GENERAL PARESIS, 
OR 
INCOMPLETE PROGRESSIVE PARALYSIS. 
BY 
JOHN P. GRAY, M. D., of Utica. 
ALBANY: 
VAN BENTHUYSEN’S STEAM PRINTING HOUSE. 
1866. GP]N ERAL PARESIS, 
OR 
INCOMPLETE PROGRESSIVE PARALYSIS. 
I propose under this head to treat of a disease of comparatively modern 
origin, at least so far as its recognition is concerned by the medical pro- 
fession, as a distinct form of cerebral disease. Though it has been recog- 
nized under various names for some years, it has not been mentioned in 
works on general practice, and has received little if any attention in the 
lectures of our medical colleges. I shall not here enter into the question 
of its remote or recent origin, or attempt an exhaustive essay, but present, 
as succinctly as possible, a brief outline of its recorded history, its etiology, 
sesmiology and morbid anatomical appearances, desiring rather to direct 
the attention of the general profession to the study of the disease, its grave 
character, and to the fact of iis increasing prevalence in this country. I 
am induced to present the subject before this medical body from two con- 
siderations: first, that of the entire number of cases placed in the asylum 
at Utica, for treatment, since my connection with that institution, but four 
cases have been recognized by the medical men in attendance before admis- 
sion to the asylum; and secondly, that most of the cases have been brought 
to our care by friends in the confident expectation of speedy recovery, gen- 
erally based on the opinion of the family physician. These facts would 
argue that few physicians are familiar with the disease, and that, assuming 
from the presence of certain psychic manifestations, the existence of mania, 
melancholia or dementia, they prognosticate accordingly; for any physician 
having once recognized a disease so marked in its somatic and psychical 
symptoms, and familiar with its character and progress, would give a posi- 
tive prognosis of its fatal issue. 
General paresis is most frequently designated under the name “ General 
paralysis of the insane.” Dr. Saloman, a Swedish physician, has substitu- 
ted the term paresis, as indicating the paresifying nature of the disease. 
By universal testimony, paresis is almost entirely confined to men. Of 
119 cases which I have observed, but 8 were women. 
It seems to be more prevalent in some localities than others. Dr. Skae, 
of Scotland, states that in the Edinburgh asylum, under his care, there are 
generally to be found from 20 to 25 cases, while at Montrose asylum, where 
there is an average of more than 300 patients, there are none. As the 
medical head cf the Montrose asylum was an assistant under Dr. Skae for 
many years, he would recognize the disease. This fact has been observed 
also in America. In the east and north there are more cases than in the 
west and south. 
The distinct recognition of the disease does not date back over 60 or 65 
years, though some maintain that they have found symptoms in the writings 
of several authors and dating back to Willis, in 1672. Esquirol, in 1805, 4 
describes it, and credits Haslam with having first called attention to it. 
Since that period it has received much attention by writers on insanity, 
and especially in France. Some authors, among whom are Esquirol, 
Delaye, Calmeil, Georget, Leubuscher and Leidersdorf, consider that the 
paretic or somatic symptoms are engrafted on various forms of insanity; 
merely a peculiar form of paralysis consequent upon and associated with 
the progress of mental disease. Bayle, Parchappe, Jules Fabret, and more 
recently Saloman, maintain that the disease is a distinct species—a form of 
insanity—and in this view I think English and American alienists will 
agree. Dr. Van der Kolk, one of the latest and ablest among German 
authors, does not recognize general paresis as a disease per se, under this 
or the more generally accepted name, general paralysis of the insane, but 
he gives a most faithful description of it under the head of idiopathic mania; 
so that there can be no doubt of its existence there, and indeed he proves 
its great prevalence in the fact of having so many cases as to induce him 
to group them in one great general division. Some authors have main- 
tained that paresis, or paralytic insanity, might exist without the mani- 
festation of paralysis, and under the term “ ambitious mania,” have given 
some cases. “Ambitious mania” is a very different disease, and only 
resembles paresis in the character of the delusions. If necessary, I could 
present a number of cases to show this. In a discussion of paresis, 
recently, in the Psychological Society of Paris, this point was brought up. 
I quote the remarks of M. Baillerger: 
“ Esquirol, as M. Parchappe still does, regarded all cases of ambitious 
mania as simple insanit}', as long as they were uncomplicated with symp- 
toms of paralysis. Bayle, on the contrary, and with him M. Jules Fabret, 
considers many of these cases as presenting a special form of insanity, even 
before the appearance of paralysis. A case of ambitious mania is reported 
in the thesis of M. Fabret, which was cured after two years duration, with- 
out the patient having presented any evidence of paralysis. But, accord- 
ing to the author, this patient was not the less attacked with paralytic 
insanity, very different from simple insanity in its etiology, in its progress, 
and in its symptoms. The diagnosis was based, in this case, upon the gene- 
ral aspect, and chiefly on the nature of the mental affection, so that the 
paralytic symptoms, which doubtless would confirm the diagnosis when 
they did appear, were nevertheless not necessary to establish it. M. Par- 
chappe, on the contrary, maintains, in this respect, the opinion of Esquirol, 
that in order to constitute paralytic insanity, it is necessary that paralysis 
should be actually present, and until it is present, the case is only one of 
simple insanity. But this difference between M. Parchappe and M. Jules 
Fabret is a circumstance of the greatest importance. Having made this 
explanation it will be easy for me to state, in a few words, the new opinion 
which I wish to see adopted. I am firmly persuaded that almost all cases of 
ambitious mania ought to be separated from simple insanity; but I do not 
agree with Bayle and M. Jules Fabret, that they should be necessarily 
referred to paralytic dementia, of which they may only constitute the form- 
ing stage. They Ought, in my opinion, to be referred to a distinct category, 
under the name of congestive mania. Their relation to paralytic demen- 
tia is the same as that of ordinary insanity to simple dementia.” 5 
The first published notice of this disease, in America, was by the late 
Dr. Luther V. Bell of the McLean Vsylurn for the Insane, Mass. : in his 
annual report in 1843. Dr. Bell had seen the disease in the European 
hospitals in 1840, and though he was not able to recall cases in that asylum 
previous to this period, as probable paralytics of this type, during the 
three years from 1840 to 1843 he had observed not less than twelve to 
fifteen well marked cases. This would infer its previous existence unde- 
tected. Dr. Conolly, an English writer of eminence, in his report of 1849 
says, in speaking of the early somatic symptoms, the slight faltering in 
the speech and a little infirmity in the gait, which he considered the most 
prominent symptoms, that they were only discovered by those who looked 
for them. By this remark he evidently intended to impress the fact that 
they are only apparent on close examination, as he immediately afterwards 
gives a clear account of the psychic symptoms, and says of this early stage, 
“ in all these cases the death-blow is struck from the first.” Dr. Bell says 
his cases, with a single exception, were men, and that none had recovered. 
In the American Journal of the Medical Sciencen for April, 1841, eleven 
well marked cases are given by Dr. Pliny Earle, the present medical 
superintendent of -the State Lunatic Asylum at Northampton, Mass., who 
was in 1847 the medical superintendent of the Bloomingdale Asylum, and 
in nine of these cases post mortem notes are given, with morbid appear- 
ances similar to those we shall hereafter describe. 
The late Dr. Brigham, in an editorial in the American Journal of Insanity 
for July 1847, on paralysis peculiar to the insane, mentions Esquirol as the 
first to call attention to the disease, in 1805, quotes from the report of Dr. 
Bell, and reproduces two of Dr. Earle’s casts and gives some which hud 
come under his own observation, but does not enter into a general con- 
sideration of the disease. 
The reports of all the leading hospitals for the insane, in this country, 
have for years recognized the existence of general paresis. The following 
table shows the number admitted each year into the institution at Utica: 
YEARS. 
ADMITTED. 
DIED. 
Men. 
Women. 
Total. 
Men. 
Women. 
Total. 
1849 
4 
4 
1850 
1 
1 
2 
2 
1851 
1 
1 
2 
2 
1 
1 
2 
1 
1 
1853 
6 
1 
7 
4 
1 
5 
1854 
4 
1 
5 
4 
4 
1855 
7 
7 
4 
4 
1858 
2 
2 
3 
3 
1857 
9 
9 
3 
3 
1858 
4 
1 
5 
4 
4 
1859 
5 
1 
6 
3 
2 
5 
1880 
9 
9 
9 
9 
1861 
8 
1 
9 
10 
10 
1862 
7 
7 
4 
4 
1863 
11 
ii 
9 
1 
10 
1864 
15 
2 
17 
12 
12 
1865 
21 
21 
12 
2 
14 
111 
8 
119 
89 
7 
96 6 
Dr. Joseph Workman, medical superintendent of the Provincial Asylum, 
Toronto, Canada, in May 1865, read a paper before the Association of 
Medical Superintendents of American Institutions for the Insane entitled, 
“ Cases of insanity illustrative of the pathology of general paralysis,” 
which was published in the American Journal of Insanity for July 1856, 
and a second paper, on the same subject, before the Association in 1858. 
The American Medical Monthly for June, 1858, contains a paper on “ Para- 
lysie Generale,” by the late Dr. Ranney of New York City Lunatic Asylum, 
in which several cases are detailed. The American Journal of Insanity 
has reproduced several monographs published in England, France and 
Germany, on the subject. 
Whatever difference of opinion exists as to the precise name this paretic 
affection should receive or as to whether it is a distinct disease or simply 
a complication in other recognized forms, all writers coincide in the descrip- 
tion of the symptoms and progress, and regard the lesions of the brain, 
spinal cord and membranes as the cause of the paralytic phenomena. If 
it is onty necessary, therefore, to show that a certain group of symptoms 
are uniformly resultant from a certain cause to establish the distinct 
character of a disease, this form of paralysis must be considered a disease 
per se. The development of mental disturbance, however slight, with the 
earliest somatic symptoms places paresis in the category of so called mental 
diseases. The uniform and parallel progress of the somatic and psychic 
symptoms and their interdependence would preclude the theory of paralysis 
engrafted on insanity or the converse—and this position, we conceive, is 
strengthened by the fact that general paresis is rarely, if ever, developed in 
the chronic insane. In my own experience of fifteen years, in the obser- 
vance of more than five thousand insane, I have not seen a single case. 
Furthermore the fact that in some sections no cases of paresis occur, 
would add assurance to this opinion, as in the instances already cited of 
Montrose and Edinburgh, both old institutions. 
We cannot admit that there is or can be disease of the mind, but that 
every case of so-called mental disease is disease of the brain, functional 
or organic, and the fact that the connection in life and action between 
mind and body is subtle and incomprehensible is not sufficient for the 
assumption that the mind may or can be sick. It is fair to infer that if it 
may be liable to disease it must be subject to death. Fortunately, how- 
ever, those who would refer such a question to the domain of science, have, 
in the organic changes discoverable after death, a satisfactory reply. Post 
mortem examinations, chemistry and the microscope answer all the 
speculations of materialistic philosophers who would subject spirit and 
body alike to disease and death. 
