cealment which so olten actuates patients, glan- 
dular indurations, exostosis, in hereditary syphilis 
the peculiar teeth described by Hutchinson, and the 
record of many miscarriages and dead births. All 
these latter incidents may greatly assist us when they 
are present, which, unfortunately, is not the case in 
a number of cases of nervous syphilis. 
At the outset, it should be clearly understood that 
syphilis may affect the whole of the nervous system 
—the brain, spinal cord, peripheral nerves, mem- 
branes, sheaths, and the bony structures surrounding 
the nervous tissues, and the bloodvessels within the 
nervous tissues. It may assume the form of a diffuse 
infiltration, or it may be limited to a gumma, or it 
may be confined to the arteries, or there may be 
diffuse infiltrations, gummata, and arterial lesions in 
one subject. This diffuse infiltration takes its de- 
parture from the capillaries, and consists of num- 
bers of round cells spread throughout surrounding 
tissues. These are the round cells of the shape of 
those formations to which Virchow has given the 
name of granulation tumors, and for which other 
German pathologists have suggested the name of 
infectious-granulation-tumors, to which class belong 
the tubercular formations, lupus, lepra, actinomy- 
cosis, and glanders. The cellular character and 
behavior of each one of these different species are, as 
is well known, different, as is also their particular 
location within the body; and two of the salient 
characteristics of the cells thrown out in a syphilitic 
infiltration are: that they have scarcely any tendency 
to suppuration, undergoing a retrogressive metamor- 
phosis by non-suppurative transformations, and that 
the individual cells are endowed with extraordinarily 
long-lived vitality. These cells may often lie among 
the normal tissues for long periods of time and not 
do any really structural damage. On the other 
hand, they may set up truly destructive processes 
that may injure the component parts of a tissue as 
much as any other destructive process whatsoever. 
The arterial lesions were first described in 1874, 
by Dr. Heubner, of Leipsic, whose observations 
have given rise to further and often contradictory 
investigations by Koster, Friedlander, Baumgarten, 
Rumpf, and many others. Heubner advanced the 
view that in syphilitic vessels the endarteritis was 
peculiar in its place of origin, which was in the 
vessel-less tissue that lies between the membrana 
fenestrata and the endothelium. Normally the mem- 
brana fenestrata and the endothelium lie so close to 
one another that no intervening tissue can be seen 
microscopically. In syphilitic endarteritis, how- 
ever, Heubner maintains, they are widely separated 
by a new cellular formation, which consists of a pro- 
liferation of endothelial cells, to which, after a cer- 
tain time, there are added numbers of round cells, as 
in the ordinary granulation tumors. Heubner very 
minutely and carefully describes the differences in 
size of the endothelial cells in health and disease, as 
well as how to obtain an endothelium that has not 
been bruised by the ordinary act of cutting the 
vessel, and it is difficult for any one who reads his 
painstaking brochure to refuse credence to his plea 
for this peculiar anatomical site of syphilitic endar- 
teritis, nor is it easy to resist the wish that it were true, 
as it would constitute so invaluable a guide in dubious 
cases. But in the thirteen years that have elapsed 
since Heubner first made his views public, no one has 
fully confirmed him. Koster, Friedlander, Baum- 
garten, Huber, Schottdius, Marchand, Rumpf, deny 
that the endarteritic process starts in the vessel-less 
structure between the membrana fenestrata and the 
endothelium, or that it consists at first of an endo- 
thelial proliferation. They maintain, on the con- 
trary, that the endarteritis is due to the outpouring 
of round cells from the minute nutritive vessels of 
the vessels themselves—from the vasa vasorum— 
contained in the outer coats, and that the endo- 
thelial proliferation is only a part of the general 
cellular disturbance that takes place in consequence 
of this outpouring of rouqjl cells. The question 
SYPHILIS OF THE NERVOUS SYSTEM 
AND ITS TREATMENT.1 
By LANDON CARTER GRAY. M.D., 
PROFESSOR OF MENTAL AND NERVOUS DISEASES IN THE 
NEW YORK POLYCLINIC. 
