Part 1
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.)
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.