SYPHILITIC SCIATICA. 
N. B. EMERSON, M.D., New Yoke. 
I wish to call attention to the causation of sciatica by syphilis. 
From the infrequency with which syphilis is mentioned as a cause 
of sciatica, it might he supposed that such causation was rather 
uncommon. In the returns made by sixty-three medical men in 
different parts of the world, in answer to Dr. Lauder Brunton’s 
circular propounding certain questions in regard to sciatica, forty- 
nine of the reporters recognize the rheumatic form; forty the 
gouty; thirty-nine the neuralgic, and eleven have seen it pro- 
duced by pressure, while the syphilitic form is spoken of by but 
twelve. Further than this, according to the reports of these medical 
gentlemen, “ chronic periostitis has been found to cause it (sciatica) 
in the experience of seven writers. No less than five speak of ma- 
larial sciatica, evidently regarding it as one of the neurosal sequelas 
of malarial infection. Other three writers describe an inflamma- 
tory form of sciatica. Of the remainder, one alludes to cancer 
as a cause, one to struma; while one speaks of a toxic form, 
one of its dyspeptic origin, and one is opposed to any divisions.” 
(See article “The Return on Sciatica,” p. 107, Practitioner, Feb., 
1877). I quote this passage partly for the curious interest at- 
taching to such a scattering vote in regard to the causation of 
sciatica. Sciatica is an affection particularly liable to develop 
itself in those who are exposed to hardship, cold, dampness, and 
over-fatigue, and therefore is relatively common, broadly consid- 
ered, among the patients who attend at our dispensaries. The 
frequency of neglected syphilis in this very class of people is such 
that if any one had met with a considerable number»of sciatic 
cases, and had failed to trace the trouble back to syphilis as a 2 
N. B. EMERSON. 
cause in any case, it would, judging from my own experience, 
give occasion for doubt whether a syphilitic origin had not been 
overlooked in some of them. 
Let me fairly introduce the subject by quoting from my notes 
the account of several cases which have come under my own 
observation. 
Case I.—Left sciatica with papulo-pustular sypliilide.—G. P., 
male, twenty-eight years old; native of United States; dock 
builder, presented himself January 3, 1870. About two months 
previously, for the first time, experienced pain in the course of the 
left sciatic nerve, with exacerbations, which were specially severe 
at night. Examination revealed tenderness to pressure over the 
sciatic nerve from the point of its emergence from the pelvis to 
the popliteal space, but particularly at the sacro-sciatic notch, 
and in the popliteal space. No tumor or thickening found in 
the course of the nerve. The limbs were full and muscular— 
equally so—and the affected limb was entirely free from atrophy. 
In searching for a cause capable of producing this affection, my 
attention was immediately arrested by a papulo-pustular eruption 
which presented itself quite thickly over the face and scalp, body, 
and extremities. The patient admitted the fact of venereal ex- 
posure, and showed a small cicatrix on the corona of the glans 
penis, which, according to my recollection, was still slightly in- 
durated. The cervical glands, including the submaxillary, were 
markedly enlarged, and one of them threatened suppuration. 
My search for a tangible cause of the neuralgia was unsuccessful. 
There was no tumor or thickening, or other neoplasm to be per- 
ceived in the course of the painful nerve; nor was the patient 
affected with any form of genital irritation, such as is capable of 
causing sciatica; the condition of his bowels, also, was satisfac- 
tory. Deeming it probable that the neuralgia was caused by the 
syphilis, I put him on treatment with mercurial preparations, 
both internally and by inunction, at the same time giving qui- 
nine and iron in tonic doses. In two weeks, having part of the 
time been without medicine, the man returned, and reported him- 
self much better. The same treatment was continued till Febru- 
ary 4, at which time the eruption had faded, and all trace of the 
sciatica had passed away. 
The diagnostic considerations that made me regard this as a 
case of sciatica dependent on syphilis may be stated thus : 
1. The man was of good bodily vigor, well nourished, and not SYPHILITIC SCIATICA. 
3 
suffering from any cachexia, nor was there anything in his habits 
or manner of life capable of explaining the causation of his neu- 
ralgic affection. 
2. His exemption from the sciatic affection previous to the 
onset of the constitutional symptoms of syphilis. 
3. The result of specific treatment. I do not agree with the 
opinion that seems to be so generally held by the profession that, 
in the lack of other evidence, the therapeutic test, i. e., the cure of 
a disease by anti-syphilitic remedies argues conclusively the syphi- 
litic nature of the complaint. Still this consideration has weight* 
and should not be disregarded in forming a diagnosis as to cause. 