1 Read, by invitation, before the Philadelphia Neurological 
Society, April' 25, 1887. 
The task which lies before me to-night is no easy 
one. It is the task of explaining, within a short 
space of time, the symptoms that may arise from a 
disease which affects the whole of the complicated 
machinery of the brain, the spinal cord, and the 
peripheral nerves. I cannot hope to do more than 
outline the subject. To treat it exhaustively would 
require a book, to which this paper might serve as 
an introduction. 
Some idea of medical interest in the matter may 
be obtained from a somewhat curious comparison. 
Professor Max Muller, the well-known philologist, 
informs us that the whole of the Sanscrit literature, 
running, as he expresses it, “like a high mountain- 
path of literature through the whole history of India, 
and extending over a period of three or four thou- 
sand years, is contained in about 10,000 manu- 
scripts”—more, the same authority estimates, than 
the whole classical literature of Greece and Italy put 
together.2 I have been able to count up some 500 
2 India; What can it Teach us. By F. Max Muller, 1883. 
different articles that have been written on the sub- 
ject of syphilis in the last thirty years, and there are 
probably many more. This is one-twentieth of the 
whole Sanscrit literature, or of the combined classical 
literature of Italy and Greece; and, therefore, in 
order that the literature of this one subject should 
equal these great national literatures, it would only 
take the time of about 600 years, or one-seventh to 
one-fifth of the time of the Sanscrit writings. 
Syphilis of the nervous system varies essentially 
from the syphilis about which the great syphilog- 
raphers of France, England, and America have 
written so voluminously, because the phenomena of 
the disease which they have described have been 
almost entirely confined to the cutaneous surface of 
the body. When this malady, however, affects the 
nervous centres and their peripheral appendages, it 
usually, I am prepared to say, has not been marked in 
its cutaneous manifestations. Most of the cases I 
have had the fortune to see have had this peculiarity. 
At the outset, therefore, we are met with one great 
difficulty, which does not bar the way of the derma- 
tologist—we are deprived of the diagnostic guidance 
of a group of symptoms which have been carefully 
studied for many long years ; and in their place no 
one has as yet suggested an equally pathognomonic 
group of nervous symptoms. Unguided by tfe tell- 
tale signs upon the exterior of the body, the history 
of the initial lesion may, as is probably well known 
to most of you, become very obscure. The primary 
sore being usually very slight, it may very easily be 
overlooked, even by those who are in search of it. 
The infection may come through the husband to 
the wife, innocently, too, so far as the latter is con- 
cerned. Not long ago I heard a lady telling some 
friends how she had been afflicted with an obstinate 
headache and subsequent inflammation of the eyes. 
Now, it so happened that this lady’s husband had 
died a short while before of intracranial syphilis, and 
on going to her attending physician, I found that he 
was entirely ignorant of the etiology of his patient’s 
symptoms. The infection may also come through a 
surgical operation, as is probably known to you; for 1 
suppose that there are very few communities of any 
size in which physicians caniiot be found who have 
infected themselves in this manner. Or the infection 
may come through a lesion innocently acquired about 
the buccal cavity, and even, perhaps, through articles 
of clothing. Ipfection through heredity is of no 
small account. F'or these different reasons, it may 
readily occur that many individuals may be entirely 
unaware of the disease of which they are the bearers. 
