cholic, and third, dementia. This prodromal or initial stage is of extreme importance and interest. It is the stage in which if there is a chance for recovery that it should be recognized. It is the stage in which at times the symptoms are so gradual and insidious that it is almost next to impossible to satisfy yourself as to whether the patient be insane or not. It is the arena of many a fiercely fought medicolegal battle. The moral traits of the individual are more prominently affected first. The individual whose character was formerly irreproachable becomes profane and abusive, associates with the lower classes, appropriates property of others, borrows money when not able to pay it back, gives checks on banks when he has nothing on deposit, or he may become extravagant, giving things of value to persons that are utter strangers to him; buying articles he has no need of, regardless of price.

The careful business man may become careless, paying no attention to his business. Memory is always bad, especially concerning recent events. In this state the patient may be reproached by his friends and relatives for obliquity of morals instead of mental unsoundness. The individual in this initial stage may talk intelligently and even shrewdly. There are cases every year that defeat the attempts of their relatives to restrain them in the asylum. The physical signs are very soon apparent, the most marked being a tremor in speech, associated with a slight twitching of the facial muscles, especially about the corner of the mouth. The peculiar slurring of pronunciation of cer tain syllables or consonants, especially the labials, is one of the pathognomonic symptoms of paresis. Such words as artillery, cavalry brigade, or truly rural will bring out the speech defect. Tremor of the fingers and of the hand in writing, myosis or loss of pupillary reflexes, or there may be irregular exaggeration of the wrist, elbow, and knee jerk (rarely diminution). All these are among the earliest somatic characteristics.

A curious feature is that paretics never recognize insanity in others, no matter how unusual their conduct may be. Later these symptoms become more and more pronounced, until diagnosis is inevitable. The mental symptoms are particularly variable. These may at first be but a melancholia or hypochrondriacal condition. This is more common as an early symptom than that feeling of wellbeing and personal importance which almost always makes its appearance at some epoch in the disease. Sometimes maniacal outbursts

occur; convulsions, epileptiform or apoplectiform, generally usher in the later stages, but they make their appearance very early and very unexpectedly.

There are a certain or rather a limited number of these cases which will progress to a fatal termination without manifesting sufficient symptoms to necessitate their removal from home, but the vast majority require the supervision and care of the infirmary ward of an institution. In the second stage the patient has added to an exaggeration of the former symptoms mentioned a melancholia or a mania, each with certain peculiarities distinguishing it from ordinary melancholias and manias. In the melancholia of general paresis there is not that persistent insomnia or post-cervical headache that is characteristic of ordinary melancholia, but the delusions and hallucinations are depressed ones in character, and suicide may be apprehended.

In the mania of general paresis there is invariably a tinge of stupidity about their delusions and hallucinations. The former are statements without effort at argument. With this stupidity is mingled an expansion and exaggeration of ideas giving rise to the term grandiosa delusions. The patient may state that he is President of the United States, or that he owns the world, or as one stated when he was awakened at "Beechhurst" to get ready for breakfast, that he owned the Galt House and had been to breakfast. If you tell him you know how much he is worth, and that he does not own or is not what he professes to be, he has no argument to make, but simply restates his former assertion. In this respect he affords a marked contrast to the paranoiac, who may have the same delusions of grandeur, but will have any number of plausible and settled reasons to lend flavor to his assertions. In the active delusional stage they are sometimes violent and dangerous to others or themselves. They act from sudden impulses and will fight any number, perfectly regardless of consequences.

The mania usually becomes violent, and in some few cases the patient dies from exhaustion. The third stage, dementia, is marked by extreme imbecility and childishness, and yet the patient is very stubborn and hard to manage. His habits become extremely unclean, his speech almost unintelligible, mental and nervous reactions are very sluggish-sometimes absent altogether. Anesthesia is often remarkable; patients sometimes show no signs of pain even after burns or painful injuries. There is a blank expression of countenance, difficulty in swallowing, imperfect mastication, bolting their food. They are

generally unable to feed themselves in this stage. They fatten, however, and will eat whatever and all that is given them. They sleep a great deal. Bed-sores are apt to form from defective innervation. Repeated convulsions or lighter congestive attacks are common, sometimes with little motor effect, but generally with the deepening or extion of the palsied condition of the patient. Under all these conditions he is game to the end. He is happy and contented and wants nothing.

There are two factors that seem to especially predispose to this disease-syphilis and alcoholic excesses. Sexual excesses have been written of considerably as a cause, especially if indulged in at or after middle life. Some writers claim that syphilis alone is the real cause. Mental shocks and strains of all kinds predispose to it—indeed, whatever tends to bring about prolonged brain irritation or exhaustion; the sudden loss or sudden acquirement of financial prosperity; speculators are frequent victims; rarely inherited. Careful analysis of statistics show that about four males are affected to one female; some writers state that the Hebrew race shows an exemption next to the negro. I understand that prior to the Civil War it was unheard-of for the negro to have the disease. It is very common among them to-day; you can go into any of the public asylums and see a great many typical cases among the negroes. I recall a case of a negro who had passed through the initial stage with delusions of grandeur, saying that he had three hundred acres in orange groves all covered in with glass; another that he was private secretary to President McKinley, and smoked gold cigars, etc.

