in any of the newly admitted patients to that building, whom I examined in every instance with reference to that as well as to other points. Up to the time that I left, the 18th of April last, there had been seven deaths from pulmonary tuberculosis in that building, five in colored, two in white women. Deaths from tuberculosis had occurred on every ward in that new building. Now whether all or most of those patients were infected at the time of their removal I cannot undertake to say positively; I presume that some of them were. In both white women the disease was initiated, as far as anything was known of it, by pulmonary hemorrhage.

I will only say in regard to prophylaxis, that I do not believe. in the efficacy of any measure short of isolation of the patients in entirely separate buildings as soon as the disease is discovered. I do not believe that amongst insane patients it is possible to carry out any such directions in regard to the disposal of the sputum as will be at all efficacious.

VARIETIES AND ANALOGUES OF GENERAL PARESIS.

BY R. M. PHELPS, M. D.,

Assistant Superintendent, Rochester State Hospital, Rochester, Minn.

My object, as indicated by the above title, is not to obliterate distinctions between variously named diseases, so much as by a study of resemblances and alliances to bring out the differentials.

For, under any decision as to names, it will be understood that the mere name is the least important part, and that by studying the broad underlying principles, we lose the narrow idea of a group named as an invariable entity, and gain conversely in the idea of each as symptomatic of certain brain and nerve changes. For example, in our subject, we would find "general paresis" and "syphilitic dementia" not exclusive of each other as are measles and typhoid fever, but blending and combining with each other, the name in each case being determined by the preponderance of certain elements.

It was not until some five years ago that I became sufficiently impressed with the immense value of tabulating and recording symptoms in asylum work in order to compare cases, and with the way it opens up new light and interest on all the work. On this account as well as for convenience I will in this discussion confine my comments to cases thus tabulated and personally studied in the past four years, cutting out with considerable rigidity any doubtful cases. I will aim at a passing study of the relationship of those forms of mental trouble, resembling in their characteristics that most studied yet most hopeless of insanities-general paresis.

Folsom1 and others have brought out prominently both the difficulty and possibility of diagnosing the prodromal or initial and neurasthenic stage of general paresis. But I would here go on record, though few have previously done so, as to the occasional difficulty of a decision in cases which are so definitely insane, as to be confined in hospitals for the insane. Even though a single speech or half a minute's observation of face or walk suffices in typical cases, yet occasionally in extremely atypical cases, no firm basis can be found.

Though I have made diagnoses when speech and co-ordination seemed correct, and have had the satisfaction of later seeing typical symptoms develop, I will also confess to having ventured in

other similar cases and to have been obliged later to cross some names from my list. Doubtless I would make fewer mistakes or ventures now, but I do not believe surety of conviction can be obtained in some cases. Before trying to speak of outlying forms, it is best to set before ourselves the main elements determining the diagnosis of general paresis. These are given with uniform sameness by everyone. The prominent ones are as follows:

: 1. Gradual invasion through neurasthenia, loss of high moral tone, irritability, to manifest dementia.

2.

A more or less excitable stage.

3. Sense of well-being and frequent ideas of grandeur.

4. Steady progression through deepening dementia, toward exhaustion and death in from two to six years.

The motor symptoms are supposed to follow closely along with the mental; they are:

8.

stammering" movements.

Disordered knee-jerk, usually exaggerated.

9. Speech slurred, slow and hesitating, writing impaired. Frequent convulsions, vertiginous attacks, or spells of like character.

11. Adult age, usually about 40.

CEREBRAL SYPHILIS. These preliminaries being settled the first variation from general paralysis to be noted, is that of "syphilitic brain disease," or "cerebral syphilis." The relationships of these two forms have been more earnestly considered than those of any other forms.

