“Until there is a definite unanimity of belief among physicians as to when the treatment of syphilis shall be begun, and some concert of action as to what constitutes the adequate treatment of syphilis, we cannot hope to make any considerable progress in the prevention of syphilis of the nervous system, save by educating the individual toward infection.”
TABETIC NEUROSYPHILIS may produce symptoms chiefly if not entirely in the region supplied by the CERVICAL plexus (“cervical tabes”).
Case 31. Paul Halleck, 35, was a salesman who had begun to find it hard to carry his sample case, since he was unable to tell whether or not he had it in his hand. There was not only an anesthesia of the hands, but they felt numb and there was often a tingling sensation. Of late it had become hard for Halleck to dress himself or to write, and these symptoms had been slowly growing worse. There was no other complaint. There was, however, a history of a chancre about 7½ years before, which had been followed by a rash and a sore throat. There had been treatment with mercury and potassium iodid alternating for a period of two years.
Physically, there was no evidence of disease except neurologically. The pupils were unequal (the right larger than the left) and reacted slowly to accommodation and not at all to light. A marked ataxia of the hands was shown in coat-buttoning. The finger-to-nose test showed a marked dysmetria. Arm-jerks as well as knee- and ankle-jerks were absent. There was a slight swaying in the Romberg position but no true Romberg sign. There was no difficulty in locomotion. Both blood and spinal fluid proved positive to the W. R.; globulin and albumin were increased. The gold sol reaction was syphilitic, and there were 85 cells per cmm.
This case is probably not a pure example of Cervical Tabes, since the knee-jerks are also absent, and we may suppose a degree of lumbar spinal cord changes in addition to the cervical changes. It well illustrates, however, that the tabetic involvement of the cord may be quite generalized and that it may strike high as well as low.
ERB’S SYPHILITIC SPASTIC PARAPLEGIA.
Case 32. Margaret Neal, a maid-of-all-work, 36 years of age, was committed to a home for inebriates on account of her excessive alcoholism, but she was shortly transferred to the Psychopathic Hospital on account of difficulty with locomotion. We found a very marked spasticity in walking, with a characteristic scissors gait. The pupils were somewhat irregular, and although both reacted to light, the left reacted far more slowly than the right and the reaction failed to hold well. The arm reflexes were very active, and the knee-jerks and the ankle-jerks were particularly exaggerated. There was a double Babinski reaction, as well as Oppenheim and Gordon reflexes and a bilateral ankle clonus. There seemed to be tenderness over the nerve trunks in the back of the leg, below the knee. There was no evidence of incoördination, no Rombergism, no disturbance of sensation, no disorder of the special senses, and not even a tremor of the tongue or hands.
Mentally, the patient was entirely negative.
Diagnosis: Symptomatically, it is entirely clear that the patient was suffering from Spastic Paraplegia. One would have to consider besides spinal syphilis, also amyotrophic lateral sclerosis, syringomyelia, and spinal cord tumor. However, there appeared to be no definite wasting of muscles, and the fact that the sensations were intact seems to rule out also syringomyelia. There was none of the characteristic pain associated with a cord tumor. There was, in fact, a strong clinical premonition that the case was one of spinal syphilis, simply because syphilis is the most common cause of spastic paraplegia in the adult. The pupillary anomalies were also highly suggestive.
The serum W. R. proved to be weakly positive, as was also the gold sol reaction in the zones characteristic of syphilis. The spinal fluid examination yielded 14 cells per cmm. There was a positive globulin test and a moderate increase in albumin. The W. R. of the spinal fluid was negative.