last stages the patient becomes demented, the bladder and rectum become unretentive, the health fails, and the patient becomes bedridden. Death results from exhaustion or from intercurrent disease.

The course of the disease is progressive, with periods of temporary improvement. The average duration is from three to four years.

The prognosis is unfavorable.

Treatment. In syphilitic cases a thorough course of iodide and mercurials should be employed, but not much is to be expected from the treatment. Nursing and a quiet life in an asylum really constitute the only treatment of the disease.

CHRONIC HYDROCEPHALUS.

An increase in the amount of fluid in the ventricles occurs in a congenital and an acquired form.

CONGENITAL HYDROCEPHALUS.-No known cause has been discovered for this condition. It has occurred in several members of the same family. The lateral ventricles are principally affected, and are distended with fluid, so that the cerebral cortex over them is thin and stretched and may be converted to a thin shell less than a quarter of an inch in thickness. The sutures and fontanelles are widely distended, so that the skull becomes enormously enlarged, in some cases exceeding thirty to thirty-two inches in diameter for a child of two or three years. The bones of the cranium are thinned, the orbital plates are so depressed as to cause exophthalmos. The fluid is limpid, contains traces of albumin and salts, and sometimes contains urea.

Symptoms. The head may be so large at birth as to interfere with natural labor. In other cases the head does not increase in size until several weeks after birth. The child is restless and irritable. There is difficulty in getting

the child to walk, or the legs may be feeble and in a condition of exaggerated reflexes. A few children are bright, but in the great majority some grade of imbecility is present. Strabismus and optic atrophy may develop; nystagmus is commonly present. Vomiting, coma, and convulsions ultimately appear, and the child rarely lives for more than three or four years.

ACQUIRED CHRONIC HYDROCEPHALUS. This condition may result from compression or obliteration of the straight sinus or of the passage from the third to the fourth ventricle by a tumor; other cases follow meningitis. In a few instances the condition arises without known cause ("serous apoplexy").

The symptoms are obscure, and a diagnosis during life is but seldom made. Headache, optic neuritis proceeding to atrophy, and attacks of stupor are commonly observed. The head in the acquired form does not enlarge. There are no localizing symptoms.

Treatment of Hydrocephalus.-Gradual compression of the skull should be made by straps of adhesive plaster crossed in various ways. When pressure-symptoms are present, puncture of the ventricles by a fine aspirating needle and the withdrawal of small quantities of fluid from time to time are justifiable procedures. The subarachnoid sac between the third and fourth lumbar vertebræ may be punctured without risk of injury to the cord, and the fluid slowly removed without much danger of collapse. Medicines are useless, although inunctions of mercury and the administration of potassium iodide have been recommended.

SYPHILIS OF THE BRAIN.

Congenital syphilis of the brain may develop during early childhood, but it is rare. The acquired form is usually a late tertiary manifestation of the disease, although

it may develop in from six months to thirty years after the primary sore. The earlier occurrence of symptoms is by some authors attributed to the appearance upon the membranes of an actual syphilitic eruption analogous to the cutaneous exanthems of the secondary period.

1. Syphilis of the Bones of the Cranium.-The lesion consists in the formation of spots of dry caries, nodes, and necrosis. Cerebral symptoms arise only if the membranes be secondarily inflamed. If the lesions involve the foramina through which the cranial nerves pass, there will be developed neuralgic pains or motor spasms, followed by anæsthesia or paralysis.

2. Syphilitic Meningitis. - The membranes show the lesions of an acute or chronic inflammation, and are invaded by gummata. The symptoms are those of the meningitis. and those of the multiple tumors pressing on the cortex, and according to the predominance of either group of symptoms the case will resemble acute or chronic meningitis or cortical tumors. The suggestive points of syphilitic meningitis are (1) Headache, existing several weeks before the onset of other symptoms, severe in character, and worse at night, preventing sleep; (2) the admixture of symptoms of inflammation of the meninges and of cortical tumors; (3) the rapid improvement under treatment.

3. Gummata of the Brain.-The symptoms of braintumor are frequently preceded by intense nocturnal headache, by temporary incomplete paralysis of an arm or a leg, or by temporary squint. These partial passing palsies are quite suggestive of cerebral syphilis. The general and localizing symptoms of cerebral gummata have been discussed under the heading of Tumors of the Brain.

4. Syphilitic Endarteritis.-The syphilitic changes in the walls of the cerebral arteries were described by Huebner in 1874, and the lesion is known as "Huebner's arteries."

The lesion consists in a thickening of the intima by connective tissue, in some cases leading even to an obliteration of the lumen. Areas of softening may occur in the braintissue, from the obliteration of the lumen of the vessel by this new growth or by thrombus-formation. The middle cerebral artery is the one most usually and most extensively affected. The symptoms resemble those of cerebral endarteritis. Syphilitic stupor and paralysis require special description.

Syphilitic Stupor.-The patient complains of severe nocturnal headache, and after a time passes into a peculiar somnolent condition; he may lie for days apparently asleep, or may sit for hours at a time in a torpid, dazed state of mind, answering questions in a peculiar, slow, automatic way, as though talking in his sleep. From time to time the patient may wander about in an aimless fashion. The evidences of severe headache are usually marked, even during the periods of stupor. Prolonged stupor is of serious import, but is not incompatible with complete recovery. The majority of cases, unless relieved by treatment, suddently pass into a condition of profound coma, which is usually fatal.

Syphilitic paralysis comes on suddenly, without loss of consciousness and without exciting cause. The paralysis, which is not complete, and is of a transitory, fugitive character, may be of irregular distribution or may be hemiplegic in type. Oculo-motor paralysis is not uncommon. These fugitive palsies are due to functional brain-disturbance from the diminished blood-supply through the narrower arteries. Should thrombus occur, softening will ensue, so that the paralysis becomes permanent.

5. Syphilitic disease of the brain may present nearly the clinical picture of general paresis. The exact pathology of these cases, however, is not known, and it cannot be

asserted as yet that this form of syphilitic brain disease is an independent affection.

The prognosis is, upon the whole, favorable, although it should be guarded. More or less recovery is to be expected unless the symptoms indicate an absolute destruction of brain-tissue.

Treatment consist in the vigorous employment of antisyphilitic drugs. Mercury should at once be ordered by inunction, and pushed until the "gums are touched." Salivation, however, should always be avoided.

Potassium iodide in 30-grain doses three times a day, largely diluted in water or milk, should be pushed rapidly until 300 grains daily are taken, unless the patient show such dangerous symptoms of iodism as hemorrhages. In cases of sudden coma timely venesection may be the means of saving life.

4. DISEASES OF THE SPINAL CORD.

(a) AFFECTIONS OF THE MENINGES.

DISEASES OF THE DURA MATER.

PACHYMENINGITIS EXTERNA occurs in an acute and in a chronic form. The acute cases regularly are secondary to inflammation of the vertebral bones or to the extension of neighboring abscesses. The inflammation is fibrino-purulent and gives the symptoms of a compression-myelitis.

CHRONIC EXTERNAL PACHYMENINGITIS is usually due to tubercular disease of the vertebræ. The external layer of the dura is rough, thickened, and covered with cheesy material.

The symptoms are due to irritation and compression of the anterior and posterior nerve-roots (hyperæsthesia and