VII., Fig. 5) shows enormous proliferation of the neuclei of the neuroglia, which takes place most along the small vessels and capillaries. The outermost layer of the convolutions is thinned, altered in appearance and structure, and in the advanced cases converted into a dense unorganizedlooking texture, instead of the beautiful and regular layer of small cells and fine granules of a healthy convolution. The larger cells further in, and the large multipolar cells, are more or less degenerated or atrophied, especially in patches and areas. The bloodvessels are diseased, their coats being thickened and full of nuclei. Sometimes they are obliterated and thready. The perivascular canals are morbidly enlarged, sacculated, and filled with all kinds of organic débris, blood coloring-matter, granules, and minute apoplexies. There can be no doubt that those canals and the spaces in the pia mater act as lymphatic ducts. Having been obstructed during life, little effete material could have been carried along them.

There is no nervous tissue that is not found diseased and degenerated in advanced cases of the disease, the retina, the peripheral nerves, the sympathetic ganglia, etc.

Its

NATURE OF THE DISEASE.-What, then, is general paralysis? There are few diseases whose essential nature we as yet know. But we know that the special trophic energy and inherent physiological qualities of different tissues become perverted in special ways, so that most tissues have their own special types of disease. There can be no doubt that the gray substance of the convolutions of the brain of man is the highest in quality and function of any organic product yet known in nature. That substance reaches its highest development in the male sex between adolescence and middle life. Its uses are called forth in the highest degree in the European races who live in towns. Its physiological abuses by alcoholic and other poisoning, by over-strain, by violent energizing stimulated by continuous strong mental and other stimuli up to the point of exhaustion, are also most common under those circumstances. outer layer or rhind is most delicately constituted, has far more blood (see Plate VII., Fig. 5) and more minute cells than any other portion of the brain, and, on the whole, may be regarded as the most important factor in mentalization, being in fact the mind tissue. Immediately underlying it in the convolutions, in certain parts of the brain, we probably have the originating motor cells. This outer rhind of gray matter, this last evolved and highest organic substance, is precisely that affected in general paralysis. The proof goes to show that this is first affected in the typical cases, and that all the other nervous degenerations which finally affect the whole nervous system are subsequent and sequential. Granted a progressive and incurable disease of this mind tissue, towards which the whole of the rest of the nervous system tends and in which it ends, which controls and regulates it all, and which is its crown and highest development, it is quite explicable that all the rest of the nervous system should degenerate in structure and function, and in fact die slowly and progressively. It is a quality of nerve tissue to degenerate in the lines of physiological activity, when that activity ceases either in a higher centre or in the part innervated. General paralysis is a disease of this outer layer of the cerebral convolutions of the mind

tissue in fact. It is essentially a death of that tissue. I look on it as being equivalent to a premature and sudden senile condition, senility being the slow physiological process of ending, general paralysis the quick pathological one. The causes of it are causes that have exhausted trophic energy by over-stimulation. Its first stage is accompanied by undoubted morbid vaso-motor dilatation, so that all the tissues enveloping the brain, and holding its elements together, receive an abnormal supply of blood, and thereby acquire tissue hypertrophy-the bones of the skullcap, the membranes, the reuroglia, the epithelium, and the arteries. Just as the tissue degenerations, especially the brain degenerations of old age, cannot be arrested, and are necessarily progressive, so is general paralysis. Those high nerve cells have lost their once inherent power of self-restoration, and so they degenerate and atrophy. The diseased process is peculiar, because the tissue in which it originates is peculiar. Its motor accompaniments are really not more inexplicable than the ordinary senile speech and senile incoördination.

LOCAL DISTRIBUTION.-General paralysis prevails in some places and in some races, and is unknown in others. As yet the Asiatic is not subject to it, the savage is free from it, and the Irishman and Scotch Highlander needs to come to the big towns or to go to America to have the distinction of being able to acquire it. The female sex is very unsusceptible of it, but if women drink bad liquor and live riotous, excited lives, as in the cotton and manufacturing districts of England, they too will become general paralytics. I have only seen one female in the rank of a lady suffering from general paralysis. The things that most excite and at the same time most exhaust the highest brain energy are those that tend most strongly to cause the disease, viz., over and promiscuous sexual indulgence combined with hard muscular labor, a stimulating diet of highly fed flesh meat, the brain being all the while excited and poisoned by alcohol and syphilis, all these things being begun early in life and kept up steadily. In this country the Durham miner, when earning good wages, fulfils the most perfect conditions yet known for the production of general paralysis. Every sixth lunatic admitted to the Durham County Asylum is a geneal paralytic. Hard study, or severe mental shocks, or traumatic injuries, or continuous anxiety, will also produce the disease. I do not think there is any proof that it is syphilitic in origin.

