An Analysis of Guislain’s Work on Insanity
401
Twelfth Lectuke. (Continued from No. XXVII., page 413.)
On delirium or disorder of the ideas.—I have shown you the moral sensibility painfully affected, the passions diseased, and the pathological perturbations of the will. Now let us consider morbid ideas, delirium. Delirium, which I shall define to be a marked aberration of reason, is an error in the conceptions, a disorder in the ideas, which the patient can neither resist, nor put an end to; it is always a chronic condition in which lie regards as realities the phantoms °1 his imagination.
. The delirium may be general, or partial when it relates to certain isolated ideas. There are two spccies of delirium—one essential, pure, constituting a disorder absolutely simple; the other symptomatic, secondary, tertiary, arising at the same time as other disorders, and disappearing with them. In special delirium, the patients preserve more or less the aspect and bearing of a healthy man. The memory remains intact; they count, calculate ; they distinguish right and wrong; they judge of events; up to a certain point they can conduct themselves suitably in society, sometimes even carry 011 their affairs. Most jequently delirious madmen are not conscious of their state; they look upon heir dreams as realities. There are states in which reason and the imagination engender errors, and in which the patient feels that he is the sport of an intel- lectual phantasmagoria. This state is not delirium.
in partial delirium, the sleep may be disturbed; but the nutritive functions are rarely disturbed.
I recognise four distinct categories of erroneous conceptions,—1. Ail accus- ative delirium.
Many patients thus affected talk of secret means which their pretended ene- mies use against them. Often these imaginary beings act at a distance; they ave electricity, magnetism at their disposal.
A” captain, formerly aide-de-camp to Byron, in Greece, now in this establish- ment, is convinced that enemies in the island of Ipsara work upon his mind by le a}d of a machine he does not describe. ” Yes, sir, those villains yonder are working the machine …. you know the machine.” If you ask him what >,UUc ‘• 1’° S1«iles cunningly, as if to say, ” You, too, are setting a trap for • ^.e ‘lave patients profoundly impressed with the belief that the pump-water Is poisoned, and that arsenic is put into all the food. They refuse iood accord- ™ I this case the refusal has a motive; they refuse because they think you tl -n r’^ them. In folly, 011 the contrary, this refusal is a caprice of ‘ ^1C i)a^en^ rcf’lscs to cat without knowing why.
1 +1 behold spies 011 every side. The features of these change, they turn P e at the sight of another patient, or of a keeper approaching them; they take wl’ “‘1 assassins or traitors. This species constitutes a form of transition tit)110 1 C01,lnc?^s delirium with mania; the whole condition announces excita- calm e 10n* simple accusative delirium, the patient is much more jj,j^V^lc delirium of inspiration. I define the condition of those affected with nmKvn ^ describing them under the term of erotic monodelirious, religious, ltious, and hypochondriac monodelirious.
J’°t acts are sometimes accompanied by a marked derangement in the onccpl 10ns and ideas. These are false interpretations, pretended marriages, deliriurSUa^0n had children contrary to the fact. This is metromono Religious monodelirium takes the forms of theomonodelirium, monodcmono- delirium, monodemonolatry, when the patient persuades himself he is in hell, and worships Satan. This vesania, in our days very rare, was common, and sometimes epidemic in the fifteenth and sixteenth centuries.
Religious delirium also includes prophets, men who believe they enjoy a celestial existence, and madmen calling themselves God. You will observe in examining these patients, that you must excite them in the direction of their delirium, in order to bring out their delirious conceptions. They may reason well upon a number of subjects, provided you do not touch upon that of their delirium.
We have also kings, queens, and princes.
There is a class of delirious illusionists whom I will call the metamorphosed. There is a patient who believes himself transported into a dwelling which is not that where he really is. There is another who believes he has grown a foot in the course of the night; all his teeth have fallen out, but he pretends to have got others, much whiter; he has no longer legs, or arms; lus legs arc glass; he has animals in his stomach; he has no bowels.
Under this order of vesania must be classed the zoanthropists, who imagine themselves changed into beasts.
A fourth group comprises those labouring under hallucinations. I have met with women who cricd out for help, imagining that their children were being butchered in the adjoining room. In others the hallucinations are visual. Others fancy thev smell foul odours. Less frequently the sense of taste or that of touch is affected.
But these forms are not often simple; several forms arc observed to- gether.
Intermissions are less perceptible in delirium than in mania. The dura- tion of this kind of alienation is very long. It may last for years without much affecting the health. Sometimes it ends in dementia; rarely in mania.
Thirteenth Lecture.
Of Dementia, or the obtusion and obliteration of the phrenic acts. The phenomenolom/ of dementia.—Dementia is the weakening or obliteration, more or less complete, of the moral and intellectual faculties, otten accompanied by the diminution or extinction of the motive power.
Five fundamental types compose this kind of vesania: Pure dementia: the exhaustion, more or less general, of the phrenic facul- ties.
Stupidity: the partial or total suspension of the intellectual and motor acts.
General paralysis •. the progressive paralysis of the moral, intellectual, vocal, and locomotive phenomena. Imbecility: the imperfect development of the moral and intellectual facul- ties.
Idiocy: the non-evolution, or defective evolution of the mental faculties, ac- companicd most frequently by disorder in the locomotivo acts; a disease con- nected with a congenital state.
This division is based upon the phenomenology. Pinel, Esquirol, and niany other physicians have adopted a division drawn from the symptoms. P, distinguish dementia from idiocy. But it is impossible to sec in idiocy, ” wC look to the morbid form, anything but a variety of dementia. I admit a dementia pure, false, complete, incomplete, special, general, primal’ consecutive, simple, compound.
Pure dementia: amentia, faluitas, anoia.