Of these discussions, however, none but the most prominent and recent of studies, need call for note. Dr. Kiernan2 in 1883 is reported as holding that "neither from clinical, therapeutical or pathological standpoint, could leuetic paretic dementia be differentiated from leuetic dementia." Dr. Henry Hurd3 in 1886 in an excellent article, in which he starts out with the proposition that general paresis is not of syphilitic origin later describes a "congestive" form of syphilitic dementia which he admits as distinguishable only by long observation. Savage in 1888, in leading the discussion in the Pan-American Congress, aimed to make clear that, in his opinion, there is no possible line to be drawn between some cases of nervous

syphilitic degeneration and general paralysis of the insane. He also maintained it as not true that all general paralysis must have a syphilitic origin. In the discussion following Dr. Mickle and Dr. Spitzka seemed to quite closely agree with these views. In the Annual of 1888 Dr. Spitzka sums up European authorities as chiefly in favor of syphilitic causation. The Annual of 1890 refers to A. Morel Lavelle, as concluding that syphilis produces a pseudoparesis, very hard to distinguish from true general paralysis. At the first Congress of Mental Medicine, at Rouen, this subject was discussed.5 Rubuisson is reported as claiming only a slight causal connection; Regnier considered them entirely distinct; Régis found 80 per cent. of paralytics to be syphilitic; Cullerre found that general paralysis of the syphilitic is not of a special clinical form. Voisin found syphilis in only 9 of 560 cases, but demanded "real tertiary syphilitic lesions" for his diagnosis. Sachs, tabulates general paresis as a sub-heading under the general subject-syphilis of the nervous system. Peterson' utters probably the latest word in December, 1893, in quoting many writers to show a consensus of opinion that 60 to 70 per cent. of cases have syphilis as a cause. He concludes by denying the probability of its being more than a predisposing factor.

6

But, selecting the commonly admitted matter from the various reports, we find practical unanimity, that syphilis is a common precedent of general paralysis, and that when it affects the brain in what is called variously a "congestive" form or the "diffuse," or a "meningeal infiltration," it sometimes produces a brain and motor trouble quite indistinguishable clinically from typically pure general paralysis.

Keeping in mind our purpose of differentiating, as well as showing resemblances, we would point out also that brain syphilis tends usually to show more gross brain signs, more localized motor impairments, a less steady progression, a more easily produced remission, and a less typically exalted mental state than does general paresis. But finally, we would claim it probable that in a series of 100 cases, there could easily be outlined a series showing gradations from the gross syphilitic lesions and signs, to a quite smoothly progressive general paralysis. The varieties of syphilitic brain trouble vary among themselves, even more than do the cases of general paralysis. And the whole ground of variation is probably what could rightly be expected, from the varied location and extent of lesions which are found.

Counting in this way, though persons might differ as to the placing of special cases, yet using our own judgment we find in the four years' study as above noted, among the list of 88 diagnosed as general paralysis about 6 cases of the syphilitic form yet so typical as to best deserve the name of general paresis. During this same time 7 syphilitic cases have been admitted, with other insanities of various kinds, none of them so closely resembling general paresis as to deserve the name.

I give a case of nearly typical symptoms.

Case I.-Man, age 35, barber, single, syphilis 6 years previous to admission, no heredity determined, admitted October 17th, 1892, gradual, rather quiet mental failure. The history described "Syphilis of the nervous system." The motor signs on admission are unequal pupils, sight somewhat impaired, inco-ordination, sluggishness and awkwardness, tremors and "stammering" use of the hands, patellar reflex extremely exaggerated, articulation markedly hesitating and slurred, facial expression typically dull and blank, has had semi-conscious conditions, has had delusions of electric currents in his head; specific treatment has had no effect. The only prominent element lacking seems to be the grandiose ideas.

During the first three months of his stay here, he passes through a rather irritable and demented activity; during the year 1893 he gradually becomes more dull and quiet, and talks very little, has said that he was President Cleveland, &c. He is usually very dull, sluggish, and seemingly too stupid to talk; at present is extremely so, will not talk intelligibly, and stumbles about in a sluggish way when he moves, which is rarely. In short his appearance is typically that of the last stage of paresis. Although starting out with prominent syphilitic signs, he seems now in a typically paretic condition.

SENILE DEMENTIA.-Senile Dementia at first seems to be widely different from general paresis, and is less often mentioned as resembling it yet at times seems to afford as close an analogy as does the syphilitic form. In a goodly proportion of senile dementias. we have a distinct progressive downward tendency, manifested by both motor and paretic signs, and mentally a dementia progressing rapidly onward toward a death from central nerve deprivation, exactly resembling that of paresis. I find perhaps more trouble