284 Prof. Monro? as seen by a Hospital Physician.

SYPHILIS AS SEEN BY A HOSPITAL PHYSICIAN*

By T. K. MONRO, M.A., M.D., Professor of Medicine, University of Glasgow.

\ " / Mr. President and Gentlemen,?I thank you heartily for the honour you have done me in inviting me to be Honorary President of this Faculty for the session which is now opening. I was duly informed by Dr. Wardlaw that my principal duty as incumbent of this honourable office was to deliver an address to the Faculty, and as his invitation reached me while I was on holiday, with other objects in view, I had time to contemplate the responsibility I had undertaken, and to consider how I was to face it. In getting over the usual initial difficulty as to the choice of a subject, some assistance was afforded me by the President's instruction that the address ought to be one for the general practitioner. Quite a number of subjects would be appropriate from this point of view. I should have been glad to say some- thing on oral sepsis, a condition often spoken of, and no doubt often wrongly blamed, but also apt to be overlooked. Dentists do not always realise how completely one may be misled by the absence of subjective and objective evidence; so that even an experienced man may pass as innocuous a tooth which subse- quent extraction shows to have disease at its root. Medical men sometimes make a mistake in the opposite direction, by insisting, without sufficient justification, on the removal of teeth, e.g., in epileptiform neuralgia. Meantime, it may be said that in all these doubtful cases the sockets ought to be examined by a>rays. In addition to the tooth-sockets, the tonsils and other parts of the digestive tract, including the appendix, may be the seat of chronic disease with general intoxication. An expert examina- tion of the nose and accessory sinuses, carried out simply as a matter of routine in cases presenting no symptoms pointing to

