H. A., aged nineteen, worker in a laundry, presented herself on account of a violent pain in the right parietal region, recurring three times daily with great regularity. The first two attacks occurred in the day-time, the third, which was always the severest, woke her out of sleep about midnight; the pain of this last was so agonizing that on more than one occasion she had become delirious. The girl (whose respectable appearance was against the notion of syphilis) was very anæmic; not, however, with the tint either of anæmic from hæmorrhage, or with that of chlorosis, exactly. It was rather a dirty sallowness of skin; but the gums and the conjunctivæ were exceedingly bloodless, and she complained of almost constant noises in the head. Menses scanty but regular. There was a soft anæmic bruit with the first sound at the base of the heart. Having failed to make any impression on the pains with iron and with muriate of ammonia in large doses, I was led to observe the fact that there was no diffuse soreness of the scalp, such as very commonly occurs in clavus, in the intervals of the pains, and the mere fact that there was this unusual circumstance in the case led me to reconsider the diagnosis thoroughly. In order to be sure of not omitting a point, I inquired, though without any expectation of an affirmative answer, as to the possibility of syphilitic disease; the girl at once confessed to having had sores, and examination detected a papular rash about the shoulders and back and on both thighs. Small doses of mercury greatly relieved the pain within a week, and cured it in less than three weeks; and it was very remarkable that the anæmia, which had obstinately refused to yield to iron, improved at once as the mercury began to relieve the pains. The eruption disappeared simultaneously.
It is the later pains of syphilis, however, that are most frequently confounded with neuralgia, and occasionally with very disastrous results. These pains, which are the precursors of the formation of true nodes, frequent the same localities as those affected by the earlier pains; they may exist in considerable severity for days, or even for many weeks, before any node-formation can be detected. The situation in which, of all others, they are likely to be mistaken for neuralgia is the scalp or face, especially when a single spot is affected on one side, and in the situation of one of the usual foci of trigeminal or occipital neuralgia. I have personally known the mistake to be made with syphilitic affections causing pain, respectively, in the superciliary region, in the malar bone, the jaw near the mental foramen, and the parietal eminence.
The possibility of mistaking tertiary syphilitic pain for neuralgia is fraught with such grave dangers, that we ought to be constantly and most vigilantly on the watch against it. But most especially is this the case when the pain is situated in some part of the cranium, as the parietal or temporal eminences, the mastoid process, or the prominences of the occipital bone. For it must be remembered that the same process, which forms syphilitic nodes upon the external surface of bones, or within bony canals, can produce them on the lining membrane of the skull, with most serious consequences, should the symptoms be neglected or misunderstood.
The pains produced by nodes upon the internal surface of the cranium are usually of a very intense character, and are mostly continuous, though aggravated from time to time, especially at night. Where syphilitic inflammation is diffused over a considerable portion of the meninges, it is certain very quickly to produce symptoms which can hardly fail to apprise us of the gravity of the affection; there will be decided and rapidly increasing impairment of memory, and general cloudiness of intellect, tending toward complete imbecility, the special senses will be greatly interfered with or lost, and muscular paralysis will be developed. But in the case of a more limited syphilitic affection of the dura mater, pain, of the kind already described, may be for some days the only very noticeable symptom. The following is an instance:
J. E., aged forty-seven, a street and tavern singer, applied to me (November 14, 1861), on account of severe pain in the right temporal region, which had on the whole the character of neuralgia, though rather more continuous than such pain usually is. He said that it commenced on the 10th, without any particular provocation that he knew of, and that it had hardly left him at all from that moment. It kept him awake at night, and that circumstance seemed to account sufficiently for a very worn and depressed look which he presented; he was otherwise a robust-looking man, and at first denied having suffered from any previous illness. The pain always came to a climax about one o'clock, a. m., waking him out of his first sleep in agony, and allowing him little rest for the remainder of the night; toward morning he would drop to sleep for an hour or so. There was no particular tender point, corresponding to any recognized neuralgic focus, yet the pain was limited most strictly to a spot that might be covered with two finger-points. There was no lachrymation nor conjunctival congestion, and nothing to remark in any way about either eye. The patient was ordered quinine in large doses, in the belief that the pain was neuralgic. On the following day he reported himself a trifle better, though still suffering greatly; and on the afternoon of that day there was an almost complete intermission of the pain for several hours; but it returned severely at the usual nocturnal period. On the 16th, at 10 a. m., he came to my house looking exceedingly ill, but the only additional symptom that I could detect was a small droop of the right eyelid. He was subcutaneously injected with one-fourth of a grain of morphia and sent home, where he immediately fell into a heavy sleep that lasted till bedtime. He awoke, undressed himself without feeling much pain, and got to bed; after an hour or so of dozing he was awakened by the pain, which was exceedingly severe. On the 17th he called on me in the morning, and I at once perceived that the ptosis of the right eyelid was much greater, and the right pupil was much dilated and insensitive, and the external rectus was paralyzed; the man also wore a look of stupidity, and answered questions with an apparent mental effort. I now cross-questioned him more closely; and also explored the tibiæ and other superficial bones: on the sternum a distinct though not very advanced node was found. Upon this he was induced to confess that he had suffered from chancre three years and a half previously, and subsequently had "blotches" on the skin, which had quickly disappeared under treatment, of which all that could be learned was, that it was fluid medicine and did not make his mouth sore. He was immediately ordered to take two grains of calomel in pill, with a little opium, every four hours. He had only taken one dose when I was sent for to him, and found him in an epileptiform convulsion, in which the left side of the body was almost exclusively affected; the convulsions recurred several times during the next twenty-four hours, and in the intervals he remained almost completely unconscious. The mercurial treatment was pushed, in the form of calomel-powders placed on the tongue. On the evening of the 18th he began to recover consciousness, and then had a little natural sleep; the next morning, at 10 a. m., he was found to be fully conscious, had had no return of convulsions, but the left arm and leg, especially the latter, were almost entirely powerless; the parietal headache had vanished; the gums were slightly tender; the third and sixth nerves of right side were completely paralyzed. Mercurial treatment was very gently continued, so as to keep the patient on the borders of ptyalism for the next three or four days; and he was then put on full doses of iodide of potassium. The pain never recurred; the left extremities recovered power rapidly; but it was six weeks before the ocular paralyses were completely well.
Late in the autumn of 1865 I was sent for hastily one evening to see this same man, and found him totally unconscious and apparently again hemiplegic, but now on the right side. He was miserably wasted, and covered with a rupious eruption; I was informed that he had been leading a most debauched and drunken life for some time past, and that, after looking extremely ill, and apparently half imbecile for a week or two past, he had suddenly fallen down unconscious in the street a few hours before I saw him. He remained deeply comatose, and died the next morning; no post mortem could be obtained.
