cheese-like specks are scattered here and there among the remaining translucent substance of the growth, but not more at the centre than elsewhere. Tubercle invariably degenerates early, the greater part of its bulk becomes cheesy, and the centre is frequently softened. Very soft fibro-cellular tumours are now and then extremely similar to gummy tumours, but the absence of syphilitic disease in the skull and dura mater, and the history of the case, render distinction easy.

Symptoms.-Disturbances of the functions of the brain and nerves often accompany the early or exanthematous stages of syphilis. Those affecting the intellect consist chiefly of unusual melancholy, sullenness, or restlessness of temper, even delirium occasionally attends the frequent febrile reaction which on rare occasions accompanies the early eruption of the skin. The bodily ailments of this stage are dull pain in the limbs, loss of appetite, nausea, temporary paralysis of a single nerve, notably of the motor oculi, and others less important. To take the following

instances: a man, aged twenty, soon after the outbreak of a papular eruption, was suddenly attacked by paraplegia. The sphincters were relaxed, and much pain was felt in the lower part of the back. In a few weeks, while he took iodide of mercury, the symptoms left the patient. In another case, the patient was seized with paralysis of the right portio dura; this also was removed by six weeks of mercurial treatment. Again, a patient was inoculated in June or July; on October 8th an eruption appeared on the body, on the 19th of October hemiplegia came on, which lasted till the 16th of November, by which time the patient was under the influence of mercury.3 The sudden onset of the

1 Follin, Zambaco, Zeissl, loc. cit.

2 Zeissl, loc. cit., p. 299, quoting Knorre, Deutsche Klinik, No. 7, 1849. 3 Bulletin de Thérapeutique, p. 267.

1866.

palsy distinguishes these affections from the paralysis accompanying the late sequelæ, which are also preceded by other symptoms of nervous disorder. What structural changes excite the temporary disturbances of the nervous. system are unknown. Zeissl supposes there is inflammation of the envelopes of the brain or nerves, possibly resembling the punctiform syphilitic iritis that occurs about the same period of the disease, where morbid changes can be observed to arise and subside rapidly without necessarily causing permanent injury to the seat of the inflammation.

The symptoms of the later forms depend much upon the nature of the injury to the brain or nerve. If the pericerebral tumour produces compression of the brain, the symptoms are mainly convulsions, delirium, and other marks of irritation. When the brain's tissue is injured by inflammation, gradual paralysis and loss of intellectual power are the leading symptoms; hence these cases may be conveniently arranged in three groups. First, those where a small area of the brain's surface or spinal cord is affected; second, those where a considerable extent of the surface of the brain, or a whole texture of a nerve, is diseased; third, those where the alteration of structure is situate chiefly in the interior of the brain; fourth and lastly, cases where a single organ or limb, or set of nerves, are attacked. This division is of practical advantage in studying these affections, but syphilitic disease of the brain often calls forth many varieties of symptoms as the malady advances and successive portions of the brain are attacked. Cases are met with where the disease is confined to a small area, involving thickening of the dura and pia mater over one or two convolutions. This causes congestion and induration of the convolutions, then softening of the brain tissue immediately surrounding them. The most prominent symptoms are continued headache referred to one spot, and sudden

paralysis of one nerve or one side of the body. After this sudden onset, the paralysis becomes general, gradually, but not always continuously, for the severity of the palsy often declines for awhile until further progress of the disease brings aggravation of the symptoms either in the same nerves or elsewhere, this state denotes much of the brain to be implicated. The intellect rarely suffers until this is the case, except that occasionally acute delirium or dulness of perception accompany the attacks of headache and local paralysis.

