Chapter XVIII: Introduction (10)

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.

Juvenile paresis—spastic paraplegia. 5 years.
]

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.=

=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