^1-vfXa.
	'-' T\ "CWCSSr
(	
	'--■"•'wSifcWBbWl
	' '•'"• ^-^-SWWtfSJE
^ ' ■	r—it. nkjisaaftap
	' ,A t^. V ^flVHff
	
	
'*■.-:•	
	
	
""* u' -V.,	.*■■:. ■"-.■''.'^^:
:'-^.WW .	* .." '. . - *£"■
S ca»t»:v: •„	T,JC , ..^.. ^ \-"
" "V ,.'    'S ■ • * •• •

   T^yX*:-"■'■*■










                 £;» d>^vL^S^-iS- .-.'•-'.V' ' ~
                 ■l4> ' .*iJ> "-''•'-•■-■'  ',■•■  •« -*' ':
iir-;^-_:

.i'v»;~,:^."'-r.. i'

 
NLfl OOSSTMTT fl
NLM005594998 
« 
 
/
A

Zl
^L^*~--i-'£

/
cnvf-

OHIO STATE  MEDICAL  SOCIETY

     TOLEDO, ()., Jink 16-17-18 1874.
      REPORT



General   Paralysis,
                   «

    I). A. MORSE, M. I).,
           OK
   LONDON,  O FT I O.
 
N\884r
 I8t4 
St
r
           REPORT


               ON



GENERAL  PARALYSIS,


               BY



      D. A. MORSE, M. D.,


           LONDON, OHIO, 
Report   on  Monomania,
                    —BY—

       I).  A.  MORSE,  M.  I).,
             OF LONDON, OHIO.
  Is there a Monomania? Is there a mania 'wit/tout delirium? withou*
delusion.? f  An Instinct ice Mania ? Is there a Reasoning Mania; the mo?--
al insanity of Prichard ?  How are instinct and intellect  related?  Can a
man be insane as to one idea, or fact, and sane as to all others?  Can a
a man be insane as to instinct and remain sane in intellect?  Is delusion a
test of insanity? Is "Knowledge, of right and wrong" a just and sufficient
test of responsibility ?
(Jchtlanai of the Ohio State Medical Society:
  Last year I directed your attention to a condition, or disease.
alleged by many writers to be entitled to rank as a form of  in-
sanity, and which is, viewing it from their standpoint, of suffi-
cient importance and distinctive characteristics to be  designated
a monomania, by name: Dipsomania.
  The  views of  any one writer upon  the  subject  are  brief,
scattered, yet I  collected them;  presented  my  theory; and
awaited the verdict of those who had given the subject  special
attention.  The reception  it met with is sufficient evidence that
m}? labor was not fruitless.
  The subject of Dipsomania involved many questions not con-
sidered  in that Report;^questions  that are  of great importance
and upon which many views there entertained must rest.   These
questions are the  foundation of all theories that  attempt to
maintain the  existence of a monomania, <>r to explain it. 
  GENERAL  PARALYSIS.
A Critical Review of the literature op the Subject ;
   to which is Appended an Analysis of the  case of
   John S. Blackburn, in which Insanity was Alleged
   as a means of Defense.
                           BY
     D. A. MORSE,  M.  D, LONDON,  OHIO.
   " Medical testimony when of any value, can be little else than a reference
to authority."—Prof. Chas. A. Lee, Notes to Guy's Forensic Medicine.
Gentlemen :
  The application of Medical Science to serve the ends  of Jus-
tice, to the interpretation of Criminal Law and Procedure, i. e.,
to the "tests" of responsibility for crime; and to determine
crime itself, requires a  special knowledge—a special training—
an extended experience  in all that pertains  to the  subjects
considered by writers upon Medico-Legal Science.
  No one sitting in the quiet of his study, with the multitude
of the works upon insanity before him, versed  in their contents
however well he may be, no one in the whirl and commotion of
busy  every-day  life, as a medical  man, however great his
experience; no one familiar with the great institutions where
the management and treatment of the insane calls for a thorough
knowledge of the symptoms, progress, pathology and therapeu-
tics of insanity; no one, to go even further, who may add to
all these attainments a theoretical knowledge of Medico-Legal
Science, can fully appreciate, until he has been called upon to 
i                  GENERAL PARALYSIS.
assume the  duties  of such  position,  the wants  of one who
attempts to work up the  details, in evidence, analyze the facts,
fit and adjust them to a proper conclusion, crystalize them into
an " opinion," if you please, in a case where alleged insanity,
although actually existing, must be  shown  by a  "preponderance
of evidence," or " beyond a reasonable doubt," or as  sometimes
held, " must be  clearly shown" to exist, which opinion will ex-
tend to and embrace  all  the ingredients  of  homicide,  relieve
from responsibility, and thereby excuse apparent crime.
  To any of the  aforementioned purposes, or  relations  of the
medical man, aside from the last, the question of responsibility
does not arise; the mental capacity to conduct a rational defense,
to form a deliberate purpose, to commit an act with intent, mal-
ice and premeditation, are not questions of feet  that  one  in the
situations named will be likely to be called upon to determine;
nor will one in the  simple  capacity of a medical man, with the
same degree of mathematical precision, be  required to make  as
thorough  analysis,  as  critical an examination of symptoms, as
exact a classification as to the form  of insanity, as when the life
of an individual, the character, reputation and social interests
of a family are thereby imperiled.
  For all purposes, to  the  medical man, insanity is  a physical
disease.  He looks upon it  as he would any other  disease that
he may be  called upon to treat; he  does not shroud it with mys-
terious obscurities,  inquire  whether the man is h free  moral
agent, whether he has will power sufficient to  enable him  to re-
sist temptation, but regards the mental phenomena only as in-
dices of existing  pathological  conditions;   his brain is  not
confused with what may be said, pro or con "irresistible impulse,"
"insanity without delirium f or what  Lord Coke, Hale  Black-
stone, or any one else may have said or thought of the "tests" of
responsibility, civil or criminal; he does not  consult authors  to 
               OHIO STATE MEDICAL SOCIETY.               •">

determine whether the action  of jalap is modified  by the ina-
bility of the patient to distinguish by his  moral sense, " right
from wrong," or to determine how much hydrate of  chloral will
outweigh an illusion or hallucination, before it produces  sleep;
but the necessity for therapeutical knowledge, medical skill, a
clear diagnosis and rational prognosis, are rested  upon the same
foundations in pathology, whether mental phenomena are or are
not interpreted by a predetermined, despotic legal criterion.
   The medical  expert, or skilled witness, is called upon to hear
facts stated  by common witnesses, whose expressions are colored
by passion, by prejudice, by sympathy, by public  opinion, by
family relationship and self-interest; or what is much more em-
barrassing to him, well knowing that  seldom are all the facts
included, nor can they be as they would be viewed by a medi-
cal man unless all the evidence be included, in  many cases; the
superficial  knowledge of the medical witnesses having  led  to
superficial examinations, all the essential facts not being drawn
out, yet upon these is he required, a hypothetical  case being pre-
sented, the expert confined to the case  constructed, without the
evidence before him, without an examination of the  defendant,
to explain to a jury facts thus submitted, and is expected to sys-
tematize and organize the chaos, however incomprehensible, im-
perfect, or disjointed the hypothesis.
   The expert who has a well digested, well arranged knowledge
of the subject, readily forms what to him is a satisfactory  opin-
ion, and if opportunity has been afforded him to examine  the
defendant, has his opinion fully confirmed, not only by an ob-
servation of conditions stated in evidence, but by  seeing in  the
appearance,  expression, demeanor or  action of the patient what
no witness can describe; yet however firmly he may be convinced
of the correctness of his views,  however clearly he may express
them before the jury, however plausible they may seem to the 
6
GENERAL PARALYSIS.
counsel upon either  side, they may be questioned, and counsel
ask  that  they be confirmed by a reference to authority.   The
witness is asked to "name some authors who entertain similar
views," or if certain authors mentioned are not good  authority,
the counsel intending afterwards to read from them.   The expert
declares them good authority, but is mortified when  the case is
argued to hear read from these very books statements that  con-
tradict every view he  has expressed.   He has declared them to
be good authority and in the main they are, but the expert  ex-
periences only when too late to remedy it, the fact, that no matter
what the view taken, unless qualified in some manner, it can be
contradicted, and he thrown into confusion by a reference to the
books.  Counsel have  no right to read boohs that  have  not  been
submitted under the  oath of medical experts as authority, other-
wise why  should experts be called, or why should not counsel
read conflicting opinions from authors and have the jury to  de-
termine what is and what is not authority.  The expert is called
to declare what is accepted by  his profession as  authority,  and
when called upon to cite authority should not state as authority
that which has been exploded, but the most recent  views  and
developments of the subject.   One expert bases an opinion  up-
on  those early teachings imbibed when medical science was as
yet in its infancy, yet presents it with all the force  and weight
of more extended modern research.    Another  who feels  the
full responsibility and difficulty arising from the position,who feels
that he must echo truly authority, is cautious, deliberate, more
reserved, if not embarrassed; and although he incurs the risk of be-
ing considered unqualified, by the ignorant, is more correct,  and
although he may  not argue the case, as I have seen frequently
done by experts, who  evidently were called to make a case rath-
er than tell the truth,  he is for science the best  champion  and
in competency and reliability, the best witness.   With a clear 
OHIO STATE MEDICAL SOCIETY.
7
knowledge of what authors state he feels the full force of the
responsibilities resting upon him, and is the much more reserved
as he feels that authorities conflict and the difficulty of showing
what is authority gradually forces itself upon him.  His knowl-
edge has  been  the  steady growth  of time, the result  of long
years of patient study and reflection, of perfect  digestion and
assimilation  of what he  has  read and observed; and  it is
as it were by intuition he forms  his opinion.   He flies  from
author to author to find that while one confirms his pathology
it ignores his classification; that while others  approve his
classification many  others perhaps  deny as a  special  form  of
insanity that which he has designated, and  perhaps others de-
clare it a  disease but not insanity at all.
   One must experience much of this, if not all, who after hav-
ing  made a   thorough examination  of John S.  Blackburn,
attempts to work up the details  of evidence, from  it alone  to
gather all the  facts, before he has concluded an elaborate opinion
that shall exhaust such facts and gjve them due significance and
place in the structure he erects; and he will feel that much  is
wanting that he would desire expressed.
   To my mind no duty a medical man  may be called upon  to
perform equals in degree  of responsibility that  of  the  expert,
and  in no one thing  are our medical institutions, in many  in-
stances, more  remiss  than in their failure  to teach  medical
students how to apply their knowledge  to  practical purposes,
and  in the manner they ignore this essential  branch of a  col-
lege curriculum.  No man can be a thorough student of Medical
Jurisprudence without receiving  new impetus—new motives, a
higher sense  of duty, a higher  appreciation of medicine as a
science.
  Without further consideration of this at the  present  time, I
desire to end the already too lengthy  introduction to  this Report 
s
GENERAL PARALYSIS.
by an extract from one of my lectures, delivered January  3d,
1870, as an introductory to a course in Indiana Medical College,
Indianapolis, Indiana, upon Medical Jurisprudence and Insanity,
entitled: "The Duties  of  the Medical  Witness and
his  Privileges."  After enumerating  the objects and end of
this  Branch, the various duties of the medical witness and  his
privileges, the lecture concludes as follows:—
   " You have, gentlemen, by this time concluded, that the  du-
ties devolving upon you as a medical witness  are not such that
you  should ardently  desire to perform them;  but as  sooner or
later you will be called upon, if found qualified to fill them, I
hope and trust that you will bear in mind their importance,  and
the fact that without a thorough acquaintance of all the author-
ities a witness is not  fully qualified to give  an  opinion  upon
questions involving scientific  knowledge.   I  frequently  see
men called into court to give evidence in cases of insanity, who
never possessed or ever  read  a  single volume upon insanity
during all their lives; they could not under any  circumstances
give you a classification of insanity, yet  courts admit their evi-
dence  unquestioned.  It is a question, whether one half who
testify  in county courts, could give a list  of different works  up-
on medical jurisprudence or insanity, to  say  nothing of what
these works  contain.  The  masses judge the expert  by  his
presumed experience.  The counsel select untnesses rather for their
influence upon a jury, than the development of truth.  Experience
teaches, but experience alone  teaches little that is valuable;  for
the mind of man is so constituted  that  passion and prejudice
blind his judgment, and resting alone upon his  own observa-
tions he is as liable to err as he is to conclude correctly.
   "Smith in  his Analysis of Medical Evidence, says, 'It is very
possible, therefore, that he who depends upon his  experience
may be inferior, as to his knowledge and  experience, to the dili- 
OHIO STATE MEDICAL SOCIETY.
9
gent student;  for an accidental observer may be unqualified  to
make use  of his  opportunities while the  other may acquire
much information, without going beyond the  labors of others.
The man of experience has to labor single-handed, as much as
all  the others put together, ere he can equal them in pretension ;
while the  student again may have opportunities of experience
to a minor extent, but  will  make a vastly better use of a few
than the uninformed  can  of many.  Presumed experience, for
that is certainly what the  word in its  ordinary use must be re-
stricted to, is in a great measure accidental; it must fall to the
share of different individuals in different forms and degrees.   I
believe that no small  portion of that odious discrepancy which
has prevailed among medical witnesses  whereby the  luster of
medicine itself has been so much  tarnished, is chargeable to the
prevalent affectation of being men of experience rather than men of
learning, to the  over anxious wish of being extensively em-
ployed rather than solidly instructed and properly qualified."
  " Prof.  Chas. A. Lee, to whom  we have so often  referred,
presents in few words the  true feature of the subject.  He says,
(page 20,  notes to Grey):   " How often do  we see medical men
of scanty experience priding themselves  upon their experience,
and disparaging all knowledge derived from books, and by so
doing demonstrate alike their ignorance and want of sense; for
what is individual experience at the best when  compared  with
all  the vast stores accumulated by the sages of the profession of
all  ages.  It is but a drop of water compared with the ocean, a
moment of time with eternity.   Personal experience un-
less ENLARGED,  IMPROVED AND CORRECTED BY  THAT OF
OTHERS IS OF LITTLE VALUE.    MEDICAL TESTIMONY, WHEN
OF  ANY VALUE, IS BUT LITTLE ELSE THAN A REFERENCE TO
AUTHORITY."
  In presenting a review  of the Literature of General Paraly- 
10
GENERAL PARALYSIS.
sis, I am conscious that I have no ordinary task to perform, of
my own inability to perform it as justice  to writers and to the
subject requires.   To follow the multitude of writers  upon the
disease through the  expensive and  almost inaccessible  works
containing their views, to seek out these views often under  the
vague and obscure names with which they have seen fit to des-
ignate the  disease, concealed  many times in works bearing  no
relation to the disease, and  in treatises upon other subjects, as
Heredite, SuicidM, &c, but few of which works are found  in the
English language—to bring all these together—express them
correctly—and in one continuous article reflect them as it were
in a mirror, is a labor from which I shrink; yet when I consid-
er that if well performed no work can be  more  desirable, will
be more acceptable to those versed in the subject,  or who have
made it a special study, I force myself to proceed, and will  en-
deavor to present  in  as brief a manner as will be  consistent
with the faithful  performance of this duty, the merits of the
Review, the interests  of the  reader, and a  true expression ol
those authors' views herein  represented, the present  Knowledge
of General Paralysis.
  Before entering upon a consideration of the various details of
symptoms, duration, progress, pathology, &c, I  shall briefly
notice  the views of those  writers who described the  disease
prior to 1826, for this reason: they had no well defined knowl-
edge of the subject, regarded general paralysis as a complication
of insanity, as something superadded  or as  a special  form of
paralysis, having no connection with the mental phenomena.
  The views of these writers are of the highest value  and  ut-
most importance, in  inducing  a thorough consideration  of  the
disease under every possible aspect, in viewing it from  many
different standpoints; they also attest the  fact that although  a
common condition in public asylums, yet like many other dis- 
OHIO STATE MEDICAL SOCfETY.
II
eases when first noticed by authors, it was but  imperfectly  de-
scribed, the aeeounts of it being crude and very  brief; but also,
that each succeeding writer carried the study  one  step  in  ad-
vance of those who preceded him—the present  knowledge  be-
ing a gradual, progressive development of the subject, the first
being  as the  early, faint, glimmering rays  of  the rising  sun
which  in due season will come forth in full splendor.


              HISTORY OF GENERAL PA KA LYSIS.

   Marce informs us, and also other writers, that the first  writer
who called attention to general paralysis was Haslam, in 1798.
He spoke of the frequency of insanity as a  cause of paralytic
affections.   He remarked that these persons have exalted ideas
of pride, that they are incurable, that they fall into  imbecility
and marasmus, and die suddenly  of apoplexy.
   Esquirol, in 1805, characterized the affection  as an  incurable
form of insanity complicated with paralysis.   He uses in differ-
ent works the same language.  In Des maladies mentales, T. ii,
46, and Dirt, dex sciences medicate*, T. xvi, p. 211, he speaks as
follows concerning the  relation  of   paralysis to  dementia:
" When paralysis complicates dementia all the paralytic  symp-
toms  appear  in  succession;  first the articulation of sounds  is
difficult, soon after locomotion is executed  with difficulty, the
arms are moved with  labor;  at length the dejections are  invol-
untary, etc.   All  these epiphenomena  ought not to be taken as
symptoms of demency, more than the signs  of  scorbutus which
often complicates this disease."
   Thus the dementia he regards as expressed in the intellectual
phenomena, and all physical symptoms as complications, or as
he terms them: epipenomenes, or additions not  essential to the 
VI
GENERAL PARALYSIS.
existence of dementia.  This we fully discuss when we consider
the nature and pathology of the disease.
   Esquirol  divides  demency  into  acute,  or  chronic,  simple
or complicated, continued, remittent or  intermittent.   On page
66, vol. ii, maladies mentales,  he says: "demency  may  co-exist
with lypemania,  mania, epilepsy,  convulsions, scorbutus, and
above all with paralysis.   Complicated  demency  is  incurable.
*   *  *  The complication of mental diseases, with  lesions of
movement, resists all curative  means and leaves no hope  of
long duration  of life.  These facts I  declare, which we also
read in the works of Calmeil, Bayle, Guislain, &c, confirm too
well this mournful truth.   The first I called attention  to this
phenomena, 1805, I showed the incurability of insanity com-
plicated with paralysis.  This paralysis  is often the sign of a
chronic inflammation of the meninges, and  ought not to be  con-
founded with  paralysis, consecutive to cerebral  hemorrhages,
cancers, tubercles, softening of the brain.   It  shows  itself some
times with the first symptoms of delirium, during the acute period
so remarkable at the onset (debut)  of almost all forms of insan-
ity.  Sometimes it precedes the delirium,  sometimes it comes as  a
kind of adjunct to it.   At first it is partial, then  it  invades  a
great number of  muscles and becomes general."
   Esquirol seems to have overlooked the fact that the patho-
logical changes induced both the mental and physical phenomena.
The study  of insanity from  a physiological,  and  anatomico-
pathological standpoint, as well as metaphysical, guards against
these errors so common with early writers who  regarded  only
mental phenomena in studying insanity, and based their classi-
fications upon the  predominant features  of these phenomena,
leaving pathological conditions and  physical symptoms uncon-
sidered, or to be  explained on separate principles.
   That Esquirol thus  erred, no one can, with the light of the 
OHIO STATE MEDICAL SOCIETY.
13
present day, dispute.  In a  controversy with Dr. Burrows he
defines his views so  clearly no one need mistake  them.   He
says:   " Dr. Burrows appears to believe that I regard the  pa-
ralysis of the insane as the effect and not as the cause of  the in-
sanity.  I said nothing of the kind; I am satisfied to designate
the paralysis as a frequent complication of insanity, and as  ren-
dering more unfavorable the prognosis."
  Georget, a pupil of Esquirol, conforms to a considerable  ex-
tent in his views to  those of Esquirol.   He does not, however,
consider  the  physical  symptoms as complications, but regards
the lesion of motion as constituting a special species of paralysis,
and gives it the name of paralysie musculaire chronique.
  Georget regards demency and the paralysis as two distinct af-
fections.  Esquirol says that paralysis may complicate all forms
of insanity ; thus Ave have mania with  paralysis, melancholy
with paralysis, dementia with paralysis, &c.
  We prefer to say that  there are two features that  may  pre-
dominate, or characterize the mental phenomena in general  pa-
ralysis : exaltation and depression, and that  dementia may be the
termination or result  in either of these.  These  writers  say
dementia may  complicate all forms of insanity.   It  is for  this
reason  that such endless confusion arises in the literature of
insanity:  cause, phenomena, effect, pathology, are all confounded,
all  mingled and commingled  until no  man  can  comprehend
what  is the view of  the writer upon any given point;  and ren-
ders it much more probable that the writer cannot himself.
  The obliteration of the mental faculties from whatever cause,
constitutes dementia—no matter whether from  shock, nervous
exhaustion, cerebral disease or  other cause.  When  there  has
been  mental development and loss of the intellectual faculties is
consecutive to  disease, there is  dementia.  Idiocy is the congeni-
tal  want  of mental  capacity; imbecility is the  arrest of devel-
        3 
 14                  GENERAL PARALYSIS.

 opment at some period during infancy or childhood.   If these
 distinctions  were  preserved there need be no confusion;  but
 when one writer says an aged man has by disease been reduced
 to imbecility, another to dementia, another  to- idiocy, what  are
 we to understand by the terms ?  Simply that he does not com-
 prehend their signification and use.
   Dementia is not a real mental state, but the absence of men-
 tal power, a negative condition, the lifeless body that remains
 when mind has expired, "the ashes that remiain in the  socket
 when the  candle has burned out," "the tomb of the mind," "the
 last infirmity of noble minds."
   Dementia may follow all forms of mental disease, but compli-
 cates  nothing; it' exists to  such extent and degree as"  loss of
 mind is manifest.  AVe might with equal propriety say that in a
 given case there is  pneumonia  complicated with death, as to sav
 that melancholy or  mania is complicated with dementia.  True,
 you may  say  there is partial dementia, that dementia begins
 long before it is fully manifest,  that it may never be complete.
 Is this not true of the body, of physical death ?
   Georget says: "Demency terminates  all  forms of insanity
 which become incurable, provided that  the  patient lives long
 enough for this transformation to take place, which almost  al-
 ways is the case.   The  disorganization which  produces  this
 mental state causes at the same time in more  than  half of  the
 cases, another nervous disease, muscular paralysix, either general
 or partial."
   In other words two diseases are the result of the same  disor-
 ganization of structure : loss  of mental and loss  of physical
 power;  the intellectual death he  calls dementia; the physical
general paralysis.
  He is the first writer who fully described the essential symp-
toms,  and  divides the disease, in its progress, into three decrees 
OHIO STATE MEDICAL SOCIETY.
15
                      FIRST  DEGREE.

  "The paralysis commences almost always by declaring itself
in the muscles of the tongue; very often  it  remains confined
there a long time before  extending elsewhere.   The patient
shows  difficulty  of speech, pronounces  badly, or  slowly  the
words,  stammers more or less; the  tongue thrust from  the
mouth is not drawn more  to one side than the other, and seems
generally affected.  Other phenomena are  soon joined to  this.
If the patient can give an account of his  condition, he  com-
plains, may be of one side only, or  of both  sides  at the  same
time, of numbness in the extremities, a feeling of pricking, of
formication in the hands, the feet and along the tracts of nerves;
pains in the head more or less general, sometimes more or  less
circumscribed, and  ordinarily  upon the opposite side from the
paralysis, sometimes nevertheless the same side ; movement be-
comes less easy,  slower; the patient ends by being able to serve
himself no longer with but the members of one side.  All the
other'functions may be regular, digestion above all  very good,
fat is not diminished.  This first degree may last  a long  time,
many years, without the general health appearing to  suffer.

                      SECOND DEGREE.

  "The patient  is entirely paralyzed upon one half of the body,
or both; he can neither walk  or  hold himself erect.   He is
forced to confine himself to the bed continually; he can  pro-
nounce but few  words; intelligence  is annihilated.   Fat  does
not yet disappear; digestion is good.  The signs which indicate
chronic  irritation present themselves ordinarily at this period;
the  pulse shows frequency,  hardness; in  the  afternoon  the
cheeks color up; there is thirst. This second degree may  last
some months, a  year or more. 
36
GENERAL PARALYSIS.
                       THIRD DEGREE.

