CLINICAL ASPECTS 
OF 
SYPHILITIC NERVOUS 
AFFECTIONS . CLINICAL ASPECTS 
OF 
SYPHILITIC NERVOUS 
AFFECTIONS 
BY 
THOMAS/BUZZARD, M.D. 
FELLOW OF THE MOYAL COLLKGX^THYSICIANS IN LONDON ; PHYSIC) AN TO THE 
NATIONAL HOSPITAL FOB.THE PARALYSED AND EPILEPTIC 
PHILADELPHIA 
LINDSAY AND BLAKISTON 
1874 PREFACE. 
The object sought to be attained in the 
publication of this work is to describe simply 
and concisely the clinical characters which the 
author has found of most value in marking the 
syphilitic nature of certain nervous disorders. 
To aid this description he has added a series of 
cases, having selected for the purpose from 
those which have come under his personal 
observation in hospital and private practice 
such as seemed best fitted to illustrate the 
numerous phases of these affections. Many of 
the cases, as well as a small portion of the com- 
mentary, have already appeared in the ' Lancet,'1 
but it is hoped that the subject will be found 
1 Dec. 3rd, 1870; March 11th, 1871; February to May, 
1873. VI 
PREFACE. 
much, more amply treated in the following pages 
than was .possible in the limited space afforded 
by the columns of a weekly journal. 
For obvious reasons, the social status, and 
other circumstances which might possibly serve 
to identify the patients whose cases are described, 
have been for the most part omitted. 
In the chapter on Pathology and Morbid 
Anatomy the author has largely availed himself 
of the writings of several continental observers; 
and in case the frequent references to their 
works in the footnotes are not sufficient to indi- 
cate how much he owes to them, he desires here 
to acknowledge expressly his great obligations 
to the scientific labours of Virchow, Zeissl, 
and Lancereaux. If he has referred more 
frequently to the writings of German and 
French authorities than to those of his own 
countrymen, it is not that he fails to appreciate 
the importance of the contributions which have 
been made to our knowledge of the subject by 
the latter, for the value of the work done, espe- 
cially by Wilks and Hughlings Jackson has not 
been surpassed, but because it seemed to him PREFACE. 
VII 
that the usefulness of his book would be 
increased by its containing the views of authors 
whose writings are not so generally available to 
the English reader. 
56, Grosvenor Street ; 
March, 1874. CONTENTS. 
On the Diagnosis of Syphilitic Nervous Affec- 
tions. 
PAGE 
General observations.'-The syphilitic element fre- 
quently overlooked-Analogy with anasarca from 
scarlatina-Individual symptoms not diagnostic, 
but the mode in which they are grouped-Case of 
paraplegia with hemiplegia and aphasia-Treat- 
ment-Recovery-Important points in diagnosis 
-Age-Simultaneous lesions in distant parts of 
cerebro-spinal axis-Cachexia-History of infec- 
tion-Curative influence of iodide of potassium- 
Characters of syphilitic convulsions-Hughlings 
Jackson's views on association of convulsion 
with double optic neuritis-Characters of hemi- 
plegia- Causes - Paralysis of cranial nerves- 
Zeissl on hemiplegia from osseous changes- 
Sudden hemiplegia-Arterial changes-Paraplegia 
- Affections of spinal cord - Period at which 
nervous affections may occur-Vertigo-Mental 
disorders-Blandford on mental disturbance of 
syphilitic origin-Senile degeneration of tissues-- 
Softening of the brain-Indications from use of 
ophthalmoscope-Evidence afforded by electrical 
examination ..... 1-41 
CHAPTER I. X 
CONTENTS. 
CHAPTER II. 
On the Pathology and Morbid Anatomy of Syphi- 
litic Nervous Affections. 
PAGE 
At what stage of syphilis do they occur ?-Difficulties 
belonging to this question-Lancereaux, Vidal, 
Kuh, Knorre, on nervous affections in early 
syphilis-Anstie on osteocopic pains-Virchow's 
views-Two series of developments-Hyperplasia 
and gummatous formation-The gumma as de- 
scribed by Virchow - Syphilitic dyscrasia-De- 
generation of the gumma-Seats of cerebral lesions 
may be the membranes, interstitial neuroglia, or 
blood-vessels - Matting together of membranes 
very characteristic-External and internal pachy- 
meningitis-Arterial changes-Partial arachnitis 
-Gummatous encephalitis-Gummy tumours of 
brain - How distinguished from tubercle by 
Virchow-Gummata of cranial nerves-Changes 
in the sympathetic-Tendency to recurrence of 
gummata-Wilks on albumino-fibroid deposit 42-73 
CHAPTER III. 
Cases Illustrative oe Syphilitic Nervous 
Affections. 
Multiple character of the affections precludes satisfac- 
tory classification-Syphilitic fever-Osteocopic 
pains-Functional disorder of digestive and cir- 
culatory organs-Faintness-Epileptic seizures- 
Insomnia-Cases illustrating paroxysmal aphasia 
-The muddy pallor in the syphilitic dyscrasia- CONTENTS. 
XI 
PAGE 
Spasmodic seizures in extremities, with and with- 
out loss of consciousness-Cases illustrating the 
large and early mortality in offspring of patients 
with syphilitic nervous affections-Cases illustrat- 
ing association of old choroiditis or optic neuritis 
with convulsion and paralysis-Cases of general 
paralysis cured by iodide and mercury-Local 
affections of muscle, bone, or joint simulating 
results of central lesion-Paralysis and atrophy in 
the district of the sciatic nerve-Cases illustrating 
the tendency to relapse-Cases of mental dis- 
order ..... 74-127 
CHAPTER IV. 
On the Prognosis and Treatment of Syphilitic 
Nervous Affections. 
General remarks on prognosis-Special reasons for a 
favourable or a guarded prognosis-Treatment- 
Ricord's views-Iodide of potassium in increasing 
doses-Mercury-Very large doses of iodide some- 
times necessary-lodism-Influence of iodide 
upon nutrition-Mode of administration-Employ- 
ment of mercury by the mouth, calomel bath, or 
subcutaneous injection-Staub's solution of the 
chloro-albuminate for injection-Author's ex- 
perience of this-Use of electricity in aiding the 
nutrition of paralysed muscles--Mode of its em- 
ployment-Other therapeutical measures . 128-140 CLINICAL ASPECTS 
OF 
SYPHILITIC NERVOUS AFFECTIONS. 
CHAPTER I. 
ON THE DIAGNOSIS OF SYPHILITIC NERVOUS 
AFFECTIONS. 
Every medical practitioner, it may be as- 
sumed, is acquainted with the fact that persons 
who have, at one time or other in their hves, 
become affected with constitutional syphilis may 
some day exhibit symptoms of nervous disorder 
which are referable to this infection and may 
prove to be curable by specific treatment. Not- 
withstanding this, it is certain that this patho- 
logical association (and consequently its im- 
portant bearing upon therapeutics) is very far 
from being generally remembered. The result 
is seen in the fact that patients frequently pre- 
sent themselves for advice who are suffering 
from some form of nervous affection dependent 2 
SYPHILITIC NERVOUS AFFECTIONS. 
upon syphilis, who have already received all 
kinds of treatment except one directed to the 
basis of their disorder, and who recover, or are 
more or less benefited when specific remedies 
are adopted. In the treatment of these dis- 
orders more, perhaps, than in any others, an 
early application of appropriate remedies is of 
the greatest importance, and frequently, it is 
certain, makes all the difference between cure 
and the continuance of irreparable injury, or 
even death. Even when from some circum- 
stance or other, often from the sufferer's 
own folly in attempting deception, a correct 
diagnosis has not been made, and the patient 
has long continued to derive no relief from the 
treatment adopted, but has been getting gradu- 
ally worse, a timely recognition of the specific 
origin of his disorder, and the application of 
suitable remedies, are very frequently found to 
stay the downward progress of his disease, and 
bring about an amount of improvement far be- 
yond what might have been anticipated. No 
doubt, in such cases, the amelioration is often 
only partial, a disorganisation of nerve sub- 
stance has taken place, which is irreparable so 
far as this has gone, but further extension is 
prevented, and time is given for the natural 
process of repair to effect a great change in the DIAGNOSIS.. 
3 
patient's condition. It becomes, then, of great 
consequence to consider what are the points 
which may aid us to the formation of a correct 
judgment in this matter. 
When we see a child who is anasarcous, and 
has albuminuria, our thoughts immediately turn 
to scarlatina, and we inquire whether the pa- 
tient has lately had a sore throat. We do not 
expect necessarily to find at that time any ex- 
ternal mark or indication of the antecedent 
fever. We know that the anasarca is a com- 
mon sequel of scarlatina, and ninety-nine times 
out of a hundred we are right in supposing that 
the child has suffered from that disorder. Here 
is an association of ideas which is always pre- 
sent to every medical man, and in this case 
constantly leads him to a right conclusion. 
Now, it seems to me that the possibility of a 
similar association in respect to syphilis ought 
to find its place in the investigation of every 
case of nerve disorder. I need scarcely say 
that the analogy will not hold good as regards 
the frequency of the connexion between nerve 
disorder and syphilis. That is manifestly im- 
possible. It is evident that all kinds of circum- 
stances may place the probability of such an 
association out of the question, and I need not 
dwell upon these. But we should especially 4 
SYPHILITIC NERVOUS AFFECTIONS. 
remember that, just as in the case of the 
anasarcous child we are content with the his- 
tory (often brought out only by our own ques- 
tioning), and require to see no mark of scarla- 
tina, so in cases of syphilitic nervous affection, 
we must not expect to find in the patient any 
definite sign which would necessarily prove the 
syphilitic nature of his malady. I cannot help 
thinking that an error in this respect is at the 
bottom of the frequent defects of diagnosis 
which occur in the examination of these cases. 
The medical man has read of syphilitic diseases 
of the nervous system, and expects, for some 
reason or other, that when such a case presents 
itself to him it will bear unmistakable marks 
of its peculiar origin. Called to a patient who 
has lost the use of his limbs on one side of the 
body, or who is in convulsions, he sees what is 
clearly to his mind a case of paralysis or 
epilepsy, differing in no respect, so far as he can 
observe, from other cases of these disorders 
which he has watched. There is nothing to 
suggest syphilis, and, unlike what happens by 
reason of the well-known bond of connexion 
between anasarca and scarlatina, his experience 
in this instance has not taught him how fre- 
quent is the association of loss of power, or 
convulsion, with antecedent syphilis. I think DIAGNOSIS. 
5 
it cannot be too distinctly affirmed that, 
although the concurrence of various symptoms 
and circumstances renders easy now and then 
a correct diagnosis of the syphilitic origin of a 
nerve disorder even without the help of the 
patient's history, yet there are no pathog- 
nomonic signs as yet definitely ascertained 
which will point conclusively, without the aid 
of the history, to the specific nature of the case. 
The lesions which result from syphilis affect 
the machinery of the nervous system like the 
lesions which are produced by many other 
causes. The wheels of a watch may be stopped 
as well by the intrusion of a hair as of a piece 
of grit, and it is only the knowledge of the 
conditions to which the instrument has been 
exposed which will enable us to decide which of 
these substances is the probable source of the 
resulting breakdown. 
But although the individual symptoms carry 
with them no conviction as to the specific 
origin of the disorder (because they are but 
symptoms of some lesion or other affecting por- 
tions of the motor or sensory tracts), the pecu- 
liar grouping of such symptoms may lead of 
itself to a probability but little short of cer- 
tainty. The following case, which occurred 
in hospital practice in 1870, affords a good 6 
SYPHILITIC NERVOUS AFFECTIONS. 
illustration of this, as well as of other points 
upon which I have touched, or shall notice in 
other parts of this work. 
Case I.-A man, aged thirty-nine, was wheeled into the 
consulting-room on a chair, being unable, except in the 
slightest possible degree, to move either leg. Neither 
could he lift his right arm, and his face also was partially 
paralysed on the right side. He had great trouble besides 
in expressing himself, being constantly at a loss for the 
right word. A touch was felt very imperfectly on the right 
side of the face and arm, and on both legs. There was 
incontinence of urine and of faeces, as well as absolute 
impotency. He was very cachectic in appearance. There 
was no evidence of disease of the heart, kidneys, or blood 
vessels, and there was no history of any injury. During a 
voyage to England five months previously he had com- 
plained of extreme weakness, which gradually merged into 
a definite loss of power in the right leg, and was accom- 
panied by incontinence of urine. Two months after his 
arrival in this state, he suddenly became paralysed in the 
right arm and face, without any attack of loss of conscious- 
ness, and a week after this his left leg began to lose power, 
until it became as much paralysed as the right. The left 
arm was the only limb left unaffected. He had been under 
constant medical treatment, which included, as I ascertained, 
strychnia, iron, and quinine, but had uninterruptedly grown 
worse. Einding, on inquiry, that seven years previously he 
had suffered from a chancre for which he took mercury till 
bis teeth were loose, and which was followed by sore throat, 
but by no skin eruption, I at once gave him iodide of 
potassium. In a month he could walk a mile with the help 
of two sticks, and could hold his urine for a short time. In DIAGNOSIS. 
7 
another fortnight he could walk a little way without sticks, 
and a month after this he could manage four miles by the 
help of a stick. His reproductive powers had returned, and 
he had much more command over his bladder and sphincter 
ani. Six months after his first visit to the hospital he had 
almost entirely recovered his usual health, could walk six 
miles " at a spell," and more than that in the day. His 
grasp was equal and perfect with either hand. There was 
still a little hesitation in speech, but he had ceased to 
employ the wrong word. There was also some slight 
remaining weakness of the sphincter ani. He told me he 
could feel nothing the matter with him, and was about to 
start for one of the colonies. I advised him to resort to the 
iodide (of which he had taken thirty grains daily for six 
months) in case he felt any tendency to a return of his 
ailment. 
This man must, probably, have had a double 
lesion-one situated in the district of the left 
middle cerebral artery, and the other in the 
sheath of the spinal cord, most likely in the 
lower dorsal portion. Leaving the previous 
history of the patient and the results of treat- 
ment out of the question, this pathological con- 
dition alone pointed to interrupted communica- 
tion in various parts of the sensory and motor 
tracts. Now, as regards the intracranial lesion, 
the resulting symptoms were consistent with 
softening consequent upon embolism of the 
middle cerebral artery, or with cerebral hasmor- 
rhage in the region supplied by this vessel, or 8 
SYPHILITIC NERVOUS AFFECTIONS. 
with pressure from some growth. But the 
lesion of the cord, if it were not dependent 
upon a partial myelitis, must be caused by 
some form of tumour, cancerous or otherwise, 
and the improbability of the almost coincident 
appearance, in a man of this age, of tumours 
which were not syphilitic in two parts of the 
cerebro-spinal axis, would practically decide 
the question. On the other hand, there would 
be nothing at all inconsistent in the occurrence 
of gummatous tumours about the same time in 
various portions of the cerebro-spinal mem- 
branes. The history, however, and the ex- 
cellent recovery from an exceedingly grave 
state under iodide, left the nature of the disease 
in no manner of doubt. 
This case will serve very well for a text 
upon which to found some general observations 
upon the diagnosis of syphilitic nervous affec- 
tions. The points specially noticeable are as 
follows :-1st. The age of the patient. He was 
too young for the hemiplegia to be reasonably 
explained by the occurrence of non-inflam - 
matory softening of the brain, such as is so 
common in advanced life from degeneration of 
the cerebral arteries, and the condition of his 
circulatory apparatus and kidneys was equally 
sufficient to exclude the probability of embolism. diagnosis. 
9 
thrombosis, or cerebral haemorrhage. The ab- 
sence of unconsciousness at the time of his 
hemiplegic seizure would also practically ex- 
clude the last. 2nd. The occurrence of lesion 
contemporaneously in two portions of the 
cerebro-spinal axis. This is a feature pecu- 
liarly noteworthy. It is exceedingly uncom- 
mon except as a result of syphilis, and very 
common in the disorders of the nervous system 
which are consequent upon that disease. 3rd. 
The existence of marked cachexia unexplained 
by evident disease of any of the viscera. 4th. 
The history of a venereal sore, which had been 
contracted seven years previously, and which, 
as it was treated with mercury, and was fol- 
lowed by sore throat, was doubtless of true 
syphilitic character. 5th. The immediate im- 
provement and rapid restoration to health under 
the employment of iodide of potassium. 
It will be remarked, if this case be analysed, 
that the individual symptoms taken singly 
presented nothing conclusive of a syphilitic 
origin of his affection. The man was para- 
lysed in one half of his body just as occurs 
in ordinary hemiplegia. He lost the use of 
both legs, the power of one failing somewhat 
before that of the other, which is not uncommon 
in ordinary paraplegia. The aphasia from which 10 
SYPHILITIC NERVOUS AFFECTIONS. 
lie suffered is constantly seen as an accompani- 
ment of hemiplegia from various causes in- 
fluencing the integrity of the motor tract, from 
the anterior ganglionic centre of the left side. 
His impotence, incontinence of fasces and 
of urine, are all everyday accompaniments 
of paraplegia, from various lesions of the 
cord. The cachexia might have been due to 
an unrecognisable disease of blood - making 
viscera. Lastly, he might have recovered health 
whilst taking iodide without that drug having 
anything to do with the restoration. Many 
cases of hysterical paralysis do so recover 
health under that treatment, although we are 
tolerably sure that the drug performs no part 
whatever in the cure. It is, however, in the 
combination of all these symptoms that we 
find, without any doubt, the key to their causa- 
tion. So strong indeed is the evidence that 
we could even afford to do without the clinch- 
ing proofs brought by the syphilitic history, 
and the results which followed a specific treat- 
ment of his paralytic condition. 
Of the various points referred to, I would lay 
by far the most weight upon the age. It is 
this which first attracts the attention in a case 
of serious lesion of the nervous system, and in 
many cases almost immediately determines the DIAGNOSIS. 
11 
diagnosis. I have little hesitation in stating 
my conviction that, putting aside cases of in- 
jury, hemiplegia or paraplegia occurring in a 
person between twenty and forty-five years of 
age, which is not associated with Bright's 
disease, nor due to embolism (from disease of 
the cardiac valves) is, in at least nineteen cases 
out of twenty, the result of syphilis. 
I need scarcely say that such a completeness 
of testimony as characterised the example 
quoted is not what we most commonly meet 
with. Were it so, there would be but little 
difficulty in our diagnosis of conditions which, 
on the contrary, are often extremely obscure, 
and require the most careful investigation and 
weighing of evidence in order that we may 
come to a right conclusion. 
In noting various points, the consideration of 
which may help us in forming a diagnosis, I 
have placed last the evidence gained by the 
employment of iodide of potassium. Prac- 
tically, for many years past, in common with 
others who see a good many examples of 
nervous disorder, I have been in the habit of 
prescribing this drug very early in every case 
which did not from its symptoms offer a ready 
solution of the cause of the disease without the 
necessity of considering whether it was possibly 12 
SYPHILITIC NERVOUS AFFECTIONS. 
of syphilitic origin. In very many instances this 
practice affords a convenient means of arriving 
at an opinion which more elaborate investiga- 
tion may then confirm. It would be rather like 
reasoning in a circle to say that " because 
iodide of potassium immediately removes certain 
symptoms, therefore the case is of syphilitic 
nature, and because it is syphilitic therefore 
iodide of potassium will cure it." But practically 
the statement is generally correct as far as it 
goes, though, of course, it is not logically an 
argument. We see a similar association of 
ideas every day in the case of intermittent fever 
and the employment of quinine, as well as in 
scabies and the local application of sulphur. 
Unfortunately a too great dependence upon the 
apparent results of treatment may lead us to 
very erroneous conclusions. As one example, 
let us take the case of peripheral paralysis of 
the portio dura. This is sometimes the result 
of syphilitic thickening of the fibrous membrane 
lining the aqueductus Fallopii, but it is still 
more frequently caused by the action of cold, 
and under these circumstances is supposed by 
some to be of rheumatic character. Now it is 
notorious that cases belonging to this last 
category will recover, sometimes rapidly, with- 
out any treatment, and if in such an instance DIAGNOSIS. 
13 
we give iodide, and the patient gets well, we 
shall wander very much astray in ascribing the 
lesion to a syphilitic origin. On the other hand 
many cases of specific character are unaffected 
by moderate quantities of iodide, some indeed 
not responding at all to such treatment even in 
large doses, but requiring the employment of 
mercury; and should a small and tentative em- 
ployment only of iodide be made without good 
results, we may easily jump to the conclusion 
that there is no syphilitic basis, and be led to 
neglect the only means of curing our patient. 
Whilst, therefore, the beneficial effects of iodide 
will often give us a strong primd facie ground 
for concluding that the case is syphilitic, we 
must not rest too confidently upon this kind of 
evidence, nor consider that the non-specific 
character of the lesion is at once proved by the 
negative results which seem to follow treatment 
addressed to such a cause. Amongst the cases 
of epileptic character which I have met with, 
and some of which are narrated further on, 
there have been several in which, after bromide 
of potassium had failed to be of service, the 
iodide was immediately successful. I think 
that under such circumstances the results of 
treatment lend very strong testimony to the 
specific nature of the disorder. With a view of 14 
SYPHILITIC NERVOUS AFFECTIONS. 
testing this point I have frequently given iodide 
of potassium in large doses to epileptics in 
whom from circumstances I could feel sure 
there was no syphilitic taint, and I have failed 
to find any well-marked influence exerted upon 
the number or severity of the attacks which, on 
the other hand, were speedily checked when the 
bromide was substituted. Convulsive attacks, 
on the contrary, dependent upon syphilis, are 
usually influenced to a remarkable extent by 
the iodide of potassium. 
And here it may be well to refer to certain 
characters which point to the syphilitic origin 
of many cases of convulsive disorder as dis- 
tinguished from what is called essential epilepsy. 
If pain in the head be associated with the 
convulsive attacks, it generally precedes the 
outbreak in syphilitic convulsion, and is often 
localised in one particular spot. There is fre- 
quently a history of antecedent pain for months 
before the first fit. In simple epilepsy it almost 
always follows the fit, is diffused over the fore- 
head, and is at no time a strongly marked 
symptom. In the simple form the attacks most 
often commence about the period of puberty; in 
the syphilitic, they do not make their ap- 
pearance till a later period, generally perhaps 
when the patient has past twenty or twenty-five DIAGNOSIS. 
15 
years of age. In syphilis there occur very 
often attacks not characterised by loss of con- 
sciousness ; the patient feels a cramp in the 
fingers of one hand, which draw up, then the 
band is contracted upon the forearm, and this 
upon the upper arm, and clonic convulsions 
ensue for several minutes. Or the tongue may 
be twisted to one side, and the cheek be then 
spasmodically drawn up. Sometimes the same 
phenomena happen in one of the lower ex- 
tremities. These attacks may cease without 
the patient losing his senses or, beginning thus, 
the seizure may proceed to insensibility and 
general clonic convulsions, as in ordinary 
epilepsy. In syphilitic epilepsy there is fre- 
quently a rapid recurrence of seizures, with in- 
tervals of more or less complete coma, and 
often loss of power in the limbs of one side 
following the attacks, and lasting for a short 
time only. The epileptic cry is often absent. 
My colleague, Dr Hughlings Jackson, to whom 
we are so much indebted for his valuable ob- 
servations in syphilitic nervous affections, has 
described a condition which, according to his 
experience, is highly characteristic of syphilis. 
He finds that double optic neuritis (or amaurosis 
from its frequent sequela-atrophy of the optic 
disc), along with convulsions beginning uni- 16 
SYPHILITIC NERVOUS AFFECTIONS. 
laterally, most frequently in the hand, and 
especially in the two first fingers, form an asso- 
ciation of symptoms which usually implies 
syphilitic disease of the brain. The convulsion 
no doubt points, he says, simply to disease of 
some kind, not to any particular pathological 
change of, or in the side of, the brain opposite 
to that in which the spasm sets in. The com- 
bination with optic neuritis merely helps us to 
say that the change is a gross one-a lump of 
something. But experience shows that the gross 
disease of the brain in these cases is usually 
syphilitic. Since Dr Jackson called my atten- 
tion to this combination, I have observed it 
sufficiently often to feel that he is right in re- 
garding it as an important diagnostic feature. 
