OPTIC NEURITIS AND THE COLOR FIELDS IN THE DIAGNOSIS OF SYPHILIS, NEURASTHENIA, HYPERTHYROIDISM, DEMENTIA PRIÆCOX, MANICDEPRESSIVE INSANITY, AND THIRD GENERATION SYPHILIS

1. From our experience in the last two years, we will say that syphilis, especially hereditary syphilis, is infinitely more common than any authorities have admitted or dreamed.

2. That the clinical evidences show the stigmata in the third, fourth, and even more generations.

3. That neurasthenia, the most widespread and common of nervous disorders, is absolutely caused by syphilis, and that it is not a psychoneurosis, but a distinct physical disease of the brain and cord. The psychoneurosis element is entirely secondary to and caused by syphilis.

4. That dementia præcox, manic-depressive insanity, general paresis are only different grades of the disease. Insanity is cerebrospinal syphilis of different degrees, ranging from irritation, mild inflammation to actual degeneration of tissue.

5. Hyperthyroidism, hypothyroidism, interstitial nephritis (with but possibly a small percentage of exceptions), and chronic sinusitis, are but symptoms that appear in syphilis. Tuberculosis has long been known to develop most easily in syphilitics, as the tissues are much less resistant.

Cancer appears to be most frequent in syphilitics. This can easily be proven on investigation, examination of cases, careful family histories, etc.

In all cases we have investigated we have seen absolutely no evidence that alcohol is the causative factor in insanity. It has always been syphilis. The neurasthenic are unbalanced; i. e., the syphilitic brain craves; the subject drinks; alcohol poured into a syphilitic brain is disastrous. The non-syphilitic alcoholic parents do not beget the idiotic, defective children, but the alcoholic syphilitics do.

One of the pleasantest experiences in this investigation is the easy recognition of cases that are already on the border line of dementia præcox; cases unmistakably genuine, school children. Many of these have been promptly arrested in development of the malady and saved fromthe state hospitals.

Also another class: the young moral defectives, little irresponsibles, lying, maliciously mischievous youngsters, perverts, etc.

The recognition of hereditary syphilis is easy in these cases. Practically all have the usual family history. All have the stigmata—optic neuritis, the majority with more or less defective vision, scaphoid scapulæ, deranged, absent, or badly mixed reflexes. Some of these are brought from the juvenile court, some from the defective sections of our schools. These show a large percentage of positive Wassermann.

As I said before, the clinical signs are easy to read in all these cases, and it has been pleasurable to be able to recognize the incipient dementia præcox cases, with the stigmata complete, the tell-tale family history, and with anti-syphilitic treatment, see those distressing symptoms disappear, the patients return promptly to mental and physical health. Much has been written and said about the hereditary taint. That is a word that should be forgotten; it is not a taint handed down, it is the spirochaete itself, and in these nervous cases it is in the parenchyma of the brain and cord, as shown recently in paretic cases by Noguchi, to whom much honor.

I wish to express my thanks to Dr. Milton H. Schutz for the drawings of the optic discs and to Dr. Stephen Wythe, one of my associates in the Oakland College of Medicine, for his assistance with the paper.

The seventeen case records presented have been selected as follows: three acknowledged, acquired syphilis, with direct history of infection; one of these has gone insane; one has acquired pulmonary tuberculosis; one has ocular neurasthenia to a slight degree, but suffers principally from annoying lacrimation; one case of exophthalmic goiter; three manic depressives; onehypophyseal case; one angio-neurotic edema. The balance are of varying degrees of neurasthenia.

Dr. Jau Don Ball reports twelve of the cases; Dr. W. S. Kuder four; Dr. W. H. Strietmann, one.

The original diagnosis was made from the eye findings. The color fields were gone over several times for confirmation. I find, that when gone over carefully, that the subsequent fields are practical duplications. The sector-like contractions show in exactly the same meridians.

Case 34 (Illustration I).—Report by Dr. Ball. American housewife; age, 29 years; married.

Heredity.—Father living, age 61 years; keen, active man, having but poor insight into sufferings of others; high-strung. Mother died suddenly after operation for uterine cyst. Suffered severe headaches, and had "eye trouble." Two brothers in poor health.

