NEUROLOGICAL REVIEWS AND CASE REPORTS By T. S. KEYSER, M. D., Cleveland, O. Syphilis of the Central Nervous System, and Its Intensive Treatment. Foster Murray. Long Island Medical Journal, Vol. X, No. 1, p. 9. The frequency of involvement of the central nervous system during secondary stages, indicated by examination of the cerebro-spinal fluid, is pointed out by reference to the researches of Ravnut, Altman and Dreyfus, and Gemmerich, who obtained positive findings 70%, 80%, and 90%, respectively, of the patients examined. In cases of syphilis meningo-vascularis, intravenous treatment is quite efficient. This conclusion is in full accord with the opinion of Head. In cases of syphilis centralis the lesions are not directly of haemotogenous origin, but probably of lymphatic origin. The choroid plexus presides over the lymphatic supply of the central nervous system (?), and does not permit the passage of salvarsan from the blood to the sub-arachnoid space. Therefore the drug does not act on the lesions in the parenchyma of the brain or cord. The author naturally concludes that salvarsan must be introduced directly into the subarachnoid space to have any effect on such cases. He employs the Swift-Ellis method supplemented by mercurial injections and potassium iodide by mouth. The salvarsan treatments are given every two weeks, some cases receiving as many as ten injections. The author claims that the results obtained clinically are "encouraging"; serologically most variable. The clinical results are, gain in weight and strength, decrease of pain, improvement of ataxia in early cases, "control" of headaches and vertigo, much relief of paraesthesias, cure of constipation and vomiting, and improvement of early bladder disturbances and sexual power. As I have given over seventy intraspinous injections according to the Ogilvie method, which method is doubtless much more scientific than the Swift-Ellis, without obtaining any definite improvement in any patient treated, I feel very sceptical of results claimed in this article. All of these cases, however, had first received thorough treatment with mercury and intravenous salIn order to prove that intraspinous treatment is effective, varsan. it must be preceded by intravenous treatment, which will practically relieve all symptoms of meningo-vascular origin. (Head, Collins, et al.). The first case described is the "star". patient of the author. However, the marked improvement is absolutely due to the intravenous salvarsan and mercury, for it is plainly a case of pure meningo-vascular syphilis, and the patient had received no previous treatment. That it is not syphilis centralis (tabes) is shown by the fact that the reflexes were normal, pupils normal, and Wassermann negative after the first treatment. The presence of ataxia is not pathognomonic of tabes. The second case is one of luetic lateral sclerosis with no other symptoms other than paraplegia mentioned in the history, yet, after ten treatments, the author states: "Clinically, he has improved in every respect except in the matter of walking"! The Wasserman was two-plus in blood and spinal fluid before treatment was started and four-plus after the ninth treatment. The third case is one of tabes dorsalis with additional meningo-vascular symptoms, as shown by the presence of ptosis several years previously which had cleared up on K. I. She had received no salvarsan or mercury before the intraspinous treatments were given, so the improvement could be entirely due to the intravenous injections of salvarsan. The fourth case, although diagnosed tabes dorsalis, is quite apparently cerebro-spinal syphilis. Tabes does not begin suddenly with headache, loud ringing in the ears, vertigo, staggering gait, and awkwardness in the use of the hands. These symptoms all point to a vascular lesion in the vestibulo-cerebellar apparatus. The marked improvement and fact that the Wassermann became negative confirm the diagnosis of meningo-vascular syphilis. The results cannot be credited to the Swift-Ellis treatment for the reasons given above. The remaining four cases are open to the same criticisms as the above. From this examination of the cases reported it is perfectly evident that no benefit whatever can be credited to the intraspinous part of the therapy. The conclusions of Head that meningo-vascular syphilis is readily cured or greatly relieved by intravenous salvarsan and mercury, while syphilis centralis is not, is clearly shown in the results obtained by the author. Drainage of Cerebro-Spinal Fluid as a Factor in the Treatment of Nervous Syphilis. Gilpin and Early. Journ. A. M. A., Vol. LXVI, No. 4, 1916. On the hypothesis that salvarsan and mercury are not found in the spinal fluid because the pressure of the spinal fluid and blood of the venous sinuses and capillaries are equal, therefore the drugs do not pass by osmosis from the blood to the spinal fluid, the authors advocate the lowering of the pressure in the spinal fluid by frequent lumbar puncture. The complete misconception of the phenomena of osmosis shown by the above hypothesis is most patent. In the first place, osmosis consists of the diffusion of water through a membrane and not of substances (salvarsan) dissolved in water; secondly, the water diffuses through the membrane from the fluid which does not contain the dissolved material to the fluid containing the substance in solution. According to the laws of osmosis, therefore, the water of spinal fluid would pass through the capillary walls into the blood, increasing the pressure of the blood above that of the spinal fluid to exactly that amount