* Honorary President's address to the Greenock and District Faculty of Medicine, 11th October, 1921. Prof. Monro?Syphilis as seen by a Hospital Physician. 285 these parts, may reveal the existence of chronic disease; and this in its turn may account for a hitherto unexplained general or intoxication, as in rheumatoid arthritis. Lethargic encephalitis also might have been taken as a subject for this address. Many cases of the disease have come under my notice in hospital and in private practice, but it seems to have died out for the present, at least in this district, and the cases which I have seen for the first time in the past few months have been brought under my notice because the patients had not yet recovered from the symptoms which attacked them at a much earlier date. Another possible subject is one that I set aside with some reluctance, viz., endocrinology, or the doctrine of the endocrine or ductless glands, about which much has been written in recent years. In the United States there is an Association for the Study of the Internal Secretions, with its journal, entitled Endocrinology. It is a fascinating subject to consider how the different glands of this group constitute one complicated and yet delicately balanced mechanism ; how the internal secretion of one tends to neutralise that of another; how a gland of this kind, such as the pancreas, may produce both an internal and an external secretion; how glands of this group {e.g., pituitary and adrenals) may be made up of different parts with entirely different functions; and how in practice we meet with cases illustrating excess, defect, or perversion of the functions of these glands. You may have noticed, as I did, that among the results of the War there was a great increase in the frequency of Graves' disease, as happened in Alsace and Lorraine after the Franco-Prussian War of 1870. One of my patients was in London at the time of the air-raids, and apparently acquired the illness as a direct consequence. Fortunately, this outbreak appears to have subsided again. But, attractive though this subject is, I pass from it at the present time, and venture to address you at greater length on a matter which is of perennial interest to us all, for many reasons, viz., that terrible infection syphilis. I know, of course, that many of those who are here to-night see syphilis in its earlier stages?in the primary, and doubtless also in the secondary stage?much more frequently than I do; but, without presuming 286 Prof. Monro?Syphilis as seen by a Hospital Physician. to teach you, I thought it might interest the members of this Faculty if I were to give some account of the guises under which syphilis presents itself to me as a physician in hospital and private practice. I do not forget that some of my audience are also engaged in both kinds of practice, but the seniors will perhaps be willing to compare their experiences with mine, while those who have more recently joined our profession may get an occasional hint that may be helpful. Perhaps it will never be definitely settled whether syphilis existed in Europe before Columbus and his sailors returned in 1493 from their discovery of the New World. The modern name, of course, was introduced by Fracastorius in 1530 in the title of " his poem, Syphilis sive Morbus Gallicus"; but the disease became well known as an epidemic at an earlier period when the French army invaded Italy in 1495; and by the close of the fifteenth century the civilised world was syphilised. That clever rogue, Benvenuto Cellini (1500-1571), refers in different passages of his autobiography to the prevalence in Italy of the "French evil," as it was then called, and tells howT he himself acquired the disease. The suspicion that syphilis is responsible for many internal diseases can be traced back to the eighteenth century, being the first important disorder of the kind to be attributed to this cause. According to Garrison, the connection between the two was first suggested by Ambroise Pare (1510-1590) in the sixteenth century. It is only, however, within the past few decades, or it might almost be said within the* past few years, that the ravages of syphilis among the community have come to be recognised in anything like their true proportion, and thus it was that some eight years ago the medical profession, feeling its own helplessness in dealing with such a gigantic problem, made its successful appeal to the State to shoulder the responsibility. The indictment against syphilis was never more ably put than by Sir William Osier in one of those charming and instructive addresses which he gave in the course of the War?a small part of the many and arduous duties he undertook during that period. He reckoned that syphilis is an easy first among the as a cause of mortality in temperate climates. But the mortality figures take no account of the Prof. Monro?Syphilis as seen by a Hospital Physician. 287 tremendous amount of physical suffering, or of the unfitness for work, which syphilis brings in its train. And even these three considerations do not complete the indictment. For I am sure you will agree with me, on the basis of your own observations, that, among the intellectual classes at anyrate, there is nothing more capable of giving rise to life-long remorse than an attack of this disease. As Gairdner put it, "Syphilis may be said to spoil a great part of a man's life." How far modern methods of diagnosis and treatment are capable of easing the burden that thus presses on the afflicted individual, and on the community, has still to be determined. A difficulty sometimes met with?more humanitarian and academic than of practical importance?is what to make of cases of undoubted syphilis where the patient denies having run the risk of infection. I am referring to cases in the primary and secondary stages, where the diagnosis is not in doubt, and occurring in intelligent individuals who realise to the full the seriousness of the situation, and in whom there is a genital sore of the usual kind. Of course, it occurs to one that a person who will expose himself to the risk of venereal infection is likely to be capable of telling an untruth, but one feels that this theory is not sufficient for all cases, and the mystery remains. In another difficult group of cases there is not only denial of risk run, but also impossibility of discovering any primary lesion. A hospital nurse consulted me some years ago on account of certain symptoms which included sore throat and a cutaneous eruption. She was seen also by the dermatologist to the insti- tution, and there was no possibility of doubt that she had secondary syphilis. No primary lesion was admitted, and on the advice of the matron she submitted herself to examination under an anaesthetic by the gynaecologist and the dermatologist; but no trace of a genital or other primary sore was found. There was a severe case of syphilis under treatment in the ward where she was on duty, and we felt compelled to assume that the nurse might have acquired the disease innocently from this patient. Among cases of syphilis that I have come across in medical practitioners, either as patients or as professional friends, and setting aside those in which the disease was acquired through 288 Prof. Monro?Syphilis as seen by a Hospital Physician. errors of conduct, most have been due to midwifery practice or to gynaecological operations, but in one instance the infection on the finger appeared to take place at an ordinary surgical operation. A medical man came to me with a chancre on the lower lip, acquired while he was blowing into the mouth of a new-born asphyxiated infant to distend its lungs. As a rule, however, the infection has been on some part of the hand. A medical friend injured his hand with a broken umbrella when hurrying to a confinement, and there the wound became infected. A lady had her hand injured by a broken hinge on her carriage door, and then had the wound infected when operating on a gynaecological case. Some of you will remember a case which came before a Civil Court some twenty years ago, when a Glasgow specialist, who was insured against accident, and had acquired syphilis on the hand in the course of his professional duties, brought an action against the Insurance Company for compensation, which they had refused to pay.

