him, and miscalls them, as if they were old friends of long years ago. He lives over old events as if they were now enacted. Later on even these old memories vanish also. With failing memory, the judgmentassociations perish. The patient commits many breaches of decorum, and later, with the degeneration of ethical feelings and the ascendancy of coarser instincts, may become very negligent, indecent, and unclean in habits; may pilfer and destroy things; may expose his person, masturbate, or attempt liberties with little girls, etc. His loss of judgment may induce him to foolishly squander his money and properties.

Illusions and hallucinations begin to manifest themselves. They are usually of terrifying character.

Delusions make their appearance. These are nearly always persecutory in nature, and arise either as primary ideas or as the result of depression or on the basis of hallucinations. Next to delusions of persecution in frequency, we observe hypochondriacal delusions, with contents modified by the weak-mindedness present. Delusions of approaching poverty are quite common.

The underlying mood is often melancholic; an exalted mood is extremely rare. Changeability with irritability is perhaps the most usual affective condition.

The behavior of these patients in relation to night is noteworthy. Illusions, hallucinations, delusions, and emotional states all become more pronounced at night. A striking feature, too, is extreme motor restlessness, especially at night. These patients try to get up from bed, to wander about the house, to get away from something or somebody. Sometimes true melancholic anxious states come on and lead to attempts at suicide.

So far as bodily symptoms are concerned, we note foremost among them a general senile decrepitude, to which are added senile tremor of the hands, and often various stigmata of focal lesions in the brain (aphasic and paraphasic attacks); sometimes hemiparesis, monoplegia, hemiplegia, etc., complicate the picture. The patients often complain of severe pains all over the body, of vertigo, ringing in the ears, sparks before the eyes, etc. Often, too, there is noticeable diminution of sensibility to touch and pain in various areas, or over the whole body. Occasionally an especial color is given to the symptoms described by true maniacal or melancholic phases appearing in the course of the dis

ease.

Course and Prognosis.-Senile dementia develops gradually upon the basis of senile psychic degeneration, and lasts, ordinarily, from three to five years, sometimes with remissions which are never so noteworthy as the remissions of paralytic dementia. In rare instances an acute course is taken, the disease terminating by death in a few months. Paralytic attacks are not infrequently observed in the course of the malady, giving it a certain analogy to paresis. The prognosis is unfavorable, as the disorder is incurable and progressive to a fatal end. Diagnosis. The most important indications for diagnosis are defects of memory and judgment and acts dependent upon loss of ethical feeling.

Pathological Anatomy.-We observe at autopsy chiefly the following conditions:

1. Osteophytic deposits on the inner surface of the skull.

2. Pachymeningitis hæmorrhagica interna (more frequently even than in paralytic dementia).

3. Opaque and thickened leptomeninges.

4. Increased fluid, subdural, and in the meshes of the pia-arachnoid. 5. Distention of the ventricles with serum, and granular ependyma. 6. Extreme narrowing of the cortex, with gaping sulei.

7. General endarteritis deformans (often with foci of softening and hemorrhage).

8. Wide-spread degeneration of ganglion-cells and association fibers. Treatment. Many cases of senile dementia can be treated at home. It is only when tendencies to suicide, sexual immoralities, waste of property, and great ideomotor excitement are exhibited that commitment is necessary. The bromids are the best hypnotic for these cases. Paraldehyd is extremely useful, too, since it is efficient as a hypnotic and does not injure the circulation or affect the digestive apparatus. In melancholic phases opium acts well. Hyoscin and its congeners are not to be recommended because of their depressing action on the heart.

PRIMARY DEMENTIA.

Synonyms. Acute dementia; Acute curable dementia; Stupiditas. Definition.-Primary dementia is an acute curable psychosis characterized by ideomotor inhibition and apathy. The inhibition of thought may attain to the degree of complete cessation of the psychic functions, and that of motion to complete immobility.

