Sustainable Development and Energy

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9 Bernadette Andreosso-O'Callaghan
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Sustainable Development and Energy Transition
in Europe and Asia
 Innovation and Technology Set
coordinated by
Chantal Ammi

Volume 9

Sustainable Development
and Energy Transition in
Europe and Asia

Edited by

Bernadette Andreosso-O’Callaghan
Sam Dzever
Jacques Jaussaud
Robert Taylor
First published 2020 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as
permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced,
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ISTE Ltd John Wiley & Sons, Inc.

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© ISTE Ltd 2020

The rights of Bernadette Andreosso-O’Callaghan, Sam Dzever, Jacques Jaussaud and Robert Taylor to be
identified as the authors of this work have been asserted by them in accordance with the Copyright,
Designs and Patents Act 1988.

Library of Congress Control Number: 2019952963

British Library Cataloguing-in-Publication Data

A CIP record for this book is available from the British Library
ISBN 978-1-78630-570-1
 Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Robert TAYLOR

Chapter 1. The Role of Microfinance in Women

Empowerment: Global Sustainable Perspectives
in the Case of Vietnam . . . . . . . . . . . . . . . . . . . . . . . . 1
Long Bui THANH, Lucía MORALES and Bernadette
ANDREOSSO-O’CALLAGHAN
1.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2. MF and women empowerment . . . . . . . . . . . . . . . . 3
1.3. Data and research methods . . . . . . . . . . . . . . . . . . . 6
1.4. Research findings and discussion . . . . . . . . . . . . . . . 10
1.4.1. Economic empowerment . . . . . . . . . . . . . . . . . . 11
1.4.2. Feminist and legal empowerment . . . . . . . . . . . . 14
1.5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.6. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 2. Is China’s Dependency on Coal a

Threat to Its Economic Development? . . . . . . . . . . . 23
Miroslava ZAVADSKA, Lucía MORALES and Bernadette
ANDREOSSO-O’CALLAGHAN
2.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . ... 24
2.2. Coal consumption and environmental implications
in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 26
2.3. Coal demand and economic growth in China . . . . ... 29
2.4. Methodological framework and findings . . . . . . . ... 34
vi Sustainable Development and Energy Transition in Europe and Asia

2.5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.6. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Chapter 3. China’s “Ecological Civilization”:

Geopolitical and Geo-economic Insights . . . . . . . . . . 45
Daniel RAJMIL, Lucía MORALES and Bernadette
ANDREOSSO-O’CALLAGHAN
3.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.2. A tale of explosive economic growth . . . . . . . . . . . . . 50
3.2.1. China’s economic model . . . . . . . . . . . . . . . . . . 51
3.2.2. Critiques to China’s growth strategy . . . . . . . . . . . 54
3.3. China’s environmental degradation . . . . . . . . . . . . . . 56
3.4. The battle for “blue skies” and the BRI . . . . . . . . . . . . 59
3.5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.6. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Chapter 4. City Logistics Foundation: Japan at

the Forefront . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Gilles PACHÉ
4.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.2. City logistics: issues and stakeholders . . . . . . . . . . . . 67
4.2.1. Economic and societal stakes . . . . . . . . . . . . . . . 67
4.2.2. Diversity of stakeholders . . . . . . . . . . . . . . . . . . 70
4.2.3. A potential development for the wholesaler? . . . . . 72
4.3. Japan: a favorable context for research on
city logistics . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... 74
4.3.1. Main areas of logistics innovation . . . . . . . ..... 75
4.3.2. From logistics innovations to theoretical
formalizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
4.4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.5. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . 87
4.6. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Chapter 5. The EU-Japan Economic Partnership

Agreement as a Norm Model for Sustainable
Development Issues in the Future EU FTAs in Asia . . . 93
Erja KETTUNEN and Claes G. ALVSTAM
5.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
 Contents vii

5.2. The EU as a norm promoter in sustainable

development . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 95
5.3. EU-Japan trade and investment imbalances . . . . . ... 97
5.4. The context of the EU’s free trade negotiations
with Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 98
5.5. The EU-Japan EPA and sustainable development
issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 100
5.5.1. The EU’s aims in the EPA negotiations . . . . . ... 101
5.5.2. Trade and sustainable development issues . . . . ... 102
5.5.3. Other issues in the negotiations and reflections
from the field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
5.6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.7. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . 107
5.8. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Chapter 6. The Relationship Between Shareholder

Value and International Transfer of Environmental
Management Practices . . . . . . . . . . . . . . . . . . . . . . . . 111
Kazuma MURAKAMI and Tatsuo KIMBARA
6.1. Introduction . . . . . . . . . . . . . . . . . . . ......... 111
6.2. Literature review . . . . . . . . . . . . . . . . ......... 113
6.2.1. Shareholder value and environmental
performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.2.2. Environmental management transfer . . . . . . . . . . 114
6.3. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
6.3.1. Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
6.3.2. Analytical framework and hypothesis. . . . . . . . . . 116
6.3.3. Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
6.4. Results of analysis . . . . . . . . . . . . . . . . . . . . . . . . 120
6.5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.7. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Chapter 7. Global Crisis of Sustainable Development

and Global Warming: A Case Analysis of Indonesia
and Laos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Jasmeet LAMBA, Bhumika GUPTA and Sam DZEVER
7.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
7.2. Background for climate change policy . . . . . . . . . . . 130
7.3. Literature review . . . . . . . . . . . . . . . . . . . . . . . . . 132
viii Sustainable Development and Energy Transition in Europe and Asia

7.4. Research objectives . . . . . . . . . . . . . . . . . . . . . . . . 133

7.4.1. Major objectives of the research . . . . . . . . . . . . . . 134
7.5. Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
7.5.1. The case of Indonesia . . . . . . . . . . . . . . . . . . . . 134
7.5.2. The case of Laos . . . . . . . . . . . . . . . . . . . . . . . 136
7.6. The 2015 Paris climate agreement . . . . . . . . . . . . . . . 138
7.7. Regression analysis . . . . . . . . . . . . . . . . . . . . . . . . 139
7.8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
7.9. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Chapter 8. Southeast Asian Energy Transformation:

Is It Enough and Sustainable? . . . . . . . . . . . . . . . . . . 145
Lucía MORALES and Bernadette ANDREOSSO-O’CALLAGHAN
8.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
8.2. Southeast Asia’s energy strategy . . . . . . . . . . . . . . . . 147
8.3. Energy consumption – dependency on fossil fuels . . . . . 150
8.4. The Southeast Asia energy dilemma . . . . . . . . . . . . . 155
8.5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
8.6. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Chapter 9. Analyzing the Reasons for the Low Ratio

of Female Researchers in Japan: An Exploration of
the Issue of Diversity and Sustainability in Japanese
Academia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Shiho FUTAGAMI
9.1. Current situation of female researchers in Japan . . . . . . 166
9.2. Research method . . . . . . . . . . . . . . . . . . . . . . . . . . 167
9.2.1. Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
9.2.2. Profile of respondents . . . . . . . . . . . . . . . . . . . . 167
9.3. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
9.3.1. Purpose of analysis . . . . . . . . . . . . . . . . . . . . . . 168
9.3.2. Reasons for the low ratio of female researchers . . . . 168
9.3.3. Reasons for the low ratio of female researchers
in leading positions . . . . . . . . . . . . . . . . . . . . . . . ... 171
9.3.4. Remedial actions for the low ratio of female
researchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 173
9.3.5. Research performance to be evaluated in the
recruitment process . . . . . . . . . . . . . . . . . . . . . . . ... 176
9.4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 179
9.5. References . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 180
 Contents ix

Chapter 10. Sustainable Agricultural Development

and Rural Poverty in India . . . . . . . . . . . . . . . . . . . . . 183
Jasmeet LAMBA, Bhumika GUPTA and Sam DZEVER
10.1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
10.2. Objective and methodology of the research . . . . . . . . 185
10.3. Review of literature on agricultural development,
credit flows, and rural poverty . . . . . . . . . . . . . . . . . . . 186
10.4. Pattern of agricultural development in India . . . . . . . 187
10.5. Classification of Indian States in context with CIAD
and rural poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
10.6. The model: relationship between agricultural
development and rural poverty in India . . . . . . . . . . . . . . 192
10.7. Suggestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
10.8. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Chapter 11. European and Chinese Consumers’

Attitude for Food with Reduced Use of Chemicals:
Results from a Survey . . . . . . . . . . . . . . . . . . . . . . . . 197
Martina MAZZAROLO, Giacomo FERRARO, Ilda MANNINO and
M. Bruna ZOLIN
11.1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
11.2. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
11.3. Data and methodology . . . . . . . . . . . . . . . . . . . . . 201
11.3.1. The sample. . . . . . . . . . . . . . . . . . . . . . . . . . 202
11.4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
11.4.1. Descriptive analysis on consumers’ behavior on
food choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
11.4.2. Regression analysis . . . . . . . . . . . . . . . . . . . . 207
11.4.3. Descriptive analysis on different patterns of
behavior on food choice between European and Chinese
respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
11.5. Discussion and conclusion . . . . . . . . . . . . . . . . . . 212
11.6. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Bernadette ANDREOSSO-O’CALLAGHAN, Sam DZEVER,
Jacques JAUSSAUD and Robert TAYLOR
x Sustainable Development and Energy Transition in Europe and Asia

