1883 The Lancet  
SENIOR PHYSICIAN TO THE HOSPITAL. GENTLEMEN,—The four cases to which I wish to call attention present, each of them, individual points of interest; but doubtless their chief value resides in the fact that they have a close pathological and clinical relationship. They are all of them cases of softening of the pons Varolii, or crus cerebri, and adjacent parts. The symptoms were in all cases those of what is roughly termed cross paralysis, and in every instance the afl'ection was ushered in by
more » ... s ushered in by premonitory symptoms. The symptoms, however, presented considerable differences of detail, and there were differences as regards etiology. The first case is that of a young man who had contracted a chancre exactly six months before his death, and who was suffering from secondary symptoms in the form of psoriasis at the time when his fatal illness seized him. The symptoms of this illness began five or six weeks before he died (and certainly therefore within five months of his syphilitic inoculation) with occipital headache and sickness. After three or four weeks, or, more exactly, fourteen days before his death, he began to ramble a little in his mind and to be .troublesome ; and the next morning it was noticed that his .pupils were contracted, his conjunctivse congested, and his left eyelid a little dropped. Five days later, when he woke in the morning, he was found to be hemiplegic on the left side ; and after another four days it was noticed not only that the left eyelid was a little dropped, but that there was paralysis of all the muscles of the right eye, excepting Drobablv the sunerior obliaue. Meanwhile the natient was becoming more and more drowsy and stupid, and he died quietly on the fourth day after the paralysis of the muscles of the right eye had declared itself. Syphilitic disease of the internal organs generally arises as a part of the so-called "tertiary symptoms" of syphilis, and therefore late in the progress of the disease, and often after many years have elapsed. Still, as the patient here appeared to have been in all other respects a healthy man, it was assumed during life that his cerebral affection was syphilitic, and he was treated .accordingly. Further, it was not difficult to speculate, from the symptoms, as to whereabouts the cerebral lesion would be found. The left-sided hemiplegia pointed to involvement of the 'motor tract, issuing from the right hemisphere of the brain; and that the part directly implicated was the right crus cerebri or the contiguous portion of the pons had been foreshadowed by the slight ptosis observed in the left upper eyelid. This surmise was confirmed when, a few days subsequently to the occurrence of hemiplegia, total paralysis of the right third nerve was added to the other phenomena. At the post-mortem examination there was found syphilitic thickening, with obstruction, of the light posterior cerebral artery, and consequent softening, with more or less disintegration in patches, of the right crus cerebri, and of some of the neighbouring parts to which this artery is distributed. The paralysis of the right sixth was no doubt due to the thickening of the membranes observed at the base of the brain, and the very partial affection of the left third was probably connected with some special hut concurrent lesion of that nerve. It may be assumed, that the patient's early and comparatively vague cerebral symptoms were due to the disease of the arterial walls and slight associated inflammation of the membranes in the neighbourhood ; that the hemiplegia took place when the channel of the posterior cerebral became suddenly occluded ; and that the right third nerve got involved as the area of softening extended. The second case was also that of a young man who had somewhat recently contracted syphilis, but who gave no history of having suffered from secondary symptoms. The duration of his fatal illness was between four and five weeks. For three weeks he complained of frontal headache, unattended with sickness or other important symptoms, at the end of which time he was seized during the night with almost complete left hemiplegia, associated with rigidity of the arm and leg, inability to speak, and well-marked paralysis of the third nerve on the same side. On the next day he had attacks of partial unconsciousness, during which the head and eyes were strongly turned to the left. On the following day he manifested some return of the power of articulation, and was evidently not aphasic. All signs of paralysis of the left third, seventh, and ninth nerves had disappeared, and the paralysed arm and leg had become limp. Three days later the urine, which from the beginning had had to be drawn off with a catheter, had become alkaline and offensive, and there were manifest signs of cystitis; and on that day his temperature reached 103 4". After this the pulse increased in frequency, the temperature rose irregularly, and on one occasion he had a prolonged rigor ; there was a slight return of the paralysis of the left third, seventh, and ninth, and the left arm and leg again got rigid ; he passed into a state of coma, and at the time of death the . temperature in his axilla had risen to 109'2°. In this case, as in the former, there was reason to suspect the presence : of some syphilitic lesion of the brain, and the sudden occur-' rence of left hemiplegia during its progress, pointed to the direct and sudden involvement of the motor tract in. or issuing from, the right cerebral hemisphere. The partial paralysis of the third nerve on the same side as the hemiplegia seemed to show that the lesion was situated somewhere about the crus cerebri or pons; and that the pons was the actual seat of disease was to some extent confirmed by the attacks of partial unconsciousness, with turning of the head and conjugate deviation of the eyes towards the paralysed side, which occurred on the second day of his hemiplegia. It will be recollected that deviation of the eyes and head in cases of cerebral disease is towards the lesion and away from the paralysed side, while it has been observed that, at any rate occasionally, when such deviation shows itself in affections of the pons the direction of the deviation is reversed. The post-mortem examination to some extent confirmed the inferences that might have been, and in a measure were, drawn from the symptoms. There was syphilitic disease of the posterior cerebral and of some of the smaller arteries in the neighbourhood ; and there was pulpy softening of the right halt of the pons. No distinct , occlusion of vessels was discovered; but there can be little : doubt, I think, that the breaking down of tissue, which was . exactly of the same kind as in the former case, and such as i one meets with when arteries are obstructed, was the result ! of obstruction of the small arteries distributed to the softened L resrion. In this case, as in the other, the cause of the partial paralysis of the third nerve on the same side as the hemiplegia is not clearly explained by the obvious position of the lesion. But the difficulty of articulation which the patient manifested, and the retention of urine with tendency to rapid inflammation of the bladder, had doubtless some relation to the seat of disease. The extremely high temperature which was reached on the approach of death is a noteworthy feature in the case. The third case was that of a man of middle age who was said to have been temperate and healthy, and never to have had syphilis. His illness began about twelve weeks before death, of which the last seven weeks and a half were spent in hospital. The onset seems to have been a kind of rigor; on which followed persistent headache and giddiness. The first definite sign of brain disease was the occurrence of double vision four days before admission, and the second left hemiplegia, which supervened on the morning of admission. When he came under observation it was found that he had partial paralysis of the right external rectus, and nystagmus of the right eye when trying to look to the right, incomplete left hemiplegia, and unsteadiness of gait. He rapidly got worse, and after four or five days it was observed that his intelligence had become affected, and that he was emotional, that his hemiplegia had become more complete, that the left internal rectus as well as the right external rectus were paralysed, and that all movements of the eyeballs, excepting that to the left, were attended with nystagmus. He had no optic neuritis. During the following two or three weeks the symptoms underwent little change; but about three or four weeks before his death partial paralysis
doi:10.1016/s0140-6736(02)23817-9 fatcat:o32hpsedzfa3zd2td2b3syo2ea