Another autopsied case is given which shows an exceedingly marked meningitis.[[127]] The meningitic processes according to the literature and experience react very readily to antisyphilitic treatment in the form either of mercury and iodid or in combination with salvarsan. The lesion here present would probably have improved had intensive treatment been given. Clinically the diagnosis of general paresis was made and, as has been the rule in the past, treatment was not given on the ground that it had no value in paresis. While this is an extreme case of meningitis, it is to be remembered that the vast majority of cases of paretic neurosyphilis show some degree of meningitis. Just as in the marked meningitis of the diffuse neurosyphilis, so with the meningitis of the paretic form, improvement is expected under treatment. As a part or even the whole of the symptomatology in a given case may be due to this meningitic process, we have reason occasionally to expect marked improvement as the result of antisyphilitic treatment.
As a contrast to this case with marked meningitis, another case of marked atrophy[[128]] is given. Here the atrophy was very perceptible on macroscopical examination and the mere view of the brain at once indicated that in such a case important results from treatment were not to be expected.
The topographical variation of the lesions in neurosyphilis must be remembered when treatment is to be instituted. Thus very marked lesions may exist in portions of the brain which do not give any very definite localizing symptoms. As a result, one may be led to believe from clinical evidence that the case is a very mild one though the lesions may really be very extensive. The topographical distribution must, therefore, be taken into consideration in trying to estimate the damage done. This point of topographical distribution of the lesions is illustrated by a case.[[129]]
It has been generally recognized that clinical improvement, if not cure, may be readily obtained in the group of diffuse neurosyphilis, i.e., so-called cerebral and cerebrospinal forms of syphilis. These are cases in which the parenchyma is very slightly, if at all, affected and in which the lesion is chiefly in the meninges and blood vessels, irritative rather than degenerative. A case[[130]] is given to illustrate this point. In our experience systematic intravenous salvarsan therapy associated with mercury and iodid gives remarkably good results in the vast majority of this group of cases.
It is generally conceded that antisyphilitic treatment, particularly salvarsan, has a very satisfactory result applied to diffuse neurosyphilis. But the same good results may be obtained in cases which are not so typically of the diffuse type. An illustration is given in the case of a machinist in which the diagnosis was in doubt between paretic, tabetic or diffuse neurosyphilis.[[131]] The result of treatment was as satisfactory as could be expected in any type of neurosyphilis and this in a case of several years’ duration with Argyll-Robertson pupils.
As a rule, the Argyll-Robertson pupil is taken as a grave omen for treatment, an idea based upon a conception that the Argyll-Robertson pupil so frequently represents the old so-called “parasyphilitic” cases, which, in the past were taught as being incapable of improvement by the ordinary antisyphilitic methods.
A second case[[132]] with Argyll-Robertson pupil shows again that the prognosis may be very good despite the Argyll-Robertson sign.
But even in the diffuse neurosyphilis, the symptomatic results of treatment may not be entirely happy. Under treatment it may be possible to reduce the spinal fluid tests to negative without, however, as in the case of our hemiplegic lady,[[133]] making the physical or mental symptoms disappear. In other words, it may be possible to stop the active progress of the disease without removing the symptoms.
One is always warned of the danger of intravenous salvarsan therapy in hemiplegic cases due to arteriosclerotic conditions. While this warning is well justified, it does not mean that the most intensive treatment is contraindicated, as shown in the case of our hemiplegic machinist.[[134]] Such may be given over long periods of time with the most satisfactory results.
A case[[135]] is given which illustrates the value of antisyphilitic treatment in cases showing symptoms of intracranial pressure due to syphilitic disease. In the case of the woman which we cite, we believe that the symptoms of intracranial pressure were probably due to a gummatous new growth, although it is possible that they were due to a marked meningitic process. However, the results of a limited amount of antisyphilitic treatment in this case were very brilliant. Similar results may often be obtained in gumma of the brain. This is not always true, however, and it may become necessary to use surgical procedure in order rapidly to overcome the effects of intracranial pressure.