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A TEXT-BOOK 
 
 MENTAL DISEASES. 
 
A TEXT-BOOK 
 
 OF 
 
 MENTAL DISEASES: 
 
 WITH SPECIAL REFERENCE TO 
 
 THE PATHOLOGICAL ASPECTS OF C^SAl^ITY. 
 
 BY 
 
 W. BEVAN LEWIS, 
 
 L.R.C.P. (LoND.), M.R.C.S. (Eng.), 
 
 MEDICAL DIRECTOR, WEST RIDING ASYLUM, WAKEFIELD, 
 LECTURER ON MENTAL DISEASES AT THE YORKSHIRE COLLEGE. 
 
 WITH ILLUSTRATIONS IN THE TEXT, CHARTS, AND 
 EIGHTEEN LITHOGRAPHED PLATES. 
 
 PHILADELPHIA: 
 
 P. BLAKISTON, SON & COMPAN-Y, 
 
 1012 WALNUT STREET. 
 
 1890. 
 
SIR JAMES CRICHTON-BROWNE, 
 
 M.D., LL.D., F.R.SS. (lOND. AND EDIN.), 
 lOED CHANCBtlOE'S VISITOR IN LUNACY, LATE MEDICAL DIRECTOK OF THE WEST BIDING ASTLUK 
 
 AT WAKEFIELD, 
 
 5n B&miratfon of 
 
 THE VIGOROUS INTELLECT, COMMANDING ELOQUENCE, AND UNTIRING ENERGY 
 
 BROUGHT TO BEAR ON THE SCIENTIFIC ASPECTS OF 
 
 PSYCHOLOGICAL MEDICINE 
 
 DURING HIS DIRECTORATE OF THE WEST RIDING ASYLUM ; 
 
 anJ) in Ikeen appreciation of 
 
 HIS WIDE-SPREAD SYMPATHIES AND GENEROUS IMPULSES, 
 
 ZTbis moth is DeOicateD 
 
 BT 
 
 THE AUTHOR. 
 
PEEFACE. 
 
 In writing a new Treatise on Mental Diseases, I have not been 
 blind to the wealth of available literature in this department, 
 nor to the claims upon the Student's attention of such works 
 as the classical Manual of Bucknill & Tuke, the English 
 translation of Griesinger's Treatise, and the admirable Lectures 
 of Dr. Blandford, nor again to the more recent additions to 
 Dr. Bristowe's Clinical Medicine, and the works of Drs. 
 Sankey, Clouston, and Savage. 
 
 It has, however, been my special object to present a resumS 
 of our knowledge of the structure and connections of the 
 cerebro-spinal nervous system, of the architecture of the cerebral 
 hemispheres, and more especially of the cortical envelope as 
 the essential organ — the material substratum — of Mind ; and to 
 afford a concise account of the morbid changes found in the 
 brain of the insane, as viewed in the light of recent research. 
 
 It appears to me that a disproportionate amount of attention 
 has been paid in former text-books to the clinical aspects of 
 Insanity, and it is hoped that this attempt to deal more fuUy 
 with the organisation of the material substratum of mind, and 
 with the evidences of morbid change to which it is prone, will 
 not prove unwelcome to the Student of Mental Disease. 
 
 In the Anatomical Section, I have endeavoured to comprise 
 such information as shall prove of utility to a more thorough 
 conception of the ground-plan and superstructure of the nervous 
 system ; and it will be at once evident that special emphasis 
 has been advisedly bestowed upon the cortical envelope — the 
 structure, nature, and autonomy of the nerve-cell. 
 
VUl PREFACE. 
 
 The Clinical Section comprises statistics based upon an 
 analysis of 4,000 cases of Insanity in both sexes, treated at the 
 West Riding Asylum. 
 
 In the Pathological Section, I have endeavoured to do justice 
 to certain morbid processes, which appear to me to be of 
 paramount importance in the history of Insanity; and more 
 particularly would I here allude to the functions of the Lymph- 
 connective system of the Brain, and the life-history of the 
 " Scavenger-cell." 
 
 To my publishers I would desire to express my acknowledg- 
 ments for the consideration uniformly received at their hands, 
 despite the delay which has unavoidably occurred — for the 
 liberal supply of illustrations, so essential to the success of a 
 work of this description, and for the special care taken in 
 their production. I can add my testimony to the admirable 
 faithfulness with which my drawings have been reproduced by 
 Mr. Danielsson. 
 
 I have also to express my obligations to my colleague, 
 Mr. St. John Bullen, for reference to a compilation of Statistics 
 from the Pathological Records of this Asylum, and for material 
 assistance in the revision of the proof-sheets. 
 
 West Riding Asylum, 
 Wakefield, November, 1889. 
 
GENEEAL CONTENTS. 
 
 PART I.— ANATOMICAL AND HISTOLOGICAL SECTION. 
 
 The Spinal Cord — The Medulla Oblongata — The Mesencephalon — The Prosen- 
 cephalon — The Encephalon as a whole — The Cerebral Cortex — Cortical 
 Lamination, Pages 1-114- 
 
 THE SPINAL CORD. 
 
 The Cerebro-Spinal Axis— The Central Grey Matter— The White MeduUated 
 Columns — Transverse Section of Cord — Substantia Gelatinosa and Vesicular 
 Columns — Caput Cornu— Sacral Nucleus of Stilling — Anterior Cornu — Inter- 
 medio-lateral Tract of Clarke — Formatio Reticularis — Conducting and Com- 
 missural Tracts — Direct Pyramidal Tract — Crossed or Lateral Pyramidal 
 Tract — Posterior Median Column — Postero-lateral Columns — Direct Cerebellar 
 Tract — Cowers' Antero-lateral Ascending Tract — Anterior Radicular Zone 
 and Lateral Limiting Layer, Pages 1-8 
 
 THE MEDULLA OBLONGATA. 
 
 Region of the Calamus Scriptorius — Clavate and Cuneate Nuclei — Solitary Fasci- 
 culus — Nucleus of Fasciculus Teres — Floor of Fourth Ventricle (lower half) — 
 Hypoglossal and Vago-accessory Nuclei — Ascending Root of Fifth Nerve — 
 Motor, Mixed and Sensory Systems— Restiform Tract — Dentate Nucleus- 
 Inner and Outer Divisions of Cerebellar Peduncles — Roof Nuclei of StilUng — 
 Arcuate Fasciculi— Fillet — Nucleus of Lateral Column — Inferior Olivary Body 
 — Internal and External Accessory Olives— Corpus Trapezoides — Origin of 
 Hypoglossal Nerve — Mixed Lateral System — Spinal Accessory, Vagus and 
 Glosso-Pharyngeal — Upper Half of Medulla — Abducens, Facial and Acoustic 
 Nuclei — Superior and Inferior Olivary — Inferior Facial Nucleus — Nuclei 
 of Acoustic Nerve — Sound-rod of Bergmann — Acoustic Striae — Facial 
 Genu — Ascending Trigeminal Root — Abducens Facialis — Superior Olivary 
 Body — Lemniscus or Fillet— Upper Angle of Fourth Ventricle — Posterior 
 Longitudinal Fasciculus — Nuclei and Root-fibres of Trigeminal — Locus 
 Cceruleus — Nuclei of Oculo-Motor and Trochlearis— Root-fibres of Fourth 
 Nerve, Pages 8-27 
 
 THE MESENCEPHALON. 
 
 Advance in Complexity — Tegmental and Crustal Tracts — Internal Capsule — 
 Corpora Quadrigemina and Thalami — Locus Niger — Knee of Capsule — 
 Posterior Perforated Space — Basal Aspect of Mesencephalon — Tsnia Pontis — 
 
X CONTENTS. 
 
 Corpora Alhicantia — Infundibulum and Pituitary Body — Conducting Tracts 
 of CrustJi— Fundamental, Mixed, and Accessory Systems — Cortical Termination 
 of Tracts — Relationships to Motor Cells of Cortex — Termini of Sensory 
 Columns of Cord — Radiations of Gratiolet — Sensory Peduncular Tract — 
 Constitution of Internal Capsule — Ansa Peduncularis — Substantia Nigra — 
 Fillet or Lemniscus — Pineal Body — Posterior Commissure — Aqueduct — 
 Tegmental Structures— Superior Bigeminal Body or Nates — Its Brachia and 
 Stratum Lemnisci — Red Nucleus — Upper Cerebellar Peduncle — Posterior 
 Longitudinal Fasciculus — Substantia Nigra — Relationships and Connections 
 of Tcgment and Crusta, Pages 27-41 
 
 THE THALAMENCEPHALON. 
 
 External Conformation — Inner and Outer Face of Optic Thalami — Subthalamic 
 Body — Thalamic Peduncles — Fimbria of Fornix — Pillars of Fornix — Cortical 
 Connections of Optic Thalami — Lamina Medullaris of Burdach — Centre 
 Median of Luys — Stratum Zonale — Anterior Tubercle of Thalamus — Pineal 
 Body and its Connections — Fasciculus Retroflexus — Posterior Commissure — 
 Corpora Geniculata, Pages 41-49 
 
 THE PROSENCEPHALON. 
 
 Configuration of Fore-brain — Lenticular and Caudate Nuclei — Lenticular Axis of 
 Revolution — Relationships of the Lenticular and Caudate Nuclei — Head of 
 Caudate Nucleus — Tail of Caudate Nucleus — Amygdaloid Nucleus — The 
 Surcingle — Loop-like Disposition of Ganglia — Stria Terminalis or Taenia 
 Semicircularis — Olfactory Area — External Conformation of the Lenticular 
 Nucleus — The Claustrum and Insula — Globus Pallidus — Lamina MeduUares 
 of Lenticular Nucleus, . Pages 49-55 
 
 THE ENCEPHALON AS A WHOLE. 
 
 Comparative and Embryological — The Neural Tube in Amphioxus and in the 
 Lamprey — The Brain in Fishes and Ampliibia — The Five Vesicles of the 
 Neural Tube — The Cerebral Hemispheres in Fishes — Hypoaria — Predomin- 
 ance of Optic Lobes in Insects — The Reptilian Brain — The Brain in Birds — 
 Development of Neural Canal — Vesicles of the Fore-brain — Olfactory Lobe — 
 Foramen of Monro — Ganglia of Fore-brain — Pituitary Body — The Neuro- 
 enteric Canal — Vesicle of ]\Iid-brain — Formation of Quadrigeminal Bodies 
 and Crura — The Iter — Vesicle of Hind-brain — The Cranial Flexures — Forma- 
 tion of Fissures, Pages 55-60 
 
 THE CEREBRAL CORTEX. 
 
 Methods of Enquiry — The Grey Matter the Tissue of Mind — Histological Elements 
 of the Cortex — Nerve-cells — Angular Cell — Its Development in the Pig, Sheep, 
 Rat, and Pvabbit — P^elatively Large Nucleus — Granule Cell — Pyramidal Cell 
 — Apex, Basal, and Secondary Processes — The Motor Cell — Giant Pyramids 
 of Betz — Primary and Secondarj' Branches — Type of Cell in Man, &c. — 
 Inflated or Irregularly Globose Cell — Its Restricted Distribution in Rodents 
 
CONTENTS. XI 
 
 — The Spindle Cell — CLaustral Formation — Nerve-fibres of Cortex — The 
 Primitive Fibril — Non-Medullated Fibres — Axis-cylinder Process — Medul- 
 lated Nerve-fibre— Myelin Sheath — Keratoid Sheath — Fromann's Lines — 
 Lantermann's Dissepiments — Centric and Peripheric Fibres — Staining of Axis- 
 cylinder — Arteries of the Cortex — Intima — Tunica Media — Tunica Adventitia 
 — Perivascular Channel of His — The Capillaries of the Cortex — Stigmata and 
 Stomata — The Veins of the Cortex — The Connective Matrix or Neuroglia — 
 Local Varieties — Cellular Elements of Neuroglia — Lymphatic System of the 
 Brain — The Perivascular Channels and Lymph Channels Proper — Epicerebral 
 Space — Pericellular Sacs — Cells of Adventitial Tunic — A Description of the 
 Lymph System— The Lymph -connective Elements or Scavenger-cells — Vascular 
 Process of Scavenger-cell — Role of Spider- or Scavenger-cells, . Pages 60-85 
 
 CORTICAL LAMINATION. 
 
 Laminated Structure of Cortex— Cerebral Hemisphere in the Rodent — Eight 
 Types of Cortex — Transition Regions in Man — Distribution of the several 
 Types — Upper Limbic Type — Modified Upper Limbic Type — Outer Olfactory 
 Type— Inner Olfactory Type — Modified Lower Limbic Type — Extra-limbic 
 Type — Type of Cornu Ammonis— Type of Olfactory Bulb — Diversities of 
 Cortical Lamination — Regional Distribution of Ganglionic Cells in Cortex — 
 The Clustered and Solitary Arrangements — Distribution in the Pig, Sheep, 
 Cat, Ape, &c. — Significance of Fissures and Sulci — Fissures defining Distinct 
 Cortical Types — Contrasts between Brain of Man and Lower Mammals — 
 Lamination of Motor Area in Man — Five-laminated Cortex — Histological 
 Structure of the Several Layers of Motor Cortex — Distribution of Motor-cell 
 Groups — Transition-realms of Cortex — Specialised Areas — Acquirement of 
 Structural Variations — Significance of Cell-groupings — Comparative Size of 
 Brain-Cells — The Nucleus of the Nerve-cell and its R6le — Electrical Excita- 
 bility of Cortex — Latent Period of Stimulation and the Summation of Stimuli 
 — Conditions Affecting Excitability — Functional Equivalence of Cortex — 
 Faradic Stimulation of Cortex- — Extra-polar Conduction — Conduction to 
 Lower Centres — Proximity of Psycho-motor Centres, . . Pages 85-114 
 
 PART II.— CLINICAL SECTION. 
 
 States of Depression — States of Exaltation — Fulminating Psychoses — States of 
 Mental Enfeeblement — Recurrent Insanity — Epileptic Insanity — General 
 Paralysis of the Insane — Alcoholic Insanity — Insanity at the Periods of 
 Puberty and Adolescence — At the Puerperal Period — At the Climacteric 
 Epoch — Senile Insanity, Pages 115-431 
 
 STATES OF DEPRESSION. 
 
 Mental Depression Defined — Decline of Object-consciousness — Rise of Subject- 
 consciousness — Muscular Element of Thought — Failure in the Relational 
 Element of Mind — Sense of Environmental Resistance — Reductions to 
 
XU CONTENTS. 
 
 Automatic Levels — Sense of Effort — Restricted Volition — Enfeebled llepre* 
 sentativeness — Transformations of Identity — The Physiological Aspect — 
 Defective Circulation — Nutritional Impairment — Explosive Neuroses — 
 Hunger of the Brain-cell — Painful and Pleasurable Mental States — Re- 
 action-time in Melancholia — Degrees of Mental Depression — Clinical 
 Varieties of Melancholia — Simple Melancholia — Delusional Melancholia — 
 Hypochondriacal Melancholia — Melancholia Agitans — States of Mental 
 Stupor — Stupor and Hypnotism — Acute Dementia, . . Pages 115-150 
 
 STATES OF STUPOR. 
 
 Stupor and Dementia — Etiology of Stuporose States — Stupor and Hypnotism — 
 Stuporose Melancholia — Acute Primary Dementia, . . . Pages 150-162 
 
 STATES OF EXALTATION. 
 
 Maniacal Reductions — Failure of Attention — Enfeebled Synthesis — Transient 
 Delusive States — Exalted Sense of Freedom — Impulsive Conduct — Nocturnal 
 Crises — Seclusion Fosters Hallucination — Sexual Illusions — Stadium Melan- 
 cholicum — Enfeebled Imagination — Bodily Symptoms — Periodicity of 
 Maniacal Phenomena — Acute Delirious Mania, . . . Pages 162-176 
 
 FULMINATING PSYCHOSES. 
 
 Uniform and Partial Denudations — Defective Control — The Neurotic and Criminal 
 Subject — Nature of Impulsive Insanity^Insane Homicidal Impulse — Exist- 
 ence of Aura — Epigastric Aura — Uncovering of the Brute Instincts — Relief of 
 Mental Tension — Illustrative Cases — Suicide in Homicidal Subjects — Etiology 
 — Effect of Physiological Cycles — Epilepsy — Masked Epilepsy — Alcohol and 
 Impulsive Insanity — The Mimetic Tendency — Suicidal Impulse, Pages 176-188 
 
 STATES OF MENTAL ENFEEBLEMENT. 
 
 Mental Deprivation in Contradistinction to Developmental Arrest — Persistent 
 Enfeeblement — Chronic Residue of Asylum Communities — Recoverability of 
 Maniacal and Melancholic Forms — Consecutive Dementia — Delusional In- 
 sanity — Genesis of Monomaniacal States — Environmental Resistance — Trans- 
 formation Completed — Mystic Symbolism — Illustrative Cases of Delusional 
 Insanity — Monomania of Pride (/. 0., E. T.) — Religious Monomania (J. B.) — 
 ^lonomania of Persecution (E. C), Pages 188-200 
 
 RECURRENT INSANITY. 
 
 Definition — Establishment of Labile Equilibrium — Prevalence at Sexual Deca- 
 dence — Heredity — Influence of Neurotic Heritage and of Ancestral Intem- 
 perance — Atavism — P»-ccurreuce in the Congenitally Defective Subject — Morbid 
 Excitement and the Moral Imbecile — Alternations of Excitement and Stupor — 
 Hysteria and Menstrual Irregularity — Eroticism {A. S., M.A.M.) — Recurrence 
 in Adolescence (J/. C. )r.)— Recurrence at the Climacteric {H. 0.) — at the 
 
CONTENTS. XUl 
 
 Senile Epoch (/. (S".) — in Puerperal Subjects {M. B.) — in Traumatic Insanity 
 (B. L.) — Morbid Impulsiveness — Hallucination and Delusion (/. £.)— Pro<r- 
 nosis — Treatment, ......... Pages 201-220 
 
 EPILEPTIC INSANITY. 
 
 Definition — Epileptic Neurosis — Immediate and Remote Results of Epileptic 
 Discharge — Diffusion-currents — Nascent Nerve-tracts — Discharge from Sen- 
 sory Areas — The Aura in Sensory Epilepsies — Epileptic Amaurosis, Hemian- 
 opsia and Hemiansesthesia — Champing Movements — Pre-paroxysmal Stage — 
 Tremonitory Stage — Special Sense Auras — Vasomotor and Visceral Aurae — 
 The Epileptic Paroxysm — Grand and Petit Mai — Post-paroxysmal Period — 
 Post-epileptic Automatism — Case of E. C. — Status Epilepticus — Inter- 
 paroxysmal Stage — Epileptic Hypochondriasis, Automatism and Impulsiveness 
 — Medico-legal Relationships — Impulse — Delusion — Malingering — Reg. v. 
 Taylor — Treatment of Epileptic Insanity, Pages 221-250 
 
 GENERAL PARALYSIS OF THE INSANE. 
 
 Prodromata — Egoism — Early Moral Perversion — Failure of Re-representative 
 States — Enfeebled Attention — Transient Amnesia — Vasomotor Derangements 
 — Early Paresis — Second Stage — Delusions of the Paralytic and Monomaniac 
 — Vanity and Decorative Propensities — Sexual Perversions — Facial Expression 
 — Articulatory Impairment — Cerebral Seizures — Syncope — Epilepsy (/. F.) — 
 Unilateral Twitching (/. S.) — Epileptiform Attacks — Conjugate Deviation — 
 Case of H. P. — Apoplectiform Seizures — Monoplegice— Hemiplegite — Spastic 
 and Paralytic Myosis — Mydriasis and Amaurosis — Reflex and Associative 
 Iridoplegia — Statistical Tables — Consensual Movements— Reflex Dilatation — 
 Reaction-time — Spinal Symptoms (if. J. R.) — Deep Reflexes— Tabetic Gait 
 [H. U.) — Incontinence and Retention — Atrophy of Vesical Muscle— The Blood 
 in General Paralysis, Pages 250-288 
 
 ALCOHOLIC INSANITY. 
 
 Alcoholism and Age — Susceptibility at Certain Developmental Phases — Adolescent 
 Period [F. S.) — Prevalence of Impulse — Influence of Sex, Heredity, Epilepsy, 
 Cranial Injury, Ancestral Intemperance — Anomalies of Systemic and Visceral 
 Sensation — Aural Hallucinations {J. J^.) — Delusions of Suspicion — Optimistic 
 Delusions — Clinical Forms of Alcoholism — Mania a Potu — Amblyopia — 
 Cutaneous Ansesthesia — Relapses — Case of IF. W. — Homicidal Impulse (G. S.) 
 — Chronic Alcoholism — Physiological Effects of Alcohol — Evolutionary Period 
 — Mental, Sensorial, and Motorial Symptoms (/. J'^.) — Amnesic Forms (/. F.) 
 —Conditions of Mental Revivability {31. H. i.)— Delusional Forms (T. S.) 
 — Instances of ' ' Environmental Resistance " — Visceral Ilhisions — The Epi- 
 gastric Voice — Various Illusory States {E. A. F.) — Evolution of Psychical 
 Phenomena — The Nervous Discharge — Hallucinations as Detennining JNIorbid 
 Ideation — Augmented Specific Resistance — Sensory Anomalies — Motor 
 Enfeeblement (/. R. ) — Twitchings, Tremors, Stolidity — Reaction-time in 
 Alcoholism — Muscular Spasms and Cramps — Oculo-motor Immunity — 
 Nystagmus— Epileptiform Attacks— Hemiplegias [T. P. and J. C.)— Classifica- 
 tion, Pages 288-333 
 
XXV CONTENTS. 
 
 INSANITY AT THE PERIODS OF PUBERTY AND ADOLESCENCE. 
 
 Evolution of Puberty and Adolescence — Pubescence as Distinguished from Adol- 
 escence —Antagonism of Growth and Development — Excessive Metabolism of 
 Infancy — Acquibitiveness and Mimetic Characters of Childhood — Initiative 
 Tendencies of Adolescence — Pubescent Insanity in the Female— Delusions 
 and Hallucinations — Relapses at Menstrual Periods — Hysteric Type of Mania 
 — Stupor Coincident with Menstrual Derangement — Case of F. ^Y. — The 
 Blood m Stuporose States— Case of M. A. II. — Etiology— Ancestral Influence 
 — Periods of Susceptibility — Statistics of Hereditary Factors — Ovarian 
 Derangements and Pubescent Insanity {A. H.) — Amenorrhaal and Ana;mic 
 States — Influence of the Environmental Factors— Percentage of Hiemoglobin 
 in Cases of Stupor — Pubescent Insanity in the Male — Sexual Divergence — 
 Symptoms of Pubescent Insanity — Modified Forms (/. M.) — Masturbatic and 
 Uncomplicated Form of Pubescent Insanity — Etiology — The Moral Imbecile, 
 
 Pages 33-4-364 
 
 INSANITY AT THE PUERPERAL PERIOD. 
 
 Symptoms — Predominance of Mania — Intensity of the Morbid Process — Obtrusive 
 Sexual Element — Hallucinations — Delusions of Suspicion — Prevalence of 
 Suicidal Feelings — Etiology — Susceptibility of the Puerperal Period — 
 Illegitimacy and Puerperal Insanity — Frequency in Primiparffi — Condition of 
 the Blood — Diminution of Haemoglobin — Prognosis — Treatment — Insanity of 
 Pregnancy — Relatively Infrequent — Primipara; Show no Special Liability — 
 Symptoms— Recoveries, Pages 365-376 
 
 INSANITY AT THE PERIOD OF LACTATION. 
 
 Risks attendant upon Lactation — Period of Uterine Involution — Period of 
 Mammary Excitation— Symptoms — Depressing Delusions— Impulsive Nature 
 (M. W.) — Suicide [M. D.) — Case oi E. E. C. — Intensity of Maniacal Excitement 
 — Sexual Perversions — Hallucinations — Etiology — Exhaustion and the 
 Sequelae of Labour — Protracted Uterine Involution — Lactation during 
 Profound Antemia— Hyperlactation — Qualifications of the Nursing Mother — 
 Period for Weaning — Prognosis — Treatment, . . . Pages 376-392 
 
 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 Symptoms — A Subacute Delusional Melancholia — Suicidal Tendency (S. H.) — 
 Nymphomania [A. A.) — Etiology — Incidence of Insanity at dififerent ages in 
 4085 cases — Influence of the Climacteric — The Psychological Transformations 
 of this Epoch — Instinctive Actions — The ^^ Time-element" in Prognosis — 
 Alcoholism and the Climacteric — Treatment, . . . Pages 392-405 
 
 SENILE INSANITY. 
 
 Mental derangements Incident to Senility — Senile !Mania — Senile Melancholia — 
 Chronic Cerebral Atrophy] — Senile Convulsions — Senile Epilepsy — Senile 
 Dementia — Inheritance as a Factor in Senile Insanities — Exhaustive Brain- 
 
COXTENTS. XV 
 
 work — Alcohol and Senility — Case of T. O. — Onset and Prodromata — 
 
 Character of the Senile Reductions — Senile Hypochondriasis (/. A.) — Senile 
 Atrophy and Tlirombosis (/. B.) — Acute Senile Melancholia and Syncopal 
 Attacks (//. D.) — Partial Exaltation in Senile Insanity — Delusional Per- 
 versions of the Monomaniac and Senile Subject Contrasted — Senile Amnesia — 
 Cases of Senile Insanity [M. H. and A[. ilf. )— Elimination of Urea in Chronic 
 Cerebral Atrophy and Premature Senility — A Local Manifestation of Chronic 
 Bright's Disease, Pages 405-431 
 
 PART III.— PATHOLOGICAL SECTION. 
 
 Morbid Condition of Cranial Bones — Investing Membranes — Brain-Substance — 
 Histological Elements of Cortex — Forms of Tissue Degradation ■ — Patho- 
 logical Anatomy of General Paralysis, of Epilepsy, and of Chronic Alco- 
 holism, Pages 432-541 
 
 GENERAL PATHOLOGY AND MORBID ANATOMY. 
 
 The Cranium — Dura Mater — Pia- arachnoid — Arachnoid Haemorrhage — Adherent 
 Pia — Vascular Apparatus — Congestion — Inflammation — Softening — Atrophy 
 — Miliary Sclerosis — Colloid Degeneration — Granular Disintegration of Nerve- 
 cells — Pigmentary or Fuscous Degeneration — -Developmental Arrest of Nerve- 
 cells — Vacuolation of Cell-protoplasm — Vacuolation of Nucleus — Destruction 
 of Intra-cortical Nerve-fibre plexus — Tissue Degradation from Over-strain — 
 Tissue Degradation from Active Morbid Processes— Tissue Degi-adation from 
 Disuse — General Summary, Pages 432-493 
 
 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 The Brain and Us Membranes : — Early Implication of Vascular Tissues — Vital and 
 Mechanical Effects • — Effects on Lymph- connective System — Intracellular 
 Digestion — B6le of Phagocytes, or Scavenger-cells — Character of Scavenger- 
 element — Its Vascular Process — Fuscous Degeneration of Nerve-cells — Three 
 Stages of Morbid Evolution : — Inflammatory Engorgement — Implication of 
 Pia-arachnoid — Nuclear Proliferation of Adventitia — Paralysis of Arterial 
 tunics — Diapedesis — Exudation — Hsemorrhagic Transudations — Arachnoid 
 Hfemorrhaoe — Second Stage : — Hypertrophy of Lymph Connective System — 
 Fuscous Change and Removal of Nerve-cells — Nature of the Destructive 
 Process — Early Implication of Apex Process — Third Stage : — Fibrillation and 
 Atrophy. The Spinal Cord: — Spinal Cases in Four Groups — Evolution of 
 Pseudo-tabetic aiid^Spastic Paraplegic Forms — Angio-Neuroses — Pathogenesis 
 of Transient Tabetic Forms — Changes in Vascular, Connective, and Nervous 
 Elements — System-implication of Lateral Columns — Secondary to Cortical 
 Lesions — Respects Systematic Barrier — Chronic Parenchymatous Myelitis — 
 Dependent on Gradual Degeneration of Cortical Cells — Amyotrophic Form — 
 Degeneration of Cornual Elements in Cervical Associated with Descending 
 
X vi CONTENTS. 
 
 Lateral Sclerosis in Dorsi-lumbar Regions — Combined System Implication of 
 Columns — Psfiulo-tabetic Forms — Ataxic Tabes — Loss of Knee-jerk — Anorexia 
 — Flashing Pains and Sensory Symptoms — Genuine Tabetic Form in General 
 Paralysis, Pages 493-521 
 
 PATHOLOGY OF EPILEPSY. 
 
 Modern View of its Nature — An Impalpable Trophic Change — Objections to 
 Methods of Examination — Change in Elements of the Second Cortical Layer — 
 Fatty Change in Nuclei of Nerve-cell — Common also to Alcoholic Insanity — 
 Vacuolation of Nucleus — Ultimate Break-down of Nerve-cell — Implication of 
 Motor-cells — Absence of Vascular Implication— Functional Endowments of 
 Nucleus — Resistance of Cell to Discharge — Nutritional Rhythm — Significance 
 of Size of Cell and Nucleus — Primitive Type of Nerve-cell — Degraded Type of 
 Nerve-cell — Cell-conformation as indicative of a Convulsive Constitution, 
 
 Pages 522-528 
 
 PATHOLOGY OF CHRONIC ALCOHOLISM. 
 
 Morbid Change in Cerebral Vessels — Scavenger-cells in Outer Zone of Cortex — 
 Sclerosis of Outer Zone — Amyloid Bodies beneath Pia— Implication of Motor 
 and Spindle-cells — Significance of these Changes — Deepest Layers more 
 generally Involved — Early Vascular Implication — Aneurysmal Bulgings — 
 Atheromatous and Fatty Change— Pigmentary Degeneration of Motor-cells — 
 Scavenger-elements in Spindle-layer — Degeneration of MeduUated Nerve- 
 fibre — Spinal Lesions — Vascularity — Hypertrophy of Tunica Muscularis an 
 Inconstant Feature — Relationships to Chronic Bright's Disease— Sclerosis of 
 White Columns of Cord — Spinal Degenerations in Typical Case — Implication 
 of Clarke's Column — Immunity from Multiple Neuritis — Neurotic Heritage — 
 Chronic Endarteritis — Fatty and Sclerous Tendency — The Brain of the 
 Criminal Class — Exceptional R,esemblance to General Paralysis — Coincidence 
 of Grandiose State and Delusions of Persecution — Inconstant Vertical Impli- 
 cation of Cord — Constitutional State that of Chronic Bright's Disease — 
 Exceptional Transition to General Paralysis — Significance of Arterial Changes 
 — Affection of the Visceral System, Pages 528-541 
 
DESCRIPTION OF PLATES. 
 
 . PLATE I. 
 Illustrative of thk " Motor Type " of Cortex. Page 60. 
 
 The section taken from the extra-limbic area of rabbit's brain, near the frontal 
 pole of hemisphere, x 200. 
 
 The three small figures represent the mesial, basal, and coronal aspect re- 
 spectively of the rabbit's brain, showing distribution of the various types of 
 cortex. 
 
 A. Sub-frontal and sulj-parietal segments of the limbic fissure. B. Gyrus 
 hippocampi or lower limbic arc. C. Limbic fissure. D. Occipital pole. 
 E. Frontal pole. F. Olfactory bulbs. G. Optic tract. I. Olfactory root. 
 J. Corpus callosum. K. Parietal sulcus. S. Sylvian depression. T. Limbic 
 fissure. The types of cortex are indicated by the subjacent scheme. 
 
 PLATE II. Page 70. 
 
 Fig. 1. Illustrative of the "Motor Type" of Cortex. 
 
 Taken from the left hemisphere of the brain of the pig to exhibit its five- 
 laminated type with the nests or clustered ganglionic cells, x 76. 
 
 Fig. 2. "Motor Cortex" of Pig. 
 Nerve-elements of second, third, and fourth layers respectively, x 306. 
 
 PLATE III. Page 88. 
 
 Fig. 1. Illustrative of the " Sensory Type " of Cortex. 
 Taken from the first annectant gyrus of human brain, x 65. 
 
 Fig. 2. " Sensory Type " of Cortex. 
 
 Nerve-elements of the third, fourth, fifth, and sixth layers of first annectant 
 gyrus of human brain, x 157. 
 
 PLATE IV. Page 94. 
 
 Fig. 1. "Sensory Cortex." 
 
 Taken from the " modified upper limbic " type in the brain of the rabbit. 
 This area is represented in the small figures of the rabbit's brain on tliis plate by 
 the dotted area covering the inner and mesial aspect posteriorly, internal to the 
 parietal sulcus, K. 
 
 b 
 
DESCRIPTION OF PLATES. 
 
 Fig. 2. "Modified Olfactory Type." 
 
 Taken from the posterior extremity of the lower limbic arc of the rabbit's bniin. 
 The area is represented in the first of the three figures, and is lettered T. The 
 large swollen cells of the second layer is a notable feature of this cortical area. 
 X :210. 
 
 PLATE V. Page 106. 
 
 Section through "Motor Cortex" of Brain of Cat. 
 
 Specially prepared to show relationships existing between the nerve-cells and 
 the lymphatic channels and saccules of cortex. The connection of the pericellular 
 sacs with the blood-vessels is clearly indicated, as is also the arching of the 
 nutrient vessel aroimd the nerve-cell. The perivascular nuclei in some cases 
 alone indicate the position of the lymphatic sheath. 
 
 PLATE VI. Page 458. 
 
 Fig. 1. Degeneration of Medullated Fibres in Lateral Columns of Spinal 
 Cord forming so-called "Miliary Sclerosis," as seen under a Low- 
 power Objective. 
 
 The pale nodular structures are the "miliary " patches into which varicose and 
 moniliform fibres are seen to pass ; most of such patches are multilocular, and are 
 surrounded by deep-stained sclerosed tissue. 
 
 Fig. 2. "Colloid" Patches resulting from Degeneration of Medullated 
 Fibres of Spinal Cord — more Highly Magnified. 
 The multilocular constitution of the patch is indicated by delicate outlines ; 
 axis-cylinders devoid of medulla are seen passing into the degenerated focus ; and 
 a scavenger-cell is seen thrusting its ramifying processes into the substance of the 
 colloid patch. 
 
 Fig. 3. " Colloid " Patch still more Highly Magnified to .show the 
 Outline of Multilocular Material with a Fine Stroma of Elastic 
 Fibres Around, x 350. 
 
 PLATE VII. Page 462. 
 
 Degeneration of Nerve-fibees of Lateral Columns of Spinal Cord in 
 so-called "Colloid Degeneration" of these Tracts. 
 
 The axis-cylinders are seen stripped of their medullated sheath, or surrounded 
 by moniliform medulla undergoing granular degeneration, each witli a super- 
 imposed nucleus, which really represents a young scavenger-cell. At other parts 
 of the field the medulla is seen in process of segmentation, and attiicked by 
 scavenger-cells crowded with granular contents. 
 
 PLATE VIII. Page 466. 
 
 "Colloid Degeneration." 
 
 Portion of inferior olivary and accessory olivary bodies in a case of glosso-labio- 
 laryngeal paralysis (T. W., p. 466), showing spheroidal products of degenerated 
 
DESCRIPTION OF PLATES. xix 
 
 ineduUated fibre, unci the complete immunity from morbid change presented by 
 the grey matter. x 22. 
 
 PLATE IX. Page 472. 
 
 Pig. 1. — "Colloid Degenkration. " 
 
 Showing degeneration of the medullated arciform fibres of the first layer of the 
 cortex in a case of chronic alcoholic insanity. A deep-stained sclerous belt bounds 
 the outer zone, crowded with degenerated products of medullated fibre forming 
 "colloid" bodies arranged in linear series. Active scavenger-cells are seen 
 scattered profusely throughout the morbid patch. x 350. 
 
 Fig. 2. — "Colloid" Transformation of Medullated Fibre forming the 
 Arciform Stripe of the Peripheral Zone op the Cortex in a Case of 
 Advanced Senile Atrophy of the Brain. 
 
 Numerous scavenger-cells are scattered amongst the degenerate fibres, and oil- 
 globules crowd upon the vessels in their vicinity. x 350. 
 
 PLATE X. Page 480. 
 
 To Illustrate Sclerosis of Cerebellar Cortex in a Case of 
 Epileptic Imbecility. 
 
 A. Healthy leaflet closely adjoining diseased tract, showing the cells of Purkinje 
 uninvolved. 
 
 B. The sclerosed leaflets united firmly together, the cells of Purkinje absent, 
 and the normal structure completely altered. 
 
 PLATE XL Page 488. 
 
 To Illustrate Sclerosis of Cornu Ammonis in Epileptic Insanity. 
 
 A. Peripheral zone in gyrus hippocampi. 
 
 B. Vacuolated cells beneath the above. 
 
 PLATE XII. Page 496. 
 
 Vacuolation of Nuclei of Nerve-Cells. 
 
 To illustrate extreme degrees of this change in the elements of the second and 
 third layers of the cortex— human brain. The nucleus, which in the normal state 
 should stain much deeper than the cell, remains colourless or is swollen into one 
 large vacuole. At times such a vacuole appears to have burst through tlie 
 cell-protoplasm, or the latter contains numerous small vacuoles, the unafl'ected 
 protoplasm still staining deeply. 
 
 PLATE XIII. Page 502. 
 
 Extreme Degrees op Vacuolation in the Multipolar Ganglionic 
 Cells of Spinal Cord. 
 
 The coincidence of granular degeneration, and vacuolation is here seen. The 
 cells are swollen with bright translucent contents, or indurated and devoid of 
 
XX DESCRIPTION OF PLATES. 
 
 branches. The retracted protoplasm and displaced nucleus are evident features. 
 X 3.J0. 
 
 PLATE XIV. Page 508. 
 
 Fuscous Degeneration of Large Ganglionic Cells from the 
 Motor Cortex of Human Brain. 
 
 The pale patches represent the areas of pigmentary degeneration, the mass being 
 coarsely granular and of bright yellow tint. The unaffected protoplasm is seen 
 retracted and stained by the aniline dye, and the apex of one of these cells is 
 pigmented and stunted. x .350. 
 
 PLATE XV. Page 518. 
 
 Fig. 1. — Fatty Degeneration and Atrophic Shrinking of the Peripheral 
 Zone (1st Layer) of Cortex in a Case of Advanced Senile Atrophy 
 OF the Brain, taken from a Section of the Ascending Frontal Con- 
 volution. 
 
 Scavenger-elements are seen profusely scattered through the upper layers, 
 invading the vascular-tracts and surrounding the nerve-cells. The latter are 
 diminished in numbers, and a notable sclerous shrinking of these superficial layers 
 of the cortex is evident. x 130. 
 
 Fig. 2. Fatty Disintegration of Cortex in a Case of Advanced Senile 
 Atrophy of the Brain. 
 The peripheral zone (first layer) is here delineated, the vascular walls as well as 
 the scavenger-cells are surrounded by collections of oil-globules and fatty debris. 
 X 350. 
 
 Fig. 3. Nerve-cells from the Deeper Layers of the Cortex undergoing 
 Disintegration and Removal by the Agency of Scavenger-cells which 
 
 SURROUNT) them. 
 
 The ner%*e-cells are seen in different stages of degeneration — swollen, irregular 
 and deformed, devoid of branching processes, or reduced to a formless heap of 
 granular debris still enclosing the nucleus. The scavenger-cells contain numerous 
 coarse granules in their interior, deeply stained and similar to the products of 
 nerv'e-disintegration aroimd them, x 350. 
 
 PLATE XV I. Page 528. 
 
 Fig. 1. Granular Degeneration of Nerve-cells. 
 
 Taken from the fifth layer of motor cortex in a case of chronic alcoholic insanity. 
 Proliferation of the perivascular nuclei as well as the pericellular elements is 
 evident, and a coarse granular degeneration of the ])rotoplasm of the ners-e-cell 
 has occurred, x 210. 
 
 Fig. 2. Invasion of Deepest or Spisdle-cell Layer of the Cortex by 
 Scavengeb-cells in a Case of Chronic Alcoholic Insanity. 
 
 The blood-vessels which are undergoing fatty degeneration are crowded by 
 perivascular nuclei and surrounded by numerous scavenger-elements, x ISO. 
 
description of plates. xxi 
 
 Fig. 3. Aneurysmal Dilatation of Perivascular Sac in a Case of 
 General Paralysis, x 210. 
 
 PLATE XVII. Page 534. 
 
 Scavenger-elements in first layer of Cortex of Human Brain, Illus- 
 trating their mode of proliferation and permeation of the Cortical 
 Structure by their Fibrillation. 
 
 The coarse vascular processes may readily be distinguished from the finer fibrils 
 given off by these organisms, x 240. 
 
 PLATE XVIIL Page 538. 
 
 Degeneration of Nerve-cells in Human Cortex. 
 
 Taken from a section of the motor region to illustrate the mode of connection 
 and relationships existing between the scavenger-elements of the lymph-connective 
 system and the cortical blood-vessels. The swollen granular degenerated nerve- 
 cells are seen attacked on all hands by the scavenger-elements, x 210. 
 
 DESCRIPTION OF CHARTS. 
 
 Chart A. Chart of recoveries in insanity of the climacteric. Page 220. 
 
 ,, „ recurrent insanity. 
 
 Chart B. Chart of recoveries in insanity of puberty and adolescence in both sexes. 
 
 Page 364. 
 
 Chart C. Chart of recoveries in insanity of the puerperal and lactational periods. 
 
 Page 390. 
 
 DESCRIPTION OF WOODCUTS. 
 
 FIG. PAOB 
 
 1. Section across transition region of medulla, showing decussation of 
 
 pyramidal tract and nuclei of posterior columns, . (Schwalhe), 6 
 
 2. Cross-section of medulla oblongata at the upper decussation of the 
 
 pyramidal tract, ....... (Schvalbe), 9 
 
 3. Section of medulla oblongata through the inferior olivary bodies, ,, 11 
 
 4. Medulla oblongata and pons with neighbouring structures seen from 
 
 behind : schematic representation of the nuclei of origin of the 
 several cranial nerves, .... {Landois & Stirling), 18 
 
 5. Section through pons on a level with the origin of the great root of 
 
 the trigeminus, ........( Wernicke), 22 
 
 6. Horizontal section throiigh hemispheres, the right at a deeper level 
 
 than the left, ...... {Landois et Stirling), 29 
 
XXU DESCRIHTIUN OF WOODCUTS. 
 
 FIO. PAOl 
 
 7. Section through hemispheres (vertical transverse), passing through 
 
 plane of middle commissure, ..... (Oeyenbaur), 50 
 
 8. Left ascending frontal aud parietal convolutions, seen from the side, 
 
 with tlie attached frontal gyri included in scheme of examination of 
 detached cell-groups, . . . . 102 
 
 9. Left ascending frontal and parietal gyri, with the attached frontal 
 
 convolutions, as seen at the vertex, to illustrate site of detached cell- 
 groups, 10.? 
 
 10. Mesial aspect of human brain, illustrative of the more frequent site of 
 
 localised softenings, in order of precedence, ..... -452 
 
 IL Lateral aspect of human brain (right hemisphere), illustrative of the 
 
 more frequent site of localised softenings, ...... 452 
 
 12. Section across hemispheres and basal ganglia, illustrative of the site 
 
 of localised softenings, in order of precedence, 45S 
 
 13. Lateral aspect of left hemisphere of human brain, illustrative of the 
 
 sites of election of atrophy, in order of precedence, .... 457 
 
A TREATISE 
 
 MENTAL DISEASES. 
 
 PART I.— ANATOMICAL AND HISTOLOGICAL SECTION. 
 
 Contents.— The Spiual Cord— The Medulla Oblongata— The Mesencephalon— The 
 Thalameucephalon- The Prosencephalon — The Encephalon as a whole — The 
 Cerebral Cortex — Cortical Lami nation. 
 
 THE SPINAL CORD. 
 
 The cerebro-spinal axis consists of a series of longitudinally disposed 
 columns of white meduUated nerve fibre, arranged around a central 
 axis of grey ganglionic substance, which in its turn surrounds a central 
 cavity or cavities. Both white and grey columns constitute symmetri- 
 cal and bilaterally disposed halves, reminding us of the double gangli- 
 onic cord in the invertebrata, and are connected across the middle line 
 by a system of commissural fibres, and by certain tracts of the white 
 columns which decussate from the one half into the other at difierent 
 levels of the system. We have certain points to allude to, both as 
 regards the idea of "medullated columns" and the central "grey axis," 
 as well as the "bilateral symmetry" referred to, ere we desci'ibe in 
 detail the structures themselves. 
 
 In the first place, the central grey axis surrounding the central 
 cavity should not be considered altogether in the light of a uniform 
 column of grey matter, but rather as a series of ganglionic masses, 
 which, fused together along the whole length of the spinal cord, 
 become dissevered into separate masses in the medulla Olblong'ata, 
 and into the much larger and more important ganglionic masses at the 
 base of the Cerebrum. Although fused in the spinal cord, an indica- 
 tion of the primitive ganglionic type of the invertebrata can still be 
 traced in the enlargement of the grey substance at the level of each 
 spinal nerve, mapping ofi", as it were, each spinal segment from its 
 neighbour above and below it. 
 
 In the next place, the columns of white medullated fibre are not 
 contmiwus tracts throughout the whole cerebro-spinal axis; they consti- 
 
2 THE SPINAL CORD, 
 
 tute rather a multiplicity of smaller columns, each of which varies in 
 its destination, and consequently in its longitudinal extent. We may 
 correctly presume that — taking as tlu; lowjest course pursued by these 
 medullated tracts that of fibres arising from the grey cortex of the 
 cerebrum, and passing down the whole length of the cord to terminate 
 in the motor cells for the lower extremities in the lumbar region — we 
 have between these and the shortest every intermediate length of 
 medullated fibre, interrupted by the ganglionic masses to which it is 
 <lestined. The shortest fibres will probably be a series of fibres running 
 as longitudinal commissures between the neighbouring spinal segments 
 alluded to : these occur in the anterior and posterior columns of 
 the cord. 
 
 We have spoken of the fibres as being " interrupted " by the grey 
 matter, by which we must understand the important fact, that at such 
 points an organic connection is established between the nerve fibres 
 and the nerve cells which abound in the grey matter at these points of 
 interruption, and from which cells a fresh start of fibres is made into 
 other realms. 
 
 With respect to the bilateral symmetry of these two halves of the 
 cerebro-spinal axis, it must be also stated that although at a first glance 
 the various parts constituting the brain, medulla, and spinal cord, 
 would appear to exactly reproduce such symmetry of arrangement, 
 yet in the former, a lateral asymmetry is detected by a more careful 
 consideration of its cortical envelope, the convolutionary surface of 
 which varies very considerably in either hemisphere as regards 
 arrangement and complexity of gyri, and superficial area of grey 
 matter. This bilateral asymmetry apparently conforms to the extreme 
 differentiation in structure, accompanying the more independent func- 
 tional activity of the cerebral hemispheres, and histological research 
 teaches us still more foi'cibly how infinite become the possibilities for 
 this hemispheric differentiation. 
 
 We must likewise attend to the reversal of conditions in the case of 
 the white and grey matter constituting the large cranial ganglionic 
 structures and the spinal cord respectively. In the latter — the spinal 
 cord — the grey matter is central, and is invested externally by the white 
 nerve fibre ; in the formei', as the cerebral hemispheres and CBPe- 
 iDellum, the white medulla is central, and invested externally by an 
 envelope of grey cortex. We need only state here that the last is 
 the type assumed by those ganglionic levels which form the starting- 
 point of fibres for centric destinations : the first is the type assumed 
 for the reception of such centric diffusions. Wherever centric fibres 
 terminate in this radiate manner, there the grey cortex assumes a sort 
 of outer capsular investment and the medullated fasciculi its centric 
 
SUBSTANTIA GELATINOSA AND VESICULAR COLUiMNS. 3 
 
 core. We sliall find tliis appertain to the radiating fibres received by 
 
 the cerebrum, the cerebellum, the thalamus, quadrig-eminal 
 bodies, the g-eniculate, and the inferior olivary, in particular; 
 
 and, in ahnost all alike, we shall find even to the cerebral hemi- 
 spheres, a zonular layer of medullated fibres bounding the gi'ey capsular 
 investment. 
 
 To revert to the lower or subordinate levels, or the spinal axis, we 
 learn to familiarise ourselves with the disposition and longitudinal 
 direction of its various columns and ganglionic centres, by studying a 
 series of sections taken in different planes and at various levels. For 
 our present purpose, however, it is but necessary to acquaint ourselves 
 with the appearance of its parts as seen in transverse section. In such 
 a section carried through the lurabar enlargement of the cord, we see 
 the irregularly crescentic masses of grey matter disposed on either side 
 and connected across the median line by the anterior and posterior 
 commissures, between which lies the minute orifice of the central 
 canal. The anterior cornu or horn is at this site thick, broad, and 
 bulbeus; the posterior horn, as in other regions, is longer and narrower, 
 directed towards the groove on the outer surface of the cord, which 
 separates the lateral from the posterior columns, and where it receives 
 the lateral section of the fibres of the posterior roots. Somewhat 
 expanded at its extremity, the posterior cornu is obliquely truncated 
 from within outwards, and capped at this site by a translucent sub- 
 stance, the substantia g"elatinosa of Rolando ; the expanded 
 
 part so capped, and forming the greater part of the posterior horn, 
 being called the caput. The connection between it and the anterior 
 horn and median grey is called the cervix or nCCk of the horn. 
 Whilst the lateral segment of the posterior roots passes into the caput 
 cornu, the median-lying fasciculi arch inwards around the gelatinous 
 substance and ascend in the outermost zones of the posterior column 
 to enter the horn at a higher level, whilst others bend downwards into 
 the grey tract. Just anterior to these arched fibres, where they enter 
 the cornu, and on either inner side of the neck of the horn, is found in 
 the upper lumbar region an insignificant cluster of nerve cells, which 
 at higher levels become an important feature, the vesicular COlumn 
 of Lockhart Clarke. 
 
 In transverse sections the cells of this column look inflated and 
 spherical ; they are really fusiform, as seen in longitudinal sections.* 
 Commencing above the third lumbar nerve, this formation extends up 
 to the ninth dorsal, and in still higher regions are found, occasionally 
 
 * These cells have been spoken of as "bipolar," but this is an error, since few of 
 the elements fail to show several processes. 
 
4 THE SPINAL CORD. 
 
 distinctly clustered, similar cells wliicli appear as the representatives 
 of the same formation. Dr. Ross traces this formation as reappearing 
 in the lower end of the medulla oblongata, where he considers it to be 
 represented by the nucleus common to the origin of the spinal acces- 
 sory, A-agus, and glossopharyngeal nerves. 
 
 A similar formation appears in the sacral region (origin of the 
 second and third sacral nerves) as the sacral nucleus Of Stilling*; 
 so that we have throughout the length of the spinal cord and lower 
 end of medulla an interrupted column appearing at the two extreme 
 ends and in the thoracic division, of which the latter is far the more 
 conspicuous, and lies exactly along the plane of emergence of the 
 visceral nerves {Gashell). 
 
 In the posterior horn, we find sparsely scattered cells of fusiform 
 contour and of small size (15 ^:«), which are regarded as sensory 
 elements probably in connection with the posterior roots. 
 
 The anterior horn presents in cervical and lumbar regions most 
 conspicuous groups of multipolar cells, which vary much in their dis- 
 tribution with changes in the form of the grey matter ; these groupings 
 are fewer and far less conspicuous in the narrow anterior cornu of the 
 dorsal region. The more important groups to be distinguished are 
 five — viz., an inner or median, an anterior, an antero-lateral, a postero- 
 lateral, and a central. 
 
 Of these clusters the first and last (median and central) are the 
 least constant ; and, in the lumbar region in particular, do we note 
 the absence of the inner or median groups, although even in this 
 region minute elements tend to appear occasionally in a somewhat 
 clustered arrangement along the mesial border of the grey matter ; at 
 all times the inner is one of the least prominent clusters in the horn. 
 
 Of the antero-lateral and postero-lateral groups, the latter is the 
 more conspicuous, both as regards size of cluster, dimensions, and 
 number of cells. 
 
 These two groups occupy the outer margin of the grey horn, the 
 one lying in front of the other, and usually occasioning a well-defined 
 anterior and posterior angular pi-ojection of the horn. 
 
 Internal to these, between them and the inner, and behind the 
 anterior, lies in certain regions a central cluster, also a well-defined 
 group. 
 
 In the upper dorsal and lower cervical region a prominent lateral 
 projection from the outer side of the grey matter betwixt anterior and 
 posterior horn has long been known as the intermedio-lateral 
 tract of Clarke : it contains a cluster of cells Avhich higher up fuse 
 with the postero-lateral group already alluded to. 
 
 The outer margin of grey is behind this site blended in a coarse 
 
CONDUCTING AND COMMISSURAL TRACTS. 
 
 mesliwork with the neighbouring wliite medullated strands, consti- 
 tuting the so-called fopmatio reticularis. 
 
 The white medullated suT)stance of the cord investing this central 
 grey mass is roughly distinguished into an anterior, lateral, and 
 posterior column — the former extending to the outermost roots of 
 the motor, nerves : the second from this point back to the attachment 
 of the sensory roots : and the last to the posterior median fissure. 
 These columns are each of them further mapped out into separate 
 tracts, indicated anatomically by a distinct groove on the surface and 
 by a difference in the dimension of their fibres ; or by the results of 
 enibryological research indicating their medullated development at 
 distinct periods of life ; or again, by the facts of the Wallerian 
 degeneration resulting from physiological experimentation or the 
 processes of disease. 
 
 By one or other of these means we ascertain that at least eight 
 physiological tracts may be distinguished in the white substance of 
 the spinal cord. These may be classed as follows : — 
 
 Anteriorly — 1. Anterior or direct pyramidal tract (also termed the 
 column of Tiirck). 
 2. Anterior radicular (or root) zone (also termed anterior 
 ground fibres of Flechsig). 
 
 Laterally — 3. Lateral or crossed pyramidal tract. 
 
 4. Direct cerebellar tract. 
 
 5. Antero-lateral ascending tract of Gowers (also ex- 
 
 tending forwards). 
 
 6. Lateral limiting layer. 
 
 Posteriorly — 7. Postero-external (or postero-lateral) column {column of 
 Burdach : 2'>osterior radicular zone : posterior ground 
 fibres of Flechsig). 
 8. Posterointernal (or postero-median) column {column 
 ofGoll). 
 
 Direct Pyramidal Tracts. — A certain proportion of the fibres of 
 the anterior pyi'amids which escape decussation in the medulla, descend 
 direct on the same side of the cord, forming the tract which more or 
 less completely bounds the anterior median fissure. This anterior 
 pyramidal tract progressively diminishes in size from above down- 
 wards, as it becomes distributed to the anterior cornu of the opposite 
 side by a continuous decussation of its fibres throughout its course 
 along the anterior commissure. It usually extends to the mid-dorsal 
 region, but occasionally passes down as far as the lumbar cord, and is 
 found to vary very considerably in size for the same levels of the 
 
b THE SPINAL CORD. 
 
 cord in different individuals, according to the more or less complete 
 pyramidal decussation at the lower end of the medulla. There are 
 strong reasons for regarding the fibres of this tract as chiefly destined 
 
 for tlio upper extremities. 
 
 Crossed or Lateral Pyramidal Tract.— Constituted by the larger 
 
 proportion of fibres from the anterior pyramids* which undergo decus- 
 sation at this high level (see fig. 1 , j)>j), the lateral tract passes down 
 in the posterior section of the lateral columns, becoming, like the anterior 
 
 Fig. 1. — Section across transition region of medulla, showing decussation of 
 ])yraniidal tract and nuclei of posterior columns. 
 
 X, Cell gronp in base of posteriorrcornu. 
 
 cc. Central Canal. 
 
 5, Lateral column. 
 
 a and 5, Cell clusters in anterior cornu. 
 
 Ca, Anterior coruu. 
 
 py. Pyramidal tract from lateral columns 
 
 decussating at d as tliey ascend. 
 f.l.a, Anterior longitiulinal fissure. 
 
 s.l.p, Posterior longitudinal sulcus. 
 n.g, Nucleus funiculi gracilis. 
 n.c. Nucleus funiculi cuneati. 
 H^, Funiculus gracilis. 
 H^, Funiculus cuneati. 
 c.e, Neck of posterior horn. 
 g. Head of i>osterior horn. 
 r.p.C.L, Posterior roots of first cervical 
 nerve. 
 
 direct tract, progressively diminished in size to the lowest level of the 
 cord. The fibres of this tract pass into the grey substance of the 
 anterior cornu between the two horns, to become connected with its 
 motor nerve cells — probably, through the intervention of a ramifying 
 
 * In rare exceptions even less than half tlie pyramidal fibres decussate at this 
 level (Flechsig). 
 
POSTERIOR AND LATERAL COLUMNS. 7 
 
 plexus of nerve fibrils derived from the processes of these ganglion cells. 
 The direct and crossed pyramidal tracts represent a continuous con- 
 nection with the cortex of the motor area of the Itrain, passing uninter- 
 ruptedly in this course through the crusta of the cerebral peduncle 
 and the internal capsule. 
 
 Posterior Median Column. — This wedge-shaped column of fine 
 nerve fibres lying on each side of the posterior median fissure, scarcely 
 recognisable below the dorsal region, extends from this site upwards to 
 its termination in the clavate nucleus in the medulla. It increases 
 steadily in size from below upwards, and undoubtedly receives fibres 
 in part from the sensory nerve-roots which pass into this column by 
 way of the postero-external column, as well as the posterior commissure. 
 
 Postero-Lateral Columns cannot, like the postero-median, be re- 
 garded as largely a continuous tract throughout the spinal cord. A 
 gi'eat part of their bulk is constituted by the inner division of the 
 posterior nerve-roots which, curving round the caput cornu, run 
 obliquely upwards or downwards, or directly outwards, to enter the 
 grey matter of the horn ; and also, in part, by a system of short, 
 vertical, commissional fibres passing betwixt different levels of the 
 grey matter throughout the whole extent of the cord. Higher up in 
 the medulla we shall find that this column terminates in the CUncate 
 
 nucleus. 
 
 Direct Cerebellar Tract. — A somewhat flattened fasciculus form- 
 ing the marginal zone of the lateral columns, from the end of the 
 dorsal region upwards, lies upon the outer side of the lateral or 
 
 crossed pyramidal tract; its fibres arise from the posterior 
 
 vesicular column of Clarke, which, as we have seen above, com- 
 mences at the level of the third lumbar nerve. It gradually augments 
 in size, and eventually terminates in the cerebellum, passing up to it 
 along the restiform tract of the inferior peduncle. At its origin, 
 and high in the cervical region also, the lateral pyramidal tract 
 becomes superficial behind, so as to separate it from the posterior cornu. 
 
 Antero-lateral Ascending" Tract (Gowers).— A column of fibres 
 
 extending up through the whole length of the cord (occasionally the 
 seat of ascending degenerative changes) has been described by Dr. Gowers 
 as situated in front of the crossed pyramidal and direct cerebellar tracts. 
 Passing across the lateral columns on a level with the posterior com- 
 missure and reaching the surface, this tract skirts the margin of the 
 cord almost as far as the anterior median fissure. The tract is 
 regarded as a sensory tract originating from root fibres of the 
 sensory nerves decussating across the posterior commissure.* 
 
 * Diagnosis of Diseases of the Spinal Cord, First Ed., 1879; and Diseases of the 
 Nervous System, vol. i., pcage 122 (Gowei-s). 
 
a THE MEDULLA OBLOXOATA. 
 
 Anterior Radicular Zone and Lateral Limiting* Layer.— 
 
 Tluse may be considered togetlier as constituting, like many of the 
 fil)res of the posterior radicular zone, a series of short commissural 
 fibres uniting the grey matter at different levels. In the case of the 
 anterior root zone a certain portion of the fibres decussate at the 
 anterior commissure, and thus " a connection may be established 
 between the two anterior cornua at different levels " {Gowers *). 
 
 We might summarise in the following short scheme the probable 
 relationships of these tracts, as taught us by the Wallerian degenera- 
 tions following upon disease or physiological experiment : — 
 
 Short commissural vertical tracts — 
 
 (1) Anterior root zones. 
 
 (2) Lateral limiting layer. 
 
 (3) Burdach's columns (in part). 
 Descending motor from cortex cerebri — 
 
 (4) Tiirck's columns. 
 
 (5) Crossed pyramidal tract. 
 Ascending sensory tracts — 
 
 (6) Goll's columns fi-om posterior roots. 
 
 (7) Direct cerebellar from visceral tract. 
 
 (8) Antero-lateral ascending from ci'ossed sensory roots. 
 
 THE MEDULLA OBLONGATA. 
 
 A transverse section taken just below the calamus SCrlptorius 
 so as to reveal the central canal intact, ere it opens out on tlie free 
 surface of the fourth ventricle, shows us the central grey matter 
 thrust back to the posterior margin of the section — yet encroached 
 upon laterally by the mass of the clavate and CUneate nuclei on 
 either side. The central grey substance situated in the middle line is 
 symmetrically disposed around the central canal, which here forms a 
 mere elongated slit. Most prominent in front, it presents an eminence 
 on each side of the median raphe, with a rich nucleus of large nerve 
 cells, really disposed in double clusters — the nuclei of origin of the 
 hypoglossal nerve, the fibres of which conspicuously run forwards 
 towards the ollvary region. On each side of these median pro- 
 minences, a lateral projection of grey matter also occurs in front of 
 and partially surrounding a conspicuous column of meduUated fibres 
 seen in transverse section encircled by meduUated loops — the solitary 
 
 fasciculus, fasciculus rotundus or respiratory fascicle. From 
 
 * Loc. clt., p. 12.3. 
 
CLAVATE AND CUNEATE NUCLEI. 9 
 
 this point the central grey matter inclines hackwarcls to the miclrlle 
 line, behind the central canal, and at an acute angle to the former. This 
 sudden inclination backwards is necessitated by the prominence of the 
 Clavate nuclei, which, lying behind the central grey substance and 
 to its outer side, approach each other near the mesial line; along the 
 backward inclination of this and the lateral prominence, nuclei for the 
 origin of the accessory nerve and vago-accessory system are found. 
 
 • Ip JT' nj n^~ ^ 
 
 f.la. A- 
 
 Fis- 2. — Cross-section of medulla oblongata at the upper decussation 
 of the pyramidal tract. 
 
 s.l.p. Posterior longitudiual sulcus. 
 H'^^ Funiculus gracilis. 
 n.g. Nucleus of funiculus gracilis. 
 H", Funiculus cuneatus. 
 n.c. Nucleus of funiculus cuneatus. 
 n.c}-, External nucleus of funiculus cu- 
 neatus. 
 a. Y, Ascending root of trigeminus. 
 g. Substantia gelatinosa. 
 f.a, f.ci}, f.d-, External arciform fibres. 
 F.r, Formatio reticularis. 
 ii.l, Nucleus of lateral column. 
 
 o^, Accessory olive. 
 
 0, Inferior olivary body. 
 
 n.ar. Nucleus arciformis. 
 
 py. Pyramid. 
 
 f.l.a. Anterior longitudinal fissure. 
 
 d.a, Anterior or upper decussation of 
 
 pyramids. 
 71. XII, Nucleus and root fibres of bypo- 
 
 glossal nerve. 
 c.r, Central canal. 
 n.XI, Nucleus of spinal accessory. 
 
 On each side of the centi'al canal a column of fibres enclosing an 
 elongated nucleus of nerve coi'puscles, measuring 23 /t x 11 /i, 
 extends forwards towards the middle line ; and here, still enclosed 
 in the central grey area, is a mesial compact cluster of small cells. 
 The former represents the nucleus of the eminentia or fasciculus 
 teres, which at higher levels becomes a prominent feature on the 
 
10 THE MEDULLA OBLONOATA. 
 
 floor of tho ventricle. Root fn)ri'.s of tlio accessory nerve will at this 
 level be traced from the lateral angle or eminence of the grey substance 
 to their site of emergence behind the olivary body. 
 
 Above the calamiis scriptorius, the opening up of the central canal 
 on the floor of the fourth ventricle, is necessarily attended by a 
 recession of the clavate nuclei; and the eminentiae teretes, which, 
 as we stated, formed the antero-lateral boundaries of the central canal, 
 become now exposed on the surface, as the innermost column seen 
 in this lower half of the venti'icle, on either side of the median 
 raphe. Formerly covered by the ala Cinerea, which represents 
 the nucleus of the vagus, the fasciculi teretes pass upwards as wliite 
 columns, strongly contrasting with the grey of the vagus nucleus ; 
 and, as they take this course, they lie superjacent to the hypo- 
 glossal nuclei. These eminences, therefore, map out the course 
 of the hypoglossal nuclei, but must not be identified with that 
 nerve, as they belong to a wholly distinct system. Whilst the 
 white columns of the eminentite teretes become wider and more 
 pronounced upwards, the ala cinerea disappears l)etween them and a 
 more external eminence — the aCOUStic tubePCle — so that transverse 
 sections exhibit on either side of the median raphe from within out- 
 wards the eminentiae teretes, the tuberculum acousticum, and 
 lastly the restiform columns. 
 
 At this plane the central grey matter is consequently unfolded 
 outwards — a strongly marked concavity directed backwards, still 
 characterises this region of the ventricle ; but this process of unfold- 
 ing proceeds at higher levels, until on a plane with the striae 
 aCOUSticae, the floor of the ventricle is almost flattened out, pre- 
 senting only a gentle depression at the middle line. As this process 
 of unfolding of the central grey matter proceeds, the restiform tract 
 diverges more and more from the mesial line ; whilst simultaneously 
 the central grey substance, notably in the region of the hypoglossal 
 nucleus, becomes shallower, and the nucleus itself nearer the surface. 
 
 Superficially viewed in the fresh medulla one readily sees between 
 the diverging restiform columns a large central V? divided midway 
 by the vertical raphe and separated from the plump acoustic tubercles 
 on either side by a well-marked depression, into which the upper 
 wedge-shaped apex of the ala cinerea plunges and loses itself. The 
 anterior border of the grey substance now loses its abrupt pro- 
 minences, and assumes a gentle sinuous course across the medulla 
 from one solitary fasciculus to the other — the several wave-like 
 summits representing the site of the hypogflOSSal and the vag'O- 
 
 accessory nuclei (fig. 3). 
 
 Having so far followed the disposition of the central grey matter. 
 
ASCENDINfJ ROOT OF FIFTH NRRVK. 
 
 11 
 
 from just l)elow the opening-up of the central canal to the level of the 
 stria; medullares of the acoustic nerve, the student should now direct 
 his attention to a cross-section of medullated fibres of a notable 
 crescentic configuration, and encircling on its outer side a coarsely 
 reticulated region largely made up of deep stained connective tissue. 
 
 nX , nX' 
 
 ii.ar 
 
 Fig. 3.— Section of medulla oblongata 
 
 n.t. Nucleus of fasciculus teres. 
 
 n.XII, Nucleus of hypoglossal nerve. 
 
 n.X and n.X^, Nuclei of vagus. 
 
 /.s, Fuuiciilus solitarius. 
 
 11. g, Nucleus of funiculus gracilis. 
 
 n.c, Nucleus of funiculus cuneatus. 
 
 n.am. Nucleus ambiguus. 
 
 C.r, Restiform tract. 
 
 g, Substantia gelatinosa. 
 
 a. V, Ascending root of trigeminus (fifth 
 
 nerve). 
 F.r, Reticular formation of lateral column. 
 a.X, Root fibres of vagus. 
 
 through the inferior olivary bodies. 
 
 o.a.l, Outer accessory olive. 
 
 ?;.?, Nucleus of lateral columns. 
 
 f.a.e, Exterual arciform fibres. 
 
 o. Inferior olivary body. 
 
 XII, Emergent root fibres of hypoglossal. 
 
 p. Anterior pyramid. 
 
 n.ar, Nucleus arciformis. 
 
 f.l.a, Anterior longitudinal fissure. 
 
 p.oJ, Olivary x»eduncle 
 
 o.a.m, Inner accessory olive. 
 
 V, Anterior column. 
 
 r, jVTediau raphe. 
 
 These conspicuous structures lie laterally disposed near the margin, 
 on either side, in all sections of the medulla up to the emergence 
 of the trifacial nerve : the dark-stained reticulum is the representative 
 of the substantia gelatinosa of the posterior cornu. The medul- 
 lated crescent is the ascending root of the fifth nerve, representing 
 the ascent of the remaining portion of the posterior root zone of the 
 spinal cord. Drawing an imaginary line from the solitary fasciculus 
 outwards to this crescent — to its anterior border in the lower levels, 
 
12 THE MEDULLA OHLOXGATA. 
 
 and to its posterior Ijordcr in tlic higher levels near the acoustic — wc 
 map otl" a region which corresponds to the posterior columns of the 
 spinal cord, and their continuation as the inferior peduncles of the 
 cerebellum : this region lies behind the imaginary line so drawn. 
 
 In like manner, a line drawn from the mesial eminence of the central 
 grey matter obliquely outwards to the root of the infi-rior olivary 
 body, maps off the remaining portion of medulla into two divisions, 
 an inner, between it and the median raphe ; and an outer, between it 
 and the former line di-awn to the crescentic root of the fifth nerve. 
 The inner of the two divisions corresponds to the anteriOF COlumn 
 of the cord ; the outer division, to the lateral COlumns. The two 
 imaginary lines, so drawn, correspond to the direction taken by a 
 motor system and a mixed motor and sensory system of cranial 
 nerves — the former line corresponding to the spinal accessory, pneumo- 
 gastric and glosso-pharyngeal nerves, the latter to the hypoglossal. 
 On the other hand, the purely sensory acoustic nerve arises from 
 a position further back than the mixed lateral system ; and above the 
 plane of the latter nerve we find the origin of other cranial nerves 
 disposed in like manner — viz., an anterior or motor, a lateral or 
 
 mixed system, and a posterior or sensory system. 
 
 Reverting now to the posterior of these three divisions of the 
 medulla, which, as we have stated, is bounded in front by the 
 emergent root fibres of the mixed lateral system of nerves — we note, 
 first, that in the lower plane (below the calamus) the greater mass of 
 this region is constituted by the derivatives of the posterior columns 
 of the cord and their nuclei. The columns of Goll with their clavate 
 nuclei, and the columns of Burdach (or posterior root zones) with their 
 cuneate nuclei, encroach by their mass upon the posterior aspect of 
 the central grey matter, nearly meeting at the middle line ; and 
 concealing, in this way, the deeper seated nuclei of origin of the 
 vagus and hypoglossal. In front of the clavate and cuneate nuclei in 
 the same territory, lies the solitary fasciculus, and the ascending 
 root fibres of the fifth nerve around the gelatinous substance of 
 Rolando. The crescentic I'oot-area of the fifth nerve is covered 
 externally by the fibres of the direct cerebellar tract from the cord ; 
 whilst behind this tract, but still forming the outer margin of the 
 medulla, is a narrow zonular layer, representing the commencing 
 restiform tract of the cerebellum. 
 
 At this level it will be apparent that large numbers of delicate 
 arched fasciculi are thrown oft' from both clavate and cuneate nuclei; 
 and these, passing forwards through the lateral columns of the 
 medulla, terminate in the inferior olivary body of their own side 
 partially, from whence fresh fasciculi start to reach the opposite resti- 
 
RESTIFORM AND INNER DIVISION OF CEREBELLAR PEDUNCLE. 13 
 
 form tract, whilst the more posterior fasciculi cross the raphe, and 
 traverse the opposite olivary body on their way to join the restiform 
 tract on this side. Hence the clavate and cuneate nucleus of each 
 side discharges itself by an extensive series of arcuate fibres into the 
 ojyposite restiform tract, through the intermediation of the olivary body 
 partially of its own side, and partially through that of the other side. 
 As a direct result of this projection, we find in our sections above the 
 calamus, the rapid attenuation of these nuclei of the posterior columns, 
 with a corresponding enlargement of the restiform tract for the cere- 
 bellum. At these higher levels the unfolding of the central grey 
 matter is permitted by the lateral recession of these structures, partly 
 induced by the attenuation and disappearance of the two nucleated 
 masses, and partly by tlie divergent course assumed by the resultant 
 restiform tract to reach the cortex of the cerebellum and its dentate 
 
 nucleus. 
 
 Near the lower angle of the fourth ventricle, our transverse sections 
 show us the restiform tract as a very conspicuous, somewhat pyriform 
 area, and pale-stained in contrast to the parts behind it, from the close 
 approximation of the medullated fibres seen in cross-section, none 
 being arranged in fasciculi. Immediately behind this tract, however, 
 is a much deeper-stained area, lying between it and the central grey 
 matter and solitary fasciculus ; it is notable for the great number of 
 small round or oval bundles by which it is constituted, measuring 
 usually 90 /x x 22 /x, pale-stained, and enclosed in grey matter with 
 a meshwork of deeply-stained tissue. In this area, which covers an 
 irregularly quadrilateral space, appear many large multipolar nerve 
 corpuscles with large nuclei ; these corpuscles attain the dimensions 
 of 32 [J. X 20 [jj. 
 
 The medullated formation so constituted is an important division 
 of the medulla to recognise. It has been long known as the 
 
 inner division of the inferior cerebellar peduncle— the resti- 
 form tract forming the outer division of the same structure. 
 Its connections above are with two nuclei, situated one on either 
 side of the median line, beneath the superior vermiform process 
 of the cerebellum, and are called, since their discovery by Stilling, 
 the roof nuclei. Its connections below have been variously given. 
 Stilling believed them to be the origin of the clavate and cuneate 
 columns ; Meynert shows that this view is incorrect, and we have 
 already seen that the latter .columns are in complete connec- 
 tion with the restiform tract. It would appear to us that these 
 internal divisions of the cerebellar peduncle break up into arcuate 
 fibres, which partly pass behind, but partly traverse the hilus of the 
 olivary body of the same side, and thence, crossing the median raphe, 
 
14 Tin: MEDULLA OBLONGATA. 
 
 terminate in tlic groy matter of the opposite olive. Nearer the 
 calamus Ave find that the clavatc; and cunoate nuclei, not as yet 
 completely resolved into arcuate fasciCUli, insinuate themselves 
 between these two divisions of the inferior peduncle — a little higher, 
 where the nuclei have disappeared, these cerebellar columns are, as 
 we have intimated, in juxtaposition. 
 
 Passing now to the region lying in front of the emergent root fibres 
 of the lateral system of nerves, between them and the motor system 
 (hypoglossal), we find the greater part of this area occupied by the 
 cross-section of ascending fibres, broken up into numerous minute 
 groups by the intertwining of complex arcuate fibres, as they curve 
 forwards and inwards to the raphe and the olivary district. To 
 this fasciculated meshwork the term reticular formation has })een 
 applied, the ascending fibres being the continuation of the outermost 
 part of the anterior root zone. Two well-defined nuclei characterise 
 this lateral column of the medulla : one, which is the richer in cells, 
 is elongated and directed from without inwards, approaching the 
 margin of the lateral column, lying parallel with the roots of the 
 lateral mixed nerves, between the substantia gelatinosa behind, and 
 the olivary and its fillet in front. 
 
 Further inwards in this lateral column, and carried backwards 
 parallel with the lateral mixed roots, is a second smaller group of cells 
 more closely clustered than the former ; nor traversed as these are by 
 dense fasciculi of arcuate fibres passing to the olivary body. The 
 former, called the nueleus of the lateral COlumn by Stilling and 
 Clarke, might be more conveniently termed the external, and the 
 second cluster the internal, nucleus of the lateral column ; or following 
 Dr. Ross, the anterior and posterior omcleus. 
 
 They almost certainly represent motor cell-groups of the anterior 
 cornua of the spinal cord, severed from the rest of the central grey 
 matter by the decussation of the pyramids across to the lateral 
 columns, and the interposition of the mass of the inferior olivary 
 body. By Dr. Ross they are regarded as detached from the antero- 
 lateral and postero-lateral group of cells in the anterior cornu by the 
 cleavage effected by the arcuate fasciculi of the medulla, whilst those 
 main groups are still found as the motor nuclei in the central grey 
 matter of the medulla. 
 
 Intei'calated l)etwecn the lateral columns of the medulla and the 
 anterior or median, is the inferior olivary body, extending throughout 
 the region we have been studying, but terminating at the level of the 
 lowermost fibres of the ;;o??s. Prominent on the superficial aspect of 
 the medulla, between the pyramids and the lateral and restiform 
 tracts, it looks like a small almond-shaped body, which upon trans- 
 
INFERIOR AND ACCESSORY OLIVARY BODIES. 15 
 
 verse section reveals a grey nucleus, imhedchd in a mcdullatcd invest- 
 ment oilo7igitudinal Ghres — the so-called fillet or olivary fasciculus. 
 The grey nucleus is in the form of a plicated capsule of many folds, 
 constituted of numerous cells imbedded in grey matter, and open 
 towards its inner side. The investing medulla of longitudinal fibres 
 passes inwards and forms a central core for this grey capsule, the 
 fibres of which then spread out into its various convolutionary plica- 
 tions to terminate in the cells here distributed : the remaining fibres, 
 which do not so turn inwards to the grey capsule, pass downwards 
 into the lower regions of the medulla and cord. We have already 
 alluded to the dense intertwining and connections of the cerebellar 
 arcuate fasciculi within these olivary bodies. 
 
 In the lower planes below the calamus, our sections exhibit the 
 olivary capsule open in front at its hilus, the anterior line of plica- 
 tions being shorter than the posterior : and here, bordering upon this 
 opening in the capsule, is an elongated belt of grey matter, containing 
 cells similar to those in the olivary body — this is the internal 
 accessory olive. Sections taken midway through the inferior olive 
 show us two such bodies ; the one, as before, situated in the anterior 
 column, separated from the olivary body by the root fibres of the 
 hypoglossal, and greatly segmented by the passage of a rich system of 
 arcuate fibres to the raphe : the other, in the lateral column just 
 behind the hilus, like a concave lens with its concavity towards the 
 olivary capsule — this latter is the external aCCCSSOry olive.* In 
 histological structure both resemble the larger olivary body, and by 
 Meynert they are regarded as continuous with its capsule. 
 
 The most external arcuate fasciculi entering the restiform tract come 
 to it by way of the anterior pyramid and olivary body, partly in front 
 of and partly behind (and so encircling) the former, and forming a 
 thick stratum of fibres over the external aspect of the olivary body — 
 its stratum ZOnale : and lastly, covering in like manner, the ascend- 
 ing root of the fifth nerve to end in the restiform tract. A similar 
 investment of the upper olivary body exists, as we shall see later on ; 
 this in the lower mammals is uncovered by the fibres of the pons, 
 which do not conceal them, as in man, and constitute the so-called 
 corpus trapezoides. The zonular layer passing over the anterior 
 aspect of the anterior pyramids is aptly referred to by Meynert as 
 a small anterior po7is. 
 
 This inferior half of the medulla, with which we have for the present 
 concerned ourselves, contains the nucleus of origin and emergent root 
 fibres of but one purely motor nerve — the h7/poglossal — but of four of 
 
 * These bodies are also known as the "external and internal parolivary 
 bodies." 
 
16 THE MEDULLA OBLONGATA. 
 
 tho mixed lateral system, viz., the spinal-accessor)/, vagus, glo88o- 
 pharijHijeal, and (the ascending root of) the trifacial or fifth. At the 
 anterior mesial prominence of grey matter in these planes, we find the 
 nuclei of the hypo(jlot<><((l, which, prior to the opening up of the central 
 canal, are arranged in a double cluster usually termed the internal 
 and external convolute of the hypoglossal, owing to the loop-like 
 arrangement of the centric and peripheric fibres connected with 
 them. The external also lies at a posterior plane to the internal. 
 The cells are large and uiulticaudate, forming the most conspicuous 
 cell-groupings in the whole sectional area of the medulla : they 
 measure 60 il x 20 //-. The centric connections of these nuclei 
 consist of certain straight fibres of the median raphe, which run back- 
 wards as far as the central grey matter, and then arching outwards, 
 form spirals around the front and outer border of each nucleus, and 
 are connected with its large cells : thence, similarly curving around 
 the inner border to pass obliquely outwards, are the peripheric fasciculi 
 — the rootfihres of the hyporjlossal. These emerge from between the 
 pyramid and the olivary body, some fasciculi traversing the latter in 
 their course. In vertical extent this centre of origin stretches from 
 just above the level of the decussation of the pyramids to the strioz 
 viedullares of the acoustic nerve ; but, as we distance the calamus, 
 the groups become less definite and merged into a less characteristic 
 form, far less rich in cells. Thi-oughout the wliole of this extent, the 
 vertical column of cells gives origin to emergent radicles, which issue 
 anteriorly. 
 
 External to the hypoglossal nuclei lie the lateral projections of 
 the central grey matter, in the angle of which we find the sensory 
 nuclei of origin of the mixed lateral system of nerves, so named from 
 their possessing both motor and sensory filaments. Some seven roots 
 of origin are enumerated by Meynert for this system of nerves ; and it 
 is probable that the three nerves of this system in the lower half of 
 the medulla ai'ise in a very similar, if not identical, manner from 
 closely associated nuclei, some of which are common to two nerves. 
 The two more important nuclei of origin for this system are — the 
 motor nucleus of the mixed nerves, and the sensory already alluded to. 
 
 The motor nuclei are found in advance of the central grey substance, 
 disposed in the lateral columns of the medulla. A somewhat 
 elongated cluster of large nerve cells, from which motor fiisciculi 
 emerge and run backwards pai-allel to the emergent root fibres of 
 this system of ner^•es, is the more important of this mode of origin ; 
 but, fibres running in the same direction can also be traced further 
 outwards, to the nucleus of the lateral column, between the ascending 
 root of the .fifth and the inferior oli\ary body. Much discrepancy 
 
SPINAL ACCESSORY, VAGUS, GLOSSO-PIIAUYXGEAL. 17 
 
 appears with respect to the descriptions given to these anterior roots 
 of origin of the mixed lateral system ; some autliorities .speak of an 
 anterior and posterior nucleus of the lateral column ; others describe 
 these fibres as being doubtfully roots of the system ; whilst others 
 with Meynert refer to one nuclear column of origin distinct from the 
 nuclei of the lateral column. In fact, Meynert traces this motor 
 nucleus as a nucleus of the spinal accessory downwards to the lateral 
 process of the anterior horn, and finds its analogue on higher levels 
 
 in the inferioF facial and motor nucleus of the trigeminal.* 
 
 Our own view of the case would be in accordance with that of 
 Meynert ; in addition to which, however, we would assign to the 
 external nucleus of the lateral colitmn a partial site of origin for these 
 motor rootlets. The important fact for the student to bear in mind 
 is that these motor nuclei are, in accordance with the spinal cornual 
 scheme, in advance of the sensory division, and reach the main roots 
 by I'ecurrent fascicvili curving round the vagus nucleus from the 
 inner to the outer side ; and this type is repeated for the motor roots 
 of the facial and trigeminal nerves. 
 
 The sensory nucleus or posterior nucleus for these three mixed 
 nerves is a somewhat compact formation of nerve cells, clustered 
 within the lateral angle of the central grey substance at the lower 
 planes of this region, where it forms the vago-accessory nucleus. 
 A little difficulty may be experienced in distinguishing between the 
 nucleus of origin for the three nerves, if we do not attend to the fact 
 that so long as arcuate fibres are seen distributed to the solitary 
 funiculus from the raphe, we are in the region of origin of the spinal 
 accessory and beloio the vagal nucleus ; the latter centre can also be 
 difierentiated into two groups, an external and internal nucleus, 
 described by Lockhart Clarke, a similar arrangement prevailing for 
 the glosso-pharyngeal centres. From the apex of this grey prominence, 
 which represents a sensory column of origin for these nerves, pass 
 outwards tlie main root fibres — the spinal accessory between tlie 
 olivary bodies and gelatinous substance ; the vagus and glosso-pharyn- 
 geal through the latter, and traversing in their course the ascending 
 roots of the fifth nerve ere they emerge at the surface. Immediately 
 outside the origin of this root, at the posterior or sensory nuclei, is 
 the conspicuous cross-section of the solitary fasciculus, which 
 really represents an ascending" rOOt for the same mixed lateral 
 system. We have seen that a dense arcuate system passes into it from 
 the median raphe (centric fibres) below the origin of the vagus ; we 
 may also just as readily trace fibres issuing from this ascending root to 
 join the emergent roots of the accessory, vagus, and glosso-pharyngeal 
 
 * PsycMalry, translated by Sachs, part i., p. 124. 
 
18 
 
 THE PON'S VAKOLII. 
 
 nerves. The posterior sensory nucleus is regarded by Dr. Ross as 
 the representative of the vesicular COlumns Of Clarke in the 
 spinal cord from their relative position, connections, character of 
 the*cells, and their distribution. 
 
 A fourth root easily traced in the region of the vagus, is one 
 
 /'anlicuiu 
 Corinis j 
 quiulri- -. 
 geiniuuin (^posticum 
 
 Locus coerule«3 - 
 
 Eiuinentia tere: 
 
 CruK cerebelli 
 
 ad pontem 
 
 or 
 
 MLMle cerebellar 
 
 peduncle. 
 
 Con&rium or pineal gland. 
 
 Urachlum coDJunctivum auacuin. 
 
 Bracliium coEjunctlv 
 posticum. 
 
 Corpus geiiiculatum 
 uedialt^ 
 
 Pedunculus cerebri. 
 
 ad corpora quadri-^ 
 pctnina. or 1 
 
 \ superior ciTCbellar 1 
 
 il pedunclt. \ 
 
 ad mcduUam oblon 
 
 fatam, or interior 
 
 cerebellar 
 
 peduacle. 
 
 J' 
 
 Ala cinerca 
 Acc^ssorius nucleus 
 
 Funiculus cuneatus 
 (Part of rcsliform body). 
 
 Funiculus cracUis 
 (I'ORtorior iivr.imid). 
 
 Fig. 4. — Medulla oblongata and pons with neighbouring structures seen from behind : 
 schematic reiireseutation of the nuclei of origin of the several cranial nerves. 
 
 which, emerging from the raphe, traverses the front of the hypoglossal 
 nucleus, and, following the curve of the grey substance anteriorly, 
 enters the vagus nerve. In traversing the gelatinous substance also, 
 the vagus and glosso-pharyngeus both derive fibres from the former 
 ere they issue from the medulla ; this is the fifth root of origin for 
 
ABDUCENS, FACIAL, AND ACOUSTIC NUCLEI. 19 
 
 tlies(^ nerves. Another small fasciculus has been described by Clarke 
 as passing from thc^ fasciculus tePGS into the vagUS. 
 
 The Upper Half. — Passing now to the upper Jialf of the medulla, 
 which upon its ventricular aspect is like the lower half triangular 
 in outline, its base being mapped out by the acoustic stride and its 
 lateral boundaries formed l)y the superior cerebellar peduncles, con- 
 verging to the quadrigeminal bodies, we meet first with tioo motor 
 nerves closely associated in their origin, and arising as do the motor 
 cranial nerves generally, from an anterior or median position on 
 either side of the raphe ; and one purely sensory nerve, which takes 
 its origin in accordance with the same morphological principle alluded 
 to, from a lateral and posterior plane. The two motor nerves are 
 the sixth and seventh pair, or the abducens and facial ; the sensory 
 nerve is the eighth, the aCOUStlC or audltory. The nuclei of origin 
 for these three nerves do not occupy the same vertical plane ; that 
 for the sixth is the highest, next below it comes the facial nucleus, 
 and lowest of all the acoustic nuclei — yet they each successively 
 overlap the other, the internal acoustic nucleus, as we have already 
 seen, descending also below the base of the arbitrary triangular space 
 drawn by the strise medullares. As in the lotmr triangular area of 
 the grey floor below the striae, we found the nuclei of a motor 
 (XII) and three mixed nerves (IX, X, XI) associated through a 
 great part of their extent with the accessory body — the inferior 
 olivary ; so in this upper triangular division we find a very similarly 
 constituted structure — the superior olivary body — occupying a 
 vertical plane corresponding very nearly to that of the two motor 
 nerves — the sixth and seventh. 
 
 Transverse sections across the levels of emergence of these latter 
 nerves exhibit a notable change in the distribution of the various 
 structures in front ; the inferior olivary bodies have disappeared ; the 
 pyramids still maintaining their integrity as independent, compact 
 columns, are now concealed beneath the most anterior fibres of the 
 middle cerebellar peduncle {^wns), which enclose them between their 
 transversely disposed fasciculi, as a more superficial and a deep 
 series of fibres ; whilst laterally the brachia of the pons diverge 
 to the cerebellum, and further back the restiform and internal 
 divisions of the inferior cerebellar peduncles in like manner pass 
 to their distribution. On a level with the stride medullares an in- 
 termediate transitional stage is apparent ; and, as we pass to higher 
 planes, the inferior olivary body loses its outward inclination, its 
 long axis becoming disposed antero-posteriorly and immediately be- 
 hind the two pyramids. Thus a lateral constriction occurs which 
 gives the medulla here from before backwards an apparent but not 
 
20 THIC PONS VAROLII. 
 
 absolute incrcasrcl dcptli. This antero-postorior dopth appears still 
 more exaggerated by the lower loops of the pons capping the pyramids 
 in front, mIucIi have just been caught at this plane and divided. 
 In such sections the nucleus of the lateral column is still well seen 
 between the diminished olivary body and the ascending root of the 
 jxj'th nerve, whilst immediately jDosterior to the inferior olives is a 
 group of large fusiform and multicaudate cells, the former in connec- 
 tion with the arcuate system here, the latter in apparent connection 
 with fasciculi which pass backwards to the median or motOP 
 
 column of grey matter. 
 
 Still somewhat higher, the inferior olive ceases, or may present 
 its upper extremity as a single minute plication ; and, in this region, 
 we find the nucleus of the lateral column compressed into a long 
 narrow tract by the interposition between it and the ascending root 
 of thefiftlt, nerve of a very notable large nucleus of almost spherical 
 outline, and by the disposition of its enclosing fibres, severed appar- 
 ently into a series of convolutes of large multicaudate cells. This is 
 
 the anterior or inferior nucleus of the facial nerve, and from 
 
 it a somewhat wide belt of sparsely scattered fasciculi pass back to 
 ascend, as Ave shall see later on, as the genu of the facial nerve, 
 whilst the compressed nucleus of the lateral columns sends in- 
 distinctly marked fibres towards the median grey. The superior 
 olivaiy does not as yet present itself; in this plane we may study 
 the various nuclei of origin of the auditory nerve. Following the grey 
 matter of the floor of the ventricle outwards from the median pi-omi- 
 nence (which here is remarkably shallow), we find it progressively 
 increases in depth to its extreme lateral limits, where the lateral or 
 sensory projection is a notable feature, and the large internal 
 auditory nucleus is seen. Immediately outside this sensory nucleus is 
 the tesselated area characterising the inner division of the inferior cere- 
 bellar peduncle ; followed still further outwards by the transverse section 
 of, the crescent-like resfi/urm tract. To the inner side of the restiform 
 tract the conspicuous ascending root of the fifth nerve is applied. 
 
 The whole of the structures above noted — the grey floor Avith its 
 lateral prominence, the inner peduncular tract, and the restiform 
 column — are embraced superficially by a zonular investment of fibres 
 issuing from the region of the raphe ; in fact, the striiv medxUarcs, 
 which, reinforced further on by others emerging from the restiform 
 tract, constitute the posterior root of the auditory nerve. 
 
 On the other hand, these same structures aboA^e enumerated, are 
 embraced from loithin by the anterior auditory root, Avhich runs 
 chiefly betAveen the restiform tract and the ascending root of the 
 fifth, although many of its fasciculi traverse the structure of the. 
 
NUCLEI OF ACOUSTIC NERVE. 21 
 
 latter. The student sliould remark lioro tliat tlio fifth ascondiii'r 
 root serves always to distinguish to him the emergent roots of the 
 facial from those of the auditory ; the facial lying to the inner, and 
 the auditory to the outer side of this root. 
 
 The anterior root of the acoustic passing inwards in front of the 
 restiform column divides into the following root fasciculi : — 
 
 (a.) An inner series passing into the internal aCOUStic nucleus, 
 with the cells of which it is connected. 
 
 (5.) A median series passing in part to the cells of the external 
 acoustic nucleus (connected with the inner peduncular division) ; 
 and in part to the restiform tract. 
 
 (c.) An outer series passing into the anterior aCOUStic nucleus, 
 which is situated between the restiform tract, auditory root, and 
 
 flocculus. 
 
 The connections of the auditory nerve roots with the cerebellum 
 are to a great extent unknown. According to the belief of Meynert, 
 the divisions of the anterior root take a decussating and non-decus- 
 sating course \ the two median and the outer pass direct into the 
 cerebellum through the inferior peduncles of the same side ; whilst 
 the inner pass from the internal acoustic nucleus across the raphe 
 partly through the internal, partly through the external acoustic 
 nuclei of the opposite side, and thence up the internal division of the 
 peduncle to the cerebellum. These obliquely ascending fasciculi give 
 rise to the superficial striae on the floor of the ventricle, the so-called 
 sound-rod of Bergmann. The posterior roots empty themselves 
 partly into the restiform columns of their own side, and partly as 
 superficial and deep arcuate fibres across the raphe into the inner 
 peduncular division of the opposite side, and thence ascend to the 
 cerebellum. In this course the superficial series form the well-known 
 acoustic striae or striae meduUareS, and do not come in contact 
 with the internal acoustic nucleus ; the deep arcuate series, however, 
 traverses the nucleus of its own side, and crossing the raphe joins 
 the cells of the opposite internal acoustic nucleus ere it enters into 
 its centric expansions by the peduncular route. 
 
 At higher planes of the medulla wherein the superior olivary body 
 appears, we reach the radicular zones of the facial and the abducens. 
 The motor area of the grey floor of the ventricle at these levels presents 
 in transverse sections, two strongly defined eminences separated by 
 the median groove and raphe — these are the eminences over the facial 
 genu and the nucleus common to both facial and abducens nerve. 
 The sensory area of the grey floor flanks these eminences on either side 
 like walls, diverging from them at a somewhat obtuse angle, the 
 enclosed space being bridged over by the cerebellum. 
 
22 
 
 THE PONS VAKOLII. 
 
 On either side of the median line at the extreme posterior end of 
 the raphe, is an oval cross-section of medulla IJ mm. by ^ mm. in 
 size, sharply defined and lying between the grey matter of the lioor 
 and the hindmost series of arcuate fasciculi given off from the raphe; 
 it represents the root of the facial nerve in cross-section at its curva- 
 ture upwards, otherwise called the facial g'enu. From its neigh- 
 bourhood medullated fasciculi sweep in a wide curve, following the 
 inner margin of the grey matter as far as the sensory area, when they 
 pass forwards and outwards to their emergence from the medulla, 
 forming in this latter course tlie boundary between sensory and motor 
 divisions. In the sensory division outside this root lies, as we before 
 indicated, the ascending" trig'eminal root. The sweep of the facial 
 in its course beneath the grey floor encloses a large and important 
 nucleus, measuring 3 mm. in widest diameter, very rich in cells which 
 are multicaudate, and are disposed in an almost circular area; from 
 
 G.f. 
 
 -Section tbrousli pons ou a level with the origin of the great 
 root of the trigeminus. 
 
 F.H, Reticular formation, 
 s.o, Superior olivary body. 
 I', Lemniscus or fillet. 
 Py, Pyramids. 
 
 s.t.f, d.t.f. Superficial and deep transverse 
 fibres of the pons. 
 
 (?./, Genu of facial nerve. 
 VII, Root fibres of facial. 
 
 Vm, Motor nucleus of trigeminus. 
 
 Va, Ascending root of trigeminus. 
 
 R, Restiform tract. 
 
 M.P, Fibres of pons varolii. 
 
 p.l.b. Posterior longitudinal fasciculus. 
 
 the outer side of this nucleus emerge root fasciculi, which are distinctly 
 seen to join the facial as it sweeps forwards round the nucleus to its 
 point of emergence. 
 
 On the other hand, from the posterior and inner margin of this 
 nucleus other fibres emerge, which upon the inner side strike forwards, 
 becoming gradually more divergent from the raphe in sharply defined 
 fasciculi, to leave at the lowest border of the pons as the abducens 
 
ABDUCEXS-FACIALIS, AND UPPER OLIVARY BOUY, 23 
 
 nerve or sixth pair. Tho nucleus itself is the abducens-facialis, 
 
 also termed the pOSteriOP or SUpeHoP facial nucleus, or a;^'ain the 
 nucleus of the sixth nerve. It is placed in communication with 
 the cerebrum by means of the tibr?e rectre of the raphe, which can be 
 readily traced as the most posterior of the arcuate fibres curving first 
 around the facial genu in front, and then passing round the lower 
 hemisphere of the nucleus. Considerably in front of the abducens- 
 facialis nucleus, and in the motor division of this region, lies the 
 
 inferior or anterior facial nucleus, almost parallel with the 
 
 trigeminal root, but separated from it by the facial emergent fasciculi ; 
 its fibres pass backwards, as we have already seen, at lower levels to 
 arch beneath the abducens-facialis to its inner and posterior aspect, 
 and thence running upwards as the genu of the facial, again bend 
 around its upper border in the graceful sweep of the emergent roots. 
 
 The Superior Olivary Body. — AVe have seen that this body 
 extends from the lowest border of the 2^ons through the whole tract 
 of origin of the facial nerve, being well-exposed in cross-sections, lying 
 between the inferior facial nucleus and the emergent root fibres of 
 the sixth nerve. The transversely disposed fasciculi lying upon its 
 anterior surface, extending from the decussation at the raphe to ascend 
 in the inferior cerebellar peduncle, form the so-called COrpuS trape- 
 ZOideS which becomes exposed superficially in animals where the 
 dimensions of the pons are greatly reduced with the diminished supply 
 of fibres reaching the medulla from the crusta. The lemniscus or 
 fillet lies in these planes to the inner side of the superior olive, 
 forming the pale-stained area of truncated triangular outline next 
 the raphe, the base traversed by the most posterior fasciculi of the 
 pons and trapezoid formation. Into the fillet at higher planes, fibres 
 of the upper olive pass to be connected with the central grey of the 
 lower quadrigeminal body, the testeS ; functionally these fibres should 
 be regarded as centrifugal, since they have been found by Flechsig 
 to degenerate downivards to the superior olive, 
 
 A cerebellar connection is established between these bodies and the 
 roof nuclei (nuclei tecti) of the middle lobe of the cerebellum ; whilst 
 other fibres pass back from them also to the nucleus of the sixth and 
 of the auditory nerve, as well as to the lateral columns of the spinal 
 cord. Motor impulses, therefore, emanate from this body to the sixth 
 nerve nucleus, which being connected by decussating fibres with the 
 nucleus of the opposite motor OCUli, subserve the conjugate deviating 
 movements of the eyeballs. In like manner, motor impulses to the 
 lateral columns of the cord explain the associated movements of the 
 head to the same side. 
 
 The quadrigeminal bodies, on the other hand, Avhich are connected 
 
24 THE PONS VAROLII. 
 
 with the optic tracts, transmit stimuli tlicnce emanating, to the 
 superior olivary l)odics through the medium of the fillet, and so to the 
 oculo-motor apparatus of the sixth and third nerves. 
 
 We have ah'eady seen that the posterior columns of the cord resolve 
 themselves through the intermediation of their clavate and cuneate 
 nuclei into the restiform tract of the cerebellar peduncle. They also 
 by the anterior sensory decussation of a portion of their arcuate 
 fasciculi pass upwards on either side of the median raphe as the fillet, 
 and thence to the quadrigeminal bodies. This portion of the fillet, 
 it will be observed, is a centripetal or sensory tract, so that the 
 fillet really contains systems of ascending and descending fibres, as 
 is indicated also by the results of lesions affecting the tract. 
 
 At the level of origin of the sixth and seventh cranial nerves, the 
 central grey forming the floor of the ventricle is, as we have seen, 
 extended laterally, shallow from before backwards, and bounded on 
 either side by the restiform tracts : as we ascend to a higher plane 
 we find the superior cerebellar peduncles on each side, which, in their 
 descent, restrict the lateral extension of the ventricle and its investing 
 grey substance. This occurs in such sections as are cari'ied through 
 the emergent roots of the fifth nerve. If we now follow the ventricle 
 towards its upper angle, we find with the convergence of the superior 
 peduncles towards the quadrigeminal bodies, the following changes 
 in the disposition of the central grey : — First, the ventricle becomes 
 narrower ; the prominent lips of the grey matter become more 
 pronounced, from the increase in the thickness of this formation ; 
 and at the same time the ventricle is roofed over posteriorly by the 
 anterior medullary velum. The nuclei of the fifth pair alone 
 of all the cranial nerves characterise this plane. 
 
 Higher still, we come upon the root fibres of the fourth nerve 
 which decussate across the aqueduct posteriorly. The central 
 grey here forms two notable protruding lips on cither side of the 
 mesial line, converting the aqueduct into a Y-shaped figure. Progres- 
 sive thickening of the central grey substance occurs as we carry 
 our sections through the posterior and anterior quadrigeminal bodies ; 
 the aqueduct restricted in size is completely surrounded thereby, 
 and suff"ers minor alterations in its outline until it opens up into 
 the central cavity of the third ventricle. From the level of the 
 crossing of the fourth nerve upwards, the Y-shaped grey exhibits 
 the heak of the Y interposed between the two notable bundles of the 
 posterior long^itudinal fasciculus, behind which we may con- 
 tinuously follow an antcrlur or motor column of grey matter, containing 
 nerve cells, and externally a lateral or sensory column, such as charac- 
 terised the cranial nerve origins in the lower half of the medulla. 
 
NUCLKI AND ROOT-FIBRES OF TRIGEMINAL. 25 
 
 Betwixt these pianos and the upper roots of the facial nerve lie the 
 emergent fasciculi of the fifth nerve, which, in accordance with its 
 mixed motor and sensorial function, also assumes a lateral site of 
 origin. We will now take these upper cranial nerves seriatim. 
 
 The fifth or trigeminal has the nucleus of origin for its motor root 
 within the motor area of the pons somewhat similar in position to the 
 nuclei of the lateral division, which at lower levels sent fasciculi to 
 the mixed system of nerves— the so-called nucleus ambigUUS. It, 
 however, lies considerably behind this nucleus of the facial — the 
 anterior facial nucleus — and cannot be mistaken for it, since it does 
 not present the same convoluted structure ; and, moreover, is not in 
 the mid planes of section of the upper olive, although the upper end 
 of this structure is still seen. Its centric fibres pass to it from the 
 median raphe where they decussate. 
 
 The origin of the sensory root of this nerve is far more extensive. 
 "We have throughout the whole of the medulla folloAved up in our 
 sections the ascending" root of the trigeminal, noting how in 
 the lower planes of the medulla the vagus and glosso-pharyngeal, and 
 higher up, the facial, traversed its cross-section near their points of 
 emergence, and now find it lying between the motor nucleus and 
 the restiform tract in the sensory area of the pons, throwing forwards 
 its root fibres to emerge between the transverse fasciculi of the pons. 
 Below, this ascending root appears to end in the tubei'cle of Rolando, 
 and so would seem to haA^e a close connection with the caput COrnu 
 pOSterioris. A median root is described as originating from a 
 nucleus at the level of emergence of the sensory root, in contiguity 
 with the ascending root and the motor nucleus. On the lateral 
 margin of the central grey around the aqueduct, as high as the 
 anterior quadrigeminal body, or nates, we find the cross-section of 
 the descending root of the fifth nerve with very characteristic spherical 
 or vesicular cells lying in the central grey upon the inner side of 
 the root fasciculi. Both cells and descending fasciculi become more 
 conspicuous at lower levels, and the latter extend to the level of the 
 exit of the sensory root, where they join it to emerge from the pons. 
 Internal to this descending root is a series of deeply pigmented nerve 
 cells, forming the substantia ferruginea, which is seen through the 
 grey floor of the ventricle at the site named the loCUS COeruleus. 
 From these cells, according to Meynert, pass root fibres to the 
 opposite trigeminal root (sensory trunk), Avhich in their coui'se 
 surround and traverse the posterior longitudinal fasciculus, 
 decussate at the posterior extremity of the raphe, and thence following 
 out the anterior margin of the central grey, arch into the opposite 
 sensory root. Associated Avith these latter fibres are described others 
 
26 THE PEDUNCULAR REOION. 
 
 whicli issue from the median raphe posteriorly, and after decussation 
 terminate in the sensory root likewise. Lastly, a cerebellar roOt 
 is described by some authorities. 
 
 In the motor column of the central grey, lying immediately behind 
 the posterior longitudinal fasciculus, on either side of the median line 
 and beneath the nates, is a well-defined grouping of cells, which, 
 however, usually presents an apparent segmentation into distinct 
 clusters. These nerve cells, commencing as high up as the posterior 
 commissure, are at first somewhat scattered, but assume a more 
 compact form as they run backwards towards the upper half of the 
 testes, in which region they appear lodged in a hollow of the posterior 
 wall of the longitudinal fasciculus. This nuclear column represents 
 the origin common to the OCUlO-motor (third) and the trochlearis 
 (fourth) nerves; the upper, scattered, segmented portion is the nucleus 
 of the third more especially ; the lower compact segment lying at the 
 junction of the two quadrigeminal bodies is the nucleus of the fourth 
 nerve. Both are believed to receive their centric fibres through the 
 median raphe, those of the third nerve decussating ere they reach 
 their nucleus. 
 
 The root fibres of the third nerve emerge in a series of arched 
 fasciculi directed forwards, with their concavities, for the most part, 
 looking towards the raphe ; and in their course traverse and partially 
 encircle the red nucleus of the tegmentum, which, as we shall see 
 further on, lies on either side of the raphe above the plane of their 
 decussation. 
 
 The root fibres of the fourth nerve take a much more circuitous 
 course, running backwards instead of forwards to their point of 
 emergence ; an anomaly accounted for by Dr. Ross by the decussation 
 of the upper cerebellar peduncles which occurs in the region of the 
 testes severing the nuclear segment of the fourth from that of the 
 third nerve, and so " compelling the former to seek its destination by 
 an independent route."* Commencing at the junction of the nates 
 and testes from this compact segment, the root fibres of the fourth 
 nerve curve around the outer zone of the central grey matter to reach 
 the anteriormeduUary velum, where they bound the aqueduct posteriorly. 
 To reach this point which lies below the testes, the root fibres must 
 necessarily have traversed the full extent of the former, passing 
 obliquely backwards and downwards to the valve Of Vieussens. 
 Crossing in the substance of this valve the fibres of opposite sides 
 decussate, presenting another anomaly — since none of the other 
 cranial nerves (except the optic tracts) decussate on the distal or 
 
 * Diseases of the Nervous System, vol. ii. , p. 44. 
 
THE MESENCEPHALON. 27 
 
 peripheral side of their nuch'i of origin, but iuvarialjly ou tlidr 
 proximal or centric side, 
 
 THE MESENCEPHALON. 
 
 Upon the most casual examination of the cereLro-spinal axis, one is 
 struck forcibly by the simple arrangement and solidarity of the spinal 
 as compared with the remaining portion or upper end of this system — 
 the gradual increasing complexity of the grey and medullated tracts of 
 
 the after- and hind-brain, the so-called medulla oblong-ata and 
 
 pons, and the uniform divergence of these tracts at higher and still 
 higher levels : both gangliated masses and medullated systems alike 
 severing their alliance, and diverging on either side in correspondence 
 with the severance of the uppermost system into the two great 
 hemispheric masses. As we rise step by step from medulla to pons, 
 from pons to corpora quadrigemina, thence to the thalamic region, and 
 lastly to the corpora striata of the prosencephalon, we find the 
 grey masses becoming larger and more widely separated ; whilst the 
 medullated tracts, in like manner, diverge and empty themselves at 
 different levels into the several ganglionic masses — in all cases, pro- 
 bably, to take a fresh departure to their final destination in the 
 cerebral cortex. 
 
 Leaving for the time the more consolidated tracts of the epence- 
 phalon or hind-brain, and concentrating our attention on the 
 
 mid-brain— i.e., the corpora quadrig-emina with the crusta — 
 
 and the central grey common to the whole cerebro-spinal system, we 
 find that the crura cerebri, athwart which the quadrigeminal bodies 
 are placed, have two distinct tracts of wholly difterent destiny — the 
 tegmentum and crusta, best seen in transverse section. 
 
 The former occupies the posterior and inner region of the crura, and 
 partly empties itself into the superjacent quadrigeminal bodies, and in 
 part into the optiC thalami : whereas the latter — the crusta, lying 
 in front and to the outer side of the tegmentum — becomes more and 
 more divergent from its fellow of the opposite side as it courses 
 upwards, passes in part into the basal ganglia, and in part expands 
 into a wide-spread fan of fibres for distribution to the extensive 
 cortex of the cerebral hemispheres. Thus we observe that the medul- 
 lated tracts of the tegmentum and crusta in turn empty themselves 
 into the several ganglionic masses met with from time to time — the 
 
 quadrigeminal bodies, pineal gland, thalami optici, striate 
 
 bodies, and cortex cerebri. It is important that the student 
 understand that the termination of the fibres upwards occurs in grey 
 masses placed at different relative levels, answering to tlie position of 
 
28 THE MESENCEPHALON'. 
 
 the liind-braiii, the mid-brain, the inter-ljrain, and the fore-brain : 
 and he should gain a clear conception of each individual tract, so far 
 as at present known, to its terminus in a grey centre. To return to 
 the meSGncephalon, the hind and inner portion of the crura forms, 
 as "sve said, the tegmentum, and on this structure rest the quadri- 
 geminal bodies and thalami ; on the other hand, if we follow the crusta 
 upwards, as exposed at the base, we find that each crusta diverges 
 more and more until it meets the emljracing optiC tractS, which 
 at this part of the base define the boundary between mesencephalon 
 behind and thalamencephalon in front. At this point each crusta 
 plunges deeply into the brain, disappearing between thalamus and 
 lenticulaP nucleus, and passes up as a compressed medullated tract 
 between the basal ganglia, emerging above their level as a wide-spread 
 fan of fibres to the hemispheres. In this course, where they form a 
 divisional wall between the large ganglia, they constitute what is called 
 the internal capsule, the formation of which merits careful study. 
 
 If we imagine the crusta as seen from the base pass up unchanged 
 in direction into the internal capsule, we shall then perceive that the 
 latter would take a direction sloping obliquely upwards and outwards, 
 presenting two surfaces — a lower, looking downwards, outwards, and 
 backwards, roofing over the lenticular nucleus, and corresponding and 
 continuous with the superficial surface of the crusta as far as the pons; 
 and an upper surface, upon which the thalamus rests, corresponding to 
 the deeper portion which lies adjacent to the tegmentum. It would 
 also present two free borders — the internal or mesial, and the external 
 or posterior. In the further expansion of this belt of fibres, the inner 
 or mesial suffers displacement through the intrusion in mesial planes 
 of the head of the caudate nucleus, whereby the anterior portion 
 of the capsular fibres is thrust outwards, forming a sharp bend or 
 "knee" with the posterior division. Thus we observe that the internal 
 capsule is a stratum of fibres with a concavity looking downwards and 
 outwards, arching as a roof over the lenticular nucleus, and forming a 
 medullated bed, upon the anterior segment of which rests the caudate 
 nucleus, and upon the posterior margin of which rests the thalamus. 
 
 If now we examine these ganglionic masses from above, as seen 
 within the lateral ventricles, it is evident that the long axis of each 
 is similarly disposed — i.e., from the mesial line obliquely backwards 
 and outwards ; that the outermost of these masses, the two caudate 
 nuclei, have their large pyriform head directed anteriorly, whilst their 
 attenuated tail-like process appears pressed outwards by the narrow 
 anterior pole of the wedge-shaped thalami. In like manner the latter, 
 which have their broad extremity hindmost, are also pressed out- 
 wards behind by the intervening quadrigeminal and g-enlculate 
 
CORPORA QUADRIGEMINA AND TIIALAMI. 
 
 29 
 
 bodies. Tliese three important structures— the corpora quadri- 
 gcniina, thalami, and caudate nuclei— which represent the tlirce 
 divisions of the mesencephalon, diencephalon, and partly of the 
 
 Septum lucidum 
 Columnae fornicis 
 
 Corpus striatum 
 Stria tenuiualis. 
 Thalamus opticus. 
 
 ^lacliiuni cr-Tiiiui 
 tivum anticum. 
 Pedunculus cerebri 
 
 [" ad corpora 
 quadrige- 
 
 ad meduUam 
 oblongatain. 
 
 Cius 
 
 eeiebelli 
 
 . ad pontem. 
 
 Cornu anticum. 
 
 Caput nuclei caudatL 
 
 — Capsula interna 
 (anterior limb). 
 
 Capsula externa. 
 
 Island o{ Reil. 
 
 — ■ Nucleus lentiformis. 
 — . Cla'istrum. 
 
 — r- Capsula interna 
 K-ia (posterior limb). 
 '•'^'J Thalamus opticus. 
 
 Corpus genicula- 
 tum mediale. 
 
 Caudate nucleus 
 
 Hippocampu*. 
 
 y Calcar avia. 
 
 Funiculus gracilis. 
 
 Fig. 6.-Horizoutal section titrough liemisplieres, the right at a deeper 
 level than the left, 
 
 prosencephalon, as before indicated, rest upon and embrace the 
 tegmental and crustal divisions of the cerebral peduncle. 
 
 On the other hand, the outer division of the striate body— the 
 
30 Tin: MESENCEPHALON. 
 
 It'iitiuular nucleus — has its base directed forwards and outwards 
 parallel Avith the insula, whilst its wedge-shaped apex is directed 
 backwards and inwards towards the base — its upper surface, convex 
 from before backwards, being adapted to the concavity of the internal 
 capsule. The general relationships of the internal capsule are well 
 seen in horizontal sections carried across the hemisphere at succes- 
 sively higher levels. Kear the base it forms a quadrilateral section 
 directed from within outwards and separating the tegmentum from 
 the lenticular nucleus, having immediately behind it the locUS 
 
 nig'ep, and parallel with it in front the anterior commissure as it 
 
 passes outwards through the lenticular nucleus. It will be recalled 
 that the crust, ere it disappeared into the depths of the hemisphere at 
 the base, was bounded by the broad optic tracts : these are destined to 
 terminate in the external g'eniculate body, and at a slightly 
 higher plane these bodies appear immediately behind the extremity of 
 the internal capsule as seen in transverse section. At a higher level, 
 however, above the anterior, and through the plane of the middle 
 commissure, the anterior portion is bent outwards, forming an 
 obtuse angle or " knee," so that a horizontal section through both 
 hemispheres at this level represents both internal capsules as an 
 X-shaped figure with two anterior and two j^osterior segments (tig. 6). 
 In the lateral angle of this X the wedge of the lenticular nucleus 
 insinuates itself; between the anterior segments of the X the nuclei 
 caudati appear ; whilst the posterior segments include the optic 
 thalami. At the central junction of these limbs, we find the fornix 
 out across. 
 
 Lastly, turning our attention again to the base of the brain, Ave see 
 that the divergence of the peduncles, as they ascend, leaves between 
 them in the middle line, first, the posterior perforated space — 
 a bridge-like extension of grey substance at the angle between both 
 peduncles, perforated by numerous vessels which enter the base of the 
 thalamus at this point ; and from which white fibres emerge and 
 course round the upper margin of the pons — the taenia pontis. In 
 front of the perforated space are two rounded bodies — the corpora 
 albicantia — round which the pillars of the fornix turn ; and from 
 these bodies a thin grey lamella stretches forwards as far as the optic 
 commissure, forming the floor of the third ventricle : from its floor a 
 hollow tube — the infundibulum — descends, to which is attached the 
 
 pituitary body. 
 
 Having thus far defined the limits of crusta and internal capsule, 
 we can the more clearly appreciate the course and distribution of their 
 fibres. Since the crusta represents the continuation upwards of the 
 pyramidal tract of the cord, it must receive a considerable rein- 
 
CONDUCTIN<i TRACTS OF CRUSTA. 
 
 31 
 
 forcenieiit of fibres within the pons to account for the much larger 
 size which the crusta bears to the corresponding anterior pyramid of 
 the medulla. An examination of the pyramidal tracts and crusta in a 
 nine months' embryo gives us most valuable information respecting 
 the origin of the fibres found therein. In the pyramids the outer 
 portion of the tract consists of distinctly medullated fibres ; the inner 
 and anterior of non-medullated fibres ; and an intervening portion 
 contains a mixture of both. In the pons a similar distribution of 
 these fibres is seen: whilst higher up still in the crusta, the non- 
 medullated fibres occupy the inner third; the medullated fibres, the 
 middle third; whilst the admixture of both is found behind and 
 between the two former. This embryological dissection maps out three 
 distinct systems of fibres which have received the respective names of 
 
 (a) the fundamental or medullated; (b) the mixed system; 
 (c) the accessory or non-medullated system. 
 
 Still further outwards, occupying the outer fourth of the crusta, 
 just beyond the fundamental system, are found the fibres which 
 represent the continuation upwards to the hemispheres of the sensory 
 columns of the cord. 
 
 If we now trace these tracts upwards into the internal capsule, we 
 find that the accessory or innermost passes up along the anterior 
 segment of the capsule ; the mixed occupies in its ascent the anterior 
 third of the posterior segment, the fundamental the middle third of the 
 same segment; whilst the posterior third or outermost part of the 
 capsule is occupied by the sensory tract of the peduncles : or tabulated 
 also with reference to their distribution, thus : — 
 
 Tracts. 
 
 Accessory Tract, 
 
 Position in 
 Ckusta. 
 Inner third, 
 
 In Intkrnal 
 
 Capsule. 
 
 Anterior segment, 
 
 Mixed Tract, Behind and between 
 
 Accessory and 
 Fundamental, 
 
 Fundamental Tract, Middle third, 
 
 Outer fourth, 
 
 Posterior segment, 
 Anterior third. 
 
 Posterior segment, 
 Middle^third, 
 
 Sensory Tract, 
 
 The above table reads as follows : — The accessory tract occupies the inner third 
 
 Do., do.. 
 
 Posterior third. 
 
 Cortical Termini. 
 
 Third frontal gyrus 
 posteriorly. As- 
 cending frontal 
 and parietal gyri 
 at their lower 
 end. 
 
 Second frontal and 
 middle portion of 
 central g3'ri. 
 
 First frontal pos- 
 teriorly. Upper 
 end of central 
 gyri; paracentral 
 and parietal gyri. 
 
 Tempore - occipital 
 regions. 
 
32 Till: MESKXCKl'llALOX. 
 
 of tlie crusta, passes up the anterioi- segment of internal capsule, and terminates 
 in tlic cortex of the tliinl frontal and lower end of ascending frontal and parietal 
 gyri — and so for the remaining tiaets. 
 
 The student must bear in mind that the crust of the peduncle 
 contains a very large system of fibres, and that the tracts above 
 described by no means represent the whole series. Thus each crusta 
 includes, not alone tracts of the pyramidal fibres, but the sensory 
 tracts of the cords — fibres to the thalamus and caudate nucleus, itc. 
 The tracts we have now traced have no connection with the basal 
 ganglia : they pass between the lenticular nucleus, thalamus, and 
 caudate nucleus uninterruptedly to their cortical termini. Thus, as Ave 
 have seen, the pyramidal tract extends uninterruj^tedly between the 
 cortex of the central g'yri and their immediate neighbourhood, and 
 the motor cells of the anterior COrnua of tlie cord at different levels 
 throughout its course : and this pertains both to the motor or pyramidal 
 and to the sensory tracts. It is obvious that the body and lower 
 extremities have the least specialised movements, just as the arm and 
 hand and the muscles of articulate speech are excessively specialised; 
 and, that whereas the accessory group of fibres which supply the latter 
 chiefly have to deal with vei-y complex and specialised co-ordinations, 
 the muscles being very numerous, but relatively very small in size : the 
 fundamental group which sujDply the large muscles of the limbs, and 
 especially of the lower extremity, have to deal with simple massive 
 movements, the musculature being correspondingly bulky and less 
 specialised. We see, therefore, that the accessoiy group, arising from 
 the cortex at the lower end of the central gyri, pass chiefly to the 
 spinal levels of the face, mouth, and hands, whilst the greater bulk of 
 the fundamental group arising at the upper end of the centi'al gyri 
 extend as far as the lumbar enlargement for the musculature of the 
 legs. Hence the former constitute comparatively sliort loops, and 
 supply many tliougli small muscles ; the latter constitute very lengthy 
 loops, and supply the largest muscles of the frame. The latter 
 originate in the largest nerve cells discoverable, the former or 
 accessory in cells of greatly reduced dimensions. The fibres of the 
 sensory columns of the cord, according to Meynert, undergo a decussa- 
 tion upon a level with the decussation of the crossed jDyramidal fibres 
 by arching forwards around the central grey column, and after decus- 
 sation passing up on the outer side of the anterior pyramid to the 
 hinder third of the internal capsule, Avhen they suddenly turn back, 
 and are distributed to the occipital and temporo-sphenoidal lobes. 
 As before stated, they have no connection with tlie thalamus or 
 lenticular nucleus. So far for the direct sensory and motor fasciculi 
 of the crusta and internal capsule. The internal capsule, however. 
 
CONSTITUTION OF INTERNAL CAPSULE. 33 
 
 includes several otliei' systems of fibres, of which the following are the 
 more readily followed out : — 
 
 (rt.) Fibres to the cortex from the outer surface of the optic 
 
 thalamus. 
 (b.) Fibres to the cortex from the outer surface of the caudate 
 
 nucleus, 
 (c.) Fibres to the cortex from the upper and inner surface of 
 
 lenticular nucleus. (Denied by Wernicke.) 
 
 (a.) Thalamic radial fibres given off from the whole length of the 
 outer surface of the thalamus radiate forwards, outwards, and back- 
 Avards ; the anterior radiations towards the frontal lobe ; the median, 
 outwards to the parietal ; and the posterior, arching backwards and 
 upwards to the occipital lobe. The latter or posterior is a very 
 important formation, and is separately distinguished as the radia- 
 tions of Gpatiolet : it serves as the means whereby the several 
 roots of the optic nerve, which terminate in the quadrigeminal, 
 geniculate bodies, and thalamus are connected with the OCCipital 
 cortex. These optic radiations pass through the posterior third of 
 the internal capsule, and are consequently brought in close relation- 
 ship to the sensory peduncular tract already described as 
 occupying this position. 
 
 (6.) In like manner, fibres radiate from the outer surface of the 
 caudate nucleus to reach the cortex in planes internal to and above 
 those of the thalamus. 
 
 (c.) Fibres arise from the upper and inner surface of the lenticular 
 nucleus to interlace with the fibres of the internal capsule. 
 
 (d.) A system of fibres has been assumed by Flechsig to pass con- 
 tinuously through the red nucleus of the tegmentum and thalamus 
 into the internal capsule, to be distributed along with the fibres of the 
 pyramidal tract to the region of the Rolandic fissure. By this 
 means a crossed connection would be established between the central 
 
 gyri and the cerebellum. 
 
 (e.) Fil)res from the olfactory bulb, after decussation in the 
 anterior commissure, are also believed by Meynert to join the optic 
 radiations of Gratiolet, to be distributed to the occipital and temporo- 
 sphenoidal cortex. 
 
 We have seen how those peduncular fibres forming the crusta 
 diverge and enter the hemisphere as the internal capsule, supporting 
 upon its upper surface the caudate nucleus and thalamus, and receiv- 
 ing into its concavity below the wedge-shaped mass of the lenticular 
 nucleus, whose apex contributes a mass of fibres to the formation of 
 the crusta. If we now imac;ine a lamella of fibres spread over the 
 
 3 
 
34 THE MESENCKPIIALON. 
 
 broad base or outer aspect of this wedge to pass downwards beneath 
 the lenticular nuck'us towards its apex, and there meeting the crusta, 
 whose fibres it crosses transversely to its inner side : we have an 
 arrangement which, from the insula and temporal regions of the brain, 
 passes to the base, as a sort of sling-like loop supporting these 
 ganglionic masses, and binding them and the peduncles together. 
 Such an arrangement is represented by the external capsule and its 
 continuation at the base, where it is termed the ansa peduncularis 
 of Gratiolet or SUlDStantia innominata of Pail ; and a portion of 
 which crossing the crusta to its inner side is named the COUar, 
 fillet, or loop of the CPUS. 
 
 This important formation of the ansa peduncularis consists of four 
 systems of fibres, according to the statement of Meynert. They 
 arise from the under surface of the lenticular nucleus, from a ganglion 
 lying in this position, and Irom the cortex of the sylvian fissure, 
 upper and temporal margin of the insula. The capsular portion of 
 the ansa has no organic connection with the base of the lenticu- 
 lar wedge over which it spreads, so that it can be readily separated, 
 and the latter enucleated by the handle of the scalpel. Its fibres, 
 which arise from the cortex of the insula and upper margin of 
 the sylvian fissure, necessarily pass to it through the claustral 
 formation ; and then, forming the compact lamella of the external 
 capsule, converge to the fasciculi at the base of the lenticular nucleus, 
 which we referred to as the ansa. At this point it is crossed 
 superficially by the anterior commissure, which has to be removed to 
 expose it in its entirety. The deepest layer of the ansa peduncularis 
 takes its origin from fibres issuing at the base of the lenticular nuchnis 
 — from those concentric lamella;, the laminae medullares. The 
 fasciculus completely crosses the crusta parallel to, and immediately 
 in front of, the optic tracts, and passing to the inner or median 
 border of the crusta, forms the innermost series of fibres, here destined 
 to pass back along the raph§ to the central grey sul)stance, where 
 they terminate after decussation in the nucleus of Origfin of the 
 oculo-motor and trochlear nerves within the nates. The second 
 layer originating in fibres from the cortex of the upper margin of the 
 sylvian fissure, the temporal lobe and the cortex of the insula, is 
 interrupted in an elongated ganglion at the base of the lenticular 
 nucleus. From this ganglion fresh fibres proceed at first parallel to 
 the course of the rest of the ansa, but then suddenly bending back- 
 wards and upwards, pursue their further course just within the grey 
 substance of the third ventricle, forming the well-marked bundle of 
 
 medullated fibres known as the posterior longitudinal fasciculus, 
 
 which may possibly be traced down into the spinal cord as the most 
 
AXSA PEDUNCULARIS. 
 
 35 
 
 posterior of the fibres of the anterior column in front of th(j grey 
 comuiissure of the coi'd. 
 
 The third layer of the ansa arises from the sylvian foSSa and 
 the cortex of the temporal lobe, runs parallel to the above-mentioned 
 fasciculi at the base of the lenticular nucleus ; and then turning 
 upwards into the thalamus, forms a brush-like radiation of its fibres 
 far back into the interior, constituting the so-called inferior peduncle 
 of the thalamus. A fourth layer of the ansa which overlies the 
 latter joins the stratum ZOnale, or capsular investment of the 
 thalamus. This substantial belt of the ansa firmly binds together 
 the region of the operculum and island to the central structures at 
 the base of the brain, forming a complete sling around the lenticular 
 wedge, consisting of a series of loops, the deepest of which connects 
 the base of the lenticular body to the motor nuclei in front of the 
 aqueduct ; the others having a more lengthened course from the 
 cortex to the anterior column of the spinal cord, or blending in- 
 timately with the structures of the optic thalamus and its capsular 
 investment. We may tabulate the fibres of the ansa as follows : — 
 
 Ansa Peduncularis (Gratiolet) or Substantia Ixnomixata (ReU). 
 
 Layers. Origin. Destination. 
 
 First or deepest, and ex- Laminfe medullares of Motor nuclei of third and 
 
 tending furthest back. lenticular nucleus. 
 
 trochlear. 
 
 Second or middle layer,* Ganglion of loop ; con- As posterior longitudinal fas- 
 
 extending furtherback 
 than third and fourth 
 layers. 
 
 nected centrally with 
 
 cortex of operculum, 
 
 insula, and temporal 
 lobe. 
 
 ciculus down the anterior 
 columns of spinal cord. 
 
 Third, more superficial Sylvian fossa, temporal As inferior peduncle of optic 
 and anterior. lobe. thalamus ; passes to pos- 
 
 terior commissure. 
 
 Fourth, most superficial Cortex of temporal lobe. Stratum zonale of optic thala- 
 and anterior. mus, bounds and unites 
 
 with ganglion of Habenula 
 and passes on to posterior 
 commissure. 
 
 Dissection. — Place the brain with the base uppermost, having carefull}' 
 removed the membranes and the lai'ge vessels. Remove with tlie blade a sliallow 
 horizontal slice from one of tlie temporo-sphenoidal lobes so as to pa^s through the 
 hook of the uncinate gyrus ; this lays bare the section of the pes hippo- 
 campi, and the amygdaloid nucleus. Pass the handle of tlie scalpel 
 
 * Greyish in colour and softer than the rest. 
 
3G THE MESENCEPHALON, 
 
 vertically tlirough tlie medullary stranils outside the pes — it enters the extremity 
 of the descending liorn of the lateral ventricle. Carry an incision along tlie 
 floor in a somewhat curved direction, backwards and outwards, along the whole 
 length of the occipito-temporal gyri. This exposes the descending cornu throughout 
 its extent, and the worm-like GOrnU ammonis is seen descending from above 
 to terminate at the pes. The tail of the caudate and lenticular nuclei are 
 now seen along the roof of the cornu, and a white, glistenin:.', narrow Ijand of 
 
 fibres curves downwards towards the amyg'dala— the tsenia semicirculapis. 
 
 Upon raising up the inner border of the uncinate gyrus, we expose the optic tracts 
 arching backwards over the crusta, and terminating in the two elevations of 
 the corpora geniculata, externa and interna, beyond which the pulvinaP of 
 the thalamus projects. In front of the optic tracts the crusta has dis- 
 appeared in the depths of the hemisphere, and we see here the triangular floor 
 of the anterior perforated space bounded by the delicate white roots of the 
 olfactory nerves. Drawing the optic nerves backwards we expose the delicate, 
 almost translucent grey lamina forming the floor of the fifth ventricle, bounded 
 by the two white peduncles of the COPpUS callOSUm, which at this juncture 
 probably tears across, revealing a broad white fasciculus, the antCPiOP COmmis- 
 SUPe, crossing from one to the other hemispliere. 
 
 Upon gently drawing apart the divergent crura cerebri in front, 
 a dark line is apparent, running the whole length of its mesial 
 aspect at a greater depth than the innermost fasciculi of the crusta. 
 This, upon dividing the crura, is seen to he the inner margin of a 
 dark pigmented body, of lenticular section, the Substantia nig'Pa 
 of Soemmering, which forms a distinct boundary wall betwixt the 
 crusta in front and the tegmentum behind : it extends from the 
 level of the corpora albicantia as far as the upper border of the 
 pons. We shall refer more minutely to its relationships when 
 studying transverse sections of this region. Immediately behind 
 lie the tegmentum and the large ganglia of the mid-lirain or quadri- 
 geminal bodies. 
 
 We can best study this posterior division of the mesencephalon 
 by first examining the external configuration and connections of 
 these ganglia, and subsequently following the course of their fibres, 
 and next by studying the relative position of the fasciculi as seen 
 in transverse section at different levels. If now we so separate 
 the occipital lobes of the hemispheres as to expose these bodies to 
 view from above, they appear in a mid position between the two 
 divergent cushions of the thalamus, overriding the cerebral peduncles 
 in the form of two pairs of tubercles — an upper and a lower, 
 each oval in form, the upper pair the larger and darker in colour, 
 both having their long axis disposed transversely. Both pairs of 
 tubercles extend upwards and forwards an arm, which is really a 
 connection for the cerebral cortex, and spreads upwards as COPOnal 
 radiations : each pair in like manner sends downwards a medullated 
 
LEMNISCUS OR FILLET AND AQUEDUCT. 37 
 
 lamella on either side of the crus cerebri — that from the nates bein" 
 
 O 
 
 deeper-placed and overlaid by that from the testes; this downward 
 extension is called the fillet of the quadrigeminal bodies, or the 
 lemniscus. We shall trace the arms or brachia and the lemniscus 
 at a subsequent stage of our examination. 
 
 Between the nates, at the upper end of their median raphe, lies 
 the COnaPium or pineal body (fig. 4), with its long delicate 
 brachia extending forwards, and bounding the white ventricular 
 surface of the thalamus above, from the median grey walls of the 
 third ventricle. Beneath and in front of the pineal body is the 
 posterior commissure, under which we observe the opening of 
 the aqueductus sylvii into the third ventricle. Hence the 
 quadrigeminal bodies lie immediately over the continuation of the 
 central grey substance of the ventricles surrounding the aqueduct, 
 which would be, therefore, laid open by a vertical incision carried 
 through the median raphe of the quadrigeminal bodies. Moreover, 
 the descending ribands called the upper and lower lemniscus are, in 
 their descent, closely approximated to the outer wall of the central 
 grey substance, which is, therefore, as it were, very largely embraced 
 by the quadrigeminal system. 
 
 Just external to the central grey substance are the various 
 structures entering into the formation of the tegmentum, extending 
 as far forwards as the substantia nigra. If the peduncular fibres 
 of the crusta exposed on one side of the pons, upon removal of 
 the superficial layers of the middle peduncle, be divided, raised, 
 and the deeper transverse fibres be dealt with in like manner, 
 we come down upon the most anterior layers of the tegmentum, 
 and these, when traced, are found to be the fibres of the lemniscus, 
 which winds round from behind, and insinuating itself beneath 
 the overlapping crusta, passes in a compact belt extending even 
 as far as the median raphe of the p)ons (fig. 5, F). In its further 
 course it is traced downwards as the most external zone of 
 the lateral columns of the spinal cord in front of the direct Cere- 
 bellar column. Whilst the lemniscus in this part of its course 
 gradually ezicloses the several other tegmental structures, including 
 the red nucleus, the fibres given ofi" from the latter after decussating 
 at the median raphe pass to the outer side of the tegment in its 
 further course, and eventually escape from the embrace of the 
 lemniscus about the level of the upper ti'ansverse fibres of the pons, 
 and, becoming superficial, pass downwards to the cerebellum as its 
 superior peduncles. We must now follow the fasciculi of the mesen- 
 cephalon in transverse sections taken across the upper and lower 
 pairs of quadrigeminal bodies. 
 
38 THE MESENCEPIIALOX. 
 
 Ill such sections passing througli the region of the nates, five 
 structures which demand examination are exposed to view ; these 
 are in order from behind forwards — (1) The nates; (2) the central 
 grey substance ; (3) the tegmentum ; (4) the substantia nigra ; (5) 
 the crusta. 
 
 (1) The Nates (Superior Bigeminal Body). — The ganglionic struc- 
 ture presents four distinct strata — (a.) Outer grey or cortical layer of 
 Forel. {b.) Longitudinal fasciculi from the external geniculate body, 
 (c.) Bundles of fasciculi passing outwards on all sides from the central 
 grey substance in delicate radiations into the substance of the ganglion. 
 (d.) The stratum of the lemniscus, embracing the grey substance, and 
 through which the radiating fibres last named have to pass outwards. 
 To appreciate correctly the structure of these ganglia, we must imagine 
 a coronal fan of fibres from the cerebral cortex converginsr in the 
 direction of the external geniculate bodies into the substance of the 
 cortical layer of the nates ; passing back to the median raphe behind 
 the aqueduct, and decussating here with a similar fasciculus from the 
 opposite hemisphere ; thence arching around the central grey as the 
 lemniscus already described. The coronal fasciculus constitutes the 
 SUperiOP brachium of the nates ; and, 2^'i"i'0r to the decussation, it 
 terminates in the ganglionic cells of the nates. From these cells arise 
 the fibres which decussate, and pass as the lemniscus downwards into 
 the spinal cord. We have, therefore, the two ganglia of the nates, 
 so to speak, enclosed between the upper and lower arms of a decus- 
 sating medulla, with an internode of ganglionic cells on the centric 
 side of the decussation; and the lower arms or stratum lemnisci 
 enclosing in like manner the central grey, and supporting as a girdle 
 the mass of tegmentum lying in front of the latter. The upper arm 
 or brachium passes in part direct to the cortex beneath the pulvinar 
 of the thalamus, and thence through the posterior division of the 
 internal capsule ; and in part, passes into the external geniculate 
 body behind and covering the former. This decussating system of 
 medulla extends downwards, presenting a similar formation for the 
 testes as for the xipper bigeminal body (nates). Here also we have 
 
 an inferior brachium of the testes, and an inferior lemniscus 
 
 given off to the medulla and cord. As we shall see later on, an 
 almost exact counterpart of this medullary system carried forwards 
 explains the formation of the posterior commissure of the third 
 ventricle. 
 
 Both geniculate bodies receive coronal radiations, both transmit 
 fibres through the brachia to the corresponding quadrigeminal body, 
 and the external geniculate is intimately connected with the optic 
 tract as the latter passes to the nates by the medium of the upper 
 
KED NUCLEUS OP TEGMENTUM. 39 
 
 bracliium ; whilst the inferior brachium and licncc tlie testes have 
 likewise a connection with the inner side of the tract. Hence the 
 nates and testes arc brought into relationship with the cortex of the 
 occipital and temporal lobes, as well as with the retina. The radiating 
 fibres spreading from the central grey substance in the nates through 
 the lemniscus, are probably direct connections between the nerve cells 
 of the nates and the nuclei of the oculo-motor nerves within the 
 central grey area. In the region of the nates also we observe in 
 cross-sections numerous fasciculi lying between the antero-lateral 
 margin of the grey substance and the lemniscus ; they pass inwards 
 between the red nucleus and the posterior longitudinal fasciculus and 
 decussate at the raphe — their destination being obscure. By Meynert 
 they are supposed to be connected with the nucleus of the descending 
 root of the fifth nerve. 
 
 Red Nucleus of Teg"mentum and Upper Cerebellar Ped- 
 uncle. — When describing the structure of the thalamus we shall find, 
 as an important constituent, a rounded nuclear mass named the red 
 nucleus, which, upon the one hand, receives coronal radiations, and, 
 on the other hand, gives off medullary fasciculi extending downwards 
 through the quadrigeminal region, where they decussate at the median 
 raphe to terminate as the superior peduncles of the cerebellum. The 
 nucleus itself, consisting of much grey matter enclosing large and small 
 nerve cells, is continued into the region of the nates, below which its 
 grey matter disappears, and white medullary fasciculi with interspersed 
 nerve cells are alone continued downwards to the points of decussation. 
 In the upper sectional planes (transverse) of the mesencephalon, we 
 see this red nucleus of almost rounded contour embraced between the 
 substantia nigra and commencing lemniscus (in front and laterally) 
 and the other fasciculi of the tegment behind. At this level also the 
 arched roots of origin of the oculo-motor nerve lie on its inner side, 
 and partly traverse its structure. 
 
 In the lower planes of the mid-brain, through the testes, the 
 medullary fasciculi derived from the red nucleus, now called the 
 superior cerebellar peduncles, approach the median raphe and 
 decussate completely with the fasciculi of the opposite side. Through- 
 out this decussation the fasciculi are embraced between the loop of the 
 lemniscus in front, and the posterior longitudinal fasciculus behind. 
 From the line of decussation the fasciculi now arch outwards and 
 backwards, and still covered by the lowest fibres of the lemniscus 
 derived from the testes, emerge opposite the greatest convexity of 
 the pons to enter the cerebellum upon the same side. If we adopt 
 
 Meynert's view of the projection system, the nucleus ruber 
 
 forms an internodc or point of interruption between the coronal 
 
40 THE MESENCEPHALON. 
 
 fibres of the cerebral hemisphere and the superior peduncular fibres 
 of the opposite cerebellar hemisphere ; and, as with the first link of 
 the projection system generally, the internode occiirs on the same 
 side as the hemispheres supplying the coronal attachments. 
 
 Posterior Long"itudinal Fasciculus.— A compact column of 
 
 large nerve fibres, oval, somewhat pyriform or lenticular, according 
 to the plane of section, presents itself immediately in front of the 
 central grey area, and, therefore, behind the red nucleus or its decus- 
 sating medulla — the cerebellar peduncles. This very obvious 
 column of fibres is seen as one of the most striking features of the 
 tegmentum throughout the mesencephalon and down the whole of the 
 medulla oblongata. We have already seen that this fasciculus 
 originates in a compressed ganglionic mass forming the second stratum 
 of the ansa peduncularis (Scheme, p. .35), and that its coronal origin 
 is from the cortex of the operculum, insula, and temporal lobe; it is 
 traced into the posterior fibres of the anterior columns of the spinal 
 cord. 
 
 Substantia Nig-ra of Soemmering'.— Another formation seen in 
 these transverse sections is the grey matter of Soemmering. It begins 
 near the posterior plane of the corpora albicantia, and stretches down- 
 wards to the lowest limits of the mesencephalon, terminating, there- 
 fore, where the transverse fibres of the pons appear. For the greater 
 part of its course it stretches completely across the mesencephalon in 
 an oblique direction forwards, a line which, if continued, would 
 meet that of its fellow at an acute angle. It owes its dark colour 
 to an abundance of large pigment cells. We shall, when referring to 
 the thalamus, find that in transverse vertical sections through the 
 hindmost part of the third ventricle, this grey matter lies between 
 the crusta and the red nucleus, and that a fan of coronal fibres is here 
 seen passing outwards beneath the thalamus to the cortex (^Meynert). 
 Fibres pass downwards and forwards from this grey belt into the 
 middle and inner divisions of the crusta, and hence this substance 
 forms a ganglion of origin for certain portions of the crusta of the 
 cerebral peduncles, and although resting close upon the tegment 
 behind, has no organic connection therewith. 
 
 We have thus traced the sevei-al ganglionic structures and medullary 
 fasciculi, entering into the formation of the mesencephalon, and it 
 remains but to summarise the results of the inquiry. The mid-brain 
 consists of two pairs of ganglia, tlu> quadrigerainal bodies seated upon 
 the brain stem or pedunculus cerebri, where it diverges as two 
 branches or crura, uncovered by the transverse layers of the pons, and 
 up to the point of its entrance into the base of the brain. The cerebral 
 peduncle consists of cruSta and tegument severed by the intervening 
 
RELATIONSHIPS AXD CONNECTIOXS OF TEGMENT AND CRUSTA. 41 
 
 substantia nig'ra. The nates and testes have intimate connections 
 through their hrachia with the cerebral cortex and retina ; and below, 
 through the girdle-like lemniscus with the olivary bodies, and, accord- 
 ing to Meynert, the lateral columns of the cord ; both ganglia are 
 also connected by their radiating central fibres with the oculo-motor 
 nuclei in the central grey substance continued from the ventricle. 
 In front of the ganglia and central grey substance lies the structure 
 of the tegment, Adz.: — The posterior longitudinal fasciculus; the 
 superior cerebellar peduncular fibres and its red nucleus of origin ; 
 certain fasciculi crossing the median raphe from the quadrigeminal 
 bodies ; and lastly, the layer of the lemniscus. Anterior and external 
 to the tegment, is the crusta with the substantia nigra lying behind 
 it. In the crusta we recognise the pyramidal tract as occupying the 
 inner, middle third, and the portion behind and between these areas, 
 representing respectively the accessory, fundamental, and mixed 
 tracts; whilst in the outer fourth pass the fasciculi of the sensory 
 tract. In high planes and upon the innermost fibres, the deepest 
 layer of the ansa peduncularis passes backwards to the nucleus of the 
 oculo-motor. Lastly, the substantia nigra, peculiar to this region, 
 represents a ganglion, from which the crusta in part arises, and which 
 in itself is but an internode for coronal radiations. 
 
 THE THALAMENCEPHALON. 
 
