -at the front live and the physical injury due to being -“buried” is probably responsible for an increasing number -of cases of neurosyphilis. Such at least is the impression -of Canadian medical officers with whom we have spoken. -See Section VI, Neurosyphilis and the War.</p> - -<div><span class='pageno' id='Page_310'>310</span></div> -<div class='box'> - -<p class='c013'><b>Traumatic exacerbation(?) in PARETIC NEUROSYPHILIS -(“general paresis”).</b></p> - -</div> -<p class='c006'><b>Case 92.</b> The case of Joseph Larkin was of note from the -point of view of the Industrial Accident Board. This Irish -teamster was said to have been injured in his head two or -three months before coming up for examination at the age of -45. For a week Larkin had had frontal headaches, had been -sleeping poorly, and had been somewhat worried. In fact, -he had stopped work. The W. R. of the serum was positive -and a diagnosis of <span class='sc'>Paresis</span> could be made. The case did not -come up for consideration by the Industrial Board until two -years after his initial appearance.</p> - -<p class='c007'>The <b>physical examination</b> showed irregular pupils, sluggish -pupillary reactions, Achilles absent, swaying in the Romberg -position, enlargement of the heart to the left, positive W. R. -of the blood and of the spinal fluid.</p> - -<p class='c007'><b>Mentally</b>, the patient’s orientation for place was poor -and his memory defective. Emotionally he was depressed or -apathetic and was apprehensive. His flow of thought was -slow, and his insight into his condition poor.</p> - -<p class='c007'>It is interesting that a variety of causes have been assigned -in this case for the condition: such as, his work, anemia, -unhygienic surroundings, and arteriosclerosis.</p> - -<p class='c007'>This case is not a sharply-defined case of post-traumatic -general paresis, since there had undoubtedly been a variety -of mental changes before the accident. Accordingly, recovery -of damages to a full amount could hardly be expected -as in certain cases in which the phenomena of paresis appear -only after the trauma.</p> - -<div class='figcenter id004'> -<img src='images/i_311.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Post-traumatic cranial gumma—developing 13 months after local injury of skull.</p> -</div> -</div> - -<div><span class='pageno' id='Page_311'>311</span></div> -<div class='box'> - -<p class='c013'><b>Trauma: syphilitic lesion of skull at site of injury.</b></p> - -</div> - -<p class='c006'><b>Case 93.</b> The medicolegal interest of Richard Marshall -is extreme, as may be seen from the following brief report by -the Psychopathic Hospital to the Industrial Board.</p> - -<p class='c015'>“As to the case of Richard Marshall, a patient under -the provisions of the temporary care act from December -1 to December 10, inclusive, this case has proved unusually -interesting in that the patient has proved to be -syphilitic by the Wassermann reaction of the blood. -There is no evidence of syphilis in the examination of -the cerebrospinal fluid. The X-ray examination of the -skull, taken in connection with the Wassermann reaction -of the blood, warrants the diagnosis of syphilitic -osteitis of the skull at the site of the old injury. We -regard his present condition as shown by the X-ray -as a syphilitic bone condition predisposed to by the -injury. We do not find that the patient has any features -of traumatic neurosis.</p> - -<p class='c015'>“Mentally, having an actual age of 30, patient grades -at 11.2 years. It may be that patient has always been -a moron. He has earned about $8.30 a week.</p> - -<p class='c015'>“We regard the patient as deserving treatment and -feel that responsible parties in the case would do well to -have such treatment instituted.”</p> - -<p class='c007'>The principal symptom of which Marshall complained -was headache chiefly felt in the region of the osteitis. -There was marked sensitiveness to percussion in this area. -It is of course difficult to decide whether the headache -was entirely due to the gummatous lesions or whether the -trauma had caused contusions of the brain as well. It is -also possible that the dura underlying this area was involved.</p> - -<div><span class='pageno' id='Page_312'>312</span></div> -<div class='box'> - -<p class='c013'><b>OCCUPATION-NEUROSIS in a granite-cutter: -SYPHILITIC NEURITIS?</b></p> - -</div> - -<p class='c006'><b>Case 94.</b> David Fitzpatrick was a case referred to the -Psychopathic Hospital by the Industrial Accident Board. -He was a granite-cutter of 52 years of age, and had begun to -complain of pain in the forearm, extending back from the -elbow, about six months before admission. It seems that -the patient had been growing progressively worse and had -thought he would have to quit work because of difficulty in -grasping the hammer. A physician had told him that he -must stop his work at granite-cutting or else he would entirely -lose the use of his arm. He was in point of fact laid -off because of slackness of work and had been unable to get -work again. The pain in the arm, however, had continued -and at times was very severe. Sometimes the pain and the -worry led to insomnia. Fitzpatrick wanted the insurance -company to pay certain accumulated bills, and maintained -that he would be able to do work at $15 a week if work could -be found for him. The general situation in this case can be -gathered from the following abstract from the report to the -Industrial Accident Board.</p> - -<div class='lg-container-l c039'> - <div class='linegroup'> - <div class='group'> - <div class='line'>“Secretary Industrial Accident Board,</div> - <div class='line in2'>“Dear Sir:</div> - <div class='line in4'>“<em>In re</em> David Fitzpatrick</div> - </div> - </div> -</div> - -<p class='c047'>referred to us with a copy of an impartial report filed -by the Massachusetts General Hospital,—we concur -with said impartial report that there is now no evidence -of paralysis of the arm. We do not find that the -positive Wassermann reaction, although it indicates a -history of syphilis, has affected the patient other than -possibly to have reduced his general mental capacity. -Our special tests yielded a percentage of 62% of what -a patient of his age and station should possess. There -seems, however, to be no connection between this reduction -of mental capacity and the difficulty with the arm. -We cannot connect the history of alcoholism with the -arm trouble.</p> - -<p class='c015'><span class='pageno' id='Page_313'>313</span>“There is some evidence that other stone workers -have at times shown such effects.</p> - -<p class='c015'>“The patient’s fairly circumstantial account of his -difficulty seems to point to a degree of myalgia or muscular -pain in the region of the forearm when held in a -certain position and a feeling of numbness in the third -and fourth fingers. Whether these phenomena are due -to local pressure upon nerves in the upper part of the -forearm due to neuritis, or whether we are dealing with -a functional neuralgic phenomenon is a question.</p> - -<p class='c015'>“We have applied some special tests for faradic -sensibility to all the fingers of both hands and have -found that the fingers of the right hand are still less -sensitive than those of the left, particularly the thumb -and the little finger. This test has not yet been applied -in a sufficiently large number of cases to prove -any difficult point, nevertheless the findings are in line -with the patient’s own circumstantial account of former -feelings of numbness in the third and fourth fingers of -the right hand.</p> - -<p class='c015'>“Obviously, then, our opinion is that there is still to -be found some effect of the disease, whatever it was, -which caused the patient to knock off work. If we had -more experience with such cases and more data with the -new test which we have applied, we should perhaps be -inclined to admit the diagnosis of <em>occupation neuritis</em> -and to suppose structural alterations in the nerve trunks -corresponding with the location of the muscular pain -and the anesthesia of fingers and the dulling of electric -sense, but in the present stage of our experience, it -is probably wiser to call the case one of <em>occupation -neurosis</em>.”</p> - -<p class='c007'>It is clear that the W. R. in this case was of peculiar value -in at least partially clearing up the findings, yet it must be -remembered that it is a principle of the modern administration -of industrial accident boards and similar organizations -that it is the employer’s lookout whether the employee has -syphilis. Recovery can be made as if the injury were due -wholly to an accident. It was not possible however definitely -to prove or disprove a relation of syphilis in the form -of a syphilitic neuritis to the condition in this case.</p> - -<p class='c007'>The special tests above referred to are the electric sensory -threshold tests of E. G. Martin.</p> - -<div><span class='pageno' id='Page_314'>314</span></div> -<div class='box'> - -<p class='c013'><b>Character change: neurosyphilis.</b></p> - -</div> - -<p class='c006'><b>Case 95.</b> Joseph Wilson offered a very serious social -problem. He was the father of two children, and his wife -was pregnant at the time of his admission to the Psychopathic -Hospital. He was a husky-looking man of 33 years of -age, but for the past four years he had been deteriorating in -his work; he had been drinking heavily, and finally had stolen -to obtain money for liquor. It was on account of his alcoholism -and delinquency, which were taken as an indication of -change of character, that he was sent to the hospital.</p> - -<p class='c007'>Examination on his arrival disclosed at once that there was -more to the case than alcoholism, for the <b>neurological examination</b> -showed that the pupils were irregular, the right -being larger than the left, both reacting sluggishly to light, -and there was an inequality in the reaction of the two eyes, -the left being better than the right. The tendon reflexes -were exaggerated, with ankle clonus on both sides, more -marked on the right. There was also a marked speech defect. -Otherwise the <b>physical examination</b> showed nothing -of importance.</p> - -<p class='c007'>The W. R. of the blood and spinal fluid was strongly -positive. The globulin test was strongly positive, the albumin -was markedly increased, there were 74 cells per cmm., -and a gold sol reaction of the “paretic” type.</p> - -<p class='c007'>A formal <b>mental examination</b> did not show very much of -consequence; his memory showed no marked impairment, -he was not deluded or hallucinated, and he had a pretty -good insight into his failings. However, he was somewhat -childish, and his irritability was quite marked. Were one -to rely upon the mental signs alone, it is probable that a diagnosis -of chronic alcoholism with deterioration would be made; -but in the presence of the physical findings and the laboratory -tests, the diagnosis of neurosyphilis had to be given. It is -obvious that, while the patient was suffering from a progressive -brain disease, and while he did show mental symptoms, -<span class='pageno' id='Page_315'>315</span>there was not sufficient ground on which to commit -him, and therefore he had to be turned out into the community. -As a matter of fact, he was not prosecuted on account -of his theft, because, although legally responsible, it -was felt that his disease was at the basis of the character -change which had led him into difficulties. Further developments -of his relations with society had to be considered, -however. It was possible to get him to discontinue the use -of alcohol altogether, and for nearly a year he has taken no -alcoholic liquor and has been self-supporting. However, his -irritability has been very great, making it very difficult for -his wife to live with him, and causing his sister to break off -all relations with him.</p> - -<p class='c007'>Here, then, is a man with a marked <span class='sc'>Character Change</span> -as the result of neurosyphilis, so that it is difficult for him -to maintain the usual social relations. It does not seem -possible to remove him from the community.</p> - -<p class='c027'>1. May one speak of general paresis without mental symptoms? -If one considers general paresis a mental disease, -of course it cannot exist without mental symptoms. -However, if one considers the disease as a chronic -syphilitic meningoencephalitis characterized by its -pathological anatomy, then one may readily speak of -general paresis although no real evidence of mental -symptoms can be discovered. It would seem that we -must take this attitude with our present conception -of brain localization, for it is easy to conceive of a -general paretic process affecting areas which do not -definitely relate to psychic function. And further, such -a process may exist but not be of such a grade as to -cause mental symptoms.</p> - -<div><span class='pageno' id='Page_316'>316</span></div> -<div class='box'> - -<p class='c013'><b>The neurosyphilitic’s family should not be forgotten -in diagnosis and treatment.</b></p> - -</div> - -<p class='c006'><b>Case 96.</b> The Bornstein family is remarkable. Let us -hang the story on Becky, the mother, an Austrian woman of -43 years, who appears to have been perfectly well up to within -a year. About a year ago, Mrs. Bornstein began to suffer -from severe headaches, which were treated with apparent -success by an osteopath: at all events, Mrs. Bornstein recovered -therefrom in about six months. However, two -months later, she had a convulsion, with foaming at the -mouth, blueness of face, and general muscular stiffening. -The convulsion lasted for several minutes. Again, a fortnight -before admission, the patient had five convulsions of -an identical nature in a single night.</p> - -<p class='c007'>Moreover, since the first convulsion, Mrs. Bornstein’s -<b>mental condition</b> has altered and become variable, so that at -times she is excited, at times depressed. She would assert -inaccurately that there was some one in the house, and that -she had at different times committed crimes of a heinous -nature. Now and then she would seem to see moving pictures. -Her memory was poor and she seemed to believe -that events of five or six years ago had just happened.</p> - -<p class='c007'>The pupils were sluggish, the knee-jerks and ankle-jerks -were absent, there was slight ataxia, and there was speech -defect. The suspicion of neurosyphilis was so strong that it -seemed surprising that the W. R. of the blood serum, even -after repeated tests and after the provocative injection of -salvarsan, proved negative. However, the spinal fluid yielded -a positive W. R., and a gold sol reaction of the “paretic” -type, together with 12 cells per cmm., and a marked increase -of albumin, with positive globulin. It would seem warrantable -to make a diagnosis at least of syphilis of the nervous -system in this case, but it is a question whether we should be -warranted in making the diagnosis general paresis.</p> - -<p class='c007'>That the diagnosis is doubtful may perhaps be seen from -<span class='pageno' id='Page_317'>317</span>the variety of diagnoses in the rest of the family. In the -first place, Mrs. Bornstein’s husband admits syphilitic infection -many years before. He states also that his wife after -marriage showed signs of syphilis and received some treatment, -although limited. It is stated also that the husband -himself at this time has a positive W. R. and has stiff pupils -and petit mal attacks. The oldest son, 22 years of age, is -confined in an institution with juvenile paresis. The second -son has recently died at the age of 20 years, receiving a diagnosis -of rupture of the aorta. A third son, 19 years of age, -has the appearance of having achondroplasia, although the -proportions of his limbs do not quite correspond with those -of an achondroplast. The fourth son, 17 years of age, is -suffering from caries of the spine. A fifth son, 14 years old, -is neurotic and has the so-called Olympic forehead. The -sixth and last son died shortly after birth of unknown cause.</p> - -<div><span class='pageno' id='Page_318'>318</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilitic’s normal-looking family proved -syphilitic.</b></p> - -</div> - -<p class='c006'><b>Case 97.</b> Walter Heinmas was a draughtsman 33 years of -age when he was brought to the Psychopathic Hospital suffering -from mental disease. This was diagnosed as general -paresis, both on account of the clinical symptomatology and -on account of the laboratory findings. In fact, it was a case -of the classical type with marked euphoria and grandiosity.</p> - -<p class='c007'>As is the routine procedure at the Psychopathic Hospital, -in the case of all syphilitic patients, the family was sent for. -This consisted of the wife and two daughters, aged 9 and 7 -respectively. The patient denied any knowledge of a syphilitic -infection. The wife, also, gave no history of any primary, -secondary, or tertiary symptoms; there had been no abortions, -miscarriages, or stillbirths; both children had been -born at term and had been entirely healthy. Examination -showed that the mother had no signs referable to syphilis, and -that both the children were mentally well endowed, with -good physique and showing no stigmata of congenital syphilis. -Still the W. R. of all three (the mother and the two children) -was positive in the blood serum. These tests were repeated -several times on the children, with and without injections -of salvarsan, and they remained consistently positive.</p> - -<p class='c027'>1. Are these children to be considered congenital syphilitics -despite the absence of stigmata or symptoms? We -must consider these children as congenital syphilitics -and candidates for the group frequently spoken of as -<em>syphilitis hereditaria tarda</em>.</p> - -<p class='c027'>2. What is the frequency of syphilitic involvement in the -mate and children of paretics? In our series, we have -found that about 15% of the marriages where one -member develops paresis, result in sterility; that in -18% abortions, miscarriages and stillbirths occur; -and that in 15% positive W. R. is obtained. We have -adopted the motto: “<b>The families of paretics are the -families of syphilitics.</b>”</p> - -<div><span class='pageno' id='Page_319'>319</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis: question of marriage.</b></p> - -</div> - -<p class='c006'><b>Case 98.</b> Mr. Jacobs’ wife was admitted to the hospital -with a diagnosis of general paresis. A few weeks after her -admission, she died as a result of her disease. According to -our routine, her husband and the children were examined for -evidences of syphilis.</p> - -<p class='c007'>Mr. Jacobs’ blood serum was found on repeated tests -to be positive. He resolutely denied any knowledge of a -syphilitic involvement, but it was later learned from his -brother that about two years before his marriage—that is, -more than 25 years before we saw him—he had acquired -syphilis and had had a very small amount of treatment.</p> - -<p class='c007'>Mr. Jacobs was put upon antisyphilitic treatment in the -form of injections of .3 gram of salvarsan every two weeks -with occasional intramuscular injections of mercury salicylate. -After seven months of treatment, the blood serum still remained -positive. At about this time, the patient came to us -to ask about getting married again. He said that he was -living with his sister, who kept telling him that he was the -cause of his wife’s death, and this was so unpleasant that he -desired to start a home for himself again!</p> - -<p class='c027'>1. What advice should be given? It is a general opinion -that the longer the period after the initial infection, the -less the chances of infecting a partner. This chance -is further reduced under antisyphilitic treatment, of -which a considerable amount had been given in the -case of Mr. Jacobs. However, when one considers -the trickiness of syphilis and the fact that there is some -chance of infection, which we would apparently overlook -if we gave him permission to marry at this time, -the only possible course was to tell the patient that he -should not consider marriage until his Wassermann -had become negative and remained so for some time. -The children in this case were negative.</p> - -<p class='c027'>2. What is the physician’s duty to the family of a syphilitic -patient? It is our firm conviction that it is the duty of -<span class='pageno' id='Page_320'>320</span>every physician to his syphilitic patient, to the patient’s -family, and to the community, to examine the mate -and the children for evidence of syphilis acquired or -congenital and to offer treatment if it is found to be -needed. This is one of the chief means at our disposal -today to prevent the late disasters of syphilis, acquired -or congenital, for by such examinations the syphilitic -condition is discovered before lesions have occurred -which are irreparable. We know that the mate and -children of a syphilitic patient have been exposed to -syphilitic involvement, and it is our duty as physicians -in possession of such knowledge, and as guardians of the -public health, to investigate such cases, so that if they -be found to have syphilis, steps may be taken to treat -them early.</p> - -<p class='c027'>3. How much danger is there of causing unhappiness and -breaking up families by this procedure? This question -offers a chance for many theoretical answers. The -facts are, however, that in doing this as a routine -for nearly three years and examining several hundred -families, there has been no instance to our knowledge -in which a family has been broken up or grave difficulties -have been encountered by this procedure.</p> - -<p class='c027'>4. In what percentage are the mates or children of neurosyphilitics -found to show definite symptoms of syphilis? -It is our opinion that the situation in regard to neurosyphilitics -is the same as for syphilitics in general: -That the same laws of attenuation of virus, and of -chance occur here as elsewhere.</p> - -<p class='c007'>Just as this book is going to press, we have learned that the -distraught Mr. Jacobs, still desirous of starting a home for -himself and feeling entirely well, consulted a physician. -This physician took a sample of blood and had it tested at a -competent laboratory, which reported the blood negative.</p> - -<p class='c007'>On the strength of this test, the physician felt himself -warranted in recommending, or at least not advising against, -Mr. Jacobs’ marriage, which has probably now taken place.</p> - -<p class='c007'>Although there is some doubt what ethical relation a state -institution shall maintain with physicians in private practice, -we took occasion to call the attention of our patient’s new -counsellor to the fact of the patient’s neurosyphilis. We -noted that the man’s serum had been constantly positive -<span class='pageno' id='Page_321'>321</span>(Massachusetts State Board of Health findings) in a score or -more of observations. We called attention to the fact that -lumbar puncture had shown positive signs of neurosyphilis, -including a positive W. R., globulin, excess albumin, pleocytosis, -and positive gold sol. These facts, according to a letter -received from the private practitioner in question, have -not altered his opinion in the slightest to the effect that our -patient is completely normal and entirely suitable for marriage. -It is clear that he regards the patient as not a victim -of General Paresis.</p> - -<p class='c027'>5. What is the significance o the negative observation -eventually obtained in Jacobs’ serum? One’s first -thought is to impugn the accuracy of the laboratory -work, but against this suspicion is the excellent reputation -of the laboratory in question, and the agreement -in the majority of its findings with those of the -State Board of Health. It is more likely, as we assured -the private practitioner at whose request the observation -was made, that this negative test was an exceptional -and isolated observation such as is not infrequent in -long series of observations, particularly those made -under therapeutic conditions. In so important a matter, -we are inclined to feel that the physician in question -should have resorted to two more observations at intervals -before running counter to the position taken -by the hospital.</p> - -<div><span class='pageno' id='Page_322'>322</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c002'> - <div class='linegroup'> - <div class='group'> - <div class='line in16'>——many a hard assay</div> - <div class='line'>Of dangers, and adversities, and pains.</div> - </div> - <div class='group'> - <div class='line in16'>Paradise Regained, Book IV, lines 478–479.</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_323'>323</span> - <h2 class='c005'>V. SOME RESULTS OF TREATMENT</h2> -</div> - -<p class='c006'>Cases 99–103 show the Variety of Structural Lesions that -Treatment has to face.</p> - -<div class='box'> - -<p class='c013'><b>SPASTIC HEMIPLEGIA in PARETIC NEUROSYPHILIS -(“general paresis”), showing marked -degenerative changes, a condition in which therapy -could be theoretically of very little avail. Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 99.</b> James McDevitt arrived at the Danvers Hospital, -July 20, 1906 (saying that he came to be “thawed -out”), and died less than six months later: January 12, 1907. -He was 34 years of age. He had been a shoe-worker after -leaving school, had worked eight years with the General -Electric Co., and had then become a bartender. He had, -however, stopped work in September, 1905, and we may -safely say that mental symptoms had begun insidiously at -about that time. His symptoms, if there were any, had been -masked by a heavy alcoholism, but an obvious change had -appeared in November, 1905. The patient lost ambition, -smoked and loafed about his room, and developed speech -disorder. He denied venereal disease, nor was there any -superficial evidence of such.</p> - -<p class='c007'><b>Physically</b>, the patient showed little or no disorder except -acne of the trunk, patches of eczema on the left lower chest, -and numerous brownish scars along both tibiae.</p> - -<p class='c007'><b>Neurologically</b>, the Romberg position was maintained, but -the gait was very unsteady on attempts to walk a straight -line; fingers, tongue, and face were tremulous, and finer -movements were performed with marked incoördination. -No direct or consensual light reactions could be obtained in -the pupils, which were dilated and irregular.</p> - -<p class='c007'>The condition of the reflexes is important on account of -the autopsy findings. The abdominal and cremasteric reflexes -were prompt, and the knee-jerks equal and very lively. -Achilles and normal plantar reactions were present; there -was no clonus; the arm reflexes were very brisk.</p> - -<div><span class='pageno' id='Page_324'>324</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>COMMON THERAPEUTIC CONCEPTION</b></span></div> - </div> -</div> - - <dl class='dl_1'> - <dt> [M]VP =</dt> - <dd>TYPICAL PARESIS - </dd> - <dt> MV[P] =</dt> - <dd>TYPICAL CEREBROSPINAL SYPHILIS - </dd> - <dt> [M]V[P] =</dt> - <dd>TYPICAL SYPHILITIC ARTERIOSCLEROSIS - </dd> - </dl> -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line in12'>(M = Membranes, V = Vessels,</div> - <div class='line in13'>P = Parenchyma, [] = not involved)</div> - </div> - </div> -</div> - -<div class='c018'> <span class='sc'>Chart 21</span></div> - -</div> - -<p class='c019'><span class='pageno' id='Page_325'>325</span>The <b>mental symptoms</b> need not detain us. Consciousness -was clear; orientation for time, place, and to some extent for -persons, was imperfect. Arithmetic had been largely forgotten. -Handwriting was irregular and scrawling, and in -places unintelligible. Although the patient claimed that -his memory was intact, it was decidedly imperfect. He -remarked that John D. Rockefeller, a Chicago king, was President; -the General Electric Works had almost 50,000 people -at work; and in fact Lynn was one of the largest cities in the -state, having over 12,000 people. The height of patient’s -room was estimated at 25 feet. There was a slight euphoria. -There was never any doubt of the <b>diagnosis</b> of <span class='sc'>Paretic -Neurosyphilis</span> (“general paresis”).</p> - -<p class='c007'>Five months after admission, slight convulsions developed, -after which the patient was more dull and demented; he -became bedridden. More convulsions followed, leaving the -right arm and hand useless. There were clonic spasms of the -muscles of both lower legs. Decubitus developed and death -occurred.</p> - -<p class='c007'>We may set the total duration of symptoms in the case of -James McDevitt at a little over a year; nor is there any -evidence of previous or prodromal symptoms beyond a total -period of about 15 months, unless we may regard his leaving -the General Electric Works to become a bartender some nine -years before death, as a symptomatic change of character. -In any event, it is of note that the <b>autopsy</b> showed singularly -few lesions. Death was due doubtless to complications -following decubitus, and there was a slight acute splenitis. -The kidneys showed some parenchymal change. The aorta -showed many patches of sclerosis, with calcification or ulceration -throughout its length. These changes were not characteristic -of syphilitic disease. There was considerable coronary -arteriosclerosis and a slight mitral valvular sclerosis. There -was a brown atrophy of the heart muscle, somewhat surprising -in a man of 34 years. The <b>brain</b> was practically normal, -weighed 1200 grams, and showed convolutions normal in -size, relation, and arrangement. There was no sclerosis -<span class='pageno' id='Page_326'>326</span>grossly evident in the blood vessels. The pia mater appeared -to contain a considerable excess of clear fluid. The calvarium -was of normal thickness and showed diploë and the dura -mater failed to show adhesions. There were no macroscopic -signs of lesion in the spinal cord.</p> - -<p class='c007'><b>Microscopically</b>, the lymphocytosis, plasmocytosis, and -phagocytosis of the perivascular spaces, (relative?) increase -in blood vessels, the gliosis, and evidence of nerve cell destruction, -taken together warranted the diagnosis of <span class='sc'>Paretic -Neurosyphilis</span>. It was plain that the nerve cell destruction -was best marked in the <em>inner layers of the cortex</em>. The -microscopic study of the spinal cord showed that there was -very possibly a slight sclerosis of the posterior columns in the -lumbar region, but this was so slight that it could hardly be -noted in the myelin sheath stains (Weigert). Very sharply -marked, on the other hand, were the <em>bilateral pyramidal -tract lesions</em> in the lumbar and thoracic regions, less marked -at the cervical levels.</p> - -<p class='c007'>Without attempting to analyze carefully all these findings, -it is interesting to note in this case a foil to the usual spinal -cord picture of paretic neurosyphilis. The spinal cord, ordinarily -normal, or perhaps more usually affected by a degree -of posterior column sclerosis, in this case showed such well marked -pyramidal tract sclerosis that we may perhaps place -the case in a subordinate group of <span class='sc'>Spastic Paretic</span> cases -of <span class='sc'>Neurosyphilis</span>. The source of the pyramidal tract disease -lodges, however, in the cortex cerebri itself, being part -and parcel of the lesions mentioned above as affecting more -directly the inner layers of the cortex. Many of the so-called -giant, or Betz, cells had undergone a complete destruction. -It will be remembered that clonic spasms of the muscles of -the legs appeared in the fortnight preceding death, and that -there had been convulsions for about six weeks before death. -There was no evidence at the autopsy why the right arm and -hand should have become useless, whereas the left upper -extremity remained normal. This case, then, forms an exception -to the ordinary paretic neurosyphilis group in that -the brunt of the microscopic process was borne by the inner -layers of the cortex. The cells of origin of the pyramidal -tract fibres had been cut in this lesion, and had become subject -to partial or complete destruction. Note, however, -that the lesion remained a microscopic one and that the -marked convulsions were not related to gross lesions, thereby -following the rule for paretic seizures.</p> - -<div class='figcenter id004'> -<img src='images/i_326.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>Bilateral pyramidal tract sclerosis, secondary to destruction of large motor (Betz) cells of motor (precentral) cerebral cortex—paretic neurosyphilis.</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_327'>327</span>From the standpoint of possible treatment, it is of course -true that few organs of the body showed grave lesions save in -the calcified and ulcerated aorta, which conceivably might -have become quiescent under appropriate treatment. But, -although the brain was almost if not quite normal in the gross, -and although its membranes showed practically no lesion, -treatment would not have been very promising. To be sure, -the exudate might have been cleared away if the spirochetes -responsible therefor had been destroyed by treatment. Yet -the destruction of the giant cells of origin of the pyramidal -tract fibres to such an extent as in this case could hardly -have been compensated for by any known process. So far -as we are aware, the destruction of considerable numbers of -the smaller association elements of the brain is subject to the -compensation of other elements of the nervous system, which -conceivably might be re-educated or newly educated to perform -certain processes. The histological picture in a case -like that of McDevitt accordingly leads to the hypothesis -that so well marked a spastic paresis, even in the presence -of otherwise favorable signs, would be of especially baneful -portent therapeutically.</p> - -<div><span class='pageno' id='Page_328'>328</span></div> -<div class='box'> - -<p class='c013'><b>NEUROSYPHILIS with total duration of symptoms -twenty-two days. The comparatively MILD -BRAIN LESIONS, INFLAMMATORY AND NOT DEGENERATIVE -in type, suggest the possibility that -therapy might have been successful. Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 100.</b> Jacob Methuen, 35, was a carpenter from -Newfoundland. He was working upon a certain Thursday -with his brother, who noticed that Jacob was lifting the tools -about in an unusual manner and talking strangely to his -fellow workmen. He fell asleep, going home in the street car, -and said afterward that he felt dazed and peculiar. He talked -all kinds of nonsense to his wife upon arrival. Methuen -remained in bed next day, fancying he was going to die, -calling his family together, and saying good-bye to them. -He remained in bed all through the next day, but on Sunday -appeared better,—more active, and in fact quite natural. -He slept only an hour Sunday night, calling to his wife that it -was time to get up. On Monday he began to be irritable -to his wife, and accused her of flirting with his brother and -intending to elope with him. He struck his wife several -times, and when two brothers came to watch him, accused -them both of trying to steal his wife, and struck them. Tuesday -he remained in bed until late at night, when he arose -and tried to assault the family.</p> - -<p class='c007'>It seems that another brother of the patient had died but -eleven days before his admission to the hospital and five days -before the onset of Jacob’s symptoms. Since his brother’s -death he had been dwelling upon religious matters, and in -fact the day after his brother’s death, he waked up during -the night, saying that he was too happy to sleep, that he -heard the Master’s voice, and at times the devil’s voice; -that there was to be a modern miracle and his spiritual life -from now on would be different.</p> - -<p class='c007'>Eleven days after admission to the hospital, Methuen -died, making a total duration of symptoms, beginning at his -brother’s death, of 22 days.</p> - -<div><span class='pageno' id='Page_329'>329</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><b><span class='large'>NEUROSYPHILITIC LESIONS</span></b></div> - <div class='c003'><b>LESIONS OF THE SECONDARY PERIOD</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line in2'>(1) INTERSTITIAL ENCEPHALITIS OR MYELITIS</div> - <div class='line in8'>(“meningitis”)</div> - <div class='line in2'>(2) PARENCHYMATOUS ENCEPHALITIS OR MYELITIS</div> - <div class='line in8'>(“encephalitis,” “myelitis”)</div> - </div> - </div> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c017'> - <div><b>LESIONS OF THE TERTIARY PERIOD</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line in2'>(1) CHRONIC INTERSTITIAL ENCEPHALITIS OR MYELITIS</div> - <div class='line in8'>(“gummatous meningitis”)</div> - <div class='line in2'>(2) CHRONIC PARENCHYMATOUS ENCEPHALITIS</div> - <div class='line in8'>(“dementia paralytica”)</div> - <div class='line in2'>(3) CHRONIC PARENCHYMATOUS MYELITIS</div> - <div class='line in8'>(“tabes dorsalis”)</div> - </div> - </div> -</div> - -<p class='c048'>“We have shown that the central nervous system is affected by syphilis -at the same periods and in the same manner as are other internal organs. -In addition the ‘parasyphilitic’ lesions are also of a typically syphilitic -nature, being directly comparable to the parenchymatous affections -found elsewhere in the body. They are ‘tertiary’ lesions differing -only from the so-called ‘gummatous’ processes in the central nervous -system in that their localization is in the parenchyma while that of the -latter is in the interstitial tissues.”</p> - -<div class='lg-container-r c049'> - <div class='linegroup'> - <div class='group'> - <div class='line in2'>McIntosh and Fildes, 1914</div> - </div> - <div class='group'> - <div class='line in2'><span class='sc'>Chart 22</span></div> - </div> - </div> -</div> - -</div> - -<p class='c006'><span class='pageno' id='Page_330'>330</span><b>Physical examination</b> showed a man 5′ 9″ tall, weighing -149 pounds, rather pale and poorly nourished, with a somewhat -enlarged heart and no evidence of venereal disease.</p> - -<p class='c007'><b>Neurologically</b> there was a slight facial and digital tremor, -but otherwise no symptom or reflex disorder except that the -tendon reflexes were generally increased; the knee-jerks -especially were very vigorous. There was no speech defect. -His handwriting was fairly legible.</p> - -<p class='c007'>The patient was very noisy and uncontrollable, tearing -clothing and biting, striking the attendants, refusing food, -talking rapidly, loudly, and incoherently. His manner suggested -auditory hallucinations but no positive evidence of -these was obtained. His clothes could not be kept on him. -The following is a sample of his reactions: As the examiner -entered, the patient stood stark naked and glaring. He -started to talk as follows: “Methuen,—I, Saviour, come -to life and ought to die—— Now I lay me—— Now I -die—— The heart beats—— No, I ain’t going to die—— I -am going out soon. I want my clothes—— You -can’t hold me; I am strong.” (Struggles violently with the -attendants.) “I am God. God. I know you, you can’t -fool me.——I am here——I can do you all. How -many doctors are there here?” (Struggles violently. Looks -at examiner.) “He is writing something. Sir, you can’t fool -me in a million years. Do you understand that, doctor? -You can’t fool me. Write all the prescriptions you want to. -Ten thousand years; you hear that, doctor? Ten thousand -years. You can’t fool me; ten thousand years. Ten thousand -years are but a day for the spirit of the Lord,” etc., etc.</p> - -<p class='c007'>The excitement continued unabated. The patient became -entirely disoriented, and finally almost unable to move. -He lay in bed trying to talk and muttering broken gibberish, -still attempting to struggle to the extent of his limited -strength.</p> - -<p class='c007'>The <b>autopsy</b> showed no sign of lesion (brain weight 1380 -grams), unless, perhaps, the occipital regions were slightly -firmer than the rest of the brain. Death was apparently -due to a bilateral pneumonia, bronchial type. There was -an acute splenitis. The only chronic lesions of the body -were a bilateral chronic adhesive pleuritis and a slight sclerosis -of the arch of the aorta.</p> - -<div class='figcenter id001'> -<img src='images/i_330.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Paretic neurosyphilis (“general paresis”) macroscopically normal, microscopically characteristic. Treatment does not have to face massive destructive processes already complete.</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_331'>331</span><b>Microscopically</b> there was a distinct though mild degree -of lymphocytosis of the perivascular spaces in many regions. -Somewhat extended <em>search failed to reveal plasma cells</em>, and -it is certain that if plasma cells existed, they must have -occurred in very small numbers.</p> - -<p class='c007'>Here, then, was a case of <span class='sc'>Diffuse Neurosyphilis</span> (with -brain picture consistent) with symptoms lasting but 22 days -and with an appearance of acute mania. It is to be noted -that this case arrived at the hospital on the eleventh day of -his symptoms. The case occurred long before the development -of the temporary care system in Massachusetts. It is -probable, or at any rate possible, that he would have been -brought to the hospital far earlier, say, upon the sixth day, -had the modern temporary care system been installed at -that time. The routine W. R. examination would then -have been made. With more effective hydrotherapy, it is -possible that the patient’s life might have been prolonged -and that treatment might have been effective. So far as -we can see, the case would have been a singularly good one -for treatment despite the practical unmanageability of the -case under ordinary home treatment, and even under hospital -conditions where modern hydrotherapeutic appliances -are not available.</p> - -<div><span class='pageno' id='Page_332'>332</span></div> -<div class='box'> - -<p class='c013'><b>PARETIC NEUROSYPHILIS showing very -MARKED MENINGITIS, suggesting that therapy -might have produced improvement. Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 101.</b> We report the case of John Baxter, a boat -tender of 48 years, because this particular victim of <span class='sc'>Paretic -Neurosyphilis</span> seems to have had the most markedly thickened -and altered meninges in our whole series. Of course, the -therapeutic theory upon which we now proceed in the treatment -of non-paretic and possibly even of paretic neurosyphilis -is that, other things being equal, the meningitis -can be removed by treatment, or in the course of treatment, -so that the degree of ultimate recovery rather depends upon -the condition of the brain substance itself than upon the -condition of the meninges. Here, at all events, is an example -of the most highly meningitic neurosyphilis that we have -seen.</p> - -<p class='c007'>Curiously enough, two of Baxter’s brothers were also -patients at the hospital at which Baxter died, and a number -of the other members of the family are reported as “nervous.” -It seems that at 35 Baxter began to drink heavily and had -never given over the habit of alcoholism.</p> - -<p class='c007'>Upon admission to the hospital, in fact, he showed a sufficiently -typical picture of delirium tremens. His consciousness -was clouded, he had vivid visual hallucinations and was -very apprehensive.</p> - -<p class='c007'>His heart was enlarged to the left; the pulse, 120, was of -increased tension and irregular; there was peripheral arteriosclerosis; -the teeth were poor; the tongue coated; and -the mouth foul. The urine showed a trace of albumin and -rare hyalin casts.</p> - -<p class='c007'><b>Neurologically</b>, the gait was somewhat unsteady, there -was an extreme tremor of the whole body, including the -tongue and fingers. The Romberg sign was negative although -there was marked swaying. The pupils were equal and reacted -normally; the knee-jerks were markedly exaggerated, the -arm reflexes somewhat exaggerated. The remainder of the -reflexes upon systematic examination were negative.</p> - -<div class='figcenter id001'> -<img src='images/i_332.jpg' alt='' class='ig001' /> -<div class='ic004'> -<p>A high degree of chronic leptomeningitis. Pia mater thick, opaque, concealing brain. In paretic neurosyphilis (“general paresis”).</p> -</div> -</div> - -<p class='c007'><span class='pageno' id='Page_333'>333</span>Upon arrival, Baxter was put to bed, but he barricaded -his door and fought with the attendants. The tremor increased, -the hallucinations were both visual and auditory. -After a few days, Baxter became so weak that he could not -move. He refused to eat for a period of two days, explaining -in whispers that he did not wish to be poisoned; a voice -had told him the food was to be poisoned. The voice was of -agreeable tones, probably belonging to a lady; it did not -speak, but sang to him. The clouding of consciousness -failed to clear up, as in delirium tremens, so that, though -patient was admitted March 3d, it was hardly possible to -speak freely with him until more than a month later, April 9th. -A good-natured conversation would run as follows:</p> - -<table class='table3' summary=''> - <tr> - <td class='c009'>“What is your name?”</td> - <td class='c050'>“Baxter.”</td> - </tr> - <tr> - <td class='c009'>“First name?”</td> - <td class='c050'>After long pause, “Don’t know.”</td> - </tr> - <tr> - <td class='c009'>“John?”</td> - <td class='c050'>Pause of 7 seconds, “Yes, I think it is.”</td> - </tr> - <tr> - <td class='c009'>“How old are you?”</td> - <td class='c050'>“There are legs——there is a body——up to here——”</td> - </tr> - <tr> - <td class='c009'>“Say the alphabet.”</td> - <td class='c050'>Term not understood.</td> - </tr> - <tr> - <td class='c009'>“Say the <em>a</em>, <em>b</em>, <em>c</em>.”</td> - <td class='c050'>“Oh yes; a, b, c, d (long pause), e, f; I cannot say it, I did not have much education; I am not intelligent.” (In point of fact, the patient had a good grammar-school education, and had long worked as a clerk in a grocery store, with good wages.)</td> - </tr> - <tr> - <td class='c009'>There was some speech defect.</td> - <td class='c050'> </td> - </tr> -</table> - -<p class='c007'>Soon the hallucinatory phase passed, and the patient -remained in a cloudy and disoriented state, inaccessible, -rarely speaking, and gradually failing physically. Death -occurred about three months after admission (pulmonary -symptoms).</p> - -<p class='c007'>In estimating the duration of the process in John Baxter, -we must take into account that he left the grocery business -and became a hard-working but poorly-paid boat tender at -<span class='pageno' id='Page_334'>334</span>about 35 years, at the same time that the alcoholic habit -began.</p> - -<p class='c007'>The <b>autopsy</b> showed that death was due to bronchopneumonia -with pleurisy. There were in the body a variety -of chronic lesions, such as gastritis, colitis, epididymitis, -splenitis, parietal and valvular endocarditis, prostatitis, chronic -appendicitis, and some mesenteric lymphnoditis. The heart -was somewhat hypertrophied. There was a slight diffuse -nephritis with cysts, emaciation, and decubitus. The calvarium -was thick and somewhat dense. The dura was -thickened and adherent, and the pia mater,—as above -stated, the most thickened and altered pia mater in our -series,—is described as everywhere thickened, of a brownish -gray and white color, especially over the vascular lines, and -as showing small white areas of deeper thickening scattered -over the surface, but most markedly over the sulci, and not -as a rule over the crowns of the gyri. There were also yellowish -brown spots with a suggestion of fibrin over the lateral -aspects of both hemispheres. The vessels at the base were -not remarkable in the gross. The brain weighed 1220 grams, -and appeared to be of darker color than usual.</p> - -<div><span class='pageno' id='Page_335'>335</span></div> -<div class='box'> - -<p class='c013'><b>Some cases of PARETIC NEUROSYPHILIS -(“general paresis”) have so much BRAIN -ATROPHY that it is not possible to expect much -improvement through antisyphilitic therapy.</b></p> - -</div> - -<p class='c006'><b>Case 102.</b> Theodosia Jewett, dead at 58 years, showed the -most remarkably wasted brain in a long series of victims of -paretic neurosyphilis. We present her case to emphasize -what therapy must face in certain instances, but would -recall the fact that exceedingly few such wasted brains have -come to our attention in cases dying in the institutions of -Massachusetts.</p> - -<p class='c007'>Mrs. Jewett, a housewife, whose parents died of shock, and -one of whose two brothers also died of shock, was a normal -child and schoolgirl, and worked as dressmaker until she -was married, at 24, to a grocer, by whom she had two children. -At the age of 46, Mrs. Jewett began to suffer from so-called -“nervous prostration.” The attack lasted some two years, -but there were no psychotic symptoms beyond worry and -insomnia. The menopause occurred at 52, at which time -the first signs of psychosis appeared, namely, a forgetfulness -concerning familiar matters, such as sewing, cooking, and -the like. At 55, this amnesia had become so marked that -Mrs. Jewett could neither write nor tell time. She, however, -was a perfectly quiet and easily manageable patient, often -subject to drowsiness in the day.</p> - -<p class='c007'>Six months before her admission to the hospital, she began -to suffer from insomnia, failed to recognize her surroundings, -and had a number of crying spells. Restlessness had begun -a month before admission; auditory hallucinations developed -in the form of imaginary conversations with dead persons. -A certain loquacity set in, and for a week before admission, -Mrs. Jewett became somewhat resistive.</p> - -<p class='c007'><b>Physically</b>, the patient was sallow, poorly nourished, with -pale mucous membranes, peripheral arteriosclerosis, no teeth, -muscular feebleness, tremor of hands and tongue, and active -<span class='pageno' id='Page_336'>336</span>knee-jerks. <b>Mentally</b>, the patient was depressed, talked to -herself, assumed a supplicating position, suddenly altered -her attitude, and was very tremulous. Her talk was low, -mumbling, and incoherent, for the most part composed of -answers to her own questions. Sometimes there was a -curious difficulty in speaking, such that the lips moved but no -sound emerged; but for the most part there was no difficulty -in uttering words. The patient either could or would not -write. Only when the attention was secured by speaking to -her sharply was she apparently able to understand questions, -and the answers to these sharp questions came spasmodically -and as if interrupting her own thoughts. Nor was it ever -possible to obtain a repetition of the same answer.</p> - -<p class='c007'>The patient died in exhaustion, with pulmonary symptoms -three weeks after admission.</p> - -<p class='c007'>The <b>autopsy</b> which was performed 3½ hours after death -showed the following points of interest:</p> - -<p class='c007'>The heart weighed 210 grams. There was marked thickening -of the aortic valve. The coronaries were slightly -thickened.</p> - -<p class='c007'>The lungs were slightly adherent to the chest wall at the -apices and posteriorly. The right lung was consolidated -in the lower two lobes posteriorly and the bronchi exuded -pus; the left lung was not remarkable. There was a chronic -splenitis.</p> - -<p class='c007'>The liver showed fibrous changes, was a brownish-red in -color, mottled with yellow.</p> - -<p class='c007'>Combined weight of the kidneys 195 grams. The capsules -were adherent, tearing the cortex when stripped.</p> - -<p class='c007'>The diploë were well marked. The dura was not adherent. -The pia was slightly thickened and raised from the cortex by -a large amount of subpial fluid (showing atrophy of the cortex). -The pial vessels were injected, more markedly so on the left -side. The arachnoid villi were reported as moderately developed, -especially along the longitudinal fissure.</p> - -<p class='c007'>The brain was rather soft in all regions. The weight -was 1045 grams. According to Tigges’ formula the weight -of the brain should be approximately 8 times the body length -in centimeters. The length in this case was 158 cm., therefore, -according to this formula the weight of the brain should have -been 1464 grams. The difference of more than 400 grams -is evidently a loss to be accounted for by atrophy, a very -heavy loss.</p> - -<div class='figleft id003'> -<img src='images/i_336a.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Perivascular exudate (low power) in atrophic cortex from case of general paresis.</p> -</div> -</div> - -<div class='figright id003'> -<img src='images/i_336b.jpg' alt='' class='ig001' /> -<div class='ic002'> -<p>Markedly atrophic cortex, but without local perivascular exudate.</p> -</div> -</div> - -<p class='c027'><span class='pageno' id='Page_337'>337</span>1. Was the “nervous prostration” at 46 of syphilitic -origin? One cannot give a categorical answer to this -question. The high incidence of shock in the family -suggests poor stock in which a psychoneurosis is not -an unusual phenomenon. The presence of syphilis -might act as a debilitating factor or <i><span lang="fr" xml:lang="fr">agent provocateur</span></i>, -if it were not to cause any demonstrable brain lesion. -As pointed out in the case of Harrison (9), however, -it is not unusual in neurosyphilis to find a history of -symptoms occurring years before the final breakdown -and symptoms frequently not recognized as of neurosyphilitic -nature.</p> - -<p class='c027'>2. Does the fairly long duration of the psychosis (at least -3 years) explain the marked atrophy? Cases having -symptoms even much longer than three years at times -show relatively very little atrophy, so that this factor -in itself cannot be said to explain the tremendous -destruction of tissue.</p> - -<div><span class='pageno' id='Page_338'>338</span></div> -<div class='box'> - -<p class='c013'><b>The THERAPY OF NEUROSYPHILIS has to face -not merely variations in the degree of brain -wasting and in the degree of meningitis, but also -variations in the topographical distribution of -lesions. Autopsy.</b></p> - -</div> - -<p class='c006'><b>Case 103.</b> To bring out this point we may instance the -case of Alfred Weed, a victim of <span class='sc'>Paretic Neurosyphilis</span>, -dying at the age of 48 years after a course of about seven -years. The following is an abstract of the clinical history:</p> - -<p class='c007'>A. W. suffered from lues some 24 years before his death at -Danvers Insane Hospital in 1907. There is no account of -insanity in his family. The patient had been undergoing -mental changes for six years before death. At the age of 42 -began to take interest in socialism and spiritualism. Would -become excited at times and was observed to talk to himself. -At times it seemed that he was reacting to visual hallucinations. -After eight months he became depressed and apprehensive -and developed delusions of poisoning.</p> - -<p class='c007'>On admission to the Danvers Insane Hospital in June, -1902, the subject was found to be ataxic, falling in the Romberg -position. Pupils were equal but of pin-point size. -There was tremor of the facial muscles. The knee-jerks were -absent. Speech was ataxic. Memory defective. Depressed. -Thought he was to be punished. Refused to eat.</p> - -<p class='c007'>Later in the year of admission, patient became more -negativistic. He refused to have his clothes brushed. His -answers were slow. Mental arithmetic was correctly but -slowly done. During January, 1903, the patient was apt to -be active and talkative for a time, and then his attitude -would suddenly change to one of silence, resistivement and -untidiness. From time to time he would be querulous -and sulky. In August, 1903, the patient became weaker -and could walk with assistance only. Paralysis developed -in the left facialis region and in the left external rectus. -Pupils were still small, but the left had become smaller than -<span class='pageno' id='Page_339'>339</span>the right. Light reaction tests unsatisfactory. Knee-jerks -could not be obtained.</p> - -<p class='c007'>In December, 1903, the patient was untidy and helpless, -lying with his thighs and legs flexed. The limbs were spastic -on passive motion. In 1905, the pain sense of the legs was -found lost and the pupils were small and stiff. The protruded -tongue was deflected to the right. The right labial -fold was more prominent than the left. Knee-jerks remained -absent. Ataxia was extreme.</p> - -<p class='c007'>The <b>Neurological Findings</b> may be summed up as follows:</p> - - <dl class='dl_2'> - <dt> 1.</dt> - <dd>Ataxia of the legs. - </dd> - <dt> 2.</dt> - <dd>(Probable) Diminished sensibility in the legs. - </dd> - <dt> 3.</dt> - <dd>Pupils small and stiff. Left smaller than the right. - </dd> - <dt> 4.</dt> - <dd>Paralysis of left facialis. - </dd> - <dt> 5.</dt> - <dd>Paralysis of left external rectus. - </dd> - <dt> 6.</dt> - <dd>Tongue protruded to right. - </dd> - <dt> 7.</dt> - <dd>Right elbow jerk greater than left. - </dd> - <dt> 8.</dt> - <dd>Knee-jerks absent. - </dd> - </dl> - -<p class='c007'>The cause of death was bronchopneumonia. The walls -and valves of the heart showed a few chronic changes. There -was a marked splenitis and an atrophy of the liver. The -kidneys showed numerous depressed scars. The arch of the -aorta was somewhat sclerotic. The following is a full description -of the head findings which we present by way of -comparison with other cases. Note especially the cerebellar, -dentate, and olivary changes. Note also the fact that palpable -sclerosis is demonstrable over a far larger area than -atrophy, so that we may almost safely conclude that the process -of induration sometimes precedes that of atrophy. One -gets the impression from the extent of visible atrophy and -tangible induration in this case, that a possible therapy would -have not merely to clear the perivascular spaces of cells and -spirochetes, but would also need to arrest the indurating and -wasting process. Nor could any therapy deal effectively with -the superior frontal and upper central atrophy of the cerebrum -of this case, or with the olivary and cerebellar lesions.