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