The prevalence of parasitic skin diseases is a striking feature. A more general use of soap, and ordinary cleanliness, would destroy half the material of the dermatological clinics here. Lupus is an every-day disease.

I have seen comparatively little of the surgical, gynecological and obstetrical work, for I have merely looked in at Von Eiselsberg's, Chrobak's and Shanta's clinics. I have seen nothing very different from our own hospital work in these departments. I note that American physicians particularly interested in surgery do not take much surgical work in the clinics, but study especially the subjects bearing upon surgery which are better taught here than with us, as, for example, bacteriology and pathology.

I am rejoiced to learn of the definite union of the medical schools of Denver and shall look for excellent work from the new school. I hope to be with you at the opening of the new work. J. W. H.

SYPHILIS OF THE NERVOUS SYSTEM.

By MILLARD P. SEXTON, M.D.,

Kansas City, Missouri.

Syphilitic affections of the nervous system are of such extreme frequency and so widely disseminated as to make it impossible to enter into a comprehensive discussion of the subject within the limits of this paper. I have chosen, therefore, to confine myself to a brief consideration of the pathology and clinical history of syphilitic affections of the nervous system with especial reference to diagnostic criteria.

I shall also devote a considerable proportion of my paper to syphilis affecting the mind, with particular reference to points of differential diagnosis between syphilis and paresis. In this connection I desire to state that for much that appears in this paper I am indebted to my friend, Dr. Hugh T. Patrick of Chicago, whose writings and published lectures along this line are, in my opinion, of the greatest value in studying the neurology and psychiatry of syphilis.

In its relation to the nervous system, syphilis may be conveniently considered under two heads, namely: (1) Those cases in which the morbid processes are directly traceable to the specific

virus, and (2) those which are due to the remote influence of the infection and which do not present neoplastic products. The first is microbic in character and the second is a chemical toxemia affecting nutritional processes. The one is styled specific, whilst the other may be more properly designated as parasyphilitic. In either form syphilis may be transmitted to offspring, some hereditary cases being marked as gummatous processes in the nervous system and others by nutritional disturbances only. It is a further fact that both forms of the disease, either acquired or hereditary, may co-exist in the same subject.

As in other parts of the body, so also in the nervous system, specific lesions always begin in the connective tissue and blood vessels, later encroaching upon the parenchyma. The primary effect is an interference with the function of the diseased organ or tissue; the ultimate result is the destruction of cell and fiber.

In a very considerable proportion of all luetic cases of acquired syphilis there are specific lesions of the central nervous system, a conservative estimate being from 2 to 3 per cent., apart from tabes and general paresis. In tertiary syphilis probably 12 or 15 per cent. of all cases involve the cerebro-spinal axis.

Syphilitic gummata are irregular masses, somewhat globular inform and vary in size from that of a filbert to that of a walnut. They are sometimes solitary, but more often multiple, and the variability in number and location of the growths, affecting brain centers and motor paths in no way related to each other, causes syphilomata to present a clinical picture apparently confusing but really characteristic.

Syphilitic meningitis occurring in the basal membrane is the principal form of this disease affecting the brain and is often quite extensive, involvng the origin of the cranial nerves, the optic and motor oculi nerves being impinged upon and producing degeneration, paralysis or impairment of function in those nerves which so strongly indicate the existence of syphilis.

It is the smearing of this gummatous inflammatory product on the basal membrane and subjacent nerves which constitutes the destructive action of syphilis on the third pair of cranial nerves. These nerves, on macroscopic examination, may seem to be normal, but upon close scrutiny they are found to be glossy gray or a yellowish white.

In 100 cases of brain syphilis reported by Uthoff and quoted by Mink of St. Louis, there were involvement of the

oculomotor 34 times, the abducens 16 times, the trigeminus 14 times, the patheticus 5 times. The great frequency of optic neuritis is well known.

The most certainly damaging lesion of syphilis is that form of endarteritis, described by Huebner, in which an exudate from the nutrient vessels serves to obliterate the lumen of the artery, areas of softening being the natural result of such a process. When we consider the various pathologic processes which so frequently occur in syphilis and the ephemeral nature of gummatous lesions, it is by no means surprising that the clinical picture should present so many diverse phenomena, not only at the same time, but succeeding each other in the same case. This statement is emphasized by the fact that brain syphilis does not at all imply a tertiary form of the disease, but the nervous system may be attacked very early in the disease, even before the advent of secondary skin symptoms. If the disease appearing thus early follows its natural course, the ensuing paralyses or focal symptoms may be exceedingly diverse in character, but if the morbid processes and gummatous deposits are being modified by half-hearted therapeutic measures, as is too often the case, the phenomena presented are protean indeed.