 The region of the thalamencephalon is best exposed within the lateral 
 ventricles, for the study of its superficial parts and their relations; and, 
 for this purpose, a dissection, such as shown in fig. 6, should be made, 
 in which the relative position of the mesencephalon and epencephalon 
 are equally exposed. We here see the two great ganglia, the optic 
 thalami, the pineal gland with its peduncle, the central grey substance 
 (and the commissure) of the third ventricle passing downwards 
 towards the infundibulum, and the two corpora geniculata beneath 
 the hinder extremity of the thalamus indicating the termination of 
 the optic tracts. These, then, form the chief structures constituting 
 
 the "tween-brain " or thalamencephalon. To appreciate their 
 
 mutual relationships — their centric and peripheric connections — a 
 careful study of sections carried through this region in three different 
 planes is requisite — viz., horizontal, longitudinal, and vertical-trans- 
 verse ; but a preliminary study of their more obvious external 
 conformation is necessary ere a more minute inquiry is instituted. 
 The reader should refer here to the illustration (fig. 6) given 
 on p. 29. 
 
42 TIIIC TIIALAMEXCEPIIALON. 
 
 The optic thalami are somewhat oval, wedge-shaped bodies, broadest 
 behind, where they diverge from each other so as to expose the 
 quadrigeminal bodies ; and narrowed anteriorly where they approach 
 the middle line. They are limited externally by thcj stria tePminaliS 
 (cornea), which is also the upper and outer boundary of the thalaraen- 
 cephalon — immediately external to which is the caudate nucleus and 
 its attenuated tail. In front, the thalamus presents a notable 
 prominence, the anterior tubercle ; behind, it projects back as 
 the pulvinar, and forms in the descending horn of the lateral 
 venti'icle the anterior wall or roof of the cornu. Mesially, the 
 thalami are bounded by the peduncleS of the pineal body ; and 
 the vertical median grey walls of the third ventricle do not, as might 
 be conjectured, represent the median aspect of the thalami, but must 
 be carefully distinguished therefrom. In fact, the mesial aspect of 
 these grey masses is here completely concealed beneath the grey 
 matter of the third ventricle, which is identical and continuous with 
 the central grey substance of the cerebro-spinal tube throughout its 
 length. To the thalami, however, belong the middle and posterior 
 commissures which cross the ventricle, and which are really deCUS- 
 
 sating" meduUated tracts of the thalami. 
 
 Whilst the inner face of the thalami covered by the central grey 
 substance is perpendicular, the outer presents a kind of obliquely 
 sloping roof resting upon the fasciculi of the internal capsule ; and 
 hence the vertical transverse section of the thalamus is likewise 
 somewhat wedge-shaped in configui-ation. Then, again, it must be re- 
 membered that the thalami in lower vertebrates — birds and reptiles — 
 are very evident projections on the upper surface of the peduncles not 
 included within the hemisphere at all ; and that in man, although 
 they appear thus to project within the ventricles and to be included 
 within the more extended hemisphere, they, in reality, are outside the 
 hemisphere of which the fornix constitutes the median boundary. 
 
 We have spoken of the thalamus as a somewhat wedge-shaped mass, 
 as seen in transverse vertical sections. In similar sections through 
 both thalami, they conjointly aj^pear like the transverse-section of a 
 boat, keel downwards, in which the arched side rests as on a couch 
 in the concavity of the internal capsule, whilst in the hollow of the 
 keel the thalamus is separated from the capsule by a region known 
 as the sub-thalamic region, in which a sharply-defined, biconvex, 
 lens-shaped body is situated, to which we shall refer later on as the 
 sub-thalamic body (lenticular body of Meynert, or Luys' body of 
 Forel). The anterior end of the thalamus, therefore, is placed at a 
 considerable distance from the base of the brain and the sub-thalamic 
 region — the mass of the cerebral peduncles and the intervening 
 
THE THALAMIC PEDUNCLES. 43 
 
 substantia nigra being immediately beneath it ; Avhilst tlic whole 
 extent of the central cavities of the third ventricle and its grey walls 
 continuous below with the infundiljulum and posterior pei-foi'ated 
 space, must be excluded from the true thalamic structure. 
 
 The interior of the thalamus consists of a large mass of grey matter, 
 split into layers in various directions by the medullated strands 
 passing into its structure. The grey matter encloses numerous nerve 
 cells, which are the thalamic termini for coronal radiations connecting 
 the most diverse regions of the cortex with this body, and the centres 
 of origin for fresh strands which pass down into the tegmenhtm of the 
 crus. The arrangement of medullated and grey elements is peculiar. 
 The cortical fasciculi, as they enter the thalamus, diverge within its 
 structure in brush-like fashion, forming concentric lamellte, between 
 which are intercalated the layers of grey matter with their nerve cells. 
 Since medullated fasciculi enter the thalamus from very distant 
 regions of the cortex — from the frontal, occipital, temporo-parietal gyri 
 and gyrus fornicatus- — they necessarily meet at varied angles, and 
 cross each other in their course within the ganglion : thus it is that 
 this body becomes moulded by its medullary cones into apparently 
 distinct segments — not, however, true centres or nuclei in the usual 
 acceptation of the term, since their grey substance freely intermingles 
 with that of neighbouring structures. 
 
 The cortical contribution to the medullated system of the thalamus 
 approaches that body in part at its anterior extremity by three 
 so-called peduncles — the anterior, superior, and internal (or infei'- 
 ior). These thalamic peduncles connect its structure with the frontal 
 lobe, the sylvian fossa, temporal lobe, and gyrus fornicatus respec- 
 tively. Such cortical fasciculi have necessarily a lengthened course 
 to pursue, and none more so than that from the g'yrus forni- 
 eatUS, which reaches its destination after a peculiarly complex spiral 
 course. The anterior peduncle approaches the thalamus from the 
 frontal cortex through the strands of the anterior segriient of the 
 internal capsule between lenticular and caudate nuclei, interlacing 
 here with its fibres, and eventually passing into the front end 
 of the thalamus, expands brush -like in its interior, its fibres 
 arching backwards, crossing the fibres of the inferior peduncle, and 
 passing chiefly to the outside of the latter. A portion decussates at 
 the middle and posterior commissure, whilst the rest continues directly 
 down the tegmentum. Part of its fibres help in the formation of the 
 capsule of the thalamus or so-called stratum ZOnale. The inferior 
 peduncle, already alluded to as the third layer of the ansa peduneulari?, 
 connected with the cortex of the temporal lobe, passes from beneath 
 the lenticular nucleus up into the thalamus, expanding also in brush- 
 
44 THE TIIALAMENCEPnALON. 
 
 like manner chiefly along its internal portion, and forming the inner 
 boundary of the thalamus. It also decussates at the middle and 
 posterior commissure to pass down as teymental fasciculi of the 
 crus. 
 
 Both these peduncular expansions ai'e interrupted by the nerve cells 
 in the grey intercalated layers of the thalamus ere they decussate at 
 the commissures. The superior peduncle takes a still mox-e com- 
 plicated course ; its centric connection is with the cortex of the gyrus 
 fornicatus — appearing first in the two fimbriae or posterior 
 pillars of the fornix arising from the cornu Ammouis; and ascending 
 as the body of the fornix connected by the transverse fibres of the 
 lyra upon the thalamus, it arches forwards at the front end of this 
 body, and thence passes downwards as the two descending" pillars of 
 the fornix. These latter pass back to the corpora albicantia, around 
 which they form a distinct loop, and again turn upwards as the 
 ascending" pillars or bundles of Vicq D'Azyr to terminate within 
 and around the anterior tubercle of the thalamus. Whilst forming 
 this loop around the COrpuS albicans, a portion of its fibres is 
 interrupted by nerve cells within this body, and a fasciculus starts 
 from this site and passes directly backwards into the tegmentum. 
 
 Whilst the frontal, insular, and median cortex is thus connected by 
 the thalamic peduncles to the anterior end of the ganglia, the posterior 
 or hinder half of the thalamus receives along its outer margin coronal 
 radiations from the occipital and mid-regions of the hemisphere. 
 These fasciculi radiate from the upper and outer border of the thalamus 
 to corresponding regions of the brain opposite them ; the middle 
 section spreading towaixls the mid-regions ; and the posterior arching 
 backwards towards the occipital pole. These latter, as they pass 
 outwards and backwards to the occiput, are associated wdth similar 
 radiations proceeding in like direction from the geniculate bodies and 
 the brachia of the nates and testes. This system of fibres arches 
 around the outer wall of the posterior cornu of the ventricle, and' has 
 long been known as the optic radiations of Gratiolet. In their course 
 they are brought into close association with the sensoi'y fibres of the 
 coi'd destined for the occipital and temporal lobes ; and, as we have 
 previously seen (fig. 6, S), occupying the outer fourth of the crusta. 
 This peduncular sensory tract, it must be remembered, has no con- 
 nection with the optic thalamus, but runs directly into the occipital 
 and temporal regions of the cortex. The coronal radiations which 
 enter this outer border of the thalamus, pass through its structure 
 as arched fasciculi towards the median line, i.e., across the long axis 
 of the thalamus ; the medullated tracts being intercalated by the grey 
 matter common to the whole ganglion. Upon a lower level than 
 
CORTICAL CONNECTIONS OF OPTIC THALAMUS. 45 
 
 the entrance of these cortical radiations, other medullated fasciculi 
 pass into its substance in an identical manner from the middle root 
 of the optic tract, and this double origin partially severs this hinder 
 region of the thalamus into an upper and a lower segment. In 
 both systems of fibres, hemispheric and retinal (through the optic tract), 
 union of the fibres is effected with the cells of the grey intercalated 
 layers. 
 
 It has been shown that the peduncles — anterior and inferior — 
 entering the anterior pole of the thalamus, run backwards through its 
 structure as brush-like formations to terminate in cells of the grey 
 matter ere they decussate at the commissures ; and that a larger pro- 
 portion of these fresh fasciculi do not decussate, but pass directly down- 
 wards into the tegmentum. The latter direct fasciculi, in passing into 
 the hinder half of the tegmentum, run immediately across the axis of 
 the optic and COPtical radiations just described; and necessarily 
 form apparent concentric dissepiments in these regions. These 
 laminated dissepiments form the new medullated tracts for the 
 tegmentum arising within the grey matter of the thalamus. The 
 anterior peduncle especially, passing backwards through the thalamus, 
 is not crossed by these transverse radiations, and its region is bounded 
 on the outer side by a strongly-marked medullated belt, the innermost 
 of the concentric dissepiments alluded to, and known as Burdach's 
 lamina medullaris. This well-marked boundary and absence of 
 transverse radiating fibres, maps out a kind of nucleus in this region 
 of the anterior peduncle, which is known as the centre median of 
 Luys. 
 
 On examining the thalamus from above, after opening-up the lateral 
 veiatricles, it is found that the grey matter forming the tail of the 
 caudate nucleus may, by gentle pressure with a brush, be raised away, 
 together with the stria cornea, from the subjacent parts; and, imme- 
 diately beneath it, radiating fibres in coarse fasciculi are seen passing 
 from the whole extent of the upper margin of the thalamus, either 
 directly outwards towards the parietal lobe, or arching back towai'ds 
 the occipital region. These fasciculi consequently form the outer wall 
 of the lateral ventricle in their course towards the parietal lobe. If 
 the scalpel divide these fibres across pai'allel to the direction of the 
 stria coi-nea, the blade passes directly into the internal capsule, and it 
 becomes evident that the outer obliquely-placed surface of the 
 thalamus rests upon the internal capsule as upon a couch, and gives 
 ofi" from the whole of its outer aspect medullated fibres which enter 
 into the constitution of this capsule, and then spread as coronal 
 radiations to the various districts of the cortex of the parietal and 
 temporo-sphenoidal lobes. The greater bulk of these pass deeply into 
 
46 THE TIIALAMEXCEPHALON. 
 
 the thalamus, and, as before said (p. 43), are crossed by the brush- 
 like fasciculi of the thalamic peduncles. The more superficial layer 
 first I'evealed upon raising the tail of the caudate, enters into the con- 
 stitution of the white capsular investment of the thalamus 
 
 {stratum zonale), which gives to this gaugliou its peculiar white hue 
 Avithin the ventricle, as contrasted with the greyish aspect of the 
 caudate nucleus. 
 
 The capsule of the thalamus spreads inwards as far as the peduncle 
 of the pineal gland ere it turns downwards to form part of the 
 inner investment of the thalamus ; and at this line it disappears 
 from view, and tlie grey matter of the third ventricle becomes 
 apparent. This cajDsule or stratum zonale is itself of complex 
 formation : it receives also fibres from the optic tracts, the upper- 
 most of those which join the thalamus; so also fasciculi from the 
 frontal lobe enter it by the anterior peduncle of the thalamus, and in 
 like manner the most superficial stratum of the ansa lenticularis ; 
 lastly, the gyrus fornicatus sends its contribution hy means of the 
 ascending pillar of the fornix, which in this course embraces a nodular 
 segmented portion of the thalamus at its anterior extremity, termed 
 the anterior tubercle. Hence the zonular layer or thalamic capsule 
 receives fibres from almost every region of the brain — the frontal, 
 parietal, temporo-sphenoidal, and occipital lobes, and the mesial aspect 
 or gyrus fornicatus, as well as the retina. This very extensive retinal 
 and hemispheric connection of the thalamus may be thus tabulated : — 
 
 Fasciculi from 
 
 Frontal lobe, . . . Through anterior peduncle of thalamus. 
 
 Temporo-sphenoidal lobe, , Coronal radiations and superficial layer of 
 
 ansa lenticularis. 
 Parietal and occipital lobes, . Coronal radiations along its whole outer 
 
 surface. 
 Gyrus fornicatus, . . Through pillars of fornix. 
 
 Retuia, .... Through uppermost thalamic connections 
 
 of optic tract. 
 
 The Pineal Body and its Connections. — Surmounting the upper 
 
 pair of the quadrigeminal bodies, immediately beneath the posterior 
 exti'emity of the callosal commissure and in the middle line between 
 the mesencephalon and diencephalon, lies a small, reddish, somewhat 
 conical structure — the pineal body. It is closely attached to the 
 velum interpositum, so that it is frequently torn away with the 
 membranes investing it. It is hollowed into several small sacculi, 
 which contain the gritty, earthy, and amylaceous material termed 
 acervulus cerebri : and the structure is peculiarly vascular. In 
 microscopic structure we find it consists, like other ganglionic struc- 
 
THE PINEAL BODY AND FASCICULUS RETROFLEXUS. 47 
 
 tares in the brain, of closely aggregated cells, varying considerably in 
 size from 5 /x. to 18 n,. 
 
 Its connection with the rest of the cerebrum is effected by means 
 of two processes, which are directed forwards along the inner bordei' 
 of the thalami optici, forming a boundary between the latter and the 
 grey matter of the third ventricle; and descending in front in conjunc- 
 tion with the taenia semicircularis and the pillar of the fornix : these 
 are the two peduncles of tlie pineal body or habenula. Tliese 
 peduncles are distinctly ganglionic in structure, and together Avith the 
 pineal body are probably to be regarded, as Meynert believes, as ganglia 
 of origin for the tegmentum. 
 
 The connections by medullated tracts are twofold — centric and 
 peripheric. The former, as a connection with the cerebral hemi- 
 spheres, takes place through the medium of the stratum zonale, already 
 described as investing the optic thalamus. 
 
 The latter or peripheric connection is effected by a large and 
 important fasciculus, which passes down vertically from the habenula 
 or peduncle, covered by the grey matter of the third ventricle, and 
 towards the region (at the base) of emergence of the motor oculi nerve 
 on the inner side of the converging crura. In this course it describes 
 a sigmoid bend, and near the base of the mesencephalon it lies between 
 the posterior longitudinal fasciculus, on the median aspect, and the 
 red nucleus of the tegmentum, external to it. Some of its fibres radiate 
 into the nucleus ruber (Meynert) ; but the larger proportion bend at 
 this point immediately backwards at right angles to their former course, 
 and appear to pass into the tegmental areas of the pons and medulla, 
 in conjunction with the posterior longitudinal fascicuhis. This rectan- 
 gular bend has gained for it the appellation of the faSCiCUlus retro- 
 flexUS — it is often termed the style of the peduncle of the pineal 
 body, where it passes vertically towards the red nucleus of the 
 tegmentum. 
 
 The style or fasciculus retrojlexus may be best exposed by trans- 
 verse vertical sections carried through the ganglion of the peduncle 
 just in front of the quadrigeminal bodies, but it may also be traced 
 in longitudinal vertical sections near the mesial plane of the " tiveen 
 and mid brain." In these sectional planes, however, owing to its 
 sigmoid flexure, a part only of its course can be usually seen. Thus 
 in a vertical longitudinal section of the brain of the dog, near the mesial 
 plane, we find the lower end of this fasciculus about to bend backwards 
 at right angles, and on this plane it is seen to descend in front of 
 medullated fasciculi passing downwards from the posterior commissure 
 and the emergent i"oots of the third nerve. In a section carried still 
 nearer the mesial plane, we see its course about complete, whilst a 
 
48 THE TIIALAMENCEPIIALON. 
 
 portion of both ascending und descending pillars of the fornix is revealed 
 likewise. 
 
 Posterior Commissure. — Wo have already traced the anterior 
 and inferiur peduncles of the tlialnmus as far as their decussation 
 in the posterior comniissiire, and it would seem extremely probable 
 that the fasciculus retrojlexus undergoes partial decussation through 
 the medium of this commissure also. Near the mesial line, we can 
 readily ti'ace these decussating fibres of the posterior commissure in 
 their further course passing downwards into the tegmentum, where 
 they bend backwards to pass into the medulla and spinal cord ; 
 whilst prolonged from the posterior commissure backwards is also 
 seen the cross-section of the meduUated fibres of the corpora 
 quadrigemina. 
 
 In these vertical longitudinal sections taken near the mesial plane, 
 we therefore see three systems of decussating fasciculi crossing at 
 the middle line, and forming periphei'ic extensions from a series 
 of ganglionic bodies, viz. : — The fasciculus retroflexUS, the mass 
 of the posterior commissure, :^nd the quadrigcminal fasciculi 
 
 called the lemnisci or fillets of the nates and testes. 
 
 Corpora Geniculata. — Beneath the pulviuar of the thalamus 
 in man we see a small club-shaped body about the size of a coffee- 
 bean, directly continuous with the optic tract anteriorly, and by a 
 notable border separating mesencephalon from tltalamenceplialon, con- 
 nected Avith the upper quadrigeminal body or nates. This small 
 ganglion, for ganglionic it is in nature, is the outer g'eniculate 
 body, and lies in the course of the arm of the nates or superior 
 hrachium, with which it is intimately connected, as it proceeds to the 
 cortex of the occipital lobe. Upon vertical longitudinal section it is 
 found to possess a peculiar plicated arrangement of a medullated and 
 a grey lamina, exhibiting alternating layers of grey and white 
 substance. 
 
 Internal to this body, that is, nearer the mesial plane, lies another 
 small structure of spindle-shaped outline, immediately beneath the 
 upper and between it and the lower brachium ; it is directed towards 
 the nates by one of its pointed extremities. This structure is the 
 inner g'eniculate body. Both geniculate bodies are connected with 
 the corpora quadrigemina on the one hand, and with the cortex of 
 the occipital lobe along with the other centric fasciculi of the 
 brachia. In a vertical section we find an extensive portion of 
 the optic tract directly continuous with this plicated outer geniculate 
 sanglion, and hence also with the nates. An inner segment 
 of the oi:)tic tract, but much more limited in extent, passes into 
 the internal geniculate and thence to the nates also ; no fibres 
 
CONFIGUnATION OF CEREBUAL IIEMISPIIERK.S. 4^ 
 
 from tlie optic nerve are believed to pass by this tract to the 
 testes. 
 
 The remaining connections of the optic tract arc the optic thalamus 
 (to the stratuvi zonule and radiating fasciculi previously described) ; 
 and the basal optic ganglion, a small body of grey matter lying beside 
 the tuber cinereiim immediately covered by the optic commissure. 
 The ganglia of origin of the optic nerves, therefore, are the upper 
 quadrigeminal, the outer and inner geniculate bodies, the optic 
 thalamus, and the basal optic ganglion : the centric or coronal 
 extensions arising in these ganglia pass by means of the posterior 
 section of the internal capsule as the optic radiations of Gratiolet to 
 the cortex of the occipital and ( % ) tempoi-o-sphenoidal lobes. 
 
 PROSENCEPHALON OR FORE-BRAIN. 
 
 Config'Uration. — We have already seen that divei'gence of the 
 brain-stem in the crura cerebri to reach either hemisphere, entails 
 also the more and more complete severance of the various ganglionic 
 masses at the base with which it is brought into connection : and 
 that from the bilateral fusion of the mesencephalon, we pass forward 
 to the divergent masses of the thalami (diencephalon), and thence to 
 the still further severed corpora striata, constituting the ganglia of the 
 fore-brain (prosencephalon). We have seen how these more divergent 
 masses are braced together by sling-like loops of medulla, such as 
 the ansa lenticularis, and united mesially by the anterior and other 
 commissural ti^acts. The ganglia of the prosencephalon form the most 
 anterior mass of grey matter surrounding the peduncular extensions, 
 and are so disposed as to constitute two incompletely-severed masses ot' 
 grey substance, whose configui-ation shadows forth the form assumed by 
 the hemispheric envelope moulded around them. The flexure of the 
 fore-brain, whereby this hemispheric arc reproduces the contour of 
 these ganglionic structures, has its site at the fissure of Sylvius ; and 
 in foetal brains, ere the further differentiation of the cortex into its 
 varied longitudinal and transverse fissures has proceeded, we see 
 readily how the hemispheres are, so to speak, moulded after the form 
 of their subjacent ganglia. The axis of this flexure is constituted by 
 the most external of these ganglionic masses, the so-called lenticulaP 
 nucleus, wedge-shaped in form, its base directed forwards and out- 
 wards, covered by the cortex of the insula — its apex downwards and 
 inwards towards the cms cerebri. Around this wedge-shaped axis, the 
 ganglionic and hemispheric arcs are severally formed — the ganglionic in 
 the form of the caudate nucleus : the hemispheric beginning at the 
 
50 
 
 THE PROSENCEPHALON. 
 
 orbital aspect of the frontal, sweeps round the fronto-parietal to the tip 
 of the teniporo-sphenoidal lobe. The more flattened aspect of the 
 retjion of tlie insula, therefore, bears the impress of the base of this 
 lenticular axis of revolution, whilst the more spheroidal contour of 
 the hemisphere conforms to the curvature of the caudate body. 
 
 Upon this constructive principle largely depends the divergence 
 observed in the primitive contour of the cerebrum in various animals 
 
 JV.c 
 
 Fig. 7.— Section through hemispheres (vertical transverse) through 
 plane of middle commissure. 
 
 I^.c, Tail of caudate nucleus. 
 
 C.c, Corpus callosum. 
 
 F, Fornix and choroid plexus. 
 
 a, Internal capsule. 
 
 T.o, Optic Tlialamus. 
 
 Cm, Middle Commissure. 
 C.e, External capsule. 
 CI, Claustrum. 
 
 1, 2, 3, Three segments of lenticular 
 nucleus. 
 
 and in man. Although identical in the nature of their histological 
 constituents, these two ganglionic masses differ widely, not alone in 
 their rough contour, but in their quantitative relationships : in certain 
 brains, the caudate nucleus assumes a mass far out of all proportion to 
 the lenticular ; whilst in man, the former is dwarfed, and the latter 
 assumes a relatively important role. The greater magnitude assumed 
 by this lenticular axis of revolution, the greater the scope for the 
 unfolding of the hemispheric arc, and the more important the develop- 
 mental features assumed by the regions of the insula and sylvian 
 
LKNTICULAR AND CAUDATE NUCLEI. 51 
 
 fussa. On the other hand, the smaller lenticular body, and the larger 
 proportionate development of the caudate bespeak a brain of simple 
 configuration, more spherical, less complex in convolutionary arrange- 
 ment, and of more uniform symmetry throughout. 
 
 In thus indicating their impress in the configuration of the cerebral 
 vault, these striate ganglia differ widely from the diencephalic 
 gang-lia previously considered, the thalami Optici ; in fact, these 
 latter bodies, so far from having any portion of the cerebral hemi- 
 sphere moulded to their form, are themselves wholly outside the 
 cerebi-al envelope in their mesial position. Thus, the adult brain 
 witnesses to the genetic relationship of the cerebral hemispheres, and 
 the related striate ganglia : the whole mass in front constituting the 
 
 fore-brain or prosencephalon in advance of the thalamence- 
 phalon. 
 
 We have spoken of these basal ganglia as incompletely severed 
 masses of grey matter, a statement at once verified by vertical 
 sections taken in anterior planes through these bodies. In such 
 antei'ior planes, the medullated interval elsewhere separating these 
 bodies is bridged by numerous broad bands of grey substance which 
 are but extensions from one to the other ganglion ; whilst, at the base, 
 complete fusion occurs between the two, the head of the caudate 
 nucleus merging into the frontal extension of the lenticular, becom- 
 ing so superficial at the base as to be merely covered over by the 
 orbital medulla and the grey matter of the anterior perforated space 
 with which it becomes continuous. 
 
 Caudate Nucleus. — The innermost or intraventricular nucleus of 
 the ganglion of the fore-brain, and the only portion superficially seen 
 within the lateral ventricles, is of pyriform shape, with a long 
 attenuated tail-like process extending into the temporal lobe. In 
 this coui-se, as before explained, it is bent upon itself, its axis of 
 revolution being the lenticular body. The head of the ganglion 
 fusing at the base with the lenticular, arches forwards and inwards 
 towards the septum lucidum, and lying on the inner aspect of the 
 internal capsule, embraces, in this first part of its course, an important 
 medullated fasciculus, which connects the coi'tex of the frontal lobe 
 with the antei'ior extremity of the optic thalamus, the so-called 
 anterior thalamic peduncle. In its further course, it ascends 
 above the level of the lenticular, and lies upon the internal capsule ; 
 its tail-like extension resting, opposite the thalamus, upon the hemi- 
 spheric fibres which pass beneath it, to form the capsular investment 
 of the thalamus [stratum zonule). Still further back, the tail arches 
 downwards into the descending liorn of the ventricle, and can be 
 traced upon the roof of the latter as far forwards as its anterior 
 
52 THE PROSENCEPHALON. 
 
 extremity, wliere it terminates in a somewhat bulbous end, liaving 
 immediately in front of it a mass of grey matter, termed tlie 
 amyg'dala. It will be seen from this descri])tion that the bulbous 
 extremity of the tail extends almost as far forwards as the head of tlie 
 caudate nucleus, and thus describes an almost complete loop around 
 the internal capsule and thalamus, hence termed the *' SUrcingle." 
 The -whole course of tliis loop can be well demonstrated l)y veitical 
 longitudinal sections of the hemisphere ; whilst vertical transverse 
 sections anywhere between the amygdala and posterior end of thalamus 
 reveal the ui)))er and losver segments of the surcingle, as isolated grey 
 masses above and below the thalamus. Each of these prosencephalic 
 ganglia has a surface perfectly free, that is, devoid of meduUated 
 attachments — and other aspects, -svhich present the termini of centric 
 and peripheric sti'ands. Thus, the ventricular aspect of the caudate 
 together with the base of the lenticular wedge (insular aspect) 
 are alike, smooth and devoid of medullated connections : whilst the 
 opposed surfaces, separated by the intervening capsular fibres, as well 
 as the basal or inferior aspect of the lenticular nucleus, are the 
 surfaces for the termination and departure of the numerous medul- 
 lated connections of this with distant regions. Since the lenticular 
 body lies beneath the internal capsule, its temporal extremity is 
 sepai-ated for some distance by that formation from the temporal 
 extremity or cauda of the intx'aventricular nucleus. Posteriorly, 
 however, they approach each other, and bridges of grey niatter connect 
 them, separated by medulla. They are also separated here by the 
 centric extension (brachiura) from the external geniculate body ; and 
 finally along the roof of the descending cornn these two temporal 
 extremities fuse together, forming the lower segment of the snrciiKjle. 
 
 The constitution of the surcingle, therefore, is diflerent in its upper 
 and lower arc, being purely an extension of the innermost nucleus 
 above ; but formed out of the fused tempoi-al extremities of both 
 prosencephalic nuclei below. It cannot fail to impress the student 
 that the ganglionic structures and their extensions, so far described, 
 encircle in a series of loop-like formations the medullated core which 
 passes from the spinal cord and medulla upwards as peduncles and 
 capsule to the cerebral hemispheres. 
 
 First, thei-e is the mesencephalon, the quadrigeminal bodies, each 
 throwing downwards its loop-like Jillet or leimdscns ; and throwing 
 upwards its centric arm in the form of the hrachia. At a liigher level, 
 the thalamencephalon shows us the optic thalamus astride the posterior 
 edwe of the internal capsule arching backwards around it to form the 
 roof of the descending horn of the lateral ventricle; whilst its centric 
 extensions pass upwards to the cortex from its outer surface beneath the 
 
STRIA TERMINALIS — OLFACTORY AREA. 53 
 
 tail of the caudate. Then still higher M'e get the arcof the caudate body 
 asti-ide the anterior edge of the internal capsule with its long tail-like 
 loop also passing down the roof of the descending cornu'^in'conj unction 
 with that of the lenticular : whilst still further outwards is the mass 
 of the internal capsule becoming free as coronal radiations to the 
 various parts of the hemisjihere. For descriptive purposes it is 
 convenient to distinguish between uppGP or ventPiCUlar, and 
 
 lower, cornual or temporal arc of tlie surcinfjle: tlie caudal 
 
 extremity', the body of the caudate nucleus, and its caput directed 
 towards tlie base : whilst we also s):)eab of its ventricular and 
 capsular aspects. 
 
 In like manner the lenticular nucleus has its frontal, its temporal, 
 and peduncular or crustal extremity; its insular aspect (or base of 
 wedge), its inferior aspect, its capsular aspect. So also the capsular 
 constituents may also bear the convenient terminology — COrtlCO- 
 Striate and COrtiCO-lentiCUlar fasciculi for the] centric bundles : 
 
 pedunculo-striate and pedunculo-lenticular for the peripheric 
 
 bundles : direct peduncular for those uninterrupted by the prosen- 
 cephalic ganglia. 
 
 Stria TerminaliS. — A glistening white band of fibres, strongly 
 contrasting with the adjacent grey cauda, varying from one to two 
 millimetres in diameter, lies along the inner border of the tail of the 
 caudate body throughout its whole length, extending ^from the tip of 
 the temporo-sphenoidal lobe along the roof of the descending cornu, 
 and along the upper arc of the surcingle betwixt it and the 
 thalamus, as far as the anterior end of the latter. Inferiorly it is 
 distributed to the amygdaloid nucleus ; and by Meynert is regarded 
 as ai'ising from the head of the caudate nucleus. Schwalbe, on the 
 other hand, regards this conclusion as dubious, and expresses the 
 ojoinion that it possibly has no connection whatever ^with the ganglion. 
 By other authorities — Meckel, Arnold, Jung, and Luys — this arciform 
 "band has been presumed to terminate in the descending pillar of the 
 fornix. This lengthened arciform structure, which has been also 
 called the tsenia semicircularis, would appear from its greater 
 proportionate development to be an important structure in the brain 
 of rodents ; in the dog, on the other hand, it is comparatively insigni- 
 ficant in size. In the rabbit it can be clearly seen to consist of a 
 superficial and deeper fiisciculus at its termination, and to be con- 
 nected throughout its course with the caudate nucleus : the latter 
 arches downwards behind the anterior commissure just to the inside 
 of the lower margin of the internal capsule, as seen in vertical sections: 
 these fibres appear to terminate in the area at the base known as 
 Gratiolet's olfactory area— embraced, in fact, within the trigonum 
 
54 Tin; imjosknckimialon. 
 
 olfactOPium. It would be liazardous to affirm that none of the 
 siipL'iticial fibres enter the descending pillar of the fornix, as stated by 
 several authorities ; but in the rodent it appears easily demonstrable 
 that this fasciculus, in great part at least, enters the anterior com- 
 missure from beliind in such a direction as to ensure decussation, and so 
 bring the hippocampal region and caudate nucleus into crossed relation- 
 ship with the olfactory bulb.* We shall refer to this connection 
 further on when dealing with the relationships of the anterior com- 
 missure. 
 
 Lenticular Nucleus. — Although in section both vertical and hori- 
 zontal, this ganglion exhibits a distinctly wedge-shaped contour, its 
 name of lenticular is justified upon inspection of its outer or insular 
 aspect. This can only be done by freeing it of its medullated connec- 
 tions — an opei'ation readily efi'ected either by dissection or the brush, 
 the ganglia being held beneath w-ater, whilst the medullated invest- 
 ments are dissected off or brushed away. In this manner it is easy 
 to isolate the two ganglia of the prosencephalon attached to each other, 
 for the pux-pose of recognising their fundamental configuration. 
 
 The lenticular then appeal's to be a distinctly lens-shaped body, 
 especially if looked at from above, where a section of the internal 
 capsule at the foot of the COrona radlata separates it from the 
 caudate nucleus within. It will then also be apparent that the 
 caudate applied at first to the inner side of the internal capsule and 
 lenticular mounts higher and higher so as to lie with its attenuated 
 tail U2)0n the former and above the latter. The smooth lens-shaped 
 exterior of this structure is overlaid by a medullated investment — the 
 external capsule, loosely applied to it, occasionally the site of haemor- 
 rhage, which, breaking into the intervening tract, separates it from the 
 surface of the lenticular. 
 
 External to this capsule comes the claustrum, and lastly the 
 medulla and cortex of the insula or island of Reil. Upon section 
 this ganglionic body shows a well-defined triple segmentation — dis- 
 tinguished by the grey aspect of the outer, and the increasing pallor 
 and tawny pigmented aspect of the more internal segments; the inner- 
 most and largest which is notably pale and pigmented being designated 
 the globus pallidus (fig. 7). These three divisions are not merely 
 distinguished by their diflerence in colour, but are separated by well- 
 marked dissepiments called laminae medullares, which, as thin 
 medullated partitions descend from the internal capsule down to 
 the basal aspect of the brain, lying concentrically to the insular 
 
 *See "Comparative Structure of the Brain iu Kodents," by the Author, in 
 the Philosophical Transactions, part ii., 1882, page 730. 
 
TUE BRAIN IX LOWER VERTEBRATA. 55 
 
 aspect of the gangliou : two and sometimes three such dissepiments 
 exist. The medullated fibres forming these dissepiments, and arising 
 from the internal capsule, bend inwards at diSerent points to form 
 radial fibres all directed towards tlie peduncular end of the wedge; 
 a certain proportion, however, comjjletely traverse the lenticular as 
 laminae meduUares ; and escaping at the base of the ganglion pui'sue 
 their course towards the crusta, as a sort of capsular sling, covering 
 the base of the lenticular and forming one layer of the so-called arisa 
 lenticularis already refen-ed to. Since each segment is traversed not 
 only by fibres originating in the cells of its territory, but also 
 receives those passing into it from an outer segment and its medullary 
 laminse, it follows that the narrow or peduncular end of the wedge 
 becomes constituted by a closely packed system of medullated fibres 
 where they enter the crus cerebri ; and it is this preponderance of 
 fibre over grey matter which gives to the inner segment (globus 
 pallidus) its characteristic pallor. 
 
 THE ENCEPHALON AS A WHOLE. 
 
 Comparative and Embryolog'ical.— The earliest indication of a 
 brain in the vertebrate series consists in a slight bulb-like dilatation 
 at the end of the neural tube. This is all that ever occurs in the 
 low^est form of vertebrate animals— the amphioxUS or lancelet, 
 which therefoi'e presents as a permanent structure the earliest, but 
 transitory, phase of development, through which all higher vertebrata 
 pass, even to man himself. A step higher, the lamppey exhibits a 
 large pyriform dilatation of the neural tube, and retains for a long 
 period this rudimentaiy form, which, however, in comparison with 
 its spinal system, bears to it scarcely a higher pi'oportionate size than 
 do the cephalic ganglia of insects to their ventral ganglia. 
 
 Still higher in the vertebrate series, in flshes and amphibia, we 
 find that this bulb-like distention of the neui-al axis becomes very early 
 transformed by ti'ansverse constrictions of the former elongated bulb, 
 into a series of five pairs of vesicles, which lie in linear series, one 
 behind the other, and which are reproduced in every form of verte- 
 brate, higher in the series, at a certain stage of its developmental 
 history. These five vesicles represent what in higher animals become 
 
 respectively the fore-brain or cerebrum, the twixt-brain, the 
 mid-brain, the hind-brain, and the after-brain. 
 
 These several parts in fishes and ampliibia represent elements of the 
 higher vertebrate brain, which remain ])ermaneut in them, but subject 
 to most diverse modifications in structural complexitv and in relative 
 
56 THE ENCEPIIALON — COMPARATIVE. 
 
 preponderance of one or other segment. The lully developed brain in 
 fishes presents great variety in the relative size of the individual lobes. 
 Tn the first place, the early ditl'erentiation between the vesicle of the 
 twixt-brain and mid-brain becomes obscured in most fishes, so that the 
 fully formed organ shows us but four gangliated swellings, lying one 
 behind the other in scries, and representing (1) the Cerebral hemi- 
 spheres; (2) the optic lobes; (3) the cerebellum; {i) the medulla. 
 
 The two former, as seen in the brain of the perch, are disposed 
 in pairs, whilst in front of the cerebral hemisi)hei-es we see yet 
 two small bulbous swellings, from which arise the olfoctory nei'ves, 
 and which are called, therefore, the olfactory g'ang'lia. These 
 ganglia are absent in the Shark, Skate, Whiting, Szc, and are replaced 
 by an elongated peduncle capped at the extremity by the ganglia as in 
 man. 
 
 The cerebral hemispheres in fishes are usually smaller than the 
 optic lobes, e.g., in the Whiting, Carp, Pike, Perch ; but in the Shark, 
 the Skate, the Lepidosiren, and others, they very greatly exceed these 
 lobes in their dimensions. Behind the cerebral hemispheres appear 
 the optic lobes, which in the fish, it must be remembered, represent 
 the thalamencephalon (thalamus and third ventricle) as well as the 
 mesencephalon (or in man what corresponds to the corpora quadri- 
 gemina). Thus, if we turn to the brain of the perch, we see in front 
 the two small olfactory lobes, followed by a lai'ge pair of cerebral 
 hemispheres, and these in their turn by the still larger pair of optic 
 ganglia, with a small tubercle projecting in front between them and the 
 cerebrum. This latter body is the pineal g'land, indicating the 
 neighbourhood of the thalamencephalon, with which it is connected. 
 At the base the same structures are seen in front; but the optic lobes 
 present two peculiar lobulated bodies called hypoaria or the lobl 
 inferiores, whose significance is unknown: they are peculiar to fishes. 
 From the centre pi-ojects the pituitary body, whilst the optic nerves 
 are seen to originate from the base of this ganglion, and cross (without 
 decussation of fibres) to the opposite sides. 
 
 In insects these optic lobes repx'esent the chief part of their 
 cephalic ganglia. Behind the optic lobes comes a single tongue-like 
 lobe — the cerebellum — the size of which apparently bears a direct 
 relation to the power and muscular activity of the fish. Thus the 
 rapacious shark has an enormous cerebellum, w^hilst in the more 
 sluggish fish, it is relatively small; in osseous fishes it is usually con- 
 siderably below the size of the optic lobes. The last division of the 
 brain is the medulla, lying immediately behind and beneath the 
 cerebellum, ni;i])ped oil from the spinal cord by its somewhat larger 
 size, and the origin of numerous im])oi'tant nerves. 
 
THE BRAIN IN AMPHIBIA, REPTILES, AND BIRDS. 57 
 
 In amphibia, the brain presents a smaller cereljellum than in 
 fishes, corresponding with their more toi'pid habit. 
 
 The reptilian brain difiers from that of fishes, chiefly in the 
 smaller relative size of the optic and olfactory lobes and cerebellum — 
 the latter being often a mere delicate transverse band across the upper 
 part of the medulla ; and in the relatively large size of the cerebral 
 hemispheres, which partly overlap the optic lobes and exhibit a 
 distinct striate body. The cerebellum is especially large in the 
 crocodile. The hemispheres are connected as in fishes by an anterior 
 commissure. 
 
 In birds, the cerebral hemispheres exhibit a great developmental 
 advance. They are very large, and cover more or less completely the 
 Clitic lobes. The cerebrum contains a distinct cavity, corresponding 
 to the lateral ventricles, and communicating with the hollOW 
 peduncle of a small olfactory lobe in front. From the floor is 
 developed a gangliated mass — the corpuS Striatum. The optic 
 lobes (corpora bigemina) are two smooth, rounded, egg-like bodies, just 
 apparent from beneath and behind the hemispheres ; widely separated, 
 but communicating through a hollow passage which also leads into a 
 channel between the third and fourth ventricles. From below we see 
 the optic nerves arise and distinctly decussate aci'oss the middle line. 
 The cerebellum is also of large size, but chiefly consists of the middle 
 lobe. 
 
 The germinal area of the mammalian ovum reveals at an early stage 
 the medullary g'rOOVe, as a longitudinal and gradually deepening 
 channel in the fore-part of this area — at first of uniform diameter 
 throughout, but soon becoming widest at one end — the cephalic. The 
 groove itself results from the thickening of the outer germ layer or 
 epiblast in two parallel linear streaks, corresponding in direction to 
 the long axis of the embryo. The thickening of these parallel ridges 
 proceeds until the groove thus produced is covered in by the bending 
 across and coalescence of these its walls — the so-called medullary 
 folds. Thus, the medullai-y groove becomes converted into the closed 
 canal destined to become the cerebro-spinal cavity, and now termed 
 the neural canal. At its fore end, this canal is dilated into a bulb 
 or vesicle— the primary cerebral vesicle; whilst shortly afterwards 
 two other vesicles, separated by constrictions of the neural canal, form 
 along this end of the canal immediately behind the first vesicle. These 
 three vesicles, placed one behind the other, lie in a straight line with 
 the axis of the neural canal, and are termed respectively the VCSiclCS 
 
 of the fore-brain, the mid-brain, and the hind-brain. 
 
 Vesicles of the Fore-brain. — From the first of these, a lateral 
 bulging on either side becomes soon apparent, and, steadily increasing, 
 
58 THE KNCEPIIALON — KMlJRYOLOfllCAL. 
 
 is lit last merely connected with the former by a narrow constricting 
 neck or tubular stalk. These give origin to the more important 
 structures of the eye and are termed the optiC vesicles. By an 
 exactly similar process, two other lateral bulgings from tlie fore-part 
 of the first cerebral vesicle become differentiated therefrom ; and these 
 are destined by rapid growth and development to become the most 
 important and conspicuous parts of tlie cranial contents. They form 
 
 the cerebral hemispheres <>r prosencephalon. At the second 
 
 month of intra-uterine life, they are mere insignificant AmpuUaj, of 
 somewhat oblong form; but even now presenting a short tubular 
 extension from their tip, which is the rudiment of the olfactory lobe. 
 The remaining portion of the primary vesicle in its median position 
 enters into the constitution of the parts around the third ventricle. 
 It has consequently been named the vesicle of the third ventricle, or 
 the tween-hrain, or from giving origin to the optic thalami — the 
 thalamencephalon. Hence the two pairs of vesicles, the optic and 
 hemispheric, have their genetic origin from the thalamencephalon, and 
 a direct connection between these structures is maintained during 
 all later stages of development. The cerebi-al hemispheres, as offshoots 
 from the primary cerebral vesicle, are hollow vesicles, communicating 
 with each other and Avith the cavity of their parent vesicle, the third 
 ventricle, by means of the foramen of MonrO. As the walls of the 
 hemispheric vesicle gain in thickness, its cavity becomes of course 
 more and more encroached upon ; yet, for a long period during uterine 
 life, the growth of this vesicle is so rapid tljat its cavity is of great 
 size ; this cavity forms therefore a relatively capacious ventricle — the 
 lateral ventricle. In the outer and lower wall of the hemispheres 
 thickening proceeds to the extent of forming a large ganglionic mass, 
 the corpora striata or g'ang'lla of the fore-brain. These ganglia, it 
 is to be noted, are not directly derived from the primal neural tube, 
 but from an offshoot of the latter — the hemispheric vesicle. The 
 posterior moiety of the first cerebral vesicle in like manner exhibits a 
 thickening of its walls, which form the ganglionic mass of the optic 
 thalami, connected behind by the posterior covimissure, just above which 
 a small median projection forms — the 2^ineal gland : its floor upon the 
 other hand, sends downwards a conical projection — the infundibulum, 
 
 wliich later on unites with the hypophysis cerebri or pituitary 
 
 body, immediately over the pharynx or extreme end of tlie aliuu'utary 
 canal. The funnel-shaped extension of tlie third ventricle is by some 
 regarded as the representative of the neuro-enteric canal, which 
 establishes connection directly between the cerebral and caudal 
 extremities of the alimentary canal and the central canal of the 
 cerebi'o-spinal system. The upper part or roof of the thalamen- 
 
DEVELOPMENT OF BRAIN-SEGMENTS AND FLEXURES. 59 
 
 cephalon becomes thinned out into a mere lamella of pia mater, 
 covering tlie tliird ventricle as the velum interpositum. 
 
 The second cerebral vesicle or mid-brain exhibits no such 
 
 budding off of secondary parts as does the primary vesicle; its upper 
 hemisphere becoming thickened, ultimately forms the quadrigeminal 
 bodies : its lower hemisphei-e or floor in like manner develops into the 
 crura cerebri or cerebral peduncles : whilst the central cavity thus 
 encroached upon becomes eventually reduced to an exceedingly narrow 
 channel, continuous in front with the third ventricle, and behind with 
 the hollow of the third cerebral vesicle — this channel is the sylvian 
 aqueduct or iter a tertio ad quartum ventriculum. The ganglia of the 
 mesencephalon or corpora quadrigemina are not completely differen- 
 tiated until the sixth or seventh month of inti'a-uterine life. At the 
 sixth month, a vertical groove severs the vesicle into lateral pairs ; at 
 the seventh month, a transverse groove separates the upper pair or 
 nates from tlie lower pair or testes. 
 
 The third cerebral vesicle or hind-brain becomes differentiated 
 into two segments — an upper, immediately behind the corpora quadri- 
 gemina, from which is derived the cerebellum, pons, and upper part of 
 the fourth ventricle ; and a lower, forming the lower half of the fourth 
 ventricle and medulla oblongata. The roof of this lower segment 
 thins away to such a degree that, like the velum interpositum, it also 
 becomes a mere membrane closing in the ventricle at this site. The 
 upper segment is termed from the cerebellum the hind-brain or 
 
 epencephalon, the lower segment the after-brain or meten- 
 cephalon. 
 
 The Cranial Flexures. — At a very early date, the first cerebral 
 vesicle begins to curve downwards around the extreme end of the 
 notOChord, until from being in a line with the latter and longitudinal 
 axis of the embryo, it becomes placed vertically at right angles to this 
 axis. An angle or bend thus occurs between it and the middle vesicle, 
 which, in its turn, becomes most prominent and in a line with the 
 notochord. A second bend in consequence of this flexure also occurs 
 between the middle and the posterior vesicle, or that portion of it 
 which becomes the cerebellum ; a third takes place between the 
 latter and the hinder half of this vesicle, which becomes the medulla 
 Oblong'ata ; and yet another between this region and the commence- 
 ment of the Spinal Cord. These cranial flexures, which occur between 
 the first cerebral vesicle and its derivatives, tlie Quadrigeminal bodies, 
 the Cerebellum, the Medulla oblongata, and the Cord, are stated by 
 Tiedemann to take place about the seventh week. 
 
 In the further process of development the cerebral hemispheres 
 or prosencephalon enlarge wholly out of all proportion to the hindt r 
 
60 THE CERKHIJAL COUTKX. 
 
 )):ii*ts of the neunil tulu', so (liiit tlic i|u;ulrii^(.'iiiiiiiil luxlies wliich 
 hitherto, as in iiniinals, have had a relatively large bulk compared with 
 the cerebrum, become now placed quite in the shade beside the rapid 
 advance made by the cerebral hemispheres. They extend upwards and 
 backwards, covering and concealing the thalamus by the third month, 
 the corpora quadrigemina by the sixth month, and the cerebellum by 
 the seventh month of intra-uterine life. Long prior to these last 
 changes — in fact, about the fourlli month, a slight depression appearing 
 on the outer as[)ect of each liemispliere midway between its anterior 
 and posterior extremity, indicates the j^osition of the sylvian fossa; 
 and were a horizontal section of the liemisphere carried tlirough this 
 depression we should find the walls of the vesicle within much thick- 
 ened at this point, the thickened mass })votruding into the central 
 cavity as the rudimentary striate g'ang'lia. This fossa, which is 
 seen early in all mammalian bniius, becomes the insula, island of 
 Reil, or central lobe, whilst tlie cortical structure, thickening 
 around it, forms a distinct fissure, the Sylvian fissure, Avhose upper 
 and lower margins encroach upon and cover the "island" from view. 
 Up to the fifth month, however, the fissure of Sylvius remains patent, 
 exposing the island to view. The fissures of Rolando often appear 
 about the end of the fifth month, whilst together with the fissures of 
 the frontal lobe, they are prominent objects on the surface of the 
 hemisphere at the termination of the sixth month of uterine existence. 
 About the same time also appears the internal parieto-occipital fissure 
 on the inner aspect of the hemisphere, mapping ott" the occipital from 
 the parietal lobe on its median aspect. This fissure in its descent 
 meets tlie hippocampal fissure at the point wliere its posterior exten- 
 sion forms the so-called calcarine fissure. 
 
 THE CEREBRAL CORTEX. 
 
 The fundamental divisions of the encephalon, or brain, in mammals 
 are identical with those existing in the whole vertebrate series of 
 skulled animals (Craniota). The early history of embryonal existence 
 is alike for all — each animal higher in the scale, even the highest — man, 
 rei)roducing at an early period of embryonic development, as a tran- 
 sient condition, the features permanently stamped in those of a lower 
 grade. Tlie infinite degree of complexity ultimately obtained by the 
 mammal's brain is ])retigured by the forms assumed in the lower classes 
 of vertebrata, and depends, for the most part, upon tlic preponderance 
 of certain divisions of the encephalic mass over others, and also upon 
 the growing complexity of individual parts, either as the result of 
 

 .'■■■=v^;;rf '^ )< ?: 
 
 I ^'x* .. i. 
 
 >-*;\ 
 
 U i> >-„i 
 
 »1 W' ^"'f ■ 
 
 -^^ 
 
 *^- •'• 
 
 
 
 CH] Exira Ir 
 
 Liiiiiiil Modvftei. Upper li 
 
 Brain of Ra'o 
 Mesial aspect, "basal asv 
 DistxiTD-ution of varioiLs 
 nated types of Corte: 
 
 ^ 
 
 "Motor Typ e " 
 
 :dr?.-lir:i'^ic are-, cf R-^btdt's Bra-ji 
 
METHODS OF ENQUIRY. 61 
 
 increasing clifFei-entiation of existing strnctnres or the addition of 
 sujipleniental parts in the form of gaugliated masses or fibrous tracts. 
 In the mammal's brain we find the first condition exemplified in the 
 complicated convolutionary surfaces of the cerebrum ; in its division 
 into lobes and lobules; in the wondrous complex structure of its 
 cortex. We find the second exemplified by certain ganglionic out- 
 growths from the oi'iginal bi'ain-vesicles, and along its fibrous tracts in 
 the large striate and thalamic ganglia, in the lenticular body, the optic 
 basal ganglion, the corpora geniculata, and others ; and yet again in 
 the extreme development of the callosal and other connecting systems 
 of the brain-mass. The endless diversity of richly-convoluted brains 
 in mammals introduces no feeling but that of confusion to the mind of 
 one who has not studied the cerebrum in its various forms as pre- 
 sented by the whole range of mammalian animals ; in fact, a compara- 
 tive investigation can alone teach the student the significance of its 
 complicated mantle, and help him towards recognising homologous 
 parts in the series. 
 
 Great advance has been made towards this end by the labours of 
 Gratiolet, Ecker, Turner, Broca, Huxley, who, amongst other valuable 
 results, have introduced a definite nomenclature which reduces to 
 precise terms, universally intelligible, the statements of different 
 workers in this department. Another field of enquiry has of late 
 added rich results in the same direction — the physiological. From 
 that epoch in the historical development of Nervous Physiology when 
 it was discovered that the cerebral cortex was excitable to electric 
 stimuli, with patient toil have questions been pvit and answers received 
 by this method of research, and a mapping out of the complicated 
 fields of the cortex into physiological territories established by Ferrier, 
 Hitzig, Horsley, and others. Another field of enquiiy has received 
 but scant attention, yet it is one which an accurate scientific know- 
 ledge of the cortex must make its own : I refer to the histological 
 structure of the whole cerebral mantle in its various districts, as 
 supplemental to the coarser examination of its medullated tracts by 
 the cleavage methods of Gratiolet, &c. It is but a natural a prioi-i 
 conclusion that differentiation in cerebral function implies likewise a 
 structural diflerentiation, and that this latter is one of qualitative as 
 well as qiiantitative vali;e. We naturally look for an alteration of 
 structure as well as disposition of individual elements, and the increas- 
 ing heterogeneity of such individual parts we regard as the logical 
 outcome of the law of evolution. 
 
 Thus it is we expect the physiological areas ascertained by Ferrier 
 to exist in the brain of the monkey and other animals to exhibit a 
 structural differentiation characteristic of those parts, and hence to be 
 
62 THE CEREnRAL CORTEX. 
 
 helpful in the recognition of analogous regions in other orders. If it can 
 be established that areas whose functional endowments are familiar to 
 \is present xiniformly specialised anatomical features, we may reasonably 
 conclude that other structui-ally differentiated areas whose functions 
 are unknown to us at present nevertheless have each and all of them 
 diverse endowments. An attempt to delineate the homologous areas 
 of the cortex in the different orders of mammalia by simple inspection 
 would (on a jn-ioi'i grounds) only lead to failure ; indeed, errors have 
 already been frequently committed with respect thereto: the method 
 of physiological experimentation can alone lead to conclusive results. 
 But, meanwhile, we should not neglect the important consideration 
 of making ourselves acquainted with the intimate structure of the 
 cortex, wliich also has its own special significance, and which would 
 frequently enable us to avoid the error of drawing our analogies 
 from a mere superficial resemblance of the convolutionary surface. 
 
 The grey matter enveloping the exterior of the cerebral hemispheres, 
 the cortex cerebri, merits our most careful stvidy, as being pre- 
 eminently the site of those deranged functions and pathological pro- 
 cesses which express themselves in mental disease. Whatever the 
 limits our definitions compel us to impose upon the sphere of con- 
 sciousness, all are agreed that here, in the wondrous web of nerve 
 cell and nerve fibre, take place those activities which underlie the 
 conscious states we denominate mind. It becomes, therefore, an 
 essential part of the training of the student of Mental Disease to 
 render himself practically acquainted with the structure and functions 
 of the cerebral cortex — the "tissue of mind." This grey envelope 
 which receives the terminal extensions of the ingoing channels of com- 
 munication with the outside world, on the one hand, and forms, on 
 the other hand, the origin for the outgoing currents of the same, plays 
 a supreme role in the nervous hierarchy, and to it all other centres of 
 grey matter are subordinate. In the human brain, the cortex is con- 
 tinuous all over the hemispheres, dipping into the various sulci between 
 its convolutions, and terminating at the median constricting ring 
 through which the bi-ain-stem of the peduncles passes and the great 
 commissural tract of the corpus callosum. 
 
 The distribution of the surface into intricate convolutionar}'" folds 
 such as occur in man, is at the outset somewhat perplexing to the 
 student. Far better is it in his case to study the brain of some of the 
 lower animals, which present a smooth non-convoluted surface, and 
 gradually extend his inquiries to the convoluted bi-ain of higher 
 animals, and, lastly, of man. Beginning thus with the simpler forms 
 of life, he is better able to appreciate in the wonderful architecture of 
 even these simple brains the profound intricacy of the nervous centres 
 
NERVE-CELLS OF TUE CORTEX. 63 
 
 of man : he meets with fewer obstacles at the outset to discourage his 
 attempts, and he lays the foundation for a comparative knowledge of 
 the brain, which will be of inestimable value to him in his subsequent 
 studies. 
 
 We shall adopt this plan in the following study of the cortex cerebri, 
 and commencing with the brain of a small Rodent, which is a smooth- 
 brained animal, take the Rat as our illustration. 
 
 Histological Elements. — In the first place, what are the elemen- 
 tary constituents of the cortex? This is a necessary question to 
 dispose of, ere we pass to their local distribution, regional preponder- 
 ance of certain elements to the exclusion of others, and their relation- 
 ships to underlying tracts of medulla. The elementary constituents of 
 the coi'tex are 
 
 (a.) Nerve cells. 
 
 (b.) Medullated and non-medullated nerve fibres. 
 
 (c.) Connective meshwork of "neuroglia cell and fibre." 
 
 (d.) Blood- vascular supply. 
 
 (e.) Lymphatic supply. 
 
 (a.) Nerve Cells. — The nerve cells distributed through any one 
 part of the cortex, with a few very local exceptions, are by no means 
 identical units ; a vast difference is observed in their size, contour, 
 constitution, connections, their locality and groupings at different 
 levels; and it is upon these divergencies that we base our classification 
 of such elements into several typical forms. With respect to these 
 cells, authorities are at variance — Luys, Arndt, and Stephany ad- 
 mitting but the pyramidal form, whilst Meynert describes three 
 varieties — the pyramidal, the granule, and the spindle form.* We 
 find, however, much diversity in form — recognising some six, if not 
 seven, varieties ; and are inclined to attribute the discrepancies 
 between difterent writers to the infrequent examination of fresh 
 frozen sections : such preparations alone reveal the typical forms of 
 some of these elements. As to the deforming influence of chrome re- 
 agents in the preparation of sections of the cortex, we have elsewhere 
 pi-actically shown the necessity of checking this method by the results 
 obtained by means of sections of fresh bi'ains.f The varieties of nerve 
 cell met with in the cortex of the cerebrum may be distinguished into 
 (1) angular; (2) granule ; (3) pyramidal; (4) motor; (5) inflated or 
 
 * " The Brain of Mammals," Theod. Meynert, in Strieker's Human and Com- 
 parative Histology, vol. ii. Psychiatry, by Theod. Meynert, transl. by Sachs, p. 61. 
 tSee on this point an article in Brain, vol. i. 
 
64 THE CKHKHKAL CORTRX. 
 
 globose ; (6) spindle cell. Tliese elements can be readily demonstrated 
 in the different regions of the cortex of the Rat or Rabbit, which the 
 student is recoinniended to examine as comprising within a small space 
 all the elements described in this section. 
 
 (1) The ang'Ular cell is of very irregular contour, occasionally 
 ajiproaching an oval, a pyriforra, or even a fusiform outline. It quite 
 as frequently assumes more of a pyramidal, and still more frequently 
 an inverted pyramidal contoui-, due to a bicorned formation of its 
 iippermost pole ; in fact, its distinguishing feature is this great irregu- 
 larity in form. These cells peculiarly characterise the seCOnd layeP 
 of the cortex, and may be well seen in the g'reat limbic lobe of tlie 
 Pig or of the Sheep. To see its more notable develojjment, we must 
 turn to the lower arc of the limbic lobe in the Rat or Rabbit, or what 
 corresponds to the gyrus hippocampi. Here, within the area limited 
 by the limbic sulcus (Plate i., a.t.c), are seen dense clamps of these 
 irregularly-shaped nerve cells closely appressed, usually measuring 
 18 II, X 10 /A in size, with a nucleus of 9 /x in diameter. An important 
 character borne by these irregular elements is the relatively large size 
 of the nucleus, as compared with the protoplasm of the cell ; this 
 featui'e, seen in these elements in the rodent, in the sheep, the pig, 
 and other mammals, is also seen in the cortex of man.* In OSmatiC 
 mammals, it forms, as we shall see, a special cortical type, and we 
 are struck further by the dense meshwork of ramifications which arise 
 from its outermost branches. The angular cell may be i-ecognised at 
 other levels, but it is here (gyrus hippocampi) that its richest develop- 
 ment occurs. 
 
 (2) The granule cell is a small element, averaging 10//. x 8 ,a in 
 size, and many not larger than 9 //, and witli a nucleus of 4 /x to 5 /i in 
 diameter. Slightly conical in form, with relatively large nucleus, the 
 delicate pi'otoplasm extends into several extremely fine processes : an 
 apical process being also often present. This element forms an im- 
 portant constituent of sensory realms of the brain, and may be seen as 
 a densely grouped formation in what we have elsewhere described as 
 the modified upper limbic type in the rodent f (Plate iv., fig. 1). 
 In the histological study of the cortex, these two varieties of cell — the 
 ang'Ular and the g'Panule — are so diverse in forms, and their regional 
 distribution is so distinct, that it would be inexcusable to confuse the 
 two formations as of identical constituents. Meynert aptly compares 
 
 *"The Cortical Lamiuation of the Motor Area of the Brain," Proc. Royal 
 Soc, No. 1S5. 
 
 t"The Comparative Structure of the Brain in Rodents," Philosoph. Trans., 
 partii., 1882, p. 709. 
 
GRANULE, PYRAMIDAL, AND MOTOR CELL. 65 
 
 them to tlie internal gi-anule layer of the retina and the elements in 
 the gelatinous nucleus of the great root of the fifth nerve, or of the 
 "granule layer" of the cerebellar cortex.* 
 
 (3) The Pyramidal Cell.— From its uniform contour, large size, 
 very general distribution (regional), and depth of formation, this cell 
 has come to be I'egarded by many as pre-eminently tJie nerve element 
 of the cortex. As in the case with the first described element, the 
 angular, for want of a better designation, these elements are likewise 
 ill-named. 
 
 Pyramidal is a name appropriate only to those cells which have 
 undergone the corrugating effects of chrome, other hardening reagents, 
 or desiccation. In the fresh state they are wholly different in con- 
 figuration from those seen in hardened specimens. On the other hand, 
 Meynert is far too exclusive in stating that their true form is that of a 
 spindle; in fact, they are very variable in form, often plump and 
 rounded ofi" at their base, lengthened out and attenuated at their apex. 
 The pyriform contour is very general — minute angular projections of 
 protoplasm on all sides mapping out the origin of delicate processes. 
 Occasionally they are elongated and truly fusiform, especially in 
 certain definite regions of the cortex ; and yet others occur where the 
 body of the cell is larger above than below, its base being in fact 
 attenuated, so that the cell has the contour of an inverted ovoid. 
 Where they approach the pyramidal form it is usually one of a very 
 irregular triangle, with sides irregularly broken by numerous 
 dentations caused by the processes distributed therefrom. From the 
 summit of the cell arises the apex pPOCesS, directed radially to the 
 surface of the cortex, whilst on either side from the basal aspect a 
 fairly stout branch diverges — not at right angles, but forming an obtuse 
 angle (of about 120° very uniformly) with the long axis of the cell. It 
 appears to us that these stout lateral branches (which, with the apical, 
 form by far the most prominent extensions of the cell) explain its 
 triangular or pyramidal form upon shrinking in chrome fluids. The 
 basal process, a fortiori, is far less clearly delineated, and, as before 
 stated, several extremely delicate processes may arise from this, the 
 lower, pole of the cell. It is, in fact, very doubtful whether a genuine 
 axis-cylinder process is developed from this variety of cell, as we 
 shall see is the case with the larger elements underlying them. These 
 bodies, therefore, throw off three sets of fibres : — 
 
 (a.) The apical, which are by far the most conspicuous, and always 
 radiate to the surface of the cortex ; 
 
 (6.) The large basal, running obliquely outwards and downwards 
 on both sides ; and 
 
 * Op. cit., 1). 3S9. 
 
 6 
 
66 THE CEREliRAL CORTEX. 
 
 (c.) Numerous very delicate lateral fibres radiating from all inter- 
 vening districts of the surface into the nervous meshwork around. 
 
 Each cell contains an oval nucleus, with well-dolinod nucleolUS, 
 7 /i X 5 ^ in size. The dimensions of the cell vary from 12/ji,x8//. 
 in tlie more suj)erlieial to 41 //, x 23 /a- in tlie deeper layex'S. 
 
 (■i) The Motor Cell. — We are alive to the exception which may be 
 taken to any Kuch implication as the above designation conveys; yet, 
 as it a])pears to us that the argument in favour of their motor endow- 
 ments has been materially strengthened l)y farther examination of the 
 question, we prefer this designation to that of giant pyramids, 
 which was proposed by Betz, more especially since these elements may 
 be recognised by certain features in certain regions, where they by no 
 means deserve the epithet ^^ giant cell," being even smaller than the 
 lower cells of tlie third layer above them. The motor cell, taking into 
 consideration the more characteristic elements, are the largest cells 
 found in the cerebral cortex. Some of the largest of these measure 
 126^1 in length by 55//. in the shorter diameter; the average dimensions 
 of a veiy large number in the ascending frontal convolution being 
 GO ijj X 25 fjj. The extremes are 30 fjj and 96 /i. for length, 12 /x and 45 /x 
 for breadth. They contain an oval nucleus, 13-20 /x in greater by 9-12 /i- 
 in lesser diameter. In form these cells are very variable, usually 
 much swollen, plump-looking bodies; they are elongated and attenuated 
 towards their aj^ex process, throwing off the gi-eater number of processes 
 from near the opposite pole. The contour of these nerve cells appears 
 related to the number and size of their branches — i.e., the greater the 
 number of such processes, the more irregular the contour; whilst the 
 apical and Ijasal processes being i;sually the larger, the cell tends to 
 lengthen out in their direction and assume a more or less fusiform 
 outline. Large processes, howevei', given out from various other 
 points of the cell, gi-eatly modify this spindle form, so that extreme 
 variations in configuration occur. We shall see that we have reasons 
 for believing that the primitive form of all these nerve cells is globose 
 or sliglitly pyriform ; that the fusiform outline is the next stage of 
 their development ; and that further modifications occur as other 
 processes beyond the apical and basal extend laterally. So likewise we 
 shall see the reverse change undergone by the cell in the dissolutions 
 of disease. 
 
 The cell has, in the normal state, no cell-wall ; but the appearance 
 of such is readily induced by reagents and disease. In fresh speci- 
 mens obtained from frozen brain, the coll is seen to consist of a 
 delicate protoplasm, which a]>pears to be directly continuous with its 
 various processes ; nor can any trace of the fibrillated structure of 
 the ccll-contcuts described by Max Schultze bo detected unless, 
 
PRIMARY AND SECONDARY BRANCHES. 67 
 
 indeed, reagents be employed. The lower pole of tlie coll is usually 
 pigrnented as a normal constituent, just as is the case with the 
 multipolar cells of the spinal cord. A large rouud or oval nucleus 
 enclosing a nucleolus is always present in these cells. Each cell 
 throws ofi" what may be termed ppimary and secondary branches — 
 the former tlie apical and basal extension ; the latter including all 
 other processes, whether coarse or fine delicate fibres. The apex 
 process, formed by the gi-adual attenuation of the cell, passes straight 
 up through the superjacent layers of cells, and can be often traced into 
 the first or peripheral cortical layer, where it becomes lost to view ; 
 we shall refer to its destination further on. Since in the motor cortex 
 these nerve elements are aggregated into groups or clusters (Plate ii., 
 fig. 1), these apical processes closely approximated often run in sheaves 
 through the more superficial layers. The basal prOCeSS often arises 
 in like manner from a gradual attenuation of the opposite pole, as in 
 the fusiform cells, and large lateral branches may strike out from this 
 extended pole. The basal process, however, continues downwards for 
 some distance, when it gains a thin investing sheath of medulla, which, 
 gradually thickens upon it, converting it into a true medullated nerve 
 fibre. Hence this process is called the axis-cylindeP prOCesS. As 
 Meynert remarks* — "It is the more rarely seen because, being the 
 process which enters the medulla, its direction is dependent on the 
 angles formed by the fasciculi of the latter, which by no means form a 
 straight line with the apical process of the pyramid." This obliquity 
 of position, therefore, necessitates its being cut ofi" in sections on a 
 plane with the radiating apical processes. 
 
 The secondary or lateral processes which radiate from the cell 
 on all sides, unlike the former, divide and subdivide almost immediately 
 after their origin, and interlace in the intricate webwork of nerve and 
 connective fibre around the cell. We are apt to overlook the extreme 
 complexity of structure in vertical sections of the cortex, and should 
 compare with such sections others carried across the long axis of the 
 cell (obtained by placing the cortex surface downwards on the freezing 
 microtome, and cutting down to the level of these cell groups). Such 
 sections show us one or two cells as the centre of an area to which their 
 branches are distributed ; their finest ramifications apparently blending 
 with those from adjacent cell territories. We have observed as many as 
 eighteen main processes divei'ge from a single cell in such sections ; in 
 vertical sections the average number seen is about seven, but as many 
 as fifteen have been observed. When it is remembered that no single 
 section can show (as the teazing methods, however, do) the actual 
 number of branches in any single cell, the above statements will 
 * The Brain of Ifamniah, Strieker's Handbook, p. 3S7. 
 
68 TIIK CEUKBRAL COUTKX. 
 
 indicate the wealth of communicating brandies which these " motor 
 units " possess. 
 
 Wlien we come to examine what appear to be the corresponding 
 cells in the cortex cei'cbi-i of some of the lower mammals, we find 
 certain strong jjoints of resemblance, together with certain distinctive 
 features by which we may very readily recognise them as not human. 
 Thus in the pig", in lieu of the great irregularity in marginal contour 
 seen in man, we observe, on the contrary, a notable uniformity of con- 
 tour, the elongate pyramid being the almost universal form. "They 
 resemble closely, both in size and form, the large pyramidal cells at 
 the deepest portion of the third layer in bimana, quadrumana, and the 
 large carnivora, as also the ganylionic cells in the parietal and temporo- 
 sphenoidal lobes of man. Nowhere do we find the irregulai", swollen, 
 and at times almost globose cells so frequent in the motor area of the 
 human brain." * Again, in the sheep, w-e fail to find the plump 
 rounded cells of man and the higher mammals; but the cell is more 
 variable in form than in the pig, the elongated pyramid being inter- 
 spersed freely with long spindle forms and large numbers of a peculiar 
 '* hOPned" cell, in which the apex process is bifurcate at its origin 
 near the cell. They measure on an average 46 /a x 11 /a. In the 
 cat, however, these elements are plump, oval, and pyriform ; average 
 51 /i X 21 /A in size, with an occasional gigantic cell of lOG //. x 32 /a j 
 and are grouped together in well-marked clusters. In the rodent 
 (rat, rabbit) the type of cell approaches that found in the sheep 
 and pig. 
 
 One may readily perceive the remarkable resemblance between these 
 cells and those of the anterior cornu of the cord in chrome-hardened 
 preparations, but still closer appear their affinities in structural 
 arrangements when teazed-out specimens of brain and coi'd are com- 
 pared. The inference that these cells are s])ccialised elements rests on 
 this resemblance, on the possession of an axis-cylinder process, on their 
 exceptionally large size and abrupt commencement, and the peculiar 
 clustered groupings assumed in a region which has been shown by 
 Fen-ier to possess motor endowments. Meynert, on the other hand, 
 who fails to recognise these larger cells,! draws a parallel between the 
 whole of the pyramidal cells of the third layer and the motor cells of 
 the cord. His statement is as follows : — " If we remember that the 
 anterior roots of the spinal cord, at their origin in the anterior cornua, 
 
 * "Researches on the Comparative Structure of the Cortex Cerebri," Proc. Fioy. 
 Soc, parti., 1880. 
 
 t See the diagram of the five-layer type in Meynert'3 Psychiatry, and also in 
 Sydenham Society's Trans, of his monograph, fig. 234. 
 
THE INFLATED OR GLOBOSE CELL. 69^ 
 
 are connected with elements which, through tlie slenderuess of their 
 bodies, the gradual transition of these bodies into the protoplasm of 
 the processes, and the greater number and size of the latter, are 
 sharply differentiated from the cells in which the posterior roots 
 originate in the interspinal ganglia, these being tumid and provided 
 with few and attenuated processes, an affinity in point of form is at 
 once seen between the pyramids of the cortex and the former, which is 
 common also to the cells of origin of all motor cerebral nerves, and 
 permits an analogy to be drawn in regard to the significance of the 
 pyramids of the cortex. " * 
 
 (5) The Inflated or Irreg'ulaply Globose Cell. — The nerve cell 
 
 to which the ejiithet inflated has been given has not been, so far as 
 we are aware, described amongst the constituents of the cerebral 
 cortex by any former writers on the subject. We first drew attention 
 to it as a specialised cell, forming a distinct layer of the cortex, in a 
 Memoir on the Comparative Structure of the Brain in Eodents (1882), 
 and subsequent examinations fully confirm the description then given. 
 The brain of the mole, rat, or rabbit is especially suitable for demon- 
 strating the presence of this element. The cell which occupies the 
 position of the small " pyramidal " and angular .bodies of the second 
 layer is no longer of pyramidal form, but swollen, inflated, globose, or 
 flask-shaped, and, moreover, oi far greater size. The average dimensions 
 attained by it are 37 /i x 33 /i, with a nucleus of 13 /a ; some are more 
 elongate, measuring 46 /a x 27 (m. Hence, these elements are more than 
 double the size of those usual to this position, and exhibit the apparent 
 anomaly of large cells in the cortex superimposed on a layer of small 
 pyramids. The region in which they are found is really tlie hindmost 
 extension of the lower limbic lobe (modified lower limbic type) in the 
 rodent. 
 
 As will be seen later on, the second layer of the coi'tex in the lower 
 limbic arc is characterised by its peculiar closely appressed clusters 
 of small pyramidal or angular elements, with bifurcate apices, which 
 subdivide into a dense meshwork of fibres ; farther back, in the region 
 above indicated, these elements appear transformed into the inflated 
 cell, retaining, however, their bifurcate aj)ices and plexiform bi'anching. 
 The cell throws ofi" numerous fine pi'ocesses on all sides; its proto- 
 plasm — exceedingly delicate — shrinks greatly under the influence of 
 alcoholic and other corrugating reagents, and should, therefore, be always 
 examined in the fresh state. When acted upon by chrome it loses its 
 chai-acteristic appearance and resembles the vesicular cell, which, in the 
 medulla and spinal cord, is regarded as possessing sensory endowments. 
 
 * Brain of Mammals, p. 3S7. 
 
70 THE CEREBRAL CORTEX. 
 
 It appears to us that tlic whole belt of the second layer of the cortex, 
 out of which this specialised cell is developed, may subserve the 
 same purpose — that of sensation in its various phases : the evidence 
 on this point had better be considered at a later stage of our 
 enquiries. 
 
 (6) The Spindle Cell. — This undoubtedly is also a specialised 
 element. The cell is a narrow fusiform body, attaining the average 
 dimensions of 25 /x x 9 [i, the largest being 32 /a x 13 /a, with an oval 
 or fusiform nucleus 11 /«- to 13 /^ in length x 6 /^ to 9 />!/ in bi'eadth.* 
 Their two principal branches arise from either pole so as to give them 
 in many cases the aspect of bipolar cells; but, as indicated by Meynert, 
 lateral projections also arise from these bodies.f Frequently this 
 lateral branch becomes large, and the resulting angular projection of 
 the cell-protoplasm into it gives the cell a triangular or triradiate 
 form. The cell is regarded as an intercalated element of the connecting 
 system of the brain, and since the claustrum is entirely composed of such 
 elements, the term claustral formation has been proposed for it by 
 Meynert. These elements are peculiarly prone to a nuclear prolifera- 
 tion, which occasionally accumulates into little heaps almost concealing 
 these cells from view. In position they underlie the other layers of 
 the cortex throughout its whole extent ; whatever be the type of 
 lamination, the lowest stratum will always present us with these 
 spindle cells of the association system of the bx-ain ; this applies 
 equally to the mammalian brain in generah 
 
 We have elsewhere indicated the existence of a perfectly g'lobose 
 cell — with a single delicate apex process, and two or more extremely 
 attenuated processes — without any angular pi'ojections from the cell, 
 but a perfectly uniform rounded contour — as existing normally in 
 the second and third layers of the cortex of the ape, and as being 
 specially characterised by this swollen globose contour, and great 
 paucity of branches. They are met with in man only in forms of 
 developmental ai-rest — in idiotcy and imbecility ; but elements which 
 remind us of these cells, occur in the second layer of the cortex of the 
 pig. These may be early stages in the development of the more 
 advanced forms of cortical cells, and may or may not have affinities 
 to the inflated irregularly globose elements already desci'ibed in a 
 specialised cortex of the rodent. 
 
 The above constitute the various forms of nerve cell which occur in 
 the mammalian cortex, and we must now direct attention to its other 
 histological constituents : these consist of— « 
 
 * Transactions of the Roy. Soc, 1SS2, part ii., pp. 714-15. 
 t Op. cit., p. 3S9. 
 
K. 
 
 
 J of seconc- 
 
 :■ t^ 
 
 •^ t^i erve -etsmeivts c 
 
 i-lP/i. 
 
 i-tpx r,f pi -> -left Iveraisv- '•-:•- 
 
 ■';K the Nei.-.. 
 IS. X76. 
 
 -__ -r -Di 
 
PRIMITIVE FIBRIL — NON-MEDULLATED FIBRE. 71 
 
 (a.) ISTerve fibres ; 
 
 (/».) Blood-vessels ; 
 
 (c) Connective matrix or neuroglia ; 
 
 (d.) Lymph channels. 
 
 (n.) Nerve Fibres. — As is well known, nerve fibres, central and 
 periphei'al, present varied forms, corresponding to five stages of deve- 
 lopment — from the viltimate fibril up to the enslieathed and medullated 
 fibre of the peri]>heral nerve trunks. The last, the most perfect and 
 complex form, does not occur in the nerve centimes at all. In the 
 cortex, as well as the nervous centres generally, three forms of fibre 
 are met with — (1) The primitive fibi'il. (2) Naked axis-cylinder or 
 protoplasmic process. (3) The medullated fibre devoid of a sheath of 
 Schwann. 
 
 (1) The Primitive Fibril. — The representative of the ultimate 
 divisions of the non-medullated fibre, is an excessively delicate 
 attenuated thread, revealed only by an amplification of 500 diameters ; 
 and which, as the result of post-mortem change, becomes beaded or 
 shows varicosities along its length. They are observed readily from the 
 occurrence of this change by lower powers of the microscope ( x 350), 
 especially by imbibition of fluid around, which causes them to swell 
 up into large oval varicosities. Such delicate beaded threads are seen 
 at all depths of the cortex in fresh sections obtained from frozen brain, 
 treated with osmic acid, '25 per cent., and protected by a cover-glass ; 
 but they are also traceable in sections which have been hardened by 
 chrome, especially in the lowermost layers. They are seen in many 
 cases to arise from the subdivision of larger fibres; they are perfectly 
 homogeneous, betraying no internal structure to the highest powers of 
 the microscope. 
 
 (2) The Naked or Non-Medullated Fibres, also called the 
 naked axis-cylinders, the protoplasmic processes of Deiters, 
 
 form an important constituent of the cortex. From what has already 
 been stated I'especting the mode of branching of the nerve cells, it will 
 be apparent that the protoplasmic extensions, which form these naked 
 axis-cylinders, occur in complicated meshwoi-ks throughout the cortex. 
 To this category really belong both primary and secondary 
 branches (p. G7) of the nerve cell in the fii'St portion of their 
 course ; but, since their destination is wholly diff"erent, so their con- 
 stitution differs at a subsequent stage. The apical ])rocess and 
 lateral extensions pass by subdivision into an intricate meshwork 
 of fibrils: the basal process becomes invested lower down with a pro- 
 tecting layer of medulla. This is the process to which, properly, 
 should be restricted the term axis-Cylinder prOCeSS ; and, for all 
 
72 THE CEREBRAL CORTEX. 
 
 otlicr extensions of the cell protoplasm, the term non-medullated 
 fibre or protoplasmic processes should be applied in lieu of naked 
 axis-cylinder. iSucli processes are very variable in size; but, at their 
 origin from the various cells of the cortex, they range between 1 (l 
 and 6 /«. in diameter : the lateral processes in particular become 
 rapidly attenuated by subdivision, but yet may be occasionally traced 
 over very lengthy tracts : the apex processes, running to the upper- 
 most layer of the cortex, may often be traced to their termination 
 here. 
 
 These fibres exhibit, under certain conditions of examination, a 
 linear longitudinal marking, which has been described as " fibrilla- 
 tion " by certain autliorities [Max Schultze,* Landois and Stirling \): 
 the homogeneous nature of the non-medullated fibre and axis-cylinder 
 has, on the other hand, been maintained by K'uUiker,'^ Waldeyer,^ and 
 others. Since those who support the view of the fibrillation of the 
 axis-cylinder regard the fibi'e as a compound of the ultimate fibrils 
 already described, separated by a small quantity of interfibrillar sub- 
 stance, and believe them to be continuous thi'ough the ganglion cell in 
 what they describe as a well-marked fibrillation of its interior, the 
 question of the homogeneity or of the fibrillated constitution of the 
 axis-cylinder V)ecomes of fundamental importance in neurology. Such 
 fibrils would be regarded as isolated tracts of conduction throughout 
 their length, the nerve fibre itself being a far more complex structure 
 than what it was once regarded as being, and the cell itself would 
 have a far different significance. Nor, according to some, need this 
 visible conlinuitij of the fibrillar be demanded to establish the case — 
 more or less fusion may occur thi'oughout the length of the fibre; 
 and the splitting up into fibrillar only be observed at the centi'ic and 
 peripheric terminations as an indication of the fibrillar constitution of 
 the axis-cylinder and its lines of molecular disturbances. If these 
 protoplasmic pi'ocesses and axis-cylinders be submitted to the action of 
 silver nitrate in the dark, subsequent exposure shows them to be marked 
 by a ])eculiar transverse striation, first indicated by Fromann. || Their 
 significance is unknown. 
 
 (3) Medullated Fibre or Axis-cylinder Process.— This may 
 
 be either examined in tlie radiating expansion arising from the medul- 
 lated core of a convolution at the site of the spindle layer of cells ; or, 
 in the different intracortical arciform belts found at a higher level. 
 
 * Strieker's Human and Comparative Hidologn, Syd. Soc., p. 158. 
 
 t Test- Book of II u man I'/n/siolorj)/, vol. ii., p. 768. 
 
 + Gewehelehre, 6th Aufl., 1867, p. 244. 
 
 § Zeituchrift Jiir Balionelle Medicin, Band xx., 1863. 
 
 II Virchow's Archiv, Band xxxi. 
 
MKDULLATED XERVE-FIBRES. 73 
 
 The medullated fibre of brain and spinal cord consists simply of an 
 axis-cylinder with an investing sheath of myelin, which gives to the 
 medullated fibre its white appearance, non-meduUated fibres having a 
 grey translucency. The myelin is of fluid consistence, and appears 
 limited simply by a very friable, soft, protoplasmic envelope [Cornil 
 and Ranvier *), and not by the strong resisting sheath (of Schwann) 
 which invests the peripheral fibres. Kiihne and Ewald have proved, 
 by the use of trypsin, that the axis-cylinder is enclosed in a 
 sheath of indigestible horny matexial, which they term the keratoid. 
 sheath. In the peripheral nerves, however, this keratoid sheath not 
 only embraces the axis-cylinder, but being reflected on the inner 
 aspect of the sheath of Schwann, really serves to enclose the white 
 medullated substance or myelin. In these more complex peripheral 
 fibres (to which we must divert, for the time, our attention), although, 
 the axis-cylinder is continuous throughout, the medullaiy sheath is not 
 so, but presents at regular intervals annular constrictions named 
 RanvieP'S nodes, after their discoverer. Eanvier called the in- 
 dividual parts formed by these constrictions interannular Seg"- 
 ments ; and showed that, whilst covered externally by the resistant 
 structureless sheath of Schwann, both were interrupted at these 
 constrictions. In a depression of the myelin, and between it and the 
 sheath of Schwann, are the nerve COPpuSCleS — one for each segment, 
 consisting of an oval nucleus surrounded by a little protoplasm. 
 
 The neuro-keratin sheath, spoken of above, lies therefore on the axis- 
 cylinder, and, reflected at each constriction upon the sheath of Schwann, 
 enjoys the same segmentation as the other constituents of the nerve 
 fibre. Traversing the medullated substance from the inner to the 
 outer portion of the keratin sheath, are numerous transverse and 
 oblique dissepiments, also of a horny nature, supporting the myelin 
 (Lantermann). At the annular constrictions, there exists a certain 
 amount of cementing mateiial, which, when the fibres are treated with 
 silver nitrate, becomes darkened, and appears as a small cross at these 
 nodal points along the fibres. The silver penetrating at these nodes stains 
 also the axis-cylinder to a very limited extent, producing Fromann's 
 lines. It is at this site that nutritive fluids gain access to the axis- 
 cylinder, which otherwise could not be reached through the keratin 
 sheath and medulla. Here also staining reagents gain admission, and 
 colour the axis; and the myelin, after imbibition of fluid by the fibre, 
 exudes at these constricting rings, pressed out by the swollen axis- 
 cylinder in the form of droplets, easily recognised by their spherical 
 form and double contour. 
 
 The medullated fibre of the central nervous system, however, 
 * Pathological Histologi/, vol. i., p. 33. Trails, by A. M. Hart. 
 
74 THE CEREBRAL CORTEX. 
 
 possesses, as we have already remarked, no sheath of Schwann ; it is 
 consequently devoid of the constrictions or nodes of Kanvier, has no 
 interannular segments, no nuclei along its length, nor does it exhihit 
 any signs of lianvier's cross on treatment by silver nitrate. The 
 constitution of tliese centric raedullated fibi-es, therefore, leads to a 
 more pe7'ishable nature. They are /ar less resistant than those of the 
 peripheral nerves, break up more readily into myelin spheres, or 
 become extensively varicose. Hence, also, we find it difficult to stain 
 such medullated fibres in fresh brain. The protoplasmic extensions, or 
 naked axis-cylinders, take up aniline dye readily, becoming stained of 
 a deep blue-black ; but, where the medullated sheath intervenes, the 
 reagent fails to penetrate except along a short length just beyond the 
 first appearance of the sheath. This want of permeability is compen- 
 sated for, as before stated, in peripheral fibres by the presence of the 
 constrictions of Ranvier. 
 
 To stain the axis-cylinder tliroughout its length in these centric fibres, 
 we must first displace the myelin.* This can be eftected by prolonged, 
 immersion of the section in water, and subsequent staining with 
 aniline blue-black. Twelve hours' immersion usually sufiices to 
 remove the whole of the medulla around the axis-cylinders ; and. the 
 latter are then seen as slightly wavy, swollen bands, often strap-shaped, 
 and occasionally contorted, from the alteration undergone by aqueous 
 immersion. They all run from the coi'tex downwards into the core of 
 the medulla, to which they conA'erge in large numbers — deejily stained; 
 and forming a striking conti'ast to the unstained aspect of nerve 
 elements at this site in sections which have been prepared in the usual 
 manner. But although such axis-cylinders present difficulties in 
 staining along their length, they are well seen in sections across their 
 axis: such cross-sections appearing especially in the lowest layers of 
 the cortex (spindle-cell layer) as a central dark axis (often slightly 
 drawn out into a short filament), surrounded by a sheath of white 
 medulla retaining its circular outline — the myelin having been 
 apparently "fixed" by the osmium treatment. The medulla in these 
 cases is not perfectly homogeneous, but has undergone a change which 
 gives it ix frosted vitreous aspect, with a very slightly granular appeai-- 
 ance, the diameter of the fibre being from three to four times that of 
 the axis-cylinder.t Large medullated fibres occur at this site, in 
 
 * lu the very ininute medullated fibres of the cortex, we have an exception to 
 this rule — the axis-cylinder staining fairly well without displacement of its 
 investing myelin sheath : a result due undoubtedly to the small calibre of the latter 
 allowing a certain amount of permeability. 
 
 t It must be borne in mind that there exists a certain definite relationship 
 betwixt diameter of axis-cylinder and medullated sheath : the larger axis-cylinder 
 always having a larger sheath and vice versa. 
 
HISTOLOGY OF ARTERIAL TUNICS. 75 
 
 section, measuring 13 ,a across, with an axis-cylinder of 4 /x ; but 
 extremely minute fibres are seen intermingled with these larger forms 
 also, if the field be carefully searched. As we shall see later on, 
 certain morbid conditions of the cerebral cortex modify to a con- 
 siderable extent the character of this investing medulla. 
 
 (6.) Blood-vessels of the Cortex— (l) Arteries.— These vessels, 
 
 as they dip into the cortex, vary in dimensions irom 4 /i to 12 /a. 
 They possess the tliree tunics which are recognisable to the naked 
 eye in large arteries elsewhere, the tunica adteutilia, media, and 
 intima; but, as in these lai-ger vessels, microscopic examination 
 reveals the fact that each of these tunics is separable into several 
 difterently-constituted layers, so the larger cortical blood-vessels 
 exhibit in the innei'most coat a double layer — an elastic and an 
 endothelial layer. 
 
 The intima, or lining membrane of the artery, in the fresh state 
 appears as a structui'eless membranous tube,with numerous oval nuclei, 
 well seen in carmine-stained preparations, scattered over its surface. 
 These niiclear elements are disposed longitudinally, i.e., in the direction 
 of the vessel's length. The action of a solution of silver nitrate (i per 
 cent.) reveals the fact that this tunic is not a homogeneous tube, but 
 that it is constituted of large squamous endothelial cells, which look 
 like polygonal flattened scales, united to each other at their mai-gin 
 by a cementing material, which is mapped out in black lines by its 
 reduction of the silver salt. Moreovex", it is then seen that the oval 
 carmine-stained elements are nuclei of these flattened cells. The 
 inner elastic tunic is in the smallest vessels a structureless mem- 
 brane, seen as a bright wavy division between the endothelial and 
 muscular coat in transverse sections of the vessel; in the larger 
 arteries it is a distinctly fenestrated membrane, the representative 
 of Henle's fenestrated and elastic laminte, which can be stripped 
 ofi" in shreds from great arterial trunks like the carotid and axillary 
 when they tend to curl at the edge and roll themselves up. It 
 forms an important line of demarcation between the innermost and 
 the muscular layer. 
 
 The tunica muSCUlaris or media consists of smooth or unstriped 
 muscular fibre with oval or strap-shaped nuclei. Such fibres being 
 ari'anged transversely to the long axis of the vessel, or, rather, coiling 
 spirally around it, appear at right angles to the longitudinally-disjtosed 
 nuclei of the intima. Where this tunic is Avell developed, a longitudinal 
 section of the vessel will often show these muscle fibres arranged in 
 series along the margin of the tube, their nucleus, also divided 
 transversely, giving them the aspect of round nucleated cells. 
 The limiting wall externally is also often thrown into slight wavy 
 
/b THE CEREBRAL CORTEX. 
 
 outline from the projection of these muscular fibres. In transverse 
 sections of the smaller arteries one or two such muscle cells surround 
 the open lumen. The muscular element does not enter largely into 
 the constitution of the cortical bloodvessels. These vessels, like those 
 of the cranial cavity generally, as well as those of the vertebral canal, 
 have much thinner tunics than vessels of corresponding calibre else- 
 where from this poverty in muscular elements and adventitial tunic 
 (^Sharpeij). 
 
 The tunica adventitia, which in the larger arteries is a connective 
 sheath directly continuous with the pia mater {intima pia), becomes in 
 the smaller vessels an extremely delicate membranous investment, 
 faintly striated or structureless, upon which are found connective 
 corpuscles, the nuclei of which ai-e round or somewhat oval, A 
 membranous nucleated tunica adventitia, similar to the above, can be 
 readily observed in larger capillaries of the hyaloid membrane of the 
 frog (^Eberih*). The corpuscles in this adventitial sheath form a very 
 delicate ^protoplasmic structure, of fusiform or stellate outline, shrink- 
 ing notably with hardening reagents and desiccation of fresh brain, so 
 as to bring their nucleus much more prominently into view; in fact, 
 mounted specimens usually show the nuclei only along the course of 
 the adventitial coat. As we shall see later on, these nuclei are prone 
 to exti'eme degrees of proliferation. Closely applied to the tunica 
 media, as a rule, this adventitial sheath is in certain conditions widely 
 separated from the vessel's wall in ampullar dilatations, and at all 
 times leaves a space between it and the middle coat in the angle 
 formed by the bifurcation of the vessel. The latter, with its sheath, 
 traverses channels in the cortical substance which form a wall limiting 
 the distention of the vessel. This limiting channel has no definite 
 endothelial lining, so fixr as can be discovered by the silver treatment ; 
 it is termed the pePivaSCUlaP Channel of His, and is continuous with 
 the epicerebral space between the intima pia and the outer surface 
 of the cortex. Traversing this perivascular space ai'e numerous delicate 
 fibrillar processes, which, arising from stellate cells in the substance of 
 the cortex, thus form connections with the adventitial sheath of the 
 artery. 
 
 (2) The Capillaries. — These channels of intercommunication be- 
 tween artery and vein are of extremely fine calibre in the cortex. 
 Taking the capillaries of all regions, excepting the enormous capillaries 
 of marrow, we may state their average dimensions as between 7 /U. and 
 10 /x, i.e., Avhen full of blood. The capillaries of the cortex, however, 
 are often not over 4 ^u. in diameter {j^.?-jjj inch), and are therefore of less 
 
 * See Strieker's Human and Comparative Histolcgy, vol. i, p. 2S7, fig. 53. 
 
THE CAPILLARIES AND VEINS OP CORTEX. i7 
 
 calibre than the red blood-corpuscle. We must allow for possible 
 shrinking of the vessel by emptying its channel, as well as for the 
 constricting effects of reagents, and can scarcely conclude that even 
 these minute ramifications do not permit the passage of the red blood- 
 corpuscle. 
 
 The only constituents of the arterial tunics, which enter into the 
 structure of the cajjillaiy, are the endothelial layer or Intlma and 
 the adventitial investment. In fact, the transition from the 
 smallest artery into the larger capillary is indicated by the disappear- 
 ance of the muscular fibi-e cell, and the continuation of the channel as 
 an apparently homogeneous tubular membrane, with oval nuclei along 
 its course, and here and there niicleated connective cells as the sole 
 representative of the adventitial sheath. The intima, which is a direct 
 continuation of the endothelial lining of the arteries and by many 
 believed to be the only constituent of the capillary, resembles that 
 lining in every particular save the number and form of its squamous 
 cells. These are not only fewer, being often reduced to two in a 
 transverse view of the vessel or its lumen ; but, instead of being 
 polygonal, are more often elongated into fusiform plates. These 
 capillaries form good subjects for the study of this endothelial tube 
 after the action of silver nitrate. The darkened cement substance 
 then displays not only the outline of the endothelial plates, but various 
 sized slits and darkened areas termed stig'mata and stomata, and 
 believed by some to indicate orifices through which the colourless 
 corpuscles migrate. 
 
 In the smaller capillai'ies the delicacy of the structure is such that it 
 is at first often overlooked until its course is noticed, mapped out by 
 short, narrow, spindle-shaped nuclei, arranged alternately at regular 
 distances on the opposite sides of the vesseh In the same direction 
 also will be found rounded nuclei, staining readily with aniline blue- 
 black, sometimes aggregated into groups or arranged in linear series 
 at very irregular intervals along the vessel. These are the deriva- 
 tives of the adventitial sheath, and are therefore always external 
 to and placed upon the fusiform nuclei. They are often the best 
 guide to the direction of the capillary loops around the nerve cell 
 (Plate V.) 
 
 (3) The Veins. — The venous channels of the cortex call but for 
 short notice at our hands, since they reproduce with certain modifica- 
 tions the structures which enter into the formation of the arterial 
 tunics. It will suffice here to show how they difier from the arteries, 
 and to point out the distinctive characteristics of these tlirec divisions 
 of the vascular supply — artery, vein, and capillary. 
 
 The veins consist, then, of but three tunics — the Intima, Media, 
 
78 THE CEREBRAL CORTEX. 
 
 and Atlventitia. The tunica intima is similar to that of the artery ; 
 but the emlotlielial plates are shorter and broader, and the nuclei 
 rounded and fewer in numbers. The media contains no smooth 
 muscle fibre cells, but consists exclusively of connective tissue, whilst 
 the elastic element (always less developed in veins tlian in arteries) 
 is wholly absent in the small veins of the cortex. The adventitia 
 repi'odiices in all respects what has been already described as consti- 
 tuting this coat in arteries. 
 
 Thus we see that the veins may be distinguished from the arteries 
 by the greater laxity of their tissue — the absence of the muscular and 
 elastic element leading to a wider lumen; moreover, the thin media, 
 due to the absence of muscle cells, results in a very ihin-ioallecl vessel; 
 in larger vessels the adventitia also is a more prominent feature than 
 the corresponding coat in arteries. 
 
 The capillary, on the other hand, commences where the middle coat 
 terminates ; but to its minutest ramifications we still find elements 
 of the adventitia around its delicate nucleated wall. This certain 
 authorities deny, but repeated examination leads us fully to endorse 
 this view, also adopted by Ebei'th, whose views are so much to the 
 l^oiut that we quote them here : — 
 
 " Between the capillaries of the lij'aloid of the Froc;, isolated stellate cells occur, 
 with round nuclei and delicate protoplasm, branching off into many processes, 
 Avhich often anastomose with the processes of the cells of the tunica adventitia. 
 Towards the small arteries and veins, the pericapillary plexus becomes constantly 
 closer, and soon in its stead there appears a delicate transversely folded and 
 nucleated membrane, which is sometimes elevated in the form of small vesicles. 
 . . . A similar nucleated membrane forms the outermost covering of the larger - 
 sized capillaries, and of the arteries and veins of the brain, spinal cord, and retina 
 of man. " * 
 
 . (c.) The Neurog-lia or Connective Basis.— The more generally 
 
 accepted fuuetious of the neuroglia matrix would i-ender structural 
 differentiation of tliis non-nervous constituent highly probable iu 
 different regions of the cerebro-spinal system. This, we find, accords 
 with actual fact ; for, as a supporting, as well as embedding and 
 jjrotecLive material, the requirements demanded will differ widely ia 
 the white medulhited structures from those of the grey centres ; whilst 
 individual sections of these territories will also differ in the special 
 qualities of this matrix requisite. Thus, the large closely-approximated 
 medulhited filtres of the Spinal Cord will be found to possess a strong 
 binding material in the form of large-sized nucleated cells, with 
 
 *"Eberth on the Minute Anatomy of the Capillaries," Strieker's Histology, 
 vol. i., p. 2SG. 
 
THE NEUROGLIA MATRIX. 79 
 
 numerous lengthened ramifying processes, together with a plexus of 
 fine fibrils (probably elastic fibre — Gerlach) ; whilst a structureless or 
 very finely granular material is found here but sparingly. Still neai-er 
 the jieriphery of the cord, this supporting structure becomes a veritable 
 fibi'illar connective sheatli of great strength, with trabeculae of like 
 constitution passing inwards to the cord. In the central grey matter 
 of the cord, however, the finely granular or molecular basis-substance 
 predominates, as most essential for the protection of the extremely 
 delicate nerve fibres present in this region. Farther up in the 
 medulla of the brain, as in the neighbourhood bordering upon the 
 grey cortex, the large bundles of medullated fibre again demand a 
 predominance of the connective fibre element, so that here we meet 
 with numerous though delicate ramifying cells. Wherever the medul- 
 lated fibre reappears, there we find the association of these branching 
 cells, and thus they are seen along the outermost or periphei-al layer 
 of the cortex as a normal element. In the grey matter of the cortex, 
 however, the delicate nerve-cell and fibre network appears largely to 
 dispense with this modification of the connective tissue, and we find 
 a structureless matrix vastly preponderating over the cell and nuclear 
 elements of the neui-oglia. 
 
 A still further modification of the neuroglia element is found on the 
 free surfaces of the cortex immediately beneath the pia, where the 
 branching cell before described fulfils the function of a flattened 
 epithelial investment, whilst the surfaces not exposed to pressure, as 
 the central canal of the cord, show us the element as a columnar 
 epithelium. 
 
 Thus, generally, we may afiirm that, when dealing with nerve cells 
 and their delicate extensions, the supporting material will be chiefly 
 the structureless or finely moleCUlaP basiS-SUbstance ; whilst as 
 we approach the medullated tracts, we shall find that the connective 
 cell and fibre networks increase at the expense of the former. 
 
 The elements of the neuroglia are usually described as nucleated cells 
 and free nuclei imbedded in a structureless, or, according to some, finely 
 fibrillated matrix, and to this view the appearance of chrome-hardened 
 preparations certainly lends support. The less we subject our sections 
 to reagents, and the more recent the section examined, however, the 
 more evident it becomes that the supposed free nuclei are invested by 
 protoplasm, and, in fact, are likewise nucleated cells. These two cell 
 elements diff'er much as regards their relationships and also their 
 dimensions. 
 
 (1) The smaller of the two hinds of cell vary^from G /x to 9 ,a in 
 diameter; have a spheroidal nucleus, surrounded by an extremely 
 delicate protoplasmic investment, which, as before intimated, is 
 
80 TUE CERKCRAL CORTEX. 
 
 shrunken, often beyond recognition, in hardened specimens. The 
 nucleus is, proportionately to the cell itself, very large, and invariably 
 stains of an intense de-pth of colour with aniline blue-Vjlack. These 
 elements appear disposed in thi-ee definite situations — (1) irregularly 
 in the neuroglia framework ; (2) in regular series around the nerve 
 cells ; (3) in more or less regular succession along the course of the 
 blood-vessels (capillary and arteriole). 
 
 (2) I'lie larger cellular elements of the neuroglia are usually 13 im in 
 diameter, and supplied with a relatively larger mass of protoplasm as 
 compared with the nucleus. They are distinguished from the former 
 not alone by this gi-eater size and the preponderance of cell over 
 nucleus ; but also by their frequent flask-like configuration, as seen 
 in situ, and the presence of a very faintly-stained nucleus, or even 
 sometimes two or three nuclei, observed within them. If these 
 elements are teazed out from the surrounding matrix, they are seen 
 to possess numerous extremely delicate radiating processes ; not only 
 the nucleus, but the cell and its extensions are likewise tinted by the 
 aniline dye ; not uniformly, howevei', for the nucleus is always of a 
 slightly deeper tint, but neither cell nucleus nor processes betray 
 anything like the vigour of staining shown by the former element 
 described. The nerve cell, its processes, and the enclosed nucleus 
 had, as we said, a si^ecial affinity for this staining reagent, a fact 
 which indicates very conclusively the non-nervous character of these 
 lai'ger elements of the neuroglia. In healthy brain, at least in the 
 human subject, we find these elements chiefly in the outermost layer 
 of the cortex and the central cone of the medulla, but their delicacy, 
 tenuity of branches, very faint staining, and poor difl'erentiation ai'C not 
 favoui'able to their immediate detection. In certain morbid conditions 
 of the cortex, as we shall see later on, these elements become a most 
 notable and important feature, xmdergoing excessive proliferation, and 
 betraying their morbid activity by the intensity of colouring which 
 they acquire. This study of the constituent histological elements of 
 the cortex prepares us for the consideration of the lymphatic system 
 of the brain, and the ultimate relationships of IS'erve cell to the 
 Blood and Lymph channels. 
 
 {d.) Lymphatic System of the Brain. — To Obersteiuer is due 
 
 the credit of first definitely indicating the existence and relationships 
 of these lymph channels.* Their existence since then has been re- 
 peatedly denied, but the evidence hitherto brought forward against 
 Obersteiner's views is most inconclusive in all respects, and in most 
 
 *"Uber einige Lymphraiime im Gehirne" [Silsb. d. K. Akad. d, Wissensch., 
 Jan. Heft, 1870). 
 
LYMPHATIC SYSTEM OF CORTEX. 81 
 
 cases appai'ently based upon incomplete methods of examination. 
 This is not tlie place to enter on debateable ground ; but we are 
 compelled, owing to the supi"eme importance of the subject as affecting 
 the physiology and ^lathology of the brain, to state the results of our 
 own investigations, which were made the subject of a special memoir 
 in 1877.* 
 
 All hardened sections of brain exhibit along the course of their 
 blood-vessels a distinct and more or less wide interval between the 
 vascular walls and the brain-substance ; in fact, the brain-cortex is 
 channelled throughout, in such a manner, that the vessels when con- 
 ti'acted are enclosed within a channel of much greater calibre. The 
 disparity betwixt the diameter of vessel and bi'ain-channel will be 
 affected undoubtedly by corrugating reagents ; and hence, we never 
 fail to find these channels disproportionately lai-ge in brain which has 
 been subject to extremes of hardening by chromic acid, (fee; but 
 recession of the brain-substance may occur from many other causes 
 acting during life — notably extreme atrophic degeneration ; and 
 then, in like manner, such channels will appear inordinately large, 
 however skilfully the brain be prepared. These channels are known 
 by the name of the perivascular Channels of the brain — the peri- 
 vascular channels of His : these are not the lynij)h channels proper, as 
 several writers seem to have supposed, but are simple channels in the 
 brain-substance, devoid of an endothelial lining, and communicating 
 freely with the space between the investing pia mater and surface of 
 the cortex, the eplcerebral space. The adventitial sheath of the 
 blood-vessels becomes closely appressed to this limiting channel, and 
 its (adventitial) nuclei often thus give it the appearance of being 
 lined by endothelial cells. This, however, is not the case, as re- 
 peated investigations by silver staining have shown. The student 
 cannot too persistently bear in mind the fact that in these channels 
 he deals purely with what seems equivalent to an involution of the 
 naked surface of tlie brain, and yet the epithelial elements of the epi- 
 cerebral surface are not continuous along this tubular channel. 
 
 In the next place we find, luider precisely similar conditions to 
 those above enumerated, a wide space around the larger nerve cells ; 
 the brain-substance, as it were, seems to have receded from the cell, so 
 that it is enclosed within a circular, oval, or pyriform space. These 
 spaces we will designate the pericellular saCS. Genuine sacs, and not 
 mere artificial gaps in the brain-substance, they undoubtedly are, as is 
 abundantly proved by cai-eful examination. To exhibit the true 
 
 * "The Relationships of the Nerve Cells of the Cortex to the Lymphatic System 
 of the Brain," Proc. Roy. Soc, No. IS'2, 1877. 
 
 6 
 
S'2 THE CEREDHAL CORTEX. 
 
 relationships of these perivascidar channels and pericellular sacs, let 
 us revert to the smaller cellular element described in the neuroglia 
 (p. 80), It was stated that beyond the scattered elements in the basis 
 substance of neuroglia, these cells were arranged in two other direc- 
 tions. Let us particularise : — 
 
 (1) The nucleated cells along the arterioles belong to the adventitial 
 tunic, and map out its course very accurately ; occasionally closely 
 applied to the perivascular channel, as before stated, or separated as 
 irregular ampullse from the vessel itself, this investment more 
 frequently lies directly upon the media, and affords one (but an 
 equivocal) evidence of the existence of a lymph channel surrounding 
 the vessel. That a complete tubular membrane exists for a certain 
 distance along the smaller arterioles, is demonstrable ; that it is 
 continuous, as a membrane, further on to the arterio-capillary plexuses, 
 is more than dubious. It is certain, however, that its representative 
 cells are to be found sui'rounding these minute channels to their 
 ultimate ramifications ; and thus the perivascular hjmfli space of the 
 adventitia becomes continuous in these districts with the general 
 perivascular channels and sacs around the nerve cells. 
 
 (2) The nucleated cells found in connection with the nerve cells in 
 certain states not only acciimulate upon the nerve cell itself, but 
 follow closely the outline of the cavity, or properly speaking, the sac 
 in which the nerve cell lies. Many pericellular sacs will show a 
 complete series of such nucleated cells around it, still more frequently 
 will they follow out a segment only of its circular outline; occasionally 
 none may be seen — an exception due probably to displacement during 
 section-cutting or further manipulation. Upon closer observation, 
 however, it becomes apparent that in the immediate neighbourhood of 
 every large nerve cell there is a minute arteriole or capillary, not 
 indicated so often by a well-differentiated contour (for these minute 
 vessels are usually most difficult to follow), as by the direction of its 
 nucleated cells. Thus, the fusiform nuclei of the intima, alternately 
 placed on opposite sides of the capillary, will lead to the discovery of 
 the outline of the vessel faintly indicated in a graceful curve or spiral 
 in close approximation to the nerve cell; but the presence of the deep- 
 stained nuclei of the adventitial cells taking the saine course, plainly 
 indicates the direction of these ultimate nutrient channels. It is 
 these adventitial elements which give us the clue to tracing the 
 obscurely marked capillary, and when this is followed out, the eye 
 becomes accustomed to trace without any difficulty the vascular loop 
 around the nerve cell. 
 
 Around a segment of the pericellular sac, mapped out by adven- 
 titial elements, we then see a delicate tubular loop, evidently con- 
 
PERIVASCULAR CHANNELS — PERICELLULAR SACS. 83 
 
 tinuous with the neighbouring arteriole, and to the sides of which 
 the pericellular sac appears to be attached, the nerve cell itself 
 being, as it were, suspended within the latter. It would appear 
 as if the geiiei-al perivascular channels at their ultimate ramifica- 
 tions around the arterio-capillary plexuses were enlarged here and 
 there laterally along the vessel by the growth of an element included 
 within it which becomes the nerve cell, and which does not come in 
 contact with the neuroglia mati'ix except through the medium of its 
 processes, which, passing through the pericellular sac, permeate the 
 neuroglia in every direction. It would appear also from examina- 
 tion of specially prepared sections, that the adventitial elements are 
 not entirely limited to the vascular loop, but may line the interior of 
 these sacs — not as a regularly applied endothelial layer, but as loosely 
 .distributed and branching cells. In like manner, similar cells may be 
 found free within the cavity of the sac between its wall and the nerve 
 cell, resembling in all particulars lymph corpuscles. 
 
 Beyond the system of perivascular channels, adventitial lymph 
 space, and pericellular sac, we have a lymph-COnnective system 
 which plays an important role in the pathology of the brain. This 
 system is constituted by the larger connective element referred to 
 above — the delicate branching masses of protoplasm supplied usually 
 with one, sometimes with two, or even three large nuclei. These 
 elements, when more closely examined, are found to have a definite 
 and constant relationship to the cortical blood-vessels ; and are always 
 discovered in larger numbers in their immediate neighbourhood, 
 external to the perivascular channels. The latter present where they 
 are well seen, and the adventitial sheath is appressed to the vessel's 
 side, a series of delicate processes, which, traversing the channel, look 
 like fibres extending from the adventitia into the brain-substance. 
 
 AVhat are these fibrous prolongations ? Careful examination of one 
 of the large neuroglia elements reveals the fact that they throw ofi" two 
 sets of processes — (1) an enormous number of extremely delicate fibres, 
 which spread into the intervascular area around, and (2) a mioch thicket', 
 coarser process, which, often after a tortuous course, ends in the 
 adventitial sheath of the blood-vessel. In crossing the perivascular sac, 
 these processes give rise to the fibres just described as extending 
 between adventitia and brain-substance. 
 
 It is in certain morbid developments of these cells that we can the 
 more readily distinguish their real relationships. We find that 
 the stouter process, which we may provisionally term the vasCUlaP, 
 terminates in a nucleated mass of protoplasm on the sheath itself, 
 corresponding to one of the perivascular or, more properly, adventitial 
 cells. In morbid states, as we shall see, this terminal protoplasm of 
 
84 THE CEREBRAL CORTEX. 
 
 the vascular process "becomes spider-like, in its turn throwing off 
 numerous branches, which embrace the vessel's -wall. In the healthy- 
 state, it is most difficult to trace the vascular branch ; but that this 
 can be done by proper methods, we have frequently satisfied ourselves. 
 The branched cells which Ave have now described have often been 
 recognised in their morbid modifications, and variously interpreted. 
 Their representatives in healthy brain were first described by Deiters,* 
 and subsequently by Ball and Golgi ; but we do not think their true 
 significance has been recognised either as normal or pathological 
 elements of the central nervous system. "We incline to regard these ele- 
 ments as comprising the distal extension of a lymphatic system, 
 
 in fact as a lymph-COnnective system permeating the neuroglia 
 in the intervascular area. The individual elements are excessively 
 delicate and pellucid, their protoplasm appearing almost of fluid con- 
 sistence, and the vascular process invariably establishing its connection 
 with the lymph sheath of a blood-vessel. In whatever manner these 
 spider cells efi"ect the reabsorption and distribution of tlie effete 
 matei'ial and surplus plasma — whether by direct assimilation into their 
 own structure, and its removal by currents within the protoplasm of 
 the cell and its processes, or by means of a true canalicular system 
 terminating in the lymph sheath — it is an undoubted fact that any 
 arrest to the escape of perivascular lymph from the cortex is imme- 
 diately followed by a morbid development and hypertrophic condition 
 of this system of spideP Cells, as we shall for the future call these- 
 elements of the "lymph-connective system." Meynert long since drew 
 attention to their freqiient pi'esence as associated with congestion 
 and degeneration of the lymphatic glands of the head and neck, and 
 we haA^e assured ourselves of the frequent association of this morbid 
 development in tuberculosis, and in several affections of the cortex and 
 its membranes which lead to obstruction of the perivascular lymph 
 channels.t The morbid changes undergone by this lymph-connective 
 
 * Hence they are often named after him — Deiters' cells. — Untersiichungcn iiber 
 Gehirn und E'uckenviark der Menschen und dcr Suitrjcthlere, 1S65. 
 
 + We have elsewhere alluded to the comparative significance of these elements as 
 follows: — "In man they appear in scanty numbers; in the Barbary ape, they 
 become more frequent ; in the cat and ocelot, they are still more abundant ; in the 
 pig and sheep so profusely scattered are they that they form a most characteristic 
 stratum immediately below the pia mater, and the meshwork formed by their 
 fibres is dense and coarse, binding the blood-vessels to the cortex and rendering the 
 pia mater strongly adherent. We find these corpuscles in human brain which 
 has undergone senile degeneration — in other diseases attended by reduction in 
 functional activity, and in vascular affections resulting in retrogressive changes 
 and a reversion to a low type of structure." — " Comxiarative Structure of the Corte.x: 
 Cerebri." Trans. Eo>jal Soc, part i., ISSO. 
 
SPIDER CELLS OF LVMPU-CONNECTIVE SYSTEM. §5 
 
 system and the effects of its moi'bid activity will be more fully dealt 
 with when ti'cating of the pathology of the cortex. For the present 
 we shall summarise the above statements as follows : — The lymphatic 
 S3'stem of the brain consists — 
 
 (1) In the fii'st place, of a distensible lymphatic sheath, loosely applied 
 around the arterioles and venules, containing numerous nucleated 
 cells in its texture — the adventitial lymph sheath, the whole being 
 included within a non-distensible channel of the brain-substance, devoid 
 of endothelial lining — the perivascicla7' channel of II is. 
 
 (2) In the second place, of a continuation of the cellular elements of 
 this sheath, loosely applied to the arterio-capillapy plexuSGS, still 
 contained within a perivascular channel, which now exhibit along the 
 capillary loop sac-like dilatations — the pericellular sacs, within which 
 the nerve cell lies, surrounded by plasma. 
 
 (3) Lastly, of a system of plasmatic cells with numerous prolon- 
 gations, which are always in intimate connection with the adventitial 
 lymph sheath, and which drain the areas between the vascular 
 bi-anches — these we have termed the lymph-connective elements. 
 
 . If we take a comprehensive view of the whole system — the channelled 
 vascular tracts, the saccular ampullse along the capillary tube, the 
 caualicular-like formation of the lymph-connective elements, all em- 
 bedded in a homogeneous matrix of neuroglia — we cannot but be 
 struck by the sponge-liJce arrangement of the cortex, and the facilities 
 so aiforded for the free circulation of plasma throughout its most 
 intimate regions. 
 
 CORTICAL LAMINATION. 
 
 Having familarised himself with the individual histological elements 
 of the cortex — the nerve cells, blood-vascular and lymph-vascular 
 systems, and the neuroglia framework — it becomes the student's duty 
 to examine their general arrangements and the local deviations to be 
 observed. 
 
 A vertical section of fresh cortex of human brain reveals to the 
 naked eye a distinctly laminated aspect, the various laminse of which 
 are more or less clearly marked out by difference in colour, the outer 
 being usually of a pale translucent grey, and the deeper of alternating 
 pale and dark grey layers, more opaque in aspect, and in certain 
 regions exhibiting a sharply defined white streak. The outer trans- 
 lucent layer has superimposed on it a delicate white stratum, scarcely 
 appreciable on the convexity of the hemisphere, but well marked 
 in the convolutions boi'dering upon the cor^tus callosum, and the 
 
8G LAMINATION OF CEREBRAL CORTEX. 
 
 convolution of the hippocampus, at tlie Laso, where its peculiar 
 aspect has gained for it the name of the reticulated White SUb- 
 Stance. As we shall see latei- on, this is a superficial layer of white 
 medullated fibre running parallel to the surface of the convolution ; 
 whilst the paler intersecting streaks deeper down in the cortex are 
 similar systems of arciform intracortical fibres intervening between 
 layers of grey substance. The deeper layers owe their opacity to the 
 relatively large proportion of medullated fibres passing through them ; 
 the upper layers are translucent from the preponderance of the 
 neuroglia element and fine protoplasmic processes of the nerve 
 cells ; the warmer grey tints are due not only to large niimbers 
 of pigmented nerve cells, but chiefly to the amount of blood in the 
 vessels of the layer. 
 
 As might be supposed from the above, the distinctness of lamination 
 not only varies with the local peculiarities of structure, but with 
 morbid states of the cortex and with the full or empty state of its 
 vessels. Probably the best introduction the student can have to the 
 study of the human cortex is to commence first with the brain of 
 one of the lower mammals, choosing one of the smooth non-con- 
 voluted brains, as of the rat or rabbit, ere he attempts the more 
 complicated brain of those animals which exhibit a convoluted 
 surface. He thereby learns to appreciate the great diversity of 
 lamination which may exist in so small an organ as the brain of the 
 rodent, as also the abrupt transition from one type of cortex to that of 
 another wholly different from it, and lastly he becomes familiar with 
 types of lamination which are strictly reproduced in higher forms up 
 to the brain of man. 
 
 Figs. 1-3 in Plate i. represent the brain of the rabbit seen from its 
 upper, lower, and median aspect, of somewhat pyriform contour below 
 at the base, and triangular above ; its frontal pole is much attenuated, 
 and rests upon the olfactory lobe. On its inner aspect we see two 
 very delicate furrows (fig. 1, A) which represent the sub-frontal and 
 sub-parietal segments of the limbic fissure, which is strongly marked 
 in the brains of the pig and of the sheep ', this ri;dimentary fissure 
 limits the upper limbic arc (between A and J) from the extra- 
 limbic or parietal mass of the hemisphere (fig. 3, Z, Y). 
 
 If we follow this upper limbic arc from before backwards, we find 
 that its anterior extremity is deep, and that it gradually becomes more 
 shallow towards the sub-parietal furrow; beyond this it is hollowed 
 out by the prominence of the mesencephalon and overhung by the 
 occipital pole (fig. 1, D), and curving downwards behind the corpus 
 callosum, it bends forwards as the gyrus hippocampi or lower limbic 
 arc (figs. 1, 2, B). 
 
CEREBRAL IIEMISPnERE OF THE RODENT. 8T 
 
 Looked at from the base, we see the lower limhic arc separated from 
 the extra-limbic mass by a well-defined fissui'e — the limbic fissure, 
 which here separates the lower limbic arc from the extra-limbic mass, 
 the latter being still prominent and not concealed from this aspect, as 
 in the rat, where the lower limbic arc extends farther outwards. 
 Extending back from the frontal pole are the olfactory lobes, the outer 
 roots of which (or superficial olfactory medulla) terminate near the 
 extremity of the gyrus hippocampi. These two external olfactory 
 roots enclose between them two pyriform grey areas, one on each side, 
 separated by the middle line, bounded behind by the optic commis- 
 sure — the optic nerves lying superficial to them. This grey area is 
 the olfactory field of Gratiolet. Between the olfactory area and the 
 lower limbic arc, a vei'y slight depression indicates the site of a 
 rudimentary Sylvian fissure. 
 
 Looked at from above, we find the surface of what Broca would call 
 the extra-limbic portion, perfectly smooth, and showing no indica- 
 tions of rudimentary furrowing beyond a very delicate, shallow, linear 
 depression, mapping off the sagittal region of the brain from the parietal 
 or extra-limbic portion in the posterior half of the hemispheres. This 
 is the representative of the primary parietal sulcus, which, in the Pig, 
 Sheep, and other Gyrencephala, separates the sagittal from the Sylvian 
 gyri of the parietal lobe. In the rat no such linear depression exists ; 
 but, this region bordering on the sagittal margin posteriorly, is clearly 
 ma'pped out by its distinctly jmle aspect as compared with the cortex 
 external to it. 
 
 The different regions which we have now indicated are all dis- 
 ting\iished by a type of cortex peculiar to each ; and thus the upper 
 limbic arc, the lower limbic arc, the olfactory area, the exti'a-limbic or 
 parietal portion — areas obviously differentiated roughly from one an- 
 other by sulci or faint indications of furrowing — all exhibit absolutely 
 distinct types of cortex. But this difi'erentiation does not stop here ; 
 the pale strip of cortex bordering upon the sagittal margin in the rat, 
 although not mapped off by a distinct furrow, has also its own peculiar 
 type of cortex ; and in the rabbit, as we have seen, this region is 
 further differentiated by a linear furrowing. Then, again, the lower 
 limbic arc, if traced backwards, presents us beneath the occipital pole 
 with a further modification, which can only be regarded as a distinct 
 type of cortex. If we add to the above the formation of the cornu 
 ammonis and of the olfactory bulb, we have presented to us eight 
 distinct types of cortex, not mere fanciful distinctions based upon 
 trivial peculiarities ; but, in all cases, abrupt transitions from one kind 
 of cortex to another. This divergence in laminar type is peculiarly 
 abrupt in these lower forms of life, the demarcation usually being 
 
88 LAMINATION OF CEREBRAL CORTEX. 
 
 sharply drawn at the furrows intervening between these regions. In 
 liigher animals, and especially in man, no such abrupt demarcation 
 occurs ; distinct tPansition TGg'ions lie between either territory, so 
 that the gradual passage from one form of cortex to another is a dis- 
 tinctive element in the evolution of the higher brains * (Brain, 
 vol. i., page 84). The eight laminar types of cortex which are thus 
 distinguishable in these small mammalian brains, we have named as 
 follows : — 
 
 (1) Type of the upper limbic arc. (5) Modified olfactory type. 
 
 (2) Modified upper limbic tyjie. (6) Extra-limbic type. 
 
 (3) Outer olfactory type. (7) Type of cornu ammonis. 
 
 (4) Inner olfactory type. (8) Type of olfactory bulb. 
 
 On the other hand, we find that Meynert enumerates but five types 
 as follows : — 
 
 (1) Common type. (.3) Sylvian type. 
 
 (2) Occipital type. (4) Type of coi-nu ammonis. 
 
 (5) Type of olfactory bulb. 
 
 If we turn to our outline scheme of the rabbit's brain (Plate i.), we 
 shall find these diverse forms of cortex distributed in the following 
 regions : — 
 
 (1) The first, or the type of the uppeP limbic arC, occupies the 
 median cortex of the hemisphere from the frontal jiole to the end of 
 the sub-parietal furrow (figs. 1-3, -h ) ; it moreover spreads beyond 
 the sagittal margin, and embraces the pointed frontal extremity of 
 the exti'a-limbic region at the vertex. 
 
 (2) The second, or modified upper limbic type, prevails also on 
 the median cortex behind the above type, extending to the occipital 
 pole, but also spreading outwards over the sagittal border to the upper 
 aspect of the hemisphere, where it terminates abruptly at the parietal 
 furrow (dotted area). 
 
 (3) The third, or outer Olfactory type, characterises the cortex 
 of the greater segment of the lower limbic arc to its extremity — the 
 gyrus hippocampi (figs. 1, 2, B). 
 
 (4) The fourth, or inner olfactory type, covers the grey pyriform 
 
 * In his earlier memoir, published in Strieker's Human and Comjmrative Ilixlology, 
 as well as in his later views expressed in Psycliiatnj, MejTiert defines but five 
 types of cortical lamination as distinctive of the brain in mammals. We find our- 
 selves unable to agree with Meyuert, not only as regards his enumeration of types 
 of lamination, but in some cases as regards his description of the specific characters 
 of individual tyjies of cortex. 
 

 t 
 
 ^r^ -.*»%>* ^^ ^ 1: ... 
 
 K^^W 
 
 ;\*^ 
 
 
 
 ' 4 
 
 '?f'% 
 
TYPES OP CORTICAL LAMINATION. 89 
 
 ai'eas enclosed witliiii the last mentioned and the outer root of the 
 olfactory bulb (tig. 2, dark area). 
 
 (5) The fifth, or modified olfactOPy type, occupies the posterior 
 segment of the lower limbic arc, where it sweeps round posteriorly to 
 meet the upper limbic arc. This form of cortex, unique of its kind, is 
 also abruptly limited externally by the great limbic fissure. 
 
 (G) The sixth, or extra-limbic type, is peculiar to the whole of 
 the extra-limbic or parietal portion of the hemisphere, except the 
 regions already described as presenting a peculiar lamination. Thus 
 it occupies the whole of the vertex except the portion internal to the 
 parietal furrow, and the pointed end of the hemisphere in front, whilst 
 elsewhere it is strictly demarcated from other regions by the great 
 limbic fissure. 
 
 (7) The seventh, or type Of the COPnu ammonis, characterising 
 the involuted free margin of the cortical envelope, is, of course, con- 
 cealed from view in these aspects of the hemisphere. 
 
 (8) The eighth, or type Of the olfactOPy bulb, has its distribu- 
 tion sufiiciently indicated by its name (figs. 1, 2, F). 
 
 A brief description of the peculiarities of these cortical belts of nerve 
 cells will be all that is needful for our present purpose. 
 
 (1) Upper Limbic Type. — The cortical lamination here referred to 
 is illustrated in Plate i. The area it covers is presented in figs. 1-3, + . 
 
 It is essentially a four-laminated type : its first or superficial layer 
 being a light grey belt of delicate neuroglia matrix, with connective 
 elements and their fine prolongations supporting the extremely delicate 
 subdivisions of the apical px-ocesses of nerve cells in the subjacent 
 layers. iVo nerve cells are found in this layer, which we term the 
 "peripheral cortical zone" (Plate i.) Next to this succeeds a layer of 
 small pyramidal cells, which, down to the confines of the third layer, 
 remain equable in size throughout ; in all respects these elements bear 
 close resemblance to the upper half of the third layer in higher 
 animals. They difi'er from the human cortex (1) in not, as in the 
 latter, rapidly increasing in size with their depth, and (2) in following 
 immediately upon the peripheral cortical zone with no intervening 
 belt of small oval and angular cells, such as characterises the second 
 layer in man. A few bifurcate cells in sparse detached clumps occur 
 on the outermost confines of this layer, probably rudimentary elements 
 of the second layer of man. Beyond the layer of small pyramidal cells, 
 is a pale belt containing the largest cells of the cortex — a pale poorly- 
 celled zone demarcating them from the superimposed layer of pyra- 
 midal cells. These elements are, however, distinguished from the 
 latter not alone by their great size, but by their distribution into 
 confluent groups or clusters, which, as we shall see later on, is a special 
 
90 LAMINATION OP CEREBRAL CORTEX. 
 
 character of the large nerve cells of the motor cortex. Their apex pro- 
 cess extends right tlirough the pyramidal series into the peri})horal 
 zone. We cannot now stop to inquire into their many striking features. 
 Beneath these large cells is a series of fusiform elements, similar in all 
 respects to those found in higher mammals. This type of cortex, 
 thei'efore, is constituted by 
 
 (1) A pei'ipheral cortical zone. (3) Ganglionic layer. 
 
 (2) Small pyramidal layer. (4) Spindle cell layer. 
 
 (2) Modified Upper Limbic Type. — This form of cortex, like the 
 last, is also a four-laminated type. Near the posterior extremity of the 
 corpus callosum (Plate iv., fig. 1), the upper limbic arc exhibits the in- 
 tercalation of a series of granule CCllS between the small pyramidal 
 and the large ganglionic cells ; but, as we proceed farther back, this 
 belt of granule cells deepens, and, approaching the surface, eventually 
 entirely displaces the small pyramids, and becomes in their place the 
 second layer in this region. The granule-like aspect is due to the 
 relatively large nucleus, as comjjared with the investing protoplasm : 
 they form a belt of densely crowded elements. The cortex, therefore, 
 of the area represented in Plate iv., figs. 1-3, is constituted of 
 
 (1) Peripheral cortical zone. (3) Ganglionic belt. 
 
 (2) Deep belt of granule-like cells. (4) Spindle cell layer. 
 
 (3) Outer Olfactory Type. — Passing now to the lower limbic arc 
 at the base, we find that the area marked Plate i., B, has a much simpler 
 form of cortex than those hitherto described — two belts of nerve cells 
 only are found in this region subjacent to its outer or peripheral zone. 
 This peripheral zone is specially characterised by the distribution 
 throughout its greater extent of fibres derived from the superficial 
 olfactory fasciculus, which lies embedded in this fix'st layer of its 
 cortex; fibres which ramify at all depths in this layer to unite with 
 the meshwork derived from the apex pi'ocesses of the cells beneath. 
 Next to this, succeeds a shallow belt of irregular cells, jjyramidal, 
 oval, or fusiform, small in size, each with a bifurcate apex process, 
 which immediately undergo rapid subdivision. They are ai'ranged 
 in peculiarly appressed clumps. Then amongst them appear a few 
 large cells of pyramidal contour, which deeper down increase in 
 number and foi'm a distinct belt, in which a few rather large elements 
 are seen. Traced outwards, beyond the limits of the great limbic 
 fissure, these larger elements appear to pass into the ganglionic series. 
 
TYPES OP CORTICAL LAMINATION. 91 
 
 ■whilst the small clumps of irregular cells pass into the small pyramidal 
 cells of the extra-limbic region. This cortex, therefore, comprises 
 
 (1) A peripheral cortical zone. 
 
 (2) Dense appressed clusters of small cells. 
 
 (3) Scanty large pyramidal cells. 
 
 (4) Inner Olfactory Type. — Covering Gratiolet's "olfactory 
 area," is a three-laminated cortex, comprising 
 
 (1) A peripheral zone. (2) A granule cell layer. 
 (3) Layer of spindle cells. 
 
 The second layer is formed of cells measuring 9 /a x 6 /x, with a 
 large spheroidal nucleus, 6 /i in diameter ; with these are associated 
 numerous minute granules only 5 ^ in diameter, like the gi-anule cells 
 of the modified upper limbic region. This layer is duplicated in 
 numerous folds, in which the outer layer does not participate. The 
 layer of spindle cells is notable for the large size of these elements : 
 they are reclinate, i.e., their long axis lies parallel with the surface of 
 the cortex. 
 
 (5) Modified Lower Limbic Type. — This unique formation, occu- 
 pying the small triangular area, shown in the figure (Plate i., T), is a 
 five-laminated type, the chief feature of which is presented by its peculiar 
 second layer of cells. These nervous elements are more than double 
 the size of those occurring in the second layer of the cortex elsewhere ; 
 they are large, swollen, globose, inflated-looking cells, which almost 
 invariably branch from the apex by a bifid or bicorned process. This 
 belt of inflated cells is superimposed on a series of small pyramidal 
 bodies, which succeeds them (Plate iv., fig. 2). A pale belt, devoid of 
 nerve cells, follows the latter, and is in turn succeeded by a series of 
 spindle cells. To recapitulate, we have here 
 
 (1) Peripheral cortical zone. (3) Small pyramidal cells. 
 
 (2) Layer of globose inflated cells. (4) Pale belt devoid of nerve cells. 
 
 (5) Spindle cell layer. 
 
 (6) Extra-LimbiC Type difiers from that of the upper limbic 
 cortex solely in the intercalation of a belt of granule or angular cells 
 between the small pyramidal and ganglionic series. This form of cor- 
 tex exhibits a very gradual transition to the upper limbic type, and, 
 therefore, presents an exception to the rule of abrupt demarcation 
 shown by other varieties of cortex. The gradual passage of one into 
 
92 LAMINATION OF CEREBRAL CORTEX. 
 
 another form we sliall have reason to refer to hiter on; for the present 
 it will suffice to enumerate tlie relative layers of this formation. 
 
 (1) Pei'ipheral cortical zone. (3) Belt of granule or angular cells. 
 
 (2) Small pyramidal layer. (4) Ganglionic series. 
 
 (5) Spindle cell series. 
 
 (7) Type of the Cornu Ammonis. — The cortex of the comu 
 
 presents several features common to other regions of the hemispheres: 
 we here have reproduced a peripheral zone to which run the radiate 
 apex processes of underlying cells : then a dense belt of ganglionic 
 cells : beneath which again we trace a spindle-form series of elements. 
 The distribution, however, of these several nervous constituents is so 
 far different as to stamp this type of cortex with features peculiarly its 
 own. Thus, the ganglionic cells form a single shallow belt of closely 
 ap])ressed elements, the apex processes of which, in close serried file 
 radiate outwards to the peripheral zone, no more cells, corresponding 
 to the second and third layers elsewhere, intervening : these radiating 
 processes give to this striate layeP the aspect from which its name 
 is derived. 
 
 Again, the peripheral zone is cleai-ly divisible into two sections — 
 an outer, with tangential, medullatcd fibres, containing sparsely scat- 
 tered spindle cells ; and an inner, which is peculiarly reticulated in 
 aspect, and is constituted by a nerve-fibre and a vascular meshwork. 
 The former is termed the nuclear layer ; the latter the lacunar 
 layer or " stratum reticulare " of Kupfter. The medullated stratum 
 corresponds to the same stratum which is found elsewhere in the peri- 
 pheral zone, and which we trace as continuous with the underlying 
 nerve-fibre plexus. The nerve-fibre plexus of the reticular Stratum, 
 howevei', reproduces that plexiform arrangement which is so well seen 
 in the olfactoiy cortex {outer olfactory type), and which is there largely 
 constituted by the bifurcate apex processes of the cells of the second 
 layer. Here, however, in the cornu these cells do not exist, and the 
 plexiform arrangement is wholly that resulting from the extensions of 
 the ganglionic belt, as well as the anastomosing network of blood- 
 vessels, Avhich are here provided with large perivascular channels. 
 
 Lastly, the spindle cell formation succeeding the ganglionic belt is 
 a fine, granular, faintly-stained layer, called by Kujjffer the " stratum 
 moleculare;" and constituted by a fine meshwork of nerve fibrils — the 
 secondary processes of the superimposed ganglionic cells, in which 
 spindle cells are freely scattered. These latter elements are found at 
 still deeper levels, where a pure white unstained stratum — the deep 
 medulla of the coi-nu — appeal's. In man the stratum nioleculare is 
 absent, tlie axis-cylinders of the ganglionic cells uniting directly with 
 
CORNU AMMONIS — OLFACTORY BULB. 93 
 
 the medulla forming the so-called alveits. We may, thex"efoi"e, regard 
 the cortex of this region as constituted by 
 
 (1) The peripheral zone divisible into — 
 
 (a.) Nuclear lamina. (6.) Lacunar or reticulated lamina. 
 
 (2) The striate layer. (3) The ganglionic belt of cells. 
 
 (4) The spindle cell layer (siratum moleculare). 
 
 (8) Type of the Olfactory Bulb. — A section through the bulb 
 
 reveals characters very distinct from those hitherto described, and in 
 some particulars reminds us of the structure of the retina. The outer 
 zone is constituted by a dense layer of nerve fibre, derived from 
 the olfactory nerves, which here terminate in globular bodies — the 
 olfactory g'lomeruli. These latter bodies really consist of fine 
 granular material imbedding the duplicatures of an olfactory nerve 
 fibre, whilst small nuclear elements are also scattered through the 
 mass. The layer itself is termed the stratum g'lomerulOSUm. This 
 is succeeded by the stratum g'elatinosum, where fusiform and 
 pyi'amidal cells in more or less scattered groups are found in a 
 connective matrix. Still deeper is an important formation of very 
 densely grouped, small granule cells in distinct clusters which resemble 
 closely the granule elements beneath the cells of Purkinje in the 
 cerebellum, and which, imbedded in horizontally disposed medulla, 
 alternate more or less regularly with the latter. We may enumerate 
 as distinct layers of the bulbus olfactorius: — 
 
 (1) A peripheral nerve layer. (3) The stratum gelatinosum. 
 
 (2) The stratum glomerulosum. (4) The stratum granulosum. 
 
 Our review of the foregoing types of cortical lamination in the 
 mammalian brain prepares the way for certain deductions which have 
 an important bearing upon the physiology and pathology of the 
 cerebrum. In the first place, let us note that the simpler forms of 
 cortex are confined to the lower margin of the cortical en^'elope, 
 where it folds round the cerebral peduncle at the base — the COrnu 
 
 ammonis, the lower limbic lobe ("outer olfactory type"), 
 
 and also the olfactory area of Gratiolet. 
 
 The more complex form of cortex, however, spreads over the 
 
 upper limbic arc and the whole of the extra limbic reg-ion of 
 
 the hemisphere. It is these more complex forms of cortex Avhich 
 concern us chiefly ; they comprise in man the extensive areas at the 
 vertex and the whole convoluted surface of the hemispheres, as seen 
 from above. Now, in studying the small brain of the rodent and 
 hieher animals we find structural modifications in the cortex of this 
 
94 DIVERSITIES OF COHTICAL LAMINATION'. 
 
 region, wliicli appear to forcsliadow tlie divergences observed in man. 
 Thus, if we examine successively the cortex at different points from 
 within outwards in a vertical section through the hemisphere, passing 
 through the Sylvian depression, we find that — 
 
 (a.) The first la^^er of the cortex is deepest at the sagittal border, 
 and steadily diminishes in depth as we proceed outwards towards the 
 limbic fissure ; 
 
 (6.) The second layer of small pyramidal cells increases rapidly in 
 depth and in wealth of cell-structure in a reverse direction — i.e., from 
 within outwards ; 
 
 (c.) The ganglionic series of cells (which assume thick clustered 
 nests in the tipper limbic arc and over the vertex bordering on the 
 sagittal fissure), gradually loses its confluent tendency and becomes 
 spread out in isolated units (" solitary type ") as we approach the 
 limbic fissui'e externally. On the other hand, if we examine similarly 
 a vertical section taken through the posterior moiety of the upper 
 limbic arc (Plates i. and ii.) we find that — 
 
 (d.) The intercalated series of granule cells increases in richness of 
 elements and depth of formation as we proceed outwards to the lateral 
 aspects of the hemispheres, and backwards to the occipital pole ; and 
 reaching the limbic fissure terminates abruptly, whilst the other layers 
 pass on iminterruptedly. If we now examine vertical sections of the 
 hemisphere in the antero-posterior plane, we find that — 
 
 (e.) The outer layer (peripheral zone) progressively diminishes in 
 depth from the frontal to the occipital pole ; 
 
 {/.) The small pyramidal cells of the second layer diminish in size 
 in the same direction ; 
 
 (g.) The granule or angular cells intercalated in the five-laminated 
 coi'tex increase in richness conspicuously towards the occipital pole ; 
 
 (Ji.) Lastly, the ganglionic series, which near the frontal pole forms 
 a deep layer rich in cell elements, thins out considerably backwards 
 into a laminar or " solitary " formation ; but, at the extreme occipital 
 pole, these cells again form a somewhat deep belt with granule cells 
 superimposed. 
 
 The obvious deductions to be made from the foi-egoing are that 
 certain elements preponderate in certain fixed areas of the cortex ; 
 and that the development of certain layers appears to exclude that of 
 another series. Thus the frontal pole and frontal extremity of the 
 tipper limbic arc are es})ecially characterised by the preponderance of 
 the g'ang'lionic series, which accumulates here in rich clustered 
 groups ; towards the .Sylvian border this element is insignificant, and 
 it is the small pyramidal layer which here prevails. Towards the 
 occipital pole mesially (" modified upper limbic type ") the granule 
 
■^1 
 
 
 riVi 
 
 • * 
 
 'I . 
 
 ^E 
 
 KIM Modifisx o^acory z-ypt 
 
 Dist 
 
 Cortex. 
 
Plate IV^ 
 
 
 
 
 -*: i^:/i' 
 
 'WVi 
 
 Mm A 
 
 
 . 1 * ^ 
 
 -4' 
 
 
 ^ 
 
 ^3^«^^ 
 
 
 
 
 ''■MS*' 
 
 \:\ 
 
 ■V-jf 
 
 
 ^'"^x_7 ,/ 
 
 C3 ti.t c/» 
 
REGIONAL DISTRIBUTION OP GANGLIONIC CELLS. 95 
 
 cell attains like importance from its notable wealth of elements and 
 its more or less complete exclusion of the small pyramidal series; wliilst 
 outside this formation, in the extra limbic cortex, the intercalated 
 granule belt is a notable feature, accompanying a corresponding 
 impoverishment of the small pyramidal and ganglionic series. 
 
 A certain relationship also would seem to exist between the depth 
 of the first layer or peripheral zone and the ganglionic series of cells ; 
 since it notably diminishes in depth as these elements thin out into 
 the solitary type of arrangement, and this despite the marked increase 
 in the small pj^ramidal series above. This mutual dependence seems 
 to us explained by the fact that the apical processes of these large 
 elements pass up into, and terminate in, this peripheral zone, so that 
 any regional difference in the depth of the outer layer will be dependent 
 on the greater or less development of these ganglionic cells. It must 
 be borne in mind, however, that the average depth of the first layer 
 increases in lower mammals and becomes shallower as we rise to the 
 more highly organised brains — a fact which does not militate, as might 
 at first appear, against the preceding conclusion. In the lower 
 mammals, the absolute and relative increase in the depth of this outer 
 layer probably means a large preponderance of the connective over 
 the nervous element.* 
 
 Reg-ional Distribution of the Ganglionic Cell.— Attention 
 
 was first dii'ected to the peculiai'ly clustered arrangement of these cells 
 in the cortex of man and the higher apes by Professor Betz,-j- who 
 denominated them "giant pyramids," and suggested their probable 
 motor signification from their form, arrangement, and connections. 
 Subsequent research appears fully to confirm the conclusion arrived at 
 by Betz,J and it becomes, therefore, important to indicate the regional 
 distribution of these elements. We find that this series of cells in man 
 and the higher mammals (Pig, Sheep, Dog, Cat, Ape, and Man) assumes 
 in separate regions of the cortex a different arrangement, which we have 
 
 * See upon this point, Meynert, "Brain of Mammals," Si/d. Soc, p. 3S3 ; also, 
 Brain, vol. i., p. 358. 
 
 t "Anatomischer Nachweis zweier Gehirucentra," Prof. Betz, Centralhlatt f. d. 
 Med. WisseMsch., Aug., 1884. 
 
 J It is true that Mej'nert would dispose of the assumed significance of these cells 
 on the grouud that their large size depends on the distance which their apical 
 process has to traverse in reaching the outer layer, and their gradual mcrease iu 
 dimensions being, as he states, proportionate to this distance. The "gradual 
 increase in size " alluded to proves to us that Meynert has failed to identify the 
 elements referred to — probably mistaking for them the larger pyramids ; and finally 
 his argument falls to the ground when it is seen that the second layer of the 
 " modified lower limbic type " contains larger elements than any of its subjacent 
 layers. 
 
96 COMPARATIVE STUDY OF CORTICAL LAMINATION. 
 
 termed the clustered or nested and the laminar or solitary 
 
 arrangement'' — the former showing tliese large cells aggregated into 
 distinct oval clusters stationed at intervals apart — the latter ap- 
 proaching the arrangement of these cells universally met with at the 
 base of a sulcus, viz. : — solitary cells, stationed like sentinels wide apart, 
 showing no tendency to gi-ouping beyond two or three at most in 
 certain exceptional areas. In lower mammals (Rabbit and Rat), these 
 discrete or distant clusters do not appear ; but what we take to be the 
 homologue of this series forms COnfluent grOUpS — the nested 
 arrangement being scarcely indicated, and a deep and dense formation 
 replacing the latter. As ali-eady observed, however, these confluent 
 groups thin out, in certain regions, into linear file, assuming the 
 laminar or solitary arrangement. The cells of this series in these 
 lowly-organised brains are peculiar in their extremely elongate pyra- 
 midal or fusiform contour, and approach in this respect the form of the 
 larger fyramiids in the human cortex rather than the configuration of 
 the motor cell. As we pass from the confluent groups of elongated 
 elements in the Rodent to the more specialised areas of higher 
 mammals, we find that — 
 
 (1) The cells become less elongate, more swollen, and irregular in 
 contour ; 
 
 (2) Their groupings become more and more discrete ; 
 
 (3) The individual groups grow larger in size ; 
 
 (4) The clustered arrangement occupies a wider range of cortex. 
 