   "This degree comprises all the last months of existence of the
patient.   It is characterized by increase of the paralysis to such
an extent that these patients are but  inert  masses.   They are
deprived of color, pale and lean.  The appetite is lost, there  is
either flux or  obstinate constipation, and at  length death ends
the troubles.   The intelligence is abolished early; paralytics
remain sometimes a year or more  without  uttering  a word,
without asking that their wants be satisfied."
   Delaye, in 1824, Considerations surune espece de paralysie qui
<xfecte particuliere ment les alienes, p. 5, added to the name given
by Georget, the word incomplete, terming the disease, paralysie
general incomplete.   His reasons were that it was  but  seldom
the extremeties were completely paralyzed.  Pie regarded it as
a special species of paralysis.    He  gave  also  the differential
diagnosis between it and other forms  of paralysis; and  after
mentioning some of these differences, says: " Other differences
still separate  it from  these  last;  thus  it  affects  all  the
muscles  of locomotion.   Its  invasion  is  slowr,  its  march
always   progressive, its termination  always  bad;  at  length,
the  organic   alteration which  produces   it  consists  in  a
modification  of a  particular kind of the cerebral substance.
The other forms of paralysis, on the contrary, are ordinarily con-
fined to a part of the body;  their invasion is more or less rapid,
their progress is sometimes arrested, they retrograde or  remain
stationary; many recover;  at length they depend upon the dis-
organization or the loss of a part of the cerebral substance.   I
will add to this that the forms of paralysis which differ the least
from the disease in question, those, for example which have for
a cause the  development of a  fungus  of the  dura  mater  a 
OHIO STATE MEDICAL SOCIETY.
17
cancer of the brain, &c, have well known signs that character-
ize them."
   Delaye described the form of paralysis considered by  him as
an affection separate and distinct from  insanity ; he  attempted
to show that it was not entirely confined to the  insane; he  de-
tailed its progress, and gave as  a  characteristic feature  of the
mental  state, at  its appearance, weakness or loss  of memory.
He  regarded  it  as   incurable,   and  designated  as  causes,
organic  changes   of   the  brain,   softening, hardening  or
atrophy,  with adherence of  the meninges.   His  table  of
symptoms comprised only those pertaining  to lesion of  mo-
tion.   His chief  attention was given to the physical phenomena.
Bayle, a wrriter of the same period, in  three  different  works
presented his  views  of  general  paralysis:  1822,  These  sur
P Arachnitis; 1825, Nouvelle doctrine desmaladies mentales;  the
third, in 1826,Traite des maladies  ducerveau etdeses membranes.
This last appeared  the same year Calmiel brought out his work,
De la paralysie consid&re' chez les aliene's,
   Bayle presented a more correct  account of general  paralysis
than any writer who had preceded him.
   He does not, as Esquirol, regard the paralysis a complication,
nor as Georget and Delaye a disease separate and distinct from
insanity.  He did not regard general  paralysis as a special par-
alysis, but as a mental disease; and after the anatomico-patho-
logic condition,designated it arachnitis chronique, in 1822,  but
later he termed it monomania  ambitieuse avec paralysie.  In his
work of 1826, he divides the course of  the  disease into  three
periods: 1st Congestion:  ambitious monomania with incomplete
paralysis; 2d Mania: inflammation of  the  meninges; 3d  de-
mency with general paralysis more marked, due to serious exu-
dation, and  a considerably greater  weakening of the intellectual
faculties, with convulsive movements and epileptiform attacks. 
18
GENERAL PARALYSIS*.
The chronic inflammation of the meninges is the essential  ana-
tomico-pathologic  character  of the disease.   He considers the
meningitis the cause not only of the paralysis but  of all mental
alienation.   Had he confined this to general paralysis the  error
would not have been so apparent; but no one will accept this
last assertion as correct.
  We do not agree with these writers  upon  many points; thus
Delaye gives as a differential diagnosis, that other  forms of pa-
ralysis may be cured, remain stationary or retrograde, we will
see  that general paralysis  frequently  when begun is  arrested,
sometimes for years, the  patient  apparently  having recovered.
We do not accept the monomania des  grandeurs  as being the
specific  delirium;  of general  paralysis, in  fact  it  has  no
specific delirium, wre do not regard the paralysis a complication.,
an  epiphenomenon, or a special form of paralysis distinct from
the  mental state.    We regard the disease as a unit with two or-
ders of  essential symptoms :  Physical and Mental; both depen-
dent upon structural lesion.
  Bayle regarded  lesion of intelligence and of motion  as con-
stituting  one disease.  He  says, p.  40: " The  symptoms  of
chronic  arachnitis all can be reduced to  a  general, incomplete
paralysis,  and a  derangement of the  intellectual faculties;  these
two orders of phenomena advance with an  equal and propor-
tionate step, and divide the disease into three periods.   In the
first  articulation is  sensibly embarrassed, walk unsteady; the
disorder of intelligence manifests itself by weakness, a monoma-
niacal delirium, which to a greater or less extent rules the patient,
and often by a state more or less considerable,  of exaltation.
  " In the second  period the motion  of the  tongue  and  other
members  preserve often the same embarrassment  as in the first
or become more difficult; the delirium maniacal  and  o-eneral
frequently attended by ruling ideas; there is agitation, from the 
OHIO STATE MEDICAL SOCIETY.
19
loquacity and mobility which causes the patient to continually
change place even to furor the most violent and incoercible.
  " The third period is in general characterized  by a state  of
demency, an increase of the general  and incomplete  paralysis:
the speech is hesitating and trembling, very difficult and some-
times unintelligible; the step is vacillating,  tottering, or  even
impossible; the excretions are involuntary; the intelligence ex-
tremely weak, preserves but a small  number of ideas  which are
completely  incoherent, sometimes vague, sometimes more or less
fixed ; the  most frequently the patient is calm with from time to
time an agitation more or less  great.   This period  terminates
itself sometimes by an almost complete paralysis of all volunta-
tary motion and a state of complete idiocy.  Every patient pre-
sents  not  the  three  distinct  periods: it is not rare to see the
second wanting, sometimes the second presents a  continued or
periodic spasmodic agitation; during the third there  supervenes
often attacks of congestion of the  brain, attended with  loss of
 consciousness, and sometimes with  convulsive and  trembling
 movements, followed by an increase of symptoms of  the disease
 and sometimes epile^iform attacks.
   "This disease appears with  a state of ambitious monomania,
 and an exaltation more or less  great, which united  to  a  light
 paralysis,  incomplete  and general, characterizes this  period.
 The affected imagine all at once  that they are rich, powerful,
 raised in dignity, covered with distinctions and titles.   One
 believes  his  fortune  doubled, tripled,  quadrupled, centupled;
 another forgets the state  of misery  in which he found  himself
 at the onset of the insanity, thinking no longer but of imagi-
 nary treasures. They make gigantic projects which are to  bring
 them immense sums; they buy all that they see, they are occu-
 pied only with acquisitions they ought, to  make.
    Ruled  by these ideas  they speak of them incessantly and 
20
GENERAL PARALYSIS.
think of nothing else.   Their prattle is inexhaustible; they heat
themselves up in speaking and are easily angered by  a contra-
diction of their extravagant  ideas.   Their face is, in  general,
red, cheerful, and expresses the  satisfaction and joy  of their
riches and grandeur.  They sing, laugh, and are in a remarka-
ble state of hilarity and gayety.  They give a reasonable  re-
sponse to questions foreign to the object of their delirium."
   Here one form of delirium is described, the ambitious, and no
mention made of a depressive variety.   He sums up his views
concerning the lesion of motion: " The general lesion of move-
ment is not a complication, an epiphenomenon  nor an  accident
of demency; there is not with  paralytic demency two  diseases,
but two  orders  of esssential  symptoms concurring with  the
same degree to characterize one only and the same morbid  en-
tity—general paralysis."
   The paralysis  is general; thought, sensation, and motion, all
are involved.
   Having now considered to as great length as our space will
permit the views of those writers whose works  appeared previ-
ous to 1826, we  are prepared to further insider the disease.
   As it is the disease in question we desire to write upon, and
not the writers, further than as they  furnish us knowledge of
the disease, we will consider hereafter each point pertaining to
the disease as a separate division of our subject.  The  authors'
views we have  presented  could not  well  be  brought under
these divisions and  still give them their respective merits fc*
original observation.  They will never cease to  be referred to
by writers who desire to express a full knowledge of the subject.
Without a careful consideration of them we are unable  to trace
to their origin many theories entertained to-day, and to explain
many views that otherwise are incomprehensible. 
OHIO STATE MEDICAL SOCIETY.
21
  We shall consider General Paralysis as follows :
  I.  Name : What shall we call the disease in question ?
  II.  Age and Sex : With whom  and when  does it appear *?
  III.  Is it Hereditary?
  IV.  Incubation :  Prodromic Period ;  perversion  of
moral faculties.
  V.  Diagnosis : Course; Duration and Termination; Prog-
nosis.
  VI.  Pathology.

  I.  Name : What shall we call the disease in question ?  We
prefer to designate the disease General Paralysis.  Writers
have given names corresponding to  their views of  the  nature,
pathology or particular character of the  disease,  as they have
viewed it from a physiological  or a psychological  standpoint.
These names are:  General Paralysis ; Paralysis of the In-
sane ; folie paralytique; paralytic demency;  demency with pa-
ralysis ;  periencephalite chronique diffuse; meningite; encepha-
lite diffuse;  paralysie  progressive; paralysie  musculaire chron-
ique ; paralysie generale incomplete; meningite chronique avec
alienation;  meningo-encephalite; General  Paresis.
  General Paralysis expresses with sufficient accuracy  the  na-
ture of the disease; if we desire to  express the predominant
features of the mental phenomena, say general paralysis of ex-
pansive, or of depressive form, as one or the other of these states
may predominate;  expansive or depressive  general paralysis;
expansive or melancholic general paralysis.

  II.  Age and Sex : With whom and at what age does it oc-
cur f Writers state that general  paralysis is observed  much
more frequently with men than  with women.  Esquirol says r
"insane  women are  rarely paralytic.  The  insane  men and 
L'2                 GENERAL PARALYSIS.

women in hot climates, in the  South of France- and  Italy, are
rarely paralytic; nevertheless ambitious  monomania showTs  it-
self at Paris among the insane females; this monomania  is not
rare in the South of  France  and Italy among both sexes.'
Griesinger, traite des maladies mentcdes, 467, says: "Allauthori-
ty agrees that paralytic insanity is infinitely more frequent with
men than with women.  Calmeil found among 15 insane men
1 paralytic; among  50 insane  women, 1 paralytic; Bayle, at
Charenton, found paralysis eight times more frequent with men
than women."
  Foville observed among 334 insane, 31  paralytics, of whom
22  were men, 9 women; Hoffman  observed 138 men  to  18
women who were paralytics.   Of  2700 insane at  Leubus, 379
were paralytic men and 82 paralytic women; Duchek observed
at Prague 63 men and 6 women;  at Stephensfeld, the  number
given  is of men,  as one to  six  of  the insane,  and one to
twenty-six of the insane women.
  Marce traite des maladies mentalcs, 470, says:  sex  exercises a
singular influence upon the production of the  disease; while it
is very frequent with men it is very rare with women.    Of 86
cases ofgeneral paralysis noted by  Parchappe, 70 were men and
16 women;  Calmiel, of 82 cases, 73 were men, 9 women."
  All authors do not agree fully with these statements, but de-
clare that when circumstances and conditions under which cases
are noted are observed, the  difference is less  apparent.   Bail-
larger says the relative proportion of  men to women is greatly
modified when we take the poorer classes into  consideration as
well as  the rich, in  France, the  number of paralytics being
much greater with the poorer classes than with the rich.  The
statistics from hospitals usually given,  are from private institu-
tions, and those where the rich and middle classes alone  enter.
Griesinger says,  general  paralysis is  nowhere as frequent as 
             OHIO STATE MEDICAL SOCIETY.               2o

at Paris.  Esquirol replied to a similar statement made by  Dr.
Burrow's as follows :  "Dr. Burrows declares there are not as
many paralytic insane in  England  as  in France.   Burrows
attributes the increased number in France to bad  management,
bad atmosphere, &c.  *  *  *  *   I know all the importance
we ought to attach to hygienic causes in the production  of dis-
ease   *  *   but I  make the  remark that in treating of the
paralysis of the insane I speak of the paralysis which manifests
itself before the admission  of the insane  into the establishments;
   *   *  they have not fallen into this state during their sojourn
in these establishments, but they were paralytics before entering
there.   I am convinced that when they know how better to dis-
tinguish the symptoms of paralysis which complicate insanity,
they will find in England, and particularly at London, as many
paralytic insane as at Paris."
   Marc, T. i, 272, says:  "There is an accident  which  in the
Northern more often than in the Southern climates, more  com-
mon with men  than women, complicates  demency.  I  wish to
speak of paralysis, the development of which is  gradual.  The
articulation of  sounds, locomotion, movement of superior ex-
tremities, are executed only with more or less  difficulty; evac-
uations become more or  less  involuntary.  These symptoms,
which we call  general paralysis,  the paralysis of the  insane,
ought not to be considered  inherent to demency, not  only be-
cause that it is  not found with the demented always, but because
the paralysis is not always in proportion to the intensity of this
form of alienation.   This epiphenomenon merits  always great
attention; for it can be overlooked at the onset, yet it plays an
important part in the diagnosis of a mental disease."
   We have quoted  this at length for reason that  it  is  all that
Marc says of general paralysis; it contains  his views so far as
expressed, upon all  points. 
24
GENERAL PARALYSIS.
   We see from the above that sex exercises a great influence m
determining the relative proportion of the number of the sexes
affected.  It is not however so much attributed to the sex as the
character of the occupations of the two  sexes; determined by
sex and by exposure, excesses &c, even sexual excess having  a
more exhaustive influence upon the male  than the female.  It
is very interesting to consider fully the operation of causes  in
determining the disease with the two sexes, but we will not fur-
ther consider it.

   Age.  We will briefly consider the influence  of age.   Cal-
meil, traite" des maladies  inflammatoire du  cerveau, T. I,  270,
says : "Age exercises  a notable influence upon the rarity or fre-
quency of periencephalite  chronique diffuse.   I do not remember
that  I ever  observed this  disease  before the twenty-second
year of life; it has appeared to  me still rare at from  twenty-
three to twenty-six years;  it increases rapidly  in frequency
from twenty-seven to thirty-five,  continues to be very  common
from thirty-five to fifty-five years, and afterward  diminishes in
frequency to sixty-five years, an epoch of existence, where it is
often replaced by interstitial encephalitis of circumscribed lim-
its."
   The books abound  with tables of cases,  occurring: at  various
ages—they confirm or accord with the above statement; it  is
therefore unnecessary  to copy them.

   III.   Is General Paralysis Hereditary ?  In form-
ing a diagnosis, all other  points being settled, this may assume
importance.   Thus, in the Blackburn  case, reported  in the
Clinic, by Prof. Carson, it is given  as an evidence that B.'s
disease is not general  paralysis, because his disease is hereditary
—general paralysis not hereditary. 
OHIO state medical society.
25
  The voice of authority is that the disease is  hereditary ; and
not the disease as disease, but the tendencies and conditions  of
nerve  organization  which induce it, or so predispose that  an
exciting cause may bring into play these  hereditary tendencies.
  Calmeil, maladies inflammatoires du cerveau, T. I, 272, says:
"More than one-fourth of  the  patients attacked with general
paralysis count among their relatives, may be maniacs, may be
melancholies, epileptics, perhaps  persons affected  with perin-
cephalitis;  hereditary and the primitive conformation of the
intra cranial nerve centers, exercise then upon the frequency of
incomplete general paralysis  an incontestible influence.  Some-
times it is the father or mother, an uncle  or an aunt, or cousin
of those who become affected, who have shown anterior cerebral
accidents.   Sometimes both lines, paternal and  maternal  have
been affected with cerebral disease.       *      *       We can
boldly  declare that one-third of the individuals with  whom gener-
al paralysis shov)S itself have had relatives either insane or para-
lytic."   Further on he says the  erotic  temperament  furnishes
more cases than any other.  This propensity is however one of
the prodromes of general paralysis.  Several years before gener-
al paralysis is developed there may be seen with individuals ex-
cessive sexual  desires,  with almost uncontrollable  impulses.
General paralysis follows—we are unable to  say  whether the
condition of the nerve centers determined the excesses, and the
excesses the paralysis, or whether one is the prodrome and the
other the fully developed disease.
  Marce says:  "All forms of  insanity, mania, melancholy, and
partial delirium engender each other reciprocally and in a dis-
tinct manner.   General paralysis itself, which by its symptoms,
its special anatomic lesions, differs so notably  from  the  pure
neuroses of intelligence, finds itself among the  ascendants  or
descendents of the insane with a  frequency that  proves  in  a 
26                 GENERAL PARALYSIS.

manner the most peremptory that it is but a branch of the same
pathologic family."
  Page 469 Marce says:   " Among  the predisposing  causes
hereditary influence plays a grand role; and Calmiel is  perhaps
yet under the true  estimate in saying that we encounter it in  a
third  of the cases.   Insanity  and general  paralysis are  two
branches of the same  family, for among the  relatives  of para-
lytics we encounter  indiscriminately  not only  paralytics, but
maniacs, melancholies or epileptics,  who succeed one generation
to another transmitting tendencies to  the  identical root, or con-
dition of disease;  it is  curious  nevertheless  to see these  dis-
positions translated in one  by simple neuroses, in others by  a
constant organic lesion of the nervous system."
  Dagonet,  traite des  maladies  mentalcs, 438, says:  "Heredite
seems to play an important part in the production of this afflic-
tion, and it  is not rare to  encounter  in  the relatives of those
who are attacked individuals who have been attacked with gen-
eral paralysis, individuals who have  been affected with apoplexy,
demency, diverse forms  of  insanity, epilepsy, &c.   This disease
is much  more  frequent with  men than women—and  rarely
shows itself before the age of thirty."    Luy's,  Des  Maladies
Hereditaires, GQ, Art,  xii, general paralysis:  "To speak  of the
hereditary influence of insanity is  to speak  in  many eases of
inherited general paralysis, since  the  greater part of the time
the first  phases of this terrible disease are indicated but by de-
lirious conceptions of  a  special  nature."   Lucas, Traite philo-
sophique et Physiologiquc del'  Heredite Natwrelle,  Tome ii, 786,
says : "But it seems above  all to be hereditary in  the highest
degree (i. e. insanity), in demency complicated  with paralysis.
A notable part   of the  observations  of Bayle, gathered  under
the name of meningitc chronique, and  where hereditary influence
has been proved, present demency both with the ascendants  and 
OHIO STATE MEDICAL SOCIETY.
27
descendents."  Bayle, pages 83,87, 115, 250, 300, 556, may be
consulted with advantage.
  Maudsley reports fifty cases of insanity of various  forms, of
which he says he labored to determine correctly the  cause.   Of
these fifty cases, nine  are diagnosed general paralysis; of these
nine cases four are  reported by him induced by  hereditary  in-
fluences, four by excesses, and of one he says "no insanity in the
family bid the patient  inherited a bad organization."  In other
words about  one-half were hereditary.
  If we go through the  clinical  reports  of those writers who
have given the subject profound attention,  who  have tried to
determine the truth of what they report, we will find, if not so
great a per cent, of cases, a  large per  cent,  resulting  directly
from hereditary influence.
  There can then be no question that general paralysis is as much
determined by hereditary influence as any other form of insani-
ty, and I am satisfied that authority, and cases reported,  which
are the best authority, will justify me in saying, that the pecu-
liar character of the mental phenomena, whether of expansive or
depressive variety, will be as fully influenced by the condition of
the nerve centers of antecedents as in any  other variety  of  in-
sanity.
  Maudsley  says :  "General paralysis is a disease which is usual-
ly the result  of continued excesses of one sort or another;  but
it may unquestionably occur without any  marked excesses, and
when it does so there will be  mostly  discoverable a hereditary
faint  in the individual."
  Some writers are silent upon the subject, so far as the  heredi-
tary influence of insanity extends in producing general paralysis,
but if we examine what they say of demency we will  observe
they regard it hereditary, i. e., the tendency of demency  to  be- 
28
GENERAL PARALYSIS.
come complicated with general paralysis, this being their  view
of the nature of the disease.
  Hence, regarding the disease in all forms, under  all consider-
ations, we say authority declares  beyond dispute  or  controversy,
that general paralysis may be inherited, as the last degree of de-
generacy transmitted by insane antecedents.

  IV.  Incubation, or Prodromic Period: perversion of
moral faculties.  The  medical man whose  acute perceptions en-
able him to foresee or anticipate general paralysis, when certain
conditions are  observed  with an individual,  may  frequently
avert threatened danger, crime and consequent disgrace, by rec-
ognizing early the prodromes of this fearful, incurable malady.
And not only this we  have stated, but the reputation of a medi-
cal man, the honor of the profession and medical science, are de-
graded by a failure to recognize  what is  plainly  manifest, al-
though it may seem trifling and  unimportant, yet which  even-
tually, perhaps too  late, declares itself of infinite value as  an
omen of impending, unavoidable evil; but  of which  in  many
instances the serious consequences, by early recognition of the
conditions, might have been avoided.
  To the educated senses of a well informed medical  man the
fully developed symptoms of general paralysis  are of no  more
interest, of no greater significance, than those that so unmistaka-
bly characterize the prodromic period.   The  reputation,  fame
we   may say, of several  eminent French alienists was due to
their ability to foresee, and declare the coining storm, that later
uprooted mind and vital power.
  Maudsley, in his recent work: "Responsibility in Mental Dis-
ease," 72-75, illustrates well, as do Winslovv and other writers,
the necessity of early  recognition  of  mental disease, and the
importance of giving full value to prodromic manifestations. 
OHIO STATE MEDICAL SOCIETY.
29
  Maudsley says;  "There is one striking form of insanity  in
which mental symptoms of a tolerably uniform character are ac-
companied by symptoms of  gradually  increasing paralysis  of
the muscular system, and which runs a definite course to  a fa-
tal termination; it is usual therefore, to  make of it a  special
doss under the name of General Paralysis of the Insane.
  " An example will serve best to show how necessary  to the
formation of a right conclusion is  observation informed by ex-
perience.
  A man who has been hitherto temperate in all his habits, pru-
dent and  industrious in business, becomes indifferent to his
wife, his family, the obligations of  his position ; his surprised
friends  see only the effects of vice, and grieve over his sad fall
from virtue; after a time they hear that he  is in  the police
cDurt accused  of assault, or of stealing money, or  jewelry, and
are not greatly astonished that his vices have  brought  him  to
such a pass.   Examined by a competent  physician, he  is dis-
covered to have a slight peculiarity of articulation and perhaps
on irregularity of size  of the  pupils, symptoms which, in  con-
junction with  the previous history, enable the physician to say
with positive certainty that he is struck with a  disease  which,
sapping by degrees his intellect and strength, will  within no
long time destroy his mental and bodily powers, and finally his
life.  Our knowledge is so exact that we can do what  is the
best test of a science—predict with certainty what will happen.
The dissipation, speculation, and the theft itself were, as they
often are, the first symptoms of general paralysis of  the insane.
Plainly, common sense without special experience could have
small chance  of coming to  a right conclusion in such a case.
The example will furthermore serve to show of what little
service  a classification by mental  symptoms only is, and what
little information we get when we are obliged to be content with 
30
GENERAL PARALYSIS.
such  a classification;  for  in the early stages of the disease it
would be necessary to describe them as those of affective or mor-
al insanity, and finally as those of dementia.   Thus one patient
might, in the course of a short time, run through all  the classes
of symptoms  while suffering  from one and the same  disease.
So plain is this, and so characteristic are the mental and bodily
features of general paralysis,  that  all writers on insanity are
agreed in making it an exception to the general rule  of classifi-
cation ; they constitute it a class by itself, thus giving the strong-
est practical condemnation  to a purely psychological classifica-
tion."
  In the prodromic period the patient is generally depressed,
and melancholy, and even those writers  who claim  exaltation
as the special delirium,  expansion, when the disease is fully de-
veloped, declare that at this period there is, lasting a longer or
shorter period,  depression,—which may  extend through the
whole course of the disease, or briefly end at the onset. Gries-
inger says:  "At the onset of general paralysis the intellectual
disturbances present not always the same  character.   It is rare
that we do not observe a melancholic period, which manifests
itself sometimes as a  simple depression, sometimes by  very
marked hypochondriasis, very rarely do  we  see supervene the
first lesions of movement  during this period  of  melancholy;
nevertheless, as has observed Calmeil p. 328, this does  occur,
patients still having for some time melancholic delirium, which
transforms itself into demency.
   During the first  period of the disease the character and man-
ner of paralytics are very  variable.   At  the onset the intelli-
gence is generally less active and energetic, the thing the  most
 frivolous afflicts  and chagrins them.   Among the prodromes we
observe also  from time  to time a perversion of the  affective
sentiments  and  character, which manifests  itself at times in a 
OHIO STATE MEDICAL SOCIETY.
31
sudden manner  with  those  who enjoy  their liberty and are
occupied  with their affairs, which oftentimes gives birth  to
medico-legal questions very embarrassing to magistrates:  thus
we see individuals commit improper acts  *   *  *  *   are in-
decent in their behavior."
   All will not show the same  impulses, the same delusions, or
manifest the same conduct.  We would expect the passive vic-
tim of melancholy  to be jovial and active, as  the excited am-
bitious  maniac.
   Baillarger, Appendix to Griesinger, Art. iv, says :  " Patients
affected with  general  paralysis show often a long time in  ad-
vance, several months, a year or more, modifications of charac-
ter, which without being very marked are not the  less  impor-
tant to  notice.  Some become irritable,  passionate,  susceptible,
and cannot suffer the least contradiction.   The  relatives  note
these changes and are astonished at them, but it is very rare  at
the onset that they regard them as evidence of grave cerebral
disease.
   I saw recently an insane man who for three months was com-
pletely at discord (brouille) with his two brothers,  as a  result
of an exaggerated susceptibility, resulting evidently from his dis-
ease.   At the same  time, before  his  two sisters-in-law, he ob-
served the utmost decorum.  No one suspected the  change tak-
ing place;  the delirium which showed  itself a little later ex-
plained all.
   Other patients are a prey to  erotic ideas and  deliver them-
selves up to little moral deviations that contrast strangely with
their anterior conduct:  ordinarily these  ideas are not attended
with any increase of virile force, but it may be otherwise and
then some patients give themselves up to venereal excesses.
  When demency is  developed, the erotic  ideas persist with
complete impuissance; patients then talk obscenely and public- 

