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Global Governance from Regional Perspectives
Global Governance from
Regional Perspectives
A Critical View

Edited by
Anna Triandafyllidou

1
3
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For my children Dionysis, Iasonas, Kimonas-Demetris, and Alexandros,
cosmopolitan travellers of the twenty-first century
Acknowledgements

Work on this book started in autumn 2013, when Tatjana Evas, then Research
Assistant at the Global Governance Programme of the European University
Institute, came to me to discuss some of her ideas concerning global govern-
ance, law, and a cultural perspective to both. This initial discussion led us to
organize a workshop, which took place on 5–6 December 2013 at the EUI
in Florence. However, this was only a point of departure for a longer journey
that took several rounds of revisions, the introduction of new authors and
chapters, exclusion of others, and a total re-thinking of our arguments in the
light of comments from colleagues in different disciplines including law,
sociology, politics, and history. Indeed, to paraphrase Shakespeare, the course
of true interdisciplinarity never did run smooth. Nonetheless, our, we believe,
risky and innovative endeavour to try and carve out a regional perspective that
is culturally informed and discuss through this lens the question of global
governance—and of global and regional governance institutions/ideas/
discourses/practices—has come to fruition, introducing an innovative view-
point from which to understand global governance (and international
relations) in today’s uncertain and dynamic world.
I would like to acknowledge here the importance of the Global Governance
Programme of the EUI, which provided the intellectual home for this book,
and, of course, all the contributors to this volume for their perseverance
throughout a journey that has lasted more than two years. Many thanks go
to Tatjana Evas for her initial contribution, even if her later professional path
has taken her away from this work. Many thanks to two anonymous reviewers
of Oxford University Press for very constructive criticisms.
Last but not least, this book, like all my scientific work, would not have been
possible without the unconditional support and patience of my husband,
Evgenios, to whom I am always indebted for time ‘stolen’ from him and
the family.
Anna Triandafyllidou
Florence, 7 July 2016
Contents

List of Figures xi
List of Tables xiii
Biographical Notes on Contributors xv

Part I. Critical Approaches to Global Governance

1. Global Governance from Regional Perspectives: A Critical View 3
Anna Triandafyllidou

2. Can the Study of Global Governance Be Decentred? 25

Andrew Hurrell

3. Measuring (Global) Governance: The Potential, the Practical,

and the Problematic Assessment of Governance within
and beyond the State 45
Gaby Umbach

4. Democracy and Global Governance: The Internal

and External Levers 70
Daniele Archibugi with Marco Cellini

Part II. Regional Perspectives on Global Governance

5. A Perspective from the Middle East: Governance and the
Problem of Knowledge 99
Nida Alahmad

6. An African Perspective on Global Governance 119

Thomas Kwasi Tieku and Linnéa Gelot

7. A Russian Perspective on Global Governance 141

Elena Belokurova

8. Global Governance with Chinese Characteristics? 161

Niall Duggan, Wei Shen, and Jörn-Carsten Gottwald
Contents

9. A ‘Rashomon’ Story: Latin American Views and Discourses

of Global Governance and Multilateralism 181
José Antonio Sanahuja

10. The European Union and Global Governance 209

Thomas Christiansen

11. The Debate on Global Governance in the United States 233

Roberto Dominguez

12. Pluralizing Global Governance: Achievements and

Challenges Ahead 256
Anna Triandafyllidou

Index 269

x
List of Figures

4.1. Global Trends in Internal Political Regimes 1946–2014 79

4.2. The Internal and External Levers 82
List of Tables

3.1. ‘Government’ vs ‘Governance’ 49

3.2. Governance: Process vs Structure 50
3.3. ‘Continuum’ of Governance Structures 51
3.4. Dimensions of Institutions 52
3.5. Main Examples of Governance Indices and Indicators 58
4.1. Democratic Criteria Indicated by Robert Dahl and
Their Possible Expansion to International Organizations 75
4.2. Democratic Principles and Intergovernmental Organizations 76
4.3. Macro-Indicators to Assess the Level of Democracy Operating
in International Organizations 77
7.1. Levada Centre Data on Russia–West Relations. Answers to the
Question: ‘Do You Think the Largest Western Countries
(US, Germany, Japan, Great Britain and others) Are Partners
or Adversaries to Russia?’ 152
7.2. Levada Centre Data on Russia–West Relations. Answers to the
Question: ‘In Your Opinion, after the Foreign Policy Changes
in Russia and the World at the End of the 1980s, Did Russia End
up the Loser in the Standoff with the West or Did Russia Win as
Much as Anyone Else?’ 152
7.3. Levada Centre Data on Attitudes to Western Policies toward Russia:
Answers to the Question: ‘Do You Agree or Disagree with the
Opinion That the West Is Currently Pursuing a Hostile Policy
in Relation to Russia?’ 153
Biographical Notes on Contributors

Nida Alahmad is a Marie Curie Fellow at the University of Ghent’s Department of

Conflict and Development Studies. She was an Academic Associate at the European
University’s Department of History and Civilization during the period 2013–2015. Her
current work is focused on state-building as a form of political expertise and engineer-
ing and its connection to forms of academic knowledge production. She holds a PhD in
Politics from the New School for Social Research (2009), and was a postdoctoral fellow
at Georgetown University and a visiting fellow at The European University Institute.
She taught at New York University, the University of Toronto, and the New School
University. She also worked as a consultant with a number of NGOs including the
Committee to Protect Journalists and the International Centre for Transitional Justice.
She is the recipient of a number of honours and awards including fellowships from the
United States Institute of Peace, The Mellon Research Fellowship in Security and
Humanitarian Action, and her dissertation won the New School’s Frieda Wunderlich
Memorial Award.
Daniele Archibugi is a Research Director at the Italian National Research Council in
Rome, and Professor of Innovation, Governance and Public Policy at the University of
London, Birkbeck College. He works on innovation and on the political theory of
international relations. He has worked at several universities, including the Universities
of Sussex, Cambridge, London School of Economics, and Harvard. In June 2006 he was
appointed Honorary Professor at the University of Sussex. He is an adviser to the
European Union, the OECD, several UN agencies, and various national governments.
Among his latest publications, he has authored The Global Commonwealth of Citizens.
Toward Cosmopolitan Democracy (Princeton University Press 2008) and has co-edited,
with Mathias Koenig-Archibugi and Raffaele Marchetti, Global Democracy: Normative
and Empirical Perspectives (Cambridge University Press 2011), and, with Andrea
Filippetti, The Handbook of Global Science, Technology and Innovation (Wiley 2015).
Elena Belokurova is a lecturer of the Faculty of Sociology at St Petersburg State
University, associated with the Centre for German and European Studies. She also
teaches courses on European integration at the St Petersburg branch of the Russian
Academy of National Economy and Public Administration. She holds a diploma in
sociology from St Petersburg State University, MA diploma from the European Univer-
sity at St Petersburg, and Candidate of Science degree from the Institute of World
Economy and International Relations in Moscow since 2000. She has participated in
a number of international research projects on civil society and local politics in Russia,
EU–Russia relations, and cross-border cooperation. Now, she also works as a Board
Biographical Notes on Contributors

