Columbia UntoersWp intbt€itvoi&tto^oxk COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by THE FAIRCHILD PREPARATIONS — or — IK PORE DIGESTIVE FERMENTS, Active, Permanent and Reliable. TRYPSIN (fairchild) Especially Prepared as a Solvent for Diphtheritic Membrane. PEPTONISING TUBES. * (fairchild). For the preparation of PEPTO- NIZED MILK and other pre digested food for the sick. EXTRACTUM PANCREATIS. (fairchild). Containing all the digestive ferments of the Pancreas. PEPSINE IN SCALES. (fairchild). The most active, permanent and re- liable pepsine made in the World. ESSENCE OF PEPSINE (fairchild). For administration where a fluid and agreeable form of pepsine is desired, and for the prep ara- ration of Junket and Whey. PEPTOGENIC MILK POWDER (fairchild). For the modification of cows' milk to the standard of Normal Mother's Milk. PEPSINE IN POWDER. (fairchild). Prepared from the scales without the admixture of any other sub- stances, to facilitate dis- pensing and the pre- paration of saccharated pepsine. DIASTASIC ESSENCE PANCREAS. OF (fairchild). For the digestion of starchy foods. Fairchild Bros. & Foster, 82 AND 84 FULTON ST., NEW YORK. SYPHILIS NERVOUS SYSTEM H. C. WOOD, M. D., LL. D. GEORGE S. DAVIS, DETROIT, MICH. Copyrighted by GEORGE S. DAVIS. 1889. CONTENTS. CHAPTER I. PAGE. Etiology CHAPTER II. The Brain and Its Membranes I7 Section I— Pathology r _ II — Symptomatology 2 o HI — Diagnosis 7 5 IV — Prognosis gg V — Treatment qj CHAPTER III. Spinal Syphilis IQ2 Section I— Pathology io2 II — Symptomatology IIO III— Prognosis 12 , IV — Treatment I24 CHAPTER IV. The Peripheral Nerves I2Q PREFACE. At a time like the present, when the world is overflowing with medical writings, it seems but right that the author who would lay claim to a portion of the time and thought of his medical brethren, should plainly state the basis on which his work rests. At the risk of being considered egotistic, I there- fore venture to say that the present brochure is largely the out- come of personal experience. In the University Hospital and Dispensary, there have been treated under my supervision five thousand cases of nervous disease, of which at least fifteen per cent., or seven hundred and fifty, have been in the persons of syphilitics. During the seventeen years of my service at the Philadelphia Hospital, there were under my care about two thousand patients suffering from various affections of the nervous system, of whom more than fifty per cent,, or over one thousand had suffered from syphilis. To these seventeen hundred and fifty cases must be added those with which I have come in contact in my private practice and as consultant to public and private hospitals for the insane— making a total of nearly two thousand cases. CHAPTER I. ETIOLOGY. In a study of syphilitic diseases affecting the nervous system, it might not be thought necessary to discuss the etiology of the subject, because in all cases syphilis is primarily the cause of the disorder; yet many questions naturally arise in connection with the relations of syphilis to the nervous system, which require notice. Certain syphilitic individuals pass through a long life, and through a long series of specific affections, without the nervous system being implicated; whilst in other cases syphilis early selects the brain or spinal cord. Rarely, however, are we able to explain these differences, or to discover in the individual case any exciting cause of the attack upon the nerve centre. It is true that Fournierf affirms that he has especially seen the disease in professional and other men whose brains were habitually over-active, and* that various other authorities attach much influence to over-study and other forms of cerebral strain as exciting causes of brain syphilis. My own experience, however, hardly corresponds with this; I have met very few instances in which excessive brain-work unmistakably appeared as a distinct etiological factor, whilst I have seen hundreds of cases from amongst the laboring f La Syphilis du Cerveau. 2 GG class, in persons in whom the intellectual faculties have been chiefly dormant; and I have also known numerous cases of syphilis occurring in intellectual workers, without specific disease of the nerve centres. It is not unnatural to expect that a disease or a traumatism which is capable of exciting an inflamma- tion of the nerve centre, may, when present in a syph- ilitic person, provoke a specific explosion in such centre. Thus, thermic fever is a very common cause of chronic meningitis, and in the Journ. de Med. et Chir. (Paris, 1879, p. 191) a case is reported in which cerebral syphilis followed an alleged sunstroke. In Roberts's case of precocious cerebral syphilis (herein- after reported), the first convulsion came on whilst the man was fishing, on a very hot day, and may have been precipitated by the exposure. In a case which was sent to me from a neighboring village by a very intelligent physician, as one of sunstroke followed by organic brain disease, the post mortem showed that the original brain lesion was a gummatous tumor involving the motor centres, and it is much more probable that the primary supposed sunstroke was really an epileptiform convulsion, the first of the series which marked the coming into view of the cere- bral disease, than that the gumma was produced by the sunstroke. A man with a latent gumma in his brain might very well have an epileptiform attack pro- voked by exposure to excessive heat: and if sunstroke ever is the starting point for brain syphilis, such cases must be rare. — 3 — Blows and other traumatisms do not seem to figure largely as exciting causes of nervous syphilis. I have seen one or two cases of specific brain disease attributed to violence by the patient, and several cases of possibly specific spinal disease — one in which a poliomyelitis followed a fall on the ice; one in which, after a fall from a cart and marked spinal concussion, a local myelitis developed; and one of a general mye- litis following an injury by a horse. The only records of such cases known to me are those reported by Broadbent* and those collected by Heubner.f A very important question connected with the etiology of nervous syphilis is as to the time of its de- velopment. It certainly belongs to the advanced stages of the disorder, and usually comes on some years after the primary infection; but I have seen it at every period from one year to thirty years. Fournier reports intervals of twenty-five years, and thinks from the third to the tenth year is the time of maximum frequency of nervous accidents. The fact that nervous syphilis may occur many years after the cessation of all apparent evidences of the diathesis, is of great practical importance, especi-' ally as the nervous system is more prone to be at- tacked when the secondaries have been very light than when the earlier manifestations have been severe. * London Lancet, 1876, ii, p, 741. j'Ziemssen's Cyclopedia, xii, p. 301. I have repeatedly seen brain syphilis in persons whose secondaries had been so slight as to have been entirely overlooked or forgotten, and who honestly asserted that they had never had syphilis, although they ac- knowledged to gonorrhoea or to repeated exposure, and confessed that their asserted exemption was due to good fortune rather than to chastity. The following citations prove that this experience is not peculiar. Dowse* says: " Often have I had patients totally ignorant of having at any time acquired or experienced the signs or symptoms of syphilis in its primary and secondary stages, yet the sequelae have been made manifest in many ways, particularly in many of the obscure diseases of the nervous system." Buzzard f reports a case of nervous syphilis where the patient was unconscious of the previous existence of a chancre or of any secondaries. Rinecker also calls attention J to the frequency of nervous syphilis in persons who afford no distinct history of secondary symptoms. Although syphilis is prone to attack the nervous system many years after the infection, it would be a 'fatal mistake to suppose that nervous disease may not rapidly follow the chancre. What the minimum possible intermediate period may be, we do not know, but it is certainly very brief, as is shown by the following cases *The Brain and its Diseases, London, 1879, vol. i, p. 7. f Syphilitic Nervous Affections, London, 1874, p. 80. X Archiv f. Psychiatrie, vii, p. 241. — 5 — of this so-called precocious nervous syphilis. Alfrik Ljunggr6n, of Stockholm, reports ] the case of H. R , who had a rapidly-healed chancre in March, followed in May of the same year by a severe head- ache, mental confusion, and giddiness. Early in July H. R had an epileptic attack, but was finally cured by active antisyphilitic treatment. Although the history is not explicit, the nervous symptoms ap- pear to have preceded the development of distinct secondaries other than rheumatic pains. Davaine is said § to have seen paralysis of the portio dura " a month after the first symptoms of con- stitutional syphilis." E. Leyden^[ found advanced specific degeneration of the cerebral arteries in a man who had contracted syphilis one year previously. R. W. Taylor details a case in which epilepsy occurred five months after the infection.* In the case of M. X , reported by Ad. Schwarz,f headache came on the fortieth day after the appearance of the primary sore, and a hemiplegia upon the forty-sixth day. S. L 1 had a paralytic stroke without prodromes six H Archiv f. Dermatol, u. Syphilis, 1870, ii, p. 155. § Buzzard, Syphilitic Nervous Affections, London, 1874* TZeitschriftf. klin. Med., Bd. v. 165. * Jour. Nervous and Mental Dis., 1876, p. 38. fDe 1' Hemiplegie Syphilitique Precoce, Inaug. Diss.' Paris, 1880. % Ibid. — 6 — months after the chancre. A. P. L 1| had an apo- pletic attack seven months after the chancre; A. S , one five months after her chancre. In a case which recently occurred in the practice of A. Sydney Roberts of this city, the chancre appeared after a period of in- cubation of twenty-six days, and two months and eight days subsequent to this came the first fit; eight days after the first, the second convulsion occurred^with^a distinct aura, which preceded by some minutes the unconsciousness. An interesting observation in this connection is that of Ern. Gaucher§ of a spinal syphilis occurring six months after the appearance of a chancre. This citation of cases might be much extended, but has probably already gone too far, and I must content myself with referring the reader to the Mem- oire sur les Affections Syphilitiques Pre'coces des Centres Nerveux, par Charles Mauriac, Paris, G. Masson, Editeur, 1879, an d to the Thesis of M. Manchon on Syphilis Cerebrate Pre'coce, ~No. 407, 1883, Paris.t. In these publications are collected 80 cases of precocious syphilis: of these the period of incubation^was: One month 3 cases. Two months 4 cases. Three months * 6 cases. Four months 8 cases. Five months 14 cases. || Ibid. § Revue de Med., 1882, ii, 678. Six months 7 cases. Eight months 3 cases. Nine months 4 cases. Ten months I case. Eleven months 1 case. Twelve months 29 cases. A third etiological question in regard to syphilis of the nervous system is, as to its production by an inherited taint, as well as by an acquired infection. Inherited syphilis seems to be less prone than is acquired syphilis to attack the nervous system, but it is certainly capable of so doing.