As regards the occurrence of hemiplegia this 
may be associated with a sudden attack of 
apoplectic character, or it may be slowly and 
gradually developed. If the attack be sudden 
there is this peculiarity, that the patient seldom 
loses consciousness; he feels giddy, perhaps, 
and on attempting to rise finds that he is para- 
lysed. This is the mode of onset described in 
several of the cases narrated further on. It is 
not, however, peculiar to syphilis, and cannot, by 
itself, be relied upon as diagnostic; and equally 
the slow development of hemiplegia only points DIAGNOSIS. 
17 
to the growth of a tumour, or progressive in- 
crease of some formation, which is not, how- 
ever, necessarily of syphilitic character. Other 
circumstances have to be considered, such as 
the age, history, condition of other organs, espe- 
cially the heart, blood-vessels, and kidneys, ere 
any approach to the probably syphilitic character 
of the lesion can be made. 
And, supposing the circumstances should 
point to its being of this nature, there is still 
the difficulty,-not, it is true, a very important 
one in practice,-that the lesion may be either 
due to the existence of a gummatous tumour 
connected with the cerebral substance, or the 
symptoms may arise from morbid changes in 
the blood-vessels, the skull, or the membranes. 
If the lesion be connected with bone alteration, it 
is usually found to have been preceded by fixed, 
intolerable pains in the head, which may have 
lasted some considerable time, and which are 
often, but by no means always, increased at 
night. In addition, an important aid to dia- 
gnosis in such cases exists in the circumstance 
that the seat of pain may be actually tender on 
pressure, and that in its neighbourhood some 
periosteal thickening may be discovered. 
Paralyses of individual cranial nerves are 
often due to morbid change existing on the 18 
SYPHILITIC NERVOUS AFFECTIONS. 
same side of the skull in the bone or the mem- 
branes. According to Professor Zeissl* hemi- 
plegias, dependent upon morbid change in the 
vitreous table of the skull, are, with the ex- 
ception of those which proceed from an altera- 
tion in the base, never so marked and complete 
as those which are brought about by disease in 
the brain substance itself, especially if the 
corpora striata and optic thalami are affected. 
When hemiplegia is sudden, it can hardly 
depend upon exostosis, which would be more 
likely to bring about a gradual loss of power 
by its growth. So, also, those phenomena 
which are marked by intermissions, loss of 
power enduring only for a short time, aphasia 
of transient character, and frequently recurring, 
can hardly depend upon exostoses, the growth 
of which is gradual, and the pressure of which 
cannot be suddenly taken off and restored. 
Cases of this kind will be found described later 
in this work. 
Huebnerf divides the symptoms of brain 
disease from syphilis into those which are per- 
sistent, and those which are intercurrent. The 
symptoms may occur in any period of syphilis, 
sometimes, indeed, from the first appearance of 
* 'Lehrbuch der Syphilis.,'2 Th., p. 290, Erlangen, 1872. 
t S. Canst. Jahresb. 1870. DIAGNOSIS. 
19 
the exanthem. In the beginning only triflin or 
troubles are to be noted, and these either con- 
tinually increase to a high degree, or constantly 
persist and show paroxysmal accessions. These 
apoplectiform paroxysms quickly lead, either 
by increase of the symptoms, to death, or di- 
minish quickly or slowly, and only trifling dis- 
turbances remain behind; or the symptoms 
vanish completely. Huebner quotes two cases 
observed by him in which the symptoms of 
brain disease showed the above-named cha- 
racters, and which ended fatally. Both patients 
evinced unmistakable signs of general syphilis. 
In one of the cases, a man, mt. 34, in whom the 
disturbances in the form of apoplexy quickly 
led to death, the autopsy showed alterations of 
different degree in the soft membranes, rigid 
spots in the left superior artery of the cere- 
bellum, and the left sylvian artery; chnging 
loosely to these rigidities were soft coagula. 
In the other case, which was that of a woman 
set. 25, in whom the fluctuation and disap- 
pearance of the symptoms of brain disease had 
occasioned an erroneous diagnosis of hysteria, 
section showed softening of the brain, clouding 
of the soft membranes, thickening of a portion 
of the right sylvian artery, a partly solid, partly 
soft coagulum firmly sticking to this point, with 20 
SYPHILITIC NEEVOUS AFFECTIONS. 
a brown-red, soft, recent coagulum behind 
it. The right artery of the corpus callosum 
showed likewise a thickening, to which an older 
thrombus clung, as also did the basilar artery- 
a gradual strata-like thrombosing of the blood- 
vessels (it was not a question of embolism), 
which was very characteristic of a syphilitic 
brain disease. In the chapter on morbid ana- 
tomy I shall have more to say about these 
arterial changes. They are especially interest- 
ing, in that it seems likely that iodide of 
potassium exerts little or no influence upon 
them. In a case in which I found such a con- 
dition unusually well-marked on post-mortem 
examination, the patient had been taking con- 
siderable doses of this drug for some time 
previous to his death. 
In the diagnosis of paralysis of the ex- 
tremities, without involvement of the cranial 
nerves, the question whether the cord or its 
membranes is the seat of a syphilitic affection 
must be considered with reference to the same 
points as those which guide us in examining 
cases of hemiplegia. The age, history, con- 
dition of the organs generally, the occurrence 
of injury and exposure to cold, the effect of 
remedies, must all bear their part in enabling 
us to arrive at a probable solution of the nature DIAGNOSIS. 
21 
of the lesion. Owing, probably, in great part 
to the trouble attendant upon examination of 
the contents of the spinal column after death, 
the relation borne by syphilis to affections of 
the cord or its coverings has not nearly at- 
tained the same degree of precision as that 
which has been arrived at in regard to diseases 
of the brain and its envelopes. Still there is 
sufficient evidence to show that syphilitic in- 
flammation of the membranes and gummatous 
deposit in them and in the cord do occur, and 
it is likely that, attention having been of late 
much drawn to this point, proofs will become 
more and more numerous. It is certain that, 
as far as clinical experience goes, a large 
number of lesions of the cord may be con- 
sidered to occur from syphilis, and the results 
of treatment based upon this diagnosis are 
every day producing the most remarkable in- 
stances of recovery from conditions which 
might otherwise be considered irreparable. In 
the illustrative case at the beginning of this 
chapter, one example of this will have been 
seen. 
There is sometimes a difficulty in deciding 
whether the central lesion, which has produced 
paralysis of one or more extremities, exists in 
the brain or cord. Paralysis of all four ex- 22 
SYPHILITIC NERVOUS AFFECTIONS. 
tremities, for example, may occur as well from 
cerebral meningitis, or from tumours lying in the 
middle line of the brain, as from a lesion within 
the spinal column. It may be well to consider 
the points which help us to decide in which, 
region to place the seat of disease. Generally 
speaking, a lesion of the brain which produces 
paralysis of all four extremities, is accompanied 
also by symptoms which enable us to refer it 
readily to the brain, such as mental disturbance, 
or paralysis of one or more cranial nerves. 
Paralysis of muscles serving involuntary move- 
ments, such as those of respiration and the 
sphincters, can usually be ascribed with great 
probability to lesions of the cord. Disease affect- 
ing the dorsal and upper lumbar portions of the 
cord will produce paralysis of the abdominal and 
lumbar muscles, impairment of respiration, so 
that breathing is mainly diaphragmatic, me- 
teorism, paralysis of the sphincter ani, and of 
the bladder. Pain in the vertebras, when it 
occurs, is an important evidence of lesion 
affecting the membranes of the cord, but it is by 
no means a common feature in paraplegic con- 
ditions. Perhaps, however, the most significant 
of all symptoms which point to spinal cord 
disease, is a sensation of a hoop, or constricting 
band, around some portion of the trunk. I DIAGNOSIS. 
23 
have seen this symptom referred in various 
cases to every part, from a segment immediately 
below the axilla to one around the pelvis, and I 
have never known it occur in any form of brain 
affection. It has always been a symptom of 
lesion of the cord or its membranes.* 
It is requisite to remember that as no period 
is too late for the occurrence of syphilitic ner- 
vous affection-twenty, thirty, or more, years 
sometimes having elapsed since the primary 
infection-so at the earliest stage of the con- 
stitutional disorder, disturbances of the nervous 
system may occur, the cause of which there can 
be no doubt is frequently overlooked with the 
result that their treatment is necessarily inef- 
fective. An example of this is shown in Case III. 
Vertigo is a very common phenomenon in 
these affections, especially in the earlier periods. 
Often associated with pain in the head or with 
convulsive seizures, it sometimes stands alone 
as a symptom. It is apt to be very constant, 
not appearing in paroxysms of intense severity 
like that form which is associated with func- 
tional derangement of the digestive organs, but 
so continual as to be a source of great discom- 
* A sensation, of somewhat similar character is occa- 
sionally described by chlorotic patients, but under these 
circumstances it is never so strongly marked. 24 
SYPHILITIC NERVOUS AFFECTIONS. 
fort to the patient. The symptom, like other 
phenomena of the earlier stages, frequently 
yields with great rapidity to specific remedies. 
In connection with the illustrative case re- 
lated early in this chapter I have already called 
attention to the important indications derived 
from the existence simultaneously of two or 
more grave lesions of the nervous system not 
necessarily connected, and I would insist upon 
this condition as of all others, perhaps, the most 
nearly approaching a pathognomonic character.* 
It is very common (and the cases narrated 
in this work will show this) for such as- 
sociations as the following to be found: hemi- 
plegia with paralysis of one or more cranial 
nerves, especially the third, fourth, fifth or 
sixth, and with or without convulsive seizures; 
hemiplegia with paraplegia either accompanying 
or following it, or vice versa. Amaurosis with 
convulsion, or with paralysis of one or more 
cranial nerves, or with hemiplegia, or para- 
plegia. Localized affections of sensibility as- 
sociated with neurosis of motility at some 
* It frequently happens that we can readily name the 
painter of a picture, although the materials used in it are 
just those common to all paintings. It is the mode in which 
they are employed which presents certain marked charac- 
teristics. DIAGNOSIS. 
25 
physiologically distant portion of the cerebro- 
spinal axis. Mental disorder with convulsive 
affection, or with paralysis of individual nerves, 
or with hemiplegia, or paraplegia. In the sequel 
of diphtheria, and occasionally also of typhus 
fever, multiple affections of motility and sen- 
sibility are sometimes observed ; and these may 
raise a suspicion of syphilitic lesion, but the 
history of the case, and the paretic rather than 
paralytic character of the phenomena in the 
former affections will serve to distinguish them 
without much difficulty. 
There is one point connected with syphilitic 
disease of the brain, which, so far as I am aware, 
has not yet received all the attention which it 
deserves in reference to diagnosis or treatment. 
In the ordinary cases of paralysis which 
occur in the middle-aged, and those in young 
adult life, and are usually due either to 
disease of the blood-vessels associated with 
granular degeneration of the kidney, or to em- 
bolism from disease of the valves of the heart 
remaining after acute rheumatism, the patient 
either dies in a comparatively short time from 
the haemorrhage which may occur when the 
disease belongs to the first category, or he 
may recover with a fair amount of health, but 
with more or less permanently rigid limbs if 26 
SYPHILITIC NERVOUS AFFECTIONS. 
the lesion has been of the latter description. 
Chronic mental disturbance in such conditions 
is very rare. On the other hand, when the 
lesion is of syphilitic character, and where there- 
fore there is a tendency to relapses, sometimes 
extending over a long series of years, various 
parts of the patient's brain and cord are from 
time to time affected, and sooner or later there 
very frequently ensues a disturbance of the 
intellectual faculties which is very peculiar. I 
have reason to think that there is a large 
number of persons at the present time suffering 
in this manner. They are usually not above 
the middle period of life, and go about as 
chronic invalids, with one or more of their 
limbs paralysed, and exhibiting, in addition, 
more or less marked impairment of mental 
powers. This may consist chiefly in defect 
of memory, or they may have delusions, 
sometimes of an exaggerative character, and 
they are often extremely indolent and slovenly 
and stupid. These conditions may alternate 
with periods of great improvement, in which 
there seems ground to hope for an eventual 
recovery, but they never, even at their best, 
return to a sound mental condition. Their 
friends, to whom they are a constant source of 
anxiety, always describe them as much changed DIAGNOSIS. 
27 
in character, and eventually they sink into a 
state of confirmed dementia, or succumb rapidly 
in a state of mania. The cause of this affection 
is generally referred to softening of the brain 
from overwork. 
Such conditions as these have been fre- 
quently confounded, especially, I think, by 
French writers, with that known as " general 
paralysis of the insane," from which, however, 
they are distinguished by several circumstances. 
General paralysis of the insane runs a some- 
what definite course, which varies, ordinarily, 
from several months to three years. The para- 
lytic affections are incomplete, not such as 
arise from gross destructive disease of the 
nervous texture. The disease commences al- 
most always with trembling of the tongue and 
lips, and, either simultaneously with this motor 
disturbance or much more frequently preceding 
it, there is marked mental derangement. The 
motor disturbances in the limbs which succeed 
are of gradual development, and of paretic 
rather than paralytic character, and the motor 
affection generally involves the two sides of 
the body to an almost equal degree. There is 
especial tendency to delusions of the most ex- 
travagant character, and the mental disease 
throughout obtrudes itself more strongly and 28 
SYPHILITIC NEEVOUS AFFECTIONS. 
persistently than the affection of motion or 
sensation. The reverse, as I have just pictured, 
more commonly obtains in cases of syphilitic 
dementia. In both, however, there may be 
periods of amelioration, interrupted by convul- 
sive or maniacal attacks. It is the difference at 
the onset which is most marked. In syphilitic 
dementia, the disordered state of mind is apt 
to follow one or more attacks of apoplectic cha- 
racter with accompanying sudden and complete 
paralysis, with evidence indeed of extensive 
destruction in a nervous centre. In general para- 
lysis of the insane, this evidence is wanting, and 
ordinarily it is an alteration in the intellectual 
faculties which first attracts attention, and, 
succeeding to this, the tremor of the lips and 
mouth only too significantly betrays the fatal 
nature of the disorder. The occurrence of 
inflammation of the membranes covering the 
hemispheres of the brain, with subsequent 
thickening and adhesions to its cortical layer 
of gummatous tumours of the pia mater, or 
brain substance, or thickening and narrowing 
of the vessels, occasioning softening, will cause 
a disorganization quite capable of explaining 
the mental as well as the physical troubles in 
syphilitic dementia. 
Dr Blandford informs me that it is in the DIAGNOSIS. 
29 
forms of dementia and melancholia he has 
most frequently been able to trace an asso- 
ciation with syphilis. He has seen several 
cases of melancholia yield to anti-syphilitic 
treatment. He has also observed one case 
in which mania came on whilst the patient 
was being treated for syphilitic ptosis. 
No doubt, just as a patient who has con- 
tracted syphilis may go through life without the 
occurrence of any lesion of the nervous sub- 
stance, so, on the other hand, he may in 
advanced life be affected with degeneration 
of the nervous centres which do not depend 
upon the syphilitic infection. Age may 
bring about alterations in the elasticity of 
his cerebral arteries leading to haemorrhage, 
or non-inflammatory softening, just as it 
does in others who have never contracted 
syphilis. It often occurs, therefore, that a 
good deal of doubt is felt in certain cases as 
to whether the symptoms of nervous lesion 
observed in a patient are due to acknowledged 
antecedent syphilis, or to alterations in his 
blood-vessels entirely independent of this dis- 
order. These, indeed, constitute some of the 
most difficult cases for a direct diagnosis. Age, 
as somebody has remarked, does not arbitrarily 
signify the number of years during which the 30 
SYPHILITIC NERVOUS AFFECTIONS. 
body has revolved around the sun, but the 
degree to which the tissues have taken on that 
degeneration which is so often associated with 
advanced life as to be included in its natural phe- 
nomena. In everyday experience we see young 
men of seventy years of age, and old men of fifty. 
It is when we meet with serious and confirmed 
symptoms of change in the cerebral substance in 
individuals who present a syphilitic history, but 
who have not yet arrived at the period of life 
when degenerations are common, that we ex- 
perience difficulty in deciding whether such 
changes should be placed to the score of prema- 
ture old age or to syphilis. And the difficulty 
is increased by the fact, which is perfectly well 
known, that there may be changes of a senile 
character in the arteries of the brain, without 
any corresponding sign of degeneration in those, 
such as the radial and temporal, which are easily 
examined. Where there is much doubt on this 
point, it is best to err on the safe side, and by a 
tentative treatment with anti-syphilitic remedies 
discover whether such will help us to a diagnosis. 
Mental disturbance of the kind which I have 
described, may be seen as a result of chronic 
softening of the brain quite independent of 
syphilis. Such cases abound in our workhouse 
infirmaries, and in private practice, although, DIAGNOSIS. 
31 
from the nature of things, they are not often 
met with in hospitals. Dr Reynolds says, in 
his article," Softening of the Brain,"* "Among 
the conditions which predispose to its occur- 
rence the most important is age, or agedness." 
And of " chronic softening," he adds, " There 
is diminution of intelligence. The patient is 
unable to pay attention, and consequently fails 
to receive new ideas. Subsequently memory 
is impaired, past ideas are not recalled with 
readiness, and there is general confusion and 
incoherence. . . . The gradual failure, one by 
one, of the intellectual faculties is, per se, one 
of the most characteristic symptoms." But the 
great peculiarity attaching to the mental dis- 
turbance as a result of syphilitic disease is, that 
it occurs so frequently in quite young persons 
-in those about whom there can be no doubt 
as to whether or not they have arrived at a 
period of life when senile degeneration can 
possibly have commenced. In such, when we 
have excluded accidental sources, such as in- 
jury to the head, sunstroke, unusual excesses 
in drinking, and manifest diseases of the 
general circulatory apparatus, if there be 
either evidences, or a history of constitutional 
syphilis, we may fairly turn to this disorder as 
* ' System of Medicine,' vol. ii. 32 
SYPHILITIC NERVOUS AFFECTIONS. 
a key to the symptoms. The diagnosis in such 
instances will not fail to be fortified by the 
peculiarities connected with the paralytic 
symptoms which accompany the mental troubles, 
distinguishing the condition alike from chronic 
softening of non-specific character, and from 
general paralysis of the insane. 
The ophthalmoscope is indispensable in the 
examination of cases in which a syphilitic basis 
is suspected; if not, indeed, in all cases of 
nervous affections. The evidence which I have 
seen afforded by it, in reference to this par- 
ticular subject, has been, to speak generally, 
of two kinds. It may disclose the results 
of past lesions of deep-seated tissues of the 
eye, such as experience has shown to be very 
frequently of syphilitic origin, and, thereby, in 
a case wanting in the more palpable external 
manifestations of the disease, supply an all- 
important link. Or it may indicate the actual 
presence of tumour within the cranium, or of 
meningitis, by presenting to our sight the 
changes belonging to optic neuritis. I may 
refer here to Cases XVI and XX as examples of 
the first category, and to Cases XVIII and XIX 
as illustrations of the second. With regard to 
the former class, the changes which I have most 
frequently met with have been due to old dis- DIAGNOSIS. 
33 
geminated choroiditis occupying the posterior 
segment of the eye, and characterised by the 
presence of numerous small white spots in 
the choroid, surrounded by black pigmentary 
rims. These have been produced by exuda- 
tions of lymph which have become absorbed, 
and the portion of choroid corresponding to 
them atrophied. Occasionally with this change 
there is also atrophy of the correspond- 
ing optic disc. One has to remember that 
choroidal atrophy - not usually, however, in 
patches-may result from the changes incidental 
upon an injury. I saw a case of this not long 
since, which had followed a heavy blow upon 
the eye. According to Von Graefe, dissemi- 
nated choroiditis, limited to the posterior seg- 
ment of the globe, is of syphilitic origin in 
seventy-five cases out of a hundred. It is to 
this affection that a great proportion of the 
amaurosis which occurs in syphilis is due. 
Atrophy of the optic disc is another condition 
frequently observed in these cases. It often 
happens that when it falls under the physician's 
notice there is nothing to show whether this 
condition represents the sequel to an attack of 
optic neuritis, or has appeared gradually as a 
simple impairment of nutrition. When it has 
resulted from choroiditis the appearances 34 
SYPHILITIC NEBV0US AFFECTIONS. 
proper to that affection will indicate the as- 
sociation. 
It ought not to be forgotten that the occur- 
rence of atrophy of the optic disc in a decidedly 
syphilitic patient does not by any means neces- 
sarily prove that the atrophy was occasioned by 
the syphilis. The following case will illustrate 
this point. 
Case II.-A gentleman, mt. 33, told me that he had been 
failing in the sight of one eye for about ten years. The 
right disc was in a state of partial white atrophy; the left pre- 
sented nothing very definite except that perhaps the arteries 
were rather small, and its colour was not healthy. He 
had had a chancre eleven years previously, followed by sore 
throat and recurrent skin eruptions. For three or four 
years past he had felt languid and wanting in energy, and 
had, moreover, been subject to " flying pains," about which 
I inquired particularly. He would have, it seemed, a 
paroxysm of them, lasting a day or two at a time, then 
ceasing altogether, and not reappearing for two or three 
weeks. The pains were described as excessively sudden, 
sharp, and darting " like knives," and they lasted only an 
instant. During a bout of these pains he would be kept 
awake by them at night. I thought that the atrophy of 
the disc was probably not due to syphilis, because it must 
have begun, if his story were true, within a year after the 
primary infection, and because it was easier to explain it 
otherwise. It seemed to me likely, judging by the "light- 
ning pains" which he described, that the affection was of 
that kind which often accompanies and sometimes precedes 
sclerosis of the posterior columns of the cord. He has as 
yet no ataxy, but this symptom will probably sooner or DIAGNOSIS. 
35 
later betray itself. I got Mr Lawson to see him after- 
wards with me in consultation, and he agreed with me 
both as to the appearances presented, and also in the 
opinion that the affection was not of syphilitic character. 
The condition which is called " descending 
optic neuritis" is full of interest and importance 
in the diagnosis of these cases. Both eyes are 
usually affected, but generally one presents a 
more advanced stage than the other. There 
may be no impairment of vision accompanying 
extensive effusion of lymph upon the disc, and 
a considerable amount of sight may coexist 
even when the disc is atrophied to some extent. 
This preservation of sight under such unlikely 
circumstances has been pointed out especially, 
and, I think, first, by Dr Hughlings Jackson, 
and I have convinced myself of the accuracy 
of his observation. The fact is evidently a 
very noteworthy one, as the patient's disclaimer 
of there being anything wrong with his sight 
is quite compatible with the presence of serious 
changes as observed by the ophthalmoscope. 
The disseminated choroiditis which the physician 
meets with is generally a matter of the past, 
and it is its results that he sees ; but descending 
optic neuritis may be watched in its progress 
side by side with symptoms of eclampsia or 
paralysis, or both. Its importance consists, not 36 
SYPHILITIC NERVOUS AFFECTIONS. 
only in the probability of eventual atrophy of 
the disc, and consequent amaurosis, but in the 
circumstance that it indicates disease of some 
kind beyond the eye-tumours within the 
cranium, meningitis, something which presses 
on the nerve or impedes the return of blood 
through the ophthalmic vein. Or the seat of 
disease may be distant from it; there may be 
e.g. a gumma on the surface of a hemisphere. 
It is not easy to explain the occurrence of optic 
neuritis under these circumstances. The tumour 
may modify the circulation in the blood-vessels of 
the optic nerve, and produce secondary trophic 
disturbance, by means, possibly, as Benedict 
supposes, of sympathetic vaso-motor influence.* 
Paralysis of one or more of the nerves which 
supply the muscles attached to the globe of the 
eye, and its upper lid, is of such frequent occur- 
rence in syphilis of the nervous system that a 
glance at a patient's face is often quite sufficient 
to take us a long way on the road to a correct 
diagnosis. Where ptosis occurs, it is seen at 
once that there is paralysis of the upper di- 
* For detailed information respecting the deep affections 
of the eye observable in syphilitic nervous disorders I 
would refer the reader especially to the writings of 
Dr Hughlings Jackson, Dr Clifford Allbutt, and Mr 
Hutchinson. DIAGNOSIS. 
