5. Narrowing of the cortex, with gaping of the fissures.

6. Distention of the ventricles with serum and granulated and thickened ependyma (chronic internal hydrocephalus).

7. Gray degeneration in the centrum ovale, brain-axis, in various columns of the spinal cord, and in some of the spinal roots and peripheral nerves.

The microscopical findings may be summarized briefly as follows: 1. Changes in the vascular walls, dilatation of the perivascular spaces, wandering white and red blood-corpuscles.

2. Increase in number of the astrocytes.

3. In the ganglion-cells: loss of the nucleus and nucleolus, cloudy swelling, shrinking of the protoplasmic processes.

4. Degeneration and disappearance of the nerve-fibers with myelinsheaths, in the white matter and in the cortex, and of the tangential fibers.

The whole cortex is more or less affected, but often the changes are more marked in one area than in another. It is usual to find the frontal lobes especially implicated.

Treatment. In the majority of cases of general paresis commitment to an asylum is necessary, owing to the dangers arising from the patient's excesses. He may squander his property or scandalize his family by his immoral or criminal acts. It is true that cases which present merely the dual symptomatology of increasing physical debility with progressive mental enfeeblement may be, and often are, treated at home. But, on the whole, it is better to act promptly in placing the patient in a place of safety.

The disease being inevitably fatal, there is little to be advised in the way of medication, save symptomatic treatment. It is quite proper, in cases with a history of syphilis, to try energetic antisyphilitic measures-mercurial inunctions and large doses of iodid. If, by any possibility, there has been any confusion of the malady with cerebral syphilis, this will at least serve to remove any doubt. The opium treatment is of value in the periods of depression, and hyoscin, hyoscyamin, or duboisin (gr. to gr.), hypodermatically, in the periods of maniacal excitement. Where epileptiform seizures are frequent the bromids are indicated, and in status epilepticus chloral and starch-water per rectum (gr. xv to 3j of starch water). Chloral combined with morphin is to be recommended in phases marked by hallucinatory excitement.

Little or nothing is to be expected from the many measures advocated by various authors: setons and vesicants to the nape of the neck, painting the neck with iodin, hydrotherapy, physostigmin, ergotin, and trepanation.

Trephining has been resorted to a number of times in the past six or eight years, but seems to have been abandoned as useless. The theory that led to its use was that there might be increased intracranial pressure, but this theory has been discarded for want of evidence.

When dysphagia is present, the patient may require feeding with the tube. In the terminal period of the disorder catheterization and careful efforts at preventing bed-sores are required.

CHAPTER XII.

PARANOIA.

Synonyms. Chronic delusional insanity; Progressive systematized insanity; Primare Verrücktheit; old term, Monomania.'

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Definition.-Paranoia may be defined as a progressive psychosis founded on a hereditary basis, characterized by an early hypochondriacal stage, followed by a stage of systematization of delusions of persecution which are later transformed into systematized delusions of grandeur. Though hallucinations, especially of hearing, are often present, the cardinal symptom is the elaborate system of fixed delu

sions.

The hypochondriacal stage is called by Régis "the period of analytic concentration"; the second stage, "the period of delusive explication"; the final stage, "the period of transformation of personality."

Varieties of Paranoia.-There is one typical form of paranoia to which the main portion of this chapter will be devoted, because it is the type which will be most readily recognized by the student and general practitioner. But there are incomplete or immature forms and atypical variations, which the special student of morbid psychology learns in the course of time to distinguish. Thus, many of those eccentric or queer individuals whom we call "cranks" are rudimentary or undeveloped cases of paranoia. Some idea of the varieties of paranoia noted by authorities may be gathered from the attempts at classification by different writers. For instance, French and Italian authors are inclined to divide paranoia into two great groups-viz., (1) degenerative, with original and late subvarieties, according to the period of life at which the insanity develops; (2) psychoneurotic, with primary and secondary subvarieties, according to whether it develops primarily or secondarily to another insanity.

