ferred to by intelligent practitioners. If rightly used there are many recorded prescriptions of considerable value, which may in some forms of disease be copied literally, and there are many more which, if not adopted in toto, are at least suggestive. At the same time we must repeat our conviction that their use favours empiricism, and will further record our impression that books of prescriptions find special favour with prescribing chemists and with self-doctoring patients, and that therefore they are accountable for a certain amount of mischief and quackery.

Original Communications.

I.-Notes on Syphilis in the Insane.-By W. Julius Mickle, M.D., Medical Superintendent, Grove Hall Asylum, London.

PART III.1

The Distinctions between Syphilitic Disease af the Encephalon and General Paralysis.

Ar the outset I may state that a study of numerous cases of general paralysis of the insane, with complete histories of the lifesymptoms and post-mortem appearances, and of a number of cases in which constitutional syphilis existed, has not confirmed the view of some Continental observers that syphilis is the cause, or one of the causes, of general paralysis. In speaking of the clinical similarities and of the diagnosis between brain syphilis and general paralysis it must, therefore, be premised that these affections are distinct and independent. The post-mortem appearances alone are sufficiently conclusive in relation to this. In general paralysis are those widely spread changes in the brain, spinal cord, and meninges which need not be detailed here, but which, though they blend with the morbid anatomy of syphilis at points, are, on the whole, distinct from the gummatous infiltrations, nodules or tumours, the arterial changes, the pachymeningitis, the localised meningitis, the ostitis, caries, and periostitis, of syphilis. It is true that in brain syphilis widespread alterations may be found in the cortical and central grey matter, in the conducting medullary fibres, and, above all, a widespread alteration in the minute cerebral and meningeal blood-vessels, which may cause a deterioration or derangement-intellectual, moral, and emotional-as great as that found in general paralysis. But well-marked differences obtain even here in the microscopical anatomy, as may be seen by comparing such of the minute changes in general paralysis as are well authenticated with the microscopical appearances detailed in a former paper by the present writer (this Review, July, 1876, pages 168 to 173), and found in those cases

1 Parts I and II, published in 'British and Foreign Medico-Chirurgical Re view,' July and October, 1876.

of syphilis which simulate the features of general paralysis, more or less.

The clinical distinctions are, however, of much greater practical importance. The two affections may coexist, and, indeed, many of those who become general paralytics have been the very individuals likely to expose themselves recklessly to sources of syphilitic infection.

Still more interesting and important are those cases in which intra-cranial syphilis simulates one or other of the symptomatolo gical forms of general paralysis; cases in which the patients are not necessarily doomed, as those are whose intra-cranial syphilis hurries on the fatal termination of their general paralysis. Not necessarily doomed, but the only hope for them rests in a correct diagnosis, and in a vigorous, judicious, and prolonged specific and general treatment founded thereupon. Thus, the differential diagnosis becomes of the greatest importance in cases of this kind. Intra-cranial syphilis may produce symptoms more or less closely resembling general paralysis. The form1 most frequently assumed is (1) that of general paralysis in which the mental symptoms throughout, or very prominently, are those of psychical failure and weakness, running a more or less unchecked and regular course to fatuity. The next in order of frequency of its simulation by brain syphilis is (2) general paralysis of the more striking form, that in which bien être, exaltation, or mania of grandeurs is present, during some periods at least. In both these instances certain motor and sensory symptoms must occur in the syphilitic cases ere the resemblance to general paralysis is established.

1. When marked mental symptoms arise from the lesions of intra-cranial syphilis they, for the most part, constitute a dementia. Sooner or later is this the case in those who become lunatic-asylum patients. Outbreaks of mania may occur early, or may complicate the disintegration of mind, and the first mental symptom of all may be, it is said, a hypochondriasis or a melancholy; but withal there is ever a dementia in the background, a slow crumbling away of the mental powers, or a fitful destruction of them by the cerebral accidents incident to the syphilitic invasion. Premising that I refer to the experience of lunatic hospitals, and therefore to cases in which the mental symptoms (in so far as a negation of mind is a symptom) are unusually well marked, the summary given in part 2 of the more usual mental symptoms which accompany intra-cranial syphilis may be reproduced here. "The first (clinical feature) is the marked tendency to mental impairment, failure, or dilapidation; the predominance of negative intellectual symptoms, often associated with

1 Several forms of general paralysis corresponding to certain differences in the symptoms are spoken of throughout this paper, but merely as a convenience in clinical description.

118-LIX.