Health History.—Always had weak stomach; "blinding headaches" when six to eight years old. Optic hallucinations; saw "great lumps of sugar and would walk around them." Appendicitis 12 years ago; operation. Has a great deal of indigestion. Measles and pertussis at age of five years. Mumps at 10 years; tonsillitis at age of 20 years. Menstruation began at age of 11 years and was regular. Pain commenced two years later, always on left side. Flow lasts seven days. One week before menstrual, headaches and pain in cervical and lumbar regions.

Injuries.—None.

Habits.—Good.

Present Illness.—Symptoms of psychomotor acceleration alternating with psychomotor inhibition. Occasionally depressed. Irritability a marked symptom. "Neuritis" pains general. Eyes feel "fuzzy." Muscular weakness.

Neurological Examination.—Plantar reflex: No response. Epigastric reflex normal. Cervical skin reflex sluggish on both sides. Tendo Achilles reflex exaggerated on right side, normal on left. Knee-kick greatly exaggerated on left; exaggerated on right. Superior tendon reflexes: Triceps, biceps, ulnar, radial, and pectoral, all sluggish. Suspicious ankle clonus on right only. Coordination fair. Sensation for pain hyper (especially marked in lower extremities). Sciatic points very tender. Extreme tenderness over both sacro-iliac joints. Subjective pains in arms and legs. Thermic sense markedly disturbed; areas of cold and anæsthesia on right and left sides and extremities; heat sense dulled in upper and lower extremities. Cranial nerves: Nothing abnormal noted. Dynamometer reading: Right 24, left 22. Dermographia present. Thyroid slightly enlarged.

Remarks.—The brother of this young woman likewise had double optic neuritis of more constant bad character than the sister. Was delicate, timid, lacked confidence in himself. Suddenly lost hearing in one ear (labyrinthine deafness).

Under treatment he has developed splendidly; gained weight, has ruddy complexion, has the looks and carriage of a man, which he lacked before. The optic discs were both swollen, bordenless, red as the retina; color fields very much contracted.

Treatment.—Patient's eyes would cloud up with a translucent swelling on the disc, which would leave perhaps in a few days. A few weeks iodipin cleared up the vision to 20/20, and a general feeling of well-being followed. [See table in the PDF file] Then iodipin was continued for two months, when such swelling in both gluteal regions took place that the patient was confined to bed. All treatment then was refused, but patient kept up the improvement for nearly eight months—no headaches, always felt well, strong and vigorous, a changed woman. In the middle of March, 1914, the eye-symptoms returned with the headaches, and treatment was resumed.

The optic discs in this case varied greatly from week to week. At no time was there a P. O. and at the times of exacerbation a cloudy swelling almost hid the disc from sight, as in plate of disc No. 7. (Page 61.)

Case 27 (Illustration II).—Report by Dr. Kuder. This case is one of the early ones, who was suspected of having a brain tumor. Age, 45; American housewife; suffered with almost constant headaches for 10 years. Lenses had been prescribed by me 10 years ago. I had not been consulted about the headaches since that time. Vision 20/30, not improved by lenses.

In April, 1912, patient came with a severe papillitis of the left eye with extensive hæmorrhages in and around the papilla. The right disc was redder than normal, dusky, no P. O., but vessels apparently normal in relation. The color field is of the "good" eye.

Several diagnoses were made by several internists. Brain tumor, thrombosis of cavernous sinus, etc.; Wassermann negative; X-Ray failed to locate anything. As this "merry widow" has had three husbands, and one of these died of syphilis, she was put on antisyphilitic treatment; Salvarsan; several injections; iodipin; and mercury injections. Her headaches cleared up, the progress of the papillitis was stayed, the vision in the right eye came up to 20/15 plus, and the patient is feeling better than in years.

Long after treatment was begun, and she began to feel better, she informed us that she had had alternate fits of exaltation and depression with suicidal tendencies and had kept poison on hand.

Case 28 (Illustration II).—Nationality, American; age, 76; married; attorney; negative heredity; diagnosis, progressive bulbar paralysis.

When the patient came under observation, the symptoms were well advanced. In this case no history of syphilis could be obtained, but a diagnosis of a syphilitic base for this organic condition was made from the eye findings and color fields, after which positive Wassermann reaction was obtained. Anti-syphilitic treatment was instituted, but the disease was too far advanced to make any impression. Within two years the patient died, paretic dementia symptoms supervening.

