59

Art. V.?GENERAL PARALYSIS.

I. Rechevches

sur

les Centres Nerveux: Pathologie et PhyPar le Dr. V. Magnan. 1876.

siologic Pathologique. II.

Rechevches sur VAnatomic Pathologique et la Nature de la Paralysie Generate. Par les Docteurs Henry Bonnet et Poincare. 2e Edition. Paris, 1876. Pp. 154.

III. Historique du Delire des Grandeurs. Ach. Foyille, fils. Paris, 1871. Pp. 55.

Par M. le Dr.

Tiiere is at

present an embarras de richesse of observations on General Paralysis. The subject is obscure, almost mysterious, and invites, even demands, further investigations. There are not less than three works on the pathology of the disease noticed in this section. That of M. Magnan claims special attention, because he is a distinguished physiologist, a psychologist intrusted with the charge of a large hospital for the insane in Paris, and the initiator?perhaps unwilling, certainly undesigned initiator?of that agitation which commenced with his advent at the meeting of the British Association at Norwich, and closed,

we

shall

vivisection.

hope,

with the

legislative

enactments

respecting

He has, besides, a discovery?or the extension and interpretation of that discovery attributed to Bayle?to propound. His text and theory is that the fundamental lesion of this affection is a General Diffused Interstitial Encephalitis which involves accessory structural changes of different characters. ^Regarding the malady as a genuine Phlegmasie, but without condescending on its origin, he regards the primary and most palpable form of the Interstitial Degeneration as Colloid. This term is of such recent introduction into scientific language, that it seems prudent to explain what it is intended by the author to describe or define. This transformed matter is presented under the aspect of a hyaline substance, semi-transparent, slightly refractory, and at certain points of a bluish tint; when existing in isolated masses of small size, it preserves the form and aspect of whatever cerebral elements it may have invaded. When more abundant and collected together in patches, they are unequal, irregular, and fissured in various directions and depths. This product of inflammation, which is not affirmed to be tubercular, is not of fatty nature, because, insoluble in ether or chloroform; it is not amyloid, because unaffected by tincture of iodine, solutions of potass and soda, and is dissolved in concentrated acetic acid; and, lastly, it is not inorganic, as there is no

60

GENERAL PARALYSIS.

reaction with hydrochloric acid. Its solubilty in hot water, especially when potass or soda is added, is supposed to establish the possession of a peculiar chemical constitution. In examining the cerebrum as the principal seat of paresis, many authors have detected granulations on the ependyma of the ventricles, and have recognised these as the consequences of inflammation; but M. Magnan claims priority in having determined this locality as the centre, or it may be one of many centres of that disorganising process which is indicated by the symptoms of general paralysis, which penetrates throughout all parts of the encephalon, and produces those secondary pathological appearances which have previously been identified as the cause of the disorders of mobility and sensibility which follow. The progress of the degeneration, or morbid formative change, as it is called, from the stage when the ventricles have become dilated, their ependyma thickened?when their surface, especially in the fourth ventricle, is covered with granulations?must be upwards along the connective and involving all tissues, must be gradual, insidious, and can only be traced by the more serious and more advanced alterations in structure. This interstitial irritation?the phrase is M. Magnan's?by whatever law or influence disseminated, is propagated by nuclear proliferation, pervades the white matter in common with the cortical substance, and the capillaries, which are thickened, tortuous, and massed together; but, although the nervous tubes are rarely implicated, the cells of the cortical layers are sometimes found infiltrated with granulations, but preserving their form. This condition obtains towards the third or terminal period of the disease, and is not compatible with the preservation of life, although death does not necessarily ensue when a similar amount of disorganisation appears in the cells of the medulla. It may be expedient to sketch more minutely the features presented by the morbid changes in the cells. The superficial stratum of the grey matter may be found intact, but in the middle and inferior portions the cells are seen to have brilliant nuclei, tending towards colloid, while their normal aspect is preserved. But the walls of the cell nearest the lesion are transformed into a shining refractory hyaline substance, the The state colloid infiltration having been propagated to both. of the blood vessels should also be particularised. When a slice of brain is cut perpendicular to the axis of the capillary a colloid envelope is distinctly seen, there being visible in its orifice a mass of red and white globules. The opening of the vessel is sometimes regular, but often displays considerable inequalities and eminences. Around the canal there may be frequently discovered a ring of connective tissue, finely streaked,

GENERAL

PARALYSIS.