* As early as 1779, Joseph Glenckf reported a case, of a girl six years old, cured by a mercurial course of an epilepsy of three years' standing, and of other manifestations of hereditary syphilis. Graefe found gummatous tumors in the cerebrum of a child nearly two years old. \ O. Huebner] details the occurrence of pachymeningitis hsemorrhagica in a syphilitic infant under a year old. Hans ChiariS reports a case in which very pronounced * It is worth while here to state that there is a form of paralysis which occurs in very young syphilitic infants, in which a monoplegia, apparently of nervous origin, is really the result of a syphilitic affection of the bones of the affected limb. For an elaborate article on this subject by M. Laffitte, see Revue Mensuelle des Maladies des Enfants, Vol. 5, 1887. f Doctrina de Morbis Veneris, Vienna. % Arch. f. Ophthalm., Bd. i. Erst Abth. || Virchow's Archiv, Bd. lxxxiv, 269. § Wien. Med. Wcchenschrift, xxxi, 1881, 17. — 8 — syphilitic degeneration of the brain-vessels was found in a child fourteen months old. Both Barlow^" and T. S. Dowse* report cases of nerve syphilis in male infants of fifteen months. For other similar instances the reader is referred to an article by J. Parrott,f and to a paper by M. E. Troisier.^ Recorded cases prove decidedly — f hat a foetus may be born with its nervous system the seat of gum- matous disease —that the nervous outbreak may occur at any time — and that even after puberty specific nerv- ous affections may primarily attack the unfortunate offspring, which has up to such time seemingly escaped the effects of parental impurity. Nettleship| reports the development of a cerebral gumma in a girl of ten years, and J. A. Ormerod§ of a tumor of the median nerve (probably gummatous) in a woman of twenty-three, both the subjects of inherited syphilis. Thomas S. Dowse** details a case of cerebral gumma at the age of ten years, and Samuel Wilksf f one of epilepsy, from inherited taint, in a boy of fourteen. J. Hughlings- 1" Lond. Patholog. Soc. Trans., 1877. * The Brain and its Diseases, vol. i. p. 76. \ Archiv. de Physiologie, 1871-72, p. 319; also to his "Lecons sur le Syphilis hered.," Progres med., 1877 and 1878. % Arch, de Tocologie, x. 411. I Trans. Lond. Path. Soc, xxxii, 13. § Ibid., p. 14. ** Loc. cit., p. 71. ff Lectures on Dis. of Nerv. Syst., Philadelphia, 1878, p. 333. Jacksonf reports paraplegia with epilepsy in a boy of eight, hemiplegia in a girl of eighteen, and hemiplegia in a woman of twenty-two; J the nervous affection in each instance being associated with, or dependent upon, inherited syphilis. E. Mendel || records the history of a child who enjoyed fairly good health until the ninth year of her age, when she suffered from weakness, with swelling of the glands of the neck, etc. At eleven years of age she was attacked with nervous symptoms, followed by delirium and hallucinations, with strabismus, irregularity of the pupils, and ending in apathy, convulsions, and death. At the post-mortem, syphilitic disease of the brain membranes was found. A remarkable case is reported by Prof. Fournier (Union Medical, 1884), in which at the age of nine years, the child was well nourished, rosy, vivaci- ous, and very intelligent, but commenced occasionally to wet the bed at night, and a little later was suddenly taken with a violent convulsion, accompanied by com- plete loss of consciousness, biting of the tongue, etc. Examination showed that the parents of the child had been syphilitic, and that at the age of three months, the child herself had unmistakable manifestations of the hereditary disorder, from which she had re- covered under treatment. After the first epileptic at- tack, the symptoms continually increased in severity, f Journal of Ment. and Nerv. Diseases, 1875, p. 516. X Brit, Med. Journal, May 18, 1872. (1 Archiv f. Phsychiatrie, Bd. i. 313. IO the convulsions recurring frequently; the disposition of the child slowly changed, and ocular paralysis came on, followed after a time by loss of muscular power, and irregular intermittent muscular contractions; still later the child became idiotic, 'and at last died hemi- plegic and comatose. At the autopsy indisputable syphilitic disease of the brain and its membranes was found. In the Revue Generale D'Ophtalmologie, Vol. 6, p. 97, Dr. V. Caudron details the case of a young woman 17 years of age, with a history of having been a somewhat delicate but generally healthy child, who had undergone general bodily development with the usual rapidity. There had been none of the custom- ary manifestations of hereditary syphilis, nor were there any cicatrical marks on the skin or mucous membranes; but she was found to be suffering from undoubted inherited syphilis. A number of cases similar to those which I have just stated, have been reported in America by Dr. Albert H. Buck and by Dr. Knapp, of New York, and by Dr. Kipp. (See New York Medical Record, Oct. 1, 1887.) I have myself known cerebral syphilis to occur at 21 years of age, as the result of the inherited taint, and report here in detail a case which was during the life, of especial interest on account of the curious" mix- ture of hysterical and organic symptoms. The hys- terical symptoms were so pronounced, and the history of hysterical selfishness so clear, that the case was brought to me originally as one of hysteria in which deception was being attempted for selfish purposes. At my first visit, however, I thought I detected under- lying evidences of organic brain disease, and the sub- sequent examination of the eyes revealed the presence of pronounced choked disks. Bertha C, aged 20; mother and father dead; said to have been healthy as a babe and child, but history not very clear. She came under my care June, 1888; about a year previous she had suffered from a violent attack of illness and had been more or less sick ever since with malaise, loss of weight, excessive headaches, repeated vomiting and constipation. Under homoeopathic treatment the symptoms had abated, but in April or May of 1888, she began to have nervous spells which (I copy now from my note book) "she states come on suddenly, some- times with the hearing of a loud noise. It is affirmed that during the spell she is entirely unconscious and very pale, and that there are peculiar movements of the head after the attack. It is also stated that at one time she lost the power to use her hands, so that she was not able to feed herself." July 13th, I noted: " There is no failure of memory or mental activity, and no evidences of palsy, although the movements of the hands are slow and unsteady, as is also the step, but there is no evidence of lack of co-ordination. She habitually sits in a very peculiar position, with buttocks slid forward just to the edge of the chair, and the upper portion of her neck and the back of head resting on the chair. She says she does this " because it rests her head." There is a distinct callosity of the neck from this habitual pressure. There is pronounced protuberance of the lower cervical vertebrae, but no tenderness on jarring or pressure. There is marked stiffness of the mus- cles of the neck, and the optic disks are choked, but vision 12 is nearly normal. There is no sense of constriction in the abdomen or other portions of the trunk; no disturbance of general sensibility; but the patient complains much of pricking pains in the stomach, and is very emotional with pronounced hysterical symptoms." She was put on the use of iodide of potassium, and of corrosive sublimate, and reported herself July 9th as much improved; but there was at this time dis- tinct stiffness in the back of the neck, and she had had one or two fainting spells in the last week. Owing to my absence from the city, the case was after this seen by Dr. F. X. Der- cum, who reported as follows: August 16, 1888. I was suddenly summoned at 6 A. m. to , was told that Miss. B. had fallen from a window. I found her lying on a mattress in the parlor. Examined her from head to foot but found no trace of injury, — nothing but a doubtful bruise in the small of the back. She complained of great pain both in the back of the head, shoulders, arms, and in the right side of the head and the right eye. She appeared to be extremely hysterical, and resisted movement of the painful (?) parts. However, when the latter were moved by stealth no signs of pain were noticed. This was noticeably the case with the right arm, and which she in addition stoutly maintained was paralyzed, when later, thinking she was un- noticed, was seen to move it quite freely. Occasionally she gave vent to shrill and piercing screams, but it was difficult to believe they were not hysterical, her emo- tional exaltation being so marked. The moment I became sympa- thetic in my demeanor she permitted free handling of the pain- ful (?) parts, and I then carried her upstairs to bed. I examined her person even more carefully than before, but with the same negative result. I now looked at the window from which I had been toM she had fallen. In height it was about twelve feet from the ground; below it was a wooden porch, a fall upon which certainly — 13 — would entail some bruises. She had been found lying on the porch directly beneath the window about four o'clock in the morning. She was crying as though in pain, appeared to be perfectly conscious, and said she had fallen out of the window. On inquiry I learned that the window had been found wide open, and also I learned the following interesting facts: Her bedroom door was found unlocked and a window on the first floor was found unfastened. On further inquiry I was told that the girl was often hysterical, and that she frequently did things to provoke sympathy. Again, I learned that her sister had lately been reading a novel to her, in which a somnambu- list was a prominent character. She evidently had been much impressed by the somnambulistic performances in this book, and she frequently spoke about them. So great was her inter- est in this novel that the fact attracted the attention of the family. The logical inference appeared to be, that the patient in an attack of real, or more probably simulated, sonambulism, had opened wide the window and blinds, and then stealthily crept down stairs, and by means of a first floor window made her exit from the house. She then lay down on the porch immediately beneath the window, and moaned until her sister sleeping in the room above was wakened. The household was at once thrown into great excitement, a neighboring physician was hastily summoned, and she was instantly the centre of anxious inquiries, loving endearments, and frantic caresses. Her object was certainly un fait accompli. The next day patient appeared much better, was sitting up, walked around, and almost free from pains except those in the back of the head and neck. August 18th, 1888. After presenting nothing unusual, she complained of feeling badly, and lay down on her bed about 8 o'clock in the evening. The nurse, a well trained woman, noticed that shortly afterward she had a fit, during — 14 — which the head, shoulders, and back became stiff, and arched backward, "like," said the nurse, " I have seen in hysterical people." Consciousness appeared, however, to be entirely absent. In a few minutes consciousness returned, and the patient spoke a few words, complaining greatly of pain in the head. In a quarter of an hour another seizure occurred, longer and more severe than the first; the head being jerked violently backward. When it had been subdued, the patient could not be roused; she was dead. Post jnortem. — Scalp normal; shows slight ecchyrcosis over vertex (caused, probably, by head striking top of bed). Calva- rium normal. Dura not adherent; inner surface smooth, but very dry. Brain bulging, pale and tolerably firm. Surface of pia very dry. Very little blood in veins. Base of brain: Meshes of pia and arachnoid cedematous with excessive gelatinous infiltration