Dr. Bucknill believes “that general paresis is essentially a disease of 
nutrition affecting the whole nervous system, and that nerve matter, both in 
the vesicular and tubular portions thereof, is imperfectly produced, and 
that the cerebral or generative and the conducting functions are conse- 
quently interrupted.” He sustains this opinion by the fact, first observed 
by him, that in paresis “the irritability of the muscles and the excito- 
motory functions of the nerves are nearly lost, while in ordinary paralysis, 
whether dependent on lesion of the spinal cord or of the brain, these func- 7 
tions are retained.” From this he would deduce the opinion that “this 
disease is not located in any one portion of the cerebro-spinal axis, but 
consists in some morbid change, pervading the whole nervous system, and 
probably implicating the distal fibrils.” Dr. Joseph Workman considers 
paresis “a distinct and essential disease of the brain,” and avers that “its 
claims to this independent status are surely not less clear and legitimate 
than are those of phrenitis, hydrocephalus, delirium tremens or apoplexy.” 
Dr. Soloman, on the essential nature of the disease, remarks: “It is a 
mental disease, and has all the characters pertaining thereto (insania). It 
is an independent form of mental disease, for it has signs, both sympto- 
matic and anatomico-pathological, belonging exclusively to itself. These 
are principally mental and paralytic symptoms, going hand in hand, and 
being progressively developed, with a dissolved state of the cortical 
substance. 
“ Mental disease, whose expression is a disturbance in the action of the 
human mind, can not exist without a morbid change in the organ of men- 
tal activity, viz: the brain. In this change science must seek the cause 
and essential nature of the disease from an anatomico-pathological point of 
view. 
“Two views have been entertained with respect to the essential nature 
of the disease, namely, the French .and the German: 
“1. The French view regards paresifying insanity as an inflammatory dis- 
ease, arising as the result of irritation produced by repeated congestions, 
and causing a disorganizing inflammation. The anatomico-pathological 
names given by French writers to the disease refer exclusively to this 
theory, as, for example, Bayle calls it meningitis chronica; Calmeil makes it 
a perirencephaJo-meningitis chronica diffusa; Belhomme calls it meningo- 
cerebritis; while Parchappe has proposed to term it cerebritis corticalis 
gcneralis. 
“ 2. The German view declares the disease to depend, as is shown by 
demonstrated facts, upon obstructions produced in the vascular walls (in 
the pia mater and cortical substance) by degeneration (hypertrophy), with 
their results, ischaemia and inflammation. The primary cause, therefore, 
is degeneration of the vascular walls, lienee proceeds derangement of 
the circulation, with its consequent disturbed nutrition. The secondary 
cause is a spreading and destructive excessive formation of connective 
tissue in the cortical substance, leading to the destruction of nerve-cells. 
“As long-continued cerebral hypermmia may exist without being attended 
with degeneration in the vessels of the pia mater, and excessive formation 
of connective tissue, it is clear that something more must also be present. 
This additional element is supposed to constitute the peculiarity of the 
disease, and to be of a degenerative nature. 
“ The diffuse periencephalitis (general paresis) presents incontestibly a 
striking analogy to diffuse nephritis (morbus Brightii). The former is 
anatomically characterized by a degeneration in the tissue of the cortical 
substance of the brain, destroying the nerve-tubes and nerve-cells. Clini- 
cally, it is characterized by a profound alteration in the function of the 
cortical substance of the brain. The latter is anatomically characterized 
by a degeneration of the tissue of the kidney, and by alteration in the 8 
urinary canals and Malpighian bodies. Clinically, it is characterized by a 
profound change in the function of the kidneys. In both diseases we 
observe stages of hypereemia, increase of volume, degeneration (softening) 
and atrophy. 
“In the present state of science, we must lay it down that the disease 
consists essentially in a degenerative process in the adventitious mem- 
brane of the vessels of the pia mater, and in the tissue connecting the elements 
of the cortical substance of the brain (neuro-glia), which degenerative pro- 
cess, in its development, causes the change of the grey cerebral cells into an 
inert mass. 
“When the disease has attained its climax, the use of the animal muscles 
is completely abolished, and the vital process is deprived of mind (anima). 
The disease is sometimes developed suddenly, but more generally it is 
insidious and slow in progress in its early stages, and nothing may be felt 
beyond a slight degree of general ill health, a sense of fullness in the 
head, or dulness and drowsiness, until the occurrence of momentary im- 
pairment of speech or slight tingling or numbness in the fingers or arms 
may attract serious notice. There is, however, in most cases, before these 
paretic premonitions, a general hyperaesthesia of the whole nervous system, 
producing restlessness, irritability and increased physical and mental ener- 
gy, and the person works and moves more quicky than natural, is more en- 
ergetic in the performance of labor or business, has better command of lan- 
guage, more rapid flow, and more exalted flight of thought, but at the same 
time he is fitful, wavering and impersistent, and though friends may not 
suspect insanity, they may notice a change of character, and are often 
pained at sudden and rude outbursts of passion, impatience and intolerance 
of opposition to plans. And these exhibitions may for a long time be con- 
trolled in the presence of strangers, but at length, under this increased 
energy and exalted idea of his capacities, he is led, without apparent cause, 
to change his vocation and embark in the wildest schemes and speculations, 
and his insanity is then fully recognized. 
In some cases there is a well-marked stage of stupor and drowsiness 
preceding this excitement, during which the patient complains of cephal- 
algia, of languor and inaptitude for exertion, and of confusion of thought, 
loss of memory and uncontrollable disposition to sleep, During this stage 
there is often a vague consciousness of illness, though the character or 
weight of the disorder is not suspected by the patient or his friends, but 
as soon as the stage of exaltation and excitement supervenes, the patient 
feels strong and vigorous, and persists that he never was so well in 
his life. 
This stage of drowsiness, cephalalgia and consciousness of indisposi- 
tion, preceding that of excitement, we have not seen mentioned, yet we 
have, in personal experience, the most unquestionable evidence that many 
cases are thus initiated, and we believe that the non-recognition of this 
stage is doubtless because patients are not placed under treatment in asy- 
lums during its existence, and the family or friends, giving the history, 
dating the insanity only from the marked symptoms of cerebral excite- 
ment, the preceding history, involving this stage, is not obtained. Careful 
inquiry from those intimately associated with patients during the incipient 9 
period, and in one instance the diary of the patient, and in another the let- 
ters written before insanity was suspected, establish this stage. There 
are cases also where the stage of exaltation and excitement is preceded by 
well-marked melancholia, with more or less confusion of thought and 
manner and indisposition to exercise, and others where melancholia alter- 
nates with excitement. Ordinarily, however, after the preliminary stage 
of hyperaesthesia and restlessness, the patient begins to develop exalted 
delusions about himself, his capacities, his wealth, present or prospective, 
and his family connections, declaring himself stronger, wiser or better 
than any other person. This undue and exalted idea of his own judgment 
leads him to talk of his plans and speculations, which, though whimsical, 
wild and impossible to others, are to him wise, prudent and feasible. 
During the early course of the disease, the sexual desire is often increased 
to such a degree as to occupy the entire thoughts of the patient, and the 
amount of indulgence in some cases mentioned to us would seem impossi- 
ble. There is also in this stage of excitement great increase of appetite 
and active digestion, which are not common in the early stages of ordi- 
nary mania, where the patient desires but little food and feels that he can 
almost do without it, while some actually despise it and appeal to the 
resources of a spiritual nature to sustain them. In general paresis, with 
all the exaltation and grand conceptions, they never desire to lessen the 
quantity of food, though they may be indifferent to the quality. A dispo- 
sition to indulge in intoxicating drinks and in the excessive use of tobacco, 
is also quite general, while at the same time, in these very cases, it is not 
rare to find among the extravagant plans projected, the erection of churches, 
hospitals and asylums, generally of the most expensive character. At this 
stage a slight tremor of the tip of the tongue and ends of the fingers may 
be detected, especially after a period of quiet. As the disease advances 
the man rises in the scale of self-importance. He becomes immensely rich 
and benevolent as well, offers his check for millions, owns all the railroads, 
telegraph lines, &c., is about to be raised to the highest social and politi- 
cal positions, then them; he is a preacher, a doctor, a general, a 
president all at the same time, and not unfrequently the Saviour of the 
world and God himself. In a few cases this stage of exaltation is attended 
with one of depression, when he will whine and cry, declare his enemies 
are trying to steal away his wealth, but in this, as in the stage of exalta- 
tion, his appetite and love of food continue, which is not the case in 
melancholia. 
All these manifestations may appear in a few days, or they may gradually 
develop during several months, increasing and remitting from time to 
time. At this period the somatic symptoms are usually so fully present 
that the disease need not be mistaken for any other form of insanity. The 
tremor of the tongue is now more perceptible. When about to speak, 
there may be observed a peculiar twitching and tremulousness of the eye- 
lids and about the angles of the mouth, and paralysis of the tongue may 
be detected in a thickness of speech, as though the man was slightly intoxi- 
cated, or this paralysis may be detected only in the pronunciation of a few 
words, or in a drawling of speech in uttering certain words or syllables. 
The first stage of the disease, as may be observed, is marked by many of 10 
the premonitory symptoms of mania, yet there are points of difference 
Both forms of disease are produced by more or less disturbance of the gen- 
eral health. In paresis, this is more marked in connection with the func- 
tion of the brain and spinal cord, as exhibited in the increased hunger and 
keen appetite for food, and in the excessive venereal propensity. In both, 
the delusive ideas are expansive, but in paresis they outstrip mania and 
are more incongruous and wild. In mania, there is perversion and sus- 
picion, and false ideas seem to be generated from a false or perverted esti- 
mate of the conduct or words of others, while in paresis there is, from the 
first, a self-consciousness and self-assertion which prevents the patient 
from taking into view the conduct or words of others. His ideas and wild 
plans and extravagant conceptions, spring from increased cerebration and 
nervous energy, as in mania; but in mania the delusive state is from per- 
verted perceptions and conceptions, and in paresis, generally, from expan- 
sive ideas touching the actual business he is engaged in. In developing 
mania, the patient fears opposition and suspects persons are plotting to 
thwart him or outrival him. The paretic has no such fears. His plans and 
schemes are too vast for competition, and his resources of money, wisdom, 
judgment, friends, social and political standing are equal to the magnitude 
of the projects entertained. As for himself, he is the center of all, and 
annihilates all opposition with a word. The delusions of the paretic are 
also progressive, while those of mania are not. The maniac may expand 
as to the number, but not as to quality. 