37 
vision of the third nerve, and where there is 
marked strabismus, or where, on passing the 
finger before the patient's gaze in various di- 
rections, it is found that his eye fails to follow 
its course, the muscles affected may be singled 
out easily enough, and the lesion at once re- 
ferred to the nerve supplying them. It is 
requisite, however, to remember that the loss of 
power may be very slight, and may be almost 
entirely expressed by a very small excess in the 
tractive capacity of the antagonistic muscle. 
In such a case the eye will follow the finger 
with apparent facility in each of the various 
directions represented by the insertions of the 
recti muscles, and there may be no objective 
sign of paralysis. But it will be found that 
there is diplopia, which the patient himself 
may have remarked, or he may not have 
noticed it on account of its only occurring 
when the gaze is directed to certain points 
of the compass. In this way subjective 
evidence is afforded of the weakening of 
some muscle. Under these circumstances it 
is not always easy to say which muscle is 
affected, but this can be made out, if thought 
desirable, by a sufficient expenditure of time and 
patience. From a practical point of view, how- 
ever, this is not often of much consequence, the 38 
SYPHILITIC NERVOUS AFFECTIONS. 
important matter being the fact that a muscle of 
the eye is partially paralysed. The discovery 
of this will frequently facilitate greatly the dia- 
gnosis in a case which might otherwise admit of 
much doubt, especially where, from circum- 
stances, inquiry as to infection has to be avoided. 
Where diplopia is described by the patient, 
but no strabismus is to be observed, there is a 
ready means of discovering which eye is 
affected. The patient should be told to walk 
a few steps with first one eye and then the 
other closed with the hand. He will stagger 
in his gait, and experience vertigo when the 
sound eye is closed, owing to inability to co- 
ordinate the muscles of the affected eye. 
A certain amount of help in the diagnosis of 
this class of nervous affections is to be obtained 
by electrical examination of paralysed muscles, 
but this is chiefly of service in distinguishing 
peripheral from central lesions. If the case be 
one of hemiplegia, although the ultimate factor 
be thrombosis of the arteries from syphilitic 
thickening of their structure and narrowing of 
their calibre, the proximate cause will still be 
softening of a portion of the motor tract, and 
the electrical condition of the paralysed limbs 
will be indistinguishable from that which be- 
longs to hemiplegia from softening dependent DIAGNOSIS. 
39 
upon non-syphilitic antecedents. In such, cases 
the muscles will probably show either a slightly 
diminished farado-excitability or a normal re- 
action, the conditions which I have generally 
found to obtain from examination of a large 
number of hemiplegic limbs. I have some 
reason to think that where hemiplegia is caused 
by thickening of the cerebral membranes, the 
electrical condition will be found to resemble that 
which is observed in peripheral paralysis- 
farado-contractility will be abolished. At 
present, however, I am unable to speak posi- 
tively upon this point, which is well worthy 
of investigation, for if this should prove 
to be the case it would furnish an impor- 
tant means of diagnosis between softening of 
the brain substance (a permanent injury) and a 
temporary interruption of nerve force owing to 
a compression, which treatment might with 
confidence be expected to remove. 
Nor am I yet in a position to point out any 
decided evidence which is to be derived from 
electrical examination of the lower extremities 
in syphilitic as distinguished from non-specific 
paraplegia. If, however, we find that the 
muscles of the legs, having entirely lost their 
farado-contractility, yet rapidly regain power, 
and coincidently their normal excitability to the 40 
SYPHILITIC NERVOUS AFFECTIONS. 
induced current, we may at least be sure that 
the lesion was situated in the membranes of 
the cord, or in the spinal nerves, and not in 
the substance of the cord, for in the latter 
case such a symptom could only be consequent 
upon an amount of softening which could not 
possibly be followed by such a recovery. An 
example of this is seen in Case XXII, where 
this point, combined with others, enabled me 
to localise the affection in the membranes. 
If we meet with a case of paralysis of a limb 
in which there exists marked atrophy, and the 
muscles which are wasted exhibit complete abo- 
lition of farado-contractility, whilst the reaction 
to the intermitted constant current is exag- 
gerated, we may safely assume that there is a 
lesion of the nerve trunk supplying the atro- 
phied muscles, and that we have not to do with 
paralysis of central origin. This is of no un- 
frequent occurrence in syphilis, from the pres- 
sure of an exostosis or a gummatous invasion 
of the nerve trunk. 
Or we may find abolition of farado-con- 
tractility without exaggerated reaction to the 
intermitted constant current, as in Case XXV, 
where the observation of this point helped 
materially to diagnose the presence of a syphi- 
litic muscular tumour. So, again, paralysis DIAGNOSIS. 
41 
with, atrophy, of peripheral origin, may be 
diagnosed from progressive muscular atrophy, 
unless this be very far advanced, by the re- 
sults of electrical examination. In the latter 
disease the farado-contractility remains normal 
(in proportion to the bulk of muscle remaining), 
whilst in the former, as just described, it is 
lost. In the same way paralysis of a limb, 
of peripheral origin, may be distinguished from 
hysterical paralysis, in which there is often 
great diminution of electro-sensibility, but the 
farado-contractility is but little, if at all, affected. 
It may sometimes at first be slightly diminished, 
but a few applications of the induced current 
will restore it, or there may from the first be 
no diminution. 
In paralysis of the facial nerve from syphilis 
(as from cold) the farado-contractility is more 
or less completely lost, and the reaction to the 
intermitted galvanic current is usually exagge- 
rated-an evidence that the lesion is not central, 
but somewhere in the trunk of the portio dura. I 
have tested the condition of the facial muscles in 
several cases of labio-glosso-laryngeal paralysis 
(an affection dependent upon disease of several 
nerve centres, including that of the seventh, in 
the medulla oblongata), and have always failed 
to find any marked loss of farado-contractility. 42 
SYPHILITIC NERVOUS AFFECTIONS. 
CHAPTER II. 
ON THE PATHOLOGY AND MORBID ANATOMY OF 
SYPHILITIC NERVOUS AFFECTIONS. 
The question of the particular stage of 
syphilis at which lesions of the nervous system 
are liable to occur is one about which authori- 
ties are not agreed, and it is evidently beset 
with difficulty. Although in many instances 
the concomitance of highly characteristic fea- 
tures in the mucous surfaces, muscles, bones, or 
their covering, enables us readily enough to 
refer the nervous affection to the tertiary stage, 
there are, according to my experience, quite as 
large a number in which symptoms appreciable 
by the eye or hand which would help us to 
decide this point are entirely wanting. Still 
more, in a very considerable proportion of cases 
strict questioning has failed to elicit evidence of 
any skin or other affection whatever, whether 
of a secondary or tertiary character, having 
preceded the nervous lesion. My attention was 
drawn to this circumstance several years ago 
by my colleague, Dr Ramskill; and I think PATHOLOGY AND MORBID ANATOMY. 
43 
Lancereaux makes a similar observation in his 
work on syphilis. In such cases the patient 
will freely acknowledge the occurrence of 
chancre and bubo, but at the same time deny 
that there have been any sequelse. Clinically3 
therefore, supposing the lapse of time since 
infection to have been very short, and knowing, 
as we do, that tertiary changes are sometimes 
early in their development, and often delayed, 
we are without data to aid us in fixing the 
period of the constitutional disorder to which 
the affection of the nervous system belongs. 
I do not think that I have seen any instance 
of the more severe forms of syphilitic nervous 
affection occurring sooner than two years after 
infection. It must be remembered, however, 
that we do not always succeed in getting 
trustworthy evidence on the point of date, 
patients being much disposed to refer to a very 
distant past the acquisition of a malady of this 
peculiar character. In other cases special cir- 
cumstances will of necessity prevent our even 
obtaining any information whatever about the 
period of time which has elapsed since the 
disease was acquired. Pathologically, and 
perhaps also in reference to prognosis, the ac- 
curate reference of nervous affections to certain 
stages of syphilis is full of interest and value, 44 
SYPHILITIC NERVOUS AFFECTIONS. 
but as a matter of practice-of the recognition 
and successful treatment of the disorder-it 
is not of so much importance, and I shall refrain 
therefore from dwelling very long upon this point 
in a work which only aims at painting in broad 
touches certain clinical aspects of the disease. 
Lancereaux* speaks of neuralgias and local 
paralyses (preferentially of the cranial nerves) 
as the disorders of the nervous system, about 
the occurrence of which, in the secondary period 
of syphilis, there is the least doubt. He ac- 
knowledges that at present we know but little 
of the changes which may happen in the ner- 
vous centres in that period. He quotes a single 
case of syphilitic hemiplegia occurring in the 
secondary period. A young man, suffering from 
syphilitic impetigo, six months after the ap- 
pearance of a chancre, was suddenly seized 
with right hemiplegia. The autopsy revealed 
no manifest lesion to the naked eye, but there 
was no microscopical examination. Dr E. 
Vidal met with a similar case, in which hemi- 
plegia supervened a short time after the dis- 
appearance of a syphilitic roseola. Dr Kuh has 
reported! the case of a woman, get. 47, who had 
a papulo-squamous syphilid, with glandular en- 
* ' Traite de la Syphilis,' 2nd edition, p. 158. Paris, 1874. 
t ' Prager med. Wochenschr.,' 23, 1864, PATHOLOGY AND MORBID ANATOMY. 
45 
largement and alopsecia. Fifteen days after- 
wards she had headache, pain, and diminution 
of sight in the right eye (iritis), and want of 
power in the lower extremities, which became 
complete, and was then followed by dropping of 
the right eyelid and a convulsive seizure. Some 
improvement was effected by the use of iodide, 
but the convulsive attacks were repeated, and 
she passed into a state of stupor and died. On 
examination the membranes of the convexity 
of the brain were discovered to be infiltrated 
with a yellow exudation, which was found also 
in the form of small masses in the thickness of 
the substance of the hemispheres. According 
to Lancereaux's own experience the secondary 
affections of the nervous centres are marked by 
symptoms but little differing from those of sub- 
acute inflammations of these centres. A young 
man whom he treated presented, in the course 
of secondary syphilis, symptoms which had all 
the character of cerebro-spinal meningitis, and 
which disappeared rapidly under the employ- 
ment of iodide of potassium. The lesions of 
the cord are generally diffused in the course of 
secondary syphilis, and present the characters 
symptomatic of subacute inflammation. A 
young American, three months after contrac- 
tion of a chancre, was attacked with a rubeolous 46 
SYPHILITIC NERVOUS AFFECTIONS. 
eruption and superficial periostoses. Towards 
the seventh month of his illness he experienced 
a sensation of " pins and needles," and weak- 
ness, at first in the right leg, then in the left 
leg, and in the course of eight days he was 
affected with complete paralysis of sensation 
and movement in the inferior half of the body, 
with abolition of reflex movements of the legs. 
This paraplegia, in spite of specific treatment, 
was followed by persistent sores and atrophy of 
the paralysed muscles. At the same time two 
small tumours, seated in the epididymis of either 
side, yielded quickly to iodine treatment. 
Pains of extremely severe character often 
accompany, or even precede, the exanthema- 
tous stage of syphilis (see Case III). They 
are frequently called, from their peculiar vio- 
lence, osteocopic (bone-shattering), and are 
described as neuralgic in character; but Dr 
Anstie justly points out that they differ from 
true neuralgia in that they are symmetrically 
disposed, and will attack several bones at once.* 
I think, too, that the elevation of temperature 
by which they are usually accompanied also 
serves to distinguish them from neuralgia. 
The pains affect especially the bones of the 
cranium, and also frequently the sternum, 
* 'Neuralgia and its Counterfeits,' p. 261. London, 1871. PATHOLOGY AND MOBBID ANATOMY. 
47 
clavicle, ulna, and tibia. They are apt to be 
increased by the warmth of bed, and thus to 
assume a nocturnal character, a circumstance 
which frequently helps the diagnosis materially. 
The pains which happen in the later periods of 
the disease, and are associated with tertiary 
changes, do not, according to my observation, 
present this feature, but rather tend to vary, 
sometimes being worse in the daytime and 
subsiding at nightfall, and often causing equal 
distress at all hours. It is a characteristic of 
syphilitic pains at any period that they are apt 
to be exceptionally severe. 
Lancereaux quotes some cases of local para- 
lysis occurring in the second stage of syphilis.* 
Bassereau has observed two cases of paralysis 
of the portio dura a little while after the ap- 
pearance of an erythematous syphilid. Davaine 
has seen this affection a month after the first 
symptoms of constitutional syphilis. In all, the 
facial hemiplegia, which occurred most often 
suddenly, or at least rapidly, was not quite com- 
plete ; the orbicularis palpebrarum muscle was 
affected, and electric excitability was diminished. 
In 1870 I saw a female patient of Mr James 
Lane's, at the Lock Hospital, in whom an in- 
durated sore was followed by skin eruption, 
* Op. cit., p. 159. 48 
SYPHILITIC NERVOUS AFFECTIONS. 
and, a fortnight after this had disappeared, by 
paralysis of the right side of the face, along 
with pain and tenderness in the right mastoid 
process. She recovered rapidly under iodide 
of potassium. The case was published in the 
c Lancet,' July 9th, 1870. 
One of the first to point out the occasional 
association of grave nervous affections with early 
syphilis was Dr Knorre, of Hamburg, who 
(c Deutsche Klinik,' 7,1849) related several cases 
of paralysis which arose either along with or 
very shortly after the first symptoms of the 
constitutional disorder.* The paralysis in these 
cases sometimes affected individual nerves, 
sometimes whole extremities, motion usually 
suffering more than sensibility; sometimes also 
the mental functions were involved, more rarely 
the nerves of special sensation. It is worth 
while quoting three of these. 
1. A metal worker, set. 20, three weeks 
previously affected with a sore on the prepuce, 
developed soon afterwards pityriasis capitis, 
and a papular eruption spread over the whole 
body. One morning the lower half of the body 
was paralysed, and there was pain in the lower 
part of the back; the urine required to be 
drawn off, and there was incontinence of faeces. 
* Quoted by Zeissl. Op. cit., p. 284. PATHOLOGY AND MORBID ANATOMY. 
49 
On treatment with. Zittman's decoction there 
was complete restoration of power, and the 
cutaneous syphilid disappeared after some 
weeks' employment of iodide of potassium. He 
remained well for three years; then a weak- 
ness in the left leg occurred, which was quickly 
cured by iodide. 
2. A feeble writer, set. 30, after similar con- 
stitutional symptoms, was attacked with para- 
lysis of the right half of the face. A six weeks' 
mercurial treatment cured him. Two months 
later he suffered from diplopia, and the left eye 
turned somewhat inwards. The iodide after 
eight days produced improvement, and four 
weeks afterwards all signs of strabismus had 
disappeared. 
3. In the case of a strong sailor, set. 24, 
coincidently with symptoms of constitutional 
syphilis, the right arm became weak and the 
right half of the face was drawn to the left. 
He was cured by mercurial treatment. 
Virchow* distinguishes two series of develop- 
ments in syphilis. There may be simple 
hyperplasia determining in each tissue homolo- 
gous products-in a bone, osseous tissue; in 
an organ containing connective tissue, all sorts 
* 'Die krankhaften G-eschwiilste,' 2 Bd., p. 394, Berlin, 
1864-5. 50 
SYPHILITIC NERVOUS AFFECTIONS. 
of tumours composed of connective tissue; in 
a lymphatic gland, lymphatic particles in larger 
quantity, and so on. These forms indicate 
simple, slight, inflammatory conditions, and 
they do not belong, he thinks, in any exact 
fashion to a determined period of syphilis. 
Some occur in the so-called secondary and 
others in the tertiary stage. He allows that 
certain local affections show themselves with 
more rapidity and earlier than others, but denies 
that distinct periods characterised by defined 
lesions can be rightly described. So-called 
tertiary accidents may show themselves in the 
secondary period, and vice versa. There is, 
however, a general tendency, but this is not 
absolute, for the disease to progress from the 
original chancre to the lymphatic glands, thence 
to the external surface of the body, and, lastly, 
to the viscera. 
Virchow distinguishes a grave and a slight 
form of the disease in different organs, and 
admits that the grave forms usually belong to the 
most advanced periods of the local affection, and 
the slight forms to the early periods. By slight 
forms he understands those which are of simply 
irritative, inflammatory, or hyperplastic cha- 
racter, as distinguished from the grave forms 
which are characterised by the presence of PATHOLOGY AND MORBID ANATOMY. 
51 
gummy tumours which approach heteroplastic 
formation. 
Although periosteal nodes, when well marked, 
are symptomatic of advanced syphilis, yet they 
are sometimes found in the earlier stages, 
accompanying eruptions of the skin such 
as are classed amongst the secondary mani- 
festations. In the later periods they are, 
doubtless, of gummatous character; in the ear- 
lier they are probably of simple inflammatory 
nature. And if they occur under these circum- 
stances upon the external surface of cranial 
bones and others, there is no reason that we 
know of why analogous swellings of simple 
hyperplastic character should not make their 
appearance on the vitreous table of the cranium, 
and in the various bony canals which transmit 
important nerves from the skull. It seems likely, 
therefore, that this may be the explanation of 
some of the local paralyses and affections of 
sensibility which occur in secondary syphilis. 
Affections of the cerebral membranes occur- 
ring early in constitutional syphilis are so 
very rarely fatal that there is but little ne- 
croscopical evidence of the fact. In judging, 
therefore, of the possibility of such a lesion, 
we may derive some help, as Zeissl* sug- 
* ' Lehrb. der Syphilis,' 2 Theil, p. 285. Erlangen, 1872. 52 
SYPHILITIC NERVOUS AFFECTIONS. 
gests, by considering what is known and seen 
to occur in structures histologically allied to 
them. We know that in the secondary period 
iritis is a common phenomenon. It does not 
seem, therefore, too much to suppose that the 
pia mater, which, at least in the richness and 
muscularity of its vessels, is allied to the iris, 
may be subject to analogous inflammatory 
disturbance. Still more marked is the resem- 
blance between the arachnoid and the serous 
envelope of the liver, or the tunica vaginalis 
of the testis, and as there may be peri- 
hepatitis and periorchitis as comparatively 
early affections in syphilis, it seems probable 
that the arachnoid may be subject to attacks 
of the same kind which may be followed by 
thickening. 
Whatever doubts may exist as to the occur- 
rence, at least in any frequency, of serious 
lesions of the nervous system during the 
secondary period of syphilis, none can be 
felt respecting the production of these by the 
changes which belong almost exclusively to the 
tertiary period. It is at this stage that the 
characteristic gumma makes its appearance, and 
it will be well, before proceeding to consider the 
influence of this growth in the causation of seri- 
ous organic changes in the nervous substance, its PATHOLOGY AND MORBID ANATOMY. 
53 
envelopes, or in the nerve-trunks, to note what 
Virchow says respecting its anatomical peculiari- 
ties.* The gumma presents itself in the form of a 
nodosity long ago described under the name of 
syphilitic tubercle, but not therefore to be con- 
founded with the product of tuberculosis, with 
wdiich it has no relation. As we have already 
noted, it is not every tumour developed in the 
course of syphilis which is a gumma. A certain 
number are of simply hyperplastic character, 
that is to say, new masses of tissue are pro- 
duced, which are of the same nature as the 
mother-tissue from which they proceed. A 
syphilitic exostosis is composed of bony tissue 
which presents no peculiar character to dis- 
tinguish it from any other pathological bony 
product. A syphilitic tubercle of the skin or a 
glandular syphilitic tumour, a bubo, may in 
its intimate structure present the greatest ana- 
logy with simple inflammatory cutaneous or 
glandular tumours. In these different parts 
the syphilitic product or tumour appears as 
the result of simple irritation which only gives 
rise to the formation of homologous tissue. 
But the other kind of syphilitic tumour deviates 
from the type of the mother-tissue from which 
* ' Die krankhaften Geschwulste,' 1 Bd., p. 76, Berlin, 
1863. 54 
SYPHILITIC NERVOUS AFFECTIONS. 
it proceeds. A gumma of the dura mater will 
not pass for a simple thickening or hyperasmia 
of the membrane; a gumma of the brain ap- 
pears as something different from cerebral sub- 
stance, something heterologous; a gumma of 
the testicle differs from simple induration of 
this organ. These are so many examples 
of heteroplastic forms. Now the influence 
which begets these two kinds of products- 
homologous and heterologous-is a dyscrasia, 
by which term Virchow would express the 
presence in the blood of a substance exer- 
cising an irritative effect upon parts of the 
body. It is usually supposed that a specific 
dyscrasia gives rise to equally specific products, 
which, indeed, are taken as proofs of a specific 
dyscrasia. But this hypothesis is false, for in 
those cases in which there is most reason to 
suppose the existence of such a general disorder 
it often happens that the products are not 
specific; there may be, indeed, side by side, 
specific and non-specific products. We cannot, 
therefore, in the face of this, go back to the 
dyscrasia and assign to it special characters. 
For, taking syphilitic exostosis as an instance, 
we should have to assume a sort of ossifying 
dyscrasia, or, arguing from the buboes, a sort 
of cellular lymphatic dyscrasia, and so on. It PATHOLOGY AND MORBID ANATOMY. 
55 
is evident that the character of each resulting 
product cannot be simply determined by that 
of the dyscrasia. The nature of the part in 
which it is developed possesses so powerful an 
influence that it is only when the specific excita- 
tion possesses considerable intensity that we 
observe the formation of similar specific pro- 
ducts in different structures. It is to this con- 
dition that is due the appearance of gummy 
products in the bones, connective tissue, and 
glands.* 
The gummy tumour of the surface of bone 
has long been known. There was found upon 
bones situated superficially (frontal, clavicle, 
tibia) a periosteal swelling, flattened and elastic, 
and containing a mass resembling the gum 
which exudes from certain trees. For ages 
so little precision was exercised that hard bony 
tumours, nodosities, and exostoses were ranged 
under the same denomination. It is only in 
comparatively recent times that these different 
forms have been separated. When it was 
found that, in cutting gummatous tumours, a 
sticky fluid presented itself, it was admitted as 
certain that there was an exudation between 
the periosteum and the bone. An attentive 
examination showed, however, that this mass 
* Virchow, loc. cit., p. 77. 56 
SYPHILITIC NERVOUS AFFECTIONS. 
was not an exudation, but a soft tissue, pro- 
liferating with a certain rapidity; that it was 
not situated between the periosteum and the 
bone, but that it proceeded especially from the 
internal layers of the periosteum, and that it 
presented the greatest analogy with soft mucous 
tissue. In this tissue is found a soft intercel- 
lular substance, gelatinous, here and there 
fibrillary, with proliferating cells, some fusi- 
form, others round, of different sizes, for the 
most part pale, and provided with one, less 
often two or more pale nuclei. The gumma is 
sometimes not semi-liquid; although elastic and 
difficult to displace, it is of tolerable firmness. 
In this case it presents a fibrillar intercellular 
substance, and includes stellate cells with one or 
more nuclei as well as fusiform and round cells 
in larger quantity; these cells are, however, 
but little developed. From this stage the de- 
velopment makes fresh progress; the mass of 
cellular elements increases, proliferation con- 
tinues so as to produce suppuration and 
ulceration. This, however, is not always the 
case, but when the cells have attained a cer- 
tain size they perish, their decay happening 
at various epochs. Sometimes the retrogres- 
sion shows itself in the large fusiform and 
reticulated elements, at other times in the large PATHOLOGY AND MORBID ANATOMY. 
57 
round elements, often in the small ones. The 
periosteal gumma has never a long duration, but 
shows itself as a transitory product; if its ex- 
istence be prolonged, that is not explained by 
the persistence of its elements, but by the pro- 
duction of new elements in the neighbouring 
parts, a mode of extension termed by Virchow 
" infection by vicinity." 
The degeneration nearly always results from 
progressive fatty metamorphosis. As this 
metamorphosis proceeds, the tissue assumes a 
yellowish opaque aspect. If the cells are of 
large size, and the intercellular substance 
dense, the morbid tissue is dry, firm, and 
caseous; it presents, indeed, an aspect which 
has much resemblance to tubercle, and is often 
confounded with it. This caseous matter is 
therefore the decayed morbid product, a mode 
of termination, not, as was formerly considered, 
the beginning of development. It is a dead, 
degenerated tissue, withdrawn from all organic 
connection, which may remain for a longer or 
shorter time in this state. 
