Landon Carter Gray.

A treatise on nervous and mental diseases: for students and practitioners of ... online

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presses upon the patient's head, for fairly cold applications will
answer every purpose of contracting the arterioles, whilst ice appli-
cations may dangerously lower the bodily temperature, and thereby



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THE CERBBRO-SPINAL NERVOUS SYSTEM. 357

seriously decrease the general strength. If there be persistent vomit-
ing, the subnitrate of bismuth, 5 to 10 grains, with ^ or J grain
of codeia, will be found of the most use; or a mustard pmster
applied over the epigastrium from time to time, or pills of ice or
opiates. In case of cardiac weakness, this should be met by a
cardiac stimulant, such as digitalis, camphor, and strophanthus.
Great attention should be paid to the fooa, and this should be of
the blandest and most nourishing character and suited to the age of
the patient. If there is persistent vomiting to such an extent as to
interiere with alimentation, injections should be used.

Bibliography.

Balmer and Frenzd. 1882.

Enut, New York Med. Joura., June 16. 1883.

OQjbes, Brit. Med. Joarn., 1882.

Heron, Lancet, Februar^r 3, 1888.

Jacabi, Keating's Cyclopeedla of the Diseases of Children.

Koch, BerUner kUn. Woch., April 10, 1882.

Uehtheim, Fortechr. d. Med., No. 1.

Pntdden, Lancet, April 14 and June 16, 1883.

Santom, Proceedings of the Royal Society, November, 1882.

Shakespeare, New York Med. Journ., August 9 and 16, 1884.

Smith, Charnley, Brit. Med. Journ.. June, 1883.

OEREBRAIi ABSCESS.

Definition. Cerebral abscess results from suppurative enceph-
alitis.

Etiology. Abscesses are caused by traumata^ caries of the
cranial bones^ nasal disease, intra-cranial tumors, and occur at times
without any assignable cause.

Although marked symptoms may not supervene immediately
upon a trauma, abscess may follow after a lapse of quite a period
of seeming immunity.

Abscess may result from caries of the cranial bones, notably that
of the petrous portion of the temporal bone, more particularly when
it is conjoined with ear disease.

Nasal polypi and caries may cause abscess, the former sometimes
causing disease of the frontal lobe by penetrating the cranial caviiy.

When abscess is caused by intra-cranial tumors, the latter are
always in dose proximity to the former.

Purulent lesions of other organs sometimes coexist with cerebral
abscess, among which may be mentioned ulcerative endocarditis,
pulmonary gangrene, bronchitis, empyema, puerperal fever, typhus,
variola, scarlatina, and measles.

Symptomatology. Only vague symptoms manifest themselves
at first. The child may show a decided malaise, complaining and
being peevish, or marked headache may occur. Delirium usually
succeeds these vague symptoms, or they may give place to hebetube
and coma. The temperature does not usually range high, seldom
going above 101°, and sometimes dropping to 99°. Convulsions
occur in most cases. Vertigo and headache are usually present.
All these symptoms culminate finally in paralysis, hel)etude, and



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858 NSRVOUS DISEASES.

»

coma. To sum up^ the symptoms progress steadily and slowly, and
the individual manifestations will vary according to the location of
the intra-cranial lesion.

Pathology. A localized encephalitis tendine to the formation
of pus is the direct cause of cerebral abscess. A limiting membrane
may or may not surround it. Secondary changes may, of course,
take place in the contiguous cerebral tissue. Except in the pysemic
cases, abscess is genertdly single.

Diagnosis. The gradual onset and variability of the symptoms,
when conjoined with nasal or aural disease, should create a suspicion
of cerebral abscess, or when such symptoms occur as a sequel to some
one of the suppurative or infectious diseases of which a history is ob-
tained, it should be differentiated from cerebral tumor or meningitis.

Tubercular meningitis is a chronic affection, either resulting m>m
an existing tuberculosis or from hei-editary pr^iisposition. Cerebral
abscess has a slow and insidious onset which distinguishes it from
cerebro-spinal meningitis, and in the latter the retraction of head
and abdomen, and the sporadic or epidemic presence of the disease,
differentiate it from the former. As cerebral abscess and suppura-
tive meningitis are oflen coexistent and proceeding from the same
cause, it is not always possible to make the diagnosis.

Cerebral tumor is usually much more chronic than cerebral abscess,
and optic neuritis is occasionally seen in it, never in cerebral abscess.

