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death is specific or not, of course such a therapeutic test as that just
given is inapplicable. We can only study as to the coexistence of the
lesion in consideration with other lesions known to be specific. Such
coexistence of course does not absolutely prove the specific nature
of a nutritive change, but renders such nature exceedingly probable.

What has just been said foreshadows the method in which the
subject in hand is to be here examined, and the present article
naturally divides itself into two sections—the first considering the
coexistence of anatomical alterations occurring in the cerebral
substance with syphilitic affections of the brain-membranes or blood-
vessels, the second being a clinical study of syphilitic insanity.

In looking over the literature of the subject I have found the following
cases in which a cerebral sclerotic affection coincided with a
gummatous disease of the membrane. Gros and Lancereaux60
report a case having a clear syphilitic history in which the dura mater
was adherent to the skull. The pia mater was not adherent. Beneath,
upon the vault of the brain, was a gelatinous exudation. The upper
cerebral substance was indurated, and pronounced by Robin after
microscopic examination to be sclerosed. At the base of the brain
there were atheromatous arteries and spots of marked softening.
60 Affec. Nerv. Syphilis, 1861, p. 245.

Jos. J. Brown61 reports a case in which the symptoms were

melancholia, excessive irritability, violent outbursts of temper, very
positive delusions, disordered gait, ending in dementia. At the
autopsy, which was very exhaustive, extensive syphilitic disease of
the vessels of the brain and spinal cord was found. The pia mater
was not adherent to the brain. The convolutions, particularly of the
frontal and parietal lobes, were atrophied, with very wide sulci filled
with bloody serum. The neuroglia of these convolutions was much
increased, and “appeared to be more molecular than normal, the
cells were degenerated, and in many places had disappeared, their
places being only occupied by some granules.” These changes were
most marked in the frontal convolutions.
 61 Journ. Ment. Sci., July, 1875, p. 271.

H. Schule reports62 a very carefully and meritoriously studied case.

The symptoms during life exactly simulated those of dementia
paralytica. The affection commenced with an entire change in the
disposition of the patient; from being taciturn, quiet, and very
parsimonious, he became very excited, restless, and desiring
continuously to buy in the shops. Then failure of memory, marked
sense of well-being, carelessness and indifference for the future,
developed consentaneously with failure of the power of walking,
trembling of the hands, inequality of the pupils, and hesitating
speech. There was next a period of melancholy, which was in time
followed by continuous failure of mental and motor powers, and very
pronounced delirium of grandeur, ending in complete dementia.
Death finally occurred from universal palsy, with progressive
increase of the motor symptoms. At the autopsy characteristic
syphilitic lesions were found in the skull, dura mater, larynx, liver,
intestines, and testicles. The brain presented the macroscopic and
microscopic characters of sclerosis and atrophy; the neuroglia was
much increased, full of numerous nuclei, the ganglion-cells
destroyed. The vessels were very much diseased, some reduced to
cords; their walls were greatly thickened, and full of long spindle-
shaped cells, sometimes also containing fatty granules.
62 Allgem. Zeitschrift f. Psychiatrie, xxviii. 171, 172.

C. E. Stedman and Robt. T. Edes report63 a case in which the

symptoms were failure of health, ptosis, trigeminal palsy with pain
(anæsthesia dolorosa), finally mental failure with gradual loss of
power of motion and sensation. At the autopsy the following
conditions were noted: apex of the temporal lobe adherent to dura
mater and softened; exuded lymph in neighborhood of optic chiasm;
sclerosis of right Gasserian ganglion, as shown in a marked increase
of the neuroglia; degeneration of the basal arteries of the brain.
63 American Journ. Med. Sciences, lxix. 433.
These cases are sufficient to demonstrate that sclerosis of the brain-
substance not only may coexist with a brain lesion which is certainly
specific in its character, but may also present the appearance of
having developed pari passu with that lesion and from the same
cause.

