With the Compliments of the Author. 
FIVE CASES OF 
CEREBRAL SYMPTOMS 
IN 
EARLY (SECONDARY) SYPHILIS. 
By F. B Greenough, M.D., 
Member of the American Dermatological Association; Physician in 
charge of the Department for Skin Diseases at the Boston Dispen- 
sary ; Clinical Instructor in the Harvard Medical School. 
(Read before the Boston Society for Medical Improvement. 
May 25,1885.) 
[Reprinted from the Boston Medical and Surgical Journal 
of June 11 and 18, 1886.] 
BOSTON: 
CUPPLES, UP HAM & CO., PUBLISHERS, 
©lb Cortur bookstore. 
1886. FIVE CASES OF 
CEREBRAL SYMPTOMS 
IN 
EARLY (SECONDARY) SYPHILIS., 
By F. B. Gheenqugh, M.D., 
Member of the American Dermatological Association; Physician in 
charge of the Department for Skin Diseases at the Boston Dispen- 
sary ; Clinical Instructor in the Harvard Medical School. 
(Read before the Boston Society for Medical Improvement, 
May 25,1885.) 
[Reprinted from the Boston Medical and Surgical Journal 
of June 11 and 18,1886.~\ 
BOSTON: 
CUPPLES, TIP IT AM & CO., Publishers, 
©lb Cortur bookstore. 
1885. CASES OF CEREBRAL SYMPTOMS IN EARLY 
(SECONDARY) SYPHILIS. 
F. B. GREENOUGH, M.D. 
That syphilis at the present time, on the whole, 
is a milder and less virulent disease than it was 
formerly is a fact which, I think, cannot be ques- 
tioned. Whether this is due to a change in the 
type of the disease itself, or to an improved and 
more rational method of treatment, is perhaps an 
open question, but probably both of these factors 
have a share in the change that has taken place. 
That there has been a change is shown by the fact 
that while without doubt the number of cases of 
syphilitic disease has been increasing, the number of 
cases where we find serious and destructive lesions 
of the skin and mucous membranes have dimin- 
ished. This is, of course, simply a statement of 
opinion, not corroborated by statistics, but I think 
the opinion I express will be endorsed by colleagues 
who have seen much of venereal practice. Of one 
thing there can be no doubt, and that is that at 
present many, that is to say, a large percentage, of 
the cases of syphilis do very well, and after the 
comparatively light symptoms of the secondary 
period have passed off do not hear from the disease 
again. I am aware that it is claimed that the dis- 
ease is not eradicated, but simply latent; but if it 
continues latent during the rest of the patient’s life, Cases of Cerebral Symptoms in 
4 
and has no influence either on him or his offspring, 
what a boon it would be to humanity (as Hebra used 
to say) if phthisis, cancer, and other diseases could be 
made latent to the same extent. That the less fre- 
quent occurrence of severe sequel® from syphilis is 
not entirely due to improved methods of treatment is 
shown by those cases in which, either from reckless- 
ness or indifference, or any other cause, the patient 
has stopped treatment long before he would have 
been advised so to do, and yet has for years been free 
from all symptoms. Although I have not attempted 
to get the exact figures, I can say that during my 
fifteen years’ experience in charge of the special 
department at the Boston Dispensary the number of 
cases that showed late and grave lesions of syph- 
ilitic disease compared to those that came for treat- 
ment for the early symptoms has been very small. 
And yet these patients are exactly of the class in 
which one would expect bad results. That is to 
say, they are poor, unable to get proper food and 
care, offryi of bad habits, and rarely follow out the 
instructions and treatment given them for the length 
of time that in private practice would be insisted 
upon. While, however, the number of cases of 
syphilis that are followed by serious later symptoms 
seems to have diminished, or at least to be compar- 
atively small in number, those in which we find 
evidence of cerebral trouble- have decidedly in- 
creased. To convince one’s self that this is the 
case one has only to look at the medical literature 
of the last decade and compare it with that previous 
to the last — twenty, or even fifteen, years. With 
regard to the recognition of cerebral syphilis by the 
older authors there seems to be some difference of 
opinion. Legrand du Saulle, in the Gazette des 
Hdpitaux, in an article on “ Cerebral Syphilis,” Early (Secondary) Syphilis. 
