CEREBRAL SYPHILIS. 
BY HENRY ALFRED ROBBINS, M. D. CEREBRAL SYPHILIS ; INUNCTION TREATMENT. 
Z?r Henry Alfred Robbins, M. D., 
Washington, D. C. 
CLINICAL LECTURE DELIVERED AT THE SOUTH WASHINGTON (D. C.) FREE DISPENSARY, DECEMBER 28, 1896. 
SIXTH PAPER. 
Reprinted from the Maryland Medical Journal, April 17, 1897. 
I am very glad that this patient puts 
in an appearance today, as I wanted to 
make some more remarks on cerebral 
syphilis, and it is not often that this 
manifestation of the disease can be seen 
at a dispensary service. This man for 
several months has been under the ob- 
servation of Dr. Arwine, and we are in- 
debted to him for influencing the pa- 
tient to come to us. 
Two years ago I became interested in 
syphilis of the brain, and published an 
article on the subject. Since then I 
have continued my investigations, and 
have collected much valuable material. 
You notice what a wonderful improve- 
ment has taken place in this man's con- 
dition. Now he does not appear to 
drag his leg at all, and his arm swings 
naturally by his side. We are more 
than pleased; the improvement has ex- 
ceeded our expectations. You notice 
that there are scars on his forehead- 
souvenirs of the ulcerative pustular 
syphiloderm that covered the upper 
portion of his face and scalp. What 
are the changes which have taken 
place in his brain, resulting 'in hemi- 
plegia? 
The other day I picked up Aitken's 
Practice of Medicine, edition of 1868, 
and looked for the special lesions of the 
brain causing hemiplegia, viz.: 
"1. Obstruction of a principal cere- 
bral artery by a plug of fibrin detached 
from an excrescence on one of the aortic 
or other valves of the heart, the result 
of a former endocarditis (Kirkes and 
Virchow). 
" 2. A coagulum in an artery, result- 
ing from some altered nutrition of its 
wall, and connected in general with 
a rheumatic or other morbid state of 
the blood. 
"3. A softened state of the brain, 
such as the condition known as white 
softening, which follows the retardation 
and diminution of cerebral circulation 
by diseased arteries, or by the complete 
stoppage of an artery by a plug. 
" 4. Apoplexy, induration, or tumors, 
e. g., tubercle or cancer in the parts 
indicated above." 
Aitken gave an exact representation 
of the ravages caused by syphilis, with- 
out suspecting that to it could be attrib- 
uted the lesions he so truly described. 
It is fully equal to that of Professor 
Heubner, who in 1874 described certain 
lesions as characteristic of syphilis. 
He mentioned fibroid indurations, and 
the syphilitic tumor known as gumma, 
and certain changes in the arteries. 
" In the cerebral arteries, the changes 
produce opacity and marked thickening 
of the vessel, with considerable diminu- 
tion in its caliber. It is this diminu- 
tion of the lumen of the vessel which is 
especially characteristic. When trans- 
verse sections of the vessel are ex- 
amined microscopically, the principal 
change is seen to be situated in the in- 
ner coat. This coat is considerably 
thickened by a cellular growth. The 
growth, which is limited internally by 
the endothelium of the vessel, and ex- 
ternally by the membrana fenestrata, 
closely resembles ordinary granulation 
tissue, consisting of numerous small, 
round and spindle-shaped cells. The 
tissue appears gradually to undergo 
partial development into an imperfectly 
fibrillated structure. In addition to 
this change in the intima, the outer 
coat is abnormally vascular and infil- 
trated with small cells, and this cellular 
infiltration usually invades the muscu- 
lar layer. The result of these changes 
in the inner coat is to diminish very 
considerably the lumen of the vessel ; 
and the consequent interference with 
the circulation frequently leads to coag- 2 
ulation of the blood (thrombosis) and 
cerebral softening." 