Add to these sources of error the tendency to con- nervous or mental disorder that it fiiay not have-a' 
syphilitic causation; and if we may draw conclu- 
sions from the nervous and mental disorders of re- 
cognized syphilitic causation, we should say that the 
prognosis of very few would be materially altered 
by such etiology. But over and above the well- 
recognized forms of nervous and mental disease, 
there are certain groups of symptoms which may 
fairly be regarded as indicative of specific infection, 
although the proof may not be greater than that to 
which the lawyers give the name of “ prima facie”— 
i. e., proof amounting to a presumption, which may, 
however, be rebutted by adequate testimony to the 
contrary. These symptom-groups, if I may allowed to 
formulate from my own experience, are as follows: 
1. Quasi-periodical cephalalgia of a peculiar kind. 
2. Hemiplegia under forty years of age, with or 
without preceding cephalalgia of the aforesaid type. 
3. Cephalalgia followed by hemiplegia, which 
bear a singular relationship to one another in that 
the cephalalgia ceases immediately upon the super- 
vention of the hemiplegia, and does not recur. 
4. Convulsions in the adult, which have not been 
preceded by convulsions in infancy, and are not of 
traumatic or nephritic origin, or due to pregnancy, 
or in an individual subject to migraine. 
5. Symptoms indicative of a lesion at the base of 
the brain. 
6. A comatose condition extending over days or 
weeks, not traumatic, meningitic, diabetic, nephritic, 
or from typhoid fever. 
7. Tabes dorsalis. 
8. General paresis. 
9. Spinal lesicns in a subject who has had intra- 
cranial syphilis. 
1. Quasi-periodical cephalalgia of a peculiar kind. 
One expression cf the quasi periodicity of syphi- 
litic cephalalgia that is well known to the profession 
is the nocturnal recurrence. But this characteristic 
may be other than nightly. I have known the head- 
ache to recur repeatedly at a certain time of the 
day, usually in the afternoon. What is very mis- 
leading, too, in the way of differentiation of malaria 
is that this cephalalgia may yield readily, although 
temporarily, to large doses of quinine. This quasi- 
periodical form of neuralgia may be accompanied 
by an obstinate insomnia, and by considerable 
mental irritability, both insomnia and irritability 
bearing no adequate proportion to the amount of 
pain ; when the latter signs are present, they are of 
considerable diagnostic importance, because the 
cephalalgia of brain tumor or nephritis is not usually 
accompanied by them. 
• 2. Hemiplegia under forty years of age, with or 
without preceding cephalalgia of the aforesaid type. 
It is a fair clinical distinction that can be used for 
guidance of one’s inquiry, upon first talking with a 
patient, to bear in mind that hemiplegia in the adult 
under forty years of age is usually of syphilitic origin, 
whilst hemiplegia in the adult above forty years of 
age is due to the chronic degenerative endarteritis 
of middle life and old age. Hemiplegia may occur 
in children, of course, from many other causes, and 
should, therefore, be ruled out in the present in- 
quiry. This adult hemiplegia of specific origin may 
be either motor or sensory, or both, for anatomical 
reasons that need not be explained. 
3. Cephalalgia followed by hemiplegia, which bear 
a singular relationship to one another, in that the 
cephalalgia ceases immediately upon the supervention 
of the hemiplegia, and does not recur. This is a 
curious clinical feature to which, so far as I know, 
no writer has yet made allusion, and one which I 
have observed in over forty cases, although I can 
offer no explanation of it whatsoever. I have never 
seen it except in syphilitic hemiplegia. I should 
like to ask the attention of the profession to this 
point, in order that it may be tested. 
4. Convulsions in the adult, which have not 
been preceded by convulsions in infancy, and are not 
of traumatic or nephritic origin, or due to pregnancy, 
or in an individual subject to migraine. It is 
too much the custom, I think, to regard convul- 
needs further investigation. But, however it may 
be decided, there is no diversity of opinion as to 
the results which follow upon the endarteritis. 