List of Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
 Introduction

Sustainable Development and Energy

Transition: Introduction and Overview

The book chapters, derived mainly from the revised versions of the
papers presented at the 24th International Euro-Asia Research
Conference held in Barsac, France, in May 2019, focus on sustainable
development and energy transition. In the face of industrial pollution,
environmental degradation and resulting climate change in the form of
global warming, Western governments – at least partly in response to
public protest – have become committed, through international
agreements like the Paris Accord, to sustainable development. In
contrast, the leaders of developing countries, for example, those of
Southeast Asia, have prioritized economic growth, even at the cost of
ecological damage, and have only lately become cognizant of
environmental cost. The adverse effects of pollution and unrestrained
carbon emissions are global, overriding national boundaries, and –
accordingly the definition of sustainable development goals – has had
to be extended, encompassing factors such as health, education,
gender equality, action on climate change, and regional peace and
stability, particularly in Asia. Following the implementation of
International Health Regulations in 2010 and the submission of
reports by subscribing countries, there is, for example, a designated
need for a collaborative response to chemical safety and radiological
emergencies. Given the challenges presented by migration, for
instance, Rohingya refugees from Myanmar, a premium is placed on

Introduction written by Robert TAYLOR.

xii Sustainable Development and Energy Transition in Europe and Asia

the provision of educational opportunities for migrants to ensure their

social integration into countries receiving them. Gender equality is
crucial in employment, given forms of discrimination against migrant
women who are vulnerable to trafficking and gender-based violence.
Women may also witness a disproportionate share of unpaid care and
domestic work. In addition, given globalization and transnational
supply chains, production and consumption in a number of countries
may be adversely affected by national disasters, as witnessed in the
2011 Japanese Tohoku earthquake and tsunami [RAJ 19, TRI 19].

The above categories lead to the discussions described below

relating to sustainable development policies in China and Southeast
Asia. As the world’s second largest economy and the major user of
fossil fuels, China’s policy may be seen as providing a template
against which approaches in other Asian countries may be judged.
China and India, in addition to the United States, may be considered
pacesetters in renewable energy development, whereas Southeast
Asian states lag behind, even though, as indicated below, the latter
have enormous potential for solar, wind, ocean, river, or geothermal
energy [MAS 18].

China’s moves to protect the environment have been in response to

pressure from both global institutions and local people, incensed by
the effect of pollution on health, and this represents a radical departure
on the part of the Chinese government which, until recently, saw
foreign blandishments as a Western conspiracy to inhibit the country’s
economic growth [CLA 17]. In response to public concern, in 2014,
Chinese Premier Li Keqiang declared war on pollution and inefficient
and blind development, but Chinese policymakers are still mindful of
any adverse impact of sustainable developments on economic growth
[US 19a].

The following indicates the magnitude of the Chinese task. China

burns 47% of the world’s coal, with consequent effect on air quality in
Beijing which is surrounded by coal-burning power plants. Similarly,
it is estimated that more than half of China’s surface water is so
polluted and undrinkable, and 90% of underground water for irrigating
farmland is polluted. The increasing demands of agriculture have led
to deforestation and desertification, as well as a drop in biodiversity.
Even more alarming has been the emergence of the so-called “cancer
 Introduction xiii

villages,” due to chemical and heavy metal pollution. These trends

have been exacerbated by increasing middle-class consumer demands,
whether for diversified diet, say in the form of beef, as well as by
expanded fuel usage for growing car ownership [LAL 13].

Especially since the introduction of reform initiatives by Deng

Xiaoping in 1978, a major obstacle faced by Chinese lawmakers has
been the local implementation of legislation, following the traditional
and often fraught relationship between the central government and the
provinces. Specifically, local governments have often been loath to
enforce health, safety, and environmental laws, given the need to
avoid unemployment and resulting social unrest which potentially
threatens social stability. One hidden agenda in the Environmental
Protection Tax Law of China being implemented since January 2018
is to provide incentives for local enforcement. The law includes air
pollution, water pollution, solid waste, and noise as the four major
categories of taxable emissions. The law specifically designates the
local tax bureaus as collectors of the new environmental protection
tax. Local governments have discretion regarding the tax rate within a
range specified by the central government. The whole amount
collected will become part of local tax revenue. In addition, the
unleashing of local government initiative and responsibility is
indicated by the enactment of the Water Pollution Prevention and
Control Law to be implemented nationally through the “river chief”
system, originally piloted in Jiangsu. In an industrial context, there are
increased penalties for breaking the law in the discharge of pollutants
[COR 17]. Finally, the Law on the Prevention and Control of Soil
Pollution continues the focus on cleaning the environment [ZHA 18a,
ZHA 18b]. The above environmental legislation officially makes no
distinction between Chinese and foreign companies, with implications
additionally for supply chain management [COR 17].

The above discussion regarding the implementation of China’s

environmental legislation, including lately a carbon emissions trading
scheme being piloted experimentally in several provinces, may be
summarized as the remedial action being taken by the Chinese
authorities [CLA 17].

The Chinese leaders have, in commitment to the 2015 global

accord aimed at curbing temperature rises, pledged to bring down
xiv Sustainable Development and Energy Transition in Europe and Asia

China’s total emissions to a peak around 2030. A Chinese climate

experts source, however, claims that this goal will not be achieved
unless limits on carbon emissions are included in the forthcoming
2021–2025 Five-Year Plan. According to the source, on a business as
usual trajectory, annual CO2 emissions would grow from 11 gigatons
in 2020 to 14.3 gigatons in 2030 and would still be rising [US 19b].

Such goals, however, demand not only the kind of remedial action
outlined earlier, but also a constructive innovative policy based on
renewable energy.

Integral to moves toward the use of renewable sources is an

increase in energy efficiency as China moves away from being the
world’s workshop, especially for labor-intensive goods, toward an
expanding service sector. Avoidance of unnecessary waste will foster
a sustainable economy and encourage renewable energy use. Energy
efficiency relates not only to consumption of energy, but also its
production; the rate of recovery in coal mining is low since much
extraction comes from inefficient small-scale coal mines. In line with
this focus on efficiency is the emphasis on green energy, a priority of
the current 12th Five-Year Plan, as stressed, for instance, in the
Renewable Energy Law. An indication of the Chinese lead in
renewable energy is research into underlying technology, with the
Chinese having a total of 29% of the global patent. China, for
example, is the leading country in the world in electricity products
from renewable energy resources, double that of the second ranked
United States, with renewable power coming mainly from
hydroelectricity and wind, such growth being faster than that of fossil
fuels and nuclear power capacity. While domestic demand is such that
coal-powered plants still satisfy many of China’s energy needs, in
2017, renewable energy represented 36.6% of China’s total installed
power capacity and 26.4% of total power generation. The rise in the
share of renewable resources in energy is also a national security
issue, given the possibility of interception of imports.

China’s investment in renewable resources will now be placed in a

global context through invested sectors. In 2007, China accounted for
US $126.6 billion or 45% of the global total of US$279.8 billion
invested in renewable energy. An example of hydropower
development is the Gansu Dang River Hydropower Project, which, in
 Introduction xv

2007, was registered as a Clean Development Mechanism project in

accordance with the requirements of the Kyoto Protocol to the United
Nations Framework Convention on Climate Change. More
hydropower projects are being approved. Global perspective also
reveals China’s production of wind power, with the country being the
largest producer after the United States, Germany, and Spain in 2008.
There has also been a spin off for industry, with the commercial
production of turbines and components. The Chinese government has
also created an incentive scheme for the technological development of
solar power, with China becoming a world leader in the manufacture
of solar photovoltaic technology. While the production of fuel is far
more contentious, given global concerns about the competition
between corn, both as an energy source and as a food, with the
potential for price rises, China has become, like the United States, and
Brazil, a major producer of ethanol. Perhaps, geothermal power is
more environment-friendly, which has considerable potential in China
as an renewable energy resource [DUD 19, WIK ND].

In pursuit of renewable energy objectives, more challenging than

green power generation is the fueling of vehicles environmentally
because, in China as elsewhere in Asia, with a rising middle class, car
ownership is also increasing, with potential for resulting deterioration
in air quality. In spite of the current quality issues discussed below,
Chinese leaders seek to dominate the global New Energy Vehicles
(NEV) industry. Since 2015, the Chinese government has, through
subsidies to car makers, battery manufacturers, and vehicle
purchasers, supported the industry, prioritizing research and
development (R&D) and obtaining technology from foreign joint
ventures. Significantly, China’s largest electric vehicle maker is BYD,
backed by the American Warren Buffett organization. Additionally,
several city authorities have restricted the issue of license plates for
traditional cars, thus encouraging drivers to buy electric vehicles.
Consequently, in 2018, Chinese manufacturers sold 1,256 million
NEVs, mainly electric cars, with China accounting for more than half
of such global sales. In June 2019, Chinese government policy
changed; subsidies relating to consumer purchasing fell at least 65%,
resulting in lower profit margins for manufacturers, the intention
being to force automakers to produce better quality electric vehicles.
Lack of quality control is indicated by the recall to manufacturers of
xvi Sustainable Development and Energy Transition in Europe and Asia

135,700 electric vehicles in 2018, representing an industry wide rate

of 10.8%. Faults include low-quality batteries, motors, and
transmission systems. In response, the government’s steps to eliminate
subsidies have been designed to restrict the growing number of low-
quality entrants to manufacturing. Closely linked is inferior battery
performance on the road which can only be remedied by better
industrial standards and certification [MIN 19, US 19c].

In addition, Chinese government policy has also sought to support

the fledgling hydrogen-powered industry. The newly established Anhui
Mingtian Hydrogen Energy Technology Company, for example,
manufactures fuel stacks for vehicles powered by the element which
produces no emissions from the tail pipe. According to
BloombergNEF, the fuel-cell vehicle industry has received more than
US $1 billion worth investments from Chinese companies. For the time
being, government support for fuel-cell vehicles may well remain, even
while subsidies for the electric car industry are being cut [US 19d].

