THE PAINS OF SYPHILIS.
Syphilis, as has already been shown in Part I. of this work, may excite
true neuralgia in subjects already predisposed to the latter. The case
of Matilda W., previously given, is an example. The pains, however,
which are now to be described, are those which occur in the ordinary
course of a constitutional syphilitic infection, and have nothing to do
with neuralgia proper, from which they should be carefully
distinguished.
There are two varieties of syphilitic pains proper, which are quite
distinct. The first kind is represented by the so-called _dolores
osteocopi_, which occur in the early stages of the constitutional
affection, coincidently with, or just before, the secondary
skin-eruptions. The second kind are those which occur in the tertiary
stage, and are the immediate precursors of the formation of periosteal
nodes.
It is the first of these varieties of syphilitic pains which is least
commonly confounded with neuralgia. The pain is referred to the
superficial bones, of which those most frequently attacked are the
forehead, sternum, clavicle, ulna, and tibia, pretty much those selected
for the growth of nodes at a later stage of the disease. Besides the
bones, the shoulders, elbows, and nape of the neck are attacked
sometimes simultaneously, sometimes successively. The pains are readily
controlled by proper treatment; if untreated, their course is very
uncertain. When they manifest themselves at the outset of the disease,
they usually cease when the cutaneous eruption is fairly out. Commonly,
there is no swelling or heat at the painful places; but, when the pains
are very severe, nodes now and then form at this early period.[52]
These early syphilitic pains, in their violent aching character, and
their intermittence, occasionally resemble true neuralgia very closely;
but they are usually distinguished from it by their symmetrical
disposition and by their attacking several bones at once. Moreover, they
nearly always show the peculiarity of being distinctly aggravated by the
warmth and repose of bed even if they be not altogether absent (as is
not unfrequently the case) when the patient is up and moving about. A
typical case of this kind is not so likely to be confounded with
neuralgia as with rheumatism; but we occasionally meet with cases in
which the pains are localized in a manner much more resembling the
former. Thus I have met with several instances in which a patient,
entirely unconscious (or professing to be unconscious) of having been
syphilized, complained of violent pain in one tibia, recurring every
night at a certain hour, and at first undistinguishable from that
variety of sciatica in which the pain is principally felt in this
situation, especially as it was relieved by firm pressure, just as
neuralgia is in the early stages. And in one remarkable case, which came
under my care at Westminster Hospital, the resemblance to clavus was
most misleading:
H. A., aged nineteen, worker in a laundry, presented herself on account
of a violent pain in the right parietal region, recurring three times
daily with great regularity. The first two attacks occurred in the
day-time, the third, which was always the severest, woke her out of
sleep about midnight; the pain of this last was so agonizing that on
more than one occasion she had become delirious. The girl (whose
respectable appearance was against the notion of syphilis) was very
anaemic; not, however, with the tint either of anaemic from haemorrhage, or
with that of chlorosis, exactly. It was rather a dirty sallowness of
skin; but the gums and the conjunctivae were exceedingly bloodless, and
she complained of almost constant noises in the head. Menses scanty but
regular. There was a soft anaemic bruit with the first sound at the base
of the heart. Having failed to make any impression on the pains with
iron and with muriate of ammonia in large doses, I was led to observe
the fact that there was no diffuse soreness of the scalp, such as very
commonly occurs in clavus, in the intervals of the pains, and the mere
fact that there was this unusual circumstance in the case led me to
reconsider the diagnosis thoroughly. In order to be sure of not omitting
a point, I inquired, though without any expectation of an affirmative
answer, as to the possibility of syphilitic disease; the girl at once
confessed to having had sores, and examination detected a papular rash
about the shoulders and back and on both thighs. Small doses of mercury
greatly relieved the pain within a week, and cured it in less than three
weeks; and it was very remarkable that the anaemia, which had obstinately
refused to yield to iron, improved at once as the mercury began to
relieve the pains. The eruption disappeared simultaneously.
It is the later pains of syphilis, however, that are most frequently
confounded with neuralgia, and occasionally with very disastrous
results. These pains, which are the precursors of the formation of true
nodes, frequent the same localities as those affected by the earlier
pains; they may exist in considerable severity for days, or even for
many weeks, before any node-formation can be detected. The situation in
which, of all others, they are likely to be mistaken for neuralgia is
the scalp or face, especially when a single spot is affected on one
side, and in the situation of one of the usual foci of trigeminal or
occipital neuralgia. I have personally known the mistake to be made with
syphilitic affections causing pain, respectively, in the superciliary
region, in the malar bone, the jaw near the mental foramen, and the
parietal eminence.
The possibility of mistaking tertiary syphilitic pain for neuralgia is
fraught with such grave dangers, that we ought to be constantly and most
vigilantly on the watch against it. But most especially is this the case
when the pain is situated in some part of the cranium, as the parietal
or temporal eminences, the mastoid process, or the prominences of the
occipital bone. For it must be remembered that the same process, which
forms syphilitic nodes upon the external surface of bones, or within
bony canals, can produce them on the lining membrane of the skull, with
most serious consequences, should the symptoms be neglected or
misunderstood.