Member of the German–Russian Exchange in St Petersburg and is a member of the

Steering Committee in the EU–Russia Civil Society Forum.
Marco Cellini is a PhD student in Political Science at the LUISS Guido Carly University
of Rome, and collaborates with the Institute for Research on Population and Social
Policies, Italian National Research Council in Rome (IRPPS-CNR). His current works
focus on globalization, democracy and inequality, and the European legislation on the
right of asylum.
Thomas Christiansen holds a Chair in European Institutional Politics in the Depart-
ment of Political Science at Maastricht University, the Netherlands, and is also part-
time professor at the Robert Schuman Centre for Advanced Studies at the European
University Institute, Florence. He is Executive Editor (with Simon Duke) of the Journal of
European Integration, co-editor (with Sophie Vanhoonacker) of the ‘European Adminis-
tration Governance’ book series at Palgrave Macmillan, and a member of the board of
the Research Committee on European Unification of the International Political Science
Association. He has published widely on different aspects of European integration. He
recently co-authored, with Christine Neuhold and Anna-Lena Högenauer, Parliamen-
tary Administrations in the European Union (Palgrave 2016). Security Relations between the
EU and China: From Convergence to Cooperation?, co-edited with Emil Kirchner and Han
Dorussen, was published by Cambridge University Press in 2016.
Roberto Dominguez is an Associate Professor at Suffolk University in Boston, Massa-
chusetts. He was a Jean Monnet fellow at the European University Institute and a
Researcher at the European Union Centre of Excellence of the University of Miami.
He has been consultant for the European Parliament. His current research interests are:
comparative regional security governance, security governance in Latin America and
European Union–Latin American relations. His recent publications include: EU Foreign
Policy Towards Latin America (Palgrave 2015); The OSCE: Soft Security for a Hard World
(Peter Lang 2014); ‘The Security Role of the United States in Asia’ in the Palgrave
Handbook of EU-Asia Relations, edited by Thomas Christiansen, et al. (Palgrave 2013);
(with Sebastian Royo) ‘The study of the European Integration process in the United
States’ in European Political Science (no. 11, 2012); (with Emil Kirchner) Security Govern-
ance and Regional Organizations (Routledge 2011).
Niall Duggan is a Lecturer in the Department of Government, National University of
Ireland (Cork). He has previously worked as a Lecturer in the Department of East Asian
Politics at Ruhr-Universität Bochum and has also been the Chair of Economy and
Society of Modern China in the Centre for Modern East Asian Studies, Georg-August
Universität, Göttingen. His research includes global governance reform, non-
traditional security issues in East and South East Asia, and interregional studies with a
particular focus on Sino–Africa and Sino–EU relations.
Linnéa Gelot is a Senior Lecturer at the School of Global Studies, Gothenburg Univer-
sity, Sweden, and a Senior Researcher at the Nordic Africa Institute (NAI), Sweden. Her
primary field of expertise has been the relationship between Africa and the UN on peace
and security issues, especially concerning Africa-led peace operations. Research inter-
ests also include regionalization, critical security studies, and norms implementation.
Her latest publication is The Future of African Peace Operations: From Janjaweed to Boko

xvi
 Biographical Notes on Contributors

Haram (co-edited with Cedric de Coning and John Karlsrud, Zed books 2016). She is
currently leading the project ‘AU Waging Peace? Explaining the Militarization of the
African Peace and Security Architecture’, in which the concept of militarization and
security practice theory are employed to study militarizing/de-militarizing institutional
discourses and practices.
Jörn-Carsten Gottwald is Professor at Ruhr University Bochum, Germany, where he
holds the Chair of East Asian Politics. He began his academic career as a lecturer in
Chinese Politics at Free University Berlin before working in Comparative Politics at
University Trier and at the Irish Institute of Chinese Studies, National University of
Ireland, Cork. His research and teaching interests in comparative political economy,
China–EU relations, and the governance of financial services have earned him invita-
tions as visiting professor to the China Foreign Affairs University Beijing, Fudan
University Shanghai, University College Dublin, and ESSCA Angers. Recent research
has been published in the Asian Studies Review, ASIEN, East Asia, The International
Journal of China Studies, Integration, and Pacific Focus.
Andrew Hurrell is Montague Burton Professor of International Relations at Oxford
University and a Fellow of Balliol College. He was elected to the British Academy in
2011 and to the Johns Hopkins Society of Scholars in 2010. He is a Delegate of Oxford
University Press and a member of the Finance Committee (the board of the company).
His research interests cover theories of international relations; theories of global gov-
ernance; the history of thought on international relations; comparative regionalism
and regional powers; and the international relations of the Americas, with particular
reference to Brazil. His current work focuses on the history of the globalization of
international society and the implications for twenty-first-century global order. He is
completing a short introduction to global governance. Publications include On Global
Order. Power, Values and the Constitution of International Society (Oxford University Press
2008), which was the winner of the International Studies Association Prize for Best
Book in the field of International Relations in 2009; (with Ngaire Woods), Inequality,
Globalization and World Politics (1999); and (with Louise Fawcett), Regionalism in World
Politics (1995).
José Antonio Sanahuja is a Full Professor of International Relations at the Sociology
and Political Science School of the Complutense University of Madrid, Spain and a
Research Fellow at Complutense Institute of International Studies (ICEI). He has carried
out research and consultancy work with the European Parliament Directorate of
Research, the European Commission (DG-RELEX), the UNDP, the Ibero-American
General Secretary (SEGIB), the Spanish Ministry of Foreign Affairs and Cooperation,
and a number of Spanish and international NGOs and research centres. For two terms
he served as an independent expert of the Development Cooperation Council, an
advisory body of the Spanish Department of International Development Cooperation.
He is a member of the board of Oxfam Intermón, the Spanish affiliate of Oxfam
International. Among his more recent books are: Teorías de las Relaciones Internacionales
(with C. Arenal, 2015); and Construcción de la paz, seguridad y desarrollo. Visiones,
políticas y actores (2012). He is also a member of the editorial board of the journals

xvii
Biographical Notes on Contributors

Foreign Affairs Latinoamérica (México), Pensamiento Propio (Argentina), and Revista

CIDOB d’Afers Internacionals (Spain).
Wei Shen is a Professor of International Business at Lancaster University Management
School and Director of the Confucius Institute at the same university. He holds the Jean
Monnet Chair in EU–China Relations, and is an Associate at EU–Asia Institute at ESSCA
School of Management in France and Vice President of EU–Asia Centre in Brussels. He
obtained his PhD in Geography from Loughborough University, after completing a
LLM at Stockholms Universitet and an MA in Economics from Erasmus Universiteit
Rotterdam. Previously he worked at the Council of Europe, Asia-Europe Foundation,
and United Nations and has taught at Sciences de Paris, University of Strasbourg, the
Antwerp Management School, and numerous Chinese universities. He co-founded the
Alliance of Chinese and European Business Schools (ACE) and is an academic expert for
the European Commission. He has published widely in academic journals and is
frequently featured in international media such as Le Monde, New York Times, and
China Daily.
Thomas Kwasi Tieku is an Associate Professor of Political Science and Coordinator of
the Social Justice and Peace Studies Program in King’s University College at Western
University in Ontario, Canada. A former director of African Studies and an award-
winning professor at the University of Toronto, Professor Tieku’s current research
focuses on conflict mediation and negotiation, peacebuilding, regional governance
innovations, international organizations, defence and security policies, as well as the
West and Africa relations. He has published three monographs and over twenty-two
refereed journal articles and book chapters. His latest book (2016) is Governing Africa: 3D
Analysis of the Performance of African Union. Professor Tieku serves on a number of
editorial and advisory boards, including Cornell University’s African Development
Monograph Series and American Social Science Research Council’s African Peacebuild-
ing Network. He has also served as a consultant to a number of organizations and
governments, including the World Bank Group, Centre for International Governance
Innovations, and Department of National Defence, and Global Affairs Canada.
Anna Triandafyllidou holds a Robert Schuman Chair at the Global Governance
Programme (GGP) of the Robert Schuman Centre for Advanced Studies (RSCAS),
European University Institute. Within the GGP she directs the Research Area on
Cultural Pluralism. She has been Visiting Professor at the College of Europe in Bruges
since 2002 and is the Editor-in-Chief of the Journal of Immigrant and Refugee Studies. Her
recent authored books include: Migrant Smuggling. Irregular Migration from Africa and
Asia to Europe (co-authored with T. Maroukis, 2012, Palgrave); and What is Europe?
(co-authored with R. Gropas, 2015, Palgrave). Her most recent edited volumes are
Circular Migration between Europe and its Neighbourhood. Choice or Necessity? (ed., 2013
Oxford University Press); European Immigration: A Sourcebook (Ashgate 2014, second
edition, with R. Gropas); The Routledge Handbook on Immigration and Refugee Studies
(Routledge 2015); After the Financial Crisis: Shifting Legal, Economic and Political Para-
digms (Palgrave 2016, with R. Gropas and P. Iglesias-Rodriguez).
Gaby Umbach is Policy Analyst responsible for Research Methodologies and Strategic
Liaison with Academia and think tanks within the European Parliamentary Research

xviii
 Biographical Notes on Contributors

Service. As Visiting Fellow of the European University Institute’s Robert Schuman