5 
says: “The first notions with regard to the cere- 
bral symptoms in cases of syphilis date back very 
far. Fracastor and Nicolas Massa even say decid- 
edly that the French disease may be accompanied 
by insanity and epilepsy.” On the other hand, 
Heubner, in his very complete article in Ziemssen’s 
Cyclopaedia on “ Syphilis of the Brain and Nervous 
System,” says: “Although Fracastor described so 
graphically the ravages of syphilis on the face, etc., 
lie knew nothing of the internal diseases of the 
same patients.” He also states that this lack of 
knowledge with regard to syphilis of the nervous 
system was due, in part, to the fact that the old 
practitioners occupied themselves chiefly with symp- 
tomatology and therapeutics. This may be very well 
as far as the Middle Ages go, but when we see that 
John Hunter classed the nervous system as one of 
the vital parts which are not at all susceptible to 
the action of syphilis, and that Ricord, in his clas- 
sical “Letters on Syphilis,” does not refer to this 
subject, it certainly looks as though not many 
cases of the kind I am about to report could 
have come under their observation. As late as 
1861 Professor as the result of his inves- 
tigations, reported to the Faculty of Medicine in 
Paris that “ the nervous manifestations of syphilis 
are rare, indistinct, and destined, at least until fur- 
ther investigation, to figure in an account of syph- 
ilis as an appendix.” It was just about this time, that 
is, 1861-62, according to Heubner, that scientific 
investigations with regard to cerebral syphilis began 
to be made. The monographs of Leon Gros, Lan- 
cereaux, and Lambuco marked out the path for 
study, and they were followed in Germany by Jaksh 
and many others. Fournier in 1879 published his 
“ Syphilis du Cerveau,” which, while it may not be 6 
Cases of Cerebral Symptoms in 
up to the later German authors as far as patholog- 
ical anatomy goes, is certainly a most wonderful 
collection of clinical observation. I will merely 
make three quotations from his preliminary chapter 
to show his deductions from his vast amount of 
material as to the frequency of cerebral syphilis at 
the present time, and ask you to remember that 
John Hunter considered the brain as non-susceptible 
to syphilitic disease, and that Ricord does not men- 
tion the possibility of cerebral syphilis. Fournier 
says : “A case of hemiplegia occurring in a subject 
less than forty years old, not affected by alcohol- 
ismus, nor suffering from a lesion of the circulatory 
system, is, in eight cases, or perhaps even nine 
cases, out of ten, of syphilitic origin.” Again : 
“ When epilepsy manifests itself in a subject over 
twenty-five or thirty yeaps old, for the first time, in 
nine cases out of ten it is of syphilitic origin.” 
Finally, according to him, at least seventy-five per 
cent, of cases of ocular paralysis are due to syph- 
ilis. To even give a list of the literature on this 
subject during the past five years would exhaust 
your patience, so I will simply state that it is a very 
rich one, and that whatever minor differences there 
may be between the different authors, they all agree 
on one point, and that is that cerebral syphilis, as a 
rule, is one of the later manifestations, that is, that 
it is a symptom occurring in the so-called tertiary 
stage of the disease. Whoever was responsible for 
the terms primary, secondary, and tertiary did a 
very poor service to syphilographv. From the 
meaning of the words one would naturally suppose 
that they were three distinct stages of the disease, 
one following the other. As a matter of fact, in many 
cases the primary lesion still exists when the sec- 
ondary symptoms appear, and secondary and ter- Early (Secondary) Syphilis. 
7 
tiary symptoms are more frequently than not seen 
coexisting. I happen to think of a dispensary 
patient who has now mucous patches of the tongue, 
such as are frequently seen during the early out- 
break of constitutional symptoms, who two years 
ago had typical muscular gummata. Neither can a 
distinction be made according to the tissues affected, 
as not infrequently the periosteum is the seat of the 
very earliest secondary manifestations. There are, 
however, two distinct sets of symptoms in syphilis, 
one of which, as a rule, is decidedly later in its 
appearance, and these are the symptoms of the dif- 
ferent tissues that are due to an inflammatory pro- 
cess, which may range from simple congestion, as 
in the case of a macular syphilitic, or in congestion 
of the fauces, through infiltration (papular erup- 
tions), desquamation, and ulceration; and, on the 
other hand, those that result from the development 
of a neoplasm, or gummy tumor. It seems to me 
that if we are to use the term tertiary at all it should 
be confined to these latter manifestations. 
To return, however, to cerebral syphilis. As I 
have stated, the evidence of the authorities is that 
it occurs, as a rule, as a late symptom, but in the 
more recent literature we find that exceptions to 
this rule are recorded. Fournier gives from the 
third to the eighteenth year (after infection) as the 
most common period for cerebral manifestations, 
and puts two thirds of the cases between the third 
and tenth year, and one third between the tenth and 
eighteenth. He says, however, that “ cases have 
been seen during the second or first year of the dis- 
ease, even as early as the seventh, sixth, or fifth 
month.” “ These are, however,” he goes on, “ I 
hasten to say, rare facts, and naturally all the more 
rare as the date of the manifestation is more preco- 8 
Cases of Cerebral Symptoms in 
cious.” Heubner states that from his figures, that 
is, from the statistics derived from the cases ob- 
served and collated by him, it appears that when a 
syphilitic growth is developed in the nervous sys- 
tem such a growth almost invariably appears at a 
late period ; in fact, when the syphilis has lasted 
for several, or often many, years. This rule, of 
course, he says, is not without exceptions. Prof. 
H. C. Wood, in an article on the “ Clinical Aspects 
of Cerebral Syphilis,”1 gives a very full account of 
the subject, more especially with reference to the 
later manifestations, epilepsy and general paralysis, 
lie says, however: “Although syphilis is most 
prone to attack the nervous system many years 
after infection, it would be a fatal mistake to sup- 
pose that brain disease may not rapidly follow a 
chancre.” 
Legrand du Saulle, in a series of articles pub- 
lished in the Gazette des Hdpitaux in 1884 (vol. lvii.) 
on “ Cerebral Syphilis,” says : “At what period of 
the disease do the cerebral symptoms show them- 
selves? In a general way, it can be said, in the ter- 
tiary. Ordinarily they show themselves from three 
to ten years after the primary lesion. But they 
may be delayed and not appear until after an inter- 
val of twenty to thirty years. Sometimes, how- 
ever, in cases of precocious, malignant syphilis, 
they form part of the secondary symptoms. 
