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 Moebius 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 Moebius 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.

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.

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.

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.

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 gonorrhoeal 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.

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).

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 2? 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.

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.

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.

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.

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.

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.

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.