Its duration is very various. In some cases, 
after a short time, the masses disappear by ab- 
sorption, just as is seen, in other places, to 
happen with the products of simple fatty de- 
generation. As they disappear, there is a 58 
SYPHILITIC NERVOUS AFFECTIONS. 
flattening, even a depression, at the part 
■which they occupied. In other cases the 
caseous mass has a longer duration, and re- 
mains in the condition of a persistent nodosity, 
but this is more frequent in the parenchymatous 
organs. In others, again, ulceration takes place, 
which is produced by the tendency to suppura- 
tion, which has been described. The bones 
rarely present this phenomenon, for syphilitic 
caries and necrosis, so much to be dreaded, are 
the result of gummatous development within 
the bone. 
The only specific character, if so it can be 
called, in this syphilitic new formation, is its 
extreme frailty -the rapid destruction of its cells 
by a process of fatty metamorphosis or conver- 
sion into caseous material. 
Such is, in general terms, Virchow's descrip- 
tion of the character of the gumma as it may 
occur in any of the tissues of the body, with 
certain slight modifications only dependent 
upon the locality affected. 
Long after cerebral disturbances, in the 
form of paralysis, convulsion, vertigo, trem- 
bling, and affections of nerve-trunks occa- 
sioning loss of power or sensation, had been 
recognised as referable to syphilis, it was 
thought that the nervous substance could only PATHOLOGY AND MORBID ANATOMY, 
59 
be indirectly affected through the medium of 
disease of the cranial bones. It is now known 
that, although many cases do depend upon such 
a cause, a probably still larger number occur 
without the aid of any affection of the osseous 
structure. The lesion in such cases affects 
either the membranes, the interstitial neuroglia, 
or the blood-vessels. Heidenhain* mentions 
cases of thickening of the membranous cover- 
ings of the medulla oblongata and the upper 
part of the spinal cord (chronic arachnitis) in 
syphilitic patients in whom there was no bone 
lesion. A similar case of syphilitic disease of 
the pia mater is related by Ziemssen. Griesingerf 
describes a case of chronic meningitis from 
syphilis, occurring in a patient six months after 
infection, who was hemiplegic, and eventually 
became imbecile. At the autopsy Griesinger 
found the dura mater normal, but the pia mater 
over the whole circumference of the brain, and 
especially over the convexity of the hemispheres, 
was intimately grown together, the arachnoid at 
the same part being thickened to a depth of 
half a line or more. 
We are reminded here of the striking analogy 
* 'Archiv der Heilkuude,' 1 Jahrg., 1 Hft. Leipzig, 1860. 
t Quoted by Zeissl, 'Lehrb. der Syphilis,' 2 Theil., 
p. 286. Erlangen, 1872. 60 
. SYPHILITIC NERVOUS AFFECTIONS. 
between the condition described and the fre- 
quent strong synechiae characteristic of syphi- 
litic iritis. L. Meyer* considers the intimate 
adhesion of the dura mater to the soft brain- 
membranes and the brain as an almost patho- 
gnomonic sign of the syphilitic character of 
the inflammation. He says that adhesion of 
the brain-membranes to one another, in spite 
of the numerous inflammatory processes in 
them, is exceedingly rare. He has never 
observed them in pachymeningitis. The sar- 
comata, also, so frequently developed from 
the inner surface of the dura mater, may 
force themselves deeply into the cerebral sub- 
stance, but they do not blend with the arach- 
noid. 
Of the membranes covering the brain the 
dura mater is most frequently the seat of inflam- 
mation in the later periods of syphilis, and two 
kinds are distinguished, according as the outer 
(periosteal) layer is affected or the inner (arach- 
noid) layer. The following is Virchow's descrip- 
tion of these lesions.f The affections of the 
outer layer nearly always present themselves 
in the form of external pachymeningitis, and 
* ' Allgem. Zeitsch. fur Psychiatric,' 18 Bd,, 3 and 4 Hft. 
Berlin, 1861. 
t Op. cit., p. 448. PATHOLOGY AND MORBID ANATOMY. 
61 
belong to the same category as external 
syphilitic periostitis, since they determine the 
occurrence of exostoses, hyperostoses, cir- 
cumscribed gummatous tumours, and dry caries. 
Even slight changes may be of great conse- 
quence when they occupy the points at which 
important nerves pass, such, for example, as 
the anterior nerves of the brain, the different 
nerves proceeding to the eye, and the trigeminus. 
On the other hand, exostoses of considerable 
size and gummatous tumours may exist under 
the vault of the cranium without notable 
symptoms. 
A more diffuse external pachymeningitis ex- 
tends over large parts of the surface of the 
cranium, and occasions, together with thicken- 
ing of the dura mater, considerable atrophy of 
the inner surface of the skull. If the dura 
mater be stripped off, the bone appears uneven, 
with superficial erosions, isolated, or irregular 
and rounded, or united into figures of jagged out- 
line. Into the depressions of the vitreous table 
thus produced, thickenings of the dura mater 
penetrate, consisting, when fresh, of a vascu- 
larised granulation tissue; later this tissue be- 
comes dense, and sometimes cretaceous. When 
this process occurs about the passage of nerves, 
for example in the neighbourhood of the sella 62 
SYPHILITIC NERVOUS AFFECTIONS. 
turcica, there may be paralysis. Or the external 
pachymeningitis may be connected with grave 
affections of the bones - gummatous osteo- 
myelitis, suppurative caries, and necrosis. 
When the outer layer of the dura mater is 
diseased, the inner layer often presents chronic 
inflammatory changes, with thickenings, adhe- 
sions to the pia mater, and even inflammatory 
alterations of the adjacent parts of the brain. 
Internal pachymeningitis is often gummatous, 
but still more frequently, perhaps, of simple 
character. The gummatous tumours are mostly 
rounded, lying flat on the dura mater, or pene- 
trating deeply into it, sometimes even seated in 
the thickness of this membrane. They have a 
caseous nucleus of yellowish colour, and their 
periphery is at one time hard and lar- 
daceous, or grey and transparent, sometimes 
even gelatinous, according as the growth is 
old or recent. Their size varies from that of 
a hempseed to that of a walnut, or still larger, 
and they are seated most commonly either 
immediately over the convexity of the hemi- 
spheres, or at the anterior part of the base of the 
brain, especially about the sella turcica, or in the 
neighbourhood of the third anterior convolution, 
or at the level of the basilar fossa. Around them 
there may be an extended inflammation giving PATHOLOGY AND MORBID ANATOMY. 
63 
rise to hsemorrhagic products, and nearly always 
causing subsequent adhesions with the pia mater. 
Sometimes the tumours penetrate so deeply into 
this latter membrane that it is difficult to de- 
termine whether they belong to the pia mater or 
dura mater. The neighbouring cerebral sub- 
stance often contains gummata. Most fre- 
quently it presents softening, either of inflam- 
matory origin or the result of ischaemia, and 
produced by the obliteration of the afferent 
vessels. Virchow first showed, in a case of this 
kind, blocking of the internal carotid, which 
passed into the midst of the patch. Bristowe 
has described an analogous case. Meyer has 
reported many cases of obstruction of cerebral 
arteries with meningeal lesions. Grildemeester 
and Hoyack have noted obstruction of the 
sylvian artery from an analogous cause. Pas- 
savant has observed obstruction of the basilar 
artery. Virchow has also met with a great 
number of arteries obliterated in a large tumour 
at the base of the brain. Wilks, Hughlings 
Jackson, Broadbent, and, I think, some other 
English observers, have also described exam- 
ples of syphilitic thickening of the walls of 
cerebral arteries. The vessels may be ob- 
literated either by the compression of tumours 
outside them, or by the thickening of their 64 
SYPHILITIC NERVOUS AFFECTIONS 
walls and parietal thrombosis. In an autopsy 
which I made in 1868, upon a hospital patient, 
a man, set. 30, with a syphilitic history, who 
died with extensive brain softening, I found 
nearly the whole circle of Willis converted into 
rigid and knotty cords by great thickening of 
the walls of the vessels. A condition of 
thrombosis existed almost throughout their 
channels. 
Occasionally it happens that a circumscribed 
point of the pia mater is found adherent to the 
thickened dura mater, and a small gummatous 
tumour may be discovered in the pia mater 
itself. This partial arachnitis, as Virchow calls 
it,* produces mostly a compact mass of indurated 
connective tissue, which presents plentiful cell 
proliferation, and soon degenerates. Small 
yellow points are seen scattered in this callous 
white or greyish tissue, flattened or rounded. 
The neighbouring cerebral substance is almost 
always changed; it is either softened, or more 
dense and sclerous, and, at the same time, of gum- 
matous character. The really characteristic affec- 
tion of the pia mater is the gummatous tumour, 
which may here attain a large size-that of a 
walnut or even a hen's egg. Such tumours are 
not limited to the pia mater, but may affect 
* Op. cit., p. 452. PATHOLOGY AND MORBID ANATOMY. 
65 
the brain substance and the nerves. The 
regions situated behind the chiasma of the 
optic nerves up to the pons Varolii, and behind 
the pons to the peduncles of the cerebellum, are 
favourite seats of these tumours. Gummatous 
tumours of the arachnoid are to be found, with- 
out doubt, at other parts, but they are at their 
largest at the base of the brain. 
The existence of a syphilitic encephalitis, as 
distinct from membranous inflammation, has 
been very much doubted, and the same may be 
said of neuritis. 
It is remarked by Zeissl* that in the 
course of dissection of the bodies of acknow- 
ledged syphilitic subjects, who had died with 
grave brain disease, certain cerebral and 
nerve changes were found which readily ex- 
plained the motor or psychical disturbances 
observed during life, but could not be proved 
to be syphilitic. In the anterior lobes of 
the cerebrum, for example, seats of softening 
were noted by Ricord, Ziemssen, and especially 
by Duchek, in a large range of cases. But 
patches of softening like these could not be pro- 
perly put down as a morbid change peculiar to 
syphilis since they might represent simply the 
softening which results from various kinds of 
* Op. cit., p. 287. 66 
SYPHILITIC NEKVOUS AFFECTIONS. 
tumours, as well as from haemorrhage. All 
that could be said of them was, that they 
represented consecutive disorder whose com- 
mencement might be morbid product of some 
kind. Together with these patches of soft- 
ening there were found reddish, yellowish- 
grey, or gelatinous transparent masses strewed 
with caseous material, or nodules the size 
of peas in a state of caseous degeneration 
in their centre. These seats of disease, 
which were found in the brains of syphilitic 
subjects, were differently described and inter- 
preted according to the changes of texture 
which were recognised. If the circumscribed 
points of disease were of firm texture, and the 
neighbouring brain substance unchanged, they 
were treated as partial cerebral scleroses which 
depended upon proliferation of connective 
tissue, and stood in no necessary relation to 
syphilis. If they were already nearly decayed 
or degenerated, they were looked upon as in- 
spissated abscesses, tubercle, or scirrhous or 
encephaloid masses. 
In process of time it was remarked that the 
smooth, hard, fibrous-looking tumours with a 
soft yellow centre called to mind in a striking 
manner the gumma as it was found in other 
organs (liver, testes, &c). And so, at a period PATHOLOGY AND MORBID ANATOMY. 
67 
which is quite recent, the syphilitic gumma has 
been identified in the frequently described and 
variously interpreted gelatinous or fibro-caseous 
nodule occurring in the brain. 
The gummy tumour of the brain is most 
often found on the surface or just below it. 
Less frequently it occurs in the substance of 
the hemispheres and great ganglionic centres. 
Next in order the pons Varolii, the cerebral, 
and cerebellar peduncles are liable to be 
invaded by these tumours, of which one or 
several may be found, sometimes of con- 
siderable size, but not so large as those which 
frequent the arachnoid.* In the gumma of 
the brain and pia mater, which is often of 
irregular shape, the exterior is a delicate, 
greyish granulation tissue traversed by nume- 
rous vessels, and lost in the neighbouring 
structures, which are frequently softened in the 
later stages of the tumour. But it often hap- 
pens, and especially in chronic cases, that the 
tumours attain great density and hardness. Not 
only do the neighbouring membranes (pia mater, 
ependyma) become thickened, and form cysts 
for the receptacle of the tumour, but the 
cerebral substance itself becomes sclerosed, 
and entire convolutions of the surface or iso- 
* Virchow, op. cit., p. 455. 68 
SYPHILITIC NERVOUS AFFECTIONS. 
lated portions may be transformed into whitish- 
grey indurated tissue, which completely isolates 
the yellow caseous points. These forms, which 
belong to gummatous encephalitis properly so- 
called, are distinguished by the boundary 
between them and the neighbouring cerebral 
tissue being less marked, their interior less 
uniform, often interrupted indeed by remains 
of cerebral substance. 
Virchow describes the structure of the 
recent and soft portions as especially distin- 
guished by its almost exclusively cellular, and 
sometimes even medullary character. Small 
round cells containing solitary, somewhat 
large nuclei, with one or more brilliant but 
small nucleoli, are found crowded, in a soft, 
and sometimes fibrillated intercellular substance, 
in the midst of the cerebral substance itself. 
When the affection invades firmer tissues, as 
the dura mater and the sheaths of nerves, 
the intercellular substance becomes firmer and 
more fibrillated, and the cells take a more fusi- 
form or reticulated form. 
How are we to distinguish these tumours 
from tubercle ? Virchow* allows that the large 
cerebral tubercle presents the greatest analogy 
with those gummata which have undergone 
* Op. cit., p. 459. PATHOLOGY AND MORBID ANATOMY. 
69 
caseous metamorphosis, but he is nevertheless 
able to speak of distinguishing signs. The large 
cerebral tubercle, especially when isolated, is 
generally less rounded, is caseous almost 
throughout, and frequently softened centrally. 
The gumma is not always round, but often ap- 
proaches the form of the part from which it 
springs, or is composed of a series of isolated, 
sometimes diffluent, patches, between which the 
cerebral substance may persist; it is more ir- 
regular, nodulous, and diffuse. Generally speak- 
ing, there is only a small portion of it which is 
really caseous; the principal mass is com- 
posed of compact connective tissue, dis- 
tinguished by well-developed fusiform or re- 
ticulated cells, or of a soft granulation tissue, 
rich in vessels, which forms distinct lobes, each 
of which undergoes caseous metamorphosis. 
Virchow has never observed central softening 
in these tumours, whilst, on the other hand, the 
softenings of cerebral substance so frequent in 
syphilis do not occur in tuberculosis. As re- 
gards the intimate structure it cannot be denied, 
he says, that nowhere do gummy tumours and 
tubercle resemble each other more closely than 
in the brain. The young portions of tubercle 
are likewise constituted of a tissue with small 
cells, and the most distinguishing point is, that 70 
SYPHILITIC NERVOUS AFFECTIONS. 
in the cells of tubercle the nuclei are smaller 
than in those of the gumma. 
That gummy tumours affect the spinal cord 
also is doubtless the case, for examples of this 
lesion have been discovered after death, but 
their presence in this region has not been 
verified to the same extent as in the brain 
and nerves. So also, it is equally certain that 
the membranes of the cord are liable to 
syphilitic inflammatory changes like those of 
the brain. 
The cranial nerves, and especially the third, 
fifth, sixth, optic and facial have been found 
pressed upon by yellowish-grey gelatinous 
transparent masses, covered with an indu- 
rated envelope. If these masses be cut 
into certain white points are seen, formerly 
considered to be nerve bundles which had es- 
caped destruction, but which turn out to be 
nothing but scattered points of caseous degene- 
ration. Not only the cranial nerve trunks, but 
those proceeding from the spinal cord may be 
invaded by gummata, and their functions thereby 
deranged. On the motor side these may be 
characterised either by paralysis, or by cramp 
and contraction of the muscles supplied by 
them. On the sensory side, the phenomena 
may take the form of pain, or loss of sensation, PATHOLOGY AND MORBID ANATOMY. 
71 
probably according as the existence of the 
tumour acts by simple pressure or by producing 
irritation. 
The alterations in the nerve trunks may be of 
two kinds : an interstitial neuritis which is of 
simple inflammatory character, or an enlarge- 
ment by nodules like neuromata, but which are 
gummy tumours. 
Quite recently Dr Petrow* has published 
the results of the examination of the cervical, 
thoracic, and solar plexuses in twelve syphilitic 
subjects. The specimens were removed a 
few hours after death, and the examination 
conducted both upon fresh preparations, 
and after they had been hardened in chro- 
mic acid. Dr. Petrow found two classes 
of alteration. One involved the nerve cells, 
and was characterised by pigmentary and 
colloid degeneration. The other consisted of 
hyperplastic modification of the interstitial 
tissue but slightly differing from that which 
syphilis causes in other organs, and which 
involved secondarily atrophy of the cells and 
nerve fibres. His conclusions are as follows: 
1. The syphilitic diathesis acts on the sympa- 
thetic, and determines very distinct alterations. 
2. The nerve cells may undergo change in- 
* ' Archiv f. Path. Anat.,' page 121. 1873. 72 
SYPHILITIC NERVOUS AFFECTIONS. 
dependently of the connective tissue, con- 
sisting of pigmentary and, less frequently, 
colloid degeneration. 
3. As happens with other organs the con- 
nective tissue of the sympathetic undergoes 
sclerosis with resulting atrophy of nerve ele- 
ments, tubes, and cells. 
4. The endothelium which surrounds the 
nerve cells participates in the changes. At 
first there is hypertrophy, with proliferation 
of cells, later a fatty degeneration. 
There is a great tendency to recurrence 
of gummy tumours. Under treatment the 
symptoms of paralysis or convulsion induced 
by them may disappear entirely, only to recur 
later and eventually cause death. Virchow is 
of opinion that there is first a proliferation, 
then fatty metamorphosis and absorption, which 
diminishes the size of the tumour, and takes 
off the pressure which has produced the symp- 
toms. If the exciting influence be again 
exerted, or if the absorption has not been 
complete, the process takes on renewed ac- 
tivity. Wilks* believes that much of the 
albumino-fibroid material formed in the true 
syphilitic stage is incapable of absorption, and 
remains during the life of the patient. Deposits 
* ' Guy's Hospital Reports.' 1863,. PATHOLOGY AND MORBID ANATOMY. 
73 
of this kind, lie says, may be found in the livers 
of those who have quite recovered from the 
disease, and have died many years afterwards 
of an independent malady, or may be ob- 
served in those who have succumbed to the 
ultimate effects of syphilis in the so-called ter- 
tiary stage. 74 
SYPHILITIC NERVOUS AFFECTIONS. 
CHAPTER III. 
CASES ILLUSTRATIVE OE SYPHILITIC NERVOUS 
AFFECTIONS. 
The multiple character so frequently to 
be observed in the more serious nervous 
affections consequent upon syphilis, renders 
well-nigh impracticable any attempt to group 
them in distinct classes. As I have already 
remarked, convulsion may be met with alone, 
or combined with paralysis. One or more 
cranial nerves may be paralysed indepen- 
dently, or in association with hemiplegia. 
Paraplegia may be an isolated phenomenon, 
or along with it there may be paralysis of 
one or both upper extremities, or of one or 
more cranial nerves. Alterations in the deep- 
seated tissues of the eye may be associated with 
paralytic phenomena in various parts, or with 
convulsion. Impairment of the mental faculties 
may be conjoined with one or several of these 
conditions, or may be entirely absent. Under 
these circumstances it will be most useful, pro- ILLUSTRATIVE CASES. 
75 
bably, if I limit myself to describing the salient 
points of a certain number of the cases which 
have occurred in practice, without attempt- 
ing any serious classification. They will serve 
to illustrate generally the variety of conditions 
which may be met with, as well as the circum- 
stances of the patient's health and previous 
history under which they have been found to 
occur. Most of the examples adduced will also 
help to show, what I have already insisted 
upon, that the syphilitic element must be sought 
for in such cases by the medical attendant him- 
self, as in the very large majority it will form 
no element in the patient's voluntary account 
of his history, and in many instances will fail 
to betray itself by any signs evident to the eye. 
The following case illustrates very well the 
character of the nervous phenomena which are 
apt to occur at an early period in the disorder. 
Having in a previous chapter dwelt upon the 
frequency with which omissions are made in the 
detection of the syphilitic basis in many nervous 
affections, I am not sorry to add this case as 
an example of one (out of many, doubtless) in 
which I was myself deceived for a considerable 
time as to the real nature of the disorder. 
Case III.-Several years ago a male patient, aged twenty- 
six, consulted me respecting certain general nervous 76 
SYPHILITIC NERVOUS AFFECTIONS. 
symptoms-fluttering, agitation, palpitation of the heart, 
from which he had long been suffering. He described also 
a pain at the prsecordia which attacked him in the middle 
of every night, and a terrible pain at the back of the head, 
which had troubled him, with brief intermissions, for three 
or four months. This was sometimes so bad, especially 
from six to eight o'clock in the evening, that he thought he 
should lose consciousness. His tongue was furred; pulse 
100, irritable, the artery seeming relaxed. The occiput was 
tender to pressure at one point, and there was a similar 
point of tenderness below each patella. He himself 
ascribed his symptoms to very frequent nocturnal emis- 
sions, which had troubled him for nine years. His skin 
seemed hot, but I am unable to give his temperature, as 
this happened before the introduction of the clinical ther- 
mometer into common use. For a fortnight I treated 
him with quinine with no beneficial effect, the only change 
to be noted being that the pain now sometimes affected 
each temple instead of the occiput. One day he mentioned 
that nine months previously he had contracted a chancre, 
which remained open for three months, and was followed a 
few weeks afterwards by a skin eruption, of which he 
showed me the remains-small brownish-coloured depres- 
sions. He had also had sore throat. I now gave him 
iodide of potassium, followed in a few days by bichloride of 
mercury. He improved in a few hours, and in two or 
three weeks had recovered his usual health. 
Lancereaux* describes two cases which re- 
semble this. A young woman complained of 
pains in the eyes and forehead, which she com- 
pared to stabs of a knife, and which attacked 
* ' Traite de la Syphilis,' Paris, 1874, p. 158, ILLUSTRATIVE CASES. 
77 
her in the evenings. On admission into the 
hospital she presented a well-marked syphilitic 
roseola. There were several points tender to 
pressure in the supra-orbital, frontal, malar, and 
sub-occipital regions. The symptoms yielded 
after some days to the employment of iodide of 
potassium. Another patient likewise who had 
formerly suffered from attacks of intermittent 
fever, on the appearance of a rubeolous erup- 
tion was attacked with a frontal neuralgia of 
periodical recurrence, for which sulphate of 
quinine was given without result, but to which, 
on the contrary, iodide gave speedy relief. 
Functional disorders of the digestive or- 
gans and circulation, accompanied by vague 
nervous sensations, are very frequently de- 
pendent upon syphilis, and are especially 
likely to give rise to mistakes of diagnosis, the 
stomach or liver being described by the patient 
himself as the offending organ. Here is a case 
in point: 
Case IV.-A male patient, aged twenty-three, con- 
sulted me on account of constant indigestion and head- 
ache, associated with attacks of faintness, which had been 
occurring about once in every three or four weeks for 
six months previously. In the attack he would turn pale, 
and, as he described it, there would be a feeling of im- 
peded circulation in his extremities, and the veins of his 
hand would diminish to the size of threads. He had never 78 
SYPHILITIC NERVOUS AFFECTIONS. 
actually lost consciousness, but was always able to struggle 
against the attacks, which sometimes ended in vomiting. 
He suffered very much from noisy flatulent dyspepsia, and 
to this cause referred his attacks of faintness. By con- 
stitution a healthy young man, he had led a fast life, and 
three years previously, as I chanced to know, contracted a 
chancre, which had been followed by a skin eruption. 
Having been acquainted with him for several years, I was 
now able to notice a great alteration in his appearance. 
He was very weak, his complexion of a pale earthy hue, 
his pulse feeble, and pupils unduly large. He had so 
lost nerve that he could not mount a horse. He suffered 
frequently from palpitation ; the heart sounds were normal. 
Knowing his antecedents, I put him at once upon iodide 
treatment. In a week his general health was very greatly 
improved, but he now showed me a small, but not deep, 
ragged ulcer on one tonsil. To this sulphurous acid was 
applied. The specific remedy was continued, and by the 
end of a month he felt perfectly well. There had been no 
return of faintness ; the throat had healed; his digestion 
had ceased to give him inconvenience; the pupils of his 
eyes had resumed their normal appearance. On one occa- 
sion only he had noticed that the veins of his hands sud- 
denly contracted. I directed a continuance of treatment, 
and then lost sight of him for eight months. He had con- 
tinued his medicine, it seemed, for four weeks, and had 
remained quite well for several months. He now com- 
plained of a tender spot on one of his ribs and on his heel, 
in both of which situations I found a small periosteal swell- 
ing. The same treatment as before was resumed with im- 
mediate good effects, but there still remained a tendency 
to a return occasionally of sudden and transient want of 
circulation in his hands. I then added a sixteenth of a grain 
of bichloride of mercury to his iodide, and gave him this ILLUSTRATIVE CASES. 
