much troubled with nausea, and it was noticed that there was difficulty in articulation, and that he dragged his feet. He soon rallied from this condition, talked much and at random on business matters, and wrote many letters full of wild projects. When he came to the asylum talked extravagantly of his plans and schemes, and his speech and walk were affected. Had much to say of buying elephants to do his farm work, said that an acre or two adjoining would be worth $25,000, styled himself the Astor of New Hampshire. Remained at the asylum willingly, and was at once at home. Said all the implements on his farm, including troughs for the pigs, were of solid silver. There was no great change for a month except that he increased in extravagance, and manifested more excitement, and was very obscene. He masturbated on all possible occasions. During next two months there was great excitement accompanied by threats, great irritability, and violence. During the next two months he was more quiet, and less extravagant, decidedly more sane, and generally quite gentlemanly in his conduct, but tremor of lips and mental enfeeblement were always apparent. He then became more unsettled and excitable, and had several dull, partially insensible attacks without convulsions, during which he vomited, and after which he was always weaker, more confused, and more excited. Often his attempts to talk were mere jargon, and his gait very feeble. These alternations continued steadily, he lost ground mentally and physically, and his incoherence and exalted ideas increased. Fifteen months after admission had his first epileptiform attack when exercising out-of-doors. From the early attacks he rallied, but they soon became very frequent, and he failed much more rapidly. His extravagance continued, and so long as he could talk he spoke constantly of his great sexual power, his powerful influence with the female sex, and insisted that Queen Victoria, whose daughter he had married, had built him a golden palace in the centre of his farm.

He died in epileptic convulsions three years and six months after admission to the asylum, and not far from five years from the first appearance of the disNo autopsy.

ease.

(To be continued.)

rence of an apoplectic or epileptic fit. Under these circumstances it will be usually noted that the resulting palsy is incomplete; in rare instances it may be at its worst when the patient awakes from the apoplectic seizure, but mostly it progressively increases for a few hours, and then becomes stationary. These sudden partial palsies probably result from an intense congestion around the seat of disease, or from stoppage of the circulation in the same locality; but whatever their mechanism may be, it is important to distinguish them from palsies which are due to hæmorrhage. I believe this can usually be done by noting the degree of paralysis.

A suddenly developed, complete hemiplegia, or other paralysis, may be considered as in all probability either hæmorrhagic or produced by a thrombus so large that the results will be disorganization of the brain substance, and a future no more hopeful than that of a clot. On the other hand, an incomplete palsy may be rationally believed to be due to pressure or other removable cause, and this belief is much strengthened by a gradual development. The bearing of these facts upon prognosis it is scarcely necessary to point out.

Although the gummæ may develop at almost any point, they especially affect the base of the brain, aud are prone to involve the nerves which issue from it. Morbid exudations, not tubercular nor syphilitic, are very rare in this region. Hence a rapidly but not abruptly appearing strabismus, ptosis, dilated pupil, or any paralytic eye symptom in the adult, is usually of syphilitic nature. Syphilitic facial palsy is not so frequent, whilst paralysis of the nerve from rheumatic and other inflammation within its bony canal are very common. Paralysis of the facial may therefore be specific, but it is of no diagnostic value. Since syphilitic palsies about the head are in most instances due to pressure upon the nerve trunks, the electrical reactions of degeneration are present in the affected muscles.

There is one peculiarity about specific palsies which has already been alluded to as frequently present, namely, a temporary, transient, fugitive, varying character and seat. Thus an arm may be weak to-day, strong to-morrow, and the next day feeble again, or the recovered arm may retain its power, and a leg fail in its stead. These transient palsies are much more apt to involve large than small brain territories. The explanation of their largeness, fugitiveness, and incom

Paralysis. When it is remembered that a syphilitic exudation may appear at almost any position in the brain, that spots of encephalic softening are a not rare result of the infection, that syphilitic disease is a common cause of cerebral hemorrhage. it is plain that a specific palsy may be of any conceivable variety, and affect either the sensory, motor, or intellectual sphere. The mode of onset is as various as the character of the palsy. The attack may be instantaneous, sudden, or gradual. The gradual development of the syphilitic gumma would lead us, à priori, to expect an equally gradual development of the palsy; but experience shows that in a large proportion of the cases the palsy develops suddenly, with or without the occur1 Continued from page 200.

other structural changes, but to congestions of the brain tissues in the neighborhood of gummatous exudations. It is easily seen why a squint will remain when the accompanying monoplegia disappears.