Neurological Examination.—Plantar reflex, Babinski toe on both sides; cremasteric reflex, absent on the right, sluggish on the left; epigastric reflex, normal; cervical skin reflex, no response; pupillary reaction, reaction to light very sluggish (one year later, no response to light); tendo Achilles, unequal and sluggish; KK, greatly exaggerated on both sides; superior tendons, all exaggerated; sensation, unsatisfactory examination; coordination, Romberg present.

Case 116 (Illustration III).—Report by Dr. Ball, January 2, 1913. American, unmarried; age, 34 stenographer; father living, age, 64; poor health for several years, having had maxillary sinusitis, pleuritis and periostitis. Mother died insane, after having suffered from epilepsy for 30 years. One brother has chronic sinusitis and an amblyoptic eye, one sister chronic maxillary sinusitis, one brother well. All have marked optic neuritis. One aunt and uncle neurasthenic. Maternal grandmother died of goiter.

This cas—116—suffered all her life from fearful headaches, prostrating in character, severe attacks of hyperacidity, paroxysmal attacks of pain in abdomen, painful over pylorus and appendix; patient describes this as chronic "stomach trouble." Crises.

Examination revealed sternum and tibiæ tender, and periosteum thickened; a few inguinal and numerous cervical glands, heart and lungs negative; patient has noticed brownish discoloration remains at sites of healed acne lesions.

Memory good, slight vertigo present, sleep variable, Romberg negative, exaggerated reflexes both upper extremities, exaggerated reflexes right knee and ankle, diminished left.

Patient at first treated with potassium iodide, as she refused iodipin injections; later however took the injections. April, 1913, reports a great improvement; gastro-intestinal symptoms gone, feels better than she has in years.

April, 1914, has had during year courses of mercury and arsenic, and is better than ever in her life; very rarely has a headache.

Case 23 (Illustration III).—Report by Dr. Ball. Jewish student; age, 22 years; single.

Heredity.—Mother psychasthenic; maternal uncle, paralysis; paternal, Wassermann spinal fluid; father apparently normal; grandfather died at 70, nervous wreck many years; two sisters, hysterical neurasthenia.

Health History.—1909, lobar pneumonia; diphtheria; chicken-pox; 1910, ophthalmic herpes zoster.

Injuries.—Head injury at age of ten, slight scalp wound.

Habits.—Good. History of excessive masturbation.

Present Illness.—Began in spring of 1908. Phobias; sense of unreality. Fatigues easily; depression; vague pains in eyes; persistency of images; flashes of darkness. Globus; at times difficulty in swallowing, making a choking, noisy effort swallowing. Constipated; dry, harsh skin; insomnia at times.

Neurological Examination.—Plantar reflex: No response, except for excessive action of muscles on anterior portion of thigh. Cremasteric reflex normally active. Epigastric reflex normally active. Tendo Achilles reflex normally active on both sides. Knee-kick: Left exaggerated; right sluggish. Superior tendon reflexes: Triceps and biceps on both sides sluggish; pectorals normal. Coordination good. Sensation normal. Cranial nerves normal, with possible exception noted in speech at times (slight tremor and a distant tone). Memory good. Logical powers good.

[See table in the PDF file]

Remarks.—October 9, 1912, optic neuritis and no P. O. April 23, 1913, P. O. present.

Had had to leave school a number of times owing to neurasthenia and phobias; at times had suicidal tendencies.

Treatment.—Iodipin intramuscularly; salicylate of mercury, cacodylate of mercury, mercury by inunction; hydrotherapy; regulation of diet and hygiene; improvement is marked, especially since intensive treatment with mercury began.

Case 54 (Illustration IV).—Report by Dr. Kuder, April 2, 1912. Housewife, American; age, 42. Father died of apoplexy, mother living and well, one sister had T. B., one sister has exophthalmic goiter.

Patient always had been remarkably healthy and full of vitality and spirits.

Water on knee 10 years ago, thinks it came from an injury. Knee symptoms returned five months ago, associated with irritation and pains in the eyes; some headache. Habits, occasionally too much champagne.