 In Plate i. this series of cells is richly represented ; they are 
 densely congregated towards the margin of the hemisphere, and thence, 
 continued to the limbic fissure, occupy the whole area embraced by 
 Nos. 7 and 9 in Terrier's work.f Further back, however, this layer 
 diminishes in depth and in wealth of cells, except at the exposed 
 margin of the hemisphere, where it still remains a rich formation; 
 beyond the margin and over the extra-limbic region, as fiir as the 
 limbic fissure, the cells rapidly thin out into a simple linear series, and 
 the five-laminated cortex appears. Still further back the series, in like 
 mannei", thins out into a mere insignificant formation — yet always most 
 richly developed along the sagittnl margin of the hemisphere. 
 
 Plate ii., fig. 1, rej)resents the ai-rangement of the ganglionic series 
 in the Pig, the regional distribution of which is almost identical in 
 formation with that of the Sheep. For both these animals, 
 it may be stated, that a Jive-laminated cortex, with clustered cell- 
 groups^ spreads over the anterior half of the upper limbic arc (which 
 
 * "Comparative Structure of Cortex Cerebri," Tranx. Hot/. Soc, part i., 1880. 
 i Functions of the Brain, second edition, p. 259, fig. 78. 
 
THE CORTEX OF THE PIG, SHEEP, CAT, APE, ETC. 97 
 
 in these animals becomes superficial on the upper aspect of the hemi- 
 sphere) over the frontal pole and along the first (or Sylvian) and 
 second parietal convolution. Between these tracts is embraced the 
 area of the third and fourth parietal convolutions, which have 
 a six-laminated cortex and a distinctly solitary arrangement of these 
 cells. 
 
 If we examine the regional distribution in the Cat, the anterior 
 portion of the upper limbic arc in front of and above the crucial 
 sulcus; the frontal lobe; the first parietal, or Sylvian; and the anterior 
 extremity of the fourth parietal or sagittal convolution, will all 
 be found to exhibit the laminated cortex and nested cells ; yet the 
 formation, excessively rich in the sigmoid gyri around the crucial 
 sulcus, becomes much poorer in other regions. The six-laminated 
 type extends over the whole extent of the upper limbic arc, behind 
 the crucial sulcus, as far back as the retro-limbic annectant. 
 
 The distribution of these nested groups of ganglionic cells in the 
 ocelot, reproduces, in fact, very nearly the arrangement met with in 
 the cat. 
 
 The distribution of the same formation in the Barbary ape fore- 
 shadows the arrangement which pertains to the more highly developed 
 cortex of man. 
 
 It will be observed from the foregoing remarks that the CPUCial 
 sulcus in all these animals foi-ms a distinct limit to two types of 
 lamination — peculiar to the vertex — the flVG- and the siX-laminated. 
 types, and that this distinction is continued upon the mesial aspect 
 of the hemisphere into which this sulcus extends ; that, similarly, at 
 the frontal pole of the hemisphere, the vertical sulcus, regarded by 
 Broca as the representative of the fissure of Rolando, also separates 
 an inner or five-laminated from an outer or six-laminated cortex ; 
 whilst the first parietal or Sylvian convolution in the pig and 
 sheep partakes, in front of the Sylvian fissure, of the five-laminated 
 type. 
 
 In 1882,* after a minute enquiry into the cortical envelope of the 
 brain in mammals, the author had reason to express himself as follows : 
 — "The more fully I investigate the minute structui-e of the cortex and 
 its deep connections, the more forcibly am I impressed with the belief 
 that the vai'ious fissui'es and su.lci are not mere accidental productions,+ 
 but have a deep significance of their own, dividing oft' the cortical 
 superficies into morphologically, if not ijhysiologically, distinct organs. 
 
 * Op. cit. , page 724. 
 
 t That is, the result of pressure merely, during the development of the cranial 
 arch. 
 
 7 
 
98 COMPARATIVE STUDY OF COUTICAL LAMINATION'. 
 
 Hitherto the fissures and sulci wliich I liave found to be boundary- 
 lines of distinct cortical realms are the following : — 
 
 "(1) The limbic fissure. (4) The superior parietal sulcus. 
 
 {2) The infra-parietal sulcus. (5) The interparietal sulcus. 
 
 (3) The crucial sulcus. (6) The olfactory sulcus. 
 
 (7) The fissure of Rolando." 
 
 Contrasts between the Brain of Man and of Lower Mam- 
 mals. — When we contrast the cortex of the human brain and of the 
 ape with that of the mammalian series below these types, certain 
 strongly-marked resemblances in intimate structure, as well as equally 
 notable divergences, present themselves. With respect first to the 
 resemblances, it is to be noted that the various types of cortical 
 lamination described in the lower mammals are reproduced in the 
 brain of the ape and man ; and that the several layers maintain the 
 same relative position throughout their depth, except where in certain 
 cases a layer is wanting, or a new layer is interposed. Again, the 
 individual elements constituting these layers — the granule cell, the 
 angular cell, the spindle, the pyramidal element — although differing 
 somewhat in dimensions and general contour, are yet sufficiently alike 
 for their identification apart from their mere position in the cortex. 
 
 In the next place, the lower limbic margin of the coi'tical envelope 
 always presents the simpler forms of cortex; while, towards the vertex 
 and mesially both towards frontal and occipital poles, the more complex 
 forms of cortex pi'evaiL Another sti'iking resemblance occurs in the 
 distribution of these laminar types — that characterised by the g'ranule 
 cell predominating towards the OCCipltal pole ; that of the five- 
 laminated type being especially developed towards the frontal pole : 
 with this there is associated finally the gradual diminution in size of 
 the one element towards the temporal and occipital lobe, and the 
 increased dimensions and richness of formation of the other element in 
 the same direction. These are some of the more striking resemblances 
 presented between the cortex cerebri of roan and that of the lower 
 mammals. 
 
 As to the diverg'ences presented by these structures, we are early 
 struck by the fact that the abruptness Of transition from one to 
 another type of cortex, seen, e.(/., in the rodent, is not a feature in the 
 human brain; in fact, transition-realms invariably intervene betwixt 
 different types of lamination. The one fades into the other form so 
 gradually that a line of demarcation can rarely be drawn. Thus, the 
 five-laminated cortex characterising the "motor area" of the human 
 brain affords no abrupt transition into the six-laminated cortex lying 
 
THE MOTOR AREA IN MAN. 99 
 
 external and posterior to it ; a mixed type intervenes, to which we 
 have applied the term of "transition-realm." 
 
 In the second place, the cells which we have ventured to term 
 " motor " in the fourth layer of the human cortex, ditfer from what we 
 have regarded as the homologous series in lower mammals, in being 
 restricted as a typical formation to a comparatively limited area of the 
 cortex — that of the rodent, e.g., being spi-ead over a far wider propor- 
 tionate area of the hemisphere. This concentration of these cell- 
 groups is best seen in carnivora, where, as already shown, they crowd 
 around the crucial sulcus, especially at the angle of the sigmoid gyrus. 
 They exhibit the tendency in a less marked degree in the higher apes 
 whilst in miin they are concentrated in three or four districts occupy- 
 ing, as before stated, but a comparatively limited area. A still more 
 notable distinction between the higher and lower forms of brain 
 presented by this formation, is the nested arrangement observed by 
 Betz in the human brain. This segregation is complete, the groups 
 being large and far apart. As we descend the scale, however, the 
 more do we observe the tendency for such gi'oups to become confluent, 
 and the series to be disposed as an equable stratum. 
 
 Lamination of the Motor Area in Man.— That region of the 
 
 cortex which has been shown in animals to be electrically excitable, 
 and which upon stimulation calls forth responsive movements, has 
 been termed the "motor area." It is, as we have just seen, charac- 
 terised by a highly specialised structural arrangement. It is all the 
 more essential that its structure in man should be clearly defined 
 here, since it has been the subject of dispute between such writers as 
 Meynert, Betz, Baillarger, Mierzejewski, and others, some authox'ities 
 speaking of it as a five-laminated and others as a six-laminated type. 
 At the outset, therefore, it is well to define our own view of the case, 
 which is briefly as follows : — The cortex typical of motor areas is a 
 flve-laminated formation, and the more absolutely the granule- 
 cell formation (which, when intercalated, gives us the six-laminated 
 type) is excluded, the more highly specialised become those groups of 
 enormous nerve cells which go by the name of the " nests " of Betz. 
 Where, therefore, these cell-clusters are best represented, there we 
 find a five-laminated, not a six-laminated, cortex ; in other words, at 
 these sites the granule-cell layer no longer exists. Such a specialised 
 cortex is not spread uniformly over a large convolutionaiy surface at 
 the vertex — any such notion would be very far from correct ; but it 
 occupies very irregular, limited, and unequal areas along the course of 
 the ascending frontal and the junctions between it and the frontal 
 gyri, as well as the "paracentral lobule." These positions we shall 
 more clearly define later on. 
 
100 THE CORTKX CEREnUI IN MAN. 
 
 Such irregularly-disposed ivreas are severed from each other by a 
 transitional form of lamination, whereby these districts gradually 
 merge into the six-laminated cortex surrounding them. This highly- 
 specialised cortical formation is constituted as follows : — 
 
 First Layer. — An extremely delicate pale zone, devoid of nerve 
 cells, limits the cortex externally ; it i)resents all the features already 
 described as peculiar to the cortical neuroglia (see p. 79). The outer 
 surface, upon which the intima pia I'ests, presents numerous flattened 
 cells, from which excessively delicate processes pass downwards into 
 this layer. These cellular elements are often found, detached from 
 fresh sections, floating in the medium around ; they form, in fact, a 
 kind of epithelial limiting layer, extremely delicate and translucent. 
 This first layer, or perijjheral zone, exhibits a pellucid homogeneous 
 matrix (becoming finely molecular with reagents) and three structural 
 constituents — (a.) cellular, (b.) nerve fibi-e, (c.) vascular. 
 
 (a.) The cellular constituents are not numerous, are widely dispersed, 
 and belong to the two categories of the perivascular or adventitial 
 elements and the elements of the lymph-connective system already 
 referred to (p. 83). The former measure 6 /x to 9 ^ in diameter, 
 possess a spheroidal nucleus, stain well, and are seen disposed along 
 the course of the blood-vessels. The latter often measure 13 jti ill 
 diameter, possess one and occasionally two or three nuclei, are spher- 
 oidal, flask-shaped, or irregular in contoui', stain uniformly and very 
 faintly, and throw off numerous excessively delicate pi'ocesses, which 
 in healthy fresh cortex can only be distinguished with difliculty. 
 
 (b.) The nervous constituents embrace a series of medullated fibres, 
 which course along the outer division of this zonular layer, and a 
 minute network of the non-medullated fibres ai'ising from the cells of 
 the subjacent layers by the subdivision of their apex processes. 
 
 (c.) The vascular elements pass as long straight vessels for deep 
 distribution, and as shoi't branched and smaller vessels through its 
 structure ; they call for no special remark here. 
 
 Second Layer. — A narrow belt of very closely aggregated nerve 
 cells of irregular marginal contour, oval, pyramidal, or angular, with 
 a proportionately large nucleus, forms this stratum. The cells vary 
 much in size, and, as we have previously remarked, are much more 
 richly developed in some than in other regions of the brain. They 
 measui'e from 11 /i to 23 //- in length, 6 /a to 9 ^ in breadth, the 
 nucleus being often 6 /i in diameter. They exhibit numerous delicate 
 processes, radiating from the base and sides ; but a distinct apical 
 process or frequently a bi-corned apex passes up radially to the surface 
 of the cortex and undergoes rapid subdivision. 
 
 Third Layer. — Subjacent to the above lies a deep belt of nerve 
 
THE MOTOR AREA IN MAN. 101 
 
 cells, the elements of which are characterised by their more or less 
 elongated or pyramidal contour, and by the tendency to gradual 
 increase in their size as they lie deeper in the cortex. The summit of 
 these cells is elongated into a long delicate apex process, which passes 
 radially upwards towards the peripheral zone. The opposite pole 
 of the cell is irregularly dentated by the extension of numerous 
 delicate processes, which are thrown off from the cell in all directions 
 around : none of these processes turn upwards and pursue the course 
 of the apex process. The dimensions of these cells in the outermost 
 zone average 12 /^ x 8 /x; those of the deeper regions of this layer 
 23 iM up to even 41 /x in length, and 23 /x in shorter diameter. Each 
 cell possesses a large nucleus and a distinct nucleolus. Small pyramidal 
 cells, however, no larger than those at the commencement of this layer, 
 occur even at the deepest part, side by side with the largest. 
 
 Fourth Layer.— This layer presents us with the highly charac- 
 teristic nerve element which we have already dealt with under the 
 name of ''motor cell.'"' These great elements are found modified in 
 different cortical realms as follows : — 
 
 (a.) In the highest regions of the motor area (summit of central gyri 
 and paracentral lobule) they are not only of gigantic size, as compared 
 with other nerve cells around, but they form here the large clusters 
 recognised by Betz. 
 
 (6.) In the lowest regions of the motor area (lower end of central and 
 junction with third frontal gyrus) they become small in size, even less 
 than the superjacent elements of the third layer, but still retain their 
 clustered disposition. 
 
 (c.) Towards every sulcus these cells, be they large or small, lose 
 their groupings, and at the base of the sulcus they always assume the 
 drawn-out single file, spoken of as the " solitary " type of arrangement. 
 {d.) Lastl}^, as this laminar type passes into that of the sensory 
 realms, these cells have superimposed on them a layer of granule 
 cells, but still retain a somewhat clustered disposition so characterising 
 the transitional cortex; and they ultimately assume the solitary arrange- 
 ment always seen in a sulcus, throughout the convolution at all heights, 
 becoming, in fact, the six-laminated cortex typical of sensory areas. 
 Such are the modifications undergone by these elements at different 
 localities in the cortex. 
 
 Fifth Layer.— This layer is represented by the series of spindle-cells, 
 which beneath the summit of a convolution are disposed radially to 
 the surface in regular columns, separated by bundles of medullated 
 fasciculi, ascending from the central medullated core of the gyrus. 
 Towards a sulcus they lose this radial disposition, and at the bottom 
 of the sulcus are disposed in a narrow belt, their long axes horizontal 
 
102 
 
 THE CORTEX CEREBRI IN MAN. 
 
 to the surface, a position aptly termed reclinale. by Dr. Major. These 
 cells measure from 25 (j, to 32 /x in length, by 9 /x to 13 /i. in breadth, 
 and exhibit a large oA-al nucleus. 
 
 Distribution of the Motor-cell Groups.— The specialised five- 
 laminated cortex, with the cell clusters above referred to, has been 
 stated to occupy certain areas of the ascending frontal, the three frontal 
 gyri and the " imracentral" lobule ; it remains for us to indicate more 
 ])articularly the exact site occupied by this type. In the scheme now- 
 presented, the I'esults of an investigation into the localisation of these 
 areas in eight human brains, made in 1878 by the author in conjunction 
 with Dr. Heniy Clarke, are given.* The arrangement and distribution 
 
 Fig. 8. — Left ascending frontal and parietal convolutions seen from the side, with 
 the attached frontal gyri included in scheme of examination. 
 
 H-K, Third group of ganglionic cells. N-0, Fourth group of ganglionic cells. 
 
 M-N, Barren area. 11, Region of large elongate cells. 
 
 P, Fifth group of ganglionic cells. 
 
 •were strangely uniform in all these cases (see figs. 8 and 9). Variations 
 in the extent of these areas of course presented themselves, but not to 
 such an extent as to vitiate the general result arrived at, viz., that 
 such cell-clusters wei-e grouped into several distinct areas, very clearly 
 and definitely interrupted by the transitional type of cortex. The 
 
 * "The Cortical Lamination of the Motor Area of the Brain," by Bevan Lewis 
 and Henry Clarke, Proc. Hoy. Soc, No. 185, 1878. 
 
MOTOR CELL-GROUPINGS. 103 
 
 variations in the extent of such areas are no more than nii^ht be 
 anticipated from the developmental variations indicated by tlie form of 
 the central and neighbouring gyri. The upper end of the ascending 
 frontal and its junction with the upper frontal gyrus are, as is well 
 known, very variable in form and complexity, and such variations are, 
 in our opinion, closely related to the more or less rich development of 
 the specialised cortex under consideration. Reference to the scheme 
 shows us that the ascending frontal gyrus may, in general, for con- 
 venience of description be considered as consisting of two seo-ments — 
 an upper, com^jrising two-thirds its length, into which run the 
 superior and middle frontal; and a lower, comprising the remainino- 
 third, continuous with the inferior frontal in front, and with the 
 ascending parietal behind. 
 
 Taking first the upper two-thirds, we find that the i;pper end has 
 a somewhat broad attachment to the upper frontal. The lower end 
 receives the middle frontal usually as a narrower-folded convolution, 
 whilst between either junction a sinuous knee-like bend of the convo- 
 lution exists. The broad upper extremity continuous with the upper 
 
 R--.. 
 
 Fig. 9. — Left ascending frontal and parietal gyri, with the attached frontal 
 convolutions, as seen at the vertex. 
 
 *A-D, First group of ganglionic cells. M-N, Barren area. 
 
 E-G, Second ,, ,, N-0, Fourth group of ganglionic cells. 
 
 H-K, Third ,, ,, R, Region of large elongate cells. 
 
 frontal is the site of two important clustered groups (A-D and E-G) ; 
 the plump lobule intervening between both upper frontals is the site 
 of tAvo other similar groups (II-K) ; lastly, the extreme posterior end 
 of the middle frontal gyrus shows similar cell-groupings (N-0), the 
 areas of which extend into those of the ascending frontal at their lines 
 of attachment. 
 
 The upper group (A-D) presents by far the larger cells and the more 
 
104 THE CORTEX CEREBRI IN MAN, 
 
 perfect and dense clusters. Such clusters occupy especially the parietal 
 aspect of the convolutiun, which is adjacent to the ascending parietal 
 convolution. They appear, therefore, in the cortex forming the wall 
 of the Kolandic fissure, and creep up towards the summit, where they 
 rapidly thin out and disappear. 
 
 The second group (E-G), connected with the lower attachment of the 
 upper frontal, is entirely restricted to the frontal aspect of this gyrus, 
 and does not overleap the confines of the vertex and spread into the 
 Rolandic fissure, except at its most inferior part. 
 
 Tlie third group (H-K) forms a large area, covering the parietal or 
 Rolandic wall of its knee-like lobule (upper two-thirds), and spreads over 
 the vertex of the convolution at this site. Between it and the fourth 
 group occurs a narrow territory wholly devoid of this formation; 
 transitional cortex extending until we reach the latter group. 
 
 At the junction of tlie middle frontal (N-O). — This group, as before 
 stated, becomes continuous with that of the middle frontal ; it also 
 begins within the fissure of Rolando and sweeps over the vertex. 
 
 The fifth and sixth groups (P) are indicated approximately on the 
 scheme, but appear subject to considerable variations in extent. 
 
 To the foregoing groups must be added a further area, occupying the 
 posterior two-thirds of the lobule on the inner or mesial aspect of the 
 central gyri, lying in front of the fissure of Rolando and above the 
 gyrus fornicatus, usually termed tlie paracentral lobule. Some enor- 
 mous cells are found in the grouping's of this area. 
 
 Transition-Realms of Motor Cortex.— It will be observed that, 
 
 in the above enumeration of specialised areas, we have by no means 
 covered the ground assigned to the motor area by Prof. Ferrier : the 
 lower end of the ascending frontal, the whole of the ascending parietal, 
 as well as the postero-parietal lobule have been omitted. In fact, 
 these latter regions do not exhibit the specialised cortex referred to, 
 but are covex'ed by cortex transitional in its character between the 
 former and what we find existing in sensory realms. If, for instance, 
 the upper extremity of the ascending parietal be subjected to examina- 
 tion, we find that its anterior aspect, dipping down into the Rolandic 
 fissure, also possesses large ganglionic cells similar to those in the 
 motor area in advance of this site. The nests or clusters, however, 
 are not only thinly scattered, but contain few cells, and the latter 
 diminish rapidly in size at lower levels along this convolution; it is 
 only at the upper extremity of the gyrus that large cells are found. 
 Throughout by far the greater extent of this convolution, the cells of 
 this layer are exact representatives of those found in the ascending 
 frontal, hut are greatly diminislied in size, and although often arranged 
 in clustered groups, the groups are poor in elements and sparse. 
 
TUAN8ITI0N-REALMS AND SPKCIALISED AREAS. 105 
 
 The major distinction between the transitional and specialised motor 
 cortex is in the presence of a gradually increasing belt of small 
 pyramidal or angular cells, which are almost identical with those of 
 the second layer, and which here insinuate themselves between the 
 largest cells of the third layer and the sparse nests of the ganglionic 
 cells. Thus, with the fading-off of this rich clustered formation, we 
 get the intercalation of an entirely new layer of elements, which grows 
 in importance as we approach sensory realms. Now the whole ascend- 
 ing parietal, postero-parietal, and lower end of the ascending frontal 
 divisions, partake of this six-laminated type of cortex ; and, moreover, 
 as we approach the margin of the brain-mantle— i.e., the lower end of 
 the central gyri — the "motor" cells become smaller and yet smaller, 
 forming eventually insignificant clusters of minute elements. Eoughly 
 stating the case, we may say that the fissure of Rolando, in the upper 
 two-thirds of its extent, separates the typical motor cortex from the 
 transitional cortex; whilst, in like manner, the interparietal fissure 
 is the boundary between the transitional and the typical sensory cortex 
 below and posterior to it. 
 
 It will be apparent from the foregoing chapter on the histological 
 structure of the cortex cerebri that its many varieties of type depend, 
 for the most part, upon the operation of one or more of the following 
 circumstances. There may be — 
 
 (1) Inverse development of superimposed layers— such, for in- 
 stance, as was noted in the rodent's brain, where the third layer of 
 cells invariably became shallower with increasing richness of the 
 second layer of angular elements and vice versa. As the one formation 
 tends to die out, the other tends to increase in thickness and density. 
 
 (2) Substitutional StPatification may occur— i.e., a layer of 
 cells may have other elements mixed with it, and gradually pre- 
 ponderating to the exclusion of its own cells, and then a change 
 in type may occur; e.g., the granule cells may gradually intermingle 
 with the angular elements, and excluding them entirely, form a deep 
 belt in their place, or vice versd. 
 
 (3) Intercalation of new layers, as in the appearance of a six- 
 laminated type, where the angular elements gradually insinuate 
 themselves between the third layer of pyramidal cells and the sub- 
 jacent ganglionic series. Or, again, an altered type of cortex may 
 proceed from — 
 
 (4) An unusual development of the elements of a certain layer, as 
 when the angular element of the second layer develops into tlie large 
 
 globose cell of this layer in the modified lower limbic type of 
 
 the Rat, Rabbit, Mole, &c.; or where the elements of the fifth layer in 
 the sensory cortex become changed into the large complex cells of the 
 
106 TIIK CORTEX CEREBRI IN MAN. 
 
 motor grouping's. As we traverse the whole range of tlie cortex, 
 one or other of the above influences is at work in modifying its 
 form of stratification. 
 
 Passing now from the question of cortical lamination to the cell 
 itself, its conditions of life and functional activity, and its relationship 
 to its immediate environment, let us first ask ourselves what signi- 
 ficance, if any, is presented by the great variations in Size of the 
 different nerve cells : is it but an accident of their position in the 
 cortex as to relative depth : is it indicative merely of the cuje of the 
 cell : is it dependent on their specific functional connections : or upon 
 the degree of complexity attained by the nerve element 1 Is it a mere 
 " accident " of their position ? This has been assumed by Meynert 
 upon premises which cannot for one moment be admitted. In an article 
 published some ten years since,* Meynert summarily dismisses the 
 observations of Betz on the "giant cells" of the anterior central 
 convolution (" ascending frontal ") as of no importance, because the 
 explanation of their huge size is solely due, according to Professor 
 Meynert, to the greater depth of the cortex of this convolution ; the 
 apex processes of these cells, therefore, having to traverse a greater 
 distance in their low-lying groups ere they reach the outer layer of 
 the cortex. Their groupings, also, he explains as a mere pressing 
 together of the cells by the bundles of nerve fibres passing upwards 
 from the medulla of the gyrus. It is unfortunate that the great 
 Vienna histologist should lend the weight of his authority to so 
 utterly untenable a position. It is obviously natural to suppose that 
 the greater the distance along which a nerve cell has to transmit its 
 energy, the lax'ger will that nerve cell probably be ; in the next place, 
 as we are dealing with the non-mechdl ated fibre of the apex, we might 
 also assume that the loss by difiusion around nuiy also demand a 
 comparatively stronger discharge in such a case, and hence a pro- 
 portionately larger cell : all this is, of course, in accordance with 
 Meynei't's assumption. Moreover, that the pyramidal cells steadily 
 increase in dimensions with their depth is also in favour of his 
 position, were it invariably true; but this is not the case. It has 
 been shown in our examination of the brain-cortex in man and in 
 mammals, that alongside the largest pyramidal cells are numbers of 
 others of the smallest dimensions, which, according to Meynert's view, 
 should be much larger than the superimposed elements. Even in the 
 woodcut illustrative of the five-laminated cortex given in Meynert's 
 original memoir,t we find numerous exceptions to his rule, that the 
 smaller element is always higher in the cortex, and, given a section 
 
 * Psi/chiairi.9ch('s Centrcdhlatt, No. 6, 1878. 
 + " The Brain of Mammals," Syd. Soc. Trans. 
 
SIGNIFICANCE OF CELL-GROUPINGS. 107 
 
 of brain examined by the fresh methods, such exceptions become very 
 nnmerous indeed. That the general tendency to this larger size with 
 tlieir deeper position is maintained, we of course allow; what we 
 dis^iiite is the explanation afforded, which leaves out of consideration 
 the numerous exceptional small elements referred to. 
 
 In the next place, were this explanation held tenable for this form 
 of cortex, the formation described by us as the modified loweP 
 limbic cortex of the rodent woiild entirely confute such a principle, 
 since here we have a series of very larg'e cells, the largest by far 
 in the whole depth, here lying quite superficial as the second layer 
 of the cortex. 
 
 What then is the more probable explanation of this increase in size 
 of the cell ? If we carefully note a section of fresh bi-ain, we find that 
 although the majority of the pyramidal cells steadily enlarge at 
 greater depths — the ganglionic cell-clusters, but a very short remove 
 from the largest pyramidal cells, represent an enormous leap in 
 dimensions. Plates i. and ii. represent conclusively what we have 
 here stated : the outlines of the cells are represented at their re- 
 spective levels as sketched by the camera lucida, and it is seen that 
 the upper elements measure but 18 <«. x 11 /x, being quite superficial 
 in the series of small pyramids : that the lowest of the series include 
 elements measuring but 36 /a x 23 /a, although at a depth of 1116 /i 
 beneath the former : whilst a little higher we find numerous cells 
 measuring 18 /^ x 13;«- in size — i.e., very slightly larger than those of 
 the superficial series, although 953 /a beneath them. When, however, 
 we pass from the largest pyramidal to the ganglionic cells lying only 
 209 ijj lower down, we come suddenly upon huge elements measui-ing- 
 from 84 /i to 97 /* in length, by 36 (m to 46 [m in breadth. The increase 
 in dimensions, therefore, is so sudden as to be out of all proportion 
 to the greater depth of this layer. Is there, then, no constant re- 
 lation between the size of the cell and other conditions to which it is 
 exposed, which may give us the required explanation 1 
 
 This we believe to be the case: we find as a constant accompaniment 
 of increasing bulk, much more complex relationships with surrounding 
 cell-districts — in other words, the larger the cell, the greater the number 
 of its branches. But the older the nerve cell, the longer time has it 
 had for the establishment of organised relationships around ; and hence 
 it follows that the older cell is also the larger element. In fact, it 
 appears to us that the size of the nerve Cell is chiefly dependent 
 
 upon its ag'e and the multiplicity of its surrounding" connections. 
 
 There is, however, another factor which must be allowed much weight 
 in the case of the motor cortex. The medullated fibre (axis-cylinder 
 process), which arises from the basal extremity of the great motor 
 
108 
 
 THE CORTEX CEREBRI IX MAN, 
 
 cells, traverses uninterruptedly an enormous distance to reach the 
 respective cell-groups which rei)reseut in the spinal cord the muscu- 
 lature of the limbs. The distance traversed is very unequal between 
 the lumbar and cervical groups ; the cortical centres representing the 
 lower extremities having not only a greater distance through which 
 to discharge their energy, but a far more massive musculature to call 
 into activity, than is the case with the arm-centres of the cortex. 
 Again, the cortical centres for the upper extremities not only act 
 through a greater range, but they innervate larger groups of muscles 
 than do the centres for the head and neck, the muscles of articulation, 
 deglutition, &,c. It would, therefore, be natural to presume that the 
 cortical cell groups representing these respective regions would differ 
 considerably in the size of their individual elements. The histology 
 of the motor area fully warrants us in stating this to be the case : 
 the smallest cells being found at the lower end of the central gyri and 
 Broca's convolution — and thence increasing rapidly in size upwards 
 towards the centres for the great musculature of the limbs, as illus- 
 trated by the following table of actual measurements : — 
 
 Comparative Size of Braix Cells. 
 
 
 AvF.RAOE Size of 
 Gakgliun Cells. 
 
 Largest Cell — 
 Maximum Sizb. 
 
 Left ascending frontal (upper end), . 
 
 60 M X 25 /x 
 
 90 m X 45 m 
 
 Frontal gyri (areas at posterior end), 
 
 45 m X 20 M 
 
 69 M X 27 /i 
 
 Left ascending frontal (lower end), . 
 
 35 M X 17 M 
 
 41 M X 18 m 
 
 Left ascending parietal (upper end), . 
 
 66 M X 41 ju 
 
 88 M X 41 M 
 
 ,, ,, (nuddle third), 
 
 46 M X 37 fx 
 
 55 M X 32 M 
 
 ,, ,, (lower third), 
 
 41 /x X 24 ,x 
 
 ... 
 
 We find this law fully borne out by the results of an examination 
 of the bulbar and spinal cell groups in different regions — the g"reat9P 
 musculature being presided over by the groups of laPgest CellS. 
 We, therefore, see reason for regarding the dimensions of these cells in 
 the cortex as influenced by — 
 
 (1) Range of discharging distance. 
 (2) Size of musculature innervated. (3) Age of nerve cell. 
 
 (4) Resulting multiplicity of cell connections. 
 
 It will be seen from these conclusions that the deopsst elements 
 are not necessarily the oldest, for some of the lowest of a series are 
 
THE NUCLEUS OF THE NERVE CELL. 109 
 
 very small and very simple in their connections — the reason for this 
 was shrewdly given by Dr. Ross from observations on the develop- 
 ment of the motor cell groups in the anterior cornu of the spinal cord.* 
 His statement is to the effect that the younger cells are in close con- 
 tiguity to the blood-vessels : that as growth proceeds, they are thrust 
 further aside, so that the larger and older cells lie midway between 
 parallel vessels. No one familiar with the structure and disposition of 
 the cortical elements of the bi'ain will fail to see the force of this sugges- 
 tion. These small pyramidal elements which we meet with constantly 
 side by side with the older cells, are found often with very few lateral 
 branchings, and the apex-process thins out rapidly and is lost to view 
 at a short distance from the cell, notably contrasting in this respect 
 with the older elements, whose apex-process can be traced up into the 
 first layer or peripheral zone. It is important to note this fact — new 
 elements are being continually formed, which for some time have no 
 connection with the grey meshworh of the outer zone of the cortex. 
 These extensions from the apex or centric pole of these young cells 
 continue to thrust themselves further outwards, meanwhile forming 
 lateral connections by delicate offshoots, with nerve-fibre plexuses 
 around. 
 
 Can we suggest the significance borne by the nucleus in the 
 autonomy of the nerve cell? — The results of physiological experimenta- 
 tion by Ferrier, Hitzig, Horsley, and Beevor, and clinical investiga- 
 tions, especially those of Hughlings- Jackson, appear conclusively to 
 indicate the anterior or fronto-parietal realms of the cerebrum as 
 especially motor ; and the occipital and temporo-sphenoidal lobes as 
 especially sensory, in their endowments ; and it is, to say the least, 
 highly suggestive that the large pyramidal and ganglionic cells 
 peculiarly characterise the former, just as the smaller elements and 
 densely aggregated granule cells characterise the latter — that, in fact, 
 as we pass from motor to sensory realms, so we find the nerve cells 
 progressively diminishing in bulk and the granule cell progressively 
 pi'eponderating in number. Dr. Hughlings-Jackson long since sug- 
 gested the representation of small muscles by small cells, requiring as 
 they would, in their almost ceaseless lively activity, rapid and frequent, 
 though short, discharges of energy ; in fact, he regards such small 
 elements as necessarily of unstable equilibi'ium. His words are as 
 follows : — 
 
 " I have suggested that the size and shape of cells, as well as their nearness to 
 the tumour, or other source of irritation, will have to do with their becoming 
 unstable ; other things equal, the same quantity of matter in many small cells will 
 present a vastly greater surface to the contact of nutrient material than the same 
 
 * Diseases of the Nervous System, vol. ii., p. 26, ISSl. 
 
110 TlIK CORTKX CEHEUHI 1\ MAN. 
 
 quantity in one large cell. I have also susfgested that small muscles, or, more 
 properly, movements which require little energy for the displacements they have 
 to etlect (tliose of the face and of the hands in touch, for example), are represented 
 by small cells. Such movements are rapidly changing during many of tiie 
 operations they serve in — writing, for example — and require repetitions of short 
 liberations of energy, and necessitate quick recuperation of tlie cells concerned. 
 Movements of the upper arm are, in comparison, little changing, and require 
 persistent steady liberation of energy." * 
 
 When, however, we consider the assumed sensory element of the 
 cortex — the minute angular and granule cells — we must not lose sight 
 of a remarkable distinction between them and the assumed motor 
 unit, and that is, the great proportionate preponderance of the nucleus 
 to the cell itself in the former. That the nucleus does exert souie 
 mysterious influence over the nutritive and functional activity 
 of the cell has long been surmised ; and the results of our histological 
 inquiry indicate that nuclear degeneration within the nerve cell is 
 peculiarly associated with certain states of mental and motorial in- 
 stability. We have long been accustomed to regard it as related more 
 definitely to the functional activity of the cell, and less direclly 
 related to the nutritive activity of the cell. In other words, the 
 cell is subject to a constant supply of nutritive plasma — it gradually 
 assumes a state of nutritive instability, and will necessarily discharge 
 its accumulated energy in accordance with the simple law of nutri- 
 tive rhythm — the resulting stable equilibrium is succeeded by a 
 measurable period ere the potential energising of the cell has once 
 more brought it up to its former state of instability. Were this all 
 
 that occurs, the process of storag"e and liberation of energ'y 
 
 would be a simpler rhythmic process than the more compounded 
 rhythm which actually pertains to mental operations. 
 
 If, however, we regard the nucleus as affecting the functional activity 
 of the cell, as, in fact, restraining or inhibiting" its discharg-e, as a 
 kind of imperium in imperio exercising a controlling influence upon the 
 perturbations which reach the cell from sensory surfaces : then the 
 presence of a healthy nucleus would become an all-important feature 
 in the cell-life — a feature of the utmost significance to us in our patho- 
 logical enquiries. What really does occur when these nuclei are 
 especially affected by morbid processes, we shall refer to more particu- 
 larly in our chapter on the epileptic neuroses. The view we have here 
 taken of the significance of the nucleus would lead to the conclusion 
 that when, from its degeneration or morbid state, it fails to inhibit the 
 cell, these nerve elements would be subject to a rapid runniny-doivn 
 
 * " On Temporary Paralysis after Epileptiform and Epileptic Seizures," Brain, 
 vol. iii. , footnote to p. 43G. 
 
EXCITABILITY OF CORTEX. Ill 
 
 on trivial excitation, and in servile obedience to the law of nutritional 
 rhythm ; in fact, we should here find an explanation of morbid insta- 
 bility such as, e.g., in motor realms results in convulsive states, and in 
 the substrata of mental operations in varied psychical states and 
 reductions in consciousness. 
 
 It is these considerations which induce us to regard the dispropor- 
 tionately large nucleus of these small angular elements of the second 
 layer of the cortex as being of some significance. Subject as such 
 minute cells are to a rapid accumulation of energy, we might presume 
 that some restraint must be established to prevent their reckless 
 liberation of energy, and, hence, we believe such restraining capacity 
 to be afi'orded by the very large nucleus. In the next place, we 
 have every reason for believing that this superficial belt of angular 
 cells is in direct organic connection with the subjacent cells of large 
 size, and that their morbid instability would, therefore, aff"ect these 
 larger units, which, from the small size of their nucleus, would be more 
 subject to the law of nutritional rhythm in their discharge of energy. 
 As indicated by Dr. Ross, and also in the preceding note by Dr. 
 Hughlings- Jackson, the large cell would present a far smaller area 
 in contact with nutrient material than the same amount of protoplasm 
 broken up into numerous minute elements; and hence, such large cells 
 would labour under nutritive disadvantages — would be reservoirs for 
 the slow accumulation and storage of energy, which, when liberated, 
 would again result in a tardy reinstatement of nutritive instability. 
 
 Electrical Excitability of the Cortex.— Fritsch and Hitzig were 
 
 the first to demonstrate, in the year 1870, the excitability of the cortex 
 in animals to the galvanic current; and three years later Prof. Ferrier 
 prosecuted with the faradaic current his first investigations into the 
 functions of the cerebral hemispheres. The method of stimulation 
 employed by Ferrier was, to use his own description, "The application 
 of the electrodes of the secondary spiral of Du Bois-Reymond's induc- 
 tion coil, connected with a cell of the mean electro-motive power of 
 one Daniell. The resistance in the primary coil was such as to give 
 a maximum current of 1-9 absolute unit, as estimated for me by 
 my colleague, Professor Adams. The induced current generated in 
 the secondary coil at 8 cm. distance from the primary spiral was of a 
 strength sufiicient to cause a pungent, but quite bearable, sensation 
 when the electrodes were placed on the tip of the tongue." * We can 
 but briefly summarise here some of the more important facts elicited 
 by these experimental methods respecting the reaction of the cortex to 
 electric stimuli. 
 
 Latent Period of Stimulation and Summation of Stimuli. 
 
 * Functions of the Brain, 2ud Edit. , p. 223. 
 
112 THE CORTEX CERp:i5Kl IN MAN. 
 
 — It is from these phenomena we infer that tlie cortical areas found to 
 be excitable are really centres, in the proper acceptation of tlx- tcim. 
 It must be remembered that a ganglionic centrum is an elabOFEtive 
 structure, and that stimuli api)lied to it meet with delay ere the result- 
 iu^' response be elicited. The excitation of a centre is therefore accom- 
 panied by the time element seen in nerve stimulation in a marked 
 degree, and this is very appreciable in the stimulation of the so-called 
 psychO-motOP centres of the cortex. This is well brought out on 
 contrasting the effects of a carefully-regulated current applied to the 
 cortex of this realm, with the effects of the same current as applied 
 to the medullated strands immediately beneath, by first excising the 
 overlying cortex. In the first place, we find (after, of course, abstracting 
 the time requiied for transmission down spinal cord and motor nerves 
 and the latent pei'iod of the muscle) that the retardation is 0045 of 
 a second, and in the latter place, 03 of a second {Franck and I'ilres). 
 So, also, if very feeble stimuli be applied to the cortical centres their 
 summation occurs, so that no contraction takes place until several 
 stimuli have been delivered. Of the many interesting facts revealed 
 by the researches of Schafer and Horsley, Franck and Pitres, relative 
 to the eflTect of electric stimuli on motor centres, the moi'e important 
 may be stated as follows : — 
 
 (1) In the savie animal tlie number Of Stimuli per second requisite 
 to produce a continuous contraction is always the same for cortex, 
 motor nerve, and muscle. 
 
 (2) A continuous contraction does not occur on stimulating a 
 motor centre, until the rate of stimuli reaches 4G per second ; below 
 this, single contraction occurs for each shock or thereabouts. 
 
 (3) The contractile rhythm of muscle, whether it be cortex, 
 corona radiata, or spinal cord that is stimulated, has been shown to 
 follow this rule : — 
 
 Rhythm of stimulus below 10 per second = muscular rhythm 
 
 identical. 
 Rhythm of stimulus at above 10 per second = muscular rhythm 
 
 constant and independent {Schafer and Horsley). 
 Rhythm of stimulus about 4G per second = continuous muscular 
 
 contraction {Franck and Fitres). 
 
 (4) The muscular curve of cortical stimulation is less sudden in 
 its rise and more sustained than the curve shown in subcortical 
 stimulation, and all voluntary muscular contractions show a similar 
 rate of iindulation in the muscular curve. 
 
 Modifying" Circumstances. — The excitability of the cortical areas 
 is subject to great variation. Thus, different animals vary in the 
 
FUNCTIONAL EQUIVALENCE. 115 
 
 intensity of stimulus required to produce the adaptive movement; 
 and the same animal will vary from time to time as regards this 
 susceptibility, according to the conditions in which it is placed. 
 Severe hsemorrhag'e greatly reduces or even abolishes, whilst 
 moderate loss of blood exalts, the excitability of these parts 
 {.\hink, IJitzig). Prolonged expOSUre and Stimulation rapidly 
 exhaust, whilst apnoea, and the deep narcOSiS of chloroform, 
 ether, chloral, and morphia abolish it (Schif), so that all animals 
 completely anjesthetised fail to reveal such excitability. So if the 
 cortex be in a state of inflammatory irritation, its excitability 
 can be readily aroused by even mechanical stimuli, which in health 
 have no such effect. In new-born puppies, Soltmann obtained early 
 response to stimulus of the corona radiata, whilst it was not until the 
 te7ith day that he was able to obtain such response by stimulation 
 of the motor cortex. 
 
 Functional Equivalence. — Some authorities have inclined to the 
 belief that a process of functional compensation occurs when 
 injury, disease, or experiment has removed a motor centre : that either 
 the opposite sound hemisphere, or even some other portion of the same 
 hemisphere, may assume the functions of the area destroyed. It is 
 undoubtedly true that centres bilaterally associated and least inde- 
 pendent recover soonest from a lesion of one centre, and are least 
 affected in the issue, as is indicated in the history of all cases of 
 ordinary hemiplegia; but this can scarcely explain what we meet 
 with in experiments on dogs. Here it has been shown that if the 
 motor centres of one hemisphere be destroyed, the resulting hemiplegia 
 is soon recovered from, and if this were due to the substitutional 
 activity of the other hemisphere, ablation of the centres in the latter 
 would presumably paralyse both sides. This, howevei', is not the 
 case ; for, as Carville and Duret clearly proved, the reinstated power 
 of the limb first paralysed is not affected by the second operation. 
 The explanation is, therefore, not one of functional substitution by 
 another region, but is really due to the more automatic character 
 of the movements in these animals ; in other words, these movements 
 are far more dependent upon the activity of lower centres and are less 
 represented in psycho-motor or cortical realms. In man and the 
 monkey such movements are brought more under the control of the 
 volitional centres— they are removed, as it were, to a higher plane of 
 activity, are less automatic, more independent, and their removal by 
 disease or injury is followed by absolute paralysis of the opposite 
 members. 
 
 Phenomena of Electric Stimulation of Cortex.— Professor 
 
 Ferrier ^ives preference to the faradic stimulation of the cortex, 
 
 a 1 g 
 
114 TlIK COUTKX CICKICUUI IN MAN. 
 
 rjitlier tliiiu tin- galvunic, .since tlie first requisite is a stimulus of a 
 certain duration, and not the momentary eilect of the opening and 
 closing of a galvanic circuit ; the latter also has the further objection 
 of inducing electrolytic decomposition of the brain-surface if its action 
 be long sustained. If the intensity of current be greater than necessary, 
 diffused stimulation occurs, so that neighbouring areas are aroused 
 into consentaneous activity. 
 
 Extra polar conduction has also been proved to occur by Carville 
 and Duret, as seen in contractions of a frog's gastrocnemius, the sciatic 
 nerve of which rested on the occiput of a brain, the motor area of 
 which was stimulated. This fact, however, does not vitiate the results 
 of a minimum current applied to the motor cortex. 
 
 Conduction to lower centres, as the basal ganglia, has been by 
 some assumed to be explanatory of the results of stimulation of this 
 motor area. This argument is, however, wholly disposed of by the 
 fact that (1) direct stimulation of these ganglia (corpora striata) results 
 in entirely different movements, not the adaptive, purposive movements 
 which the psycho-motor centres elicit; and that (2) when we bring the 
 electrodes upon their immediate superficial aspect, at the insula, no 
 response whatever occurs. As might have been surmised, the radiations 
 of the coronal medulla, entering into connection with the motor cortex, 
 are in like manner functionally differentiated ; and, as shown by 
 Burdon-Sanderson, when the cortex is removed and they are stimulated, 
 similar purposive movements can be called forth. 
 
 Proximity of Psycho-Motor Centres. — It has been seen that 
 
 the so-called motor cortex, distinguished by the nested cell-g"rOUps 
 of the fourth layer, is so distiibuted as to occupj^ distinct areas, 
 separated only by narrow intervals from each other. This fully 
 accords with the fact that the phenomena of electric stimulation of 
 the cortex demonstrate the clOSe proximity of wholly distinct 
 centres, as Pi-ofessor Ferrier remarks—" Areas in close proximity to 
 each other, separated by a few millimetres or less, react to the electric 
 current in a totally different manner." * 
 
 * Loc. cit., p. 229. 
 
PART II.— CLINICAL SECTION. 
 
 General Contents.— States of Depression — States of Exaltation — Fulminating 
 Psyclioses— States of Mental Eufeeblement— Recurrent Insanity— Epileptic 
 Insanity— General Paralysis of the Insane— Alcoholic Insanity— Insanity at 
 the Periods of Puberty and Adolescence- At the Puerperal Period— At the 
 Climacteric Epoch — Senile Insanity. 
 
 STATES OF DEPRESSION. 
 
 Contents.- Mental Depression Defined— Decline of Object-Consciousness— Pase of 
 Subject-Consciousness— Muscular Element of Thought- Failure in the Rela- 
 tional Element of Mind— Sense of Environmental Resistance— Reductions to 
 Automatic Levels- Sense of Effort— Restricted Volition— Enfeebled Repre- 
 sentativeness—Transformations of Identity— The Physiological Aspect— Defec- 
 tive Circulation— Nutritional Impairment— Explosive Neuroses— Hunger of the 
 Brain -Cell— Painful and Pleasurable Mental States— Reaction-Time in Melan- 
 cholia—Degrees of Mental Depression— Clinical Varieties of Melancholia- 
 Simple Melancholia— Delusional Melancholia— Hypochondriacal Melancholia- 
 Melancholia Agitans— States of Mental Stupor— Stupor and Hypnotism— Acute 
 Dementia. 
 
 Painful mental states are of course normal under certain conditions 
 in health and sanity. As in the intellectual sphere it is but human 
 to err, so in the emotional sphere it is but human to suffer, and 
 to feel acutely : hence it is not the intensity of mental pain (although 
 this is often far greater than in healthy states similarly aroused) that 
 characterises this phase of disease, for if the anguish be the outcome of 
 commensurately painful circumstances, we regard it as but a natural 
 reaction. It is in the fact that the emotional storm is out of all 
 proportion to any exciting cause, that we recognise the departure from 
 the standard of health. It is essential, therefore, that we carefully in- 
 quire into the antecedent circumstances of our patient's disorder, so as to 
 determine whether there are adequate causes to account for the distress 
 apparent — if so, there is but normal physiological reaction, and cerebral 
 function cannot be regarded as deranged. If, however, the mental 
 pain is the result of trivial exciting agencies, if moral or physical 
 agencies arouse emotional states out of all proportion to what would 
 occur in the healthy mind, then we infer that the grey cortex of the 
 brail! is so far disordered as to functionate abnormally, and we speak 
 of the result as pathological depression. It is clear, therefore, that our 
 chief difficulty in distinguishing normal from abnormal states of 
 depression depends on our correct estimate of the correspondence 
 of emotional states and their excitants, due allowance being made for 
 
116 STATES OF DEPRESSION. 
 
 special ppcuHaritios of tonipcramcnt. We cannot apply the same rule 
 to a callous, nncinotional nature as to one refined and sensitive. 
 
 In our search for adequate causes we do not confine our attention 
 to the patient's environment ; we must look for possible moral agencies, 
 such as shock, disappointment, domestic affliction, together with 
 physical agencies, such as injury, disease, privation, or, again, overstrain 
 of mind or vicious habits of life — in all alike, the real causes are 
 centric, and consist in a disordered function — the incapacity of reacting 
 commensurately in the conditions in which the organism is placed — 
 in physiological terms it is a "disproportionately excessive" reaction. 
 " The melancholia which precedes insanity is distinguished from the 
 mental pain experienced by healthy persons by its excessive degree, 
 by its more than ordinary protraction, by its becoming more and more 
 independent of external influence, and by the other accessory affections 
 which accompany it " (^Griesinger)* By one thoughtful writer it has 
 been suggested that melancholia might be spoken of as a homologous, 
 while mania and monomania might be termed heterologous affections.! 
 This, of course, would imply a quantitative and qualitative distinction ; 
 but, since emotional and intellectual states may be disordered quali- 
 tatively as Avell as quantitatively, the parallel is scarcely applicable. 
 Emotional disturbances as the result of disease differ from the normal 
 reactions of health, not only in volume but also in nature : as Herbert 
 Spencer indicates, the correspondence may vary in two directions, 
 quantitatively and qualitatively, in degree as well as in kind. 
 
 With respect to the non-relational feelings — the appetites, pains, 
 &c. — Herbert Spencer says : — " Their great indefiniteness of limitation 
 and accompanying want of cohesion forbid unions of them, either 
 simultaneous or successive. Obviously, the emotions are characterised 
 by a like want of combining power. A confused and changing chaos 
 is produced by any of them which coexist." | This very want of 
 relativity, this dissociability and absence of a tendency to form strong 
 coherent groups, at once account for the comparative difficulty of 
 estimating the degree of mental alienation in melancholia, as contrasted 
 with states of delusion, where we are dealing with definitely measurable 
 factors. 
 
 Simple pathological depression is ushered in by that failure in 
 object-consciousness which invariably inaugurates a corresponding 
 rise in subject-consciousness ; and which, we have reason to infer, 
 implies a diminished functional activity in those realms of the cerebrum 
 correlated thereto. The patient exhibits a growing indifference to his 
 
 * Mental Disrates, p. 210, 
 
 t Piojc/iohgical Medicine, Bucknill & Tuke, 3rd edit., p. 440. 
 
 t Principles of Psychology, vol. i., p. 177. 
 
ORIECT- AND SUBJECT-CONSCIOUSNESS. 117 
 
 former pursuits and pleasures : the ordinary duties of life and business 
 become irksome and devoid of interest : especially do all forms of 
 mental exertion cause ennui and distaste — the attention cannot as 
 formerly be directed without undue effort, and so reading becomes 
 laborious and thought sluggish and monotonous. The environment 
 fails to call up pleasurable associations — a dreariness and gloom 
 pervade the outside world, since it is interpreted in terms of the 
 predominant feeling. All aspects of object-consciousness alike indi- 
 cate the neg"ative state. There is a want of vigour in the 
 representation of the environment, and feelings aroused thereby are 
 at a low ebb. 
 
 Corresponding to this there is a rise in SUbject-COnSCiOUSneSS, 
 shown in the prevalence of painful mental states — the predominance 
 of gloomy emotions. This is the positive aspect of the patient's 
 mental state, and this aspect is the one which chiefly obtrudes itself 
 upon our notice. It is characterised especially by an all-prevailing 
 gloom, varying in degree from mild depression uj) to acutely painful 
 mental states. The subject may complain of vague anxiety — a feeling 
 of some impending evil — an indefinite prevision of coming sorrow, 
 which gives its own colouring to objective existences : he retires from 
 social converse, which but adds to his irritation and mental distress, 
 gives himself up to introspective states, in which he dwells upon 
 the present contents of his mind, broods over his morbid feelings, 
 and falls into long reveries, the subject-matter of which partakes of 
 the same gloomy colouring. He is hyper-sensitive over trifles, irritable 
 and impatient, or his querulous humour may alternate with sullen 
 silence and obstinacy. Even in this reticence and retirement from 
 social responsibilities, this growing apathy to all around or feeling 
 amounting to dislike or direct hostility, we recognise the origin of 
 that subjectivity, that egoistic state which, in more advanced affections 
 of the mind, conjures up delusions of encroachment and persecution. 
 
 In every case of mental depression we have this duplex state to 
 study — the negative affection of object-consciousness, and the positive 
 affection of subject-consciousness. 
 
 Griesinger also asserts that forms of mental depression are due to 
 states of cerebral irritation and mental excitation; but he apparently 
 fails to recognise the duplex nature of the phenomena in neglecting 
 the distinction between the two realms which comprise the totality of 
 consciousness. Thus he says : — 
 
 " In employing the term, ' states of mental depression,' we do not wish to be 
 understood as implying that the nature of these states or conditions consists in 
 inaction and weakness, or in the sitpprms'ion of the mental or cerebral phenomena 
 which accompany them. We liav-^e much more cause to assume that very violent 
 
118 STATES OF DEPRESSION. 
 
 stales of irritation of the brain and excitation in the mental processes are here very 
 often the cause; but the general result of these (mental and cerebral) processes 
 is depression, or a paii)ful state of mind. It is sufficient to recall the analogy to 
 physical pain ; and to those who imagine they make things better by substituting 
 'cerebral torpor' and 'cerebral irritation' for 'depression' and 'exaltation,' 
 it may fairly enough be objected that in melancholia there is also a state of 
 irritation." * 
 
 Had he asserted that both conditions co-existed, a state of cerebral 
 torpor in the physical substrata of object-COnsciOUSneSS, and a state 
 of cerebral irritation in the substrata of SUbject-COnSClOUSneSS, 
 he would, we think, have faithfully recorded the morbid phenomena. 
 The normal variations in these antithetic halves of consciousness, with 
 which reverie and dreamy states render us familiar, have been thus 
 lucidly expressed by Herbert Spencer, when in reference to the vivid 
 and faint aggregates of consciousness he says : — 
 
 " Though entire unconsciousness of things around ui? is rarely if ever reached, yet 
 tlie consciousness of them may become very imperfect ; and this imperfect 
 consciousness, observe, results from the independence of the faint series becoming 
 for the time so marked that very little of it clings to the vivid series." t 
 
 Decline in Object-consciousness. — The various states of con- 
 sciousness and the changes from one to the other constitute collectively 
 the sole elements of mind ; and our considerations, therefore, apply to 
 feelings and the relations between feelings. First, let us note that the 
 variations from the normal state embrace a quantitative and a qualita- 
 tive change. Feelings may succeed each other in rapid order, or in 
 slow, monotonous file ; they may arise in serial order, or numbers of 
 disconnected states may simultaneously thrust themselves into the 
 field of consciousness, producing turmoil and indefinite vague emotion 
 and thought. On the other hand, mental phenomena may exhibit a 
 qualitative alteration, such as, e.g., is shown in degrees of intensity of 
 feeling, or again, of definiteness as due to the more or less relational 
 character of the product. The decline in object-consciousness which 
 occurs in states of pathological depression, such as we are now dealing 
 with, presents us with the following features : — 
 
 (a.) Enfeebled representativeness: (6.) a lessened seriality of thought 
 (weakened attention) : (c.) diminution or failure in the muscular 
 element of thought. 
 
 The last appears to us so important a factor in these morbid states, 
 as to demand here somewhat careful and detailed consideration. 
 
 Failure in the Muscular Element of Thoug-ht.— The constant 
 
 accompaniment of depressed mental states is an enfeebled range of 
 
 * "Mental Diseases," Syd. Sor., p. 210. 
 t Principles of Psycholor/y, vol. ii. , p. 459. 
 
FAILURE IN THE MUSCULAR ELEMENT OF THOUGHT. 119 
 
 perception; and, since every perception is a complex phenomenon of 
 coniposite states of consciousness — if one or other of the essential 
 elements of an idea or of a presented object be wanting — the definite 
 realisation of such object or idea is defective. The loss may be in the 
 more sensuous element of the perception — in those qualities, in fact, of 
 body which are categorised as dynamic (" primordial "), e.g., colour, 
 odour, taste, or the pure sensations appreciated by the specialised 
 senses of sight, hearing, taste, or smell ; again, the loss may pertain 
 chiefly to the statical or primary attributes of the perception— 
 those of size, position, form. A vigorous perception of these primary 
 or space attributes of body is dependent largely ttpon our " sixth " or 
 muscular sense. If, therefore, this sense undergo any diminution, 
 so will the space-attributes of body become less vividly conceived— 
 the cognition is hut feebly produced. The sense of sight is pre-eminently 
 interwoven with the muscular mechanism involved in our perception 
 of objects : and, since the retinal field can only receive the impress of 
 these dynamic attributes of body by means of a musculature, which 
 rotates the eyeball and so disposes the visual axis suitably, the know- 
 ledge of such movements, comprising figure, bulk, and position in space, 
 becomes inextricably blended with these dynamic attributes. 
 
 There is little doubt that the retinal impressions are, in states of 
 melancholic depression, but feebly produced; but whether the muscular 
 element of perception is first or simultaneously aflfected, is an enquiry 
 of special interest. And here we must distinguish between that portion 
 of the muscular element which enters into our higher intellectual con- 
 cepts, and that grosser factor of the large musculature of the limbs, kc, 
 which subserves the purpose of locomotion and coarse movements. The 
 sense of muscular contractions which forms the basis of the primordial 
 ideas of form, size, position, lapses eventually in consciousness as a pure 
 sense of muscular contraction. With the larger musculature this is 
 not so : it is essential that the movements of the limbs, their con- 
 traction, and tension should be exquisitely registered centrally, as 
 thereby alone can we gain an idea of their position in space apart 
 from the sense of sight, and appreciate the relative weight of objects 
 and the resistance ofi'ered by them. The unrestrained action of 
 these muscles signalises to our minds the absence of external resist- 
 ance, and the rise in the muscular sense which accompanies any 
 resistance opposed is the direct measure of such resistance. Similarly, 
 with the " muscularity of thOUg"ht," which in the normal state is 
 of free and easy play, the rise into consciousness of its primordial 
 muscular element means efi'ort, and at once suggests to the mind 
 the same notion of resistance in the environment. It is obvious, 
 we think, that the muscular element is the first to decline : for 
 
120 STATES OF DKl'RESSION. 
 
 cases of intense grief, as from a sudden mental shock, are associated 
 with a notable contraction of this sphere, and space diinemsions are 
 altered and contracted. This feature is one of importance, since it 
 clearly points to the decline of the more relational elements of 
 
 the perceptive process. 
 
 The rohitions of bulk, coiitignration, and position are recognisable only by the 
 intellectual operations of the miud, and it is this intellectual element which is 
 earliest enfeebled. This follows, therefore, the inverse order of the evolution 
 of psychical powers. Muscular sense, which appears much later in the evolution 
 of the nervous system than do the general or the specialised sensations of 
 sight, hearing, &c., is in morbid states the first to succumb. The infant learns 
 to appreciate the colour of an object long before he has received the visual percep- 
 tion of its form, bulk, and position : he learns to recognise sounds ere the direction 
 whence they proceed establishes the organised series of reflected changes in certain 
 nuclei of the medulla, which enables him to turn the head and localise the source 
 of such sounds. 
 
 Just as in the infant we trace the sensuous element of mind as 
 preceding in evolution the relational element, so, in dissolutions of 
 the nervous system in the insane, the inverse order is followed, and 
 the relational decline before the sensuous or " primordial " sensations : 
 and, since a relation can best be defined as a state of consciousness 
 " holding together other states of consciousness " (Herbert SjJencer), so 
 individual conscious states become dissociated or unrelated. The loss 
 of such relational element implies a certain degree of intellectual 
 torpor ; but, as we shall have reason to see, the sense of volitional 
 freedom, which is probably an abstract product of the muscular sense, 
 must in like manner decline. Our vigorous perception of the outside 
 world depends largely upon vivid states of consciousness : our realisa- 
 tion of such related states by muscular sense and its derivatives may 
 be compared to a mental g'rasp of the environment : and, in direct 
 proportion to the vigour of such grasp, does our power over the envi- 
 ronment predominate, and the resistance of the latter diminish. In 
 states attended by decline of the muscular or relational element of 
 mind, therefore, external resistance must be ^?ari jmssu intensified, and 
 the apparent energy and freedom of the will restricted. 
 
 Let us analyse this component of ideation more thoroughly, and we 
 shall find that not only is every perception evolved from a series of com- 
 plex related states of consciousness, but that every concrete perception or 
 idea is attended by certain vivid primaxy states of consciousness and other 
 secondary component impressions which fail to rise into consciousness, 
 or are more or less revivable or i-epresentative. Now such unconscious 
 components of an idea which we take, so to speak, for granted — these 
 lapsed states of consciousness, although they form an integral com- 
 ponent of the perception or ideal representation, are chiefly of mus- 
 
SENSE OF ENVIRONMENTAL RESISTANCE. 121 
 
 CUlaP OPig"!!!. If, in every conception of a spliere, the roll of the 
 eyeball on its axis were induced, the objective origin of the perception 
 of its form would be evident : but, although such actual muscular 
 movements do not occur, yet the musculatures productive of such 
 movements have their centres innervated by each such perception. 
 Still, such innervation as a direct muscular state or sense of muscular 
 tension and movement fails, in health, to rise into consciousness — an 
 automatic play calls up vivid representation of form and figure without 
 any consciousness of muscular action or strain. As before stated, the 
 frequent repetitions of the muscular act essential to the knowledge of 
 figure, position, &c., have eventually resulted in a lapse of the same 
 muscular action in consciousness. 
 
 If, however, delaij occur in the production of such relational states, 
 the statical attributes of body will be perceived only after COnsCiOUS 
 effort ; even actual muscular movement and the tension so brought 
 about for the realisation of more vivid conception of form, configur- 
 ation, and bulk, will give that sense of strange effort which metes 
 out to us the resistance of the environment. Do actual muscular move- 
 ments occur in the deranged states with which we are now concerned, 
 and does eonscious effOPt thus arise upon planes which are normally 
 devoid of such feelings 1 The melancholic exhibits to a notable degree 
 the effort which it causes him to think, reflect, or attend to what is said, 
 or to what he reads. It appears to us that the true explanation is 
 due to mental operations being reduced in level so far as to establish 
 conscious effort in lieu of the usual unconscious operations, or lapsed 
 states of consciousness which accompany all intellectual processes. The 
 restless movements of the intellectual eye (in the artist, poet, <fec.), as 
 well as those of the state of maniacal excitement, bespeak in the former 
 case the exalted muscular element of thought, and in the latter a highly 
 reflex excitability; but in the melancholic these muscles of relational 
 life are usually at rest, the eye is fixed, dull, heavy, sluggish in its 
 movements and painful in effort, the eyelids are drooped, the limbs 
 motionless. The only muscles in a state of tension are those which 
 subserve emotional, and not relational life, viz., the small muscles of 
 expression. 
 
 Hence, the failing vigour of representative states aroused in simple 
 perception or ideation, issues in the sentiment of objective resistance. 
 The environment encroaches pari passu with the failure of that faculty 
 whereby the mind projects out of itself, so to speak, an environment, 
 or revives in idea impressions received from the environment. It is 
 the motOP element of mind which is here at fault — the relational 
 element of thought, since it is the space attPibuteS of bodies which 
 are involved. Now, since in the appreciation of these attributes of 
 
122 STATES OF DKPRKSSION. 
 
 body (form, bulk, itc.) tlie subject is active and the object passive, it 
 results that the motor constructive element of tlu; idea is the one which 
 suffers. In other words, failure in the muscular element of thought 
 has as its results on the subjective side, enfeebled ideation and the 
 sense of objective resistance. 
 
 With respect to the sense of resistance from the environment, it is 
 of interest to note its artificial production in the reductions of con- 
 sciousness by the agency of antesthetics. To any one, e.g., who has 
 been anaesthetised, and who recalls his experiences, say, with nitrous 
 oxide, it must be obvious how the environment crowds in upon one 
 more and more, and how the ego, or personality enslaved by its power, 
 finally feels that thought itself is succumbing to its resistless advance. 
 
 Restricted Volition. — As in the sphere of perception, so when 
 taking into account consciousness in its totality, we likewise find the 
 same failure in those complex muscular centres, which, in their adjust- 
 ment to the environment, issue in what we term conduct. All 
 volitional acts categorised under this head are the resultants of many 
 factors, or rather the result of the struggle between many contending 
 forces. A certain line of conduct or a certain action being determined 
 upon, presupposes the repi'esentation in consciousness of the several 
 possible lines of action. This, in other words, is equivalent to saying, 
 that various feeble motor excitations are represented in consciousness, 
 and that the stronger the aggregate of excitations in any special direc- 
 tion, the more does it tend to issue in action. Volitional actions are 
 hence preceded by nasCent motOF excitations. Such excitations 
 are the basis of the act represented to the mind in ideas which more 
 or less vividly precede the act as realised. 
 
 In this conflict volition may be enfeebled as the result of failure of 
 those initiative emotions, desires, and sentiments which are in abey- 
 ance in states of depression; or it may be convulsively restricted as the 
 result of two opposing antagonistic forces, as when such groups of 
 motor excitations divide the attention between them, and the mind 
 sways from one to the other in hesitation and doubt ; or, again, such 
 motor excitation as forms the impulse to action cannot be definitely 
 and strongly represented, and this enfeeblemcnt of muscular represen- 
 tativeness issues in apathy and inaction. 
 
 A clearer conception of the resultant phenomena may be gleaned by 
 contrasting the voluntary and the involuntary or automatic acts. In the 
 latter, the ideal movements have lapsed in consciousness — the stimulus, 
 whatever it be, is followed so rapidly by the appropriate reaction that 
 the nascent motor excitations do not rise into consciousness. The 
 start of surprise, the suddenly assumed attitude of self-defence, the 
 mechanical movements employed in conveying food to the mouth, and 
 
ENFEEBLEMENT OF MOTOR REPllESENTATION. 123 
 
 the masticatory actions following thereupon, as well as other complex 
 though automatic acts, have no initial motor antecedent represented 
 in our consciousness ; yet all these movements are exquisitely co- 
 ordinated and rapidly executed. 
 
 In the enfeeblement of motor I'epresentations preceding volitional 
 acts during states of depression, the actions themselves, if performed, 
 are sluggish, mechanical, and devoid of normal energy ; and herein 
 lies the distinction between healthy automatism and these abnormal 
 states. The distinction is more important than at first sight may 
 be apparent, for upon it hinges the explanation of the automatic 
 freedom of maniacal states, which implies, as we shall see further 
 on, a grave and more serious reduction. The apathy and sluggish 
 reaction of melancholia appear in part due to this want of vigorous 
 motor representation; the true characteristic of a normal and vigorous 
 mind is the vivid realisation in consciousness of the action or line 
 of conduct to be pursued — the ideal recognition of all alternative 
 lines of conduct by the contrasting faculty, together with the repre- 
 sentations of similar actions previously performed, with the result as 
 affecting the organism. 
 
 In normal states, each group of the feelings which we class as desires 
 and sentiments rapidly tends to swell the aggregate of its own motor 
 excitations: so rapidly does this natural attraction of "like to like" go 
 on, that the contrasting faculty whereby the result is obtained appears 
 often to act with incalculable rapidity by a process which Spencer 
 calls "automatic segregation." This process is impaired in 
 states of depression, and becomes sluggish, feeble, and hesitating. Those 
 faint summations of ideal movements which are aroused as the incitants 
 to volitional acts may mutually antagonise each other ; and their very 
 want of vigour will of itself neutralise that distinctive quality wliich 
 enables the one group to preponderate and overcome the other in 
 action. 
 
 To employ a figurative illustration — thus do we witness in the surgiug tide 
 advancing upon a rocky shore, two waves diverging at an angle ; the one, receiving 
 fresh impulses from minor wavelets which take the same course, swells into a rising 
 crest ; the other, receiving no additions, subsides exhausted. Or, two such waves 
 of different size advancing the one upon the other, the higher, representing the 
 aggregate swing of numerous undulations, overcomes and carries with it the surgiug 
 elements of the weaker. Or again, to illustrate the feeble representations alluded 
 to, let us picture the Uniform ripplets advancing by thousands on the surface ; from 
 want of co-operation, each maintains its own distance from the other, no great con- 
 trasting aggregate of movement is formed, collecting to itself stray pulses of force, 
 and hence all alike come to the shore with similar insignificant results. 
 
 Want of vigorous representation, enfeebled contrasting faculty of 
 thought, antagonistic tendencies, or lastly, recession or restriction of 
 
124 STATES OF DEPRESSION. 
 
 those feelings which normally excite to voluntary reactions, may one 
 or all take part in that restriction of the ego which we speak of as a 
 restrained volition. 
 
 Here again, we have suggested to the mind that resistance of the 
 environment which inevitably results where subject-consciousness has 
 a diminished range. It may at first sight appear contradictory to 
 speak of a Jail in object-consciousness and a rise in subject-consciou.s- 
 ness as issuing in a sense of resistance from the object-world, and a 
 state of enfeebled subjectivity : this is, however, the case, since the less 
 definitely the mind conceives of external realities, the less vivid their 
 representations — the wider the margin for doubt, suspicion, and ideas 
 of encroachment from without. We fail to grasp the environment : 
 we do not hioiv it, in the sense of measuring our strength against it — 
 and hence ive/ear it. 
 
 So again, the enfeeblement of subject-consciousness pertains only to 
 that " faint aggregate of conscious states which the vivid aggregate 
 tends to draw after them into being " {Spencer), viz., the ideas con- 
 nected with the outside world, and the representation of our reactions 
 upon the same — hence the faculties of ideation and volition are im- 
 paired. Far otherwise is it, however, with the more sentient element 
 of the self-consciousness — that mass of bodily sensations, visceral, 
 muscular, articular, cutaneous, and the feelings and emotions and 
 sentiments which in the aggregate constitute the sentient or passive 
 eg'O — it assumes a concentrated and exaggerated intensity, and this 
 is what we refer to as the rise of subject-consciousness as distinguished 
 from the decline of object-consciousness : a truly self-analytiC 
 state. 
 
 Failure of Personal Identity. — If, now, we attempt to trace 
 
 further the decadence of mind, in progressive forms of mental disease, 
 we arrive at a very notable stage, and one of profound import, when 
 the failure of object-consciousness is so far advanced as to lead to 
 alterations in the patient's notions of his relationship to the outer 
 world, and to a confusion in his own identity.* A considerable difier- 
 ence is observable in these cases of confused identity, but the more 
 important distinction appears to exist between 
 
 (a) Cases of transformed identity associated with general feelings of 
 regard or good-will to the outer world, and a universal sense of well- 
 being, or, at all events, a complete indifference to the environment ; 
 and 
 
 (6) Cases where, with the transformation of the ego, the environ- 
 ment or non-ego is also transformed in the patient's mind into a 
 
 * See on this point especially Pdbot, p. 107-110; also Griesinger's Mental 
 Diseases, p. 51 ; cf. Spencer, Sully. 
 
TRANSFORMATIONS OF IDKNTITY. 125 
 
 formidable, encroaching, and persecuting foe ; whilst all its manifesta- 
 tions usually tend to call up a sense of repugnance and hostility. The 
 ego may exist as a double personality, each independent of the 
 other, or the one swayed by the other, and utterly dissentient in their 
 nature. We need not here deal with these minor differences, but 
 rather consider the development of the latter class, where the 
 identity is transformed and the non-ego is estimated in terms of the 
 malign. It is well, perhaps, at once to state, that these latter forms 
 appear to us to arise out of the various melancholic types of alienation, 
 whilst the former are educts of the more purely maniacal affections. 
 
 How does this mysterious transformation arise 1 The ego is consti- 
 tuted by the vast aggregate of sensations derived immediately from the 
 body, which are a complexus of all grades of sensory manifestation, 
 from visual and other special senses to tactual and general sense, as 
 well as the far less definite organic or visceral sensations. 
 
 All those ingoing currents which arouse, more or less definitely, our 
 knowledge of the existence of a body, its limbs, _musculatui-e, and 
 viscera, conjointly aid in the elaboration of the ego or personal identity. 
 But the ego is far more than this. We must associate therewith those 
 representations of the same, and moreover the ''faint aggregate," as 
 Spencer terms it, of states aroused by presentative cognitions of the 
 outer kosmos. 
 
 Our sentiments, ideas, emotions, as well as our memory of presenta- 
 tive states, all alike go to form that complex elaboration — personal 
 identity, which is severed sharply from the "vivid aggregate" known 
 as the non-ego — the physical in contradistinction to the physiological 
 environment. Now, since in all normal states, the internal order 
 bears a definite relationship to the "outer order" of things, when 
 either of these is profoundly disturbed, the identity tends to suffer 
 considerably, as indicated by Sully. We are all acquainted with 
 transient confusion of identity, in those waking states when we fail to 
 realise the impressions suddenly received from the environment ; and 
 were the latter completely and suddenly transformed, we should fail 
 to restore immediately the balance necessary to re-establish our own 
 identity. 
 
 So, when the internal mechanism is deranged, and the orderly 
 relationship of inner to outer kosmos is confused, personal identity is 
 apt correspondingly to suffer. We have already seen how this may 
 occur in the progressive failure of object-consciousness. 
 
 The failure to appreciate external relationships, again, is associated 
 with that gathering gloom, that sense of outward resistance, fear, and 
 insecurity of the non-ego already alluded to. Impressions from the 
 outer world fail to arouse the normal representative states of cogni- 
 
126 STATES OP DEPRESSION. 
 
 tion, but aid in the welling-up of the emotional life of the subject, and 
 it is from this latter source that falsifications Of senSG arise. 
 
 As subject-consciousness becomes nion; and more pronounced with 
 failure of object-consciousness, all impressions alike, received from the 
 non-o2jo, become the pabulum for the growth of an all-pervading 
 effOism. The subject broods over his multiform and novel feelings — 
 niorl)id introspection and egoistic musings replace the healthy 
 altruistic feelings and sentiments : and, since the emotional life is 
 itself in part the origin of representative cognitions of the outer kosmos, 
 so oiU of this source there novj arise falsifications of the environment. 
 
 The pervading gloom, the sense of objective restriction, and the 
 emotional states so aroused, attract to themselves like groupings of 
 ideas—" attempts at explanation," as Griesinger has it ; and this 
 state progressing, tends eventually to the establishment of a neW 
 nexus of ideas correlated to impressions received from without, in 
 lieu of the old and normal relationships pre-existing. It would be a 
 fallacy to assume that the falsifications of the environment irrecede the 
 emotional disturbance, or that delusions of persecution beget gloomy 
 and malignant passions — this would really invert the actual sequence 
 of phenomena. A gloomy emotional background begets a gloomy 
 interpretation of the non-ego, and all delusions of persecution are 
 be^ot in like manner out of disordered emotional states. 
 
 Such translations, if we may so speak, from emotional realms to the realms of 
 thought are, even in normal states of mental life, of frequent occurrence: they 
 peculiarly characterise the poetic faculty, and distinguish the purely emotional and 
 imaginative from the intellectual type of mind; but, where such emotional incitants 
 to thought are in themselves the product of morbid action, the intellectual result 
 of such operations is liable to be delusive and false. The more immediaie concepts, 
 as we may term those which are the result of pure intellectual operations, unas- 
 sisted by, or only associated with, emotional states, are more subordinate to 
 accurate laws of logic : the more mediate concepts, emotionally derived, are less 
 siisceptibl-e to such exactitude of classifying and grouping. Such concepts, in the 
 morbid states now under consideration, are utterly illogical, uuclassifiable, frag- 
 mentary, and betray but the dixjecia memhra of a once rational mind. It appears 
 to us that such distinctions between the immediate and the mediate knowledge, 
 so acquired in the case of the insane, are all-important in our conception of the 
 genesis of these morbid conditions of the ego. 
 
 We have been tracing in these mental operations the transformation 
 of the environment to the alien's mind : out of the old tissue, by a 
 species of rearrangement and reconstruction, is woven a fabric repre- 
 senting to him the reality of external things, and which to him is the 
 only reality, but, to his former state of sanity, is an utter falsification. 
 Since this morbid concept is projected out as the actual kosmos, and 
 since internal order must correspond to the external, so a transfer- 
 
TUANSFOllMATIONS OF IDENTITY. 127 
 
 mation of the ego itself responds to this altered state — the former 
 identity is lost and replaced by the new. 
 
 And here we have an explication of tliat newly-acquired freedom, 
 which, at this juncture, appears to dawn upon the mind of tlie mono- 
 maniac. No longer are phenomena in the outer world laboriously 
 investigated and subordinated to rigid laws of logic and of science — 
 they pass, as through a magic crucible, the morbid tissue of his brain, 
 and are transformed in accordance with no objective laws, but take 
 their colour wholly from the morbid emotional states present. Self- 
 creations arise with wondrous celerity and of protean form ; and the 
 morbid imagination conjures up fantastic groupings utterly devoid of 
 coherence and objective reality. A feeling of new freedom replaces 
 the old one of restriction and aggression by the environment, and the 
 ego is consequently endowed with new faculties, new powers — becomes 
 a mighty potentate or a god. Still, the environment is indelibly 
 stamped with the malign character which the former emotional state 
 fostered, and it is only in late stages of the malady that such realisa- 
 tion of a new-got freedom entirely effaces the enmity of the non-ego 
 from the mind. 
 
 Like all sudden and extensive transformations of mind, the change 
 thus delineated must be accompanied, as Griesinger has indicated, by 
 great emotional disturbance, "as the results of the conflict between the 
 old and the new." He says, referring to the new sensations and 
 instincts which become generated : — 
 
 "At first these stand opposed to the okl / in the character of a foreign thoii, often 
 exciting amazement and fear. Frequently their forcible entrance into the whole 
 sphere of the perception is felt as if it were the possession of the old I by an 
 obscure and irresistible power, and the fact of such forcible possession is expressed 
 by fantastic images. But this duplicity, this conflict of the old I against the new 
 inadequate groups of ideas, is always accompanied by painful opposing sensations, 
 by emotional states, and by violent emotions. " * 
 
 It will be seen that we differ from the above statement, in regarding 
 the emotional perturbation not as the outcome of the " conflict between 
 the old and the new ego," since it appears more in accord with the 
 sequence of the phenomena to regard the morbid emotional storm of 
 this period as being the direct origin of the newly-generated identity. 
 
 Reductions such as ensue from nervous dissolutions alone, can scarcely 
 explain the phenomena with which we meet : we must, in addition, 
 suppose a process of re-illteg"ration to ensue. 
 
 The level to which the mental life is reduced is still one of active, 
 nascent, mental life,t and, like all such nascent life, is accompanied by 
 
 * "Mental Diseases," Sjid. Sue, p. 50. 
 
 + Dr. Hughlings-Jackson has repeatedly insisted upon the negative and positive 
 results of epileptic seizures. 
 
128 STATKS OP DEPKKS8I0N. 
 
 much emotional disturbance. Even in these morbid minds there is no 
 reason to suppose that the same process does not proceed, which we 
 assume to occur in profound sleep, where the re-e^iery'isimj in planes, 
 while the individual is for the time unconscious, still proceeds, and 
 so mental potentialities are unconsciously acquired. So also in the 
 monomaniac, though the activities be those of lower planes, still they 
 indicate developmental activities, and those groups of sensations 
 and ideas are conserved which are the fittest to survive : irrational 
 as may be the beliefs, inconsistent the new concepts with the actual 
 trutli, still, as Hughlings-Jackson indicates, they are the best possible 
 in the patient's state of reduction.* 
 
 As the tide of intellectual life retires, so does it well-up into emotional 
 states ; but such emotional Avave must have its rebound, and this is 
 expressed in the re-integration Avhich pervades the mental organism 
 with fresh ideas and concepts; and when such groups acquire a certain 
 
 definite cohesion amongst themselves, we have the g^enesis of a 
 new identity. 
 
 It is only at an advanced stage of dissolution that this transfor- 
 mation of the ego can occur — we may safely assert that extensive 
 connections between distant nervous mechanisms must be deranged or 
 dissolved, ere that failure of association of ideas could occur which 
 always precedes this morbid change. Fresh connections probably 
 arise, through the newly-forced channels of the emotional wave, and 
 new centres of internal cohesion are begot and evolve the fresh 
 association of ideas of the transformed ego. 
 
 And here we might note what we shall later on deal with more 
 fully — -viz., those transformations of the personality which characterise 
 certain critical or climacteric periods of life — notably that of puberty. 
 It can readily be conceived how powerfully the mental life is affected 
 by the re-integration of the new encroaching sensations into fresh 
 instincts, desires, impulses ; or as at the menopause by the ablation, so 
 to speak, of one of the strongest instincts of the nervous constitution, 
 the sexual. Can it be a matter of wonder that, at these critical 
 periods, the risk to the mental integrity should be great, or that, 
 
 * We are prone, by the loose phraseology of common life, to regard the subjec- 
 tive as a permanent i)0Sfeession — to speak of our mind as a something lieyond the 
 simple active contents of the moment and as the accumulated i)sycliical activity 
 of our total existence ; as if thoughts could be buttlcd-up permanently and 
 unchangeably. It is the material substratum of thouoht — the organised nervous 
 plexuses — which represents the permanent and the potential revivabilities of former 
 experiences, as Herbert Spencer says: — "Just as the external nexus is that which 
 continues to exist amid transitory appearances, so the internal nexus is that which 
 continues to exist amid transitory ideas." — Principles of Pbijcholofjii, p. 485. 
 
THE PHYSIOLOGICAL ASPIXT. 129 
 
 in many subjects, permanent damage should ensue 1 So interwoven 
 are these instincts with the whole fabric of mind, that a complete 
 transformation of the sentiments and feelings follows, as the result 
 of such incorporation. Obscure longings and yearnings, imperfect, 
 indefinite perceptions, emotional surgings wliich have no obvious origin 
 or purpose, characterise a period of perturbation of the mental life, 
 which may readily lead to misdirected efforts or morbid impulse and 
 disease.* 
 
 The Physiological Aspect. — In dealing with states of mental 
 depression, did we attempt anything like an artificial division of this 
 class of the vesania?, it would appear to us more important to lay 
 emphasis upon the morbid pi-ocesses to which they are traced, when- 
 ever such processes can with justice be assumed. It is clear that the 
 symptomatic indications of the so-called varieties of melancholia point 
 not so much to a fundamental distinction in their essential nature as 
 to one in their mode of origin : they indicate quantitative as well 
 as qualitative variations in the nutritive functions of the nervous 
 centres, and, hence, are roughly divisible into groups, comprising 
 those which arise from direct disturbance of the blood-current, and 
 those which are induced in the nervous tissues primarily. 
 
 Two groups stand strongly contrasted here : the one, in which a 
 defective cerebral circulation is the more prominent feature ; the 
 other in which an acute nutritional anomaly of the nerve-centres 
 expresses itself in still more unmistakable symptoms. A further 
 group may be constituted by the vai-ious qualitative variations of 
 the blood-plasma — tOXSemia, kc. — a group conveniently placed 
 between the two former. It will at once be evident that this is a 
 very arbitrary grouping, the one condition being often associated 
 with the other — nay, evolved out of the other. Thus, defective 
 circulation leads eventually to grave nutritional anomalies, so that 
 the symptoms of the first group may pass into those of the third, 
 although the usual result is not its passage into the acute but into 
 chronic forms of nutritional impairment. Again, quantitative and 
 qualitative variations of the blood, affecting centric nutrition, may 
 co-exist, whilst such nutritional disturbance of the nerve-centres reacts 
 again upon their blood-supply. Yet this inter-dependence of func- 
 tionally related systems, although it renders any sharp demarcation 
 into separate groups impossible, does not impair the practical value 
 of a division into the three groups, since it always holds good that 
 we may cleai'ly distinguish those affections in which the 2^'''ominent 
 indication is that of simple depressed circulation, from a state in which 
 
 * See on this subject the section on the "Insanities of the Period of Pubes- 
 cence." 
 
130 STATES OF DEPRESSION. 
 
 the vitiated quality of the blood chiefly appeals to us, and lastly, 
 from those grave affections in which acute and chronic n^itritio^ial 
 anomalies are the chief factors concerned. 
 
 States of defective circulation will comprise all the simpler forms of 
 melancholia characterised by lowered cerebral activity. Excitations 
 from the environment do not arouse the normal reaction ; they are 
 sluggishly transmitted, slowly elaborated, and wholly fail to react 
 with due vigour or purposive result. The registry of all impressions 
 is faint or imperfect, the latent period prolonged, the reaction-time 
 delayed. 
 
 The very earliest signs preceding genuine pathological depression 
 are really the symptoms of cerebral anjemia and nervous exhaustion. 
 The cerebral functions are torpid, there is diminished activity both 
 of the impressive and of the expressive realms of the cortex, as above 
 described, and negative states predominate throughout. The subject 
 is heavy, languid, sleepy; frequent yawning occurs — not the insomnia of 
 a more advanced stage; intellectual efforts are oppressive, and thought 
 becomes dreary, monotonous, and painful. If the warnings thus afforded 
 be disregarded, there arises the frequent recurrence of a painful idea, 
 
 occasional sensory hallucination, sleeplessness, all indicative of 
 
 a commencing pathological change — of impaired centric nutrition. 
 In the earlier stage, where warning is not taken, and where, despite 
 such clear evidence of cerebral exhaustion, the brain is still made to 
 do its daily round of duty, in a state utterly inadequate for such exer- 
 tion, unless absolute rest be here enjoined, the next step will certainly 
 issue in patholOg"ical depression. The morbid nature of this 
 change is sufficiently evident in the fact, that the diurnal cycles of 
 nutritional rhythm are frequently inverted, or at least gravely dis- 
 turbed. 
 
 Viewed from the mental aspect, the highest psychical operations are 
 first enfeeT)led : abstract thought becomes oppressive or impossible ; 
 attention impaired or restricted ; sensations are less vivid, and per- 
 ception is incomplete or wanting in detail or imaginative vigour — the 
 representative faculty especially being enfeebled. Apathy and indif- 
 ference to the surroundings, associated with painful gloom, pervade 
 the mind, betraying the decline of object-consciousness and the rise 
 of subject-consciousness. * In these states, the reaction on the outer 
 Avorld may be characterised by fitful irritability, impatient conduct, 
 sluggish, mechanical actions, or by entire suppression of volitional 
 initiative. Both sensorial and motorial functions are sluggish or in 
 
 * So the converse of an over-active circulation reveals itself in increased cerebral 
 activity — often in extraordinarily vivid memories. This we see in fevers, also after 
 the use of certain drugs, as opium, hashish, &c. — (Ribot, Op. c'tt., p. 198). 
 
THE FULMINATING PSYCHOSES. 131 
 
 abeyance, and the functions of organic life arc all depressed. The 
 vitality of the organism as a whole, being largely dependent upon the 
 activity of the nervous centres, must necessarily suffer when this, 
 inipoi'taut regulative system is deranged : the condition is truly one 
 
 of devitalisation— life is carried on at a lower level. 
 
 Should the nutrition of the nerve-centres suffer materially, a fresh 
 series of symptoms is aroused : illusory states and hallucinations 
 disti'act the attention — the mental pain and disquiet is intensified 
 thereby : apathy and indifference may be replaced by timidity, fright,. 
 or terror ; and the reaction becomes expressive of such emotional', 
 states — restless movement and agitated demeanour replacing the former 
 negative condition. All this indicates impaired nutrition of the nerve- 
 centres, owing to the defective supply of blood : the nerve-cells, im- 
 poverished, exchange their normal functional irritability for an exag- 
 gerated abnormal explosiveneSS, and fitful irregular discharges 
 replace the rhythmic outflow of the nervous discharges which regulate-- 
 the subordinate centres and relational apparatus of animal life. 
 
 These nutritional anomalies reach their climax in the third group tO' 
 which I have referred, the explosive or fulminating psychoSeS, 
 These affections are characterised by the suddenness and explosive 
 nature of the nervous discharge, which relieves the pent-up and accumu- 
 lating energy of highly unstable centres. In lieu of the equable 
 rhythm of discharge and repair, corresponding to the wants of the 
 organism, and adapting it to its environment, there is disproportionate 
 accumulation of energy ; the centres are brought up to a degree of high; 
 nutritional instability, and the least excitant, however trivial, may,, 
 like the spark to the fulminate, issue in an explosion of serious inten- 
 sity. The nerve pulse is irregular, fitful, intermittent. 
 
 This group comprises certain varieties of so-called impulsivfr 
 insanity — the homicidal and suicidal — the subjects of epileptie 
 neuroses, and affections arising at the climacteric cycles. 
 
 The cortical expanse of the cerebral hemispheres is certainly 
 the site of the highly representative and re-representative opera- 
 tions : a defective circulation here results in a genuine starvation 
 of the nerve-elements. How does this starvation betray itself? 
 In replying to this enquiry let us briefly refer to the case of the 
 physiological appetites for food, etc., and parallelise them with the 
 case in point : we shall then find that all animal appetites are de- 
 pendent upon two essential factors : — 
 
 (a.) The reception of peripheral excitations by a centric register. 
 
 {h.) The supply of blood to this centre. 
 
 Thus, the sense of hunger is the indication of a want of this due 
 excitation of the peripheral nerves of the gastric mucous mend raiie ; 
 
1^ HTATMS OF DEPRESSION'. 
 
 and for its alleviation the centres must receive impressions thus 
 created. 13ut excitation of the peripheral ends of the vagus, produced 
 by any mechanical contact other tlian by the ingestion of aliment, 
 suflices to restore the nutritive equilibrium of the nerve-centres tem- 
 porarily. The rhythmic pulse of excitations thus transmitted to the 
 centruui calls up the increased vascular flux associated with all brain 
 functionising — and thus, these two agencies combine to raise the 
 nerve-elements into their normal physiological condition of satiety. 
 The reinstatement of molecular equilibrium in the centric nerve-cells 
 <lepends not alone upon the transmission of the physiological stimuli, 
 but also upon the collateral flow of hlood to the yarl. So as regards 
 the special senses — the aljolition of the usual afferent impressions 
 begets a condition which is truly a pathological hunger. Strikingly is 
 this the case with the sense of heariwj : depression of spirits is a well- 
 niarked phenomenon in suddenly-induced deafness, partial or com- 
 plete. The depression so induced we regard as a genuine instance of 
 .sensorial hunger — as the expression of starvation of the nerve-cells, 
 thus deprived of the normal ingoing currents. 
 
 Sameness and monotony of sensory impressions produce identical 
 states ; and the want of " a change " is nothing more than the ex- 
 pression of this physiological hunger of the nerve-centres. 
 
 On the other hand, the more highly representative the special-sense 
 ikeulty is in its evolution — the less dejJendent is it in this respect upon 
 presentative excitations ; and thus the sense of siylit, when similarly 
 affected, fails to indicate in the same notable degree a corresponding 
 <iepression of the emotions — idealising or centi-ic initiation so com- 
 pletely supplementing the loss that the results are far different : yet, if 
 the sphere of such operations is in itself implicated, if the nervous 
 mechanisms initiating representative processes are starved out by 
 •deficiency of blood, then there is begotten a corresjionding hunger of the 
 brain-cell. For, cerebral activity in these realms being restricted, as 
 shown in the poverty of active ideation and thought, there is an arrest of 
 <iiffusion-currents provocative of the pleasurable emotional states which 
 always accompany healthy energising of these centres. Corresponding, 
 •therefore, to the dreariness of thought in cognitive realms, we have 
 hi. the region of feeling such painful mental depression as accords 
 with what we should term the hunger of the brain cell. 
 
 Again, those ganglionic structures which are the regulative centres 
 ■for the organs of vegetative life, subserve the wants of the system 
 ■fck rough the agency of an inscrutable law of nutritional rhythm, 
 differing for each organ concerned : yet, whether we consider the 
 ganglia connected with the visceral sensations, or those which receive 
 epirpcriplieral excitations, as those of the special senses — i.e., whether 
 
GENESIS OF PAINFUL AND PLEASURABLE STATES. UiS 
 
 the physiological stimuli arc continuously received, or have intervals 
 of some duration, or, as in the case of the heart, arc erjuahle and 
 periodic — in all cases alike, the excitation of such centres depends 
 much in its degree upon a due supply of blood to the part ; unless 
 this be the case, the centre, exhausted by discharge and not renovated 
 by due nutritional flux, must lose in its excitability. 
 
 Further, this exhaustion means a weakenincj of that associative ajfinitij 
 which arouses correlative centres, and which is the physical basis oT 
 ideal association. In like manner, the directive agency of such ex- 
 hausted centres must be enfeebled, and the blending of imjiressions 
 and associated states into the "serial line of thought" [Spencer) 
 must be correspondingly enfeebled. As we shall see further on, 
 this weaving of the crude material into forms of thought becomes a 
 greater and yet greater effort: " gang'lionic fpiction," as Pvomanes 
 aptly terms it, becomes arrestive of the higher processes of thought, 
 and this resistance in the intellectual sphere is associated with a 
 difiusion towards the more purely emotional sphere. 
 
 Painful and Pleasurable Mental States.— Since these states 
 
 form so important an element in conditions of mental depression and 
 exaltation, it will repay us here to summarise briefly our views as to 
 their nature. 
 
 Mental pain has been defined as the result of iinder-action or over- 
 action — its antithesis, pleasure, finding a place midway between these 
 extremes ; as though, we might say figuratively, an ocean of sluggish 
 waters and of stormy billows lay on each side respectively, with a mid- 
 region of rippling sun-lit wavelets. We think this definition fails — 
 under-action certainly leads to apathy and torpor — over-action to all the 
 various grades of painful mental states; yet, the essence of this mental 
 pain is surely not over-action, but pent-up activity. jMental pain 
 varies in degree from mild indefinite gloom up to extremes of anguish 
 and despair, in which restricted volition is replaced by agitated and 
 frenzied movement. Now, immediately the sphere of object-conscioiis- 
 ness declines in functional activity, the minus quantity of the one sphere 
 becomes the plus quantity of the other; which, in physiological terms,, 
 implies that ingoing nervous currents which normally would arouse 
 appropriate reactions in the intellectual and motor realms, become 
 difiused in the realms of feeling and emotion : what is lost for per- 
 ception is gained in feeling. The restricted accumulation of energy 
 is surely at the basis of states of mental pain. If we allude to suck 
 states as the result of under-action, the under-action is distinctly that 
 of the higher planes, whilst there is a corresponding surjolus of activitij 
 aroused in the subordinate planes of feeling and emotion. The so- 
 called states of over-action, again, are similar conditions more defnitelif 
 
134 fTATKS OF DKPKESSIOX. 
 
 <exp)'e8sed — the over-action being that of the recipient, afferent, or im- 
 pressive sphere, with a corresponding under-actiou of the efferent, 
 intellectual, and exi)ressive sphere — in fact, all grades of mental pain 
 
 Arc dependent upon over-action on the impressive and restricted 
 activity on the expressive plane. 
 
 In normal states, ingoing currents, or impressions centrally initiated, 
 Are translated into realms of motor activity or high intellectual phases; 
 in states of mental pain, such translation is restricted, and such 
 activities expend their energy in those diffused spreading discharges 
 which are the correlatives of emotional conditions. 
 
 We find pleasurable states invariably associated with the translation 
 oi feeling into ilwuijld and action: we likewise find iiainful mental 
 states associated with the surging tide of feeling vainly struggling to 
 iburst the barriers, in order that it may appear under the varied forms of 
 intellectual or muscular activities : yet, we find all degrees of the latter — 
 from that of high-strung emotional potentiality, down to those minor 
 states where feeling is expressed in terms of general gloom or irritable 
 impatience and fi'etfulness — passing, in fact, towards states where feel- 
 ing as a higher emotional state seems well-nigh abolished, and passive 
 indifference and apathy indicate a purely negative state of mind. These 
 latter cannot be comprised under the head of states of mental jiain, 
 however consistently they may be classed as states of mental depression 
 or anorexia. 
 
 The Reaction-Time in Melancholia. — Any estimate of the 
 
 reaction-time in health or disease must take account of many 
 possible sources of error ; and such fallacies are but intensified when 
 dealing with the insane mind. A large proportion of the insane do 
 not, of course, admit of such methods of examination : and even 
 amongst such as cheerfully respond to experimentation, a certain 
 proportion are likely to falsify results from individual peculiarities, 
 and the unpredicable vagai'ies of the insane : delusional cases are in 
 this connection the most doubtful subjects. Where the reductions 
 involve much impairment of memory, or profound mental torpor, the 
 test of reaction-time, however taken, is perfectly futile and unreliable : 
 and it is only in those instances of incipient mental derangement, where 
 the intellectual operations are not grossly involved, that a failure 
 in the energy of cerebral reflex can l)e regarded as of important signifi- 
 cance. 
 
 In applying the test, the patient should, so far as possible, be made 
 to take an interest in the experiment, and this can frequently be done 
 •with great success, by a little tact, even in serious cases of melancholic 
 depression, or acute maniacal outbursts. Each subject should be 
 repeatedly tested short of actual fatigue ; and no average sti'uck of the 
 
REACTION-TIME IN HEALTH AND DISEASE. 
 
 135 
 
 rapidity of reaction from less than twenty trials. In our own experi- 
 ments with the insane we have restricted ourselves to the estima- 
 tion of the total time required for reaction to the stimulus of sound 
 or light; and have not attempted to investigate the more complex 
 reaction-time of a more involved process. "We have employed one of 
 the instruments devised by Mr. Galton for anthropometric experi- 
 ments, and found it admirably suited for the purpose. 
 
 The general results, so far obtained, would indicate a decided 2^Tolon- 
 fjation of the reaction-time in many forms of insanity. Simple affective 
 forms — as in melancholic depression or maniacal excitement of a 
 simple nature — as well as insanity, the outcome of alcoholism, or of 
 ■epilepsy, and associated with general paralysis — were made the subjects 
 •of enquiry. In none of these were the results more strikingly uniform 
 than in alcoliolic forms of insanity, where, after eliminating every 
 probable source of fallacy, the reaction to an optic stimulus was almost 
 invariably delayed, and, in most instances, the reaction to the acoustic 
 stimulus was likewise involved. None of the patients tested suflei-ed 
 from any serious degree of dementia, such as would have prevented 
 their fully entering into the interest of the trial. 
 
 In general 2^c(,ralysis also, the same delay in reaction occurred, but 
 for such cases we must refer the reader to the series of experiments as 
 given in the section treating of these forms of derangement. Here 
 "we more particularly desire to record the results obtained from the 
 subjects labouring under melancholic depression, simple or otherwise. 
 In the following table we have contrasted the results obtained from a 
 series of individuals presumed to be healthy, and from the subjects of 
 more or less acute melancholic depression : — 
 
 Reaction-Time in Health and Disease. 
 
 Self, 
 
 E. H. 
 
 T. H. 
 
 R. L. 
 
 D. A., 
 
 R. \V., Simple MelancJiuli'i, 
 
 M. L., „ 
 
 S. W, 
 
 J. W. 
 
 G. A. 
 
 C. K. 
 
 Acoustic Stimulus. 
 Sec. 
 
 •13 
 
 , Climacteric Mdanclmliu, 
 , Hjjpochomlriacal ,, 
 , Ddwiional ,, 
 
 •15 
 •IG 
 •13 
 •16 
 •29 
 •22 
 •29 
 •23 
 •20 
 •14 
 
 Optic Stimulus. 
 Sec. 
 
 •16 
 ■17 
 •18 
 •21 
 •21 
 •30 
 •25 
 •29 
 •24 
 •26 
 •24 
 
 With the above we also contrast the results given in a table by 
 
Acoustic Stimulus. 
 
 Optical Stimulus 
 
 Sec. 
 
 Sec. 
 
 . O-HO 
 
 200 
 
 . Ol.-)! 
 
 0-225 
 
 . o-i,so 
 
 0-1 88 
 
 . 0-1 S-2 
 
 0-194 
 
 . Uii28 
 
 0-175 
 
 . ()18(;0 
 
 150G 
 
 . ()-l'2-i 
 
 0-191 
 
 . 120 
 
 0-193 
 
 13G STATES OF DEPRESSION. 
 
 von Kries and Aiurbacli, oinbraeing the investigations of several 
 observers * :— 
 
 Observer. 
 
 Hirscli, 
 Hankcl, 
 Doiulurs, 
 Von Wittiuli, 
 Wumlt, 
 Exner, . 
 Auerljach, 
 Von Krics, . 
 
 It will be apparent from tlie observations on healthy subjects, that 
 •whereas from -^jf^ to y^j^^ of a second formed the limit of variability 
 for acoustic stinmU, and -j^j^'^^ to -j-y-^ for visual stimuli — in the insane, 
 the former is only exceptionally below -f^^, and the latter rises from 
 _2^^ to y"~ of a second. In healthy states the reaction to visual 
 stimuli is slower than to acoustic impressions : — 
 
 There seems good reason to suppose that the reaction-time of siii^lit is necessarily 
 longer than that of hearing or touch, on account of the photo-chemical nature of 
 its more immediate stimulus. One observer (von Wittich) has even gone so far as 
 to conjecture that the s[)eed of conduction in the optic nerve is less than that of 
 the other nerves of sense; it is rather to be concluded, however, that the latent 
 time of the sensory end-apparatus, and of the cerebral processes by wliich sensory 
 impulses pass over into motor impulses is different {Ladd).^ 
 
 The prolongation of the reaction-time in cases of insanity generallijj 
 Avould indicate a special impairment in the visual as contrasted with 
 the auditory sphere : both are often involved ; but, the former often 
 suffers to the exclusion of the latter, it being frequently observed 
 that a subject who responds readily and normally to an acoustic 
 stimulus, exhibits notable delay in the response to a visual stimulus. 
 
 There are many reasons for agreement with Professor Ladd that 
 the distinction in reaction-time for these two kinds of stimuli is due, 
 
 not to a different rate of conduction, but to the different latent 
 period of end- and centric-org'ans : and we may assume, with 
 
 nearly as mueli cortainty, that in the deranged states met with in the 
 insane, the protraction of reaction-time found is due, either to im- 
 plication of the sensory end-organ, or to the intra-central link whereby 
 the sensory is transformed into the motor impulse ; the former is 
 probably illustrated by certain subjects of chronic alcoholism — the 
 latter in ordinary forms of affective insanity. 
 
 * Arcldv.f. A'nat. u. PhyMol., Phys'iolocj. Ahlh., 1877. 
 t Elements of Phyalolofjlcal Psychology, p. 477. 
 
DKORERS OF PATHOLOGICAL REDUCTIONS. 137' 
 
 Deg"rees of Mental Depression.— Of the innumcraLlo conihina- 
 
 tions of mental syinptoms cinliraccd under states of mental depression, 
 certain forms present themselves, having many features in common of 
 suffieipnt distinctive value to constitute them arbitrary varieties for 
 the purposes of systematic study : such so-called varieties, however, 
 it must be understood, are by no means other than purely artificial or- 
 arbitrary divisions, which are nevertheless essential for the orderly 
 grouping before the mind's eye of what otherwise would form but a- 
 chaotic and confusing assemblage of facts. 
 
 It is thus we hear of a purely affective melancholia,* in Avhich the 
 emotional or affective sphere is chiefly at fault ; and of a delusional 
 melancholia, in which the intellectual or ideational sphere sufters. 
 
 Whilst fully recognising the utility of such grouping — whereby we 
 keep in view the more notable affective implication in the one case, 
 and the more prominent intellectual perversion in the other — we- 
 must insist that the student is here likely to fall into the serious- 
 error of regarding such arbitrary divisions as the negation of a principle 
 which we regard as one of the greatest importance in our studies of 
 insanity— viz., the universality Of Implication which characterises 
 mental disease. 
 
 By this universality of implication we do not mean that all mental facul- 
 ties suffer alike in extent or degree— this would be obviously absurd : but, 
 that however prominent and obtrusive may be the implication* of any- 
 special faculty— however limited at first sight may appear the derange- 
 ment, further investigation shows that the mind in its totality has- 
 suffered. The psychological aspect of mental depression presented to 
 the student in the foregoing remarks, will have prepared him for the- 
 recognition of this fact of the universal implication of the mental sphere- 
 in cases of morbid depression — as subject-consciousness rises in intensity,, 
 so he has learnt to appreciate the wane of object-consciousness. It 
 matters not how mild the form of pathological depression— how slight 
 the degree of mental pain — object-consciousness invariably presents 
 this corresponding enfeebleraent : but this latter feature has to be 
 carefully looked for, whilst the former is the obtrusive and prominent 
 indication of the derangement. 
 
 We do not here allude to delusional perversions, but simply to those 
 minor grades of failing representativeness Avhich we have already traced 
 in the sluggishness and poverty of ideation, its lessened vigour, and 
 the dubiety of mind respecting objective existences, which, later on, 
 culminates in delusions of suspicion. When we consider how, in tran- 
 sient functional disturbances falling far short of pathological depres- 
 sion, we find a gloomy emotional tone associated so frequently with 
 a morbid suspicion, bordering at times upon actual delusive states 
 
138 STATES OF DEPRESSION. 
 
 — inconsistent, irrational mis judgments of our fellow-men and universal 
 <iistrust, we may be fully prepared in states of genuine melancholia, 
 however mild in type, to recognise in the sphere of the intellectual 
 operations a corresponding wane. 
 
 Whilst mhior deyrees of pathological reduction result in a welling-up 
 of feeling as the more obtrusive feature (simple melancholia) — dcfpor 
 reduciioiis, resulting in more serious implication of representative 
 operations, issue in delusive perversions (delusional melancholia) as 
 the more striking feature, whilst the emotional gloom, in its place, aids 
 in the creation of further delusional notions as "attempts at ex- 
 planation," to use Gi'iesinger's phraseology. 
 
 It will at once be ap[)arent how this view differs from that which enunciates, as 
 its leading doctrine, an afftdlre origin for insanity : our own view being that the 
 ■relational and the sentient elements of mind must be conjointly implicated, and that 
 the priorltij of implication pertains to the relational. 
 
 Of the clinical groups arbitrarily constituted, from amongst the sub- 
 jects of mental depression, we may cite as the more important — 
 
 (a.) Simple melancholia. 
 
 (6.) Melancholia with delusiojis, including the hypochondriacal form. 
 
 (c.) Melancholia agitans. 
 
 {d.) Melancholia atonita, or melancholy with stupoi'. 
 
 To these separate groups we must now devote some attention : in 
 the first place, it is necessary to indicate, that the varied states which 
 these terms connote are the outcome of the same morbid process in the 
 ■cerebral cortex, and represent but differoU depths of dissolution — serial 
 stages in the same disease. 
 
 A still lower stage of reduction is that of maniacal excitement : and 
 "»ve mention this fact here, since it is so frequently implied that mania 
 and melancholia are distinct diseases, rather than ditferent stages of the 
 same moi'bid process. 
 
 («.) Simple Melancholia. — Under the term of simple melancholia 
 .are embraced forms of a purely emotional or affective insanity, where 
 there is mental pain or emotional distress apart from obvious intellectual 
 disturbance — if such mental pain be abnormal in its intensity and 
 ■disproportionate to any exciting cause, we have a species of simple 
 melancholia. 
 
 Here, at the outset, we must (pialify the phrase, " a purely emotional or affective 
 insanity :" for it requires but little iusight into the operations of the sound mind, 
 to lead us to the conclusion that so interblended are all the mental faculties in 
 their mutual co-operation, that no such division can be drawn, in a strictly scientitio 
 aense, between the purely emotional and the intellectual states. When we speak of 
 .f motional states, we must ever bear in mind that the term connotes more or less 
 
MINOR DEGUEKS OF REDUCTION. 130 
 
 of the intellectual element of mind— that every mental operation presupposes in 
 its very simplest form— feeling, memory, reason, volition; or rather that these are 
 but different aspects of the same state. It is, therefore, only in the greater pre- 
 ponderance of the one or the other factor that we distinguish between abnormal 
 mental states. 
 
 Simple luelancliolia, tliereforo, really embraces tho.sc states of morljid 
 depression in which the painful emotional element of mind preponder- 
 ates to the exclusion of disorder of the more relational element ; or, to 
 be more exact, where the disordered feelings by their inten.sity and 
 obtrusiveness overshadow any slight intellectual disorder which may 
 be present. Definite delusional states, therefore, are evidently excluded 
 from our definition; reason still as.serts herself; there is no enfeeble- 
 ment of memory ; volitional control is not withdrawn. The cerebral 
 dissolutions which such states of melancholia imply tend certainly 
 tow^ards a lower level, towards more complete dissolutions — and the 
 psychical expressions then vary with it to those of disordered reason, 
 memory, and will : yet, for purposes of clinical study, it is convenient, 
 althouo-h this tendency be obvious throughout the attack of insanity, 
 to fix the mind's eye upon the affective disorder. 
 
 The subject may long have struggled against the gradually increasing 
 depression, and may have concealed his actual state from the notice 
 of relatives or associates — any undue reticence, absence of natural 
 buoyancy, or change in demeanour being usually explained away 
 upon any other grounds than those of mental implication : and thus 
 the barrier between simple functional disturbance and a genuine 
 pathological process is passed without notice. A universal gloom 
 pervades his mind, and a distaste for all previous avocations and 
 interests declares itself : exercise and all forms of recreation no longer 
 appeal to him, and a dull uniform level of indiflference is engendered 
 towards the outside world. Life has lost its freshness— Nature pre- 
 sents him with no delights, and whatever there be of beauty or 
 happiness or gaiety around, but serves to emphasise his gloom as he 
 feels their want of kinship to his nature. With still greater emphasis 
 can he say with Nature's poet : 
 
 " But yet I know, where'er I go, 
 
 That there hath pass'd a glory from the earth." 
 
 Retiring into the solitude of his own self-consciousness, he broods 
 abstractedly over his alien state— fully cognisant of the nature of his 
 malady ; often dreading to reveal his condition to those most interested 
 in his welfare. 
 
 But though the object-world has lost for him its pleasurable 
 aspects, and thought and feeling with regard thereto are laboured, 
 restricted, and wanting in vigour— yet subjective states of introspec- 
 
140 STATKS OF DKPRKSSIOX. 
 
 tion, of self-analytic activity are keenly dominant, and this self- 
 inflicted torture grows apace as sleep is lost, as defective appetite and 
 sedentary habits of life still further retard the processes of nutrition, 
 and repair and sap the foundations of his uu-ntal vigour. 
 
 It is at this period that suicidal prompting's often come to the 
 front ; but, here we see Reason asserting herself — the patient recognises 
 his moral obligations clearly — often shrinks with horror from the 
 suggestion — or may be driven to implore protection such as may be 
 afforded by asylum supervision. Many, however, in the gentle forms 
 of depression, are equally conscious of a degree of .self-control which 
 enables them to meet any such suggestion with perfect confidence : 
 tlipy may utter the usual formula of being wearied of life, but, with 
 the utmost self-assurance, deny that they could ever be induced to lay 
 violent hands upon themselves. As we shall see later on, it is in 
 much more serious nutritional anomalies, that the helplessness of the 
 victim and the dread of impulsive acts prevail, as in the fulminating 
 psychoses. Every degree of mental pain may prevail in the subjects 
 of simple melancholia, from such as do not materially interfere with 
 their pursuits — home or ])usiness duties, to such as result in utter 
 paralysis of volitional energy : and, in these cases, their daily wants 
 have to be strictly attended to — as they would starve rather than 
 exert themselves to eat. 
 
 If the patient does not improve, a further stage is reached in which 
 we observe a still greater wane in object-consciousness : the jaundiced 
 view of the environment is no longer coi'rectly interpreted as due to 
 the subject's own indisposition, liut doubts arise — distrust prevails — 
 and a SUSpiciOUS bGaPing" towards those around inaugurates this 
 further state of dissolution. The patient, not actually deluded, begins 
 to misinterpret all interference, however kindly meant — looks suspi- 
 ciously at his nurse — struggles violently at the most trivial attention 
 paid him ; whilst the preparations for feeding him or other necessary 
 procedures may be met with every sign of terror. And yet, on 
 questioning him, he admits no definite deluded state — is readily re- 
 assured — only the next moment to relapse into his state of all- 
 prevailing fear that something may hapj^en — he knows not what. 
 The volitional restriction here is serious — self-confidence is greatly 
 enfeebled, and suicide is not unusual : the stage is one of transition to 
 the more definitely deluded or acutely melancholic forms. The follow- 
 ing is a typical illustration of simple melancholic depression: — 
 
 M. A. W., aged .sixty-tliree, a iiianiod woman witli a family of two clnUlreii, 
 was admitted suflt'ering from an attack of depression, whicli had commenced about 
 three weeks previously. She had an earthy complexion — the cheeks mottled with 
 dilated capillaries: her bodily condition approached the obese. No pronounced 
 
DELUSIONAL MELANCHOLIA. l-il 
 
 cartlio- vascular change was apparent, although the heart's action was somewhat 
 feeble: the geuito-urinary system appeared healthy. It was stated that she had 
 just attempted to drown herself in a water-butt. For three weeks past she had 
 slept but little ; had become more depressed from day to day. From her friends' 
 statement, it appeared that she had led a perfectly steady, temperate life; had 
 never before exhibited any mental disturbance or eccentricity, and was not known 
 to have had insane or neurotic ancestors. She was exti-emely depressed, wept 
 constantly, was reluctant to enter into particulars about her mental state. She 
 admitted that she had been failing in health for some months prior to her attack, 
 and that she did not know the cause of her bodily or mental ailment— could not 
 explain why she was distressed, but ^\•as constantly the subject of vague fear, and 
 frequently asked what was to become of her. No delusions were apparent: she 
 had suliered from no hallucinations. This condition continued for some three 
 weeks: she always presented a most melancholic expression, but slept well at night 
 without sedatives, and only on one occasion required forcible administration of 
 food. Through the day she sat rocking herself to and fro, sobbing aloud, and at 
 times became greatly agitated. The more acute symptoms then subsided, and she 
 turned her attention to household work. She became more reticent, and when 
 pressed with questions grew miserable and wept bitterly : could still give no exidana- 
 tion for her fretting. In less than a month she fully realised her own improvement 
 in health — grew more hopeful, less reticent, but now troubled herself much at 
 having attempted suicide. She was now given small doses of opium and ether 
 (15 and 10 minims respectively) twice dailj', and in a few weeks later was cheerful, 
 active, industrious, longing to return to her friends and home, and left the asylum 
 some ten weeks after her admission. 
 
 (h.) Delusional Melancholia. — This form, as before stated, we 
 regard as presenting us with a deeper stage of reduction than that 
 of the simple form of affective insanity (simple melancholia). Gloomy 
 apprehension and suspicion have here passed into definite and per- 
 sistent delusional states; and intense as may be the emotional 
 implication, the intellectual derangement now appeals more forcibly 
 to us : and, being constantly insisted upon by the patient, is apt to be 
 regarded by the friends as the real cmise of the malady. It would be 
 quite apart from our purpose here, even if it were practicable, to illustrate 
 the various features assumed by these cases of delusional melancholia 
 — they will receive sufficient notice in the sevei'al clinical forms of 
 insanity which we shall deal with later on. The perversions of the 
 intellect may apply to any one of the whole range of things outside the 
 subject, or may be entirely restricted to the bodily and organic 
 sensations : or again, to his relationships to another state of existence 
 — to his moral being. An infinity of delusive notions, therefore, 
 necessarily presents itself, often in such strange and contrasting 
 combinations as to be utterly unclassifiable. 
 
 Px'ominent, however, amongst such delusive notions are those which 
 deal with the subject's corporeal frame — the head, the body, limbs, or 
 viscera — often of a grim, and as often of a grotesque character, and 
 
142 STATES OF DRPUKSSION. 
 
 which, if the attention lie riveted thercuijon, constitute tlie so-called 
 hypochondriacal melancholia. Then again, we meet with de- 
 lusions rrlativc to tlir inoml licing — the victim has committed tlie 
 unpardonable sin, or for some, perhaps, insignificant action, his soul 
 is eternally lost — or passages in scripture constantly recur to him 
 of a gloomy denunciatory nature as applicable to his own state, 
 forming one of the class of so-called relig'ious melancholia. Or 
 again, the encroachment of the environment is the more perceptible 
 feature — and the mind conjures up those malign agencies therein 
 which are expressed in the multitudinous ideas Of persecution, 
 tyranny, troachorv. And yet again, a well-marked class of patients 
 infer demoniacal possession, witchcraft, or other unseen agency 
 as accounting for their states of mental perturbation. In these con- 
 ditions of delusional melancholia, hallucinations are not only frequent, 
 but often form the chief material out of which such delusional states 
 are framed. Aural hallucinations more frequently occur than visual, 
 and both far more generally than affections of smell or taste. Halluci- 
 nations of smell are of ominous import — they are frequent associations 
 of irreparable alcoholic brain disease — of epileptic states — of traumatic 
 forms of brain disease, ttc. In the following case, however, we find 
 such hallucinations of smell in acute insanity induced by alcohol, 
 but I'apidly recovered from : — 
 
 M. A. S., a iDavried woman, aged forty-eight, suffering from her first attack of 
 insanity, stated to have been of ten days' duration. She liad lived an immoral life 
 for twelve years past, and lately had been of intemperate habits, drinking heavily 
 up to the onset of her attack of insanity. She is not known to have inlierited 
 insanity. She was of corpulent proportions, her complexion duskj% and e.xprcssion 
 dissipated : her bodily health had not very materially suffered. On admission she 
 was greatly agitated and terrified, shaking her limbs violently in bed, or trying to 
 rush from the room. She slept for a few hours after taking .30 miuims of paralde- 
 hyde. Much melancholic agitation continued next day: she struggled violently to 
 open the doors, declaring "there was a charm to open them," that there \\as "a 
 woman after her to bui-n her," that " she wny the flames." The following uiglit six 
 hours' sleep ensued upon the administration of 25 grains of chloral : she awoke 
 calm and orderlj\ 
 
 At this period she was composed, attentive, and coherent, but betrayed the 
 presence of numerous delusions and recent aural hallucinations: thought she wiis in 
 an asylum; came here for protection from tlie noise in her own house. There was 
 such shouting and calling; if ulte did not answer, then got louder and louder. Voices 
 kept calling, "Mrs. Birkett, Mrs. Smith, Mrs. Birkett, Mrs. Smith, come and help 
 me, come and help me out ! " when she asked, "Who has put j'ou there?" thej' 
 shouted " Rustan, Rustan, Rustan ; " that had been the cry in her house for the 
 last two years. (She had gone to the police for protection against a man she called 
 Rustan, and had stated that she then saw his body blown up by dynamite.) She 
 had "smelt an earthy smell like that of a dead hodij in her house for the past few 
 weeks." When she went to the police for protection, "hundreds of blackguards 
 
IIYPOCIIOXDRIACAL MELANCHOLIA. ^ I^;? 
 
 followed shouting after her." She went the same day to get water from a tap ia 
 the yard. "She was sure it was drugged, it dried up her mouth, which begaa 
 burning and swelling; slie was confident somebody wanted to stab her," As usual 
 in such cases, she absolutely repudiated any suggestion of intemperate habits. 
 
 Her calmness of demeanour continued, but she required a sedative each night 
 to secure any sleep. A week later she affirmed that at home she constantly heard 
 a voice from beneath a stone table calling out, "O Mrs. Rustan, Mrs. I'ustan, 
 Mrs. Birkett, Amy, come down here ; I'm down here under the stone." She 
 went and searched under the stone, and saw what "would have blown her up if she 
 had remained in the iiouse." None of these voices have been heard since coming, 
 to the asylum. 
 
 A fortnight after her admission she exhibited but very gentle depression, and for 
 the first time began to question the real or imaginary nature of the voices heard. 
 No relapse occurred, and in less than two mouths from admission she left, perfectly 
 recovered. 
 
 (c.) Hypochondriacal Melancholia.— In this form of delusional 
 
 insanity, the morbid interest of the patient is concentrated upon his. 
 bodily organism and its functions. In healthy states of activity the 
 ingoing curi-ents arouse, as we have seen (p. 134), none but the 
 massive feeling of p/easwra&^e toell-heing, and it is only when the bodily 
 functions are deranged that we become directly conscious of the- 
 existence of our organs. So interblended, so inextricably interwoven 
 is the web of sensuous feeling produced by such activities, that out of 
 it arises the central core of the personality — the ego : around the latter 
 there crowd the impressions received from objective existences — the- 
 2yhysical in contradistinction to the j^^^'l/^'iological environment ; yet,, 
 these two halves are dissevered, and although they help to form the 
 aggregate mind of the individual, the characteristic stamp of healthful 
 mental operations consists in the continuous and vivid realisation of 
 this distinction between the subject and the object-world. 
 
 In the lower forms of life, we conceive of the subjective element as forming by far 
 the larger factor of mental states — a vast series of impressions received fropi the- 
 physical environment are not referred thereto ; and, although the appropriate 
 reaction may occur, this by no means proves that such sensations are not referred to 
 some part of the oi'ganic or physiological environment. The higher we rise, the more 
 definite becomes the reference of its own series of excitations to the object- world ; 
 and this, iu certain special lines, we see to a remarkable degree in certain insects, 
 such as bees and ants. In man, of course, we attain the complete severance 
 between these antithetic halves which renders possible his knowledge of uatuie as 
 embraced iu the various sciences. 
 
 We have seen how the failure of the one half (object-consciousness) 
 may proceed to a serious extent without implicating the groundwork 
 of our being — the personality ; and states of advanced dementia realise 
 this still more fully : we may equally well conceive how the other half 
 (subject-consciousness) may suffer disruption, if this " SCnSUOUS 
 
144 STATES OP DEPRESSION. 
 
 core" of the pePSOnality I'l- implicated either by peripheral or 
 centric deraiigeiiK-uis. That tlie foniier is possible, we have confirmed 
 by numerous instanc(?s of hypochondriasis with mental derangement, 
 .arising from disease of the abdominal and thoracic viscera ; that the 
 latter occurs, is sufficiently obvious in the excitation of similar states by 
 mental agencies — the perusal of morbid and sensational books, obscene 
 pamphlets, and the association with similar cases of hypo-chondriasis. 
 
 The anxieties and delusions of the hypochondriacal patient may 
 have reference to any part of his bodily organisation: amongst the 
 insane, however, prominence is given to the tract innervated by the 
 pueuiiioyastric nerve, and thus the regions of the throat, thorax, and 
 .abdomen — the respiratory, circulatory, and gastro-intestinal organs — 
 .are peculiarly the subjects of the patient's anxious attention and 
 • coinplaint. 
 
 The hypochondriacal tendencies of the subjects of epileptic insanity 
 .are almost invariably towards referring all their ailments to the 
 stomach and bowels — obscure feelings, pains or imaginary diseases, 
 torpidity or obstruction, are incessantly dwelt upon by them; and in 
 most instances, if not all, have some basis in actual derangement ; but 
 it is in the constant brooding over these states, and the exaggerated 
 ■colouring of their ailments, that the hypochondriacal condition is 
 revealed. 
 
 In the alcoholic subject, on the other hand, liypochrondriacal notions 
 have reference often to the peripheral ends of the nerves of common 
 sensation : thus, they continuously examine their limbs, complain of 
 pricklings and other strange sensations in tlie skin : assert that they 
 are poisoned, so that the skin is black, diseased, or "corrupted" 
 ,(see Alcoholic Tnsanilij). 
 
 To take the more frequent ailments complained of in hypochon- 
 driacal melancholia, there is the idea so frequently leading to obstinate 
 refusal of food, that " the throat is made up," or that the gullet is 
 wanting, an idea which persists in spite of the frequent passage of the 
 feeding-tube. In such cases, a spasmodic stricture of the oesophagus is 
 not infrequently met with as an obstruction in feeding — the spasm is 
 always high up : it is a reflex spastic state intensitied at once by the 
 introduction of the u'sophageal tube. Although met with in men, it is 
 ■of more frequent occurrence in women, and then often associated with 
 functional uterine disturbances, as in the resophagismus of hysterical 
 subjects. Organic stricture we have very rarely met with in such 
 subjects; but direct compression from enlarged thyroid we have 
 frequently found, associated Avith such delusive conceptions of the 
 absence or total occlusion of the gullet. Such patients are intensely 
 dejected, often seen with the head bent forward, the hands grasping 
 
HYPOCHONDRIACAL MELANCHOLIA. 145 
 
 the throat, and fully persuaded that they arc dying of inanition, 
 whilst fed artificially with ample meals. They will point to their 
 limbs (often well nourished) as evidence of their advanced emaciation ; 
 and they will often induce vomiting, by irritating the fauces after 
 feeding, declaring that the food so introduced can do them no good. 
 
 In like manner, other subjects declare that they have no stomach, 
 and transform various dyspeptic symptoms into indications of grave dis 
 ease : they may on these grounds resent any attempt at feeding, and 
 struggle violently to thwart one's efforts. Others may take food 
 heartily, yet declare it does not nourish them, and that they are 
 slowly undergoing starvation. 
 
 Obstruction of the bowels is a most frequent idea, aperient medicine 
 is asked for repeatedly, and despite the daily action of the bowels, the 
 insane patient reiterates his belief that no stool has been passed for 
 •days or weeks. Such patients are pictures of misery, importunate 
 about their treatment, querulous, irritable, wholly absorbed in their 
 own feelings, and can be induced to talk upon no subject without 
 at once reverting to their miserable plight. 
 
 In other cases, the genital organs are the source of anxiety — the 
 subject believes himself to be impotent or the subject of syjDhilis, 
 and no possible argument can be used to assure him that his whole 
 system is not permeated by the virus. One patient, at the ^yest 
 Riding Asylum, believed his generative organs had been displaced : 
 another that his sexual organs were diseased and mortified. Numb- 
 ness of the epigastrium was a sore grievance to another patient, who, 
 moreover, believed that his stomach contained pins and needles. In 
 the case of a middle-aged man who died of tubercular phthisis, an 
 accident (from which he had really suffered some years since, and in 
 which he fractured an arm and two ribs), was made the basis of 
 •extravagant delusional notions. He insisted that his skull was nearly 
 hollow — "half his brains having been scattered about at the time;" 
 that he also lost "two gallons of blood;" and that a screw placed in his 
 bowels by some unknown agency caused him continual and terrible 
 agony. The strangest combinations of delusional notions arise out of 
 the most trivial disturbances of function — slight constipation, flatulence, 
 heartburn, eructations, mild intestinal catarrh are exaggerated to 
 ludicrous proportions : the subject has a huge animal within him 
 _gnawing at his vitals, or is full of serpents ; or his meat and drink 
 are poisoned by vitriol; he is "full up inside;" or flames of fire con- 
 tinually burn within him. A male patient who died at Wakefield 
 Asylum of the marasmus induced by long continued refusal of food 
 and melancholia, was wont to believe himself covered with a skin 
 eruption from head to foot ; he would also blow his nose forcibly 
 
 10 
 
146 STATES OF DEPRESSION. 
 
 to demonstrate Iiow liis liraiu Avas gradually passing out Ijy that 
 channel. 
 
 Out of these morbid sensations the hypochondriac occasionally con- 
 jures up elaborate delusions of persecution, as in the cases of .f. V>.. 
 <i. L., and J. S. (see Alcuholic Insanity). They will lie in bed declaring^ 
 their inability to rise because they have no body or no legs : and one 
 well-known character at Wakefield, when asked her name, would 
 always reply, " I have no name ; I am no-one ; I have no body, no 
 liead, no limbs ; I'm a voice ; I'm an echo." 
 
 Burrows speaks of hypochondriasis as never occurring before the 
 age of twenty-five;* but Injpochondriacal melancholia is by no means 
 infrequent at puberty : in fact, we might well expect the onset of such 
 a disturbance from what we know of the physiological cycle of events 
 which occurs at this age (see Insanity of Puberty). "Hypochondriacal 
 states are sometimes observed in the years of childhood, and more 
 frequently at the age of puberty. They are extraordinarily frequent 
 in young people, and more rare in advanced age " (Griesinger). j 
 
 We notice in all forms of hypochondriacal melancholia, one feature 
 wholly distinct from that characterising most forms of simple mental 
 depression, and that is the insatiable craving for sympathy in place 
 of reticence and ^self-retirement. This tendency renders hypochon- 
 driacal subjects the most unpleasantly egoistic, and the most tedious 
 of all cases of insanity : it induces them frequently to stoop to 
 any depth of deception, and to ape almost any condition so as to- 
 attract attention. It is in such instances that the hypochondriac 
 so closely approaches the hysterical type, that it becomes a moot point 
 how to distinguish the one from the other. One of the most striking 
 instances of the kind which I have met with, was that of a young- 
 tabetic subject, in whom cerebral disturbance supervened, and in 
 Avhom this morbid craving for sympathy led to simulation of many 
 symptoms, such as voluntarily induced eructations, retching, and 
 exaggeration of [his genuine tabetic state, and then to the most 
 mendacious and vindictive, yet groundless attacks upon the attendants 
 and medical officers. :J: In like manner, we find patients who will 
 lie in bed, forcibly and continuously eructating, or obtrusively sham- 
 ming efforts at vomiting to attract the attention of the passer-by. 
 In a case to be referred to later on, the patient utters loud exclamations 
 of distress as the medical officer approaches ; or induces startings of his 
 limbs, which he refers to electric shocks passing through his frame ; or 
 makes hideous grimaces, if he thinks he is observed, rolling his eyeballs 
 
 * Commenlarks, p. 4GG. t Op. cit., p. 217. 
 
 t The case was one of interest throughout, and has liccn fully detailed by my 
 colleague, Dr. F. St. John Bullcu, L'mbi, part xli., April, ISSS. 
 
MELANCHOLIA AOITANS. 147 
 
 about as if in torture. In another instance of hypochondriasis, a 
 female endeavoured, for months together, to attract notice by loud 
 belching noises, but found a more ready means of commanding atten- 
 tion by picking, scratching, and defacing her forehead and cheeks 
 with her nails, presenting a most piteous aspect : scarcely had she 
 recovered ere she recommenced the same practice, and only appeared 
 satisfied by the sympathy it evoked. 
 
 Occasionally, the morbid epigastric sensations induce unnatural 
 cravings, as is the case with hysteric subjects: we have known the case 
 of a female hypochondriac advanced in years, who, in this state, cleared 
 away gradually a square yard or more of plaster from a wall by con- 
 tinuously swallowing small fragments, ere the cause of the disap- 
 pearance of the plaster was detected. This same patient subsequently 
 took to pulling out the hair of her head and swallowing it ; by this 
 means, she had become on two occasions completely bald over the 
 scalp : ere she died, she manifested the still more revolting habit 
 of devouring excrement. Yet, this woman even declared she- 
 had no body, and would moan piteously for hours at her forlorn 
 condition. 
 
 Aiiother aged hypochondriac would restlessly pace the rooms and 
 corridors of the asylum day by day, bleating like a goat in distressful 
 tones, a picture of abject misery. He had been fed for months together 
 twice daily, but his evening meal, purposely concealed on a scullery 
 shelf by the attendant who had discovered his weakness, he would 
 always secure and drink sui-reptitiously ; but he could never be 
 induced to take his other meals by a similar stratagem. In these 
 cases of chronic hypochondriacal melancholia in advanced age, dementia 
 progressively advances and no recovery is to be anticipated. 
 
 Suicidal tendencies are presumed by the friends to exist in all cases 
 of hypochondriacal melancholia, and we frequently hear of attempts at 
 strangling, hanging, drowning, or other measures in Avhich we may 
 fairly conclude that a bona fide suicide was not the patient's object, but 
 rather a morbid wish to attract attention to his case : in fact, these 
 subjects very rarely make such attempts within the walls of an asylum. 
 Occasionally, however, as the outcome of alcoholic intemperance, we 
 meet with a form of melancholic hypochondriasis, which, once recog- 
 nised, will not again be readily overlooked : it is one of hypochondriacal 
 delusions associated with extreme enfeeblement of the will, and des- 
 perate impulsive conduct is its invariable accompaniment (/. F., J. S.) 
 Such cases are highly neurotic by heritage. 
 
 {d.) Melancholia Ag^itans. — We have referred to delusional forms 
 of melancholia as a deeper reduction than the simple alfective form : 
 now such cases of delusional insanity frequently exhibit acute symp- 
 
148 STATKS OF DEPRESSION. 
 
 toms * — i.e., restlessness, incessant movcniont, insufferable anguish, and 
 every indication of an agonised state of mind — those forms of acute 
 melancholia are still deeper stages in reduction : thoy are in every 
 «ense an approach to the maniacal reductions. By melancholia agitana, 
 ■we do not indicate this acuteness or intensity of mental pain, for the 
 actual pain is often fixr more superficial in character than might at first 
 sight be apparent : but wc denote by tliis term the prevalence of a 
 motor ag'itation, Avhich, in like manner, approximates to the 
 maniacal states. Huch forms of melancholia may be of short, but 
 usually are of prolonged, duration, even lasting over several years ; 
 they may form but a stage in any mental disturbance, or may charac- 
 terise the case throughout, to its termination in recovery, in dementia, 
 ■or in deatli. 
 
 The patient is quiet only when asleep ; rocks her body to-and-fro, or 
 paces up and down the room incessantly ; the hands are in constant 
 movement, grasping the head, tearing the hair, rubbing the chest, 
 pricking the skin until it bleeds, biting the nails, tearing or disarrang- 
 ing the clothing — or huddled in a corner, her face buried in her hands, 
 she sways to-and-fro, lamenting her fate in loud sobbing, or ejaculations 
 sufficiently expressive of mental distress. Almost invariably the 
 •delusive ideas from which slie suffers are prominent from the first — 
 her soul is eternally lost; she is cast out from God and the world; 
 she is disgraced, or has brought ruin upon herself and family. 
 
 Hallucinations do not appear to prevail in this form — they may 
 liave occurred as a prelude to this stage of reduction, and in their 
 recall may constitute material for delusive ideas. The hypochondriacal 
 forms whicli we have just studied may exhibit this state of motor 
 agitation at different periods of its course. Let us take as our illusti'a- 
 tion of this form of mental depression the following case, wdiere, after 
 ■an onset of acuts melancholic reductions and grave moral perversions, 
 the patient passed into this chronic stage of melancholia agitans : — 
 
 S. A. A., aged 52. and niarried. Tlie medical certiticate runs as follows— 
 ■" Will not leave her bed, rocks herself about, moaning and repeating that she is 
 doomed to go to hell. Says she can see the flames of hell before her eyes : that it 
 is of no use ealini,' or doing anything in the house, as she is bound to go to the bad 
 place." Her daughter states that patient got out of bed to strike her, and said : 
 "I could tear j^ou all to pieces : ^11 my love is turned to liatred." Here, then, we 
 have a case of acute melancholia, utterly unfitted for home treatment— tortured 
 by hallucinations of the senses, and delusions based tliereupon : also b}^ impulses 
 to violence— "I could tear you all to pieces;" and grave moral iicrversion, as 
 indicated in her confession to her daughter— " All my love is turned to hatred." 
 These impulses, if neglccterl, would just as readily issue in a suicidal act. They 
 indicate extreme instability of nerve-tissue, and the explosion must occur in some 
 
 * Acuta in the sense of intensity, not of duration. 
 
CASE OF MOTOR MKLANCIIOLIA. 149 
 
 form of suicidal, homicidal, or (generally destructive conduct. The patient had a 
 similar attack of three months' duration, some twenty years ago, occurring after 
 labour. Slie has had considerable anxiety caused her by a drunken husband, who 
 has squandered all his means, and lost much property. A brother of the patkiit 
 hanged himself. 
 
 The acutcness of the patient's symptoms rapidly subsided after admission, but 
 she still remains the subject of continued melancholic agitation. She is most 
 demonstrative in her conduct and obtrusive in expressing her mental ailments- 
 Her states of mental pain no longer well-up into explosive outbursts— in impulses 
 towards self-destruction, &c.; but, on the other hand, obtain continuous relief 
 in motor agitation and querulous complainings. There is no pent-up energy 
 here as in the case of //. T. : it seeks and obtains relief in incessant garrulity. 
 She will talk for hours upon her miserable state, swaying her body toand-froj, 
 wringing her hands as in extreme agony of mind, and expressed herself one- 
 day as follows : — " You may think of me talking in this way that I am out of 
 my mind, but I am not. I feel that agitated tliat I don't know what to do with 
 myself. I feel that my soul is lost by having these burning feelings in my inside. 
 I was made happy, but did not seem to keep it ; was frightened, and something 
 seemed to say I was given up to the hardness of my heart. When in a dark 
 room and my eyes were open, lights seemed to fall on the pillow — they were as 
 big as a candle : they are real. I can't get a bit of love, not for my children. 
 I feel there is no hope for me. I feel so vicious with the enemy that I could do' 
 anything with myself. I could see I was lost— I don't want to hurt myself, for I 
 shall go to the bad place soon enough." And thus she contmues for hours, 
 lamenting her lost soul, and relieving her feelings by incessant repetition of scrip- 
 tural denunciations as applicable to her own state. 
 
 There is here undoubtedly a frittering away of nerve-force from ill- 
 conditioned cortical areas; but there is a vast distinction between such 
 states and the genuine agony of mind apparent in acute melancholia. In 
 the former, one is more struck by the continuous self-analysis, incessant 
 introspection, and the fascination which the revelation of such states 
 to others seems to possess for such patients : by the voracious appetite 
 exhibited, and the maintenance of good bodily health, despite all this 
 apparent distress. This accounts, in fact, for the chronicity of the 
 case : for nearly four years this melancholic agitation has been main- 
 tained, and so far from exhaustion ensuing, the patient is well- 
 nourished and robust. In fact, the painful mental state is far less real 
 than one is inclined to imagine — the symptoms falsify the actual 
 state : her utterances are but formula? from frequent repetition. 
 
 We recall one patient, the subject of chronic mania, Avho woulcT 
 meet one every day with a lugubrious expression, and the remark : — 
 " I'm going to be burnt to-day — I'm going to be burnt : they are 
 building a huge fire in the park, and they are going to roast me on it." 
 When questioned, she would enter into minute details of a horrible- 
 crime which she imagined she had committed, in whicli she had 
 poisoned fifteen children with corrosive sublimate : would describe 
 how she deceived the mothers : hoN^ she " watched the little brats 
 
150 STATES OF DEPHKSSIOX. 
 
 partake of the poisoned meal, and wriggle about in their agony." 
 Then she would grin maliciously or shake with laughter, ending with 
 her accustomed formula — " I'm going to be Ijurnt to-day." 
 
 Such cases impress us with the superficial nature of what often 
 looks at first like profound mental pain ; we must remember the 
 peculiar cunning of the insane, who are always observant of the eifect 
 which they produce on the mind of the observer, tlu.'ir fondness for 
 mimicry, extravagance, and distortion. 
 
 STATES OF MENTAL STUPOR. 
 
 Contents. — Stii])or and Dementia — Etiolo.cry of Stuporose States — Stupor anil 
 Hypnotism— Stuporose ^Melancholia— Acute Primary Dementia. 
 
 By states of stupor we understand a suspension more or less com- 
 plete of the emotional, intellectual, and volitional operations — a 
 suspension in contra-distinction to an abolition of these faculties : 
 the latter condition we denominate "dementia," a term which denotes the 
 absence of certain mental faculties, through impairment or destruction of 
 the mechanism whereby such operations are rendered possible. What- 
 ever be the change whereby these faculties are suspended, whether as the 
 result of pressure on the nerve-elements, the physical correlatives ; or 
 the result of the inhibitory effects of powerful sensorial stimuli ; or 
 temporary circulatory changes through vaso-motor influence ; or ex- 
 haustive centric nervous discharges — the distinguishing feature is that 
 of an arrest, transient or more enduring, of the intellectual operations, 
 Avhich may be suddenly re-initiated under an altered state of things. 
 
 x\.s in cases of dementia, the abolition or impairment of these faculties 
 lias often notable accompaniments extending over a wide range of the 
 cerebrospinal operations, in impairment of sensation, blunting of the 
 emotions, enfeeblement of volitional activities — so, in states of stupor, 
 a similar impairment of the sensori-motor functions is apparent. These 
 are the accompaniments, but the intrinsic nature of stupor depends 
 upon the arrest of ideation and suspension of the intellectual operations. 
 
 The insane present us with every grade of these states of stupor, 
 from cases of mild apathy, to depths of profound and persistent lethargy, 
 in which the subject closely simulates the aspect of genuine dementia. 
 
 Mild forms of stupor often find their parallel in normal physiological life, as in 
 the confusion of ideas which our waking moments arc occasionally prone to exhibit. 
 We knew a medical friend, accustomed to sleep heavily, thus partially awakened by 
 the night-bell, receiving the message, dressing, and proceeding a considerable way 
 upon his mission ere his destination and import of the visit were clear to his mind. 
 
 In these states, the perceptive faculties may correctly apprehend 
 external things, but not their relationships to ourselves, and a state of 
 
ETIOLOGY OF STUPOHOSE STATES. 151 
 
 tro.nsient stupor ensues. The state of post-epileptic stupor exhibited 
 after a series of severe fits is interesting in this connection, as presenting 
 a similar mental obnubilation to that seen in the cases of insanity to 
 which we now refer. The vacant gaze, the dream-like look cast 
 around, suthciently indicate the torpor of the perceptive faculties : 
 with the gradual reinstatement of the mental powers, semi-unconscious 
 movements commence — fumbling of clothing, feeling or rubbing of the 
 limbs, pulling about of furniture, incessant restlessness, and ill-regulated 
 nervous discharges which usher in awakening consciousness. Such 
 restless movements betoken the re-awakening mind, the re-energising 
 of discharged centres, and find no parallel in states of stupor where the 
 dormant intellect is shewn by sluggish motorial reaction, fixation, and 
 immobility. 
 
 We frequently observe, both in epilepsy and general paralysis, 
 instances of suddenly assumed stupor, often of long continuance and 
 not necessarily preceded by any obvious motor discharge or convulsion : 
 undoubtedly, in these cases, there has been discharge of unstable grey 
 matter from sensorial realms of the cortex. 
 
 Thus, a case of tabes dorsalis associated with mental symptoms has 
 shown us this feature ; whilst a similar case of insanity in a tabetic 
 subject has, on the other hand, presented the post-convulsive stupor. 
 
 States of mental stupor may be variously induced thus — 
 
 (a.) A mental shock, such as the sudden commotion caused by joyous 
 or painful news in a high-strung sensitive subject, may have the effect 
 of inducing such conditions of stupefaction : the acceptance of this fact 
 is sufficiently attested to by such conventional phrases as "transfixed 
 with horror ;" " petrified by the scene ;" " dumb with terror ;" itc, ttc. 
 
 {h.) Nervous discharges from tracts of unstable cortex, as in 
 epilepsy and general paralysis, lead to mental stupor through exhaustion 
 of the centres so discharged : much here depends as to whether the 
 centres so discharged have few or many sensorial or psychical correla- 
 tives. 
 
 (c.) Other influences leading to exhaustive expenditure of force — 
 exhaustive drains from the system— e.r/., phthisis — the vicious habit 
 of masturbation. 
 
 {d.) Acute forms of insanity are prone to be followed by stupor. 
 
 (e.) Bromism, in like manner, whilst aftecting the peripheral nerves, 
 reducing the excito-motor functions of the spinal cord, and inducing 
 torpor and sluggishness of secretions, leads to a loss of centric energy 
 resulting in stuporose states : and other toxremite have a like effect. 
 
