BILATERAL CEREBRAL THROMBOSIS DUE TO 
SYPHILITIC ARTERITIS, 
WITH INCONTINENCE OF THE VESICAL AND 
ANAL SPHINCTERS. 
BY 
\ / 
J. T. ESKRIDGE; M.D., 
OF DENVER, COL. ; 
PROFESSOR OJ* NERVOUS AND MENTAL DISEASES IN THE UNIVERSITY OF COLO- 
RADO ; NEUROLOGIST TO THE ARAPAHOE COUNTY, TO THE ST. LUKE’S, 
AND TO THE DEACONESS HOME HOSPITALS 
FROM # 
THE MEDICAL NEWS, 
January 6, 1S94. [Reprinted from The Medical News, January 6, 1894.] 
BILATERAL CEREBRAL THROMBOSIS DUE 
TO SYPHILITIC ARTERITIS, WITH INCON- 
TINENCE OF THE VESICAL AND ANAL 
SPHINCTERS.1 
By J. T. ESKRIDGE, M.D., 
OF DENVER, COL. ; 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE UNIVERSITY OF 
Colorado; neurologist to the arapahoe county, to the 
st. luke's, and to the deaconess home hospitals. 
I wish to study carefully with you to-day the case of 
the man who is before us, as since his admission into the 
hospital it has presented several difficulties in regard to 
diagnosis. His history is as follows : 
J. C., thirty-three years of age, a male laborer, of New 
York, but living in Colorado during the past three years, 
was admitted into this hospital July n, 1893. His 
family history is unimportant, except for the occurrence of 
tuberculosis on his mother’s side. His health was always 
good until four years ago, when he contracted a hard 
chancre, but without secondary manifestations. Afterthis 
his health seems to have been fairly good until about one 
month prior to the occurrence of the paralysis for which 
he was brought to the hospital. The symptoms premoni- 
tory of the paralysis consisted of headache and mental 
dulness for one month, and, for a few days immediately 
antedating the attack, dizziness. On the morning of 
July nth (the day of his admission into the hospital), 
while he was sitting in a chair, his left side became 
1 A clinical lecture delivered at the Arapahoe County Hospital. 2 
paralyzed. He felt dizzy at the time, but he is quite 
sure that he did not lose consciousness. When he was 
brought to the hospital a few hours later, he seemed 
confused, but realized vaguely what was going on. His 
temperature was 98°, pulse 80, respirations 30, and 
there was incontinence of urine. He remained in about 
the same condition for four or five days, with normal 
temperature, total motor aphasia, and with complete 
paralysis on the left side, and nearly complete on 
the right side. At the end of this time he seemed 
brighter, and I had the following account of his condi- 
tion recorded: 
The mental condition seems to be good. The apparent 
mental dulness is partially caused by the motor aphasia, 
which is complete, as he is unable to utter the simplest 
monosyllable. The right leg is almost completely 
paralyzed. He is able to slightly flex and extend the 
right foot, but it is impossible for him to raise the foot 
from the bed. The flexors and extensors of the right 
knee and hip are extremely weak. Every muscle of the 
left leg is completely paralyzed and the knee-jerks are 
absent. The plantar reflexes on the right are slight, and 
for the great toe only, and on the left are absent. There 
is no ankle-clonus and the cremaster and abdominal re- 
flexes are absent. The trunk muscles are weak, but not 
completely paralyzed, and the diaphragm acts well. The 
left arm and hand are entirely powerless ; the right hand 
registers 48 on the dynamometer. The right-arm mus- 
cles are weak, but stronger than those of the leg. The 
deep reflexes are increased and most marked in the 
biceps muscle. The man has lost control of the sphincters 
of the bladder and anus. The muscles of the left side 
of the neck and face are paralyzed; those of the right 
side are weak. He is able to open and close the eyes 
and to frown. He can only protrude the tip of the tongue. 
Tactile sense, even over the external genitalia and 
around the anus, is well preserved. Although he seems 
a little slow in recognizing the contact of a substance, 3 
this delay may be only apparent on account of his in- 
ability to talk. The senses of temperature, pain, pos- 
ture, and localization are normal, but the pressure-sense 
seems a little deficient on the right side. Smell, taste,, 
and hearing seem nearly normal. 
