thickened, greyish white, and hard, and Virchow recites others. According to this author, too, the gummy nodules sometimes open into the cavity of the heart, and cause cardiac aneurism; even death by sudden syncope. Wilks1 also describes a tumour in the septum ventriculorum that, however, was the only nodule of the kind in the body. All these instances are included by Lancereaux, who adds two cases to the number published by others.

Vessels. Obstruction of the internal carotid artery has been observed in several instances as a consequence of disease of the dura mater at the base of the skull. Virchow,

Wilks, and Lancereaux, all mention cases of this kind, where cerebral disease and softening were so originated. Wagner quotes a case of O. Weber's, published in the Verhandlungen der Niederrhenische Medicinische Gesellschaft," 1863, p. 171, where a nodule was found in the substance of the right pulmonary artery in a woman whose liver, bones, and other organs were syphilitic. This nodule, by its bulk, caused diminution of the calibre of the vessel. Wilks has also met with hard, round grains projecting on the surface of the larger blood-vessels, which he attributes to syphilis. This includes nearly all that is known respecting the alterations of the blood vessels occasioned by syphilis.

SUMMARY.

The bones and periosteum are attacked by syphilis before and during the epoch of eruptions, and at a time when eruptions have commonly subsided.

The early form consists chiefly of aching pains in the bones, worse at night than by day, and changing from place to place. The bones attacked are, the os frontis, sternum, clavicles, ulna, and tibia. The pain usually subsides when

1 Guy's Hospital Reports. 1863.

the eruption is fairly out. The painful places are not tender or swollen, unless the progress of the disease be unusually rapid, and a true node appear while the pain is present.

Late affections.-These are met with on the superficial bones, and their existence is revealed by fixed pain, great tenderness, and soft, fluctuating, colourless swelling over the painful part. The osseous enlargements sometimes compress the trunks of nerves, and cause violent pain or paralysis of the parts supplied by the nerve. The bone is altered by slow inflammation and special gummy formation. These produce nodes of the surface, caries and necrosis of the substance, and gummy outgrowths in the midst of the preceding nodes. A small area of the periosteum next the bone is reddened and congested, the effusion of fluid raises it above the surface of the bone (the fluctuating tumour); presently fibrous tissue and rough bone convert the fluid into a solid permanent tumour, that is called a syphilitic exostosis.

In gummy periostitis the course is slower and different. A meshwork of fibres filled with cells degenerates into fatty globules and serous fluid; this either shrinks into opaque masses, or alters into puriform matter and forms abscess, or is replaced by a more active tissue that developes into bone.

Caries and Necrosis.-The hard tissue of the bone is worn away or absorbed along the canals and spaces to make way for an increase of the medullary tissue, which itself then withers, and leaves the bone a porous honeycomb. Necrosis is produced in the thin bones, where the inflammation and degeneration of the vascular periostitis cut off their nutrition; the thin bones of the nose and hard palate are most frequent examples. The bone around these parts, attacked by simple death and by absorption, is irritated into chronic inflammation, and often becomes hard, dense, and

thick. It rises sometimes to a ridge about the carious parts. Again, the dead bone, acting like a foreign body, sometimes excites the neighbouring living bone to ulceration and suppuration.

The diagnosis of syphilitic disease in the bones depends on the severe pain, the slow action, the history of previous syphilis, the age of the patient, the dense parts and not the cancellous or articular parts of the bones being attacked.

The Joints. In the late stage of the disease gummy deposits around the joint outside the synovial membrane, and acute inflammation of the articular end of the bones have been noticed a few times.

Muscles and tendons have two forms of disease, the gummy nodules and interstitial diffused inflammation. The gummy form occurs as greyish or yellowish-white distinct nodules among the fibres of the muscles, usually near the attachment to the bones. The muscles of the upper extremity are most often attacked. There is usually pain, and sometimes the nodules can be felt in the muscle.