It will sometimes be possible to make use of the cerebral ther-
mometer, to which I directed attention about twenty years ago. But
it must be remembered that the slight changes of import in rectal
and axillary thermometers are useless in cerebral thermometry, as
here from three to five d^rees are necessary to indicate anydiing
abnormal. (See page 153.)

Prognosis. Cerebral abscess is of very grave prognosis. The
tendency to recovery idiopathically is so slight that an operation
should never be delayed on account of this probability.

Treatment. WTien cerebral abscess is positively diagnosed an
operation should at once be resorted to. Reference is made else-
where in this work to anatomical data that may be used in local-
izing it. ( Vide " Cranial Topography," page 77.) I have diagnosed
two cases of cerebral abscess in the centrum ovale, in spite of the
prevailing opinion that localizing s^inptoms alone cannot be depended
upon for this purpose, and Von Bergmann has located one in the
temporal lobe. The pain which follows percussion upon the skull
may sometimes localize an abscess, but unless this symptom coincided
with others of localizing value, I must confess that I should hesitate
to follow this indication. I have, however, known these symptoms
to conjoin in several instances. The localizing process will be materi-
ally assisted by the use of my cerebral thermometers. Every case
of cerebral abscess should be operated upon, as great relief has often
been the result of surgical interference. Von Bergmann reports a
case where the patient had suffered from a purulent discharge from
the right ear for fifteen years, caused by a cerebral abscess, which
was cured by an operation.



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THE CBREBRO-SPINAL NERVOUS SYSTEM. 359



Bibliography.

Biermer, Vlrchow's Arohlv, Bd. xix„ 1860.

LAert, Virchow'8 Arohlv, Bd. x., 1856.

Uebenneiaterj Vorlesangen Uber die Krankhelten des Nervensystems, 1886.

Jtow, DleeawB of the Nervous System, 1882.

SeetiffmuOer, Lehrbuch der Krankhelten des RUckenmarks and Gehirns, 1887.

Tbynftee, Diseases of the Ear, 1868.

Von Bergmann, Deutsche med. Wochenschrift, December 13, 1888.

SYPHILIS OF THE NERVOUS SYSTEM.

j

I Hlstory. Syphilis seems to have been known first to the Euro-

I pean world about the end of the fifteenth century^ and the earliest writer

I upon its connection with the nervous system is said to have been Leo

Nicenus. Ulrich von Hutten first observed the relation between
syphilis^ apoplexy, and paralysis. Massar first called attention to
syphilitic neuralgias, although Paracelsus had previously described
syphilitic phthisis, diarrhoea, and hydrocephalus. Astruc, in 1740,
spoke of syphilis as a probable cause of circulatory disturbances in
the cranium. Van Swieten, Carrerfe, and Swediaur attributed many
chronic diseases to syphilis ; but, singular to say, so keen-sighted an
observer as Hunter positively stated that no brain or other viscus dis-
eased by syphilis had ever been seen. This was in 1787. The enor-
mous influence of Hunter^s dictum paralyzed observations of this kind
for some time, and the discovery by Morgagni, in 1 779, of gummatous
tumors of the cortex was entirely overlooked, and it was not until
the time of the great Virchow that men uncovered their eyes and
recc^nized the iniport of that which lay before them. In 1854
Gildemeester and Hoyack published a description of occlusion of the
right Sylvian artery by a neighboring syphilitic formation. Then
I b^n a great strife between Robin and Wagner on the one hand,

and Virchow on the other, as to whether these new formations were
specific pathological products or whether they were new formations
of granular tissue, Virchow maintaining the latter position. The
I solution of this question was due to the observations of a Dane,

I Steenberg, in 1860. Still the subject did not attract the attention



that it deserved and that it has since obtained, although confirma-
tions of Steenber^s statements were contributed by Griesinger, Pas-
savant, Wilkes, Wejber, and Wagner. The great work of Heubner,
in 1874, however, conclusively confirmed Steenberg, and settled the
matter beyond the shadow of a doubt, and especially did the former
do this by his minute description of the peculiar syphilitic diseases
of the intra-cranial arteries. Since that time the literature has
become so enormous that, in a monograph written some five years
ago, I was able to count up five hundred different articles on the
subject in the preceding thirty years; and this, as I stated, was
one-twentieth of the whole Sanskrit literature, or of the combined
classical literature of Italy and Gi*eece. In the course of this chap-
ter and in the biblic^raphy, all the prominent writers will be
mentioned, and it must suffice here to say that, salient among the
salient, are Koster, Friedlander, Chvostek, Eichhorst, Greiff, Leyden,



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360 NERVOUS DISBA8BS.