The right pupil is regular and normal in size, and reacts 
to light and in accommodation ; vision is good and the 
fields are preserved ; there is no disturbance of any of 
the external ocular muscles; vessels, disc, and fundus 
present a normal appearance. The condition of the left 
eye is about the same as that found in the right eye. On 
account of the loss of control of the vesical and anal 
sphincters, the tactile sense was repeatedly tested over 
the external genitalia and around the anal region, but it 
was always found normal. 
A few days after his admission into the hospital his 
temperature, which had before been normal, rose to ioi°, 
and remained above normal four or five days, one even- 
ing registering 102°. 
The condition of the man from the time of his admission 
to the present has shown a gradual improvement, especi- 
ally in the power of walking. His speech is very much 
improved, and the side that was totally paralyzed has 
gained considerable power, but the bladder has never 
entirely regained its function. He is able to control the 
sphincter ani, and sometimes for several days at a time 
he is able to control the bladder; at other times he is 
totally unable to prevent the bladder from involuntarily 
emptying itself. 
I will examine him again to day. He has fair power 
in the right leg, and uses it quite well. His gait is ex- 
ceedingly awkward. The left leg is moved in a very un- 
gainly manner, and in walking backward the left foot 
drags. He walks very much better forward than back- 
ward. The imperfect gait is due to muscular weakness 
and rigidity, and to lack of confidence in his ability to 
control his leg-muscles. You notice that his gait is dif- 
ferent from that found in a person suffering from poste- 4 
rior spinal sclerosis. Whilst there is some incoordina- 
tion in his gait, it is of a jerky character and is due 
largely to increased muscular irritability, and to contrac- 
tures that have taken place in the flexor muscles of the 
legs, especially on the left side. He experiences little 
difficulty in standing with his feet close to each other, 
and on closing his eyes the difficulty is only slightly in- 
creased. Turning around makes him decidedly dizzy. 
The right knee-jerk is greatly increased, the left still 
more increased. On the left side several contractions of 
the rectus femoris muscle occur from once tapping the 
patellar tendon—a rectus-clonus. Ankle-clonus is absent 
on the right; present on the left. There is increased 
irritability, both of the anterior and posterior tibial 
groups of muscles on the left side, causing “ paradoxical” 
contraction of the tibialis anticus when the left foot is 
forcibly dorsally flexed. The plantar reflexes on the 
right side are absent on the inner side of the foot and 
are slight on the outer; on the left they are nearly the same. 
The cremaster and lower abdominal reflexes are absent. 
The epigastric reflex is decided on both sides. The 
deep reflexes of the arms are slightly increased on the 
right side, and on the left are decidedly increased. The 
muscular power in the right leg is fairly good ; in the left, 
rather weak. The dynamometer on the right registers, 
130; on the left, 112, so that muscular power is pretty 
good, even in the left hand, with which he was unable to 
move the register of the dynamometer at all when he 
entered the hospital. The muscles of the face show but 
little weakness. The tongue is protruded fairly well now, 
although for several weeks he was unable to get it far 
beyond the teeth. The pupils react to light and in 
accommodation, and are equal in size. The sensory 
functions, including the special senses, are all preserved. 
His speech is perfect now, but his mental power is slow. 
I wish to study this case with you somewhat in detail, 
as it presents many interesting features, both as to the 
seat and nature of the lesion. With the exception of head- 5 
ache and mental dulness, which antedated the paralysis 
for about a month, and dizziness, which immediately 
preceded the paralysis for only a few days, the man had 
always enjoyed good health, with the exception of syph- 
ilis four years ago, until the morning of July nth, when, 
while sitting in his chair, without apparent shock or loss 
of consciousness, his entire left side, including the face, 
became completely paralyzed. Just when the right-sided 
partial paralysis came on he is not aware, but it probably 
was almost simultaneous in its onset with that of the left 
side, as both sides were affected on his admission into the 
hospital, a few hours after his attention was attracted by 
the paralysis of the left side. He had incontinence of 
urine and feces, and was unable to speak, although he 
was conscious. 
The question naturally arises : Where are the lesions 
situated that would give rise to these symptoms ? Are 
they in the brain, the cord, or the peripheral nerves, or 
are all these involved ? The paralysis of the left side of 
the face, and the paresis of the right side, as shown by 
his inability to protrude the tongue, and the affection of 
speech, demonstrate conclusively that the brain is in- 
volved. 
What evidences have we of a cord-lesion? In all 
cases attended with incontinence of urine and feces due 
to central nervous lesion, unassociated with loss of con- 
sciousness or dementia, we naturally expect to find the 
lesion in the spinal cord. 
