tor of a criminal or violent act, that the distinction between such an act and one committed under the influence of any form of insanity is to be made. CHAPTER XII THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. As constituting the basis of many of the forms of insanity, and as themselves being one of the classes of mental derangement described in this work, I thought it expedient, for the more thorough elucidation of the subject, to consider the pathology and morbid anatomy of illusions and hallucinations in conjunction with the symptomatology of these affections. It will only, therefore, be necessary in the present connection to prosecute the inquiry so far as concerns the remaining groups. Although these are five in number, they may properly be reduced to three-the intellectual, the emotional, and the volitional insanities-for the compound and constitutional groups, though necessary in a classification for the study of symptoms, are in reality composed of combinations in varying proportions of the phenomena of the three groups mentioned, with certain peculiarities in some instances which can receive such special considerations as may be required. The part of the encephalic mass with which we have most to concern ourselves in the study of the pathology and morbid anatomy of insanity is the cerebrum, and the portion of that organ to which our inquiries must especially be directed is the cortex. From their proximity to and intimate anatomical relations with the cortex, the membranes are also of importance, but this importance is quite secondary to that of the structure with which they are in immediate connection. We have seen, in the earlier chapters of this work, that there is scarcely a doubt that the centres for intellect, emotion, and will, are seated in the cerebral cortex. It is equally certain, therefore, that derangements of either of these categories of mental faculties are the results of lesions perceptible to our means of research, or imperceptible to all the instruments of precision we can bring to bear. But whether visible or invisible, tangible or intangible, is really a matter of very little consequence, so far as the rationale of insanity is concerned. For it follows with all possible logical force that, if the intellect, the emotions, and the will result, as we believe they do, from the action of the gray matter of the cortex in its normal condition, the aberrations to which they are subject must be due to the action of the gray matter of the cortex in its abnormal condition. Further than this we cannot at present go. We cannot say that this or that particular form of insanity is directly associated with lesions of any one portion of the cortex any more than we can say that the intellect is derived from this part, the emotions from that, and the will from some other. Perhaps in time we may acquire this knowledge, but we certainly do not possess it now. It is possible, in view of the researches of Luys' and Meynert,' that the superior layer of cortical cells is concerned with the intellect and the emotions, and the lowest with volition, but this cannot yet be considered as definitely established. Beginning with the intellectual insanities, and locating their immediate patho-anatomical cause in the cortex, we have to inquire what are the morbid conditions of this part of the brain to which they can owe their origin? Although the records of morbid anatomy do not teach us as much as we might wish, we are not altogether without information on this point. In those cases-and they comprise by far the largest proportion-of intellectual monomania with exaltation and intellectual monomania with depression, in which there are illusions and hallucinations, many instances show, on postmortem examination, the evidences of disease of the optic thalamus of one or both sides, in addition to the lesions of the cortex associated with the intellectual derangement. These latter consist, in recent cases, of dilatation and a tortuous state of the blood-vessels of a greater or less part of the cortex, sometimes of the whole surface of the brain, at others of a single lobe, and again of a portion of a lobe or of even a single convolution. This condition often extends to the membranes, and these may be in patches more or less extensive, adherent to each other, to the cranium, and to the 1 "Recherches sur le système nerveux cérébro-spinal," etc., Paris, 1865. 2 Vierteljahrschrift der Psychiatrie, 1867, Heft i, p. 77 et seq. cortex. In addition, there are often the lacunæ of the perivascular canals, made by the distended blood-vessels, and remaining after the contraction of these latter at death. These are found both in the gray and white matter. These changes, which were noticed by the older writers, Foville,' Parchappe,' Fischer,' Ekker,' and others, have been confirmed by later observers, among them Griesinger,' Rindfleisch,' Tuke,' Luys," and Voisin. Sometimes there is a diffused redness extending over portions of the brain, and again there is a swelled or turgid condition of one or more of the convolutions. Microscopically it is found that the vessels of the cortex are often obstructed by agglomerations of red corpuscles, that the lymphatic sheaths are infiltrated with fatty matter, that the smaller vessels are distended and tortuous, that minute extravasations have taken place, and that there are deformations of various kinds in the nerve-cells. Sometimes these are swollen, at others atrophied; again, they have lost to a greater or less extent their processes; and, again, they are infiltrated with fatty and other granular matter. Sometimes there is pigmentation of certain portions of the cortex. Voisin reports an instructive case, of which I give the following abstract: L., a woman forty-one years of age, with some hereditary tendency to neurotic disturbances, and of an impressionable character, became smitten while in church with a missionary. Becoming jealous, she was angry if he spoke to any other woman, and finally accused him of sending men to her apartment to insult her. After the missionary departed to foreign regions, her fury against him increased, and she made many 1 Dictionnaire méd.