SPINAL ANAEMIA 
DUE TO 
SYPHILIS. 
BY 
ORVILLE HORWITZ, M.D., 
Demonstrator in Surgery, Jefferson Medical College; Surgeon to the 
Philadelphia Hospital. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, APRIL zj, 1892. 
DETROIT, MICH. : 
GEORGE S. DAVIS, PUBLISHER. 
1892. SPINAL ANEMIA DUE TO SYPHILIS- 
AS our knowledge of this affection is to a 
great extent of recent date, beginning, it 
is believed, with the monographs of Gross, Lan- 
cereaux, Layneau, and Zambaco, who, during 
the years 1860-61, first called the attention of 
the profession to syphilis of the nervous sys- 
tem, it is presumed that it will not be unin- 
teresting to present to the reader such obser- 
vations as I have been enabled to make, and 
the deductions that I have drawn, while 
having under my care six cases of the 
disease. 
It is to be regretted that I can offer but 
little that is new respecting the pathology of 
this affection, for the reason that I was una- 
ble to obtain post-mortem examinations of 
those who died, save in one case ; yet I trust 
that a study of these cases will demonstrate 
that much can be done besides following the 
usual specific treatment, which, I believe, in 
some stages of the disease, to be harmful, and 
to be avoided. 
During the past nine years I have had 
under observation but six cases of spinal 
anaemia occasioned by syphilis, and as I have 
had an unusual opportunity for seeing large 
numbers of patients afflicted with all forms of venereal disease, it is natural to infer that 
it is not a common sequel to this disorder. 
Of the six patients under observation, four 
were women. That spinal anaemia more fre- 
quently occurs in females than in males is 
well known, but why this law should apply to 
syphilitic subjects is not readily understood. 
The cause of the anaemic condition appears to 
be due to certain changes which take place in 
the coats of the artery supplying the cord. 
The question naturally arises whether these 
vessels are more predisposed to the changes 
referred to in the female than in the male. 
From the limited number of cases that came 
under observation, it would not be wise to 
infer that the disease really occurs more 
frequently in one sex than the other. 
Syphilitic diseases of the nervous system 
are more apt to be developed in individuals 
of either an hereditary or acquired neuro- 
pathic constitution. 
The patients were all addicted to the abuse 
of alcoholic stimuli; they all indulged in ex- 
cessive sexual intercourse ; all suffered more 
or less mental strain, and led very irregular 
lives ; one was an opium-eater. It is not 
astonishing, then, that a nervous type of 
syphilis was developed in these cases. 
The pathological condition can only be 
one of surmise, which is in a measure due to 
the fact that the symptoms are excessively 
slow in developing themselves, and that the 
disease is exceedingly chronic in its progress. 
The patient will sometimes lie for years in 
a semi-paralyzed state, when the original 
cause of disease will be well-nigh lost sight 
of; the poor creature possibly dying of 
2 3 
some intercurrent affection. During the long 
period that the sufferer has been under treat- 
ment he has necessarily been from time to 
time under the care of numerous physicians, 
the history of the case is lost, and there will 
be no one especially interested in it, when at 
last death ensues. 
When a post-mortem examination is finally 
made, the spinal cord will most probably be 
overlooked, neglected, and not subjected to 
examination ; that its careful investigation is 
attended with more difficulties than any other 
portion of the body will probably explain 
why its examination in the dead-room re- 
ceives so little attention by the investigator. 
Inflammation of the coats of arteries fre- 
quently follows as a result of syphilis ; no 
part of the arterial system being exempt, and 
of course the most serious consequences must 
follow the involvement of the vessels of the 
brain and spinal cord. 
The greatest danger to life is when the 
minute ramifications of the small vessels sup- 
plying the nervous system become involved ; 
the canals of these arteries becoming almost, 
and, in some cases, completely occluded, thus 
cutting off the blood supply to the very centres 
of life. 
As the calibres of the vessels dwindle, and 
the blood-supply becomes inadequate for the 
nourishment of the nervous substance, it, as 
a result, undergoes softening, which, when 
examined after death, is often erroneously 
ascribed to a syphilitic inflammatory condi- 
tion of the cord or its membranes ; whereas 
the changes in the cord are really due to 
ansemia, produced by the alterations that have taken place in the vessels of the pia 
mater, the real cause of mischief being over- 
looked. 
