ment and violence during the progress of the disease frequently occur: during them the temperature of the head was observed by L. Meyer to be raised, and afterwards the mental decay is found to be increased. Dr. Westphal, however, has denied any connexion between these attacks of excitement and the increase of temperature, pointing out that in most of Meyer's cases some other disease co-existed which would itself raise the temperature. "As the disease approaches its end, the end of life, the dementia is extreme, and the face becomes an expressionless inask, across which now and then flickers the broken ripple of a smile, or it is fixed in a ghastly sardonic grin; but even in the last stage of mental disorganization, when the capability of a distinct delusion is gone, the muttered words may be about gold, and carriages, and millions of money."

General paralysis is a disease of special pathological interest because of the co-existence of mental and motor disorder, not as an accidental circumstance, but as a constant occurrence. The patient loses the power of performing both ideas and movements, and gradually gets worse and worse until he dies. There is a certain analogy between drunkenness and general paralysis which Bayle was the first to point out; the embarrassed speech, the vacillating walk, the exalted ideas, and the mixture of stupidity being common to both conditions. Many times in the course of this work I have laid stress on the manner in which movements enter into our intellectual life, and on the close analogy between ideas and motor intuitions; and now I cannot refrain from calling particular attention to the phenomena of general paralysis as confirmatory of the views enunciated. That the nervous centres of ideas are disordered is plain enough, but it is equally plain that something more than these centres is affected; for we get all kinds of morbid ideas in other forms of insanity, without any interference with motor power. Nor are the muscles themselves at all affected: the patient has not lost muscular power, but intelligent power over the muscles. In fact, what is further diseased is the region of the motor intuitions or actuation-the nervous centres in which the motor residua are organized. In progressive locomotor ataxy the motor centres are diseased, but then it is only the spinal centres, and the mind is quite clear: in general paralysis, however, those motor residua

are affected which are in the closest relations with the intellectual life, indeed essential to complete intellectual action-the motor residua of speech, those which words in their intellectual meanings as symbols or signs of the ideas imply. One of the earliest symptoms of general paralysis is the difficulty noticed in giving fit outward expression to the ideas, by reason of some affection of the motor intuitions which are the internal equivalents of the words externally audible. But the mischief does not end there not only does the morbid state of the motor centre lead to a difficulty of expression by the appropriate movements, but the diseased motor intuition enters into the intellectual life, and, in conjunction with morbid ideas there, gives rise to all sorts of extravagant and outrageous delusions as to personal power. Now it is well known that, when a delusion is fixed in the mind, the evidence of the senses does not avail to correct it-it is a morbid product, not in relation with the surroundings, but creating its own surroundings in general paralysis the possibility of correction by the influence of external circumstances is made more hopeless, is in fact practically cut off, by the failure of the muscular sense; thereby, indeed, the avenue by which are acquired the notions of the size, form, and position of objects in space is closed, and the patient is left an easy prey to the internal disorder.

The course of general paralysis is towards death, though not steadily so. Under proper treatment a great improvement takes place in the early stages, and the disease appears sometimes to be arrested. A few cases of actual recovery have been put on record; and, whether the recovery in such cases has been permanent or not, there can be no question that there have been in exceptional cases intermissions of such length that the disease has lasted for ten years or more. On the whole, however, it

It may be considered tolerably certain that we could not think without some means of physical expression, though thought is possible without speech. Laura Bridgman's fingers moved both during her waking thoughts and her dreams. Children who have learnt to speak, and afterwards become deaf, lose by little and little all they have learnt, unless great pains is taken with them. Note, again, how frequently deficiency of speech and movement accompanies the incapacity of thought in idiots. It is not difficult, therefore, to believe that the gradual failure of the power of movement in general paralysis may aggravate the mental disorder and decay.