GENERAL PARALYSIS.
iy commit acts in a manner that renders it necessary that great
vigilance be exercised over them.
  Propensity to theft is encountered often at the onset of  gen-
eral  paralysis when  weakness of intellect  characterizes this
period of the disease.  Examples are numerous, and the  thefts
are of so little importance  or so badly done that it should,
although it does not always, awaken a suspicion of their state."
Lelut reports cases where persons  have  been condemned for
theft and this condition not recognized.
  Many patients at this period, show  a prolonged state  of stu-
por, very decided and lasting  at  times  many  months.   They
often  are inert and remain in a mute condition.  This  state at-
tended by congestion of the face, with persons of from 30 to 50
years of age, and who have not had previously attacks of mel-
ancholy, ought to make us suspect the invasion of general par-
alysis.  If the pupils are  unequal and there are  delirious  con-
ceptions of a melancholic  or  hypochondriacal nature the pre-
sumptions are strong.—Baillarger.
   Marc6 traite"  des Maladies Mentales,  416,  says:  "Several
months before the invasion of general paralysis,  we see mani-
fested changes of character, of habits, which  singularly  aston-
ish us and of which we seek vainly the cause.  Sometimes there
is an irritability that leads to violence and that is excited  by
the most trifling cause; sometimes on the  contrary, a placidity,
an apathy that  renders impossible all  serious  occupation;  or
a perversion of  the moral and affective faculties which prevents
 the subject from performing his duties;  leading to acts of indeli-
 cacy, improbity, and  of debauchery,  that  no  precedent can
 make us  foresee, and to which Brierre de Boismont  has justly
 called the attention of  medical men.   The families  afflicted by
 these acts attempt to repair the mischief done, the public  scan-
 dals, but comprehend  not the value of these modifications of 
OHIO STATE MEDICAL SOCIETY.
33
the moral state but when the malady has taken a turn more  de-
cided, and has entered upon its first period."
  The monograph of Brierre, referred to by Marc6, we obtained
from Paris, and find it full of satisfactory  material  confirming
the views expressed;  it is entitled: Etudes  Medico-legales  sur
la perversion des faculties morales et  affectives dans la periode
prodromique de la Paralysie generate.
  On p. 4 we read:  " One of the first and most  constant  in-
tellectual disorders appreciable is the change of character which
consists ordinarily in an  irritability extremely great, in move-
ments of impatience, wrath, violence.   If  the  disposition  has
naturally this  tendency, it takes  a form more decided which
awakes the attention of relatives and friends.   This moral per-
turbation can last six months, one, two or three years, and offer
no concomitant symptom.
  In other circumstances, the derangement of  mind is announ-
ced by extravagant conversation: an employee in  contact every
day, when at his place, with hundreds of persons, is invited to
a wedding; all at once  he holds the  strangest discourse  and
presents a mobility of ideas nothing can fix—sometimes  these
are the acts which reveal the disorder of the faculties: a woman,
excellent manager, makes purchases beyond her means; despair
seizes her, she wishes to put an end to her life; sometime after
general paralysis is evident.  Several times we have noted  the
first indices of the evil to be the threats of suicide.  The change
of character  can present clouds very different.   Four years  be-
fore the  invasion of the paralysis, a man who  had  even  then
shown  firmness, became irresolute, uncertain, wept easily, di-
rected nevertheless his affairs for three years, then at the end of
this time, he showed a new change of disposition,  he became ir-
ritable, passionate, cole"re, and paralytic insanity succeeded these
two metamorphoses.   When  apathy  succeeds,  the  affected 
34
GENERAL PARALYSIS.
cease all their pursuits, yet give with calmness good  reasons for
their conduct, but it seems impossible for them to do anything.
*     *   • * ■    A long time before the appearance of the pa-
ralysis, we have noted cases going back six or seven years, we
see manifest, with certain individuals, perversions of the mora)
and affective faculties, which do not  hinder them from filling
the positions and performing the duties of social life.  The sur-
prised, desolated families murmur at the base  acts,  the  indeli-
cate, immoral, the debauchery for which no precedent can  pre-
pare them; they excuse the  wrongs, pay the damages,  stifle
complaints, when at last this long and secret martyrdom is ter-
minated by an outburst of the disease."
   Brierre made an analysis of 100 cases  of general paralysis; on
page 16 of the work we have cited, he says : "In the  analysis
of  one hundred cases  of general paralysis, we find when we
come to the third category, comprising the disorders of intelli-
gence preceding those of motion, and which  are composed of 42
observations, that one of the first and most constant disorders of
the intellect appreciable, is a change of character which consists
ordinarily in excessive irritability, impatience, anger, violence.
This is observed with three-fourths of the cases.   With a  more
limited number of individuals, the disease is, on  the  contrary,
preceded by a state of calmness,  placidity, indolence, apathy.
These persons reason well, confess that they ought to labor, do
manifest interest in their affairs ;  but between the word and ac-
tion there is an  abyss they never  leap.   One  of  the most an-
cient cases we have observed of this change is that of a  chief
gardener of a rich  house.   During several years he  acquitted
himself well in his situation, in which, however,  it  was neces-
sary to follow only a routine.  His activity being extreme, he
was sufficient   Little by  little he  became silent; relaxed in
vigilance; complained of difficulty  in his  head; he reasoned 
OHIO STATE MEDICAL SOCIETY.
35
well yet, but declared that rest would be  useful to him.   He
was sent two months to the asylum.  During the first he  ap-
peared better; the second he eonversed lucidly  concerning  his
horticultural labors; he was interesting, and appeared desirous
of living to resume his  occupations; he still showed signs of
improvement.   We believed him completely restored, and re-
quested his master to remove him.  Sometime after we received
information of him; on his return to the country he commented
an what ought to be done, but did nothing; he was always  un-
decided.  It was necessary to send him back.
   A  second example  is that of an architect, also confided to
ray care.  Married to a young wife, who was much attached to
him,  she perceived at the end of two years  that he  concealed
his plans and appeared no more to be occupied or interested in
his  pursuits:  he  would  promise to visit, to begin things, to
walk, and never left the houses  When this was represented to
him by his wife he replied he liked nothing better  than work,
and continued to do nothing.  This continued one year.   He
became  more irritable, peevish,  and  absented himself from
home.  At  times  he  stammered.  It was at this time he  was
placed  in my  care.   He was  in the second degree of general
paralysis of which the symptoms had existed five or six months.
He became  more quiet and  remained in a state of apathy.  At
the end of six months his family finding him better took  him
home.  This stationary condition lasted more than a year; then
the disease advanced, and he died two  years  afterwards.    In
place of the choleric irritability,  of reasoning apathy, or  with
both of these  states, there may be manifested graver symptoms;
thus we note perversions of the moral  and affective  faculties.
Families are  afflicted by these changes without knowing that
very often  they  are  the offspring of mortal disease;  and, in
effect these  persons continue to perform well the duties of social 
36
GENERAL PARALYSIS.
life.   *  *   *  This period of general  paralysis, the  prodro-
mic, may persist  many years, as we see with men, who up to
this time have been  religious, chaste, honest, present the  most
striking contrasts  to their  former  life.   Of these  perversions
that which has been the most marked is mania for thieving."
  These limited propensities, perversions  of instinct, treated of
generally as forms of monomania, are but the expression of de-
lusions that are deeply rooted in  the mind: thus those who are
Lord of all the earth, King upon the throne, the  Savior of the
world, possessed of unbounded wealth, &c., take what their de-
lusion suggests to use for their own purposes; and although at
first we are inclined  to regard the stealing as an exhibition of
natural corruption, if we study well the case  and draw out the
tendencies  of mind we will find that it  was in the line of the
delusion, or of some delusive idea.   These we have mentioned,
and  the victim  of suicide, of melancholy, the homocide are all
governed  by  the  ruling delusion, the general tendencies that
characterize the disease.
  It is of the utmost importance, at times, in these cases to de-
termine whether an act committed was in  the  line of some de-
lusion or not.   Thus the  mother  commits suicide, kills her
children, or  takes  the  life  of others; if we study the ruling
ideas we will find that she thought herself too wicked  to  live,
or that her children would be safe from the evils of this world,
or would starve if not killed, or that God commanded  her to
make a sacrifice, everything being seen  only from  the stand-
point of delusion and performed in  obedience to its stern  com-
mands.
  Brierresays:  " It is then  evident that insanity, and  general
paralysis in particular, can change the character  of individuals,
and give origin to  eccentric, bad, reprehensible acts in entire
opposition to their known habits.  But here is presented a  dif- 
OHIO STATE MEDICAL SOCIETY.              37
ficulty:  how can we distinguish between the perversity of pas*
8ion and disease?  It is unfortunately  demonstrated by experi-
ence that some men  who  have  acquired a  reputation without
blemish, under the influence of a violent passion, contradict all
precedents and commit bad actions; this is a matter pertaining
to justice, as a consideration of  crime; but  it happens oftener
that those sudden  falls, unforeseen, are the result of mental dis*
ease;  and, as in  this species of disease, there are frequently pre-.
cursory symptoms, avant couriers, as has very well  remarked  a
celebrated English  alienist, Dr. Winslow,  in his remarkable
work:  On  Obscure  Diseases  of the Brain and  Mind.  These
are premonitory symptoms that it is necessary to seek  out and
put in evidence.   In a great  number of cases the  task is easy,
and the physician  appointed promptly  points out facts that fami-
ly affection has overlooked, palliated or explained away.  Noth-
ing is more common than to hear the relatives say:  ' We have
noticed  nothing  of all this; we attached no   importance  to it;
or we regarded these things as eccentricities;  as  the   result  of
disappointments; the idea of insanity was far from our minds.'
Some say, 'you are dreaming; these peculiarities to which you
call our attention have lasted a long time/   Some say, 'we weep
at this conduct, we cannot comprehend it, we gave  as a  cause
the age, disease, Sec.'
   But there are  cases that surprise the expert, for  which even
he is not prepared; it is then necessary for him to  redouble his
care in  his examinations and  researches.  The  indices  which
ought to guide are at first ideas of disease; in the  greater  part
of cases, in effect  where  these  transformations of character, of
humor,  of conduct, are marked,  it is proper to suspect general
paralysis; if the age  is from 35 to 45 years,  if there has been
sexual excesses or intellectual, the presumption will be strong;
if to this hereditary influence is united,  the. presumption acquires 
38
GENERAL PARALYSIS.
more force.  But there are some evidences much  more certain ;
these are furnished by disorders of three important functions:
the intelligence, motion and sensation.  General paralysis  may
show itself by muscular lesion, it can manifest itself by  united
alterations of intelligence and motion;  it can show itself  with
trouble of intelligence alone.
  Before describing the characteristic symptoms of these differ-
ent lesions, it is necessary not  to lose sight  of an initial phenom-
enon, which, without being as universal as  attributed by Bayle,
is frequently observed, and deserves to be taken into considera-
tion.   I wish to speak of congestion.   In one hundred observa^
tions it figures sixty times.   This accident can consist in a  sim-
ple deafening, vertigoes, that pass  unperceived,  but generally
recognized,  or in congestions with grave consequences and  of
a special nature.  The congestion determines a weakness of the
intellectual forces; they become absent minded, lose the memo-
ry, hesitate in their judgments and conclusions; attention, com-
parison, judgment, have no longer their clearness and force  or
precision, nor have they their  ordinary firmness.   If we engage
the individual to make a resume" of something,  to present  in
writing his observations  upon a subject in litigation that re-
quires developing, we notice the great difference  between this
work and those to which he has habitually accustomed himself;
by times the writing itself is changed.   When the disease is more
advanced we notice omissions  of words, words forgotten, or let-
ters at least.  Benevolence is often more marked than is custom-
ary; there is a confidence shown in conversation that later char-
acterizes ambitious monomania..  At other times, on the contrar
ry, but more  rarely, we observe  a state of mournfulness, a
tendency to melancholy,  to hypochondriasis.   Few  show the
same degree of astonishment natural to  men  when strangers
meddle with their affairs, that should be manifest at the interro- 
OHIO STATE MEDICAL SOCIETY.
39
gation of a physician when  the examination  is  unknown  to
them.
  The disorders of the muscular system are  the key  notes  of
the disease, and often reveal the existence of the paralysis.  It
is these,  above all, that we consider the point  of  departure  in
the series  of  degenerations  the  patient is about to  undergo.
This sign  so  characteristic for the specialist, and which but re-
cently was unobserved by expert medical men,  manifests  itself
by  a slight trembling of the  lips, an  embarrassment, scarcely
sensible, of the tongue, a  hesitation  of  a letter,  of a  word,,
which is supplied  sometimes after a  long interval.   Without
doubt this sign alone is not sufficient  upon which to declare
general paralysis but it weighs heavy in the  balance, it directs
forcibly  the attention, and when it is joined to other well known
symptoms, there is no longer doubt.  This muscular  weakness
extends  in effect to all the system; the  figure has  no  longer its
expression because the muscles which  respond to  intellectual
operations no longer contract, or only with difficulty;  standing
is no longer perpendicular, movements  no longer have  their or-
dinary precision;  the pupils become unequal; a certain number
of these patients recognize the  fact  that  they  are  no longer
competent to perform their duties, that the sexual functions are
in  abeyance or abolished ; while others, on the  contrary, aban-
don themselves to excesses  of all kinds.  In order to  recognize
if this diminution of motility is extensive, we  ask  the patient
to  put out the hand and we learn  that the pressure is  not of a
force  sufficient to correspond with  the appearance.   Standing
upon one leg announces  also lesion of motion.
   Sensation   can   present an  appreciable  alteration.  M. De
Crozant has  indicated this fact as  existing at the onset of gen-
eral paralysis; many have demonstrated it; we have encounter-
ed it in  an incipient general paralysis,   in consultation  with 
40
GENERAL PARALYSIS.
Ferrus, Baillarger, Brochin and Carriere,   Anaesthesia, studied
with care in insanity, has been encountered a great  number  of
times; it is common in the second and  third degree.   Since a
long time  we  have experimented with our cases of paralysis,
and in almost all cases we have observed a diminution of cuta-
neous sensibility, extended at times to its total loss.  We ought
to assure ourselves of the  composition of the urine and of the
state of muscular contractility under the influence of electricity.
At length, in several of our cases we have seen amaurosis, par-
tial deafness, paralysis of the sixth pair preceding many years
the development of general paralysis, of which the  diagnosis
had been extended to that time.
  The observations of this work, and the remarks to which they
have given place, ought to be by right,  concluded as follows:
  1. That those individuals  who, at an epoch not  advanced  in
life,  present a  change  of character, of conduct, commit acts
which  are in disaccordance completely with their principles and
precedents, ought to create a suspicion that there is an alteration
of their intellectual faculties.
  2. This probability becomes a  certainty when we show with
them the greater part or a  certain  number  of the symptoms
characteristic of general paralysis, we have enumerated.
  3. The doubt which arises at a degree of the  disease not far
advanced, is dissipated by a prolonged observation, because  95
times out of every 100 general paralysis tends towards continued
progress and a termination in death.
   4.. At length the symptoms  described  have  an importance
that is real, for they point out to us, unquestionably, traces of
general paralysis when the disease has  not yet been declared."
   It is unnecessary to add more;  a multitude of cases could be
reported, illustrating every  symptom and phase  of the  prodro-
mic period, yet they would only  lengthen without  adding  fur- 
OHIO STATE MEDICAL SOCIETY.
41
ther to the subject.   The  above consideration of the prodromic
period, together with what we shall present upon diagnosis, will
enable any one to recognize the disease and will convey  an idea
of all we desire to express upon the subject of diagnosis.

  V. Diagnosis;  Course; Duration  and  Termination;
Prognosis.   We present the subject of diagnosis as follows:
  1. Physical.   1st the  Speech;  2nd Pupils, vision; 3d
Muscular action: walk, co-ordination; the paralysis general or
partial,  complete or incomplete; 4th  Sensation; 5th Physical
symptoms not always present, less frequently observed than the
preceding;  6th Congestions, effusions of blood.
   2. Intellectual phenomena: Delirium, general or partial.  Is
there a specific delirium ?    Two  varieties: Expansive ;  depress-
ive.

                   PHYSICAL PHENOMENA.

    1. Speech,  articulation.   Writers mention, with scarce an ex-
 ception, a change of speech, a difficulty  in the articulation of
 sounds, as one of the earliest manifestations  of physical distur-
 bance characterizing the early derangement  preceding  the de-
 velopment of general paralysis.   The  speech is said  to be
 brusque, a sudden stoppage, stuttering or stammering,  or  hesi-
 tation.  It is described also as being like  that  of a  drunken
 man.   The tongue seems thick, unmanageable—co-ordination of
 muscles so essential to perfect articulation seems impossible. At
 the same time this difficulty of speech is  observed other  mus-
 cles of  the body may be  affected, but as the muscular action of
 the tongue  must be more  perfect to produce distinct sounds,
 those may  escape notice.    This is not always present in the
 same case with the same  degree; it may be observed at  one time 
42
GENERAL PARALYSIS.
and altogether absent at another.   Under excitement the  trou-
ble is aggravated—articulation acquires its greatest degree of in-
tensity;  it then assumes an explosive, or convulsive character.
Another feature described by Bonquin is slowness.  ^The words
or syllables are separated • and  dragged.   Hesitation alone, or
even  stuttering, is not  a  symptom  of  importance with  many
men, yet when an individual whose articulation has  been  per-
fect, whose speech is fluent and easy, shows  hesitation, difficult
articulation, it should awake suspicions  of cerebral disease.
  As general  paralysis develops  itself and the  paralysis of
muscles is  more complete, intelligence also  abated, the  trouble
of articulation increases  until at length power to utter articu-
late, intelligible sounds is lost.
  The trouble of speech, at the onset, is due  to  irregular con-
traction of the muscles,  portions contracting  spontaneously, as
it were, and portions under the influence  of the Will.  This
fibrillary, or vermicular  motion, destroys co-ordination, or ren-
ders it impossible.  With some it is not  manifest  when there is
agitation, although with others, in  general, the contrary is ob-
served.   With some it is not apparent until there is  fatigue, as
after reading or speaking for a considerable time.
  Difficult articulation does not always indicate general paraly-
sis,  yet when taken in  connection with other symptoms, intel-
lectual and physical, it assumes great  importance; it  is positive
evidence of  cerebral disease and co-existing symptoms will de-
termine its significance.
  2. Pupils, Vision.  The state of the pupils,  whether variable,
whether contracted alike, as to whether  contracted or  dilated,
has received considerable attention from  those investigating and
writing upon general paralysis.
  In the congestive periods, and in some cases,  at other times,
both pupils are observed to be unduly contracted, the usual con- 
OHIO STATE MEDICAL SOCIETY.
43
dition, however, is, that where there is  alteration of the pupils
one is contracted more than the other.
  Total blindness, partial, or only slight defect of Vision  may
be observed, with  one eye  generally  more than the other, yet
both may be affected.
  Baillarger claims that he first pointed out unequal contraction
of the pupils as a diagnostic sign of general paralysis; but says:
" this may be discovered with persons perfectly healthy in mindj
and who never  subsequently  are attacked with general paralysis.
This unequal contraction  of the pupils observed, is also observed
in simple insanity.   We learn that they have had, at  a period
very remote, some affection of one of the eyes, and that since,
the sight is more feeble upon one side.  These facts have noth-
ing in common with those connected with the  onset of  general
paralysis, or its course.
   Of one hundred cases we will  see,  for example, one-half or
two-thirds who offer for the first time,  without having had  any
previous affection of one  eye, this symptom of unequally con-
tracted pupils.
   It  will certainly come into the minds of many to declare that
an individual,  because he has unequal pupils, is threatened with
general paralysis, but if to this symptom be  added other indices,
very slight, of another nature (greater  activity, change of char-
acter, irritability,  &c.,)  then  the inequality  of the  pupils be-
comes a sign of sure significance.  There is  no disease of which
the development is preceded by more insidious signs  than  gen-
eral paralysis.   All signs, however slight, deserve the  highest
degree of attention during this prodromic period.  .  Inequality
of the pupils is one of these signs.  I believe we ought always
to seek to determine its  existence."   Griesinger says Seifert
found with twenty-five paralytics seventeen cases of which there
 was inequality of pupils, but says  it must not  be regarded as a 
44
GENERAL PARALYSIS.
 certain sign, for reason that it sometimes precedes  for  years
 outbreaks of insanity in which there is no paralysis."
   Moreau, says Griesinger, observed irregular pupils  with half
 of those afflicted with general paralysis; Laseque, in  one-third.
 u Considering the rarity of this symptom with  other forms  of
 insanity this proportion is very great.  This symptom, when it
 presents itself, well marked, at the onset of insanity, is  one  of
 those which causes us to fear the invasion  of general  paralysis,
 more or less immediate.   It may then be the first or among the
 first that excites attention.   This was recently observed with a
patient thirty years of age who presented no difficulty of speech
 for two months after the invasion of insanity.   Four physicians
 united in consultation dared not decide whether the disease was
 a simple insanity or  general paralysis, but  basing their opinion
.upon the inequality of the pupils declared that he was  threatened
 with general paralysis.
   " Inequality of the pupils  may have in  certain  particular
cases, a special importance; thus with certain  patients attacked
with melancholic stupor, immobility, mutism, we are prevented
from showing the essential symptoms of general paralysis; and
the inequality of  the pupils, above all if persistent, excites at-
tention and justifies us in reserving our  opinion  until the ap-
pearance of other symptoms of the disease.  It may be observed
in cases in which general paralysis is not to be expected, and jn
other forms of insanity.   It appears notwithstanding  this, that
aside  from  these  cases, inequality of the pupils may make  us
suspect the invasion of general paralysis."   (Griesinger).
   Moreau found in 58 cases the right pupil was dilated  more
than  the left  24 times, the left more than the right 34 times.
From all sources of information at my command I  derive the
opinion, that inequality of the pupils as a specific sign of gen-
eral paralysis is overrated by many writers; that it is indicative 
OHIO STATE MEDICAL SOCIETY.
45
of cerebral disease and is observed in many forms of insanity I
will not dispute; but that we are able  from  this sign alone  to
declare general paralysis, or from its absence to say there is not
general paralysis, is more than facts justify.
  Nasse, of Prussia, has contributed  much valuable informa-
tion upon this subject.  He says :  " Observations continued for
years in several large asylums, during which time I  have given
particular attention to the difference of pupils, and  the  symp-
toms  of  partial  paralysis  accompanying the same, give me a
certain claim to speak on this question."
  He says:  Pelman notes the  difference in 25 out of 50 par-
alytics.   Yon  Linston (Zeitsehrift xxiv, p. 440,) has observed
in one third of his cases  variation of the pupils.
  Nasse says: "Of 108 cases of general paralysis  which have
come under my observation during the last  four years, at Sieg-
burg, the  ratio was as follows:  of 25 female patients one  only
showed no change of pupil, three others suffered from  various
diseases  of  the  eye (Glaucoma,  dimness   of  the  cornea,
Synechia of the iris,) precluding  a judgment of the changes in
the iris; but the remaining  21 had evident inequality  of the
pupils.  Of 83 paralytic  male patients, 76 showed  a  marked
difference of pupils; in  two others were noted constant con-
traction of both pupils to the size of a pin's head.   Two  suf-
fered from diseases of the eye, viz: contraction of the iris  and
dimness of the cornea, which did not permit an appreciation  of
the state of the pupils, whilst in three cases only, no difference
of the pupils was observed.  Out of 103 cases, therefore, only
4 patients showed no changes."
  Austin  found only two cases in one hundred, of general pa-
ralysis, in which inequality did not exist.  Thus while it is no-
ted so constantly by some observers others have found it present
in but half of their cases.  Why  this  discrepancy ?   But 
46
GENERAL PARALYSIS.
among the insane irregularity of pupils is noted as  of frequent
occurrence.  Among 146 insane Castiglioni found only 36 with
normal pupils.   Nasse says an inspection made during the past
year of all the sick, then inmates  of the  asylum  at  Siegburg,
gave this result, that out of 229 patients  only 83 were without
this difference of pupils.  He  says about  one  fourth and  no
more of the patients under his  observation show  no  abnormal
state of pupil, face, and tongue.
   He adds: "This frequent occurrence shows that these irregu-
larities are in no way  confined to the forms  of  general  paraly-
sis and dementia; but involve also in  a  considerable  measure
the primary forms  of mania  and  melancholy."    Nasse says
other writers have not observed the inequality  of pupils to  be
as frequent as his observations show it to be.
   Marce says,  in  doubtful cases inequality of the pupils, as  a
symptom, is of great importance.   This inequality is explained
by several writers, especcially Baillarger and Marce, to be clue
to the predominance of organic disease iii one side of the brain.
Nasse says the cause must be sought in the brain itself; Linston
affirms the same. Budge attributes it  to disturbed  nutrition.
Marce says:  "In many cases I have proved the  inequality  to
be due not to dilation  of one but constriction of the other pupil
which remains immovable and strongly contracted, even when
placed in darkness.  I have observed with some  patients both
pupils contracted at  the same time beyond a normal  state."
   Dr. Austin attempted to show a connection between the state
of the pupils and the nature of the delirium:  alterations of the
left corresponded to maniacal  excitement  and ambitious de-
lirium; alteration of the right indicated  melancholic  delirium;
when both were affected equally, the delirium was mixed; when  *
neither pupil was affected there was no delirium.  This he con-
fines to general paralysis.  Pelman and Nasse, after making ob- 
OHIO STATE MEDICAL SOCIETY.
47
servations to test this, declare it incorrect.   Nasse says Austin's
reports are not reliable, and  makes  this remark  in connection
with the report  cited of Austin, in which Austin found  the
pupil altered in 100 cases with all except 2 cases.   Jacobi found
the pupil altered  in four only out of fifty cases.  Notwithstand-
ing this remark  of Nasse he agrees with the report of  Austin
concerning the proportion of cases in which there is alteration
of the pupils  which no other writer  does.  The fact is  singular:
with Blackburn,  whenever there was a difference  in the  size of
the pupils noted, the  right was the largest,  coinciding with the
views of  Austin, Blackburn's  delirium being  of melancholic
form.  We do not, however, believe this theory  of Austin, or
accept it as correct.
  Many writers note  changes of the eyebrows  resulting from
paralysis of the  muscles.  They also  note change of  vision.
Marce says: "I have  seen, five or six times, progressive weak-
ness of sight,  extending to complete blindness, some cases of"
strabismus,  some of paralysis of the upper eyelid, before  the
trouble of speech appeared."
  Calmiel  says the sight is paralyzed wholly, or  in part, in
many cases.  Many times, he says, the  pupil  is  contracted  or
enlarged with both eyes, sometimes only with  one, sometimes
contracted upon one side, dilated upon the other.
  Several writers remark, that the pupils may vary much from
one month   to another,  with the  same paralytic.   (Calmiel,
Roussellin, &c.)
  The ophthalmoscope has been interrogated  upon the  condi-
tions of the optic nerve and  retina.  The reports of observa-
tions are too limited to enable us to form any positive, definite
opinion.
  Henry D.  Noyes, (Amer. Jour. Insanity, 412,  1872,) upon
this subject, reports eleven observations.  He says:  " In  all 
48                   GENERAL PARALYSIS.
these cases,  with the  exception  of  two, there is hypersemia
and   infiltration   of the  nerve,  and  retina.   The  striation
of the retina, near the nerve, is often extremely pronounced, and
may render the edge of the nerve  hazy and  indistinct.   The
nerve is often opaque in texture, or may be of a slaty hue.   In
one instance the nerve is found pallid, and doubt  is  expressed
whether this may not correctly be called a sign of atrophy."
  In some  cases pathological  changes  explain  the troubles
of vision, in others the cause must be  referred beyond  to  the
brain.
  We may conclude this division of our subject by saying that
one-half to two-thirds of those affected  with  general  paralysis
show alteration of one or both pupils; this  may be either  con-
traction or dilatation; that it is not constant, in all cases,  with
the same patient, but may be present at one  observation and ab-
sent at another.
  3.  Muscular Action:   Co-ordination of muscles; walk;  the
paralysis, general or partial; complete or incomplete.
  Griesinger has pointed out in the early stages of general  pa-
ralysis, spasmoelic action, as a cause of the want of co-ordinating
power, instead of paralysis.  Falret and  Duchenne have also
remarked that this inability to co-ordinate muscular action is due
rather to imperfect, spasmodic contraction  of muscles than a
want of power to  cause contraction.   To  produce accurate
movements the muscles must contract uniformly, and in unison.
This is impossible where a portion of a  muscle contracts vio-
lently under a  slight stimulus, and another portion but slowly.
The same is true where one muscle responds readily to  the will
and another slowly or not at all.   This  may be illustrated  by
the tongue;  it can be seen to  contract  unequally, and to  con-
tract in small portions spasmodically when protruded, producing
the  so called fibrillar contraction,  or  vermicular motion, some 
OHIO STATE MEDICAL SOCIETY.
49
fibers contracting, others not.  This must explain many features
of muscular action observed in walking, talking, etc.
  Griesinger says:  " The tongue is the  first organ  of which
there is any inequality.   The patient  begins to have  a little
trouble in speaking, he articulates not very well the words, he
stutters.   The tongue is not for that deviated from  a straight
line, but when the patient thrusts it from his mouth it trembles
a little and sometimes we see convulsive movements.   This first
symptom, diminution of the  volubility of speech, which soon
degenerates into stammering, has now an extraordinary  impor-
tance.  When we observe  this with one insane we can say with
certainty that he is incurable.   Very often  these patients  have
all the appearance of  health and affirm, in every manner, they
never felt better in their lives, yet we  see develop with  them
progressively a series of symptoms that leaves no  doubt  upon
the nature of the affection.  At the same time that the speech
becomes embarrassed, or more frequently a little after this phe-
nomenon appears, we notice a change in the  walk, the  patient
does not raise the legs as is necessary, he walks bad, awkwardly,
he wanders unconsciously from his road, the  least inequality
trips him. Nevertheless he yet walks readily  and is able  to
walk  for a long time; there are  even some patients who feel
impelled to walk constantly, they  make  long  promenades and
an experienced person, as long as they walk upon  level ground,
would notice nothing peculiar in their walk.    The  arms  pre-
serve a long time their force;  but in the same measure that ar-
ticulation of words becomes more and more hesitating and diffi-
cult, and as we are  obliged  to exert ourselves to  determine
(se chercher) what these patients wish to say, the'walk becomes
reeling as if they were drunk, they drag the feet, the  knees ap-
pear to desire to flex themselves, they are forced to  aid them-
selves by seeking support from the walls, they stumble at  each 
50                  GENERAL PARALYSIS.
footstep and often fall; the arms and hands become stiff and
awkward, they seize things convulsively, by times they let them
fall; all  movements that  demand precision (writing, carving,
the piano, &c.,) become by degrees impossible.   When lying in
bed these patients can always move more freely their legs and
arms, but these movements are always slower and stiffer than is
normal.  In proportion as the disease advances muscular power
is lost until these  patients can no longer hold  themselves  erect
nor speak, they utter only confused sounds that are meaningless; if
seated upon a chair they are unable to raise themselves or extend
a leg, sometimes the arms enjoy greater liberty of movement.
  " The  muscular affection seems now to be very extensive, and
almost general from the onset, although not  well  defined; it
manifests itself at first in the  organs of which the  movements
have need of great  delicateness  and precision; the tongue is
first affected,  and  the embarrassment of  speech  is always a
characteristic  feature of  this form  of paralysis.   Ordinarily
there exists also irregularity, at  the  same time, in  the move-
ments of the lips, the pronunciation  of  labials  is difficult, and
even when the patient does not speak we observe slight convul-
sions  about the  mouth.  In the superior extremities we  no-
tice, at the onset,  a certain trembling without veritable weak-
ness, tremblings which render the  movements  irregular,  awk-
ward,  and  uncertain.   In the  inferior  extremities  there is
often  less  trembling, at the onset, it is  rather an involuntary
agitation, rendering the  walk jerking and abrupt;  the  patient
cannot regulate properly  the  movements  of the legs; at this
period the walk is brusque, but later by continued weakening of
the muscles he cannot walk  at all; we  see  certain  groups  of
muscles of  the legs seized with a stiffness, sometimes  but  slight
at other times  persistent for a long time.   *       *        *
  " Later there exists in all cases muscular weakness more or 
              OHIO STATE MEDICAL SOCIETY.               51