over pons, crura, and medulla, especially of all portions lying in the posterior cranial fossa. Infundibulum excessively distended and giving the appearance of a thin walled cyst. Third ventricle ex- tremely dilated; lateral ventricles somewhat villous. Choroid plexuses very cystic. White matter of brain and cortex reveal nothing abnormal. Base of skull reveals a healthy dura, except perhaps in the posterior cranial fossa, where it seems thicker and softer than normal. Unfortunately no microscopic examination was made because the family objected so strenuously to its being done, and would not allow the cutting of any portions of the cere- brum. A very careful macroscopic survey of the membranes and brain vessels was, however, made, to determine the pres- ence of tubercles, but none were found. The father had been very dissipated, and the gross character of the lesions was dis- tinctly syphilitic. The fact that the cerebral symptoms lasted for over a year before the fatal result, is a strong argumen, against there having been tubercle. — i5 — When a syphilitic nervous affection first develops in a child ten or more years old, in whom there has been no pronounced evidence of the inherited taint, there is great danger of the character of the case being misunderstood. Indeed, in some instances I have seen, I believe an immediate diagnosis was scarcely possible. It is probable that in most, if not all, of the alleged recoveries from tubercular meningitis, the dis- ease has been syphilitic. A child, reported to me by a very good practitioner as having been cured of tuber- cular meningitis, subsequently came under my care, and, I am sure, suffered from hereditary syphilis. Some time since I saw in my University clinic an orphan child, fourteen years of age, suffering from a chronic basal meningitis, and in the absence of any history or of any evidences of syphilis, I gave the fatal prognosis of tubercular disease; but, to my astonishment, after a prolonged treatment with iodides, complete recovery was obtained. Cases in which chronic basal menin- gitis has resulted, in young children, from inherited syphilitic taint, have also been given by F. Dreyfous.* It is of the utmost importance to recognize that an apparently tubercular meningitis is really due to hereditary syphilis. Without a history, certainty may not be possible, but a general indefiniteness of symp- toms and slowness of progression should arouse sus- * Revue mensuelle des Malad. des Enfants, 1883, i, 497; see also Gaz. hebdom. Sci. med. de Montpellier, 1883, v, 89. — i6 — picion, especially if the absence of pulse retardation, or the presence of any characteristic symptoms, indi- cate that the vault rather than the base of the cranium is involved. The relation of inherited syphilis to various nerv- ous affections not distinctly specific, cannot yet be positively determined; but arrested development and the consequent epilepsy, idiocy (see Brain, vol. vii, 404),' and early brain sclerosis, are probably some- times the outcome of such inheritance; and the cases collected by E. Mendel * show that chronic hydro- cephalus is frequently of specific origin. *Archiv. f. Psychiatrie Bd., i, 309; see also Virchow's Archiv. Bd., xxxviii, 129) CHAPTER II. THE BRAIN AND ITS MEMBRANES. Section I. Pathology. There is much reason for believing that there is a close connection between syphilis and sclerosis of the nerve centres; but in the present brochure are con- sidered only those affections which are indisputably, directly syphilitic. There are two lesions of the cere- brum belonging in this category, which for pre- sent purposes may well be considered distinct, al- though their relations are in nature very close— if they be not indeed different manifestations of the same thing. The first of these is gummatous menin- geal inflammation: the second, disease of the blood vessels; beside these two is a third lesion or affection, meningo-encephalitis, whose relations with syphilis is very close, but whose nature has not hitherto been well made out. As has been taught, by Rindfleisch, Fournier, Wagner, and others, the gummatous tumor probably always commences in the sheath of the arterioles, and by the formation of minute cells, which, as was in- sisted upon by Wilks in 1863, are produced by the proliferation of the nuclei which lie immediately un- der the vascular endothelium. Heubner, seems to me correct in teaching that a localized gummatous in- 3 GG — 18 — flammation always starts in the brain membranes, and never in the brain substance; although Fournier, whilst admitting the peripheral origin of most gumma, still claims that they are not always meningeal. I have never seen a gummatous brain tumor which had not really sprung from the brain membranes, although a number have come under my notice which were situ- ated within the brain, and might be supposed to have arisen in the brain itself. Always, however, they had come from an infolding of the pia-mater in some deep fissure, or from the velum interpositum in the lateral ventricles. The most common seat of the tumor or gummatous inflammation, is the base of the brain, and it is very frequently found in the neighborhood of the pons varolii and corpora quadrigemina. It may, however, locate itself upon the vault of the cranium, and in my experience, has been especially frequent in the anterior and motor regions of the cortex; not rarely, especially affecting the immediate neighborhood of the Rolandic fissure. The gummatous mass is usually surrounded by a reddish zone of inflamed nerve tissue, into which it is sometimes fused. It may exist as a roundish, isolated tumor, but more usually is spread out, irregu- lar in shape, and more or less confluent with the brain beneath it. When there is wide spread men- ingeal inflammation, the exudation is often large, constituting an extended, formless, gelatinous mass; this form of gummatous exudation is much more — i 9 — frequently met with at the base than at the vault of the cranium. The cerebral gumma varies in size from a mere grain to a mass several inches in length, and is very apt to be multiple. Its color is whitish or yellowish, or occasionally reddish, according as it has undergone degeneration, and is more or less vascular. Not rarely two distinct zones exist in the gumma, the inner one being dry, yellowish in color, opaque, and resembling somewhat the region of caseous degenera- tion in the tubercle, whilst the outer is pinkish, and more or less semi-translucent. The only lesion with which the cerebral gumma can be readily confused is tubercle, and usually the distinc- tion is easy. Rarely is the mass so spherical as that of tubercle; moreover, it is usually surrounded by a zone of reddish tissue, which is commonly wanting in tuber- cle; then it is never completely caseous, as it does not, like the tubercle, undergo degeneration uniformly and regularly. Moreover, it much more frequently gives rise to cerebral softening, than does tubercle. There are, however, some cases in which it is necessary to study the tumor with the microscope in order to distinguish it with certainty from tubercle. On microscopic examination of a cerebral gumma, the most characteristic structures to be detected are small cells, such as are found in gummatous tumors in other portions of the body. These cells are most abundant in the inner zone, which, indeed, may be entirely composed of them. In the centre of the 20 tumor they are more or less granular and atrophied; in some cases the caseous degeneration has progressed so far that the centre of the gumma consists of minute acicular crystals of fat. In the external or peripheral zone of the tumor the mass may pass imperceptibly into the normal nerve tissue, and under these circum- stances it is that it contains the spider-shaped cells or stellate bodies described by Jastrowitch, and especi- ally commented upon by Charcot and Gombault, and by Coyne. These are large cells containing an ex- aggerated nucleus and a granular protoplasm, which continues into multiple, branching, rigid, refracting prolongations, which prolongations are scarcely stained by carmine. Alongside of these cells other largish cells are often found without prolongations, but furnished with oval nuclei and granular proto- plasm. Amongst these cells will be seen the true gummatous cells, as well as the more or less altered neuroglia and nerve-elements. In the perivascular lymphatic sheaths in the outer part of the gumma is usually a great abundance of small cells. The spider- shaped cells are probably hypertrophied normal cells of the neuroglia, and have been considered by Charcot and Gombault as characteristic of syphilitic gummata of the brain. In a solitary gumma, however, of con- siderable size, from the neighborhood of the cere- bellum, studied by Coyne and Peltier, there were no stellate cells. Coyne considers that their presence is due to their previous existence in the normal state of the regions affected by the gumma. Exactly how syphilitic gumma of the brain are removed in cases of recovery, it is difficult to deter- mine. It is certain that they become softened, and disappear more or less completely; and it is probable that the cicatrices or the small peripheral cysts which are not rarely found in the surfaces of the brain are oftentimes remnants of gummatous tumors. In a number of cases collected by Gros and Lancereaux there were small areas of softened tissue, or small calcareous and caseous masses, or cerebral lacunae cor- responding to the cicatrices of softening, or imperfect cysts, coincident with evidences of syphilis elsewhere. V. Cornil also states that he has found small areas of softening with well-established syphilitic lesions of the dura mater and cranium, but believes that the lacunae or cysts depend rather upon chronic syphilitic lesions of cerebral arteries than upon gummatous inflamma- tion. When a gummatous tumor comes in contact with an artery, the latter is usually compressed and its walls undergo degeneration. The specific arteritis may pass beyond the limit of the syphilome and ex- tend along the arterial wall. Not rarely there is un- der these circumstances a thrombus, and if the artery be a large one, secondary softening of its distributive brain-area occurs. Cortical Syphilis. — Our knowledge of the lesions of the brain cortex produced by syphilis, is im- perfect and uncertain, but there seem to to be two conditions which require notice here. 22 The first of these varieties is a diffused gumma- tous infiltration of a wide territory of the cortex, with or without pronounced exudation in the cerebral mem- brane. This syphilitic infiltration is probably always attended with irritation of the pia mater, and aggluti- nation of this with the brain substance. I have, at various autopsies, seen the brain substance involved with the under surface of an irregular gummatous exudation, which apparently had sprung, first from the the membranes, and most of the cases of recorded cortical disease are of this character. Moreover, I have never seen cases in which the main infiltration was in the cortex of the brain itself and the membranes only slightly or secondarily involved. Such cases must be extremly rare. The descript* 3ns of the older writers, without careful microscopic studies, are of no value in determining the existence of syphiltic infiltra- tion of the cerebral cortex, and the satisfactory cases are very infrequent in medical literature. Two in- stances are very briefly recorded by Rumpf,* who sim- ply states that he found a diffuse syphilitic disease of the capillaries and small arteries in the brain cortex: the symptoms during life having more or less closely resembled those of