SYPHILITIC EXUDATIONS INTO THE MENINGES 749 The prognosis, as to recovery, is bad, but death is usually due to some other disease. Occasionally the disease is arrested, and although there are deforming contractures, the patient may live for years. Treatment. In addition to potassium iodide, we may employ counterirritation and vibration to the diseased portion of the spine. SYPHILIS OF THE NERVOUS SYSTEM Nervous derangements due to syphilis often present a most serious aspect, but generally respond readily to specific treatment. The inflammatory process uusally begins in the blood vessels, and extends from there to the meninges and connective tissue structures of the brain and cord. Inflammatory syphilitic disease of the nervous system may be classed as cerebral, spinal, cerebrospinal, and syphilis of the peripheral nerves. Cerebral syphilis includes syphilitic endarteritis, syphilitic meningoencephalitis, syphilitic deposits in the brain itself (gummata), and hereditary syphilis. SYPHILITIC ENDARTERITIS Syphilitic endarteritis is one of the simplest forms of brain syphilis. It results in anæmia and malnutrition of those parts nourished by the vessels involved or in thrombosis and hence softening. Symptoms. We observe symptoms of neurasthenia, anæmia, etc., as we should from endarteritis due to other causes. The most characteristic symptoms, however, are temporary attacks of aphasia, paralysis, hemianopsia, weakness, double vision, vertigo, delirium, headache, etc. think from such symptoms that an apoplexy is imminent, but the process seldom advances to this degree. We The prognosis should be guarded, for if the process has gone on to thrombosis, the cure by antisyphilitic treatment is not complete. The treatment should be vigorous. Mercurial inunctions should be given to the point of salivation. They should be preceded by a hot bath. and an alcohol sponge to remove all grease and aid absorption. Potassium iodide in large doses should be given, beginning with gtt. xx of a saturated solution and increasing up to xl t. i. d. In extreme cases 500 grains may be given in a day. SYPHILITIC TOXÆMIA In this form there may be the general symptoms of neurasthenia, with insomnia and headache. The latter is worse at night. In ordinary neurasthenia the patient feels worse in the morning. In the cases due to a poisoning with syphilis the patient feels worse at night. The treatment is as above stated. SYPHILITIC EXUDATIONS INTO THE MENINGES These exudations are likely to occur in the lowest portions of the cranial cavity or at places of least resistance, as at the base of the brain, at the crura, at the sides of the pons, or in the medulla. The disease may affect the cranial nerves. It occurs in from one to two years after the chancre, or it may occur later. The exudation may gather in a short time, so that the symptoms may develop rapidly. The cortex may be covered by this exudate, creating localized spasms, hallucinations, and supersensitiveness to light (photophobia). These irritation symptoms may be followed by paralysis. There are also headache (which is worse at night), insomnia, irritability of temper, dulness (especially in the morning), restlessness, vertigo, fulness of the head, throbbing in the head, and vomiting, which is sometimes projectile and has no relation to the ingestion of food. As to the localization of the exudate, there may be involvements of the cranial nerves, especially the third, sixth, seventh, and eighth. The fifth is less frequently involved. There may be optic neuritis, aphasia, convulsions, apoplexy, increased thirst and hunger from disturbance of the frontal lobes, polyuria, etc. The symptoms, in fact, may be those of a tumor of the brain, and we can distinguish them sometimes only by the greater rapidity of development of symptoms in syphilitic cases. Antisyphilitic treatment will surely show the difference. OTHER SYPHILITIC CONDITIONS Syphilitic Deposits in the Brain.-There may be small areas of softening or sclerosis-a diffuse syphilitic softening. The symptoms are those of general paresis. The diagnosis is impossible except by trying antisyphilitic treatment (therapeutic test). Gummata of the brain give rise to the same symptoms as tumors, and can be distinguished only by antisyphilitic treatment. Hereditary syphilis of the brain causes faulty development, cerebral atrophy, or cerebrospinal sclerosis. Look for other signs of syphilis. Spinal Syphilis.-There may be the same pathological changes here as in the cerebrum, such as gummata attached to the meninges, arteritis with. secondary softening, meningitis with secondary cord changes, or sclerosis developing late in the disease. The symptoms are extremely varied. Cerebrospinal syphilis gives rise to the symptoms of both brain and cord disease. Syphilis of the Peripheral Nerves.