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Salvarsanized Serum in Syphilitic Nervous Disease

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Salvarsanized Serum in Syphilitic Nervous Disease blb Salvarsanized Serum in Syphilitic Nervous Disease SOME SALIENT FACTS: THE METHOD, THE DRUG, THE RESULTS C. EUGENE R I GGS, A. M., M.D. ST. PAUL Repriuted from The Journal of the Ame1·ica11 Medical Association · Sept. 4, 1915, Vol. LXV, pp. 840-845 CoPYRIGHT, 1915 AM ERICAN MEDICAL AssociATION FivE HuNDRED AND TniRTY·FIVE NoRTH DEARBORN STREET C H I CAGO Q.Jv SALV ARSANIZED SERUM IN SYPHILITIC NERVOUS DISEASE SOME SALIENT FACTS: THE MET HOD, THE DRUG, THE RESULTS * C. EUGENE RIGGS, A.M., M.D. ST. PAUL T he cl inical history of syphili s with its therapy is in the process of making, and is greatly in need of restat­ ing. Especially is this true of nervous syphilis. T he report of many investigators are so incomplete, so lackin g in scientific accuracy, as to cloud their findings and give rise to great confusion and difference of opini on. Paucity of experience, the failure to follow lines of procedure marked out by previous well-known and competent investigators, substituting therefor per­ sonal and theoretical mod ifications, are all important factors in the production of this deplorable condition. There are but few Noguchis or Marinescos, few Swifts and E llises. There must be mutual endeaYor; a cooperation of effort, so to speak, along definite lines among those in terested in the therapy of syphilitic nervous diseases, if order is to come out of chaos and definite and reli able data be obtained. Mattauschek found from the examin ation of 4,134 cases of syphilis that 3. 19 per cent. of the patients in fectecl sutferecl from ce rebrospin al syphilis. If we believe with Robertson and Klaudner that syphilis is a septicemia, that the organi sm is invaded by the spirochetes within a clay or so after in fection, that the nervous system is involved from the beginning, and that the majori ty of syphilitics a re essentiall y candi­ dates for nervous syphili s f rom the very outset, the all ­ important thing in the trea.tment of this disease is the *Read be fore the Section on Nervous and Mental Diseases :tl th e Sixty- ixth Annual Session of th e American l\fedical Associat ion, San Francisco, June. 1915. 3 early recognition of the primary lesion: Th~ s is. readily nerves) , modification of sensibility, changes in the effected by the means _of da: k-ground 11lummat10n or_a reflexes, positive Babinski, pupils unequal and differing microscopic examinat10n ot the . exudate of the s?re, in their reaction, etc., are frequently demonstrable in be its resemblance to a huntenan chanc_re never so both stages. sli aht. This is the psychologic moment m the treat­ "The way the central nervous system is involved in m ~1t of syphilis. early syphilis," says Coriat, "is certainly surprising, Gibbard and H arrison have observed that r e l a p s ~ s and this is also borne out by the spinal fluid tests. I are more than doubled when medication is begun 111 am making complete neurologic examinations of all the secondary rather than the primary stage, and the_Y cases of constitutional syphilis, in all of its stages, with­ beli eve that by the employm_ent of ~11 o d e n;. th e r a p ~ utJ c out nervous complaints. " 1 methods syphilis may be ltm1ted t ~ 1ts earhe_st mamfes­ The neurologic findings may, or may not, be associ­ tati ons and that eventually congcmtal syphtl! s wtll cease ated with definite serologic changes. E ither one of to exist. A most valuabie addition to our knowledge these may exist independently of the other. Quincke of syphilis is the significa nt fact . that the . nerv_ous and Mayer consider that there is a parallelism between system is subject to an early sp1rochetal ~n vas 1_on . pleocytosis and the neurologic symptoms; the former Serology has enlightened us g r e~t l y on. tJ-: ts pomt: is believed to bear a relation to the severe headaches Ravaut has fo und an abnormal sp ma~ _flmd m ~7 p ~ r (Jeanse lme and Barbe) . If the serologic changes only cent. of his cases of secondary sy ph1l_1 s ;~D r eyt u s m are present we have what Ravaut call s the "preclinical" 80 per cent.; Robertson and Klaudner 1_n 10 pet: cent.: stage of nervous syphilis, which may last for months Gennerich in 90 per cent. ; Mattauschek m 80 per cent. or years before the fi rst clinical sign makes its appear­ N onne and Mantoux in 40 per cent. ; \tV 1le a n~ Stokes ance. I have now under observation two cases in m from 60 to 70 per cent., and t~1~ latter ~eh eve that which fifteen years elapsed between infection and the in every case