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failure, weakness, or loss of the moral sense. . . . . and the general inclination to a degraded state of feeling, as evidenced by the habits of the patients. In some, early or intercurrent outbreaks of maniacal symptoms occurred; in a few there was causeless depression or fear, or emotional weakness."

Now, this is a description which in its general outlines applies also to the mental phenomena of many a case of general paralysis. Altogether, too much has been made of the exalted delusions and the expansive feeling of some general paralytics. These brilliant coruscations, signalising a destructive conflagration of mind, are, indeed, striking phenomena, and add a dramatic element to the spectacle when they occur. But they are by no means so very frequently present, and in some cases they have but a slight development or a transitory existence, may have entirely passed away ere the patient comes under care, and, unnoticed or forgotten, may find no place in the history furnished to the physician. In many instances they are entirely absent throughout the whole course of the affection; intellectual decay sets in early and progresses to fatuity, chequered only by intercurrent conditions of confusion and subexcitement, in which the patient is restless, fidgety, destructive, denudes or defiles himself by day or night, or wanders in an aimless way, and mulishly resists everything that is done for, or with, him; and yet the physical symptoms, the general course and duration of the disease, and the post-mortem appearances, are fundamentally the same as we find when the typical grandiose delirium has been present. Fundamentally the same, but differing in slight details, and not differing more from those of the typical paralytic mania of grandeur, as described, than do the cases of this amongst themselves.

This dementia form of general paralysis is sometimes simulated by brain syphilis, and not only as to the mental symptoms, but in part as to the physical also; its physical symptoms, indeed, are often more akin to those of brain syphilis than are those of the other forms of general paralysis; and it is better for our present purpose to examine the two diseases and contrast them as far as possible by choosing the varieties of case in which their clinical similarity is greatest. It is greatest where there is a distinct history of constitutional syphilis, or evidences of past or present syphilis, in certain demented general paralytics. This history or evidence of constitutional syphilis are often much more readily obtained or obvious in general paralysis-dementia than in the cases of some actual subjects of intra-cranial syphilis. In distinguishing between cases such as these a study of the symptoms in all their relations alone can guide us, aided sometimes by the diagnostic significance of the effects of specific treatment.

Using cases of general paralysis in which dementia obtains from the first, and some of which have the history or traces of constitu

tional syphilis, as being those in which the distinction from encephalic syphilis is the more difficult, some differences are found in the mode of onset and early symptoms of the two affections. Of the earlier symptoms of general paralysis with predominant dementia, and sometimes complicated with a syphilitic history, the following summaries may be taken as illustrations. All the patients were soldiers.

1. Aged 27. Mental disease insidious in origin, but had been marked for several months before admission. Cause unknown. There had been constitutional syphilis, at what date not stated. There was gradual mental failure, confusion of thought, defective memory, insomnia, restlessness, occasional terror and excitement, propensity to wander about in an aimless and listless way, or to collect and hoard rubbish in his pockets, which upon one occasion he is said to have called "diamonds." There were also temporary right hemiplegia, continued and increasing impairment of articulation, tremors of the muscles of the tongue and lips, especially during speech; later, a tremulous state of the hands, general tremulousness when standing, and slight right hemiplegia, which was paroxysmally worse; also troublesome habits of undressing, of clothes-tearing, and of involuntary passages. The motor symptoms, &c., of general paralysis became fully developed, and no lesion characteristic of brain syphilis was found after death.

2. Aged 39. Of long service; mental disease of three months' duration when admitted, and the assigned cause indefinite; had had constitutional syphilis fifteen years previously. Mental weakness increased rapidly, memory failed, at times he was restless and fidgety; incomplete right hemiplegia came on without any accompanying seizure. Later, fatuity increased, othæmatoma developed; for some time traces of the hemiplegia remained; convulsions and spasms, entirely or mainly unilateral, recurred frequently, and affected sometimes one and sometimes the other side, often occurring as a typical "hemispasm." There was general tremulousness, especially when standing, and once choreiform movements were superimposed upon the constant decided tremulousness of the right upper extremity, while now and then temporary incomplete palsies followed the more severe convulsions. The speech, state of lips and tongue, and universal motor paresis, were characteristic of general paralysis, and the necropsy yielded evidence of only that disease of the nervous system.

3. Age 31; long service; temperate; no constitutional syphilis ; had been exposed to the sun in the East four years previously. Mental impairment is gradual and insidious. His temper changes; he becomes irritable, passionate, and at times even violent towards his wife, and from time to time exhibits considerable mental excitement and restlessness, but still continues at his duties. Neglecting a military duty, he is reduced to the ranks, and the alteration in