The present illness began two years ago with irritation in the eyes with persistent lacrimation; no treatment or fitting with lenses had the slightest effect on this distressing symptom. She consulted several oculists between Oakland and New York, and the best she got was the advice to try Christian Science. (Her husband is a known syphilitic, though not married until io years after the initial lesion was obtained.) On her return to Oakland I was again consulted about her hearing which had become defective; on examination further 1 found the vision had also reduced to 20/30; taste was markedly off; everything tasted alike; sense execrable; said she got furiously angry over little things that previously did not affect her; nervous and depressed for no apparent reason. Had sensation as of swollen hands.

The neurological examination is incomplete, as the patient did not submit to it, except the following: Romberg marked, superior tendon reflexes exaggerated, lower right exaggerated, lower left diminished, sensation, right upper hypo; left upper normal.

On vigorous anti-syphilitic treatment, this patient has improved remarkably, the persistent lacrimation has disappeared, and she has gained markedly in weight and is superlatively good natured and happy.

Case 25 (Illustration IV).—Report by Dr. Ball, September 25, 1912. American; age, 34; bookkeeper; married. Primary syphilis seven years ago; treated at Arkansas Hot Springs for a short time; pronounced well; married 1909; has one child thirteen months old. Consulted me on account of intense headaches, frontal, vertical and occipital; stabbing in character, and more or less constant.

There was an intense double optic neuritis—border of discs indistinct and fiery red in color, no P. O.

Neurological examination by Dr. W. H. Strietmann, reflexes apparently normal throughout, tibiæ show slight periostitis with marked tenderness.

Romberg, slight; sensations; hypersensitive to pain; thermal sense normal, iodipin injections.

October 15, reports improvement of headaches, put on potassium iodide.

December 18, headaches becoming worse.

December 28, /12 Neo Salvarsan six decigrams.

April 15, reports by letter that headaches have almost gone and has gained 15 pounds in weight during treatment. This patient lived some distance from Oakland, and owing to that could only come in occasionally for treatment. In June, 1913, patient suddenly developed bulbar paralysis, general paresis and was taken to a hospital for the insane.

Case 119 (Illustration V).—Report by Dr. Ball. American housewife; age, 38 years; married (divorced).

Heredity.—Mother suffering from melancholia.

Case History.—Married at the age of 20, and divorced after six years. Has one son 15 years old. Had two abortions prior to the birth of this child, and one three years following its birth. Had no injuries. Is a constant user of alcoholic stimulants. Has always been delicate. Had "stomach trouble" for years. Spells of nausea and vomiting. Fifteen years ago had a skin eruption in the form of vesicles or blisters. Ten years ago face was swollen; typical angio-neurotic edema. After husband returned from the Orient, wife developed this skin trouble.

Present Illness.—At present time patient is suffering from angio-neurotic edema, neurasthenic symptoms, periodical pain, and great irritability, and fatigues easily.

Neurological Ezaminotion.—Plantar reflex: No response. Epigastric reflex present. Cervical skin reflex present. Tendo Achilles reflex sluggish on both sides, hard to elicit. Knee-kick greatly exaggerated on the left; less on the right. Suspicion of Gordon paradoxical reflex. Coordination: On both feet, fair; on one foot, poor. Sensation somewhat delayed. Occasionally tender sternum. Right lobe of thyroid enlarged, tenderness over the liver, marked tenderness over the appendix, left iliac region tender, considerable tenderness over the course of the left sciatic nerve. Hair is undoubtedly gray, but patient dyes the hair. Very anemic. Wassermann negative.

Treatment.—Refused intramuscular treatment, but takes internal treatment intermittently. Improves rapidly; treatment ceases; then takes treatment again, and again improves.

Case 26 (Illustration V).—Report by Dr. W. S. Kuder. American housewife; born August 19, 1860; married.

Heredity.—Nervous and mental history negative. Mother died at age of 50 (pneumonia); father died at age of 63 ("dropsy"); one brother died at age of 40 (pulmonary tuberculosis); a half-sister died at age of 24 years (eclampsia). Oldest daughter (25 years) healthy. Second daughter (22 years) has fainting and dizzy spells, and frequent headaches; is subject to "colds"; has tenderness over appendix; has a mitral systolic murmur; has dry, harsh skin. Third daughter (14 years) has headaches, and a marked acne.