Centre for Advanced Studies she is Director of ‘GlobalStat—Database on Developments
in a Globalised World’ and co-directed the research projects ‘Global Governance by
Indicators’ and ‘On the Political Economy of Measuring State Capacity and Govern-
ance’ at the Global Governance Programme. She holds a PhD in Political Science from
the University of Cologne, where she was Senior Research Associate of the Jean Monnet
Chair for Political Science and the Seminar for Social Policy from 2000 to 2014. In both
positions she analysed and taught European integration issues. Since July 2015 she has
served as Book Review Editor of the Journal of Common Market Studies (JCMS). Over the
past fifteen years, she has been engaged in numerous international research projects.
Her fields of expertise include European integration studies and theories; Europeanisa-
tion; multi-level and new modes of governance; policy coordination; environmental,
employment, and socio-economic policies; EU constitutionalization and institutional-
ization; EU enlargement; and curriculum development in EU studies. Her current
academic work focuses on global governance, sustainable development, institutional
crisis reactions, and global governance by indicators.

xix
Part I
Critical Approaches to
Global Governance
1

Global Governance from Regional

Perspectives
A Critical View

Anna Triandafyllidou

1.1 Introduction

The notion of global governance has attracted significant attention during the
last two decades but remains notoriously elusive. The term ‘global’ has been
adopted to point to the emerging transnational world order and interactions
that go beyond traditional state actors which have been the focus of inter-
national relations since the 1990s. Similarly, the term ‘governance’ goes beyond
government to designate the interaction and networking between public and
private actors, both in horizontal (non-hierarchical) and vertical (hierarchical)
ways. These actors are not only states but also include civil society and formal
and informal networks of various kinds.
Governance typically involves cooperation, negotiation, and regulation.
Global governance activity may occur at the national and subnational level,
but can have consequences at the transnational level; likewise, it may occur at
the transnational level and have implications for the national. Unlike govern-
ment, governance does not have a clear polity to which it refers, as its contours
usually trespass those of the state. Thus, governance has no clear democratic
legitimacy, although it may have a strong efficiency legitimacy as it contrib-
utes to developing satisfactory solutions to complex problems. It is also seen as
a better fit for contemporary societies, as it enables actors such as the private
sector or civil society, which are quick to act and provide more timely infor-
mation, to make up for the lacunae of state action that involves longer time-
frames for response and less flexibility.
Anna Triandafyllidou

Governance (and global governance at that) may appear as a value-neutral

term that describes a ‘method’ of government rather than a doctrine on how
government should take place. It may thus be presented as a form of dealing
with a broad range of problems and conflicts in today’s increasingly inter-
dependent and complex world, without prejudice to the values that may
underpin it. But governance is far from value-neutral. Rather, its embedded-
ness in specific western conceptions of government, premised on liberal
moderately secular democracy and the rule of law, are so deep that they
become invisible. It is like the ‘colour’ of the ‘white race’. Other races are
coloured, white is not a colour. Similarly the hegemonic western discourse
on governance appears to provide the baseline, it is the governance against
which other modes and methods of managing public goods and resolving
conflicts are measured and assessed.
Global governance discourses and studies are also imbued by this apparent
value-neutrality. They neglect, for instance, the fact that non-state actors
involved in governance can be very different in their nature, interests, and
capacity to act (civil society may simply not exist in other countries
and continents). Thus, presumed universal adherence to individual liberty
and autonomy as the basis for liberal democracy may ignore different regional
cultural perspectives that give precedence to the community and to mutual
ties and interdependence as the basis for governance. Also, assumptions of
equality before the law or equality within democracy may be shaped by higher
beliefs in ethnic or kinship hierarchical relations. Studies and research pro-
grammes in Europe have often had an implicit Eurocentric agenda, looking at
what global governance is or means for Europe and/or ‘the West’ writ large,
but without fully taking into account how global governance is defined or
understood in countries and continents beyond Europe. They have not suffi-
ciently engaged with regional and non-western paradigms or weaker states
and societies in the international system and hence do not reflect the emer-
ging twenty-first-century global governance dynamics and challenges. Thus,
to advance interdisciplinary thinking and innovative solutions to global issues
it is necessary to promote, as we try to do in this volume, more informed and
nuanced analysis of what various networks, actors, institutions, and states
across the globe mean by global governance.
Much in the same vein as Edward Said spoke of Orientalism in Cultural
Studies to uncover the ways in which western scholarly research and literature
was creating the ‘Oriental Other’ and the ‘Western Self ’ twenty years ago, we
currently need to adopt a critical way of thinking in the area of global
governance.
While global governance is a transnational phenomenon, the term ‘global’
in practice is embodied in sectorial and local frameworks. Indeed, any under-
standings or practices of global governance are informed by specific cultures

4
 Global Governance from Regional Perspectives

and value constellations. Culture is here understood broadly as encompassing

institutional, legal, economic, and social organization, development, and prac-
tices. It is, of course, dynamic and constantly evolving, even if it is crystallized at
each given point in time in specific forms, traditions, sets of values, within which
individuals are socialized. Our understanding of culture here is dynamic and
networked, encompassing cultural forms and contents as well as the boundary-
making function of culture.
We, as individuals, states, and organizations, tend to perceive and act out
‘global’ through particular ‘local’ understandings that are shaped by our cul-
ture. Culture is arguably not a mere context but a pretext that structures and
makes meaningful political, social, and individual actions on the global level.
We are not assuming here that the relationship between culture, and institu-
tions or practice is unidirectional. Culture is embodied in institutions and
shapes practices, but, at the same time, it is also shaped by them. The rela-
tionship is interactive.
The aim of this book is to investigate, discuss, and confront the different
cultural and geopolitical understandings of global governance in different
regions of the world. The main research questions addressed in this book
are: How is global governance understood in different regions of the world?
What normative and political challenges does the concept of global govern-
ance and the emerging regimes of global governance institutions raise in
different parts of the world? Is there something like a regional texture of global
governance that builds upon regional cultural, social, historical, political, and/
or institutional features and characteristics and that adapts the meaning of
global governance to the spatial context in which it is adopted?
The ‘local’ dimension can be conceptualized in a variety of ways. It can refer
to single countries but also to wider regions. Here we adopt a regional perspec-
tive that is operationalized on the basis of linguistic and geopolitical frame-
works and narratives. We assume that linguistic and geographical boundaries
demarcate a certain level of cultural commonality within and cultural difference
between them. However, such a regional conception can also be contested.
Indeed, Nida Alahmad, in this volume, argues that there can be no regional
perspective as, even if there are common historical trajectories; common lin-
guistic and cultural traits, this is not sufficient to speak of a common regional
view. She also rightly points to the role of colonialism and foreign intervention
in ‘constituting’ world regions.
We certainly acknowledge here the limits of a regional conception and that
is why the book includes both regional and country-focused chapters—in the
effort to pluralize the discussion of global governance but also to strike a
balance between what can be conceived as world regions and those large
and important countries whose governments and elites conceive of them-
selves as global players (and which are conceived by other governments and

5
Anna Triandafyllidou

elites as such). Thus, we engage with Africa, Latin America, and of course
Europe as world regions even if their level of regional organization and par-
ticipation in global governance differs. The European Union, which, as Chris-
tiansen in this volume acknowledges, is only a partial expression of what is
understood as Europe writ large, has perhaps the most developed institutional
make-up and engages clearly with global issues and global governance insti-
tutions as a regional actor. However, Africa and Latin America have their own
regional institutions which do adopt regional cultural perspectives, as argued
by Tieku and Gelot, and by Sanahuja in this volume. Such perspectives contest
western dominance in global governance both culturally (Africa) and in terms
of distribution of power and a realist world order (Latin America). They also
both point to the need for a ‘southern’ perspective on global governance.
However, in the workshop that preceded this volume it became clear that it
would be difficult to speak of a Eurasian regional perspective or an Asian or
South East Asian one. Hence we have opted for country-specific chapters on
Russia and China. The same was true for a North American perspective as
opposed to a US-specific viewpoint. It was felt that these three countries are
important global players (both in terms of how they perceive themselves
and how they are perceived by others) and engage in different ways with
global issues and global governance structures. We further elaborate on
these different perspectives and on the national vs regional register as an
appropriate approach for analysing global governance in the concluding
chapter of this volume.
The aim of this introductory chapter is to place the book in its historical
context of the early twenty-first century; to provide for working definitions
and discuss the contested nature of global governance, thus clarifying our
analytical framework; and to offer an example of how cultural perspectives
and their power connotations can be disguised and become ‘invisible’ in the
theory and practice of global governance. The chapter concludes with an
explanation of the choice of regions and countries included here and an
outline of the contents of this book.