The Wassermann test is of great value in diagnosis, but it must not be allowed to replace the ordinary clinical methods. The fact that a man has the syphilitic infection in his blood does not prevent him from acquiring non-syphilitic diseases. But in addition to its value in diagnosis and as a guide to treatment, this test has proved useful in another way. Many years have elapsed since Jonathan Hutchinson compared syphilis to a long drawn-out fever, and now the Wassermann test has shown how long drawn-out it may sometimes be. The Report of the Royal Commission mentions instances in which the reaction in the blood was positive after twelve, sixteen, nineteen, and in one instance, twenty-nine years. I am inclined to think that long periods are quite common. Last year I was consulted by a man who was suffering from syphilis of the nervous system. The disease was acquired twenty-six years previously, and the Wassermann test was reported positive on the day he consulted me. In 1917 I saw a man who complained of symptoms which, like the physical signs and the #-ray plates, were suggestive though not quite conclusive, of aneurysm. He told me that he acquired syphilis in 1887. An examination of the blood after he came under my observation showed that the Wassermann Prof. Monro?Syphilis as seen by a Hospital Physician. 289 reaction was still positive?i.e., in the thirtieth year after infection.

Cases of multiple superficial gummata sometimes come under observation. These may be accompanied by fever, but should give rise to no serious difficulty in diagnosis, particularly if one or more of the gummata are present in the form of nodes on the cranium. Few results of treatment are more striking than the quick relief of pain and resolution of the swelling at the seat of a periosteal node, under the influence of iodide. It will sometimes avert a diagnostic error if one bears in mind three local diseases which may appear to follow, or may be attributed by the patient or the friends to, a blow or other injury, viz., tubercle, syphilis, and sarcoma.

The variety of chronic stomatitis known as leukoplakia sometimes comes under notice in a medical clinic. Fournier regarded it as a quaternary manifestation of syphilis, and it is of special importance, because it is apt to lead to cancer of the tongue. In December, 1891, a man came to the Outdoor Department of the Royal Infirmary, complaining of nervous attacks which resembled Jacksonian epilepsy, and were probably due to syphilis. Soon afterwards he developed well-marked leukoplakia, involving the tongue and lower lip; and though it caused him a good deal of inconvenience, it was difficult or impossible to persuade him to stop smoking, and the condition lasted for some years. By December, 1898, however, it seemed to have cleared away completely. Shortly before I left the Royal Infirmary in 1913,1 got a letter from the Cancer Hospital, asking for the earlier medical history of this man, who was now in that institution with cancer of the tongue. This case shows, not only the importance of curing leukoplakia as quickly as possible, but also how, in spite of apparently complete cure, a protracted attack of the disease may pave the way for subsequent cancer.

It is easier to suspect than to be confident that an enlargement of the liver is due to acquired syphilis, and in actual practice one can rarely be sure of it. In 1906 I saw a woman of 32 years No. 5. T Vol. XCVI. 290 Prof. Monro?Syphilis as seen by a Hospital Physician.

who, at the age of 16, had been outraged by a strange man in a railway carriage. A genital sore developed after some weeks. She married at 20 and had two premature children, and then another which was idiotic and died at the age of 5 years. This woman's liver was considerably enlarged, hard, irregular and tender. My last notes of her case are dated 1911, and at that time it was scarcely possible to recognise any enlargement of the liver.

I do not need to refer here to syphilis of the fauces or larynx. Syphilis of the trachea entirely below the level of the larynx is, in my experience, rare. I once met with a fatal case of of the trachea at and above its bifurcation. This was many years ago, long before the Wassermann test was introduced, and the real nature of the condition was not diagnosed during life.

Syphilis of the lung can rarely be diagnosed with certainty within the patient's lifetime, but it is possible that some cases of pulmonary fibrosis, which are otherwise difficult to account for, may be due to this infection. A miner, aged 46 years, was admitted to my wards in December, 1920. He had been healthy until a year before, and then began to suffer from severe cough, especially on waking in the morning. In course of time, , weakness, and expectoration were added to the other symptoms. He said he had acquired venereal disease twenty-two years previously. The blood gave a positive Wassermann reaction. The left side of the chest was retracted, and there were physical signs of bronchitis. No T.B. were found in the sputum. The urine and temperature were normal. X-ray examination showed extensive fibrosis of both lungs?on the right side, chiefly in the lower half; on the left side, more widespread, but not so advanced. Both apices were practically clear, and there was no evidence of aneurysm. He was treated with mercury and iodide, and was dismissed in February, 1921, much improved.