Health History.—Pertussis, age four years; measles, age 20 years; typhoid, age 15 years, after which she was very "nervous," and would "scream out" in public. This "gradually wore off." Scarlet fever at age of 11 years; chicken-pox during infancy. As a child, she was naturally timid. Married at age of 24 years; four children, three girls and one boy (girls born 1886, 1889, 1898; boy born 1893). One abortion and one miscarriage. One miscarriage between first and second child. Badly lacerated after first child. Felt as if she was "going out of mind" after first child was born. Could not sleep for a long period; "took months to get well and strong." Attached placenta after second child; hemorrhage, followed by septicemia; four weeks in bed; months recovering; slight phlegmasia alba dolens; could not stand for long time; always wished to sit down. Hemorrhage after third child; placenta again adherent. This confinement was followed by ulceration or patches in vagina and labia, visible to the eye and "looked like canker-sores in the mouth." This was followed almost immediately by "rheumatism" in all joints, especially painful in knees. After second child, had "sciatica" in left leg. After fourth child, had severe hemorrhage and adherent placenta; but health improved up to five years ago, with exception of occasional "touches" of rheumatism. Four years ago, had "nervous breakdown" and has not been well since. At age of 24 years, a few weeks after marriage, developed "shingles." Also had enlarged cervical glands and night-sweats.

Injuries.—None.

Habits.—Good.

Present Illness.—Began four years ago with a "nervous breakdown," since which time she has had pain in back of head, a "sapping of strength," a "leakage somewhere," "insomnia," fainting spells, especially when standing; felt she could not talk; belched great quantities of gas; had various phobias; pain in head gradually growing worse at night; irritable and weak; did not wish to meet friends and avoided making calls.

Neurological Examination.—Plantar reflex: No response. Epigastric reflex unequal, sluggish on left. Cervical skin reflex sluggish. Pupils slightly irregular. Tendo Achilles reflex: Both sluggish. Knee-kick exaggerated on both sides, more so on left. Superior tendon reflexes all exaggerated. Coordination: Both upper and lower fair, no Romberg. Sensation slightly delayed on soles of feet. Threshholds for pain and touch hypo on right, apparently normal on left. Blood pressure: Systolic, 210 mm. Hg; dyastolic, 196 mm. Hg.

Remarks.—January 30, 1913. Since the first of the year improvement is marked. Is not longer depressed, has no headaches, and is happy and easy in mind. Reported last, July 20, 1913; says that she "does not need a physician" as she is feeling so well and is entirely free from all symptoms.

Treatment.—Iodipin, mercury, and sajodin.

Case 98 (Illustration VI).—Report by Dr. Ball. German; married; at present salesman, formerly prize-fighter.

Hercdity.—Father died at age of 76 (cystitis); was very "nervous," alcoholic, and had a fiery temper. Mother died at age of 84, cause unknown; rheumatic, has "heart disease," and was operated on for hydrocele; one brother, 52, good health, was operated on for hydrocele, married, six children, all well; one brother, 50, is "wild," alcoholic, married, one son in good health. Patient has three children: two boys, seven years and 17 years; one girl, 14 years. Oldest boy has rheumatic attacks, asthma, strabismus, and optic neuritis.

Health History.—Travelled a great deal and lived in the Orient for a number of years; drinking more or less excessively. Had ordinary diseases of childhood; also suffered from boils or abscesses on neck. Gonorrhœa twice; herpes zoster, right intercostal, two years ago, followed by cough of several months duration.

Injuries.—Ordinary injuries incident to life of a prize-fighter. Eleven years ago was hit on the head, in right parietal region; momentarily unconscious. Plain rectal fistula on left side, treated by "injection."

Habits.—Alcoholic, great smoker; dissipated life.

Present Illness.—Began three years ago with "stomach trouble." At that time, and off and on since, had shooting pains in the shoulders, more marked on the right side. Failing sexual power past two and a half years, and at present is impotent. At present is easily frightened and worried, easily irritated; has vertigo, headaches noticed past two months for the first time. Two months ago noticed diplopia, which was followed by exophthalmos and paralysis of inferior rectus muscle of the right eye. Typical exophthalmic goiter developed, the marked symptoms being exophthalmos, tremor, and tachycardia.