The pains produced by nodes upon the internal surface of the cranium are
usually of a very intense character, and are mostly continuous, though
aggravated from time to time, especially at night. Where syphilitic
inflammation is diffused over a considerable portion of the meninges, it
is certain very quickly to produce symptoms which can hardly fail to
apprise us of the gravity of the affection; there will be decided and
rapidly increasing impairment of memory, and general cloudiness of
intellect, tending toward complete imbecility, the special senses will
be greatly interfered with or lost, and muscular paralysis will be
developed. But in the case of a more limited syphilitic affection of the
dura mater, pain, of the kind already described, may be for some days
the only very noticeable symptom. The following is an instance:
J. E., aged forty-seven, a street and tavern singer, applied to me
(November 14, 1861), on account of severe pain in the right temporal
region, which had on the whole the character of neuralgia, though rather
more continuous than such pain usually is. He said that it commenced on
the 10th, without any particular provocation that he knew of, and that
it had hardly left him at all from that moment. It kept him awake at
night, and that circumstance seemed to account sufficiently for a very
worn and depressed look which he presented; he was otherwise a
robust-looking man, and at first denied having suffered from any
previous illness. The pain always came to a climax about one o'clock, A.
M., waking him out of his first sleep in agony, and allowing him little
rest for the remainder of the night; toward morning he would drop to
sleep for an hour or so. There was no particular tender point,
corresponding to any recognized neuralgic focus, yet the pain was
limited most strictly to a spot that might be covered with two
finger-points. There was no lachrymation nor conjunctival congestion,
and nothing to remark in any way about either eye. The patient was
ordered quinine in large doses, in the belief that the pain was
neuralgic. On the following day he reported himself a trifle better,
though still suffering greatly; and on the afternoon of that day there
was an almost complete intermission of the pain for several hours; but
it returned severely at the usual nocturnal period. On the 16th, at 10
A. M., he came to my house looking exceedingly ill, but the only
additional symptom that I could detect was a small droop of the right
eyelid. He was subcutaneously injected with one-fourth of a grain of
morphia and sent home, where he immediately fell into a heavy sleep that
lasted till bedtime. He awoke, undressed himself without feeling much
pain, and got to bed; after an hour or so of dozing he was awakened by
the pain, which was exceedingly severe. On the 17th he called on me in
the morning, and I at once perceived that the ptosis of the right eyelid
was much greater, and the right pupil was much dilated and insensitive,
and the external rectus was paralyzed; the man also wore a look of
stupidity, and answered questions with an apparent mental effort. I now
cross-questioned him more closely; and also explored the tibiae and other
superficial bones: on the sternum a distinct though not very advanced
node was found. Upon this he was induced to confess that he had suffered
from chancre three years and a half previously, and subsequently had
"blotches" on the skin, which had quickly disappeared under treatment,
of which all that could be learned was, that it was fluid medicine and
did not make his mouth sore. He was immediately ordered to take two
grains of calomel in pill, with a little opium, every four hours. He had
only taken one dose when I was sent for to him, and found him in an
epileptiform convulsion, in which the left side of the body was almost
exclusively affected; the convulsions recurred several times during the
next twenty-four hours, and in the intervals he remained almost
completely unconscious. The mercurial treatment was pushed, in the form
of calomel-powders placed on the tongue. On the evening of the 18th he
began to recover consciousness, and then had a little natural sleep; the
next morning, at 10 A. M., he was found to be fully conscious, had had
no return of convulsions, but the left arm and leg, especially the
latter, were almost entirely powerless; the parietal headache had
vanished; the gums were slightly tender; the third and sixth nerves of
right side were completely paralyzed. Mercurial treatment was very
gently continued, so as to keep the patient on the borders of ptyalism
for the next three or four days; and he was then put on full doses of
iodide of potassium. The pain never recurred; the left extremities
recovered power rapidly; but it was six weeks before the ocular
paralyses were completely well.
Late in the autumn of 1865 I was sent for hastily one evening to see
this same man, and found him totally unconscious and apparently again
hemiplegic, but now on the right side. He was miserably wasted, and
covered with a rupious eruption; I was informed that he had been leading
a most debauched and drunken life for some time past, and that, after
looking extremely ill, and apparently half imbecile for a week or two
past, he had suddenly fallen down unconscious in the street a few hours
before I saw him. He remained deeply comatose, and died the next
morning; no _post mortem_ could be obtained.
