Diagnosing Tabes Dorsalis in HIV-Negative Patients: Clinical Features, Neuroimaging, and Laboratory Insights in the Modern Antibiotic Era.

Background: Tabes dorsalis is a late manifestation of neurosyphilis, characterized by progressive ataxia, lightning pains, loss of proprioception, and urinary incontinence. The absence of a definitive diagnostic standard and the non-specific clinical manifestations have led to a significant rate of misdiagnoses. Methods: Hospitalized patients with tabes dorsalis at Peking Union Medical College Hospital between January 2010 and December 2023 were reviewed. Results: A total of 13 patients were included, with 10 males and 3 females. The median age was 50 years (range, 34-64). The most frequent initial symptoms were limb numbness (30.8%) and lightning pains (30.8%). Eleven patients (84.6%) received misdiagnoses prior to the final diagnosis. The most frequently observed physical sign was positive Romberg's sign (84.6%). Notably, Argyll Robertson pupil was presented in 7 subjects (53.8%). Serological tests revealed positive rapid plasma regain (RPR) and Treponema pallidum particle agglutination (TPPA) for all patients. All CSF samples were TPPA-reactive. Intramedullary hyperintensity on T2-weighted imaging of spinal MRI was found in 5 patients (38.5%). All patients received anti-syphilitic treatment, with effective treatment recorded in five cases. Conclusion: This study underscores the importance of neurological symptoms and signs in diagnosing tabes dorsalis. Individuals with progressive ataxia and positive Romberg's sign should be closely monitored for potential neurosyphilis. Integrating clinical features, laboratory tests, and neuroimaging could reduce misdiagnosis and expedite the initiation of anti-syphilitic therapy.

Sífilis: formas de presentación poco frecuentes / Syphilis: uncommon presentation forms

Resumen Existen formas de presentación poco frecuentes de sífilis, dentro de las cuales se incluyen la neurosífilis, otosífilis y sífilis ocular. La neurosífilis es la infección del sistema nervioso central por Treponema pallidum. Las manifestaciones clínicas de neurosífilis son variadas e incluyen formas tempranas, tardías y atípicas. Además, la sífilis puede comprometer prácticamente cualquier estructura ocular, en cualquier etapa de la enfermedad, como así también la otosífilis. El diagnóstico de estas en tidades suele ser dificultoso. Sin embargo, resulta impor tante considerarlas como diagnósticos diferenciales, ya que la mayoría de estas manifestaciones son reversibles con tratamiento antibiótico adecuado. Se presenta una serie de casos de pacientes con diagnóstico de neurosí filis, otosífilis y sífilis ocular, que cursaron internación en un hospital de tercer nivel: meningitis sifilítica con compromiso de pares craneales y convulsiones (caso 1), sífilis ocular (caso 2), paresis general (caso 3) y tabes dorsalis (caso 4). La mitad de los pacientes presentó hipoacusia neurosensorial bilateral. El 50% presentó VDRL reactiva en líquido cefalorraquídeo. Todos fueron tratados con penicilina G sódica y en el 50% se optó por el uso de ceftriaxona como modalidad para finalizar el tratamiento en internación domiciliaria. Respecto a la evolución de los pacientes, uno de ellos falleció como consecuencia del cuadro de neurosífilis (caso 1), otro se perdió en el seguimiento (caso 4) mientras que, de los dos restantes, el caso 3 presentó recaída de su enferme dad a los 6 meses del tratamiento y el caso 2 resolvió ad integrum su sintomatología.