The treatment recommended by Ait- 
ken, such as administration of ergot, 
would only aggravate brain syphilis, as 
it would contract the blood vessels still 
more, causing what you most wish to 
avoid. Five years before the publica- 
tion of Aitken's Practice of Medicine, 
and six years before Virchow cleared up 
syphiloma of the brain and its mem- 
branes, and eleven years before Heubner 
published his description of brain syph- 
ilis, Dr. Samuel Wilks of Guy's Hos- 
pital showed himself to be far in ad- 
vance of all others in syphilology. He 
gained his knowledge in the dead-house, 
as well as by the bedside, and he had a 
happy faculty of imparting what he 
knew to others. 
Dr. Wilks in 1863 said : " Modern 
research has been mainly in the direc- 
tion of discovering a wider influence for 
the venereal virus, and tends to show 
that the internal organs may be affected 
equally with the external. Syphilis, in 
its ultimate form, is capable of affecting 
every organ of the body ; the internal 
may become equally as obnoxious to the 
effects of the virus as the external. 
Many obscure and intractable organic 
disorders are cases of visceral syphilis, 
and it cannot be too forcibly impressed 
upon the young practitioner that syph- 
ilis may affect not only the cranium, 
but the brain within it, or the nerves ; 
not only the muscles of the limbs and 
tongue, but the heart ; not only the 
pharynx, but the esophagus ; not only 
the larynx, but the trachea, bronchi and 
lungs ; also the liver, spleen and other 
viscera." (Guy's Hospital Report, Vol- 
ume IX, 1863.) 
Associated with Dr. Samuel Wilks at 
Guy's Hospital was the late most ac- 
complished pathologist, Dr. Walter 
Moxon. Together they wrote theirgreat 
work on pathology, which is in daily 
use by every anatomist. For several 
months, I had the honor of being an 
assistant to Dr. Moxon in the post-mor- 
tem room of Guy's Hospital. The 
changes which occur in the brain in 
this dread disease were thus described 
by him: 
"Syphilis attacks the surface of the 
brain and the membranes; it attacks 
them in limited spots, and spreads 
slowly. The morbid changes are, on 
the one hand, adhesion of the mem- 
branes to each other and to the surface 
of the brain by means of an adventitious 
material of firm consistence and yellow 
color, which may be called lymph, but 
is harder, tougher and more opaque. 
This exudation may be found at any 
part of the surface ; it invades and de- 
stroys the gray matter, interferes with 
the supply of blood, and when it occu- 
pies the membranes at the base of the 
brain surrounds and involves the nerves 
in the inter-cranial part of their course. 
In the examination of the brain after 
death (over 1000), I have been surprised 
to find in how small a number this dis- 
ease appeared to originate in the under 
layer of the periosteum of the endo-cra- 
nium. I think this, perhaps, may be 
accounted for by the fact that when 
a gumma of the inner table of the skull 
does arise, the chemical features evi- 
denced by pain, etc., are so marked 
(for these manifestations usually occur 
with the existence of external gum- 
mata) that remedial measures are 
adopted early, and thus promote ab- 
sorption before the membranes of the 
brain become involved.'' 
Professor Claude Bernard, the noted 
physiologist, many years ago proved by 
experiments on the lower animals the 
very interesting fact that an injury in 
the median line of the floor of the left 
ventricle would be followed both by al- 
buminuria and the presence of sugar in 
the urine. We know that gummata 
not infrequently attack the brain and 
by pressure it is not unreasonable to 
think that it may give rise to many of 
the so-called cases of Bright's disease 
and diabetes. I can not find any au- 
thority in my own library to sustain me 
in this supposition. 
In looking over my scrap books I 
found the following, which seems to 
corroborate the views I have expressed. 
