The patient strikes one physically as having the development of a child of about five years (actual age, 7). There are a few lymph nodes palpable in the anterior triangles of the neck. The dilated and slightly unequal pupils react neither to light nor accommodation. There is practically complete deafness; loud sounds are not at all noticed.
Withal, the child in a general way presents a somewhat attractive appearance, being very playful and mischievous, lying about on the floor and playing with whatever comes to hand, talking to himself or making a few indistinct remarks to the bystanders. He walks awkwardly, on the toes of the left foot. He pays little or no attention to his toilet and needs to be dressed and cared for in all ways. He is quick-tempered and at times very difficult to manage.
There was, of course, little doubt of the diagnosis of Congenital Syphilis and of Feeblemindedness. The W. R. was positive both in the blood and in the spinal fluid. The gold sol reaction of the fluid was of the “paretic” type; there were 44 cells per cmm. and there was a large excess of albumin and much globulin.
As to prognosis, there is doubt.
1. Is, or is not, this a case of juvenile paresis?
2. Is it, perhaps, a relatively permanent case of feeblemindedness due to congenital syphilis? On the whole, on account of the spinal fluid symptoms, we should be inclined to give the case a relatively poor prognosis, namely, of death in a few years. However, we may perchance be later surprised to learn that the patient has lived on, at least into early adult age.
Note: Mercury tablets in some cases of congenital syphilis do not seem effective. John Friedreich was treated most intensively by syphilographers from birth.
Dr. W. E. Fernald in a personal communication stated that syphilitic cases of feeblemindedness are rather those of the imbecile and idiot groups than of the higher levels. This statement emphasizes again that the true hereditary cases of feeblemindedness are rather those of the higher group, whereas the cases in which special causes have operated in the uterus or in early life eventuate in idiocy and imbecility. However, such a case as that of Friedreich shows that now and then a case of feeblemindedness without evidence of neurological disorder and looking in almost all respects like an hereditary case may be at times produced by syphilis.
3. How often is the central nervous system involved in hereditary syphilis? An interesting table bearing on this point is presented by Veeder.[[16]] The table concerns the lesions in various parts and systems of the body in 100 cases of late syphilis. It appears that in 47, or approximately one-half of Veeder’s series of 100 late cases, the infection developed some form of lesion of the nervous system. As Veeder remarks, this result runs counter to the common statements of pediatricians, notably of Holt.
| Bones: | |
| Periostitis tibia | 4 |
| Periostitis skull | 1 |
| Osteomyelitis | 1 |
| Joints: | |
| Acute arthritis knee | 8 |
| Acute arthritis ankle | 1 |
| Skin: | |
| Macular eruption | 1 |
| Condyloma anus | 3 |
| Gummata | 3 |
| Alopecia | 3 |
| Eye: | |
| Interstitial keratitis | 24 |
| Choroiditis | 1 |
| Ulcerations: | |
| Nasal | 2 |
| Laryngeal | 1 |
| Pharyngeal | 1 |
| Central Nervous System: | |
| Mental deficiency | 23 |
| Cerebrospinal syphilis | 14 |
| Hemiplegia | 6 |
| Epilepsy | 5 |
| Spastic paraplegia | 4 |
| Chorea | 2 |
| Hydrocephalus | 2 |
| Miscellaneous Conditions: | |
| Ozena | 1 |
| Enlarged spleen (only symptom) | 1 |
| Torticollis | 1 |
| Aortitis | 1 |
| Obscure abdominal pain | 1 |
| Obscure pain in legs | 2 |
| Endarteritis obliterans | 1 |
| Paroxysmal hemoglobinuria | 1 |
| Raynaud’s disease | 1 |
| Hutchinson’s teeth | 4 |