Case 4. (See previous figure for brain lesion.) Three levels of the spinal cord showing unilateral pyramidal tract sclerosis, 10 years after cerebral thrombosis.
JUVENILE PARETIC NEUROSYPHILIS (“juvenile paresis”). Autopsy.
Case 5. John Lawrence was an under-sized negro, who came under hospital observation when he was 23 years of age. There was some evidence that the patient’s father was a neurosyphilitic although accurate data were out of the question. At all events, John had Hutchinsonian teeth, a forward bowing of the tibiae, and Argyll-Robertson pupils. These findings together with a history of backwardness at school seem to stamp the diagnosis. It seems that there had been a change for the worse from the age of 18, though the boy had been able to sell newspapers and black shoes up to within a year of his arrival at the hospital. During the last months of his life, he showed a general incoördination, with false movements suggesting those of a drunken person. There were numerous tremors, the glance was shifting, and there was a tendency to nystagmus. Some of these phenomena (taking into account that the Hutchinsonian teeth were not entirely typical and there was even at times some doubt as to whether the pupils were actually stiff) led to a question of the diagnosis multiple sclerosis.
There was, however, little doubt that the case was one of juvenile paresis. Among the symptoms found at various times in this case are the following: disorientation for time, place and persons, confusion, with coarsely irrelevant replies to questions, ill-defined and transitory delusions of persecution, auditory, tactile, and visual hallucinations, and defective memory.
Early in life, the patient had had a habit of falling asleep in school hours, and had experienced a number of falls at various times. During an attack of measles he had had a number of spasms, each of which lasted ten minutes or more.
The autopsy showed death to be due to an early bronchial pneumonia. The thymus was persistent, measuring 3 × 2 × .5 cm. The marrow of the femur was red.
There was a moderate degree of sclerosis of the aorta confined to a few plaques in the arch (not a characteristic syphilitic scarring of the aorta). The spleen was small and had a thickened capsule.
The majority of the lesions, however, were in the nervous system, and the following description is taken from the routine hospital records to exemplify the findings in a fairly characteristic case of Juvenile Paresis.
Head: Scalp closely adherent to calvarium. Calvarium heavy without diploë. Dura adherent to calvarium in bregmatic region. Sinuses contain liquid blood. Arachnoidal villi in considerable quantity. Pia mater contains considerable clear fluid and shows diffuse haziness and focal thickenings. The diffuse haziness is almost universal and is best marked over the superior surface of the cerebellum. The focal thickenings are of general distribution over the veins of the sulci on the superior surface of the brim and are heaped up to form considerable linear mounds near the region of the arachnoidal villi. The superior surface of the cerebellum is traversed by similar linear mounds of fibrous tissue running at an angle to the laminæ. There is no notable increase of fibrous tissue at the base.
Brain: Weight 965 grams. The sulcation is roughly symmetrical except in the occipital poles where there is unusually rich and complex but shallow sulcation. The cortical substance is everywhere firmer than normal, but the sulci fail to flare notably. In a few places there is a focal increase of consistence of still greater degree with apparent local hypertrophy (or gliosis with increase of substance). These foci are in the right second temporal gyrus (3 cm. in diameter) and in the left first temporal gyrus (of same size but somewhat less firm) and are of a whitish, waxen appearance, being visible several feet away by reason of their color and apparent encroachment upon the adjacent sulci. The foci are sharply limited by the sulci laterally, but pale out gradually before and behind.