We can exclude myelitis in this case, because the tac- 
tile, pain, temperature, muscular, localization, and pos- 
ture senses are all normal. Tactile sense has repeatedly 
been tested over the external genitalia and around the 
anal region, and at each examination it has been found 
normal. 
In poliomyelitis there would be no incontinence of 
urine if the case were uncomplicated; and what is of 
more significance, in excluding poliomyelitis, we have 
the presence of increased myotatic irritability in muscles 6 
hat were, a few weeks ago, absolutely paralyzed, and 
are at present paretic. The absence of muscular wast- 
ing and the presence of electric irritability to the faradic 
current also aid in excluding poliomyelitis, as well as 
myelitis. 
Multiple neuritis of alcoholic origin is occasionally 
attended with incontinence of urine, and perhaps with 
an increased knee-jerk, while, possibly, ankle-clonus may 
be present in some cases. 
This man has been addicted to the use of alcohol, but 
he never drank steadily or heavily. One of the chief 
features of multiple neuritis is its symmetry. From the 
start this case has been asymmetrical. There has been 
absolute paralysis of the left side, including the face, arm, 
and leg, with incomplete paralysis of the right side. 
Other points against multiple neuritis even of alcoholic 
origin are : involvement of the trunk and face-muscles ; 
the affection of speech, with inability to protrude the 
tongue; the absence of the psychical disturbances so 
common in alcoholic multiple neuriti^; and the main- 
tenance of muscular nutrition, which is never found in 
any case of multiple neuritis, no matter what its cause 
may be. The paralysis of multiple neuritis never comes 
on suddenly, as it has in the present instance, and this 
disease is usually attended with sensory perversion, all 
symptoms being most marked at the distal portion of 
the extremities. 
After a careful review of all the symptoms presented 
by our patient, both now and throughout his illness, I 
feel justified in excluding multiple neuritis and disease 
of the spinal cord. Our patient must be suffering from 
multiple brain-lesions which are bilateral. Will bilateial 
brain-lesions account for all the symptoms presented by 
this patient ? 
One hemisphere of the brain controls the muscles of 
the opposite side of the body concerned in movements 
of a higher or more differentiated character, and, to a 
certain extent, the muscles on both sides of the body, 7 
which usually act in association with each other. The 
muscles that are most highly differentiated in their func- 
tion from those of the opposite side of the body are those 
of the hand. The best types of bilaterally acting mus- 
cles are those of respiration, mastication, and those that 
move the eyes; therefore, a motor-paralyzing lesion of 
one side of the brain may cause absolute paralysis of the 
unilaterally-acting muscles of the opposite side of the 
body, and a slight weakness of the bilateral muscles of 
both sides. Such a lesion, unassociated with shock, un- 
consciousness, or mental disturbance of any kind, does 
not produce incontinence of urine or feces. 
Sudden bilateral lesions of the brain occasionally 
occur, but they are usually unequal in their severity on 
the two sides of the brain. I see no reason for not at- 
tributing the incontinence of the sphincters of the blad- 
der and anus to a bilateral brain-lesion. 
Granting, then, that we have bilateral brain-lesions, it 
will be more convenient, in the present instance, to con- 
sider their location before trying to determine their 
nature. In all cases of sudden bilateral brain-lesions, 
our first thought is that the pons or medulla is implicated. 
The cranial nerves affected in our patient are the hypo- 
glossal, making it impossible for him to protrude the 
tongue, and that portion of the facial, or seventh pair, 
distributed to the lower portion of the face. A sudden 
lesion in the nuclei of these nerves in the medulla must 
necessarily involve the nuclei of other cranial nerves, 
especially of the fifth, sixth, and eighth, adjacent to the 
facial nuclei, and of the ninth, tenth, and eleventh, which, 
are found close to the nuclei of the hypoglossal. Besides, 
such an extensive lesion must involve all the nuclei of the 
facial, thus affecting the upper as well as the lower por- 
tion of the face. Absolute paralysis of the same side of 
the face as of the body, with the upper portion of the face 
escaping, places the lesion above the middle of the pons. 