Abstract Uncommon forms of syphilis exist, among which neurosyphilis, otosyphilis, and ocular syphilis are included. Neurosyphilis is the infection of the central nervous system caused by Treponema pallidum. The clinical manifestations of neurosyphilis are diverse and include early, late, and atypical forms. Syphilis can affect virtually any ocular structure and can oc cur at any stage of the disease, as well as otosyphilis. The diagnosis of these conditions is often challeng ing. However, it is important to consider them as a differential diagnosis, as most of these clinical mani festations are reversible with appropriate antibiotic treatment. A case series study of patients diagnosed with neurosyphilis, otosyphilis, and ocular syphilis, who were admitted to a tertiary-level hospital, is here presented: syphilitic meningitis with cranial nerve in volvement, and seizures (case 1), ocular syphilis (case 2), general paresis (case 3), and tabes dorsalis (case 4). Half of the patients presented bilateral sensori neural hearing loss; and also half of the patients had reactive VDRL in cerebrospinal fluid. All were treated with aqueous penicillin G, and in two of these cases, ceftriaxone was chosen to complete ambulatory treat ment. One patient had an unfavorable outcome and died (case 1); another was lost in follow-up (case 4); one completely resolved his symptoms (case 2); and another one experienced symptom relapse six months after treatment (case 3).

[Syphilis: uncommon presentation forms]. / Sífilis: formas de presentación poco frecuentes.

Uncommon forms of syphilis exist, among which neurosyphilis, otosyphilis, and ocular syphilis are included. Neurosyphilis is the infection of the central nervous system caused by Treponema pallidum. The clinical manifestations of neurosyphilis are diverse and include early, late, and atypical forms. Syphilis can affect virtually any ocular structure and can occur at any stage of the disease, as well as otosyphilis. The diagnosis of these conditions is often challenging. However, it is important to consider them as a differential diagnosis, as most of these clinical manifestations are reversible with appropriate antibiotic treatment. A case series study of patients diagnosed with neurosyphilis, otosyphilis, and ocular syphilis, who were admitted to a tertiary-level hospital, is here presented: syphilitic meningitis with cranial nerve involvement, and seizures (case 1), ocular syphilis (case 2), general paresis (case 3), and tabes dorsalis (case 4). Half of the patients presented bilateral sensorineural hearing loss; and also half of the patients had reactive VDRL in cerebrospinal fluid. All were treated with aqueous penicillin G, and in two of these cases, ceftriaxone was chosen to complete ambulatory treatment. One patient had an unfavorable outcome and died (case 1); another was lost in follow-up (case 4); one completely resolved his symptoms (case 2); and another one experienced symptom relapse six months after treatment (case 3).

Existen formas de presentación poco frecuentes de sífilis, dentro de las cuales se incluyen la neurosífilis, otosífilis y sífilis ocular. La neurosífilis es la infección del sistema nervioso central por Treponema pallidum. Las manifestaciones clínicas de neurosífilis son variadas e incluyen formas tempranas, tardías y atípicas. Además, la sífilis puede comprometer prácticamente cualquier estructura ocular, en cualquier etapa de la enfermedad, como así también la otosífilis. El diagnóstico de estas entidades suele ser dificultoso. Sin embargo, resulta importante considerarlas como diagnósticos diferenciales, ya que la mayoría de estas manifestaciones son reversibles con tratamiento antibiótico adecuado. Se presenta una serie de casos de pacientes con diagnóstico de neurosífilis, otosífilis y sífilis ocular, que cursaron internación en un hospital de tercer nivel: meningitis sifilítica con compromiso de pares craneales y convulsiones (caso 1), sífilis ocular (caso 2), paresis general (caso 3) y tabes dorsalis (caso 4). La mitad de los pacientes presentó hipoacusia neurosensorial bilateral. El 50% presentó VDRL reactiva en líquido cefalorraquídeo. Todos fueron tratados con penicilina G sódica y en el 50% se optó por el uso de ceftriaxona como modalidad para finalizar el tratamiento en internación domiciliaria. Respecto a la evolución de los pacientes, uno de ellos falleció como consecuencia del cuadro de neurosífilis (caso 1), otro se perdió en el seguimiento (caso 4) mientras que, de los dos restantes, el caso 3 presentó recaída de su enfermedad a los 6 meses del tratamiento y el caso 2 resolvió ad integrum su sintomatología.

The early history of the knee-jerk reflex in neurology.