A detail of the case about to be cursorily 
presented will serve as an illustration : 
I. R., aged 40, retired merchant, married, 
gives the following history : He had a severe 
outbreak of syphilis when twenty-two years 
of age, for which he was under treatment for 
the space of ten months, when he was pro- 
nounced by his attending physician entirely 
cured. During the next few years, however, 
he had several attacks of tertiary syphilis, for 
which he underwent treatment by different 
physicians. He had been free from any 
manifestations of disease for two years pre- 
vious to my first seeing him, when he began 
to suffer from pains in the back, legs, and 
arms of a dull, aching character, which were 
worse at night. Coincidently with the pains 
were progressive emaciation, loss of strength, 
and finally complete paralysis of the lower 
extremities. This was his condition one 
week before his death, when first seen by 
me. He died from marasmus. 
Autopsy twelve hours after death. 
Rigor mortis marked ; great emaciation; 
large bed-sore on lower portion of back. 
Contents of cranial, thoracic, and abdom- 
inal cavities normal. 
The Cord.-The lower dorsal and upper 
portion of the cord was very soft and flat- 
tened. The gray matter was of a dark color. 
The pia mater, removed from about the dis- 
eased portion of the cord, appeared normal, 
but on subjecting it to the microscope, the 
vessels were seen to be enormously thick- 
4 ened, degenerated, and in parts completely 
occluded ; others gave evidence of fatty de- 
generation. 
The portion of the pia mater just above the 
softened portion of the cord showed evidence 
of inflammatory changes having taken place, 
such as occur in the earlier stages of the 
affection, and tallied exactly with the descrip- 
tion given by Heubner of the changes that 
ensue in the cerebral arteries under the in- 
fluence of syphilitic poisoning. 
This case clearly proves that the altera- 
tions that occur in the pia mater cannot be 
observed without the aid of the microscope ; 
for to the unaided eye the membranes looked 
entirely normal. Had a study of the mem- 
branes not been made, the changes would 
have been ascribed to a specific inflamma- 
tion of the cord or its coverings. 
How far changes in the vessels which sup- 
ply the cord are the primary causes of many 
cases of spinal syphilis it is impossible to de- 
termine without more extended observation. 
I think, however, that it is much more fre- 
quently the starting-point of specific spinal 
trouble than has hitherto been suspected. 
The microscopical study of the diseased 
pia mater may be divided into that por- 
tion of the membrane which lies immedi- 
ately above or below the softened mass, and 
that portion which surrounds the diseased 
cord. 
The difference between the two portions of 
the membrane was very marked ; that re- 
moved from the healthy part of the cord 
showed the changes which occur in the acute 
stage of inflammation, whereas the other por- 
5 6 
tion was in the condition usually associated 
with a part chronically inflamed. 
The pathological alterations may be di- 
vided into the stage of congestion, that of 
acute inflammation, and if the process con- 
tinues, into that of chronic inflammation. 
The process is essentially very slow, con- 
tinuing over a period of months, and even 
years, before the calibre of the vessels be- 
come so occluded that the nourishment to the 
cord is sufficiently interfered with to produce 
softening. In the specimen which showed 
the disease in its earlier form, it was found 
that the structure consisted almost entirely of 
a new cell-growth, which had not undergone 
organization to connective tissue. 
In the second specimen, the embryonic tis- 
sue had become organized into fibrous con- 
nective tissue, and not only had the walls of 
the vessels become enormously hypertrophied, 
but the contraction of the new-formed con- 
nective tissue had in most cases almost, and 
in some cases completely, occluded the tube 
of the arteries. 
The principal changes were found in the 
intima, while the external coat was nodular 
and thickened; the elastic coat was very 
slightly altered from its normal condition. 
It was somewhat wrinkled ; probably due 
to the contraction of the newly-formed con- 
nective tissue. 
It is probable that at first very few vessels 
are involved, hence the slow development of 
the symptoms ; the inflammation, too, is not 
of an active type, even in the first stages. 
The changes in the structure of the arteries 
involved takes place very slowly, hence a long time is consumed before any secondary 
modifications take place in the cord. It, fur- 
thermore, shows that if a perfect cure is to 
accrue, it must be effected during the first 
stage, for after the arteries have become 
blocked, and the vascular supply to the cord 
permanently interfered with, the patient 
either becomes a hopeless paralytic or, what 
frequently happens, dies from exhaustion, if 
not from some intercurrent disease. 