Dementia contrasts strongly with the vesaniaj we have hitherto considered. It is an exhaustion, a falling-back of the phrenic powers. The patient hears, sees, and cannot distinguish ; he neither understands nor appreciates. Dementia is announced by an expression of subjection, of apathy, of intellectual nullity, by an attitude relaxed and indolent, a want of dignity, a certain incapacity for bodily movements, a slow elocution, inane, childish, or unmeaning answers, a difficulty, an impossibility of forming ideas, a stupid and indifferent bearing.
Dementia is false or real. There is a condition which often deceives the world. Whenever an insane person has no spontaneity, ceases to recognise and to understand, remembers 110 longer, he is looked upon as an imbecile. Well! these are not the true elements. In such a man there may be an oppression, and not an extinction of force. This is especially applicable to acute melan- choly and acute mania, in which diseases the intelligence seems to be covered with a veil.
This is the acute dementia of some authors. Dementia may be complete or incomplete.
In the lirst case, the mental faculties are dead. Dementia is incomplete when the patient, recognises the members of his family, remembers the name of the street he lives in, when his evacuations are not involuntary. The Eng- lish call this ” apathetic insanity.” Recovery is not hopeless. 1 have met with m men recently married, in drinkers, in epileptics, taking the place of con- vulsive attacks, and after long sorrows.
Another variety of intellectual decadence has been called hebetudo psychica; consists especially in the weakening of the judgment, ot the reason.
there are special dementias, and general. The patient may experience, a considerable impairment in a certain range of his phrenic faculties; he may be jf11 a state of monodementia, preserving the remaining lacultics intact, llius . may retain an artistic talent, remain a good painter, a good musi- Cian. There is a phrenopathic condition which consists simply in loss of memory.
In another class of vesaniaj opposed to those I am speaking of, the patient performs tolerably well ccrtain acts, but he is affected with extreme disorder 111 his speech. This is incoherence of ideas.
■Dementia is primary or secondary. AY hen primary, it is closely linked to the causes from whence it sprang. This is especially the case when the disease is asanmVi.j 1. 9 - ■ > .• 1 • 1 i 1 have entered an exorbitant number of cases of primary dementia. Dementia is secondary when it follows upon melancholy, mania, lolly, delirium, ecstasy. J Sometimes dementia is a compound disease. An elementary dementia, strictly speaking, is rarely met with. Thus there is dementia with mania, the desire ot incendiarism, disposition to suicide, to homicide, with automatic gestures.
Generally, the gastric organs perform their functions with regularity in de- mentia. Sometimes, however, deglutition is impeded. The pulse is feeble, and preserves an acceleration we have observed in the other kinds of alienation, frequently we remark an abundant accumulation of fat. Dementia tollous a progressive course, during which the degradation of the intellectual faculties is seen to be gradually affected, until at length the patient falls into a state o more or less complete moral annihilation.
Sometimes, however, mania succeeds to dementia, which undergoes a rans- lormation.
Commonly, dementia ends in cerebral marasmus, in a peculiar condition 011) seen in Ihe insane. The patient wastes away, his body becomes bowed, atro- phied, and anchylosed; lying in bed, his knees are in the air, his head scarcely touches anything. Intelligence goes first, then instinct, and the man ends in being no more than a stomach, calling in vain upon the cerebral centre for assistance. Dementia may go on for many years, but from the moment that cerebral marasmus appears, a few months, or weeks, carry the patient to the grave. Death mostly comes on suddenly.
Stupidity.—As to its form, this condition resembles the other kinds of de- mentia. It differs essentially, in offering a great prospect of recovery. It lias been regarded as an elevated degree of melancholy, a phrenalgia passed over into a state of dementia. This would be the melancholia attonita of ancient pathologists. This view is perhaps not far wrong.
Fourteenth Lecture.
General paralysis.—The patient now brought to us presents a look that ex- presses astonishment. See his smile of imbecility, his faltering gait! He is affected with general paralysis. His age is thirty-four. His wife is twenty- one. His life has been marked by great excesses. He is a cooper, employed in a brewery. He was habitually given up to drunkenness and debauchery. He has not been happy in his home. His attitude betrays a loss of equilibrium; in walking, he spreads out his legs, and carries his arms out and his head back- wards. 1 will speak to him. You will remark in his answers, a hesitation quite characteristic in the formation of words and phrases He does not understand what we say to him. He sees, but he docs not look; he does not conceive in seeing. He no longer recognises anybody. His discourse is marked by strong exaggeration He is subject to gusts of passion; lie excites himself, and complains. He has delirious ideas ; he thinks everything belongs to him; he talks of his fine clothes, his beautiful wife, his handsome chairs, his goblets of crystal.
The disease has been preceded by a long period of incubation, marked by weakening of the phrenic faculties. Then symptoms of delirious mania ap- peared. From the commencement, a slight hesitation was observed in his speech, a certain tension was noticed in his neck, a fixedness in his look, a fades quite peculiar betrayed to the eye of the practitioner the gravity of the case.
Generally, the course of this disease is marked by two orders of phenomena, permanent and transitory. The first consists in gradual failing of conccption, memory, and all the phrenic faculties; the others in outbreaks, effervescence, crises, fits appearing at various intervals, and which, after having first mani- fested themselves by rigidity, entail relaxation of the muscles, paralysis, finally convulsions and sopor.
In this disease one pupil is at times more dilated than the other. M- Baillar^er has described this as a new symptom of general paralysis. But it also belongs to mania.
In general paralysis it is not so much the strength of the movements that is lost, as their precision, as Foville has well remarked. As the paralysis of intelligence and motion advances, sores form on the back; frequently the patient gives no sign of suffering, but fever consumes him. A comatose state supervenes, epileptiform convulsions appear. The pharynx becomes paralysed.