Medical interest in the knee-jerk reflex began in about 1875 with simultaneous and independent publications by Wilhelm Heinrich Erb (1840-1921) and Carl Friedrich Otto Westphal (1833-1890) contending that the knee jerk was absent (and the ankle clonus was present) in all clear cases of locomotor ataxia (tabes dorsalis). Physicians in the medical communities of Europe, Great Britain, and North America responded with case and large group studies that tested this contention. These studies revealed the usefulness of the knee jerk and other myotatic reflexes, but also unexpected characteristics. The knee jerk, apparently so simple, proved to be a complex phenomenon depending the strength of the strike on the patella, induced muscle tension, and inhibition from the brain. Was it a reflex with afferent and efferent nerves and an intervening process in the spinal cord, or was it a local phenomenon confined to the muscle itself? Experimental studies directed at the reflex issue investigated latencies from patella strike to leg extension or muscle contraction and compared them with latencies from direct muscle strikes and theoretical calculations based on reflex components. Such studies were unable to resolve the reflex issue during the nineteenth century. The physicians were shown to be limited, like all scientific explorers of the unknown, by their knowledge, methodology, and technology.

An Approach for Diagnosing and Treating Neurosyphilis: A Case Report.

Neurosyphilis is a disease caused by systemic infection with Treponema pallidum, which infiltrates the central nervous system and preganglionic dorsal roots. This process presents as neurological deficits and can occur any time during the infection course, but usually takes many years. Neurosyphilis is rare in the developed world where antibiotics are readily available to treat the early stages of syphilis. This report describes a case of neurosyphilis in a 71-year-old woman who presented with ataxia and vision changes and was ultimately found to have a positive rapid plasma reagin test and protein in the cerebrospinal fluid. She was treated with intravenous penicillin for two weeks with a good response.

Traditional Neurosyphilis in 21st Century - Tabes Dorsalis, Dementia Paralytica, Aseptic Meningitis and Unilateral Oculomotor Nerve Palsy in an HIV-Negative Man.

Syphilis is potentially a multisystem chronic infection caused by Treponema pallidum. Late symptomatic neurosyphilis has been less reported in developed countries, most often seen in untreated patients or in patients with HIV coinfection. We present a case of complicated neurosyphilis with widespread neurological involvement (dementia paralytica, tabes dorsalis, leptomeningitis and left oculomotor nerve involvement) presenting in the 21st century in an urban area of a well-developed European country in an HIV-negative patient.

Copper Deficiency Myeloneuropathy in Autoimmune Disease.

Copper deficiency is a rare and potentially treatable cause of myeloneuropathy. The most common causes of acquired copper deficiency include malabsorption following gastric surgery and excessive zinc supplementation. Clinical manifestations can be localized to the dorsal spinal cord and present similarly to those that characterize classic vitamin B12 deficiency. In this report, we present the case of a 76-year-old female with copper deficiency myeloneuropathy as a presumed consequence of advanced systemic sclerosis (SSc).

Tabes Dorsalis in a Patient Presenting With Right Lower Extremity Paresthesia and Cervical Spine Pain.

Syphilitic myelitis, also known as tabes dorsalis, is a disease affecting the posterior columns of the spinal cord and dorsal roots and presents as sensory ataxia and neuropathic pain and less commonly as paresthesia and gastrointestinal disturbance. Tabes dorsalis is the clinical manifestation of a previous infection with syphilis, and the average latency period from initial infection to presentation of symptoms is approximately 25 years. This is a rarely encountered manifestation of syphilis since the widespread usage of antibiotics. Penicillin G is the mainstay therapy of neurosyphilis and has been shown to improve and resolve spinal cord lesions associated with tertiary syphilis. We present a case of tabes dorsalis in a 56-year-old female with a history of extensive autoimmune disease who initially presented with neck pain and numbness of the right lower extremity. The unique nature of this case lies in the patient's clinical course, as her symptoms were initially attributed to her history of autoimmune disease. A reactive CSF-VDRL (cerebrospinal fluid Venereal Disease Research Laboratory) test and MRI findings led clinicians to suspect neurosyphilis and begin penicillin G. The patient began to show significant clinical improvement after penicillin G therapy was begun and was discharged to a rehabilitation facility to continue antibiotics and begin aggressive physical therapy.