Within this overall context of remedial and constructive innovative

action, attention is now turned to Southeast Asia. Current economic
and social trends suggest that the states of the region will, even though
belatedly, follow a sustainable development trajectory similar to that
of China. Energy consumption in Southeast Asia has doubled in the
last two decades, with heavy reliance on fossil fuels, especially coal,
both for power generation and transportation [IRE 18]. Demand is
likely to increase, with an increasing number of middle-class
consumers enjoying rising living standards. This has resulted in the
greater accumulation of waste. Significantly, individual Southeast
Asian countries, like China, have taken steps to limit the importation
of waste, Malaysia and Vietnam being examples. Ironically, advanced
economies exporting waste are in a much better position to develop
environmentally recycling technologies, even though businesses, for
instance, in Indonesia, have gained a profitable source of income by
such measures [SEM 19].

Although the above has outlined some initiatives by individual

Southeast Asian countries, there is a growing acceptance that waste
management must proceed at a regional level, an instance being the
recently adopted Bangkok Declaration on Combating Marine Debris
at the Association of Southeast Nations (ASEAN) Summit in Bangkok
 Introduction xvii

in June 2019. Although the agreement is a major step forward, it does

require policy coordination between countries, which often lack
proper disposal facilities to curb, say, plastic pollution. Moreover,
shared river systems, like that of the Mekong, are the conduits for
ocean plastic pollution, land-based activities being a major source of
marine debris. One solution is the circular economy model, currently
being developed by Singapore and Thailand, through which the
disposal of waste and the need for raw materials is lessened by
implanting the system of reduce, reuse, recycle, refurbish, and re-
manufacture in the production, distribution, and consumption
processes [TRA 19].

Although remedial measures are crucial in the short term, in the

long run the key lies in the development of sustainable energy sources.
In fact, Southeast Asia’s renewable energy potential is still largely
untapped. This potential was implicitly acknowledged in the
establishment of the ASEAN Centre for Sustainable Development
(ACSDSD) in Thailand, signaling growing cooperation among
regional countries [PIT 19].

Although there is still a greater need for policy coordination at a

regional level, national initiatives have led to cumulative investment in
renewable energy amounting to US$27 billion between 2006 and 2016
[IRE 18]. It is realized at regional levels that energy demand now
exceeds supply and, given environmental degradation, renewable
resources are the preferred sources to reduce greenhouse gas emissions,
lest future economic and social development be impeded. Importantly,
energy demand has increased by 60% in Southeast Asian countries in
the last 15 years, challenging the availability of existing energy
resources, especially in relation to the dominant transportation sector.
Most Southeast Asian countries remain heavily dependent on fossil
fuels for energy needs, but national governments are seeking to
develop environment-friendly energy sources through incentives and
carbon taxes. ASEAN has agreed on a 23% target for sustainable
renewable resources by 2025. The following national examples will
briefly illustrate progress to date. In Indonesia, the government’s target
is the achievement of optimal energy use nationally by 2025, the
objective being to reduce dependency on oil, gas, and coal which are in
danger of not coping with future demand. Similarly, the Philippine
xviii Sustainable Development and Energy Transition in Europe and Asia

government has introduced legislation to promote the use of renewable

energy by developing resources and organizing management to support
policy implementation. Singapore, a regional pacesetter in many policy
areas, has a strategy to achieve efficient renewable energy, with the
aim of reducing emissions at the business as usual level between 7%
and 11% by 2020. Likewise, the Vietnamese have a target to increase
the share of renewable energy by 5% in 2020, with an estimated
increase of 11% in 2050. Malaysia’s policy is to achieve 5% renewable
energy use for nationwide electrical energy needs by 2030. The
Malaysian authorities are instigating surveillance concerning marine
energy potential. Lastly, to promote energy conservation, the Thai
government has a target of 3%–5% renewable energy use for all
power-generation capacity projects. Geothermal and marine energy
have also been slated as renewable energy sources in Thailand.

In summary, these targets, while presenting challenges, also offer

opportunities. Policies require investors who may reap substantial
returns. The development of renewable resources locally may not only
help to ensure local control over energy supply, but also provide
employment through job creation, with attendant revenue generation.

Nevertheless, national subsidies for fossil fuels and slow

implementation of supporting policies in individual countries as yet
preclude regionally integrated commitment to sustainable
development. The large-scale development of renewable resources
may be furthered through national and regional measures. National
governments can target a long-term energy mix including renewable
resources. In the implementation of energy policies in individual
countries, incentives are crucial for financing the development of
renewable resources and involve financial policy instruments.
Exchange of information and expertise between states to enforce
sustainable energy standards is also necessary. The expansion of the
ASEAN Power Grid will link the energy resource endowments in the
region as a whole [ERD 19].

Concluding remarks

In conclusion, this overview serves as an introduction to the

general rubric of sustainable development and energy transition,
 Introduction xix

discussed in the following chapters. The leaders of China, still often

categorized as a developing country, have, in recent decades, become
increasingly aware of the adverse environmental effects of unfettered
economic growth. Accordingly, under pressure from global
institutions and in the face of domestic public opinion incensed by the
damage done to health, the Chinese authorities have taken remedial
action to stem, for example, the harm caused by air and water
pollution as well as by the effects of deforestation and desertification.
A major problem, however, is local implementation, given the
regional government’s fear that strict enforcement will affect
employment and result in social unrest. Changes in tax laws have,
however, been designed as incentives for local authorities.

The above constitutes the remedial action. Reducing the effects of

climate change and global warming demands more affirmative action
in the form of a constructive innovative policy based on renewable
energy, with priority given, for instance, to the development of
electric vehicles, hydroelectricity, and wind and solar power. Given
that carbon emissions in transportation are a cause of global warming,
the Chinese leaders have sought domination of the electric vehicles
industry, even though there are quality issues.

The Chinese approach may serve as a template for Southeast Asian

countries which are still heavily reliant on fossil fuels, given demand
from increasingly affluent middle-class consumers. Although there are
initiatives by individual countries, the key to successful remedial
waste management may well best proceed at a regional level; river
systems like the Mekong are conduits for ocean-based pollution.
Because of heavy dependence to date on fossil fuels, some Southeast
Asian countries have targeted the development of, for instance,
geothermal and marine energy sources.

Regionally integrated commitment to sustainable development via

renewable resources has been hindered by national subsidies for fossil
fuels and ineffective supporting policies in individual Asian states.
Exchange of expertise between states and the expansion of the
ASEAN Power Grid will further regional-level coordination.

The chapters in this volume offer a wide-ranging perspective

relating to sustainable development and energy transition in Asia. The
xx Sustainable Development and Energy Transition in Europe and Asia

Chinese case is examined in Chapters 2 and 3. In particular, Chapter 2

investigates China’s coal dependency by looking at the short- to
medium-run dynamics existing between coal price volatility and
sectoral stock exchange performance. Chapter 3 discusses the steps
that the Chinese government is taking in order to implement a clean
energy strategy with the idea of “ecological civilization” in mind.
Energy transformation and the move toward a sustainable green
energy sector are also issues dealt with in Chapter 8 which considers
the case of Southeast Asian countries. Chapter 7, focusing on
Indonesia and Laos, analyzes the effects of the rapid expansion of
palm oil production in both countries.

The notion of “ecological economics” is also explained and

developed in Chapter 4 in the context of urban logistics in the case of
Japan. The international dimension of sustainable development is
covered in Chapter 5 which investigates whether the recent EU–Japan
free trade area (FTA) can be regarded as a norm-setter regarding
sustainable development issues in the future FTAs that the EU
will/might sign with other countries in Asia. Chapters 1 and 9 deal
with a socioeconomic issue of sustainable development, namely the
role of women in economic growth: Chapter 1 from the perspective
of microfinance in Vietnam and Chapter 9 from the viewpoint of
female researchers in Japan. Chapter 6 provides an analysis of the
relationship between shareholder value within multinational firms
and the international transfer of environmental management
practices. Finally, the central issue of food and agricultural
development is explored in Chapters 10 and 11. Chapter 10 is
devoted to sustainable agricultural development and rural poverty in
India, whereas Chapter 11 is on consumers’ attitudes toward food
products containing a low level of chemicals in China when
compared to the EU.