It has already been stated in this article that cerebral meningeal

syphilis may coexist with various forms of insanity, and cases have
been cited in proof thereof. It is of course very probable that in some
of such cases there has been that double lesion of membrane and
gray brain matter which has just been demonstrated by report of
autopsies; but if we find that there is a syphilitic insanity, which exists
without evidences of meningeal syphilis, and is capable of being
cured by antispecific treatment, such insanity must be considered as
representing the disease of the gray matter of the brain. Medical
literature is so gigantic that it is impossible to exhaust it, but the
following list of cases is amply sufficient to prove the point at issue—
namely, that there is a syphilitic insanity which exists without obvious
meningeal disease, and is capable of being cured by antisyphilitic
treatment:

Reporter
No. Symptoms. Results.—Remarks.
and Journal.
1 Luis Epilepsy, delirium of exaltation, alteration of Rapid cure with mercury.
Streisand speech, headache, failure of memory.
Die Lues als
Ursache der
Dementia,
Inaug. Diss.,
Berlin, 1878.
2 Ibid. Delusions, delirium, general mania, great Cure with mercury.
muscular weakness.
3 Müller of Symptoms resembling general paralysis, and Cure by iodide of
Leutkirch diagnosis of such made until a sternal node potassium.
Journ. of was discovered.
Mental Dis.,
 1873–74,
561.
4 Esmarch Sleeplessness, great excitement, restlessness, Cure by mercury.
and W. great activity, incoherence, and violence.
Jersen
Allgem.
Zeitschrift f.
Psychiatrie.
5 Leidesdorf Complete mania; played with his excrement, Complete cure by iodide
Medizin. and entirely irrational. of potassium.
Jahrbucher,
xx., 1864, 1.
6 Beauregard Symptoms resembling those of general Cure by iodide of
Gaz. paralysis. potassium.
hébdom. de
Sci. méd. de
Bordeaux,
1880, p. 64.
7 M. Rendu Loss of memory, headache, irregularity of Mercurial treatment, cure.
Ibid. pupils, ambitious delirium, periods of
excitement, others of depression,
embarrassment of speech, access of furious
delirium, ending in stupor.
8 M. Rendu Hypochondria, irregularity of pupils, headache, Mercurial treatment, cure.
Gaz. failure of memory, melancholy, stupor.
hébdom. de
Sci. méd. de
Bordeaux,
1880, p. 64.
9 Albrecht Melancholia with hypochondriasis, Iodide of potassium, cure.
Erlenmeyer sleeplessness, fear of men, and belief they
Die were all leagued against him.
Luëtischen
Psychosen,
Neuwied,
1877.
10 Ibid. Religious melancholia, with two attempts at Iodide of potassium, cure.
suicide, ending in mania.
11 Ibid. At times very violent, yelling, shrieking, Iodide of potassium, cure.
destroying everything she could get hands on,
at times erotomania; no distinct history of
infection, but her habits known to be bad, and
had bone ozæna and other physical syphilitic
signs.
12 Ibid. Epileptic attack followed by a long soporose Cured by mercurial
condition, ending in mental confusion, he not inunction.
knowing his nearest friends, etc.; almost
dementia.
13 Ibid. Great fear of gensd'armes, etc., mania, with Cured by mercurial
hallucinations, loud crying, yelling, etc., then inunctions with iodide
convulsion, followed by great difficulty of internally; subsequently
speech. return of convulsions,
followed by hemiplegia
and death.
14 Ibid. Great unnatural vivacity and loquacity, wanted Iodide of potassium, cure.
to buy everything, bragged of enormous gains Attended to business,
at play, etc.; some trouble of speech. and seems as well as
before. Relapsed. (See
Symptoms.)
Ibid. Fifteen months after discharge from asylum Failure of various anti-
Relapse of relapse; symptoms developing very rapidly, specific treatment.
Case 14. delirium of grandeur of the most aggravated
type, with marked progressive dementia, failure
of power of speech, and finally of locomotion.
15 A. Failure of mental powers, inequality of pupils, Iodide of potassium in
Erlenmeyer trembling of lip when speaking, uncertainty of ascending doses failed.
Die gait, almost entire loss of memory, once Recovery under mercurial
Luëtischen, temporary ptosis and strabismus. inunctions.
etc.
16 Ibid. Failure of mental powers, pronounced delirium Iodide of potassium,
of grandeur, hallucinations of hearing, failure of corrosive-sublimate
memory, strabismus and ptosis coming on late. injections. Cure.
17 Ibid. Failure of memory and mental powers, slight Cure with use of iodide
ideas of grandeur, disturbance of sensibility and mercurial inunctions.
and motility, aphasia coming on late.
18 Ibid. Melancholy, great excitability, ideas of Iodide of potassium
grandeur; after a long time sudden ptosis and failed; mercurial course
strabismus. improved; joint use cured
patient.
19 Ibid. Various cerebral nerve palsies, great relief by
use of mercurial inunctions, then development
of great excitement, delirium of grandeur,
failure of memory and mental powers, and
finally death from apoplexy; no autopsy.
20 J. B. Chapin Melancholia with attempted suicide, epilepsy, Iodide of potassium, cure.
Amer. Journ. headache, somnolent spells.
Insanity, vol.
xv. p. 249.
21 Ibid. Acute mania, noisy, very destructive; syphilitic Iodide of potassium, cure.
disease of tibia.
22 Snel Maniacal excitement. Cured by specific
treatment.
23 Wm. Smith Apathetic melancholy, indelicate, speaking only Rapidly cured by conjoint
Brit. Med. in monosyllables, and much of the time not at use of iodide and
Journ., July, all, sullen and menacing. mercurials. The
1868, p. 30. symptoms first developed
3 months after chancre.

