That the attacks of syphilitic insanity, like the palsies of syphilis, may at times be temporary and fugitive, is shown by a curious case reported by H. Hayes Newington,59 in which, along with headache, failure of memory, and ptosis in a syphilitic person, there was a brief paroxysm of noisy insanity.
59 Journ. Ment. Sci., London, xix. 555.
DIAGNOSIS.—In a diagnosis of cerebral syphilis a correct history of the antecedents of the patients is of vital importance. Since very few of the first manifestations of the disorder are absolutely characteristic, whilst almost any conceivable cerebral symptoms may arise from syphilitic disease, treatment should be at once instituted on the appearance of any disturbance of the cerebral functions in an infected person.
Very frequently the history of the case is defective, and not rarely actually misleading. Patients often appear to have no suspicion of the nature of their complaint, and will deny the possibility of syphilis, although they confess to habitual unchastity. My own inquiries have been so often misleading in their results that I attach but little weight to the statements of the patient, and in private practice avoid asking questions which might recall unpleasant memories, depending upon the symptoms themselves for the diagnosis.
The general grounds of diagnosis have been sufficiently mapped out in the last section, but some reiteration may be allowable. After the exclusion of other non-specific disease, headache occurring with any form of ocular palsy or with a history of attack of partial monoplegia or hemiplegia, vertigo, petit mal, epileptoid convulsions, or disturbances of consciousness, or attacks of unilateral or localized spasms, should lead to the practical therapeutic test. Ocular palsies, epileptic forms of attacks occurring after thirty years of age, morbid somnolence, even when existing alone, are sufficient to put the practitioner upon his guard. It is sometimes of vital importance that the nature of the cephalalgia shall be recognized before the coming on of more serious symptoms; any apparent causelessness, severity, and persistency should arouse suspicion, to be much increased by a tendency to nocturnal exacerbations or by the occurrence of mental disturbance or of giddiness at the crises of the paroxysms. Not rarely there are very early in these cases curious, almost indefinable, disturbances of cerebral functions, which may be easily overlooked, such as temporary and partial failures of memory, word-stumbling, fleeting feelings of numbness or weakness, alterations of disposition. In the absence of hysteria an indefinite and apparently disconnected series of nerve accidents is of very urgent import. To use the words of Hughlings-Jackson, “A random association or a random succession of nervous symptoms is very strong warrant for a diagnosis of a syphilitic disease of the nervous system.” Cerebral syphilis occurring in an hysterical subject may be readily overlooked until fatal mischief is done. When any paralysis occurs a study of the reflexes may sometimes lead to a correct diagnosis. Thus in a hemiplegia the reflex on the affected side in cerebral syphilis is very frequently exaggerated, whilst in hysteria the reflexes are usually alike on both sides. When both motion and sensation are disturbed in an organic hemiplegia, the anæsthesia and motor paralysis occur on the same side of the body, whilst in hysteria they are usually on opposite sides.
In all cases of doubtful diagnosis the so-called therapeutic test should be employed, and if sixty grains of iodide of potassium per day fail to produce iodism, for all practical purposes the person may be considered to be a syphilitic. No less an authority than Seguin has denied the validity of this, but I believe, myself, that some of his reported cases were suffering from unsuspected syphilis. I do not deny that there are rare individuals who, although untainted, can resist the action of iodide, but in ten years' practice in large hospitals, embracing probably some thousands of cases, I have not met with more than one or two instances which I believed to be of such character. Of course in making these statements I leave out of sight persons who have by long custom become accustomed to the use of the iodide, for although in most cases such use begets increase of susceptibility, the contrary sometimes occurs. Of course the physician who should publicly assert that a patient who did not respond to the iodide had syphilis would be a great fool, but in my opinion the physician who did not act upon such a basis would be even more culpable.
PROGNOSIS.—Cerebral meningeal syphilis varies so greatly and so unexpectedly in its course that it is very difficult to establish rules for predicting the future in any given case. The general laws of prognosis in brain disease hold to some extent, but may always be favorably modified, and patients apparently at the point of death will frequently recover under treatment. The prognosis is not, however, as absolutely favorable as is sometimes believed, and especially should patients be warned of the probable recurrence of the affection even when the symptoms have entirely disappeared. The only safety after the restoration of health consists in an immediate re-treatment upon the recurrence of the slightest symptom. The occurrence of a complete, sudden hemiplegia or monoplegia is sufficient to render probable the existence of a clot, which must be subject to the same laws as though not secondary to a specific lesion. If a rapid decided rise of temperature occur in an apoplectic or epileptic attack, the prognosis becomes very grave. An epileptic paroxysm very rarely ends fatally, although it has done so in two of my cases.
The prognosis in gummatous cerebral syphilis should always be guardedly favorable. In the great majority of cases a more or less incomplete recovery occurs under appropriate treatment, and I have seen repeatedly patients who were unconscious, with urinary and fecal incontinence, and apparently dying, recover. Nevertheless, so long as there is any particle of gummatous inflammation in the membrane the patient is liable to sudden congestions of the brain, which may prove rapidly fatal, or he may die in a brief epileptic fit. On the one hand there is an element of uncertainty in the most favorable case, and on the other so long as there is life a positively hopeless prognosis is not justifiable.
PATHOLOGY.—Gummatous inflammation of the brain probably always has its starting-point in the brain-membranes, although it may be situated within the brain: thus, I have seen the gummatous tumors spring from the velum interpositum in the lateral ventricle. The disease most usually attacks the base of the brain, and is especially found in the neighborhood of the pons Varolii and the optic tract. It may, however, locate itself upon the vault of the cranium, and in my experience has seemed to prefer the anterior or motor regions. The mass may be well defined and roundish, but more usually it is spread out, irregular in shape, and more or less confluent with the substance of the brain beneath it. It varies in size from a line to several inches in length, and when small is prone to be multiple. The only lesion which it resembles in gross appearance is tubercle, from which it sometimes cannot be certainly distinguished without microscopic examination.
The large gummata have not rarely two distinct zones, the inner one of which is drier, somewhat yellowish in color, opaque, and resembles the region of caseous degeneration in the tubercle. The outer zone is more pinkish and more vascular, and is semi-translucent.