The vessels may become narrowed in their lumen 
by the thickening inward of the fenestrated mem- 
brane and the intima. They may become en- 
tirely occluded from the same cause. The inner 
surface of the intima may become roughened or 
altered in its chemical constitution, and a thrombus 
may form, which may, in its turn, give rise to an 
embolus. It may even happen, rarely however, that 
minute aneurisms may be formed from the wasting 
of the muscular coat of the vessel, and occasionally 
there may be a hemorrhage. In other words, a* 
syphilitic infiltration may set up an endarteritis 
which usually leads to a narrowing of the canal of 
the vessels, or to an occlusion of it, but which may 
occasionally lead to thrombi, emboli, aneurism, and 
hemorrhages. 
The prevailing tendency of thought among modern 
pathologists has naturally led to an endeavor to trace 
syphilis to a microorganism. As is usual in researches 
of this kind, our German friends have led the van. 
As far back as 1S69 Hallier thought that he had 
detected peculiar microbes in the blood corpuscles, 
and Lustdorfer described syphilitic bodies in the 
blood. These statements do not seem, however, to 
have been verified. Klebs, in 1879, Aufrecht, in 
1881, and Birch-Hirschfeld, in 1882, described 
microorganisms which they would have us regard as 
the cause of the phenomena of syphilis. But the 
investigations of Lustgarten and Doutrelepont since 
1S84 have been more precise than those of their 
predecessors, have been largely confirmed, and have, 
therefore, attracted far more attention. These gen- 
tlemen have described slender bacilli, like straight 
or somewhat curved rods of about the size of 
the tubercular bacilli, and they are found singly 
or in groups in cells. They bear spores, which 
appear as clear, oval, glittering spots. They are 
colorable by a method described by Lustgarten. 
A most energetic discussion of these bacilli, their 
relations to syphilis and their differentiation from 
other bacilli, has been and is still going on in 
France and Germany. The mere catalogue of the 
disputants will indicate the interest that is felt in the 
subject—Cornil, Giacomini, Disseand Taguchi (two 
Japanese medical men writing in German), Klem- 
perer, Kobner, Matterstock, Rumpf, Gottstein, Le- 
loir, Weigert, Baumgarten, Tavel, Alvarez, Eve, 
Longuard. As a result, it may be stated, that the 
question is not by any manner.of means yet decided; 
that the bacilli described by Lustgarten have been 
found by many in syphilitic individuals; that bacilli, 
similar in some respects to those of Lustgarten, are 
found in normal smegma and the secretions of the * 
genital organs; that ihe bacilli of Lustgarten and 
those of the smegma and the genital secretions differ 
from one another distinctly in several particulars; 
that there are probably several bacilli in syphilis, 
two varieties being described by Rumpf. The 
bacilli of Lustgarten have been found in all stages 
of syphilis and in syphilitic alterations in many dif- 
ferent tissues, and nothing like them has been fourid 
in non-syphilitic individuals, except in the smegma 
or the genital secretions, and even here there are 
alleged points of difference: hence it would certainly 
seem as if Lustgarten’s bacilli bore some relation to 
syphilis. No one has as yet succeeded in obtaining 
any pure cultures of these bacilli, and this test is 
therefore lacking. # 
So much do we know of the pathology of syphilis. 
These diffuse infiltrations, these gummata, these 
arterial lesions, may, as must be evident to all of you, 
cause symptoms that are coextensive with the symp- 
toms of derangement of any part of the nervous 
system. All the recognized mental and nervous 
disorders may have a syphilitic basis, and in the case 
of any one of them it simply becomes a question as 
to whether a history of the infection is obtainable. 
So far as is known, it is not possible to say of any > 7- Tabes dorsalis, and 
8. General paresis. 
It is not of much practical importance to ascertain 
the presence or not of a specific infection in these 
two grave maladies, because, so far as I have seen, 
the syphilitic causation has for them only this sig- 
nificance, that they will do rather better upon anti- 
specific treatment than the non-syphilitic cases; the 
course of the disease, however, is not materially 
altered. 
9. Spinal lesions in a subject who has had intra- 
cranial syphilis. These spinal infections always re- 
quire unusually large doses of the anti-specific 
remedy. 