less considerable; the trunk is inclined  forward, the arms  hang
at length by the body, the head at times inclines backwards, the
sphincters or muscles which concur to expel the urine and  fecal
matter are affected, and at length  the respiratory  muscles are
invaded.   Occasionally  tec  see one-half of the  body paralyzed
more than the other, a deviation of  the tongue or  one half of the
face; in these cases the lesion  appears  to  have  for  a cause a
more considerable  atrophy of one  of  the hemispheres or a  uni-
lateral hsemitoma of  the dura mater."
   This lengthy  quotation shows the  progress and development
of the muscular paralysis;  the relation of the difficulty of ar-
ticulation to the paralysis, and that all troubles  are alike   due,
where muscular action is the trouble  observed, to  want of co-
ordinating power,  until finally paralysis  puts an end to all mus-
cular effort.

MUSCULAR CONTRACTION AS  INFLUENCED  BY  ELECTRICITY.

   The influence of electricity upon muscles paralyzed in general
paralysis is stated  to be the  same as  in  other cerebral  palsies;
contrary to that which obtains in paralysis of peripheral  origin
or many spinal paralyses.
   Griesinger says  of muscular contractility, under the electric
stimulus, in general  paralysis: "this circumstance is of no great
value because this persistence of contractility is observed equally
 in a multitude  of  other palsies, as hysteric paralysis,  paralysis
 from cerebral tumors, &c.   Duchenne has observed this fact in
 his traite de V'electrization localisec, Paris 1855, and in  his mem-
 oire sur Vataxic locomotrice,  Archiv. de med., p. 68, 1859."
    Daffonet cites also the observations of Duchenne  concerning
 the influence  of electricity  upon the  contractility  of muscle.
 He says:  " This learned  experimenter  has  arrived at  very 
52                 GENERAL PARALYSIS.
interesting results.  He has proved that in paralysis  consecu-
tive to lesion of the brain, and particularly in general paralysis
with alienation, muscular irritability  is  preserved.   On the
contrary, electric excitation will not solicit the contraction of
muscles in lead palsy, in those  which  are  consecutive to  trau-
matic lesions of the nerve trunks, or in  those  symptomatic of
of an affection of the spinal marrow.  In  that disease we have
designated: paralysie generate progressive sans al'iencdion, which
is not accompanied by any disturbance of intellectual function,
and in which no special appreciable  lesion  of the nervous cen-
ters is observed, muscular irritability is especially wanting.  In
consequence electrization is adapted to  distinguish all  doubtful
cases of general paralysis from those without mental disturbance.
Nevertheless, in  general  paralysis  muscular  con-
tractility  CAN BE  REDUCED TO HALF,  ONE-THIRD OR  ONE-
FOURTH of its habitual force ; it can  also be shown  very
clearly at  an advanced  stage  of the disease,  especially when
this has followed a rapid progress."
  Marce  says :  " General Paralysis resembles no other form;
it is not only the abolition of muscular contractility  that  finds
itself here displayed, since these patients seated or lying  down
can move  very well their arms and legs, and since in their mo-
ments of agitation they discover surprising strength; but  it is
also in the defect of co-ordination, a want  of precision  in the
movements which is very  different from the abolition  of the
muscular sense or muscular ataxic, but which alone can explain
the abolition of the locomotor faculties so complete.   The state
of the muscles and of their contractility as influenced  by  elec-
tricity deserves mention from  this point  of view; in  effect
whatever has been the duration of the paralysis, the muscular
masses are relatively little atrophied ; they undergo  very  rare-
ly fatty degeneration,  and even to the last  moment,  even  with 
               OHIO STATE MEDICAL SOCIETY.               53

patients who remain in bed, preserve intact  their electric  con-
tractility."
  Brierre de Boismont confirms  the above.  His experiments
were in part made with Duchenne.
  Dr.  Bucknil says;  "In the year 1852 we published, in the
Report of the Devon County asylum, an  account of some  ex-
periments we  had  made  in the  diagnosis of such  cases, by
means  of the electric stimulus.   The electro-galvanic apparatus
was applied by us to the lower limbs of patients suffering from
mental disease without paralysis,  from dementia  with ordinary
paralysis.   The results of our experiments proved, that in  de-
mentia without paralysis, and in  dementia  "with  ordinary  pa-
ralysis, there  is  no  loss  of excito-motory sensibility, while in
general paralysis  there is a great loss of  this power.  In  some
cases the strongest  stimulus of the electro-magnetic machine
failed  to produce any  movement of the legs  of the patient,
beyond a slight tremor, not amounting to  muscular  contraction,
and incapable  of  moving the limb in the slightest degree.  This
experiment may be more conveniently, but less effectually, tried
by tickling  the soles of the feet.  In common paralysis it is
caused but in general paralysis it is  not  caused.    These  ex-
periments establish  a pathological rule  of  much  importance  in
diagnosis, that in  paralysis having its  seat in the brain, the
excito-motory  functions of the nerve is not lost'; that in gener-
al paralysis, the pathological conditions of which  involve  the
whole nervous system, the excito-motory  sensibility  is almost
abolished." 
54                 GENERAL PARALYSIS.
THE  PARALYSIS:  GENERAL  OR  PARTIAL;  COMPLETE  OR
                        INCOMPLETE.

  Particular attention should be given to determine these ques-
tions, for the character of the paralysis, its extent and complete-
ness throws great light upon the nature of the disease.
  Requin,  Sauze, &c, say, general paralysis may run its  course
and terminate fatally  without lesion  of intellect.    We do not
believe it.   The general voice of authority is that no case runs
on to a fatal termination without lesion of the intellectual  fac-
ulties.  There  is weakness and  unsoundness of mind  in  all
cases that have entered upon the second or third period of the
disease, but the mental phenomena enter  as constituents  of the
fact determined by  diagnosis, hence physical  symptoms alone
do not include all the facts upon Avhich an opinion should rest.
No two cases present  precisely the same degree of advancement
in respect to lesion  of intellect, sensation  and motion.   Lesion
of intellect may be observed before that of  motion; lesion  of
motion  before  that of  intellect; numbness, tingling, pricking
and other lesions of sensation before  either of the above.  Lesion
of sensibility may be very decided.  Much of this is depended
upon and governed by the point at which the  disease begins  to
manifest itself.   Attention will be directed by the  competent
observer to all three of  these :  intellect, sensation, and motion;
yet not  so that one will be studied wholly to the exclusion of facts
revealed by observation of the others.  When we observe a want
of co-ordinating power, and of sensation, without lesion  of in-
tellect, we  locate the primary trouble in  the  base of the  brain
and spinal  cord.  When the cortical substance is  involved in-
tellectual phenomena appear.
   Calmiel  says : (T. i. 494,)  " Microscopic researches  tend  to
prove each  day more and more, that diffused, chronic  perien- 
             OHIO STATE MEDICA L SOCIETY.                55

cephalitis (general paralysis) can propagate itself into a  certain
number of cases from the intra-cranial nerve centers to the raehidi-
an prolongation :  that is, tlie march is from above doirnwards.
  "We have seen it follow a course precisely opposite, in a cer-
tain number of cases.  There certainly exist  cases where the
inflammation begins in a chronic form  in  the spinal marrow,
where movement and sensibility, at first, are alone  disordered,
the moral and mental faculties are  afterwards compromised  in
their turn;  and where the functional derangements are the con-
sequence  evidently  of diffused,  chronic  periencephalitis: we
impress upon you the necessity of noting this observation, that
the inflammation proceeds from beloio upwards, and we can take
these exceptional facts for the rule."
   In other  words the phenomena express the seat of the  dis-
ease, the chief difficulty being in establishing clear pathological
views, or determining the nature of pathological changes before
death—the  same  phenomena accompanying changes at  differ-
ent points;  yet on the whole the above will  serve  as rules  to
guide in forming an opinion.
   Baillarger also observes that general paralysis sometimes be-
gins in the cord,  or spinal marrow, what has been termed "mus-
cular sense," that  is  the  recognition  of muscular conditions,
muscular tonicity and contractile power, is a power of the mind.
No matter how perfect all organization below the  hemispheres,
if they are diseased or wanting, there is  no  executive  power.
Cut the thread of communication between the brain  and spinal
cord and muscular power is lost.
   The lesion of movement in general paralysis, or paralysis of
the  muscles, is  characterized by its incompleteness.   No  one
muscle seems completely paralyzed until life is  nearly extinct.
While the muscles seem to retain their size, unlike cases of pa-
ralysis following apoplexy, we find there is a gradual, progres- 
5G
GENERAL PARALYSIS.
sive loss of muscular  power.   While  this extensive paralysis
implicates  great  numbers  of  muscles, at length nearly all in
the body, no one seems  completely paralyzed, and  the  loss of
muscular power seems so gradual the patient is unable  to  say
positively when it first begun.
  All writers, who speak of the subject at all, observe that  the
paralysis may be developed upon one side of  the  body, or upon
one  side more than the other.   Baillarger, Calmiel, Dagonet,
and others explain this fact by saying that there is greater com-
pression upon one side than the other, and that this compression
is  due to  more  excessive  congestion upon the  side  where
such compression exists.  Baillarger (Ann. Med. Psych.  1858,
p 175,) remarks that " hemiplegies are observed of  a  persistent
character, always located upon the same side, which depend upon
the congestive predominance of one cerebral hemisphere,and which
ends by determining an atrophy of the same side,  well marked."
  " Incomplete hemiplegia  appears to  be observed more  fre-
quently upon  the left side of the body;  it may  change to  the
other side;  it seems to be dependent upon dropsy of the ventri-
cles, or of the arachnoid, the effusion being more abundant up-
on one side than the other."  Dagonet, p. 425.
  The lesion of motion then, in general paralysis, may be said
to be characterized, as a rule, by a gradual, progressive exhaus-
tion of muscular energy and contractile  force, beginning  with
the tongue—showing itself next in the extremities; the muscles
of the neck, back, and internal organs  are in succession or sim-
ultaneously affected;  the muscles of involuntary  action are  last
affected; in no case complete until late in the disease, when the
patient, an inert, helpless mass, is  speedily relieved by  death.
The very incompleteness of the paralysis excites  attention,  that
although so general there is yet so great muscular activity.
   4.  Sensation.  To what extent and at what period of the disease 
OHIO STATE MEDICAL SOCIETY.
57
will disorder  of sensation appear?   What  is  its value  as a
diagnostic sign ?
  According to  Calmiel and Dagonet troubles of sensibility are
observed but at  the expiration of some time after the disease is
manifest—when lesion of movement and intellect have  existed
for a considerable length  of time.   According  to  Baillarger
sensibility of  the skin is diminished in the  last  two  stages  of
the disease.   Dagonet observes that those affected  with general
paralysis  often  manifest  loss of sensibility, or a diminution,
especially in the extremities of the fingers.   " The special senses
may be weakened—sight, hearing, smelling may be  intact,  yet
it is common  to find signs of partial paralysis, amaurosis, droop-
ing of the upper eyelids, diplopie, deafness, &c.,"  Dagonet.
   According to Connolly sexual desires  will be extinguished.
Dagonet says  this is not always correct, that some  patients dis-
cover a super excitation of the genital  organs.  He observed a
case, he says,  in which the disease had  advanced to a considera-
ble extent, and  yet the individual became a father.
   Griesinger  says, special sense,  as hearing, seeing, &c, may re-
main intact to the last, yet may   be affected.   He  says :  "The
sensibility of the skin presents some very  remarkable  particu-
lars.   In almost all cases it appears in the  beginning, obtuse,
and later almost completely abolished,  to such  extent that we
can pinch  them without their exhibiting signs of pain.  At
times we have observed cases where sligh hyperesthesia of the
cutaneous surface was manifest: the lightest contact with  the
skin provoked extensive reflex  movements,  convulsions  of all
voluntary muscles,, a state that offered the  greatest  analogy to
the effects of- strychnia."
    Crozant says, lesion of sensibility ought always to be regar-
ded as a precursory symptom of paralysis, which will follow.
Baillarger, says, lesion of sensibility should be examined  for in 
58
GENERAL PARALYSIS.
all cases threatened with general paralysis.  He  says, however,
that he has  demonstrated  the  existence  of  anesthesia  where
there was no appreciable lesion  of motion.    One then  under
his care had ambitious delirium, with signs  of demency, hallu-
cinations of hearing, believed the  owner of the house in which
she lived had given it to her; the intelligence was feeble, the skin
completely insensible.
  Marce" says, the troubles of sensibility in the early period of
the disease are of little importance.   He  says:   " We have
spoken of the weakness of sight, we have observed it in  some
exceptional  cases.  Besides  this  Crozant  has  noticed in  his
thesis* an almost complete general paralysis;  I have  had  occa-
sion almost complete general paralysis; I have  had occasion to
verify several times the correctness of this assertion.   This an-
esthesia exists but in a light manner and disappears as soon as
the troubles of motility are more  decided, and reappears  later,
in the last period of the disease."
  From this we conclude that the pathological changes induc-
ing lesion of motion and intellect  also  involve the  sensorium
and organs of special sense.  These last being modifications  of
general sensation, their centers in the base  of the  brain,  with
the common seat of sensation, no other result  is expected than
that  all should share in the general ruin and degeneration of
nerve structure.   It is not expected that constant, identical  le-
sions of sensibility should be manifest more than  the same  of
intellect and motion.   In the early  stage then we  may  have
predominate lesion of motion with anesthesia; lesion of intel-
lect may predominate ; or lesion of sensibility at an  extremely
early period but soon  giving way to  predominance of other
symptoms; lesion of motion may appear before other symptoms.

