Case 85. At first Mrs. Annie Monks, a widowed seamstress, 50 years of age, did not particularly suggest syphilis. Mrs. Monks was sent to us from a general hospital. She had been found unconscious in her room, with gas turned on, and a diagnosis of gas poisoning was made. Mrs. Monks remained unconscious for 24 hours, and her apparent suicidal attempt seemed to warrant her being sent to the Psychopathic Hospital. Mrs. M., however, scoffed at the idea of any attempt at suicide, and claimed to have had no recollection of any such affair. On the contrary, she had gone to mass the morning of the day on which she was taken to the hospital, remembered well enough returning to her room but nothing of what followed until she woke up.
Mrs. Monks was not coöperative and would reveal few facts about her history. For years, she had had edema of the feet and palpitation of the heart (the heart was somewhat enlarged, with a double murmur in the aortic area, systolic louder, and a blood pressure of 160 systolic and 85 diastolic; clubbed fingers; palpable liver). She had been treated in the out-patient department of a general hospital for a number of months. We could obtain no evidence of mental impairment, particularly none of memory.
Aside from the heart lesions above indicated, the patient was fairly well nourished, with a slight enlargement of superficial glands, and was otherwise normal.
Neurologically, the slightly irregular pupils reacted poorly to light; the right knee-jerk could not be obtained, whereas the left knee-jerk was very active. Systematic examination revealed no other disorder except that the abdominal reflexes could not be obtained.
Here we have, in a cardiac patient, a possibly or probably accidental gas poisoning, and little to go upon for a profounder diagnosis than the sluggish irregular pupils and unilateral absence of knee-jerk.
The routine serum W. R. came through as positive. Following custom, we examined the spinal fluid, finding the W. R. here again to be moderately positive (strongly positive to 1 cc., moderately to 0.7 cc., and negative to 0.5, 0.3, and 0.1 cc.). The gold sol index was 1 2 2 1 0 0 0 0 0 0, which must be interpreted as syphilitic. There were 16 cells to the cmm., the albumin was 1+, and the globulin stood at 2+.
Here, then, we seem to have evidence of an inflammatory process of the central nervous system, and it is natural forthwith to be sceptical as to the accidental nature of the gas poisoning. Perhaps there was an attempt at suicide based upon a passing impulse, or perhaps there was a period of confusion in which the cock was not turned off.
In any event, we feel justified in making the diagnosis of cerebrospinal syphilis on the basis of the neurological and laboratory findings. On the whole, we are inclined to make a diagnosis of Vascular Neurosyphilis with a moderate involvement of the Meninges.
1. What is the outcome in such cases as that of Annie Monks? The case somewhat resembled that of Martha Bartlett, who still survives. The case of Annie Monks illustrates another outcome. A few days after her admission, she became unconscious once more, and upon recovery remained very much confused and aphasic, moaning, and unable to handle herself well, although without definite paralysis. Three weeks later the patient died, although in the meantime strenuous antisyphilitic therapy was practised. Death was sudden. We thought death due to cerebral embolism.
Early delinquency and neurosyphilis in a juvenile.