General paralysis is rarely an acute condition. It is a chronic disease which may terminate in the course of a year, but which may last two, three, five years. Most frequently the patient finishes in the second year. Several questions present themselves touching the pathology. Is paralysis of motion the radical symptom of the disease!’ Does the phrenic psychical state succeed the disorder of motion ? Is the phrenic state, the moral intellectual disorder, primitive; and is the paralysis of motion the consequence of the first state ? Is then general paralysis, without perturbation, a marked failing of the psychical state ?
Is there psychical paralysis without muscular paralysis ? I answer, that no one of the phenomenal groups of general paralysis has f constant priority in the order of development of the disease. These pheno- mena by turns predominate, muscular failure, intellectual failure, delirium of ideas. Each of these elements may have a maximum or a minimum of value in the course of the disease.
The most initial of all the paralysiform symptoms is the hesitation of speech ; but it is not always the first.
Latterly M. Balllarger has communicated facts which prove the importance of the basis of the movements.
M Lunier adduces facts to show that general paralysis is a distinct disease from mental alienation. M. Moreau considers the physical symptoms and the psychical symptoms as belonging to the same source. I can call to mind cases which exhibited the distinction between the physical and psychical symptoms. Is the disease ever secondary ? is it always primary ?—In the great majority °f cases it is primary. I do not remember even to have seeu it occur as an accidental symptom in the course of melancholy, as a consequence of ecstasy, °r of a destructive phrenopatliy. But I have observed it, occasionally, as an epiphenomenal termination of delirious congestive mania.
The general paralysis of the insane must be distinguished from apoplectiform Paralysis.
. Imbecility, amentia, morosis of Sauvages.—The imbecile have not lost their intelligence; the faculty is only weakened, imperfect. The imbecile have become such after birth; they could never learn to read or write, or a trade; they express themselves with tolerable correctness; but judgment is wanting, and Very few of them have memory.
Imbecility is frequently associated with other states, especially with vices of character, or attacks of mania. Many imbeciles are thieves, many quarrelsome, mischievous, &c. It is rarely associated with delirium.
Idiocy is a congenital dementia in which the degradation of the intellectual Acuities is such as to debase man below the brute, even below the nlant, since a’l the functions arc so lowered, that without the assistance of another person, S01pc idiots would be incapable of feeding themselves.
Most modern authors have made a distinct genus of idiocy. I do not see the necessity of this. I therefore include it under the genus amentia, dementia, sec°rdia, fatuitas, paratioi of the Greeks.
Idiocy is frequently associated with epilepsy; sometimes with paralysis, or muscular atrophy. M. Ferrus has established a distinction between idiocy and cretinism. J Imbecility and idiocy have an especial interest in relation to legal medicine. imbeciles and idiots frequently figure before courts of justice, accused of u rages against decency, of theft, arson, and murder.
Fifteenth Lecture.
^!ie manner °f considering the organic alterations which present themselves in lental diseases. The anatomical diagnosis. How identical ce I he anatomical di diseases may manifest themselves without mental alienation; and this may exist without cerebral disease. In either case, there are often presented identical phenomena. Art should consist in determining whether this symptom be a functional disorder, whether that, announce an anatomical lesion. Most fre- quently alienation is a functional affection; but this latter may induce a cere- bral disease. The symptoms which indicate a cerebral disease are, incoherence, the delirium of ideas, impairment of conception, loss of memory; coma vigilans, coma, sopor especially; loquacity, gesticulations; more or less general tension of the muscular system; a great prostration; singing in the cars; vertigo; pains in the head, in the limbs, a painful condition of the skin, formication; nausea, vomiting, dilatation, contraction of the pupils.
Now, incoherence, sopor, disorder of the intelligence, have a quite different signification in mental diseases to that which they possess in affections of the brain, in febrile diseases, and in nervous affections and intoxications. In the insane, delirium is far from indicating an inflammation of the meninges; stupor is by no means connected with inflammatory or purulent congestion. In cere- bral diseases, there exist direct relations between the cause and the cffect more appreciable than in mental diseases. In the latter, the action of the anatomical element escapes us.
The idiopathic phrenopathies arc the only diseases to which it is proper to give the name of mental affections; they have especial origin, coursc, and phenomena. We must admit these fundamental species of mental diseases; idiopathic phrenopathies; symptomatic; and sympathetic phrenopathies. It follows, that in order to be a mental physician, your practical knowledge ought not to be limited to the insane; you ought not to be a speciality in the rigorous acceptation of the word. I cannot tell you often enough that the way to make progress in the study of the phrenopathies is to call to your aid the general notions of the theory and practice of medicine. It is especially when the question of the diagnosis anil treatment of mental affections arises, that the necessity of having seen many insane and many patients of other kinds is felt in all its force.
Cerebral alterations which present themselves in mental diseases ; the symptomst by which tlicy may be recognised.—I reduce to the number of nine the lesions oi the encephalon, to which 1 wish to direct your attention. These arc: 1 > sanguineous congestion of the meninges, of the brain, of the meninges and brain. 2. Serous congestion of the same structures. 3. Cerebral softening* 4. Opacity, thickening of the Arachnoid. 5. Meningeal and ccrebro-meningeal adhesions. (5. Cerebral induration. 7. Cerebral hypertrophy. 8. Cerebral atrophy. 9. Faults of conformation of the brain and skull.
Even this number may be greatly reduced. The essential conditions arc: sanguineous and serous congestion, softening, induration. .
Congestion occurs under two different forms. It may be active, arterial; 1 may be an inflammatory state, or closely approaching; or it may lie passive, venous. The active state declares itself in alienations, characterised by vioh” reactions. But you must not believe that the brain is congested every tnfle that the phrenic disorder is announced by the violence of the passions. l<our times out of five, the most turbulent mania is not accompanied by a true con- gestive state. The most fearful errors are committed in this- respect.