A lesion in the upper portion of the pons, causing 
paralysis of the opposite side of the body, will most 8 
invariably affect the fifth nerve on the side of the lesion, 
and when the lesion is bilateral in this portion of the 
pons, sudden and extensive enough to give rise to the 
extensive paralysis found in this case, it seems impos- 
sible for the fifth nerve to escape. A lesion in the crura 
would affect the third nerves, so that we may conclude 
that the lesions that have caused the symptoms pre- 
sented by this man, are situated in the cerebral hemi- 
spheres. In the cerebral hemispheres, bilateral lesions, 
or a unilateral one, giving rise to motor paralysis on both 
sides, or on one side of the body, as the case may be, may 
occur in the internal capsule, in the centrum ovale, or in 
the cortex. Sudden occlusion of the large branches of 
the middle meningeal arteries on each side of the brain, 
sufficient to give rise to bilateral paralysis of the face, 
arm, and leg, would be attended by convulsions, pro- 
found unconsciousness, marked disturbance in tempera- 
ture, and probably speedy death. It is rare, even in 
unilateral sudden cortical lesions, that they are so ex- 
tensive as to involve the whole of one side of the body. 
Lesions of the centrum ovale, causing bilateral par- 
alysis, are exceedingly rare. When they occur near the 
cortex they give rise to symptoms simulating those of 
cortical lesions, and when near the basilar ganglia, 
symptoms very much like those of lesions occurring 
from injury to these ganglia. It is not always possible 
to differentiate them ; neither is it necessary for any prac- 
tical purposes, except in a few rare instances. We must 
conclude, then, that the lesions in the patient whose case 
we are considering, are in the internal capsules, or in the 
white substance near them, but more probably in the 
former situation. 
We shall next consider the probable nature of this man’s 
lesions. For this purpose brain-lesions may be divided 
in regard to duration of onset into sudden, acute, and 
chronic. The chronic lesions that we need to consider 
to-day are morbid growths, aneurysm, and chronic ab- 
scess. The first two of these may be excluded by the 9 
history and the absence of optic-nerve inflammation and 
resulting atrophy. Chronic abscess is excluded from the 
history and the absence of a cause. The acute lesions 
are inflammatory in their nature, are several days, or 
longer, in reaching their height, and are attended by a 
rise in temperature. The absence of temperature-eleva- 
tion, and the sudden onset of the paralyzing lesions in 
the patient before us, enable us to exclude inflammation. 
The onset of our patient’s trouble was sudden, and the 
lesions reached their height in from a few minutes to a 
few hours. All such lesions, excluding traumatism, are 
vascular in their nature. 
The diagnosis then rests between embolism, hemor- 
rhage, and thrombosis. In young subjects the chances 
are in favor of embolism, as against hemorrhage, with 
the presence of endocardial disease or syphilis, except 
when the apoplectic symptoms are severe, especially 
with prolonged and profound coma. The less the pri- 
mary disturbance of temperature, in the majority of 
cases, the less likely is the lesion of a hemorrhagic 
nature. 
It seems to me that in all cases of sudden and exten- 
sive paralyzing lesions of the brain, not attended with un- 
consciousness and deepening coma, and with but slight 
disturbance of bodily temperature, a hemorrhagic lesion 
can be excluded. Slight hemorrhages may occur sud- 
denly, with but little variation of temperature ; so also 
may large, gradually-increasing hemorrhages take place 
without great affection of consciousness or bodily tem- 
perature at first. This man’s paralysis was extensive 
from the first; therefore, from the symptoms that he pre- 
sented at the time of admission into the hospital, we are 
justified in excluding hemorrhage. The age of the 
patient is more in favor of occlusion of a cerebral vessel 
than of rupture, but we must bear in mind that the 
youth of a patient is never very strong evidence against 
cerebral hemorrhage. 
Gowers (International Medical Magazine, October, 10 
1893) implies that a hemorrhagic brain-lesion in the 
substance of the brain in the young is always fatal. 
This may be so, but I think I have seen at least one ex- 
ception. 
Having excluded hemorrhage, we have left to con- 
sider embolism and thrombosis. We are not justified 
in diagnosticating embolism unless we can find a source 
for the embolus outside of the cerebral circulation. In 
the vast majority of cases of embolism the embolus is 
caused by an old or recent endocarditis, a vegetation 
washed from the endocardium or from the valves of the 
cardiac orifices. 