Concerning the so-called degenerative diseases due to the more remote or residual effects of syphilis-the parasyphilitic diseases, such as tabes and general paresis-it must be remembered that the direct ravages of the virus are not operative in their genesis or perpetuation, and therefore specific treatment, as such, is unavailing in these cases. It is a fact, however, that in many diseases of the nervous system the removal of exudates is facilitated by the administration of large doses of iodides. Now, since specific disease and parasyphilitic disease may co-exist in the same case, and since the latter may be benefited by the administration of iodides and the former may invade the nervous system in spite of the most vigorous antisyphilitic treatment, it follows that the therapeutic test is not always a reliable diagnostic criterion. Still, upon the theory that the proof of the pudding lies in the eating, if a serious affection of the brain or cord is cured or markedly benefited in a short time by specific treatment, the inference is strong that the disease was syphilitic. If the focal symptoms are diversified and ephemeral and rapidly clear up under specific treatment, the diagnosis may be fairly positive. Furthermore, if the somatic symptoms do not accord with the pathology of any other disease, we may oftentimes look to

syphilis for a key to the atypical symptom complex. In other words, syphilis of the nervous system is pre-eminently a disease to diagnosticate by exclusion.

There is no sort of doubt but that too much weight is given to negative history in the diagnosis of syphilis. There are too many innocent means of contracting the disease for real or supposed purity of life to be given very much consideration in excluding syphilis. This, for obvious reasons, is particularly true of women, but it is measurably true of men as well. When I find convincing evidence of syphilis I pay very little attention to the asseverations of the patient, and very little to the statements of his family physician, from whom he is often most anxious to conceal his disease if he knows that he has it.

Reverting to the diagnostic value, or want of value, of specific treatment, even when it is inaugurated early, is often futile in protecting the nervous system from the ravages of the disease, and thus, notwithstanding the fact that the treatment appears to be efficacious along other lines than appertaining to the nervous system. In other words, there is no question but that the views entertained by the profession, and even by the laity, are too optimistic as regards the efficacy of treatment of brain or cord syphilis.

The treatment of syphilis of the nervous system embraces the same principles as those that apply in any other form of the disease, unless it may be that there is, at least apparently, greater urgency required to obtain prompt results. I say apparently, because the danger of invasion of nerve centers is so great in all cases as to indicate the propriety of vigorous therapeusis without delay. And by delay I do not mean procrastination, but I mean dilly-dallying with small doses-beginning with what will do no good and increasing it day by day in a timorous sort of way as if the iodide were more dangerous than the disease. As Patrick so well puts it, "When a man sets out to kill a serpent with a club he does not begin by castigating it with a switch." I never begin with less than 30 grains t. i. d., and this amount I increase rapidly, and not gradually, to the limit of tolerance. I wish to state, however, that it is my opinion that the iodides are nearly always given too soon after the meal and much of their potency is neutralized by the starchy elements in the food. And I believe that 60 grains given two hours after a meal will have as much effect as 100 grains given immediately or shortly after the meal.

SYPHILITIC INSANITY.

Although neural or brain tissues are not directly attacked by the virus of syphilis, the degradation of fibers and cells brought about by alterations in the blood supply, the pressure of tumors and syphilitic meningitis naturally results in frequent and varied psychic disorders. I am satisfied from my own limited experience that Berkley and Patrick are correct in attributing to syphilis a much larger proportion of cases of insanity than some of the older authorities do. Further, it is my belief that failure to recognize syphilis as a cause of insanity is due mainly to the resemblance of syphilitic insanity to general paresis and largely to the fact that when syphilis is suspected ineffectual means are employed for its eradication, and the erroneous conclusion is reached that because the patient had not been cured by antisyphilitic treatment, therefore the diagnosis. or suspicion of syphilis was incorrect.

In calling attention to some of the points of difference between syphilitic insanity and paresis or paretic dementia. I wish it understood that I do not allude to such cases of insanity as accidentally or incidentally occur as a sequence of syphilis, but to mental disorder due directly to brain syphilis. Whatever opinion may be expressed to the contrary by over-confident alienists and syphilologists, the clinical points of resemblance between syphilitic insanity and paresis are so close as to puzzle the most expert diagnostician, and in some cases to make a differentiation impossible without careful study and continued observation of the case. In has been well said that there is no mental symptom in one of these diseases which may not be found in the other. The expansive ideation, the delusions of grandeur and the childish tendency to be pleased and enthusiastic over commonplace things are common to both, and in the absence of a satisfactory history and of somatic signs the diagnosis presents considerable difficulty. If there be any type of crossed paralysis, such as paralysis of the oculo-motor nerve on one side and of the extremities on the other, the case is so characteristic of syphilis as to readily exclude paresis. On the one hand syphilis is almost positively excluded by the concurrence of the Argyll Robertson pupil and the abolished knee-jerk. Single or multiple cranial nerve paralysis, associated with severe headache and stupor and not occurring as a sequel to scarlet fever or diphtheria, are indications of syphilis. Chasmus and ptyalism indicate paresis. In a general way it may be said that paresis is more slow and insidious in its onset than