Diagnosis of cerebro-meningeal determination.—The symptoms which giye r,s to uneasiness in the physician are: the persistence of the disease; the incrcuS of the disorder in the ideas; the complete absence of days of calm and lucidity* the resemblance of an acute delirium in a chronic case; confusion, incoheic”^. of ideas, proceeding side by side with the decadence of conception “llL memory. There is a veil stretched over all the conceptions.
What marks more purely congestion is: 1st, the robust plethoric c°>18 .a tion of the subicct; the injection of the facc; a certain brilliancy of c)1” strong heat on the surface of the cranium ; the febrile frequency of the pulse ; sweats, often clammy, bathing the surface of the head; ammoniacal, hypostatic urine; an air of astonishment, a deafness, a blindness of the intelligence, drunken ideas.
What marks especially congestion, inflammatory fluxion of the brain and meninges, is: the agitation of the patient; the stiffness of his limbs ; disorder in Ids muscular acts; prostration; involuntary evacuations; a dementia which fol- lows mania; convulsions: paralysis. Rarely, however, the symptoms express a fierce inflammatory state, and end quickly. Generally the disease assumes the chronic form. , .
Sudden abolition of the faculty of spccch, of all the faculties of the intelli- gence, denotes compression of the cerebral surfaces. These patients present a false appearance of apoplexy; but true paralysis is wanting: the eyes remain °pcn, and the patient can move his limbs. Automatically the patient carries his hand to his head, which seems to sutler shocks ; it is tossed from side to side ; s°metimes there is grinding of the teeth, distortion of the features, stiffness of the limbs. Sometimes vomiting announces a rapid and fatal progress.
These symptoms may give way under appropriate treatment. In speaking of crisis, of treatment, 1 shall take care to show you that recovery is sometimes preceded by :i febrile, comatosc state: this must not be contounded with that Condition which may be the effect of a congestive inflammatory orgasm of the jneniuges or of the brain. In this state there arc stages : first, a period in which he ideas give a colour to the passions: so long as these arc clear, though extravagant, there is no fear ot congestion and its consequences. T.o tins period succeeds a phase of obscuration of the ideas and ot disorder in their ‘Manifestation. A third period marks the gradual extinction of the tacultics of the understanding.
-Bayle first called attention to the relation between notions of greatness and the congestive state of the meninges, and the cortical substance of the hemispheres.
. In the presence of this group of symptoms, we may believe that a congestion forming on the surface of the brain; and this especially when the subject has been addicted to alcholic drinks. You will also meet with it in persons become insane from the action of the solar rays on the skull, or under the influence of mtense radiant heat. It is observed in cases of retrocession of an exanthema. »Vhen congestion leads to sanguineous effusions between the meninges, the symptoms are usually vcrv alarming. They arc characterised bj a sudden change in the physical and moral state of the patient. First, a comatose state, then a sensible diminution in the sum of the intellectual acts. At other times, a C01nplete hemiplegia, or convulsions.
In drawing the diagnosis of these congestions, of these orgasms, of these spinal inflammations, take care not to perceive in the phenomena which cha- racterise them the whole disease. I shall tell you by and bye that mental alienation is not in its intimate nature a congestive state, an inflammation. Inflammation may be developed in alienation, it may be strictly associated with ie first state; but it is not the sum of the mental affection.
Ii an epileptic maniac dies during a fit, we may be almost ccrtaiu to find a Suite of red congestion of the meninges and of the cerebral substance, even ecchymosis, blood cxtravasatcd in the tissue of the membranes, especially in he temporal regions. If the epileptic die during an interval, nothing ot the sort is tound. bo it is with alienation; the congestive state is subordinate to he exaltation of the intellectual phenomena.
Out of five hundred patients congregated here, I cannot at this moment snow you one case of lluxionary congestion 111 its first phase. enous or black congestions.—1 believe that there arc amongst the insane cnous congestions, independently of the congestions which proceed troni a nenous orgasm. Cases of venous hypera;mia are frequent in the dementia following upon chronic mania. It is especially when the patient has vociferated much that the cerebral substance is found gorged with black blood. In melancholy, we find sometimes the sinuses and veins of the arachnoid strongly congested; but it is rare to find an active congestion in these patients. Do not lose sight, also, that the congestion is at times only apparent, and that it depends upon cerebral hypostasis formed in the last moments.
The congestional state is a very frequent symptom in general paralysis; out of 25 cases, it is met with at least 11 times.
Microscopical examination.—I have committed to the microscope cerebral substance congested and not softened, and I have satisfied myself that the ana- tomical result of congestion consists in a cellular development. It seems as if the primitive cells constituting the intimate web of the brain undergo a certain distension; that they swell from the presence of a fluid. There is a remark- able difference between congested cerebral substance and that which is not: in the first, the field of the microscope is covered by a stratum of granulated matter interspersed with corpuscles, which 1 conclude to be fatty, since they dissolve in ether. I will state, with reference to these corpuscles, that they are seen in the healthy brain as well as in the diseased.
Serous collections.—YVe meet in the insane with serous accumulations in the cavities of the membranes and in the ventricles. It is principally the pia mater that is cedematoscd; the oedema is united with a venous congestion. The serosity is more frequently gathered between the meninges than in the ventricles. Sub- arachno’idean collections are especially common.
Recently there has been discovered an oedema seated in the brain itself. MM. Foville and Ferrus were the first to speak in precise terms of an intersti- tial infiltration of the brain. Esquirol, it is true, had mentioned it. M. listoc has studied this condition with great carc, pointing out the kind of alienation in which it is most frequently seen.