61

as to sliow that it has partaken of the colloid such rings, "when the walls of the vessels have Around change. it as were, rudimentary, there may be perceived cylinbecome, ders composed of several concentric layers of hyaline, differing in thickness, and almost or altogether obscuring the course of the vessel. The second of these envelopes is furrowed in different directions, across which at certain points may be observed one or more nuclei so disposed as to resemble the presence of vesicular cells, fusiform, radiated, in fact, cell elements of various forms. More narrowly observed, these lines and spaces may be recognised as disintegrated fragments of hyaline. These nuclei are spherical, distended, and present various shades of brilliancy, according to the point from which they are viewed. Occasionally colloid constitutes the inner face or wall of the fibrous rings, its concentric layers furrowed and separated, in the middle of which are seen nuclei, which justifies the belief that the connective tissue is the framework of the interstitial deposit. It seems, consequently, that this degeneration, like others, acquires a basic tissue, which is itself under the influence of the morbid formative irritation affecting the whole organ, and is thus prepared for the whole series of subsequent changes. (P. 12.) These microscopic features, as well as those conspicuous to the naked eye, may appear first in the brain and its appendages, and afterwards in the medulla; or they may appear first in the medulla and afterwards in the brain ; and they may appear simultaneously in both organs; or, in other words, the progress may be upwards or downwards along these nervous tracts. According to priority in the development of these pathological conditions are observed perversions of mind, of motility, of sensibility. Should the brain be originally attacked, the psychical signs predominate, or are exclusively manifested ; should the medulla be the primary seat of the disease, muscular pain, tremor, in fact, ataxic symptoms, spreading gradually to the lips and tongue, disturbance of the internal viscera corresponding to the portions of the spinal column involved, precede alienation, and greatly augment the difficulties in diagnosis; and, lastly, when the whole cerebro-spinal axis participates at once in the colloid degeneration, the characteristic indications of paresis will appear simultaneously, or in rapid succession. But in addition to the diffusion of colloid over the great centres, and especially within the medullary canal, where there may likewise be detected thickening of the meninges, serous, and purulent effusions, and other subsidiary or supplemental alterations, and followed by perversions or abolition of general sensibility; the nerves of the special senses are likewise involved,

and

so

bright

62

GENERAL PARALYSIS.

or abolition of vision, hearing, etc., which that sclerosis, as it is vaguely designated, involves all parts subservient to nervous action. We have scrupulously excluded from this vidimus of M. Magnan's observations all except what he has claimed, or may be disposed to claim, as original, in order to present his opinions in as simple and succinct a form as possible. Perfectly reliant upon the trustworthiness of post-mortem teaching, rigid in his deductions, and arrogating the credit of a discoverer, he consents to dismiss the visible alterations rather summarily and suspiciously, as depending upon constitutional, and not local morbid action, except when those alterations are taken together: the only alterations, in fact, which Bayle, Calmiel, and the great majority of pathologists have relied upon ; to relegate the appearances seen by various investigators in the Corpus Callosum, the Pillars of the Fornix, in Paresis, to that refuge for the destitute, the category for exceptional cases; but is compelled to admit that the Colloid Degeneration, upon which he has so fully insisted, is far from being constant in Paresis, and that it may be met with in other diseases remotely connected, or in In illusno degree connected, with that under consideration. tration of this latter proposition examples are cited where the affection of the Ependyma of the fourth ventricle signalised has been met with after Muscular Atrophy, Chronic Alcoholism, Senile Dementia, Tetanus, and the Tubercular Meningitis of children. The contents of this volume could not easily be divined from its title, or that of its principal component parts. It is an Omnium Gratherum of able, but rather incongruous, essays and lectures, which have previously done good service, on the Physiology and Clinical Pathology of the effects of Alcohol and Absinthe; on Hemianesthesia as a consequence of the abuse of stimulants; on the Strait Waistcoat; on the Statistics of the admissions and relative proportions of cases of insanity from abuse of alcohol into the hospital of St. Anne during the gloomy reign of Communism. The object of the first of these disquisitions is to establish a generic distinction between the intoxication produced by alcohol and that produced by absinthe; this differentiation is demonstrated by experiments upon the lower animals. Drunkenness and a number of signs common to the toxic consequences of both of these stimulants, follow the rapid administration of large quantities of both poisons in quadrupeds; but where alcohol alone is exhibited the succeeding paralysis is at first confined entirely to the muscles of the posterior part of the body, and the subject is agitated by fearful illusions ; whereas when absinthe is given the muscles of the anterior part of the body are first palsied,

entailing impairment is adduced as a proof

63

GENERAL PARALYSIS.

hallucinations ensue, and towards the close the characteristic and diagnostic sign appears, in convulsions, varied in their seat and extent, but representing genuine epileptic seizures. The distinctions will be best indicated by introducing two typical experiments. In dogs, we are assured, absinthe, whether introduced into the stomach or injected into the veins, excites delusions, fear, anger, contractions of the muscles of the neck and trunk amounting to episthotonos and pleurothotonos, and ultimately general convulsions and death. One animal, under five grammes of the essence, is graphically described as without provocation rising to his feet, his hair erect, his aspect ferocious, with his fiery eyes fixed upon a bare wall; then as rushing to and fro against an ideal enemy, barking, gnashing his teeth, and then appearing to tear what has roused him to fury; the scene ending in convulsions. When dogs are treated in the same manner with alcohol, the phenomena, both psychical and physical, are widely different. They become slightly excited, rush or reel, or leap to and fro, then pass from hebitude into semi-stupor, comatose sleep; anaesthesia and paralysis succeed, at first confined to the hind, but ultimately involving all the extremities, with general relaxation of the body, but never convulsions. When death terminates these

