chiefly a poison for the nervous system, and of all the organic systems this is most frequently attacked by tertiary syphilis.

The

Mott tells us that "syphilis is becoming more widespread." "The struggle for existence is falling more and more upon the nervous system and thus it becomes the "locus minoris resistentiae," consequently functional diseases of the nervous system are greatly increased in number, and with the increase of the neuroses and psychoses certain combinations of factors leading to degenerative processes are much more likely to occur. same author states that while statistics are difficult to secure, yet all physicians agree that syphilis acquired or inherited, is the most important cause of organic as well as functional disease of the nervous system. "The more civilized, the more syphilized" is unfortunately true. Long before the discovery of the Spirochaete pallida by Schaudinn and Hoffman, it was maintained that syphilitic conditions were the result of a microorganism of some character, which, when discovered, would be regarded as the specific organism of this disease, if a protozoon or bacterium, is still seemingly a disputed question.

It is scarcely worth our while to take the time of this society to explain how true the above deduction has proven, or how devious are the methods by which the disease is disseminated, and while both subjects are of interest as well as of importance, the title of the paper must be adhered to. Syphilis and its relation to the central nervous system has always been of interest but one of the questions of greatest interest has been that of its diagnosis, hence before taking up this subject in detail so far as cord diseases especially are concerned, it is well for us to turn attention to a few of the general landmarks, as it were, of the disease.

The general manifestations of syphilitic disease for sake of convenience so far as our present purpose is concerned, and, as suggested by Wilks are naturally divided into the early and late, or specific and parasyphilitic divisions. These, of course, are only relative terms, one must frankly admit, but so are primary, secondary and tertiary, and are equally objectionable.

Naturally the objection arises how are we to differentiate a syphilitic manifestation, be it early or late, from that of some other disease that may present a similar pathology, or involve similar structures. The symptoms produced by a specific vascular lesion of a given extent in the cord, are not essentially different, per se, from those produced by other lesions involving the same vessels, not syphilitic. That is a thrombosis, an embo

lism or a hemorrhage involving the cord, due to syphilitic disease from a purely clinical standpoint, closely resembles the same pathological change due to other causes. The same statement may be made regarding inflammations and gummata, but perhaps not to the same extent.

The early, specific lesions are always more difficult to differentiate than are the later or parasyphilitic. Just at this point it is well to remember that our deductions are at fault if, be cause a patient says he has been infected by syphilis at some past period, and we know the statement to be true, we conclude that whatever disease he may develop of the cord, or even the brain, it must, therefore, of necessity be syphilitic. Tihs would be most erroneous. We should be able to state the "reasons for the faith that is in us." We should be able to state why a given condition is syphilitic. There are certain landmarks and groupings of symptoms which if we will keep them in mind will assist in reaching fairly safe conclusions along this line.

First-There is an unusual tendency to remissions and relapses; cases of a syphilitic character seem for a time to improve, then later without any apparent cause, or alteration in therapy, they grow worse again. This is more generally prominent in syphilis than any other disease.

Second Generally there is found to be a peculiar association or combination of symptoms that indicate multiple lesions. Third-The onset of the case while not always sudden is generally rapid, and the general course is subacute or subchronic rather than chronic.

Fourth-The symptoms, usually, but not always, resolve rapidly under anti-specific treatment.

Remembering these rules carefully we must observe there is a peculiar grouping or sequence of symptoms not characteristic of any other disease. The most frequent lesions of the early manifestation of syphilis involving the cord, are those of the bloodvessels, a vascularitis involving the arteries or veins, or both, resulting often in thrombosis, embolism or hemorrhage. Next, perhaps are to be found meningeal inflammations, especially located in the dura, that of the cervical region being especially prominent. Almost as frequently may be encountered gummata and exudative growths. A meningo-myelitis is frequently encountered and when the cord is involved it has been stated that it is a condition often of multiple thrombosis followed by acute softening, rather than inflammation. It is easy to understand that in the same patient all three changes above

referred to, may be present to some extent at the same time. The anatomical arrangement of the bloodvessels of the cord, it is believed, especially favors the pathological conditions mentioned. So far then as pathology is concerned, it may readily be divided as is suggested by Mott into three groups.

First-Affections of the vascular system.

Second Affections of the meninges..
Third-Existence of new growths.

Of recent years the laboratory has come to our aid upon the question of diagnosis, the Wasserman, Noguchi and butyric acid tests, together with the use of the microscope to determine the cellular elements, have been valuable adjuncts to our previous knowledge, but a word of warning may be necessary not to put too much confidence in the laboratory findings to the exclusion of the clinical; one helps to support the other in the present state of our knowledge, but should not be used to the entire exclusion of the other.