Ziehen classifies paranoia into two great groups, according to the predominance of either delusions or hallucinations-where hallucinations are the most prominent symptom, he terms the psychosis paranoia hallucinatoria; where delusions are preeminent, he denominates it paranoia simplex. Either form may be acute or chronic. Hence he makes four chief types: (1) Paranoia hallucinatoria acuta; (2) Paranoia hallucinatoria chronica; (3) Paranoia simplex acuta; (4) Paranoia simplex chronica.

This last form is the name given by Ziehen to the complete typical form of paranoia which is described in this chapter, and which he describes as having four stages (prodromal, persecutory, expansive, and pseudodemented). Ziehen also specifies several varieties of acute hallucinatory paranoia-viz., the fleeting-idea form, the stuporous, the incoherent, the exalted, and the depressive forms.

Krafft-Ebing makes two great divisions-original paranoia, appear

ing in early childhood or before puberty, and acquired (tardive) paranoia, appearing between the ages of puberty and sixty years. The latter class he subdivides as follows:

(A) Paranoia persecutoria: (1) the typical form; (2) subtype (paranoia sexualis); (3) paranoia querulans.

(B) Paranoia expansiva: (1) paranoia inventoria and reformatoria ; (2) paranoia religiosa; (3) paranoia erotica.

Etiology. Heredity is a more important etiological factor in paranoia than in any other form of insanity. Krafft-Ebing states that he has never seen a case without hereditary taint. Tanzi and Riva found in their cases of paranoia 77 per cent. of heredity and 9.5 per cent. of infantile cerebral disorders, while in the remaining 14 per cent. hereditary factors could not be ascertained, but were not, of course, excluded. It is more common in females than in males. It affects by preference individuals who are even from childhood peculiar, morbid, shy, irritable, mistrustful, and misanthropic. It is very common to find, in cases of paranoia, some of the various stigmata hereditatis described in the chapter on Etiology, such as cranial or facial asymmetry, malformations of the ear or palate, etc.

Symptomatology.-We will examine the symptoms of the different stages in the order of their development. In the prodromal period, the hypochondriacal stage or period of subjective analysis, as it has been variously termed, which may have its conception in early childhood, the patient is morbidly shy, peculiar, eccentric, avoids the companionship of others, and is prone to withdraw himself into the solitude of his own thoughts. The physiological commotion of puberty and adolescence, with its inflow into consciousness of innumerable new sensations, its flood of new instincts, powers, ambitions, and ideas, tends to intensify the morbid proclivities already evident. The patient notes his own peculiarities of conduct, and begins to recognize the singularity of many of the somesthetic sensations which come to him-sensations which at this time might well be considered more or less neurasthenic in character: paresthesias of the head, trunk, viscera, and limbs; pains in various parts of the body, tinnitus aurium, sparks and dots before the eyes, and the like. The unnaturalness of these sensations leads to his spending much time in contemplation of them, so that a hypochondriacal complexion is given to his thoughts. To these physical sensibilities are now added a consciousness of difficulty in the concentration of his thoughts; a difficulty in the proper control of the direction and subject matter of his thoughts. He becomes extremely introspective, and, the more he studies the somesthetic sensations brought to his attention, the more he contemplates the phenomena of the uncontrollability of his thoughts, of their rising unbidden from his subliminal consciousness, of the unrestrained constellation of his presentations, the more is he inclined to search for some cause of his morbid condition. At first, like an ordinary hypochondriac, he investigates himself to find a solution of the problem, and, failing in that, he extends the region of his observation to his environment, seeking there the reason of his strange feelings, general disquietude, and morbid stream of thought. He be

