wedged his bedroom door, covered the key-holes with blankets, stuffed his ears and nostrils with cotton wool, and his mouth with a pocket handkerchief, all these defensive measures against his imaginary bombardment taking him an hour to carry out before he went to bed. I have under my own care just now a woman who had led a dissipated life, and had syphilis, who imagines that she is put into a "stove" by night, is tortured, her head beaten, and her person ravished until she is nearly dead.

2. The second symptom they all had in common was that they were suicidal and dangerous to others. 3. The next was that they all had hallucinations of the senses, and were all much worse at night. 4. The last symptom was that they all suffered much from cephalalgia of the syphilitic kind.

Such cases are very hopeless from the beginning. We may call them cases of syphilitic insanity engrafted on an original insane neurosis in the patient.

The next striking variety of Syphilitic insanity is where it follows distinct syphilitic epilepsy or apoplectiform attacks, and in this way partakes of the character of the ordinary epileptic insanity. Two of Dr. Duncan's cases were of this character.*

The last variety I shall refer to is that where there are delusions of grandeur at first, and progressive paralysis afterwards; cases in fact where the symptoms are almost identical with general paralysis. Several German writers, Meyer, Westphal, Oedmansson, and Griesinger, have specially studied this kind of case: and, while they do not altogether agree as to their conclusions, the weight of evidence is in favour of the view that those are cases of general paralysis, who, having previously had syphilis, have the character of their symptoms influenced by it to some extent, a casual relation only existing between the two diseases. That many

Since the above was written very characteristic cases of this variety of Syphilitic insanity have been published, by Mr. H. Hayes Newington and Dr. Batty Tuke., in the Jan. No. of the "Journal of Mental Science," pp. 555 and 560, and in the No. of the same Journal for July, 1874, p. 262 Dr. Batty Tuke gives an admirable description of the morbid appearances found after death in one of his cases, illustrated by lithographs. His paper is a most valuable and original one. Mr. Newington suggests that where the symptoms result from a gummatous tumour the insanity should be called " 'Syphilo. matous."

In the same Journal, p. 564, Dr. Cadell relates a case of mental excitement occurring contemporaneously with the secondary symptoms of syphilis. In the April No. for 1874, Dr. Wilks relates cases of this disease, and in the Jan. No. for 1875, Dr. Hughlings Jackson gives cases of nervous symptoms in congenital syphilis.

more general paralytics are not so affected seems the only surprising thing, for their disease in many cases has undoubtedly been caused by excessive venery.

The most careful attempts have been made by the German physicians to elucidate the pathology of syphilitic mental disease, and to connect the mental disturbances present with the pathological changes found in the brain after death. Very much has been done to make us certain in regard to some points, but the whole matter has not yet been settled. Pathologically four forms of syphilitic disturbance of the brain have been made out:-1. Nodes formed on the internal surface of the skull pressing on and setting up irritation of the brain substance. 2. Gummatous tumours of the brain and its meninges, most commonly the latter. These two forms seem to be very constantly associated with the epileptiform kind of syphilitic insanity. 3. Meningitis affecting the cortical substance of the brain secondarily, the general result being a sort of gluing of the membranes to the convolutions to each other and to the skull. This is usually associated with the typical syphilitic insanity with its initiatory cephalalgia and hypochondriasis, its gradual loss of mental power, its dis turbances of motion and sensation in the cerebral nerves, and its terminal dementia and paralysis. The fourth pathological species of syphilitic insanity said to exist is a purely hypothetical one. It is described as the irritative form, from cerebral anæmia, and the irritant effect of the virus on the central nervous system. In other words, cases where nothing at all can be found after death are so classed. Such are the cases of acute syphilitic insanity following the infection very soon, and associated with the insane neurosis. The important thing which may be regarded as quite certain is, that a form of insanity may occur as the result of the syphilitic virus, which shows no post mortem appearances in the brain after the death of the patient. In some few cases, while no trace of the disease is found in the brain, yet gummatous deposits, or caries of the bones, or nodes, are found in other parts.*

* A fifth pathological state as definite as the first three, and one which will probably be found to be associated with them all when looked for micros. copically, is the thickening of the coats of the small cerebral vessels by the depositions of concentric rings of plasma, thus producing a gradual diminution of the calibre of the vessels, a diminished blood supply, and subsequent softening of the brain substance and apoplexies, described by Dr. Tuke in this Journal for Oct., 1874, p. 352. This condition had been indicated by German syphilographers, but not described and figured as fully as Dr. Tuke has done.

In a conversation I had with the late Dr. Skae, about syphilitic insanity, with reference to this course of lectures, he told me that the form of syphilis connected with condylomatous tumours, which he was the first to show was innoculable when he was one of the surgeons to the Lock Hospital, he believed to be specially prone to be connected with insanity. These condylomatous tumours are found chiefly on the mucus membranes, causing the huskiness of voice so universal in prostitutes, but the virus also seems to show a special affinity for the central nervous system, thus causing a form of syphilitic insanity.