Etiology. This is essentially a disorder of youth. A rare disease in itself, it is chiefly encountered in young persons between the ages of puberty and thirty years. After thirty-five it is extremely infrequent. A neuropathic constitution is found in some sixty per cent. of the cases. Any mental or physical stress that induces exhaustion of the nervous system may act as an exciting cause of primary dementia. Fright, concussion of the brain from trauma, hemorrhages, frequent child-bearing, physical and mental overwork or overexertion, and masturbation have all been cited as etiological factors.

Symptomatology.-The development of the malady is gradual. At first there is difficult concentration of the thoughts with loss of interest in everything and a certain restlessness. The patient perceives a lack of energy in his idea-associations; nothing suggests thoughts to him, and he begins to feel a sort of depressed wonder at his own condition. Complicated processes of thought become impossible, and even the simplest concrete memory-pictures are difficult of recollection. He can not recall the countenances of his friends, the position of the furniture in his room, the situation of his home, the events of the past or of yesterday. He feels his head empty of ideas. Things seem to grow distant; voices sound far away. The senses become blunted and respond at first slowly,

later not at all, to stimuli. The patient sinks deeper and deeper into a dream-state. His face becomes expressionless, his eyes staring into vacancy. He makes no response to questions. He pays no attention to his surroundings, to his dress, to his physical needs. He grows anesthetic and analgesic. The cutaneous reflexes are markedly diminished. The pupils are widely dilated, and react but sluggishly. The tendon-reflexes are exaggerated. There are no delusions, hallucinations, or illusions, as a rule, though in some rare instances there may be some transient manifestation of such symptoms. The immobility is flaccid in character, only seldom presenting any indication of spastic tension. For hours and days he will stand, sit, or lie in one place. He is usually speechless, but if an attempt is made to utter an interjection or phrase, the voice is so low as to be little more than the movement of the muscles of articulation. The pulse is small and weak, the heart-action retarded, the temperature subnormal, the respiration shallow.

A peculiar feature of the condition is the occurrence of sudden episodic periods of excitement, with a certain amount of exaltation lasting an hour or two, in which the patient runs about, sings, dances, and talks incoherently.

There are forms of primary dementia which are more or less complicated with melancholia, stuporous paranoia, and neurasthenia.

Course and Prognosis.-The psychosis lasts from a few months to a year or more, and about three in five gradually recover. Most of those who recover show a defect of memory for what has occurred. Some cases recover incompletely, and some undergo an imperceptible transition into secondary dementia.

Diagnosis. The chief difficulty in diagnosis lies in the differentiation of apathetic forms of melancholia from primary dementia. From the expression, attitude, gestures, and speech, one determines the existence of the anxious state or hallucinations which lie at the base of melancholia passiva or melancholia attonita. The history of the patient will distinguish congenital or acquired idiocy from this form of insanity.

Pathological Anatomy.-No physical basis has been established for this disease. It is regarded as a purely functional psychosis.

Treatment.-Mild cases may be treated at home under propitious conditions. At the same time, most of these patients are better off in asylums, where the discipline, regular life, and expert care favor speedy recovery. Rest in bed and overfeeding are requisite at first. Regular hydrotherapeutic measures are of value (at first short warm baths, later on showers and spinal douche). Medicines are of no especial value except in the episodic periods of excitement, when the bromids may be employed, together with hot wet-packs.

CHAPTER XI.

PARALYTIC DEMENTIA.

Synonyms.-Dementia paralytica; Progressive general paralysis; General paresis ; General paralysis of the insane.

Definition. Paralytic dementia, as its name implies, is a disorder characterized chiefly by progressive enfeeblement of the mind, together with a progressive general paralysis of the whole body. It is essentially a cortical disease, but its symptomatology is frequently modified by spinal complications. The psychic symptoms, in addition to the characteristic progressive dementia, present multiform phases, neurasthenic, hysterical, hypochondriacal, melancholic, maniacal, circular, paranoiac, etc. An expansive phase with delusions of grandeur is very common at one period or another in the course of the malady.