A study of the brief analyses of the symptoms just given shows that
syphilitic disease of the brain may cause any form of mania, but that
the symptoms, however various they may be at first, end almost
always in dementia unless relieved.

Of all the forms of insanity, general paralysis is most closely and

frequently simulated by specific brain disease. The exact relation of
the diathesis to true, incurable, general paralysis it is very difficult to
determine. It seems well established that amongst persons suffering
from this disorder the proportion of syphilitics is not only much larger
than normal, but also much larger than in other forms of insanity.
Thus, E. Mendel64 found that in 146 cases of general paralysis, 109,
or 75 per cent., had a distinct history of syphilis, whilst in 101 cases
of various other forms of primary insanity only 18 per cent. had
specific antecedents. H. Obersteiner has 1000 cases of mental
disease,65 175 cases of dementia paralytica; of these, 21.6 per cent.
had syphilis; moreover, of all the syphilitic patients 51.4 per cent. had
dementia paralytica.
64 Progres. Paral. der Irren, Berlin, 1880.

65 Monatshefte f. prakt. Dermat., Dec., 1882.

Various opinions might be cited as to the nature of this relation

between the two disorders, but for want of space the curious reader
is referred to the work just quoted and to the thesis of C. Chauvet66
for an epitome of the most important recorded opinions.
66 Influence de la Syph. sur les Malad. du Syst. nerveux, Paris, 1880.

Those who suffer from syphilis are exposed in much greater

proportion than are other persons to the ill effects of intemperance,
sexual excesses, poverty, mental agony, and other well-established
causes of general paralysis. It may be that in this is sufficient
explanation of the frequency of general paralysis in syphilitics, but I
incline to the belief that syphilis has some direct effect in producing
the disease. However this may be, I think we must recognize as
established the opinion of Voisin,67 that there is a syphilitic
periencephalitis which presents symptoms closely resembling those
of general paralysis. Such cases are examples of the pseudo-
paralysie générale of Fournier.68
67 Paralysie générale des Alienés, 1879.

68 La Syphilis du Cerveau, Paris, 1879.

The question as to the diagnosis of these cases from the true

incurable paresis is of course very important, and has been
considered at great length by Voisin,69 Fournier,70 and Mickle.71
 69 Loc. cit.

70 Loc. cit.

71 Brit. and For. Med.-Chir. Review, 1877.

The points which have been relied upon as diagnostic of syphilitic

pseudo-general paralysis are—

The occurrence of headache, worse at night and present amongst

the prodromes; an early persistent insomnia or somnolence; early
epileptiform attacks; the exaltation being less marked, less
persistent, and perhaps less associated with general maniacal
restlessness and excitement; the articulation being paralytic rather
than paretic; the absence of tremulousness, especially of the upper
lip (Fournier); the effect of antispecific remedies.

When the conditions in any case correspond with the characters just
paragraphed, or when any of the distinguishing characteristics of
brain syphilis, as previously given, are present, the probability is that
the disorder is specific and remediable. But the absence of these
marks of specific disease is not proof that the patient is not suffering
from syphilis. Headache may be absent in cerebral syphilis, as also
may insomnia and somnolence. Epileptiform attacks are not always
present in the pseudo-paralysis, and may be present in the genuine
affection; a review of the cases previously tabulated shows that in
several of them the megalomania was most pronounced; and a case
with very pronounced delirium of grandeur, in which the autopsy
revealed unquestionably specific brain lesions, may be found in
Chauvet's Thesis, p. 31.