</p> - -<p class='c007'><b>Head</b>: Hair thin at vertex. Scalp normal. Calvarium -<span class='pageno' id='Page_340'>340</span>thin and dense. Dura mater slightly adherent to calvarium -at vertex. Sinuses normal. Arachnoidal villi well developed. -Pia mater of anterior and central regions contains an -excess of fluid. The pial veins well injected.</p> - -<p class='c007'>The <b>pia mater</b> exhibits one unusual lesion: Faintly yellowish -brown spots of miliary and slightly larger size are scattered -irregularly in clusters over the vertex. These miliary -pial macules are observed especially over the posterior third -of the left superior frontal gyrus (a group of twelve or more). -Two are seen in the pia mater of the right superior frontal -gyrus. One is seen in the upper part of the left post central -gyrus. The upper end of the right postcentral gyrus contains -three macules.</p> - -<p class='c007'>Besides these brownish macules, the pia mater also shows -focal white thickenings which resemble the more frequent -appearances of chronic fibrous leptomeningitis. The white -thickenings are of irregular size but are, as a rule, larger than -the macules above mentioned. They occur, as a rule, over -the sulcal veins and are most frequent in the anterior region.</p> - -<p class='c007'>The vessels at the base are normal. There is no evidence -of pial thickening at the base of the brain. <b>Brain</b> weight, -1265 grams. There is visible atrophy of both superior frontal -gyri and of the upper two-thirds of both central gyri. The -extent of palpable sclerosis surpasses that of visible atrophy. -Palpable increase of consistence is shown by the prefrontal, -orbital (more marked on left side), frontal, central, hippocampal -and occipital regions. The temporal cortex is of -normal or slightly reduced consistence.</p> - -<p class='c007'>Section of the cerebral cortex shows everywhere preservation -of the cortical markings. The sclerosed areas show a -diminution in depth of the cortex, which is more marked in -the left prefrontal region. The white matter of the centrum -semiovale of the prefrontal and occipital regions on both -sides shows an increase of consistence. The cerebellar cortex -also shows variations in consistence. The clivus and lobus -cacuminis and the posterior half of the inferior surfaces of -both cerebellar hemispheres are firmer than normal. The -laminæ of the left clivus are a trifle narrower than those of -the right. There is visible extensive atrophy of the laminæ -<span class='pageno' id='Page_341'>341</span>on both sides of a fissure in the middle of the left lobus cacuminis. -In the coördinate portion of the right cacumen there -is a similar process which is less marked. The dentate nuclei -are firm. The olives show an increase of consistence, equal -on both sides. The left olive shows on section a crowding -together of its folds in the middle part of the upper limb.</p> - -<p class='c007'>Spinal cord was not remarkable.</p> - -<p class='c007'><b>Summary</b>:</p> - -<ul class='index'> - <li class='c046'>Adhesive pachymeningitis</li> - <li class='c046'>Chronic fibrous leptomeningitis</li> - <li class='c046'>Miliary pial macules</li> - <li class='c046'>Cerebral atrophy</li> - <li class='c046'>Cerebral sclerosis</li> - <li class='c046'>Cerebellar atrophy and sclerosis</li> - <li class='c046'>Bronchopneumonia</li> - <li class='c046'>Chronic splenitis</li> - <li class='c046'>Nephritis</li> - <li class='c046'>Aortitis</li> -</ul> - -<div><span class='pageno' id='Page_342'>342</span></div> -<div class='box'> - -<p class='c013'><b>It is generally recognized that DIFFUSE NEUROSYPHILIS -(“cerebrospinal syphilis”) frequently -is cured through antisyphilitic therapy. Example. -Mental improvement, in one month; recovery from -paralysis, ten months.</b></p> - -</div> - -<p class='c006'><b>Case 104.</b> John Edwards, a man of 28 years, well developed -and nourished, with general enlargement of glands -and skin lesions, came to the hospital in a stuporous condition, -with evidences of a complete hemiplegia.</p> - -<p class='c007'>According to the wife, Edwards had had a chancre of -the lip about a year before, for which he had been treated -with an intravenous injection, presumably of salvarsan, and -also presumably with mercury. The lip lesion had then -disappeared. For a month before admission, Edwards had -had headache and dizziness, for which he was given pills -and drugs. There had also been difficulty with speech and -numbness of the left arm as far up as the elbow, but this -paresthesia had quickly disappeared. The hemiplegia was -of only a few days’ duration. After a feeling of nausea and -vomiting, the patient had fallen with left-sided paralysis. -Afterwards, he had shown mental peculiarities, eventually -becoming noisy, hard to manage, and appropriate for hospital -care.</p> - -<p class='c007'>The <b>physical examination</b> showed a variety of increased -reflexes, including ankle clonus on the left side.</p> - -<p class='c007'>The question might arise whether this case was one of -hemorrhage or thrombosis, and the facts about the onset -of the hemiplegia are inadequate for a decision. However, -at so early an age, the probability of syphilis is large and the -history of labial chancre was quite suggestive. If we may -conclude neurosyphilis, the diagnosis of thrombosis rather -than rupture of blood vessel is likely. The laboratory tests -bore out the diagnosis since the W. R. of serum and fluid -both proved positive; the gold sol reaction was syphilitic; -there were 176 cells per cmm.; there was excess albumin, -and a positive globulin reaction.</p> - -<div><span class='pageno' id='Page_343'>343</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='2'><span class='large'><b>NON-PARETIC NEUROSYPHILIS</b></span></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='2'><b>DIFFUSE NEUROSYPHILIS, MENINGOVASCULAR PARENCHYMATOUS, CEREBROSPINAL SYPHILIS</b></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c024'>CASES SYSTEMATICALLY TREATED</td> - <td class='c033'>13</td> - </tr> - <tr> - <td class='c024'>CLINICAL RECOVERY, C.S.F. NEGATIVE</td> - <td class='c033'>11</td> - </tr> - <tr> - <td class='c024'>UNIMPROVED</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c024'>UNIMPROVED, BUT C.S.F. NEGATIVE</td> - <td class='c033'>1</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='2'><span class='sc'>Massachusetts Commission on Mental Diseases</span>,</td></tr> - <tr><td class='c022' colspan='2'><em>November, 1916</em></td></tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='2'><span class='sc'>Chart 23</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_344'>344</span>The outcome in such a case is dubious. If death does -not occur soon, recovery is not impossible under treatment. -At all events, a considerable improvement is likely.</p> - -<p class='c007'>Edwards was given bi-weekly injections of salvarsan, -intramuscular injections of mercury salicylate, and doses of -potassium iodid, averaging 100 grains, three times a day. -Under this treatment, he slowly recovered and became -mentally clear after a few weeks. The paralysis seemed -complete and permanent. Even after three or four months, -there was absolutely no change in the condition, and Edwards -was quite unable to move either arm or leg. Meanwhile, -the spinal fluid had become practically negative to all tests.</p> - -<p class='c007'><em>Treatment</em> was somewhat optimistically continued and -was <em>rewarded at the end of ten months</em> with marked improvement -such that the patient was able to stand on the -paralyzed leg and move the arm to a certain degree. This -improvement is still continuing. The spinal fluid and the -serum have remained negative to laboratory tests.</p> - -<p class='c007'>Note: A period of six months is commonly regarded as -that period in which improvement in paralysis is to occur -if there is to be any improvement. There was certainly -not the slightest improvement in the paralysis of this case -before eight or nine months of treatment had elapsed, and -it took ten months to secure the marked improvement -mentioned.</p> - -<p class='c027'>1. What is the significance of the prodromal symptoms? -The headache and dizziness should have been viewed -with great gravity. They are characteristic in <span class='sc'>Meningovascular -Neurosyphilis</span>.</p> - -<p class='c028'>Moreover in this case there had also been difficulties -with speech and other transient symptoms which -should have called attention far earlier to the possibility -of neurosyphilis.</p> - -<p class='c027'>2. What is the significance of the high cell count: 176 per -cubic millimeter? Such high cell counts are frequent -enough in diffuse neurosyphilis, but low cell counts are -frequent also. But although the high cell count taken -alone is of lesser significance, the fact that the high -<span class='pageno' id='Page_345'>345</span>cell count in this case is associated with a “syphilitic” -gold sol reaction is of far greater significance for diagnosis. -These associated findings are characteristic of -meningovascular neurosyphilis.</p> - -<p class='c027'>3. What kind of recovery may be expected in successful -examples of treatment in meningovascular cases? -Recovery with defect. It will be noted that ten -months elapsed before any marked improvement occurred -on the paralyzed side. We could not expect a -complete recovery from this paralysis.</p> - -<p class='c027'>4. Was inadequacy of treatment following the chancre -responsible for the early cerebrospinal involvement? -In this connection one must remember that such neural -involvements occur occasionally even during active -treatment (neurorecidives). The discontinuance of -treatment after a short period, in this case less than -a year, is always a risk to say the least. And this is -true even though the W. R. becomes negative, for -trouble of a neurosyphilitic nature may occur later; -this when both blood and spinal fluid have previously -been found negative. The old rule of following and -treating a syphilitic for several years despite the disappearance -of symptoms is still a good rule.</p> - -<div><span class='pageno' id='Page_346'>346</span></div> -<div class='box'> - -<p class='c013'><b>The results of systematic, intensive, intravenous -salvarsan therapy in atypical neurosyphilis (cases -not certainly paretic, tabetic or the common types -of meningovascular neurosyphilis) may be in our -experience as good as the results of treatment in -common meningovascular cases: example.</b></p> - -</div> - -<p class='c006'><b>Case 105.</b> Henri Lepère, a machinist, 48 years of age, -came voluntarily to the Psychopathic Hospital for a gradually -failing memory and inability to work. He had had -indigestion for four years (epigastric distress, nausea, no -vomiting). He was still suffering from epigastric distress -and from headaches. At times he had had difficulty in -walking.</p> - -<p class='c007'><b>Physically</b>, Lepère looked older than he was; he was very -poorly developed and nourished, and seemed very weak. -There was a slight visceroptosis.</p> - -<p class='c007'><b>Neurologically</b>, there was considerable speech defect, particularly -well marked in test phrases. The pupils were -contracted and gave the Argyll-Robertson reaction. Neurologically -there were no other signs.</p> - -<p class='c007'><b>Mentally</b>, there was a depression with worry; but it was -a question whether these phenomena were not entirely -natural. The special complaint was of failing memory.</p> - -<p class='c007'>The Argyll-Robertson pupil also <i><span lang="la" xml:lang="la">prima facie</span></i> signifies -neurosyphilis. Lepère, in fact, admitted syphilitic infection -at 23. The gastric symptoms at once suggested tabes. The -knee-jerks and ankle-jerks were, to be sure, preserved; however, -this is not very unusual in tabes. The amnesia and -aphasia naturally suggested paresis. Without resort to -laboratory findings, accordingly, the diagnosis of taboparetic -neurosyphilis (“taboparesis”) was suggested.</p> - -<div><span class='pageno' id='Page_347'>347</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='4'><span class='large'><b>EFFECT OF EARLY TREATMENT ON THE DEVELOPMENT OF NEUROSYPHILIS</b></span></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>TOTAL CASES</td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'>4134</td> - </tr> - <tr> - <td class='c009'>DEVELOPED GENERAL PARESIS</td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'>198 = 4.8%</td> - </tr> - <tr> - <td class='c009'>DEVELOPED TABES DORSALIS</td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'>113 = 2.7%</td> - </tr> - <tr> - <td class='c009'>DEVELOPED CEREBROSPINAL SYPHILIS</td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'>132 = 3.2%</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'><hr /></td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'>443 = 10.5%</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='4'><b>EFFECT OF TREATMENT</b></td></tr> - <tr> - <th class='c009'></th> - <th class='c041'>None</th> - <th class='c041'>1 course</th> - <th class='c042'>Repeated energetic</th> - </tr> - <tr> - <td class='c009'>NUMBER OF CASES</td> - <td class='c041'>100</td> - <td class='c041'>134</td> - <td class='c042'>924</td> - </tr> - <tr> - <td class='c009'>DEVELOPED G.P.</td> - <td class='c041'>25 = 25%</td> - <td class='c041'>31 = 23.1%</td> - <td class='c042'>30 = 3.2%</td> - </tr> - <tr> - <td class='c009'>DEVELOPED TABES</td> - <td class='c041'>11 = 11%</td> - <td class='c041'>16 = 11.9%</td> - <td class='c042'>25 = 2.7%</td> - </tr> - <tr> - <td class='c009'>DEVELOPED C.S.S.</td> - <td class='c041'>3 = 3%</td> - <td class='c041'>21 = 15.6%</td> - <td class='c042'>71 = 7.6%</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c041'> </td> - <td class='c041'> </td> - <td class='c042'> </td> - </tr> - <tr> - <th class='c009'></th> - <th class='c041'>Poorly treated<br />1880–84</th> - <th class='c041'> </th> - <th class='c042'>Better treated<br />1895–99</th> - </tr> - <tr> - <td class='c009'>NUMBER OF CASES</td> - <td class='c041'>617</td> - <td class='c041'> </td> - <td class='c042'>1139</td> - </tr> - <tr> - <td class='c009'>DEVELOPED G.P.</td> - <td class='c041'>60 = 9.7%</td> - <td class='c041'> </td> - <td class='c042'>37 = 3.2%</td> - </tr> - <tr> - <td class='c009'>DEVELOPED TABES</td> - <td class='c041'>22 = 3.5%</td> - <td class='c041'> </td> - <td class='c042'>16 = 1.4%</td> - </tr> - <tr> - <td class='c009'>DEVELOPED C.S.S.</td> - <td class='c041'>15 = 2.4%</td> - <td class='c041'> </td> - <td class='c042'>28 = 2.4%</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='4'>MATTAUSCHEK AND PILCZ</td></tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='4'><span class='sc'>Chart 24</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_348'>348</span>The serum W. R. proved positive, but the spinal fluid W. R. -very slightly so (yielding only moderate reaction with 1 cc., -0.7 and 0.5 cc., and a negative reaction with 0.3 and 0.1 cc.). -Globulin was moderate, and albumin was found in only -moderate excess. There were 21 cells per cmm. in the spinal -fluid. The gold sol reaction was that which we regard as -typical of syphilis or tabes. If we were to rely upon the -weakness of the fluid W. R. and the nature of the gold sol -reaction, we should be inclined to favor the diagnosis of -<span class='sc'>Diffuse Neurosyphilis</span> (“cerebrospinal syphilis”) rather -than resort to the diagnosis of paretic neurosyphilis.</p> - -<p class='c007'>Salvarsan treatment was attended by the rapid disappearance -of headaches and gastric symptoms and by a rapid -gain in weight and feeling of well-being. Salvarsan was -continued twice a week for two months, whereupon Lepère -returned to work. He has been successfully at work now for -seven months without return of symptoms. Four months -after beginning of treatment, the spinal fluid was examined -and found entirely negative. Nevertheless, the serum W. R. -has remained positive despite eight months of salvarsan treatment.</p> - -<p class='c027'>1. What is the meaning of the titrations in the spinal fluid -Wassermann reaction? When Plaut originally applied -the Wassermann reaction to spinal fluids, he used 0.2 of -a cc. of spinal fluid. With this amount of fluid he found -that cases of general paresis gave a positive reaction -in about 100% of the cases while this positive reaction -was only given by 40 to 60% of the cases of cerebrospinal -syphilis and tabes dorsalis, hence he promulgated -a differential point that a negative reaction in -spinal fluid indicated that the case was not general -paresis. Hauptmann later showed that if 1 cc. of spinal -fluid were used, a positive reaction would occur in -practically 100% of the cases of general paresis, cerebrospinal -syphilis and tabes. Therefore, at present, -we use the different titers of spinal fluid from which we -draw the following conclusions: If the reaction in the -untreated case is negative with 0.1 and 0.3 of a cc. and -positive with the 0.5, 0.7 and 1 cc. dilutions as in the -case of Lepère, we are probably dealing with non-paretic -neurosyphilis. With this method of titration -we are also better able to watch the progress of treatment -as the dilutions of 0.1 and 0.3 cc. become negative -first.</p> - -<p class='c027'><span class='pageno' id='Page_349'>349</span>2. How soon can one expect improvement after commencement -of salvarsan therapy in cases of diffuse neurosyphilis? -The time relation of results in treatment varies -with each individual case. In the case of Lepère -gastric symptoms that had been present for a number -of months disappeared as if by magic after the first -injection of salvarsan. As a rule, it is true that the -more acute the symptoms the quicker their disappearance -but this does not hold for all cases, as in this -particular instance the long-standing symptoms disappeared -very rapidly. The symptoms often disappear -very much more rapidly than the laboratory, tests -change.</p> - -<p class='c027'>3. How can the mental symptoms (depression and failing -memory) of which patient complained be explained? -In the first place, as has been stated, it is doubtful if -these are more than subjective and the result of the -patient’s feeling of discomfort and pain. However, it -is also possible that there may be intracranial involvement -of the meninges or of the brain itself. And, if -such were the case, the improvement might be the -result of the treatment.</p> - -<div><span class='pageno' id='Page_350'>350</span></div> -<div class='box'> - -<p class='c013'><b>The Argyll-Robertson pupil should not be used as -a basis for a necessarily bad prognosis if treatment -can be given.</b></p> - -</div> - -<p class='c006'><b>Case 106.</b> Frederick Stone was a business man of large -interests. He had been in the hands of physicians for several -years for a variety of disorders such as renal, respiratory, -cardiovascular, and so on. No suspicion of syphilis had -apparently been uttered by the physicians despite the fact -that Mr. Stone readily stated that he had had a chancre -thirty years before, and that he had received several years’ -treatment of mercury and potassium iodid by mouth.</p> - -<p class='c007'>It appeared that a few years ago he had begun to have -trouble with his nose, which was cauterized and operatively -interfered with without satisfactory results. This nasal -condition had later been diagnosticated as gummatous, and -had improved considerably under a mild antisyphilitic -treatment. However, this nasal condition had been considered -and treated quite separately from the remainder of -Mr. Stone’s troubles.</p> - -<p class='c007'>What brought him to attention was a sudden diplopia with -ptosis. There was a paralysis of the external rectus of the -left eye, as well as a drooping of the lid on this side. The -left eye was much inflamed. The diplopia greatly bothered -the patient, and there was also considerable pain in the left -frontal region, confined chiefly to the distribution of the first -division of the trigeminal nerve. According to the patient -this headache was periodic. There was considerable tenderness -to pinprick over the area and a diminution of sensory -discrimination of fine touch. Both the pupils failed to react -to light.</p> - -<p class='c007'>The remainder of the neurological symptomatic examination -was surprisingly clear of disorder, nor was there anything -in the history suggestive of tabes. There was ozena as -well as evidence of the operative work upon nares and throat. -Possibly the arteries were slightly hardened; blood pressure -was 165 systolic. There was a large trace of albumin, and -there were numerous hyalin casts in the urine.</p> - -<div><span class='pageno' id='Page_351'>351</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='6'><b><span class='large'>PARETIC NEUROSYPHILIS</span></b></td></tr> - <tr><td> </td></tr> - <tr><td class='c020' colspan='6'><b>(GENERAL PARESIS)</b></td></tr> - <tr><td> </td></tr> - <tr> - <th class='c009' colspan='2'>Cases systematically treated</th> - <th class='c008'> </th> - <th class='c008'>50</th> - <th class='c008'> </th> - <th class='c033'> </th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c009' colspan='2'>CLINICAL REMISSIONS</td> - <td class='c008'> </td> - <td class='c008'>34</td> - <td class='c008'> </td> - <td class='c033'>68%</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>C.S.F. ALTERED TO NEGATIVE</td> - <td class='c008'>4</td> - <td class='c008'> </td> - <td class='c008'>8%</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>C.S.F. ALTERED TO WEAKER</td> - <td class='c008'>16</td> - <td class='c008'> </td> - <td class='c008'>32%</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>C.S.F. UNALTERED</td> - <td class='c008'>14</td> - <td class='c008'> </td> - <td class='c008'>28%</td> - <td class='c033'> </td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c009' colspan='2'>CLINICALLY UNIMPROVED</td> - <td class='c008'> </td> - <td class='c008'>16</td> - <td class='c008'> </td> - <td class='c033'>32%</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>C.S.F. WEAKER</td> - <td class='c008'>7</td> - <td class='c008'> </td> - <td class='c008'>14%</td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>C.S.F. UNALTERED</td> - <td class='c008'>9</td> - <td class='c008'> </td> - <td class='c008'>18%</td> - <td class='c033'> </td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='6'><span class='sc'>Massachusetts Commission on Mental Diseases</span></td></tr> - <tr><td class='c022' colspan='6'><span class='sc'>November, 1916</span></td></tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='6'><span class='sc'>Chart 25</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_352'>352</span><b>Mentally</b>, there was a degree of depression and worry -hardly out of keeping with the general situation. Despite -the preservation of memory, Mr. Stone failed to do rather -simple arithmetical calculations; this was the more remarkable -as in his business he had to handle figures a great -deal and had been doing so until recently. There was a -slight tremor in his writing, as well as a certain difficulty in -enunciating test phrases. Insomnia, irritability, and a feeling -of nervousness and of being tired out, completed the -picture.</p> - -<p class='c007'>A suggestion for diagnosis would be classically offered -by the Argyll-Robertson pupils. Should not a patient with -the Argyll-Robertson pupils have either tabes or paresis? -However, in favor of tabes, besides the pupil, are to be counted -merely the troubles with the eyes. In the direction of paresis -we have to consider speech defect, to say nothing of less definite -symptoms such as insomnia and increased irritability.</p> - -<p class='c007'>We are inclined to think, however, that the disease in this -case is meningovascular. This diagnosis is suggested by the -cranial nerve palsies and by the headache. Headache is -much more rarely a phenomenon in the paretic type of neurosyphilis -than in the meningovascular type.</p> - -<p class='c007'>In point of fact, the spinal fluid phenomena bore out the -diagnosis of <span class='sc'>Meningovascular Neurosyphilis</span> inasmuch as -the globulin, albumin, cellular content, gold sol, and W. R.’s -were all weakly positive.</p> - -<p class='c027'>1. How far can we regard the cardiorenal defects as syphilitic? -Perhaps we may do so on the general principle -of parsimony in scientific interpretation.</p> - -<p class='c007'>The diagnostic lumbar puncture led to an extremely -severe exacerbation of the pains on the left side of the head. -In fact, these pains could not be held in check by the exhibition -of pyramidon. Mr. Stone regarded the pain as due -to the lumbar puncture. However, there was no improvement -in the pain in the prone position,—a feature characteristic -of lumbar puncture pains. Upon administration of -<span class='pageno' id='Page_353'>353</span>salvarsan, this local pain rapidly disappeared. In fact, there -was a startling improvement; the ocular palsies disappeared -in a few weeks, although these palsies had been present -for several months before the administration of salvarsan. -The blood pressure was reduced; the urine became negative. -Perhaps the most startling feature of all (although of this we -are not sure) was that the patient states he was accepted by -a life insurance company although he had been twice refused -previously.</p> - -<p class='c007'><b>Note</b> in this case the 30–year interval between infection -and generalized neurosyphilitic involvement. Note also -the amenability of the process despite this duration. We -are perhaps entitled also to note that a neurological examination -careful enough to detect an Argyll-Robertson pupil -should have been made by a number of examiners long -before the particular crisis which we have sketched. It is -also permissible to note that the rhinological work should not -have been carried out independently of all other medical -work.</p> - -<p class='c027'>2. What are the untoward results of lumbar puncture? -It is true that there is always a possibility of setting up -a septic meningitis by lumbar puncture, but this is a -very remote possibility and with any reasonable care -it is not to be considered. Lumbar puncture also has -a considerable danger in cases of increased intracranial -pressure. In cases of brain tumor where the tumor is -located in the posterior fossa, sudden death may occur -from withdrawal of spinal fluid. This is supposed to -be due to the medulla being pressed down into the -foramen magnum and causing paralysis of respiration. -Therefore lumbar puncture should never be performed -except with the greatest caution in a case in which -brain tumor is suspected.</p> - -<p class='c028'>However, aside from these remote serious consequences -which play very little rôle in the ordinary procedure -of lumbar puncture, certain unpleasant symptoms -do frequently arise. These symptoms are chiefly -headache and nausea, but, however, may go as far as -vomiting. These symptoms occur almost entirely in -the cases in which there is no abnormal condition producing -increased spinal fluid pressure. Such unpleasant -<span class='pageno' id='Page_354'>354</span>symptoms may last as long as four or five days; as a -rule, however, last only for a period of a day or two.</p> - -<p class='c027'>3. What is the treatment of discomfort following lumbar -puncture? It is a rule well worth observing that the -patient after lumbar puncture should remain flat on his -back without a pillow for 24 hours in order to avoid any -unpleasant symptoms. If any symptoms do occur, -it will be almost certainly when the patient arises, and -in nearly every instance they will be overcome if the -patient again assumes the prone position. Raising -the foot of the bed so as to lower the head also helps. -Veronal or bromides may be given but as a rule are not -very satisfactory.</p> - -<p class='c027'>4. How permanent is the improvement obtained in the -case of Mr. Stone likely to be? As a matter of fact, -the patient discontinued treatment as soon as he felt -well again, but after two months the pain returned to -be again quickly dispelled by salvarsan. This improvement -must be considered as only temporary. -Under continued treatment there may be no further -relapse. There is, however, evidence that much damage -has been done to the body by the spirochetes, -much of which is irreparable. It is even possible that -further disintegration might occur even while undergoing -treatment. Still treatment offers much in such -a case and is to be highly recommended.</p> - -<div><span class='pageno' id='Page_355'>355</span></div> -<div class='box'> - -<p class='c013'><b>In DIFFUSE NEUROSYPHILIS, rendering the -spinal fluid negative by treatment may mean -neither cure nor disappearance of symptoms.</b></p> - -</div> - -<p class='c006'><b>Case 107.</b> Greta Meyer, a widow, 51 years of age, came -voluntarily to the hospital, seeking medical aid for a marked -depression. She was also suffering from a right hemiplegia. -It appeared, according to Mrs. Meyer, that she was married -at 16, and lived with her husband until 29, whereupon she -left him on account of his alcoholism, his abuse of her, and -the discovery through his physician that he was suffering from -venereal disease. She had had two healthy children and -there never had been miscarriages or stillbirths. Six years -after the separation, namely at 35 years of age, and 16 years -before resort to the Psychopathic Hospital, Mrs. Meyer -developed certain red areas on her hand, and learned at a -hospital that these were due to syphilis. She kept up -treatment for these lesions for a year, until she seemed perfectly -well.</p> - -<p class='c007'>She had, in fact, remained perfectly well for some 14 years, -until at 49, a small tumor had appeared on the right side of -the forehead, near the hair line. This tumor was firm and -not sore. Medical treatment reduced it, leaving, however, -a depression in the bone. One day, about a month after the -appearance of the tumor, the patient lay down for a nap, -and upon awaking found she could only with difficulty move -her right arm and leg. Her face was not affected; she was -not in pain; and there was no disorder of speech. In a few -days she got much better and she had been improving -for some time past through the administration of further -medicine.</p> - -<p class='c007'>However, since the onset of the hemiplegia Mrs. Meyer -had been very despondent. There had been ups and downs -but she had rarely felt well. The depression was a mild one -and in point of fact may perhaps be regarded as non-psychopathic, -since at her age with her disability, there might well be -a degree of sadness and unhappiness concerning the future. -<b>Mentally</b>, there was no other disorder of note, and in particular -no disorder of memory.</p> - -<div><span class='pageno' id='Page_356'>356</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><b><span class='large'>METHODS OF TREATMENT</span></b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line in2'>I. BY MOUTH.</div> - <div class='line in5'>1. MERCURY</div> - <div class='line in5'>2. IODIDES</div> - <div class='line in5'>3. ARSENIC</div> - </div> - <div class='group'> - <div class='line in1'>II. INTRAMUSCULAR INJECTIONS</div> - <div class='line in5'>1. MERCURY</div> - <div class='line in5'>2. SALVARSAN, NEOSALVARSAN, OTHER ARSENIC PREPARATIONS</div> - <div class='line in5'>3. SODIUM NUCLEINATE</div> - <div class='line in5'>4. ANTIMONY</div> - </div> - <div class='group'> - <div class='line'>III. INTRAVENOUS</div> - <div class='line in5'>1. MERCURY</div> - <div class='line in5'>2. MERCURIALIZED SERUM</div> - <div class='line in5'>3. SALVARSAN, NEOSALVARSAN, ARSENIC</div> - <div class='line in5'>4. IODIDES</div> - </div> - <div class='group'> - <div class='line in1'>IV. SPINAL INTRADURAL</div> - <div class='line in5'>1. SALVARSANIZED SERUM (<span class='sc'>In Vivo—Swift-Ellis</span>)</div> - <div class='line in5'>2. SALVARSANIZED SERUM (<span class='sc'>In Vitro—Marinesco-Ogilvie</span>)</div> - <div class='line in5'>3. MERCURIALIZED SERUM (<span class='sc'>Byrnes</span>)</div> - </div> - <div class='group'> - <div class='line in2'>V. CEREBRAL SUBDURAL AND INTRAVENTRICULAR</div> - <div class='line in5'>1. SALVARSANIZED SERUM (<span class='sc'>In Vivo</span>)</div> - <div class='line in5'>2. SALVARSANIZED SERUM (<span class='sc'>In Vitro</span>)</div> - <div class='line in5'>3. MERCURIALIZED SERUM</div> - </div> - </div> -</div> - -<div class='c018'> <span class='sc'>Chart 26</span></div> - -</div> - -<p class='c019'><span class='pageno' id='Page_357'>357</span><b>Physically</b>, the patient showed a right-sided hemiplegia -with excessive right knee-jerk, but without Babinski or other -abnormal reflex phenomena. The extraocular movements -were somewhat restricted in range but there was neither -strabismus nor nystagmus.</p> - -<p class='c007'>The question arose whether the hemiplegia was of hemorrhagic -or thrombotic origin. After all, at 51 years, hemiplegia -is rather unlikely to be of a non-syphilitic arteriosclerotic -origin; moreover, we had a clear history of syphilis. The -serum W. R. proved positive as well as the spinal fluid W. R. -The finding of 77 cells per cmm., excess albumin, and positive -globulin test, taken in connection with the entire picture -seems to warrant a diagnosis of <span class='sc'>Cerebrospinal Syphilis</span>. -If we proceed on statistical grounds, it might be regarded as -more probable that the hemiplegia is <span class='sc'>Thrombotic</span> in origin -rather than hemorrhagic. It appears that syphilitic cerebral -thrombosis rather characteristically occurs without preliminary -symptoms, despite the fact that many cases do show -headache, dizziness, and restlessness as prodromal symptoms.</p> - -<p class='c027'>1. What is the treatment indicated in the case of Mrs. -Meyer?</p> - -<p class='c028'> It would appear that little or nothing can be done -for the hemiplegia unless the claims of Franz with -respect to reëstablishment of a degree of function in -certain hemiplegics are substantiated. However, the -indication of meningitic process as shown by the spinal -fluid, suggests that the case is not a purely vascular one -but may be regarded as meningovascular. (Possibly, -also, we should regard the left frontal depression and -scar as indicative of a non-parenchymatous and non-vascular -process.) Accordingly, antisyphilitic treatment -should be theoretically of some value.</p> - -<p class='c028'>In point of fact, the patient was given injections of -mercury salicylate, mercury by mouth, and potassium -iodid. Her psychopathic depression under this treatment, -supported by proper hygiene and rest, diminished. -However, six months later, the patient slipped -on a wet floor and fell. Though the impact seemed -<span class='pageno' id='Page_358'>358</span>hardly sufficient to cause a fracture, the pelvis was -somewhat severely fractured. Very probably there -was a syphilitic rarefaction of the bone. Six months -later the patient’s depression was still in evidence, -though somewhat less than upon admission. The -blood serum remained positive but the spinal fluid had -become entirely negative, both in respect to the W. R. -and in respect to the other findings.</p> - -<p class='c027'>2. How may one explain the continuance of the depression -after the spinal fluid had become entirely negative under -treatment? It may be that while the active process -had been stopped, as seems probable from the negative -spinal fluid, that a permanent destruction of brain -tissue may account for the depression. We recognize -this readily in instances of vascular disturbance where -(as also in this case) the active process being stopped, a -residual defect remains.</p> - -<p class='c027'>3. Should treatment have been discontinued on reduction of -the gumma? It cannot be too often emphasized that -the disappearance of symptoms in cases of syphilis can -not be considered as evidence of cure. The neurologist -and psychiatrist see only too often cases of neurosyphilis -occurring in patients who have been declared -cured at some time previous because the symptoms then -present had cleared up and remain in abeyance for -years.</p> - -<div><span class='pageno' id='Page_359'>359</span></div> -<div class='box'> - -<p class='c013'><b>Contrary to various warnings, arteriosclerosis by -no means absolutely contraindicates intensive -salvarsan therapy.</b></p> - -</div> - -<p class='c006'><b>Case 108.</b> Victor Friedberg, 42 years of age, gave the following -history. He acquired syphilis at 22 years. He had -“adequate” medical treatment for two years with inunctions -of mercury and mercury by mouth and potassium iodid. -The only secondary symptoms were skin lesions of the legs; -these disappeared upon treatment. Married, Friedberg has -one child, apparently normal. There had been no miscarriages -or stillbirths.</p> - -<p class='c007'>At about 34 years, there began to be shooting pains in the -legs, occurring at first about once in three months, but later -much more frequently. These pains were severe, lightning -in character, lasting several days at a time, at which period -his head would feel heavy; but there were no disturbances, -crises, or difficulty in locomotion.</p> - -<p class='c007'>At 36 years of age, Friedberg waked up with pain one night, -and found he was unable to move his left leg or hand, and he -felt his mouth drawn to the left. Upon trying to get out of -bed, he fell to the floor. In five hours, however, he was -entirely recovered, able to get up and walk about, and to use -his left arm quite normally. He went to sleep, but upon -waking up after an hour, discovered that his left side was -again paralyzed. After two weeks in a hospital, he was able -to walk with a crutch. The arm remained helpless for about -a year. Both arm and leg improved slowly for two years, -after which time his condition had remained stationary. -For four years past, there had been no more pain, but at 42—about -two years before admission—the pains returned in his -legs, back, and side. At that time he received four injections -of salvarsan, mercury tablets, and potassium iodid. Three -weeks before admission to the hospital, Friedberg again -began having headaches, very much worse than formerly. -At first these headaches were frontal, then occipital, and there -<span class='pageno' id='Page_360'>360</span>was a feeling as if something were growling inside of the head. -There was a feeling of pressure in front on the head and at the -base of the nose.</p> - -<p class='c007'><b>Physically</b>, Friedberg appeared somewhat older than his -assigned age. There was a degree of general peripheral -arteriosclerosis, but in general the physical examination was -negative. <em>Neurologically</em>, there was a left hemiplegia with -appropriate increase of the reflexes on that side, spasticity, -Babinski reflex, and an Oppenheim; the pupils reacted properly; -there was no Romberg reaction.</p> - -<p class='c007'><em>Mentally</em>, Friedberg was entirely negative.</p> - -<p class='c007'>The W. R. of the blood serum was doubtful, as was that of -the spinal fluid. There were but two cells per cmm. and there -was neither globulin nor excess albumin in the spinal fluid.</p> - -<p class='c007'>The <b>differential diagnosis</b> might lie between cerebral -hemorrhage and syphilitic thrombosis. Thrombosis is much -more common as a result of syphilis than is hemorrhage. -The occurrence of the thrombosis during sleep without premonitory -symptoms is also characteristic in syphilis. Possibly -there was a low-grade spinal meningitis at the bottom of -the lancinating pains. Whether the headache is an arteriosclerotic -effect or due to a meningitis not shown in the -cerebrospinal fluid is doubtful. However, the absence of inflammatory -products in the cerebrospinal fluid rather indicates -that the headache is of arteriosclerotic origin. Autopsies, -however, warn us that we may have a localized meningitis -in various parts of the cranial cavity without the determination -of any inflammatory products in the spinal fluid.</p> - -<p class='c027'>1. How shall we explain the doubtful (slightly positive) -W. R. in the spinal fluid if the case is one of <span class='sc'>Vascular -Brain Syphilis</span>? The finding is not unusual in these -cases. The W. R. producing body is recognized to be -of a separate nature from the globulin and albumin -bodies, and is probably also separate from the gold sol -reaction producing bodies.</p> - -<p class='c007'>Treatment: The theory of treatment is that any spirochetes -that may be still active in the body should be destroyed. -Accordingly, although salvarsan can certainly have -<span class='pageno' id='Page_361'>361</span>no effect in reproducing nerve tissue, it nevertheless seems -indicated. It is frequently stated, however, that salvarsan -is dangerous in cases of this group. We have not found this -statement correct. In this case, there was a symptomatic -improvement, as far as pain and discomfort went, under -salvarsan and iodids.</p> - -<p class='c027'>2. What precautions should be taken in intensive salvarsan -treatment of syphilitic arteriosclerosis? Treatment -should be begun with very small doses of salvarsan, -that is, about 0.1 of a gram and then the amount slowly -increased. The injection should be given slowly so as -not to put too great a load upon the cardiovascular -system.</p> - -<p class='c027'>3. What rôle does the mental attitude of the patient play in -a case like that of Friedberg? It was quite evident -that Friedberg was neurotic and that he had a syphilophobia. -Consequently some of the symptomatic improvement -may have been more results of assurances -offered by the physician and knowledge that he was -being treated, than results of salvarsan. In some cases -mental anguish suffered by the patient is of more -importance than the actual symptoms of the disease -and this point must be always borne in mind in handling -syphilitic patients.</p> - -<div><span class='pageno' id='Page_362'>362</span></div> -<div class='box'> - -<p class='c013'><b>Symptoms of intracranial pressure cured by antisyphilitic -treatment.</b></p> - -</div> - -<p class='c006'><b>Case 109.</b> Mrs. Annie Rivers, a housewife 36 years of age, -sought advice and treatment for severe convulsions which -she had had during a period of several weeks. She left the -hospital before being properly examined, and had several -more convulsions, after which she was brought back in a state -of marked confusion. The confusion shortly disappeared -almost completely, and a good history was obtained.</p> - -<p class='c007'>It appears that the patient led a normal life and had had -six children, the last of whom was born about four months -before her coming to the hospital. The first symptoms -appeared about a month after the birth of the child, when, -one afternoon, Mrs. Rivers suddenly fell unconscious while -ironing. She remained unconscious for nearly three hours. -During this attack there were no convulsive movements or -tongue-biting; and after the spell, she felt neither lame nor -sore, but merely tired. This was Mrs. Rivers’ statement; -but her daughter stated that the patient really did have convulsive -movements. A week later came a second convulsion, -followed by daze and stupor. This second attack -lasted two hours.</p> - -<p class='c007'>About a week before entrance, the patient had remained -in bed on account of dull grinding pain in the left side of the -head, below the ear, and upon this day the patient vomited -twice. In addition to the dull grinding pain, there were -pains referred to the ear itself and to the left side of the head, -especially over the left eye; there were no pains on the right -side of the head. The next day the patient was better, but -the day thereafter again remained in bed. The only other -symptoms were cold feelings at times and bright spots in the -field of vision.</p> - -<p class='c007'>No <b>mental symptoms</b> were observed in Mrs. Rivers except -a bit of depression after her hasty retreat from the hospital -the first time. Upon her second admission, however, after -a week or ten days’ residence, apathy developed together -with considerable amnesia for the same facts she had quite -readily remembered a few days previously. Along with the -apathy and amnesia developed considerable headache; and -there were attacks of vomiting.</p> - -<div><span class='pageno' id='Page_363'>363</span></div> -<div class='chart'> - -<div class='nf-center-c0'> -<div class='nf-center c016'> - <div><span class='large'><b>UNTOWARD SYMPTOMS OF THERAPEUTIC AGENTS</b></span></div> - <div class='c003'><b>A. SALVARSAN</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>CYANOSIS MALAISE</div> - <div class='line'>RAPID PULSE</div> - <div class='line'>PERSPIRATION</div> - <div class='line'>RESPIRATORY DIFFICULTIES</div> - <div class='line'>FEVER</div> - <div class='line'>NAUSEA, VOMITING, DIARRHOEA</div> - <div class='line'>DERMATOSES</div> - <div class='line'>EDEMA</div> - <div class='line'>KIDNEY IRRITATION</div> - <div class='line'>LIVER IRRITATION</div> - <div class='line'>INTENSIFICATION OF SYMPTOMS</div> - <div class='line'>COLLAPSE</div> - </div> - </div> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c017'> - <div><b>B. MERCURY</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>SALIVATION</div> - <div class='line in2'>FETID BREATH</div> - <div class='line in2'>EXCESS FLOW OF SALIVA</div> - <div class='line in2'>TENDERNESS OF TEETH—LOOSENING AND FALLING OUT</div> - <div class='line in2'>SPONGY GUMS—EROSION</div> - <div class='line in2'>METALLIC TASTE</div> - <div class='line in2'>NECROSIS OF BONES OF JAW</div> - <div class='line in2'>SORENESS OF PARETIC AND MAXILLARY GLANDS</div> - <div class='line in2'>SWELLING AND EROSION OF TONGUE AND MUCOUS MEMBRANES</div> - <div class='line'>GASTRO-INTESTINAL SYMPTOMS</div> - <div class='line'>ANEMIA</div> - <div class='line'>PAIN IN JOINTS</div> - <div class='line'>NEPHRITIS</div> - </div> - </div> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c017'> - <div><b>C. IODINE</b></div> - </div> -</div> - -<div class='lg-container-b c017'> - <div class='linegroup'> - <div class='group'> - <div class='line'>SKIN LESIONS</div> - <div class='line'>METALLIC TASTE</div> - <div class='line'>SALIVATION</div> - <div class='line'>CORYZA</div> - <div class='line'>URTICARIA (EVEN TO GRADE OF ANGIONEUROTIC EDEMA)</div> - <div class='line'>PAINS</div> - <div class='line'>CONSTIPATION</div> - <div class='line'>INVOLVEMENT OF JOINTS</div> - <div class='line'>FEVER</div> - <div class='line'>SOFTENING AND BLEEDING OF GUMS</div> - <div class='line'>EROSION OF MUCOUS MEMBRANES</div> - <div class='line'>GASTRO-INTESTINAL SYMPTOMS</div> - <div class='line'>ANOREXIA</div> - <div class='line'>WEAKNESS</div> - </div> - </div> -</div> - -<div class='c018'> <span class='sc'>Chart 27</span></div> - -</div> - -<p class='c019'><span class='pageno' id='Page_364'>364</span>On the <b>physical</b> side, it is interesting to note that the ophthalmoscopic -examination upon Mrs. Rivers’ first admission -to the hospital was entirely negative, whereas a week later, -pronounced difficulty with vision appeared so that in a few -days she was able to make out only very large type. The -fundi now showed hazy and indistinct disc outlines, with -small yellowish areas of fatty degeneration above the disc, -reduction of arterial calibre, and dilated and somewhat tortuous -veins (no projection of papillæ), so that the ophthalmological -diagnosis was chronic neuritis.</p> - -<p class='c007'>The physical examination otherwise was mostly negative. -The skin presented irregular areas covered with silvery scales -over the arms and chest, back, abdomen, and legs (the patient -had had psoriasis several years before). Both pupils reacted -to light and distance, though the right was slightly larger -than the left and somewhat irregular. There was a slight -tremor of the tongue and extended fingers. The reflexes -were active, especially the knee-jerks; no abdominal reflexes -could be obtained. The serum W. R. was positive, but the -spinal fluid W. R. was negative. The spinal fluid showed -but 3 cells per cmm., but there was a positive globulin test -and an excess of albumin.</p> - -<p class='c007'><b>Diagnosis</b>: After the symptoms had fully developed, it -became clear from the optic neuritis, headaches, and vomiting -that a condition of intracranial pressure existed. In view -of the positive serum W. R., it is natural to conceive that the -agent producing the intracranial pressure was a gumma.</p> - -<p class='c007'>It is, of course, possible that a marked degree of meningitis -might be so localized as to produce the same symptoms. The -diagnostician would crave a pleocytosis of the spinal fluid -if a diagnosis of meningitis is to be made; and there was no -such pleocytosis. On the whole, we do not feel that it is -possible to make a diagnosis either of <span class='sc'>Meningitis</span> or of -<span class='sc'>Gumma</span>.</p> - -<p class='c007'><span class='pageno' id='Page_365'>365</span><b>Treatment</b>: Treatment, however, caused a disappearance -of all symptoms. The treatment consisted of but one injection -of 0.3 gram of salvarsan, followed by a few injections of -mercury; whereupon Mrs. Rivers became much brighter, -recovered her vision, lost her headaches, ceased to have convulsions -or vomiting spells.</p> - -<p class='c027'>1. Is salvarsan contraindicated in cases with involvement of -the optic or auditory nerves? Such a contraindication -exists according to prevailing opinion. In this particular -case, a hemorrhagic retinitis occurred after the -injection of salvarsan, but this retinitis disappeared -along with the other symptoms. On the whole we -believe that in many cases of optic or auditory nerve -involvement salvarsan should be used. However, one -should never lose sight of the possibility of untoward -results and should advise such treatment only when -other treatment seems inefficient.</p> - -<div><span class='pageno' id='Page_366'>366</span></div> -<div class='box'> - -<p class='c013'><b>TABETIC NEUROSYPHILIS (“tabes dorsalis”) -may show very marked improvement as a result -of intraspinous therapy.</b></p> - -</div> - -<p class='c006'><b>Case 110.</b> Mr. McKenzie<a id='r18' /><a href='#f18' class='c014'><sup>[18]</sup></a> was a retired merchant of 42 -years whose complaint was that he tired very easily, could not -make his legs go where he wished, was unsteady and felt a -numbness in his legs. These symptoms had been in progress -for a few months only when the examination was made. -This disclosed Argyll-Robertson pupils, absent knee-jerks -and ankle-jerks, Romberg sign, unsteady gait, moderate -ataxia and dysmetria. The W. R. was negative in the -blood serum but positive in the spinal fluid with 0.2 cc., and -there were 107 cells per cmm. With the symptoms and signs -it was therefore easy to make the diagnosis of <span class='sc'>Tabetic -Neurosyphilis</span> (“tabes dorsalis”).</p> - -<p class='c007'>The patient was given five intraspinous injections of mercuric -chloride in blood serum (mercurialized serum) according -to the method of Byrnes. The dose was 0.001 gm. of mercury. -Two weeks after the first injection the cell count was 58 cells -per cmm., the Wassermann was positive only with 0.4 cc. -After the fourth injection there were but 18 cells and the -Wassermann reaction was negative even with 1½ cc. of spinal -fluids. The symptoms had improved to such a degree that the -patient had no complaint whatsoever and considered himself -cured.</p> - -<p class='c027'>1. What are the unpleasant results of intraspinous therapy? -Frequently there is an exacerbation of symptoms and -pain may be quite severe after intraspinous injections. -This, however, lasts only a short period, that is, as a -rule less than 24 hours. There may be other symptoms -of cord irritation as retention of urine or lack of -sphincter control. A rise of temperature is not unusual.</p> - -<div><span class='pageno' id='Page_367'>367</span></div> -<div class='box'> - -<p class='c013'><b>Treatment may alter the W. R. to negative in -blood and spinal fluid in TABES DORSALIS.</b></p> - -</div> - -<p class='c006'><b>Case 111.</b> Ivan Rokicki was a baker, 43 years of age, who -came complaining of exceedingly severe attacks of abdominal -pain with vomiting. He described these attacks as having -occurred periodically for a number of years, lasting sometimes -as long as a week, during which time Rokicki could not eat or -get relief short of large doses of morphine.</p> - -<p class='c007'>Upon his arrival, Rokicki was seen in one of his attacks; -he was curled up with excruciating pain, and the abdomen -was rigid, though it was impossible to produce additional -pain by external pressure. There was spasmodic vomiting, -frequently followed by slight relief from the pain, which -however shortly recurred and caused the patient to cry out in -his suffering. The condition was controlled by opiates but -lasted a full week. The leucocytes remained normal and -there was no rise of temperature. The attack ceased spontaneously.</p> - -<p class='c007'>Save for the pain, Rokicki’s <b>mental examination</b> proved -entirely negative. <b>Physically</b>, Rokicki was fairly well developed -and nourished. His pupils were slightly irregular: the -left markedly larger than the right; both pupils failed to -react to light, and the left pupil also failed to react in accommodation. -There were no other reflex disorders evident -to systematic examination, nor was there sensory disturbance -or speech defect. The heart seemed somewhat enlarged -but there were no murmurs; blood pressure: systolic -150; diastolic 110.</p> - -<p class='c007'>The correct symptomatic diagnosis in Rokicki’s case proved -to be gastric crises, and this diagnosis must perforce be the -first to entertain in view of the chronicity, the periodicity, -the non-relation to diet, and the spontaneous cessation of -the seizures. The observation of Argyll-Robertson pupils -was naturally held to substantiate the diagnosis of <span class='sc'>Tabes -Dorsalis</span>.</p> - -<p class='c007'><span class='pageno' id='Page_368'>368</span>The possibility of abdominal inflammation could be shortly -dismissed on account of the absence of tenderness (the rigidity -in this case was not accompanied by tenderness), fever, -and other characteristic signs. There was no diarrhoea, such -as is found in lead colic, and there was no other sign of -plumbism. Jaundice was absent and there was no special -radiation of pain from the abdomen. One had to think of -gastric ulcer and hyperchlorhydria, and possibly malaria or -gastroenteritis.</p> - -<p class='c007'>The pupillary reactions pointed to a syphilitic condition -despite the fact that the lack of reaction to accommodation -(over and above the Argyll-Robertson phenomenon) in the -right pupil is not entirely typical. Accordingly, although -there was no areflexia, Romberg sign, or ataxia, resort was -had to the W. R. This however proved negative, in blood -and spinal fluid; nor was there any globulin or excess albumin; -there were 5 cells to the cmm., in the spinal fluid.</p> - -<p class='c007'>We are left, accordingly, with characteristic gastric crises; -Argyll-Robertson pupils, slightly irregular; and a somewhat -enlarged heart.</p> - -<p class='c007'>Upon investigation, it appeared, however, that a year -before the attack above described, the patient had been -examined and both blood and spinal fluid found positive to -the W. R. At that time, treatment, consisting of intravenous -injections of salvarsan and intraspinous injections of salvarsanized -serum (Swift-Ellis), had been instituted. Whereupon -the laboratory tests had become negative, as above stated, -and there had been no alleviation of the symptoms.</p> - -<p class='c027'>1. How can Rokicki’s normal deep leg reflexes be explained? -The abolition of the deep reflexes is of course due to -lesions properly localized. It is probable that this -particular case of tabes dorsalis is more truly “dorsal” -than most cases; for most cases exhibit lesions involving -regions lower than the dorsal. Both in these dorsal -cases and in certain rare cases of cervical tabes, the -deep leg reflexes are preserved. (See cases Green (30) -and Halleck (31).)</p> - -<p class='c027'>2. What is the mechanism by which a characteristic gastric -crisis is produced? The mechanism is unknown. Some -endeavors have been made to meet gastric crises by -<span class='pageno' id='Page_369'>369</span>surgery of the posterior roots, on the assumption that -the irritation causing the pain was located either in -the posterior ganglion or in the passage of the nerve -through the meninges. In only a few instances, however, -has the result been what was desired. In many -instances the gastric crises and pain continued uninterrupted -and in addition came discomfort due to the lack -of sensation in the part supplied by the severed nerve. -At present this treatment is seldom carried out.</p> - -<p class='c027'>3. Should antisyphilitic treatment be continued in such a -case? As far as our present knowledge of syphilis goes -one would hesitate to suggest further antisyphilitic -treatment, feeling that the active process had been entirely -stopped as suggested by the absence of any positive -findings either in the blood serum or in the spinal -fluid. We should perhaps conclude that there was no -more activity in this case and that the crises were due to -the changes that had already taken place in the nerve -tissue and which could no longer be changed.</p> - -<div><span class='pageno' id='Page_370'>370</span></div> -<div class='box'> - -<p class='c013'><b>The literature is in doubt concerning (in fact is -preponderantly against) the success of treatment -in PARETIC NEUROSYPHILIS (“general paresis”). -Our experience has yielded a number of -apparently successful results through systematic -intensive intravenous salvarsan therapy. Example.</b></p> - -</div> - -<p class='c006'><b>Case 112.</b> Albert Forest had always been a successful -salesman, but in the middle of March, in his 46th year, he -was arrested for grabbing a purse from a woman in front of -a theatre and running down the street with it. In court, -Forest acted strangely and he was sent to the Psychopathic -Hospital for observation. Upon investigation, it appeared -that his wife thought he had been showing mental changes -for about a year. For example, he would embrace his wife -on a street car, or refuse to pay her fare. He once attempted -to hit his son on the head with a red-hot poker. Now and -then he would become sleepy and stupid. He looked rather -older than his age and had a coarse tremor of the hands. -Otherwise, no change could be detected in the physical -examination, either neurologically or otherwise. As for the -manual tremor, Forest’s wife gave a history of considerable -alcoholic indulgence on his part.