Digitalis From this time special labels with the exact date on which all fluid preparations of ERGOT and DIGITALIS were physiologically tested and approved by our laboratories, will be placed on each package. Fluid preparations of ERGOT and DIGITALIS may deteriorate, and because of the POSSIBILITY of such deterioration, we believe the physician prescribing and the pharmacist dispensing these drugs are entitled to know the age of the preparation. Most galenicals, particularly those containing alkaloids as active principles, are quite stable and hence there is no necessity for dating them. Fluid preparations of DIGITALIS and ERGOT, however, if improperly stocked, may deteriorate, and should therefore be dispensed in as fresh a condition as is possible. The dating on the package will be of much service to the pharmacist and the physician in enabling them, to use reliable preparations. We do not presume to say how long these preparations will keep. We have had preparations returned to us after two or three years which were entirely satisfactory for use, and, on the other hand, a considerable deterioration has occurred in less than one year. We believe, however, that liquid preparations of these drugs will remain satisfactorily active for at least a year, if they are kept in a cool place, tightly stoppered and protected from the light. Preparations of the H. K. Mulford Company protected by the above dating system will include: TINCTURE AND FLUID EXTRACT of DIGITALIS. DIGITOL, a fat-free, standardized TINCTURE OF DIGITALIS. CORNUTOL, a LIQUID EXTRACT OF ERGOT, especially prepared for hypodermic use. FLUID EXTRACT OF ERGOT. We recommend the purchase of quantities to supply your needs for not longer than six months. Should the demand for these preparations justify purchasing in bulk, we recommend that the contents of the bulk package be transferred to tightly stoppered pint bottles, keeping them in a cool place protected from light. THE NEW ENGLAND VOL. XLVII JANUARY, 1912 ORIGINAL COMMUNICATIONS. No. 1 SOME FACTS CONCERNING SYPHILIS OF THE CENTRAL NERVOUS SYSTEM * BY E. M. JORDAN, M. D., Boston, Mass. In the study of cerebro-spinal syphilis we early learn a division of the subject into those processes which are due to the active specific virus, and those parasyphilitic degenerations which are not marked by truly syphilitic characteristics. Either of these conditions may attack the subject of the acquired disease or the offspring of a syphilitic parent. Both processes may be present in the same individual. According to some authorities, from one and one-half per cent. to two and one-half per cent. of all syphilitics develop cerebro-spinal symptoms at some time, while of patients showing tertiary syphilis, from twelve to twenty per cent. are said to develop cerebro-spinal involvement. The nervous symptoms may come as early as the sixth month or as late as the fortieth year following the initial lesion, and they seem more prone to attack those persons in whom the secondary conditions are light. This is probably due to the fact that such patients take the disease syphilis less seriously and are less thoroughly treated. Be this idea true or false, a large number of persons showing syphilitic involvement of the central nervous system, deny knowledge of the initial sore and admit no recollection of secondary symptoms. It is unnecessary to state that the actual cause of syphilis is believed to be the spirocheta pallida which is found in the primary, the secondary and sparingly in the tertiary processes. The anatomical basis of syphilis is an infectious granulomatous tissue which is but partially vascularized, and which shows some tendency to develop into cicatricial tissue, but far more tendency to undergo degeneration. Infiltration of brain and spinal cord, their meninges, their nerve roots and their blood vessels with this granulation tissue seems to be responsible for the symptoms of cerebro-spinal syphilis. This granulomatous material appears in the meninges as a gelatinous, translucent exudate and as gummatous masses, varying in size from that of the miliary tubercle to that of the acorn. The diffuse exudate may be scanty or profuse, while the gummatous masses may be few or many. Read at the April meeting of Massachusetts Homœopathic Medical Society, 1911. The syphilitic process is very apt to attack the base of the brain, especially the interpeduncular area. Often it extends along the fissure of Sylvius to the external surface of the hemispheres. From the soft meninges, extension to the brain and cord is easy and the process thus may become a syphilitic meningoencephalitis or a meningomyelitis. Arterial degeneration of syphilitic origin gives the vessel a grayish opacity to the eye and renders it firm and stiff to touch. On cross section the arterial wall is found much thickened, diffusely, or in distinct foci. Narrowing of the arterial lumen results, and entire obstruction easily occurs, particularly if thrombosis takes place. If we add to this lastly survey of the pathological basis for the symptoms of syphilis of the nervous system, the statement