I have myself seen symptoms of general paralysis occurring in

persons with a specific history in which of these so-called diagnostic
differences the therapeutic test was the only one that revealed the
true nature of the disorder. In these cases a primary, immediate
diagnosis was simply impossible.
Case 14 of the table is exceedingly interesting, because it seems to
represent as successively occurring in one individual both pseudo
and true general paralysis. The symptoms of general paralysis in a
syphilitic subject disappeared under the use of mercury, to return
some months afterward with increased violence and with a new
obstinacy that resisted with complete success antisyphilitic
treatment. Such a case is some evidence that syphilis has the power
to produce true general paralysis.

In conclusion, I may state that it must be considered as at present

proven that syphilis may produce a disorder whose symptoms and
lesions do not differ from those of general paralysis; that true general
paralysis is very frequent in the syphilitic; that the only constant
difference between the two diseases is as to curability; that the
curable sclerosis may change into or be followed by the incurable
form of the disease. Whether under these circumstances it is
philosophic to consider the so-called pseudo-general paralysis and
general paralysis as essentially distinct affections, each physician
can well judge for himself.

Spinal Syphilis.

The subject of spinal syphilis is at present a difficult and

unsatisfactory one. The recorded cases with well-observed
autopsies are comparatively few, and when recovery occurs much
uncertainty must rest upon the nature of the lesion. More than this,
there is scarcely any chronic degeneration of the spinal cord which
has not been attributed to syphilis, and my own experience as well
as the records of medical literature lead to the very positive
conclusion that all the various spinal scleroses are much more
frequent in infected than in non-infected persons. Whether this is due
to a direct or indirect influence of the disease is uncertain, but I shall
not here discuss the relation of these chronic inflammations of the
cord to syphilis.
It seems necessary to briefly consider at this place acute and
subacute myelitis in their relations to syphilis. That these affections
are not rare in syphilitics is certain. In the Revue de Médecine (Jan.,
1884) Dejerine records the case of a person suffering from chronic
syphilis in whom there were fulgurant pains with increasing
weakness of the legs, and subsequently, after very severe exposure
to the weather, a sudden development of complete paraplegia
followed by trophic troubles, and death in twenty-eight days. At the
autopsy there was found a central myelitis with pronounced lesion of
the ganglionic cells, inflammatory changes of the pia mater,
capillaries, and neuroglia, extreme alteration of the nerve-roots, and
secondary degeneration of the columns of Goll and the lateral
columns. In a second case recorded by Dejerine there appears to
have been no exposure or apparent immediate exciting cause. The
symptoms and lesions were similar to those just spoken of, but death
occurred in eight days.

Whether such attacks as these occurring in syphilitic subjects are

produced directly by the syphilis or not is at present doubtful. The
same is true of subacute myelitis, of which I have reported two rather
peculiar fatal cases in syphilitic subjects. The general symptoms of
this affection are progressive loss of power with grossly exaggerated
reflexes, severe twitchings and jerkings of the legs, rigidity, usually
more or less marked pain, and other sensory disturbances in the
legs, and finally partial anæsthesia and complete paraplegia,
paralysis of bladder, bed-sores, and death from exhaustion. At the
autopsy the most important change in the cord has been the
presence of great numbers of round neuroglia-cells in both gray and
white matter. One of my cases died of a rapidly developed central
myelitis supervening upon the subacute disease, and affording
lesions similar to those described by Dejerine in addition to the
changes of the subacute affection.

