been what Dr. Major, perhaps, would call insanity of Bright's disease. If we accept Dr. Major's facts we must admit the existence of a definite pathological condition; granular degeneration of the nerve-cells occurring altogether out of proportion to the coexisting changes in the vessels and neuroglia. In general paralysis the prominent lesions were in these last-named elements, and the changes in the cells were secondary to and evidently resulted from the chronic interstitial encephalitis. The last group of cases which we shall discuss is one which has given rise to much dispute, and lately formed the subject of an article in these columns; we refer to syphilitic insanity. Dr. Wilks has contended that the cases of insanity due to gummatous deposit cannot rightly be termed syphilitic insanity, because the symptoms are due not to the syphilitic growth but to ordinary pathological changes resulting from its presence as a focus of irritation. Dr. Willes describes three pathological conditions; 1, irritation due to anæmia; 2, meningitis and softening; 3, circumscribed inflammatory softening, atheroma of the vessels, and gummatous neoplasm of the brain and meninges. The first is quite hypothetical, and if true is allied to other forms of anæmic or postfebrile insanity, the second, as it stands, presents no specific characters, though such changes might be caused by syphilitic endarteritis; while both it and the last are open to the objection made by Dr. Wilks. It does appear, nevertheless, as admitted by Dr. Hughlings Jackson, that the term syphilitic insanity is clinically justifiable and necessary; and as any classification is useful in so far as it correlates the clinical and pathological facts, we believe that it is worth while inquiring to what extent pathologists have been successful in establishing distinctive morbid conditions in the brains of the syphilitic insane. Putting aside gummatous deposits without further discussion as to the title they give us to consider syphilitic insanity a pathological entity, we have had two conditions brought forward, additional to those described by Wille. Dr. John P. Gray publishes a case of syphilitic insanity in which the only specific lesion was the "fatty degeneration observable in constitutional syphilis," which affected the nervous system as well as the other organs of the body. Fatty degeneration is such a universal change in all marasmic conditions that we cannot consider this an addition of any value; it is altogether too general a condition for our purpose. The other observations are a case published by Dr. Batty Tukel and one by Dr. J. J. Brown.2 Dr. Tuke's paper is of importance; omitting the clinical part and assuming for the sake of argument that it was a typical case of syphilitic insanity, we give the postmortem appearances almost verbatim. "The dura mater was adherent and the arachnoid was slightly opalescent; small local atrophies existed in the neighbourhood of the intra-parietal fissure. There was an apopletic clot about the size of a walnut in the centre of the occipital lobe of the right hemisphere; below its level and on a level with the corpus striatum of the same side an apopletic clot was found, measuring from five to six inches in length, and about one and a quarter inches in breadth at its widest part, extending from about an inch from the tip of the frontal lobe to about the same distance from that of the occipital lobe, bounded on the left by the motor tract, which was not implicated. The two clots were unconnected. In the left hemisphere a yellow softening, irregularly round in shape, and about the size of a large walnut, was found impinging on the corpus striatum, involving the extra-ventricular nucleus and claustrum, and extending to within a few lines of the grey matter of the convolutions. The external arteries were much thickened; on the basilar artery large deposits of a yellowish colour existed. The middle cerebral artery in the fissure of Sylvius on both sides was seen to be nodulated and rendered moniliform by this deposit. Microscopic examination of recent specimens showed thickening of the vascular coats on which irregular swellings were seen consisting of molecular matter. In the grey matter cells undergoing fuscous degeneration were observed in large numbers. In prepared sections the muscular coats of the arteries in the frontal lobes were thickened and the capillary walls were well defined; in the ascending parietal convolutions, transverse sections of the arteries showed the muscular and outer coats much thickened; surrounding the latter coat were concentric rings of a material in which were held corpora amylacea; in some instances empty spaces existed between this material and the brain substance, in others this interspace was filled with a colloid-looking substance; in many of the smaller arteries complete occlusion had taken place. Fuscous degeneration of the cells of the fourth and six layers was observed in degrees between simple and slight deposit and complete destruction. In the occipital lobes and cerebellum the same lesions were noted in a slighter degree. In the corpora striata and in the cerebral convolu tions most contiguous to them the diseased condition was more thoroughly marked than in any other region. In some instances the muscular coat was found at least four times thicker than normal, and the connective rings of new material extended from the 'th to 1Journal of Mental Science,' Oct., 1876. theth of an inch around the smaller arteries. The smaller vessels were very generally completely occluded. Immense deposits of hæmatoidin were found immediately below the ependyma ventriculorum and in the perivascular canals." He goes on to describe the lesions in the pons, medulla, and cord, in which there was nothing special except that the lesions were symmetrical. "No evidence of syphilitic deposit was found in any other organ." After referring to the general correspondence of the post-mortem appearances with the symptoms observed during life, Dr. Tuke says "Microscopic dissection showed that the seat of the most marked morbid changes was in the neighbourhood of the left corpus striatum, producing a softening, implicating its extra-ventricular nucleus and claustrum." And again he says "The specimens on the table show that heterogeneous disease of the vessels is best marked in the immediate neighbourhood of the diseased tracts." He assumes that the affection of the vessels was primary and also that it was syphilitic, referring to the descriptions of Oedmansson and Fränkel in support of the latter view; he is willing to concede, if need be, that all previously described affections of the nervous system scarcely justify the term syphilitic insanity. The real question is whether this affection described by Dr. Tuke is syphilitic or whether it is not. Since Dr. Tuke published his case the researches of Heubner1 have become known in this country, and we are now familiarised with the microscopical appearances of a primary syphilitic endo-arteritis which attacks the medium-sized and smaller vessels, and consists in the formation of circumscribed tumours growing chiefly by proliferation of the elements of the intima, projecting into the lumen of the vessel, tending to undergo organization and leading frequently to thrombosis. It might have been possible that the nodules described by Dr. Tuke as occurring on the basilar and middle cerebral arteries were instances of this affection, but he says that they consisted of molecular matter, which strongly inclines us to believe that they were atheromatous. It is, however, to the changes in the small vessels near the patch of yellow softening that Dr. Tuke especially directs our attention as instances of syphilitic arteritis. In the 'Centralblatt' for 1876 Friedländer describes an extremely widespread affection of the arterial system, which, he says, hitherto had remained almost unknown.3 He says 1 Die Suetische Erkrankung der Hirnarterien,' Leipzig, 1874. 