   * De la paralysie generale ehez les aliens, Ann. Med Psychol, 1846, 132. 
OHIO STATE MEDICAL SOCIETY.
59
  5. Physical symptoms of secondary importance,  less  constant
in their appearance, non-essential to general paralysis.
  Grinding of the teeth:  This has been noted by observers as  a
symptom frequently manifest during the course of general  par-
alysis.   It is an  involuntary, spasmodic action of the muscles,
at times annoying to the patient, occurring in spite of his men-
tal efforts to resist it and also during his hours of activity.  It
is in part due to spinal irritation, in all probability, or will be
found more frequent with those having spinal difficulty in addi-
tion to cerebral.   However it occurs generally during the  con-
gestive periods and may  be  due to meningeal  excitement, in-
flammatory action, and irritation of motory centers  consequent
upon the congestion—the same irritation inducing the  conges-
tion being powerful enough to excite convulsive  action.   It is
not generally observed   except when a congestive  period  has
exaggerated muscular activity.
  Baillarger says ;  " We observe frequently this symptom  in
the course of general paralysis, and in some rare cases, we see
it manifested at  the onset of the disease.   *   *   One of these
patients has had for eight years hemiplegia of the left  side, of
which  there  yet remain traces, and he is a prey at  times, to  a
cerebral excitement which forces him to acts of violence.   The
second patient has had two attacks  of facial hemiplegia."
   Trembling  is another symptom mentioned by  writers.   It is
but the constant twitching of portions of muscle, or the  vibra-
tory, fibrillary contraction, or vermicular  motion seen in  the
tongue, manifest elsewhere by trembling.
   This action with the  tongue—it is  not always  present, is
not always of the  same  intensity when present, may  be  ob-
served some  days and not upon others, may be manifest in  the
morning and not in the evening; in short it is said to be  more
apparent when the nervous system  is not modified by  any  ex- 
60
GENERAL PARALYSIS.
ternal influence.  It  is  but a  lesser degree  of that  state  of
the  muscular system observed  in these cases,  Stiffness, chiefly
observed in the  melancholic or hypochondriacal varieties of the
disease.  This may occur at the onset, during the  prodromic
period, during the course, or only during  the  terminal  period.
It is a prolonged cramp or rigidity  of the muscles.
   Continued efforts to swallow, spasmodic action of the muscles  of
deglutition, constant tasting, have been remarked upon  by writers.
They are either due  to  the modification  of sensibility, or the
same causes operating to induce involuntary  muscular action
elsewhere, in some cases to  both of these causes.
  Exaggerated activity.   This as a  condition the opposite of the
apathetic, stupid, semi-comatose  state sometimes observed should
be regarded as an essential symptom—or as one of great signifi-
cance ; but having no special significance,  except as  indicating
the activity of the nerve centers, that  is,  undue influence  upon
them of some exciting power, whether local or general  distur-
bance, it is not regarded as an essential symptom.  It is but  a
modification of the condition giving rise to  irregular muscular
contraction and spasmodic action—an impulse  being  added to
move forwards.   Many are unable  to keep  quiet, but are  im-
pelled to keep moving, walking, or are in some state of agita-
tion.  It occurs rather in the prodromic period, or at the  onset
of the disease than at a  later period.  As  a symptom its value
consists in its indicating the condition of the nerve centers, and
the striking contrast it presents to the apathy, immobility   and
obtuseness of the depressive varieties.  It is however not  con-
fined to general paralysis—hence is no specific symptom.
  6.  Congestive periods, effusions of blood,  &c.
  We come now to one of, if not the most important element of
the disease: congestion.   To do it justice we  would  require as
much space as we occupy with the whole consideration  of  gen- 
OHIO STATE MEDICAL SOCIETY.
61
eral paralysis, yet sufficient may be presented to enable it to be
recognized, and its importance in forming a  correct opinion  as
to the nature and results of the condition.
   Griesinger comments upon the congestive attacks that  usher
in, and aggravate the symptoms during the course of the dis-
ease, as follows, the full force of which can be appreciated only
when considered in connection with  the anatomico-pathologi-
cal conditions observed after death.  " We have  made  a  very
great number of highly interesting researches upon the state of
the brain in general paralysis;  they demonstrate  that  the al-
teration which determines the disease,  is  not  the same  in all
cases.  Here as in other affections of the nervous system, differ-
ent anatomic lesions can give rise to the  same group  of symp-
toms.  Ordinary apoplexy never determines this form of paral-
ysis ; on the other hand we often see during the attacks of con-
gestion with loss of knowledge, effusions of blood more or less
considerable form in the cavity of the arachnoid, effusions which
afterwards encyst, when the quantity of *blood  is small, being
transformed into thin false membranes,  as efflorescences upon the
internal  face of the  dura  mater,  upon  the convexities of the
hemispheres.
   But we cannot admit that the apoplectiform conges Are attacks
are always the result of a hemorrhage  into the arachnoid cavity
(hematome);  there are cases where these  attacks  occur a  great
number  of  times and with considerable intensity, in  which
there is no hemorrhage.  We  see  sometimes, but this  is  rare
enough, traces of ordinary apoplexy in the brains of those  who
have succumbed to general paralysis; it is a simple complication;
never, I repeat it, does this form of apoplexy determine  general
paralysis."
   Marce, upon the prodromic period says:  " It  is worthy of
interest to remark that general paralysis when it  arrives  at  a
                                                      6 
62
GENERAL PARALYSIS.
period of complete development may offer  uniform symptoms,
yet at its onset it may present aspects the most opposite.   For
example, Jules Falret and Linas have elucidated this point with
great clearness, and we admit with them that  general  paralysis
presents at its onset four varieties, with  progress  very distinct,
in two of which physical symptoms predominate, the  congestive
and paralytic varieties;  and two which  are  characterized by in-
tellectual troubles, the expansive and melancholic varieties.  The
expansive form with ambitious delirium is  without doubt the
most frequent, but it is not specific  as Bayle has  thought it  to
be, and the others ought  to be described with much greater care
as they have been the origin of the greater part of the contro-
versies which have been raised upon the subject."
   Marce" describes the congestive variety, his 4th variety, as fol-
lows, we omit the first three : "4th variety.   In the congestive
variety the apparent onset of the disease is  a  cerebral conges-
tion, supervening in the  midst of  prodromic accidents as yet
badly marked.  This .congestion  that  we  discuss  in another
place in detail, for it complicates all varieties of general paraly-
sis, presents itself in a  comatose form, in  a  convulsive form,
or a hemiplegic form.  At first it presents nothing that distin-
guishes ifrfrom ordinary  cerebral congestions, but when at the
end of some hours or some days, the acute apoplectic symptoms
are dissipated, we see them replaced by a maniacal  excitement
with ambitious ideas; more often yet the congestion  seems to
give place to a complete return to  reason, but the  speech re-
mains slightly embarrassed, memory is  weakened,  intelligence
has lost its clearness and vigor.  In  proportion  as we depart
from the initial congestion, these symptoms tend, in general, to
diminish; we see even the mental faculties return to their  nor-
mal state, when a new congestion leads  to a new aggravation :
the disease progresses thus by abrupt periods (saccades), for the- 
OHIO STATE MEDICAL SOCIETY.
6a
amelioration which is produced between two congestions goes
always towards attenuating and  conducting,  little by little, to
the second period of the disease.  These paralytics  have a pe-
culiar physiognomy: with them  the capillary network  of the
face is dilated and varicose, red  cheeks,  face, neck, ears and
scalp injected.  The temperature  seems not increased  of the
skin, it is a passive congestion of all the cephalic extremity."
  Further on Marce says, " cerebral congestion plays a  role of
the first order in the progress of general paralysis.  It is some-
times the first initial phenomenon; it can also terminate it sud-
denly by death.   At length we encounter it at all periods, as  a
complication.  All congestion, when it spares the life of the pa-
tient, leaves after it a notable aggravation of the  troubles of
motion and intelligence; and upon also  another  point, conges-
tion determines congestion; in proportion as the number of at-
tacks increase, its  frequency, intensity  and  form, modify the
prognosis.   There is  nothing  in the general  nature  of the
encephalic  congestions that differs from congestions repeated
elsewhere.   The cortical substance with its  vascular network
abnormally developed, with the  products of exudation,  which
alter profoundly its structure, can  assimilate itself to these  cir-
cumstances as well as to cerebral  tumors, softenings, cicatrices,
about which at irregular intervals  congestion  takes place, con-
tributing considerably to the organic  lesion, and  manifesting
itself by the habitual phenomena  of congestion  superadded  to
the phenomena of the first disease."
  Aubanel, Ann. Med. Psychol,  T. viip. 189, 1846, gives eight
forms of cerebral congestion occurring in  general paralysis:
1, forme legere;  2, maniaque ;  3, convulsive; 4,  hemiplegique;
5, coup  de sang; 6, comateuse; 7, intermittent;  8,  irregulikre
avec alternance de tons les symptomes.
  Marce presents six forms:  1, light with excitement; 2, mani- 
64
GENERAL PARALYSIS.
acal;  3, comatose; 4, hemiplegic ;  5 convulsive  apoplectiform;
6, irregular forms.
   "1. The first form, the mildest, consists simply in an  abnor-
mal increase of the cerebral circulation.  The patient does  not
fall, remains conscious;  but the face becomes red, eyes injected,
pulse  accelerated, gestures  rapid; he  becomes loquacious, can-
not remain in one  place, embarrassment  of speech is sensibly
augmented.  Digestion  is laborious,  constipation, a temperature
a little elevated serves to introduce this condition, of which the
duration varies from  a few hours  to two or three days,* and
which generally   yields to  a  purgative or  moderate  blood
letting.   It is necessary to remember that these symptoms  may
be frequently renewed, and constitute less a real congestion than
a permanent congestive  state which leaves the patient without
cessation under the threatenings of the most  serious  accidents.
   " 2. The second form differs from  the  preceding but  in  the
degree of the excitement that the maniacal agitation  assumes.
Under the  influence of the sanguinous afflux, the patient is
given  up to acts of violence and rage, and the delirious ideas
redoubling with  incoherence,  and  intense mental confusion.
The redness of the face, and rational symptoms  of congestion
coincide with that  state, which disappears readily under the in-
fluence of moderate loss of blood, prolonged baths, and habitu-
al anodynes.
,   " 3. In the comatose  form the congestion is announced  uni-
formly  by the tendency  to somnolency, redness  of the  face,
physical and  intellectual inertia.  In a few hours this state at-
tains to  coma.    The  patients remain  insensible  to  external
agents, respond to no questions, and  their muscles  are in  a
state of complete firmness;  respiration is as easy  as in sleep.
*See Blackburn case at the end of this Report. 
OHIO STATE MEDICAL SOCIETY.
G5
The comatose form, pure, is not extremely grave; it is not rare
to see it dissipated in a few hours under appropriate treatment.
  "4. The hemiplegic form can manifest itself at the onset and
then becomes most serious.   It is not rare too see  paralytics in
the  midst of a meal, during a walk, let fall all at once an object
that they hold in the hand, and cease to be able to  stand  upon
one of the inferior extremities.  They remain thus paralyzed of
an arm, of a leg, or of one half of the body during some hours
or some days, without any grave general symptoms accompany-
ing these partial congestions of one hemisphere.  The paralyses
thus produced (almost  always disappear, but in an incoviphfe
manner, and leave after them a notable weakness of one half of
the body.
  " 5.   The apoplectiform  convulsive  congestion  is of all the
most grave, and perhaps  the most frequent.   In this the attack
is sudden and really apoplectic.  The patient falls as  if thun-
derstruck, unconscious, insensible to all  external excitants, and
if he  succumbs  not immediately, is  taken with  convulsions.
These convulsions  are sometimes general, sometimes  limited,
may be to one-half of  the  body, half of the  face, an arm, or
leg; they can be  purely eclamptic,  without well determined
character, or  clothed  with  all the appearances of  an epileptic
attack, i. e. convulsive, with the initial shriek alternating  with
paleness and redness of face, bloody foam, and special  convul-
sions.  In two cases they were manifested  by  separate  attacks
at intervals of short duration, sometimes several attacks in twen-
ty-four hours, separated by a state of coma more or less complete.
  " 6. The irregular forms  are  a mixture of the  preceding.
The convulsions, comatose state, paralysis, maniacal excitement,
succeed  without order to  constitute a complete state that cannot
be described."
  These convulsive periods may occur four, five, or six  times a 
•66
GENERAL PARALYSIS.
year, ending often in the  death of the patient.  In 86 observa-
tions Parchappe found death result 40 times from this cause.
   Calmiel, T. i. p. 501, says  of the  convulsions:  "In  other
circumstances the  contractions  of muscular fiber are incessant.
In the cases of this species we see sometimes convulsions  re-
produced for twenty-four, thirty, forty, sixty hours without  in-
termissiou,  spasms  of the eyelids,  muscles of the  jaws, lips,
arms,  hands, hips, the legs are incessantly shaken by  a series of
shocks more or less violent."
   All the forms of congestion mentioned by Marce may be suc-
cessively  observed  with  the same person, one attack may  be
slight, the next convulsive, followed  by  coma, paralysis  more
or less complete.
   Baillarger, Appendix to Griesinger, p.  633-736,  gives  an
extended consideration of the  congestive periods of general
paralysis.  Calmiel, T. i. p. 510-680 and T.  ii, we  have the
subject fully considered, and will be of interest to all  who can
read the French.
   Baillarger says Bayle deserves the honor of having demon-
strated that cerebral congestion is the immediate cause of gen-
eral  paralysis, and adds "this  opinion  is  to-day  generally ac-
cepted."
   Aubanel  says  cerebral  congestions  are  the cause  of all the
pathologic alterations which successfully  supervene  in general
paralysis.  They determine at first lesions of the meninges and
end  by  altering  and softening the gray substance,  then the
white, if the disease is prolonged.
   Parchappe says:  "The frequency of cerebral congestion more
or less decided at the onset of  general paralysis, is to me a fact
so well  established  that often  I have been able to foresee the
immediate  exhibition of  paralytic phenomena in some  cases
where the intellectual trouble,  still free from all paralytic com- 
OHIO STATE MEDICAL SOCIETY.
67
plication, or sometimes but very  slight  has been preceded  by
or accompanied by cerebral congestion.
   Falret makes a distinct  form—the  congestive  variety—of
general  paralysis, reducing  the  disease   to  three  varieties:
1. congestive;  2.  paralytic; 3. mental  variety. Dagonet adopts
this division of the characters of the disease and treats first of
the congestive  variety:
   "1.  Congestive variety.   All authors have noted the frequency
of congestions, more or less defined, in the prodromic period of
general  paralysis; they show themselves  under the  form of
shocks, loss of consciousness  more or less  complete, sometimes
epileptiform attacks.   These  congestions are accompanied with
 or followed by various paralytic phenomena,  ordinarily tem-
porary;  an embarrassment of speech, often intense  after  the
 attack, but which becomes afterwards  less perceptible, a weak^
 ness of intellect,  or, even in  some  cases, delirium, either of a
 quiet or of an agitated character."
   General paralysis may be ushered in with an attack, or series
 of attacks, of congestion; after each period of congestion  the
 paralytic as well as  intellectual  symptoms  are  aggravated.
 Some cases seem to advance in no other way.  These congestive
 attacks may vary in  intensity from  a slight afflux  of blood to
 full unconsciousness, resulting in death.  They seem to bear the
 same relation  to inflammation that  congestion  does elsewhere.
 The vegetative system of nerves—sympathetic—the vaso-motor,
 undergo  profound radical change of character, either  from ex-
 haustion or depression  as may  be seen in these  congestions.
 With the melancholic, except during these congestions, there is
 paleness.   The turgescence resembles that produced by a sec-
 tion of the sympathetic in many  cases.   The  continued conges-
. tion as shown  by the redness of the face, can not result other-
 wise than in organic lesion.  Nutrition must  be greatly modi- 
68
GENERAL PARALYSIS,
fied, and this is attested by post mortem examination, when the
changes  brought about  are  observed, as we shall see.  The
softened  blood vessels, relaxed and crowded,  give way, and ef-
fusions of blood follow, in the brain,  eyelids, ears,*  &c.  The
external  appearances, congestion of face, ears and  scalp, are of
the highest significance in general  paralysis, indicating  the con-
dition of circulation within.  If with great restlessness there be
excessive congestion  of the  external  surface of the head,  we
would expect  the same  condition  to exist within the  cranium.
Hence, declarations that they are  of no value as signs, or that
the condition  indicates  nothing, only expresses the superficial
knowledge of the observer.  Continental  writers speak of this
highly congested state,  followed by  local effusion of blood, as
an erysipelatous condition—some call it erysipelas.
  Griessinger, 505, lrait6 des Maladies Mentales, says:  "One of
the most frequent local affections with the insane is that malady
of the external ear that we ordinarily designate under the name
of sanguinous tumor, or erysipelas  of the  ear.  The skin of the
pavilion  of the ear is tumified, becomes  brilliant, tender and
offers a fluctuation well marked ; the ear  thickens, it is bright
red, hot, painful.  If we  incise the  tumor,  we see  that it is
formed by a cavity filled  with  blood, semi-liquid, which  runs
out by the wound produced, and is rapidly replaced; sometimes
this pocket empties itself by spontaneous  rupture.   When  we
examine  closely we find a sanguinous effusion beneath the  peri-
chondrium of the cartilage^ which is as it were stripped.  Generally
the swelling and redness diminish  in a few weeks, and  nothing
remains more than a thickness more or less considerable of the
pavilion  of the ear, which is  sometimes shriveled and deformed."
  Marce 453, says: " With cerebral congestion we note another
*See Blackburn Case. 
OHIO STATE MEDICAL SOCIETY.
69
remarkable complication, not for its gravity, but for  its  singu-
larity : I wish to speak of the sanguinous tumors of the ears, or
hematomes auriculcdres.
  " We find sometimes with the insane and  above all with  the
paralytic, sanguinous tumors which are developed at the  exter-
nal face of the pavilion of the ear:  described first  in France,
in 1838, by Ferrus, in his cliniques at  the  Bicetre. They have
since  been studied by  Bellhomme, Cossy, Thore, Lunier  and
Renaudin, by Merland in his inaugural Thesis, 1853, and more
recently by Foville who has designated  more  accurately than
his predecessors  the seat of the condition.  In  Germany, Bird,
in 1838, published a good work upon the subject, and  in  1848
Franz Fisher wrote an article  for the Journal of Damerow.   "It
is almost exclusively with men that we observe this condition,
and generally in general paralysis, but sometimes also in simple
demency, acute mania and melancholy, where they are signs of
its incurability;  also we observe them in other affections than
insanity, in hysteria, in typhoid fever, with professional  wrest-
lers,  with  scholars  with whom  the  ears  have been pulled.
(Bastien, Jarjavay, Mallez).
  " The formation of these tumors has been attributed to a  va-
riety of causes;  they have  accused external  violence, striking
of the head against the  walls, thereby -injuring the ears,  and
above all the  afflux of blood towards the head.  There  exists, in
effect an intimate connection between the circulation of the ears
and that of the rest of the  head; every time there  is  cerebral
congestion the ears become red and turgescent,  sometimes they
become pale as in syncope; in general paralysis where the con-
gestion of the head is incessant, it is natural to think  that  the
vessels of the ear dilate and thus favor the effusion  of blood.
This view is  sustained by Bellhomme, Cossy, Renaudin, De-
lasiauve, and Foville in his Recherches sur les tumeurs sangidnes 
70
GENERAL PARALYSIS.
du pavilion de Voreille chez les alienes.  Ann. Med. Psychols, 1859.
  " I will cite also an observation published by me in  1858, in
which the eyelids were at the  same time as the pavilion  of the
ear, the seat of a sanguinous collection, as if all  the capillaries
of the face were at the time the seat of the same turgescence.
  " A little before the appearance of the tumor, we notice  that
both ears or only one, becomes red, sensitive and swollen; at the
same  time the patient presents all the signs of an active cerebral
circulation; by times the skin  has  its  normal  color  and  the
pavilion presents an  odoema purely  serous.   The sanguinous
effusion is rapidly produced, sometimes in seven or eight hours,
and more frequently we observe its existence only  when fully
developed.
  " The volume of the tumor is variable, it may be small as  a
pea or  large as a pigeon's egg: it then makes a  considerable
projection, and when existing  in both ears gives the  physiog-
nomy a singular and characteristic aspect.  It extends to all the
pavilion, except the  lobule, obliterates the meatus  and leads  to
deafness.  The hard tumor sometimes offers a sort  of crepita-
tion within  due to the  crushing of clots; in some cases  it is
fluctuating at the center and indurated at  the circumference."
   Schroeder Van Der Kolk, Pathology of Insanity, 115, speak-
ing of the nature of this condition, says:   " The suspicion  may
easily arise that the swelling was the consequence  of  previous
maltreatment.  I have, however, observed one case where an
insane patient made this accusation, but it was thoroughly  un-
founded, for afterwards without  any obvious cause, a  similar
swelling appeared in the  other ear."  E. R. Hun, M. D., in the
American Journal of Insanity, July, 1870, with photographic
plates illustrates fully the appearance of  the condition.   (Cases
in the New York Asylum,  Utica).  He says, "The  form  of in-
sanity in 24 cases was:  general paresis 8, melancholia 6, acute 
OHIO STATE MEDICAL SOCIETY.
71
mania 4, chronic mania 4, dementia 2,."  It occurred  23 out of
24 times with men.   Both ears were affected in nine  ctfses, the
right ear  alone  in nine cases, the left ear alone in five, in one
case the records do not state which ear was affected."  In  rela-
tion to prognosis its importance may be seen  by  the fact: in
nine cases the patient died insane at the asylum, nine were  dis-
charged unimproved and six remain in  a  state  of dementia.
He says it occurs only with the insane and  denotes the  incura-
bility of the affection.   " It is idiopathic, depending upon  a
pathological condition of the brain, and is  incapable  of being
produced by external violence alone."
  We believe the  condition in question is one peculiar to in-
sanity.  We believe the cause to be, the most direct, the paraly-
sis of the walls of the blood vessels, the organic changes conse-
quent upon it, malnutrition,  causing  when there  is  afflux of
blood the weakened walls to yield to  the pressure, and without
as well as within the cranium, effusion of blood.   It is more
frequently  observed within the cranium, giving  rise to apoplectic
attacks, sudden loss of consciousness, or paralysis complete of one
half of the body.  Where the effusion is small the effects will be
in a corresponding ratio  less manifest.  The condition  is evi-
dently due to the paralysis invading the vaso motor centers, in-
ducing thereby stasis of  blood, consequent upon  which is  the
malnutrition of the vessels.
  Morel, citing Calmiel  upon the tendency of  certain  insane to
suffer from attacks of erysipelas, says: " In the commencement
of my practice, I confess that I did not take sufficient account
of the attacks of erysipelas which with certain insane,  invade
the face, the scalp, neck; and of the phlegmons  of the  paroti-
dian region; they ought to be taken into serious consideration.
  " We think, says Calmiel, that these accidents  ought  to  be
classed among the manifestations purely essential and  dynamic. 
72
GENERAL PARALYSIS.
This is true for a great number of the  insane, and I except not
the hereditary.  But it is among these, who owe their  predispo-
sition to inflammatory disease of the brain to  their ascendants
that I am speaking at this moment."
  Thus those whose vegetative system is characterized by a de-
praved condition, without energy, as a  consequence  of heredi-
tary influences are predisposed by virtue  of this adynamic state
to congestion and effusion.
  Foville, Recherches sur les tumeurs sanguines du pavillion de
Voreille, p. 21, cites four conclusions of  Bernard concerning the
nature of these effusions of blood, deduced from section  of the
great  sympathetic: " 4. The formation of bloody tumors of the
pavilion of the ear is most generally preceded by, and accom-
panied with a general disturbance of the circulation of the head,
and it is worthy of remark that the increase of redness  and of
sensibility, that we demonstrate in these  cases, resembles in  a
striking manner that which we observe with animals  of which
we have cut the great sympathetic at the neck, or have removed
the superior cervical ganglion."

                INTELLECTUAL  PHENOMENA.