Dr. Sidney Phillips, at a recent meeting 
of the Harveian Society of London, read 
the notes of a case of diabetes insipidus, 
due to syphilis. The patient, a man 3 
aged thirty-three, had ten years pre- 
viously been treated for a chancre, fol- 
lowed by secondary symptoms; and had 
since, at various times, suffered from the 
effects of syphilis. When first seen by 
Dr. Phillips, he stated that he was pass- 
ing very large quantities of urine, as 
much as ten quarts in a night; he com- 
plained also of severe pain, increased at 
night, in the the right fronto-parietal re- 
gion, with localized tenderness; the 
right pupil was irregular from old iritic 
adhesions and he had a gumma of the 
size of a marble in the substance of the 
tongue. 
He was treated by iodide of potassium 
in large and increasing doses and in 
three weeks he made rapid progress to- 
ward recovery. The headache had 
ceased; he was passing a little over three 
pints of urine in the twenty-four hours, 
and the gumma of the tongue had much 
diminished in size. Dr. Phillips re- 
marked that, in this case, the increased 
flow of urine was due to syphilis, but 
whether it was due to the lesion on the 
cortex ofthe brain was not so clear. In all 
the recorded cases where a growth had 
been found as the cause of the polyuria 
it had been situated at the base of the 
brain. Trousseau, however, recorded a 
case of polyuria, following an attack of 
ordinary hemiplegia, where the lesion 
was presumably elsewhere than at the 
base; and possibly, in the present case, 
it was due to the node on the surface of 
the brain, which softened and dimin- 
ished in size under the influence of io- 
dide, as the gumma of the tongue was 
simultaneously observed to do. 
I have in my mind a very dear friend 
who is not under my professional care, 
who has aphasia, and whose urine is 
loaded with sugar. I do not mean to im- 
ply that the trouble is of specific origin. 
I know that it is not, but there is a plug- 
ging up of a cerebral vessel (throm- 
bosis) and there may be some pressure 
on the median line of the fourth ventri- 
cle. Whatever the cause may be, the 
proper remedy to give is the iodide of 
potassium. You remember what Dr. 
Dowse said about "its removing a tu- 
mor as readily as the knife of a surgeon, 
etc." 
The following case is one that occurred 
in my private practice; I reported it 
in my article on "cerebral syphilis'' al- 
ready referred to: "On the nth of De- 
cember, 1894, I was consulted by Mr. 
, aged forty-two years, who stated 
that for many months he had had per- 
sistent headaches, occurring at night. 
He had consulted many physicians, 
who had treated him for neuralgia of 
malarial origin. The treatment, he 
said, making his condition worse. I 
obtained the following history: Eight 
years ago he had had a suspicious sore 
on the prepuce. At first his physicians 
were in doubt whether the sore was the 
initial of syphilis or not. Subsequent 
syphiloderms, however, put at rest the 
question of diagnosis. He was placed 
under mercurials, and in a few months 
he was pronounced cured. 
For eightyears he had taken no treat- 
ment, and, as a rule, enjoyed good 
health. I gave a prescription contain- 
ing bichloride of mercury and iodide of 
potassium, which, he stated, relieved 
the headache. On the evening of the 
22d, he appeared bright and cheerful. 
On the next evening he called and said 
that he had not taken the medicine and 
that he was not feeling well. While he 
was standing up about to leave, he said 
he felt exactly as if some one had struck 
him a violent blow on the back of the 
head. He sank to the floor and it was 
with considerable difficulty that I lifted 
him to my sofa. In half an hour he was 
able to get up, and he passed some urine. 
I examined it and found no albumen or 
sugar; specific gravity normal. I took 
him home in a carriage and placed him 
in bed, and applied oleate of mercury 
(10 per cent.) over his bald head and the 
nape of his neck. There was no eleva- 
tion of temperature, pulse 72, full and 
regular. 
I commenced giving him fifteen grains 
(saturated solution) of iodide of potas- 
sium every three hours. The rext day 
he complained of thickness of speech, 
and a sense of numbness on the right side. 
