Part 24

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.

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.=