Case 110. Mr. McKenzie[[18]] was a retired merchant of 42 years whose complaint was that he tired very easily, could not make his legs go where he wished, was unsteady and felt a numbness in his legs. These symptoms had been in progress for a few months only when the examination was made. This disclosed Argyll-Robertson pupils, absent knee-jerks and ankle-jerks, Romberg sign, unsteady gait, moderate ataxia and dysmetria. The W. R. was negative in the blood serum but positive in the spinal fluid with 0.2 cc., and there were 107 cells per cmm. With the symptoms and signs it was therefore easy to make the diagnosis of Tabetic Neurosyphilis (“tabes dorsalis”).
The patient was given five intraspinous injections of mercuric chloride in blood serum (mercurialized serum) according to the method of Byrnes. The dose was 0.001 gm. of mercury. Two weeks after the first injection the cell count was 58 cells per cmm., the Wassermann was positive only with 0.4 cc. After the fourth injection there were but 18 cells and the Wassermann reaction was negative even with 1½ cc. of spinal fluids. The symptoms had improved to such a degree that the patient had no complaint whatsoever and considered himself cured.
1. What are the unpleasant results of intraspinous therapy? Frequently there is an exacerbation of symptoms and pain may be quite severe after intraspinous injections. This, however, lasts only a short period, that is, as a rule less than 24 hours. There may be other symptoms of cord irritation as retention of urine or lack of sphincter control. A rise of temperature is not unusual.
Treatment may alter the W. R. to negative in blood and spinal fluid in TABES DORSALIS.
Case 111. Ivan Rokicki was a baker, 43 years of age, who came complaining of exceedingly severe attacks of abdominal pain with vomiting. He described these attacks as having occurred periodically for a number of years, lasting sometimes as long as a week, during which time Rokicki could not eat or get relief short of large doses of morphine.
Upon his arrival, Rokicki was seen in one of his attacks; he was curled up with excruciating pain, and the abdomen was rigid, though it was impossible to produce additional pain by external pressure. There was spasmodic vomiting, frequently followed by slight relief from the pain, which however shortly recurred and caused the patient to cry out in his suffering. The condition was controlled by opiates but lasted a full week. The leucocytes remained normal and there was no rise of temperature. The attack ceased spontaneously.
Save for the pain, Rokicki’s mental examination proved entirely negative. Physically, Rokicki was fairly well developed and nourished. His pupils were slightly irregular: the left markedly larger than the right; both pupils failed to react to light, and the left pupil also failed to react in accommodation. There were no other reflex disorders evident to systematic examination, nor was there sensory disturbance or speech defect. The heart seemed somewhat enlarged but there were no murmurs; blood pressure: systolic 150; diastolic 110.
The correct symptomatic diagnosis in Rokicki’s case proved to be gastric crises, and this diagnosis must perforce be the first to entertain in view of the chronicity, the periodicity, the non-relation to diet, and the spontaneous cessation of the seizures. The observation of Argyll-Robertson pupils was naturally held to substantiate the diagnosis of Tabes Dorsalis.
The possibility of abdominal inflammation could be shortly dismissed on account of the absence of tenderness (the rigidity in this case was not accompanied by tenderness), fever, and other characteristic signs. There was no diarrhoea, such as is found in lead colic, and there was no other sign of plumbism. Jaundice was absent and there was no special radiation of pain from the abdomen. One had to think of gastric ulcer and hyperchlorhydria, and possibly malaria or gastroenteritis.
The pupillary reactions pointed to a syphilitic condition despite the fact that the lack of reaction to accommodation (over and above the Argyll-Robertson phenomenon) in the right pupil is not entirely typical. Accordingly, although there was no areflexia, Romberg sign, or ataxia, resort was had to the W. R. This however proved negative, in blood and spinal fluid; nor was there any globulin or excess albumin; there were 5 cells to the cmm., in the spinal fluid.