In this case I am of the opinion that the relief to the neuralgia 
which followed the use of anti-syphilitics argues a relation of 
cause and effect between the constitutional disease and the sciat- 
ica. The later history of this patient I am not acquainted with. 
Case II.—Sciatica occurring in the late stage of syphilis; 
potassium iodide; cure; return of pain in nine or ten months.— 
S. II., female, age 29 years, native of Ireland, came to me at the 
Demilt, February 7, 1876. Four weeks previously this patient for 
the first time had a pain along the left sciatic nerve of “ a draw- 
ing, quivering sort,” as she described it. There 'were al§o various 
dysaesthesiaB, sensations of coldness and numbness in the lower 
part of the left leg. Questioning elicited the following history : 
This woman had been married twelve years, during which time 
she had given birth to two children, including a still birth at the 
fifth or sixth month of utero gestation, at which time she had been 
three years married. During this pregnancy there appeared on 
her vulva a small sore which soon healed, while at the same time 
she suffered from a vaginal discharge. Within a year from this 
she had a rose-colored eruption over her body, sore throat, alo- 
pecia, and enlargement of the cervical glands. For the four years 
before coming to me she had had rheumatoid pains in her limbs 
and body, and for two years headaches, which were worse by night. 
This woman was markedly cachectic and illy nourished. Ex- 
amination showed tenderness to pressure over the lumbar and 
sacral spines, sacro-iliac synchondroses, sacro-sciatic notches, and 
along the sciatic nerves, also tenderness over the tibiae. For treat- 
ment she took potassium iodide in large doses, with iron and 
quinine, under the use of which she improved, and soon ceased to 
attend at the dispensary. 
. At the time of writing this (January, 1877), I have again 4 
N. B. EMERSON. 
seen this Avoman, and have had the facts above mentioned con- 
firmed by her reiterated statement. She informs me that my 
treatment entirely relieved her of sciatic as well as of all rheuma- 
toid pains, and that she remained free from pain until toward the 
close of the year, when she was attacked first with the bone aches, 
and then with a renewal of the sciatica. 
She is still subject intermittently to attacks of violent pain in 
the sciatic nerve, with tingling, numbness, and subjective sen- 
sations of heat and cold in the limb. Examination of the leg 
shows tenderness over the sacrum and left sacro-ischiatic foramen. 
I would add that I have again seen this patient within a day or 
two, and that at the present time (June, 1877), she has pain along 
the left sciatic, also in the right, which are of a dull, heavy sort, 
nearly continuous, and are worse by night when warm in bed. 
Has often had sensations of pricking, tingling, burning, and some 
numbness, she thinks, in the left leg. She thinks the left leg is 
as strong as the right. Exercise or standing causes the legs, 
particularly the left, to swell, and greatly increases the pain along 
the nerve. To measurement, the calf of the left leg is about one 
quarter of an inch smaller in diameter than the right; but no 
atrophy is apparent to the eye. There is considerable tenderness 
along the course of both sciatics, particularly the left, from the 
notch to the popliteal space. The pain she locates with anatomi- 
cal accuracy in the course of the nerve, not at the points of emer- 
gence. The woman is markedly cachectic, and presents numer- 
ous evidences of syphilitic affection. This woman has certainly 
grown slowly but progressively worse during the last six or seven 
months, since the return of her sciatic pains, during which time 
she has been almost without treatment. It is worthy of remark, 
that while the general symptoms—diurnal osteocopic pains, with 
nocturnal exacerbations, mucous patches, periosteal thickening 
over sternum and tibiae, and increased cachexia—show that her 
constitution is even more profoundly affected than ever, the 
special sciatic symptoms, though changed, are not increased in 
violence. They have extended, and now to some degree affect the 
right as well as the left sciatic; but instead of the intense darting 
pains that were felt at first, they are now rather of a dull, con- 
tinuous sort, and, like the osteocopic pains, are more severely felt 
at night than by day. 
Case III.—Sciatica occurring in the late stage of syphilis ; 
relief.—E. D., 32 years of age, Irish, widow, came under my SYPHILITIC SCIATICA. 