  We have fully considered the physical symptoms and occas-
sionally have made reference  to  the intellectual.   We have
already remarked that the intellectual phenomena are character-
ized by two features,  opposite in character: expansion or ex-
altation, and depression or melancholy.
  The monomania des grandeurs, ambitious delirium, has been
by a few writers, and is still regarded by some, as specific,  i. e.,
characteristic of general paralysis.  When we study the works
of those  writers whose experience, ability and reputation entitle
them to great weight, we find without  exception they do not 
OHIO STATE MEDICAL SOCIETY.
73
accept this doctrine, but on the contrary emphatically  declare it
unsupported  by correct  observation.   Calmiel, Baillarger,
Marce, and others, have so clearly proved the  contrary  to  be
true, that we have little confidence in the  views of any  writer
upon  any other point connected with the disease who  does not
repudiate this error of the past, for to adhere to it shows a lim-
ited knowledge of the subject, or an unwillingness to  profit  by
the experience of others.
  Bayle thought the delire des grandeurs  the only type of men-
tal phenomena existing in general paralysis.   Is it correct?  Do
his own reported cases justify the conclusions?
  Brierre de Boismont, Article:  Demence paralytique,  in the
Bibliotheque du medecin praticien, T. ix, 548,  speaks of the rel-
ative  frequency  of ambitious  delirium.  He says: In seeking
the frequency of ambitious delirium in 42 observations in the
work of Calmiel we  have found 25 who offer this type;  in  85
observations of  Bayle, 52 presented symptoms  of the mania  of
riches, honors, &c,"  He remarks that some who did not mani-
fest ambitious delirium at first, did later in the  disease, and that
with some who manifested this form of delirium early in the
disease,  later it was not manifest.   In the pamphlet we have
quoted before, upon the perversions of moral character in the
prodromic period, he says : "We still  remark that this delirium
ought to be studied  during the whole  course of the disease;
for some paralytics who at the onset have not exalted ideas  of
grandeur, manifest them later, and the contrary ; in  some cases
these ideas are transient, flashing along like meteors."
   Baillarger has made a similar  remark,  in Gaz. des  Hopitaux,
July  14, 1844, "some individuals who in the first stage  of the
disease do not manifest ideas of grandeur, offer them later, and
vice versa."
   Crozant expressed himself as follows in 1844:   "The coin- 
74
GENERAL PARALYSIS.
 cidence  of the  manie des grandeurs and general paralysis is  a
 truth that I am unable to comprehend but I am able to  estab-
 lish it.   I  affirm that there is not at the Bicetre, at this moment
 I have observations of them under my eye,—a  single  patient
 attacked with general paralysis who does  not manifest  ambi-
 tious mania, provided that at all times we  properly  interrogate
 him, and who will  not be moved when we  say he  is  either
 rich or poor.
   I went through the Bicetre one day with a physician who de-
 voted his attention to insanity, and asked him to show  me  one
 case of general paralysis that did  not present  this species of
 mania, his  opinion  nevertheless was  to the  contrary.   After
 many attempts he led me with an air of triumph to  one  and
 asked him  before me  whether he was rich, whether he was  a
 prince  or  worthy  to be  one,  or  hoped  to be one  in  the
 future.
   The patient replied very wisely that he was a  tailor,  that he
 scarcely gained a support for his family and that he  never  had
 other troubles than to do well his calling.  All his conversation
 was very reasonable, and to the  physician  seemed very  fairly
 an  exception.   I hesitated  not to show him he was mistaken.
 In interrogating him in detail upon his condition, upon his busi-
 ness and his manner of pursuing it we found we  had  a  tailor
 the most expert, the most distinguished, the most  eminent that
 ever lived, a tailor most vain, proud, one could find.   My con-
frere declared his error.  The paralyzed show this presumption
 in all that they touch; their beauty, their health, their muscular
 force, their talents, are in succession boastingly displayed, in  a
 manner the most pompous, and with rich images and epithets."
 (Gazzette des Hopitaux, April 26, 1842.)
   The most recent writers  are disposed to  multiply varieties,
 and perhaps to too great an extent, dividing and sub-dividing 
OHIO STATE MEDICAL SOCIETY.
75
until one  becomes  weary in tracing out all the details  upon
which the divisions are based.
  Briande and Chaude,  in  the new edition of their  classical
work upon Legal Medicine, make four varieties.
  Marce divides general paralysis into four varieties;  two are
based upon the intellectual  phenomena; two  upon the physical.
They are:  1. Expansive;  2.  Melancholic;  3.  Paralytic;   4.
Congestive.
  We will consider the  melancholic  form,  in connection with
that of exaltation, as the relative number of each, the frequency,
will be better determined, as well as other facts.
  Marce describes the expansive variety as follows: After a pro-
dromic period, of which the duration  is variable, the patients,
now violent and  irritable, become little  by little, more active
than is consistent with a normal state.  They write, compose,
speak, move  without cessation, form, without  cessation, new
projects, and think  nothing impossible; at  the same time their
memory weakens; they forget that which they have done a few
hours before.   Without  having yet the seal of ambitious delir-
ium, their conceptions are  difficult to realize, based upon foun-
dations unsound, and present a  striking contrast with all the
habits of their life.   On the side of the  organic functions the
excitation betrays  itself by symptoms not  less decided; these
patients cannot remain an instant in a place; they feel the need
of walking,  of running, and are  indefatigable; I have  seen a
landlord, at this  period of the  disease, strike with force, want-
ing power to repeat it, the  furniture and staircase of the house
where he lived.  It is with these we observe a genesique excita-
tion that is insatiable and  which respects nothing that will sat-
isfy it,  and  which   forces, even  in public, to  most  deplora-
ble acts; with others it causes an unquenchable  thirst for alco-
holic drinks  which aggravates the disease.   There results from 
76
GENERAL PARALYSIS.
it a disordered and irregular manner of living, excesses of all
kinds and delirious acts which attract attention.
  These patients quit their  homes, wander in the streets  and
fields, undress  themselves, sleep in  the  open  air, purchase at
shops and hire conveyances  by the day without power  to  pay
for them, even commit thefts of a special nature, as  if without
intention and by mistake, from the front  of a shop  or a  store
window.  It is at this period that, under  the influence  of this
impulse to  continued action which rules  them, of  this spirit
they manifest in everything  and which  renders  them fearless,
bold, and disposed to doubt nothing, that the subjects the most
avaricious,  the most stingy in their dealings, enter  upon hazard-
ous speculations, foreign to all their former prudent  and well-
considered habits, make purchases  out  of proportion to their
resources, and give orders to fit up their property and embellish
and adorn it in a way they can never realize.
  When the cerebral excitement arrives at  this degree it soon
assumes the proportions of a veritable maniacal delirium, and
then shines out in all its plentitude  the  delirium  of ambition,
so curious, so characteristic, so variable  in its  manifestations.
Most generally the ruling ideas are of money and  riches.  The
patients refuse to  work; they  acquire  20  francs, 100  francs,
100,000 francs per day.   Without transition they gain millions,
and even more as declared daily by them.   They possess castles,
immense lands;  they speak  of gold, of diamonds; they  regard
the walls, the furniture, the objects  which  surround  them  as
formed of precious metal; in their expansion that  nothing lim-
its, they  make considerable presents  to their  friends, relatives,
and promise fabulous sums  for the most  trifling service.   To
the ideas of richness they add ideas of glory, honor and  power.
They are presidents, kings, emperors, according to the political
form of government, or system of their age; they flutter with 
OHIO STATE MEDICAL SOCIETY.
77
ribbons of all colors, with titles of nobility, giving themselves
titles of illustrious birth, going even  further, regarding  them-
selves as endowed with  supernatural  power, genius; they are
Gods themselves.  Nothing equals their grand conceptions, their
gigantic projects;  they wish to change the surface of the earth;
they  give a banquet to the universe  upon a table a  thousand
miles long; they are going to create men 30 arm-lengths high;
they can heal the  sick; bring to life the dead.
   At the  onset of the paralysis while  the intelligence  preserves
yet a certain force, this delirium can be produced  with a rich-
ness  of imagination, with a vivacity  of colors attaining  to the
most strange conceptions, and the most fantastic, ending always
in a state of good fortune, of riches, of power not only for the
patient, but for all who surround him.  A paralytic  informed
me that he was about to create a new world, traversed by rivers
of immense size, filled with gigantic fish, and valleys of extra-
ordinary fertility; every inhabitant of  his palaces ' should have
100,000 francs income and live in extreme good  fortune.   He
would be God and his wife a Goddess.
   This ambitious  mania which can vary  to  infinity, never ar-
rives at its complete development at the onset of the  disease;
then it may be of a modest nature, announced by a certain re-
serve, and is progressive but as the patients  advance with  the
disease.   The poor  workman, interrogated upon  his  fortune,
doubles the price of his day's work, and counts upon resour-
ces he does not possess; but his pretensions are so little exagger-
ated that research  into them alone will reveal the truth.   The
merchant, the manufacturer attribute to their  industry  propor-
tions far  exceeding  the truth and which they have in no way
realized.  It is but progressively that these exaggerations reach
an extreme degree and strike all by their unreasonableness.
   At the  side of this delirium of ambitious form there  exists 
78
GENERAL PARALYSIS.
another variety, which though less marked than the  other, pos-
sesses as considerable semiologic  value; the patients attacked
have not so to speak delirious conceptions, but  they  live in  a
state of happiness and self-satisfaction nothing can alter.  They
make  pretensions to  poetry, to literature, to  force; they  feel
vigorous, endowed with robust health, never were they  better.
They bare  their arms, admire the beauty of their  forms,  the
vigor of their muscles ; full of an unaccustomed coquetry they
pass hours  before the glass, painting themselves, smoothing and
arranging  their  toilet; their countenance is open and smiling ;
they approach with open hand, obliging, affiable, satisfied with
all, and show with pride  their  houses, furniture, clothing  and
the most minute objects they possess.   This form  of delirium
is prolonged often during the last periods of general paralysis,
contrasting in the most powerful manner with the degradation,
physical and intellectual, manifested by the patients; but in re-
ality they show no suffering and are only happy fools.
  Thus, as  has  remarked  with  much justness,  Falret, the
ambitious delirium of paralytics, whatever  it may be, compli-
cates itself with the assembly of characters of demency.  Very
different are the monomanias of pride, which systematize their
delirium with  perfect art, conform their actions to their words,
and sustain their convictions with vigorous logic; paralytics are
remarkable for the particular nature of their absurd  ideas,  am-
bitious, multiplied, contradictory. We see very soon that with
these patients, memory, reason, and logical sense are profoundly
attacked; they speak of leaping the Seine on stilts, of building
a village of gold, of creating a universe.  To-day  they are  an
Emperor, to-morrow they  will be King, Pope, a General or
God; they show no fixed  opinions, but  cede  willingly  if we
contradict  them, passing from one idea to another, are  afflicted
and mournful  the same moment, forgetting the  false conceptions 
               OHIO STATE MEDICAL SOCIETY.              79

they had the evening before, and when we interrogate them they
relate parallel their real and imaginary life.
  " 2d  Variete Melancholique.
  At the side of the expansive  form,  at  the onset of  general
paralysis, we notice the melancholic variety which makes  with
the preceding so striking a contrast.   Calmiel and several  au-
thors have remarked that if we inquire with care into the his-
tory of paralytics found in the asylums, we will show the  ex-
istence of a melancholic state, sometimes  short sometimes  very
prolonged.  The patients believe themselves  ruined,  lost, dis-
honored ;  we see them fly; they have  committed crimes; they
are destined for prison or the guillotine, and have ideas  of sui-
cide, even attempt it; they offer, in  a  word, that assembly  of
symptoms, of delirious  conceptions and  acts which  constitutes
melancholic delirium.  Often, and this fact strikes me forcibly,
in the midst of the most oppressive, false  ideas,  we see  appear
ideas of grandeur, riches, and pride, which manifest themselves
at irregular intervals, and in a light manner, the patient  forget-
ting them a moment afterwards, and which contrast so strangely
with their  attitudes and lamentations.   With  these  subjects,
melancholic depression can extent! even to stupor ; they remain
incapable of acting, mute, immobile, refusing all food, falling as
often as we raise them or they attempt to  walk, and  having  to
a certain extent knowledge of their physical and moral annihi-
lation.
  " Melancholic ideas can be associated with  hypocondriacal
which give  to the patient a peculiar physiognomy.  Not  only
the patients are mournful, dejected, but still they experience a
vague and  general malaise which shows itself and is correlated
by the fear of death, by  fantastic  conceptions, and  singular
views of the manner in which their  organic functions are execu-
ted.  They declare they can neither swallow, urinate nor go  to
                                          t 
80                   GENERAL PARALYSIS.
stool; that their intestines and natural passages are closed. That
they have no longer throat, stomach or belly.   This form of
delirium is not specific, as insisted upon recently  by Baillarger,
and has no value in a  diagnostic  point of view  except when
associated with lesions of motion.
  The melancholic or hypochondriacal delirium, as well  as the
disposition to commit suicide, and the stupor, may be prolonged
many entire months; I have even seen it persist to an advanced
period of the disease and give  place but  slowly  to  ambitious
ideas or to an  abnormal  state  of satisfaction  and  well-being.
Experience shows, moreover, that this variety of onset  is  very
grave, and that often it accelerates the fatal march of the  dis-
ease.  The melancholic depression, refusal  of  food,  add  them-
selves to the other symtoms of general paralysis; they result in
profound lesion of nutrition, emaciation, tendency to sloughs,
and a promptly, mortal adynamic state.
  All writers  say that in all these cases the delirious conceptions,
melancholic or hypochondriacal, are so decidedly marked  that
at the onset they mask all other symptoms, and under the diag-
nosis of general paralysis, very serious, until later when it be-
comes clearer.  In these cases ft is necessary not to  forget the
embarrassment of speech, inequality of the pupils  andthe troub-
les of motion existing here as in other cases, but  with variable
shades and going back far  into the antecedents  of the disease,
we find almost always a weakness of memory that has preceded
several months the appearance of other symptoms."
  Notwithstanding that Marce,  Calmeil,  Baillarger  and others
mention the melancholic variety and the fact that the depression
amounts in some cases to actual stupor, late writers,  those  who
are in positions calculated to render  them  familiar  with  these
facts, assert as if a newly discovered  truth,  they have not seen
this  mentioned before.  The American Journal  of Insanity, for 
OHIO STATE MEDICAL SOCIETY.
81
April, 1872, contains the views of Dr.  Gray, Superintendent of
the Asylum at Utica, Editor of the Journal.  The article  con-
taining his views is entitled:  Psychological Retrospect; being a
review of the English Psychological Literature for 1871.   The
reviewer uses this language concerning the name of the  disease:
"We believe, with Dr. Bacon, that the term General  Paralysis
is 'bad enough.'   It is  a much less accurate and scientific  term
than General Paresis, asthereis no paralysis in any just sense of
the term in this  disease."  The views of Dr. Gray  referred  to
are taken by the reviewer from an asylum report.  We  present
it at length, as it covers other points as prognosis, &c.  Dr. Gray
says:  "Since my connection with the institution 198 cases of pa-
resis have  been  admitted.   Of  these  no  case  has  recovered,
though in a number remissions have occurred, in which the men-
tal  disturbance  seemed entirely to have disappeared.  Four
years ago, in a paper on general paresis communicated to the
State Medical Society, I reported a  case where this  remission
continued for almost a year.  A most  important question has
been, what physical symptoms precede  the mental  disturbance?
In the paper alluded to I made the following remarks upon this
point:
  In some cases there  is a   well-marked  stage of stupor and
drowsiness preceding this excitement, during which the  patient
complains of cephalgia, 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 con-
sciousness of illness, though the character or weight of the dis-
order 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 state of  drowsiness,  cephalgia, and  consciousness of in- 
82
GENERAL PARALYSIS.
disposition, preceding that of  excitement, we have not  seen
mentioned, yet we have, in personal experience, the most un-
questionable evidence that many cases are thus initiated, and we
believe that the non-recognition of this stage  is  doubtless be-
cause patients are not placed under treatment in asylums during
its existence, and the family, or friends, give the history, dating
the insanity only from the marked symptoms of cerebral excite-
ment; the preceding history  involving this  stage, is  not ob-
tained.   Careful inquiry from those intimately associated   with
patients  during  the  incipient period, and in  one  instance, the
diary of  the patient, and in another the letters written before
insanity was suspected, established this stage."
  Thus the acute, well-informed  observer, Dr. Gray, has set
forth the same facts observed by continental observers, his awn
penetrating mind having at about the same period of time, or
but  little  later, discovered the same  facts, which a  study of
French and German authors would have revealed to  him.   He
goes  on in the  asylum report to  speak of headache, dizziness,
dullness and  drowsiness, a sense of insecurity in  walking, of
muscular weakness, having preceded the full  outburst of the
disease for many months—one case two years.   He says:  " He
suddenly became maniacal and  violent; attacked  physician and
others.   In the office was excited  in  manner, and  showed  a
slight hesitancy in pronouncing certain  words.  Muscular tre-
mor could be felt in fingers and hand when arm and hand were
extended.  There was slight vibratory  movement of  the  eye-
ball, also a slight twitching at the  angles of the mouth.   The
tongue, when protruded beyond the line of the teeth, was  sud-
denly retracted.   Lips were highly  congested.  His gait was
characteristic—shuffling, irregular, uncertain;  one foot was  lifted
higher than the other, and the heel was  dropped more heavily.
Complained of occasional spasm  of the throat, as  though  a 
OHIO STATE MEDICAL SOCIETY.
83
hand had suddenly grasped the larynx.   Maniacal excitement
continued for a short time only.  This was followed by marked
mental enfeeblement.  Paretic seizures supervened, which were
repeated until paralysis became complete, and the patient help-
less.  In this condition bed-sores were developed, and the pa-
tient demanded great care.   He  died  from paralysis  a year
after admission."
  Griesinger says:   " At the onset of general paralysis the in-
tellectual disturbances present not always the  same  character.
It is rare that  we do not  observe  a  melancholic period,  which
manifests itself sometimes as a simple depression, sometimes  by
very marked hypochondriasis.  Very rarely do  we see  super-
vene the first lesions of movement during this  period of mel-
ancholy; nevertheless, as  has been observed by Calmiel, p. 328,
this does occur, patients still having for some time melancholic
delirium which transforms itself into demency."
  Brierre de Boismont, in the work cited, Observation vi, p. 12,
reports a case of the hypochondriacal form that is very interest-
ing, the more so as Calmiel, Parchappe  and  Brierre  consulted
and together made the  diagnosis.   It is also  interesting as  an
hereditary disease.   He says:   "This  observation, the  subject
of which has  never been lost from sight, is  interesting on ac-
count of more than one point.  We follow at first step by step
the long incubation of the general  paralysis to which this un-
fortunate  organization is  thus to  say, fatally predisposed.   A
first derangement of mind, characterized by an  exaggerated hy-
pochondriasis, announces the approach  of the disease; this fact
confirms the opinion advanced by Baillarger, upon  hypochon-
driacal delirium, considered as a precursor of general paralysis.
  *  *  *  This phenomenon is followed by symptoms of para-
lytic mania  of ambitious  form, and this, after  a duration  of
some months  is  replaced by paralytic demency, mingled now 
84
GENERAL PARALYSIS.
and then with melancholic depression, in which the patient dies,
after a struggle of more than two years."
   Calmiel says, T. i, p. 276:  " The melancholic type occupies a
place as important among the functional manifestations of gen-
eral paralysis, and since twelve years, is as frequent with the sub-
jects of attacks as the monomania of ambitious form."
   Baillargeit observing the great number of melancholic cases of
general paralysis, and  recognizing  the truth of the assertion of
Griesinger, that there is with all cases a period more or less pro-
longed, of melancholy, at the onset, in 1860, read at the French
Academy of Sciences a paper declaring that hypochondriacal de-
lirium is the special delirium of general paralysis.  In the ap-
pendix to Griesinger he says:  " In  place  of but one special
delirium in general paralysis, there  are two.   The  ambitious de-
lirium will be the special delirium of the monomania and of mania,
i. e. of the forms we call expansive; the hypochondriacal, on the con*
trary, will be the proper delirium of the melancholic  forms  we
call depressive."  Moreau, Michea,  and Dufour subsequently  a£*
firmed the same of general paralysis.
   Dr.  Comes reported to  the French Academy a case of the
melancholic form, in a thesis advocating this view, in which the
predominant idea was  that the patient was lost, " that he is going
to die, if he is not now dead, and that his members were annihilated,
thai he has no limbs."
   Baillarger remarks concerning the stupor  observed with some
cases, that it greatly hinders  investigation  and  renders more
difficult a correct diagnosis.
   Writers mention as a  feature of the melancholic form, bad,
offensive breath, a loaded tongue, &c.  Authors  mention  that
the melancholic cases frequently  declare  they are insane, are
about to die, have lost some important organ, as  the  heart  or
stomach, that the pulse has ceased to beat, that their bowels are 
OHIO STATE MEDICAL SOCIETY.
85
so sealed they can never move, that they have lost all power to
do certain things which it is  wholly in their power to do if they
could be so convinced, &c.
  We will not multiply authority upon this, but close  this di-
vision of the subject by one  more quotation from Brierre—his
work upon Suicide.   We have all the important foreign works
upon this subject but none except this contain any thing directly
to the point—being silent upon the subject in general.
  Brierre, Du suicide et de  la  Folie Suicide,   p.  224,  says:
" Suicide has been reported several times in the  course  of gen-
eral paralysis.  It exists with that species  of  alienation  of a
melancholic form, less frequent than the ambitious variety; it
is not rare, in these  cases, to  hear the patient say he is insane,
lost, and that nothing remains for him but death; I  have  had
care of several who  have made attempts  and have   wished to
die of hunger.   Sometimes the paralytic will end his own life
without having knowledge of it.   One drew his cravat so  tight
around his neck that when we found him he was not conscious.
He would have repeated it had we not taken measures  to  pre-
vent it,"

    COURSE; DURATION AND TERMINATION; PROGNOSIS.

  Nothing is more  important in  the diagnosis of any given
disease, that is obscure, than  to determine when   its existence is
suspected whether the history of the case conforms to the course,
duration and termination of such  disease.   Thus if the  univer-
sal result of the disease is death,  and the patient recovers, our
faith is shaken—we  suspect our diagnosis is incorrect.   Again
if a disease runs a speedy course and our case  is  prolonged  over
many years again we doubt.   It is important  to  determine  at
the  outset in all cases, whether the  disease is  one that is  self- 
86
GENERAL PARALYSIS.
limiting, i. e., runs a  definite  course, in a  given time, or  one
that may be prolonged an indefinite  period, and  also  whether
it be curable or not; this determined prevents  oftentimes  use-
less medication, anxiety and suspense, and is the means of  pre-
serving the reputation of the medical attendant, for who is there
that will retain the confidence of patrons when after months  of
medication they learn the disease is one that is incurable.  But
however unfavorable the  prognosis it is all the more important
that it be formed, and that it be based upon correct diagnosis.
  What is the course  of general  paralysis—uniformly  steady
in  its progression, or does it  at intervals retrograde, remain
stationary, or seemingly disappear, thus prolonging life and ex-
tending the course of the disease ?   What is the usual duration
of the disease ?   The same " Psychological  Retrospect," in the
American Journal  of Insanity, revie^ying a  paper from  Dr.
Boyd in the Journal of Mental Science, Oct. 1871, contains the
following:   " Dr. Boyd has in this number continued his  ob-
servations on General Paralysis, and the morbid changes of the
Spinal Cord.  The Doctor very justly  remarks, that any hope
we  may have of being able to arrest the progress  of  this  dis-
ease, or to promote  recovery,  must  rest on a just appreciation
of its pathology.  He quotes cases, given in his former commu-
nication  as proving  the  fact, that by rest and  proper treat-
ment, the progress of the disease may be  checked, even when
the symptoms had continued for some  time.    Two cases  dis-
charged recovered were  readmitted, one two   years, the other
thirteeu months afterwards.  Another  case now in the  asylum,
is said to have recovered from the  paralysis;  and in  another
case, the paralytic symptoms were arrested, without mental  im-
provement for six years; such cases, we  believe, can be  quoted
from the records  of all institutions, where this form of disease
has occurred to any extent, and where no treatment  of  anv 
OHIO STATE MEDICAL SOCIETY.
87
kind has been employed.   They cannot  in fairness be called
cases of improvement, or recovery by the use of remedies."
  The duration of general paralysis varies from a few  months
to several years, and is dependent upon the intensity of  the  at-
tack and the progress of the disease, as modified  by  remissions,
in which the progress for a season seems arrested.
  Sauze,  Ann. Med. Psychol, 1860, p. 493 says:  "Remissions
may present three forms.   In the first, we see disappear entirely
the signs of paralysis and a persistence of the demency; in  the
second, the paralysis persists and  the intelligence approaches a
normal condition; the third consists in an improvement  of both
the symptoms of paralysis and demency.   In all the remissions
whatever may be the ruling form  we encounter one common
symptom : a weakness of the  intellectual and moral faculties.
These  patients ought not to be considered as free moral agents;
and in their own interests as well as those of their  family they
should be interdicted."
  Dagonet remarks that these patients return almost to a nor-
mal state of health, and even appear healed, after having mani-
fested the gravest symptoms.  He says:  " We have encoun-
tered striking examples; the symptoms of irritation retire little by
little, motion retakes insensibly its functions as before, stammer-
ing and  embarrassment of speech  are dissipated, the delirium
effaced, the individual attains  to such a  degree of health as to
lead one  to believe the recovery more or  less complete.   This
period of remission may have a prolonged duration sometimes
even of many years.
  General paralysis has a variable duration;  in some cases it is
arrested at the first period,  sometimes at  the second period; it
can then remain stationary for a great number  of years, before
resuming its progress.
  Sometimes,  as  Trelat  has remarked, it is galloping, and runs 
88
GENERAL PARALYSIS.
its different periods in an extremely brief space of time; some-
time weeks suffice to terminate it in a fatal  manner.   Rarely
this disease terminates, nevertheless, in death in the course of a
year its medium duration is two or three years; notwithstand-
ing, this depends on the care given them.
  Death occurs most  frequently during the second period after
a series of epileptiform convulsive attacks, or hypostatic pneu-
monia.  When the paralysis reaches its last period, we observe
a state of weakness and muscular paralysis that makes deglutition
and respiration difficult which causes inanition and asphyxia."
  Griesinger says:  The duration of general  paralysis varies
from a few months to about three years.   There  are  some  ex-
ceptional cases (Brierre, Trelat,) in which the  disease has lasted
much longer, even ten years, but it presents then long  periods of
remissions.  When the patients are cared  for  in  their  families
they live longer than  in the asylums; they ought to have  the
same care  as  little children.   The attacks  of congestion of
which we  have spoken exercise a bad influence upon the disease
by greatly accelerating its progress;  often even we see the  dis-
ease  aggravated from  day to day without appreciable cause."
  Griesinger says: " General paralysis is characterized by a pro-
gressive course, but in general this progression is rather irregu-
lar than constant, it is often even by abrupt spells.  It is very
frequent that we  see  supervene remissions as well in the  intel-
lectual as  in the  symptoms  of movement;  in some  cases  the
patient  presents no longer a  trace of delirium; he can engage
in his affairs;  the signs of general paralysis being confined  to a
light stammering—a certain weakness of intellect and of  char-
acter.  These remissions may last a few  weeks—we  have  seen
them a year and a half; at all times these slight  symptoms  are
sufficient to declare the  individual  not of healthy  mind, and
this in certain cases is of great importance as strangers to medi- 
OHIO STATE MEDICAL SOCIETY.
89
cine do not discover evidences of insanity.   Often these remis-
sions are interrupted brusquely by congestive attacks, in conse-
quence of which the patient refalls into a grave  condition  and
the paralysis marches on to a  fatal teTmination."
  Tardieu, Manual de Pathologie et de clinique medicates, p. 563,
presents a resume of the subject of general  paralysis, worthy of
translation.  We do not think he correctly represents the  liter-
ature of the period in all respects—the reader will however now
be able to observe  for himself concerning this point.  It  is  as
follows:
  "Folieparalytique *  * *  is one of the most decided forms of
insanity and almost constitutes a distinct disease.  But it is cer-
tainly one  of the   most  frequent forms  of mental  alienation.
Among the general causes we cite, having  the  greatest influ-
ence upon  the  production of general  paralysis, are  drunken-
 ness, venereal  excesses, abuse of mental labor, reverses  of for-
tune, torments  of  ambition.   It is, above  all,  in  the  higher
classes, a  little more  frequent  with  the   men  than women,
and toward the term of adult age, that the disease is developed.
   An attentive observation demonstrates, that almost constant-
ly general paralysis is announced long enough  in  advance  by
very characteristic  precursory phenomena.   Sometimes  a sud-
den cerebral congestion, with slight loss of consciousness is  the
first sign of the lesion that attacks the  encephalon.   Several
successive attacks precede the proper phenomena of the paraly-
sis.  At the same  time  the  constitution weakens by degrees;
the character is insensibly modified, and  these  changes result
generally from exaggeration of the qualities and defects,  by  a
susceptibility,  a very great irritability, an   extreme  facility  to
become angry.  The least labor causes fatigue, a little tingling
is felt  in the hands; and when the patient is fatigued or anima-
ted by discussion   we  observe a slight  embarrassment in  the 
90
GENERAL PARALYSIS.
speech, the pupils are unequally dilated.   Under the influence
of congestions more or less frequently repeated, this trouble aug-
ments, the movement of the members are badly executed.  Lit-
tle by little the memory weakens; in writing the patient  forms
the characters badly, omits letters or even  whole words.  The
mind is idle, apathetic, and unable to find words or to  express
its thoughts.   Aberrations are  manifested in the acts.    From
time to time  nevertheless  the intellect awakens and presents an
increase of activity excessive, but it soon again falls into a state
of torpor where it languishes even to the day when without ap-
parent motive breaks out  an attack of acute  mania, or  furious
delirium,  with hallucinations that last several days, rarely sev-
eral  weeks.   At the  issue of   this paroxysm, the lesions of
movement of the tongue and other members  have made  great
progress, and the maniacal delirium is replaced by a partial de-
lirium, which consists almost exclusively in ideas of grandeur,(?)
of riches and of ambition.
  At variable intervals, we see reappear a period of excitement
characterized, may be by   congestion, may be  by epileptiform
convulsions, may be by  only the return of the agitation  and the
fury.   It  is to these congestive  movements  toward  the head
that it is necessary to attach these infiltrations of blood into the
cellular tissue of  the  eyelids (Marce) the  sanguineous  tumors
of the ears,   seated  between the  perichondrium  and cartilage
(A Foville), and pointed out by several authors in general pa-
ralysis : Ferrus, Bird, Franz, Fisher, Belhomme, Cossy, Thore,
Lunier, Renaudin.
  With some patients during entire weeks, the  convulsive  at-
tacks are reproduced several times a day and the  excitement is
prolonged a considerable time afterwards.   In certain cases the
disease remains stationary during several months or several years,
but most frequently at-each paroxysm the disease makes  pro- 
OHIO STATE MEDICAL SOCIETY.
91
gress.  The intellectual  faculties  weaken more and more;  the
walk becomes more and more difficult;  articulation is very dif-
ficult; the monomaniacal delirium persists with the same charac-
ters.  Soon it is necessary to keep the patient confined  to the
bed; the head no longer sustained falls  upon  the breast; the
legs  cannot  support the  body;  the hands are incapable of
seizing or of directing objects, the taking of aliments is  even
impossible, deglutition is performed only with the extremest dif-
ficulty ; the stools and urination become involuntary.   This ex-
haustion leads to a premature old age; all sensibility  is  extin-
guished,  all  intellectual  expression  or delirium  has  ceased.
Feruncles, abscesses, disseminated eschars  upon various  parts
of the body complicate this  frightful disease, to  which death
comes happily to put an end inevitable.  Death results at times
from  asphyxia  caused by food passing into the air passages;
more rarely it follows at a stage more or less advanced of the dis-
ease, upon an accession  of  maniacal agitation.
  General paralysis is characterized by constant special lesions,
which consist in chronic inflammation of the pia mater, and the
gray substance of the brain."
  The termination being death there is no grounds upon which
to base  any favorable prognosis.   The few cases  reported as
cured are so very limited in number, compared to the frequency
of the disease and the numbers affected, that we may say it is
incurable.