I am inclined to agree with Wyeth that 
the cause of syphilitic arteritis is the inflam- 
matory poison, travelling in the line of the 
blood-current through the vasa vasorum, al- 
though the direct irritation of the passage of 
the poisoned blood upon the endothelium, 
which Heubner believes to be the cause of 
the changes which take place in the vessels, 
may also act as a factor in lighting up the 
low grade of inflammation. 
Of the six cases that came under observa- 
tion, four belonged to the lowest walks 
of life ; they were addicted to the abuse 
of alcoholic liquors and to all manner of 
excesses. 
The disease does not appear to be developed 
until late in the tertiary stage of syphilis ; 
the following gives the period of development 
in each case after the initial lesion : Three 
and a half years, four years, five years, seven 
years, eight years, and sixteen years. 
The earliest symptom is a loss of desire for 
any mental effort, and should the patient at- 
tempt to use his brain, it usually results in a 
confusion of ideas, and he experiences a 
feeling of mental and physical exhaustion. 
He is tormented with insomnia, though at 
7 8 
times the sleep is deep, heavy, and prolonged, 
from which condition he will wake up unre- 
freshed, and unable to make use of any men- 
tal or physical effort ; as one of the victims 
expresses it, as " though he were a dead 
man." 
The slightest emotional excitement, such 
as anger or apprehension, produces trem- 
bling of the limbs, especially of the hands, 
which shake as though the patient were suf- 
fering from paralysis agitans. When the ex- 
citement wears off, the hands continue to be 
unsteady. 
Very soon an irritating twitching of certain 
muscles of the body is observed, especially 
those of the thighs, back, legs, and arms, be- 
ginning in the order named. The tensor 
vaginae femoris, the quadriceps extensor 
femoris, and the muscles of the back were 
usually the first to become affected. This 
condition ordinarily obtained when the pa- 
tient was in the recumbent posture. It was 
especially the case at night. It was absent 
or unobserved when the individual was sit- 
ting up, and when.the mind was more or less 
diverted from his ailments; the twitchings 
appeared to be increased when lying on the 
back, and were modified or absent when 
resting on the side. 
Excesses of any kind, whether over- 
indulgence in the use of tobacco, alcohol, 
or sexual intercourse, increased the nervous 
twitchings, and filled the mind of the patient 
with alarm. 
The general feeling of discomfort is very 
distressing ; it is usually accompanied by a 
sensation of fatigue in the lumbar region ; at first this is noticed after unusual exertion or 
fatigue, but it soon becomes constant, and is 
readily brought about by violent and jolting 
exercise, such as riding over rough roads and 
the like. 
This feeling of discomfort is greatly re- 
lieved by flexing the legs upon the thighs, 
and by placing a pillow under the back ; and 
great comfort is experienced by resting on 
the side and drawing the knees up towards 
the abdomen. 
Soon the patient begins to lose flesh, is 
weak, dispirited, irritable, and hysterical ; 
limbs subject to alternations of feelings of 
heat and cold ; face frequently becoming 
flushed without any apparent cause. 
One patient exhibited a curious perver- 
sion of sensation ; from being naturally very 
sensitive to cold, he passed to the other ex- 
treme, and suffered greatly from a feeling of 
oppressive heat, so that having had all his 
life to clothe himself in the heaviest under- 
wear, he found that even the lightest gauze 
shirt in midwinter was oppressive. 
The evolution of these symptoms seemed 
to occupy a period varying from six months 
to a year, and probably corresponded with 
the early changes that were taking place in 
the coats of the arteries of the pia mater ; 
and is possibly due more to some disturbance 
in the circulatory apparatus than to a diminu- 
tion in the calibre of the vessels supplying the 
cord. 
The similarity of the symptoms of this 
stage of the disease to those observed in 
nervous prostration or spinal neurasthenia is 
readily noticed. 
9 Case II. is typical as illustrating the symp- 
toms of this disease. This person had been 
an inmate of the Venereal Ward of the Phila- 
delphia Hospital on four previous occasions ; 
had contracted syphilis eight years previous 
to her last admission ; the tertiary symptoms 
were well developed a year and a half after 
the appearance of the initial lesion. She had 
been under treatment at irregular intervals. 