79 
three times daily. Under this treatment he speedily lost 
all his symptoms. In the following winter I was called 
to him, and found him suffering from symptoms closely 
resembling subacute rheumatism-fever, pain, swelling 
of joints, and insomnia, which had troubled him in the 
country for several weeks. For this he took ten grains of 
iodide every four hours, and in a few days he had recovered 
completely. This was a case which, there can be but little 
doubt, would have resulted in marked epileptic seizures 
under any but specific treatment. 
There was much resemblance to many of the 
symptoms of this patient in those of another 
who consulted me about the same time, but 
whose progress I had not the opportunity of 
observing closely. He had become epileptic, 
and the phenomena described occurred in the 
intervals of his fits. 
Case V. - The patient, set. 32, came to me com- 
plaining of extreme weakness, confusion in the head, 
and sense of weight in the forehead and vertex, flatulent 
dyspepsia, and loss of flesh. Two years previously he had 
first had an epileptic seizure, the immediate warning of 
which was a feeling as though his tongue swelled, and had 
since had, I think, two or three only at long intervals, the 
last having taken place the week before his visit to me. 
It had occurred in the night, and he only knew of it from 
finding his tongue bleeding in the morning, and a bruised 
sensation in his limbs. He was cachectic in appearance, 
with a furred tongue, and feeble pulse. He described a 
sensation of tingling in both hands, and of grains of sand 
running down the right side of his face. He had for some 80 
SYPHILITIC NERVOUS AFFECTIONS. 
time been unable to sleep at night. He was daily subject 
several times to a sudden feeling of want of breath, and 
coincidently the veins on the back of his right hand would 
assume the appearance of blue threads. Whilst in my 
room he was so attacked, and I was able to observe this 
latter phenomenon. I noted also that he moved the right 
leg clumsily, and he described that it and the corresponding 
arm felt numbed. He felt, when the contraction of his 
veins occurred, that without a determined effort on his part 
he would become insensible ; and this effort he was able to 
make. It should be said that he had formerly drunk a good 
deal, but there seemed reason to believe that he was no 
longer indulging in any great excess. I saw him very ir- 
regularly, and at long intervals, for about a twelvemonth. 
On each occasion I prescribed iodide for him, and always 
with immediate relief to his symptoms ; but he failed to 
persevere in any regular course of treatment. This patient 
came of a family which had no neurotic history, and he was 
thirty years of age when his first fit occurred. Six years 
before this attack he had suffered from chancre, for which 
he had taken mercury until, as he expressed it, he " tasted 
copper." He had never had any skin eruption or bad sore 
throat. As he was a man of superior intelligence, and 
showed no reservation in speaking of his history, I think 
this statement is to be relied on. 
In such cases as these it is probable that the 
lesion lies in the membranes of the brain. 
It is worth noting, as regards the symptom 
of sleeplessness, that the occurrence of pro- 
longed insomnia, without any evident cause, 
should always suggest an inquiry into the 
history as to the existence of constitutional ILLUSTRATIVE CASES. 
81 
syphilis. This applies at least as strongly to 
children affected with this symptom, as they 
may be suffering from the inherited disease. 
If this should be the case the insomnia will 
quickly yield to specific treatment, after having 
defied all other means to overcome it. 
The following is a very interesting case of 
paroxysmal aphasia, which circumstances showed 
was of syphilitic origin, although the patient was 
not aware that he had ever had a chancre : 
Case VI.-A man, aged thirty, whom I had attended 
a year and a half previously for a trifling disorder of 
digestion, came to me so altered in appearance that I 
recognised him with some difficulty. His complexion 
was of a peculiarly muddy pallor, and his manner was 
extremely dazed and stupid. His speech was laboured 
and indistinct, and he said that he had to think much 
before he could find the right word to use. He could not 
remember names, and had observed that in writing he 
frequently substituted one word for another. He walked 
without a halt, his grasp was equally good on either side, 
and there was no traction of his mouth. 
It seemed that two months previously, whilst at dinner, 
lie suddenly lost his speech without any failure of con- 
sciousness, and an attack of precisely similar character had 
occurred five or six times since. Described in detail it was 
this. He suddenly found himself unable to Lhold things 
with his right band. A peculiar sensation then travelled 
up from the first two fingers of that hand into his arm, 
which became numbed, so that he could not move his 
fingers. Thence it passed to the right cheek, which it 82 
SYPHILITIC NERVOUS AFFECTIONS. 
seemed to draw up as in a knot, and his tongue was then 
drawn over to the right side, so that for a minute or two he 
could not speak a word. In a few minutes the sensation 
disappeared, and the arm resumed its normal condition. 
But the power of articulation still remained impeded to the 
extent which I observed. The attacks described had oc- 
curred, on an average, once in ten days. He had been 
under medical treatment, in the course of which he had 
taken bromide of potassium, but without effect in prevent- 
ing the attacks, one of which had happened ten days pre- 
viously. Urine acid, 1028, free from albumen or sugar. 
With the exception of dyspeptic ailments, his general health 
had been good; but I elicited that five years before he had 
suffered for no less than thirteen months from an ulcerated 
sore throat, of which the tonsils still showed slight cicatri- 
cial traces. He had never, to his knowledge, suffered from 
chancre, but was affected with gonorrhoea at the time when 
his throat became ulcerated. He was ordered ten grains of 
iodide of potassium with twenty of bromide of ammonium 
three times daily. After five days he spoke more clearly, and 
had experienced no return of the loss of speech nor of the 
queer feeling in his arm. His intelligence was brighter, 
and he told me, with some amusement, that for weeks past 
he had been dull and stupid to a degree. As an example 
of this he mentioned that he had constantly caught himself 
making puns, an occupation which was not at all his natural 
habit, and which vexed him much. Ordered fifteen grains 
of iodide with twenty of bromide three times a day. In 
three days more I found his complexion very much im- 
proved. His speech was still embarrassed, but he had no 
return of the " sensations." He had now been free from 
them for three weeks, having never previously gone more 
than ten days without an attack. Ordered twenty-grain 
doses of iodide. This he fancied did not agree with him, ILLUSTRATIVE CASES. 
83 
so, after taking it for four days, I reduced the dose to five 
grains, and combined with it one sixteenth of a grain of 
bichloride of mercury. 
It is unnecessary to give his further progress in detail. 
Mercurial treatment was continued, broken on one occa- 
sion by the occurrence of diarrhoea, and he gradually im- 
proved vastly in health. On one or two occasions, either 
from overwork or exposure to a hot sun, he got a slight 
thrill in the first two fingers of his right hand, but he had 
no return of the transient loss of speech, and his articula- 
tion at all times became quite distinct. Ten weeks from 
the time of his first visit he felt as well as he had ever 
been, and was quite able to attend to his business. 
The curious muddy pallor of this patient, and 
his dazed expression were such as I have fre- 
quently noted in patients affected with nervous 
symptoms which there has been reason to refer 
to syphilis. They are phenomena which form 
no part of ordinary epilepsy, and are peculiar, 
so far as I know, to cases of this description. 
No doubt, shortly after an ordinary epileptic 
seizure something of the same kind may be 
observed, in consequence, probably, of the 
blood not having as yet recovered its normal 
aeration, but in the present case, and others 
resembling it, the condition is a permanent 
one, enduring throughout the intervals of the 
attacks. It is a sign well worthy of being 
especially noted. The attacks of transitory 
aphasia, followed by persistent ataxy of articu- 84 
SYPHILITIC NERVOUS AFFECTIONS. 
lation, from which this man suffered, are of a 
kind frequently noted in syphilitic affections. 
Lancereaux relates a case in which he dia- 
gnosed a gummatous tumour of the membranes, 
situated in the neighbourhood of the third 
(left ?) cerebral convolution in a female, set. 43, 
who had syphilitic antecedents, and after 
complaining of fixed pain in the left side of 
the head, was attacked with epileptic seizures, 
followed at first by a total loss of speech, and 
afterwards by great difficulty in the pronun- 
ciation of articulate sounds for the period 
of a fortnight. According to Dr Hughlings 
Jackson, an affection of the membranes on 
the surface of the left hemisphere anteriorly 
may originate this symptom, by causing dis- 
ordered circulation in the middle cerebral 
artery. 
I met with a case at the hospital a short time 
ago, which seemed at first to be of this descrip- 
tion, but the patient's history makes it very 
doubtful. It is a good illustration of the fact 
that the mere occurrence of syphilis in a 
patient should not lead us to jump to the con- 
clusion that his nervous symptoms necessarily 
depend upon this cause. 
Case VII.-A man, set. 28, complained that in the course 
of the past seven years he had been attacked four or five ILLUSTRATIVE CASES. 
85 
times with a " mistiness," followed by imperfect power of 
articulation. The first attack was on the day following a 
bad sick headache. He found that he could not express 
himself to a friend, who laughed at him in consequence. 
He could say words, but not what he wished to say. Ask- 
ing to have the fire shaded from him, he said " table." He 
never had any abnormal sensation in the right side of his 
body. Besides these seizures he suffered from daily giddi- 
ness, which was worse towards the evening. It was like the 
motion of a vessel. The pavement seemed to sway, and he 
often chose the rough road in preference. He never lost 
his senses, although he often felt that if he continued walk- 
ing he should do so. I learnt that five years previously he 
had a sore, accompanied by a non-suppurating lump in the 
groin, for which he took mercury till his gums were sore. 
This was followed by soreness of the tongue, and last year 
spots appeared on his face and limbs. On examination I 
found that his heart was considerably enlarged. There 
was no albumen in his urine. He acknowledged being 
rather a " free liver." If this man's story be correct his 
first attack of passing aphasia occurred two years before 
the syphilitic infection. The pathology of the affection in 
his case is obscure, but the attacks may be owing, possibly, 
to disordered circulation arising from the state of his 
heart. 
There is evidence of intracranial disease in 
the following case which offers a good example 
of this transient loss of the faculty of expression: 
Case VIII.-A man, set. 42, had a sore in 1854, for which 
he took mercury, but not to salivation, accompanied by in- 
durated buboes, and followed by slight cervical glandular 
swelling and lichenous eruption. In 1864 he had another, 86 
SYPHILITIC NERVOUS AFFECTIONS. 
which readily yielded to iodide of potassium, but was fol- 
lowed by pustular eruptions on the face and shoulders. 
He was salivated in 1866. In 1871 he had a pustule on 
the left forearm, evidently a subcutaneous gumma, which 
has left a scar. Whilst the sore was open he was standing 
one day by the fire, when he suddenly felt that his right 
arm was powerless, and began to give foolish answers, 
being conscious that he was using one word for another. 
During dinner this went off, but he had a dizzy feeling and 
bad headache, which lasted ten minutes. About two months 
afterwards he felt that his left leg dragged; he went to 
bed, and at the end of the day the power returned. He 
did not lose consciousness on either occasion, and the 
faculty of speech was not affected during the second attack. 
In July, 1872, he sometimes found that during dinner he 
could not say anything, although he was quite conscious 
and able to eat. A paroxysm would last perhaps half an 
hour, and would not recur the same day, but only occa- 
sionally. In September, 1872, he was unconscious for a 
day, but did not lose the use of any limbs. Shortly after- 
wards he had another attack, and was unconscious for ten 
days or so. On recovering there was nothing wrong with 
his limbs or his power of speech. Since then he has twice 
lost his speech ; one day on getting out of a cab he almost 
lost himself for two minutes ; he did not fall, but was un- 
able to speak ; he paid the cabman correctly. In October 
last he lost his speech again, and now it is a little thick. 
A friend of his tells me that in his first attack he lost his 
speech, more particularly after meals ; he spoke, that is, 
very little, and in an unintelligible manner, using wrong 
words. He did not seem provoked at this, but rather 
laughed, and made a joke of it. In August, 1871, at the 
dinner table one day he suddenly failed to speak, and wrote 
the following :-" I pay paper do wrote," " ink," " printed," ILLUSTRATIVE CASES. 
87 
"pen," " pencil," " I want irritating first to paper 
(blank paper) quanty pencil pen ink and quanty quite 
paper." I ought to say that he is of exceedingly tem- 
perate habits. 
In April last he began to have pain at the upper and 
outer part of the right humerus. At first this would wake 
him up once in the night ; but it became worse, till it kept 
him awake nearly all night. For this he underwent a 
variety of treatment, the only relief he obtained being, as I 
ascertained from his prescriptions, whilst for a short time 
he took iodide of potassium. When I saw him first in 
January, 1874, be was in a very cachectic state, and worn 
out from want of sleep, and I found a node on the right 
upper arm, and a smaller one in a corresponding position 
on .the left arm. Under doses of iodide of potassium, 
rapidly increased from fifteen to thirty grains four times a 
day, and cod-liver oil, he lost all pain within a week, slept 
well, and his general condition at the present time is 
strikingly improved. I should note here that about the 
time of his attacks he occasionally had a subjective sensation 
of smell, lasting two minutes. The odour he describes as 
being strongly pungent, but not offensive. 
The following case I lately saw in consulta- 
tion : 
Case IX.-The patient, a male, set. 31, had a sore in 1867, 
followed by secondary eruption, and a few months after- 
wards by nocturnal pains and sore throat. Three years 
afterwards he lost a large piece of the hard palate by 
necrosis. A twelvemonth later he had paralysis of the 
third nerve, causing external strabismus, ptosis, and dila- 
tation of the pupil, first on the right side for four weeks, 
then on the left side for three months. The symptoms 88 
SYPHILITIC NEEVOUS AFFECTIONS. 
disappeared under plentiful doses of iodide of potassium.. 
About the same time there was considerable alteration in 
his character. He became silent, sullen, forgetful, and 
somewhat foolish. A year later he had periostitis in the 
right elbow and shoulder, afterwards in the right knee. 
These affections were relieved by iodide of potassium. On 
one afternoon in June last he began to talk nonsense- 
German and French mixed up together; he went to sleep, 
and woke up as he was before. No return of this took 
place till September, when he had an attack of the same 
sort, followed, by an epileptic fit. In October he again lost 
his speech for some hours, and could not write. His own 
description is, that in the attacks he knows what he wishes 
to say, but either cannot utter a word or talks nonsense, 
and is aware of it. On one occasion during an attack of 
this description he had a great sense of numbness in the 
right arm. He has never suffered from headache. He 
shows no sign of disease of the circulatory apparatus, and 
the ophthalmoscope discloses no changes in the eye. He 
has still some ulceration at the root of the uvula, and 
slight periosteal enlargement. 
With, the foregoing cases I may class the fol- 
lowing, in which passing loss of speech was 
associated with spasm of the right upper ex- 
tremity : 
Case X.-A wife, aged thirty-two, gave me this account 
of her symptoms :-Nine weeks before, she had felt one 
day that she could not get her words out, then lost her 
speech altogether, and had a jerking in the fingers of her 
right hand for two hours, during which she did not lose 
her senses. Then she managed to articulate some intel- 
ligible words. An hour afterwards she felt something run ILLUSTRATIVE CASES. 
89 
up her right leg, "just as if the dog had run up it," and 
an indescribable sensation took her in the right hand and 
right eye (the eyelid, no doubt), which severely jerked and 
quivered, and her teeth chattered; this condition lasting 
about fifteen minutes. These fits, always without loss of 
consciousness, were repeated at short intervals for two or 
three hours. She appears then to have received some very 
appropriate treatment (iodide and mercury), and the fits 
left her for two months, when they returned after discon- 
tinuance of the remedies, and she came to the hospital. 
Her aspect was not unhealthy. I found the scar of an 
ulcer at the junction of the hard and soft palate, and she 
acknowledged that there had been an aperture at that 
point for some months, which closed under the specific 
treatment. Five years previously she had noticed spots 
about her, and had suffered from sore throat. For three 
months before the fits she had experienced dreadful head- 
ache, worse at night. She had produced six children, ot 
whom only one survived. The other five had died of 
" teething" or " consumption," all at about fifteen months 
old. She had besides miscarried twice. The living child 
had suffered from a sore under its arm. I gave her large 
doses (fifteen and twenty grains) of iodide for six weeks, 
and she had no recurrence of fits. Then I lost sight of 
her. 
Here is another instance of attacks of spasm 
in the right upper extremity, occasionally at- 
tended with loss of consciousness : 
Case XI.-A man, set. 38, who had been remarkable 
for his powerful physique, applied to me on February 12th, 
1873, on account of attacks which he thus described. 
He would get a tingling in the thenar eminence and 90 
SYPHILITIC NERVOUS AFFECTIONS. 
knuckles of the right hand, and this travelled up the arm, 
which became contracted and " worked" very fast; thence 
it spread on the right side of his trunk, and worked his in- 
testines into a ball; thence up inside his throat to the back 
of the neck, and deep into the ear. Then a "working" 
took place between the ear and eye, and his eyelids screwed 
up ; then he lost his senses. From the onset until he was 
insensible, fifteen minutes; duration of unconsciousness, 
about ten minutes. Whilst insensible the tongue was 
bitten. On two occasions the fit had stopped short of in- 
sensibility, and then the right arm and right side of trunk 
were convulsed for an hour. He could not stop the move- 
ment, although he knew what was going on. Such attacks 
as those described he had been having every fortnight or 
three weeks since November, 1871. But besides these he 
had suffered still more frequently from seizures in which he 
did not lose himself, but which were characterised by symp- 
toms of this kind. He felt great pain in the elbow, fingers, 
and shoulder of the right arm, as if the extremity was 
being wrenched off. The pain then extended to the in- 
testines, testicles, and fundament. Both before and after 
the seizure he would pass a large quantity of urine, and 
much flatus. He told me that if he rubbed his right arm 
or leg when an attack was coming on, he would bring up 
much wind. 
The man was pale, with a furred tongue, extremely 
languid, and very liable to get faint and giddy. His right 
side was apt, he said, to get very cold, and sometimes very 
hot, and then there was excessive sweating on that side. 
He nearly fainted whilst describing his symptoms. He was 
reduced to great necessities from being unable to work. 
The general health of this patient had been excellent. 
Fifteen years ago he had a chancre, which was followed by 
attacks of sore throat, but not of severe character, and by a ILLUSTRATIVE CASES. 
91 
scaly eruption on the scrotum and thighs. In the winter of 
1868 he had neuralgia all over the right half of his head for 
four months. It was accompanied by swellings as if of the 
bone, which were very tender to the touch. I found on 
examination that on his legs he had purplish-red papules, 
inclined to scale. He said that they itched when he was 
warm in bed, and that he had seen them more or less for 
three years. There was nothing wrong with his heart or 
kidneys, and the ophthalmoscope showed the fundus oculito 
be normal on each side. 
He was ordered twenty grains of iodide of potassium 
with ten of bromide of ammonium three times a day. On 
February 26th the dose of iodide was increased to thirty 
grains, and on March 5th to forty grains. Cod-liver oil was 
also prescribed. On March 12th it is noted that he had 
experienced no return of attacks since the treatment com- 
menced. I now gave him one drachm of the Liquor 
Hydrargyri Perchloridi with ten grains of iodide three 
times a day, and this treatment was continued for some 
months. He had no seizure. On one or two occasions in 
March he had a slight tingling running up the arm. My 
last note is dated June 25th. He had been at work for 
four months, and had not had any attack since February. 
The following cases illustrate many of the 
points to which I have already referred, and, 
especially, the difficulty of finding any system 
of classification quite suitable to this class of 
disorders: 
Case XII.-A wife, aged thirty-seven, of whose case I 
find only a brief note, had ptosis of the left eyelid, dilata- 
tion of the corresponding pupil, imperfect left hemiplegia, 
with numbness of the left side of the face, imperfection of 92 
SYPHILITIC NERVOUS AFFECTIONS. 
taste and smell, and sluggish action of the recti muscles sup- 
plied by the left third nerve. These symptoms were quite 
recent, but for five or six years she had been liable to faint 
away once or twice daily. Fourteen years previously she 
had a chancre, and for five or six years afterwards she had 
annually a bad sore throat, lasting some weeks. She had 
produced six children, of whom three had died in fits 
or " consumption," and one, then living, at six weeks 
old had developed an eruption on its face which lasted 
three months. She herself had never seen any spots on 
her skin. 
Case XIII. -Another wife, aged thirty-four, who applied 
the hospital, had suffered from " congestion of the brain" 
twelve years previously, and was quite out of her mind 
for some weeks. This was followed by fits, which recurred 
at intervals of a few weeks for six years, and afterwards 
with longer delays, till, two months before I saw her, she 
began to get constant shaking of the left limbs, with occa- 
sional fits. She had been quite well before her marriage, at 
twenty years of age. She had borne one living child, which 
died when four months old of "bronchitis and had mis- 
carried six times. She had suffered from eruptions of 
pimples on her back and chest, and had frequently had sore 
throat, lasting two or three weeks, and dreadful headache, 
increased at night. 
Case XIV.-A man, aged forty-three, had a succession 
of fits for several days, eventuating in maniacal excitement, 
about nine months before his application to the hospital, 
and since then two at a few months' interval. I found the 
right angle of the mouth lower than the left, and the grasp 
of the right hand feeble. He reported that about nine 
months before his fits began he had suffered from bad eyes. ILLUSTRATIVE CASES. 
93 
and had been blind for three days. Nineteen years pre- 
viously he had been affected with chancre and indurated 
bubo, which were not followed by sore throat or general 
skin eruption. He showed me a patch of squamous eruption 
on the scrotum, which had been there for a very long time. 
Great pains in the head had preceded his fits. He im- 
proved at first very much under specific treatment, and the 
grasp of his right band was quite restored to its normal 
power; but after some months I learnt that he had lost 
the use of both legs; and as there was no room for him in 
the hospital, and he could not attend, I saw no more of him. 
His domestic history was this : Married six years; wife had 
miscarried twice, and had produced, besides, four children, 
of whom one was stillborn, one died in convulsions at four 
months, and one at a few months of diarrhoea; the living 
child had " a very large head, and was liable to a screaming 
cry of very peculiar kind." 
These latter examples-and they are types of 
a class which is common enough-incidentally 
throw a strong light upon the probable cause 
of a vast amount of the early mortality in 
children from fits, so-called " teething" and 
" consumption." There can be, I think, but 
little doubt that the syphilitic element inherited 
from the parents often plays a most important 
part in the production of these conditions, and 
that this is very frequently overlooked. As re- 
gards the pathology of these particular cases, the 
result necessarily leaves it in some doubt. In 
Case XI, however, there is evidence of tumour, 94 
SYPHILITIC NERVOUS AEEECTIONS. 
probably in the neighbourhood of the left hemi- 
sphere anteriorly. In Case X the concurrence 
of perforation of the palate (a tertiary lesion) 
would point to the probability of a gummatous 
intracranial formation, and so, perhaps, would 
the long duration of the disease in the third 
case. In Cases XIII and XIV it is probable that 
there had been more or less diffused inflamma- 
tion of the inner cerebral meninges, leading to the 
" congestion of brain" and maniacal excitement 
which are noted in these cases, and to exudation 
and subsequent thickening of the membranes in 
certain parts. 
I may conveniently class together here a 
series of cases in which alterations in the deep- 
seated tissues of the eye either accompanied or 
preceded paralytic or convulsive affections. 
And I will refer first to an instance in which, 
although there is a syphilitic history, and the 
symptoms would incline one to believe in the 
specific origin of the affection, the results of 
treatment afford no' support to this idea. If 
it had no other value, it would be interesting 
as an illustration of the fact that the diagnosis 
of these affections is at times attended with 
great difficulty. 
Case XV.-A man, set. 32, who had suffered from syphilis 
ten years previously, attended at the hospital on account ILLUSTRATIVE CASES. 
95 
of fits from which he had suffered during five years, and ex- 
treme giddiness. He also complained of an extraordinary 
amount of noisy flatulence; " extortionate," he called it. 