But of all the varieties of syphilitic disease which come under the notice of the physician, those which involve the nervous and Prof. Monro?Syphilis as seen by a Hospital Physician. 291 cardiovascular systems are by far the most important; not only because of their frequency, but much more because of the disability, the physical and mental suffering, and the mortality, for which they are responsible. A large proportion of the sufferers are persons who, but for the syphilis, would have continued at some occupation useful to the community. The heart, , and larger cerebral are the parts of the vascular system principally affected; but since disease of the cerebral arteries is effective through its influence on the nervous tissues, it is appropriate to consider it in connection with syphilitic nervous disease. Of the vascular system, the aorta appears to be the part which is most vulnerable or most susceptible. This great vessel, from its very commencement, and all along its arch, is apt to suffer from syphilitic . From the commencement of the arch, the disease may spread down to the aortic valve and alter its structure; or it may so alter the aorta at and above the level of the valve as to interfere seriously with the function of the valve. This aortitis, which is very common, often leads to aneurysm. Among of special interest which I recall, there was one which was about as big as a football, and involved almost the whole of the descending thoracic aorta. The case was seen in private, but an autopsy was granted, and the specimen was transferred to the Museum of the Glasgow Royal Infirmary. In January, 1920, a man was admitted to my wards with a large pulsating tumour above the left sterno-clavicular joint. It was looked upon and treated as , though it is to be noted that the first symptoms which had troubled the patient were pain and loss of power in the left upper limb. After his death in May, 1920, it was found that the aneurysm was not in the aortaA but on the left subclavian , beginning half an inch from its commencement. It was of great size, and had eroded the clavicle, scapula, ribs, and vertebrae, and the cords of the brachial plexus. The Wassermann test had been positive, and the autopsy showed syphilitic disease of the aortic arch and the first part of the subclavian artery.

By interfering with the aortic valves, either by spreading into them from the aorta, or simply by its influence on the ring of 292 Prof. Monro?Syphilis as seen by a Hospital Physician. attachment of the aortic curtains, syphilis causes a very common and very grave form of heart disease. The mischief is doubtless often aggravated by interference with the orifices of the coronary arteries. The symptoms and physical signs in this form of heart disease point to aortic incompetence, and if this condition is met with in an adult below 56 or 58 years of age,.in whom there is no history of rheumatism or of heart disease in early life, it is almost always syphilitic. In such cases the Wassermann reaction is usually positive (just as it is in aortic aneurysm); the outlook is unfavourable, as the patient is likely to die within a very few years after the onset of symptoms; and in a considerable proportion of cases the end is sudden death. I looked through the indices of my Ward Journals for the ten months from September, 1920, to June, 1921, and selected the cases which were admitted in the course of that period on account of a disability which was undoubtedly or in great probability due to syphilis. Thus, I have not included a case of chronic Bright's disease with old syphilitic changes in the eye; nor a case of syphilitic paraplegia which apparently sought admission because of the additional trouble due to scurvy; though both of these cases gave a positive Wassermann reaction. The list I made up consists of 20 cases (16 males and 4 females), including 8 cardiac cases of the type I have been referring to, 3 cases of aneurysm, 4 of tabes, 1 fatal case of paraplegia in a woman, 1 case of general paralysis of the insane, 1 of bilateral paralysis of the larynx, and 2 of multiple superficial gummata. In two of the cardiac cases post-mortem examination revealed, in addition, an unruptured aneurysm of the aorta. Brief notes of three of the cardiac cases will suffice to illustrate this form of syphilis:? L. L., 46 years, admitted on 2nd November, 1920. Duration of illness less than one year. Weakness set in gradually. Three months ago, dyspnoea began to trouble him at night, and more recently by day on the slightest exertion. No pain. Swelling of feet began four days ago. Double aortic murmur. pulsation. Enlarged liver. No history of rheumatism. Wasser- mann positive. On 7th December was removed home by his own desire, not improved by antisyphilitic treatment. Died the following day. Prof. Monro?Syphilis as seen by a Hospital Physician. 293

