1. Why was the spinal fluid W. R. negative in this case of spinal syphilis? The explanation of negative W. R.’s in spinal syphilis is not easy. Possibly, however, in the course of years the intensity of the process has been reduced and possibly the W. R. has been one of the first tests to disappear.
2. How shall we explain the nerve trunk tenderness? We might consider this to be due possibly to an inflammation about the posterior roots. On the whole, partly on account of the situation of the pains below the knee, it seems probable that the nerve trunk tenderness of this case is the residuum of an alcoholic neuritis.
Treatment: Under injections of mercury salicylate, there was a rapid improvement. In fact, in the course of several months, the patient regained an ability to walk long distances. There still remains a certain spasticity, but the abnormal spinal reflexes above mentioned are no longer present.
SYPHILITIC MUSCULAR ATROPHY, probably due either to spinal parenchymal lesions, or to root neuritis, or to both.
Case 33. Joseph Graham, now 50 years of age, seemed no longer to be able to do good work as a teamster. His arms had become weak and the muscles had become tremulous and apparently wasted. There was also pain in the left leg and hip. It appears that this latter symptom had been thought to be rheumatism, having begun about 8 years before with a sudden sharp shooting pain in the left hip, about the region of the sciatic notch. Graham had rubbed the hip with liniment, but without reducing the so-called rheumatism. The trembling of the hands had begun some years later, but no wasting had been noticed except during the past year. The pain in the leg had suddenly become so severe that a month before medical observation he had quit work. The question immediately arose whether Graham was not suffering from some familial form of muscular atrophy; but according to his representations, there was nothing of the sort in the family.
Physically, there was little to note. Neurologically, there was more. The pupils were somewhat irregular in outline, and the right was larger than the left. The left pupil failed to react to light, and the right pupil reacted very slowly and with but a slight excursion. There was no tremor of the tongue and no evidence of facial palsy nor was there smoothing of the nasolabial folds. It was somewhat remarkable, that in the absence of these signs, there was a marked speech defect. The atrophy of arms, forearms, and hands was well marked, especially the atrophy of the thenar and hypothenar eminences of the right hand. The extended hands, especially the right, showed a marked coarse tremor. Fibrillation was found in the muscles of the hands, forearms, arms, and pectoral muscles. There was no dysmetria, and the diadochokinesia was normal. Strength was diminished (dynamometer right hand, 32 kg., left 31 kg.). There was little or no atrophy of the legs, although the left thigh was perhaps slightly atrophic and the gluteal muscles of the left side were somewhat flabby. The patellar and Achilles reflexes were absent on both sides. There was a slight swaying in Romberg position. Gait was normal. There was a marked tenderness on the left side of the sciatic notch, as well as over the entire distribution of both external and internal popliteal nerves. This area of skin was also hyperesthetic. There were no other neurological signs on systematic examination.
Diagnosis: The sensory disorder, the speech defect, and the pupillary abnormalities seem to render the diagnosis of progressive muscular atrophy doubtful. Nor was there any dissociation of sensations to suggest a syringomyelia. Under such circumstances, one must fall back upon the question of syphilis. Both blood and spinal fluid proved to be positive to the W. R.; the globulin was increased and the albumin markedly so; there were 61 cells per cmm., and the gold sol reaction read 4 4 4 4 3 2 1 0 0 0.
1. Is there a relation of Syphilitic Muscular Atrophy to amyotrophic lateral sclerosis? Spiller, some years since, claimed such a relation, and it would seem with some justice.
2. How shall the present case be classified? There is evidence of root pains (left hip). We may naturally suppose that these root pains are reasonably good clinical evidence of a meningitic lesion, of which the spinal fluid clinically gave a confirmation. The fibrillation in this case somewhat suggests, however, a central origin for the muscular atrophy. Accordingly, it would be difficult to definitely classify the present case as either one of meningovascular syphilis or one of central syphilis. It will be remembered that Head and Fearnsides classify muscular atrophy under both these headings.
The period of SECONDARY SYPHILIS is frequently (over a third of all cases?) MARKED BY approved signs of NEUROSYPHILIS precisely like those of full-blown paretic or diffuse (meningovascular non-paretic) neurosyphilis. These signs occur sometimes in association with severe clinical symptoms, sometimes without clinical symptoms.