 Cases of stuporose insanity may be studied with advantage in con- 
 nection with those exceedingly interesting conditions of hypnotism, 
 which the researches of Mr. Braid, Di-. Carpenter, and more recently 
 
152 STATES OF DEPRESSION. 
 
 Heidenheim, Charcot, and Richer have revealed to us ; and wliich 
 now assume a more intclligibl(! form as the phenomena Lecome investi- 
 gated by strict scientific metliods. It appears tliat, in tliese artificially- 
 induced states, every conceivable degree of suspension of the higher 
 cerebral functions may be obtained, and the subject may pass from 
 those light forms of induced reverie ("biological states"), through 
 somnambulistic and cataleptic phases, into the more profound stage of 
 mental lethargy. 
 
 The nerves of cutaneous sensibility, the nerves of special sense, the 
 sympathetic centres in the medulla, may each be stimulated — the two 
 former into a greatly exalted state of sensitiveness. The intellect 
 may remain acute, but only on that train of thought for the time 
 dominant : or the senses may, one or more, undergo notal)le blunting, 
 and the reverie and state of expectant attention pass into dreaminess 
 or profound sleep. Again, the muscular sense may be much exalted — 
 automatism of an elaborate nature may prevail, reflex movements 
 occur on suggestion, or tonic spasm ensue from excitation of muscles 
 and tendons.* 
 
 Now, the states of mental stupor wliich jjrevail in the insane, exhibit 
 features which at times strongly suggest allied conditions of the 
 cerebrum to those found in the '* biolog'ised " and "hypnotic" 
 subject. In them, the suspension of the mental faculties and implica- 
 tion of sensation vary much in degree ; may be suddenly induced 
 and as suddenly relieved: in them, also, dominant ideas appear 
 to prevail and cataleptiform states may be assumed, or still more 
 profound torpor take the place of a half-dreamy state of consciousness. 
 In them, also, the blunting of general and special sensation may be 
 observed — analgesia, loss of taste, of appreciation of temperature, 
 of sight, hearing, or of smell, noted in hypnotic subjects (Zandois),i 
 and in those conditions which pre-eminently favour what ai'e known 
 to be predisposing causes of hypnotic and trance-like states. 
 
 Mild stimulation of a special sensory tract, to the exclusion of 
 others, notably of the trifacial, optic, and acoustic, as by the "passes" 
 of the mesmerist, or the fixation of the eye on a bright spot above and 
 near the eye to induce effort by convergence, or by soothing mono- 
 tonous sounds — will, in many subjects, induce the hypnotised state. 
 So, states of mental abstraction, where a monotonous impression or 
 
 * The earliest S3iiiptoms of lij'pnotism appear as the result of stimulation of the 
 nuclei of the oculo-iuotor tract in the medulla : there is spasm of acconiniodatiou, 
 restricted accommodative range, the p.r. approaches the p.p.: then stimulation of 
 the sympathetic occurs with exophthalmos, widening of palpebral fissure, dilatation 
 of pupil, quickened pulse, and breathing. 
 
 t Landois and Stirling's Physiolojij, vol. ii., p. 2G9. 
 
STUPOR AND HYPNOTISM. 
 
 108; 
 
 
 Diminished. 
 Diminished. 
 
 Fall. 
 
 Closed. 
 
 Eoll upwards. 
 
 Contracted. 
 Ann?mic (Hugh- 
 
 Circulation and 
 breathing slow- 
 ed : i^eristalsis 
 and secretion 
 lessened. 
 
 2 s 
 
 -< O 
 
 i-lM 
 
 Profound sleep. 
 
 Exalted. 
 Exalted. 
 
 Fall. 
 
 Not anwmic 
 [Forder). 
 
 True Catalkptic 
 OR Somnambulistic var. 
 
 Intellect and senses acutely 
 sensitive: colourblindness 
 on hypnotised side (Heiden- 
 
 helm). 
 Normal. 
 
 Normal. 
 
 Light and remain long fixed. 
 
 No effect. 
 
 Open. 
 
 Fixed or roll down with ab- 
 sorbed gaze. 
 Dilated. 
 
 Not anajmic. 
 
 Circulation and breathing 
 
 quickened. 
 
 Automatic balancing : obeys 
 suggestion and command : 
 occasional hallucinations. 
 
 ii 
 
 o 
 
 Sleep. 
 
 Exalted. 
 Slightly raised. 
 
 Heavy and soon 
 
 fall. 
 Resolves sjJasm. 
 
 Closed. 
 
 ]ao11 upwards 
 {Charcot). 
 
 Not anaemic. 
 
 2 
 
 u 
 
 H 
 •Jl 
 
 Much impaired. 
 
 Normal. 
 Normal. 
 
 Heavy, resisting, soon fall. 
 
 No effect. 
 
 Partial closure with fre- 
 quent clonic blinking;. 
 
 Roll upwards and twitch 
 convulsively. 
 
 Dilated. 
 
 Heart & breathing natural: 
 flushings: vasomotor par- 
 alysis. 
 
 
 Consciousness. 
 
 Reflexes. 
 
 Neuro - muscular 
 hyper-excitability. 
 
 Limbs. 
 
 Massage of catalep- 
 tic limbs. 
 
 Eyelids. 
 
 Eyeballs. 
 
 Pupils. 
 Fundus oculi. 
 
 Organic functions. 
 Other features. 
 
 3, '3 
 
 a >»- 
 
 n » 
 
 > •« 
 
 O a. 
 
 
 H- 
 
154 STATKS OF DKPKESSIOX. 
 
 liclea is the sole subject of thought, and where other impressions are 
 n'oluntarily excluded, are conditions which pre-eminently favour states 
 of induced hypnotism and stupor. It will be of interest to tabulate 
 .here certain prevailing features in the state of stupor and hypnotism, 
 so as to indicate more clearly any physiological or psychological relation- 
 ship existing amongst such groups of symptoms. 
 
 It would appear from the foregoing Table, tliat mental stupor approxi- 
 onates more closely to the cataleptiform type of hypnotism, rather than 
 'to the truly cataleptic type. The subject is not, as in the latter state, 
 .accessible through the special or general senses, and suggestion 
 •through these channels fails to elicit responsive movements ; but, on 
 the other Laud, it does appear that the mind is often the subject of 
 
 • dominant ideas imposed through external agency, and that the cata- 
 leptiform positions which the body and limbs may be made to assume, 
 
 • can be plausibly explained on the principle of suggestion through the 
 muscular sense. 
 
 Yet, the patient in these states of stupor is not asleep, nor does 
 ■massage or kneading resolve the rigid muscles which have assumed 
 the cataleptic state. Herein, then, we see how the subject approxi- 
 mates to, and how far he differs from, the hypnotised individual. It 
 must be added, that these clinical forms are by no means grouped 
 together as suggestive of identical pathological states — the patho- 
 genesis may be wholly distinct for each class. 
 
 The fixation of the limbs in artificially-imposed postures, would 
 .seem to indicate a dominant notion of the necessity for preserving 
 .such a posture, illustrating the obedience induced to external agencies 
 ■whereby the will is subjugated — the subject's attention being reached 
 principally through liis muscular sense. 
 
 The greater depth of reduction in these states of stupor is attested 
 by the fact, that suggestions by command fail to elicit such trains 
 
 • of ideas and resulting movements as the hypnotised will present, 
 dlosing the fists and advancing the arms of a hypnotised individual, 
 and placing him in an attitude of defence, will often bring about 
 fighting movements in reality {Gaiy enter); and muscular posturing 
 will elicit the associated mental states of which it is normally the 
 •expression. This, of course, does not occur in cases of genuine stupor, 
 •or the more profound reductions of "acute dementia." 
 
 We see, again, simple forms of hypnotism in which the sole muscular 
 anomaly consists in an inability to open the eyelids or the mouth : 
 parallel states of mental stupor present themselves in which the same 
 features prevail. 
 
 H. S. L., aged twenty-six, a married woman, witli two children ; the youngest, 
 .an infant, aged nine weeks, was weaned upon the outbreak of mental symptoms 
 
STUPOR AXD HYPNOTISM. 155 
 
 six weeks ago. No history of inheiited insanity, neuroses, drink, or other 
 vice. The labour liad been natural in all particulars. On admission, she had 
 a very vacuous expression : " stared round the room in a vacant manner : was 
 wliolly inattentive to what was said, and very rarely spoke. When questioned 
 she usually remained silent, even though the query was repeated many times, 
 and efforts were made to rouse her attention; or she repeated the concluding words 
 of the question, or the words which she heard uttered by a neighbouring patient." 
 She was emaciated and antemic : her pupils widely dilated. The thoracic and 
 abdominal viscera revealed no evidence of disease to phj^sical exploration : but the 
 bowels were torpid, and the tongue was foul and thickly coated. 
 
 After the operation of a saline aperient, patient was ordered a mixture con- 
 taining 10 grs. of ammouio-citrate of iron, and 5 minims of liquor strychnia; in 
 each dose {bis die). 
 
 The condition was one of painful stupor : the expression was melancholic and 
 timorous, or one of complete stupor, in which she stood gazing vacantly into 
 space : she was silent, but occasionally would give utterance to monosyllabic 
 replies. Her habits were frequently negligent. She required feeding by hand, 
 but was induced in this way to take abundantlj\ Her hands were cold and 
 somewhat livid : all her movements were very sluggish. 
 
 About a week later, she became one day suddenly and violently excited — 
 exclaimed aloud — "Cut my throat and let me die." Asked why she wished to 
 die, she replied, "Because I am so shocked." Then she relapsed into her former 
 abstracted, silent state, requiring continuous attention on account of her rest- 
 lessness at night, her dirty habits, and her inattention to food. 
 
 A month after her admission her bodily condition had considerably improved : 
 she slept better, but was still depressed and in a state of semi stupor : the 
 menstrual functions were in arrest. 
 
 Slow improvement took place in her bodily health, but ameuorrhcea persisted 
 for some six months, during which period the same treatment, alternated with 
 iron and aloes, was maintained. She remained sluggish in her movements and 
 somewhat depressed in spirits, but would freel^^ converse about her state of health, 
 and was eventually discharged as relieved to the care of her husband. 
 
 In sucli a case as the foregoing, we see the distinction between simple 
 melancholic depression and the more acute depression often associated 
 with stnporose states : whereas the gentle depi'ession of the former 
 induces apathy, disinclination for exertion, bodily or mental, and 
 brooding silence, the latter may result in one of two conditions — either 
 in the demonstrative expression of these painful states {inelanchoUa 
 agltans) ; or in a spell-bound stupor in which the organism seems, so 
 to speak, petrified by its intensely painful mental state — the melancholy 
 with stupor or the stupidlte of French alienists. 
 
 Such patients are often completely dumb — their whole aspect that 
 of intense stujDidity : but, if you closely examine their features, you 
 will observe evidence of painful emotion, or intense anxiety, of inex- 
 pressible grief, or perhaps a look of extreme bewilderment or concen- 
 trated astonishment. 
 
 Numerous patients, who have suffered from melancholy with stupor, 
 
156 STATICS OF DEPRESSION. 
 
 liave, upon recovery, recorded i'ull details of (heir mental state : they 
 are generally lahouring under some frightful delusion, which utterly 
 sways their consciousness and will : the outside-world may be a blank 
 to them, and their whole mental life is subject to this all-absorbing 
 delusion. Perhaps they imagine they have committed some terrible 
 murderous deed, or that the end of all things is at hand : whatever it 
 be, the attitude, facial expression, and demeanour indicate complete 
 subjection to the engrossing delusion. This concentration of the mind 
 upon one painful idea, which sways like an autocrat the whole organism, 
 has been figuratively alluded to as a "crystallised delusion" — body and 
 mind are crystallised around one morbid idea. Such patients often 
 resist powerfully any attempts at feeding or other interference, and the 
 refusal of food is sometimes most persistent. 
 
 Then come sudden, fitful gleams of mind at times; a rai)id, hurried 
 utterance, with as sudden a relapse into silence and self-absorption: or 
 a sudden, mad attempt at self-destruction — an impulse, the direct 
 result of the painful mental state. One should ever Ijear in mind this 
 suicidal tendency in stuporose melancholia : it is a constant danger to 
 be feared, and all the more since the apparent stujDor is more that of 
 hodUy activity, and one is apt to forget that the mental state is often 
 one of intensely acute and painful strain, most liable to explosi\'e acts 
 and impulses towards self-inflicted violence : all such suicidal attempts 
 in this disease are frantic and determined in the extreme. 
 
 The following is an instance of permanent mental enfeeblement 
 resulting from stuporose melancholia of long standing : — 
 
 H. T., short of stature, slight iu build, and thin, was admitted at the age 
 of twenty-six. She is a married woman, of steady, temperate, industrious habits, 
 and Mas suffering from her first attack of maniacal excitement, the onset of wliich 
 occurred a week ago. No predisposing or exciting cause could be ascertained for 
 her attack. 
 
 Shortly after admission she became violently excited, and apparently in great 
 terror and suspicion, of all around. After a short remission of this excited stage, 
 she became depressed, apathetic, and torpid in appeai'ance. She would stand or 
 sit in one position for hours, gazing vacantly before her — nor could she in any way 
 be roused from this abstracted state. The catamcnia have not appeared since her 
 admission. Ten weeks after admission, her mental condition had so far improved 
 as to permit of her attending Church service and entertainments ; her bodily 
 health also was considerably better. Shortly after this it is noted : — She is in a 
 state of profound reverie^mental state apparently one of painful tension : fixed 
 as though petrified to the seat or floor, her gaze is one iiidi(;ative of intense self- 
 abstraction and the prevalence of some delusional idea wliich dominates her whole 
 life, and which now frequently issues, without any warning, in sudden, impulxlre, 
 and most frantic attempts at self-destruction, by throwing herself violently on the 
 floor, or dashing her head against the wall. She would then lapse into a cata- 
 leptic state, in which her limbs might be made to assume any position for a 
 
STUPOU : PRIMARY DKMENTIA. 157 
 
 lengthened period — her aspect trance-like, her expression indicative of intense 
 and painful mental concentration : no vacuity, nor any appearance suggestive of 
 dementia. Five months after admission, the painful mental state had subsided, 
 but there was much stupor, with, Iiovvever, occasional gleams of intelligence — 
 transient recognition of her surroundings. She could not be induced to employ 
 lierself ; Avas found one morning in a fixed attitude in the centre of the laundry 
 wash-house, and on being questioned, said she was "at the Mi<lland Station 
 awaiting the down train. " She was very pale and anemic — there was amenorrha-a. 
 .Siie now takes iron and arsenic in mixture: subsequently altered to iron and aloes. 
 
 On June G, 1SS3. — Slie cannot bo persuaded to employ herself: still at times 
 assumes fantastic, rigid, cataleptic postures, but is not now \'iolent to herself — 
 spasmodic outbursts of temper occur, when she is aggressive and destructive. Her 
 expression now indicates a full ajjpi'eciation of all tliat occurs around her, and 
 judging from it, an absence of mental pain. Iron with cantharides and guaiacuin 
 ordered to-day. 
 
 June 11. — The catamenia have now appeared. 
 
 July 23. — A Faradaic current applied to the head daily for five to eight minutes. 
 
 July 31. — No benefit has resulted from Faradaism : to-day a constant current, 
 from six to eight (C4aiffe's) cells, was substituted, one electrode to forehead, the 
 other to occiput, the direction of the current changed by commutator several 
 times, during five or eight minutes daily. 
 
 August 4. — Somewhat brighter in mind, cleaner iu her habits, still idle : shows 
 signs of indecency — exposing herself, and on being reproved threatens to slap the 
 officer in the face. There is wide dilatation of the pupils ; cataleptiform positions 
 are still assumed, and long retained. 
 
 August 9. — Continued improvement : catameuia have occurred naturally again ; 
 has commenced employing herself at needlework : galvanism still continued. 
 
 October 11. — Constant current discontinued to-day: her attacks of impulsive 
 violence and excitement, as also her cataleptic states, occur frequentlj'. Ko 
 improvement occurred subsequent to that above noted, and in June, lSS-1, it is 
 recorded that she still has a fixed ecstatic look, is undoubtedly deluded, sudden, 
 and dangerous. The case then assumed the character of ordinary chronic mania.* 
 
 Acute Dementia. — We have stated above that the extremes of 
 stuporose states represent such profound lethargy as closely to 
 ;simulate the aspect of genuine dementia: in fact, stuporose melancholia 
 passes, by almost imperceptible gradations, into unequivocal dementia, 
 and in several instances, we observed the melancholic stupor which 
 characterised the onset of an attack pass into typical dementia. 
 
 In other instances, however, the reductions are from the onset so 
 profound that a primary dementia occurs quite suddenly, and this 
 
 * In connection with stuporose states, Ur. Whitwell, Pathologist to the Menston 
 Asylum, has communicated to me certain observations, whilst these sheets were 
 passing through the press, which appear to have an important bearing upon the 
 pathology of some, at least, of these instances of stupor. Careful measurement of 
 the blood-vessels at the base, by the graduated cone, leads him to infer the presence 
 of a congenital narrowing of their lumen, associated also with a universal cardio- 
 vascular enfeeblement. Dr. Whitwell's observations will appear in extenso in the 
 Journal of Mental Science. 
 
158 STATKS OF DEPRESSION. 
 
 represents the condition 'usually known as typical acute dementia. 
 Acute primary dementia lias been by some confounded with the 
 stuporose lonii of niihiiicliolia — melunchoUe avec stupetir : by others, 
 with simple stupor, i.e., suspension of the intellectual operations apart 
 from melancholic states, and not one of actual ahoUtlon of function. 
 
 Undoubtedly, however, there is a genuine acute dementia, in which 
 the patient recovers to a certain extent, but invariably exhibits much 
 impairment of his mental faculties ever afterwards. It is, of course, 
 not suggested that the profound torpor, amounting in these cases to 
 the appearance of utter fatuity, represents the degree of actual 
 dementia, i.e., of destruction of function: much of this is truly due to 
 simple, though profound^stupor — we can only judge of the amount of 
 actual destruction of function upon the patient's so-called recovery. 
 We lind that this statement applies to all forms of dementia: all alike 
 are liable to a certain admixture of stuporose states, which appear to 
 emphasise the degree of abolition of mind — but which, dissipated by 
 rousing the patient, indicate to us no such profoundly inactive con- 
 dition as we should at first sight bo inclined to predicate. In severe 
 cases of acute dementia no such rousing can be induced, and upon 
 restoration to raoi-e active function, the mind of the subject still fails 
 to recall much (if anything at all) that has taken place throughout the 
 attack. 
 
 The following is an interesting case of this primary dementia, 
 occurring in a young girl at the West Riding Asylum : — 
 
 A. J., who is now twenty-two years of age, was admitted seven j'ears ago in 
 a state of partial stupor. She had been regarded as imbecile from birth. Had 
 never been able to read or write: although troublesome, she had not proved 
 vicious, dangerous to others or herself, or of destructive habits. Had not suffered 
 from epilepsy. Her family history was free from insanity, apojjlexj', epilepsj% and 
 phthisis. Patient had never injured her head. Quite recently it was recorded tiiat 
 she had become sileut, gloomy, stupid, standing about staring vacantly before her ; 
 her habits were degraded — required compulsory feeding. At times it was recorded 
 that she appeared in terror,[|and behaved as though she saw and heard imaginary 
 objects about her. Upon admission there was much stupor: she remained per- 
 fectly mute to all questions, 'and her conduct did not lead one to believe that she 
 appreciated either spoken^ or pantomimic language: a slight inarticulate cry alone 
 escaped her. Facial conformation of low type — expression heavj', torpid. She 
 showed a slight cataleptic^tixity of the body and limbs at times: the limbs were 
 cold and bluish. She was quite helpless, of dirty habits, and had to be clothed 
 and fed. 
 
 The stupor rapidly passed off, and she Avas found to be a lively, good-humoured 
 girl, very childish and imbecile, however, but able to speak in broken utterances. 
 Became active, industrious, and cleanly : she was somewhat boisterous and excitable 
 in l)ehaviour at times. 
 
 In August, 1SS2, it is noted: — She has become heavy, apathetic, ajiparently 
 demented; is negligent in her habits, never speaks, and requires all her bodily 
 
ACUTE PlilMAKV DKMKXTIA. 159 
 
 wants to be ministei'ed to by othfirs; she slavers at the mouth, extremities are cold 
 and livid; catamenia have not occnrred for six weeks. Is led about readily and 
 exercised. 
 
 On the 11th of September she suddenly spoke to some patients, calling them 
 by name, and remarked upon the beauty of some flowers near her. She then 
 relapsed into her former heavy, drowsy state, and so remained until the 2nd of 
 December, when she recovered her speech and mental powers as suddenly as they 
 were annulled, and immediately began working in the wards. She was, however,, 
 flighty and excitable, and on the 9th of this month it is noted that she "is^ 
 extremely excited and destructive, giving much trouble— is mischievous, dis- 
 orderly, and violent" — for which attack she was treated by ^ grain doses of 
 hyoscyamin, and also by bromide with Indian hemp. 
 
 During the year 1SS3, she had repeated attacks of stupor which were charac- 
 terised by their sudden onset and rapid relief; but, in all cases alike, a stage of 
 maniacal excitement followed upon the stupor. In these attacks of stupor she- 
 stands about in a stooping attitude— motionless unless led ; does not resist ; 
 head droops, the face is expressionless, and saliva runs from the partially open, 
 mouth; the pupils are widely dilated, the arms hang helplessly, the hands and 
 feet are cold and livid. She has the aspect of one whose mental faculties are in 
 complete abeyance. She remains where she is placed, and no voluntary movement 
 is initiated — moves a step or two when pushed, and there remains motionless until 
 again moved by others. She never attempts to feed herself, nor does she resist the 
 efforts made to feed her, but swallows the bolus when introduced into her mouth : 
 she is wholly inattentive to the state of bowels and bladder. The subsequent 
 attack of excitement on return of partial consciousness was invariably of the same • 
 character — loud, hilarious, boisterous merriment, mischievous propensities, and 
 occasional vicious conduct : she was also destructive of clothing, and wilfully 
 destroyed glass and ornaments. Upon the reinstatement of her former mental 
 health, she never could recall any experiences of her stage of stupor, although 
 frequeiitly questioned upon this point. The last attack of the kind occurred on 
 the 15th of May, 1SS5, and her mental faculties did not clear up until the 20th of 
 November, a period of six months. 
 
 In stich cases, we do not find the subject prone to sudden, Avild 
 outbvirsts of maniacal or melancholic frenzy, such as we found pre- 
 vailed in stiiporose melancholia — to active and desperate attempts at 
 self-destruction, foUoived by as sudden a lapse into the stupor ose state. 
 The condition of mind is distinct in the two affections : in the one 
 (the melancholic) it is strained and ever ready to explosive outbursts,, 
 in the other (the demented) too feeble to initiate any such attempt. 
 
 Tlie maniacal outbursts characterising the last case detailed, were- 
 really upon the road towards a restitution of the normal state of 
 mental health : as the stupor lifts, so the maniacal reductions come to 
 the front, ere the subject is restored to her former self And yet, not 
 to her former self, for a passage of her life, as we see, is comY)letely 
 obliterated, and the mind is a blank to the events of each attack. 
 
 The apathetic passivity of such cases also contrasts strongly 
 with the resistance, and often violent struggling, olfered by the subject 
 
1*60 STATKS OK UKPRKSHIOX. 
 
 of melancholia cum stuj»ore. Tlio blank, stu)ti(l, idiotic stare, and tlio 
 artterly demented expression, are likewise very diflerent from the aspect 
 (presented by the latter afiection, where mental tension is very evident 
 dn the pained look, wjiich sometimes is varied by gleams of transient 
 •t'cstasy. Cataleptic fixation of the limbs is a frequent, but by no 
 jneans invariable, iu-conipaiiiiaent of acute dementia. 
 
 Some subjects of this disease are, according to Dr. Blandford, in 
 -incessant movement : " One girl used to snap her jaws together for 
 ■ days at a time, and then changed to wagging her head from side to 
 ^ide." These are the less profound instances of reduction. 
 
 The heart is feeble, and there is great toi-por of circulation — the 
 fliands and feet being cold and livid to an intense degree. Such 
 ■jiatients arc utterly negligent in their habits, they require feeding 
 ■throughout the attack, and all their wants have to be attended to by 
 •others. 
 
 The following instance of acute dementia of three years' standing is 
 :a remarkable instance of the relief afforded by an acute pulmonary 
 affection. The fact is well establislied, that certain acute mental 
 ailments derive transient or even, permanent benefit — at times attain 
 complete recovery — from the incidence of an inflammatory implication of 
 •distant organs, or even upon the appeai'ance of furunculi or carbuncle, 
 •or erysipelas of the head or face. The case in i)oint jjresents a parallel 
 instance. 
 
 W. S., aged nineteen, a gardener — of strong neurotic inheritance, his fatlier having 
 liad repeated attacks of insanitj', and his brother being at present an inmate of 
 this asylum — was admitted on the 19th of June, 1885. There is no criminal family 
 iliistory. Patient was spoken of as a quiet, sober, stead}', well-conducted young 
 man, always somewhat taciturn until about four months preceding his admission, 
 when he began to attend meetings of the Salvation Army every niglit, and became 
 excitable and preached frequently in the streets. A fortnight preceding his admis- 
 .sion, he talked much in a religious strain, was restless, sullen, and wilful: at a 
 Wesleyan service, which he attended, force had to be employed to prevent his rush- 
 ing into the pulpit, declaring that he would preach. This same evening he left his 
 ^stepfather's house secretly through the window, walked to his brotlier-indaw's house, 
 ^nd tried to get into the bed where his married sister slept. Upon his admission 
 he was much distressed: had stated on one occasion that he was to be burnt: was 
 evidently exceedingly timid, suspicious, and would lie sobbing aloud, gazing before 
 ?!iim with distressed exj)ression, and obstinately reticent. He was a fairly nourished 
 lad — hair brown, irides greenisli, complexion fresh, teeth regular, but palate high- 
 . arched : the pupils were equally dilated and their reactions normal : the tongue -was 
 protruded straight and steadily. The pulse was of fair streugth, ninety-six — the 
 circulatory and respiratory systems normal. The urine amber-coloured, sp. gr. 
 1018, acid, free from deposit, albumen, or sugar. 
 
 On the 29th of the month, i.e., ten days after admission, he is noted as exhibit- 
 ing a depressed and vacant aspect — as very slow in all his movements, and 
 .maintaining an obstinate silence. He becomes negligent in his habits, wets his bed 
 
ACUTK PUIMAHY DKMENTIA. Id 
 
 nif;htly. When asked to protrude his tongue, he does so; he feeds himself. He 
 thus remained until the month of October, when the stupor became more pro- 
 found, and up to the present date, sixteen months subsequently, his condition has 
 been unchanged. During the whole of tliis period he has presented a typical 
 instance of mental stupor, the former melancholic phase having quite passed away. 
 He sits in a slovenly stooping attitude, the liead bent forwards upon the chest— the 
 legs tliriist out, and the arms hanging helplessly down. In whatever position his 
 body or limbs are placed, so they remain : if the arms be extended above his head, 
 tliey long remain so, and are gradually allowed to drop to his side. The whole 
 limb thus gi-avitates downwards, the separate flexions of hand and forearm not 
 occurring. 
 
 Now, in this case, if he be made to stand up, he does so in slouching fashion, and 
 remains fixed in any position we choose to place him in : if pushed along, he walks 
 a few steps only, then halts, and is again immobile : if pushed towards an obstruc- 
 tion, as a table or bedstead, he shows his consciousness of the obstacle by tending 
 to veer round with each step so as to avoid it. If we raise his arms, they are found 
 to be heavy and cumbrous, and not so readily adapted to varied posturing. There 
 is an absence of that lightness and flexibility whereby they may be, so to speak, 
 moulded into any form — this absence of plasticity is due to resistance, which is 
 very appreciable in our patient's state. The contraction of the muscles is not 
 resolved or in any degree influenced by fi'iction, by kneading, or massage. If, now, 
 we place our patient in an upright position in a chair, and incline it at various 
 angles, we find that he adapts himself to the altered position, and maintains 
 his equilibrium up to a certain point, when he allows himself to fall. His 
 eyelids are partially closed, resist opening, and the eyeballs are convulsively 
 rotated upwards, so that it is impossible to examine the pupils. There is often, 
 but not constantly, rapid clonus of the eyelids, which can be arrested by firm 
 pressure of the fingers over the supra-orbital notch, and is always increased by 
 forcibly raising the upper lid. The face has always a most stupid, heavy expres- 
 sion, and never indicates mental pain or distress : the head falls forward on the chest, 
 and resists efforts to raise it. If shouted at, he does not appear to notice what is 
 said, although he starts at a sudden shock; if pinched or pricked by a pin, he does 
 not flinch, but has on one occasion shown evidence of feeling — a tear trickled down 
 his cheek. The knee-jerk is exaggerated in both legs. He makes no attempt to 
 feed himself : the mouth is kept firmly closed, and the spoon has to be forcibly 
 passed into the mouth, when he immediately swallows the bolus of food. He is, 
 in all respects, utterly negligent and uncleanly. This patient has not spoken a 
 word for the period of three years. 
 
 The blood, examined by Gower's hfemacytometer and hremoglobinometer, gave 
 the following results : — 
 
 Ked Corpuscles. Hoemoslobin. White Corpuscles. Value per Corpuscle. 
 
 100 per hffimic unit. G8 % to SO %• '4 per hremic unit. -68 % to -80 %. 
 
 He had remained in this condition for exactly three years, when, one morning, 
 he spoke for the first time, became mildly excited, and shouted aloud the names of 
 certain patients around. It is noted the next day, that he sat with his eyes 
 open, watching with apparent interest what went on around, that he asked for 
 some bread and cheese, but would not reply to any questions put to him. He was 
 still at times cataleptic, and ivas neijlirjent in his habits: "another patient makes 
 him laugh by imitation." 
 
 This partial relief was, however, attended with loss of flesh, pallor, and debility, 
 
 11 
 
162 
 
 STATES OF EXALTATIDX. 
 
 and he continued for nearly three months in this condition, occasionally lapsing into 
 more profonntl stupor. At tins date an abscess, glandular in origin, was opened in 
 the neck, and a little later, dulness at the right base and increasing debility 
 revealed pneumonic consolidation. He was put to bed, and almost immediately 
 upon this regained a more normal state of consciousness. He became cheery, 
 briglit, chatty, and it M'as evident that he was rapidly recovering from his mental 
 derangement. He was kept for six weeks bedridden by his attack of pneumonia ; 
 but from the first, his mind remained clear, and no lapse of stupor intervened. 
 
 Just prior to the appearance of. chest symptoms his weight was 106 lbs. : three 
 months later, with extra diet and cod-liver oil, he weighed 140 lbs., looked 
 vigorous and robust, and was an active, cheerful, and fairly intelligent ward 
 helper. He recalls certain incidents during his attack, as the opening of the 
 abscess in the neck, the feeding and clothing by his attendants : but, for the most 
 part, the whole three years are a blank to his mind, and he gives most hazy 
 accounts of himself just prior to coming to the asylum, where he thought he 
 had been resideut but a few months. The blood examined, just prior to his dis- 
 charge from the asylum, gave the following indications : — 
 
 Bed Corpuscles. Htemoglobin. "White Corpuscles. Value per Corpuscle. 
 
 100 per hc-emic unit, 90 %. '28 '90 %. 
 
 STATES OF EXALTATION. 
 
 Contents. — Maniacal Eeductions — Failure of Attention — Enfeebled Synthesis — 
 Transient Delusive States— Exalted Sense of Freedom— Impulsive Conduct — 
 Nocturnal Crises— Seclusion Fosters Hallucination— Sexual Illusions- Stadium 
 Melaucholicum — Enfeebled Imagination— Bodily Symptoms— Periodicity of 
 Maniacal Phenomena— Acute Delirious Mania. 
 
 Viewed from the clinical aspect, cases of mental depression chiefly 
 impress ns with the prevailing feature of mental pain ; although, as 
 we already have seen, mental pain is by no means an essential element 
 in states of mental depression. The latter term to us connotes far 
 more than simple melancholic pain, since we regard all cases of simple 
 intellectual torpor, morbid apathy, and states of simple stupor (all of 
 which may be devoid of painful emotional states), as comprised under 
 the category of states of mental depression. In like manner, although 
 we may take the prevailing emotional tone, the exuberant flow of 
 thought, and the general objective indications of maniacal excitement 
 respectively, as characterising states of mental exaltation, we must 
 remember that any one of these indications may be variably pro- 
 nounced, or even supjiressed. We should, therefore, carofullj' define 
 to our minds the connotations of these respective terms — exaltation 
 and depression; and we shall then learn that the more ai-bitraiy, nar- 
 row, and exclusive our definition, the less I'eadily do we perceive that the 
 one is the converse of the other ; and that tlie freer our definition 
 becomes, so as to embrace all mental operations within its limits, the 
 
THE REDUCTIONS -OF MANIA. 163 
 
 more readily do we find in the infinite varieties of both classes, states 
 in the one which are the exact antitheses of states in the other. 
 
 It is, however, of far greater interest to recognise, in the morbid 
 process which underlies these states of mental exaltation, that the 
 process of reduction is usually more sudden in its onset, more rapid in 
 its course, more intense, and the level reached always lower than that 
 of simple mental depression. In states of mental exaltation, we also 
 trace the same fiiilure in object-consciousness, with the corresponding 
 rise in subject-consciousness, which states of mental depi-ession present, 
 but how difierent are the features of the two viewed in contrast ! 
 
 Here we have in the welling-\ip of feeling, pleasurable emotions 
 in place of painful states ; a genei'al sense of well-being, exuberant 
 joy, excessive hilaiity, an overflowing of the spirits in generous 
 impulses, an egoistic self-confidence — all strongly contrasting with the 
 grim foreboding of coming evil, the gloomy aspect of the present, the 
 sorrows of the past, the sense of the subject's helplessness before an 
 encroaching and malign environment. So also in the rapid flow of 
 thought — disconnected, incoherent as it is — expressed in rapid utter- 
 ance, associated with restless movement, energetic pantomime, and a 
 sense of utter lawlessness (often issuing in reckless conduct), we have a 
 striking contrast to the sluggish ideation, enfeebled imagination, apathy, 
 paralysed energy, and restricted movement of the melancholic. 
 
 Yet, fundamentally distinct as these mental states would appear to 
 be, we have little doubt that the process of reduction is the same for 
 both ; but in maniacal states the dissolution is to a g'reateP depth — 
 the difi"erence is one of degree. 
 
 All maniacal conditions are pre-eminently distinguished by a failure 
 of attention, or the capacity for serial thOUg"ht, and a rise of the 
 pur-ely sensuous in place of the intellectual operations — in fact, the 
 latter ai'e enfeebled, and the emotional elements are aroused ; and, as 
 before indicated in cases of dej^ression, the intellectual sphere presents 
 the negative, and the sensuous the positive results of the reduction.* 
 
 Since seriality of thought requires high nervous pressure — a high- 
 tide of the nervous wave to force the ultimate ramifications of the 
 
 * Just as the sensitiveness of the retinal field declines progressive!}^ from piie 
 acutely sensitive spot outwards, until impressions received upon the outermost 
 peripheral areas are more and more dimly perceived and eventually fade, and 
 just as we tend by concentrating our attentive gaze on a fixed point to limit the 
 field of conscious perception and to jve^s out of consciousness those obscure faiut 
 excitations of the outer field of vision : so Mith the mental field, as the serial line 
 of thought becomes restricted, as object-consciousness fails in vigour, so there 
 crowd into our conscious life those obscure and multitudinous impressions which 
 are always present, but are, for the most part, excluded from the immediate gaze of 
 the mind's eye. 
 
164 STATES OF EXALTATION. 
 
 cerebral cortex — so here in. mania we must recognise an ebb of tliis 
 cerebral tide, corresponding to the lowei-ed plane of psycliical activity ; 
 for the activity which we recognise in the excitement of lower levels 
 is one of disorderly nngoverned license, indicative of the removal of 
 the influence of higher controlling planes. 
 
 Of the three laws of association of ideas which regulate our normal 
 mental operations, the law of association by similarity embraces opera- 
 tions of a far more abstract nature than is the case with that of 
 association by contiguity, and the same may be said of tlie latter as 
 contrasted with the process of association by accident or incongruity. 
 It is the more abstract representative jirocesses of association by 
 similarity which are first involved in maniacal reductions — tlie less 
 abstract presentative-representative processes not being so far involved. 
 This fact explains much of what we observe in the maniac's conduct ; 
 his pei'ceptions are crude, and his notion of the essential utility of objects 
 around him is frequently at fault— the result is often comical, but at 
 other times it is disastrous to himself or others. Thus we may see such 
 a subject trying to put his coat on b}' thrusting his legs into the .sleeves, 
 mistaking the garb for a pair of trousers ; here we observe that the 
 association by similarity suggests to his mind only imperfectly the 
 utility of the garment. In fantastic attempts at decoration, in the 
 ■wanton destruction of objects around, in the tearing-iap of clothing and 
 bedding, in the swallowing of garbish, and in some of the most repulsive 
 tendencies of the maniacal, we must recognise the failure of conscious- 
 ness implied in the imperfect operation of association by similarity, 
 and not refer such acts, as is so often done, to sheer wilful mischief. 
 The imperfect operation of the same law is seen also in the remarkable 
 rhyming tendency presented by some, viz., that of stringing together, 
 in verse, numerous lines utterly devoid of sense, but in which a well- 
 regulated rhythm pervades the whole, and each line accurately rhymes 
 with its fellow. Numerous instances of the restricted operation of this 
 law will occur to any one familiar with the vagaries of the insane. 
 
 It is in this failure of the highly representative processes that we 
 must also learn to trace the early origin of those deluded states to 
 which mania and melancholia tend ; for we may well see how by 
 their failure sense-presentations are not so likely to have their falsi- 
 fications corrected — an appeal to a higher tribunal is not permitted. 
 Transient delusions thus characterise the maniacal turmoil through- 
 out its history ; they are often but indications of a want Of balance 
 established between contiguous groups by discharges from higher 
 controlling realms, leaving, so to speak, certain islets "flooded ;" such 
 pei'vei'sions are of a very recoverable nature. As contrasted with the 
 fi.xed perversions of monomania, Griesinger thus alludes to them : — 
 
TRANSIENT DELUSIVE STATES. 165 
 
 "But if these two forms in their extreme degree are so utterly distinct as 
 mutually to exclude the possibility of mistaking the one for the other, still 
 observation shows that in mania itself such delirious ideas of self-importance are 
 by no means unfrequent, whicli certainly ought not to be regarded in an onto- 
 logical sense as ' fragments of monomania,' as phenomena of quite another affection 
 which in this case present themselves in a very simple form, but as the result of 
 the primary mental condition. , . . They {i.e., the delirious ideas) share in 
 the tumult and precipitancy which agitate the motory sphere of tlie soul-life ; 
 they become so confused in their hurry, and pursue each other so rapidly, that 
 they have no time to l)ecome fixed or to dwell in the mind." * 
 
 An " over-action on lower planes," as Dr. Huglilings-Jackson would 
 term the state to wliicli we allude, cliaracterises these maniacal states 
 in the intellectual sphere, revealing a profound failure in object- 
 consciousness. Ideas arise in extremely rapid sequence, often as the 
 mere result of casual or accidental association, the subject being swayed 
 by every passing incident. Every degree of incoherence may present 
 itself according to the rapidity of the cerebral processes at fault ; yet, 
 in all the simpler forms of mania, a temporary command of the atten- 
 tion can be obtained by an authoritative gesture, command, or other 
 artifice, when a perfectly coherent statement may be elicited, the 
 memory exhibit normal vigour, and reason momentarily assume her 
 sway ; then they pass back again into the wild turmoil of disconnected 
 ideas and strange mental combinations. It is in the changeable, 
 fleeting nature of the mental images that we hope for the patient's 
 complete restoration to mental health. 
 
 It must not be imagined that all states of mental exaltation imply 
 the tumultuous career of ideas above described. Ideation is always 
 quickened by unnatural vigour — the images become more vivid; but a 
 superficial coherence may be observed which enables the patient to hold 
 rational converse, to employ cogent argument, raillery, sarcasm, or 
 wit. In the simplest types of mania, slight garrulity, a restless move- 
 ment, and rapidly-varying mood may alone betray the mental 
 disturbance. 
 
 If we turn our attention to the sphere of subject-consciousness, we 
 find here in the majority of cases a rise of the pleasurable emotions 
 and an unwonted sense of freedom, undoubtedly engendered by 
 the coincident, unrestrained activity dominant in the intellectual 
 sphere. The high-tide of the emotional wave reacts on the intellectual 
 sphere — the exalted self-feeling issues readily in action, or begets 
 with equal ease notions of power and self-importance — transient 
 delusive concepts, which rise as new creations, answering to the pre- 
 vailing mood. The exuberance of feeling usually expresses itself in 
 goodwill to all mankind — in a universal optimism, which often issues. 
 
 * Op. cit., Y>. -Ili. 
 
166 STATES OF EXALTATION'. 
 
 in schemes of philantlii'opy as impracticable in their nature as they 
 are transient in their duration — in extravagant and ludicrous proffers 
 of patronage to science and arts ; or the mood may vary from this to 
 one of supreme ari'ogance, in like manner conjured up by the ex- 
 af cerated self-feeling ; and the subject may announce liimself to be 
 some mighty personage, and assume a defiant, threatening, or savage 
 aspect. We observe that these reductions in maniacal states bring the 
 subject to a more automatic OP instinctive level ; impressions 
 received from without are liable to issue in immediate action — mature 
 deliberation no longer characterises the mental operations, but a state 
 of exaggerated mental reflex; in like manner, the animal passions and 
 instinctive desires, uncovered, as it were, spring into life and show an 
 unregulated activity — impulsive COnduct, therefore, is especially 
 prevalent in states of mental exaltation, and the maniac may be 
 destructive, violent, blindly impetuous, or dangerously homicidal, or 
 react to any of the grosser animal passions and instinctive desires by 
 which he is swayed. 
 
 Nocturnal Crises. — The insane are peculiarly liable to be afl"ected 
 by those cyclical conditions which are recognised in the healthy in- 
 dividual, and thus the periods of waste and repair, embraced by the 
 clay's labour arid the night's rest, are shown in their case also. The 
 phenomena of nocturnal crises, and the periodic character of their 
 excitement, are very notable and well-recognised facts. The daily 
 routine of work may be passed through in a quiet, orderly manner ; 
 obedient to the "law of the room" and the injunctions of the nurse, 
 tractable and reasonable in conduct, the insane may exhibit no outward 
 indication of mental anomaly until more closely examined ; yet, 
 invariably, as night approaches, they pass the hours in loud, boistei'ous 
 excitement, shouting, singing, incessantly chattering, replying to 
 imagined voices, restlessly wandering about, or beating the dooi's or 
 shutters of their room. During the day, the association with their 
 fellow-patients, application to theii' various duties, and the general 
 discipline of their immediate surroundings may have just sufficed to 
 engender that control over their conduct to which there is now no 
 incentive. The seclusion and quiet of their rooms, the release from all 
 imposed reserve, permit of that wane of object-consciousness wljich is 
 invariably followed by a rise of subject-consciousness. This nocturnal 
 crisis must be regarded as the outcome of those rhythmic changes, 
 which, in a normal state, should issue in sleep. 
 
 Such reductions, however, are but partial, spasmodic, and limited to 
 psychical processes only — whereas in sleep the whole excito-motor 
 apparatus is more or less deeply involved. In sleep, object-consciousness 
 quickly, even suddenly, succumbs; subject-consciousness goes more 
 
NOCTURNAL CRISES : HALLUCINATIONS : ILLUSIONS. 1G7 
 
 sloioly, and the more profound depths are not usually reached for an 
 hour, or even longer ; the reflex excitability of all the nei-vous centres 
 (si^inal also) is reduced — the organic functions are lessened. In these 
 cases of nocturnal excitement, however, the effect of this periodic lapse 
 of consciousness is to call up moi-e turmoil at lower levels; all those sub- 
 jective states arising from epi- and ento-peripheral stimuli, or centrally 
 initiated, become the subject-matter of the mental view; all those dis- 
 connected and simultaneously originating ideas which crowd the mind, 
 and which, in healthy waking states, are reduced to serial, orderly 
 thought, now run riot — and beyond this, hallucinations of the special 
 senses prevail. 
 
 Seclusion tends to foster hallucination ; this fact, so well-recog- 
 nised amongst the criminal community in prison life, is especially true 
 as regards the insane. It is to the existence of hallucinations that we 
 must largely attribute the insomnia and noisy outbursts ; and it is an 
 undoubted fact that many such cases, judiciously selected, are benefited 
 by removal to an associated dormitory, and thus nights previously 
 passed in noisy excitement become intervals of repose and quiet. 
 
 Such hallucinations, often peculiarly vivid, fascinate the mental 
 vision, and according to their nature call forth corresponding results — 
 the patient may be passionate, wild, threatening, and defiant, abject 
 with terror, shouting in alarm for succour, joyous, exultant, or in 
 boisterous merriment ; every phase of emotional life may present itself 
 as the hallucinations vary, and he enacts his little drama alone. 
 
 In general paralysis these nocturnal orgies are frequent — noisy rest- 
 lessness, with or without hallucination, accompanying the hiter stages 
 of most cases. 
 
 In many, the hallucinatory phenomena are recognised by the patient 
 as having no real objective origin, and yeb they will be fostered by the 
 fascination which they entail ; especially is this the case with SGXUal 
 illusions which are frequent in the female sex, and which, it is pro- 
 bable, are very largely entertained and fostered. Cases occur where 
 the nocturnal reductions having been recovered from, the patient is 
 filled with remorse or shame, or accuses certain individuals of criminal 
 conduct, accompanied by threats of retribution and violence ; each night 
 the phenomena recur, attended by erotic excitement, and each returning 
 morning they form the incentive to indignant protest or violent conduct. 
 
 To many again, the reductions entailing rambling, disconnected 
 thought and garrulity, are in themselves a source of pleasure — easily 
 controlled when the patient is brought into association. 
 
 The. exhaustion which often follows such nights of excitement and, 
 possibly, the accumulation of decomposition and waste products in the 
 blood, induce in many prolonged sleep throughout the day. , 
 
168 STATES OF EXALTATION. 
 
 Mania. — The incubative period of mania is but a record, in most 
 cases, of a very gradual declension in mental vigour, not perhaps at 
 all apparent to the friends, but sufficiently evident to the subject 
 himself. Intellectual operations become more laborious than usual, 
 thought is sluggish and tends to wander (attention being fugacious) ; 
 strange and unusual lapses of memory occur — the patient is "absent" 
 and forgetful. All mental operations are not only difficult and 
 tedious, but are followed by weariness and ennui, and a gloom over- 
 spreads the mind, for which there is often no obvious cause. At night 
 the subject is restless, obtains but little sleep, and awakes uni-efreshed, 
 with gloomy forebodings, and a disinclination for all forms of exertion ; 
 in fact, a frittering away of nervous energy has brought him into the 
 first stage of his malady — that of simple melancholic de])ression, to 
 which all the foregoing remarks we have made with respect to simple 
 melancholia apply. This, the first stage of his reductions, is the stadium 
 melancholicum which precedes all forms of mental disease. It is 
 not implied by this that the subject necessarily exhibits such a stage 
 in all cases — although, undoubtedly, many cases cited of sudden onset 
 of excitement without previous warning, are instances of a defective 
 observation on the part of others. The absolutely SUdden onset 
 of maniacal sijmiitoms does occur at times, as in instances of epileptic 
 insanity from sudden and severe discharges ; nor is there any prima 
 facie reason for supposing that such serious and sudden reductions 
 should not occasionally be induced. We must, however, regard the 
 melancholic stadium as the usual feature, and the sudden onset of 
 mania as quite exceptional. This premonitory stage is of most vari- 
 able duration, ranging from days to weeks, or from weeks to months ; 
 it may pass off under favourable circumstances, and again recur as 
 former conditions of life are resumed. 
 
 Then suddenly, and often quite unexpectedl}', comes a marked 
 transformation, signalising the maniacal reduction. The gloom and 
 despondency appear to be lifted ofi" — reticence and brooding are 
 replaced by sociability and vivacity : a strange light gleams in the 
 eye ; an animated expression replaces the pained and stolid aspect ; 
 the moods are mobile, and an exalted, pleasurable self-feeling pervades 
 the subject. His thoughts, no longer under painful restriction, fiow 
 in unlicensed freedom and in unwonted rapidity, reproducing the 
 symptoms of early alcoholic intoxication. The patient is garrulous — 
 obtrusively so : talks about his own allairs ; is confidential and com- 
 municative to utter strangers ; is egoistic, makes profuse offers to 
 befriend all around him ; is energetic in his movements, incessantly 
 restless, and rapid in his utterances. If we test his individual 
 faculties, we may find his memoiy fairly intact, or partially obscured, 
 
MANIACAL REDUCTIONS. 1G9 
 
 upon events occurring during Lis maniacal attack ; his attention is 
 commanded with more or less difficulty, according to the intensity 
 of the excitement (depth and extent of reduction), but in all simple 
 forms of mania it is readily brought under control; yet only to lapse 
 the next moment before the tumultuous flow of incoherent thought. 
 If we leave him to his own devices, and listen to his rambling speech, 
 we discover that fragmentary condition of language which attests the 
 want of coherence of ideas — a weakening of that synthetic process 
 which i-enders intelligent and rational thought possible ; a cohesion of 
 ideas still is apparent, but it is that of the trivial associations chiefly, 
 and suggestive movements, utterances, or other impressions presented 
 casually by those near him, will often blend promiscuously with the 
 subject-matter of his thoughts, in the most grotesque and unregulated 
 manner; and, as we have before explained, the serialitij of thought 
 becomes impossible. Every degree of incoherence may thus present 
 itself, from the mildest occasional rambling, to utter incoherence, 
 where speech is qiiite unintelligible, as in the deepest reductions 
 of typho-mania or acute delirious-mania. Tlie patient is reduced 
 to a more automatic level ; his actions are more instinctive than 
 volitional, just as his ideation is more reflex in its arousal and 
 expression. A slave to every passing impression, to every casual 
 thought, to every emotional incitant, his conduct is wholly unpredi- 
 cable, subject to no rule or means of calculation. The maniacai 
 subject is not imaginative, in the proper sense of the term ; at times 
 we find what savours of imaginative vigour, but all such gleams are 
 superficial, transient, and accidental ; the strangest combinations of 
 ideas must necessarily prevail at times, and produce this apparent 
 imaginative turn — and the unexpected scintillations of wit which 
 characterise certain maniacal subjects. Like the child, his imag'ina- 
 tion is feeble and inchoate, and, like the child, too, his flimsy fancy 
 wanders aimlessly, and replaces the truly synthetic, creative opera- 
 tions of the imaginative faculty. Judgment may be perverted upon 
 certain points, but is just as freqiiently unafTected ; in fact, the mental 
 faculties exhibit only such derangement as would occur from the 
 excessive activity of the maniacal process — a transient confusion or 
 partial suspension due to the rapid flow of ideas. By this we do not 
 mean that the subject of mania does not suffer from delusions. Delu- 
 sions are a constant feature in maniacal excitement ; but they are 
 extremely transient, rapidly varying in their nature, and changing 
 with the ever-changing mood ; their superficiality declares itself 
 in their continuous displacement by fresh delusive ideas, for they do 
 not remain permanent, as in the false conceptions of so-called mono- 
 mania. Their origin can be attributed only to the confusion and 
 
170 STATES OF KXALTATIOX. 
 
 tumult of ideas occurring with the emotional biickground of exaggerated 
 ^vell-being and unnatural egoism ; in fact, on the prevailing tone of the 
 moment seems to depend the character of the false belief entertained. 
 The following case illustrates what we have just said : — 
 
 G. K. L., aged twenty-one, single, by occui)atiou a dyer. A younj^ man of 
 moderate height, muscular, pale, and ana;mic, with an icteric tinge of skin : a 
 very retreating forehead. Last year he had suffered for some five months from a 
 .similar attack to his present seizure. An uncle of patient's was depressed, but no 
 further clue to heredity was obtainable. He had suffered from convulsions during 
 dentition, but his health had proved satisfactory up to his first attack of mania. 
 He had been somewhat intemperate in his habits. He was in a state of continuous 
 mianiacal excitement, shouting aloud, singing, laughing, and gesticulating frantically. 
 At lirst he did not sleep well, and was noisy through the night; chloral was 
 given with good results. Through the day he was boisterous and unruly, 
 rambling incoherently, and destroying his clothing. He raps the walls with 
 his knuckles — calls out in imperative tones to imaginary individuals with 
 whom he holds converse; but calms down on being spoken to authoritatively, 
 and condescends to give certain information respecting himself in a grandio.se 
 :Style and a pompous voice. In almost the same breath, he declares himself 
 to be the "Prince of Wales — the Prince of Peace — Lord of lords and King 
 ■of kings; his mother is the Duchess of Kent." He is fully aware that he is 
 in the West Riding Asylum, and gives correctly the date of the month and other 
 particulars. He assumes fantastic attitudes, which symbolise his prevailing feelings 
 for the time ; struts about in pompous style, throws himself into an attitude of 
 wrapt attention ; or with lowering brow and clenched teeth apes an aspect of rage 
 ;and defiance ; then, as suddenly, with a lordly wave of the hand and gracious 
 •smile, he addresses those around him by dignified titles, the very next instant to 
 lapse into the clown and turn summersaults about his room. At one moment he 
 announces himself as General Gordon— at another he is Sir Garnet Wolseley, and 
 by tone and gesture assumes a military bearing. These rapidly varj'ing delusional 
 rstates, the one supplanting the other, all indicate the egoistic sentiments of the 
 mind, the overflow of animal spirits, the superabundance of energy finding free and 
 ready expression in incessant movement, pantomime, and speech. From the very 
 •outset, his habits were negligent and degraded, and he \vas early found to be 
 .addicted to masturbation; his gestures, also, and expressions, often indicated 
 a, sexual excitement. When referring to insanity at the adolescent period, we 
 shall find this arrogant and egoistic state of mind to be often associated with habits 
 of masturbation. 
 
 In the course of six months, this patient's excitement entirely disappeared, and 
 he was able to give a fair account of his feelings, athrmiug that he believed him- 
 :self, throughout the attack, to be some great personage with military fuuctions. 
 
 The exuberant swell of feeling, and the torrent of disconnected ideas, 
 iUiay express themselves in continuous gaiTulity, in nois}' chattering, 
 in threatening and abusive tones, in laughter, singing, or loud shout- 
 ing, with coi'responding pantomime and almost ceaseless activity ; or 
 •the feeling of unusual freedom and energy may find relief in destruc- 
 tive tendencies — smashing of glass, breaking of furniture, tearing of 
 .clothing, or, perhaps, in violent aggressiveness. 
 
BODILY SYMPTOMS IX MAMA. 171 
 
 The rapid alternations of disposition are peculiarly striking ; the 
 surging of the emotional wave is followed by an ebb, only to reappear 
 in other forms, so that intervals of calm may find the patient even 
 reticent, despondent, or abjectly miserable, until some trifling cause 
 liglits up the flame afresh. These intervals of depression ai'e in nowise 
 difl^erent from the melancholic states ; in fact, it is but a step from the 
 maniacal to the melancholic stage. At tliis instinctive level, the 
 patient instantly I'eacts to the most trivial excitant, with utter dis- 
 regard to decency ; peripheral irritation may thus induce open and 
 shameless masturbation, or nymphomaniacal states may render the 
 subject of either sex repulsive in the extreme. In like manner — dirty, 
 degraded, negligent habits arise, and depraved appetites spring into 
 life. Sensorial disturbances, in the form of illusions and hallucina- 
 tions, are of very frequent occurrence in mania ; and, at times, it 
 becomes difficult to engage such patients in conversation, so intent are 
 they listening to these phantom voices, or busy shouting aloud their 
 replies ; or, whilst talking to \is, the rapid tu.rn of the head, the 
 hurried gesture, the interposed exclamation, or irrelevant remark, 
 indicate these sensorial phenomena. 
 
 Bodily Symptoms. — Although, in a certain proportion of cases, 
 especially in alcoholic and senile subjects, and in the maniacal excitement 
 of general paralysis, we note considerable injection of the vessels of the 
 head and neck with a sufi'used aspect of the face — the great majority 
 of maniacal subjects ujidoubtedly exhibit 7narlced pcdlor of the face — the 
 skin generally being also of yellowish tinge, unctuous feel, and foul 
 odour. The pulse is small, somewhat frequent, and the heart's sounds 
 are often mufiled. Griesinger* speaks of the heart's sounds as being 
 indistinct during the paroxysm of excitement, and becoming clear 
 during moments of calm ; during the maniacal paroxysm also we learn 
 from Dr. ClitFord Allbuttf that the optic diSC iS anasmic, becoming, 
 in a few days subsequent to the attack, sufi'used and oKscure. The 
 spasm of the retinal vessels, presumably present in these cases, appears 
 to us of great importance in revealing the true nature of the maniacal 
 process as distinguished from states of mental depression. 
 
 The tongue is often coated and foul ; the bowels are torpid ; whilst 
 the. appetite, sometimes indifferent, is more frequently exalted and 
 often insatiable. It matters not how well the patient takes his food — 
 incessant activity and continued insomnia are sure to result in loss of 
 body-weight ; in most instances great emaciation prevails — the face 
 
 * Op. clt. , p. 2SS. 
 
 t The Ophthalmoscope in Diseases of the Nervous S!/ste7n. Dr. Allbutfs observa- 
 tions are based upon the exanimation of as many as tifty-one cases of mania at the 
 West Riding Asylum. 
 
172 STATES OF EXALTATION. 
 
 assuming a pinclied appearance, the featui-es are sliarpened, a dark 
 areola surrounds the oycs, the eyeballs are sunken, yet restlessly 
 active and mobile. The reinstatement of a well-nourished frame is a 
 rapid process cet. par. upon cessation of the maniacal symptoms. 
 There is frequent interference with the menstrual function, during 
 the course of mania. Despite the incessant motor agitation and 
 
 excitement, tlic body temperature is apyrexial and normal. 
 
 Periodicity. — During the course of mauia.cal excitement, a remark- 
 able periodicity is often noted in the exacerbations and remissions 
 which occur. We have already alluded to the nocturnal crises which 
 are very prevalent, and we may now draw attention to diui-nal varia- 
 tions of excitement and calm occurring upon alternate days, and to 
 which the attention of the nurse is often attracted — an observant nurse 
 will often speak of such a patient's '^ quiet day'''' or his '■'■had day,''' 
 referring to this strange alternation. We quite as frequently find 
 the subject alternate between mental exaltation and depression from 
 day to day, and this ready transition from one form to the other 
 appears to us of the highest importance for a proiier comprehension of 
 the pathogenesis of these mental states. 
 
 The menstrual molimen is especially prone to arouse in these subjects 
 an exacerbation of excitement, so that a monthly periodicitj" in these 
 maniacal outbursts (with more or less complete remissions intervening) 
 is by no means infrequent. Frequent relapses occur in certain sub- 
 jects, apparently attributable to the vicious habit of masturbation — 
 maniacal reductions and stuporose states being often readily incurred. 
 
 Acute Delirious Mania. — This, the delire aig'u of French 
 
 writers, represents the most profound maniacal reductions wjiicli we 
 meet with, just as simple mania connotes the symptoms of the milder 
 reductions. The disease is often most sudden in its onset, and 
 frequently appears to follow upon some moral cause — shock or fright. 
 This, however, is attributable to the special predisjiosition of the subject, 
 evidence of excessive instability being in most of these cases afforded 
 by the history. It differs from ordinary acute mania in the intensity 
 of the process, the extreme reductions in object-consciousness, the 
 absolute oblivion in most cases to all around, and in the rapid course 
 and /requeue y of a fatal termination. It is quite exceptional for a case 
 of acute mania to prove fatal ; in fact, \inless the individual is much 
 debilitated prior to the attack — suffei'ing from some exhausting ailment, 
 such as phthisis — or Avhen it is the sequel of exhausting ha?morrhages, 
 as after parturition, we augur well for our most wildly - excited 
 patients. A case of uncomplicated acute mania usually means a certain 
 and rapid recovery. Not so, however, in acute delirious mania; here 
 the outlook from the first is most ominous, and the gravest prognosis 
 
ACUTE DELiniOUS MANIA. 173 
 
 miist be given. Tlic tongue is dry and brown; the lips and teeth 
 become covei'cd witli sordes ; food is often most persistently i-cfiised, 
 and violent struggles made upon attempting artificial feeding. The 
 patient is usually quite oblivious to our intentions, and obstinately 
 resists all we do for him. He presents a pitiable spectacle, is unsteady 
 on his feet, totters and sways from sheer muscular debility and exhaus- 
 tion, and trembles in his limbs. His utterances are a broken strain of 
 
 completely unintelligible jargon — the incoherence being" absolute ; 
 the lips tremble, and speech becomes eventually a mere babble of inarti- 
 culate sounds, interspersed with sobbing respiration. Sleep is entirely 
 abolished, muscular wasting rapidly proceeds, and in a few days he is 
 so prostrate that he lies helplessly on his back, unable even to assume 
 the sitting posture. He now represents the condition often described 
 as typho-mania. The temperature is always raised more or less, 
 sometimes to 102°. The urine may be scanty or suppressed ; it mav 
 pass involuntarily, as do the stools. If intelligently-directed treatment 
 be not early adopted, a rajiidly fatal termination ensues ; and even 
 under the most favourable circumstances, the struggle to bring the 
 patient safely through the storm is an anxious and pi"oIonged one. 
 Cases of Delirious Mania. 
 
 A. H., a married woman, forty-seven years of age, was admitted after excitement 
 of seven days' duration. She had sufiered from mental derangement some four 
 years ago, attributed by her friends to her son's running away from his liome; was 
 under treatment at an asylum. A week ago the same son again decamped from 
 home, and the mother's distress culminated in the present seizure. 
 
 No history of insanity, neuroses, drink, or other vice in her ancestry. She was 
 a very emaciated subject, of pallid, sallow, pasty complexion, with dilated malar 
 venules ; there was a strongly marked divergent strabismus. She was suffering 
 from considerable bronchial catarrh; the pulse was 148, regular, but verj"- small 
 and feeble. There was extreme ausemia — the jaws were edentulous, the abdomen 
 sunken, the left hypochondrium rather tender, no splenic enlargement. The genito- 
 urinary system appeared normal. 
 
 She was restless, excited, trying incessantly to leave her bed, and talked 
 continually — uttering ejaculations such as, "Oh! my God! what shall I do!" 
 She was extremely prostrate, fainted on admission, and nourishment liad to be 
 forcibly administered by means of the stomach-tube. 
 
 She did not sleep the first night, and next morning was in a condition of acute 
 delirious excitement, rolling her head about in bed, tossing her legs, fumbling with 
 the bedclothes. All her utterances were irrational and completely incoherent. 
 When asked why she came here, she remarked — " To drink ! it makes great dis- 
 tinction in the sex of your business — Follow me — I have been in the feminine of 
 giving drink — Oh ! oh ! — I am receiving gentlemen, not you — Remember the sex 
 — The feminine discretion of the place of my lips." She refused food, "because it 
 is so abominable, it is so obstinate to the effect of my heart." She was not 
 violent, and her tone was elated, not depressed. 
 
 Essence of beef with milk, eggs, and port wine (6 ozs. daily) were ordered ; 10 
 grains of the citrate of irou and quinine, bis die. Two days subsequent to admis- 
 
174 STATES OF EXALTATION. 
 
 sion it is noted : — " Exceedingly prostrate; pulse 120, very feeble; respirations 28. 
 She was noisy and rambling last night, and is quite incoherent this morning — 
 refuses food; bowels torpid; tongue swollen and glazed. Acute delirious condition 
 has so far subsided as to permit her partially to understand what is said, and to 
 replj' coherently ; compulsor}' feeding has still to be resorted to." The foUosving 
 day it is stated that — " Patient was more than usually excited again last night, 
 repeatedly sjirang out of bed, and jumped into other patients' beds. Slept one 
 hour after two ounces of stimulant. .She remained sleepless and wild all niglit, 
 despite a sedative then given. Has taken her food for the first time voluntarily." 
 On the fifth day following her admission, she was fairly calm and rational, having 
 slept some four hours during the night; but there was now noticed a considerable 
 swelling over the left parotid region, so that she could hardly open her mouth; the 
 lobe of the ear was also red and inflamed, the pulse had improved in quality. 
 From this date, the patient improved rapidly in mind, and she was quite con- 
 valescent three days after the appearance of the swelling. The latter had extended 
 over the mastoid region and down the neck, quite obscuring the angle of the 
 jaw ; the integument is of a rather congested redness, thickened, and the swelling 
 hard and tense; the left eye is completely closed by great o?dema of the lids; 
 temperature has fallen from 102' to 100", pulse lOS. There is considerable 
 tumefaction of the left tonsil. Suppuration occurred in the swollen part, and dis- 
 charge took place from the external meatus three days later. No relapse of mental 
 symptoms occurred, and patient left in six weeks from the date of her admission. 
 
 J. G., a married man, aged forty-nine, by occupation a plumber, had been 
 treated at home for the past month for mental symptoms of a maniacal type ; he 
 had violently assaulted his wife and threatened her life. His mental disturbance 
 was attributed by his friends to excessive drinking ; one point was certain — he 
 had no insane or neurotic heritage, both parents had lived healthily to a good old age, 
 and no other member of the family had been mentally affected or had suffered from 
 nervous disease. His drinking habits had extended over a period of many years ; 
 and evidence of nervous disease or mental flaw had undoubtedly been regarded by 
 his friends as but the result of intemperance. Probably he had been deranged for 
 much longer than was stated ; yet he had w^orked at his regular occupation up to 
 a few weeks of admission. When admitted, he was at once recognised to be 
 the subject of general paralysis ; he had pin-hole pupils (spastic myosis) ; his voice 
 and lips were tremulous ; he had suffered during his journey to the asylum what 
 the Relieviug-officer believed to be "a stroke." 
 
 But the important feature about his state was the intensity of his maniacal 
 reductions ; he was evidently in a profoundly prostrate condition, and was likely 
 to sink rapidly from acute maniacal delirium. His urine was retained, and had 
 to be withdrawn by a very small catheter, owing to his having a contracted prepuce 
 with extremel3' minute aperture ; surgical measures, however, were at once adopted 
 to relieve this state. He could not stand upon his feet, but immediately " doubled 
 up," and lay for the most part in a helpless, prostrate, dorsal decubitus. Acute 
 visual hallucinations were constantly present ; he made continuous snatches with 
 his hands as though to grasp imaginary objects, and lay muttering utterlj' inco- 
 herent gibberish. There were much tremor of the limbs, and muscular jerkings 
 generallj'. Patient's consciousness was so far obscured that he failed to appreciate 
 the purport of anything said or done for him. Paraldehj'de (mins. xxx. ) was ad- 
 ministered, but wholly failed to induce sleep; strong nourishment of milk with eggs, 
 essence of beef, and concentrated foods, was given him, but with much difficulty, 
 
ILLUSTRATIVE CASES OF DELIRIOUS MANIA. 175- 
 
 owing to his resolute resistance and tcrriiied state of mind. He was pale, pinched, 
 and haggard, and continually restless through the next day, requiring regular 
 catheterism, a normal amount of urine being each time withdrawn. The following 
 night he obtained no sleep, tossing about restlessly, and muttering incessantly ; the- 
 heart's action was becoming excessively enfeebled, his limbs cold, and his lips slightly 
 cyanosed. Every precaution was observed, and small quantities of nourishment- 
 were given frequently to keep his body warm and stimulate the circulation ; bub 
 he died the following day from cardiac failure. 
 
 Pi. M., aged forty, married, with a family of six children, had suffered previously 
 from slight depression some ten years ago, but recovered in a week, or so. Her 
 attack had began a fortnight prior to admission. She had become restless and 
 forgetful — "put the bread into drawers, and things that should have gone into- 
 drawers she put into the bread-trough;" she got up and walked about restlessly 
 at night. The day prior to her admission, sudden wild excitement ensued ; said 
 she would jump out of the window, cut her throat, and kill her husband. The- 
 family history records no insanity, epilepsy, apoplexy, intemperance, or phthisis ;. 
 the patient had been a steady, temperate woman, and had had a comfortable home 
 — was naturally cheerful and talkative, but given to religious musings. On her 
 arrival at the asylum she was found to be in a state of acute delirious mania ; she 
 was of short stature (5 ft. 2 in.), extremely thin, ill-nourished, and very feeble; her 
 weight was 78 lbs. ; her complexion earthy ; expression maniacal ; the pupils were- 
 dilated, but equal and reacted normally ; her limbs exhibited several recent bruises. 
 The tongue was dry, but not coated or brown ; the thoracic and abdominal organs- 
 appeared normal; the urine, however, contained a trace of albumen, and a large- 
 deposit of pale urates, but no sugar ; it was acid; sp. gr. 1032. She talked inces- 
 santly, was ceaselessly restless, clapping her hands, and rolling about the bed ; she 
 generally kept her eyes shut. Her language was mostly incoherent, rarely having' 
 reference to her surroundings; and she repeated each sentence twice or oftener 
 before uttering another. Her utter incoherence may be illustrated by the following 
 specimen : — " I '11 let you save — The devil — If it 's for your sake — The devil — I 'IL 
 try you once more — His own son — I've known another — They never will — I'm dead 
 long since— I'm lost —They won't let me— The devil— Another song — A poor old 
 woman — The devil — I knew — I should like it — Save a hundred — He 's lost — You're 
 saved — A palace— I 'm dead long since — Her own father— Hundreds — Lord help me- 
 — They 've brought another in — You 've lost him — This is a chariot — It 's my own^ 
 son — I won't answer, because they won't save me — I make such a noise, because 
 you 've saved so many — They 've driven me mad — Why haven't you resisted when I 
 should be in a palace, you have thousands — When I shall be in a palace — I 've 
 saved hundreds, save poor old woman — I 've hundreds — Why didn't you save me 
 when I 'm lost. " She did not strike, nor show hostility beyond resisting. A 
 liberal diet was ordered with 3 ozs. of whisky daily, and 20 grains of chloral at 
 night. The following day it was reported that she had slept after the chloral ; 
 was still incessantly restless, but not so talkative ; clapped her hands, and buried 
 her head in the bedclothes. 
 
 Each night she was restless until chloral was ordered, when she slept several 
 hours, and awoke far less maniacal, not so talkative ; took food well ; stayed in 
 bed. In nine days after admission she had become obstinate about her food, and 
 had to be fed by the tube ; her consciousness, however, was less obscured, and she 
 recognised nurses and doctors ; her language was less unmeaning, she was less 
 delirious, but still deluded, and at times very incoherent. Thus, she would 
 
17G THE EXPLOSIVE OR FULMIXATINO PSYCHOSES. 
 
 exclaim: "(Jod is in— They're watching, ami they've broke my Ijrain— I want your 
 wife." Slept well witli chloral. The .secoiul week after adnjis.sion, it is noted — 
 " Patienfs mania has lost its delirious character ; slie now lias the lixed delusion 
 that her food is poisoned ; declares that poi.son lias heen put into it, and that is 
 wliy she refuses it. Asserts that slie has plenty of relatives, but they (the nurses) 
 keep locking them up. Calls out, ' Charlie, Mr. Haggas, &c.' Struggles 
 violently when fed ; is abusive and hostile." At the end of the following week she 
 was much calmer, slept without sedative ; was fed by the spoon, and had lost 
 most of her hostility ; still remained deluded, declaring that her aunt was present. 
 Four days later (twenty-five days after admission) we find her convalescent ; the 
 mania has passed off; she is calm, and occupies herself with sewing; appears to 
 have lost her delusions and hallucinations, and recognises their nature ; is a little 
 unreasonable in wanting to return home at once. Takes food well, ami sleeps 
 without sedative. A few days later she became slightly despondent, expressed 
 the delusion that she Avas confident some injury would be done to her at night, 
 and believed that the patients abused her. This sliglit relapse passed away 
 rapidly ; she made steady and satisfactory progress, and left recovered within two 
 months of her admission. 
 
 FULMINATING PSYCHOSES. 
 
 Contents. — Uniform and Partial Denudations— Defective Control— The Neurotic 
 and Criminal Subject— Nature of Impulsive Insanity- Insane Homicidal 
 Impulse— Existence of Aura— Epigastric Aura— Uncovering of the Brute 
 Instincts— Relief of Mental Tension- Illustrative Cases— Suicide in Homicidal 
 Subjects— Etiolo^'y-Effect of Physiological Cycles— Epilepsy— Masked Epilepsy 
 —Alcohol and Impulsive Insanity— The Mimetic Tendency— Suicidal Impulse. 
 
 The dissolutions of the nervous system which issue in insanity by 
 no means reduce the subject to pre-existent levels of mental life corre- 
 sponding in all respects to former stages of evolution ; the denuda- 
 tion, to use an apt term, is by no means uniform, so that the mental 
 wave recedes along the whole line of its former advance. Such a 
 uniform recession does occur in physiological senescence, and is still 
 more pronounced in the prematui-c decay of senile dementia; but, in 
 most forms of insanity, the denudation is a localised one, or, at all 
 events, begins in many separate areas, and the resulting mental dis- 
 turbance is wholly unlike any of the results of a uniform physiological 
 denudation. The general results also will vary with the intensity and 
 rapidity of the diseased process, and the factors so often insisted upon by 
 Dr. Hughlings-Jackson in his studies of convulsive diseases must also not 
 be neglected in considering the less acute processes of mental disease. 
 
 It is by these partial denudations that we seek to explain the 
 incongruous results of tlic dLseased process and the overbalance of 
 faculties so characteristic of mental disease. At no stage in the 
 history of insanity, except, perhaps, the senile forms, do we find the 
 man altoffethcr reduced to the mental state of childhood — a 7)?«s or 
 minus quantity ever prevents an exact parallel being drawn, so that 
 
PARTIAL DEXUDATIOXS : DEVELOPMENTAL DEFECTS. 177 
 
 we readily distinguish such auonialous reductions from tlie results of 
 a xmiform physiological or pathological denudation. Certain features 
 which characterise the mental life of the child spring into obvious 
 prominence in the adult subject of mental disease. The infantile mind 
 is above all things characterised by the lack of control — its instincts, 
 passions, desires, actions, all alike, exhibit in a high degree a want of 
 inhibitory restriction, and the further development through childhood 
 and youth to adolescence and adult age is a recoi'd of the slow 
 progressive superposition of controlling centres. iSTormal mental 
 development is specially characterised by this uniform and progressive 
 establishment of self-control (so to speak) upon higher and still higher 
 levels; but, just as we get in the dissolutions of disease 2J(f''^tial de- 
 nudations — so here, in the progress of mental evolution, we meet with 
 developmental phases of a monstrous chai'acter, presenting, not the 
 normal uniformity of level, but the bizarre irregularities, exaggerated 
 here and defective there, which signalise so frequently the neurotic 
 heritage of the subject. Defective control over certain animal passions 
 and instinctive desires (often associated with an intense staccato 
 restriction over others, amounting to a morbid hyper-sensitiveness) is 
 a peculiar characteristic of such predisposed subjects 3 whilst a still 
 more universal defect of the inhibitory faculty is illustrated by the 
 criminal class of the community. The reductions of mental disease, 
 therefore, will move readily find their parallel in the vaiious anomalous 
 developmental phases of the neurotic subject, or in the extremes of 
 inhibitory defect presented by the criminal, rather than in earlier 
 stages of the healthy and normally-developing brain, and our studies 
 of these developmental types should facilitate our comprehension of 
 the varied reductions of insanity. 
 
 Much may be said of the ill eflects of injudicious training of the 
 mental faculties of the young ere they have attained an age when 
 such faculties should be called into operation ; and we quite agree 
 with Dr. Cloiiston that different brains attain their power of control at 
 different ages, and we also have seen " many children whose anxious 
 parents had made them morally hypersesthetic at early ages through an 
 ethical forcing-house treatment;" but we opine that all pronounced 
 instances of the kind are neurotic subjects, as in the case of the little 
 boy of four mentioned by him, who " was so sensitive as to right and 
 wrong, that he never ate an apple without first considering the ethics 
 of the question as to whether he should eat it or not" — yet who was, 
 at the age of ten, "the greatest imp I ever saw, and could not be made 
 to see that smashing his mother's watch, or throwing a cat out of the 
 window, or taking what was not his own, were wrong at all."'* What 
 
 * Op. cit., p. 311. 
 
 12 
 
178 THE FULMINATING PSYCHOSES. 
 
 we specially insist upon here is the fact that the subject presenting 
 such mental distortions is not the product of a vicious educational code 
 so much as the victim of an organised neurotic heredity ; and that we 
 should in these developmental forms learn to recognise features com- 
 mon to them and the reductions of mental disease. So also as regards 
 the true criminal type, the difficulty of drawing any clear line of 
 demarcation between crime and insanity is well recognised ; certain 
 forms of insanity, more especially the so-called "moral insanity," 
 presenting peculiar difficulties to our arriving at a conclusion as to the 
 decree of criminal responsibility involved in the case. Nor need this 
 fact surprise us, since the one presents us with partial developmental 
 arrests at levels to which tlie brain of the insane must frequently 
 become reduced ; what must always be kept in mind is the fact that 
 the one is the outcome of a developmental failure, or vice, the other is 
 a genuine dissolution. 
 
 All acute forms of insanity are peculiarly characterised by this loss 
 of control. We recognise it in the failure of attention and the inco- 
 herent flow of ideas expressed in rambling speech, in the unrestrained 
 passions, varying moods, incessant movement, gesture, and all the 
 outrageous conduct of the maniac ; but it is not in these universal and 
 complex disturbances of faculties that we find the symptoms of "im- 
 pulsive insanity," as generally understood by that term. There are 
 mental aifections in which the chief, nay, the sole discoverable feature 
 is this failure of inhibition exhibited in ungovernable, sudden imp\ilse, 
 and in entirely unrestrained conduct, whilst the intellectual and 
 emotional spheres remain wholly or only in part xmafiected. It is in 
 this freedom of the affective sphere of mind from implication, and the 
 purely impulsive nature of the act, that we must learn to recognise the 
 genuine impulsive insanity, as understood by older writers. Both 
 Pinel and Esquirol at first doiibted the existence of pure insane im- 
 pulse apart from intellectual flaw or delusion; and many authorities 
 of repiite have since their day considered the doctrine a dangerous as 
 well as a fallacious one ; yet eventually Pinel and Esquirol asserted 
 the existence of this tei-rible malady, and painted its distinctive 
 features in uo uncertain colours. Either there is, or there is not, such 
 a disease as impulsive insanity ; and we must remember that our 
 denial of its existence carries with it the implication that the impulsive 
 conditions which we recognise in a minor degree in healthy physio- 
 logical states, such as the almost irrepressible desire to break a 
 delicate glass globe held in the hand, and many other similar ex- 
 periences which we are all familiar with, cannot arise in an absolutely 
 uncontrollable form as the result of pathological disturbance. It 
 may appear to the student an unnecessary refinement to insist uj^on 
 
IMPULSIVE AND MORAL INSANITY: HOMICIDAL IMPULSK. 179 
 
 this distinction, but a moment's consideration will assure him that 
 the distinction is one of vital import, not from its scientific bearing 
 only, but more especially from its medico-legal aspects. 
 
 The lawyer is naturally suspicious of the existence of this form of 
 insanity, and is, very properly, guarded in his acceptance of the 
 doctrine which carries with it such far-reaching results ; he perceives 
 the difficulty of distinguishing between what is and is not controllable 
 — between an insane impulse and the outcome of criminal volition ; 
 and he, moreover, perceives the difficulty — :nay, the impossibility — of 
 recognising its existence, and at the same time reconciling it with the 
 legal criterion of responsibility : and, lastly, he must recognise that 
 the admission of this fact throws on the medical witness the full 
 responsibility of defining what is and what is not of the nature of aii 
 incontrollable impulse. 
 
 Great as may be the difficulty, in many cases, of clearly distinguishing 
 between the blind incontrollable impulse of the insane, and the rash, 
 impetuous act of the responsible criminal, we must not shrink from the 
 imperative duty of affirming the existence of this form of insanity if 
 our clinical experience justifies the belief, so momentous are the 
 conseqiiences embraced by its acceptance or rejection. 
 
 In insisting upon such a distinction, we must not forget that it 
 is more or less an arbitrary one — that nature imposes no such 
 absolute line of demarcation between what we elect and what we do 
 not elect to the dignity of morbid types ; that in reality, one, or a few, 
 or many of the mental faculties may be deranged, and in all possible 
 degrees of intensity, and so forms of impulsive insanity may merge 
 into forms characterised by intellectual or emotional disturbance ; 
 and vice versd, intellectual impairment with delusion may merge inta 
 the typical forms of impulsive insanity, exhibiting every shade of 
 transition from the one to the other type. What is of still further 
 import is the fact — ^which clinical experience very strongly emphasizes 
 — that alternations of pure impulsive insanity and forms of intellectual 
 or moral insanity occur in many insane subjects. 
 
 Nature of the Insane Homicidal Impulse.— In the first place, 
 
 we should note the causeleSS or motiveleSS nature of the act; the 
 impulses arise wholly apart from any incentive, delusional or other- 
 wise, nor is the victim able, in the great majority of cases, to trace 
 any connection between any pre-existing emotional or intellectual 
 phase, and the onset of the insane impulse. Its irrelevancy to sur- 
 rounding circumstances is in itself so characteristic a feature, that the 
 subject invariably insists strongly ixpon this fact. Suddenly, amidst^ 
 it may be, the pleasures of the family circle, or at the moment of 
 devotional exercise, to the intense horror of the subject, the morbid 
 
180 Tin: FiLMixATiXf; psychoses. 
 
 feeling suggests itself without any obvious provocation (like a phantom 
 demon), and requires all his efforts to disjjcl it. The horror of the 
 position will often drive the sufferer to a free confession of his 
 state, and to urgent entreaties for protection against such unbidden 
 mysterious impulses, as numerous cases attest ; but instances occur, 
 where the unfortunate subject has struggled for years with his in- 
 firmity, and never revealed his deadly secret until compelled to do so 
 upon the commission of some desperate act.* The motiveless nature 
 of such acts may be called in question, and grave suspicion be ex- 
 pressed, from the admitted difficulty of always assigning a consistent 
 motive even for the acts of the sane; but, just as readily as we may err 
 in imputing no motive to an act when such is not clearly obvious, so, 
 we may even more easily fall into the opposite error of assigning a 
 wrong motive to an insane impulse, influenced by accidental circum- 
 stances in which the sul)ject happens to be placed. The motiveless 
 nature of the morbid impulse is forcibly illustrated by cases in which 
 the subject suffers from such feelings when no one is near, or at the 
 moment of awaking from sleep ; for, as in the case of the suicidal 
 impulse (an impulse which is equally transient), the commission of 
 the fatal act is often averted by the absence of opportune means ; 
 so, in the homicidal impulse, the morbid energy is dissipated and 
 the murderous act averted by the absence of the object. 
 
 In the second place, we must note the prodromal indications and 
 accompaniments of the insane impulse so far as they are afforded by 
 subjective and objective indications. The subjective accompaniments 
 vary considerably in different cases ; in many, the cerebral discharge 
 which initiates the impulse, is productive of a g'enuine aura such as 
 often precedes the epileptic convulsion. The morbid sensation is often 
 peripherally referred, is of sudden accession, and may rapidly pervade 
 distant parts of the body. Thus in the case of one unfortunate victim 
 {Reg. V. Mountain), we were informed that an intense burning heat 
 suddenly seized him in the epigastrium and was rapidly transferred to 
 the throat, accompanied by a sense of constriction and urgent thirst, 
 upon which the homicidal fury arose, and momentarily bereft him of 
 all control. Others complain of colicky pains, a sense of heat in the 
 abdomen or chest, headache, restlessness, loss of appetite, and lowness 
 of spirits (r«v/^ort), of sensations referrible to the head, "flushings 
 of blood to the brain,'' a sense of constriction or tightening, as of a 
 ligature, round the scalp, or a feeling as if a cold fluid were poured 
 upon the head and along the spine. Dr. Skae, in his Annual Reports 
 for 1866 and 1868, describes a well-marked aura as preceding homicidal 
 
 * See, on this point, Drs. Buckwill and Take, op. cit., p. 2GS. 
 i Med. Jurisprudence, vol, 11., p. 553. 
 
THE EPirJASTRIC AURA AND HOMICIDAL IMPULSE. 181 
 
 impulse. In certain other cases a definite hallucination of the special 
 senses may be tlie immediate forerunner of the homicidal impulse. 
 The connection of these phenomena with epileptic discharges is often 
 apparent in such subjects, and the following case, quoted by Maudsley 
 from Mai'c, seems to indicate the repression of the impulse by the 
 arresting of the aura : — 
 
 "Mr. Pv., a distinguished chemist and poet, of a naturally mild and sociable 
 disposition, placed himself under restraint in one of the numons cle santii of the 
 Faubourg St. Antoine. Tormented with an homicidal impulse, he prostrated 
 liimself at the foot of the altar, and implored the divine assistance to deliver him 
 from the atrocious propensity, of the cause of which he could give no account. 
 When he felt himself likely to yield to the violence of it, he hastened to the head 
 of the establishment, and requested him to tie his thumbs together with a ribbon. 
 This slight ligature was sufficient to calm the unhappy P^., who subsequeotly 
 endeavoured to kill one of his friends, and finally perished in a fit of maniacal 
 fury." 
 
 The epigastric aura, followed by spasm of the throat and intense 
 thirst, alluded to above in one case, has been noted in other subjects ; * 
 it is of interest as indicating a primary 'disturbance of the vagus, and 
 as giving rise to the most intense and massive feelings of organic life, 
 which in the brute arouse the most ferocious instincts. 
 
 Thus, Professor Bain says— " They (the feelings of inanition and thirst) are 
 far more intense than mere nervous depression, and, therefore, stimulate a more 
 vehement expression and a more energetic activity. Even when not rousing u]> 
 the terror of death, they excite lively and furious passions. The unsophisticated 
 brute is the best instance of their power." And again, "There is something 
 intensely kindling in the ay)petite of carnivora for food, which rises to fury when 
 the flesh is scented out and begins to be tasted, "f 
 
 The association of these organic sensations with the springing into 
 life of the brute propensities in the human subject is, we take it, 
 a suggestive fact. Certain objective indications of the morbid process 
 are also occasionally afforded, chiefly of vaso-motor origin — intense 
 pallor may precede the act, or the face may become suffused, and a 
 copious sweat break out over the body as the impulse is resisted and 
 subsides ; the heart usually shows excited action, and the arteries of 
 the neck and temples pulsate violently. 
 
 The intensity of the morbid process is further indicated in the utter 
 loss of self-control. " Everything passes out of mind," said one such 
 unfortunate subject to us, " except the one thing I wish to accomplish 
 — I can think of nothing but the desire to kill some one." The one 
 burning idea prevails to the exclusion of all others at the height of the 
 
 * See a case by Piuel quoted in Dr. Maudsley's ResponmhUittj in Mental Disease, 
 p. 141. 
 t The Senses and the Intellect, Alex. Bain, pp. 1*26 and '2o3. 
 
182 THE FULMINATING PSYCHOSES. 
 
 attack, and is (in all respects, as Maudsley has insisted) " a convulsive 
 idea springing from a morbid condition of nerve-element, and com- 
 parable with a convulsive movement." * In other respects the 
 condition shows its kinship to the convulsive neuroses, viz., in the 
 
 immediate relief atTorded by the accomplishment of the act, or 
 
 the dissipation of the morbid energy in otlicr directions ; like all 
 transient nervous discharges from the cortex, the associated mental 
 tension is instantly relieved thereby. Yet, it must not be forgotten, 
 that the impulse is in many instances successfully resisted ; and that 
 the early history of many cases of homicidal mania is one of a long- 
 continued and secret .struggle of the victim against the morbid feelings 
 which create in his mind a dread and a horror indescribable. Fully 
 recognising the atrocious nature of the crime to which he seems 
 impelled, he is in constant dread lest in some weak moment his power 
 of resistance, already enslaved, should wholly succumb in the frenzy 
 of the seizure. Instances have occurred where this struggle was 
 carried on for years — thus in the case of Reg. v. Mountain the prisoner 
 admitted the existence of such insane impulses for a period of ten 
 years prior to the murder, the exceptional atrocity of which, with 
 other related circumstances, make it worthy of note here. 
 
 The prisoner was a young man, aged thirty-two years, of undoubted neurotic 
 heritage ; his mother, maternal grandmother, and maternal aunt had been insane ; 
 his maternal uncle had cut his throat, and his brother was of feeble intellect. 
 The maternal aunt, who was under our observation for years, was the .subject of 
 suicidal impulses, had tried on several occasions to strangle, to hang, or to drown 
 herself, as the result of imperative feelings distinctly arising from the group of 
 organic sensations. The unfortunate subject of such ancestral frailty liad always 
 been timid and imnaturally suspicious ; but no decided delusional })hase liad been 
 observed at any time until a few months preceding the murder, and then only 
 as the immediate outcome of drink. Ten years prior to the event in question, 
 he first became subject to the peculiar sensations which we have already referred 
 to, and which were invariably the forerunner of intense homicidal impulses ; they 
 almost invariably occurred at times when he was alone, and he would pace wildly 
 up and down his room to "work the feeling down;" and often he has rushed 
 from the house where his aged mother and servant lived when he felt the feeling 
 arising lest he should not be able to resist the murderous impulse. He had 
 struggled against these feelings, and " prayed to be delivered from them" in agony 
 of mind without success for j'ears. They were increasing in intensity, and to 
 arid to his misery his natural nervousness and suspicion were also more prominent. 
 
 His mother's attack of insanity some years previously, and his aunt's state (when 
 he had visited at the asylum), constantly preyed upon his mind, and engendered 
 the feeling that he would become insane. He had kept his dangerous feelings 
 and propensities a profound secret, so that his closest acquaintances had failed 
 to recognise any indications of his real condition until, latterly, when he gave 
 way to drinking ; and then it was observed that very small quantities of alcohol 
 
 * Op. cit., p. 156. 
 
CASE OF REfJ. r. MOUNTAIN. 183 
 
 produced grave mental disturbance, characterised by persistent delusions of 
 persecution and errors of identity. On two occasions he suffered from genuine 
 attacks of maniacal excitement, but of transient duration only. As a natural 
 result of tlicsc intemperate habits, his former symptoms became further intensified ; 
 yet, up to the evening of the murder (except when under the influence of drink), 
 no intellectual disturbance was recognised by his friends. On this evening, after 
 taking stimulants freely, he locked his mother and the servant girl in a room to- 
 gether, and in the most brutal and atrocious manner attacked his mother, kicking 
 her to death, and causing the most horrible mutilation of the body, keeping the 
 girl at arm's length by a loaded pistol. For five hours this brutal violence was 
 continued, he meanwhile affording abundant evidence of a deluded state of mind 
 by his conduct and utterances. His subsequent condition upon arrest was con- 
 sistent with an attack of mania-a-potu. Subsequent to his recovery from the 
 alcoholic delirium, he had experienced a return of homicidal impulses in prison, 
 a man wlio slept in the same room having nearly been a victim to his murderous 
 frenzy. The prisoner was considered irresponsible at the time of the murder 
 on the ground of insanity, and was ordered to be retained during Her Majesty's 
 pleasure. 
 
 The case is of interest in its medical aspects as reproducing some of 
 the most important features of homicidal impulse in the insane. There 
 is the fact of the peculiarly hereditary nature of impulsive insanity; 
 there is the strange association of deranged organic sensations with 
 the convulsive conduct ; there is the emphatic proof of the fatal effects 
 of alcoholic indulgence in such cases, and the ready passage into 
 delusional forms of insanity ; and, lastly, there is the secrecy so often 
 maintained by the subjects of this form of malady, lasting over a period 
 of ten years. A notable instance is recorded by Dr. Tuke * of a young- 
 man, aged twenty-five years, of gentlemanly appearance : — 
 
 "After giving his address, and declaring himself to be a schoolmaster in a certain 
 well-known college, he begged that the commissary of police would take him in 
 charge, with a view to his confinement in the asylum of St. Ann. He then 
 explained that he was not mad in every respect ; on the contrary, he possessed the 
 full use of his mind, only whilst sleeping amongst the pupils confided to his 
 charge he was seized with the most destructive inclinations. Night after night, in 
 an agony of fear, he had struggled with himself, and it was with the greatest 
 difficulty that, so far, he had succeeded in restraining his intense desire to strangle 
 one or two of the little boys. Now all his energies were exhausted; he felt that 
 this unknown power would ultimately triumph over him, and, rather than commit 
 the crime, he placed himself in the hands of the police. At this moment a 
 boy accused of theft was brought into the room. The eyes of the schoolmaster 
 were immediately lit with a strange light, and, had it not been for the timely 
 assistance of a brawny policeman, the boy would have been throttled before the 
 verj' eyes of justice." 
 
 We have little doubt that many instances of mysterious suicides are 
 to be accounted for by the prevalence of homicidal feelings — the victim 
 tortured by the terrible secret seeks relief in self destruction rather 
 * Psijchological Medicine, 1S74, p. 26S. 
 
ISl THE FULMIXATIXG PSYCHOSES. 
 
 than reveal his condition, or subject those near and dear to him to any 
 further risk. The condition of the homicidal subject immediately 
 subsequent to the act is characteristic — it is usuallv one of complete 
 relief from anxiety, and utter indifference to the enormity of his crime; 
 fi^quently his first act is to coolly confess his crime and give himself 
 up to justice. 
 
 Exceptions, however, occur where the subject of insane impulse 
 endeavours to conceal his crime like the responsible criminal. Thus, 
 at the West Riding Asylum, a subject of such impulses secured an 
 iron bar and struck a harmless imbecile patient on the head as he lay 
 asleep within a few yards, fracturing his skull seriously, and then 
 deliberately concealed the instrument in some shrubbery near at hand, 
 and coolly took up the paper he had been reading a moment before, 
 apparently free from the least concern. Up to the present day, four 
 years since his homicidal act, he denies positively any knowledge of 
 the affair, and he exhibited the utmost indifference on being questioned 
 immediately subsequent to his violence. In fact, his nonchalance at 
 the time, and his subsequent behaviour, might almost have been 
 rec^arded as consistent with the impulsive automatic act of an epileptic, 
 were it not that the subsequent history of the case revealed clearly the 
 existence of insane impulses preceded by a definite aura, but not of 
 genuine epileptic paroxysms : and, moreover, proved him to be pos- 
 sessed of considerable insane cunning. In the genuine impulsive 
 forms of insanity, consciousness is never so fer impaired as to issue in 
 forgetfulness of the details of the homicidal act. "VThen such is the 
 case — when any marked obscuration of memory is apparent — we may 
 presnme the impulse to have been of epileptic origin, or to be the 
 outcome of alcoholic delirium. 
 
 Etiology. — In all these cases of pure impulsive insanity there is, we 
 believe, a weU-established basis of a neurotic heritage, and if the 
 individual's history is scrutinised with sufficient care, we are assured 
 that evidence of niental instability will be discoverable throughout his 
 life. It is, however, at the critical epochs of life that this predisposi- 
 tion especially tends to assert itself — periods at which grave nutritional 
 disturbances are prone to arise in the central nervous system, inducing 
 the peculiarly convulsive outflow of nervous energy which characterises 
 these epochs, even in normal physiological operations. Puberty and 
 the climacteric are prone to the convulsive type of the neuroses, and 
 the same prevails at the puerj^eral period during lactation, and associ- 
 ated with the various forms of meTUtrual derangenx^rd. Several 
 instances are on record where the revolutionary epoch of puberty 
 has aroused the homicidal feelings in youth, as in the case of Margaret 
 Messenwer, aged thirteen years, who killed her brother and drowned 
 
ETIOLOGY OF IMPULSIVE IXSAXITY. 185- 
 
 another child, six months old, "without any discoverable motive. 
 Young girls suffering from temporary menstrual derangement are 
 subject, as is well-known, to various perverted instincts and appetites^ 
 and the hysterical outbursts are often associated with an almost 
 irresistible tendency to destructiveness, and not very rarely with a 
 homicidal feeling (see case of Reg. v. Brixey).* We have known, 
 several instances where the subject has expressed her dread of sleep- 
 ing in the same room with other members of the family, and of being 
 left alone with her younger sisters, lest she should not be able to 
 restr-ain the impulse felt to injure them. 
 
 The climacteric in woman is a period during which mental dis- 
 turbances are frequently associated with suicidal impulse; but, as we 
 shall see later on, the impulse is usually the outcome of intellectual 
 derangement and grave delusional perversions. Yet, homicide and 
 suicide may occur at this epoch as the result of a purely impulsive 
 condition, and more particularly in such cases as have developed intem- 
 perate habits. The puerperal period, as is well-known, renders 
 neurotic subjects liable to insane impulse, and, although usually a 
 symptom of the general disturbance of puerperal mania, the simple 
 instinctive form may alone prevail. We recognise a similar condition 
 in animals, which, in the deranged states following parturition, will 
 kill and even devour their young. Epilepsy is a frequent source of 
 these depraved and resistless feelings. Homicidal impulses may prevail 
 in one of four conditions in the epileptic subject, viz. : — 
 
 (a.) In epileptic furor or mania, associated with hallucination or 
 delusion ; 
 
 {h.) In the so-called '"'epilepsia larvata" (Jforel), the "masked 
 epilepsy " of Esquirol ; 
 
 (c.) In the dreamy state of epilepsy ; or, lastly, 
 
 (d.) As a simple impulsive derangement during the inter-paroxysmal 
 period. 
 
 It is the latter alone which can be regarded as genuine Impulsive- 
 Insanitv : the three former conditions are attended by such general 
 mental derangement as to exclude them from the category of pure 
 affective forms of insanity. It will be more convenient, however, to- 
 refer briefly to such forms at the present juncture, and to deal with 
 them in further detail in our remarks upon insanity associated with 
 Epilepsy. In the reductions of Epileptic Mania, or the post-par- 
 oxysmal excitement, of which we see so much in our asylums, the 
 homicidal impulse springs into life almost invariably as the result of 
 delusion. The murderous act is traced to a pre-existing delu- 
 sioual state, with which it has often a direct connection (see case of 
 * Quoted in T.iylor"s Medical Jurisprudence, vol. ii., p. 564. 
 
IS6 THE FULMINATING PSYCHOSES. 
 
 Reg. V. Taylor, see Alcoholic Insaniti/) ; or, again, hallucination of sight 
 or hearing may prompt the act — a voice may be heard commanding the 
 epileptic subject to kill, and the impulse arises in resistless force (case 
 •of £. C, see Epileptic I)isanity) — or a visual hallucination, in the form 
 of some object of terror, may call forth these same results. The 
 epileptic furor may be of some considerable duration, and the subject 
 remain in a dangerously homicidal state during its continuance ; but 
 subsequent to the paroxysm, the subject will remain either greatly 
 bewildered (retaining only very partially some fragmentary recol- 
 lections of the attack), or, still more commonly, be wholly oblivious 
 of the circumstances and of the conduct which he has just displayed. 
 
 In the masked epilepsy of older writers, we find that a fit of 
 iomicidal mania may replace the convulsive seizure (a convulsive idea, 
 as Maudsley would say, takes possession of the mind), and, without 
 any of the usual epileptic phenomena preceding, a sudden irresistible 
 murdei-ous impulse (probably prompted by delusion or hallucination) 
 occurs ; but here, again, the subject fails to recall any conception of his 
 actions. So, likewise, in the dreamy state of epileptics, approaching 
 the somnambulistic condition, homicidal acts have been committed in 
 a semi-unconscious automatic state of mind. It is astonishing how 
 complicated may be the acts performed in these states by the epileptic 
 automaton. A better illustration could not be found than that quoted 
 by Dr. Gowers, where a carman in this state of automatism, after an 
 epileptic seizure, " drove through the most crowded parts of London, 
 uithout any object, but also without any accident." * 
 
 Genuine impulsive insanity, apart from grave mental derangement, 
 however, is also occasionally seen in epileptic insanity; in the intervals 
 between the convulsive seizures, certain patients are subject to frequent 
 insane impulses to murder f without any motive or malice) any one 
 '»vith whom they are brought in contact. These conditions usually 
 alternate with delusional states, and with the maniacal outbursts suc- 
 ceeding the epileptic attack — they are the most anxious cases to treat, 
 and the most difficult patients to control Such subjects are peculiarly 
 susceptible to the efi"ects of small quantities of alcohol, which may 
 induce, even in very trivial amount, the most furious outbreak of 
 mania, or the impulsive homicidal state alluded to. 
 
 Alcoholic excess may induce the impulsive form of insanity in 
 certain predisposed neurotic individuals ; a condition of alcoholic 
 delirium of extremely short duration (mania transitoria) f, in which a 
 mad impulse to murder prevails, may thus be induced by what is 
 
 * Diseases of tlie Xervous System, vol. ii., p. G91. 
 
 -tMaadsley is undoubtedly correct in asserting that many cases of mania 
 transitoria are really instances of "mental epilepsy." — Op. cit., p. 230. 
 
THE SUICIDAL IMPULSE. 187 
 
 ■usuaHy considered by no means immoderate drinking. The symptoms, 
 however, embrace much mental confusion, and the suljject remains, 
 after the attack is over, in a state very similar to an epileptic after an 
 attack of petit mal.* Amongst other ^etiological factors we must not 
 fail to note the vicious agency of imitation which was originally 
 emphasised by Esquii'ol, as one of the causes of this affection. 
 Undoubtedly, the morbid excitement engendered by the perusal of 
 records of criminal horrors, by the publicity afforded in our Assize 
 Courts to the revolting details of crime, and, up to within the last 
 few years, the demoralising effect of public executions, have greatly 
 fostered the development of these states of mental disease. If there 
 is one fact in mental physiology more established than others, it is 
 that the continuous direction of the mind to the sensual and purely 
 animal passions of our nature tends to intensify their potency — to 
 render their channels of operation more pervious, and so to withdraw 
 them from the inhibitory control to which they should ever be subject. 
 The brutal instincts are still less protected in those persons of weak 
 mind, who, not endowed with an average amount of controlling power, 
 require but the intensification of such instinctive states to lead to 
 explosive outbursts ; in such cases mental strain, anxiety, ill-health, 
 and other exhausting conditions, and especially alcoholic and sexual 
 intemperance, may readily lead to attacks of homicidal mania at 
 periods when the public mind is horrified by some stai'tling crime. 
 
 The Suicidal Impulse. — What ^-e have said respecting the 
 homicidal impulse applies in most particulai's to the self-destructive 
 propensity; it also arises in subjects who exhibit no intellectual 
 disturbance, and in whom the moral sense is intact, in so fai', that 
 they, recognising the horx-or of their situation, and the unnatural 
 chax'acter of the morbid promptings, revolt against the perpetration 
 
 * On the subject of mania transitoria Maixdsley remarks : — "Although epilepsy, 
 masked or overt, will, I think, be found to be at the bottom of most cases of mania 
 transitoria, it must be admitted that there ai'e some cases in which there is no 
 evidence of epilepsy in any of its forms to be found ; but it may well be doubted 
 Avhether a distinct insane neurosis is not iilways present in these cases. With 
 sucli a constitutional predisposition, a genuine attack of acute insanit}', lasting for 
 a few hours only, or for a few days, may break out on the occasion of a suitable 
 exciting cause, and during the paroxysm homicidal or other violence may be 
 j)erpetrated. After childbirth it sometimes happens that a woman is seized with 
 a paroxysm of acute mania of short duration, during which perhaps she kills her 
 child without knowing what she is doing. The efiect of alcoholic intemperance 
 upon a person strongly predisposed to insanity, or upon one whom a former attack 
 has left predisposed to a second, is sometimes a short but acute mania of violent 
 character with vivid hallucinations and destructive tendencies ; and a like efl'ect 
 may be produced by powerful moral causes, sexual excitement, and other 
 recognised causes of insanity." (Refpojisibtlilij hi Mental Disease, p. 247.) 
 
188 STATES OF MKNTAI, i:\FEEBLEMENT. 
 
 of the act. Like tlic homicide, tliey may implore protection, and 
 voluntarily resign themselves to asylum supervision, dreading lest 
 they may be overmastered hy the suicidal impulse. So likewise do 
 we find the impulse of convulsive nature sudden in its onset, transient 
 in its course, and followed by immediate and complete relief; its 
 analogy to the epileptic state being still further indicated by the 
 occurrence of an aura, usually an aural hallucination. The condition 
 to which we allude is, of course, not the ordinarj"- suicidal tendency of 
 simple melancholia, where the morbid depression pi'ecedes and ex- 
 ])lains the negative suicidal state ; but the condition Avhei'e, from the 
 first, the suicidal propensity presents itself, any depression being 
 secondary, and induced by the patient's helpless condition. The 
 climacteric epoch not imfrequently develops this impulsive form of 
 insanit}^ just as it does homicidal states ; and a good illustrative case 
 is detailed further on iu our study of the insanity prevailing at this 
 period of life (see case of S. II.) Winslow recoi-ds the statement 
 of one patient as follows : — ■" For six months I have never had the 
 idea of suicide, night or day, out of my mind. Wherever I go, an 
 unseen demon pursues me, impelling me to self-destruction. My wife, 
 friends, and children observe my listlessness and jierceive my des})on- 
 dency, but they know nothing of the Avorm that is gnawing within." * 
 
 STATES OF MENTAL ENFEEBLEMENT. 
 
 Contents. — Mental Deprivation in Contradistinction to Developmental Arrest — 
 Persistent Enfeeljlement— Chronic Eesidiie of Asylnni Coinmnuities — Recover- 
 ability of Maniacal and j\lelancholic Forms— Consecutive Dementia— Delusional 
 Insanity— Genesis of Monomaniacal States — Environmental Eesistance— Trans- 
 formation Completed— Mystic Symbolism— Illustrative Cases of Delusional 
 Insanitj'— Monomania of Pride (.1.0., E.T.) — Religious Monomania (J.B.) — 
 Monomania of Persecution (E.C). 
 
 Amongst states of mental enfeeblement are comprised numerous 
 ■widely different groups, which constitute the large bulk of our 
 asylum communities, and in which the mental ailment difi'ers in its 
 mode of origin, essential nature, and the characteristic features 
 presented. The term mental " enfeeblement " is jierhaps the least 
 objectionable which we may employ for the varioi;s groups comprised 
 under this class of mental ailments, but there is a sense in which 
 its application is faulty. The term should, we think, include states 
 
 of mental deprivation only— fe., states of acquired defect, 
 
 whilst comjeuital and developmental arrest would be more appropri- 
 ately considered under a distinct categor}'. Idiocy and imbecility would, 
 therefore, be excluded from this class, which would, however, compi'ise 
 the various forms of monomania, of chronic mania, and dementia. 
 
 * Obscure Diseases of the Brain, p. 265. 
 
TRANSIENT AND PERSISTENT ENFEEBLEMENT. 
 
 189 
 
 All instances of mental reduction are, of course, states of mental 
 enfeeblement, and, therefore, in one sense, all cases of acute insanity 
 are alike cases of mental enfeeblement, as is the stage of stupor fol- 
 lowing acute insanity, or an epileptic outburst. We do not, however, 
 extend to this term so wide a significance ; we arbitrarily exclude 
 states of transient mental deprivation, and limit its connotation to 
 conditions of persistent enfeeblement, whetlier primary or con- 
 secutive in their origin. In fact, we comprise under it the incurable 
 terminations of acute insanity— the chronic insane residue which 
 remains, as wrecks remain after the storm ; also, such cases of per- 
 manent enfeeblement, as are not preceded by acute mental symptoms, 
 e.g., the "primary dementia" of organic disease of the brain — from 
 morbid growth, apoplectic foci, and cerebral ramollissement — and the 
 
 Number 
 
 of 
 Cases. 
 
 
 
 
 Percentage. 
 
 
 Form of Mental Disease. 
 
 Recovered. 
 
 Died. 
 
 Relieved. 
 
 Chronic 
 Remainder. 
 
 
 
 Per cent. 
 
 Per cent. 
 
 Per cent. 
 
 Per cent. 
 
 134 
 
 Mania — Simple, .... 
 
 61 
 
 11-9 
 
 11 
 
 16 
 
 201 
 
 Acute, . 
 
 
 65-5 
 
 13-4 
 
 8-4 
 
 11-9 
 
 66 
 
 Hysteric, 
 
 
 75-7 
 
 3-0 
 
 9 
 
 12 
 
 46 
 
 Chronic, 
 
 
 
 13 
 
 36-9 
 
 50-0 
 
 237 
 
 Delusional, 
 
 
 37-0 
 
 130 
 
 lS-5 
 
 31-0 
 
 85 
 
 Recurrent, 
 
 
 57-6 
 
 8-2 
 
 14-0 
 
 20 
 
 46 
 
 Puerperal, 
 
 
 71-7 
 
 15-2 
 
 6-5 
 
 6-5 
 
 141 
 
 Melancholia — Simple, 
 
 
 61-7 
 
 14-0 
 
 13-4 
 
 10-6 
 
 51 
 
 Acute, 
 
 
 54-9 
 
 23-5 
 
 5-S 
 
 15-6 
 
 299 
 
 Delusional, . 
 
 55'5 
 
 14-0 
 
 14-3 
 
 160 
 
 16 
 
 Recurrent, . 
 
 50 
 
 12-5 
 
 12-0 
 
 25-0 
 
 11 
 
 With Stupor, 
 
 63-6 
 
 9-0 
 
 
 27-2 
 
 68 
 
 Dementia — Senile, 
 
 
 60-0 
 
 26-4 
 
 13.-0 
 
 28 
 
 With Excitement, . 
 
 39-0 
 
 35-7 
 
 10-7 
 
 14-2 
 
 39 
 
 ,, Depression, 
 
 41-0 
 
 23 
 
 28-0 
 
 7-6 
 
 33 
 
 Organic, . 
 
 9-0 
 
 54-0 
 
 30-0 
 
 6 
 
 121 
 
 Epilepsy, 
 
 11 -o 
 
 20-4 
 
 23 
 
 38-8 
 
 74 
 
 General Paralysis, 
 
 
 72-9 
 
 21-6 
 
 5-4 
 
 82 
 
 Imbecility, ..... 
 
 
 17 
 
 51-3 
 
 30-7 
 
 13 
 
 Idiocy, 
 
 
 38 4 
 
 15-3 
 
 45-9 
 
 IS 
 
 Chronic Cerebral Atrophy, . 
 
 
 77"7 
 
 22 
 
 
 1809 
 
 
 
190 STATES OF MKNTAL KNFKKDLKMENT. 
 
 dementia of senile atrophy. Under tlie respective headings of epileptic, 
 apoplectic or paralytic, senile, and alcoholic insanities, we shall allude 
 to the features presented by the mental decadence accompanying such 
 affections; but we must here devote our attention to a consideration 
 of consecutive dementia as a sequel to the acute forms of mental 
 disease in general. 
 
 A glance at the preceding Table, which affords us the results 
 of treatment in the case of 1,809 female patients admitted into the 
 "West Riding Asylum, Avill serve to indicate whence our chronic insane 
 inmates are chiefly dei'ived. 
 
 In the Table it will be observed that a large proportion of 
 maniacal and melancholic patients are discharged "relieved," and this 
 class comprises a number of iKrmanenthj enfeebled minds, in which the 
 acute symptoms having subsided, the subjects are safely disposed of 
 under the care and supervision of their friends ; hence the chronic 
 remainder in our asylums do not represent by a long way the COn- 
 secutive dementia of acute insanity. Bearing this fact in mind, one 
 may still advantageously compare the total number of chronic cases 
 remaining after maniacal and melancholic seizures respectively — it is 
 then found that out of 815 instances of all the forms of mania, a 
 percentage of 20"6 remain permanently crippled in mind; and that out 
 of a total of 518 instances of melancholia, a percentage of 15'0 remain 
 as a chronic residue. 
 
 This is what we might anticipate from our knowledge of the deeper 
 reductions pertaining to the maniacal forms, and confirmatory of it we 
 note a progressively-increased tendency to chronic enfeeblemcnt, result- 
 ing in the acute, delusional, and recurrent forms, as compared with the 
 simple form of melancholia {vide Table). If we summarise results for 
 all forms of mania and melancholia, we obtain the following : — 
 
 
 Percentage 
 
 
 
 Chronic 
 
 
 Recovered. 
 
 Died. 
 
 "Relieved."' 
 
 Remainder. 
 
 Maniacal forms. 
 
 . 53-2 
 
 11-9 
 
 14-0 
 
 20-6 
 
 Melancholic „ 
 
 . 57-i 
 
 U-8 
 
 12-9 
 
 15-0 
 
 The more unfavourable chai-acter of mania depends upon the incur- 
 ability of its delusional forms ; the simple and acute maniacal seizures, 
 if they do not tend to the delusional form, are usually of high recover- 
 ability, as indicated by our table ; certain forms especially so, as the 
 puerperal and hysterical. Were it not for the large proportion of 
 suclb acute cases, the unfavourable nature of maniacal, as compared 
 ■with the melancholic forms of insanity, would be strikingly obvious. 
 
 Consecutive Dementia. — Ordinary consecutive dementia, how- 
 ever, presents us with a progressively advancing enfeeblemcnt of mind, 
 
COXSECUTIVE DEMENTIA. 191 
 
 a complete change in tlie disposition and character of the patient, a 
 lack of interest in former pursuits and associations, an incapacity for 
 any form of mental effort, a tendency to an automatic routine in the- 
 habits of life, and a notable blunting of the emotions. Maniacal or 
 melancholic states occasionally return, and betray, in a marked degree, 
 the incoherence of thought and the enfeeblement of the mental faculties ; 
 but, subsequent to such attacks, the mental weakness continues to 
 advance, until it issues in complete fatuity. Yet we find great diver- 
 sity in the progress of individual cases : in many, the advent of such a 
 mental void, as we have just alluded to, only comes after a very pro- 
 longed life, during which they show no mental perturbations, but an 
 apathy and indifferentism, a lack of initiative which renders super- 
 vision necessary to provide them with the wants of life ; others take 
 a more genial interest in their surroundings, but yet are childish in' 
 their actions, are docile and easily led, but subject to great instability 
 if annoyed ; in others, again, the brutalising of their nature is more' 
 apparent — degraded habits come to the front, vicious tendencies are 
 apparent, but conduct is wholly devoid of all intelligent direction or 
 rational initiative. Many of these chronic dements are utterly lazy, 
 disinclined for any form of exertion, and cannot be induced to employ 
 themselves at the simplest manual labour. They will stand about foi' 
 hours, slovenly and disorderly in attire, fumbling with their fingers,, 
 disarranging or tearing their clothing, and uttering continuously a 
 string of incoherent gibberish. Some of these subjects may have no- 
 delusion apparent, as a rule; but yet, at times, a mild maniacal attack 
 may reveal some delirious conception, which again fades away as the 
 excitement abates. The expressionless features betray the lifelessness. 
 of mind ; or a fixed, hideous grimace, or unmeaning aspects, its- 
 unreason. 
 
 It would not serve our purpose here to attempt any classification 
 of such numerous and incongruous types as ai'e presented by the 
 cases of chronic enfeeblement amongst the insane ; they can only be 
 studied by prolonged clinical observation in the wards of an asylum.. 
 Griesinger has, however, distinguished between the class of excitable- 
 and that of apathetic dements, and to his vivid delineation of these- 
 types we would direct the student's attention.* They represent but 
 different depths of reduction, the former being allied to mania — 
 in fact, retaining a certain degree of its mobility as relics of the 
 maniacal condition ; the latter being the more profound reduction, in 
 which sluggishness of mind verges upon absolute fatuity. We shall 
 revert to the morbid evolution of these phases of dementia in our 
 section on the morbid histology of the brain. 
 
 * Op. cit., pp. 340-315. 
 
192 STATICS OF MENTAL EN'FEEBLEMENT. 
 
 The transition from acute insanity is by no means always a direct 
 transition to these forms of mental enfeeblement — an intermediate 
 stage of peculiar chronicity often precedes the more profound dementia 
 which we have just considered. To these forms of monomania or 
 delusional insanity proper, we must now revert. 
 
 Delusional Insanity. — We have spoken of maniacal states as 
 jjresrntiiig us with reductions to a stage lower than that attained by 
 melancholic states ; and we now come to a group of cases comprising 
 symptoms wholly distinct from those presented to us by the foregoing. 
 "This third group lies, so to speak, in the order of dissolutions, on the 
 border-land between the two former. In the first (mania), we noted 
 the general exaltation and the free translation into action ; in the 
 second (melancholia), we observed the rise of painful feeling associated 
 with general depression and restricted activity ; in the third we find, as 
 ■often as not, an emotional indifierentism allied with false beliefs of an 
 exalted stamp — a calm, which is, however, ever ready to pass into 
 states of transient excitement, on the one hand, or into gloom and 
 'despondency on the other. This third group comprises the so-called 
 states of monomania. ^Monomania as a morbid entity must be re- 
 garded as a state evolved out of melancholic and maniacal perversions — 
 as a special derivative of these conditions ; never as a primary form of 
 
 disease, but as itself one of the terminations in chronic insanity. 
 
 It can be studied to the gx'eatest advantage in association with the pre- 
 ceding forms ; nor is it possible correctly to appreciate its significance, 
 if we have not previously analysed the forms of melancholic and 
 maniacal perversions. 
 
 Genesis of Monomaniacal States.— We have seen that a special 
 feature of maniacal states is the hurry and tumult of the process, and 
 the prevalence of delusive conceptions of a fleeting nature. It is this 
 very I'apidity of the cerebral process which accounts for the transient 
 nature of such falsifications ; time is required, a certain persistence of 
 impression, or a frequent repetition of the same impression, to form 
 any indelible stamp upon the memory. As stated, one delusion 
 c-hases another out of the mind in the tumultuous superficial hurry of 
 the maniacal state. The welling-up of feeling, which we have spoken 
 of as the rise in subject-consciousness, finds easy vent in mania in 
 rapid ideation, incessant garrulity, and active movement ; yet all 
 maniacs obtain at times full relief in active ideation alone — for the 
 maniacal subject need not be at all times restless, nor need he be 
 garrulous — yet his expression will indicate to us the varying moods 
 and rapid process of incoherent thought goijig on within. We speak 
 occasionally, but incorrectly, of such cases as instances of siippressed 
 mania — there is no mental tension, but complete relief in the active 
 
MONOMANIACAL PERVERSIONS. 193 
 
 ideational process. Monomauiacal states are essentially those where 
 the rise in sul)ject-consciousness does not tend to r.^cape in outward 
 action, but rather to find relief in forms of perverted ideation ; and 
 hei'ein lies the distinction between the two forms — in monomania there 
 is no longer emotional exaltation and tumult, but perfect calm ; the 
 false conceptions arising at these levels of reduction have a far more 
 serious import, since the existing conditions favour their fixity. They 
 rise more definitely and more for'cibly into consciousness. 
 
 The turbulence of the intellectual life in mania and the heightened 
 mental reflex, we have associated with spasm of the cerebral arterioles, 
 and the resultant quickened circulation in the cerebral cortex ; in 
 monomaniacal states, a quiescence of the circulatory current appears 
 coeval with the decline of such exalted cerebral reflex, and we approach 
 the stage of melancholic reductions except for the absence of vaso- 
 motor paresis and the stagnant circulation of the latter states ; hence, in 
 lieu of a feeling of restricted translation from emotional to intellectual 
 realms, the feeling of freedom and power still predominates. Such 
 freedom, as before stated, finds its output in phases of aberrant 
 ideation. 
 
 And yet there are times when the monomaniac realises somewhat 
 painfully a sense of environmental resistance — a sense which must be 
 generated whenever he attempts to put his impossible schemes into 
 practical operation, or tries to convince others of the logicity of his 
 absurd speculations and belief. Especially, however, does this sense 
 of resistance make its appearance in cases of fully developed mono- 
 mania, where languor of circulation, induced by cardiac enfeeblement 
 and exhausting aff'ections, such as phthisis, reproduces the melancholic 
 phase afresh. This sense of outward hostility — the irritation and 
 excitement thereby engendered — is a more prominent feature in the 
 earlier stage of monomania ; and in most cases it is found, in some one 
 or other form, at this period of the disease, as the natural outcome of 
 the antagonism which the subject must recognise as existing between 
 his beliefs and "the circumstances around him. It is a feature which 
 indicates the incomplete severance of this afiection from the purely 
 maniacal form. As the mania subsides and calm succeeds — as the 
 egoistic feelings predominate more and more, and obtain more complete 
 ascendancy over the intellectual life, the transformation slowly, but 
 elaborately, undergone by the personality is in itself a sufficient answer 
 to all outward antagonism ; the all-sufliciency of the ne-w ego, with its 
 wondrous powers, capabilities, and motives for action, dissipates all 
 apparent opposition, or ignores its existence. 
 
 It is thus that we find our patients at first, in the early transition- 
 period between mania and monomania, intolerant of contradiction — no 
 
 13 
 
194 STATES OF MENTAL ENFEEBLEMENT. 
 
 opposition offered to their delusive utterances fails to arouse passionate 
 outbursts, violent abuse, and even vindictive conduct ; he who risks 
 this often wins for himself the open and long-continued hostility of 
 the patient, at no time a justifiable or politic procedure. At this stage, 
 the deluded subject is loudly assertive of his beliefs, and actively 
 aggressive in his endeavours to carry them into practical operation ; 
 in interminable writings, in incessant declaration he will assert his 
 newly-acquired prerogatives ; whilst acute hallucinations frequently 
 occur at this period, lending fresh intensity to the drama which he 
 enacts. 
 
 In the more confirmed calm of a later stage, a love of mystiC 
 Symbolisin is almost invariably apparent ; the monomaniac will 
 point to some common-place picture on the wall, expatiating on its 
 secret meaning ; he will assume some fantastic badge as the emblem of 
 his exalted dignity — spiritual or temporal ; by fantastic gestures or 
 significant movements of the head he will express some meaning 
 hidden from all except himself; or by uncouth scrawls, or geometric 
 devices, he will symbolise Scriptural truths, Biblical records, or 
 scientific discoveries. By such means endlessly diversified, the sub- 
 jects of monomania beguile their time, and form meanwhile prominent 
 characters in all asylum communities. Their loud threats, their lofty 
 denunciations, their fulminating proclamations, contrast strangely 
 with their impotence in action. They live in an ideal, not a real, 
 world ; and are satiated to the full by the mere semblance of authority 
 and power which such expressions conjure up. On this account they 
 are rarely violent and never dangerous patients ; they are ruled with 
 the greatest facility, requiring only tact upon the part of the nurse to 
 transform them into most useful and willing helping-hands at various 
 employments. Thus we see the patriarch and delegate of the Deity 
 [J. 0.) actively at work in the bookbinder's shop of the West Riding 
 Asylum ; the Empress of Hermon {E. P.) busily plying the needle, 
 trimming the patients' bonnets in the workroom ; the " Saviour of 
 mankind " (.7. B) taking an active part in the domestic arrangements 
 of her ward ; and a notorious admiral who formerly ruled the seas in 
 days gone by, contentedly framing pictures in the joiner's shop. 
 
 Cases of Monomanixi. 
 
 In the following case of J. 0. we see the subject pass through the 
 transition period from mania to genuine monomania ; his case forms a 
 good illustration of the mystic symbolism in which these patients, as 
 we have said above, so frequently indulge : — 
 
 J. 0., formerly a prison warder in South Wales, has been resident at the West 
 Riding Asylum for nearly nine years. When first admitted he was thirty-six 
 
CASES OP MONOMANIA. 195 
 
 yeai'S of age, a well-nourished man of medium height, and free from any Ijodily 
 ailments. His wife had long recognised his mental failure, but maniacal excitement 
 had now compelled her to place him under restraint. He was at this time, 
 undoubtedly, the subject of fixed delusions: "all human agencies were in league 
 against him, and there was a conspiracy in high quarters to damage him." He had 
 written to the prison commissioners repeatedly about these plots, and was at that 
 time writing a book, on "Religion." He talked much about various instruments he 
 had invented, especially "an air and water engine, requiring no boiler," for which 
 he was about to obtain a patent. His condition at this time, and during the following 
 twelve months, was much mixed-up with mauiacal excitement — in fact, it was the 
 transition period to typical monomania. During this period he was often hostile, 
 most unsociable, and utterly indolent ; had an arrogant, overbearing demeanour ; 
 stalked up and down the wards as though in a position of authority, and grew 
 angry at the most trifling opposition. He was usually reticent, but occasionally 
 talked upon the subject of his inventions and of his experiments upon lightning, 
 which he had conducted by " holding pieces of various metals in his hand during a 
 thunderstorm." He then commenced working on the farm, but would spend 
 most of his spare time reading his Bible — making many differently shaped crosses 
 out of bits of wood, straw, &c., often carrying one in his hand. He declares that 
 he was wrongfully sent here ; that he is deputy-governor of a gaol, and possesses 
 the warrant of his appointment; and that he has made numerous discoveries in 
 electricity and magnetism. Since this period he has been regularly employed in 
 the bookbinder's shop, where he is a useful and industrious worker; he is an 
 intelligent workman, and is calm and consistent in his behaviour at all times, 
 outwardly betraying no evidence of the profoundly delusive state under which he 
 labours. He regards himself as a patriarch of the church, and as the appointed of 
 God to denounce judgments against all evil-doers. Feeling his confinement here 
 inconsistent with these views, he applies to all the crowned heads of Europe for 
 assistance against the perseci;tions of the medical profession, of whom the writer is 
 the arch-traitor. He writes denunciatory letters to the medical superintendent, 
 calling upon his head the curse of the Almighty, and sends him, every week or so, 
 a pen and ink outline sketch of a coffin, as a last warning, often accompanied by 
 the words, "Behold thy doom;" addressing his missives, "To all whom it may 
 concern," or "Let this find its owner," with some similar suggestive memento mbrl. 
 Occasionally his letters to the medical staff are lengthy and argumentative, freely 
 interspersed with numerous texts, or scriptural references, containing also words of 
 exhortation and warning, often dictated in the style of the New Testament writings ; 
 but it is more usual to find them full of fierce denunciation and threats of divine 
 judgment, as e.g., the following: — 
 
 " May 6, 1SS7. 
 " Professed Englishmen or Britons, 
 
 "I, an English-born subject, J. 0., born in the County of 
 Yorkshire, near Huddersfield, Do hereby solemnly declare in the name of 'God,' 
 the Almighty, the Supreme and Invisible Spirit, and pronounce through His 
 Almighty authority, His damnable curses and judgments upon you, and your 
 supposed and so-called Gracious Sovereign and all her subjects, both spiritual 
 and temporal, for this my incarceration in this Asylum or any other. 
 
 "J. 0., late of Hahfax." 
 
196 STATES OF MENTAL ENFEEDLEMENT. 
 
 A few mouths later the following incoherent address was issued : — 
 
 St. John vi., 31, 49, 50, 51. Hebrews ix., 4. 1 Corinthians 
 ix., 11-27; xii., 12-36. 2 Corinthians viii., 12-15, 20, 21; 
 i.x., 6-9, 10, 11 ; xi., 22, Galations iii., 2, 4, 5, 10, 20, 21, 
 
 22, 23, 24, 25, 26, 27, 28, 29 ; v., IG, 17, IS, 19, 20, 21, 22, 
 
 23, 24; vi., 8-16. 
 
 Ckntlemen, — Now you may be able to judge for yourselfs once more; whom is 
 most ablest, to the work of a Doctor or Physician of Bodily weakness, temporally, 
 moral or as Physician of the Soul; spiritually according to the Gift of the Grace 
 of "God," and of His Spirit; for His Spirit lies in a vast number and quantity of 
 human and animal beings, in different ways and forms, actively and inactively ; I 
 should think it is quite essentially that you may perhaps have known these things, 
 but how arbitrary and selfish have you seemed to hold them so close ; which may 
 well be defined in one single instance through your Incapacity in not being able to 
 discharge me, your supposed patient in Lunac}', whose name is and ever was J. 0. 
 in England, his Home-born countrj\ 
 
 Believe me, yours ever 
 
 Faithful and sincere, 
 
 Dr. J. 0., 
 
 PItysician Temporal and Spiritual of Ikulti, 
 Y,Jl, Mind, and Soul. 
 
 To Professio Medico De la Russ; 
 Austria; Germany et Prussia; 
 Italia et Continental Europe. 
 
 He then proceeds to call down the anathemas of the Romish Church upon his 
 persecutors, addressing long epistles to "the Head Pontiff of the Church of 
 Rome," every other word or so in his address distinguished by a capital letter. 
 Another of his curious vagaries showed itself prominentlj'^ at this time, and he 
 essayed to address the various European potentates all in their own tongue, 
 or rather in a garbled mass of foreign and unmeaning words, strung together in 
 the form of an epistle — affecting Latin, Greek, German, French, Spanish, Italian. 
 These productions of his facile pen were often decorated by a cross, a crown, an 
 archbishop's mitre, a national flag or other device in coloured inks. The following 
 is a fragment of one of his strange letters to the Spanish Consul in South Wales: — 
 
 "Marzo, Tkiext.\, 
 
 "DlEZ Y OCHO OCHENTA SlETA. 
 
 "MoN Amlso, — Escribo si bien me acuerdo caballero ; hace mas de cinto amos 
 entonces envoyo aquis ; yo lo pongo en usted a Judicio la mameso ; yo no u 
 minimo el loco ; telmpo acero envoyo, ni el altro entonces, Siempre Bastante 
 bien a, ir grande. Que le parece u usted, &c., &c. 
 
 "JOSE 0. 
 "espanal consulato, 
 
 "Cardiff, Wales." 
 
 But our friend, J. O., was shrewd enough to turn such vagaries to good account, 
 and fearing that his letters were intercepted and read, he concealed under an out- 
 landish foreign garb his real English-uttered sentiments ; it was some tinje ere 
 this w"as discovered. Thus the unintelli^'ible jargon — " ikaudonomor butri 
 
CASES OF MOXOM/NIA. 197 
 
 miliesttno enkuraj u, ii everso cnkiirajme, bel evmc stilyuis in anforkrisf, 
 yurstokomzun, J. 0." — turns out to be, "I can do no more but try my best to 
 encourage you, you ever so encourage me. Believe me, still yours in and for 
 Christ, yours to come soon, J. 0." 
 
 Tliese fruitless epistles brought down his further maledictions in the following 
 pointed declaration : — 
 
 To THE Medical Profession 
 
 AND 
 
 Co JI MIS SIGNERS OF LuNACY, 
 
 Yunr King or Queen or any of your Princes, or Bishops, or Priests, 
 or Judges, or Helpers. 
 Through and by the will of God you're not safe one hour or day so long as I 
 and such as 1 — J. 0. — is within such Institution or any other adversity of 
 incarceration. 
 
 (At the foot of this was a neatly drawn outline of a coffin.) 
 
 In the following case we have a remarkable instance of the trans- 
 formation into the monomaniacal state upon the occurrence of epileptic 
 seizures : — 
 
 J. B. was admitted at the age of forty-two years in an acutely melancholic state. 
 She was of slight build, thin, reduced and anaemic, having been in feeble health 
 since her last confinement, twelve months before. She was not known to be an 
 epileptic. At this period she was greatly distressed by aural hallucinations, and 
 when at home the previous day had heard people moving about beneath the floor 
 of the room she occupied, sharpening knives and saws to murder herself and 
 family ; all night long she heard her child crying distressingly on the staircase, 
 and men scraping at the walls of her bedroom. She was firmly convinced that 
 her soul was eternally lost — could see no escape from destruction, and under these 
 impressions she made several desperate attempts at strangulation. She refused 
 food and medicine most persistentlj'^, and accused herself of every form of iniquity. 
 This despondency continued for some six months, when the patient had a series of 
 epileptic fits, the character of which was not noted at the time ; but now an 
 entire change was inaugurated in her mental life — the depression abated, and she 
 assumed a cheerful aspect ; took an intense interest in all around her, and became 
 an active and valued ward-help. The epileptic seizures have occurred ever since, 
 but invariably at night, and with very long intervals, often of years, between 
 the attacks. For many years she has been a typical example of religious mono- 
 mania. The fits she believes are caused hy the "working of the spirit — which 
 has been w^orking very powerfully upon her for some time — because the Father 
 has thought proper that she should bear it for the salvation of the world." She 
 is still in delicate health, and suffers considerably at times from migraine. Always 
 smiling and cheei'ful, afiable with all alike, she is a great favourite in her ward ; 
 all who are brought into contact with her are, she believes, made eternally happy 
 through her instrumentality. She is still in idea a sufferer — a Christian martyr. 
 " She came here because she thought she had to save all the world. She knows 
 that Christ died to save sinners, but feels that (JJod has given her that power. 
 She thinks that if persons touch her it does them good, and saves them. All who 
 have come here have come through her, and she feels responsible for them. If 
 all their souls rest on her, what an account she will have to give at the day of 
 
198 STATES OP MENTAL ENFEEDLEMENT. 
 
 judgment ! She cannot sleep at times because the ' spirit keeps working in her 
 like quicksilver.'" 
 
 Thus all former painful mental states have been sublimated into this higher ideal 
 existence. She still answers to her former name, but her jjcrsonality is, as we see, 
 completely transformed. At times she will state that she feels she is Jesus Ciirist, 
 that she existed before the foundation of the world, and will cite scriptural 
 passages referring to the Messiah, as applicable to herself. She "loves every- 
 body in the world," and during the evening is often found at the window singing 
 aloud, " Hold the fort, for I am coming," in shrill accents, with the object, as she 
 says, of "helping those outside." She has a gentle, quiet, inobtrusive manner, has 
 the sweetest disposition, spends much of her time perusing her Bible, and is often 
 found seated musing, with her hands crossed upon her breast, and an expression 
 of peaceful resignation stirred into beaming animation when she is addressed. 
 
 E. T. , aged forty-six years. This patient, who is a married woman, the mother of 
 six children (the youngest born four years prior to her admission into the asylum), 
 was then suffering from her first attack of insanity of a few weeks' duration only. 
 She had been confined to bed for twelve months, suffering from bronchitis and 
 emphysema, and troubles incidental to the climacteric period. 
 
 The history of her case was one of depression, groundless fears, and delusions of 
 suspicion fostered against her family, who she believed conspired to poison her ; 
 under the influence of these fears she obstinately refused food, and passed restless 
 nights, sitting up in bed continually praying. 
 
 She was regarded as at tlie climacteric. Family history devoid of neurotic taint. 
 On admission she was extremely thin and wasted. She is short of stature, bony, 
 and of a somewhat masculine type ; she has light blue eyes, a sharp penetrating 
 glance, and a suspicious demeanour. vStates that her husband, daughter, and 
 neighbours have conspired to remove her from her home, that her daughter has 
 the power of witchcraft, and can appear in various forms ; that her family and 
 neighbours introduce saliva and other disgusting matter into her food ; and that 
 she has been given gold dust and serpents to swallow. She stoutly maintains these 
 statements, and declares that on the previous night she believed herself to be in 
 labour of serpents. She hears her son and daughter whispering through tiie wall, 
 and addressing her by foul and abusive names. No visual hallucinations are at 
 present obvious. The physical examination revealed general bronchitis with 
 emphysema, but no consolidation or evidence of incipient phthisis, such as her 
 appearance suggested. 
 
 Steady improvement occurred in her case, her delusions faded away, and within 
 a month she was regarded as convalescent. Then occurred a sudden relapse, in 
 which maniacal excitement replaced the former mental depression, and a downward 
 career of mental reductions has ensued unchecked ever since. Her general health 
 underwent marked imi)rovement, but slie always remained pale and anaemic. Her 
 excitement was characterised by loud, abusive, and lilasphcmous language to all 
 around her, and l)y a hostile ilemeanour and threats of violence to those who 
 approached. Little or no abatement of her excitement took place under treatment 
 by succus conii, bromide, with Indian hemp, opium, or hyoscyaminc. Her con- 
 dition, during the five years succeeding the onset of attack, was that of typical 
 monomania. She would sit isolated from other patients in a recess before a win- 
 dow, choosing a position where a portrait of one of the Royal Princes hung opposite 
 her. Here, decorated in fantastic attire, her hair adorned with feathers, coloured 
 
MONOMANIA OF PKIDE. 19D 
 
 ribbons, or mock diadem, and her dress decorated with coloured devices, all of 
 ■whicii had some mystic symbolism to herself, she would sit in state, the embodi- 
 ment of pride and arrogance. From hence she issued her mandates to the world 
 around, or met those who approached her with scornful defiant gaze, together with 
 a torrent of lofty abuse and imperative orders to withdraw from her presence. 
 Occasionally she would deign to expatiate on her lofty rank, would point to the 
 porti-ait of the young Prince, and speak of herself as the Empress — his motlier. 
 llcr conversation was now very incoherent at times, but was invariably tinctured 
 by her grandiose delusions. She frequently complained of sudden sharp pain in 
 the side, which she attributed to having been shot there by the medical officer. 
 On one occasion she was heard to utter a loud piercing shriek, and was observed, 
 transfixed witli horror, gazing at, and pointing to, an imagined tragedy, which was 
 being vividly enacted before her — " See ! see ! " she cried, "they have the knife in 
 him — look at the blood ; " then she fell back in her chair and laughed with 
 derisive laughter. 
 
 Ten years after her admission her habits are noted as similar, and the mental 
 features as unaltered. "She has a forbidding, arrogant, threatening demeanour, 
 says — •'! am the Queen — I will have your blood;' also calls herself Lady Skelton. 
 and is very angry if addressed by her proper name. Calls herself the Scotch Queen 
 — the Queen of the whole earth — and in this transformation of her own identity is 
 now involved the personality of all around her, to whom she gives wrong names. 
 Being accosted by her medical attendant, she asserts — ' I am the Queen, and can 
 get you hanged ; that vagabond talks about the Queen ; you are a tall young man, 
 and will lose your life in seven days if you are not quick; I've been chopped to 
 bits.' " 
 
 Twelve months later, evidence of phthisis was revealed, and a slight attack of 
 haemoptysis occurred. She complained of pain in the lower dorsal region, and 
 asserted that "that part of my spine has been cut out, and made into jelly ; all 
 parts of my body have been made into jelly and thrown on the floor ; I've been 
 a doctor 300 years." 
 
 Latterly, she has broken down completely in health ; phthisical symptoms have 
 been for some time prominent, and occasional haemoptysis has occurred ; completely 
 bed-ridden, and a great sufferer from exacerbations of her chest symptoms ; much 
 prostrated in health, pallid and emaciated, she still asserts her royal prerogative, 
 insists upon being addressed by her formal title ; issues her mandates to her 
 courtiers, princes, and statesmen, with gestures of mock authority ; and still, at times, 
 becomes irate at the least appearance of opposition. There is now considerable 
 mental enfeeblement ; increasing incoherence of ideas, and a tendency to substitute 
 unmeaning words, and interpolate them in her sentences so that they constitute 
 at times a confused and unintelligible jargon. She is now tractable and devoid of 
 all the repellent features characterising the early stage of her alienation — amiable, 
 as a rule, but still subject to mild outbursts of irritability and excitement, in 
 which her delusional notions become very prominent. 
 
 All these cases, we observe, are of many years standing ; in fact, 
 monomania is a most chronic form of insanity, gradual in its inception, 
 and very slowly progressing towards general mental enfeeblement ; 
 the coherence of former associations becomes successively loosened, 
 whilst the fictitious personality persists and erects itself skeleton-like 
 amidst the ruins of mind. 
 
200 STATES OF MKXTAL ENFEEBLEMENT. 
 
 E. C. was admitted at the age of thirty-one years. Slic was a married woman 
 with a family of three cliildrcn. Subsecmcnt to certain disappointments in 
 money matters, she became maniacally excited two months prior to her admis- 
 sion, and had attempted suicide by cutting her throat with a knife. The 
 history, which on most points was defective, testifies to excitement, incoher- 
 ence, a tendency to rhyming in her utterance, and several gross delusions. For 
 some years she had suffered from spinal curvature, which was found to be in 
 the dorsi-lumhar region, with a convexity strongly directed backwards and to the 
 left. Her excitement abated in the course of some six months— she became calm, 
 orderly, and industrious. With this emotional calm, however, it was found that 
 she was the subject of fixed delusional notions, all of which suggested suspicion 
 and persecution upon the part of her neighbours and those immediately associated 
 with her. These delusions were of very varied nature. She believes that by the 
 agency of machinery, concealed beneath the building, she is subjected to constant 
 torture at night — her body " screwed up" and her flesh torn from the bones, and 
 that she is "rocked in her bed by invisible power." Believes she has a second 
 body beneath the floor, which, when operated upon, causes suffering in her tcaX 
 body. " When they tie the rope round the other body down yonder (pointing to 
 the floor) my bowels are screwed up and my bones crushed ; they (her persecutors) 
 often fetch me to Halifax from Wakefield by electricity, and they have taken my 
 children out of their graves and dragged them about for one and twenty years." 
 Aural hallucinations were frequent phenomena, and she was often detected listen- 
 ing at the window to imaginary voices, receiving messages from distant towns, 
 holding communication with her daughter, &c. Associated with these ideas of 
 cruelty and persecution, there were feelings of great self-importance and authority 
 encroached upon. The as5'lum buildings were her possession, and the staff of 
 officers her subordinates, whom she threatened with instant dismissal if they 
 ne^^lected her commands. She invariably met the medical oflBcer, day by day, 
 with the authoritative order for her dinner, and, as invariably after her meal, 
 demanded a cab to take her home. When questioned upon dates, it was noted that 
 she was always a j'ear in advance, although correct as to the day of the month. 
 This, upon examination, was found to depend upon the delusion that, "in the year 
 1865 {ichen she icas admitted into the asylum), they (her persecutors) did not add 
 the figure, but allowed two years to slip by as 186G, for reasons best Jcnovn to them- 
 selves." She is sadly perplexed at times about the quantity of food consumed by 
 her fellow-patients, believing that the institution is supported by her bounty. 
 Between the years 1884 and 18SG, she suffered from three very sudden and pro- 
 longed attacks of acute maniacal excitement in which she was utterly incoherent, 
 noisy, voluble, and was greatly reduced by insomnia and restlessness. In the 
 intervals between such attacks, her delusions remain unchanged. She refers 
 to " the annoyance that is kept in the wall ; they can move it elsewhere, or 
 she would have had the wall down long since. Evil trauslatings issue from the 
 wall to her back. Persons act on her by electricity, so that if she be walking, 
 they can throw her flat down on her face ; it is their interference that has caused 
 the deformity in her back." 
 
PERSISTENT MENTAL INSTABILITY. 201 
 
 RECURRENT INSANITY. 
 
 Contents.— Definition — Establishment of Labile E(nnlibriura— Prevalence at Sexual 
 Decadence — Heredity — luHuence of Neurotic Heritage and of Ancestral Intem- 
 perance— Atavism— Recurrence in the Congenitally Defective Subject— Morbid 
 Excitement and the Moral Imbecile— Alternations of Excitement and Stupor- 
 Hysteria and Menstrual Irregularity- Eroticism {A. S., M. A. J/. )— Eecurrence 
 in Adolescence [M. C. (K.)— riecurreuce at the Climacteric (//. 0.)— at the Senile 
 Epoch (/. <S.)— in Puerperal Subjects {M.B.)—m Traumatic Insanity (Z>. X.)— 
 Morbid Impulsiveness — Hallucination and Delusion (./. B.) — Prognosis — 
 Treatment. 
 
 All forms of insanity are prone to recur ; from whatever source the 
 unstable condition of the nervous centres is derived, whether from 
 inherited neurotic tendencies, acquired vices, or physical ailments, all 
 alike (even the most recoverable forms) have such a predisposition, 
 intensified by the occurrence of an attack. It is a general law that 
 the more frequently a centre discharges its energy, the more sensitive 
 to excitation becomes the mechanism, and the more readily the dis- 
 charge repeats itself. Hence, the extensive cortical discharges which 
 account for the reductions of insanity will, even in the most complete 
 recoveries, tend to foster a similar hyper-sensitiveness, and a labile 
 
 equilibrium of the parts previously involved. 
 