1.2 Global Governance in the Twenty-First Century

There is wide agreement among international relations (IR) and transnational

governance scholars that the pace of change in global or international gov-
ernance has accelerated during the last thirty years. Thus, while after the 1989
implosion of the Communist regimes we spoke of the post–Cold War period,
we are already now considering that the twenty-first century is a post-post–
Cold War era marked by very different geopolitical situations and power
dynamics compared to the ten years that followed the fall of the Berlin Wall.

6
 Global Governance from Regional Perspectives

It has been more than twenty years since Francis Fukuyama proclaimed the
end of history (Fukuyama 1989, 2006). Indeed it was not only Fukuyama who
thought that the failure of Soviet Communism signalled the end of a dialect-
ical relationship between different conceptions of progress, politics, and a
good society. Capitalism and a free market liberal democracy were greeted
by political elites on both sides of the Atlantic as the good political and
economic system. From then on, it was believed, human history would be a
linear path without any significant ideological conflicts. While Fukuyama did
not necessarily mean that people were happier or better off thanks to historical
‘progress’, he argued that history as a coherent intelligible process had come to
an end and liberal democracy had affirmed itself as the form of government.
While several international crises marked the 1990s (the first Gulf War, the
break-up of Yugoslavia, the bankruptcy of Argentina, the Oslo Agreements,
the Wadi Araba Agreement of peace between Jordan and Israel, the Kosovo
War), it was perhaps 9/11 and the emergence of international terrorism that
began to shake the grounds of this vision that ideological conflict had ended.
Indeed, even though the global order was no longer about two opposed poles
of power, history had not come to an end as Fukuyama had argued; rather, it
was actually (re-)started. Nonetheless, American hegemony over the world,
which was further re-affirmed through the invasion of Afghanistan in 2001
(after the events of 9/11) and the Second Gulf War and invasion of Iraq (2003),
and the quasi-unilateralism that it managed to impose, disguised this process.
The development and activities of international terrorist networks of course
marred the view of this new harmonious global order, but they were also seen
as a necessary evil, a marginal aberration of an otherwise successful and
hegemonic international system. Of course, terrorism is not a new phenom-
enon, what was new was the transnational nature of these networks and their
thus contestation of western hegemony.
Along with jihadist terrorism, there were two concomitant processes which
took place peacefully and discreetly, and yet profoundly destabilized the ‘end
of history’ narrative and the hegemony of the United States. The first was the
rise of new global economic powers, indeed, a phenomenon that has affirmed
itself most forcefully during the last decade with the rise of China, India, and
Brazil as global economic powerhouses. The second and closely related phenom-
enon was the range of regional integration processes that developed or further
reaffirmed themselves in various regions, including Latin America, Africa, and
Asia, alongside deeper economic if not political integration in Europe.
The international system has had to reinvent itself, replacing the former G7
and G8, which was largely western dominated, with the more open and
multilateral G20 forum. At the same time, rising global powers such as
China, India, and Brazil have also had to rethink their roles and reorient
themselves from actors that were primarily concerned with their internal

7
Anna Triandafyllidou

socio-economic or political challenges, to global players that accept that they

have a role to play on the international scene. Similarly, the processes of
regional integration have strengthened themselves, not least because, in the
emerging multilateral international system, single countries could not rely on
privileged relations to a global hegemon (in the Cold War, the Soviet Union
and the United States; in the post–Cold War era, mainly the US). Instead, they
have had to build alliances and position themselves in a multipolar environ-
ment with shifting power balances.
In addition, the last decade has seen the re-emergence of transnational
social movements and a global civil society. Concerns with global challenges
such as environmental protection or world peace date back to the 1970s,
and even if the end of the Cold War and preoccupation with international
terrorism temporarily took them off centre stage, climate change in particular,
along with environmental degradation, has not ceased to attract the attention
of governments and to mobilize civil society. In recent years, starting with the
‘no logo’ movement and the contestation of the capitalist liberal democracy
model, these social movements have reinvented themselves. An important
factor that has enabled them to acquire new strength and develop important
transnational connections and networks has been the development of new
information and communication technologies. Not only the internet but also
smartphones and related technologies, as well as different types of social
media, have allowed for global connections of civil society actors to emerge
and for civic participation and protest activities to be organized across bound-
aries in real time. The Arab Spring protests are but an example of this new
power potential of grassroots movements.
These three new elements that characterize the post-post-Cold War order,
notably the emergence of new powers; the emergence/formation of a global
civil society; and the increasing regional integration in different parts of
the world have created a new environment that requires new global gover-
nance arrangements and practices (Acharya 2012). The context of the global
financial crisis that has been unfolding since 2008 is actually accelerating the
centrifugal and multilateral pressures within the global system. While the
global crisis has affected all continents and all countries in different ways, it
surely has further accelerated the reorganization of economic and geopolitical
power relations, making the role of emerging economies as global players and
regional actors more apparent, thus forcing these countries to think globally,
acknowledge their role in the global arena, and force western powers to
rethink their strategies.
It has been widely acknowledged by scholars and practitioners that the
current institutions of the international system may be facing too great a
stretch of their capacities (EUISS 2010) as the quasi-unilateralism imposed
by the US in the 1990s, and the multilateralism under US hegemony of the

8
Another random document with
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the brain at this period of life leads to an early death, while children
affected with partial atrophy may continue to live, though almost
always in a state of idiocy. The forms mostly observed in children are
unilateral or bilateral atrophy of the cerebrum, partial or almost entire
absence of the cerebellum, imperfect development of the large
cerebral ganglia, and slight partial atrophy of the medulla oblongata.
The large commissures as well as the crura cerebri are very seldom
found atrophied.

The most frequent and, from a practical point of view, the most
important of these forms is the unilateral atrophy of the cerebrum, for
the reason that in a mild form it is to a certain degree consistent with
the mental and physical development of the child. It is mostly found
on the left side. In some cases the atrophy extends evenly
throughout the hemisphere, while in others it affects more or less
one or the other lobe. The loss in the bulk of the hemisphere may
amount to only a slight diminution, or to as much as to one-half of
the normal size. Its thickness above the ventricle may be reduced to
a few millimeters; in some cases even the membranes of the brain
may lie in contact with the ependyma. The ventricle of the atrophied
hemisphere is almost always enlarged. The convolutions of the
cerebrum are very narrow, sometimes quite indistinct. One or both of
the corpora striata also are generally found atrophied. In many cases
even the atrophy extends to one of the crura cerebri and to the
pyramid of the same side, and to the anterior and lateral columns of
the spinal cord on the opposite side. Frequently, one or the other
lateral half of the cerebellum also is found affected. The condition of
the substance of the cerebrum is nearly the same as in the senile
atrophy of the brain to be described hereafter. The skull is mostly
thickened on the side of the atrophy, and frequently asymmetrical.