</p> - -<p class='c007'>For several days, nothing abnormal could be detected in -the man; and in particular, his memory for both remote and -recent events was very good and his knowledge of current -events was good. Simple arithmetic was easy to him.</p> - -<p class='c007'>One evening his temperature was found to be 104° F. and -no cause could be discerned for this. The next morning, -Forest was discovered in a stupor, with a complete right -hemiplegia. The Babinski reflex, the Oppenheim reflex, and -ankle clonus had appeared on the right side, and the right -arm was spastic.</p> - -<p class='c007'>However, all symptoms of this paralysis had disappeared -by four o’clock in the afternoon, and the paralytic phenomena -were replaced with violence. The patient fought with the -<span class='pageno' id='Page_371'>371</span>attendants and for some time remained extremely difficult to -manage, being confused and subject to outbreaks of violence -with destruction of furniture and other property about the -ward.</p> - -<p class='c007'><b>Diagnosis.</b> At first we were naturally inclined to dismiss -the case with a diagnosis of alcoholism. The transient -hemiplegia at once raised a considerable question of brain -syphilis or of brain tumor.</p> - -<p class='c007'>The W. R. of the serum was doubtful. The spinal fluid -yielded, besides marked excess of albumin and much globulin, -also a “paretic” gold sol reaction and 75 cells per cmm. -The W. R. was positive.</p> - -<p class='c007'><b>Treatment.</b> The patient was given injections of salvarsan, -0.6 gram, twice a week, with potassium iodid. After -a few weeks improvement followed, and after several months -all the laboratory tests became negative, the patient was -apparently perfectly normal mentally and was discharged -from the hospital, and has remained well for 18 months -without further treatment. The serum W. R. has continued -to be negative.</p> - -<p class='c027'>1. What is the significance of the so-called “doubtful” -W. R.? Where there is not a complete uniformity the -results of the strong and weak antigens (see appendix -on technique of Wassermann reaction) the result is -reported as doubtful. In the majority of instances -repetitions will give a strong positive reaction.</p> - -<p class='c027'>2. Is the case of Forest to be regarded as one of general -paresis? Sometimes such cases are termed in the -literature <em>syphilitic pseudoparesis</em> (see case Burkhardt -(58)). The differential diagnosis of this group is -entirely therapeutic. There are, unhappily, no laboratory -tests which will suffice in the present stage of -knowledge to differentiate a case of so-called pseudoparesis -from general paresis. We are inclined to term -the case one of <span class='sc'>General Paresis</span>, with recovery, or, -at all events, with remission.</p> - -<div><span class='pageno' id='Page_372'>372</span></div> -<div class='box'> - -<p class='c013'><b>The literature is in doubt concerning (in fact is -preponderantly against) the success of treatment -in PARETIC NEUROSYPHILIS (“general paresis”). -Our experience has yielded a number of -apparently successful results through systematic -intensive intravenous salvarsan therapy. Example.</b></p> - -</div> - -<p class='c006'><b>Case 113.</b> We present the case of Gussie Silverman, a -housewife, 35 years of age, among other reasons, for its social -interest. The case is, on the whole, sufficiently typical of -<span class='sc'>General Paresis</span>. <b>Physically</b>, for example, the pupils failed -to react to light and accommodation and were unequal, the -right being larger than the left. The knee-jerks were sluggish -though equal. The ankle-jerks could not be obtained. The -abdominal reflexes were not obtained. Otherwise, there was -no reflex disorder.</p> - -<p class='c007'>From the <b>laboratory</b> point of view, the W. R. was positive -in the blood and in the spinal fluid. There were 80 cells per -cmm. and there were an appropriate globulin and albumin -reactions. Mrs. Silverman was rather poorly nourished and -had a slight edema of the ankles.</p> - -<p class='c007'><b>Mentally</b>, she was found on admission to be markedly -depressed. It appeared that during a recent pregnancy, -terminated by the birth of a 7–months child, she had fainted -several times a day, that since the confinement she had been -very nervous, that she had been asking her husband not to -send her away, that she had refused to leave the house, that -she had become excited even to the point of injuring herself, -especially at night, and that she would go so far as to scratch -her husband, shortly afterward being very sorry for her performances. -Before this last pregnancy there had been four -others and the resulting children were all apparently in good -health. Except for the fainting spells during the pregnancy, -it would not appear that the story just told is at all characteristic -of paresis.</p> - -<p class='c007'><span class='pageno' id='Page_373'>373</span>However, in the hospital Mrs. Silverman could hardly be -got to answer questions, continually saying, “You know what -it is; I don’t have to tell you.” She claimed so marked a -degree of confusion as not to know where she was and what -she was doing. She would beg despondently that something -be done for her, and iterate and re-iterate these claims. -There appeared to be a marked degree of amnesia. Some -one, she felt, had controlled her thoughts and made her do -things she did not want to do and say things she did not want -to say, things she did not know she was about to say. She -said, “I feel like jumping around. I couldn’t believe myself -as if I am me. Some one is making me jump around. I used -to hear him talking. I don’t know who it is. I used to keep -my eyes open and I couldn’t move. I feel only I would like -to talk, and talk, and talk, and talk all the time. It seems to -me that some one talks in me. I couldn’t sleep for five minutes. -My God, I wish I could sleep! I used to feel something -in my heart. I used to faint. It seems to me I used to see -a funny thing. What it was I can’t tell. It used to talk to -me, make me get out of bed, throw me about, make me do -things. O, I don’t know what it was.”</p> - -<p class='c007'>These not entirely characteristic mental symptoms, together -with the suggestive physical signs and the laboratory -examination, caused treatment to be instituted; under which -treatment (intravenous injections of salvarsan) she improved -rapidly. Mental symptoms disappeared under the administration -of 12 injections of salvarsan within two months. -Moreover, the spinal fluid became entirely negative. Two -and a half years have now elapsed since her discharge and she -has shown no return of symptoms. The serum W. R. has -always remained negative although there has been no treatment -since leaving the hospital. There has, however, been -no change in the reflexes, which remain as on admission. The -7–months baby has continued to be perfectly healthy. Its -W. R. is negative, as are the W. R.’s of the husband and the -other three children. It must seem surprising that a healthy -child could have been born from a mother with generalized -syphilis as in this case. However, perhaps there are more -instances than we imagine like the case of baby Silverman.</p> - -<p class='c027'><span class='pageno' id='Page_374'>374</span>1. May a patient be considered permanently cured although -there has been no recurrence of symptoms for 2½ years -and although the Wassermann has remained negative? -One would hesitate to give a definite statement that the -patient was cured until more time had elapsed. It is -quite possible that spirochetes may be lurking in some -portion of the body without causing the production of -symptoms or Wassermann bodies and yet ready to -break out at any time. This hypothesis has added -weight from the recent work of Warthin already quoted. -We advise examination of this patient at intervals of -not longer than six months for a good many years.</p> - -<p class='c027'>2. Should the course under treatment cause us to change -the diagnosis? It has often been stated that a differential -point between cerebrospinal syphilis and general -paresis is the reaction to treatment, that is, that a case -which recovers could not be general paresis. Head -and Fearnsides state that if six months after beginning -of treatment the spinal fluid has become negative, the -case should be considered as one of cerebrospinal -syphilis and not general paresis. We do not feel ready -to concur in this view as we know of no similar logic in -medicine. We have many cases in which a spinal -fluid has remained positive for six months and later -become negative, so that where the symptoms shown -are those of paretic neurosyphilis, we are inclined to consider -the case such until such time as more definite -evidence checked by post mortem examination causes -us to change this point of view.</p> - -<p class='c027'>3. Do the reflexes change under treatment? The signs of -spasticity often do disappear under treatment and also -when there is no treatment. A few instances have -been reported in the literature where Argyll-Robertson -pupils are said to have altered to normal. It has never -been our good fortune to see such a change nor have -we seen an absent knee-jerk become normal, as has -also been reported, except where it is the result of -pyramidal tract disease superimposed upon the posterior -column sclerosis causing a return of reflex. This, -of course, is not to be considered as a return of the -normal. (See Case 1.)</p> - -<div><span class='pageno' id='Page_375'>375</span></div> -<div class='box'> - -<p class='c013'><b>Some RESULTS of systematic intravenous salvarsan -therapy are PARTIAL (<em>e.g.</em>, clinical recovery -and persistence of positive laboratory tests).</b></p> - -</div> - -<p class='c006'><b>Case 114.</b> Walter Henry was an undertaker in a small -town. He was married and the father of two healthy children. -In May, 1914, he began to lose his appetite. He felt restless -and seemed to be losing his grip, and in August he repaired -to a sanatorium, where he remained for two months. Shortly -after leaving the sanatorium, he fainted one day, while digging -a grave, during a spell of great heat. Since that time -there had been numerous “weak spells,” with headaches and -general debility, insomnia, and loss of weight.</p> - -<p class='c007'>In February, 1916, Mr. Henry came to the hospital for -advice, but the trip from a distant part of the state was apparently -such a strain for him that shortly after admission -he collapsed. There were no convulsive movements in this -collapse, but the patient was confused and his breathing was -rapid and stertorous. The semi-stupor lasted for about 48 -hours. Upon recovery from the stupor, Henry was found -entirely disoriented, much confused, and laboring under the -belief that he was digging a grave. After a time he again -fell into a stupor and his temperature rose to 103° F.</p> - -<p class='c007'>The emaciation of this man was striking and unusual, -but systematic <b>physical examination</b> showed no special disease. -<b>Neurologically</b>, there were marked tremors, and there -were purposeless movements of the arms. There was a -marked speech defect. The pupils were dilated, regular, and -equal, and reacted, though slightly, to light. Nothing abnormal -was noted upon systematic examination of the reflexes.</p> - -<p class='c007'>The W. R. was strongly positive in the blood and in the -spinal fluid; the gold sol reaction was typically “paretic”; -there were 16 cells per cmm., globulin was present, and albumin -was greatly increased.</p> - -<p class='c007'>The <b>diagnosis</b> <span class='sc'>General Paresis</span> was accordingly made, and -treatment instituted. Intravenous injections of arsenobenzol, -<span class='pageno' id='Page_376'>376</span>at first, and later of diarsenol, were given, as a rule twice a -week (usual dose, 0.6 of a gram). Mercurial injections and -potassium iodid were also given. This treatment was continued -as the patient began to improve. The improvement -was of such a degree that at the end of four months, Mr. -Henry returned to his home and his work. He had had 30 -intravenous injections of salvarsan substitutes. Despite the -treatment and the clinical improvement, the laboratory tests -remained essentially unchanged. The W. R.’s of the blood -and spinal fluid remained strongly positive, as well as also the -globulin and albumin; the gold sol reaction was still “paretic”; -the cells stood at one per cmm. The patient has continued -antisyphilitic treatment since leaving the hospital, and has -remained apparently well, with good insight into his condition.</p> - -<p class='c027'>1. What is the significance of a temperature of 103° in a -paretic without signs of infection and a normal leucocyte -count? Temperatures of this type are not infrequent -in the course of general paresis. They are usually -spoken of as “paretic temperatures.” Their meaning -is not understood, but they are often stated to be due to -a disturbance of the heat-regulating mechanism. Such -temperatures may remain elevated for a considerable -period of time, but the elevation may be very transitory. -At times they vary, like septic temperatures.</p> - -<p class='c027'>2. What can be argued from the fact that the cell count -became normal? If thorough antisyphilitic treatment -is vigorously given, it will be found that in the vast -majority of cases of neurosyphilis the cell count will -return to normal. It matters not whether the treatment -be intravenous or subdural. It is very difficult, -however, to obtain this result in general paresis by the -use of mercury alone. It cannot, however, be urged -that this finding has any great prognostic significance -as it occurs in the cases which do poorly as well as in -those which recover symptomatically.</p> - -<p class='c027'>3. Is it safe to give large doses of salvarsan to a patient in -a stupor? It is not a good plan to give a large dose to -such a patient on account of the danger of sudden -death. This is probably due as much to the strain -put on the heart as it is to any effect on the nervous -system, or specific arsenic effect. In this particular -instance, a dose of 0.15 gm. was the initial injection -and this was increased five centigrams per injection.</p> - -<div><span class='pageno' id='Page_377'>377</span></div> -<div class='box'> - -<p class='c013'><b>IMPROVEMENT IN PARETIC NEUROSYPHILIS -(“general paresis”) may become evident -only after several months of intensive treatment.</b></p> - -</div> - -<p class='c006'><b>Case 115.</b> Henry Ryan was a shipping clerk, 54 years of -age, who was brought to the hospital following a convulsion. -For a few months preceding this period, Mr. Ryan -had been failing in his abilities. He had been very forgetful, -showed no energy, and had become very irritable. He also -complained of insomnia and of feeling nervous.</p> - -<p class='c007'>On admission to the hospital, the most striking feature in -the mental situation was that he claimed that he had not -slept a wink for three months, and each day he would solemnly -affirm that he had not slept at all the preceding night, although -the records might show that he had slept eight hours. Argument -was of no avail against this conviction. In addition, -his memory was very poor; he showed little knowledge of -current events, and had no ability with arithmetical problems.</p> - -<p class='c007'><b>Neurologically</b> viewed, the points of chief significance were -contracted immobile pupils and a speech defect, especially -noticeable on the repetition of test phrases. The whole -picture was suggestive of general paresis, and this diagnosis -was confirmed by the laboratory findings. It was found that -the W. R. was positive in the blood and spinal fluid, that -there was a pleocytosis, positive globulin reaction, excess of -albumin, and a “paretic” gold sol reaction. Consequently, -the diagnosis of <span class='sc'>General Paresis</span> seemed justified, although -the patient denied any knowledge of a syphilitic infection.</p> - -<p class='c007'>Treatment in this case consisted of intravenous injections -of salvarsan, diarsenol, or arsenobenzol, whichever drug was -most easily obtainable, given twice a week in doses of 0.6 -gram each. In addition, he was given occasional injections -of mercury salicylate as well as potassium iodid by mouth. -Once or twice a week, 40 to 60 cc. of spinal fluid were withdrawn. -Under this treatment for a period of three months, -the patient showed no improvement whatsoever, either in -<span class='pageno' id='Page_378'>378</span>his mental condition or in the laboratory findings. However, -treatment was faithfully persevered in, and shortly after the -three months, improvement began to be noticed. At first, -the patient began to admit that possibly he may have slept -a few winks some time during the previous six months, for -he said he realized it was not possible for a man to live without -sleep for that period. Then he began to admit that he might -have slept a few hours during the night, and later that he -was sleeping pretty fairly. His memory also showed improvement. -His general attitude showed alertness, and he -began to interest himself in his surroundings and in the events -of the world, and finally he gained complete insight into his -condition.</p> - -<p class='c007'>In the meantime, that is after three months of treatment, -the laboratory findings began to grow weaker. The gold sol -reaction was the first to decrease in strength, and after four -months of treatment, it vacillated between negative and a -mildly positive “syphilitic” reaction. Then the globulin -and albumin became less in amount, and the W. R. began -dropping off in the 0.1 and 0.3 cc. dilutions. As is usually -true in those cases of neurosyphilis that receive adequate -treatment, the cell count early dropped to normal. The -W. R. in the blood serum, however, remained positive.</p> - -<p class='c007'>As the patient’s condition seemed so much better, he was -allowed to leave the hospital at the end of five months. He -took things easily for the following seven months, and then, -after being out of employment for the period of a year, as his -health continued good, he decided to return to work. Before -doing so, he entered the hospital again for a lumbar puncture. -At this time, it was found that the cell count was normal, -there was a very faint trace of globulin, possibly a slight increase -above normal albumin content, and a very mild gold -reaction. The W. R. in the spinal fluid was negative including -the 1.0 cc. dilution; the blood serum remained positive.</p> - -<p class='c007'>The patient then returned to his old position and has done -satisfactorily for the past six months. During this entire -time, he has been coming to the hospital for treatment: -during the major portion of the time, about once in two weeks; -of late, once in four weeks.</p> - -<p class='c007'><span class='pageno' id='Page_379'>379</span>The significant point in this case is that improvement did -not show itself until after more than three months of intensive -treatment, and then the improvement was synchronous with -a weakening of the spinal fluid tests.</p> - -<p class='c007'>It is further significant that his mental and physical condition -was good before the tests had reached anything like -normal; and that under treatment, these tests continued -to grow weaker and weaker, until at the end of a year, they -were practically negative.</p> - -<p class='c007'>The case further illustrates the enormous number of injections -of salvarsan preparations that may be given to a -patient without causing any appreciable damage to the general -health or to the kidney function. Mr. Ryan has had -more than 60 injections.</p> - -<p class='c027'>1. How soon after treatment is instituted does improvement -usually occur in paretic neurosyphilis? In our experience -improvement usually shows itself in from two -or three months of treatment. Occasionally the improvement -may be very marked shortly after treatment -is commenced, that is, after three or four injections of -salvarsan. This is not, however, the rule and as in -the case of Ryan, it may be only after more than three -months that improvement is seen. This means that -in the treatment of these cases patience must be exercised -and much work done.</p> - -<p class='c027'>2. What is the point of withdrawing large amounts of spinal -fluid as in the case of Henry Ryan? It has been stated -that the withdrawal of 40 or more cc., of spinal fluid -while the patient is under treatment has the effect of -reducing the intraspinous and intracranial pressure and -thereby allowing the drug to diffuse into the nervous -tissue better than it would do under ordinary conditions. -How much truth there is in this contention it is -difficult to say and there is as yet no experimental evidence -to confirm this contention. As a matter of fact, -the spinal fluid in cases of paresis is usually under -increased pressure and it is at least plausible to conceive -that a reduction of this pressure may give some symptomatic -relief.</p> - -<div><span class='pageno' id='Page_380'>380</span></div> -<div class='box'> - -<p class='c013'><b>Evidence of the activity of syphilis outside the -central nervous system may be seen in cases of -neurosyphilis despite intensive treatment.</b></p> - -</div> - -<p class='c006'><b>Case 116.</b> William Rosetti was a speculator, 43 years of -age, when he was brought to the Psychopathic Hospital on -account of an outbreak in which he smashed a showcase at -the store where his sweetheart was employed; he caused so -much commotion that he was arrested.</p> - -<p class='c007'>On admission, he was very excited, talking loudly and at -length. For some days it was very difficult to manage him, -he was so active. At any moment, he would insist upon -undressing and taking physical culture exercises. He was -very euphoric and expansive, and had no insight into his -condition.</p> - -<p class='c007'><b>Physically</b>, he was a powerfully-built man and in very good -physical condition except for an iritis and moderate thickening -of the peripheral arteries. The <b>neurological signs</b> of importance -were Argyll-Robertson pupils, and absent knee-jerks -and ankle-jerks. With these findings in mind, a tentative -diagnosis of <span class='sc'>General Paresis</span> was made, and this was substantiated -by the laboratory tests, which gave positive W. -R.’s in blood and spinal fluid, globulin, excessive albumin, -slight pleocytosis, and a “paretic” gold sol reaction.</p> - -<p class='c007'>When the patient’s mental condition was somewhat better, -he gave a history of syphilitic infection 15 years before, for -which he had had almost continuous treatment. As a matter -of fact, treatment had been pretty strenuous because he had -recurring skin lesions and iritis. It was practically impossible -to get the skin lesions to heal with mercury, and it was -not until salvarsan was introduced that a good result was -obtained in this respect. After one or two injections of this -drug, the skin lesion disappeared and has never returned. -However, at least once a year, he has had attacks of iritis, -and for this reason was still being treated for syphilis at the -outbreak of his psychosis.</p> - -<p class='c007'><span class='pageno' id='Page_381'>381</span>He was at once placed on more strenuous antisyphilitic -treatment in the form of diarsenol, semi-weekly, aided by -mercury injections. After a few months of this treatment, -his mental condition improved so much that he seemed to be -entirely normal. Treatment was continued, however, without -any abatement, and it was of great interest to note at the -end of five months of such treatment that, although mentally -he seemed entirely well, he had an attack of iritis, which was -considered as a sign of active syphilis. This would appear -to indicate the great difficulty of getting results in certain -cases of syphilis with any drugs at our command at present, -as in the iritis we are dealing with a condition which as a -rule reacts fairly readily to antisyphilitic remedies.</p> - -<p class='c027'>1. Are there different strains of spirochetes showing various -degrees of malignancy? This question has been discussed -at length in the literature but there is no satisfactory -answer at the present time. We must always -consider the reaction of the organism and the host; and -it is true in syphilis, as in every other disease, that in -some individuals it is more difficult to get any therapeutic -results than in others.</p> - -<p class='c027'>2. Was the failure to obtain results by long years of treatment -due to “drug fastness” of the spirochetes? It has -been held that the organism of syphilis will develop an -immunity after a time to mercury and arsenic preparations. -This led Fournier to recommend intermittent -treatment as more efficient than continuous treatment. -Noguchi has shown that in test tube experiments, the -spirochetes develop a tolerance to increasing doses of -arsenic. It must be emphasized, however, that this finding -has not been established for the conditions <i><span lang="la" xml:lang="la">in vivo</span></i>. -Another explanation of the failure of treatment in certain -instances has been offered by McDonagh, who describes -a life cycle of the organism of syphilis under the name of -<em>cytorrhyctes luis</em>, of which he believes the spirochete to be -merely one form, the other forms not being affected by -arsenic or mercury.</p> - -<div><span class='pageno' id='Page_382'>382</span></div> -<div class='box'> - -<p class='c013'><b>Some results of systematic intravenous salvarsan -therapy in PARETIC NEUROSYPHILIS (“general -paresis”) are partial in the sense that with -clinical recovery the laboratory tests remain partially -or less strongly positive.</b></p> - -</div> - -<p class='c006'><b>Case 117.</b> Annie Martin was a charwoman, 37 years of -age. She had applied for relief at a general hospital, to which -she was admitted on the suspicion of nephritis; but upon -admission she became markedly excited and noisy, and spoke -of seeing angels and hearing God speak to her. As the attendants -were unable to quiet her, she was promptly transferred -to the Psychopathic Hospital. She maintained that -she had been sent to the Psychopathic Hospital through the -spite of the general hospital doctors, and she claimed that -other people were also attempting to work her harm for the -purpose of taking her children from her. Visual and auditory -hallucinations were marked, as was the patient’s loquacity, -irritability, and flight of ideas. However, she seemed entirely -oriented and her memory appeared to be intact. She was -able to explain somewhat clearly her supposed condition. -The voices told her that somebody was after her and that -her soul belonged to the devil; that she was to be married -but that her soul was to be damned. These voices probably -belonged to priests. She was under the impression that she -was going to be sent to an electric chair and said, “I think I -am coming to the end and I want a pair of rosary beads -before the end comes.”</p> - -<p class='c007'>This patient’s pupils were markedly unequal and entirely -stiff to light and accommodation. <b>Neurologically</b>, however, -there were no other symptoms. There was a slight trace of -albumin in the urine and there were no casts.</p> - -<p class='c007'>The psychiatric <b>diagnosis</b> in this case would off-hand -undoubtedly be dementia praecox. Yet the stiff pupils are -almost proof positive of neurosyphilis. If further proof -were necessary, it is found in the laboratory tests, which -<span class='pageno' id='Page_383'>383</span>showed a positive W. R. of the serum and fluid, with a -“paretic” gold sol reaction; there were 22 cells per cmm., -there was excess albumin, and a positive globulin reaction.</p> - -<p class='c007'>Under intensive antisyphilitic treatment, there was a slow -improvement. After several months, the patient was entirely -free from mental symptoms; the spinal fluid tests -became entirely negative except that the gold sol reaction -has remained strongly positive.</p> - -<p class='c027'>1. Should treatment be continued in the case of Annie -Martin in spite of the clinical recovery and the negative -tests except the gold sol? We would again emphasize -that it is unreasonable to suppose that a long-standing -case of syphilis can be cured in a period of a few months -of treatment and while the tests may become negative, -it would seem foolhardy to stop treatment on this -account. We do know that in many cases a Wassermann -reaction remaining negative for many months -may again become positive, indicating that the negative -reaction did not mean cure but rather the absence -of the Wassermann bodies in the circulation at the time -the test was made.</p> - -<p class='c027'>2. What is the significance of the paretic gold sol reaction -when the other tests have become negative? As -previously stated, the gold reducing substance in the -spinal fluid seems to be different from the substances -which give the other pathological reactions. We -should feel in this case that the process which was -producing these gold reducing bodies had not been -stopped, in other words, cure was not complete.</p> - -<p class='c027'>3. Should one make a diagnosis on the “paretic” gold sol -reaction alone? The so-called paretic gold sol curve -is not always indicative of general paresis or even of -syphilis but may occur in non-syphilitic conditions as -brain tumor, multiple sclerosis, etc. In our experience -we have seen no case of <em>untreated</em> neurosyphilis in -which the gold sol alone was positive, that is, in cases -in which therapy has not changed the findings in the -spinal fluid. In our experience the gold sol reaction -has been fortified by one or several of the other tests -as the W. R., globulin test, pleocytosis.</p> - -<div><span class='pageno' id='Page_384'>384</span></div> -<div class='box'> - -<p class='c013'><b>Some effects of systematic intravenous salvarsan -therapy in PARETIC NEUROSYPHILIS (“general -paresis”) are limited to the laboratory findings -without clinical improvement.</b></p> - -</div> - -<p class='c007'>Two examples of such limitation are offered: William -Roberts (118) and John Silver (119).</p> - -<p class='c006'><b>Case 118.</b> A bank teller, William Roberts, 39, was sent -to the Psychopathic Hospital for a depression so marked that -he had become entirely unable to work or care for himself. -The story was that some money had been left him by his -uncle, that Roberts could not prove his right to the money, -and that depression, insomnia, and occasional periods of -confusion had followed during a period of about five months.</p> - -<p class='c007'>On admission, Roberts appeared wholly disoriented and -unable even to give his correct age. Attention could not -be held, and the patient would slide off into statements like: -“Oh, I made a mistake, I fooled a lot of people, I have a -terrible disease, they are going to get it, they are going to get -me,” etc., etc. There was great difficulty in thinking, and a -marked reaction of fear. This cluster of phenomena certainly -suggested very strongly the diagnosis of manic-depressive -psychosis.</p> - -<p class='c007'><b>Neurologically</b>, Roberts proved quite negative except that -the tendon reflexes were very active and the pupils reacted -somewhat sluggishly to light. The blood serum W. R. was -negative. No history of syphilis could be obtained; nevertheless, -Roberts kept dropping remarks about the terrible -disease from which he was suffering. It seemed best to proceed -to lumbar puncture, and the spinal fluid disclosed a -positive W. R., globulin, increased albumin, pleocytosis, and -“paretic” gold sol reaction.</p> - -<p class='c007'>The <b>diagnosis</b> of <span class='sc'>General Paresis</span> was accordingly made. -During the next year and a half, no improvement was made; -a slight speech defect was developed, and tremors of the hand -and tongue appeared.</p> - -<p class='c007'><span class='pageno' id='Page_385'>385</span>The effect of treatment is particularly instructive. Only -after 18 months in the hospital was intensive antisyphilitic -treatment instituted; but after a few months of this treatment -the W. R. of the spinal fluid had become negative, the -cells normal in number, globulin absent, albumin present -only in normal amount. Only the gold sol reaction remained -positive. It is still of a paretic type. Treatment, -however, did not succeed in altering the patient’s mental -condition in the slightest. At the end of many months of -treatment, we still confront a man showing marked psychic -symptoms and a “paretic” gold sol reaction without other -laboratory signs.</p> - -<p class='c027'>1. What is the significance of the practically negative tests -in this case without clinical improvement? One must -believe that the tests became negative as the result of -treatment, and that this change in the tests was due to -the clearing up of some inflammatory reactions which -were present. This may mean that the syphilis had -been reduced to inactivity or latency if not cured, or -at least that there was no activity sufficient to cause -a positive W. R. in the blood serum, whereas whatever -activity was present in the brain was in such a region -that it did not cause any reacting substances to be cast -into the spinal fluid. This would not mean that there -would necessarily be any return of function already lost, -because this may be considered as a permanent loss which -cannot be compensated for. As to these tests, we now -feel that the case should remain stationary; that is, -that no new symptoms will be added. However, we -believe that it is somewhat premature with our present -knowledge to make this claim very forcibly, and would -rather suggest that this case be considered as demonstrating -an interesting fact, the meaning of which can -be learned only after a period of years.</p> - -<p class='c027'>2. Why does the gold sol reaction remain strongly positive -when all the other tests become negative? As already -pointed out, above (Case Martin (117)) there is no known -rule about the disappearance of one or other of the abnormal -findings in spinal fluid under treatment, and we -can at present offer no explanation of this phenomenon. -It does, however, illustrate how careful we must be in -drawing any conclusions from tests in cases that are -being treated.</p> - -<div><span class='pageno' id='Page_386'>386</span></div> -<div class='box'> - -<p class='c013'><b>Diminution in the spinal fluid tests may occur -in treated cases of neurosyphilis without clinical -improvement.</b></p> - -</div> - -<p class='c006'><b>Case 119.</b> John Silver, a man 29 years of age, presented -classical symptoms of <span class='sc'>General Paresis</span>: He had a convulsion -shortly before his admission to the Psychopathic Hospital, -his memory was poor, he was only partially oriented, he was -very euphoric and expansive—thought he had millions, -that he was the Czar of Russia, and so on. His tendon reflexes -were very much increased and there was a marked -speech defect. The W. R. of both blood and spinal fluid -were strongly positive; the spinal fluid showed globulin, -increased albumin, pleocytosis, and a “paretic” gold sol -reaction. There was, therefore, no question about the -diagnosis, and the patient was at once put under antisyphilitic -treatment. This was continued for five months; slowly -the intensity of the reactions in the spinal fluid diminished. -At the end of the five months, there was the very slightest -possible trace of globulin, with a doubtful increase in albumin, -one cell per cmm., and a mild syphilitic gold sol reaction. -The W. R.’s in the blood and spinal fluid, however, remained -strongly positive. There was no mental improvement coincident -with the weakening of the spinal fluid tests, and at -the end of the five months, the patient had a series of convulsions -in which he died.</p> - -<p class='c007'>This case is given as a contrast to Case Henry (114) in which -clinical improvement occurred without diminution in laboratory -tests; in the case of John Silver, marked diminution -in the intensity of these tests had no prognostic significance. -This was in keeping with the condition as shown in -Case Roberts (118) where, while the gold sol was the only test -to remain positive, the patient did not improve mentally.</p> - -<p class='c027'>1. What is the explanation of the lessening of the pathological -elements in the spinal fluid under treatment? -We have seen that the various findings may occur independently -<span class='pageno' id='Page_387'>387</span>of one another, and we must admit that -we do not know definitely what it signifies, or why one -may be present or absent. It has been held by Head -and Fearnsides that the findings in the spinal fluid -represent conditions in the spinal cord and spinal -meninges, or at the base of the brain only, and not -conditions elsewhere. This is in keeping with our -finding that the gold sol reaction in the spinal fluid -post mortem very often differs from that in the ventricular -fluids or cerebral, subdural, and subpial fluids. -And further, we have found that during life the findings -in paresis in the spinal fluid may differ markedly from -those in the third ventricle, and that the change in the -fluid in these two areas under treatment may not occur -simultaneously.</p> - -<div><span class='pageno' id='Page_388'>388</span></div> -<div class='box'> - -<p class='c013'><b>Systematic intensive treatment of PARETIC -NEUROSYPHILIS (“general paresis”), including -intraventricular injections of salvarsan, may entirely -fail.</b></p> - -</div> - -<p class='c006'><b>Case 120.</b> James McGinnis, aged 39, came to the hospital -on a stretcher, semi-conscious, moaning, unable to reply to -questions; there were signs of a right hemiplegia.</p> - -<p class='c007'>The next day, McGinnis cleared a little and became able -to utter a few words. His wife said that he had been entirely -well up to four years ago. At that time he was struck -in the eye by the head of a hammer that flew off the handle. -Diplopia had developed, but disappeared.</p> - -<p class='c007'>Only two years later did a marked change appear. McGinnis -became careless as to personal appearance. Seemed -absent-minded, apathetic and drowsy; he would fall asleep -in his chair or while at work. He lost his position and became -apprehensive, making not very strenuous efforts to -find work, and finally consulted a physician. The physician -told him that he had a sluggish liver and gave him calomel.</p> - -<p class='c007'>Six months later, McGinnis was restored to his position -as foreman, and his work remained satisfactory for some six -months. Then (about six months before coming to hospital), -his speech became slow and somewhat unintelligible. He -quit work, saying that his speech was going from him and -that he might be considered to be drunk. His memory -grew rapidly worse. There was improvement after a vacation -and he returned to work, but continued to be ataxic, complained -of vertigo, and fell down several times, though -without loss of consciousness. On the very day of his admission -to the hospital, in attempting to get out of bed, he -fell, and psychotic symptoms at once appeared. There -was slight improvement again with entire disappearance of -all paralysis after a few days, a slow clearing up of the speech -disturbance, and a certain return of memory.</p> - -<p class='c007'><b>Physically</b>, there was little to note. <b>Neurologically</b>, the left -<span class='pageno' id='Page_389'>389</span>pupil failed to react to light. The tendon reflexes were all -very active, and more active on the left side. Other abnormal -reflexes were absent. Improvement continued for a number -of weeks, but the patient never recovered from his speech -defect, and his memory remained impaired. Irritable at -times, McGinnis was for the most part very happy and sure -he would get well. The W. R. of the blood serum was -negative, but the spinal fluid reaction was strongly positive, -even down to 0.1 cc. The globulin and albumin amounts -were excessive. There was a “paretic” gold sol reaction. -There were 7 cells per cmm. The diagnosis of <span class='sc'>General -Paresis</span> was made.</p> - -<p class='c007'>Intravenous injections of salvarsan, arsenobenzol or diarsenol -were made, and intramuscular injections of mercury, -and potassium iodid by mouth were given. No real improvement -occurred after a certain initial betterment; the -spinal fluid yielded no changes. Diarsenolized serum according -to the Swift-Ellis technique was then injected into -the third ventricle. Under this treatment also there was no -change for the better over a period of several months. The -patient died suddenly after a series of convulsions, apparently -from paralysis of respiration.</p> - -<p class='c027'>1. What are the causes of hemiplegia and confusion or -unconsciousness? We must consider epilepsy, brain -tumor, cerebral thrombosis, cerebral hemorrhage, multiple -sclerosis, cerebral spinal syphilis, and general -paresis.</p> - -<div><span class='pageno' id='Page_390'>390</span></div> -<div class='box'> - -<p class='c013'><b>MILD TREATMENT, often thought “adequate,” -MAY FAIL, WHEN INTENSIVE TREATMENT -PROVES SUCCESSFUL.</b></p> - -</div> - -<p class='c006'><b>Case 121.</b> Arthur Bright, a printer, had acquired syphilis -in his 49th year, some six months before examination. He -had been treated during these six months by three injections -of salvarsan, injections of mercury, and mercury by mouth. -He had been apparently cured until about a month before -admission. He had fallen without warning from his chair -in a convulsion accompanied by unconsciousness, which lasted -about two hours. The patient had since been feeling rather -peculiar. For instance, time seemed to flow too rapidly. -Sometimes the patient had had difficulty in talking.</p> - -<p class='c007'><b>Physically</b>, nothing abnormal could be found either in -general condition or <b>neurologically</b>. The patient was, however, -incontinent. <b>Mentally</b>, he was apathetic and unalert, -even paying no attention to his outside physician when he -came to visit him.</p> - -<p class='c007'>The <b>diagnosis</b> of cerebrospinal syphilis already suggested -by his history was confirmed by the laboratory tests, which -showed a positive serum and spinal fluid W. R., paretic -gold sol reaction, 41 cells per cmm., an excess of albumin, -and a positive globulin test.</p> - -<p class='c027'>1. What is the prognosis in cerebrospinal syphilis in the -early secondary stage? The prognosis appears very -good provided that intensive treatment be given and -provided that no vascular insult or other focal destructive -lesion occurs before treatment has had time to do -its work.</p> - -<p class='c027'>2. Why did not the “effective” (?) treatment for the syphilis, -dating from the primary lesion, succeed in staving off -the cerebrospinal syphilis? It remains a question -whether the treatment by three injections of salvarsan -was efficient in this particular case. Of course, it may -prove true that no treatment whatever in the present -stage of knowledge will stave off cerebrospinal symptoms -in certain cases.</p> - -<p class='c007'><span class='pageno' id='Page_391'>391</span><b>Treatment</b>: Bright was given intravenous injections of -diarsenol twice a week, with occasional injections of mercury -salicylate. After two weeks, the patient seemed markedly -improved, and continued to improve rapidly. He was symptomatically -well at six weeks. The spinal fluid had then -become negative, although the serum W. R. had remained -positive.</p> - -<p class='c007'>After discharge from the hospital, Bright returned to his -work, but continued to take the diarsenol treatment weekly, -and two months later the serum W. R. became negative.</p> - -<p class='c007'>Small injections of diarsenol at intervals of a month were -continued, and Bright remained perfectly well for four -months, when a peculiar seizure developed and lasted for -several hours. This seizure consisted in a sort of somnambulism -in which Bright stood up at a table, making marks -on paper, and could not be persuaded to desist. After this -seizure, Bright re-entered the hospital, again showed no -mental or physical symptoms and no abnormalities of blood -or spinal fluid.</p> - -<p class='c027'>3. What is the explanation of this seizure? It is possibly -due to a small vascular insult, for which potassium -iodid may be suggested with precautions as to hygiene -and continued observation. He has since remained -entirely well.</p> - -<div><span class='pageno' id='Page_392'>392</span></div> -<div class='box'> - -<p class='c013'><b>Another example where MILD MEASURES -(though conceived to be “adequate”) SEEMED -TO BE LEADING TO FAILURE; INTENSIVE -THERAPY SUCCESSFUL.</b></p> - -</div> - -<p class='c006'><b>Case 122.</b> Levi Morovitz, a waiter, 39 years of age, came -to the hospital with evidences of an old left hemiplegia, including -the left side of the face (there was a left-sided Babinski, -Gordon, and Oppenheim, and all the reflexes were -fairly active; sluggish pupil reactions, Rombergism, and -speech defect). Morovitz was much depressed, very slow -in thinking processes, had a marked memory disturbance in -general and apparently much deterioration mentally.</p> - -<p class='c007'>A history was obtained to the effect that Morovitz had -acquired syphilis at about 33, but that he had received -practically continuous treatment ever since at a dispensary. -He had, in fact, received four injections of salvarsan a year -before coming to the hospital. Of late, Morovitz had become -much more cheerful and talkative, imagining he could do -great things if he had money. He had begun to eat very -rapidly and to be very nervous. His feet had begun to drag; -a distinct speech defect developed, but from this he had recovered. -About six weeks before entrance, Morovitz had a -shock, which left him with the left hemiplegia above mentioned -and with considerable headache.</p> - -<p class='c007'>Even while the preliminary examination was being performed, -Morovitz developed a minor seizure without loss of -consciousness. First came severe pain over the frontal -region, which grew in severity so that the patient held his -head in his hands. A bit later, twitching movements began -in the thumb and in the fingers of the left hand, and the -small muscles of the extensor group of the thumb and third -finger showed contractions. These contractions grew more -general and the excursions of the fingers greater, until finally -every finger of the left hand became involved, whereupon -movements of the same sort, though of smaller amplitude, -<span class='pageno' id='Page_393'>393</span>began in the other hand. Finally the left arm began to jerk -with alternate contractions of the biceps and triceps. The -whole seizure lasted more than five minutes. During the -seizure there was dizziness and pain in the head, chiefly on -the right side.</p> - -<p class='c007'><b>Diagnosis</b>: The attention is at once arrested by the data -of the seizures described. It appeared that we had to assume -an irritation of the right side of the brain, possibly due -to vascular disease, or to brain tumor, or perhaps to syphilis. -The shock with residual hemiplegia would be consistent -enough with any of these diagnoses. However, the history -seemed somewhat long for brain tumor. Nor were there -any definite symptoms of intracranial pressure. “Adequate” -treatment unfortunately does not rule out syphilis. The -comparatively early age (39) of the patient makes it difficult -to explain the vascular disease except on the basis of syphilis. -Add to the hemiplegia the euphoria and grandiose ideas of a -year’s duration, and we arrive at a diagnosis of neurosyphilis, -probably <span class='sc'>Paretic Neurosyphilis</span>.</p> - -<p class='c007'>The laboratory tests showed the W. R. of the serum and -spinal fluid positive, 80 cells per cmm. in the fluid, large -amounts of globulin and albumin, and a “paretic” type of -gold sol reaction.</p> - -<p class='c007'>To be sure the Jacksonian seizure is not especially characteristic -of paretic neurosyphilis, and even suggests a local -irritation in the motor area, such as a localized meningitis, -possibly of a diffuse gummatous nature.</p> - -<p class='c007'>This patient was put on intensive antisyphilitic treatment, -namely, salvarsan twice a week and injections of -mercury. He recovered rapidly. After a few months he -left the hospital, and after treatment had continued for a -year, he resumed his work by which time both blood and -spinal fluid had become negative.</p> - -<p class='c007'>It must be recalled that this patient had from the time of -his infection what has been considered good antisyphilitic -therapy, in spite of which he developed after a period of -years, the symptoms and signs of neurosyphilis in its most -dangerous form. The conclusion must be drawn that -however good such treatment is for the majority of cases, it -<span class='pageno' id='Page_394'>394</span>was insufficient for Morovitz. That the early failure to cure -was not due to any “drug fastness” of the spirochete or to any -peculiarity of strain is proved by the result of more vigorous -antisyphilitic treatment which caused an apparent if not a real -cure. With our modern methods of treatment checked by -Wassermann reactions and spinal fluid examinations, treatment -is given according to the <em>needs of the individual patient</em> -rather than according to general preconceptions. We have -reason to believe that under these conditions there will be -fewer cases developing late symptoms on account of insufficient -treatment given even to patients who are willing -to co-operate to the last degree.</p> - -<p class='c007'>The fact that Morovitz had no apparent symptoms for -several years led to rather desultory treatment chiefly in the -form of mercury by mouth. Previous to the time when the -W. R. and lumbar puncture were available, the physician had -no exact means of determining cure except the non-appearance -of symptoms. But a period of years of quiescence before -the outbreak of symptoms referable to the involvement of -the nervous system is characteristic of syphilis. With this -knowledge in mind it is evident that today the care of a -syphilitic patient must be guided, in part at least, by examinations -of the spinal fluid and W. R.</p> - -<div><span class='pageno' id='Page_395'>395</span></div> -<div class='box'> - -<p class='c013'><b>Salvarsan treatment may even occasionally be of -value in simple FEEBLEMINDEDNESS due to -congenital syphilis.</b></p> - -</div> - -<p class='c006'><b>Case 123.</b> The somewhat unattractive Robert Matthews -was brought, at 5 years of age, to the hospital for backwardness -of mind. It appears that the patient was born at term, -with instruments, that he began to talk at a year, and to -walk at 13 months, but that in point of fact, he had not -talked intelligibly to date. Robert had never played with -other children and is regarded by his parents as backward. -In fact, Robert’s sister—a year his junior—is much -brighter. Robert had had scarlet fever but without sequelae.</p> - -<p class='c007'>Examination by the Binet scale showed that, although he -is actually 5½ years, he graded by the Binet scale at 4 and -was regarded as feebleminded.</p> - -<p class='c007'>The <b>physical examination</b> showed a general adenopathy -and prominent frontal bosses. In the study of the family -history in the search for an etiology for the evident feeblemindedness, -little or none could be found. There were no -miscarriages or stillbirths; the parents were living and well. -There was only the one sister above-mentioned, who is -brighter than Robert.</p> - -<p class='c007'>The advantage of a routine W. R. is here well shown, for -the W. R. in the serum was positive.</p> - -<p class='c027'>1. What is the prognosis of cases of syphilitic feeblemindedness? -It would appear that every case is an individual -problem.</p> - -<p class='c027'>2. What is the effect of treatment? Robert Matthews was -given mercury protoiodid ⅛ gr., three times a day, by -mouth, for three months. The protoiodid was followed -by ten injections of salvarsan, average: 0.15 gram, -during six months. At the end of this period, the W. R. -in the blood had become negative. A re-examination by -the Binet scale, when Robert was 6<span class='fraction'>5<br /><span class='vincula'>12</span></span> years of age, -showed him to grade at 5⅖, so that one might conclude -that Robert had shown more mental progress in a year -than he had previously.</p> - -<p class='c007'><span class='pageno' id='Page_396'>396</span>Note: The patient’s sister, 4 years of age, is attractive -and bright, measuring beyond her actual age according to -the intelligence tests. However, the girl was found to have -a positive W. R. It may be that Robert and his sister -illustrate the hypothesis of Mott: that the syphilitic virus -becomes less potent as the years go on, and that the younger -children in the family are less affected than the older. However, -in our series, there are a number of instances in which -this hypothesis is not substantiated.</p> - -<p class='c027'>3. What is the share of syphilis in the production of feeblemindedness? -The percentage of syphilitic cases found -in institutions is not high. A variety of cases have -been proved to be congenitally syphilitic in the absence -of a positive serum W. R.</p> - -<p class='c007'>Fernald<a id='r19' /><a href='#f19' class='c014'><sup>[19]</sup></a> has charted a comparison of cases diagnosticated -“moron” (that is, feeblemindedness proper, in the -narrower English sense) and “imbecile.” Fernald says that -the morons have, as a group, many more bad family histories -than have the imbeciles, to quote—“Only 70% of the -[imbecile] group have bad family histories. This at first -seems surprising, but when we consider that more of our -syphilitic, traumatic, and sporadic cases tend toward the -lower end of the feebleminded group, and when we remember -that with such cases there is often a seemingly normal family -tree, the drop in the curve appears logical.”</p> - -<p class='c007'>The situation with the idiots, of whom only 38 came into -Fernald’s study, was similar; 12 out of 38, or 32%, of idiots, -had good family histories. On these figures, how unfortunate -it would be to dub feeblemindedness hereditary! It is -true, however, that 68–70% of the idiots and imbeciles, -judging by W. E. Fernald’s intensive study, do have bad -family histories.</p> - -<p class='c007'>Goddard<a id='r20' /><a href='#f20' class='c014'><sup>[20]</sup></a> states that of all the causes of feeblemindedness, -<span class='pageno' id='Page_397'>397</span>there is perhaps none for which there is less evidence than -syphilis. Goddard found syphilis in 27 of his intensively -charted cases of feeblemindedness, that is, in 9% of all his -charts. He finds the majority of the syphilis cases occurring -in relatives of the feebleminded to be in the hereditary group; -for example, of 164 charts in the hereditary group, 17, or 10%, -showed syphilis. In 34 charts in a group termed “probably -hereditary” 3, or 9%, showed syphilis. Of 37 charts in the -group termed “neuropathic” 4, or 11%, showed syphilis, -whereas in 57 “accident” and 8 “no cause” groups, there -were but 2 (4%), and one, or 13%, showing syphilis. However, -Goddard concedes that much more careful studies are -necessary if we are to give an exact evaluation of syphilogenic -feeblemindedness.</p> - -<p class='c007'>The first ten of the Waverley Anatomical Series are shortly -to be described in a forthcoming publication.<a id='r21' /><a href='#f21' class='c014'><sup>[21]</sup></a> Of these ten -cases, four showed some slight evidence of chronic inflammatory -changes, indicating the possibility of a syphilitic or -similar infectious condition. These cases, be it remembered, -were not cases of juvenile paresis, but cases of what, for the -lack of a better name, may be called “ordinary” feeblemindedness.</p> - -<p class='c007'>If all or any of these processes are syphilitic, the syphilis is -virtually extinct. The cases had not been treated for syphilis -and were not regarded as syphilitic, though several of them -showed a few stigmata somewhat suggestive of syphilis. The -anatomical conclusion at this time is still doubtful.</p> - -<p class='c007'>As in the text case, the hypothesis of syphilis as a direct -cause for simple feeblemindedness must be entertained for a -few cases. In any event, it would not seem logical to let -any institution for the feebleminded run without a Wassermann -analysis of the population. In addition to the Wassermann -data from the blood serum, osteological data from the -X-ray have proved of occasional value for syphilis diagnosis -in this as in other groups.</p> - -<div><span class='pageno' id='Page_398'>398</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c002'> - <div class='linegroup'> - <div class='group'> - <div class='line'>“Within the gates of Hell sat Sin and Death.”</div> - </div> - <div class='group'> - <div class='line in28'>Paradise Lost, Book X, Line 230.</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_399'>399</span> - <h2 class='c005'>VI. NEUROSYPHILIS AND THE WAR</h2> -</div> - -<p class='c006'>Although the American toll of war syphilis has not yet -begun and although the crop of neurosyphilis due to war -infections may not arrive until the mid or late twenties of -the century (witness German experience in the eighties of -the last century), it seems proper here to give a number of -abstracts <i><span lang="la" xml:lang="la">re</span></i> neurosyphilis as it has developed in the war. -Available reports from English, French, and German sources -have been levied upon for the years 1914–16.</p> - -<p class='c007'>It is clear that all the armies have had their share of -neurosyphilitics, some clearly diseased before enlistment, -some developing symptoms as a result of training, stress, -or shock, others hastened or made worse by war conditions.</p> - -<p class='c007'>There are important questions of pension, retirement, and -compensation for neurosyphilitics. No previous war has -had the benefit of the Wassermann reaction and other exact -tests bearing upon the nature, progress, and curability of -neurosyphilis.</p> - -<p class='c007'>That we shall have our fill of pension and other problems -can already be seen from continental reports. Thibierge,<a id='r22' /><a href='#f22' class='c014'><sup>[22]</sup></a> -for example, states that syphilis has become a real epidemic -among the French soldiers and mobilized munition workers.