p-?LD ACASE Of EXTENSIVE BRAIN DISEASE FROM EN"DARTERITIS -PROBABLY Of SYPHILITIC ORIGIN ,p (l S A'J\•[ U E,_L T. 0 R T 0 N, M.D. WORCES'.l'Bll, i\IASS. R ep1'iute£l t•·om The Journal of t he American Medical Association October 5, 1912, V.ol. LIX, 1'1'· 1275-1277 C OPYRIGU'l', 1012 A~li~ RICAN MEDICAL ASSOCIATION l•'IYJ-: IlUNDRED AN D TIIIR '£Y·l~ IVE D EARBOHX AVEXUE CHICAGO ~\ OA 'E OF B.'\.'J'ENSl\'B BRAIN DISE_\ SB FRO?\ [ ENDAH'I'EIU'L'I S l'ROBABT_jY OF SYPH ILl'I'J 0 OHJGlN ':' \VORCF:STEB. J\r AS S. The .following u1::e off ers evidence o[ some interest in the OCClllTeme of: a diplopia explainable only On the hmctional a ct i vit~· of a Fmall remaining portion of on Yisual fi eld and of the retention of a Yery limited word­ hearing capacity, in spite of tbe destruction of practi­ cally all of the ldt cortical auditory anival-platform and tl1e sunounding and itopsychic skirt. From the history there can be li ttle ll onbt tl1at the concli ·on was luetic and yet the microscopi · examination failed to reveal eYidcnce of the specific nature . .lfisl01·y.- Tlle patient, a man of :12. with n n egati,·c f am i\ ~ · l1i story RR far ns could be a scerta in ed. was born an1l r a i;;c:l in ]3rookline . :\lass. fli s childhood was llne ven tfnl. lk proYcd to be :t stnde nt of a\·eragc ability, bnt le ft sch ool at t he thi rd gradt> of t he high school. After one ~ ·ca r ''" an !'rrnnd ho_,. in a l:trgc d cpart111e nt .<;lore• he w ent into the lPnlh er llll s in<'ss and ro~c rap i d\~ · lo the pos ition of a ssistant 111>1nnger. _U t he onll1reak of t he i'pnn ish \\'ar he e nlisted " ·ith l he ::\aya\ HPSl'tTe a nd wa s a"igned to duty on the l-. Fi. f'::. ]'rai,.,ie and >c n :e<l Utrottglto u t t he w:tr. He " ·as :t m oderate though not cons t an t drinker. ]n April , J!l0:3 , ·he hn<l a sore on his penis fol lowed by n. had sore t hroat lasti ng· Lwo months ancl a n t,;h l:t sling· hYo \\"(•cks, ::mel was under· treatm ent for syphilis for o ne ye:tr. On di scl1a rge fro nt tl1e ""'-~ ' h e was in p oor phys ic:tl healtl1 a nd sho\\·e <l some irri tab ilil~ · . fn .'Jul~ · . l!JO+, one ~· e ar and three m o nths n ftt' r l\1e primar~ · les ion, h e exprrien cc1l sonw dillicul ty in 11 Si11g his ri).!·hL leg. This was tm n s i lor~· and • R cacl in the Rt•c li on on i\'r rvou R ancl M ental DiRcaRcs o f t h e Am eri ca n 1\frdical A ~~oc i ntion. nt the Sixty-Third Annual Session, belcl at .I tlnntic City.. Tu1 w . 1012 . • From the Lno ll':ltOI'_\" or Ill(' \\'QI'('CRtrr Rtate Jl ospilal, :uas3U­ chu sc• 1t~. 2 ,,.,, , d iag nosed '" a r!t r ttm a t ic di ~l nrua n cr . T\\'o '"''ck,; hi ler lt P had a "shock" \\' ltil c a t hi s p laeP of uus ine,;,; , \\'lti clt was fo ll o\\'cd u.v SO II H' loss of ]10\\'Cr in hoth lei!'· At t lti ,; time it " ·as noted t ha t hi s mt·mo r ~ ' a nd j udg ment lacked t ltrir for mer a cc n nt c ~ · . The shock did not gi,·e ri;;c lo u nconscions­ li <'S ,;, l> nt left a d iplopia w hi ch necPssitatr(l the clos in g of one ,._,.<' to (' Il l out UtP second image. ·La ter he lost t lt e nst• of hi ,; r ig·lt t <'Y'' for a ." lt ort pe riod. Earl_,. in Srptemher he lt ad a g('ncra l Ppil <·plifo rm co nvul sion nml " ·a s sent to t he Ho ~to n 'Cil,v Jlos pita l \\'he re the dial!'nosi,; of ce rcbrospi 11 al sypl ti li ,; \\'as mttrlP and \\'here he rema i11 ed six " ·ecks ll ndcr actin• iod id t reatment. F rom t he middle of October, l !JO.