Etiology. Intellectual overwork or strain, working on a foundation impaired by syphilis or alcoholism, or both, may be said to be the chief cause of general paresis. Heredity, undoubtedly, plays a part in the causation of this form of mental disorder, though perhaps not so great as in other classes of insanity. The rôle of heredity has been variously computed at from ten to forty per cent. As regards sex, it may be stated that on an average, among all classes of society, twelve times as many males as females are affected the disproportion seems to be less among lower orders of people. The age of onset is usually during the fourth or fifth decad, bespeaking in general the climacteric period of human life. But general paralysis may be encountered at almost any Some fifty cases have been recorded as occurring in children. Occasionally late cases are met with after the age of sixty. It is a common disease in the great centers of civilization, where the intelleetual stresses are most severe, and is comparatively rare among lower races. For instance, it is almost never observed among the native Egyptians. The disease is more frequent among men of ability in professional or business life than among the ignorant and uncultured.

age.

As regards the position of syphilis as an etiological factor, it may be said that a certain history of syphilis is obtainable in at least fifty per cent. of the cases, and it is probable that the true relation is considerably larger. Several years ago, in a study of this subject,2 I examined the contributions of no fewer than seventy authors to the elucidation of this problem. There was wide divergence in the statistics presented ; but from my examination of all these figures, it is fair to assume that between sixty and seventy per cent. of all cases of general paralysis are probably syphilitic.

By a comparison of statistics of the relation of syphilis to all other

"The Insane in Egypt," by the author, "Med. Record," 1892.

2 "The Relation of Syphilis to General Paresis," "Medical Record," Dec. 9, 1893.

forms of insanity, which I have estimated to be from six to ten per cent., we have the further fact that syphilis is seven to ten times as frequent in dementia paralytica as in insanity in general.

The fact is thus established beyond dispute that syphilis is a striking etiological factor in general paresis, but that thirty to forty per cent. of the cases are not syphilitic. It is, therefore, an important, but not exclusive, etiological factor.

A much more difficult problem is to determine the exact nature of the relationship between syphilis and general paresis. Is it a direct cause, or merely a contributing agent? Is it in syphilitic cases a postsyphilitic affection, or is foregone syphilis merely a predisposing factor? The problem may be examined from several standpoints. In the first place, we have the rather remarkable statistics of Lewin of 20,000 cases of syphilis, one per cent. of which became insane, and in which not a single case of general paresis developed. Then we have the further fact, to which I have already alluded, that among the native Egyptians, where syphilis is one of the most wide-spread of disorders, scarcely a case of general paresis has been reported; and in the asylums at Cairo, which I visited a few years ago, not one such case was to be found. It is significant, by the way, that alcoholism is seldom or never observed among them, the drinking of spirituous liquors being interdicted by the Koran. Such facts as these it is impossible to reconcile with a hypothesis ascribing to syphilis the direct causation of paralytic dementia.

Again, from the pathological standpoint, it is well known that the direct invasion of the brain by syphilis is characterized by changes in the blood-vessels (endarteritis obliterans), by the formation of gummata, or by diffuse meningeal infiltration (specific leptomeningitis or meningo-encephalitis). The first and third of these processes are most frequent in and about the base of the brain. The second is more common in cortical regions. On the other hand, in general paralysis we have a chronic meningitis of the convexity with atrophy of the cortex, and the processes in this disease and in syphilis are quite distinct, although there are cases in which a syphilitic meningo-encephalitis may closely simulate symptomatically dementia paralytica. The pathological processes are different.

There are some who assume that tabes and general paresis are frequently associated, and that tabes, being so decidedly a syphilitic disease (ninety per cent.), general paresis must, in consequence, originate from syphilis. The first part of this assumption is, however, not true; and if it were, there is a singular lack of correspondence between the percentages of syphilis in the etiological statistics of the two diseases. The conclusions reached by the writer in the study just referred to are as follows:

1. A history of syphilis is found in sixty to seventy per cent. of cases of general paralysis of the insane.

2. The fact must not be lost sight of that in thirty to forty per cent. of these cases no history of syphilis, congenital or acquired, is to be found.