J. R., 51 years, admitted on 2nd November, 1920. Pain in right chest began on 27th July, 1920, three days after he had been knocked down by a bicycle. Two days later he had dyspnoea in addition. Took to bed on 28th August. Double aortic murmur. Much pain. Wassermann positive. Died 12th November, 1920. Post-mortem?Syphilitic aortitis with unrup- tured aneurysm of ascending aorta. No noteworthy change in valves. G. R., 49 years, admitted on 10th December, 1920. In March of that year began to have pains in chest. Dyspnoea set in one month, and swelling of feet one week before admission. No rheumatism. Venereal disease fifteen years ago. Wassermann positive.' Double aortic murmur. Capillary pulse and Corrigan's pulse. Liver enlarged. Died on 6th January, 1921. Post- mortem?Small unruptured aneurysm of aortic arch. Extensive disease of aorta. No marked change in aortic valves, the incompetence being explained by general dilatation of the aortic arch. Fibrosis of myocardium. Heart weighed 21 oz. The other cardiac cases in this list were not unlike the three just quoted, but the woman and one of the men had been conscious of some pain or discomfort about the chest four or five years before admission. One of the eight patients was aged 38 years; the other seven were of ages varying from 46 to 54. It will be noted that while rheumatism causes a large propor- tion of the heart disease which comes under our notice in is hospital, syphilis also responsible for much. Rheumatism . attacks by preference the mitral, syphilis the aortic valve. In the case of the rheumatic heart, compensation may break down and undergo repair, over and over again, during many years. With the syphilitic heart it is a matter of a much shorter time. Reckoning from the earliest onset of the symptoms, it may be a year or two for the syphilitic, as compared with ten or twenty or more years for the rheumatic heart before the end comes.

Syphilis of the nervous system is a comprehensive group, including affections of the brain, spinal cord, membranes, and cranial nerves. Some years have elapsed now since I had the honour of addressing this Faculty on syphilis of the nervous system, and while our means of reaching certainty in diagnosis 294 Prof. Monro?Syphilid as seen by a Hospital Physician. have increased since that time, and while we are bound to hope that the recently introduced methods of treating early syphilis will greatly diminish the frequency of these nervous affections, I doubt if any advance has been made in the treatment of these affections themselves once they have set in. Some are curable, as before; but for others there is as yet no known specific. Some time ago I saw a man of 53 years, previously healthy, who was suffering from severe headache. This had begun a week previously, and was generalised, and intense, interfering with sleep. He had vomited repeatedly, chiefly after taking food. No objective sign of disease could be discovered, and he felt that if he could get rid of his headache he would be all right. Now, scarcely anything except syphilis could cause headache with the special features, negative and positive, which were present in this case. It might mean an intracranial or meningitis, or might simply be due to irritation of the membranes by syphilitic . This patient made a good recovery under treatment by potassium iodide in doses of 20 grains thrice daily, phenacetin being administered at first, in addition, as a palliative. It is of particular importance that one should at once suspect the nature of this headache, not only because of the patient's great suffering, but also because the headache may be the premonitory symptom of paralysis from vascular disease. It may wTell be that by our prompt treatment we have prevented an attack of hemiplegia, though we cannot actually prove that this has been the case. Intracranial tumour is sometimes syphilitic. It may be a gumma of the soft membranes. In almost all cases of intra- cranial neoplasm, it is wise to begin treatment immediately with iodide in full doses; and to continue this for three or four weeks. Harm is rarely if ever done in this way; and, on the other hand, not only is the gumma that was diagnosed likely to be removed, but one sometimes obtains a cure in cases where syphilis seemed improbable or scarcely credible. Some years ago I was asked to see a man who was suffering from head symptoms, including headache, vomiting, and slowness of the pulse. There was a history of past pleurisy, and it was thought probable that he had meningitis or tumour, very likely tuber- culous in its nature. Under iodide he made a complete recovery, Prof. Monro?Syphilis as seen by a Hospital Physician. 295 and his medical adviser, a man of ripe experience, told me afterwards that he never got a greater surprise than when he found that this patient was cured by iodide. Palsies of the cranial nerves are common in syphilis, and arise in different ways. Well-marked paralysis of one or more of the motor nerves of the eyeball is likely to be due to a gumma in or behind the orbit, and if the patient is at once submitted to the appropriate treatment by iodide in full doses, recovery may be looked for. Slight and transient diplopia may, of course, be an early result of nuclear degeneration in tabes, while persistent ptosis is common in the fully-developed disease. By far the gravest of the familiar results of syphilis upon the cranial nerves is optic atrophy. This is occasionally associated with tabes, but if the optic atrophy comes first, the spinal symptoms do not, as a rule, progress to any important extent.

