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proprioceptive bers in the sensory roots The hypotonia and insensitivity of the bladder are due to deafferentation at the S2 and S3 levels; the same is true of the impotence and obstipation Lightning pains and visceral crises cannot be fully explained but are probably attributable to incomplete posterior root lesions at different levels Analgesia and joint insensitivity relate to the partial loss of A and C bers in the roots If there is no pleocytosis, the CSF protein content is normal, and there is no evidence of cardiovascular or other types of syphilis, no further antisyphilitic treatment is necessary If the CSF is positive, the patient should be treated with penicillin, as described below Residual symptoms in the form of lightning pains, gastric crises, Charcot joints, or urinary incontinence frequently continue long after all signs of active neurosyphilitic infection have disappeared These should be treated symptomatically rather than by antisyphilitic drugs Syphilitic Optic Atrophy This takes the form of progressive blindness beginning in one eye and then involving the other The usual nding is a constriction of the visual elds, but scotomata may occur in rare cases The optic discs are gray-white Other forms of neurosyphilis, particularly tabes dorsalis, not infrequently coexist The CSF is almost invariably abnormal, though the degree of abnormality may be slight in some cases The prognosis is poor if vision in both eyes is greatly reduced If only one eye is badly affected, sight in the other eye can usually be saved In exceptional cases, visual impairment may progress, even after the CSF becomes negative The pathologic changes consist of a perioptic meningitis, with subpial gliosis and brosis replacing degenerated optic nerve bers Exceptionally there are vascular lesions with infarction of central parts of the nerve Spinal Syphilis There are several types of spinal syphilis other than tabes Two of them, syphilitic meningomyelitis (sometimes called Erb s spastic paraplegia because of the predominance of bilateral corticospinal tract signs) and spinal meningovascular syphilis, are observed from time to time, though less often than tabes Spinal meningovascular syphilis may occasionally take the form of an anterior spinal artery syndrome In meningomyelitis, there occurs a subpial loss of myelinated bers and gliosis as a direct result of the chronic brosing meningitis Gumma of the spinal meninges and cord seldom is found It was not present in a single case in Merritt and Adams study of spinal syphilis Progressive muscular atrophy (syphilitic amyotrophy) is a very rare disease of questionable syphilitic etiology; most cases are degenerative (see Chap 39) Also rare is syphilitic hypertrophic pachymeningitis or arachnoiditis, which allegedly gives rise to radicular pain, amyotrophy of the hands, and signs of long tract involvement in the legs (syphilitic amyotrophy with spastic-ataxic paraparesis) In all these syndromes there is an abnormal CSF unless, of course, the neurosyphilitic infection is burned out (See Chap 44, on spinal cord diseases) The prognosis in spinal neurosyphilis is uncertain There is improvement or at least an arrest of the disease process in most instances, though a few patients may progress slightly after treatment is begun A steady advance of the disease in the face of a negative CSF usually means that there has been a secondary constrictive myelopathy or that the original diagnosis was incorrect and the patient suffers from some other disease, eg, a spinal form of multiple sclerosis as a degenerative disease.

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