dementia paralytica. Heubner reports a case recorded by Schule.f * Die Syphilitischen Erkrankungen des Nervensystems, P. 159- f Ziemssen Cyclopoedia of Practical Medicine, vol. xii, P- 31. — 23 — The symptoms had been those of dementia paralytica, with frequent outbreaks of confirmed constitutional syphilis, and the patient had been in an asylum for twenty years. At the autopsy there were found, be- side a circumscribed gummatous inflammation between cranium and dura mater: "A hemorrhegic pachymeningitis, an old opacity and thickening of the soft membranes, and an atheromatous de- generation of the large arteries of the base; a peculiar pale gray, as it were, swollen condition of the cerebral cortex; a small softening of the left nucleus lenticularis; and a gray de- generation of the lateral columns of the spinal cord, chiefly on the left side. Upon microscopic examination, it appeared that in the cerebral cortex the texture of the neuroglia had taken on another and homogenous quality, and was abnormally filled up with nuclei, single and in groups, chiefly along the vessels, which were themselves much altered. Their walls were thick- ened, sclerosed, and their cells had undergone fatty degenera- tion, or their ^channels were accompanied by close rows of nuclei, or by lines of spindled cells, others being surrounded by a dense web of connective tissue, or obliterated so as to become fibrous bands. The ganglion cells were shrunken in various degrees." The second variety of cortical brain lesion is not spoken of by writers, but is that in which change ap- pears to be a subacute inflammation affecting the vessels and the neuroglia. I report later in this brochure, in detail, -a case of this character. The disease occurred in the person of a young man who was suffering from undoubted syphilis, and presented during life many of the symptoms of cere- — 24 — bral syphilis. In this case the alterations had appar- ently reached their fullest extent in the anterior lobes, where there was a total destruction of the normal nerve tissues; towards the posterior lobes the alterations of the cortical structure grew less and less, until they gradually disappeared in normal tissue. This made it possible, in the single case, to study the develop- ment of the lesion. Whilst in the anterior portion of the brain the pia mater was completely adherent, in the posterior portions it was entirely free. It was found that in some places there was evident structural alteration of the cortex without the pia mater being distinctly abnormal, even the vessels of the cortical substance being more diseased than those of the pia mater, showing that the lesion commenced in the brain and spread from it to the membranes, rather than vice versa. In portions of the brain in which the neuroglia and the nerve cells appeared to be entirely normal, the coats of the blood vessels were distinctly thickened, and the walls of the vessels themselves cov- ered externally more or less closely with small cells, or large nuclei imbedded in, or adherent around, them, the vascular spaces being well developed, perhaps even a little abnormally large. Here and there in such portions of the tissue would be found places where these cells had aggregated in groups, or small masses, about some larger vessels. In the anterior portions of the brain a similar condition of the vessels was found, only much exaggerated, the — 25 — walls being enormously thickened, and the small cells or large nuclei more abundant; but no where, how- Fig. I. Showing edge of convolution bordering upon inflamed Pia Mater. Arteriole entering between convolutions, showing Periarteritis. X 250. — 26 — ever, were the cells aggregated into even minute gum- matous masses. My studies indicated clearly that the Fig. 2. Cross Section in Pia Mater. X 250 disease commenced in the external coats of the ves- sels, but soon involved the general neuroglia tissue, the — 27 — whole structure being more or less filled with cellular elements similar to those found adhering to the vessels. At the same time there was a destruction of the proper nerve tissue, so that in the most advanced por- tions of the brain the cells had entirely disappeared. In this portion of the brain were also found, loosely Fig 3. Leucocytes tending to organize into tissue. X 5°° (reduced). adhering to the pia mater, curious reticulated, proto- plasmic (many nucleated) masses, apparently the re- sult of fusing together and development of white blood corpuscles into a sort of connective, tissue. Syphilis of the Blaod Vessels. — Syphilis is one of the most frequent causes of atheroma of the arteries, and in syphilitic subjects atheroma of the vessels of the brain is very frequent. As in the changes which it causes, as well as in the course of its development, it does not differ from athe- 28 — roma elsewhere, I shall not discuss its pathology in detail; but there is a form of syphilitic disease which is especially prone to attack the arteries at the base of the brain, and is more destructive in its his- tory. The first change in the blood vessel is a loss of its transparency, with the development of a peculiar whitish appearance which increases until the whole artery is grayish-white. Little by little the vessel loses its flat cylindrical form until it becomes per- fectly round; at this time it is much firmer to the touch than normal, and at last it remains stiff and and hard. The naked eye is sufficient to show that the lumen of such a vessel is irregularly encroached upon. Under the microscope, this encroachment is seen to be due to zones of newly formed substance of white or grey color, which at first is dry and tough, but in the last stage hard and cartilaginous. Accord - to Heubner, this newly-grown substance is developed between the elastic lamina of the intima and the endo- thelium, and consists at first of endothelial cells, which constantly increase and alter until they form a firm felted tissue composed of spindle and stellate cells, into which run prolongations from the nutritive vessels. This mass may increase longitudinally, involving more and more of the main artery. It may become organ- ized and take upon a structure similar to that of the original wall of the vessel, when the process comes to a standstill with great lessening of the lumen of the vessels; or it mav be transformed into a fibrous con- — 2 9 — nective tissue, the whole affected portion of the artery becoming useless. This degeneration especially at- tacks the carotids and their branches, the arteries of the Sylvian fissure and of the corpus callosum, near their origins, and by interference with the terminal arteries which supply the corpus striatum, not rarely produces softening of it. The disease of the brain cortex, which has been spoken of as connected with disease of the vessels, is probably largely dependent upon, and secondary to, the affection of the blood vessels. It might therefore well be considered at this place, had it not already been discussed in sufficient detail. Syphilomata may produce softening and breaking down of the brain tissue by pressure upon the vessels, or even upon the brain substance, but the softenings, the wide spread degenerations of brain tissue which are so frequent in syphilitic subjects, are much more frequently due to disease of the blood vessels, either alone or in connection with syphilitic disease of the membranes. It must also be remembered that the peculiar degeneration described in the last paragraph, although more frequent in the large vessels, may oc- cur in the smallest and that a large or a small vessel so diseased is unable to properly exercise its function, and very frequently becomes the seat of a thrombus. Section II. Symptomatology. It has always been stated that syphilis may produce various more or less distinct lesions of the nerve cen- — 3° — tres. It must be remembered, however, that it is not usual for one of these lesions to exist by itself, but that in any individual case, usually two, or perhaps all of them, are present. Since the lesions of cerebral syphilis vary, it is evident that the symptoms of the dis- order must also vary: moreover, the same lesion occupies now this, now that, brain region, and as the symptoms which it produces are the outcome of inter- ference with the function of the part of the brain immediately implicated, it is evident that the same lesion must in different cases cause different symp- toms: it is, indeed, rare to find two cases of syphilitic brain disease offering exactly similar symptoms and running parallel courses, so that it is difficult to make a picture of a typical or ideal case of the dis- ease. In attempting the study of symptomatology, it is best to begin with gummatous meningitis as the most ordinary form of the specific brain affection. As the gummatous mass may diffuse itself widely, or may be strictly localized, under the head of gummatous syph- ilis of the brain membrane are included cases of localized gummatous tumors, and also cases of syph- ilitic meningitis, /. e., cases in which the large regions of the meninges are involved in an inflammation with gummatous exudation. Gummatous Syphilis of the Brain Membrane. Cases of gummatous brain syphilis may, for our present purpose, be very well divided into the acute — 3 1 — and chronic, it being remembered that a case which in its onset is most acute, almost invariably ends in a chronic disorder. Although the clinician is justified in talking about acute syphilitic meningitis, I am myself much inclined to doubt whether acute inflammation of the brain membranes or of the brain substance, ever develops as a primary syphilitic lesion. It seems to me much more probable that such acute inflammation is al- ways preceded by a chronic meningitis, or by the formation of a distinct gummatous tumor; neverthe- less it is very certain that acute meningitis may de- velop in a case when there have been no apparent symptoms, and therefore may seem to be absolutely abrupt in its onset. Some years ago, I was asked to see in consulta- tion, a patient who was suffering from a partial hemi- plegia as the result of an attack of acute brain con- gestion, and was told that in the midst of apparently perfect health, the man came home from business complaining of sleepiness, was shortly afterwards found comatose, and almost immediately after this became violently convulsed. The convulsions per- sisted for some time under the administrations of a homoeopathic practitioner; the doctor who was then summoned, found the patient comatose, fiercely convulsed, with a full bounding pulse and high temperature. Very free venesection was practiced and the patient became quiet, although still un- — 3 2 — conscious. A few hours later a recurrence of the convulsive movements was subdued by cupping the back of the neck. Shortly after this treatment the convulsions ceased, the respiration became regular, and after a few hours consciousness returned. After this return to consciousness, however, there was slight weakness of the left side, which in the course of forty-eight hours had distinctly increased. Believing that the case was one of syphilis, I suggested the free exhibition of mercury, and a few days later my diagnosis was confirmed by the appearance of a plainly specific squamous eruption on the hand. Un- der antisyphilitic medication, complete recovery was obtained. In this case the mode of coming on and the gradual increase of the hemiplegia after the con- vulsion, indicated that a latent gumma had preceded the acute attack. Almost always very careful investigation will, in these cases of acute brain syphilis, show that there have been prodromic symptoms which have been overlooked. As