Yvaren, Gros and Lancereaux, Charcot, Hughlings-JacksoD, Taylor,
Moxon, Gifford Albutt, Fournier, Morel-Lavall6e, Beli^res, and
finally, in 1887, appeared the complete and decisive work of Bumpf.

Etiology. Syphilis of the nervous system usually occurs in the
secondary and tertiary stage. Thus, of 150 cases of my own 87, have
belonged to the tertiary stage, whilst 41 have occurred in the second-
ary and 22 in the primary stage. It will thus be seen that, contrary
to the affirmations of those who have limited their observation of
syphilis to the skin and mucous membranes, the nervous system may
be affected at any time. Indeed, the great French syphilographer,
Fournier, goes so far as to say that syphilis manifesting itself
prominently in the cutaneous organs and mucous membranes is of the
benign form, and is not so likely to afterward affect the nervous sys-
tem as is syphilis in which there have been scanty cutaneous mani-
festations ; and this view is confirmed by my own observations as I
have just stated them. Syphilis may be communicated in various
ways. Thus, a chancre may be acquired in the ordinary fashion, or
through the buccal membrane, through examinations by a physi-
cian, or through a surgical operation, and it is even a question as to
whether it cannot be acquired through articles of clothing, whilst
heredity is an occasional cause. Physicians should bear all these
sources of infection well in mind, and should emancipate themselves
from the traditional idea that it can only be acquired in the usual
way. I have known several physicians who have infected them-
selves through examinations of patients or through surgical opera-
tions ; and I also know of numerous cases in which the wife has been
innocently infected through the husband. For all these reasons, it
is evident that we cannot exclude syphilis because of a lack of a
clear history of infection or because of a lack of the usual typical
cutaneous manifestations.

In 150 cases of my own the average age was thirty-five, the maxi-
mum being fifty- two years and the minimum eighteen; 135 were
males and 15 females.

Pathology. ' Syphilis of the nervous system may affect any por-
tion of it — intra-cranial contents, spinal cord, peripheral nerves, and
the membranes and bony structures surrounding the spinal cord and
intra-cranial contents, as well as the arteries and capillaries within
them. The arterial lesions were first described in 1874 by Heub-
ner, of Leipsic, whose observations have given rise to further and
even contradictory investigations by Koster, Friedlander, Baum-
garten, Rumpf, and many others. Heubner advanced the view that
in syphilitic vessels the endarteritis was peculiar in its place of
origin, which was in the vessel-less tissue that lies between the fenes-
trated membrane and the endothelium, which two structures are nor-
mally so closely approximated that no intervening tissue can be seen
microscopically. In syphilitic endarteritis, however, Heubner
maintains, they are widely separated by a new cellular formation
which consists of a proliferation of endothelial cells, to which, after
a certain time, there are added numbers of peculiar round cdls, of
which we shall have more to say later. Heubner very minutely



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THE CERSBRO-8PINAL XERVOUS SYSTEM. 361