Not to take up time by more quotations, I will 
state that the mass of authors on the subject agree 
with great unanimity on the fact that cerebral syph- 
ilis is of late development, and that, although there 
are exceptions, cases which show affection of the 
nervous centres within the first year are decidedly 
exceptional. It is this unanimity of opinion that 
1 Boston Medical and Surgical Journal, 1884, vol. cx., Nos. 9 and 10. Early (Secondary) Syphilis. 
9 
has made me think that the five cases that have 
come under my observation during the last few 
years, in which symptoms of syphilitic cerebral 
trouble appeared quite early (the average of the 
five cases being a little more than five months), 
were worth reporting. While our standard 
textbooks give very good descriptions of cerebral 
syphilis, and speak of the possibility of its occur- 
rence, exceptionally, quite early, they do not suffi- 
ciently, if at all, call attention to the indication 
for the modified course of treatment which such 
cases, I think, imperatively show. The num- 
ber of cases reported of precocious cerebral symp- 
toms, while small compared with those in which the 
cerebral lesions came on late in the disease, are, in 
recent literature, fairly numerous. Fournier reports 
a dozen or more. Dr. Webber, in his paper pre- 
sented to this Society, reported some precocious 
cases, that is, one of ten months, one eight to nine 
months, and one a little over three months. I find 
a case reported in the New York Medical Journal 
(1884, xv. p. 430) as a “ Case of brain disease ” 
(probably syphilitic), by Lucy M. Hall, M.D., and 
it is one of the very few in which a careful autopsy 
was made and recorded. Unfortunately, it may be 
objected to the case that it is not absolutely proved 
that it was a syphilitic one. I will give an 
abstract of it: The patient was a girl of sixteen, 
an inmate, I infer, of the Reformatory Prison for 
Women at South Framingham. The first record is 
December 1, 1883. No special symptoms, but poor 
appetite, pale, and nervous. January 24, 1884, 
some general febrile disturbance, high pulse and 
temperature, with pain in left temporal region, and 
vomiting. The pain in left side of forehead was 
constant, and unyielding to treatment. February 10 
Cases of Cerebral Symptoms in 
4th small excavated ulcers were noticed on side of 
tongue, and she was dull, stupid, and somewhat 
comatose. February 17th, tongue was swollen, left 
half being half (sic) dry, right half moist; the 
mouth was drawn to right side slightly, and partial 
paralysis of the facial muscles of the left side was 
noticed. She died at midnight. The autopsy 
showed the organs in the pelvic and abdominal cav- 
ities to be normal. There was thickening both of the 
dura and pia, and the cerebral vessels were dis- 
tended, especially on the left side. Tallow-like 
bodies, from, the size of a millet-seed to a grain of 
wheat, were found along the surface of the dura in 
the line of the longitudinal sinus ; also in the region 
of the third frontal convolution on the left side. 
The bases of the second and third convolutions on 
the left side were so soft that the handle of the 
scalpel laid lightly upon them penetrated the brain- 
substance. Section of the left anterior cerebral 
lobe showed a partially absorbed haemorrhagic in- 
farction of the third, or Broca’s, convolution, occu- 
pying about half its extent. If this was a case of 
syphilis, the age of the subject, sixteen, shows that 
it must have been of not long standing. 
From Professor Wood I will quote the following 
cases of precocious cerebral symptoms: Dr. Alfrik 
Ljunggr6n, of Stockholm, reports a case where a 
rapidly healed chancre in March was followed in 
May by severe headache, mental confusion, and 
giddiness. Early in .Tilly (four months) he had an 
epileptic attack. This case was cured. Davaine 
reports paralysis of the portio dura a month after 
the first symptoms of constitutional syphilis. Dr. 
E. Leyden found advanced specific degeneration of 
the cerebral arteries in a man who had contracted 
syphilis one year previously. Dr. R. W. Taylor Early (Secondary) Syphilis. 
11 
reports a case where epilepsy occurred five months 
after infection. Dr. Schwarz’s case had severe 
headache forty days after the development of the 
primary lesion, and on the forty-sixth day hemi- 
plegia. Another case had an apoplectic attack 
seven months after the chancre, a female patient 
one five months after the appearance of her primary 
lesion. Dr. A. Sydney Roberts’s (Philadelphia) 
case had a fit two months and eight days after the 
appearance of a chancre, which developed after a 
period of incubation of twenty-six days. Unmis- 
takable cerebral syphilis followed, but convales- 
cence under active antisyphilitic treatment. 
These are some of the cases of early cerebral 
syphilis that I find record of, and are enough to 
show that, although rare, precocious cerebral syph- 
ilis is recognized. The following cases that have 
come under my own observation I will report in as 
condensed a manner as is consistent with calling 
attention to their important points. 