In paresis, the poor man is first rich by owning a few hundreds, then 
thousands, then millions, then lands without limit. The politician is suc- 
cessful and advances steadily till he exceeds the grandest climax of human 
ambition; then he is Christ and God, and, as in one case which I present, 
proclaims himself the father and grandfather of God. This we know is not 
found in mania. In what the French have called “ambitious mania,” 
which has by some been confounded with paresis, we find the most extrava- 
gant delusions as to wealth and power, but these have been reached at once, 
and associated with them are no indications of paresis. From such supposed 
paretics recoveries are sometimes reported, and in other cases remissions 
or intervals in paresis are reported as recoveries, as recently, by M. Pinel. 
Sooner or later a maniacal paroxysm is developed. Often in a few days, 
at other times weeks and months after tin1 first symptoms appear. After 
this all the symptoms are aggravated. The tongue on protrusion is not 
oidy tremulous, but, if well protruded, is jerked back suddenly, apparently 
and really against the effort of the patient to continue the protrusion. 
There is noticable dullness and want of animation in the whole physiognomy 
of the face. The eyes are generally more prominent than normal. If the 
arm is extended, a tremor of the extremities of the fingers and often of the 
whole hand may be detected. If the patient writes, the letters will be 
angular and scratchy and connecting words and parts of sentences omitted. 
He has more or less difficulty in all detailed actions, such as picking up 
small articles with his fingers, buttoning his clothes, putting his fingers in 
a vest in the general movement of the arms this may not 
so readily appear. His walk is slow, irregular and uncertain, and one foot 
may be lifted higher than the other or drop harder on the lloor, or drag 11 
somewlitit behind, or the walk may be a sort of straddling1 stride, something 
like the walk of a sailor. The restlessness characterizing the earlier period 
of the malady may abate and the patient become qniet in manner, and 
occupy himself in the contemplation of all the good things surrounding 
him—for in this stage they are not only well pleased with themselves, but 
almost universally with everything about them. Their clothing and bed- 
ding are of the finest material. They have the most sumptuous dinners, 
the greatest number of the most charming friends, and the best wives and 
child ren, and often scores and hundreds of each. 
After longer or shorter periods repeated attacks of epileptiform seizures 
supervene, each leaving the patient more and more prostrated and more 
feeble in mind, and not unfrequently in one of these attacks, the scene closes 
in a convulsion or hemorrhagic apoplexy, but more commonly death 
ensues from gradually accumulated serum within the arachnoid, producing 
coma. 
On the diagnosis of paresis, Dr. Bucknell remarks : 
“The diagnosis of general paralysis is practically of the most facile 
sort, although it is not easy to describe in words the slight but pathogno- 
monic changes which speak so forcibly to the practiced eye and ear of the 
observer. The one diagnostic symptom of the early stage of paralysis, is 
the modification of articulation. This is neither stammering nor hesitation 
of speech. It more closely resembles the thickness of speech observable in 
a drunken man. It depends upon a loss of power over the co-ordinate 
action of the muscles of vocal articulation. In many instances the speech 
of the early paralytic is fluent and clear, except in the pronunciation of 
certain words, or sequences of words, which require the neat and precise 
action of the muscles of speech. Words composed of vocal sounds con- 
nected by single consonants are articulated with correctness ; but words 
composed of numerous consonants, with few vocalic sounds, are articulated 
in a shuffled manner, which is perfectly characteristic. The patient may 
even possess the power of articulating these words correctly, if he pur- 
posely attempts to do so ; but if the examiner holds him in conversation for 
a few minutes, the ear will infallibly detect the slight but fatal symptom of 
incurable disease.” 
It is unnecessary to discuss further this branch of the subject, but I 
propose to present a few cases practically illustrative of the symptoma- 
tology, psychic and somatic, of the disease. 
The following cases illustrate in a very marked degree the early stage, 
the expansive ideas, the excessive sexual appetite and indulgence in 
intoxicating beverages. 
Case First. 
G ; aged 50 ; married twice ; father of six children ; temperate 
habits; admitted February, 1804. On admission he had the somatic 
symptoms of speech, twitching at angles of mouth and uncertainty of walk 
well marked ; and his ideas were of the most wild and expansive kind, lie 
wanted to buy the farms on either side of the Hudson fora number of miles ; 
to build a horse railroad from lloosick Falls to Troy ; to dam the Hudson 
and make a great water privilege } to build a large free church, and to 12 
make large donations of money to many of his friends. When told his 
means were too limited, he replied : “Money ! Why I am all money—can 
command millions and issue checks whenever I please, and they must be 
cashed. My name is good everywhere.” 
On his way to the Asylum he tried to kiss every woman he met, and 
proclaimed his intention to marry all the women in the world, and raise fifty 
million of children. Offered also to take people’s “ insides ” out, or to take 
their heads off and replace them by new and much better ones. Thought 
also he could raise the dead and kill people and bring them to life again. 
Had also the delusion that he could make a flying machine, by which he 
could sail through the air, propelled by perpetual motion. Said that by 
eating half a ton of coal and drinking a barrel of water he could “ steam 
up” (to use his own words), “and go to Heaven and bid God good morning 
before breakfast.” He ate enormously of the most nutritious food. 
All these symptoms were developed suddenly about four months prior to 
his being brought to the Asylum, and were initiated by a great debauch in 
New York ; a thing hehad never been guilty of before. Such is the history 
obtained from a friend of the patient who brought him to the Asylum. His 
wife visited him about three weeks after admission and gave the following 
additional history : 
She said her husband’s health had been gradually failing for more than 
a year before the attack. He had complained of languor, severe pains in 
his head, and unusual heat of body generally. At times he appeared much 
abstracted ; and at other times irritable, excitable and sleepless. And this 
condition was nearly always followed by great drowsiness, so that he would 
often fall asleep while people were talking to him. During this time 
attended to his business steadily and successfully. During all this time 
was very anxious. After five or six months his restlessness, nervousness 
and irritability increased, and he had what he called “shocks” about his 
throat, inducing a sensation as though some one caught him by the throat. 
In one of these “ shocks ” he lost his voice, and ever afterwards had a 
“ trembling” in speech. At this time he had a constant desire to micturate ; 
he increased in flesh rapidly. 
His appetite was keen add voracious. His hands and fingers became 
quite tremulous, and he walked with feet wide apart and faster than usual, 
as though he was balancing himself. 
In the spring of 1863, from being cautious and prudent, became extrava- 
gant in ideas, and proposed expensive and unnecessary changes about the 
house. From being kind and genial in his family, became selfish and 
indifferent. Up to this time still attended prudently and cautiously to busi- 
ness. His head ache continued. Occasional attacks of diarrhoea came on 
which relieved his head ache and left him more composed and rational. 
In May, and subsequently, he had hallucinations of sight, whether his 
eyes were opened or closed. He saw beautiful moons, stars, flashes of 
light, &c. These he continued to describe up to October. During the 
spring and summer was subject to night sweats, often wetting his shirt 
and sheets thoroughly. Towards the fall his sexual appetite diminished 
very much, although he talked about women in a way to indicate the 
opposite of this. 13 
This, it will be seen, brings us to the time at which the final explosion 
took place, and at which the history first detailed commences. 
This case has run and is now running the usual course. lie has con- 
tinued to maintain the same general range of delusions with little varia- 
tion, except that as he becomes more demented he has fewer notions, and 
the few he has are less active. 
The somatic paresis is also gradually increasing and he has had four or 
five slight apoplectic seizures, rendering him unconscious for a short time 
at each attack, and leaving more or less paralysis of left hand and side. 
lle appears now to have arrived at the third stage of the disease, but has 
not yet passed through the period of excitement common to the second stage; 
and we apprehend he may gradually fail and the case terminate without 
excitement. He eats largely and voraciously ; he sleeps well and is very 
fat. His bowels are very torpid and require laxatives every week at least. 
,T ; male; aged 53; married; 7 children; merchant; temperate habits; 
admitted, November, 1804. A sister once had a maniacal attack, and a 
cousin was insane. 
lias suffered from chronic catarrh for sixteen years. Has frequently 
complained, during the past year, of sensation of fatigue, difficulty of con- 
centrated mental effort, loss of memory, particularly of recent events, 
failure of eyesight (amaurosis?), occasional rigors (nervous?). Three 
weeks ago remarked that he must have had a stroke of palsy in the night, 
as he had awaked cold, clammy, feeble, with a stiffness in the left side, 
some difficulty of articulation, and inability to “ collect his thoughts.” 
This condition was not such as to attract any special notice until the 3d 
inst. At one o’clock in the morning he was wakeful and restless, and on 
being interrogated, informed his wife that he was contemplating the build- 
ing of a very large hotel, which he would commence in the morning. At 
3, a. m., complained of inability to sleep, said he would take a walk and 
left the house. Was discovered some hours later making bargains for the 
contemplated edifice; drew check on bank for 82,500, and offered to bet the 
amount on either side in the impending election. The same day attended 
a political meeting, and on returning home at night asserted he was the 
richest man in the county and the State; he was a Governor, President, 
Saint, King, Washington, a God. Was seen by his physician the next 
evening when he was maniacal, with quick, rapid pulse, flushed face, hot 
head, etc. On being restrained, became violent and destructive, artd was 
bound and shackled. Was bled 16 oz., cathartics given, blistered on nucha, 
and then ordered potassi iiodidi, gr. v, ter in die. On Thursday, in a struggle 
with his attendant at home, dislocated from his spine the 6th, 7th and 8th 
ribs. Brought to the asylum to-day, and has cough, difficult respiration 
and bloody expectoration. November 22d. Quiet most of the night. Visi- 
ted this morning by wife and friends. At noon refused food, swearing he 
would eat no more here. Threw off his coat and threatened to slay any 
one who opposed his departure. 23d. Last night destroyed his mattrass; 
noisy; talking in exalted, incoherent manner of his wealth, power and 
graudeur. 29th. Quiet-since last note, but incoherent and exalted in his 
Case Second. views. December 2d. Says Governor S. has been to see him; that he (pa- 
tient) has been twice killed; that this institution is a d—d place which he 
built and carries on as he pleases. Accuses a fellow-patient with having 
destroyed his property, and wants it charged to him. Takes anodynes. 8th. 
Every afternoon at 2 o’clock his face is flushed, head hot, and he is drowsy; 
this followed by reaction, restlessness and loquacity. 24th says the world 
will, by his command, be destroyed next Saturday. 30th. visited by wife. 
Soon after her departure he became noisy and abusive of his wife. Last 
night he was up, kicking the door, throwing bed about the room, etc. 
January 25th, 1865. Delusions unchanged; paresis of muscular system, 
tongue, etc., increasing; appetite voracious; has no realization of his con- 
dition. February 2Tth. Quiet, but ideas the same. April 22d. Quiet since 
last note; at times reads or plays dominoes. July 7th. Discharged “ unim- 
proved,” by request of friends. 