Iritis and choroiditis or chorio-retinitis come under my observation chiefly after they have ceased to be active, and are then of importance as evidences of a past attack of syphilis. Though the ocular disease is no longer active, the blood may still yield the Wassermann reaction. Many years ago I engaged in a little research at the Royal Asylum for the Blind in Glasgow. My purpose was to discover any cases of cerebral tumour that had undergone arrest. The matron was kind enough to select all the cases of blindness which were not due to disease of the transparent media. On examining these selected cases I found that only a very few of them were of the kind I was looking for, viz., post-neuritic atrophy with a history pointing to cerebral tumour. The remainder consisted mainly of two groups. In the one there were cases of post-neuritic atrophy following an attack of cerebro-spinal fever; and in the other were cases of choroiditis, evidently due to inherited syphilis.

Transient deafness of slight or moderate degree is a common enough symptom of secondary syphilis. Complete bilateral in deafness may occur both in the inherited and the acquired disease. When it occurs congenitally or in early life, it is a cause of deaf-mutism. When it occurs in adolescence as 296 Prof. Monro?Syjyhilis as seen by a Hospital Physician. a result of the inherited disease, or in adult life as a result of the acquired disease, the loss of hearing may develop very rapidly indeed.

Cases of general paralysis come under my notice from time to time. As a rule, the well-known delusions of grandeur are not very striking in such cases; if they were, the patient would probably be sent direct to the alienist. The cases I see are more apt to show thickness of speech, with tremor of the lips or tongue, alteration of manner or conduct, impairment of memory, or mistakes in business. A patient who was admitted to my wards in the period I have mentioned complained of pains in the head and of difficulty in speaking and walking. Tabes is, of course, common, and is familiar to you all, but I should like to refer here to a few points in connection with it. It may be mistaken for rheumatism. Thus, the patient's complaint may be of obstinate pains in all four limbs, which are not materially influenced by anti-rheumatic remedies. A not uncommon mistake is to regard a so-called gastric crisis as a primary disorder of the stomach, or as an acute abdominal emergency calling for operation, and accordingly such patients are liable to fall into the hands of a surgeon and have laparotomy performed. Now, if only the possibility of tabes had occurred to the mind of the medical man when puzzled by anomalous features in a case of what looked like rheumatism or indigestion or some other trouble, so that he was led to examine the knee-jerks and pupils, and to enquire into the functions of the bladder and the ocular muscles, he would probably have got on the right track forthwith. If the data thus obtained should prove insufficient, an investigation of the cerebro-spinal fluid might then suffice to clear up the case. In tabes we should expect to find in this fluid a positive Wassermann reaction, a lymphocytosis, an increased protein content, and the paretic type of colloidal gold reaction. The blood is pretty frequently negative to the Wassermann test, while the cerebro-spinal fluid is positive. Another interesting point about tabes is that occasionally, though rarely, tabetic arthropathy may undergo cure. I had once under my care a man who had arthropathies in his right Prof. Monro?Syphilis as seen by a Hospital Physician. 297 lower limb, viz., at the hip, knee, and foot. After some time I wished to show him to a post-graduate class, and I asked him to come and see me beforehand. At one of the three places a certain amount of change could still be traced, but the limb was so nearly restored to the normal that it was not worth while asking him to return to be shown at the lecture. Under favourable conditions of life tabes may become arrested, from the clinical point of view, and almost every symptom may cease to trouble the patient. In the ten months' period I have referred to, four cases of tabes were admitted to my wards (three male and one female). The female had arthropathy of the left hip with great dis- organisation of the joint, so that the affected limb was about 3 inches shorter than the other. This woman suffered great pain at times, and the history of her married life \yas a good illustra- tion of the malign influence exercised by syphilis upon the birth- rate, and of the ruthless manner in which it kills the young infant and the unborn babe. Of this patient's nine pregnancies, eight ended in still-births (some at or before half-time, and one at seven months). The other pregnancy ended in the birth of a child which lived for only a few hours. One of the very common results of syphilis is paraplegia; weakness of the lower limbs, of varying degrees in different cases, often with some bladder disturbance, and with less to a sensory than motor loss. This is often attributable meningo-myelitis involving the cord at or above the lumbar enlargement. With prompt recognition and treatment of the disease its progress should be arrested, and considerable improve- ment may be secured. In some instances, however, the loss of power sets in suddenly or within a few hours or a day or two; and in such cases the paraplegia is to be explained by a vascular lesion, viz., syphilitic arteritis. As this leads to softening of the related part of the cord, complete recovery cannot be expected. The vagueness or anomalous character of the symptoms, together with such facts as the preservation of the knee-jerks and the pupillary reflexes, sometimes makes it difficult to decide whether the case should be regarded as a neuron-disease like tabes, or as a meningo-myelitis, or as a combination of the two. The prognosis may be largely influenced by the diagnosis 298 Prof. Monro?Syphilis as seen by a Hospital Physician.