When the outbreak was slight, she was pre- 
scribed for at a dispensary; when more 
severe, she resorted to a hospital. In the 
intervals, she led a fast life and drank to 
excess. 
She stated that two years previous to her 
last admission she noticed that she was 
losing strength, that she was easily fatigued, 
that she was beginning to suffer from hebe- 
tude, that she took little or no interest in 
anything, that she felt a continual desire to 
sleep, and that she awakened unrefreshed, 
with a dull headache, usually located in the 
back part of her head. She began to expe- 
rience what she described as a " weak back." 
She had a constant sense of fatigue, which, 
very slight at first, increased on exertion, 
until finally it was constantly present, and 
assumed the form of a dull, aching pain, 
which increased to such an extent that she 
could with difficulty retain the erect posture 
longer than half an hour at one time. The 
pain increased when she reclined on herback, 
and to obtain relief it was necessary to lie on 
her side, with her knees drawn up. She had 
lost flesh and strength, was pale, and suffered 
frequently from palpitation of the heart, pro- 
duced by any trifling exertion, or any slight 
10 11 
disturbing cause. She suffered from consti- 
pation ; her menstruation was scanty, and 
frequently absent. Twitching of the muscles 
of the thigh and back began to annoy her ; 
her hands became tremulous, and any agita- 
tion would so increase the shaking that she 
could with difficulty retain her hold on any- 
thing. She would frequently break out in 
profuse perspiration. 
She had been under the care of numerous 
physicians, whose diagnoses widely differed, 
one giving it as his opinion that she was suf- 
fering from nervous prostration, others that 
her troubles were due to uterine disturbance, 
and others, again, that she was suffering from 
marasmus. 
Deriving no benefit from the treatment to 
which she had been subjected, she applied 
for admission into the Philadelphia Hospital, 
and was received in the Venereal Ward, where 
she remained six months, when she was dis- 
charged at her own request, having gained 
thirty pounds in weight, her general health 
greatly improved. She returned to her life 
of dissipation. 
The advance from the first to the second 
stage is so gradual that it is only by carefully 
comparing the condition of the patient from 
time to time that the observer comes to the 
conclusion that he is slowly and surely be- 
coming worse. He now keeps his bed, or, if 
he sits up for an hour or so during the day, 
he is very much exhausted, and gladly returns 
to the recumbent position. 
He is pale, anaemic, and wasted, has little 
or no appetite, and the food that he takes 
does not seem to nourish him. The pain, that has hitherto been present only at night, 
begins now to be felt during the day, 
until finally it is seldom or never absent; the 
administration of an anodyne becomes neces- 
sary to give repose. 
There are periods of increased pain, though 
their accessions do not appear to be due to 
atmospheric changes. Instead of being con- 
fined to the back and limbs, it is now felt 
along the subcutaneous surfaces of the more 
exposed bones, as the radius, sternum, tibia, 
etc. There is no thickening of the perios- 
teum, tenderness on touch, nor does there 
appear on examination to be any symptoms 
of inflammation. 
The pain is described as dull and aching ; 
there is often great difficulty in locating it; 
it does not follow the course of the large 
nerves. It seems to resemble the " bone 
pains" of early syphilis, but is much more 
severe. 
The joints retain their normal condition. 
The muscles respond naturally to elec- 
trical stimulation. 
Temperature is normal ; heart irritable ; 
pulse increased in frequency, generally being 
about 100 per minute. 
The urine is usually normal, though at 
times it is loaded with phosphates, a condi- 
tion often found to exist in cases of spinal 
ansemia associated with atonic impotence. 
The wasting, due somewhat to insomnia 
and loss of appetite, increases until, in the 
last stage, the patient is reduced to a skele- 
ton, when death closes the scene. 
The third case that came under my obser- 
vation at the Philadelphia Hospital presented 
12 all the symptoms of the second stage of the 
disease, which have already been given. 
She was a woman about 30 years of age, 
very anaemic, and wasted to the last degree, 
weighing not over ninety pounds. She had 
several unhealed rupial ulcers upon her 
legs and back, and a spot of superficial 
necrosis on her frontal bone. 
She stated that her health had begun to 
fail about a year and a half previous to her 
admission to the hospital. She had lost her 
strength ; had twitching of the muscles of the 
thighs ; pain in the back, frequently so in- 
tense that she could with difficulty retain the 
erect posture ; was hysterical and irritable. 