The origin of serous collections is in many respects an enigma in the study of mental diseases. It must be concluded that most commonly they depend upon venous congestion. But frequently we find, instead of a red injection of the vessels, a true anccmic condition of the cerebral substance. In many cases of chronic dementia, serous collections are formed when the shrunk brain falls away from the internal table of the skull. Magcndie’s experiments seem to explain the formation of an intra-cranial fluid whensoever a vacuum is formed between the surface of the brain and the internal surface of the cranium. Diagnosis.—Here is a patient who, I have been told, is affected with stupi- dity. I exhibit him to you again, in order to point out the symptoms, or rather the appearances which announce the presence in the brain of an cxccss of sero- sity, infiltrated in the nervous tissue itself, perhaps also on the surface of the convolutions.
The whole head appears swollen. The colour of the skin of the face is quite peculiar: it has lost its freshness, it has become serous. There is a heaviness in the eyelids; the eye is dead, void of expression. The globe of the eye pr0” jects behind the lids; the lids arc slightly swollen; the eyebrows are moist; the head is bent upon the chest; the patient’s attitude is heavy; lie answers only yes, or no; his urine passes involuntarily ; the tension of general paralyses is wanting. You observe no hesitation in his speech, nothing in his iueas that reveals ambitious exaggerations or conceptions.
Consider all these symptoms in the aggregate, and you will arrive at a co - lcctive phenomenon. This phenomenon is a state of stupefaction, of numbness. Thus modern observers are inclined to admit, as a constant tin » in stupidity, a serous collection, even oedema of the brain. ,, of a Serous collections always announce themselves by some false appcf^l’ancC u3 comatosc state. This occasionally calls to mind serous apoplexy. rIhe ac apoplectiform condition is frequently met with in general paralysis. It is an- nounced by transitory paralysis of an eyelid, an arm, a leg, remarkable for dis- appearing in a few days.
In a hydrocephalic patient, properly so called, there are indications always sure by which the presence of a serous collection may be known: vomiting, dulness, mark the progress of the evil; the dilatation of the pupils, strabismus, paralysis of the eyelids, piercing cries, extreme slowness of the pulse, confirm it. But in the hydrocephalus of the insane, all often becomes doubt and uncer- tainty. In many patients we meet after death, serous collections, even consi- derable, that we were far from suspecting.
Sixteenth Lecture.
Cerebral softening. J ‘patient affected with general paralysis.—This patient is about thirty years old; he has been here a few months. You recognise his disease at a glance; that silly look, that uneasy bearing, cannot deceive you. Make him talk, and you will observe the hesitation of his speech; make him wove, and you will sec the uncertainty of his movements. Isothing so strange as his discourse: he talks of his strength, of the number of languages lie knows ltussian, Danish, Spanish,—of his beautiful children, his young wife, the sums lie has won. It is among patients of this category that you must seek for creberal softening. It is not found in all cases of general paralysis, but it is found exclusively in this affection.
% what sign can we recognise this organic lesion ? The difficulty is great. If I consult my own observations, I discover in general paralysis and other para- lyses, that which reveals to me that the cerebral substance is undergoing decom- position. This is a permanent, ascending, progressive paralysis. It is not the apoplectiform paralysis, but something resembling it. Ideas of grandeur, of exaggeration, the puerile aspect, which remind us of drunkenness, are not signs that indicate exclusively softening. They belong rather to an irritation of the grey substauce, a work of decomposition that is preparing. The most charac- teristic marks of this state are clearly defined paralysis.
Cadaveric, phenomena.—It is almost always the cortical substance^ that we find softened in the insane : this may be either the deep or the supeificial layers. Sometimes there is softenin,r of the white substancc; but this alteration rarely affects the white substancc exclusively; sometimes the white and grey sub- stances arc softened together. The parts most frequently affected are, in my opinion, the parietal regions, next the frontal. Sometimes the softening invades the upper median bonier of the hemispheres. It is rare to find it aflecting the inner median surfacc of the hemispheres. Sometimes we see in the insane softening of the optic thalami, of the corpora striata, of the cerebellum. In the dead body we rccognisc cerebral softening by—1, the abnormal aspect of the altered part; 2, the want of consistency of the cerebral substance; changes in t he intimate structure revealed by the microscope.
1- The grey substance acquires an ashy hue, greenish, sometimes violet, or yellowish, livid, rosaceous, or brownish ; or it may be of a striking white. 2. The substance gives way under the slightest touch; it turns to pap, a semi-fluid element, easily taken up by the edge of the scalpel. The softening Usually occupies a large extent. It is rarely an isolated condition; it is asso- ciated with serous collections, vascular engorgements, adhesions, thickening of the arachnoid.
3. MM. Vogcl and Gluge, and Pool of Amsterdam, have communicated inte- resting observations on the microscopic appearances. There have been found: capillary engorgement; extravasations ot blood; inflammatory fibrinous pro- ducts; nucleated cells; fatty globules; cumuli of red substance, llicse re- searches were made on subjects not insane. My investigations have been made on the sane and insane. 1 have compared the conditions observed in the two classcs. My results differ from those of the microscopists I have named. I have not found traces of an inflammatory state: no fibrinous coagula, 110 in- flammatory corpuscles, no islets of red matter.
The grey substance of a maniac seen under 400 degrees shows opaque nucleoli, tolerably regular in form, but irregularly distributed, soluble in ether, showing their fatty nature. I have found the same in bodies of persons not insane. They must not therefore be considered as a morbid result. The rest of the field seems formed of a cellular, granular web. It is in this web that the morbid histological phenomena take place.
If the cerebral substancc is simply congested, you will perceive an infinity of cells, offering the appearance of a piece ot Florence marble.