5 
treatment February 21, 1876. One month before she began to 
suffer from a feeling of discomfort in her left hip. This grew 
worse and became a shooting pain, following the course of the 
sciatic nerve and its branches (internal and external popliteal 
and external saphenous), as far down as the ankle and into the 
foot. The pain was not specially worse at night, but was aggra- 
vated by pressure and by working on the sewing machine. There 
were tingling and numbness of the parts affected, also stiffness 
and lameness of the limb. I learned from this woman that about 
seven years before her husband had become affected with an erup- 
tion over his body, and later had pains in his limbs and body 
resembling those of rheumatism. Several years after this she 
found herself affected with sores on her tongue, gums, and lips, 
which she described as like whitish patches, that persisted about 
five months. Following this she never noticed any eruption on 
her skin. 
This woman’s appearance was decidedly cachectic, her com- 
plexion being aptly described by Dr. Buzzard’s term “ muddy 
pallor.” (Syphilitic Nervous Affections, p. 83, London, 1874.) 
Her body was meagre and ill-nourished. There were points of 
tenderness over the sacrum, both sacro-iliac synchondroses, left 
sacro-ischiatic foramen, along the course of the sciatic nerve, over 
the popliteal space and the head of the fibula on the same, left 
side. There was also periosteal thickening, with tenderness, over 
the anterior surface of both tibiae. On making a vaginal exam- 
ination there was marked tenderness when pressure was made 
backwards against the sacrum and toward the left side. The 
patient was put upon treatment with a combination of potassium 
iodide and mercury, with iron and cod-liver oil. In a month she 
was nearly free from pain and considered herself quite well. 
Since then the state of her health and the degree of sciatic pain 
has varied according as she lias omitted or followed the treat- 
ment. The syphilitic taint is evidently not yet conquered, but 
she is only reminded of her active enemy, the sciatica, by an 
occasional twinge. 
Attention has been frequently called to the fact that pain 
referred to the sciatic or to any nerve, may be either, first, 
symptomatic of some lesion of the nerve, or second, be unaccom- 
panied by any change capable of detection in the nerve itself.* 
* Landouzy. De la Sciatique et de T Atropine Musculaire, qui peutla com- 
pliquer. Arclx. Gen. de Med., March, April. May, 1875. 6 
N. B. EMERSON, 
In the one case the seat of the pain is real, in the other it is 
said to be virtual. However difficult it may be to establish this 
proposition pathologically and clinically, it undoubtedly makes a 
true distinction, and one which it is important to bear in mind 
clinically. 
I. What are the lesions which syphilis inflicts upon the 
sciatic nerve, and after what modus operandi do they produce 
sciatica ? There is sufficient clinical and post-mortem evidence, 
first, that the neoplasmata, which occur principally in the late 
stage of syphilis, are capable of producing violent pains and loss 
of motor function in the sciatic, as in other mixed nerves, by 
pressure. While the deep position of the sciatic nerve does not 
entirely shield it from injury by external violence, it rather ex- 
poses it to pressure from new growths that may occur in its course, 
at the same time that it makes it easy for this to happen without 
the liability to detection. This might take place by new forma- 
tion seated at its point of emergence from the spinal canal, in its 
course through the pelvis from tumors attached either to the walls 
of the pelvis itself or to the viscera contained therein. Again, it 
Avould require but an inconsiderable amount of thickening, a 
small deposit of new material about the margin of the ischiatic 
notch, to so narrow its gate of exit, as to set up all the symptoms 
of compression in the sciatic nerve. Outside of the pelvis the 
sciatic is still exposed to injurious pressure from syphilitic gum- 
mata and bony or periosteal growths. But owing to the double fact, 
that the sciatic—including its branches—is largely tolerant of 
pressure, and that in its course through the thigh and leg, where 
not bound firmly down by muscles, as beneath the glutei, or by 
fascia, as where its peroneal branch turns over the head of the 
fibula, it has considerable lateral play, a tumor or new growth 
occurring in relation with the nerve outside of the pelvis, will re- 
quire to be of great size in order to necessitate harmful pressure. 
Zambaco (Des Affections Nerveuses Syphilitiques, par D. A. 
Zambaco, Paris, 1862, p. 250), gives the case of a man in the 
service of M. Rostan, at the Hotel Dieu, Paris, who four years 
after becoming affected with an indurated chancre, for which he 
liad been submitted to a mercurial treatment, was taken with a 
series of very grave symptoms; two exostoses began to form, 
one on the anterior part of the sternum, the other on the hori- 
zontal portion of the inferior maxilla. “When he entered the 
hospital, he was as thin as a skeleton, and presented the ap- SYPHILITIC SCIATICA. 