-It is quite rare that syphilis attacks the peripheral nerves, but we occasionally see cases of nerve irritation and compression due to a syphilitic exudate. There is said to be a form of multiple neuritis produced by syphilis. In cerebral and spinal syphilis the nerve roots may be attacked, causing a radical neuritis. Treatment. In general, as regards treatment, we should always try antisyphilitic drugs in the nervous diseases of obscure origin, as from time to time we are unable to get a history of a primary lesion. INJURIES TO THE BRAIN 751 MISCELLANEOUS LESIONS IN THE BRAIN AND SPINAL CORD, SUCH AS CONTUSION, LACERATION, CONCUSSION, COMPRESSION, HÆMORRHAGE, TUMORS, CYSTS, ABSCESS, SINUS THROMBOSIS, AND PARASITES In this group of lesions we usually observe pressure symptoms, and localization is of practical importance on account of the possibility of surgical aid, which might be indicated except in syphilitic gummata. INJURIES TO THE BRAIN CONTUSION AND LACERATION By contusion and laceration of the brain an injury is meant which is severe enough to cause symptoms due to the contusion or laceration or to be followed by grave symptoms independent of those caused by concussion. The same injuries that occur in other parts of the body may occur here. In addition, peculiar injuries may take place, owing to the nature of the hard bony covering, the blood supply of the brain and cerebrospinal fluid, by contrecoup and by rupture without external manifestations. Symptoms. We first observe those of concussion, and then, from extravasation of blood, those of compression; and again, there may be no symptoms of compression. In laceration of the cortex, according to the location and degree of injury, there may be spasms or rigidity of the muscles whose centres are involved, with more or less paralysis. There may be no evidence of a laceration having taken place until after four or five days, or even later, when there may appear convulsions or rigidity of muscles. These later symptomatic manifestations are due to vascular changes, probably in the nature of a spreading oedema or posttraumatic hæmorrhage. There may also appear, frequently within a few hours, mental symptoms supposed to be due to cerebral irritation. The patient lies on his side, curled up in bed, with the limbs flexed and the back curved forward. The eyelids are kept closed, and although sometimes the patient may be induced to use a bed pan, he usually exercises no control over the sphincters. The pupils are contracted and react to light. The pulse is slow and weak, and the temperature is normal or subnormal. But the most characteristic feature is an intense irritability of temper, a lack of control. The patient seems to wish to lie undisturbed, and if efforts are persistent to rouse him, he may get excited and use strong and even blasphemous and abusive language. It may be necessary to offer him food in order to have him take sufficient nourishment. These mental symptoms gradually disappear in from one to three weeks. The mind may be affected for some time afterward in some cases, and in some it is permanently affected. One may have no remembrance of this mental condition after recovery, or it may remain a hazy recollection. Diagnosis. It is often impossible to ascertain the extent of contusion or laceration immediately after an injury. The advent of convulsions, rigidity, or paralysis of groups of muscles, from the second to the fifth day, points strongly to contusion. It is stated that oedema of the optic nerve or of the retina is often present in these cases, but absent in pure concussion. Prognosis. This depends principally upon the extent of the injury and upon the entrance of infection. Edema or hæmorrhage may take place and cause death from spreading, which it tends to do. If microorganisms lodge in the bruised brain tissue, death may result from acute encephalitis. Or the purulent process may remain localized and result in an abscess. The spreading oedema may cause a gradual necrosis (yellow softening), which is limited by the amount of vascular disturbance. Remote changes, such as the formation of a cyst from the lacerated tissue and extravasated blood, may take place. Scar tissue may result, irritating the adjacent tissue, and if situated in the motor area, may give rise to Jacksonian epilepsy. If an extensive growth of fibrous tissue results at the seat of the injury (sclerosis) and spreads, it may disturb the brain functions. A descending degeneration takes place, extending down the pyramidal