of seco ndary syph!lts there 1s more or first manifestation of nervous symptoms. Serology less involvement of the nervous system. We c h s ~l. mann enables us to recognize this preclinical period in its states that in the ma jority of cases _of syphths the in cipiency when treatment is most effective. spinal fluid shows an _in c r ea~e d prot ~m c~nt e nt: A ~ examination of the sp111al flmd of 221 p a tl ~nt s 111 the T HE M ETHOD early stages of syphilis by_ yVechsel_mam: , vV2lhelm and As to the best method for the use of salvarsan in Dinkelacker, showed pos1t1ve fi ndm g~ 111 b ~ , and of nervous syphilis, the profession is hopelessly at vari­ these there were nervous symptoms 111 98; 1:1 the 63 ance. There have been too many contributions by neaative cases there were nervous symptoms 111 32. men whose training and acquaintanceship with the S imilar investigations of the primary peri?d h_ave more delicate methods of diagnosis were too faulty to elicited equally interesting resL:lts. A path?loglC spmal permit of their drawing reliable neurologic conclu­ fluid is common ; an increase 111 the a lbum~n a ~d glob­ sions. "The stage of temperate and critical criticisms ulin content, with or without p l ~ocy ~ os 1 s, IS often of results," says Schwab, "has evidently not yet been obse rved. The \Vassermann react10n IS the _l east ~ o reached." There are two modes of treatment that be relied on; a negative spinal _flui_d i ~ of d1agnosttc merit serious consideration, viz., the intensive and the value only when all symptoms _md!Cattve of n e r y ot~ s intraspinal methods. The former, when given intra­ involvement are absolutely laclong: One of Knda ~ venously and combined with the intramuscular injec­ patients, with a chancre on_ the ltps of hyo weeks tions of mercury, is of unquestioned value; some duration, showed a marked mcreased protem content believe that the results are in every way equal to those in the spin al flui d. obtained by the intraspinal methods (Sachs, Strauss Certain neuroloaic fi ndings, such as headache, and Kaliski ) . This procedure, when practiced by the in Yo h·ement of the "'second and eighth nerves (the lat­ 1. Dr. Co riat' s work :-t long thi s line will app ~a r wh en he and Dr. ter accordina to Benario, bein g more fr e qu e n~l y Sa nborn publish their results of th e treatment of nervous syphilis in ~o l Ye d in ea~·l y syphilis than any of the other cramal b2. sed on over 700 injections. 4 5 injection of salvarsan at the upper part of the nates. of clinical and biologic fact. I can best make clear in the loose tissues between the subcutaneous fat and the present status of intraspinal medication by a brief fascia ( in unctions or inj ections of mercury ~eing giv_en review of its literature and by a few excerpts from in the intervals), may be harmless and practically pam­ personal communications to me from representative less, but in the light of the studies of Tilney and vVoo~­ American workers. sey in vital staining with s~ luttm: s of trypan blue, IS Ehrlich, in his address on chemotherapy before the clearly inefficient. Th~se mv est t ga t_o~ s have shown International Medical Congress, August, 1913, referred that if solutions of thts agent are mJ ected subcuta­ to the intraspinal use of salvarsanized serum as prac­ neously or intra-arter_ially, tl:e skir~ and thoracic and ticed at the Rockefeller Institute, as being "not only abdominal viscera stam readtly whtle the ce ntr ~ l ner­ novel but suitable in so far as it obviates all possible vous system absolutely escap~s. If the solutwn be ill effect on the sensitive central nervous system, by injected intravenously, the stam reaches the dur~ and employing a serum obtained from the patient himself, pia mater, ~ut d?es 1:ot penet~ate th~ nervous ttssue. while at the same time it is possible to apply the cura­ vVhen the lllject!On IS gtven mtraspmally, the mem­ tiYe agent in sufficient quantities." branes are affected as before and the dye penetrates Drs. P urves Stewart and Harry Campbell both the nervous ti ssues through the walls of the veins and advise the treatment of nervous syphilis by intraspinal capillaries, affecting even th~ el?ithelium o ~ the latter. injections. "It is too early to claim," says the former; These experiments would mdtcate _that. mtravenous ·'that we possess a cure for tabes or general paralysis. inj ections of salvarsan are not sufficient m p a_re n c h~ ­ but we can, in suitable cases, do a good deal toward matous syphili s, however valuable they may be mluet1c arresting both diseases; time alone can tell whether meningitis, endarteritis and gumma.
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