In another class of spinal cases occurring in syphilitics the symptoms

resemble those of the so-called acute ascending paralysis (Landry's
paralysis). The fourth variety of syphilitic diseases of the spinal cord
of Huebner72 includes these cases. According to Huebner, they are
without anatomical lesions, but in the majority of the recorded cases
no proper microscopic study of the cord has been made. Huebner
states, however, that Kussmaul failed in one case after such study to
detect lesion. As some of these cases may really have been
instances of peripheral neuritis, it is essential that in the future the
peripheral nerves as well as the spinal cord be carefully studied. I
have seen one case which might be placed in this category. The first
symptom was some numbness in the legs, with a small deep sharp-
cut ulcer on the plantar surface of the great toe; directly after this
loss of motion and sensation in the legs and thighs, rapidly becoming
almost complete and spreading quickly to the trunk and arms, so that
in one week the patient was a flaccid, helpless mass, and the
breathing so interfered with that he was believed to be dying. After
almost losing the power of swallowing this patient began to get
better, and finally so regained power of his hands and feet that he
was able to partially dress himself and walk a distance of ten or
twelve feet, when he was suddenly seized with a pleural effusion and
died. During the first week of his disease his temperature was 100°
F. At the autopsy the spinal membranes were found to be normal.
But in the cord there were very distinct lesions found; the neuroglia
seemed everywhere more granular than normal; the ganglionic cells
were not distinctly diseased; the white matter in various places was
much changed, the tissue appearing abnormally dense and opaque
where most affected; the nerve-tubules appeared to gradually lose
their myeline, and in places were reduced to simple axis-cylinders.
Finally, the axis-cylinders became smaller and smaller until in the
most altered portions of the cord they disappeared. As the autopsy
was obtained with great difficulty, it was not possible to get the
peripheral nerves for study.
72 Ziemssen's Encyclopædia, vol. xii.

In regard to these very acute cases, it seems to me uncertain

whether the disease should be attributed to the syphilis. In my own
case twenty years had elapsed since the chancre, alcohol was
habitually used in great excess, and the attack was apparently
precipitated by great exposure. On the other hand, the man bore well
enormous doses of iodide of potassium, and lowly progressed under
them.

Finally, there is a class of disease of the spinal cord in which the

lesion is undoubtedly the direct outcome of a syphilitic diathesis. In
these cases the exudation commences primarily in the membranes
of the cord, and may extend into the cord itself. In this class I would
include the first two varieties of syphilitic spinal disease of Huebner.
The number of recorded autopsies is not great; the only cases with
which I am acquainted are those referred to in the note at the bottom
of this page.73
73 Winge (Dublin Med. Press, 2d Series, vol. ix., 1863); Moxon (Dublin Quarterly
Journ., li., 1870); Charcot and Gombault (Archiv. d. Physiologie, tome v., 143, 1873);
Schultze (Archiv. Psychiat., xii. 567); Thos. Buzzard (Diseases of Nervous System,
1882, p. 407); Julliard (Étude Crit. sur les Localis. Spinal de la Syphilis, 1879);
Westphal (Arch. Psychi., vol. xi.); Greif (Arch. Psychiat., xii. 579); Homolle (Progrès
méd., 1876).

The lesions in these cases are entirely similar to those of brain

syphilis. The disease very rarely or never begins in the interior of the
cord. I know of no recorded case: Wagner's case, in which a yellow
nodule was found within the cervical marrow, was probably not one
of syphilis. If a gummatous inflammation does occur inside of the
cord, it probably starts from the ependyma. The gummatous exudate
may occur in the form of small multiple formations or of an extensive
meningitis, with an infiltration of the membranes and their spaces
with gummatous material. The membranes are usually agglutinated
with one another and with the surface and with the cord. The
exudation is usually made up of roundish cells, and in several cases
spindle-shaped cells have been noticed, as have also the peculiar
Deitres corpuscles already described as they occur in brain syphilis.
The changes in the cord itself vary somewhat. In Winge's case the
white matter seems to have undergone a rapid myelitis from
pressure. It was of a grayish color, with numerous fine granular
masses, corpora amylacea, pigment-masses, and fatty globules, the
nerve-fibres being broken up. In other cases the change has been a
sclerosis. The vessels of the cord have been noticed by various
observers in the different stages of the degeneration seen in syphilis
of the brain. They are often greatly dilated, their walls thickened,
and, together with the lymph-spaces, infiltrated with small cells.
Minute hemorrhages have been found.

The so-called syphilitic callus, as described by Heubner, is probably

the remnant of a true gummatous inflammation. It consists of a
circumscribed induration one to several lines in thickness, originating
apparently from the dura mater, and causing sometimes adherence
with the vertebræ, in others with the membranes of the spinal cord.
In a case described by Virchow of this character the lesion was
cervical, and the symptoms were stiffness in the nape of the neck,
pains in the neck and arms, and finally paralysis in both arms. A
second case is elaborately described by Heubner in his article in
Ziemssen's Encyclopædia.

