the brain or spinal cord was detected. This nucleus was probably the remainder of a gummy tumour, of which the pressure had caused the pain, softening, and palsy. Zambaco enumerates nine more cases of a similar kind. His twenty-eighth case is probably an instance of recovery after much cerebral disease. A man had, in 1843, general syphilis; in 1847 he had nodes. Mercury was taken at both periods with benefit. In 1851 he felt pains about the body, most intensely in the right leg; after a while these disappeared, leaving muscular weakness and stiffness in the limb, and loss of tone in the bladder. General tonic treatment was of no service; on the contrary, the feebleness of the right leg extended in some degree to the arm and side. In 1852 the patient passed under Ricord's care, who gave him mercury endermically, and iodide of potass internally; after five weeks' treatment, great improvement ensued, nevertheless, he suffered relapses of his paralysis for four years more, complete recovery being ultimately obtained by large doses of iodide of potass. Twelve days after his discharge, the patient again returned to Ricord, with strabismus of the left eye, diplopia, and mental confusion. Iodide of potass removed these disorders in one month, whereon the patient omitted his medicine for a few days. His recovery was then interrupted by hemiplegia of the left side, and quiet continuous delirium. Specific treatment for three months again removed all symptoms of the disease. Sometime afterwards the patient died of cholera. At the post mortem no disease of the brain or its membranes was to be found.

Syphilitic Epilepsy.-The most common conditions seen post-mortem in patients who have suffered from epileptiform convulsions are nodules in the bone and dura mater,

1 Murchison 2 cases, Pathological Transactions, vol. xiii. p. 250, et seq.

:

or tumours compressing the convexity of the cerebrum; much less frequently the tumours press into the base of the brain.

The convulsions resemble those of ordinary epilepsy; but in syphilis, when the fits are violent, several succeed each other almost continuously, and then cease during some weeks; in addition, the syphilitic patient more often suffers from severe fixed headache in the interval between the attacks than he who has the true epileptic disease. This was the case in a patient under my care, who suffered in November, 1866, and April, 1867, from three series of fits before he died. In the second series he was six days in a succession of attacks of convulsions, separated from each other by an hour or two of relaxation, but of continuous unconsciousness; the irritant in this case being disease at the base of the brain.

The part convulsed is often very limited; for instance, to the group of muscles supplied by a particular nerve, but probably only a small part of the brain is irritated in these cases. Zambaco1 notes instances of one limb, or only some of the muscles of a limb, being rigidly contracted during the progress of an eruption, or late in the course of syphilis, when the time for eruptions is almost past. The contractions were sometimes accompanied by violent pain, in others there was none.

In consequence of its origin, syphilitic epilepsy is rare before middle life. Gros and Lancereaux collected 13 cases, in 10 of which the disease appeared about the 30th year, and Lancereaux quotes Jaksch's 43 cases-31 of which were between 30 and 40; 11 between 40 and 50; and only one was of the age of 20. In five cases of my

1 Cases 49 and 50, loc. cit.

Jaksch: Präger Med. Wochenschrift, 1864; Lancereaux, p. 450.

own the ages vary between 39 and 47. When epilepsy is caused by syphilis it has rapid progress, and is complicated with other nervous disorders-amaurosis, or ptosis, loss of memory, of speech, and even, as related by Zambaco, in one case with maniacal delirium that ended in complete dementia. Some of the foregoing symptoms are present in every case.

The diagnosis of syphilitic convulsions from ordinary epilepsy is generally easy by attention to the following:The patient is of middle age, there is history of previous syphilis, syphilitic affections are present elsewhere, and there has been no epilepsy in youth. More important symptoms are the sudden access and close succession of the fits. These distinctions mark the origin of the disease. The readiness with which the fits yield to specific treatment, but return if medicine is omitted, also markedly separates these convulsions from common epilepsy.

Syphilitic Chorea. Of this extremely rare affection, Zambaco relates two cases, in which choraic movements of considerable severity took place during the general eruption on the skin. Their severity continued several months unabated until mercurials and iodide of potash were given, which treatment caused one to subside in three weeks, the other in even less time.

Syphilitic affections of the spinal cord and its membranes. are very rare or little known; but, apparently, these structures are affected in precisely the same manner as the brain and its envelopes. According to Lancereaux, the gummy nodules have been most often found on the visceral surface of the dura mater, with interstitial inflammation and gummy formation extending into the substance of the cord. Wagner relates a case where a nodule, lying in the upper part

1 Lancereaux, loc. cit.,

p. 487.

2 Archiv der Heilkunde, Bd. iv. 1853.

of the spinal cord, resembled a large one found in the cerebellum of the same patient, who had had syphilis during life, and for about twelve months before his death symptoms of tumour in the brain. Dr. Wilks1 mentions a case of the cord being compressed by an outgrowth of the membranes investing it. In Zambaco's thirty-fourth case, the patient, who had contracted syphilis four years before, had almost complete paraplegia, violent sciatica of the left thigh, and tertiary ulcers on various parts of the body. Post mortem, a gummy mass was found around the lower dorsal and lumbar part of the cord. Beneath the muscles of the left thigh there was a similar tumour, the size of a nut, pressing on the sciatic nerve.

Paraplegia is the most common symptom of the disease in the cord. It is slow in development, and also never appears until several years have elapsed after contagion. In these cases the eruptions on the skin have been obstinate and repeated, and in other respects syphilis has run a severe course. The loss of muscular power in the lower extremities sometimes exists without other symptoms, but very frequently there is severe pain in the spine, increasing at night, and girdling pains in the loins. Loss or dulness of sensibility in the paralysed part is another common sign. The course of the affection is slow, and though it may be checked by treatment for a time, it is seldom cured.

Paralysis sine Materia.-Now and then cases occur of paralysis in persons who are suffering from syphilis in other parts of the body, or whose strength has been exhausted by repeated attacks in various organs, but in whom, after death, no lesion of the spinal cord can be found to account for the disease which destroyed life. There is no doubt, nevertheless, that syphilis has been concerned in producing the

1 Guy's Hospital Reports. 1863.

affection ending in death. Zambaco relates, among others, two cases where paraplegia came on gradually in persons who had long suffered, and were then suffering, with syphilitic disease in other parts (sarcocele, and ulcers of the skin). The loss of control of the lower extremities and of the sphincters ultimately became complete and continued till the death of the patients. Post mortem, the most careful examination could not detect any disease in the spinal cord or its membranes. In a third case, the paralysis began with loss of power of one side, in a patient who had long suffered from syphilis, but who had no other syphilitic affection in actual progress at the time of his death. In attributing these to syphilis, it is reasonable to allow to that disease what is possessed by other agencies, namely, the power of destroying the functions of the spinal cord without leaving traces of its action that our present knowledge of disease can detect.

Loss of sensation without loss of motility is rare, still there are a few cases on record. Follin cites one, described by Petrequin, where necrosis of the frontal bone was accompanied by insensibility in the lower extremities and loss of taste. Zambaco narrates two cases. In one, the man had suffered from syphilis for nine years, when general pains in the limbs came on; these were dissipated for a time by iodide of potassium. Presently they returned again, but subsided into insensibility of the whole surface of the body except the head. When this insensibility had lasted some time paraplegia followed. At first large doses of iodide of potassium relieved his symptoms, and he discontinued the iodide. A relapse ensued, and further treatment restored the motor power and the sensory power sufficiently for the patient to distinguish heat and cold; but sensation was never completely restored, and the "muscular sense" only to a certain extent.