This quasi periodical cephalalgia, this hemiplegia 
under forty years of age, this cephalalgia ceasing 
upon the supervention of hemiplegia, these convul- 
sions in the adult, these lesions at the base of the 
brain, these comatose conditions may be present 
singly or in varied grouping, and singly or in groups 
they should always give rise to a strong suspicion of 
antecedent specific infection. 
We have.seen how difficult it may be to obtain the 
precise history of the initial lesion in such cases. 
The question at once arises as to what significance 
may attach to the success or non-success of anti- 
specific treatment. There can be no question that 
the profession are illogical in attaching the im- 
portance that they usually do to the results of such 
anti-specific treatment, because mercury and the 
iodides are efficacious in many affections that have 
no specific etiology. All the same, however, I can- 
not disabuse my mind of the fast-rooted impression 
that a disease which disappears rapidly and com- 
pletely under anti-specific treatment, and which has 
not been affected by other forms of medication, is of 
specific origin. 
The prognosis is dependent upon the question as to 
whether the lesions are destructive or non-destruc- 
tive, and in many cases it is treatment alone that can 
determine this point. In general terms it may be said 
that syphilis of the nervous system is of good prog- 
nosis except where it has set up actual organic disease, 
except where it has excited in the normal tissue the 
formation of some other structure that is foreign 
to the particular texture. The infiltrations of the 
nervous tissues themselves, the gummata, the arte- 
rial lesions, are by themselves remarkably harm- 
less. It is singular to see, as we often do, how much 
and how long the nervous structure will present evi- 
dences of syphilitic disease and yet recover entirely 
under adroit and vigorous treatment. Buzzard tells 
of an artery that had been almost occluded, being 
tested by the sphygmograph and yet was freed by 
proper treatment. To speak more precisely, it may 
be said that the symptoms of good omen are: 
Nervous syphilis in its early stage ; lesions at the 
base of the brain; spinal lesions without preceding 
intracranial specific disease ; peripheral lesions. 
Of uncertain omen are : 
Long standing nervous syphilis; 
Syphilitic insanities; 
Spinal lesions with preceding intracranial specific 
disease; 
Convulsions; 
Comatose conditions; 
Hemiplegia. 1 
Of bad omen are : 
Tabes dorsalis ; 
General paresis; 
Nervous syphilis in persons whose general health 
is bad; 
Relapses in spite of anti-specific treatment; 
Nervous syphilis in persons who bear the iodides 
badly. 
sions in infancy as harmless, and not prone to re- 
currence. In a paper which I read several years 
ago,1 I called attention to the fact that a large pro? 
1 The Treatment of Epilepsy, N. Y. Med. Journal, June 28 and 
July 5, 1884. 
portion of the cases of epilepsy in youths or adults, 
would be found upon careful inquiry to have had a 
convulsion in early life, that had; usually been attri- 
buted to dentition or intestinal or febrile com- 
plaints; and of such early convulsions it may be 
very difficult to obtain a history unless the parents 
or some other near relatives are interrogated. The 
convulsions occurring in nephritis, or in certain 
women during pregnancy, are too well known to 
need more than a bare reference. Again, it is a 
curious fact, to which I have referred in the paper 
just mentioned, that migraine is interconvertible in 
certain individuals with epilepsy, so that most indi- 
viduals who have a personal or hereditary history of 
migraine will be found upon minute and patient in- 
terrogation to have had a loss of consciousness or 
epileptic-like convulsion at some period of their life. 
If, however, pregnancy, migraine, nephritis, trauma, 
and preceding infantile convulsions, are excluded, 
a convulsion in an adult should give rise to grave 
suspicions of intracranial syphilis. 