</p> - -<p class='c007'>Hecht<a id='r23' /><a href='#f23' class='c014'><sup>[23]</sup></a> of Austria claims that no less than an equivalent -of 60 army divisions have been temporarily withdrawn from -fighting on the Teutonic side for venereal diseases. He -commends Neisser’s idea that salvarsan and mercury should -be given in the trenches. While hundreds or thousands of -Austrians are sick with syphilis, sound and healthy men are -being shot down in their stead. The diagnosis of syphilis, -according to Hecht, ought to be a signal for sending the men -to the front. He makes even the somewhat bizarre suggestion -<span class='pageno' id='Page_400'>400</span>that special companies of syphilitics should be formed, -for convenience of treatment, on the firing line.</p> - -<p class='c007'>Not only is the syphilis problem in the army of importance -to the military authorities, but also to the civil population, -and perhaps to them a greater problem. With the great -increase of venereal disease that is the result of the conditions -of army life in war time, there will be a considerable percentage -of cases developing neurosyphilis a number of years after -discharge from the army, but caused by the infection acquired -during service. In addition many men will bring the disease -back to America in an infectious stage and spread it. We -would advocate that the names of all soldiers who had -acquired syphilis and were not considered cured at time of -discharge should be given to health organizations in their -home states that they may be given further care.</p> - -<p class='c007'>These practical and several theoretical questions are -raised by the following fourteen cases which we have condensed -from their sources.</p> - -<div><span class='pageno' id='Page_401'>401</span></div> -<div class='box'> - -<p class='c013'><b>A tabetic lieutenant “shell-shocked” into paresis? -Case from Donath of Vienna.</b></p> - -</div> - -<p class='c006'><b>Case A.</b><a id='r24' /><a href='#f24' class='c014'><sup>[24]</sup></a> An apparently competent German professor in -an intermediate school, a lieutenant of infantry reserves, 33 -years old, on the 17th August, 1914, was stunned for a while -by the shock of a cannon-firing 25 feet away. Urination -became difficult. Headaches and limb pains ensued, with -paralysis of fingers, gastric troubles, forgetfulness especially -for names, insomnia, and general scattering of mental faculties.</p> - -<p class='c007'><b>Neurologically</b>, the pupils were irregular, left larger than -right; Argyll-Robertson reaction. Right knee-jerk livelier -than left. Achilles reactions absent. Slow and dissociated -pain reactions in feet, lower thighs and lower quarter of upper -thighs, with hypalgesia or analgesia. Station good; gait -steady. Mentally depressed, slow of thought. Speech poor -and of indistinct construction (mild dementia). Calculation -ability poor. No pleasure in work.</p> - -<p class='c007'>Wassermann reaction of serum weakly positive.</p> - -<p class='c007'>It seems that for a year the patient had been subject to -spells of anger. He was irritated by his wife who had been -nervous since an earthquake.</p> - -<p class='c007'><em>On the occasion of the earthquake</em>, 1911, the patient himself -had had a spell of <em>difficulty with urination</em>. The spell had -lasted two or three months. The patient had had a chancre -in 1902, “cured” in four or five weeks with xeroform. In -1908, when about to marry, he had had six mercurial inunctions.</p> - -<p class='c027'>1. Is this a case of traumatic paresis? From the somewhat -meagre account it would appear that Donath’s -lieutenant should rather be termed “shell-shock paresis,” -in the sense of a paretic neurosyphilis liberated by -<span class='pageno' id='Page_402'>402</span>shell-shock (using shell-shock in the sense of a shock -<em>without</em> direct brain injury).</p> - -<p class='c027'>2. What compensation is due such a man as Donath’s -lieutenant? The ordinary principles applicable to -traumatic paresis are not here in point, since no -symptoms pointing to trauma of brain ever supervened. -See discussion under Case G.</p> - -<p class='c027'>3. How frequent is paresis in armies? R. L. Richards in -White and Jelliffe’s Treatment of Nervous and Mental -Diseases writes as follows (of course concerning peace -times):</p> - -<p class='c028'>“The French estimate that paresis cases are 7 per -cent of all their military cases. The German estimate -is 6.6 per cent. In our own army at the Government -Hospital for the Insane, of 490 cases of mental diseases -among officers and enlisted men, 37, or 7 per cent, were -paresis. During the Russo-Japanese War, in the -Russian Psychiatric Hospital at Harbin, the percentage -of paresis was 5.6 per cent among the cases developing -at the front.”</p> - -<div><span class='pageno' id='Page_403'>403</span></div> -<div class='box'> - -<p class='c013'><b>A French soldier “shell-shocked” (also burial) -into incipient tabes dorsalis? Case from Duco and -Blum of Paris.</b></p> - -</div> - -<p class='c006'><b>Case B.</b><a id='r25' /><a href='#f25' class='c014'><sup>[25]</sup></a> A French soldier was buried by effects of shell -explosion September 8th, 1914. He sustained no wound or -fracture.</p> - -<p class='c007'>Incontinence of urine developed. Anesthesia of penis and -scrotum. Reflexes absent; pupils sluggish. Wassermann -reactions suspicious.</p> - -<p class='c007'>The diagnosis <b>tabes dorsalis incipiens</b> was made (hematomyelia -of conus terminalis eliminated).</p> - -<p class='c007'>The patient was estimated to be “40% incapacitated,” -according to the French “<i><span lang="fr" xml:lang="fr">échelle de gravité</span></i>” of conditions. A -full pension would not be justified in the opinion of the -French authors.</p> - -<p class='c027'>1. Is there evidence of an increase or exacerbation of -tabes dorsalis in the war? Birnbaum,<a id='r26' /><a href='#f26' class='c014'><sup>[26]</sup></a> reviewing -German war neurology, quotes Weygandt as believing -that the war has probably had to do with the production -of both tabes and paresis in many instances. -Other cases, however, have merely been made worse -by the war stress. Thirdly, there are cases in which -the war stress has done no harm whatever. Westphal -has seen both tabes and paresis develop in men who -had never before shown any mental or physical symptoms -whatever, and accordingly, Westphal must be -counted among those who regard war stress as a liberating -factor for these diseases. Redlich and Donath are -cited in the same connection. (The case of Donath is -the case presented above as Case A.)</p> - -<p class='c028'>A very interesting claim was made by Cimbal to the -effect that he found many examples of paresis developing -in the early period of the war, particularly in November -and December, 1914. Later, according to Cimbal, -cerebrospinal syphilis and tabes became more prevalent.</p> - -<div><span class='pageno' id='Page_404'>404</span></div> -<div class='box'> - -<p class='c013'><b>Neurosyphilis in a German recruit, possibly AGGRAVATED -ON military SERVICE. Pension not -allowable. Case from Weygandt.</b></p> - -</div> - -<p class='c006'><b>Case C.</b><a id='r27' /><a href='#f27' class='c014'><sup>[27]</sup></a> A German, long alcoholic and thought to be -weakminded, volunteered, but shortly had to be released from -service. He began to be forgetful and obstinate, cried, and -even appeared to be subject to hallucinations. The pupils -were unequal and sluggish. The uvula hung to the right. -The left knee-jerk was lively, right weak. Fine tremors of -hands. Hypalgesia of backs of hands. Stumbling speech. -Attention poor.</p> - -<p class='c007'>It appeared that he had been infected with syphilis in 1881 -and in 1903 had had an ulcer of the left leg.</p> - -<p class='c007'>The military commission denied that his service had -brought about the disease. In the phrase of the Canadian -Pension Board the German commission would probably have -rendered a report “aggravated on service,” not “by service.” -(See Canadian cases D, E, and F.)</p> - -<p class='c027'>1. Has paresis increased in the war? Both French and -German figures controvert the claim. Marie, for -example, found not a single paretic amongst the skull -injury cases at the Salpétrière. Most authors are -found demonstrating cases which they clearly regard as -in some way produced or unfavorably influenced by -the war. There seems, therefore, to be a little inconsistency -between the general statement that paresis has -not increased in the war and the somewhat frequent cases -described as occurring in and modified by the war. -However, Bonhoeffer, on the basis of nine months’ war -experience, also holds it to be probable that paresis is -no more frequent in the field than in the home population.</p> - -<p class='c027'>2. Is the old syphilitic especially liable to break down under -war conditions? According to Richards, Shaikewicz -says that in the Russo-Japanese war paresis was noted -<span class='pageno' id='Page_405'>405</span>especially among the officers and non-commissioned -officers, and that it was undoubtedly hastened in its development -by war conditions. Steida says that while -ordinarily we find paresis developing twelve to twenty -years after the primary sore of syphilis, in these cases it -developed in five to ten years after the primary sore. -Some of the cases progressed with unusual rapidity. It -was also noticed that among soldiers from the front, -under treatment, evidences of syphilis were present in -20%, while among the other soldiers under treatment, -evidences of syphilis were present in 1.6%. Undoubtedly -the old syphilitic is especially liable to break -down under war conditions.</p> - -<p class='c028'>But, on the whole, the German authors in this war -find no evidence favoring Steida’s claim of the hastened -post-infective outbreak.</p> - -<p class='c028'>3. How did it come about that the efficient German system -permitted this alcoholic and weakminded syphilitic to -enter the army? As will be seen, he was a volunteer. -In general, the German system has been supplied with -army surgeons who have been trained, not by brief and -“brush-up” courses, but by longer periods, sometimes -two years in duration.</p> - -<div><span class='pageno' id='Page_406'>406</span></div> -<div class='box'> - -<p class='c013'><b>Syphilis contracted before enlistment, “AGGRAVATED -BY SERVICE.” Canadian case, courtesy -of Dr. J. L. Todd, Canadian Board of Pension -Commissioners.</b></p> - -</div> - -<p class='c006'><b>Case D.</b> A laboring man, 42, who always strenuously -denied syphilitic infection, proceeded to France eight months -after enlistment. He had not been in France three weeks -when he dropped unconscious. He regained consciousness, -but remained stupid, dull in expression, and with memory -impaired. His speech was also impaired. There was dizziness -and a right-sided hemiplegia.</p> - -<p class='c007'>He was confined to bed four months and was then -“boarded” for discharge.</p> - -<p class='c007'><b>Physically</b>, his heart was slightly enlarged both right and -left; sounds irregular; extra systoles; aortic systolic murmur -transmitted to neck; blood pressure 140:40. Precordial -pain, dyspnea.</p> - -<p class='c007'><b>Neurologically</b>, there was a partial spastic paralysis of the -right thigh which could be abducted, could be flexed to 120°, -and showed some power in the quadriceps. There was also -a spastic paralysis of the right arm, but the shoulder girdle -movements were not impaired. There was a slight weakness -on the right side of the face. There was no anesthesia -anywhere.</p> - -<p class='c007'>The deep reflexes were increased on the right side, Babinski -on right, flexor contractures of right hand, extensor contractures -of right leg, abdominal and epigastric reflexes absent, -pupils active, tongue protruded in straight line.</p> - -<p class='c007'>Fluid: slight increase in protein. W. R.+++</p> - -<p class='c007'>The Board of Pension Commissioners ruled that the condition -had been aggravated <em>by</em> service. (See Case E, “aggravated -<em>on</em> service.”)</p> - -<p class='c027'>1. In view of the fact that the majority of the cases here -abstracted happen to be in common soldiers, is there -any evidence bearing on relative incidence in officers -and men? Quoting R. L. Richards:</p> - -<p class='c028'><span class='pageno' id='Page_407'>407</span>“The percentage of paresis cases among officers alone -is variously estimated from 50 per cent in the German -army (Stier) to 58.9 per cent in the Austrian army -(Drastich). Since paresis is a disease of more advanced -life, it is but natural that the percentage of paresis -among officers, non-commissioned officers, and older -soldiers should be higher than among the whole military -body, where the average age is, as we have seen, well -below thirty years. Hence the above figures do not -mean a greater prevalence of syphilis among those -classes, but that we have no means of knowing how -many of the others develop paresis. If anything it -shows that these ‘soldiers by calling,’ have a more -stable mental make-up, since they succumb chiefly to -an exogenous toxin.”</p> - -<p class='c028'>Rayneau at the 19th Congress of French Alienists -and Neurologists at Nantes in 1909, discussing the -insane of the army from a medicolegal point of view, -states that the most frequent mental disease amongst -officers and soldiers is general paresis. At least, this -disease is the most frequent basis of invaliding, retirement, -or placing in the inactive list. He states that -French and foreign statistics are at one upon this -matter, quoting Christian as finding 32% among the -soldiers interned at Charenton; Gamier at Dijon, -59%; Meilhon at Quimper, 42% and Talon at Marseilles, -33.8%. Grilli found 31 of 40 officers interned -in Florence, Sienna and Milan victims of general -paresis. Stier’s German statistics indicate about 50%. -Rayneau himself found 16 of 20 officers paretic and 17 -out of 27 subalterns and <i><span lang="fr" xml:lang="fr">gendarmes</span></i>.</p> - -<p class='c028'>The Neurological Society of Paris held a conference -December 15, 1916, with the chiefs of the neurological -and psychiatric military centres of France, and discussed -a variety of questions concerning invaliding, -incapacity, and compensation in neuroses and psychoses -of war. Dupré dealt especially with the psychoses -of war as caused by trauma, strain, infection, -and intoxication. General paresis is regarded by -Dupré as the most important of the dementias found in -the army. The medicolegal point of view is, of course, -that general paresis is necessarily related to an old -syphilis, but its late development leads to misinterpretations -as to its probable cause, both by the family and -friends and even by magistrates. The war acts in -the French nomenclature as an <i><span lang="fr" xml:lang="fr">agent revélateur</span></i> or as an -<span class='pageno' id='Page_408'>408</span><i><span lang="fr" xml:lang="fr">agent accélérateur</span></i>. Although its cause is prior and -exterior to the war, general paresis in a majority of -cases is brought out (<i><span lang="fr" xml:lang="fr">revélé</span></i>) by the lack of adaptability -of the general paretic to the novelty and difficulties of -his surroundings and duties in war. Trauma, strain, -and alcohol in a certain number of cases accelerate the -progress of a general paresis. The aggravation of -paresis is produced by these same factors, but especially -by violent cerebral trauma. According to Dupré, the -Val-de-Grace statistics show that the number of paretics -has not been increased by the war. Medicolegally, -the victim of general paresis, like the victim of -traumatic or infectious chronic mental disorder, may -be assigned an incapacity of from 50 to 100%, and -these patients are invalided under <i><span lang="fr" xml:lang="fr">Réforme No. 1</span></i>,—a -permanent invaliding.</p> - -<p class='c028'>Lépine of Lyons also discusses the compensation -question in general paresis. Lépine thinks that, although -syphilis is indispensable in paresis, yet the truth -is that syphilis plus something else unknown to us is -responsible for general paresis. This something else is -neither a special kind of virus nor is it a particular kind -of prepared soil alone. Trauma, physical, intellectual, -and moral strain, and insomnia are the factors to which -he calls special attention as adjuncts in the production -of general paresis. As to the responsibility of the State -for the production of general paresis, according to -Lépine, the maximal responsibility should be 40% on -account of the very considerable predisposition to paresis -created by pre-existent syphilis.</p> - -<p class='c028'>Marie remarked that, although there had been -thousands of head cases at the Salpétrière, there had -not been a single case of general paresis. Dupré agreed -with Marie that trauma was not a frequent etiological -factor; strain and alcohol were more important. The -Society agreed that in exceptional cases, where an -encephalic trauma could be regarded as accelerating -or aggravating the disease, the degree of incapacity -might be set at from 10 to 30 per cent.</p> - -<div><span class='pageno' id='Page_409'>409</span></div> -<div class='box'> - -<p class='c013'><b>Syphilis contracted before enlistment, “AGGRAVATED -ON SERVICE.” Canadian case, courtesy -of Dr. J. L. Todd, Canadian Board of Pension -Commissioners.</b></p> - -</div> - -<p class='c006'><b>Case E.</b> A laboring man, 44, acquired syphilis at a time -unknown. Ten months after enlistment this man developed -symptoms on the firing line. He was inattentive, irrational, -incoherent. The diagnosis was then “mania.”</p> - -<p class='c007'>There were, however, scars at angle of mouth and on lower -lip. Occipital glands were palpable, fine tremor of hands. -The W. R. was +++.</p> - -<p class='c007'>Later the patient became violent, destructive, untidy, -disoriented. Auditory hallucinations are recorded.</p> - -<p class='c007'>He was “boarded” for discharge five months after the first -symptoms. The board agreed that these symptoms would -have appeared in civil life. In view of a difference of opinion -as to the part played by stress of service, his condition was -set down as “<em>aggravated on service</em>” (not, it will be noted, <em>by</em> -service, see Case D).</p> - -<p class='c027'>1. Under what conditions should pensions be awarded for -disability resulting from venereal diseases? According -to a personal communication from Dr. J. L. Todd, -Chairman of the Board of Pension Commissioners for -Canada, pensions are awarded for all disabilities appearing -<em>during</em> service, unless they can be shown certainly -to be due to the men’s own fault and negligence. It -would appear that <em>during</em> service covers both aggravations -<em>by</em> and <em>on</em> service. There remains some doubt -as to whether contraction of venereal disease constitutes -negligence.</p> - -<p class='c027'>2. What have been conditions in the small inactive American -army of the past? Richards has made a study of -statistics at the Government Hospital for the Insane, -Washington.</p> - -<p class='c028'>“The leading features of this mental disease were -well exemplified in our cases the past year. They -formed 7.5 per cent of the total number. They averaged -forty years of age, and Ziehen says 80 per cent of -<span class='pageno' id='Page_410'>410</span>all cases are in the fourth or fifth decade of life. They -averaged ten and a half years’ service, which would -indicate that the military life was their calling. Only -one had any serious hereditary defect. Stigmata of -degeneration were infrequent, averaging only two for -each case. 66 per cent had good schooling, considering -their opportunities. Physical signs were frequent in -each case. Only one showed normal light reaction. -Ziehen says the light reaction is retained in only 20 -per cent of the cases. Patellar reflex was absent in one -case and normal or exaggerated in five. The speech -defect was slight in four cases. Other physical signs -were present in the usual proportions. Memory defects -existed in all the cases. In four the onset was -with excitement. One began with a character change -as the most marked feature. In only two were the -transfer diagnoses correct. One, beginning as a quiet -dementia, was diagnosticated paralysis agitans, because -of a marked tremor. One was excited and -euphoric and was called a manic-depressive psychosis. -One with an obscure onset was diagnosticated as a -neurasthenic. The other one was first observed in this -hospital. The physical signs should have led to a -correct diagnosis in each of these cases.”</p> - -<div><span class='pageno' id='Page_411'>411</span></div> -<div class='box'> - -<p class='c013'><b>Duration of neurosyphilitic process important <i><span lang="la" xml:lang="la">re</span></i> -compensation. Canadian case, courtesy of Dr. -C. B. Farrar, Psychiatrist, Military Hospitals -Commission.</b></p> - -</div> - -<p class='c006'><b>Case F.</b> A Canadian of 36 enlisted in 1915, served in -England, and was returned to Canada in February, 1917, -clearly suffering from some form of neurosyphilis (W. R. -positive in serum and fluid, globulin, pleocytosis 108).</p> - -<p class='c007'>There is no record of any disability or symptom of nervous -or mental disease at enlistment. The first symptoms were -noted by the patient in May, 1916, six months or more after -enlistment. The case was reviewed at a Canadian Special -Hospital, October 11, 1916, by a board of examiners. This -board reported that:</p> - -<p class='c007'>“The condition could only come from syphilitic infection -of three years’ standing” (a decision bearing on compensation); -but the general diagnosis remained:</p> - -<p class='c007'>“Cerebrospinal lues, <b>aggravated by service</b>.”</p> - -<p class='c007'>The picture which the medical board regarded as of at least -three years’ standing was as follows:</p> - -<p class='c007'>History of incontinence, shooting pains, attacks of syncope, -general weakness, facial tremor, exaggerated knee-jerks, -pupils react with small excursion. Speech and writing disorder, -perception dull, lapses of attention, memory defect, -defective insight into nature of disorder, emotional apathy.</p> - -<p class='c027'>1. Was the conclusion “aggravated by service” sound? -On humanitarian grounds the victim is naturally conceded -the benefit of the doubt. But it is questionable -how scientifically sound the conclusion really was.</p> - -<p class='c027'>2. Could the condition come only from syphilitic infection -of at least three years’ standing? Hardly any single -symptom in this case need be of so long a standing; yet -the combination of symptoms seems by very weight of -numbers to justify the conclusion of the medical board.</p> - -<div><span class='pageno' id='Page_412'>412</span></div> -<div class='box'> - -<p class='c013'><b>Can PARETIC NEUROSYPHILIS (“general -paresis”) be lighted up by the stress of military -service without injury or disease? A possible -example from P. Marie, Chatelin and Patrikios -of Paris.</b></p> - -</div> - -<p class='c006'><b>Case G.</b> In apparently good health a French soldier -repaired to the colors, in August, 1914, being then 23 years -old.</p> - -<p class='c007'>Two years later, August, 1916, symptoms appeared: -speech disorder with stammering, change of character (had -become easily excitable), stumbling gait. He became more -and more preoccupied with his own affairs, grew worse, and -was sent to hospital in October, 1916.</p> - -<p class='c007'>He was then foolish and overhappy, especially when interviewed. -There was marked rapid tremor of face and tongue. -Speech hesitant, monotonous, and stammering to the point -of unintelligibility. His memory, at first preserved, became -impaired so that half of a test phrase was forgotten. Simple -addition was impossible and fantastic sums would be given -instead of right answers; handwriting tremulous, letters often -missed, others irregular, unequal, and misshapen.</p> - -<p class='c007'>Excitable from onset, the patient now became at times -suddenly violent, striking his wife without provocation. -After visit at home, he would forget to return to hospital. -Often he would leave hospital without permission (of course -the more surprising in a disciplined soldier).</p> - -<p class='c007'>No delusions were found.</p> - -<p class='c007'>The serum and fluid W. R. were positive, albumin in fluid, -lymphocytosis.</p> - -<p class='c007'><b>Neurological examination.</b> Unequal pupils, slight right-side -mydriasis, pupils stiff to light, weakly responsive in -accommodation, reflexes lively, fingers tremulous on extension -of arms.</p> - -<p class='c007'>The patient had, December 5, 1916, an epileptiform attack -with head rotation, limb-contractions and clonic movements.</p> - -<p class='c027'><span class='pageno' id='Page_413'>413</span>1. Should this soldier recover for disability obtained in -service? Marie was inclined to think military service -in part responsible for the development of the paresis. -Laignel-Lavastine thought so also, but that the -amount assigned should be 5%–10% of the maximum -assignable.</p> - -<p class='c027'>2. What is the duty of the military authorities relative to -so called traumatic paresis? Medicolegally speaking, -Froissart, quoted by Rayneau, states that a victim of -traumatic paresis <em>may or may not</em> have presented mental -disorders before the accident, that is, that the paretic -symptoms may develop out of a clear sky as a result -of the accident. The accident itself must be of a -serious nature. The accident must be followed by -phenomena pointing to brain injury of traumatic -nature. These phenomena need not be characteristic -symptoms of general paresis at the outset. The period -elapsing between the trauma and the supervening condition -of paresis must be occupied without notable -interruption, at first by phenomena of a purely traumatic -nature, later by signs indicating the onset and -evolution of general paresis.</p> - -<p class='c028'>The French invaliding process called <i><span lang="fr" xml:lang="fr">Réforme No. 1</span></i> -with pension is granted according to the governmental -instructions only to officers, subalterns, and soldiers -whose disease is due to trauma. In view of this -governmental regulation, the military surgeon must -write out certificates describing every cranial trauma, -however slight, which might have a bearing on the -development of paresis. However, he should not too -readily admit trauma as a cause of paresis. If a long -period of quietude, a period in which the trauma itself -seems to have undergone a complete recovery, supervenes, -then general paresis should not be reported by -the surgeon.</p> - -<p class='c028'>Lépine has recently noted the following features as -desirable in board reports concerning paretics: nature -of trauma, length of service, fatigue endured, insomnia, -date of infection, treatment, W. R.</p> - -<div><span class='pageno' id='Page_414'>414</span></div> -<div class='box'> - -<p class='c013'><b>Can “gassing” light up a paresis? Example from -de Massary of Issy-les-Moulineaux.</b></p> - -</div> - -<p class='c006'><b>Case H.</b> A soldier, 35, was sent to the <em>Centre Neurologique</em> -with a hospital ticket reading:</p> - -<p class='c007'>“Neurasthenia, general weakness following intoxication -by gas.”</p> - -<p class='c007'>The soldier was thought at first to be a neurasthenic. But -he soon showed signs of more pronounced mental trouble. -The voice was suspicious. There was a slight irregularity of -pupils.</p> - -<p class='c007'>An epileptiform attack occurred, followed by aggravation -of symptoms.</p> - -<p class='c007'>Lumbar puncture showed pleocytosis. The W. R. of the -serum proved positive.</p> - -<p class='c007'>Yet the evident <b>neurosyphilis</b>, possibly <b>paretic</b> (de Massary’s -diagnosis), was preceded by a neurasthenia and the -neurasthenia was preceded by “gassing.”</p> - -<p class='c007'>De Massary believes the patient <em>and his family</em> would -perhaps be justified in believing the condition produced by the -injury. De Massary is not clear as to the financial deserts of -the patient. It is not a manifest case of aggravation of antebellum -symptoms, even if it be neuropathologically an instance -of acquired loss of resistance to pre-existent spirochetes -in body or brain.</p> - -<p class='c027'>1. What adjuvant factors have been recognized in military -paresis? Aside from syphilis, Rayneau finds that alcoholism, -malaria, sunstroke and various intoxications -serve as causes for paresis. Rayneau points out that the -apparent integrity of the mind in general paresis may -be such that they last in the army some time and have -their oddities ascribed to misconduct or breaches of -discipline. In fact the Legrande du Saulle called this -early period in general paresis the <em>medicolegal period</em>, -showing, as it so often does, thefts, outrages against -decency, frauds, assaults, exhibitionism and the like. -To be sure these acts are absurd and infantile and not -difficult to recognize as of psychotic origin.</p> - -<div><span class='pageno' id='Page_415'>415</span></div> -<div class='box'> - -<p class='c013'><b>Syphilis may bring out epilepsy in a subject having -taint. Case from Bonhoeffer, 1915.</b></p> - -</div> - -<p class='c006'><b>Case I.</b><a id='r28' /><a href='#f28' class='c014'><sup>[28]</sup></a> A man of 35 in the <em>Landwehr</em> acquired syphilis -some time in the summer of 1914. He was a good soldier, -passed through several clashes, and was promoted to <i><span lang="de" xml:lang="de">Unteroffizier</span></i>.</p> - -<p class='c007'>To understand what followed it must be stated that he had -been a bed-wetter to 11, had been practically a teetotaler -(Bonhoeffer’s point is perhaps that otherwise epilepsy might -have developed sooner?), and, when he did drink, vomited -almost at once, and had amnesia for the period of drunkenness. -His father had been somewhat of a drinker. His -sister had suffered from convulsions as a child.</p> - -<p class='c007'>February, 1915, the <i><span lang="de" xml:lang="de">Unteroffizier</span></i> lost appetite, got headaches, -and went to hospital for a time. Upon getting better, -he was sent on service to Berlin. In a Berlin hotel he had -his first convulsions and unconsciousness, biting his tongue. -He was confused for several days, and, when he had become -clear, had a pronounced retrograde amnesia together with a -tendency to fabricate a filling for the lost period.</p> - -<p class='c007'>This retrograde amnesia is uncommon in epilepsy and -suggests organic disease. No sign of organic disease was -found on neurological examination. The patient had no -signs of the epileptic make-up. The serum W. R. was -negative. On the whole, Bonhoeffer regards the epilepsy as -“reactive” to the syphilis, as a syphilogenic epilepsy.</p> - -<p class='c007'>As to the amnesia, it is of interest that alcohol should long -before have been able to cause amnesia in this man in the -same way as does now the syphilitic epilepsy.</p> - -<p class='c027'>1. In view of the fact that this <em>Landwehr</em> man appears to -have acquired syphilis while on campaign, what is the -responsibility of the government for treatment? The -<span class='pageno' id='Page_416'>416</span>Canadian authorities, as stated under Case E, are in -doubt whether contraction of venereal disease constitutes -negligence on the part of the soldier. It would -appear to us that where a government does not take -suitable steps to prevent the acquisition of syphilis by -the soldiers, the government must assume a measure -of responsibility for the syphilis incurred. The government’s -responsibility would be still greater in equity, -it would appear, if commercial opportunities for the -acquisition of syphilis are maintained under more or -less close government supervision or (even as has been -claimed for certain encampments on our own Mexican -border) if shelter for illicit sex relations is afforded -within the limits of a military camp. In a certain community, -“E,” for example, it is claimed by Exner,<a id='r29' /><a href='#f29' class='c014'><sup>[29]</sup></a> the -district for prostitutes was “situated within the lines of -military camps and protected and ‘regulated’ by the -military authorities.”</p> - -<p class='c028'>But even if the government has no legal responsibility -in this regard, it would be well to consider the -ultimate results of the syphilis that will probably be -acquired by great numbers of soldiers under campaign -conditions. Aside from the ravages of syphilis outside -the nervous system, it is well known, as Weygandt -intimates for German conditions, that the aftermath -of war will be a high proportion of cases of neurosyphilis.</p> - -<p class='c028'>Weygandt remarks in his review of the influence of -the war upon psychiatry, that the opportunity for -syphilitic infection in the campaign is considerable. -In the war of 1870, the conditions in this regard were -extremely unfavorable, and writing in 1915, Weygandt -remarks that at present there should be a prophylaxis -against syphilitic infection by the soldiers, which -prophylaxis should be the most energetic possible. -Continence on the part of the soldiers and the isolation -of infected women, with examination by specialists, -have been advocated by Neisser and by Mendel. In -the ’80’s a great number of cases of locomotor ataxia -developed in Germany, which were due to syphilis -acquired by the soldiers and officers in the war of 1870.</p> - -<div><span class='pageno' id='Page_417'>417</span></div> -<div class='box'> - -<p class='c013'><b>Syphilis in a psychopathic subject. Convulsions -5 days after Dixmude. Case from Bonhoeffer, 1915.</b></p> - -</div> - -<p class='c006'><b>Case J.</b><a id='r30' /><a href='#f30' class='c014'><sup>[30]</sup></a> A soldier in the reserves, 23, was, subsequently -to his being brought to hospital, described by his wife as a -rather over-sensitive fellow, who could hardly look at blood -and was meticulous about the household. He had always -been subject to headaches, especially after hard work. -However, he had passed through his military training well in -1910, not even having been <em>bestraft</em>.</p> - -<p class='c007'>He began service in October and fought at Dixmude on -the 19th. On the 24th in the trench and while being carried -back, he had several spells of pallor, falling stiff, and then -having convulsions. Brought finally to the Charité in Berlin, -he had more spells of sudden pallor, collapse with brief convulsions, -tossings in bed, and absences, post-convulsive headaches, -and mild bad humor.</p> - -<p class='c007'>There were numerous attacks several days apart in the -first seven weeks. The patient was not of an “epileptic” -disposition, though he was rather readily dissatisfied. Headaches -also occurred without relation to convulsions.</p> - -<p class='c007'>The serum W. R. was positive. Treatment by mercurial -inunctions. No further convulsions. Prognosis as to the -possibility of a constitutional epilepsy unknown.</p> - -<div><span class='pageno' id='Page_418'>418</span></div> -<div class='box'> - -<p class='c013'><b>SYPHILITIC ROOT-SCIATICA (lumbosacral -radiculitis) in a fireworks man with a French artillery -regiment. Case presented from Dejerine’s -clinic by Long.</b></p> - -</div> - -<p class='c006'><b>Case K.</b> No direct relation of this example of root-sciatica -to the war is claimed nor was there a question of -financial reparation.</p> - -<p class='c007'>There was no prior injury. At the end of March, 1915, -the workman was taken with acute pains in lumbar region -and thighs, and with urgent but retarded micturition.</p> - -<p class='c007'>Unfit for work, he remained, however, five months with the -regiment, and was then retired for two months to a hospital -behind the lines. He reached the Salpétrière October 12, -1915, with “double sciatica, intractable.”</p> - -<p class='c007'>There was no demonstrable paralysis but the legs seemed -to have “melted away,” <i><span lang="fr" xml:lang="fr">fondu</span></i>, as the patient said. Pains -were spontaneously felt in the lumbar plexus and sciatic -nerve regions, not passing, however, beyond the thighs. -These pains were more intense with movements of legs; but -coughing did not intensify the pains. Neuralgic points could -be demonstrated by the finger in lumbar and gluteal regions -and above and below the iliac crests (corresponding with -rami of first lumbar nerves). The inguinal region was -involved and the painful zone reached the sciatic notch and -the upper part of the posterior surface of the thigh.</p> - -<p class='c007'>The sensory disorder had another distribution objectively -tested. The sacral and perineal regions were free. Anesthesia -of inner surfaces of thighs, hypesthesia of the anterior -surfaces of thighs and lower legs. The anesthesia grew more -and more marked lower down and was maximal in the feet, -which were practically insensible to all tests, including those -for bone sensation. There was a longitudinal strip of skin -of lower leg which retained sensation.</p> - -<p class='c007'>Position sense of toes, except great toes, was poor. There -was a slight ataxia attributable to the sensory disorder—reflexes -<span class='pageno' id='Page_419'>419</span>of upper extremities, abdominal, and cremasteric -preserved, knee-jerks, Achilles and plantar reactions absent.</p> - -<p class='c007'>The vesical sphincter shortly regained its function, though -its disorder had been an initial symptom.</p> - -<p class='c007'>Pupils normal.</p> - -<p class='c007'>The “sciatica” here affects the lumbosacral plexus. -Signs of disorder at one time or other affected the first lumbar -distribution of the third lumbar and first and second sacral -nerves.</p> - -<p class='c007'>As to the syphilitic nature of this affection, there had been -at eighteen (22 years before) a colorless small induration of -the penis, lasting about three weeks. There was now evident -a small oval pigmented scar. The patient had married at -20 and has had three healthy children.</p> - -<p class='c007'>The lumbar puncture fluid yielded pleocytosis (120 per -cmm.). Mercurial treatment was instituted.</p> - -<p class='c007'>The treatment has not reduced the pains. Long thinks it -was undertaken too long (six months) after onset. The -warning for early diagnosis is manifest. There was somehow -a delay under the medical conditions of the army.</p> - -<div><span class='pageno' id='Page_420'>420</span></div> -<div class='box'> - -<p class='c013'><b>Can the “lighting up” of NEUROSYPHILIS IN -CIVIL LIFE be induced by the domestic stress of -war? A possible example from Dr. R. Percy Smith, -London.</b></p> - -</div> - -<p class='c006'><b>Case L.</b> A German Jew in London passed into the -<span class='sc'>Paretic</span> form of <span class='sc'>Neurosyphilis</span> shortly after the outbreak -of war under conditions suggesting that the stress of emotions -directly or indirectly lighted up the neural process.</p> - -<p class='c007'>The man was a bank-officer, 52 years old, and married. -He had lived many years in England and was in fact a -naturalized citizen. He had been under treatment for -syphilis by Sir Jonathan Hutchinson, 29 years before, namely, -at the age of 23. Subsequently, Sir John had given him permission -to marry.</p> - -<p class='c007'>It proved that for years the man had had fixed pupils, -absent knee-jerks, and a perforated ulcer of the foot. However, -there had been no other mental or nervous symptoms -preventing bank-officer’s work.</p> - -<p class='c007'>At the outbreak of war the man was discharged from the -bank. He grew worried and sleepless. He began to charge -himself with sex irregularity. He went down to the city and -burned trust documents belonging to others.</p> - -<p class='c007'>From worry and self-accusation he passed into depression -and agitation. He developed a belief that not only he but -also his German wife were to be executed. He thought he -was a criminal and was to be hanged.</p> - -<p class='c007'>The depression then altered to a condition of hilarity and -loquacity.</p> - -<p class='c007'>In addition to the fixed pupils and absent knee-jerks, a -speech disorder shortly developed.</p> - -<p class='c007'>The patient was placed under care, but quickly (a few -months?) passed into an advanced stage of paretic neurosyphilis -and died.</p> - -<div><span class='pageno' id='Page_421'>421</span></div> -<div class='box'> - -<p class='c013'><b>SHELL-SHOCK PSEUDOPARESIS (non-syphilitic). -Recovery. Case from Pitres and Marchand -of Bordeaux.</b></p> - -</div> - -<p class='c006'><b>Case M.</b> June 19, 1915, a shell exploded some distance -from Lieutenant R. He remembers the gaseous smell, the -bursting of several shells nearby and a sensation of being -lifted into the air. When he recovered consciousness, he was -in hospital at Paris-Plage, covered with bruises and scratches. -They told him he had been delirious and had vomited and -spat blood.</p> - -<p class='c007'>June 24, his wife came to see him, but this visit he could -not remember. Nor could his wife at first recognize him, he -was so thin. He roused a few moments and recognized his -wife, but relapsed into torpor again. Speech was difficult -and ideas confused.</p> - -<p class='c007'>A few days later he was able to rise; but his mental status -grew worse, especially as to speech and writing; the latter quite -illegible. There was insomnia, or, if he slept, war dreams.</p> - -<p class='c007'>August 7, he began a period of five months’ convalescence -passed with his family, depressed, given to spells of weeping, -confined to bed or couch, unable to “find words,” conscious -of his state and troubled about it, speaking of nothing but -the war, and afraid to go out for fear of ambuscade. There -was at first a slight lameness of the right leg. Although he -could walk, he felt pain in the knee on flexing the right leg -on the thigh. He walked holding this leg in extension.</p> - -<p class='c007'>On going back to the colors, he was immediately evacuated -to the <em>Centre Neurologique</em> at Bordeaux, January 20, 1916.</p> - -<p class='c007'>Examination found a bored, impatient, irritated man, vexed -that a man who was not sick should be sent up “<i><span lang="fr" xml:lang="fr">comme fou</span></i>.”</p> - -<p class='c007'>Omitting negative details, <b>neurological examination</b> showed -slight lameness as above, body stiff and movements jerky; -difficult, unsteady gait. The lieutenant could stand for some -time on either leg, tongue and face tremulous during speech. -Limbs moderately tremulous, especially in the performance -of test movements.</p> - -<p class='c007'><span class='pageno' id='Page_422'>422</span>Knee-jerks and Achilles jerks absent. Other reflexes, including -pupillary, normal. Segmentary hypalgesia of right -leg, especially about knee. Tremulous speech and writing. -Patient would stop short in speaking for lack of words.</p> - -<p class='c007'>Malnutrition. Appetite good, but a bursting feeling after -meals.</p> - -<p class='c007'>Skin dry, scaly on legs, fissured on fingers.</p> - -<p class='c007'>Serum W. R. negative. Fluid not examined.</p> - -<p class='c007'><b>Mental examination.</b> Conscious and complaining of his -troubles, Lieutenant R. claimed persistently that he was not -sick. Memory for recent events was in general poor. Errands -easily forgotten. Lost in the street. Complaint of -corpse odors round him. Everybody is looking at him and -making fun of him. He was apt to insult bystanders. He -was afraid of German spies. Things in shops angered him -as they seemed to him to be of German manufacture.</p> - -<p class='c007'>There were frequent periods of depression, with pallor and -no spontaneous speech for some hours to a half-day. Headaches -coming on and stopping suddenly.</p> - -<p class='c007'>As to diagnosis, the first impression, say Pitres and Marchand, -was that of general paresis. The progress of symptoms -after the shock was consistent with this diagnosis. The -mental state and the physical findings seemed consistent, -although the pupils were normal. His partial insight into -his symptoms was not inconsistent with the diagnosis. He -had a characteristic self-confidence. There had been four -stillbirths (two twins) two children are alive, 11 and 13. -Typhoid fever at 30. Syphilis denied. No mental disease -in the family.</p> - -<p class='c007'>The patient had never done military duty, having been -invalided for “right apex.” But he had volunteered and been -accepted in September, 1914.</p> - -<p class='c027'>1. Was this diagnosis, general paresis, at any time justified? -The spinal fluid should of course have been examined. -The peculiar lameness of the right leg was certainly -not characteristic of general paresis, and was perhaps -hysterical. (There was no limitation of visual fields or -any other definite sign of hysteria.) Presumably some -quality of speech defect, the amnesia, and the euphoria, -<span class='pageno' id='Page_423'>423</span>together with absent knee-jerks, led to the diagnosis -general paresis. By the 20th of March, 1916, the knee-jerks -had become lively; the Achilles jerks normal. At -this time the patient had gained in weight, could walk -though stiffly, had headache (especially right frontal) -and a feeling of lead in head, less tremor, lack of desire -to undertake anything. He still wanted to go back -into service. He still saw spies about. Dreams terrible; -devoured by spiders, leggins instruments of -torture. Skin still atrophic. June 4 there was no more -tremor of speech or face. Symptoms largely disappeared -except a few ideas of persecution. Recovery -October, 1916.</p> - -<p class='c027'>2. How was Lieutenant R. cured? Apparently by rest in -the <em>Centre Neurologique</em>. Pitres and Marchand do not -speak of the subtle relation between mental state and -the idea of non-return to military service. This motive -might still work even if Lieutenant R. kept protesting -quite sincerely that he wanted to go back into military -service.</p> - -<div><span class='pageno' id='Page_424'>424</span></div> -<div class='box'> - -<p class='c013'><b>SHELL-SHOCK PSEUDOTABES (non-syphilitic, -serum W. R. positive). Improvement. Case from -Pitres and Marchand of Bordeaux.</b></p> - -</div> - -<p class='c006'><b>Case N.</b> Innkeeper B., 36, a shell-shock and burial victim -June 20, 1915, was looked on by a number of physicians as -a case of genuine tabes.</p> - -<p class='c007'>Even eight months after the episode, he still showed (when -observed by Pitres and Marchand, February 3, 1916) -absence of knee-jerks and Achilles jerks, a slight swaying in -the Romberg position, pupils sluggish to light, incoordination, -delayed sensations. There was also a history of pains in the -legs, compared by the patient to those of sciatica. These -pains came in crises, the longest of which had lasted 30 hours.</p> - -<p class='c007'>It seems that this soldier’s troubles began the day after his -shock with a feeling of swollen feet and of cotton wool under -them. He stayed on service, however, walking with increasing -difficulty.</p> - -<p class='c007'>At the time of his evacuation, July 10, he could walk with -great difficulty. “Strips of lead were between his legs.” He -could hardly control movements in the dark, or descend -stairs. Often his legs would bend under him. Vesical function -sluggish.</p> - -<p class='c007'>After a few months the patient could walk better. On -February, 1916, he walked thrusting his legs forward trembling, -and dragging toes a little. He could not support himself -on either leg. Jerkiness and incoordination in extension -or flexion of leg on thigh.</p> - -<p class='c007'>The muscular weakness was decidedly against tabes or at -all events a pure tabes. The incoordination proved to be due, -not to loss of position sense (which was intact) but to unsteady -muscular contractions. Deep sensibility was intact.</p> - -<p class='c007'>There were no mental symptoms. There was a slight -hesitation in speech and doubling of syllables, but nothing -demonstrable with test phrases.</p> - -<p class='c007'>The serum W. R. was positive. Syphilis denied.</p> - -<p class='c027'><span class='pageno' id='Page_425'>425</span>1. What is the cause of these phenomena? Pitres and -Marchand lean to the hypothesis of slight internal -traumatism. They believe that there is either (a) slight -internal hemorrhage in the nervous system, or possibly -(b) what they call “nerve cell contusion,” or perhaps -(c) caisson-disease-like phenomena from aerial decompression. -Some authors incriminate (d) the gases. It -has been reported by certain French authors that -shortly after shell-shock injury or burial there is a -pleocytosis in the spinal fluid as well as evidence of -hemorrhage. The pleocytosis is said to last only a short -time; hence when patient arrives at a base hospital -lumbar puncture usually discloses nothing.</p> - -<div><span class='pageno' id='Page_426'>426</span></div> -<div class='chapter fs=.9em c012'> - -<div class='lg-container-b c002'> - <div class='linegroup'> - <div class='group'> - <div class='line'>Baalim and Ashtaroth</div> - </div> - <div class='group'> - <div class='line in16'>Paradise Lost, Book I, line 422.</div> - </div> - </div> -</div> - -</div> - -<div> - <span class='pageno' id='Page_427'>427</span> - <h2 class='c005'>VII. SUMMARY AND KEY</h2> -</div> - -<p class='c006'>No more important human problem now exists than -syphilis. Syphilis of the nervous system or, briefly, neurosyphilis -is a highly important fraction of the total problem. -The few outstanding dates and items which we present on the -following page give but a faint idea of the amount of observation -and thinking which the medical aspects of neurosyphilis -alone have required. The present work deals with but a small -fraction of the results of this work, nor can we more than -glance at the scientific history of syphilis and neurosyphilis—a -history that would form an epoch in itself.</p> - -<p class='c007'>It is only in the most recent years that syphilology and -the narrower science of neurosyphilology have threatened to -become separate disciplines boasting full time specialized -workers. Up to recent years the contributions to the theory -of syphilis have been largely by-products of work in larger -sciences and arts. Thus, the cellular pathology of syphilis -as worked out by Virchow and the more special vascular -features as worked out by Heubner were incidental in the -progress of pathological anatomy and histology. The bold -procedure of Quincke in proposing lumbar puncture also had -its more general ground in the extension of clinical medicine,—an -interpretation likewise true of the French achievements -in the cyto-diagnosis and chemical diagnosis of the lumbar -puncture fluids. The careful histological definitions of the -Nissl-Alzheimer group were incidental to the application of -approved and classical pathological methods to neurological -and psychiatric material.</p> - -<p class='c007'>Again, the work of Schaudinn, as well as that of Metchnikoff -and Roux, was ingenious work with the methods of parasitology -and experimental pathology. The great work of -Schaudinn in establishing the constancy of the spirocheta -pallida in syphilis may be said to have started syphilology -as something approaching a special discipline. The ideas -of one of the greatest of immunologists, Bordet, were almost -immediately applied to the serum diagnosis of syphilis by -Wassermann and the further application of this method to -the problems of neurosyphilis was almost immediate, with the -spirocheta pallida as an object of attack. The commanding -intelligence of Ehrlich could at once seek application of long -incubated ideas of chemotherapy with the startling outcome, -salvarsan.</p> - -<div><span class='pageno' id='Page_428'>428</span></div> -<div class='chart'> - -<table class='table0' summary=''> - <tr><td class='c020' colspan='3'><span class='large'><b>DATES, NEUROSYPHILIS</b></span></td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009'>VIRCHOW</td> - <td class='c009'>PATHOLOGY</td> - <td class='c033'>1858</td> - </tr> - <tr> - <td class='c009'>HEUBNER</td> - <td class='c009'>ENDARTERITIS</td> - <td class='c033'>1874</td> - </tr> - <tr> - <td class='c009'>QUINCKE</td> - <td class='c009'>LUMBAR PUNCTURE</td> - <td class='c033'>1891</td> - </tr> - <tr> - <td class='c009'>RAVAUT, SICARD, NAGEOTTI, WIDAL</td> - <td class='c009'>CYTODIAGNOSIS, C.S.F.</td> - <td class='c033'>1901</td> - </tr> - <tr> - <td class='c009'>WIDAL, SICARD, RAVAUT</td> - <td class='c009'>ALBUMIN, C.S.F.</td> - <td class='c033'>1903</td> - </tr> - <tr> - <td class='c009'>METCHNIKOFF AND ROUX</td> - <td class='c009'>TRANSMISSION TO APES</td> - <td class='c033'>1903</td> - </tr> - <tr> - <td class='c009'>ALZHEIMER</td> - <td class='c009'>HISTOPATHOLOGY, BRAIN SYPHILIS</td> - <td class='c033'>1904</td> - </tr> - <tr> - <td class='c009'>SCHAUDINN AND HOFFMANN</td> - <td class='c009'>SPIROCHETA PALLIDA</td> - <td class='c033'>1905</td> - </tr> - <tr> - <td class='c009'>WASSERMANN, NEISSER AND BRUCK</td> - <td class='c009'>SERUM DIAGNOSIS</td> - <td class='c033'>1906</td> - </tr> - <tr> - <td class='c009'>PLAUT</td> - <td class='c009'>WASSERMANN REACTION, C.S.F.</td> - <td class='c033'>1908</td> - </tr> - <tr> - <td class='c009'>EHRLICH</td> - <td class='c009'>SALVARSAN</td> - <td class='c033'>1909</td> - </tr> - <tr> - <td class='c009'>SWIFT AND ELLIS</td> - <td class='c009'>SALVARSANIZED SERUM</td> - <td class='c033'>1912</td> - </tr> - <tr> - <td class='c009'>NOGUCHI AND MOORE</td> - <td class='c009'>SPIROCHETES, BRAIN TISSUE, PARESIS</td> - <td class='c033'>1913</td> - </tr> - <tr> - <td class='c009'>LANGE</td> - <td class='c009'>GOLD SOL TEST</td> - <td class='c033'>1913</td> - </tr> - <tr><td> </td></tr> - <tr><td class='c022' colspan='3'><span class='sc'>Chart 28</span></td></tr> -</table> - -</div> - -<p class='c019'><span class='pageno' id='Page_429'>429</span>The history of syphilis and neurosyphilis was now to be -thickly sown with ideas and results growing from the achievements -of Schaudinn and Ehrlich. The positive reactions -in the blood and spinal fluid in the most striking of mental -diseases, general paresis, led to the impression that general -paresis itself might at last be proved to be what Mœbius had -suspected, namely, 100% syphilitic. We know how difficult -is the technical proof of spirochetosis in the brains of general -paretics both post mortem and ante mortem, but no one -doubts the certainty of the syphilitic hypothesis concerning -the origin of general paresis.</p> - -<p class='c007'>The data of the gold sol reaction ultimately obtained from -the ideas of Thomas Graham concerning colloids, as developed -by Szigmondi and effectively applied by Lange, have broadened -and solidified the whole plane of attack.</p> - -<p class='c007'>The ingenious suggestions of Swift and Ellis (salvarsanized -serum) and the notable work of Noguchi and Moore (spirochetosis -in paretic brains) indicate to us as Americans what -the establishment of scientific institutes may do to permit the -rapid application of new ideas to branches of inquiry that are -opened out. Scientific institutes do not manufacture a -Virchow, a Metchnikoff, a Schaudinn, a Bordet or an Ehrlich -but they directly permit such men to work and indirectly -stimulate the development of more.</p> - -<p class='c007'>The series of 137 cases here at least presented does not -touch systematically the problems of the neuropathology of -syphilis, which would themselves require a textbook of respectable -size. We have, however, presented in Part I, cases 1 to 8, -some indication of the protean nature of the material and -from time to time in the remainder of the book somewhat -fuller accounts of the pathological anatomy and histology -have been presented than are strictly necessary in the demonstration -<span class='pageno' id='Page_430'>430</span>of the principles of modern systematic diagnosis -and treatment.</p> - -<p class='c007'>Our work may be said to represent psychopathic hospital -practice as available to us in our official capacities at the -Psychopathic Department of the Boston State Hospital. -A word is necessary concerning the nature of this practice. -The dispensary and ward practice of a modern state psychopathic -hospital, such as the Boston institution (founded in -1912) and the Ann Arbor institution (founded in 1906), is -to be sharply distinguished from asylum practice. Those -who have not followed the evolution of the modern psychopathic -hospital with the lowering of bars to the admission of -patients and the extension of its benefits to a group of sick -persons far removed from the medicolegal concept “insanity” -may not soon grasp the general nature of psychopathic -hospital material. Psychopathic hospital practice stands, -in fact, almost midway between asylum practice in the classical -sense and private practice. This has come about through -the great extension of the so-called voluntary relation under -which hundreds of patients now resort to the beds and out-patient -rooms of a psychopathic hospital, who would formerly -have remained untreated or inadequately treated. Moreover, -the broadening of the concept of mental diseases as a -whole has permitted in some parts of the world the establishment -of laws under which psychopathic and psychotic patients -may be brought to psychopathic hospitals and even to asylums -under the easiest possible conditions and restrictions, omitting -court procedure altogether. The operation of the voluntary -and temporary care provisions of law has accordingly yielded -us, in the Boston institution, a great group of cases formerly -not at all accessible to hospital diagnosis and treatment. -Needless to say, as always under such conditions, we have -been able to show not merely that hospital diagnosis or treatment -is of importance to a new group of cases, but also that -home treatment, especially home treatment under supervision, -is possible and even ideal for a large group of cases -about which utter darkness or profound misgivings ruled in -the not very distant past.</p> - -<p class='c007'>Accordingly, we are fain to insist that our material is of -<span class='pageno' id='Page_431'>431</span>importance in new programs of community organization for -the stamping out of disease. The work in psychopathic -hospitals upon neurosyphilis in particular is essentially a -part of the public health program, although our special work -will not soon be taken over by the public health officers, -so complicated are the ramifications of medical and social -diagnosis and treatment in the neurosyphilis group.