7 
pearance of marked cachexia. . . . The inferior portion of 
the trunk offered only very dull sensibility to touch. Pinching 
and pricking with pins caused but slight pain. The lower limbs 
refused to support the body, and the patient could only move with 
pain and great difficulty. He had violent osteocopic pains in the 
lower limbs, but chiefly suffered from an incessant left sciatica.” 
“The autopsy revealed within the vertebral canal, extending 
from about the lower half of the dorsal through the whole extent 
of the lumbar portion of the (rachidian) cavity, a gelatinous thick- 
ening of a gummy consistency which compressed the spinal cord. 
In the left buttock, beneath the muscles, wras a tumor of the size 
of a nut which compressed the sciatic.” Microscopic examina- 
tion, made by Charles Kobin, showed this and the other tumors 
to be composed of such material as is found in gummata. In this 
case the syphilitic origin of the affection could not be in doubt, 
but the whole extent of the lesion was not to be made out before 
death. 
Piorry gives a case in which a periostosis or an exostosis on the 
left transverse process of the third lumbar vertebra compressed 
the corresponding lumbar nerve, and produced pains in the lum- 
bar and sciatic plexus, and in the sciatic nerve; also enfeeblement 
of the limb on the same side. Treatment was followed by com- 
plete recovery. (Prof. Piorry, Moniteur des Hopifaux, May 17, 
1853, p. 470, quoted by Gustave Lagneau, fils, Maladies Syphi- 
litique du Systeme Nerveux, Paris, 1800, p. 337.) Yvaren nar- 
rates the case of a lady who became infected with syphilis soon 
after her marriage. During the following seven years she gave 
birth at not long intervals to six children, of which one was still- 
born, two had unmistakable evidences of hereditary syphilis, and 
only one outlived early infancy. 
As before pointed out, a syphilitic growth, capable of making 
harmful pressure on the sciatic in the thigh, will as a rule be of 
such a size as to insure its easy discovery by physical exploration. 
Within the pelvis, or directly at the outlet of the sciatic from the 
same, the case may be quite different. In such a case the diagno- 
sis would have to rest mainly upon a careful study of the symp- 
toms. In most cases of pressure by tumors upon nerves of mixed 
function, wre have, according to Weir Mitchell, “the usual se- 
quence pointed out by Bastian and Yulpian. First prickling, 
tingling, and sense of heat, then exaltation of sensory function 
and even hyperesthesia, with, finally, loss of sensibility and motion 8 
N. B. EMERSON. 
in the affected limb.” (Weir Mitchell, Injuries to Nerves, Phila., 
p. 119.) Let me remark here that it is much to be regretted that 
the reports of the cases just cited from Zambaco, Piorry, and 
Yvaren, do not inform us whether this order of symptoms was 
observed in them. 
Anstie gives his views in the following words: “A third vari- 
ety of sciatica, is the rather uncommon one, so far as my experi- 
ence goes, in which inflammation of the tissues around the nerve 
is the primary affection, and the neuralgia is mere (sic) second- 
ary effect from mechanical pressure on the nerve, which, how- 
ever, is not apparently itself inflamed.” “I believe,” he con- 
tinues, “that these cases are sometimes caused by syphilis, and 
sometimes by rheumatism. One of the most violent attacks of 
sciatic pain which ever came under my notice was in a syphilized 
subject, a discharged soldier, who had been the victim of severe 
tertiary affections, and had been mercilessly salivated into the 
bargain. This unfortunate man suffered dreadful agony, which 
was aggravated every night, but was never totally absent. The 
pain started from a point not far behind the great trochanter; 
pressure here caused intolerable darts of pain which ramified into 
every offshoot of the sciatic nerve, as it seemed, and made the 
man quite faint and sick. Large doses of iodide of potassium, 
together with the prolonged use of cod-liver oil, completely re- 
moved the pain and tenderness.” (Francis E. Anstie, Neuralgia 
and its Counterfeits, London, 1871, p. 52.) 
2. A priori it would seem highly probable that syphilis should 
be a frequent cause of neuritis or perineuritis, and thus of neural- 
gia in the sciatic nerve. While I am inclined to believe that such 
is sometimes the case, and while it cannot be doubted that a syphi- 
litic neuritis of the sciatic would produce symptoms not differing 
widely from those caused by any other neuritis, I have yet been 
unable to find the proof necessary to establish the existence of 
such a lesion, either in the cliuical records of cases, or in the re- 
ports of autopsies. 