PARALYTIC INSANITY.

Paralytic Insanity, or Organic Dementia, is that form of mental disturbance which accompanies and results from such gross brain lesions as apoplexies, ramollissements, tumors, atrophies, and chronic degenerations of the brain, affecting the convolutions and their functions either primarily or secondarily. It has nothing whatever to d, with general paralysis. Its symptoms vary according to the position, kind, and intensity of the pathological process. But it is typically a dementia, an enfeeblement, a lessening of the mental power, superadded to some sort of motor paralysis. Along with this enfeeblement there may be, and there usually is, a certain amount of depression at first, followed afterwards by a mild exaltation and

emotionalism of a childish kind, this gradually passing off and leaving the patient, if he lives long enough, forgetful, helpless, and torpid. Paralytic insanity, like general paralysis, has a gross and demonstrable pathological basis, but it differs widely and essentially from it in not being a specific disease of the brain convolutions, in not running a progressive course, in not being necessarily incurable, in the irregularity and variety of the mental symptoms present, and of the pathological lesions. It is best and most commonly seen in a case where there has been apoplexy from rupture of a bloodvessel in one of the great basal ganglia, or embolism, or thrombosis, followed by local starvations of brain tissue, and ramollissement; those destructive processes cutting off large tracts of the convolutions by destroying part of the projection and association systems of fibres by which the convolutions are brought into connection with the basal ganglia, the cerebellum, and the cord and the muscles, or with each other. This interruption may of itself sensibly affect the mental power, and those pathological processes tend to advance up into the convolutions, so destroying the sources of mental energy directly. A brain affected by apoplexy or embolism, and in that case probably having its blood vessels generally diseased, is an organ on the verge of dissolution. Such processes are the beginning of the end in most cases, and the mental symptoms are often the most prominent and by far the most troublesome. Yet, after all, they are not the essential part of the disease. This disease is not an insanity in the popular acceptation. In most cases the gradual mental decay is never thought of as a mental disease at all. It is rather looked on as a necessary and natural accompaniment of the bodily disease. In most cases it is not at all beyond the ordinary nursing capacity and management available in the patient's home, if he has any money or relatives at all. The very poor in the great towns, when affected by it, are sent to workhouses, and not usually to asylums for the insane. It is only the worst and most troublesome cases that it is necessary to send there the noisy, the restless at night, the very dirty, the troublesome. Motor restlessness is a special characteristic of the worst class of cases, and this often needs, for the protection of the patient, special nursing and special rooms. But there is no essential difference between the helpless hemiplegic whose memory is gone, his energy impaired, his thinking capacity paralyzed, and his affective power deadened, who sits in his easy-chair at home, and the restless, shouting, sleepless paralytic insane man in the hospital ward of an asylum.

The heredity of the patient plays an important part in the origination of paralytic insanity of the more marked kind. While a man with no nervous heredity will have a large spot of progressive softening in one of his corpora striata, and yet will be calm, reasonable, and quite manageable, though forgetful, torpid, and emotional, the man with a bad nervous heredity will become, under the same conditions, restless, depressed, noisy, and sleepless. There is no doubt that apoplexies and all sorts of other gross limited lesions produce, in unstable brains, great convolutional disturbance through reflex excitation. If such brains are unstable in their motor centres, we have convulsions, local or general; if there is hereditary mental instability, then we have the ordinary symptoms of mania or melancholia. I had once as a patient a young woman (G. N.) under

thirty, who, having heart disease, became hemiplegic on her right side, and aphasic after the birth of a child. Immediately after these came on great mental depression, with suicidal tendencies, for which she had to be sent to an asylum. The hemiplegia soon passed quite away, but the aphasia remained all her life; and when the mental depression passed off in a few months she gradually became exalted, and remained so for some months. Then she again became depressed, and was mentally a typical case of alternating insanity (folie circulaire) for the seven years she lived after this. She at last died of the heart disease, and I found Broca's convolution almost destroyed by an old embolism, but the rest of the brain with only the traces of repeated excitations and congestions. In this case, which I mention as being a very rare and most unusual kind of paralytic insanity, the embolism and its consequences no doubt excited into pathological activity a previously existing hereditary weakness of the mental portions of the convolutions which had before that been stable in their working. In the more typical cases of paralytic insanity the same thing occurs in old and partially worn-out brains.