Wilhelm Erb (1840-1921), an influential German founder of neurology in the nineteenth century.

As an internist, Wilhelm Erb (1840-1921) developed neurology (he also used the term "neuropathology" synonymously) in the tradition of his teacher, Nikolaus Friedreich, in Heidelberg. He left behind a huge corpus of semiological and nosological elements that now constitute our current knowledge of neurology, much more than just the eponyms associated with his name. In 1891, he founded the journal Zeitschrift für Nervenheilkunde [Journal of Neurology] together with internist-neurologist colleagues, thus creating the counterpart to the Archiv für Psychiatrie und Nervenkrankheiten [Archive for Psychiatry and Neurology], which was founded by Berlin neuropsychiatrists Wilhelm Griesinger and Carl Westphal. Despite his reservations about the Gesellschaft Deutscher Nervenärzte [Society of German Nerve Doctors], he was elected its first president in 1907. Erb was also one of the most important representatives of electrodiagnosis and therapy in Europe. He had many disciples who were part of the Heidelberg School of Neurology. His anti-Semitism-a widespread Zeitgeist phenomenon-was documented in several letters to his friend, neurologist Adolf von Strümpell, in which he expressed his contempt for the growing role of Jewish neurologists. Erb's retirement years were marked by illnesses, depression, and grief over the death of three of his sons.

Tabes dorsalis in the 19th century. The golden age of progressive locomotor ataxia.

Tabes dorsalis, a late neurological complication of syphilis, is nowadays almost extinct. The path to understanding this disease and its pathophysiology was long and winding, spanning multiple centuries. The 19th century was a crucial period for understanding it. In the first third of the century, German and French physicians defined the semiology of tabes dorsalis, renamed in France "ataxie locomotrice progressive [progressive locomotor ataxia]." Nevertheless, the multiplicity of ancient and recent terms and the description of sometimes unclear nosological concepts (tabes nervosa, tabes spasmodic, nervo-tabes, etc.) were a hindrance to understanding it. Tabes dorsalis was a fertile ground for the description of many clinical signs that have become classics in medicine. No real treatment was available and various unusual therapies were performed. For a long time, the etiology of this disease remained unknown. The link between syphilis and tabes dorsalis was slowly established in the second part of the 19th century from epidemiologic observations. We present an overview of the concept of tabes dorsalis in the medical context of the 19th century and discuss the medical observations of some famous patients suffering from the disease such as Édouard Manet (1832-1883) and Alphonse Daudet (1840-1897).

Tabes dorsal y meningitis sifilítica en paciente con virus de inmunodeficiencia humana / Tabes dorsalis and syphilitic meningitis in a patient with human immunodeficiency virus

RESUMEN La neurosífilis es una infección causada por la bacteria Treponema pallidum, subespécie pallidum (T. pallidum). Se puede presentar en cualquier momento del curso de la sífilis, e ingresa al organismo por la primoinfección derivada de chancro primario sifilítico. La mayoría de los pacientes genera una repuesta inmunológica efectiva que evita el desarrollo de las complicaciones de la infección en el SNC, sin embargo, algunos no eliminan eficazmente tal invasión, por lo cual desarrollan neurosífilis asintomática o sintomática. La enfermedad, en cuanto a su evolución, se divide en etapas tempranas y tardías. Las primeras etapas incluyen meningitis asintomática, meningitis sintomática, goma sífilitica y sífilis meningovascular, mientras que las etapas tardías incluyen demencia paralítica y tabes dorsal. Dado que a la fecha no se cuenta con una prueba altamente específica y sensible, el diagnóstico se basa en la sospecha clínica, estudios serológicos y presencia de anormalidades del LCR. La importancia de su diagnóstico consiste en evitar complicaciones y secuelas potencialmente graves de la evolución de la enfermedad sin tratamiento. El manejo de la neurosífilis se circunscribe a recibir la terapia con penicilina. El seguimiento incluye el seguimiento de las pruebas serológicas y del LCR en pacientes específicos. Los pacientes con coinfección con VIH pueden tener un desarrollo más temprano de las características neurológicas que las personas sin la infección, así como alta probabilidad de una respuesta incompleta al tratamiento. Se presenta el caso de un hombre en la quinta década de la vida con infección por el virus de inmunodeficiencia humana (VIH) sin terapia antirretroviral, con cuadro subagudo de fiebre, compromiso de las funciones mentales superiores, pupila de Argyll Robertson, mioclonías y marcha atáxica. Las pruebas treponémicas desarrolladas en la hospitalización fueron positivas, se obtuvo un LCR anormal por la presencia de hiperproteinorraquia, así como anticuerpos antitreponemapallidum en 6,56 positivos en LCR. Se consideró el diagnóstico de tabes dorsal, por lo que se inició un tratamiento con penicilina cristalina intravenosa, 24 millones de unidades internacionales (UI)/día, durante 14 días, con evolución clínica favorable. Este artículo revisa la definición etiológica, la patogénesis, las manifestaciones clínicas, el diagnóstico y el tratamiento de la neurosífilis, con especial atención a la presencia de la neurosífilis con la coinfección con VIH y su relevancia para los clínicos en el ámbito de la neurología.