I gradually increased the iodide until 
he was taking 35 grains every three 
hours. There was no gastric disturb- 
ance. After a time there was slight 4 
coryza and I commenced decreasing the 
dose until he was taking 2dgrains every 
three hours. He daily 'improved in 
strength; headache disappeared. On 
January 26, I prescribed the follow- 
ing: 
R.-Hydg. biniodidi . . . grs. ij 
Ammonii iodidi ... 5ii 
Potass, iodidi . . . 5iv 
Tinct. Gentian, comp. . f §iv 
M. Sig. Teaspoonful in water three 
times'a day, after meals. 
Patient would go out walking or driv- 
ing every day. On January 28, he 
went to New York City and I gave him 
a letter to Dr. R. W. Taylor, who 
stands, as you all know, so pre-eminent 
in our profession. I gave a favorable 
prognosis in this case. 
On the first of February, I received a 
letter from Dr. Taylor, which contains 
the following sentence, which gave me 
supreme satisfaction: "Your diagnosis, 
prognosis and treatment are all correct. 
I think, with you, that the patient can 
be cured, provided he follows treatment 
repeatedly. He undoubtedly has had 
endarteritis of syphilitic origin." 
It is two years ago, and more, since I 
wrote that history. A year later the 
patient sent me a handsome fee. Rast 
week he called on me, looking the pic- 
ture of health. He had gained in weight 
and his mind was as brilliant as ever, 
and he is noted as being a man of won- 
derful attainments and splendid ad- 
dress. To have one such case is enough 
to make a physician feel that life is 
worth the living, and goes a long way 
in counteracting the lack of gratitude, 
which is generally his recompense. 
It is not necessary for anything to be 
new to be valuable. So with the treat- 
ment of syphilis. I do not suppose that 
away back, centuries ago, before Amer- 
ica was discovered, the effects of mer- 
cury were understood, nor did our im- 
mediate predecessors know why they 
gave calomel for everything. Professor 
Samuel Jackson of the University of 
Pennsylvania used to say "when in 
doubt give calomel" and when it has 
been properly given it has cured many 
a disease, without our having compre- 
hended the reason. 
Since the bacteriologist has appeared 
with his immersion lens and staining 
fluid and culture tubes, we begin to re- 
alize that almost every disease is of 
germ origin. Now we are taking our 
turn in hunting down and destroying 
them. This has made a Lord of Joseph 
Lister and we would like to add a 
wreath to his crown of glory. Robert 
Koch has stained and brought into 
view the bacilli of tuberculosis. Stern- 
berg, the Surgeon-General of our army, 
has acquired more fame in capturing 
the micro-organism of croupous pneu- 
monia with his microscope than many a 
general has done with his sword. Lav- 
eran has lassoed the plasmodium of 
malaria. Eberth aimed at the typhoid 
germ with his lens and it surrendered 
at discretion. Neisser discovered the 
gonococcus of gonorrhea and with it the 
fact that its disastrous effects are equal, 
if not greater, than syphilis. Gynecol- 
ogists affirm that it is the most frequent 
cause of their ovarian and tube cases. 
At present, Klebs-Lbffier diphtheria ba- 
cilli are household words, making every- 
one afraid of Washington, as if the 
germ of diphtheria existed nowhere 
except in this maligned city. The 
germ of syphilis has not yet been cap- 
tured, but we hope soon to hear that it 
is imprisoned under a microscopic slide. 
Excuse this digression. I began on 
the treatment of syphilis by mercurial 
inunctions. Our forefathers gave mer- 
cury empirically. Now we know that 
it is the most deadly foe to germs of 
every variety. I consider this method 
of giving mercury is the best of all, per- 
haps so, because it is the favorite of my 
old teachers, Neumann and Kaposi. It 
is the oldest of all. In a surgical work 
compiled by Theodoric, a Dominican 
monk, in 1250, a chapter is devoted to 
the malum mortuum and a treatment by 
means of mercurial inunctions is recom- 
mended. This, from the description, 
was undoubtedly syphilis, and if the 
ancients knew how to use mercury by 
inunction, we cannot boast of much 
progress. They did not know what the 
disease really was. Up to a few years 
ago we were in worse than Egyptian 
darkness ourselves in everything relat* 5 
ing to syphilis and it still seems to be 
the desire in certain quarters that it 
should remain so. 
