A system of practical medicine. By American authors. Vol. 5

by Unknown

I have myself seen symptoms of general paralysis occurring in persons with a specific history in which of these so-called diagnostic differences the therapeutic test was the only one that revealed the true nature of the disorder. In these cases a primary, immediate diagnosis was simply impossible.

Case 14 of the table is exceedingly interesting, because it seems to represent as successively occurring in one individual both pseudo and true general paralysis. The symptoms of general paralysis in a syphilitic subject disappeared under the use of mercury, to return some months afterward with increased violence and with a new obstinacy that resisted with complete success antisyphilitic treatment. Such a case is some evidence that syphilis has the power to produce true general paralysis.

In conclusion, I may state that it must be considered as at present proven that syphilis may produce a disorder whose symptoms and lesions do not differ from those of general paralysis; that true general paralysis is very frequent in the syphilitic; that the only constant difference between the two diseases is as to curability; that the curable sclerosis may change into or be followed by the incurable form of the disease. Whether under these circumstances it is philosophic to consider the so-called pseudo-general paralysis and general paralysis as essentially distinct affections, each physician can well judge for himself.

Spinal Syphilis.

The subject of spinal syphilis is at present a difficult and unsatisfactory one. The recorded cases with well-observed autopsies are comparatively few, and when recovery occurs much uncertainty must rest upon the nature of the lesion. More than this, there is scarcely any chronic degeneration of the spinal cord which has not been attributed to syphilis, and my own experience as well as the records of medical literature lead to the very positive conclusion that all the various spinal scleroses are much more frequent in infected than in non-infected persons. Whether this is due to a direct or indirect influence of the disease is uncertain, but I shall not here discuss the relation of these chronic inflammations of the cord to syphilis.

It seems necessary to briefly consider at this place acute and subacute myelitis in their relations to syphilis. That these affections are not rare in syphilitics is certain. In the Revue de Médecine (Jan., 1884) Dejerine records the case of a person suffering from chronic syphilis in whom there were fulgurant pains with increasing weakness of the legs, and subsequently, after very severe exposure to the weather, a sudden development of complete paraplegia followed by trophic troubles, and death in twenty-eight days. At the autopsy there was found a central myelitis with pronounced lesion of the ganglionic cells, inflammatory changes of the pia mater, capillaries, and neuroglia, extreme alteration of the nerve-roots, and secondary degeneration of the columns of Goll and the lateral columns. In a second case recorded by Dejerine there appears to have been no exposure or apparent immediate exciting cause. The symptoms and lesions were similar to those just spoken of, but death occurred in eight days.

Whether such attacks as these occurring in syphilitic subjects are produced directly by the syphilis or not is at present doubtful. The same is true of subacute myelitis, of which I have reported two rather peculiar fatal cases in syphilitic subjects. The general symptoms of this affection are progressive loss of power with grossly exaggerated reflexes, severe twitchings and jerkings of the legs, rigidity, usually more or less marked pain, and other sensory disturbances in the legs, and finally partial anæsthesia and complete paraplegia, paralysis of bladder, bed-sores, and death from exhaustion. At the autopsy the most important change in the cord has been the presence of great numbers of round neuroglia-cells in both gray and white matter. One of my cases died of a rapidly developed central myelitis supervening upon the subacute disease, and affording lesions similar to those described by Dejerine in addition to the changes of the subacute affection.

In another class of spinal cases occurring in syphilitics the symptoms resemble those of the so-called acute ascending paralysis (Landry's paralysis). The fourth variety of syphilitic diseases of the spinal cord of Huebner⁷² includes these cases. According to Huebner, they are without anatomical lesions, but in the majority of the recorded cases no proper microscopic study of the cord has been made. Huebner states, however, that Kussmaul failed in one case after such study to detect lesion. As some of these cases may really have been instances of peripheral neuritis, it is essential that in the future the peripheral nerves as well as the spinal cord be carefully studied. I have seen one case which might be placed in this category. The first symptom was some numbness in the legs, with a small deep sharp-cut ulcer on the plantar surface of the great toe; directly after this loss of motion and sensation in the legs and thighs, rapidly becoming almost complete and spreading quickly to the trunk and arms, so that in one week the patient was a flaccid, helpless mass, and the breathing so interfered with that he was believed to be dying. After almost losing the power of swallowing this patient began to get better, and finally so regained power of his hands and feet that he was able to partially dress himself and walk a distance of ten or twelve feet, when he was suddenly seized with a pleural effusion and died. During the first week of his disease his temperature was 100° F. At the autopsy the spinal membranes were found to be normal. But in the cord there were very distinct lesions found; the neuroglia seemed everywhere more granular than normal; the ganglionic cells were not distinctly diseased; the white matter in various places was much changed, the tissue appearing abnormally dense and opaque where most affected; the nerve-tubules appeared to gradually lose their myeline, and in places were reduced to simple axis-cylinders. Finally, the axis-cylinders became smaller and smaller until in the most altered portions of the cord they disappeared. As the autopsy was obtained with great difficulty, it was not possible to get the peripheral nerves for study.

⁷² Ziemssen's Encyclopædia, vol. xii.