14 
B ; aged 32; married; no children; real estate broker; common edu- 
cation; a great smoker from boyhood, and for several years a bon vivani; 
was admitted November, 1804; had been stout and robust from childhood; 
was regarded as somewhat eccentric; noted for his irritable, capricious and 
emotional temperament. At the age of puberty he fell into the habit of self- 
abuse, and continued it more or less up to his marriage, two years before his 
admission; although he was known to have frequently indulged in sexual 
excesses during this time. Two years before admission he was married to 
a young woman 14 years his junior, and during the honeymoon he made 
many presents to her and her friends, and spoke much and in glowing 
terms of his future business prospects. 
His friends thought him a little peculiar, but never suspected his mental 
capacity. lie managed his own business prudently, but was lavish and 
extravagant in his expenditures for domestic purposes. 
In nine months more he became gradually restless and nervous, and 
engaged in petroleum speculations, and sundry other more extravagant 
things. About this time became very suspicious of his wife, and insisted 
on having her with him wherever he went. Began at this time also to 
exhibit all the usual paretic symptoms of the muscular system. 
His wife informed us that his sexual appetite was beyond all bounds for 
a year after marriage, insisting in cohabiting three, four, or more times, 
even eight, in succession; but part of this time he could not contain him- 
self ui*til intromission was effected. The more incompetent he became in 
this respect, the more excessive his appetite appeared to grow, and his wile 
was obliged to leave him and go to her friends. 
On admission he was greatly demented and scarcely able to walk. His 
speech was very slow and indistinct, and his appetite large. The few ideas 
he yet had were gloomy and depressing; he thought he was rotten inside, 
or transformed Soon after he came he refused food under the delusion he 
was dead. Was very helpless and filthy, addicted to self-abuse and had to 
be restrained. Under generous diet, with ale and cod liver oil, he improved 
in health and began to grow fat. He is now much demented. 
This case well exhibits the peculiar temperament most liable to the dis- 
Case Third. ease, its early stage, the exaltation and ideas of wealth, the excessive 
appetite for food and spirits and the gradual somatic paresis. It also 
shows a great change from exaltation to depression, and also excessive 
venereal appetite. How much these excesses may have had to do with the 
induction of the disease, we would not venture to conjecture, but that they 
may have been sufficient there can be little doubt. 
15 
W ; admitted April 18G1 ; aged 48 ; married ; nine children ; 
produce, cattle and real estate dealer ; strictly temperate ; of quiet domes- 
tic habits ; a strong, vigorous man ; occasionally has sutiered from sick 
headache. Two years ago had an attack of inflammatory rheumatism after 
which had sick headache. Several months before admission suffered con- 
siderably from rheumatism, but was unusually active and speculative. 
Friends did not suspect insanity but were anxious about him, as they feared 
he would go too far, and lose his property, which was large. lie talked well 
but extravagantly ; was early and late at business ; sleepless ; ate largely 
and in harmony with his increased energy and work. Became excessive 
in sexual indulgence*, and made overtures to his servants which were so 
antagonistic to his character that they thought he had been drinking. 
This excitement steadily increased, and from being reticent about his 
business affairs, he »egaa to talk them to every one, boasted of his wealth 
and influence and proposed the most extravagent speculations. One day 
he burned a lot of bank notes to show his indifference to small things, and 
when the act was characterized as foolish, and that no one would gain 
thereby, he replied, “yes they were greenbacks, and the government will 
gain by it, and I can afford it.” His physician says that at this time his 
rheumatism disappeared, and he suddenly developed furious mania. Ilis 
delusions of wealth and power were of the most extravagent character, 
lie was taken to an asylum, but paresis was not suspected. Soon after- 
wards he was brought here. 'The paretic symptoms were all well marked. 
He entered the ward quietly, but subsequently proposed to leave, and when 
again told that he was to remain he declared he would take the house 
down. In a few days he became maniacal, and this state subsiding, he had 
several epileptiform seizures. After this he was comparatively quiet, but 
the somatic symptoms increased, and his delusions became more and more 
extravagant. He had purchased California, Texas and Illinois, which he 
was about to plant in onions. Had 1,000 horses which increased to 
40,000. Had five millions of men working for him. Had constructed a 
ship canal from Chicago to San Fransisco, and contemplated carting the 
Rocky Mountains into the Atlantic ocean to make a bed for a railroad to 
England; the removal of the asylum to his home for a residence, which 
at one time he would propose to draw with two mules, at another he 
would draw it himself, and start the next morning ; that he would marry 
the Queen and Jenny Lind and set up a harem, and out rival Brigham Young 
in wives and children. 
He had epileptiform attacks which increased in frequency, and at length, 
seven months after admission he died apoplectic after a scries of these con- 
vulsions. 
Case Four. 16 
D ; admitted August 1864 ; aged 57 ; married ; three children ; 
shoemaker ; good habits. 
This case came on gradually much as the others, but after the appear- 
ance of the marked somatic symptoms, progressed rapidly, and he died nine 
months after the attack, entirely paralysed. The striking feature in this 
case was the occurrence of priapism for several weeks before death, and 
the almost constant discharge of seminal fluid diluted with mucus. 
The following cases illustrate the intervals or lulls in the progress of the 
disease which sometimes occur, and the consciousness of illness. 
Case Five, 
Case Six. 
C ; admitted January 1857 ; aged 34 ; married ; physician ; intem- 
perate ; smokes and chews ; academic education ; not religious ; native 
of New York. Hereditary ; paternal grandmother insane. 
Was a healthy, intelligent child, but was indulged at home to his own 
detriment. At the age of 18 was an egotist, a profligate and a spendthrift. 
Graduated in medicine at the age of 22, but did not succeed rapidly in prac- 
tice. Was infidel in his notions and low in his associations. 
Letters written by patient August 1855, show mental derangement ; an 
exalted affection for his family, wild notions of fame, great boastings and 
slight disconnectedness of ideas. Subsequent to this, nothing learned as 
to his condition until the spring of the following year, when he became 
dejected, remorseful, accusing himself; gave up drinking ; became taci- 
turn, seclusive, meditated suicide (melancholia). At present appears in 
good physical condition ; eats heartily and sleeps fairly. Has all the 
somatic symptoms of paresis. 
Condition in April ; that of a paretic dement, is taciturn, filthy, &c. 
Between this and November he had one or two maniacal paroxysms with 
great prostration. During this period tonics and stimulants were adminis- 
tered. 
In November he began to improve, and by the 15th of the following 
June he was removed by his friends, they thinking him well, and went 
home to resume his practice as a physician. It is proper here to state that 
we informed the friends that this was but a treacherous lull in the disease, 
and that its return at no distant day was certain. 
Patient was re-admitted on the 20th of May, 1859, (18 months). His 
history during his absence is briefly this. During the summer he was 
indoleht, taciturn, irritable, apparently disheartened at having nothing to 
do. In the fall of 1858 he visited this asylum, and applied for the 
situation of assistant physician. At that time was thought by his friends 
to be well enough to attend to professional duties if under some supervi- 
sion, but not well enough to conduct a general practice. About three 
months ago, his irritability left him, he became exalted, held delusions of 
wealth. Is now exhilarated and excited. 
June 10. Is very filthy, chewing rags and shavings from spitboxes. 
July 26. Two days ago, first symptoms of simple sanguineous cyst 
(hfematoma auris) occurred—effusion in three days and ridges and depres. 
sions of ear quite obliterated. July 31. Tumor fluctuating. There has 17 
been little or no pain, or any modification of mental state since ear trouble 
began. Patient’s conversation seldom turns upon himself, and he apolo- 
gizes when he speaks of himself as “the best physician in the world,” 
excusing his selfishness, &c. A few days ago bit his attendant in the arm. 
Is destructive, filthy, occasionally requiring restraint. Tumefaction of ear 
not abated but rather augmented. August 2 Filthy, smearing wall with 
feces and defiling room. August 8. Asserts that he is the “grandfather 
of (fid Almighty. That dame nature is his wife—that he formed her out 
of the most precious materials, jewels, diamonds, butterfly’s wings, &c., 
which he made with a forty horse power.” Says he “died once of bilious 
cholic—was buried for fifteen years, corruption taking place, but that an 
angel came down and resurrected him.” August 14. lias slept badly for 
some time past. Is up *md about room much of the night; when spoken 
to of his wakefulness, insists that he has the most perfect repose—that it 
seems as though he could not sleep enough or keep his eyes open a minute 
at night. August 29. Appears feeble this morning; slept none last night, 
was delirious and noisy. September 6. Up to-day. Talks incoherently 
and incessantly—is destructive of clothing. January 7, 1860. Another 
maniacal paroxysm. 11th. Occasional attacks of diarrhoea. February 17. 
Excitement abated—emaciating. Takes ol. jec. asal; is destructive. March 
24. Complains of itching of face, which he picks and wounds unless he 
wears camisole. Emaciates in spite of ol. jec. During April no special 
change. May 3. For past two months there has been a remission in the 
maniacal excitement—conversation more rational—absence of character- 
istic delusions but mind more feeble; manner listless; habits still filthy at 
times; perversion of taste; no control over sphincters; emaciating; right 
lower jaw tumefied; asks to go home. May 8. While sitting up this a. m. 
had epileptiform seizure, resulting in slight facial paralysis. Is more feeble 
and failing; ordered special night attendant. May 10. Died suddenly 
this A. M. 
Case Seventh. 
15 , admitted December, 1863, with all the symptoms of paresis well 
marked. In the early part of 1863, for four or five months, was drowsy 
and dull, but these symptoms did not then attract attention. When the 
stage of exaltation developed, lie left home, entered into speculative 
schemes and lost property. Subsequently went to a neighboring State and 
enlisted in the cavalry service. His wife found out his whereabouts, and 
endeavored to obtain his discharge on the plea of insanity, but failed; the 
officer insisting that he was at times only under the influence of intoxica- 
ting drinks. In a short time, however, he became noisy, incoherent, and so 
manifestly insane, that he was discharged and immediately brought home. 
On admission all the somatic symptoms were fully manifest. His appe- 
tite was keen and large, digestion good, and he presented the appearance 
of a man in full health. The tremor of tongue and fingers was very per- 
ceptible and bis speech characteristic. lie had exalted delusions of wealth 
and power. The delusions soon subsided and the paretic symptoms soon 
receded, lie spoke of his former state and present condition, his difficulty 
of speech, uncertainty of gait, loss of memory and of power of attention at 
times, and in power of thinking. He, however, did not manifest an appre- 18 
ciation of his clanger, and this could not be impressed upon him. He was 
confident and hopeful—went out in the garden to work in the spring of 
1864, and though we could detect by examination the continuance of the 
paresis, to ordinary observers he seemed well. His conversation was 
rational. He eloped in May, and on reaching home seemed so well that his 
friends wished him to remain. He worked through the summer, and though 
he continued muscular and stout in appearance, he was not able to accom- 
plish a great deal. In the fall all the somatic symptoms began to increase. 
