On microscopic examination the most characteristic structures are small cells, such as are found in gummatous tumors in other portions of the body. These cells are most abundant in the inner zone, which, indeed, may be entirely composed of them. In the centre of the tumor they are more or less granular and atrophied; in some cases the caseous degeneration has progressed so far that the centre of the gumma consists of minute acicular crystals of fat. In the external or peripheral zone of the tumor the mass may pass imperceptibly into the normal nerve tissue, and under these circumstances it is that it contains the spider-shaped cells or stellate bodies described by Jastrowitch, and especially commented upon by Charcot and Gombault and by Coyne. These are large cells containing an exaggerated nucleus and a granular protoplasm, which continues into multiple, branching, rigid, refracting prolongations, which prolongations are scarcely stained by carmine. Alongside of these cells other largish cells are often found without prolongations, but furnished with oval nuclei and granular protoplasm. Amongst these cells will be seen the true gummatous cells, as well as the more or less altered neuroglia and nerve-elements. In the perivascular lymphatic sheaths in the outer part of the gumma is usually a great abundance of small cells. The spider-shaped cells are probably hypertrophied normal cells of the neuroglia, and have been considered by Charcot and Gombault as characteristic of syphilitic gummata of the brain. In a solitary gumma, however, of considerable size from the neighborhood of the cerebellum, studied by Coyne and Peltier, there were no stellated cells. Coyne considers that their presence is due to their previous existence in the normal state of the regions affected by the gumma. Exactly what becomes of syphilitic gumma of the brain in cases of recovery it is difficult to determine. It is certain that they become softened and disappear more or less completely, and it is probable that the cicatrices or the small peripheral cysts which are not rarely found in the surfaces of the brain are sometimes remnants of gummatous tumors. In a number of cases collected by Gros and Lancereaux there were small areas of softened tissue or small calcareous and caseous masses or cerebral lacunæ corresponding to the cicatrices of softening or imperfect cysts, coincident with evidences of syphilis elsewhere. V. Cornil also states that he has found small areas of softening with well-established syphilitic lesions of the dura mater and cranium, but believes that the lacunæ or cysts depend rather upon chronic syphilitic lesions of cerebral arteries than upon gummatous inflammation.
When a gummatous tumor comes in contact with an artery, the latter is usually compressed and its walls undergo degeneration. The specific arteritis may pass beyond the limit of the syphilome and extend along the arterial wall. Not rarely there is under these circumstances a thrombus, and if the artery be a large one secondary softening of its distributive brain-area occurs.
TREATMENT.—The treatment of cerebral syphilis is best studied under two heads: First, the treatment of the accidents which occur in the course of the disease; second, the general treatment of the disease itself.
It must be remembered that in the great majority of cases in which death occurs in properly-treated cerebral syphilis the fatal result is produced by an exacerbation—or, as I have termed it, an accident—of the disease. Under these circumstances the treatment should be that which is adapted to the relief of the same acute affection when dependent upon other than specific cause. In a large proportion of cases the acute outbreak takes the form either of a meningitis or else of a brain congestion. In either instance when the symptoms are severe free bleeding should be at once resorted to. The amount of blood taken is of course to be proportionate to the severity of the symptoms and the strength of the patient. I have seen life saved by the abstraction of about a quart of blood, whilst in other cases a few ounces suffice. Care must be, of course, taken not to mistake a simple epileptic fit for a severe cerebral attack; but when this fit has been preceded by severe headache and is accompanied by stupor, with marked disturbance of the respiration, measures for immediate relief are usually required; and if the convulsions be perpetually repeated or if there be violent delirious excitement, the symptoms may be considered as very urgent. In taking blood the orifice should be large, so as to favor a rapid flow, and the bleeding be continued until a distinct impression is made upon the pulse. In some cases which I have seen in which the action of the heart continued to be violent after as much blood as was deemed prudent had been taken, good results were obtained by the hypodermic injection of three drops of the tincture of aconite-root every half hour until the reduction of the pulse and the free sweating indicated that the system was coming under the influence of the cardiac sedative.
Of course, I do not mean to encourage the improper or too free use of the lancet in these cases, but in the few fatal cases which I have seen I have almost invariably regretted that blood had not been taken at once very freely at the beginning of the acute attack. In most of these cases the symptoms had progressed too far for good to be achieved before I reached the patient. After venesection, or in feeble cases as a substitute for it, the usual measures of relief in cerebral congestion should be instituted. I shall not occupy space with a discussion of these measures, as they are in no way different from those to be employed in cases not syphilitic.