I was told that there were a great many cases in the institution as well marked as these. In Cuba it occurs much oftener among the negroes than the native whites. I have also seen a great many typical cases among the Hebrew race, and think, in these cases, that the worry over business, both mental and physical strain, is a causative agent. The ages at which most are affected is between thirty-five and fifty, but cases have been reported as early as six and as late as seventy.

It occurs very often among military men, especially officers, also with conductors and engineers. While syphilis causes true paresis, it also causes a disease called by some pseudo-paresis, the symptoms of which resemble paresis, differing pathologically and curable in considerable proportion of cases by antisyphilitic remedies. It is next to impossible to diagnose pseudo-paresis from the true form, and it

becomes the duty of practitioners to make trial of the antisyphilitic treatment in every case in which there is the smallest reason for suspecting that the subject has ever had syphilis.

At a session of the New York Academy of Medicine, March 16, 1901, Dr. C. K. Mills, of Philadelphia, read a paper in which he said that syphilitic pseudo-paresis was of good or bad prognosis according to the stage of the disease when the treatment was begun. The discussion of the pathology of paralytic dementia in a brief paper, when so little of a distinctive character has been settled upon, would be profitless.

In fact, much difference of opinion exists among brain pathologists who have conducted the most careful investigation as to the exact nature of the changes observed and the order of their appearance. By some it is considered that the primary change begins in the bloodvessels; by others that some alteration in the nuclei of the cells is first to be seen, while a recent and painstaking investigator asserts that all the structures making up the molecular layer of the cortical area are alike involved. The question as to whether the disease is primarily a true interstitial encephalitis remains unsolved. Whatever the initial change may be, or wherever it may begin, no tissue of the infected area is exempt-cells, fibers, neuroglia all undergo a degenerative alteration.

The blood-vessels and lymphatic spaces are affected and the membranes covering the brain are often thickened and adherent. The cerebral hemispheres are soft and the continuity easily destroyed; the part showing the greatest change are the ascending frontal and parietal convolutions, the third frontal convolution and the island of Reil. Next in order come the remaining frontal and parietal convolutions, the occipital being the last involved.

The prognosis is very unfavorable, and I believe hopeless. Remissions at times with considerable improvement lasting from a few months to one, two, or more years may be anticipated in a small number of cases, but have no influence on the unfavorable prognosis. They rarely live over five years, and I believe the majority die in three. However, there are cases that live for years. Dr. Clouston records a case of well-defined general paresis that lived twenty-five years. There is a case at the Western Kentucky Asylum which, if still alive, is of twelve years' duration; she had been there ten years, two years ago; these cases are rare.

If the cause can be ascertained, every effort should be made to remove it; this should be persistent and begun as early as possible, as it is only in the early stages that treatment promises any hope of recovery. Antisyphilitic treatment should always be tried unless positive assurance can be had to the contrary. Give nerve and general tonics. Where there is a tendency to convulsions or apoplectic seizures, the bromides, in doses of ten to fifteen grains, are useful. Hyoscine, bo gr. hypodermatically, or given in combination with some of the bromides by the mouth, are of service in the maniacal outbursts; hot baths are often quieting. The bowels should be well open. During the third stage, careful nursing, every means being used to prevent or cure bed-sores; in fact, make the patient as comfortable as possible.

LOUISVILLE.

THE MOST PRACTICABLE ORGANIZATION FOR THE MEDICAL
DEPARTMENT OF THE UNITED STATES ARMY
IN ACTIVE SERVICE.*

BY THOMAS PAGE GRANT, M. D.

Late Captain and Assistant Surgeon, K. S. G., of Louisville, Ky.

INTRODUCTION.

Of necessity the sick and wounded of an army must, in some degree, be an impediment to its movements. The medical and hospital corps being non-combatants (and at no very remote day held by some commanders to be a hindrance, but from a broader and more enlightened point of view no part of an army is less so), it would not be too much to say that there is no part of an army so indispensable as the medical department, and none that will repay so well the care and attention given its training as will the hospital corps.

The care for and disposal of the sick and wounded of an army is one of the most important duties that will confront a commander, for, while men will go into the jaws of death under the leadership of a commander that they feel will care for them when they are wounded, nothing will disorganize and discourage a body of troops quicker than to feel that their commander does not feel an interest in them.

*Submitted to the Association of Military Surgeons of the United States in competition for the Eno Sanders Prize, 1902.