</p> - -<p class='c007'>We have tried in Part IV (medicolegal and social cases) -to give a few examples to illustrate the part played by neurosyphilis -in society; but we regard this part of our work as the -least satisfactory and the least representative in the total -work. Our colleagues in social service, in mental hygiene, -in psychopathology and in criminology will easily in the next -few years provide a far more adequate basis for a full account -of the public and social aspects of neurosyphilis. One point -we should emphasize here. The psychopathic hospital worker, -whether physician or social worker, must shortly decide -upon and consolidate a program with relation to the families -of neurosyphilitics.</p> - -<p class='c007'>The syphilographers of the dermatological and special -syphilis clinics have their identical problems with the families -of syphilitics; but the dispensaries for mental cases and in -particular the psychopathic hospital and asylum out-patient -departments tap another reservoir of syphilitic families at a -stage when the memory of the initial horrors of syphilitic -infection is dimmed or erased. Any program for the diagnosis -and treatment of syphilis of the innocent must take into -account not only the skin, syphilis, and internal medicine -clinics but also the clinics for mental and nervous diseases -wherein neurosyphilitics are not infrequent. Whether the -ultimate percentage will stand at 10, 15 or 20% for the neurosyphilitics -in mental clinics, is of no importance to the principle. -There are enough neurosyphilitics having economical -importance and humanly precious families to warrant definite -steps.</p> - -<p class='c007'>The Massachusetts Commission for Mental Diseases has -in the last few years employed the services of two medical -workers whose time has been largely devoted to the applications -of our recent knowledge in neurosyphilis and has gone -<span class='pageno' id='Page_432'>432</span>so far as to establish a neurosyphilis ward in one of the district -state institutions (Summer Street, Worcester, under the -Grafton Hospital Board). Special social workers in the -field of neurosyphilis have also been available from time to -time. These social workers are enabled with the support -of the medical profession to do a great deal of good, for example, -with the slogan <span class='sc'>The Child of a Paretic is the -Child of a Syphilitic</span>.</p> - -<p class='c007'>The nature of the intake of patients into psychopathic -hospital wards and out-patient clinics is such that great -numbers of non-mental syphilitics arrive for diagnosis and -possible treatment. Moreover, the existence of syphilis in -non-suspects is a fact picked up by the way in routine Wassermann -serum diagnosis.</p> - -<p class='c007'>The mental clinic in the modern sense with the medicolegal -bars lowered or well nigh removed, turns rapidly into -a clinic for neurological cases as well. The German models -for mental and nerve clinics are rapidly being imitated. -The result of this administrative novelty in our hospital -procedure has incidentally yielded us many representative -cases of entirely non-psychotic and even non-psychopathic -neurosyphilis. Our impression grows and deepens that <em>the -neurosyphilitic is seldom merely a spinal syphilitic</em>. The -neurosyphilitic is nearly always the victim not merely of -spinal disease but also of intracranial disease. Per contra, -the victim of intracranial neurosyphilis is almost always -more or less importantly affected by spinal neurosyphilis.</p> - -<p class='c007'>The net result of the modern work on neurosyphilis has -been to bring the neurologist and the psychiatrist together -upon one platform in diagnosis and more and more upon one -platform in treatment. But aside from the clinical evidence -that the neurosyphilitic is apt to be a victim of both brain -syphilis and cord syphilis, the autopsy evidence is stronger -still. Even the victim of tabetic neurosyphilis (“tabes -dorsalis”) himself is rarely found at autopsy without more -or less evidence of significant encephalic disease of a chronic -inflammatory or degenerative nature. Aside from tabes -dorsalis and Erb’s paraplegia, the rule is almost universal -that neurosyphilis is a matter of the entire nervous system.</p> - -<p class='c007'><span class='pageno' id='Page_433'>433</span>In view of the generalization of neurosyphilitic process, -one might question the advantage of any topical grouping of -neurosyphilitic disease. Practically speaking, however, as we -have shown in Chart 5, it seems advisable to separate the -neurosyphilitic diseases into six roughly distinguishable groups. -First, there is the great group that we have chosen to term -<b>diffuse neurosyphilis</b>, including many of the cases of so-called -cerebral or cerebrospinal syphilis of the neurological clinics -and the group of cases that have been treated in private -practice by internists and neurologists without recourse to -institutions. These cases have lived at home and have not -been socially hard to manage until the late phases of their -disease when the victims, if poor, are sent to almshouses and -infirmaries under municipal or state care. These are the cases -which have been in the past regarded as most amenable to -the classical iodid and mercurial treatment. Indeed there -is record of numerous therapeutic successes in the group.</p> - -<p class='c007'>Whereas the lesions in diffuse neurosyphilis are chiefly -chronic inflammatory and degenerative changes of a diffuse -nature (with vascular changes incidental or subordinate to -the inflammation and the degeneration), there is an important -and large group of cases that we have termed <b>vascular neurosyphilis</b> -in which the factors of inflammation and degeneration -are subordinate to vascular insults. These are cases of syphilitic -arteriosclerosis and the best examples are victims of -cerebral thrombosis. The clinical symptoms of the immediate -attacks (of apoplectiform, epileptiform or other acute nature) -are not in themselves distinguishable from the immediate -effects of non-syphilitic vascular disease; nevertheless the -establishment of their syphilitic etiology is of the utmost -importance on account of the possibilities of treatment of -the underlying syphilis. For, as the neuropathologist must -always insist, the immediate effects of vascular insults whether -syphilitic or non-syphilitic are much more extensive than the -ultimate paralytic or residual irritative effects; and by consequence -a greater optimism is justifiable in the confronting of -these cases than the nihilistic observer is likely to entertain.</p> - -<p class='c007'>Physicians dealing with chronic disease in general are apt -to be somewhat nihilistic, but this nihilism is increased a -<span class='pageno' id='Page_434'>434</span>hundred fold in disease of the nervous system. How important -then is any work which shall demonstrate partial -or even complete recovery from serious looking apoplectic -and other seizures, besides all of which the point of syphilitic -treatment naturally lies in the prevention of future insults -of the same sort. Therapeutic experience in this vascular -group has almost as good a toll of successes as in the diffuse -neurosyphilis group above mentioned, that is to say, the -modern systematic treatment and even the old pre-salvarsan -treatments have succeeded fairly well in removing the products -of inflammation from the membranes of the nervous system -and in abolishing vascular disease.</p> - -<p class='c007'>The old principle that the dead neurone in the central -nervous system cannot be regenerated remains a perfectly -firm principle; but there are any number of neurones and even -neurone systems that are not essential to life or to the pursuit -of happiness. We accordingly have just as good a theoretical -therapeutic outlook in many instances of chronic neurosyphilis -as we have in chronic diseases of many other organs. -Add to this the fact that a great number of the most sharply-defined and grave symptoms are probably not due to destruction -of neurones but to irritation and functional disability -of neurones, and the conclusion is compelled that, as -hinted above, an entirely unjustifiable pessimism and nihilism -have prevailed in some quarters. Of course, the recoil from -such pessimism with the onset of salvarsan treatment led -various enthusiasts to an undue optimism.</p> - -<p class='c007'>Another great group distinguished by the existence of -spinal cord disease is the group we have termed <b>tabetic -neurosyphilis</b>, which group contains the classical tabes dorsalis -or locomotor ataxia and its congeners.</p> - -<p class='c007'>The question of therapeutic optimism comes up most -forcibly in the field of tabes. It is hard, however, at this -time to give a proper and scientifically founded estimate of the -therapeutic outcome in tabetic neurosyphilis with modern -methods. So much can be said: namely, that the alleviation -of pain and the palliation of other symptoms can be successfully -claimed as a result of the renewed interest in the treatment -of this affection. What was said above concerning the -<span class='pageno' id='Page_435'>435</span>finality of the death process in a dead neurone is very strikingly -true, of course, of some of the neurones of the posterior -columns in tabes dorsalis. Still only portions of these neurones -(namely, those which run an intradural course) are -strikingly altered in a great many cases. Now and again -one is greatly astonished to observe the restoration of the -lost knee-jerk in cases of neurosyphilis (see for instance the -case of Alice Morton (1), with discussion). In short, the relation -of several tabetic symptoms to irritative conditions -and functional disability of neurones may be considered -established. Naturally, moreover, if therapy can stop the -upward course of the affection as it passes from lower to -higher nerve roots (according to reasonably well-established -ideas of the genesis and progress of this affection), we are -entitled to a further degree of optimism.</p> - -<p class='c007'>The question of therapeutic optimism <i><span lang="la" xml:lang="la">versus</span></i> pessimism is -forced upon attention in the fourth great group of neurosyphilitic -diseases which we have chosen to distinguish, namely, the -group of <b>paretic neurosyphilis</b> including the disease formerly -known as general paresis, paralytic dementia, softening of -the brain and the like.</p> - -<p class='c007'>Of course, no one can gainsay there is a group of cases -having in the natural course of events a prognosis of fatality -within a term of years, say three to five years, and we have -cases in our series which go to show that even with the modern -intensive treatment the characteristic down-grade symptomatic -progress and ultimate fatality occur. Still, we have -other cases diagnostically on all fours with the fatal cases -that have seemed to get either entirely well with the laboratory -tests returning to normal and without further mental -symptoms, or else lose mental symptoms on the one hand or -laboratory signs on the other. We should strongly object -to any account of paretic neurosyphilis which should insist -that its necessary outcome is fatality within a term of years. -Of course, viewing our knowledge of the affection in the past, -we should be compelled to object to the generalization “<em>paresis -fatal</em>” on the evidences of the universally recognized remissions. -If nature can stop a paretic process, why cannot -man do as much? Can it be alleged that our own apparent -<span class='pageno' id='Page_436'>436</span>therapeutic successes and those of others are merely curious -examples of coincidences, namely, that remissions have chosen -to occur precisely when therapy was systematically applied? -The percentage of therapeutic successes with modern intensive -treatment, wherever it may ultimately stand, is already too -high for this hypothesis of fortuitous remissions.<a id='r31' /><a href='#f31' class='c014'><sup>[31]</sup></a></p> - -<p class='c007'>Moreover, we believe that the details of the clinical progress -of some of the reported cases are convincing on this point. -What, however, is the distinguishing feature of paretic neurosyphilis? -It is in one sense a particular kind of diffuse neurosyphilis. -The tissues are apt to show not only encephalic but -also spinal changes. There is apt to be a more or less well-defined -meningitis, but the characteristic feature, without -which the diagnosis of paretic neurosyphilis would hardly -be rendered, is the existence of disease of the cerebral cortex. -This disease is parenchymatous in the sense of showing nerve -cell destruction. There is also an interstitial reaction in the -shape of a neuroglia overgrowth, but the striking and pathognomonic -feature is the infiltration of the sheaths of the -small vessels in the cortex, giving evidence of an inflammation -very intimately affecting the cellular mechanisms of the -nervous system. It is striking how often a smaller or larger -share of the cells found in the vessel sheaths are plasma cells. -It does not appear, however, that the diagnosis of paretic -neurosyphilis as against diffuse non-paretic neurosyphilis can -be made in the stained sections with complete safety on the -basis of plasmocytosis in the former and lymphocytosis in -the latter. Whatever the results of careful histological differentiation -by future neuropathologists may yield, it is at all -events true that we cannot yet make an important differentiation -clinically on the basis of the differential count of -plasma cells and lymphocytes in the puncture fluids. However -<span class='pageno' id='Page_437'>437</span>this may be, there is an important distinction between -diffuse neurosyphilis of the non-paretic type and paretic neurosyphilis -in that paretic neurosyphilis rarely if ever fails to -show important degrees of intracortical perivascular inflammation -with larger or smaller numbers of plasma cells.</p> - -<p class='c007'>What has the therapeutist to face in this matter? The -answer, as elsewhere, depends somewhat upon what the future -may decide as to the habitat and toxic or antitoxic activities -of the spirocheta pallida. The early claims that the spirocheta -pallida was extravascular and lay for the most part -in the parenchyma and not in the vessel sheaths were perhaps -overbold, since other workers have found the spirochete in -the vessel sheaths also (Mott).</p> - -<p class='c007'>Aside from the spirochete and its accessibility to spirochetocidal -drugs, there seems to be no reason for supposing -that the perivascular sheaths cannot be cleansed of their -inflammatory contents. There is, again, no reason why the -phagocytic cells should not continue to perform their scavenger -function until such time as the degenerative process in the -parenchyma (a process not necessarily progressive in the absence -of the spirochete or its products) ceases. There is every -reason to suppose that a great many of the clinical phenomena -are not necessarily due to permanent destruction of neurones -and neuronic organs (dendrites, axis-cylinders, nets and the -like) but are due to various microphysical conditions of -pressure, intoxication and the like.</p> - -<p class='c007'>The inflammatory conditions in the spinal cord of poliomyelitis, -which conditions are precisely as striking as those of the -paretic cortex, are beyond a question cleared away in the -progress of the affection. Reference to the paradigm case (1) -will show the type of our argument. There is no manner of -doubt that in this paradigm case almost every portion of the -nervous system had been sometime swept by spirochetosis -and many of its small vessel sheaths stuffed with chronic -inflammatory products. As for paretic neurosyphilis itself, -a great many of its most striking clinical phenomena, such as -loss of memory and disorientation, as well as great degrees of -apparent dementia, are found virtually as often in cases with -very slight anatomical changes as in cases with marked cortical -<span class='pageno' id='Page_438'>438</span>devastation. The inference is plain, that these phenomena -are to a degree functional rather than structural.</p> - -<p class='c007'>In brief, we conclude not only from therapeutic experience -but also on <i><span lang="la" xml:lang="la">a priori</span></i> grounds that the histological conditions in -paretic neurosyphilis are not entirely hopeless, and certainly -not more hopeless than conditions in many chronic diseases -outside the nervous system. Accordingly, we plead for a temperate -optimism as to therapeutic results in general paresis.</p> - -<p class='c007'>A fifth group of neurosyphilitic cases bulking rather largely -in textbooks of pathology is the group of the <b>gummata</b>. -For a variety of reasons (therapeutic and otherwise) the -actual number of gummata of the nervous system available -for clinical or even for anatomical study is much smaller than -the books might lead one to infer.</p> - -<p class='c007'>The sixth and last of the main groups of neurosyphilitic -diseases is that of the <b>juvenile forms</b>, among which we find not -only diffuse forms without a special and well-defined course, -but also characteristic examples of paretic and tabetic neurosyphilis. -The distinction of a juvenile or congenital group -of neurosyphilitics is, on theoretical grounds, perhaps hardly -defensible. On practical grounds, however, the juvenile -neurosyphilitics do form a group having special relations to -feeblemindedness, epilepsy and the like.</p> - -<p class='c007'>We must be clearly understood as to the rough, six-unit -classification just given. It is practical merely. For comparison -we have given in other charts more expanded lists -of the diagnostic entities in neurosyphilis among which that -of Head and Fearnsides is of special interest, see Chart 2, -page <a href='#Page_21'>21</a>.</p> - -<p class='c006'>We shall now proceed to a brief analysis of the findings in -our chosen series of 137 cases. We shall not reproduce the case -headings of these cases, but expand their statements where -necessary and tie them together so far as possible into a -reasonable and systematic statement of the situation in neurosyphilis. -The footnotes will contain references to other cases -in which identical points are illustrated as in the leading -cases. The leading cases will in all instances be placed first -in the footnotes.</p> - -<p class='c007'><span class='pageno' id='Page_439'>439</span>The paradigm<a id='r32' /><a href='#f32' class='c014'><sup>[32]</sup></a> shows meningeal, vascular and parenchymatous -lesions and thus illustrates our definition of the -term <span class='sc'>Diffuse</span> which means precisely meningeal, vascular and -parenchymatous. The meningeal lesions gave rise to two -prominent sets of lesions, first, the marked tabetic lesions of -the spinal cord (due to the spinal root neuritis incidental to -the spinal meningeal inflammation), secondly, the characteristic -asymmetrical and focal atrophy of cranial nerves incidental -to a now largely extinct meningeal process at the base -of the brain. The vascular lesions are responsible for another -important and characteristic factor in the case, namely, the -bilateral pyramidal tract sclerosis; the bilateral cysts of softening -of the corpora striata are characteristic effects of old -syphilitic cerebral thromboses. The parenchymatous disease -in our paradigm is everywhere obvious, less so perhaps in -the cortex itself than elsewhere, although here also evident -in the shape of lesions suggesting an early phase of tissue -atrophy.</p> - -<p class='c007'>The paradigm is of interest in demonstrating what in broad -lines must be taken as an ascending disease proceeding not -only from spinal cord to encephalon but also traceable as -proceeding from lower parts of the spinal cord to upper parts -thereof and from the lower encephalon to the higher structures -of the cerebral cortex itself.</p> - -<p class='c007'>The paradigm insistently calls attention to the advantage -of persistent therapy not only in its display of remarkable -successive recoveries from permanent looking symptoms but -also histologically from the remnants of inflammatory process -to be found in an otherwise almost wholly dismantled nervous -system with extinct lesions.</p> - -<p class='c007'><span class='sc'>Tabetic Neurosyphilis</span><a id='r33' /><a href='#f33' class='c014'><sup>[33]</sup></a> (“tabes dorsalis”), of course, -often proceeds to death without special complications of syphilitic -nature. We have chosen a case, however, to demonstrate -a terminal complication with vascular insult. Incidentally the -case shows another complication inasmuch as the cause of -death was rupture of aortic aneurysm. It is important to -bear in mind these complications in tabes dorsalis which go -<span class='pageno' id='Page_440'>440</span>to prove that the spirochetosis of tabetic neurosyphilis is not -limited to the region of the spinal roots or to the spinal region -in general. Tabetic neurosyphilis is apt to be only a part of a -total picture of neurosyphilis just as neurosyphilis itself is -only a part of the general syphilitic process.</p> - -<p class='c007'>Our case of <span class='sc'>Paretic Neurosyphilis</span><a id='r34' /><a href='#f34' class='c014'><sup>[34]</sup></a> (“general paresis”) -is a characteristic one in duration (three years and three -months). The aortic sclerosis almost constantly found in -neurosyphilis and especially in paretic neurosyphilis is here -also shown. The spinal cord showed lesions which are also -almost always found in paretic neurosyphilis. The characteristic -frontal emphasis of the atrophic and indurative lesions is -shown. There is also a display of gross changes in the pia -mater. The characteristic so-called granular ependymitis or -sanding of the ventricular surface is shown. The case is distinguishable -from the paradigm in not showing the effects of -vascular insults in the shape of cysts of softening. The cerebellar -sclerosis of the case is fairly characteristic of paretic -cases. There is even a suggestion of atrophy in the temporal -region suggesting the so-called Lissauer’s paresis. Clinically -the case belongs in the classical grandiose group of paretics -(“O. K. No. 1 superfine”).</p> - -<p class='c007'><span class='sc'>Vascular Neurosyphilis</span><a id='r35' /><a href='#f35' class='c014'><sup>[35]</sup></a> is illustrated in a fourth autopsied -case. It may be noted that the pia mater in this case is -practically normal. The tissues outside the area of softening -due to the syphilitic thrombosis of nutrient vessels are practically -normal. The case was one of almost complete sensory -aphasia with word-deafness. The clinical picture is accordingly -quite distinct from those of the paradigm (1) and of the -case of general paresis (3) just discussed.</p> - -<p class='c007'><span class='sc'>Juvenile Paresis</span><a id='r36' /><a href='#f36' class='c014'><sup>[36]</sup></a> is illustrated by a case with exceedingly -extensive lesions, largely meningeal and parenchymatous. -The cerebral lesions are atypical since in places they suggest -the tuberous sclerosis of Bourneville. The brain atrophy is -extreme (965 grams) and it is possible that this apparent -brain atrophy was in part hypoplasia, since the spirochetosis -<span class='pageno' id='Page_441'>441</span>of this case was doubtless congenital. However, clinically -the patient was fairly normal up to the age of 18.</p> - -<p class='c007'>A case of so-called <span class='sc'>Syphilitic Extraocular Palsy</span><a id='r37' /><a href='#f37' class='c014'><sup>[37]</sup></a> demonstrates -a characteristic meningeal process more extensive -than the clinical symptoms would have indicated. In fact, -focal clinical nerve palsies are as a rule, if not constantly, -partial phenomena of a far more extensive process of neurosyphilis. -They are far more limited clinically than anatomically -and histologically. It seems at first sight improper -to term them cases of diffuse neurosyphilis in view of their -clinical focality, yet they are best described as partial cases of -diffuse neurosyphilis.</p> - -<p class='c007'>A case of <span class='sc'>Gumma</span><a id='r38' /><a href='#f38' class='c014'><sup>[38]</sup></a> of the left <span class='sc'>Hemisphere</span> is presented -which appears to have led to death in about four years from onset. -This case, like many others, is not an example of purely -focalized syphilitic process inasmuch as cysts of softening -indicating slight vascular insults are present elsewhere (pons). -There is also a degree of leptomeningitis, particularly basal.</p> - -<p class='c007'>Our discussion of the nature and forms of neurosyphilis -is completed by a rare case probably belonging in the so-called -<em>cervical hypertrophic meningitis of Charcot</em> but actually -due to a <span class='sc'>Gumma of the Spinal Meninges</span>.<a id='r39' /><a href='#f39' class='c014'><sup>[39]</sup></a> The importance -of therapeutic optimism is emphasized in this case as in -the paradigm. Theoretically the meningeal inflammation of -neurosyphilis ought to be almost entirely if not entirely -removed by therapy, and these two cases, like several others -in the series, seem to illustrate this possibility.</p> - -<p class='c006'>Neurosyphilis sometimes receives the clinical diagnosis neurasthenia -simply through omission to apply proved diagnostic -methods. An instance is given in which the <span class='sc'>Paretic</span> form -of <span class='sc'>Neurosyphilis</span> (“general paresis”) received the diagnosis -<em>neurasthenia</em><a id='r40' /><a href='#f40' class='c014'><sup>[40]</sup></a> for a period of five years, at any time during -which period it would doubtless have been possible to render -the correct diagnosis and apply treatment.</p> - -<p class='c007'><span class='pageno' id='Page_442'>442</span>Neurosyphilis may imitate not only the psychoneuroses -but also the psychoses themselves. We present a case of an -architect, which looked almost precisely like <em>manic-depressive -psychosis</em><a id='r41' /><a href='#f41' class='c014'><sup>[41]</sup></a> and had a history of attacks, but in which the -positive serum W. R. led (in accordance with hospital rules) -to an examination of the spinal fluid. The spinal fluid tests -proved the case to be one of <span class='sc'>Paretic Neurosyphilis</span>.</p> - -<p class='c007'>However, a positive serum W. R., even when associated -with mental symptoms, and when those mental symptoms -include grandiosity, does not prove the existence of neurosyphilis -either in its paretic or non-paretic form. Our instance -seems to be one of <span class='sc'>Manic-Depressive Psychosis</span>.<a id='r42' /><a href='#f42' class='c014'><sup>[42]</sup></a> -The spinal fluid tests were entirely negative. The course of -the disease was also that of manic-depressive psychosis. In -the absence of positive spinal fluid tests, the diagnosis neurosyphilis -was excluded.</p> - -<p class='c007'>Neurosyphilis and even <span class='sc'>Paretic Neurosyphilis</span> may -result in symptoms that would ordinarily lead to the diagnosis -<em>dementia praecox</em>.<a id='r43' /><a href='#f43' class='c014'><sup>[43]</sup></a></p> - -<p class='c007'>It is important not to rule out neurosyphilis on the ground -of a <em>negative serum</em> W. R. The fluid W. R. may turn out -positive. We present a case (of a salesman)<a id='r44' /><a href='#f44' class='c014'><sup>[44]</sup></a> in which the -serum W. R. was repeatedly negative (even salvarsan did -not act provocatively) yet the spinal fluid W. R. proved -positive. The case was clinically one of classical <span class='sc'>Paretic -Neurosyphilis</span> (“general paresis”). It is a good rule to proceed -to lumbar puncture, even when the serum W. R. is negative, -if there are suspicious symptoms (e.g., speech defect and -<span class='pageno' id='Page_443'>443</span>memory impairment, grandiosity) or signs (e.g., marked reflex -disorder, especially pupillary disorder).</p> - -<p class='c007'><span class='sc'>Diffuse Neurosyphilis</span> was above defined as “meningovasculoparenchymatous.” -This disease is typically associated -with six positive tests (positive serum W. R., positive fluid -W. R., pleocytosis, gold sol reaction, positive globulin reaction -and excess albumin). One or more and frequently -several of these six tests are likely to run mild in diffuse -neurosyphilis; that is to say, these tests are apt to run milder -than the identical tests in paretic neurosyphilis (“general -paresis”). The clinical course of the diffuse, and especially -the meningovascular cases, is likely to be protracted. The -prognosis as to life is good, barring fatal vascular insults. -The illustrative case<a id='r45' /><a href='#f45' class='c014'><sup>[45]</sup></a> was a case with slow course. There -was a series of attacks followed by a paralytic stroke, a finding -highly typical of the diffuse form of neurosyphilis. The -spinal fluid reactions were mild, suitable to the general principle -above stated.</p> - -<p class='c007'>These tests are likely to run stronger, as above stated, -in paretic neurosyphilis (“general paresis”), than in the -diffuse form. In particular, the gold sol reaction is likely -to be shown in what is termed “paretic” form rather than -in what is termed “syphilitic” form. The clinical course of -<span class='sc'>Paretic Neurosyphilis</span> is likely to be brief. A characteristic -case<a id='r46' /><a href='#f46' class='c014'><sup>[46]</sup></a> with very heavy globulin and albumin tests is -presented.</p> - -<p class='c007'><span class='sc'>Taboparetic Neurosyphilis</span><a id='r47' /><a href='#f47' class='c014'><sup>[47]</sup></a> (“taboparesis”) is clinically -a combination of the symptoms of tabetic (“tabes -dorsalis”) and those of paretic neurosyphilis (“general -paresis”). First comes the tabes dorsalis lasting often -for many years. Afterward follows a characteristic general -paresis. The ultimate paretic picture is likely to retain, -however, various characteristics of tabes. The laboratory -tests in the paretic phase of taboparesis are characteristic -<span class='pageno' id='Page_444'>444</span>of general paresis and not of tabes dorsalis. The prognosis -after the paretic phase has arrived is that of general paresis.</p> - -<p class='c007'>The diagnosis of the neurosyphilitic forms would be easy -if these principles were always carried out to the letter. -The important fact is as follows: diffuse (that is, meningovasculoparenchymatous -neurosyphilis) may look like paretic -neurosyphilis (“general paresis”)<a id='r48' /><a href='#f48' class='c014'><sup>[48]</sup></a> at certain periods of the -clinical and laboratory examination. This fact is of obvious -importance. The general prognosis of diffuse neurosyphilis -is regarded as good <i><span lang="la" xml:lang="la">quoad vitam</span></i>. The general prognosis of -paresis is bad. If, however, the differential diagnosis cannot -be rendered at particular phases of a given case, then no safe -prognosis can be offered in the individual case. In particular -no prognosis affecting the administration or non-administration -of modern systematic treatment can or should be -offered in these doubtful phases.</p> - -<p class='c007'>It is not always safe to exclude neurosyphilis even when the -<em>fluid</em> W. R. is <em>negative</em>.<a id='r49' /><a href='#f49' class='c014'><sup>[49]</sup></a> Particularly in vascular neurosyphilis -the fluid W. R. and even all the other laboratory signs -in the spinal fluid may sometimes be negative. A positive -serum W. R. yields the correct pointer to diagnosis. Of -course, also in many cases of vascular neurosyphilis one or -more of the laboratory signs may be suggestive even when -the fluid W. R. is negative. Theoretically there may be -cases in which all the six tests are negative and yet the diagnosis -neurosyphilis be the correct one.</p> - -<p class='c007'>A clinically important sign in neurosyphilis is the so-called -<em>seizures</em>. These occur both in <span class='sc'>Diffuse Non-paretic Neurosyphilis</span><a id='r50' /><a href='#f50' class='c014'><sup>[50]</sup></a> -and in <span class='sc'>Paretic Neurosyphilis</span>.<a id='r51' /><a href='#f51' class='c014'><sup>[51]</sup></a></p> - -<p class='c007'><span class='pageno' id='Page_445'>445</span><em>Aphasia</em> is likewise a symptom in both these forms of -neurosyphilis, namely, in the <span class='sc'>Diffuse</span> non-paretic<a id='r52' /><a href='#f52' class='c014'><sup>[52]</sup></a> and in -the <span class='sc'>Paretic</span> form.<a id='r53' /><a href='#f53' class='c014'><sup>[53]</sup></a></p> - -<p class='c007'>The literature contains reference not only to seizures and -aphasia as characteristically paretic but also to <em>remissions</em>. -Remissions like seizures and aphasia are found in both the -<span class='sc'>Paretic</span><a id='r54' /><a href='#f54' class='c014'><sup>[54]</sup></a> and <span class='sc'>Non-Paretic</span> forms of neurosyphilis.<a id='r55' /><a href='#f55' class='c014'><sup>[55]</sup></a> They -have important bearings on prognosis in all forms of neurosyphilis -and are of especial significance in the evaluation of -treatment. (Remissions coincident with apparent cure.)</p> - -<p class='c007'>So far we have been dealing with cases of neurosyphilis -in which there was no doubt of the existence of mental -symptoms. There are cases, however, in which although the -laboratory signs of neurosyphilis exist, proving beyond doubt -the existence of a chronic inflammatory reaction and allied -pathological conditions in the cerebrospinal axis, there are no -mental symptoms of neurosyphilis. We have called some of -these cases <span class='sc'>Paresis Sine Paresi</span><a id='r56' /><a href='#f56' class='c014'><sup>[56]</sup></a> and present examples.</p> - -<p class='c007'>To illustrate complications we give a case of <span class='sc'>Paretic Neurosyphilis</span> -with autopsy in which there were ante mortem -signs of <span class='sc'>Herpes Zoster</span><a id='r57' /><a href='#f57' class='c014'><sup>[57]</sup></a> or, at all events, of a skin eruption -limited to the area of a thoracic nerve.</p> - -<p class='c007'>A case of <span class='sc'>Gumma</span> of the brain<a id='r58' /><a href='#f58' class='c014'><sup>[58]</sup></a> in which decompression -was warranted and performed is presented. The fluid W. R., -as in many such cases, was negative; serum positive.</p> - -<p class='c007'>A case of <span class='sc'>Cranial Neurosyphilis</span> (extraocular palsy<a id='r59' /><a href='#f59' class='c014'><sup>[59]</sup></a> -without mental symptoms) showed a positive Wassermann -serum test and a negative spinal fluid.</p> - -<p class='c007'><span class='pageno' id='Page_446'>446</span>The laboratory reactions in <span class='sc'>Tabetic Neurosyphilis</span><a id='r60' /><a href='#f60' class='c014'><sup>[60]</sup></a> -(“tabes dorsalis”) run somewhat like those of diffuse non-paretic -neurosyphilis and are accordingly milder than those -of paretic neurosyphilis. The fluid W. R. and the gold sol -reaction in particular are apt to run mild. The clinical course -of tabes dorsalis is well known to be protracted and the prognosis -<i><span lang="la" xml:lang="la">quoad vitam</span></i> is good except that we must always bear in -mind the possibility of vascular insults and complications -of a syphilitic origin in the rest of the body.</p> - -<p class='c007'>It is important to remember that <span class='sc'>Tabetic Neurosyphilis</span> -is often quite atypical<a id='r61' /><a href='#f61' class='c014'><sup>[61]</sup></a> clinically and may even show no -single symptom warranting the old clinical name locomotor -ataxia.</p> - -<p class='c007'>There are even cases in which the name tabes dorsalis is -not warranted in view of the fact that the lesions are not -low in the cord but are higher up (<span class='sc'>Tabes Cervicalis</span><a id='r62' /><a href='#f62' class='c014'><sup>[62]</sup></a>).</p> - -<p class='c007'>A rare form of neurosyphilis is <span class='sc'>Erb’s Syphilitic Spastic -Paraplegia</span><a id='r63' /><a href='#f63' class='c014'><sup>[63]</sup></a> against which one needs to consider a number -of non-syphilitic spinal cord diseases. Our case showed a -weakly positive serum W. R., a negative fluid W. R., and the -other tests of the spinal fluid were moderately positive.</p> - -<p class='c007'><span class='sc'>Syphilitic Muscular Atrophy</span><a id='r64' /><a href='#f64' class='c014'><sup>[64]</sup></a> is classified by Head and -Fearnsides both in their meningovascular group and in their -group of the so-called syphilis centralis. Our case affecting -in large part the small muscles of the hands in a teamster, -may be due either to spinal parenchymal lesions or to root -neuritis or to both.</p> - -<p class='c007'>It is a little extraordinary and very important that the -<em>laboratory signs</em> are apt to be positive even in the <span class='sc'>Secondary</span> -period of <span class='sc'>Syphilis</span>. Perhaps a third of all cases of syphilis in -the secondaries would, if tested, yield positives precisely -like those of full-blown paretic or diffuse neurosyphilis. -<span class='pageno' id='Page_447'>447</span>Strangely enough, these signs may occur without clinical -symptoms. The illustrative case,<a id='r65' /><a href='#f65' class='c014'><sup>[65]</sup></a> a mechanic, yielded various -mental symptoms. The cases of secondary syphilis with -laboratory signs of neurosyphilis but without clinical symptoms -are of the greatest theoretical importance in relation -to the problem above mentioned of <em>paresis sine paresi</em>. It -may well be inquired whether in some instances the neurosyphilis -of the secondaries does not persist until the exhibition -of mental or physical symptoms of neurosyphilis -years later. It must be remembered that this conception is -hardly more than a hypothesis at the present time. That -such signs of chronic inflammation could exist without -symptoms is not so surprising when one thinks of the startling -immediate improvement seen after treatment or even in -remissions without treatment. One is reminded of the crisis -in pneumonia wherein clinical improvement takes place entirely -independent of the mechanical conditions in the lung -which just after the crisis remain as suppurative as before.</p> - -<p class='c007'>The diagnosis of <span class='sc'>Juvenile Neurosyphilis</span> is made upon -the same lines as that of neurosyphilis in the adult. We present -two cases, one with optic atrophy<a id='r66' /><a href='#f66' class='c014'><sup>[66]</sup></a> and the other with signs -of congenital syphilis antedating the symptoms of paresis.<a id='r67' /><a href='#f67' class='c014'><sup>[67]</sup></a></p> - -<p class='c007'>Congenital syphilis is also apparently capable of producing -a simple form of <span class='sc'>Feeblemindedness</span>,<a id='r68' /><a href='#f68' class='c014'><sup>[68]</sup></a> that is to say, a form -of disease non-paretic, non-tabetic, and without special tendency -to vascular insults.</p> - -<p class='c007'>We present a case of <span class='sc'>Juvenile Tabetic Neurosyphilis</span> -(“juvenile tabes”).<a id='r69' /><a href='#f69' class='c014'><sup>[69]</sup></a> The tests were all positive.</p> - -<p class='c007'>The line of separation between typical and atypical cases -of neurosyphilis is vague and indistinct and some of the -<span class='pageno' id='Page_448'>448</span>cases classified by us amongst puzzles perhaps belong under -systematic diagnosis and vice versa. The section on PUZZLES -AND ERRORS in the diagnosis of neurosyphilis is -introduced by six cases of error in the diagnosis of the paretic -form of neurosyphilis.<a id='r70' /><a href='#f70' class='c014'><sup>[70]</sup></a> These errors were made known by -autopsy. Aside from the sixth case, whose etiology must remain -in doubt and which was a unique case of <span class='sc'>Perivascular -Gliosis</span>, there is ground for the belief that the other five cases -in this Danvers Hospital study of diagnostic errors were perhaps -actually syphilitic though not of the paretic form of -neurosyphilis. At all events, the brain tissues in these cases -failed to show the plasma cell deposits which are characteristic -in the sheaths of the intracortical vessels in paretic neurosyphilis.</p> - -<p class='c007'>A case illustrates the complication of <span class='sc'>Tabes</span> by <em>arteriosclerotic -symptoms</em>, in which case the arteriosclerosis may -naturally have been of syphilitic origin. Two cases especially -illustrate the possibility of confusing the ataxia of general -paresis with <span class='sc'>Cerebellar Ataxia</span>. These cases showed -lesions of the cerebellar structures, notably of the dentate -nucleus. No one can read these cases or any of the autopsied -cases in our series, without perceiving how fundamental -and even critical is the demand for autopsies in fatal cases -of neurosyphilis. The practitioner who can secure an autopsy -in a fatal case of neurosyphilis and have the tissues worked -up by approved neuropathological methods is almost bound -to add his bit to neurological theory. Even cases of classical -tabes dorsalis are often signally important to the theorist on -account of the relations of the neural to the non-neural complications.</p> - -<p class='c007'>We then proceed to a group of cases without special order -in which a variety of diagnostic questions arose.</p> - -<p class='c007'>A case of questionable neurosyphilis in the secondary stage -of syphilis brings up the problems of syphilitic <em>neurasthenia</em>.<a id='r71' /><a href='#f71' class='c014'><sup>[71]</sup></a></p> - -<p class='c007'><span class='pageno' id='Page_449'>449</span>Syphilis may act as <i><span lang="fr" xml:lang="fr">agent provocateur</span></i> of <span class='sc'>Hysteria</span> as -Charcot insisted.<a id='r72' /><a href='#f72' class='c014'><sup>[72]</sup></a></p> - -<p class='c007'>A case illustrative of difficulties in diagnosis between neurosyphilis -and manic-depressive psychosis follows.<a id='r73' /><a href='#f73' class='c014'><sup>[73]</sup></a></p> - -<p class='c007'>A case for diagnosis is given which shows that errors in -the diagnosis of neurosyphilis are entirely possible even when -abundant clinical and laboratory data are available. A case -with a weakly positive Wassermann reaction in the spinal -fluid finally turned out to be one of <span class='sc'>Brain Tumor</span>.<a id='r74' /><a href='#f74' class='c014'><sup>[74]</sup></a></p> - -<p class='c007'>Some questions as to the diagnosis of <span class='sc'>Neurosyphilis</span> <em>versus -Idiopathic Epilepsy</em> are brought up by a case in which phenomena -of paresis seemed to have occurred very early, about -two years after the initial syphilitic infection.<a id='r75' /><a href='#f75' class='c014'><sup>[75]</sup></a></p> - -<p class='c007'>A case of <span class='sc'>Paretic Neurosyphilis</span> is offered in which -<em>hemiplegia</em> and <em>hemitremor</em> strongly suggested <em>vascular</em> lesions; -but the autopsy showed no coarse lesions and merely confirmed -the diagnosis paresis microscopically.<a id='r76' /><a href='#f76' class='c014'><sup>[76]</sup></a></p> - -<p class='c007'>An autopsied case of <span class='sc'>Paretic Neurosyphilis</span> is given, in -which the pupils persisted in reacting normally. Herpes -zoster-like lesions in life yielded no special signs at autopsy -(all root-ganglia looked alike above and below zone of -“shingles.”)<a id='r77' /><a href='#f77' class='c014'><sup>[77]</sup></a></p> - -<p class='c007'>An example of <span class='sc'>Neurosyphilis</span>, probably <span class='sc'>Paretic</span>, yielded -symptoms highly suggestive of <em>manic-depressive psychosis</em>.<a id='r78' /><a href='#f78' class='c014'><sup>[78]</sup></a> -An interesting feature in this case was the birth of a healthy -child nine months after the onset of the psychotic attack.</p> - -<p class='c007'>An example of <em>exophthalmic goitre</em><a id='r79' /><a href='#f79' class='c014'><sup>[79]</sup></a> following the acquisition -of <span class='sc'>Syphilis</span> showed at autopsy a heavy scarring of -the optic thalamus and unilaterally atrophic process in the -cerebral cortex.</p> - -<p class='c007'><span class='pageno' id='Page_450'>450</span>We come to some questions concerning the <em>Argyll-Robertson -pupil</em>. It is agreed on all hands that the Argyll-Robertson -pupil is characteristic of the paretic and tabetic forms, -but the sign occurs also in other neurosyphilitic conditions;<a id='r80' /><a href='#f80' class='c014'><sup>[80]</sup></a> -in fact the sign does not necessarily indicate neurosyphilis -as an instance of <span class='sc'>Pineal Tumor</span> demonstrates.<a id='r81' /><a href='#f81' class='c014'><sup>[81]</sup></a></p> - -<p class='c007'>The question raised above as to the possibility that neurosyphilis -may exist in the absence of positive findings in the -spinal fluid is illustrated in a man, a mechanic, who claimed -syphilitic infection and showed an <em>Argyll-Robertson pupil</em> -on one side.<a id='r82' /><a href='#f82' class='c014'><sup>[82]</sup></a> The serum W. R. was positive; the <em>fluid tests</em> -were <em>negative</em>.</p> - -<p class='c007'>An extraordinary case is given in some detail in which -<span class='sc'>Neurosyphilis</span> in the form termed <span class='sc'>Disseminated Encephalitis</span><a id='r83' /><a href='#f83' class='c014'><sup>[83]</sup></a> -proved fatal within seven months of the initial infection.</p> - -<p class='c007'>We have frequently mentioned the classical assumption -that paretic neurosyphilis (“general paresis”) is a fatal disease. -Some have suggested that there is another form clinically -almost identical with general paresis except that it pursues -a long course and the suggestion has been made that these -cases be termed <em>pseudoparesis</em>.<a id='r84' /><a href='#f84' class='c014'><sup>[84]</sup></a> We are of the opinion that -this term should be dropped and advocate the use of the -word pseudoparesis only for non-syphilitic disease looking -like paresis, such as alcoholic pseudoparesis and the like.</p> - -<p class='c007'>The question whether there is a form of mental disease -<span class='sc'>Syphilitic Paranoia</span><a id='r85' /><a href='#f85' class='c014'><sup>[85]</sup></a> is raised by a case with auditory hallucinations, -ideas of persecution and attacks of excitement. -The diagnosis of alcoholic hallucinosis was actually made although -there is no proof that the patient ever drank alcohol.</p> - -<p class='c007'>Alcohol may cause symptoms identical with those of -<span class='pageno' id='Page_451'>451</span>paretic neurosyphilis, including seizures, Argyll-Robertson -pupils, speech defect and mental symptoms. The differentiation -is readily made by the negative laboratory findings. -An illustration is given in our case of the alcoholic teamster. -Cases such as this bear the name <span class='sc'>Alcoholic Pseudoparesis</span>.<a id='r86' /><a href='#f86' class='c014'><sup>[86]</sup></a></p> - -<p class='c007'>However, when the clinical picture is the same as in the -case of our teamster, the alcohol may only be a complicating -factor in neurosyphilis, as shown by our next case of the -<em>alcoholic</em> steamfitter who in fact was shown to have <span class='sc'>Neurosyphilis</span>.<a id='r87' /><a href='#f87' class='c014'><sup>[87]</sup></a></p> - -<p class='c007'>Sometimes cases of apparently frank <em>alcoholism</em>, even with -apparently characteristic delirium tremens and neuritis, prove -to be essentially neurosyphilitic.<a id='r88' /><a href='#f88' class='c014'><sup>[88]</sup></a> On the other hand, true -combinations of <span class='sc'>Alcoholism</span> and <span class='sc'>Neurosyphilis</span> occur which -it would be proper to classify under either heading and in which -therapy must take serious account of both conditions.<a id='r89' /><a href='#f89' class='c014'><sup>[89]</sup></a></p> - -<p class='c007'>As above stated, we elect to use the term pseudoparesis only -for non-syphilitic cases. There are other forms of pseudoparesis -than alcoholic pseudoparesis. The question of <em>Diabetic -Pseudoparesis</em> is raised by an exceedingly complicated -case of which our best interpretation is that the patient, a -proved syphilitic (with syphilitic osteomyelitis (?)), a huge -doorkeeper, was perhaps suffering from an old <span class='sc'>Syphilitic</span> -scarring of the <span class='sc'>Pituitary</span> body.<a id='r90' /><a href='#f90' class='c014'><sup>[90]</sup></a> Neither this case nor a -second case, one of <span class='sc'>Paretic Neurosyphilis</span> with <em>glycosuria</em> -is actually entitled to the diagnosis diabetic pseudoparesis. -The second case of paretic neurosyphilis with glycosuria -brings up some unanswerable questions as to the pancreatic -or basal meningitic or other origin for the glycosuria.<a id='r91' /><a href='#f91' class='c014'><sup>[91]</sup></a></p> - -<p class='c007'><em>Isolated symptoms</em> are often presented by neurosyphilitics -(e.g., hemianopsia);<a id='r92' /><a href='#f92' class='c014'><sup>[92]</sup></a> but we tend to regard these cases as due -to focal lesions that are merely part and parcel of <span class='sc'>Diffuse -Lesions</span>.</p> - -<p class='c007'><span class='pageno' id='Page_452'>452</span>A neurosyphilitic case (a steward) with the rather unusual -complication (for our northern region) of severe <span class='sc'>Malaria</span> -producing cerebral thrombosis is reported.<a id='r93' /><a href='#f93' class='c014'><sup>[93]</sup></a></p> - -<p class='c007'>The diagnosis <em>Dementia Praecox</em><a id='r94' /><a href='#f94' class='c014'><sup>[94]</sup></a> was actually made in -the case of a young school-teacher in whom the laboratory -findings proved conclusively that the condition was one of -<span class='sc'>Neurosyphilis</span>. The gold sol reaction in this case was mild. -The chief lesion at autopsy was a fresh looking, gelatinous -pial exudate over the spinal cord which turned out to contain -an almost pure display of very numerous plasma cells.</p> - -<p class='c007'>The question of <span class='sc'>Lues Maligna</span><a id='r95' /><a href='#f95' class='c014'><sup>[95]</sup></a> is brought up in a rectifier -of spirits in whom the characteristic tremendous destruction -of tissue, toxemia and failure to react to antisyphilitic treatment -were illustrated. Moreover, this case had a trauma -(cautery) to the tonsil, as in other cases of lues maligna.</p> - -<p class='c007'>A case somewhat suggestive of <em>brain tumor</em>, of <em>neurosyphilis</em> -and of <em>multiple sclerosis</em><a id='r96' /><a href='#f96' class='c014'><sup>[96]</sup></a> turned out to be <span class='sc'>Multiple -Sclerosis</span> (the fluid showed a pleocytosis and a moderate -amount of globulin with a paretic type of gold sol reaction).</p> - -<p class='c007'>As a foil to this case that we regard as multiple sclerosis, -we present a second case with nystagmus, optic atrophy and -spasticity in which the suspicion of <em>multiple sclerosis</em> might -well be raised but which the tests demonstrated to be -<span class='sc'>Neurosyphilitic</span>.<a id='r97' /><a href='#f97' class='c014'><sup>[97]</sup></a></p> - -<p class='c007'>An even stranger imitation of well-defined non-syphilitic -entities was presented by a case apparently of <em>Huntington’s -chorea</em><a id='r98' /><a href='#f98' class='c014'><sup>[98]</sup></a> (except for absence of the hereditary taint) which -case, however, proved to the surprise of all diagnosticians to -be one of <span class='sc'>Neurosyphilis</span>.</p> - -<p class='c007'>Frequent errors of diagnosis must occur in the field of the -senile psychoses. We present a case that would at first -blush warrant the diagnosis of <em>senile arteriosclerotic psychosis</em><a id='r99' /><a href='#f99' class='c014'><sup>[99]</sup></a> -<span class='pageno' id='Page_453'>453</span>in a sea captain of 75 years (wife dead 15 years before of -general paresis) who turned out to be a characteristic case -from the laboratory standpoint of <span class='sc'>Neurosyphilis</span>.</p> - -<p class='c007'>The Protean nature of the symptomatology of neurosyphilis -is sufficiently established. Still, a case that might fit into textbooks -concerning <span class='sc'>Dissociation of Personality</span><a id='r100' /><a href='#f100' class='c014'><sup>[100]</sup></a> is certainly -a clinical oddity, as illustrated by a fugacious musician.</p> - -<p class='c007'>A case with strong suspicions of <em>neurosyphilis</em> of <em>tabetic</em> -type turned out to be more probably one of neural complications -in <span class='sc'>Pernicious Anemia</span>.<a id='r101' /><a href='#f101' class='c014'><sup>[101]</sup></a></p> - -<p class='c007'><span class='sc'>Neurosyphilis in Juveniles</span> presents puzzling conditions.</p> - -<p class='c007'>One case was marked clinically by <em>attacks of excitement</em>.<a id='r102' /><a href='#f102' class='c014'><sup>[102]</sup></a> -It is impossible to place this case among the main groups of -juvenile neurosyphilis.</p> - -<p class='c007'>Another case of <span class='sc'>Feeblemindedness</span>,<a id='r103' /><a href='#f103' class='c014'><sup>[103]</sup></a> also <span class='sc'>Neurosyphilitic</span> -in origin, presented physical symptoms and laboratory -signs of paretic neurosyphilis; yet this case had been -considered one of <em>simple feeblemindedness</em>.</p> - -<p class='c007'>A case apparently of <span class='sc'>Juvenile Paretic Neurosyphilis</span> in -a 15 year old boy presented the rather unusual complication -of shocks with quadriplegia,<a id='r104' /><a href='#f104' class='c014'><sup>[104]</sup></a> a <em>vascular complication</em> not -usually expected in the paretic type of neurosyphilis in adults.</p> - -<p class='c007'>Epileptic phenomena<a id='r105' /><a href='#f105' class='c014'><sup>[105]</sup></a> are rare as the effect of <span class='sc'>Juvenile -Neurosyphilis</span>, but occur as demonstrated in a case which -slipshod methods of diagnosis might well have regarded as -one of <em>idiopathic epilepsy</em>.</p> - -<p class='c007'>A case of <span class='sc'>Juvenile Paretic Neurosyphilis</span> with the -complication of <span class='sc'>Addison’s Disease</span><a id='r106' /><a href='#f106' class='c014'><sup>[106]</sup></a> is given (autopsy -confirmation).</p> - -<p class='c007'>The puzzle in diagnosis offered by syphilis in the secondary -stage<a id='r107' /><a href='#f107' class='c014'><sup>[107]</sup></a> is illustrated by a case which showed the characteristic -<span class='sc'>Neurosyphilitic</span> complications of the <span class='sc'>Secondary Stage</span> of -<span class='pageno' id='Page_454'>454</span>syphilis. This patient may well have been a moron at the outset -and exhibited some reactions (refusal to talk) explicable on -the basis of feeblemindedness. She was a neurosyphilitic only -in the sense of the neural complication that we find in the -secondary stage of syphilis. As stated above, we do not yet -know what the fate of these neural complications of secondary -syphilis is to be. The frequency of this finding in secondary -syphilis is probably too great to warrant the hypothesis that -it must always go on to a chronic neurosyphilis; but we -certainly are warranted in regarding these cases as potential -chronic neurosyphilitics.</p> - -<p class='c007'>A case of <span class='sc'>Taboparetic Neurosyphilis</span> in which the heavy -exudate characteristic of paresis became a soil for a growth -of the typhoid bacillus is presented with autopsy.<a id='r108' /><a href='#f108' class='c014'><sup>[108]</sup></a> This -fatality with <span class='sc'>Typhoid Meningitis</span> is merely a concrete example -of the many complications which syphilitics and especially -neurosyphilitics have to sustain.</p> - -<p class='c006'>The case series then goes on to illustrate, though quite -inadequately, a variety of MEDICOLEGAL AND SOCIAL -complications of neurosyphilis. It is well known that many -social complications with grave moral, economic and even -political difficulties occur.</p> - -<p class='c007'>Our series starts with a “public character”<a id='r109' /><a href='#f109' class='c014'><sup>[109]</sup></a> whose eloquence -and reformatory efforts led to a considerable notoriety. -The autopsy in this case showed singularly few lesions -despite the fact that the case was microscopically one of -wholly characteristic <span class='sc'>Paretic Neurosyphilis</span>. The question -might arise how far we are entitled to correlate the reformatory -efforts of this always eccentric character with syphilis. -The man himself a physician, was aware of the doubt which his -Argyll-Robertson pupils threw upon his medical situation. -He explained them on the basis of an old smallpox! We are -inclined to think that the whole of this man’s life, from his -giving up of medical practice to live as a kind of literary and -political hack, was due to subtle changes of neurosyphilitic -<span class='pageno' id='Page_455'>455</span>origin. The fact that there was a certain delinquent streak -in the man is not inconsistent with this idea. Interestingly -enough, a fall on the ice in the man’s 61st year actually -started up the fatal process, a condition of affairs amply -illustrated in cases of neurosyphilis, brought out by trauma -that come to the attention of the Industrial Accident Board -in connection with claims for compensation.</p> - -<p class='c007'>A case of sudden <em>grandiosity</em><a id='r110' /><a href='#f110' class='c014'><sup>[110]</sup></a> illustrates an episode of -<span class='sc'>Neurosyphilitic</span> origin. Such a person might well be regarded -by the lay newspaper reader as a crank or a grafter but -the neurosyphilitic possibility should always be entertained -in cases of this order.</p> - -<p class='c007'>As against the social difficulties that look in the direction -of the classical paretic grandeur, we present a case of apparent -<em>suicidal attempt</em> by gas, which attempt was followed by a -period of amnesia that, taking into account the laboratory -findings, was probably <span class='sc'>Neurosyphilitic</span>.<a id='r111' /><a href='#f111' class='c014'><sup>[111]</sup></a></p> - -<p class='c007'>Vistas of extraordinary interest are opened out by studies -of the relation of neurosyphilis to <em>delinquency</em>. The case -of the psychopathic reformer (Case 83) above mentioned was -one in which the delinquency may possibly have been related to -acquired syphilis. We present also a case of juvenile neurosyphilis, -a young man of reform school type<a id='r112' /><a href='#f112' class='c014'><sup>[112]</sup></a> in which <span class='sc'>Juvenile -Paretic Neurosyphilis</span> was established. This patient, -in fact, deteriorated very rapidly to a condition of considerable -dementia a few months after the diagnosis was established.