Case I. On July 5, 1878, I was visited by a 
gentleman for advice. He was a lawyer, aged thir- 
ty-eight, reported his health as good, and ap- 
peared to be a strong, healthy young man. About 
two weeks after connection he had noticed a sore on 
the prepuce, which at the time of visit was a t}rpical 
primary syphilitic lesion. The induration was well 
marked and quite large, and the inguinal glands in 
both groins were enlarged. In the latter part of 
August he had some soreness and congestion of the 
fauces, and on September 7th a macular syphilide 
appeared on his trunk and thighs. The eruption 
was not a very full one, and was entirely macular. 
In October he had some manifestations of seconda- 
ry symptoms on the mucous membranes, that is, 
sore throat, with some congestion of the fauces, 12 
Cases of Cerebral Symptoms in 
superficial plaques on the tonsils, and slight lesions 
on the sides of the tongue. He was put on a mer- 
curial course of treatment from the first appear- 
ance of the constitutional symptoms, and seemed 
to be having a very mild case, until (some time, in 
September) he began to be troubled with headaches, 
which came on in the afternoon, were aggravated 
toward night, and became very severe. These 
were relieved for a time by the iodide of potash, 
and it did not require very large doses (ten to fif- 
teen grains three times a day) to control them. 
During October, November, and December 1 saw 
him about once in two weeks, and with the excep- 
tion of an occasional attack of cephalalgia, lasting 
for two or three days, and yielding to increased 
doses of the iodide, which, however, never exceeded 
twenty grains three times a day, he seemed to be 
doing very well. The eruption had faded out, and 
the mucous membrane of the throat and mouth 
was healthy. I have heard since, however, that 
his friends noticed that he was heavy and sluggish 
mentally at this time. On December 27th he called, 
his previous visit having been on the 9th, and while 
there were no definite symptoms, except a more 
persistent headache, it was evident that he was not 
doing well. Besides increasing his dose of iodide, I 
thought it best to increase the action of his mercu- 
rial treatment, and as he objected to the use of 
inunctions I put him on small and frequent doses 
of calomel, and he was asked to report in a few 
days. 
I did not see him again, as he came under the 
care of the family physician after that time, by the 
kindness of whom I am enabled to condense the 
following record from his very full notes on the 
case: — jEarly (Secondary) Syphilis. 
13 
On January 6, 1879, that is, ten days after I had 
seen him, while at dinner, he felt that he had lost 
power over his left leg. It was not completely par- 
alyzed, but he could barely move it, and he was 
takpn up to his room. On being questioned, he said 
that on the 4th, two days previous, he had noticed a 
prickly feeling in his right hand, and some loss of 
power in the fingers, shown by difficulty in using his 
pen. Also some dull headache. This loss of power 
in the right hand was more noticeable on the next 
day, and on the next one, that is, January 6th, the 
decided, but partial, paralysis of the left leg came 
on while he was dining with his family. On the 
7th, that is, the day after his attack, in trying to 
get about his chamber he fell, and is reported to 
have been quite shaken up by his fall. The cause 
of his trouble being suspected by his physician, he 
was asked with regard to his previous syphilis, and 
gave a very good account of his disease, both as to 
symptoms and treatment. The paralysis of the left 
leg increased, and his mind became sluggish, al- 
though he would answer questions when aroused. 
The sphincters of the bladder and anus became 
paralyzed, as was shown by involuntary passage of 
urine and faeces, and on the 12th it was noticed 
that there was paralysis of the left facial muscles, 
the mouth being drawn to the right side. On the 
13th complete paralysis of the left upper extremity 
was evident. His mind was wandering, but he 
would answer when roused. On the 18tli he was 
delirious, and muttering about matters that he was 
interested in, and died quietly at 5.30 p.m., twelve 
days after his attack of paralysis of the left leg. 
The specific origin of his attack was recognized 
from the first, and he was given a most thorough 
antisyphilitic treatment. Iodide of potassium was 14 
Cases of Cerebral Symptoms in 
given in increased doses, as well as mercurial in- 
unctions. 
A careful examination of the brain was made, 
but the full record of it cannot be found. In the 
case-book of the attending physician the fact that 
there was thickening of the pia at both vertices was 
noted, as well as a partial plugging up of some of 
the cerebral arteries by means of an apparently 
new formation. lie, however, simply noted these 
main points, referring to the source where he sup- 
posed the full record could be found. 
Case II. I saw this patient, a civil engineer, 
aged twenty-one, first on January 13, 1883. lie 
was tall, thin, not well developed as far as muscular 
development goes, but reported his general health 
as good. lie consulted me on account of a lesion 
which had appeared on his penis after intercourse, 
which proved on examination to be a primary syph- 
ilitic chancre. The induration was well marked, as 
was the enlargement of the lymphatic glands in 
both groins. Under the topical use of iodoform the 
chancre healed, and on April 1st a pretty generally 
distributed macular secondary eruption broke out. 
There was also at that time some congestion of the 
fauces. He was put on a mercurial course of treat- 
ment, and when seen on April 19th the eruption 
simply showed some spots of pigment; the mucous 
membranes were healthy, but there were some small 
crusts scattered over the scalp. 
On the 21st of May I received a letter from him 
from an inland town, where he was engaged in pro- 
fessional work, stating that he had been for some 
days troubled with a very severe headache, which was 
much aggravated at night; that he was very fever- 
ish, and felt generally very unwell. I wrote to him 
to take ten grains of iodide of potassium three Early (Secondary) Syphilis. 