+. to .Jn 11 . l , l!JO;:i. l11· rema in ed at home and durin g t hi s t ime he !tad a genera l con \'ltl s ion, which " ·as Yer.v se,·e rr. lasting th rcl' lt ot ll·,; , a nd wl ti d1 was foll owed b~ · aphasia. l[r det e· r ioratl'<l rapidl.v dming t hi s limr. '"as ofte 11 co nfused and d i,;orie ntc•d. and fi nally l> N·ame aplta ~ i c a nd fil t h~ · . Ja n. l. l!JO.i. lt c \\' as co mmitted to the Boston State Hos- pita! wlterc lte rcmn in0d until tra nsfe rred to t his hosp itrtl , :\Iarl'h ~8 , 1!)0.>. , Hxamilla.lio'II.- On ad;n i,-sion he was q uiet aml showed n dement ia-l ik e reaction. 1-fe showed par t ial wonl -deafnes,;. paraphasia. and jargon aplta. ia, woul d not o u e ~ - req ue,;t s, wa,; unaull' t o name olJj <'rb. ex hi bited paralex ia. paragraphia 'and con t inun ll.v c l o~etl hi ,; ll'ft eye in attempt ing to Tead or obsrn ·e objects. ~ ' nolt• at· this t ime sugge,;ts t ha t a hem ianopsi;t was a lready present . On p h ~ · s i ca l exa min;ttion on the da~ - ;t.fter adtnission, t he patie nt " ·as qu iet w it lt expre. s ion less :feat. llr <'~ ; talked frcel.v " ·it lt out slur o r trC'ntor of words, hnt was mar ked ly paraphas ic and appeared demented. ) lan .l' of lltl' test s of spec ial srnses eould 11 0l be a ppl icd on a ccou nt of fa ilure of coopcra t ion. neaction to p in-pri ck " ·as pro 111 pt and equal on t!tr t11·o s ide• . T he knee-jerks wNc exaggerated, especia ll y on t he right . Bauin,;ki was p resent on ri g ht ; no an kl e-clonus. T lt r pupils reactc<l Yer_v s l11 ggi,hl y to bot h light a nd ac<'om tnodation. lie was 11na hle to wa lk willto11t suppor t. The ha nd-g ra sp was weak . espccialh- on Tig lt t . The le ft a ngle of mo11 t h wn;; a li ttl!' depressE'll. T he right. na solabial fold was obl itrrated. _T hen• was 110 \\T inkli ng of forehead on Ti ght. Oph t halmoscopic rxn min a t ion q 11 oted as showing a probable s 11 bsid ing 11 eurit i,; wit. h C'O mmencin g cons<'c utive atrop h ~ -. Course of Diseosc.- During his Tcsidencc i n t he hospita I (a .p r ri otl of six yrn rs and fo ur m ont hs) he rema in ed for t iH' mo,;t pa rt q lli<'t. eithe r i n brd or in a eha ir, t ho11gh occasionally h0 was n ois~ · , a nd on a fe11· occasion . he appar­ entl)' Teacted to hall 11 cinntions. H e " ·as filt h ~ - at all t imes. I J' e fe<l himsrlf s pn nla neousl .v an tl 11 Re d t he spoon COI T ect l~ ­ and when atlempling to writ e nsetl t he pencil co n cctly w ith 3 his r ight hand. ,; !l owing JJ O el'idcnre of a prax i<l, t hough f m ­ t her t ests of t hi s co uld not be <· an·ietl out ow ing to t he dement ia and lar k of cooperat ion. .Hi s a ttent ion wa .-; Pa sil y h eld a nd at t imes he seemed to n •cogni ze thP physicia 11 " <UHL attendant s. lJ e w as u nable t o g in , t iH• •tl phal.J et and eoul<l not name t he da ~ ·s o i' t he \\·eek or co unt spontaneon,; ly . .- \ t t imes he was a ble to gi 1·e his surname 11· hen asked and wonlrl r ecognize h is gi 1·e n name 11 · h L• n spoken t o and g <' nen d ly would r eact t o h i ~ 11ame, a nd on Ol H' occ a sion j>rodnccJ " <·oherent sent ence in r espoJJ se t o t he imi t a t io 11 of ca b' m ew ­ in g·. !Je " ·a s nnal.J le to na c p id.1 n·c,; w illt one except ion (oog) or geomet ri cal fi g·nres and 11·o nld obe:'' onl y t he s im pl est co mmands. S pon tane0 11 S drawing produced s ~r mb o l.-; of no l ikeness to t he figure r e<Ju estcd.