comes wholly preoccupied with himself. He can not employ himself, either physically or mentally, as he should. as he should. He fails in his duties in everything he undertakes. People seem strange to him in their conduct and in what they say. He grows suspicious and distrustful of everything and everybody. What is done and said by others appears to have some significant relation to himself. People alter in their conduct toward him, look at him curiously, smile sarcastically when he passes, wink at or make signs to one another when he is near; make observations among themselves which, overheard by him, are construed as having a double meaning, as being derogatory to him, reflecting on his character. The more he studies the extraordinary condition of affairs, the more gloomy, solitary, and self-absorbed he becomes. Naturally, the growing alteration in himself really does provoke the notice of others a fact which tends to intensify his ever-increasing suspiciousness of concealed animosity among those with whom he comes in contact. Many things in his past life rise up in his memory to find a new interpretation in the light of his present general distrust. His physical sensations have become more marked, have taken on a new character, have altered from paresthesias to illusions, and even hallucinations, of general or special sensibility. He feels peculiar general sensations, shooting pains, sudden prickings in his skin. Unusual and unpleasant odors or tastes harass him. Extraordinary sensations flow into consciousness from his genital organs. Much more serious and remarkable, however, are the peculiar changes in his auditory perceptions. At first these are usually confused noises, or roaring and tinkling sounds, with the gradual perversion of sounds and words heard into illusions colored by the suspicious contents of the patient's consciousness; later, actual hallucinations of hearing, which become a fixed and permanent feature of his malady.

The patient now enters into the second or persecutory period of paranoia, the period of delusional explication of his troubles. He has arrived at what he conceives to be a logical result of his reasonings, a rational explanation of the distress and affliction he has undergone. Everything he has suffered has been due to the machinations of unknown enemies. The delusions of persecution are at first somewhat confused in character. No particular individual or group of individuals is thus far responsible for the inflictions. It is simply some unknown persons who take pains to manifest ill-will or malevolence toward him. "They" talk against him, call him names, attempt to poison him with gases or by tampering with his food, and try to injure him with electric shocks or by throwing corrosive substances at him. Since wherever the patient may be, wherever he may go, the voices, shocks, poisons, etc., seem to pursue him, he comes to think that no single person could manage so vast a conspiracy. It must be some large aggregation of persons who are concerned in the effort to humiliate, cripple, or destroy him; an aggregation bound together by ties of secrecy, and able to permeate all classes of society. What could such body be but a secret society, an order of Masons or Odd Fellows; some religious or political brotherhood-the Jesuits, Catholics, Protestants, anarchists, or police.

Perhaps some one individual is at the head of the band of plotters, some arch-conspirator, but the work is done by innumerable aides, who employ all manner of means and apparatus to accomplish his ruin. This system of persecutory ideas is built up in the most elaborate way, and the more educated the individual suffering from paranoia, the more wonderful the organization and adjustment of the various parts of the delusional system. The persecutory delusions of other forms of psychoses, such as toxic insanity, senile dementia, and melancholia, may have a certain interest and fixity, but those of the paranoiac are woven together like a romance. The relation of the former to the latter is that of the brief sketch to the serial novel. The telephone, the phonograph, telepathy, hypnotism, and other and more mysterious apparatus and

phenomena are brought into service by the relentless league. I do not know the origin of Du Maurier's conception of his novel, "Peter Ibbetsen," but I suspect that many of its unique features, especially that of "dreaming true," were suggested by conversations with some well-educated paranoiac in a lunatic asylum.

Many patients seek in a most elaborate way to explain one peculiarity of their auditory hallucinations-viz., the fact that their thoughts are read off by the voice or voices simultaneously with the appearance of the thoughts in consciousness. This adds naturally a new terror to the persecution, for the ability of the conspirators to read off and taunt the patient with his own most secret thoughts is a particularly refined species of deviltry, as well as evidence of the extraordinary psychological power of his tormentors. The voice which speaks his thoughts, or answers his thoughts before he can himself utter them, may be referred to the external world or to some part of his own body. This phenomenon has been variously termed echoing of the thoughts, motor representation of articulation, and verbal psychomotor hallucination. It depends upon the close relation existing from earliest infancy between the auditory word-center and the motor speech-center. Any irritation of this auditory area is immediately, synchronously, irradiated to the motor speechcenter. However slight this stimulation of the speech-muscles, recurrent sensations of movement in them are carried back to the brain, giving rise to the hallucinations of internal hearing.

The patient is driven by his delusions to make complaints to the