Scaphoid Scapulae.
JUVENILE TABETIC NEUROSYPHILIS (“juvenile tabes”); TREATMENT.
Case 38. The point in presenting Archibald Sherry, a Juvenile Tabetic of 12 years on admission, is perhaps to exhibit pride in therapeutic results.
There was little or no doubt of the diagnosis; in an adult, the phenomenon would be called tabes dorsalis with a question of general paresis. The right pupil was larger than the left and reacted neither to light nor to distance. There was a slight tremor of the tongue and of the outstretched hands. The knee-jerks and ankle-jerks could not be obtained, nor could the periosteal reflexes in the legs. There was a slight unsteadiness in the gait and in various finer movements, and a slight ataxia of the legs. There was not a classical Romberg sign but there was slight swaying in Romberg position. The teeth were Hutchinsonian. For the rest, the physical examination was practically negative.
The family history was of interest. On the paternal side there was nervousness as well as alcoholism and degeneracy. The maternal grandmother had cancer. Archibald’s father was immoral and alcoholic. There was a girl four years older than Archibald, who, though nervous and unstable, has shown no signs or symptoms of syphilis and does not yield a W. R. in blood or spinal fluid.
Archibald himself was born at term, a large child, who, however, lost weight rapidly, developing a marked skin eruption on head and back three weeks after birth. This skin disease lasted for a month and a half and then spontaneously disappeared. Archibald remained weak and sickly, not walking until three years of age. However, he did well in school up to the end of his 11th year, when he failed to keep up with the children. He had been an amiable child and had gotten on well with his playmates. Some time in his 10th year physical disability had begun; there was numbness in the legs with weakness; at times, actual inability to walk. The right pupil was noticed by the mother to have increased in size; the eyelashes had turned white. There was pain over the left eye and a feeling of weight on top of the head. Speech became difficult or even confused.
Consistently enough, the W. R. both in blood and spinal fluid was positive. Globulin and albumin were present in large amounts; there were 150 cells per cmm.
Granting that this be in some sense a case of juvenile tabes we may raise a doubt whether the case is one of congenital syphilis. The W. R.’s of the blood of both father and mother are negative. Syphilis is denied by them. The nervous and unstable older sister failed to show definite symptoms of syphilis or a positive W. R. There had been no miscarriages or stillbirths. The question arises whether the Hutchinsonian teeth do not indicate congenital syphilis. It appears, however, that it is possible to develop Hutchinsonian teeth if syphilis is acquired before the teeth are formed. We have no data as to how or why this particular baby should have acquired syphilis, if he did so acquire it, at the age of three weeks. On the whole, sceptics may doubt our suggestion that the case is one of acquired juvenile tabes. Possibly the question is academic so far as treatment is concerned.
Prognosis: The rarity of juvenile tabes is such that little can be said as to prognosis. Three and a half years have passed since a few injections of salvarsan were made. The pains above mentioned rapidly disappeared, the gait became steadier, the attacks of confusion ceased, and the speech improved. Unfortunately, on account of a lack of coöperation on the part of Archibald’s mother, we have been unable to continue treatment. However, we have from time to time followed the patient in his home and he seems to have shown no falling back after the initial improvement. It would be of great value could we know the situation in the spinal fluid at the present time.
1. Is there any explanation why paresis should occur in some juveniles and tabes in others? There is no available explanation for this difference nor any for the characteristic early optic atrophy of juvenile tabetics.