SYMPTOMS.—In most cases the mental capacity is below the normal

standard, and frequently borders on or represents a state of idiocy.
The temperament of the patient is generally irritable and very
excitable. The most prominent symptom is an incomplete paralysis
on the side opposite to the atrophied hemisphere, which is the more
pronounced the more the corpus striatum, thalamus opticus, and
crus cerebri are involved. Frequently, there are contractures of the
flexor and pronator muscles of both extremities, particularly of the
upper; the muscles of the trunk remain free; sometimes one or the
other half of the face is also paralyzed. Epileptic convulsions also are
frequently present. Blindness and deafness, with a defective sense
of smell and a blunted sensibility of the paralyzed limbs, as well as
neuralgia of the latter, and headache, have also been observed.

CAUSES.—Besides the causes already mentioned, atrophy of the

brain occurring in children after birth may be induced by injuries of
the head, inflammation of the enveloping membranes, of the
ependyma, or of the substance of the brain itself.

TREATMENT.—Atrophy of the brain in children is perhaps, in the

majority of cases, incurable; it is therefore only in the milder cases
that the patient may be benefited by treatment. Electricity and
gymnastic exercises have been recommended. At any rate, it must
be pursued in a very systematic manner, and based upon the
principles established and practised by the late E. Seguin of New
York in his Physiological School for Weak-minded Children,
consisting in improving the mind, first by training the child to the use
of his limbs by means of light mechanical work, etc.

2. Atrophy of the Fully-developed Brain.

In the brain of the adult the atrophy may be partial or total,

symmetrical or asymmetrical, in the same sense as before used in
connection with the atrophy of the brain of children. It may, further,
be stationary, when the atrophying process remains limited to the
part where it originated; or, progressive, when it extends to other
parts of the brain. Generally, partial, asymmetrical, and stationary
atrophy is due to certain accidental pathological processes,
producing a destruction or loss of portions of the substance of the
brain, such as apoplexy, softening, etc., by which the nutrition of the
neighboring parts becomes disturbed. Total, symmetrical, and
progressive atrophy, on the other hand, actually depends upon
certain constitutional disturbances of the nutritive process in general,
such as chronic alcoholic intoxication, etc.

CAUSES.—As already mentioned, the causes of atrophy of the brain

in the adult may be direct or indirect. The former are generally
represented by certain pathological processes which directly affect
the substance of the brain, as, for instance, apoplectic hemorrhagic
effusions into the brain-substance, thrombosis or embolism of the
cerebral arteries, encephalitis, chronic serous effusions into the
ventricles, inflammation and œdema of the pia mater, etc. To the
latter or indirect causes, which affect the organ by disturbing or
lowering the nutrition of its substance, belong the retrogressive
processes of old age or of insanity; the introduction into the system
of certain noxious substances, such as lead or alcohol; furthermore,
certain wasting diseases, such as phthisis, Bright's disease, etc.

PATHOLOGICAL ANATOMY.—The cerebrum particularly is found

diminished in volume. While the convolutions are thinner than
normal, their intervening sulci are broader. The white substance
presents a dirty-white color, and is abnormally dense and tough,
especially near the ventricles. The latter are enlarged and filled with
serum; their ependyma is thickened and frequently covered with
granulations. The cortical layer appears of a dirty, rusty-brown or
yellow color, is pale, soft, or hard, and frequently is found to adhere
to the pia mater. In very pronounced cases the white substance is
almost as tough as leather, and contracts upon section, especially in
the convolutions; its cut surface is rendered concave. Sometimes the
surface of the convolutions, after the removal of the pia mater,
appears finely shrivelled. The dura mater is often found thickened
and adhering to the skull. The space created in the cavity of the
cranium by the atrophy of the brain is filled by serous effusions into
the tissue of the pia mater, the subarachnoidal space, arachnoid sac,
and ventricles.

The histological changes associated with atrophy of the brain differ

in the different forms. In cases of partial atrophy caused by
hemorrhages, etc. the destructive process generally embraces all
the tissues at first, while the secondary degenerations particularly
affect the nervous elements. In total atrophy the pathological process
appears to commence in the connective tissue, and to involve the
nervous elements subsequently; though in a number of cases,
especially of senile atrophy, the nervous elements appear to be
primarily affected. The blood-vessels also undergo certain changes,
giving rise to the contraction of the brain-substance.

SYMPTOMS.—In partial atrophy of the brain the primary symptoms

resemble those which characterize the particular destructive process
to which the atrophy is due. The most prominent are the symptoms
of motor disturbance, which are always semilateral and correspond
to the extent and seat of the lesion; frequently they remain
stationary. The sensibility of the paralyzed parts is but slightly
diminished, and the mind generally undisturbed. But when the
effects of the original lesion extend, in the form of a secondary
degeneration of the nervous elements, to neighboring parts, or even
to the other hemisphere, the cerebral functions may become
secondarily disturbed.

In senile atrophy of the brain, which represents the most simple form
of total atrophy of this organ, the first symptoms frequently appear
toward the end of some intercurrent disease. They consist in a very
slow and gradually increasing derangement of the cerebral functions,
associated with a general loss of innervation, manifesting itself by
talkative wanderings of the mind, restless sleep, hallucinations,
foolish activity, attacks of tremor senilis, etc. The intellectual
functions diminish and the memory is lost. The physical forces also
gradually sink, the tremor senilis increases, and the patient, no more
able to walk, becomes confined to bed. Finally, a relaxation of the
sphincters takes place, and death is produced by the disturbance of
the automatic functions of deglutition and respiration.

Total atrophy of the brain, when due to an extensive meningitis or to

a general disturbance of the nutrition, as is met with in drunkards,
may finally lead to a condition known as general paralysis of the
insane. This disease, however, will be found treated elsewhere in
this work.

TREATMENT.—There is no special treatment for atrophy of the brain;

all that can be done is to palliate and combat the symptoms as they
arise.

HYPERTROPHY OF THE BRAIN.

INTRODUCTION.—Notwithstanding the numerous measurings and

weighings of human brains made in the course of time by different
investigators, no absolute standard measure or weight has as yet
been established by which we can accurately determine a
pathological increase or decrease in the size and weight of this
organ. The want of such a standard is principally due to the
difference generally existing in the dimensions and weights of even a
certain number of brains taken from individuals belonging to the
same race or nation. The same difficulties are met with in the
attempt at establishing a rule by which to measure the mental
capacity of a certain brain, for the question has as yet not been
solved whether this capacity depends upon the quantity or quality of
the brain-substance. In speaking of hypertrophy of the brain,
therefore, we must keep in mind that a large brain must not be
considered hypertrophied unless there exists a disproportion
between its size and that of the cavity from which it was removed; in
other words, when its growth or hypertrophy meets a resistance at
the inner walls of the cranial cavity. According to Virchow, a further
distinction must be made between the increase (hyperplasia) of the
nervous elements themselves and that of the supporting connective
tissue, the neuroglia. To the latter condition particularly corresponds
the peculiar doughy consistence of the white substance of
hypertrophied brains.
ETIOLOGY.—Hypertrophy of the brain is sometimes congenital, and
then associated with dwarfishness and a defective development of
the cranium. Generally, however, it is an extra-uterine affection,
originating mostly during infancy and childhood, though it is also met
with at the age of puberty, and even in adult life. The male sex is
more predisposed to the affection than the female. When
hypertrophy of the brain occurs during infancy, it is almost always
associated with an excessive development of the lymphatic glands,
with a defective involution of the thymus gland, and with rachitis, but
generally without cachexia. No special exciting cause can be
assigned to the affection during youth or adult age, though it has
been stated that during these periods of life the disease may
supervene upon tubercle or carcinoma of the brain. Repeated active
or passive congestion (Rokitanski, Andral), as well as the
introduction of lead into the system, has also been supposed to
incite the disease.