FE

must be pronounced irregularly progressive, its duration being usually from about a few months to three years. In the more advanced stages sudden attacks of loss of consciousness with epileptiform convulsions are frequent, after which the paralysis and mental decay are both found to have increased. These epileptiform or apoplectiform attacks consist of slight or deeper losses of consciousness, with or without convulsions, disappearing generally in a short time; sometimes paralysis of one side may occur, with convulsions of the same side, or contraction of one arm or leg. It has been observed by Dr. Saunders that the temperature of the body in general paralysis is generally one or two degrees below the average, but that it rises during the accesses of maniacal excitement, falling again as calmness returns. During the so-called congestive attacks, when there is complete coma or epileptiform convulsion, there is generally a considerable rise of temperature: in one case the temperature was for some time 98°, but it rose an hour after one of these attacks to 105°, and next day to 106°, the patient dying in thirty-six hours from the commencement of the attack.* "In the last miserable stage of all, when life flickers before expiration, large sloughing bedsores form, notwithstanding the best care, and diarrhoea or pueumonia hastens the long-expected ending."†

In the following chapter it will be seen how well the morbid appearances found in the bodies of those who have died from general paralysis agree with the symptoms exhibited during life.

Report of the Devon County Asylum for 1864. See also the note on the temperature of the insane, p. 146.

+ Article "Insanity," op. cit.

NOTE ON CLASSIFICATION.

The classification of mental diseases now generally adopted in Germany is a modification of that proposed by Esquirol, and is as follows:

It is easy to point out the defects of this classification; but it is not so easy to propound a better one. The fact that more than fifty different systems of classification have been devised, is sufficient proof of the dissatisfaction felt, and of the difficulties encountered in making a real improvement. Hitherto no other classification has found favour with any one but its ingenious author. The principal and most evident objection against the received system is, that it is vague and artificial, because it embraces in the same class forms of disease sufficiently distinct to warrant separate description, and because there are many forms of mental disease which, presenting the characters of two or more of the different classes, might be placed in one or the other, or cannot be placed satisfactorily in either. It cannot be denied. that this is a well-grounded objection; that it is so, however, is owing to the imperfect state of our knowledge. The same cause vitiates all other classifications that have been proposed. What is wanted now is an exact observation of the causes, the symptoms, bodily and mental, and the course of all the different forms of mental disease, and an accumulation of such observations; so that we may arrive at a natural historyf the disease, and be able ultimately to arrange the manifold varieties in natural groups or families, each according to its kind. Instead, then, of four or five classes having characters so vague and general that a knowledge of them conveys very little definite information, we may perhaps hope to have numerous groups or families, each having certain characteristic features, a knowledge of which will in-truct

us as to the causation, course, probable termination, and suitable treatment of a particular case belonging to the family. For what is the question which occurs to the practical physician when he sees a case of insanity, and is asked to give his opinion concerning it? What has been the cause, and what the natural history, of the disease, up to its present stage? Is it hereditary? Is it associated with epilepsy; or caused by masturbation? Or is it a case of general paralysis? Instinctively putting to himself questions of this kind, and drawing upon the stores of his experience for information respecting the natural course and termination of insanity so caused or so associated, he is able to give something like a definite answer to the anxious inquiries made of him concerning the origin, course, duration, and termination of the disease.

Dr. Skae has proposed and sketched out an arrangement in groups of the different varieties of mental derangement. "My proposition," he says, "is this, that we ought to classify all the varieties of insanity, to use a botanical term, in their natural orders or families; or, to use a phrase more familiar to the physician's ear, that we should group them in accordance with the natural history of each." Why, he asks, should we attempt to group and classify the varieties of insanity by the mental symptoms, and not, as we do in other diseases, by the bodily diseases, of which those mental perversions are but the signs? The answer, we fear, is only too obvious: because in a great many cases of insanity there is yet no recognisable bodily disease to become the basis of a classification. This being so, a symptomatological classification is the only classification practicable, though we may dislike it ever so much; it becomes a natural classification, which, if it be made with care, will most likely not be abolished entirely, but rather developed, by future discoveries. The groups which Dr. Skae, fully recognising the difficulties of the subject, proposes, are twenty-five; and I shall now briefly indicate them.

The first natural group is idiocy, including imbecility under all its various forms and degrees. To this class must be referred a large number of cases of moral idiocy and imbecility, many of which are mixed up in the present system of classification as monomaniacs of various sorts, e.., cases of instinctive cruelty, destructiveness, and theft. "Many of our most noted kleptomaniacs have had that tendency from childhood, and have been moral imbeciles." He would refer all those cases of insanity, which are but the development and aggravation of a congenital moral perversion, or want of balance, to the class of congenital moral imbeciles,