The most satisfactory way of approaching this subject is, however, to study the important symptoms in severalty, rather than to attempt to group them into recognizable varieties of the disease; and this method I shall here adopt.
Headache is the most constant and usually the earliest symptom of meningeal syphilis; but it may be absent, especially when the lesion is located in the reflexions of the meninges which dip into the ventricles, or when the basal gumma is small and not surrounded with much inflammation. The length of time it may continue without the development of other distinct symptoms is remarkable. In one case39 at the University Dispensary the patient affirmed that he had had it for four years before other causes of complaint appeared. It sometimes disappears when other manifestations develop. It varies almost indefinitely in its type, but is, except in very rare cases, at least so far paroxysmal as to be subject to pronounced exacerbations. In most instances it is entirely paroxysmal; and a curious circumstance is, that very often these paroxysms may occur only at long intervals: such distant paroxysms are usually very severe, and are often accompanied by dizziness, sick stomach, partial unconsciousness, or even by more marked congestive symptoms. The pain may seem to fill the whole cranium, may be located in a cerebral region, or fixed in a very limited spot. Heubner asserts that when this headache can be localized it is generally made distinctly worse by pressure at certain points, but my own experience is hardly in accord with this. Any such soreness plainly cannot directly depend upon the cerebral lesion, but must be a reflex phenomenon or due to a neuritis. According to my own experience, localized soreness indicates an affection of the bone or of its periosteum. In many cases, especially when the headache is persistent, there are distinct nocturnal exacerbations.
39 Book Y., p. 88, 1879.
It will be seen that there is nothing absolutely characteristic in the headache of cerebral syphilis; but excessive persistency, apparent causelessness, and a tendency to nocturnal exacerbation should in any cephalalgia excite suspicion of a specific origin—a suspicion which is always to be increased by the occurrence of slight spells of giddiness or by delirious mental wandering accompanying the paroxysms of pain. When an acute inflammatory attack supervenes upon a specific meningeal disease it is usually ushered in by a headache of intolerable severity.
When the headache in any case is habitually very constant and severe, the disease is probably in the dura mater or periosteum; and this probability is much increased if the pain be local and augmented by firm, hard pressure upon the skull over the seat of the pain.
Disorders of Sleep.—There are two antagonistic disorders of sleep, either of which may occur in cerebral syphilis, but which have only been present in a small proportion of the cases that I have seen. Insomnia is more apt to be troublesome in the prodromic than in the later stages, and is only of significance when combined with other more characteristic symptoms. A peculiar somnolence is of much more determinate import. It is not pathognomonic of cerebral syphilis, yet of all the single phenomena of this disease it is the most characteristic. Its absence is of no import in the theory of an individual case.
As I have seen it, it occurs in two forms: In the one variety the patient sits all day long or lies in bed in a state of semi-stupor, indifferent to everything, but capable of being aroused, answering questions slowly, imperfectly, and without complaint, but in an instant dropping off again into his quietude. In the other variety the sufferer may still be able to work, but often falls asleep while at his tasks, and especially toward evening has an irresistible desire to slumber, which leads him to pass, it may be, half of his time in sleep. This state of partial sleep may precede that of the more continuous stupor, or may pass off when an attack of hemiplegia seems to divert the symptoms. The mental phenomena in the more severe cases of somnolency are peculiar. The patient can be aroused—indeed in many instances he exists in a state of torpor rather than of sleep; when stirred up he thinks with extreme slowness, and may appear to have a form of aphasia; yet at intervals he may be endowed with a peculiar automatic activity, especially at night. Getting out of bed; wandering aimlessly and seemingly without knowledge of where he is, and unable to find his own bed; passing his excretions in a corner of the room or in other similar place, not because he is unable to control his bladder and bowels, but because he believes that he is in a proper place for such act,—he seems a restless nocturnal automaton rather than a man. In some cases the somnolent patient lies in a perpetual stupor.
An important fact in connection with the somnolence is that it may develop suddenly without marked premonition. Thus in a case reported by J. A. Ormerod40 a man who had been in good health, save only for headache, awoke one morning in a semi-delirious condition, and for three days slept steadily, only arousing for meals; after this there was impairment of memory and mental faculties, but no more marked symptoms.
40 Brain, vol. v. 260.
Apathy and indifference are the characteristics of the somnolent state, yet the patient will sometimes show excessive irritability when aroused, and will at other periods complain bitterly of pain in his head, or will groan as though suffering severely in the midst of his stupor—at a time, too, when he is not able to recognize the seat of the pain. I have seen a man with a vacant, apathetic face, almost complete aphasia, persistent heaviness and stupor, arouse himself when the stir in the ward told him that the attending physician was present, and come forward in a dazed, highly pathetic manner, by signs and broken utterances begging for something to relieve his head. Heubner speaks of cases in which the irritability was such that the patient fought vigorously when aroused; this I have not seen.