manifestations, of

the

pathological

appearances

are not

further record than that they resemble those

drunkards,

worthy

met with in

such as fatty or steatomatous degeneration, espeof the liver. It may interest our vivisectors to know that the opisthotonos and other modifications of convulsions, commencing in tonic and ending in clonic spasm, have been noticed in dogs after the removal of the cerebral hemispheres. Whenever absinthe is swallowed by man, the immediate impressions, if not pleasures, are a feeling of nausea and then of giddiness ; and when the dose is large, or the debauch repeated or protracted, epilepsy may be induced, but does not invariably follow. As a most suitable and a solemn corollary of his experience upon this point, M. Magnan alludes to the recherches of M. Marce, of Bicetre, who first, in 1864, determined the he quotes power of absinthe to produce delirium, etc.; secondly, and the reports of MM. Marce, Contesse, Morel, who, during years undisturbed by moral or political convulsions, calculated that in 6,000 lunatics about 20 per cent, could be traced to the abuse of alcohol; and thirdly, to the fact that in the asylum of which he is superintendent there were received during four months of the eventful years of 1870 and 1871, 1,589 insane persons, in 387 of whom the mental disease was complicated with alcoholism, either as a cause or a consequence. But when the darkest months during which this social storm raged

cially

64 were rose

GENERAL PARALYSIS.

reached, it is found that the proportion of dipsomaniacs per cent., while in the corresponding month of

to 48

the preceding year it amounted to 26. This disparity may be so far explained by the facts that the insane drinkers in the ranks of the National Guards during the first year would escape detection, and that law, order, and the preservation of peace, health, and personal safety, had all disappeared, amid the general confusion of the second year. It must naturally be very difficult at all times to ascertain the precise nature of that excess which has been consummated in derangement; but our author has come to the conclusion that absinthe was less accessible, and brandy was actually served out to the belligerents during the Commune?a circumstance which must materially affect his subsequent enquiry. Perhaps, as a result of this, of the inebriates admitted in 1871, only five individuals laboured under epilepsy, four of whom took absinthe; several, however, in addition to In 1870, of 155 dipsomaniacs admitted, 17 other intoxicants. 16 appear to have been absinthe were epileptics; of these drinkers, although not exclusively so. In reference to the occurrence of convulsions in patients who had limited their potations to wine or alcohol, M. Magnan believes that he could trace a predisposition to epileptiform or apoplectiform attacks. It is quite evident that, however suggestive these statistics may be, the data furnished are altogether insufficient to demonstrate a more intimate connection between indulgence in absinthe and convulsive seizure, than between them and the abuse of other stimulants. In a chapter devoted to the mental manifestations during the acute and chronic stages of alcoholism, the author has recorded many valuable conclusions upon, first, the early invasion of delirium and tremor in absinthe drinkers, as well as the painful colouring of their delusions ; secondly, upon the permanence of delusions independently of delirium in insane inebriates; thirdly, upon the tendency to Suicide and General Paralysis in this class, giving a table in which, of 438, 34 had attempted to commit suicide, and 10, homicide ; fourthly, on the enfeeblement of memory, judgment, imagination, blunting of the moral sense, and general degradation, which are the results of frequent attacks of delirium tremens or continued intemperance; fifthly, on the culminating physical alterations, especially fatty degeneration, which close a similar course; but we must regard as superfluous his exhaustive portraiture of the fancies, follies, extravagance, and varied tempers and tendencies which mark the progress of inebriation, seeing that these are generally the faithful representations of the dispositions, the habits, or constitutional condition of the individual.

GENERAL

65

PARALYSIS.

Besides these grave lesions of the understanding, chronic alcoholism is often accompanied with diminished or abolished sensibility of one side, technically designated hemianesthesia, the sequence probably of congestive, hemorrhagic, or other conditions of the brain or medulla. This deprivation comprehends the sense of resistance, temperature, and so on, is not merely cutaneous, but extends to subjacent organs; but the sensation of cold is sometimes experienced in the member affected, which is invariably less warm than that of the opposite side. The contractility of the muscles in the paralysed region continues unimpaired. The border limits of superficial anesthesia are sharply defined, extending to within a few lines of the Median line; but when profound and general, all tactile impressions without the co-operation of vision, whether imparted by the hand of a companion or the limbs of a compass, are with regard to the parts implicated obscure, imperfect, and topographically incorrect. As has been noticed by other observers, this condition often persists while the impaired motility which contemporaneously indicated the supervention of brain disease disappears. The sclerosis and subsequent disease of the organs of circulation upon which these phenomena are supposed to depend often invades the nerves of the external senses and the surrounding tissues, so that the eye, ear, nasal and buccal membranes lose their special function as well as the general sensibility by which the exercise of that function is effected and regulated. It may be stated as an instance of minute observation that the sclerotic tissue of the eye is less sensible to physical irritation than the cornea in such cases, the explanation of the difference in degree being afforded by the origin of the nerve supply. But such suspension of sensation is not necessarily connected either with alcoholism, apoplexy, softening, or sclerosis; but may originate in functional disturbance or in some structural but unknown condition of the encephalon. The seat of this obscure cause has been sought and supposed to be found in various regions of the organ, supposed on theoretical, sometimes on physiological, grounds to preside over the perception of normal sensible impressions. Longet and Vulpian localised this power, and the opinion has been generally adopted in France, in the annular protuberance; Todd and Carpenter regard the optic thalamus as the point where tactile impressions enter consciousness, and the corpus striatum as the tract through which volitions are propagated; Turck, guided by several pathological observations, concludes that impairment of the external senses may be traced to various changes, such as extravasation of blood and ramollissement, in either hemisphere; Charcot found lesions in the posterior half of the optic thalamus and adjacent part, in cases where the paralysis, -

PART I.