There is a close analogy in symptoms, pathology, and course, between paralytic and senile insanity. In fact, the majority of paralytic cases are also senile. In a brain with general senile degeneration and diseased arteries, a local lesion occurs, and we have it exciting and lighting up a general convolutional flame. I have had many cases where there was a family tendency to mental disease, but it had never shown itself in any actual symptoms till the very end of life, when an attack of paralysis occurred, and this was followed by melancholic or maniacal symptoms and subsequent dementia. I have had several such patients whose children had become insane at an early age long before them, but they remained well till they became hemiplegic. One such case was G. O., æt. 67, who remained quite well mentally, and did his work till he had a slight attack of left hemiplegia. Then he became melancholic, sleepless, and suicidal, and had to be sent to the asylum, where his daughter, G. P., had been a patient for thirteen years, suffering from essential paralysis of infancy on the right side, epilepsy, and dementia.

The motor symptoms in paralytic insanity must be regarded as integral parts of the disease. The speech is the most characteristic of these in the ordinary hemiplegic cases. It is a thick articulation, not a tremulous speech. Every word from the beginning of a sentence to the end is imperfectly pronounced. There is no tendency to fail more at the end of a sentence than at the beginning. The labial and facial muscles do not quiver before or during the articulatory process, as in general paralysis, though the tongue usually trembles when put out. It is a simple paretic, not a convulsive, speech. Long, difficult words and sentences are attempted, and got through with in a way, but are not found impossible of attempt, or end in a more inarticulate prolonged vowel sound, as often in general paralysis. In the latter disease it is essentially a convolutional lesion speech; in the former it is a basal motor ganglia lesion speech. In the former it is the originating motor speech coördinations in the convolutions that are affected, in the latter the secondary coördinations lower down. In very many of the paralytic cases we have apoplexies and similar lesions of the convolutions themselves, and in such

the speech symptoms are always more like those of general paralysis. In such patients, too, we are apt to have epileptiform, epileptic, and congestive attacks. In many instances, even when the original lesion has been in the corpora striata or in the motor fibres of conduction near it, destruction of tissue will go on up to the convolutions; in fact, if the patient lives long enough it is sure to do so, and the speech will become more like that of the second stage of general paralysis.

I need hardly say that if the lesion affects the posterior portion of the third frontal convolution of the left side, or the Island of Reil on that side, or the fibres of communication inwards from those parts, or certain portions of the extra-ventricular nucleus of the corpus striatum of that side-in such cases we will have the aphasic speech symptoms. It is a disputed question whether complete aphasia can coexist with perfect integrity of the intellectual faculties. If the lesion be strictly limited to the speech centre, which it very rarely is, the loss of mental power may be slight, but whether we can have mental completeness according to the previous standard of perfect health of the individual is another matter. I do not believe we can have such completeness if we could apply proper tests. I have never seen a case where it existed.

Here is a kind of case, very common indeed where extreme bodily helplessness coexisted with such mental symptoms as made the patient's presence almost intolerable in a private house, and even to the neighbors who lived near.

G. Q., æt. 64. Had an attack of apoplexy with left hemiplegia four months before it was necessary to send her to the asylum. Her mother died of apoplexy at the age of eighty-four. There was no other neurotic heredity discoverable. During the first month after the apoplexy she was stupid and half comatose. Then she began to have hallucinations of sight, and to be fanciful, irritable, and very unreasonable, to sleep badly, and to have a morbid craving for food with no sense of satiety. The mental symptoms got gradually worse, while the hemiplegia remained complete. She became subject to periodic fits of depression, lasting whole days and nights, during which she would cry and scream loudly without intermission in a peculiar baby-like voice that penetrated through the house and into the street, and was most annoying to the neighbors, especially at night. There was no reasoning with or soothing her. It was evident that she had a sense of extreme organic discomfort, and that she probably had pain. Her delusions all took their origin from her sensations. She affirmed that her left leg and arm did not belong to her, and would order that they should be taken away. She affirmed her food was poisoned, and she said the people near her were going to kill her. She could not attend to the calls of nature, and when moved to be dressed and washed screamed at the pitch of her voice. She had no memory at all for recent events, but lived in the past. She was very emotional, crying nearly every time she was spoken to, but her appearances of emotion, like the rest of her mental life, were merely automatic. She showed no real affection for her family. She constantly threatened suicide. She mistook the identity of those about her, calling strangers by the names of old friends. With the hand she could move she would try to tear and destroy and break things. After about three months of