The true neuralgias in which syphilis only plays the part of secondary factor, and which have been referred to in Part I. of this work, may depend for their exciting cause on local syphilitic processes, affecting either the peripheral distribution, the main trunk or the central origin of a sensory nerve; but I have pointed out the fact that, whatever the reason may be, syphilis does but rarely attack the central portions of individual sensory nerves, in comparison, with the frequency with which it attacks individual motor (cranial) nerves. But without any neuralgic predisposition at all, and without any limitation of the syphilitic process to a particular sensory nerve, the latter may become neuralgic in consequence of being involved in extensive intracranial or intra-spinal syphilitic mischief. The trigeminus is liable to suffer in this way from spreading syphilitic processes about the base of the brain; and my own impression is, that the cause of the neuralgic pain in some such cases is the extension of the mischief to the vertebral artery of the affected side, leading to interfering with the nutrition of the trigeminal nucleus in the medulla. A very interesting case is reported by Dr. Hughlings Jackson (who has done so much to acquaint us with syphilitic affections of cerebral arteries) in vol. iv. of the "London Hospital Reports," pp. 318-321. The patient was a woman, aged twenty-seven, and the initial symptoms of the malady which destroyed her life were violent trigeminal neuralgic pains on the right side: subsequently she had complete paralysis of the fifth, and of the sixth, seventh, and eighth nerves of the right side. After death the right vertebral artery was found engaged in the mass of syphilitic deposit; it must be added, however, that the (superficial) origin of the fifth nerve was itself softened, opposite the pons. Another mode in which syphilitic disease very probably causes neuralgia of the fifth, in a certain number of cases, is by injuring the Gasserian ganglion, upon the integrity of which (according to Waller's general law concerning the ganglia of posterior nerve-roots) the nutrition of the sensory root of the trigeminus materially depends. I have seen an example (as I cannot but suppose) of this sequence of morbid events; the evidence appears sufficiently complete, although I was unable to obtain a post mortem examination:
W. M., a house painter, of extremely dissipated habits, but who had never suffered either from distinct symptoms of alcoholism, nor from any affection traceable to lead-poisoning. In March, 1867, he applied to me on account of neuralgic pain, affecting chiefly the right eyeball, but also darting along the course of the frontal nerve of that side; after a short time it extended also into the infra-orbital nerves. He bore several scars of tertiary ulcers about the nose and forehead, and made no secret of having suffered from chancre six or seven years before, and from subsequent secondary and tertiary symptoms. I was consequently not at all surprised at his developing severe iritis (right) after he had been a fortnight under my care, although I had from the first given large doses of iodide of potassium; but I was not prepared for the extensive processes of destruction which followed, notwithstanding that I immediately commenced mercurial treatment, and applied atropine. I remarked that while the inflammation of the iris proceeded with great violence, the cornea was also much more severely affected than is usually the case in syphilitic iritis; in fact, the changes closely resembled those which have been noted after section of the fifth at the Gasserian ganglion, and at the date of the patient's death (seventeen days from the commencement of the iritis) a corneal ulcer was on the point of perforating. For the first three or four days after the iritis set in, the neuralgic pains went on augmenting in intensity, and extended into all three divisions of the fifth; there was a copious discharge from the right nostril. Almost suddenly, on the fourth day, the pains abated and then ceased, and it was now evident that the whole surface of the right half of the face was completely anæsthetic. Two days later a dark-red patch appeared on the cheek, and in the course of the next two days this ulcerated, the ulcer presenting a somewhat livid appearance, and exuding a sanious discharge; at the same time, superficial ulcers appeared on the right side of the tongue, and coalesced to form one large sore. The sores both on cheek and tongue assumed more and more a gangrenous appearance, and on the sixteenth day from the commencement of iritis there was considerable loss of substance in both these situations. On the evening of this day (the patient having become extremely depressed and much emaciated) general epileptiform convulsions set in, and followed each other rapidly; in a few hours coma supervened, and the patient sank the next day. No post mortem could be obtained; but it seems extremely probable, from the above history, that the Gasserian ganglion was early involved in the syphilitic inflammation, and that the neuralgia and subsequent anæsthesia, the iritis, and the other trophic lesions, were due to the injury inflicted upon it.
The treatment of syphilitic pains will, in doubtful cases, often give us valuable assurance of the correctness of our diagnosis. Where the disease is extensively diffused, we may fail to do any good; but, in cases where the syphilitic mischief is limited to a small portion of the meninges, we may often arrest it. In all merely suspicious cases, where the pain is thus limited, it will be well to use iodide of potassium tentatively—forty to sixty grains daily. But, where the pains are very severe and continuous, and there is danger to the integrity of the eye, or threatenings of a paralytic attack are observed, it is better not to trust to anything short of mercury, used in such a manner as just to stop short of absolute ptyalism. In very bad cases, like the last one narrated, we may fail to produce any good effect, but, where the specific treatment is commenced in good time, we may not unfrequently succeed in arresting the symptoms with a rapidity that assures us of the correctness of the diagnosis of syphilis.