There are two periods of the disease 
when we rely on mercurial inunctions 
and that is in the early secondaries and 
when we suspect arterial changes, or 
we dread formation of gummata in the 
internal organs. We order the patient 
two ounces of mercurial ointment put 
up in sixteen parts in oiled paper pack- 
ages, and we carry out as far as possible 
the directions of Dr. R. W. Taylor. 
** Taking the head and neck one day, 
and one or two arms the next, and the 
other portions of the body in anatomical 
succession, thus going on, day after 
day, if there are no other contrary in- 
dications, until the whole rash is 
brought under a local mercurial treat- 
ment, and, at the same time, the gen- 
eral system is affected by absorption of 
the drug into the circulation." 
Before rubbing in the mercury we 
direct the patient to apply to the part 
for a few minutes a small quantity of 
carbolated vaseline. Then rub in the 
mercurial ointment for twenty minutes. 
The best time to apply this method is 
just before retiring for the night and it 
is well for the patient to have under- 
clothing to wear especially during the 
treatment. Once a week we stop treat- 
ment and let the patient take a hot bath 
and begin again the next day. I pur- 
sue this treatment until there is scarcely 
any eruption on the patient's skin. I 
continue this method for twenty days 
and stop ten. I then return to the 
mercurial pill, or the mixed treatment. 
Should there be symptoms of internal 
syphilis, or tertiary manifestations, we 
give at the same time as many drops, 
saturated solution, of iodide of potas- 
sium every three or four hours, as the 
patient can stand. Beginning with ten 
drops in water or milk, increased five 
or ten drops every day, until symptoms 
of iodism commands a halt. Give only 
the amount of mercury and iodide of 
potassium that can be given without 
producing the toxic effects of the drugs. 
Six weeks ago, a man about forty 
years of age, who had a history of syph- 
ilis dating back many years, called at 
my office. He was in a wretched con- 
dition. He was afraid to go out alone 
on account of frequent attacks of vertigo. 
He suffered from night headaches and 
he complained of numbness of his right 
leg. He was of stout build. He had 
just come out of a hospital and was 
worse than when he entered it. I put 
him on drachm inunctions of mercurial 
ointment and commenced with ten 
drops of the saturated solution of potas- 
sium iodide three times a day. In a few 
days he returned, presenting a perfect 
picture of despair. He was salivated 
and covered with an iodide eruption. I 
stopped treatment, gave chlorate of pot- 
ash internally, as well as mouth washes, 
etc., and gave directions that after the 
.ptyalism had disappeared, to begin 
treatment with one-half a drachm of 
mercurial ointment as inunction and 
directed him to begin with five drops, 
gradually increased, of the saturated 
solution of the iodide of soda until the 
physiological effects were produced. 
I did not expect to see the man 
again and assigned the patient to the 
third classification of skin diseases of 
John Hunter. His division of dermato- 
logical diseases was very simple, con- 
sisting of three classes: " Those which 
are cured by sulphur, those which are 
cured by mercury, and those which the 
devil himself could not cure." 
Last week, however, the patient turned 
up again, and said that he had been out 
of town for a month. The headaches 
had disappeared, and he was not trou- 
bled with vertigo and he felt himself on 
the highway to recovery. He had taken 
just the right amount of mercury, and 
he was taking twenty-five drops of the 
iodide of soda solution three times a 
day. He had found the exact amount 
of the drugs that he could tolerate. I 
had done better than his Satanic Ma- 
jesty. We will take up at an early day 
the treatment of syphilis by hypoder- 
mic injection,