References

[CLA 17] CLARK A., “Opinion beyond brics. China’s environmental clean-up
to have big impact on industry”, Financial Times, May 22, 2017.
[COR 17] CORNE P., BROWAEYS J., “China cleans up its act on
environmental enforcement”, The Diplomat, December 9, 2017.
 Introduction xxi

[DUD 19] DUDLEY D., “China is set to become the world’s renewable energy
superpower, according to new report”, Forbes, available at: www.
forbes.com/sites/2019/01/11 [accessed August 24, 2019], January 11, 2019.
[ERD 19] ERDIWANSYAH, MAMAT R., SANI M.S.M., et al., “Renewable
energy in Southeast Asia: policies and recommendations”, Science of the
Total Environment, vol. 670, pp. 1095–1102, 2019.
[IRE 18] IRENA AGENCY PUBLICATION, Renewable energy market analysis:
Southeast Asia [accessed August 24, 2019], 2018.
[LAL 13] LALLANILLA M., “China’s top 6 environmental concerns”, Expi
CHO Thermo Fisher Scientific, available at: http://irena.org/publications/
2018/Jan/RenewableEnergy MarketAnalysisinSoutheastAsia, 2013.
[MAS 18] MASLOG C., “ASEAN countries lag on renewable energy”,
SciDEVNet, July 30, available at: https:www.scidev.net/asia-pacific/energy/
columns/aseancountrieslagonrenewables, 2018.
[MIN 19] MINTER A., “Electric car fires in China should set off alarms”,
Bloomberg, L.P., March 20, 2019.
[PIT 19] PITAKDUMRONGKIT K., 34th ASEAN Summit and Thailand:
headway or uncertainty? Rajaratnam School of International Studies (RSIS)
Commentary No. 133/2019, July 3, 2019.
[RAJ 19] Rajaratnam School of International Studies (RSIS) NTS Bulletin,
The final countdown – ten years to achieve the sustainable development
goals [accessed August 22, 2019], available at: https:mail.google.com/mail/
u/o?ik=b6fa8ceda&view=pt&search=all & permthid=thr, 2019.
[SEM 19] SEMBIRING M., Global waste trade chaos: rising environmentalism
or cost–benefit analysis? Rajaratnam School of International Studies (RSIS)
NTS Insight, No. IN19-02, July 2019.
[TRA 19] TRAJANO J., GONG L., Combating marine debris: what after the
Bangkok declaration? Rajaratnam School of International Studies (RSIS)
Commentary No. 136/2019, July 8, 2019.
[TRI 19] TRIAS A.P.L., Managing disasters 4.0: need for new thinking,
Rajaratnam School of International Studies (RSIS) Commentary, No.
166/2019, August 23, 2019.
[US 19a] US-China Trade Council News Overview, “China has made major
progress on air pollution: Wuhan protests show there is still a long way to
go”, CNN, July 11, 2019.
[US 19b] US-China Trade Council News Overview, “China’s government
think tank presses for 2025 CO2 cap”, Reuters, August 14, 2019.
xxii Sustainable Development and Energy Transition in Europe and Asia

[US 19c] US-China Trade Council News Overview, “Electric vehicles run
into China’s regulatory change”, WSJ, August 22, 2019.
[US 19d] US-China Trade Council News Overview, August 23, 2019.
[WIK ND] Wikipedia, Renewable energy in China, available at: en.wikipedia.
org/wiki [accessed August 24, 2019], n.d.
[ZHA 18a] ZHANG J.Q., “Two new environmental laws to go into effect in
2018”, available at: China.org.cn, January 1, 2018.
[ZHA 18b] ZHANG Z.Y., New laws in China to impact business, trade from
January 1, 2019, available at: www.china-briefing.com/, 2018.
 1

The Role of Microfinance in Women

Empowerment: Global Sustainable
Perspectives in the Case of Vietnam

This study analyzes the impact of microfinance (MF) on women

empowerment in the context of Vietnam. Our analysis is based on the
examination of primary data obtained from the MF organizations and
women’s unions in the Tra Vinh province in Vietnam. We interviewed
managers from various organizations at district levels to know their
insights on how MF services have been made available to female
borrowers and to find out the extent to which access to financing
through MF products has helped them to develop their economic
independence and to strengthen their role in their household and
community. This study offers evidence on the positive role played by
MF in the empowerment of women and also highlights the importance
of economic, feminist and legal factors in the process. The main
research findings point out the benefits offered by MF services not
only in the context of short-term economic goals for poor women, but
also in the long term with regard to improving women’s role so that
they become economically more independent and contribute to
government planning of sustainable developmental goals.

Chapter written by Long Bui THANH, Lucía MORALES and Bernadette ANDREOSSO-
O’CALLAGHAN.

Sustainable Development and Energy Transition in Europe and Asia,

First Edition. Edited by Bernadette Andreosso-O’Callaghan, Sam Dzever,
Jacques Jaussaud and Robert Taylor.
© ISTE Ltd 2020. Published by ISTE Ltd and John Wiley & Sons, Inc.
2 Sustainable Development and Energy Transition in Europe and Asia

1.1. Introduction

Microfinance (MF) tools have been used quite successfully in

economic development among disadvantaged social classes that are
characterized by high levels of poverty, economic inequality, and
social discrimination. In particular, microfinance institutions (MFIs)
have been quite focused in offering support to female borrowers,
aiming to help them advance and consolidate their economic
independence in their families and society by offering them access to
needed capital [ADB 00, BAS 07, HAS 96, RAH 17]. The cases of the
self-help groups in India and Grameen Bank in Bangladesh are
examples of the successful implementation of MF tools to provide
loans to the poorest and to support them for the creation of small
business activities that help alleviate their social and economic
exclusion. The focus of MFIs over the years has been on female
borrowers identified as a clear disadvantaged social class. [BAS 07,
HAS 96, RAH 17]. Women are regarded as ideal clients, as they are
effective in savings and repayments of microloans when compared to
men [AGI 13, ILO 08, WEB 14]. In the context of Vietnam,
researchers’ findings suggest that women are found to be more
responsible with regard to financial affairs, especially in poor families
[HOL 12]. However, poor Vietnamese women face significant
challenges and disadvantages as they are generally powerless in their
families, and also with regard to their social and economic role that is
heavily influenced and founded on a patriarchal social system, which
does diminish the role of women. In this regard, MF services are of
special importance, as they target female clients and offer support that
helps them to manage received capital and access non-financial
services that contribute to the empowerment of women in the social
and family context of Vietnam [ADA 16, DIN 15, LE 13]. For these
reasons, many countries across the world have become interested in
the role that MF can play as a key component in the development and
enhancement of the economic system. Countries have realized that
MF can play a valuable role as it can contribute to social cohesion,
integration of disfavored groups, and facilitation of financial resources
to deprived classes. Moreover, MFIs have also helped to minimize the
degree of bureaucracy associated with access to funds that deters the
access to needed resources from disfavored and marginalized social
classes [ADA 16, ADB 00]. To contribute to this line of research, this
 The Role of Microfinance in Women Empowerment 3

study analyzes the roles of MFIs and women’s unions (WUs) in

Vietnam. The study explores how MF services have helped to achieve
goals of poverty reduction and gender equity in the Tra Vinh (TV)
province in Vietnam, a region with a significant representation of poor
women. The research is supported by a qualitative approach, with in-
depth interviews carried out with managers of MFIs and WUs at
district levels. The research findings offer insights into the available
policies, levels of access to MF services, and the positive impact that
MF has on poor women in Vietnam in terms of their social and
economic integrity.

1.2. MF and women empowerment

In the last 30 years, researchers examining the value of MF as a

tool to promote economic development and social integration and
cohesion have also considered the important aspects with regard to the
role that MF can play in poverty reduction in developing countries
[WOL 99, YUN 03]. Most of the poor and low-income people cannot
access financial resources due to their limitations on knowledge,
information, and resources available. On the other hand, gender
inequity in developing countries represents major challenges for
socioeconomic sustainable development and for poor women around
the world who are being identified to be disadvantaged and vulnerable
[ELS 02, HAW 11]. Existing support to women in MF programs come
from many organizations, such as governments, societies, and non-
governmental organizations (NGOs) with a variety of political
perspectives [HUN 12, KAB 03, WB 12]. According to the current
apparent consensus, it is possible to identify three elements with
different basic aims and understanding of different policy
prescriptions and priorities in relation to both MF and gender policy.
The research findings by Mayoux [MAY 05] indicate that when
women are empowered to access MF services through WUs, they are
able to make a positive economic and social contribution. The
author’s findings suggest that women’s contributions can help
increase economic well-being and social, political, and legal
empowerment. Furthermore, female borrowers can gain access to
financial and non-financial services by combining the three main
objectives, vis-à-vis, poverty alleviation, financial self-sustainability,
and women empowerment [AGI 13, DES 13, NGO 12, WAR 15].
4 Sustainable Development and Energy Transition in Europe and Asia

A close consideration of these three core objectives suggests the

following:
1. Women empowerment is considered being an important goal of
sustainable development strategies in many countries, as women are
able to make a significant contribution to socioeconomic development.
However, gender inequity in many countries is driven by culture,
religion, social thinking, and beliefs according to which men are
preferably the ones that play a central role. As such, men are
considered more important than women, leading to neglecting
women’s contribution in their family and society [BOS 13]. MF
programs focus on the poor women through feminist organizations that
have been settling in numbers across countries following movements
such as the Self Employed Women’s Association (SEWA) in India, the
Consultative Group to Assist the Poor (CGAP) in the USA, the
Community Development Centre (CODEC) in Bangladesh, the
Grameen Bank in Bangladesh, the Small Foundation (SEF) in South
Africa, the Mbonweh Women’s Development Association in
Cameroon, Women’s World Banking in the USA, and many more.
These organizations foster socioeconomic sustainable development
goals (SDGs) such as gender equity and economic empowerment for
women [BHA 03, ELS 02, NGO 12, WB 12]. Most of the feminist
organizations focus on underdeveloped and developing countries to
promote women empowerment through MF solutions, because women
in these countries are considered exposed to significant challenges
regarding gender inequity. In this regard, MF services are considered
the best channel to offer financial opportunities for poor and low-
income people [BAL 15, SHA 07]. In the context of Vietnam, WUs
play a significant role in social and political development. The system
of WUs integrates four national levels that start from the central level
and then go down to provinces, districts, and communes. The
presidents of WUs for each level are members of the committee of the
communist party of Vietnam who help represent women’s voice in
politics and society [LE 13, WU 19].
2. Poverty reduction is at the center of millennium development
goals of the United Nations, aiming to target global sustainable
development [KIM 15]. MF programs focus on disadvantaged groups
to promote sustainable livelihoods and to enable social services to
reach the poor and the poorest and facilitate them access to financial
 The Role of Microfinance in Women Empowerment 5

opportunities [DAL 06]. Then, poor women are considered the most
vulnerable and disadvantaged of the poor group that is dominated by
gender inequity in developing and less-developed countries. The
combination of MFIs and WUs to outreach poor women and to target
socioeconomic development is not only helping women to empower
economically, but also supporting them to get out of poverty
[REE 11]. At the same time, MF tools are contributing to improve
their knowledge in legal and social matters regarding gender
education that promotes their roles in the household and society
[ADD 17, AJW 17, LE 13].
3. Financial self-sustainability plays an important role in financial
inclusion of relevant stakeholders including MF clients and providers
in related organizations. The outreach and efficiency of MF services
target poor women to ensure that the right goals on economic
empowerment and poverty reduction are achieved. Women’s effective
use of financial resources and timely repayment can contribute to
ensure financial safety and sustainability for MF clients [HAI 12]. As
regards the targets of self-sustainable MF for female borrowers and
financial providers, WUs play significant roles when articulating
bridges between women and MF providers and by supporting
financial and non-financial services. WUs can directly reach out to
members on non-financial services through self-help groups such as
sharing information, training in business activities, crops, livestock,
guidelines for borrowers on using MF tools, and targeting good
performance for making repayments on time [ADE 17, ATT 15,
SEH 16, TRU 14].