VOL. III.?NEW SERIES.

E

66

GENERAL

PARALYSIS.

tremor, and anesthesia existed on the same side. M. Magnan's own investigations have led to the belief that the optic thalamus, the lenticular nuclei, the internal capsule, and the radiated tract are the portions of the brain chiefly implicated in the morbid manifestations of sight, hearing, &c. These perplexing contradictions in physiological pathology, accentuated though many of them may be, instead of exposing the worthlessness of such inquiries, or that they lie outside the domain of science, should be accepted as suggestive of further and more laborious observation and in a different direction. M. Magnan is an apologist of restraint in the management of the insane. He denounces the camisole as entailing evils such as necrosis of the elbow joint, unheard of even during the epidemic furor against all bonds which agitated England about thirty years ago ; and prefers a loose jupe or maillot, the arms of which terminate in culs-de-sac, which are affixed to the dress, as imposing no restriction on the thorax or abdominal

muscles,

and

as

free from all similar

evils enumerated death appears

objections.

Among

the

occasional accident. But what mainly concerns our present purpose is that he conceives it important to state the comparative mortality of insane inebriates under the two different methods of coercion; thus the proportion in Bicetre Avas as 8 to 1*30 in St.. Anne's, the mode of medication being analogous in both, except that the camisole was employed in the former, the maillot in the latter. It is expedient to mention here that many of the facts and opinions of M. Magnan have previously appeared under other forms and collocations in his L'Acoolisme, 1874. as an

II. From the preamble of the work of MM. Bonnet and Poincare it might be reasonably anticipated that a Terra Incognita had been explored, a North-West passage discovered, a Gordian knot unravelled ; that the difficulties involved in the origin and progress of General Paresis had been solved. Such expectations are scarcely realised ; but the authors have de-

veloped an ingenious and perhaps new explanation of the pathology of this obscure disease, which is deserving of investigation. They initiate the inquiry by describing the first stage in the history of the observation of the malady as mythological, attributing the views originally entertained to defective anatomical and physiological knowledge, and to the ambiguity of To Haslain is the terms used to record clinical observations. traced the mere discovery of the symptoms now recognised as indicating a distinct nervous affection; but to Georget, Esquirol, and, above all, to Bayle, is awarded the merit of having recorded its principal features and characteristics. In our own opinion,

67

GENERAL PARALYSIS.

while the latter author may be regarded as having presented the morbid anatomical appearances which were supposed to explain the nature of the hitherto unknown affection, Calraiel, who is still alive, was the first psychologist who formulised the whole subject, and assigned to its dual aspect and to the physical and psychical signs their true position among mental diseases. Our authors not merely dispute the propriety of the designation of general paralysis, and the rank it has assumed in systems of nosology, but they prefer to define it as an interference with vaso-motor and reflex action, which gradually attacks and destroys the functions of every organ ; but, while admitting the of congestion accuracy of Bavle's observation as to the presence of the brain and its envelopes, they dispute the relations which these were supposed to occupy in the causation of the mental and muscular phenomena, holding them to be secondary, or, rather, one of a series of structural changes, the primary origination of which constitutes the central fact in the theory which they have propounded. The following propositions precede, and are perhaps intended to preface, the special objects of the monograph: 1st. Is this malady a cause or a consequence of insanity ? 2nd. Are the somatic symptoms invariably and inevitably connected with mental disturbance ? 3rd. Are the structural changes in the brain the cause of the paralytic condition ? 4th. Do not other lesions exist to which the symptoms may be referred ? 5th. Is the affection developed insensibly, or is its progress marked, step by step, by specific mental signs ? fitli. Is the advance of the physical and psychical changes parallel, or may they not reciprocally mask each other so that certain indications of one or other may appear latent ? Curious transcendentalisms occasionally crop up in other forms, but they do not obstruct nor obscure the really plain and practical bearing of the discussion. A copious catena of opinions and authorities in connection with the pathology of paresis is supplied, which shall be cited in an abbreviated form, as it bears upon the history of what is pointed to as a new disease, as a product of civilisation, and even by MM. Bonnet and Poincare as an outcome of luxury and irregularities in digestion and nutrition. Bayle designated the disease chronic arachnites; Calmiel, diffuse chronic meningeal encephalites, and, with a long train of disciples, held it to be of inflammatory origin. To Baillarger two sets of anatomical alterations, congestion of the membranes and chronic hydrocephalus, with atrophy and softening of the brain, appear of different import. He adds likewise a pathoK

2

68

GENERAL

PARALYSIS.

gnomic cretiform expansion radiated in the grey substance. The objections to the early opinions, according to Marce, are the impossibility of conceiving a malady appearing in a chronic stage, of the non-appearance of exudation in its progress, and of its prolongation during many years. Brunet and Lancereaux speak of a neo-membrane, or a pachymeningitis, the formation of which they explain by the exudation of aparietal layer from its walls,which is insensibly organised, and which bears the marks of fatty degeneration. The rupture of these vessels leads to the

occurrence

of arachnoid cysts.