15 
times a day, and to report as soon as possible. On 
the 24th, that is three days afterward, he came to 
my office in what certainly seemed a very critical 
condition. It was with difficulty that he spoke, 
his mouth being drawn to the left side during ar- 
ticulation, and his gait was very unsteady. He 
reported that after writing to me his headache was 
so excruciating, and feeling a decided numbness of 
his right side he had consulted a local practitioner, 
and by his advice had taken a cathartic and Dover’s 
powder. On receipt of my letter he had begun on 
the iodide, and although his severe headache had 
ceased, as he had great difficulty in enunciation and 
noticed a decided loss of power in, and control of, 
his right arm and leg, he had come to see me. In 
addition to the partial right-sided muscular paraly- 
sis he had double vision. His symptoms improved 
gradually, and by June 15th, three weeks after, he 
was apparently all right, and has had no relapse 
since, having been under treatment and observation 
up to date. He is now doing his work as a civil 
engineer, is able to do it, and weighs more than he 
ever did. 
Case III. This patient, a student, aged twenty, 
consulted me July 12, 1883, for a urethral trouble, 
complicated with an acute epididymitis. He was 
small in size, pale, and, as far as muscular develop- 
ment goes, decidedly below par. He dated his 
gonorrhoea back to the middle of the previous De- 
cember, and stated that shortly after his gonorrhoea 
had appeared he noticed a sore on the penis, which 
proved to be a primary syphilitic lesion, and which 
was followed by secondary constitutional symptoms. 
These had entirely disappeared by the time of his 
first visit to me ; but from his report, which, by the 
by, was a very clear one, they must have been quite 16 
Cases of Cerebral Symptoms in 
mild, and have yielded readily to treatment. His 
urethral trouble did well, and is of no interest in 
this connection, but his account of his syphilitic 
infection was so clear and consistent that I felt it 
my duty to put him on specific treatment, in the 
propriety of which I was confirmed by the appear- 
ance, later, of slight mucous patches on his tongue. 
He was doing very well when I saw him on July 
28th, and on October 8tli, when 1 saw him after his 
return from his vacation, he made the following 
report: On August 2Gth he had what was considered 
a sunstroke, as a result of which he was laid up in 
bed for a week, and was “ under the weather” for 
some time more. On investigation, the “ sunstroke ” 
was reported to have come on two days after the 
supposed cause, that is, playing tennis in the sun, 
and getting much fatigued. He had had severe 
headache for some days previously, which was worse 
toward evening. His first symptom was a feeling 
of giddiness, in which he stumbled, and felt that he 
had lost control of his muscles. He had difficulty 
in articulation, and even when seen October 8th I 
noticed a decided difficulty or hesitancy in his 
speech. For some time after he got about he re- 
ported a tendency to stumble, and at times a feeling 
of numbness in his left arm. Under a mixed treat- 
ment of a mercurial and iodide he improved in gen- 
eral condition and gained in weight. On November 
28th he reported having had for a few days a very 
severe headache, which ceased at once on increasing 
his dose of iodide. In February, 1884, he went to 
the Hot Springs, Arkansas, where he went through a 
thorough course of inunction, and returned about the 
middle of April, having gained flesh and strength, 
and showing no specific symptoms. He is still 
under observation and treatment. jEarly (Secondary) Syphilis. 
17 
Although this case was not seen by me, either 
during the first outbreak of syphilis or at the time of 
his partial paralysis, I do not see how there can be 
a question as to the connection of the two. He did 
show decided and unmistakable symptoms of con- 
stitutional syphilis, that is, mucous patches on the 
tongue, and his account of the appearance of the 
sore on his penis, in December, followed by consti- 
tutional symptoms, which under treatment disap- 
peared, was so precise as to leave no doubt in my 
mind as to the date of contagion. His account 
of his supposed sunstroke, eight months afterward, 
was also very clear, showing that he had had an 
attack of vertigo and loss of power over his limbs 
and speech, the latter symptom not having entirely 
passed off when I saw him about six weeks later, 
which attack was referred to an exposure to the sun 
and fatigue, two days previously. As additional 
evidence, there is the fact of these attacks having 
been preceded by headaches, with nocturnal exacer- 
bations, and that since then he has had headache of 
the same nature, which has yielded at once to a 
course of iodide of potassium. 
Case IV. A mechanic, aged thirty-eight, con- 
sulted me on January 2, 1884. The patient was a 
tall, heavily framed man, but very much reduced in 
flesh and anaemic. About the middle of the previ- 
ous August he had a sore appear on his penis, which 
was at first supposed to be a chancroid, but it was 
followed by symptoms of constitutional syphilis, 
and as he did not agree with his physician’s diagno- 
sis he put himself under the care of one of our 
quack institutes. When seen he showed marked 
symptoms of quite severe secondary syphilis. He 
had a very generally distributed papular, crusta- 
ceous eruption on his trunk, limbs, and scalp, as 18 
Cases of Cerebral Symptoms in 
well as decided mucous patches on his tongue and 
tonsils. What he complained of most was an ex- 
cruciating headache, worse at night, which had con- 
tinued for some days. lie reported that on several 
occasions, while at work, he had had “ giddy spells,” 
in which he had stumbled about, and two or three 
times had actually fallen down. At these times he 
had lost the power of speech, by his report, and in 
this respect he was confirmed by the gentleman, one 
of his employers, who brought him to see me. He 
was heavy and dull, and was evidently suffering 
from severe pain in his head at the time of his visit. 