 By recurrent insanity we mean a type of mental disturbance in 
 which there is an establishment of this labile equilibrium ; and the 
 conditions under which such recurrence is brought about, together 
 with the essential nature of the attack, form the subject of our inquiry. 
 In the first place, it must be remembered that a neurotic inheritance, 
 however strong, does not necessarily result in recurrent insanity ; and, 
 in the next place, it should be noted that simple relapses of insanity, 
 which may occur at diflTerent periods throughout life, do not imply 
 the existence of the neurotic type here alluded to as recurrent insanity. 
 
 Recurrence, with long intervals of repose, is not the characteristic 
 of this type, but rather the rapid succession of attacks, each followed 
 by an apparent complete convalescence. " Notwithstanding the 
 authentic instances of recurrent insanity showing intervals of lucidity 
 for very long periods, so that the disease is known to be dormant for 
 years, it is by no means to be inferred that every case that is a second 
 attack belongs to such a categoxy" (Sankei/).* A large section of the 
 insane community is, therefore, constituted by these unfortunate ones, 
 who pass many years of their life between an asylum and their home 
 during frequent alternations of sanity and insanity. Those not con- 
 versant with statistics of insanity have but a faint notion of the miserable 
 existence of such victims. The following scheme of some fifty recurrent 
 cases amongst women will exhibit this fact in a striking manner : — 
 * Lectures on Mental Disease, p. 179. 
 
'202 
 
 persistknt mkntal instability. 
 Table of Female Recurrents. 
 
 Number of 
 Attacks. 
 
 Occurring between 
 the Ago of 
 
 Representing 
 lutorval of 
 
 Number of 
 Attacks. 
 
 Occurrins between 
 the Ago of 
 
 Representing 
 lutorval or 
 
 5 
 
 16 and 32 y IS. 
 
 16 yrs. 
 
 Several 
 
 3 1 and 36 yrs. 
 
 5 yrs. 
 
 3 
 
 17 „ 20 „ 
 
 •i „ 
 
 5 
 
 32 „ 48 „ 
 
 16 „ 
 
 3 
 
 17 „ 21 „ 
 
 4 „ 
 
 8 
 
 32 „ 42 „ 
 
 10 „ 
 
 Several 
 
 IS „ 30 ,, 
 
 12 „ 
 
 5 
 
 33 „ 37 „ 
 
 4 „ 
 
 3 
 
 19 ,, 24 „ 
 
 5 „ 
 
 4 
 
 35 „ 50 ,, 
 
 15 „ 
 
 3 
 
 20 ,, 21 „ 
 
 1 „ i 
 
 6 
 
 35 ,, 53 „ 
 
 18 „ 
 
 3 
 
 20 „ 25 „ 
 
 5 „ 
 
 4 
 
 35 „ 48 ,, 
 
 13 „ 
 
 3 
 
 20 „ 33 „ 
 
 13 „ 
 
 3 
 
 39 „ 46 „ 
 
 7 „ 
 
 3 
 
 19 „ 28 „ 
 
 9 „ 
 
 5 
 
 38 „ 50 „ 
 
 12 „ 
 
 4 
 
 24 „ 44 „ 
 
 20 „ 
 
 3 
 
 38 „ 40 „ 
 
 
 3 
 
 23 „ 25 „ 
 
 2 
 
 4 
 
 38 ,, 56 „ 
 
 18 „ 
 
 5 
 
 24 „ 36 „ 
 
 12 „ 
 
 3 
 
 40 ,, 45 „ 
 
 5 „ 
 
 4 
 
 25 „ 35 ,, 
 
 10 ,, 
 
 3 
 
 42 „ 59 „ 
 
 17 „ 
 
 3 
 
 26 ,, 40 ,, 
 
 14 „ 
 
 7 
 
 43 „ 53 ,, 
 
 10 .. 
 
 5 
 
 28 „ 45 „ 
 
 17 „ 
 
 5 
 
 43 „ 58 „ 
 
 15 „ 
 
 4 
 
 29 „ 42 „ 
 
 13 „ 
 
 Several 
 
 43 „ 58 „ 
 
 15 „ 
 
 5 
 
 29 ,, 52 „ 
 
 23 „ 
 
 6 
 
 42 „ 51 „ 
 
 9 „ 
 
 3 
 
 29 „ 33 „ 
 
 4 ,, 
 
 4 
 
 41 „ 58 „ 
 
 14 „ 
 
 3 
 
 30 „ 41 „ 
 
 11 „ 
 
 3 
 
 47 ,, 55 ,, 
 
 s „ 
 
 4 
 
 30 „ 44 „ 
 
 14 „ 
 
 3 
 
 46 „ 50 „ 
 
 4 „ 
 
 4 
 
 30 „ 42 „ 
 
 12 „ 
 
 4 
 
 48 „ 63 „ 
 
 15 „ 
 
 6 
 
 30 „ 43 „ 
 
 13 „ 
 
 5 
 
 50 „ 53 ,, 
 
 3 „ 
 
 3 
 
 30 „ 35 ,, 
 
 5 ,, 
 
 3 
 
 50 „ 58 „ 
 
 8 „ 
 
 3 
 
 30 „ 42 „ 
 
 12 „ 
 
 5 
 
 51 „ 54 „ 
 
 3 „ 
 
 3 
 4 
 
 1 
 
 30 „ 35 „ 
 
 30 ,, 55 ,, 
 
 5 „ 
 25 „ 
 
 3 
 
 Total, .00 
 
 Persons. 
 
 lS3(TSevei-alj 
 
 Attacks. 
 
 54 „ 56 „ 
 
 2 „ 
 
 When dealing with the insanity incident to the periods of puberty 
 and adolescence, it will be seen that recurrences are not frequent in 
 the proper acceptation of the term ; up to the stage of complete con- 
 valescence relapses are peculiarly prone to occur, but, once the cure is 
 complete, a recurrence of insanity is not frequent, sixteen instances 
 only of a third or fourth attack being given in 277 cases. 
 
 Recurrent forms of insanity are far more prevalent in adult life, and 
 increase gradually towards the decline of manhood and womanhood. 
 In men, quite one half the cases of recurrent insanity occur after forty 
 years of age ; and out of a total of G6 individuals so affected, 49 had 
 
INCIDENCE OF IlECURUENT INSANITY. 
 
 203 
 
 passed their thirtieth year of life ; similarly in women, we find that 
 nearly half the cases cover the period of life between forty and fifty- 
 five, which may be safely taken as the limit of the climacteric period. 
 In fact, the period of life between forty and sixty years in the female 
 is peculiarly susceptible to this form of mental derangement, being the 
 period involved in sexual decadence and the advance of senility. In 
 man this feature is not so apparent, there being other influences, 
 as we shall see later on, which tend to beget in him such recurrent 
 attacks at a somewhat earlier period of life. 
 
 Respective Age in Qcinquennial Periods, in 164 Cases of 
 Recurrent Insanity, 
 
 Age. 
 
 Males. 
 
 Females. 
 
 Up to 25 years, 
 
 10 
 
 9 
 
 „ 30 „ 
 
 7 
 
 8 
 
 „ 35 „ 
 
 7 
 
 9 
 
 „ 40 „ 
 
 9 
 
 8 
 
 ,. 45 „ 
 
 7 
 
 21 
 
 „ 50 „ 
 
 9 
 
 9 
 
 „ 55 „ 
 
 5 
 
 13 
 
 „ 60 „ 
 
 4 
 
 17 
 
 ,. 65 „ 
 
 3 
 
 4 
 
 „ 70 „ 
 
 5 
 
 
 
 66 
 
 98 
 
 Who are the subjects most liable to this form of mental disturbance? 
 
 They have a strongly stamped hereditary history of insanity ; 
 
 the parentage, when facts are procurable, revealing attacks of insanity 
 often along both paternal and maternal lines. It is also notable, that 
 in a large proportion of cases, we find the history of ancestral insanity 
 attached to the grandparents, or the collateral line of uncles and 
 aunts, significant of a more remote origin for the neurosis. The actual 
 proportion of cases revealing strongly marked hereditary features 
 (often involving several members of the subject's ancestry) amounts to 
 36 per cent.; but, in 12-5 per cent, only was it discoverable that the 
 subject's parents had been insane. 
 
 In the next place we observe that other neuroses, notably epilepsy, 
 are absent in the antecedent history. Chorea, hysteria, epilepsy, 
 hemiplegic seizures are prone to occur in the ancestry of a certain 
 class of the insane, as was seen to be the case in the insanity of female 
 
204: PERSISTENT MKN'TAL INSrAHILITY. 
 
 adolescents, wlici'c 20 per cent. I'evealed this predisposition ; but such 
 a neurotic history is attached to only 4-4 per cent, of the recurrent 
 forms of alienation. 
 
 Again, parental intemperance— a potent source of all forms of 
 convulsive neuroses — is revealed in 11 •! per cent, (males 89, and 
 females 12-6), or over tioo-tliirds the proportion of cases shown by 
 adolescent forms of insanity ; and in 80 per cent, of such instances 
 of parental intemperance, the fatJier was at fault. This fact is a 
 suggestive one, and the question naturally arises — why one form of 
 insanity should appear, as the result of an insane inheritance, and 
 another as the heritage from epileptic parents or grandparents, or as 
 the outcome of parental drink *? If we accejit, as we have reason for 
 so doing, the dictum that the hereditariness of insanity, like the 
 heredity of other pathological tendencies, is restricted by sex and 
 age, it may reasonal)ly be assumed that the neuroses of early life — 
 chorea, hysteria, epilejDsy — will be especially prone to reassert them- 
 selves also at a similar epoch in the life of the offspring ; and that, 
 thei'efore, an epileptic father or grandfather who became epileptic at 
 jmherty Avill be liable to transmit to his sons a morbid tendency which 
 appears as epilepsy or the like at the adolescent period. Insanity, on 
 the other hand, is not a disease of early years, and, as we have seen, 
 is far more frequent towards the middle period of life ; hence we 
 might expect its appeai'ances as an inherited affection to be regulated 
 by the same laws. This is seen to be the case with the recurrent 
 form, which is strongly inherited, and which conforms to the law of 
 insanity in general, in being most prevalent at the middle epoch of 
 life. Adolescent forms, however, must be differently accounted for, 
 and may indeed with justice be conceived of as the morbid expression 
 of an inherited neurosis of the epileptic type — epilepsy in the collateral 
 or direct line tending to issue in insanity; often even by atavic descent. 
 It is generally conceded that alcoholic craving is often an inherited 
 condition, as in the form of " dipsomania ; " and that parental intem- 
 perance frequently results in the imbecility, idiocy, epilepsy, or deaf- 
 mutism of the offspring — all, we observe, indications of arrested 
 development or disease in early life. To this category we may add 
 adolescent insanity, which is especially apt to be engendered in the 
 offspring of those addicted to heavy drinking, under certain physio- 
 logical conditions and the operation of other excitants. 
 
 To revert, however, to the recuri-ent form — the heredity observed 
 in such subjects is more often atavic than direct — its frequent 
 appearance in the collateral line of uncles and aunts, being strong 
 presumptive evidence in favour of an atavism even where no other 
 record exists. Its comparatively later development than the adolescent 
 
INTEMPERANCE AND RECUKRENT INSANITY. 205 
 
 form appears to be governed by the law of limitation by age, wliich 
 is enforced in most hereditary atiections ; the ancestral affection 
 occurring in adult life tends to reproduce itself at the same epoch. 
 Parental intemperance declai-es itself almost exclusively on the father's 
 side, but is by no means a prominent predisposing element. The 
 neurotic temperament of these subjects is revealed in an undue excita- 
 bility, and a defective moral control, exhibited often in ungoverned 
 passion, and generally mobile emotional states ; occasionally, such lack 
 of control amounts to mild forms of imbecility of the moral type — 
 congenital defects occurring in some 12 per cent, of such cases. For 
 the first start in life, such organisations may readily adapt themselves, 
 and the period of puberty and adolescence passes by without serious 
 risk; but, as the complexity of life increases in the ever more complex 
 environment, corresponding developments do not occur, and adapta- 
 tion is at fault. The organism but awaits some exciting cause which, 
 as with a fulminate, determines the attack of insanity. If a female, 
 the period of gestation or parturition may so act, or, still more forcibly, 
 the epoch of the menopause ; if a male, alcoholic indulgence is a most 
 potent agency in causing the fui'ther reduction which issues in acute 
 insanity. 
 
 The climacteric, as we have already .stated, is a period prone to 
 induce and foster a craving for stimulants ; and hence, we find that 
 13-7 per cent, of female recurrents were addicted to intemperate 
 habits, whilst 30 per cent, of the male recurrents had succumbed 
 to this vice. In short, the subjects prone to recurrent insanity are, 
 in general, congenitally predisposed by defective mental organisation, 
 and inherit a strong parental or atavic tendency to insanity, which 
 usually appears upon the indulgence in alcoholic stimulants, or at 
 the later critical epochs of life — notably the climacteric and senile 
 decrepitude. 
 
 Dr. Sankey, on the other hand, regards the periodicity of recurrent 
 insanity as bringing this disease into close alliance with epilepsy; his 
 statement is to this effect : — " By the very character of periodicity 
 (a character of the utmost importance in their pathology), they are 
 allied to epilepsy, and in certain cases actually terminate in well- 
 marked symptoms of that disease; especially when our views of epilepsy 
 include all the phenomena and variation of the j^et'd mal, now generally 
 classed with true epileps3^" * 
 
 Nature of the Attack. — The seizui-e varies as to its symptoms 
 and course with the exciting cause at work, and the period of life 
 when it occurs. There may be' mild maniacal excitement, without 
 obvious delusional perversion ; or the attack may be characterised by 
 
 * Loc. cil., p. 179. 
 
20G PERSISTENT MENTAL INSTAUILITV. 
 
 delusions of sns|iicioii unci persecution ; or by an ordinary lijpemania, 
 ■with delusions of a depressant nature. Maniacal conditions certainly 
 prevail in the earlier and later periods of life — in adolescence and in 
 senility ; whilst the climacteric cycle usually calls forth emotional 
 depression and mehincholic delusions. Of subjects prone to recurrent 
 seizures of nuuiia or melancholia, the more important are cases of 
 
 Congenital mental defect. Insanity with menstrual deraogenient. 
 
 Adolescent insanity. Puerperal insanity. 
 
 Alcoholic insanity (acute). Climacteric insanity. 
 
 Traumatism (cranial injur}'). Senile insanity. 
 
 Epileptic subjects, in whom recurrent seizui'es are frequent, are 
 necessarily excluded here by their intrinsic importance, and will be 
 considered apart. 
 
 Recurrence in Congenitally Defective States.— Those whose 
 
 mental organisations ai'e congenitally defective in both sexes are pro- 
 verbially subject to passionate explosiveness, to rapid alternations of 
 mood, and to other indications of great instability. Such cases are often 
 misjudged, the normal undisturbed state being one of striking placidity 
 and great amiability, which seems to render it highly improbable that 
 the passions will so readily assume the opposite exti'eme ; but, so it is, 
 that such extremely amiable natures will pass, upon the most trivial 
 disturbance, to a bitterness and a passionate demonstrativeness often 
 exhibiting an inherent cruelty and viciousness. 
 
 "With lack of inhibitory "staying" power, sucli individuals, as before 
 stated, meet a severe trial during the adolescent period of life ; but, if 
 they do not succumb to insanity at this epoch, they are still subject, 
 upon the occurrence of trivial agencies, to an attack of insanity at any 
 subsequent period of life. 
 
 The agencies which are thus potent towards such an issue are alco- 
 holic and sexual excess, masturbation, and indulgence in morbid excite- 
 ment of any class. jNIasturbation, especially, lays the groundwork for 
 an attack of insanity by the nutritive changes induced in the nervous 
 centres — their exhaustion and the ultimate impoverishment of blood. 
 If this vice be associated with alcoholic indulgence, the effect is vastly 
 augmented, and the worst forms of recurrent insanity occur. Another 
 frequent source of the attack is the powerful influence of morbid emo- 
 tional excitation — sensational plays, sensational literature, " revival " 
 services, "Salvationist" crusades; all have much to answer for in 
 their effect upon the moral imbecile, ;nul those lacking in moral 
 control. Menstrual derangements, again, foster in the congenitally 
 defective an explosiveness which may issue in an attack of insanity. 
 In all these cases the agency, whether it be menstrual irregularity, 
 
STUPOR AND HYSTERIA IN RECURRENT INSANITY. 207 
 
 masturbation, sexual excess, alcoliolic intoxication, or undue nervou?> 
 excitement from moi'al causes, acts by occasioning a malnutrition of 
 the central nervous system, already j>redisposed to insanity through 
 a neurotic inheritance, expressed in a defective mental organisation. 
 
 In the male subject, so constituted, the attack of insanity is almost 
 invariably one of excitement, characterised by noisy, boisterous 
 humoui', mischievous conduct, destructiveness, viciousness, and out- 
 bursts of violence. Diurnal quiet often alternates with nocturnal 
 excitement — the nights, in such cases, being spent in noisy, incoherent 
 rambling, and often prolonged insomnia. Frequent relapses of excite- 
 ment are prone to occur before convalescence is more permanently 
 established. Should masturbation complicate the case, the subject 
 becomes a prey to delusions of suspicion, and altGPnations Of excite- 
 ment and stupor will often take place. 
 
 In the female subject, the attack of insanity occurring is also one of 
 acute excitement, where mild forms of moral imbecility or naturally 
 defective inhibition are maintained. The type is usually that of 
 so-called hysterical insanity, I'eproducing, as it does, many promi- 
 nent hysteric symptoms. 
 
 The typically hysteric subject is generally the subject of menstrual 
 irregularities, as in the following cases : — 
 
 A. S., aged twenty years, mill-hand, admitted May, 1870. A cousin was insane 
 and epileptic. This patient was, in 1868, placed in Morningside Asylum, and 
 remained there five months, being discharged at the request of her friends, 
 although probably not recovered. Her second attack, for which she was treated 
 here, was characterised by violent eroticism ; she conversed incessantly on 
 marriage, &c. Its duration was short, but she was not considered sufficiently 
 stable to be discharged under nine months. The menstrual function had been 
 regularly performed as regards time, but in amount variable, occasionally rather 
 profuse, more often there was amenorrhoea. In less than two years she again 
 required restraint ; the catamenia having ceased, she, about a month afterwards, 
 became restless, sleepless, and excitable, prone to destructiveness, and very 
 indecent both in sjieech and demeanour. When admitted, she was somewhat 
 maniacal, but intensely erotic — betraying much perverted sexuality. Showed 
 evidence of the existence of aural hallucinations. She improved, and was dis- 
 charged under a twelvemonth. A fourth recurrence of msanity took place 
 twenty months later, the catamenia being on this occasion regular. Only slight 
 premonition was given, and the patient became suddenly excited, violent, inco- 
 herent, with much religious matter mixed up in her ravings; but the sexual 
 feeling only displayed itself once in three weeks, during which time the mania 
 subsided. Eroticism was alone manifested in connection with irregularity of 
 menstrual function, which occurred later ; it did not cease until the catamenia 
 had resumed their normal characters. Discharged in thirteen months. 
 
 Another relapse, eight mouths subsequently, was purely maniacal in kind ; 
 there was rambling at tirst upon religious topics, slight or no evidence of eroticism, 
 and no added irregularity of menstrual performance — which, it was stated, 
 generally erred on the aide of insufficiency. Seven months accomplished a cure. 
 
208 PERSISTEN'T MENTAL IXSTABILITV. 
 
 The sixth and last admission occurred eight months later ; menstrual derange- 
 ment had again preceded. The condition was one of simple mania, with great 
 religiosity, but without sexual characters predominating. Convalescence occurred 
 immediately the catamenial irregularity was remedied. Sent out in seven months. 
 
 M. A. M. , aged twenty years, domestic servant, admitted May, 1881, Patient's 
 father and mother eccentric. No insane relations. M. A. M. was a girl 
 of steady, industrious, and healthy habits, until one year before the above date, 
 about which time, it was said, she had two transient attacks of mental disorder. 
 One week ]irior to admission here, she became altered in manner, depressed about 
 religious subjects, restless, excitable, and ^'iolent. When received into the asylum, 
 she was in a state of acute mania — boisterous, mischievous, and of rather dangerous 
 and treacherous propensities ; she remained in this condition for a few days, when 
 she gradually settled down and behaved quietly and rationally, excepting for a 
 little chance flightiness, during three weeks — then gave way to a burst of unruly 
 excitement, showing much erotic tendency and depravation of habits. There was 
 no catamenial irregularity. She merited her discharge, recovered, five months 
 after admission — and remained outside in domestic service for fifteen months, 
 during the last five weeks of which she began to fail in general health and to 
 become wild, restless, noisy, and turbulent. Her manner on admission varied 
 between excitability and garrulousness, and obstinate reticence and brooding. 
 The maniacal state, with considerable prominence of sexual feeling, continued for 
 a week and then began to subside. On a few occasions, however, she had slight 
 relapses of excitement, at times preceded bj' gloomy reserve. On the whole, 
 behaved in an orderly and industrious manner, and after seven months' lapse, was 
 convalescent and sent out. Catamenia very irregular. It appeared that from the 
 period of her discharge to that of her readmission, two months later, the patient 
 had been flighty and excitable, and became unmana:_'eable. Her symptoms on 
 this third recurrence were, in the main points, repetitions of those exhibited during 
 previous attacks, including some erotic display; and the progress of her case wais, 
 in most respects, similar to that of the preceding one, but uninterrupted by 
 relapses, although the jjatient's irritable intolerance of supervision rendered need- 
 ful much tact in her management. She remained excited at night for some time, 
 after her behaviour during the day-time had improved; the erotic tendencies 
 ceased shortly after her admission. She was quite convalescent in thirteen 
 months; but was only outside the asylum for two weeks, having had a fourth 
 recurrence of mania almost immediately after leaving. Sleeplessness, wandering, 
 excited and violent conduct prevailed, and, when put under care, she was very 
 maniacal, gay, flippant, and inattentive; j-et, as on previous occasions, recognis- 
 ing all with whom she had previously been brought into contact. In the following 
 three mouths, frequent relapses into a turbulent condition interrupted longer 
 periods of industry and quiet. For twenty months she remained free from any 
 outburst, and again, for three months, passed through a phase of excitement, 
 characterised by silly and indecent talk, gay carelessness, and violent tendencies. 
 For the last year, no relapse. Still an inmate. 
 
 Recurrence in Adolescent Cases. — Adolescence occasionally 
 
 ushers in recurrent attacks of mania — three or four such seizures, 
 between the ages of seventeen and twenty-five years, being sometimes 
 witnessed. In all such instances, the symptoms reproduce overaud, 
 
RECURRENT INSANITY IN ADOLESCENCE. 209 
 
 over again the features (already delineated) of insanity occurring at 
 this epoch. Recurrent mania originating during adolescence is of 
 very ominous portent ; the prognosis is exceptionally unfavourable, in 
 so far that it indicates, for a large j)roportion of cases, a congenitally 
 defective mental organisation ; that many others are doomed to succes- 
 sive attacks beyond this period of life; and that the rest remain chronic 
 residents of our asylums, or are discharged as partial " recoveries " 
 only — or their recovery, if at all complete, takes place after a protracted 
 illness, often embracing successive relapses. 
 
 M. C. W., aged eighteen, single; a tall, well-proportioned girl, of somewhat 
 delicate aspect, feeble muscular development, dark brown hair, light blue eyes, 
 complexion fair, expression bright, animated, and intelligent. For some time jiasb 
 she has been in delicate health, and is distinctly anfemic. She brings with her 
 a strong neurotic heritage ; her maternal grandmother was twice under treatment 
 at an asylum, her mental balance overtlirown each time by "some love affair;" 
 her own mother is highly eccentric; and she herself has been regarded as very 
 unstable, flighty, and erratic. The lungs and heart are healthy, and the alimen- 
 tary system free from derangement. The catamenia have been excessive of late, 
 and of fortnightly occurrence. For a month prior to her attack, the patient had 
 been attending exciting religious services, "revival meetings," and had been 
 excited over these subjects, talking much in a religious strain. The attack 
 occurred a few days before admission; she became acutely maniacal, garrulous, 
 and incoherent. On removal to the workhouse infirmary, she tore down the pads 
 of the padded room, was extremely violent, and her conduct most outrageous. 
 When brought to the asylum, the maniacal condition was still acute; she was 
 good-tempered, jovial, mischievous, talked incessantly, and gambolled from subject 
 to subject, but could carry on a connected discourse on closely questioning her, and 
 insisting i;pon a reply. She had a flippant air, was pert in her remarks, and 
 shrewd. Appeared quite unaware of the nature of her surroundings. Left to 
 herself, she talked incoherently, interspersing her remarks with frequent allusions 
 to " angels, hell, and devils," saying that she heard " trains whistling telegrams 
 to heaven, when at the workhouse. " 
 
 Half an ounce of the succus conii was ordered twice daily, and chloral was 
 given occasionally at night to secure sleep. In four days it is noted — " Much 
 more composed and rational ; sleeps well, and is trying to employ herself usefully ; 
 has not yet lost the flightiness of behaviour and demeanour; appetite good." In 
 a fortnight she was in the "convalescent" ward. A month subsequent to her 
 admission a complete relapse occurred, characterised as before by noisj'^, boisterous 
 behaviour, great hilarity, pertness, and occasional insolence ; her nights were not 
 disturbed by excitement. Conium (succus conii) was given in one ounce dose 
 twice daily, and towards the middle of the month the excitement abated, and she 
 became sufficientlj' staid to attend the weekly dance. Exactly a month after the 
 jirst rclapxe, a second occurs, in which she again proves boisterous, \aolent, and 
 destructive; her bodily health, however, has been progressively improving since 
 her admission. It was clearly seen that her relapses were coincident ivith the 
 menstrual periods ; but the occurrence of the next period was passed witiiout any 
 mental disturbance, and she Avas discharged, recovered, a few weeks subsequently. 
 
 Six years later, that is, when twenty-four years of age, this patient again became 
 
 u 
 
2T0t: 
 
 PERSISTENT MENTAL INSTABILITY. 
 
 an' inmate of our wards. She had kept well, and regnlarl}' employed as a dyer 
 during the interval, when, upon tlie occurrence of a pecuniary loss by her mother, 
 the daughter again succumbed to her inherited weakness. She was maniacally 
 excited, though not in an extreme degree. There was marked elevation of spirits; 
 she was well-satisfied, gay, flippant, and saucy. She talked loquaciously, very 
 irrationally, and incoherently. Evidently has a strong propensity to render things 
 absurd. Her tone is careless, almost abandoned. She states — "I am Adam's 
 first daughter, and came here in the year 1 ; came here because my mother came 
 first: I think I couldn't give you more straightforward answers, could I?" then 
 lauglis and becomes obscene and repulsive. 
 
 As on the former occasion, the excitenvent completely abated in a fortnight's 
 time from admission; but only to return again in a violent form, marked by all 
 tlie features above depicted, and extending over a period of about two months, 
 when a gradual improvement succeeded, until complete convalescence was ensured. 
 
 Recurrence at the Climacteric. — Here, again, we recognise the 
 form of insanity which is regarded as more or less characteristic at 
 this period of life ; it signifies little when the recurrent seizures 
 originated, whether during adolescence, later adult life, or at the 
 menopause, the symptoms of the attack existing at this latter period 
 conform to those with which we are familiar at this revolutionary 
 epoch. Former attacks may have been characterised by maniacal 
 excitement — the attack at the climacteric is almost certainly one of 
 depression, mental unrest and gloom, and of delusional perversions of 
 the melancholic stamp. Take for instance, as illustrative of this 
 statement, the following case in which climacteric insanity eventually 
 issued in senile insanity : — 
 
 H. 0., aged forty-eight, married ; admitted Ma}", 1S69. Historj- of paternal in- 
 temperance — an aunt hung herself — an uncle died in a lunatic asylum. H. 0. had 
 been intemperate, but had enjoj-ed good health. Of three children borne Viy her, 
 one died of convulsions. The alleged cause of her present attack was domestic 
 anxiety, embracing supposed infidelity on the part of her husband, and occurring 
 at the period of the climacteric. Depression of mind, lasting some six months, 
 culminated in an attack of melancholia, with marked delusions of suspicion, from 
 which she recovered after a residence of ten weeks. 
 
 Was re-admitted after the lapse of thirteen years. Part of this inter\-al had 
 been spent in Wadsley, and she had been discharged but one week when 
 depression of spirits and apprehensive fears beset her, and she developed the 
 tlehision that chloroform was secretly administered to her. She admitted having 
 been addicted for years to alcohol in excess ; showed great defect of memory, 
 witii much blunting of intellect and emotions. Was industrious in habits, but 
 heavy and sluggish in manner, and of vacant expression. Recovered four months 
 after admission. 
 
 Remaining at home for nineteen months, she managed to perform her household 
 duties fairly, and though never quite well, was orderly and manageable. Gradually, 
 she developed delusions of the former type — suspicion of intended harm and 
 attempts to chloroform her, basing these on tremulous conditions of her limbs, and 
 apparently also on certain anomalous subjective sensations, perhaps hallucinatory'. 
 
Till'; CLIMACTERIC AND SENILE EPOCHS. 211 
 
 There was some pro^'rc.ss^vo dementia and slu^gisliness of intellectual operations, 
 with emotional dulness and, especially, defect of memory. Xevcrtheless, in two 
 months' time she improved sufficiently to justify her discharge. Her recovery 
 only lasted a couple of months, though she abstained from alcohol ; she developed 
 restlessness, insomnia, melancholic fear.s, and delusions. When re-admitted for 
 the fourth time, she was anxious and apprehensive, but not burdened with sus- 
 picion to the same e.Ktent as before ; complained of confused feeling in her head, 
 was inappreciative and highly forgetful. From that time forth she was often 
 restless and unsettled, fancying that her relatives were about the building, 
 experiencing both aural hallucinations and visual illusions, and showing much 
 mental enfeeblement and ever-increasing failure of memory. There was much 
 pallor of the face, the skin assumed a parchment-like aspect, and the larger 
 vessels began to evidence atheromatous change. In this state she still remains an 
 inmate of the asylum. 
 
 The instances of recurrent insanity, recorded in eighty women, 
 took their origin at the follovving respective ages : — 
 
 Up to 23 yrs.— 30 yrs.— 10 yrs.— 50 yrs.— GO yrs.— 70 yrs. Doubtful. Total. 
 Number of recurrent cases 
 
 occurring, ... 2 10 15 25 24 2 2 SO 
 
 Number in which first at- 
 taclc occurred at each 
 period, .... 11 22 17 15 3 ... 12 80 
 
 From this table we glean the fact that although the largest pro- 
 portion of cases of recurrent insanity admitted are from forty to sixty 
 years of age, yet the greater number of recurrents date their first 
 attack from twenty to thirty years of age ; and that nearly the same 
 proportion of first attacks occur from thirty to fifty years, as for all 
 periods below thirty. The large accumulation of cases, therefore, 
 which appears from forty to sixty years of age, is due not to the 
 greater tendency to the origination of this form of insanity at this 
 epoch of life — in fact, we see the tendency decline towards fifty — but 
 to the addition of patients who have already had attacks in earlier life. 
 Hence, we must conclude that this epoch of life has no special 
 influence in originating this form of insanity ; but that it is especially 
 prone to excite its recurrence in those who have already sufi"ered 
 therefrom. 
 
 Recurrence at the Senile Epoch. — The same reasoning applies 
 to the later epoch of senility. Reverting to the same table, it is 
 evident that although as many as twenty-four cases of recui-rent 
 insanity were admitted between the ages of fifty and sixty years, the 
 great bulk were but relics of former storms, since three out of the 
 number only appear to have had their first attack of insanity in this, 
 the sixth decade of life. 
 
 J. S., aged sixty, married; admitted April, 1S74. Patient belonged to a highly 
 neurotic stock. Her mother and sister were both iusauc; her brother cut his 
 
212 PERSISTENT MENTAL INSTABILITY. 
 
 throat; ami, at a subsequent period, her sister's son, hecominc; the subject of 
 impulsive insanity, murdered liis mother in tlie most Ijrutal manner, kicking; her 
 to death, and causing the most terrible mutilations of her head and body. Her 
 symptoms had shown a long ])rcmonitory stage ; but four months prior to admis- 
 sion, she was restless, garrulous, betrayed alternations of despondency and excit- 
 ability, with suspicious tendencies. When she came under observation, she was 
 low-spirited, possessed of ill-defined apprehensions of evil, and betrayed painful 
 emotion over trivialities, totally inadetjuate to jirovoke such distress in a normal 
 state. She had a sharp, weazened aspect, with dark piercing; eyes; was emaciated 
 and shrunken. A decided liypochondriacal element was indicated by the promin- 
 ence assigned to imaginary ailments and a craving for sympathy. She would talk 
 for hours about her ailments, and was most importunate upon such subjects at all 
 times. Incessantly restless, she, at times, proved most im])ulsive; her uncon- 
 trollable feelings being embodied by her in an imaginary ailment, " itch in the 
 blood," to which she declared she was subject. At her worst moments, she would 
 fly passionately at other patients without any provocation, endeavouring to inflict 
 injury upon them, and subsequently, evince a hypocritical penitence, and queru- 
 lously dwell upon her ailments ; at other times, her impulsiveness tended to 
 suicidal acts. Being discharged, "relieved," to her husband's care, she subse- 
 quently relapsed, and then attempted hanging herself in a wardrobe ; but, being 
 detected, rushed to the window with intent to leap from it. She was readmitted, 
 and remained at the asylum fretful, self-engrossed, importunate, and impulsive in 
 conduct to her death at the age of seventy-two. 
 
 All our evidence, therefore, points to the late adoleSCent and 
 early adult life as the period peculiarly prone to this form of 
 nervous disease; nor need we be surprised at the fact, for at this 
 period we meet with important revolutionary changes in the economy, 
 the tendency to the fostering of morbid excitement, and alcoholic 
 indulgence : at a period when in the struggle for existence the demands 
 for a more refined, delicate, and complex adaptation are imperativel}' 
 made upon the organism, and tell with especial effect, therefore, on 
 the central co-ordinating nervous system. Given these as the in- 
 fluences operating in the development of the parental form, the law 
 of "limitation by ag'e" will apply as explanatory of its reappearance 
 at the same period in the offspring. 
 
 Recurrence in Puerperal Cases. — A certain proportion of 
 
 women betray a tendency to maniacal perversions upon the accom- 
 plishment of each parturition, or during the early days of each 
 puerperum. These are subjects whose heritage is probably identical 
 with those already considered. In no particular does the seizure 
 differ from what we know of ordinary puerperal mania, other than in 
 this simple tendency to recur. 
 
 M. B., aged twenty-eight, married ; admitted February, 1S79. History of pater- 
 nal intemperance — a sister melancholic, but did not require asylum treatment. The 
 patient, after her fourth confinement, a severe one, in 1876, developed symptoms of 
 insanity, and was removed to Wadsley, where she was retained about two months. 
 
PUERPERAL AND TRAUMATIC CASES. 213 
 
 Four months prior to her admission at Wakefield, her fifth confinement occurred, 
 after which she became depressed, distrustful of her husband, and manifested 
 distaste towards her infant; finally, threatened to commit suicide and cut the 
 throats of her husband and family. When received into the asylum, she was con- 
 valescing from mania and rapidly became quiet, industrious, and fairly cheerful. 
 There was neither continuance of, nor return to, the homicidal tendency ; she 
 was sent out recovered in less than two months. The interval between the pre- 
 ceding and the following attack was five years, during which time patient had 
 two children ; the last labour being followed by post-parlum haemorrhage and, 
 more remotely, by profuse menstruation. It appeared that she soon showed 
 mental aberration after her discharge, developing suspicious ideas about her neigh- 
 bours, and fancying that they jeered at her and called her names, and it was 
 stated that she attempted to cut her child's throat. On re-admission, there was 
 much intellectual and emotional torpor, gloom and apprehensiveness of evil, and 
 for some time much querulous and fretful behaviour, anxiety, and hypochondriacal 
 fancies, which, at times, were exaggerated into actual delusions of suspicion ; 
 after a period of four months she gradually became more cheerful and composed, 
 and one month later was fitted for discharge. 
 
 Recurrence in Traumatic Cases.— It is a fact of no small 
 
 import, that 20 per cent, of the male recurrents had suffered from 
 cranial injury, usually due to falls from a height \ipon the head, or 
 to a violent blow causing teraporaiy unconsciousness. The injury in 
 no case amounted to fracture, or depression of bone, but was probably 
 confined to molecular disturbance and nutritive anomalies thereby 
 established. The following case is an instance of insanity engendered 
 in an individual of the criminal type, wherein cranial injury and 
 alcohol were important factors in the causation : — 
 
 B. L., aged twenty-seven, married, hawker; transferred from gaol, December, 
 1883. The only information as to the family history of this patient was obtainable 
 from the latter herself, who stated that her father had been an excessive drinker, 
 and her sister an inmate of the W. R. Asylum. 
 
 She was committed to twelve months' hard labour for assaulting and wounding 
 a woman whom she believed to cohabit with her husband. This belief, as well as 
 the alleged cruelty towards her of the latter, appeared to be actual facts, which, 
 added to long and excessive indulgence in alcoholic stimulants, had produced her 
 l)resent mental disorder. Her forehead was deeply scarred, as the result of 
 injuries received by a fall upon the head some years previously. 
 
 Whilst in prison, the patient behaved with great violence to her fellow- 
 prisoners and the warders, and, on one occasion, made a desperate attempt at 
 suicide, being discovered in her cell, black in the face from strangulation, eft'ected 
 by a piece of cord tied round the neck. During this time, also, she maintained an 
 obstinate silence. She spoke on removal to the asylum, explaining that God had 
 enjoined her to be dumb while she was in hell— /.e., prison. At first abstracted 
 and suspicious, exhibiting many purposeless tricks of gesture and countenance, she 
 quickly became an active and industrious inmate, showing, however, some irra- 
 tionality, together with considerable want of control. Although no delusions of 
 suspicion regarding those surrounding her were manifest, yet the low type of her 
 
214 • PKHSISTKNT MKNTAF. INSTAI5IMTY. 
 
 ■a]H)carance received coiifiimation in occasioual outbursts of violence, witliout 
 adequate cause, and at all times characterised by the utmost Ijrutality. Her 
 behaviour, however, not deserving of the license of insanity, siie was, after a resi- 
 dence of three months, sent Ijack to gaol. 
 
 In less tlian two months she had another outbreak, and became most violent, 
 abusive, and foul-mouthed ; procuring a medicine bottle belonging to another 
 prisoner she, with the intention of suicide, drank half its contents before she 
 could be prevented. She was, on her return to the asylum, most maniacal, 
 aggressive, obscene, and apparently the subject of hallucinations. In this state 
 she remained for nearly a week, when she commenced gradually to improve, 
 and ultimately settled down into a quiet affable patient of industrious habits, witii 
 the exception of two or three passionate outbursts of short duration. Apart from 
 actual insanity, nevertheless, she could only be regarded as of low and degraded 
 nature. Discharged within a month of the expiration of her sentence, " relieved." 
 Since her discharge she has frequently figured in the police courts; has been 
 several times in prison, and, during her imprisonment, her conduct has been 
 characterised by the utmost brutality, ferocious violence, and vindictiveness. 
 
 Frequency of Morbid Impulse.— ^ome 31 per cent, of tlie 13G 
 
 instances of i-ecurrent insanity manifested suicidal tendencies, Ijotli 
 sexes being about equally subject to sucli promptings. The melancholic 
 forms, and the maniacal outbursts associated with depressing delusions, 
 were especially prone to such impulses; thus, six cases alone show 
 this tendency in women below the age of forty years, all the remaining 
 suicidal cases being at the climacteric period. 
 
 In the male, on the other hand, this morbid tendency comes out 
 strongly in the younger members; but in all these instances the form 
 of insanity was that characteristic of alcoholic and masturbatic 
 excesses, and delusions of persecution prevailed in each. Even in tlie 
 few cases occurring below forty years of age in the female, the self- 
 destructive impulse appeared based upon congenital instability or 
 alcoholic indulgence. 
 
 Dangerous aggressive conduct prevailed in over 52 per cent, of 
 female recurrents, and in 64 per cent, of the males, or an average for 
 both sexes of 57 per cent. 
 
 Hence, recui-rent insanity embraces a very high ])roportion of in- 
 dividuals dangerous to others — a fact exi)hiined, in like manner, by 
 the large number addicted to vicious habits of life, and especially 
 alcoholic excess. With respect to this morbid impulsiveness, Dr. 
 Sankey, reaffirming witli M. Morel its i-csemblance to epilepsy, 
 writes : — " There is the same periodicity in the cases, the same im- 
 pulsiveness, and the same ignorance or blindness of their own 
 position ; and though the acts of violence are not attended witli 
 any unconsciousness, yet they seem scarcely voluntary." * Amongst 
 
 * Op. ci(., p. 175. 
 
THE CRIMINAL INSANE : HALLUCINATIONS AND DELUSIONS. '■ 21~} 
 
 this class are comprised many of the criminal community of low 
 mental type, often associated witli a degraded physical conformation. 
 These patients are almost all confirmed drunkards ; spend the greater 
 part of their life between the prison and the asylum; and, in the 
 former, often sham insanity with the object of attaining tlieir removal 
 to an asylum. Here, if not repressed, they would become the tyrants 
 of the community amongst whom they live ; and, in their maniacal 
 attacks, are most dangerously impulsive, reckless of life or limb ; their 
 conduct often i^rompted by the utmost brutality and the most vicious 
 instincts. Beyond the trouble given by the criminal class in an institu- 
 tion where severe repressive measures are to be discouraged, they form 
 a scourge to the younger and more respectable class of patients whose 
 malady is their misfortune, and whose former associations were far 
 different. This social evil is a blot upon our legislature that loudly 
 calls for redress. 
 
 Hallucinations and Delusions.— Hallucinations prevailed in 
 22-7 per cent, of the recurrent cases— the visual and aural in about 
 the same proportion, and both associated in a few cases; olfactory 
 hallucinations or illusions were seldom noted, and gustatory were 
 notably absent. Delusions occur in at least half the cases (53 per cent.) 
 Both hallucinatory and delusional states vary with the proximate 
 cause of the outbreak : if alcoholic excess enters largely into the 
 causation, we may anticipate associated ideas of self-importance, rank, 
 power, wealth, and suspicion of perfidy upon the part of those 
 around him. One patient receives a nightly visit from his satanic 
 majesty; another sees imps around him, hears voices beneath the 
 floor — the noise and rumble of machinery, which his morbid imagina- 
 tion frames into some idea of coming torture. Another patient, 
 twentj^-eight years of age, addicted to intemperance in drink, and 
 the subject of a serious cranial injury in youth, calls himself Sir 
 Eoger Tichborne, and accuses his relatives of filling his bedroom with 
 the vapour of chloroform. Another young alcoholic subject owns 
 property "to the value of thousands a year"— has extraordinary 
 muscular power, and can "walk eighty miles a day continuously." 
 Delusions of poisoning are frequent in these alcoholic cases, as are 
 also notions of being deprived of property and rights, or being pur- 
 sued by the messengers of the law. One typical case, aged thirty-eight 
 years, with a history of paternal intemperance and strong collateral 
 insanity (two sisters being insane), himself for years a heavy drinker, 
 developed, upon his third outbreak of insanity, the notion (from certain 
 subjective feelings referred to the chest) that some mysterious clock- 
 work was concealed there, which caused him much agony and deranged 
 his mind. He could scarcely be restrained from injuring himself, 
 
216 PERSISTENT MENTAL INSTADILITY. 
 
 and often begged to be operated upon witli a view to its removal. 
 He frequently bruised himself seriously over the front of the chest 
 by violent blows of the closed fist. 
 
 J. B., aged thirty-six, married, a fish-hawker, admitted August, 1S82. Has had 
 no previous attack of insanity. Eight days previously he became maniacal and 
 dangerously aggressive ; was under the constant charge of two men at the work- 
 house, whitlier he had been taken. There he attempted to leap from a window, 
 and struck his forehead with a soda-water bottle, inflicting a severe gash, with 
 suicidal intent. U])on admission he was depressed, heavy, and sluggish, yet 
 sufiBciently calm to give a clear account of himself. His height was ii feet 5 inches ; 
 his weight 124 lbs. ; he was ill nourished, with flabby muscles ; complexion sallow 
 and dirty ; several deeply-incised wounds recently inflicted were observed on fore- 
 head ; expression depressed and torpid. The tongue was not foul, no anorexia, 
 and no functional derangement of the several viscera present. Patient gave a 
 history of excessive drinking for some years past, as also of an attack of delirium 
 tremens; had been drinking quite recently, and "saw all sorts of things about 
 him." Two sisters were insane, but all other antecedents free from neuroses ; his 
 father was a heavy drinker. He admitted being jealous of his wife, whose fidelity 
 he questioned, and he had therefore deserted her and his children. During 
 the first week he remained morbidly depressed, pensive, self-absorbed, and in- 
 active ; rarely spoke, but said he was quite "beside himself" when he cut 
 his forehead; appetite good; "nasty foul objects" surround him; was gloomy. 
 A week later no further illusory or hallucinatory state prevailed ; appeared of nor- 
 mal consciousness, and was shortly afterwards employed for a time at work, and 
 discharged. 
 
 The next occasion upon which we hear of him was in December, 18S4, about two 
 years following his discharge. During the interval he had gone to America, 
 resumed his drinking habits, and was soon an inmate of the Trenton Asylum. 
 When re-admitted here, he had developed typical delusional notions; declared that 
 some clockwork machinery was within his chest — the movements were incessant, 
 caused him great suffering, and allowed him no rest ; felt impelled to commit 
 suicide. The voice of a man also was heard speaking to him from within his 
 body. He was irritable, violent, dangerously suicidal, and his language abusive 
 and blasphemous. He describes the "clock" in his chest as causing sensations 
 like "a chopping machine ;" it feels as if it would "rive his heart out:" begs to 
 have a surgical operation performed iijion his chest, that "the machinery may be 
 cut out ;" and he points to several recent bruises over the manubrium inflicted by 
 his clenched fist to relieve the anguish he feels. Believes certain men have placed 
 the " clockwork" there to make him jump and dance about whenever they choose. 
 He became much agitated and excited during this narration ; talked hurriedly and 
 incoherently. He had increased in weight ; his tongue was clean and steady ; 
 there were notwitchings of facial muscles or labial tremor ; articulation was unim- 
 paired ; pupils were normal in size and reaction ; bodily functions all well 
 performed. 
 
 For two months he continued to exhibit the symptoms above described, was 
 alwaj's excitable, s])oke in a hurried flow of words, but was coherent ; he proved 
 friendly in his di.'^position to those around him, took much interest in his domestic 
 employments, and was fairly cheerful. 
 
 Mt/i February, 1885. — A relapse occurred at this date ; the delusion became 
 
ALCOHOLIC RECURRENTS : PROGNOSIS. 217 
 
 again more prominent, and he repeatedly threatened to cut his throat. For the 
 subjective anomalies leeches were applied to the manubrium, but without result. 
 Bromide and chloral were then given with very considerable benefit ; the pain 
 gradually subsided ; his sleep was ensured at night ; and by tlie 30th of March he 
 declared himself free from any morbid sensations, had lost his delusional notions, 
 was quite rational in converse, and left the asj'lum. 
 
 In one month later he again became an inmate, suffering from his fourth attack 
 of mania-a-potu. His delusional state was similar in nature to that above noted. 
 The "clockwork" still drives him frantic; he must cut open his own chest 
 and remove it, or will "split open the chest of some ooe else ;" he will "murder 
 those who persecute him." Says he went home, worked steadily, and remained 
 quite well, abstaining from drink for two weeks, and then the terrible feehngs in 
 his chest began again, causing sharp lancinating pains, which had " the power of 
 arresting his breathing, and caused agony even to his finger-tips." He strikes 
 himself violently upon the chest in sheer despair, and is much bruised over the 
 sternum. Threatens to take his own life unless relieved by some operation ; is 
 very excitable, garrulous, circumlocutory, irate. He took liquor opii with sjiiritus 
 aitheris sulph. (aa mins. xv.) twice daily. During the first fortnight he derived 
 relief from the opiate, but continued to exhibit mild maniacal excitement ; was 
 very garrulous, easily upset, and became passionate when talking of his morbid 
 sensations. He remained very deluded, and about this time, having secured a 
 knife, he retired to a. closet, and inflicted a deep incised wound down the front of 
 the chest over the sternum ere he was detected. Chloral and bromide (aa grs. xxx. ) 
 were substituted for the opiate twice daily ; steady improvement took place — he 
 lost his painful sensations, but upon retrospect he still affirmed the reality of the 
 diabolical machinery which had been introduced into his chest. A few weeks 
 later he was finally discharged as recovered. 
 
 PPOg'nOSiS. — A large pi'oportion of the recurrent insane who enter 
 our asylums after successive attacks of insanity become chronic inmates, 
 or are discharged as partial cures only, or the disease proves fatal. 
 Considerable disparity, however, appeal's to be maintained between the 
 rate of recovery amongst the male and the female residents; the former 
 range as high as 714 per cent, of the total number, the latter 57*5 
 per cent. If we group together as " unfavourable cases " all partial 
 recoveries, deaths, and chronic remnants of the recurrent female class, 
 we find these amount to 40 out of a total of 100 cases. 
 
 We find that of the "relieved," the deaths, and the "remaining," 
 only 10 cases of the 40 wex'e under forty years of age, the melancholic 
 form which prevails beyond this age being a far less recoverable form 
 of insanity than the acute excitement of earlier life. One most 
 unfavourable aspect of recurrent insanity, therefore, is that of a 
 recurrence at the period of forty and upwards ; in fact, if we fail to 
 break through the periodicity established in our patients' morbid 
 tendencies, before this age, the outlook is very ominous — the lucid 
 intervals between their attacks become of shorter duration, and the 
 mental stability at their best moments so insecure, that in impulsive 
 forms it becomes imperative to keep them under continuous super- 
 
218 PEnSISTKNT MENTAL INSTAI5ILITV. 
 
 vision. The period of calm between the attacks is not only more 
 uncertain in its duration, but there is now betrayed a steadily 
 advancing mental enfeeblement ; and, as dementia deepens, so do the 
 attacks of excitement or depression become more frequent and more 
 prolonged ; yet, even in these advanced cases, the periodicity of the 
 disease is maintained. Dr. Blaudford cites the case of a man of more 
 than eighty years of age, who came under his observation, whose 
 first attack happened wlien lie was seventeen, and who had Vjeen 
 placed under supervision for recurrent attacks three-and-thirty times.* 
 A patient at the "West Hiding Asylum between the age of thirty-two 
 and forty-two had an attack almost every year, nine in fact ; between 
 each of which she was dischai'ged, and resumed her household duties 
 with energy and ability, manifesting no intellectual impairment or 
 emotional instability. 
 
 In another case— a mai'ried woman, addicted to heavy drinking, 
 had her first attack at the age of thirtj'-five, and from this period 
 through the whole of the climacteric, was subject to repeated attacks 
 of maniacal excitement of a wild, boisterous, and dangerous nature, 
 with obscene and most objectionable behaviour. In her case, asylum 
 supervision was required on ten occasions up to the age of sixty years ; 
 but, for several other attacks of excitement, she was treated at home 
 and recovered. 
 
 In yet another instance, a young girl of congenitally weak moral 
 control sutfered from three successive attacks, with complete lucid 
 intervals, between the ages of seventeen and nineteen ; she returned 
 home and resumed her duties in the intervals of her attacks. Three 
 further attacks occurred up to the age of twenty -four years, when her 
 mental equilibrium was so far unsteadied that she continues, up to the 
 present time (a pei'iod of two years), an inmate of our wards. During 
 this latter residence she has had repeated attacks of excitement, and 
 her periods of calm are now greatly broken by hysteric symptoms, in 
 which erotic manifestations are prominent. In her case, also, diurnal 
 calm often alternates with nocturnal restlessness, gentle excitement, 
 and garrulity. 
 
 "The disorder, once set up in the individuars constitution, is prone to recur, 
 and we must examine the whole question of the periodicity of disease, as well as 
 the conditions of the first attack, before we can hope to throw any light upon the 
 subject. This much we may conclude, that the conditions which precede the first 
 are not necessary to subsequent attacks; that as epileptic seizures may continue 
 after the ostensible cause of the first fit is removed — e.rf., worms, so the disorder 
 once recurrmg may repeat itself, persistently remaining as a vice of the constitu- 
 tion of the individual, of which it now forms a portion " {Bla7id/ord)f. 
 
 * Insanity and its Treatment, p. "1. + Oj). cit., p. 72. 
 
PROGNOSIS IN HIX'UimENT INSANITV. *2l9 
 
 "Witli this statement of Dr. Blaiidfoi'd we fully agi-oe, so long as it 
 is inulerstood that the conditions of the first attack, to whicli he. 
 alludes, are environincj, and not organised, conditions ; for it is all- 
 important to bear in mind that a very large proportion of the cases 
 exhibit a powerful hereditary predisposition to insanity, and that we 
 always ftiil to elicit to the full extent from the most careful enquiries 
 the magnitude and importance of inherited neurotic conditions. Yet 
 out of the 136 persons who were subject to recurrent seizures, permitting 
 them to return to their homes in the intervals of their attacks, we 
 found very definite and undoubted evidence of inherited insanity, of 
 other neuroses, or a history of parental intemperance, or of severe 
 cranial injury in seventy individuals (51-4 per cent.) If, therefore, in 
 one-half tYie cases such powerful predisposing factors be found, any one 
 familiar with statistical research in this direction will add a wide 
 margin for similar agencies in other cases not divulged, too remote for 
 detection, or in patients whose antecedents are utterly unknown, as so 
 often occurs in the class with which we deal at large pauper institu- 
 tions. If we now group together promiscuously all the recurrent 
 individuals of our past ten years' expei'ience at the West Riding 
 Asylum, we may construct from their histories a chart of recoveries, 
 such as is given on Plate 6". 
 
 A steady increase occurs in the number of recoveries up to the sixth 
 month, when a climax is reached — fifty -four of the total 105 cases of 
 recovery (or 167 total cases under treatment) having been discharged. 
 One-half the recoverable cases, therefore, are well by the sixth month ; 
 a notable fall occurs between the seventh and eighth months, with 
 a slight rise of seven cases at the ninth month, again to decline to the 
 level of one or two cases monthly until the thirteenth month, after 
 which the recoveries are few and distant— (?.(/., one at twenty months, 
 one at two years, and one at six years. 
 
 The recovery line for the men diflTers from that of the women in 
 attaining the climax two months later ; the largest proportion of cures 
 for female recurrents (seventeen) ta,king place during the fourth month 
 of their attack, and steadily declining to the seventh ; whilst the 
 maximum of male recoveries (twenty -six) occui's at the sixth month, 
 dropping suddenly to one case for the seventh and eighth months. Of 
 the females, whose recovery was protracted beyond the ninth month, 
 all without exception were above forty years of age, had suffered from 
 several previous attacks, or were subjects of congenital mental defect. 
 
 Treatment. — When considering the etiology of recurrent forms of 
 insanity, we emphasised the hereditariness of the affection, and the 
 unstable, defective, mental organisation of the subject. We regard the 
 indulgence in alcoholic stimulants as having, perhaps, a more fatal effect 
 
220 PERSISTENT MENTAL INSTABILITY. 
 
 upon the subjects of this, than of those of any other form of insanity. 
 Alcoholic treiitment here is decidedly most pernicious. In fact, all 
 forms of the explosive neuroses do better without any alcohol — even 
 when their disease does not appear to have been engendered by undue 
 indulgence in stimulants. We often tind that the subject craves for 
 alcohol, and also for all sorts of mental excitation ; but these must be 
 withheld wherever they tend to induce the least emotional instability. 
 Our sheet-anchor in the treatment of these affections is much outdoor 
 exercise, with active manual employment for both sexes, long walks, 
 cheerful society, and avoidance of association with the more excitable 
 chronic lunatics. With this there should be given a liberal, whole- 
 some dietary. By some authorities it has been considered well to 
 limit the meat-diet, and to add largely to the farinaceous and vege- 
 table constituents of the food — a suggestion which applies also to the 
 epileptic and other convulsive neuroses. We do not ourselves regard 
 the question of the advisability of a farinaceous diet as conclusively 
 proved in the case of the convulsive neuroses ; the most important 
 attempt to practically test the question in epilepsy, was recorded by 
 Dr. Merson, in the " West Riding Asylum Medical Repoi'ts for 1875," 
 the result being in the main favourable to this dietary, but based upon 
 too limited a number of instances to warrant final acceptance. 
 
 Bromide of potassium, in combination with Indian hemp (30 grains 
 of the former to a fluid drachm of the tincture), is the best remedy for 
 the states of acute excitement. The patient's appetite is never pre- 
 judicially aflfected by it. In most cases of this class they take food 
 more readily with, than without, this treatment. 
 
 The exaltation of the sexual instincts, which so often characterises 
 these recurrent seizures, renders iron and the compound phosphates inad- 
 missible in many cases. In most adolescents the recurrent attacks are 
 best met by bromides alone, careful attention to the bowels, regular 
 exercise, the spinal douche, followed by friction of the surface; and, if 
 there be much insomnia, an occasional chloral draught. 
 
 The phosphatic preparations, with cod-liver oil, may, however, be 
 given with benefit in the recurrent attacks of melancholia incident to 
 the climacteric, and the bromide of potassium, in combination with the 
 perchloride of iron is often advantageously ])rescribed. 
 

Chart A 
 
 
 
 CH 
 
 INSAN 
 
 ART of RECOVERIES, 
 
 ITY AT THE CLIMACTERIC. 
 
 Number of 7 
 
 
 
 Cases 
 
 
 
 
 
 
 \\ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 l\ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j\ 
 
 7 
 
 
 
 A 
 
 / 
 
 / \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 v. 
 
 
 Duration pr Attack 
 
 4» 
 
 6,v. 
 
 2m. 
 
 5 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 II 
 
 12 
 
 ij 
 
 1+ 
 
 15 
 
 16 
 
 19 
 
 20 
 
 2y 4y 
 
 ,, , r CHART |of RECOVERIES in RECURRENT FORMS of INSANITY. (167 Cases.) 
 
 Cases, 10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 % 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A 
 
 \ 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 /\ 
 
 
 
 
 
 
 / 
 
 
 \ 
 
 J 
 
 
 
 
 
 A 
 
 
 
 
 
 /\ 
 
 v' 
 
 
 \ 
 
 
 
 
 
 '/ 
 
 
 
 
 
 
 
 / 
 
 
 V 
 
 X 
 
 
 '"{ 
 
 
 
 \ 
 
 n\ 
 
 /■^ 
 
 \ 
 
 
 ■'" 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 \ 
 
 
 
 
 
 Duration of Attack 
 up to 
 
 ,... 
 
 6.1 
 
 2« 
 
 i 
 
 4 
 
 5 
 
 e 
 
 7 
 
 8 
 
 9 
 
 10 
 
 II 
 
 12 
 
 15 
 
 14- 
 
 15 
 
 18 
 
 2/ 
 
 3/ 
 
 5/ 
 
 Note- Black J.inc MALE Jtecitmnbi 67 Caa, 
 FEMALE . 700 . 
 
 ANALYSIS OF RESULTS. 
 
 Recovered RelievetJ Died Chronic 
 Male 4-6 1+3 4. 
 
 Female 5 9 15 8 18 
 
221 
 
 EPILEPTIC INSANITY. 
 
 Contents: — Pefiiiition — Eiiileiitic Neurosis — Immediate and Eemote Kesults of 
 Epileptic Discharge — Diffusiou-curreuts -- Nascent Nerve-tracts — iJiscliarKc 
 from Sensory Areas— The Aura in Sensory Epilepsies— Epileptic Amaurosis, 
 Hemianopsia and Hemiansesthesia— Ciiaiiii)ing Movements— Pre-paroxysmal 
 Stage— Premonitory Sta^e — Special Sense Aurae-Vaso motor and Visceral 
 Aur:e— The Epileptic Paroxysm — Grand and Petit Mai— Post-jiaroxysmal 
 Period— Post-epileptic Automatism — Case of E. C— Status Epilepticus- Inter- 
 paroxysmal Stage— Epileptic Hypochondriasis, Automatism and Impulsiveness 
 — Medico-legal Relationships — Impulse— Delusion --Malingering— Peg. v. Taylor 
 —Treatment of Epileptic Insanity. 
 By epileptic insanity we mean that form of mental derangement 
 in the antecedent history, oncome, and further deveh:)pment of which 
 we recognise an intimate connection with the epileptic neurosis. Such 
 functional disturbances of the nervous mechanism as issue in what are 
 termed epilepsies may, or may not, have for their accompaniment 
 serious mental derangement. Epileptic fits may continue for years 
 with slight, or scarcely appreciable, mental disturbance. If, however, 
 the epileptic neurosis presents on the psychical side a parallel disorder 
 of mind, we speak of -it as epileptic insanity. Epilepsies may develop 
 during the course of other cerebral diseases associated with insanity as 
 pure accidents, or as an intercurrent affection, in chronic disorganisa- 
 tion of the brain, in softening from embolism or thrombosis, in senile 
 atrophy and decay, during the progress of general paralysis of the 
 insane, or in certain cases of chronic insanity, the epilepsy then being 
 merely an accidental complication of the primary affection, and depen- 
 dent, probably, in part upon the direction taken by the disease. Nor 
 can it be questioned that epilepsy may arise as an independent and 
 intercurrent disturbance in subjects mentally afilicted, having no direct 
 connection with the primary cerebral derangement, and it becomes 
 therefore imperative that we learn to recognise such morbid linea- 
 ments, so to speak, in the mental affection as indicate its kinship to 
 
 an epileptic neurosis. 
 
 The niental derangement of the epileptic may assume the form of 
 maniacal excitement, of melancholic depression, of mental enfeeble- 
 ment or dementia, or of delusional perversion or perversions of the 
 moral being ; any one or more of these states may be revealed by the 
 patient. As in all cases of insanity alike, so epileptic insanity notably 
 presents periods of heightened functional commotion, with intervals of 
 comparative calm, periods of sudden and excessive, though transient, 
 dissolutions, and the persistent impairment due to a consta,ntly 
 advancing, though gradual, dissolution. 
 
 The immediate results of an epileptic discharge are seen in the deep 
 reductions of epileptic mania — a transient condition only; the ultimate 
 results of repeated attacks in the gradual and persistent impairment of 
 
009 
 
 KPILEPTIC INSANITY. 
 
 tlie mental faculties seen in epileptic dementia. Hence, in studying 
 epileptic insanity, -sve have to consider the acute symptoms or 
 immediate after-etlects of a tit, as well as the chronic impairment 
 presented during the intervening periods between the attacks. It is 
 not, as before stated, everrj form of epilepsy which is prone to issue in 
 mental derangement, if by epilepsy we mean what Dr. Hughlings- 
 Jackson means; that is — "A sudden, rapid, excessive, occasional, and 
 local discharge of cerebral cortex." * 
 
 It is when the functional disturbance occurs in the highest nervous 
 arrangements of the cerebral cortex ("the substrata of conscious- 
 ness ") that the mind is prone to suffer. An all-important principle 
 which the same authority has taught us to recognise is that, in 
 these epileptic seizures, there is a brutal expenditure of force wholly 
 (jut of proportion to the normal physiological outlay, and wholly 
 inconsistent with continued healthy activity of the parts concerned. 
 So severe is the explosive violence, that the nervous tracts traversed 
 by the storm are so damaged as to be rendered transiently incapacitated 
 for the further conduction of the nerve current, and the centre itself 
 is paralysed for the time by its enormous expenditure of energy. 
 
 If we attend carefully to this fact, it will be apparent to us that the 
 transient paralysis of the motor centres and ner^•es is not the only or 
 most important sequel of the seizure. We are aware that every vivid 
 mental rehearsal initiatory of an act (especially when the action is 
 itself suppressed) is attended by diffusion currents, which, according 
 to the physiological law of least resistance, affect first the smallest mus- 
 culature, e.g., the eyeball and facial muscles; and even when these results 
 are not apparent, expend themselves along intra-cerebral tracts, arous- 
 ing sensory excitations and correlated feelings. Just as the substrata 
 of these representative states affect cortical realms other than those in 
 which the primary excitation arises, so likewise, during the accom- 
 plishment of every volition, the act is accompanied by so-called 
 associated actions {e.g., the associated contraction of pupil and conver- 
 gence of eyeball), and this series of associated movements is a very 
 large one in the active manifestations of the organism. But this is not 
 all. We know that both the initiatory energising of the cortex and 
 its eventual actualisation are attended by numerous complex feelings, 
 such as a memory of similar acts previously performed, of their results, 
 and of the notion of the utility of the act to the " individual's" welfare. 
 All this means, of course, diffusion currents around the primary 
 discharging centre. 
 
 If, then, all energising and discharging of motor centres be accom- 
 panied by such effects in related c<entres, how much greater will be the 
 *See West Iiidiug As>/him Heports, vol. iii., p. 331. 
 
EFFECTS OF DIFFUSED CURRENTS. 223 ' 
 
 effect when the motor areas are overfloocled by the brutal explosiveness 
 of epileptic discharges. We shall then have not only the paralysis of 
 the conducting tracts, but also a dangerous flooding of those delicate, 
 yet indefinitely extended, tracts of intra-cortical nerve-tissue, upon 
 which the very evolution of the nervous structure depends. If we 
 place any credence whatsoever in the theory of nerve-genesis so 
 elaborately worked out by Herbert Spencer, we must regard this 
 undue foPCing" of nascent nerve-tracts, as yet incomplete in their 
 formation, as a most serious matter in epilepsy. 
 
 It is important to observe that any one part of the cerebral cortex 
 may be the site of an epileptic discharge ; and hence, the resultant 
 phenomena will be co-extensive with the multiplicity of cerebral 
 functions, and as varied in their nature as tliey are varied. Discharges 
 in motor realms will thus afford endlessly diversified combinations and 
 sequences of spasms, whilst discharges from sensory realms will like- 
 wise implicate correspondingly complex centres. The former are open 
 to objective study ; the latter, as being purely subjective, can only be 
 gleaned by information given us by the patient. Again, local dis- 
 charges initiated in motor realms may spread to other motor areas, or, 
 from being of hemispheric origin, may become bilateral in their 
 distribution, oi', spreading backwards into sensory realms and the 
 highest and most complex of centres, issue in loss of consciousness. 
 As regards this implication of consciousness, "all depends on the 
 momentum of the discharge, and, therefore, on how far it spreads " 
 {II iighlings- Jackson).* In like manner may arise pure sensory epilejD- 
 sies, with, or without, loss of consciousness in the full acceptation of 
 the phrase; or a j)rimary sensory epilepsy may spread into more purely 
 motor realms, and issue in general convulsion, the discharge, as it were, 
 being reflected on to the motor sphere. We thus see how infinitely 
 varied may be the resultant of epileptic discharge from any unstable 
 area of cortex. In unilaterally commencing convulsions, viz., those 
 due to local discharges in one hemisphere, we can usually trace the 
 spread of the discharge with facility ; this is, however, not the case 
 with the epileptic seizures associated with insanity. Here we more 
 frequently observe attacks of petit mal, or else that form of g'rand 
 mal, in which the loss of consciousness is early and comjjlete, and the 
 spread of the dischai'ge so rapidly general that the whole body is 
 almost simultaneously affected by the convulsion. This rapid run- 
 down of mechanism, comparable to the rupture of the mainsj^ring of 
 a watch, renders it impossible in most cases to distinguish any sequence, 
 in the resulting spasms. It is truly a universal spasm, ov, to use Dr. 
 Hughlings-Jackson's vigorous phi^ase, " a clotted mass of movements." 
 
 * Loc. ell., p. 2GS. 
 
224 EPILEPTIC INSANITY. 
 
 In like manner consciousness is then lost at so early a period, and this 
 so suddenly that the patient falls instantly, as though struck senseless 
 by a blow. 
 
 The discharge from seiisori/ areas cannot, from the very nature of 
 the case, be followed ; we can only learn the existence of an aura 
 by the subsequent statements of the jjatient ; but — impressed only by 
 the results of the motor discharges — we must not lose sight of tlie fact, 
 tliat equally powerful discharges, of whicli we see no result, may pass 
 along sensory areas at the jieriod when consciousness is abolished. 
 Undoubtedly the muscular spasms ai-e likely to attract to themselves 
 undue attention on the student's jiart ; and he forgets for the time 
 that still more noxious effects ai'e being produced in the areas of 
 mental and sensorial activity silently and concealed from his view. 
 It is, thei'efore, all the more important that one should keep these 
 unseen results in mind, and watch carefully for such evidence as may 
 arise of the implication of the sensory portion of the brain, for such 
 evidence is forthcoming at certain stages of the affection. 
 
 It is very obvious that amongst a large number of epileptics in our 
 asylums who suffer from mental dei'angement, there is very great 
 divergence in the history and progress of their affection — the pheno- 
 mena of their disease by no means pi'esent a dead uniform level. 
 Some remain inmates for very many years with the intellect but 
 little impaired, and then only at those periods when they become 
 subjects of epileptic seizures ; others (with few, if any, convulsive 
 attacks) betray at long intervals periods of depression, of moroseness, 
 or of excitement, during which they are more or less irresponsible 
 for their actions ; yet, in the interim, they ai-e perfectly rational, 
 cheerful, amiable, considerate for others, and obliging. In others 
 again, the mind becomes rapidly enfeebled ; and during the period 
 of their "fits" the reductions are so profound that absolute dementia 
 and stupor, or perhaps wild ungovernable fury, prevail. And, yet 
 again, with but little essential difference in the motor disturbance 
 of two cases, the wreck of mind in the one may stand out in strange 
 contrast with the clearness of intellect in the other. The resulting 
 dementia therefore (so-called "effects of the fits") varies very con- 
 siderably in degree, so that each individual case may be unlike the 
 others in this respect; and this is undoubtedly dependent upon the 
 varying seat of the primary discharge from the cortex. To quote 
 Dr. Hughlings-Jackson — " From this it follows that there is, scientifi- 
 cally sjjeaking, no entity to be called epilepsy ; but innumerable 
 different epilej^sies as there are innumerable seats of discharging 
 lesions. And as the first symptoms in the paroxysm is the first effect 
 of the discharge of the centre unstable, any two paroxysms beginning 
 
SENSORY EPILEPSIES. 225 
 
 differently will differ throughout, liowever little."* From all this it 
 becomes sufficiently obvious that we must not rest satisfied with a 
 mere observation of tlio motor discharge exemplified by the convulsive 
 seizure ; but, we must likewise question our patient closely upon his 
 sensations and mental disturbance immediately preceding the loss of 
 consciousness, and observe closely his condition as presented after the 
 paroxysm and up to the full re-establishment of conscious activity. 
 
 What are some of these indications of discharges in sensory realms ? 
 A patient at the West Riding Asylum after each severe attack of fits 
 becomes completely blind, and gx'opes about on hands and knees — 
 epileptic amaurosis is, however, an infrequent effect of this disease. 
 
 Another epileptic becomes hemianoesthetic on the left side of the 
 body after certain convulsive seizures ; and this anaesthesia is 
 attended with a corresponding state of the retinal fields ; there is left 
 homonymous hemianopsia, associated also with impairment of the 
 other special senses of the same side. Indications of discharges in 
 sensory realms are afforded during this stage of re-energising, by the 
 champing movements of the jaws, with corresponding movements of 
 the tongue, probably indicative, as has been stated by Terrier, of dis- 
 charges from the centre for taste, the movements being thus reflexly 
 induced. The rubbing of the hands together — the attention of the 
 patient evidently being attracted thereto — probably means that morbid 
 sensations are referred to those parts, A very frequent action amongst 
 such patients is the rubbing of the open hand iipon the knees, or the 
 slapping of their thighs with the palm of the hand. We must, however, 
 be careful to avoid arriving prematurely at a decision, that this is due 
 to discharges in sensory realms, initiating the movement ; it certainly 
 may be due to a more complex mental state. Thus one intelligent 
 patient explained this action, of which he seemed conscious, by saying, 
 that he did it because he thought he could " bring himself by this 
 means more rapidly out of the fit." Discharges from the substrata of 
 visual sensori-motor areas of the cortex will often be indicated in 
 fantastic movements of the hands, as though the patient were dis- 
 entangling imaginary skeins of thread in the air. Other subjects, 
 and these are by no means infrequent, appear to be following 
 imaginary objects on the floor, or peer in some one direction; or again 
 scrutinise with incessant vigilance the floor and furniture around 
 them, as though searching for some lost object. With all this there 
 may be considerable motor automatism ; the subject may climb upon 
 tables or the window-sills still seai'ching apparently for some object; 
 or he may remove his coat, turn out the contents of his pocket, &c. 
 One of our patients invariably after his fit empties his pockets on the 
 
 * Loc. ciL, p. 270. 
 
 15 
 
226 EPILEPTIC IN'SAXITV. 
 
 table, secures his \n\)o, and placing it (althougli empty) in liis moutli, 
 marches to and fro witli a self-satisfied look and contented mien. 
 
 All cases of epileptic insanity should be rigidly studied with a view 
 to (1) eliciting the condition of mind immediately preceding an attack ; 
 (2) the essential features of the epileptic seizures; (3) the subsequent 
 period of reinstatement of consciousness ; (4) and lastly, the mental 
 state prevailing in the period intervening between the " fits." We, 
 therefoi'e, divide our remarks under the headings of — Firstly, the 
 preparoxysmal stage; secondly, a premonitory stage (often absent); 
 thirdly, the paroxysmal stage ; fourthly, a post-paroxysmal stage ; 
 fifthly, the interparoxysmal period. 
 
 1. The Preparoxysmal Stag"e. — The epileptic insane are especially 
 prone to exhibit indications of an approaching seizure ; nor is this 
 surprising, when we recall how slight departures from the normal 
 state of healthy cerebral nutrition, betray themselves in all our sub- 
 jective feelings and moods. The grave nutritional anomalies upon 
 which an explosive neurosis depends, might well be expected to declare 
 its advent thus — subject, of course, to the special site of nutritional 
 derangement. A change in character is thus frequently recognised 
 during a period of hours or even days antecedent to a seizure. An 
 able and intelligent attendant will so study his cases, that he at once 
 detects the little minor changes in the patient's disposition, indulges 
 his whims, endeavours to sooth his morbid irritability, and especially 
 guards the subject at this period from unnecessary annoyances. Thus, 
 we frequently hear excuse made for some patient's lapses of temper, 
 or unseemly behaviour, "Oh, he's just going to have his fits, sir, he 
 will then be all right." In asylum life, amongst the intelligent class 
 of nurses, the fact is uniA'ersally recognised that a premonitory stage 
 of great irritability is often seen, and the effect of a convulsive attack 
 will be to clear up the mental atmosphere. 
 
 The mental disturbance thus preceding the epileptic paroxysm pre- 
 sents very variable features — (1) melancholic gloom and despondency 
 may prevail; (2) hypochondi'iacal perversions, which may haA'e been 
 persistent during the[patient's interparoxysmal stage, may now become 
 exaggerated and intensified ; (3) restless, objectless wandering may 
 indicate the uneasy discontented mind ; and the subject may complain 
 of this unrest, of being unable to follow his usual occupation, incapable 
 of keeping his mind upon any subject long together; he cannot read; 
 his sleep fails him ; he becomes indifferent to his meals and inattentive 
 to his wants generally ; (4) a vague dread of impending evil is occa- 
 sionally expressed ; but this] is moi'e frequent as a genuine aui'a — a 
 psychical state, the immediate accompaniment of the commencing 
 epileptic discharge ; ^(5) joyous elation may precede an attack, a 
 
Tirn; aura epilkptica. 227 
 
 goiionil slatn of optimism l)o pi'csont, often associated, liowevei", with 
 gross egoistical sentiments; (6) confusion of ideas, diminislied. vigour 
 of attention and memory are also peculiar to this stage ; this is 
 the first symptom, for instance, betrayed by an epileptic compositor 
 employed at this asylum ; with him there is also at this time a notable 
 degree of irritability and irrepressible garrulity ; (7) delusions of 
 suspicion are a pi'ominent feature before epileptic seizures in certain of 
 the insane, and may form the incitants to acts of dangerous or 
 homicidal violence. 
 
 An inmate of the West Riding Asyhim almost invariably betrays to his 
 attendant this state of mind ; he stalks up and down the wards, assumes a defiant 
 attitude and bearing to all around, keeps a vigilant eye upon each passer-by ; and 
 occasionally beckoning the attendant, reveals to him privately the existence of an 
 imaginary conspiracy to poison him. This patient wholly ignores the fact that he 
 has fits^"Oh, they say I take fits, you know" (with an incredulous smile), "but, 
 I know what ails me;" and then with a mysterioiis air — "Wliat they put m my 
 food and medicine explains everything." At times he openly accuses the doctors 
 of drugging his food and drink, and always in the stage precedlnr) convulsion. In 
 this preparoxysmal stage, depression always prevails ; the convulsive seizure 
 occurs, and as the attendant emphatically and truthfully asserts — " he is then a 
 new man." This patient also believes he can ward off the effects of the poison hj 
 drinking his own urine, which he has been detected doing on more than one 
 occasion, and with this avowed object in view. 
 
 2. PpemonitOPy Stag'e. — This is not truly a stage, but the first 
 period of the paroxysm itself; yet it is convenient to consider it 
 separately in accordance with the old notion of the phenomena, the 
 so-called warnings or aUPSB. In fact, the phenomena embraced by this 
 period, the epileptic aura, are but the subjective aspects of the nervous 
 discharges in cortical centres, the initiatoiy symptoms preceding that 
 loss of consciousness which leaves the remainder of the convulsive 
 paroxysm minus a positive mental counterpart. For it must be 
 remembered that in all these excessive discharges along highly 
 specialised sensori-motor mechanisms the subjective phases are of but 
 ti'ansient duration, only during the earliest peiiod of the attack ; the 
 objective are obtrusively present, but from the early failure of con- 
 sciousness have no mental correlate. Since, however, the epileptic 
 aura constitutes the earliest symptom of the actual discharge, when 
 correlated with the physical accompaniments of the attack, it facilitates 
 our comprehension of cerebral activity, and the parallel series of 
 psychical manifestations. To the student of psychology it is of intense 
 interest, and should be studied with the greatest care. 
 
 And, in the first place, since any of the regions of the cerebral cortex 
 (which are the anatomical substrata for all forms of conscious activity) 
 may be the site whence an epileptic discharge originates, so the 
 
228 EPILEPTIC INSANITY. 
 
 phenomena of an aura may be co-extensive witli all forms of sensation 
 whatsoever, and may even be constituted Ijy more elaborate foi-ms of 
 psycliical activity. The sensation constitutinf,' an aura is, therefore, 
 referred to any portion of the environment, includin;^ in the latter term 
 the body and its organs generally. We tlms may get aurce of — (1) the 
 special senses; (2) of the visceral or organic sensations; and (3) 
 intellectual or psychical aura?. A few remarks on these sensations will 
 render the subject clearer : — 
 
 («.) Special-Sense Aurse. — It must be remembered that in the five 
 special senses — taste, smell, touch, hearing, and sight, we have an 
 ascending scale of sensations entering more and more intimately into 
 connection with our intellectual life. TastC and smell have the 
 least intellectual element, and are specially characterised by their 
 slight recoverability in idea, i.e., in persistence or capability of being 
 recalled in the absence of the object; although both are capaljle of 
 much improveability by education {Bain). On the other hand, tOUCh 
 is a much more intellectual sense, highly discriminative as to locality, 
 and capable, in conjunction with other senses (and especially the 
 muscular sense), of giving iis ideas of the form, dimensions, and position 
 of objects in general ; its essential intellectual factor is dependent on 
 the conjoint agency of the muscular sense {Bain). Hearing" and 
 sight attain the maximum as regards intellectuality ; are highly 
 co-operative ; exquisitely discriminative in their powers ; highly 
 persistent and recoverable; as well as capable of almost unlimited 
 education. Sig"!!! is, of all the senses, pre-eminently characterised by 
 the faculty of objectivising, and in fact enters much the most largely 
 as an ingredient into the constitution of object-consciousness. On 
 the other hand, at the further end of the scale, the sense of taste and 
 of smell (and still more notably the sensations of organic life) are 
 characterised by their inherent subjectivity, or the greater difficulty 
 experienced by us in discriminating between subject and object. The 
 drift of these remai-ks will be at once apparent to the student when he 
 considers that the least discriminating and most subjective of these 
 series of sensations (the organic or visceral, and taste and smell) have 
 least connection Avith the intellectual operations of the mind ; the 
 most discriminating and most objectivising (the high or special senses) 
 have intimate connection with the intellectual operations, and that, 
 therefore, aurse, consisting of the former sensations, must be referred to 
 the implication of the substrata of the crude sensations of organic life, 
 and the emotions — those of the latter — to the substrata of the highest 
 activities of the mind, although they also enter into the emotional life 
 of the being. 
 
 Organic Sensations. — The innumerable impressions which must 
 
OR(iANIC AND SPECIAL-SENSE AUR^E. 229 
 
 arise momentarily and co-instantaneously throughout the organism 
 during the healthy activity of all its tissues, its muscles, bony frame- 
 work, viscera, and vascular appaivitus form in their aggregate what are 
 termed the sensations of org'anic life. Many of these, such as the 
 visceral and vascular, have phases of " unfelt " sensations, or, at least, 
 sensations not discriminated from the vast mass of sensations created 
 by the functional activity of the body at large, with periods of emphatic 
 expression — e.g., hunger and thirst. The " unfelt " sensations, however, 
 rise into prominence in morbid states of the system, and we then get 
 those intensified organic sensations, which cause much discomfort and 
 contrast with the normal massive feeling of hien-etre. In the epileptic, 
 likewise, we get such sensations aroused in the organic aurse ; they are 
 distinguished by the massive and all-pervading character of the 
 sensation. We may take Professor Bain's classification * as embi'acing 
 these sensations of organic life, which are thus liable to derange- 
 ment : — 
 
 Sensations arising from 
 
 (1) Muscles. (4) Organs of circulation. 
 
 (2) Bones and ligaments. (5) ,, respiration. 
 
 (3) Nerves and nerve centres. (6) ,, digestion. 
 To which we may add those of the uriuo-genitoiy apparatus. 
 
 Visual Aurce. — These occasionally precede the seizure in epileptic 
 insanity, but, as pointed out years since by Sir Crichton-Browne, 
 aurse are not of frequent occurrence amongst this class of epileptics, f 
 When they do occur, the visual aurse consist usually of crude sensa- 
 tions, balls of fire, coloured light, glittering sparks, &c.; thus G.M. sees 
 a number of sparkling stars before his eyes, all around " looks dim ; " 
 and if he holds a book in his hand, ere it falls " the letters all run into 
 one another." W.B. has a warning described as a doubling of objects 
 around him, as if by " cross sight," meaning that he supposed it 
 was due to a transient squint. E-ed and blue are the colours more 
 frequently seen in these visual aura3 {Goicers). 
 
 Auditory Warnings. — These are less frequent than the visual ; but are 
 occasionally met with in elaborate form, as in the case of E. C. Dr. 
 E-oss speaks of hissing, singing, or explosive noises ; of a noise in the 
 ears, followed by vocal utterances, in some cases of ordinary epilepsy | 
 (p. 919). Dr. Gowers speaks of a crash, a whizz, a hiss, or whistle ; or 
 on the other hand, a loss of hearing, strange stillness preceding the loss 
 of consciousness. These are rarely recognised in asylum epileptics. 
 
 * The Senses and Intellect, Alexander Bain — " Sensations of Organic Life." 
 + West Biding Asylum Medical Bepoi'ts, vol. iii., p. IGO. 
 J Quoted by Dr. Hughlings- Jackson, p. 303. 
 
:230 KPILKPTIC IXSANIXy. 
 
 Consciousness, as a rule (p. G84), is in thorn too early lost f(jr these 
 phenomena to occur. 
 
 Gustatory and Olfactory Aura. — These are the least frequent form of 
 aunu met with in epileptic insanity. In the patient J. V. the con- 
 vulsive seizures were invariably preceded by such affections of the 
 sense of taste as would justify us in regarding them as gustatory 
 aurae. The intimate connection, between the sense of taste and that of 
 smell renders the differentiation between hallucinations of these senses 
 dubious, and at times impracticable. We must carefully exclude the 
 instances of perverted sensibility which so frequently engender sense 
 illusions in the epileptic subject, giving rise to delusions of being fed 
 upon human flesh, or similar revolting notions. 
 
 Vaso-JIotor Aurce. — This form is exemplified in the case of a patient 
 whose fits are always preceded by unilateral vaso-motor disturbance — 
 marked mottling of the skin of the palm, associated with morbid sensa- 
 tions ; the patient invariably opens the hand and inspects it critically, 
 turning it over and over again, and feeling the skin with the fingers 
 of the other hand. Consciousness is then lost, and the arm so affected 
 becomes convulsed. 
 
 (b.) Visceral or Org'aniC Aurse. — These are the more prevalent 
 sensations recognised in epilepsy, as stated by Sir Crichton-Browne.* 
 The feeling is one of weight at the epigastrium, or a fulness or disten- 
 tion of this region. This feeling often rises to the throat, causing a 
 sense of great discomfort — the patient beginning to pull at his collar or 
 necktie as if to loosen it. Occasionally, the sensation creeps up to the 
 head, becoming, as one patient described it to me, " an expansion or 
 swelling of the head — an opening and a shutting." Again, the epi- 
 gastric sensation may be one of actual pain, which remains until 
 consciousness is lost. Another very frequent symptom of the onset 
 is that of a sinking or of actual j)ain in the pra^cordia, or violent 
 palpitation of the heart. A feeling, identical with the globus hystericus, 
 is also very frequently observed in epileptic insanity (Goioers). All 
 these aura?, it will be noted, are referi'ible to a centric disturbance of 
 the vagus and spinal accessory. 
 
 3. The Epileptic Paroxysm. — This paroxysm may be charac- 
 terised by the predominance of the mental or motorial implication — 
 that is, we may have transient, though complete, loss of consciousness, 
 with little or no spasm ; or the general convulsions may be the pro- 
 minent feature, accompanied by early or later loss of consciousness ; 
 and since every shade of interblending of such phenomena may occur 
 in difterent subjects, so no shai-p line of demarcation can be drawn 
 between the two extreme limits. Classically, and for convenience of 
 
 * Loc. cit. 
 
GRAND MAL — PETIT MAL. 231 
 
 description, we recognise the two forms, called respectively le grand 
 
 mal :in(l le petit mal. 
 
 («.) Grand Mal. — An aura may or may not precede, and the 
 patient, if standing, may, without any warning, stagger to a seat, or 
 fall suddenly down on the face or back, often seriously injuring him- 
 self There may be the " epileptic cry," which is very frequent 
 amongst the epileptic insane. It may consist in a subdued plaintive 
 wail, or a loud, wild scream, or a succession of piercing shrieks, as 
 though the subject were actuated by terror j at times it is a mere hoarse 
 gurgling in the throat, or a loud, prolonged groan ; all probably due 
 to the sudden forcible expulsion of air through a constricted glottis 
 during the tonic spasms. The face is now deadly pale, the pupils 
 dilate widely, and consciousness is completely lost. The convulsions 
 beginning by tonic spasm, usually cause conjugate deviation of the 
 head and eyes to one side, to which the body tends to roll ; the 
 spasm is usually more marked on one side of the body than the other ; 
 the chest is fixed, and respiration being arrested, the face becomes 
 now injected and livid— the tongue, congested and swollen, is often 
 forcibly protruded from between the teeth, the veins of the neck are 
 swollen and rigid, and intense cyanosis prevails. The position of body 
 and limbs will vary much in each individual case, depending upon the 
 origin of the centric discharge, its strength and spread to collateral 
 parts. Flexion and extension may be combined in different limbs — or 
 flexion prevail throughout — the body being drawn up into a state of 
 emprosthotonos. In the latter case the patient, if sitting or standing, 
 almost invariably falls forwards ; at other times the head is strongly 
 drawn backwards, or backwards and to one side, so that the subject is 
 twisted round in his chair as if looking over his shoulder. The tonic 
 spasm now gives way very gradually to clonic convulsions — froth 
 foams from the mouth, often tinged with blood, the tongue having been 
 caught between the teeth and bitten by closure of the jaw ; the fine 
 vibratory character of the movement becomes coarser and broken up 
 into rapid rhythmic movements, which eventually are large, inter- 
 rupted, and cease entirely after a few irregular shock-like jerks of the 
 limbs. The clonic spasms last from half a minute to two minutes, and 
 after this cessation the patient lies stupefied and breathing stertorously. 
 This, the third period of the fit, is very variable in duration, lasting 
 from a few minutes to as many hours. There is a gradual return of 
 normal breathing; sensibility and motor power are regained, and, 
 with the exception of some heaviness and a dazed feeling, the previous 
 condition of the patient may appear perfectly re-established. 
 
 (b.) Petit Mal. — In these attacks there may be nothing observed 
 beyond momentary loss of consciousness and pallor of face. The 
 
232 EPILEPTIC INSANITY. 
 
 patient may be sitting or standing during the attack ; he does not fall. 
 He may drop what he holds in liis hands, or be suddenly arrested in 
 movement, but may instantly recover liimself, and act as if notliing 
 unusual had occurred. Esquirol ^-elates the case of a lady equestrian 
 who liad frequent attacks of petit mal when on horseback, yet never 
 fell ofi'. There was momentary arrest in her conversation, the bridle 
 dropped irom her hand, but, in a few seconds, she had recovered and 
 iinislied the sentence interrupted by the attack. Very often the face, 
 subsequent to pallor, becomes flushed (Gowers). In these slight seizures 
 there may be slight facial spasm — the expression is momentarily y?a;ec^; 
 or a spasm of the hand may occur, or a more noticeable (but limited) 
 convulsion of very transient duration. 
 
 One of the premonitory aurce, before noted, with some vertigo and 
 reeling, may constitute such an attack. A patient may be subject to 
 such attacks for years without a single seizure of grand mal occurring, 
 or these two forms of epilepsy may occur indifferently, now one and 
 now another, in the same subject — or attacks oi grand onal interspersed 
 with the minor attack, may gradually predominate and eventually 
 wholly replace the j^^tit mal. Thus one of our patients at the West 
 Riding Asylum, subject to such seizures, was, while sitting up in bed 
 one morning, requested to write his reply to a question ; he wrote a 
 lengthy answer, interrupted by some four or five such attacks. There 
 was momentary loss of consciousness — the head drooped slightly, the 
 pencil slipped through his fingers, but was almost instantly regained, 
 and the sentence Avas continued without any apparent disconnection of 
 words or displacement of letters ; the interruption was so slight that, 
 if he had not been closely watched, the conditioii might readily have 
 been overlooked. In the case of this patient, a letter might \\a\e been 
 easily written by him showing no confusion of ideas, and consistent in 
 all respects, during a frequent repetition of such slight seizures as the 
 above ; and, in a medico-legal sense, this is of the utmost importance 
 to recognise. At the same time, these slight attacks of epilepsy are 
 well known to issue in the most rapid impairment of intellect — a fact 
 recognised long since by Esquirol. This is because the disease is of 
 the " very highest nervous arrangements in the whole nervous system, 
 and of those which have the greatest integration, that is to say, of the 
 substrata of consciousness " (Ilughlings-Jackson).* 
 
 4. Post-paroxysmal Period. — It is during this post-paroxysmal 
 period that much valuM))]e information may be gleaned, as the mental 
 automatism then displayed is in many cases prolonged, and affords us 
 the opportunity of careful study. Epileptic mania of transient duivt- 
 tion is a most common result of the paroxysm, but it is by no means 
 
 * Loc. at., p. 304. 
 
POST-PAROXYSMAL PERIOD. 233 
 
 .always of SO fleeting a nature. Cases occur where the maniacal 
 excitement extends over many days without any furthei- epileptic 
 seizures intervening. It apparently bears no direct relationship to 
 the severity of the attack, or to the number of epileptic seizures ; it 
 may follow slight seizures {petit mal), just as it may be the sequel to 
 the major convulsive attacks {grand mal), and a single "fit," convulsive 
 or non-convulsive, may leave the patient in this maniacal condition just 
 as frequently as a succession of such attacks. This want of connection 
 between the epileptic paroxysm and the occurrence of a maniacal 
 outburst is perhaps more apparent than real. We are apt .to lose sight 
 of the fact that the slightest seizures are just the very cases where 
 consciousness is prone to be most impaired or involved, and where a 
 seizure is most likely to be wholly overlooked by the friends or even 
 the patient himself; and thus it happens that a paralysis of the central 
 hierarchy of the nervous system may so withdraw control over lower 
 centres as to issue in wild excitement, although the epileptic seizure 
 Avas so slight as to be scarcely, if at all, appreciable to the onlooker. 
 In like manner the major discharge, if it sta,rts (as in cases of insanity 
 it most frequently does), from the highest cortical centres, may also 
 leave these parts so paralysed as to result in a post-epileptic mania. 
 One single attack may suffice for this issue ; all depends upon the site 
 of the disease being in the realms constituting the cerebral substrata 
 of consciousness, and hence the vital importance of noting whether in. 
 our cases consciousness is lost completely or only partially, and whether 
 early or later in the course of the paroxysm. 
 
 The attack of epileptic mania is usually highly characteristic in all 
 extreme cases. The excitement is most acute, attended by almost 
 ungovernable violence and frenzied fury — no maniacs show such blind, 
 uncalculating fury as the epileptic. On this account he is one of the 
 most dangerous subjects we have to deal with in our asylums, for the 
 attacks often occur with slight, if any, warning, the signal first given 
 being often an attack of brutal and impulsive violence. The aspect of 
 the patient fully accords with the impulsive conduct ; he is usually 
 pale, ghastly, the eyes staring vacantly, and the face expressionless or 
 betraying wild and passionate emotions. There is much incoherence, 
 yet often the patient utters not a word, but struggles wildly, rushes 
 madly at his attendants, and appears wholly oblivious to existing 
 conditions around. At these moments he is in peril to himself and 
 others; and suicidal and homicidal acts are not seldom accomplished 
 under such circumstances. Occasionally some leading idea, usually a 
 delusional notion of persecution, is expressed by the subject of this 
 mania. It was before stated that a delusional state frequently pre- 
 cedes the attack, becoming very apparent during the few last hours of 
 
234 
 
 KPILKPTIC INSANITY. 
 
 the pre-paroxysmal stage. In the state of epileptic mania such delu- 
 sional perversions are very likely to reappear, and to prompt the 
 subject to deeds of violence. There is a tendency apparent after 
 epileptic seizures in the insane, for ccjnsciousness, on its reinstatement, 
 to be occupied immediately with the subject-matter of thought pre- 
 ceding the attack, which means no more than that certain nervous 
 currents established just upon the onset of the seizure are liable to be 
 re-established immediately as consciousness is regained ; what was 
 most vivid to the patient's mind before the "fit" still remains most 
 vivid when the attack is over. Thus, a question put to the subject 
 and replied to, just before a convulsive seizure, will often be replied 
 to again immediately at the first look of recognition on regaining con- 
 sciousness. A female epileptic, e.g., asked her name, replied, " I am 
 Annie Thornbury," immediately fell in a fit, and, on regaining normal 
 consciousness, looked around and said again, "I am Annie Thornbury." 
 An epileptic lad, asked his name and age, replied, "Sixteen years, 
 Samuel Speight"; he thereupon turned pale, uttered a loud cry, fell to 
 the left side, the head and eyes turned to the left, the left arm was 
 ■extended and convulsed; he then turned over upon his face, and 
 •convulsively moved his left hand wide-spread, as though scrubbing the 
 boards. On regaining consciousness he rose to his feet, and looking 
 straight at us, said, " Sixteen, I am Samuel Speight." So also in the 
 case of U. C. in her automatic endeavour to pull out her hair (see p. 235). 
 We mention these cases more particularly because they appear to us 
 ■often to afibrd a clue to the persistence of a delusional notion, which, 
 being present in the pre-paroxysmal stage, may rise into being in the 
 post-paroxysmal period during the reductions of this stage, and issue 
 in immediate action — suicidal or homicidal attempts. In the stage 
 preceding the seizure, they may have little influence on the subject's 
 conduct — he then retains at least his normal self-control ; but during 
 the automatic stage of post-epileptic mania they may be of terrible 
 import. 
 
 Erom a medico-legal point of view, we cannot too strongly insist 
 upon this feature, that leading ideas, delusional or otherwise, prevail- 
 ing in the pre-paroxysmal stage are likely to become operative in 
 conditions of post-epileptic automatism. Wild, delirious excitement 
 after Jits is more frequent amongst women than men ; they lie awake 
 all night, chanting aloud a song or sacred air, batter their bedroom 
 doors with their hands, meet one with defiant glance, and are utterly 
 reckless of life or limb if interfered with. Fortunately, their very 
 reductions in consciousness prevent them from providing against tact 
 and address on the part of an able attendant, so that they are readily 
 overpowered and managed in most cases. 
 
IIYSTEROID ATTACKS IX EPILEPSY. 235 
 
 It is not, liowcver, all c;ises of epileptic mania which exhibit 
 these wild and delusional states. Some subjects remain incessantly 
 garrulous, and ramble in an incoherent and utterly absurd strain, often 
 peer into one's face with a scrutinising look, or arrest the passer-by 
 and address their irrational converse to him, but show no signs of 
 vindictiveness or passion. Some betray their excitement by incongru- 
 ous and unmeaning gesticulation and grimace ; others by incessant 
 pacing up and down their rooms, exhibiting strange and fantastic 
 mannerisms. One epileptic female in this stage invariably hastens 
 down the corridor of her ward and kisses the pictures hanging to the 
 walls; another is found kneeling with clasped hands before the busts 
 and pictures. A case of epileptic imbecility in whom the fits are now 
 very infrequent, even twelve months or more elapsing between each 
 observed seizure, has a single attack of convulsions one night, and 
 suffers from epileptic excitement for a fortnight subsequently. She 
 lies in bed in a huddled heap, covering her head with the bed-clothes, 
 muttering incoherently. When disturbed, she utters an unintelligible 
 jargon, interspersed with curses, and, showing her teeth with a fierce, 
 vindictive look — half snarl, half grin — plunges beneath the bedding. 
 In some cases, but rarely, the acute maniacal excitement sets in 
 immediately ujDon the cessation of the comatose stage. This was 
 notably the case with E. C, in whom a wild struggle usually ensued 
 after the convulsive seizure, homicidal and suicidal promptings being 
 prominent features. In the case of a compositor, already alluded to, 
 in whom garrulity augured an epileptic seizure, excitement has followed 
 for a period of some eight or ten days. During this attack of epileptic 
 mania he would wander aimlessly to and fro, or perform peculiar 
 gyrations, talking incoherently in a loud, declamatory manner, and 
 indulging in a rhyming propensity carried to a ridiculous extent. 
 
 Hysteroid Attacks. — These are not at all infrequent accompani- 
 ments of the epileptic seizure in the insane. Of these attacks Dr. Gowers 
 says — ''Instead of presenting such automatic action, some patients 
 pass, as already mentioned, into a state of violent hysteroid convul- 
 sions. This sequel occurs chiefly at the age at which hysteria is met 
 with, under thirty-five. It is most common in young women, frequent 
 in boys and girls, occasional in young men. Hence it is evidently the 
 result, not merely of the preceding epileptic fit, but also of the presence 
 of the cerebral state which underlies the manifestations of hysteria."* 
 
 Case ofE. C. 
 The most remarkable case we have met with occurred at the ^Yest Riding 
 Asjdum some fourteen years ago. 
 
 It was that of a young woman aged twentj^-eight, and single, who continued 
 * Op. cit., p. 692, 
 
23G EPILEPTIC INSANITY. 
 
 for sixteen months under our observation, and who for the first twelve months 
 was subject to epileptic and hysteroid seizures, whilst during tlie latter four 
 months she was completely free from fits, and was discharj^cd recovered. Her 
 seizures occurred with great regularity every three weeks, and lasted from three 
 to six da3's — the convulsive seizures occurring both night and day. The .symptoms 
 of the several stages were tlius distributed. 
 
 Pre-paroxysmal Stage. — For some days before a seizure, restlessness, irritability, 
 a pale and anxious look, depression amounting to despondency, and much insomnia, 
 were noted. Then supervened a notable peculiarity of manner, and she confessed 
 to aural hallucinations, viz. — a voice repeatedly calling out, "Kill them! kill 
 them! kill them!" She was at this time distinctly suicidal and homicidal in 
 her impulses, and always recognised that the "fits" were pending when tlie 
 phenomenal voice occurred. Occasionally, Muthout a seizure, she now became 
 very violent and destructive. 
 
 P remon'duru Period. — Restlessness more urgent, the "voice" more imperative, 
 then the sensations of "a clock " within the head "woimd up tighter and tighter," 
 when all becomes dark, and consciousness is abolished. Asked afterwards to 
 describe the "clock," she defined a circular sweep about 4 inches in diameter, 
 and in a horizontal plane around the vertex of the head ; and adds that if her 
 hair were cut off she believes it would obviate the tight feeling of the winding. 
 {Her last automatic act after an actual seizure is that of puUiiKj out her hair.) 
 Associated with the "voice," she occasionally hears bells ringing, and has a 
 feeling of prickling pain within the eyeballs. She never refers to her suicidal 
 impulses or to the "voice" which prompts her to the act until after the S'.'izure ; 
 but, she often refers to the clock as it begins, crying out, "The clock," "the 
 clock," and then becomes unconscious.* 
 
 Tlie paroxysm was invariably notable for the following features : — 
 
 (a.) Deliberate rise of temperature and quickened pulse during the quarter of 
 an hour preceding the fit. 
 
 {h.) Peculiar recurrence of convulsive seizui-e in series of threes or sixes. 
 
 (c.) Extraordinary periodicity of both diurnal and nocturnal seizures. 
 
 (d. ) Post-epileptic automatism replaced hy hysteroid seizures occasionally ; or 
 l)y wild ei)i]eptic mania with determined suicidal or homicidal impulses. 
 
 The rise of temperature usually amounted to a degree above noi-mal, occasionally 
 higher ; the pulse often rising to 130 before loss of consciousness ; it was also 
 peculiar in the fact that when the convulsion was arrested bj' chloral, the viae in 
 temperature still took place, and became even more marked when the lit was thus 
 suppressed. The attack of convulsions presented two varieties — in one, com- 
 mencing almost simultaneously, and occurring bilaterally ; in the other, beginning 
 on the right side and spreading to the left, "Violent twitching of right angle of 
 mouth ; the head drawn slowly to the right ; right arm affected by clonic spasm — 
 then the left arm and hand ; eyeballs drawn upwards ; the feet raised from the 
 floor, the left first, then the right, both rigid and quivering. Whole fit lasted 
 about ten seconds, and terminated suddenly with complete muscular flaccidity." 
 Another series of attacks is thus described. " Twitching of both eyes and angles 
 of mouth ; then clonic spasms of both arms and legs, a preliminary tonic spasm 
 hardly observed ; next, tonic spasm of the chest muscles with a loud scream ; 
 universal clonic spasms ; relaxation of muscles, and tit over. Three or six such 
 
 * This case, of which the main features are given here, has been published in 
 
 detail in the West Eiilinfj Asylum lieporls, vol. vi. 
 
CASE OF IIYSTERO-EPILEPSY. 237 
 
 attacks occur in succession, the last always followed by closure of the eyes, which 
 tliroughout tlie attack had been kept open. " Then after tliree or four minutes' calm 
 tlie liiisteroid attack occurred ; the eyes opened suddenly, staring vacantly, the head 
 was drawn rigidly back, the body arched Ijackwards in a position of opistliotonos 
 for about fifteen to thirty seconds ; then the head was thrown violently forwards 
 and backwards several times, and a severe struggle ensued in which she had to be 
 forcibly restrained by several nurses to prevent her rushing to the window or 
 injuring herself or others. When watched (unknown to herself) in the padded 
 room at nio-ht, the same attacks occur, and in the succeeding hysteroid seizure her 
 body has been tossed from end to end of the room against the pads by the violence 
 of the contortions ; her Ijedclothes, also, after such attacks, were invariably torn 
 to shreds. 
 
 The epileptic seizures above described maintained an extraordinary periodicity 
 in their sequence ; each series of fits almost invariably taking place at about the 
 same hours throughout both day and night. Several features of the case would 
 naturally suggest a purely hysterical origin for such an attack ; but that the 
 seizures were genuinely epileptic associated with sequent hysteroid seizures, was 
 conclusively shown by associated conditions which were invariably present ; these 
 were — (1) initial rise of temperature and pulse; (2) aura of the "clock" followed 
 by intense pallor of face ; (3) extreme dilatation and inequality of pupils, the right 
 always the larger ; and (4) well-marked nystagmus. 
 
 The number of epilei)tic attacks occurring in this subject varied from SO to 120 
 (both day and night), and these became somewhat less frequent and less severe 
 towards the fourth or fifth day as the termination of the attack approached. The 
 following note made by the writer at the time illustrates the thermal disturbance 
 preceding the attack : — "Immediately preceding the attack a rise of temperature 
 occurred of 1° to 1 "2° Fahr. ; and at the struggle a still further rise, often to the 
 extent of 1°, or even more. The temperature then slowly fell again to 98 '6°, and 
 on one occasion as low as 98 "2°, except when two fits succeeded each other quickly. 
 On the occurrence of six struggles, the total elevation of temperature recorded 
 was fully 2 ■2°, slowly falling to 99 "2 during the following hour and a-half. The 
 previous administration of chloral invariably arrested the rise occurring hefore the 
 fit ; hut at the exact rnoment when the fit loas expected, instead of a convulsive 
 seizure, there was sudden profound sleep and a rise of about six-tenths of a degree." 
 
 Another peculiar phenomenon was noted after the convulsive seizures had 
 ceased and whilst a still childish, pettish mood prevailed, with distinct alienation, 
 the temperature taken at periods corresponding to the time of her fits was found 
 from six-tenths to 1 '8° above normal, although at other periods of the same day 
 (not corresponding to the hour of a fit) the temperature was 98 '4°. "As these 
 periods arrived she would become greatly depressed, often starting up and com- 
 plaining to the nurse of her low spirits." At these times (although naturally an 
 intelligent, bright, and cheerful young woman) she would remain for days subse- 
 quent to the attack, childish in her pursuits, woiild make dolls' clothing, and 
 fondle a doll like a child not out of her teens ; was capricious in likes and dislikes, 
 pettish and ill-humoured. This case illustrates in a forcible manner most of the 
 very variable features of epilepsj'. The premonitory depression ; the tendency 
 to distinct mental aberration ; hallucinatory phenomena ; the aura, epileptic, 
 hysteroid and cataleptic states ; impulsive homicidal and suicidal violence ; and 
 the resultant mental reductions following the more marked post-epileptic automatic 
 stages. 
 
238 Kl'ILCPnC INSAMTV. 
 
 Epileptic Katatonia. — We may here advert to cases of so-called 
 katatonia— a tLim intended by Kalilbaum to include those multiple 
 symptoms of stupor, cataleptiform, and ecstatic states, with phases of 
 dumbness or reiterative speech — all running a certain cyclical course ; 
 and, according to this author, constituting in their ensemble a distinct 
 morbid entity, as characteristic as general paralysis. Such symptoms 
 are not infrequent in epileptic insanity ; they especially prevail in the 
 mental alienation of puberty and adolescence, in the puerperal forms 
 of insanity, and arc closely associated with the vice of onanism. The 
 more closely we study these cases of katatonia described by Kahlbaum 
 and other writers, the more convinced are we that we are dealing, 
 not with any distinct patliological entity, but with some of the multiple 
 phases of hysteria. Melancholia attonita closely approximates to the 
 states to which we now allude. 
 
 Status EpileptiCUS. — The very extraordinary periodicity of the 
 attacks narrated in the last case is, of course, exceptional ; yet a well- 
 marked tendency to the periodic return of epileptic seizures has long 
 been recognised, and especially emphasised by Reynolds — "A large 
 number of epileptics have their seizures every day, every two weeks, 
 three weeks, and four weeks, while only a much smaller number suffer 
 at such irregular intervals as cannot be thus expressed." This opinion 
 can be endorsed by all who have had acquaintance with epileptic 
 insanity, for it is undoubtedly true that these subjects exhibit a 
 notable degree of such periodicity. A periodic recurrence is more 
 frequent in the female than the male ; but, this is attributable to the 
 associated menstrual derangements so often connected with the 
 epileptic convulsion. The number of seizures varies greatly in some 
 individuals: an enormous number have been recorded within short 
 periods of time ; thus, a patient at the West Riding Asylum had 
 1,849 convulsive attacks recorded in a period of fifteen days; and 
 Delasiauve mentions an epileptic who had 2,500 attacks in one 
 month.* In general a patient has one, two, or three attacks during 
 the day or night, recovering full consciousness between each seizure, 
 possibly passing many days before a recurrence. 
 
 But if the attacks succeed each other rapidly, and consciousness be 
 not restored between the convulsive seizures, if fit succeed fit at 
 intervals of a few minutes only, the patient remaining comatose, we 
 have developed what has been termed the epileptic StatUS, a 
 condition of most serious import. The pulse and breathing become 
 quickened, and, as Bourneville first indicated, the temperature rises to 
 105° or 107°, with deepening coma and stertor ; the patient is liable to 
 sink. As the fatal termination approaches, the convulsions become 
 * Quoted by Eoss, op. clt. , p. 932. 
 
EPILEPTIC AUTOMATISM — INTEH-PAROXYSMAL .STATE. 239 
 
 more frequent, a few seconds only intervening between each discliai-ge, 
 so that at times they appear ahnost continuous, a fresh dischai-ge Ix'ing 
 only recognised as a slight increase in the intensity of the convulsions. 
 When this period arrives, however, the epileptic discharge becomes 
 progressively feebler, and the fit may be characterised by a slight 
 turning of the head and eyes to one side, with slight clonic movements 
 of the limbs, or merely convulsive twitchings of one side of the mouth 
 without conjugate deviation. The conjunctivae are, of course, quite 
 insensitive, the pupils being widely dilated and fixed to the strongest 
 glare of light, while the face and body are bedewed with a cold sweat. 
 Often the temperature exhibits unilateral deviations, being highest, by 
 a degree or more, on the side first (or most) convulsed. If the patient 
 recover, the fall of temperature is most rapid on this side until a 
 balance is established ; and subsequently, an equable and continuous 
 decline of temperature proceeds on both sides. Many epileptics are 
 subject to these occasional outbursts of convulsions passing into the 
 status ; these cases an observant medical officer soon learns to recognise, 
 and experience teaches him the necessity of keeping them for pro- 
 longed periods upon bromide treatment. In the section on treatment 
 of epilepsy we shall deal with this serious condition in detail ; suffice 
 it here to remark, that prompt and vigorous measures must at once be 
 adopted if we wish to save our patient's life. The mortality from the 
 status epilepticus is said to be due to (a.) collapse, and (b.) meningitis, 
 the fits ceasing, the patient becoming delirious, developing bed-sores, 
 &c. We cannot say that this latter termination has been seen by us ; 
 the mode of death has always been, according to our experience in 
 asylum practice, exhaustion with hypostatic congestion of the lung. 
 
 Epileptic automatism, of a most elaborate kind, is a prominent 
 and often j)erilous feature in some epileptics after their fits ; its interest 
 as a medico-legal question is great. Thus we constantly obsei-ve 
 patients at this stage perform not only the most incongruous acts, but 
 carry out what would seem to be complicated purposive acts, to which 
 they are entirely oblivious on return to normal consciousness. They 
 will pick the pockets of fellow-patients ; pui'loin articles in the most 
 deliberate fashion ; conceal weapons, such as knives, &c., in their 
 pockets or beneath their clothing ; and follow out, as before stated, a 
 series of actions in accordance with the promptings of some leading 
 delusional idea, such as a somnambulist would perform. The case of 
 W. T., detailed below, illustrates this point forcibly, and still more so 
 the case following it (York Assizes). 
 
 Interparoxysmal State. — We come now to the mental condition of 
 epileptics in general at the periods intervening between their seizures, 
 when the immediate effects of the attack are past, aiul prior to the 
 
240 EPILEPTIC INSANITY. 
 
 disturbance engendered by tlie approacli of a fi-esh series of fits. In 
 fcict, we have to study the peculiar characters of the epileptic neurosis, 
 and the permanent mental reductions whicli Ijecorae established, in 
 consequence of the diseased state of the nervous centres and the dis- 
 ordered function. In reviewing a large number of the epileptic inmates 
 of an asylum, it becomes evident that they may roughly be arranged 
 in four classes. 
 
 (a.) A small section is comprised by those who, upon the subsidence 
 of the seizures, exhibit a perfectly normal state of mind ; no emotional 
 or intellectual disturbance can be traced by the strictest scrutiny, and 
 their conduct (consistent in every respect) enables thera to take up any 
 emi^loyment for which they were fitted, and carry on responsible 
 functions in various departments. Why are they, then, inmates of an 
 asylum? Because their epileptic seizures are preceded or followed by 
 such transient mental aberration, or by such reductions as render them 
 at these times a risk to themselves and others ; or, because the interval 
 between their attacks is so short and exposes them to such risks in 
 their usual avocations, that they demand continuous supervision and 
 treatment. Outside an asylum this class is a large one ; comprising, 
 as it does, all those in whom the nature of the epileptic seizure is such 
 as to affect the mental faculties but slightly, if at all, even in the 
 pre-paroxysmal as well as post-paroxysmal stage. It is a well recognised 
 fact, which the student must bear carefully in mind, that certain forms 
 of epilepsy with frequent fits may last for many years, and yet the 
 mental faculties remain, in the interval between the successive 
 seizures, perfectly intact ; nor must he be misled by any such notion 
 (as we once heard expressed in a court of j ustice), that becaitse a man 
 has had Jits for viany years his mind must necessarily have suffered 
 jjermanently ; although, of course, in a large number of cases, the 
 presumption is in favour of such implication. 
 
 (6.) Then there are those cases of epilepsy in whicli the affective 
 sphere of the mind is almost exclusively at fault ; where, with a normal 
 and often vigorous intellect, we still find, as a permanent residue, an 
 emotional perversion, which maps them off from the healthy com- 
 munity, and which reveals itself by certain oddities, eccentricities of 
 conduct and want of control ; or, by an abnormal welling-up of feeling, 
 an instability of emotions highly characteristic of the class. To this 
 section, also, belong many who might be called moral imbeciles. 
 
 (c.) Then there is the extensive class of those in whom the main 
 feature is intellectual perversion ; in whom delusional states are rife ; 
 and in whom the passions are violent and uncontrolled ; a class which 
 comprises some of the most dangerous elements amidst our asylum 
 communities, since with all the natural impulsiveness of the epileptic, 
 
EPILEPTIC HYPOCHONDRIASIS. 241 
 
 the delusional states engendered render tliem, at all times, apart from 
 their paroxysmal seizures, pi'one to acts of desperate violence. 
 
 ((/.) Lastly, there are the advanced cases of epileptic dementia, in 
 which the reductions are so extreme, that the higher emotions and 
 moral sense are well-nigh extinct, and the intellectual operations 
 correspondingly enfeebled ; and in whom the mental life of the indi- 
 vidual consists of the lower animal instincts and passions, and the 
 impulses towards their immediate gratification. None of the insane 
 arrive at a more degraded level than the epileptic dement ; none of 
 them exhibit more rejDulsive traits — more obnoxious passions ; and in 
 none does the physique undergo sucha corresponding degradation in type. 
 
 Amongst the several arbitrary divisions thus enumerated, there are 
 certain mental characteristics common to the whole class which largely 
 enter into what we mean by the " epileptic neurosis." Notably pro- 
 minent is the tendency to self-engrossment which may pertain, not 
 only to the bodily sensations, giving rise to the grosser forms of 
 hypochondriasis, but also to the passions, and feelings, and senti- 
 ments of the individual, which are morbidly dwelt upon and, so, 
 intensified. Any bodily discomfort, however trivial, is thus apt to be 
 exaggerated into a serious ailment, and incessant complaint is made to 
 the medical attendant as to the state of the stomach, the bowels, the 
 heart, &c. The epileptic is essentially a hypochondriac; on the other 
 hand, irritability of temper, to which he is prone, is sure to find an 
 object of complaint ; imagined ills are conjured up, and he conceives 
 himself the most injured individual in his ward. In like manner, his 
 sentiments respecting his own abilities and aptitudes undergo a like 
 intensification, and he becomes vain and self-laudatory. This rise in 
 the self-consciousness begets an egoistic state of mind, which renders 
 the epileptic the most selfish and narrow of all beings, and the corre- 
 sponding decline of object-consciousness is well illustrated in his 
 utter regardlessness of the time or comfort of others — his incessant and 
 wearying importunity and demands upon the patience of his fellow- 
 creatures, his obtrusive display of self-interested motives — in fact, in 
 the profound decline of the altruistic sentiments and higher moral 
 incentives to action. Opposed to this moral decadence, at first sight, 
 might appear the statement that the epileptic often betrays a notable 
 degree of religiosity ; above all others of the insane, he is distinguished 
 for his adherence to religious rites and formalities ; importunate in his 
 requests to attend religious services, addicted to repeating Scripture 
 texts, to constant perusal of the Bible and devotional works, to singing 
 sacred hymns, to falling on his knees in prayer upon inapt occasions 
 and with an obtrusive show of mock piety ; he but illustrates another 
 phase of the rise of self-consciousness as it pertains to the religious 
 
 IG 
 
242 
 
 EPILEPTIC INSANITY. 
 
 sentiments. His religious life fails in its intellectual grasp ; it is essen- 
 tially egoistic, shallow, selfish, and similar to the undeveloped phases 
 of the religious life in a low grade of civilisation. The grossest animal 
 passions find their gratification pari passu with this mock display of 
 pietistic fervour, with a sanctimonious bearing and a profuse indul- 
 gence in religious cant, and with apparent consistency in the epileptics 
 mind. The realisation of the religious life in action — the objectivising or 
 actualisation which is its proper sphere — is at fault; there is a decline in 
 object-consciousness ; hence he finds no difficulty in reconciling these feel- 
 ings with the continuous gratification of low and depraved instincts. 
 
 The lower types of epileptics also exhibit a characteristic low 
 cunning and deceit ; they are treacherous in their dealings with their 
 associates, thievish in their propensities, and when arraigned upon a 
 charge of misconduct, will meet it with the coolest audacity, and lie to 
 the bitter end. The epileptic shows a tendency, akin to that of the 
 hysteric subject, to malingering. Both will falsely accuse of violence 
 those with whom they are aggrieved; Avill treasure up a tooth, or 
 wilfully pull out their hair by the handful, and present it, to counten- 
 ance their charge ; and will cunningly call to their defence certain 
 delusional notions to which they may be prone during the period 
 of their seizure, if they can benefit their position thereby — this 
 tendency should be carefully borne in mind. All the apparent 
 delusional statements of an epileptic are not to be received, except 
 with ca\ition, as their sole object may be to obtain some indulgence or 
 requirement, and especially so with the hypochondriacal subject. Con- 
 sorting with this moral decadence the epileptic is eminently instinc- 
 tive and impulsive, a feature demanding the utmost tact in his 
 management at the hands of those who undertake his case ; his conduct, 
 when aroused, is peculiarly brutal and ferocious, and often charactei'ised, 
 like liis actions during periods of epileptic automatism, by wholly 
 disproportionate and excessive violence. 
 
 The reaction-time in epileptic insanity is delayed as will be 
 apparent from the following series, taken indiscriminaitely from a 
 large number of cases examined : — 
 
 Reaction-time in Epileptic Insanity. 
 
 
 AcocsTic Stimulus. 
 
 Optic Stimulus. 
 
 J. J. M., . 
 
 •20 of a second. 
 
 •23 of a second. 
 
 J. v., . . . 
 
 •21 
 
 •25 
 
 F. P., . . . 
 
 •18 
 
 •23 
 
 J. D., . . . 
 
 •19 
 
 •21 
 
 W. P., 
 
 •17 
 
 •19 
 
 R. H 
 
 •24 
 
 •26 
 
 A. D., 
 
 •28 
 
 •29 
 
FORENSIC ASPECTS OP EPILEPTIC INSANITY. 243 
 
 MediC0-leg"al Relationships. — No form of insanity so frequently 
 presents itself to the medico-legal expert as epileptic insanity, and 
 this from two very obvious reasons. Epilepsy is a disease to which 
 the criminal class are peculiarly subject ; it is the associate of in- 
 temperance, moral degradation, vicious bodily organisation, and 
 the very varied heritage of a criminal parentage ; and, in the 
 second place, of all cerebi'al diseases it is the one which tends to 
 engender impulsive fox-ms of insanity, as well as to degrade and 
 brutalise the victim's nature, whilst the phenomena of post-epileptic 
 automatism often lead to acts of apparent criminality although 
 the subject is really an irresponsible agent. First, then, we would 
 ask : How far does the fact of epilepsy render its subject irresponsible 
 for his actions 1 It is obvious from the foregoing considerations that 
 epileptic insanity no more presents a uniform series of symptoms than 
 do the physical accompaniments of the epileptic paroxysm always 
 assume the same orderly sequence of events. Just as it is allowable 
 to speak of epilepsies, rather than epilepsy, as regards the physical 
 features presented by the attack ; so the correlated mental symptoms 
 exhibit very varied forms of insanity. And, apart from the varying 
 type of the insanity, we also witness a great variation in degree ; so that, 
 we may not only find that our patient is prone to melancholia, mania, 
 delusional insanity, impulsive insanity, dementia, but also that all these 
 anomalies may vary in degree from the slightest to the most intense 
 manifestations, or long periods may intervene Avherein no mental 
 anomaly presents itself It cannot be questioned that many epileptics 
 suflfer little, if any, mental derangement jDrior, or subsequent, to their 
 seizures ; and, that the interparoxysmal period 'tna.j be one consistent 
 with the most perfect sanity, with vigorous mental activities, with 
 intellectual capacities of a high order, and with special aptitudes and 
 executive address which enable them to hold positions of trust and high 
 responsibility. It is only as the immediate forerunner or outcome of the 
 epileptic seizure that they may be truly irresponsible agents. The "fits" 
 may even be of frequent occurrence, and yet the interval between two 
 consecutive seizures may present no obvious mental derangement. We 
 must not, therefore, assume that because a patient is epileptic and has 
 many fits, even with mental disturbance, that he is necessarily alienated 
 in the interval between such attacks, and therefore irresponsible for his 
 actions. The longer the interval between two seizures, cceteris jid-rihuti, 
 the greater the presumption also that the mental faculties may escape 
 implication ; and since frequent occurrence of fits is damaging to the 
 mental constitution, especially fits of a certain type, so, conversely, we 
 anticipate more interparoxysmal mental derangement in cases of 
 rapidly-recurring attacks. In fact, the 2)'>'oxinii(!j of an act of outrage 
 
244 KPILEI'TIC INSANITV. 
 
 or violence to an epileptic seizure directly favours the presumption of 
 mental impairment ; and, in this connection, it must be sti-ongly in- 
 sisted upon that the mental disturbance following upon a single 
 epileptic iit is frequently prolonged over many hours or even days. 
 
 The question might, therefore, be naturally put: if an act of violence 
 be committed by an epileptic a day or two subsequent to an epileptic 
 seizure, is the agent to be regarded as responsible for his conduct, 
 because on the expiration of a further period he is found perfectly 
 sane 1 Obviously, from what was implied above, we are not justified 
 in assuming that, since he is free from obvious mental derangement 
 a week or so subsequent to his seizure, he was not alienated for some 
 liours, nay, days, after the attack. Acts of suicidal or homicidal 
 nature may be committed subsequent to epileptic seizures as the out- 
 come of 
 
 (a.) Genuine automatism ; 
 
 (b.) Or as an incontrollable impulse devoid of motive ; 
 
 (c.) Or during the blind fury of epileptic mania ; 
 
 (d.) Or, lastly, the act may be instigated by the promptings of a 
 deluded mind. 
 
 It is essential that we clearly distinguish these states in investi- 
 gating the hidden springs of a murderous or suicidal attempt. 
 
 First, as regards epileptic automatism, it must be remembered 
 that actions of very considerable complexity may be performed whilst 
 the individual is a mere machine acting like a purely reflex mechanism, 
 the patient upon return of normal consciousness being completely 
 oblivious to the act which he has perpetrated ; in this condition he is 
 neither conscious of the act performed nor of its consequences. 
 
 Incontrollable impulse is another form of morbid activity which 
 reveals itself in the subjects of epilepsy ; like the motor explosivencss 
 of the convulsive paroxysm, a leading" idea may prompt to action 
 with an imperative demand which brooks no denial. Epileptics are 
 often conscious of this dire necessity ; it may ai'ouse within them the 
 ancient docti-ine of fatalism ; they may be terrified at their own help- 
 lessness, and implore us to impose restraint — a plea the veiy last to be 
 neglected by the medical adviser. The impulsiveneSS of the epi- 
 leptic is proverbial, and should never be lost sight of in questions 
 involving his responsibility ; for, where other evidence of mental im- 
 pairment is wanting, where delusion cannot be traced, where the 
 subject was possessed of presumably normal consciousness at the time 
 of his act of violence, still a factor of the gravest moment in this line 
 of conduct may have been a notably diminished self-control. The 
 essence of an impulsive act is, of course, its spasmodic suddenness and 
 want of apparent motive. The lawyer naturally enquires for a 
 
IMPULSE DELUSION — MALINGERIXG. 245 
 
 motive, which, if found, he regards as evidence presumptive of the 
 volitional nature of the act, and subversive of the doctrine of its im- 
 'puhive character. He assumes that the presence of motive warrants 
 him in regarding the epileptic as fully conscious of the deed he per- 
 forms — of its nature and probable issue. We should be most guarded 
 in accepting this conclusion. 
 
 The motives prompting to action in healthy mental operation are so 
 complex as often utterly to defy our most careful scrutiny ; much more 
 so will this be the case when dealing, not with an organism which re- 
 acts within fairly constant or calculable limitations, but with the 
 perturbed brain of the epileptic, in which the line of conduct is subject 
 to no method of calculation. Even if there be a strong colouring of 
 evidence that the act was the outcome of apparent motive, the natural, 
 and often inborn, impulsiveness of the epileptic neurosis should warn 
 us seriously against arriving at too hasty a conclusion upon this head. 
 
 In the third place, outi'ageous actions may be committed durino- the 
 wild mania incident to epilepsy ; in these cases, of course, no doubt 
 can arise as to the agent's utter irresponsibility. The natUFG of SUCh 
 acts in these latter cases will often be characterised by their frightful 
 violence; the crime can thus often be instantly identified by its blind, 
 aimless, uncalculating, utterly reckless fury, which at once stamps it as 
 the work of an epileptic {^Maudsley). There are in these murderous 
 outrages of epileptic mania indications of — (1) an utter loss of control, 
 (2) of deep reductions in consciousness, (3) of violent explosive conduct. 
 
 Lastly, the act may be done, as stated above, at the instig'ation of 
 a deluded mind. The epileptic insane are not necessarily (or even 
 frequently) deluded, and we should look with some suspicion upon cases 
 of affirmed delusion, fostered by those whose paroxysms are infrequent, 
 or occur at long intervals. The delusions of epilepsy arise, as before 
 stated, during the eai'ly and premonitory stages of the attack; the 
 paroxysm itself often having the effect of clearing ofi" the mental 
 clouds, and of leaving the subject often better than before the seizure. 
 One crucially important feature, however, to recognise from a medico- 
 legal standpoint is, that the delusions prevailing prior to the epileptic 
 seizure may be operative immediately subsequent to the fit, and before 
 consciousness is completely regained. This has already been noted, 
 but its importance merits emphasis here. When an epileptic sutlers 
 notably from delusion prior to his seizures, the outcome of his 
 paroxysm should be carefully watched [E. C, W. T.). 
 
 It is, of course, of the greatest importance to recognise any connec- 
 tion existing between the conduct of the epileptic and the previously 
 existing delusional state ; since, if the act be the direct outcome of, or 
 can be traced up to, such an aberrant state of mind, he must, of course, 
 
246 EPILEPTIC INSANITY. 
 
 be regarded as an irresponsible agent. The depth of reduction in these 
 epiloi)tic derangements should receive attention. 
 
 (a.) Was the act characterised by complete automatism 1 
 
 (b.) Or was he sufficiently conscious as to recognise its nature 1 
 
 (c.) Or was he sufficiently conscious to recognise its criminal nature 
 also — the distinction between right and wrong, and the probable issue 1 
 
 (d.) Or, even if the latter was the case, was it the outcome of 
 insane delusion, or perpetrated as a purely incontrollable impulse 1 
 
 Maling'ering". — Epilepsy is, as is well known, frequently feigned 
 by the criminal community ; often with the object of exciting com- 
 miseration and extorting pecuniary assistance ; and this is done with 
 considerable cunning and success by some. But, though the com- 
 munity generally may Vje imposed upon with ease, it is scarcely possible 
 that one well versed in the subject could be deceived by the most 
 cunning and expert. The intense pallor preceding the strong con- 
 vulsions, the widely-dilated pupils, the disturbed organic functions, 
 and, often, the minute extravasations of blood over the surface of the 
 body cannot be assumed ; and would, therefore, lead to speedy detec- 
 tion of the fraud. It is not so with the forms of mental derangement 
 associated with epilepsy, the delusional perversions of this stage being 
 readily counterfeited, and by no means easy of detection. 
 
 The plea of epilepsy is one so frequently established in defence of 
 cases of outrage, assault, or murder, that the possible feigning of this 
 disease and its forms of mental disturbance should always be borne in 
 mind. The difficulty is greatly enhanced by the fact that the criminal 
 class are so much associated with those subject to epilepsy, that they 
 acquire considerable address in feigning the disease ; and they have 
 .sufficient cunning to assert the presence of hallucinatory and delusional 
 states if thereby they can gain their ends. 
 
 And here we are face to face with another difficulty : the genuine 
 epileptic is also notably cunning, and often much given to shamming 
 — not bodily ailments alone, but mental also — usually with the object 
 of obtaining some desired indulgences ; it is by no means infrequent 
 to discover an epileptic girl " shamming" a fit, just as others affirm they 
 suffer excruciating pain, &c. Such a subject, arraigned on a trial of 
 murder, would be most likely, if he thought the plea of insanity would 
 save his life, to reproduce his former experiences, and assume delusions 
 from which he might have suffered at times. In the case of Beg. v. 
 Taylor, where the prisoner was charged with the murder of his infant 
 child and of the police-superintendent, it was believed that the state- 
 ments advanced by the defence as evidence of delusional perversion 
 (obtained J zfs^ prio7- to his trial) were of this nature. The closest obser- 
 vation and repeated examination during his early imprisonment wholly 
 
CASE OF REG. V. TAYLOR. 247 
 
 failed to elicit a deluded state ; and it is strongly suspected that the 
 frequent subsequent examinations which he underwent suggested to 
 his mind the policy of malingering. That he was fully aware of the 
 gravity of his oflfence, and the probable issue, was made apparent by 
 his statement to a fellow-prisoner on the night preceding the trial, 
 that he would probably have to go to a lunatic asylum ; a recognition 
 of his position wholly inconsistent with the assumption of the defending 
 counsel, that the prisoner was a complete mental wreck. That he was 
 subject to delusions, about the period of his " fits," could not be 
 doubted ; and that the murderous act was instigated by such delusion 
 is equally free from objection; yet the facts, that a period of some 
 months had elapsed without such a seizure, and that no clue to 
 delusion was forthcoming until just prior to his trial, were strong 
 evidence in favour of his malingering. In this case also no epileptic 
 seizure had occurred for three months subsequent to the murder ; and 
 the question as to the very existence of epilepsy in his case required 
 examining. It was found that his neighbours and fellow-townsmen 
 knew little or nothing about his " fits," and evidence as to such could 
 only be obtained from interested parties — his wife, parents, and a 
 lodger. But here again, on the other hand, it was obvious how 
 readily a genuine description of epileptic seizures may be recognised 
 from a feigned account. A most graphic account of grand mal and 
 'pet'it mal was given by each witness separately examined, consistent 
 with each other in every detail, evidence which most distinctly would 
 have broken down if the witnesses had not actually and indivi- 
 dually witnessed the seizures. Another question of interest in this 
 case was the actual condition of the prisoner's mind at the time of the 
 act. Was the act characterised by impulsiveness, or was it the out- 
 come of the delusions previously fostered % There is little room for 
 doubt that the act was deliberate and intentional, according to his own 
 account. He had for hours barred himself within his house, handlina: a 
 loaded gun ; his pockets contained several loaded cartridges ; and it 
 was only after watching his pursuers for some long time through 
 the window of the house that he eventually took deliberate aim 
 "behind the ear" of the police-superintendent and discharged his gun. 
 He both intended to kill his victim and fully recognised the surround- 
 ing circumstances. . In short, the act was very clearly not the impulsive 
 act of epileptic furor, but the well-planned and determined act of a 
 deranged mind prompted by delusion.* One of the most striking 
 
 * As these sheets are passing through the press, I hear that this criminal-lunatic 
 has, in a fit of maniacal fury, destroyed his eye-sight by self-iuUicted violence, at 
 the Broadmoor Criminal Asylum ; and, in a letter subsequently dictated to his 
 wife, he says:— "Old Satan told me to pull out my eyes, and 1 camiot see at all now. " 
 
248 KPILKPTIC INSANITY. 
 
 instances of liallucination, or the aura epileptica, becoming the motive 
 for action during the automatic stage i.s illustrated by a aise whei-e the 
 subject (who was undoubtedly neurotic, of a very bad stock, but who 
 was not known to have previously suffered from epilepsy), as he lay in 
 bed beside his wife, imagined he saw two burglars rifling the contents 
 of a chest in his room. He spi'ang out of bed, and, according to his 
 own statement, as he rushed from the room for help, he saw one of the 
 men rush upon his wife and strike at her with a hatchet. He 
 remembers nothing more ; but was found by a policeman (to whom he 
 made the above statement) wandering in the streets, vacant and con- 
 fused, and holding a hatchet in his hand. It appeared, from all the 
 evidence produced in this case, that the poor man had a fit, jjreceded 
 by the visual aura of the burglars in his room, that the idea of the 
 hatchet prompted him to rush down stairs to the cellar in order to 
 secure that wea^oon, and during this automatic stage he murdered his 
 wife. No case could more forcibly indicate the friglitful risk to which 
 the aura may expose certain epileptics during the post-convulsive stage, 
 and the necessity for close supervision. 
 
 Treatment. — No drug has so powerful an influence over the 
 convulsive attacks of chronic epilepsy as the bromide of potassium, or 
 the combinations of bromine with sodium and ammonium. The first- 
 mentioned is most relied upon, and may be administered for very 
 lengthened periods of many months without inducing hroniism, and 
 with very marked benefit. There are a certain proportion of the epileptic 
 insane — doubtless the minority — in whom the bromides are of little or 
 no avail ; but by far the lai'ger number exhibit a notable reduction in 
 the frequency and severity of their fits upon their administration. The 
 bromides have no immediate action in checking the fits, so that a 
 somewhat prolonged treatment is necessary ere the desired effect is 
 obtained ; hence, if the attack is threatening (owing to the severity 
 and rapid succession of the convulsions) to pass into the status epile^}- 
 ticus, it is of little use depending upon the bromide for cutting short 
 the attack. For tins purpose we have no rival to chloral, which, 
 given in sufficiently large doses, rarely ftxils to arrest the seizures. 
 Where there is an enfeebled heart and torpid circulation, large doses of 
 chloral naturally suggest great risk — hypostasis certainly is to be 
 feared ; yet the imminent peril from exhaustion, due to the repeated 
 seizures, renders it necessary to administer this drug, with certain 
 precautions. It is Avell, first, to inject subcutaneously from -jVjy to 
 -j^ of a grain of atropine if a large dose (40 grs. to a drachm) of 
 chloral has to be given. Thus shielded, a sufficient dose of the drug 
 may be given to completely arrest the attack, a procedure preferable, 
 we thiidc, to the more frequent administration of small doses. It is 
 
TREATMENT OF EPILEPTIC INSAMTY. 249 
 
 imper.ative in these cases that nourishment be given in the intervals 
 between the fits ; and, if the patient be too unconscious or torpid to 
 swallow, it must be introduced by the stomach tube. In a few cases 
 vomiting may occur and food so given be constantly rejected, and yet 
 a nutrient enema may be retained, and, with this chloral may be 
 combined. It should always be borne in mind that chloral has its-; 
 role in the emergencies of epileptic outbursts, bromide in the more 
 prolonged treatment. Many patients in asylums cannot live without 
 the bromide treatment ; if it be neglected, the fits become at once so 
 frequent that they run imminent risk of passing into the epileptic 
 status, and dying thus. Hence it is that in most asylums we tind 
 chronic epileptics who for years together, with short intervals of rest, 
 are taking bromides continuously, who maintain their health well, 
 have hearty appetites, are cheery and industrious, and whose fits, 
 recurring at long intervals, would at once assume a serious character 
 if the drug were suspended. 
 
 Prolonged treatment usually entails in many a very troublesome 
 form of acne. It is customary, in such cases, to suspend the drug for 
 a few weeks, and order the jiatient saline laxatives; but it may equally 
 well be met by the combination of a small dose of the liquor arsenicalis 
 with the bromide salt. In fact, arsenic may be given in all cases alike 
 with decided benefit from the outset. 
 
 On the other hand, a certain proportion of our epileptic insane have 
 a sei'ies of convulsive attacks periodically, often with intervals of 
 months between. During the intervening period they are free from 
 excitement, active, and cheerful subjects, but when once the fits 
 are about to occur they become querulous, hypochondriacal, and 
 violent. Such patients may often have their attacks cut short by 
 a dose of chloral, and by removal from sources of irritation to the 
 quiet of a darkened room ; nor do they by any means invariably call 
 for prolonged bromide treatment. To select those cases suitable for 
 bromide treatment from those who can be safely kept without this 
 drug, requires a prolonged experience — each case must be judged upon 
 its individual merits; but, in all alike, bromide treatment should, in 
 the first place, be adopted with the hope of possibly lessening the 
 frequency and alleviating the severity of the attacks. 
 
 In the epileptiform attacks, such as characterise the history of many 
 cases of general paralysis, we shall find that the bromides are of no 
 avail ; here chloral must be our sheet-anchor. The long-continued 
 maniacal excitement of epileptics is best met by repeated doses of the 
 asylum "green mixture" — i.e., bromide in combination with the tinc- 
 ture of Indian hemp ; half-drachm doses of the former, with one-drachm 
 of the latter, given twice or thrice daily, rarely fail to alleviate tlie 
 
250 GENERAL PARALYSIS. 
 
 excitement. In the more serious delirious outburst of epileptic furor, ifc 
 is well to administer chloral at intervals, followed by the former mixture. 
 
 How bromide acts upon the nervous centres we do not know; by 
 what means it induces more stability of the discharging cells is at 
 present a complete mystery. " Bromides are said to cause contraction 
 of the small arteries of the brain, but it is exceedingly doubtful whether 
 any part of their infliionce in epilepsy is due to this action." {(Jowers). 
 
 Iron, given in combination with bromide, is of indubitable value in 
 all such epileptics as exhibit any notable disturbance at the menstrual 
 periods, at which time there is often not only a succession of fits, but 
 iilso much maniacal excitement. Its vise is also called for in all the 
 hysteroid attacks. 
 
 GENERAL PARALYSIS OF THE INSANE. 
 
 Contents.— Prodromata — Egoism— Early Moral Perversion — Failure of Re-repre- 
 sentative States — Enfeebled Attention — Transient Amnesia — Vaso-motor 
 Derangements — Early Paresis— Second Stage— Delusions of the Paralytic and 
 Monomaniac— Vanity and Decorative Propensities- Sexual Perversions— Facial 
 Expression — Articulatory Imjiairment — Cerebral Seizures — Syncope— Epilepsy 
 (J. F.) — Unilateral Twitching (J. S.)— Epileptiform Attacks — Conjugate Devia- 
 tion — Case of H. P. — Apoplectiform Seizures — Monoplegia- Hemiplegiai — 
 Spastic and Paralytic Myosis— Mydriasis and Amaurosis — Reflex and Associative 
 Iridoplegia — Statistical Tables— Consensual jSlovements— Retiex Dilatation — 
 Reaction-time— Spinal Symptoms (M. J. R.) — Deep Reflexes- Tabetic Gait 
 (H. U.)— Incontinence and Retention — Atrophy of Vesical Muscle — The Blood 
 in General Paralysis. 
 
 It is not an easy task for the student to gain a clear and compre- 
 hensive view of so protean a malady as that of general paralysis of the 
 insane ; nor need he be surprised or discouraged at this when he is 
 informed that most authoi'ities on the subject difter as to supposed 
 varieties of the disease — whilst others are sceptical as to whether the 
 term does not comprise several rather than one pathological entity. 
 "When he is further told that no single portion of the entire cerebro- 
 spinal system and its peripheral nerves (not even the sympathetic 
 system itself) is safe from the encroachments of this far-reaching 
 disease, he will be prepared to meet with a most complex sympto- 
 matology, and one in which vai'ied groupings of symptoms may present 
 themselves as one or other region of the nervous centres is implicated. 
 Although the whole cerebro-spinal axis may become involved in this 
 disease, it yet undoubtedly expends its chief force upon the cei-ebral 
 cortex, which is primarily the affected site ; yet, cerebral, bulbar, or 
 spinal symptoms may one or the other preponderate, or be so variously 
 grouped and associated, that several artificial subdivisions of general 
 paralysis have been framed by different French writers of eminence, 
 the utility of which, however, is questionable, except as a matter of 
 
EGOISM EARLY MORAL PERVERSIOX. 251 
 
 pure convenience for purposes of description ; they do not represent 
 genuine pathological varieties. What the student should more 
 especially bear in mind is the fact that, in this affection, he is 
 dealing with a coarse brain disease, which, implicating primarily the 
 highest nervous arrangements, is prone to spread progressively, both 
 laterally and in depth ; a disease which ultimately leads in all cases 
 to dissolution of such nervous mechanism, and to correlated mental 
 reductions. The progressive impairuient of highly elaborated motor 
 mechanisms and the mental reductions comprise the characteristic 
 features of this disease, however diversified in type. Moreover, his 
 anatomico-physiological studies of the brain will have taught him that 
 in a disease spreading over the sensory and motor areas of the cortex 
 (involving so universally the substrata of the mental operations) the 
 mode of onset, the signs and symptoms, the progress and duration, 
 will vary greatly with the regions first implicated. 
 
 ProdPOmal Stag's. — The prodromal stage of general paralysis is of 
 very variable duration ; it is usually prolonged over many months, 
 and often embraces a period of several years. Many of the symptoms 
 then apparent are trivial, taken by themselves ; but several are of the 
 gravest import and highly significant, especially when the ensemble is 
 considered. A restless, unwonted activity (mental and physical) is of 
 frequent occurrence, a feeling of superabundant energy prevails, for 
 which there appears no adequate relief; often there is undue irritabil- 
 ity and a perverseness which will not brook control or contradiction — 
 an unreasonable demand upon the time and indulgence of others ; 
 waywardness, fickleness, or outbursts of furious passion upon trivial 
 pretexts in those who had previously been more self-controlled and 
 amiable ; a growing change in the disposition and character, usually 
 signalised by perversion of some one or more of the moral sentiments 
 — a fact of primary import from a medico-legal point of view. 
 