The true neuralgias in which syphilis only plays the part of secondary
factor, and which have been referred to in Part I. of this work, may
depend for their exciting cause on local syphilitic processes, affecting
either the peripheral distribution, the main trunk or the central origin
of a sensory nerve; but I have pointed out the fact that, whatever the
reason may be, syphilis does but rarely attack the central portions of
individual sensory nerves, in comparison, with the frequency with which
it attacks individual motor (cranial) nerves. But without any neuralgic
predisposition at all, and without any limitation of the syphilitic
process to a particular sensory nerve, the latter may become neuralgic
in consequence of being involved in extensive intracranial or
intra-spinal syphilitic mischief. The trigeminus is liable to suffer in
this way from spreading syphilitic processes about the base of the
brain; and my own impression is, that the cause of the neuralgic pain in
some such cases is the extension of the mischief to the vertebral artery
of the affected side, leading to interfering with the nutrition of the
trigeminal nucleus in the medulla. A very interesting case is reported
by Dr. Hughlings Jackson (who has done so much to acquaint us with
syphilitic affections of cerebral arteries) in vol. iv. of the "London
Hospital Reports," pp. 318-321. The patient was a woman, aged
twenty-seven, and the initial symptoms of the malady which destroyed her
life were violent trigeminal neuralgic pains on the right side:
subsequently she had complete paralysis of the fifth, and of the sixth,
seventh, and eighth nerves of the right side. After death the right
vertebral artery was found engaged in the mass of syphilitic deposit; it
must be added, however, that the (superficial) origin of the fifth nerve
was itself softened, opposite the pons. Another mode in which syphilitic
disease very probably causes neuralgia of the fifth, in a certain number
of cases, is by injuring the Gasserian ganglion, upon the integrity of
which (according to Waller's general law concerning the ganglia of
posterior nerve-roots) the nutrition of the sensory root of the
trigeminus materially depends. I have seen an example (as I cannot but
suppose) of this sequence of morbid events; the evidence appears
sufficiently complete, although I was unable to obtain a _post mortem_
examination:
W. M., a house painter, of extremely dissipated habits, but who had
never suffered either from distinct symptoms of alcoholism, nor from any
affection traceable to lead-poisoning. In March, 1867, he applied to me
on account of neuralgic pain, affecting chiefly the right eyeball, but
also darting along the course of the frontal nerve of that side; after a
short time it extended also into the infra-orbital nerves. He bore
several scars of tertiary ulcers about the nose and forehead, and made
no secret of having suffered from chancre six or seven years before, and
from subsequent secondary and tertiary symptoms. I was consequently not
at all surprised at his developing severe iritis (right) after he had
been a fortnight under my care, although I had from the first given
large doses of iodide of potassium; but I was not prepared for the
extensive processes of destruction which followed, notwithstanding that
I immediately commenced mercurial treatment, and applied atropine. I
remarked that while the inflammation of the iris proceeded with great
violence, the cornea was also much more severely affected than is
usually the case in syphilitic iritis; in fact, the changes closely
resembled those which have been noted after section of the fifth at the
Gasserian ganglion, and at the date of the patient's death (seventeen
days from the commencement of the iritis) a corneal ulcer was on the
point of perforating. For the first three or four days after the iritis
set in, the neuralgic pains went on augmenting in intensity, and
extended into all three divisions of the fifth; there was a copious
discharge from the right nostril. Almost suddenly, on the fourth day,
the pains abated and then ceased, and it was now evident that the whole
surface of the right half of the face was completely anaesthetic. Two
days later a dark-red patch appeared on the cheek, and in the course of
the next two days this ulcerated, the ulcer presenting a somewhat livid
appearance, and exuding a sanious discharge; at the same time,
superficial ulcers appeared on the right side of the tongue, and
coalesced to form one large sore. The sores both on cheek and tongue
assumed more and more a gangrenous appearance, and on the sixteenth day
from the commencement of iritis there was considerable loss of substance
in both these situations. On the evening of this day (the patient having
become extremely depressed and much emaciated) general epileptiform
convulsions set in, and followed each other rapidly; in a few hours coma
supervened, and the patient sank the next day. No _post mortem_ could be
obtained; but it seems extremely probable, from the above history, that
the Gasserian ganglion was early involved in the syphilitic
inflammation, and that the neuralgia and subsequent anaesthesia, the
iritis, and the other trophic lesions, were due to the injury inflicted
upon it.
The treatment of syphilitic pains will, in doubtful cases, often give us
valuable assurance of the correctness of our diagnosis. Where the
disease is extensively diffused, we may fail to do any good; but, in
cases where the syphilitic mischief is limited to a small portion of the
meninges, we may often arrest it. In all merely suspicious cases, where
the pain is thus limited, it will be well to use iodide of potassium
tentatively--forty to sixty grains daily. But, where the pains are very
severe and continuous, and there is danger to the integrity of the eye,
or threatenings of a paralytic attack are observed, it is better not to
trust to anything short of mercury, used in such a manner as just to
stop short of absolute ptyalism. In very bad cases, like the last one
narrated, we may fail to produce any good effect, but, where the
specific treatment is commenced in good time, we may not unfrequently
succeed in arresting the symptoms with a rapidity that assures us of the
correctness of the diagnosis of syphilis.
FOOTNOTE:
[52] Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.