FOCAL BASILAR MENINGEAL NEUROSYPHILIS (“syphilitic extraocular palsy,” plus other symptoms). Autopsy.
Case 6. Flora Black, a housewife of 43 years, had been tired out for a year but had been apparently in fair health. She awoke one day with double vision due to a left internal strabismus. The visual difficulty gradually passed away so that five months after the sudden seizure she was apparently quite well again. There was one exception: about three or four months after the attack of diplopia, Mrs. Black had begun to feel a kind of weakness in various parts of the face and there were also fairly definite paresthesiæ. In the sixth month after the initial attack, the patient began to be unable to chew and was fain to support the lower jaw with a bandage to aid in mastication. Deglutition was, however, quite unaffected and there was never any regurgitation of food. There were pains in the face, the forehead and the back of the neck.
Upon physical examination at entrance to a general hospital, no changes in the body at large were discoverable. There was a slight edema of the ankles, otherwise no sign of bodily disease.
Conditions in the head were as follows: The facial lines were (notes by courtesy of Dr. E. W. Taylor) smoothed out; both upper and lower eyelids and the corners of the mouth drooped slightly and more markedly on the left side. There was slight photophobia and considerable lachrymation. The patient was unable to pucker forehead, nose or mouth. The unsupported lower jaw fell and the patient was unable to open the mouth widely. The movements of the tongue were normally performed. Speech was mumbling. Sensations of touch, heat and cold were preserved all over the face except that the left cheek below the level of the mouth yielded a less accurate registration of tactile sensations. A hot test tube did not feel as hot in the lower left cheek as elsewhere. Quinine and sugar could not be tasted over the left half of the tongue in front. Smell and hearing were also diminished on the left side. It appeared that there was a complete paralysis of the 5th and 7th nerves and a partial paralysis of the 8th, 11th and 12th, as well as a defect in smell.
The patient died suddenly, three weeks after admission, running a slight temperature during her stay. The autopsy showed (rather surprisingly) a double ovarian carcinoma with metastases into the retroperitoneal glands. Both kidneys were found to be riddled with nodules of carcinoma. The pelvic veins were thrombosed and there was a complete occlusion of the pulmonary artery. There was a riding embolus in the foramen ovale and there was coronary embolism.
The striking nature of these complications and the interest of the case neurologically would warrant its publication in complete detail. We here present the case with utmost brevity as an example of a Syphilitic Cranial Neuritis by extension from the meninges.
The brain was in general without change but there was a considerable exudate over the entire pontine region which had involved several cranial nerves. The 5th nerves, especially the left, showed gross effects of the inflammatory lesion. There seems to be little or no doubt that this neuritis was of syphilitic origin despite the complication of the case with carcinoma of the ovary and despite the fact that the case was observed and came to autopsy before the modern methods of systematic diagnosis could be applied. It is the best case available to us for the demonstration of a focal cranial nerve lesion of the type characteristic of neurosyphilis. We may well suppose that similar conditions would have been found at various stages in the development of Case 1 (Alice Morton). The pontine region of Case 1 was entirely free from lymphocytic exudate at the time of the autopsy. Possibly the clearing up of the pontine pia mater in Case 1 was a therapeutic effect of the thorough treatment therein used. Whether a case like Mrs. Black’s could be cured (aside from the ovarian carcinoma and its complications) by the institution of vigorous systematic treatment is a matter of doubt. Still, in a general way, these cases of focal syphilitic neuritis are among the most favorable cases for treatment.
Summary: We present the case of Flora Black to emphasize how slight in extent and theoretically curable neurosyphilis may be. We fear that Case 1 (Alice Morton) may present too unrelieved and pessimistic a picture. The extensive vascular lesions and complications of Alice Morton, of Case 2 (Francis Garfield), of Case 4 (James Pierce) arrest attention by the incurability of their residual effects (if we omit modern attempts at reeducation of lower arcs). On the other hand the unrelenting progress to destruction of important parenchymatous structures, as shown in the paretic James Dixon (Case 3) and his juvenile replica John Lawrence (Case 5), as well as in Alice Morton (Case 1) and the tabetic Francis Garfield (Case 2), lead to a certain justifiable pessimism. For it is only the meningeal and fine vascular infiltrations of these cases that we can theoretically hope to combat, probably by destroying the spirochetes in these meningeal and perivascular loci. We seem theoretically less able to stop the progress of the often highly systemic and symmetrical, parenchymatous lesions of the tabetic and paretic group.
The condition in Flora Black is clearly much more hopeful, both being more focal and being almost purely meningeal and therefore accessible to therapy.
The two cases which conclude our general survey of neurosyphilis are also focal cases, one of gumma (Lecompte) and one of focal dural lesion (Wyman).