an example I may cite the case of B. R., aged 28, whom I also saw in consultation. It was stated that in the afternoon of January 21, 1887, with- out prodromes, he suddenly became dizzy and fell, the fall being followed by light delirious stupor, high fever, very rapid pulse, succeeded after some hours by clear mental action, with persistent headache and malaise, and five days later by an epileptic convulsion. In this instance, however, careful cross-questioning — 33 — elicited from the man's wife the statement that, although he had been attending to his business regu- larly up to January 21, he had previously complained of great drowsiness. The further course of this case is sufficiently interesting to be worthy of noting: On January 28th there was weakness of the external rectus muscle without ocular paralysis, with violent headache, and very rapid and feeble pulse When left to himself, Mr. R. continually talked nonsense, but when aroused would answer questions with a fair degree of correct- ness. He did not, however, recognize clearly those about him, and at night was irrational and frequently delirious, with periods of profound, almost stuporous sleep. Under active mercurial treatment, by the 18th of February he was much better, but on that day, he was suddenly seized with epilepti- form convulsions lasting for some hours, followed by pro- longed hebetude with wandering delirium at night, great head- ache, hallucinations, retention of urine and strabismus. Mr. R. was now freely ptyalized, and subsequently given a drachm of iodide of potassium three times a day. By the 2nd of March all the symptoms had vanished and convalescence seemed fairly established. Early in May he returned to his business, and since that time has remained in good health, under the continued use of small doses of the iodide of potas- sium. Another case illustrative of the form of syphilis now under consideration, is that of Patrick McC, who was picked up by the police patrol, and brought into the University Hospital as a case of apoplexy. He was profoundly unconscious, with flushed face and conjunctiva, with contracted pupils which responded very feebly to the light; pulse, 58; temperature, 96.8. He remained for — 34 — some hours in a condition of stupor, with retention of urine; but calomel being very freely administered, in 48 hours he was able to answer questions and to complain of headache. Under the continued use of iodide of potash, which was rapidly increased to a drachm three times a day, he soon conval- esced, and in two weeks after his admission was discharged from the hospital without the appearance of any symptoms. This patient, after recovery of consciousness, stated that he was entirely well until three days before his admission into hospital, when he was seized by violent headache increased by light, giddiness, ringing of the ears, and a marked sense of hebetude. Unmistakable evidences of syphilitic infection, past and present, were upon his person. It is evident, that a case of chronic syphilis may, at any time suffer from an epileptic or an apoplectic attack, readily mistaken for an acute disease. It is perhaps not so universally recognized that a sufferer from a chronic syphilitic brain lesion is liable to an attack of not only simple brain congestion, but also of an acute meningitis. At the University Hospital Dis- pensary, I once made the diagnosis of chronic cerebral syphilis in a patient who the next day was seized with violent delirium, and typical evidences of acute meningitis, accompanied with excessive pain in the head and convulsions. After the convulsions had persisted for four days, I was sent for, and found the man offering every symptom of explosive meningitis, and after his death it was discovered that an acute meningitis had been engrafted upon a chronic menin- gitis evidently of syphilitic origin. A similar case to — 35 — this is reported by Gamel,* in which intense headache, fever, and delirium, came on abruptly in an old syphil- itic subject, and ended in general palsy and death. At the autopsy the symptoms were found to have de- pended upon an acute meningitis secondary to a large gumma. In this connection may well be cited the observa- tion of Molinier f in which violent delirium, convul- sions, and coma, occurred suddenly. A very curious case is reported by D. A. Zambaco,]; in which attacks simulating acute meningitis, occurring in a man with a cerebral gummatous tumor, appear to have been mala- rial. In such a case the diagnosis of a malarial parox- ysm could only be made out by the presence of the cold stage, the transient nature of the attack, its going off with a sweat, its periodical recurrence, and the therapeutic effect on it of quinine. The symptoms of chronic brain syphilis are so pro- tean, so polymorphic, sometimes in the single case so kaleidoscopic in the weekly or even daily shiftings and combinations, that it is almost impossible to reduce them to any order. Possibly the most danger- ous cases are those in which the symptoms are least severe, and so elusive that they fail to call attention to the existence of severe organic disease of the brain. * Inaug. Diss., Montpellier, 1875. f Revue Med. de Toulouse, xvi, 1880. X Des Affectiones Nerveuses Syphilitique, Paris, 1862, p. 485. _ 3 6 - Malaise, a little brain failure, a succession of causeless headaches — these may for a long time be all the out- comes. The following outline of a case taken from my notebook will serve to illustrate this mild form of the disorder: Mr. A. J. F., aged 50, was first seen by me April 28, 1880. The history that he gave was that during 1875 and 1876, being the head of a large corporation engaged in legal struggles for existence, he was under great strain and overwork, and gradually failed in health until April 1876, when he was sud- denly seized with partial blindness, and loss of power in his legs. This continued, at times worse, at times better, for some months, until finally he was forced to take to his bed with great prostration, and mu h distress in the head, and a sense of pressure of the forehead. July 1876 he began to get about, but was unable to attend to business; any mental exertion brought on distress of the head with confusion of thought. He stated that he had never had any distinct spells of giddiness, but much numbness about the head, and that there was loss of control over his muscles so that, to use his words, " when he wanted to change position he could not tell how to do it." This symptom varied in intensity from time to time. There had been distinct failure of memory for recent events, but no convulsive attacks. In February 1880, without warning, he fell unconscious, but was not convulsed. The unconsciousness lasted for five minutes followed by delirium and great excite- ment. Under the administration of chloral he went to sleep, but it was several days before he recovered completely. Since the beginning of the illness his eyesight had not been very good, but he had obtained some imperfect relief from glasses. In 1878 he noticed that he could see a great deal better in the night than in the day, — in the day everything seemed blurred. Dur- ing all these years he had been a good walker; no disturbance — 37 — of bladder or rectum or of the sexual functions; had had some tingling in the hands and feet; at times heard very distinctly bands of music, voices, etc. ; — the hearing of these sounds was sometimes so distinct as to deceive him, but had never pro- duced any mental delusion; there had been no visual delusions; he had had no second attack of unconsciousness. April 28, at the time he came under my care, his symptoms according to my notes were as follows: "Appetite and digestion good; no disturbance in the power of electro-muscular contractility or reflexes of the arms and legs; some little lack of sensibility in the legs so that he can not separate the points of the aesthesio- meter at two and a half centimeters; has some sensation of numbness on the right side of the head associated with some loss of power of separating the aesthesiometrical points as con- trasted with the opposite side of the head. Vision at times perfect, but often duplex, and not infrequently he sees, two, three, four, or even five secondary images, all the secondary images being blurred. There has been distinct change of dis- position, he having become irritable and apathetic. Under the frequent cauterization of the neck and the ad- ministration of iodide of potassium, Mr. F's symptoms gradu- ally abated and after some months he left me perfectly cured. March 13, 1886, Mr. F. reported at my office with symp- toms of failure of health accompanied with loss of power to do mental work; some mental confusion, some headache, but more pronounced general distress in the head, and very marked right ptosis. He was first salivated, and afterwards iodide of potassium was administered to him in doses of half a drachm three times a day, associated with small doses of mercurials. Under this treatment he greatly improved, and by June had recovered his general health, and also the use of his right eye- lid. Oct. i883. Mr. F. returned suffering from the old symp- toms, with, however, the ptosis not so pronounced as before, - 3 8 - but affecting very distinctly both eye-lids. Under the use of large doses of iodide and mercurials he again recovered. In the more severe cases of chronic brain syphilis which have come under my observation, most usually after a greater or less continuance of prodromes such as have been mentioned, epileptic attacks have oc- curred with a hemiplegia, or a monoplegia, which is almost invariably incomplete, and usually progressive; very frequently diplopia is manifested before the epilepsy, and on careful examination is found to be due to weakness of some of the ocular muscles. Not rarely oculo-motor palsy is an early and pronounced symptom, and a marked paralytic squint is very com- mon. Along with the development of these symptoms there is almost always distinct failure of the general health and progressive intellectual deterioration, as shown by loss of memory, failure of the power to fix the attention, mental bewilderment, morbid somnol- ence, perhaps aphasia, and towards the end of life not rarely dementia. If the case convalesce under treat- ment, the amelioration is gradual, the patient travel- ing slowly up the road he has come down. If the case end fatally, it is usually by a gradual sinking into complete paralysis, or the patient is carried off by an acute inflammatory exacerbation, or, as in two of my cases, amelioration may be rapidly occurring and a very violent epileptic fit produce a sudden fatal asphyxia. Death from brain-softening around the tumor is not infrequent, but a fatal apoplectic hemor- rhage is rare. — 39 — I do not think much is to be gained by attempt- ing to classify cases of cerebral syphilis, but Fournier separates them into the cephalic, congestive, epileptic, aphasic, mental, and paralytic, although in so doing he scarcely facilitates description or study. Heubner makes the following types: "i. Psychical disturbances, with epilepsy, incom- plete paralysis (seldom of the cranial nerves), and a final comatose condition, usually of short duration. " 2. Genuine apoplectic attacks with succeeding hemiplegia, in connection with peculiar somnolent conditions, occurring in often-repeated episodes; fre- quently phenomena of unilateral irritation, and gener- ally at the same time paralyses of the cerebral nerves. " 3. Course of the cerebral disease similar to paralytica dementia." In regard to these types, the latter seems to me clear and well defined, but contains those cases which I shall discuss under the head of Cortical Disease. Meningeal syphilis as seen in this country does not conform rigidly with the other asserted types, although there is this much of agreement that, when the epilepsy is pronounced, the basal cranial nerves are not usually paralyzed, the reason of this being that epilepsy is especially produced when the gumma- tous change is in the ventricles or on the upper cortex. In basal affections the epileptoid spells, if they occur at all, are usually of the form of petit mal; but this rule is general, not absolute. The apoplectic somno- — 4o — lent form of cerebral syphilis, for some reason, is rare in this city, and it seems necessary to add to those of Heubner's, a fourth type, to which a large proportion of our cases conform, and a fifth, and still more rare form of the disorder. These types I would charac- terize as follows: 4. Psychical disturbance without complete epilep- tic convulsions, associated with palsy of the basal nerves and often with partial hemiplegia. 