The reviewed literature indicates that women empowerment and

poverty reduction are two core objectives of sustainable development
planning. In particular, allies of WUs and MFIs focus on providing
MF services to poor women that tend to target both gender equity and
poverty reduction on SDGs [BOS 13, CAL 06, DRO 10, SAN 09,
WES 79]. In the context of Vietnam, the government has been
implementing policies, such as the Law on Gender Equality that was
introduced in 2006, the Law on Domestic Violence Prevention and
Control brought in 2007, and the Law on Marriage and Family
introduced in 2014, that help promote gender equity for decades.
These laws were aimed at enhancing a more active approach on the
efforts that lead toward women empowerment. In particular, the
Another random document with
no related content on Scribd:
partial unconsciousness, or even by more marked congestive
symptoms. The pain may seem to fill the whole cranium, may be
located in a cerebral region, or fixed in a very limited spot. Heubner
asserts that when this headache can be localized it is generally
made distinctly worse by pressure at certain points, but my own
experience is hardly in accord with this. Any such soreness plainly
cannot directly depend upon the cerebral lesion, but must be a reflex
phenomenon or due to a neuritis. According to my own experience,
localized soreness indicates an affection of the bone or of its
periosteum. In many cases, especially when the headache is
persistent, there are distinct nocturnal exacerbations.
39 Book Y., p. 88, 1879.

It will be seen that there is nothing absolutely characteristic in the

headache of cerebral syphilis; but excessive persistency, apparent
causelessness, and a tendency to nocturnal exacerbation should in
any cephalalgia excite suspicion of a specific origin—a suspicion
which is always to be increased by the occurrence of slight spells of
giddiness or by delirious mental wandering accompanying the
paroxysms of pain. When an acute inflammatory attack supervenes
upon a specific meningeal disease it is usually ushered in by a
headache of intolerable severity.

When the headache in any case is habitually very constant and

severe, the disease is probably in the dura mater or periosteum; and
this probability is much increased if the pain be local and augmented
by firm, hard pressure upon the skull over the seat of the pain.

Disorders of Sleep.—There are two antagonistic disorders of sleep,

either of which may occur in cerebral syphilis, but which have only
been present in a small proportion of the cases that I have seen.
Insomnia is more apt to be troublesome in the prodromic than in the
later stages, and is only of significance when combined with other
more characteristic symptoms. A peculiar somnolence is of much
more determinate import. It is not pathognomonic of cerebral
syphilis, yet of all the single phenomena of this disease it is the most
characteristic. Its absence is of no import in the theory of an
individual case.

As I have seen it, it occurs in two forms: In the one variety the patient
sits all day long or lies in bed in a state of semi-stupor, indifferent to
everything, but capable of being aroused, answering questions
slowly, imperfectly, and without complaint, but in an instant dropping
off again into his quietude. In the other variety the sufferer may still
be able to work, but often falls asleep while at his tasks, and
especially toward evening has an irresistible desire to slumber, which
leads him to pass, it may be, half of his time in sleep. This state of
partial sleep may precede that of the more continuous stupor, or may
pass off when an attack of hemiplegia seems to divert the
symptoms. The mental phenomena in the more severe cases of
somnolency are peculiar. The patient can be aroused—indeed in
many instances he exists in a state of torpor rather than of sleep;
when stirred up he thinks with extreme slowness, and may appear to
have a form of aphasia; yet at intervals he may be endowed with a
peculiar automatic activity, especially at night. Getting out of bed;
wandering aimlessly and seemingly without knowledge of where he
is, and unable to find his own bed; passing his excretions in a corner
of the room or in other similar place, not because he is unable to
control his bladder and bowels, but because he believes that he is in
a proper place for such act,—he seems a restless nocturnal
automaton rather than a man. In some cases the somnolent patient
lies in a perpetual stupor.

An important fact in connection with the somnolence is that it may

develop suddenly without marked premonition. Thus in a case
reported by J. A. Ormerod40 a man who had been in good health,
save only for headache, awoke one morning in a semi-delirious
condition, and for three days slept steadily, only arousing for meals;
after this there was impairment of memory and mental faculties, but
no more marked symptoms.
40 Brain, vol. v. 260.
Apathy and indifference are the characteristics of the somnolent
state, yet the patient will sometimes show excessive irritability when
aroused, and will at other periods complain bitterly of pain in his
head, or will groan as though suffering severely in the midst of his
stupor—at a time, too, when he is not able to recognize the seat of
the pain. I have seen a man with a vacant, apathetic face, almost
complete aphasia, persistent heaviness and stupor, arouse himself
when the stir in the ward told him that the attending physician was
present, and come forward in a dazed, highly pathetic manner, by
signs and broken utterances begging for something to relieve his
head. Heubner speaks of cases in which the irritability was such that
the patient fought vigorously when aroused; this I have not seen.

This somnolent condition may last many weeks. T. Buzzard41 details

the case of a man who after a specific hemiplegia lay silent and
somnolent for a month, and yet finally recovered so completely as to
win a rowing-match on the Thames. I have seen a fair degree of
recovery after a somnolence of four months' duration.
41 Clinical Lectures on Dis. Nerv. Syst., London, 1882.

In its excessive development syphilitic stupor puts on the symptoms

of advanced brain-softening, to which it is indeed often due. Of the
two cases with fatal result of which I have notes, one at the autopsy
was found to have symmetrical purulent breaking down of the
anterior cerebral lobes; the other, softening of the right frontal and
temporal lobes, due to the pressure of a gummatous tumor, and
ending in a fatal apoplexy.

This close connection with cerebral softening explains the clinical

fact that apoplectic hemorrhage is very apt to end the life in these
cases of somnolent syphilis. But a prolonged deep stupor in persons
suffering from cerebral syphilis does not prove the existence of
extensive brain-softening, and is not incompatible with subsequent
complete recovery. As an element of prognosis it is of serious but not
of fatal import.
Paralysis.—When it is remembered that a syphilitic exudation may
appear at almost any position in the brain, that spots of encephalic
softening are a not rare result of the infection, that syphilitic disease
is a common cause of cerebral hemorrhage, it is plain that a specific
palsy may be of any conceivable variety, and affect either the
sensory, motor, or intellectual sphere. The mode of onset is as
various as the character of the palsy. The attack may be
instantaneous, sudden, or gradual. The gradual development of the
syphilitic gumma would lead us, a priori, to expect an equally gradual
development of the palsy; but experience shows that in a large
proportion of the cases the paralysis appears suddenly, with or
without the occurrence of an apoplectic or epileptic fit. Under these
circumstances it will be usually noted that the resulting palsy is
incomplete; in rare instances it may be at its worst when the patient
awakes from the apoplectic seizure, but usually it progressively
increases for a few hours, and then becomes stationary. These
sudden partial palsies probably result from an intense congestion
around the seat of disease or from stoppage of the circulation in the
same locality; whatever their mechanism may be, it is important to
distinguish them from palsies which are due to hemorrhage. I believe
this can usually be done by noting the degree of paralysis.

A suddenly-developed, complete hemiplegia or other paralysis may

be considered as in all probability either hemorrhagic or produced by
a thrombus so large that the results will be disorganization of the
brain-substance, and a future no more hopeful than that of a clot. On
the other hand, an incomplete palsy may be rationally believed to be
due to pressure or other removable cause; and this belief is much
strengthened by a gradual development. The bearing of these facts
upon prognosis it is scarcely necessary to point out.

Although the gummata may develop at almost any point, they

especially affect the base of the brain, and are prone to involve the
nerves which issue from it. Morbid exudations, not tubercular or
syphilitic, are rare in this region. Hence a rapidly but not abruptly
appearing strabismus, ptosis, dilated pupil, or any paralytic eye
symptom in the adult is usually of syphilitic nature. Syphilitic facial
palsy is not so frequent, whilst paralysis of the nerve from rheumatic
and other inflammation within its bony canal is very common.
Paralysis of the facial nerve may therefore be specific, but existing
alone is of no diagnostic value. Since syphilitic palsies about the
head are in most instances due to pressure upon the nerve-trunks,
the electrical reactions of degeneration are present in the affected
muscles.