that any one or more of the nerve roots may be entangled and more or less severely injured by the disease under discussion, we shall see that we have to deal with no certain and unvarying picture, but with one which may present unending variety. To recognize the early symptoms of syphilitics disease of the nervous system is highly important, since efficient treatment at this time may result in entire disappearance of symptoms. After this early stage is fully past, our best efforts are apt to leave the patient more or less crippled. The so-called premonitory symptoms include many of the ordinary general cerebral symptoms. The patient's wits may become dull. His apathy and forgetfulness may be decided. He often sleeps unnaturally, during the day, over his meals or at his desk. He is particularly prone to headache of much severity at night. These symptoms are likely to be followed soon or late, if untreated, by more definite signs, such as ptosis, strabismus, aphasia, spasm or paralysis. Syphilitic arterial disease is frequently especially well marked at the base of the brain and in the middle cerebral artery. This vessel supplies by cortical branches the motor area, the speech area in its motor and sensory phases and by perforating branches it supplies the internal capsule and the basal ganglia. Obstruction of the circulation through this vessel by syphilitic endarteritis or by the thrombosis which frequently ensues, leads inevitably to cerebral softening with its aphasia, monoplagia, hemiplegia, etc. Frequently preceding the final obliteration of vessels incident to syphilis, the patient has warning in the form of fleeting palsy, transient aphasia, with or without spasm. In studying the symptoms of syphilitic meningitis and tumor we need to remember those of meningitis and tumor of other than syphilitic etiology. Since the base of the brain is a favorite place of attack, signs of involvement of the cranial nerves appear many times. To interpret the symptoms properly we need definite knowledge of the anatomy and physiology of the twelve pairs of nerves. Ocular signs are important and include, of course, contraction of visual fields, hemianopsia, inequality, irregularity and rigidity of the pupils, along with changes in the fundi and defects in the movement of eyeballs and lids. Irritation of the fifth cranial results in pain in its distribution, with perhaps spasm in the muscles of mastication. Destructive disease of the same nerve causes anææsthesia of the corresponding area and paralysis of the muscles concerned in chewing. In Facial paralysis with loss of function of the adjacent auditory nerve occasionally results from syphilis, while the lower cranial nerves are said to be less frequently involved in this disease. the less frequent syphilitic assault on the meninges over the convexity of the cerebrum we again may find any or all of the general cerebral symptoms, but soon or late cortical irritation appears, evidenced by local or general convulsions. Severe crippling processes here entail loss of function of the areas concerned, which may be those of motion, sensation, vision, hearing or speech. In studying spinal syphilis we find the disease attacking meninges, nerve roots and blood vessels primarily, and that actual disease of the cord itself comes by way of a preceding meningitis or endarteritis of specific origin. The symptoms induced are very little different from those of other pathological processes in the same situation. Uni Meningomyelitis of syphilis causes the backache, the root pains, the sensory, motor, sphincteric and trophic disturbances which are the familiar signs of spinal disease in general. lateral interruption cord gives the Brown-Sequard complex of palsy below the lesion on the same side with anæsthesia below the lesion on the opposite side as surely when due to syphilis as when owning any other cause. Thrombosis of vessels incident to syphilis is undoubtedly the basis of some of our cases called myelitis. In individuals who have had syphilis we sometimes see the scraping toes, the weak, more or less rigid, adducted knees with active reflexes incident to Erlir type of syphilitic spastic paralysis. Any of the ill effects wrought upon the nervous system by acquired syphilis may and do appear at times in those who inherit that taint. The evidence may be congenital, or it may appear in childhood, at puberty, or even later. The history of a syphilitic parent with such signs as Hutchinson's teeth, interstitial keratitis, depression of the bridge. of the nose, rhagades about the mouth, etc., aid the recognition of the causative factor. That the parasyphlides, tabes and dementia paralytica may appear early in life from a specific inheritance. should not be forgotten. In making the diagnosis of syphilis of the central nervous system, a plain admission of a specific history on the part of the patient helps us out at once. The value of negative history is impaired from the frequency with which syphilis attacks the nervous apparatus of those whose early symptoms were mild and even unnoted. In searching our patient for confirmatory |