The literature of syphilitic nervous diseases, though not lack- 
ing in hints and assertions of belief in regard to the production 
of syphilitic sciatic neuritis, is singularly unsatisfactory and lack- 
ing in definiteness on this point. I have not been able to lay 
my hands upon the account of an actual case. 
Lagneau, under the head of the pathological anatomy of syphili- 
tic affections of the sciatic, makes no mention of neuritis, but SYPHILITIC SCIATICA. 
9 
contents himself with considering the production of its neuralgic 
pains by tumors engaging the nerve either at its roots, or as it 
leaves the pelvic cavity. The lesions causing these neuralgic 
pains, remarks this author, are little known. (Lagneau, fils, Mal- 
adies Syphilitiques du Systeme Nerveux, Paris, 1860, p. 337.) 
Gros and Lancereaux use the following language: “Some an- 
cient authors connect neuralgias, especially sciatica, with lesions of 
the neurilemma, with inflammations of, effusions into, or solid de- 
posits in the substance of the nerve itself. Cotugno and Cirillo 
are of this number. They have seen nerves increased in size 
more than one-third, and presenting the consistency of tendons. 
(Leon Gros and E. Lancereaux, Des Affections Nerveuses Syphi- 
litiques, Paris, 1861, p. 165.) 
Weir Mitchell has seen neuritis brought on by cold or rheu- 
matism, and as a result of acute neuritis; but only once as 
a consequence of syphilis. In subacute neuritis, according to 
Weir Mitchell, the affected nerve is tender over a large portion 
of its track, and the points of emergence from a bone or through 
a fascia are still more sensitive, thus differing from true neural- 
gia. The sensitive nerve tracks of neuritis also differ from the 
hyperaesthetic spots of neuralgia in being constant and alike 
tender at all times. 
“In many old cases of neuritis” (Weir Mitchell, loc. cit., 
p. 6£), “ unless the nerve is small and deeply seated, it can 
be felt as an enlarged and hardened cord, so that it is 
frequently easy to distinguish even the deeply-placed sciatic 
nerve.” “ The redness which may overlie an acutely inflamed 
nerve I have not,” says the same author, “seen in cases of 
chronic neuritis; but, when long continued, it is the cause of 
structural changes, such as atrophy of the skin, with causalgia, 
changes in the nails, oedema, and rarely of sclerotic thickening of 
the dermis. The pain of subacute neuritis is aching in char- 
acter, and less distinctly follows the larger nerve tracks than does 
that of neuralgia. Like neuralgia it is, however, liable to in- 
crease at night, and may even affect such returns of violence at 
fixed hours, although it is rather to be described as remittent 
than intermittent.” 
I count it extremely unfortunate that peripheral nerves are not 
oftener examined at autopsies. If such examinations were more 
common than they are, it is possible that the observations of 
Cirillo and Cotugno, previously referred to, might be substan- 10 
N. B. EMERSON. 
tiated. As it is, I am not able to find the report of any modern 
observer who has seen and handled such syphilitic sciatic nerves 
as these writers are said to have found. 
Syphilitic lesion of the nerves is undoubtedly most common in 
the cranial, especially the oculo-motor, abducens, and patheticus. 
But even in these the disease rarely produces directly, as it would 
seem, a neuritis. The affection of the nerve is, if I mistake not, 
most frequently the result of pressure from neoplasmata or in- 
flamed tissues in the nerve’s immediate neighborhood. In certain 
cases the inflammation may, I believe, even extend by continuity, 
and invade the sheath of the sciatic nerve, thus producing a 
neuritis with all the symptoms of this affection. But this I be- 
lieve to be a rare occurrence; even more rare in my opinion is it 
for syphilis to set up a primary neuritis of the nerve trunk itself. 
In the lack of means for the study of syphilitic neuritis of the 
sciatic nerve, it seems to me worth while to consider the following 
case of syphilitic lesion of the oculo-motor nerve, which I find 
given by Heubner with admirable clinical and critical detail. 
Though I think it very doubtful if in this case the syphilitic hy- 
perplastic inflammation first attacked the nerve itself, i. e., its 
sheath, and did not rather spread to it by continuity, yet it seems 
as if it were more instructive to study it in this, which I think is 
its customary way of approaching and attacking a nerve. 