5. Paraplegia associated with ocular or other symptoms indicative of lesions at the base of the brain. I have seen a number of cases in which, along with the symptoms of disease of the spinal cord, have been present evidences of implication at the base of the brain, such as headache, dilatation of the pupils, squint, or some times even paralysis of the facial, trigeminal, or other basal nerves not connected with the vision; multiple lesions in syphilis of the nerve centres, are of course very frequent, and in the cases now under consideration I believe that the lesions existed at different levels upon the cord, some implicat- ing the medulla oblongata, or even the pons, whilst others are placed at varied heights in the spinal column. As an example of this class of cases, I ap- pend an account of one which was long under my care. The history of syphilitic infection was not com- plete, but the character of the symptoms and the fact that they rapidly yielded to anti-syphilitic medica- — 41 — tion, and were not obviously affected by other treat- ment, is sufficient evidence as to the real nature of the disease. X. Y., aged 27, has no knowledge of specific infection, although acknowledges frequent exposure. Health good until March 14, 1884, when he was taken with a general feeling of malaise and languor, which increased for a week, and then be- came so bad that it forced him to go to bed. At this time power to pass water failed, so that his urine had to be drawn off by catheter; bowels costive; complete anorexia; great weakness; some headache, and dull, steady pain in the arms, which, with restlessness, kept him awake. He came under my care April 7th; at this time bis body, and especially the legs, were emaciated. The notes read: " Muscles soft and flabby, and reflexes greatly exaggerated, especially knee jerk; grasp of hands very weak; is able to stand, but walks very feebly, and only a few steps, with much staggering; station not affected by shutting the eyes; aesthesiometer shows the sensibility de- cidedly impaired in the legs, normal in the arms; has drooping of right eyelid and double vision; urine has to be drawn with catheter; suffers no pains, except some dull pain in the arms." He was first treated with alternate hot and cold water, douches to the legs, and iodide of potassium. He improved steadily, and by April 20th the double vision had disappeared. On the 20th it was noted that vision, the bladder functions, and sensibility, were normal, and that his grip was stronger; but the legs were still distinctly weak, although he was able to walk a little, and went about a great deal on crutches; the knee jerk had become nearly normal. There was little head- ache, but a great deal of dizziness. The large doses of iodide of potassium and the small doses of corrosive sublimate, were continued through the sum- mer, and by the first of August the patient was able to walk — 4 2 — very well. Near the middle of August he recommenced his office work, when one day, after standing three or four hours, a sense of weakness developed in the legs, which, in spite of treatment, grew steadily worse, until he was forced to take up crutches again. Simultaneously with the lameness, there de- veloped pain in the elbows very similar to that from which he had first suffered; also headache. There was no return of the urinary symptoms, except occasionally slowing or arrest of the passing of the urine. The iodide, which he had been taking through the summer in small doses, was increased to rso grains a day. In four days slight evidences of iodism developed, and the dose was de- creased to 75 grains a day. Under this treatment the symp- toms ameliorated, and by the latter part of September the pa- tient had become quite strong and able to walk freely, although there was still some pain in the arms and head. In October, treatment with small doses of the alteratives was continued, iodide of potassium and the green iodide of mercury being used. In October a violent headache with dizziness came on, but was relieved by blisters back of the ears, leeches to the back of the neck, and an increase of the iodides. . In February of 1885 there was still a tendency to headache after study; but # his legs seemed entirely well, and he could use them freely. The patient's condition slowly improved, with occasional back- sets, and in November, 1887, he appeared to be entirely re- covered, and was able to run and jump about as freely as ever. Subsequently there were several slight relapses, with headache, weakness of the legs, etc. Under mild but persistent anti- specific medication, the health of the patient became more thoroughly established; and at the date of present writing (March, 1889) he has remained for many months entirely free from abnormal manifestations, and able to do a very large amount of work in his profession. It must be remembered that the separation of — 43 — these varieties of cerebral syphilis, is artificial and arbitrary, so that the most satisfactory way of ap- proaching this subject is to study the important symp- toms in severalty,* rather than to attempt to group them into recognizable varieties of the disease; and this method I shall here adopt. Headache is the most constant, and usually the earliest, symptom of meningeal syphilis; but it may be absent, especially when the lesion is located in the reflexions of the meninges which dip into the ventri- cles, or when the basal gumma is small and not sur- rounded with much inflammation. The length of time it may continue without the development of other distinct symptoms, is remarkable. In one case * at the University Dispensary, the patient affirmed that he had had it for four years before other causes of com- plaint appeared. It sometimes disappears when other symptoms develop. It varies almost indefinitely in its type, but is, except in very rare cases, at least so far paroxysmal as to be subject to pronounced exacer- bations. In most instances it is entirely paroxysmal; and a curious circumstance is, that very often these paroxysms may occur only at long intervals. Such dis- tant paroxysms are usually very severe, and are often accompanied by dizziness, sick stomach, partial un- consciousness, or even by more marked congestive symptoms. The pain may seem to fill the whole cra- *Book Y, p. 88, 1879. — 44 — nium, may be located in a cerebral region, or fixed in a very limited spot. Heubner asserts that when this headache can be localized, it is generally made dis- tinctly worse by pressure at certain points; but my own experience is hardly in accord with this. Any such soreness plainly cannot directly depend upon the cerebral lesion. In the great majority of cases I have seen, there has been no local tenderness; indeed, both in cerebral and spinal syphilis, according to my own experience, localized soreness indicates an affec- tion of the bone or of its periosteum. In many cases, especially when the headache is persistent, there are distinct nocturnal exacerbations. It will be seen that there is nothing absolutely characteristic in the headache of cerebral syphilis; but excessive persistency, apparent causelessness, and a tendency to nocturnal exacerbation, should in any cephalalgia excite suspicion of a specific origin — a suspicion which is always to be increased by the oc- currence of slight spells of giddiness, or by delirious mental wandering accompanying the paroxysms of pain. When an acute inflammatory attack supervenes upon a specific meningeal disease, it is usually ushered in by a headache of intolerable severity. When the headache in any case is habitually very constant and severe, the disease is probably in the dura mater or periosteum; and this probability is much increased if the pain be local and augmented by firm, hard pressure upon the skull over the seat of the pain. — 45 — Disorders of Sleep. — There are two antagonistic disorders of sleep, either of which may occur in cere- bral syphilis, but which have only been present in a small proportion of the cases that I have seen. In- somnia is more troublesome in the prodromic than in the later stages, and is only of significance when com- bined with other more characteristic symptoms. A peculiar somnolence is of much more determinate im- port. It is not pathognomonic of cerebral syphilis, yet of all the single phenomena of this disease it is the most characteristic. Its absence is, however, of little import in the diagnosis of an individual case. As I have seen it, it occurs in two forms. In the one variety, the patient sits all day long, or lies in bed in a state of semi-stupor, indifferent to everything, but capable of being aroused, answering questions slowly, imperfectly, and without complaint, but in an instant dropping off again into quietude. In the other variety the sufferer may still be able to work, but often falls asleep while at his tasks, and especially toward evening has an irresistible desire to slumber, which leads him to pass, it may be, half of his time in sleep. This state of partial sleep may precede that of the more continuous stupor, or may pass off when an attack of hemiplegia seems to divert the symptoms. The mental phenomena in the more severe cases of somnolency are peculiar. The patient can be aroused — indeed, in many instances he exists in a state of torpor rather than of sleep; when stirred up he thinks — 4 6 — with extreme slowness, and may appear to have a form of aphasia; yet at intervals he may be endowed with a peculiar automatic activity, especially at night. — Getting out of bed; wandering aimlessly and seem- ingly without knowledge of where he is, and unable to find his couch; passing his excretions in a corner of the room or in other similar locality, not because he is unable to control his bladder and bowels, but be- cause he believes that he is in a proper place for such act — he seems a restless nocturnal automaton rather than a man. In some cases the somnolent patient lies in a perpetual stupor. Apathy and indifference are the characteristics of the somnolent state, yet the patient will sometimes show excessive irritability when aroused, and will at other periods complain bitterly of pain in his head, or will groan as though suffering severely in the midst of his stupor — at a time, too, when he is not able to rec- ognize the seat of the pain. I have seen a man with vacant, apathetic face, almost complete aphasia, per- sistent heaviness and stupor, arouse himself when the stir in the ward told him that the attending physician was present, and come forward in a dazed, highly pathetic manner, by signs and broken utterances beg- ging for something to relieve his head. Huebner speaks of cases in which the irritability was such