SUMMARY Neurosyphilis is an infection caused by the bacterium Treponema pallidum subspecies pallidum (T. pallidum). It can occur at any time during the course of syphilis, and enters the body through the cousin-infection derived from primary chancre syphilitic, most patients generate an effective immune response that prevents the development of complications of infection in the CNS, however, some patients do not effectively eliminate the invasion to the CNS, thus developing asymptomatic or symptomatic neurosyphilis. It has been divided into early and late stages. The early stages include asymptomatic meningitis, symptomatic meningitis, gum syphilis, and meningovascular syphilis, while the late stages include paralytic dementia and tabes dorsalis. Since, to date, there is no highly specific and sensitive test, the diagnosis is based on clinical suspicion, serological studies, and the presence of CSF abnormalities. The importance in its diagnosis derives in avoiding the complications and potentially serious sequelae of the evolution of the disease without treatment. The management of neurosyphilis is limited to receiving penicillin therapy. Follow-up includes follow-up of serological and CSF tests in specific patients. Patients with co-infection with HIV may have an earlier development of neurological characteristics than people without the infection, as well as a high probability of an incomplete response to treatment. We present the case of a man in his fifth decade of life with human immunodeficiency virus (HIV) infection without antiretroviral therapy, with subacute fever, compromise of higher mental functions, Argyll Robertson pupil, myoclonus, and ataxic march. The treponemal tests developed in the hospitalization were positive, an abnormal CSF was obtained due to the presence of hyperprotein spinal cord, as well as anti-treponema pallidum antibodies in 6.56 positive in CSF, the diagnosis of tabes dorsalis was considered, for which treatment with penicillin was started intravenous crystalline 24 million international units (IU) day, for 14 days, with favorable clinical evolution. This article reviews the definition of aetiology, pathogenesis, clinical manifestations, diagnosis and treatment of neurosyphilis, with special attention to the presence of neurosyphilis with co-infection with HIV and its relevance to clinicians in the field of neurology.

A comprehensive review of the treatment and management of Charcot spine.

Charcot spine arthropathy (CSA), a result of reduced afferent innervation, is an occurrence of Charcot joint, a progressive, degenerative disorder in vertebral joints, related mostly to spinal cord injury. The repeated microtrauma is a result of a lack of muscle protection and destroys cartilage, ligaments, and disc spaces, leading to vertebrae destruction, joint instability, subluxation, and dislocation. Joint destruction compresses nerve roots, resulting in pain, paresthesia, sensory loss, dysautonomia, and spasticity. CSA presents with back pain, spinal deformity and instability, and audible spine noises during movement. Autonomic dysfunction includes bowel and bladder dysfunction. It is slowly progressive and usually diagnosed at a late stage, usually, on average, 20 years after the first initial insult. Diagnosis is rarely clinical related to the nature of nonspecific symptoms and requires imaging with computed tomography (CT) and magnetic resonance imaging (MRI). Conservative management focuses on the prevention of fractures and the progression of deformities. This includes bed rest, orthoses, and braces. These could be useful in elderly or frail patients who are not candidates for surgical treatment, or in minimally symptomatic patients, such as patients with spontaneous fusion leading to a stable spine. Symptomatic treatment is offered for autonomic dysfunction, such as anticholinergics for bladder control. Most patients require surgical treatment. Spinal fusion is achieved with open, minimally-open (MOA) or minimally-invasive (MIS) approaches. The gold standard is open circumferential fusion; data is lacking to determine the superiority of open or MIS approaches. Patients usually improve after surgery; however, the rarity of the condition makes it difficult to estimate outcomes. This is a review of the latest and seminal literature about the treatment and chronic management of Charcot spine. The review includes the background of the syndrome, clinical presentation, and diagnosis, and compares the different treatment options that are currently available.