tracts into the spinal cord, in all cases where the cortex in the motor area is lacerated. Treatment. As it may be several days before we can determine whether contusion or laceration has taken place, our treatment is largely expectant. The patient should be kept absolutely quiet, the head shaved, and ice bags or Leiter's coil applied. Should extravasated blood give signs of compression, trephining is indicated, and should abscess develop, we should aim to find its location and drain the pus cavity. MENINGEAL HÆMORRHAGE Blood may accumulate between the dura mater and the skull or between the dura and pia mater. Hæmorrhage between the Dura Mater and the Skull Etiology. This is generally due to injury, either from a fracture or from concussion which separates the dura from the bone and tears the middle meningeal artery. Symptoms. We observe first those of shock, then those of compression, and then those of meningitis. The diagnosis is very important from a medicolegal standpoint (see chapter on Coma). The treatment is surgical. Hæmorrhage between the Dura Mater and the Pia Mater Etiology.-1. Traumatism; 2. Thrombosis of the venous sinuses; 3. Chronic hæmorrhagic pachymeningitis; 4. Rupture of an aneurysm of one of the cerebral arteries; 5. After convulsions in children; 6. Hæmorrhagic diseases. Under traumata are included the injuries to the new-born from pressure during delivery, as the result of severe labor or from forceps. We find the hæmorrhage at different points, as at the base of the brain, at the convexity, or equally distributed. Cerebral hemorrhage may make its CONCUSSION OF THE BRAIN 753 way to the cortex or through the fourth ventricle, to appear between the membranes. Symptoms. These differ according to the situation. If there is a large clot over one cortex, there are sudden coma, stertorous breathing, slow pulse, and abolition of all reflexes. The paralysis may be a hemiplegia or a monoplegia. The paralysis is preceded by twitching of the muscles, which later become paralyzed. At first the temperature falls, even to 96°, but later may rise to 105° or higher. The condition may improve and recovery takes place if the clot is small. Otherwise the patient dies in coma or with symptoms of meningitis. If the clot is small, coma may be absent, but the symptoms of meningitis may develop. If there are clots over both hemispheres, there are sudden coma and general convulsions. The diagnosis may be difficult in these cases. If the clots form at the base of the brain, pressure of the medulla, the centre for the vital functions, may cause death in a few hours. Frequently the pressure here causes high temperature. In the new-born, after a difficult labor, the child may be born dead. It may be deeply asphyxiated and die soon, or recover to go into coma and convulsions and die in a few days. If it recovers, it may have paralyses, sometimes with athetosis, mental defects, and epilepsy. Cerebral atrophy may occur. The prognosis is bad except in those cases where the clot is small. If the patient recovers, there may be paralysis and convulsive movements. In the fatal cases death usually ensues earlier than in cases of cerebral hæmorrhage. CONCUSSION OF THE BRAIN By this term we mean the condition into which a person is thrown after a blow upon the head. This may result from one blow or a succession of blows upon the head or from a blow transmitted through the vertebral column. Pathology. There are only theories concerning the true pathological conditions. One is that there are multiple minute hæmorrhages, or that the symptoms are due to a vascular disturbance, such as paralysis of brain capillaries with distention and pressure. The Symptoms. These vary according to the severity of the injury. mild cases show merely a loss of consciousness for a few seconds, with arrest of respiration and pallor. Recovery is rapid. In case of severe injury, however, a person may die in a few minutes. The cases coming between these two extremes show the following symptoms: 1. STAGE OF COLLAPSE.-There is sudden loss of consciousness; the patient may be roused by shouting or pricking, or the unconsciousness may be complete; this may last from a few seconds to several days. The pulse is weak and, as a rule, slow. The skin is pale and cold. The respirations are slow, shallow, and sometimes irregular. There is a temporary muscular paralysis, although usually the patient will swallow fluid introduced into the mouth. Pinching or pricking the skin will arouse the patient in all except the severe cases. In mild cases the reflexes are present, but in severe cases all are lost, even the corneal. The pupils are equal, more or less dilated, |