Epilepsy.—Epileptic attacks are a very common symptom of meningeal syphilis, and are of great diagnostic value. The occurrence in an adult of an epileptic attack or of an apoplectic fit, or of a hemiplegia after a history of intense and protracted headache, should always excite grave suspicion.
Before I had read Fournier's work on Nervous Syphilis I taught that an epilepsy appearing after thirty years of age was very rarely, if ever, essential epilepsy, and unless alcoholism, uræmic poison, or other adequate cause could be found was in nine cases out of ten specific; and I therefore quote with satisfaction Fournier's words: “L'épilepsie vraie, ne fait jamais son premier dêbut à l'âge adulte, à l'âge mûr. Si un homme adulte, au dessus de 30, 35, à 40 ans, vient, à être pris pour la première fois d'une crise épileptique, et cela dans la cours d'une bonne santé apparente, il y a, je vous le répète, hui ou neuf chances sur dix pour que cette épilepsie soit d'origine syphilitique.”
Syphilitic epilepsy may occur either in the form of petit mal or of haut mal, and in either case may take on the exact characters and sequence of phenomena which belong to the so-called idiopathic or essential epilepsy. The momentary loss of consciousness of petit mal will usually, however, be found to be associated with attacks in which, although voluntary power is suspended, memory recalls what has happened during the paroxysm—attacks, therefore, which simulate those of hysteria, and which may lead to an error of diagnosis.
Even in the fully-developed type of the convulsions the aura is only rarely present. Its absence is not, however, of diagnostic value, because it is frequently not present in essential epilepsy, and it may be pronounced in the specific disease. It is said that when in an individual case the aura has once appeared the same type or form of approach of the convulsion is thereafter rigidly adhered to. The aura is sometimes bizarre: a severe pain in the foot, a localized cramp, a peculiar sensation, indescribable and unreal in its feeling, may be the first warning of the attack. An aura may affect a special sense. Thus, I have at present a patient whose attacks begin with blindness.
In many, perhaps most, cases of specific convulsions, instead of a paroxysm of essential epilepsy being closely simulated, the movements are in the onset, or more rarely throughout the paroxysm, unilateral; indeed, they may be confined to one extremity. This restriction of movement has been held to be almost characteristic of syphilitic epilepsy, but it is not so. Whatever diagnostic significance such restriction of the convulsion has is simply to indicate that the fit is due to a cortical organic lesion of some kind. Tumors, scleroses, and other organic lesions of the brain-cortex are as prone to cause unilateral or monoplegic epilepsy when they are not specific as when they are due to syphilis.
Sometimes an epilepsy dependent upon a specific lesion implicating the brain-cortex may be replaced by a spasm which is more or less local and is not attended with any loss of consciousness. Thus, in a case now convalescent in the University Hospital, a man aged about thirty-five offered a history of repeated epileptic convulsions, but at the time of his entrance into the hospital, instead of epileptic attacks, there was a painless tic. The spasms, which were clonic and occurred very many times a day, sometimes every five minutes, were very violent, and mostly confined to the left facial nerve distribution. The trigeminus was never affected, but in the severer paroxysms the left hypoglossal and spinal accessory nerves were profoundly implicated in all of their branches. Once, fatal asphyxia from recurrent laryngeal spasm of the glottis was apparently averted only by the free inhalation of the nitrite of amyl. The sole other symptom was headache, but the specific history was clear and the effect of antisyphilitic remedies rapid and pronounced.
It is very plain that such attacks as those just detailed are closely allied to epilepsy; indeed, there are cases of cerebral syphilis in which widespread general spasms occur similar to those of a Jacksonian epilepsy, except that consciousness is not lost, because the nervous discharge does not overwhelm the centres which are connected with consciousness.49 On the other hand, these epileptoid spasmodic cases link themselves to those in which the local brain affection manifests itself in contractions or persistent irregular clonic spasms. Contractures may exist and may simulate those of descending degeneration,50 but in my own experience are very rare.51
49 Case, Canada Med. and Surg. Journ., xi. 487.
50 Case, Centralbl. Nerv. Heilk., 1883, p. 1.
51 A case of syphilitic athetosis may be found in Lancet, 1883, ii. 989.