If the congestion has passed to the state of softening, you will have the same elements, but modified. In this case, the whole field presents a surfacc com- posed of these cellules. They are very irregular in their disposition, which may depend upon the traction the cerebral substance has undergone in charging the field. These cellules are polygonal, and have a visible nucleus. Each has usually but one; many are empty; and it is easy to detect here and there free nuclei. The cellules appear heaped together. At different points are remarked fatty cellules, recognised by their greater size and transparency. In a few points we discover blood-globules, but larger than usual, distended. With great care, at a lower power, I have sometimes met with capillaries; they were gorged with deformed blood-globules. These capillaries were found at the surface of the cortical substance; deeper towards the white substance I could not distinguish them.
Such are the lesions which may be proved experimentally; but there is in this disease a complete series of phenomena, of which we cannot form an idea without the aid of the imagination and of reasoning. It is sometimes per- mitted to us to extend our judgment beyond the limits imposed by our senses; there are demonstrations, interpretative facts, which result from the collcctive examination of many facts, which, taken singly, are sometimes without value. Intimate phenomena.—We may figure to ourselves the succession of the phe- nomena which characterise the formation of cerebral softening in the insane thus:—First, an excitation of the passions, of the ideas; a stimulation caused by the abuse of alcohol, or otherwise. A constant call of the circulating fluids into the capillaries. Distension of the capillaries. Engorgements. Stagnation of the fluids in these vessels. A serous transudation into the organic areola). An accumulation of serous fluids into the ‘issue of the pia mater. A penetra- tion of these fluids into the grey substancc of the brain, effected through the channels which give passage to the capillaries connecting the pia mater with the cortical substancc. Then, the deformation of the primitive cellulcs. Con- siderable distension of these cells. Displacement of their nucleoli.
Clearly the nucleoid cells found in softening are not new formations; they arc the cells of the fundamental tissue of the grey substance. But they may exist ten times bigger than in the normal state. The reason is, that in soften- ing, a serous fluid, escaped from the vessels, has penetrated them, and caused the distension. It is a true imbibition. In my opinion there is in the softening of the insane a maceration of the cerebral substance, a distension and a rupture of the primitive cells.
Let us dwell a moment upon what I have called the channels which transmit the capillaries running from the pia mater into the grey substance. These chan- nels have attracted 110 attention; they :ire only discovered by a lens; they on a small scale, to the capillaries of the cortical substancc what the canals °i the liver of the capsule of Glisson are to the vessels of the vena porta, the arte- ries and biliary ducts. Myriads of capillaries, visible to the naked eye, in cases of stasis or inflammation, quit every point of the pia mater and (lip into tU’ coitical substance. It is by these vessels, which have not aiiastonioseu, that l/ pia mater is made adherent to the grey substance of the convolutions. In cases of congestion these vessels acquire such a volume as to be distinguished by the naked eye.
Thus we may easily understand that in cases of serous collection between this covering and the convolutions, a road may be opened into the intimate tissue of the cortical substance, alongside the vessels. This infdtration produces maceration of the central substance.
A result little known, yet of great importance, is the extreme aptitude of the cerebral substance to be easily penetrated by foreign liquids. It may be com- pared in this respect to a sponge. Fred, and Ilerm. Nasse have shown that softened brains are much less easily penetrated by water than healthy brains. When I say that general paralysis may exist without appreciable softening, I do not wish to utter an absolute dogma. The organic detritus may no doubt exist when our means of investigation cannot discover it.
Another remark : In every softening there is not paralysis.
I am anxious to say that the entire pathological state of this alteration is not summed up in congestion or in serous exaltation. What proves this is, that byperuiinia, sometimes considerable in mania and melancholy, rarely leads to softening. Cerebral softening is not a normal termination of the congestion in the insane. It is the same with stupidity which oilers some analogy with the symptoms of softening, and which, viewed as an anatomical lesion, presents another serous infiltration. And yet in stupidity the cerebral tissue rarely passes into softening.
There is therefore something at the bottom of general paralysis, of the chief tactile alteration to which it is united, an obscured point, a boundary hitherto impassable.
, Must, we then admit different kinds of softening ? I hesitate not to answer in the affirmative… . .
I here is an acute softening, a chronic softening. It is the latter winch is found in the insane. I believe that there are anaemic softenings. “Let us add that the causes which debilitate the organism are commonly hurtful to patients affected with this disease, and that the analeptic regime tends to prolong their days. . … .
Opacify of the arachnoid thickening.—In many cases the arachnoid is much altered. Part injections of this membrane are not frequent unless the patient was much exalted in the domain of ideas, or of a verv sanguine temperament. The most frequent appearance is a greyish white thickening. It may also present milky spots, and stria;. In some rare cases we find vitrifonn masses between the membranes. These alterations are principally found on the hemi- spherieal surfaces, on the cranial layer, and not 011 that which covers the falx cerebri. They arc rarely seen at the base of the organ ; sometimes they arc con- fined to one hemisphere ; most frequently they extend to both. This condition especially belongs to chronic cases. It is really an isolated alteration. When isolated arachnoi’deal thickening is present, it is symptoms of compression that are observed There is however aoscncc of paralysis of the limbs unless the thickening be considerable or accompanied by sanguineous effusions. If false membranes have formed between the meninges, they most commonly determine convulsions, alternating with a soporous state and transitory paralysis. I recognise four morbid conditions, proceeding from the same source, which, in a diagnostic point of view, demand a long practical experience. These are, injection of tin; meninges, serous collections, chronic thickening of the mem- branes, cerebral softening. There exists between all these an affinity of origin, and a similitude of form. They all lead to obliteration of the intellectual acts. But an attentive observer may distinguish the individual character of each. Thus a disorder simulating a marked degree of drunkenness, corresponds more particularly to a fluxion of the meninges, especially of the pia mater, and of that of the cortical substance.