and careftiUy describes the di£Perences in size of the endothelial cells
in health and disease, as well as how to obtain an endothelium that
has not been produced by the ordinary act of cutting the vessel, and
it is difficult for anyone who reads his painstaking brochure to re-
fuse credence to his plea for this peculiar anatomical site of syphilitic
endarteritis ; nor is it easy to resist the wish that it were true, as it
would constitute so valuable a guide in dubious cases ; but in the
eighteen years that have elapsed since Heubner first made his views
public no one has fully confirmed him. K5ster, Friedlander,
^umgarten, Huber, Schottelius, Marchand, and Rumpf deny that
the endarteritic process starts in the vessel-less structure between the
fenestrated membrane and the endothelium, or that it consists at
first of an endothelial proliferation, maintaining, on the contrary,
that this endarteritis is due to the outpouring of round cells from the
minute nutritive vessels of the vessels themselves — from the vasa
vo^orum— contained in the outer coats, and that the endothelial
proliferation is only a part of the general cellular disturbance that
takes place in consequence of this outpouring of round cells. The
Question needs further investigation. But, however it may be
decided, there is no diversity of opinion as to the results which
follow the endarteritis. The vessels may become narrowed in their
lumen by the thickening inward of the fenestrated membrane and
the intima. They may be entirely occluded from the same cause.
The inner surface of the intima may become roughened or altered in
its chemical constitution, and a thrombus may form, which, in its
turn, may give rise to an embolus. It may even happen, though
rarely, that minute aneurisms may be formed from the wasting of
the muscular coat of the vessel, and occasionally there may be a
hemorrhage. In other words, the syphilitic infiltration may set up
an endarteritis, which usually leads to a narrowing of the canal of
the vessels or to an occlusion of it, but it may occasionally induce
thromboli, emboli, aneurism, and hemorrhages. Around the vessels
will be found a number of cells reaching out into the tissue for a
considerable distance, tapering oiT into the normal tissue and becom-
ing scantier and scantier as the normal tissue predominates. The
tissue in which these cells lie is finely granular, and is traversed by
bands of connective tissue. This tissue is evidently the product of
the cellular infiltration, with slight exudation. The cells are in all
appearances similar to the white blood-cells, but their histolc^ical
conduct is peculiar. They preserve their vitality for a great length
of time in some places, and when they do undergo retrogressive
metamorphosis, it is into caseous and calcareous products and con-
nective tissue, and seldom into pus — differing in these respects
entirely from the cells that are found in tuberculosis, and acting
rather like the cells of lupus, leprosy, and actinomycosis. Virchow
classifies them with the granulation tumors, Klebs with the infectious
tumors, and Ziegler witfi the infectious granulation tumors. Rurapf
states that the cells that are near a vessel are very tardy in under-
going any retrogressive metamorphosis, and it is only those that are so
far away from a Vessel as to be deprived of their proper nutrition, either



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362 NKRVOUS DISEASES.

because of their distance or because of the disease in the vessel, that
undergo degenerative changes. It matters not what portion of the
nervous system is affected, the changes are always essentially similar
in character, differing only in the form somewhat according to the
histological peculiarities of the tissue affected. In the nervous sys-
tem there is usually a general infiltration of all the different tissues^
varying in degree in different parts.

To the naked eye these pathological conditions will present different
pictures. The bones of me skull or vertebral column may be thick-
ened, or there may be spicular or long pencil-like formations. The
membranes are usually greatly affected, especially at the hase. One
of the most characteristic appearances is the infiltration of the pia
mater at the base as it stretches along over the quadrangular space
that is formed by the pons behind, the tips of the temporo-sphenoidal
lobes at the sides, and the posterior portions of the frontal lobes in
front. ( Vide Fig. 5.) Here the membrane will be found to be pul-
taceous, like thoroughly wetted blotting-paper, instead of presenting
the translucent appearance that is usual of the normal pia mater.
This is very much the same appearance as is presented in cases of
tubercular meningitis ; and, indeed, as we shall have occasion to see,
there is no means of distinguishing between the two except by the
accompanying history and the accompanying pathological findings.
The membranes are usually adherent, so that the cerebral substance
tears as they are pulled away. It is very seldom, however, that any
purulent formation is observed. Studding the membranes in places
may be found little granulations, and these are often -large in size, con-
stituting veritable tumors. The cranial nerves at the base, especially
in the anterior portion that has been alluded to, are often found infil-
trated by the diseased membranous structures, or surrounded by them,
frequently both. In the spinal cord the periphery may be affected,
or there may be infiltration of the whole cora, so that the process
would seem to extend to the cord either through the membranes or
the vessels. When the spinal or cranial nerves are affected there is
an intense infiltration of the peculiar cells, with a degenerative process
of many nerve fibres, or there may be granulations or actual tumors
of the nerves. In some cases the nerves attain to an enormous size,
and the bony canals through which the nerves run may also be
affected by osseous infiltration. Donn6 found a vibrion lineola in the
secretion of chancre in 1837, without, however, attributing to it any
importance. Hallier, in 1869, thought that he found multitudes of
micrococci in the blood globules. In 1872 Lostorfor saw on the
third day, in syphilitic blood preserved in a humid chamber, small
brilliant corpuscles with minute prolongation, these becoming laroer
and mulberry-shaped ; but it has since been shown that these phe-
nomena are observed in normal blood, especially in cachectic indi-
viduals. In 1878 Klebs found little rods animated by very slow
movements in the liquid from a chancre, and, cultivating this liquid
in gelatin, he developed these rods into agglomerations forming large
spiral masses, which he called hdicomonadea. The injection of this
liquid into a^xis produced circumscribed buccal alterations like mucous