There is one peculiarity about specific palsies which has already

been alluded to as frequently present—namely, a temporary,
transient, fugitive, varying character and seat. Thus an arm may be
weak to-day, strong to-morrow, and the next day feeble again, or the
recovered arm may retain its power and a leg fail in its stead. These
transient palsies are much more apt to involve large than small brain
territories. The explanation of their largeness, fugitiveness, and
incompleteness is that they are not directly due to clots or other
structural changes, but to congestions of the brain-tissues in the
neighborhood of gummatous exudations. Squint due to direct
pressure on a nerve will remain when the accompanying monoplegia
due to congestion disappears.

Motor palsies are more frequent than sensory affections in syphilis,

but hemianæsthesia, localized anæsthetic tracts, indeed any form of
sensory paralysis, may occur. Numbness, formications, all varieties
of paræsthesia, are frequently felt in the face, body, or extremities.
Violent peripheral neuralgic pains are rare, and generally when
present denote neuritis. Huguenin, however, reports42 a severe
trigeminal anæsthesia dolorosa, which was found, after death from
intercurrent disease, to have depended upon a small gumma
pressing upon the Gasserian ganglion. A somewhat similar case has
also been reported by Allen McLane Hamilton.43
42 Schwiez. Corr. Blät., 1875.

43 Alienist and Neurologist, iv. 58.

The special senses are liable to suffer from the invasion of their
territories by cerebral syphilis, and the resulting palsies follow
courses and have clinical histories parallel to those of the motor
sphere. The onset may be sudden or gradual, the result temporary
or permanent. Charles Mauriac44 reports a case in which the patient
was frequently seized with sudden attacks of severe frontal pain and
complete blindness lasting from a quarter to half an hour; at other
times the same patient had spells of aphasia lasting only for one or
two minutes. I have seen two cases of nearly complete deafness
developing in a few hours in cerebral syphilis, and disappearing
abruptly after some days. Like other syphilitic palsies, therefore,
paralyses of special senses may come on suddenly or gradually, and
may occur paroxysmally.
44 Loc. cit., p. 31.

Among the palsies of cerebral syphilis must be ranked aphasia. An

examination of recorded cases shows that syphilitic aphasia is
subject to vagaries and laws similar to those connected with other
specific cerebral palsies. It is usually a symptom of advanced
disease, but may certainly develop as one of the first evidences of
cerebral syphilis. Coming on after an apoplectic or epileptic fit, it may
be complete or incomplete: owing to the smallness of the centre
involved and the ease with which its function is held in abeyance, a
total loss of word-thought is not so decisive as to the existence of
cerebral hemorrhage as is a total motor palsy. Like hemiplegia or
monoplegia, specific aphasia is sometimes transitory and
paroxysmal. Buzzard45 records several such cases. Mauriac46 details
a very curious case in which a patient, after long suffering from
headache, was seized by sudden loss of power in the right hand and
fingers, lasting about ten minutes only, but recurring many times a
day. After this had continued some time the paroxysms became
more completely paralytic, and were accompanyed by loss of the
power of finding words, the height of the crises in the palsy and
aphasia being simultaneously reached. For a whole month these
attacks occurred five or six times a day, without other symptoms
except headache, and then the patient became persistently paralytic
and aphasic, but finally recovered. To describe the different forms of
specific aphasia and their mechanism of production would be to
enter upon a discussion of aphasia itself—a discussion out of place
here. Suffice it to say that every conceivable form of the disorder
may be induced by syphilis.
45 Loc. cit., p. 81.

46 Aphasie et Hemiplégia droite Syphilit., Paris, 1877.

Owing to the centres of speech being situated in the cortical portion

of the brain, aphasia in cerebral syphilis is very frequently associated
with epilepsy. Of course right-sided palsy and aphasia are united in
syphilitic as in other disorders. If, however, the statistics given by
Tanowsky47 be reliable, syphilitic aphasia is associated with left-
sided hemiplegia in a most extraordinarily large proportion. Thus in
53 cases collected by Tanowsky, 18 times was there right-sided
hemiplegia, and 14 times left-sided hemiplegia, the other cases
being not at all hemiplegic. Judging from the autopsy on a case
reported in Mauriac's brochure, this concurrence of left-sided
paralysis and aphasia depends partly upon the great frequency of
multiple brain lesions in syphilis, and partly upon the habitual
involvement of large territories of the gray matter secondarily to
diseased membrane. An important practical deduction is that the
conjoint existence of left hemiplegia and aphasia is almost diagnostic
of cerebral syphilis.
47 L'Aphasie syphilitique.

Probably amongst the palsies may be considered the disturbances

of the renal functions, which are only rarely met with in cerebral
syphilis, and which are probably usually dependent upon the specific
exudation pressing upon the vaso-motor centres in the medulla.
Fournier speaks of having notes of six cases in which polyuria with
its accompaniment, polydipsia, was present, and details a case in
which the specific growth was found in the floor of the fourth
ventricle. Cases have been reported of true saccharine diabetes due
to cerebral syphilis,48 and I can add to these an observation of my
own. The symptoms, which occurred in a man of middle age, with a
distinct specific history, were headache, nearly complete hemiplegia,
and mental failure, associated with the passage of comparatively
small quantities of a urine so highly saccharine as to be really a
syrup. Under the influence of the iodide of potassium the sugar in a
few weeks disappeared from the urine.
48 Consult Servantié, Des Rapports du Diabète et de la Syphilis, Paris, Thèse, 1876;
also, case reported by L. Putzel, New York Med. Record, xxv. 450.

Epilepsy.—Epileptic attacks are a very common symptom of

meningeal syphilis, and are of great diagnostic value. The
occurrence in an adult of an epileptic attack or of an apoplectic fit, or
of a hemiplegia after a history of intense and protracted headache,
should always excite grave suspicion.

Before I had read Fournier's work on Nervous Syphilis I taught that

an epilepsy appearing after thirty years of age was very rarely, if
ever, essential epilepsy, and unless alcoholism, uræmic poison, or
other adequate cause could be found was in nine cases out of ten
specific; and I therefore quote with satisfaction Fournier's words:
“L'épilepsie vraie, ne fait jamais son premier dêbut à l'âge adulte, à
l'âge mûr. Si un homme adulte, au dessus de 30, 35, à 40 ans, vient,
à être pris pour la première fois d'une crise épileptique, et cela dans
la cours d'une bonne santé apparente, il y a, je vous le répète, hui
ou neuf chances sur dix pour que cette épilepsie soit d'origine
syphilitique.”

Syphilitic epilepsy may occur either in the form of petit mal or of haut
mal, and in either case may take on the exact characters and
sequence of phenomena which belong to the so-called idiopathic or
essential epilepsy. The momentary loss of consciousness of petit
mal will usually, however, be found to be associated with attacks in
which, although voluntary power is suspended, memory recalls what
has happened during the paroxysm—attacks, therefore, which
simulate those of hysteria, and which may lead to an error of
diagnosis.

Even in the fully-developed type of the convulsions the aura is only

rarely present. Its absence is not, however, of diagnostic value,
because it is frequently not present in essential epilepsy, and it may
be pronounced in the specific disease. It is said that when in an
individual case the aura has once appeared the same type or form of
approach of the convulsion is thereafter rigidly adhered to. The aura
is sometimes bizarre: a severe pain in the foot, a localized cramp, a
peculiar sensation, indescribable and unreal in its feeling, may be
the first warning of the attack. An aura may affect a special sense.
Thus, I have at present a patient whose attacks begin with blindness.

In many, perhaps most, cases of specific convulsions, instead of a

paroxysm of essential epilepsy being closely simulated, the
movements are in the onset, or more rarely throughout the
paroxysm, unilateral; indeed, they may be confined to one extremity.
This restriction of movement has been held to be almost
characteristic of syphilitic epilepsy, but it is not so. Whatever
diagnostic significance such restriction of the convulsion has is
simply to indicate that the fit is due to a cortical organic lesion of
some kind. Tumors, scleroses, and other organic lesions of the
brain-cortex are as prone to cause unilateral or monoplegic epilepsy
when they are not specific as when they are due to syphilis.

Sometimes an epilepsy dependent upon a specific lesion implicating

the brain-cortex may be replaced by a spasm which is more or less
local and is not attended with any loss of consciousness. Thus, in a
case now convalescent in the University Hospital, a man aged about
thirty-five offered a history of repeated epileptic convulsions, but at
the time of his entrance into the hospital, instead of epileptic attacks,
there was a painless tic. The spasms, which were clonic and
occurred very many times a day, sometimes every five minutes,
were very violent, and mostly confined to the left facial nerve
distribution. The trigeminus was never affected, but in the severer
paroxysms the left hypoglossal and spinal accessory nerves were
profoundly implicated in all of their branches. Once, fatal asphyxia
from recurrent laryngeal spasm of the glottis was apparently averted
only by the free inhalation of the nitrite of amyl. The sole other
symptom was headache, but the specific history was clear and the
effect of antisyphilitic remedies rapid and pronounced.
It is very plain that such attacks as those just detailed are closely
allied to epilepsy; indeed, there are cases of cerebral syphilis in
which widespread general spasms occur similar to those of a
Jacksonian epilepsy, except that consciousness is not lost, because
the nervous discharge does not overwhelm the centres which are
connected with consciousness.49 On the other hand, these epileptoid
spasmodic cases link themselves to those in which the local brain
affection manifests itself in contractions or persistent irregular clonic
spasms. Contractures may exist and may simulate those of
descending degeneration,50 but in my own experience are very
rare.51
49 Case, Canada Med. and Surg. Journ., xi. 487.