He at length requested his wife to secure his return to the asylum, and 
while arrangements were being made, he left home and came here and 
begged to be received at once, stating that he “ was sick and losing his 
mind again.” Since then he has had several epileptiform seizures, and is 
now so paralysed that he is unable to dress or undress. He is serene and 
comfortable—dementing—yet he is conscious of his condition, and has had 
other patients write letters for him in which he informs his wife of his pro- 
gressive illness and loss of mind. 
We have as yet little positive knowledge touching the predisposing or 
prominent cause or causes of this terrible disease. In many cases there is 
strong hereditary tendency to other forms of insanity or other cerebral dis- 
eases, and most of these patients have been nervous or excitable people, 
manifesting in health great buoyancy, vivacity and mobility of mind. 
As a prominent cause it was thought formerly that intemperance stood 
foremost, but it is found that some of the most marked cases were through 
life of the most strictly temperate habits, up to the period of attack, and 
that, in such cases, intemperance was only a result of the disease. Some, 
however, have been intemperate for years. Two of those admitted this 
year were not only intemperate from boyhood, but always exceedingly sus- 
ceptible to the influence of ardent spirits, so that in their best state of 
health a comparatively small quantity would set them wild and almost 
delirious. 
We have nothing to offer in the way of treatment beyond the general 
statement that this class require a large amount of nutritious food in all 
stages of the disease. Active treatment, after the disease is fully devel- 
oped, blisters, setons or low diet only procure discomfort and hasten 
death. The treatment should be sustaining in the sense of nourishing and 
sustaining the system and securing sleep. 
On the pathology much has been written, but with little satisfaction. It 
is true that post mortem examinations, under the naked eye and under the 
microscope of distinguished observers, exhibit much that is interesting to 
the pathologist; yet there is no pathological condition sufficiently grave 
and constant to account for the manifold symptoms. Moreover, the condi- 
tions we are mainly limited to, in our examinations, are not the exponents 
of the early symptoms, but the termination of a long chain of disordered 
action, which, though revealing ample cause of death, does not enable us, 
by any process of inductive reasoning, to reach a satisfactory explanation 
of the conditions inducing the disease. 
I have not followed the general rule of dividing into stages, because I 
have not sought to present an essay on the disease, but simply, as already 19 
stated, to give an outline and sketch, witli some cases which might induce 
more careful observance of the early symptoms, by the general profession, 
and stimulate the study of the disease, that one might, if possible, solve 
the question as to the conditions in which it has its origin. Until this is 
done it will remain, as it is now, the opprobrium of the profession; for after 
actual lesion of structure has taken place, as indicated in the paralysis of 
the tongue, we cannot hope to do more than palliate and delay, or smooth 
the inevitable road to death. 
I have not dwelt on differential diagnosis, though I took occasion, while 
noticing the early stage, to point out some distinctions between the devel- 
oping symptoms of mania and paresis. This, I think, is the only stage in 
which the two affections are likely to be confounded. The early stage, and 
especially the premonitory symptoms, should receive study and observa- 
tion. There is, unfortunately, no want of material to perfect the history 
and character of the disease, and its fatal issue after the paretic mani- 
festations. 
The diseases with which paresis has been confounded are apoplexy, 
chronic alcoholismus, and paralysis from muscular atrophy, and I cannot 
do better than present the remarks of Salomon upon this point: 
“1. Apoplexy.—In a slighter attack of apoplexy, where the paralysis 
affects the tongue, it is exclusively or predominatingly unilateral, on which 
account the tongue turns to one side when it is protruded. Hemiplegia, 
paraplegia, &c., present not the slightest similarity to general paresis, for 
in such cases the paralysis is complete in the parts of the body affected, 
and moreover is partial and not general. 
“ 2. Alcoholismus Chronicus.—General paresis has almost invariably 
been confounded with this toxical disease. Even in the present day French 
writers especially confound these diseases, in consequence of insufficient 
acquaintance with chronic alcoholismus. 
“The group of symptoms included under the denomination dementia 
paralytica, belongs essentially to paresifying insanity, but it may also be 
met with in chronic alcoholismus, when the latter has attained a higher 
degree of development. A man may arrive at dementia in many ways; 
dementia, with bodily paralysis, he may reach especially through general 
paresis or chronic alcoholism. When the patient has already reached the 
goal, it may often be difficult to say immediately, from the existing symp- 
toms, in what way he has attained to it; but when information is afforded 
as to the cause of the disease, the decision is as easy as it is certain. 
“The principal feature of the differential diagnosis is to be found in the 
dissimilar starting-points of the diseases. General paresis proceeds from 
a morbid process in the fine membranes of the brain; chronic alcoholism 
from a general intoxication. In the former case the physical symptoms 
occupy the first place; the degeneration of the mind tends to produce that 
of the body. In the latter, the paralytic symptoms are the first; the gene- 
ral intoxication of the body tends to the degeneration of the mind. The 
dissimilar etiological source of the diseases differentiates them in a decided 
manner. A person who has indulged in an excessive use of brandy at 
length becomes poisoned, and, in consequence thereof, becomes the subject 
of chronic alcoholism, but never of paresifying insanity. If he has, at the 20 
same time, indulged in enervating excesses, particularly in those of a 
sexual character, he may, in addition to his chronic alcoholism, acquire 
general paresis. 
“ 3. Paralysis from Muscular Atrophy.—This disease has been confounded 
with paresifying insanity. If this mistake is still made, it is attributable 
to deficient scientific knowledge in the physician. The diseases have this 
in common, that in both progressive paralysis proceeding from the muscu- 
lar system occurs. In other respects they are wholly dissimilar. In the 
one the seat of the disease is in the brain; in the other it is in the muscles. 
Paretic patients may, under the influence of delirium, employ their muscles 
in a very violent manner; such a patient may dash in pieces the door of 
the room in which he is confined. A person suffering from paralysis from 
muscular atrophy does not rave, and, in consequence of the degenerated 
state of his muscles, cannot be violent.” 
He might have added that in paresis, even in the third stage, after a 
period of days and weeks of the most helpless paralysis, patients some 
times so far apparently improve as to get up and walk about, and occasion- 
ally suffer a maniacal paroxysm, whereas in paralysis from muscular atro- 
phy no remissions occur. 
Dr. Saloman describes the disease under four stages: 
1. The stage of mental alteration. 
2. The stage of mental alienation. 
3. The stage of dementia. 
4. The stage of amentia—paralysis of mind—complete dementia. 
This is perhaps as acceptable as any, however, I have not always found 
found it easy to mark the stages as arbitrarily as these divisions would 
demand. 
There is unquestionably a stage of alteration in which the character, 
habits and physical condition are abnormal, and in many cases the de- 
velopment of mania is sudden, but in others the transition is gradual from 
a changed state, not of a marked character, to an exalted or delusive state 
of mind and increased energy of body, and this state merges slowly into 
one of pronounced paresis; sometimes the somatic symptoms, and at other 
times the psychic symptoms first appearing. Now these latter cases indi- 
cate the true character of the disease—its progressive nature; that it is not 
general paralysis, but paresis; a paresifying disease; an incomplete but 
constantly increasing paralysis. The cases coming on thus gradually, run 
a more regular course and live longer than others. 
I shall present a few additional cases, observed in the asylum at Utica, 
with post mortem notes, with the pathological views entertained by some 
of the most prominent and distinguished writers and observers. 
J. D., cabinet-maker, aged 38, of intemperate habits, entered the asylum 
on the 18th July, 1854. He had then been insane for six months; “had 
been strange in his appearance and talked foolishly,” had manifested 
exalted delusions respecting property, and had an impediment in his speech. 
When admitted was, apparently, in good physical health, was rapid and 
skillful at his handicraft, which he pursued for several mouths in the asylum 
Case One. 21 
workshop. During the fall lie was attacked with epileptiform convulsions, 
accompanied hy maniacal excitement. One of these attacks was attended 
by htcmatoma auris. The paroxysms subsiding, left him with marked 
paralysis of the lower extremities, greater difficulty of speech and degluti- 
tion, and more prominent delusions ot wealth, power, and happiness. By 
the spring of 1855 he had so far improved that he could dress himself and 
take out-door walks. The following summer he emaciated, but was free 
from maniacal attacks. With winter the paroxysms returned, but the 
excitement was of transient character, and the intervals characterized by 
greater mental and motor impairment. In the spring of 1857 the stage of 
dementia was reached, and from this time until his death in June 1858, he 
was bed-ridden, and presented the usual characteristics of the concluding 
epoch of this disease. It is a curious circumstance, that on the day pre- 
ceding death, heematoma auris again occurred, and this time in both ears; 
the cysts forming simultaneously and within a few hours. 
Head and spinal cord examined.—The white and grey substance of the 
hemisphere generally presented a healthy appearance. There was some 
dear scrum in the lateral ventricles, and a considerable collection also of 
serous fluid, strongly tinged with blood, in the cavity of the spinal sheath. 
The bloody exudation here had the appearance of a post-mortem transuda- 
tion. The meninges of the spinal cord were also stained of a reddish hue, 
apparently from the same cause. Otherwise, the meninges, both of the 
brain and spinal cord, were natural. 
There was a very remarkable induration of the substance of the tuber 
annulare, on each side of the median line, which could be easily traced by 
the fingers, and even resisted distinctly the edge of theknife. This indura- 
tion was not situated in the superficial layer of transverse fibres, form- 
ing the pons Varolii, but deep in the substance of the tuber annulare, and 
occupied precisely the track of the anterior columns of the cord, as they 
pass upwards from the medulla oblongata towards the crura cerebri. There 
was a similar induration of the two olivary bodies, even more strongly 
marked than that of the tuber annulare. The anterior pyramids were not 
indurated to any appreciable extent, and the remainder of the medulla 
oblongata and spinal cord were unaltered in consistency and texture. The 
induration of the nervous matter was not accompanied by any fibrinous or 
purulent effusion, or by any appearance of an inflammatory character. 
Microscopic examination of the parts above mentioned, showed the natural 
elements of the nervous substance, both white and grey, presenting a nor- 
mal appearance. In the substance of the tuber annulare there were some 
fatty granules and oil drops, but not very abundant. Weight of brain was 
two pound and ten ounces. 