Classical syphilitic lesions from the museum.

Syphilis is an increasingly diagnosed venereal disease which has four distinctive stages that may last over decades if appropriate treatment is not given. Review of the files of the Pathology Museum in the Faculty of Medicine at The University of Adelaide revealed three cases with classical cardiovascular and neurological findings. Case 1: An 80-year-old man with a large syphilitic aneurysm of the ascending aorta with a smaller aneurysm of the proximal descending aorta. Case 2: A 56-year-old man with chronic syphilitic meningoencephalitis with cerebral atrophy. Case 3: A 77-year-old man with tabes dorsalis. Given the increase in cases coming to medical attention in recent years due to high-risk sexual activity, migration, travel and reduced access to medical treatment, an awareness of the classical features of syphilis is appropriate as some cases will undoubtedly require medicolegal evaluation.

Syphilis-Cardiovascular Manifestations of the Great Imitator.

Rates of syphilis are beginning to once again increase, with the World Health Organization estimating that in recent years there were 12 million new cases of syphilis each year; in 2002, syphilis was responsible for 0.3% of deaths globally. At-risk groups include young males (20-29 years), prisoners, and sex workers. Increased rates in young females have elevated the numbers of congenital cases. Review of the University of Adelaide Pathology Archive revealed four cases with significant pathology, which included cardiac gummas and aortic arch aneurysms. These cases demonstrate the cardiovascular characteristics of untreated syphilis in the tertiary stage. Cases with such advanced pathology will only occur where diagnoses have not been made, and/or standard antibiotic therapy has not been implemented in the early stage of disease.

Neurosífilis / Neurosyphilis

Durante muchas décadas la sífilis y neurosifilis han sido consideradas condiciones poco frecuentes. Con el advenimiento del virus de inmunodeficiencia humana la incidencia de estas enfermedades se ha incrementado. La neurosifilis puede estar presente tanto en estadios tempranos como tardíos de sífilis; sus manifestaciones clínicas son variadas y dependerán de la respuesta del huésped y la duración de la exposición a esta espiroqueta; estas pueden ir desde meningitis asintomática, meningoencefalitis hasta eventos cerebrales vasculares y condiciones más crónicas como tabes dorsalis y/o demencia sifilítica. La esencia del enfoque diagnóstico es un alto índice de sospecha en pacientes con factores de riesgo. La sola presencia de pruebas no treponémicas no son diagnósticos de neurosifilis sino serán necesarios la confirmación con pruebas treponémicas junto con anormalidades en liquido cefalorraquídeo y la presencia de VDRL o RPR en el mismo. La piedra angular en el tratamiento de sífilis y neurosifilis continúan siendo dosis altas de penicilina y alternativamente doxicilina o ceftriaxona.

For decades syphilis and neurosyphilis were considered infrequent conditions; however with the advent of the human immunodeficiency virus the incidence of both diseases have increased. Neurosyphilis could be present in early or late stages of syphilis; the clinical manifestations are varied and will depend on the host response and the length of exposure to the spirochete; this could range from asymptomatic meningitis, to meningoencephalitis, strokes and more chronic conditions such as tabes dorsalis or syphilitic dementia. The key diagnostic approach is a high index of suspicion in patients with risk factors. The only presence of non treponemal studies is not diagnostic of neurosyphilis; it will be necessary to confirm it with treponemal serology and abnormalities in the cerebrospinal fluid (CSF) and positive VDRL and RPR in CSF. The cornerstone of treatment of neurosyphilis is still high doses penicillin and alternatively doxycycline or ceftriaxone.