SYMPTOMS.—As the lesion of gummatous spinal syphilis affects

primarily membranes of the cord, in the beginning of the attack the
symptoms chiefly arise from the implication of the nerve-roots. Of
course these symptoms vary with the seat of the lesion, for it must
be remembered that the meningeal irritation is at first usually
localized in a small region. As in a majority of cases this lesion
affects a posterior portion of the cord, and as the posterior nerve-
roots seem especially sensitive to irritations of this character, pain is
usually a very marked and precocious symptom of spinal syphilis.
The seat of the pain varies with the seat of the lesion. At first the
pain is slight, but in most cases it soon becomes severe. It is
sometimes situated at a fixed spot on the spinal column, where,
according to Heubner, it may be increased on pressure. I have seen
two or three such cases, but have and still do believe that under
these circumstances the patient was suffering not simply from a
spinal syphilis, but also from an implication of the vertebral
periosteum or of the vertebræ themselves. In one of my cases this
diagnosis was confirmed at the autopsy. When the lesion is purely
meningeal there is probably no marked local tenderness. The severe
pains usually felt in the extremities or in the trunk are often fulgurant;
sometimes they are described as resembling the thrust of a knife,
and not rarely they closely resemble the pains of locomotor ataxia. In
some instances the pains are comparatively slight and are aching in
character. Paræsthesiæ are not rare phenomena: such are
formications, tingling in the extremities, numbness and feeling as
though the limb were asleep, intense sense of coldness on the
surface, sensation of water running over the limb. Early in the
disorder there is sometimes very marked hyperæsthesia, but later,
even though the pain persists, blunting of sensibility is marked, and
there may be a complete anæsthesia. This anæsthesia is sometimes
localized in certain parts of the limb. Thus, in a case reported by
Alfred Mathieu,74 although there was complete anæsthesia of the
outer side of the left leg and foot, the inner side retained its normal
sensibility. In some cases there is the abdominal cincture of ordinary
myelitis. The records show that even in these early stages there may
be diplopia, amblyopia, or other disorder of vision, and the pupil may
be distinctly affected. In these cases it is probably the upper portion
of the cord which is affected.
74 Ann. de Dermatol. et Syph., vol. iii., 1882.

Disturbances of motility in the majority of cases do not develop until

some time after sensation has been affected, but may come on very
early. Usually, the first symptoms are those of irritation, such as
rigidity of the neck, back, and limbs or even of isolated groups of
muscles. Tremors have been described as frequently present. These
may be convulsive, and are often plainly reflex in their origin; indeed,
I am inclined to believe that they are always reflex tremblings, and
never true tremors. Heubner describes a case in which a paralyzed
limb was thrown into violent tremblings whenever passive motion
was attempted. The patella-reflex is usually grossly exaggerated,
although it may be lost in the later stages of the disorder. Not rarely
there is the condition which has received the misnomer of spinal
epilepsy. This exaggeration of the reflexes may be limited to one leg,
when it is almost pathognomonic. In some cases severe cramps are
excited by movement. Usually there is no tenderness. These
symptoms of the meningitic stage may continue for weeks or months
without there being pronounced paralysis, although locomotion is not
rarely interfered with by the stiffness of the legs. Finally, if the case
progresses the patient notices a weakness in one or both legs, or (if
the disease be situated high up in the spinal cord) in one arm, which
rapidly increases until there is almost complete loss of power. This
rapid increase of palsy following long-continued disturbance of
sensation is almost pathognomonic. In most cases one side of the
body is more affected than the other. The sphincters are prone to be
implicated, and in advanced stages of the disease there is usually
complete loss of control over the bladder and rectum. The patient
may live for months without very distinct change of this condition, or
bed-sores and other trophic disturbances may rapidly develop and
death ensue in a short time. I have seen under these circumstances
marked elevation of temperature, rapid feeble pulse, mental
weakness, and the general symptoms of septicæmia last for many
weeks. Ammoniacal cystitis is of course prone to be developed
during this stage. When motility fails, sensibility is usually blunted,
although the pains may even increase. Heubner affirms that an
incompleteness of the anæsthesia is characteristic of the disorder.