 The implication of the aff'ective sphere of mind may issue in melan- 
 cholic gloom or despondency; or, on the other hand, in undue elation 
 and hien-etre ; but just as often in sudden alternations of mood fi'om 
 one extreme to the other. The general restlessness spoken of pertains 
 particularly to the ordinary pursuits of life and business; there is undue 
 eagerness, a planning, scheming spirit, often exhibited in extravagant 
 investments or in extraordinary outlay incommensurate with the sub- 
 ject's resoui'ces. Or it may show itself as intense anxiety about his 
 prospects, his home and family. This frequently passes into more 
 marked elation, an egoism which displays an exalted view of his own 
 attainments in science, in art, or in general intellectual capacity ; an 
 officious self-gratulation ; a tendency to extravagant talk, to laudation 
 of his own status, his wife and family, and a yearning to test his 
 
-';)-' OENERAL PAnALYSIS. 
 
 intellectual or physical vigour. The religious sentiment is often in 
 the ascendency, and may lead to various philanthropic schemes ; and 
 new projects may be based upon similar exaltation of the domestic or 
 social feelings. Emotional waves are of frequent occurrence ; and 
 silly, uncontrollable laughter may replace passionate weeping, for whicji 
 no adequate cause can be assigned. It will be observed that we do 
 not infer from all this a distinctly dehuhd state of mind — the existence 
 of delusions becomes a more prominent feature in the subsequent 
 stage — although at this period the patient hovers on the borderland of 
 delusional perversion. The judgment is enfeebled and clouded (not 
 necessarily perverted), and the condition is, in fact, one of over- 
 balance. As before remarked, moral pervePSion is what appears so 
 frequently to present itself at this period of incubation; moral lapses 
 are so frequent at this time that the unfortunate subject, especially if 
 he belong to the lower strata of society, becomes lodged in prison and 
 detained for offences committed during this early period of alienation. 
 It is a most common experience in public asylums to receiA'e from 
 prison authorities subjects of this disease, who have been arrested for 
 theft, drunkenness, violence, or indecent assault. The moral lapses 
 to which we now refer differ essentially from the acts of those suffer- 
 ing from so-called moral insanity. In the latter, the actions indicate 
 impulsive and uncontrollable states, as the result of a lowered or 
 defective moral sense ; the normal inhibitory control is wanting and 
 instinctive impulses rise into full activity. It is not so with the 
 acts of the general paralytic ; they are neither premeditated nor 
 impulsive, but casual, often appearing to be unconsciously performed ; 
 even if the act appear determinate, its nature and consequences are 
 wholly obscure to the agent's mind. 
 
 And here the essential nature of these acts on the part of such 
 subjects becomes apparent ; that high degree of representativeness 
 essential for the recall of similar actions previously performed, and the 
 vivid realisation of the consequences of such actions in the past, is here 
 
 icholly loanting ; and still less is that re-representative facility 
 
 intact, which enables him to contrast the act as ^•icwcd in its nature 
 with certain ethical canons. The moral lapse is, therefore, truly 
 significant of a clouded intellect, of an incipient dementia — the 
 cognitive, relational, or intellectual element of mind is on the wane. 
 That such acts are not merely the result of simple perversions of 
 the moral feeling is sufficiently attested to, by the complete absence 
 of forethought and judgment which characterises them, by the absence 
 of choice of circumstances favouring the act, by the want of object or 
 reasonable motive — as when a wealthy man purloins an article of 
 trivial value, as well as by the silly character of the act and manner 
 
ENFEEBLED ATTENTION — TRANSIENT AMNESIA. 253 
 
 of its accomplishment. An act of theft may be comiiiittcd with open 
 cfTrontery, no attempt at conceahnont Ijoing made ; the most wanton 
 outrage on public decency — the most audacious libertinism — may be 
 committed by an individual apparently quite oblivious to a brcacli 
 of public morals. Thus, a respectable member of society, of good 
 social standing, gifted with many amiable virtues and natural talents, 
 suddenly develops an unusual and objectionable freedom of speech and 
 action, shocks his wife and family by various irregularities ; plays the 
 "hero to the barmaid;" indulges in unwonted alcoholic excesses; makes 
 extravagant purchases or silly presents to quondam friends and casual 
 acquaintances, for whom he suddenly professes a sincere attachment. 
 In one such case, observed by the writer, extreme emotional instability 
 prevailed, violent passion would ensue upon the most trivial occur- 
 rence, and just as readily might the patient be calmed into good 
 humour, or made to shed tears profusely. Another patient, watched 
 through this stage of the disease, conceived exalted notions respecting 
 his family ; his eldest daughter became a constant theme of converse, 
 on which he would fondly dwell until he had utterly wearied his 
 hearers. He then developed a too amiable weakness for the other sex, 
 and from being a model husband, became careless, suddenly left his 
 home, and was not heard of for some weeks. It then appeared he had 
 developed a craze for preaching, and had travelled as an itinerant 
 preacher amongst the mining community of South Wales. He re- 
 turned to his friends deeply impressed with the importance of his 
 mission; talked incessantly upon religious topics; and became morbidly 
 depressed and hypochondriacal. In a case of incipient general paralysis, 
 the subject of which was a highly talented mathematician, one of the 
 earliest psychical symptoms was intense despondency, together with 
 sudden lapse of attention and memory. Often when absorbed in the 
 interest of solving a problem have we seen him cover his face with his 
 hands; rise from his chair; and with a pained expression and the 
 hurried remark, " It's of no use — it's all gone," hurriedly leave the 
 room. He frequently confessed how painful such a state was to him ; 
 how utterly incapable he felt of exercising the slightest eftort of atten- 
 tion ; and how completely oblivious he became to the various links 
 of the argument followed, before this disruption occurred. In this 
 instance these sudden amnesic attacks prevailed for many months 
 before definite aberration was recognised, and the onset of the estab- 
 lished disease was one of sudden maniacal excitement, accompanied by 
 acute hallucinations. This subject also spoke to his medical friends of 
 the sudden and causeless emotional states — "as a welling-up of his 
 feelings, only relieved by a passionate flood of tears." 
 
 The transitory amnesic states are very frequent as an early 
 
25-t GENERAL PARALYSIS. 
 
 symptom of the disease, and almost invarialily imply a serious failure 
 in attention — the faculty which, as Sir Crichton-Jirownc has insisted, 
 is earlier impaired than any other. To the same origin must be 
 attributed the furr/e.tj'ulness which is an invariable accompaniment 
 of this early stage, and which so often leads to inconsistent, ludicrous 
 conduct; inattention to the claims of others ; and unconscious infringe- 
 ment of codes of honour, or of courtesy, 
 
 ' ' This loss of memory will be observable in many ways ; especially is he likely 
 to forget what he has done a day or two previously ; and he will not only be 
 forgetful, he will be careless, apathetic, and indifferent about that which formerly 
 interested him ; and, when he takes up new schemes and projects, his attention 
 soon flags, and his interest vanishes. We see, in short, in his whole mamier of 
 life a weakening of mind, such as may be noticed in the commencement of senile 
 dementia ; but which, occurring in a fine and vigorous man of, it may be, thirty- 
 live, too surely indicates the ruin even now commencmg" {Bland/ord).* 
 
 We observe, at this pei'iod, that a very impressionable state of 
 the vaso-motor system often prevails; palpitation with alternating 
 flushing and pallor of the face, or, often, severe headache and neuralgic 
 pains are complained of; the circulation is generally sluggish; and an 
 early symptom (one for wdiicli the patient ' often first comes under 
 notice) is that of a torpid liver. The hepatic functions are almost 
 invariably deranged, leading to obstinate constipation, bulimia, and 
 digestive troubles; the skin often assumes an icteric tinge; such symp- 
 toms affording material for hypochondriacal complaints ; numbness 
 of the hands, with tingling and formication of the skin, are also not in- 
 frequently complained of. Another frequent premonition is that of 
 A-ertiginous attacks ; slight attacks of vertigo often escape notice, the 
 patient not complaining unless his attention is directed to the matter; 
 they occasionally, however, become severe. 
 
 Even at this early date there may appear distinct motor troubles, 
 a fine fibrillary quivering of the tongue may be observed, or a coarser 
 twitching of individual fibres ; an inco-ordinate jerky protrusion of 
 the organ ; a tremulousness of the upper lip or the facial muscles 
 during conversation. Pupillary anomalies may coexist also, or may 
 antedate the above paretic symptoms by months or even years, as 
 aflSrmed by Griesinger. Another highly significant group of .symp- 
 toms is constituted by certain epileptiform or apoplectiform seizures 
 which may now ensue, and which may become frequent at a later 
 stage of the disease. They may usher in the fully-established affection, 
 and thus may form, so to speak, a definite line of demarcation between 
 the earlier and the second stage; but it is just as frequent to hear of 
 such seizures, both convulsive and apoplectiform, far back in the 
 
 history of the case. 
 
 * Op. cit., p. 2G0. 
 
ESSENTIAL NATURE OF THE DELUSIONS. 255 
 
 Second Stag's. — After this stage of alienation has prevailed, for a 
 longer or shorter period, more active symptoms are liable to arise ; 
 it may be by a gradual transition; but, often, there is an abrupt 
 passage into a maniacal condition in which vivid hallucinations pre- 
 vail. The intensity of the excitement is often extreme, acute 
 maniacal states (verging even upon delirious mania) are frequent j 
 incessant restlessness, obstinate sleeplessness, noisy boisterous excite- 
 ment, and blind uncalculating violence, especially characterise such 
 states. The reductions are so great that the subject wholly fails to 
 appreciate the meaning of the simplest assistance rendered him ; he 
 struggles violently, and resists attempts to dress or undress him, or 
 to give him the necessary food. His violence is often so great as to 
 expose him to the most serious risk of fractured bones, even from 
 the best directed efforts to nurse and nourish him ; such cases are a 
 source of the greatest anxiety in our asylums. The blind fury of 
 these states remind us of similar states of excitement in the epileptic; 
 and, as a fact, are frequently a sequence of epileptiform seizures or of 
 attacks simulating petit mal. In the less acute maniacal attacks the 
 characteristic delusional state of mind reveals itself. With beaming 
 face and muscles, tremulous from emotions, he endeavours to fix the 
 glorious but transient visions which float before his mind's eye; in 
 rambling incoherent utterances he insists upon his wealth, his exalted 
 station or future destiny. 
 
 It will repay us to study a little more closely the nature of this, 
 expansive delirium. In the first place the delusional state is the 
 antithesis of the so-called monomaniacal delusion, which is essentially 
 fixed in character, and is in itself a direct perversion of the individual's 
 intellectual life. The grandiose conceptions of the general paralytic 
 ai"e wholly difierent in their nature, and are the direct outcome of 
 an unrestrained imaginative faculty, no longer subject to the coercion 
 of the reason. Those standards of objective reality which a life-long 
 experience and knowledge may have established, no longer exist for 
 him, or are clouded by the mental storm ; and the only criteria of 
 truth perceived are the subjective impressions aroused by the morbid 
 excitation of his imaginative sphere of life ; there is no reason why he 
 should doubt their reality, as no challenge can be giA'^en by the over- 
 clouded reason, and so the sensuous procession of impressions pass by 
 in cverchanging kaleidoscopic hues, uniting and reuniting in fantastic 
 combinations, conjuring up visions of immortal life, of love, of beautyj 
 of wealth, or of honour, or of all that mortal could desire. Challenge 
 him iipon the absurdity of his statements and a momentary irritation 
 may occur; but he readily wanders off" into his grandiose strain, asserting 
 and reasserting with stronger emphasis still more extravagant delusions. 
 
•256 r.EXERAL PARALYSIS. 
 
 It is in these states that the enfeeblement of attention, is pre- 
 eminently noticeable ; faulty it was in the earlier stage, as we saw in 
 the resulting nmeraonic lapses and amnesic states ; but, its failure 
 now is a far more serious matter. The contrasting faculty of the 
 mind, whereby a rational judgment can be formed, must decline with 
 this enfeebled attention, since it depends for its existence upon the 
 vigour of the latter. This failure of attention can be occasionally 
 elicited in a remarkable manner as regards certain special mental 
 operations. It is readily observed upon testing this faculty that it 
 occasionally fails more with certain mental operations than with 
 others — naturally with those less habitual to the subject — and, if we 
 continue to test the patient in this direction, the strain becomes 
 at times intolerable, and has a strange result. Thus in a patient, 
 who was garrulous and optimistic, talking incessantly upon the 
 subject of his " coursers and blood-horses," it was detected that he 
 could not direct his attention to simple numerical calculations without 
 much painful effort ; upon one occasion, therefore, when his attention 
 was forcibly directed towards a simple sum of addition, after giving a 
 wrong answer once or twice, the effort resulted in a sudden (but 
 transient) loss of consciousness, a twitching of the facial muscles and 
 rio-ht hand, and an aphasic state lasting some five minutes after 
 re"-aining consciousness. The following day a similar test was applied 
 to this patient with identical results, except that the convulsive dis- 
 charge was spread over a wider range. 
 
 Beyond the fact that the delusions of the general paralytic are so 
 transient and variable, there is their simple, sensuous and fragmentary 
 nature to be noted ; they bear no logical connection the one to the 
 other, and are therefore most incongruous and self-contradictory. 
 Then, again, such delusions are simple assertions, the general paralytic 
 does not reason out his delusive concepts, or attempt to erect a system 
 of belief thereupon ; he simply asserts, reasserts, and never attempts 
 a proof. Herein again we see the distinction between his delusions and 
 those of the monomaniac. In normal states the imaginative faculty, 
 however active, if duly controlled by reason, may find its expression 
 in poetic imagery or on the painter's canvas ; but in the case of 
 general paralysis, emancipated from such guidance, its vagaries become 
 so astounding that they defy expression. We all know how the very 
 indetiniteness of emotional states renders their expression by language 
 difticult, and at times impossible ; and how, in contrast with the 
 feelings, the subjects of exact knowledge find a ready medium for 
 their expression and elucidation in the faculty of speech. The 
 mental life of the general paralytic at this stage is so far made up 
 of sensuous feelings and their residual emotions, that he wholly fails 
 
DELIRIOUS CONCEPTIONS — FACIAL STOLIDITY. 257 
 
 to his own satisfaction, to express by language what rises before his 
 mind, liis feeling and mental imagery are illimitable, and submit not 
 to the definition of words. Thus, in each repeated utterance, he tries 
 to rival his former extravagance ; he has not simply millions, but 
 "thousands of millions of millions of millions." 
 
 The nature of our patient's occupation, and the subjects which have 
 chiefly engrossed his mind, will usually afford material for these delirious 
 conceptions ; thus, a poor labourer who through years of anxious toil 
 has struggled to support a large family believes that he has accumulated 
 enormous wealth — "is heir to extensive domains, and his children 
 princes of royal blood ; " another, a schoolmaster, talks on schemes of 
 universal education. One who had squandered his means upon the 
 turf was the imagined possessor of twenty hunters which he had just 
 sold for £350 each; another, a poor carter, is possessed of a magnificent 
 team of horses, each of which he calls by name, and excitedly smacks 
 an imaginary whip, as he drives them on in mad career. One who 
 had occupied a foreign diplomatic post had conceived extraordinary 
 schemes for developing the industrial and mercantile resources of all 
 the European nationalities. Some are agitated by vast philanthropic 
 schemes ; one of our patients was going to empty all the prisons, 
 asylums, and workhouses in England, and start each individual afresh 
 in life " upon a sovereign each ; " another intended paying off the 
 National debt. The exuberant welling-up of feeling transforms the 
 status and surroundings of the subject without affecting his real 
 identity ; he still retains his name, but is now a duke, a king, or 
 emperor ; his wife and children still are his, but are exalted into 
 corresponding dignities ; whilst the asylum is a gorgeous palace, the 
 nurses or attendants transformed into princes or courtiers. 
 
 Fantastic decoration is much indulged in, especially by the female 
 paralytic ; scraps of coloured stuffs, ribbons, and coloured paper are 
 stitched on to their clothing as insignia of distinction, or as an 
 addition to the attractiveness of the subject. The sexual charac- 
 teristics are prominently developed ; the female, especially, betraying 
 much personal vanity or much self-consciousness in the presence of 
 the opposite sex ; she is often engaged on matrimonial alliance ; 
 connubial subjects occupy the chief theme of her delusions ; and, 
 occasionally, a well-marked erotic state prevails. On the other hand, 
 the male paralytic raves upon wealth, property, social position, pro- 
 fessional attainments, manual dexterity, artistic ability, muscular 
 power, and endurance. The variety and transient nature of these 
 delusions ; their utter silliness, impossibility, and inconsistencies, in- 
 dicate a serious degree of dementia in which an enfeebled attention 
 and an unbounded license of the imaginative faculties coexist. The 
 
 17 
 
258 GENERAL PARALYSIS. 
 
 associated excitement may at times be in abeyance, to be called up 
 readily upon the slightest reference to optimistic or grandiose sub- 
 jects, when the stolid, half-vacant impression lightens up into a look 
 of fatuous rapture as he pours out his delirious notions. Even in 
 the calmest moments an undercurrent of excitement usually exists, 
 especially manifested in restless, purposeless movements and mis- 
 directed energy, with nocturnal exacerbations, during which he is 
 noisy, destructive of clothing and bedding, and dirty in his habits. 
 
 It is at this stage of our enquiry that two groups of physical signs 
 become prominent features ; present as they may be in the earliest 
 stage of the disease, they are, however, almost invariably found at 
 this period. They consist in certain articulatory troubles and oculo- 
 motor paralysis. Grandiose delusions with maniacal outbursts, a 
 delire ambitieux, are by no means an unusual feature in some other 
 forms of insanity; but when to this delirium there is superadded a 
 tremulousness of the lips, an inco-ordinate ataxic state of the tongue, 
 and certain pupillary anomalies, the diagnosis of general paralysis 
 is next to conclusive. The facial expression of the general paralytic 
 is characteristic ; when unmoved by emotional excitation there is 
 great stolidity, with a somewhat vacant demented aspect, but when 
 roused into conversation the face beams with emotional excitement, 
 the lips and facial muscles become tremulous, and twitchings of the 
 muscles of the brow are noticeable. The tremulousness of the lips 
 is well compared by Dr. Bucknill to the like tremulousness in a 
 person about to burst into a flood of tears. An uneasy fixity of the 
 lips is noticed in some, and a tendency to place the hand over the 
 mouth whilst speaking, in full consciousness of the failure. When 
 the tongue is protruded, it is with ataxic jerks or irregular inco- 
 ordinate movements ; and a fine fibrillar tremor will be perceptible 
 whilst it is extended. In advanced cases the tongue will be protruded 
 only with great effort, the mouth being widely opened, the eyes 
 staring, and the whole head trembling and unsteady with the effort 
 expended. The articulation is now distinctly impaired. 
 
 Articulatory Troubles. — The character of the articulation is 
 distinctive; it is slowed, hesitating, blurred, approaching that of a 
 drunken man ; its utterance is broken, syllaT)ic recurrences are inter- 
 polated, and the difficult enunciation may end in an explosive effort. 
 In the early stages of the disease, however, a slow, laboured enuncia- 
 tion, with slight blurring of consonantal sounds, may be all that is 
 recognisable ; but, upon excited converse, as when rallied on the 
 subject of his delusions, the impairment may be at once exaggerated 
 and accompanied by the characteristic treinor of the upper lip. It is 
 the labial and lingual utterance which suffers chiefly; and, if present. 
 
ARTICULATORY TROUBLES — CEREBRAL SEIZURES. 259 
 
 it is at onco manifested by requesting liiui to repeat any alliterative 
 doggrel; to repeat distinctly such words as hippopotamus or peram- 
 bulator. The paralysis of lips and tongue advances in later stages 
 to a more profound degree, and attempts at speech issue in an 
 inarticulate muttering of broken unintelligible jargon, in which here 
 and there some woi'd is recognised. 
 
 "Cerebral Seizures." — During this stage, or later still, the 
 patient may be subject to convulsive, apoplectic, or paralytic seizures ; 
 and very few indeed pass through the descending series of dissolutions 
 of general paralysis without suffering from one or more of these 
 accompaniments. Such "seizures" are — 
 
 Syncopal or quasi-syncopal attacks. Epileptiform discharges. 
 
 Petit mal, or, exceptionally, grand Apoplectiform (or true congestive), 
 
 mal. attacks. 
 
 Limited (or unilateral) twitching. Hemiplegiae and inonoplegise. 
 
 Syncopal Attacks. — These are by no means infrequent during 
 the progress of general paralysis, and are often the first warnings • 
 given of a failing heart, and of the necessity for keeping the patient 
 in bed. Thus a patient taking his customary meal will suddenly turn 
 pale and fall forwards ; his pupils are dilated, his pulse imperceptible, 
 and the skin cold and damp ; no convulsive twitching occurs, and 
 after a momentaiy prostration, he rallies and recovers his former 
 state. Such patients demand rest in bed. Attacks of jjeiti mal 
 are occasionally mistaken for syncopal attacks, and reported as slight 
 *' faints " by the nurse or friends. 
 
 Epileptic Seizures. — These are of frequent occurrence, yet by no 
 means so frequent as the epileptiform and limited convulsive attacks. 
 They also occur in early stages of the disease, and are usually referred 
 to by the friends of the patient as slight faints. Attacks of the 
 nature of j^^tit mal are the more usual. They are characterised by very 
 transient loss of consciousness preceded by pallor, wide dilatation or 
 pupils, and perhaps a slight twitching of one side of the mouthy 
 followed Ijy much confusion of thought, obvious in inconsistent speech, 
 and conduct ; or by more prolonged automatic states. 
 
 J. F., March 21, 18S1, seized this morning with convulsions, which occur every 
 ten or fifteen minutes, and are identical with epileptic seizures, except that the 
 convulsions are chiefly unilateral, involve the chest muscles but slightly, there 
 being also no lividity of face nor obstructed breathing ; each attack hists for 
 thirty seconds or thereabouts. 
 
 The convulsive phenomena in their sequent stages were as follows : — 
 1. No pallor, but head and eyes deviate to the right ; there is a broken inarti- 
 culate cry ; the pupils dilate widely ; the brow is raised by the occipito-frontalis. 
 
260 GENERAL PARALYSIS. 
 
 2. The mouth is drawn to the right, lips twitcli strongly and uncover the 
 canines. 
 
 3. Riglit arm flexed, with forefinger extended ; then raised and convulsively 
 jerked at shoulder ; tiie brow twitelies violently. 
 
 4. In certain seizures the discharge spread to the right leg also, but did not 
 involve the left. 
 
 After the fit there was paralytic deviation of head and eyes to the left and 
 notable helplessness of the right arm ; the left pupil was much larger than the 
 right, but slowly regained its former size ; there were champing movements of 
 the jaw ; no exaggeration of patella-reflex ; no ankle-clonos ; at the onset of each 
 attack the heart, previously beating strongly, became imperceptible during the 
 tonic stage. The cry always precedes each attack. 
 
 Limited or Unilateral Twitching". — Sudden, rhythmic twitching 
 
 of the muscles about the mouth, or of the specialised groups of the 
 hand, or of the forefinger and thumb of one side are very frequent, 
 either alone or in combination ; or convulsive twitching of the flexors 
 of the wrist or elbow may also be associated therewith. The various 
 muscles of the thigh or leg may be observed picked-out by the con- 
 vulsive discharge, or the whole arm or leg jerked spasmodically. 
 Siich twitching is often increased by handling and passive movement 
 of the limb. The limb may be fixed in rigid extension, whilst the 
 toes or fingers are flexed by clonic movements. The muscular twitch- 
 ing may be very general, involving both sides of the body (although 
 unequally) ; and its duration may be protracted over days or even 
 weeks without interruption. The following case illustrates this fact: — 
 
 J. S., a general paralj'tic, was seized with convulsive twitchings of the limbs on 
 the 25th of November, 18S6. His face was flushed and the skin covered with a 
 greasy unctuous sweat. Both arms, but especially the left, are continually and 
 consentaneously jerked by the convulsive twitching of the extensor group for the 
 elbow and wrist, the fingers of the left hand are suddenly spread as in the act of 
 playing the pianoforte ; the toes also show a tendency to "spread," the feet being 
 rigidly extended, whilst there is almost continuous clones of both ankles, especially 
 increased by flexion of the foot ; if, during a period of partial cessation of this 
 clonic state, the sole be irritated by a pin, clonos is again briskly established. 
 There is a notable degree of the "paradoxical contraction." The superficial 
 abdominal reflexes are dulled. Tache cerehrah is rapidly produced, and is vivid 
 over all parts of the body. Both conjunctivre are injected ; both pupils show 
 mydriasis, but the left is larger, and both are fi^ed to a bright beam of light. 
 Bowels and bladder paralysed. Patient is greatly demented and quite 7nute. 
 
 The following day the twitching was limited to the left foot and hand; the same 
 expansive movements of the digits occurring. 
 
 November 30, 1886. — -The convulsive twitching of the left hand and foot 
 remains unchauged ; the plantar reflex is greatly exaggerated and hj-per-sensitive. 
 
 April 16, 1S87. — The movements above described have continued up to this 
 date (nearly five months) without interruption, but are now gradually declining. 
 
 The above was of course an instance of such ccfevulsive movements 
 
VARIED CONVULSIVE AFFECTIONS. 261 
 
 ill an advanced stage ; but similar seizures may occur at a very early 
 period of the disease. The convulsive twitching is usually associated 
 ■with a certain degree of reduction in consciousness ; and, when the 
 discharge involves the right side of the face and hand, aphasic 
 states may prevail, and a certain degi-ee of WOrd-blindness or 
 deafness presents itself. 
 
 EpileptifOPm Seizures. — Under this term are comprised general 
 convulsive seizures, or convulsive discharges fx'om motor centres, 
 representing large associated groups of the musculature of the body 
 and limljs. Such attacks are often ushered in by premonitory twitch- 
 ings, such as those just described ; they ai-e not, as a rule, accompanied 
 by complete loss of consciousness. The convulsion or spasm may 
 start, as indicated by Mickle, " from some point as it were, becoming 
 widely spread and severe, then ebbs away and ceases evei-ywhere 
 except at the starting point, usually the mouth, eye, or hand, where 
 occasional jerks are seen which may gradually die out ; or, on the 
 conti'ary, the preceding cycle of events may be repeated, or the renewed 
 convulsion may chiefly affect the other side." * 
 
 The onset of the attack is almost invariably hemispheric — i.e., the 
 convulsions begin unilaterally, and may or may not spread to the 
 opposite side ; they are often preceded by a well-marked tonic stage 
 as the rapid pi'imary discharges occur; the clonic stage being often 
 long jjroti-acted, becoming more and more broken-up into intervals of 
 comparative rest until at last an occasional convulsive jerk of the 
 limb or separate muscular contractions alone prevail. 
 
 Another form occasionally met with is that of an associated move- 
 ment of the head and arm ; the head and eyes turn as if looking over 
 the shoulder, the pupils dilate widely, and the arm of this side is 
 simultaneously raised in the same direction with the forefinger ex- 
 tended, and a painful cry escapes tlie patient. This movement may 
 be repeated over and over again for hours in succession. It is 
 important to recognise this form as occasional in general paralysis 
 since it has been afiirmed that the cry is a distinctive feature, thus : — 
 "Patients in the fits of general paralysis seldom bite the tongue, the 
 convulsions are not so violent, there is not the aura, nor the cry, and 
 the mental symptoms will of coui'se be quite different." f (Blandford). 
 
 These convulsive attacks will be followed by the usual results 
 observed after severe discharges from cortical grey matter. There will 
 be partial, or more or less complete, paralysis of the muscles involved; 
 the facial muscles may be involved, the cheek flattened, and the 
 mouth drawn to the opposite side ; there may be more or less g'loSSO- 
 
 * Treatise on General Paralysis, p. 163. 
 t Op. cit., p. 266 (Italics not in original). 
 
262 GENERAL PARALYSIS. 
 
 pleg'ia, or the patient may be completely aphaslc with right brachial 
 monopleg'ia ; or the log only may bo tomporarily paralysed, or 
 hemiplegia may prevail. Conjug'ate deviation of the head and eyes 
 is also frequent as a })Ost-convulsive sign. 
 
 Epileptiform seizures may occur at an early period of the disease, 
 usually not until twelve months have elapsed. According to Dr. 
 Newcoml)e, out of 100 general paralytics, 51 patients suffered from 
 epileptiform seizures, and of these 51, as many as 19 did not develop 
 such symptoms until between twelve to twonty-fuur months after the 
 commencement of the disease, whilst one only had convulsions within 
 three months of the onset.* 
 
 The immediate result of these general, wide-spread, epileptiform 
 convulsions is of far greater import as affecting the mental aspect of 
 oiir patient. They usher in the gravest reductions, often leaving the 
 subject a complete mental wreck. Take for instance the case of 
 
 H. P., who was in the second stage of general paralysis, was mildly excited, 
 and the subject of extravagant, grandiose notions, yet retaining a fair amount of 
 mental energy sufficient to enable him to read, write, or to converse in a connected 
 strain of thought, so long as his delusional ideas were not entrenched upon. He was 
 suddenly seized with epileptiform convulsions, commencing on the left side of the 
 body, but usually spreading to the opposite side ; such seizures occurring several 
 times in the course of the day and night, and lasting for several days together. On 
 their cessation he was left in a condition of profound imbecility, from which he 
 never rallied. In his case, persistent and copious watery alvine evacuations 
 accompanied tlie convulsive attacks. 
 
 The mental deterioration following epileptiform seizures is often so 
 notable as to sharj)ly demarcate the stage of maniacal excitement and 
 delusional perversion from the last stage of hopeless dementia and 
 motor helplessness. 
 
 The epileptiform seizui*e is also ominous of rapid break-down ; " in 
 twenty-four out of sixty cases, death occurred within a month after an 
 attack" {N/'wcomb'').j 
 
 Apoplectiform Seizures. — The patient may be struck down 
 suddenly by symptoms of an apoplectic type, associated occasionally, 
 but by no means necessarily, with slight convulsive discharge. He 
 becomes helpless in his limbs, heavy, lethargic, and stupid, and this 
 state may deepen into complete coma. The face is deeply flushed, 
 the head hot, and the body generally bedewed Avith perspiration ; 
 the breathing may be heavy and laboured, the jnilse rapid, and the 
 temperature quickly rises to 103° or higher. The condition is always 
 
 * See "Epileptiform seizures in general paralysis of the insane," Went Iiidinj 
 Asylum Reports, vol. v. 
 t Loc. cit. 
 
PARALYTIC SEIZURES — REACTION-TIME IN GENERAL PARALYSIS. 2G3 
 
 a critical one, there being hypostatic engorgement of the lungs and 
 pneumonia threatening the patient's life; if this is not fatal, it is 
 always followed by serious results — viz., by various motor paralyses, 
 the advance of dysphag'ic symptoms, and by much increased mental 
 enfecblement. 
 
 Monoplegiae and Hemiplegise. — Paralysis suddenly occurring 
 without apoplectic or epileptic premonitions involving one or both 
 limbs, or complete hemiplegia, of very transient duration, is another 
 feature frequ.ently occurring in the course of this disease. The sudden- 
 ness of onset is notable ; the hand drops whilst at work utterly helpless; 
 or the patient suddenly stumbles whilst walking, and is found paralysed 
 in one leg ; the deep reflexes will be exaggerated and ankle-clonos 
 prevail. Patients will thus be found after a quiet night's rest suffering 
 from a CPUPal or a brachial monoplegia which may have com- 
 pletely disappeared in a few hours or days. 
 
 Reaction-Time. — A large proportion of paralytic subjects are 
 necessarily excluded from attempts at estimating the rapidity of 
 reaction to the stimuli of light and sound ; it is only in the earlier 
 stage of the disease, ere the patient has succumbed to any notable 
 degree of dementia, that a reliable record is obtainable. Such results, 
 however, have been secured in the accompanying series of patients, 
 special care having been exercised to exclude any source of fallacy, the 
 result being accepted only after repeated observations, and each record 
 being the average of twenty trials. 
 
 Reaction-Time in General Paralysis. 
 
 T. P., . Maniacal, garrulous, egoistic, 
 
 W. W. , . Subacute mania, grandiose, noisy, and obtrusive, 
 
 J. M., . Calm, subdued, demented, .... 
 
 W. L., . Wild, maniacal, incoherent,exiravaga7it optimism, 
 
 J. E. , . Subacute mania, grandiose and egoistic, 
 
 T. S., . Tremulous with excitement, oiitimistic, notable x>aresis, 
 
 R. C, . Calm, notable bulbar pai-alysis, much optimism, 
 
 S. M., . Calm, dull, heavy, demented, 
 
 J. N., . Heavy and demented, depressed, much paresis, 
 
 C. P., . Dejnessed, obscure egoism, sluggish, 
 
 W. II., . Mania, garrulous, obtrusively egoistic, . 
 
 T. E.., . Cheerful, calm, slight dementia, on optimism, 
 
 F. L., . Heavy, demented, ..... 
 
 Ace 
 Stii 
 
 ustic 
 nulus. 
 ec. 
 
 Optic 
 Stimulus 
 
 Sec. 
 
 
 16 
 
 •25 
 
 
 17 
 
 •24 
 
 
 17 
 
 •24 
 
 
 IS 
 
 •IS 
 
 
 IS 
 
 •21 
 
 ?, 
 
 18 
 
 •27 
 
 
 19 
 
 •23 
 
 
 19 
 
 •24 
 
 
 20 
 
 •27 
 
 
 21 
 
 •27 
 
 
 22 
 
 •23 
 
 
 24 
 
 •30 
 
 
 •o.:^ 
 
 .07 
 
 OculO-motor Symptoms. — The eye-symptoms in general paralysis 
 form a highly characteristic and significant group. Both the extrinsic 
 
264 GENERAL PARALYSIS. 
 
 and intrinsic muscles suffer ; but, whilst the former present derange- 
 ments in exceptional cases only, the lattor or intrinsic muscles of the 
 eyeball exhibit deranged innervation, in some way or other, in all 
 cases at some stage of the affection. 
 
 The motor derangements of the intra-ocular musculature are indi- 
 cated by — (a) size of pupils ; (b) inequality ; (c) marginal contour ; 
 (d) mobility; (e) reflex adjustments; (/) accommodative adjustments; 
 (g) accommodative power. The reflex adjustments (e), comprise the 
 pupillary reactions to — (1) cutaneous or sympathetic stimulation; (2) 
 consensual stimulation; (3) direct light stimulation.* 
 
 Taking indiscriminately a group of general paralytics in various 
 stages of the disease, the student may meet with one or other of the 
 following pupillary anomalies : — The pupils may be extremely small, 
 perfectly fixed to light, so that on exposing or shading the eye, no 
 movement can be obtained — the pin-hole pupil as it has been called; 
 and it is then said to be in a state of spastic myosis. Such a state 
 of contraction is highly important, as being frequently present in 
 general paralysis, locomotor ataxy, and other spinal afi'ections. The 
 pupil may be small as the result of paralysis of its dilator or circular 
 fibres; this is called paralytic myosis, and may be due to a des- 
 tructive lesion in the cilio-spinal regions of the cord ; in this case 
 the pupils no longer dilate with atroijine. It is a rare affection, but 
 has been recorded by Baerwinkel in sclerosis of the medulla oblongata.t 
 Unilateral myosis of this description has also been recorded by 
 Nothnagel in disease of the pons. The pupils may be unequal in size, 
 there may be only the slightest degree of inequality, yet if associated 
 with other paretic symptoms, or suspicious mental states, the ocular 
 reflexes should be carefully examined ere the student is pi-epared to 
 discard such inequality as of trivial import. Care, of course, should 
 be taken to exclude opacities of cornea, capsular adhesions, or retinal 
 changes. The inequality may be very extreme from paralysis of one 
 sphincter iridis. 
 
 One or both pupils may be in a state of wide dilatation, acting 
 sluggishly, or not at all, to the strongest beam of light — a state of 
 paralytic mydriasis. Such a condition may be associated with 
 
 amaurosis. 
 
 Or the pupils may be (one or both) ii-regular in contour ; may be 
 
 * It must be miderstood that the remarks in this chapter apply exclusively to 
 those persistent or gradually progressive impairments of the oculo-motor adjust- 
 ments, wholly irrespective of those variations in tlie size of the pupil which may 
 occur from day to day, and which inchule an inconstant factor, such as intra- 
 cranial discharges, &c., or other source of transient stimulus. 
 
 + Jour. Mental Science, 1878. 
 
PARALYSES OF INTRA-OCULAR MUSCULATURE. 265 
 
 oval or not quite circular — the upper or lower arc not conforming to 
 the circular outline; here, again, we must carefully exclude adhesions and 
 effects of old iritis. At times the irregularity is very marked and bizarre. 
 
 Again, the reflex adjustments may fail, and thus upon stimulating 
 the skin by the electric brush, or by a pin, or by pinching the skin, we 
 do not observe the usual dilatation of the pupils in one, or perhaps in 
 either case ; or upon alternately closing one or other eye, the other 
 fails to exhibit the consensual movements of the normal state ; and 
 this, likewise, may be observed in one eye only or in both. In a state 
 of sjmstic myosis, of course, both the foregoing reactions are abolished. 
 " In the healthy eye the consensual contraction, according to Listing, 
 does not begin until two-fifths of a second after the opening of the 
 other eye, and lasts about one-fifth of a second, after which the pupil 
 again dilates slowly, and vibrates for some seconds. The consensual 
 dilatation he observed to commence about half a second after the 
 closing of the other eye, and with diminishing rapidity to continue for 
 one or two seconds."* Then again, the sphincter iridis, either when, 
 the pupils are equal or very dissimilar in size, may not respond to the 
 stimulus of light, or may respond with a sluggishness evidently morbid. 
 This condition of failure of the light-reflex without a similar impli- 
 cation of the accommodative movements of the iris is called reflex 
 iridopleg'ia, or the Argyll-Robei-tson symptom, which is one of great 
 significance in early stages of tabes and general paralysis. Yet again, 
 the sphincter may show no response to light, nor to the effort of 
 accommodation, nor the movements of convergence and divergence; and 
 the resulting paralysis we speak of as an associative iridopleg'ia. 
 
 Any one of these numerous anomalies may present themselves in 
 the subjects of general paralysis. The contraction which occurs during 
 accommodation for a near object, and when the eyeballs are convergent, 
 must be regarded as of the nature of an associated movement ; yet we 
 must not understand by this that the accommodative movement is 
 involuntary. " The fact that this last (contraction during accommo- 
 dation) is only an associated movement, does not deprive it of its 
 voluntary character, "t 
 
 The more frequent motor derangements met with may thus be 
 summarised : — 
 
 1. Spastic myosis. 5. Loss of sympathetic reflex. 
 
 2. Paralytic mydriasis. 6. Loss of consensual movements. 
 
 3. All degrees of irregularity of pupil. 7. Reflex iridoplegia (Argyll-Eubertson). 
 
 4. Irregular contour from partial S. Associative iridoplegia. 
 
 spasm or paralysis. 9. Cycloplegia. 
 
 * Quoted by Bonders, "Accommodation and Refraction of the Eye," Stjil. Soc, 
 p. 573. t Donders, loc. c'U., p. 574. 
 
2GG 
 
 GENFKAL PARALYSIS. 
 
 As to the relative frequency with which tliese derangements to the 
 iritlo-inuscular apparatus occurs, we usually find as an early sign 
 a slight, perhaps scarcely appreciable, inequality of the pupils, the 
 sizes of M'hich are otherwise not abnormal, accompanied by a little 
 sluggish delay upon the part of the larger in reacting to light, while 
 the smaller contracts and dilates briskly. If the light be bright 
 this want of active mobility may not be appreciable, hence the 
 necessity of testing in a subdued light as well as by focal illumination. 
 If the patient be now told to converge the eyeballs, the pupils con- 
 tract readily and equably, and we regard the case as one of com- 
 mencing reflex iridoplegia. If this be the case, we shall now almost 
 certainly find associated with it, the loss of the sympathetic dilatation 
 which should occur on irritating the skin ; for this is, of all other 
 iridal paralyses, the earliest observed. The strong stimulation of a 
 sensory nerve is well known to inhibit reflex actions ; and upon this 
 physiological principle, Bechterew would explain this pupillary dilata- 
 tion as, in fact, an inhibition of the usual light-reflex ; it is equally 
 produced by noises in the ear, or by stimulation of the sexual organs, 
 uterine pain, kc. The constant association of these two anomalous 
 states is readily explained by the proximity of the sympathetic tract 
 supplying the dilator iridis to that nucleus of the oculo-motor which 
 regulates the sphincter iridis imder the stimulation of light. 
 
 The large proportion of paralytics who present themselves in an 
 early stage will afibrd us these signs — viz., a moderate-sized pupil, 
 slightly larger than its fellow, sluggishly reacting to light, even to 
 a bright beam, and absence of the sympathetic dilatation. 
 
 In the more advanced stages, the larger puj^il will now be found 
 quite fixed to light or may contract very partially ; and, if a strong 
 beam of light be used to illuminate the eye, the initial slight con- 
 traction is followed by a sudden dilatation beyond its original limits ; 
 remaining wide throughout the illumination of the retina. One eye 
 succumbs to this reflex iridoi")legia before the other ; but, we often 
 recognise a failing mobility in the healthier organ also, and eventually 
 both become quite fixed and immobile to light. The small-sized pupil 
 {myosis), although usually noted at an early stage of the disease, is not 
 thus restricted ; it may retain this size throughout the disease, and 
 be a notable sign even to the fatal termination. On the other hand, 
 mydriasis, if not associated with distinct amaurosis, is a feature of 
 the later stage of general paralysis. The student would do well, when 
 examining the eye of a presumed case of general jiaralysis, not only 
 to measure with the pupilometer but also to compare the dimensions 
 with the healthy eyes of those standing by, under the same intensity of 
 light. As the small pupil in the early days of general paralysis 
 
PUPILLARY ANOMALIES. 
 
 267 
 
 becomes gradually larger with advancing reflex iridoplegia, it afTords us 
 evidence of a deeper implication of the nuclei in one half of the pons, 
 as loell as of the cerebral hemisplcere of the same side ; for it has con- 
 stantly occurred to the writer to observe that when unilateral convul- 
 sions or paralysis occur in the early stages of general paralysis, the 
 dilated pupil is 07i the side of the discharging/ or 2y<^i'(d!/sing lesion* 
 It appears to us unquestionable that the oculo-motor disturbances, 
 Avliich we have above alluded to, are greater on the side of the more 
 deeply-implicated hemisphere. 
 
 The pi7ihead jmjjil may 2:)ersist to the end, and yet present no impair- 
 ment of the associated movements on accommodation, as in the 
 followinc: cases : — 
 
 
 Size of Pui'Ils. 
 
 Reaction to Stmpathetic 
 Light. Beflf.x. 
 
 consf.kscal 
 Bf.flkx. 
 
 Accommodation. 
 
 D. K. 
 
 S. A. L. 
 
 1 .,.- millimetres. 
 1 o 
 
 1-5 
 
 1-7^ millimetres. 
 
 Immobile. 
 Immobile. 
 
 Immobile. 
 Immobile. 
 
 Immobile. 
 
 Slight in 
 left only. 
 
 Normal and ac- 
 tive. 
 
 Brisk. 
 
 In estimating the significance of these ocnlo-motor anomalies, the student must 
 bear in mind the teaching of experimental physiology upon the subject, which 
 demonstrates 
 
 (1) That centripetal retinal excitations travel by way of the optic nerve and 
 tracts to tlie upper quadrigeminal arc, i.e., by the nates, its hrachki, the external 
 geniadate, and the pjtlvinar of the optic thalamus, which constitute a first stage or 
 level, and from which such excitations pass by the optic radiations to the occipito- 
 angular region, or visual centre of Ferrier. 
 
 (2) That section of one optic nerve causes monocular blindness, together with 
 loss of the light-reflex {reflex iridoplegia) of the same eye, still with persistent 
 contraction of both eyes on stimulation of the second eye — a phenomenon explained 
 by the coupling of the oculo-motor nuclei. 
 
 (3) That section of one optic tract issues in homonymous hemiopia, from paraly- 
 sis of the corresponding retinal halves of both eyes. Whilst Bechterew shows 
 that, in the dog, division of one tract is unaltered by reflex contraction of the 
 constrictor iridis. Knoll indicates that in the rabbit (with its complete decussation 
 at the chiasma) division of one tract abolishes the light-reflex in the opposite eye. 
 
 (4) That enucleation of one eyeball in animals with fairly complete decussation 
 at chiasma (rabbit) issues in atrophy of the nates, its brachia, and external genicu- 
 late, with the pidvinar, all of the opposite side ; that in animals with very incom- 
 plete decussation, i.e., where the direct fibres preponderate (Erh and Day), such 
 atrophy pertains more equally to these parts on both sides. The representation of 
 the retinal fields in these ganglionic centra Ijehind the optic commissure will vary 
 with the animal ; and so lesions of the tract or of the quadrigeminal body of one 
 
 See Article by Author in West Biding Asylum Reports, vol. vi. 
 
26S GENERAL PARALYSIS. 
 
 side will issue in varj-ing results. Thus Baunii,'arten * records secondary degener- 
 ation of both optic tracts in man after destruction of one eye. 
 
 In this lower arc, therefore, connecting the retina with the mesencephalic 
 centres, we find that section and destructive lesions on tlie peripheral side of the 
 ganglia issue in — 
 
 Partial or complete amaurosis, with partial loss of the consensual reflex and 
 
 reflex -iridoplegia. 
 Homonymous hemiopia, with, or without, impairment of light-reflex ; certain 
 
 secondary degenerative changes affecting the tracts and the (juadrigeminal 
 
 structures with the pulvinar alluded to above. 
 
 In like manner, destruction of these ganglia also issue in degenerative changes 
 in both optic nerves, especially that opposite the lesion. Such degenerations are 
 limited to this arc, and do not travel centralbj beyond the quadrigeminal centres to 
 the cerebral cortex. 
 
 On the other hand, the upper arc of optic radiations is connected with the 
 visual perceptive centres of the cortex. Its division is followed by atrophy of the 
 cortex and of the quadrigeminal arc, as well as of the lower arc connected with 
 the retina ; but it must be remembered that the retinal reflexes are not abolished 
 by lesion above the mesencephalon. 
 
 Size of Pupils. — The pupillary aperture is more frequently found 
 dilated than unduly small and constricted, and a moderate-sized pupil 
 is less frequent than one distinctly larger than usual. In fact, if "we 
 take note of all cases of unilateral mydriasis, as well as of those 
 wherein both are dilated, we shall find that it is met with in one- 
 half of our cases. If we arbitrarily assume any size up to 2 milli- 
 metres diameter to include the small or contracted 2)^2^11, from above 
 2 millimetres to 3 millimetres for the moderate-sized 2iU2^il, and all 
 above 3 millimetres as large dilated pupils, we get the following 
 propox'tions : — 
 
 Small contracted pupil, .... 4 cases. 
 
 Moderate-sized, . . . . . . 13 ,, 
 
 Dilated, ^7 „ 
 
 In about half the cases, i.e., in twenty-one, one or both pupils measured 
 -i millimetres or upwards, and in six of these cases both pupils were 
 equal in size. Very large pupils — 6 to 7 millimetres — prevailed in 
 three cases (see Summary, pp. 269-273). In the Summary, the upper 
 figure of the fraction in col. 2, and corresponding line in col. 3, indi- 
 cate in each case the size of pupillary aperture and iridal reactions 
 of the right eye ; the lower figure and line refer to the same features 
 in the left eye. In all other cases the i-eactions are alike for both eyes. 
 
 * Central-hlatt. f. d. Med. Wisaenschajt, 1SS3. (Quoted by /erncr.) 
 
ANALYSIS OF OCULAR DERANGEMENTS. 
 
 269 
 
 
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 T3^- 
 
 
 lO 
 
 lO 
 
 
 CO 
 
 o 
 
 
 c^ 
 
 
 
 "^^ 
 
 ■* 
 
 "* 
 
 
 CO 
 
 CO 
 
 
 CI 
 
 
 g c 
 
 ^ ^H 
 
 
 
 
 CO 
 
 (—1 
 
 
 
 
 o 53 
 
 Ph 
 
 
 
 
 
 
 
 
 
 So 
 
 lO 
 
 (N 
 
 (M 
 
 
 00 
 (M 
 
 CO 
 
 
 -' 
 
 
 
 _J^ 
 
 
 
 
 
 
 
 
 
 ^ 
 
 so 
 
 
 UO 
 
 VO 
 
 eo 
 
 CO 
 
 
 CI 
 
 
 x2 
 
 f!co 
 
 
 TfH 
 
 ^ 
 
 1— 1 
 
 CO 
 
 
 CI 
 
 
 
 
 
 
 
 
 
 
 
 
 «3 
 
 f^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 « 
 
 CO 
 
 
 (M 
 
 (>) 
 
 iO 
 
 CO 
 
 
 1—1 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 ^ 
 
 gr-l 
 
 lO 
 
 (M 
 
 
 
 CO 
 
 CI 
 
 
 
 3 
 
 
 TjH 
 
 CI 
 
 o 
 
 LO 
 
 CO 
 
 CI 
 
 
 
 3 
 
 o 
 
 Pi 
 
 
 
 
 
 
 
 
 
 C5 
 
 CM 
 
 1— I 
 
 ^ 
 
 ^ 
 
 o 
 
 ^ 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 
 
 ^• 
 
 
 
 
 
 
 
 
 
 § 
 
 a 
 
 
 C^ 
 
 
 C5 
 
 t- 
 
 CO 
 
 
 (N 
 
 ""* 
 
 
 (M 
 
 o 
 
 o 
 
 C<l 
 
 CO 
 
 
 CI 
 
 ci rt 
 
 SCO 
 
 
 
 
 1— 1 
 
 d 
 
 1— ( 
 
 
 
 ^." 
 
 f^ 
 
 
 
 
 
 
 
 
 
 f^a 
 
 
 
 
 
 
 
 
 
 
 
 uo 
 
 
 1— 1 
 
 rP 
 
 t^ 
 
 o 
 
 CO 
 
 
 1— 1 
 
 t-( 
 
 
 
 
 
 
 '"' 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 X 
 
 SM 
 
 o 
 
 CO 
 
 CO 
 
 CI 
 
 !M 
 
 
 
 
 w 
 
 "■o 
 
 -* 
 
 
 
 CO 
 
 CO 
 
 
 
 
 /v* 
 
 SM 
 
 
 r— ( 
 
 1— ( 
 
 (— 1 
 
 1—1 
 
 
 
 
 '^- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 io 
 
 O 
 
 (M 
 
 lO 
 
 lo 
 
 CO 
 
 CO 
 
 
 
 
 ^ 
 
 f— 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , — ■ — , 
 
 
 
 
 
 
 
 
 
 
 
 
 (U 
 
 
 
 
 
 
 
 
 CJ 
 
 
 so 
 
 
 
 
 
 
 
 
 m 
 
 
 
 
 
 ^ 
 
 
 
 
 
 o 
 
 
 c3 
 
 a 
 
 
 ri3 
 
 
 ■ 
 
 
 
 
 
 P^i 
 
 
 
 
 
 
 
 
 
 
 <p 
 
 c3 
 
 
 
 >^ 
 
 4J 
 
 
 
 "S ^ 
 
 
 
 s 
 
 ^ 
 
 0) 
 
 g 
 
 O 
 
 
 
 m 
 
 
 5 
 
 
 
 
 
 
 
 
 
 
 
 'S. 
 
 ;i. 
 
 - 
 
 -u 
 
 so 
 
 
 -i-J" 
 
 ^ 'l 
 
 ^-• 
 
 "oj 
 
 3 
 CM 
 
 
 
 1- ■ 
 
 02 
 
 Is 
 
 g 
 
 S-l 
 
 
 +i 
 
 g 
 
 
 o 
 
 ^ 
 
 ^ 
 
 ^ 
 
 
 
 o 
 
 o 
 
 X 
 
 
 W 
 
 
 
 
 :z; 
 
 ^ 
 
 <1 
 
 a 
 
 a 
 
 3 
 
 P4 
 
 f4 
 
270 
 
 OCULO-MOTOn ANOMALIES. 
 
 Summary of Oculo-Motou and Associated Anomalies in 
 
 
 Size 
 
 iu 
 mm. 
 
 Light-Uenes. 
 
 Focal Illuminatioa 
 
 ConsensuaL 
 
 Ilenex 
 Dilatation. 
 
 Associated 
 Movement 
 
 J.W. M., 
 
 45- 
 3 
 
 Almost fixed. 
 Slight contii. 
 
 Slight contn. 
 
 Normal. 
 
 Fixed. 
 
 Normal. 
 
 J. 0. 0., 
 
 3 
 4 
 
 Slight. 
 Normal. 
 
 Slight. 
 Normal. 
 
 >> 
 
 >> 
 
 >> 
 
 M. P., . 
 
 2^ 
 4 
 
 Normal. 
 
 Normal. 
 
 >, 
 
 >> 
 
 >> 
 
 A. S., . 
 
 34 
 
 44 
 
 )> 
 
 ,, 
 
 Sluggish. 
 
 )> 
 
 Sluggish. 
 
 J. D., . 
 
 4 
 
 H 
 
 Sluggish. 
 
 Slight, then oscillates. 
 2dy dilatation. 
 
 Normal. 
 
 Normal. 
 
 Normal. 
 
 M. B., . 
 
 3 
 3 
 
 Normal. 
 
 Normal. 
 
 >j 
 
 Fixed. 
 
 >» 
 
 L. B., . 
 
 24 
 
 " 
 
 Normal for both. 
 2dy dilatation. 
 
 >. 
 
 Normal. 
 
 »> 
 
 F. S., . 
 
 4 
 4 
 
 )) 
 
 Normal. 
 
 > > 
 
 Normal. 
 
 Sluggish. 
 
 >> 
 
 K. T., . 
 
 3 
 
 >y 
 
 " 
 
 Normal. 
 Dilates. 
 
 Sluggish. 
 
 >> 
 
 S. S., . 
 
 2 
 2 
 
 " 
 
 > J 
 
 Normal. 
 
 Normal. 
 
 >> 
 
 J. P., . 
 
 3i 
 
 - 
 
 jj 
 
 " 
 
 Fixed. 
 
 >> 
 
 J. w., . 
 
 3 
 3 
 
 Sluggish. 
 
 Normal, then oscillates. 
 2('y dilatation. 
 
 >) 
 
 Normal. 
 
 Normal. 
 
 Sluggish. 
 
 J. L., . 
 
 9L 
 
 3 
 
 Sluggish and of 
 limited range. 
 
 Normal but of 
 limited range. 
 
 ,, 
 
 Slight. 
 
 NormaL 
 
 R. S., . 
 
 91 
 
 24 
 
 Fixed. 
 Slight. 
 
 Slight. 
 Normal. 
 
 )> 
 
 Normal. 
 
 )> 
 
 A. H., . 
 
 S. A. L., 
 
 2 
 
 3 
 
 1-5 
 1-5 
 
 Fixed. 
 
 Fixed. 
 
 Sluggish. 
 
 Fixed. 
 
 Fixed. 
 
 Slight. 
 Fixed. 
 Slight. 
 
 Fixed. 
 Slight. 
 
 Fixed. 
 
 Fixed. 
 Slight. 
 
 NormaL 
 
 D. R., . 
 
 1? 
 14 
 
 >> 
 
 >) 
 
 Fixed. 
 
 >i 
 
 >i 
 
 J. W., . 
 
 If 
 
 >) 
 
 Fixed or of extremely 
 limited range. 
 
 " 
 
 " 
 
 Extremely 
 sluggish 
 
 and 
 limited. 
 
 G. B., . 
 T. W. H., 
 
 2 
 
 ol 
 
 -4 
 
 3 
 
 " 
 
 Fixed. 
 
 19 
 
 >» 
 >» 
 
 >> 
 »> 
 
 NormaL 
 
 J. C, . 
 
 24 
 
 " 
 
 »» 
 
 1 
 i 
 
 )> 
 
 >i 
 
 
 
 
 
 
 
 
oculo-motoii anomalies. 
 Forty-Four Cases of General Paralysis. 
 
 271 
 
 Accom- 
 modation. 
 
 Visual Acuity. 
 
 Colour 
 fcjense. 
 
 Patella- 
 Kellcx. 
 
 Plantar 
 llelle.x. 
 
 Gait, &c. 
 
 J. 22 S"- 24 
 J- 22 ^"- '22 
 
 J. No. 4 
 J. No. 4 
 
 Sn. 
 Sn. 
 
 Normal. 
 
 Sn. ? 
 
 Sn. - Sn. 
 
 Sn. ^ Sn. 
 b 
 
 No. 2 
 
 s».- 
 
 ? dil. 
 
 6 
 
 J. 
 
 16 
 
 J ^ 
 
 28 
 
 J.No.3Sn.„" 
 2o 
 
 Sn. 
 
 34 
 
 J. 1 Sn. 
 
 25 
 
 Sn. 
 
 30 
 
 J.No.lSu, 
 
 20 
 
 J. 
 
 1 
 20 
 
 Sn 
 
 2i 
 20 
 
 Sn. 
 
 Sn. 
 
 10 
 6^ 
 12 
 
 Q 6 
 
 Sn. 
 
 Sn. 
 
 Sn. 
 
 30 
 
 10 
 
 10 
 
 Sn. - 
 
 Sn. 
 
 Sn.| 
 
 Sn. 
 
 Sn 
 
 Sn. 
 
 Sn. 
 
 Normal 
 
 but green 
 
 = blue. 
 
 Normal. 
 
 Normal 
 
 but b. = 
 
 puce, y. " 
 
 pink. 
 
 Normal 
 
 but b. = 
 
 green. 
 
 y. = orange 
 
 g. = puce. 
 
 Normal. 
 
 Normal 
 but green, 
 more like 
 blue than 
 
 yellow. 
 
 r. = pink, 
 
 y. = purple, 
 
 b. & green 
 
 = Normal. 
 
 Normal. 
 
 Normal 
 but green 
 = yellow. 
 
 Normal. 
 Exag. 
 
 Slightly 
 exag. 
 
 Sluggish. 
 Normal. 
 
 Sluggish. 
 
 Almost 
 absent. 
 
 Exag. 
 
 Normal. 
 Absent. 
 
 Sluggish. 
 Normal. 
 
 Exag. 
 Normal. 
 
 SI. exag. 
 
 Slight. 
 Absent. 
 
 Absent. 
 
 Normal. 
 
 Sluggish. 
 
 Normal. 
 
 Absent. 
 Exag. 
 
 Normal. 
 
 Exac. 
 
 Absent. 
 
 Exag. 
 Normal. 
 
 Normal. 
 
 Sluggish. 
 
 Normal. 
 
 Brisk. 
 
 Brisk. 
 
 Brisk. 
 
 Brisk, trunk stiff. 
 
 Brisk. 
 
 Brisk. 
 
 Brisk. 
 
 Brisk, and runs. 
 
 Sways, staggers, and leans to right. 
 Stiff, tottering, feeble. 
 
 Brisk, but stiff, a little tottering. 
 
 Stooping, staggering, and falls if eyes 
 be closed. 
 
 Brisk. 
 
 Right leg stiff — not dragged ~ right 
 hemiplegia c. aphasia, horizontal 
 nystagmus. 
 
 Stiff, slow, sways. 
 Brisk, elastic. 
 
 Brisk and springy. 
 
 Slow, laboured, leans to left side. 
 
 Brisk. 
 
 Stiff. 
 
 Stiff. 
 
OCULO-MOTOU ANOMALIES. 
 
 
 Size 
 
 In 
 
 mm. 
 
 Light-Reflex. 
 
 Focal Illumination. 
 
 Consensual. 
 
 Ri-flet 
 Dilatation. 
 
 A880ciat«d 
 Movement. 
 
 J. H. W., 
 
 2? 
 
 Fixed. 
 
 Fixed. 
 
 Sli-ht. 
 Fixed. 
 
 Fixed. 
 
 Normal. 
 
 B.K., . 
 
 34 
 
 >) 
 
 II 
 
 Fixed. 
 
 )» 
 
 Fixed. 
 
 W. M., . 
 
 3 
 
 3 
 
 »» 
 
 >i 
 
 )i 
 
 >i 
 
 II 
 
 C. J. C, . 
 
 
 >> 
 
 II 
 
 M 
 
 >) 
 
 Fixed. 
 Normal. 
 
 J. J., . 
 
 4 
 
 j> 
 
 II 
 
 )l 
 
 >> 
 
 Sluggish. 
 
 J. H., . 
 
 4 
 3 
 
 » 
 
 11 
 
 11 
 
 )) 
 
 Fixed, 
 Normal. 
 
 J. L., . 
 
 4^ 
 44 
 
 ,, 
 
 >» 
 
 ,, 
 
 ,, 
 
 Fixed. 
 
 J. C. C, 
 
 64 
 6 
 
 »> 
 
 II 
 
 1) 
 
 u 
 
 II 
 
 J. M., . 
 
 7 
 5 
 
 )j 
 
 II 
 
 .' 
 
 M 
 
 II 
 
 J. A., . 
 
 34 
 4| 
 
 Slight, 2'ly dilatation. 
 Fixed. 
 
 II 
 
 ,, 
 
 ) I 
 
 ?dil. 
 
 E. B., . 
 
 2i 
 1^ 
 
 Fixed. 
 Slight, 2Jy dilatation. 
 
 Fixed. 
 Slight, 2iy dilatation. 
 
 5) 
 
 ,, 
 
 Normal. 
 
 J. H., . 
 
 34 
 
 Sluggish. 
 
 Sluggish. 
 2'ly dilatation. 
 
 Slight. 
 
 Normal. 
 Slight. 
 
 .. 
 
 A. S., . 
 
 4 
 4 
 
 Normal. 
 Sluggish. 
 
 Normal. 
 Sluggish, 2'ly dilatation. 
 
 Fixed. 
 
 Fixed. 
 
 1) 
 
 J. T., . 
 T. T., . 
 
 4 
 
 M 
 4 
 
 4 
 
 Sluggish and of 
 limited range. 
 
 Sluggish and of 
 limited range. 
 
 Sluggish. 
 Sluggish. 
 Normal. 
 Sluggish. 
 
 Sluggish. 
 
 Fixed. 
 
 Sluggish. 
 
 Slight. 
 
 >> 
 
 C. G., . 
 
 6 
 6 
 
 Sluggish. 
 
 Normal with 
 2''y dilatation. 
 
 >i 
 
 Sluggish, 
 Fixed. 
 
 Sluggish. 
 
 J. M., . 
 
 2i 
 
 
 Slight with 
 2'ly dilatation. 
 
 Slight with 
 2<ly dilatation. 
 
 Fixed. 
 
 Fixed. 
 
 Normal, 
 
 J. B., . 
 
 3^^ 
 3i 
 
 )> 
 
 Normal witli 
 2'ly dilatation. 
 
 ,, 
 
 )) 
 
 i> 
 
 W. T. S., 
 
 W. S., . 
 
 ■1 
 
 44 
 4.^ 
 4i 
 3? 
 
 Slug-ish. 
 Sluggish. 
 
 Sluggish. 
 
 Normal. 
 
 Sluggish, 2'ly dilatation. 
 
 Normal, then oscillates 
 
 with 2'ly dilatation. 
 
 Normal. 
 Sluggish. 
 
 Sluggish. 
 
 Sluggish, 
 
 Sluggish. 
 Fixed, 
 
 Normal, 
 Sluggish. 
 
 Normal. 
 
 H. M., . 
 
 3 
 
 2? 
 
 SlUfT-ish. 
 
 Fixed. 
 
 Normal. 
 Fixed, 
 
 Normal. 
 Fixed. 
 
 Fixed. 
 
 Slight. 
 Fixed, 
 
 B. H., . 
 
 4 
 3 
 
 Slight. 
 
 Slight. 
 
 Slight. 
 
 >> 
 
 Normal, 
 
 'J. B., . 
 
 44 
 
 44 
 
 Slight with 
 2'ly dilatation. 
 
 Slight, 2'ly dilatation. 
 Normal, 2'ly dilatation. 
 
 )> 
 
 9 
 
 »} 
 
 Note. —The upper figure of the fraction in col. 2 and corresjionding line indicate in each case the size 
 
 same features in the left eye. In all other 
 
OCULO-MOTOR ANOMALIES. 
 
 273 
 
 Accom- 
 modation. 
 
 ^■i 
 
 S°-20^"- 20 
 
 J. No. 1 Sn. "o 
 J- 25 ^''- 2f, 
 
 J. No. 2 
 
 J- 2^4 
 ? dilatn. 
 
 ^^•27 
 ? dilatn. 
 
 Sn. ;4 
 
 1/ 
 
 S"-fs 
 
 Visual Acuily. 
 
 Colour 
 Sense. 
 
 Sn. 
 
 Sn. 50 only 
 Sn.^Sn.-*^ 
 
 Sn. 
 Sn. 
 
 s°- ro ^"- (5 
 
 Sn. 
 
 Normal. 
 
 2 
 
 19 
 5 
 21 
 
 J. 
 
 J. 
 
 J. No. 1 
 J. No. 4 
 
 J. 
 
 42 
 
 Su. 
 
 Su. 
 
 Sn. 
 Sn. 
 Sn. 
 
 10 
 
 18 
 
 _6 
 24 
 6^ 
 40 
 
 10 
 
 ^"•10 
 Sn.5 
 
 Sn. 
 
 30 
 
 Sn. ,; Sn. - 
 b o 
 
 Normal 
 but gv. =': 
 
 Normal. 
 
 Normal 
 
 but y. =? 
 
 Normal. 
 
 Normal 
 
 but gr. 
 
 = yellow. 
 
 Normal. 
 
 Normal 
 
 but gr. 
 
 = crimson, 
 
 Normal. 
 
 Normal 
 but gr. 
 = puce. 
 
 Normal. 
 
 r.itella- 
 Itellex. 
 
 Normal. 
 
 Normal. 
 
 Exag. 
 
 Normal. 
 Exacc. 
 
 Absent. 
 
 Exag. 
 clonos. 
 
 Almost nil, 
 
 Exag. 
 
 Absent. 
 
 Exag. 
 
 Normal. 
 
 Sluggish. 
 Normal. 
 
 Exag. 
 
 Absent. 
 
 Normal. 
 
 Exag. 
 
 Exag. 
 Absent. 
 
 Absent. 
 Sluggish. 
 
 Exag. 
 
 Plantar 
 Keflex. 
 
 Sluggish. 
 
 Nonnal. 
 Absent. 
 Normal. 
 
 Exag. 
 Sluggish. 
 Normal. 
 
 Sluggish. 
 
 Normal. 
 
 Slight. 
 
 Sluggish. 
 
 Exag. 
 
 Sluggish. 
 Normal. 
 
 Sluggish. 
 Normal. 
 
 Exag. 
 Normal. 
 
 Normal. 
 Sluggish. 
 
 Stiff, broad basis, heels down first. 
 
 Legs drop, left hemiplegia = contrac- 
 ture of left arm, cannot stand un- 
 supported. 
 
 Brisk. 
 
 Leans to left side. 
 Stiff. 
 
 Brisk. 
 
 Quick, elastic. Both lenses opales- 
 cent. 
 
 Brisk. 
 
 Flexion and rigidity of both legs and 
 right elbow; cannot stand. Adhe- 
 sions in both, pigmentary deposit 
 on front of lens. 
 
 Stiff, waddling, but stands unsup- 
 ported. 
 
 Stiff. 
 
 Heavy, tottering. 
 
 Stooping, bent, unsteady, insecure. 
 
 Left eye strongly convergent when 
 eyes are directed to right. 
 
 Brisk. 
 
 Brisk. 
 
 Brisk. 
 
 Right leg dragged ; right arm con- 
 tracted ; feeble gi-asp. 
 
 Brisk. 
 
 Brisk, spring}'. 
 
 Stooping, shuffling, most hisecure. 
 
 Stiff. 
 
 Cannot walk or stand. 
 
 of pupillary aperture, and iridal reactions of the right eye : the lower figure and line refer to the 
 cases the reactions are alike for both eyes. 
 
 18 
 
274 GENERAL PARALYSIS. 
 
 Unilateral deviations were noted in twenty-seven cases, the remain- 
 ing seventeen having pupils of equal dimensions. In sixteen cases the 
 right, and in eleven cases the left, was the larger pupil of the two. 
 
 Lig'ht-Peflex. — Referring to our table of actual figures, it is found 
 that over 3G per cent, have hoth pupils 'perjtclhj immobile and fixed 
 to the stimulus of light, and that half as many again, i.e., 18 per 
 cent., show fixity or sluggish reaction in one or other eye. Further, 
 in 11 per cent, both pupils were noted as excessively sluggish in 
 reaction and limited in their range, and in 18 per cent, only 
 could it be stated that the pupils reacted normally under the stimulus 
 of light. The immobility of the pupils is rigid even to focal illumina- 
 tion of the eye by a convex lens, and with a strong light — as many as 
 24 per cent, still exhibiting both pupils immobile. 
 
 An early indication of commencing iridoplegia is given by focal 
 illumination, for, as shown by the table, 13-6 per cent., although active 
 to light, show (for a concentrated beam of light) a most limited range 
 of movement, together with an oscillation which then tends to wide 
 dilatation even under this bright illumination of the retina. This ten- 
 dency to dilate during stimulation by light appears to me to be the 
 earliest augury of coming pai'alysis. 
 
 Consensual Movements. — These reactions were abolished in 
 43 per cent, of the total cases, and were almost invariably absent 
 where the light-reflex was absent in both pujnls. A considerable 
 number, however, of cases of incomplete or commencing paralysis to 
 light showed perfectly normal consensual movements (25 per cent.), 
 or but slight impairment, amounting to sluggish response or unequal 
 response, on both sides. 
 
 The failure of the consensual movements apparently never occurs 
 apart from impairment of the direct or light-reflex (the only excep- 
 tion, if it is one at all, is that of K. T., where very sluggish dilatation 
 is noted with normal light-reflex): It appears invariably to follow 
 upon the latter impairment, and thus we find in a few cases [R. S., 
 e.g.), that the light-reflex is impaired, whilst the consensual activity is 
 normal in both eyes. 
 
 Reflex Dilatation {Erb). — This movement, which, as before stated, 
 Bechterew regards in the light of an inhibitory action, fails at an early 
 date. It was completely abolished in 63 "6 per cent., and normal 
 response was obtained only in 11-3 per cent. Excitation of any avail- 
 able sensory surface alike fails to produce response in such cases ; and, 
 it is of interest to note, that unilateral failure of this reflex dilatation 
 also occurs (being present in 13*6 per cent.) In several of the cases 
 tabulated, it will be noted that this reflex dilatation failed where the 
 pupils showed healthy and active response to the stimulus of light, 
 
REFLEX IRIDOPLEGIA. 275 
 
 both directly and consensually (see U. P. ; A. S. ; M. B. ; K. T. ; and 
 J. P.) This anomalous condition we believe to be the earliest sign of 
 approaching irido-raotor implication ; following in its wake comes the 
 sluggish reaction of one pupil to light with a tendency to dilate on 
 sustained illumination ; then a gradually extending paralytic mydriasis, 
 with which becomes associated the impairment of consensual activity. 
 
 Associated Irido-MotOP States. — The associated movements of 
 contraction and dilatation of the pupil during the act of accommodation 
 and eflbrts of convergence are affected only in the later stages of the 
 disease; and in five cases only (or 11-3 per cent.) was it absolutely 
 lost in both eyes ; whilst, as many as twenty-eight (or 63-6 per cent.) 
 showed perfectly-normal response. It may likewise show unilateral 
 impairment or abolition ; and in several cases i^F. B. ; C. J. C; 
 A. H. ; and J. W.) with complete abolition of the light-reflex in both 
 eyes, the associated iridoplegia appeared but on one side, the other 
 pupil acting vigorously to convergent efforts.* 
 
 From the study of a large number of cases of paralytics showing 
 these oculo-motor troubles, it appears to us that — 
 
 Firstly, the smaller pupil is upon the side of lesion of the oculo- 
 motor nucleus, or the larger pupil is opposite to the nucleus involved. 
 
 Secondly, that the smaller pupil is the one which fails to act con- 
 sensually, if one only shows a faikire in this respect. 
 
 Thirdly, that the smaller pupil is the one in which light-reflex 
 is most impaii'ed or is abolished, if both are not equally implicated in 
 this respect. 
 
 If it be accepted that the path of the light-reflex is through the 
 central decussating fibres of the chiasma to the opposite oculo-motor 
 nucleus (the decussating opto-geniculate tracts), as well as to the 
 constrictor centre of the same side by means of the intercentral link, 
 then a lesion of one centre, say the right motor-oculi, will intercept 
 the path of stimuli between, the left retinal field and both irides. But 
 although the left eye can pass no stimuli to either constrictor jmpillce,. 
 its iris can still be affected by stimulation of the opposite eye, through 
 the crossed opto-geniculate tract, or even through the inter-retinal 
 commissure. The left pupil, therefore, as well as the right, would be 
 paralysed or fixed to direct light stimulation ; but whilst the left would 
 still be consensually afiected, the right would be fixed to both in- 
 fluences. The six cases afforded by our series confirm these A'iews in 
 every respect. 
 
 * It has been conclusively shown by Donders, as well as by De Ruiter and 
 Cramer, that the associated contraction of the pupil occurs with the act of accom- 
 modation, when there is no increased convergence of the visual Hnc, and also with 
 the latter when there is no change in acconunodation, Loc. cit., p. 574. 
 
27G GENERAL PARALYSIS. 
 
 It thus appears tliat tliore are two links betwixt the quadri- 
 geminal centres and tlie coi'tex. on tlie one hand, and tlie jieriphery 
 on the other. An upper cortical und a lower or retinal — consisting 
 respectively of the optic radiations from the thalamus and mesen- 
 cephalon, extending to the occipito-angular region ; and a lower link 
 from the retina to the mesencephalon ; the upper being essential for 
 visual perceptions — the lower being also the centripetal paths for the 
 irido-motor reflexes. Lesions of the lower retinal link are productive 
 of secondary changes backwards to the quadrigeminal regions (Obs, 4, 
 p. 267), but not beyond this limit ; lesions of the upi)er or cortical 
 link cause degenerations, which spread both centrally and peripheri- 
 cally, involving both cortex, optic tracts, and the intervening ganglionic 
 centre. The immediate result of a lesion of one of the lower links is 
 impairment of vision — either complete amaurosis or paralysis of the 
 associated retinal tields [equatorial or liomonymous hemlojna), the irido- 
 motor reflexes being involved only when the lesion is on the peripheral 
 side of the chiasma. Since, howevei", the escape of the irido-motor 
 reflexes depends (in this case, when the nuclei in the medulla are 
 intact) upon the commissural connections, incomplete implication of 
 both tracts must necessarily result not only in visual, but also in reflex- 
 iridal, disturbances. On the other hand, the cortical, or upper link, 
 when first implicated, has visual disturbances only for its symptoms, 
 for the ii'idal reflexes are not involved ; and thus complete blindness 
 with still active pupils indicates a blindness due to cortical lesion or one 
 beyond the quadrigeminal bodies (this condition as a functional dis- 
 turbance occurs, e.g., in urcemic poisoning). Eventually, however, the 
 consecutive degeneration passing to the upper quadrigeminal and 
 external geniculate bodies, etc., leads also to disturbances of irido-motor 
 reaction. The individual nuclei, defined by Henson and Yoelcker as 
 extending in front of the aqueduct, may, however, be picked out by 
 morbid processes; and, in this case, the iridal reactions sufier without 
 any necessary implication of vision, a condition frequently seen in the 
 early stages of general paralysis. 
 
 Spinal Symptoms. — In a large projiortion of subjects of general 
 paralysis the failure in the vigour and co-ordination of the greater 
 raxxsculatures comes on veiy gradually and insidiously ; the lower 
 extremities remain unart"ected to any appreciable extent for even two 
 or three yeai-s after the onset of the attack. Locomotion is unre- 
 stricted, equilibration is good, the gait steady, firm, and no swaying 
 is induced on closing the eyes. In fact, in 50 per cent, of the cases 
 examined the walk was brisk and not devoid of spring, and no 
 muscular enfeeblement was apparent. Yet although the rule is that a 
 gradually progressive paresis occurs, in a considerable number of cases 
 
SPINAL SYMPTOMS IN GENERAL PARALYSIS. 277 
 
 ft sudden paralytic seizure may occur, rendering the patient temporarily 
 luilpless in his limbs, or permanently paralysed with exalted reflexes and. 
 contractions established by consecutive spinal degenerative changes. In 
 other cases, again, we find the deep reflexes abolished, and true tabetic 
 symptoms obtrude themselves, of transient duration only ; on their 
 disappearance, hemiplegia or convulsive seizures may occur, and symp- 
 toms of a descending lateral sclerosis come to the fore. The fre- 
 quency with which we meet with spinal symptoms, and the general 
 nature of these moi'bid signs, may be gleaned from an analysis of the 
 forty-four cases before referred to. In six cases only (or 13-G per 
 cent.) were the deep reflexes ascertained to be perfectly normal ; in 
 sixteen cases (or 36 per cent.) they were decidedly exaggerated ; 
 whilst in some eleven cases (or 25 per cent.) the patellar reflexes 
 were both abolished, or both very sluggish ; in three more cases the 
 knee-jerk was abolished on one side, and in a fourth very nearly 
 absent. Thus we see a very notable degree of impairment of the 
 deep reflexes characterises the afi'ection, and the general results may 
 be thus tabulated : — 
 
 
 
 
 Deep R 
 
 EFLEXES. 
 
 
 
 
 
 s^nee-jerk 
 
 normal on both sides 
 
 
 in 
 
 6 
 
 cases 
 
 (13-6 
 
 per cent. ) 
 
 
 
 
 exaggerated 
 
 absent 
 
 very sluggish 
 
 absent on one side 
 
 nearly absent 
 
 either exaggerated 
 
 doubtful 
 
 or 
 
 sluggish 
 
 
 16 
 
 7 
 4 
 3 
 1 
 4 
 3 
 
 
 (36-3 
 (15-9 
 ( 9 
 ( 6-8 
 ( 2-2 
 ( 9 
 ( 6-8 
 
 r, ) 
 
 ) 
 
 ] 
 
 j34 
 
 15 or 
 
 per cent 
 
 Increased Knee-jerk. — The exaggerated knee-jerk, it will be 
 observed, is tlie more frequent phenomenon ; it may be a purely 
 functional disturbance, ti'ansient in dui^ation, induced by nervous 
 discharge from the cerebral cortex, and hence by removal of its 
 inhibitory control. In this connection it is often found as the im- 
 mediate result of a general convulsive seizure, or as actually accom- 
 panying the convulsive twitching of general jmralysis ; on the other 
 hand, it may be a sign of organic disease of the spinal coxxl, and have 
 as its accompaniments the usual motor enfeeblement and muscular 
 contractions of descending sclei'osis. The former association is illus- 
 trated by the table, which shows that out of twenty-two cases where 
 the gait was elastic and brisk, seven present very notable increase 
 of knee-jerk. It is important, therefore, to note that we have as 
 associated phenomena in many cases of general paralysis, a firm elastic 
 walk, loith full muscidar vigour of limbs, exaggerated deep . reflexes, and 
 pronounced irido-motor j'ici.ralysis. 
 
278 GENERAL PARALYSIS. 
 
 The latter association — i.e., of increased knee-jerk with structural 
 disease of cord, is exemplified in cases /. M., J..B., Ji. S., B. K., and 
 may be instructively associated with the ocular troubles as follows : — 
 
 Case — J. ISI. — Riglit aiiii and Ijotli legs paralysed and contracted ; knee-jerk notably 
 
 exaggerated in both ; marked ocular paralysis. 
 „ J. B. — Right aim ])aralysed and rigid ; right leg drags ; knee-jerk notably 
 
 exaggerated in right ; marked ocular paralysis. 
 ,, R. S. — Right henuplegia with aphasia; right leg stiff; knee-jerk notably 
 
 exaggerated in right ; marked ocular paralysis. 
 ,, B. K. — Left hemiplegia with contractures; knee-jerk notably exaggerated in 
 
 right ; horizontal nystagmus ; ocular troubles. 
 
 Besides the above, sevei-al (three) of the cases of hemiplegia, with early 
 commencing changes in the cord, were found associated with disturbed 
 reflexes and marked intra-ocular pai-alysis. 
 
 M. J. R., aged thirty-six, a gardener's wife, with a family of three children, 
 was admitted May 24, 1882. It was stated that for the past ten months she had 
 suffered from "fits," 'the last seizure a month since, leaving her in her present 
 demented state. No hereditary predisposition could be ascertained, no history of 
 drink, or syphilis. She understood all that was said to her, but was incorrect in 
 all her replies involving time, dates, and locality ; she did not recognise the nature 
 of her surroundings, and memory was faulty regardmg recent and remote events. 
 Was very emotional, wept constantly, and wished to go home. She betrayed much 
 self-satisfaction, was inclined to joke and laugh at her own statements, adding — 
 "Not such a bad wife after all, am I?" The right pupil was the larger of the 
 two, but both were regular in contour and active in their reactions ; the tongue 
 and lips were tremulous and speech somewhat impaired. The grasp of tlie right 
 hand was much weakened ; she was in good bodily condition. She continued 
 thus at times depressed, at times irritable and interfering, fretful and discontented 
 until August 9, when several seizui-es were noted affecting left side of face and 
 arm, but continuing only a few moments ; the arm was left powerless, and remained 
 so for twelve hours. 
 
 About nine months after admission it is noted : — Patient can stand with eyes 
 closed, but staggers much on endeavouring to walk along a straight line ; she 
 is more feeble. Knee-jerk exaggerated on right and normal on left side ; ankle- 
 clonos present on right side. Tongue extremely unsteady, protruded in ataxic 
 jerks ; lips tremulous, fails to whistle ; phonation luiimpaired, sings well without 
 any tremor of voice ; deglutition unaffected. The right pupil is much the larger, 
 but both act to light and accommoilation. 
 
 May 13, 188.3. — Passes restless nights, laughing incessantly in a cliildisli fashion, 
 or bursting into pitialde lamentations under deluded notions respecting her home. 
 Has most exalted notions respecting her personal attractions ; usually speaks of 
 herself in the third person — "Mrs. R. has had a good dinner, tliank you ; Mrs. R. 
 is a beautiful woman ; yes, she is a channing person." 
 
 June 6. — Suddenly showed loss of power on the left side of body, a condition 
 preceded by excitement ; the paralysis was not ushered in by con^nilsion, nor 
 accompanied by loss of consciousness ; the leg is more paralysed than the arm ; 
 
TABETIC SYMPTOMS IN GENERAL PARALYSIS. ^7& 
 
 reflexes are acute as formerly, but there is no apprecialjle clouos ; she grinds her 
 teeth continuously. The right pupil is still the larger of tlie two. 
 
 Aug. 20. — Her gait is now much impaired, an unsteady jog-trot— and ankle- 
 clonos is again produced in right foot. There is marked tremor of tongue, lips 
 and facial muscles, and constant grinding of teeth, even during conversation. 
 Voice is tremulous, and raised in pitch. Exhi))its a peculiar state of double 
 consciousness — thus, in crying aloud and disturbing other patients, she immedi- 
 ately rebukes herself by — "Mrs. R., hold your tongue !" Again becoming noisy 
 and complainmg, she interrupts herself with — ' ' Be quiet, Mrs. R. , you are the 
 noisiest child in tlie house ! " Ocular examination gives the following results :— 
 
 Size of pupils, -^' mm. ; no opacities of lens, no adliesions, &c. 
 
 Both contract and dilate actively and normally to light; they are extremely 
 mobile iinder emotional excitation. 
 
 Movements with accommodation, are normal. 
 
 Dilatation, on cutaneous stunulation, is scarcely appreciable. 
 
 Visual acuity = Reads Jaeger No. 1 slowly and with effort, No. 2 with fair ease. 
 Snellen '5 at 12 inches distance, and No. 5 at 3 metres. 
 
 Optic discs normal to ophthalmoscopic examination. 
 
 Ai^ril 10, 1S84. — Bedridden; both limbs held stiff and rigid by voluntary effort; 
 knee-jerk is now absent in the right, but present in left leg; no ankle-clonos. 
 There is now profound dementia; she is vaeant in aspect, rarely speaks, but often 
 cries aloud in a frightened voice. 
 
 About ten months later it is noted : — Sinking rajjidly — when approached, or any 
 movement near her occurs, she opens her mouth instinctively like a young bii'd ; 
 never uses her hands, although they show no contractures or clones — the muscles 
 are, however, greatly wasted. Both legs are becoming stiff from assumed flexion — 
 not contracture ; knee-jerks are wholly abolished ; plantar reflex greatly diminished 
 in right and absent in left foot. Cutaneous sensibility almost abolished on both 
 sides, especially the left. Right pupil double the size of the left; both remain 
 almost fixed to a concentrated beam of light ; accommodative movements are very 
 limited in range, and sluggish. She swallows only with the greatest difficulty, 
 retaining the bolus of food long in the mouth. 
 
 She is terribly emaciated ; looks up when called by name, and opens her mouth 
 loidely ; is extremely timid, shruiking away when touched. Died February 
 23, 1885. 
 
 Knee-jerk Abolished or Much Impaired. — We see by the table 
 
 given above that fifteen cases, or 34 per cent., exhibited an abolition of 
 the knee-jerk or its very notable impaii-ment. Of the ten cases in 
 which the knee-jerk is abolished, on one or both sides, five cases are 
 notable for a brisk, elastic walk, yefc all present serious oculo-motor 
 paralysis; whilst of the remaining five, the gait is noted as being 
 stiff and waddling ; swaying, staggering, and leaning to right side ; 
 stiff, slow, swaying ; and two others stiff. In all these latter the 
 pupils are likewise fixed to their usual reflex stimuli. With one 
 exception only, the deep reflexes when impaired, abolished, or in- 
 tensified, were accompanied in all cases by irido-motor paralysis ; but 
 the latter condition was often found advanced with a perfectly normal 
 
280 GENERAL PARALYSIS, 
 
 reaction of the knee-jerk. Just, therefore, as we may find the 
 association of an elastic, easy gait, or of a spastic or paretic gait, with 
 exalted deep reflexes and advanced intra-ocular paralysis ; so, on the 
 other hand, we may encounter the association of a normal gait, or of a 
 paretic or tabetic gait, with an abolition of the deep reflexes, and like 
 irido-motor troubles. The tabetic gait, occasionally associated with 
 this absence of the knee-jerk, is peculiarly disorderly, hurried, spas- 
 modic, and insecure ; the legs are jerked forwards, the feet planted 
 wide apart, and the heels brought down with considerable force ; there 
 is often a tendency to propulsion ; the patient sways from side to side 
 or falls when the eyes are closed and feet approximated, or makes 
 tottering efforts to secure his equilibrium. The case of //. U., given 
 here in detail, indicates how such symptoms may entirely disappear and 
 be replaced by those of another system-disease of the spinal cord. 
 
 H. U,, aged thirty, a married woman without family, was admitteJ in October, 
 1S8.3, suffering from depression, exhibiting great apathy and reticence, refusing 
 food, and passing sleepless nights. Her family history was obscure. It was 
 ascertained that the patient had suffered much privation of late. 
 
 On her admission she spoke occasionally, her remarks being rational ; but she 
 soon lapsed into apathy again, assumed a stolid expression, and was reticent. 
 Her memory was found to be very defective. The pupils measured # mm. ; the 
 light-reflex was abolished in both eyes ; consensual movements were absent ; 
 accommodative movements were normal; dilatation upon cutaneous stimulation 
 ■was abolished. She read No. 1 Jaeger slow^ly and at a fair distance; visual 
 acuity = Snellen §. Appreciation of colour normal. She was unsteady and 
 tottering in gait, swayed much, and could not close her eyes without falling ; nor 
 could she walk along a straight line. Lying on her back, she could resist fairly 
 well an effort to extend her limbs. The grasping power in both hands, measured 
 by the dynamometer, did not exceed 4 kilos. 
 
 During the first month of her residence, she remained much depressed and hea\-y, 
 but was less reticent. She became easily fatigued upon slight exertion. The 
 oculo-motor troubles were well marked, the pupils being rigidly fixed to a con- 
 centrated beam of light showing a tendency to sliriht dilalatlon upon sustained 
 illumination of the fundus. She read Snellen '6 at 50 cm, with ease. The follow- 
 ing electric reactions were noted : — 
 
 K.M.C. A.M.C. K.B.C. A.B.C. 
 
 Deltoid, . , . 12 26 Nil at 50 Nil at 50 
 
 Pectoralis major, . . .34 22 ,, ,, 
 
 Supinator longnis, . . IS 26 „ ,, 
 
 Biceps, .... 14 34 ,, ,, 
 
 The pectoralis major showed the R.D. on both sides. 
 
 Urine = sp, gr. 1020; no albumen, sugar, or deposits. Heart normal, free 
 from briut. 
 
 StiJt. 3, 1S83. — A crop of herpetic vesicles has formed over the supraorbital 
 branches of the fifth ner\-e on the right side. The parts are tumid, the conjunc- 
 tiva mjccted, and there is " shooting pain " over brow and hairy scalp. 
 
TABETIC SYMPTOMS — CASE OF II. U. 281 
 
 Nov. 14. — Much depressed and agitated; asks for her husband, and bursts into 
 tears; the herpetic eruption has disappeared. She sways much during equilibra- 
 tion ; her gait is unsteady, and tiic lindis are thrown about in the disoi-derly style 
 characteristic of tlie tabetic subject. Ataxy of the upper limits is very notable on 
 endeavouring to thread a needle. 
 
 Nuv. IS. — A sudden convulsive seizure occurred this evening, followed by 
 transient right hemiplegia and hemianesthesia; the reflexes v;ere normal. She 
 now lies in a state of stupor, associated with great depression ; mouth full of 
 frothy saliva ; she resists feeding, and does not sleep well. A notable degree of 
 corneal opacity has remained since the herpetic attack. 
 
 Nov. 20. — The day following the stroke she uttered just one word, but has 
 remained mute ever since. Has been fed regularly by the funnel. Sensibility has 
 fully returned to the limbs. 
 
 Nov. 24. — In a state of wild delirious excitement, dominated by the one idea of 
 terminating her life by her own hands ; made a most desperate attempt to secure 
 a knife, and piteously implored a nurse to give her one. 
 
 Nov. 26. — Acute excitement continues, with intense restlessness ; endeavours to 
 undress, and fling herself into the fire. 
 
 Dec. 1. — Has now lapsed into a state bordering on imbecility, associated wdtk 
 much hysteric excitement and general mental exliaustion. Her face at times 
 beams with delight, or she glares vacantly before her, giving utterance to a flow 
 of delirious ideas indicative of a grandiose state of mind. Articulation is tremu- 
 lous, syllabic, explosive, hesitating, and indicative of grave implication of lips and 
 tongue — especially the labial muscles. There is a distortion of facial symmetry 
 at tunes, ahnost amounting to a grimace or a hideous grin; her eyelids quiver 
 greatly. 
 
 Dec. 18. — Aspect like that of a general paralytic, beaming and ecstatic ; enuncia- 
 tion most difficult, speech explosive ; always applies her fingers to her mouth to 
 steady her lips wliilst sjieaking ; there is much mental vacuity. Her gait is more 
 steady, still tabetic, comes down heavily upon the heel ; knee-jerk exaggerated in 
 Ijoth Ihnbs ; no clonos. 
 
 Jan. 12, 18S4. — Mental distress much alleviated of late by chloral in conjunction 
 with bromide of sodium. Still has a happy, beamuag but imbecile look, and a 
 childish simpering manner. Labial articulation excessively difficult ; lingual less 
 so ; great tremor of voice, but phonation unimpaired as regards pitch and timbre. 
 Is conscious of failing vision in her right eye. Knee-jerks still exaggerated ; gait- 
 much less notably tabetic. 
 
 Jan. 19. — An attack of right hemiplegia, involving arm and leg complete!}', and 
 associated with aphasia ; no facial asymmetrj'^ ; complete hemianesthesia ; reflexes 
 as last noted. 
 
 April 10. — Another attack of right hemiplegia on the lOtli of March has now 
 left her bedridden, speechless, helpless, and apathetic. Her legs are tiexed upon 
 the thighs and the thighs upon the abdomen, but can be fully extended ; right 
 arm shows commencing rigidity, resists flexion strongly, and then elbow-clonos 
 arises ; wrist-clonos readily induced on the same side. Knee-jerk on right side is 
 extremely exalted ; slight ankle-clonos ; deep reflexes of left leg are brisk but 
 less marked ; plantar reflexes acutely exaggerated. There is no marked vaso- 
 motor or trophic change in the skin and little muscular atrophy. 
 
 May 5. — Now sits up in a low arm-chair ; is fatuous and vacant ; makes sudden 
 darts forwards in a stooping attitude, or attempts progression on lier hands and 
 knees ; can just support herself with a little assistance, but is tottering and 
 
282 GENERAL PARALYSIS. 
 
 slovenly in gait, lier feet are kept wide apart or rotate helplessly outwards. The 
 right leg is free from contractures ; tlie vastus contracts upon percussion ; the knee- 
 jerk is now normal; the plantar reflex excecilingly dulled; no clonos, back-tap, nor 
 hamstring-jerk. The left leg shows well-marked clasp-knife rigidity, and the 
 knee-jerk is brisk ; sensation in both soles mucli impaired. The skin is cold and 
 livid, especially over left foot. The right arm is contracted strongly at elbovr, 
 semi-flexed and pronated ; exhibits triceps-reflex and elbow-clonos ; wrist con- 
 tracting, lield rigidly, and fingers bent upon palm. The left arm is uncontracted, 
 and sliows nothing abnonnal beyond greatly impaired sensibility as in the opposite 
 member. Cutaneous sensibility remains normal only over the face. Swallows 
 with much difficulty and spluttering. The sphincters of bladder and bowel are 
 paralysed. Sense of smell appears unimpaired ; but hearing is defective. 
 
 June 30. — Has just recovered from a series of strong convulsive seizures. The 
 right arm is rigid, flexed, and slightly pronated; it can be forcibly extended; 
 there is no clasp-knife phenomenon, but slight triceps-reflex. All the extensors of 
 the arm contract upon percussion. The wi'ist is bent at right angles to the arm ; 
 fingers and thumb flexed tightly on palm. The left arm can be fully extended, 
 l)ut is usually flexed and pronated ; reflexes absent ; no affection of the hand, the 
 fingers move freely, and are kept constantly in her mouth. She fails to use the 
 right arm at all, but resists strongly with the left ; there is little special wasting, 
 both forearms 4 inches below olecranon measure 6f inches around. Epigastric 
 and hypogastric reflexes exalted. The legs are flexed on abdomen, but both can be 
 freely extended ; the left becoming sUglitbj fixed in a sort of clasp-knife extension 
 i?ery temporarily. In l)oth legs the knee-jerk is notably lessened, and only 
 elicited by very forcible percussion. Quadriceps percussion-wave is present ; 
 no ankle-clonos on right, but a very slight tendency to it on the left side ; constant 
 involuntary twitchings of foot and toes prevail ; muscles flabby, but not specially 
 wasted. Plantar reflexes are now excessive, pricking the soles causes convulsive 
 jerhings and withdrawal ; but no complaint, movement, or attempt at withdrawal 
 occurs upon pricking the calf of the legs or thighs. She appears only to appre- 
 ciate irritation of the skin of the face. She constantly grinds her teeth, and for 
 two weeks past has invariably opened her mouth widely upon bringing any object 
 near her, or upon touching her cheek or lips ; sioalloivs ivell and rapidly. She lies 
 perfectly mute, smacking her lips and incessantly rolling her tongue about, and 
 sucking her fingers; bowels greatly constipated. The right pupil is now the 
 larger, and both are dilated. Died November 27, 1SS4. 
 
 Microscojnc Examination of Spinal Cord — Lumbar Cord. — Anterior columns 
 exhibited a very small wedge-shaped tract of sclerous tissue close to anterior 
 commissure ; elsewhere and along whole of anterior root-zone the structure was 
 healthy, beyond some proliferation of the spider-cells. The lateral columns were 
 healthy, beyond showmg on the right side a few closely -aggregated vessels, with 
 small lumen and thickened walls, near the centre of the column. In the posterior 
 columns, however, the structure was coarsely vascidar, the vessels crowded around 
 by spider-cells, forming coarse tracts along median raphe and posterior commissural 
 zone, spreading from side to side across tliis latter region within and in front of 
 the posterior ground-fibres. The root-zone and peripheral zone of these columns 
 had escaped implication. Anterior and posterior cornua were free from obvious 
 lesion. 
 
 Domal Cord — Anterior columns appeared iiitact ; the lateral columns exliibited 
 great vascularity of their central part, with abundance of spider-cells, especially 
 on left side. Posteriorly the columns of GoU were normal, but those of Burdach 
 
TABETIC, SYMPTOMS — CASE OF II. U. 283 
 
 betrayed much coarse vascularity near the commissural zone, with numerous 
 spider-cells distributed parallel to the raph6 and along the ribands of Burdach. 
 Clarke's columns showed perfectly healthy cells, and the anterior and posterior 
 cornua with the emergent roots were normal. The central canal, as elsewhere, 
 was crowded with leucocytes. 
 
 Cervical Cord. — Here the anterior columns and l)oth cornua were also found intact. 
 In the right lateral column, liowever, a deep-stained sclerosed area lay internal 
 to the direct cerel^ellar tract, extending almost as far forwards as the antero- 
 external angle of the cornu. The nerve-fibres were much obscured by the 
 extraordinary development of the spider-cells, which were profusely scattered 
 throughout the whole of the crossed pyramidal tract, surrounding numerous 
 enlarged blood-vessels. Much finely punctated tissue was seen here, but no 
 amyloid bodies. The left lateral column was normal in all respects, except that a 
 slight increase of its connective indicated a little unusual depth of staining — a 
 generally dilated state of its vessels, and a larger supply than usual of its spider 
 elements. 
 
 The posterior columns exhibited well-marked changes as in the other regions ; 
 coarsely-distended vessels with deeply-stained spider- cells formed a notable 
 feature in a large patch of sclerous tissue, just at the junction between the 
 columns of GoU and Burdach, and also along the posterior connnissural zone. 
 Such changes were most marked on the left side. 
 
 Hypoglossal Fegion of Medulla. — Both hypoglossal convolutes were degenerated 
 on either sides ; their nerve-cells were shrunken and diseased, and surrounded by 
 numerous colloid bodies ; the emergent root-fibres were notably varicose. The 
 vagal nuclei exhibited many minute degenerate cells or their disintegrated relics. 
 The ascending root of the fifth nerve was degenerated in its posterior two -thirds, 
 but the olivary and its arcuate series of fibres did not appear implicated. Another 
 notable site of degeneration was the solitary fasciculus (f. rotundus). The floor of 
 the fourth ventricle was covered by little heaps of cell-growth, giving rise to its 
 sand-papery aspect (graniilar ependyma). 
 
 Bladder. — It is at this period that urinary troubles arise, and 
 cause much anxiety to the guardians of the paralytic patient. When 
 spinal symptoms have fully developed themselves and the lumbar cord 
 is known to be involved, the patient is never secure from possible 
 retention of urine, which, if not relieved by catheterism, may lead to 
 a ruptured bladder ; an accident frequent enough as to be a source of 
 real anxiety, when large numbers of such paralytic cases are massed 
 together in asylums. 
 
 In the earliest period of the disease, retention, or incontinence, 
 may occur, but, as a rule, as a transient condition only ; and at this 
 time the patient is sufficiently conscious of his state to draw the 
 medical attendant's notice to the point. 
 
 Retention may occur from spasmodic contraction of the sphincter 
 urethra'., due to irritation of the lumbar cord, a loaded and torpid 
 bowel being a most frequent starting-point for such troubles. It may 
 be due, on the other hand, to the presence of a chronic cystitis and 
 
'2S4: GENERAL PARALYSIS. 
 
 the alkaline urine so en^'ondored, the cystitis having a neuropatliic 
 origin not infrecjuently in changes within the cord and sj)inal nerves. 
 
 RetGntion far more frequently is an indication of paralysis of the 
 bladder; it is, then, usually accompanied hy a dribbling away of 
 water, which fails to relieve the gradually augmenting accumulation, 
 and a time arrives when the organ becomes dangerously distended, 
 and no expulsive power can be exerted by the patient. Such patients, 
 by being constantly more or less Avet in their bedding and clothing, 
 "would readily deceive an experienced nurse. The condition is identi- 
 cal with that induced upon section of the spinal cord above the level 
 of the anterior and posterior roots of the third, fourth, and fifth sacral 
 nerves — the sensory and motor arcs for the sphincter iLrethro'. Such 
 section withdraws the inhibitory control of the cerebrum, thus increas- 
 ing the reflex activity of the sphincter (Landois*). All such cases 
 should be uniformly treated by a periodic catheterism, allowing no 
 great accumulation to occur. 
 
 A still more dangerous condition arises in certain cases, fortunately 
 somewhat rare. The bladder becomes attenuated, or undei-goes con- 
 siderable fatty degeneration, as the immediate result of s[)iual disease 
 — a genuine tropho-neurosis. Nor is this very surprising when wc 
 learn from the results of autopsy in general paralysis how extensive 
 are the trophic disturbances which other organ.s, and especially the 
 ■muscular, undergo. In this degeneration the muscular coat of the 
 bladder especially sutlers, and the organ may be ruptured by a slight 
 distending force when aided by such accidents as a fall or a blow, cr 
 even powerful expulsatory efforts, as in severe vomiting. 
 
 A recent convulsive seizure, or an apoplectiform attack, may leave 
 the patient subject for some time subsequently to paralytic retention; 
 and in our treatment of a case of this nature the state of the bladder 
 should be almost the first snl/ject to engage our attention, f 
 
 A similar condition of the bladder often prevails in advanced cases 
 of tubes, and, as indicated by Dr. Buzzard, may even form the most 
 prominent symptoms and, like gastric crises, or optic atrophy, if ataxy 
 be absent, be readily regarded apart from the real cause — " I have 
 little doubt that not a few cases of atony of the bladder for which the 
 
 * Op. ciL, p. G53. 
 
 t A well-trained medical officer with many paralytic cases under liis care will 
 never fail to direct the nursing staff to keep a record of all such cases, and 
 check the same himself by daily reference, morning and evening, to the wanler's 
 report, and by actual examination of the abdomen. Even under the strictest 
 supervision an accident may still occur at times, as in the cases of degenerated 
 muscular wall of the bladder. It is, liowever, quite inexcusable for any such 
 patient, known to be suflfering from paralytic enuresis, to escape examination 
 night and morning. 
 
PAIiALVSES FUOM SPINAL IMPLICATIONS. 285 
 
 surgeon is consulted are examples of tabes, with the hladder trouble 
 predominating." * Ai)avt from any well-marked spinal paralysis, 
 retention frequently occurs as the result of simple inattention, the 
 accompaniment of ])rofound dementia, with which there is often 
 associated a diminished reilex-excitability of the bladder, the organic 
 reflexes corresponding to the general impairment of the superficial 
 spinal retlexes. There is not only the diminished excitntion of the 
 spinal centre necessary to initiate the act, but the patient does not 
 feel the need of micturition. It is found necessary in our asylum 
 wards, where some sixty or seventy general paralytics are often 
 congregated, to keep a daily and nightly record of all such inattentive 
 cases, and of all bed-ridden cases alike. 
 
 Enuresis. — Incontinence of urine invariably occurs in the paralytic 
 stage of this affection, as in all cases where the dementia also is 
 advanced. It forms, together with like bowel troubles, the daily 
 source of trial to the nurse — a burden which may be considerably 
 alleviated by tact and careful observance of simple rules of treatment. 
 
 AVhilst retention is produced by section of the cord above the level 
 of the reflex centres of the sphincter (above the third sacral nerve) by 
 removal of its inhibitory centre, so section or disease on a level with 
 the reflex centres produces incontinence, as will any incompetence in 
 the reflex sensory or motor arc. It must be remembered that 
 voluntary impulses passing down the motor tract of the cord do not 
 act directly upon the smooth muscular fibre of the bladder, but they 
 act in two directions — (a) onjthejsphincter urethrse or its motor centre 
 in the cord, so intensifying the reflex contraction; (6) on an inhibitory 
 centre in the cord above the reflex apparatus, which antagonises the 
 latter and allows the sphincter to relax, f 
 
 The necessity for continuous care and change of bed-clothing in these 
 wet cases is emphasised by the otherwise certain occurrence of bed- 
 sores which, in these debilitated subjects, become a formidable compli- 
 cation to the nurses. The irritation of the skin, by its constant 
 soakage in urine, develops, moreover, pajndar eruptions over the back, 
 the groin, and thighs, which are abraded by the patient's hands. 
 
 Bowels. — Another troublesome and objectionable condition of the 
 later stages of general paralysis, is the paralysis of the anal 
 sphincter, which results in such, frequent incontinence of the bowel; 
 the condition, of course, is at once recognised on introdixcing the finger 
 per rectum, when the patency and want of tone of the sphincter is very 
 obvious. As is the case with the bladder and sphincter urethr£e, the 
 
 * "Ou little-recognised phases of Tabes Dorsalis " in Diseases of the Nervous 
 Sy.'itcm. Dr. Buzzard, 1SS2, p. 274. 
 tLandois and Stirling, op. c'U., p. 654. 
 
286 GENERAL PARALYSIS. 
 
 cerebrum can voluntarily contract the external sphincter ani, or can 
 inhibit its contraction; such motor fibres descending through the 
 cerebral peduncles to the lumbar cord. 
 
 The centre for this inhibitory agency is stated by Masius to be in 
 the optic thalamus. So likewise, energetic voluntary contractions of 
 the levator ani and sphincter arouse the active rectal peristalsis neces- 
 sary to initiate defsecation, by bringing the excrementitious mass down 
 into the rectum. When once there, it creates the uneasy feeling 
 which prompts the voluntary inhibition of the sphincter ani, and 
 allows the mass to be extruded. Thus the act of defoscation is in 
 every way similar to that of micturition, it being really a reflex 
 spinal act during a voluntary inhibition of the sphincter. There 
 is the reflex loop constituted by the sensory nerves of the rectum, and 
 the motor nerve of the sphincter and the plexus myentericus inducing 
 peristalsis ; a tract for voluntary impulse to excite conti'action of the 
 sphincter ; a centre in the cerebrum for the inhibition of the latter. 
 
 Degenerative changes in the lumbar cord occasionally give rise to 
 the complete paralysis of the anal sphincter ; much more frequently is 
 it a matter of sluggish or incomplete reflex of this muscle than of 
 actual paralysis, as well as a defective tonicity which has been much 
 alleviated by the apjilication of tannin suppositories, a treatment first 
 recommended by Dr. Robert Lawson.* 
 
 In bed-ridden cases of general paralysis, a not unusual symptom is 
 that of frequent alvine evacuation from simple increased peristalsis, 
 not amounting to a genuine diarrhcea, but a very frequent " formed " 
 stool ; at times, however, the stools become very loose, yet without 
 any pyrexial accompaniments, and due apparently to centric irritation 
 of the vagus. Epileptiform seizures in general paralysis are apt to be 
 accompanied or followed by such, but are then watery alvine fluxes. 
 Thus in the case of R. E. P., severe, continued convulsions, aff"ecting 
 the left side of the body only, were associated with very copious and 
 frequent evacuations. 
 
 A similar condition has been noted by Dr. Buzzard in certain cases 
 of tabes, and which he regards as possibly dependent upon irritation of 
 the vagal nucleus in the medulla.! 
 
 In these cases the flux is probably the result of paralysis of the 
 splanchnics, the vaso-motor nerves of the intestines ; and to the 
 resulting transudation of fluid from the blood-vessels into the bowel, 
 with the accompanying increased j)eristalsis. 
 
 * " Clinical Notes on Conditions incidental to Insanity," by Robert Lawson and 
 W. Bevan Lewis. No. 1, West Riding Asylum Reports, vol. vi. 
 
 t Opldhalmopleri'ia Externa with Tabes Dursatis (Dr. Buzzard, p. 200). See also 
 case described by the same writer in Diteases of Nervous Si/stem, p. 218. 
 
HAEMOGLOBIN IN THE nLOOD IN GENERAL PARALYSIS. 
 
 287 
 
 The Blood in General Paralysis.— A diminution of hsemoglobin 
 
 is clearly indicated in all cases of general paralysis examined by us. 
 The corpuscular richness varied considerably — in fact, from 75 to 12G 
 per hcemic uoiit, the higher register pertaining to cases where maniacal 
 excitement prevailed. No connection is established, however, between 
 mania and such corpuscular richness, since a diminution in the number 
 of red corpuscles is quite as often, and, in our experience, more 
 frequently, met with in maniacal conditions. What is of more im- 
 portance to note is the diminished colorimetric power of the corpuscle, 
 the proportion of haemoglobin varying from 52 to 75 per cent. 
 Taking into consideration the corpuscular richness, we find, that the 
 absolute deficiency of haemoglobin gives a corpuscular value varying 
 between 56 and. 89 per cent. The accompanying table gives the 
 results obtained in fifteen cases of general paralysis at diflferent periods 
 of the disease : — 
 
 Amount or Hemoglobin in the Blood in Geneeal Paralysis. 
 
 • 
 
 Heemoglobin. 
 
 Red Vi 
 
 Corpuscles. Corj 
 
 ^hite 
 uscles. 
 
 Value per 
 Corpuscle. 
 
 
 Per cent. 
 
 Per heemic unit. Per ha 
 
 emic unit. 
 
 
 T. G. (July 24, '87), 
 
 70 
 
 125 
 
 40 
 
 •56 
 
 „ (Aug. 2, „ ), 
 
 72 
 
 126 
 
 40 
 
 •57 
 
 W. W. (Aixg. 5, ,, ), 
 
 70 
 
 124-6 
 
 13 
 
 •56 
 
 „ (Nov. S, ,, ), 
 
 70 
 
 108-8 
 
 16 
 
 •65 
 
 T. C. (July 24, „ ), 
 
 60 
 
 103 
 
 60 
 
 •58 
 
 (Aug. 3, „ ), 
 
 75 
 
 110 
 
 50 
 
 •68 
 
 „ (Sept. 21, „), 
 
 63 
 
 85 
 
 40 
 
 •74 
 
 W. A. (Dec. 16, ,, ), 
 
 58 
 
 91-2 
 
 20 
 
 •63 
 
 T. W. (Aug. 4, ,, ), 
 
 " 52 
 
 80 
 
 30 
 
 •65 
 
 ,, (Sept. 29, „ ), 
 
 54 
 
 75-6 
 
 40 
 
 •72 
 
 J. R. (Nov. 9, „ ), 
 
 66 
 
 102-4 
 
 25 
 
 •64 
 
 S. S. (Oct. 9, „ ), 
 
 68 
 
 100-6 
 
 24 
 
 •68 
 
 J. H. (Dec. 16, ,, ), 
 
 60 
 
 86 
 
 32 
 
 •69 
 
 J. B. S. (Dec. 16, „ ), 
 
 70 
 
 91 
 
 22 
 
 •76 
 
 E. E. (Aug. 4, „ ), 
 
 62 
 
 81-8 
 
 50 
 
 •76 
 
 „ (Sept. 29, „), 
 
 70 
 
 96-2 
 
 32 
 
 •72 
 
 C. W. (Nov. 5, „ ), 
 
 64 
 
 79 
 
 20 
 
 •SI 
 
 J. W. (Dec. 16, „ ), 
 
 70 
 
 78-4 
 
 22 
 
 •89 
 
 G. H. (July 17, „ ), 
 
 68 
 
 81-8 
 
 20 
 
 •S3 
 
 T. H. (Oct. 9, „ ), 
 
 
 77-2 
 
 25 
 
 
 B. W. (Nov. 8, „ ), 
 
 64 
 
 
 10 
 
 ... 
 
288 ALConoLic insanity. 
 
 In the cases of 7?. A'., ./. B. S., J. A., as of several others not noted 
 ill the above list, the blood flowed with great sluggishness, rendering 
 its collection by the usind means extremely ditKcult. In such cases 
 the surface! Avas cold and very pallid, the vessels being undoubtedly in 
 a state of si)asm, and insldutaneous couz/xlation was prone to occur, ere 
 the blood could be withdrawn by the pipette; no inflammatory 
 complication existed in these subjects. Similar cases of exti-emely 
 slow oozing blood exhibited, on the other hand, abnormal delay in 
 coagulation. 
 
 ALCOHOLIC INSANITY. 
 
 Contents. — Alcoliolism and Age— Susceptibility at Certain Develoiimental Phases — 
 Adolescent Period (F. S.) — Prevalence of Impulse— Influence of Sex, Heredity, 
 Epilepsy, Cranial Injui-y, Ancestral Intemperance— Anomalies of Systemic and 
 Visceral Sensation— Aural Hallucinations (J. J^)- Delusions of Susjiiciou — 
 Optimistic Delusions— Clinical Forms of Alcoholism — Mania a Potu — Amblyopia 
 Cutaneous Anaisthesias — llelapses— Case of W.^Y.- -Homicidal Impulse (G. S.) — 
 Chronic Alcoholism— Physiological Effects of Alcoliol— Evolutionary Period- 
 Mental, Sensorial, and Jlotorial Symptoms (J. J^.) — Amnesic Forms (J. F.)— Con- 
 ditions of Mental Pievivability (M. H. L.)— Delusional Forms (T. S.)— Instances of 
 "Environmental Resistance" — Visceral Illusions- The Epigastric Voice— Vari- 
 ous Illusory States (E. A. F.) — Evolution of Psychical Phenomena— The 
 Nervous Discharge — Hallucination as Determining Morbid Ideation — Augmented 
 Specific Eesistance— Sensory Anomalies— Motor Enfeeblement (J. P.)- Twitch- 
 ings, Tremors, Stolidity — Eeaction-Time iu Alcoholism — Muscular Spasms 
 and Cramps— Oculo-Motor Immunity — Nystagmus — Epileptiform Attacks — 
 Hemiplegiie (T. P. and J. C) — Classification. 
 
 Alcohol is a fertile source of nervous disease, and its implication of 
 the nervous centi'es is so general and far-reaching, that the resultant 
 symptoms are of most protean nature ; no poison, except the A'irus of 
 syphilis, plays so extensive a role in the morbid affections and degener- 
 ations of the tissues, nervous or non-nervous. Yet, as regards its 
 effects upon the nervous system, it is possible to trace its march with 
 a fair degree of accuracy, and to classify into definite groups the 
 victims of over-indulgence in accordance with the degree of implica- 
 tion — the depth to which nervous dissolutions have attained. Ere we 
 classify, however, the more or less distinctive forms of such aflfections, 
 it will be well to glance generally at the insanity induced by alcoholic 
 indulgence; and for this pui'pose we have inquired into the history and 
 antecedents of 4G4 patients, whose insanity was attributable to excessive 
 drinking; of which number 344 were males. And, in the first place, who 
 are the subjects most liable to thejjdifferent forms of alcoholic neurosis? 
 
 Ag'e. — The period of life is here an element which it is important 
 to examine. Were we acquainted with the actual amount of excessive 
 drinking in the community at large, and at different ages, as also with 
 the percentage of those who succumbed to insanity as the direct result 
 
ALCOHOL AND TIIIi: ADOLESCENT PERIOD. 289 
 
 of drink, and tlu; time roquiri'd for excessive drinking to evolve such 
 results, we might, by a comparison of asylum statistics, ensure some 
 degree of accuracy in estimating the incidence of alcohol as a causative 
 agency of insanity. Such absolute data are at present out of our 
 reach ; and we must, consequently, rest content with the ascertained 
 history of our asylum community without reference to the sane. Nor 
 is this altogether devoid of immediate iitility, since our object is not so 
 much that of ascertaining the exact incidence of alcohol in insanity, as 
 to extract the characteristic features of the neurosis which alcohol 
 induces. Every period of life shows its proclivities towards special 
 diseases ; and the action of toxic agencies demonstrates the peculiar 
 susceptibility of the nervous system to their operation at certain stages 
 of its evolution. Some such law would appear to govern the origin of 
 mental affections induced by alcoholic indulgence, since these are 
 certainly far more prone to occur between the ages of twenty-five 
 and thirty, and, again, from thirty-five to forty-five, than at other 
 periods of life. It is easy to assume that at these periods of life the 
 actual number of excessive drinkers is larger than at other times ; at 
 present no data supporting such assumption are forthcoming, nor do 
 we see any reason why the age of thirty to thirty-five should claim 
 special immunity. It must be remembered that this age, from twenty- 
 five to thirty, is one peculiarly characterised by intellectual advance, 
 as contrasted with the more emotional developments and expansion of 
 the moral nature which takes place during adolescence. 
 
 It is also the age when the struggle for existence, in its widest sense, 
 makes itself felt upon the organism in fullest force ; it is not the 
 period of longing and yearning for activity, for plans of action and 
 castle-building, but it is peculiarly the age of active being, when the 
 mettle of the man is tried, and his weight as a social unit fairly esti- 
 mated. It is upon his intellectual advance, which at this epoch is 
 so important and so notable, that his success as a social factor largely 
 depends ; for a successful life is the outcome now-a-days of a well- 
 balanced adjustment, and hence depends on a highly appreciative and 
 intelligent recognition of complicated relationships. 
 
 It is a period when feeble and indifferent organisations often feel 
 a want for an artificial stimulus to goad them on, and many succumb 
 to such perilous inducements ; and it is peculiarly a period when 
 certain inherited neuroses place the individual at a disadvantage in 
 the competition of life. In fact, it is a period when the first great 
 swellings of the intellectual tide make themselves felt throughout 
 the whole organism, and when inherited frailties, coeval in their 
 manifestation in parent and offspring, assert the supremacy of the 
 laws of periodicity in development. All such nascent developments 
 
 19 
 
290 ALCOHOLIC INSANITY. 
 
 are most prone to early decay in dissolutions of the nervous system ; 
 and upon them chiefly appears to be expended the full force of those 
 agencies credited with the proximate causation of insanity. Thus it 
 is that in the moral and emotional developments of the adolescent epoch, 
 sexual and alcoholic excesses tell more directly upon this phase of 
 mental life, and that hysteric forms of insanity and a stunted moral 
 development are so often revealed at such an age. In like manner, 
 this latter epoch of intellectual expansion exhibits the earliest eflects 
 of alcoholic excess as inducing reductions in the intellectual sphere, 
 and only later on, as profoundly affecting the emotional and moral 
 being of the individual. This is why we regard age as an important 
 element in the evolution of these forms of alcoholic insanity. 
 
 F. S., aged twenty-five, widower, and a warehouseman. When admitted he had 
 been insane for six weeks ; had been very wild, rambling in speech ; called himself 
 the "Holy One," the " Great Physician." Patient's father is of dull intellect and 
 of intemperate habits ; paternal uncle was insane ; patient was addicted to excessive 
 drinking from the age of fourteen to that of twenty-one, remained temperate for 
 two years subsequently, and has again relapsed into his former excesses. Upon 
 admission he exhibited great exaltation, spoke excitedly, and loudly, giving 
 expression to optimistic delusions ; he had exalted notions respecting his muscular 
 powers; was "perfect in body and mind, and surpassed all others in know- 
 ledge and skill;" he has "a perfect knowledge of the human frame, is a great 
 physician, and can cure all diseases. " He declares that he can ' ' easily lift half -a- 
 ton, and has often raised many hundred tons aloft ; all England will become his, 
 ere long; is possessed of enormous wealth." His manner is abrupt, but he is 
 inclined to be friendly and jovial ; expression flushed and excited ; pupils widely 
 dilated, but equal and of normal reaction ; tongiie shows notable and extensive 
 fine fibrillar tremor, no ataxic jerks ; articulation is unimpared ; the reflexes are 
 normal ; cutaneous sensibility is unimpaired. Patient is muscular and well 
 nourished. Examination of other systems proved negative. 
 
 In a fortnight he was considerably calmer ; the same liien-etre was manifest, but 
 he was so far reasonable as to be employed. This remission lasted but two weeks, 
 and he relapsed into severe maniacal excitement, in which with every varying 
 mood, from abrupt rudeness to jovial humour, he maintamed the same exalted, 
 grandiose notions. His habits now became degraded and filthy at night, and 
 masturbation was practised. 
 
 Six months after admission, excitement continued unabated, he was insolent, 
 threatening, and demonstrative. Habits of masturhation so reijulsively sliamcless 
 and open that the liquor epispasticus was aj^plied locally, and chloral with bromide 
 of potassium given internally with only temporarily good results. These habits 
 kept xvp persistently seemed to account for the slow progress made in his case, 
 for he remained twelve months in the asylimi ere the excitement abated ; even 
 then for several months he exhibited an imbecile aspect, laughed umnoderately 
 without cause, was restless, untidy, senseless or irrelevant in his observations, 
 and given also to insane gesticulation and grimace. 
 
 Twenty months elapsed ere he was discliargeil recoveretl. 
 
 We must, as before hinted, make due allowance for this age as one 
 offering peculiar inducements to heavy drinking; and for the fact that 
 
PREVALENCE OF IMPULSIVE STATES. 291 
 
 a certain period, even for those specially predisposed, must elapse ere 
 alcoholic excess results in actual mental alienation ; but, when all such 
 factors arc allowed for, wo still think the evolutional phase of this 
 epoch is the chief reason why so large a proportion of mental cases are 
 attributable to alcoholic excess. 
 
 The facts as given in our statistical Tables ai-e striking, for out of 
 344 males suffering from one or other of the forms of alcoholic insanity, 
 29 cases alone occur between the ages of fifteen and twenty-five, 
 whilst as many as 52 occur during the next five years, or 87 up to 
 thirty-five years of age ; each of the two succeeding quinquennial 
 periods of life claiming some 50 victims of these afi'ections. 
 
 Predisposition. — The subjects of alcoholic insanity admitted into 
 our asylum do not exhibit any unusual degree of the insane heritage, 
 the proportion of hereditary cases not rising above 27 per cent., and, 
 consequently, not attaining to the average heredity of all Jorms of 
 insanity alike. All recurrent cases of insanity taken together 
 exhibit a far higher insane inheritance than this. If we now 
 group together all cases of insanity, epilepsy and other neuroses, 
 occurring in the family history of these insane subjects, as also all 
 cases of ancestral intemperance, we find such predisposing elements 
 present in 37 "2 per cent, of the total number of cases of male patients. 
 Where ancestral intemperance was the sole ascertained predisposing^ 
 cause, it was almost exclusively limited to the father, and in no case 
 was the mother addicted to this vic'e. Taking a history of insanity 
 and excessive drinking collectively, we find such present in the case 
 of thirty-one fathers and sixteen mothers, so that the influence of 
 sexual limitation in transmission is here apparently demonstrated. 
 
 Nature of the Attack. — Taking first the 344 males — maniacal 
 excitement prevailed in 57*8 per cent., of which over 26 per cent, are 
 delusional forms of insanity, only 6"3 per cent, being acute maniacal 
 states. On the other hand, melancholic dej)ression prevailed in 28 "7 
 per cent. ; 42 cases were attended with delusional perversion, 28 were 
 simple melancholic forms, while 12 (or 3*4 per cent.) were cases of 
 chronic cerebral atrophy. The maniacal states were, therefore, con- 
 siderably in excess of the melancholic forms of alienation, in fact, 
 they were twice as numerous ; whilst pronounced dementia apper- 
 tained to a small section, forming only 8-4 per cent, of the whole. 
 
 Taking the aggregate of 344 cases where alcoholic excess preceded 
 the attack of insanity, the fii-st important fact taught us by a 
 glance over our statistics is the essentially imjndsive nature of the 
 afi'ection; it is in all its phases a COnvulsive neurOSis. Whether 
 excitement pi-evails, and the disordered propensities exliibit sudden, 
 explosive impulses; or whether depression, with its frequent accom- 
 
292 ALCOHOLIC INSANITY. 
 
 pauiment of hallucination, predominates, and painfully pent-up feeling, 
 or suddenly-aroused terror results in determined violence to self 
 or others ; or, lastly, whether they are forms of mental fatuity 
 Avith depression — the all-important feature to be borne in mind is 
 this prevailing convulsion of conduct. The maniacal forms exhibit 
 such impulsiveness, nut so niucli in attempts at self-injury as in 
 a dangerous aggressiveness to others, in destructive fits, in 
 sudden, treacherous, and often brutal violence, a tendency which 
 renders these lunatics a peculiarly dangerous element in our 
 asylum communities; about 68 per cent, were thus returned as 
 dangerously impulsive toward others. The melancholic victim, 
 however, is more likely to turn his hand against himself; one half 
 of such cases at the lowest estimate being dangerously SUicidal. 
 The tendency to suicidal and homicidal impulse is high even in 
 advanced forms of dementia, and it is a noteworthy feature that in those 
 cases of dementia which are dependent upon chronic alcoholic cerebral 
 atrophy, suicidal and homicidal impulse reaches its climax of fre- 
 quency; as many as 66'6 per cent, of such forms being determinedly 
 suicidal, and 83'3 per cent, being dangerously aggressive. The 
 intrinsically impulsive outbursts of alcoholic insanity, whether mania, 
 melancholia, or dementia prevail, should never be forgotten by those 
 dealing with the insane. 
 
 Taking into account only the male alcoholics, age apparently had 
 no distinct influence over the character of the mental symptoms, one 
 half the cases of mania, as of melancholia, occurring up to forty years 
 of age, and the other half, subsequently. We may anticipate the 
 largest number of maniacal or melancholic patients to be between 
 twenty -five and thirty years of age, and the next largest proportion 
 to be in the quinquennial periods immediately preceding and following 
 the age of fox'ty. A considerable rise in the number of melancholic 
 cases amongst such a class of insane inebriates again occurs at the age 
 of fifty to fifty-five, and a similar rise in maniacal ailments from fifty- 
 iive to sixty years of age. We may, thei-efore, conclude that although 
 certain periods of life are especially prone to the development of alco- 
 holic insanity, such as the ages of twenty-five to thirty, from thirty-five 
 to forty, and again towards forty-five, maniacal and melancholic forms 
 appear in the same relative frequency at these epochs of life. 
 
 If we attempt to explain why the form of insanity should assume 
 in one case the maniacal and in the other the melancholic type, we 
 are able to afl'ord but little explanation and that purely of a negative 
 character. Thus age is, as just noted, an indifferent element in this 
 connection ; in like manner inheritance cannot be stated to have 
 any very definite influence in either direction ; excitement does, 
 
IIALLUCIXATIONS AND DELUSIONS. 293 
 
 however, })rccloniinate in liereditary insanity ; Ijut tlie propovtionato 
 number of maniacal to depressed cases appears still greater among 
 those who afford the history of ancestral intemperance. Epilepsy and 
 other neuroses also appear to be wholly indifferent factors. Then 
 again, as regards sex, it is noted that melancholic states are to 
 maniacal proportionately more frequent in male than in female 
 inebriates, being but one-fourth in women and one-half in men. Sex, 
 therefore, does appear to lend some influence in predisposition to the 
 one or the other type of insanity. Lastly, recurrent seizures 
 throw no light upon the subject, depression and excitement occurring 
 with about the same relative frequency in relapsed cases (mania, 
 forty-three, and melancholia, thirty-seven). Cranial injuries occur 
 in a lai'ge jiroportion of the subjects of alcoholic insanity (18"9 per 
 cent.), but this element comes in as frequently in maniacal as in 
 melancholic states. Of the circumstances which modify the type of the 
 psychosis age, recurrence, and cranial injury may be excluded from 
 consideration ; whilst sex, lieredity, and ancestral intemperance have 
 some influence in this direction. 
 
 Hallucinations of Special Senses.— Illusions and hallucinations 
 are extremely frequent in all the acute forms, as well as in a large pro- 
 portion of the chronic forms of alcoholic insanity; in 344 males as many 
 as 131 (or 38 per cent.) presented such disturbed sensorial phenomena. 
 The visual were the more frequent, and visual or aural were separ- 
 ately more frequent than both combined. But what is peculiarly 
 characteristic of these alcoholic forms of alienation are the illusoxy anci 
 hallucinatory phenomena of the nerves of g'eneral sensation and of 
 the systemic or visceral system of nerves, giving origin to 
 delusions of an extraordinary nature, and often of a very complicated 
 system of intrigue. Tingling, prickling, burning, stinging sensations 
 over different areas of the integument are frequently complained of; 
 anaesthetic patches are discovered over the skin of the arms and face, 
 and a feeling of general numbness in a limb may ensue ; electric-like 
 shocks are described in the limbs, and head, and neck, often associated 
 with muscular twitching, or facial contortions; and these subjective 
 states, induced usually by centric changes, are referred to an objective 
 origin, giving rise to the most varied delusional concepts, such as those 
 of unseen, mysterious agencies operating upon the system — electi-icity, 
 magnetism, mesmerism, Avitchcraft, diabolical machinery are in turn 
 invoked to account for these mysterious sensations. In like manner, 
 unusual visceral sensations referred to the heart, lungs, stomach, 
 bowels, itc, become the basis for similar delusional beliefs of a malign 
 influence within. Belief in demoniacal possession is not uncom- 
 mon, but more frequently is the imagined torture supposed to be 
 
294 ALCOHOLIC INSANITY. 
 
 produced l)y individuals known to tlie patient, who, he believes, have 
 the power of operating upon him from a distance, or have obtained 
 access to his body, and restrict, enslave, and govern the whole life of 
 his organism, control his thoughts, and have dominion over his mind 
 and its utterances. 
 
 J. J^., aged thirty-one; admitted March, 1886. Had been a soldier, and for the 
 past five years on service in India; he was invalided by "fever," confined to a 
 military hospital, and then sent home to England. During his voyage home, a 
 "galvanic battery began to ])lay npon him," and he heard the voices of his late 
 officers, Capt. P., Lieut. C, Drs. W. and C, talking of murders and other crimes, 
 although they were not present. He has heard these voices persistently since coming 
 to the asylum ; they are always above him, and he points up to a distant roof of the 
 building where he believes they are located. He often hears the whistling of gas 
 over his head, which, he says, afi'ects him so as " to snip a word in two," just as 
 he utters it, and confounds the meaning of what he says — it also affects his 
 memory; this gas is produced by the same agencies as the voices which he hears. 
 Flashes of lightning show him all the events of his life. " I have seen my whole 
 life, good and bad, in yon back-yard " (referring to an airing- court). The battery 
 sends electric shocks through his body, causes a heavy pressure (not a paiu) at his 
 epigastrium, twitches up his chest, but does not affect arms or hands. His speech 
 is hesitating, and he often, in explanation, uses the statement that, " Thetj rule my 
 speech, and tell me what I have to say at times." Has noticed foul odours, wliich 
 he knew were unnatural, and caused by " the electric machine ; " they jjrevent him 
 from sleeping. These malevolent agents are treacherously pursuing him wherever 
 he goes; he knows not why — he cannot rid himself of them, although he has 
 " oQered them his life." Frequent twitchings of the facial muscles on the left 
 side occur, and he explains them as due to the electric shocks, which draw his 
 breath out of him at these times ; his " head shakes," and his eyes " are made to 
 twitch thereby." He admits having been of very intemperate habits since the 
 age of eighteen, but had never suffered from delirium tremens; both his father 
 and mother were excessive drinkers. He himself drank raw spirits freely. Had 
 never suffered from fit or stroke. 
 
 Dynamometer registers for right hand 56 kilos.; for the left hand 54 — as the 
 average of four trials. 
 
 jEathesioivcter gives the following measurements of comparative sensibility: — 
 
 1l'\]) of forefinger, 
 
 ,, thumb. 
 Ball of thumb. 
 Centre of palm, 
 Wrist, dorsal. 
 Wrist, volar. 
 Forearm, dorsal, 
 Forearm, volar. 
 
 Sensibility elsewhere appears good, active, without delay ; yet he complains that 
 his legs frequently feel " dead," as he sits at table. Both knee-jerks are quite 
 abolished; yet e(iuilibration is midisturbed, he balances well with ej'es closed; 
 stands on tiptoe, and can walk "heel and toe" along a straight line; plantar 
 
 Right 
 
 Side. 
 
 Left 
 
 Side. 
 
 "05 of an inch. 
 
 ■05 of 
 
 an inch, 
 
 •05 
 
 
 •10 
 
 
 ■3 
 
 
 •4 
 
 
 •4 
 
 
 •4 
 
 
 •9 
 
 
 rs 
 
 
 1-7 
 
 
 1-4 
 
 
 2-8 
 
 
 1-7 
 
 
 1-9 
 
 
 1-8 
 
 
DELUSIONS OP SUSPICION, KTC. 295 
 
 reflexes are good. Has never had pains in his limbs, but flashing pains continually- 
 pass through his body in "all directions." No eye-symptoms are apparent, the 
 pupils are equal, the reflexes perfect ; has never sufi'ered from diplopia or 
 strabismus. 
 
 On analysing the varied delusions in male alcoholics, which were 
 well expressed in 208 out of 344 individuals, it was found that 131 
 entertained ideas of persecution; 29 others, religious delusions affecting 
 their moral welfare ; and the remaining 48, optimistic and grandiose 
 conceptions ; or, as tabulated, thus : — 
 
 Nature of Delusions in Alcoholic Males. 
 
 C ises. 
 
 Percentage of whole 
 (omitting decimals 
 
 Delusions of Persecution — 
 
 (a) By poisoning, . 24 12 
 
 {b) By magnetic and unseen, mysterious, agencies, 25 12 
 
 (c) By various other means beyond the above, . 82 39 
 
 Delusions afi'ecting the moral being, ... 29 , 14 
 
 Delusions of grandeur and of wealth, ... 48 23 
 
 208 Too 
 
 Fpequency of Delusions of Suspicion.— Thus, about 63 per 
 
 cent, of such false notions are of the nature of delusions of suspicion, 
 and of the 23 per cent, of a grandiose and optimistic character, it was 
 also observed that such notions were very rarely unmixed with 
 distrust and suspicion — the exalted position — the large possessions or 
 wealth of the individual being cited as in themselves the explanation 
 of the malignity of his imaginary foes. 
 
 A summary of all the cases of delusions of mysterious or unseen 
 agencies, based on illusory states of general or visceral sensibility, 
 vividly suggests the terrible mental torture which these alcoholic 
 subjects endure. It should be remembered that the prevalence of 
 these latter forms of delusion, based on illusions of the nerves of 
 visceral and general sensation, is much greater than our statistics 
 would lead us to infer, since therein are comprised only definitely 
 expressed states of the kind, while a much larger section exhibit 
 suspicious evidence of these. 
 
 Optimistic Delusions. — These states of optimism closely resemble 
 those presented by the subject of general paralysis, in the inteiisity of 
 the false belief, and their grossly exaggerated chax-acter, but they differ 
 in almost invariably exhibiting the feeling of distPUSt just alluded to, 
 and their far greater fixity. The subject is restrained in the 
 exercise of his exalted mission, or in the recovery of his just rights ; 
 his functions, delegated by the Almighty or by a great earthly 
 potentate, ai-e checked by the malignity of his former friends and 
 
29G 
 
 ALCOHOLIC INSANITY. 
 
 relatives, perhaps by his own wife and children, to all of whose actions 
 sinister motives are attributed. Aural hallucinations prompt him to 
 action — a voice from the heavens declares to him his mission — yet his 
 enemies thwart him, endeavour to poison him, or otherwise ill-treat him, 
 and this leads to frequent impulsive violence. Yet, when contrasted with 
 the other forms of delusion of pei'secution, it is found that hallucinations 
 which are found in one-half of these cases are not so frequent an 
 accompaniment of the exalted mental states, occurring in but one- 
 fourth of the series. The general character of these delusions may be 
 gleaned from a few typical cases — thus one of our patients calls him- 
 self the "Son of God, and the Father of all nations;" another declares he 
 holds the sun and moon in his bauds, and regulates the movements of 
 the planets ; another has been left a fortune of one million pounds 
 sterling by Baron Rothschild; another has just produced a great patent 
 "whereby his fortune is secured. One acute case (recovering in the course 
 of four months) declares that he drives six of the finest horses in the 
 world. Noble ancestry is boasted of by some, or matrimonial alliance 
 claimed with members of royal blood ; and one of our most acute cases 
 always spoke of his wife as Queen Elizabeth, and was possessed of 
 fabulous wealth ; the son of another was so wealthy that he was about 
 to buy up Wakefield. 
 
 Delusions of pePSeCUtion comprise, as we have before stated, 
 nearly G3 per cent, of the whole series, with the very frequent 
 association of hallucinations of the special and general senses. A. 
 very large proportion of such entertain ideas of poisoning — their 
 food, medicine, or tobacco is drugged ; attempts are made to stupefy 
 them by chloroform, to smother them when asleep in bed, and to 
 burn them alive; ideas of murder in every conceivable way are rife; 
 their house is to be blown up; they are to be "cut in 2)ieces and 
 boiled," or divided limb from limb, and " their bui'ied children 
 disentombed." Policemen dog their footsteps ; soldiers lie concealed 
 in their houses; voices are heard next door intriguing with the 
 wife against their life ; rats and vermin surround the bed ; the wife's 
 fidelity is frequently called in question. These are some of the more 
 prominent instances occurring in our series of male alcoholics, of 
 which details are afforded in the Table. 
 
 Of the Clinical forms of Alcoholic Insanity.— We shall now 
 
 proceed to a study of the varied forms of alcoholic insanity, under 
 their respective headings of acute and of chronic alcoholism ; premis- 
 ing, that by the former we indicate a purely toxic form of insanity in 
 which the mental derangement (often very acute as regards intensity) 
 is of rapid course and short duration — a more purely functional 
 derangement, due to the presence of the poison in the system ; and 
 
MANIA A POTU. 297 
 
 tliufc by the latter we refer to the more remote effects of tlio pr)i.s()n in 
 altering structure, through modifying the nutrititni of thi; censl^ro- 
 spinal system — an insanity based upon organic disease of the brain and 
 spinal cord. The statistics already dealt with when considering 
 alcoholic insanities generally, have presented us with some 50 per 
 cent, of cases running a rapid course towards complete recovery ; but 
 in which there are also some 40 per cent, of others whose recoveries 
 were very partial, or death resulted, or the patient remained an 
 addition to the chronic insane community. It is upon such categories 
 we shall now draw for illustrations of the various phases presented by 
 the mental perversions induced by prolonged alcoholic excess. 
 
 Acute Alcoholic Insanity. — Under this term we com])rise mania 
 a ■potu, or the acute alcoholic delirium of Magnan, and delirium tremens, 
 or " febrile " delirium tremens of Magnan. 
 
 Mania a fotu {acute alcoholic deliriu7n ; deliruni ebriosum). — Our 
 patient usually comes befoi-e us in a state of acute maniacal excitement, 
 and with some such history as the following : — He has been for a long 
 period addicted to intemperate habits — perhaps, not so much contin- 
 uous, heavy drinking, as repeated excesses, often with prolonged 
 intervals of comparative sobriety between the bouts. There is jn'o- 
 bably a clue to one or more attacks of delirium tremens, from which 
 on recovery he has shortly relapsed into his former excesses leading 
 to an acutely-delirious outburst. 
 
 It is by no means unusual to be told that, for several weeks prior to 
 the seizure, there had been entire abstinence from alcoholic indul- 
 gence ; but that the health had been notably affected, with gastric 
 disturbance and general malaise ; nervous symptoms had been pro- 
 minent, and mental instability, moroseness, irritability, insomnia, 
 hideous dreams, and nervous startings had been witnessed ; and that, 
 consequently, on the occurrence of some moral agency, shock, grief, 
 disappointment, &c., an exciting cause is afforded sufficiently potent to 
 develop the attack of mania. Our enquiries probably elicit the fact 
 of hereditary predisposition to insanity — possibly of ancestral intem- 
 perance ; but especially are we likely to discover that the subjects 
 have been regarded as congenitally defective in self-control, as wanting 
 in moral tone, and as the victims of a stunted development, in which 
 instinctive desires and impulsive responses predominate over higher 
 intellectual promptings. The excitement is often one of great intensity ; 
 but, in this respect, we witness various depths of reduction, yet all 
 forms are invai'iably accompanied by characteristic illusions and hallu- 
 cinations ; in fact, the m.ost notable feature of the delirium is the 
 predominance presented by such sensorial disturbance. In typical 
 deliritim tremens motor symptoms are as prominent a feature as the 
 
298 ALCOHOLIC INSANITY. 
 
 sensorial ; whilst in the more clironic forms uf alcoliolism, as we shall 
 see later on, we get both features less emphasised, less acute, and, 
 together with intellectual enfeeblement, assuming a permanence want- 
 ing to the acute forms. 
 
 The special sense illusions and hallucinations are ever of a most 
 distressing natui-e, usually very vivid, and exhibit the usual mobile 
 state of such sensorial anomalies seen in acute mania. This fleeting 
 character is in itself of favourable augury when contrasted with the 
 more persistent fixity, or monotonous repetition, seen in other states 
 of mental disease, and indicative of an approaching or of an established 
 chi'onicity. The variable, fleeting nature of the sense-disturbances in 
 alcoholics has been long recognised (Lasegue, Alagnan). The forms 
 thus coujured-up by the disordered sensorium bear a striking resem- 
 blance to the other form of acute alcoholism, delirium tremens, as also 
 to the phenomena described as induced by certain drugs, notably 
 hyoscyamine [Robert Lawson). As under the influence of hyoscyamine, 
 pleasurable or painful visions troop before tlie mind's eye incessantly ; 
 yet the general mood in acute alcoholism is always painful, and the 
 visions, however fascinating in character, beget distrust and suspicion. 
 Much more frequently are these false impressions of a most painful, 
 terrif^dng nature ; and hideous, loathsome forms surround the victim. 
 Snakes, tigers, furious dogs are seen or heard, and the attendant is 
 transformed by tlie diseased mind into a fiend or other dreaded form. 
 
 If we now test our patients carefully, we discover in many a very 
 decided degree of amhhjopia — vision is clouded, and the visual activity 
 diminished; and, with the amblyopia, there is also occasionally con- 
 joined a difficult perception of colours [dyschromxitopsia). It has been 
 shown by M. Galezowski that the cliromatic aniesthesia thus produced 
 pertains chiefly to the composite colours, and especially yellowish- and 
 bluish-greens. Impaired or perverted sensibility may also be recog- 
 nised in other sensory expansions, as the olfactory and gustatory ; 
 the palate is in all cases more or less art"ected, and tlie antesthetic con- 
 dition of tlie upper lip is an early symptom familiar to all who indulge 
 too freely in alcoholic drinks. Similar anaesthesias, byperaesthesias, 
 and perverted states of general cutaneous sensibility have likewise 
 been apjjealed to as explanatory of the many forms of illusion pertain- 
 ing to the surface of the body from which alcoholics sufter. That 
 these sensorial expansions do become aff"ected seriously in acute 
 alcoholism is undoubted ; but such symptoms are of transient duration, 
 and are far more frequent in chronic alcoholics ; they but indicate the 
 taking oft' " of the fine edge," which all mental faculties alike suflfer. 
 from as the result of alcoholic reductions. 
 
 Relapses. — Alcoholic excess, long ere structural change can be 
 
SENSOHIAL TIIOUBLES IN ALCOHOLISM. 299 
 
 predicted in tlie nervous centres, is answerable for something more 
 than the mere transient functional disturbance described ; it engenders 
 a nutritive perversion, which is more marked after each attack of 
 acute alcoholism, and which is expressed in a notable tendency to 
 recurrence. This i-elapsing character is especially seen during the 
 progress of the alcoholic subject under treatment ; repeated outbursts 
 of excitement occur, after intervals of comparative calm and often 
 apparent convalescence, ere the case may be considered fit for dis- 
 charge from asylum-supervision. Thus, in the case of /. J., four 
 distinct relapses occur during one year of his residence at the asylum, 
 and although the remissions were not so complete as in many cases, 
 yet it was sufficiently apparent in his case that each relapse was 
 characterised by symptoms exactly reproducing his previous state ; 
 and that the immediate exciting cause was some trifling moral 
 agency, such as a dispute with a patient, or some trivial disappoint- 
 ment. It is all-important for tts to recognise the fact, that the 
 presence of alcohol in the blood or tissues is not necessary to the 
 continuance of the characteristic delusions of persecution, to which 
 these individuals are subject ; it is in the nutritive change engendered 
 in the nerve-cells of the cortex through the agency of alcohol, that 
 a more permanent instability of the discharging centres becomes 
 established, and the mental anomalies assume gradually a more stereo- 
 typed aspect. Whatever be the centres of the brain which ai-e more 
 prone to disturbance through the agency of alcohol — when once their 
 nutritive equilibrium is upset seriously by this agency — these centres 
 are prone to stiffer first in any relapse, whatever be the exciting 
 cause. 
 