5. Symptoms indicative of a lesion at the base of the 
brain. Syphilis is especially apt to hug tfie base of the 
brain, and more especially that anterior portion of 
it which forms the hexagon wherein lie the olfactory, 
the optic, the motor oculi,. and the fourth pair of 
nerves, as well as the crura cerebri, and lesions of 
which impair the functions of these cranial nerves 
. on one side of the body, and induce disturbances of 
motion and sensation upon the opposite side, giving 
rise to the so-called “ crossed paralysis.” Of course, 
tuberculosis has a predilection for the same site, but 
the history of the patient and the presence of pul- 
monary symptoms make easy a diagnosis of this 
affection. It is true also that tumors of non-specific 
origin may be found in the same location, but usu- 
ally they are not so diffuse as a syphilitic infiltration, 
and usually also the specific lesions of this part of 
the brain are accompanied or have been preceded 
by a characteristic cephalalgia. 
4. A comatose condition exten ding over days or weeks, 
not traumatic, meningitic, diabetic, nephritic, or from 
typhoid fever. It is not always easy to exclude the 
coma of meningitis, especially in the early stage before 
the characteristic symptom of retraction of the head 
has made its appearance, although the temperature 
curve maybe of great assistance. In my experience, 
this retraction of. the head is of well-nigh infallible 
importance. Frankel, however, has reported a rare 
and curious case, from the wards of the Charite 
Hospital in Berlin, in which this retraction of the 
head was found (post-mortem) to be due to a lesion 
in the middle portion of the ascending frontal con- 
volution, just where the centre for the muscles of the 
neck has been located on a priori grounds by Wer- 
nicke. The coma of nephritis, it must also be 
borne in mind, is not always of the profound nature 
that is seen where the urine contains large amounts 
of albumen. It may be light, variable in its mani- 
festations, simulating a profound hysterical con- 
dition. Nor will it do to exclude nephritis by a 
mere cursory examination of one specimen of the 
urine for albumen. Several specimens should be 
obtained. Best one at morn, midday, and evening, 
and the amount of urea should be estimated, casts, 
blood-corpuscles, and pus should be carefully searched 
for, and albumen should be sought for by the finer 
modern methods, rather than by the old and rough 
test by heat and nitric acid. I have more than once 
been called into consultation regarding conditions 
of coma, and have been informed that nothing had 
been found in the urine to indicate nephritis, and 
yet the autopsy has disclosed advanced disease of the 
kidney. Diabetes can, of course, be easily ascer- 
tained. Some anomalous cases of typhoid fever are 
apt to mislead one at the start, although the progress 
of the disease almost invariably makes the diagnosis 
very certain. I have very pronounced ideas in regard to treat- 
ment. I know of no reason for dogmatism except 
considerable experience, ar.d that is my excuse for 
my dogmatism. I have no faith whatsoever in mer- 
cury, and I have discontinued its use for some time 
past. Again and again have I seen cases go halting 
along in the most uncertain manner, under mercurial 
treatment, and yet have the symptoms been smoothly; 
gradually, and certainly removed by the iodides' 
In several cases, too, I have known of death' 
although the most careful mercurial treatment had 
been pursued in enormous doses, and these cases 
have been precisely similar, as far as anyone is able 
to judge of one case by another in the practice of 
medicine, to others that I have been accustomed to 
regard as of favorable prognosis under the treatment 
by the iodides. I am quite prepared to say, that un- 
less the iodides with their proper adjuvants—of which 
I shall speak in a moment—can cure a case of ner-' 
vous syphilis, it cannot be cured at all. But the 
dose of the iodides which are administered by the 
Germans and French will often be entirely inade- 
quate. I give the iodides until the symptoms yield, 
or until iodism is produced. I make use of the satu- 
rated solution of the iodide of potash, each drop of 
which contains almost a grain of the salt. I com- 
mence with twenty drops three times a day, and in- 
crease it each day by two or three drops at each dose, 
and keep increasing until the symptoms yield or 
iodism is produced. Should iodism ensue before the 
symptoms yield, I pursue one of two methods. I first 
increase the dose of the iodide by about one-third, 
and rapidly increase each succeeding day. Singular 
to say, in some cases this increased dosage will cause 
the iodism to disappear, and the larger doses will be 
borne very well. Should, however, these larger 
doses still more increase the iodism, I decrease to 
one-half of the dose at which the iodism had begun, 
and continue this decreased dose until the iodism 
diminishes or disappears, when I again rapidly in- 
crease the dose, and am usually able to go on without 
further trouble. In some few individuals, however 
no amount of care will cause more than a certain 
amount of the iodide to be borne, and such cases, as 
I have said, are usually of unfavorable prognosis. 