Her sense of fatigue was continuous even 
after awakening from a sound sleep. The 
pain in the bones of her legs and arms, and in 
her ribs was constant and, as she expressed 
it, "horrible." She suffered greatly from 
insomnia, which could only be relieved by 
giving her morphine in half-grain doses. 
The temperature was normal ; skin dry 
and cold ; heart normal; pulse increased in 
frequency ; no appetite ; tendency to consti- 
pation ; was hysterical and irritable. 
Keeps her bed, not having strength to sit up. 
Eye-ground normal ; urine loaded with 
phosphates. 
She was removed from the hospital by her 
friends, when the further history of the case 
was lost. 
Judging from the clinical history obtained 
from Case I., paralysis gradually supervened. 
In the case referred to, paralysis of sensation 
preceded loss of motion. The paralysis of 
the lower limbs was complete. Control over 
13 14 
the sphincters was lost for some two months 
before the patient died, proceeding appar- 
ently from exhaustion. 
At the outset the diagnosis must be made 
between this disease, incipient ataxia and 
incipient myelitis ; and, later on, from para- 
plegia, due to lesion of the cord and its 
membranes. 
In ataxia, lancinating pains, girdle pains, 
early disorders of vision, paresis of the ocu- 
lar muscles, and exaggeration of galvanic 
excitability are prominent symptoms. 
In incipient myelitis, the sudden appear- 
ances of vague neuralgia, paresis, and paraly- 
sis of the lower limbs, obliteration of sensibil- 
ity in some regions, stiffness of the joints, and 
difficulty of movement of the body generally 
exist. 
As the disease progresses, the symptoms 
between spinal ansemia of syphilis and those 
presented by ataxia and incipient myelitis 
differ so widely that there can be no doubt 
on the part of the observer which disease he 
is called upon to treat. 
The treatment naturally divides itself into 
that to be pursued before any marked change 
has taken place in the calibre of the arteries, 
which may be denominated the first stage; 
the period when the changes in the blood- 
vessels have taken place, which is the second 
stage ; and the period when paralysis has 
fairly set in, which is the third stage. 
The first subject for consideration is diet ; 
its method of administration ; the character 
of food to be allowed ; its quantity ; and the 
intervals that should elapse between attempts 
at nourishment. All those who make a specialty of treating 
diseases of the nervous system agree that in 
cases of malnutrition, the first and most im- 
portant thing is to get the patient to assimi- 
late a proper amount of easily-digested food. 
This is often found to be the most difficult 
part of the treatment. 
From the first the patient should be placed 
upon a plan of forced feeding. As there is 
usually a loss of appetite, and, in many in- 
stances, even a disgust for food, accom- 
panied by weak digestion, it will be neces- 
sary to feed him with small quantities of 
concentrated nutritious aliment. It should, 
as a rule, be entirely liquid. It should 
be administered every second hour during 
the day, and every third hour during the 
night. 
This plan should be pursued for a period 
varying from six weeks to two months, when 
it may be hoped that the invalid will not 
only have gained in weight but in strength, 
and that he may likewise have recovered his 
normal appetite, and even have a craving for 
solid food. 
Should the stomach rebel at the frequent 
repetitions of food, or at the quantity put 
into it, the intervals of repetition should be 
lengthened, until it is ascertained by actual 
experience how much nourishment the pa- 
tient can assimilate. As the case goes on to 
improve, the intervals can be decreased and 
the amount of nourishment increased. 
Milk is by far the best article that can be 
administered ; but, to prevent the appetite 
becoming cloyed, good strong beef-soup 
should be alternated with the milk. 
15 A quart of milk and a pint of beef-soup 
during the twenty-four hours is the minimum 
amount to be given. The quantity of milk 
should be gradually increased and the soup 
decreased, until the milk diet alone is used. 
The milk should be gradually increased in 
quantity, until from three to four quarts 
daily are consumed. 
Should the milk be hot readily assimilated, 
it will be rendered more acceptable to the 
stomach by adding four ounces of lime-water 
to every pint, shaking the mixture well; then 
adding the whites of two eggs ; again shaking ; 
then sweetening to the taste, and rendering 
palatable by the addition of a tablespoonful 
of sherry. 