Nerve-stretching in the 19th century.

Operative nerve-stretching was first described in 1872 to relieve incurable pain from sciatica and tabes dorsalis. It became popular for 20 years and numerous articles were published on the subject. It had many complications but relief was only transient and, consequently, it fell into disuse. This paper analyses the literature, contemporary views on the benefits of nerve stretching and its influence on more recent neurological practice.

Neurosyphilis in psychiatric practice: a case-based discussion of clinical evaluation and diagnosis.

OBJECTIVE: Neurosyphilis can present with a wide range of neuropsychiatric symptoms. Hence, psychiatrists need to be familiar with tests for syphilis screening and how to interpret syphilis serologic tests. METHODS: We present four cases of patients with positive syphilis tests encountered in a psychiatric hospital. RESULTS: Two cases were treated for neurosyphilis, while the other two cases did not have active syphilis infection despite positive results. CONCLUSION: We thus highlight the challenges encountered by psychiatrists in screening for and diagnosing cases of neurosyphilis.

Frederick Delius: controversies regarding his neurological disorder and its impact on his compositional output.

Frederick Delius was born in Yorkshire, England, on June 29, 1862, the son of German immigrants. He showed early musical talent but his father, a wealthy wool merchant, insisted he pursue a business career. After several failures, including an assignment managing an orange grove near Jacksonville, Florida, his father agreed to support his musical studies in Leipzig, assuming he would then become self-sufficient. Delius spent most of his adult life in France, living with and ultimately marrying Jelka Rosen, a painter of independent means, composing prolifically, and being sexually promiscuous both before and after starting life with Jelka. He contracted syphilis in 1895 and manifestations of neurosyphilis appeared in 1910. Despite periods of relative good health over the ensuing 10 years, he became progressively disabled from 1920 on, ultimately quadriparetic and blind but with preserved cognition and musical inspiration. In his final years, he completed several compositions aided by a young British musician, Eric Fenby, who served as his amanuensis and caregiver, along with Jelka, to his death on June 10, 1934.

Heinrich Obersteiner and his contributions.

Heinrich Obersteiner (1847-1921) was amongst the most influential neuroscientists in the 19th century. Born into a family of physicians, he gained early exposure to medicine, and as a medical student, he focused much of his research in neuroanatomy, eventually becoming a professor of neuroanatomy at the University of Vienna. Throughout his academic career, he focused greatly on neuropathology, and incorporated much of his research into his textbook, "Introduction to the Study of the Structure of the Central Nervous Organs in Health and Disease," which was considered the foremost reference text of neurology for many generations of scholars. The culmination of his contributions to the neurological world can be seen as the Neurological Institute of Vienna, which he founded in 1882. Scholars from all over the world sought out his expertize and tutelage. While he was the director of the Institute, over 500 articles were published within the Obersteiner-Arbeiten. Much of this work helped set the foundation for the eventual development of neurology as a medical discipline. A review of his life will help us better understand the legacy Heinrich Obersteiner left in the field of neurology.

Moritz Heinrich Romberg (1795-1873): Early founder of neurology.

Moritz Heinrich Romberg (1795-1873) began his pursuit of neurology in 1820 by translating into German Andrew Marshall's The Morbid Anatomy of the Brain. In 1830, Romberg was hired as Privatdozent of special pathology and therapy in the Charité, the University Hospital of Berlin. He quickly rose to director of the royal clinic in 1845, at which time he wrote Lehrbuch der Nervenkrankheiten des Menschen, a text generally regarded as the first formal treatise on nervous diseases. He identified the role of proprioception in tabes dorsalis, and became the first neurologist to describe the typical pupillary presentation found in patients with tertiary syphilis. Romberg is perhaps most famous for identifying "Romberg's sign," the distinctive sensory ataxia observed in neuropathies of the dorsal columns.