What that designation may imply I do not know, hut he 
was quite remarkable for the stormy gusts of flatulence 
which burst from his mouth whenever he consulted me, 
and which greatly interfered with his description of 
symptoms. The condition reminded one of a certain form 
of hysteria in woman. It seemed that five years previously 
whilst carrying two hundredweight he had a bad fall, 
in which he struck his occiput, and lost his senses 
for two hours. He was taken to a hospital, where he 
stayed nine weeks, during six or seven of which he was 
insensible. Soon after coming out he had a fit, and since 
then had been liable to fits, once in a week or so, and two or 
three at a time. I should hardly venture to include this 
case in the category of syphilitic nervous affections, but 
that the ophthalmoscope showed evidences of old choroiditis 
in each eye, and partial atrophy of the right disc-ap- 
pearances which were noted also by my colleague Dr 
Gowers, who examined his eyes. Whether the injury 
is alone responsible for his attacks, or that this formed 
a starting-point for syphilitic manifestations, I do not 
know. I relate the case without committing myself to 
an opinion upon it, especially as I failed to observe 
any marked benefit from specific treatment, and as I 
learnt from the patient that he had indulged freely in 
drink. 
In the following case, too, there was a his- 
tory of injury which threw some doubt upon 
the nature of the case, otherwise resembling a 
syphilitic affection; 96 
SYPHILITIC NERVOUS AFFECTIONS. 
Case XVI.-A discharged soldier applied at the hospital 
with left hemiplegia on October 16th, 1872. It seemed that 
two years previously he had been seized with severe pain in 
the head, from back to front, chiefly on the left side, and 
worse at night, and when this had lasted for nearly two 
months his left arm and leg one day "went to sleep," and 
he found that he could not rest his weight upon his leg and 
could do nothing Avith his arm. He was quite helpless for 
two months, and then got somewhat better. I found that 
he was partially paralysed in the left arm and leg, the 
former being a good deal wasted; the limbs not stiff. He 
suffered occasionally from vertigo. He told me that seven 
years previously his horse had fallen upon him, and he was 
hurt at the back of his head. He bled very much, and lost 
his senses for two or three hours. Ophthalmoscopic exami- 
nation showed traces of lymph upon his discs, best marked in 
the right eye, probably from old optic neuritis. He had had 
a venereal sore ten years previously, followed by some skin 
eruption. An aortic regurgitant bruit was perceptible at 
the base of the heart. I took him into the hospital, gave 
him large doses of iodide and faradized his muscles. 
Under this he improved considerably, but never regained 
completely the use of his limbs. 
A similar appearance on the optic discs, 
probably resulting from optic neuritis, was 
observed in the following case of convulsions, 
beginning at the age of twenty-three years, in 
a man who had suffered from syphilis: 
Case XVII.-A man, set. 25 (married 3 years, 1 child, 
wife miscarried once), had suffered from fits for nearly two 
years-about one in ten days. The fits always took place ILLUSTRATIVE CASES. 
97 
in the night, and he bit his tongue. Four years previously 
he had had a sore with " little knots " in the groin, which 
went away without suppuration as the sore healed. The 
sore was open for six weeks, and he was under treatment 
for three or four months. I found on examination with 
the ophthalmoscope that there were glistening white fibres 
following the course of the vessels on the right disc. Under 
iodide and bromide of potassium he had scarcely any fits for 
six months. Then I lost sight of him. 
The following case, which I have now under 
treatment in the hospital, offers a good example 
of double optic neuritis, with convulsions 
affecting especially the right arm: 
Case XVIII.-A compositor, set. 33, cachectic in appear- 
ance, married ten years, one child living, one dead, applied to 
me at the hospital on June 11th, 1873, on account of fits, of 
which he had had nine in seven weeks. The first fit occurred 
when he was in bed and asleep, and two hours afterwards he 
had a second. A week after this attack he had four fits, with 
an interval of an hour or two between each. In these fits 
he describes a contraction occurring in both arms. He then 
lost his senses and bit his tongue. After the next attack 
he lost the use of his right limbs and speech for a quar- 
ter of an hour. He tells me that he wakes up with pain 
in the left temple, and that for eight months past he has 
suffered much pain in the left side of his face and temple-a 
darting and shooting pain. It would occur, perhaps, once or 
twice a week, and make him jump. His face would swell up 
with it, and was tender to the touch. It seems that twelve 
or thirteen years ago he had a sore, which was open for two 
months, and for which he was treated with mercury to sali- 
vation. At the same time there was a lump in his groin, 98 
SYPHILITIC NERVOUS AFFECTIONS. 
which did not suppurate. He had afterwards an eruption 
on his skin. He was ordered ten grains of iodide three 
times daily. On June 25th he said that he felt much 
stronger and had had only two slight fits. Repeated the 
iodide. On July 16th he said that he had had sis fits. He 
was now ordered thirty grains of bromide twice a day. 
July 30th.-He had had four fits, one very severe. Ten 
grains of iodide were now given twice a day with thirty of 
bromide. August 13th.-He had had no fits. This treat- 
ment was continued till October 29th, when the dose of 
iodide was increased to fifteen grains. I have no note as to 
the ophthalmoscopic appearances during this time. I 
presume, therefore, that he had been examined and that 
nothing abnormal was observed. On November 26th he 
came complaining of much loss of power in his legs and of 
pain across his eyes. He said that for six weeks past his 
sight had been much weakened, so that he could not read. 
I examined his eyes with the ophthalmoscope and found 
the following appearances:-In the right eye there was no 
outline to the disc, which was of a pinkish-grey colour, 
swollen and prominent, and merging by imperceptible 
gradations of colour into the choroid. The arteries were 
small and lost at various points ; the veins were large, dark, 
and very sinuous; at certain points, indeed, they appeared 
to turn suddenly at a sharp angle, suggestive of a " kink " 
in wire. In the left eye the appearance was of the same 
character, but less pronounced. Dr. Gowers, who tested 
his visual powers at this time, informs me that he could 
read No. 1 Jaeger with either eye. 
December 10th.-Admitted into the hospital and ordered 
Liq. Hydrarg. Perchloridi $38 with Pot. lod. gr. xv 
twice a day. On the 29th he informed me that he had 
eleven fits, in only one of which (the first) he lost con- 
sciousness. The fit begins in his face, his mouth is twisted ILLUSTRATIVE CASES. 
99 
on one side and his jaws are fixed. This lasts two 
minutes; then it conies in the right hand (always in the 
right hand), and this gets drawn up. In all the fits except 
the first the symptoms entirely consist of contraction of 
the fingers, then of the wrist upon the forearm, and then of 
the forearm upon the arm. If he could get any one to 
draw his arm forcibly down it would stop the attack. 
January 3rd.-Has had several attacks, but of slight char- 
acter. 9th.-The left eye has nearly lost its morbid 
appearances. In the right there is great improvement; 
one vein still much diverted. Still some streakiness of the 
retina and the disc margin still obscured. January 20th.-- 
Has had two fits, in one of which he lost his senses. He 
was now ordered Hyd. c. Cret. gr. iij twice a day. His 
general condition had much improved, but the persistence of 
seizures induced me to try the effects of more complete 
mercurial treatment. On February 16th I found on exam- 
ining him with the ophthalmoscope that his eyes had quite 
recovered, and he had had no attack for more than a fortnight. 
Here is a case of eclampsia, accompanied by 
optic neuritis affecting one eye : 
Case XIX.-A railway porter, set. 29, applied on March 
13th, 1872, having had seven fits since September, 1871. Ou 
the first occasion he felt a swimming in the head and fell 
down on the platform, lost his senses and was convulsed, not 
becoming conscious for four hours. He did not bite his 
tongue. The other fits were of the same character. He 
does not know whether the convulsion was unilateral or 
not. Previous to the first fit he had suffered for a year 
from attacks of headache at irregular intervals, accompanied 
by vomiting. He had entirely lost the sense of smell for 
six mouths, but he sometimes had subjective sense of a 100 
SYPHILITIC NERVOUS AFFECTIONS. 
brimstone odour. There was ulceration of mucous mem- 
brane of the nares. The ophthalmoscope showed the 
outline of the right disc much obscured and swollen, the 
vessels tortuous and in part lost. He had had a sore nine 
years previously, and attacks of sore throat, once lasting 
three weeks, but never any skin eruption. Two years ago 
he had a lump in the groin, which suppurated and was 
lanced. His last fit occurred four days before his applica- 
tion to me, and three days previously he had had two fits of 
severe character. He was ordered ten grains of iodide with 
twenty of bromide three times a day, and this treatment 
was continued for seven months, during which he had no fit; 
his headaches had much diminished and the sense of smell 
improved. On October 6th he had a fit. He was now 
ordered Liq. Hydrarg. Perchloridi Jss with Pot. Bromid. gr. 
xx three times a day, which he took till February 26th, when 
he had two fits. I then gave him a drachm of the per- 
chloride solution with ten grains of iodide three times a day. 
He had no return of fits, but as he still complained of 
headache I ordered him on March 12tb, 1873, three grains 
of Hyd. c. Creta twice a day. Under this treatment he 
very greatly improved; he had no fits, lost his headaches, 
and felt perfectly well. He continued to follow his 
occupation, taking this dose, until January 16th, 1874, when 
his gums became sore. He now had a fit for the first time 
for nine months. At the present time the outline of the 
right optic disc remains still a little obscure and the 
vessels are somewhat tortuous. He has not absolutely 
recovered, therefore, from the old optic neuritis. 
I may include here a brief reference to a case 
now under observation, in which double 
amaurosis from old disseminated choroiditis is ILLUSTRATIVE CASES. 
101 
associated with loss of power in the lower 
extremities and increasing intellectual impair- 
ment. 
Case XX.-A male patient, set. 51, came to me in'October 
last, having lost his sight at the age of 38 years, after 
a few days' pain and uneasiness in his eyes. He was of 
powerful physique, with excellent family history. No 
disease of heart, or blood-vessels, or kidneys. He had 
worked very hard. The amount of sight retained was just 
sufficient to enable him to get about without assistance, but 
not to read. I found on examination with the ophthal- 
moscope that in both eyes the fundus was covered with 
numerous white pigmented patches. There was difficulty in 
gathering any distinct account of his general condition 
since the loss of his sight, as his memory was bad and his 
manner odd and flighty. He staggered in walking and 
occasionally would feel what he described as a " sort of 
giddiness " in his hips, and his legs would give way. There 
was want of power to empty the bladder, and constipation. 
Two years previously on one occasion he had lost his speech 
for a few minutes. He complained of peculiar sensations, 
in his right arm and leg especially. It seemed that eight 
years before his eyes were attacked he had a sore, which 
was followed after six weeks by slight sore throat, and four 
months later by copper-coloured spots on his forehead. I 
have given him iodide, which he thought did him some good, 
and some calomel baths, but he has not shown any real 
improvement, and his case is a very unpromising one ; 
indeed, he shows signs of drifting into a state of dementia. 
I cannot help regarding this case as one which would 
probably have taken a more favorable course had the 
patient been submitted, from the time of the attack in his 
eyes, to systematic antisyphilitic treatment. Disorganiza- 102 
SYPHILITIC NERVOUS AFFECTIONS. 
tion of cerebral substance had too far advanced, as it seems, 
when I saw him for such treatment to have much effect. 
Instances, however, do occur where even at a very 
advanced stage appropriate treatment has stopped the 
progress of what seemed a very hopeless condition, and I 
thought it right, therefore, to give this patient the only 
chance which was open to him, although I did not expect 
that it would be successful. 
The following is an example of the multiple 
character of the nervous affections in syphilis, 
to which I have already adverted as so often 
characteristic of these disorders : 
Case XXL-A wife, aged 34, was carried into the hospital 
consulting-room with complete paralysis of the right arm 
and leg, and to a certain extent of the right half of the 
face, ptosis of the right eyelid, traction inwards of the right 
globe, which could not be turned outwards beyond the 
middle line, and not at all upwards or downwards, dilata- 
tion of the right pupil, some loss of sensibility in the face, 
and to a less extent in the limbs of the right side. There 
was thus, besides the condition belonging to ordinary right 
hemiplegia, paralysis of the third, sixth, and partially of 
the fifth nerves of the right side. It seemed that three 
months previously her right eye became turned inwards 
gradually. Two months afterwards, on rising one morning, 
she felt a numbness of the right half of the face and right 
extremities ; and a fortnight after this she rapidly lost the 
power of moving the right arm and leg. Her speech, too, 
became indistinct. The arm, a few days before she applied 
at the hospital, became rigidly contracted, the leg remaining 
limp. The sight of the right eye was very imperfect, and 
the ophthalmoscope showed partial atrophy of the disc. ILLUSTRATIVE CASES. 
103 
Before her attack of numbness she had suffered for some 
time from great pains in her head, worse at night. On 
inquiry I ascertained that she had been married eight 
years, had produced two still-born children, and none living 
at birth. Her husband, whom I sent for, presented on his 
forehead a large patch of serpiginous ulceration which had 
existed, he said, for two years. He acknowledged that ten 
years previously he had suffered from a sore which had been 
followed by spots on the skin. She, however (and this is 
interesting), utterly denied ever having a skin eruption or 
sore throat, and asserted that she had enjoyed excellent 
health until this attack, and had been, indeed, a very active 
person. She presented no cachectic aspect, and said that 
she slept well and had a good appetite. She had no signs 
of disease of the heart, blood-vessels, or kidneys. She was 
treated with ten-grain doses of iodide three times a day for 
two months, and then she walked fairly enough with a stick, 
and reported herself as very much better in every respect 
except that she could not move her arm. Unfortunately, at 
this point my notes are defective, so that I am unable to 
give details of her improvement, and she does not appear 
to have again attended at the hospital. Even with this 
drawback I record the case, as it is one eminently charac- 
teristic of syphilitic lesion, and illustrating many points of 
importance, not the least being the existence of grave 
intracranial lesions in a person who showed no other 
external signs of syphilis, and who denied that any of the 
more common symptoms had ever occurred. The evidence, 
indeed, may be said to be entirely circumstantial, but is 
nevertheless convincing. 
Of far less importance, from a clinical point 
of view, is it to endeavour to localise the lesions 
in such, cases. I suppose there were two. At 104 
SYPHILITIC NERVOUS AFFECTIONS. 
the onset gummatous deposit at the base of the 
brain, in the right side of the middle fossa of 
the skull, involved the sixth, third, and in part 
the opfic tract, and this was followed by a similar 
lesion in the neighbourhood of the left corpus 
striatum. No one lesion, so far as I know, 
would account for the whole train of symptoms. 
Whether or no there was disease of the peri- 
osteum or bone at these parts, or whether the 
pia mater alone was involved, there is no 
evidence to show. The rigid contraction of 
the arm occurring at a late period as a sequel of 
the paralysis was an evidence of mischief to the 
motor tract of a kind which did not admit of 
repair. 
As an instance of recovery from a most grave 
condition the following case, of which I confine 
myself to an abstract, is very interesting. I 
showed the patient before the Clinical Society 
this session quite recovered, and his case will, 
I hope, be published in detail in the c Transac- 
tions ' of the society for 1874. 
Case XXII.-A working man, set. 45, of previous good 
health, was brought to me on January 8th, 1873, in the follow- 
ing condition :-He had double facial paralysis, total absence 
of power of voluntary contraction in the muscles of either 
leg, grasp of hands almost entirely lost, partial paralysis of 
deglutition and of respiration, cutaneous anaesthesia more 
or less general throughout the trunk, extremities, and face. ILLUSTRATIVE CASES. 
105 
There was thickness of utterance. His breathing was so 
difficult, and his general condition so alarming, that I feared 
to allow him to return home, as it seemed likely that he 
might die on the road, and therefore at once admitted him 
into the hospital. His attack commenced, it seemed, on 
December 10th with numbness in the finger ends and 
■weakness in the legs, which increased day by day, so that 
on the 14th he was confined to his chair, unable to move 
his legs, and his bands and arms in a state of tingling 
numbness, and feeling very heavy. For the first week he 
could use a knife and fork, but in the second he could only 
lean upon a table, and with his face low down contrive to 
carry some fluid food into his mouth by a spoon held be- 
tween the first and second fingers of his right hand. A little 
later he could not do even this, but required to be fed with 
small quantities of liquid nourishment, which he swallowed 
with great difficulty. He complained of the feeling of a 
tight band round the belly just above the hips. Excita- 
bility to the induced current was lost in the legs and face, 
and greatly diminished in the thighs and arms. The in- 
terrupted constant current gave no reaction anywhere but 
in the muscles of the face, where the excitability to it was 
far above the normal. He could not lie down on account 
of his breathing. There was slight diplopia and very slight 
weakness of the bladder. Temperature 99°; pulse weak. 
No diphtheria, injury, or exposure to weather or metallic 
influence had preceded his attack, which commenced whilst 
he was carrying on his usual avocations. 
Ten grains of iodide of potassium were given to him at 
once, and the dose repeated three times a day. Next day 
his condition had already somewhat improved, and in a 
week he could swallow a little solid food, could lie down in 
bed, and the muscles of his leg began to respond to a strong 
induced current. The dose of the iodide was rapidly 106 
SYPHILITIC NERVOUS AFFECTIONS. 
increased to 15, 20, 25, 30, 40, and eventually, in the 
middle of February, 60 grains three times a day, his im- 
provement appearing to take place faster as the dose was 
enlarged. By January 25th he could close both eyes, and 
had acquired some power in his limbs, could swallow freely, 
and his breathing was nearly normal. On February 25th, 
when he had remained stationary for some days, I ordered him 
to be injected subcutaneously with five minims of Staub's 
solution of the chloro-albuminate of mercury, and next day 
with ten minims. Faradism was employed daily to his 
muscles. From February 27th to April 2nd he had ten 
minims of the mercurial solution injected daily, and from 
the latter date to the 19th twenty minims. From April 19th 
to May 21st twenty-five minims daily. On May 6th he 
could walk with help of two men, on the 13th with the aid 
of a stick, and he was discharged on May 21st able to walk 
pretty well as ever. I ought to say that he had been lame 
in the right leg since two years old from the consequences 
of what had evidently been an attack of infantile paralysis. 
His leg was wasted, and his foot in a state of talipes 
equino-varus. 
This man had a sore fourteen years previously, for which 
he did not take mercury. It was accompanied by a bubo, 
the size of an egg, which was lanced, giving exit to blood 
alone. It was then poulticed, and afterwards matter was 
discharged. I found on examination that he had slight in- 
duration in the right groin, and a scar at the seat of the 
bubo. He had never had sore throat, skin eruption, or nodes. 
I believe that the symptoms in this interest- 
ing case were due to syphilitic pachymeningitis 
about the basilar process and upper part of the 
spinal column, occasioning pressure upon the 
pons Varolii and at least the cervical por- ILLUSTRATIVE CASES. 
107 
tion of the cord. A lesion of the pons alone 
might, no doubt, produce paralysis of the four 
extremities, but would not, according to my 
experience, give rise to two symptoms present 
in this case, viz. paralysis of respiratory 
movements, and the marked feeling of a 
tight constricting band around the belly. I 
ought to add that the patient resumed work 
in July, and has since continued to follow 
his employment, being able to get about, in 
spite of his old lameness, without the aid of a 
stick, except when he undertakes long dis- 
tances. He describes a slight tingling as still 
remaining in his legs and arms, and some sense 
of fulness about the praacordial region, but he 
is otherwise in perfect health. 
I have lately met with a case which occurred 
in the practice of Professor Wagner, which has 
an interesting bearing upon this one :* 
Case XXIII.-A military man, set. 35, had a chancre in 
1862, followed in a few months by sore throat, later by skin 
eruption, and in 1866 by a swelling on the upper part of 
the spinal column, and on the left parietal bone. On May 
5th, 1867, the patient complained of weariness in his legs, 
which could not next day be lifted out of his bed without 
trouble, and in the course of another day eventuated in 
complete paralysis. At this time the arms became also 
affected in a like manner, and the action of the bladder was 
* ' Archiv der Heilkunde,' p. 105, Leipzig, 1869. 108 
SYPHILITIC NERVOUS AFFECTIONS. 
enfeebled. His temperature, pulse, and respiration were 
normal. The cutaneous sensibility was impaired in the 
lower extremities. From May 22nd the sensibility of his 
legs began to improve, and gradually a return of power 
took place in them, as well as in the arms, so that on June 
21st the patient was able to stand, and with the help of 
an attendant to walk a little. A week later he moved 
briskly with the aid of a stick, andon July 1st without any 
aid. At the end of July he had quite recovered. He was 
treated with mercurial inunction, iodide of potassium, and 
Faradism to the muscles. 
It occasionally happens that symptoms of im- 
paired motion and sensation in a limb simulating 
some central lesion are found on examination 
to depend upon syphilitic tumour of some muscle, 
or local change in a joint or bone. As such 
cases are likely to mislead, I will briefly refer to 
three instances in which a close examination of 
the limb led to a discovery of this condition. 
Case XXIV.-Several years ago, a male patient, past 
middle age, applied to me on account of persistent cramp in 
his thigh. So severe was this that he could only walk with the 
greatest difficulty and pain. On stripping the limb I found 
a great lump of thickening on one of the hamstring mus- 
cles, a good deal resembling a state of cramp, which, indeed, 
I took it to be, and applied a constant current on two or 
three occasions with the hope of relaxing it, but without 
effect. I then chanced to note a patch of serpiginous ulce- 
ration in a certain part of his skin, and this led me to con- 
ceive that the apparent cramp really consisted in a muscular 
tumour of syphilitic origin. Iodide of potassium confirmed ILLUSTRATIVE CASES. 
109 
the diagnosis by clearing away the symptoms in a few 
days. 
Case XXV.-A wife, set. 48, was admitted into the hos- 
pital in October, 1872, with tingling in the tips of the fingers 
of the right hand, and loss of power in the same arm, so that 
she would frequently let things drop from her hand. She 
complained also of great pain and tenderness in the upper 
arm, at the back of the neck, and at the bottom of her 
spine, of weakness in her legs, and imperfect command of 
her bladder. She had great difficulty in lifting her arm. 
It chanced that I stripped and examined the upper arm, a 
precaution which one ought always to take, but frequently 
omits. The right deltoid muscle was thickened and hardened 
between the acromion process and its insertion as com- 
pared with the left, and it could not be pinched up and 
moved freely over the bone. It was painful when squeezed, 
but the skin over and about it was deficient in common 
sensibility. It was difficult to say where the thickening 
and stiffness began and ended, but it seemed as though the 
deltoid and perhaps a portion of the triceps muscles were 
not only themselves altered but that there was something 
which intervened between them and the bone, gluing them 
to it; and this was the more probable inasmuch as the 
functions of the circumflex and musculo-spinal nerves were 
to a certain extent impaired. This localised lesion ex- 
plained the want of power and the altered sensibility of the 
arm. The electrical examination was interesting. I found 
that the muscles generally of this arm showed great dimi- 
nution of excitability to the induced current, but this was 
very much the most marked in the deltoid. There was also 
considerable diminution of cutaneous electro-sensibility. 
The excitability to the intermittent constant current was 
not increased. There was pain and tenderness on pressure 
over the lower cervical and upper dorsal region of the spinal 110 
SYPHILITIC NERVOUS AFFECTIONS. 
column. The pains in this situation and also in the arm 
were much worse at night. The left arm was weak, and she 
was beginning to feel tingling in the tips of the fingers in 
this also. The lower extremities were partially paraplegic. 
The patient was a not unhealthy looking woman, who had 
never suffered, she said, from sore throat or eruption of the 
skin, and had never had rheumatism or gout. The diagnosis 
made was syphilitic spinal meningitis with localised mus- 
cular and probably periosteal gummata, and she was put 
upon iodide of potassium (from ten to twenty grains) and 
faradism to the right arm. Under this she improved, but 
not to any remarkable extent, and after a month I stopped 
the specific treatment and gave her iron. But she did not 
do so well with this, and now began to complain of the 
feeling of a constricting band around the belly. On 
February 6th iodide was resumed in doses of thirty grains, 
and afterwards forty grains three times a day. She 
improved considerably for a time, but then remaining 
stationary I had her injected subcutaneously with Staub's 
mercurial solution, but this caused so much local irritation 
that it was only used some half-dozen times. The iodide 
was resumed, and in the spring I sent her to Finchley, 
whence she returned in May. She was then able to do 
much more than she could formerly with the right arm. 