Motor palsies are more frequent than sensory affections in syphilis, but hemianæsthesia, localized anæsthetic tracts, indeed any form of sensory paralysis, may occur. Numbness, formications, all varieties of paræsthesia are frequently felt in the face, body, or extremi ties. Violent peripheral neuralgic pains are rare, and generally when present denote neuritis. Professor Huguenin, however, reports 2 a case in which a severe trigeminal anesthesia dolorosa had existed during life, as the only cerebral symptom, and death occurring from lung disease, a small gumma was found on the sella turcica pressing upon the Gasserian ganglion.

The special senses are liable to suffer from the invasion of their territories by cerebral syphilis, and the

2 Schwiez. Corr. Blat., 1875.

rarely, throughout the paroxysm, unilateral; indeed, they may be confined to one extremity. This restriction of movement has been held to be almost characteristic of syphilitic epilepsy, but it is not so. Whatever diagnostic significance such restriction of the convulsion has is simply to indicate that the fit is due to a cortical organic lesion of some kind. Tumors, scleroses, and other organic lesions of the brain cortex are as prone to cause unilateral or monoplegic epilepsy when they are not specific as when they are due to syphilis.

Sometimes an epilepsy, dependent upon a specific lesion implicating the brain cortex, may be replaced by a spasm which is more or less local and is not attended with any loss of consciousness. Thus, in a case now convalescent in the University Hospital, a man, aged about thirty-five, offered a history of repeated epileptic convulsions, but at the time of his entrance into the hospital, instead of epileptic attacks, there was a painless tic. The spasms, which were clonic, and occurred very many times a day-sometimes every five minutes were very violent and mostly confined to the left facial nerve distribution. The trigeminus was never affected, but in the severer paroxysms the left hypoglossal and spinal accessory nerves were profoundly implicated in all of their branches. Once, fatal asphyxia from recurrent laryngeal spasm of the glottis was apparently averted only by the free inhalation of the nitrite of amyl. The sole other symptom was headache, but the specific history was clear, and the effect of antisyphilitic remedies rapid and pronounced. Psychical Symptoms. As already stated, apathy, somnolence, loss of memory, and general mental failure are the most frequent and characteristic mental symptoms of meningeal syphilis, but, as will be shown in the next chapter, syphilis is able to produce almost any form of insanity, and therefore mania, melancholia, erotic mania, delirium of grandeur, etc., etc., may develop along with the ordinary manifestation of cerebral syphilis, or may come on during an attack which has hitherto produced only the usual symptoms. Without attempting any exhaustive citation of cases, the following may be alluded to:

Dr. A. Erlenmeyer reports1 a case in which an attack of violent headache and vomiting was followed by paralysis of the right arm and paresis of the left leg with some mental depression; a little later the patient suddenly became very cheerful, and shortly afterwards manifested very distinctly delirium of grandeur with failure of memory. 2 Dr. Batty Tuke reports a case in which with aphasia, muscular wasting, strabismus, and various palsies there were delusions and hallucinations.

In the same journal, April, 1869, Dr. S. D. Williams reports a case in which there were paroxysmal violent attacks of frontal headache. The woman was very dirty in her habits, only ate when fed, and existed in a state of hypochondriacal melancholy.

M. Leiderdorf details a case with headache, partial hemiplegia, great psychical disturbance, irritability, change of character, marked delirium of grandeur, epileptic attacks, and finally dementia, eventually cured with iodide of potassium. Several cases illustrating different forms of insanity are reported by Dr. N. Manssurow.*

3

That the attacks of syphilitic insanity, like the palsies of syphilis, may at times be temporary and fugitive, is shown by a curious case reported by Dr. H. Hayes Newington," in which along with headache, failure of memory, and ptosis in a syphilitic person there was a brief paroxysm of noisy insanity.

DISEASES OF BRAIN SUBSTANCE.

