“Obviously, then, our opinion is that there is still to be found some effect of the disease, whatever it was, which caused the patient to knock off work. If we had more experience with such cases and more data with the new test which we have applied, we should perhaps be inclined to admit the diagnosis of occupation neuritis and to suppose structural alterations in the nerve trunks corresponding with the location of the muscular pain and the anesthesia of fingers and the dulling of electric sense, but in the present stage of our experience, it is probably wiser to call the case one of occupation neurosis.”
It is clear that the W. R. in this case was of peculiar value in at least partially clearing up the findings, yet it must be remembered that it is a principle of the modern administration of industrial accident boards and similar organizations that it is the employer’s lookout whether the employee has syphilis. Recovery can be made as if the injury were due wholly to an accident. It was not possible however definitely to prove or disprove a relation of syphilis in the form of a syphilitic neuritis to the condition in this case.
The special tests above referred to are the electric sensory threshold tests of E. G. Martin.
Character change: neurosyphilis.
Case 95. Joseph Wilson offered a very serious social problem. He was the father of two children, and his wife was pregnant at the time of his admission to the Psychopathic Hospital. He was a husky-looking man of 33 years of age, but for the past four years he had been deteriorating in his work; he had been drinking heavily, and finally had stolen to obtain money for liquor. It was on account of his alcoholism and delinquency, which were taken as an indication of change of character, that he was sent to the hospital.
Examination on his arrival disclosed at once that there was more to the case than alcoholism, for the neurological examination showed that the pupils were irregular, the right being larger than the left, both reacting sluggishly to light, and there was an inequality in the reaction of the two eyes, the left being better than the right. The tendon reflexes were exaggerated, with ankle clonus on both sides, more marked on the right. There was also a marked speech defect. Otherwise the physical examination showed nothing of importance.
The W. R. of the blood and spinal fluid was strongly positive. The globulin test was strongly positive, the albumin was markedly increased, there were 74 cells per cmm., and a gold sol reaction of the “paretic” type.
A formal mental examination did not show very much of consequence; his memory showed no marked impairment, he was not deluded or hallucinated, and he had a pretty good insight into his failings. However, he was somewhat childish, and his irritability was quite marked. Were one to rely upon the mental signs alone, it is probable that a diagnosis of chronic alcoholism with deterioration would be made; but in the presence of the physical findings and the laboratory tests, the diagnosis of neurosyphilis had to be given. It is obvious that, while the patient was suffering from a progressive brain disease, and while he did show mental symptoms, there was not sufficient ground on which to commit him, and therefore he had to be turned out into the community. As a matter of fact, he was not prosecuted on account of his theft, because, although legally responsible, it was felt that his disease was at the basis of the character change which had led him into difficulties. Further developments of his relations with society had to be considered, however. It was possible to get him to discontinue the use of alcohol altogether, and for nearly a year he has taken no alcoholic liquor and has been self-supporting. However, his irritability has been very great, making it very difficult for his wife to live with him, and causing his sister to break off all relations with him.
Here, then, is a man with a marked Character Change as the result of neurosyphilis, so that it is difficult for him to maintain the usual social relations. It does not seem possible to remove him from the community.
1. May one speak of general paresis without mental symptoms? If one considers general paresis a mental disease, of course it cannot exist without mental symptoms. However, if one considers the disease as a chronic syphilitic meningoencephalitis characterized by its pathological anatomy, then one may readily speak of general paresis although no real evidence of mental symptoms can be discovered. It would seem that we must take this attitude with our present conception of brain localization, for it is easy to conceive of a general paretic process affecting areas which do not definitely relate to psychic function. And further, such a process may exist but not be of such a grade as to cause mental symptoms.