-chir. pratique, art. "Aliéné," Paris, 1829, t. i. 2 "Recherches sur l'encephale," Paris, 1836-'42, p. 90. "Pathologisch-anatomisch Befunde im Leichen von Geisteskranken,” Lu cerne, 1854. "De cerebri et medulla spinalis vasorum," Utrecht, 1853. "Mental Pathology and Therapeutics," New Sydenham Society Translation, P. 427. 6 "A Text-Book of Pathological Histology," American translation, Philadelphia, 1872, p. 644. 392. 'British and Foreign Medico-Chirurgical Review, April, 1873. "Traité clinique et pratique des maladies mentales," Paris, 1881, pp. 336, 9.66 10 Op. cit., p. 60. attacks on persons in the street whom she mistook for him. Then she was arrested and placed in the Salpêtrière. It was found that her memory was good for names, things, and events; articulation normal; often spoke to herself; at times exaltations; hallucinations of sight and hearing; ideas of persecutions. Two years after admission-her mental aberration continuing-she died of typhoid fever. The encephalon weighed 1,130 grammes. There was no atheroma of the cerebral vessels visible to the naked eye. No thickening or adhesions of the meninges, no sub-arachnoidal effusion. Cranial nerves healthy, except the eighth pair, which were softened. Bulb and protuberance normal. The most internal part of the fissure of Sylvius was covered with a thickened, tough, and opalescent arachnoid, as was also the region in front of the chiasma. The gray olfactive centre of the right sphenoidal lobe presented to the unaided sight many black points and aborizations in large numbers. The left gyrus hippocampi presented also this dotted appear ance. There was a red punctation of the left tubercular quadrigemina. In the space between the corpora geniculata externa and interna there were little lacunæ and slight depressions. A horizontal section of the left hemisphere showed that in front the gray substance was of ordinary color and thickness, but the first frontal convolution (the ascending frontal of Meynert) presented at its most interior part an abnormal appearance characterized by the existence of a general yellow tinge and of a well-defined yellow zone of the breadth of 0 m., .001, which divided the gray substance of this convolution into two very nearly equal parts. This state was found, though to a less extent, in the left second parietal convolution (first parietal of Meynert). Throughout these altered parts the vessels were found to be larger than was normal, as were also those of the subjacent white substance. The gray centre of the right optic thalamus was in more than a normally vascular condition, and on antero-posterior section it was seen to be very vascular. In the part immediately subjacent to the olfactive centre there was a little spot the color of lees of wine, and a corresponding depression. There was a lacuna in the middle part. A portion of the gray substance of one of the parietal con volutions was submitted to microscopical examination, with the following results: 1. There was a large number of vessels of which the lymphatic sheaths were infiltrated with oil-globules. 2. Many vessels were gorged with red corpuscles. 3. Many cells were infiltrated with orange-yellow fat-granules. 4. There were several extravasations. A part of the olfactive centre of the right sphenoidal lobe, where the black points existed, showed 1. A large vessel completely gorged with red corpuscles. 2. A mass of orange-yellow hæmatine crystals. 3. A large number of dark-brown extravasations along the course of the vessels. 4. Many fatty cells. 5. Masses of hæmatoidin and hæmatin in the lymphatic wall of some of the vessels, especially at the points of bifurcation. The examination, therefore, showed the existence of congestion of one optic thalamus and of one sphenoidal lobe, with lesions of the parietal convolutions. The following case, from my own experience, afforded similar results: I. L., a man aged forty-five, came to my clinique at the University of New York, in November, 1876, and several times thereafter. He had the delusion that he was about to receive a large fortune, and was in consequence in a mild state of exaltation. At the same time he had hallucinations of persons speaking to him and advising him what to do with his money when he received it. These were supposed to come from both living and dead persons. Among the former were Queen Victoria, General Grant, Victor Hugo, and the King of Sweden, the latter being the chief adviser. His physical symptoms consisted mainly of pain in the head, vertigo, and insomnia. There were no oculo-pupillary symptoms, and his articulation was normal. He talked a good deal, but without much incoherence. I diagnosticated the case as one of intellectual monomania, with exaltation. In February, 1877, he died of dysentery, and, assisted by Dr. Charles T. Whybrew, my clinical assistant, I made the post-mortem examination. The brain only was examined. There were no adhesions of the dura mater to the skull, |