 The case of W. W. will illustrate this point : — 
 
 W. W., aged forty, coal-miner; admitted Feburary, 1885. Mother had been an 
 inmate of this asylum, and was said to have died in Pontefract Hospital from 
 softening of the brain. The patient was a heavy drinker until ten months previous 
 to his entry into this asylum ; an attack of mental disorder, the nature of which is 
 unknown, but which was treated at home, served, however, to check his habits of 
 intemperance. From that time he worked steadily, at such scanty employment as 
 he could procure, till within a week of his admission here, when he was seized 
 suddenly with .symptoms of excitement and ravings on religious topics ; this 
 speedy onset was attributed, by his friends, to his attendance at the Salvation 
 Army meetings and consequent excitement. On his reception into the asylum, he 
 was .suffering acute mental depression, and was too agonised to offer any information 
 regarding his subjective state ; but, according to the certificate, he had avowed the 
 delusions that " tliere were devils inside him, and that a man h.ad come outside his 
 house to attack him," and he had taken up a poker in order to kill him. In a few 
 days, having quieted down, he affirmed that he heard people coming down on the 
 top of his head, and although he could not remember what they said, comprehended 
 
300 ALCOHOLIC INSANITY. 
 
 it at the time; was fearful of sleeping at night. IJajiid convalescence supervened, 
 delusions and hallucinations disap[ieared, and the patient was discharged six weeks 
 after entry. 
 
 Here then, we find, after nine months' abstinence, the recurrence 
 of acute melancholia apparently attrilmtable to the morbid excite- 
 ment of certain religious services. In every feature the attack 
 reproduced what was previously engendered as the direct result of 
 heavy alcoholic indulgence ; and it is well to be familiar with the 
 fact, that the symptoms of acute alcoholism may thus be over and 
 over again reproduced, without fresh excesses, when the cerebral 
 nutrition has been impaired as above described. It is noticeable how, 
 in the case just described, the characteristic hallucinations and 
 delusions were also freely interspersed with religious delusions, and 
 how his ramblings brought prominently into relief the subject with 
 which he had been chiefly occupied at the onset of his attack. As 
 Magnan and othei's have noted in other cases, here also the hallucina- 
 tions gradually lose their definiteness, a confused voice replacing tiie 
 alarming cry of " poison !"; then the voices are in their turn replaced 
 by an occasional humming sound in the ears, which ultimately fades 
 away upon his recovery. It is impossible not to be impressed, when 
 attentively studying such gradual recoveries, with the apparent 
 obnubilation of the illusory states by the strenr/theninr/ itn^ii-essions of 
 ohjeciive existences, forcibly reminding one of what occurs occasionally, 
 even in perfectly healthy states, when awaking from sleep ; illusory 
 states are then not infrequent ere more vivid preseutative feelings 
 force themselves into being. In a case of mania a potu* (IF. R.) 
 special interest attached itself to the visual illusions to which 
 the patient was subject, especially at the moment of waking. It 
 was, as it were, a projection of a dream into his waking hours, frag- 
 ments of the illusory dream persisting and refusing for some little 
 time to be dispersed ujoon the reinstatement of wakeful consciousness. 
 This state is not unfamiliar in normal health ; and a case is known to 
 the writer, where for some time after aj)parently complete wakefulness, 
 the subject saw distinctly what he conceived to be his own corpse 
 lying in a collin beside his bed, and which for some time he failed 
 to resolve into its real elements of a bundle of clothing. We reason- 
 ably conclude that such resolution is affected by the freer circulation 
 in higher cortical realms ; and that zones ])reviously ansemic become, 
 on complete wakefulness, once more the site of functional activity. 
 There is a strong presumption that a parallel condition exists in 
 acute alcoholism, and that a projection of hideous dreau)s and frag- 
 
 * See on this point, J/«j7«a)i— Transl. by Dr. Greenfield, p. 50. 
 
IMI'ULSIVK VIOLENCK. 301 
 
 montary detaclied illusory states arc thus interininglod with tlio 
 realities of waking hours; the wliolc history of the case during its 
 acvite stage is that of a waking dream. The re-energising of 
 higher cortical planes which occurs during waking may require a 
 certain well-defined interval, and in lieu of dispersing any exis- 
 tent morbid symptoms will, in certain conditions, call them into full 
 activity as in the movements of paralysis agitans. Thus in a case of 
 Charcot's hemii)legic type of j^cirabjsis agitans, the writer well I'ecalls 
 the statement of the patient that the hand which was the site of 
 continuous fumbling movements during complete consciousness, and 
 especially during voluntary action, remained often quiescent for some 
 time after waking — a very appreciable interval existing before the 
 afi'ected centres were sufficiently energised to permit of their inter- 
 mittent discharge. 
 
 In the case of W. 1>. it is also to be noted that both he and his 
 grandmother, " could foresee events," by which we may infer that 
 both were subject to these peculiar waking dreams, and were apt at 
 such moments to confuse illusory appearance with actual existence, 
 and visions arose before them in their waking hours. It is by no 
 means unusual amongst the insane to discover a power of calling into 
 existence such illusory appearances ; and we are frequently told by 
 them that they have the power of conjuring up almost any form they 
 choose ; nor is this to be wondered at, if the analogy of dreaming be 
 considered ; for we opine that the morbid imagery is always ready (in 
 certain cases) to spring into life, but are suppressed by the attentive 
 direction of the mind to presentative states ; if, on the other hand, 
 such contrasting states are voluntarily suppressed, the morbid 
 imagination may have fidl play. At all times liable to dangerous 
 impulsiveness, the acute alcoholic is a fortiori more prone to exhibit 
 such impulses at night ; and especially, when roused from slumber, at 
 the moment of loaldng, from the occurrence then of vivid, illusory, and 
 hallucinatory states. A colleague of the writer's thus narrowly 
 escaped with his life a violent attack on the part of a patient, who had 
 concealed beneath his bedding an improvised weapon, with which to 
 attack the medical officer at the night-visit to his bedside ; and who 
 confessed subsequently that each night he had imagined his visitant to 
 be under the form of Satan, and planned this means of attack upon 
 him. Such impulsiveness very frequently betrays itself in suicidal 
 attempts ; and we find by our statistics as many as 40 per cent, 
 regarded as decidedly suicidal. According to Bouclereau and Magnan, 
 from 7 to 15 per cent, of alcoholic cases attempt suicide. The latter 
 writer is especially guarded in distinguishing genuine suicidal and 
 homicidal attempts from mere accidents, which are, of course, peculiarly 
 
302 ALCOHOLIC INSANITY. 
 
 prone to occur in the terror infused by the delusional states of acute 
 alcoholics. Such suicidal impulses may be associated with desperate 
 conduct, not truly homicidal nor suicidal but having as its object the 
 relief of the existing tortui-e. 
 
 G. S., aged forty-seven, married, a woollen spinner by occupation. For two 
 months prior to admission lie had been depressed, sleepless, and had taken but 
 little food. A fortnight before he would not leave his house, was silent, sullen, 
 and obstinate, betraying much terror because he was "to be taken away and 
 deserved hanging. " Wife stated that for years he had been an excessively sottish 
 drinker, but less intemperate for the past six months. Brother was insane. 
 Patient was a fairly nourished, muscular individual, well built, with a hea\'y, 
 stupid expression, sluggish in all his movements, his whole bearing indicative of 
 great apathy. He was very illiterate ; was reticent, wilful, and refuseil food 
 upon admission. There was no oculo-motor paralysis ; tongue was protruded 
 straight and steadily — it was covered with foul epithelia ; heart's action feeble, 
 no murmur. Abdominal viscera apparently free from all but slight functional 
 derangement. 
 
 During his first week's residence, when sleeping under observation, he suddenly 
 sprang out of bed, threw himself upon a patient next to him without any pro- 
 vocation, and nearly strangled hini ; he was removed to a single-room where he 
 was discovered mutilating himself, having succeeded in inflicting a deep mcision 
 with his finger nails around the penis. 
 
 Up to this period, he had been taking morphia ; hyoscyamine (J gi-. Merck's 
 Extract) was now ordered. A month after admission it is noted — " Much quieter, 
 but still has a hang- dog look, as if m\ich afraid of something or someVjody ;" and, 
 a few days later, he became greatly excited and suspicious, attacking his night- 
 attendants and fellow- patients. Chloral (grs. xxx) ordered ni;;^ht and morning. 
 
 Musciilar enfeeblement, especially of the loioer limhs, was now noted ; in his 
 wild excitement he frequently fell and bruised himself badly, so that he had to 
 be confined to his bed in a padded room. Six weeks after admission, the excite- 
 ment had passed away ; patient was left extremely depressed in spirits and pro- 
 foundly demented ; was very restless, and utterly negligent in hal)its. 
 
 He had at this time the aspect of an advanced general paralytic, but with no 
 labial, lingual, or ocular paralysis. Some paralysis of the muscles of deglutition 
 subsequently supervened, necessitating very cautious feeding. He remained help- 
 less, bedridden, and extremely demented, dying somewhat siuldenly six months 
 after admission. 
 
 Secfio cadav. Skull cap bulging in left parietal region, bones generally thick, 
 very dense and almost devoid of diploii ; sinuses contained dark clotted blood ; there 
 was no adhesion of dura" mater. The brain exteraally very pale, was of average 
 consistence, and the membranes were slightly clouded in frontal and parietal 
 regions, where the convolutions were equally and slightly wasted in both hemi- 
 spheres ; no external tract of softening. The pia stripped with great freedom 
 from all parts, and the soft membranes were generally thickened and buoyed up 
 as in senile atrophy. There was no atheroma of the basal vessels. 
 
 Whole brain weighed . 1432 grms. Left frontal lobe weighed 2.35 grms. 
 
 Eight hemisphere ,, . 630 ,, Cerebellum ,, 150 ,, 
 
 Left „ ,, . 624 „ Pons „ 17 „ 
 
 Right frontal lobe ,, . 2S6 ,, Medulla ,, 6 ,, 
 
CHRONIC ALCOHOLISM. 303 
 
 The gvey matter of cortex was normal to the naked eye ; the white suVjstance 
 was somewhat softened, but presented no coarse vessels ; there was no recent or 
 old focus of softening or hivmorrhage. Heart weighed 272 grms., the organ was 
 normal. 
 
 Right lung, 994 grms. ; adherent at apex by old fibrous tissue, by which also 
 the lobes were united firmly together ; generally congested and presenting at 
 extreme base a small cheesy nodule. 
 
 Left lung, 574 grms. ; apparently normal throughout. 
 
 Liver, 1,708 grms.; capsule much thickened ; substance congested. 
 
 Spleen, 108 grms.; normal. 
 
 Eight kidney, 141 grms.; left kidney, 165 grms. Both organs were considerably 
 lobulated ; capsules firmly adherent, leaving on removal a distinctly granular 
 surface ; cortex was much wasted, structure firm, fibrous, granular ; pyramids 
 obviously diseased ; right organ in most advanced state of degeneration. 
 
 The case of J. B. (p. 216), is a typical one of mania a potu passing- 
 into chronic alcoholism in a subject predisposed to insanity, and inherit- 
 ing the resvilts of paternal intemperance. Prior to his visit to America, 
 his seizures were of the nature of acute alcoholism ; bvit, upon his return 
 to England, the fixed delusion of the machinery in his chest augured 
 the transition towards chronic alcoholism. In the latter stage we 
 observe the tendency to allude to his sufferings as terrible, and to 
 speak in the most exaggerated, terms of the tortures to which he is 
 subject. This is a feature highly characteristic of chronic alcoholism ; 
 such exaggerated statements are not wilful misrepresentations, for 
 the subject fully conceives the terrors he depicts. The suffering is 
 evidently not extreme physical suffering, but a distortion of disordered 
 sensations, so that slight pains and discomfort, from a loss of balance 
 in comparison, are apt to be magnified into voluminous distressing 
 feelings. Such subjects usually have hearty appetites, gain flesh, 
 and enjoy themselves freely, when their attention is distracted from 
 their subjective states ; but, immediately they are spoken to concern- 
 ing their delusions, the hypochondriacal self-engrossment is assumed, 
 and they begin to lament their pitiable condition. 
 
 Cases of alcoholic delirium have been divided by Magnan into 
 three groups, viz. : — 
 
 1. Those affected with alcoholic delirium, with easy, complete, and 
 rapid convalescence. 
 
 2. Those affected with alcoholic delirium, of slow convalescence, 
 with ready relapse. 
 
 3. Those specially predisposed, who have frequent relapses, and a 
 convalescence interrupted by delirious ideas, and in which the 
 intellectual disturbance is from the outset much more notable than 
 the motorial. 
 
 Chronic Alcoholism. — The establishment of persistent nervous 
 
304 ALCOHOLIC INSANITY. 
 
 symptoms as the result of too fi-et; an indulgence in intoxicating liquors, 
 has been for centiu-ies recognised by the ))rofession. Even in classic 
 times, we find occasional allusion to such states (Soieca). Nor, indeed, 
 could we conceive this to be otherwise, if we take into account the 
 excessive vicious indulgence of the luxurious class in the later Roman 
 Empire. Nearer our times, Lettsom has clearly demonstrated the 
 sensory and motor troubles induced by long-continued alcoholic indulg- 
 ence ; but, it was not until quite recent days (1852), that a group of 
 symptoms was formulated as constituting a distinct morbid entity under 
 the name of chronic alcoholism, and to Dr. Magnus Huss, in parti- 
 cular, is due the credit of clearly enunciating the relationship of 
 this important disease, which in his day was making such sad havoc 
 among his countrymen. Northern nations have always been most 
 susceptible to the alluring temptation of alcohol ; the Russian, 
 >Scandinavian, and Scotch, being notoriously addicted to the vice. 
 In Sweden, the consumption of large potations of raw spirit by all 
 classes of the population (and especially of a most impure and 
 pernicious spirit, distilled from diseased potatoes, which formed the 
 staple commercial article), proceeded to such an extent as to demand 
 State interference, in which the reigning family and the medical 
 profession took a prominent part, doing much to point out the 
 pernicious social effect of the habit, and check its further advance. 
 The raw brandy thus consumed in Sweden was not only notoriously 
 impure and noxious, but correspondingly cheap, and the most 
 deleteiious effects were widely apparent. It is, therefore, not 
 surprising that the most valuable treatise upon chronic alcoholism 
 should have emanated from our Scandinavian neighbours, and that 
 in the classic work of Magnus Huss* we find detailed in no uncertain 
 terms the ominous group of symptoms constituting a disease, whose 
 differential diagnosis before his day had been, to say the least, most 
 obscure and ill-defined. 
 
 Van-der-Kolk + dealt with alcoholism as he met with it in Holland ; 
 and later (187G), Magnan I has done for France, in his elaborate 
 treatise on alcoholism, what Huss did for Sweden ; and in our own 
 country, Drs. Carpenter, § Marcet, || Anstie, U Wilks, ** and Parker, 
 
 * AlcohoUsmiis Chronicus. Dr. M. Huss, Stockholm, 1S49 51. 
 
 t Jvflnence of Stroiuj Drinks on the Human Budij, by J. L. C. Schnieder 
 Van-der-Kolk. Utrecht, 1S53. 
 
 X Alcoholi'^m. Dr. V. Magnan. Translated by Dr. Greenfield, 1S70. 
 
 § Use and Abuse of Alcoholic Liquors in Health and Disease. W. B. Carpenter, 
 1S50. 
 
 II Chronic Alcoholic Intoxication. Dr. Marcet, 1S62. 
 
 ^ Stimulants and Xarcotics. Dr. Anstie. Macinillan, 1864. 
 ** Alcoholic Paralysis, Dr. Wilks. Lancet, 1S72. 
 
CHRONIC ALCOHOLISM. 305 
 
 have, amongst many otliers, contributed largely to the physiological, 
 clinical, and pathological aspects of alcoholic intoxication, and its 
 ulterior effects upon the nervous economy. Nor must we omit to 
 mention the highly suggestive experiments of Dr. Ogston and of 
 Dr. Percy, * which gave so great a stimulus to further research into 
 the physiological action of alcohol, and from which have directly 
 emanated the more enlightened views now held respecting the 
 physiological operation of this agent, its true dietetic and therapeutic 
 value, and its operation as an incitor to morbid change. 
 
 It is unnecessary here to do more than very briefly allude to the 
 injurious efiects of alcohol on systems other than the nervous. Dr. 
 Carpenter's "Prize Essay" did much to popularise true ideas on the 
 subject, portraying in vivid colours, as it did, the injurious effects of 
 drunkenness upon all the tissues of the organism. The chronic 
 gastric catarrh ; the hsemorrhagic mucous membrane ; the inter- 
 stitial changes in the liver and kidney ; f the atheromatous condition 
 of the blood-vessels ; the fatty changes in various organs, and notably 
 in the heart ; the functional disturbances leading to albuminuria, 
 ascites, anasarca, gout, rheumatism, and the long list of nervous 
 ailments ; all these are familiar to any one who has paid attention 
 to the subject. It is well, however, to recall to mind certain estab- 
 lished physiological facts as our groundwork for further observation. 
 
 (1.) Alcohol may be absorbed through the serous, mucous, or respir- 
 atory surfaces ; the last fact was demonstrated by Orfila, who produced 
 drunkenness by the inhalation of the vapour. 
 
 (2.) It is absorbed unchanged ; and may leave the system in an 
 unchanged form, since it has been detected by appropriate tests in all 
 the fluids and in many of the tissues. Thus Dr. Percy, relying on its 
 odour and inflammability, found it in the bile, urine, blood, the liver, 
 and the brain ; whilst Rudolf Masing, 1854, | and subsequently, 
 MM. Lallemand, Perier, and Duroy detected it by the chrome test S 
 in exhalations from the skin and in the urine. 
 
 (3.) As early demonstrated by Dr. Percy's experiment, it is found in 
 proportionately largest quantity in the brain ; evidencing, according 
 to that authority and Dr. Carpenter, a peculiar " elective affinity " of 
 nervous tissue for alcohol. 
 
 (4.) Changes of a profound significance are induced in the blood 
 
 * An Experimental Enquiry concerning the presence of Alcohol in the Ventricles of 
 the Brain. 1839. 
 
 t The frequency of its action on the kidney has been denied by Dr. Dickinson 
 and Dr. Anstie. Medical Times and Gazette. November, 1872. 
 
 X Da rdle de V Alcohol et des Anesthetiques dans I'Orr/miisme. Paris, 1860. 
 
 § Bichromate of potash, 1 grain ; sulphuric acid, 10 grains. 
 
 20 
 
306 ALCOHOLIC INSANITY. 
 
 itself at an early period, laying the foundation for the various tissue- 
 changes which ensue, and which directly aff'ect the well-being of the 
 nervous centres by the immediate functional disturbances which are 
 induced by the agency of the nutritive pabulum of the blood. Such 
 changes are the devitalisation of the red corpuscles leading to impaired 
 reration ; to the accumulation of hydro-carbon in the blood-current, 
 fatty specks in the red globules, whilst it causes these globules to be 
 very slowly reddened on exposure to air. 
 
 (5.) Paralysis of the sympathetic system, leading also to impaired 
 nutrition and an extravagant expenditure of animal heat. 
 
 The effect of alcohol in stunting the growth of the body is a well- 
 known fact ; animals may thus be affected when fed from an early age 
 upon alcohol. At the West Riding Asylum a dog, to which alcohol 
 had been administered for a lengthened period, not only succumbed to 
 all the symptoms described in alcoholism in animals by Magnan 
 (hallucination, terror, savage temper, motor tremblings, and paralysis); 
 but the nutrition of the skeleton also became affected, so that a notable 
 degree of mollities and attendant deformity ensued. Upon death, 
 extensive fatty degeneration of the nerve-cells and arteries of the 
 cerebrum was observed. The dwarfed stature of our mining com- 
 munity (amongst whom excessive indulgence in drink is only too 
 frequent) is largely due to this cause, associated with the abnormal 
 conditions of their life and strong hereditary proclivities. 
 
 Period of Evolution of Nervous Symptoms.— Important as 
 
 it is that we should, for the sake of statistical accuracy, arrive at 
 definite views as to the period during which alcoholic indulgence may 
 be prolonged (ere permanent nervous symptoms are indicated), it is 
 apparent, at first-sight, that the question is one of extreme difficulty ; 
 and, with our existing data, cannot be answered with even an approach 
 to accuracy. Much dvspends upon the hind of drink indulged in, the 
 specific effects of raw spirit, wines, malt liquors, absinthe, and other 
 drinks being too well recognised to be dealt with here ; much dei)ends 
 also upon the quantity taken ; the eliminating powers of the system ; 
 sex ; certain diatheses (as the aguish) where the individual can take 
 large quantities often, are all important points. 
 
 As regards neurotic inheritance, it is certain that, from this class of 
 the community, drink reaps its greatest quota of the more persisting 
 kinds of alcoholic delirium and chronic alcoholism. (See on this point, 
 Magnan).* Those specially predisposed to the rapid incidence of 
 delirium upon drinking are readily recognised. We are all acquainted 
 
 * " Patients specially predisposed, who, when suffering from alcoholic delirium, 
 have frequent relapses, and a convalescence often interrupted by delirious ideas, 
 assxuning more or less the form of partial delusion." Loc. ciL, p. 63. 
 
EVOLUTIONARY PERIOD OF ALCOHOLISM. 307 
 
 with friends in whom a single glass or two of wine will produce 
 striking degrees of nervous instability ; just as we recognise (jthers in 
 whom hal)itude, idiosyncracy, or other cause permits a continuous and 
 heavy intlulgence in alcoholic drinks with but little obvious effect. 
 It is astonisliing what large quantities may thus be taken for prolonged 
 periods with impunity; although, eventually, the nervous centres must 
 undergo irrecoverable injury. A picture of the so-called 'moderate 
 dram-di-inker from the working-classes of Sweden, is thus given by 
 Dr. Huss : — 
 
 " He rises at Kve or six in the morning, according to the season of the year, and 
 swallows, before going out, a cup of coffee with a glass (2 to 3 ozs.) of brandy in it. 
 He returns at eight to breakfast, which meal is washed down with another glass 
 of his favourite spirits. At dinner he repeats the dose of brandy, and often adds 
 another half glass. About five or six p.m., when his work is finished, another 
 glass is swallowed ; and supper at eight is concluded by a similar libation. During 
 the day, therefore, he consumes from five to six glasses of brandy, or from ten to 
 fifteen ounces of spirit. Such a mode of life is far from being regarded as 
 intemperate." 
 
 Dr. Huss has known some who drank every day sixteen to twenty 
 glasses of raw brandy. In the case of J. C, the patient assured me- 
 he had frequently taken for days together twelve to fourteen glasses, 
 of raw whisky ; nor did he regard this as by any means excessive. 
 
 As regards sex, it has been affirmed that chronic alcoholism was- 
 unknown amongst women. Dr. Marcet in his intei'esting tables,*' 
 unfortunately, does not help us, as he excludes women from his 
 category, because of the well-known difficulty of eliciting truthful 
 statements in such cases. This, however, is certainly not a coi'rect 
 statement. Females undoubtedly enjoy a remarkable immunity from 
 the disease, as they likewise do from general pai'alysis ; and our 
 experience would lead us to infer that Dr. Huss gives a fair statement 
 of the case in his statistics, wherein he finds but sixteen women 
 amongst a total of 139 cases of alcoholismus chronicus. The case of 
 J/. T. is a well-marked instance of this affection in women. 
 
 Lastly, as regards affe. The statistics of Magnus Huss fix the Ji/th 
 decade as comprising the larger number of cases, and the fourth decade,, 
 as presenting a smpJler proportion, his figures are as follows : — 
 
 20 to 30 years of age, ...... 14 cases. 
 
 30 to 40 ,, „ ,, 44 „ 
 
 40to50 ,, ,, ,, 'u „ 
 
 50 to 60 ,,,,,, 23 ,, 
 
 00 to 03 ,, ,, ,, 1 ,, 
 
 139 ,, 
 
 " An inquiry into the influence of the abuse of alcohol as a piedisposing cause 
 of disease." By W. Mircet. Brit, d: Fo;\ Aledlco-Chir. Ikv., 1SG2, Xos. 57-5S. 
 
308 ALCOHOLIC INSANITY. 
 
 In estimating the value of tliis taltlc it must 1)6 borne in niiii<l tluit 
 allowance must he made, as in all statistical tables, not only for the 
 varying population at such period of life ; but, also for the prolonged 
 period during which the agent was at work ere the malady was fully 
 evolved ; this latter consideration may have much to do with the high 
 number of cases between the ages of thirty and fifty. 
 
 Symptoms of Chronic Alcoholism.— The functional disturb- 
 ances described as present in acute alcoholism become interblended 
 (if drinking be still persisted in) with symptoms indicative of struc- 
 tural Chang's, the injurious action of the stimulant becomes stamped 
 upon the organism; and the more freely the vice is indulged in, the 
 deeper is its impress. The chief indications of such organic change 
 are, advancing and persistent mental enfeeblement, with certain 
 equally persistent senSOry and motor anomalies. The general 
 enfeeblement of the intellectual faculties supervenes slowly, but pro- 
 gressively; the faculties of attention, of judgment, and of comparison 
 suffer; and memory is specially implicated. The finer sensibilities are 
 worn off; the subject is less impressionable and sympathetic, less 
 charitable, as well as moi-e narrowed and selfish in his desii'es, his 
 altruistic sentiments rapidly declining. The imaginative faculties are 
 early affected, the higher emotional states are warped, and the whole 
 moral nature undei'goes a profound and serious change. " Apathetic, 
 indifferent, stupefied, the chronic alcoholic bestows no attention on his 
 person; he takes no care of his family; he is lowered in all his 
 intellectual, moral and social faculties, and finds himself yielded 
 defenceless to the caprices of his iiistinctive appetites" {Magnan).* 
 Aural hallucinations are (as in the acute form) still present, and are 
 now no longer transitory phenomena, but often of such pei'sistence as 
 to constitute the chief mental symptom in the earlier stage of chronic 
 alcoholism ; the victim to such sensoiy disturbances suffers terribly, 
 and not infrequently is driven to acts of desperate A'iolence through 
 their influence. He seeks in vain to release himself from the intoler- 
 able persecution of such voices, which blaspheme, abuse him, prompt 
 him to commit hideous crimes, or to utter obscene and revolting 
 language. Pursued equally by night and by day, he passes sleepless 
 hours ; often he is found sitting up in bed in a state of suspicion or of 
 terror, declai-ing his enemies are beneath his bed, or outside the 
 window plotting his destruction. At times the expressions used by 
 his unseen foes are unintelligible to himself, are distant and scarcely 
 audible ; and he distresses his mind much in endeavouring to attach 
 the proper meaning to such words ; at other times they are loud and 
 near, and he will attribute them to those who immediately surround 
 
 * Op. cit., p. 153. 
 
AMNESIC FORMS. 309 
 
 him. 01(1 associates are especially accused by tlie patient of thus 
 torturing him ; thus, J. M'G. constantly heard the voice of a disreput- 
 able girl with wliom he had associated ; J. J^. heard the voices of his 
 comrades and officers of the regiment in which he had served in India; 
 and, in fact, what Magnan states for acute alcoholic delirium is equally 
 true for the early stage of chronic alcoholism — " The hallucinations 
 have for their subject either the ordinary avocations, or the dominant 
 interest of the moment." * This is but an indication of the change 
 wi'ought in the last-evolved structures of the cortex, which are the 
 first to be affected in the dissolutions induced by alcohol. Thus it 
 was that the first patient just named (who had lived a reckless 
 dissipated, and immoral life of late) imagined himself to be surrounded 
 by prostitutes who uttered the vilest language, and accused him of the 
 most unnatui-al cx'imes ; and so it was that the soldier, J. J^., thought 
 that he was influenced by the persons with whom he had recently 
 associated in his military service in India. 
 
 The forms of clu'onic alcoholism which usually present themselves 
 may be conveniently studied in three categories. 
 
 1. Amnesic cases with, or without, delusional perversion. 
 
 2. Chronic delusional insanity. 
 
 3. Alcoholic imbecility and dementia. 
 
 1. Amnesic FOPms. — Cases comprised in this category show the 
 earliest evidence of structural change due to the prolonged use of 
 alcohol ; they are of most serious moment, as they indicate that the 
 border-land between disordered function and real structui'al change 
 has been passed. We by no means assert that such cases cannot be 
 relieved — indeed, great relief is frequently experienced by the subjects 
 of alcoholic amnesia; but it is not going too far to insist that absolute 
 recoverability is rarely (if ever) obtained from this stage of alcoholism. 
 The more notable feature characterising this class is the peculiar 
 failure in memory — an instantaneous forgetfulness of events which 
 have only just occurred. Every degree is found, from slight reten- 
 tiveuess up to a complete, and almost immediate, abolition of the 
 latest impression. A patient so afi"ected forgets names, dates, and 
 order of sequence, to an almost inci-edible degree. If a name not 
 familiar be repeated over and over again, a moment's conversation will 
 often obliterate its memory ; even when told to keep the word as a 
 test-word in mind — the recall fails, if the attention be momentarily 
 attracted in another direction. Patients fully i-ecognise their enfeeble- 
 ment and often strive to the utmost to overcome the difficulty, such 
 
 * Op. cit., p. 34. 
 
310 ALCOHOLIC INSANITY. 
 
 efforts eventually prove successful, and are suggestive indications as 
 to tlie nature of the lesion. 
 
 J. F. , aged tliirty-oue, a dyer's labourer; admitted in January, 1S87. For 
 four inontlis prior to admission, he had l)ecn strange in manner, restless, and of 
 vagrant habits. He was known to be of intemperate habits, but no satisfactory 
 histoiy could be obtained. Upon admission he was free from excitement and 
 delusion; his intellectual operations were enfeebled, but tins failure was evidently 
 due to the marked impairment of memory. The following conversation, held with 
 him in the month of February, illustrates the peculiar defect alluded to: — " What 
 is the day of the week?" "/ don't know." "What is the present month?"' 
 " Don't Icnow for certain; November, as near as I can tell." " How long have you 
 been here ? " *' Don't remember sleeping more than one nifjht here." "You gave me 
 the same reply yesterday ! " " Did I? I don't remember; if so, I suppose I have slept 
 here longer.'" He was now told that the day was Mondaj^ February 7, 1887, and 
 was requested to bear it in mind. In a few seconds afterwards he was asked 
 the date, and he replied, with some hesitation, "November, 188G; October, or 
 November, I don't know fairlj\" He was quite oblivious to the names of all with 
 whom he had been associated for some four weeks, and when attempts were made 
 to impress them upon his memory, he rarel}' retained them be^'ond one minute; and, 
 if any trivial question were put meanwhile, he became immediately oblivious to the 
 preceding impression. Old familiar airs he sings correctly, both as regards intona- 
 tion and words ; but any unfamiliar sequence, such as the alliterative doggerel 
 "Peter Piper," he blunders over hopelessly and repeatedlj'. There is no word- 
 blindness or deafness, no tendency to ataxic aphasia ; his visual impressions are 
 correct, as tested for colours, and general sensibility is not impaired, as registered 
 by the cesthesiometer. The dynamometer registers for the ri^ht hand 28 kilos. 
 pressure, and 23 kilos, for the left hand. After a residence of three months, he 
 still affirmed that he had only slept two or three nights at the asylum. Eventu- 
 ally, this patient gradually improved, and a few months later he ^vas discharged 
 recovered. 
 
 The revivability of a former impression as a resultant depends upon 
 several factors; thus, there are — 
 
 1. The intensity of the previous impression. 
 
 2. The vig^our of circulation and nervous energy. 
 
 3. The organisation of such impressions in the establishment of 
 
 associated sense-impressions. 
 
 4. The vig'our of the faculty of attention. 
 
 5. The element of time. 
 
 Now in the case with which we are dealing, the intensit}/ of the pre- 
 vious impi'ession appears to be of minor importance, but the vigour 
 of circulation and of nervous energy is decidedly at fault. Alcohol in 
 its chronic results induces vascular paresis in various organs ; and the 
 brain and spinal cord are by no means exceptions to this rule. Then, 
 again, the conduction along the nervous circuit is impeded in such 
 cases as px'oved by the retarded I'esponse made to sensory stimuli, 
 
AMNESIC TROUBLES IN ALCOHOLISM. 311 
 
 visual or auditory ; and this we have more reason to attribute to delay 
 in the sensory arc tlian in the 'motor arc, or it may be due to delay in 
 the transference from the one to the other. Such sluggish transmission 
 can only be regarded as resistance in the nervous arc, and as resulting 
 in a diminution of the eftective force of the original impact at the 
 periphery. Hence it is, that the organisation of such impressions by 
 the establishment of associative links, i.e., the forcimj of nevj nervous 
 tracts into adjacent areas (the third factor mentioned above), becomes 
 greatly impeded, since this greatly depends upon the vigour of the 
 nervous current, and the vascular supply of the part. 
 
 This failure in the organisation of recent impressions was a prominent 
 feature in the case of J. F., in whom associability of ideas was most 
 strikingly enfeebled, and au impi'ession was received only to be the 
 next moment obliterated ; very rarely, indeed, did a recent impression 
 act with such vigour, as to call up associated states and elicit such a 
 response as to indicate the establishment thereby of an intellectual 
 nexus of ideas. Such organisation is greatly aided by the faculty of 
 attention, which, when directed towards the impression we tend to 
 revive, fosters the growth of that associative process whereon a per- 
 sistent and efficient memory is based. Thus it is that slight distrac- 
 tion of the mind, even momentarily, by directing the attention to any 
 other line of thought will abolish the feeble tendency to organisation 
 of the original imjjressions which might otherwise occur. 
 
 M. H. L., aged thirty-six, married; family history apparently free from 
 neuroses. She maintained that her habits had always been strictly temperate. 
 Thirteen months before admission, and after her foiu'th confinement, she suffered 
 for two days succeeding labour from convulsive seizures. From that date to the 
 present time she had suffered from great depression of spirits, and liad threatened 
 to commit suicide. Upon admission there appeared but slight depression, but a 
 notable failure of memory was apparent with respect to any recent circumstance, 
 in so far that she could not recall the events of her daily life from hour to hour ; 
 could not name those with whom she was continually associated ; forgot almost 
 immediately any event occurring, such as a meal, a walk, or a conversation, unless 
 such circumstances had been impressed by some unusual occurrence. She faUed 
 to recall dates or the duration of her stay here — believing she had been at the 
 asylum but two or three weeks after a residence of eighteen months. She would 
 read persistently "for the sake of employing herself," but confessed she could not 
 follow the drift of any continuous narrative, "as every fresh Ime seemed to blot 
 out the one preceding it." However forcibly she was enjoined to remember a 
 name uttered to her, a moment's conversation or even a casual question sufficed 
 to obliterate the name from her mind. In all other particulars, this patient waa 
 intelligent and Avell-informed, and her conduct rational and consistent. She 
 recalled bygone events preceding her confinement very clearly ; but the month 
 following the latter event was to her mind a complete blank. Very slight 
 improvement took place in her amnesic state during her residence at the asylum, 
 and she was subsequently transferred elsewhere. 
 
312 ALCOHOLIC INSANITY, 
 
 The faculty of attention is in these cases itself impaired, and the 
 mind tends to wander aimlessly. Time, again, is an important 
 element here, and in the case of ./. F. it will be noted that any name 
 which he was requested to bear in mind could rarely be retained for 
 a longer time than thirty seconds, or a minute at most. 
 
 2. Delusional Forms. — A much larger class is comprised by those 
 whose reasoning faculties are warped, and judgment falsified, where, 
 ixi fact, delusional perversions form the most notable feature of the 
 case. In these, as in the former class, anomalies of the sensorial and 
 motorial apparatus may be present, and to a much more serious 
 extent, exhibiting a far greater persistency than is observed in 
 acute alcoholic delirium ; and, in like manner, the other intellectual 
 faculties may be involved, the power of attention enfeebled, and the 
 faculty of recollection impaired, yet the predominance of delusions is 
 the distinguishing feature of this class. The repeated storms which, 
 in the acute stage, have swept over the delicate nervous arrangements 
 of sensory and motor mechanisms have damaged these mechanisms to 
 an irremediable extent, the emotional perturbations, the hallucinatory 
 phenomena, ever changing and fleeting in the earlier stage, now begin to 
 assume a more persistent, a more stereotyped form, corresponding with 
 actual structural change in the sensorium ; the intellectual aberrations 
 evolved out of such sensory disorders, likewise lose their changeful 
 nature, and take on a more fixed and persistent character. The 
 exhausting character of the dischai-ge from the highest nervous 
 mechanism during the acute stages has left these centres in a more 
 or less paralysed state — the energy of their cell-elements is expended, 
 or escapes in streams too feeble to produce adequate results ; muscular 
 tremor prevails ; the whole life of relation is affected, and its motor 
 activities cramped and restricted from this cause. The natural resis- 
 tance to be overcome in the motor centres, although not actually 
 increased, appears enormously disproportioned to the capacities of the 
 volitional activities, and the subject consequently feels the encroach- 
 ment of the environment which must result therefrom. The registry 
 of this outer resistance, and the impotence of the will, must engender 
 distrust, suspicion, fear, and allied depressing emotional states, whilst 
 the illusory and hallucinatory states afibi'd still more tangible basis 
 for the fostering of a gloomy, sus])icious, distrustful nature. 
 
 We have seen howj^morbid sensations may be fostered and enormously 
 exaggerated by the persistent direction thereupon of the attention. 
 We likewise are aware |how emotional states may be aroused to 
 unnatural intensities' by the morbid tendency of the mind to dwell 
 thereupon : so, delusional states, especially the hypochondriacal class, 
 are fostered by the same influence, and the sense-impressions upon 
 
KATURE OF THE DELUSIONAL PERVERSION. 313 
 
 which they may be based are distorted to an extraoi'dinary degree. 
 Here, again (as indicated elsevvliore), with tlie decline of object- 
 
 consciousness, there is a corresponding" rise of subject-con- 
 sciousness, and the conception is formed of a hostile and aggressive 
 environment. 
 
 T. S., aged fifty-sLx, married, commercial clerk, admitted in January, 1873, 
 suffering from his first attack of insanity, of fourteen months' duration. He wa& 
 somewhat above the middle height, stout, muscular, and well-nourished ; of some- 
 what swarthy complexion ; hair black, turning grey ; irides bluish-grey ; pupils 
 normal in size and reaction ; malar and nasal capillaries dilated. Patient had been 
 of intemperate habits, but, although often drunk, could not be called an habitual 
 drunkard — his brother committed suicide. He had only recently been discharged 
 from a private asylum, where he had resided for six months. He was agitated 
 and suspicious when examined ; declared he had passed a wretched night, and 
 could not breathe naturally as the " air in the room was exhausted by some means." 
 The instant he places his head upon his pillow he hears a whistling sound, and the 
 voice of his late governor speaks to hun ; at times, the whistling and the voice 
 are heard in the air above, and even now the voice is heard distinctly taimting him 
 from outside the window — "Thou 'st made a nice job of thyself, T. S., by getting 
 in here." He feels impelled to accuse himself of extraordinary crimes, such as 
 murder, poisonmg, and a robbery of £50,000, " although he knows it is not true." 
 The whistling under the pillow produces "an electric current, which calls up a 
 feeling in his hands as if he had taken morphia." When at home, voices outside 
 his window were heard threatening his own and his sou's life. Patient was a 
 highly-intelligent man, and would talk for hours upon the subject of his delusions, 
 which caused him much mental torture. The aural hallucinations (although 
 present at all times, more or less) became terribly real to him at night, and 
 deprived him of rest. He wrote a good clerical hand, and was actively employed 
 during the first few months of his residence here ; but, when left to his own 
 resources, he invariably occupied himself in writing out lengthy epistles descriptive 
 of the persecutions to which he was subjected. About eighteen months after 
 admission, he made a desperate attempt to poison and hang himself. He had 
 secreted some putty and some whisky (which he had bribed a patient on his 
 parole to obtain for him) ; these he mixed up with a quantity of tobacco-juice, 
 and, having swallowed this strange compound, he suspended himself by some 
 knotted twine and a handkerchief. Being a very heavy man his M-eight broke the 
 ligature, and his life was saved after free emesis. He confessed to having planned 
 this attempt several days previously ; his persecutors having threatened (through 
 the medium of a mysterious influence which he calls a "new science ") to cremate 
 him alive. 
 
 The persistency of these delusions is evidenced by the followmg letter written 
 three and a-half years after admission : — 
 
 CONSPIRACY. 
 Mr. F. 
 
 Dear Sir,— I beg you will read the following without prejudice. . . . My 
 first wife's sister's husband, who resides forty miles south of "London, is the 
 mventor of an electro-animal-magnetic machine, and other inventions, made, I 
 suppose, somewhat similar to a camera obscura, or camera lucida, both of which or 
 
314 ALCOHOLIC INSAXITY. 
 
 all are fixed at Leeds or Wortley (Imt I believe at the last-named place). Five or 
 six persons whom I know ]>y tlieir voices (but tiiere are many others I don't know) 
 can see and hear all that transpires in the district (and to mj' own knowledge) 
 within a radius of thirty miles, from Wortley ; they can also tell (after having 
 applied the electro-magnet to his head) what any person is thinking, and he is 
 compelled and cannot avoid hearing all they say. It is impossible that mesmerism 
 or electro-biology may be combined. The mind of the individual operated upon 
 is affected through a material living agent, it may be througli a material fluid — 
 call it electric, call it odic, call it what you will, which has the power of traversing 
 space, and passiuc; obstacles, so that tlie material effect is communiaited one to 
 another. No man or woman's life is safe that they have any ill-feeling or hatred 
 towards, so long as those infernal inventions are allowed to be practised by them. 
 I have been operated upon for upwards of three and a-half years, by the inventor's 
 infernal machines, by him, his, and my first wife's relatives, and others who have 
 a deadly hatred towards me, and are intent on schemes to shorten my life, their 
 object is to make me commit suicide, then they think they will have their own 
 Avay in the disposal of all I have, say about £1,500, which I liave made by railway 
 shares, and saved out of my wages (salary) in about forty-one years. I have no 
 doubt, whatever, in saying that these infernal inventions have been practised on 
 me from the day I was married to my present wife, as I well remember at times, 
 I was affected by peculiar voices, and whisperings close to my head, which were 
 the causes of my being so very nerveless. — 1 am, dear sir, yours truly, T. S. 
 
 P. S. — For the last three and a-half years they have sent a continual current of 
 electro-magnetism (or be it what it may) through my head day and night, I am 
 prepared to prove the truth of what I have written, also can refer to parties who 
 will verify the same. If you w'ill come over and see me, I will give you all the 
 information I can on the subject ; also, who some of the parties are, and give you 
 an idea where the machines, &c., are fixed. I have been twice driven from my 
 home, from fear of being barbarously murdered. They sometimes send an electric 
 shock through my head and say— "Take that to be going on wnth . . . 
 (here follow abusive and obscene epithets). Don't imagine I am insane because I 
 ■write this from a lunatic asylum. — T. S. 
 
 This letter was further crossed by the following postscript : — They now say 
 they thouglit tliey could make me commit suicide in about three days ; they never 
 thought it would take them three and a-half years, or they wouldn't have made 
 the attempt. Had some of the parties written a similar letter to those I have 
 written to Mr. B., also to the Magistrates of Leeds (six or eight foolscap-pages) 
 and I had been a party conspiring to deprive an innocent man of his life, money, 
 property, &c., and had stolen a wooden case out of any of their houses, and put a 
 <lead Ijody (corpse) into it, and buried it in their gardens, I sliould have very soon 
 been in the hands of the police, committed to ])rison, tried at the assizes, con- 
 <lemned, and executed, but they and others are allowed to do just as they like — 
 there is in Leeds one law for the rich and another for the poor. They arc 
 justice's justice. — T.S. 
 
 Three years after admission he made another and nearly successful attempt to 
 poison himself whilst employed in the asylum stores ; having secured and swal- 
 lowed a consideraljle quantity of marking ink. 
 
 No words could adequately describe the terrible mental torture to which 
 this poor man was doomed, and although, at tunes (through the administration of 
 opiates, cheerful society or employment, and conversation to distract his mind), 
 his symptoms were somewhat alleviated— the evening invariably found him suflFer- 
 
CASE OF T. S. 315 
 
 ing, with rodoubled force, from his invisible persecutors. Like most cases of this 
 category, lie exhibited the restless anxiety to discover some tangible cause for his 
 sufferings; some plausible explanation of the diabolical means employed by his 
 enemies. With this object he ransacked every book, periodical, and newspaper 
 he could lay his hands upon ; and eagerly questioned the medical officers as 
 to the proV>aliilitios of mesmerism, electro-ljiology, witchcraft, odyle, electricity, 
 and magnetism being the means employed. We well remember his excited expres- 
 sion one day when, handing us a newspaper, he indicated a passage bearing upon 
 the telephone and phonograph, of which he liad for the first time heard, and which 
 lie convincingly and triumphantly regarded as the solution to the whole mystery 
 of his case. The possibilities of science are now invoked to account for mysterious 
 feelings, which long ago would have been explained by the patient as due to 
 diabolical agency or to witchcraft. Demonomania is by no means so common as it 
 once appears to have been ; man's powers over natural agencies has supplanted 
 Satanic agency from the possession it held over the minds of men in explanation 
 of the weird symptomatology of certain forms of insanity. — [(Janes of E. A. F. ; 
 G. L.) 
 
 We have already alluded to the resistance offered by the environ- 
 ment to the activities of the organism in its life of relation ; to the 
 sense of proportionately increased resistance to motor energy, due 
 to the feeble initiatory discharge ; in a certain sense this applies to all 
 the mental faculties alike. We find amongst the delusional forms of 
 chronic alcoholism this sense of obstruction presented to every form 
 of intellectual operation. In one, ideation is impeded — " Thought is 
 fettered and enslaved by the unseen agency ; " in another, the faculty 
 of memory is impaired and recollection becomes painfully irksome, and 
 this is likewise attributed to a similar power ; in another, the expres- 
 sive faculty of speech is restricted, and the patient declares that he is 
 often compelled to say otherwise than he would ; he will often add, 
 " Now I am speaking my own thoughts ; but, by-and-by, I shall be 
 made to speak the thoughts of others." One patient {J. J^.) graphically 
 describes his troubles thus : — " As I speak, the force within me will 
 clip a word in two, and so wholly alter the meaning of what I wished 
 to say." 
 
 In the case of T. S., it will be noticed that he felt swayed by the 
 unseen influence so far as to feel impelled to self-accusation of crimes 
 of which he knew he was innocent. And just as J. J^. believed that 
 he was impelled to speak the thoughts of others, so he was compelled 
 to think as they wished him, however atrocious, however sickening, 
 obscene, or blasphemous the line of thought. In T. S., again, the 
 revolting language to which he was doomed to listen — the horrible 
 obscenity of speech, which he hesitated to record in writing — was a 
 notable feature, and was equally prominent in the case of J. M^G. 
 All these are instances of the enthralment of the individual faculties 
 of the mind, leading to the sense of an invasion by an antagonistic 
 
316 ALCOHOLIC INSANITY. 
 
 environmental ajj;ency ; the noxious character of which is inversely 
 proportioned to the growing sense of helplessness and incapacity of the 
 organism. The patient, J. S., died of an intercurrent affection, and, 
 as a sad sequel to his history, his only son was admitted, at the 
 age of forty, suffering from delusional insanity, as the result of 
 alcoholic excess. He had had repeated seizures of delirium tremens ; 
 had squandered a large sum of money away by his dissipated habits ; 
 and was, on admission, the subject of phthisis, to Avhich he succumbed 
 in five months time. His history was one of persistent hallucinations 
 and gloomy delusions, in which he often thought himself accused of 
 atrocious crimes. He was determinedly suicidal, refused food for 
 a long time, and struggled desperately against its compulsory admin- 
 istration. He was surly, suspicious of all alike, could be induced to 
 talk but little upon the subject of his delusions, and never volunteered 
 any reference to them unless repeatedly prompted. 
 
 These cases of delusional hisanity due to chronic alcoholism fall into 
 several natural groups corresponding with the nervous centres 
 primarily, or more prominently, implicated. Thus, there are those in 
 whom sensorial anomalies preponderate, and in tliese the centres of 
 special sensation, and chiefly the auditory, may be implicated ; or the 
 centres for the organic sensations emanating from the various viscera ; 
 or the centres for the generative organs and the sexual instincts ; all 
 leading up to delusional perversions. There are those in whom the 
 intellectual operations are specially, and often primarily, affected when 
 the delusions (although often associated with aural hallucinations or 
 hallucinatory states of other special or general sensations) are not 
 necessarily evolved out of these. Their special character consisting 
 in a primary change in the centres of other intellectual operations, and 
 the resistance offered to the diminished mental energy, is registered as 
 the immediate antagonism of a malevolent power, which has gained 
 access to the organism. Besides these two categories there is the class 
 already alluded to of the primary amnesic form, in which the faculty of 
 recollection is the one mure prominently or exclusively affected. 
 
 In the primarily sensorial forms we find aural hallucinations 
 preponderate ; and although other senses (more often those of taste, 
 smell, and general sensation) may be likewise disturbed, in most 
 cases the auditory disturbance is the only anomaly complained of. 
 The phenomena observed may embrace every possible combination of 
 articulate or inarticulate sounds. ]f voices be heard, they may be 
 distant and scarcely audible, or near and loud, or in close propinquity 
 may whisper in the sufferer's ears ; they may be above, below, on 
 the right or the left, and may be referred to casual passers-by, to 
 animals, or to birds. Thus, one patient heard the sparrows talking to 
 
VISCERAL ILLUSIONS. 317 
 
 him as tlioy flitted to and fro ; another was addressed by the crows 
 as they flew past him ; but, the voice was the voice of human beings 
 wliom he recognised as his enemies. Certain French writers have 
 alluded to bilateral hallucinations in which the patient hears with 
 one ear threatening, denouncing, or revolting language ; and with the 
 other encouraging, kindly, and conciliatory words ; this condition we 
 have never met with in alcoholics. In all such cases, the malign 
 influence makes itself felt in discouraging or alarming terms. 
 
 A form of visceral hallucination is, however, often present, 
 which is of great interest as indicative of the manner in which new 
 but morbid groupings arise within the sensorium. It is that of the 
 epig'astriC voice, in which a sensation felt at the epigastrium is 
 • often spoken of as a " voice," which the patient describes as not an 
 auditory perception but still "a voice" which makes itself understood, 
 and by which he feels himself impelled to act — this was the case vrith 
 J. W. It would appear that a centric disturbance projected to the 
 epigastric region is associated in some way with a disturbance 
 impressive of the auditory centres of speech ; and that the associated 
 sensory change is referred in both cases to the same site. In fact, it 
 may be often observed that any morbid sensation, cutaneous or 
 visceral, will, in like manner, determine the direction from which an 
 aural hallucination appears to emanate ; both phenomena being 
 referred centrally to the same category of maleficent agencies. 
 
 An important class is comprised of those whose characteristic 
 delusions and illusions are those of the sexual feeling's and 
 instincts. A large number of alcoholics exhibit some degree of 
 perversion of the sexual feelings^ referred by them to an antagonistic 
 agency ; but we more especially allude to those who exhibit this 
 perversion as the ruling spirit of their insanity. Out of such cases, 
 the most astounding delusions are begot. A typical case who has 
 been for years an inmate of the West Riding Asylum, refers all his 
 morbid sensations to the generative system, which he believes to be 
 operated upon by various agencies — electricity, poisons, caustic, red- 
 hot iron, and elaborate mechanical contrivances worked by magnetism, 
 which have been invented by his unseen enemies with the object of 
 rendering him miserable and ultimately insane. Impressed with the 
 notion that these agencies afiect, not only himself, but thousands of 
 others who are confined in asylums, he writes manuscript by the yard, 
 revealing his feelings to the Government, and describing the various 
 ingenious and diabolical means used for such purposes. He sketches 
 large figures in coloured crayons, representing the human form in both 
 sexes, delineating their anatomical structure according to his own 
 notions, in which the generative apparatus occupy a most conspicuous 
 
318 ALCOHOLIC INSANITY. 
 
 position, and in which are mapped out the course of the " electric 
 Huid," and the structures which are supposed by him to be concealed 
 within the body for such purposes of torture. 
 
 During his relapses of excitement he recorded (on a roll of paper 
 measuring a dozen yards in length, both sides closely written upon) 
 his feelings and maledictory comments dedicated to his persecutors. 
 The eflusion throughout was couched in the most obscene and revolt- 
 ing language obtrusively exposed ; in his calmer moments, no one 
 could be more decorous and punctilious in his behaviour and conversa- 
 tion. The case of J. M^G. is allied to this ; in him, also, the sexual 
 organs were the subject of delusional perversions. Sexual hallucina- 
 tions at night were frequently complained of; and his female persecutor 
 was believed to act prejudicially upon his system from a distance 
 through the medium of a " mirror." He, moreover, heard lewd, 
 lascivious utterances from old associates, who imputed to him various 
 unnatural crimes. 
 
 E. A. F., aged fifty, married, printer by occupation; a tall, powerfully- built , 
 muscular man, somewhat prematurely aged, with a suspicious, furtive look, a 
 dusky, sallow complexion; pupils active, the right somewhat the larger of the 
 two; no facial or lingual tremor; no impairment of articulation. The heart's 
 sounds were exceedingly weak, but there was no murmur, no intermission, and 
 the pulse, which was very feeble, was regular. No insanity was traceable among 
 his antecedents, no history of neurosis or ancestral intemperance. Patient had 
 long been addicted to excessive drinking. 
 
 Upon examination he betrayed much nervous agitation, stared at the ceiling 
 and walls, declaring the room was surrounded by instruments, whereby people in 
 Leeds and Bradfoi'd could hear all that he said; certain perforations in the 
 wainscotting he asserted were telephones ; the bed he lies upon is electrified, and 
 he even now feels the current passing through him. At his own home a telephone 
 wire ran beneath the floor of his room, and upon placing the legs of his chair 
 parallel with this wire, he could himself feel the electric current; people in 
 adjacent houses constantly spoke audibly through the walls of his house; they 
 were in intrigue with his wife, whose fidelity he distrusted. He found that she 
 used secret signs — e.g., folding her shawl in a certain manner meant that he 
 slept, &c. ; and so she communicated with his enemies. 
 
 Memory was unimpaired ; his attention good ; and his replies were prompt ; he 
 freely admits alcoholic excess. 
 
 Sept. 25. — Nine days after admission — still very suspicious; firmly believes his 
 wife conceals herself in the building, and goes about looking for her. Thirty 
 grains of chloral given nightly to relieve insomnia. 
 
 Oct. 3. — Is convinced his tobacco is poisoned ; hears voices of unseen persons. 
 The sounds issue through the ventilating outlets near the ceiling. "Cannot you 
 hear them now ? " Manner very suspicious ; requests a private interview, and, 
 when conversing, frequently expresses the fear that he is overheard. 
 
 Oct. 10. — Aural hallucinations constant during his waking hours; asserts that 
 he hears his wife upstairs calling out, "Fool, fool, fool!" is quite convinced it 
 is she, and if his iuterlocutor would but spend half-an-hour with him, he would 
 
CASE OF CHRONIC ALCOHOLISM. 319 
 
 also be convinced; heard his niece this morning, and his daugliter's voice last 
 night. He made a most violent attack iipon an attendant later on. 
 
 Nov. II.— "They galvanise all the chairs, and the current goes through me 
 
 strongly." 
 
 /)ec. 7. — Eemarked to an attendant, who opened his door this morning, " Now 
 or never! " and followed him closely, it is not certain with what intentious. 
 
 Jan. 19. — "Hears attendants in the rooms overhead making a huzzing noise 
 and talking;" hut does not hear what they say. 
 
 fg})^ 1. — No change of late; quiet, well-conducted, and sleeps well; fancied he 
 heard a sound last night like a female voice talking to him through the ventilators 
 of his room; and feels something like an electric current running through his right 
 side to-day— he often feels it; fully convinced that wires convey . electricity all 
 through the wards; the voices are not sounds in reality, but " thoughts conveyed 
 by electricity. " 
 
 May 4. — Discharged " relieved," at the urgent request of his friends. 
 
 He remained fairly well-conducted and temperate for twelve months, then 
 relapsed into his drinking-habits, which induced an exacerbation of his mental 
 symptoms, leading to a second admission eighteen months later. The hallucina- 
 tions had become far more distressing ; and whilst walking in the open streets, he 
 heard voices of people miles away talking to him ; suspicions against wife and 
 children returned with redoubled force; he accuses the former of the grossest 
 immorality ; had been dangerously violent to her, and had once nearly strangled 
 her. The night preceding his admission here, he had driven wife and children out 
 of doors, threatening that, if they did not leave, he would murder them all. 
 
 His subsequent history was but a repetition of what had preceded this attack, 
 and he left the asylum relieved in the course of seven months. 
 
 Then we have the class of cases where disturbances of cutaneous 
 sensibility lead to delusional concepts of a mysterious principle, 
 known or unknown, acting upon the body. Thus, in the case of G. L., 
 the room was surrounded by invisible tubes, from which issued currents 
 of air producing electricity, and affecting his body and limbs — con- 
 torting and twisting them into various attitudes, and causing him 
 much agony ; often leaving him weak and prostrate upon waking in 
 the morning. The unseen fluid enters his ears, and aff"ects his brain ; 
 but his malignant enemies always keep " prudently at a distance." 
 
 A very special form of delusion, already alluded to and illustrated, 
 becomes elaborated in such cases as that of J. B. Here the resistance 
 met with by the organism appears chiefly to aftect the intellectual 
 operations, and in a very direct manner. The faculty of thought and 
 speech become impaired, and, as the victim believes, by the direct 
 operation of a power which has gained access to his bi-ain ; which rules 
 his thoughts and dictates his very utterances. In such cases, where (as 
 in thiit of/. B.) no sensory hallucinations have been experienced, we 
 may safely infer that the centres of the intellectual operations are 
 primarily diseased. Thus we find attention, ideation, memory, volition 
 in varying degrees afi"ected in this class of cases, and delusional 
 
320 ALCOHOLIC INSANITY. 
 
 concepts evolved out of tlie resistance which is engendered by such 
 failure. 
 
 Evolutions of Psychical Phenomena.— A case of chronic alco- 
 holism of the purely sensorial form is obviously not one of alcoholic 
 insanity ; and it becomes an interesting and ijuportant point to trace 
 the progress of the affection from the sensory areas pure and simple 
 to the planes of intellectual operations — to recognise the gradual 
 overstepping of the boundary line where intellect itself becomes 
 involved and the case relegated to the category of the insane. AVith 
 this object, let us study the nature and effects of the sensorial distur- 
 bances. The hallucinatory phenomena are, as we know, presumed to 
 be due to certain abnormal discharges from the sensory areas of the 
 cortex. 
 
 Nature of the Discharge. — If the nervous discharge be carefully 
 considered we shall find it one of high tension; sudden explosive onset; 
 rapid escape; irregular or fitful occurrence. The centres are in a state 
 of extremely unstable equilibrium — a state of sensory hypersesthesia 
 prevails. When such unstable centres discharge themselves, one or 
 more of several results may occur. In the first place, as indicated by 
 Dr. Hughlings-Jackson, the discharging centre exhausts itself — is, for 
 the time being (in the case of the sensory area), less imj^ressionahle — 
 and has assumed a state of molecular stability. In the second place, 
 the centres subordinate to the paralysed centres rise into uncontrolled 
 activity. In the third place, the discharge takes a certain course and 
 produces certain results. 
 
 (a.) Thus, it may react along a motor tract and issue in active 
 movement ; 
 
 (h.) It may dift'use itself in sensorial realms, producing emotional 
 perturbation ; 
 
 (c.) It may involve nervous mechanisms subservient to the intel- 
 lectual sphere of mind, and active ideation may be aroused thereby. 
 
 Whichever course it takes, whether one or the other or many, it is 
 to be observed that the point for us to consider is the forcing of other 
 and distant nervous tracts which are hereby rendered more permeable to 
 such discharges in future. 
 
 Hallucinations a determining" Factor of Morbid Ideation. — 
 
 Let us revert to our original conception of the phases of object- and 
 subject-consciousness. The sensory fibres are the channels for those 
 pulsatile tremors which arouse the sensory cortex into activity coinci- 
 dent with the presentative states of consciousness. In other words, 
 these vibratile thrills, transmitted up to the centres of general and 
 special sensation, constitute the raw material of object-consciousness. 
 
HALLUCINATIONS A FACTOR OF MORBID IDEATION. 321 
 
 In alcoholism we say there is a general augmentation in nerve-resist- 
 ance, both in sensory and motor channels. 
 
 In the sensory nerves it is indicated by the tingling, prickling, and 
 formication whicli follow the hyperjesthetic stage of the cutaneous 
 surface — all of which phenomena are probably due to the broken-up 
 current — the nervous impulse interrupted by augmented resistance 
 — whereby successive shocks are no longer fused into a single 
 impulse. Hence, excitations from the periphery do not reach these 
 centres in the normal state; and a decline in object-consciousness occurs, 
 with a corresponding rise in suhject-consciousness. The centres them- 
 selves are in a state of hypersesthesia, of extreme instability, and their 
 intermittent, spasmodic discharges must take some determinate course. 
 The discharge from the centres of special senses (which is the physical 
 side of a hallucination) may diffuse itself along lines of least resistance 
 in the sensory realms, discharging the numerous extremely minute 
 nerve-granules (the reservoirs of feeling) found in these regions ; and 
 issuing in emotional states which require but slight impact for their 
 arousal. On the other hand, if the energy of the sensory discharge 
 be sufficiently great it will break through lines of great resistance and 
 flood the channels of those centres which have for their psychical 
 correlate the ideational faculties ; or, overcoming the resistance of 
 motor nerves, issue in determinate movements. 
 
 In alcoholism the specific resistance of the afferent and efferent fibres 
 is augmented ; the former resulting in a decline in ohject-consciotisness ; 
 whilst the centric discharges opposed by the latter originate the 
 depressing, emotional states associated with feelings of environmental 
 antagonism, which is so notable a feature in this affection. Nor is the 
 resistance ahead other than a favourable condition; for, by this means 
 emotional states form a safety-valve for unstable discharging centres — 
 often by motor lines, and so relieve the plane of more purely intellectual 
 operations from the fatal results of the inrush of morbid discharges. 
 It is only when the barrier of resistance partially gives way that the 
 development of delusional conceptions becomes possible. 
 
 Continued discharges from these sensory areas eventually break 
 through this barrier of resistance, but only in certain determinate 
 lines, which become, so to speak, channelled out, and more and 
 more pervious by the repetition of discharges along the same tract. 
 Thus it is, that in the psychical side we find that certain hallucinations 
 eventually beget certain determinate lines of thought corresponding 
 thereto ; that imagination becomes tinctured by the distressing hallu- 
 cination and gloomy emotional background ; and that, thus, the 
 spheres of the intellectual operations become pervaded by such 
 agencies, and strong contrasting feelings and ideas arise, overbalancing 
 
 21 
 
322 ALCOHOLIC INSANITY, 
 
 the former intellectual being ; hence, the genesis of delusional states. 
 The forcing of such tracts, or the more pervious channelling caused by 
 energetic or oft-repeated discharge, may often be witnessed in health — 
 note the continual recurrence, despite our inclination, of a song we 
 have lately heard, or been impressed with ; and the incontrollable 
 tendency at times to hum or whistle over a tune which we in vain 
 attempt to dismiss from the mind. Again, the tormenting recurrence 
 of a line of thought, after prolonged and fatiguing mental work, 
 which so often deprives a student of his night's rest. This persistence 
 of sensory and ideational excitation is due to a too-pervious channel 
 established, and loss of higher controlling centres; and it can only arise 
 after discharge from the uppermost series, leaving these latter exhausted. 
 So in these morbid states certain tracts become permeated, to the 
 exclusion of others, by the powerful but intermittent discharge from 
 sensorial realms, and unstable molecular arrangements are built up in 
 the substrata of the ideational centres. 
 
 Sensory troubles. — An early symptom in chronic alcoholism, is 
 disordered common cutaneous sensibility, and tactile sensibility ; ex- 
 altation of both usually preceding the various modifications, their 
 diminution or abolition. Tingling, prickling sensations are often felt, 
 and formication is especially frequent ; the patient feels as though 
 insects were crawling beneath the skin — over the thigh and gluteal 
 regions, and gradually extending to the trunk and arms — until 
 the feeling is at times quite intolerable : it indicates that a change 
 is progressing in the sensory trunk and centres. Patches of hyper- 
 aesthesia are often noted, as in the wrist of the patient {J. J^.), 
 where tactile sensibility is greatly exalted ; the site is also equally one 
 of hyperalgsesia. The variety of hyperalgsesia, when contact causes a 
 sensation as of burning, or of a sharp cutting edge, is also a frequent 
 phenomenon, and in one patient the peculiar modification called 
 by Fischer 2^olycesthesia, in which one point is recognised as two 
 or three points, was observed. Shooting pains are prevalent in 
 advanced cases, the pain being not infrequently associated with 
 muscular shocks, the patient often regards them as due to electric 
 discharges. The excessive exaltation of the sense of pain, associated 
 with spasms and cramps, leads to ideas of the limbs being torn, 
 wrenched oflf and mutilated. Later, we find numbness and blunting 
 of general sensibility, passing into areas of complete anaesthesia (often 
 with an extreme degree of vaso-motor paresis) which, beginning at 
 the tips of the fingers and toes, creeps up the dorsal aspect of the 
 limbs. 
 
 Motor Symptoms. — The group of symptoms described under the 
 head of sensorial anomalies, though highly characteristic of chronic 
 
SENSORIAL AND MOTORIAL DISTURBANCES. 323 
 
 alcoholism, is by no means necessarily distinctive of this affection, since 
 such symptoms may arise (individually or collectively) in other nervous 
 diseases : the same remark applies also to the mental anomalies 
 exhibited by alcoholics. Ordinary forms of delusional insanity often 
 show the selfsame symptomatology, the dementia of later stages of 
 alcoholism being scarcely distinguishable from other non-alcoholic 
 states of mental decadence. Even the amnesic type referred to, may 
 be recognised as sequent occasionally to other convulsive neuroses. 
 
 It is in the motor anomalies that we find the most definite indica- 
 tion of an alcoholic etiology, for they especially present a distinctive 
 group rarely, if ever, exhibited by other neuroses than the alcoholic. 
 Perhaps too much emphasis has been laid upon the sensory and 
 mental disturbances of chronic alcoholism to the exclusion of the 
 motorial in the diagnostic indications usually appealed to ; for, cer- 
 tainly, the motor group are the "tell-tale" symptoms which most 
 clearly indicate the agencies which have been at work. It is not, how- 
 ever, by the grouping of such symptoms (whether sensorial, mental, or 
 motorial) that we shall be chiefly aided in eliciting an alcoholic factor; 
 we must chiefly rely upon the historical aspect of our case — the mode of 
 evolution of such symptoms, and the tendency of the disease towards 
 fresh nervous implications. Here, especially, do we recognise the 
 scientific process pursued by Magnan in his classical work, when indi- 
 cating the tendencies of alcoholism to pass into dementia, or general 
 paralysis. The tendency alluded to more particularly at this phase, 
 and upon which we do not think suflcicient emphasis has been 
 placed, is this : the morbid process due to alcoholism evolved in 
 sensory areas ever tends to he translated into the motor realms of the 
 brain, establishing necessarily a co-existent disturbance in what we 
 may speak of as the motor realms of the mind. However acute, however 
 persistent may be the sensorial disturbance, we shall always recognise 
 a tendency towards this tPanslation in physico-mental terms — the 
 delusional distortions being often nothing more than mere symbols 
 of motOP enfeeblement which may not be so obtrusive a symptom 
 to the observer. 
 
 J. R., aged thirty -four, single, a blacksmith; admitted November, 1883. He 
 had previously been an inmate from August, 1882, to March, 1883, and was then 
 discharged as relieved. Five years ago he suffered from a blow on the head by a 
 stone in a quarry falling upon him. Upon leaving the asylum he went to work in 
 a colliery, but was soon thrown out of employment by a pit accident, when he 
 returned to irregular habits of life, drinking very heavily, and speedily developed 
 mental symptoms. He became violent, and talked much of the sim, moon, and 
 stars. His sister stated that patient's father was a notorious drimkard, that 
 three of patient's brothers were excessive drinkers, and that two others, as well 
 as a sister, had died of phthisis. The mother and her parentage, however, were 
 
324 ALCOHOLIC insanity. 
 
 healthy and temperate. Patient heg<an drinking raw spirits at the age of 
 sixteen, when employed in "bottling" at a spirit-store. Since this time he has 
 wandered to and fro about the country, often lost .sight of for years l)y his 
 relatives ; but he remained to the end a very heavy drinker. At times he would 
 reappear amongst his relatives, shocking them with his dissolute habits ; secreting 
 spirits, and drinking by the pint daily, in spite of every effort to restrain him. 
 During his second residence at the asylmn he was excited, incoherent, incessantly 
 garrulous, restless, and irrational ; " has the sun and moon — lialf the moon in his 
 head." He was destructive of clothing. He had a somewhat imbecile expression, 
 was good-humoured, jocose, and talked recklessly. His face was thin, complexion 
 earthy, cheeks and nose dusky ; the pupils were equal — consensual, reflex, and 
 associative movements were active. There was no defect of articulation ; no 
 muscular tremor ; was of spare habit, weighing 126 lbs. ; height, 5 ft. 7 ins. 
 Thoracic and abdominal systems appeared normal. 
 
 Nov. 29. — Six days after admission — excited, destructive, yet his bodily strength 
 keeps up, and he takes food well. Hyoscyamine (^ grain) ordered. 
 
 Dec. 4. — Sleeps well, and is improved mentally ; more rational and coherent. 
 Dec. 19. — More excited, mischievous, negligent in habits, restless, untidy in 
 dress ; hides anything he can secure ; sleeps well ; appetite good. 
 
 Some four months later he still continues maniacal ; grotesque, pretends to be 
 timid and humble, picks the patient's pockets, upsetting all the ward, and delighted 
 with the mischief he has done. He remained for twelve months an inmate, and 
 was then discharged — "recovered." 
 
 Upon his tldrd admission (February 13, 1886) he was excited, wild, and threat- 
 ened to cut his own throat or strangle himself. He was quite incoherent. He, 
 however, soon fell into his usual noisy, garrulous, jocular humour ; inclined to 
 much merriment and to the use of obscene terms ; talked much of the other sex, 
 and had apparently sexual hallucinations. He was in incessant movement, 
 undressing himself, gnawing at his clothing, gesticulating, and grimacing like a 
 monkey ; no grandiose notions. The pupils were equal, normal in reaction ; deep 
 and superficial reflexes were normal ; he was thin and reduced ; the heart seemed 
 healthy, but the vessels were corded. 
 
 Feb. 20. — Excited, restless, in and out of bed constantly ; obscene, incoherent. 
 March 2. — Quieter, yet noisy at nights ; degraded and obscene — masturbates. 
 March 9. — Has a comic expression ; acts like a monkey ; accosts eveiyone in 
 flippant terms ; asks for better clothing, yet destroys all he secures. 
 
 June 12. — Makes random statements ; says he has been here twenty-four years. 
 He now works regularly, but still has the same simian look and habits. 
 
 Aug. 16. — No notable dementia ; his conversation is sonaewhat childish ; health 
 much improved. 
 
 Jan., 1887. — He left the asylum "recovered." 
 
 He was admitted for the fourth and last time in November, 1887. At this 
 date he was in a state of continuous maniacal excitement, usually stark naked in 
 his room, crawling upon hands and knees, degraded in his habits, and requiring 
 manual feeding. He was still in a jocular humour, laughed much, and gave 
 absurd random replies ; snatched things out of the attendant's hands, grimaced 
 apishly, and gesticulated much. He was very tliin, his muscles flabby ; facial 
 capillaries much dilated ; pupils were equal and active ; deep reflexes normal. 
 
 Dec. 2. — Has become very suddenly feeble, totters much in his gait, and is iticlined 
 to ''double-up ;" is still maniacal, but mutters more to himself ; tongue somewhat 
 brown. 
 
CASE OP J. R. 325 
 
 Dec. 9. — Can just support himself with his feet wide apart and hands against 
 the wall; the feet are purplish, with dark, livid patches; skin looks tense, 
 swollen, and glazed ; the soles of feet are blistered ; both feet are of icy coldneSs, 
 and are kept somewhat rigid, but there is no genuine contracture ; Ijoth knee- 
 jerks are extremely sluggish. He takes a wide basis of support, straddles much, 
 and tends to roll over on his head ; tongue is protruded in a slovenly fashion, first 
 on one side, then on the other ; no labial tremor ; voice loud, boisterous and 
 harsh ; hands tremble much with voluntary efforts ; much twitching and corruga- 
 tion of brow-muscles, and also of facial muscles generally ; fi-equent sudden 
 startings of the body and limbs. He is still incoherent and jocular; habits 
 degraded ; sensibility is not much impaired in the limbs. 
 
 Dec. 10. — Again improved; walks, however, insecurely; knee-jerk almost abolished 
 in right leg, but somewhat brisk on left side. He is garrulous, incoherent, jocular, 
 and mischievous. 
 
 In this connection, therefore, the further evolution of symptoms 
 has a topographical significance, and the morbid lesions have their site 
 indicated in the motor-areas of the cortex, or the ganglionic masses at 
 the base. The cortical motor-areas are especially indicated as those 
 earliest implicated ; upon them seems to fall the full weight of the 
 toxic agency ; these, the fountain-heads of volitional activities, have 
 their energies impaired and vitiated. It is no disorder of co-ordination 
 which we witness here ; it is that of a g'enuine paFesiS — an absolute 
 impairment of energy in the highest motor mechanisms. Far different 
 is it with an allied affection of the nervous centres, also associated with 
 psychical disturbances — general paralysis. It is characteristic of this 
 latter disease that the implication results in disorders of cO-OPdination ; 
 in it, also, the moSt Special muscular adjustments are disturbed, but in 
 the direction of their co-ordinate action, and not so notably in an actual 
 dhninution of motor energy. In another affection also, a system-disease 
 of the spinal cord, apt to be associated with special mental symptoms 
 (that of locomotor ataxy), we also find the muscular power unimpaired, 
 but the associated groupings of muscular movements vitiated. 
 
 Motor impotence, therefore, not inco-ordination or ataxy, is 
 
 the distinctive feature of alcoholism of the motor sphere of the cere- 
 brum. How does this motor enfeeblement betray itself? The earliest 
 indication! is usually a notable degree of fine muscular tremor, impli- 
 cating in the first place the fingers and hand, and gradually spreading 
 up the arm ; in the next place involving the tongue, lips, and articu- 
 latory muscles generally ; and lastly, extending to the foot and leg. 
 This tremor is always more marked in the morning, and may be 
 dissipated by a glass of spirits ; if at first not obvious, it may often be 
 brought out^by prolonged extension of the arm ; any slight voluntary 
 exertion tending to establish it, it appears as a rapid and fine oscilla- 
 tion of the fingers and hand. A still more important sign, however, is 
 
326 ^ALCOHOLIC INSANITY. 
 
 that of muscular timtching, varying from the twanging of individual 
 fibres to a somewhat coarse fascicular contraction, implicating those 
 muscles which co-operate in the most special forms of movement — the 
 lips and tongue (as in speech), the corrugatores and orbicularis palpe- 
 brarum (as in emotional expression). Occasionally, the spasmodic 
 action of the orbicularis palpebrarum is such as to distort the features 
 into sudden and changeable grimaces, or the whole muscular apparatus 
 of lips and mouth is shaken with a universal tremor ; or the head and 
 neck may be violently jerked to one side by the convulsive action of 
 the scaleni and sterno-masioidei, as in the patient, J. J., who attributed 
 the movement to electric currents applied by the medical officers. 
 When the facial muscles are widely affected, the subject often presents 
 a highly characteristic state. Immobile fixation of the facial muscles 
 gives a stolid aspect to the expression, whilst silent and undisturbed ; 
 but when roused to converse, the efibrt at times causes such universal 
 tremor as is seen on the eve of a flood of violent, incontrollable 
 weeping, or upon the onset of an explosion of passion. The tremulous 
 convulsive wave which passes over the face can be often aroused 
 by pressing questions upon the patient, or any slight confusion. 
 Convulsive jerking of the tongue may be complained of; thus the 
 patient J. C, when recovering, especially alluded to the fact that he 
 no longer found his tongue "jumping in his mouth." The patient 
 will often recognise this muscular failure, and when speaking will put 
 up his hand to conceal the mouth or steady its movements. Pari 
 passu with this muscular twitching, paresis of the tongue proceeds, 
 its movements become generally impeded, and speech is thick and 
 blurred. The stolidity of aspect is due to defective tone ; and when 
 voluntary innervation occurs, then only is such stolidity dissipated ; 
 yet irregular asymmetpic fUPPO wing's of the muscles of the brow 
 are often oVjvious, due to irregular contractions or paralysis of the 
 antagonistic groups. 
 
 Reaction-Time in Alcoholic Insaniti'. 
 
 G. H., . . Much muscular tremor, ..... 
 
 J. M., . . Chronic alcoholism, delusions of persecution, 
 
 H. W., . Chronic alcoholism, delusional insanity, violent, 
 
 H. G., . . Dangerous, homicidal, delusions of persecution, 
 
 W. W., . Chronic alcoholism, dement<-d, morbus Brifjhtii, 
 
 J. C, . . Slight mania, liallucinations, suspicious, tremulous, 
 
 E. L., . . Chronic alcoholism, haHucinatioJis and delusio?is 
 of suspicion, ...... 
 
 R. B., . . Chronic alcoholism, hypochondriasis, suspicion, 
 
 Acoustic 
 
 Stimulus. 
 
 Sec. 
 
 Optic 
 
 Stimulus. 
 
 Sec. 
 
 •14 
 
 •23 
 
 •15 
 
 •21 
 
 •17 
 
 •26 
 
 ■18 
 
 •21 
 
 •18 
 
 •25 
 
 , -18 
 
 •25 
 
 •19 
 
 •25 
 
 •19 
 
 •26 
 
MOTOR ENFEEBLEMENT — REACTION-TIME. 
 
 327 
 
 Reaction-Time in Alcoholic Insanity— Cowimued. 
 
 J. Ji., 
 
 G. A., . 
 
 J. 
 
 M., . 
 
 G 
 
 M., . 
 
 W 
 
 . S., . 
 
 P. 
 
 T., . 
 
 J. 
 
 J-*., . 
 
 M 
 
 . H. L 
 
 J. 
 
 G., . 
 
 J. 
 
 J3., . 
 
 J. 
 
 F., . 
 
 T. 
 
 C, . 
 
 Acoustic 
 Stimulus. 
 
 •20 
 
 Optic 
 Stimulus. 
 
 •26 
 
 Chronic alcoholism, hallucinations, delusions of 
 persecution, ...... 
 
 Chronic alcoholism, delusions of persecution, 
 violent, ...... 
 
 Extreme depression, suicidal, suspicious, . 
 Mania a potu, excited, voluble, . 
 Tabetic, deluded, treacherous, homicidal, . 
 Chronic alcoholism,, hallucinations, suspicious, 
 Delusions of persecution, grim, treacherous, 
 homicidal, ...... 
 
 Apathetic, slight mental enfeeblement, amnesic. 
 Chronic alcoholism, delusions of persecution. 
 Chronic alcoholism, maniacal, ivild, boisterous. 
 Chronic alcoholism, notable amnesia, 
 Chronic alcoholism, demented, degraded, . 
 
 The above may be usefully compared with the results obtained from 
 subjects of ordinary forms of depression and exaltation. 
 
 •20 
 
 •26 
 
 21 
 
 •24 
 
 21 
 
 •25 
 
 21 
 
 •25 
 
 •21 
 
 (Blind) 
 
 •22 
 
 •2.3 
 
 22 
 
 •25 
 
 22 
 
 •27 
 
 22 
 
 •29 
 
 •22 
 
 •29 
 
 •30 
 
 » 
 
 Reaction-Time in Depression and Exaltation. 
 
 J. H. B., 
 
 Simple melancholia, . 
 
 
 C. K., . 
 
 Hypochondriacal melancholia. 
 
 C. P., . 
 
 . Delusional „ 
 
 s. s., . 
 
 Chronic 
 
 
 E. H., . 
 
 Simple 
 
 
 E. D., . 
 
 > J 
 
 
 J. M., . 
 
 Hypochondriacal 
 
 
 J. H., . 
 
 ,, 
 
 
 J. E., . 
 
 Simple 
 
 
 G. H., . 
 
 ,, 
 
 
 G. P., . 
 
 Chronic 
 
 
 J. W., . 
 
 Hypochondriacal 
 
 
 T. E., . 
 
 Chronic 
 
 
 R. W., 
 
 Simple 
 
 
 S. W., . . 
 
 Climacteric 
 
 
 W. T., . 
 
 Acute mania, . 
 
 W. W., 
 
 )> >> 
 
 W. H., 
 
 Simple subacute mania. 
 
 M. R., . 
 
 j> >) 
 
 W. M'C, 
 
 Acute mania, . 
 
 
 Acoustic 
 
 Stimulus. 
 
 Sec. 
 
 Optic 
 
 Stimulus 
 
 Sec. 
 
 •13 
 
 •20 
 
 •14 
 
 •24 
 
 •18 
 
 •21 
 
 •18 
 
 •18 
 
 •18 
 
 •18 
 
 •21 
 
 •28 
 
 •21 
 
 •20 
 
 •21 
 
 •27 
 
 •13 
 
 •27 
 
 •19 
 
 •24 
 
 •22 
 
 •27 
 
 •23 
 
 •23 
 
 •26 
 
 •27 
 
 •29 
 
 •30 
 
 •29 
 
 •29 
 
 •17 
 
 •24 
 
 •17 
 
 •24 
 
 •18 
 
 •23 
 
 •19 
 
 •25 
 
 •22 
 
 •22 
 
 Increase of the specific resistance in the motor nerve- trunks may 
 possibly explain the tremor, but that it is largely due to defective 
 innervation of nerve-centres discharging along those tracts is highly 
 
328 ALCOHOLIC INSANITY. 
 
 probable, both elements taking part in the morbid state ; for, even if 
 the former (that is, the specific resistance) he not directly augmented, it 
 is relativeli/ so increased by a fall in the energy of the centre. A 
 continuous contraction is thereby rendered impossible from want of a 
 sufficiently rajiid discharge from the nerve-centre; such nerve-shocks are 
 not given off sufficiently quick ; and the resulting contractions do not 
 fuse into one tonic contraction, as in a healthy physiological state. 
 That a pathological change occurs in the motor nerve-trunks is also 
 indicated by the occurrence of muscular twitchings, indicative of an 
 irritative process of the nerve-fibres affecting the motor end-plates, and 
 terminating later on in a more or less pronounced paresis of certain 
 muscular groups, which are then overbalanced by their antagonistic 
 series, producing the asymmetric muscular modelling of the face already 
 alluded to. 
 
 Muscular spasms and cramps are another frequent accompaniment 
 of chronic alcoholism of the nerve-centres. They chiefly occur at 
 night, and especially when waking from sleep. Their severity is 
 great; the muscles of the upper and lower extremities chiefly suffer, 
 and the resultant pain and contraction is often attributed by the 
 subjects to the influence of their unseen foes. They speak of their 
 wrists being wrenched round, their arms twisted and deformed, and 
 their legs subjected to frightful torture, and they complain of aching 
 pains and feelings of fatigue in the limbs for prolonged periods. Such 
 cramps occur late into the history of the alcoholic, and are often at 
 night associated with frightful dreams, when phantasms are often 
 woven into the delusional web constituting his mental life. 
 
 The oculo-motor apparatus is by no means so frequently involved 
 as in the allied affection — general paralysis. The pupils are often 
 dilated and sluggish in reaction, they are seldom unequal in size, and 
 the most advanced cases show often no impairment in the reflex 
 adjustments apart from indications of a localised sclerosis. 
 
 Nystagmus (as the result of cerebro-spinal sclerosis) is of somewhat 
 frequent occurrence in chronic alcoholics. Thus, in J. IF., continuous 
 movement of the eyeballs occurred in a horizontal plane. 
 
 Epileptiform Attacks. — A highly characteristic group of symptoms 
 inaugurates a later stage of alcoholism. The patient is suddenly 
 seized with faintness, tremblings in the limbs, extreme pallor, and 
 breathlessness ; vomiting may supervene ; and then slight twitching 
 may or may not extend to a convulsive starting of a whole limb (or 
 one side of the body), or become generally spread over all the limbs, 
 but rarely with complete loss of consciousness. Upon recovery a 
 
 monopleg"ia or hemipleg'ia may be found to exist, and aphasic 
 
 conditions are by no means infrequent. At times symptoms ominous 
 
CONVULSIVE ATTACKS CASE OP T. P. 329 
 
 of such attacks present themselves, but do not issue in convulsion 
 or paralysis ; a slight dizziness or actual vertigo, accompanied by syn- 
 copal attacks, or a mere tendency to faint, may be noted ; or there 
 may be pallor of face, associated with a cold perspiration, while the 
 patient sinks exhausted into a chair, but may rapidly recover, com- 
 plaining only of numbness or tingling in arm or leg. The sudden 
 onset of unilateral twitching in the face, followed by slight paralysis of 
 that side, is of frequent occurrence in such cases ; and slight " strokes " 
 of one side of the face, or of a limb (that is, slight in degree of impli- 
 cation), and of very transient duration, is a prevailing symptom which 
 recurs over and over again in this aifection. 
 
 T. P., aged sixty-two, widower, a shoemaker by trade, a man of moderate 
 height, well-nourished, but bald at vertex with scanty grey hairs around the 
 head ; the right pupil somewhat the larger of the two, both active in their re- 
 action ; the tongue protruded straight, is tremulous, superficial arteries hard, 
 corded, tortuous, incompressible. There is no history of inherited insanity. For 
 many years he has been a drunken, worthless character, but has not before 
 suffered from insanity; for twelve years past his drinking habits had become 
 most excessive, and it was apparent to all that his memory was implicated, his 
 mental powers were becoming enfeebled, and his behaviour childish. Three 
 months prior to his admission at the asylum, he was taken to the Union Work- 
 house, where he developed more active symptoms, was restless at night, developed 
 vague fears, could not sleep, "because some one might kill him." Aural hallu- 
 cinations became now apparent, and a voice distinctly ordered him to take his 
 own life. Then it became evident that he was the subject of convulsive seizures; 
 he denied ever having had a paralytic stroke. He was attentive in his habits, not 
 destructive, and not violent. 
 
 The morning succeeding his admission he was restless, emotional, bursting into 
 tears whenever mterrogated ; there was profound dementia. He was quite 
 oblivious to his recent history, and did not know whether he had been days, 
 months, or years at the asylum ; in fact, all his notions respecting time were 
 faulty. His memory failed to retain even for a few moments what he was told. 
 His articulation was thick, blurred, and at times so indistinct as to be wholly 
 unLutelligible. In general appearance he was decidedly sottish. 
 
 Shortly after admission, he had one slight epileptoid seizure ; and, with this 
 exception, he had no further convulsive seizures for some months, when a succes- 
 sion of eight fits occurred one morning, leaving him exceedingly torpid and sub- 
 conscious. From this state he rallied sufficiently to go about again ; but was 
 weak and tottering in his gait, and frequently staggered backwards. His dementia 
 was more pronounced — he was very quarrelsome. One morning, shortly after 
 this, he was seized with severe convulsions, occurring almost without intermission 
 in the right limbs, side of face and body, and slightly in the left leg. Thirty 
 grains of chloral, given per rectum twice in half-an-hour, caused arrest of the 
 convulsions. Next morning he was aphasic, but no paralysis persisted in the 
 limbs recently affected. During the succeeding three or four months, he had 
 frequent recurrence of such convulsive seizures, with precisely the same motor 
 distribution as in the former attack, and chloral in all cases rapidlj' arrested the 
 convulsions. 
 
330 ALCOHOLIC INSANITY. 
 
 Two years after admission, it is noted — " Fits occur at rather short intervals ; 
 patient is much more demented and feeble, reels and falls backwards if standing 
 whilst in conversation, and at other times when simple forward movements are 
 interfered with ; his movements are stiff aud awkward ; usual attitude, with the 
 arms crossed firmly on front of chest, his head bowed forwards. He is gloomy, 
 irascible, and rarely smiles ; curses, and attempts to strike when irritated. Habits 
 usually clean. Acne rosacea very marked over nose and cheek." 
 
 Eight months later — " Articulation is now an unintelligible, low-pitched mumble, 
 except when angry ; he then uses curses which are plain. Pupils equal, of normal 
 size ; no tremor of tongue ; he drivels much ; is very tottering and feeble ; gradually 
 emaciating." A few months later, he sank in a condition of stupor, following 
 convulsive seizures of the same nature as those already described. 
 
 (Sectio Cadav.) Skull-cap symmetrical, bones thicker than normal aud very pale ; 
 slight adhesions of the dura mater. In frouto-parietal lobes of brain there is con- 
 siderable wasting, most marked in the left hemisphere, and peculiarly so in the 
 ascending parietal convolution and the boundaines of the Sylvian fissure ; both 
 hemispheres, however, have suffered much from this atrophic process. The great 
 vessels at the base are all extremely atheromatous. The brain is pale as a whole, 
 and its consistence somewhat reduced ; the membranes are thickened, cedematous, 
 and readily strip ; the section of the brain shows much pallor of the cortex, which 
 is notably diminished in depth in the regions already referred to as wasted ; the 
 white substance is firmer than usual, but evidently diminished in bulk, and 
 encroached upon by greatly dilated lateral ventricles, which contain 9 ounces of 
 fluid. A very small patch of brown induration was found, implicating the pos- 
 terior portion of the right corpus striatum. The ganglia elsewhere and the 
 cerebellum presented nothing abnormal. Whole brain weighs 1,234 grammes. 
 
 Right hemisphere. 
 
 . 516 grms. 
 
 Left hemisphere, 
 
 . 515 grms. 
 
 Right frontal lobe. 
 
 . 235 „ 
 
 Left frontal lobe. 
 
 . 204 „ 
 
 Cerebellum, 
 
 • 127 „ 
 
 Pons and medulla. 
 
 . 23 „ 
 
 Heart and lungs present nothing unusual beyond hypostatic engorgement of the 
 latter. Liver weighs 1,366 grms. ; is adherent to diaphragm by tough adhesions 
 of its capsule ; its substance is dark-pigmented, and very firm ; in the right lobe 
 near its upper surface is a large cyst with a distinct, white, tough capsule, and 
 containing clear fluid. Spleen, 85 grms. ; also firmly adherent to stomach ; its 
 substance congested, soft and dark. Right kidney, 163 grms.; capsule thin, strips 
 from a smooth, pale surface, revealing numerous shallow scars ; both cortical and 
 medullary portions are much reduced — the pelvis dilated and full of fat ; the organ 
 generally is pale and unduly fibrous. Left kidney, 130 grms. Structure reduced 
 to a narrow strip \ inch in diameter by a huge hydro-uephrosis — the pelvis being 
 enormously dilated. 
 
 It must be obvious from the foregoing considerations that any 
 division of chronic alcoholism into separate clinical groups must be a 
 purely arbitrary measure, justified only on the grounds of convenience 
 in clinical teaching, and in the study of the wide-spread meanderings 
 of the diseased process; that, with greater or less psychical disturbance, 
 either sensorial or motorial anomalies may preponderate ; and that the 
 
CONVULSIVE ATTACKS — CASE OF J. C. 331 
 
 most notable fact is the tendency to a serious degenerative process, 
 first (but not necessarily so) implicating sensory areas, and then trans- 
 ferred to motor realms of the brain, implicating in its course the 
 moral and intellectual faculties. Huss divided his cases of chronic 
 alcoholism into six forms : — 
 
 1. The Prodromal. 4. Hyperaasthetic. 
 
 2. Paralytic or Paretic. 5. The Convulsive. 
 
 3. Anaesthetic. 6. Epileptic. 
 
 Magnan, whilst justly criticising this division as not a genuine 
 clinical grouping, specially calls attention to one form — the hemian- 
 sesthetic type — which, from clinical and pathological considerations, 
 he deems worthy of this dignity. 
 
 J. C, aged sixty, a widower, employed at his trade as currier up to a week 
 preceding his admission, although his mental enfeeblement must have been of some 
 duration, judging from his state at that time. It would appear that a woman, 
 with whom he cohabited after his wife's death, had concealed his mental ailment 
 from notice, with the object of profiting by his earnings. A maniacal outburst, 
 however, rendered him dangerously violent, and she had to seek assistance from 
 the Union authorities, who found him incoherent and wildly excited. He was 
 said to have lived a temperate life ; to have had no convulsion, stroke, or cranial 
 injury ; and to have exhibited failure of memory only quite recently. All these 
 statements, however, were received with reserve, owing to the relationship exist- 
 ing and alluded to above. The maniacal attack may possibly have been the 
 sequel to a convulsive seizure unperceived; be this as it may, the Relieving Officer 
 found him noisy, incessantly talking in an incoherent strain, violent to all around, 
 and kicking his furniture downstairs, declaring he was moving his home. He had 
 slept but little for nearly a week. 
 
 He was a short, thick-set individual^ 5 feet 3 inches high, and weighing over 
 10 stones; of florid complexion, with dilated malar capillaries; bald at vertex, with 
 grey tonsure. His locomotor system appeared unafi^ected, and his grasping power 
 was good; his speech betrayed no defect. His body generally was obese, but 
 there was no distinct evidence of cardiac degeneration upon auscultation, nor 
 were the superficial vessels notably hard or corded. His mental state was 
 that of maniacal excitement ; he was garrulous, silly in his utterances, and 
 always irrelevant. His memory for remote events was good, but for recent events 
 it was wholly at fault ; he was utterly inappreciative of the nature of his surround- 
 ings and present condition; attention could only be commanded wibh extreme 
 difficulty, owing to his rambling off into disconnected utterances. His mood, 
 although variable, was usually cheerful and lively ; no delusion was expressed, and 
 no hallucinations were apparent. 
 
 For a week following his admission, he was given four-drachm doses of succus 
 conii three times daily ; the physiological effect of the drug was freely induced, 
 but his excitement did not succumb to its influence; and as he was weak and 
 somewhat exhausted, the drug was discontinued. The excitement persisted for 
 two months, during which he lost weight and looked very ill ; but, upon its abate- 
 ment about this time, he again began to gain in weight, betraying, however, a very 
 
332 ALCOHOLIC INSANITY. 
 
 notable degree of dementia. No further maniacal outburst occurred, and he was 
 relegated to the class of indolent, harmless, and helpless jiatients. A large 
 haematoma auris now developed — it was believed as the result of a fall on the floor. 
 Eighteen months after admission, lie appears to have had a paralytic seizure affect- 
 ing both limbs on the left side, in which common sensation was somewhat blunted 
 and the siiperticial reflexes were impaired. He remained torpid and heavy for 
 a few days, and was then allowed to get up ; he was very feeble in limb, and the 
 left leg dragged slightly during progression. The ensuing two months were 
 marked by rapid advance of physical and mental prostration, due to progressive 
 atrophy of the brain ; his mental faculties were now almost wholly abolished ; nor 
 could he stand up, although he was able to move his hands and arms freely, and 
 with some degree of force ; if placed in the erect position, unless supported, he 
 would double up at once. The tongue is protruded to the left, and is tremulous. 
 At tliis period he was subject to threatening attacks of passive congestion of the 
 lungs, due to failing cardiac energy. 
 
 Two years after admission, he was completely bedridden, quite helpless, and 
 incapable of changing his position; a bedsore formed over each great trochanter; 
 his lungs were congested at their bases, but his pulse was fair, and his appetite 
 good, much fluid nourishment being taken ; he was utterly fatuous in aspect, and 
 mindless. Cardiac energy, however, upon which so much depends in the survival 
 of these chronic invalids, at last became rapidly exhausted; the lungs became 
 greatly engorged, and he died comatose two years and four months after admission 
 to the asylum. 
 
 The pod-mortem examination revealed a thickened, gelatinous, and opaque aspect 
 of the soft membranes over the anterior half of both hemispheres. They were 
 removed witli the greatest ease, presenting no morbid adhesion at any site, and were 
 buoyed up by a considerable amount of serous fluid efi"used between them and the 
 brain-surface. Very considerable atrophy w^as noted in the frontal, anterior part 
 of parietal, and temporo sphenoidal lobes, their convolutions being notably wasted 
 and their sulci gaping. The large vessels at the base were atheromatous — and the 
 nutrient vessels of the basal ganglia were notably coarse. The grey cortex was 
 much diminished in depth; the white substance appeared normal; no focus of 
 softening, no undue reduction in consistence, and no clot, recent or old, were 
 noted. The cerebellum, pons, and medulla appeared healthy. Xine ounces of 
 compensatory fluid escaped. 
 
 Right hemisphere, 
 
 . 456 grms. 
 
 Left hemisphere, 
 
 . 450 grms. 
 
 Right frontal lobe. 
 
 . 185 „ 
 
 Left frontal lobe. 
 
 • 173 „ 
 
 Cerebellum, 
 
 . 130 „ 
 
 Pons and medulla. 
 
 • 19 „ 
 
 
 ^Vhole brain = 
 
 = 1067 grammes. 
 
 
 Heart, 353 grms. ; valves competent to the water-test; atheromatous deposits at 
 base of aorta; muscular walls unusually thinned, softened, and fatty. There was 
 much dilatation of all its cavities. The lungs presented much congestion of their 
 bases. 
 
 Liver, 1233 grms. ; pale externally, and upon section fatty, and very friable. 
 
 Spleen, 133 grms. ; dark and softened. 
 
 Right kidney, 148 grms. ; capsule stripped with ease from a pale, fatty surface; 
 the cortical layer was considerably thinned, and a large cyst was present. 
 
 Left kidney, 145 grms. ; condition in every way similar to its fellow. 
 
TYPES OF ALCOHOLIC INSANITY. 333 
 
 It has already been shown by our remarks on the evolution of the 
 psychical symptoms, that the invasion of the cerebrum by this agency 
 often follows a very definite course ; and it is only in the later stages, 
 when the wide-spread sclerosic changes in the nerve centres and the 
 degenerative vascular lesion are most apparent, that we may get that 
 protean aspect from a multiplicity and complexity of symptoms, which 
 led Magnan to state that " we do not know, in fact, what symptom 
 there is which might not be associated with chronic alcoholism under 
 one or other of these conditions." * Such multiform symptomatology, 
 however, does not pertain to the earlier stage of the affection, and we 
 then cannot fail to note the tendency to a restriction of the more 
 2yronouncecl symptoms to one or the other sphere of cerebration. 
 Thus it is often noted that the symptoms are almost exclusively 
 sensorial, hallucinations being a most pronounced feature, whilst 
 little or no genuine intellectual disturbance is recognised or but trivial 
 motor ailment ; other cases present themselves where the ailment, 
 from the outset, has been a failure in the sphere of the intellect, with 
 little or no sensorial or motorial implication ; and lastly, there are 
 those cases where the full action of alcohol appears to have been ex- 
 pended upon the motor sphere of the brain after a very short term 
 of sensorial disorder. Yet, the symptoms of implication of special 
 cerebral territories too often dovetail and overlap for any trustworthy 
 clinical classification to be adopted ; and still more frequently, if the 
 history be one of progressive invasion of one territory after another. 
 The more characteristic forms, however, under which cerebral alcohol- 
 ism presents itself to our notice in asylums for the insane, are the 
 following : — 
 
 1. Purely sensorial type — {a) common sensibility; (h) visceral; 
 (c) special. 
 
 2. Primary amnesic forms. 
 
 3. Premature senility, especially implicating motor areas of cortex. 
 
 4. Delusional forms with vascular lesions in basal ganglia and 
 medullated tracts of the cerebrum. 
 
 5. Motorial types. 
 
 * Op. ciL, p. 158. 
 
334 TDK INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 INSANITY AT THE PERIODS OF PUBERTY AND 
 ADOLESCENCE. 
 
 Contents. — Evolution of Puberty and Adolescence— Pubescence as Distinguished 
 from Adolescence — Antagonism of Growth and Development— Excessive 
 Metabolism of Infancy — Acquisitiveness and Mimetic Characters of Childhood 
 —Initiative Tendencies of Adolescence— Pubescent Insanity in the Female — 
 Delusions and Hallucinations — Relapses at Menstrual Periods — Hysteric Type 
 of Mania— Stupor Coincident with Menstrual Derangement — Case of F. W. — 
 The Blood in Stuporose States— Case of M. A. H.— Etiology— Ancestral 
 Influence— Periods of Susceptibility— Statistics of Hereditary Factors— Ovarian 
 Derangements and Pubescent Insanity (A. H.) — Amenorrhceal and Anaemic 
 States— Influence of the Environmental Factors— Percentage of Hjemoglobin in 
 Cases of Stupor — Pubescent Insanity in the Male— Sexual Divergence- 
 Symptoms of Pubescent Insanity — Modified Forms (J. M.) — Masttirbatic and 
 Uncomplicated Form of Pubescent Insanity — Etiology — The Moral Imbecile. 
 
 The Physiolog'ical and Psycholog"icaI Evolution of Puberty 
 
 and Adolescence. — Of all phases of human life, physiology deals 
 with none more instructive than that of its critical periods. 
 During the first and second dentition necessitated by altered condi- 
 tions of life ; during puberty and adolescence, when the procreative 
 faculties are being unfolded ; during the decay and obsolescence of 
 these faculties at the menopause and grand climacteric ; and lastly, 
 during the final retrogression of senility — the physiological changes are 
 fraught with profound interest, and in no less a degree do serious 
 departures from normal functional activities prove suggestive to the 
 pathological enquirer. The period of puberty, if we neglect those 
 variations due to climatic and social influences, is usually fixed 
 between the ages of thirteen and fifteen for females, and of fourteen 
 and sixteen for males. It is emphasised by certain well-marked 
 external signs, such as the prominence and elongation of the larynx, 
 and lengthening of the vocal cords in the male, with a corresponding 
 lowering of the voice an octave or more ; an increased compass of 
 voice in the female ; the appearance of hair on the pubes, in the 
 axilla, and on the face in the male ; the widening of the hips in the 
 female, and the greater vascularity of the external genitalia; an 
 enlargement and greater activity of the sebaceous glands. These 
 superficial evidences accompany the development of the internal 
 genital organs, the maturation of the Graafian follicles, and the 
 menstrual flux ; whilst the galactophorus ducts of the mammae pro- 
 liferate, and true acini appear. 
 
 The genital organs are usually mature at this epoch, so far as their structure 
 and functional activity are concerned ; therefore, we may regard menstruation 
 (which is conclusive evidence of puberty) as significant of the arrival of sexual 
 
thp: pubescent epoch. 
 
 335 
 
 maturity. But it is well-established that sexual maturity — that is, the capacity 
 Jor hearimj children — need not necessarily coincide with puberty, for some girls 
 are mature before menstruation has occurred. If we have recourse to Dr. White- 
 head's statistics,* we find that the larger proportion of cases of first menstruation 
 occur at the age of sixteen, and that nearly 60 per cent, of the four thousand cases 
 of puberty recorded by him, occurred between the ages of fourteen and sixteen 
 years. I have appended to his Table the percentages for each year : — 
 
 At age of 10 years, 9 first menstruated ; or a percentage of 0"25 
 
 0-65 
 3-40 
 8-30 
 15-95 
 19-02 
 24-17 
 12-47 
 9-82 
 3-45 
 1-77 
 0-225 
 0-15 
 0-05 
 0-025 
 0-025 
 0-025 
 
 These Tables indicate that we may safely exclude all cases of insanity under the 
 age of thirteen years, as not coming under the category of what we are about to 
 consider, viz., insanity occurring in the male and female on the attainment of 
 sexual maturity, and through the period of adolescence. The small percentage of 
 3-4 who show themselves sexually mature at the age of twelve, may be safely left 
 out of consideration, more especially since cases of insanity occurring at this early 
 age and up to fifteen are comparatively very uncommon. The term "sexual 
 maturity" is liable to mislead; we must clearly understand by it — procreative 
 maturity, and nothing more, since it by no means refers to full sexual divergence, 
 in which the whole frame-work of the body participates, and in which the central 
 nervous system also undergoes a profound change. 
 
 The period of adolescence, however, may be regarded as extending 
 from puberty to the age of twenty-one in females, and twenty-five 
 in males ; and is characterised by most profound changes — especially 
 by the completed development of the osseous system (Power and 
 Sedgwick). 
 
 Puberty involves changes of vast moment to the subsequent stage 
 of manhood. Anomalous conditions are but too frequently established 
 at this epoch, which lay the foundation for future physical and mental 
 disability. Growth is actively proceeding, and the osseous and 
 muscular systems are adding largely to their bulk, so as to vastly 
 
 of 10 years, 9 
 
 11 , 
 
 , 26 
 
 12 , 
 
 , 136 
 
 13 , 
 
 , 332 
 
 14 , 
 
 , 638 
 
 15 , 
 
 , 761 
 
 16 , 
 
 , 967 
 
 17 , 
 
 , 499 
 
 18 , 
 
 , 393 
 
 19 , 
 
 , 148 
 
 20 , 
 
 71 
 
 21 , 
 
 9 
 
 22 , 
 
 6 
 
 23 , 
 
 2 
 
 24 , 
 
 1 
 
 25 , 
 
 1 
 
 26 , 
 
 1 
 
 Sterility and Abortion, p. 46. 
 
336 
 
 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 increase the force and range of their activities ; but, with this active 
 growth, differentiation and subordination of parts proceed until 
 
 maturity is reached, and adolescence issues in full seXUal diver- 
 gence. It is a well-recognised fact that full sexual divergence is not, 
 as a rule, ensured until the framework and its musculature are 
 approaching maturity {Carpenter); and in fact, the extreme differen- 
 tiation requisite for this divergence of sexual characters appears 
 ultimately to demand a cessation of that exaggerated nutritive activity 
 which prevails in the earlier periods of adolescence.* The estab- 
 lishment of an equilibrium in the metabolism is but one illustration 
 of the great law of " antagonism between grOWth and develop- 
 ment, which is intimately connected with the law of reproduction " 
 {G. H. Lewes j). Tissue metabolism, therefore, is by no means a 
 constant for different periods of life. The epoch we are considerino- 
 is ushered in by greatly augmented activity of the nutritive functions, 
 and affords a parallel to the conditions existing in earliest infancy and 
 childhood. 
 
 Thus, an infant is known to treble its weight within the first year 
 of its life (LanJois and Stirling 1) ; and from Quetelet's researches it is 
 seen that the first three years (and especially the first year) are 
 periods of wondrously active growth, the increase in stature being as 
 follows : — 
 
 First year, a growth of 
 
 Second ,, ,, 
 
 Third „ 
 
 Fifth to sixteenth year, ,, 
 Twenty-tifth to thirtieth year. 
 
 20 Centimetres. 
 10 
 
 7 
 
 54 M per anniun. 
 
 Full stature attained. 
 
 As Trousseau states — the rapidity of growth during the first three 
 years would, if not checked, result in a gigantic stature, but, " from 
 the beginning of the fourth year, growth proceeds more slowly up to 
 the age of puberty, when it takes a fresh start." § As at this infantile 
 period (when the metabolism is so extremely active), every precaution 
 is demanded to maintain the nutritive replacement of such tissue- 
 change both in due quantity and quality, so also during puberty and 
 
 * Thus Spiegelberg affirms that, "So long as the body has to provide for its own 
 development, and consequently requires a large amount of formative material, it 
 has no energy to spare for propagatbig the species. Till development has ceased, 
 the organs which serve for that purpose remain inactive and small, and most of 
 the important distinctions between the two sexes are absent." (Text-book of 
 3Iidwi/ery, New Syd. Soc,, vol. i., p. 59.) 
 
 t Li/e 0/ Goethe, p. 355. + Op. cit., p. 528. 
 
 § Clinical Medicine, Syd. Soc, vol. v., p. 82. 
 
ANTAGONISM OF GROWTH AND DEVELOPMENT. 337 
 
 adolescence, too much care cannot possibly be lavished in providing 
 for the wants of the system — for it is at this epoch, beyond every 
 other, that the physical and mental characteristics of the man or 
 woman are permanently moulded or stereotyped. A parallel has been 
 drawn by Trousseau betwixt this period of active infantile growth 
 and the subsequent stage of adolescence, wherein he recognises 
 analogies in morbid states at these respective epochs — the osteo- 
 malacia of adults he thus places parallel to the rickets of infancy. 
 Excessive expenditure of nutritive forces occurs with especial frequency 
 at the period of puberty — the lad in usual parlance is said to be " out- 
 growing his strength ; " he may add 5 or 6 inches to his stature in a 
 single year {Trousseau). As Dr. Edward Smith also states it: — ''The 
 period of puberty is associated with two classes of evils, viz., excessive 
 development of the cerebro-spinal axis, and defective growth of the 
 organs of organic life." * Such greatly-augmented metabolism taxes 
 to the utmost the constitutional powers ; the requirements of the very 
 rapidly increasing mesodermal tissues are imperative and urgent ; 
 circulating albumen is rapidly abstracted by the growing tissues ; so 
 that, unless a more generous diet be given, whereby such loss may be 
 replaced, serious impoverishment must ensue. Functional disturbances 
 as a consequence occur, whilst mal-assimilation furthers still more the 
 vicious progress, and lays the foundation for nutritional ailments, such 
 as tubercle, to which this epoch is so prone. 
 
 The excito-motor irritability of infancy with its jerky, spasmodic, 
 ill-directed movements, wanting in object, wanting in power, co-ordina- 
 tion and skill, pass, in the growing youth, under the control of higher 
 centres now evolving. Action is now directed to a definite purpose, 
 and muscular activity becomes, in one form or another, the supreme 
 pleasure of the organism ; yet, such activity is still chiefly tenta- 
 tive, imitative, and wanting in indications of prescience, and in the 
 accomplishment of elaborate or far-reaching results. Enjoyment 
 appears to be the purport of this vigorous and active stage of life ; 
 restless movement seems to be necessary for the expenditure of super- 
 abundant energy ; and mental acquisitiveness lays up its store of facts 
 for future use and application. The growing lad mimics the man. 
 
 ' ' A wedding or a festival, 
 A mourning or a funeral, 
 
 And this now hath his heart, 
 And unto this he frames his song ; 
 Then will he fit his tongue 
 
 * Cyclical Changes, p. 236. 
 
338 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 To dialogues of business, love, or strife, 
 But it will not be long 
 Ere this be thrown aside. 
 And with new joy and pride. 
 
 The little actor cons another part ; 
 
 ****** 
 As if his whole vocation, 
 Were endless imitation." — Wordsworth. 
 
 With the advent of puberty and adolescence all this is changed ; the 
 rapid growth of the organism is now accompanied by rapid transforma- 
 tions of the nervous centres, and as the parts chiefly afiected are the 
 bony framework, blood-vascular tissues, and the musculature, so should 
 we expect a greater or less tumult in the molecular transmutations 
 occurring at the centric expansions of the motor system of nerves; 
 hence, the higher co-ordinating centres — the psycho-motor area — must 
 undergo important developmental changes. Correlatively, there dawns 
 upon the mind the consciousness of fresh motorial capabilities — the 
 overflowing nascent energies are directed into new channels of activity, 
 rendering new tracts of cei'ebral tissue permeable ; and fresh motor 
 combinations arise. An undue estimate of the subject's capacities 
 usually exists ; the imitativeness of youth declines before the self- 
 
 assuranee and originating" tendencies of the adolescent. Then 
 there crowd in upon the sensorium the impressions aroused by the 
 slowly-developing generative organs, and the vague indefinite notions 
 of sexual relationships gradually take form in the definite divergence 
 of mature age ; life begins to assume a reality which it formerly 
 wanted. The mental characteristics are peculiarly of a constructive 
 kind ; and the issue may be favourable or vicious, according to the 
 education and training then received. In some, the emotional element 
 will be favoured, and reverie indulged in to a vicious extent, may 
 paralyse more useful and rational activities. In others, the imagina- 
 tive faculties may be chiefly stimulated ; the love-sick lad will pour 
 out his plaint in verse ; while girls, especially, are prone at this period 
 to reverie and "castle-building." For the fostering of such vapid states 
 in this class of subjects, the sensational novel of modern days appears 
 specially designed. In the female we find the amiable virtues especially 
 aroused, whilst in the male the dormant motor potentialities express 
 themselves in the form of extravagant, half-developed, ill-digested 
 plans, overweening self-esteem, and an egOism at once obtrusive 
 and objectionable. 
 
 In the Female Subject. 
 Symptoms. — The insanity peculiar to this epoch is essentially an 
 acute neurosis, not that the intensity of the symptoms is so great, 
 
PUBESCENT INSANITY IN THE FEMALE, 339 
 
 as that exaltation and excitement, the symptoms of an acute cereVjral 
 process, prevail. Other forms of insanity (notably that incident to 
 the early puerperal period) exhibit far greater intensity of excite- 
 ment, yet acute mania prevails ; and, although extremely rare, even 
 acute delirious mania has appeared. This predominance of maniacal 
 states over states of depression is also a feature in the insanity of the 
 puerperal ; but it is even more prevalent in the form occurring in 
 adolescent females. Here, however, we note the influence of sex in 
 modifying the type of the nervous process. Maniacal symptoms like- 
 wise predominate over depression in the male ; but their frequency 
 and intensity are notably less than in the other sex, so that the pre- 
 valence of melancholic states with depressing delusions becomes in 
 this sex a far more obvious feature. This we attribute partly to 
 vicious habits, which also to a considerable extent influence our 
 prognosis. With this emotional perturbation we find associated 
 much intellectual derang-ement ; delusions of a definite form 
 betray themselves at an early period of the affection ; and, as we shall 
 see later on, are, in the maniacal forms, highly characteristic. The 
 melancholic pei'versions usually embrace ideas of persecution or im- 
 pending trouble ; notions which commonly assume the form of beliefs 
 that the food was poisoned by relatives or friends. From a study of 
 such intellectual and sensorial perversions, we find that delusions 
 prevailed in one-half the cases of both sexes alike ; whilst about one- 
 fourth of either sex were subject to hallucinations of the special 
 senses, the visual and aural hallucination, separately or combined, 
 being far the more frequent.* As many as 16 per cent, of the deluded 
 cases entertained ideas of poisoning. Religious delusions existed in a 
 few cases, but far more frequently did their imagined troubles afiect 
 their social or domestic well-being, such as the following: — '■'■Robbed 
 of all her possessions ; her house in flames ; mother dead and home 
 ruined ; has murdered some one and is pursued by policemen ; is to be 
 burnt alive ; men concealed in her toardrobe ; fellow-patients try to 
 murder her." These were the delusive concepts of some typical cases 
 of this class. In most cases of this form of mental derangement, 
 however acute be the symptoms, it will be found that excitement 
 abates usually at an early period, even within a few days or a week 
 of admission to asylum care. The removal from prejudicial home 
 influences, the regular administration of good nutritious diet, and the 
 ensurance of a due amount of sleep, cuts short the attack very rapidly. 
 Yet this is not permanent; one or more relapses are almost certain to 
 
 * Or to be exact — delusions were present in 52 per cent, males, and 49 '3 per 
 cent, females ; hallucinations prevailed in 25 per cent, of either sex. 
 
340 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 occur ere convalescence is finally established. All such rapid transi- 
 tions from mental turmoil to calm are to be regarded with suspicion ; 
 but more especially here, where the mental derangement is itself the 
 expression of a process closely related to the cycle of ovario-uterine 
 excitation. At each monthly period the menstrual molimen will be 
 associated with greater or less cerebral excitation ; hence at these 
 periods relapses are apt to occur {M. C. W., p. 209). 
 
 When there is decided catamenial irregularity or suppression, when 
 the anaemia of puberty exists, we may with confidence anticipate 
 a relapse ; nor will the more general improvement in health ensure 
 perfect recovery in the majority of cases, until the anaemia is so far 
 removed as to issue in the re-establishment of this function. Not that 
 the return of the menses cures the insanity, but that the natural advent 
 of this flux indicates a state of healthy function generally, and a 
 condition of the circulating fluid which brings up the nutrition of the 
 cerebrum to its wonted vigour. Dr. Clouston has noted this tendency 
 to relapse in the insanity of adolescence. 
 
 "This tendency to short, sharp attacks, with intermissions of more perfect 
 sanity than occurs in most other kinds of mental disease, with relajjses occurring 
 one, two, three, four, and five times, and even more frequently, before recovery or 
 dementia finally takes place, may be taken to be especially characteristic of this 
 insanity of adolescence." * 
 
 The excitement in the less intense forms is peculiarly associated 
 with hysteric symptoms ; the subjects are, withal, often shrewd, calcu- 
 lating, watchful of the effect produced on the bystanders, artful, and 
 cunning, they will sham epileptic fits or other ailments. They are 
 often wanton, exhibit much abandon, are erotic in gesture, conduct, 
 and speech, and obscenity of remark is by no means infrequent. One 
 patient at her home, regarded as oblivious to all that her medical atten- 
 dants were doing for her, enumerated afterwards every remedy tried, 
 mentioning the dose she had heard the doctor order, and repeating his 
 diagnosis which she had likewise overheard. Others will show much 
 hysteric sobbing or laughter, or, assuming a childish, pettish tone, will 
 become querulous or wildly passionate. The extravagant nature of 
 the delusion often stamps this hysteric temperament. Thus such sub- 
 jects will declare that they are mangled, cut into small pieces, are to be 
 boiled alive or crucified, yet exhibit no corresponding terror. Again 
 we often find indecent conduct and erotic tendencies associated with 
 conditions of religious ecstasy, and boisterous, unruly demonstra- 
 tiveness alternate with states of great stupor. 
 
 F. W., aged twenty, a married woman, had been deranged for a short period 
 when seventeen years of age, but recovered at home. She was tall, of fair com- 
 
 * Loc. cil., p. 551. 
 
STUPOR AND COINCIDENT MENSTRUAL DERANGEMENT. 341 
 
 plexion, muscular, but extremely pale and anaemic. Highly nervous and excitable. 
 Regarded as of unstable mental equilibrium, a neurotic inheritance was naturally 
 suspected, but upon close enquiry no clue was obtainable to such. Her former 
 attack (mania) had been attributed to a lover's quarrel. About three months 
 before admission to the asylum, she had shown a strangeness of behaviour not 
 customary with her ; had become careless of her household duties, indolent, 
 negligent of her husband's requirements, reticent and avoiding contact with her 
 relatives, passing her mother and others without speaking to them. She then, 
 without any expression of definite delusion, betrayed strong jealousy of her 
 husband, was watchful and suspicious of his movements, passed restless nights, 
 took food scantily, her health becoming more and more impaired. Sudden out- 
 bursts of excitement supervened ; she was violent, and when thwarted, would try 
 to escape by the window. During the whole of this time she suffered much from 
 headache, and had what were described as fainting fits upon several occasions. 
 Under medical examination her condition was that of acute mania, a strongly- 
 marked hysteric element being associated therewith. She would roll upon the 
 floor and sham an epileptic fit, talking incessantly much incoherent nonsense ; no 
 rational reply could be obtained from her. Later, she exhibited a tendency to 
 intersperse religious phrases and ejaculations, with utterances of an erotic and 
 obscene nature ; her demeanour meanwhile varying from that of a fixed ecstasy 
 to conduct betraying strongly-marked erotic features, boisterous laughter, or 
 causeless weeping alternating with violent passion and destructive tendencies. 
 The respiratory and circulatory systems were normal ; but, as before stated, there 
 was extreme anaemia, which accounted for the persistent amenorrhoea from which 
 she suffered. Easton's syrup was ordered, and a full nutritious dietary enforced 
 when necessary by compulsory feeding. The maniacal symptoms continued for 
 three weeks unabated ; then periods of calm, interrupted by sudden excitement, 
 passed into a stage where nocturnal excitement alone prevailed, during which her 
 habits were degraded. She was utterly regardless of all decency, and erotic 
 tendencies were still pronounced. The patient's health now steadily improved ; 
 she put on flesh, but was still very pale and anaemic. There was now no excite- 
 ment manifest, her condition passing into one of listless apathy and indifference, 
 and even partial stupor. Decoction of aloes with iron was administered, and 
 a full amoimt of nourishment was secured, her appetite being satisfactory. At 
 intervals, she was aroused from her lethargy and would engage in a little needle- 
 work ; six months after admission menstruation supervened for the first time, 
 and a notable degree of mental improvement appeared almost coincident there- 
 with. She became cheerful, affable, and active, and left the asylum completely 
 recovered a few weeks subsequently. 
 
 The tendency to stupOP is especially marked in those cases where 
 there is well-pronounced menstPUal derangement, and its alter- 
 nation with hysteric excitement is a frequent and interesting feature 
 in the insanity of puberty.* In the stage of stupor complete apathy 
 
 * In such instances of stupor associated with menstrual derangement, changes of 
 undoubted moment occur in the constitution of the blood. The red corpuscles are 
 seldom diminished in number to any notable extent, but their hajmoglobin is in all 
 cases alike reduced in amount. In some we find the corpuscular value below half 
 the normal, as in the case of C. \V. (p. 351), where it is represented at •4.5, or that 
 
342 INSANITY OP PUBERTY AND ADOLESCENCE. . 
 
 prevails, amounting at times to fatuity ; the expression is stupid and 
 demented; the pupils widely dilated; saliva dribbles from the mouth; 
 none of the wants of the system are attended to ; the hands hang 
 helplessly, and both extremities are cold and livid. The subject is 
 usually profoundly ansemic, a haemic bruit may be heard over the 
 aortic valves, or the bruit-de-diable over the subclavian. Such symp- 
 toms are almost invariably associated with suppressed menses, and 
 frequently the vicious habit of masturbation prevails. 
 
 M. A. H., aged nineteen, single, a young girl of delicate physique, very thin 
 and reduced, pale and exceedingly anaemic, suffering from her first attack of 
 insanity of about seven days' duration. She inherited a neurotic tendency from 
 the father's side ; the great-grandmother was a paralytic ; the father was insane ; 
 and the daughter was described as being of high-strung ner\'ous tempera- 
 ment. She had been intelligent, and had taken an active interest in her father's 
 business (mercantile) ; his late illness was regarded as the exciting cause of her 
 attack. The patient had always suffered from catamenial irregularities, and the 
 menses were now completely suppressed. Restlessness and insomnia were followed 
 by hallucinations of the special senses and delusions ; she believed she was to l>e 
 sent away as a soldier ; was pursued by a policeman ; thought her food was 
 poisoned, and obstinately refused it. When brought to the asylum, her blood- 
 less aspect was very notable, and her physical prostration great ; she stared 
 vacantly around, quite inappreciative of her position and relationships, occa- 
 sionally uttered a few articulate words or disconnected meaningless sentences, 
 and did not reply to any question asked. Her hands were decidedly cold and 
 livid ; in fact, the previous excitement had lapsed, and a condition of stupor 
 existed ; the catheter had to be regularly used before her admission. Port \v'ine, 
 milk and eggs, with extract of beef, were given freely. Ammonio-citrate of iron 
 ordered twice daily and 30 grains of chloral when required at night (chloral, 
 however, was required but seldom, as she soon obtained sleep without its aid). 
 During the whole of the succeeding month, patient's state was one of extreme 
 mental torpor and apathy ; she usually sat in a half-bent posture, utterly slovenly, 
 and negligent in her habits ; saliva dribbling from her mouth ; her expression 
 vacant, fatuous ; the pupils were dilated and sluggish ; the extremities blue and 
 cold ; volitional effort was rare, and compulsory feeding had to be continuously 
 resorted to. Occasionally she swayed to and fro, and gave utterance to a 
 piteous whining or a meaningless babbling. This condition of acute dementia 
 continued for twelve months. Her Ijodily health then slowly but progressively 
 improved, and during two succeeding months she regained flesh at the rate of 10 
 lbs. per month ; mental torpor, however, still continued, and persistent amenorrhcea 
 was associated therewith. With this progressive physical improvement there now 
 
 of R. W, J. at '44. The amount of haemoglobin, as given by the several cases at 
 page 351, fluctuates between 40 per cent, and 80 per cent. Even in the most pro- 
 found stupor of W. S. associated with habits of masturbation (see pp. 160, .351), the 
 percentage of haemoglobin never fell below 68 ; nor in any case of simple uncom- 
 plicated stuporose insanity have we seen the colouring-matter reduced to the 
 extreme limits seen in cases of haemorrhage. Thus, in the case of M. A. M., the 
 haemoglobin registered as low as 20 per cent. 
 
ETIOLOGY. 343 
 
 appeared a gradual advance to more noi-mal states of consciousness ; quietly seated 
 in her chair, it was noticed that she was becoming observant of what passed before 
 her, and she watched with apparent interest, but without assummg any further 
 initiative, the occupation of the patients around her, and soon her blank staring 
 gaze gave place to occasional expressions of intelligent recognition, an amused 
 smile or a play of furtive emotional states. Not until seventeen months had elapsed 
 did she begin to speak rationally, and about this time the catamenia appeared. 
 She beciime bright and lively, but still betrayed many morbid propensities, and 
 was mischievous, unruly, and excitable. Her progress to perfect sanity was 
 interrupted by a short relapse ; but her recovery was ensured two years after her 
 admission. 
 
 Impulsive as these forms of insanity appear, our records show few 
 of those desperate attempts at self-destruction which characterise some 
 other forms of insanity. The actual percentage of cases returned as suici- 
 dal is high (40 per cent.), whilst in male adolescents it falls to 22 per cent. 
 This might lead one to infer that the cases were nigh as suicidal as in 
 the form of insanity prevailing at the climacteric, when such impulses 
 are strongly developed. This, however, is not the case. Hysterical 
 forms of mania are prone to suggest or threaten such acts, but all such 
 attempts are usually feigned and prompted by the morbid desire to 
 create sympathy or produce effect. We must, therefore, not be misled 
 by the fact that these cases have committed outrageous acts which 
 seem to imply a suicidal tendency, or have frequently threatened to 
 destroy themselves. They are not in the majority of cases suicidal in 
 the sense that the subjects of puerperal and climacteric mania are 
 suicidal. On the other hand, they are far more likely to turn their 
 destructive efforts against others, and our statistics emphasise this 
 aggressive, dangerous tendency in 48 per cent, of the female, and 55*5 
 per cent, of the male inmates. 
 
 Etiolog'y. — The excito-motor exaltation of the nervous system, 
 during the first dentition, has also its parallel in the explosive 
 condition of the nervous centres in higher planes of cerebral activity 
 during the evolution of the generative functions, and the sexual 
 divergence of the epoch of early adolescence. Hence, this period is 
 the second great trial of the constitutional powers of the subject, and 
 is especially prone to reveal any dormant inherited vices, and call 
 them into full activity, either as convulsive affections of the motory 
 apparatus, such as chorea or epilepsy, or as psychical anomalies, 
 especially of an hysteric type. We shall see further on, that the 
 type of insanity which prevails at this period of life is essentially 
 that of an hysterical form. We have alluded to the rhythm of 
 nutrition, that mysterious law which dominates the evolution of all 
 organic forms, vegetable and animal alike, as exenipliticd in the high- 
 tide of infantile growth ; the ebb of growing youth ; the renewed 
 
344 INSANITY OP PUBERTY AND AD0LE3CENCE. 
 
 flow at puberty and adolescence ; and the final arrest at the maturity 
 of manhood. Along this curve of simple vegetative growth appear 
 the pulsations of ancestral influence. Those epochs of new develop- 
 ments, or the points when differentiations occur, fitting the organism 
 for new or altered conditions of life ; the ancestral energy, so to 
 speak, adapting the organism to its altered environment — dentition, 
 puberty, adolescence, are such epochs. They are characterised 
 especially by the tendency to reproduce anCGStPal developments — 
 whether normal and physiological, or only deviations from the laws 
 of health — the new character appearing at COPPespondingf periods 
 of life in parent and offspring. Yet it must be borne in mind that 
 ancestral vices do not necessarily reappear in the offspring at tlie same 
 period of life as they appeared in the ancestor, and that then, " the 
 transmitted characters much oftener appear before, than after, the 
 corresponding age." {Darwin).* This law of inheritance has a direct 
 bearing upon the insane heritage of adolescents, since, in them, it 
 appears that with special frequency, we find the ancestral vice developed 
 late in the life of the parent, and to be frequently an illustration of 
 atavism. If we recall Darwin's remarks on the distinction between 
 tPansmission and development of characters, we may also more 
 readily comprehend such pathological atavism. 
 
 A remarkable persistence of any developmental vices at these 
 periods of active life also exhibits itself, whether inherited or acquired, 
 with which it is well to be acquainted. 
 
 In this connection, it was shown by M. Gosselin many years since, in a com- 
 munication to the Academie des Sciences, that many special surgical afifections of 
 adolescents tend to persist, increase, or relapse throughout adolescence, but such 
 tendency is lost at manhood — e.g., ingrowing nail, valgus doloureux, suppura- 
 tive epipbysal osteitis, epiphysal exostosis, subungual exostosis of great toe, and 
 fibrous naso-pharyngeal polypi will usually defy permanent cure tmtil the twenty- 
 fifth or twenty-sixth year is reached, and temporising, therefore, is often called for 
 until adult age is attained. + 
 
 Then again, it would appear reasonable to presume that all 
 ancestral tendencies which are transmissible, would be peculiarly 
 potent at those periods when the organism strives to reproduce itself; 
 and that as ovulation occurs there would be concentred towards 
 Certain points, so to speak, the tendency to reproduce similar 
 peculiarities, <kc. The nervous system must necessarily sympathise 
 with such conditions, and hence parental vices, and weaknesses — 
 insanity, epilepsy, chorea — may be developed with greater frequency 
 
 * Descent of Man, chap. viii. Variation of Animals and Plants under Domesti- 
 cation, vol. ii., 1868. 
 
 t See Med. Times and Oaz., April, 1872. 
 
ANCESTRAL INFLUENCE. 345 
 
 at this period of sexual divergence in the adolescent. That the 
 insanity of this period is strongly hereditary, is indicated by the fact 
 that 40 per cent, showed an insane heritage, and that lO'G per cent, 
 afforded a history of ancestral epilepsy ; and 1)'3 per cent, of apoplectic 
 seizures. It is this genetic influence which so powerfully manifests 
 itself at this period, and especially towards the end of adolescence, 
 that forms the organised groundwork of the psychosis, and which we 
 regard as the most important feature in the evolvition of these forms 
 of insanity ; for, given an organism predisposed by inheritance to 
 insanity, such predisposition will tell with special force at periods 
 of reproduction and development. 
 
 A related law has long been recognised, viz., that variations appear- 
 ing in either sex before sexual divergence is well-established, will 
 probably be equally transmitted to either sex of the progeny ; and 
 that variations occurring late in life, when sexual divergence is 
 complete, will be transmitted to the same sex (Darwin).* 
 
 Taking the 3,470 cases of insanity in our statistics, we find a 
 clear history of family predisposition to insanity in 29-5 per cent. — for 
 the women, 31-5 per cent., and for the men, 27*2 per cent.; hence, 
 the inheritance by 40 per cent, in the adolescent forms is a note- 
 worthy feature. Again we find the neurotic inheritance generally is 
 far above what is usual to all forms of insanity alike, as the following 
 instructive Table reveals : — 
 
 Cases of Insanity. 
 
 Hereditary 
 Insanity. 
 
 Parental 
 Epilepsy. 
 
 Parental 
 Apoplexy. 
 
 Parental 
 Intemperance. 
 
 3,470 of both Sexes, . 
 
 29-5 
 
 3-68 
 
 3-57 
 
 
 1,810 Females, . 
 
 31-5 
 
 3-37 
 
 5-35 
 
 6-6 
 
 1,660 Males, 
 
 27-2 
 
 
 
 
 75 Adolescent Females, 
 
 40 
 
 10-6 
 
 9-3 
 
 160 
 
 It is, also, a noteworthy fact that the insanity incident to the male 
 at this period of life is not (as it is in the female) characterised by a 
 strongly-marked heredity, since only 27 per cent, male adolescents 
 afford a history of inherited insanity, against 40 per cent, female 
 adolescents ; the inherited tendency, then, in the male sex is not 
 above that common to all forms of insanity taken together. 
 
 On studying a series of cases of insanity occurring in the female at 
 
 this period of life, we are at once struck by the paucity of cases in the 
 
 earlier, as compared with the later years of puberty and adolescence. 
 
 This is, of course, what we might have anticipated. The early period is 
 
 * Descent of Man, p. 232. 
 
346 INSANITY OP PUBERTY AND ADOLESCENCE. 
 
 one chiefly occupied with the active growtlx of the organism as a 
 ■whole ; and it is only towards the later period (when this activity of 
 growth, subsiding, allows the generative organs to develop, and the 
 sexual element to force itself into the mental life — when, too, tracts 
 of cerebral tissue come to represent the reproductive system in all its 
 relationships), that the developmental tide may issue in a stormy 
 commotion of the nervous centres. This is forcibly illustrated by our 
 statistics. Out of seventy-seven cases occurring from the age of 
 twelve to twenty-one inclusive, fifty-six (or nearly three-fourths) were 
 from eighteen to twenty-one years of age ; three cases only occurred 
 up to the age of fifteen ; whilst nine cases occurred in each of the two 
 following years. The age of nineteen and twenty was the period of 
 greatest frequency, hence the great prevalence of insanity was clearly 
 shown by these figures to pertain to the years of approaching sexual 
 maturity, coincident with that physiological cycle of mental evolution, 
 which fits the woman for the duties of wife and mother. 
 
 Ovarian Derang'ementS. — It is important that we here fully 
 understand the relationship borne by deranged states of the sexual 
 organs to the mental anomalies under consideration. Often is the 
 question asked in cases of insanity, accompanied by amenorrhoeal 
 states at this period of life — Is, the menstrual derangement the origin 
 of the cerebral disturbance, a simple coincidental state, or the result 
 of the nervous disturbance ? If, however, we regard this period as a 
 great cyclical developmental stage, in which the unfolding of the 
 generative system goes on, pari jjassu, with its representation through- 
 out the innermost penetralia of the central nervous system, then we 
 must regard the physical and mental expression of this development 
 (the sexual characteristics, bodily and mental, and the menstrual flux) 
 as associated features, as but the obvious signs of what is going on 
 within the pelvis and within the cranium. 
 
 Menstruation, then, as an evidence of ovarian maturation and 
 excitement, and the various secondary sexual characteristics of hairy 
 growth, irritation of the breasts, and the modified bodily conformation, 
 must be regarded as phenomena occurring coincident with certain mental 
 transformations in which the girl becomes evolved into full womanhood. 
 By no means can they be considered to be related invariably to each other 
 as cause and effect; noi', moreover, can derangements in the functions 
 of the one organ be spoken of as the chief cause of derangement in the 
 functions of the other. It can be readily understood that persistent 
 derangement in the menstrual flow must eventually lead (through de- 
 pravation of blood) to nutritive changes in the nervous system expressed 
 in mental terms; and so also cerebral derangements may modify or arrest 
 the menstrual molimen and flux, through the trophic system of nerves. 
 
OVARIAN DERANGEMENTS. 
 
 347 
 
 But the arrest of the menses may be due to inherent developmental 
 defect in the ovarian gland itself; to a primary vitiation of the circu- 
 lating fluid ; to want of trophic energy centrally initiated ; or, lastly, to 
 the influence of external agencies gaining access to the economy in 
 some one or other form. The etiology, therefore, may be of very com- 
 plex nature ; and in summarily dismissing the case as one of mental 
 derangement attributable to amenorrhoea, we should grievously err by 
 perhaps taking one indication of a wide-spread developmental arrest of 
 ovario-uterine evolution as the cause of a mental storm, which in itself 
 is often but a symptom of associated arrest in the development of 
 the central nervous system. 
 
 A. H., aged nineteen, a single girl, occupying the position of housemaid, had 
 been maniacal for four weeks before coming under our observation. There was a 
 history of a slight transient maniacal attack at the age of seventeen, which did 
 not necessitate asylum treatment. She was described as a fairly intelligent girl, 
 of good moral character, and no clue to family neurosis was elicited. She had 
 exhibited no eccentricity prior to the attack, and had suffered from no serious 
 illness. For a considerable period the catamenia had been suppressed, and her 
 health had greatly failed her. Her height was 5 ft. 4 ins.; her weight, 115 lbs. 
 The complexion was exceedingly pale and waxy, and the body generally most 
 exsanguine in appearance ; the viscera generally were healthy, but the bowels had 
 been torpid for some time. At home her excitement was intense, and she could 
 scarcely be restrained from rushing blindly aboiit the house, shouting wildly, 
 whistling, or reading m a loud tone, appearing utterly regardless of decency. 
 She mistook the identity of all around her, and did not appear to recognise her 
 parents. Under observation she continued incessantly garrulous, but fairly coherent 
 in speech. Her behaviour was flighty, sudden, and impulsive ; she sprang out of 
 bed repeatedly, listened to imaginary voices, and replied to them ; was abrupt in 
 reply to questions, wilful, and covered her face with the bedclothes. Her conscious- 
 ness was greatly impaired ; she failed to recognise the nature of her surroundings, 
 and evidently mistook the identity of those around her. An aloetic purge was 
 ordered, and a drachm-dose of the syrup of the phosphate of iron three times daQy. 
 Fortunately, her nights were passed m quiet sleep, and her appetite was not 
 defective. In less than a week there was decided improvement, all acute excite- 
 ment had abated, and a little flightiness of manner was alone perceptible. She 
 was quiet, composed, quite rational in speech and conduct ; complained much of 
 occipital headache. From this date her health steadily improved, and in a fort- 
 night from admission she was actively at work in the needle-room. She complained 
 much of numbness, with formication, and some weakness in the lower extremities ; 
 also of lumbar pains and occasional linear cramps round the abdomen ; incontinence 
 of urine was noted, and the bowels acted invohmtarily at nirjUt. These symp- 
 toms apparently were due to congestion of the cord and its membranes from 
 the suppressed menstrual flow. Iron and aloes, with cod-liver-oil emulsion, were 
 now ordered, and spinal douches commenced. The patient subsequently had a 
 relapse, preceded by increased occipital pain and depression. Much wild hysterical 
 excitement supervened, and she continued noisy, abusive, and violently disposed 
 for the period of a month, when she again became calm, self-controlled, and was 
 convalescent in three months from her admission into the asylum. The catamenial 
 flow was re-established coincident with the greatly-improved health, the spinal 
 symptoms referable thereto disappeared, and the patient was discharged recovered. 
 
348 INSANITY OP PUBERTY AND ADOLESCENCE. 
 
 It has been already stated that insanity occurs in a rapidly-increas- 
 ing ratio from the age of fifteen to twenty, the three last years 
 embracing three-fourths of the total number of cases. Of all these 
 cases 57 per cent, suffered from menstrual derangements — a very high 
 proportion — illustrating the frequent association of these conditions. 
 If, now, we take into consideration the relative female population of the 
 county, and even of the district, involved between the ages of 10 to 15, of 
 15 to 20, and of 20 to 25, we find there is a steady decrease in numbers. 
 Thus, the last census-returns give for the West Riding of Yorkshire, 
 the number of females living at these respective periods, as follows : — 
 
 From 10 to 15 years, 119,023 
 
 „ 15 ., 20 „ 109,604 
 
 „ 20 ,, 25 „ 104,473 
 
 So, for England and Wales together, the population between the ages 
 10 to 15 and 20 to 28 has fallen from 1,398,101 to 1,225,872. Between 
 the ages of 13 and 15 we have all the disturbing elements of puberty 
 and its incident changes ; yet, though the numbers living at this age 
 are far greater than at a later period, menstrual derangements, associated 
 with cerebral disturbance, are exceptionally rare, whilst after 18 they 
 become extremely frequent. The annexed table includes those cases 
 in whom menstrual derangement or notable anaemia prevailed in 
 association with this form of insanity. 
 
 We must bear in mind the fact that every fresh development in the 
 organism is attended by a correlated development in the nervous 
 centres which represent the part ; and that in no case is this more 
 marked than when the organism attempts to reproduce its kind. Thus, 
 at the menstrual m oilmen, when the germ is produced and shed, 
 whatever be the mysterious influence which leads up to this effort, the 
 ebb and flow of the developmental tide is registered faithfully in the 
 nervous centres by a similar wave. At each menstrual molimen the 
 sexual characteristics are more strongly emphasised by well-recognised 
 mental states ; and, a fortiori, derangements amenorrhojal, dys- 
 menorrhoeal, <fec., are attended by deranged cerebral functions correlated 
 thereto, and the result of discharges of grey matter. Thus most of 
 our cases clearly show exacerbation of their mental symptoms at 
 pei'iods corresponding to the natural monthly term when this could 
 be ascertained, either when the flux was present, scanty or absent. 
 Ovarian excitation and increased functional excitation of correlated 
 nervous centres are set up by the same influence; and this influence 
 may expend itself sometimes on one, and sometimes on the other, 
 system almost exclusively. It is thus we find a considerable pi'O- 
 portion of our cases of insanity still unattended by any actual evidence 
 of deranged ovario-uterine functions, just as amenorrhoeal states may 
 be unaccompanied by serious mental disturbance. 
 
INSANITY ASSOCIATED WITH AMENORRHOiA. 
 
 349 
 
 Insanity at Puberty and Adolescence, with Co-incident Menstbual 
 Derangement or Notable AnjKmia. 
 
 Age. 
 
 Menstrual Condition. 
 
 10 
 
 11 
 
 18 
 
 12 
 
 16 
 
 13 
 
 19 
 
 14 
 
 20 
 
 15 
 
 19 
 
 16 
 
 19 
 
 17 
 
 20 
 
 18 
 
 17 
 
 19 
 
 20 
 
 20 
 
 20 
 
 21 
 
 20 
 
 22 
 
 19 
 
 23 
 
 20 
 
 24 
 
 16 
 
 25 
 
 17 
 
 26 
 
 19 
 
 27 
 
 18 
 
 28 
 
 20 
 
 29 
 
 18 
 
 30 
 
 20 
 
 31 
 
 20 
 
 32 
 
 15 
 
 33 
 
 16 
 
 34 
 
 18 
 
 35 
 
 20 
 
 36 
 
 19 
 
 37 
 
 16 
 
 38 
 
 17 
 
 39 
 
 16 
 
 40 
 
 18 
 
 41 
 
 19 
 
 42 
 
 17 
 
 43 
 
 18 
 
 44 
 
 17 
 
 45 
 
 19 
 
 46 
 
 17 
 
 Amenorrhcea for four months. 
 
 ,, of late. [tack. 
 
 ,, for eight months throughout at- 
 
 ,, for eight months after admission. 
 
 ,, throughout attack. 
 
 ,, for six months. 
 
 ,, throughout attack. 
 
 ,, for five months prior to admission 
 and persistent up to discharge. 
 
 ,, for six mouths prior to admission ; 
 not re established up to four 
 months later. 
 
 ,, for five months after admission. 
 
 ,, persistent up to discharge. 
 
 forfourmonths preceding and three 
 
 months following admission. 
 for seven months after admission, 
 persistent throughout attack, 
 of late, but precocious puberty. 
 
 for six months after admission. 
 
 „ for eighteen months upon admis- 
 sion. 
 
 , , for ten months prior to admission. 
 
 , , for four months prior to admission, 
 persistent throughout attack. 
 
 ,, history of hysteria for two years. 
 
 ,, persists for three months after 
 admission. 
 
 ,, for three months prior to and four 
 months subsequent to admission. 
 
 ,, for three months after admission. 
 
 ,, for five months before admission, 
 and persistent up to discharge. 
 
 „ for six months after admission. 
 Menstruation irregular. 
 
 for many months. 
 
 and scanty. 
 
 for a short period. 
 ,, regular. 
 
 Amenorrhsea for months prior to, and ir- 
 regularity subsequent to admission. 
 
 Suppression or irregularity throughout at- 
 tack. 
 
 Menstruation becoming for the first time 
 established. 
 
 Menstruation first established ten months 
 prior to admission was suppressed or 
 irregular throughout attack. 
 
 Deferred puberty. 
 
 Deferred puberty; catamenia established 
 seven weeks after admission (recovery). 
 
 Deferred puberty; catamenia not established, 
 
 Great mental stupor. 
 