The most important part of the treatment of cerebral syphilis itself is antisyphilitic, and the practitioner is at once forced to select between the iodide of potassium and the mercurial preparations. In such choice it must be remembered that even a very small amount of syphilitic deposit in the brain may at any time cause a sudden congestion or other acute attack, and is therefore a very dangerous lesion. I have seen a cerebral syphilis which was manifested only by an epileptic attack occurring once in many months, and in which after death the affected membrane was found to be not larger than a quarter of a dollar, and the deposit not more than an eighth of an inch in thickness, suddenly produce a rapidly fatal congestion; and I have known a case fast progressing toward recovery suddenly ended by the too long continuance of the arrest of respiration during an epileptic fit. I have, myself, no doubt of the superiority of the mercurials over the iodide of potassium as a means of producing absorption of gummatous exudates; and as these exudates in the brain are so very dangerous, a mercurial course should in the majority of cases of cerebral syphilis be instituted so soon as the patient comes under the practitioner's care. When, however, there is a history of a recent prolonged free use of the mercurial, or when there is marked specific cachexia, the iodide should be chosen. Cachexia is, however, a distinctly rare condition in cerebral syphilis, the disease usually developing in those who have long had apparent immunity from the constitutional disorder. In my opinion the best preparation of the mercurial for internal use is calomel. It should be given in small doses, one-quarter of one grain every two hours, guarded with opium and astringents, so as to prevent as far as possible disturbance of the bowels, and should be continued until soreness of the teeth, sponginess of the gums, or other evidences of commencing ptyalism are induced. After this the dose of the mercurial should be so reduced as simply to maintain the slight impression which has been created, and the patient should be kept under the mercurial influence for some weeks.
A very effective method of using the mercury is by inunction, and where the surroundings of the patient are suitable the mercurial ointment may be substituted for the calomel. It should be applied regularly, according to the method laid down in my treatise on therapeutics. I have sometimes gained advantage by practising the mercurial unction and at the same time giving large doses of iodide of potassium internally.
After a mercurial course the iodide of potassium should always be exhibited freely, the object being not only to overcome the natural disease, but also to bring about the complete elimination of the mercury from the system. There is no use in giving the iodide in small doses; at least a drachm and a half should be administered in the twenty-four hours, and my own custom has been to increase this to three drachms unless evidences of iodism are produced. The compound syrup of sarsaparilla covers the disagreeable taste of the iodide of potassium better than any other substance of which I have knowledge. Moreover, I am well convinced that there is some truth in the old belief that the so-called “Woods” are of value in the treatment of chronic syphilis. I have seen cases in which both the iodide of potassium and the mercurials had failed to bring about the desired relief, but in which the same alteratives, when given along with the “Woods,” rapidly produced favorable results. The old-fashioned Zittmann's decoction, made according to the formula of the United States Dispensatory, may be occasionally used with very excellent effect. But I have gradually come into the habit of substituting a mixture of the compound fluid extract and the compound syrup of sarsaparilla in equal proportions. The syrup itself is too feeble to have any influence upon the system, but is here employed on account of its flavor. A favorite method of administration is to furnish the patient with two bottles—one containing a watery solution of the iodide of potassium of such strength that two drops represent one grain of the drug, and the other the sarsaparilla mixture above mentioned. From one to two drachms of the solution of the iodide may be administered in a tablespoonful of the sarsaparilla well diluted after meals. When the patient has been previously mercurialized, or there is any doubt as to the propriety of using mercurials, corrosive sublimate in small doses may be added to the solution of the iodide, so that one-tenth to one-fifteenth of a grain shall be given in each dose. I have never seen especial advantage obtained by the use of the iodides of mercury. They are no doubt effective, but are not superior to the simpler forms of the drug.
Syphilitic Disease of the Brain-Cortex.
The psychical symptoms which are produced by syphilis are often very pronounced in cases in which the paralysis, headache, epilepsy, and other palpable manifestations show the presence of gross brain lesions. In the study of syphilitic disease of the brain-membranes sufficient has been said in regard to these psychical disturbances, but the problem which now offers itself for solution is as to the existence or non-existence of syphilitic insanity—i.e. of an insanity produced by specific contagion without the obvious presence of gummatous disease of the brain-membranes. Very few alienists recognize the existence of a distinct affection entitled to be called syphilitic insanity, and there are some who deny that insanity is ever directly caused by syphilis. It is certain that insanity often occurs in the syphilitic, but syphilis is abundantly joined with alcoholism, poverty, mental distress, physical ruin, and various depressing emotions and conditions which are well known to be active exciting causes of mental disorder. It may well be that syphilis is in such way an indirect cause of an insanity which under the circumstances could not be properly styled syphilitic.