</p> - -<p class='c007'>A striking case of so-called <span class='sc'>Defective Delinquency</span> is -presented, an alcoholic prostitute of the reformatory group.<a id='r113' /><a href='#f113' class='c014'><sup>[113]</sup></a> -The <span class='sc'>Neurosyphilis</span> in this case was a complication rather -than an original factor in the delinquency.</p> - -<p class='c007'>One case of <span class='sc'>Paresis Sine Paresi</span> was that of an habitual -criminal<a id='r114' /><a href='#f114' class='c014'><sup>[114]</sup></a> and forger who, without showing mental or physical -symptoms of neurosyphilis, yielded the laboratory signs of -paretic neurosyphilis. Again, as in the case of the prostitute -<span class='pageno' id='Page_456'>456</span>just mentioned, the <span class='sc'>Criminality</span><a id='r115' /><a href='#f115' class='c014'><sup>[115]</sup></a><a id='t456'></a> seems to have antedated -the neurosyphilis and even to have been hereditary.</p> - -<p class='c007'>By way of introducing the next group of Industrial Accident -Board cases, we present a case of <span class='sc'>Juvenile Paresis</span> -with initial <span class='sc'>Traum</span>.</p> - -<p class='c007'>The Industrial Board group is of note in that the signs of -the traumatic form<a id='r116' /><a href='#f116' class='c014'><sup>[116]</sup></a> of paretic neurosyphilis do not occur -immediately upon the accident. Some time elapses in which -the physical, chemical or parasitological changes have time -to work themselves out in the injured tissues. Many hypotheses -may be raised as to the reason why a trauma lights -up a syphilitic process. Of course, <b>false claims</b><a id='r117' /><a href='#f117' class='c014'><sup>[117]</sup></a> <b>may be -made for compensation by neurosyphilitics</b> in whom the -symptoms were already in existence before the accident and -in whom they may not even be markedly exacerbated by the -accident. The false claimants can probably not readily -frame a story which the expert psychiatrist cannot discredit -if he is allowed to perform laboratory tests and give the patient -the benefit of thorough examination. However, some cases -of established <span class='sc'>Paretic Neurosyphilis</span> are perhaps truly -subject to <em>exacerbations</em><a id='r118' /><a href='#f118' class='c014'><sup>[118]</sup></a> of the clinical process and it may -well be held that such exacerbations warrant partial compensation.</p> - -<p class='c007'>The fact that a trauma may light up a syphilitic process -is illustrated in a case that came to the Psychopathic Hospital, -in which a <span class='sc'>Syphilitic Lesion</span> developed in the skull <span class='sc'>at the -Site of Skull Injury</span>.<a id='r119' /><a href='#f119' class='c014'><sup>[119]</sup></a></p> - -<p class='c007'>A case of <span class='sc'>Occupation-neurosis</span><a id='r120' /><a href='#f120' class='c014'><sup>[120]</sup></a> that might be interpreted -as a <em>syphilitic neuritis</em> is presented. The case is still in doubt -as to its scientific evaluation.</p> - -<p class='c007'>The workmen’s compensation group of syphilitic cases is -of extraordinary general interest since it indicates that -<span class='pageno' id='Page_457'>457</span>employers may well be on the lookout not to employ known -syphilitics unless fortified by special insurance arrangements. -Whether in future employers may desire <b>to employ only W. R. -negative workmen</b> is one of the highly complicated questions -<i><span lang="la" xml:lang="la">re</span></i> workmen’s compensation and health insurance.</p> - -<p class='c007'>But the problems of neurosyphilis are not merely medicolegal -and broadly public or social. The most appealing difficulties -lodge within the bosom of the family. Now and -then a case of <span class='sc'>Incompatibility of Temperament</span>, perhaps -complicated by <em>alcoholism</em>, occurs which tests prove to be -<span class='sc'>Neurosyphilitic</span>.<a id='r121' /><a href='#f121' class='c014'><sup>[121]</sup></a></p> - -<p class='c007'>Special attention should be drawn to a certain <span class='sc'>Neurosyphilitic -Family</span><a id='r122' /><a href='#f122' class='c014'><sup>[122]</sup></a> in which both parents and five children -showed a variety of syphilitic diseases, including syphilis -without apparent neural complications, paretic neurosyphilis, -juvenile paresis, aortic aneurysm, achondroplasia and caries -of the spine, and an as yet indefinite neurosis. There was a -sixth child that died shortly after birth, as well as three stillborn.</p> - -<p class='c007'>One <b>cannot conclude</b> from the normal<a id='r123' /><a href='#f123' class='c014'><sup>[123]</sup></a> look of a neurosyphilitic’s -family <b>that the normal-looking members are not -syphilitic</b>, as illustrated by the family of our draughtsman.</p> - -<p class='c007'>The most <b>intricate social complications</b> may arise. We -present a case of a syphilitic man (a well-to-do merchant) -who was apparently being goaded into a second marriage<a id='r124' /><a href='#f124' class='c014'><sup>[124]</sup></a> -because he was continually being charged with having caused -his first wife’s death. This he had actually done in a certain -sense because his wife had died of general paresis, having -contracted syphilis from him.</p> - -<p class='c006'>In the fifth section on THERAPY, we have attempted to -outline some of the principles and problems that arise in the -treatment of neurosyphilis. Enough has probably been said -<span class='pageno' id='Page_458'>458</span>concerning the attitude of optimism or pessimistic nihilism -that may be adopted toward the whole subject. It must be -borne in mind, however, that a great deal of the work on -treatment of neurosyphilis is still in the experimental stage. -As a rule, each case must be considered separately and individually -and the prognosis can be made satisfactorily only -after treatment has been given. This section contains a -group of cases that have been treated rather intensively and -the results of this treatment are indicated. The section is -introduced by <em>five untreated cases</em>, the brains and cords of -which have been studied post mortem. These illustrate the -pathological conditions which we have to meet, and from -these examples we can draw the theoretical conclusion that -some cases are beyond the aid of therapy on account of the -brain destruction. Others, in which the symptomatology -bespeaks just as grave a situation, turn out on autopsy to have -very little actual damage to the brain tissues and therefore -should theoretically at any rate be amenable to antisyphilitic -therapy.</p> - -<p class='c007'>In order to get any adequate conception of the possibilities -of therapeutic results in cases of neurosyphilis, one must -consider the pathological changes that occur and how far -these changes are reparable. In cases in which the destruction -of tissue is marked, it is, of course, out of the question to -expect to get any marked clinical improvement. A case of -spastic hemiplegia<a id='r125' /><a href='#f125' class='c014'><sup>[125]</sup></a> in paretic neurosyphilis is given with the -autopsy findings as an illustration of irreparable damage -that may occur to the parenchymatous structure, thus precluding -any chance of functional recovery.</p> - -<p class='c007'>On the other hand, there is a group of cases in which the -symptoms may be exceedingly severe and yet the actual destruction -of tissue be almost nil. This point is illustrated by -a case<a id='r126' /><a href='#f126' class='c014'><sup>[126]</sup></a> in which <em>total duration of symptoms</em> terminating in -death was <em>only 22 days</em>. At autopsy there was very little in -the way of macroscopical lesions, and microscopically there -was no marked evidence of destruction in the parenchymatous -<span class='pageno' id='Page_459'>459</span>tissue. The lesions were represented chiefly by perivascular -infiltration. According to all our modern ideas, this type of -reaction is resolvable under antisyphilitic treatment. Though -this case was one of very short duration, similar pathological -pictures may be obtained in cases of considerably longer -standing. It is also of great importance to remember that -symptomatically such a case may be in no way distinguished -from a case with marked atrophy.</p> - -<p class='c007'>Another autopsied case is given which shows an exceedingly -<b>marked meningitis</b>.<a id='r127' /><a href='#f127' class='c014'><sup>[127]</sup></a> The meningitic processes according to -the literature and experience react very readily to antisyphilitic -treatment in the form either of mercury and iodid or in -combination with salvarsan. The lesion here present would -probably have improved had intensive treatment been given. -Clinically the diagnosis of general paresis was made and, as -has been the rule in the past, treatment was not given on -the ground that it had no value in paresis. While this is an -extreme case of meningitis, it is to be remembered that the -vast majority of cases of paretic neurosyphilis show some degree -of meningitis. Just as in the marked meningitis of the -diffuse neurosyphilis, so with the meningitis of the paretic -form, improvement is expected under treatment. As a part -or even the whole of the symptomatology in a given case may -be due to this meningitic process, we have reason occasionally -to expect marked improvement as the result of antisyphilitic -treatment.</p> - -<p class='c007'>As a contrast to this case with marked meningitis, another -case of <b>marked atrophy</b><a id='r128' /><a href='#f128' class='c014'><sup>[128]</sup></a> is given. Here the atrophy was very -perceptible on macroscopical examination and the mere view -of the brain at once indicated that in such a case important -results from treatment were not to be expected.</p> - -<p class='c007'>The <b>topographical variation</b> of the lesions in neurosyphilis -must be remembered when treatment is to be instituted. -Thus very marked lesions may exist in portions of the brain -which do not give any very definite localizing symptoms. As -a result, one may be led to believe from clinical evidence -that the case is a very mild one though the lesions may -<span class='pageno' id='Page_460'>460</span>really be very extensive. The topographical distribution -must, therefore, be taken into consideration in trying to -estimate the damage done. This point of topographical distribution -of the lesions is illustrated by a case.<a id='r129' /><a href='#f129' class='c014'><sup>[129]</sup></a></p> - -<p class='c007'>It has been generally recognized that <b>clinical improvement</b>, -if not cure, may be <b>readily obtained in the group of diffuse -neurosyphilis</b>, i.e., so-called cerebral and cerebrospinal forms -of syphilis. These are cases in which the parenchyma is very -slightly, if at all, affected and in which the lesion is chiefly -in the meninges and blood vessels, irritative rather than -degenerative. A case<a id='r130' /><a href='#f130' class='c014'><sup>[130]</sup></a> is given to illustrate this point. In -our experience systematic intravenous salvarsan therapy -associated with mercury and iodid gives remarkably good -results in the vast majority of this group of cases.</p> - -<p class='c007'>It is generally conceded that antisyphilitic treatment, -particularly salvarsan, has a very satisfactory result applied -to diffuse neurosyphilis. But the same good results may be -obtained in cases which are not so typically of the diffuse -type. An illustration is given in the case of a machinist in -which the diagnosis was in doubt between paretic, tabetic or -diffuse neurosyphilis.<a id='r131' /><a href='#f131' class='c014'><sup>[131]</sup></a> The result of treatment was as satisfactory -as could be expected in any type of neurosyphilis -and this in a case of several years’ duration with Argyll-Robertson -pupils.</p> - -<p class='c007'>As a rule, the Argyll-Robertson pupil is taken as a grave -omen for treatment, an idea based upon a conception that -the Argyll-Robertson pupil so frequently represents the old -so-called “parasyphilitic” cases, which, in the past were -taught as being incapable of improvement by the ordinary -antisyphilitic methods.</p> - -<p class='c007'>A second case<a id='r132' /><a href='#f132' class='c014'><sup>[132]</sup></a> with Argyll-Robertson pupil shows again -that the <b>prognosis may be very good despite the Argyll-Robertson -sign</b>.</p> - -<p class='c007'><span class='pageno' id='Page_461'>461</span>But even in the diffuse neurosyphilis, the symptomatic results -of treatment may not be entirely happy. Under treatment -it may be possible to reduce the spinal fluid tests to -negative without, however, as in the case of our hemiplegic -lady,<a id='r133' /><a href='#f133' class='c014'><sup>[133]</sup></a> making the physical or mental symptoms disappear. -In other words, it may be possible to stop the active progress -of the disease without removing the symptoms.</p> - -<p class='c007'>One is always warned of the danger of intravenous salvarsan -therapy in hemiplegic cases due to arteriosclerotic conditions. -While this warning is well justified, it does not mean that the -most intensive treatment is contraindicated, as shown in the -case of our hemiplegic machinist.<a id='r134' /><a href='#f134' class='c014'><sup>[134]</sup></a> Such may be given over -long periods of time with the most satisfactory results.</p> - -<p class='c007'>A case<a id='r135' /><a href='#f135' class='c014'><sup>[135]</sup></a> is given which illustrates the value of antisyphilitic -treatment in cases showing symptoms of intracranial pressure -due to syphilitic disease. In the case of the woman which -we cite, we believe that the symptoms of intracranial pressure -were probably due to a gummatous new growth, although it is -possible that they were due to a marked meningitic process. -However, the results of a limited amount of antisyphilitic -treatment in this case were very brilliant. Similar results -may often be obtained in gumma of the brain. This is not -always true, however, and it may become necessary to use -surgical procedure in order rapidly to overcome the effects of -intracranial pressure.</p> - -<p class='c007'>While it has always been conceded that treatment would -greatly help cases of diffuse and vascular neurosyphilis, the -utmost pessimism has existed concerning the results to be -obtained by treatment in cases of tabetic and paretic neurosyphilis. -Only in the last five or six years, due to the stimulus -of Ehrlich’s discovery of salvarsan and the introduction of the -intraspinous methods of therapy, have intensive work and -study been given to the treatment of these cases. And though -it has been by no means settled in the minds of the various -workers in this field, as to what the ultimate results of such -<span class='pageno' id='Page_462'>462</span>treatment will be and though some do not believe that there is -any good to be expected from our present methods, still the -majority of men who are treating these cases systematically -feel very much encouraged.</p> - -<p class='c007'><b>At times very brilliant results</b> are to be obtained by intraspinous -treatment <b>in tabetic neurosyphilis</b> (“tabes dorsalis”). -A very striking illustration is given of a case of -this sort in which the symptoms dated only a few months but -which had all the classical symptoms, signs and laboratory -tests. Five intraspinous injections of mercurialized serum -were sufficient to cause the disappearance of the subjective -symptoms and to reduce the spinal fluid test to negative.<a id='r136' /><a href='#f136' class='c014'><sup>[136]</sup></a></p> - -<p class='c007'>It must be emphasized that the best results in cases of -tabetic neurosyphilis are usually to be expected in cases in -which the symptoms are of short standing. Where the process -is of long duration and much destruction of spinal cord -tissue has occurred, the best one can expect is that the activity -and progress may be halted. This is illustrated by our -case of a baker, 43 years of age, who had been suffering from -the symptoms of tabes for some years. Under treatment it -was possible to get an entirely negative serology of the blood -and spinal fluid.<a id='r137' /><a href='#f137' class='c014'><sup>[137]</sup></a> Despite this evidence that the activity -of syphilis had ceased, the symptoms continued unabated. -We are ready to believe, however, that much good was accomplished. -For the patient should not have any further -untoward developments or the appearance of any new -symptoms. These, without such treatment, might well be -expected. At times excellent clinical results are obtained in -long-standing cases.</p> - -<p class='c007'>The results of treatment in paretic neurosyphilis (“general -paresis”) have been considered even less hopeful than in -tabetic neurosyphilis (“tabes dorsalis”); indeed, it has -often been stated that the patients are made worse by -treatment. Recent work, however, supports a much more -optimistic viewpoint. We feel that <b>intensive treatment has -been of the greatest value in a number of cases of paretic -<span class='pageno' id='Page_463'>463</span>neurosyphilis</b>. Two cases are given which show the most satisfactory -and brilliant results of intensive intravenous salvarsan -therapy in cases diagnosed as general paresis. The first case, -an excellent salesman, 46 years of age, with most aggravated -mental symptoms, recovered symptomatically and all his -tests were rendered negative.<a id='r138' /><a href='#f138' class='c014'><sup>[138]</sup></a> He has now remained entirely -well and economically efficient for about two years without -further treatment. The other case,<a id='r139' /><a href='#f139' class='c014'><sup>[139]</sup></a> a housewife, also with -very marked symptoms suggestive in all ways of general -paresis, also recovered rapidly under treatment and her -tests became negative. Her remission has now lasted for -nearly three years without further treatment.</p> - -<p class='c007'>At times it is not possible to get the spinal fluid tests to -become negative in cases of paretic neurosyphilis under the -most intensive salvarsan therapy. In spite of this, the -clinical condition of the patient may improve so greatly that -the patient can be considered <b>clinically recovered</b>. An illustration -is given of an undertaker<a id='r140' /><a href='#f140' class='c014'><sup>[140]</sup></a> who was brought from a -condition of the greatest cachexia and mental confusion to a -condition of robust appearance and mental efficiency under -intravenous salvarsan therapy, in spite of the fact that his -tests were very slightly if at all reduced in intensity. He -has been able to resume his former occupation and his former -life with great satisfaction to himself and his family.</p> - -<p class='c007'>Improvement in paretic neurosyphilis under treatment is -not to be expected very early. <b>Two or three months of -active treatment</b> may elapse before one sees signs of improvement. -Indeed, as illustrated by our case of the shipping clerk, -this improvement may begin to make its appearance only -after more than four months of intensive treatment consisting -of two injections of salvarsan per week.<a id='r141' /><a href='#f141' class='c014'><sup>[141]</sup></a> In spite of the long -delay in this case, complete clinical recovery occurred and the -tests became almost negative at the end of a year of treatment.</p> - -<p class='c007'><span class='pageno' id='Page_464'>464</span>It is not only in the central nervous system that the -syphilitic process may resist the most intensive treatment. -In the case of the speculator, a victim of paretic neurosyphilis, -which we cite, a perennially recurrent iritis appeared after -several months of the most intensive salvarsan treatment -which was apparently sufficient to reduce the symptoms of -the paretic neurosyphilis,<a id='r142' /><a href='#f142' class='c014'><sup>[142]</sup></a> but not of non-neural syphilis.</p> - -<p class='c007'>We give the case of a charwoman having the diagnosis of -paretic neurosyphilis, who, under intensive treatment, made a -symptomatic recovery. The interesting point in her findings -is that all the tests in the spinal fluid became negative except -the gold sol reaction which remained of the “paretic” type.<a id='r143' /><a href='#f143' class='c014'><sup>[143]</sup></a> -There is no general rule as to the reaction of the spinal fluid -tests under treatment. At times one test is the first to disappear -under treatment; again it is another. We have seen -many cases in which the gold sol was the first test to become -negative and others, as the case given, in which it is the last to -show any change. As in our undertaker, symptomatic clinical -improvement may be practically complete without any -change in the spinal fluid tests.</p> - -<p class='c007'>One must remember that it is the condition of the patient -that is of first importance; not so much the laboratory tests. -Having shown the clinical recoveries with the tests remaining -positive, we now have to report two cases in which there -was <b>improvement</b> as shown <b>by the tests but no clinical improvement</b>. -The first patient, a bank teller<a id='r144' /><a href='#f144' class='c014'><sup>[144]</sup></a> of 39 years, with -a diagnosis of paretic neurosyphilis, received intensive intravenous -salvarsan for several months. Under this treatment -all the tests became negative except the gold sol which remained -of the paretic type. In spite of this, there was not -the slightest improvement in his mental condition.</p> - -<p class='c007'>The second case, a young man of 29 years in whom the symptoms -of neurosyphilis had recently appeared, under treatment -showed a marked diminution in the intensity of the spinal -<span class='pageno' id='Page_465'>465</span>fluid tests, notwithstanding which the patient became more -and more demented and died after a series of convulsions.<a id='r145' /><a href='#f145' class='c014'><sup>[145]</sup></a></p> - -<p class='c007'>Of course, good results indicated above in some of our cases -of paretic neurosyphilis are not to be expected in every case -no matter how intensive the treatment. We give a case of -paretic neurosyphilis in which the most intensive intravenous -salvarsan therapy gave no satisfactory results. This was -followed by several intraventricular injections of salvarsanized -serum. The results of this combined treatment, however, -were still not satisfactory, and the patient died.<a id='r146' /><a href='#f146' class='c014'><sup>[146]</sup></a></p> - -<p class='c007'>In order to emphasize as strongly as possible what we believe -is a great <b>advantage of systematic intensive treatment</b> -for neurosyphilis, we offer two cases in different time periods -of neurosyphilis. The first is a printer with the symptoms of -diffuse neurosyphilis six months after the appearance of his -chancre.<a id='r147' /><a href='#f147' class='c014'><sup>[147]</sup></a> These symptoms appeared despite three injections -of salvarsan, injections of mercury and mercury by mouth. -Under intensive treatment (meaning injections of salvarsan -twice a week and continued injections of mercury), complete -recovery occurred in a few weeks.</p> - -<p class='c007'>The second case is that of a waiter with signs and symptoms -of neurosyphilis in whom the diagnosis lay between the diffuse -and paretic forms.<a id='r148' /><a href='#f148' class='c014'><sup>[148]</sup></a> This patient developed his symptoms -in spite of continuous antisyphilitic treatment during the six -years since his infection. This treatment had been comparatively -mild, consisting in great part of mercury by mouth. -However, he had had courses of injections of mercury and -several injections of salvarsan. Under a systematic course of -intravenous injections of salvarsan twice a week for a number -of months, all symptoms disappeared and the spinal fluid tests -became negative as well as the W. R. in the blood serum.</p> - -<p class='c007'>A final case is offered which indicates that antisyphilitic -treatment may occasionally be of service in improving the -mentality of a <span class='sc'>Feebleminded Congenital Syphilitic</span>.<a id='r149' /><a href='#f149' class='c014'><sup>[149]</sup></a></p> - -<p class='c007'><span class='pageno' id='Page_466'>466</span>No attempt has been made in this section to give a per -cent evaluation of the results of treatment in any one group of -neurosyphilis. Two charts (charts 25 and 26), however, are -appended which give an indication of some of our results. It -seems to us, however, that it is too early to make any definite -statements as to how far treatment will take us in the groups -of neurosyphilis. We do feel decidedly, however, that many -patients, in whatever group of neurosyphilis the diagnosis -may place them, will respond to intensive systematic antisyphilitic -treatment. <b>It is unfair to give an entirely grave -prognosis in any case of neurosyphilis until the effect of -treatment has been tried.</b></p> - -<p class='c006'>In a separate section, entitled NEUROSYPHILIS AND -THE WAR, we have presented fourteen cases selected from -British, French and German writers in the war literature of -1914–16. Most of these cases were naturally somewhat inadequately -reported under the critical conditions of literature -made in the war. We present the cases for what they are -worth: at all events they draw attention to the extraordinary -interest of the neurosyphilis problem in relation to the war.</p> - -<p class='c007'>Such cases as A, one of tabes dorsalis apparently developing -paresis by a process akin to shell-shock, is of value in the -interpretation of the development of paresis in civil life. -By “shell-shock” we commonly refer to a condition in which -there is no actual traumatic injury of the brain. The hypothesis -must be then that the explosion in some way indirectly -caused an alteration of living conditions of the spirochetes, -permitting the development of paresis.</p> - -<p class='c007'>Case B similarly seems to be a case in which a latent syphilis -has turned shell-shock into tabes dorsalis.</p> - -<p class='c007'>Cases C, D, E bring up the question of aggravation of -neurosyphilis <em>by</em> service and <em>on</em> service, respectively.</p> - -<p class='c007'>Case F likewise shows how, in the determination of amount -of pension, the probable duration of the neurosyphilitic process -is important.</p> - -<p class='c007'>Case G seems to show that war stress alone, without the -emotional or physical effects of shell-shock, may kindle a -latent syphilis into paretic neurosyphilis.</p> - -<p class='c007'><span class='pageno' id='Page_467'>467</span>Case H similarly suggests that the “gassing” process may -effect the same result.</p> - -<p class='c007'>Case I seems to show that the neuropathically tainted -person may have latent epilepsy brought out through syphilis, -the syphilis in this case having been acquired during the first -summer of the war.</p> - -<p class='c007'>Case J was an interesting case of a syphilitic who, after -the stress of the Battle of Dixmude, became an epileptic.</p> - -<p class='c007'>Syphilitic root-sciatica was developed in Case K at work -in the war zone.</p> - -<p class='c007'>Case L is one of a civilian who apparently would not have -developed paresis at precisely the moment when he did, if -he had not been discharged as a German Jew from his long-held -bank position in London.</p> - -<p class='c007'>Two cases, M and N, are cases of shell-shock, non-syphilitic; -yet the picture of paresis in the one case and of tabes -in the other was for a long time almost convincing to the -examiners. They are better termed cases of pseudoparesis -and pseudotabes, using the prefix “pseudo”, as usual, to -signify a non-syphilitic imitation of the disease in question.</p> - -<p class='c007'>To sum up in the most general way the lessons of this -book, we may emphasize again (1) <em>the unity-in-variety of the -phenomena of neurosyphilis</em>, (2) <em>the value of a hopeful approach -to the therapy of all cases of neurosyphilis</em>, <em>even the paretic form</em>, -and (3) <em>the value of applying syphilis tests to every case of neurosis -or psychosis</em>.</p> - -<p class='c007'>(1) <span class='sc'>Re</span> <em>unity-in-variety of neurosyphilitic phenomena</em>.</p> - -<p class='c007'>The unity of these phenomena is confirmed, theoretically, -by the common factor of spirochetosis: practically, by the -Wassermann reaction, positive in serum or spinal fluid! Almost -at this point the unity of phenomena ceases. Neither -chronicity, nor evidence of mononuclear cell deposits, nor -evidence of serious structural damage to the nervous system, -nor presence of other positive tests than the W. R.,<a id='r150' /><a href='#f150' class='c014'><sup>[150]</sup></a> nor -<span class='pageno' id='Page_468'>468</span>existence of mental or nervous symptoms or signs, is a common -feature of neurosyphilis. Sometimes the nervous system -appears to harbor spirochetes in the most cordial manner as -guest-friends (<em>paresis sine paresi</em>.) Again, perhaps as an -expression of elaborate processes of immunity, the spirochetes -take effect in relatively huge gummata. Sometimes -the neurosyphilitic process rises as if by a regular process of -siege from spinal nerve-root to spinal nerve-root (tabes -dorsalis and diffuse neurosyphilis). Again, the nervous -system is taken by storm, as it were (disseminated encephalitis). -Very frequently the neurosyphilis is simply an indirect -effect of blood-vessel disease, and huge masses of -tissue are scooped out in necrosis with dependent secondary -degenerations; and later the extinct lesions of vascular origin -may or may not betray evidence of their syphilitic origin. -Sometimes diffuse processes run on, apparently, with perfect -fatalism to a mortal issue in a few years both with and without -treatment. Again treatment appears to accomplish much -(see fuller discussion under 2). The laws governing the preference -of processes to lodge in membranes, vessels, and -parenchyma, and in all combinations of these, have not been -worked out. Hardly a case of neurosyphilis, properly studied -ante mortem and post mortem, but would throw important -light on our medical approach to one of the great problems -of civilization, the problem of syphilis as a whole.</p> - -<p class='c007'>(2) <span class='sc'>Re</span> <em>value of a hopeful approach to the therapy of neurosyphilis</em>.</p> - -<p class='c007'>The prognosis of neurosyphilis is not worse than that of -the chronic diseases in general. In fact, the prognosis of -neurosyphilis <i><span lang="la" xml:lang="la">quoad vitam</span></i> is either good or dubious, certainly -not bad. The surprising reversals of form which the spirochete -shows in certain remissions are always to be awaited. -Treatment of neurosyphilis has certainly effected amazing -results, not so much by way of Ehrlich’s <em>therapia sterilisans -magna</em> as by means of systematic intensive treatment. -Even paretic neurosyphilis (general paresis) seems to have -been cured. Preparetic phases are theoretically hopeful. -Nor is it so certain that paretic neurosyphilis will ultimately -prove a perfectly distinct species of neurosyphilis. General -<span class='pageno' id='Page_469'>469</span>paresis seems to us at least to be more closely related to diffuse -neurosyphilis than is tabes dorsalis to diffuse neurosyphilis. -In any particular case, moreover, <b>during a good part of the -early months or years</b>, <b>it is difficult or impossible to tell the -paretic from the non-paretic forms of diffuse neurosyphilis -by any combination of clinical observations and tests</b>. In -the instance of more protracted neurosyphilis, e.g., tabetic, -the outlook for vascular complications is such that antisyphilitic -treatment directed at prevention of these complications -is scientifically warrantable, even if the tabetic process itself -proves unassailable. The old distinction of syphilis and -parasyphilis, so striking and apparently satisfactory when -introduced by Fournier, seems to be a false distinction which -should be dropped. Therapeutically, we should approach -all cases of neurosyphilis without bias or nihilistic prejudgments.</p> - -<p class='c007'>(3) <span class='sc'>Re</span> <em>universal applicability of syphilis tests in nervous -and mental cases</em>.</p> - -<p class='c007'>The importance of putting every neurosis or psychosis -through syphilis tests is not based alone on the frequency of -neurosyphilis, though neurosyphilis is surely frequent enough. -The importance of universally applying these tests is established -by the experience of lingering doubts both in the physician’s -mind and (nowadays increasingly) in the patient’s -and friends’ minds, so long as these tests are not applied. -Nor should the positive serum Wassermann reaction fail to -be followed by lumbar puncture and appropriate tests. The -general practitioner confronting neuroses or psychoses—and -what practitioner does not?—must not expect valuable -results from consultation with neurologists and psychiatrists -when he does not carry to these specialists the results of at -least the serum W. R. in his patient. Not only are practitioners, -specialists, and patients subject to discomfiture on -the eventual and delayed proof of syphilis or neurosyphilis, -but valuable time has been lost to treatment. How often -the physician of yore (and really not so long since) had to be -regarded as an eccentric virtuoso if he tested urine as routine! -Well, for routine use in nervous and mental diseases, the -Wassermann serum reaction is at least as important as urinalysis. -<span class='pageno' id='Page_470'>470</span>Nor would we cease our homily with the general -practitioner. We know neurologists and psychiatrists who -use the Wassermann test <em>only when it is likely to be positive</em>! -But they are dying out.</p> - -<div class='chapter'> - <span class='pageno' id='Page_471'>471</span> - <h2 class='c005'>APPENDIX A</h2> -</div> - -<p class='c006'>In appendix A a brief outline is given of the six tests (W. R. -on blood serum and spinal fluid, cell count, globulin test, -albumin test, gold sol test). This is not intended as a complete -working manual but rather as indicating the methods -used in diagnosis in the cases presented herein. For more -complete details the reader may be referred to textbooks -on the subject of serology, among which may be mentioned -Kaplan: “Serology of the Nervous System”; Plaut, Rehm -and Schottmüller: “<span lang="de" xml:lang="de">Leitfaden zur Untersuchungen der -Zerebrospinalflüssigkeit</span>”; Kolmer: “Infection, Immunity -and Specific Therapy,” and, for the Wassermann technique, -an article by Dr. W. A. Hinton in M. J. Rosenau’s “Preventive -Medicine and Hygiene.”</p> - -<p class='c007'>Our own W. R’s. have been performed at the Wassermann -laboratory of the Massachusetts State Board of Health -(formerly the Neuropathological Testing Laboratory, Harvard -Medical School), under the supervision of Dr. W. A. -Hinton. The other tests are performed at the Psychopathic -Hospital. It is very important that a close relationship should -exist between the clinician and the Wassermann laboratory -if the most is to be obtained from the reactions. This relationship -has been effectively close between the authors and -the above-mentioned laboratory; and has enabled us to get -very much clearer ideas about certain cases than could otherwise -have been obtained.</p> - -<p class='c007'><b>Cell Count.</b> In order to obtain the number of cells per -cmm., the examination should be made of the fresh fluid as -soon as possible after this is withdrawn. The most convenient -counting chamber for this purpose is the so-called -Fuchs-Rosenthal counting chamber, the ruled spaces of which -contain slightly over 3 cmm. (an ordinary blood cell counting -chamber may be used). According to the method used by -us the cells are stained in a pipette with Unna’s polychrome -methylene blue. Using a white-counting pipette, stain is -<span class='pageno' id='Page_472'>472</span>drawn up to the first or second marking and the remainder of -the pipette filled with spinal fluid. This makes no change -in the dilution for practical purposes. After two or three -minutes the staining is satisfactory and the counting may -be done. With this stain a differential count may be made. -Plasma cells stain a lavender as contrasted to the blue of -the lymphocytes. The characteristic halo surrounding the -eccentric nucleus is visible. The blood cells do not assume -color with this stain; hence it is unnecessary to add any acetic -acid.</p> - -<p class='c007'>For permanent preparations, and more accurate differential -counts of the spinal fluid, the Alzheimer method may -be used. The technique is given in a paper by H. A. Cotton -and J. B. Ayer as follows:<a id='r151' /><a href='#f151' class='c014'><sup>[151]</sup></a></p> - -<p class='c007'>1. Lumbar puncture in the usual manner.</p> - -<p class='c007'>2. 96% alcohol, in proportion to twice the amount of -cerebrospinal fluid, is added drop by drop and well mixed.</p> - -<p class='c007'>3. Centrifuge the mixture for one hour at high speed in a -glass tube with conical end. (An ordinary electric urinary -centrifuge apparatus can be employed, the tube to be well -stoppered to prevent evaporation.)</p> - -<p class='c007'>4. The supernatant fluid is poured off, leaving a small -coagulum in the bottom of the tube.</p> - -<p class='c007'>5. Add absolute alcohol—alcohol and ether—ether, each -separately for one hour, to dehydrate and harden coagulum.</p> - -<p class='c007'>6. The coagulum can now be gently loosened from the -bottom of the tube by a long needle. The tube is then inverted, -and the coagulum allowed to fall into the hand by a -quick tap on the end of the tube. Care must be taken not to -squeeze or handle the coagulum. The hand is placed over -a small homeopathic vial, containing thin celloidin, and the -coagulum allowed to drop into the celloidin, where it remains -over night (twelve hours usually).</p> - -<p class='c007'>7. Coagulum is placed in thick celloidin which is allowed -to evaporate slowly. It is then mounted on blocks and -sections cut 14µ in thickness.</p> - -<p class='c007'><span class='pageno' id='Page_473'>473</span>8. The sections are stained and mounted according to -the following procedure:</p> - -<p class='c007'>(<em>a</em>) Remove celloidin by absolute alcohol and ether.</p> - -<p class='c007'>(<em>b</em>) 80% alcohol.</p> - -<p class='c007'>(<em>c</em>) Water.</p> - -<p class='c007'>(<em>d</em>) Sections are carried on glass or platinum needle into -a dish of Pappenheim’s pyronin-methyl green stain and kept -in a water bath at 40° C. five to seven minutes.</p> - -<p class='c007'>(<em>e</em>) Quickly cool dish in running water.</p> - -<p class='c007'>(<em>f</em>) Wash off superfluous stain in plain water.</p> - -<p class='c007'>(<em>g</em>) Absolute alcohol to differentiate—until no more -stain comes away from section.</p> - -<p class='c007'>(<em>h</em>) Clear in Bergamot oil.</p> - -<p class='c007'>(<em>i</em>) Mount in balsam.</p> - -<p class='c006'>The normal cell count may be stated as being up to 6 cells -per cmm.; from 6 to 12 cells may be considered as suggestive -of pathological condition and more than 12 cells per cmm. as -definitely pathological. The type of cell in syphilitic diseases -is preponderantly the small lymphocyte. A low percentage, -that is, very rarely over 20%, of large lymphocytes, endothelial -phagocytic cells, polymorphonuclear leucocytes and -plasma cells may also be found. The finding of plasma -cells in any number in the spinal fluid is suggestive although -not conclusive evidence for the diagnosis of paretic neurosyphilis.</p> - -<p class='c007'><b>Globulin</b> is an albumin which is precipitated by half saturation -with a salt. A very simple and satisfactory test is known -as the Nonne-Appelt test, which has been modified by Ross-Jones. -Into a test tube of small diameter, run 1 cc. of spinal -fluid. Place under this fluid with a pipette, 1 cc. of a saturated -solution of ammonium sulphate ((NH<sub>4</sub>)<sub>2</sub>SO<sub>4</sub>). If any -globulin is present a white, sharply-defined ring will form at -the junction of the two fluids. According to our readings, a -ring that is just visible with the aid of a black background is -called 1+, a ring that is just visible without the black background, -2+; a ring easily perceptible, 3+ and a relatively -very heavy ring, 4+. On shaking the tube, if globulin is -present, the fluid will show turbescence.</p> - -<p class='c007'><span class='pageno' id='Page_474'>474</span>Another simple globulin test used in our laboratory as a -check on the Nonne-Appelt test is the Pandy test. A few -cc. of a clarified 10% solution of phenol are placed in a watch -glass. One drop of spinal fluid is run into this solution. A -milky turbescence indicates globulin.</p> - -<p class='c007'>The presence of globulin in the spinal fluid is always an -indication of abnormality of the cerebrospinal axis. There -is nothing differential in this finding as it occurs in all inflammatory -processes. However, it is characteristically present -in most cases of neurosyphilis (exception to the rule: the pure -vascular type does not show globulin in a very high per cent).</p> - -<p class='c007'><b>Albumin Test.</b> Albumin in small quantities is present -in all spinal fluids. Increase over the normal amount occurs -in pathological conditions such as most cases of neurosyphilis, -especially in those in which globulin is found. Any albumin -precipitant may be used for rough clinical calculation, -comparing the amount of precipitate with that from the normal -fluid. Our method is to place 1 cc. of spinal fluid in a -small test tube of about 5 mm. diameter and to precipitate the -albumin by the addition of 3 drops of 33⅓% of trichloracetic -acid. This test has its chief value as confirmatory of the -globulin test, since in the vast majority of instances where -globulin is found there will also be found an increase in -albumin.</p> - -<p class='c007'>The <b>Gold Sol Reaction</b> is an empirical test discovered by -Carl Lange in the utilization of the work of Zsigmondi with -solutions of colloidal gold and albumins. Briefly the details -of the test are as follows:</p> - -<p class='c007'>Ten tubes are set up in a rack. To the first tube 1.8 cc. of a -0.4% of salt solution is added and to each of the following -tubes 1 cc. of this solution. Then to the first tube containing -1.8 cc. of salt solution one adds 0.2 cc. of the spinal fluid to be -tested. This gives a dilution of 1 to 10. From this tube 1 -cc. is pipetted into the second tube and this process continued -through the ten tubes. This gives dilutions of spinal fluid -of 1 to 10, 1 to 20, 1 to 40, etc., to 1 to 5120 in the last tube. -Then 5 cc. of colloidal gold solution is added to each tube. -A positive reaction is indicated by the precipitation or -throwing down of the colloidal gold into its metallic form. -<span class='pageno' id='Page_475'>475</span>This produces a change in color. This precipitation may -be partial or complete and the amount of precipitation is -indicated by the color and is read as follows:</p> - -<p class='c007'>The unchanged fluid is called 0; a slight change giving a -red-blue as 1; a further change giving a blue-red as 2; a -straight blue as 3; a lavender or violet as 4; and the colorless -fluid representing complete precipitation as 5. The numbers -are placed in a row, indicating the tube in which the -color occurs. The fluid from a case of paretic neurosyphilis -will give a complete precipitation beginning in the first tube -and running through a number of tubes and then grading off. -It may be indicated 5 5 5 5 4 3 1 0 0 0. The characteristic -reaction of fluids from tabetic and diffuse neurosyphilis is -less strong than from the paretic. The greater part of the -reaction will take place, however, in the first five tubes, but -as a rule it will not begin very strongly in the first two. -A characteristic reaction is 1 2 3 3 2 1 0 0 0 0. Another -reaction that may be considered characteristic of the tabetic -or diffuse form is 3 3 3 2 1 0 0 0 0 0. Fluids from non-syphilitic -cases as a rule give a reaction having its greatest -intensity beyond the fifth tube, that is, in the high dilutions.</p> - -<p class='c007'>A reaction characteristic of brain tumor or tuberculous -meningitis is 0 0 0 0 1 3 3 2 1 0.</p> - -<p class='c007'>The conclusions that may be drawn from the gold sol -reaction have been summarized by one of the authors as -follows:</p> - -<p class='c007'>1. Fluids from cases of general paresis will give a strong -and fairly characteristic reaction, especially if more than one -sample is tested, in the vast majority of cases.</p> - -<p class='c007'>2. Very rarely a general paresis fluid will give a reaction -weaker than the characteristic one.</p> - -<p class='c007'>3. Fluids from cases of syphilitic involvement of the -central nervous system other than general paresis often give -a weaker reaction than the paretic, but in a fairly high percentage -of cases give the same reaction as the paretics.</p> - -<p class='c007'>4. Non-syphilitic cases may give the same reaction as the -paretics; these cases are usually chronic inflammatory conditions -of the central nervous system.</p> - -<p class='c007'>5. When a syphilitic fluid does not give the strong “paretic -<span class='pageno' id='Page_476'>476</span>reaction,” it is good presumptive evidence that the case -is not general paresis; and this test offers a very valuable -differential diagnostic aid between general paresis, tabes and -cerebrospinal syphilis.</p> - -<p class='c007'>6. The term “syphilitic zone” is a misnomer, as non-syphilitic -as well as syphilitic cases give reactions in this -zone; but no fluid of a case with syphilitic central nervous -system disease has given a reaction out of this zone (test -thus valuable negatively). Any fluid giving a reaction outside -of this zone may be considered non-syphilitic.</p> - -<p class='c007'>7. Light reactions may occur without any evident significance, -while a reaction of no greater strength may mean -marked inflammatory reaction.</p> - -<p class='c007'>8. Tuberculous meningitis, brain tumor and purulent -meningitis fluids characteristically, though not invariably, -give reactions in higher dilutions than syphilitic fluids.</p> - -<p class='c007'>9. The unsupplemented gold sol test is insufficient evidence -on which to make any diagnosis, but used in conjunction -with the Wassermann reaction, chemical and cytological -examinations, it offers much information looking toward -the differential diagnosis of general paresis, cerebrospinal -syphilis, tabes dorsalis, brain tumor, tuberculous meningitis, -purulent meningitis.</p> - -<p class='c007'>10. We believe that no cerebrospinal fluid examination -is complete for clinical purposes without the gold sol test.</p> - -<p class='c006'>The <b>Wassermann reaction</b> as carried out in the Wassermann -Laboratory is based on the principles of the original -method—the only essential modification consists in the employment -of cholesterinized alcoholic extracts of human -hearts as antigen instead of aqueous extracts of foetal livers -from cases of congenital syphilis. Experience has shown that -properly standardized antigens made from human hearts are -much more sensitive in the detection of true cases of syphilis.</p> - -<p class='c007'><b>Antigens.</b> Three antigens are used, each being an alcoholic -extract of human heart which is saturated at room temperature -with cholesterin. These antigens differ slightly in their -sensitiveness. Before the test is made each antigen is diluted -with 0.85% salt solution in the proportion of four parts of -<span class='pageno' id='Page_477'>477</span>the cholesterinized antigen extract to sixteen parts of 0.85% -salt solution. The amount to be used, the dosage, is carefully -determined by testing each antigen against a large -number of known positive and known negative specimens of -blood. The dosage of the antigens employed is less than one-half -the amount which inhibits hemolysis when the antigen is -incubated for one hour with the hemolytic system which -consists of complement, amboceptor and cells in the proper -proportions. These antigens are designated as A, B, and C. -Antigen A is the most sensitive. B and C are very similar -to each other quantitatively and qualitatively.</p> - -<p class='c007'><b>Specimens to be tested.</b> The serum which separates from -the clot is withdrawn, centrifugalized if necessary, and then -heated at 55 degrees for thirty minutes. 0.1 cc. of serum -is used in the test and 0.2 cc. of each specimen is used as -a control to exclude the presence of anti-complementary substances. -Spinal fluids are tested in two ways. As a routine -0.5 cc. of the spinal fluid is used in the test and 1.0 cc. is -used in the control; or when especially requested spinal fluids -are titrated by using respectively 1.0, 0.7, 0.5, 0.3, and 0.1 cc. -of the spinal fluid for each test and 1.0 cc. of spinal fluid -for the control. Spinal fluids are not inactivated.</p> - -<p class='c007'><b>Complement.</b> The complement is obtained from the serum -of guinea pig’s blood. No complement is used when older -than eighteen hours. A 10% solution and 0.85% salt solution -is used in the test. The amount used is twice the minimum -quantity necessary to hemolyze the sensitized cells.</p> - -<p class='c007'><b>Sheep’s Corpuscles.</b> A 5% suspension of sheep’s corpuscles -in 0.85% salt solution is prepared from defibrinated -sheep’s blood. The corpuscles are washed three times and -for each washing four to five times as much 0.85% salt -solution is used as the original volume of the defibrinated -blood.</p> - -<p class='c007'><b>Amboceptor.</b> The amboceptor is prepared by injecting -sheep’s corpuscles into a rabbit. The serum of this rabbit -which contains amboceptor is diluted with 0.85% salt solution -so that 0.25 cc. will hemolyze 0.5 cc. of a 5% suspension of -sheep’s corpuscles. In the test twice the quantity or 0.5 cc. -of amboceptor is used.</p> - -<p class='c007'><span class='pageno' id='Page_478'>478</span><b>Sensitized Cells.</b> The sensitized cells consist of equal -parts of washed sheep’s corpuscles and diluted amboceptor. -This mixture is incubated in a water bath at 37° C. for a -half hour to effect the sensitization of the cells.</p> - -<p class='c007'><b>Technique of the Wassermann Test.</b> One-tenth cubic -centimeter of each inactivated specimen of serum and 0.5 cc. -of each uninactivated specimen of spinal fluid is pipetted into -a separate tube. A mixture is freshly prepared in salt solution, -each cubic centimeter of which contains the proper -amount of antigen A (the most sensitive antigen), and two -units of a 10% solution of guinea pig serum (complement). -One cubic centimeter of this mixture is pipetted into each -test tube. These tubes are then incubated for forty minutes -in a water bath at 37° C. At the end of this period, sensitized -cells are added, and the tubes are again incubated in a -water bath at 37° C. for one hour. Each specimen which -shows any degree of inhibition of hemolysis is retested in -the afternoon. For this second test antigen A is again used -and in addition antigens B and C. A control is also made -for each specimen retested to eliminate any possibility of -the inhibition of hemolysis being due to anti-complementary -substances in the serum or spinal fluid tested. The technique -of the second test differs in no wise from that of the first, -except for the use of a control in each retested specimen -and the employment of three antigens instead of one. The -degree of positiveness is noted for each retested specimen and -compared with the degree of positiveness obtained for the corresponding -specimen with the same antigen-complement-salt -solution mixture in the morning’s test. The specimen is retested -on the next day when discrepancies occur between the -morning reading for antigen A and the afternoon reading -for antigen A. From the above description it will be noted -that the negative specimens have but a single test with one -antigen only, while the positive specimens are retested, thus -permitting a confirmation of any positive reaction. In this -way attention is focalized on the positive specimens.</p> - -<p class='c007'><b>Interpretation of Results.</b> Antigen C (the weakest of the -three antigens) is used entirely for diagnostic purposes and -any specimen showing the slightest degree of inhibition with -<span class='pageno' id='Page_479'>479</span>this antigen and stronger degrees of inhibition with the other -antigens is reported as positive. The specimens which are -strongly or moderately positive with antigens A and B and -negative with antigen C are reported as doubtful. In testing -spinal fluids by the titration method, antigen C is used and -the readings are based upon the degree of inhibition of hemolysis -noted. The intensity of this inhibition is indicated by -Arabic numerals: “5” indicates complete inhibition, -while “1” means a faint cloudiness, hence a weak reaction. -Intermediate numbers show relative intensity varying between -complete inhibition “5” (strong positive) and slight -inhibition “1” (weak positive); “—” equals no inhibition -(negative).</p> - -<p class='c007'>Although it is commonly believed that the recent administration -of antisyphilitic treatment will affect the reaction -by making it negative, this is not our experience, and it is, -therefore, not necessary that treatment be withdrawn for a -short period before the specimen is submitted for examination.</p> - -<p class='c007'>The reaction as carried out in this laboratory has the -following diagnostic significance: <b>Positive indicates syphilis</b>, -except very rarely in acute febrile conditions such as malaria -and pneumonia. <b>Negative does not exclude syphilis.</b> In -obscure conditions a series of less than three negatives has -little diagnostic significance. <b>Doubtful suggests syphilis.</b> -It is therefore advisable to submit three or more specimens -in such a case, and interpret a persistently or predominatingly -doubtful reaction as indicative of syphilitic infection.</p> - -<p class='c007'><b>Bruck Test.</b> A new serum test for syphilis has recently -been described by C. Bruck.<a id='r152' /><a href='#f152' class='c014'><sup>[152]</sup></a> Following are recent results -in our laboratory with this test.<a id='r153' /><a href='#f153' class='c014'><sup>[153]</sup></a></p> - -<p class='c007'>This new test for the diagnosis of syphilis by C. Bruck -has aroused much interest. The scientific standing of Bruck -and the simplicity of the technique led us to overcome -our prejudice, that has been the offspring of the numerous -tests that have been offered of late. Bruck states that since -<span class='pageno' id='Page_480'>480</span>the discovery of the complement fixation test for syphilis by -Wassermann, Neisser and himself in 1906, he has been trying -to find a simple chemical reaction that would take the place -of the complicated technique of the Wassermann reaction. -This method, as he has published it, was worked out and is -being used at the front, in the present war, where complete -laboratory equipment is not available.</p> - -<p class='c007'>Commencing our experiments with a great deal of -scepticism, we were much surprised at the results obtained, -which are given below. Whatever may be the final status -of the test in the determination of syphilis, we feel that there -is a great deal of interest in the fact that this simple chemical -reaction does pick out certain differences in the composition -of blood sera and that apparently a large number of syphilitic -sera differ in their chemical composition percentage from the -majority of non-syphilitic sera.</p> - -<p class='c007'>The technique, while exceedingly simple, offers many -chances for errors and individual variations so that we have -thought it well to give directions and cautions at some -length.</p> - -<p class='c007'>Bruck’s<a id='r154' /><a href='#f154' class='c014'><sup>[154]</sup></a> technique is described as follows: “The test is made -with 0.5 cc. clear serum in a test tube, to which is added 2 cc. -of distilled water, and the whole shaken. Then, with a -precision pipette, 0.3 cc. of the ac. nitr. purum of the German -pharmacopeia is added and the whole thoroughly shaken and -then set aside at room temperature for ten minutes. Then -16 cc. of distilled water at room temperature is added, and -closing the tube with the finger, it is shaken up and down -three times carefully, not vigorously enough to make it foam. -This is repeated ten minutes later, and the tube is then set -aside for half an hour. By this time the precipitate is -entirely dissolved in the tube with the normal serum, while -the syphilitic serum shows a distinct, flocculent turbidity. -In two or three hours, or better still, in twelve hours, the -gelatinous and characteristic precipitate is piled up on the -floor of the test tube.”</p> - -<p class='c007'><span class='pageno' id='Page_481'>481</span>The acid is prepared by diluting the Acidum nitricum of -the U. S. P. (Sp. gr. 1.403) with distilled water until the -hydrometer shows the specific gravity 1.149, which corresponds -to the nitric acid of the German pharmacopeia, but -since this requires a special hydrometer, a simpler method is -to make a 25 per cent solution of the Acidum nitricum, which -will give about the proper specific gravity.</p> - -<p class='c007'>The serum is obtained by allowing 10 cc. of blood to stand -at room temperature for an hour, and then centrifuging. -Serum that has stood for some time may be used as well as the -fresh, and even bloody serum does not seem to confuse the -results to any great degree. The serum gives the same -results with or without inactivation. Post mortem blood -gave results as constant as that obtained during life, in the -few cases that we had in this series. But the reaction may -be influenced markedly by the size of the test tubes. We -have found that the 13×1.9 cm. is the most favorable size.