Physically, Lepère looked older than he was; he was very poorly developed and nourished, and seemed very weak. There was a slight visceroptosis.
Neurologically, there was considerable speech defect, particularly well marked in test phrases. The pupils were contracted and gave the Argyll-Robertson reaction. Neurologically there were no other signs.
Mentally, there was a depression with worry; but it was a question whether these phenomena were not entirely natural. The special complaint was of failing memory.
The Argyll-Robertson pupil also prima facie signifies neurosyphilis. Lepère, in fact, admitted syphilitic infection at 23. The gastric symptoms at once suggested tabes. The knee-jerks and ankle-jerks were, to be sure, preserved; however, this is not very unusual in tabes. The amnesia and aphasia naturally suggested paresis. Without resort to laboratory findings, accordingly, the diagnosis of taboparetic neurosyphilis (“taboparesis”) was suggested.
| EFFECT OF EARLY TREATMENT ON THE DEVELOPMENT OF NEUROSYPHILIS | |||
| TOTAL CASES | 4134 | ||
| DEVELOPED GENERAL PARESIS | 198 = 4.8% | ||
| DEVELOPED TABES DORSALIS | 113 = 2.7% | ||
| DEVELOPED CEREBROSPINAL SYPHILIS | 132 = 3.2% | ||
| 443 = 10.5% | |||
| EFFECT OF TREATMENT | |||
| None | 1 course | Repeated energetic | |
|---|---|---|---|
| NUMBER OF CASES | 100 | 134 | 924 |
| DEVELOPED G.P. | 25 = 25% | 31 = 23.1% | 30 = 3.2% |
| DEVELOPED TABES | 11 = 11% | 16 = 11.9% | 25 = 2.7% |
| DEVELOPED C.S.S. | 3 = 3% | 21 = 15.6% | 71 = 7.6% |
| Poorly treated 1880–84 | Better treated 1895–99 | ||
| NUMBER OF CASES | 617 | 1139 | |
| DEVELOPED G.P. | 60 = 9.7% | 37 = 3.2% | |
| DEVELOPED TABES | 22 = 3.5% | 16 = 1.4% | |
| DEVELOPED C.S.S. | 15 = 2.4% | 28 = 2.4% | |
| MATTAUSCHEK AND PILCZ | |||
| Chart 24 | |||
The serum W. R. proved positive, but the spinal fluid W. R. very slightly so (yielding only moderate reaction with 1 cc., 0.7 and 0.5 cc., and a negative reaction with 0.3 and 0.1 cc.). Globulin was moderate, and albumin was found in only moderate excess. There were 21 cells per cmm. in the spinal fluid. The gold sol reaction was that which we regard as typical of syphilis or tabes. If we were to rely upon the weakness of the fluid W. R. and the nature of the gold sol reaction, we should be inclined to favor the diagnosis of Diffuse Neurosyphilis (“cerebrospinal syphilis”) rather than resort to the diagnosis of paretic neurosyphilis.
Salvarsan treatment was attended by the rapid disappearance of headaches and gastric symptoms and by a rapid gain in weight and feeling of well-being. Salvarsan was continued twice a week for two months, whereupon Lepère returned to work. He has been successfully at work now for seven months without return of symptoms. Four months after beginning of treatment, the spinal fluid was examined and found entirely negative. Nevertheless, the serum W. R. has remained positive despite eight months of salvarsan treatment.
1. What is the meaning of the titrations in the spinal fluid Wassermann reaction? When Plaut originally applied the Wassermann reaction to spinal fluids, he used 0.2 of a cc. of spinal fluid. With this amount of fluid he found that cases of general paresis gave a positive reaction in about 100% of the cases while this positive reaction was only given by 40 to 60% of the cases of cerebrospinal syphilis and tabes dorsalis, hence he promulgated a differential point that a negative reaction in spinal fluid indicated that the case was not general paresis. Hauptmann later showed that if 1 cc. of spinal fluid were used, a positive reaction would occur in practically 100% of the cases of general paresis, cerebrospinal syphilis and tabes. Therefore, at present, we use the different titers of spinal fluid from which we draw the following conclusions: If the reaction in the untreated case is negative with 0.1 and 0.3 of a cc. and positive with the 0.5, 0.7 and 1 cc. dilutions as in the case of Lepère, we are probably dealing with non-paretic neurosyphilis. With this method of titration we are also better able to watch the progress of treatment as the dilutions of 0.1 and 0.3 cc. become negative first.
2. How soon can one expect improvement after commencement of salvarsan therapy in cases of diffuse neurosyphilis? The time relation of results in treatment varies with each individual case. In the case of Lepère gastric symptoms that had been present for a number of months disappeared as if by magic after the first injection of salvarsan. As a rule, it is true that the more acute the symptoms the quicker their disappearance but this does not hold for all cases, as in this particular instance the long-standing symptoms disappeared very rapidly. The symptoms often disappear very much more rapidly than the laboratory, tests change.
3. How can the mental symptoms (depression and failing memory) of which patient complained be explained? In the first place, as has been stated, it is doubtful if these are more than subjective and the result of the patient’s feeling of discomfort and pain. However, it is also possible that there may be intracranial involvement of the meninges or of the brain itself. And, if such were the case, the improvement might be the result of the treatment.