PATHOLOGICAL ANATOMY.—Directly after the removal of the vault of the

cranium, and on cutting through the dura mater, the brain, as if
liberated from pressure, is observed to swell out to such a degree as
to render the replacement of the removed skull-cap impossible. The
enveloping membranes are found closely adapted to one another
and to the brain; they are very thin, bloodless, and dry, and their
vessels are empty and pressed flat. The hemispheres of the
cerebrum are large, and their convolutions, mutually pressing
against one another, are flattened at their surfaces, so that the
intervening sulci are hardly recognizable. After the removal of the
brain from the skull the abnormal dimensions of the cerebrum
present a remarkable contrast to the normal size of the cerebellum,
pons, and medulla oblongata, which also appear flat and broad from
pressure. When a horizontal section is made through the
hemispheres of the cerebrum and a little above the corpus callosum,
the centrum ovale appears unusually large. The cavities of the
ventricles are very narrow, their walls touching one another. There is
no serum in the pia mater or in the ventricles. The substance of the
brain is pale, bloodless, and dry. The white substance, upon which
the hypertrophy particularly depends, is of a doughy consistence,
comparable to the boiled white of an egg or cheese, whilst the gray
substance is so pale as to be hardly distinguishable from the former.

The condition of the skull is, according to Rokitanski,1 as follows: In

cases in which the hypertrophy of the brain has advanced to a high
degree, and in which the sutures of the skull are united, the bones of
the cranium are found thinner and their inner table roughened by
absorption. This is especially the case in the bones which form the
vault of the cranium. The holes or other deficiencies found at the
base of the cranium in the plates of the frontal, ethmoid, and
sphenoid bones are not entirely due to the absorbing process, but
rather to the thinness of these bones. In infants the cavity of the
cranium enlarges in proportion to the hypertrophy of its contents; the
head then resembles in form so much that of hydrocephalus that it
may lead to errors in diagnosis. In some cases in which the disease
rapidly develops to a high degree there is observed on the infant's
skull a loosening and separation of the sutures of the cranial vault,
with red coloration and suffusion of their cartilages.
1 Lehrbuch der Pathologischen Anatomie, 3d ed., 1855, vol. ii. p. 431.

SYMPTOMS.—There is a gradually increasing muscular weakness,

manifesting itself especially in the lower extremities, and giving rise
to an unsteady, stumbling gait and frequent falling, caused perhaps
by the excessive weight of the head, and also an inability of securely
grasping objects. Besides these disturbances of motion, epileptic
spasms appear, at first light in degree and at long intervals, but
becoming later on in the course of the disease more frequent and
severe. Continuous or intermittent attacks of headache almost
always accompany the disease, and, furthermore, vertigo, tinnitus
aurium, photophobia, and dimness of sight with dilatation of the
pupil; general sensation also becomes blunted, but without ever
amounting to anæsthesia. In a number of cases there is no
disturbance of the psychical functions, though in others symptoms of
mental excitement amounting even to delirium have been observed.
Most frequently the intelligence sinks from the beginning of the
disease, to end in complete idiocy. The pulse also has been
observed to fall considerably during the last stage.

The COURSE of the disease is, according to Andral and Hasse,2

almost always chronic, and if an acute development of the affection
has been spoken of, it may be supposed that the latter has
commenced a considerable time previous to the manifestation of the
symptoms during the last stage. Andral divides the disease into two
stages, of which the first is chronic and frequently latent, whilst the
other is more acute and leads to a rapid fatal termination. In most
cases death is caused by such intercurrent affections as give rise to
irritation and hyperæmia of the brain, and thus increase the already
abnormal pressure upon this organ.
2 “Krankheiten des Nervensystems,” 2d ed., 1869, in Handbuch der Speciellen
Pathologie und Therapie, edited by R. Virchow, vol. iv. 1st div., p. 578.

DIAGNOSIS, PROGNOSIS, AND TREATMENT.—It has already been

mentioned that errors in diagnosis may very easily be committed on
account of the great resemblance in the form of the head in cases of
hypertrophy of the brain and of hydrocephalus, though it has been
stated that in the former affection convulsions, in the form of epileptic
spasms, predominate, to be followed during the last stage by
symptoms of depression; whilst in hydrocephalus the symptoms of
depression manifest themselves from the beginning of the disease,
and, moreover, the rachitic deformities are more prominently shown
in the form of a chicken-breast. A positive diagnosis can only be
made by the autopsy.

There are no remarks to be made on the prognosis and treatment of

hypertrophy of the brain.
 SYPHILITIC AFFECTIONS OF THE NERVE-
CENTRES.

BY H. C. WOOD, M.D., LL.D.

Introduction.

Syphilitic affections of the nerve-centres are best studied by

separating those of the spinal cord from those of the cerebrum, and
in the present article this natural division of the subject is adopted.
Further, cerebral syphilis in its most characteristic or gummatous
form usually attacks the brain-membranes, or perhaps in some
cases the perivascular sheaths of the vessels, and only secondarily
affects the tissue of the brain itself. The question of the occurrence
of specific disease of the brain-cortex is so important that it shall
have a separate discussion. It is perfectly well proven that with or
without other brain lesion the vessels of the brain may undergo an
atheromatous degeneration as the direct result of a syphilitic
dyscrasia; but such disease links itself on the one hand with the
subject of syphilitic disease of the general vascular system, and on
the other hand with cerebral apoplexies, softenings, and other
degenerations. Moreover, the space here allotted to brain syphilis is
very insufficient. I, therefore, shall not enter upon the further
discussion of syphilitic degeneration of the brain-vessels. The
etiology of brain and spinal syphilis is best discussed under one
heading.
GENERAL ETIOLOGY.—We do not know why in any individual case
syphilis selects one portion of the nervous centres rather than
another for attack; indeed, it is only rarely that any exciting cause
can be discovered.

It is not unnatural to expect that any agency which is capable of

exciting an inflammation of a nerve-centre may, when present in a
syphilitic person, provoke a specific disease of such centre. Thus,
thermic fever is a very common cause of chronic meningitis, and in
the Journ. de Méd. et Chir. (Paris, 1879, p. 191) a case is reported in
which cerebral syphilis followed a sunstroke; I have myself seen one
similar instance, and in Roberts's case of precocious cerebral
syphilis (see p. 804) the first convulsion came whilst the man was
fishing on a very hot day, and may have been precipitated by the
exposure.

Blows and other traumatisms would be expected to figure largely as

exciting causes of nervous syphilis, but they, in fact, are only rarely
present. I have seen one or two cases of specific brain disease
attributed to violence by the patient, and several cases of possibly
specific spinal disease—one in which a poliomyelitis followed a fall
on the ice; one in which, after a fall from a cart and marked spinal
concussion, a local myelitis developed;1 and one of a general
myelitis following an injury by a horse. The only records of such
cases are those of Broadbent2 and those collected by Heubner.3
1 Univers. Hosp. Dispen. Service-Book, x., 1875, p. 58.

2 Lond. Lancet, 1876, ii. p. 741.

3 Ziemssen's Encyclopædia, xii. 301.

Various authorities attach much influence to over-study and other

forms of cerebral strain in exciting brain syphilis. Engelstedt is stated
to have reported cases having such etiological relations, and
Fournier4 affirms that he has especially seen the disease in
professional men and other persons habitually exercising their brains
to excess. Neither in private nor public practice have I met with an
instance where over-brainwork could be considered a distinct
etiological factor, whilst I have seen some hundreds of cases from
amongst the laboring classes, in whom the intellectual faculties are
chiefly dormant.
4 La Syphilis du Cerveau.

The drift of the evidence in medical literature is so pronounced, and

so in accord with my own experience, that I believe it may be
positively affirmed that in the vast majority of cases of nervous
syphilis no exciting cause can be found.

Inherited syphilis seems to be less prone than the acquired diathesis

to attack the nervous system, but is certainly capable of so acting.
As early as 1779, Joseph Glenck5 reported a case of a girl, six years
old, cured by a mercurial course of an epilepsy of three years'
standing and of other manifestations of hereditary syphilis. Graefe
found gummatous tumors in the cerebrum of a child nearly two years
old.6 O. Huebner7 details the occurrence of pachymeningitis
hæmorrhagica in a syphilitic infant under a year old. Hans Chiari8
reports a case in which very pronounced syphilitic degeneration of
the brain-vessels was found in a child fourteen months old. Both
Barlow9 and T. S. Dowse10 report cases of nerve syphilis in male
infants of fifteen months. For other similar cases the reader is
referred to an article by J. Parrott,11 and to a paper by M. E.
Troisier.12
5 Doctrina de Morbis Venereis, Vienna.