arrived at. Some years ago I had under my care at one time, in the same room in a nursing home, a husband and wife who were severely afflicted with neuro-syphilis. The husband's case was characteristic tabes. The wife's also might justly have been regarded as tabes, and yet, though she had suffered for years from pains in the legs, the knee-jerks were exaggerated. The husband admitted that once or twice before marriage he had exposed himself to the risk of venereal infection. The couple had been married for twenty-eight years, and in both cases the reaction of the blood to the Wassermann test was positive.

Syphilitic arteritis is a fruitful cause of mischief in the brain. The arteritis leads to thickening of the walls of the larger cerebral vessels and obstructs the opening of the minute nutrient twigs which arise from them. It is very likely that a small thrombus completes the blocking. Even in such a large vessel as the basilar there may be in association with endarteritis. The piece of nervous tissue, deprived of its blood- supply, quickly dies. The symptoms arising from syphilitic arteritis will naturally vary according to the vessel that is attacked, but one of the most common consequences is hemiplegia from disease of the middle cerebral. A few points in diagnosis may be referred to. The onset of symptoms is sudden, as with vascular lesions in the brain generally. The patient is usually an adult in the prime of life. In many cases he is short of the age at which senile arterio-sclerosis usually begins to show its effects, and, moreover, the usual accompaniments of arterio- sclerosis (high blood-pressure, cardiac hypertrophy, albuminuria, retinal changes) are not present. The patient's appearance, apart from the hemiplegia, may be that of a very healthy person. Inquiry may show that the onset took place daring sleep, or if by day, then without loss of consciousness. For a week or two beforehand there may have been headache and possibly vomiting, but without other premonitory symptoms. Hemiplegia develop- ing suddenly in an adult under 40 years of age is usually due either to syphilis or to , and it is generally possible to determine which of these two causes is operative. Embolism is most commonly due to mitral stenosis, and signs of that disease are likely to be present. Occasionally, however, hemiplegia Prof. Monro?Syphilis as seen by a Hospital Physician. 299 develops suddenly in pregnancy without signs of heart disease, or, indeed, any evidence of organic disease, but even then embolism seems to me the likeliest explanation.

Meningitis may show itself in syphilis in different ways. We occasionally meet with a form of muscular atrophy in the upper limbs, which is probably due to meningitis in the region of the cervical enlargement. It is characterised by a good deal of pain at one or other stage; its distribution does not quite correspond with that of typical progressive muscular atrophy, and the Wassermann test gives a positive result. Very occasionally one meets with what seems to be cerebral meningitis, characterised mainly by stupor, with or without delirium, and clearing away in a week or two under energetic treatment. One of my cases succumbed in after years to aortic aneurysm; and one of this man's sons was the subject of paroxysmal hemoglobinuria.