In our patient there is no history of cardiac trouble, 
and on careful auscultation no murmur is found over the 
heart. We must remember that it is possible to have 
slight vegetations attached to the cardiac orifices, and yet 
no murmur be discoverable. This is most likely to be 
met with several months afte r the acute cardiac inflam- 
mation. But, even in such cases, there is commonly a 
history of heart-trouble. In certain profound blood- 
changes there may be a tendency to coagulation of the 
blood in distant portions of the body, and a clot thus 
formed may reach the brain and occlude one of the main 
arteries. The only blood-change in the patient before us 
is due to syphilis, but this has not been very marked, as 
his color seems fairly good. Having failed to find a 
source of embolism we are justified in excluding it. 
There are, however, two other reasons for dismissing 
embolism: the bilateral character of the lesions in the cere- 
bral hemispheres, and the preservation of consciousness 
at the time of the occurrence of such extensive paralysis. 
Excepting in cases of involvement of the basilar artery, 
the brain-symptoms from cerebral embolism are usually 
unilateral. When a vessel is occluded by an embolus, 
the occlusion takes place suddenly without premonitory 
symptoms, and if the vessel involved is a large one, con- 
sciousness is necessarily lost. 
Having excluded the probability of hemorrhage or 11 
embolism in this case, let us see if the indications of 
thrombosis are sufficiently well-marked to justify such a 
diagnosis. Thrombosis is generally preceded by distinct 
premonitory symptoms. These were fairly well-marked 
in our patient, and consisted of headache and mental 
dulness for a month or more, and dizziness for a few days 
immediately preceding the onset of the paralysis. The 
occurrence of extensive paralysis without loss of con- 
sciousness is rather in favor of thrombosis than of em- 
bolism. The rise of temperature that occurred in this 
patient several days after his admission into the hospital, 
usually occurs in most cases of extensive occlusion of 
the cerebral arteries, due either to embolism or throm- 
bosis. 
Having arrived at the diagnosis of cerebral thrombosis, 
let us extend our inquiries further, to determine, if possi- 
ble, the nature of this condition. A thrombus may 
form in one of two ways: first, by coagulation of blood 
in the vessel at the point at which the thrombus forms, 
from profound blood-changes, as in cases of marked 
anemia, great blood-deterioration from the syphilitic virus, 
and from vitiated blood-states from various other causes ; 
and secondly, from changes in the walls of the vessels, 
also at the site at which thrombotic occlusion takes 
place. In considering the subject of embolism, we found 
no reason to suspect an undue tendency in this man’s 
blood to coagulation; therefore, we must attribute the 
cause of the thrombosis to changes in the arterial walls. 
There are only two forms of disease of the arterial 
vessels that favor occlusion of the arteries that go to the 
great ganglia at the base of the brain. These are atheroma 
and syphilis. Atheroma is essentially a senile change, 
and probably rarely, if ever, occurs in a person as young 
as the man before us. We have, then, narrowed our 
diagnosis down to thrombotic occlusion of the arteries 
supplying the great ganglia at the base of the brain, and 
especially of those that carry blood to the anterior two- 
thirds of the posterior half of the internal capsules ; and 12 
this condition we have seen is due to syphilitic disease 
in the walls of these vessels. The changes that take 
place in vessels affected with syphilis consist in gum- 
matous deposits, inflammation, swelling, and in conse- 
quence a narrowing of the caliber of the vessel at the 
point affected. Often the inner surface of the vessel at 
the seat of narrowing is rough, and thus the formation 
of a clot at this point is still further favored. The most 
marked changes take place in the larger arteries at the 
base of the brain, but the lessening of the caliber of 
the vessels is most pronounced in the smaller arteries 
given off from the main branches. Sometimes the 
narrowing goes on gradually, almost to the point of 
occlusion of the caliber of the vessel, but finally com- 
plete occlusion by the formation of a clot takes place 
suddenly. 
If you bear in mind the essential difference between 
embolism and thrombosis, it will not be difficult for you 
to account for the difference in the onset of the symptoms 
in the two processes of arterial occlusion. In embolism, 
up to the time of the lodgment of the plug in the vessel, 
the cerebral circulation had been perfectly normal, and 
no premonitory symptoms precede the arterial occlusion. 
In thrombosis, on the other hand, the arterial blood- 
supply to a portion of the brain has been gradually 
lessening for weeks or months, and premonitory symp- 
toms, in proportion to the diminished blood-supply, are 
the result. In some cases these are slight, and unless 
diligent inquiry into the previous health is made, will be 
entirely ignored by the patient; whilst in other cases 
they are pronounced, and often consist of temporary 
numbness, paresis, or paralysis, with or without aphasia. 