J. C., music teacher, aged 34, for several years past had been intemperate 
and had practiced vicious habits. Admitted to asylum July 14, 1856. Had 
then been months insane. Patient entered the ward for convalescents, 
where he behaved with propriety. He soon evinced inordinate eating1 pro- 
pensities, and laughed and talked boisterously, engaged eagerly in the 
musical entertainments and amusements of the patients, rarely alluded to 
Case Second. 22 
his delusions in conversation, but filled letters with extravagant descrip- 
tions of his wealth and future expectations; was very particular as to his 
dress and personal appearance, and often surveyed himself complacently 
in the mirror. He soon exhibited slowness of utterance and unsteadiness 
of gait. He generally occupied a seat with the choir in the chapel, but 
found much difficulty in applying words to music. In October ’51, fifteen 
months after admission, he had an epileptiform convulsion. These seizures 
recurred at short intervals, and were attended by transient excitement or 
bewilderment. The ideas became more expansive, and the paralytic phe- 
nomena more noticeable. By August, ’58, had become quite demented. Iu 
September, was unable to walk, lost control over sphincters, was deficient 
in power and consentaneous action in upper extremities. His appetite was 
good. During the following month he emaciated, and was singularly 
wakeful. On the 2d of November he appeared brighter, attempted to con- 
verse in a lively way, called for a bottle of wine, exhibited less difficulty 
of articulation. During the morning of the 2d, appeared much as on tlie 
the 3d—he talked, ate well, and his pulse was of good strength. Later in 
the day he had an epileptiform seizure, with slight muscular tremors and 
contraction of extremities and about mouth, face drawn down towards left 
shoulder, pupils unaffected. The following day his condition was the same 
—mouth firmly shut, eyes fixed and staring. He died on the 5th. 
Examination of brain.—The entire brain has a strongly marked dusky or 
cineritious look, not owing to any venous congestion, but apparently due 
to a change in the color of the brain substance. There is no unnatural 
appearance about the meninges. There is a little more serum in the ventri- 
cles than usual, but not enough to exert any serious impression on the 
brain. The consistency of the external portions of the encephalon is natu- 
ral, except in the olivary bodies on each side the medulla oblongata, and 
in the tuber annulare on each side of the median line. At these situations 
there is a well marked hardening, rather less pronounced than in cane one, 
but still very distinct. On cutting open these parts there is, however, ibo 
unnatural appearance appreciable to the eye, and the microscopic anatomy 
is also normal so far as can be ascertained; no fatty degeneration, no 
morbid growth, no perceptible alteration of nerve-fibres or cells. There is 
no hardening of anterior pyramids as iu case one. The hardening in tuber 
annulare is not superficial, but deep-seated. In the cerebellum the dis- 
tinction in color between the inner and outer layers of grey substance is 
exceedingly well marked, but microscopic appearances here, also present 
nothing abnormal. White substance both of cerebrum and cerebellum 
generally, natural in color and consistency, but there is some softening 
(not excessive) of fornix only. 
W. M., aged 41, merchant, temperate habits. Admitted October 18, 
1857. One year before, while in Germany, he began to make improper 
purchases of goods, in selling was careless as to security for payment, and 
speedily involved himself in financial ruin. Had a period of depression 
lasting two months, during which he drank to the extent of four or five 
bottles of champagne daily. Was careless in dress, wandered about from 
Case Three. 23 
place to place, and was at last sent to the asylum at Wurtemberg. There 
he remained four months and left “ unimproved.” Two months ago he 
came to America, and has since been quiet, free from excitement, indiffer- 
ent to his family and himself. Has manifested gradual impairment of 
speech, and his gait has at times been feeble and paralytic. He has, how- 
ever, had no convulsion or paroxysm, and general health has been well 
sustained. The delusions are of an exalted nature ; he desires to return to 
Germany where an inheritance of millions awaits him, and will start off by 
day or by night to take the nearest road to his Germany, which he thinks 
a few hours travel on foot will enable him to reach. His present state is 
one of paralytic dementia. He manifests a feeling of great comfort, but 
has no appreciation of distance or time, and his memory is impaired. The 
left pupil is more dilated than the right, the left side is weaker, and he 
grasps more feebly with the left hand. Soon after entering the asylum he 
was seized with epileptiform convulsions. These recurred from time to 
time, and were accompanied rather by transient cerebral erethism than by 
true maniacal excitement. He gradually sank into a condition of more 
profound mental degradation and paralysis, and died in September, 1859. 
Examination of brain and spinal cord 12 hours after death. Slight putre- 
factive odor. Superficial redness over lateral parts of middle lobes of both 
cerebral hemispheres—most marked on left side. This redness apparently 
due to a post mortem settling of blood in the parts. No coagula or other 
unusual exudations about surface of brain. Arachnoid of natural moisture 
and polish ; no marked opacity or thickening anywhere ; brain everywhere 
firm to the touch externally, excepting just at junction of middle and 
posterior lobes ; here it is a little soft and yielding. Under surface of brain, 
has a more distinctly putrefactive odor, and projecting portions of anterior 
and middle lobes inferiorly, have a greenish slate color. Vessels of pia 
mater, internal carotids, and other arteries at base of brain, have a natural 
appearance. On slicing brain from above downward, its cut surface has 
a very distinct dusky or slaty hue, which becomes lighter and more fresh 
colored after a few moments exposure to the air. Substance of cortical 
medullary portion quite firm to touch, remarkably so considering the com- 
mencing stage of putrefaction. Corpora striata, optic thalami, and other 
central parts of brain not altered in consistency or external appearance. 
In corpora striata and optic\thalami, on both sides, many of the minute arteries 
and capillary blood-vessels had undergone advanced fatty degeneration. This 
degeneration was confined to isolated spots and streaks in the vessel, and 
many of the vessels were entirely free from it for a considerable part of 
their length, but it was still very abundant in the parts above mentioned. 
Fatty degeneration of the blood-vessels was not found in any other situa- 
tion, though it was looked for in the hemispheres, tuber annulare, olivary 
bodies, crura cerebri, cerebellum and spinal cord. 
Tuber annulare very firm in consistency, as were also the olivary bodies. 
Corpora pyramidalia, rest of medulla oblongata and whole of cerebellum 
rather soft. 
Spinal cord, pia matter, and surface of cord natural in cervical portion, 
but of a deep permanent dark slaty or blackish color in dorsal portion, parli- 
tularly on posterior aspect. In lumbar portion dark red posteriorly, as if 24 
from post mortem settling of blood. No thickening or exudation. Anterior 
surface of cord tolerably healthy in appearance. Cord, divided transversely 
in thin sections throughout its entire length, showed no unnatural appear- 
ance, either to naked eye or to microscopic examination. 
J. McG., aged 29, mason, habits intemperate. Was observed to be con- 
fused in his manner and unable to apply himself to his work, in March, 
1801. Had since grown steadily worse, but without at any time manifest- 
ing excitement. There is no account of a convulsive attack, although his 
mouth on one side is drawn down. When admitted to the asylum, Sep- 
tember 9, 1861, he was demented, indifferent to matters of interest, had a 
pleased, self-satisfied expression, a hesitancy in his speech, and defective 
co-ordination of movements. This state continued without notable change 
until September of the following year, when a slight, transient paroxysm 
of excitement ushered in a state of greater mental and motor impairment. 
From this time until his death, February 9, 1803, frequent epileptiform 
seizures occurred and were followed by more or less profound stupor and 
paralysis. 
Post-mortem examination of the brain.—There was evident thickening of 
the dura mater, as compared with the dura mater of a healthy brain ex- 
amined at the same time. Thickening and opacity of the arachnoid every- 
where existed, but especially distinct where the membrane was stretched 
over the anfractuosities of the cerebral hemispheres. On raising, or 
attempting to raise the arachnoid from the brain, it appeared unusually 
adherent, and the cerebral substance was lacerated and clung to the mem- 
brane. There was an abnormal degree of congestion of the superficial 
vessels, and a marked injection of the vessels of the pia mater. The con- 
sistence of the brain seemed natural. 
The vessels of the pia mater were very carefully examined with the 
microscope, and in order to appreciate more accurately the microscopical 
appearances, the brain of a sane persou who died of phthisis pulmonalis 
was procured for the sake of comparison. Repeated examinations of the 
arteries, veins and capillaries from the pia mater, and the superficial layers 
of grey matter of the brain, failed to discover the hypertrophy of the con- 
nective tissue which Wedl describes. The obliteration of the capillaries 
and their change into corresponding bundles of fiber could not be detected, 
nor any approach to such change. The fatty and calcareous degeneration 
of the capillaries was not nearly so extensive as in the case of the phthisis 
patient, whose cerebral functions to the last day of his life were unim- 
paired. The changes which Wedl describes as affecting the nerve-cells 
and fibers, this examination did not confirm. There did not seem to be any 
abnormal appearance in the cerebral tissue. 
Case Fourth. 
Case Fifth. 
T. C.—Aged 35 ; married ; five children ; tanner ; common education ; 
not religious ; temperate ; Irishman ; admitted 1863. Four months prior 
to this time, appeared well and attended his work regularly. The tannery 
in which he worked burned down, and he worked very hard to save stock 25 
and became greatly excited. Soon after he was depressed, gloomy and 
taciturn. Two months later had an epileptiform seizure, which left him 
nearly blind and unable to speak distinctly. In this condition he was 
brought to the asylum, and on examination it was found that all the somatic 
symptoms of paresis were present, though he did not have the characteristic 
restlessness and exalted notions, but was, on the contrary, fearful and 
melancholy. 
Only the head was examined. Dura mater was adherent at apex along 
both sides of falx. Inside of it of yellowish red color ; within arachnoid 
a large quantity of serum. Pia mater of dirty creamy color. Whole of 
brain substance softened throughout, and in some places more than in 
others. Cortical portions, jelly-like in consistence. Puncta vasculosa 
not noticeable Thalami optici, corpora striata, falx and crura cerebri, all 
softened. Optic commisure and proximal end of optic nerves of creamy 
consistence. 
Case Si.rth. 
W. G.—Aged 35 ; married ; one child ; good habits ; shoemaker. His- 
tory on admission vague and trivial ; said to have had a fever, and while 
convalescent from it, to have been frightened by a dog. On admission 
very feeble and restless, and greatly emaciated ; voided his excreta invol- 
untarily ; tongue tremulous, and was jerked back involuntarily on pro- 
trusion. Eyes very prominent and pupils large ; speech very slow and 
indistinct ; a great part of the time he had to be fed ; deglutition difficult ; 
constant vigilantia. In a short time became paralyzed in both left 
extremities. 
Had tonics and anodynes and extra diet, but all to no purpose, for he 
continued to emaciate ; his pupils enlarged more and more ; his eyeballs 
became more prominent and his speech and deglutition failed, and he died 
from coma. 
Post mortem twenty-four hours after death. The head only was exami- 
ned. Calvarium of normal thickness and consistence. On opening the 
dura mater a large quantity of serum, more or less tinged with blood, 
ilowed out, and on elevating it, on the right side, lying between it and the 
arachnoid covering the pia mater, or rather within the arachnoid, we found 
a cyst of tolerably firm darkly bloodstained false membrane, covering the 
whole upper surface of this hemisphere. It was firmly adherent to the dura 
mater, and more or less on the other side, and it contained over an ounce 
of red fluid, besides a firm blood coagulum. The membranes, wdiere they 
were in contact with the cyst, were somewhat discolored from the serum, 
but exhibited no further indications of inflammatory action. Underneath 
the cyst, the cortical portion of the brain was firmly compressed, and of a 
yellowish color, and somewhat softened. The remainder of the cortical 
portion of the brain was somewhat discolored yellow, and in several places 
slightly softened, though not to any great extent. 