Erlenmayer explains the atrophy which has been noticed the successive, by the repeated, effusion of serum, the nerby vous elements being replaced by an amorphous substance. While Calmiel described the adhesion of the pia-mater to the grey substance, and the formation of vascular loops in the capillaries,

where the inflammation was intense; and while others described the intimate soldering of this membrane to the surface, so that it cannot be separated without rupture of vessels, and the difference in coloration, and density,of the grey matter itself, even its ramol-

lissement, M. Parchappe localises this degeneration inthe middle layer of the substance, the superior and inferior remaining healthy. Although Grratiolet has demonstrated distinct cortical strata, it has been contended that a scalpel could not separate "

and individualise these with such accuracy that any deductions could be established so as to justify reliance upon the pathognomic sign propounded by M. Parchappe. M. Frcerichs adduces the induration of the grey matter as connecting the pathological condition with sclerosis. Although the alterations in the white matter are slight, they exist, and consist chiefly in hardening or softening, the augmentation of the fluid of the ventricles, the thinning of their parietes, which resemble indurated ependyma. Asperities are found were formerly detected by Joire in the which the surface, upon

fourth ventricle, and are, according to Rokitansky, exudations of plastic albumen; and, according to Meyer, hypertrophy of the

epithelium of the arachnoid. M. Luys' conviction, that

in the softening of the cortical substance of the cerebellum may be discovered the source of general paralysis, is asserted by M. Magnan to have been Inflammation of the same founded on exceptional cases. organ has been elected by M. Bouillaud as the source of the disease; but this view may have been so far governed by the supposed connection of this portion of the nervous system with the regulation of motion. In dealing with the results of microscopic anatcmy, M. Luys represents the vessels of the pia-mater as of considerable size, the walls of the

GENERAL PARALYSIS.

69

incrusted with granulations, the surface of the membrane presenting scattered cell granules and molecules, and extravasated blood globules. The opaque plates consist of hypertrophied cellular tissue, in which the vessels are infrequent and small. The grey substance is greatly developed, with palpable vascular arborisations, often in the form of a plexus. The calibre of the capillaries is almost always contracted by the incrustation of minute granules, or by cells deposited chiefly at the bifurcations, which are of irregular shapes, often break down, The nerve tubes are malformed, and discharge, their contents. their contents escape, and they present little more than a mass of debris. M. Rokitansky has detected three distinct pathological appearances: 1st. Where a mass of connective tissue embraces in its network the nervous element, and, in chronic cases, is stiff, fibrous, and induces adhesions of the pia-mater; 2nd. The tubes are varicose, broken, while the cells appear swollen; 3rd. The presence of anyloid or colloid bodies. Wedl's special observations on these points are: The contraction of the capillaries and small blood-vessels, in consequence of the cells upon their walls, leads to obliteration, their conversion into bands or connective tissue, and the consequent impairment of the nutrition of the part. He has further described hypertrophy of the cortical substance. M. Salomon looks upon the degeneration of the adventitious membrane of the vessels of the pia-mater, and of the connective tissues of the cortical substance, ultimately involving the cells and reducing them to an inert mass, as the seat of the disease. Dr. ErtzbischofF attributes the hypersemia of the cortical

capillaries

layers

to

as

the

extreme

development

of the

embryoplastic

element in the capillaries; which, compressing the vessel without and within, diminishes and ultimately destroys the cavity. This stasis necessitates granulation and adhesion. The majority of German pathologists localise the disease in changes of the walls of the vessels, and in the development of the connective tissue; but Meschede sees the essential characteristics of paresis in the degeneration of the cerebral cells, but especially of those of the cortical substance, which he depicts as of abnormal shape, and as filled, nodulated, or surrounded with fatty and

granulations.

pigmentary

Lockhart Clarke in like manner signalises the conversion of the cells of the convolutions into pigmentary bodies, irregularly shaped and about to break up. He adds that, contemporaneously with this change, the spinal marrow, especially in chronic cases, is softened, even to the consistency of cream; or there may be granular degeneration in its grey matter or its surroundings.

70

GENERAL PARALYSIS.

Westphal has, like our countryman, discovered in certain granular degeneration in the posterior column of the spinal marrow, which did not, however, extend higher than the peduncles of the cerebrum, so that the alteration could not be regarded as secondary, or as proceeding from the pathological

cases

condition of the convolutions. He likewise adverts to a cross alteration between the posterior column and the posterior portion of the lateral column, which he refers to local myelitis inducing necrobioses, by what he calls functional inertia. M. Magnan, while writing copiously upon the structural changes in paresis, selects as the diagnostic feature nuclear proliferation of the interstitial tissue ; parenchymatous changes are consecutive, and characterised by granular transformations. It must be further noticed that this description involves the presence of fatty degeneration and the consequent destruction of the Myeline sheath, and that the bias of this pathologist is? in harmony with that of Lockhart Clarke and Westphal?that the morbid process ascends from the spinal marrow to the brain rather than that it descends from the brain to the spinal marrow.