In some cases, too—fortunately they are rare even 
small doses of the iodide will produce a cardiac 
disturbance that prohibits its administration. But 
this last fact should not be confounded with the 
phenomenon that the profession generally does not 
seem to be cognizant of, namely, that small doses of 
the iodide, five or ten grains, will usually produce 
more iodism than the larger doses. I am perfectly 
well aware that the medical chemist will object 
that these large doses of the iod;de pass through 
the body and are quickly excreted by the urine; 
but I am equally well aware, in the face of this 
fact, that these large doses of the iodide will cause 
symptoms to yield that cannot be made to yield by 
lesser doses. I have given as much as eight hundred 
grains of the iodide of potash in the twenty-four 
hours, and have seen symptoms disappear with these 
enormous doses that would not yield to minor ones. 
I administer the iodide after meals, and either in 
a full tumbler of ice-water, or in a glass of Vichy, 
or in agla s of a Bohemian spring water, the Giess- 
hiibler. I prefer the Giesshubler to the Vichy, 
although it is more expensive, because it is much 
more pleasant to the taste, and agrees much better 
with the average stomach. Moreover, the Vichy 
water which is put up in siphons in this country is 
artificial, by no means equal in its effects to the 
natural water, and the natural water, either of this 
country or of Europe, does not keep as well in 
bottles as does the somewhat similar water of the 
Bohemian spring. 
But he who expects to cure his patient with the 
iodides alone, unless the case be so grave as to call for 
immediate relief, will be disappointed. The human 
organism must be put in the best possible condition. 
A generous diet should be employed. Freedom 
from care and worry, where possible, should be 
enjoined, and all strenuous exertion of body or 
mind avoided. And let me say here that in many 
broken-down individuals the mo->t satisfactory results 
may be obtained from a conjunction of the iodides 
with the brilliant treatment that has been made 
known by Dr. Weir Mitchell, under the name of 
“ Fat and Blood making ”—a therapeutical proced- 
ure that, in my humble opinion, will rank in coming 
years with the surgical revolution inaugurated by 
Lister. When the acute symptoms have been 
brought under control, tiavel, especially an ocean 
voyage, will often work wonders. In every case 
that tends to chronicity staple tonics and altera- 
tives should be used. 
I have often asked myself when a person can be 
considered to be cured of nervous syphilis; and I 
have never succeeded in answering the question to 
my own satisfaction. I know of no data by which 
we can guide ourselves. I have seen relapses occur 
years after the disappearance of every untoward 
symptom, and I have seen them even where a cer- 
tain moderate treatment by the iodides had been 
maintained. I usually impress this uncertainty upon 
my patients, warn them to be on the lookout for 
future symptoms, and apprise whoever miy be their 
attending physician of their possible significance, and 
I enjoin them to keep up moderate doses of the iodide 
for years. This last precaution I observe the more 
readily because I have but seldom seen any ill-effects 
from the continued administration of the iodides, 
to which patients usually become accustomed as 
they do to, common salt. Occasionally it may hap- 
pen that an obstinate pharyngeal or post-nasal 
trouble may be induced, or some unsightly cuta- 
neous eruption, but, as a rule, these are controllable, 
and in any event they are far preferable to the pos- 
sibilities of nervous syphilis. 
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Cornil: Gaz. des Hopit. No. 90, 1885. Doutrelepont: 
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