On section we found the thalami optici, corpora striata, corpus callosum 
and fornix so much softened that their respective outlines could not be dis- 
tinctly traced. The tubercula quadrigemina, crura cerebri and pons varolii 
were likewise softened, and the cerebellum was intensely congested. 26 
Dr. Pliny Earle records two arachnoid cysts of this character in Ameri- 
can Journal of Medical Science for 1847; Calmiel reports several in his 
Treatise on Inflammatory Diseases, &c., in 1859, and in the January num- 
ber for 1865 of the Journal of Mental Science, London, we find two similar 
cases recorded. This is the first case of the kind that has ever fallen under 
our observation, and we regret that we have not a fuller history of its 
incipient stages and development prior to admission. 
Case Seventh. 
R. R., aged thirty-eight. Married. Three children. A blacksmith of 
strictly temperate habits. Insane for two months and a half. Admitted 
1864. He was depressed, self accusing, timid and fearful. Speech slow 
and stuttering, twitching at angles cf the mouth. General erethism and 
large appetite. All the above symptoms gradually increased and he became 
filthy, helpless and destructive, and died May, 1865. 
In this case all the usual somatic symptoms of paresis were well marked, 
but the mental phenomena were unusual. Gloom and depression, fear and 
anxiety, with a partial realization of his condition and a great dread of the 
future, were the most prominent mental symptoms. 
Cadaveric inspection, twenty-four hours post mortem. Head only exam- 
ined. Calvarium was rather thinner than normal. Dura mater was adhe- 
rent on both sides of falx for several inches along apex. Both flexures of 
arachnoid were much discolored, and within the cavity we found eleven 
ounces of a pale straw colored fluid. The whole of the cortical portion of 
the brain was much softened, and also the white part, though not so much 
as the former. The puncta vasculosa could not be discerned. The ven- 
tricles contained a little more than their normal quantity of fluid. All the 
gray centers so much softened that their outlines could not be traced, 
and when moved all ran into a creamy mass. Cerebellum intensely con- 
gested and somewhat softened. Medulla oblongata and upper end of spi- 
nal cord much discolored and slightly softened. About three ounces fluid 
in theca vertebralis. 
Case Eighth. 
G. H ; aged 34; single; boat builder; common education; not reli- 
gious; was admitted November 27th, 1863. His father had been insane, 
and his mother was an epileptic. He had always been of fickle, rambling, 
unsteady character, always changing from one kind of work to another. 
For some time had been living with a woman of ill-fame, and had several 
times been treated for venereal. 
His insanity is said only to have appeared eight weeks before admis- 
sion, and was characterized by sleeplessness, restlessness, wild business 
schemes, impeded speech, large appetite and general muscular paresis. 
He retained the same general delusions up to the third stage of his dis- 
ease, and then became melancholy and lachrymose. Thought himself rot- 
ten, dead, &c., and on this account refused to eat. He gradually failed, 
and died comatose, March 5th, 1865. 
Inspection, thirty-four hours post mortem. Body rather fat, in good con- 
dition. Skull normal. Dura mater adherent along apex from anterior to 27 
posterior fontanelle, and sideways from this line about two inches. Lower 
or inner surface yellowish, tinged with dark, deep red color, showing chronic 
inflammation with discoloration from effused fluid. Arachnoid, dark yel- 
lowish color. Pia mater same color, and very easily peeled off' from brain 
proper. All the vessels running from brain into pia mater appeared cut. 
About half a pint of serum in sub-arachnoid space and in theca vertebralis. 
Glandular pacchioni very numerous. 4 
Dissection. Centrum ovale, major and minor, normal, except that puncta 
vasculosa very small, almost absent. Each lateral ventricle contained 
about two drachms serum. Central gray commissure wanting. Choroid 
plexuses normal. Corpora striata and tenia semi-circulari normal. Optic 
thalamus somewhat softened. Fornix, hippocampi, crura cerebri and tuber- 
cula quadrigemina all softened. Pons Variolii softened below. This pro- 
bably from having lain in fluid. Cerebellum and its crura normal. Fourth 
ventricle and medulla oblongata normal. 
Thorax. Right lung had numerous adhesions all round upper lobe; left 
lung at apex and along external border. Both upper lobes and middle of 
right were excessively congested, looking very much like the second stage 
of pneumonia. Heart. Normal. Abdomen. Liver, stomach, kidneys, spleen 
and pancreas normal. At the fundus, about one inch from border on pos- 
terior side, and in mesial line, was found an ulcer, round, with rough, rag- 
ged edges, large enough to permit the insertion of a man’s index finger. 
Mucous membrane of bladder much thickened and congested, and all 
around ulcer a series of corrugations like radii existed. Ulcer probably 
due to chronic inflammation, or may possibly have originated from a syphi- 
litic chancre, as he has had venereal several times. Peritoneal cavity con- 
tained about three quarts of urine undergoing decomposition, dark in color, 
of very offensive smell. 
In this case the question might arise whether general paresis itself was 
not the result of venereal. 
I present, in conclusion, the views of Parchappe, Belhomme, Salomon, 
and Culmeil respecting the pathologico-auatornical conditions of the dis- 
ease under discussion. 
M. Parchappe.—“All the facts afforded by pathological anatomy agree 
in affirming the inflammatory nature of the characteristic lesion of the cor- 
tical substance of the brain in general paralysis. The special character of 
this lesion is to affect simultaneously both cerebral hemispheres, principally 
in the anterior and middle lobes, and to be associated nearly always with 
an inflamed condition of the meninges, frequently with inflammatory soft- 
ening of the gray substance of the intra-cerebral ganglia, of the cerebel- 
lum, and of the medulla spinalis, with a granular condition of the ventri- 
cular walls, and with induration of the white substance; and finally, very 
frequently with atrophy of the convolutions. 
“ The softening of the cortical portion, and the changes of this substance 
or of the meninges, offer, in the first or acute stage, all the characters of 
an inflammatory condition; a rose, lilac, or even amaranth color of the cor- 
tical substance, hyperaemia, pointed injection, extravasations of blood in 
the cortical substance or in the membranes, adhesion of the pia mater to 
the surface of the convolutions, sometimes separation of the pia mater and 28 
collection of a sanious liquid between it and the cortical substance. At a 
more advanced period, if the patient’s life is prolonged, hypersemia is no 
longer fcund. The softened cortical substance has a pale, dirty gray or 
yellowish lint. At this period of the disease are found atrophy of the con- 
volutions, serous effusion in the anfractuosities, with thickening and opa- 
city of the membranes. 
“ This rapid sketch of the principal characters which belong to the essen- 
tial elements of general paralysis, appears to me to be an unanswerable 
proof of the necessity of referring it to a distinct nosological species. It is 
in fact a morbid entity, different from all others—a disease which is pro- 
duced by causes which bring on over excitement of the brain, generally in 
men, and during the adult period of life; whose symptoms may be summed 
up in general and simultaneous iesion of the intelligence, the voluntary 
motions and sensibility, which has for its seat the cortical substance of the 
hemispheres, and fur its constant anatomical character inflammatory soft- 
ening of the cortical substance of both hemispheres, which, aggravated by 
cerebral congestions, causing every day a more marked impairment of 
motion, intelligence and sensibility, terminates fatally in an attack of con- 
gestion, or by cerebral marasmus. 
“Though simple insanity may not be characterized by any constant 
change in the cerebral structure, nevertheless the alterations which are 
frequently found in the brains of the insane, and which, as some observers 
assert, are always found there, have the greatest analogy with the altera- 
tions which are met with in paralytic insanity. These are hypercemia and 
thickening of the membranes, hypersemia or decoloration of the cortical 
substance, induration of the white substance, atrophy of the convolutions, 
and collections of serum in the anfractuosities of the convolutions. Besides, 
it is essential that the importance of appreciable organic lesions should not 
be overrated. Because no constant structural change is found in the cor- 
tical substance in simple insanity, which is therefore classed with the 
neuroses, and considered a purely functional disorder, shall we therefore 
conclude that morbid action can be set up without structural change in the 
organ; but functional passes into structural disease in the lowest grades 
of dementia by atrophy of the convolutions. In my opinion, simple insanity, 
from being purely functional disorder, becomes organic in those cases in 
which it becomes complicated with general paralysis.” 
M. Belhomme.—“ I reported in detail fifteen cases, which proved that 
general paralysis depends upon the alterations which I am about to enu- 
merate. Thickening of the membranes and their adherence to the cortical 
substance of the brain, which is removed with them; the different layers 
of the cortical substance are softened, and present various shades of color, 
red, yellow and brown. The central portions diseased are the medullary 
substance, which is strongly injected, of a yellowish tint, softened in dif- 
ferent degrees, sometimes only to a limited extent, and very often one of 
the hemispheres more altered than its fellow. The ventricles, often dis- 
tended with serum, the arachnoid lining their walls is often thickened, and 
the medullary matter in contact with it either harder or softer than natural. 
The central parts constituting the cerebral peduncle and the commissure 
are often altered, the septum lucidum destroyed, the fornix softened to a 29 
greater or less extent, the corpora striata atrophied or changed in color, 
the* optic thalami, forming the principal wall of the third ventricle, are 
more or less softened. The cerebral peduncles are less consistent than in 
the normal condition; the annular protuberance sometimes partakes of the 
general condition of hardening or softening; in fine, the fourth ventricle 
and the rachidian bulb present various degrees of unequivocal hardening 
or softening, and the cerebellum partakes sometimes of the general diseased 
condition. 
“I conclude by expressing the belief that general paralysis is an ence- 
phalitis of a particular kind, an inflammation wliiyli is developed under the 
congestive form, a disorganizing hy perse mi a which is established slowly, 
producing at first induration and afterwards softening of the cerebral sub* 
stance. At the same time there is a gradual impairment of all the func- 
tions of the brain, motion, sensibility and intelligence.” 
M. Salomon.—“ I shall include the description of the pathological anato- 
my of the disease under four divisions, each being referable to a corres- 
ponding symptomatic stage: 
1. Leptomeningitis chronica (16) (—the stage of mental alteration ) 
“ 2. Periencephalitis chronica diffusa (=the stage of mental alienation ) 
“ 3. Degeneratio substantial corticalis cerebri (or marasmus substantiae cor- 
ticalis= he stage of dementia.) 
“ 4. Atrophia vera substantia3; corticalis cerebri (=the stage of amentia.) 