He was put on a course of mixed treatment, that is, 
the bichloride of mercury and tiie iodide of potas- 
sium, and the lesions of the cutis and mucous mem- 
branes improved at once, but his cephalalgia was 
more obstinate. It did yield, however, to inunc- 
tions, combined with the iodide, but as his gums 
showed decidedly the action of the mercury these 
had to be suspended. He also showed a sensitive- 
ness to the iodide, having a very copious eruption 
of acne on his back and chest, as well as on his 
face, and a decided coryza. By carefully regulat- 
ing the dose, however, he was kept on a mixed 
treatment, and by March 12th, about two months 
after he was first seen, he had gained twelve pounds, 
and his headache was reported to be a thing of the 
past. He is still under treatment, apparently well, 
and able to do his work. 
Case V. I first saw on May 23, 1884. The pa- 
tient was a thin, nervous man, aged forty-three, 
interested in manufacturing, and evidently much 
upset by the trouble for which lie sought advice. 
A few days after exposure he had noticed a lesion 
on the glans penis, which he had treated by an ap- 
plication of strong carbolic acid. The result was Early (Secondary) Syphilis. 
19 
an inflamed, indurated sore, covered by a sloughy, 
whitish eschar, with some glandular reaction in both 
groins. As, owing to the artificial irritation from 
the application he had made, the diagnosis was 
rendered doubtful, no decided diagnosis was given. 
Under soothing local treatment the acute inflamma- 
tory condition passed off, but even after the sore had 
healed some induration remained, and the inguinal 
glands, instead of diminishing in size with the sub- 
sidence of the inflammation, became larger. On 
July 5th (six weeks after he was first seen) he had 
a quite fully developed macular syphilide, and was 
put on a mercurial course. The eruption was sim- 
ply macular, and disappeared rapidly, as on the 
19th, that is, in two weeks, no traces of it were to 
be seen. As his symptoms disappeared his fussi- 
ness about himself seemed to increase, and it was 
with the greatest difficulty that he was made to con- 
tinue his treatment. On October 2d, while showing 
no symptoms, he complained of having had, on two 
occasions, very severe headaches, and was ordered 
the iodide of potassium in addition to his mercurial. 
He was seen three times between then and the 28th, 
when he protested so strongly against the iodide, 
which, he said, he was sure did not “ agree with 
him,” as he had omitted it for a day or two at inter- 
vals, always with good results, that I stopped it, 
and substituted a simple tonic. I was induced to 
do this as, although he had more or less cephalalgia, 
he insisted that it was not constant, or aggravated 
at night, and felt sure that it was connected with 
indigestion, which he laid to the iodide. On the 
30th, two days afterward, he entered my office, 
and I thought he would tumble on the threshold. 
He stumbled into a chair, and, after a good deal of 
twitching of his mouth, managed to articulate, “I 20 
Cases of Cerebral Symptoms in 
am paralyzed! ” After a few moments’ rest his 
articulation improved, and he was able to give an 
account of himself, but there was undoubted partial 
paralysis of the muscles of speech, and his mouth 
was drawn, in speaking, to the left side. lie said 
that he woke up that morning with a feeling of 
numbness in his right arm and leg, and difficulty of 
speaking. There seemed to be a loss of power in 
the right arm, as tested by the grasping-force of 
the hand, and the right leg seemed to drag in walk- 
ing. His difficulty in speaking was, however, the 
most marked symptom, and although that improved 
after he had been sitting quietly in my office, it was 
very decided. His condition was almost an exact 
counterpart of Case No. II. As he was a stranger, 
at a hotel, I advised him to take a room at a hospi- 
tal, and he was admitted to the City Hospital, and 
came under Dr. Webber’s care. Dr. Webber has 
reported his case before this Society in full, and as 
it will be published in the coming report of the City 
Hospital, I will merely say that under mixed treat- 
ment the patient recovered, and that I have seen 
him since, free from specific symptoms and appar- 
ently well. 
These five cases, which, excepting the first, which 
occurred in 1878, have been seen in my private 
practice during the past two years, showed symptoms 
of cerebral trouble, coming on during the early period 
of syphilitic infection, respectively six, four and a 
quarter, eight, four and a half, and five months from 
the appearance of the primary lesion, or on an aver- 
age of five and a half months. They all were pre- 
ceded by severe cephalalgia, all showed partial paraly- 
sis of certain muscles, and, with the exception of 
the fatal case, all yielded quickly to treatment. 
With one exception, Case IV., they were cases in Early (Secondary) Syphilis■. 
21 
which the manifestations on the skin and mucous 
membranes were decidedly mild and of short dura- 
tion. It is perhaps fair to assume that if Case IV. 
had continued under regular treatment, instead of 
getting into the hands of a quack, his secondary 
symptoms might not have been as severe as they 
were when I first saw him. They certainly disap- 
peared very quickly after he came under my.care. 
