1. How far can we regard the cardiorenal defects as syphilitic? Perhaps we may do so on the general principle of parsimony in scientific interpretation.
The diagnostic lumbar puncture led to an extremely severe exacerbation of the pains on the left side of the head. In fact, these pains could not be held in check by the exhibition of pyramidon. Mr. Stone regarded the pain as due to the lumbar puncture. However, there was no improvement in the pain in the prone position,—a feature characteristic of lumbar puncture pains. Upon administration of salvarsan, this local pain rapidly disappeared. In fact, there was a startling improvement; the ocular palsies disappeared in a few weeks, although these palsies had been present for several months before the administration of salvarsan. The blood pressure was reduced; the urine became negative. Perhaps the most startling feature of all (although of this we are not sure) was that the patient states he was accepted by a life insurance company although he had been twice refused previously.
Note in this case the 30–year interval between infection and generalized neurosyphilitic involvement. Note also the amenability of the process despite this duration. We are perhaps entitled also to note that a neurological examination careful enough to detect an Argyll-Robertson pupil should have been made by a number of examiners long before the particular crisis which we have sketched. It is also permissible to note that the rhinological work should not have been carried out independently of all other medical work.
2. What are the untoward results of lumbar puncture? It is true that there is always a possibility of setting up a septic meningitis by lumbar puncture, but this is a very remote possibility and with any reasonable care it is not to be considered. Lumbar puncture also has a considerable danger in cases of increased intracranial pressure. In cases of brain tumor where the tumor is located in the posterior fossa, sudden death may occur from withdrawal of spinal fluid. This is supposed to be due to the medulla being pressed down into the foramen magnum and causing paralysis of respiration. Therefore lumbar puncture should never be performed except with the greatest caution in a case in which brain tumor is suspected.
However, aside from these remote serious consequences which play very little rôle in the ordinary procedure of lumbar puncture, certain unpleasant symptoms do frequently arise. These symptoms are chiefly headache and nausea, but, however, may go as far as vomiting. These symptoms occur almost entirely in the cases in which there is no abnormal condition producing increased spinal fluid pressure. Such unpleasant symptoms may last as long as four or five days; as a rule, however, last only for a period of a day or two.
3. What is the treatment of discomfort following lumbar puncture? It is a rule well worth observing that the patient after lumbar puncture should remain flat on his back without a pillow for 24 hours in order to avoid any unpleasant symptoms. If any symptoms do occur, it will be almost certainly when the patient arises, and in nearly every instance they will be overcome if the patient again assumes the prone position. Raising the foot of the bed so as to lower the head also helps. Veronal or bromides may be given but as a rule are not very satisfactory.
4. How permanent is the improvement obtained in the case of Mr. Stone likely to be? As a matter of fact, the patient discontinued treatment as soon as he felt well again, but after two months the pain returned to be again quickly dispelled by salvarsan. This improvement must be considered as only temporary. Under continued treatment there may be no further relapse. There is, however, evidence that much damage has been done to the body by the spirochetes, much of which is irreparable. It is even possible that further disintegration might occur even while undergoing treatment. Still treatment offers much in such a case and is to be highly recommended.
In DIFFUSE NEUROSYPHILIS, rendering the spinal fluid negative by treatment may mean neither cure nor disappearance of symptoms.
Case 107. Greta Meyer, a widow, 51 years of age, came voluntarily to the hospital, seeking medical aid for a marked depression. She was also suffering from a right hemiplegia. It appeared, according to Mrs. Meyer, that she was married at 16, and lived with her husband until 29, whereupon she left him on account of his alcoholism, his abuse of her, and the discovery through his physician that he was suffering from venereal disease. She had had two healthy children and there never had been miscarriages or stillbirths. Six years after the separation, namely at 35 years of age, and 16 years before resort to the Psychopathic Hospital, Mrs. Meyer developed certain red areas on her hand, and learned at a hospital that these were due to syphilis. She kept up treatment for these lesions for a year, until she seemed perfectly well.
She had, in fact, remained perfectly well for some 14 years, until at 49, a small tumor had appeared on the right side of the forehead, near the hair line. This tumor was firm and not sore. Medical treatment reduced it, leaving, however, a depression in the bone. One day, about a month after the appearance of the tumor, the patient lay down for a nap, and upon awaking found she could only with difficulty move her right arm and leg. Her face was not affected; she was not in pain; and there was no disorder of speech. In a few days she got much better and she had been improving for some time past through the administration of further medicine.