Neurological Ezamination.—Plantar reflex absent on left, sluggish on right. Cremasteric reflex sluggish on right, exaggerated on left. Epigastric reflex sluggish. Cervical skin reflex absent on right, sluggish on left. Tendo Achilles reflex greatly exaggerated. Knee-kick greatly exaggerated on both sides. Superior tendon reflexes all greatly exaggerated. Coordination poor; ataxic gait; keeps eyes on floor when walking. Slight incoordination of facial muscles. Faint fibrillary tremor of both hands, and of upper lip. Inspection: Darwin ear; exophthalmus, both eyes; fingers are clubbed and blistered; skin scaly on both hands, especially marked on the first and second finger and the palmar aspect; jaws abnormally large; cachexia. Sensation: Sluggish reaction to pain; tender shins; thermic sense exaggerated for heat; cold normal up to knees and elbows. Dynamometer reading: Right, 44 pounds; left, 34 pounds.

Remarks.—The wife had several miscarriages after the birth of the first child.

Treatment.—Iodipin 10 cc. in series of 10 doses, alternating with mercurial inunctions, 6o gr. each, in series of 22 inunctions; hygiene and dietetic; hydrotherapy.

Eye examination, September, 1912: Vision 20/30, both eyes; media clear, slight swelling and haziness of both discs. No P. O. December 16, 1912: Vision OD 20/30(⅓). April 12, 1913: OD 20/20+, OS 20/15(½). July 19, 1913: 20/15 both eyes, with corrections, and diplopia disappeared. November 28, 1913: Discs level, normal color, light spots appearing where P. O. should be. March 11, 1914: Both discs clear, P. O.'s showing as P. O.'s, though small.

Case 128 (Illustration VI).—Report by Dr. Ball. Male; age, 32.

Heredity.—Father living, a man of high mental attainments, a lawyer and politician by profession, characterized as somewhat eccentric, age about 72. Mother living, quiet woman, of melancholy disposition. History of grandparents negative except for paternal grandmother, who had senile dementia. Two brothers living, one aged 30, one aged 36; both intelligent men and yet somewhat eccentric. The one aged 36 has a very violent temper as a psychical characteristic. The one aged 30 is noted for his stubbornness and great unreasonableness. One sister living, who is of a depressed nature, seclusive in her attitude toward life and not liking company.

Health History.—The patient has had the ordinary diseases of childhood. Rural life until the age of 18; then college life; then occupation as a civil engineer. Acquired syphilis nine years ago. Six years ago acquired pulmonary tuberculosis.

Present Illness.—This case is an actually known syphilitic case and, as such, gives typical fundi findings and color fields. Several positive Wassermann reactions prove the existence of the disease.

Neurological Examination.—Apparently some atrophy of the interossei muscles dorsal of the hand. Hypertrophy: None. Plantar reflex: Delayed normal response. Cervical skin reflex decidedly sluggish. Epigastric reflex normal. Cremasteric reflex very sluggish. Gordon paradoxical reflex present on the right. Tendo Achilles reflex unequal and very sluggish, more sluggish on the right. Knee-kick: Right absent, left very sluggish. Superior tendon reflexes apparently normal; if anything, a little sluggish. Cranial nerves apparently normal, except that pupillary reaction to light seemed sluggish. Coordination not good for lower. Sensation delayed. Thyroid slightly enlarged. Scapulæ scaphoid.

Treatment.—This man was treated vigorously for 18 months after the primary sore, then spasmodically thereafter up to the present time.

Case 133 (Illustration VII).—Report by Dr. Ball. Irish housewife; age, past 50 years; married.

Health History.—Had several miscarriages followed by the birth of one child, which lived to be 17 years old. Had measles at 12 years of age. Five years ago had skin disease, forming vesicles which dried and became scaly, leaving raw and painful surfaces.

Injuries.—Has had no injuries.

Habits.—Is possibly an alcoholic.

Present Illness.—Complains of numbness and tingling of the extremities.

Various paræsthesias, abdominal pain, cardiac palpitation. Badly constipated, and has hemorrhoids, badly lacerated perineum and cervix. Pulse 110. Former weight, 195 pounds; present weight, 150 pounds. The patient is cachectic; occasionally has involuntary urination. Dried ulcer on the right great toe unaffected by treatment to date. Very emotional, cries easily and is distressed. Complains of vertigo and sleeps very poorly.

