cranially.1

Somewhat encouraging results have been reported,' though it is still very doubtful if a permanent arrest of the process has been brought about in any case.

For the rest, the treatment is merely symptomatic. An institutional environment seems to have a beneficial influence in many cases, a calming down and general improvement being often observed soon after admission.

Excitement, insomnia, suicidal tendencies, and refusal of food are to be treated by the usual methods. In the last stage great care must be taken to prevent the development of bed sores. This is a matter of proper nursing. The patient must be kept thoroughly clean and dry, especially when, owing to loss of sphincter control or to mental deterioration, he soils and wets himself several times a day. His position in bed must be changed frequently and systematically so as not to expose either one side or the other or the back to continuous pressure and friction; a pad may have to be placed between the knees or the ankles in cases with a tendency to contractures. The

1 Swift and Ellis. The Direct Treatment of Syphilitic Diseases of the Central Nervous System. N. Y. Med. Journ., July 13, 1912. H. S. Ogilvie. The Intraspinal Treatment of Syphilis of the Central Nervous System by Salvarsanized Serum of Standard Strength. Journ. Amer. Med. Ass'n., Nov. 28, 1914. D. M. Wardner. A Report of Five Cases of Intracranial Injection of Auto-Sero-Salvarsan. Amer. Journ. of Insanity, Jan., 1915.

2 G. S. Amsden. The Intraspinal Treatment of Paresis. N. Y. State Hosp. Bulletin, Feb. 15, 1915. — H. A. Cotton. The Treatment of Paresis and Tabes Dorsalis by Salvarsanized Serum. Amer. Journ. of Insanity, July and Oct., 1915.

bed must be made carefully, avoiding unevenness, roughness, or wrinkles in the bed clothes. The skin over the parts that are exposed to pressure may be somewhat protected by sponging with alcohol, drying, and dusting with talcum powder. An air- or water-bed may be used, but will be found hardly necessary where the above-mentioned precautions are carefully observed. When bed sores develop they are to be treated by frequent and careful cleansing and protected by a simple dressing; the application of a saturated solution of picric acid seems often to promote healing.

Broncho-pneumonia is a common complication of general paresis and is in the majority of cases the immediate cause of death. No doubt the general debilitating effect of the disease renders the patient more liable to develop this complication, and the chances are further increased in the last stage when difficulties of deglutition develop and food is apt to find its way into the respiratory passages. Yet here too careful nursing can accomplish a good deal, and it is safe to say that the frequency of broncho-pneumonia can be considerably reduced. Demented patients will not complain of feeling cold, and it is the nurse's duty to have the patient at all times comfortably clad, well covered if in bed, and protected against draughts; special care must be observed when the patient has occasion to sit up in his bed, or leave his bed, and in bathing. Patients having to take their meals in bed should be placed in an easy, natural position, propped up with pillows, and not so as to have to reach over the side of the bed to get the food

or to have to eat while partly reclining; when deglutition becomes difficult or uncertain they must not be allowed to feed themselves, but must be fed by a nurse or attendant slowly with finely divided food.

There is nothing ordinarily to be done for convulsions beyond protecting the patient against injury. Continued convulsions are sometimes successfully combated by a high enema followed by the administration of 30 grains of potassium bromide and 20 grains of chloral hydrate per rectum, repeating the dose in an hour if necessary.

CHAPTER XII.

CEREBRAL SYPHILIS.

THE distinction between general paresis and cerebral syphilis has already been given in the preceding chapter, where also attention has been drawn to the fact that cases have been reported which seem to constitute transition or combination forms.

Cerebral syphilis is not so often met with as general paresis, at least in hospitals for the insane. Thus, of a total of 6265 first admissions to the New. York state hospitals during the year ending September, 30, 1914, 774 were cases of general paresis, and but 47 of cerebral syphilis. It is probable, however, that some cases failed to be included in this number having been placed in the cerebral arteriosclerosis group.

Three types of cases are usually distinguished, diffuse meningitic type, gummatous type, and endarteritic type, the distinctions being drawn more or less arbitrarily and, of course, not on the basis of any essential difference in the nature of the pathological process. Yet the distinctions are valuable not only from a scientific standpoint, but also from that of prognosis, as the three types vary considerably in clinical course, reaction to treatment, and

outcome.

1 Twenty-sixth Annual Report of the N. Y. State Hospital Commission, Albany, 1915.

Diffuse meningitic type. Nearly half of all cases may be said to be of this type. It is apt to occur comparatively early in the course of syphilis, as a rule within five years after the initial lesion. Its onset is usually rapid, the symptoms reaching complete development in two or three weeks. Anatomically it is characterized by a subacute diffuse meningeal inflammation, most marked at the base or even limited to that region, with occasional miliary gummata; the pial blood vessels are the seat of more or less widespread and more or less pronounced endarteritis; the process may subside in one area while extending to another, thus producing a peculiarly varying clinical picture.

The symptoms are physical and mental. The physical symptoms, in order of importance, are headache, dizziness, vomiting, convulsions, and evidences of cranial nerve involvement, amaurosis,

ptosis, strabismus, facial neuralgia, hyperæsthesia or anæthesia, facial paralysis, impairment of the sense of smell, and possibly deafness; the pupillary reaction to light and distance may be sluggish or limited in excursion, but the Argyll-Robertson sign is generally absent; a spastic and partly paralytic condition of the lower extremities with increased knee jerks and bilateral or unilateral Babinski sign is often found. The mental symptoms are also very important. "A very characteristic sign of basic syphilitic meningitis is the semi-somnolent, semi-conscious, semi-comatose condition, in which the mental functions are more or less obfuscated rather than obliterated. The patients may present