Case XLYI. — One month after a syphilitic chancre of Gort 
duration (about which there is question as to ivhether it was the 
first), eruption, headache. About one month after the outbreak of 
the eruption, during which the patient already had to keep his 
chamber, an apoplectic attack ivithout loss of consciousness. In a 
short time ocular paresis. Onset of a drowsy condition, tempo- 
rary aphasia, dizziness, headache, free intervals between. Again, 
one month later, further impairment, continued drowsiness, only 
occasional free moments, alternating delirium, involuntary stools, 
spastic convulsions of the extremities, at first left, later right 
sided ; deep coma ; death two and a half months after the outbreak 
of the severer brain symptoms. 
Autopsy: Syphilitic swelling of the left oculo-motor nerve; 
fusion thereuntil of the left posterior communicating artery ; de- 
generation of this artery; extension of the process to a great 
number of other arteries, leading to narrowing of their caliber in 
a high degree. Syphilis of the testicles.” (Dr. 0. Heubner, Die 
luetische Erkrankung der Hirnarterien, Leipzig, 1874, p. 67.) 11 
SYPHILITIC SCIATICA. 
The normal structure of the affected nerve had disappeared 
throughout its entii’e course within the cranium. The external 
portion was not examined. The right homonymous nerve dis- 
played medullary nerve-fibers with axis cylinders and sheath of 
Schwann in due fashion. The degenerated nerve fibers had given 
place to an abundant growth of connective tissue elements, which 
had choked out the proper nerve tissue. 
“ The important question,” says the writer, “ is, whence originate 
these cells? I hope the list of described cell-forms will furnish 
sufficient proof that we have to do with a vast proliferation of the 
normal endothelial sheath of the nerve-bundles. One can follow 
in complete succession the changes from the normal delicate en- 
dothelial plates into divided, then into long-shaped, and finally 
into spindle-shaped cells. It is by no means to be thought of as 
analogous to that of pus-formation. Besides these, round cells 
[(leucocytes)] were to be found here and there; but they were 
distinguishable by their nucleus and their whole form from ever 
so young spindle cells, between which and the round cells no 
transitional forms were to be observed. Along the vessels was seen 
0 I 
but an inconsiderable collection of white blood corpuscles. In 
short, the whole appearance of every section and teased pre- 
paration declared plainly that the round, wandering cells played 
here no important role. On the contrary, I must decidedly main- 
tain and here confirm the view already expressed by Petrow, that the 
starting-point of this syphilitic hyperplasia in nerves lies in the 
endothelial connective tissue-cell-plates, which the nerve, accord- 
ing to Ranvier’s researches, possesses already in large amount.” 
“ The syphilitic irritation imparts a tendency to the connective 
tissue of the nerve to proliferate. The granulation-tissue which 
is developed thereby and now represents the syphilitic new forma- 
tion, choking out the original elements, arises in this case decid- 
edly in the same way as, according to the old view of Virchow, 
every granulation tissue must arise, i. e., through hyperplasia of 
the connective tissue elements situated at the spot.” (Heubner, 
loc. cit., p. 85.) 
In this case we have, besides the nerve and its sheath, many 
arteries and much surrounding tissue affected in such a way, and 
to such an extent, as to make it appear that the nerve, though 
itself the seat of excessive cell-proliferation, and despoiled thereby 
of nearly all trace of axis-cylinder, was by no means the first tis- 
sue in the neighborhood affected with the syphilitic hyperplasia. 12 
N. B. EMERSON. 
Nerves, it seems to me, are not favorite points for the deposit of 
syphilitic new formations. Even less often than many other peri- 
pheral nerves does the sciatic seem to be exposed to the direct 
attack of syphilitic inflammation. 
Recurring to the case by Yvaren, which I related early in this 
paper, I would call attention to the fact that in this and in nearly 
all the cases of syphilitic lesion affecting the sciatic nerve, there 
exists a history of previous extensive syphilitic lesions throughout 
other parts of the system. The syphilitic process attacks the 
sciatic only after having previously ravaged other more favorite 
fields. The reason for this does not appear, unless, being a nerve 
of keen sensibility, it would naturally happen that an early at- 
tack upon the sciatic would be at once severely felt, and demand 
attention by the pain produced. Further color is perhaps given 
to this hypothesis by the fact that the nerves found to be most 
obnoxious to severe syphilitic lesions are the third, sixth, and per- 
haps the fourth cranial, all of them endowed with little or no 
sensibility. 