50 Case, Centralbl. Nerv. Heilk., 1883, p. 1.

51 A case of syphilitic athetosis may be found in Lancet, 1883, ii. 989.

The clonic spasms of cerebral syphilis may assume a distinctly

choreic type, or may in their severity simulate those of hysteria,
throwing the body about violently.52 It is, to my mind, misleading, and
therefore improper, to call such cases syphilitic chorea, as there is
no reason for believing that they have a direct relation with ordinary
chorea. They are the expression of an organic irritation of the brain-
cortex, and are sometimes followed by paralysis of the affected
member; in other words, the disease, progressing inward from the
brain-membrane, first irritates, and then so invades a cortical centre
as to destroy its functional power.53
52 See Allison, Amer. Med. Journ., 1877, 74.

53 Case, Chicago Med. Journ. and Exam., xlvi. 21.

Psychical Symptoms.—As already stated, apathy, somnolence, loss

of memory, and general mental failure are the most frequent and
characteristic mental symptoms of meningeal syphilis; but, as will be
shown in the next chapter, syphilis is able to produce almost any
form of insanity, and therefore mania, melancholia, erotic mania,
delirium of grandeur, etc. etc. may develop along with the ordinary
manifestation of cerebral syphilis, or may come on during an attack
which has hitherto produced only the usual symptoms. Without
attempting any exhaustive citation of cases, the following may be
alluded to.

A. Erlenmeyer reports54 a case in which an attack of violent

headache and vomiting was followed by paralysis of the right arm
and paresis of the left leg, with some mental depression; a little later
the patient suddenly became very cheerful, and shortly afterward
manifested very distinctly delirium of grandeur with failure of
memory. Batty Tuke reports55 a case in which, with aphasia,
muscular wasting, strabismus, and various palsies, there were
delusions and hallucinations. In the same journal56 S. D. Williams
reports a case in which there were paroxysmal violent attacks of
frontal headache. The woman was very dirty in her habits, only ate
when fed, and existed in a state of hypochondriacal melancholy.
Leiderdorf details a case with headache, partial hemiplegia, great
psychical disturbance, irritability, change of character, marked
delirium of grandeur, epileptic attacks, and finally dementia,
eventually cured by iodide of potassium.57 Several cases illustrating
different forms of insanity are reported by N. Manssurow.58
54 Die luëtischen Psychosen.

55 Journ. Ment. Sci., Jan., 1874, p. 560.

56 April, 1869.

57 Medicin Jahrbucher, xx. 1864, p. 114.

58 Die Tertiäre Syphilis, Wien, 1877.

That the attacks of syphilitic insanity, like the palsies of syphilis, may
at times be temporary and fugitive, is shown by a curious case
reported by H. Hayes Newington,59 in which, along with headache,
failure of memory, and ptosis in a syphilitic person, there was a brief
paroxysm of noisy insanity.
 59 Journ. Ment. Sci., London, xix. 555.

DIAGNOSIS.—In a diagnosis of cerebral syphilis a correct history of the

antecedents of the patients is of vital importance. Since very few of
the first manifestations of the disorder are absolutely characteristic,
whilst almost any conceivable cerebral symptoms may arise from
syphilitic disease, treatment should be at once instituted on the
appearance of any disturbance of the cerebral functions in an
infected person.

Very frequently the history of the case is defective, and not rarely
actually misleading. Patients often appear to have no suspicion of
the nature of their complaint, and will deny the possibility of syphilis,
although they confess to habitual unchastity. My own inquiries have
been so often misleading in their results that I attach but little weight
to the statements of the patient, and in private practice avoid asking
questions which might recall unpleasant memories, depending upon
the symptoms themselves for the diagnosis.

The general grounds of diagnosis have been sufficiently mapped out

in the last section, but some reiteration may be allowable. After the
exclusion of other non-specific disease, headache occurring with any
form of ocular palsy or with a history of attack of partial monoplegia
or hemiplegia, vertigo, petit mal, epileptoid convulsions, or
disturbances of consciousness, or attacks of unilateral or localized
spasms, should lead to the practical therapeutic test. Ocular palsies,
epileptic forms of attacks occurring after thirty years of age, morbid
somnolence, even when existing alone, are sufficient to put the
practitioner upon his guard. It is sometimes of vital importance that
the nature of the cephalalgia shall be recognized before the coming
on of more serious symptoms; any apparent causelessness,
severity, and persistency should arouse suspicion, to be much
increased by a tendency to nocturnal exacerbations or by the
occurrence of mental disturbance or of giddiness at the crises of the
paroxysms. Not rarely there are very early in these cases curious,
almost indefinable, disturbances of cerebral functions, which may be
easily overlooked, such as temporary and partial failures of memory,
word-stumbling, fleeting feelings of numbness or weakness,
alterations of disposition. In the absence of hysteria an indefinite and
apparently disconnected series of nerve accidents is of very urgent
import. To use the words of Hughlings-Jackson, “A random
association or a random succession of nervous symptoms is very
strong warrant for a diagnosis of a syphilitic disease of the nervous
system.” Cerebral syphilis occurring in an hysterical subject may be
readily overlooked until fatal mischief is done. When any paralysis
occurs a study of the reflexes may sometimes lead to a correct
diagnosis. Thus in a hemiplegia the reflex on the affected side in
cerebral syphilis is very frequently exaggerated, whilst in hysteria the
reflexes are usually alike on both sides. When both motion and
sensation are disturbed in an organic hemiplegia, the anæsthesia
and motor paralysis occur on the same side of the body, whilst in
hysteria they are usually on opposite sides.

In all cases of doubtful diagnosis the so-called therapeutic test

should be employed, and if sixty grains of iodide of potassium per
day fail to produce iodism, for all practical purposes the person may
be considered to be a syphilitic. No less an authority than Seguin
has denied the validity of this, but I believe, myself, that some of his
reported cases were suffering from unsuspected syphilis. I do not
deny that there are rare individuals who, although untainted, can
resist the action of iodide, but in ten years' practice in large hospitals,
embracing probably some thousands of cases, I have not met with
more than one or two instances which I believed to be of such
character. Of course in making these statements I leave out of sight
persons who have by long custom become accustomed to the use of
the iodide, for although in most cases such use begets increase of
susceptibility, the contrary sometimes occurs. Of course the
physician who should publicly assert that a patient who did not
respond to the iodide had syphilis would be a great fool, but in my
opinion the physician who did not act upon such a basis would be
even more culpable.

PROGNOSIS.—Cerebral meningeal syphilis varies so greatly and so

unexpectedly in its course that it is very difficult to establish rules for
predicting the future in any given case. The general laws of
prognosis in brain disease hold to some extent, but may always be
favorably modified, and patients apparently at the point of death will
frequently recover under treatment. The prognosis is not, however,
as absolutely favorable as is sometimes believed, and especially
should patients be warned of the probable recurrence of the affection
even when the symptoms have entirely disappeared. The only safety
after the restoration of health consists in an immediate re-treatment
upon the recurrence of the slightest symptom. The occurrence of a
complete, sudden hemiplegia or monoplegia is sufficient to render
probable the existence of a clot, which must be subject to the same
laws as though not secondary to a specific lesion. If a rapid decided
rise of temperature occur in an apoplectic or epileptic attack, the
prognosis becomes very grave. An epileptic paroxysm very rarely
ends fatally, although it has done so in two of my cases.

The prognosis in gummatous cerebral syphilis should always be

guardedly favorable. In the great majority of cases a more or less
incomplete recovery occurs under appropriate treatment, and I have
seen repeatedly patients who were unconscious, with urinary and
fecal incontinence, and apparently dying, recover. Nevertheless, so
long as there is any particle of gummatous inflammation in the
membrane the patient is liable to sudden congestions of the brain,
which may prove rapidly fatal, or he may die in a brief epileptic fit. On
the one hand there is an element of uncertainty in the most favorable
case, and on the other so long as there is life a positively hopeless
prognosis is not justifiable.

PATHOLOGY.—Gummatous inflammation of the brain probably always

has its starting-point in the brain-membranes, although it may be
situated within the brain: thus, I have seen the gummatous tumors
spring from the velum interpositum in the lateral ventricle. The
disease most usually attacks the base of the brain, and is especially
found in the neighborhood of the pons Varolii and the optic tract. It
may, however, locate itself upon the vault of the cranium, and in my
experience has seemed to prefer the anterior or motor regions. The
mass may be well defined and roundish, but more usually it is
spread out, irregular in shape, and more or less confluent with the
substance of the brain beneath it. It varies in size from a line to
several inches in length, and when small is prone to be multiple. The
only lesion which it resembles in gross appearance is tubercle, from
which it sometimes cannot be certainly distinguished without
microscopic examination.

The large gummata have not rarely two distinct zones, the inner one
of which is drier, somewhat yellowish in color, opaque, and
resembles the region of caseous degeneration in the tubercle. The
outer zone is more pinkish and more vascular, and is semi-
translucent.