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THE CBREBRO-SPINAL NERVOUS SYSTEM. 363

patches, aud at the autopsy of one of these animals caseous deposits
were found between the dura mater and the skull resembling gum-
mata, whilst caseous patches were seen in the lungs, the pleura, the
kidneys, etc. Other apes were injected by Klebs subcutaneously
with fragments of chancre, and at the autopsy caseous deposits were
found, and the cultivation of the blood of these animals again gave
rise to the peculiar rods and the helicomonades. Cornil and Babes,
however, doubt whether these caseous nodules might not have been
due to tuberculosis, to which malady apes are peculiarly subject in
northern climates. The next year Klebs confirmed these researches,
but it is singular that he was never able to obtain these results from
inoculation in any other animal than the ape. Aufrecht found
microbes in the secretion of condylomata in 1881. Birch-Hirsch-
feld gave a description in 1881 of certain bacteria which he had
found in chancre condylomata and visceral gummata. They con-
sisted of rods varying in length from one millimetre to three or five,
and were found in the cells or in the intra-cellular tissue. In 1882
Martineau and Hamonic stated that they had observed a multipli-
cation of rods obtained by culture of fragments of chancre, and tnat
inoculations of apes had produced eruptions comparable to those of
syphilis, such as bard chancre and the secondary phenomena. Letnic
(1883) obtained n^ative results in inoculation of the hog and the rab-
bit with the micrococci cultivated from chancre and mucous patches.
Kobler, Neumann, Bayer, Horand, and Comevin experimented
upon a numl)er of animals, and arrived at the conclusion that no
animal had yet Jbeen found capable of receiving the syphilitic virus.
Cognard (1884) inoculated an ape with the cultivated secretion of a
mucous patch, and, like Martineau, obtained an induration at the
point of inoculation and a general eruption, but the objection has been
raised that this was probably a species of septicemia. Morison
(1883) has found bacteria in the secretions of chancre and mucous
patches. Tornery and Marcus (1884) have cultivated micrococci.
Adniger has seen bacilli in a case of pulmonary syphilis, these bacilli
being somewhat finer and longer than those of tuberculosis, and not
colorable by Ehrlich's method, but many objections have been raised
to his observations both because of their lack of evidence in the
results and because of the methods of cultivation and inoculation ;
and the same objections are pertinent to the observations of Schiitz,
who claims to have found similar bacilli. Lustgarten has observed,
in indurated chancre and in gummata, bacilli that were isolated or in
groups, resembling those of tuberculosis. They were sometimes some-
what curved and enclosed in tumefied lymphoid cells, resembling the
bacilli of leprosy and tuberculosis. In a subsequent conmiunication the
same author stated that he had detected them in the lymphatic vessels
and the capillaries. They are colorable by a method described by Lust-
garten, who found them in sixteen cases of indurated chancre, mucous
patches, and the secretions of tertiary syphilitic productions, as well
as in the gummata of an infant afflicted with hereditary syphilis.
Doutrelepont has seen these bacilli described by Lustgarten in eight
cases of chancrfe of the prepuce, in one condyloma of the labia majora,



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364 NBRYOUS DISEASES.

and in five papules, and he has observed the greatest number of them
in cases of syphilis that have not been treated. One indurated
chancre without secretion did not contain them^ but they were
found in many of the sections. Alvarez and Tavel have found the
Lustgarten bacilli in the smegma and the desquamation of the humid
portion of the genital region, as well as upon the surface of syphilitic
and non-syphilitic ulcerations of the genital organs, and from this
it would seem at first sight that these bacilli may be found under
normal conditions ; but the method employed by Alvarez and Tavel
is not identical with that of Lustgarten, as the bacillus described by
the latter is not colored by simple colors or by Ehrlich's methoci,
whilst the microorganisms of Alvarez and Tavel are ; nor have the
latter found their bacilli in sections. Klemperer and Matterstock
have confirmed the observations of Alvarez and Tavel. Cornil and
Babes are undecided as to which of these authors is right. Other
writers upon the subject on different sides of the question have been
Oiacomini, Disse and Taguchi (two Japanese medical men writing in
Grerman), Gottstein, Leloir, Weigert, Baumgarten, Eve, and Lonmiard.
As a result of all these researches it may be stated that the bacilli
described by Lustgarten and Doutrelepont have been the ones that
have attracted most attention ; that the question is not by any manner
of means yet decided ; that the bacilli described by Lustgarten have
been found by many in syphilitic individuals ; that bacilli similar in



Online LibraryLandon Carter GrayA treatise on nervous and mental diseases: for students and practitioners of ... → online text (page 37 of 84)