6 Arch. f. Ophthalm., Bd. i. Erst Abth.

7 Virchow's Archiv, Bd. lxxxiv. 269.

8 Wien. Med. Wochenschrift, xxxi. 1881, 17.

9 Lond. Patholog. Soc. Trans., 1877.

 10 The Brain and its Diseases, vol. i. p. 76.

11 Archiv. de Physiologie, 1871-72, p. 319; also to his “Leçons sur le Syphilis hered.,”
Progrès méd., 1877 and 1878.

12 Arch. de Tocologie, x. 411.

Recorded cases prove decisively that even after puberty specific

nervous affections may primarily attack the unfortunate offspring.
Thus, Nettleship reports13 the development of a cerebral gumma in a
girl of ten years, and J. A.. Ormerod14 of a tumor of the median nerve
(probably gummatous) in a woman of twenty-three, both the subjects
of inherited syphilis. Thomas S. Dowse15 details a case of cerebral
gumma at the age of ten years, and Samuel Wilks16 one of epilepsy,
from inherited taint, in a boy of fourteen. J. Hughlings-Jackson
reports17 paraplegia with epilepsy in a boy of eight, hemiplegia in a
girl of eighteen, and hemiplegia in a woman of twenty-two;18 the
nervous affection in each case being associated with or dependent
upon inherited syphilis. E. Mendel reports19 a case of a child who
had inherited syphilis, and developed in her fifteenth year a maniacal
attack with hallucinations. I have seen cerebral syphilis occur at
twenty-one years of age as the first evident outbreak of the inherited
disorder.
13 Trans. Lond. Path. Soc., xxxii. 13.

14 Ibid., p. 14.

15 Loc. cit., p. 71.

16 Lectures on Dis. of Nerv. Syst., Philada., 1878, p. 333.

17 Journ. Ment. and Nerv. Diseases, 1875, p. 516.

18 Brit. Med. Journal, May 18, 1872.

19 Archiv f. Psychiatrie, Bd. i. 313.

When a nervous affection develops first at a comparatively late
period, and no very apparent evidences of the inherited taint are
present, there is great danger of the case being misunderstood;
indeed, in some instances an immediate diagnosis may be scarcely
possible. It is probable that in most of the reported recoveries from
alleged tubercular meningitis the disease has been syphilitic.

Some time since I saw, in an orphan of fourteen, a chronic basal

meningitis, and in the absence of any history and of any evidences
of syphilis gave the fatal prognosis of tubercular disease; but, to my
astonishment, under the long-continued and free use of iodide of
potassium complete recovery occurred. Another child, reported by a
very good practitioner as cured of tubercular meningitis, and
afterward for a long time under my own care, I believe suffered from
hereditary syphilis. Cases of this character have also been reported
by F. Dreyfous.20
20 Revue mensuelle des Malad. des Enfants, 1883, i. 497; see also Gaz. hébdom.
Sci. méd. de Montpellier, 1883, v. 89.

It is of course very important to diagnose between a tubercular

meningitis and one due to hereditary syphilis. Without a history
certainty is not possible, but a general indefiniteness of symptoms
and slowness of progression should arouse suspicion, especially if
the absence of the pulse-retardation indicated that the vault rather
than the base of the cranium was involved.

The relation of inherited syphilis to various nervous affections not

distinctly specific cannot yet be determined. Arrested development,
and the consequent epilepsy, idiocy,21 early brain sclerosis, are
probably sometimes due to the inheritance; and the cases collected
by E. Mendel22 show that chronic hydrocephalus is frequently of
specific origin.23
21 See Brain, vol. vii. 409.

22 Archiv f. Psychiatrie, Bd. i. 309.

 23 See, also, Virchow's Archiv, Bd. xxxviii. p. 129.

Another very important question connected with the etiology of these

disorders is as to the time of their development. Nervous diseases
following acquired syphilitic infection certainly belong to the
advanced stages of the disorder. Huebner reports24 a case in which
thirty years elapsed between the contraction of the chancre and the
nervous explosion. I have seen a similar period of thirty years.
Fournier reports intervals of twenty-five years, and thinks from the
third to the tenth year is the period of maximum frequency of nervous
accidents.
24 Ziemssen's Encyclopædia, xii. 298, New York ed.

The fact that nervous syphilis may occur many years after the
cessation of all apparent evidences of the diathesis is of great
practical importance, especially as the nervous system is more
prone to be attacked when the secondaries have been very light
than when the earlier manifestations have been severe. I have
repeatedly seen nervous syphilis in persons whose secondaries
have been so slight as to have been entirely overlooked or forgotten,
and who honestly asserted that they never had had syphilis,
although they acknowledged to gonorrhœa or to repeated exposure,
and confessed that their asserted exemption was due to good
fortune rather than to chastity.

The following citations prove that this experience is not peculiar.

Dowse25 says: “Often have I had patients totally ignorant of having at
any time acquired or experienced the signs or symptoms of syphilis
in its primary and secondary stages, yet the sequelæ have been
made manifest in many ways, particularly in many of the obscure
diseases of the nervous system.” Buzzard26 reports a case of
nervous syphilis where the patient was unconscious of the previous
existence of a chancre or of any secondaries. Rinecker also calls
attention27 to the frequency of nervous syphilis in persons who afford
no distinct history of secondary symptoms.
25 The Brain and its Diseases, London, 1879, vol. i. p. 7.
 26 Syphilitic Nervous Affections, London, 1874, p. 80.

27 Archiv f. Psychiatrie, vii. p. 241.

Although syphilis is prone to attack the nervous system many years

after infection, it would be a fatal mistake to suppose that nervous
disease may not rapidly follow the chancre. What is the minimum
possible intermediate period we do not know, but it is certainly very
brief, as is shown by the following cases of this so-called precocious
nervous syphilis. Alfrik Ljunggrén of Stockholm reports28 the case of
H. R——, who had a rapidly-healed chancre in March, followed in
May of the same year by a severe headache, mental confusion, and
giddiness. Early in July H. R—— had an epileptic attack, but was
finally cured by active antisyphilitic treatment. Although the history is
not explicit, the nervous symptoms appear to have preceded the
development of distinct secondaries other than rheumatic pains.
28 Archiv f. Dermatol. u. Syphilis, 1870, ii. p. 155.

Davaine is said29 to have seen paralysis of the portio dura “a month

after the first symptoms of constitutional syphilis.” E. Leyden30 found
advanced specific degeneration of the cerebral arteries in a man
who had contracted syphilis one year previously. R. W. Taylor details
a case in which epilepsy occurred five months after the infection.31 In
the case of M. X——, reported by Ad. Schwarz,32 headache came on
the fortieth day after the appearance of the primary sore, and a
hemiplegia upon the forty-sixth day. S. L——33 had a paralytic stroke
without prodromes six months after the chancre. A. P. L——34 had an
apoplectic attack seven months after the chancre; A. S——, one five
months after her chancre. In a case which recently occurred in the
practice of A. Sydney Roberts of this city the chancre appeared after
a period of incubation of twenty-six days, and two months and eight
days subsequent to this came the first fit; eight days after the first the
second convulsion occurred, with a distinct aura, which preceded by
some minutes the unconsciousness. An interesting observation in
this connection is that of Ern. Gaucher35 of a spinal syphilis occurring
six months after the appearance of a chancre.
 29 Buzzard, Syphilitic Nervous Affections, London, 1874.

30 Zeitschrift f. klin. Med., Bd. v. 165.

31 Journ. Nervous and Mental Dis., 1876, p. 38.

32 De l'Hémiplegia syphilitique Prêcoce, Inaug. Diss., Paris, 1880.

33 Ibid.

34 Ibid.

35 Revue de Méd., 1882, ii. 678.

This citation of cases might be much extended, but is sufficient to

show that nervous syphilis occurs not very rarely within six months
after infection, and may be present in two months.