The diet may be varied by the use of 
"Mellin's Food" mixed with milk. A cup 
of cocoa, chocolate, or rocohout may be used 
as a substitute for the milk. 
Pure vanilla ice-cream, made of arrow- 
root and cream, home made, if possible, may 
be allowed occasionally. 
The juice of raw beef will be found to be 
a very agreeable dietetic change. It is pre- 
pared by taking a pound of lean beef, cutting 
it up, squeezing out the juice by means of a 
lemon-squeezer, adding a single clove, placing 
the cup containing the juice into a vessel of 
hot water, and letting it remain until it be- 
comes hot, before drinking. 
Koumiss may be allowed, and, for a change, 
buttermilk may be given. 
Nutrition being of the utmost importance 
in the depressed condition of the nervous 
system, the greatest attention is to be paid 
to diet, for, as soon as the general condition 
16 improves, there is a corresponding ameliora- 
tion of the nervous symptoms. 
The plan recommended should be per- 
sisted in until the patient has greatly gained 
in weight,-say ten pounds or more,-when 
there is usually a craving for solid food ; but 
the change from fluid to solid food should 
be very gradual. Only very small quantities 
of the most easily-digested substances should 
be at first allowed, gradually adding new arti- 
cles to the diet-list as the case progresses. 
The patient's appetite may be stimulated by 
allowing such digestible material as is par- 
ticularly fancied. 
If the appetite falls off, and the patient 
begins to lose in weight, he must at once re- 
turn to the method of forced feeding. 
Care must be taken to prepare no article 
of diet in the sick-room, and when the meal 
is served, it should be made to look as appe- 
tizing as possible. Every article should be 
perfectly clean, and should be served as 
nicely as the circumstances of the individual 
will permit. 
If possible, the patient should not be al- 
lowed to know of what his meal is to consist, 
nor when it is to be served. 
Stimulation is not only necessary, but is 
usually indicated. As a rule, the sick person 
is already addicted to the use of ardent spirits, 
and their continuance is a necessity. From 
three to four ounces of whiskey during the 
twenty-four hours will be sufficient; and, as 
the patient goes on to become convalescent, 
the quantity should be reduced, until, finally, 
it may be discontinued long before he leaves 
the physician's hands. 
17 18 
The use of tobacco should be allowed only 
in minimum quantities, or, if possible, be dis- 
carded altogether. It is always injurious in 
depressed forms of nervous affections. 
The previous history and the condition of 
the patient must be the guide to medication. 
Generally speaking, those who present them- 
selves for treatment have already been sat- 
urated with mercury, and their stomachs 
have lost all tone, and the power of assimila- 
tion is very poor. Usually, when the case 
first presents itself, medicine does more harm 
than good, by taking away the little appetite 
that the patient has left and producing con- 
tinued nausea. 
When, however, the digestive apparatus is 
in fairly good condition, and an active course 
of treatment has not been pursued, or if even 
the patient has been under medication, there 
will generally be indications for the renewal 
of specific treatment, as syphilitic lesions in 
some form, such as rupial ulcers and the like, 
will be found to exist. The question then 
presented is, What is the best remedy, how 
and when shall it be used ? 
If the forced feeding for the first three 
weeks has been persevered in, and the diges- 
tion has improved therefrom, then specific 
treatment may begin. 
But if the digestion has been weakened, 
either through over-medication or the abuse 
of alcoholic stimulants, good results may be 
hoped for from judicious fumigation, which 
may be resorted to daily for the space of ten 
minutes, after which the patient is to be 
wrapped in a blanket and put to bed, there 
to remain until perspiration entirely ceases. Should the perspiration produce exhaustion, 
the fumigation must be postponed to every 
other day. 
Fumigation should be continued for the 
space of three weeks, when it should be dis- 
continued and medication per os commenced. 
Should the stomach be in condition to bear 
internal treatment, the administration of 
iodide of potassium in small doses may be 
commenced. Five drops of the saturated 
solution well diluted, and taken after meals, 
may be administered. If the case progresses 
favorably, the dose should be increased to 
ten drops. If the iodide of potassium is not 
well borne, thirty drops of the aromatic 
spirit of ammonia should be added to each 
dose. 
The iodides should be continued for 
the space of six months or thereabouts, 
when mercury, in tonic doses, should be 
prescribed, either in combination with the 
iodide or by itself. This should be perse- 
vered in for another period of six months. 