which the dissolved substance would exert if gasified at the same temperature without change of volume. All a reduction in the pressure of the spinal fluid would accomplish would be to possibly decrease the amount of spinal fluid which would diffuse into the blood. However, on this hypothesis, patients are subjected to a biweekly lumbar puncture and 20-40 cc. of spinal fluid removed while regular treatment with mercury and intravenous salvarsan are carried out. The result obtained in the first case reported is very good, really remarkable for a case of general paresis. It probably would be very embarrassing to the writers to be asked on what ground the diagnosis is based. The history alone suggests cerebral meningo-vascular syphilis, while the fact that the Wassermann in the spinal fluid was negative on six occasions practically excludes general paresis. The recovery confirms the diagnosis of cerebral syphilis. The second case is called tabo-paresis, but many features, including cranial nerve involvement, definite insight regarding his condition, high cell count, and marked improvement, suggest rather the diagnosis of tabes combined with cerebro-spinal syphilis. The third case is one of tabes and showed marked improvement under treatment. The criticisms of the article, especially of the diagnoses, is made solely for the purpose of showing how prone all of us are to draw conclusions without adequate consideration of the facts in hand. The leading neurologists and psychiatrists all emphasize the difficulty of distinguishing general paresis and cerebro-spinal syphilis. Head, in his article in Brain, states that frequently the therapeutic test is the only means of distinguishing the two conditions. The only way in which any conclusion can be reached in regard to the advantage of the form of treatment described in this article would be to first submit the patient to a thorough course of mercury and intravenous treatment, after which further improvement by the "drainage method" might give some idea of its therapeutic value. The Blastophthoric Effect of Clinical Lead Poisoning. C. A. Weller. The Journal of Medical Research, Vol. XXXIII, No. 2, p. 271. From a series of experiments on guinea-pigs, the author draws the following conclusions: 1st. In chronic lead poisoning there is a definite blastophthoric effect. In the male it manifests itself in some instances by sterility without loss of sexual activity and in the offspring by a reduction of about 20 per cent in the average birth weight, an increased number of deaths in the first week, and a general retardation in development. 2nd. The offspring of a lead poisoned female are underweight at birth and are frequently still-born. 3rd. From the apparent recovery of reproductive power some time after stopping the administration of lead it seems that the deleterious effect must be borne especially by that portion of the germ plasm which is undergoing maturation and not by that which is stored as undeveloped germinal epithelium. For the effect of lead poisoning on the human offspring the reader is referred to the editorial on page 2242 of the Journal of the A. M. A. for December 25, 1915. A Case of Paget's Disease (Osteitis Deformans), with a Note Upon the Pathology. Geoffrey Jefferson. The British Journal of Surgery, Vol. III, No. 10, p. 219. The feature of special interest in this article is the emphasis of the role which the internal secretions probably play as an etio logical factor. The fact that the parathyroid, thyroid, and pituitary glands influence the metabolism of the bone-salts has been quite fully established. Da Costa, in the Journal of Biological Chemistry for March, 1914, recounts the results obtained in an investigation of the metabolism of the bone-salts in two cases of Paget's Disease, in which there was a marked retention of calcium, magnesium and phosphorus, and a pronounced loss of sulphur. Harbitz and Molineus found small tumors of the parathroids in four cases of osteomalacia, a disease which, together with osteitis fibrosa, is surely closely related to Paget's Disease. Le Réflexes D'Automatisme Dits De Défense. Pierre Marie et Foix. Revue Neurologique, An. XXII, No. 16, p. 225. The automatic reflexes considered in this article are five in number: 1. The flexion reflex. 2. The extension reflex. 3. The crossed extension reflex. 5. The contralateral rythmic reflex. Clinically these reflexes have all been obtained in various patients by superficial or deep stimulation of the various parts of the lower extremities and occasionally by stimulation applied to the shoulder, neck, or face. The principal object of the author is to show that these phenomena are not defense movements but are due to the automatic functions of the spinal cord. A great many experiments on decerebrated animals are referred to to show the existence of such automatic spinal functions. The movements occurring in man are related especially to the walking reflex. The crossed extension reflex in which there is flexion of the leg on the side stimulated and extension of the opposite side, and the contralateral rythmic reflex in which there is an alternating flexion and extension of both legs in reverse order, are quite similar to the co-ordinated movement of the muscles in walking. As in the spinal animals in which automatic stepping, standing, walking, running, and other more complicated reflexes occur, so in man, similar though less definite, automatic steppage reflexes occur. These reflexes are seen in cases in which there is some lesion in the cerebro-spinal motor tract, that is, the hemiplegic and paraplegic syndromes. |