that the patient fought vigorously when aroused; this I have not seen. This somnolent condition may last several weeks. — 47 — T. Buzzard* details the case of a man who, after a specific hemiplegia, lay silent and somnolent for a month, and yet finally recovered so completely as to win a rowing match on the Thames. I have now un- der my care a patient who is entirely rational, though he still suffers from occasional uncontrollable head- aches; who several years since was profoundly somno- lent for four months, much of the time so absolutely comatose that his discharges were passed in his bed without his knowledge, and his food swallowed auto- matically when put into his mouth by a nurse. In its excessive development, syphilitic stupor puts on the symptoms of advanced brain-softening, to which it is indeed often due. Of the two cases with fatal result which I have notes, one at the autopsy was found to have symmetrical purulent breaking down of the anterior cerebral lobes, apparently from disease of the basal arteries; the other, softening of the right frontal and temporal lobes, due to the pressure of a gum- matous tumor and ending in a fatal apoplexy. This close connection with cerebral softening ex- plains the clinical fact that apoplectic hemorrhage is apt to end the life in these cases of somnolent syphilis. But a prolonged deep stupor in persons suffering from cerebral syphilis does not prove the ex- istence of extensive brain-softening, and is not incom- patible with subsequent complete recovery. As an * Clinical Lectures on Dis. Nerv. Sys., London, 1882. - 4 8 - element of prognosis, it is of serious but not of fatal import. Paralysis. — When it is remembered that a syphi- litic exudation may appear at almost any position in the brain, that spots of encephalic softening are a not rare result of the infection, that syphilitic disease is one of the causes of cerebral hemorrhage, it is plain that a specific palsy may be of any conceivable variety, and affect either the sensory, motor, or intellectual sphere. The mode of onset is as various as the character of the palsy. The attack may be instantaneous, sudden, or gradual. The gradual development of the syphi- litic gumma would lead us, a priori, to expect an equally gradual development of the palsy; but experi- ence shows that in a large proportion of the cases the paralysis appears suddenly, with or without the occur- rence of an apoplectic or epileptic fit. Under these circumstances it will be usually noted that the result- ing palsy is incomplete; in rare instances it may be at its worst when the patient awakes from the apoplectic seizure; but commonly it progressively increases for a few hours and then becomes stationary. These sudden partial palsies, probably result from an intense conges- tion around the seat of disease, or from stoppage of of the circulation in the same locality: whatever their mechanism may be, it is important to distinguish them from palsies which are due to hemorrhage. I believe this can usually be done by noting the degree of par- alysis. — 49 — A suddenly-developed, complete hemiplegia, or other paralysis, may be considered as in all probability either hemorrhagic or produced by a thrombus so large that the result will be disorganization of the brain-substance, and a future no more hopeful than that of a clot. On the other hand, an incomplete palsy may be rationally believed to be due to pressure or other removable cause; and this belief is much strengthened by a gradual development. The bear- ing of these facts upon prognosis it is scarcely neces- sary to point out. Although the gummata may develop at almost any point, they especially affect the base of the brain, and are prone to involve the nerves which issue from it. Morbid exudations, not tubercular or syphilitic, are rare in this region. Hence a rapidly but not abruptly appearing strabismus, ptosis, dilated pupil, or any paralytic eye-symptom in the adult, is usually of a syphilitic nature. Syphilitic facial palsy is not so frequent, whilst paralysis of the facial nerve from rheumatic and other inflammation within its bony canal, is very common. Paralysis of the facial nerve may therefore be specific, but existing alone is of no diagnostic value. Since syphilitic palsies about the head are in most instances due to pressure upon the nerve-trunks, the electrical reactions of degeneration may be obtained in the affected muscles. There is one peculiarity about specific palsies which has already been alluded to as frequently pres- s GG _ 5 o — sent — namely, their temporary, transient, fugitive nature, they varying in character and seat. Thus an arm may be weak to-day, strong to-morrow, and the next day feeble again, or the recovered arm may re- tain its power and a leg fail in its stead. These transient palsies are much more apt to involve large than small brain territories. The explanation of their largeness, fugitiveness, and incompleteness is that they are not directly due to clots or other structural changes, but to congestions of the brain-tissues in the neighborhood of gummatous exudations. Squint, due to direct pressure on a nerve, will remain when the accompanying monoplegia due to congestion disap- pears. Motor palsies are more frequent than sensory affections in syphilis, but hemianaesthesia, localized anaesthetic tracts, indeed any form of sensory paraly- sis, may occur. Numbness, formications, all varieties of paresthesia, are frequently felt in the face, body, or extremities. Violent peripheral neuralgic pains are rare, and generally when present denote neuritis. Huguenin, however, reports* a severe trigeminal an- aesthesia dolorosa, which was found after death, frqm intercurrent disease, to have depended upon a small gumma pressing upon the Gasserian ganglion. A somewhat similar disease has been reported by Allen McLane Hamilton, f * Schwiez. Corr. Blat.. 1875. f Alienist and Neurologist, iv, 58. — 5 1 — The special senses are liable to suffer from the invasion of their territories by cerebral syphilis, and the resulting palsies follow courses, and have clinical histories, parallel to those of the motor sphere. The onset may be sudden or gradual, the result temporary or permanent. Charles Mauriac * reports a case in which the patient was frequently seized with sudden attacks of severe frontal pain and complete blindness, lasting from a quarter to half an hour; at other times the patient had spells of aphasia lasting for one or two minutes. I have seen in two cases nearly com- plete deafness develop in a few hours in cerebral syphilis, and disappear abruptly after some days. Like other syphilitic palsies, therefore, paralysis of special senses may come on suddenly or gradually, and may occur paroxysmally. Among the palsies of cerebral syphilis must be ranked aphasia. An examination of recorded cases shows that syphilitic aphasia is subject to vagaries and laws similar to those which dominate other specific cerebral palsies. It is usually a symptom of advanced disease, but may certainly develop as one of the first evidences of cerebral syphilis, and I have seen it as the most marked symptom in an acute syphilitic paroxysm when no distinct history of prodromes was obtainable. Coming on after an apoplectic or epileptic fit, it may be complete or incomplete; owing to the smallness of * Loc. Cit., p. 31. — 52 — the centre involved, and the ease with which its func- tion is held in abeyance, a total loss of word-thought is not so decisive as to the existence of cerebral hemor- rhage as is a total motor palsy. Like hemiplegia or monoplegia, specific aphasia is sometimes transitory and paroxysmal. Buzzard* records several such cases. Mauriacf details a very curious case in which a patient, after long suffering from headache, was seized by sudden loss of power in the right hand and fingers, lasting about ten minutes only, but recurring many times a day. After this had continued some time, the paroxysms became more completely paralytic, and were accompanied by loss of the power of finding words, the height of the crises in the palsy and aphasia being simultaneously reached. For a whole month, these attacks occurred five or six times a day, without other symptoms except headache, and then the patient became persistently paralytic and aphasic, but finally recovered. To describe the different forms of specific aphasia and their mechanism of production, would be to enter upon a discussion of aphasia itself— a discus- sion out of place here. Suffice it to say that any con- ceivable form of aphasia may be induced by syphilis, although on account of the tendency of the syphilitic lesion, when placed near the speech centres, to spread its influence over a wide territory, I have very rarely * Loc. cit., p. 81. | Aphasie et Hemiplegie Droite Syphilit., Paris, 1877. — 53 — been able to detect any of the more extraordinary forms of aphasia, such as word-blindness, etc. The aphasia may be the result of a gummatous tumor involving the artery, or of a clot; but I have seen passing, repeated, attacks of complete aphasia, fol- lowed by a permanent condition of partial aphasia caused by syphilitic degeneration of the middle cerebral artery, as proven by autopsy, when there was no localized meningeal gumma present. Owing to the centres of speech being situated in the cortical portion of the brain, aphasia in cerebral syphilis is very frequently associated with epilepsy. Of course right-sided palsy and aphasia are united in syphilitic as in other disorders. If, however, the statistics given by Tanowsky* be reliable, syphilitic aphasia is associated with left-sided hemiplegia in an extraordinarily large proportion of cases. Thus in 53 cases collected by Tanowsky, 18 times there was right- sided hemiplegia, and 14 times left-sided hemiplegia, the other cases being not at all hemiplegic. Judging from the autopsy on a case reported in Mauriac's brochure, this concurrence of left-sided paralysis and aphasia, depends partly upon the great frequency of multiple brain lesions in syphilis, and partly upon the habitual involvement of large territories of the gray matter secondarily to diseased membrane. An im- portant practical deduction is that the conjoint exist- L'Aphasie Syphilitique. — 54 — ence of left hemiplegia and aphasia is almost diagnos- tic of cerebral syphilis. Probably amongst the palsies may be considered the disturbances of the renal functions, which are only rarely met with in cerebral syphilis, and which are probably in most instances dependent upon the specific exudation pressing upon the vaso-motor centres in the medulla. Fournier speaks of having notes of six cases in which polyuria with its accompaniment, polydipsia, was present, and details a case in which the specific growth was found in the floor of the fourth ventricle. Cases have been reported of true saccharine diabetes due to cerebral syphilis,* and I can add to these an observation of my own. The symptoms, which occurred in a man of middle age with a distinct specific history, were headache, nearly complete hemi- plegia, and mental failure, associated with the passage of comparatively small quantities of urine so highly saccharine as to be really a syrup. Under the influ- ence of iodide of potassium, the sugar in a few weeks disappeared from the urine. Epilepsy. — Epileptic attacks are a very common symptom of meningeal syphilis, and are of great diag- nostic value. The occurrence in an adult of an epileptic fit, after a history of intense and protracted headache, should always excite grave suspicion. * Consult Servantie, Des Rapports du Diabete et de la Syphilis, Paris, These, 1876; also case reported by L. Putzel, New York Med. Record, xxv, 450. — 