</p> - -<p class='c007'>When one first thinks of this test it appears very simple -and probably somewhat crude as a chemical reaction, but -there are certain precautions that must be observed, and -several hundred normal and syphilitic sera should be tried -before the investigator can feel that he has a refined routine -technique. There is the personal equation which must be -watched, for here is probably the greatest source of error, -and readily explains why two different persons get widely -varying results with the same sera if they have done only a -few dozen tests. We must take it for granted that the -reaction is a quantitative one, where some positive reactions -may differ only slightly from the normal non-syphilitic, and, -furthermore, any normal serum may be made to give a positive -reaction, and almost any positive serum be made to give a -negative by improper manipulation at some point in the test. -There are as many places for error to creep in as there are -steps in the process. Bruck has omitted many details in -his publication, which allow personal variations, and so we -have tried to develop a routine process that will eliminate -as many of these as possible.</p> - -<p class='c007'>We shall here attempt to explain the methods which we -have found most satisfactory and at the same time indicate -<span class='pageno' id='Page_482'>482</span>the places where error is likely to occur. The 0.5 cc. of -serum is added to 2 cc. of distilled water, and shaken thoroughly. -Now add slowly exactly 0.3 cc. of acid from a -precision pipette, care being taken it does not flow down the -side of the tube. The tube should be shaken gently while the -acid is being added, for this prevents the formation of a -flocculent precipitate in normal serum which is difficult to -dissolve later. After the acid is added shake each tube -gently to make sure that these flakes do not persist. It is -difficult to shake each tube in exactly the same manner, as -must be done if we expect uniform results.</p> - -<p class='c007'>The first 250 tests of this series were made by allowing the -tubes to stand for ten minutes as Bruck advocates. Then we -found that practically all sera gave a positive reaction if -allowed to stand 15–20 minutes, and so in the other tests of -the series an attempt was made to make the reaction more -sensitive by allowing the tubes to stand only 6–7 minutes. -During this time the tubes should be shaken gently once or -twice. The manner in which the 16 cc. of water is added also -influences the reaction. If allowed to flow freely in upon -the precipitate, the positive may be forced into solution as -well as the negative. Both pipette and tube should be -slanted and the water allowed to flow down the side of the -tube without disturbing the precipitate. If all has gone well -up to this point, we may see a marked difference between the -normal and syphilitic precipitates, in that the normal will -begin to go into solution at once, thus clouding the water, -while a positive precipitate will be composed of large flakes -which show little or no tendency to go into solution or cloud -the water above. It must be remembered that the most -flocculent positive precipitate will go into solution if the fluid -is splashed or shaken too hard while the tube is being inverted. -If any doubt as to the character of the precipitate now exists, -it may be allowed to stand ten minutes longer, and again -inverted as before, or even repeated several times during the -next hour or two. We see no reason why the tubes should be -left to stand over night, for during this time a precipitate -usually settles in the normal tubes. This, however, differs -from the syphilitic precipitate in that it is still finely granular -<span class='pageno' id='Page_483'>483</span>and goes back into solution readily when the tubes are -inverted.</p> - -<p class='c007'>In view of these possible grounds for error, it is only -logical to run controls of known positive and known negative -sera along with each group of unknown bloods, and even then -certain tubes will seem doubtful, in which event the test -should be repeated with added precaution to see if a definite -positive or negative reaction may be obtained.</p> - -<p class='c007'>In the last tests of this series we seemed to aid the reaction -by rendering the serum-water solution alkaline by one or two -drops of 10 per cent potassium hydroxide before the acid was -added. The positive sera have a larger precipitate, while -the normal seem to dissolve more readily.</p> - -<table class='table3' summary=''> - <tr><td class='c020' colspan='4'><span class='sc'>Table I</span></td></tr> - <tr><td> </td></tr> - <tr><td class='c051' colspan='4'>Syphilis: nervous system involved.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c009' rowspan='3'>General Paresis</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>47</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>negatively</td> - <td class='c033'>7</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck at</td> - <td class='c009'>variance</td> - <td class='c033'>10</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009'>Tabes Dorsalis</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>3</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009' rowspan='2'>Cerebrospinal</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>8</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>negatively</td> - <td class='c033'>3</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009'>Juvenile Paresis</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>1</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009' rowspan='3'>Summary:</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>59</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>negatively</td> - <td class='c033'>10</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck at</td> - <td class='c009'>variance</td> - <td class='c033'>10</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr><td class='c020' colspan='4'><span class='sc'>Table II</span></td></tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr><td class='c051' colspan='4'>Syphilis: nervous system not involved.</td></tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009' rowspan='2'>Syphilis</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>12</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck at</td> - <td class='c009'>variance</td> - <td class='c033'>5</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009' rowspan='2'>Congenital Syph.</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>3</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>negatively</td> - <td class='c033'>2</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr> - <td class='c009' rowspan='3'>Summary:</td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>15</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>negatively</td> - <td class='c033'>2</td> - </tr> - <tr> - - <td class='c009'>Wassermann and Bruck at</td> - <td class='c009'>variance</td> - <td class='c033'>5</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr><td class='c020' colspan='4'><span class='sc'>Table III</span></td></tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr><td class='c051' colspan='4'>Non-syphilitic: Wassermann reaction negative.</td></tr> - <tr> - <td class='c009'> </td> - <td class='c009'>Doubtful or positive Bruck</td> - <td class='c009'> </td> - <td class='c033'>86</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>Bruck test negative</td> - <td class='c009'> </td> - <td class='c033'>216</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c009'> </td> - <td class='c033'> </td> - </tr> - <tr><td class='c051' colspan='4'>Total for three groups:</td></tr> - <tr> - <td class='c009'> </td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>positively</td> - <td class='c033'>74</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>Wassermann and Bruck agree</td> - <td class='c009'>negatively</td> - <td class='c033'>230</td> - </tr> - <tr> - <td class='c009'> </td> - <td class='c009'>Wassermann and Bruck at</td> - <td class='c009'>variance</td> - <td class='c033'>101</td> - </tr> -</table> - -<p class='c007'><span class='pageno' id='Page_484'>484</span>The tests here reported were made on blood sera obtained -from patients admitted to the Psychopathic Hospital and its -Out-Patient Department. As a routine Wassermann test -is made on each patient who enters the hospital, it was only -necessary to take another tube of blood from each patient, -and check the results in each instance with the Wassermann -reaction. As it takes several days to get the report -from the Wassermann laboratory of the State Board of -Health, there was no chance of being prejudiced by a previous -knowledge of the Wassermann reaction. The cases for the -most part were those of mental disease; the majority in good -general physical health.</p> - -<p class='c007'>A comparison of the total number with the Wassermann -reaction shows that there was a general agreement of 304 of -the 405 cases tested, or a percentage agreement of practically -75%. In considering the cases of syphilis of the central -nervous system in a group by themselves, we find that the -agreement is closer, since 69 of the 79 cases tested, or 87% -agreed without any question of doubt. It will be noted that -in several cases of general paresis, the Wassermann reaction, -which was repeated at intervals, was negative, and in most of -these cases the Bruck test was negative also. Our few cases -of congenital and latent syphilis also checked very closely -with the Wassermann test. In the various groups of mental -cases in this series, no factor of interference was discovered. -It is also of interest that in the cases where the blood was -obtained post mortem, the Bruck test agreed with the Wassermann -result obtained on ante mortem blood serum. Further -work on post mortem sera will be reported. Some of the -patients not included in the syphilitic groups that have a -negative Wassermann and no clinical signs of syphilis, give a -history of previous infection at some time, which might partly -account for the variations in the two tests.</p> - -<p class='c007'>CONCLUSIONS</p> - -<p class='c027'>1. We present results of the Bruck sero-chemical test in 405 -cases. In 101 of these cases there were definite clinical -manifestations of syphilis, in which the Wassermann -and Bruck tests agreed positively in 74 or 75%. The -<span class='pageno' id='Page_485'>485</span>two tests agreed negatively in 12 instances, and were -at variance in 15.</p> - -<p class='c027'>2. In the group which showed syphilis of the nervous system -we had 64 cases of clinically certain general paresis, of -which the Wassermann and Bruck tests agreed in 54 -instances, or practically 85%. In other forms of central -nervous system involvement the agreement was 100% -in the 15 cases tested.</p> - -<p class='c027'>3. In the cases with no apparent involvement of the nervous -system the agreement was somewhat less, being 76%. -This may be in keeping with the fact that the Wassermann -test was not so strongly positive in these cases.</p> - -<p class='c027'>4. The advantages of the test are: (1) the short time -required to do the test; (2) the limited amount of -apparatus necessary, and (3) the simplicity of the -technique.</p> - -<p class='c027'>5. The disadvantages of the test seem, for the most part, -to be bound up in the personal variations that are apt -to occur.</p> - -<p class='c027'>6. We are here dealing, most probably, with a quantitative -chemical difference in the protein content of syphilitic -and non-syphilitic sera, the nature of which is not -understood by us. It is our hope that this may be -brought to light in the near future in the field of chemistry.</p> - -<div class='chapter'> - <span class='pageno' id='Page_486'>486</span> - <h2 class='c005'>APPENDIX B<br /> COMMON METHODS OF TREATMENT USED IN CASES OF NEUROSYPHILIS</h2> -</div> - -<p class='c006'>The <b>treatment for neurosyphilis</b> according to the viewpoint -of the authors <b>is treatment for syphilis</b>. It is necessary in -order to cure a case of neurosyphilis to cure the syphilis in -the patient. Accordingly, the methods of treatment best -adapted for the cure of syphilis are indicated in the treatment -of neurosyphilis. As experience shows that it is often more -difficult to cure the neurosyphilitic cases, treatment will have -to be pushed with greater intensity than in some non-nervous -system syphilis. In general, then, the methods that have -been applied by the syphilologist will be used in the treatment -of cases of neurosyphilis. In addition, methods attempting -to bring the drug into local contact with the central -nervous system have been devised. The methods of treatment -have been in part indicated in Chart 27.</p> - -<p class='c007'>The method chiefly used in treatment of the cases of this -book is what we have called <b>intensive systematic intravenous -treatment</b>. The treatment consists of intravenous injections -of salvarsan (or a substitute for salvarsan, as arsenobenzol -and diarsenol) given in a dose of about 0.6 gram and repeated -twice a week over a period of a number of months. In -addition, injections of mercury salicylate averaging 0.065 -gram once a week are given and potassium iodid by mouth. -As indicated, the important point is to keep up treatment for -a long period of time. This method has produced practically -no untoward results, certainly no more untoward results -than are to be expected with salvarsan in smaller quantities -and it has seemed to us that the therapeutic results have -been as satisfactory as in any other form of treatment.</p> - -<p class='c007'>Specialized forms of treatment intended to place the drug -in contact with the central nervous system may be described -<span class='pageno' id='Page_487'>487</span>under the headings of <b>spinal intradural treatment</b> and <b>cerebral -subdural</b> and <b>intraventricular treatment</b>.</p> - -<p class='c007'>Three main therapeutic agents have been largely used. -These are (1) salvarsanized serum according to the <b>method -of Swift-Ellis</b> (<b><span lang="la" xml:lang="la">in vivo</span></b>). The serum according to this method -is prepared as follows: An intravenous injection of salvarsan -is given to a patient and blood withdrawn at the end of one-half -hour. This is allowed to clot. The serum is removed -and after inactivation at 56° C. for one-half hour it is ready -for use. The average dose is 15 to 30 cc. of serum. As a -matter of fact, it is not necessary to use the blood serum from -the same patient to whom the intraspinous injection is to be -given. (2) The salvarsanized serum according to the <b>method -of Ogilvie</b> (<b><span lang="la" xml:lang="la">in vitro</span></b>). Blood serum is prepared from any -patient and to it is added salvarsan in such a strength that -the amount to be injected, 10 to 30 cc. of serum, will contain -0.0001 to 0.001 gm. (3) Mercurialized serum according to -the <b>method of Byrnes</b>. Mercury bichloride is added to blood -serum in such proportion that the amount of serum to be -injected will contain from 0.00065 gram to 0.0026 gram.</p> - -<p class='c007'>The method of intraspinous injection is to perform lumbar -puncture, withdraw an amount of fluid approximately -equivalent to the amount to be injected; then allow the serum -to be injected to run in by gravity.</p> - -<p class='c007'>For the <b>cerebral</b>, <b>subdural and intraventricular</b> injections, -the same sera may be used as for the intraspinous. Five or six -times as much salvarsan may be given, but a smaller amount of -serum may be advisable, that is, 10 to 15 cc. To perform injections -a trephine opening is made in the calvarium about the size -of a dime. The location of choice for the opening is slightly -back of the longitudinal prominence just to the right of the -median line, to avoid the frontal sinus. For subdural injections -a curved needle is thrust between the dura and the -brain and the serum allowed to flow in slowly by gravity. For -the intraventricular injections a blunted spinal puncture -needle is thrust through the brain substance into the 3rd ventricle. -When the 3rd ventricle is reached the clear cerebral -fluid will flow out; then after withdrawing a sufficient amount, -the serum may be introduced by gravity. The trephining may -<span class='pageno' id='Page_488'>488</span>be done under local anesthesia but as a rule it is better to -induce general anesthesia. The subsequent injections can -be made without recourse to any anesthesia whatsoever, as -they are practically painless.</p> - -<p class='c007'>All procedures both in the injections and in the preparation -of sera are naturally to be performed under aseptic conditions.</p> - -<div class='chapter'> - <span class='pageno' id='Page_489'>489</span> - <h2 class='c005'>INDEX</h2> -</div> - -<ul class='index c002'> - <li class='c046'>Abscess, tonsillar, associated with neurosyphilis, <a href='#Page_250'>250</a>.</li> - <li class='c046'>Addison’s disease in juvenile paretic, <a href='#Page_279'>279</a>.</li> - <li class='c046'>Agraphia, <a href='#Page_101'>101</a>.</li> - <li class='c046'>Albumin test, <a href='#Page_474'>474</a>.</li> - <li class='c046'>Allbutt, Clifford, <a href='#Page_257'>257</a>.</li> - <li class='c046'>Alcoholism, chronic, <a href='#Page_227'>227</a>.</li> - <li class='c046'>Alcoholic dementia, <a href='#Page_237'>237</a>. - <ul> - <li>epilepsy, <a href='#Page_229'>229</a>.</li> - <li>hallucinosis, <a href='#Page_225'>225</a>.</li> - <li>pseudoparesis, <a href='#Page_222'>222</a>, <a href='#Page_223'>223</a>, <a href='#Page_451'>451</a>.</li> - </ul> - </li> - <li class='c046'><i><span lang="fr" xml:lang="fr">Allergie</span></i>, <a href='#Page_129'>129</a>, <a href='#Page_204'>204</a>.</li> - <li class='c046'>Alzheimer, <a href='#Page_428'>428</a>. - <ul> - <li>method, <a href='#Page_472'>472</a>.</li> - </ul> - </li> - <li class='c046'>Amboceptor, <a href='#Page_477'>477</a>.</li> - <li class='c046'>Amnesia, <a href='#Page_195'>195</a>.</li> - <li class='c046'>Anaphylaxis, <a href='#Page_129'>129</a>.</li> - <li class='c046'>Anatomical formulae, <a href='#Page_25'>25</a>.</li> - <li class='c046'>Antigens, <a href='#Page_476'>476</a>.</li> - <li class='c046'>Aortic aneurysm, <a href='#Page_35'>35</a>, <a href='#Page_439'>439</a>.</li> - <li class='c046'>—— sclerosis, <a href='#Page_41'>41</a>, <a href='#Page_46'>46</a>, <a href='#Page_135'>135</a>.</li> - <li class='c046'>Aphasia, <a href='#Page_31'>31</a>, <a href='#Page_43'>43</a>, <a href='#Page_101'>101</a>, <a href='#Page_262'>262</a>, <a href='#Page_445'>445</a>.</li> - <li class='c046'>Apoplexy, <a href='#Page_197'>197</a>.</li> - <li class='c046'>Argyll-Robertson pupil, <a href='#Page_209'>209</a>, <a href='#Page_212'>212</a>, <a href='#Page_217'>217</a>, <a href='#Page_291'>291</a>, <a href='#Page_450'>450</a>. - <ul> - <li>as isolated symptom, <a href='#Page_217'>217</a>.</li> - <li>in alcoholism, <a href='#Page_214'>214</a>, <a href='#Page_229'>229</a>.</li> - </ul> - </li> - <li class='c046'>Arndt, Junius and, <a href='#Page_249'>249</a>.</li> - <li class='c046'>Arsenobenzol, <a href='#Page_375'>375</a>, <a href='#Page_377'>377</a>, <a href='#Page_389'>389</a>, <a href='#Page_486'>486</a>.</li> - <li class='c046'>Arteriosclerosis, cerebral, <a href='#Page_101'>101</a>. - <ul> - <li>not a contraindication to intensive salvarsan therapy, <a href='#Page_359'>359</a>.</li> - <li>radial, <a href='#Page_68'>68</a>.</li> - </ul> - </li> - <li class='c046'>Ascending lesion, <a href='#Page_23'>23</a>.</li> - <li class='c046'>Asymmetrical lesions, <a href='#Page_19'>19</a>.</li> - <li class='c046'>Ataxia, <a href='#Page_31'>31</a>, <a href='#Page_223'>223</a>.</li> - <li class='c046'>Atheromatous degeneration, <a href='#Page_35'>35</a>.</li> - <li class='c046'>Atrophy, cerebellar, <a href='#Page_39'>39</a>. - <ul> - <li>cerebral, <a href='#Page_47'>47</a>, <a href='#Page_134'>134</a>, <a href='#Page_205'>205</a>.</li> - <li>parenchymal, <a href='#Page_41'>41</a>.</li> - <li>pontine, <a href='#Page_39'>39</a>.</li> - </ul> - </li> - <li class='c046'>Atypical case congenital neurosyphilis, <a href='#Page_270'>270</a>.</li> - <li class='c046'>Ayer, J. B., <a href='#Page_472'>472</a>.</li> - <li class='c002'>Ballet, <a href='#Page_72'>72</a>.</li> - <li class='c046'>Barrett, A. M., <a href='#Page_54'>54</a>, <a href='#Page_175'>175</a>, <a href='#Page_187'>187</a>, <a href='#Page_212'>212</a>, <a href='#Page_218'>218</a>, <a href='#Page_219'>219</a>.</li> - <li class='c046'>Bechterew, <a href='#Page_219'>219</a>.</li> - <li class='c046'>Binet and Simon, <a href='#Page_304'>304</a>.</li> - <li class='c046'>Binet scale, <a href='#Page_277'>277</a>.</li> - <li class='c046'>Birnbaum, <a href='#Page_403'>403</a>.</li> - <li class='c046'>Blood pressure, high, <a href='#Page_70'>70</a>, <a href='#Page_262'>262</a>, <a href='#Page_124'>124</a>.</li> - <li class='c046'>Bly, <a href='#Page_252'>252</a>.</li> - <li class='c046'>Bonhoeffer, <a href='#Page_404'>404</a>, <a href='#Page_415'>415</a>, <a href='#Page_417'>417</a>.</li> - <li class='c046'>Bordet, <a href='#Page_427'>427</a>.</li> - <li class='c046'>Bratz, <a href='#Page_278'>278</a>.</li> - <li class='c046'>Bruck test, <a href='#Page_479'>479</a>.</li> - <li class='c046'>Bruck, C., <a href='#Page_479'>479</a>.</li> - <li class='c046'>Bumke, <a href='#Page_214'>214</a>.</li> - <li class='c002'>Canavan, <a href='#Page_256'>256</a>. - <ul> - <li>and Southard, <a href='#Page_70'>70</a>.</li> - </ul> - </li> - <li class='c046'>Cell count, <a href='#Page_471'>471</a>.</li> - <li class='c046'>Cerebral syphilis, see diffuse neurosyphilis.</li> - <li class='c046'>Cerebrospinal syphilis, see diffuse neurosyphilis.</li> - <li class='c046'>Cervical hypertrophic meningitis of Charcot, <a href='#Page_56'>56</a>, <a href='#Page_441'>441</a>.</li> - <li class='c046'>Chancre, extragenital, <a href='#Page_75'>75</a>, <a href='#Page_342'>342</a>.</li> - <li class='c046'>Character change, neurosyphilis, <a href='#Page_314'>314</a>.</li> - <li class='c046'>Charcot, <a href='#Page_60'>60</a>, <a href='#Page_186'>186</a>.</li> - <li class='c046'>Choroiditis, <a href='#Page_242'>242</a>.</li> - <li class='c046'>Christian, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Cimbal, <a href='#Page_403'>403</a>.</li> - <li class='c046'>Civilization and syphilis, <a href='#Page_76'>76</a>.</li> - <li class='c046'>Clinical evidences of syphilis, <a href='#Page_131'>131</a>.</li> - <li class='c046'>Clouston, <a href='#Page_158'>158</a>.</li> - <li class='c046'>Collins, Joseph, <a href='#Page_145'>145</a>.</li> - <li class='c046'>Compensation in neurosyphilis, <a href='#Page_309'>309</a>, <a href='#Page_402'>402</a>, <a href='#Page_456'>456</a>.</li> - <li class='c046'>Complement, <a href='#Page_477'>477</a>.</li> - <li class='c046'><span class='pageno' id='Page_490'>490</span>Conduct disorder, <a href='#Page_38'>38</a>.</li> - <li class='c046'>Congenital syphilis, absence of stigmata, <a href='#Page_318'>318</a>. - <ul> - <li>as cause of feeblemindedness, <a href='#Page_159'>159</a>, <a href='#Page_447'>447</a>.</li> - <li>involvement of nervous system in, <a href='#Page_274'>274</a>.</li> - </ul> - </li> - <li class='c046'>Congenital neurosyphilis, <a href='#Page_270'>270</a>, <a href='#Page_395'>395</a>. - <ul> - <li>resembling feeblemindedness, <a href='#Page_272'>272</a>.</li> - </ul> - </li> - <li class='c046'>Conjugal neurosyphilis, <a href='#Page_263'>263</a>.</li> - <li class='c046'>Convulsions, <a href='#Page_43'>43</a>, <a href='#Page_101'>101</a>, <a href='#Page_248'>248</a>, <a href='#Page_362'>362</a>. - <ul> - <li>cause of in paretic neurosyphilis, <a href='#Page_232'>232</a>.</li> - <li>in psychopathic subject with syphilis, <a href='#Page_417'>417</a>.</li> - </ul> - </li> - <li class='c046'>Corneal opacity, syphilitic, <a href='#Page_234'>234</a>.</li> - <li class='c046'>Cotard, <a href='#Page_73'>73</a>.</li> - <li class='c046'>Cotton, H. A., <a href='#Page_472'>472</a>.</li> - <li class='c046'>Craig, C. B., <a href='#Page_152'>152</a>, <a href='#Page_196'>196</a>.</li> - <li class='c046'>Cramer, <a href='#Page_125'>125</a>.</li> - <li class='c046'>Cranial neurosyphilis, <a href='#Page_140'>140</a>. - <ul> - <li>tenderness, <a href='#Page_139'>139</a>.</li> - </ul> - </li> - <li class='c046'>Crises, gastric, <a href='#Page_367'>367</a>.</li> - <li class='c046'>Cysts, ependymal, <a href='#Page_59'>59</a>. - <ul> - <li>of softening, <a href='#Page_27'>27</a>, <a href='#Page_36'>36</a>, <a href='#Page_54'>54</a>.</li> - </ul> - </li> - <li class='c046'>Cytorrhyctes luis, <a href='#Page_381'>381</a>.</li> - <li class='c002'>Dana, Charles L., <a href='#Page_65'>65</a>, <a href='#Page_77'>77</a>, <a href='#Page_78'>78</a>.</li> - <li class='c046'>Dazed states, <a href='#Page_264'>264</a>.</li> - <li class='c046'>Deafness, <a href='#Page_63'>63</a>.</li> - <li class='c046'>Decompression, <a href='#Page_138'>138</a>.</li> - <li class='c046'>Defective delinquent—diffuse neurosyphilis, <a href='#Page_300'>300</a>, <a href='#Page_455'>455</a>.</li> - <li class='c046'>Dejerine-Tinel, <a href='#Page_61'>61</a>.</li> - <li class='c046'>Delinquency and juvenile neurosyphilis, <a href='#Page_298'>298</a>.</li> - <li class='c046'>Delirium tremens, <a href='#Page_332'>332</a>.</li> - <li class='c046'>Dementia, <a href='#Page_137'>137</a>.</li> - <li class='c046'>Dementia paralytica, see paretic neurosyphilis.</li> - <li class='c046'>Dementia praecox, <a href='#Page_74'>74</a>, <a href='#Page_185'>185</a>, <a href='#Page_247'>247</a>.</li> - <li class='c046'>Depression, <a href='#Page_95'>95</a>, <a href='#Page_126'>126</a>.</li> - <li class='c046'>Depressive drugs, <a href='#Page_189'>189</a>.</li> - <li class='c046'>Diabetes, and neurosyphilis, <a href='#Page_240'>240</a>. - <ul> - <li>insipidus, <a href='#Page_190'>190</a>.</li> - </ul> - </li> - <li class='c046'>Diabetic pseudoparesis, <a href='#Page_238'>238</a>.</li> - <li class='c046'>Diarsenol, <a href='#Page_377'>377</a>, <a href='#Page_389'>389</a>, <a href='#Page_391'>391</a>, <a href='#Page_486'>486</a>.</li> - <li class='c046'>Differential diagnosis, alcoholism and neurosyphilis, <a href='#Page_227'>227</a>, <a href='#Page_231'>231</a>, <a href='#Page_234'>234</a>, <a href='#Page_236'>236</a>. - <ul> - <li>brain tumor, diabetic pseudoparesis and neurosyphilis, <a href='#Page_238'>238</a>.</li> - <li>diffuse and paretic neurosyphilis, <a href='#Page_165'>165</a>, <a href='#Page_193'>193</a>, <a href='#Page_247'>247</a>.</li> - <li>manic-depressive psychosis and neurosyphilis, <a href='#Page_69'>69</a>.</li> - <li>multiple sclerosis and neurosyphilis, <a href='#Page_253'>253</a>, <a href='#Page_255'>255</a>.</li> - <li>neurasthenia and neurosyphilis, <a href='#Page_65'>65</a>, <a href='#Page_183'>183</a>.</li> - <li>senile arteriosclerotic psychosis and neurosyphilis, <a href='#Page_262'>262</a>.</li> - </ul> - </li> - <li class='c046'>Diffuse neurosyphilis, cerebrospinal syphilis, cerebral syphilis, spinal syphilis, <a href='#Page_17'>17</a>, <a href='#Page_80'>80</a>, <a href='#Page_85'>85</a>, <a href='#Page_97'>97</a>, <a href='#Page_103'>103</a>, <a href='#Page_122'>122</a>, <a href='#Page_140'>140</a>, <a href='#Page_183'>183</a>, <a href='#Page_193'>193</a>, <a href='#Page_300'>300</a>, <a href='#Page_331'>331</a>, <a href='#Page_342'>342</a>, <a href='#Page_359'>359</a>, <a href='#Page_433'>433</a>, <a href='#Page_439'>439</a>, <a href='#Page_443'>443</a>. - <ul> - <li>premonitory symptoms, <a href='#Page_342'>342</a>.</li> - <li>prognosis, <a href='#Page_80'>80</a>, <a href='#Page_103'>103</a>, <a href='#Page_124'>124</a>, <a href='#Page_433'>433</a>, <a href='#Page_443'>443</a>.</li> - <li>spinal fluid findings in, <a href='#Page_348'>348</a>.</li> - <li>symptoms, <a href='#Page_99'>99</a>.</li> - <li>treatment, <a href='#Page_98'>98</a>, <a href='#Page_103'>103</a>, <a href='#Page_184'>184</a>, <a href='#Page_302'>302</a>, <a href='#Page_390'>390</a>.</li> - <li>treatment, results, <a href='#Page_343'>343</a>.</li> - </ul> - </li> - <li class='c046'>Diplopia, <a href='#Page_50'>50</a>, <a href='#Page_184'>184</a>, <a href='#Page_253'>253</a>, <a href='#Page_356'>356</a>. - <ul> - <li>causes, <a href='#Page_140'>140</a>.</li> - </ul> - </li> - <li class='c046'>Donath, <a href='#Page_401'>401</a>, <a href='#Page_403'>403</a>.</li> - <li class='c046'>Drastich, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Duco and Blum, <a href='#Page_403'>403</a>.</li> - <li class='c046'>Dupré, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Dysdiadochokinesis, <a href='#Page_231'>231</a>.</li> - <li class='c002'>Ehrlich, <a href='#Page_184'>184</a>, <a href='#Page_428'>428</a>, <a href='#Page_429'>429</a>.</li> - <li class='c046'>Encephalitis, <a href='#Page_27'>27</a>, <a href='#Page_248'>248</a>. - <ul> - <li>disseminated, <a href='#Page_218'>218</a>.</li> - </ul> - </li> - <li class='c046'>Endarteritis, <a href='#Page_220'>220</a>.</li> - <li class='c046'>Ependymal cysts, <a href='#Page_59'>59</a>.</li> - <li class='c046'>Ependymitis, <a href='#Page_40'>40</a>, <a href='#Page_47'>47</a>, <a href='#Page_49'>49</a>, <a href='#Page_134'>134</a>.</li> - <li class='c046'>Epilepsy, <a href='#Page_192'>192</a>. - <ul> - <li>alcoholic, <a href='#Page_229'>229</a>.</li> - <li>brought out by syphilis, <a href='#Page_415'>415</a>.</li> - <li>Jacksonian, <a href='#Page_103'>103</a>.</li> - <li>parasyphilitic, <a href='#Page_194'>194</a>.</li> - <li>relation to juvenile neurosyphilis, <a href='#Page_277'>277</a>.</li> - <li>syphilitic, <a href='#Page_103'>103</a>, <a href='#Page_194'>194</a>.</li> - <li>syphilogenic, <a href='#Page_415'>415</a>.</li> - </ul> - </li> - <li class='c046'>Epileptic neurosis, <a href='#Page_195'>195</a>.</li> - <li class='c046'>Erb’s syphilitic spastic paraplegia, <a href='#Page_147'>147</a>. - <ul> - <li>treatment of, <a href='#Page_148'>148</a>.</li> - </ul> - </li> - <li class='c046'>Euphoria, <a href='#Page_73'>73</a>.</li> - <li class='c046'>Excited states, <a href='#Page_95'>95</a>.</li> - <li class='c046'>Exner, M. J., <a href='#Page_416'>416</a>.</li> - <li class='c046'>Exophthalmic goitre, syphilitic (?), <a href='#Page_205'>205</a>.</li> - <li class='c046'>Extraocular palsy, <a href='#Page_140'>140</a>, <a href='#Page_441'>441</a>.</li> - <li class='c046'>Eye changes in neurosyphilis, <a href='#Page_257'>257</a>.</li> - <li class='c046'>Eye muscles, paresis of, <a href='#Page_17'>17</a>, <a href='#Page_50'>50</a>.</li> - <li class='c046'><span class='pageno' id='Page_491'>491</span>Facial paralysis, <a href='#Page_53'>53</a>.</li> - <li class='c046'>Families of neurosyphilitics, <a href='#Page_275'>275</a>, <a href='#Page_316'>316</a>, <a href='#Page_318'>318</a>, <a href='#Page_320'>320</a>, <a href='#Page_373'>373</a>, <a href='#Page_431'>431</a>, <a href='#Page_457'>457</a>.</li> - <li class='c046'>Family of neurosyphilitic, normal-looking, but syphilitic, <a href='#Page_318'>318</a>.</li> - <li class='c046'>Familial syphilis, <a href='#Page_299'>299</a>, <a href='#Page_306'>306</a>.</li> - <li class='c046'>Farrar, C. B., <a href='#Page_411'>411</a>.</li> - <li class='c046'>Fearnsides, Head and, <a href='#Page_21'>21</a>, <a href='#Page_140'>140</a>, <a href='#Page_150'>150</a>, <a href='#Page_193'>193</a>, <a href='#Page_217'>217</a>, <a href='#Page_374'>374</a>, <a href='#Page_378'>378</a>.</li> - <li class='c046'>Feeblemindedness, <a href='#Page_395'>395</a>. - <ul> - <li>and congenital syphilis, <a href='#Page_159'>159</a>.</li> - </ul> - </li> - <li class='c046'>Fernald, W. E., <a href='#Page_159'>159</a>, <a href='#Page_273'>273</a>, <a href='#Page_396'>396</a>.</li> - <li class='c046'>Fildes, McIntosh and, <a href='#Page_129'>129</a>, <a href='#Page_329'>329</a>.</li> - <li class='c046'>Focal changes, <a href='#Page_221'>221</a>. - <ul> - <li>meningitis, <a href='#Page_50'>50</a>.</li> - <li>softenings, pontine, <a href='#Page_54'>54</a>.</li> - </ul> - </li> - <li class='c046'>Fournier, <a href='#Page_142'>142</a>, <a href='#Page_222'>222</a>, <a href='#Page_186'>186</a>, <a href='#Page_194'>194</a>, <a href='#Page_381'>381</a>.</li> - <li class='c046'>Franz, <a href='#Page_357'>357</a>.</li> - <li class='c046'>Froissart, <a href='#Page_413'>413</a>.</li> - <li class='c046'>Fugue, hysterical, <a href='#Page_264'>264</a>.</li> - <li class='c002'>Garnier, <a href='#Page_407'>407</a>.</li> - <li class='c046'>General paresis, see paretic neurosyphilis.</li> - <li class='c046'>Glands, <a href='#Page_270'>270</a>.</li> - <li class='c046'>Gliosis, <a href='#Page_39'>39</a>, <a href='#Page_47'>47</a>, <a href='#Page_49'>49</a>, <a href='#Page_136'>136</a>, <a href='#Page_180'>180</a>.</li> - <li class='c046'>Globulin, <a href='#Page_229'>229</a>. - <ul> - <li>tests, <a href='#Page_473'>473</a>.</li> - </ul> - </li> - <li class='c046'>Glycosuria, <a href='#Page_238'>238</a>, <a href='#Page_241'>241</a>.</li> - <li class='c046'>Goddard, <a href='#Page_397'>397</a>.</li> - <li class='c046'>Gold sol reaction, <a href='#Page_247'>247</a>, <a href='#Page_474'>474</a>. - <ul> - <li>in brain tumor, <a href='#Page_100'>100</a>.</li> - <li>paretic, <a href='#Page_85'>85</a>, <a href='#Page_98'>98</a>.</li> - <li>paretic, other tests negative, <a href='#Page_383'>383</a>, <a href='#Page_385'>385</a>.</li> - <li>in purulent meningitis, <a href='#Page_100'>100</a>.</li> - <li>syphilitic, <a href='#Page_85'>85</a>, <a href='#Page_98'>98</a>, <a href='#Page_345'>345</a>.</li> - </ul> - </li> - <li class='c046'>Graham, Thomas, <a href='#Page_429'>429</a>.</li> - <li class='c046'>Grandiosity, <a href='#Page_72'>72</a>, <a href='#Page_295'>295</a>, <a href='#Page_455'>455</a>.</li> - <li class='c046'>Graves, W. W., <a href='#Page_157'>157</a>.</li> - <li class='c046'>Grilli, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Gross, <a href='#Page_257'>257</a>.</li> - <li class='c046'>Gumma, see gummatous neurosyphilis.</li> - <li class='c046'>Gumma of tonsil, <a href='#Page_250'>250</a>.</li> - <li class='c046'>Gummatous neurosyphilis, <a href='#Page_53'>53</a>, <a href='#Page_56'>56</a>, <a href='#Page_137'>137</a>, <a href='#Page_138'>138</a>, <a href='#Page_140'>140</a>, <a href='#Page_221'>221</a>, <a href='#Page_362'>362</a>, <a href='#Page_438'>438</a>.</li> - <li class='c002'>Hallucinations, <a href='#Page_53'>53</a>. - <ul> - <li>in paretic neurosyphilis, <a href='#Page_249'>249</a>.</li> - </ul> - </li> - <li class='c046'>Hauptmann, <a href='#Page_348'>348</a>.</li> - <li class='c046'>Head and Fearnsides, <a href='#Page_21'>21</a>, <a href='#Page_140'>140</a>, <a href='#Page_150'>150</a>, <a href='#Page_193'>193</a>, <a href='#Page_210'>210</a>, <a href='#Page_217'>217</a>, <a href='#Page_374'>374</a>, <a href='#Page_387'>387</a>.</li> - <li class='c046'>Headache, <a href='#Page_53'>53</a>, <a href='#Page_63'>63</a>, <a href='#Page_122'>122</a>, <a href='#Page_247'>247</a>, <a href='#Page_352'>352</a>. - <ul> - <li>causes of, <a href='#Page_209'>209</a>.</li> - </ul> - </li> - <li class='c046'>Hecht, <a href='#Page_399'>399</a>.</li> - <li class='c046'>Hemianopsia in neurosyphilis, <a href='#Page_242'>242</a>.</li> - <li class='c046'>Hemiplegia, <a href='#Page_31'>31</a>, <a href='#Page_45'>45</a>, <a href='#Page_80'>80</a>, <a href='#Page_122'>122</a>, <a href='#Page_262'>262</a>, <a href='#Page_360'>360</a>. - <ul> - <li>causes of, <a href='#Page_389'>389</a>.</li> - </ul> - </li> - <li class='c046'>Hemitremor, <a href='#Page_197'>197</a>.</li> - <li class='c046'>Heredity, neuropathic, <a href='#Page_84'>84</a>.</li> - <li class='c046'>Herxheimer reaction, <a href='#Page_152'>152</a>.</li> - <li class='c046'>Heubner, <a href='#Page_427'>427</a>, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Hinton, W. A., <a href='#Page_471'>471</a>.</li> - <li class='c046'>Huntington’s chorea, <a href='#Page_258'>258</a>.</li> - <li class='c046'>Hutchinsonian teeth, <a href='#Page_45'>45</a>.</li> - <li class='c046'>Hydrocephalus, <a href='#Page_134'>134</a>, <a href='#Page_306'>306</a>.</li> - <li class='c046'>Hyperreflexia, explanation of, <a href='#Page_233'>233</a>.</li> - <li class='c046'>Hypochondriacal ideas, <a href='#Page_133'>133</a>.</li> - <li class='c046'>Hysteria, <a href='#Page_185'>185</a>, <a href='#Page_301'>301</a>.</li> - <li class='c046'>Hysterical symptoms, <a href='#Page_18'>18</a>.</li> - <li class='c002'>Incontinence, vesical in tabetic neurosyphilis, <a href='#Page_144'>144</a>. - <ul> - <li>rectal, <a href='#Page_56'>56</a>.</li> - </ul> - </li> - <li class='c046'>Incubation period of neurosyphilis, <a href='#Page_152'>152</a>.</li> - <li class='c046'>Infectiousness of neurosyphilis, <a href='#Page_95'>95</a>.</li> - <li class='c046'>Insight, <a href='#Page_95'>95</a>.</li> - <li class='c046'>Insomnia, <a href='#Page_63'>63</a>.</li> - <li class='c046'>Intracranial pressure, <a href='#Page_139'>139</a>, <a href='#Page_362'>362</a>.</li> - <li class='c046'>Intraspinal lesions, <a href='#Page_95'>95</a>.</li> - <li class='c046'>Intraspinous therapy, <a href='#Page_122'>122</a>, <a href='#Page_366'>366</a>, <a href='#Page_486'>486</a>. - <ul> - <li>unpleasant results of, <a href='#Page_366'>366</a>.</li> - </ul> - </li> - <li class='c046'>Intraventricular injections, <a href='#Page_389'>389</a>, <a href='#Page_487'>487</a>.</li> - <li class='c046'>Involution-melancholia, <a href='#Page_187'>187</a>.</li> - <li class='c046'>Iodine, untoward results, of, <a href='#Page_363'>363</a>.</li> - <li class='c046'>Iritis, <a href='#Page_17'>17</a>.</li> - <li class='c002'>Järisch-Herxheimer reaction, <a href='#Page_72'>72</a>.</li> - <li class='c046'>Joffroy, <a href='#Page_214'>214</a>. - <ul> - <li>and Mignot, <a href='#Page_64'>64</a>.</li> - </ul> - </li> - <li class='c046'>Junius and Arndt, <a href='#Page_249'>249</a>.</li> - <li class='c046'>Juvenile neurosyphilis, <a href='#Page_438'>438</a>, <a href='#Page_447'>447</a>. - <ul> - <li>relation to epilepsy, <a href='#Page_277'>277</a>.</li> - </ul> - </li> - <li class='c046'>Juvenile paresis, see juvenile paretic neurosyphilis.</li> - <li class='c046'>Juvenile paretic neurosyphilis, juvenile paresis, <a href='#Page_45'>45</a>, <a href='#Page_154'>154</a>, <a href='#Page_157'>157</a>, <a href='#Page_272'>272</a>, <a href='#Page_275'>275</a>, <a href='#Page_298'>298</a>, <a href='#Page_306'>306</a>, <a href='#Page_440'>440</a>. - <ul> - <li>age of onset, <a href='#Page_158'>158</a>.</li> - <li>and Addison’s disease, <a href='#Page_279'>279</a>.</li> - <li>and delinquency, <a href='#Page_298'>298</a>.</li> - <li>prognosis, <a href='#Page_156'>156</a>, <a href='#Page_158'>158</a>, <a href='#Page_162'>162</a>, <a href='#Page_273'>273</a>, <a href='#Page_275'>275</a>.</li> - <li>treatment, <a href='#Page_154'>154</a>, <a href='#Page_161'>161</a>, <a href='#Page_278'>278</a>, <a href='#Page_299'>299</a>.</li> - </ul> - </li> - <li class='c046'><span class='pageno' id='Page_492'>492</span>Juvenile paretic neurosyphilis, with initial trauma, <a href='#Page_306'>306</a>. - <ul> - <li>congenital amputation of toes in, <a href='#Page_158'>158</a>.</li> - </ul> - </li> - <li class='c046'>Juvenile tabetic neurosyphilis, <a href='#Page_161'>161</a>, <a href='#Page_447'>447</a>.</li> - <li class='c002'>Kaplan, <a href='#Page_255'>255</a>, <a href='#Page_471'>471</a>.</li> - <li class='c046'>Kéraval, <a href='#Page_257'>257</a>.</li> - <li class='c046'>Key, <a href='#Page_427'>427</a>.</li> - <li class='c046'>Knee-jerks, absence of, <a href='#Page_223'>223</a>. - <ul> - <li>lively, <a href='#Page_75'>75</a>.</li> - <li>return of, <a href='#Page_24'>24</a>.</li> - </ul> - </li> - <li class='c046'>Koefod, Solomon and, <a href='#Page_243'>243</a>.</li> - <li class='c046'>Kolmer, <a href='#Page_471'>471</a>.</li> - <li class='c046'>Kraepelin, <a href='#Page_65'>65</a>, <a href='#Page_66'>66</a>, <a href='#Page_69'>69</a>, <a href='#Page_88'>88</a>, <a href='#Page_91'>91</a>, <a href='#Page_95'>95</a>, <a href='#Page_187'>187</a>, <a href='#Page_225'>225</a>, <a href='#Page_249'>249</a>.</li> - <li class='c046'>Krafft-Ebing, <a href='#Page_84'>84</a>.</li> - <li class='c002'>Laignel-Lavastine, <a href='#Page_413'>413</a>.</li> - <li class='c046'>Lange, C., <a href='#Page_428'>428</a>, <a href='#Page_429'>429</a>, <a href='#Page_474'>474</a>.</li> - <li class='c046'>Lancinating pains, <a href='#Page_92'>92</a>, <a href='#Page_141'>141</a>.</li> - <li class='c046'>Lépine, <a href='#Page_408'>408</a>, <a href='#Page_413'>413</a>.</li> - <li class='c046'>Leptomeningitis, <a href='#Page_47'>47</a>, <a href='#Page_54'>54</a>, <a href='#Page_135'>135</a>.</li> - <li class='c046'>Lewandowski, <a href='#Page_210'>210</a>.</li> - <li class='c046'>Liability of paretic, <a href='#Page_295'>295</a>.</li> - <li class='c046'>Lissauer’s paralysis, <a href='#Page_38'>38</a>.</li> - <li class='c046'>Locomotor ataxia, see tabetic neurosyphilis.</li> - <li class='c046'>Long, <a href='#Page_418'>418</a>.</li> - <li class='c046'>Lucke, Baldwin, <a href='#Page_93'>93</a>, <a href='#Page_144'>144</a>.</li> - <li class='c046'>Lues maligna, <a href='#Page_250'>250</a>, <a href='#Page_452'>452</a>.</li> - <li class='c046'>Lumbar puncture, untoward effects, <a href='#Page_352'>352</a>. - <ul> - <li>treatment of, <a href='#Page_354'>354</a>.</li> - </ul> - </li> - <li class='c046'>Lüth, <a href='#Page_278'>278</a>.</li> - <li class='c046'>Lymphocytosis, <a href='#Page_23'>23</a>, <a href='#Page_30'>30</a>, <a href='#Page_40'>40</a>, <a href='#Page_49'>49</a>.</li> - <li class='c002'>McDonagh, <a href='#Page_381'>381</a>.</li> - <li class='c046'>McIntosh, Fildes and, <a href='#Page_129'>129</a>, <a href='#Page_329'>329</a>.</li> - <li class='c046'>Malaria, cerebral, simulation of paretic neurosyphilis, <a href='#Page_245'>245</a>.</li> - <li class='c046'>Mallory and Wright, <a href='#Page_472'>472</a>.</li> - <li class='c046'>Manic-depressive psychosis, <a href='#Page_68'>68</a>, <a href='#Page_71'>71</a>, <a href='#Page_77'>77</a>, <a href='#Page_187'>187</a>, <a href='#Page_202'>202</a>, <a href='#Page_291'>291</a>, <a href='#Page_384'>384</a>, <a href='#Page_442'>442</a>.</li> - <li class='c046'>Marie, Chatelin and Patrikios, <a href='#Page_412'>412</a>.</li> - <li class='c046'>Marie, <a href='#Page_408'>408</a>, <a href='#Page_414'>414</a>.</li> - <li class='c046'>Martin, E. G., <a href='#Page_313'>313</a>.</li> - <li class='c046'>Massary, de, <a href='#Page_414'>414</a>.</li> - <li class='c046'>Mattauschek and Pilcz, <a href='#Page_347'>347</a>.</li> - <li class='c046'>Medicolegal and Social, <a href='#Page_454'>454</a>. - <ul> - <li>period of paretic neurosyphilis, <a href='#Page_414'>414</a>.</li> - </ul> - </li> - <li class='c046'>Meilhon, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Memory, failing, <a href='#Page_63'>63</a>.</li> - <li class='c046'>Meningitis hypertrophica cervicalis of Charcot, <a href='#Page_56'>56</a>. - <ul> - <li>sympathica, <a href='#Page_19'>19</a>.</li> - <li>syphilitic, <a href='#Page_103'>103</a>.</li> - </ul> - </li> - <li class='c046'>Mercurialization, <a href='#Page_98'>98</a>.</li> - <li class='c046'>Mercury, <a href='#Page_58'>58</a>, <a href='#Page_83'>83</a>, <a href='#Page_85'>85</a>, <a href='#Page_98'>98</a>, <a href='#Page_148'>148</a>, <a href='#Page_193'>193</a>, <a href='#Page_235'>235</a>, <a href='#Page_376'>376</a>, <a href='#Page_377'>377</a>, <a href='#Page_389'>389</a>, <a href='#Page_391'>391</a>, <a href='#Page_395'>395</a>, <a href='#Page_486'>486</a>. - <ul> - <li>untoward results of, <a href='#Page_363'>363</a>.</li> - </ul> - </li> - <li class='c046'>Metasyphilis, <a href='#Page_89'>89</a>.</li> - <li class='c046'>Metchnikoff and Roux, <a href='#Page_427'>427</a>, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Microgyria, occipital, <a href='#Page_47'>47</a>.</li> - <li class='c046'>Mignot, Joffroy and, <a href='#Page_64'>64</a>, <a href='#Page_66'>66</a>.</li> - <li class='c046'>Migraine, <a href='#Page_19'>19</a>.</li> - <li class='c046'>Mitchell, H. W., <a href='#Page_218'>218</a>.</li> - <li class='c046'>Mœbius, <a href='#Page_429'>429</a>.</li> - <li class='c046'>Mott, F. W., <a href='#Page_158'>158</a>, <a href='#Page_257'>257</a>, <a href='#Page_308'>308</a>, <a href='#Page_396'>396</a>, <a href='#Page_437'>437</a>.</li> - <li class='c046'>Multiple sclerosis, <a href='#Page_253'>253</a>, <a href='#Page_256'>256</a>. - <ul> - <li>relation of syphilis to, <a href='#Page_254'>254</a>.</li> - <li>spinal fluid findings in, <a href='#Page_254'>254</a>.</li> - </ul> - </li> - <li class='c046'>Muscular atrophy, <a href='#Page_149'>149</a>, <a href='#Page_446'>446</a>. - <ul> - <li>syphilitic relation to amyotrophic lateral sclerosis, <a href='#Page_150'>150</a>.</li> - </ul> - </li> - <li class='c046'>Muscular weakness, <a href='#Page_279'>279</a>.</li> - <li class='c046'>Myerson, A., <a href='#Page_196'>196</a>.</li> - <li class='c002'>Nageotti, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Nausea, <a href='#Page_63'>63</a>.</li> - <li class='c046'>Neisser, <a href='#Page_399'>399</a>.</li> - <li class='c046'>Nerve trunk tenderness, <a href='#Page_148'>148</a>, <a href='#Page_234'>234</a>.</li> - <li class='c046'>Nervousness, <a href='#Page_63'>63</a>.</li> - <li class='c046'>Nervous indigestion, <a href='#Page_63'>63</a>.</li> - <li class='c046'>Neurasthenia, <a href='#Page_63'>63</a>, <a href='#Page_183'>183</a>.</li> - <li class='c046'>Neuritis, cranial, <a href='#Page_51'>51</a>. - <ul> - <li>optic, <a href='#Page_365'>365</a>.</li> - <li>root, <a href='#Page_235'>235</a>.</li> - <li>syphilitic, <a href='#Page_235'>235</a>.</li> - </ul> - </li> - <li class='c046'>Neurorecidive, <a href='#Page_152'>152</a>, <a href='#Page_153'>153</a>, <a href='#Page_184'>184</a>, <a href='#Page_196'>196</a>, <a href='#Page_235'>235</a>.</li> - <li class='c046'>Neuroses, relation of syphilis to, <a href='#Page_186'>186</a>.</li> - <li class='c046'>Neurosyphilis, <a href='#Page_187'>187</a>, <a href='#Page_238'>238</a>, <a href='#Page_240'>240</a>, <a href='#Page_242'>242</a>. - <ul> - <li>aggravated on military service, <a href='#Page_404'>404</a>.</li> - <li>atypical, <a href='#Page_258'>258</a>, <a href='#Page_346'>346</a>.</li> - <li>atypical case resembling hysterical fugue, <a href='#Page_264'>264</a>.</li> - <li>dates, <a href='#Page_428'>428</a>.</li> - <li>forms of, <a href='#Page_20'>20</a>, <a href='#Page_21'>21</a>, <a href='#Page_28'>28</a>, <a href='#Page_29'>29</a>, <a href='#Page_95'>95</a>.</li> - <li>galloping, <a href='#Page_328'>328</a>.</li> - <li>history of, <a href='#Page_427'>427</a>.</li> - <li>incubation period, <a href='#Page_152'>152</a>.</li> - <li>infectiousness of, <a href='#Page_95'>95</a>.</li> - <li><span class='pageno' id='Page_493'>493</span>laboratory findings in, <a href='#Page_82'>82</a>.</li> - <li>latent, <a href='#Page_142'>142</a>, <a href='#Page_203'>203</a>.</li> - <li>lesions, <a href='#Page_303'>303</a>.</li> - <li>lighted up by stress of military service, <a href='#Page_412'>412</a>.</li> - <li>and marriage, <a href='#Page_319'>319</a>.</li> - <li>prevention, <a href='#Page_320'>320</a>.</li> - <li>onset, <a href='#Page_64'>64</a>.</li> - <li>in primary stage, <a href='#Page_186'>186</a>.</li> - <li>in secondary stage, <a href='#Page_185'>185</a>, <a href='#Page_283'>283</a>, <a href='#Page_390'>390</a>.</li> - <li>in secondary stage, prognosis, <a href='#Page_390'>390</a>.</li> - <li>in secondary stage, treatment, <a href='#Page_153'>153</a>.</li> - <li>spinal, <a href='#Page_23'>23</a>.</li> - <li>and the war, <a href='#Page_399'>399</a>, <a href='#Page_466'>466</a>.</li> - </ul> - </li> - <li class='c046'>Nissl-Alzheimer method, <a href='#Page_427'>427</a>.</li> - <li class='c046'>Noguchi, <a href='#Page_381'>381</a>. - <ul> - <li>and Moore, <a href='#Page_428'>428</a>, <a href='#Page_429'>429</a>.</li> - </ul> - </li> - <li class='c046'>Nonne, <a href='#Page_82'>82</a>, <a href='#Page_125'>125</a>, <a href='#Page_152'>152</a>, <a href='#Page_186'>186</a>, <a href='#Page_195'>195</a>, <a href='#Page_196'>196</a>, <a href='#Page_214'>214</a>, <a href='#Page_216'>216</a>, <a href='#Page_235'>235</a>, <a href='#Page_254'>254</a>, <a href='#Page_265'>265</a>. - <ul> - <li>-Apelt test, <a href='#Page_473'>473</a>.</li> - </ul> - </li> - <li class='c046'>Numbness, <a href='#Page_56'>56</a>.</li> - <li class='c046'>Nystagmus, <a href='#Page_45'>45</a>, <a href='#Page_253'>253</a>, <a href='#Page_256'>256</a>, <a href='#Page_279'>279</a>.</li> - <li class='c002'>Obersteiner, <a href='#Page_249'>249</a>.</li> - <li class='c046'>Occupation-neurosis, <a href='#Page_312'>312</a>.</li> - <li class='c046'>Ogilvie method, <a href='#Page_487'>487</a>.</li> - <li class='c046'>Operation for gumma, <a href='#Page_139'>139</a>.</li> - <li class='c046'>Optic atrophy, <a href='#Page_256'>256</a>. - <ul> - <li>in juvenile paretic neurosyphilis, <a href='#Page_154'>154</a>.</li> - </ul> - </li> - <li class='c046'>Optic thalamus, syphilitic lesion of, <a href='#Page_205'>205</a>.</li> - <li class='c046'>Osteitis, syphilitic, <a href='#Page_311'>311</a>.</li> - <li class='c046'>Ozena, <a href='#Page_350'>350</a>.</li> - <li class='c002'>Pains, <a href='#Page_31'>31</a>.</li> - <li class='c046'>Pandy test, <a href='#Page_474'>474</a>.</li> - <li class='c046'>Paralysis, <a href='#Page_123'>123</a>. - <ul> - <li>recovery from, <a href='#Page_342'>342</a>.</li> - <li>of respiration, <a href='#Page_248'>248</a>.</li> - </ul> - </li> - <li class='c046'>Paranoia, syphilitic, <a href='#Page_225'>225</a>.</li> - <li class='c046'>Paraphasia, <a href='#Page_19'>19</a>, <a href='#Page_43'>43</a>.</li> - <li class='c046'>Paraplegia, <a href='#Page_26'>26</a>, <a href='#Page_30'>30</a>.</li> - <li class='c046'>Parasyphilis, <a href='#Page_89'>89</a>.</li> - <li class='c046'><em>Paresis sine paresi</em>, <a href='#Page_126'>126</a>, <a href='#Page_186'>186</a>, <a href='#Page_204'>204</a>, <a href='#Page_303'>303</a>, <a href='#Page_445'>445</a>.</li> - <li class='c046'>Paresis, see paretic neurosyphilis.</li> - <li class='c046'>Paretic neurosyphilis, dementia paralytica, general paresis, softening of the brain, <a href='#Page_37'>37</a>, <a href='#Page_63'>63</a>, <a href='#Page_68'>68</a>, <a href='#Page_74'>74</a>, <a href='#Page_78'>78</a>, <a href='#Page_80'>80</a>, <a href='#Page_85'>85</a>, <a href='#Page_97'>97</a>, <a href='#Page_131'>131</a>, <a href='#Page_188'>188</a>, <a href='#Page_192'>192</a>, <a href='#Page_197'>197</a>, <a href='#Page_199'>199</a>, <a href='#Page_202'>202</a>, <a href='#Page_227'>227</a>, <a href='#Page_241'>241</a>, <a href='#Page_262'>262</a>, <a href='#Page_289'>289</a>, <a href='#Page_295'>295</a>, <a href='#Page_309'>309</a>, <a href='#Page_314'>314</a>, <a href='#Page_323'>323</a>, <a href='#Page_338'>338</a>, <a href='#Page_372'>372</a>, <a href='#Page_375'>375</a>, <a href='#Page_377'>377</a>, <a href='#Page_382'>382</a>, <a href='#Page_384'>384</a>, <a href='#Page_386'>386</a>, <a href='#Page_388'>388</a>, <a href='#Page_392'>392</a>, <a href='#Page_435'>435</a>, -<a href='#Page_440'>440</a>, <a href='#Page_442'>442</a>. - <ul> - <li>adjuvant causes of, <a href='#Page_414'>414</a>.</li> - <li>causing social complications, <a href='#Page_289'>289</a>.</li> - <li>causes of death in, <a href='#Page_197'>197</a>.</li> - <li>course, <a href='#Page_85'>85</a>.</li> - <li>duration, <a href='#Page_88'>88</a>.</li> - <li>forms, <a href='#Page_95'>95</a>.</li> - <li>improvement, <a href='#Page_377'>377</a>.</li> - <li>incidence among officers, <a href='#Page_407'>407</a>.</li> - <li>incidence among soldiers, <a href='#Page_402'>402</a>.</li> - <li>lesions of, <a href='#Page_131'>131</a>.</li> - <li>“lighted up” by domestic stress in civil life, <a href='#Page_420'>420</a>.</li> - <li>“lighted up” by “gassing,” <a href='#Page_414'>414</a>.</li> - <li>mortality from, <a href='#Page_89'>89</a>.</li> - <li>nomenclature, <a href='#Page_88'>88</a>.</li> - <li>onset, <a href='#Page_192'>192</a>.</li> - <li>pathology of, <a href='#Page_436'>436</a>.</li> - <li>prognosis, <a href='#Page_435'>435</a>, <a href='#Page_444'>444</a>.</li> - <li>symptoms, <a href='#Page_90'>90</a>, <a href='#Page_131'>131</a>.</li> - <li>symptoms, mental, <a href='#Page_87'>87</a>.</li> - <li>symptoms, physical, <a href='#Page_86'>86</a>.</li> - <li>versus diffuse neurosyphilis, <a href='#Page_165'>165</a>.</li> - <li>versus vascular neurosyphilis, <a href='#Page_169'>169</a>, <a href='#Page_172'>172</a>.</li> - <li>with very marked meningitis, <a href='#Page_332'>332</a>.</li> - <li>with very marked brain atrophy, <a href='#Page_335'>335</a>.</li> - <li>without mental symptoms, <a href='#Page_315'>315</a>.</li> - <li>traumatic exacerbation, <a href='#Page_310'>310</a>.</li> - <li>traumatic form, <a href='#Page_308'>308</a>, <a href='#Page_413'>413</a>.</li> - <li>traumatic, shell-shock, <a href='#Page_401'>401</a>.</li> - <li>treatment of, <a href='#Page_85'>85</a>, <a href='#Page_370'>370</a>, <a href='#Page_372'>372</a>, <a href='#Page_377'>377</a>, <a href='#Page_382'>382</a>, <a href='#Page_384'>384</a>, <a href='#Page_386'>386</a>, <a href='#Page_388'>388</a>, <a href='#Page_392'>392</a>.</li> - <li>treatment, results of, <a href='#Page_351'>351</a>.</li> - </ul> - </li> - <li class='c046'>Pensions for disabilities resulting from venereal disease, <a href='#Page_409'>409</a>.</li> - <li class='c046'>Pensions for neurosyphilis, <a href='#Page_411'>411</a>.</li> - <li class='c046'>Peripheral neurosyphilis, <a href='#Page_19'>19</a>.</li> - <li class='c046'>Perivascular infiltration, <a href='#Page_41'>41</a>.</li> - <li class='c046'>Pernicious anemia with spinal symptoms, <a href='#Page_267'>267</a>.</li> - <li class='c046'>Petit mal attacks, <a href='#Page_195'>195</a>.</li> - <li class='c046'>Pförringer, <a href='#Page_61'>61</a>.</li> - <li class='c046'>Phobia, <a href='#Page_67'>67</a>.</li> - <li class='c046'>Pilcz, Mattauschek and, <a href='#Page_347'>347</a>.</li> - <li class='c046'>Pitres and Marchand, <a href='#Page_421'>421</a>, <a href='#Page_424'>424</a>.</li> - <li class='c046'>Plaut, <a href='#Page_249'>249</a>, <a href='#Page_348'>348</a>, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Plaut, Rehm and Schottmüller, <a href='#Page_471'>471</a>.</li> - <li class='c046'>Plasmocytosis, <a href='#Page_40'>40</a>, <a href='#Page_49'>49</a>, <a href='#Page_55'>55</a>.</li> - <li class='c046'><span class='pageno' id='Page_494'>494</span>Pleocytosis, <a href='#Page_23'>23</a>, <a href='#Page_220'>220</a>, <a href='#Page_247'>247</a>, <a href='#Page_344'>344</a>. - <ul> - <li>effect of antisyphilitic treatment on, <a href='#Page_244'>244</a>, <a href='#Page_376'>376</a>.</li> - <li>in remissions, <a href='#Page_243'>243</a>.</li> - <li>significance of, <a href='#Page_243'>243</a>.</li> - <li>spinal fluid otherwise negative, <a href='#Page_270'>270</a>.</li> - </ul> - </li> - <li class='c046'>Polydipsia, <a href='#Page_190'>190</a>.</li> - <li class='c046'>Polyuria, <a href='#Page_190'>190</a>.</li> - <li class='c046'>Pontine hemorrhage, <a href='#Page_219'>219</a>. - <ul> - <li>softening, <a href='#Page_54'>54</a>.</li> - </ul> - </li> - <li class='c046'>Posey and Spiller, <a href='#Page_257'>257</a>.</li> - <li class='c046'>Potassium iodid, <a href='#Page_58'>58</a>, <a href='#Page_85'>85</a>, <a href='#Page_98'>98</a>, <a href='#Page_193'>193</a>, <a href='#Page_222'>222</a>, <a href='#Page_376'>376</a>, <a href='#Page_377'>377</a>, <a href='#Page_389'>389</a>, <a href='#Page_486'>486</a>.</li> - <li class='c046'>Preparesis, <a href='#Page_65'>65</a>, <a href='#Page_77'>77</a>, <a href='#Page_78'>78</a>.</li> - <li class='c046'>Prince, Morton, <a href='#Page_195'>195</a>.</li> - <li class='c046'>Psammoma, <a href='#Page_213'>213</a>.</li> - <li class='c046'>Pseudoneurasthenia, <a href='#Page_66'>66</a>.</li> - <li class='c046'>Pseudoparesis, <a href='#Page_449'>449</a>. - <ul> - <li>alcoholic, <a href='#Page_222'>222</a>, <a href='#Page_229'>229</a>, <a href='#Page_451'>451</a>.</li> - <li>diabetic, <a href='#Page_238'>238</a>.</li> - <li>senile, <a href='#Page_263'>263</a>.</li> - <li>shell-shock, <a href='#Page_421'>421</a>.</li> - <li>syphilitic, <a href='#Page_223'>223</a>, <a href='#Page_371'>371</a>.</li> - </ul> - </li> - <li class='c046'>Pseudoparetic neurosyphilis, <a href='#Page_222'>222</a>.</li> - <li class='c046'>Pseudotabes, shell-shock, <a href='#Page_424'>424</a>.</li> - <li class='c046'>Psychogenic neurosyphilis, <a href='#Page_189'>189</a>.</li> - <li class='c046'>Psychographic disturbance, <a href='#Page_228'>228</a>.</li> - <li class='c046'>Psychopathic personality, <a href='#Page_302'>302</a>.</li> - <li class='c046'>Ptosis, <a href='#Page_350'>350</a>.</li> - <li class='c046'>Pupillary reaction, changes in, <a href='#Page_261'>261</a>. - <ul> - <li>signs, <a href='#Page_69'>69</a>.</li> - </ul> - </li> - <li class='c046'>Pupils, Argyll-Robertson, see Argyll-Robertson pupils. - <ul> - <li>irregular, <a href='#Page_79'>79</a>, <a href='#Page_201'>201</a>.</li> - <li>normally reacting in paretic neurosyphilis, <a href='#Page_199'>199</a>.</li> - <li>sluggish reaction to light, <a href='#Page_188'>188</a>.</li> - <li>stiff as isolated symptom, <a href='#Page_265'>265</a>.</li> - </ul> - </li> - <li class='c046'>Purkinje cells, binucleate, <a href='#Page_48'>48</a>.</li> - <li class='c046'>Putnam, James J., <a href='#Page_19'>19</a>, <a href='#Page_56'>56</a>.</li> - <li class='c046'>Pyramidal tract lesion, bilateral, <a href='#Page_326'>326</a>. - <ul> - <li>sclerosis, <a href='#Page_44'>44</a>.</li> - </ul> - </li> - <li class='c002'>Quadriplegia in juvenile paretic neurosyphilis, <a href='#Page_275'>275</a>.</li> - <li class='c046'>Quincke, <a href='#Page_427'>427</a>, <a href='#Page_428'>428</a>.</li> - <li class='c002'><em>Randsklerose</em>, <a href='#Page_24'>24</a>.</li> - <li class='c046'>Ravaut, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Ravaut, Sicard, Nageotti, Widal, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Rayneau, <a href='#Page_407'>407</a>, <a href='#Page_413'>413</a>, <a href='#Page_414'>414</a>.</li> - <li class='c046'>Recovery, <a href='#Page_77'>77</a>.</li> - <li class='c046'>Recurrences, <a href='#Page_70'>70</a>.</li> - <li class='c046'>Redlich, <a href='#Page_403'>403</a>.</li> - <li class='c046'>Régis, <a href='#Page_73'>73</a>.</li> - <li class='c046'>Remissions, <a href='#Page_122'>122</a>, <a href='#Page_435'>435</a>, <a href='#Page_445'>445</a>.</li> - <li class='c046'>Retardation, <a href='#Page_187'>187</a>.</li> - <li class='c046'>Retention of urine, <a href='#Page_56'>56</a>.</li> - <li class='c046'>Retinitis, hemorrhages, <a href='#Page_365'>365</a>.</li> - <li class='c046'>Richards, R. L., <a href='#Page_402'>402</a>, <a href='#Page_404'>404</a>, <a href='#Page_406'>406</a>, <a href='#Page_409'>409</a>.</li> - <li class='c046'>Robertson, A. R., <a href='#Page_59'>59</a>.</li> - <li class='c046'>Rod cells, <a href='#Page_226'>226</a>, <a href='#Page_297'>297</a>.</li> - <li class='c046'>Romberg sign, <a href='#Page_141'>141</a>, <a href='#Page_216'>216</a>, <a href='#Page_279'>279</a>.