Headache, mental dulness, and dizziness are often well- 
marked, as they were in our patient. 
The result of thrombotic occlusion of a vessel is ne- 
crotic softening of the part supplied by the occluded 
vessel. When a large vessel is occluded, extensive 
softening will take place unless the circulation to that 13 
part of the brain is restored by collateral vessels. In the 
great ganglia at the base of the brain the nutrient arte- 
ries of these ganglia do not communicate with the arte- 
ries from the cortex, and in consequence, if the affected 
vessels are completely and permanently occluded, the 
softening will be complete, and the function of those 
areas of the directly-affected ganglia will be permanently 
lost. Fortunately, however, the vessels that are usually 
occluded in thrombosis at the base of the brain, in 
the neighborhood of the great ganglia, are often the 
smaller ones, so that the softening is not extensive. In 
all such cases the primary paralysis is more extensive 
than the permanent loss of power. 
The prognosis in a case of thrombosis, other things 
being equal, is always worse when the trouble is bilateral 
than when it is unilateral. The immediate prognosis, or 
the chances of the patient escaping with his life, need 
not be considered here, as this man has passed this stage. 
What are the probabilities of his permanent recovery ? 
It is unnecessary for me to go into all the elements that 
guide us in such an opinion, but let it suffice for the 
present for me to state that when ankle-clonus, exagger- 
ated knee-jerk, and other evidences of increased myo- 
atic irritability, with contractures of the flexor muscles 
of the extremities, are present, we have positive evi- 
dences of degeneration of the lateral columns of the cord, 
and neither a fair recovery nor marked improvement 
can take place. 
The treatment of this case consists largely in making 
the man as comfortable as possible, encouraging him to 
go around on his crutches, but not allowing him to get 
fatigued ; paying attention to the condition of the bladder, 
and trying to combat the affection of the arteries in order 
to prevent a recurrence of thrombosis. 
In considering the treatment of syphilitic arteritis, it is 
necessary to bear in mind that the nodular deposits that 
take place chiefly in the outer and inner coats of the 
vessel are of slow and gradual growth, the caliber of the 14 
vessel being narrowed more and more, until finally the 
vessel is occluded by clotting of the blood in the diseased 
vessel. The deposition in the walls of the artery is a 
specific process, and to a greater or less extent is influ- 
enced by anti-syphilitic treatment, but the clot that finally 
occludes the vessel is a non-specific process, and is but 
little, if at all, influenced by mercury and potassium 
iodid. When thrombosis occurs in a syphilitic subject, 
the thrombus and the resulting softening take the same 
course in spite of active, specific treatment, that we find 
to occur in occlusion of a vessel from atheroma; there- 
fore the outlook, so far as the brain-injury is concerned, 
is no better than in the case of a similar injury due to 
embolism, hemorrhage, or atheromatous thrombosis. 
Please remember that the occluded vessel or vessels in a 
case of thrombosis due to syphilis is not the only vessel 
diseased, but that in all probability many of the vessels at 
the base of the brain are similarly affected, but to a slighter 
degree. Your course of treatment then must not be an 
expectant plan, but you should endeavor to prevent other 
vessels from becoming occluded. The time when anti- 
syphilitic treatment is most effective, both in relieving 
the patient from present symptoms and in averting a 
hopeless paralysis, is when the premonitory symptoms 
first manifest themselves. 
In what must this treatment consist ? In the ad- 
ministration of mercury and' potassium iodid only? 
No. I believe that we often fail in accomplishing 
the object of our treatment in syphilitic cases by sole 
reliance upon these two agents. We must remember 
that most persons who are suffering from the chronic 
effects of syphilis are in an impoverished state of 
health; therefore it is often necessary to administer 
iron, quinin, arsenic, together with the most nutritious 
food, in order to get the desired effects of mercury and 
potassium iodid. I have seen syphilitic subjects who 
had failed to improve after weeks of active treatment by 
these agents, begin to feel better, and lose one symptom 15 
after another on the same doses of potassium iodid and 
mercury that they had taken ineffectually for weeks be- 
fore, after their general health had been improved by a 
tonic course of treatment. In syphilitic arteritis the 
large doses of potassium iodid that are so effectual in 
gummatous tumors of the brain are not only uncalled 
for, but they may be positively harmful by depressing 
the patient, impoverishing the blood, and thus favoring 
coagulation in the diseased arteries. The Medical News. 
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