Imbecility. In the second group of symptoms, where the disease extends over much of the periphery, clouding of the intellect by gradual complete imbecility is most common. A large number of faculties are impaired—the memory, the senses of taste, sight, hearing, and the control of the muscles, all suffer. This is called general wasting paralysis. Post mortem there are commonly found gummy tumours of the meninges, atrophy and softening of the grey substance over a considerable part of the brain's surface. Westphal relates the following case. A man having had syphilis was for some time subject to fits, to persistent headache, and other symptoms. After suffering thus for some time, his memory grew weak; his utterance became hesitating, for want of the right word to express his meaning; his gait tottering, and he lost control of the sphincters. This case terminated in utter imbecility and death. Post mortem the skull was thickened internally by exostoses; the dura mater was beset with nodules growing from it into the Sylvian fissure. The pons varolii was softened and congested, and the right second, and third nerves were infiltrated with gummy nodules.2 The following is also a very clear instance.3 A man, æt. 55, previously under Ricord's care for constitu

1 Zeitschrift für Psychatrie, Bd. 20, S. 481. 2 Zambaco, loc. cit.

3 Idem.

tional syphilis, after a fatiguing journey in September, 1845, was seized with cerebral excitement; this was soon followed by general paralysis. The muscles of the face were relaxed; utterance was inarticulate, and deglutition difficult; saliva dribbled from the mouth; the lower limbs tottered, and the upper ones shook. By bleeding and purging his condition. was much improved, though his utterance still remained slow and drawling. In February, 1846, he had a second attack, with full pulse, coma, and stertor. By mercurial inunctions and iodide of potash he was sufficiently restored to be able to follow his occupation of a painter for some months. In 1847 he was again seized with paralysis, diarrhoea, and exhaustion. This time specifics were not borne, and he died. Post mortem there were found, thickening of the pia mater and arachnoid, general softening of the grey substance, and calcification of the anterior twothirds of the falx cerebri; but careful examination discovered no further lesion of the brain.

Muscular Rigidity is said to be produced in rare cases by gummy tumours in the brain. Lancereaux quotes a curious. but not very satisfactory instance of this kind, where a gummy tumour was believed to exist. A man suffering from syphilitic eruption, &c., was seized with giddiness and intense headache. Soon afterwards hemiplegia of the left arm came on, and an irresistible inclination to deviate to the left in walking. About the same time his memory failed, and his speech grew hesitating. Iodide of potash and mercury removed all the man's symptoms in a short time, and being apparently in good health, he left the hospital, and was seen no more.

When the tumour is in the substance of the brain, and not on its surface, the headache is constant, but varies in intensity; shortly after the headache becomes settled, giddiness or confusion of the memory, and loss of ideas, are

added; next to these come drowsiness, that passes now and then into coma. Convulsions, and maniacal excitement, which often accompany these symptoms, denote peripheral disease of the brain, in addition to the internal tumour. (See S. epilepsy and S. chorea, page 178.) Hemiplegia is generally well marked when the tumour is at the base of the brain; it often comes on suddenly, but is sometimes preceded by the severe headache and other symptoms just narrated. The following interesting example is taken from Lancereaux. A woman, 31 years old, having had syphilis ten years before, and having suffered for two years from headache, giddiness, and dim sight, was seized with left hemiplegia, and a tubercular eruption spread over her face and neck. Under the influence of iodide of potash and mercury the eruption departed, and the paralysis improved for a time, but in a few months she died. Post mortem, the interior of the brain was found to be studded with small yellow nodules, easily isolated from the brain tissue, and many of them undergoing fatty degeneration. Faurés, in a paper read before the Medical Society of Toulouse, quoted by Zambaco, narrates three cases of syphilitic disease in which hemiplegia was a prominent symptom, and where a gummy tumour of the brain was discovered by the post mortem examination. The next case is from Zambaco. The patient, a café waiter, suffered constant pain in the right side of the head, progressive loss of motor power of the left side, and syphilitic eruption of the skin. When iodide of potassium had removed the pain and eruptions, he took strychnia to remove the palsy. After fifteen days' improvement, he accidentally took three-quarters of a grain of strychnia at one dose, and died. The post mortem showed a large amount of softening in the right middle lobe of the brain, and a yellowish nucleus, the size of a pea, in the corpus striatum. Nothing else of any moment in

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