</li> - <li class='c046'>Root-sciatica, syphilitic, <a href='#Page_418'>418</a>.</li> - <li class='c046'>Rosenau, <a href='#Page_471'>471</a>.</li> - <li class='c046'>Ross-Jones test, <a href='#Page_473'>473</a>.</li> - <li class='c046'>“Rum fit,” <a href='#Page_229'>229</a>.</li> - <li class='c046'>Ryder, Charles T., <a href='#Page_42'>42</a>.</li> - <li class='c002'>Saddle-shaped nose, <a href='#Page_210'>210</a>.</li> - <li class='c046'>Salivation, <a href='#Page_98'>98</a>.</li> - <li class='c046'>Salmon, Thomas W., <a href='#Page_89'>89</a>.</li> - <li class='c046'>Salvarsan, <a href='#Page_75'>75</a>, <a href='#Page_83'>83</a>, <a href='#Page_85'>85</a>, <a href='#Page_193'>193</a>, <a href='#Page_222'>222</a>, <a href='#Page_377'>377</a>, <a href='#Page_389'>389</a>, <a href='#Page_486'>486</a>. - <ul> - <li>provocative, <a href='#Page_78'>78</a>, <a href='#Page_79'>79</a>.</li> - <li>untoward results of, <a href='#Page_363'>363</a>.</li> - </ul> - </li> - <li class='c046'>Salvarsanized serum, <a href='#Page_75'>75</a>.</li> - <li class='c046'>Schaudinn, <a href='#Page_427'>427</a>, <a href='#Page_429'>429</a>.</li> - <li class='c046'>Sciatic pain in neurosyphilis, <a href='#Page_149'>149</a>.</li> - <li class='c046'>Seizures, <a href='#Page_31'>31</a>, <a href='#Page_64'>64</a>, <a href='#Page_83'>83</a>, <a href='#Page_103'>103</a>, <a href='#Page_444'>444</a>. - <ul> - <li>causes of in paretic neurosyphilis, <a href='#Page_194'>194</a>.</li> - <li>Jacksonian, <a href='#Page_392'>392</a>.</li> - <li>minor, <a href='#Page_392'>392</a>.</li> - </ul> - </li> - <li class='c046'>Senile arteriosclerotic psychosis, <a href='#Page_262'>262</a>.</li> - <li class='c046'>Sensitized cells, <a href='#Page_478'>478</a>.</li> - <li class='c046'>Sérieux and Ducaste, <a href='#Page_96'>96</a>.</li> - <li class='c046'>Shaikewicz, <a href='#Page_404'>404</a>.</li> - <li class='c046'>Shanahan, <a href='#Page_278'>278</a>.</li> - <li class='c046'>Sheep’s corpuscles, <a href='#Page_477'>477</a>.</li> - <li class='c046'>Shock, <a href='#Page_42'>42</a>, <a href='#Page_81'>81</a>.</li> - <li class='c046'>Sicard, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Six tests, <a href='#Page_80'>80</a>, <a href='#Page_85'>85</a>. - <ul> - <li>in tabetic neurosyphilis, <a href='#Page_141'>141</a>.</li> - </ul> - </li> - <li class='c046'>Smith and Solomon, <a href='#Page_479'>479</a>.</li> - <li class='c046'>Social cases, <a href='#Page_454'>454</a>. - <ul> - <li>service, <a href='#Page_232'>232</a>.</li> - </ul> - </li> - <li class='c046'>Solomon, <a href='#Page_142'>142</a>, <a href='#Page_255'>255</a>. - <ul> - <li>and Koefod, <a href='#Page_243'>243</a>.</li> - <li>Smith and, <a href='#Page_479'>479</a>.</li> - <li>Southard and, <a href='#Page_202'>202</a>, <a href='#Page_303'>303</a>.</li> - </ul> - </li> - <li class='c046'>Somnolence, <a href='#Page_45'>45</a>.</li> - <li class='c046'><span class='pageno' id='Page_495'>495</span>Southard, E. E., <a href='#Page_48'>48</a>, <a href='#Page_134'>134</a>, <a href='#Page_212'>212</a>. - <ul> - <li>and Canavan, <a href='#Page_70'>70</a>.</li> - <li>and Solomon, <a href='#Page_202'>202</a>, <a href='#Page_303'>303</a>.</li> - <li>and Taft, <a href='#Page_397'>397</a>.</li> - </ul> - </li> - <li class='c046'>Spasms, clonic, <a href='#Page_326'>326</a>.</li> - <li class='c046'>Spastic hemiplegia in paretic neurosyphilis, <a href='#Page_323'>323</a>.</li> - <li class='c046'>Spastic paraplegia, Erb’s, <a href='#Page_147'>147</a>, <a href='#Page_306'>306</a>.</li> - <li class='c046'>Spasticity, <a href='#Page_18'>18</a>, <a href='#Page_256'>256</a>.</li> - <li class='c046'>Speech defect, <a href='#Page_69'>69</a>, <a href='#Page_133'>133</a>.</li> - <li class='c046'>Spiller, <a href='#Page_150'>150</a>. - <ul> - <li>Posey and, <a href='#Page_257'>257</a>.</li> - </ul> - </li> - <li class='c046'>Spinal fluid findings in secondary stage of syphilis, <a href='#Page_151'>151</a>, <a href='#Page_185'>185</a>, <a href='#Page_283'>283</a>. - <ul> - <li>in juvenile paretic neurosyphilis, <a href='#Page_275'>275</a>.</li> - <li>negative in diffuse neurosyphilis, <a href='#Page_140'>140</a>.</li> - <li>negative in gummatous neurosyphilis, <a href='#Page_138'>138</a>.</li> - <li>negative in neurosyphilis, <a href='#Page_216'>216</a>.</li> - <li>negative in tabetic neurosyphilis, <a href='#Page_269'>269</a>.</li> - <li>in tabetic neurosyphilis, <a href='#Page_141'>141</a>.</li> - </ul> - </li> - <li class='c046'>Spinal fluid, withdrawal for therapeutic purposes, <a href='#Page_377'>377</a>, <a href='#Page_379'>379</a>.</li> - <li class='c046'>Spinal syphilis, see diffuse neurosyphilis.</li> - <li class='c046'>Spirochetes, “drug fastness,” <a href='#Page_381'>381</a>, <a href='#Page_394'>394</a>. - <ul> - <li>strains, <a href='#Page_76'>76</a>, <a href='#Page_263'>263</a>, <a href='#Page_276'>276</a>, <a href='#Page_381'>381</a>, <a href='#Page_394'>394</a>.</li> - </ul> - </li> - <li class='c046'>Steida, <a href='#Page_405'>405</a>.</li> - <li class='c046'>Sterility in tabetic neurosyphilis, <a href='#Page_144'>144</a>.</li> - <li class='c046'>Stier, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Stokes, Wile and, <a href='#Page_186'>186</a>.</li> - <li class='c046'>Suicide, <a href='#Page_92'>92</a>, <a href='#Page_126'>126</a>, <a href='#Page_240'>240</a>, <a href='#Page_296'>296</a>, <a href='#Page_301'>301</a>.</li> - <li class='c046'>Summary, <a href='#Page_427'>427</a>.</li> - <li class='c046'>Syphilis aggravated by service, <a href='#Page_406'>406</a>, <a href='#Page_411'>411</a>. - <ul> - <li>on service, <a href='#Page_409'>409</a>.</li> - </ul> - </li> - <li class='c046'>Syphilis as cause of diabetes, <a href='#Page_241'>241</a>. - <ul> - <li>as cause of feeblemindedness, <a href='#Page_396'>396</a>.</li> - <li>hereditaria tarda, <a href='#Page_160'>160</a>, <a href='#Page_318'>318</a>.</li> - <li>history of, <a href='#Page_427'>427</a>.</li> - <li>lesions in, <a href='#Page_329'>329</a>.</li> - <li>of lung, <a href='#Page_211'>211</a>.</li> - <li>from Mongolian, <a href='#Page_76'>76</a>.</li> - <li>primary, <a href='#Page_65'>65</a>.</li> - <li>secondary, <a href='#Page_65'>65</a>.</li> - <li>tertiary, lesions in, <a href='#Page_329'>329</a>.</li> - </ul> - </li> - <li class='c046'>Syphilitic feeblemindedness, pathology of, <a href='#Page_160'>160</a>. - <ul> - <li>neuritis, <a href='#Page_312'>312</a>.</li> - <li>psychosis, <a href='#Page_91'>91</a>.</li> - </ul> - </li> - <li class='c046'>Syphilophobia, <a href='#Page_67'>67</a>, <a href='#Page_361'>361</a>.</li> - <li class='c046'>Syphilotoxins, <a href='#Page_72'>72</a>.</li> - <li class='c046'>Swift, <a href='#Page_129'>129</a>, <a href='#Page_212'>212</a>.</li> - <li class='c046'>Swift and Ellis, <a href='#Page_428'>428</a>, <a href='#Page_429'>429</a>. - <ul> - <li>method, <a href='#Page_428'>428</a>, <a href='#Page_487'>487</a>.</li> - </ul> - </li> - <li class='c002'>Tabes dorsalis, see tabetic neurosyphilis.</li> - <li class='c046'>Tabetic neurosyphilis, tabes dorsalis, locomotor ataxia, <a href='#Page_30'>30</a>, <a href='#Page_31'>31</a>, <a href='#Page_141'>141</a>, <a href='#Page_146'>146</a>, <a href='#Page_366'>366</a>, <a href='#Page_367'>367</a>, <a href='#Page_434'>434</a>, <a href='#Page_446'>446</a>. - <ul> - <li>associated with cerebral symptoms, <a href='#Page_177'>177</a>.</li> - <li>atypical, <a href='#Page_143'>143</a>.</li> - <li>cervical, <a href='#Page_146'>146</a>.</li> - <li>course, <a href='#Page_141'>141</a>.</li> - <li>with negative spinal fluid findings, <a href='#Page_269'>269</a>.</li> - <li>prognosis, <a href='#Page_94'>94</a>.</li> - <li>shell-shock, <a href='#Page_403'>403</a>.</li> - <li>“shell-shocked” into paretic neurosyphilis, <a href='#Page_401'>401</a>.</li> - <li>symptoms, <a href='#Page_93'>93</a>.</li> - <li>symptoms in order of frequency, <a href='#Page_145'>145</a>.</li> - <li>treatment, <a href='#Page_145'>145</a>, <a href='#Page_366'>366</a>, <a href='#Page_367'>367</a>.</li> - <li>plus vascular neurosyphilis, <a href='#Page_175'>175</a>.</li> - <li>with vascular insult, <a href='#Page_30'>30</a>, <a href='#Page_439'>439</a>.</li> - <li>versus pernicious anemia, <a href='#Page_267'>267</a>.</li> - </ul> - </li> - <li class='c046'>Taboparesis, see Taboparetic neurosyphilis.</li> - <li class='c046'>Taboparetic neurosyphilis, taboparesis, <a href='#Page_92'>92</a>, <a href='#Page_135'>135</a>, <a href='#Page_195'>195</a>, <a href='#Page_284'>284</a>, <a href='#Page_443'>443</a>. - <ul> - <li>course, <a href='#Page_92'>92</a>.</li> - <li>nomenclature, <a href='#Page_94'>94</a>.</li> - <li>prognosis, <a href='#Page_92'>92</a>, <a href='#Page_443'>443</a>.</li> - <li>and typhoid meningitis, <a href='#Page_284'>284</a>.</li> - </ul> - </li> - <li class='c046'>Taft, A. E., Southard, E. E., and,</li> - <li class='c046'>Talon, <a href='#Page_407'>407</a>.</li> - <li class='c046'>Taylor, E. W., <a href='#Page_50'>50</a>.</li> - <li class='c046'>Temperature, paretic, <a href='#Page_376'>376</a>.</li> - <li class='c046'>Tests, changes under treatment, <a href='#Page_102'>102</a>. - <ul> - <li>changed to negative in paretic neurosyphilis without clinical improvement, <a href='#Page_385'>385</a>.</li> - <li>changed to less strongly positive in paretic neurosyphilis without clinical improvement, <a href='#Page_386'>386</a>.</li> - </ul> - </li> - <li class='c046'>Therapeutic conception, <a href='#Page_324'>324</a>.</li> - <li class='c046'>Thibierge, <a href='#Page_399'>399</a>.</li> - <li class='c046'>Thierry, <a href='#Page_158'>158</a>.</li> - <li class='c046'>Throbbing in head, <a href='#Page_63'>63</a>.</li> - <li class='c046'><span class='pageno' id='Page_496'>496</span>Thrombosis, cerebral, <a href='#Page_36'>36</a>, <a href='#Page_42'>42</a>, <a href='#Page_342'>342</a>, <a href='#Page_357'>357</a>, <a href='#Page_360'>360</a>, <a href='#Page_124'>124</a>.</li> - <li class='c046'>Thymus, persistent, <a href='#Page_282'>282</a>.</li> - <li class='c046'>Tibial exostoses, <a href='#Page_100'>100</a>.</li> - <li class='c046'>Tigges’ formula, <a href='#Page_248'>248</a>.</li> - <li class='c046'>Todd, J. L., <a href='#Page_406'>406</a>, <a href='#Page_409'>409</a>.</li> - <li class='c046'>Transient deafness, <a href='#Page_18'>18</a>. - <ul> - <li>blindness, <a href='#Page_18'>18</a>.</li> - <li>paralysis, <a href='#Page_124'>124</a>.</li> - <li>paralysis, condition in which occurs, <a href='#Page_123'>123</a>.</li> - </ul> - </li> - <li class='c046'>Trauma and juvenile neurosyphilis, <a href='#Page_278'>278</a>, <a href='#Page_306'>306</a>. - <ul> - <li>neurosyphilis, <a href='#Page_456'>456</a>.</li> - <li>paretic neurosyphilis, <a href='#Page_199'>199</a>, <a href='#Page_308'>308</a>, <a href='#Page_310'>310</a>.</li> - <li>syphilitic osteitis, <a href='#Page_311'>311</a>.</li> - </ul> - </li> - <li class='c046'>Treatment of neurosyphilis, <a href='#Page_67'>67</a>, <a href='#Page_75'>75</a>, <a href='#Page_83'>83</a>, <a href='#Page_124'>124</a>, <a href='#Page_148'>148</a>, <a href='#Page_184'>184</a>, <a href='#Page_222'>222</a>, <a href='#Page_235'>235</a>, <a href='#Page_299'>299</a>, <a href='#Page_328'>328</a>, <a href='#Page_332'>332</a>, <a href='#Page_335'>335</a>, <a href='#Page_342'>342</a>, <a href='#Page_346'>346</a>, <a href='#Page_350'>350</a>, <a href='#Page_351'>351</a>, <a href='#Page_355'>355</a>, <a href='#Page_384'>384</a>, <a href='#Page_390'>390</a>, <a href='#Page_392'>392</a>, <a href='#Page_395'>395</a>, <a href='#Page_419'>419</a>, <a href='#Page_439'>439</a>, <a href='#Page_457'>457</a>. - <ul> - <li>case in which theoretically of no avail, <a href='#Page_323'>323</a>.</li> - <li>methods, <a href='#Page_356'>356</a>, <a href='#Page_486'>486</a>.</li> - </ul> - </li> - <li class='c046'>Treatment of syphilis, effect on development of neurosyphilis, <a href='#Page_142'>142</a>, <a href='#Page_347'>347</a>.</li> - <li class='c046'>Tremor, <a href='#Page_197'>197</a>. - <ul> - <li>intention, <a href='#Page_256'>256</a></li> - </ul> - </li> - <li class='c046'>Tubercle, <a href='#Page_80'>80</a>.</li> - <li class='c046'>Tuberous sclerosis of Bourneville, <a href='#Page_47'>47</a>.</li> - <li class='c046'>Tumor, cerebral, <a href='#Page_53'>53</a>, <a href='#Page_191'>191</a>, <a href='#Page_238'>238</a>, <a href='#Page_253'>253</a>. - <ul> - <li>pineal, <a href='#Page_213'>213</a>.</li> - </ul> - </li> - <li class='c002'>Unconsciousness, <a href='#Page_53'>53</a>. - <ul> - <li>causes of, <a href='#Page_389'>389</a>.</li> - </ul> - </li> - <li class='c002'>Vascular changes, <a href='#Page_220'>220</a>.</li> - <li class='c046'>Vascular neurosyphilis, <a href='#Page_31'>31</a>, <a href='#Page_42'>42</a>, <a href='#Page_72'>72</a>, <a href='#Page_296'>296</a>, <a href='#Page_359'>359</a>, <a href='#Page_433'>433</a>, <a href='#Page_440'>440</a>. - <ul> - <li>plus tabetic neurosyphilis, <a href='#Page_175'>175</a>.</li> - <li>prognosis, <a href='#Page_433'>433</a>.</li> - <li>versus paretic neurosyphilis, <a href='#Page_169'>169</a>, <a href='#Page_172'>172</a>.</li> - </ul> - </li> - <li class='c046'>Veeder, B. S., <a href='#Page_274'>274</a>.</li> - <li class='c046'>Vertigo, <a href='#Page_122'>122</a>.</li> - <li class='c046'>Viet, <a href='#Page_278'>278</a>.</li> - <li class='c046'>Virchow, <a href='#Page_427'>427</a>, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Vomiting, <a href='#Page_53'>53</a>, <a href='#Page_63'>63</a>.</li> - <li class='c002'>Warthin, <a href='#Page_241'>241</a>.</li> - <li class='c046'>Wassermann reaction, <a href='#Page_191'>191</a>. - <ul> - <li>and alcoholism, <a href='#Page_230'>230</a>.</li> - <li>in congenital syphilis, <a href='#Page_160'>160</a>, <a href='#Page_271'>271</a>.</li> - <li>meaning of “doubtful,” <a href='#Page_360'>360</a>.</li> - <li>negative in diffuse neurosyphilis, <a href='#Page_184'>184</a>.</li> - <li>negative in juvenile paretic neurosyphilis, <a href='#Page_298'>298</a>.</li> - <li>negative in spinal fluid in spinal syphilis, <a href='#Page_148'>148</a>.</li> - <li>negative in spinal fluid in neurosyphilis, <a href='#Page_101'>101</a>.</li> - <li>negative in neurosyphilis, <a href='#Page_252'>252</a>.</li> - <li>negative in paretic neurosyphilis, <a href='#Page_77'>77</a>.</li> - <li>technique, <a href='#Page_476'>476</a>.</li> - <li>titrations in spinal fluid, <a href='#Page_348'>348</a>.</li> - </ul> - </li> - <li class='c046'>Wassermann, Neisser and Bruck, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Weiler, <a href='#Page_214'>214</a>.</li> - <li class='c046'>Weygandt, <a href='#Page_403'>403</a>, <a href='#Page_404'>404</a>.</li> - <li class='c046'>Widal, Sicard, Ravaut, <a href='#Page_428'>428</a>.</li> - <li class='c046'>Wiles and Stokes, <a href='#Page_186'>186</a>.</li> - <li class='c046'>Word-deafness, <a href='#Page_35'>35</a>, <a href='#Page_43'>43</a>.</li> - <li class='c002'>X-ray diagnosis of bone conditions, <a href='#Page_136'>136</a>.</li> - <li class='c002'>Yerkes-Bridges, <a href='#Page_304'>304</a>.</li> - <li class='c002'>Ziehen, <a href='#Page_409'>409</a>.</li> - <li class='c046'>Zsigmondi, <a href='#Page_429'>429</a>, <a href='#Page_474'>474</a>.</li> -</ul> - -<hr class='c052' /> -<div class='footnote' id='f1'> -<p class='c007'><a href='#r1'>1</a>. The cases chosen to illustrate the propositions of the -boxed headings always illustrate several other points. See -the footnotes of Section VI for lists of cases illustrating -special points. The names assigned to the cases are fictitious -and chosen to suggest race or descent.</p> -</div> -<div class='footnote' id='f2'> -<p class='c007'><a href='#r2'>2</a>. Notes of Dr. James J. Putnam.</p> -</div> -<div class='footnote' id='f3'> -<p class='c007'><a href='#r3'>3</a>. </p> -<ul class='index'> - <li class='c046'>M = meningeal</li> - <li class='c046'>V = vascular</li> - <li class='c046'>P = parenchymatous</li> -</ul> -</div> -<div class='footnote' id='f4'> -<p class='c007'><a href='#r4'>4</a>. E. E. Southard: Lesions of the granule layer of the -human cerebellum; <cite>Journal of Medical Research</cite>, XVI, 1907.</p> -</div> -<div class='footnote' id='f5'> -<p class='c007'><a href='#r5'>5</a>. Proof of marked parenchymatous lesions must hang on -post mortem data; the inference here as to the presence of -parenchymatous lesions is a clinical inference.</p> -</div> -<div class='footnote' id='f6'> -<p class='c007'><a href='#r6'>6</a>. Reprinted from an article by Southard & Solomon: -“Latent neurosyphilis and the question of <em>Paresis sine -paresi</em>.” Boston Medical & Surgical Journal, XXIV, 1.</p> -</div> -<div class='footnote' id='f7'> -<p class='c007'><a href='#r7'>7</a>. Solomon: “How Shall Latent Syphilis be Treated? The -Prophylaxis of Syphilis of the Central Nervous System.” -Interstate Medical Journal, XXIII, 8.</p> -</div> -<div class='footnote' id='f8'> -<p class='c007'><a href='#r8'>8</a>. Joseph Collins: Syphilis of the Brain, <cite>Journal American -Medical Association</cite>, July 10, 1915, Vol. LXV, pp. 139–144.</p> -</div> -<div class='footnote' id='f9'> -<p class='c007'><a href='#r9'>9</a>. A. M. Barrett has recently discussed this subject in a -paper in the <cite>Journal of the American Medical Association</cite>, -Vol. LXVII, Dec. 2, 1916.</p> -</div> -<div class='footnote' id='f10'> -<p class='c007'><a href='#r10'>10</a>. Reprinted from an article by Southard & Solomon: -“Latent neurosyphilis and the Question of <em>Paresis sine -paresi</em>.” Boston Medical and Surgical Journal, XXIV, 1.</p> -</div> -<div class='footnote' id='f11'> -<p class='c007'><a href='#r11'>11</a>. E. E. Southard. A case of glioma of the pineal region, -<cite>Am. Jour. of Ins.</cite>, Vol. LXI, 1905.</p> -</div> -<div class='footnote' id='f12'> -<p class='c007'><a href='#r12'>12</a>. Since this was written Collins has had further difficulties -related to his neurosyphilis, improving under treatment.</p> -</div> -<div class='footnote' id='f13'> -<p class='c007'><a href='#r13'>13</a>. Warthin: “Persistence of active lesions and spirochetes -in the tissues of clinically inactive or ‘cured’ syphilitics,” -<cite>American Journal of Medical Sciences</cite>, CLII, 1916.</p> -</div> -<div class='footnote' id='f14'> -<p class='c007'><a href='#r14'>14</a>. “The Significance of Changes in Cellular Content of -Cerebrospinal Fluid in Neurosyphilis,” <cite>Boston Medical and -Surgical Journal</cite>, CLXXIII, 27.</p> -</div> -<div class='footnote' id='f15'> -<p class='c007'><a href='#r15'>15</a>. <span lang="de" xml:lang="de">Plaut: Ueber Halluzinosen der Syphilitiker, Berlin, 1913.</span></p> -</div> -<div class='footnote' id='f16'> -<p class='c007'><a href='#r16'>16</a>. Borden S. Veeder: Hereditary Syphilis in the Light of -Recent Clinical Studies; Am. Jour. of Med. Sc., CLII, 1916.</p> -</div> -<div class='footnote' id='f17'> -<p class='c007'><a href='#r17'>17</a>. Reprinted from article by Southard and Solomon: “Latent -Neurosyphilis, the Question of <em>Paresis sine paresi</em>,” <cite>Boston -Medical and Surgical Journal</cite>, XXIV, 1.</p> -</div> -<div class='footnote' id='f18'> -<p class='c007'><a href='#r18'>18</a>. (This case was furnished by Dr. D. A. Haller from the -Peter Bent Brigham Hospital series.)</p> -</div> -<div class='footnote' id='f19'> -<p class='c007'><a href='#r19'>19</a>. Fernald, W. E. Standardized Fields of Inquiry for -Clinical Studies of Borderline Defectives. Mental Hygiene, -Vol. 1, No. 2, April, 1917.</p> -</div> -<div class='footnote' id='f20'> -<p class='c007'><a href='#r20'>20</a>. Goddard, H. H., Feeblemindedness, its Causes and -Consequences, 1914.</p> -</div> -<div class='footnote' id='f21'> -<p class='c007'><a href='#r21'>21</a>. W. E. Fernald and E. E. Southard. Waverley Research -Series in the Pathology of the Feebleminded. Proceedings -of the American Academy of Arts and Sciences, 1917.</p> -</div> -<div class='footnote' id='f22'> -<p class='c007'><a href='#r22'>22</a>. <span lang="fr" xml:lang="fr">Thibierge. La Syphilis dans l’armée, 1917.</span></p> -</div> -<div class='footnote' id='f23'> -<p class='c007'><a href='#r23'>23</a>. <span lang="de" xml:lang="de">Hecht. Wien. klin. Woch., xxix, 51.</span></p> -</div> -<div class='footnote' id='f24'> -<p class='c007'><a href='#r24'>24</a>. <span lang="de" xml:lang="de">Donath. Beiträge zu den Kriegsverletzungen und -er-krankungen -des Nervensystems. Wiener klin. Wehnschr.</span>, -No. 27–8, 1915.</p> -</div> -<div class='footnote' id='f25'> -<p class='c007'><a href='#r25'>25</a>. <span lang="fr" xml:lang="fr">Duco et Blum. Guide pratique du Médecin dans les -Expertises médicolégales militaires. Paris, 1917.</span></p> -</div> -<div class='footnote' id='f26'> -<p class='c007'><a href='#r26'>26</a>. <span lang="de" xml:lang="de">Birnbaum. Kriegsneurosen und -psychosen auf Grund -der gegenwärtigen Kriegsbeobachtungen: Sammelbericht. -Z. f. d. ges. Neurol. u. Psychiat., Bd. XII, H. 1, 1915.</span></p> -</div> -<div class='footnote' id='f27'> -<p class='c007'><a href='#r27'>27</a>. <span lang="de" xml:lang="de">Weygandt. Kriegseinflüsse und Psychiatrie. Jahreskurse -f. ärztl. Fortbildung, Maiheft, 1915.</span></p> -</div> -<div class='footnote' id='f28'> -<p class='c007'><a href='#r28'>28</a>. <span lang="de" xml:lang="de">Bonhoeffer. Erfahrungen über Epilepsie und Verwandtes -im Feldzuge. Monatschr. f. Psychiat u. Neurol., -Bd. 38, H. 1–2, 1915.</span></p> -</div> -<div class='footnote' id='f29'> -<p class='c007'><a href='#r29'>29</a>. Exner, M. J., Prostitution in its relation to the army on -the Mexican Border, <cite>Social Hygiene</cite>, Vol. 3, 2, April, 1917.</p> -</div> -<div class='footnote' id='f30'> -<p class='c007'><a href='#r30'>30</a>. Bonhoeffer, <i><span lang="la" xml:lang="la">loc. cit.</span></i></p> -</div> -<div class='footnote' id='f31'> -<p class='c007'><a href='#r31'>31</a>. We have recently reviewed the outcome in 300 <em>untreated</em> -cases of paretic neurosyphilis (Psychopathic Hospital material, -strictly comparable with treated cases) finding but 5 -now capable of self-support and 10 more in normal-looking -remission. This percentage is far lower than that in treated -cases (at present, July, 1917, 50 in 200 capable of self-support).</p> -</div> -<div class='footnote' id='f32'> -<p class='c007'><a href='#r32'>32</a>. </p> -<ul class='index'> - <li class='c046'>Alice Morton (1).</li> -</ul> -</div> -<div class='footnote' id='f33'> -<p class='c007'><a href='#r33'>33</a>. </p> -<ul class='index'> - <li class='c046'>Francis Garfield (2).</li> -</ul> -</div> -<div class='footnote' id='f34'> -<p class='c007'><a href='#r34'>34</a>. </p> -<ul class='index'> - <li class='c046'>John Dixon (3).</li> -</ul> -</div> -<div class='footnote' id='f35'> -<p class='c007'><a href='#r35'>35</a>. </p> -<ul class='index'> - <li class='c046'>James Pierce (4).</li> -</ul> -</div> -<div class='footnote' id='f36'> -<p class='c007'><a href='#r36'>36</a>. </p> -<ul class='index'> - <li class='c046'>John Lawrence (5).</li> -</ul> -</div> -<div class='footnote' id='f37'> -<p class='c007'><a href='#r37'>37</a>. </p> -<ul class='index'> - <li class='c046'>Flora Black (6).</li> -</ul> -</div> -<div class='footnote' id='f38'> -<p class='c007'><a href='#r38'>38</a>. </p> -<ul class='index'> - <li class='c046'>Mrs. Lecompte (7).</li> -</ul> -</div> -<div class='footnote' id='f39'> -<p class='c007'><a href='#r39'>39</a>. </p> -<ul class='index'> - <li class='c046'>John Wyman (8).</li> -</ul> -</div> -<div class='footnote' id='f40'> -<p class='c007'><a href='#r40'>40</a>. </p> -<ul class='index'> - <li class='c046'>Greeley Harrison (9). <em>Also</em></li> - <li class='c046'>Albert Robinson (45),</li> - <li class='c046'>Alice Caperson (46),</li> - <li class='c046'>Abel Bachmann (74).</li> -</ul> -</div> -<div class='footnote' id='f41'> -<p class='c007'><a href='#r41'>41</a>. </p> -<ul class='index'> - <li class='c046'>Lyman Agnew (10). <em>Also</em></li> - <li class='c046'>Ethel Hunter (47),</li> - <li class='c046'>Bessie Vogel (52),</li> - <li class='c046'>Isaac Thompson (83),</li> - <li class='c046'>Juliette Lachine (11).</li> -</ul> -</div> -<div class='footnote' id='f42'> -<p class='c007'><a href='#r42'>42</a>. </p> -<ul class='index'> - <li class='c046'>Juliette Lachine (11). <em>Also</em></li> - <li class='c046'>Lyman Agnew (10),</li> - <li class='c046'>Ethel Hunter (47),</li> - <li class='c046'>Bessie Vogel (52),</li> - <li class='c046'>Isaac Thompson (83).</li> -</ul> -</div> -<div class='footnote' id='f43'> -<p class='c007'><a href='#r43'>43</a>. </p> -<ul class='index'> - <li class='c046'>Henry Philipps (12). <em>Also</em></li> - <li class='c046'>Bridget Curley (59),</li> - <li class='c046'>Margaret O’Brien (68),</li> - <li class='c046'>Annie Martin (117).</li> -</ul> -</div> -<div class='footnote' id='f44'> -<p class='c007'><a href='#r44'>44</a>. </p> -<ul class='index'> - <li class='c046'>William Twist (13). <em>Also</em></li> - <li class='c046'>Lester Crane (20),</li> - <li class='c046'>Thomas Donovan (23).</li> -</ul> -</div> -<div class='footnote' id='f45'> -<p class='c007'><a href='#r45'>45</a>. </p> -<ul class='index'> - <li class='c046'>John Jackson (14). <em>Also</em></li> - <li class='c046'>Martha Bartlett (21),</li> - <li class='c046'>Paolo Marini (28),</li> - <li class='c046'>Margaret O’Brien (68).</li> -</ul> -</div> -<div class='footnote' id='f46'> -<p class='c007'><a href='#r46'>46</a>. </p> -<ul class='index'> - <li class='c046'>Pietro Martiro (15). <em>Also</em></li> - <li class='c046'>Meyer Levenson (22),</li> - <li class='c046'>Achilles Akropovlos (50).</li> -</ul> -</div> -<div class='footnote' id='f47'> -<p class='c007'><a href='#r47'>47</a>. </p> -<ul class='index'> - <li class='c046'>Joseph Sullivan (16).</li> -</ul> -</div> -<div class='footnote' id='f48'> -<p class='c007'><a href='#r48'>48</a>. </p> -<ul class='index'> - <li class='c046'>Gregorian Petrofski (17). <em>Also</em></li> - <li class='c046'>Richard Lawlor (25),</li> - <li class='c046'>John Bennett (34),</li> - <li class='c046'>Julius Kantor (54),</li> - <li class='c046'>Albert Forest (112).</li> -</ul> -</div> -<div class='footnote' id='f49'> -<p class='c007'><a href='#r49'>49</a>. </p> -<ul class='index'> - <li class='c046'>Frederick Wescott (18). <em>Also</em></li> - <li class='c046'>Martha Bartlett (21),</li> - <li class='c046'>James Burns (56),</li> - <li class='c046'>Victor Friedburg (108).</li> -</ul> -</div> -<div class='footnote' id='f50'> -<p class='c007'><a href='#r50'>50</a>. </p> -<ul class='index'> - <li class='c046'>Agnes O’Neil (19). <em>Also</em></li> - <li class='c046'>Michael O’Donnell (24).</li> - <li class='c046'>John Edwards (104).</li> - <li class='c046'>Arthur Bright (121).</li> -</ul> -</div> -<div class='footnote' id='f51'> -<p class='c007'><a href='#r51'>51</a>. </p> -<ul class='index'> - <li class='c046'>Lester Crane (20). <em>Also</em></li> - <li class='c046'>Greeley Harrison (9).</li> - <li class='c046'>David Borofski (49).</li> - <li class='c046'>David Collins (61).</li> -</ul> -</div> -<div class='footnote' id='f52'> -<p class='c007'><a href='#r52'>52</a>. </p> -<ul class='index'> - <li class='c046'>Martha Bartlett (21). <em>Also</em></li> - <li class='c046'>Agnes O’Neil (19),</li> - <li class='c046'>Vivian Walker (87).</li> -</ul> -</div> -<div class='footnote' id='f53'> -<p class='c007'><a href='#r53'>53</a>. </p> -<ul class='index'> - <li class='c046'>Meyer Levenson (22). <em>Also</em></li> - <li class='c046'>Albert Forest (112).</li> -</ul> -</div> -<div class='footnote' id='f54'> -<p class='c007'><a href='#r54'>54</a>. </p> -<ul class='index'> - <li class='c046'>Thomas Donovan (23). <em>Also</em></li> - <li class='c046'>William Twist (13),</li> - <li class='c046'>Bessie Vogel (52),</li> - <li class='c046'>David Collins (61).</li> -</ul> -</div> -<div class='footnote' id='f55'> -<p class='c007'><a href='#r55'>55</a>. </p> -<ul class='index'> - <li class='c046'>Michael O’Donnell (24). <em>Also</em></li> - <li class='c046'>Alice Morton (1).</li> -</ul> -</div> -<div class='footnote' id='f56'> -<p class='c007'><a href='#r56'>56</a>. </p> -<ul class='index'> - <li class='c046'>Richard Lawlor (25). <em>Also</em></li> - <li class='c046'>Bessie Vogel (52),</li> - <li class='c046'>—— —— (88).</li> -</ul> -</div> -<div class='footnote' id='f57'> -<p class='c007'><a href='#r57'>57</a>. </p> -<ul class='index'> - <li class='c046'>John Morrill (26).</li> -</ul> -</div> -<div class='footnote' id='f58'> -<p class='c007'><a href='#r58'>58</a>. </p> -<ul class='index'> - <li class='c046'>David Tannenbaum (27).</li> - <li class='c046'><em>Also</em> Mrs. LeCompte (7),</li> - <li class='c046'>Annie Rivers (109).</li> -</ul> -</div> -<div class='footnote' id='f59'> -<p class='c007'><a href='#r59'>59</a>. </p> -<ul class='index'> - <li class='c046'>Paolo Marini (28). <em>Also</em></li> - <li class='c046'>Flora Black (6).</li> -</ul> -</div> -<div class='footnote' id='f60'> -<p class='c007'><a href='#r60'>60</a>. </p> -<ul class='index'> - <li class='c046'>Mario Sanzi (29). <em>Also</em></li> - <li class='c046'>Stephen Green (30),</li> - <li class='c046'>Paul Halleck (31).</li> -</ul> -</div> -<div class='footnote' id='f61'> -<p class='c007'><a href='#r61'>61</a>. </p> -<ul class='index'> - <li class='c046'>Stephen Green (30). <em>Also</em></li> - <li class='c046'>Paul Halleck (31),</li> - <li class='c046'>Henri Lepère (105),</li> - <li class='c046'>Ivan Rokicki (111).</li> -</ul> -</div> -<div class='footnote' id='f62'> -<p class='c007'><a href='#r62'>62</a>. </p> -<ul class='index'> - <li class='c046'>Paul Halleck (31).</li> -</ul> -</div> -<div class='footnote' id='f63'> -<p class='c007'><a href='#r63'>63</a>. </p> -<ul class='index'> - <li class='c046'>Margaret Neal (32).</li> -</ul> -</div> -<div class='footnote' id='f64'> -<p class='c007'><a href='#r64'>64</a>. </p> -<ul class='index'> - <li class='c046'>Joseph Graham (33).</li> -</ul> -</div> -<div class='footnote' id='f65'> -<p class='c007'><a href='#r65'>65</a>. </p> -<ul class='index'> - <li class='c046'>John Bennett (34). <em>Also</em></li> - <li class='c046'>Alice Caperson (46),</li> - <li class='c046'>Florence Fitzgerald (81),</li> - <li class='c046'>Vivian Walker (87),</li> - <li class='c046'>Arthur Bright (121).</li> -</ul> -</div> -<div class='footnote' id='f66'> -<p class='c007'><a href='#r66'>66</a>. </p> -<ul class='index'> - <li class='c046'>Mary Coughlin (35).</li> -</ul> -</div> -<div class='footnote' id='f67'> -<p class='c007'><a href='#r67'>67</a>. </p> -<ul class='index'> - <li class='c046'>Theresa Mullen (36). <em>Also</em></li> - <li class='c046'>John Lawrence (5),</li> - <li class='c046'>John Friedreich (77),</li> - <li class='c046'>Gridley Ringer (78),</li> - <li class='c046'>James Arnold (80).</li> -</ul> -</div> -<div class='footnote' id='f68'> -<p class='c007'><a href='#r68'>68</a>. </p> -<ul class='index'> - <li class='c046'>Isaac Goldstein (37).</li> -</ul> -</div> -<div class='footnote' id='f69'> -<p class='c007'><a href='#r69'>69</a>. </p> -<ul class='index'> - <li class='c046'>Archibald Sherry (38).</li> -</ul> -</div> -<div class='footnote' id='f70'> -<p class='c007'><a href='#r70'>70</a>. </p> -<ul class='index'> - <li class='c046'>Caroline Davis (39).</li> - <li class='c046'>H. F. (40).</li> - <li class='c046'>Samuel North (41).</li> - <li class='c046'>Elizabeth Brown (42).</li> - <li class='c046'>Robert Allen (43).</li> - <li class='c046'>John Hughes (44).</li> -</ul> -</div> -<div class='footnote' id='f71'> -<p class='c007'><a href='#r71'>71</a>. </p> -<ul class='index'> - <li class='c046'>Albert Robinson (45). <em>Also</em></li> - <li class='c046'>Greeley Harrison (9).</li> -</ul> -</div> -<div class='footnote' id='f72'> -<p class='c007'><a href='#r72'>72</a>. </p> -<ul class='index'> - <li class='c046'>Alice Caperson (46). <em>Also</em></li> - <li class='c046'>Florence Fitzgerald (81).</li> -</ul> -</div> -<div class='footnote' id='f73'> -<p class='c007'><a href='#r73'>73</a>. </p> -<ul class='index'> - <li class='c046'>Ethel Hunter (47). <em>Also</em></li> - <li class='c046'>Lyman Agnew (10),</li> - <li class='c046'>Bessie Vogel (52),</li> - <li class='c046'>Juliette Lachine (11).</li> -</ul> -</div> -<div class='footnote' id='f74'> -<p class='c007'><a href='#r74'>74</a>. </p> -<ul class='index'> - <li class='c046'>Milton Safsky (48). <em>Also</em></li> - <li class='c046'>Daniel Falvey (55).</li> -</ul> -</div> -<div class='footnote' id='f75'> -<p class='c007'><a href='#r75'>75</a>. </p> -<ul class='index'> - <li class='c046'>David Borofski (49). <em>Also</em></li> - <li class='c046'>Lester Crane (20).</li> -</ul> -</div> -<div class='footnote' id='f76'> -<p class='c007'><a href='#r76'>76</a>. </p> -<ul class='index'> - <li class='c046'>Achilles Akropovlos (50).</li> -</ul> -</div> -<div class='footnote' id='f77'> -<p class='c007'><a href='#r77'>77</a>. </p> -<ul class='index'> - <li class='c046'>Daniel Wheelwright (51).</li> -</ul> -</div> -<div class='footnote' id='f78'> -<p class='c007'><a href='#r78'>78</a>. </p> -<ul class='index'> - <li class='c046'>Bessie Vogel (52). <em>Also</em></li> - <li class='c046'>Lyman Agnew (10),</li> - <li class='c046'>Juliette Lachine (11),</li> - <li class='c046'>Ethel Hunter (47).</li> -</ul> -</div> -<div class='footnote' id='f79'> -<p class='c007'><a href='#r79'>79</a>. </p> -<ul class='index'> - <li class='c046'>Carrie Pearson (53).</li> -</ul> -</div> -<div class='footnote' id='f80'> -<p class='c007'><a href='#r80'>80</a>. </p> -<ul class='index'> - <li class='c046'>Julius Kantor (54). <em>Cf.</em></li> - <li class='c046'>James Burns (56).</li> - <li class='c046'>Henri Lepère (105).</li> - <li class='c046'>Frederick Stone (106).</li> -</ul> -</div> -<div class='footnote' id='f81'> -<p class='c007'><a href='#r81'>81</a>. </p> -<ul class='index'> - <li class='c046'>Daniel Falvey (55). <em>Cf.</em></li> - <li class='c046'>Francis Murphy (60).</li> -</ul> -</div> -<div class='footnote' id='f82'> -<p class='c007'><a href='#r82'>82</a>. </p> -<ul class='index'> - <li class='c046'>James Burns (56). <em>Also</em></li> - <li class='c046'>Frederick Wescott (18),</li> - <li class='c046'>Martha Bartlett (21),</li> - <li class='c046'>Victor Friedburg (108).</li> -</ul> -</div> -<div class='footnote' id='f83'> -<p class='c007'><a href='#r83'>83</a>. </p> -<ul class='index'> - <li class='c046'>John Summers (57).</li> -</ul> -</div> -<div class='footnote' id='f84'> -<p class='c007'><a href='#r84'>84</a>. </p> -<ul class='index'> - <li class='c046'>Peter Burkhardt (58).</li> -</ul> -</div> -<div class='footnote' id='f85'> -<p class='c007'><a href='#r85'>85</a>. </p> -<ul class='index'> - <li class='c046'>Bridget Curley (59).</li> -</ul> -</div> -<div class='footnote' id='f86'> -<p class='c007'><a href='#r86'>86</a>. </p> -<ul class='index'> - <li class='c046'>Francis Murphy (60).</li> -</ul> -</div> -<div class='footnote' id='f87'> -<p class='c007'><a href='#r87'>87</a>. </p> -<ul class='index'> - <li class='c046'>David Collins (61).</li> -</ul> -</div> -<div class='footnote' id='f88'> -<p class='c007'><a href='#r88'>88</a>. </p> -<ul class='index'> - <li class='c046'>Joseph Buck (62).</li> -</ul> -</div> -<div class='footnote' id='f89'> -<p class='c007'><a href='#r89'>89</a>. </p> -<ul class='index'> - <li class='c046'>Albert Fielding (63).</li> -</ul> -</div> -<div class='footnote' id='f90'> -<p class='c007'><a href='#r90'>90</a>. </p> -<ul class='index'> - <li class='c046'>Calvin Hall (64).</li> -</ul> -</div> -<div class='footnote' id='f91'> -<p class='c007'><a href='#r91'>91</a>. </p> -<ul class='index'> - <li class='c046'>Donald Barrie (65).</li> -</ul> -</div> -<div class='footnote' id='f92'> -<p class='c007'><a href='#r92'>92</a>. </p> -<ul class='index'> - <li class='c046'>Lawrence Washington (66).</li> -</ul> -</div> -<div class='footnote' id='f93'> -<p class='c007'><a href='#r93'>93</a>. </p> -<ul class='index'> - <li class='c046'>Joseph Temple (67).</li> -</ul> -</div> -<div class='footnote' id='f94'> -<p class='c007'><a href='#r94'>94</a>. </p> -<ul class='index'> - <li class='c046'>Margaret O’Brien (68). <em>Also</em></li> - <li class='c046'>Henry Phillips (12).</li> - <li class='c046'>Bridget Curley (59).</li> - <li class='c046'>Annie Martin (117).</li> -</ul> -</div> -<div class='footnote' id='f95'> -<p class='c007'><a href='#r95'>95</a>. </p> -<ul class='index'> - <li class='c046'>Frank Mason (69).</li> -</ul> -</div> -<div class='footnote' id='f96'> -<p class='c007'><a href='#r96'>96</a>. </p> -<ul class='index'> - <li class='c046'>Annie Kelly (70).</li> - <li class='c046'>James Lauder (71).</li> -</ul> -</div> -<div class='footnote' id='f97'> -<p class='c007'><a href='#r97'>97</a>. </p> -<ul class='index'> - <li class='c046'>James Lauder (71).</li> -</ul> -</div> -<div class='footnote' id='f98'> -<p class='c007'><a href='#r98'>98</a>. </p> -<ul class='index'> - <li class='c046'>Margaret Green (72).</li> -</ul> -</div> -<div class='footnote' id='f99'> -<p class='c007'><a href='#r99'>99</a>. </p> -<ul class='index'> - <li class='c046'>Marcus Chatterton (73).</li> -</ul> -</div> -<div class='footnote' id='f100'> -<p class='c007'><a href='#r100'>100</a>. </p> -<ul class='index'> - <li class='c046'>Abel Bachmann (74).</li> -</ul> -</div> -<div class='footnote' id='f101'> -<p class='c007'><a href='#r101'>101</a>. </p> -<ul class='index'> - <li class='c046'>Mrs. Brown (75).</li> -</ul> -</div> -<div class='footnote' id='f102'> -<p class='c007'><a href='#r102'>102</a>. </p> -<ul class='index'> - <li class='c046'>James Seabrook (76).</li> -</ul> -</div> -<div class='footnote' id='f103'> -<p class='c007'><a href='#r103'>103</a>. </p> -<ul class='index'> - <li class='c046'>John Friedreich (77). <em>Cf.</em></li> - <li class='c046'>Isaac Goldstein (37).</li> -</ul> -</div> -<div class='footnote' id='f104'> -<p class='c007'><a href='#r104'>104</a>. </p> -<ul class='index'> - <li class='c046'>Gridley Ringer (78).</li> -</ul> -</div> -<div class='footnote' id='f105'> -<p class='c007'><a href='#r105'>105</a>. </p> -<ul class='index'> - <li class='c046'>John Doran (79).</li> -</ul> -</div> -<div class='footnote' id='f106'> -<p class='c007'><a href='#r106'>106</a>. </p> -<ul class='index'> - <li class='c046'>James Arnold (80).</li> -</ul> -</div> -<div class='footnote' id='f107'> -<p class='c007'><a href='#r107'>107</a>. </p> -<ul class='index'> - <li class='c046'>Florence Fitzgerald (81). <em>Also</em></li> - <li class='c046'>John Bennett (34),</li> - <li class='c046'>Alice Caperson (46),</li> - <li class='c046'>Vivian Walker (87),</li> - <li class='c046'>Arthur Bright (121).</li> -</ul> -</div> -<div class='footnote' id='f108'> -<p class='c007'><a href='#r108'>108</a>. </p> -<ul class='index'> - <li class='c046'>Frederick Estabrook (82).</li> -</ul> -</div> -<div class='footnote' id='f109'> -<p class='c007'><a href='#r109'>109</a>. </p> -<ul class='index'> - <li class='c046'>Maj. Isaac Thompson, M.D. (83).</li> -</ul> -</div> -<div class='footnote' id='f110'> -<p class='c007'><a href='#r110'>110</a>. </p> -<ul class='index'> - <li class='c046'>Lester Smith (84).</li> -</ul> -</div> -<div class='footnote' id='f111'> -<p class='c007'><a href='#r111'>111</a>. </p> -<ul class='index'> - <li class='c046'>Annie Marks (85).</li> -</ul> -</div> -<div class='footnote' id='f112'> -<p class='c007'><a href='#r112'>112</a>. </p> -<ul class='index'> - <li class='c046'>Frank Johnson (86).</li> -</ul> -</div> -<div class='footnote' id='f113'> -<p class='c007'><a href='#r113'>113</a>. </p> -<ul class='index'> - <li class='c046'>Vivian Walker (87).</li> -</ul> -</div> -<div class='footnote' id='f114'> -<p class='c007'><a href='#r114'>114</a>. </p> -<ul class='index'> - <li class='c046'>—— —— (88). <em>Cf.</em></li> - <li class='c046'>Richard Lawlor (25).</li> - <li class='c046'>Bessie Vogel (52).</li> -</ul> -</div> -<div class='footnote' id='f115'> -<p class='c007'><a href='#r115'>115</a>. </p> -<ul class='index'> - <li class='c046'>Margaret Tennyson (89).</li> - <li class='c046'>John Lawrence (5).</li> - <li class='c046'>Mary Coughlin (35).</li> - <li class='c046'>Theresa Mullen (36).</li> - <li class='c046'>John Friedreich (77).</li> - <li class='c046'>Gridley Ringer (78).</li> - <li class='c046'>James Arnold (80).</li> -</ul> -</div> -<div class='footnote' id='f116'> -<p class='c007'><a href='#r116'>116</a>. </p> -<ul class='index'> - <li class='c046'>Joseph O’Hearn (90).</li> -</ul> -</div> -<div class='footnote' id='f117'> -<p class='c007'><a href='#r117'>117</a>. </p> -<ul class='index'> - <li class='c046'>Levi Sussman (91).</li> -</ul> -</div> -<div class='footnote' id='f118'> -<p class='c007'><a href='#r118'>118</a>. </p> -<ul class='index'> - <li class='c046'>Joseph Larkin (92).</li> -</ul> -</div> -<div class='footnote' id='f119'> -<p class='c007'><a href='#r119'>119</a>. </p> -<ul class='index'> - <li class='c046'>Richard Marshall (93).</li> -</ul> -</div> -<div class='footnote' id='f120'> -<p class='c007'><a href='#r120'>120</a>. </p> -<ul class='index'> - <li class='c046'>David Fitzpatrick (94).</li> -</ul> -</div> -<div class='footnote' id='f121'> -<p class='c007'><a href='#r121'>121</a>. </p> -<ul class='index'> - <li class='c046'>Joseph Wilson (95).</li> -</ul> -</div> -<div class='footnote' id='f122'> -<p class='c007'><a href='#r122'>122</a>. </p> -<ul class='index'> - <li class='c046'>Becky Bornstein (96).</li> - <li class='c046'>Walter Heinmas (97).</li> - <li class='c046'>Mr. Jacobs (98).</li> -</ul> -</div> -<div class='footnote' id='f123'> -<p class='c007'><a href='#r123'>123</a>. </p> -<ul class='index'> - <li class='c046'>Walter Heinmas (97).</li> -</ul> -</div> -<div class='footnote' id='f124'> -<p class='c007'><a href='#r124'>124</a>. </p> -<ul class='index'> - <li class='c046'>Mr. Jacobs (98).</li> -</ul> -</div> -<div class='footnote' id='f125'> -<p class='c007'><a href='#r125'>125</a>. </p> -<ul class='index'> - <li class='c046'>James McDevitt (99).</li> -</ul> -</div> -<div class='footnote' id='f126'> -<p class='c007'><a href='#r126'>126</a>. </p> -<ul class='index'> - <li class='c046'>Jacob Methuen (100).</li> -</ul> -</div> -<div class='footnote' id='f127'> -<p class='c007'><a href='#r127'>127</a>. </p> -<ul class='index'> - <li class='c046'>John Baxter (101).</li> -</ul> -</div> -<div class='footnote' id='f128'> -<p class='c007'><a href='#r128'>128</a>. </p> -<ul class='index'> - <li class='c046'>Theodosia Jewett (102).</li> -</ul> -</div> -<div class='footnote' id='f129'> -<p class='c007'><a href='#r129'>129</a>. </p> -<ul class='index'> - <li class='c046'>A. W. (103).</li> -</ul> -</div> -<div class='footnote' id='f130'> -<p class='c007'><a href='#r130'>130</a>. </p> -<ul class='index'> - <li class='c046'>John Edwards (104). <em>Cf.</em></li> - <li class='c046'>Henri Lepère (105),</li> - <li class='c046'>Frederick Stone (106),</li> - <li class='c046'>Arthur Bright (121),</li> - <li class='c046'>Agnes O’Neil (19),</li> - <li class='c046'>Paolo Marini (28).</li> -</ul> -</div> -<div class='footnote' id='f131'> -<p class='c007'><a href='#r131'>131</a>. </p> -<ul class='index'> - <li class='c046'>Henri Lepère (105). <em>Cf.</em></li> - <li class='c046'>Julius Kantor (54).</li> -</ul> -</div> -<div class='footnote' id='f132'> -<p class='c007'><a href='#r132'>132</a>. </p> -<ul class='index'> - <li class='c046'>Frederick Stone (106).</li> -</ul> -</div> -<div class='footnote' id='f133'> -<p class='c007'><a href='#r133'>133</a>. </p> -<ul class='index'> - <li class='c046'>Greta Meyer (107). <em>Cf.</em></li> - <li class='c046'>John Jackson (14).</li> -</ul> -</div> -<div class='footnote' id='f134'> -<p class='c007'><a href='#r134'>134</a>. </p> -<ul class='index'> - <li class='c046'>Victor Friedburg (108).</li> -</ul> -</div> -<div class='footnote' id='f135'> -<p class='c007'><a href='#r135'>135</a>. </p> -<ul class='index'> - <li class='c046'>Annie Rivers (109).</li> -</ul> -</div> -<div class='footnote' id='f136'> -<p class='c007'><a href='#r136'>136</a>. </p> -<ul class='index'> - <li class='c046'>Mr. McKenzie (110). <em>Cf.</em></li> - <li class='c046'>Ivan Rokicki (111).</li> -</ul> -</div> -<div class='footnote' id='f137'> -<p class='c007'><a href='#r137'>137</a>. </p> -<ul class='index'> - <li class='c046'>Ivan Rokicki (111).</li> -</ul> -</div> -<div class='footnote' id='f138'> -<p class='c007'><a href='#r138'>138</a>. </p> -<ul class='index'> - <li class='c046'>Albert Forest (112). <em>Cf.</em></li> - <li class='c046'>Gussie Silverman (113),</li> - <li class='c046'>Walter Henry (114),</li> - <li class='c046'>William Rosetti (116),</li> - <li class='c046'>Annie Martin (117),</li> - <li class='c046'>Levi Morovitz (122),</li> - <li class='c046'>Peter Burkhardt (58).</li> -</ul> -</div> -<div class='footnote' id='f139'> -<p class='c007'><a href='#r139'>139</a>. </p> -<ul class='index'> - <li class='c046'>Gussie Silverman (113).</li> -</ul> -</div> -<div class='footnote' id='f140'> -<p class='c007'><a href='#r140'>140</a>. </p> -<ul class='index'> - <li class='c046'>Walter Henry (114).</li> -</ul> -</div> -<div class='footnote' id='f141'> -<p class='c007'><a href='#r141'>141</a>. </p> -<ul class='index'> - <li class='c046'>Henry Ryan (115).</li> -</ul> -</div> -<div class='footnote' id='f142'> -<p class='c007'><a href='#r142'>142</a>. </p> -<ul class='index'> - <li class='c046'>William Rosetti (116).</li> -</ul> -</div> -<div class='footnote' id='f143'> -<p class='c007'><a href='#r143'>143</a>. </p> -<ul class='index'> - <li class='c046'>Annie Martin (117). <em>Cf.</em></li> - <li class='c046'>William Roberts (118).</li> -</ul> -</div> -<div class='footnote' id='f144'> -<p class='c007'><a href='#r144'>144</a>. </p> -<ul class='index'> - <li class='c046'>William Roberts (118).</li> - <li class='c046'>John Silver (119).</li> -</ul> -</div> -<div class='footnote' id='f145'> -<p class='c007'><a href='#r145'>145</a>. </p> -<ul class='index'> - <li class='c046'>John Silver (119).</li> -</ul> -</div> -<div class='footnote' id='f146'> -<p class='c007'><a href='#r146'>146</a>. </p> -<ul class='index'> - <li class='c046'>James McGinnis (120).</li> -</ul> -</div> -<div class='footnote' id='f147'> -<p class='c007'><a href='#r147'>147</a>. </p> -<ul class='index'> - <li class='c046'>Arthur Bright (121). <em>Cf.</em></li> - <li class='c046'>Levi Morovitz (122),</li> - <li class='c046'>John Bennett (34).</li> -</ul> -</div> -<div class='footnote' id='f148'> -<p class='c007'><a href='#r148'>148</a>. </p> -<ul class='index'> - <li class='c046'>Levi Morovitz (122).</li> -</ul> -</div> -<div class='footnote' id='f149'> -<p class='c007'><a href='#r149'>149</a>. </p> -<ul class='index'> - <li class='c046'>Robert Matthews (23). <em>Cf.</em></li> - <li class='c046'>Isaac Goldstein (37).</li> -</ul> -</div> -<div class='footnote' id='f150'> -<p class='c007'><a href='#r150'>150</a>. For cases in which, without autopsy we have risked the -diagnosis neurosyphilis <em>in the absence of W. R. in serum or -fluid</em>, see William Twist (13), Frederick Wescott (18), Martha -Bartlett (21), Thomas Donovan (23), Paolo Marini (28), -Margaret Neal (32), Bridget Curley (59), Victor Friedburg -(108), Ivan Rokicki (111).</p> -</div> -<div class='footnote' id='f151'> -<p class='c007'><a href='#r151'>151</a>. From Mallory and Wright: Manual of Laboratory Technique.</p> -</div> -<div class='footnote' id='f152'> -<p class='c007'><a href='#r152'>152</a>. Bruck. Münch. med. Wochen. Jan. 22, 1917.</p> -</div> -<div class='footnote' id='f153'> -<p class='c007'><a href='#r153'>153</a>. Smith and Solomon. Boston Medical and Surgical -Jour.</p> -</div> -<div class='footnote' id='f154'> -<p class='c007'><a href='#r154'>154</a>. Bruck: Journal of American Medical Association, Vol. -lviii, No. 12, March 24, 1917, p. 944.</p> -</div> - -<div class='pbb'> - <hr class='pb c003' /> -</div> -<div class='tnotes'> - -<div class='section ph2'> - -<div class='nf-center-c0'> -<div class='nf-center c001'> - <div>TRANSCRIBER’S NOTES</div> - </div> -</div> - -</div> - - <ol class='ol_1 c002'> - <li>Pg. <a href='#t456'>456</a>, added footnote anchor for footnote A. - - </li> - <li>Silently corrected typographical errors and variations in spelling. - - </li> - <li>Archaic, non-standard, and uncertain spellings retained as printed. - - </li> - <li>Footnotes were re-indexed using numbers and collected together at the end of the last - chapter. - </li> - </ol> - -</div> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of Neurosyphilis, by -Harry Caesar Solomon and Elmer Ernest Southard - -*** END OF THIS PROJECT GUTENBERG EBOOK NEUROSYPHILIS *** - -***** This file should be named 63313-h.htm or 63313-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/3/3/1/63313/ - -Produced by Richard Tonsing, Bryan Ness, and the Online -Distributed Proofreading Team at https://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive/Canadian Libraries) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for the eBooks, unless you receive -specific permission. If you do not charge anything for copies of this -eBook, complying with the rules is very easy. You may use this eBook -for nearly any purpose such as creation of derivative works, reports, -performances and research. They may be modified and printed and given -away--you may do practically ANYTHING in the United States with eBooks -not protected by U.S. copyright law. Redistribution is subject to the -trademark license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country outside the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - This eBook is for the use of anyone anywhere in the United States and - most other parts of the world at no cost and with almost no - restrictions whatsoever. You may copy it, give it away or re-use it - under the terms of the Project Gutenberg License included with this - eBook or online at www.gutenberg.org. If you are not located in the - United States, you'll have to check the laws of the country where you - are located before using this ebook. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm web site -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from both the Project Gutenberg Literary Archive Foundation and The -Project Gutenberg Trademark LLC, the owner of the Project Gutenberg-tm -trademark. Contact the Foundation as set forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org - - - -Section 3. Information about the Project Gutenberg Literary Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's principal office is in Fairbanks, Alaska, with the -mailing address: PO Box 750175, Fairbanks, AK 99775, but its -volunteers and employees are scattered throughout numerous -locations. Its business office is located at 809 North 1500 West, Salt -Lake City, UT 84116, (801) 596-1887. Email contact links and up to -date contact information can be found at the Foundation's web site and -official page at www.gutenberg.org/contact - -For additional contact information: - - Dr. Gregory B. Newby - Chief Executive and Director - gbnewby@pglaf.org - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without wide -spread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg Web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works. - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our Web site which has the main PG search -facility: www.gutenberg.org - -This Web site includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. - - - -</pre> - - </body> - <!-- created with ppgen.py 3.57c on 2020-09-05 23:02:57 GMT --> -</html> diff --git a/old/63313-h/images/cover.jpg b/old/63313-h/images/cover.jpg Binary files differdeleted file mode 100644 index 15c06f3..0000000 --- a/old/63313-h/images/cover.jpg +++ /dev/null diff --git a/old/63313-h/images/i_024.jpg b/old/63313-h/images/i_024.jpg Binary files differdeleted file mode 100644 index 30972a3..0000000 --- a/old/63313-h/images/i_024.jpg +++ /dev/null diff --git a/old/63313-h/images/i_038a.jpg b/old/63313-h/images/i_038a.jpg Binary files differdeleted file mode 100644 index 4f8eb09..0000000 --- a/old/63313-h/images/i_038a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_038b.jpg b/old/63313-h/images/i_038b.jpg Binary files differdeleted file mode 100644 index d6d1374..0000000 --- a/old/63313-h/images/i_038b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_040a.jpg b/old/63313-h/images/i_040a.jpg Binary files differdeleted file mode 100644 index 8653676..0000000 --- a/old/63313-h/images/i_040a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_040b.jpg b/old/63313-h/images/i_040b.jpg Binary files differdeleted file mode 100644 index d1213d0..0000000 --- a/old/63313-h/images/i_040b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_040c.jpg b/old/63313-h/images/i_040c.jpg Binary files differdeleted file mode 100644 index f642266..0000000 --- a/old/63313-h/images/i_040c.jpg +++ /dev/null diff --git a/old/63313-h/images/i_044.jpg b/old/63313-h/images/i_044.jpg Binary files differdeleted file mode 100644 index 01b33c1..0000000 --- a/old/63313-h/images/i_044.jpg +++ /dev/null diff --git a/old/63313-h/images/i_045.jpg b/old/63313-h/images/i_045.jpg Binary files differdeleted file mode 100644 index 3614f38..0000000 --- a/old/63313-h/images/i_045.jpg +++ /dev/null diff --git a/old/63313-h/images/i_052a.jpg b/old/63313-h/images/i_052a.jpg Binary files differdeleted file mode 100644 index 16f6bc1..0000000 --- a/old/63313-h/images/i_052a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_052b.jpg b/old/63313-h/images/i_052b.jpg Binary files differdeleted file mode 100644 index cda20f1..0000000 --- a/old/63313-h/images/i_052b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_052c.jpg b/old/63313-h/images/i_052c.jpg Binary files differdeleted file mode 100644 index 513725c..0000000 --- a/old/63313-h/images/i_052c.jpg +++ /dev/null diff --git a/old/63313-h/images/i_080.jpg b/old/63313-h/images/i_080.jpg Binary files differdeleted file mode 100644 index cebfa02..0000000 --- a/old/63313-h/images/i_080.jpg +++ /dev/null diff --git a/old/63313-h/images/i_083.jpg b/old/63313-h/images/i_083.jpg Binary files differdeleted file mode 100644 index 35e0449..0000000 --- a/old/63313-h/images/i_083.jpg +++ /dev/null diff --git a/old/63313-h/images/i_088.jpg b/old/63313-h/images/i_088.jpg Binary files differdeleted file mode 100644 index 331b51f..0000000 --- a/old/63313-h/images/i_088.jpg +++ /dev/null diff --git a/old/63313-h/images/i_116a.jpg b/old/63313-h/images/i_116a.jpg Binary files differdeleted file mode 100644 index dcba4bc..0000000 --- a/old/63313-h/images/i_116a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_116b.jpg b/old/63313-h/images/i_116b.jpg Binary files differdeleted file mode 100644 index 8778459..0000000 --- a/old/63313-h/images/i_116b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_116c.jpg b/old/63313-h/images/i_116c.jpg Binary files differdeleted file mode 100644 index f181d3d..0000000 --- a/old/63313-h/images/i_116c.jpg +++ /dev/null diff --git a/old/63313-h/images/i_116d.jpg b/old/63313-h/images/i_116d.jpg Binary files differdeleted file mode 100644 index 8826d1f..0000000 --- a/old/63313-h/images/i_116d.jpg +++ /dev/null diff --git a/old/63313-h/images/i_116e.jpg b/old/63313-h/images/i_116e.jpg Binary files differdeleted file mode 100644 index 9b7de49..0000000 --- a/old/63313-h/images/i_116e.jpg +++ /dev/null diff --git a/old/63313-h/images/i_116f.jpg b/old/63313-h/images/i_116f.jpg Binary files differdeleted file mode 100644 index 5fc9f3d..0000000 --- a/old/63313-h/images/i_116f.jpg +++ /dev/null diff --git a/old/63313-h/images/i_138.jpg b/old/63313-h/images/i_138.jpg Binary files differdeleted file mode 100644 index 1668ccf..0000000 --- a/old/63313-h/images/i_138.jpg +++ /dev/null diff --git a/old/63313-h/images/i_158.jpg b/old/63313-h/images/i_158.jpg Binary files differdeleted file mode 100644 index efea5bd..0000000 --- a/old/63313-h/images/i_158.jpg +++ /dev/null diff --git a/old/63313-h/images/i_160.jpg b/old/63313-h/images/i_160.jpg Binary files differdeleted file mode 100644 index 4a11025..0000000 --- a/old/63313-h/images/i_160.jpg +++ /dev/null diff --git a/old/63313-h/images/i_206.jpg b/old/63313-h/images/i_206.jpg Binary files differdeleted file mode 100644 index 8b770f1..0000000 --- a/old/63313-h/images/i_206.jpg +++ /dev/null diff --git a/old/63313-h/images/i_218a.jpg b/old/63313-h/images/i_218a.jpg Binary files differdeleted file mode 100644 index a0fb8e7..0000000 --- a/old/63313-h/images/i_218a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_218b.jpg b/old/63313-h/images/i_218b.jpg Binary files differdeleted file mode 100644 index f51b385..0000000 --- a/old/63313-h/images/i_218b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_218c.jpg b/old/63313-h/images/i_218c.jpg Binary files differdeleted file mode 100644 index 552ba0a..0000000 --- a/old/63313-h/images/i_218c.jpg +++ /dev/null diff --git a/old/63313-h/images/i_220a.jpg b/old/63313-h/images/i_220a.jpg Binary files differdeleted file mode 100644 index da0f5a6..0000000 --- a/old/63313-h/images/i_220a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_220b.jpg b/old/63313-h/images/i_220b.jpg Binary files differdeleted file mode 100644 index c405c23..0000000 --- a/old/63313-h/images/i_220b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_221.jpg b/old/63313-h/images/i_221.jpg Binary files differdeleted file mode 100644 index 7e6fd79..0000000 --- a/old/63313-h/images/i_221.jpg +++ /dev/null diff --git a/old/63313-h/images/i_272.jpg b/old/63313-h/images/i_272.jpg Binary files differdeleted file mode 100644 index f7ac08f..0000000 --- a/old/63313-h/images/i_272.jpg +++ /dev/null diff --git a/old/63313-h/images/i_306.jpg b/old/63313-h/images/i_306.jpg Binary files differdeleted file mode 100644 index a9a0d2e..0000000 --- a/old/63313-h/images/i_306.jpg +++ /dev/null diff --git a/old/63313-h/images/i_311.jpg b/old/63313-h/images/i_311.jpg Binary files differdeleted file mode 100644 index d48acdf..0000000 --- a/old/63313-h/images/i_311.jpg +++ /dev/null diff --git a/old/63313-h/images/i_326.jpg b/old/63313-h/images/i_326.jpg Binary files differdeleted file mode 100644 index 4c42b46..0000000 --- a/old/63313-h/images/i_326.jpg +++ /dev/null diff --git a/old/63313-h/images/i_330.jpg b/old/63313-h/images/i_330.jpg Binary files differdeleted file mode 100644 index d2350b5..0000000 --- a/old/63313-h/images/i_330.jpg +++ /dev/null diff --git a/old/63313-h/images/i_332.jpg b/old/63313-h/images/i_332.jpg Binary files differdeleted file mode 100644 index 2eb5f6c..0000000 --- a/old/63313-h/images/i_332.jpg +++ /dev/null diff --git a/old/63313-h/images/i_336a.jpg b/old/63313-h/images/i_336a.jpg Binary files differdeleted file mode 100644 index 7f63f99..0000000 --- a/old/63313-h/images/i_336a.jpg +++ /dev/null diff --git a/old/63313-h/images/i_336b.jpg b/old/63313-h/images/i_336b.jpg Binary files differdeleted file mode 100644 index bb62355..0000000 --- a/old/63313-h/images/i_336b.jpg +++ /dev/null diff --git a/old/63313-h/images/i_frontis.jpg b/old/63313-h/images/i_frontis.jpg Binary files differdeleted file mode 100644 index fef52f9..0000000 --- a/old/63313-h/images/i_frontis.jpg +++ /dev/null |
