While it has always been conceded that treatment would greatly help cases of diffuse and vascular neurosyphilis, the utmost pessimism has existed concerning the results to be obtained by treatment in cases of tabetic and paretic neurosyphilis. Only in the last five or six years, due to the stimulus of Ehrlich’s discovery of salvarsan and the introduction of the intraspinous methods of therapy, have intensive work and study been given to the treatment of these cases. And though it has been by no means settled in the minds of the various workers in this field, as to what the ultimate results of such treatment will be and though some do not believe that there is any good to be expected from our present methods, still the majority of men who are treating these cases systematically feel very much encouraged.
At times very brilliant results are to be obtained by intraspinous treatment in tabetic neurosyphilis (“tabes dorsalis”). A very striking illustration is given of a case of this sort in which the symptoms dated only a few months but which had all the classical symptoms, signs and laboratory tests. Five intraspinous injections of mercurialized serum were sufficient to cause the disappearance of the subjective symptoms and to reduce the spinal fluid test to negative.[[136]]
It must be emphasized that the best results in cases of tabetic neurosyphilis are usually to be expected in cases in which the symptoms are of short standing. Where the process is of long duration and much destruction of spinal cord tissue has occurred, the best one can expect is that the activity and progress may be halted. This is illustrated by our case of a baker, 43 years of age, who had been suffering from the symptoms of tabes for some years. Under treatment it was possible to get an entirely negative serology of the blood and spinal fluid.[[137]] Despite this evidence that the activity of syphilis had ceased, the symptoms continued unabated. We are ready to believe, however, that much good was accomplished. For the patient should not have any further untoward developments or the appearance of any new symptoms. These, without such treatment, might well be expected. At times excellent clinical results are obtained in long-standing cases.
The results of treatment in paretic neurosyphilis (“general paresis”) have been considered even less hopeful than in tabetic neurosyphilis (“tabes dorsalis”); indeed, it has often been stated that the patients are made worse by treatment. Recent work, however, supports a much more optimistic viewpoint. We feel that intensive treatment has been of the greatest value in a number of cases of paretic neurosyphilis. Two cases are given which show the most satisfactory and brilliant results of intensive intravenous salvarsan therapy in cases diagnosed as general paresis. The first case, an excellent salesman, 46 years of age, with most aggravated mental symptoms, recovered symptomatically and all his tests were rendered negative.[[138]] He has now remained entirely well and economically efficient for about two years without further treatment. The other case,[[139]] a housewife, also with very marked symptoms suggestive in all ways of general paresis, also recovered rapidly under treatment and her tests became negative. Her remission has now lasted for nearly three years without further treatment.
At times it is not possible to get the spinal fluid tests to become negative in cases of paretic neurosyphilis under the most intensive salvarsan therapy. In spite of this, the clinical condition of the patient may improve so greatly that the patient can be considered clinically recovered. An illustration is given of an undertaker[[140]] who was brought from a condition of the greatest cachexia and mental confusion to a condition of robust appearance and mental efficiency under intravenous salvarsan therapy, in spite of the fact that his tests were very slightly if at all reduced in intensity. He has been able to resume his former occupation and his former life with great satisfaction to himself and his family.
Improvement in paretic neurosyphilis under treatment is not to be expected very early. Two or three months of active treatment may elapse before one sees signs of improvement. Indeed, as illustrated by our case of the shipping clerk, this improvement may begin to make its appearance only after more than four months of intensive treatment consisting of two injections of salvarsan per week.[[141]] In spite of the long delay in this case, complete clinical recovery occurred and the tests became almost negative at the end of a year of treatment.
It is not only in the central nervous system that the syphilitic process may resist the most intensive treatment. In the case of the speculator, a victim of paretic neurosyphilis, which we cite, a perennially recurrent iritis appeared after several months of the most intensive salvarsan treatment which was apparently sufficient to reduce the symptoms of the paretic neurosyphilis,[[142]] but not of non-neural syphilis.
We give the case of a charwoman having the diagnosis of paretic neurosyphilis, who, under intensive treatment, made a symptomatic recovery. The interesting point in her findings is that all the tests in the spinal fluid became negative except the gold sol reaction which remained of the “paretic” type.[[143]] There is no general rule as to the reaction of the spinal fluid tests under treatment. At times one test is the first to disappear under treatment; again it is another. We have seen many cases in which the gold sol was the first test to become negative and others, as the case given, in which it is the last to show any change. As in our undertaker, symptomatic clinical improvement may be practically complete without any change in the spinal fluid tests.
One must remember that it is the condition of the patient that is of first importance; not so much the laboratory tests. Having shown the clinical recoveries with the tests remaining positive, we now have to report two cases in which there was improvement as shown by the tests but no clinical improvement. The first patient, a bank teller[[144]] of 39 years, with a diagnosis of paretic neurosyphilis, received intensive intravenous salvarsan for several months. Under this treatment all the tests became negative except the gold sol which remained of the paretic type. In spite of this, there was not the slightest improvement in his mental condition.
The second case, a young man of 29 years in whom the symptoms of neurosyphilis had recently appeared, under treatment showed a marked diminution in the intensity of the spinal fluid tests, notwithstanding which the patient became more and more demented and died after a series of convulsions.[[145]]