Neurosyphilis

   The syphilitic infiltration of the central nervous system, though today belonging to internal medicine or neurology, was once treated by psychiatrists. The patients themselves frequently landed in asylums because the illness first becomes manifest in the form of psychiatric symptoms; paralysis and convulsions are later symptoms. But because neurosyphilis progresses from psychiatric symptoms such as the compulsive shopping of mania to the frank neurological symptoms accompanying lesions in central nervous tissue, it was formerly called "progressive paralysis," or "general paralysis of the insane" (also known as "GPI"). In some asylums, up to half of all patients in the men’s wards had neurosyphilis, and so the history of the diagnosis and treatment of the condition is highly germane to the history of psychiatry. Although careful clinical descriptions of the spinal form of neurosyphilis, called "tabes dorsalis" (wasting of the posterior columns of the spinal cord), or "locomotor ataxia," go back to Sigismund Loewenhardt’s (1796–1875) Latin treatise De myelophthisi chronica in 1817, it was only in 1822 that the young Paris physician Antoine Laurent Jessé Bayle (1799–1858) described in his medical thesis what turned out to be the cerebral form of syphilis. (See Unitary Psychosis.) Not until 1894 did Jean-Alfred Fournier (1832–1914), a distinguished Parisian syphilologist, link statistically a primary syphilis infection to the later appearance of paresis and tabes (in Les affections parasyphilitiques). (Paresis means paralytic symptoms.) Indeed, in the real world of medical practice, before 1905 there was great confusion about the difference between syphilis and gonorrhea and about whether progressive paralysis was caused by an infectious organism at all, but was not rather the result of masturbation or overwork.

   Then in 1905, the Berlin parasitologist Fritz Schaudinn (1871–1906), in serum that Erich Hoffmann (1868–1959), an associate professor (Privatdozent) at the Berlin university clinic for syphilis and dermatology, had obtained from a genital lesion, identified the spiral organism that causes syphilis, the "Spirochaeta pallida." Schaudinn later renamed the organism "Treponema pallidum." Their classic discovery appeared in the Studies of the Imperial Health Office (Arbeiten des kaiserlichen Gesundheitsamtes) in Berlin, where Schaudinn was employed.

   In terms of the diagnosis of neurosyphilis, a vexatious issue for physicians dealing with previously healthy middle-aged men acutely presenting with the symptoms of mania, it had long been known that there was some kind of relationship between syphilis and the symptom of paresis (paralysis). Yet, many writers considered cerebral syphilis and progressive paralysis separate diseases. Then in 1905, August Wassermann (1866–1925), a staff physician at Robert Koch’s Institute for Infectious Diseases at the Charité Hospital in Berlin, described in the German Medical Weekly (Deutsche Medizinische Wochenschrift) a diagnostic test for syphilis based on the cerebrospinal fluid; later that year in the same journal he and Felix Plaut (1877–1940), a young assistant physician at Emil Kraepelin’s psychiatric clinic in Munich, showed that the test obtained positive results in the great majority of paresis patients. In 1913, Hideyo Noguchi (1876–1928) at the Rockefeller Institute for Medical Research in New York and Joseph W. Moore (1879–?) at the Central Islip State Hospital on Long Island reported in the Journal of Experimental Medicine that out of 70 "paretic" brains, Noguchi had succeeded in obtaining a culture of T. pallidum in 12; Moore then confirmed the finding. This strongly suggested that general paralysis of the insane was a form of late syphilis.

   As for therapy, a specific treatment for primary syphilis had been discovered in 1909, as Frankfurt internist Paul Ehrlich (1854–1915) established the efficacy of an organic arsenical that became marketed as Salvarsan (generically arsenobenzol; arsphenamine in the United States). Yet, Salvarsan does not cross the blood–brain barrier well and was less effective in neurosyphilis; it was also quite toxic and difficult to administer. In 1917, Julius Wagner von Jauregg initiated the malarial-fever cure of neurosyphilis, which involved giving neurosyphilis patients injections of the blood of malarial patients, then, several weeks later, after the neurosyphilis patients had started spiking malarial fevers, curing them with quinine. (The spirochaete that causes syphilis is heat-sensitive.) In 1944, the penicillin panel of the subcommittee on venereal diseases of the United States National Research Council, led by John H. Stokes (1885–1961), a Philadelphia dermatologist, announced in the Journal of the American Medical Association that penicillin was effective in neurosyphilis. This represented the definitive treatment, and the prevalence of the condition declined sharply.