  VI.   Our sixth and last division of the subject is the

                        PATHOLOGY.

  We omit much that  we have written upon the  functions of
the cerebrum, whether there be motor centers in the gray sub- 
92
GENERAL PARALYSIS.
stance,  the functions of the spinal cord, and  the character of
phenomena indicating lesion of  particular  portions  of  nerve
structure.   To do justice to the subject of the  pathology,  not
only  results, i. e., not only  anotomico-pathological  conditions
should be considered, but the action of causes  whereby  results
are brought about.  We should try to determine what structural
changes induce  lesion of intellect, what of motion, and what
induce lesions of sensibility.
   According to  Parchappe, Delaye,  Foville and Pinel-Grand-
champ the following conclusions exhibit these points:
   " 1. The alterations of the cortical substance  are  closely re-
lated to intellectual derangements.
   " 2, Alterations of the white substance are directly related to
alteration of movements.  The anatomico-pathologic  character
of general paralysis of the insane  consists  in  an induration of
the white substance of the brain."
   Bayle, as we have remarked, attributed general paralysis  to
inflammation of the membranes of the brain.
   Parchappe, in  1838, attributed the disease to alteration of the
cortical substance, and termed it a  distinct  species of insanity.
   Morel, 805, says : " The lesions of cortical substance so clear-
ly described by Parchappe in 1838, are clearly  recognized  to-
day by all physicians.  That which separates them is  the ques-
tion as to whether the morbid  action  has its seat of  origin  in
the membranes of the brain or in the brain itself."
   Belehomme  thought lesions of intelligence precede always
those of motion,  and lesions  of the cortical substance  those  of
the white.
   Brierre  and Duchenne  thought general paralysis a special
form  of  disease, that might  be distinguished  as a  cerebral
disease from disease of the spinal cord by the means of electric-
ity.   Other observers found that while  spinal disease prevents 
OHIO STATE MEDICAL SOCIETY.
93
muscular contraction, muscular contractility is much lessened in
some cases of general paralysis, but this is probably due to im-
plication of the spinal cord.
   If we believe the centers that co-ordinate muscular action are
in the gray substance of the brain, then this explanation is un-
necessary.   The muscle may contract from the power  inherent
to the cord, yet there will not be co-ordination if the  centers in
the brain are not intact.   There  can be no question that " mus-
cular sense " is located in the brain—that  feeling or conscious-
ness of muscular action that enables us to recognize precision
and co-ordination, yet there is apparently such independent  ac-
tion of the spinal cord as to induce some to believe the cord en-
dowed with consciousness.   For  instance, when a person  has
co-ordinated muscular action for a long period in a  certain  di-
rection, as performing upon the piano,  it  is  but  necessary  for
the  will to institute the action when it will be continued, the
attention being directed wholly to conversation or other matters,
and not to the  performance.
   We desired to discuss these questions to considerable length,
but as our paper is now  drawn out to great length we will  re-
luctantly pass them and  will in future  give them attention in
connection with nervous  disorders, hoping that more extended
research may enable us to present the subject better than at this
time.
   Falret thought general paralysis a special form  of  insanity,
the most natural of all because  of the  union of mental  and
physical symptoms.
   Parchappe, p. 25, says: "Is not a disease  a distinct  morbid
species which is produced under  the  influence  of causes  that
produce super-excitation  of the brain, principally with men and
at the age of virility of  which the symptoms may be  expressed
as a general  and  simultaneous  lesion of intelligence, voluntary 
94
GENERAL PARALYSIS.
movement and sensibility; which has for its seat the cortical sub-
stance of the two hemispheres of the brain; which  has for  its
anatomico-pathologic character constantly, a  softening, the re-
sult of inflammatory action of the cortical substance in the two
hemispheres; which disturbed by  cerebral congestion  more  or
less violent from day to day, causes a weakness more decided of
the intelligence, of  motion, of sensibility, ending in death by
congestion or cerebral  marasmus."
   Tardieu, Manuel de  Pathologic et de Clinique Medicales, 564,
says:  "Folicparalytique is  characterized  by constant lesions,
altogether special, which consist in chronic inflammation of the
pia  mater and of the gray substance of the brain (meningo-
encephalite diffuse of Calmiel, Bayle).  At its onset  this inflam-
mation presents, upon  the gray substance and upon the corres-
ponding points of the pia mater, rose shaped spots,  formed by a
great number of little  ecchymosses, in close proximity, present-
ing a very apparent  mark, tenacious, not disappearing even by
the most prolonged washing.  This roseate coloration  occupies
at first the superficial layer of the gray substance, but it delays
not to invade all its  depth.  The situation and number of these
points (plaques) is variable; sometimes we find but  few, some-
times  they  occupy all   the  surface  of  the  brain.   They
are  habitually  more numerous  upon  the  part of the hemi-
spheres we  call  the  frontal  cornu.   At  first  these   spots
present  a  circumscribed  redness  resisting  washing  and
maceration.  Later, in the same points, are formed adhesions of
the pia mater of the brain;  and when we  have deprived the
brain with care of its membranes a part more or  less  thick  of
the superficial cortical  layer remains adherent to the pia matert
so that the brain seems to be the seat of irregularly round ulcers
of which the bottom presents a  rosy gray, granulated aspect.
   At length when the  lesion has attained the last degree of its- 
               OHIO STATE MEDICAL SOCIETY.               95
 evolution, the adherence is general, and it requires much  labor
 to  separate  the pia mater  from the brain, of which the  torn,
 roseate surface presents in certain places a total oblation of  the
 gray substance.  This, at the same time,  becomes  friable, and
 as  if formed of little grains  having a  substance  analogous  to
 that of tuberculous matter, and crushing as  it were  under  the
 finger.   The pia mater is red, thick  and  adherent  to itself in
 places where it is in contact, so  that a variable  number of cir-
 cumvolutions are found intimately united.
   By microscopic examination we observe the increase of diam-
 eter of the capillary vessels'of the pia mater and of the softened
 gray substance, as well as their  multiplication.   This  increased
 vascularity extends even to the  white substance.
   Further, the walls  of the capillaries  are incrusted with  fine
 molecular granulations or sprinkled with little  agminated cells
 which abound in the  bifurcations  of the vascular trunks, and
 the tube of these is encumbered with sanguinous globules piled
 up so as to render all circulation impossible.  Some piles of ex-
 travasated globules, more or  less deformed, we encounter equal-
 ly in the gray substance  concurrently  with plastic  molecular
 granules and little spheres or disks finely  marked, which  con-
 stitute here and there groups or trains in the angles correspond-
 ing to the branching of the capillaries.
  The  extravasation of a blastema has for a consequence  the
 organization  of plastic products  which alter  profoundly  the
 parenchymatous texture of the cerebrum.
  The nerve cells are rare, their contour losing its perfect state
 and normal aspect, they are  deformed, and  end by emptying
their contents.  The nerve tubes are deformed, atrophied, their
 contents escape without, and  they  present no more an  appear-
 ance of a tube, but of debris scattered under the field of the mi-
 croscope.  (Calmiel, Marce, Luys). 
96
GENERAL PARALYSIS.
   To this principal lesion are joined others which are  directly
 connected with it: injection and thickening of the bones of the
 cranium; opacity of the membranes; dropsy of the ventricles;
 granulations of the serous membranes, which cover their walls;
 atrophy of the central  circumvolutions, false* membranes, san-
 guinous pellicles, fibrinous  growths, hemorrhages encysted, in
 the great cavity of the arachnoid.  (Calmiel, Bayle).  Paralyt-
 ic insanity is very often complicated with organic  lesions  very
 diverse of the thoracic or abdominal viscera."
   Calmiel, T. i, presents in the third chapter of his work upon
 Inflammatory Diseases of the Brain, a synopsis  of thirty-seven
 cases.   I translate it from the work.
   " The observations contained in this chapter are thirty-seven
 in number, of which four only are women.
   Among the men, we observed  four  patients  aged thirty  to
 thirty-five years, eleven aged thirty-five to forty years; ten aged
 forty to forty-five, three aged forty-five to fifty years; two aged
 fifty to fifty-five, two aged fifty-five to sixty, one only aged six-
 ty five years.  The youngest woman was thirty-five;  the oldest
 forty-eight; the two others placed by conditions of age between
 forty and forty-two years.
   The average age of the thirty-three men is at the  onset  of
 the disease, forty-one years.   (I fix the debut at the day we first
 notice the manifestation of the muscular symptoms).  The av-
erage age at death is forty-one years and sixty-three hundredths.
They have then lived six months and a fraction.  The average
age of the women at the  onset  was thirty-eight years seven
months; they lived an average of thirty-two months.   *    *
*    *    The troubles of intelligence have assumed the form of
general mania in nine cases, with or without furor.
   They have assumed the form of a profound melancholy in six
cases, the form of ambitious delirium complicated with exaltation 
OHIO STATE MEDICAL SOCIETY.
97
mfiive cases.   In six cases the symptoms are  manifest under the
form of demency complicated with variable and restrained  de-
lirious conceptions.  In  nine cases the intelligence was  struck
with impuissance or paralysis.   Sometimes the expression of in-
tellectual troubles has  been  more  variable;  in  general, even
this expression has not been uniform except in extreme demen-
cy.  Chronic diffused periencephalitis, in the  simple state, has
never failed to show lesion of motion.
   Embarrassment  of speech has not been  wanting in but one
case of the thirty-seven.  The ivalk was unsteady or almost im-
possible in all the  cases, we have cited.  Weakness of the arms
has been observed in twenty-three cases; nine patients presented
spasmodic twitchings of the muscles of the  face; three  grind-
ing of the teeth; several have had difficulty of swallowing food,
and in passing urine.
   Almost always the lesions of motion  are  manifested  in  the
first times of the  phlegmasia by the  impossibility which these
patients find of regulating the action of the muscular agents, of
which the contractions are accomplished but by irregular efforts
and without precision.   At length, these same agents find them-
selves with still greater loss of  power and this impuissance con-
stitutes a true state of relative paralysis.
   The modifications which are  produced in the condition of the
skin, respiratory functions, and  digestive functions  cannot be
indicated in a satisfactory manner in a simple analytical table,
for they are often varied from one day to another with the  in-
sane,  with the subjects  of ambitious delirium: we can  say
nevertheless in a general manner that general paralysis  when
announced by a violent maniacal exaltation is accompanied by
heat of the skin, dryness of the tongue  and lips, thirst, disgust
for alimentary substances,   accelerated  pulse.   It  is  almost
always  the same when  the periencephalitis appears  with  a 
98
GENERAL PARALYSIS.
violent  ambitious delirium; but  when the subjects resist the
first  shock  of the  phlegmasia, the thirst, and redness of the
tongue disappear, the appetite is re-established, the pulse ceases
to be accelerated, and then ceases the general lesion of function.
   Paleness of the tongue, distaste  for food, observed very  fre-
quently with the melancholic form of general para-lysis, are al-
most always accompanied with coldness of the extremities, pale-
ness, and weakened pulse.  In the  forms characterized by de-
mentia the state of the intra-cranial nerve  centers exercises but
insignificant reactions upon the general functions:  the tongue is
moist, no thirst, the appetite either ordinary or voracious, diges-
tion rapid, pulse natural.
   The cadaveric  alterations shown in the thirty-seven cases may
be enumerated as follows:  The substance  of the  cranial bones
has been "found colored red in a notable manner  in ten cases; the
vessels of the cerebral  dura mater were injected in six cases.
The cavities of the cerebral arachnoid contained serum in fifteen
cases; false membranes in three cases; coagulated blood in one case.
   The vascular net work of pia mater has been found more or
less red and injected in thirty-one cases;  infiltrated with pus in
one case;  infiltrated with serum  in  twenty  cases;  thickened in
seven cases; marked by opaque lines in nine cases.  It  adheres
with more or less tenacity in thirty-five cases.
   The cortical substance situated at the periphery  of the  same
hemispheres is remarkable for the degree of coloration, red, vio-
let, rose, or by the degree of sanguinous injection in thirty-four
cases.   There was softening in fourteen cases; excess  of resist-
ance in five cases; atrophy in four  cases.
   The white substance which constitutes the greatest part of the
cerebral mass was found injected with  blood in  twenty-three
cases;  too great firmness  or  induration  in  thirteen  cases; too
soft in three cases. 
OHIO STATE MEDICAL SOCIETY.
98
  The thalami optici were remarkable for their intense  redness
in fourteen cases, orange or yellow in three cases; too  hard in
one case; too soft in one case.
  The corpora striata offered  tints of flesh color or  violet in
eighteen cases; orange in four;  hardened in one case;  softened in
one.
  The walls of the lateral ventricles were injected in four cases,
covered with miliary granulations in five cases; bathed with se-
rum in six cases; softened in two cases, hardened in  two.
  The pia mater of the cerebellum was colored and  red, injec-
ted, in nine cases, slate color in one, adherent in  twelve cases.
The cortical substance colored red seventeen times, injected ten
times, colored orange five times, softened eight times, hardened
in one.  The annular protuberance red or  rose colored in its
center in fourteen cases, orange in three cases,  atrophied in one
case, softened  in  one case, hardened in  one  case, in  one case
contained a small cicatrix.
   The medulla oblongata presented coloration in eleven cases,
a rusty tinge in one, was atrophied in one case, hardened in two
cases, softened in  one case, its proper  membrane covered with
fibrine once.
   The spinal marrow was covered  with depressions in one case,
hardened in four cases, softened in  one, colored or injected in
four, soot color in one, covered with plastic coagulation in one case.
   Twelve brains were examined with  the  microscope, without
counting those cited  in our corollaries.    These examinations
were made in one case where the delirium had presented  the
character of mania, two of melancholic  delirium, one of am-
bitious delirium, three of demency with  delirious conceptions,
three simple demency, one where the patient was epileptic.  It
is difficult to represent in  figures  the  alterations observed, yet
certain alterations were almost constant. 
100
GENERAL PARALYSIS.
   Of these were infiltration  of the  cortical substance, its  dis-
integrated state, its  sanguinous injection, its being  dispersed
with granular elements, sometimes upon the walls of the vessels,
sometimes upon the surface of the great nerve  cells; the state
of injection of the vessels of the corpora  striata; the presence
of molecular granules and of little agminated cells in the midst
of the gray substance in these same columns, the dilatation  of
the vessels of the  cerebellum, of the  annular protuberance, the
formation of granular products upon the vessels or in the gray
substance of these same regions; at length the dilatation  of the
vascular net work of the pia mater, its infiltration."
   The relation of Progressive Locomotor Ataxia  to General
Paralysis, is interesting as a study, especially the relation  of the
respective lesions of motion observed;   but this  will  render  it
neeessaiy for me to present what I have omitted upon the func-
tions of the spinal cord, etc.
   In both diseases there is not so much loss of muscular  power
as want of co-ordination. When there  is some support muscular
power is great, thus the paralytic when lying upon his back can
exercise the arms and legs with great freedom.   It is not paraly-
sis in the true sense.  The ataxic seems to perform  all muscular
actions better than to co-ordinate them.  When lying down or
supported  he seems to have  often as  much muscular power as
ever he had, yet lacks power to co-ordinate his actions.
   It is met with at about the  same  ages  as general paralysis;
affects males more frequently than females.  Writers regard  it
also  a condition into which some hereditary nervous  state  has
been transformed: i. e. hereditary.
   It may be distinguished from general paralysis by the  walk,
writing, and other muscular activity when the eyes are  closed.
The  ataxic cannot  turn suddenly around without becoming  diz-
zy, he cannot stand with his feet close together, if his  eyes  are
closed; not so with paralysis. 
OHIO STATE MEDICAL SOCIETY.
101
   There may be blindness  and deafness  complete or  partial,
with  one or both eyes, the same as with paralytics.  The sen-
sibility is affected, special and general, destroying what we have
referred  to  as  termed by Sir Charles Bell muscular sense, with
other modifications of sensation. Sight is important to the ataxic:
he can co-ordinate muscular action much better when vision is
unimpaired; it is necessary for him to keep his eyes fixed in some
cases, upon  the  lower  extremities, otherwise he immediately
falls.   He cannot walk any great  distance, cannot walk  without
the aid of support as a stick, gets  easily tired—on  the  contrary
the victim of general paralysis will frequently make  long jour-
neys, will endure muscular exertion that is surprising.
   There is more disturbance of the functions of the organs with-
in the pelvis in ataxia than with general paralysis, it  coming on
only in the  third period with  paralytics.   Articulation is not
affected,  there is not the marked fibrillar contraction of  muscles
that is observed in general paralysis.   Pupils are more gener-
ally contracted, one may be larger than the other, although  it
 s not significant of ataxia.   There is said to be  dilatation  of
pupils when an attack of pain  is  experienced, with the ataxic.
   A  singular  and apparently undescribed cause of  locomotor
ataxia is given   by Dr. G. C. Lawrence, in  Chicago Med. Ex-
aminer, March  15,  1873: the motion of railroad  trains.   He
says his attention was first directed to it by the disproportionate
and increasing  number of railroad men  to others, among his
patients at the  Hot Springs, Arkansas.   He is satisfied the oc-
cupation holds  some close relation to the disease  as a cause.
   We also noticed one or two other articles calling attention to
this fact, stating that memory is first affected, vision and hear-
ing in some cases, and lastly co-ordination  of muscular  action.
The pelvic organs suffer.
   We now bring our.article to a close; many questions  arising 
102                GENERAL PARALYSIS.
we  would be  pleased to discuss but cannot for want of space.
We hope this review of the subject will excite attention to this
form  of insanity so  common, and induce those who  observe
cases to make records of all important facts calculated to throw
light upon contested points, as the state of the pupil, the  form
of delirium, &c.

        THE INSANITY OF JOHN SAMUEL BLACKBURN.

  The evidence in this case,  State of Ohio vs. John S. Black-
burn, as presented at the trial in November, 1871, (upon an in-
dictment alleging that upon the 20th of March,  1871, he mur-
dered Mary Jane Lovell, by forcing down her wine containing
Strychnia): and at the trial, in April, 1874,  to  determine  the
question of his sanity, was to the effect  that Blackburn was a
native of Virginia,  in 1871 was  48 years  old, was  raised a
farmer, had been a stock-raiser and trader for  eight years.   He
was  always considered a jovial,  lively, active  business  man;
elated with success but easily  depressed by misfortunes.
  About five years before the murder, as Blackburn himself
informed me, he began  leading an immoral, licentious  life with
the deceased.   He stated to  me that previous to this time his
sexual passions had given him little trouble—were under his
control, but that from this time to 1871,  the  girl absorbed his
whole attention-;—he  was unable  to sever his connection with
her—that she  held him in her power.   He  stated  that  about
the time of her death, in this respect, he underwent a radical
change, suffered loss of sexual appetite,  and up to April,  1874,
the  date  of conversation with him,  had no  return  of  the
passion.
  He became changed  in character and feeling and business
capacity, some  months, a year  or  more,  before  the date of the 
OHIO STATE MEDICAL SOCIETY.
103
alleged murder; but he says that during the five years preced-
ing March, 1871, or during the existence of his errotic propen-
sity, he "was not the man he was before."
  Called on the part of the State, the evidence taken at pre-
vious trials having been put in my hands, I visited Chillicothe,
April 13, of the present year.  I was unacquainted with Black-
burn,  and from  the  unsatisfactory nature of the medical evi-
dence, was much prejudiced  against  the  theory of  his  in-
sanity, believing  that  if insane  he Avas still responsible,  not
conceiving it  possible that one suffering from Melancholia, or
Dementia, as testified by experts, could be so  profoundly disor-
dered in mind and so wholly irresponsible, and yet be able to
write letters exhibiting no mental defect sixteen days before the
alleged murder, the insanity dating back  for months.   Believ-
ing incoherency to be the character if not  the essence of de-
mency I could not understand how one so demented could  be
coherent.   With these views and conclusions  I visited  him  in
jail, April 13, expecting to  find  that  condition of mental  de-
pression peculiar to  those  who have  suffered from dyspeptic
troubles, the  result  of sexual  excesses;  believing that if any
form of insanity existed that the  evidence  pointed to general
paralysis.
  It seemed  singular, however,  that  if general paralysis was
the form of disease that it had not been so declared in evidence,
no medical witness having so diagnosed the condition  in  ques-
tion.
  Blackburn's father died  insane, melancholic; previous to his
death  he had  been  confined several months in the  asylum  at
Columbus, O.   His chief complaint was that he would  come
to want.  Mrs. Margaret  Blackburn,  his wife and mother of
the prisoner, testified:
  "We owned the farm we were  on, and he bought one just as 
104
GENERAL PARALYSIS.
he took ill.  He used to think he would  come  to want;  that
was his constant notion after his mind  was affected.  He was
perplexed about the deed of the second  farm he  bought, and
acted strange about it.
  "After his mind got wrong he said:  'Mother, I shall have to
kill Henry.'  She then sent Henry away for fear, but his father
begged to have him back.   Henry had cut his  name on the
fence:  <C. H.  Blackburn.   Forget  me  not.'   My husband
would go out every  day and look at the name and cry over  it.
He used to think everybody ought to be in the asylum but him-
self, and he always insisted that I  was crazy, and that  he was
not. He was always angry.  He  would lay  down in bed and
get up  again the next minute.  He would cry about his troubles
but could never tell what they were.   He was in this condition
and finally died."
  This statement of Mrs. Blackburn, concerning John's father,
was fully confirmed  by  Drs. Wilson and  Strain  and  numerous
witnesses.
  A sister of the prisoner was insane at  the time  of the  trial,
in April, who had an insane daughter.    Cases were reported in
other branches  of  the family but not upon direct evidence,
these last cases were testified to by physicians who had  treated
them.
  So much for  hereditary influence.  The question  then natu-
rally arose with some whether John, knowing the form of in-
sanity of his father, had not tried to  imitate it.   We  will  let
the evidence answer the question.
  The alleged  murder was committed  the  night of March 20,
1871;  in July 1870, Dr. Wilson pronounced Blackburn insane
and directed his removal to an asylum—without effect.    John
opposed his removal upon the ground that his father went to an
asylum and died.  In December of the same year, three months 
OHIO STATE MEDICAL SOCIETY.
105
previous to the death of Miss  Lovell, Dr.  Strain  pronounced
Blackburn insane and also advised his removal  to  an asylum.
Mrs. Blackburn testified that during all this  period she  saw
" John was going like his father."
  Her evidence was :  "John used to complain about his head.
He could not keep still, but kept walking  up and down, and  I
used to walk with him and try to calm him.  He would come
sometimes  and sit down in a corner and cry.  He  would talk
about his family starving.  I told him no; that they were well
enough, but he would not be satisfied.   Sometimes he would be
afraid to go home at night alone.  He would take a handful of
money out of his pocket and say: ' Look, my family will starve
to death with all this money  in my pocket.'  He would come
and bid me 'a.  long farewell, mother, you will never see me
again,' I cannot tell how many times."
  Dr. Wilson  who had clearer  views upon the nature of  the
case than any witness who testified of it, said upon  the stand
"John applied to me for advice in July, 1870; he had a sorrowful,
dejected look, and told me he had been to Baltimore, the Octo-
ber before {i. e. 1869) and was taken sick at the stomach  and
with a pain  in the back and  right side of the  head; some-
times he said it felt empty, then again as  if there was water in
it; I found his tongue coated, and noticed  twitching about  the
muscles of his face; he seemed to be nervous; he also manifest-
ed a hesitancy of speech; he complained about his mind and said
he was afraid he was going to. lose it like  his  father  did;  I
prescribed for  him but he would not take the medicine regular-
ly ; his tongue was always coated."   This  evidence was given
in November 1871.   At  the trial in April 1874, Dr. Wilson
testified substantially the same.  "He said:  "Blackburn's
disease is  general paralysis."  When asked to give  Blackburn's
symptoms he gave them as follows:   " Pain in  the  head, com- 
106
GENERAL PARALYSIS.
plained that it felt like a block of wood, or as if there was wa-
ter in it.   He has variableness of pupils—the right  sometimes
the largest, fibrillation of the tongue, tongue drawn to one side;
a shuffling, unsteady gait,  when he put his foot down it  came
down with a thud, twitching of muscles of the face."   He de-
tailed the  changes of character, difficulty of speech, melan-
choly, &c.
  Dr. Wilson stated, as did many other  witnesses, that Black-
burn  had  the idea he could  not buy anything even if he did
have  money.   Blackburn said  he  " could not buy a loaf of
bread if he had a million dollars."
  Dr. Johnson stated to me that  he met him in Cincinnati, in
December, 1870, that Blackburn had plenty of money, but de-
clared he could not buy a ticket to go home.  Johnson  bought
the ticket for him and with difficulty got  him on  the  train.
Blackburn believing he had not power to enter the train.
  Wilson's description of Blackburn's walk gave a very correct
idea of it, "slow, slovenly."  He said Blackburn would  come
down from his house upon the pavement front of it.   Wilson
lived  where he could see  him.    Blackburn  would  stand and
gaze upward  into vacancy, sometimes hang  over the horse rack
front  of the house.   Blackburn  complained in 1870 of a feel-
ing of expansion, or something within the head  was pressing
outwards.  Wilson was asked  what  the condition   of Black-
burn's ears denoted.  He replied congestion and a low grade of
inflammation of the brain.
  Blackburn's ears were swollen, hot, red and very painful. On
the 13th I entered his cell with his brother, Major  Blackburn.
Blood was running from the right ear, and a  bloody puriform
discharge from the left.  The auricle  was greatly  increased in
thickness.  John had a sharp pointed oak stick which  he run
in the ear, and punctured it at  a point near  where the meatus 
OHIO STATE MEDICAL SOCIETY.
107
and ear are united.   This relieved the swelling although several
days afterward it was not entirely abated.   The  end of the
nose was also congested.  Wilson's idea was that this condition
indicated the character of the changes  within the head.   He
said there was " a gradual breaking down and weakening of his
mental and physical faculties.  I do not think he has  capacity
enough to reason against his delusion.  He could not  compre-
hend."
  Blackburn constantly expressed fear of death—that he would
never get well.
  The evidence of Dr. Strain was: " called on me first in De-
cember 1870; complained of his head  and right leg; when  he
put out his tongue it would go to the right  side; his secretions
were depraved, and his general condition bad; his mental con-
dition was disturbed ; he would suddenly break  off talking as
though he forgot; saw him in latter part  of March  (1871) and
thought him worse physically and . mentally;  saw him  in  June
and thought him better in  body,  but  worse  in  mind; regard
him as a monomaniac on the subject  of want.  Could  not state
the cause of his illness; believed  that  excessive sexual indul-
gence  had something to do with it."  This was Blackburn's
opinion also.
  Numerous  witnesses testified to the change of  character—
from activity and energy he became  apathetic,  indifferent, tor-
pid.  Incapable of doing anything, he ran around crying, com-
plaining of his head, saying his family would  starve.
  Two Chillicothe physicians testified to a difference in the size
of the pupils, at that time, April,  1874. Dr.  Graham,  of Cin-
cinnati, testified in  November,  1871: "Blackburn's disease  is
dementia, a depression of all the faculties, he is morally insane,
has no  will to execute what his judgment tells  him^is  right
and proper to do, and  on account of his mental and  physical 
108
GENERAL PARALYSIS.
condition, is an irresponsible being.   Did not test his powers of
calculation; did not test his memory  or judgment."
   Dr. Carson,  at this  time, said  the  disease  was: Melancholia,
partial dementia and some paralysis."
   The Clinic*, Dec. 30, 1871, contains an article upon the case,
by Dr. Carson.   He  reviews the  main  medical points.  Dr.
Carson says the  examination made  by Drs.  Graham,  Carey,
Culbertson  and himself give the following results:
   "First, his physical, and second his mental condition.   Coun-
tenance rather  pale—tolerably full.  Digestive organs: tongue
much furred, and breath sometimes offensive—appetite variable
but generally fair;  bowels inclined to constipation.  Circulation:
heart healthy—pulse variable, at one time being 80 in a minute,
at another 92, and still more frequent when his sister came in.
All these figures  were  obtained  during  the same session.  It
was soft and not  full.   Lungs healthy—respiration calm—not
counted.  Nervous system:  Size  of head measured by its filling
a hat of No. 7|; the cranial developement  was good.   Facial
expression deficient, irregular movement of the two sides of the
face; twitching of  right side at  times; some dropping at times
on the right side.   Sensibility to pain  about the face, good.—
Constant reference to pain on right side of the head.  Sometimes
.all over  head.  Dr. Graham had made examination of Black-
burn the day before my arrival,  partly  with an aesthesiometer
and dynamometer,  we repeated  the examination jointly with
the following results: 1st as to special senses; 2d as to  general
sensibility and  motor power.
   Hearing: difference of  hearing distance being 4 inches less on
right  side.
   Sight: right eye, vision blurred, imperfect at a distance, where