3. Writers on syphilitic nervous diseases are in the habit of 
appealing to congestion in explanation of a certain class of 
syphilitic neuralgias. The proneness of syphilis to produce con- 
gestion in other parts of the body lends a certain probability to 
this claim. 
It seems to me more than probable that congestion plays a con- 
siderable, though not an independent part in the production of 
syphilitic sciatica. Syphilitic inflammation of periosteum, or of a 
gland, or a neoplasm, occurring in close proximity to the sciatic 
nerve, must cause a varying amount of congestion. It is the me- 
chanical pressure of this congestion, and not congestion of the 
nerve itself, which, I believe, has to do with the production of 
sciatica in such cases. The same remark would in my opinion 
hold true of oedema. 
II. We come now to that class of cases of sciatic neuralgia 
which are uncaused by structural change of the nerve itself. 
4. There seem to me good grounds for believing that the syphi- 
litic diathesis can cause sciatica, as it does other neuroses, in some 
occult manner, without producing any discoverable lesion. The 
truth of this proposition is not easy of demonstration. It rests on 
grounds very analogous to those by which the malarial poison is 
believed to produce neuralgia or any other neurosis. 13 
SYPHILITIC SCIATICA. 
It may be stated thus: 1. Cachexia is acknowledged to be a 
frequent cause of neuralgia. 2. Syphilis is a notable cause of 
cachexia. 3. Syphilitic cachexia and neuralgia are frequently 
found to coexist, and with the relief of the cachexia there comes 
relief of the neuralgia. 
If in any particular case of this sort it has repeatedly happened 
that relief of the sciatica has followed the use of anti-syphilitic 
remedies, it will be difficult to refrain from believing that the 
cachexia and the sciatica have toward each other the relation 
of cause and effect, or, at least, that they are both the offspring of 
the same parent cause. 
As to the modus operandi of the production of sciatica, when 
thus caused, whether directly through the action of the materies 
morbi on the nerve, or whether from the impoverishment of the 
blood by rendering it unfit nutriment to the system at large and 
the affected nerve in particular, is not known. 
In each of the three cases given by myself, there Avas tenderness 
to pressure along the course of the sciatic, with special tender- 
ness at the points of emergence and the popliteal space. But in 
none of them could the sciatic be felt as a hardened cord. Nor 
Avere there any of those trophic changes in the muscles, the skin, 
or its appendages, Avliich are among the early results of neuritis. 
To my mind, of the cases I have given, none are to be considered 
as decidedly neuritic in nature unless possibly at the very earliest 
stage of this condition. In the patient, S. H., there are at the 
present time syphilitic growths beginning to sIioav themselves in 
various parts of the body, besides Avhicli she is markedly cachectic. 
The continuous, persistent character of her pains, which are noAV 
beginning to appear in the right as Avell as the left sciatic, and are 
dull and heavy in character, folloAV the sciatic and are not referred 
to its points of emergence; I am inclined to think that in her, if a 
post-mortem examination Avere made, there would be found some 
hyperplastic change in the nerve itself. As I before said, there is 
no atrophy to be detected by the eye in the limb—the left—but 
the tape-line shows its circumference to be about one quarter of 
an inch less-than its felloAV. 
DIAGNOSIS. 
1. In making the diagnosis of syphilitic sciatica, it is necessary, 
in the first place, to establish the fact that, in addition to having 
neuralgic pain of the sciatic nerve, the patient has previously had 14 
N. B. EMERSON". 
syphilis. If lie exhibits decisive symptoms of this disease at the 
time of examination, the problem will be much simplified. If, how- 
ever, no such symptoms appear, and the patient—as is especially 
likely to be the case if a woman—denies all history of syphilis, the 
problem becomes more complicated. It should not be forgotten 
that the fact of sciatica occurring in a syphilitic patient does not 
warrant the assumption that the nervous complaint is necessarily 
due to constitutional syphilis; it may be merely a coincidence. 
2. If the patient has been free from sciatica previous to syphilitic 
infection, this fact will weigh in favor of the supposition that the 
neuralgia is of syphilitic origin. The converse of this proposition, 
however, need not necessarily be true. 
3. "While syphilitic sciatica may occur at an early period of 
constitutional infection, it is more likely to appear late. Conse- 
quently the occurrence of a first attack of sciatica late in the his- 
tory of syphilis, is more significant of a syphilitic causation than 
its early appearance. 