She could lift it and use it generally, but could not put her 
hand behind her. The hardness about the deltoid had 
almost disappeared. The power of the bladder was much 
improved. There was great deficiency in the power of the 
right leg, and a painful sensation of an iron band across the 
back and hips. I lost sight of her after this till October 
last. There was then nothing wrong with the movement of 
the right arm, and the right leg was much improved, but 
she complained of the left leg being stiff, sore, and painful. 
On examination I found just such a thickening about the ILLUSTRATIVE CASES. 
111 
lower portion of the left glutasus maximus muscle as had 
existed formerly in the right deltoid; the tumour was 
painful, but the skin over it anaesthetic, and the electrical 
condition also corresponded to those described in relation 
to the deltoid. She described both hands as feeling numbed 
and as though she were wearing thick gloves. 
Iii a case which. I am at present attending, 
and which has been referred to previously (see 
Case VIII), where there have been symptoms of 
extremely grave central cerebral lesions, a want 
of power in the right arm. was complained of. 
I found that the elbow could not be voluntarily 
raised to more than an angle of about 45° 
from the side. The deltoid muscle was some- 
what wasted, but of normal electrical excita- 
bility. A few applications of Faradism restored 
its volume, but although the elbow could now 
be lifted a little higher, yet neither by voluntary 
action nor by passive movement could the 
humerus be brought up nearly to its proper 
position. I found that this limitation depended 
upon adhesions in the scapulo-humeral joint, 
evidently consequent upon old synovitis, which 
would seem to have coincided in date with the 
commencement of periostitis about the insertion 
of the deltoid some eight months previous to 
my first seeing him. 
A case which it is difficult to class with 
others came before me in June, 1873. From 112 
SYPHILITIC NERVOUS AFFECTIONS. 
the history and the result of remedies I look 
upon it as syphilitic, but I do not feel able to 
localise the lesion with any precision : 
Case XXVI.-A wife, set. 30 (married fifteen years, one 
child, which died when three weeks old, no miscarriages), 
applied complaining of what she called " twittering" pain all 
down the limbs of the right side, and in right half of the face 
and head. This pain was accompanied by numbness, and she 
could scarcely walk. The symptoms had persisted for one 
month. The palm of the right hand was sore to the touclf. 
No unusual circumstances had immediately preceded the 
attack, but on inquiry I found that in the preceding 
summer she had squinted for three months. The left eye 
was affected, and she had been cured by taking medicine at 
an ophthalmic hospital. 
The ophthalmoscope showed nothing abnormal. Under 
iodide of potassium, in doses ranging from ten to forty 
grains three times a day, she has almost entirely recovered. 
When I last saw her, a week or two ago, she had only to 
complain of a slight and unimportant tingling in the right 
foot. In all other respects she was perfectly well. 
The age of this patient precluding brain lesion from de- 
generation, and the previous occurrence of a strabismus 
which had quickly yielded to medical treatment, gave the 
key to the specific nature of this disorder, and naturally 
suggested treatment the success of which goes far to con- 
firm the diagnosis of its character. 
In the following case any syphilitic infection 
was denied, but the character of the affection 
and concomitant circumstances pointed strongly 
to such an origin : 
Case XXVII.-A labourer, tet. 31, applied in Feb., 1873, ILLUSTRATIVE CASES. 
113 
\vith. paralysis of the right lower extremity, of two and a 
half years' standing. The limb was greatly wasted and the 
foot could not be moved at all. It seemed that on getting 
up one morning he found his foot useless. No pain had 
preceded or followed the, attack, and he had not been ill. 
Excitability to the induced current was lost in all the 
muscles below the knee, and very much diminished in the 
muscles at the back of the thigh, whilst it remained good 
in those on the anterior aspect of the thigh, in which also 
he retained voluntary power. The sensibility of the skin in 
parts corresponding to the paralysed muscles was greatly 
diminished. There was no increased excitability to the 
intermitted constant current. The seat of paralysis coin- 
cided completely with the distribution of the great sciatic 
nerve. There was no impairment of the functions of the 
bladder nor of the other leg. It appeared evident that 
there was a lesion of the sciatic nerve alone. Although he 
positively denied any syphilitic infection, the existence of a 
very ugly looking sore on the right leg (suggestive of a 
gummatous ulceration), which he had had for three months, 
made it likely that there had also been a gumma of the 
sciatic nerve, and he was accordingly ordered iodide and 
mercury. Under this treatment the sore rapidly healed, he 
gained a certain amount of power in the leg, and he 
described himself as feeling more than usually well in his 
general health, but in April he ceased to attend, so that I 
am unable to give the sequel of his case. 
The tendency to relapse which strongly cha- 
racterises syphilitic affections of the nervous 
system frequently lends important aid to their 
diagnosis. In the histories which I have 
hitherto related this peculiarity has not always 114 
SYPHILITIC NERVOUS AFFECTIONS. 
been prominent, for reasons easily explained. 
Either sufficient time has not yet elapsed since 
they were observed and treated for this tendency 
to manifest itself, or the sufferers have been lost 
sight of after more or less complete recovery of 
health, and their subsequent history remains 
unknown. The subjoined instances are exam- 
ples of relapse after intervals of various 
duration, and on this account are worth noting. 
It may be said generally that paralysis of motion 
in early middle life (if not of hysterical origin), 
which are characterised by repeated relapses 
after prolonged intervals of immunity, point 
almost conclusively to a syphilitic basis for their 
origin. - 
Case XXVIII.-A single man was attacked at twenty-five 
years of age with a " stoppage " in his bladder and rectum, 
associated with great numbness and loss of power in his legs, 
so that he could scarcely stand. He was laid up in bed for 
two or three weeks, and was about four months altogether 
in recovering. Nine years afterwards, having remained well 
in the interval, he presented himself at the hospital, ex- 
hibiting almost complete paraplegia, with greatly impaired 
cutaneous sensibility of the lower limbs, having sometimes 
long delay in passing bis urine, and occasional incontinence 
both of urine and faeces. He could not stand. He had 
suffered in early life (date unknown) from a discharge. At 
twenty-three he had dimness of sight in both eyes, for which 
he was treated at an ophthalmic hospital. The left eye re- 
covered, but the right did not, and with it ever afterwards ILLUSTRATIVE CASES. 
115 
he could only distinguish light from darkness. He denied 
having ever had sore throat or eruption on his skin. I 
found a scar as of old ulceration on the inside of one of his 
legs, and in the right eye the ophthalmoscope showed 
numerous small pigmented patches as of old choroiditis. 
Case XXIX.-A man when twenty years of age had a 
sore, not followed by secondary symptoms. At twenty-nine 
he had a chancre, succeeded about a year afterwards by 
" something wrong with his skin, eyes, ears, and lips." At 
thirty-nine he got a weakness in his legs, which became 
gradually worse for two or three weeks, so that he could not 
stand. As he lay in bed he could not draw up his feet, and 
he completely lost sensibility in his legs. There was nothing 
wrong with his bladder or rectum. He lay in this powerless 
state for a week, and was then seized with cramps in his legs, 
which started of themselves. His illness lasted for a month 
or so. He had received no injury, and was unable to refer 
his condition to any cause. At fifty-seven he felt one day 
a strange sensation in his legs, especially the right, then a 
weariness, lost his senses for a moment, but was not con- 
vulsed, and found himself paralysed in the limbs and face 
of the right side. In this state I saw him at the hospital 
two months afterwards, and gleaned the above particulars 
of his history. He described a state of aphasia which had 
accompanied his attack, but had nearly passed away, though 
he still found himself at times somewhat deficient in power 
of expression. There was nothing apparently wrong with 
the kidneys, heart, or blood-vessels. Under specific treat- 
ment for a month he improved, and then, as too frequently 
happens in hospital practice, ceased to attend. 
Case XXX.-A wife had partial left hemiplegia at thirty- 
eight years of age. At forty the attack was repeated, this 116 
SVFHILITIC NERVOUS AFFECTIONS. 
time with epileptic symptoms. At forty-six she had an 
attack of right facial paralysis, and a few days afterwards 
a third paralytic seizure on the left side. Violent head- 
aches preceded each attack. She had suffered from bad 
ulcerated throat and skin eruption, had miscarried twice, 
and had lost the two children to whom she had given 
birth. 
Case XXXI.-I saw on one occasion only, a few years 
ago, a military man, aged thirty, whose symptoms were pro- 
longed insomnia, weariness, pains of long standing in both 
lower extremities, and who, seven years previously, had been 
affected with a sore, accompanied by a bubo, which suppu- 
rated. He told me that whilst under treatment for this he had 
an attack of left hemiplegia, together with paralysis of the 
left upper lid, so that his eye was closed, and that from this 
illness he recovered in about a month. He had never had 
sore throat or eruption of the skin. I could find nothing 
wrong with his circulatory apparatus or kidneys. He had 
not been exposed to the action of sunstroke. Early as was 
this attack-earlier, indeed, than in any case which I have 
verified for myself-the history leaves little doubt of its 
syphilitic origin ; and to this cause also I think that his 
later symptoms, which arose after an interval of four or five 
years, must be referred. 
Since I published this case in the £ Lancet,' 
another has fallen under my notice which may 
be compared with it: 
Case XXXII.-A man, set. 28, came to me in July, 1873, 
complaining of some want of power in the left arm. He 
said that eighteen months previously he one day suddenly lost 
power in the left arm for a few minutes, and let fall a water- ILLUSTRATIVE CASES. 
117 
pot. This was followed by a sensation of pins and needles 
in the limb. He had no loss of consciousness. At the time 
of attack he was recovering from a primary sore for which 
he was under treatment. This was followed later by sore 
throat and skin eruption. He had felt no recurrence of 
the attack till the day I saw him, when a precisely similar 
seizure had taken place. The grasp of the hand was 
good, but he complained of a little numbness about the 
elbow. 
I have already referred (in Chapter I) to the 
affections of intelligence, transitory or perma- 
nent, which constitute some of the most im- 
portant features of intra-cranial syphilis. I 
may add here that it is not at all uncommon, in 
cases of comparatively early date, to find in as- 
sociation with paralysis of one or more cranial 
nerves or of the limbs on one side of the body, 
either a restlessness and excitability which are 
almost maniacal in character, or a condition of 
more or less prolonged stupor. In later cases, 
where repeated attacks of paralysis or convul- 
sion during some years have given evidence of 
extensive cerebral disorganization, conditions 
somewhat allied to paralytic dementia, or to 
what is termed "general paralysis of the in- 
sane," are more common. The distinguishing 
clinical features have been already noted. In 
the first class it is probable that the mem- 
branes immediately investing the brain are 118 
SYPHILITIC NERVOUS AFFECTIONS. 
the seat of simple inflammation ; in the second, 
the brain-substance itself has suffered, either 
by inflammation of its connective tissue or by 
interference with its nutrition and consequent 
softening induced by changes in the cerebral 
vessels, or by some structural alteration in the 
cortical layer brought about by the pressure 
of thickened and adherent membranes. The 
former condition, provided that suitable treat- 
ment is adopted early enough, is remediable 
and temporary; the latter, although often 
capable of some amelioration, always leads ere 
very long to a fatal termination without restora- 
tion of the mental faculties. I have selected 
the following cases as illustrative of these 
varieties of mental disturbance, although I 
must allow that the history of some of them 
leaves it open to objectors to deny that their 
syphilitic origin is absolutely proved. My 
reasons for so classing them are briefly these. 
The age of the patient, the history of syphilitic 
infection, the absence of indications of other 
causes (especially in the circulatory apparatus 
and kidneys) capable of producing the phe- 
nomena, the absence of neurotic family history, 
the mode in which they were influenced, at 
least temporarily, by specific remedies, and 
their general resemblance to well-attested cases ILLUSTRATIVE OASES. 
119 
of other authors in which autopsies have been 
performed. With the mass of evidence before 
us which has been accumulated by such ob- 
servers as Virchow, Wagner, Ricord, Lance- 
reaux, Wilks, Hughlings Jackson, and others, 
the time seems to me to have passed for re- 
quiring such proof as dissection affords in cases 
the clinical features of which are alone sufficient 
to enable us to class them with those in 
which this source of confirmation has been at- 
tainable. 
In the following case of right hemiplegia 
with aphasia, of syphilitic origin, which was 
treated by me in the hospital four years ago, 
the patient, a young man, showed such 
symptoms of mental aberration that we had 
some difficulty in retaining him in the hospital. 
For the first few days he was at times in a state 
of the greatest excitement, talking violently of 
persons injuring him, and occasionally falling 
for hours into a condition of deep stupor. 
Under the influence of specific treatment his 
mental symptoms quickly subsided, and in three 
months he was also in other respects quite 
well. 
Case XXXIII.-A male, aged twenty-nine, single, applied 
at the hospital on August 17th, 1870, in the following con- 
dition ;-He walks very lame, dragging the right foot, and 120 
SYPHILITIC NERVOUS AFFECTIONS. 
can scarcely lift the right hand. There is no loss of 
sensation in the limbs. With Duchenne's dynamometer 
the result with the right hand is 0, and with the left 25°. 
His manner is very odd, the face having a dazed look, and 
he displays great irritability towards his companion, a 
young woman to whom he is engaged. His speech is 
laboured, and he is often at a difficulty for the right ex- 
pression. Whilst the right limbs are paralysed, the left 
side of the face is chiefly affected. On being told to shut 
his eyes, the left upper eyelid fails to cover the globe by 
one eighth. In laughing, the right angle of the mouth is 
drawn a little higher than the left. In whistling, the 
mouth is pushed over to the left. The tongue is protruded 
straight. He cannot eject saliva to any distance. There 
is no apparent loss of sensation on either side of the face. 
On examination a scar is found half an inch in front of, 
and extending for an inch below the external auditory 
ineatus of the left ear, and a line of cicatrices runs down 
the front of the left sterno-mastoid muscle. He says that 
he had abscesses on this side of the face and neck two 
years ago ; that one in the situation first mentioned was 
lanced, and that " the water used to run from the scar for 
two months." At this time he first noticed that he could 
not close his left eye, and the inability has continued ever 
since. 
He contracted syphilis two years and a half ago, followed 
by bad sore throat. His present attack (which had oc- 
curred three weeks previously to my seeing him) was pre- 
ceded for a fortnight by great pain in the back of the head and 
over the left eye; and then one night, whilst in bed, he 
suddenly lost his speech, and the power of moving the right 
arm and leg, but did not become unconscious. The speech was 
absolutely lost for three or four days, and then gradually 
returned, but remained imperfect at the time of his appli- ILLUSTRATIVE CASES. 
121 
cation. He was in the habit, it seemed, of using words 
erroneously-e.g., calling his watch, " hat." 
He was admitted into the hospital, and ordered five 
grains of iodide of potassium three times a day. This 
dose was increased to ten grains after twelve days, then to 
fifteen grains after another week, and to twenty grains 
after another fortnight. During the first few days of his 
stay in hospital his manner was very flighty, and occasion- 
ally violent, and at times he was comatose for hours to- 
gether ; but these symptoms soon subsided, and he gradu- 
ally improved also in the condition of his limbs. 
He left the hospital on October 15th, but continued 
taking twenty grains of the iodide of potassium three times 
a day. 
On November 16th he could use his arm freely, and the 
grasp of his right hand measured 30° on the dynamometer, 
as against 0 at his first examination. There was slight 
lameness of the right leg, but so little remained of his 
paralysis that he was at work again as a groom. Asked 
about his speech, he acknowledged that he still occasionally, 
but rarely, substituted words, and that his tongue would 
sometimes catch against his teeth in speaking. The facial 
paralysis of the left side, which had existed for two years, 
remained unchanged. 
There is a point of special interest in this 
case beside the symptoms of intellectual dis- 
turbance, namely, the association of hemiplegia 
of the right side with facial paralysis of the 
left. The first glance at this patient gave rise 
to the idea that the case might be one of cross 
or alternate paralysis, dependent probably upon 
lesion of the pons Varolii. But there was a 122 
SYPHILITIC NERVOUS AFFECTIONS. 
feature which speedily threw doubt upon this 
view, and drew attention to the trunk of the 
left facial nerve. When the patient was asked 
to close his eyes, the left eyeball remained ex- 
posed to the extent of one eighth of an inch, 
the right eye being perfectly closed. Now, in 
that form of facial paralysis which is of cerebral 
origin, and which is constant to a greater or 
less extent in hemiplegia, the ability to close 
the eyes (at least simultaneously, if not always 
also independently) is never lost. This facial 
paralysis not being therefore of cerebral origin, 
inquiry and examination easily traced it to in- 
jury to the trunk of the nerve, as it passed 
through the parotid gland. It would seem 
that the injury took place in the body of the 
nerve before it divided, as the muscles about 
the mouth, as well as the orbicular muscle of 
the eyelids, were paralysed. Whether the 
damage had been done by suppuration or by 
the surgeon's knife did not appear, but at any 
rate the nerve had not been completely divided, 
as the paralysis was incomplete. 
Case XXXIV.-A single man, aged twenty-eight, was 
brought to the hospital a year ago in a state of great mental 
■confusion. He was suffering from paralysis of the right 
external rectus muscle, and partial paralysis of the left leg, 
which he could only just lift from the ground. His symp- ILLUSTRATIVE CASES. 
123 
toms dated from six months previously. His friend.s, who 
considered him out of his mind, said that he was constantly 
talking of persons who were either dead or far from 
England, and holding imaginary conversations with them. 
He had a large cicatrix of old ulceration on one leg. I 
placed him upon specific treatment, but before he could 
commence it he fell into a state of coma which lasted three 
days. He then began treatment, with immediate and 
rapidly progressive improvement; and was soon able to 
inform me, in answer to questions, that six years previously 
he had been affected with a chancre, which had been followed 
by eruption on the skin. Under treatment he recovered 
his usual health in a few weeks. 
Case XXXV.-A gentleman, aged thirty-eight, applied 
to me with thickness of speech, loss of memory, inability to 
write letters without numerous mistakes, noise in the ears, 
and deafness. He had no deficiency in muscular power. 
There was a history of hard, perhaps excessive, work. His 
symptoms, he said, had commenced three months previously 
with " biliousness," recurring every morning, accompanied 
by vomiting, heaviness, and several times a day a feeling as 
of blood rushing to his head, giddiness, singing in the ears, 
pains in the arms and legs, and cramps in the fingers, so 
that, during the attacks, he could not hold a pen. He 
never lost his senses. His habits were extremely tem- 
perate, and he had no recognisable lesion of the heart, 
blood-vessels, or kidneys. There was no family neurosis. 
As regards his earlier history, it seemed that many years 
previously (I could not learn the date) he had suffered from 
syphilitic symptoms, including spots on the face, and bad 
sore throat. Not long after this (and ten years before I 
saw him) he had an attack in which, to use his own de- 
scription, his mouth was " drawn down on the right side, 124 
SYPHILITIC NERVOUS AFFECTIONS. 
and he could not speak distinctly." About the same time 
he suffered from pain in the right eye, and his sight was 
affected. He remembered that he was said to have iritis, 
and that he took medicine which made his gums sore. His 
face was paralysed for three weeks, and it was three or four 
months before he could speak distinctly. Since then he had 
enjoyed good health until the attack for which he sought 
my advice. 
I prescribed mercury and iodide for him, and he imme- 
diately began to improve. His speech became clearer, he 
was able to write with but few mistakes, and lost all the 
other symptoms of which he had complained. I still, how- 
ever, noticed something queer in his manner, and his replies 
to questions were wanting in logical accuracy. After two 
months' treatment, although I considered his condition as 
by no means satisfactory, he returned to business, but 
found himself incapable of continuing it after a few days. 
I then lost sight of him for five months, during which, I 
believe, he underwent treatment elsewhere. At the end of 
that time I was called to see him at his home, and found 
him in a state of restless excitement, with tremulousness of 
features and mental delusions. He was by turns tender 
and affectionate to his family and violently harsh to them. 
His manner was full of suspicion, and he told me of persons 
in the house who were following him about, making remarks 
and laughing at him. It became necessary to send him to 
an asylum, where he died after ten days, during which he 
had been extremely violent and had suffered from con- 
vulsions. 
Case XXXVI.-A clerk, aged forty-six, married six years, 
applied at the hospital in January, 18*72, with imperfect 
right hemiplegia, occasional incontinence of urine and faeces, 
and considerable mental disorder. It seemed, from his ILLUSTRATIVE CASES. 
125 
wife's account, that in November, 1870, he had a succession 
of fits in one day, which were followed'by prostration, and 
kept him from his employment for a month, when he re- 
turned and worked fairly well at his duties. At times, 
however, he seemed lost, called people by wrong names, and 
frequently expressed an opinion that " Michael, the paper- 
man, was flying about his head, and making him ill." In the 
December and January following he suffered very much 
from pain coming on night after night in his head. In 
July, 1871, he had another batch of fits, ten in number, 
and it was a month before he rallied and became quite con- 
scious. About this time, it appears from his wife's account, 
he had a succession of " bumps" upon his head, often as big 
as a walnut, and lasting sometimes a few days, but occa- 
sionally much longer. They were very tender to the touch, 
and were doubtless periosteal nodes. A month afterwards 
there was again a recurrence of fits, on the cessation of 
which he returned to his office, and resumed duty until a 
fortnight before his visit to me, but it appeared that he had 
really been useless there since his attack in July. It was 
at that time that his hemiplegia had been first observed. 
He complained of occasional pain in the head, and was 
described as sleeping very much, in the day, and being very 
restless and unmanageable at night. I ascertained from 
him that he had first suffered from venereal disorder in 
1840, and since then had been affected on no less than seven 
occasions with primary sores, the last dating eight years 
back. He had never had skin eruption, but had suffered 
from bad sore throat. In the beginning of 1870 he had 
some ulceration of the scrotum, which remained open for 
three months, and during this time he felt very weak and 
low-spirited. 1 ordered him full doses of iodide, under 
which at first he improved considerably, obtaining rest at 
night, regaining power over the bladder and rectum, and 126 
SYPHILITIC NERVOUS AFFECTIONS. 
becoming clearer in bis intellect. Subsequently mercury 
was given to him. The improvement, however, which was 
at first manifested, did not last, his mind became more and 
more fatuous, and in April he was sent to an asylum, where 
he died about a twelvemonth afterwards. 
Case XXXVII.-Six years ago a male patient, aged 
twenty-eight, was sent to me, suffering from imperfect 
left hemiplegia. This condition dated from an attack 
four years previously, in which, as he sat by the fire, 
his left leg worked violently up and down, and he fell 
into the fender, without, however, losing consciousness. 
He then found that his face was drawn to one side, and 
there was a great loss of power in the arm and leg of the 
left side. He gradually recovered to a certain extent, and 
resumed his occupation three or four months afterwards, 
but never felt quite well. I advised that he should be 
treated with bichloride of mercury. In November, 1867, 
he again had a fit, and this time was unconscious for 
thirty hours. On regaining his senses he found himself 
paralysed in the right arm, and aphasic. Before this 
attack he had suffered from partial loss of sight. In 
January, 1869, I saw him again. His grasp was then equal 
on each side, but the left leg was stiff and halting. In 1870 
he had a third attack, in which his left leg became power- 
less. In November, 1871, he was affected, for the fourth 
time, with a paralytic seizure. On this occasion he became 
paraplegic and lost his consciousness for so long a time that 
he remembers little or nothing that occurred during many 
months. 
This man had a syphilitic sore in 1860, for which he was 
salivated, and a few months afterwards a pimple-like erup- 
tion, which lasted, as he says, for years. He also suffered 
from ulcerated throat. ILLUSTRATIVE CASES. 
127 
Last year I had the opportunity of again examining this 
patient. Since I had last seen him, he had been on one 
occasion for several months in a hospital, where, so far as I 
could make out, his mind had been much affected. On 
examination I found partial paraplegia, diplopia from 
imperfect power of moving the right globe, and contrac- 
tion of the right pupil. He could grasp very strongly 
with either hand, and his speech was not affected. Sensi- 
bility was everywhere perfect. The right optic disc was 
partially atrophied, and there were evidences in this 
eye of old choroiditis. His memory, he told me, was 
very imperfect, but he answered my questions for some 
time with very fair intelligence and quite to the point. 
