place, numerous illusions which often lead to mistakes of identity, and occasional hallucinations which are more or less fleeting.

The emotional tone is usually one of indifference; sometimes there is slight euphoria or undue irritability.

In spite of their intensity the psychic symptoms are in many cases not very apparent at first. The patients are quiet, understand well the questions put to them, and reply in a calm and often even in an intelligent manner. They often appear to be normal because a conversation of several minutes may not suffice to reveal the pathognomonic amnesia and disorientation.

The signs of polyneuritis, paresis of the lower extremities, abolition of the tendon reflexes, paræsthesias, lightning pains, hyperesthesias of circumscribed muscular masses, to mention only the principal ones, vary widely in intensity. They are at times mild, while the mental disturbance may be quite marked. Possibly they may be even entirely wanting in certain cases that are perfectly typical from the psychic standpoint.

The general health is always affected to some extent. Occasionally cachexia may develop and end fatally. Also cardiac disturbances are often noted, feeble action, irregularity, etc., which in a number of cases are dependent upon a neuritis of the pneumogastric

nerve.

Duration, prognosis, diagnosis. The duration of the active period of the disease is usually several months, seldom over a year. There then remains a

characteristic state of mental deterioration dependent upon a persisting and more or less pronounced impairment of the power of retention, with resulting disorientation and amnesia for recent occurrences. The tendency toward active fabrications and pseudoreminiscences becomes less marked and often disappears.

In some few cases there is partial restoration, so that the patients are again able to keep track of dates and current events, but complete recovery is a rare exception in alcoholic cases, though it is said to be common in cases with a different etiology.

Another mode of termination, also infrequent, is death, which results either from cachexia or from some intercurrent complication: influenza, pneumonia, tuberculosis.

The diagnosis is based on (a) the very marked and characteristic disorders of memory; (b) the apparent lucidity of the patient, contrasting with the real disorientation; (c) the coexisting signs of polyneuritis.

Treatment. The treatment in the acute stage of the disease consists chiefly of rest in bed combined with a reconstructive diet.

It is scarcely necessary to add that abstinence from all alcoholic beverages should be rigorously enforced, especially where alcoholism is the cause.

CHAPTER XI.

GENERAL PARESIS.

Synonyms. Chronic arachnitis and chronic meningitis (Bayle). Incomplete general paralysis (Delaye). General paralysis of the insane or chronic diffuse periencephalo-meningitis (Calmiel). Paralytic insanity (Parchappe). Progressive general paralysis (Lunier, Sadras). Paralytic dementia (Baillarger). Chronic diffuse interstitial encephalitis (Magnan). In German: Progressive allgemeine Paralyse. In general it is convenient to employ the Latin term dementia paralytica.

The earliest mention of the somatic and psychic disorders corresponding to general paresis dates back to 1798, when Haslam, pharmacist at the Bethlehem Hospital, described in a few lines and with remarkable precision the principal features of the disease.

It was only in 1822, thanks to the memorable work of Bayle, that general paresis gained a footing in classical psychiatry. The history of this disease is a subject much too vast for the limits of this work. It has been quite recently treated by Vignaud1 in his inaugural thesis, which contains also a good bibliography.2

1 Histoire de la paralysie générale. Paris. Thèse.

2 Monographs on general paresis: Lasègue. De la paralysie générale progressive. Th. d'agrég. Paris, 1853; also Leçons sur la paralysie générale, 1883. — Falret. Recherches sur la folie paralytique et les diverses paralysies. Paris, 1853. - Voisin. Traité de la paralysie générale. 1879. Baillarger. Théorie de la paralysie

générale. Ann. méd. psych., 1883. Mendel. Die progressive

Prodromal period. It is marked (a) by changes of affectivity and of the character; (b) by neurasthenic and psychasthenic phenomena.

(a) The mood becomes either irritable and changeable, with sudden alternations of joy and sorrow, kindness and anger, discouragement and optimism; or gloomy, and marked by pessimism and by a tædium vitæ which may lead the patient to attempts of suicide. Often the patient is conscious of being stricken with a grave disease and has dark presentiments for the future.

(b) The neurasthenic and psychasthenic symptoms are usually very pronounced: a feeling of general lassitude, fatigue, muscular weakness, diffuse neuralgic pains, headache, a sort of grinding sensation felt especially in the head, and other peculiar sensations which the patient is unable to describe clearly: it may seem to him that his head is empty, that his brain is falling to pieces, etc.

These symptoms are, however, not identical with those of true neurasthenia. The following are, according to Ballet, the most important points of difference:

allgemeine Paralyse der Irren, 1880. Mairet et Vires. De la paralysie générale. Etiologie. Pathogénie. Traitement. 1893.Magnan et Sérieux. La paralysie générale (collection Léauté), 1894. Coulon. Considérations sur la nature de la paralysie générale. - Klippel. Les paralysies générales. L'œuvre médico-chirurgicale, 1898. For a bibliography of general paresis, see G. Ballet et J. Rogues de Fursac. Article Paralysie Générale in Traité de Médecine Charcot-Bouchard-Brissaud. Paris, 1905.-E. Kraepelin. General Paresis. Eng. trans. by J. Moore. Nerv. and Ment. Dis. Monograph Series. New York, 1914.

"(1) The stigmata, that is to say, the permanent signs of neurasthenia (helmet sensation, pain in the spine), are usually absent.

"(2) Neuralgic pains occupy a prominent place in the clinical picture. These pains (excluding the lightning or lancinating pains dependent upon the spinal lesions of general paresis) are disseminated, essentially mobile, varying from day to day. The patients often speak of them as 'pains that are peculiar, unusual.'

"(3) From one moment to another sudden changes are produced in the state of the patient. It is surprising to see the neurasthenic paretic, who but a short time before complained of severe suffering and ill health, forget his pains under the influence of some incident or conversation in which he is interested and in which he takes an active part. These momentary changes, appearing at the instance of chance occurrences, may manifest themselves in a more lasting manner on instituting some treatment, though insignificant. The patient, hitherto excessively discouraged and gloomy, speaks with joy of his cure; his satisfaction is exuberant and out of proportion, as was his despair shortly before."

Often some transient phenomenon, exceptional or unknown in neurasthenia, alarms the physician: slight seizures, transitory strabismus with diplopia, slightly marked momentary disorders of speech.

The period of prodromata is seldom absent. It is often very long, lasting several months or even years.