The psychical symptoms which are produced by syphilis are often very pronounced in cases in which the paralysis, headache, epilepsy, and other palpable manifestations show the presence of gross brain lesions. In the study of syphilitic disease of the brain membranes sufficient has been said in regard to these psychical disturbances, but the problem which now offers itself for solution is as to the existence or nonexistence of syphilitic insanity, that is, of an insanity produced by specific contagion without the obvious presence of gummatous disease of the brain membranes. Very few alienists recognize the existence of a distinct affection entitled to be called syphilitic insanity, and there are some who deny that insanity is ever directly caused by syphilis. It is certain that insanity often occurs in the syphilitic, but syphilis is abundantly joined with alcoholism, poverty, mental distress, physical ruin, and various depressing emotions and conditions which are well known to be active exciting causes of mental disorder. It may well be that syphilis is in such way an indirect cause of an insanity, which under the circumstances could not be properly styled syphilitic.

If there be disease of the brain cortex produced directly by syphilis, of course such disease must give rise to mental disorders, and, if the lesion be situated in such a way as to affect the psychic and avoid the motor regions of the brain, it will produce mental disorder without paralysis, that is, a true insanity; again, if such brain disease be wide spread, involving the whole cortex, it will cause a progressive mental disorder, accompanied by gradual loss of power in all parts of the body and ending in dementia with general paralysis; or, in other words, it will produce an affection more or less closely resembling the so called general paralysis of the insane, or dementia paralytica.

As a man having syphilis may have a disease which is not directly due to the syphilis, when a syphilitic person has any disorder there is only one positive way of determining how far said disorder is specific, namely, by studying its amenability to antisyphilitic treatment. In approaching the question whether a lesion found after death is specific or not, of course such a therapeutic test as that just given is inapplicable. We can only study as to the coexistence of the lesion in consideration with other lesions known to be specific. Such coexistence of course does not absolutely prove the specific nature of a nutritive change, but renders such nature exceedingly probable.

What has just been said foreshadows the method in which the subject in hand is to be here examined, and the present chapter naturally divides itself into two sections: the first considering the coexistence of anatomical alterations occurring in the cerebral substance with syphilitic affections of the brain membranes or blood-vessels, the second being a clinical study of syphilitic insanity.

In looking over literature I have found the following cases in which a cerebral sclerotic affection coincided with a gummatous disease of the membrane. Gross 5 Journ. Ment. Sci., London, xix., 555.

and Lancereaux1 report a case having a clear syphilitic history, in which the dura mater was adherent to the skull. The pia mater was not adherent. Beneath, upon the vault of the brain, was a gelatinous exudation. The upper cerebral substance was indurated, and pronounced by M. Robin after microscopic examination to be sclerosed. At the base of the brain were very atheromatous arteries and spots of marked softening.

2

Dr. Jos. J. Brown reports a case in which the symptoms were melancholia, excessive irritability, violent outbursts of temper, very positive delusions, disordered gait ending in dementia. At the autopsy, which was very exhaustive, extensive syphilitic disease of the vessels of the brain and spinal cord was found. The pia mater was not adherent to the brain. The convolutions, particularly of the frontal and pariétal lobes, were atrophied with very wide sulci, filled with bloody serum. The neuroglia of these convolutions was much increased and "appeared to be more molecular than normal, the cells were degenerated and in many places had disappeared, their places being only occupied by some granules." These changes were most marked in the froutal convolutions. H. Schule reports 8 a very carefully and meritoriously studied case. The symptoms during life exactly simulated those of dementia paralytica. The affection commenced with an entire change in the disposition of the patient; from being taciturn, quiet, and very parsimonious, he became very excited, restless, and desiring continuously to buy in the shops. Then failure of memory, marked sense of well-being, carelessness and indifference for the future, developed consentaneously with failure of the power of walking, trembling of the hands, inequality of the pupils, and hesitating speech. There was next a period of melancholy, which was, in time, followed by continuous failure of mental and motor powers, and very pronounced delirium of grandeur, ending in complete dementia. Death finally occurred from universal palsy with progressive increase of the motor symptoms. At the autopsy characteristic syphilitic lesions were found in the skull, dura mater, larynx, liver, intestines, and testicles. The brain presented the macroscopic and microscopic characters of sclerosis and atrophy; the neuroglia was much increased, full of numerous nuclei, the ganglion cells destroyed. The vessels were very much diseased, some reduced to cords; their walls were greatly thickened, and full of long, spindle-shaped cells, sometimes also containing fatty granules.

