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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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Environment Variables for Windows (continued)

Syphilitic Nerve Deafness This may occur in either early or late syphilitic meningitis and may be combined with other syphilitic syndromes We and our colleagues have had little clinical experience with this disorder and have no pathologic material Treatment of Neurosyphilis The treatment of these tertiary forms of neurosyphilis consists of the administration of penicillin G, given intravenously in a dosage of 18 to 24 million units daily (3 to 4 million units every 4 h) for 14 days Erythromycin and tetracycline, in doses of 05 g every 6 h for 20 to 30 days, are suitable substitutes in patients who are sensitive to penicillin The so-called JarischHerxheimer reaction, which occurs after the rst dose of penicillin and is a matter of concern in the treatment of primary syphilis, is of little consequence in neurosyphilis; it usually consists of no more than a mild temperature elevation and leukocytosis The effects of treatment on certain symptoms of neurosyphilis, especially of tabetic neurosyphilis, are unpredictable and often little in uenced by treatment with penicillin; they require other measures Lightning pains may respond to gabapentin or carbamazepine Analgesics may be helpful, but opiates should generally be avoided Neuropathic (Charcot) joints require bracing or fusion Atropine and phenothiazine derivatives are said to be useful in the treatment of visceral crises In all forms of neurosyphilis, the patient should be re-examined every 3 to 6 months and the CSF should be retested after a 6month interval If after 6 months the patient is free of symptoms and the CSF abnormalities have been reversed (disappearance of cells as well as reduction in protein, gamma globulin, and serology titers), no further treatment is indicated Follow-up should include clinical examinations at 9 and 12 months and another lumbar puncture as part of the latter examination Satisfactory progress is judged by absence of symptoms and further improvement in the CSF These procedures should be repeated every 6 months until the CSF becomes completely negative In the opinion of most experts, a persistent weakly positive serologic (VDRL) test after the cells and protein levels have returned to normal does not constitute an indication for additional treatment Such a CSF formula assures that the disease is quiescent or arrested Others are not convinced of the reliability of this concept and prefer to give more penicillin If at the end of 6 months there are still an increased number of cells and an elevated protein in the uid, another full course of penicillin should be given Clinical relapse is almost invariably attended by recurrence of cells and increase in protein levels Rapid clinical progression in the face of a negative CSF suggests the presence of a nonsyphilitic disease of the brain or cord A proven maxim for treatment was that a syphilitic patient who has neither abnormal CSF nor aortitis needs no therapy (In the days of arsenical treatment, the therapy put patients at greater risk than did the disease) Finally, it may be said that even with the mild resurgence of the disease due to AIDS, the neurologist nds the various forms of neurosyphilis of more theoretical than practical importance But no other disease has portrayed more vividly the effects of a chronic, continuously active cerebrospinal meningitis on the entire neuraxis.

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Until comparatively recent times, the nonvenereal treponematoses were of little interest to neurologists of the western world Yaws, pinta, and endemic syphilis rarely if ever affected the nervous system Leptospirosis was essentially an acute liver disease, with only one variant causing a nonicteric lymphocytic meningitis; tick- and

is what you added using Visual Studio 2008 Remember that the Label form is an ASPNET web form, and Text is one of the form s properties Also, keep in mind that the form runs on the server, and the only way for the code from the ASPX file to execute is through the links that the ASPX file has to the C# file and inheritance of its class At this point, you need not expect to understand everything The example used is to show how to use Visual Studio 2008 and not how C# and ASPNET work in concert However, you should be able to see a general picture of the process for developing applications using Visual Studio 2008 Also, keep in mind that Visual Studio 2008 is huge, and as you progress through the book, you will find more and elements of this important development tool In the next section, you will see a bit more of what you can do with Visual Studio 2008 and how it can be used to give you exactly what you want

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