On microscopic examination the most characteristic structures are

small cells, such as are found in gummatous tumors in other portions
of the body. These cells are most abundant in the inner zone, which,
indeed, may be entirely composed of them. In the centre of the
tumor they are more or less granular and atrophied; in some cases
the caseous degeneration has progressed so far that the centre of
the gumma consists of minute acicular crystals of fat. In the external
or peripheral zone of the tumor the mass may pass imperceptibly
into the normal nerve tissue, and under these circumstances it is that
it contains the spider-shaped cells or stellate bodies described by
Jastrowitch, and especially commented upon by Charcot and
Gombault and by Coyne. These are large cells containing an
exaggerated nucleus and a granular protoplasm, which continues
into multiple, branching, rigid, refracting prolongations, which
prolongations are scarcely stained by carmine. Alongside of these
cells other largish cells are often found without prolongations, but
furnished with oval nuclei and granular protoplasm. Amongst these
cells will be seen the true gummatous cells, as well as the more or
less altered neuroglia and nerve-elements. In the perivascular
lymphatic sheaths in the outer part of the gumma is usually a great
abundance of small cells. The spider-shaped cells are probably
hypertrophied normal cells of the neuroglia, and have been
considered by Charcot and Gombault as characteristic of syphilitic
gummata of the brain. In a solitary gumma, however, of considerable
size from the neighborhood of the cerebellum, studied by Coyne and
Peltier, there were no stellated cells. Coyne considers that their
presence is due to their previous existence in the normal state of the
regions affected by the gumma. Exactly what becomes of syphilitic
gumma of the brain in cases of recovery it is difficult to determine. It
is certain that they become softened and disappear more or less
completely, and it is probable that the cicatrices or the small
peripheral cysts which are not rarely found in the surfaces of the
brain are sometimes remnants of gummatous tumors. In a number of
cases collected by Gros and Lancereaux there were small areas of
softened tissue or small calcareous and caseous masses or cerebral
lacunæ corresponding to the cicatrices of softening or imperfect
cysts, coincident with evidences of syphilis elsewhere. V. Cornil also
states that he has found small areas of softening with well-
established syphilitic lesions of the dura mater and cranium, but
believes that the lacunæ or cysts depend rather upon chronic
syphilitic lesions of cerebral arteries than upon gummatous
inflammation.

When a gummatous tumor comes in contact with an artery, the latter

is usually compressed and its walls undergo degeneration. The
specific arteritis may pass beyond the limit of the syphilome and
extend along the arterial wall. Not rarely there is under these
circumstances a thrombus, and if the artery be a large one
secondary softening of its distributive brain-area occurs.

TREATMENT.—The treatment of cerebral syphilis is best studied under

two heads: First, the treatment of the accidents which occur in the
course of the disease; second, the general treatment of the disease
itself.

It must be remembered that in the great majority of cases in which

death occurs in properly-treated cerebral syphilis the fatal result is
produced by an exacerbation—or, as I have termed it, an accident—
of the disease. Under these circumstances the treatment should be
that which is adapted to the relief of the same acute affection when
dependent upon other than specific cause. In a large proportion of
cases the acute outbreak takes the form either of a meningitis or
else of a brain congestion. In either instance when the symptoms are
severe free bleeding should be at once resorted to. The amount of
blood taken is of course to be proportionate to the severity of the
symptoms and the strength of the patient. I have seen life saved by
the abstraction of about a quart of blood, whilst in other cases a few
ounces suffice. Care must be, of course, taken not to mistake a
simple epileptic fit for a severe cerebral attack; but when this fit has
been preceded by severe headache and is accompanied by stupor,
with marked disturbance of the respiration, measures for immediate
relief are usually required; and if the convulsions be perpetually
repeated or if there be violent delirious excitement, the symptoms
may be considered as very urgent. In taking blood the orifice should
be large, so as to favor a rapid flow, and the bleeding be continued
until a distinct impression is made upon the pulse. In some cases
which I have seen in which the action of the heart continued to be
violent after as much blood as was deemed prudent had been taken,
good results were obtained by the hypodermic injection of three
drops of the tincture of aconite-root every half hour until the
reduction of the pulse and the free sweating indicated that the
system was coming under the influence of the cardiac sedative.

Of course, I do not mean to encourage the improper or too free use

of the lancet in these cases, but in the few fatal cases which I have
seen I have almost invariably regretted that blood had not been
taken at once very freely at the beginning of the acute attack. In
most of these cases the symptoms had progressed too far for good
to be achieved before I reached the patient. After venesection, or in
feeble cases as a substitute for it, the usual measures of relief in
cerebral congestion should be instituted. I shall not occupy space
with a discussion of these measures, as they are in no way different
from those to be employed in cases not syphilitic.

The most important part of the treatment of cerebral syphilis itself is

antisyphilitic, and the practitioner is at once forced to select between
the iodide of potassium and the mercurial preparations. In such
choice it must be remembered that even a very small amount of
syphilitic deposit in the brain may at any time cause a sudden
congestion or other acute attack, and is therefore a very dangerous
lesion. I have seen a cerebral syphilis which was manifested only by
an epileptic attack occurring once in many months, and in which
after death the affected membrane was found to be not larger than a
quarter of a dollar, and the deposit not more than an eighth of an
inch in thickness, suddenly produce a rapidly fatal congestion; and I
have known a case fast progressing toward recovery suddenly
ended by the too long continuance of the arrest of respiration during
an epileptic fit. I have, myself, no doubt of the superiority of the
mercurials over the iodide of potassium as a means of producing
absorption of gummatous exudates; and as these exudates in the
brain are so very dangerous, a mercurial course should in the
majority of cases of cerebral syphilis be instituted so soon as the
patient comes under the practitioner's care. When, however, there is
a history of a recent prolonged free use of the mercurial, or when
there is marked specific cachexia, the iodide should be chosen.
Cachexia is, however, a distinctly rare condition in cerebral syphilis,
the disease usually developing in those who have long had apparent
immunity from the constitutional disorder. In my opinion the best
preparation of the mercurial for internal use is calomel. It should be
given in small doses, one-quarter of one grain every two hours,
guarded with opium and astringents, so as to prevent as far as
possible disturbance of the bowels, and should be continued until
soreness of the teeth, sponginess of the gums, or other evidences of
commencing ptyalism are induced. After this the dose of the
mercurial should be so reduced as simply to maintain the slight
impression which has been created, and the patient should be kept
under the mercurial influence for some weeks.

A very effective method of using the mercury is by inunction, and

where the surroundings of the patient are suitable the mercurial
ointment may be substituted for the calomel. It should be applied
regularly, according to the method laid down in my treatise on
therapeutics. I have sometimes gained advantage by practising the
mercurial unction and at the same time giving large doses of iodide
of potassium internally.
After a mercurial course the iodide of potassium should always be
exhibited freely, the object being not only to overcome the natural
disease, but also to bring about the complete elimination of the
mercury from the system. There is no use in giving the iodide in
small doses; at least a drachm and a half should be administered in
the twenty-four hours, and my own custom has been to increase this
to three drachms unless evidences of iodism are produced. The
compound syrup of sarsaparilla covers the disagreeable taste of the
iodide of potassium better than any other substance of which I have
knowledge. Moreover, I am well convinced that there is some truth in
the old belief that the so-called “Woods” are of value in the treatment
of chronic syphilis. I have seen cases in which both the iodide of
potassium and the mercurials had failed to bring about the desired
relief, but in which the same alteratives, when given along with the
“Woods,” rapidly produced favorable results. The old-fashioned
Zittmann's decoction, made according to the formula of the United
States Dispensatory, may be occasionally used with very excellent
effect. But I have gradually come into the habit of substituting a
mixture of the compound fluid extract and the compound syrup of
sarsaparilla in equal proportions. The syrup itself is too feeble to
have any influence upon the system, but is here employed on
account of its flavor. A favorite method of administration is to furnish
the patient with two bottles—one containing a watery solution of the
iodide of potassium of such strength that two drops represent one
grain of the drug, and the other the sarsaparilla mixture above
mentioned. From one to two drachms of the solution of the iodide
may be administered in a tablespoonful of the sarsaparilla well
diluted after meals. When the patient has been previously
mercurialized, or there is any doubt as to the propriety of using
mercurials, corrosive sublimate in small doses may be added to the
solution of the iodide, so that one-tenth to one-fifteenth of a grain
shall be given in each dose. I have never seen especial advantage
obtained by the use of the iodides of mercury. They are no doubt
effective, but are not superior to the simpler forms of the drug.
 Syphilitic Disease of the Brain-Cortex.

The psychical symptoms which are produced by syphilis are often

very pronounced in cases in which the paralysis, headache,
epilepsy, and other palpable manifestations show the presence of
gross brain lesions. In the study of syphilitic disease of the brain-
membranes sufficient has been said in regard to these psychical
disturbances, but the problem which now offers itself for solution is
as to the existence or non-existence of syphilitic insanity—i.e. of an
insanity produced by specific contagion without the obvious
presence of gummatous disease of the brain-membranes. Very few
alienists recognize the existence of a distinct affection entitled to be
called syphilitic insanity, and there are some who deny that insanity
is ever directly caused by syphilis. It is certain that insanity often
occurs in the syphilitic, but syphilis is abundantly joined with
alcoholism, poverty, mental distress, physical ruin, and various
depressing emotions and conditions which are well known to be
active exciting causes of mental disorder. It may well be that syphilis
is in such way an indirect cause of an insanity which under the
circumstances could not be properly styled syphilitic.

If there be disease of the brain-cortex produced directly by syphilis,

of course such disease must give rise to mental disorders; and if the
lesion be so situated as to affect the psychic and avoid the motor
regions of the brain, it will produce mental disorder without paralysis
—i.e. an insanity; again, if such brain disease be widespread,
involving the whole cortex, it will cause a progressive mental
disorder, accompanied by gradual loss of power in all parts of the
body, and ending in dementia with general paralysis; or, in other
words, it will produce an affection more or less closely resembling
the so-called general paralysis of the insane, or dementia paralytica.

As a man having syphilis may have a disease which is not directly

due to the syphilis, when a syphilitic person has any disorder there is
only one positive way of determining during life how far said disorder
is specific—namely, by studying its amenability to antisyphilitic
treatment. In approaching the question whether a lesion found after