parent, or firm gummatous masses alluded to. On cutting them open few white points can be seen, which were formerly regarded as undestroyed nerve-fibers, but which, in reality, are nothing more than cheesy deposits.

In regard to the spinal cord, those diseases must first be considered which are caused by the syphilitic affection of its envelopes-the vertebræ, and the meninges. As the result of exostoses or inflammatory products developed in the vertebræ, or marked thickening of the meninges, the entire thickness, or only a section of the cord, may become incapable of transmitting impressions, partly as the result of pressure, partly as the result of extension of the inflammation to it, and the wellknown phenomena of compression-myelitis will ensue. The symptoms which appear in such cases vary greatly, according to the height of the vertebræ or meninges affected, and according as the process attacks the anterior, lateral, or posterior sections of the spinal cord.

In such cases there occur the so-called root-symptoms, i. e., disturbances which originate from pressure upon, or inflammation of, the spinal nerve-roots that take their origin from the diseased places. In the progress of the disease the symptoms of spastic spinal paralysis,* or symptoms of ataxia, or finally, in rare cases, so-called spinal hemiplegia may ensue, according to the part of the cord that is compressed. Later, certain symptoms regularly appear which indicate a partial or complete division of the cord, such as paraplegic conditions, anæsthesia, paralysis of the sphincters, and bed-sores.

In two cases we saw the symptoms of transverse myelitis appear at the same time as the secondary phenomena of syphilis; they had resisted all kinds of treatment, but finally were cured by the use of mercury. There are as yet, to our knowl edge, no descriptions of undoubted pathological facts published; still, the clinical pictures admit of no other conclusion. In one case, Seeligmüller, by active antispecific treatment, cured a very extensive muscular atrophy in a person suffering from syphilis.

*This term is used here only for the purpose of describing the symptomatology germane to it, and not in the sense employed by Erh.

Fournier and Erb claim that a causal relation exists between tabes and syphilis that has preceded it. In eighty per cent of the cases which he has observed, Fournier confirmed the coincidence of tabes with syphilis, while Erb cured some and improved others of his cases by antispecific treatment. The question is not yet definitely decided. We are forced, however, to side with Westphal, Leyden, and others, against Fournier and Erb. In some syphilitic cases certain phenomena of serious disease of the spinal cord have been observed, most frequently symptoms of the so-called ascending spinal paralysis (Landry's paralysis), and yet, at the autopsy, not even the microscope could detect any abnormal condition of the cord.

The peripheral nerves very often become diseased in consequence of syphilis. They are affected most frequently by the pressure of exostoses, or the thickened meninges, or by gummata of the meninges or bones. Thickening of the meninges at the base of the brain most frequently produces similar phenomena, and for that reason paralyses of the muscles of the eye are seen so often in syphilitic patients, since the nerves, for a long distance of their peripheral course, run close to the affected part of the meninges, and are involved in diseases of the latter. Paralysis of the muscles of the eye is a complication so common in syphilis that an antispecific treatment should be tried in every case.

In addition to the oculo-motor, abducens, and trochlearis, all the other cerebral nerves may become affected by syphilis. Primary affection of the nerves occurs less frequently in this disease. In the latter, one or more reddish, grayish-red, or yellowish foci form on the nerves, which seem to be much thicker, but sometimes they atrophy to such a degree that only the nerve-sheath remains. The spinal nerves have seldom been found affected; usually they show only secondary changes.

The diagnosis of cerebral, spinal, and nervous syphilis is all the more difficult, because in the majority of cases no symptoms of syphilis in other organs-on the mucous membrane or skin-can be discovered. The sudden appearance of a cerebral, spinal, or nerve affection, the age and the history, will form important guides; still, not even the good results obtained

from antispecific treatment will establish the diagnosis beyond a doubt.

Unfortunately, non-specific nervous affections engender symptoms similar to those produced by specific diseases. From the present standpoint of our knowledge we can make the following statement:

In its first period syphilis produces affections of the meninges and the basilar cerebral arteries, while the diseases of the nervous system that come on later sometimes originate in the manner just mentioned, or are due to gummata developing in the nervous substance or in the meninges. In general, the following groups of symptoms are observed with remarkable frequency: Cerebral diseases, consequent upon bone-lesions, manifest themselves by fixed violent headache that becomes aggravated at night. The painful places are often sensitive to external pressure, and upon those places, or near them, a periosteal gumma is sometimes found. In quite a number of cases cerebral hemiplegias ensue, which are usually caused by points of softening that develop in the vicinity of a gumma, or as a result of Heubner's disease of the arteries. These hemiplegias occur either suddenly, like apoplexy, or oftener gradually in successive attacks. The cases belonging to the first variety are almost always the result of arterial disease, and originate partly from thrombosis, partly from embolism (as a result of the conveyance of fibrinous coagula from projecting points on the walls of large cerebral arteries) resulting in sudden plugging of a large vessel. They thus give rise to the clinical phenomena of cerebral emboli. Syphilitic hemiplegias not infrequently vacillate in their course, sometimes get better and then worse; often, indeed, they get well entirely. This is especially true of the apoplectiform cases which have been properly treated by antisyphilitic remedies. In many cases, again, only a moderate degree of improvement, indeed, sometimes not even this much, can be achieved by similar treatment. In such cases we have to deal with plugging of large vessels, which becomes permanent, or with softening in the vicinity of a gumma.

In some cases the manifestations of so-called cortical epilepsy (Jacksonian epilepsy) are observed in syphilitic patients.

This affection, as a rule, is either produced by morbid alterations in the bone (exostoses, gummata) or by specific meningitis. Under such circumstances the processes mentioned may be located in the region of the central convolutions or in their immediate vicinity. We then almost always notice attacks of convulsions, sometimes with, sometimes without, loss of consciousness, but in which the spasms differ from ordinary epilepsy in not attacking the entire muscular system, but only groups of muscles.

It frequently happens that syphilitic patients, after suffering from the phenomena already described, or even if they have not suffered from them, are attacked by peculiar cephalic disturbances which are hardly ever observed in any disease but syphilis. They form the so-called "drunken" conditions that develop in patients suffering from cerebral syphilis. These patients often complain for days and weeks of intense pains, numbness, and confusion in the head, before the picture that will presently be described develops. They are unable to attend to their occupations, especially if any mental effort be necessary, for the least mental strain aggravates the trouble markedly. Having lasted for a while, these symptoms gradually grow worse, unconsciousness supervenes, or the cephalic disturbances rapidly become aggravated, and then change into profound stupor. The patients lie in bed for days with their eyes shut, and can only be awakened from their semi-unconscious condition by being loudly spoken to or shaken. While this condition lasts, they are sometimes perfectly quiet for days; oftener, however, they tug at the bedclothes, play with their genital organs, become restless, and get out of bed. When roused, they will answer slowly and hesitatingly, often manifesting loss of memory and psychical disturbance. During the time that this condition has been developing, other disturbances not infrequently arise, namely, cortical convulsions and hemiplegic phenomena. In quite a number of cases the psychical disturbances become aggravated, maniacal symptoms supervene, or the patient becomes comatose. In the latter event death is the usual termination. In other cases the condition improves, a temporary or permanent cure is achieved, but although the patients regain consciousness, they

are frequently affected with some mental trouble, such as loss of memory. At the post-mortem examination of such cases Heubner usually found morbid meningeal alterations along with the diseased condition of the arteries, and softening of the brain depending upon it.

Lastly, in some cases of syphilis psychical disturbances of various kinds have been observed, namely, hypochondria, melancholia, chorea with mania (Wunderlich), and other psychoses.

In regard to the time at which syphilis of the nervous system is likely to appear, it may come on in a very short time after infection. In the majority of cases, however, many years elapse before it manifests itself. The predisposing causes for the development of this form of syphilis, as for all the other grave forms, are: too early use of mercury, incomplete treatment of the disease, excessive indulgence in wine and sexual intercourse during the treatment, mental worry, and exertion in business.

A permanent cure can only be achieved when the nervesubstance remains unaffected. Improvement takes place rapidly, especially when large doses of mercury and iodide of potassium are employed. Syphilitic diseases of the nerves require a long course of after-treatment to make the cure permanent.

Syphilitic Affections of the Nose.

The three cardinal forms of disease already described occur also in the nose, but with this difference, that erythema may appear on the lower as well as on the upper part of this organ, the papules more in the lower part, and the ulcerating nodes seem to have a preference for the upper and posterior parts of the nasal passages.

Syphilitic erythema of the nasal mucous membrane, or syphilitic nasal catarrh, develops with phenomena which are similar to ordinary coryza. It is attended by a sensation of tickling, burning, and dryness of the parts; frequent sneezing soon supervenes, and the visible part of the mucous membrane is reddened. If the catarrh is limited to the anterior part of the mucous membrane the discharge will be only slightly angmented, but if it spreads to the mucous membrane of the