The presence of serosity causes different shades of dulness, stupor, inertia, coma.
Thickening, the retractation of the arachno’id compressing the brain, causes to a certain degree a diminution of intellectual energy, but leaves considerable freedom of motion.
Softening affects more directly motility, and paralysis more directly the motor influx, especially of speech.
I cannot say often enough how important it is to acquire two general notions. That which teaches us to know a brain disordered only in its functions, not in its structure; that which enables us to recognise a brain diseased in its anatomical elements.
Clearness, neatness of expression, absence of disorder in the connexion of ideas, demonstrate that there exists no anatomical lesion : this is only known by observation, failure of the phrenic acts. To this, we must add the elements of appreciation. It is known that alterations of tissue are rare in melancholy, ecstasy, delirium, folly.
It is in two forms of alienation that doubt always arises : dementia, mania. Conviction springs up when we see signs of compression of cerebral destruc- tion. This certainly is wanting so long as the signs which belong to paralysis are absent; i. e., paralysis in the formation of words, of the intelligence, of memory, of movements, of prehension, of locomotion. What adds to the clearness of the diagnosis is the reunion of paralysis, of convulsions, of cbrious ideas.
Meningo-cerebral adhesions.—I have 110 settled opinions concerning adhesions between the arachnoid and the dura mater. It would be a grave error to conclude that tlicy are the result of inflammation.
Cerebral induration.—It is considered that induration is met with in 25 out of 100 insane. It is most frequently found in chronic mania, in dementia, and in maniacal epileptics ; also in general paralysis with softening. I think 1 have observed that this alteration is most commonly seen at the base of the brain and in the external walls of the lateral ventriclcs. More than once I have found the pons Varolii so hard as to be nearly crepitant under the knife. Induration of the olivary bodies is not at all rare. It chiefly affects the grey matter; but may affect the white also.
The intimate nature of the pathological alteration is difficult to determine. My microscopical investigations have taught me nothing precise. Are there any symptoms which permit us to recognise induration in the living subject ? Hitherto they have not been pointed out.
Cerebral hypertrophy and atrophy.—I have often observed hypertrophy, especially in maniacs. I11 these cases the convolutions arc so compressed against the skull, that they arc sometimes only traced by lines. This state is euliarto congcstional mania.
Atrophy may be general or partial. Partial—it is often conflncd to a scries of convolutions. General—the brain has diminished in volume, and is l’ounu separated from the inner table of the cranium, as Gall was the first to observe. It has been supposed that atrophy was most, common in the frontal region and I have several times verified this observation. Parcliappe says it is met with in If, out of 100 cases. lie calls it cerebral marasmus. This condition belongs especially to chronic dementia. I think also it belongs to melancholy.
Vices of conformation of the skull and brain.—These are chiefly seen among idiots.
Of the anatomical alterations of the abdominal and thoracic viscera. , M. Parcliappe, the man who has best investigated this subject, calculates tlia out of 1000 insane patients, 423 present after death lesions of the cere. spinal system; 202 lesions of the digestive canal; 110 in the respiratory systc A. Affections of the alimentary canal.—I have found thickening of the walls of the stomach. Scirrhous induratioivof the pylorus, inflammation, ulceration, softening. But in most instances these have appeared to me independent of the mental malady. I have observed in suicide inflammation of the intestinal mucous membrane, once in a case where there was 110 cerebral disease. Some physicians have attributed great importance to the pathological state of the intestines in melancholy.
2. The ideas of Esquirol as to the displacement of the colon have been con- firmed ; in the insane we do indeed sometimes find this intestine lodged in the true pelvis.
3. Inflammations of the peritoneum, the omentum adhering to the mesentery, and this lat ter to the abdominal wall, &c.
In suicide, considerable abdominal lesions are observed.
B. Affections of the liver and spleen.—It is not rare to find red spots upon the liver. It is found crepitant, often gorged with blood, and exhibiting traces of inflammation. Alterations in the liver are frequent in drunkards.” But I have examined the bodies of persons dead from delirium tremens without unding any appreciable lesion of the liver.
I remember a case of joyous mania which presented to me an enormous distension of the spleen which contained a very black blood. I asked myself 11 this case did not support the opinion of some of the ancients who placed gaiety in the spleen and anger in the liver.
In the melancholic, the suspension of respiration—i. e., its performance at °.nS intervals and imperfectly, explains in a great measure the frequent presence °f engorgements of the system of the vena porta; and especially of the liver and spleen. Very often the mesenteric veins are found loaded with black blood.
In dementia we sometimes find enormous distensions of the urinary bladder. I have recognised disease of the ovaries, after a violent delirium accompanied y hysterical symptoms. The menstrual suppression, so frequent in insane -men, should point to the conjecture that the ovaries are frequently C. Affections of the lungs.—In estimating the pathological condition of the jungs, we must bear in mind the influence of the variations of temperature to which the insane have been exposed, their cries and vociferations, disease of lle pneumogastric nerve, insufficient food, spermatic evacuations, the use of 00douches, a strumous constitution.
j ulmonary tuberculosis is frequent amongst the insane. It has appeared to me 0 have a direct relation to mental alienation. Sometimes this is allied with meningeal or cerebral tuberculosis. A tuberculous condition of the substance the brain has been denied. But this is a serious error. I have observed it Maresk^’ UU<^ ^ 11’ay call in the testimony of my colleague, Professor IJiavc observed gangrene of the lungs, and this has been exclusively in XnS(fS T- patients refused to eat. This has been subsequently confirmed, ber a/ 5 niadnien also gangrene of the intestinal mucous membrane has ^1 found. There is evidently a disordered hsematosis in these patients, to ■ 1? symP^oms pulmonary gangrene arc announced in too clear a manner n a practised eye to be deceived. There is 110 disturbance in the alt phenomena of respiration. It is in the blood that a profound rat’on exists. The general colour of the skin indicates this; it becomes ” °^, brownish, the colour of beer,. The conjunctiva puts 011 a bluish tint. sw*rr’ c decomposition is observed in the features. Bed spots and - fn>+ ^c aPPe?r in different parts of the l ody. The breath exhales a horrible frntl>r c°metimes a slight cough appears-: the patient at first expectorates 1 7 mucus, next, the mucus is streaked with blood; then this is replaced j a brownish sanies of extreme fcetidity. We must not, however, conclude that gangrene of the lungs takes place in every case of refusal to eat.