In the interstitial inflammation the fibres are welded together by fibrous tissue; the muscle is contracted and atrophid. This change is accompanied by much aching wearing pain, increased by movement.

The tendons are attacked by gummy tumours like the muscles; hitherto, they have been observed only in the tendo Achillis.

The heart has been found attacked by both forms of disease; the gummy nodules seated in the papillary muscles between the ventricles, where they may soften, and, by breaking into the interior of the heart, cause a cardiac aneurism.

Vessels. Not much is known respecting the change the disease produces on the vessels. The internal carotid has been obstructed by growths extending from the dura mater, and nodules have been found in one or two other arteries.

SYPHILIS.

CHAPTER VIII.

THE BRAIN, NERVES, AND ORGANS OF SPECIAL SENSE.

Different Modes of affecting the Brain and Nerves: Disease in the Skull or Membranes, in the Brain itself-Symptoms: Disorders attending early outbreak of the Eruption; those in late Affections, General Wasting, Palsy, Dementia, Hemiplegia, Epilepsy, Chorea-The Cord, Paraplegia, Paralysis sine Materia-Single Nerves-Cranial NervesSpecial senses, Smell, Hearing, Sight, Taste.

The Syphilitic Diseases of the Nervous System of late have received unusual attention from many observers. The authors to be consulted with most advantage on this question are, Gros et Lancereaux, Lagneau fils, Ricord, Ludwig Meyer, Virchow, Wagner, Yvaren, Zambaco, Zeissl, and many others who have written ably on this subject.

8

Much confusion has arisen from not distinguishing between nervous disorders, arising from ordinary causes in

Maladies Nerveuses Syphilitiques, Paris, 1860; and Lancereaux, Traité de la Syphilis, Paris, 1866.

* Maladies Syphilitiques du Système Nerveux. Paris, 1860.

3 Clinique Iconographique.

4 Constitutionelle Syphilis des Gehirns, Algemeine Zeitschrift für Psychiatrie, Bd. xviii., S. 287.

5 Krankhafte Geschwülste, Band ii. Berlin, 1864-1865.

* Archiv für Heilkunde, Band iv.

7 Metamorphoses de la Syphilis.

1863.
Paris, 1859.

8 Des Affections Nerveuses Syphilitiques. Paris, 1861.

9 Constitutionelle Syphilis. Erlangen, 1864.

syphilitic persons, and those produced by the action of the poison itself. Syphilis may impede or destroy the function of a nerve in three ways,-the first two of which are well recognised, the last is ill explained. They are―1st, the nerve-tissue is unaltered, but is pressed upon by growths of neighbouring parts; 2nd, the nerve-tissue is itself the seat of disease; 3rd, a syphilitic patient may suffer from a nervous disorder, of which no traces remain in the nerves post-mortem, but evidence of syphilitic disease is found in other tissues. In such cases the nervous symptoms are, doubtless, sometimes not attributable to syphilis; but it is not requisite, in all cases, for syphilis to produce appreciable change in the structure of the brain or nerves when influencing their functions. Zambaco relates many cases where the disturbance is very likely to have been of this kind. Hildenbrand1 thinks them due often to the chlorotic condition of the blood in syphilis. Virchow, when referring to them, observes, that as we do not know how far morbid processes in the brain may be arrested and cured, it would be rash to infer when nothing is found that nothing has ever gone wrong in the structure of the nerves or brain, during life.

The nervous affections which are consequent on disease of the meninges, are far more common than those excited by morbid changes in the brain or nerves alone; perhaps the most frequent condition is for both meninges and nervous centres to be implicated in the disease. Sometimes the nervous derangement depends mainly on disease of the bones of the skull, from which new growths or tumours press down the brain. Before this arrives, the bone grows worm-eaten and thinned into shallow hollows; gummy

1 Thèses de Strasbourg: De la Syphilis dans ses Rapports avec l'Aliénation mentale, 1859. Quoted by Zambaco, loc. cit.