I refer to the mildness of the secondary symptoms 
in these cases, as it confirms the statistics which 
other observers have collected, which go to show 
that in the majority of cases where cerebral symp- 
toms show themselves early the previous manifesta- 
tions have not been of a severe type. I think, how- 
ever, that it would be very far from the truth to infer, 
on that account, that the fact of a case of syph- 
ilis showing a mild and benign type, as far as the 
manifestations on the skin and mucous membranes 
go, is an indication that cerebral trouble is to be 
anticipated ; in other words, that a mild course of 
development of the constitutional symptoms is a 
bad feature in a given case. This is far from being 
so, as a large number of the cases, which run a 
mild course and in which the symptoms disappear 
quickly under treatment, not only do not have any 
cerebral trouble, but are exempt from relapses of 
any kind. In all five of these cases headache was 
a prominent premonitory symptom, and, moreover, 
a headache having certain well-marked and definite 
characteristics, such as its decided tendency to ex- 
acerbations toward evening, its severity, and its 
very quick yielding to the administration of the 
iodide of potassium. While cases of early cerebral spe- 
cific trouble are rare, cases that complain of cephal- 
algia, exactly identical to that described, are quite 
frequent. I have seen many that I am convinced 22 
Cases of Cerebral Symptoms in 
would have resulted iu cerebral trouble had they 
not been recognized and properly treated. The 
proportion of these cases in dispensary practice is 
much greater than those observed at my ollice, and 
as the former class of patients are much less under 
control, to say nothing of their being so situated 
that they are unable to get proper care, nourish- 
ment, etc., and do not follow out the instructions 
given, it is not to be wondered at that such is the 
case. The fact that in patients who are careless or 
unable to follow up the treatment prescribed the 
symptom of early syphilitic cephalalgia, with the 
possibility of the occurrence of cerebral symptoms, 
is comparatively frequent, is of course a strong proof 
of the need of regular treatment as a safeguard, to 
say nothing of giving the patient relief from what is 
at times an excruciatingly painful symptom. The ap- 
pearance of a patient who has been suffering for some 
days from this specific headache is very characteristic. 
Even if seen early in the day, before the attack comes 
on, they show a worn and wearied expression. I 
have not been able to corroborate the statement 
made by some of the writers on this subject that 
these headaches are usually confined to one half of 
the head. On the contrary, my experience has been 
that they are either frontal or occipital, in the early 
stages chiefly the former. Some patients describe 
the pain as feeling as though there was a great 
pressure inside the skull, or, as one expressed 
himself, as though his “ whole brain had swollen, 
and was too big for its box.” Others, again, refer 
the pain more to the exterior, and even complain of 
tenderness to the touch of certain points of the 
scalp. 
Prof. LeGrand N. Denslow, in the Northwestern 
Lancet, May 1, 1885 (vol. iv. No. 14), reports four Early (Secondary) Syphilis. 
23 
interesting cases of “Persistent headache in early 
syphilis,” in all of which the phenomena were ob- 
served within six months from the appearance of 
the chancre. In one of the cases, where treatment 
was neglected, complete hemiplegia, with aphasia, 
came on, and, although the patient recovered, at 
the end of a year there still remained marked hes- 
itancy in speech. He got excellent results in these 
cases, as early as two or three days after commenc- 
ing treatment, by administering minute (one twen- 
tieth of a grain) doses of calomel hourly. I will 
refer later to this question of treatment. 
With regard to the influences which may act as 
predisposing causes in producing cerebral symptoms 
in syphilis, the writers on the subject, especially 
Fournier and Heubner, have made thorough inves- 
tigations. Beyond the influence of the weak spot, 
the pars minoris resistentice, they find that ex- 
cesses in venery, abuse of alcohol and tobacco, 
great fatigue either physical or mental, mental 
griefs or shocks, etc., may act as such. In the cases 
I have reported nothing of especial interest in this 
line of investigation is to be noted. 
The diagnosis of these early cases of cerebral 
syphilis is very much simplified by the fact that 
they occur either while the symptoms of constitu- 
tional infection on the cutis and mucous membranes 
are still apparent, or so shortly afterward that 
the fact of the patient’s having recently had syph- 
ilis could not very well be ignored. Their diagnosis, 
however, by no means depends on this point of 
time alone. The fact that the attack had been pre- 
ceded by the characteristic headaches which I have 
described would be of importance. The muscular 
paralysis in these cases is always, at first at least, 
an incomplete one ; loss of power or of control of 24 
Cases of Cerebral Symptoms in 
one arm or leg, or both, is first noticed, and this 
gradually increases. A certain amount of aphasia, 
or rather a hesitancy in speech, seems to be a pretty 
constant symptom. The comparative youth of the 
patient in many cases is of diagnostic value. Lastly, 
the fact of the symptoms improving under spe- 
cific treatment would, of course, decide the question. 
The lesion which is most likely to be confounded 
with these early cases of cerebral syphilis is an 
embolus of a cerebral artery. In such a case, how- 
ever, the symptoms of paralysis would come on 
more suddenly, be more complete, and there proba- 
bly would be some indication of the cause of the 
embolus. 