4. The occurrence coincidently with the sciatica of other neu- 
rotic troubles clearly traceable to syphilis as a cause, constitutes a 
presumption in favor of the syphilitic origin of the sciatica, and 
this presumption will be strengthened if the patient had, pre- 
vious to constitutional infection, been free from both sciatica and 
the other neurotic affections. 
5. Muscular atrophy occurring in sciatica is, according to Lan- 
douzy (Arch. Gen. de Med., March, April, May, 1875), to be looked 
upon as diagnostic that the affection is not simple neuralgia. 
The muscular dystrophy points to Wallerian degeneration of the 
nerve, the result of neuritis. This atrophy is not the result of 
enforced quiet; for the patient is able to move his limb about, 
and can even use it with considerable freedom until an ad- 
vanced stage of the affection, whereas the atrophy shows itself 
quite early. The pains of sciatic neuritis are dull, continuous, or 
nearly so, and persistent; also are felt equally throughout the 
whole course of the sciatic nerve, thus offering a marked contrast 
to the lancinating pains of a pure sciatica, which are chiefly felt at 
the extremities of the nerve, or in certain well-defined points of 
emergence along its course. (Valleix.) 
6. In sciatic neuritis, again, the nerve is tender to touch, and can 
often be felt as a thickened cord beneath the skin. 
The prognosis of syphilitic sciatica will depend upon a num- 
ber of considerations. When the trouble is of ancient date, SYPHILITIC SCIATICA. 
15 
has had many relapses, or has resulted in degeneration of the 
nerve, as evidenced by atrophy, or where the syphilitic taint is 
hereditary in origin, or still profoundly affects the system gener- 
ally, as evidenced by cachexia, ulcerations, gummata, etc., and 
does not yield readily to treatment, the prognosis will, of course, 
have to be modified unfavorably. In general, however, the op- 
posite is found to be the case. Speaking from my own experience, 
I would say that, as a rule, the fact of a sciatica owing its origin 
to a syphilitic cause should inspire the physician with confidence 
in his ability to cure it. The cause being removed, the effect also 
will be removed. 
The treatment of sciatica due to syphilis is, in the main, the 
same as that of syphilis itself. In all the cases I have seen, which 
now number not less than six, I have mainly relied upon prepara- 
tions of mercury or potassium iodide, and have not been dis- 
appointed in the result. The question which of these anti-syphi- 
litics is to be preferred should be decided in the same manner as 
in the treatment of syphilis proper. 
In Case I., where, synchronously with the neuralgic manifesta- 
tion, there was present an extensive crop of papulo-pustular svph- 
ilide of recent date, pills of the protiodide of mercury with inunc- 
tions of mercurial ointment were used with the happiest effect, as 
evidenced by the early disappearance of both the eruption and 
the neuralgia. 
In Case II., the syphilis Avas already an old affair,and potassium 
iodide was given with good success. 
In Case III., also the syphilis had advanced to a late stage. 
Here again I administered potassium iodide, but combined with 
a mercury salt; and though the dose given wTas, as I now think, 
rather too small, the symptoms were relieved and removed for 
a time, only however to reappear later, in which they well illus- 
trate the tendency of this complaint to relapse. But this was 
due, I take it, not to the inefficacy of the medicines employed, 
but to the lack of persistency with which the patient followed up 
the treatment. For, on resuming the treatment and pushing it 
with increasing doses, the pains were again even more quickly and 
effectually subdued. I have generally found that improvement is 
first marked by an amelioration or cessation of the more acute 
and violent pains—those intermittent twinges, which seem to 
pierce and traverse the limb like a knife or the transit of an elec- 
tric shock. The dull, heavy, nearly continuous pains are more 16 
N. B. EMERSON. 
persistent and difficult of removal. Both of these kinds of pain 
may exist during the same period. The question here arises, 
whether the nerve may not be the seat at the same time of purely 
neuralgic and also of symptomatic pains. I deem it not impos- 
sible nor inappropriate so to think. By persistency in the use of 
the remedies mentioned, the pains of this last sort may also 
generally be entirely removed. 
The decision of the question whether in any case it is necessary 
to resort to the use of preparations of opium or other narcotics for 
the relief of pain and the production of sleep, will rest on the 
same general considerations as in any case of neuralgia. 
The use of electricity in its two forms, both for the relief of 
pain and the maintenance of muscular nutrition when this is 
affected, should not be forgotten. 
It hardly seems necessary to add that the use of iron, cod-liver 
oil, and other tonic and nutritive preparations for the relief of the 
cachexia and mal-nutrition should not be omitted.