Affections of the heart.—These arc not infrequent among the insane. You will not lose sight of the fact that the heart plays a great part in the moral acts. The cries and continual groans of the patients disturb the action of the heart, and drive the blood back upon the right cavities; sorrow, muscular prostration, render the dilatation of the chest imperfect, and oppose an ob- stacle to the circulation of the blood.
Conclusion. General inductions.—The anatomical diagnosis presents no in- considerable difficulties in its application to mental diseases. But I will en- deavour to sum up what science permits as to formulizc in this respect. Every kind of phrenopathy may present cadaveric lesions ; but these may also be found in other diseases, in which their signification is altogether different. Melancholy.—If melancholies die accidentally during the phrcnalgic state, they present for the most part no trace of organic alteration cither of the brain or meninges. The solidity of the cerebral substance, a venous turgescence, a slight sinking in, a slight serous collection, arc the only phenomena observed inside the cranium.
If the disease is protracted beyond the ordinary term of cure, if it bccome insensibly associated with debility of the functions of the understanding, we may admit that a change has taken place in the organic change of the en- cephalon, an opacity of the arachnoid, a hypertonia of the pia mater, and most frequently an inter-membranous serous effusion.
In melancholy, more than in any other kind of mental disease, autopsy leads to the discovery of visceral lesions, of engorgements of the vena porta), inflamma- tions of the peritoneum, affections of the cliest; but, in the majority of eases, these are the result of the disease or of fortuitous circumstances.
Ecstasy.—It is rare to sec patients affected with ecstasy succumb- to the disease : we must conclude that it is exempt from any disorganizing condition; and that in this affection as in melancholy, as in the generality of manias, the cerebral disorder is simply functional.
Mania.—When mania is accompanied by injection of the conjunctiva, great heat in the scalp, we must conclude that there is cerebro-meningeal hypenemia, but not inflammatory or disorganizing. It is the expression of a functional exaltation, of an orgasm communicated to the vascular system.
When mania is characterized by a great influx of will, by erics, tumult, agi- tation, the encephalon is gorged with blood. We often find in patients who have vociferated much, congestions of the pia mater and sub-arachnoid ccchy- mosis : they usually exist in the parietal and temporal regions.
If the patient die accidentally 111 the course of a tranquil mania, if he have preserved intact conception, memory, the all’ective sentiments, autopsy hardly ever reveals the slightest organic alteration. This is also true of manias which break out periodically; in the intervals, the brain presents nothing abnormal. When mania is complicated with epilepsy, the head is congested at every ht; often there arc found sub-arachnoideal ecchymoses of the brain itsf :lf, of the cortical and medullary substance, indurations of the pons, of the medulla oblongata. When mania, after having lasted several months, passes insensibly into » state of intellectual prostration, we can no longer say with certainty if V1® j exist in the patient one or other of the anatomical alterations 1 have pointy out. If the symptoms of mania go on diminishing, and those of dementia in- creasing, we may be almost sure that a morbid organic change has bcc^ wrought. Most frequently we then meet with congestion of the cortical su stance, of the pia mater, thickening of the arachnoid, rarely with softening- ^ Sometimes in maniacs we find hyperemia, opacity of the arachnoid; we “> conclude that these lesions mark a serosity unusual in this disease. I do not hesitate to lay it down as a principle, that in the majority of cases mania excludes appreciable organic lesions.
Folly.—I cannot say what is the condition of the brain in incendiary, homi- cidal, fasting suicidai madmen. If the disease has been of long duration, a morbid condition of the thoracic and abdominal viscera is frequently re- cognised.
Delirium.—The same uncertainty pervades the entire series of phrcno- pathics we have comprised under the name of delirium. Dementia.—It is especially in dementia that we must expect to find anato- mical lesions of the brain. Amongst all the phenomena which announce these lesions, the principal are, subtraction, nullity, volition of the cerebral and mus- cular acts. These are occasioned by compression, destruction, or even by irrita- tion of the ccrebral pulp.
In dementia, more than in any other phrenopathy, we may expect thickening, shrinking of the arachnoid, infiltration, vascular engorgement of the pia mater, lmodification in the vascular state and texture of the neighbouring convolu- tions.
But we cannot always say that there is, or that there is not softening. We may often affirm the existence of a serous collection.
As to cerebral induration, the little certainty as to its symptoms docs not allow us to conjecture its presence.
It is essential to remember that dementia is not invariably linked with an 0rganic state of the brain; this disease is often completely independent ot such a state.
Such is the character of the greater number of pure primitive dementias. In senile dementia, in that form which follows immediately upon a strong moral commotion, in dementia the result of great misery, in that which is connected with spermatorrhoea, the cadaveric inspection usually reveals no morbid state whatever. I except serous accumulations, a state oi discoloration of the grey substance, falling m of the brain. But I repeat it; it is not always permitted us to say, 1° shall find in such a patient a discoloration, a shrinking, an mter-membranous hydrocephalus.
Here we terminate the phcnomenological part of mental diseases. We shall next discuss the etiology oi these affections.
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