The second section of the volume is entitled, " The Clinical Philosophy and Physiology of Paresis." It is appropriated to a rather promiscuous assemblage of the causes, causative and collateral influences which may lead or tend to the production of this neurose. The following introductory remarks are noteworthy : Idiots and imbeciles are entirely exempt from this degeneration; that the flushing swelling of the countenance in certain individuals, even after a moderate repast, indicates the effect of ganglionic influence upon nutrition; that, when eating is indulged in to repletion, the immediate effect is the exhaustion and enfeeblement of the sympathetic system, the ultimate effect being paralysis or symptoms of vaso-motor and reflex disturbance; that intemperance and irregularities in conduct, of whatever kind?syphilis for example?may create or accelerate the course of paresis. This course is divided into four stages: 1st, that of delirium, with or without slight physical lesions; 2nd, that of defective co-ordination of movement, exaggerated sentiments, alterations in the secretions, with continued delirium; 3rd, that of special dementia, with greater stupidity and degradation than in other forms, control of muscles diminished, habits dirty; 4th. perception of impressions by external senses abolished; insensibility to pain; extinction of functions of relation and organic life, disturbance in circulation, complete adynamic ataxy, marasmus. It is affirmed that the dynamic signs are developed at an earlier stage than the organic; but, even if advancing simultaneously, the different degrees of intensity in these may

(3ENERAL PARALYSIS.

71

conceal the progress of either. Optimism and ambitious ideas constitute the essential mental characteristics; but lypemania may exist, without, however, altering the special form, or leading to the fallacy of confounding the affection with other forms of alienation. Previous to the establishment of complete delirium or delusions, there may be traced deviations from healthy mentalisation, which, though faint or latent, should be accepted as prodromata. It might be difficult to determine upon what cerebral change these precursors may depend, but it may be confidently believed that the gradual evolution of physical and psychical symptoms corresponds intimately with structural alterations in nervous substances. Accordingly, there are found grave morbid appearances not merely in the brain, spinal marrow, and their dependencies, but in the viscera subservient to organic life, which must be embraced in constructing a correct and exhaustive pathology of the disease under consideration. The universality and connection of these conditions may be represented as a circle, along the links of which the pathogenic process primarily moves from below upwards. As a penumbra or illustration of their theory of an ascending morbific current from an abdominal origin, the authors have sketched the phe^ nomena of intoxication. It is conceived, from the universal distribution of the plexus of the sympathetic through the viscera, that the excitation following the absorption and assimilation of stimulants must be incessantly propagated to the spinal marrow, to be from thence passed along every nerve distributed to the organs of circulation throughout the economy. From this excitement arise various changes in the vital functions, and especially in the brain. While, consequently, alcoholic intemperance directly induces paralysis, it remotely injures the fundamental laws of nutrition and of the ganglionic system. This influence of the great sympathetic creates congestion at Orievery point, but especially where it acts upon the brain. the base, the congestion radiates at the at ginating ganglions to all the contents of the cranial cavity, even to its osseous walls. By a sudden transition from the effects of .an artificial and to those of permanent morbid action, MM.

temporary poison

Bonnet and Poincare represent the changes in nervous matter in paresis as all flowing from the congestion originating, they

ganglia of the sympathetic, transmitted along the spinal cord, ultimately involving every tissue within the cranium, and eventuating in, simultaneously, the degeneration of bloodvessels, cells, and nervous tubes and the mental and motor perversions which distinguish, in so marked a manner, general paralysis from all other diseases of the same class. The third section of the treatise contains a large collection

believe,

in the

72

GENERAL PARALYSIS.

which may be divided into Wo series, the first of which symptoms and general pathological results of the disease as exemplified in impaired nutrition, ganThe second and detailed grene, and widespread necrobiosis. series describes the local and specific lesions in which the origin, nature, and symptoms are supposed to be detected. The chapter is followed by eleven plates, which, although not boasted of as precisely exact, exhibit with sufficient fidelity the microscopic appearances which the authors have observed, and upon which they base the doctrine which they have initiated and support. This doctrine may be epitomised in the following terms:? 1. There are proliferations of the cellular tissue around the vessels of the nervous tissues; but these do not diminish nor efface their continuity, nor, consequently, interfere with the circulation, or, in other words, induce sclerosis. 2. The essential change in the encephalon consists in fatty degeneration of the cells; but there are likewise noticed, though more rarely, free fatty globules mingled with granular matter, sometimes free, sometimes agglomerated; such masses of ferruginous granulations are not enclosed in a common membrane; pigment, hematosine are met with in the walls of the vessels; sometimes the fatty granules form enormous agglomerations upon the periphery of the vessels; often large fat globules, free or mingled with blood disks; but the nerve tubes are unchanged. 3. We have found no other alterations in the spinal cord than ferruginous granulations adjoining the ependyma. 4. The cells of the whole chains of the grand sympathetic present a brown, rusty pigment much more intense than in other subjects, such as those who have died from old age or typhoid fever. In the cervical, and often in the thoracic ganglia, there is an obvious substitution of adipose for true nerve cells, which are comparatively rare, in which we recognise the primary origin of the disease, while the alteration of the vessels of the encephalon of itself can be held as secondary only. There is always a marked pigmentation of the spinal ganglia, and of those connected with the cranial nerves. The fat globules substituted for the nerve cells in the ganglia of the grand sympathetic are often blackish. 5. All such alterations proceed from irregular or defective nutrition, and assimilation such as occurs in the luxurious, the intemperate, the abstinent, the studious, which entail fatty degeneration and its subsequent manifestation in ataxy, and enfeeblement of all the functions of relative and vegetative life. It should be added that in addition to the rusty coloration, and the presence of superabundant cellular and fatty tissues in

of

cases

is intended to show the

73

GENERAL PARALYSIS.