♦Cincinnati, O., Edited by James T. Whittaker, M. D. 
              OHIO STATE MEDICAL SOCIETY.              109
in left eye it was clear.   Sensibility: Dr. G. thought that in his
last two examinations instrumentally, there was defective sensi-
bility on  right  side.   My own observations on one  of  these
occasions  were not sufficient to convince  me entirely  on this
point.  By  the  dynamometer,  the  right arm was defective  as
compared with  the left,  though  he  was right-handed,  and
though his right biceps measured 11J inches,  and his left, only
10£.  With neither arm was he able to move the  index  clear
through the scale.  With the right arm, the index, at several
trials pointed  at 63|,  or near it; with the left, 68 and 72 were
reached.   Dr.  Waddle,  called by the prosecution, tested the'
electro-contractility of  the two sides,  and  found   right  side
defective.   At one time, I  observed  a general tremor  with
greater movement on left side.   Tongue protruded to the right,
always, at our last examinations.
  It has varied,  sometimes being protruded straight, but  with
tremulousness.
  The temperature was taken on two  occasions: the first time
before breakfast,  it was  98J; the  second  time it  was in the
presence of Dr. Graham, and, as copied from his record, made
after joint examination, it stood in mouth,  by two counts; first,
on right side, 101-J; second, on left side,  100|-.  Axillary count;
first, on right side, 99f; second, on left 98 J.  These latter figures
were noted after  dinner.  We  were interupted by  the officer
calling for the prisoner to conduct him to the Court.   Doctors
Graham and Culbertson also noted unsteadiness of walk.
  The mental phenomena observed were, in general, feeble
concentration of attention on any subject,  and abrupt transition
to other subjects, or sudden  silence, while in the  midst  of a
train of thought; hesitancy of speech;  sometimes an impeded
articulation, though not so marked as the  previous fact; mem-
ory judged defective by the non-recognition of me after an ab«- 
ne
GENERAL PARALYSIS.
sence of a month; and sometimes he would  say positively he
could not recall certain events which were intimated  to  him;
tests of his business judgment would lead him directly to one
of his delusions,  of which  there  were  three; first,  that his
children were starving; he would  beg  with  tears streaming
down his cheeks that when we went out, we  would  give his
children a dollar; and he would ask us for some old clothes for
them.   Any allusion  to  his family  would  bring tears  in  a
moment to his eyes, and  faltering to  his  eyes  and speech, no
matter when attempted.  Second; he had the delusion  that his
money had no purchasing power; that 'he would starve to death
with  plenty  of money  in his pockets;'  he would contrast his
former control of money with his present inability to make use
of it; would ask how I bought my watch, or  my  clothes, in-
timating no power to provide  such things.   Third,  that his
health would never be good again.   One phase  of the  depress-
ing feeling was, that he  had no pulse, that it had stopped beat-
ing, and insisting that it could not be felt."
  Carson then considers  the  influence of the  hereditary  taint
upon Blackburn, as  predisposing to insanity: "We have, then,
a predisposing cause in the  hereditary taint.   His age,  also, be-
comes a predisposing  cause, because it  approaches that of his
father's, and because it is a  period of degenerative changes.
  Exciting causes are conspicuous in the history  of the  indi-
vidual.  Probable excessive  venery,—the maintenance of im-
moral relations with a woman, under circumstances of probable
exposure to his own family  and the general public, and failure
in business—belong  to the recognized exciting causes of in-
sanity."
  Blackburn had failed in business previous to  this time.
  Carson  further says: "Next,  we have  not only the presump-
tion of age as affirmative of degenerative tendencies;  but we 
              OHIO STATE MEDICAL SOCIETY.             Ill
have  physical signs, as evincing those  changes in  progress.
Impairment of special senses, and of general sensibility  on the
right  side; of motor power in tongue and right arm; irregular
movement of facial muscles and  unsteadiness of gait;  pain in
the head, persistent for years; not  only pain, but peculiar sen-
sations, of water in the head; of its feeling like a block  or log
of wood;   hesitancy  of speech, which seemed  more amnesic
then ataxic—form a group  of symptoms which  taken together
with  the  hereditary tendencies, afford a substantial physical
basis for mental  change."
  He then reviews the mental symptoms, and says;
  "The theory of insanity, then, has this for its proof:
  1st. Hereditary  taint, with unquestioned transmission  to
other  members of the family—both this and age being  predis-
posing causes.
  2d. Exciting  causes, immoral habits,  distress  in business
and consequent unusual nervous tension.
  3d. Physical  changes in the brain, which under the influence
of the predisposing  causes, might be  considered  a basis for
mental change.
  4th. Consistent physical and  mental  phenomena of concur-
rent and cumulative force."
  When at Chillicothe I made every possible effort  to  deter*
mine the true nature of this case and to obtain all  information
that could be gained.  The physicians who had  observed  him
for  three years informed me that he had a very variable pulse-
sometimes  as low  as 50.   The  jail  physician  and  sheriff
informed  me that he was subject to "spells" of excitement.
When I first visited him the sheriff informed me: " He  is  hav-
ing one of his spells now—is very excited—walks and talks a
good deal."  I inquired how often he had them.  Was informed
that at first, when he came to Chillicothe  they were frequent) 
 112                  GENERAL PARALYSIS.
 but that he had had none then for several months.  This began
 on the 10th, they said, it being the  13th  when I made the  in-
 quiry.
   In the last trial, in April 1874, Dr. Strain, who had  treated
 Blackburn in 1870, said upon the stand :  " I treated John,  be-
 ginning in December, 1870.  Said he was going to starve to death,
 and his family.  Could not buy them anything if he had money.
 Complained of a great deal of pain about his head—there was de-
 rangement of the secretions.  Pulse as low as 40  at  one time
 and as high as 100.   Could not sleep—tongue drawn to  right
 side—bowels constipated—weight and fullness at  the stomach.
   Complained of right leg—was  always dragging—would catch
 on everything  he went to step over. Memory impaired.   Nev-
 er drank to excess—would cry  when he came to my  office, said
 his family were in want—could not send his children to  school
ifor want of clothes—were going all  of the time* and  were well
 dressed.  Cause of disease excessive sexual indulgence."
   It may appear to the reader that  the evidence  of Dr.   AYil-
 son and of Mrs. Blackburn conflicts upon one point:  he speaks
 of his torpid, apathetic, stupid  condition—the melancholic state,
 while she mentions that John used  to come to her house—would
 not be still—would keep moving—cried and complained, &c.
   By investigating these points when at  Chillicothe, talking
 both with Dr.  W. and Mrs. B. I  found  that both stated only
 the truth.   During the periods of excitement he had been very
 restless and at once went to his mother's where  he  would  re-
 main for hours^—once over night.
   The jail physician stated  to me that a great portion  of  the
 time after Blackburn came into the jail his circulation was very
 feeble—extremities congested, covered with a cold sticky sweat.
   My own examination of Blackburn was to this effect:  I vis-
 ited him twice in jail  on April  13th, the last time remaining in 
              OHIO STATE^IEDICAL SOCIETY.             113
his cell some time.  I spent an hour and a half with him on the
14th in the jail, and examined him with reference to his pulse,
tongue and pupils several times afterwards.
  As I have stated, when reaching  Chillicothe I went at  once
to the jail, with Mr. Mayo, the gentlemanly Prosecutor of  Ross
county.  As I entered the jail my ears were greeted by a mourn-
ful voice: " I shall  never get well no more mother."   " I  used
to be  a good man before I got this disease in my head, didn't I
mother ?"  John and his mother were alone in  the  cell.   He
was walking backwards and fbnvards, tears were running  free-
ly.   He did not perceive me at first, but on turning to walk
towards the door where  I stood, observed me.  Mr. Mayo was
hunting the jailor, to admit me to the  cell—during  this  time
through the grating I talked with  John, examined  his pulse,
eyes and  tongue.   He asked me to examine his ears.   Both
pupils were contracted until they were very small.   The  face
and head were flushed, hot, while the hands v|jre cold, and pur-
ple with congestion.—covered with a cold clammy sweat.  The
face was congested,  indicated a* high degree of cephalic conges-
tion.   I had observed his walk before he saw me and became
satisfied as to its character, for being alone with his  mother no
motive was afforded to counterfeit any gait unnatural to  him.
After dark, this was about 4 o'clock, P. M., I returned with his
brother to the jail, entered the cell and remained  long enough
to examine him thoroughly upon all points.  He was greatly
excited—walked all the time—I could scarcely fix his attention
upon  any  subject.   Major Blackburn at last commanded  him
to be  still and directed him to answer such questions as I asked
him.   For a minute or two this quieted  him—but not long.  I
inquired: "John, when  you were taken, sick  what troubled you
first?  where did you feel sick?"   He replied "in my spine; I
believe my spine is  melted.  Does the spine ever melt, doctor?" 
114
GENERAL PARALYSIS.
I replied, John it is hardly probable your spine is melted, what
makes you think so ?  He answered "I know it is melted by the
way it feels."
  He then began to cry—to talk  about his family—about his
head—asked me if I could give him something  to  relieve  the
pain, &c.
  I asked him if  he ever had cramps in the legs.
  " No, but  sometimes I draw all over."
  " Doctor what makes my teeth  grit so ?"  he asked.    I  had
observed that every few minutes there would be apparently a
spasmodic closure of the jaws and grinding of the teeth.    The
muscles of the face and scalp would contract—sometimes a gen-
eral tremor as if he had a slight  convulsion.   He would be
talking, this occurring he would make an effort as if to swallow
—turn up the face—stop instantly and if he began again it was
always upon some other subject.
  By the aid offartifieial  light I   examined the pupils; both
were contracted more than was natural and  more than  I  saw
them at any  period afterwards even during daylight.   Holding
a light close  to the eyes the pupils  would contract, then  dilate,
the right remaining the largest.  This repeated in the  morning
of the next day gave not so marked results.   Monday  evening,
the 13th, his walk was more unsteady than at any time after-
wards.  It was a  peculiar, unsteady, shufflng gait—uncertain.
At one time he tripped upon the level  floor, fell  against  the
wall  and if it had not supported him he would have fallen.
  The pain complained of in the head was  located by him in
the left side  of the head.
  The ears were both swollen, congested and very painful—the
right much the worst of the two.   Prisoner had  in his hand a
sharp pointed stick, a few inches long.  He stated that he  had
"opened" his ear with  it.  Blood running  from  it  I  was 
              OHIO STATE MEDICAL SOCIETY.              115
 unable to determine as to whether there  was effusion and  that
 it escaped by the prisoner opening it or not, but concluded, the
 highly congested condition occurring with the period of excite-
 ment, that this determined the condition.   The  sheriff informed
 me he first noticed the trouble with the ears on the  10th, the
 day the period of excitement began.  I agree with Dr. Wilson
 in this, that the erysipelatous condition indicated the character of
 the cerebral changes—the defective nutrition and changed  cir-
 culation,  that the  congestion had  modified nutrition and in
 this respect the condition was valuable as  a pathognomic sign.
   Drs. Carson and Graham testified that  as a  sign  it  had no
 value—when asked  what it indicated, replied:  a bad hygienic
 condition.  Dr. Carson said:  there is no condition of the  ears
 peculiar to insanity.   I believe the ears are sometimes deformed,
 of the insane.   This however is very unsatisfactory as both of
 these physicians declared Blackburn had  improved  physically,
 but not mentally.  Those having him under medical supervision
 testified to  his  improved  physical  state.  The test with  the
 dynamometer was indicative of returning  vigor in the right arm
 or diminished force in the left, as there was less  difference than
 at previous examinations.  The congestive  period  passed  off
 Monday night, the 13th, few traces remaining  upon the 14th.
 The ears were still swollen and congested when I  left Chilli-
 cothe, upon the night of the  17th.
  The examination of Drs. Carson and Graham was  made  on
 the afternoon of the 16th. The voice of  the patient  was loud,
 harsh, discordant.  His face was expressionless.   He stated to
 me his head had troubled him for several  years, that  it  began
 about the  time he first  experienced  erotic  propensities.  I  ob-
 served him closely  during the trial, to determine if possible
whether he would manifest any interest in the evidence.  When
the most important points were being presented he appeared  in- 
116                GENERAL PARALYSIS.
different and as unconcerned as  if he was  not the defendant.
At one time when all were laughing he turned his head  to  one
side, gazed with  a quizzical, wondering  look, as  if to say  he
knew not what it meant.  I went to him once when one impor-
tant witness was detailing interesting  points, addressed him, in
order to call off his attention that I might see if he would man-
ifest any impatience.  He began at once  to complain  of his
head, asked me if I could cure  him  and  showed no interest
whatever in the evidence.
   On Tuesday afternoon and Wednesday,  14th and  15th, in
the Court room I could detect no difference in the size of the
pupils or but slight.  They were less contracted than they  had
been Monday  night in  the jail.   The court room was very light.
There was not the mental or muscular agitation after  Monday,
that was observable that day.
   On Tuesday, by an effort, I could  cause  B. to fix his  atten-
tion, and  at  one time he talked very rational for half an hour.
He displayed no mental disturbance during this period and made
no reference  to  his delusions, as coming  to  want,  starving,
dying, &c.
   I  tried to determine  if possible whether jealousy had entered
as a constituent in determining a motive for the crime.   This
had  been alleged  as a probable cause of the murder.   A letter
written on March 4th,  sixteen days before  the death of Miss
Lovell apparently indicates  such  motive.    While he talked
freely of the girl, during his lucid interval, said she had com-
plete power over  him, and detailed his trip the night  of  the
20th, I could not  obtain  the  least intimation of any  jealous
feeling.  He said the trip of that night seemed like a  dream.
   The letter referred to is as follows :
   " Respected Friend :—You will not allow me to call  you
anything else, will you?  Oh, how different Ave both are to-day 
               OHIO ST A TE MEDICAL SOCIETY.              11"
from what we was this day one year ago as 1 was at your  house
to pay Huff some money.   I have been  within  nine miles of
the Cherokee Indians and God only  fcimws when I may  leave,
but will be back  in some week or ten days and then we will fix
all of our troubles up or I hope so.
   Xow when I come do not do as you have  been on  some  oc-
casions treat me  so indifferently but be as  good  as you  once
was; take me to your room without  me having to ask you  and
then I will feel towards you.  Put a letter in the  postoffice  for
me and I will get it and say where you will be.   I am writing
part of this on the train and had to  back it as I  walked along.
Xow do not fail to be there.   I am  sorry 1 am so hurried.  I
am now in the postoffice and the train is  moving.   I felt  bad
last night thinking of you.  I am one  thousand miles from you
but still you are fresh in my mind.    Oh  come  back  to  me.
Xow say yes."
   We  must draw this to a close.
   We  regard the  only condition that includes all the symptoms
to be general paralysis, of melancholic  form, and  dementia   the
tendency and partial result.
   Like multitudes of  these cases, after  entering upon the  first
period, or when scarcely emerging from  the prodromic  period,
the disease has been arrested.  The "spells" referred to are to my
mind congestive periods—and John S. Blackburn may suffer a
renewal of them at any  time, in an intense form, destroying his
life.   He may apparently recover, but never will.
  The two orders of symptoms, physical and mental, presented
by Dr. Carson indicate, if they indicate  anything, the early
stage of general paralysis.   Melancholy is  only  a  designation
of the  predominant form of the mental  phenomena—dementia
only indicates the effects of the disease.
  Blackburn's  delusions  are  to some  extent variable.   He
    10 
MS
GKXKKAIi I'AI-JA l.\ SIS.
would be considered by C'ro/.ant now a victim  of ambitious ma-
nia.   His conversation shows he believes himself the most suc-
eessful trader, the most active, muscular man alive.   He boasted
Tuesday morning, 14th April, continually of his ability  to  out
run, out jump or throw down any man.   Yet this  was  always
qualified by a mournful look and  expression " if 1  could  only
•i'et rid of this disease in my head."
   A word as to his responsibility; as expressed by  Dr. Wilson,
he has not mental vigor enough to reason against his delusions-
he is therefore insane—any act committed in  the  line of such
delusions would not be  criminal—but great  difficulty  would
arise in any attempt to determine this fact, for  three-fourths, at
least, of the time there is such  chaos and  confusion  of mind
with him that he  himself cannot sufficiently  co-ordinate  his
ideas to enable him to conclude whether any act corresponds to
his ideas or  not.
   It has been said the  Ohio Supreme Court holds " knowledge
of right and wrong" the test  of responsibility.   We do  not
from a careful study of the  Ohio Reports, believe this to  be
true.    In  the syllabus to the Blackburn  Case,  23d O. S. R.
146, it is said, and page 165, "the question is (the same as laid
down in Clark's ra.se, 12 Ohio,  494, foot note)  and seems to  us
to embody the true rule, namelv:  was the accused a free agent
in forming the purpose to kill?   Was he at the  time capable of
judging whether tlmt art was right or wrong ?   And  did  he
know  at the time that  it was an offense against the  laws of God
and man ?"   (Welch J.)
   Other cases than the Clark ease might be cited where this
question of " free will" has  been held in Ohio, for to be a "free
agent in  forming a purpose" is to have  freedom of will.  The
will is the supreme executive power of the mind and that power
which purposes.   Hence intent, purpose, all the result of im- 
              OHIO STATE MEOh'AT, SOCIETY.                119
puUe ,.„• desire, acting to determine volition, pertains to  the will
—concerns free agency.   All that relates in  these  indictments
to  premeditation, pertains  to the reasoning faculties ;  intellect.
The will  may be directed  by an impulse and intellect not be in-
volved, as when  an act  is performed  without premeditation,
which reduces the grade of the offense, tor he  who kills  in the
heat of sudden impulse is  not held responsible to the  same de-
gree as he who willfully, feloniously and with malice prepense,
premeditation, commits sin offense.   Hence metaphysical  con-
siderations are the  basis of these  distinctions.   Where there  is
knowledge of right and wrong but the  will  is  paralyzed,  and
hence inability to refrain from doing an act, the Ohio Supreme
('ourt holds it to We  an  irresponsible  insane  condition.   Sec
rases cited foot of page l.V>, -J;5 Ohio State Report.
   Blackburn was tried  as to the question of his  sanitv,  was de-
clared insane, and  sent  to Athens  where  he  now  is, in  the
Asylum.
   The question to he determined  at that trial was not the  guilt
of the defendant as alleged in the indictment,  but under the act
of March 31. 1*74, O.  L., whether the defendant had sufficient
mental capacity  to enable him to conduct a reasonable  defense ;
to determine the question of his  sanitv at  that  time. April 14,
1S74, and not whether  sane or insane March  20, 1K71, the time
of the alleged murder.
   He having been declared incompetent to conduct a  rational
defense and the  evidence  extending the  condition  back  four
years, or 8 months beyond  the   time  of the  alleged   murder,
would any  Prosecuting Attorney, if the prisoner  did  recover,
ever be willing to prosecute the ease further?   We  think  not.
If a prisoner is incapacitated  by reason of mental  disease  from
conducting a defense to an  indictment, such disease having ex-
isted previous to the commission of the  crime  alleged,  will  he
62 
1-n                 <;exeuae paralysis.

be held responsible for the act?  Will a man whose brain  has-
undergone the  degenerations expressed  by  the  mental  and
physical phenomena in Blackburn's case, be responsible for any
act, civil or criminal—the act  the  result  of delusion  op  not?
We think not—for who  can decide whether delusion is a motive
to induce  the act, when the prisoner  can  not explain  his  mo-
tives.
  Extra copies of the reports of Dr. I). A. Morse, published by the Ohio
State Medical Society, for the years  1S73-4, may be obtained of the Au-
thor.  They are:
   Dipsomania.................................................................. .">:> paires.
   Gkxekal, Paralysis....................................................120   "
   Monomania,..............................................................tyi
t/UrM^ 
• 
 
,0^*017
MAR 2 2 1960  H& 
NLM005594998