The typical course of spinal syphilis, such as has been described,

may be variously departed from. Sometimes the power of co-
ordination is early affected, and the symptoms may resemble those
of locomotor ataxia. I doubt, however, whether under any
circumstances there is a loss of the patella-reflex in the early stages
of the gummatous disease of the spinal cord. In other cases the
paralytic symptoms may be very prominent from the beginning: thus,
in the case of R. P——, aged 27, which I believed to be gummatous
disease of the spinal cord, the first disorder was a feeling of malaise
lasting for about a week, followed by the sudden, rapidly-developed
paralysis of the bladder, loss of power in the legs, and to a less
extent in the arms, the only pain being a dull, steady ache in the
arms. The bowels were obstinately costive. Double vision was soon
very pronounced. When I first saw the patient, about three weeks
after this, there was decided impairment of sensibility in the legs, but
not in the arms; marked muscular weakness of both legs and arms;
no loss of co-ordinating power; dropping of the right eyelid, with
double vision; and only some slight aching pains in the arms. By the
use of large doses of iodide of potassium and other appropriate
measures a good recovery was secured.

A case illustrating the occasional difficulty of diagnosing spinal

syphilis is reported by C. Eisenlohr.75 The first symptom was
obstinate constipation, with very great discomfort after defecation;
then appeared incontinence of urine with weakness of the legs:
finally, a sudden complete palsy of the right leg occurred, with
marked anæsthesia in both legs, partial loss of power in left leg,
violent boring abdominal pains, and distress in the bladder. In the
last stages there were severe neuralgic pains in both legs, with
complete loss of sensation, bed-sores, atrophy of the leg-muscles,
with reactions of degeneration, and death from exhaustion. At the
autopsy an advanced meningitis was found which had apparently
commenced in the regions of the cauda equina, and given rise to
complete degeneration of the nerves. The only alteration of the cord
was an ascending degeneration of the posterior columns.
75 Neurolog. Centralb., 1884, p. 73.

Again, owing to the diseased condition of the vessels, a spinal

syphilis may be suddenly interrupted by an apoplectic accident.

In a patient of my own, who was believed to be suffering from

gummatous spinal meningitis, there was an abrupt development of
violent tearing pains, loss of power and sensibility, and all the other
symptoms which are characteristic of meningeal spinal hemorrhage.
A. Weber reports a case in which, after doubtful premonitory
symptoms, such as vertigo, loss of power on the right side, pressure
on the top of the head, and tinnitus aurium, there was a sudden
development of convulsions, and death. At the autopsy a syphilome
of the right vertebral artery was found with a recent thrombosis of the
basilar artery.76
76 American Journ. of Neur. and Psychiat., vol. ii.
 TUMORS OF THE BRAIN AND ITS ENVELOPES.

BY CHARLES K. MILLS, A.M., M.D., AND JAMES HENDRIE LLOYD

A.M., M.D.

DEFINITION.—Under the head of Tumors of the Brain and its

Envelopes will be considered all forms of growths occurring within
the skull, whether these involve the cranium itself, the membranes of
the brain, the brain-substance, or several of these parts conjointly. A
large majority of these growths spring from the brain-membranes.1
1 To this article will be appended a table of one hundred cases of brain tumor. Our
researches included the investigation of many more cases, four to five hundred in all.
Such a table, indeed, could be indefinitely extended. Our object, however, has been
not so much to present a large number of cases, and these in great detail, but rather
in the most condensed manner to give a definite number, carefully selected, from
which to draw conclusions. The cases have not been chosen with the view of
upholding any peculiar or preconceived views as to pathology, diagnosis, localization,
etc., but because of the carefulness with which they have been recorded. They have
been selected also, as will be seen, with the view of determining by clinico-
pathological data the possibility of localizing such growths during life. Many of our
general conclusions as to pathology, symptomatology, and diagnosis have been
drawn from this table.
With the exception of such merely substitutional terms as cerebral or
intracranial growths, neoplasms, or adventitious products, we have
no general synonyms for brain tumors.

The literature of the subject of brain tumors is second only to that of

such subjects as syphilis and hysteria. Vol. ii. of the Index Catalogue
of the Library of the Surgeon-General's Office, U. S. A., contains no
less than 632 references to this subject: number of books, 43;
articles, 589. The books and papers occur in different languages, as
follows: British, 142; French, 174; German, 133; American, 91;
Italian, 30; Latin, 15; Swedish, 14; miscellaneous, 33.

ETIOLOGY.—Under predisposing or constitutional causes are first to

be classed such special inheritances as tuberculosis or carcinoma
and tendencies to vascular degeneration. The occurrence of syphilis
of course predisposes its victims to cerebral or membranous
growths, as it does to other so-called tertiary forms of this disorder.

