Case 95. Joseph Wilson offered a very serious social problem. He was the father of two children, and his wife was pregnant at the time of his admission to the Psychopathic Hospital. He was a husky-looking man of 33 years of age, but for the past four years he had been deteriorating in his work; he had been drinking heavily, and finally had stolen to obtain money for liquor. It was on account of his alcoholism and delinquency, which were taken as an indication of change of character, that he was sent to the hospital.

Examination on his arrival disclosed at once that there was more to the case than alcoholism, for the neurological examination showed that the pupils were irregular, the right being larger than the left, both reacting sluggishly to light, and there was an inequality in the reaction of the two eyes, the left being better than the right. The tendon reflexes were exaggerated, with ankle clonus on both sides, more marked on the right. There was also a marked speech defect. Otherwise the physical examination showed nothing of importance.

The W. R. of the blood and spinal fluid was strongly positive. The globulin test was strongly positive, the albumin was markedly increased, there were 74 cells per cmm., and a gold sol reaction of the “paretic” type.

A formal mental examination did not show very much of consequence; his memory showed no marked impairment, he was not deluded or hallucinated, and he had a pretty good insight into his failings. However, he was somewhat childish, and his irritability was quite marked. Were one to rely upon the mental signs alone, it is probable that a diagnosis of chronic alcoholism with deterioration would be made; but in the presence of the physical findings and the laboratory tests, the diagnosis of neurosyphilis had to be given. It is obvious that, while the patient was suffering from a progressive brain disease, and while he did show mental symptoms, there was not sufficient ground on which to commit him, and therefore he had to be turned out into the community. As a matter of fact, he was not prosecuted on account of his theft, because, although legally responsible, it was felt that his disease was at the basis of the character change which had led him into difficulties. Further developments of his relations with society had to be considered, however. It was possible to get him to discontinue the use of alcohol altogether, and for nearly a year he has taken no alcoholic liquor and has been self-supporting. However, his irritability has been very great, making it very difficult for his wife to live with him, and causing his sister to break off all relations with him.

Here, then, is a man with a marked Character Change as the result of neurosyphilis, so that it is difficult for him to maintain the usual social relations. It does not seem possible to remove him from the community.

1. May one speak of general paresis without mental symptoms? If one considers general paresis a mental disease, of course it cannot exist without mental symptoms. However, if one considers the disease as a chronic syphilitic meningoencephalitis characterized by its pathological anatomy, then one may readily speak of general paresis although no real evidence of mental symptoms can be discovered. It would seem that we must take this attitude with our present conception of brain localization, for it is easy to conceive of a general paretic process affecting areas which do not definitely relate to psychic function. And further, such a process may exist but not be of such a grade as to cause mental symptoms.

Case 96. The Bornstein family is remarkable. Let us hang the story on Becky, the mother, an Austrian woman of 43 years, who appears to have been perfectly well up to within a year. About a year ago, Mrs. Bornstein began to suffer from severe headaches, which were treated with apparent success by an osteopath: at all events, Mrs. Bornstein recovered therefrom in about six months. However, two months later, she had a convulsion, with foaming at the mouth, blueness of face, and general muscular stiffening. The convulsion lasted for several minutes. Again, a fortnight before admission, the patient had five convulsions of an identical nature in a single night.

Moreover, since the first convulsion, Mrs. Bornstein’s mental condition has altered and become variable, so that at times she is excited, at times depressed. She would assert inaccurately that there was some one in the house, and that she had at different times committed crimes of a heinous nature. Now and then she would seem to see moving pictures. Her memory was poor and she seemed to believe that events of five or six years ago had just happened.

The pupils were sluggish, the knee-jerks and ankle-jerks were absent, there was slight ataxia, and there was speech defect. The suspicion of neurosyphilis was so strong that it seemed surprising that the W. R. of the blood serum, even after repeated tests and after the provocative injection of salvarsan, proved negative. However, the spinal fluid yielded a positive W. R., and a gold sol reaction of the “paretic” type, together with 12 cells per cmm., and a marked increase of albumin, with positive globulin. It would seem warrantable to make a diagnosis at least of syphilis of the nervous system in this case, but it is a question whether we should be warranted in making the diagnosis general paresis.

That the diagnosis is doubtful may perhaps be seen from the variety of diagnoses in the rest of the family. In the first place, Mrs. Bornstein’s husband admits syphilitic infection many years before. He states also that his wife after marriage showed signs of syphilis and received some treatment, although limited. It is stated also that the husband himself at this time has a positive W. R. and has stiff pupils and petit mal attacks. The oldest son, 22 years of age, is confined in an institution with juvenile paresis. The second son has recently died at the age of 20 years, receiving a diagnosis of rupture of the aorta. A third son, 19 years of age, has the appearance of having achondroplasia, although the proportions of his limbs do not quite correspond with those of an achondroplast. The fourth son, 17 years of age, is suffering from caries of the spine. A fifth son, 14 years old, is neurotic and has the so-called Olympic forehead. The sixth and last son died shortly after birth of unknown cause.

Case 97. Walter Heinmas was a draughtsman 33 years of age when he was brought to the Psychopathic Hospital suffering from mental disease. This was diagnosed as general paresis, both on account of the clinical symptomatology and on account of the laboratory findings. In fact, it was a case of the classical type with marked euphoria and grandiosity.

