Our case of Paretic Neurosyphilis[[34]] (“general paresis”) is a characteristic one in duration (three years and three months). The aortic sclerosis almost constantly found in neurosyphilis and especially in paretic neurosyphilis is here also shown. The spinal cord showed lesions which are also almost always found in paretic neurosyphilis. The characteristic frontal emphasis of the atrophic and indurative lesions is shown. There is also a display of gross changes in the pia mater. The characteristic so-called granular ependymitis or sanding of the ventricular surface is shown. The case is distinguishable from the paradigm in not showing the effects of vascular insults in the shape of cysts of softening. The cerebellar sclerosis of the case is fairly characteristic of paretic cases. There is even a suggestion of atrophy in the temporal region suggesting the so-called Lissauer’s paresis. Clinically the case belongs in the classical grandiose group of paretics (“O. K. No. 1 superfine”).
Vascular Neurosyphilis[[35]] is illustrated in a fourth autopsied case. It may be noted that the pia mater in this case is practically normal. The tissues outside the area of softening due to the syphilitic thrombosis of nutrient vessels are practically normal. The case was one of almost complete sensory aphasia with word-deafness. The clinical picture is accordingly quite distinct from those of the paradigm (1) and of the case of general paresis (3) just discussed.
Juvenile Paresis[[36]] is illustrated by a case with exceedingly extensive lesions, largely meningeal and parenchymatous. The cerebral lesions are atypical since in places they suggest the tuberous sclerosis of Bourneville. The brain atrophy is extreme (965 grams) and it is possible that this apparent brain atrophy was in part hypoplasia, since the spirochetosis of this case was doubtless congenital. However, clinically the patient was fairly normal up to the age of 18.
A case of so-called Syphilitic Extraocular Palsy[[37]] demonstrates a characteristic meningeal process more extensive than the clinical symptoms would have indicated. In fact, focal clinical nerve palsies are as a rule, if not constantly, partial phenomena of a far more extensive process of neurosyphilis. They are far more limited clinically than anatomically and histologically. It seems at first sight improper to term them cases of diffuse neurosyphilis in view of their clinical focality, yet they are best described as partial cases of diffuse neurosyphilis.
A case of Gumma[[38]] of the left Hemisphere is presented which appears to have led to death in about four years from onset. This case, like many others, is not an example of purely focalized syphilitic process inasmuch as cysts of softening indicating slight vascular insults are present elsewhere (pons). There is also a degree of leptomeningitis, particularly basal.
Our discussion of the nature and forms of neurosyphilis is completed by a rare case probably belonging in the so-called cervical hypertrophic meningitis of Charcot but actually due to a Gumma of the Spinal Meninges.[[39]] The importance of therapeutic optimism is emphasized in this case as in the paradigm. Theoretically the meningeal inflammation of neurosyphilis ought to be almost entirely if not entirely removed by therapy, and these two cases, like several others in the series, seem to illustrate this possibility.
Neurosyphilis sometimes receives the clinical diagnosis neurasthenia simply through omission to apply proved diagnostic methods. An instance is given in which the Paretic form of Neurosyphilis (“general paresis”) received the diagnosis neurasthenia[[40]] for a period of five years, at any time during which period it would doubtless have been possible to render the correct diagnosis and apply treatment.
Neurosyphilis may imitate not only the psychoneuroses but also the psychoses themselves. We present a case of an architect, which looked almost precisely like manic-depressive psychosis[[41]] and had a history of attacks, but in which the positive serum W. R. led (in accordance with hospital rules) to an examination of the spinal fluid. The spinal fluid tests proved the case to be one of Paretic Neurosyphilis.
However, a positive serum W. R., even when associated with mental symptoms, and when those mental symptoms include grandiosity, does not prove the existence of neurosyphilis either in its paretic or non-paretic form. Our instance seems to be one of Manic-Depressive Psychosis.[[42]] The spinal fluid tests were entirely negative. The course of the disease was also that of manic-depressive psychosis. In the absence of positive spinal fluid tests, the diagnosis neurosyphilis was excluded.
Neurosyphilis and even Paretic Neurosyphilis may result in symptoms that would ordinarily lead to the diagnosis dementia praecox.[[43]]