Paroxysmal hemoglobinuria, as you are aware, is usually accompanied by a positive Wassermann reaction. In a consider- able proportion of the cases which have come under my notice the attacks have first showed themselves in childhood or adolescence, and the infection was therefore often due, as in the case of the boy I have just mentioned, to inheritance. The tendency appears, in some cases at least, to die out completely with the lapse of years.

As for the treatment of syphilis, there is nothing so good, so far as our present knowledge goes, as a series of intravenous injections of salvarsan, or one of its equivalents, combined with a prolonged course of mercury, orally or intramuscularly. If for any particular reason salvarsan is contra-indicated, a long course of mercury (4 or more years) is still our best resource. I know no reason to doubt that in the pre-salvarsan days mercury often eliminated the syphilitic infection when the drug was perse- veringly employed for a sufficient length of time. Iodide is still the specific remedy for tertiary lesions (gumma, arteritis, &c.). It is to be noted that the symptoms by which we recognise the existence of cerebral arteritis are (with the possible exception of 300 Prof. Monro?Syphilis as seen by a Hospital Physician. premonitory headache) not due to the arteritis, but to the destruction of brain tissue which has resulted from the arteritis; so that, even if the iodide heals the arterial lesion, the cerebral softening, and very likely the resulting symptoms also, will remain. As Gowers pointed out long ago, a course of iodide should not be prolonged unduly. This drug is likely to do in three or four weeks all it can do in the way of removing a tertiary lesion, and if it is continued much longer, the virus may become resistant. Gowers illustrated the risk by mentioning the case of a woman who was admitted with an illness diagnosed as syphilis of the nervous system. Under treatment by iodide the symptoms were removed, but later on, while the iodide was still being adminis- tered, fresh symptoms developed. The patient died, and the autopsy showed that the new symptoms were due to a new syphilitic lesion which had developed in spite of the iodide. If iodide has been used to remove a tertiary lesion, it is good practice to advise a three or four weeks' course twice a year for some years to come. Naturally also, the considerations I have mentioned do not forbid the prolonged administration of iodide in such conditions as aortic aneurysm, if the drug is found to be of service in relieving pain. If venereal disease, tuberculosis, rheumatism, and alcoholism were got rid of, a great change would take place in the life of the community as well as in the wrork of the medical man? a change that would be heartily welcomed by the most con- servative amongst us. Numerous agencies, in addition to the medical man's labour, must co-operate to bring about such a result. To deal with the venereal diseases, education of the lay public on this subject seems to be necessary, in addition to the early and thorough treatment of cases. Of alcoholism I scarcely need to speak to an audience of medical men, who, in their daily rounds, see so much of the evil it does. I would simply remind you of our war-time experience that the State can do a great deal to make men sober if it likes. As for tuberculosis, one of the most urgent needs is a pure milk supply, for at present it is dangerous to give children milk which has not been boiled or otherwise sterilised. The provision of sanatoria for consumptives is still insufficient, and public opinion still Prof. Monro?Syphilis as seen by a Hospital Physician. 301 requires to be educated by medical teaching, so that these sufferers will be induced to submit to appropriate treatment at an early stage of their illness. The phthisis-mortality figures

' to ' to for Glasgow,o in relation different districts of the citv,?/ and the number of rooms in a house, show, in a most striking manner, the importance of good housing. We ate on less sure ground with regard to the rheumatic infection, since we are not certain about the organism, and we do not know its natural history. It may be assumed, however, that it attacks the body by way of the tonsils or nasopharynx, and attention to these parts in children may make them less susceptible. Growing pains at that age should be regarded as danger signals, calling for special watchfulness over the throat and heart, and for protection of the child against undue exposure and fatigue. If the four evils I have named were removed, we should expect a great reduction of mortality, sickness, and disablement in childhood and throughout adult life, so that a far larger propor- tion of the population than at present would reach the age of 60 in health. It is just after that age that arterio-sclerosis often begins to show its effects on the functions of the brain and heart. But under the new conditions many who are now cut off before the age of 60, either in childhood or in adult life, would live to be 70 years and upwards. And when one bears in mind the extinction, or practical extinction, of leprosy and malaria, which were formerly important diseases in this island, the control which has been obtained over , small-pox, and enteric, and the great decline which has already taken place in the prevalence of tuberculosis, one has indeed good ground for encouragement.