While the pathology of cases of late cerebral 
syphilis has been very thoroughly studied by the 
French and German pathologists, these early cases 
have not been, or at least I have not .been able to 
find much on the subject. The important point, 
practically, is to know whether these cases are the 
result of a precocious development of the neoplasms 
which, as a rule, are only found in the later stages 
of the disease, or whether the symptoms are pro- 
duced by a simply temporary, inflammatory process 
affecting the meninges of the brain itself, which 
corresponds to the macula on the cutis, and the su- 
perficial mucous patches of the mucous membranes, 
and which leaves no structural alteration behind it. 
Heubner, with the characteristic caution of the Ger- 
man scientific observer, who refuses to go one step 
beyond the path which his scalpel cuts out for him 
and his microscope illuminates, says, with regard to 
this point, that “while not denying the possi- 
bility of intercranial simple inflammation of syph- 
ilitic origin existing, neither originated nor ac- 
companied by a new formation, the cases so far Early (Secondary) Syphilis. 
25 
reported are not sufficient to justify it, and for 
the present it must be regarded as an open ques- 
tion.” From a clinical point of view it seems un- 
likely that these cases of early cerebral syphilis, 
which show themselves simultaneously with symp- 
toms on the skin and mucous membranes due to 
simple inflammatory action, and which yield almost 
at once to treatment, should be caused by a differ- 
ent pathological process in the nervous system from 
that which is manifest elsewhere, and the question 
presents itself, whether in the same way, as we see 
at an early stage of the disease, the periosteum of 
certain bones, such as the sternum, the clavicles, 
and the tibiae, become tender, painful, and swollen, 
all of which symptoms disappear rapidly under 
treatment, the same thing may not take place in the 
dura, and by pressure give rise to the cerebral symp- 
toms noticed. 
Fortunately, when we come to the question of 
treatment of these cases we leave all regions of 
uncertainty and doubt, for if there is one proved 
fact in medical science it is that in the iodide of 
potassium we have a specific in the true sense of 
the term. Of course, there are exceptions to every 
rule, and more especially so in medicine, but in spite 
of the many examples I have seen of its efficacy I am 
constantly astonished at the almost immediate result 
of this drug in cases of syphilis where its use is indi- 
cated. Time after time patients will come, complain- 
ing of the most excruciating headache, which has been 
torturing them for weeks, and on the second day 
they will report themselves as absolutely freed from 
their trouble. The importance of giving the iodide 
in all cases of syphilitic headache as not only a 
means of saving the patient from great suffering, 
but as a prophylactic against more serious cerebral 26 
Cases of Cerebral Symptoms in 
symptoms in the future, is, I think, the most impor- 
tant practical deduction to be drawn from the cases 
I have reported. While I would insist upon the use 
of the iodide in these cases, I would by no means be 
understood to deny the importance of a mercurial 
course. On the contrary", if we want to give the 
patient the full benefit of treatment, and, more es- 
pecially, guarantee him as far as possible from 
relapses, the adjuvance of a mercurial which should 
be continued even after all indications for the 
iodide have ceased is absolutely necessary. The 
old dictum — secondary, mercury; tertiary, iodide 
— no longer holds. The fact is that in mercury 
properly administered we have a true specific for the 
treatment, and I think 1 can venture to say for the 
cure, of syphilis in whatever stage or period it may be, 
where its use is not contraindicated, while in the 
iodide of potassium we have an equally powerful 
specific to use against certain symptoms, at the head 
of which stand those affecting the brain. I have 
not found that it has been necessary in these early 
cases to push the iodide to the very large doses that 
we see reported ; ten, fifteen, or twenty grains three 
times a day will generally show decided results. 
On the other hand, I have seen cases where the pa- 
tients had been doubling up on their doses of 
iodide and getting daily worse, improve most de- 
cidedly on having the iodide cut down to a very 
moderate amount and a mercurial added to it. 
AVhere the mercurial is administered internally it is 
well to combine the iodide with some simple bitter, 
and have it taken just before meals and the mercu- 
rial after. In cases, however, of present or threat- 
ened cerebral trouble a more rapid and thorough 
action of the mercurial is indicated, and inunctions 
are very efficacious. The method mentioned by Early (Secondary) Syphilis. 
27 
Dr. Denslow of giving small and frequent doses of 
calomel will act even more rapidly than inunctions, 
but the patients must be watched very carefully, as 
the chances of salivation must be taken into consid- 
eration. It may be asked why, if the treatment by 
inunction is the most successful one, not always 
use it? To this I would reply that, in point of fact, 
most patients do very well under internal treatment. 
I am referring now to the general treatment of syph- 
ilis, and as long as they do so it is just as well 
to reserve our most powerful weapon for any emer- 
gency that may arise. Moreover, the process of 
inunction is so dirty and troublesome that few pa- 
tients, in my experience at least, can be kept on it 
for any length of time. 
With regard to the prognosis of these cases of 
early cerebral syphilis it is, of course, too soon to 
draw any deductions from those I have reported. 
One of them, Case II., seems absolutely well, but 
it is only two years since his attack, and, of course, 
too soon to feel sure as to the future. That cases 
in which such serious symptoms show themselves so 
exceptionally early should be warned as to the need 
of their giving themselves the full benefit of care- 
ful life and regular habits there can be no doubt. 
Fortunate as we are in the possession of methods of 
treatment, which in many cases will overcome the 
threatening symptoms, we must feel that there is 
always a possibility of permanent injury having 
been done to one of the most important of the 
vital organs.