Lettsomian Lectures on Syphilis as a Cause of Disease of the Nervous System
Authors: W. H. Broadbent
Journal: BMJ (1874)

Syphilitic Disease oft/e Ceroebool Memizbrozes.-The cases in which the membranes are more gravely affected, and the grey matter of the surface invadced or insvolved, or deprived of blood, present an inexhaustible v-ariety of symiiptoms, from different combinations and successions of con- vulsive and paralytic affections and intellectual derangements.Speak- ing generally, paralysis of cranial nerves and of the limbs, gradual in their mode of access, are characteristic of disease about the base of the brain ; convulsions and mental affections of disease on the convex sur- face of the hemisphere.No strict line of demarcation can be drawn between the cases in which there is extensive exudation in the membranes, and those in which the morbid process results in the formation of distinct tumours.In the -former, the deposit frequently here and there takes the form of a nodule, which projects into the brain-substance, and a syphiloma is accompanied by, or sets up, changes in the adjacent part of the meninges.I shall not, therefore, attempt to lay down distinctions between difflsed and localised syphilitic exudations, but, in the brief comments I may make on the cases, show how I have come to my conclusions as to the seat andl character of the lesion.The cases I give first will be illustrations of disease in the membranes about the base of the brain.CASE I. James A., aged 58, a tinman, of drunken habits, was ad- mitted into St.Mary's Hospital, under Mr. Spencer Smith, December 12, I870.He had had some venereal affection twenty years before; had suffered from ulcerated sore throat two or three times since, but not from cutaneous eruiptions.Eighteen months before admission, he had fallen and struck his head.After this, a swelling appeared, which, after nine months, w,as opened.There was a large discharge of pus, and the wound healed in five wveeks.While the abscess was forming, he had a fit, which came on suddenly, while he was sitting by the fire; he was convulsed and unconscious, stupid during the night, and quite well next morning.Tw-o months before admission, pain came on in the right side of the head, more at the back than in the forehead ; at the same time the eyelid dropped, and soon afterwards numbness and weakness of the left arm came on.The pain in the head continued.When he came under my observation, there was complete ptosis of the right eyelid, and the only movement of the eye was a slight up-and-down motionl; it could not be carried laterally in either direction.The eye -wra fixed in the median plane; the pupil was about the same size as in the other eye, sluggish in responding to light, and apparently more ready to act on the other eye being opened and closed, than when light was admitted to it.When both eyes were open, by the right lid being raised, there wvas double vision.There was no obvious facial inequality; he could whistle, and show the upper teeth well.A very little deviation of the tongue to the left was observed.Sensation was diminished on the left side of the face, and in the left arm, side, and leg, and the left limbs w-ere decidedly weakened, without being absolutely paralysed.Pulse, 50.lIe lay in bed, taking no notice, unless compelled by questions; the expression was that of suffering, and he moaned from time to time ; the face was flushed.He passed urine naturally; the bowels were confined.A depression could be felt near the posterior end of the sagittal suture, where the abscess had been situated.Leeches were applied to the temple.Iodide of potassium and bichloride of mercury were given, and he gradually recovered, except that paralysis of the right external rectus, supplied by the sixth nerve, persisted.Here, with complete paralysis of the right third and sixth, and pro- bably fourth, nerves, and partial motor and sensory paralysis of the entire opposite half of the body, there could be no doubt as to the seat of the lesion.It could only be at the base of the brain, round the right crus cerebri, involving the nerves of this side in the intracranial part of their course, and affecting the crus, which here contains the fibres, sensory and motor, of the entire opposite half of the body.The character of the morbid change was, with almost equal certainty, syplhilitic inflammation, attended with gummatous deposit in the pia mater.