Sclerosis with atrophy of occipital and hippocampal white matter of right side.
Gliotic lesion (1.5 × 2 × 2 cm. of right lenticular nucleus involving anterior commissure).
1. Was the exophthalmic goitre in Carrie Pearson due to syphilis? Unfortunately we have no clear proof that Carrie Pearson was syphilitic. She was stated to have been syphilitic by the physician who treated her before her commitment to Danvers Hospital. There is, however, no proof of syphilis, inasmuch as the patient died in the pre-Wassermann period.
2. Is the thalamic lesion probably syphilitic? No lymphocytosis or plasmocytosis characterizes the lesion, which is the only lesion of the sort in the Danvers collection. It would not do to call a lesion syphilitic just because it is sui generis. In any event, the clinical analysis of the case faced the claim of syphilis as an actual factor in the patient’s life and as a possible factor in the goitre.
It is well known that the ARGYLL-ROBERTSON PUPIL is characteristic of the so-called “PARA-SYPHILITIC DISEASES” (“general paresis” and “tabes”); does this sign occur in other neurosyphilitic conditions?
Case 54. Julius Kantor was a shoemaker of 35 years, who came to the hospital for treatment because his family physician had found a positive W. R. in Kantor’s blood serum. He had had a cough for a number of years, and during the last year a little blood had been found in the sputum; whereupon Kantor had been placed under active anti-tuberculosis treatment. The enterprising family physician had found the positive W. R. in the first days of his treatment for tuberculosis. There was, in fact, a history of a chancre nine years before, which had not been followed by any secondary or tertiary symptoms, and which had been but scantily treated.
There were no mental symptoms.
Kantor was physically fairly well developed and nourished. There were a few piping râles in the left upper chest, both in front and back, and also a slight dulness with increased vocal and tactile fremitus. No tubercle bacilli, however, could be found on repeated sputum examination.
Neurologically, the pupils were myotic and both showed the Argyll-Robertson reaction. There were no abnormal reflexes whatever, and there was neither ataxia nor speech defect. Not only the blood but also the spinal fluid W. R. proved to be positive; there was a marked increase in the albumin and globulin; there was a gold sol reaction of the syphilitic type, and there were but three cells per cmm.
1. In view of the headache in case Kantor, what other causes of headache are to be considered? It is certain that irritations of the dura mater can produce headache, and the physiological observation of the sensitiveness of the membranes and the non-sensitiveness of the brain substance is an ancient and classical observation. Internal hemorrhagic pachymeningitis produces severe headache. The relations of this disease to trauma, to arteriosclerosis, and possibly to syphilis (alcohol perhaps should also be considered) in certain instances have not been entirely cleared up. Syphilitic headaches are, according to Lewandowski, dependent also upon a dural affection or upon a periosteal affection. The headaches of brain tumor are also commonly related to dural conditions, either directly due to the pressure of the tumor itself, or indirectly to the heightened intracranial pressure consequent upon the tumor. It is clear that the tension under which the dura mater lies is not always localized in the region of a brain tumor or a syphilitic lesion. Head has claimed that brain tumor produces headaches of two kinds, according to whether the disease affects the dura mater or is dependent upon an increase of pressure in the brain. It does not appear that the pia mater has any relation to headaches, but meningitis, in which the inflammation is confined to the pia mater, is nevertheless associated with headache; the headache is here supposed to be due to the increase in brain pressure, and thus actually to an effect wrought upon the dura mater. Vasomotor disorders and various types of cephalic hyperemia are thought to produce a kind of headache, but Lewandowski calls this kind of headache somewhat in question. Reflex headaches are stated to be produced indirectly by a process of radiation from interior lesions in the brain. There are certain headaches called nodal headaches (Schwielen-Kopfschmerz). Hypermetropia, caries of the teeth, adenoids, and diseases of the nose and axillary cavities, to say nothing of thoracic and abdominal diseases, are also counted among conditions that may produce headaches. In this connection, Head has claimed differential zones of headache corresponding to certain diseases.