As a rule, after having used the iodide for 
the prescribed time, it is well to stop it and 
have recourse to mercury, resuming the iodide 
after an interval of one month. If the pa- 
tient is found not to be losing weight, it is 
well to combine the iodide with the mercury. 
The nerve tonics, such as strychnine and 
phosphorus, are especially indicated. Strych- 
nine, administered hypodermically, grain, 
three times daily, is recommended. Later it 
may be given by the mouth, in combination 
with such remedies as have a tendency to 
produce reconstructive metamorphoses. 
Iron, though indicated, usually cannot be 
19 employed while the patient is weak and de- 
pressed, as it invariably produces headache, 
causes constipation, and deranges the diges- 
tion ; but when marked improvement be- 
comes manifest, then it is exceedingly bene- 
ficial. 
Of all the numerous preparations of iron, 
ferrum redactum, or reduced iron, is pre- 
ferred. It can be pleasantly administered 
by sprinkling together with it a little black 
pepper on a piece of well-buttered bread, 
when it will be eaten by the invalid without 
his being aware that he is taking medicine. 
The bowels should be carefully regulated ; 
a glycerin suppository, or an enema of warm 
water, will answer every purpose. 
When the. tongue becomes coated and the 
breath " heavy," a powder composed of calo- 
mel, gr. ; creosote, gtt. i; pepsine, gr. ii; 
sugar, gr. v, administered every two hours, 
and repeated until the calomel produces 
slight purgation, will usually suffice to restore 
the digestion and clear the tongue. 
Care must be taken in the administration 
of hypnotics ; their influence is but evanes- 
cent, the effect of the remedy soon wearing 
off, and augmented doses are rendered neces- 
sary. In fact, they may be considered as 
positively injurious; other methods of pro- 
ducing sleep, to be presently referred to, are 
considered preferable. 
From the first the patient should be kept 
in bed, where he should remain until he has 
gained both in weight and strength, which 
will usually occupy a period of about six 
weeks. 
At his usual hour for retiring, he should be 
20 thoroughly massaged, when he will in all 
probability drop into a natural sleep. 
In the morning he should receive a warm 
bath, and then be returned to bed, placed be- 
tween blankets, and thoroughly rubbed with a 
a mixture composed of liquid cosmoline, 3 
parts ; alcohol, 1 part; the rubbing persevered 
in until the alcohol is evaporated and the cos- 
moline, as far as possible, absorbed by the 
skin. The body should then be rubbed dry 
with a coarse towel. 
It is of the utmost importance to keep the 
spine at perfect rest. With this object in 
view, a leather jacket, braced with wire, is to be 
fitted to the body, and worn unintermittingly 
(save when the patient is being bathed or 
massaged). A plaster-of-paris jacket may be 
substituted for that of leather when it is 
necessary to take expense into consideration. 
The jacket should be worn from three to 
four months. 
In all cases of spinal anaemia, no matter 
from what cause, great benefit will be de- 
rived from suspension, practised as is done 
in cases of ataxia. At the first going off, it 
should be repeated every day, and continued 
for the space of thirty seconds. As the pa- 
tient becomes accustomed to the suspension, 
the time should be gradually increased to five 
minutes, and should be employed daily. 
The utmost gentleness must be observed 
both in elevating and in lowering the patient, 
so as not to twist, jerk, and jar the spine ; and, 
when the treatment is concluded, he should 
be put to bed, and kept at rest for at least 
one hour. This treatment to be persevered 
in for a period of from four to five months. 
21 22 
In cases of spinal anaemia, associated with 
atonic impotence, applications of ice to the 
spine have given very gratifying results, espe- 
cially when the invalid suffers greatly from 
pain in the lumbar region. In making the 
application, a spinal ice-bag is preferred, es- 
pecially when there is great pain in the lum- 
bar region. Its application should be grad- 
uated, using it at first not longer than twenty 
minutes, and gradually extending the time to 
one hour. At first the sensation is unpleasant, 
but in a short time the patient enjoys the 
feeling, and in some cases it has been found 
so grateful that he is with difficulty persuaded 
to discontinue its use. 
A spray of cold water, squirted over the 
body while standing in the bath-tub, so 
that the benefit of a needle-bath may be 
received, is very beneficial; it should be 
used for the space of about three minutes, 
and applied, preferably, over the spine. 
