The Argyll-Robertson pupil should not be used as a basis for a necessarily bad prognosis if treatment can be given.
Case 106. Frederick Stone was a business man of large interests. He had been in the hands of physicians for several years for a variety of disorders such as renal, respiratory, cardiovascular, and so on. No suspicion of syphilis had apparently been uttered by the physicians despite the fact that Mr. Stone readily stated that he had had a chancre thirty years before, and that he had received several years’ treatment of mercury and potassium iodid by mouth.
It appeared that a few years ago he had begun to have trouble with his nose, which was cauterized and operatively interfered with without satisfactory results. This nasal condition had later been diagnosticated as gummatous, and had improved considerably under a mild antisyphilitic treatment. However, this nasal condition had been considered and treated quite separately from the remainder of Mr. Stone’s troubles.
What brought him to attention was a sudden diplopia with ptosis. There was a paralysis of the external rectus of the left eye, as well as a drooping of the lid on this side. The left eye was much inflamed. The diplopia greatly bothered the patient, and there was also considerable pain in the left frontal region, confined chiefly to the distribution of the first division of the trigeminal nerve. According to the patient this headache was periodic. There was considerable tenderness to pinprick over the area and a diminution of sensory discrimination of fine touch. Both the pupils failed to react to light.
The remainder of the neurological symptomatic examination was surprisingly clear of disorder, nor was there anything in the history suggestive of tabes. There was ozena as well as evidence of the operative work upon nares and throat. Possibly the arteries were slightly hardened; blood pressure was 165 systolic. There was a large trace of albumin, and there were numerous hyalin casts in the urine.
| PARETIC NEUROSYPHILIS | |||||
| (GENERAL PARESIS) | |||||
| Cases systematically treated | 50 | ||||
|---|---|---|---|---|---|
| CLINICAL REMISSIONS | 34 | 68% | |||
| C.S.F. ALTERED TO NEGATIVE | 4 | 8% | |||
| C.S.F. ALTERED TO WEAKER | 16 | 32% | |||
| C.S.F. UNALTERED | 14 | 28% | |||
| CLINICALLY UNIMPROVED | 16 | 32% | |||
| C.S.F. WEAKER | 7 | 14% | |||
| C.S.F. UNALTERED | 9 | 18% | |||
| Massachusetts Commission on Mental Diseases | |||||
| November, 1916 | |||||
| Chart 25 | |||||
Mentally, there was a degree of depression and worry hardly out of keeping with the general situation. Despite the preservation of memory, Mr. Stone failed to do rather simple arithmetical calculations; this was the more remarkable as in his business he had to handle figures a great deal and had been doing so until recently. There was a slight tremor in his writing, as well as a certain difficulty in enunciating test phrases. Insomnia, irritability, and a feeling of nervousness and of being tired out, completed the picture.
A suggestion for diagnosis would be classically offered by the Argyll-Robertson pupils. Should not a patient with the Argyll-Robertson pupils have either tabes or paresis? However, in favor of tabes, besides the pupil, are to be counted merely the troubles with the eyes. In the direction of paresis we have to consider speech defect, to say nothing of less definite symptoms such as insomnia and increased irritability.
We are inclined to think, however, that the disease in this case is meningovascular. This diagnosis is suggested by the cranial nerve palsies and by the headache. Headache is much more rarely a phenomenon in the paretic type of neurosyphilis than in the meningovascular type.
In point of fact, the spinal fluid phenomena bore out the diagnosis of Meningovascular Neurosyphilis inasmuch as the globulin, albumin, cellular content, gold sol, and W. R.’s were all weakly positive.