Westphal states that there is a marked pathologico-anatomical distinction between syphilitic paralysis and general paralysis. Not to speak of the caries of the bones of the skull, so often found in syphilis, or the specific gummatous tumours and gluey inflammation of the membranes, he says that the products of the morbid changes in the arachnoid are cellular in the syphilitic cases, and fibrous in the general paralytic, and that the adherence of the pia mater alone to the cortical substance, which is almost always found in the latter disease, is never found in the former.

The prognosis in syphilitic insanity is generally unfavourable, though in cases where the poison seems merely to have acted as the match to set in a blaze an already smouldering fire of latent insanity, it is more favourable. But when convulsions, paralysis of single nerves, and local anesthesia have appeared the prospect of recovery for the patient is very bad, and when progressive paralysis and advancing dementia have set in, the case is almost hopeless. There is this to be always kept in mind, however, that the most desperate cases have recovered, or got partially better. In all cases relapses are to be anticipated for some time.

Before leaving the subject of syphilitic insanity, I shall refer to a counterfeit or pseudo variety of it, which Dr. Skae specially alluded to in the conversation I have mentioned, and which I find also described by Dr. Wille. Cases of this kind are often as common as the real disease. The following is one of them.

A gentleman admitted into Morningside Asylum said. he had had syphilis, that he must die, was depressed, and apparently hypochondriacal, refused to take food, and said he would infect anyone with whom he came in contact. There was no evidence of syphilis to be found on any part of his body. He had enlarged tonsils, but this did not

appear to be specific. He continued a long time most miserable, assuring the medical attendant that he was suffering from "the disease;" that he had it in all his bones, that it was killing him fast. So far as could be made out from his relatives, he had never had any venereal disease, more than perhaps gonorrhoea.

In such cases, the whole idea about syphilis is a mere delusion, and is usually only one part of the delusional insanity under which the patient labours.

Delirium Tremens.-I shall not take up your time in describing this well-known neurosis. It may, perhaps, be thought a misnomer to call it a form of insanity, but it is so clearly allied to Dr. Skae's other groups that I think he was quite right to include it. It would be a mistake to confine the varieties of insanity in any classification to those patients who have only mental symptoms, or require to be sent to lunatic asylums. This would be specialism carried into medical nosology. Rather every student of insanity should specially devote attention to those varieties of nervous affection that combine bodily symptoms with the mental. Looked at from a psychical point of view, Delirium Tremens may be said to be a malady caused by alcohol in virtue of its special chemical affinity for the nervous tissue, in which there are great mental excitement, terror, and confusion, sleeplessness, hallucinations of vision, having in addition motor symptoms partially involuntary, partial paralysis of certain nerves and ganglia, notably those regulating the heart's action. There is one mental symptom of much importance, that frequently occurs at the commencement of delirium tremens, the non-observance of which is apt to prove fatal to the patient, and that is the suicidal impulse. This is part of the fear, and the "thousand miseries" to which the patient is a prey, but is so apt to exist before the other symptoms of the disease have been fully developed that it is not thought of or guarded against as it should be. Of the two thousand suicides that occur in this country in a year, a very large proportion indeed must be due to this cause. This fact is much lost sight of by systematic writers on the disease. Delirium tremens is one of the fields on which those who devote themselves to the treatment of mental diseases and the ordinary physician meet, and a correct idea of it is not obtained except when looked at from both points of view.

There is a variety of true insanity that is very apt to follow an attack of delirium tremens, the one running into the other, that is not alluded to by systematic writers on the subject. When the motor and acute mental symptoms have passed off, the patient is found to labour under confusion of mind with suspicions, and often with hallucinations of hearing. This I consider a most critical stage in the disease whenever it occurs. It is most apt to be seen in cases who have a hereditary tendency to insanity, or in those who have had very many previous attacks of this disease. It is always a very anxious stage of the disease for the medical attendant, and is not without danger to the patient, suicide being frequently committed. The prognosis is in most cases good if proper treatment is adopted, and the points of the greatest importance in such cases is to get the patient out of bed whenever the suspicions appear, to stop any sedative or hypnotic medicines he may be getting, to have him walk much in the open air, or to send him for a change of scene under the charge of a trustworthy attendant or companion, and on no account think of sending him to an asylum. The mistake most apt to be committed by the family practitioner is to persist in keeping such cases in bed, while the specialist is apt to err in pronouncing such symptoms as true insanity requiring asylum treatment. The symptoms most apt to persist, and if so to affect the favourable prognosis, are the hallucinations of hearing.

The Insanity of Alcoholism.-This is, as you are all aware, a slow and chronic form of Delirium Tremens. As Trousseau says, "The mental phenomena are the same-they develope themselves more slowly, but their change of type is only apparent. Slacken the tumultuous pace of the fancies which jostle and caper in the maniac's brain, and although you do not thereby effect any essential modification, you will completely alter the aspect of his delirium. For the disgust, the repugnance at food which characterize febrile anorexia, substitute passive indifference, absence of appetite-the gastric state of chronic alcoholism. In place of disturbance of vision, or the changing hallucinations of delirium tremens, there are confused perceptions, musca volitantes, cloudiness, fogginess, and transient flashes of false light." An attack of chronic alcoholism is ushered in by the same sleeplessness and motor restlessness as one of delirium tremens, and Dr. Anstie thinks this "motor disturbance is independent of the