The brain itself may produce headache through intoxications, through conditions produced by a variety of diseases; may follow neuroses. Alcohol may produce headaches in some persons even when it is taken in very small doses. Certain uremic cases yield headaches, as do also gouty and chlorotic conditions. According to Lewandowski, the headaches of arteriosclerotics are due possibly to vasomotor disturbances in the membranes, or one may think of nutritive cerebral disorders. A peculiar form of headache is that of fatigue after mental work, allied to which is the neurasthenic headache; constitutional headaches have been assumed to occur, to say nothing of hysterical headaches. There remains also the important question of migraine, for which a vasomotor explanation has been proposed.
2. Was Kantor suffering from tuberculosis of the lungs? The hypothesis of lung syphilis ought certainly to be very seriously considered. Upon repeated sputum examination, no tubercle bacilli have yet been found.
3. Is Kantor a case of general paresis? In the absence of mental symptoms, and in consideration of the mildness of the reactions, it is certainly not easy to make the diagnosis of general paresis. However, the diagnosis of tabes dorsalis is not justified either. Accordingly, we may answer our question: whether the Argyll-Robertson pupil occurs in other neurosyphilitic diseases, by pointing out that in the case of Julius Kantor, as in the case of Henri Lepère (105) and Frederick Stone (106), the Argyll-Robertson pupil has been found in syphilitic conditions that are neither typically paretic nor typically tabetic.
Does the Argyll-Robertson pupil necessarily indicate neurosyphilis?
Case 55. Daniel Falvey, 44 years of age, was an almshouse transfer to the Danvers State Hospital in the year 1904, when the principle of state care was adopted in Massachusetts. As in most of the almshouse transfers of that day, little could be discovered as to antecedents. He had been a mill-worker from the time of his immigration in 1890, at 30 years of age. He had been somewhat alcoholic. There was a shock some 17 months before his death, which occurred about seven weeks from the date of transfer.
Not only was he unable to walk unsupported, but when supported there was a slight dragging of the left leg and the gait was noted to be somewhat propulsive. The tongue and hands were tremulous, and the left grasp was somewhat weaker than the right. Both knee-jerks were increased although neither more than the other. There was no sensory disorder.
Although but 44 years of age, Falvey presented the appearance of a much older man. His heart was somewhat enlarged and there was a degree of peripheral arteriosclerosis. On the whole, no special attention was attracted to this case clinically and he was regarded as an example of arteriosclerotic dementia, like many another among the transfers. However, we owe to Dr. H. M. Swift the important observation of the Argyll-Robertson pupils. The case was studied long before the Wassermann method was available, and is here reported merely to call attention to the fact that the stiff pupils may have other neural origin than neurosyphilis.
The autopsy material in the case was worked up by one of the authors.[[11]] The autopsy had been performed by Dr. A. M. Barrett, who found on section through the brain stem at the anterior border of the pons a mass springing from and continuous with the pineal gland, lying in the third ventricle and the aqueduct of Sylvius. Upon further study, this mass was found to begin posteriorly in the pineal body itself, from which the mass could hardly be told in the gross except by an injected border.
This mass proved upon microscopic examination to be a psammoma, which histologically resembled a glioma rather than a sarcoma. Throughout the mass there was a variable content of fibrillary intercellular substance having the histological reactions of neuroglia fibrillæ. The histological details (mitosis, large giant cells with multiple nuclei, etc.) do not here concern us. We deal with a neoplasm springing from the pineal gland growing on the posterior half of the third ventricle, the anterior orifice of the aqueduct of Sylvius, and the space between the velum interpositum as far back as the posterior corpora quadrigemina. There is no evidence in the body of old syphilis; although it is possible that the stiff pupils were neurosyphilitic, it seems probable that they were related to the pineal tumor. At all events, there are in the literature evidences that the pineal-quadrigeminal group of tumors and other lesions may bring about pupillary disturbances. On this account, we here include the case. The tumor hardly led to an error in diagnosis since neither neurosyphilis nor brain tumor was at all expected clinically.
1. Can alcoholism produce identical results? See Case Murphy, (60), one of alcoholic pseudoparesis.