A point of great importance and perhaps more frequently overlooked in syphilis of the cord is the broad, general conception of the disease, remembering that if syphilis is to be considered the cause of the conditions encountered, some general evidence of its existence is most likely to be found in other portions of the body; in the pupils, irregularity, inequality, or the Argyll Robertson phenomenon, the glands, skin, periostium, throat, or perhaps the history, but a word regarding the history. In at least 50 per cent of the cases of undoubted syphilis the history is defective; too much strees and importance is usually placed on the history. We should become familiar with the tracks of the beast if we would be successful in trapping him.

The particular symptoms of each individual case of syphilitic disease of the cord will depend upon the location of the lesion as well as its nature, just as is found in cord disease in general from any other cause, that is, a meningitis in many ways will resemble an inflammation of the meninges from any other cause; a myelitis or thrombosis will closely resemble the same condition produced from any other cause, save as altered by the general rules already referred to, which should always be kept in mind.

One should always remember that no portion of the cord, or the membrane, or even the vertebrae are exempt from the ravages of this disease; and another point of importance, as pointed out by Mott, namely, that spinal syphilitic meningitis

seldom occurs without involving the cerebral coverings, and that basic syphilitic meningitis does not occur without involving the spinal. When syphilitic infection involves the subarachnoid space we can readily see why this should be true, for by means of the foramen of Majendie the spinal and cerebral cavities are directly connected. Also it has been suggested that syphilitic meningitis may be considered an eruptive meningitis similar in a way to a syphilitic skin eruption.

The general symptoms of the usual cord diseases as found in the modern text books of today first must be comprehended before one is able to appreciate the syphilitic coloring when applied to the same conditions. It is a fact that almost all cord diseases due to other causes than syphilis are found duplicated by syphilis. In other words the vertebrae, the meninges, new growth, myelitis, spastic spinal paralysis (Erb), anterior polimyelitis, pseudo bulbar paralysis, amyotrophic lateral sclerosis, (we exclude disseminate sclerosis, but not disseminated myelitis), have all been found and reported, and probably truly, the result of an early syphilis.

In order to make a correct diagnosis, one must first have a working knowledge of cord diseases as found on a non-syphilitic basis, and in addition he must have the broad, general conception of syphilis. Syphilitic disease of bone is common, but of the vertebrae is rare, yet it does occur, and the following forms have been described; ostitis, periostitis, exostoses, bony gummata, caries and necroses, all being of a syphilitic nature.

Time, as a factor in the early manifestation of syphilis of the cord and membranes is variable; in rare instances spinal syphilis has been found present at the same time with the skin eruption, also cases have been reported present simultaneously with the initial lesion, but just as the skin eruption may appear at any time after three months onward from infection, so may cord diseases be expected; especially is this true of meningitis. Lange suggests that at this period many mild cases may be overlooked. Buzzard seems to have been correct when he made the statement that a large proportion of spinal paralyses occurring in the adult under 30 years of age were probably due to syphilis.

Predisposing Causes may be considered of importance in the following order; chronic alcoholism, sexual excesses, exposure and trauma. These all serve as it were to accentuate syphilitic disease. In obtaining the history of any cord affection, especially in the adult, it is well always to take into account the predisposing factors just mentioned.

The Treatment of active syphilitic conditions of the cord is of much importance. When Erlich first reported the use of salvarsan, 606, it was hoped a genuine specific had been discovered, but time has proven it to be only an adjunct and the old remedies are not yet to be discarded entirely.

When the evidence is all collected it will be found that many cases of syphilis of the cord as well as the nervous system and other organs, have been allowed to perish and have been taking mercury or the iodides much of the time. The fault does not reside in the remedies, but in the method of administration. Many patients are drugged to death by these remedies who would have been saved by an intelligent exhibition of the very same remedies. As to remedies themselves, those just mentioned are the only ones worthy of consideration in the treatment of syphilis. How they should be given, and when, are most pertinent questions.

Unfortunately the leaders in neurological work of today differ as to the size of the dose and the length of time treatment should be continued. However, personally, the method of Gowers would seem most satisfactory. Perhaps that is because we are the more familiar with it. So far as inflammations are concerned he rather believes that they are best controlled by mercury, while gummata are possibly better controlled by iodides, or at least as readily controlled by them as by any remedy. In the Lettsomian lectures he makes this statement: "I am inclined to think that when a lesion is distinctly influenced by either drug (referring especially to (referring especially to mercury and the iodides), if this is given freely the effect of one is as great as the other.'

In his hospital practice, in many instances it is his custom to first give mercury until the physiological effects are established, then follow with iodides. He does not sanction but discourages the large dose and long-continued use of the latter drug as given in this country, and fortifies his position by pathological findings, that would seem conclusive and incontrovertable. The theory advocated is that the tissues become accustomed eventually to the remedy in large doses and that in certain cases syphilitic lesions are not controlled as they are when the remedy is first administered, hence a moderate dose, ten to fifteen grains of the iodide three or four times daily and continued for from six to ten weeks only, then an interval is allowed and the treatment is resumed later. The two remedies are not usually given at the same time unless a very rapid action is