55 ~ Before I had read Fournier's work on Nervous Syphilis, I taught that an epilepsy appearing after thirty years of age was very rarely, if ever essential epilepsy, and unless alcoholism, uraemic poison, or other adequate cause could be found, was in nine cases out of ten specific; and I therefore quote with satisfaction Fournier's words: " L'epilepsie vraie, ne fait jamais son premier debut a l'age adulte, a l'age mur. Si un homne adulte, au dessus de 30, 35, a 40 ans, vient, a etre pris pour la premiere fois d'une crise epileptique, et cela dans la cours d'une bonne sante apparente, il y a, je vous le repete, hui ou neuf chances sur dix pour que cette epilepsie soit d'originie syphilitique." Syphilitic epilepsy may occur either in the form of petit mal or of haut mal, and in either case may take on the exact characters and sequence of phenom- ena which belong to the so-called idiopathic or essen- tial epilepsy. The momentary loss of consciousness of petit mal will usually, however, be found asso- ciated with attacks in which, although voluntary power is suspended, memory recalls what has happened during the paroxysm — attacks, therefore, which simu- late those of hysteria, and which may lead to an error of diagnosis. Even in the fully developed type of convul- sions, the aura is only rarely present. Its absence is not, however, of diagnostic value, because it is fre- quently not present in essential epilepsy, and it may be pronounced in the specific disease. It is said that -56 - when in an individual case the aura has once appeared, the same type or form of approach of the convulsion is thereafter rigidly adhered to. The aura is some- times bizarre: a severe pain in the foot, a localized cramp, a peculiar sensation indescribable and unreal in its feeling may be the first warning of the attack. Again, an aura may affect a special sense: thus, I had a patient whose attacks began with blindness. When- ever, under such circumstances, I have had an oppor- tunity of making a post mortem, I have found an organic lesion of the special sense centre or tract whose function had been disturbed during life. In many, perhaps most, cases of specific convul- sions, instead of a paroxysm of essential epilepsy be- ing closely simulated, the movements are in the onset, or more rarely throughout the paroxysm, unilateral : indeed they may be confined to one extremity. This restriction of movement has been held to be almost characteristic of syphilitic epilepsy, but it is not so. Whatever diagnostic significance such restriction of the convulsion has, is simply to indicate that the fit is due to cortical organic lesion of some kind. Tumors, scleroses, and other organic lesions of the brain-cortex are as prone to cause unilateral or monoplegic epilepsy when they are not specific, as when they are due to syphilis. Indeed what has here been said in regard to the occurrence of aura, of spasm, or of paralysis, applies almost as equally well to other organic brain diseases as syphilis. — 57 — Specific and non-specific tumors or growths, produce by their interference with the function of a part, similar results. Sometimes an epilepsy dependent upon a specific lesion implicating the brain-cortex, may be replaced by a spasm which is more or less local, and is not at- tended with any loss of consciousness. Thus, in a case which recovered in the University Hospital, a man aged about thirty-five, offered a history of re- peated epileptic convulsions, but at the time of his entrance into the hospital, instead of epileptic attacks, there was a painless tic. The spasms, which were clonic, and occurred very many times a day (some- times every five minutes), were very violent, and mostly confined to the left facial nerve distribution. The trigeminus was never affected, but in the severer par- oxysms, the left hypoglossal and spinal accessory nerves were profoundly implicated in all of their branches. Once, fatal asphyxia, from recurrent laryn- geal spasm of the glottis, was apparently averted only by the free inhalation of nitrite of amyl. The sole other symptom was headache; but the specific history was clear, and the effect of antisyphilitic remedies rapid and pronounced. It is very plain that such attacks as those just de- tailed are closely allied to epilepsy. Indeed, there are cases of cerebral syphilis in which wide spread gen- eral spasms occur similar to those of a Jacksonian epilepsy, excepting in that consciousness is not lost, — 5 8 — because the nervous discharge does not overwhelm the centres which are connected with consciousness. (Case, Canada Med. and Surg. Joum , xi, 487). On the other hand, these epileptoid spasmodic cases link themselves to those in which the local brain affection manifests itself in contractions or persistent irregular clonic or tonic spasms. Contractures may exist, and may simulate those of descending degeneration (case, Centrbl. Nerv. Heik., 1883, p. 1), but in my own ex- perience are very rare. A case of syphilitic athetosis maybe found in the Lancet, 1883, ii, 989. The clonic spasms of cerebral syphilis may assume a distinctly choreic type, or may in their severity sim- ulate those of hysteria, throwing the body about vio- lently. (See Allison, Amer. Med. Jour., 1877, 74). It is, to my mind, misleading, and therefore improper, to call such cases syphilitic chorea, as there is no rea- son for believing that they have a direct relation with ordinary chorea. They are the expression of an or- ganic irritation of the brain-cortex, and are sometimes followed by paralysis of the affected member; in other words, the disease, progressing inward from the brain membrane, first irritates, and then so invades a corti- cal centre as to destroy its functional power. (Case, Chicago Med. Jour, and Exam., xlvi, 21). Psychical Symptoms. — As already stated, apathy, somnolence, loss of memory, and general mental failure, are the most frequent and characteristic mental symptoms of meningeal syphilis; but, as will be shown — 59 — in the next chapter, syphilis is able to produce almost any form of insanity, and therefore mania, melan- cholia, erotic mania, delirium of grandeur, etc., may develop along with the ordinary manifestation of cere- bral syphilis, or may come on during an attack which previously has been attended by only the usual symp- toms. Without attempting any exhaustive citation of cases, the following may be alluded to: A. Erlenmeyer * reports a case in which an attack of violent headache and vomiting was followed by paralysis of the right arm, and paresis of the left leg, with some mental depression; a little later the patient suddenly became very cheerful, and shortly afterward manifested very distinctly delirium of grandeur with failure of memory. Batty Tuke \ reports a case in which, with aphasia, muscular wasting, strabismus, and various palsies, there were delusions and hallucina- tions. S. D. Williams J records a case in which there were violent paroxysmal attacks of frontal headache. The woman was very dirty in her habits, only ate when fed, and existed in a state of hypochrondriacal melan- choly. Leiderdorf details a case with headache, par- tial hemiplegia, great physical disturbance, irritability, change of character, marked delirum of grandeur, epileptic attacks, and finally dementia, eventually cured by iodide of potassium. | Several cases illus- * Die Leutischen Psychosen. f Jour. Ment. Sci., Jan. 1874, p. 560. % Ibid, April, 1869. || Medicin. Jahrbucher, xx, 1864, p. 214. — 6o — trating different forms of insanity are reported by N. Manssurow.* That the attacks of syphilitic insanity, like the palsies of syphilis, may at times be temporary and fugitive, is shown by a curious case reported by H. Hayes Newington,f in which, along with headache, failure of memory, and ptosis, in a syphilitic person, there was a brief paroxysm of noisy insanity. Syphilis of the Brain Cortex. The mental symptoms which are produced by syphilis are often pronounced when paralysis, head- ache, epilepsy, or other palpable manifestations show the presence of gross gummatous lesion. In pre- vious paragraphs much has been said about these psy- chical disturbances, but it seems necessary further to discuss the question whether alienation disturbances can be produced by syphilis without the accompaniment of headache, or other evidences of the presence of or- ganic disease, and whether syphilis is capable of pro- ducing an insanity or a paralysis except by causing a distinctly gummatous lesion. According to our present nomenclature, a case in which psychical disturbances are present without more definite symptoms of organic brain disease, is properly spoken of as one of insanity; whereas if the other * Die Tertiare Syphilis, Wien, 1877. f Jour. Ment. Sci., London, xix, 555. — 61 — organic symptoms are present, the case should be spoken of as one of gummatous syphilis. There are a few alienists who recognize the existence of a distinct form of insanity properly entitled to be called syphil- itic, and there are others who deny that insanity is ever directly caused by syphilis, i. . B. St. John Roosa, M. D. The Physiological, Pathological and Ther- apeutic Effects of Compressed Air. By Andrew H. Smith, M. D. GranularLids and ContagiousOPhthalmia. By W. F. Mittendorf, M. D. Practical Bacteriology. By Thomas E. Saiterthwaile, M. D. Pregnancy, Parturition, the Puerperal State and their Complications. By Paul F. Munde. M. D. SERIES II. The Diagnosisand Treatmentof Haemor- rhoids. By Chas. B. Kelsey, M. D. Oiseases of the Heart. Vol. 1. By Dujardin-Beaumetz, M. D. Diseasesof the Heart. Vol. II. By Dujardin-Beaumetz, M. D The Modern Treatmentof Diarrhoea and y By n A^B. Palmer, M. D. Intestinal Diseases of Children, By A. Jacobi, M. D. The Modern Treatment of Headaches. By Allan McLane Hamilton, M. D. The Modern Treatment of Pleurisy and Pneumonia. By G, M. Garland, M. D. How to Use the Laryngoscope. By J. Solis Cohln7iVl. D. Diseasesof the Male Urethra. By Kessenden N. Otis, M. D. The Disorders of Menstruation. By Edward W. Jenks, M. D. The Infectious Diseases. In 2 vote. By Karl Liebermeister. SERIES III. Abdominal Surgery By Hal C. Wyman, M, D. Diseasesof the Liver. By Dujardin-Beaumetz, M.D. Hysteria and Epilepsy. . ,, ^ By J. Leonard Corning-, M. D. Diseases of the Kidney. , _ By Dujardin-Beaumetz, M. D. The Theory and Practice of the Ophthal- moscope. By J. Herbert Claiborne, Jr., M. D. Modern Treatment of Bright's Disease. By Alfred L. Loomis, M. D. Clinical Lectures on Certain Diseases of Nervous System. By Prof. J. M. Charcot, M. D. \ The Radical Cure of Hernia. By Henry O. Marcy, A. M., M. D., L. L. D. i The Treatment of Diseases of the Blad- der, Prostate and Urethra. By H. O. Walker, M. D. ! Dyspepsia. 3 Hy Frank Woodbury, M. D. | The Treatment of the Morphia Habit. By Erlenmeyer. The Etiologly, Diagnosisand Therapy of Tuberculosis. J By Frof. H. von Ziemssen. SERIES IV. Nervous Syphilis. By H. C. Wood, M. D. Education and Culture as correlated to the Health and Diseases of Women. By J. A. C. Skene, M. D. Diabetes. By A. H Smith, M. D Rheumatism and Gout. ^ By F. Leroy Satterlee, M. D. Hypodermic Medication. By Bourneville and Bricon. A Treatise on Fractures. By Armand Despris, M. D. Neuralgia. By S E. P. Hurd, M. D. Auscultation and Percussion. By Frederick C. Shattuck, M. D. Practical Points in the Management of Diseases of Children. By I. N Love, M. D. Electricity its application in Medicine, By Wellington Adams, M. D. Taking Cold. By F. H. Bosworth, M. D. Some Minor and Major Fallacies con- cerning Syphilis. By E. L. Keyes, M. D. GEORGE S. DAVIS, Publisher, 3P. O. Boas -irro. Detroit, Ifc^iclx. DATE DUE OCT I 9 2002 -NOV 19J nn? i . i DEMCO 38-296