Gummatous Brain Syphilis.

CLINICAL HISTORY.—Brain syphilis of the type now under

consideration may declare itself with great suddenness. An
apoplectic attack, a convulsive paroxysm, a violent mania, or a
paralytic stroke may be the first detected evidence of the disease. In
most of these cases the coming storm ought to have been foreseen,
and to a greater or less degree averted. The onset of cerebral
syphilis is, however, generally more gradual, the symptoms coming
on slowly and successively. Proper treatment, instituted at an early
stage, is usually successful, so that a careful study of these
prodromes is most important. They are generally such as denote
cerebral disturbance, and, although they should excite suspicion, are
not diagnostic, except as occurring in connection with a specific
history or under suspicious circumstances.

Headache, slight failure of memory, unwonted slowness of speech,

general lassitude, and especially lack of willingness to mental
exertion, sleeplessness or excessive somnolence, attacks of
momentary giddiness, vertiginous feelings when straining at stool,
yelling or in any way disturbing the cerebral circulation, alteration of
disposition,—any of these, and, a fortiori, several of them, occurring
in a syphilitic subject, should be the immediate signal of alarm, and
lead to the examination of the optic discs, for in some cases the eye-
ground will be found altered even during the prodromic stage. Of
course if choked disc be found the diagnosis becomes practically
fixed, but the absence of choked disc is no proof that the patient is
free from cerebral syphilis. In regard to the individual prodromic
symptoms, my own experience does not lend especial importance to
any one of them, although, perhaps, headache is the most common.
There is one symptom which may occur during the prodromic stage
of cerebral syphilis, but is more frequent at a later stage—a symptom
which is not absolutely characteristic of the disease, but which, when
it occurs in a person who is not hysterical, should give rise to the
strongest suspicion. I refer to the occurrence of repeated, partial,
passing palsies. A momentary weakness of one arm, a slight
drawing of the face disappearing in a few hours, a temporary
dragging of the toe, a partial aphasia which appears and disappears,
a squint which to-morrow leaves no trace, may be due to a non-
specific brain tumor, to miliary cerebral aneurisms, or to some other
non-specific affection; but in the great majority of cases where such
phenomena occur repeatedly the patient is suffering from syphilis or
hysteria.

The first type or variety of the fully-formed syphilitic meningeal

disease to which attention is here directed is that of an acute
meningitis. I am much inclined to doubt whether an acute syphilitic
meningitis can ever develop as a primary lesion—whether it must not
always be preceded by a chronic meningitis or by the formation of a
gummatous tumor; but it is very certain that acute meningitis may
develop when there have been no apparent symptoms, and may
therefore seem to be abrupt in its onset. Some years ago I saw, in
consultation, a man who in the midst of apparent health was
attacked by violent meningeal convulsions, with distinct evidences of
acute meningitis. He was apparently saved from death by very
heroic venesection, but after his return to consciousness developed
very rapidly a partial specific hemiplegia, showing that a latent
gumma had probably preceded the acute attack. On the other hand,
an acute attack is liable at any time to supervene upon a chronic
syphilitic meningitis. At the University Hospital dispensary I once
diagnosed chronic cerebral syphilis in a patient who the next day
was seized with violent delirium, with convulsions and typical
evidences of acute meningitis, and died four or five days afterward.
At the autopsy an acute meningitis was found to have been
engrafted on a chronic specific lesion of a similar character. In the
case reported by Gamel,36 in which intense headache, fever, and
delirium came on abruptly in an old syphilitic subject and ended in
general palsy and death, the symptoms were found to depend upon
an acute meningitis secondary to a large gumma.
36 Tumeurs gommeuses du Cerveau, Inaug. Diss., Montpellier, 1875.

In this connection may well be cited the observation of Molinier37 in

which violent delirium, convulsions, and coma occurred suddenly. A
very curious case is reported by D. A. Zambaco38 in which attacks
simulating acute meningitis occurring in a man with a cerebral
gummatous tumor appear to have been malarial. In such a case the
diagnosis of a malarial paroxysm could only be made out by the
presence of the cold stage, the transient nature of the attack, its
going off with a sweat, its periodical recurrence, and the therapeutic
effect on it of quinine.
37 Revue méd. de Toulouse, xiv. 1880, 341.

38 Des Affections nerveuses-syphilitiques, Paris, 1862, p. 485.

In the cases of chronic brain syphilis which have come under my

observation, most usually after a greater or less continuance of
prodromes such as have been mentioned, epileptic attacks have
occurred with a hemiplegia, or a monoplegia, which is almost
invariably incomplete and usually progressive; very frequently
diplopia is manifested before the epilepsy, and on careful
examination is found to be due to weakness of some of the ocular
muscles. Not rarely oculo-motor palsy is an early and pronounced
symptom, and a marked paralytic squint is very common. Along with
the development of these symptoms there is almost always distinct
failure of the general health and progressive intellectual
deterioration, as shown by loss of memory, failure of the power to fix
the attention, mental bewilderment, and perhaps aphasia. If the case
convalesce under treatment, the amelioration is gradual, the patient
travelling slowly up the road he has come down. If the case end
fatally, it is usually by a gradual sinking into complete paralysis, or
the patient is carried off by an acute inflammatory exacerbation, or,
as in two of my cases, amelioration may be rapidly occurring and a
very violent epileptic fit produce a sudden fatal asphyxia. Death from
brain-softening around the tumor is not infrequent, but a fatal
apoplectic hemorrhage is rare.

The clinical varieties of cerebral meningeal syphilis are so

polymorphic and kaleidoscopic that it is almost impossible to reduce
them to order for descriptive purposes. Fournier separates them into
the cephalic, congestive, epileptic, aphasic, mental, and paralytic,
but scarcely facilitates description by so doing. Heubner makes the
following types:

"1. Psychical disturbances, with epilepsy, incomplete paralysis

(seldom of the cranial nerves), and a final comatose condition,
usually of short duration.

"2. Genuine apoplectic attacks with succeeding hemiplegia, in

connection with peculiar somnolent conditions, occurring in
often-repeated episodes; frequently phenomena of unilateral
irritation, and generally at the same time paralyses of the
cerebral nerves.

"3. Course of the cerebral disease similar to paralytica

dementia.”

In regard to these types, the latter seems to me clear and well

defined, but contains those cases which I shall discuss under the
head of Cortical Disease.
Meningeal syphilis as seen in this country does not conform rigidly
with the other asserted types, although there is this much of
agreement, that when the epilepsy is pronounced the basal cranial
nerves are not usually paralyzed, the reason of this being that
epilepsy is especially produced when the gummatous change is in
the ventricles or on the upper cortex. In basal affections the
epileptoid spells, if they occur at all, are usually of the form of petit
mal; but this rule is general, not absolute. The apoplectic somnolent
form of cerebral syphilis, for some reason, is rare in this city, and it
seems necessary to add to those of Heubner's a fourth type to which
a large proportion of our cases conform. This type I would
characterize as follows:

4. Psychical disturbance without complete epileptic convulsions,

associated with palsy of the basal nerves and often with partial
hemiplegia.

The most satisfactory way of approaching this subject is, however, to

study the important symptoms in severalty, rather than to attempt to
group them into recognizable varieties of the disease; and this
method I shall here adopt.

Headache is the most constant and usually the earliest symptom of

meningeal syphilis; but it may be absent, especially when the lesion
is located in the reflexions of the meninges which dip into the
ventricles, or when the basal gumma is small and not surrounded
with much inflammation. The length of time it may continue without
the development of other distinct symptoms is remarkable. In one
case39 at the University Dispensary the patient affirmed that he had
had it for four years before other causes of complaint appeared. It
sometimes disappears when other manifestations develop. It varies
almost indefinitely in its type, but is, except in very rare cases, at
least so far paroxysmal as to be subject to pronounced
exacerbations. In most instances it is entirely paroxysmal; and a
curious circumstance is, that very often these paroxysms may occur
only at long intervals: such distant paroxysms are usually very
severe, and are often accompanied by dizziness, sick stomach,