Neurological Examination.—Plantar reflex: No response. Epigastric reflex normal. Cervical skin reflex sluggish. Tendo Achilles reflex unequal, very hard to elicit on the right. Knee-kick greatly exaggerated on both sides. Superior tendon reflexes: Biceps and triceps cannot be elicited; very sluggish. Sensation is markedly delayed in feet and hands. Coordination poor, especially on one foot. Frequent examination of the urine shows glycosuria varying from 2 per cent to 6 per cent. Mental condition: Memory is poor for recent events; logical powers are poor. Is very emotional. Vertigo is occasionally present, and sleep is poor. Wassermann reaction is negative. Three years ago had melancholia for three months.

Treatment.—Improved markedly under antisyphilitic treatment; then abandoned treatment, and died four months later from "uremic coma."

Case 160 (Illustration VII).—Report by Dr. Ball. German-American woman; age, 63 years; married.

Case History.—Patient's husband left her about 30 years ago. He was a man who was away from home a great deal and who went around with other women; especially did this occur during the last year that he lived with her. Patient says her husband was healthy, except that he had "granulated eyelids." Had three children, two of whom died under the age of five. No miscarriages. Had children's diseases, as measles, scarlet fever, etc., when a child; but in young adult life was very healthy and strong, except for the "rheumatism" mentioned below. Had tape-worms when a young woman. Had had "lumbago" during last two or three years.

Present Illness.—Complains of twitching of eyelids. Twitching has been going on for past seven months, following fall which produced blackening of entire face. Also has worried a great deal. Has worn glasses for a few months. Has had "rheumatism" a great deal for a number of years, with some sharp pain in left eye. Optic neuritis.

Neurological Examination.—Babinski negative. Oppenheim negative. Gordon negative. Ankle clonus negative. Knee-kick slightly exaggerated on right, normal on left. Tendo Achilles reflex normal. Cervical skin reflex normal. Pupillary reflexes normal.

Treatment.—Took KI and mercury iodid, and "rheumatism" and twitching disappeared.

Case 118 (Illustration VIII).—Report by Dr. W. S. Kuder. Mrs. E., American, 47 years of age, was referred to me for consultation in May, 1912.

Her mother died of pulmonary tuberculosis. Her father at an advanced age came to death unknown. One sister died of apoplexy at 51, otherwise the family history was negative.

In childhood she had measles three times, and she thought most of the other diseases common to childhood, including diphtheria, Four years ago she suffered a severe attack of typhoid, and two years previously she had the left breast amputated for cancer. She had only one pregnancy, which resulted in premature birth at the eighth month without apparent cause. She dated the beginning of her illness to two years previous following the removal of the breast. She was wakened at night with tingling of the right great toe, bone pains in right tibia, and rheumatic pains in the right arm. There was also considerable numbness and tingling of the left hand. She complained of vague pains in the head and attributed her falling hair to them. She had been unable to walk in the dark for a number of months, and her sister informed me that she had difficulty in walking with her on the street, because of the patient's inability to walk straight. On inquiry she acknowledged to a tendency towards hysteria and great difficulty in writing and speaking at times. The bladder was incontinent and there was dribbling when stepping off a curb or car. She complained of frequent feelings of vertigo, poor memory and very poor sleep. In addition to the above mentioned pains there were almost daily seizures of lancinating pains in the head.

In appearance the patient was healthy but extremely stupid. Questions had to be repeated and cross examination was necessary to verify her answers. The pupils reacted to light and distance. There was no abnormality of the head.

The sternum was equisitely tender, as were also both tibiæ. Examination of the heart and lungs negative. The only finding in the abdomen was a somewhat enlarged liver. The examination of the nervous system revealed a pronounced Romberg, exaggerated reflexes of all extremities, with a marked diminution of sensation of the right upper and lower extremity. There was no Babinski, Gordon or Oppenheim.

The patient was treated in courses with iodipin, mercury, sodium cacodylate, intramuscularly until the following March when a recurrence of the cancer required a second operation, making further treatment useless.

Case 51 (Illustration VIII).—Report by Dr. Ball. American housewife; widow.

Heredity.—Negative.

Health History.—As a child "abscess of spine"; typhoid fever about age of 14, followed by squint. Numerous miscarriages. "Nervous prostration" one year ago, since which time she has been unable to see in right field, and has had difficulty in using right leg and right arm.