As is the routine procedure at the Psychopathic Hospital, in the case of all syphilitic patients, the family was sent for. This consisted of the wife and two daughters, aged 9 and 7 respectively. The patient denied any knowledge of a syphilitic infection. The wife, also, gave no history of any primary, secondary, or tertiary symptoms; there had been no abortions, miscarriages, or stillbirths; both children had been born at term and had been entirely healthy. Examination showed that the mother had no signs referable to syphilis, and that both the children were mentally well endowed, with good physique and showing no stigmata of congenital syphilis. Still the W. R. of all three (the mother and the two children) was positive in the blood serum. These tests were repeated several times on the children, with and without injections of salvarsan, and they remained consistently positive.

1. Are these children to be considered congenital syphilitics despite the absence of stigmata or symptoms? We must consider these children as congenital syphilitics and candidates for the group frequently spoken of as syphilitis hereditaria tarda.

2. What is the frequency of syphilitic involvement in the mate and children of paretics? In our series, we have found that about 15% of the marriages where one member develops paresis, result in sterility; that in 18% abortions, miscarriages and stillbirths occur; and that in 15% positive W. R. is obtained. We have adopted the motto: “The families of paretics are the families of syphilitics.”

Case 98. Mr. Jacobs’ wife was admitted to the hospital with a diagnosis of general paresis. A few weeks after her admission, she died as a result of her disease. According to our routine, her husband and the children were examined for evidences of syphilis.

Mr. Jacobs’ blood serum was found on repeated tests to be positive. He resolutely denied any knowledge of a syphilitic involvement, but it was later learned from his brother that about two years before his marriage—that is, more than 25 years before we saw him—he had acquired syphilis and had had a very small amount of treatment.

Mr. Jacobs was put upon antisyphilitic treatment in the form of injections of .3 gram of salvarsan every two weeks with occasional intramuscular injections of mercury salicylate. After seven months of treatment, the blood serum still remained positive. At about this time, the patient came to us to ask about getting married again. He said that he was living with his sister, who kept telling him that he was the cause of his wife’s death, and this was so unpleasant that he desired to start a home for himself again!

1. What advice should be given? It is a general opinion that the longer the period after the initial infection, the less the chances of infecting a partner. This chance is further reduced under antisyphilitic treatment, of which a considerable amount had been given in the case of Mr. Jacobs. However, when one considers the trickiness of syphilis and the fact that there is some chance of infection, which we would apparently overlook if we gave him permission to marry at this time, the only possible course was to tell the patient that he should not consider marriage until his Wassermann had become negative and remained so for some time. The children in this case were negative.

2. What is the physician’s duty to the family of a syphilitic patient? It is our firm conviction that it is the duty of every physician to his syphilitic patient, to the patient’s family, and to the community, to examine the mate and the children for evidence of syphilis acquired or congenital and to offer treatment if it is found to be needed. This is one of the chief means at our disposal today to prevent the late disasters of syphilis, acquired or congenital, for by such examinations the syphilitic condition is discovered before lesions have occurred which are irreparable. We know that the mate and children of a syphilitic patient have been exposed to syphilitic involvement, and it is our duty as physicians in possession of such knowledge, and as guardians of the public health, to investigate such cases, so that if they be found to have syphilis, steps may be taken to treat them early.

3. How much danger is there of causing unhappiness and breaking up families by this procedure? This question offers a chance for many theoretical answers. The facts are, however, that in doing this as a routine for nearly three years and examining several hundred families, there has been no instance to our knowledge in which a family has been broken up or grave difficulties have been encountered by this procedure.

4. In what percentage are the mates or children of neurosyphilitics found to show definite symptoms of syphilis? It is our opinion that the situation in regard to neurosyphilitics is the same as for syphilitics in general: That the same laws of attenuation of virus, and of chance occur here as elsewhere.

Just as this book is going to press, we have learned that the distraught Mr. Jacobs, still desirous of starting a home for himself and feeling entirely well, consulted a physician. This physician took a sample of blood and had it tested at a competent laboratory, which reported the blood negative.

On the strength of this test, the physician felt himself warranted in recommending, or at least not advising against, Mr. Jacobs’ marriage, which has probably now taken place.

Although there is some doubt what ethical relation a state institution shall maintain with physicians in private practice, we took occasion to call the attention of our patient’s new counsellor to the fact of the patient’s neurosyphilis. We noted that the man’s serum had been constantly positive (Massachusetts State Board of Health findings) in a score or more of observations. We called attention to the fact that lumbar puncture had shown positive signs of neurosyphilis, including a positive W. R., globulin, excess albumin, pleocytosis, and positive gold sol. These facts, according to a letter received from the private practitioner in question, have not altered his opinion in the slightest to the effect that our patient is completely normal and entirely suitable for marriage. It is clear that he regards the patient as not a victim of General Paresis.

5. What is the significance o the negative observation eventually obtained in Jacobs’ serum? One’s first thought is to impugn the accuracy of the laboratory work, but against this suspicion is the excellent reputation of the laboratory in question, and the agreement in the majority of its findings with those of the State Board of Health. It is more likely, as we assured the private practitioner at whose request the observation was made, that this negative test was an exceptional and isolated observation such as is not infrequent in long series of observations, particularly those made under therapeutic conditions. In so important a matter, we are inclined to feel that the physician in question should have resorted to two more observations at intervals before running counter to the position taken by the hospital.