Evan W. Thomas

Criteria for the management of neurosyphilis

Abstract 1.1. The need for differentiating between active and inactive neurosyphilis is discussed. 2.2. Rules for establishing the activity of neurosyphilis by means of spinal fluid examinations are given. 3.3. The advantages of the New York State laboratory technics for quantitative spinal fluid complement fixation and colloidal gold tests are briefly outlined.

The results of treatment in 1,086 general paralytics the majority of whom were followed for more than five years☆

Abstract Paresis strikes most frequently during lifes most productive years. It is seen approximately three times as frequently in males as females, and over twice as frequently in whites as in Negroes. The usual incubation period is 10 to 24 years after infection. The simple dementing type of psychosis is more frequent than all other types combined. In the absence of previous treatment the spinal fluid complement fixation reaction is always positive and the spinal fluid cell count is almost always elevated. The blood serologic test may, rarely, be negative. Penicillin prevents paresis. None of the present group of 1,086 patients had received penicillin for early syphilis. Paresis has not been observed to develop following the penicillin treatment of asymptomatic neurosyphilis. The present study cannot be said to reflect the effect of penicillin alone, but only the effect of penicillin with or without fever therapy on a mixed group of paretics, a small but undetermined number of whom already had a process perhaps wholly or partly arrested by other types of therapy before penicillin was given. The trend in recent years in the United States has been toward the treatment of paresis with penicillin alone. The possible additive effects of fever therapy are not sufficient to justify its use in any significant number of patients. The early diagnosis and prompt penicillin treatment of incipient paresis result in clinical remission and ability to work in more than 80 per cent of patients and will prevent practically all deaths from neurosyphilis. Even the severe or institutionalized patient has one chance out of three of improvement and rehabilitation for work. In contrast to the dire prognosis of untreated paresis only 9 per cent of penicillin-treated paretics are dead of paresis 10 years after treatment. Even so, the penicillin-treated paretic has nearly four times the death rate of his or her nonsyphilitic age, race, or sex counterpart. The effects of treatment upon the individual signs and symptoms of paresis are in general strikingly beneficent. In the majority of cases, however, abnormalities of speech, insight, calculation, judgment, and general information do not entirely disappear. Repository penicillin is quite as suitable as aqueous penicillin. Although the minimal effective dose is unknown, the present study suggests that 6 million units is probably ample. In general, more than one course of penicillin is of no demonstrable additional value. Absence of clinical improvement, persistently abnormal spinal fluid protein level, or persistently positive spinal fluid complement fixation reaction are not indications for re-treatment. Re-treatment with penicillin is indicated under the following circumstances: an initial course of therapy of less than 6 million units, temporary clinical improvement following an initial course with subsequent clinical progression, or spinal fluid cell count of 5 or more after the first post-treatment year. The essentially identical probability of death in patients who receive one course and patients who receive more than one course of treatment is strong evidence against the value of routinely repeated courses of penicillin in the treatment of general paralysis. Herxheimer reactions, notably exacerbation of the paretic psychosis or convulsive seizures, occur more frequently in the presence of spinal fluid pleocytosis than in its absence. The Herxheimer reaction does not appear to cause long-term damage. Skilled neuropsychiatric examination affords definite prognostic data as to the probability of improvement in psychosis, rehabilitation for work, and to a certain extent as to death itself. Progression and death due to neurosyphilis occurred almost altogether in patients with “severe” pretreatment psychosis. Post-treatment psychiatric hospitalization was directly proportional, and clinical improvement and rehabilitation for work inversely proportional to the severity of pretreatment psychosis. Type of psychosis was of less importance prognostically. The shorter the duration of psychosis at the time of treatment the more frequent was clinical improvement and rehabilitation for work. The presence at the time of treatment of incontinence, inability to perform simple acts of personal toilet, and of convulsions afforded a particularly poor prognosis for longevity. Work status at the time of treatment was of great prognostic import, and of perhaps equal significance was the length of time which had elapsed since the patient had been able to work at his usual occupation. Age, race, and sex were relatively unimportant factors in prognosis. Pretreatment pleocytosis indicates an active inflammatory process more susceptible of improvement by treatment, but in a minority of patients leaving behind sufficient brain damage to nullify any real clinical effect. The absence of pleocytosis indicated a relatively static process less susceptible of improvement. Pretreatment spinal fluid protein levels were of less prognostic import. Persistent cell counts of 11 or more were for practical purposes not encountered after penicillin treatment. Clinical progression did, however, occur significantly more frequently with persistent cell counts of 5 to 10 than with cell counts of 4 or less. Persistent spinal fluid protein elevation was relatively frequent but of no prognostic import. Considering the fact that as the incidence of syphilis itself decreases, dementia paralytica is becoming something of a neuropsychiatric rarity, the data which I have presented are perhaps of more historical interest than practical importance. They are, however, a dramatic illustration of the progress of medicine in four decades. A disease which was uniformly fatal within a few short years prior to Wagner von Jaureggs 1917 discovery of the efficacy of malaria therapy has now become curable in some, and partially remediable in many, by virtue of brief treatment with penicillin. The credit for this accomplishment is shared by your country through Fleming and Florey, and my own through Mahoney. Most of it belongs to Britain. May our future scientific and friendly brotherhood prove as profitable!

Results of therapy of latent and asymptomatic syphilis in a prison population. II. Seroreversal following definitive treatment as shown by the New York State complement fixation test.

Abstract The pattern of seroreversal, as measured by the New York State complement fixation test following “curative” treatment for latent syphilis, is shown and discussed with respect to a prison population experience involving 2,820 patients. The rate of seroreversal as measured by this single procedure is slow, reaching 25 per cent after 5 years and 50 per cent after 11 years of observation. It is pointed out that the duration of infection at the time of treatment is a major factor in the rate of reversal. The relationship of serologic findings to the management of the patient with latent syphilis is discussed.

Results of therapy of latent and asymptomatic syphilis in a prison population: I. Clinical outcome with reference to cardiovascular and central nervous system syphilis and related to a nonsyphilitic control population

Abstract 1. 1. A report is given of the long-term results of therapy of latent syphilis with “adequate” arsenobismuth therapy in terms of clinical and serologic response. 2. 2. The prison milieu of treatment made possible close and careful serologic and clinical follow-up. Thus, a 10 per cent sample was given complete posttreatment examination at a time averaging about 14 years after treatment. 3. 3. To provide a control group against which to assess the significance of the so-called abnormal neurologic findings, reflex and pupillary examinations were performed by the same physicians, utilizing identical examination techniques, on a group of 847 nonsyphilitic prisoners in the same institution. 4. 4. The minimum rate of progression to neurosyphilis in the group “adequately” treated for latency was 0.3 per cent. 5. 5. The proportion of patients in the sample showing clinical evidence of possible neurosyphilis or cardiovascular syphilis was small. Of 255 for whom complete records are available, out of the final 277 examined, only 36 showed any tendon reflex abnormalities, and only 19 showed pupillary abnormalities of any kind. In none of these patients could a diagnosis of neurosyphilis be made unequivocally, and it appears that the abnormalities reported are of the same order as found in a nonsyphilitic group of comparable status. 6. 6. In this same group, only 11 findings in 10 patients suggestive of cardiovascular syphilis were found; and, of these, only one with aortic aneurysm had evidence permitting an unequivocal diagnosis of cardiovascular syphilis. 7. 7. “Adequate” arsenotherapy, given according to the standards utilized at Sing Sing prison for treatment of latent syphilis, results in a high degree of success in prevention of the development of neurosyphilis or cardiovascular syphilis.