the cervical ganglia, there has been discovered distension and varix of the vessels, which, in common with the morbid changes enumerated above, is supposed to suspend the innervation upon which the health of all parts of the nervous system depends, and ultimately to issue in that cerebral congestion, adhesion of membranes, and cell alterations, which have hitherto been esteemed the proximate anatomical cause of this affection. This analysis has already exceeded the proportions to which MM. Bonnet's and Poincare's clever disquisition is fairly entitled; but the objects of scientific criticism would be altogether baulked were we not to mention that, with pathological appearances closely resembling those described above, but in the abdominal ganglia, M. A. Voisin* has found connected, hypochondriacal insanity, suicidal melancholia, altogether independent of muscular complications, and in striking contrast with the exaltation of the sentiments and imagination, and the delusions characteristic of general paralysis. even

III.

Such grave questions have been proposed by and to whether general paresis is of recent birth and growth ; whether Pinel, living about one hundred years ago?a keen observer and benevolent innovator?did not observe disturbance of the muscular system in conjunction with the monomania of pride and aggrandisement, which he did actually observe; and whether, until 1820-30, the affection had altogether escaped medical notice or record. M. Foville has essayed to answer or elucidate these inquiries. He considers that he has discovered two examples of the malady in extreme antiquity; one of these, cited from "Heraclides de Pont," by Claudius JElianus, occurring in the fourth century. The patient conceived that all the vessels entering the port where he resided were his property, registered them, sold them in imagination, and, subsequent to his recovery under medical advice, luxuriated in the splendour and delights of his

psychologists, as

delusions.

Horace," who paints a visionary attending an empty theatre, seeing and applauding imaginary tragedians, who in all the other relations of life was a sane and The other is taken from

"

sober citizen, and who recovered reason under the use of hellebore. His cure brought to him regret and misery. We suspect that the curability of these individuals, who evidently laboured under partial delirium, removes them from the category under

consideration.

By *

1876.

an

acrobatic feat,

Lemons Cliniqucs

tur

displaying

Lcs Maladies Merit ales.

marvellous

agility,

Par le Dr. A. Voisin.

but Paris,

74

GENERAL PARALYSIS.

the barrenness of the intervening- space, the third outside of medical literature is found in the astronomer, the possessor of all power over the heavens and the earth, in the happy valley depicted by Samuel Johnson. Sneering, like Shakespeare, at the potency of a name, and exposing the long prevalent fallacy of comprehending many varieties of derangement under the generic titles of mania and melancholia, it is demonstrated that cases closely allied to,, if not identified with, those of general paralytics, such as of the woman who conceived that she supported the world on her little finger, that the slightest motion would involve universal ruin; and that of the youth who proclaimed himself monarch of all But the author confesses that he surveyed, were so classed. that until the eve of our own time night brooded over the inventive faculties of the early, mediaeval, and modern physicians, and that the only light shed upon the complication of which he treats was accidental and partial, and when reference was made to

betraying

instance

insane ideas of greatness and grandeur. Linnaeus, the real inventor or originator of classification, followed by Sauvage, applied the same rigid and narrow principles in the definition and distinction of diseases as had been employed in botany. In the Vesanise of the latter is included a happy melancholy,

a lively moroseness, under which the patient feels joy ancl gaiety, and has ideas of wealth, power, and even of divine attributes. Cullen, Boerhaave, and Van Swieten all accept the melancholia moria of Sauvage as a distinct species of disease; while Plouquet rushes back into the infinite, or rather the indefinite, in establishing 196 species of these affections; so that it was not until a school, a secession, had separated from the general mass of the medical profession, nor until the bright sunrise of Esquirol and his disciples, that clear and precise experience dawned upon the minds of scientific men. The solidarity of Arnold, in his opinion as to the nature of alienation, may be contrasted with his multitudinous metaphysical divisions into genera and species; and it should be recollected that among the latter are placed two varieties of the insanity of Vanity, and that none of his compeers or compatriots appear to have outstripped him in the progress of discovery. Haslam, Eush, Dubuisson, Esquirol, and many others, have in turn signalised grandiose notions as features of alienation; but to Bayle is due the discovery, if it be a discovery, that with these mental deviations were conjoined affections of motility, that

this combination constituted one distinct individual disease depending upon inflammation of the membranes of the brain, While Bayle emand designated by him chronic arachnitis. braced the whole subject, detecting and describing the different

GENERAL PARALYSIS.