As the case goes on to improve, and the 
nervous symptoms are ameliorated, the leather 
jacket and the massage may be discarded, 
and in their stead the Swedish movement 
and gentle exercise with light dumb-bells 
substituted. 
As soon as the patient is strong enough to 
stand the exercise, a daily walk in the fresh 
air should be directed, going no farther than 
a single square the first day, and gradually 
increasing the distance by adding at first 
but a block each day, until the patient can 
achieve three or four miles without discom- 
fort. Much good will result from travel- 
ling abroad, if the patient can afford the 
expense. The specific treatment that has been 
pointed out should be renewed every spring, 
for the space of six weeks, to be recurred to 
for the ensuing five years. 
It is hardly necessary to add that the pa- 
tient should be warned to lead a regular and 
simple life. 
In some cases of syphilis of long-standing, 
where the patient has been for a long time 
on specific treatment, medicine seems to have 
little or no effect. In one of those that 
came under observation at the Philadelphia 
Hospital, the woman had taken as many as 
sixty grains of iodide of potassium, together 
with a twentieth of a grain of bichloride of 
mercury, three times daily, and grew pro- 
gressively worse; the old rupial sores re- 
mained unhealed, and the necrosis of the 
frontal bone was unstayed. In such a con- 
dition of affairs, it is best to stop all specific 
treatment, and turn attention to nourishing 
the patient and building up the constitution, 
when, should there be evidence of improve- 
ment, some good may be hoped for by re- 
turning to the judicious employment of spe- 
cific remedies. 
Very often patients complain and suffer 
from continuous pain in the bones, and, in 
spite of all treatment, grow progressively 
worse. The proper treatment is the careful 
employment of opium and its compounds. 
Avoid the use of chloral and the bromides, 
as in this condition they tend to produce 
nervous complications as serious as the ail- 
ments under which the patient is already 
suffering. 
When, however, the pain is not severe nor 
23 continuous, a combination of eight grains of 
antipyrin with fifteen grains of the bromide 
of ammonium, given pro re nata., will often 
act very well. These remedies, however, 
soon lose their power. 
Galvanic electricity will often give tempo- 
rary relief, but is not believed to produce 
permanent benefit. 
The faradic current is of service in stimu- 
lating the wasted muscles. It appears to be 
slightly stimulating, and has a tendency to 
produce a feeling of temporary comfort. It 
may be considered a substitute for light 
exercise. 
When paralysis supervenes, attention to 
nutrition, the condition of the patient's skin, 
bowels, and general health are the indi- 
cations. 
The prognosis in the first stages is very 
favorable, when the patient is enabled to 
enjoy the comforts of a home and has the 
means to carry out the prescribed treatment, 
which is always expensive, and will occupy a 
lengthened period of time. The outlook, of 
course, is not as hopeful for a person who is 
relegated to a general hospital ward, where 
the luxuries of home and the necessary care- 
ful treatment are not possible. That they do 
recover, however, even under these disadvan- 
tageous circumstances is apparent from the 
result of one of the cases received into the 
Philadelphia Hospital, where the woman re- 
covered health sufficiently to leave the insti- 
tution. This person returned to her life of 
dissipation, experienced a relapse, again en- 
tered the hospital, and finally died from 
exhaustion. 
24 In the second stage, where there is marked 
emaciation, attended with ansemia and great 
pain, the patient becoming slowly and pro- 
gressively worse, the outlook is most grave ; 
the poor creatures die either of marasmus, 
anaemia, or exhaustion. 
Of the six cases so frequently referred to, 
three died, one quitted the hospital by request 
in a hopeless condition, and two recovered. 
When the disease has passed to the stage 
of softening, the result, of course, is only a 
question of time. 
The tendency to relapse is marked ; indeed, 
it may be said that it is doubtful if a condi- 
tion of robust health is ever attained. It is 
probable that there is always a great suscep- 
tibility to the development of some nervous 
disorder. 
Any indiscretion in the manner of living 
will produce a relapse. After recovery, it 
will be necessary to make the art of living a 
study. The person must lead the most regu- 
lar life, keep good hours, take care not to be 
guilty of any nervous strain, indulge in no 
excesses of any kind, eschew the use of alco- 
holic stimuli, and, if possible, avoid the use 
of tobacco. 
25