Diagnosis: “Cerebral syphilis.”
1. What is the anatomical cause of this condition? It is thought to be due in a number of cases to a small diffuse gummatous lesion at the basis cerebri. In the case of Marini this lesion appears to have been a little more extensive and to have interfered with the tenth and twelfth nerves also.
2. Why is the spinal fluid negative in such a case as that of Marini? Head and Fearnsides believe that intracerebral lues is characterized by a negative spinal fluid, under which circumstance one has always to consider the possibility of brain tumor or migraine in addition to the suspicion of syphilis.
3. What other causes besides syphilis should one consider for the sudden diplopia? Brain tumor, multiple sclerosis, cerebral arteriosclerosis, tuberculous meningitis, trauma and migrainous ophthalmoplegia, are not infrequently at the bottom of this condition. Cases also occur in which the etiology remains obscure, even at autopsy.
Under antisyphilitic treatment, Marini slowly improved.
The SIX TESTS in TABETIC NEUROSYPHILIS (“tabes dorsalis”) may run milder than in paretic neurosyphilis (“general paresis”) and characteristically run somewhat like those of diffuse (meningovascular) neurosyphilis; in particular, the fluid Wassermann Reaction and the gold sol reaction are apt to run milder. The clinical course of tabes dorsalis is protracted and the prognosis as to life is good.
Case 29. Mario Sanzi, 55 years of age, had been having what he called rheumatism since his 43d year. This rheumatism affected only the hips and legs, had at times been very severe, and for two years past had been almost constant. Before that time, pains had come at intervals, lasted a variable period, and suddenly disappeared. They were of knife-thrust character, and could probably be called “lancinating.” In a given attack, these pains would come at intervals of seconds or more. There was also a certain unsteadiness in locomotion and inability to control the vesical sphincter.
Physically, the patient was entirely normal so far as could be made out except neurologically. Argyll-Robertson pupils, absence of knee-jerks, and ankle-jerks, Romberg sign, and characteristic gait, left no cause for doubting the diagnosis of Tabes Dorsalis. The blood and spinal fluid both proved positive to the W. R., though the W. R. in the fluid gave a negative reaction with 0.1 cm. and became positive with 0.3 cm. or more. The globulin was somewhat increased though less markedly so than in paresis. The gold sol reaction was “syphilitic” but weak. It is to be noted that the disease had run a 12–years’ course before a doctor had been consulted. The primary infection occurred at 32 years, namely, 11 years before the symptoms began. At the time of his primary infection, Sanzi had received several years of treatment, chiefly in the form of mercury by mouth.
1. What is the value of mercurial treatment of syphilis in the prevention of tabetic or other forms of neurosyphilis? “Fournier strove for many years to convince the medical profession that a syphilitic patient should be treated for at least two years after his infection, whether the syphilis seemed latent or patent. The method of treating only the symptoms he characterized as the opportunist method; treatment in the absence of definite symptoms the preventive method, as preventing the later manifestations. That prolonged treatment does prevent is shown by Fournier’s figures analyzing 2396 cases presenting tertiary signs. These he divides into three groups: Group I, comprising 1878 cases, or 78 per cent of the whole number, having no treatment or inadequate treatment—that is mercury for less than one year; Group 2, comprising 455 cases, or 19 per cent, having moderate treatment—that is, mercury for one to three years; and Group 3, comprising the remaining 19 cases which represent only 3 per cent of the whole number, having treatment for more than three years.”[[7]]
In the light of what we now know concerning latent neurosyphilis, it would seem well for patients to be followed from time to time with the W. R. on blood and spinal fluid after the supposed completion of the treatment of primary and secondary syphilis. The examination of the spinal fluid is not superfluous, as our experience with the so-called paresis sine paresi abundantly shows. At the present day it is not good practice to assure a patient that he is cured after two years of ordinary mercurial treatment without resort to frequent spinal fluid tests, even though the serum W. R. be negative.