Presently, however, apropos of nothing connected with the 
subject, he gravely remarked, " If the Bible is true, I am the 
prodigal son, and the future king of England," and went on 
to announce that the Holy Ghost was in his body. He also 
assured me that he constantly saw a black dot and a hair 
following him about, evidently to watch him, and believed 
that they came from the hospital in which he had been a 
patient. 128 
SYPHILITIC NERVOUS AFFECTIONS. 
CHAPTER IV. 
On the Prognosis and Treatment of Syphilitic 
Nervous Affections. 
As a broad general rule, I think it may be 
considered that the prognosis in syphilitic ner- 
vous affections of an important character is 
much more favourable than in lesions with 
analogous symptoms which do not depend 
upon this specific cause. The immediate 
tendency to a fatal termination in cases the 
nature of which has been recognised sufficiently 
early, and for which appropriate treatment is 
applied, is comparatively slight. The effect of 
remedies in improving the patient's condition is 
usually of a remarkable character, and quite 
beyond anything which is seen in the ordinary 
treatment of nervous affections arising from 
indifferent causes. So much may, doubtless, be 
asserted with confidence, and yet there are 
modifying circumstances, of which I shall 
presently speak, which serve to lower consider- 
ably the hopeful tone of such a prognosis when 
it has to be applied to the patient's future, PROGNOSIS AND TREATMENT. 
129 
instead of the particular attack under which he 
happens to be suffering. 
Cases of nervous affections of this class are 
of favourable prognosis in proportion as the date 
of the constitutional affection at which they 
occur is early, and as the lesions are of a small 
and local character. Just as it is a matter of 
common experience that the secondary skin 
eruptions will subside and leave no trace of 
the affection, so it is reasonable to expect, and 
in practice it is found, that those affections of 
the membranes, or of the fibro-osseous canals 
which, like the skin eruptions and the sore 
throat of the same period, are of simple 
inflammatory character, will disappear without 
resulting disorganization. But when the lesion 
is caused by the presence of gummata in the 
membranes, interstitial neuroglia, or vessels, we 
have to deal with conditions much more likely 
to cause disintegration of important parts. 
Just as, in the stage corresponding to this, the 
affections of the skin, throat, palate, and 
osseous system, are apt to leave behind them 
permanent traces in consequence of ulceration 
and suppuration, so the delicate structures 
of the nervous system are likely to receive 
impressions which are lasting in their effects. 
Moreover, at this period, even when, under 130 
SYPHILITIC NERVOUS AFFECTIONS. 
treatment, the gummata are more or less 
absorbed, there is a great tendency to a re- 
production of this new formation, and it often 
happens that this takes place with ever in- 
creasing rapidity. Treatment may cause the 
symptoms to clear off with much rapidity, and 
yet the apparent prospect of a complete cure 
turns out to be illusory. 
As is well known, however, it does not 
happen that infected persons who have passed 
through secondary symptoms always exhibit 
afterwards tertiary phenomena. These may 
never occur. It is evident, therefore, that a 
patient who has recovered from nervous affec- 
tions which, in their simple inflammatory 
character, may be associated with the changes 
belonging to the secondary period, need not 
necessarily be subject later on to those belonging 
to gummatous formation. But the same doubt 
as to the future which prevents us from pre- 
dicting of a patient who has lost his secondary 
skin eruption, that he will not be troubled with 
symptoms of a tertiary kind, is sufficient to make 
us guarded in our prognosis after a subsidence 
of early nervous affections. It is pretty well 
agreed that treatment removes the results of 
syphilis, not the dyscrasia itself, and so 
when the nervous affections have been of a PROGNOSIS AND TREATMENT. 
131 
character which enables us to refer them to the 
presence of gummatous formation, we are never 
in a position to say that they will not be 
repeated. On the contrary, it is only fair to 
expect that there will be a recurrence, and it 
is our duty, under these circumstances, to urge 
long-continued treatment, and when this has 
been dropped for a time, a resumption of it on 
the slightest appearance of relapse. By this 
means we may at least lend important aid to 
the patient by promoting the absorption of new 
formations as soon as they begin to declare 
themselves. Meantime we have always to hope 
that time will gradually bring about such a 
change in the §tate of the constitution that the 
hazard of a relapse may grow appreciably and 
constantly less. But, with all this, it would be 
futile to deny the fact that in too many cases 
recurrences will take place, and, in spite of 
treatment, leave the patient, after each attack, 
in a worse condition than he was before. How- 
ever, this is by no means always the case, per- 
haps even not most commonly, and there can be 
no doubt that as a general rule, supposing the 
disease to be recognised, and proper treatment 
promptly and systematically given, the prospects 
either of eventual recovery or of a fair amount 
of health are extremely encouraging. Should. 132 
SYPHILITIC NERVOUS AFFECTIONS. 
the syphilitic basis of the disorder be over- 
looked it constantly happens that most valuable 
time is lost, and the sufferer drifts into a per- 
fectly hopeless condition. It is then the imme- 
diate results of syphilis which we endeavour to 
treat, not the irreparable disorganizations of 
nervous structure which those resulting forma- 
tions have caused, and against which our specific 
remedies are of course worthless. 
So much has been incidentally said in this 
work respecting the treatment of diseases of 
the nervous system dependent upon syphilis 
that but little remains to be added upon this 
point. Ricord's views as to the most appro- 
priate treatment for the different stages of 
constitutional syphilis ma^ be thus epitomised. 
In the primary stage, mercury. For secondary 
symptoms, when they are uncomplicated, 
mercury; when they are blended with those of 
a tertiary character, the treatment is a mixture 
of mercury and iodide of potassium. In the 
tertiary stage he relies upon iodide of potas- 
sium. And this scheme would probably represent 
very fairly the views of those who have had 
large experience of the disease. In the class of 
cases, however, with which we are specially 
concerned, as I have before described, it is not 
by any means always possible to say whether PROGNOSIS AND TREATMENT. 
133 
the symptoms of nervous affection which are 
observed belong to the secondary or tertiary 
stage. Our treatment, therefore, must be to a 
certain extent tentative. My own plan is always 
to commence, in a case of this kind, with 
iodide of potassium. In a majority of instances 
this drug, which will often require to be pushed 
to large doses, will be sufficient to bring about 
a cure of the symptoms, or at least a very 
important improvement. If, however, after 
three or four weeks of such treatment, employed 
with sufficient boldness, the improvement is not 
marked, I give mercury, which will sometimes 
then act with remarkable effect. The prepara- 
tions which I chiefly employ are the perchloride 
and the red iodide; and I do not know that 
preference, for any particular reason, is to be 
given to one or other of these forms. As a 
matter of practice, I think I have found that 
the red iodide, given in solution of iodide of 
potassium, is less apt to cause irritation of 
the abdominal organs than the perchloride. 
It is seldom that either causes salivation. 
Where it is desired to produce, and to keep up 
for some time, a slight action upon the gums, 
this can be effected in the usual manner by 
appropriate doses of blue pill or grey powder. 
The French very largely employ the green 134 
SYPHILITIC NERVOUS AFFECTIONS. 
iodide, a preparation but seldom used in Eng- 
land, probably because it is unstable, some 
biniodide being apt to form in it when it has 
been long kept. 
A word as to the dose of iodide of potassium. 
After a good deal of hesitation, and trial of 
various quantities in a considerable number of 
cases, I feel convinced that in syphilitic affec- 
tions of the nervous system it is often necessary 
to employ doses of this drug which are far 
beyond those usually ordered. In several 
instances I have observed something of the 
following kind to take place. An improvement 
up to a certain point has been produced by 
doses of iodide of from ten or fifteen to twenty 
grains three times daily. The patient has then 
remained at this stage, or progress has been 
very slow, whilst he continued to take this 
amount. On increasing it, however, by rapid 
steps, to thirty, forty, sixty, or even ninety 
grains three times a day, the case has responded 
immediately and pari passu to the additional 
quantity of the drug. I had two patients in the 
hospital last year who were striking instances 
of this effect. In each the dose was pushed 
gradually to ninety grains three times a day 
with marked beneficial effect, and I may add 
that the patients themselves expressed an PROGNOSIS AND TREATMENT. 
135 
unhesitating opinion upon this point. There is 
nothing new of course in the employment of 
large doses. Forty years ago the late Dr. 
Elliotson used to give as much as two drachms 
three times a day,* and with remarkably good 
results. But of late years, as a general rule, 
the dose has been so moderate that to many 
practitioners the employment of ten grains at a 
time is only gradually arrived at, and with some 
caution. No doubt in a very large number of 
cases a comparatively small dose is all that is 
required, and in practice, therefore, it is well to 
begin with a dose of ten grains, and increase it 
if necessary. I feel tolerably sure from repeated 
experiments that the iodide may be used, if 
occasion require it, as freely as the bromide of 
potassium, and that the opportunity of doing 
great good in syphilitic nervous affections is 
nearly as often missed by the employment of 
inadequate doses of the former drug as used 
notoriously to happen in respect of epilepsy 
from the exhibition of too small doses of the 
latter. Symptoms of iodism, very like those of 
severe nasal catarrh, will occasionally present 
themselves, but just as frequently, so far as I 
have seen, when the amount of the salt employed 
is small as when it is considerable, and it is very 
* ' The Lancet,' Feb. 12th, 1838. 136 
SYPHILITIC NERVOUS AFFECTIONS. 
rare indeed that the use of the drug has to be 
given up on this account. Occasionally, too, a 
kind of large pustular acne is a disagreeable 
consequence of its administration, but this is 
not so common as where the bromide has been 
given. I often see the symptoms of iodism as 
well as this condition of the skin subside whilst 
the patient continues to take the iodide. 
There is something quite remarkable in the 
influence of the iodide of potassium in cases of 
this class. The drug seems to act almost as a 
food to the patient. It is not only that he finds 
under its employment that the special nervous 
symptoms for which it is prescribed are benefi- 
cially influenced, but he describes a condition of 
bien etre as accompanying its use which makes 
him unwilling to give it up. I know of nothing 
in all therapeutics more extraordinary than the 
rapid effects of iodide in improving the con- 
ditions of these patients except it may be per- 
haps the influence of lemon juice in scurvy. 
Conditions of anaemia, which seem to de- 
mand a treatment by iron, are often found to 
be uninfluenced by that metal, whilst a few 
doses of iodide will bring about a surprising 
improvement in the colour of the patient and 
his general tone. The common idea of the 
" lowering" action of the drug would seem to PROGNOSIS AND TREATMENT. 
137 
be incorrect, at least in cases where its employ- 
ment is demanded, and patients will constantly 
assert that on leaving off the iodide even for a 
few days they perceive so marked a diminution 
in vital energy' that they are only anxious for 
its resumption. And this in spite of the local 
inconveniences belonging to a tongue thickly 
covered with grey fur, and an accompanying 
metallic taste, which are indications that the 
system is saturated with the drug. 
I am in the habit of administering the drug 
simply dissolved in water, and have not found 
that any advantage is gained by the addition of 
ammonia or vegetable bitters. It has been 
alleged that the former prevents the occur- 
rence of iodism, and that, by conjunction with 
the latter, the digestive system is less likely 
to be deranged by the iodide, but my experience 
has not confirmed this statement, although I 
have repeatedly tried the experiment. 
As regards the employment of mercury I do 
not think that a condition of cachexia should 
necessarily stand in the way of its use. One very 
often sees a surprising improvement in the aspect 
and state of nutrition under its administration. 
It is not possible, however, to indicate with 
anything like precision the class of cases in 
which it should be pushed in preference to per- 138 
SYPHILITIC NERVOUS AFFECTIONS. 
severance with the iodide. As a general rule I 
should say that supposing the diagnosis pointed 
very strongly indeed to a syphilitic origin of the 
nervous affection, and that this, although bene- 
ficially influenced by iodide, yet persisted in 
spite of the employment of large doses, it is 
advisable to try the effects of mercury. I have 
already referred to some of the forms in which 
this drug may be given. I may add that in 
certain cases the use of the calomel bath, as 
perfected by Mr. Henry Lee, offers a safe 
although somewhat wearisome mode of employ- 
ing the drug. 
In that condition of very advanced cachexia 
which is associated with symptoms of lardaceous 
changes, neither iodide nor mercury will prove 
of any service to the patient. 
It is to be desired that some form of sub- 
cutaneous injection of mercury may be dis- 
covered which will be free from the objections 
at present belonging to this method. The 
common occurrence of small abscesses at the 
seat of puncture is a fatal objection to most of 
the solutions which have been tried. In three 
cases I have used the solution of the chloro- 
albuminate of mercury as introduced by Dr. 
Staub, of Paris,* but I am not satisfied with it. 
* The following is Dr. Staub's formula quoted by the PROGNOSIS AND TREATMENT. 
139 
In each patient the injection was immediately 
followed by great pain at the seat of puncture, 
and the formation of a hard swelling which 
persisted in one case during several weeks, and 
in this instance was accompanied by continuous 
pain. In the other two cases the pain ceased 
after about half an hour, the swelling remain- 
ing. In none of these, however, was there any 
suppuration. It is evident that if a solution of a 
salt of mercury could be met with which would 
not give rise to local irritation, the subcutaneous 
method, from the certainty attainable by it as 
respects the quantity of the drug employed, 
would be a most valuable, means of treatment. 
It will often be found that the muscles para- 
lysed from lesion of the nerves supplying them 
' Lyon Medical,' June 9th, 1872. I have not been able to 
meet with the original pamphlet: 
Grammes. 
1. Hydrarg. Bichlorid. . . . 1'25 
Ammonii chloridi .... 1'25 
Sodii chloridi .... 4'15 
Aq. destill. ..... 125 0 
Dissolve and filter. 
2. White of one egg, water enough to make a 
solution of 125 grammes-filter. 
Mix the solutions and filter. One gramme 
of the liquid contains 5 milligrammes of 
mercury-medium dose, one centigramme 
daily in two injections. 140 
SYPHILITIC NERVOUS AFFECTIONS. 
fail to respond, or respond but imperfectly, to 
the induced electrical current. Under these 
circumstances it will sometimes happen that 
the intermitted galvanic current from a few 
cells of Stohrer's or Foveaux's battery will 
readily cause contractions, and advantage may 
be taken of this reaction to exercise the 
muscles, and thus contribute to their nutrition. 
Where the induced current produces con- 
tractions it may be employed with the same 
object. The paralysis resulting from syphilitic 
nervous affections is so frequently of a 
peripheral character that the same objection 
does not apply to the early use of electrical 
treatment in these cases as in those which are 
dependent upon central lesions. I have in 
several instances seen a rapid improvement in 
the power of the external muscles of the eye by 
the employment of the induced current. Owing 
to the pain which attends touching the con- 
junctiva with the rheophores, these should 
always be applied over the closed lids. 
I do not know that much more can be said 
as to the therapeutics of these disorders. 
Whether iodide of potassium or mercury, or 
both be employed, a very long continuance of 
the treatment seems always to be required, and 
an immediate resumption of it at the slightest PROGNOSIS AND TREATMENT. 
141 
indication of relapse. In certain cases, arsenic 
and iron may be used with advantage in addi- 
tion to these means; bromide of potassium may 
be added in cases of convulsion, and cod-liver 
oil will always be useful in cachectic conditions ; 
but essentially the treatment of this class of 
nervous affections is the treatment of the 
constitutional disorder. INPEX. 
Acne, from use of iodide, 136 
Age, importance in diagnosis, 88, 10 
Anaemia, 136 
Anstie, Dr., on pains, 46 
Aphasia, transitory, 81, 84, 85, 8, 115 
Arachnitis, partial, 64 
Arterial changes, 19, 63 
Atrophy of optic disc, 33 
„ of muscles, 40 
Blandford, Dr., on mental disorders, 28 
Brain, softening of, 64 
„ gummata of, 67 
Cachexia, 137 
„ with lardaceous changes, 138 
Cases:- 
I.-Paraplegia-incontinence of urine and faeces-hemiplegia- 
aphasia, 6. 
II.-Atrophy of optic disc-flying pains, 34 
III.-Syphilitic fever-secondary eruption-osteocopic pains, 75 
IV.-Functional disorder of digestive organs-ulcer of tonsil-• 
epileptoid seizures-in the sequel, fever with pain and 
swelling of the joints, 77 
V.-Epileptic seizures-nervous sensations in the intervals, 79 
VI.-Paroxysmal aphasia-obscured intelligence-spasmodic con- 
tractions of the right upper extremity and cheek, 81 
VII.-Peelings of " mistiness," followed by transitory aphasia, 84 
VIII.-Comatose seizures-transitory aphasia-nodes on upper 
extremities-attacks of subjective sensation of odours, 85 144 
INDEX. 
Cases-continued. 
IX.-Necrosis of hard palate-paralysis of third nerve-intellectual 
disturbance-periostitis-transitory aphasia, 87 
X.-Attacks of spasm of right upper extremity without loss of con- 
sciousness-transitory aphasia-scar of ulcer on palate, 88 
XI.-Attacks of spasm of right side-occasional loss of conscious- 
ness, 89 
XII.-Left hemiplegia-paralysis of left third nerve-attacks of 
syncope, 91 
XIII.-Tremor of limbs of left side-previous " congestion of brain " 
and insanity for some weeks-epileptic seizures, 92 
XIV.-Epileptic seizures, resulting in mania-right hemiplegia- 
previous affection of eyes-subsequent paraplegia, 92 
XV.-Epileptic seizures-noisy flatulence-old disseminated choroi- 
ditis, 94 
XVI.-Pain in head-left hemiplegia-vertigo-old optic neuritis, 96 
XVII.-Epileptic seizures-old optic neuritis, 96 
XVIII.-Convulsive seizures in right upper extremity-double optic 
neuritis, 97 
XIX.-Convulsive seizures-optic neuritis, 99 
XX.-Imperfect paraplegia-commencing dementia-double amau- 
rosis from disseminated choroiditis, 101 
XXI.-Right hemiplegia-paralysis of third, fifth, and sixth nerves 
-partial atrophy of optic disc, 102 
XXII.-Paralysis of four extremities and both sides of face- 
partial paralysis of respiration and deglutition-cutaneous 
anaesthesia, 104 
XXIII.-Periostitis-paralysis of four extremities, 107 
XXIV.-Persistent cramp in thigh-gummatous tumours of muscle, 
108 
XXV.-Paresis of right arm, both legs, and bladder-gummatous 
tumours of muscles, 109 
XXVI.-Pain in limbs of right side-previous strabismus, 112 
XXVII.-Paralysis and wasting of muscles in the district of right 
sciatic nerve-gummatous ulceration of leg, 112 
XXVIII.-Paresis of legs and bladder-recovery-nine years later 
complete paraplegia-old disseminated choroiditis, 114 
XXIX.-Paraplegia-recovery-eighteen years later right hemi- 
plegia, 115 INDEX. 
145 
Ci ses-continued. 
XXX.-Left hemiplegia-two years later recurrence with fits-six 
years later facial paralysis of right side and left hemiplegia 
-pains in head, 115 
XXXI.-Insomnia-paresis of lower extremities-pains-history of 
old hemiplegia whilst under treatment for chancre, 116 
XXXII.-Primary sore-during treatment, loss of power in left arm, 
116 
XXXIII.-Right hemiplegia-aphasia-noisy intellectual disturb- 
ance-occasional coma, 119 
XXXIV.-Mental confusion-ulcer of leg-paralysis of right sixth 
nerve-partial paralysis of left leg, 122 
XXXV.-Loss of memory-vertigo-vomiting-nervous attacks-- 
eventual mania and convulsions, 123 
XXXVI.-Right hemiplegia-incontinence of urine and faeces-- 
convulsions-periosteal nodes-dementia, 125 
, XXXVII.-Left hemiplegia-four years later right hemiplegia- 
three years later left leg paralysed-one year afterwards 
paraplegia-dementia, 126 
Choroiditis, 33 
Constriction, sense of, in spinal cord lesions, 23. 
Convulsion, 14 
Cprd, spinal, affections of, 22 
Cranial nerves, paralysis of, 17, 36, 87, 91,102,104,122 
„ „ gummata in, 70 
Dementia, 26 
Diagnosis, general remarks on, 1 
„ of hemiplegia, 8 
„ of paraplegia, 20 
„ of convulsion, 14 4 
„ use of electricity in, 38 
„ „ iodide of potassium in, 11 
„ „ ophthalmoscope in, 32 
Digestion, functional disorder of, 77 
Diplopia, 37, 38 
Dura mater, inflammation of, 60 
Dyscrasia, syphilitic, Virchow's views on, 54 
Electricity, in diagnosis, 38 
„ „ treatment by, 139 146 
INDEX. 
Encephalitis, gummatous, 68 
Epilepsy, 13 
„ without loss of consciousness, 15 
Faintness, 77,80, 90 
Fever, syphilitic, 75 
Griesinger, Dr., on adhesion of membranes, 53 
Gumma, Professor Virchow on the, 53 
,, distinguished from tubercle, 69 
Heidenhain, Dr., on thickening of membranes, 59 
Hemiplegia, 16 
Hereditary influence, 93 
Huebner on brain disease, 16 
Hyperplastic tumours, 53 
Hysterical paralysis, 41 
Insane, general paralysis of the, 27 
Insomnia, 80 
Iodide of potassium, use of, in diagnosis, 11 
„ „ treatment, 133 
,, large doses of, 134 
„ mode of administration, 137 
lodism, 135 
Jackson, Dr. Hughlings, on double optic neuritis with convulsions, 15 
„ „ on preservation of sight with optic neuritis, 35 
„ ,, on aphasia from meningeal affections, 84 
Knorre, Dr., cases of nervous affections, 48 
Lancereaux, on neuralgic pains, 44 
,, on hemiplegia, 44 
„ on local paralysis, 47 
Maniacal Symptoms, 117,119 
Mental disorder, 27 
Mercury, treatment by, 133,137 
„ subcutaneous injections of, 138 
Meyer, L., on adhesion of membranes, 60 
Morbid anatomy, 42 
Multiple character of lesions in syphilitic nervous affections, 74 
Muscular tumour, 108, 109 INDEX. 
147 
Nerves, cranial, paralysis of, 17, 36, 87, 91, 102, 104, 122 
Nerve-trunks, affections of, 71 
Nerve, sciatic, paralysis of, 112 
Nerve, sympathetic, Dr. Petrow on changes in, 71 
Ophthalmoscope, use of, in diagnosis, 32 
Optic neuritis, 15 
„ associated with convulsions, 15 
Osteocopic pains, 46 
Pachymeningitis, 60, 62 
Pain in head, associated with convulsion, 15 
Pains, 46 
Paralysis of cranial nerves-see cranial nerves 
„ extremities, 22 
„ facial nerve, 12, 41 
„ general, of the insane, 27 
Pathology, 42 
Paralytic dementia, 42 
Partial arachnitis, 64 
Peripheral paralysis, 12 
Period of occurrence of nervous affections, 23 
Pia mater, gummata of, 64 
Periosteal gumma, 56 
Prognosis, 128 
Ptosis, 36 
Petrow, Dr., on syphilitic changes in the sympathetic, 71 
Recurrence of gummata, 72 
Reynolds, Dr., on softening of the brain, 31 
Ricord, Prof., on treatment, 132 
Relapse, tendency to, 113, 131 
Secondary syphilis, nervous disorders in, 44, 48 
,, „ meningitis in, 51 
Simultaneous lesions of the nervous system, 9, 24 
Spasmodic seizures, 15 
Spinal cord, symptoms of affections of, 22 
Stages of syphilis, 42 
Strabismus, 37 
Staub, Dr., solution of mercury for injection, 138 148 
INDEX. 
Synovitis, 111 
Subcutaneous injections of mercury, 138 
Treatment, 132 
Vertigo, 23 
Virchow, Prof., on hyperplasia, 49 
„ „ obliteration of arteries, 63 
„ „ the gumma, 53, 67 
„ „ pachymeningitis, 60 
„ ,, partial arachnitis, 64 
„ „ gummatous encephalitis, 68 
Vision, preservation of, with optic neuritis, 35 
Wagner, Prof., case from the practice of, 107 
Wilks, Dr., on albumino-fibroid deposits, 72 
Zeissl, Prof., on meningitis in early syphilis, 51 
„ „ hemiplegia, 18 
„ „ cerebral softening, 65 
FEINTED BY J. E. ADLAED, BAETHOLOMEW CLOSE.