Dr. C. E. Stedman and Robert T. Edes report a case in which the symptoms were failure of health, ptosis, trigeminal palsy with pain (anesthesia dolorosa), finally mental failure with gradual loss of power of motion and sensation. At the autopsy the following conditions were noted: apex of the temporal lobe adherent to dura mater and softened; exuded lymph in neighborhood of optic chiasm; sclerosis of right Gasserian ganglion, as shown in a marked increase of the neuroglia; degeneration of the basal arteries of the brain.

These cases are sufficient to demonstrate that sclerosis of the brain substance not only may coexist with a brain lesion, which is certainly specific in its charac

1 Affect. Nerv. Syphilis, 1861, page 245.

2 Journ. Ment. Science, July, 1875, page 271.

3 Allgem. Zeitschrift f. Psychiatrie, xxviii., 1871-1872. Amer. Journ. Med. Sci., Ixix., 433.

ter, but may also present the appearance of having developed pari passu with that lesion, and from the same cause.

It has already been stated in this memoir that cerebral meningeal syphilis may coexist with various forms of insanity, and cases have been cited in proof thereof. It is, of course, very probable that in some of such cases there has been that double lesion of membrane and gray brain matter which has just been demonstrated by report of autopsies; further, if we find that there is a syphilitic insanity, which exists without evidences of meningeal syphilis, and is capable of being cured by antispecific treatment, such insanity must be considered as representing the disease of the gray matter of the brain. Medical literature is so gigantic that it is impossible to exhaust it, but the list of cases given in the Table (see p. 224) is amply sufficient to prove the point at issue, namely, that there is a syphilitic insanity which exists without obvious meningeal disease, and is capable of being cured by antisyphilitic treatment.

A study of the brief analyses of symptoms given in the Table shows that syphilitic disease of the brain may cause any form of mania, but that the symptoms, however various they may be at first, end almost always in dementia unless relieved.

Of all the forms of insanity general paralysis is most closely and frequently simulated by specific brain disease. The exact relation of the diathesis to true incurable general paralysis it is very difficult to determine. It seems well established that amongst persons suffering from this disorder the proportion of syphilitics is not only much larger than normal, but also much larger than in other forms of insanity. Thus Dr. E. Mendel found that in 146 cases of general paralysis 109, or seventy-five per cent., had a distinct history of syphilis, whilst in 101 cases of various other forms of primary insanity only eighteen per cent. had specific antecedents.

5

Various opinions might be cited as to the nature of this relation between the two disorders, but for want of space the curious reader is referred to the work just quoted, and to the thesis of C. Chauvet for an epitome of the most important recorded opinions.

Those who suffer from syphilis are exposed in much greater proportion than are other persons to the ill effects of intemperance, sexual excesses, poverty, mental agony, and other well-established causes of general paralysis. It may be that in this is sufficient explanation of the frequency of general paralysis in syphilitics, but I incline to the belief that syphilis has some direct effect in producing the disease. However this may be,

7

I think we must recognize as established the opinion of Voisin that there is a syphilitic periencephalitis which presents symptoms closely resembling those of general paralysis. Such cases are examples of the pseudo-paralysie générale of Fournier.

8

The question as to the diagnosis of these cases from the true incurable paresis is, of course, very important, and has been considered at great length by Voisin, Fournier,10 and Mickle."

The points which have been relied upon as diagnostic of syphilitic pseudo-general paralysis are:

5 Progres. Paral. der Irren, Berlin, 1880.

6 Influence de la Syph. sur les Malad. du Syst. nervuex, Paris, 1880.

7 Paralysie générale des Alienés, 1879.

8 La Syphilis du Cerveau, Paris, 1879.

9 Loc cit.

10 Loc cit.

11 Brit. and For. Medico-Chirurg. Review, 1877.