Hereditary predisposition only enters in so far as the individual

inherits a general tendency to the development of such affections as
cancer and tubercle. Hereditary tendency to a brain tumor per se
does not exist, but the individual who is of the tuberculous or
cancerous diathesis under special causes may develop an
intracranial growth. As to the comparative frequency with which
diathetic tumors originate, a reference to the tabular statement which
will be given under Pathology will be sufficient. Gliomata are very
common, but with them vie in frequency sarcomatous, tubercular,
and gummatous growths. Any table, unless it includes a very large
number of cases—at least a thousand or more—would be
misleading as to the proportionate frequency of these different forms
of intracranial constitutional diseases; but it is safe to say that
syphilitic, tuberculous, and carcinomatous or sarcomatous tumors
are of comparatively frequent occurrence.

Tumors of the brain occur oftener among men than women. This fact
is dependent largely upon the difference between the habits and
occupations of the two sexes. Men, in the first place, are much more
addicted to alcoholic, venereal, and other abuses which give rise to
special degenerations or constitutional infection; and secondly, they
are more exposed to traumatisms. In 100 cases the tumors occurred
among males in 58 cases, among females in 40 cases, and sex was
not recorded in 2 cases.

Statistics show that intracranial growths are more likely to occur

between puberty and middle age. Although gliomata may be found at
any age, brain tumors in children are more likely to be of this
character. This is what might be expected from the nature of these
growths. Histologically, gliomata are most closely allied to the
embryonal stage of the connective tissue, and, according to
Cohnheim, tumors generally are the result of a surplusage of
embryonal tissue—tissue which has remained over after the
requirements of normal development have been met. Of 16 gliomata,
3 occurred in patients under ten years, 2 between the ages of ten
and twenty, and 4 between twenty and thirty.

One hundred cases gave the following results as to age:

Under 10 years 10cases.

From 10 to 20 years 12cases.
From 20 to 30 years 18cases.
From 30 to 40 years 24cases.
From 40 to 50 years 12cases.
From 50 to 60 years 13cases.
From 60 to 70 years 3cases.
Over 70 years 1cases.
Not recorded 7cases.
100cases.

It is now generally admitted that injuries play a most important part

as exciting causes of brain tumors. Frequently in our experience an
apparently direct relation has existed between a head injury and the
origin of the neoplasm. In 6 out of 12 cases reported by one of us,2 a
history of traumatism was present, although in 5 of these a history of
syphilis was also present. The great frequency with which injuries of
all kinds occur must of course not be overlooked in this connection. It
is said by those who oppose the idea of the direct causal relations of
injury that almost every one could trace such disease to falls or
blows which few escape. In some of the cases of brain tumor,
however, the history of injury bears a direct relation in time to the
initial symptoms of the tumor. Certain tumors, as the fibromata,
osteomata, angiomata, would appear to be of more frequent
occurrence as the direct result of traumatism. The part played by
injuries in the production of carcinomata and sarcomata, whether in
the brain or elsewhere, has not infrequently been the subject of
dispute. We have no doubt that, a constitutional predisposition
existing, an injury frequently leads directly to the development of
some form of malignant growth. In not a few of the syphilitic cases
the history would appear to show that an injury to the skull had
localized the constitutional poison.
2 Archives of Medicine, vol. viii. No. 1, August, 1882.

Echinococci and cysticerci are found within the cranium, and

sometimes give rise to tumors, but the statement of Obernier can
hardly be regarded as true, that they play an important part in the
production of cerebral tumors. Our table shows only two cases of
this kind.

SYMPTOMATOLOGY.—The symptoms of intracranial tumors from the

standpoint of the course or progress of the affection can be divided
into an early or beginning, a middle or developed, and a late or
terminal stage.

Headache, vertigo, and vomiting are early symptoms, varying in

severity from slight to very serious manifestations, and slight and
changing mental phenomena are present. Eye symptoms, such as
slight diminution or blurring of vision, may or may not show
themselves; the ophthalmoscope may reveal the earliest
appearances of choked disc or neuro-retinitis.

In the second or middle stage, the period of the fully-developed

disease, we have an intensification and greatly increased constancy
of all the general symptoms, with some additional manifestations.