75

downward progress, and electing optimism as the mark of this neurose, and while he was opposed by Greorget and others on the very ground that he gave undue prominence to this symptom; but for Calmiel, not merely as the first and most catholic monographist of general paralysis as a unified group of symptoms, but as having placed these in their due rank and relations, must be claimed the merit of having described the intractability and fatality of the malady, its marked preference for the male sex, and the various but invariable phases which its history presents. In his judicious estimate there is due allowance made for intellectual enfeeblement as a precursor of other symptoms, cheered, however, by pleasurable if not happy fancies and follies, and for the exceptional development of depression, hypochondriasis, even lypemania, in the course of the mental degeneration. In the present day many instances are mentioned where melancholia appears to take the place and play the part of exuberant joyousness; but we have always held the opinion that this transformation may be traced to the exhaustion prevailing towards the termination of life; for general paralysis may be styled an asylum disease, a disease consigned to seclusion towards its close; whereas optimism, extravagance, misconceptions and miscalculations of health, wealth, real position precede the cognisable commencement, and may predominate over the character for years, or for a whole life, and may be interpreted as the manifestations of natural dispositions and habits of thought. That the mania of pride and ambition may exist independently of paralysis is true; that the malady may follow as the last stage of other, even depressive, modifications of insanity, is likewise true; but that lypemania is encountered more frequently than optimism as the primary stage, as has been affirmed in his latter writings by Calmiel, is This is an age not supported by experience in this country. of differentiation, and that malady which was recognised by Bayle, &c. as one, has been split up into acute, progressive, chronic, necrobiosis, and into psychical modifications determined by the original or acquired tendencies of the individual. Even Esquirol contended that the association of motor with sensory affections might be a mere complication ; and even down to the epoch of Trelat, there have been suggested speculations upon the difference between a madness which revolved upon egoism, and that of riches, property, power. That all paralytics may become delirious may be doubted; but the question is whether such a delirium assumes a particular aspect, that aspect being partial, limited, ambitious, and whether, as Billod and some recent writers have affirmed, these restricted limits may not include a vast number of grandiose ideas. But amid this

stages of diagnostic

76

GENERAL PARALYSIS.

multitude of counsellors and plethora of counsel, Brierre de Boumont is orthodox to the creed of Bayle. It would be vain to discuss here how far paresis can be created by our own conduct, or rather the non-regulation of our mental constitution; how far the will enters into and may dominate the mind during the process of decay; whether this power be greater or less than in simple monomania, or whether all delirious conception may not be tinted or tainted by exalted feelings; but it is worthy of record that Baillarger has recently introduced a new element of diagnosis, and that while he admits ambitious mania as the initiatory stage of paralytic dementia, he conjoins with this embarrassment of speech; or, should that be absent, an inevitable descent towards deterioration and death. But he admits a class of exceptional cases in which the ambitious mania appears in circular mania, and in conditions resembling the maniacal form of paresis, but ultimately or permanently ceases and gives place to lypemania. Upon this formula M. Baillarger confers the name of congestive mania, and argues that it should hold the same relation to paralytic dementia that simple mania does to dementia. This denomination has become popular within a privileged circle, but not beyond. M. Falret, at the head of a numerous phalanx of psychologists, including Parchappe, Delasauve, and Brierre de Boumont, rejects these propositions, and argues that the delirium of grandeur, incoherent, wandering, contradictory, united to affections of motility, distinguishes general paralysis from its commencement and continues to its close, and that the brief simulations of amelioration offer no exception to this rule; and contends that the morbid individuality thus recognised is in no degree affected by the transitory development of proud or vain delusions or emotions during the progress of other mental affections. M. Foville concurs in this definition, but confesses the existence of anomalies which it does not include, and which increase the difficulty of diagnosis. The coincidence of ideas of aggrandisement with partial delirium, altogether unconnected, either at the commencement or the close, with paresis, prompted M. Dagonet to propose the term Megalomania as more significant than monomania of this state. But this appropriateness has not been homologated by others, except the word be limited to the combination of morbid pride and delirium, to distinguish which it was suggested, and be not substituted for other forms of monomania or partial The views of the originator of this specific term delirium. have been advocated by M. Broc in his thesis on that partial delirium in which the predominating passion is the exaggerated sentiment of personality. In a later, but unfinished, work, M. Baillarger says that congestive mania is not the first stage

GENERAL PARALYSIS.

77

of paresis, nor of simple insanity; that the mania of ambition may exist without general paralysis ; that general paralysis may exist without the mania of ambition; and, in fact, approaches the opinions of every author who has written since Bayle, and who, without adopting his propositions in their breadth and detail, have recognised the specificity of general paralysis, and that, in the majority of cases, it is characterised by the mania of ambition. An attempt has been made to distinguish non-paralytic mania of ambition by describing the mental state as slowly elaborated, fixed, and systematised from paralytic mania of ambition in which the mental state is multiple, mobile, inconsistent, motiveless, and bearing the stamp of fatuity; but this distinction has not secured the approbation of other psy-

chologists.

the

The present state of the discussion may be

following propositions:?

1st. A certain

represented by

number of authorities have accepted the of M. Dagonet as to megalomania. 2nd. That all authorities concur in holding that the central and essential symptoms of general paralysis is, at one period or another, the delirium of ambition. 3rd. That M. Baillarger almost alone affirms that this delirium of ambition does not necessarily eventuate in general paralysis, but in passing or permanent re-establishment of health ; his opponents retorting that this restoration is merely apparent and deceptive, where the patient is removed from medical observation; but where, could his path be followed, it would be found to terminate in the full development and general results of general paralysis. We have endeavoured to extract all that can be regarded as historical, leaving much that is metaphysical, argumentative, and controversial, from the able excursus of M. Foville, which formed a part of a work to which was awarded, we think deservedly, the Civrieux Prize of the Academy of Medicine, and which first appeared in the Annates Medico-Psychologiques.

opinions