2Centralblatt für die Medicinischen Wissenschaften,' Jan. 22, 1876. London, Med. Record,' 1876, p. 58. 3 It is described by Cornil and Ranvier, Manuel d'Histologie Pathologique.' Paris, 1873. 118-LIX 24 "I refer to the development of a connective tissue, very rich in cells, within the inner coat of the middle and smaller arteries, which leads to a narrowing of the lumen, and at last to a complete filling of the lumen with firm material and obliteration. The affection begins in the acute stage with a proliferation of small thickly crowded round cells, between the inner elastic lamina and the epithelioid lining. The cells afterwards increase in size, a larger or smaller quantity of intercellular substance appears, the tissue acquires the character of granulation tissue, or even of mucous tissue (there being, however, no mucin reaction); new vessels are also observed, often very small arteries, proved beyond doubt to be such by the presence of circular muscular fibres. The proliferation either takes place at all points of the periphery simultaneously, so that a gradual constriction of the lumen is produced, or with greater intensity on one side than on another. In the latter case a transverse section has the form of a meniscus. The lumen is then narrowed on one side, and has an eccentric, often quite peripheral position. The character of granulation tissue is either retained by the proliferated layer for a long time, or it passes into a finer and, in some circumstances, perfectly sclerotic connective tissue, such as is found in firm fibromata." Further on he says "It may be laid down as a general law, that the wandering ele ments of the arteries also, on their part, take a considerable part in the great group of interstitial processes. According as acute inflammation (collective of small round cells), formation of granulation tissue (in chronic inflammation), induration or caseation, takes place in the interstitial tissue supporting the vessels, the corresponding processes take place in the arterial wall itself, especially in the inner coat." He alludes to similar changes having been observed by him in most neoplasia, and in fact the sum of his observations is that wherever hyperplasia is going on in the tissues the arterial walls, especially the intima, share in that change. We have paid considerable attention to this subject, and have succeeded in verifying Friedländer in a large number of cases, and we are in a position to state, from our own actual observations, that the arteries described and figured by Dr. Batty Tuke do not present any specific anatomical characters of syphilis, but resemble those we have found in chronic inflammatory tissues of non-syphilitic nature. We have communicated these views to Dr. Tuke and have forwarded him a drawing of an artery taken from a simple polypus of the uterus, which is strikingly like the central figure in his plate. We would refer especially to the stress laid by Dr. Tuke upon the occurrence of these changes in the neighbourhood of the softening, and our view is that the necrosed area, originally resulting from rupture or plug ging of some of the diseased terminal vessels, branches of the middle cerebral, distributed to the corpus striatum (see Heubner and Duret's descriptions), formed a focus of irritation leading to chronic inflammatory changes in the adjacent brain substance which were shared in by the coats of the arteries. The same criticisms apply equally to Dr. Brown's case, in which the changes were consecutive to an old-standing hæmorrhage into the pons; the thickening of the coats was much less marked, and the molecular matter around the vessels looks to us like the remains of old extravasation; it is, however, quite possible, or even probable, that the original disease which led to the hæmorrhage may have been syphilitic, but we contend that this has not been shown. In Dr. Brown's case the age of the patient at the time of the hæmorrhage (20), is much in favour of the primary disease having been syphilitic; in Dr. Tuke's there is considerable doubt from the probability of the disease of the larger vessels being atheromatous; but in both cases the authors believed they had discovered a general disease of the cerebral vessels productive of insanity, and of this we contend there is great want, if not entire absence, of evidence. On these grounds we must contend that these attempts to establish syphilitic insanity as a pathological entity have failed. We cannot conclude without expressing our feeling that, so far as the work has extended, the results are very encouraging; more labourers are wanted, more reports of special cases with accurate post-mortems and microscopical examinations of the brain, and we would add that the reports of the post-mortems should give information as to the conditions of other organs. We do not know enough of the general histological changes in what are looked upon as local affections; we want to know whether other organs share to any extent with the nervous system in the pathological changes. Every carefully recorded case is an addition to our knowledge, and we hope to see more productions from histologists like Dr. Brown; his two cases are very ably recorded, and apart from the question of syphilis are valuable, and we must not forget that the criticisms we have made are based upon observations which were at the time Dr. Brown wrote scarcely known in this country. Dr. Tuke has done so much for the morbid anatomy of insanity that we can only hope his labours have not ended. Pathological knowledge must be slowly built up; we gladly welcome all additions to it. At present the morbid anatomy of the brain is in a very fair degree of development; but the problems of pathology in correlating lesions with clinical phenomena and in explaining the ætiology of morbid processes depend upon physiology and general pathology, which are at present still far too imperfect to permit of any trustworthy synthesis. We are of opinion that all elaborate |