Habits.—Good.

Present Illness.—Began over one year ago. Loss of weight, some "stomach trouble," "nervous prostration," right homonymous hemianopsia, paresis of right leg and right arm; can burn right hand without feeling heat.

Neurological Examination.—Plantar reflex: Sluggish response. Epigastric reflex: Sluggish response. Tendo Achilles reflex unequal; right very sluggish, left sluggish. Knee-kick greatly exaggerated on left. Superior tendon reflexes all very sluggish and hard to elicit. Oppenheim toe reflex on right. Gordon paradoxical reflex on right (also compression of left calf induces paradoxical reflex on right, contra-lateral Gordon).

Coordination: Romberg present. Slight tremor in upper extremities. Sensation: Threshold for pain hypo generally, and quite sluggish on soles of feet. Threshold for heat and cold markedly diminished in upper extremities, more especially on right side. Tactile sense preserved, giving a suggestion of dissociation of tactile and thermic senses such as is often seen in syringomyelia. Mental examination: Flow of ideas slow, generally retarded (both motor and sensory retardation). Somewhat confused. Irritable at times.

Remarks.—Fundus difficult to see; dusky red disk; no P. O.; vision, right eye 20/80, left eye 20/120.

Treattnent.—This patient had to be assisted into the clinic, head wobbling from side to side, gait like that of an intoxicated person. After three weeks' anti-syphilitic treatment, patient became herself, vision improved and her general feeling was fine; after this she disappeared.

Case 10 (Illustration IX).—Report by Dr. Ball. Male; farmer; married.

Case History.—Patient first came under observation for his mental condition in May, 1908, showing typical manic-depressive insanity with marked suicidal and homicidal impressions. Had always been considered an accentric individual; rather flighty; ideals above the average; somewhat of a dreamer at times; excellent ability in his line, as orchardist and farmer; some literary tendency.

After a short residence in a private sanitarium, he was fairly well recovered, so as to be able to live with friends, but had his depressions and exhaltations, during which time he had to be carefully guarded.

Present Illness.—Examination in 1912 shows a double optic neuritis of the type described above, and of disc No. 4. (Page 61.) Also contracted and interlaced color fields. Notwithstanding a denial of venereal diseases, the assumption of a syphilitic base for his condition was made wholly on the eye findings. A subsequent positive Wassermann reaction was obtained.

Neurological Ezamination.—Atrophy: None. Hypertrophy: None. Movements: Voluntary, active and rapid; involuntary, slight tremor of lips at times. Plantar reflex: No response. Cervical skin reflex sluggish. Epigastric reflex normal. Cremasteric: Sluggish. Tendo Achilles reflex: Plus 2 on the right, slightly exaggerated on the left. Knee-kick greatly exaggerated on both sides, and a little more so on the left Superior tendon reflexes all exaggerated. Sensation: All thresholds were hyper. Subjectively, there was a feeling of unreality at times, and various paræsthesias. Tender areas over tibiæ and sternum. Coordination fair for lower extremities, good for upper extremities. Cranial nerves were normal.

Treatment.—Immediately anti-syphilitic treatment was vigorously instituted with surprising improvement, which has reached the point, during the past year, where the patient has been able to earn a good living for himself and has been enabled to send money to his wife. Prior to the time when anti-syphilitic treatment was instituted he could not sustain a continued effort along any one line for any length of time. All sorts of schemes pervaded his brain, and an ultimate organized existence seemed impossible.

This man is faithful, taking his treatment at the present time; and although I do not consider him entirely recovered, the improvement has been so marked and so even, since the day of the beginning of the antisyphilitic treatment, that I feel hopeful of a recovery of at least 90 per cent of his former efficiency.

Case 44 (Illustration IX).—Male; age, 36; musician. Right eye.

Primary syphilis eight years ago; treated with the ordinary potassium iodide, and protoiodide of mercury for two or three years. His physician now gives him a little treatment "every little while."

His vision is 20/15 and 20/20 respectively, accepts a cylinder plus .25 ax 90. Has constant trouble with irritative lacrimation and has come once or twice a year to have lenses refitted.

Optic discs deeply reddened and slightly cloudy. No p. o. This case is given simply to show a syphilitic with a direct history.