“ That the disease commences with leptomeningitis of a chronic nature 
is proved by the fact that in the cases where the patient dies in the stage 
of mental alienation, signs of a still persistent or recently terminated in- 
flammatory process are met with in the pia mater (=lepto-periencephali- 
tis.*) If the patient dies in the third or in the beginning of the fourth 
stage, we constantly observe a change in the pia mater, the result of a 
preceding leptomeningitis. The process indicated under 2, is recogniza- 
ble by the increased volume (“ trube Schwellung ") of the cortical substance 
of the brain. The degeneration referred to under 3 has been demonstrated 
by Rokitansky. The atrophy mentioned under 4 is discoverable principally 
by the circumstance that when the patient has lived to the commencement 
of the fourth stage, the most superficial portion of the cortical substance, 
corresponding to the lamina nervea in the healthy condition, is changed 
into cicatricial tissue, giving the sensation, on feeling with the point of 
the finger the now nearly obliterated surface of the convolutions, of a firm 
brain, and of a certain fluctuation of the subjacent dissolved cortical por- 
tion. 
“ The honor of having demonstrated the anatomical changes in para- 
lysis with mental alienation belongs to the Vienna school (Wedl, Roki- 
tansky ) 
“K. Wedlf has, in every case of general paresis, demonstrated an 
hypertrophy of connective tissue in the small arteries and veins in the pia 
mater and cortical portion of the brain. On the outer wall of the vessel 
is a hyaline, imperfect layer of connective tissue studded with partly scat- 
* A contraction of lepto-meningo-periencephalitis. 
f “Beitriige zur Pathologie der Blutgefiisse.” Wein, 1859. 30 
tered, partly grouped oblong or rounded nuclei. This layer of connective 
tissue, projecting over a greater or less extent of the vessel, undergoes, 
with the nuclei occurring in it, in the direction from without inwards 
(from the periphery of the vessel towards its center) a fibrillar change. 
The veins of capillary structure can not resist the pressure, but are also 
drawn into this process, and are completely obliterated, and changed to 
corresponding bundles of filers. The abnormal layer of connective tissue 
not unfrequently serves as a seat of deposit for finely divided olein and 
amorphous calcareous salts, while in other places c ileareous depositions 
take place in the inner elastic and muscular la37er. The small and slender 
cerebral vessels thus calcified can, on section, be observed in the cortical 
substance as a number of needle points. Wedl endeavors to explain the 
adhesion of the superficial layer of the cortical substance to the pia mater 
by the penetration of the grouped nuclei in the adventitious membrane of 
the pia mater to a certain depth into the cortical substance. When the 
pia mater is separated, a layer of the softened cortical substance often 
accompanies it, corresponding to the depth to which the nuclei have pene- 
trated. 
“The complete obliteration of the calibre of the small veins caused by 
this degenerative process, demonstrated by Wedl, must give rise to a con- 
siderable obstruction to the circulation, both in the pia mater, and subse- 
quently in the cortical substance of the brain, with consequent ischaemia;* 
to stasis, pressure, irritation and inflammation. All this produces a pro- 
gressive aggravation of the cerebral symptoms, and disturbs the nutrition 
of the cortical substance. 
“ Rokitansky f has, in all genuine cases of paresifying insanity, demon- 
strated a considerable increase of the connective tissue enveloping the 
cortical elements. The pathologically augmented connective tissue is at 
first of a tough and viscid nature, and imparts to the cortical substance a 
somewhat looser consistence than exists in the normal state. The connec- 
Colloid (and amyloid) metamorphosis of the cortical substance in the person affected with 
paresifying insanity. The pia mater is represented as separated with loss of a portion of the 
cortical substance. In the cortical substance, the superior white filamentous layer (lamina 
nervea) is replaced by a layer of colloid corpuscles of various sizes; under this separate 
colloid granules lie in a mass studded with numerous granular nuclei. Lower down are 
ganglionic cells swollen or changed to colloid bodies. 
* Virchow—ld%O)—to check. 
t “ Ueber Bindegewebeswucherung im Nervensysteme.” Woin, 1857. 31 
tive tissue subsequently, in the course of the disease, assumes a harder 
and more fibrous form. This excessive formation of connective tissue 
causes the breaking up of the nerve-tubes. Those are first attacked which 
constitute the lamina nervea covering the cortical substance of the brain; 
afterwards those which horizontally traverse the same and separate the 
several layers of cortical substance; lastly, the degeneration attacks also 
the nerve-tubes, passing singly through the grey substance. The nerve- 
tubes broken up by the pathological process, are changed into colloid or 
amyloid granules (granular cells, granular bodies), which are met with 
in variable quantity in the extending connective tissue. The ganglionic 
cells of the cortical substance are often found dissolved, and in a state of 
colloid degeneration. See woodcut on preceding page (alter Rokitansky). 
“ The cortical substance has split asunder, and (in the third stage) yields, 
to the least touch. In the transition to the fourth stage, the superior layer 
(corresponding to the lamina nervea in the healthy state) is in a firm and 
tough condition. The inferior layers still retain their pappy and soft state. 
The convolutions are now nearly obliterated, and the mass of the cortical 
substance is diminished in volume. 
“ In consequence of this pathological process, set in action by ischaemia, 
determination of blood, hyperaemia, or inflammation, the grey cerebral 
cells become destroyed, and changed to an inert mass. 
“ The constant changes met with in every well-marked case of fully 
developed insania paremns, are: 
“1. In the arachnoid, results of previous inflammation in the form of 
condensation, diminished transparency, &c. 
412. In the pia mater, results of previous inflammation appearing as 
opacity and condensation of the vascular membrane. 
44 3. In the cortical substance, the consistence is looser than is normally 
the case. It is often pappy and soft.* 
“In addition we frequently have— 
“4. In the dura mater, results of previous pachymeningitis exhibiting 
themselves in adhesion of the membrane to the inside of the calvarium, 
thickening, <fcc. 
“5. In the calvarium thickening and hypersemia. 
44 6. In the sac/c of the arachnoid, effusion of variable nature. 
44 7. Pia mater often intimately connected with the cortical substance. 
“8. In the ventricles, more or less, abundant serous effusion. If the 
changes enumerated under 1, 2 and 3 are not met with, the patient has had 
some other disease than insania paresans. 
M. Calmed. “1st. The progress of general chronic inflammation of the 
brain and its membranes (periencephalite clironique diffuse), is frequently 
marked by developments of an alarming character. 
“ 2d. These developments are especially characterized by sudden mani- 
festations of apoplectic, of comatose and convulsive symptoms, and by 
strong indications of paralysis, showing a marked tendency to localize 
itself in some one of the members. 
* When the patient has died in the beginning of the fourth stage, the cortical substance 
may appear resistant, and normal to the touch. The most superficial layer must in that ca&0 
be removed, before the dissolved state of the subjacent tissue can be observed (17). 32 
“3d. The breaking out of these phenomena is owing to sudden conges- 
tive and inflammatory recrudescences (sudden augmentations of the con- 
gestive and inflammatory condition.) 
“ 4th. The progress of chronic phlegmasia is marked then by genuine 
accessions of acute enceplialite (inflammation of the brain.) 
“5th. During the violence of these recrudescences (augmentation), the 
inflammation may localize itself in the cavities of the cerebral arachnoid, 
in the depth of one hemisphere of the brain, of the cerebellum—in the 
annular protuberance, the spinal marrow, and penetrates more deeply than 
usual into a certain number of places in the superficial grey matter. 
“ 6th. The material alterations which may occur during these species of 
inflammatory attacks, can with difficulty be diagnosed during the life of 
the patient. 
“7th. These alterations are, notwithstanding, easily understood. 
“ 8th. They are indicated by the products of the sanguineous extravasa- 
tions, by the fibrinous coagulations, by the cellular or granular deposits, 
by heightened vascular coloring, by variations occurring in the degree of 
consistency of the encephalic nervous element. 
“9th. The sanguineous extravasations of the arachnoidal cavities, the 
inflammatory crust (les couennes), often found therein, the cystic sacks, 
which may form these also, arising from the congested or inflamed capilla- 
ries (des capillaires fluximnes), filled with globules of blood, undergoing 
for the time being the inflammatory influence (Viojluencephlegmasique.) 
“10th. It is the same wTith the sanguineous suffusions so often noticed, 
in the cases under discussion, beneath the visceral fold of the arachnoid. 
(dufeuillet visceral de Varachnoide.) 
“11th. As to the granular deposits also frequently observed, whether 
they exist in the midst of the arachnoidal cysts, or in the substance (trame) 
of the pia mater, or in the centers which inflammation has produced in a 
marked manner upon certain places of the encephalic mass, they have 
arisen in virtue of that kind of law of construction which impels them to 
self-formation, as soon as the living fibrine has been able to spread itself on 
the outside of the vascular ducts which everywhere carry and distribute 
the blood necessary for the nutrition of our organs and tissues. 
“12th. The intercurrent phenomena of periencephalite (la periencephalite 
chronique diffuse) are soon followed in certain cases by a fatal termination. 
“ 13th. More frequently, however, immediate death does not ensue, be- 
cause the congestive state of the encephalic capillaries is soon partially 
dissipated ; but many of these capillaries nevertheless continue to retain 
blood in excess, and the condition of the patients who survive these pheno- 
mena is much aggravated. 
“ 14th. Finally, many of these patients do not die until they have suffered 
a great number of these incidental encephalic attacks (d'attaques d'ence- 
phalile incidentes) and this circumstance explains the multiplicity and the 
gravity of those material variations which we sometimes find in our anato- 
mical descriptions. 
“15th. We should put under contribution all the resources of hygiene, 
all the contrivances (combinations) of an active and enlightened foresight, 33 
to prevent if possible inflammatory recrudescences (augmentations) of peri- 
encdphalite (la perienctphalite chemique diffuse). 
“ 16th. The antiphlogistic treatment is often necessary to attain this end, 
and cannot be resorted to witli too great promptness and vigor when the 
unexpected development of comatose phenomena, or of epileptiform seizures, 
threaten the existence of the subjects attacked with perienc6phalit6 (la 
periencephalite chemique diffuse). 
1 append a table, showing the morbid appearances found in 122 cases, 
by I)r. Skae of Scotland: 
Calvarium of unusual thickness 16 
do do thinness 9 
Diploe absent 7 
Osseous projections from inner surface of cranium 3 
Ossific deposits in dura mater 4 
Tumors in dura mater 2 
Abnormal adhesion of do. to calvarium 20 
Opacity and thickening of arachnoid 82 
Congestion of membranes 41 
Abnormal adhesion of do. to convolutions 60 
Arachnoid and sub-arachnoid effusion 76 
Sub-arachnoid sero sanguinolent do 4 
Sero sanguinolent do. into sac of arachnoid 4 
Pus in do 1 
Granular deposit in do 5 
Coagulable lymph in do. at base of brain 6 
Atrophy of optic nerves 4 
Grey matter unusually pale 12 
do do dark 27 
do do of a veolaceous tint 11 
do do softened 37 
White matter softened 11 
do hardened 21 
Lateral ventricles contained serous effusions 50 
do do do sero sanguinolent do 1 
Granular deposit in living membranes of do 43