 Fair bodily condition. 
 Stout, approaching obese. 
 
 Fair bodily condition. 
 
 Pallid, feeble; wide, dilated 
 pupils. 
 
 Very pale and anaemic. 
 
 Pupils widely dilated. 
 
 Thin, pallid and reduced ; pupils 
 
 widely dilated. 
 "Very pale, anemic ; shows much 
 
 torpor. 
 Very pale and anaemic. 
 
 Pale and very feeble ; livid ex- 
 tremities ; " acute dementia." 
 Pale and anaemic; cold livid hands, 
 
 Phthisical. 
 
 Pupils widely dilated; feeble 
 
 health. 
 Pale and anaemic. 
 
 Wide, dilated pupils. 
 Extremely thin and reduced. 
 
 Pupils widely dilated. 
 
 Very spare and pallid ; haemic 
 bruit; widely-dilated pupils; 
 much stupor. 
 
 Very anaemic : haemic bruit. 
 
 Pale and chlorotic. 
 
 Profound waxy pallor. 
 Widely-dilated pupils. 
 
 Very pallid, weakly ; great stupor. 
 Very pale and anaemic ; developed 
 
 spinal disease. 
 Very pale and anaemic. 
 
 Extreme anaemic pallor. 
 
 Greatly reduced- 
 Stout and well-nourished. 
 
350 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 The development of the organism is (at such periods as we are now 
 engaged with) strongly affected by the environment and employment ; 
 social influences, and educational systems will greatly modify the 
 growth of mind as it does that of the body. In either case the 
 natural lines of development may be blocked by unfavourable social sur- 
 roundings, a vicious educational rule, or by unhealthy occupations, 
 which, while they undermine the physique or check its healthy expan- 
 sion, often afford no food for the mental life, but dwarf its stature and 
 cramp its unfolding energies. The periods of puberty and adolescence 
 are peculiarly prone to suffer thus in the present day, when the struggle 
 for existence amongst the poorer classes often demands a self-imposed 
 bondage of body and mind, by which the conditions of life are too 
 dearly purchased. It is amongst the poorer class, exposed to such 
 unfavourable conditions of life, that we find the worst forms of insanity 
 of the adolescent period prevalent.* 
 
 The Blood in StuporOSe States. — In this connection, it is of 
 interest to note the constant and often profound implication of the 
 blood in cases of adolescent and pubescent insanity, characterised by 
 a notable degree of stupor. The following cases illustrate forcibly the 
 impoverishment of the red blood-corpuscle in such subjects : — 
 
 * One of the most glaring instances is presented by certain white-lead manu- 
 factories, where young women are occasionally employed at an early age. They 
 are continuously exposed during their employment to the direct contact of the 
 metal with tlie skin, and to the acid fumes arising from the stacks. Their work is 
 laborious, irksome, devoid of interest, and most prejudicial to health. The metal 
 is rapidly absorbed, and produces profound changes in the constitution of the blood ; 
 extreme ansemia results, nutrition is generally impaired, and the menstrual 
 discharge, if not present, is checked and suppressed indefinitely ; or, if it has 
 appeared, it becomes irregular and soon absent. Lead colic is frequent ; yet the 
 poor sufferers persist in their insanitary occupation. Their pallid faces, immature 
 growth, and arrest of the usual indications of budding wouiauhood, gain for them 
 in their neighbourhood the sobriqiiet of the "white-lead ghosts."' Emijloyment 
 here at an early age, before puberty is established, always results in its arrested 
 development, and in indications of serious mal-nutrition of the nervous centres. 
 Hysteric attacks are frequent ; the natural womanly instincts are not aroused, or 
 are replaced by morbid sentiments, unnatural desires, and vicious habits. In place 
 of the expansion of the higher emotional nature which befits her for the 
 duties of womanhood, and which render her an object of respect and regard upon 
 the part of the other sex, she remains a girl with childish sympathies up to 
 mature years ; or, sexual instincts awakened into partial life, uncontrolled by 
 higher emotional developments, render her an object of aversion to others. 
 Nervous derangements arc peculiarly frequent ; chorea, epileptiform seizures, 
 cataleptic states or actual insanity may develop. 
 
THE BLOOD IN STUPOROSE STATES. 
 
 351 
 
 Amount of HyEMOULOBiN in Blood of Adolescent Subjects (Male and Female). 
 
 Profoundly Stuporose. 
 
 «i 
 
 o 
 
 O 3 
 
 RliMARKS. 
 
 C. W., . Oct. 1, '87, 
 Nov. 2, '87, 
 
 Dec. 1, '87, 
 
 Jan. 11, '£ 
 
 L. E. S.,. Nov. 4, '87, 
 
 E. H., . Sep. 28, '87, 
 Oct. 8, '87, 
 Nov. 4, '87, 
 
 M. A. P., Nov. 15, '87, 
 
 H. S. L., Nov. 2, '87, 
 
 W. S., . July 25, '88, 
 July 26, '88, 
 Aug. 2, '88, 
 Aug. -.i, '88, 
 Aug. 12, '89, 
 
 R. W. J., Aug. 10, '89. 
 
 E. H., . July 29, '87, 
 
 T. T., . Aug. 3, '87, 
 
 Sept. 28, '87, 
 
 T. M., . July 25, '87, 
 July 26, '87, 
 Aug. 2, '87, 
 Sept. 28, '87, 
 
 M. B., . Oct. 1, '87, 
 
 Nov. 15, '87, 
 W. R., . Mar. 4, '88^ 
 
 Per 
 
 cent. 
 
 58 
 
 60 
 
 72 
 
 90 
 
 70 
 
 58 
 50 
 
 58 
 
 74 
 
 78 
 
 70 
 74 
 68 
 90 
 55 
 
 78 
 68 
 
 72 
 
 60 
 68 
 62 
 
 55 
 
 72 
 
 72 
 70 
 
 Per 
 haemic 
 
 unit. 
 
 94-2 
 133-8 
 
 107-8 
 
 115 
 
 107-2 
 
 84-2 
 66 
 95-8 
 93-6 
 
 102-8 
 
 100 
 100 
 75 
 100 
 100 
 124 
 
 97-2 
 95 
 
 85 
 
 115 
 126 
 105 
 
 82 
 
 lis 6 
 
 84-2 
 73-4 
 
 Per 
 htemic 
 unit. 
 -20 
 •04 
 
 •10 
 
 •10 
 
 •40 
 
 -22 
 -25 
 
 •28 
 
 •22 
 
 •4 
 •25 
 •25 
 •40 
 
 •285 
 •18 
 
 •60 
 •40 
 •20 
 
 •60 
 •08 
 •40 
 •25 
 
 •18 
 
 •22 
 •53 
 
 •61 
 
 •45 
 
 •67 
 
 •78 
 
 •64 
 
 •70 
 
 •75 
 •61 
 •79 
 
 -76 
 
 •68 
 -70 
 •98 
 •68 
 •90 
 •44 
 
 •80 
 •71 
 
 •84 
 
 •52 
 •54 
 •59 
 •67 
 
 •61 
 
 •85 
 •95 
 
 Complete relapse into stupor. 
 
 Stupor of seven days' duration ; 
 catamenia scanty fourteen 
 days ago ; second time since 
 admission; face heavy antemic, 
 lips blanched, pupils normal, 
 headache. 
 
 Cheerful and active at convales- 
 cent home; amenorrhoea; gums 
 ruddy and anaemia decidedly 
 lessened. 
 
 During menstrual period ; cata- 
 menia normal ; lively, chatty, 
 jocular ; blood coagulates 
 rather too readily. 
 
 Great stupor ; widely-dilated 
 pupils. 
 
 Melancholic ; profound pallor. 
 
 Cheerful and lively. 
 
 Intense melancholia (lactational) 
 compulsory feeding. 
 
 Considerable stupor and heavi- 
 ness ; yet works and smiles 
 when addressed ; pupils large ; 
 no catalepsy ; fair colour. 
 
 Case oi profound stupor of several 
 years' duration ('85, '89) re- 
 ported at page 160. 
 
 Quite mute, yet far less stupor 
 than on admission; no resist- 
 ance, but shrinks — expression, 
 calm repose. 
 
 Melancholy with stupor. 
 
 Hysteric outbursts occasional ; 
 impulsive, treacherous. 
 
 Stupor ; masturbates. 
 
 Stupor persistent. 
 
 Less torpid. 
 
 Cheery and much improved ; far 
 less torpid. 
 
 Relapse of hystero-epilepsy, 
 fortnightly scanty menstrua- 
 tion, considerable pain. 
 
 Catamenia present, much more 
 cheei-y and communicative. 
 
 Melancholy ; profound stupor. 
 
352 INSANITY OF PUBERTY AND ADOLESCENCK. 
 
 In tlie Male Sex. 
 
 Sexual Diverg'ence. — The divergence occurring at this epoch 
 does not proceed pari passu in both sexes, it appears in the male 
 generally in advance of the female of the same age. In the boy the 
 sexual instincts are earliest aroused. In the boy such instincts are 
 likewise sublimated at an early period of his history, into higher 
 emotional forms ; and during adolescence the progress made in the 
 direction of intellectual activities is more apparent, more obstrusive 
 than in the girl. The female chiefly exhibits the recipiency of her 
 nature at this epoch, the male its ppojectivity in a life of action; 
 the former is the receptive organism, as the latter is the effective and 
 distHhutive one. In the flooding of new areas of the cortex — in the 
 opening up of new tracts of tissue occurring during the development 
 of the sexual organisation in woman as in man,* the consequent 
 differentiation is due not so much to the development proceeding 
 entirely along a divergent tract, as in becoming more pronounced in 
 one direction than in another, and in being more advanced in the 
 male than in the female. The arousal of new instincts, the develop- 
 ment of higher emotional states — vague yearnings, wide-spread sym- 
 pathies, tender passions, half-understood promptings — bespeak in 
 woman a high subjectivity, devoted, however, to the most generous 
 ends. In man, on the other hand, the expansion of the amiable 
 qualities is never so great; his love is from the first of a more 
 selfish nature, and its further developments are likewise devoted to 
 more selfish ends. More calculating, more ingenious, more inventive, 
 his schemes and plans of action from the first must, from the very 
 constitution of society, embrace antagonism to his fellow-man in the 
 competition and race for life. The dependence of the one sex is notably 
 in contrast with the self-reliance of the other. Thus Darwin, alluding 
 to sexual distinctions, says : — 
 
 " Woman seems to differ from man in mental disposition, chiefly in her greater 
 tenderness and less selfisliness ; and this holds good even with savages. . . . 
 Woman, owing to her maternal instincts, display's these qualities towards her 
 infants in an eminent degree ; therefore it is likely that she would often extend 
 them towards her fellow-creatures. Man is the rival of other men, he delights in 
 competition, and this leads to ambition, which passes too easily into selfishness. 
 These latter qualities seem to be his natural and unfortunate birth-right." + 
 
 These considerations would in themselves suffice to indicate the 
 divergence in type of mental ailment to which the two sexes are 
 
 * The correlation of these coincident developments is seen in the fact, that if man 
 be emasculated, the sexual characteristics never appear (Darwin, op. dt., p. 557). 
 t Descent of Man, chap. xix. 
 
SEXUAL DIVERGENCE. 353 
 
 exposed at this period of life. Whilst the female shows a prepon- 
 derating effect on the affective sphere of mind, the adolescent youth 
 J>etrays an aberrant tendency in the reactive faculties of his mental 
 being. His newly-awakened faculties, like all nascent mental products, 
 are wondrously fresh, active, and potent ; hence, naturally tending 
 to falsify relationship from want of a due contrasting power, his 
 powers and abilities are vastly exaggerated, and beget an unfortunate 
 egoismus. His plots and schemes savour of the wildest vanity ; 
 whilst the self-complacent all-sufficiency with which he reveals these 
 plans betoken the overpowering of normal contrasting experiences by 
 the new-begot factors. Every faculty whereby he becomes a unit of 
 power in the domestic or social circle is represented in false quantities, 
 and a disproportionately intensified and overweening self-esteem is 
 the natural outcome. The sexual divergence at this immature age 
 certainly tells in favour of the gentler sex. The male adolescent has 
 had his characteristics faithfully rendered by the amiable satire of 
 Thackeray in the person of Pendennis, whilst his frailties have 
 received less consideration at the hands of Carlyle.* 
 
 The aiflative emotional states, the newly-awakened instincts, the 
 flood of new impressions, and the sense of widely-expanding faculties, 
 constitute a physiological sta^^e of development which is natural to 
 all at this period of their life. Its obtrusiveness will always be 
 more or less noted ; manly sports and exercises, with a moderate 
 use of the intellectual faculties, will, however, do much to carry 
 ofi" the overflowing mental energy in a healthy channel ; but of 
 all ftiults, that of introspection and subjectivity at this age should 
 be avoided. A false code of morals does much to foster this ten- 
 dency, and has much to answer for in the intensification of mental 
 anomalies in youth. Need we recall the religious asceticism of 
 the Middle Ages as confirmatory of this fact 1 A transitional epoch, 
 such as this, is surely not a suitable period for self-analysis; and 
 this is emphasised by the well-known fact that youths, encouraged 
 
 * " I have heard it affirmed (surely in jest) by not unphilanthropic persons, that 
 it were a real increase to human happiness, could all young men from the age of 
 nineteen be covered under barrels, or rendered otherwise invisible, and there left to 
 follow their lawful studies and callings, till they emerged sadder and wiser at the 
 age of twenty-live. With which suggestion as a practical scheme I nowise 
 coincide. Nevertheless, it is plausibly urged, that as young ladies are to mankind, 
 precisely the most delightful in those years, so young gentlemen do then attain their 
 maximum of detestability. Such gawks ai'e they, and foolish peacocks, and yet 
 such vulturous hunger for self-indulgence, so obstinate, obstreperous, and vain- 
 glorious ; in all senses so froward and so forward." — Sartor Eesartus, "Getting 
 under way." 
 
 23 
 
354 INSAN'ITY OK PUBERTY AXD ADOLKSCENCE. 
 
 at this period by misguided parents or tutors to lead a too studious 
 sedentary life, devoid of healthsome exercise, and to subject their 
 mental life to a pseudo-religious training, embracing rigid introspec- 
 tive exercises, lapse readily into the worst forms of mental derange- 
 ment, and indulge, above all others, in secret sins and sexual vices. 
 
 This period witnesses the profound changes of complete sexual 
 divergence, and the attainment of those mental chai'acteristics which 
 distinguish the one sex from the other. The late epoch is charac- 
 terised by certain important features, which especially map it out as 
 the earliest marriageable period free from special risks, and has, 
 therefore, been termed the period of nubility {Matthews Duncan). 
 This author shows us, that, if we compute the number of first births 
 in newly-marvied women at difi"erent ages, we shall find that the 
 greatest "initial fecundity" occurs between the ages of twenty and 
 twenty-five. Precocious marriages expose the mother to the risks of 
 death in child-bed, or, if she survive, predispose to the bearing of an 
 excessive number of children. 
 
 In women, the changes occurring in the pelvic bones from puberty 
 forward are, of course, of vital importance, and illustrate well the 
 immaturity of the ossific skeleton for the full functions of maternity 
 up to the age of twenty. 
 
 Symptoms. — The subject usually comes before us excited, highly 
 elated, his attitude, demeanour and expression indicative of intense 
 self-complacency and assurance. The excitement may be very acute, 
 attended with continuous garrulity, incoherence and movement, yet 
 the buoyancy of spirits is a striking feature at all times. In the more 
 coherent states the subject, unprompted, reveals his exalted notions ; 
 talks of his acquirements as a scholar; expatiates on his skill as a 
 workman; revels in the supposed possession of rare and much-esteemed 
 faculties, of persuasive eloquence, of poetic talent, of wondrous vocal 
 powers, of the gift of tongues, of artistic abilities, or histrionic powers 
 of a high order ; or his thoughts course in the direction of his 
 muscular energies and capacities, he assumes his strength to be almost 
 superhuman, and regards himself as a champion walker, runner, 
 wrestler, or the like {F. S., p. 291). 
 
 Even if such beliefs are not definitely expressed, egoistic sentiments 
 prevail, and are the fount from which issue extravagant schemes of 
 action. Inventiveness, ingenuity, cunning, are all assumed by this alien 
 being, whose mental life is awaking, though in an anomalous form, 
 to the appreciation of the keen competition of existence. We observe 
 a similar condition arise at a later period of life, in that fatal malady 
 general paralysis ; but here, to account for the symptoms, there is a 
 far more profound structural alteration, which progressively becomes 
 
SYMPTOMS OP PUBESCENT INSANITY. 355 
 
 more and more involved, until utter fatuity and paralysis result ; yet 
 in the eai-ly stages of this disease the same egoism, the same lofty ideas 
 of the subject's physical powers, wealth, capabilities, ingenuity and 
 skill come to the fore. 
 
 Towards their own sex this self-assumed superiority calls forth often 
 an aggressive conduct, an overbearing manner amounting to arrogance, 
 which involves them in frequent disputes and quarrels. To the 
 gentler sex their behaviour is often gallant and condescending, sav- 
 ouring of a precocious manliness which does not accord with their 
 mental and physical development. As Dr. Clouston states : — " In 
 the males heroic notions, imitation of manly airs and manners, an 
 obtrusive pugnaciousness, and, sometimes, a morbid sentimentality 
 Avere present." * And again : — " The physical appearance of the males 
 Avas boyish, and of the females girlish." On the other hand, it must 
 not be forgotten that such adolescent forms of insanity are prone to 
 prurient thoughts and erotic promptings which make them objects of 
 anxiety to their guardians in relation to the other sex. All the above 
 symptoms are liable to intensification by the vicious habit of mastur- 
 bation still further reducing the nutrition of the nervous centres ; 
 above all agencies does it prove most powerful in leading up to chronic 
 delusional insanity, or into hopeless dementia. 
 
 The cases of insanity occurring from puberty to the completion 
 of adolescence naturally arrange themselves under two categories : — 
 
 («.) There are those in whom maniacal excitement (often very 
 intense) prevails, with the egoistic, self-laudatory state alluded to ; and 
 often alternating with conditions of mental stupor and cataleptic states. 
 
 (b.) And there are those of a later age, in whom delusionS are the 
 prominent characteristic — delusions more often associated with mel- 
 ancholic depression than with maniacal excitement. 
 
 In fact, the proportion of delusional cases occurring between the 
 ages of twenty-one and twenty -five is far greater than that which 
 occurs between thirteen and twenty-one. It has already been 
 remarked, that cases of melancholic depression are of far less frequent 
 occui'rence in the female than in the male adolescent, and since 
 adolescence is completed in the female earlier than in man, age 
 possibly has much to do with its predominance in the later adolescence 
 of the male sex. Our statistics indicate, that of all cases of insanity 
 apparently influenced by adolescence in men, i.e., from the age of 
 fourteen to that of twenty-five, inclusive, about one-half occur up to 
 twenty-one years of age,t and the remainder subsequently ; or, to be 
 
 * Lectures on Mental Diseases, p. 552. 
 
 t From the age of thirteen to that of seventeen there were iO cases of insanity 
 out of a total of 3,000. 
 
356 INSANITY OP PUBERTY AND ADOLESCENCE, 
 
 exact, 142 occurred before twenty-one, and 135 afterwards and np to 
 twenty-five years of age. As in women, so in men we find that there 
 is a rapidly-increasing number of cases from the age of fourteen up 
 to that of twenty-one. 
 
 As modified by the vice of masturbation, we find tlic prevalence of 
 pseudo-religious exaltation, indulgence in cant, and development of 
 fixed religious delusions. One patient conceived himself transformed 
 into the Almighty; another believed he was inspired by spiritual 
 agency and could perform miraculous works; another had the gift of 
 tongues. Then come periods of great impulsiveness (often prompted 
 by visual and aui'al hallucinations), sudden ferocious violence, indecent 
 assaults ujjon the other sex, and even suicidal acts of determined 
 character, attempts at rape, strangling, drowning; these are not i;nusual 
 features in the masturbatic adolescent. The type is by no means always 
 that characteristic of the ordinary sane masturbator, for, though the 
 jihysical symptoms of cerebro-spinal irritation may be equally pro- 
 minent in both, yet the mental ailment borders more often on that of 
 delusional insanity. The shy, averted look, timidity, obsequious- 
 ness, and shunning of society, may be replaced by a bold audacious 
 bearing, a shameless confession (and even defence) of their habit, a 
 shocking disregard of decency, and an entire absence of the sense 
 of moral degradation. Even if the vice be concealed, the pale 
 ansemic aspect, the dark areola around the eyes, the dilated pupil 
 and the general atony exhibited in feeble heart and languid circula- 
 tion, enfeebled motor power and disturbed co-ordination, the amnesic 
 states, occipital headache {Sjntzica), the vague unreasonable alarm, 
 eccentric dislikes fostered, and unfounded suspicions, soon attract 
 our attention. 
 
 J. M. , aged nineteen, labourer; admitted June, 1S82, A paternal uncle died 
 demented; a second cousin, S. M., is at present a patient in this Institution — no 
 intemperance. J. M. had been addicted to masturbation since the age of fourteen, 
 and though conscious after some time of its prejudicial effects, was unable to discon- 
 tinue its indulgence. During the four years preceding his admission to the 
 asylum he grew more and more despondent, brooding ever over his Bible and 
 Prayer-book, neglecting his work, and wandering abstractedly about the fields. 
 This condition was interrupted by longer and shorter remissions, but finally 
 settled into a permanency of deep depression, the outcome of which appeared, 
 some five months before being put under care, in a successful attempt to emasculate 
 himself. Immediately on its performance lie had two convulsive seizures, not, 
 however, recurring. A short period of mental improvement followed, and then 
 he became worse tlian ever. Three years befoi'e this occurrence he had had a 
 fall from a hayloft upon his head. 
 
 When admitted, he was tearful and much depressed, but communicative. His 
 object in castration was ''to prevent the jiossibility of masturbation," but the 
 object attained, he was overcome by fear of having "cut himself off from God, 
 
MODIFIED FORMS — CASE OF J. M. 357 
 
 and lost his soul." This belief he maintained during his residence, but became 
 nevertheless more slightly oppressed by it, less gloomy and despondent, and 
 decidedly improved in some points inasmuch as he employed himself actively, 
 and showed sociability. Was sent to home-care at the expiration of fourteen 
 weeks. Of the interval of twenty months which preceded his second attack, the 
 first eight were spent satisfactorily on the whole, although occasional relapses 
 occurred ; the ensuing twelve months witnessed a gradual deterioration of his 
 condition, ending in a return of his despondency, with some outbursts of violence. 
 When brought back to the asylum he was much depressed, partly by his religious 
 fears, partly by his regret at having emasculated himself; he disclaimed suicidal tend- 
 ency. Considerably hypochondriacal for a few weeks, he then made really steady 
 improvement, and became active, conversable, and easy in his mind regarding his 
 future. Was discharged "recovered" at the end of four months. He kept fairly 
 well for about five months ; but during the next two, he fell again into a state of 
 depression, brooding, and occasional turbulency. 
 
 Tlie same prominence was not given to religious sentiment in this attack, but 
 he expressed his belief that it was his duty and God's will that he should blow 
 up London. No further delusion was manifested, nor suicidal inclination acknow- 
 ledged ; he always maintained a taciturn, moody expression, and evinced much 
 hypochondriacal feeling. At times he expressed himself as hopeless of his future 
 salvation, &c. , but these phases were short, and probably not of such real intensity 
 as on previous occasions. Convalescence occurred after the lapse of ten months. 
 
 A fresh recurrence took place a month after his discharge, and he showed 
 suspicious and violent tendencies. This attack was characterised by continuous 
 sullen, quarrelsome, vindictive conduct, and utter refusal to employ himself, 
 for the greater part of the time. Was wont to stand in a corner of the 
 room, staring blankly in front of him, with his hands in his pockets, and to 
 become violent and abusive if disturbed, and even so, without any provocation. 
 Pwequired forcible alimentation. On one occasion he was found to have tied his 
 neckerchief tightly around the scrotum, producing much cedema. After twenty 
 months' care showed no improvement. He was transferred to Menston, 
 
 "Without attempting any refined analysis of the multifarious groups 
 which might be comprised under the head of insanities at adolescence, 
 still less att(^.mpting to dignify with specific significance the varied 
 symptoms of such groups, it will best serve the purpose of the student 
 to direct his attention to the symptoms proper to insanity at this 
 l)eriod of life, and to the modifying influence of vicious habits of life, 
 e.g., masturbation and drink; intercurrent afiections, such as phthisis; 
 or defective states of the blood, as in anaemia. And first, let us draw 
 the distinction clearly between the forms of insanity arising during 
 adolescence, and those subject to the modifying efli'ects of masturbation. 
 
 In drawing such a distinction we must keep in mind the fact that 
 the vice is so frequent that a pure xmcomplicated form of insanity at 
 this period of life is the exception, not the rule. As already stated, a 
 great proportion of our adolescent cases are found to be mild cases of 
 congenital defect, and these are, as is well known, prone to the vice. 
 
 Again, the period of life is prone to induce the habit in a case of 
 
358 INSANITY OP PUBERTY AND ADOLESCENCE. 
 
 insanity of any standing, even if the subject were not previously 
 acUlicted thereto ; and in the later stages of such unfavourable cases as 
 lapse into dementia, the habit almost invariably exists. 
 
 In a pure uncomplicated form of insanity at adolescence, we find the 
 patient in a state of sub-acute or acute excitement, with exalted self- 
 feeling. His egoism (which is the prominent feature) is like that of 
 the victim of general paralysis in its obtrusive aspects ; there are 
 notions of wealth, superabundant enei'gy and power, enviable dis- 
 tinctions and rank, a general feeling of bien etre ; or the youth may 
 have wondrous plans in view, exhibit restless energy, incessant 
 scheming, yet withal he shows a frank, bold, generous bearing wholly 
 distinct from that worn by the masturbutor. He is garrulous, 
 obtrusive, often objectionably so to his elders, yet there is nothing of 
 a repulsive character. His egoism is ever tending outwards towards 
 the realisation of his phantom schemes j there is no self-engrossment 
 and abstraction. His egoism, again, has more self-confidence, and 
 appears as a self-assertiveness and assurance, so well grounded in the 
 patient's sentiments and beliefs, that opposition, dissent, restriction 
 appear impossible, or too contemptible to be taken into account ; 
 there is not the fear, suspicion, hatred of the environment fostered 
 by the other form. Then again, the physical symptoms due to the 
 vice are absent in the uncomplicated form. The recoverability, 
 again, of insanity at adolescence is very great ; the prognosis in 
 insanity modified by onanism is veiy grave ; in fact, the majority 
 of unfavourable cases of the former are accounted for by the 
 frequent lapsing into this habit. As modified by the vice, however, 
 the mental symptoms are those of a narrow repulsive egoism, 
 flavoured by pseudo-religious hypochondriasis, often with much shy- 
 ness and reserve at first, but later on, obtrusive and unseemly 
 {F. S., p. 291). The pseudo-pietistic notions early developed, long 
 before marked mental derangement is actually recognised by the 
 patient's friends, are of the most cramped and selfish nature. Obsti- 
 nate narrow bigotiy often results in a complete intellectual famine, the 
 patient becoming a prey to some sectarian community, which succeeds 
 only too well in checking the due expansion of the moral nature, and in 
 fostering the self-opinion and conceit of its victim. We find the parents 
 often speak of such an one as of deeply-pious habits of thought and life, 
 as eminently conscientious, as of an amiable, modest, and retiring 
 nature, failing wholly to realise the deep-seated egoism and self- 
 contemplative abstraction which lies beneath such natures. 
 
 "With this morbid subjectivity there is often associated much timidity, 
 unexplained dread, tremblings, frightful dreams and " nightmares," 
 often hysteric seizures. In the intellectual sphere there is a great 
 
ETIOLOGY. 359 
 
 want of spontaneity, lack of energy and mental movement, which may 
 border on imbecility; irritability, spasmodic temper, impulsive conduct 
 alternate with gloom, despondency, torpor ; the mood is very variable. 
 
 Then, again, hallucinations of sight and of hearing very fi-equently 
 prevail ; and often explain the timidity and terror of such cases. The 
 physical symptoms are no less striking than the mental, and bespeak 
 the wide-spr-ead exhaustion of the cerebro-spinal centres. Such 
 symptoms are— the ansemic aspect, associated with general atony ; 
 the dilated pupil ; the languid circulation and vasomotor paresis ; 
 cold blue extremities, a sense of weakness in the lower extremities, 
 and a slightly ataxic gait, often swaying and inco-ordinate movements. 
 
 We thus see that the symptoms indicative of the psychosis, inci- 
 dental to this period of life, are far different to those aroused by the 
 vice of masturbation. The egoism and afflative state of the maniacal 
 adolescent are readily recognisable, but their symptoms undergo 
 varied modification and intermixture upon addiction to this vice. 
 Thus, when we find the adolescent, instead of improving rapidly, makes 
 several partial recoveries only to relapse, and especially when such 
 relapses are towards mental torpor with general lack of muscular 
 energy and vascular tone, we at once suspect addiction to this vice. 
 So when we find the averted glance, the widely-dilated pupil, the 
 expression and demeanour indicative of efi'eminate self-engrossment, 
 and delusions based on the sexual instincts, indications of sexual 
 pel-versions or intensified egoism, we naturally look for a similar 
 origin. Aural hallucinations, timidity, distrust, loss of self-confidence, 
 with this concentration of the self-feeling are all harbingers of the 
 same vicious habit. 
 
 EtiolOg'y. — A very large proportion of the cases of acute excitement 
 are constituted by congenitally-weak minds, and the number of such 
 cases which precede the age of twenty-one is nearly double that of those 
 which follow ; in fact, the age of puberty and adolescence is peculiarly 
 the trial-period for subjects of congenital defect — then, if at all, will 
 their deficiencies become notably prominent. This remark does not 
 necessarily apply to cases wanting in intellectual aptitude, but rather 
 to those with the defective moral control which characterises so many 
 of our cases of congenital weakness. The whole moral being, as we have 
 seen, is subjected at this period to revolutionary changes through the 
 incoming of new sensations and the turmoil produced by this inter- 
 penetration of the old self; new sentiments spring into life, fresh- 
 begotten emotions (redundant in energy) tend to further ovei-throw 
 canons of belief; and the judgment is strongly swayed by such overbal- 
 ancing factors. At this period, if at any time, is a duly-balanced moral 
 control necessaiy to the well-being of the subject. How often it fails 
 
360 INSANITY OF PUDERTY AND ADOLESCENCE. 
 
 is too flagrant a fact to be dwelt upon. How much of such failure is 
 due to immature and narrow systems of education, to vicious and 
 cramping customs of life, and to injudicious parental training is also 
 only too apparent. Of the most vital importance is it that the lines 
 of development of the moral nature at this critical epoch should be 
 watched with the greatest interest, and that the parental and tutorial 
 guidance should be of the most enlightened and prospective kind, to 
 insure the due integration and elaboration of the chaotic mass of 
 impressions incrowding at this stage of mental evolution. It is out of 
 such misguided states arise the religious fanatic, the sordid sensualist^ 
 the repulsive masturbator, the nerveless sentimentalist, and the 
 vicious and impulsive characters who are to the end moral wrecks, 
 bearing witness through their lives to the violence and tyranny of the 
 adolescent storm. It is the epoch of great moral convulsions, which in 
 the insane is accountable for those extraordinary delusional concepts 
 of a religious character, which (even in the insane) have so bizarre an 
 effect. The ideas of being crucified or of being subjected to martyr- 
 dom of a revolting kind, of being transformed into the Almighty, 
 exemplify the kind of notions which readily spring into life at this 
 epoch in those who become alienated. Such conceptions, it may be 
 noted, would be scarcely possible at a much earlier age ; they deal 
 with the subject-matter of late periods of development, the material of 
 religious doctrines and sentiments, and therefore indicate an early 
 denudation of evolving mind. Prior to the mental commotion of 
 puberty these moral imbeciles have, maybe, shown an aptitude for 
 learning, a brightness of intelligence proportionate to their age, and 
 little (beyond an ill-governed passion, or vicious or cruel tendencies) 
 to indicate the approaching danger.* 
 
 When the sexual instincts are aroused at piiberty, their dwarfed 
 morale renders them easy victims to the vice of masturbation, which, 
 perhaps, is the best criterion of defective moral control. If persisted 
 in, it no longer remains the symptom of a mental defect, but the prolific 
 source of a deepening malady of the nervous centres, whereby the mental 
 affection is itself coloured. Masturbation, as a symptom of disease, is, of 
 course, prevalent in insanity at all pei-iods of life; but adolescence is 
 the epoch, especially, when its indulgence is apt to be the exciting cause 
 of a grave developmental malady, which otherwise might have been 
 tided over. We have on moi'e than one occasion watched the advent 
 of puberty in the successive members of a highly-neurotic family where 
 insanity, drink and apoplexy had been the ancestral curse, and have 
 seen one after the other succumb to this epoch of their life, the vice 
 
 * See also on this subject Dr. Hack Tuke. Psychological Medicine: Art., 
 " Pubescent Insanity." 
 
ILLUSTRATIVE CASES OF ADOLESCENT INSANITY. 361 
 
 being successively engendered as the sexual instincts came to the fore. 
 There are few physicians who do not meet with numex'ous instances of 
 this class. 
 
 The explosiveness of nerve-tissue in the imbecile is a characteristic 
 feature of their case, and we can conceive no condition more likely to 
 issue in the impulsive forms of insanity than that of a vicious imbecile 
 arriving at the period of puberty and a victim to a perverted sexuality. 
 
 The two following cases are typical instances of the insanity, incident to the 
 period of adolescence, with its alternations of stupor, and of wild maniacal excite- 
 ment and dangerous impulsiveness :— 
 
 L. C, aged twenty, single, a clerk in a merchant's office. Had previously been 
 insane for five months at the age of eighteen and was then strongly suicidal. He has 
 been always anxious since this attack lest he might take his own life some day. A few 
 days prior to his admission he had become peculiar, reserved, depressed, and showed 
 much failure of appetite ; and on the previous night he went to bed and stabbed 
 himself in the chest (though not dangerously) with his penknife. His health in 
 other respects had been good ; there was no neurotic history ; no personal history 
 of drink or cranial injury. He was of average height, somewhat thin and reduced ; 
 his complexion was pale and pasty ; his pupils were dilated and mobile. He had a 
 heaAy, listless expression, averted his face during conversation, was evasive and 
 flippant in rei)ly. He at times assumed a languid affected air ; and his mental 
 operations were slowly performed : he was reticent, depressed, and sighed deeply. 
 He was suspected to be addicted to masturbation, and this suspicion was fully 
 confirmed on admission ; his vicious habits were most inveterate, and all 
 remedies tried for the purpose of reducing this tendency completely failed. The 
 patient made a most determined indecent assault iipon a female the day after his 
 admission. He remained dull and lethargic, in a state at times amounting to 
 stupor ; took no interest in anything occurring in his ward ; was careless in his 
 habits, but at times wilfully mischievous. Suddenly, however, after several 
 months of stupor, he asked for a pipe of tobacco, spoke cheerily, rationally, and 
 began to sing an old air, play dominoes, and read. He attributed his own improve- 
 ment to his discontinuance of his vicious habits. 
 
 P. C, aged twenty-three, a labourer, but intelligent, was admitted for his 
 first attack of insanity, from which he had suffered for three days past. The onset 
 was very sudden, and quite unexpected by his friends. He had worked as iisual 
 up to eight o'clock one evening. On returning home he became obstinately 
 silent, and, on retiring to bed with his brother, he attacked the latter savagel}-, 
 smashed the pictures on the walls, &c. He has been maniacally excited since, 
 shouting, laughing, and singing aloud ; proclaims himself the second Messiah, at 
 other times another Saint Patrick, and broke a hole through the ceiling (as he 
 explained) " to let the Devil out." On admission he was very furioiis, was haggard 
 and exhausted in appearance, and required compulsory feeding. Milk and egg, 
 with brandy and soda-water, were immediately given him, and feeding had to be 
 resorted to for two days, during which period the excitement continued unabated 
 and he passed sleepless nights. Six ormces of brandy have been given liim daily 
 with milk and egg and lieef-tea. He has had the succus conii in four-draelim doses 
 three times daily. The third morning after his admission a qiiiet night and peace- 
 
362 INSAXITV OF PUBERTY AND ADOLESCENCE. 
 
 ful sleep were reported, and he took his breakfast voluntarily. He was now able 
 to converse and give a coherent account of himself and his feelings. He stated 
 that he had been recently attending religious services, and that they had "opened 
 up his mind more clearly to religious truths." He then began to feel that all his 
 movements were prompted by "inspiration," and things around looked different ; 
 the face of every one he looked at brightened up. When he attended the con- 
 fessional subsequently, upon stating that he did not drink, a voice intimated to 
 him that he would go to Heaven ; and he at once Ijecame tilled witli a supernatural 
 joy. His religious fervour now passed into feelings of great excitement, during 
 which he often believed himself to be crucilicd with his head downwards. On one 
 dark night the room became suddenly lit up by spectral lights, and voices were 
 heard by him frequently when he could see no one present. He believed that his 
 own rambling talk were the utterances of the Almighty. There was no history of 
 hereditary epilepsy, or of drink. He had taken very special interest in the Catholic 
 missions, just about the time when he became maniacal. He was still a little hazy 
 and confused, but quite rational, when giving the above account of himself. From 
 this period he made a steady recovery, and was discharged in five weeks without 
 a relapse. 
 
 Prognosis. — Of all types of insanity that occurring at the puerperal 
 period is one of the most recoverable (80 per cent.), yet the recovery- 
 rate is nearly as high for the insanity incidental to adolescence; in the 
 female sex the mania runs a course of some months, usually marked 
 by one or more relapses, but one half of the cases recover by the seventh, 
 and neai-ly three-fourths are well by the tenth month. {See Chart B.) 
 It is far otherwise with the same affection amongst men; in them, 
 ■where (as alread}^ stated) depression is often largely present, the 
 prognosis is far less favourable, and a wide margin must be allowed 
 for partial recoveries, chronic incurables, and fatal cases. On com- 
 paring the percentage of recoveries in puerperal, adolescent male and 
 female cases, the above statement is fully verified, thus : — 
 
 Puerperal Adolescent Adolescent 
 Cases. Females. Males. 
 
 Kecovery-rate per cent., . . SO'O 73'3 oS'4 
 
 A glance at the following table of results of treatment in either sex, 
 ■will indicate in no uncertain terms the more unfavourable nature of 
 this form of insanity in the male sex : — 
 
 Recovered. Believed. " ,"^,° ; . Died. 
 
 Remained 
 as Chronic. 
 
 Female adolescents per cent., . 73 '.S 7'G 13 "5 5 "4 
 
 Male adolescents ,, . 5S'4 14 4 17*3 9'7 
 
 The unfavourable cases form 2G-5 per cent, of the total number of 
 cases in females, and 41-4 in males. 
 
 We have already alluded to the actual recoverability of this form of 
 insanity in its i-elationship to sex; it will also repay us to observe 
 more particularly the duration of the attack up to cure in both sexes, 
 
PROGNOSIS AND RECOVERY-RATE. 363 
 
 in other words, the recovery-rate as affected by time. [See Chart B.) If 
 for this purpose we glance at the chart of recoveries first as regards 
 the male adolescent, it will be evident that during the first six weeks 
 but ten cures will result out of a total of one hundred and sixty-two: 
 during the next fortnight an addition of ten recoveries just doubles 
 this number, and then for the third, fourth, and fifth months a rapid 
 inci'ement of cures, viz., seventeen, fourteen, and twenty-five respec- 
 tively; so that the summit of the curve is I'eached at the fifth month,* 
 bij which jyeriod nearly one-half the total member of cases have recovered. 
 Then a sudden drop midway occurs for each month from tlie sixth to the 
 ninth inclusive — i.e., from ten to twelve cases for each month respectively. 
 From this time up to twenty months the monthly cui've once only 
 rises above four, being usually much lowei", and a few rare and unex- 
 pected cures occur (as in other forms of insanity) at later periods still. 
 
 Now the curve of recovery for females differs considerably from the 
 foregoing, being less abruptly broken, being more uniform and sus- 
 tained in the early half of the period of recoverability, f and exhibiting 
 beyond this but one abrupt elevation; also by the critical period, if by 
 this term we may so name the period of greatest recoverability, occur- 
 ring from the fourth to the seventh month, and not as in the male 
 subject from the third to the fifth. From this it results, that whereas 
 one-half the male recoveries are established by the fifth month, nearly 
 seven months elapse ere a proportionate number of females recover. The 
 second abrupt rise of eleven cases, and as sudden a fall shown at 
 the tenth month in the female chart, I'eproduces in a modified form the 
 sustained recovery-rate shown between the sixth and ninth months in 
 male adolescents. From such a chart we might augur that the chances 
 of recovery, apart from any specially-favourable points inherent in the 
 case, are equally good between the fourth and seventh months from 
 onset; that if from some unfavourable element in the nature of the 
 case recovery does not then take place, a further hope may be enter- 
 tained of recovery at the tenth month, beyond which the chances are 
 greatly reduced ; and, also, that if a male adolescent is not included in 
 the favoux'able list of cures up to the fifth month, we may still hope on 
 with reasonable expectation of recovery to the ninth month, beyond 
 which the case must be regarded as assuming a serious character, and 
 the outlook is certainly ominous. 
 
 Not only are the cases prior to the age of twenty-one more often 
 
 * It must be remembered that the period dealt with in these cliarts is that bc- 
 tM'cen actual onset of Insanity and recovery. 
 
 t The period of recoverability may be arbitrarily fixed at twelve months from 
 the onset of the insanity ; the few recoveries subsequent to this date not militating 
 strongly against the utility of this doctrine. 
 
3G4 IXSAXITY OF PUBERTY AND ADOLESCENCE. 
 
 characterised by excitement, but the type of insanity then prevalent 
 is distinctly a more recoverable form ; the recoveries in the earlier con- 
 trasting with those in the later period, as ninety-one to seventy-one. 
 In other words, if we group together the partial recoveries, the f\xtal 
 cases, and the chronic remnant as the unfavourable class, we shall find 
 that such a class constitutes 31 per cent, of the acute forms of insanity, 
 and 49 per cent, of the melancholic forms; in fact, the chronic cases are 
 double, and the partial recoveries (" relieved ") more than double in 
 the melancholic, that which obtains in the maniacal forms. 
 
 Treatment. — The simpler forms of hysteric excitement occurring at 
 this jieriod often do not call for other than moral and dietetic measures; 
 removal from the home circle and possible sources of irritation to 
 entirely-novel relationships, the administration of a due amount of 
 aliment, regular habits of life, and means to ensure sleep will often 
 suffice to eflfect a cure. Nourishment should be given in an easily- 
 assimilable form, its nature dictated by our knowledge of the systemic 
 wants at this developmental phase of the patient's life. The secretory 
 and excretory organs should be especially attended to, liable as they 
 are at these periods to derangement and sluggish action. Sleep should 
 be secured by out-door exercise, active employment, commensurate 
 with the patient's powers of endurance within the limits of absolute 
 fatigue; sedatives should be studiously avoided. It is only when pro- 
 longed insomnia persists for several nights together, in spite of the 
 abov-e measures, that sedatives are admissible, and then a single dose 
 of chloral, sufficiently large to ensure absolutely the desired amount of 
 rest, may be given; its frequent administration for this purpose is to 
 be strongly dejjrecated. In such cases as inherit a strongly-neurotic 
 temperament, and in which the cycle of developmental change has not 
 resulted in much physical over-strain and wear and tear, large doses of 
 potassium bromide (30 to 60 grains three times daily) may be admin- 
 istered with decided benefit so long as a due amount of wholesome 
 food can be taken. Most often we have to deal with the menstrual 
 irregularities of this epoch and its attendant anaemia, our subject 
 having succumbed to the developmental wave; the nutritive and 
 assimilative capacities having been overtaxed by the exaggerated de- 
 mands of the gi'owing organism. Here a strictly-hygienic regimen 
 should be carefully and persistently enforced, such as out-door exercise 
 and the spinal douche or sponge-bath. Iron, especially the carbonate, 
 should be given in pill or mixture. It is well to vaiy the form of 
 iron, occasionally administering it in the form of iron-and-alocs pill; 
 or as the ammonio-citrate; or as the sulphate of iron in combination 
 with extract of nux vomica and rhubarb in pill; or again as the com- 
 pound syrup of the phosphates with malt-extract and cod-liver oil. 
 
CHART of RECOVERIES m FEMALES. 
 PUBERTY & ADOLESCENCE. 
 
 Chart B 
 
 
 
 
 
 
 
 11" 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Rmv' R 
 
 
 
 
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 1 
 
 
 
 
 
 
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 733% 
 
 
 
 
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 \ 
 
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 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 J 
 
 \ 
 
 V!S 
 
 1 
 
 
 
 ^^s. 
 
 ,„ 
 
 
 Duratinn of Attack 4ll! 6» .?« 3 ♦ 5 6 7 a 9 10 II 12 13 14- 15 20 2y 3y iy. 6/ 
 
 CHART of RECOVERIES in MALES. 
 
 
 
 
 
 
 J 
 
 
 PUBERTY 
 
 & 
 
 ADOLESCENCE 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 /< 
 
 j 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 f 
 
 
 
 / 
 
 
 
 
 ij. 
 
 S" 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 / 
 
 
 
 
 
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 ,, 
 
 
 
 
 
 
 
 
 
 
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 J 
 
 
 
 [ 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
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 -A! 
 
 
 
 
 
 
 \. 
 
 Recov' Relieved Died Remaininj 
 
 162 40 27 48 
 
 584% I44°i 9-7!. 17 3% 
 
 IUrationilfAttacl(.4iv 6w 2/» 3 4 5 6 7 8 9 10 II 12 13 14 15 20 2y 3y 
 
SYMPTOMS OP PUERPERAL INSANITY. 365 
 
 INSANITY AT THE PUERPERAL PERIOD. 
 
 Contents. — Symptoms — Predominance of Mania — Intensity of the Morbid Process- 
 Obtrusive Sexual Element — Hallucinations — Delusions of Suspicion — Prevalence 
 of Suicidal Feelinj^s — Etiology — Susceptibility of the Puerperal Period — Illegiti- 
 macy and Puerperal Insanity — Frequency in Primiparae — Condition of the 
 Blood — Diminution of Hajmoglobin — Prognosis — Treatment — Insanity of 
 Pregnancy — Relatively Infrequent — Primiparfe show uo S^jecial Liability — 
 Symptoms — Recoveries. 
 
 Symptoms. — The onset may be absolutely sudden, following upon 
 delivery ; but more frequently the development is gradual, being pre- 
 ceded by evidence of nervous exhaustion, until the fully-matured 
 disease bursts out in all its fury at the end of the first week succeeding 
 labour. The patient suffers from early insomnia, becomes restless, 
 fidgetty, unnaturally gai'rulous ; she exhibits a waywardness not 
 customary, takes strange and unreasonable dislikes, especially towards 
 her husband, or refuses to have her infant brought to her. There is a 
 furtiveness of glance auguring a suspicious state of mind, a startled 
 look on the slightest sound, or even intolerance of light. All her 
 relatives observe a change of disposition, and perhaps attribute it to a 
 wilful temper merely, but the pulse becomes hurried and small, the 
 face pale and haggard, the eye startlingly bright. She cannot be in- 
 duced to sleep, or sleep is broken by distui'bing dreams, from which 
 she starts up in bed rambling in disconnected utterances. Then come 
 hysteric outbursts, extravagant conduct, and all the features of an 
 acute maniacal attack. The presence of delusions and hallucinations 
 declare themselves, she shouts aloud to imaginary persons, listens to 
 their voices, rejects her food with repugnance, declaring it to be 
 poisoned. 
 
 Maniacal excitement usually characterises these outbursts ; out of 
 68 puerperal cases as many as 45 or 66 per cent, suffered from mania, 
 whilst states of depression prevailed in 23 patients or 33-8 per cent. 
 If we associate with these the cases which, originally puerperal, had 
 been allowed to suckle their infants for some time after symptoms of 
 mental alienation had been observed, we get from a total of 111 as 
 many as 74 or 66 per cent, as subjects of mania, and nearly the same 
 proportion, 30 per cent., as subjects of melancholia. 
 
 The mental afiection, then, at this stage is essentially an acute 
 maniacal state, in which there is intense excitement, great incoherence, 
 continuous garrulity, and a dangerous explosiveness, which may issue in 
 most desperate impulsive conduct; there is, moreover, a special pi-o- 
 clivity to indulgence in obscene language, indecent exposures of the 
 person, and genuine nymphomaniacal states ; or the deep-rooted erotic 
 
366 INSANITY AT THE PUERPERAL PERIOU. 
 
 feelings may, partially controlled, reveal themselves in the sudden 
 gestures, or sensiial glances, or prurient demeanour in a less obtrusive 
 manner. 
 
 There is, despite the adverse view of high authorities upon this 
 point [Gooch, Marce, Fuville), abundant evidence in support of the view 
 that this sexual element stamps the insanity of parturition and the 
 early i)nerperal period with features whicli demand special attention ; 
 but whether such features should exalt the mental affection into a dis- 
 tinct nosological entity is very doubtful, and, in our opinion, unjusti- 
 fiable from considerations already appealed to.* 
 
 Hallucinations. — Visual and aural hallucinations, or both com- 
 bined, occur to the almost complete exclusion of other forms of sensory 
 disturbance ; in fact, 17 per cent, of our puerperal cases exhibit such 
 anomalies — the average for the total admissions in all forms of insanity 
 being 29 per cent. This is not so high an estimate as that of Dr. 
 Clouston, who also assumes the aural to be the more frequent; in our 
 experience they occur in about equal frequency.! 
 
 Delusions. — Quite 63-2 per cent, showed obvious delusions of very 
 varied chai-acter, but chiefly tending towards ideas of persecution, the 
 patient believing herself the victim of intrigues at the hands of her 
 nearest relatives — her husband, children, her former friends and neigh- 
 bours ; her life, or that of her children, is threatened, or some terrible 
 tragedy is being enacted ; in two cases, the house was believed to be 
 haunted. Ideas of poisoning are prominent featui'es, the food being 
 frequently rejected upon this plea. Another not infrequent delusion 
 was that of a sexual nature ; the husband's fidelity was called in 
 question, or there were ideas that men entered her bedroom at night 
 for illicit purposes ; one patient believed herself to have been confined 
 of twins who were falling into a canal. In five cases the subject 
 believed herself eternally lost, forsaken by God, and given up to the 
 machinations of the evil one. This delusion that the soul is lost was 
 as fi-equent as in forms of insanity of a more melancholic type, occurring 
 later on during lactation ; in fact, religioiis delusions were frequent. 
 Hypochondriacal delusions were not observed in a single case. 
 
 To take a brief summary of some of the more important hallu- 
 cinations betrayed by puerperal cases : — 
 
 Faces besmeared with blood peep through tlie windows ; spirits hover around ; 
 angels and devils surround the bed ; the patient's deceased mother confronts her, 
 and mysterious lights flit about the room ; voices are heard ; the form of the evil one 
 appears ; or they shout aloud to imaginary voices ; sounds are heard, interpreted 
 as conspirators beneath the building ; or a voice within prompts her to suicide. 
 
 * See also on this point Dr. Sankey's Lectures on Insanity, pp. 128, 195. 
 t Vide Lectures on Mental Disease, p. 507. 
 
DELUSIONS OF SUSPICION — SUICIDE — ETIOLOOY. 367 
 
 From tlicsc considerations it will be obvious that the general tone 
 of feeling is that of distPUSt and suspicion, implicating her conjugal 
 relationsliips, her friends, and former associates, or as affecting her moral 
 well-being ; or utter failure of self-confidence and delusions, sometimes 
 of a most harrowing description, based thereupon. 
 
 Suicide. — We have alluded to the explosiveneSS of the disease, 
 and the tendency to impulsive acts is a most notable feature in 
 insanity at this period. Attempts to murder the offspring have been 
 frequently recorded, and no woman suffering from this form of insanity 
 should be brought into close i-elationship with her children. About 
 25 per cent, presented active suicidal propensities ; but nearly double 
 this proportion, or 47 per cent., were impulsively dangerous to those 
 around them. The suicidal impulse was often prompted by delusion ; 
 thus, one patient believed her husband wished to cut her throat, and, 
 consequently, sprung from her bedroom window. Another leapt from 
 her window under the impression that her husband had just murdered 
 his two children, and under similar impi-essions. One case tries to 
 end her days by a desperate attempt at strangulation, and another by 
 cutting her throat. 
 
 The various forms of mental disturbance found at this period may 
 be thus classified in the order of their frequency of occurrence : — 
 
 Acute mania, .... 
 
 31 cases 
 
 Melancholia, with delusions, . 
 
 13 „ 
 
 Mania, with delusions, . 
 
 7 ,, 
 
 Simple mania, 
 
 7 ,, 
 
 Simple melancholia, 
 
 8 „ 
 
 Acute melancholia. 
 
 1 ,, 
 
 Melancholy with stupor, 
 
 1 „ 
 
 68 ,, 
 
 EtiolOg'y. — It would be indeed strange if, at a peiiod embracing 
 such revolutionary changes as are comprised in the onset of labour 
 and the first half of uterine involution,* the mental stability was 
 not endangered beyond the average usual at the same period of life 
 in the non-parturient. So numerous are the novel relationships into 
 which the nervous system then enters, and so powerful are the new 
 agencies brought to bear as excitants to morbid reaction, that subjects 
 hei'editarily predisposed to insanity, must necessarily incur imminent 
 risks at this crisis of their histoiy. As Burrows says : — " Gestation 
 itself is a source of excitation in most women, and sometimes provokes 
 
 * The term "puerperal mania" is arbitrarily assigned to the mental derange- 
 ment occurring during the first six weeks of the jnierperal state ; involution of the 
 uterus being usually not complete for three months. 
 
368 INSANITY AT THE PUKUPKKAL PEUIOIx 
 
 mental derangement, and more especially in those with a hereditary 
 predisposition.""* 
 
 Let us consider what are the peculiar circumstances which favour 
 such issues. First, there is the mental transformation incident to 
 this latter period of gestation ; the arousal of maternal instincts, 
 especially for the first time, is frequently associated with unstable 
 states of nerve-centres, issuing in introspective states, exalted self- 
 feeling, voluminous emotional waves, vague fears of impending 
 troubles, and often hysteric outbursts. Such conditions must be 
 attributed to the eccentric irritation of the gravid uterus, as well as 
 to the deteriorated state to which the maternal blood has succumbed ; 
 and, unless the depurative processes become more active, nutritional 
 anomalies are liable to arise, producing undue nervous instability 
 during gestation and subsequent to parturition. If the functions 
 of secretion and excretion be checked, as by loaded bowels, or the 
 accumulation of morbid products in the blood, a source of irritation 
 to the nervous system at once appears ; and, if albuminuria coexist, 
 the urcemic state of the blood may tend towards actual convulsion.! 
 Then come the physical and moral shock of labour, the emotional 
 tension, and recoil of this crisis ; and, lastly, the immediate and 
 more remote consequences (local and general) of parturition. 
 
 The physical and moral shock is ever a varying quantity ; but, 
 in all cases, nervous exhaustion is always attendant on such an 
 enormous outlay as is demanded during parturition, especially in 
 those constitutionally enfeebled, reduced by the ailments of the later 
 stages of gestation, by insomnia, or by a tedious protracted labour, 
 or attendant haemorrhage. The moral shock is regarded as an all- 
 powerful excitant to mental ailments of this period, as illustrated in 
 cases of illegitimacy ; and authorities have constantly drawn attention 
 to the prevalence of puerperal insanity amongst those who have 
 borne illegitimate offspring. "Esquirol speaks of a sort of frenzy 
 incident to unfortunate girls in giving birth, in misery and secrecy, 
 to bastard children ; a condition of mind, which it is to be feared, 
 often prompts either infanticide or suicide." | 
 
 Again, subsequent to labour, we have the whole uterine surface 
 exposing the system to the perils of haemorrhage by imperfect 
 contraction, to retention of excretory products, to the absorption of 
 septic agencies, metritis, phlebitis, and its attendant evils. Later, 
 still, come the evils due to imperfect depui'ative processes, requisite 
 
 ■* Commentaries, p. 3G3. 
 
 t The urajmic element in the causation of puerperal eclampsia lias been called 
 in question ; see, however, the very apposite i-emarks by Dr. Gowers in his 
 Biicases of the Nervotis System, vol. ii., p. 71C. i Burrows' Commentaries, p. 3C4. 
 
PUERPERAL INSANITY AND ILLEGITIMACY'. 3G9 
 
 fov the removal of adventitious products during the slow involution 
 of the uterine muscle ; the fatty disintegration of the giant-fibre, and 
 its replacement by the nucleated fibre-cell, which prevailed in the 
 nulliparous state. The products of such disintegi-ation found copiously 
 in the lochia, and probably as the fatty elements in the ui-ine, and 
 caseous elements of the early mammary secretion, will, if these 
 secretory and excretory functions be arrested, lead up to the evils 
 now alluded to. In fact, the whole puerperal period is one of 
 extPeme susceptibility.* The explosive condition of the nerve 
 centres is at its height during parturition, and it is then, especially, 
 that eccentric irritation of the cerebrum may lead to transient 
 psychical anomalies, or to the motor discharges of general eclampsia 
 convulsions ; and it seems but a question of individual susceptibility, 
 or intensity of the eccentric irritation, which determines the one or 
 the other, the psychical often preceding the convulsive phenomena. 
 Thus, at the acme of a supreme uterine effort, and especially during 
 the passage of the head, if large, in excitable primiparse, the intensity 
 of the pain is often accompanied by complete, though transient, 
 alienation, by grave reductions in consciousness, by rambling inco- 
 herent talk, by outrageous and impulsive actions — the new-born 
 infant may be sacrificed to the mother's frenzy, f 
 
 Illeg'itimacy. — I have already drawn attention to Esquirol's state- 
 ment of the prevalence of insanity amongst those who have been 
 illegitimate children; it has also been shown by Dr. Clouston that this 
 cause is a potent factor in Scotland — where illegitimacy abounds. He 
 estimates that 25 per cent, of his cases occurred where the offspring 
 were illegitimate. When we take our English asylums into considera- 
 tion, the results are far different; illegitimacy is far less rife; and it 
 appears that out of a total of sixty-six cases sixty-one were married, 
 and the children l^orn in legitimate wedlock, whilst in seven only 
 were the patients unmarried women. Now the proportion of single to 
 married patients in the total admissions of 1,810 cases was 35 per cent, 
 to 50 per cent, respectively ; hence the proportion of 10 per cent, of 
 single women who sufiered from puerperal insanity is exceptionally low. 
 Frequent in Primiparae. — Frequent child-bearing has apparently 
 no connection with the development of insanity; of the sixty-eight 
 puerperal cases, twenty-two were first confinements, or a percentage of 
 32'3; 20*5 per cent, had had two children ; 10 per cent, and 14 per cent, 
 respectively had had three and four children; and of those who had fami- 
 lies ranging between five and nine, 22 per cent, were also represented. 
 
 * Burrows, op. cit., p. 3GG. 
 
 t There is, likewise, a temjiorary delirium sometimes accompanying difficult 
 labours, in the fever on the secretion of milk, or the inflammation of the breasts. 
 Burrows, lb., p. 364. 
 
 2i 
 
370 
 
 INSANITY AT THE PUERPERAL PERIOD. 
 
 Second attacks occurred in eight cases, of whom two were primiparae 
 and the remaining six had families ranging from two to nine. No case 
 liad suffered from a third seizure. 
 
 The Blood in Puerperal Insanity.— Tested by the ha?moglobino- 
 
 motcr the amount of lufinoglobiu was found below the normal, as 
 indicated by the series of observations recorded in the following 
 table : — In the case of R. W. J. it amounted to but 55 per cent., and 
 in C. C. to 60 per cent, of the standard of healthy blood ; in two other 
 cases it varied between 74 per cent, and 78 per cent. The first case or 
 the tabulated series {M. A. M.) in which profound ansemia had resulted 
 from post-j-)artum, haemorrhage, gave upon one occasion as low a per- 
 centage as 20, rising subsequently to 32 per cent. 
 
 The corpuscular richness (numerical) in the uncomplicated cases came 
 near that of normal blood,* being 80-6 to 124 per hsemic unit — 
 i.e., from 4,030,000 up to 6,200,000 corpuscles per cubic millimetre ; 
 but, the corpuscular value estimated in hsemoglobin was invariably 
 low — the lowest register being 44 in the case of R. W. J., the other 
 three subjects giving -75, -76, and "79 respectively of the normal value. 
 In the case of J/. A. J/., however, the numerical corpuscular richness, 
 commencing at 2,680,000, fell to 2,040,000, and eventually rose to 3i 
 million corpuscles per millimetre cube ; the corpuscular value at one 
 time but -35 rose to -68 and subsequently fell to -60 and even '45 — 
 the latter coincident with a wild maniacal outburst. 
 
 Amouxt of H^moglobix IX THE Blood in 
 
 THE SUB-TECTS OF PuERPERAL LvSANITY. 
 
 
 d 
 
 o c 
 |l 
 
 0-" O 
 
 o o 
 
 IS 5 
 
 c o 
 
 2 s 
 B c< 
 
 ^0 
 
 Bemases. 
 
 M. A. M., (Oct. 1, '87), 
 
 (Oct. 4, '87), 
 (Oct. 8, '87), 
 (Nov. 6, '87), 
 
 M. A. P., (Nov. 15, '87), 
 
 H. S. L., . (Nov. 2, '87), 
 C. C, . . (Dec. 2, '87), 
 R. W. J., (Aug. 10, '89), 
 
 20 
 
 28 
 24 
 32 
 
 74 
 
 78 
 60 
 55 
 
 53-6 
 
 41-4 
 40-8 
 71-6 
 
 93-6 
 
 102-8 
 80-6 
 124 
 
 •25 
 
 •06 
 •12 
 •16 
 
 •28 
 
 •22 
 
 •24 
 •IS 
 
 •35 
 
 •68 
 •60 
 •45 
 
 •79 
 
 •70 
 •75 
 •44 
 
 Extreme waxy pallor: blood rert/pa'e, watery, 
 and instantly separates into serum on 
 withdrawal; "contains many minute cells 
 like nuclei and ill-formed corpuscles. 
 
 Minute fat jrlobules in the blood and many 
 ill-formed corpuscles. 
 
 Still many minute nuclear bodies; blood pale 
 but has more consistence. 
 
 Red discs all contain minute glistening 
 nuclear bodies; some tend to form dumb- 
 bell shapes and readily split up. iVild 
 excitement for some davf past. 
 
 Profound melancholia; waxy pallor of face; 
 compulsory feeding requisite. Many 
 minute corpuscles in the blood, some of 
 dumb-bell form; larger corpuscles mea- 
 sure C to S^i; smaller measure Su. 
 
 Considerable torpor of movement; much 
 stupor but no cataleptic phenomena; 
 pupils dilateii ; betrays but slight antcmia. 
 
 Medium size corpuscles (5/^): a few small 
 nuclei ('2 /j.) ; white corpuscles measure 
 S^i.. 
 
 * Assuming normal blood to be correctly computed at 5,000,000 per cubic millimetre. 
 
PROGNOSIS — PROTRACTED RECOVERIES. 371 
 
 Prog'nosis. — Of the seventy cases, fully fifty-six completely re- 
 covered at the asylum, whilst four others were discharged "relieved" 
 — hence the recovery-rate reached the favourable pei'centage of 80. 
 The mortality was 8*5 per cent, of the whole sixty-eight cases — i.e., six 
 died. On the other hand, four patients (5-7 per cent.) still remain in 
 the asylum as chronic incurable cases of several years' standing. On- 
 consulting the recovery-chart it is observed that, up to the second 
 month, but nine cases recover ; thence, up to the sixth month, the 
 recovei-ies rise gradually to an aggregate of thirty-seven; during the 
 following two months, but five cases recover; at the ninth month there 
 is a sudden rise in the recoveries, from which period, up to two years- 
 and a-half, a few casual recoveries are still noted. The recovery-rate 
 does not, therefore, contrast so favoui-ably as appears in Dr. Clouston's 
 statistics, in which it is stated that in three months over half had 
 recovered, and in nine months 90 per cent, were well. Our own results 
 show that rather more than one-half of the recoveries occurred by the 
 fifth month, and an advance of the number of recoveries to forty-four 
 by the end of the sixth month; whilst, as in Dr. Clouston's cases, 87-5 
 per cent, had recovered by the ninth month from the commencement 
 of their insanity. 
 
 The incalculable advantage of early treatment is very obvious in the 
 recovery-list; since of four-and-twenty who were placed in the asylum 
 within one week of the onset of their insanity, as many as thirteen 
 were recovered within three months, and the remaining eleven left 
 recovered within five months, and this despite the fact that several of 
 these patients had inherited strong neurotic tendencies; thus, the 
 family records of these twenty-four (early) recoveries testify to the- 
 following facts : — 
 
 Mother paralysed, ..... 
 
 Brother insane, . . . . . 
 
 Mother insane, . . . . "j 
 
 Sister insane ; father a heavy drinker, / 
 Sister insane, ...... 
 
 Grandfather insane and committed suicide, . 
 Father insane, ...... 
 
 Father and mother insane (second attack), 
 Aunt and two cousins insane (second attack), 
 Aunt insane, ....... 
 
 Even direct inheritance does not, therefore, seem so sti'ongly to aflect 
 the recovery-rate in such cases when placed at an early date undei- 
 suitable treatment. 
 
 Let us now turn from the favourable cases to those in which 
 recovery was protracted to six months and later. It becomes a 
 significant fact that these are cases where asylum treatment has beea 
 
 Recovery 
 
 ill 2^ 
 
 months 
 
 
 
 5 
 
 
 
 
 5i 
 
 
 
 
 2 
 1 
 
 
 
 
 4| 
 
 
 
 
 OJ. 
 
 4 
 
 
372 
 
 INSANITY AT THE PUKUPKHAL PERIOD. 
 
 deferred, and the patient kept under their friends' supervision for a 
 period ranging from two weeks to several months. 
 
 Case. 
 
 Onset prior to 
 Asylum '1 reatincnt. 
 
 1 
 
 4 wenks . 
 
 
 2 „ (brotlie 
 
 4 
 
 3 M 
 
 5 
 
 4 ,, . 
 
 G 
 
 3 „ . . 
 
 / 
 
 9 
 
 S 
 
 6 months 
 
 9 
 
 7 !) 
 
 10 
 
 •7 
 
 11 
 
 3 „ 
 
 12 
 
 3 „ 
 
 13 
 
 2 
 
 14 
 
 3 weeks . 
 
 15 
 
 2 ,, . . 
 
 16 
 
 3 months 
 
 17 
 
 2 ,, 
 
 IS 
 
 ? 
 
 19 
 
 7 weeks . 
 
 20 
 
 7 ,, . . 
 
 21 
 
 9 ,, (paterL 
 
 22 
 
 . 2 „ ( „ 
 
 23 
 
 4 months 
 
 24 
 
 ■ 1 „ 
 
 25 
 
 . 25 ,, 
 
 
 Recovered. 
 
 Age. 
 
 7 months 
 
 26 
 
 
 7 1, 
 
 36 
 
 
 ' 1) 
 
 22 
 
 
 7i „ 
 
 25 
 
 
 9 
 
 24 
 
 
 9 
 
 24 
 
 
 
 25 
 
 
 94 „ 
 
 48 
 
 
 9 
 
 38 
 
 
 9 
 
 21 
 
 
 10 „ 
 
 24 
 
 
 11 „ 
 
 27 
 
 
 Hi „ 
 
 25 
 
 
 !•- 
 
 29 
 
 
 i3i „ 
 
 22 
 
 
 1-1 „ 
 
 27 
 
 
 2 J'ears 
 
 27 
 
 
 -a )) 
 
 24 
 
 
 Gj months 
 
 25 
 
 
 . H „ 
 
 22 
 
 ty) 
 
 H „ 
 
 26 
 
 ) 
 
 6i „ 
 
 28 
 
 
 G 
 
 28 
 
 
 6 
 
 24 
 
 
 Oi „ 
 
 25 
 
 Equally instructive is it to note, that the failures amongst those who 
 were but partially relieved and so discharged, or who remained, as 
 chronic insane, or who succumbed to a fatal malady were, with very 
 few exceptions, either late admissions or over thirty years of age. A 
 glance at the following three tables illustrates this point in a very 
 forcible manner : — 
 
 MOKTAUTV. 
 
 Date and Cause of Death, 
 in 11 montlis; of tubercle, 
 in 6| years ; of phthisis, 
 in 14 years ; of general paralysis, 
 in 1 month ; of pneumonia, 
 in 3 months ; of phthisis, 
 in 2 years 7 months; of general paralysis, 
 in 1 month; of pelvic cellulitis, 
 in 2 weeks; of chronic brain atrophy, 
 in 1 week ; of pulmonary congestion, 
 in 4 months; of acute cercbritis 
 (father and mother insane). 
 10 days, . . 22 . in 4 years ; of phthisis. 
 
 Duration of Attack 
 on Admission. 
 
 Age of 
 Patient. 
 
 3 months, 
 
 27 
 
 3 „ 
 
 38 
 
 Several months. 
 
 42 
 
 7 months, 
 
 40 
 
 1 
 
 21 
 
 11 „ 
 
 28 
 
 1 week, 
 
 30 
 
 1 ,. 
 
 36 
 
 1 » 
 
 40 
 
 1 „ 
 
 35 
 

 PROGNOSTIC INDICATIONS — TREATMENT. 3/3 
 
 
 Discharged "Relieved." 
 
 urntion of Attac 
 
 Ic Age of 
 
 
 on Admission. 
 
 Patient. 
 
 Date of Discharge. 
 
 2 weeks, 
 
 30 
 
 2 years. 
 
 3 months, 
 
 29 
 
 6 months. 
 
 5 weeks. 
 
 39 
 
 2 years and 4 months. 
 
 7 months, . 
 
 38 
 
 2 months (father and brother insane). 
 
 Sevei-al months, . 32 
 
 84 months. 
 
 
 Remaining 
 
 'Chronic Insane." 
 
 8 weeks, 
 
 34 
 
 7 years ; still an inmate. 
 
 6 „ 
 
 26 
 
 7 ,, ,, strong heredity 
 
 8 months, 
 
 39 
 
 1 year and 8 mouths. 
 
 1 week, 
 
 30 
 
 4 years. 
 
 1 „ 
 
 28 
 
 5 „ 
 
 In conclusion, tlien. it may be stated that the insanity occurring at 
 the puerperal period is one of most acuts character, yet most faVOUP- 
 ablG as regards the ultimate issue of treatment. 
 
 The prognosis will be influenced more especially by — 
 
 (a.) Duration of the symptoms when the patient is brought under 
 treatment, and 
 
 (b.) Largely by the age of the patient. 
 
 If the patient be under thirty, and judicious treatment be employed 
 within a week of the onset, the prognosis is favourable; every day's 
 delay after this adds to the ultimate risk. 
 
 If the patient be over thirty years of age, and, more especially, if 
 the treatment has been delayed for two weeks or longer, then the 
 recovery if ensured will pi-obably be prolonged, yet the risks of i^artial 
 recovery only will be strengthened. 
 
 Treatment. — Our first enquiries should be directed towards the 
 genito-urinary system, with the object of discovering any local uterine 
 mischief, whether tenderness upon palpation, a rising temperature, a 
 history of arrested or foetid lochia, indicate lurking troubles consequent 
 upon labour.- The most careful examination should be made with the 
 object of ascertaining any source of peripheral excitation which may be 
 removable or palliated. A slight pyrexial movement will generally be 
 found in the acute maniacal attacks following immediately upon partu- 
 rition. It is always advisable to begin our treatment with a saline 
 aperient, and secure a free evacuation of the bowel; the condition of 
 the breasts may also merit attention. A bland but nutritive and fluid 
 or semi-fluid food (including milk, beef-tea, broths, and eggs) should then 
 be given at very regular intervals — forcible feeding being resorted to 
 should the exigencies of the case demand it, and, in fact, this is usually 
 the rule. The condition of the blood would appear to indicate tjie 
 
374 INSANITY AT THE GESTATION PERIOD. 
 
 administration of iron; but, in all these cases of acute excitement, it is 
 well not to give chalybeate preparations until a much later date in the 
 history of the case ; at all events, not until the patient takes food spon- 
 taneously and sleeps fairly well, without having recourse to sedatives. 
 
 The form of sedative and soporific is of importance ; bromide salts 
 are of less avail singly than in combination with chloral. The latter 
 is the better drug to rely on in obstinate insomnia. Paraldehyd has 
 been given with considerable success, and is certainly more ethcacious 
 than sulphonal ; Itut, of the three, we give the preference to chloral. 
 Later on, with abatement of maniacal symptoms, it will be well to 
 administer phosphatic foods, the syrup of the phosphates, or a mixture 
 of the ammonio-citrate of iron along with malt extract. 
 
 In later stages, the question of uterine involution is one of much 
 moment — undoubtedly a defective involution has much to do with the 
 persistent excitement of these cases. Here Easton's syrup, the liquor 
 strychnife, or tincture of nux vomica, may be of avail ; or the chloride 
 of ammonium may be given with advantage. 
 
 Early association with the insane should be avoided, as likely to 
 increase the irritative process going on. The subject should be kept 
 at first confined to her bed, attended by a nurse, and only when the 
 maniacal excitement is somewhat abated should she be taken into the 
 ■open air for short walks, or allowed to associate with others similarly 
 deranged. Warm baths may be utilised with advantage dviring the 
 progress of the case, and by their aid it is possible to ensure sleep in 
 many cases without resorting to the employment of sedatives. 
 
 Insanity of Ppeg"nancy. — Insanity during the period of gestation 
 is i^emarkable for the infrequency of its occurrence ; upon this point 
 all authorities are agreed. Our statistics in lai-ge pauper-asylums 
 ■certainly corroborate this statement, and, when we deduct the cases 
 admitted subsequent to confinement, but whose mental ailment de- 
 finitely dates from a period prior to pai'tui'ition and only estimate 
 those who were enceinte on admission, we reduce the numbers 
 so far that they are of little or no value for statistical purposes. 
 Eleven cases of insanity occurring dux'ing gestation were admitted 
 amongst a total of 1,814 female admissions, or the very low proportion 
 of 0"6 per cent. ; hence our experience with respect to insanity at this 
 physiological cycle is indeed greatly restricted. So great is the repug- 
 nance to the admission of such cases, and very naturally so, that 
 undoubtedly many subjects escape asylum supervision, and are nursed 
 through transient attacks of alienation under the guardianship of 
 their friends at home ; and, on the other hand, so frequent are the 
 trifling mental ailments of the earlier mouths of ])regnancy — the 
 juorbid cravings, the emotional and moral perversions — that they are 
 
SYMPTOMS — COURSE AND TERMINATION. 375 
 
 regardetl with little concern ; whilst a more serious mental ailment 
 may be excused as but an exaggerated expression of the same states. 
 Our very limited experience at the West E,iding Asylum would indi- 
 cate that insanity at this period is by no means more prevalent amongst 
 jrrimiparce, for nine of the eleven cases had previously borne children, 
 and in none of these cases had the patient suffered from a previous 
 attack of insanity. Cases have been recorded where every confinement 
 has been preceded by mental disturbance amounting to genuine in- 
 sanity ; but it is much moi'e usual to find such frequent recurrence 
 as the sequel to successive parturitions, than in the pregnant periods 
 of a woman's life. 
 
 There is usually a period of mild depression for some time observed 
 ere the more acute outbreak of symptoms ; nervous timidity is a 
 frequent accompaniment ; the patient loses confidence in herself, and 
 di'eads that some imaginary evil is about to befall her; she becomes 
 suspicious, and often exhibits want of confidence in her husband and 
 i-elatives. All the cases which required removal to the asylum were 
 fully-developed forms of the disease, and, without exception, were 
 instances of acute maniacal excitement ; they were not associated with 
 expansive emotional states, but the reverse. Distrust, timidity were 
 apparent in all ; and, at times, terror induced by acute hallucinations 
 culminated in frequent frenzied excitement and the wildest conduct. 
 Periods of sullen reserve would alternate with sudden outbursts of 
 mania ; and the subject was usually watchful, intensely suspicious, and 
 suddenly aggressive. There was in most of the cases a special danger 
 of suicidal acts, attempted usually under the influence of some terrible 
 delusion ; as in the case of one patient who believed herself seized by 
 Satan, and who made frantic efibrts to leap through a window. The 
 excitement is accompanied by great incoherence ; but their ramblings 
 usually betray the dominant feelings in frequent reference to blood- 
 shed, murder, treachery, or the like. The most persistent insomnia 
 often prevails, and destructive tendencies are at first obvious. Later 
 on the patient may have alternations of depression and mild excite- 
 ment ; in which she is flighty, meddlesome, treacherous, and prone to 
 vicious conduct. 
 
 The larger proportion of cases occurred heyond the third month of 
 gestation, and two cases alone left the asylum recovered before their 
 confinement. The proportion of " recoveries " amounted to 54*5 per 
 cent., whilst two others left, after a prolonged residence, sufiiciently 
 relieved for home treatment ; two, however, died — one from puerperal 
 fever, and the other of chronic plithisis. 
 
 With respect to the origin of the mental derangement we can pre- 
 dicate but little from the scanty figures at our disposal and the history 
 
376 INSANITY AT THE PKRIOD OF LACTATION. 
 
 of tLe few instances afforded us. It was ascertained, however, that 
 strong hereditary jn'edisposition prevailed in 3G per cent. ; that two other 
 cases subsequently died of general paralysis ; and that three others, 
 although afibrding no history of ancestral insanity, were considered 
 to be of comjenitally-defective mental organisation. 
 
 INSANITY AT THE PERIOD OF LACTATION. 
 
 Contents. — Eisks Attendant ni>on Lactation — Period of Uterine Invohition — Period 
 of Mammai-y Excitation — Symjitoms — Depressing Uehisions — Impulsive Nature 
 (M. W.) — Suicide (M. D.) — Case of E. E. C. — Intensity of Maniacal Excitement 
 — Sexual Perversions — Hallucinations — Etiology — Exhaustion and the Se(iuela; 
 of Labour — Protracted Uterine Involution — Lactation during Profound Anaemia 
 — Hyperlactation — Qualilications of the Nursing Mother — Period for Weaning 
 — Prognosis — Treatment. 
 
 To a certain proportion of the puerperal, the whole period of lacta- 
 tion is one fraught with risks. The period is one of acknowledged 
 susceptibility, and when conjoined to this normal exaltation "we have 
 the predisposition engendered by ancestral insanity, the acquired 
 elements evolved out of vicious modes of life, and inattention to the 
 plainest physiological dicta, the moi'bid impetus towards insanity is 
 greatly strengthened. Undoubtedly, the factors peculiar to this period 
 of lactation, to which are attributable in part the mental reductions, 
 vary with the physiological changes incident to this period. Thus, 
 in the earlier period of lactation, the immediate effects of gestation 
 and parturition, or the changes normally aroused in the uterus on the 
 completion of labour, are of paramount importance in our estimate of 
 the origin of the mental ailment ; and so, throughout the period of 
 uterine involution, the reflex irritation from the ovario-uterine ap- 
 paratus is of primary importance. As, however, uterine involution 
 becomes complete, so the activity of the mammary secretion assumes 
 an increasing importance in its effects upon the economy ; in lieu of 
 reflex excitations from the uterine surface, or of the faults arising from 
 defective depuration, the nutrition of the nerve-centres becomes more 
 directly involved. 
 
 To attempt, however, to distinguish betwixt the insanity incident 
 to these periods as distinct nosological entities would be highly 
 inconsistent, and not justified by .a scientific estimate of the relative 
 value of symptomatic indications. The insanity of the partiirient and 
 early puerperal stage imperceptibly glides into that which characterises 
 the later stages of lactation ; and none but an arbitrary division can 
 be assigned (for convenience in study) as the termination of uterine 
 involution. Then, again, the completion of involution is an uncertain 
 
PREDOMINANCE OF MANIA -WITn DELUSIONS. 377 
 
 poriod, vai-ionsly assigned by diflcrcnt authorities. One month is 
 given as the term in healthy subjects, under good hygienic sur- 
 roundings ; six weeks is the accepted time in continental Lying-in 
 Hospitals {Barnes'*) ; whilst Tylor Smithf quotes tioo or even three 
 months as the probable period. We may, however, accept six weeks 
 after parturition as the period when the uterus and ovaries are passing 
 into the quiescent stage, during which lactation assumes its own 
 important rule. It is highly essential that we should clearly recognise 
 this overlapping of physiological stages, as thereby are explained 
 certain exceptional cases which occur about the transition-period here 
 alluded to. 
 
 Symptoms. — The prevailing condition at this period is, in fact, that 
 of an acute j)sychosis, in which excitement predominates, and in which 
 terrifying hallucinations (visual and aural, or combinations of these) 
 lead-up to various delusional notions, and in which suspicion of friends, 
 relatives, and neighbours is prominent; fears of supernatural agency 
 are not infrequent, strange phantasms haunt the eye, mysterious 
 whisperings, unexplained sounds, or more definite A^oices issue in the 
 moi'bid imagery of angels or ministers of darkness. The loss of self- 
 confidence begets the frequent notion that the "soul is lost," or that all 
 future good is sacrificed by some imagined crimes committed. The 
 moral being has its ultimate foundations shaken, and confidence is lost 
 even in those who should be nearest and dearest to the afilicted one; 
 the husband's fidelity is openly challenged; intrigues of acquaintances 
 dreaded; the food declared to be poisoned. 
 
 The 0nS6t may be sudden; it is far more frequently preceded by 
 mild depression. The patient becomes restless, irritable, variable in 
 mood, suspicious of her friends, impatient and fretful; she is apt to 
 misinterpret the conduct, gestures, and words of others. Then come 
 fitful outbursts of anger, extravagant accusations, or actual violence, 
 and the onset of genuine maniacal symptoms. Insomnia usually 
 prevails; noisy, boisterous, incoherent ramblings ensue, in which the 
 patient gives utterance to fragmentary sentences from which we glean 
 the condition of mind to be one of distrust, suspicion, or terror, or to 
 be dominated by aural hallucinations. 
 
 Tlie delusional notions vary from time to time, and periods of 
 exaltation alternate with mental })ain, rising even to the pitch of acute 
 melancholia. Such subjects usually come under our notice in asylums, 
 looking exceedingly pallid from anpemia, reduced, thin, and jaded from 
 continued sleeplessness and excitement. In this stage of excitement 
 they are often dangerously impulsive, and require most careful 
 
 * Diseases of Women, p. 469. + Manual of Ohdetrics, p. 92. 
 
378 INSANITY AT THE PERIOD OF LACTATION. 
 
 watching. Thus, one of oiu' patients, wlio had suckled her infant up 
 to the twelfth month, althou;rh much enfeebled in health, became 
 suddenly maniacal at home; she struck her husband on the head with 
 a poker, ran a darning-needle into his side, and eventually got possession 
 of a knife at night and gashed his throat ere she could be secured. 
 
 M. W., aged thirty-nine, married, and the mother of three cliildren. Patient in- 
 herited insanity from the mother, who was an inmate of this asylum twenty years 
 ago after confinement. The patient was confined twelve months prior to admission, 
 and had brought the infant up at the breast until four months since, when depres- 
 sion first supervened : her health began to fail, restlessness, low spirits, suici<lal 
 feelings, and the delusions that her soul was lost, that the devil was in her house, 
 and that all lier friends had become her enemies, characterised this period. She 
 had suffered from continued insomnia. Patient had been of temperate habits. 
 
 She was communicative upon admission, and discoursed readily upon the subject 
 of her mental ailments. Ever since weaning the child she had been depressed, 
 filled with morbid fancies, frequently felt tempted to injure herself, had lost all 
 control, and (unless closely observed) would certainly have destroyed herself. Had 
 foimd her memory much impaired of late, and this had troubled her greatly ; she 
 had also taken a deep-rooted dislike to her home, because she fancied that a friend 
 ■who lived opposite was constantly watching her. Admitted that she btlieved her 
 soul to be lost, and felt given-up to despair. The catamenia had l)een regular and 
 normal for some months. Cod-liver oil emulsion ordered, and a mixture containing 
 iO mins. of liq. opii, and aromatic sulphuric acid three times daily. 
 
 From this date she made a steady progressive improvement, although restless at 
 nights, and suspicious of the patients with whom she was associated ; she was much 
 given to brooding and introspection, but recovered sufficientlj' to employ herself in 
 household occupations within two months of her admission to the asylum. Then 
 came a relapse with sudden suicidal impulse, and it is noted, Xovember '2nd — "This 
 morning, when employed in the chief female officer's bedroom, she was caught in 
 the act of suspending herself to the bed-post by the blind-cord.^' 
 
 She was again placed xmder opium treatment, which had been discontinued for a 
 time, and from this date onwards physical and mental improvement continued, and 
 she was discharged recovered, after a residence of eight and a-half months. 
 
 Another young girl in the sixth month of nursing was admitted in 
 a state of rambling incoherence, fiighty, erratic, and given to silly 
 laughter ; reduced in health, and anaemic, with a htemic bruit. She 
 violently assaulted her mother, and nearly succeeded in throttling 
 her father, whose identity she appears to have mistaken. 
 
 Others make equally determined attempts upon their own life, as 
 in the case of a poor weakly woman, who, struggling against the odds 
 of penury, had been suckling other infants besides her own for a 
 period of twelve months with bai'ely a subsistence diet. Upon 
 admission she made a most desperate attempt to drown herself in a 
 bath in which she was placed, fiercely struggling with the nurse in 
 her efforts to keep her head under water. 
 
SUICIDAL AND IMPULSIVE TENDENCIES. 379 
 
 M. D., aged thirty-two, married, and the mother of tliree cliildren, showed her 
 fii'st symptoms of mental alienation four weeks prior to admission. Four months 
 before this date she gave birth to twins, and had suckled both u[) to the present time. 
 The history testifies to great depression, with attacks of intense and prolonged 
 excitement, with incoherent raving, and violent aggressive conduct. She had 
 frequently threatened to take her own life, and had once tried to cut her throat. 
 The family liistory was defective, but an aunt is stated to have died in an asylum. 
 On admission (Oct. 18th) she was low, despondent, aud emotional; querulous 
 and discontented. She conversed readily upon the subject of her depression, and 
 narrated how she had felt low and depressed, even back to the early months of 
 pregnancy, when she used to visit a neighbour's farm, where there was a great 
 black dog ; when she became more despondent she developed the delusion that 
 her child would be like a dog. She was at this time very thin and delicate ; the 
 complexion anaemic and blanched, the eyes sunken with dark pigmented areolae 
 around. The breasts were swollen, distended with secretion, and tender. Oleum 
 ricini was at once administered, and belladonna liniment applied to the breasts. 
 The patient was ordered full extra diet and chloral, if necessary, at night. 
 
 A week later, she was greatly depressed ; stated that she had suffered when at 
 home from impulses to kill he)' children, but denied this fact to the doctor. She 
 now regards this artifice as a great sin for which she cannot be forgiven. 
 
 Nov. 1st. — Is most determinedly suicidal, aud sleepless at night. Last night 
 she tore up her sheet and attempted strangulation, and this morning repeated the 
 attempt with her apron-string. Expresses her determination to die. Tinct. opii., 
 mins. XXX., ter die. 
 
 Hov. 27th. — To-day attempted to swallow a needle, which became impacted in 
 phaiynx, and was removed with some difficulty. 
 
 Nov. 29th. — It was discovered by the appearance of swelling and stiffness of 
 the neck, that she had also on the 27th inserted a darning-needle there ; she was 
 (questioned on the ^Doint, aud admitted the act. There was no mark in the skin, 
 Ijut by pressure on the opposite side of the neck a prominence could be felt over 
 the left sterno-mastoid muscle, just in front of the external jugular. It was cut 
 down upon, and a large darning-needle removed. 
 
 Bee. 14th. — After slight improvement has again become desperately suicidal; 
 tries to choke herself by anythmg she can lay hands upon, aud constantly seeks 
 to obtain needles by stealth. 
 
 Dec. 16th. — This morning a sharp projection like the head of a needle was felt 
 beneath the skin on the right side of the neck, about the middle of the sterno- 
 mastoid. An unsucoessful attempt at removal was made, owing to her desperate 
 struggling to prevent it. On the 26th inst., the prominence was again felt, and a 
 needle an inch aud a-half in length removed. She is still greatly depressed and 
 suicidal. 
 
 Then follows an account of peritonitis, during the course of which no foreign 
 body was detected by external palpation ; but the patient rapidly succumbed to 
 the attack, and died on the 14th of January. A post-mortem examination ex- 
 hibited a localised peritonitis, the coils of small intestine being matted together by 
 a considerable amount of lymph and ^Durulent material : the large bowel had 
 escaped implication. Slight ulcerative points, with patches of intense congestion, 
 were revealed along the jejunum and duodenum, behmd which was a purulent 
 collection in whicli a needle 1 h incli long lay embedded. Three other needles were 
 found in the substance of the mesentery, and one in the tissues of the neck ; none 
 ■were present in the stomach or intestine. In the stomach Avas a piece of charred 
 wood, 3^ inches in length by about 1 in thickness. 
 
380 INSANITY AT THE PERIOD OP LACTATION. 
 
 A similarly enfeebled, exsanguine, nursing mother, reduced by seven 
 former pregnancies and nursings during tlio period often yeai's — the first 
 accompanied by puerperal convulsions, and each subsequent jjuerperum 
 followed by severe headache and symptoms of exhaustion — still persists 
 in nursing, despite four months' warning of steady progressive en- 
 feeblement. In a state of acute melancholia so induced, she rushed 
 off one morning with the intention of throwincr herself into the river 
 Nidd, but was arrested in the act by the "sudden remembrance of her 
 child at home ; " she returned home, and next day swallowed a large 
 quantity of laudanum.* 
 
 E. E. C, aged thirty-eight, the mother of seven children, the youngest an infant 
 at the breast until a few days previous to her admission, when it was weaned. She 
 became morbidly depressed about a month before ; despite which fact she continued 
 to nurse the child. Had been married ten years, and throughout this period her 
 health had been very delicate. Seven years since, whilst pregnant, she is stated 
 to have had several convulsive seizures, which had not recurred since; but at each 
 subsequent period of gestation she suffered from prolonged and severe headaches. 
 Her health had been steadily deteriorating during the last three or four months of 
 lactation. She inherited a strong neurotic temperament, and had always l^een 
 excitable; her maternal grandmother was unstable and melancholic, and patient's 
 brother was insane. The morbid depression occurred a month since, with a 
 general indifference or dislike to her family and home; she expressed decided 
 aversion to her husbaud, and accused him of wishing to rid himself of her. A 
 week later she tried to drown herself, but was prevented b}' the thought of her 
 cliildren at home ; she then attempted to poison herself with laudanum, and the 
 symptoms became very acute; she declared that she felt herself to be a burden to 
 her family, and was determined not to live ; obstinately refused food, and struggled 
 violently against any interference, so that upon admission she was found severely 
 bruised. When received into the asylum she was in a state of acute melancholia, 
 greatly terrified and agitated, struggled violently, clutching at all who approached 
 her, and having a pained but vacant, staring aspect. She was very emaciated, 
 blanched, and antemic. Her breasts were flaccid. 
 
 The treatment adopted was a full nutritious diet of eggs, milk, beef-tea, with 
 port wine, given forcibly (if necessary) by funnel; chloral was given at night to 
 combat the incessant wakefulness, and the catheter had to be freely employed. 
 
 The agitation was extreme, her speech quite incoherent, her utterances broken 
 but mdicative of suspicion and distrust ; she was continuallj^ trying to get out of 
 bed and crawl under it to conceal herself. Hy the end of the week she slept well, 
 was less resistant and obstinate, but forced alimentation had still to be employed. 
 Eleven days after admission she was somewhat calmer, and told the medical olficer 
 he was a "London detective." Great torpor of the bowels continued after admis- 
 sion. For three weeks compulsory feeding had to be carried on, and for a con- 
 siderable time subsequent to this it required much tact on the part of her nurse to 
 induce her to take food. In two months there was some improvement, less agita- 
 
 * The suicidal propensity was witnessed in 31 'S per cent, of our cases; impulsive 
 violence to others in 59 per cent. The subjects of puerperal insanity gave the lower 
 estimate of 25 per cent, and 47 per cent, respectively. 
 
ACUTE MANIACAL DELIRIUM. 381 
 
 tion, but a dazeil, vacant, dcraeutod aspect; she still ■would not converse, and her 
 habits were utterly negligent. This condition was maintained for five months 
 succeeding her admission, but steady improvement in general health was pro- 
 ceeding; she was putting on flesh, was far less anaemic, and began to employ her- 
 self in the wards. In nine mouths she was discharged, recovered ; but her con- 
 valescence really dated a month earlier, she having had an attack of sub-acute 
 rheumatism, which prevented her earlier discharge. 
 
 The character of the maniacal state is especially one of intensity. 
 It is essentially an acute mania with or without hallucinations ; but, 
 yefc, it is distinguished from the still more intense excitement of the 
 early puerperal alienation, just as ordinary acute mania is distinguished 
 from the furor of epilepsy. The jiuerperal form is peculiarly prone to 
 wild, impulsive, indiscriminate conduct, as the outcome of very extreme 
 reductions ; it is peculiarly a convulsive affection, as in epileptic furor; 
 hut such ])rofound reductions do not present themselves in the mania 
 of early lactation. Occasionally, but very rarely, acute delirious 
 mania may occur, as in the following case : — 
 
 S. M., aged thirtj'-one, married twelve months ago, and delivered of her first child 
 three months before her admission. The labour had been natural, but her health, 
 previously reduced, had become progressively worse, and she had been wholly 
 incapable of attending to any household duties. Still she nursed her infant at the 
 breast, and persisted in doing so until four days ago, when sudden and intense 
 maniacal excitement supervened. No predisposition was discoverable, and the 
 family history was avowed to be free from insanity, epilepsy, or apoplexy. The 
 parents were both living and healthy. There was no moral element involved in 
 the causation. On admission she was found considerably reduced, pale, feeble, 
 tremulous ; the pupils widely dilated ; there was great anaemia ; the breasts were 
 considerably distended. She was in a state of the wildest excitement, absolutely 
 incoherent, and uttei'ly oblivious to the nature of her surroundings. No rational 
 or even coherent reply could be obtained from her, but she occasionally repeated 
 a word she had heard uttered just before. She was almost incessantly restless, 
 and could with difficulty be kept in bed. At home she had obtained no sleep, and 
 persistently refused food since her attack. Abimdant strong nourishment, with 
 extract of beef, was ordered, and half-drachm doses of chloral to be given at 
 bed-time. 
 
 Fortunately, she took her food readily, and the first draught procured her a 
 little sleep. For four days she continued in a state of acute delii'ious mania, quite 
 incoherent, and extremely prostrate, the tongue dry and coated, the lips covered 
 with sordes. She then became somewhat calmer, and in six daj's was able to sit 
 up in the day-room, being fairly quiet and manageable. She still took food 
 readily, the tongue became clean and moist, the lips free from sordes, and the 
 general health improved considerably. Chloral was now given only occasionally 
 at night; all critical sjTnptoms had entirely subsided. One month after admission 
 there is noted — "Mild excitement, with gentle, rambling incoherence, and aural 
 hallucinations. Chloral at night wholly suspended." There was mild maniacal 
 excitement for the following two months, characterised by no notable symjjtoras. 
 She was stated to be erratic, wilful, pert, and idle, but steadily improving in 
 bodily health. Amenorrhcea, however, existed, and she was consequent Ij' ordered 
 
382 INSANITY AT THE PERIOD OF LACTATION'. 
 
 the iron and aloes pill twice daily. It was not until six months had elapsed from 
 lier admission that the catamenia were re-established, after which the patient's 
 mental symptoms (which consisteil of very slight excitement, suspicion, and unrea- 
 sonable irritaliility) passed oil' entirelj', and in a few weeks she left recovered. 
 
 Tlie intensity of excitement is accompanied in these cases by great 
 incoherence and much motor agitation ; but, in many instances, the 
 patient is dominated by delusions, is reticent, evasive, suspicious, 
 yet watchful, and (as already alhrmed) dangerously impulsive. 
 
 The delusional conceptions are strikingly similar to those found 
 in the early puerperal weeks, when, as we have seen, the idea of 
 eternal punishment of the lost soul, of ruin and misfortune to self 
 and family, of persecution at the hands of husband or neighbours, are 
 the more prevalent perversions; the idea of poisoning is less frequently 
 expressed in the insanity of the puerperal months than at this period. 
 
 In. a small minority of these forms of alienation, exalted notions 
 are apparent. They are usually evolved out of religious conceptions, 
 the patient falls into ecstatic states, clasps her hands and is wrapt 
 in prayer, or, maybe, believes herself to be Christ. With such 
 religious delusions, however, far more frequently prevail obscure 
 notions of demoniacal agency ; the black-art or witchcraft is by no 
 means an unfrequent form of explanation given. Thus, one of our 
 patients believed herself bewitched, and called herself the " scarlet 
 ■woman of Revelation ; " another believed herself and husband were 
 bewitched by the sorceries of her neighbours, whom she constantly 
 saw peeping at her through the windows, and whose voices as 
 constantly intimidated her ; and yet another accuses her neighbours 
 of entering her room, "crossing her furniture, and so putting all 
 things wrong." 
 
 The sexual condition, if not apparent in a directly-expressed 
 delusion, is often manifest in the patient's behaviour, indelicacy, 
 obscene erotic language or gesture ; but sexual delusions and hal- 
 lucinations are by no means infrequent. The revulsion to husband 
 and children often promj^ts to violence ; one poor woman whose case 
 we recall, publicly disowned her child, and then attempted to smother 
 it. Of sixty-six cases recorded of " lactational insanity," forty-six — 
 i.e., 69 -G per cent. — had delusions. 
 
 Hallucinations of the special senses were expressed in twenty-two 
 (33-8 per cent.) of our cases; and, hence, were of more frequent 
 occurrence than in ordinary puerperal insanity. Visual and aural may 
 occur separately or conjointly; but the prevalence of the aural was 
 notably greater and more pronounced, even when both senses were 
 affected. They were always of a depressing and painful nature ; and 
 many of the delusional notions referred to were based thereupon. 
 
FORMS OF MENTAL DERAXGEMEXT ASSUMED. 
 
 383 
 
 Tlie vivid nature of such creations, the enfeeljled frame of the patient, 
 the complete loss of self-assiirance, and the resulting anguish induced, 
 produce a picture which strongly enlists our sympathies, and is painful 
 to witness. Thus one of our patients is surrounded by spiritual beings 
 — angels — fiends — who tell her that her soul is damned; another is 
 tortured by abusive epithets continually shouted to her down the 
 chimney ; another hears the baying of furious dogs, and sees her 
 children killed before her eyes. In their intrinsic nature, therefore^ 
 these hallucinations are similar to those of puerperal insanity. 
 
 Upon analysing the various forms of alienation fi-om which our sixty- 
 six cases suffered, we find them, as contrasted with the puerperal 
 cases, distributed as folloAvs: — 
 
 Forms of Mental Ailment, 
 Simple mania, ..... 
 Acute ,, 
 
 Acute delirious mania, 
 Mania with prominent delusions, 
 Eccurrent mania, . ... 
 Dementia with excitement, 
 Simple melancholia, .... 
 Acute ,, .... 
 
 Melancholia with prominent delusions, 
 Melancholy with stupor, . 
 General paralysis, .... 
 Congenital mental defect, 
 
 Lactational. Puerperal. 
 6 7 
 
 18 
 1 
 
 11 
 3 
 1 
 
 31 
 
 3 
 
 17 
 
 2 
 
 1 
 
 GO 
 
 1 
 
 14 
 
 1 
 
 69 
 
 It is clearly apparent, then, that at both periods excitement pre- 
 dominates over depression, and a larger proportion of acute maniacal 
 attacks characterise the puerperal period. On the other hand, acute 
 depression (melancholia agitans) is rarely met with, whilst melancholy 
 with delusions is frequent at both periods. 
 
 Excitement in the early Months. — The more acute forms of 
 
 excitement prevail within the first three months foUoicing parturition ; 
 and the delusions of persecution and associated gloom and despondency 
 of melancholia, predominate where mental symptoms first betrayed 
 themselves six months or more after labour. Thus, of twenty-seven 
 cases where alienation occurred within the first six months, there were 
 eight cases of melancholia to seventeen of mania ; whereas, in twenty- 
 seven cases, between six and twelve months subsequent to labour, there 
 were ten of depression to fourteen of excitement ; and, later still — 
 after twelve months — there were but eleven cases, viz., seven of depre-s- 
 sion and four of maniacal excitement. 
 
 Etiolog'y. — It is highly conducive to the correct appreciation of 
 these forms of mental disturbance that we keep in view the numerous 
 
384 INSANITY AT THE PERIOD OF LACTATION. 
 
 factors which may operate as exciting causes of the attack ; we are not 
 dealhiff in the majority of our cases with a simple agency, such as 
 hyperlactation ; we have to consider not only the peculiar mental 
 temperament and physique of the nursing mother, but also the series 
 ot" accidents which may have occurred before, at, or subsequent to 
 labour, and their often far-reaching results ; we have to bear in mind 
 the possible divergence from normal physiological reversions of the 
 ovario-uterine system, as well as the prolongation of suckling beyond 
 the limits which the mother's health will stand, the deprivation of 
 food which penury may entail, and the long list of moral agencies which 
 poverty and wretchedness so frequently call up. Amongst the more 
 important of this category of causes are : — 
 
 1. Severe protracted labour with instrumental delivery. 
 
 2. ^Qv'yows pod-partum hemorrhage, or the Hooding occurring before or during 
 
 labour. 
 
 3. Protracted or arrested uterine involution. 
 
 4. Lactation where profound anaemia already exists. 
 
 5. Lactation continued after the appearance of genuine mental alienation. 
 G. Hyperlactation. 
 
 Exhaustion and Sequelae of Labour.— As regards the first two 
 
 causes (which give rise more frequently to mental alienation at an 
 earlier period) — the so-called puerperal insanity — it is but what we 
 should expect that the attendant exhaustion or anaemia, if it does not 
 at once issue in mental derangement, will so result if the tax of lacta- 
 tion be severe ; and as illustrating this we append the following from 
 the prior history of a few cases of insanity during lactation occurring 
 over six weeks after labour : — 
 
 Case 1. Primi]iara, labour very protracted and severe. 
 
 ,, 2. Instrumental delivery, severe po'it-partum haemorrhage. 
 
 ,, 3. Protracted labour, profuse haemorrhage. 
 
 ,, 4. Instrumental delivery, profuse flooding, phlegmasia. 
 
 ,, 5. Very severe post-partuni haemorrhage. 
 
 , , G. Severe flooding during gestation, menorrhagia at all catamenial periods, 
 
 profound auremia. 
 ,, 7. Menorrhagia at all monthly periods; profound aniumia. 
 
 In the foregoing series, it will be observed, one case alone was that 
 of a primiparous subject ; and, in fact, insanity during lactation is 
 infrequent after first confinements. In the insanity occurring at, or 
 shortly following, labour {puerperal insanity), primipai'se play a far 
 more important part; 32-3 per cent, of such cases being first confine- 
 ments. The insanity occurring during lactation presents us with but 
 IG'G per cent, as primiparous subjects.* 
 
 * First labours, 16'G per cent. Third labours, 22"7 per cent. 
 
 Second ,, 13 6 ,, Fourth ,, 19 '6 ,, 
 
PROTRACTED INVOLUTION — EXHAUSTION. 
 
 385 
 
 Uterine Involution.- — Wo have strong reasons for suspecting that 
 defective utcriiie involution plays a most important role in the earlier 
 cases of lactational insanity ; and it is to this cause we may often 
 attribute the preponderance of excitement over depression in the 
 earlier months of lactation. The reflex nature of the neurosis closely 
 ai)proximates to that which we know to be largely dependent upon 
 the direct agency of a gravid or parturient uterus; and the results of 
 treatment, moreover, directed towards this condition, warrant us in 
 assuming protracted involution as being a large factor in these earlier 
 weeks of lactation. 
 
 Suckling" in a stag-e of cerebral exhaustion is, perhaps, of 
 
 all causes the source of the more severe and prolonged insanity at this 
 ])criod. It is by no means uncommon to find mothers suckling their 
 infiints several months after the appearance of indubitable indications 
 of profound cerebral derangement, loss of memory and attention, 
 morbid feelings and desires, hallucinations of sight and especially of 
 hearing, complete change of disposition — yet the infatuated patient 
 clings to the habit, and will say, as one of our poor patients did to her 
 medical attendant — " I cannot give up the child, but it will drive me 
 mad." We need only glance at the accompanying table, abstracted 
 from the history of sixty-five cases of insanity during lactation, to 
 have enforced on our minds the importance, as an etiological factor, of 
 such vicious persistence despite failing vigour, progressive anaemia, and 
 even well-marked mental disturbance. 
 
 Case. 
 ]. 
 
 9. 
 10. 
 
 11. 
 12. 
 13. 
 
 14. 
 15. 
 
 10. 
 
 Suckled infant nine months, and for two or three weeks indubitably insane. 
 , , infant seven months, and for several weeks had been failing in health 
 and ailing mentally. 
 
 several other infants, as well as her own, during the year. 
 
 infant nine months, whilst extremely delicate and in feeble health. 
 
 child for four years, and had always indulged in prolonged lactation. 
 
 infant four months, although for years depressed and garrulous. 
 
 infant fifteen months, last three months during alienation. 
 
 infant eleven months, yet peculiar and deranged throughout the 
 whole period of lactation, 
 
 infant nine months, yet for three months distinctly deranged in mind. 
 
 infant ten months; several urajmic convulsions three months after 
 confinement. 
 
 infant four months, yet has been insane for two years. 
 
 infant ten months; in very feeble health and deranged of late. 
 
 infant, whilst becoming for four months past steadily and progres- 
 sively enfeebled and blanched from ana^nia. 
 
 infant nine months and a-half, although for three months deranged, 
 
 infant nine months, j'et depressed for years. 
 
 twins four months, yet for one month deranged in mind. 
 
 '2o 
 
38G IXSANITT AT THE PERIOD OF LACTATION'. 
 
 Injudicious nursing, thei'cforc, pl.ays a very important part in the 
 causation of many of these cases of insanity ; but in all such cases 
 alike, it is to be noted that cerebral malnutrition from anremia, whether 
 induced by hyperlactatiou, by copious haimorrfiages, by the cachexy of 
 intercurrent fevers, by phthisis, or causes associated with semi-starva- 
 tion, arouses the self-same form of mental anomaly. 
 
 To supply the wants of the infant with a food sufficient in quantity 
 and of proper quality, the nutritive processes of the mother and tissue- 
 metabolism must maintain a well-regulated balance. The mammary 
 secretion requires not only saccharine and fatty, but nitrogenous 
 materials in certain due proportions, and this demand is made upon 
 the blood-current of the gland. The relative amount of circulating 
 albumen and carbo-hydrates in the blood is apt to be powerfully affected 
 by many agencies, apart from the actual amount introduced by the food. 
 Should the respiratory function be diminished or retarded, as by living 
 in badly-ventilated, overheated rooms, the carbo-hydrates must accumu- 
 late in the blood-current, and tend to be deposited more largely in the 
 tissue ; the same result must accrue in anaemic states where the oxygen- 
 carriers — the red corpuscles, lessened in numbers, fail to oxidise the 
 hydrocai-bons circulating in the blood. In the nursing-mother the 
 accumulation of hydrocarbon thus brought about must issue, more or 
 less, in a relatively-increased amount of fatty matters in the milk (as, 
 for instance, occurs in stall-fed animals). On the other hand, should 
 frequent exposure to cold stimulate the respiratory functions and 
 oxygenation proceed more vigorously, the hydrocarbons are diminished 
 and the protein-compounds undergo a relative increase, so that the 
 milk contains more casein, whilst the fats decrease. If much muscular 
 exertion be demanded the protein metabolism increases and appears 
 directly to affect the composition of the milk, increasing its casein.* 
 The same result occurs in anaemia ; it is found that the excretion of 
 urea is increased, and carbonic acid diminished; in other words, protein 
 metabolism is increased and fat metabolism lessened. It is, therefore, 
 obvious that a due proportion of nitrogenous and hydrocarbonaceous 
 constituents in the blood, regulated by a rational diet and by the nor- 
 mal metabolic changes occurring in the tissues, is an all-important 
 feature in healthy lactation ; yet the function itself may be pi'ofoundly 
 disturbed by a vicious system of suckling. Thus frequent application 
 of the infant to the breast not only stimulates the secretion of milk, 
 but also modifies its quality. The quantity is largely augmented, 
 and the milk becomes much richer in casein ; hence a serious drain 
 
 * Thus we are told that the cattle exposed to cold and much muscular exertion 
 in Switzerland yield a very small quantity of butter, but an vmusually large pro- 
 portion of cheese. — Carpenter's Physiology, p. 013. 
 
QUALIFICATIOXS OF THE NURSING MOTHER. 387 
 
 from the albuminous constituents of the blood is occasioned and anocmia 
 results. In the nursing-mothei' an accumulation of storage-fat appears 
 to occur, reminding one of the condition of hyl^ernating animals, in 
 which, during a prolonged winter's sleep, the entire absence of food 
 requires (despite the cessation of activity and the extremely lowered 
 rcspii'atoiy and heat processes) a large storage of fat to supply the slow, 
 though continuous, waste. So in the nurse, the waste occurring through 
 the mammaiy secretion appears to demand a fat-storage both for the 
 maintenance of such a secretion and the respiratory functions ; the early 
 months of lactation are consequently roarked by the plumpness of the 
 body generally — healthy nursing mothers almost invariably "put on 
 fat" at this time of life; and it is only late on in lactation, when the 
 system begins to appreciate a serious drain, that the rotundity of the 
 figure lessens {Trousseau). It is a condition of serious moment when 
 we find the nurse not so px'epared for her arduous functions, and it is a 
 notable fact that, in a very large proportion of cases of insanity occur- 
 ring during lactation, this symptom of ominous significance is recorded. 
 It should always be accepted as a note of warning in those who are 
 predisposed to insanity, or who have afforded evidence of cerebral 
 malnutrition. Such failings are usually due to injudicious nursing ; 
 and injudicious nursing is at the root of most of the cases of aberration 
 occurring during lactation. It is not so much jwolonged lactation as 
 over-indulgence, often of a strong, robust infant, whilst the nurse is in 
 a delicate state of health. If we consult our statistics we find that, 
 out of sixty-five cases, twenty-seven had suckled but six months, and 
 twenty-seven others had suckled up to the ninth and twelfth months ; 
 obviously, then, protracted suckling had not so much to do with the 
 cause as other factors. 
 
 "What occurs is this, a woman in delicate health, often after 
 numerous rapidly - succeeding confinements, or perhaps after a 
 tedious puerperum, or, maybe, hremorrhage before or during labour, 
 suckles her infant with injudicious frequency, saci-ifices her rest 
 night after night, and probably takes insufficient or unsuitable 
 nourishment. The constant drain from her system and loss of rest 
 engender antemic and dyspeptic symptoms, still less favouring the 
 restoration of the material lost from her blood. The superficial fat 
 disappears to supply the demands of the exhaustive secretion. The 
 carbohydrates, rapidly diminished, no longer can exert that protective 
 influence over protein metabolism (Landois and Stirling*), and a 
 further waste occurs in this direction — first, the circulating albumen 
 feels the drain, and later, the organised albumen must still further 
 
 * It must be remembered that only part of the fat is derived from the food 
 dircctl}'- ; the rest is a product of a splitting-up of proteids in tissue metabolism 
 (Landois and Stirling's Human Physiology, p. 518). 
 
388 INSANITY AT THE PERIOD OF LACTATION. 
 
 aid in the formation of the fatty principles required.* In this way, 
 as in all cases where a similar drain upon the system occurs 
 (leucorrhcea, diarrhoja, profuse suppuration), ansemia of profound 
 character supervenes ; our patient comes before us with pallid face, 
 with blanched lips, with small feeble pulse, the heart's muscle 
 exhausted, and the breathing often hurried and panting, and the 
 muscles of the limbs flabby and ill-nourished ; she complains of 
 headache, vertigo, dimness of vision, lassitude and aching limbs. In 
 lieu of the fresh-coloured healthy glow of the cheeks, the plumpness 
 and firmness of tissue, indicative of active functionising and 
 vigorous health, the normal ebb and flow of lively emotion, and 
 warm interest in the nursling, which characterise the good efiicient 
 nurse, we have a miserably pallid wasted object, half-starved, queru- 
 lous, full of imaginary ailments, tormenting fears, and morbid sus- 
 picions. 
 
 Despite all these symptoms, some women will still persist in 
 suckling their ofi"spring from misguided maternal instincts, and often 
 with the object of deferring a subsequent conception ; the hydrremic 
 state of the blood results in a slow and sluggish circulation, and in 
 the splenic pulp, and especially the portal circulation of the liver,t 
 as in the marrow of bone such sluggish flow favours the destructive 
 hfemolytic action which goes on here — the red corpuscles are rapidly 
 disintegrated {Quincke). 
 
 Although it has been demonstrated that in inanition, the central 
 nervous-system loses in weight more slowly than almost all tissues 
 and organs (with the exception of the spleen, kidneys, and heart), and 
 incomparably less than the fat, muscles, and even bones (see V. Yoit's 
 experiments quoted by Landois, p. 514), yet, the brain is undoubtedly 
 the organ which earliest registers any disturbance in its nutrition. 
 This is what we might expect ; since, being the custodian of all 
 organic impressions, to which is relegated the function of giving the 
 alarm when the activity of other organs is disturbed, it is highly 
 necessary that its own welfare when threatened should be expressed 
 with no uncertain ciy. 
 
 Wliat is the pro2:ier time for weaning ? The period is, of course, a 
 
 * Then, also, M'e must remember that (as Voit shows), although in ordinary 
 health a large amount of circulating albumen is split -up, whilst the organic 
 albumen of the organs and tissues continues comparatively stable ; yet, in certain 
 pathological states, the organic albumen becoming very imstable may undergo 
 rapid disintegration, as in fevers, &c. (Stirling, op. cit., vol. i. , ji. 506). 
 
 + The liver is regarded as one of the chief sites of haemolysis " because bile- 
 pigments are formed from hemoglobin, and the blood of the hepatic vein contains 
 fewer red corpuscles than the blood of the portal vein" (Stirling, op. cit., vol. i., 
 p. 17). 
 
PERIOD FOR WEANING. 389 
 
 most variable and uncertain time ; eacli individual case must be 
 judged upon its own merits, and in considering, as we are compelled 
 to do, tlie interests of both parties, the mother and offspring, the 
 question necessarily becomes peculiarly trying and delicate, owing to 
 the fact that the immediate interest of the one often appears antag- 
 onistic to that of the other. Ultimately we know that, if the nurse 
 suckle beyond her strength, the result will prove highly prejudicial 
 to both, yet, the infant's health may be such that artificial feeding is 
 inadmissible and urgently demands breast-milk of a quantity and 
 quality beyond the mother's capability to supply. Undoubtedly, 
 natural feeding at the breast should be adopted in all cases where the 
 health of the nurse is not seriously imperilled, and when the breasts 
 supply a due amount of nourishment for the infant's wants ; as, 
 hereby, the well-being of both is best secured ; but, when the lacteal 
 secretion is scanty, or its quality such as to render it unsuitable in 
 the case of a weakly infant, to whom artificial feeding might prove a 
 greater peril, the , balancing of odds is often a difficult matter. 
 Consistently with the mother's health, every effort must be made to 
 bring up the child at the breast, over the more eventful dentition 
 crisis through which it has to pass, and this might be oftener done by 
 weakly nurses if due regard were paid to a judicious course of 
 suckling and avoidance of errors so notoriously frequent. 
 
 The child has to be educated into a regular system of feeding ; and 
 this should be so managed, that the mother may secure a pi'olonged 
 rest and sleep at night, and the injurious habit avoided of indulging 
 at night every passionate outcry by application to the breast. 
 
 The rule given by Trousseau holds good for most cases wdiere we 
 deal with a healthy nurse — viz., that the period of lactation be 
 extended in most cases over the period of evolution of the canine 
 teeth. 
 
 "My rule, provided there be no serious obstacles to surmount, other than the 
 wishes of the family, is not to wean the child until after the complete evolution 
 of the canine teeth, which is generally a more difficult process than the evolution 
 of the incisors or first molars. My rule, therefore, is to wait, irrespective of age, 
 till the infant has sixteen teeth."* 
 
 Of course any such rule falls short in its application to cases such 
 as we are now considering. The welfare of the mother, if of neurotic 
 inheritance, and exhibiting emaciation and anaemia in the early 
 months of lactation, is so greatly threatened as to demand the 
 immediate cessation of nursing. 
 
 Prognosis. — The recovery-rate appears to be directly affected by 
 the date subsequent to parturition at which the insanity appears ; the 
 
 * Trousseau, op. cit., vol. iv., p. 163. 
 
390 INSANITY AT THE PEIUOD OF LACTATION. 
 
 earlier the symptoms of mental alienation occur, the more favourahle is 
 the issue likely to be. Hence, the recovery-rate is higher for puerperal 
 cases — that is, cases arising within six weeks of confinement, than dur- 
 ing later lactation, as SO per cent, is to 65 -G per cent. The percentage 
 of recoveries for the whole number of female cases of insanity was 44-G, 
 so that the percentage of 65*6 represents a very favourable rate of 
 recovery, and justifies a good prognosis, although of a less favourable 
 nature than in puerperal insanity. {Chart C.) 
 
 If a chart of recoveries in puerperal and lactational forms be con- 
 trasted, a notable uniformity is recognised throughout, the largest 
 number of recoveries in both occurring at the fifth or sixth months 
 and rapidly declining in the subsequent period. At the ninth month 
 of puerperal females, however, a remarkable rise again occurs in the 
 recoveries of seven cases, somewhat paralleled by a less conspicuous 
 rise at the eighth month in lactational cases. "Whatever be the cause 
 of these wave-like recurrence of cases, it is obvious that the periods at 
 which the recoveries chiefly tend to occur in both series of cases are 
 from two to three, from five to six, and, again, from eight to nine 
 months from the onset of the disease. Age exercises less apparent 
 influence upon the number of occurring cases than upon the nature of 
 the attack, and so indirectly aflecting the issue. The influence of age 
 upon insanity occurring during suckling, in a series of sixty -five cases 
 where the age was definitely given, may be illustrated by the following 
 table : — 
 
 Age. 
 
 Kecovered. 
 
 Eeaeved. 
 
 ^'^^- Chronic. 
 
 Tota 
 
 om 15 to 20 
 
 1 
 
 (at 19) 
 
 
 
 1 
 
 „ 20 to 25 
 
 9 
 
 
 2 
 
 2 
 
 13 
 
 „ 25 to 30 
 
 15 
 
 
 3 
 
 1 2 
 
 21 
 
 „ 30 to .35 
 
 13 
 
 
 1 
 
 3 3 
 
 20 
 
 „ 35 to 40 
 
 5 
 
 
 1 
 
 2 1 
 
 9 
 
 „ 40 to 45 
 
 
 
 
 \(G.P.) ... 
 
 1 
 
 43 7 9 65 
 
 If we compute as failures the fatal and chronic cases, it will be 
 observed that the ratio of these unfavourable cases steadily augments 
 towards the age of forty, increasing from one-sixth of the whole at the 
 age of twenty, to one-third at the age of forty. The large proportion 
 of cases of insanity appear from the total column in the above table to 
 have occurred between the ages of twenty-five and thirty-five. We 
 find, moreover, that the proportion of maniacal to depressed, melan- 
 cholic subjects is far greater at the earlier age of twenty to twenty-five, 
 and progressively lessens until, at forty, excitement and depression 
 prevail in about the same relative frequency. It would thus apj^ear, 
 
L- 
 
CHARTof RECOVERIES m 70 PUERPERAL 4 67 LACTATION CASES 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 h 
 
 s.. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 ^t 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 v^ 
 
 
 ANALYSIS OF RESULTS. 
 
 Recovered Relieved Died Chrc 
 
PROGNOSIS — TUEATMENT. 391 
 
 at first sight, tliat youth is favoured as regards greater immunity from 
 such affections ; in the attack being more acute, and hence more 
 favourable ; and in the ultimate issue in recovery. Tliis would not, 
 however, express the case truthfully, since the proportion of married 
 women in the population of our asylum-district between the ages of 
 twenty and twenty-five is considerably below the married population 
 of the following decennial period of life. In fact, between the ages of 
 twenty-five and thirty-five, the population is nearly 122,000 as against 
 37,500 who are from twenty to twenty-five years of age; this represents 
 a ratio of 3-2i6 to 1. Taking, therefore, into consideration this fact, 
 that the number of married women in the West Ptiding between the 
 ages of twenty-five and thirty-five is more than trijde that of the 
 married from twenty to twenty-five years of age, it is seen that the 
 younger class do not share an immunity from the ills attendant on 
 lactation; the incidence of insanity at these ages being almost identical. 
 That depression prevails in the later quinquennials and that \infavour- 
 able results multiply disproportionately may be regarded as established, 
 so far as these statistics lead us to infer. A fatal issue in these cases of 
 insanity during lactation is not to be feared apart from the complication 
 with other affections, especially the phthisical tendency, which is prone 
 to declare itself at this epoch ; more than half the deaths were due 
 to this cause in our own statistics, tAvo others issued in general 
 paralysis, and the remaining fatal case was one of suicide, already 
 recorded. 
 
 Treatment. — In most instances our patient's bodily condition claims 
 the chief attention ; her strength must be nursed and supported by 
 every possible measure. Should the breasts be tumid, we must treat 
 that condition by the employment of belladonna inunctions, by 
 atropine internally, by local friction, and by gentle saline laxatives. 
 A general tonic regimen must be from the first enforced. The food 
 should be liberal, nutritive, and easy of digestion; for errors, diges- 
 tive and assimilative, are almost of constant occurrence in such 
 cases. The peptonised and pancreatised preparations, and zymine 
 in intestinal derangement, may be utilised with advantage, more 
 especially if we endeavour to associate therewith cod-liver oil and 
 malt extractives. 
 
 Combinations of iron with arsenic, or with other mineral nervine 
 tonics, are especially useful, and the physical improvement so induced 
 is usually accompanied by a decided mental reinstatement — dej)ression 
 abates, and a healthier tone prevails. The sulphate of iron, in com- 
 bination with aloetic purgatives as a pill, is a useful remedy for the 
 constipation associated with the hepatic and intestinal torpor of some 
 of these cases ; cascara sagrada may also be given here with advantage 
 
392 INSANITY AT THE CLIMACTKRIC EPOCH. 
 
 alone, or, better still, in combination with euonymin. Shower-l)aths, 
 cold spinal douches, and open-air exercise arc applicable in most 
 instances. It is not, as a rule, advisable to adopt sedative treatment, 
 except in the more intense forms of depression, when morphia given 
 subcutanoously, or the liquor opii, Avill prove the more useful drugs ; 
 "we should trust far more to general hygienic means for restoring tone 
 to the system, improving the appetite, and the digestive and assimi- 
 lative powers, and for inducing sleep. 
 
 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 Contents.^ — Symptoms — A Subacute Dehisional Melancholia — Suicidal Tendency 
 (S. H.) — Nymphomania (A. A.) — Etiology — Incidence of Insanity at diflerent 
 ages in 4085 cases — Influence of the Climacteric — The Psychological Trans- 
 formations of this Epoch— Instinctive Actions — The " Time-de7nent" in Prog- 
 nosis — Alcoholism and the Climacteric — Treatment. 
 
 Symptoms. — The mental ailment most frequent at this period in 
 ■women is an affective insanity, in which gloom and despondency are 
 associated with paralysed energies, indecision, and volitional inactivity ; 
 a condition pertaining to melancholic states at all periods of life ; yet, 
 the peculiar character of the psychosis is the frequency of religious 
 despondency, and delusions respecting the moral well-being of the 
 subject. The sj^mptoms grow in severity; suicidal feelings become 
 prevalent; and the delusion that the soul is lost often creates fits of 
 mental agony or despair.* 
 
 At its early evolution painful mental states invariably prevail, and 
 in over 55 per cent, of our cases mental depression existed throughout 
 the attack— a sub-acute delusional melancholia being far the more 
 frequent form ; yet maniacal states are by no means unfrequent, and 
 outbursts of excitement, alternating with dejjression, are prone to occur 
 at a later stage of its history. Sensorial anomalies early arise and are 
 strangely tinctured by the prevailing emotional gloom. The spirit- 
 world is the subject-matter of her broodings ; mystic communications 
 are received from above announcing her hopeless fate, or threatening 
 terrible judgments; or supernatural agents appear visibly and terrify 
 her in her half-waking moments. Visual and aural hallucinations 
 occur in about the same proportion of cases, 27 per cent, of the whole 
 series being subject to such anomalies ; whilst evidence of the imjjli- 
 cation of other special senses was very rarely obtained. Intellectual 
 
 * Thus Dr. Skae characterised the alienation occurring at this period of life as: — 
 "A monomania of fear, despondency, remorse, hopelessness, passuig occasionally 
 into dementia." 
 
SYMPTOMS — DELUSIONS — DESPONDENCY. 393 
 
 perversions soon ensue, sometimes evolved out of the sensorial dis- 
 turbances, often independent of such states, but invariably intensified 
 bv hallucinatory and illusional phenomena when present. Delusional 
 states were recognised in 73 per cent., and out of a total of sixty-one 
 deluded cases, sixteen were victims to the terrible delusion that the 
 soul was eternally lost, and that the subject was to be consigned to 
 the flames of lieU. It is strange to witness the prevalence of this 
 religious despondency at a period when, as we are aware, the 
 generative organs are undergoing an important cyclical transformation; 
 and to contrast it with the converse states of religious exaltation sO' 
 frequently associated with the sexual transformations and excitation 
 of adolescence, of hysterical and epileptic forms of insanity. Usually 
 the victim of this ailment accuses herself of the most heinous crimes, 
 and dreads the pursuit of human or spiritual beings who thirst for her 
 life's blood ; but, at times, a case presents a somewhat dilferent char- 
 acter of delusive belief; thus, one subject believed herself to be bitten 
 by venomous toads, that dogs pursued her and sucked her blood ; 
 whilst another declai-ed she was fed on human flesh. Such delirious 
 concepts are by no means frequent in this form of insanity, nor are 
 the patient's children or husband usually the theme of her perverted 
 imagination. 
 
 Such gloomy forebodings of coming evil or the mental disquiet 
 aroused by a sense of her irrevocable doom, eventually issue in suicidal 
 promptings, in fact, a large proportion freely admit this tendency. 
 We find that of all the cases of mental depression taken together 
 quite 60 per cent, are actually suicidal ; but, of the class of patients 
 now under consideration, about 44 per cent, only could be so con- 
 sidered. Impulses to suicide are certainly not so frequent ; yet, in 
 the worst cases, they do present themselves. Dr. Clouston expresses 
 the opinion that : — " The very loss of courage and vigour of will 
 operate against any effectual attempts at suicide " ; yet experience 
 teaches that in the worst forms most desperate attempts are occasioii- 
 ally made with the object of eluding the torture to which the mind is 
 at times subjected by the terror of impending evil. Thus one poor 
 victim of such terrors imagined herself haunted by evil spirits, who 
 audibly told her she was to be burnt alive, and, consequently, she 
 made a desperate attempt at hanging herself; another attempted 
 strangulation under the impression of being pursued by the evil one ; 
 a third attempts poisoning with vermin-powder, upon the assumption 
 that she was " cast off by God "; and three others attempt to end their 
 misery by drowning, choking, or the knife, under the influence of 
 similar perverted sensorial states. Especially have we learnt to dread 
 the impulsiveness of depression at the climacteric when associated Avith 
 
394 INSANITY AT TUE CLIMACTEEIC EPOCH. 
 
 the tendency to drink lieavily. Tlie purely impulsive form of insanity 
 may appear at this period of life ; and homicidal, as well as suicidal, 
 impulses may characterise the case, apart from any notable intellectual 
 or emotional disturbance whatever. As we have before stated, the 
 convulsive neuroses are prone to occur at all the cyclical epochs of life 
 with special frequency. 
 
 S. H., aged forty-two, a marrieJ woman, in comfortable circiunstances at home, 
 was admitted suffering from severe mental depression. She was a strong, muscular 
 subject of medium height, but somewhat pale and anajmic ; had a family of three 
 children living ; and was last confined, some eighteen months ago, of a still-bom 
 child. Her habits of life w-ere affirmed to have been consistent and temperate ; 
 and at the present time she was regarded as suffering from the functional ailments 
 incident to the menstrual climacteric ; the menopause was not established but much 
 irregularity existed. Paternal ancestry neurotic; the father, who was regarded as 
 insane, had committed suicide on hearing of his wife's death. For three months 
 she had been melancholic, and had made repeated attempts to drown, choke, and 
 suffocate herself, and also to cut her throat. Had expressed no delusion, and did 
 not sufifer from hallucination. 
 
 No cardiac or arterial disease was ai:)parent ; the respiratory and alimentary 
 systems were normal. The urine was 1020 specific gi'avity, famtly acid, and 
 devoid of albumen or sugar. Catamenia were in arrest. A few days after admis- 
 sion her morbid propensities declared themselves, and she attempted, by filling 
 her mouth with paper, leaves, or anj'thing at hand, to choke herself. Her restless- 
 ness at night was relieved by chloral, and the sedative solution of opium in 20 
 minim doses was administered twice daily. Her aspect was expressive of a sour 
 discontent, and from being reserved, reticent, and brooding, she developed hypo- 
 chondriacal fancies ; and querulously and persistently drew attention to her 
 imagined ailments. A slight attack of pleurisy a fortnight after admission was 
 followed by marked relief to her mental symptoms, and she left perfectly re- 
 covered two months later. She had not been at home over a fortnight ere her 
 restless depression recurred, and further suicidal tendencies led to her readmission 
 three months subsequently. Her condition was as follows : — "Free from any aspect 
 of depression ; utterly indifferent and callous to her existing state ; admits, with 
 some flippancy of manner, being subject to sudden and incontroUable impulses to 
 destroy herself; no delusion or hallucination can be traced in her account of 
 herself ; she is perfectly calm, rational in all her statements, and intelligent. 
 Amenorrhcea has existed for eight months." Under similar treatment she pro- 
 gressed during the first mouth so far as to be cheerful, active, industrious, and, 
 according to her own statement, had suffered from no return of morbid impulse. 
 She had, however, a somewhat careless, flippant maimer, which was unsatisfactorj' 
 as indicating a reduction in the moral sense not natural to her. About this time 
 she again became somewhat querulous, importunate about returuing home, and 
 there was slight hypochondriasis. This culminated in her abstracting from a 
 cupboard a quart bottle of spirits, locking herself in the bath-room of an olScer's 
 house, and deliberately swallowing the whole of the contents of the bottle. She 
 was discovered in time to rescue her, and on her recovery from her semi-comatose 
 state she avowed that she had taken the spirits with suicidal intent. Again she 
 became more cheery, less hyi)ochondriacal, active, and useful, and in six weeks 
 time she was tried once more in an associated dormitory, where she slept ■with 
 
IMPULSIVE STATES. 395 
 
 fifty otiier patients. She protested her freedom from impulses ever sinec her last 
 attack, and was most anxious to be tried at home once again. The night following 
 this apparently genuine statement, she retired to bed, and was found in the early 
 morning .strangled by a piece of braid which she had secured and concealed. The 
 ligature was tightly secured, the bed-clothing perfectly undisturbed, and the 
 sheet drawn over the face to secure her fi-om the observation of the patients sleep- 
 ing beside her — sulEcient evidence of the desperate determination which had 
 initiated the act. 
 
 Contrasted with the case of S. II. we may take that of A. A.^ in which 
 maniacal perversions of a prominent nymphomaniacal nature prevail. 
 
 A. A., aged forty-seven, a married woman, of steady, temperate habits of life, 
 without any ascertainable neurotic history in her antecedents, came under treat- 
 ment after two weeks' excitement. She had only recently been discharged from 
 another asylum. She was in a state of subacute excitement iipon her admission 
 and was dangerously aggressive ; she expressed the delusion that she was Queen, 
 that her liusband was king, and that she held the keys of heaven and hell ; a sus- 
 picious tendency was also present which induced her to refuse her food. She was 
 pale and somewhat haggard ; a hoemic bruit was heard at the base ; had a furtive 
 suspicious expression, and an agitated eager manner ; spoke of a contest about to 
 occur in the country which she might be able to arrest. She admitted being at the 
 menopause. For some weeks after admission the excitement abated sufficiently 
 to allow her to occupy herself usefully. Soon, however, maniacal symptoms again 
 supervened, and she has remained since this period subject to outbursts of excite- 
 ment and intervals of calm. The patient entertained the most bitter feelings of 
 animosity against her husband whom she repeatedly accused of being untrue to 
 her ; she denounced him in loud and threatening language, became most furious 
 and violent, and in her frenzy destroyed all within her reach. Upon one occasion 
 she tried to strangle herself by tying her hair round her neck. "At these periods 
 of excitement she shows much hysterical emotionalism, sobs aloud, simulates 
 physical ailments, complains of imaginary pains or assumed grievances, the abdo- 
 men is usually distended by flatus, and she then eructates for hours together. 
 She has a peculiarly wild agitated manner ; is most irrational, deluded, and 
 dangerously impulsive. Throughout her intervals of calm she occupies herself 
 usefully ; but there is always a suppressed under-current of excitement readily 
 aroused by trivial circumstances into a passionate outburst. She now betrays a 
 strongly erotic condition evidenced by expression and gesture and lascivious re- 
 marks ; when less under self-control this tendency gives vent to repulsive 
 and obscene language. She has developed the delusion that one of the asylum 
 officials is married to her, and she repudiates her former husband." It is now 
 three years since the onset of her derangement ; she is incoherent in conversa- 
 tion, betrays the same agitated manner, and is subject to periodic attacks of wild 
 nymphomaniacal excitement as formerly. 
 
 Etiology. — In endeavouring to estimate statistically the influence 
 of tlie climacteric involution upon the development of forms of mental 
 alienation pi-evailing at this epoch, we naturally first question oux'selves 
 as to the relative frequency of insanity at this and other periods of 
 life. "Were we to take promiscuously an aggregate of cases becoming 
 
396 INSAXITY AT THE CLIMACTERIC EPOCH. 
 
 insane at different ages over an extended series of years, we should 
 become early convinced that the question, far from being a simi)le 
 one, as it might at first be regarded, was really a very complicated 
 problem to unravel. 
 
 In the first place, the population at different ages of life varies ; so 
 that admissions in quinquennial or decennial periods are derived from 
 disproportionate sections of the community. Hence we desire to 
 learn not only the actual number of cases of insanity occurring at 
 different ages, but also the ratio of such numbers to the population ex- 
 isting at similar periods of life. Thus a glance at Table on p. 397, show- 
 ing the relative frequency of insanity at different ages for 1,808 female 
 cases, admitted into West Riding Asylum, indicates the period from 
 thirty to thirty-five as affording the highest number of admissions, 
 and that each succeeding quinquennial affords a rapidly decreasing 
 series of cases ; yet, when we come to compare these numbers with 
 the existing population at a corresponding age, we find, in lieu of 
 a rapid decrease of insanity at these years, that the ratio of occurring 
 cases is maintained at an equable rate or, according to some authorities, 
 is even increased. 
 
 In the next place, our statistics would embrace subjects from most 
 varied conditions of life and occupation, each sphere of life bringing its 
 own disturbing and exciting elements into the field ; hence it is advis- 
 able, in estimating the influence to be attached to the climacteric, to 
 compare only that class of the community whose social status exposes 
 them to more or less similar conditions of life. Unless this be done, 
 we may drift into the error of attributing to a physiological cycle 
 solely, what might more reasonably be expounded upon other grounds 
 — the encroachment of environmental agencies. The Avealthy and the 
 pauper class (exposed as they are to such widely-different exciting 
 agencies) must be judged apart upon the respective merits of their 
 cases, for any such statistics embracing all sections of the communit}', 
 irrespective of class distinctions, must be more or less vitiated thereby. 
 In the next place, we must not forget that we are dealing with other 
 important social factors — the single, the mai'ried, or the widowed state; 
 and, that our aggregate certainly includes a number of relapsed and 
 recurrent cases, in which a well-marked predisposition to insanity 
 existed, and in which, therefore, the climacteric epoch simply supplies 
 the disturbing forces. 
 
 In our attempts to classify such forms as appeared more especially 
 dependent upon the climacteric change, we found it essential to 
 eliminate a very large proportion of cases occurring at this period of 
 life. Recurrent cases had obviously to be rejected, and so had all 
 forms of insanity Avhich had not originated at this epoch of life ; and 
 
INCIDENCE OF INSANITY IN 4,085 CASES. 
 
 397 
 
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398 IXSAKITY AT THE CLIMACTERIC EPOCH. 
 
 SO also cases of epilepsy, imbecility, and organic brain affections, where 
 the climacteric was .but the spark to the fulminate. This rigid 
 exclusion of dubious cases left but a meagre residue of eighty out of 
 1,808 cases, or a percentage of 44 upon the total admissions. The 
 astonishing disparity in estimates upon this point by different writers 
 is seen in the following table : — 
 
 Classed as Climacteric Insanity. 
 
 ■n^-A-^ Ti„.,^«ii Skae'a Edin- Clouston's Edin- ,.,„„„„.„ Trr^of Bevan Lewis' 
 
 EeidsHanw5ll burgh Eoyal bur?h Royal Merson s West WestBidiDg 
 
 Statistics of ,03 Tilt s Statistics. A.vluni. Asylum, Kidmg Asylum, Asvlum, 
 
 Cases of Insamty. 5o8 Cases. 1,549 Cases. I,0o4 Cases. i^gOS Cases. 
 
 1-1% 3 to 4% 11-1 7o 12-6% 14 to 15% 4-4% 
 
 Obviously from the above the discrepancy must be involved in the 
 personal equation ; in fact, in the want of unanimity of opinion as to 
 what really constitutes the criterion of a so-called case of climacteric 
 insanity. It will be observed that our estimate (founded upon personal 
 observation) closely agrees with that of Dr. Tilt, and we differ, there- 
 fore, in regarding his results as an under-estimate ; * at the same time 
 we glean from Dr. Merson's able paper f the real cause of such dis- 
 crepancy. He there states in reference to his percentage of 15 that: — 
 
 "It by no means follows that in all these cases the climacteric condition was 
 the only, or even tlie chief, element in the causation of the mental disorder, though 
 it may be affirmed that in most cases it exercised a causative or modifying influence 
 more or less marked. The history of the cases investigated points to the conclusion 
 that the change of life is not often of itself the immediate cause of insanity.'' 
 
 The same writer then proceeds to particularise 76 out of his 149 cases 
 as influenced by other exciting agencies, giving amongst such some 31 
 cases of organic brain disease, cases of alcoholic excess, &c. Clearly 
 such cases would not comprise pure cases of so-called climacteric insanity 
 as understood by Dr. Skae, and with this qualification we fully agree 
 with Dr. jMerson's remarks on causation quoted above. Our own 
 tables, which give but 4*4 per cent., include only such cases where the 
 disturbances of the climacteric change and menopause were uncom- 
 plicated with other potent exciting agencies, and where we could 
 justifiably presume that the insanity was the more immediate outcome 
 of this revolutionary period. 
 
 In what way is this physical predisposition to insanity incurred? 
 From the standpoint of the evolutionist, we are led to observe that the 
 crrowth and development of the nervous-system is but a progressive 
 representation and re-representation in ever-advancing and more com- 
 
 * PsychoIo[/'ical Medicine, Drs. Bucknill and Tuke, 3rd edit., p. 360. 
 
 + " Climacteric Period in Relation to Insamty," W. B. A. ]ie2)oris, vol. vi., 1S76. 
 
ETIOLOGICAL FACTORS. 390 
 
 plex terms of the wliole organism ; tliat the cci-cbrum itself is but a 
 vast assemblage of sncli liighly-complex representative realms ; and 
 that in the higher realms such nervous mechanisms as foi'm the 
 jihysical expression of such representation have linked to them the 
 psychical correlatives of feeling and of thought. The loss of any portion 
 of the organism which has entered largely into our conscious life, or, in 
 other words, has been frequently, or at all largely, represented in 
 consciousness, will necessarily disturb the mental balance. Nor could 
 it be reasonably conceived that a portion of the body which had long 
 subserved the wants of the organism, and whose physiological history 
 was represented in certain organised tracts of the cerebrum, could 
 suffer ablation without some attendant commotion in the brain. In 
 .fact, the systemic and least relational structures are in their genesis so 
 closely interwoven with the physical substrata of feeling and emotion 
 that wide-spread disturbance results from their derangements, functional 
 and organic. The enormous share taken by the generative system in 
 the physiological and psychological life of the female is a subject of 
 2)araraount importance in our studies of the varieties of insanity. The 
 organs subservient for some five-and-thirty years or longer to the 
 important functions of menstruation, ovulation, gestation, lactation, 
 lind their nervous rejoresentatives in the fundamental tracts of the 
 nervous system, and draw largely upon that system during their life of 
 functional activity. Periodic relays of nerve-force demanded for the 
 regulation of their blood-supply and of their muscular apparatus, and 
 the ingoing currents crowding upwards from so extensive a system, 
 enter intimately into the very web which forms the physical correla- 
 tives of emotions and moral instincts. The vast accession of new impres- 
 sions registered by the sensoriuni when these organs awake to functional 
 activity during puberty has a most profound effect on the mental 
 constitution — an effect whose significance cannot be misinterpreted; 
 for the result is a real transfOPmation, more or less, of the eg'O, 
 with all its feelings, emotions, sentiments, and desires. At each 
 subsequent periodic crisis incident to menstruation, gestation, lactation, 
 uterine involution, the nervous-centres are profoundly affected by the 
 resultant transformations undergone, such periods being eminently 
 periods of nerve-instahility. 
 
 Pre-eminently is this the case at the menopause and grand climac- 
 teric, when the whole of this system loses its functional activity, 
 degenerates, and, in fact, passes almost completely out of the life of 
 the individual. Both subjective and objective accompaniments of the 
 menstrual molimen in a greatly-exaggerated degree emphasise and 
 usher-in this serious distui-bance of the nervous-centres — headache, 
 vertigo, faintness, "heat-flushes," emotional waves, phases of moral 
 
400 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 perversity, irritability, querulous impatience, even intellectual disturb- 
 ance (especially of memory and of attention) prevail ; and, wanting the 
 relief aftbrded by the depurative ])rocess of menstruation, the distress 
 is often a long-continued and urgent one. This, however, is the earlier 
 stage of functional decrepitude, the early phase of which is characterised 
 by want of decision, lassitude, and hebetude. It is essentially a period 
 of voluminous emotions, purposcdess waves of feeling, abortive yearn- 
 ings, redundant, vague, uncontrolled desires, and misdirected energy. 
 That great reservoir of nerve-force, which had for its object the jiro- 
 creative functions of the organism, is now objectless, and its expendi- 
 ture must now be directed into other channels ; a period of emotional 
 instability ushers-iu a period of reconstructions. 
 
 J. F., aged forty-one, single; admitted January, 18S0. Patient's father was very 
 intemperate; her mother and brother liad been inmates of this asjdum. J. F.'s life 
 had been a very unhappy one. For many years she had been compelled to dwell 
 with her brother, a brutal, drunken scoundrel. During the two months before 
 being taken to the asylum, she had developed dangerous, impulsive tendencies, 
 suddenly striking, biting at, and kicking those happening to be around her. 
 "When admitted, a condition of fairly calm attention and apprehensiveness was 
 constantly interrupted b}^ outbursts of furious excitement and violence. An insane 
 self-con :,'ratulation in her power of occasioning terror by her actions, seemed 
 possibly of influence iu the production of her paroxj'sms of passion. 
 
 For three months she was liable to these dangerous impulses, of which she was 
 aware, and expressed her grief at being unable to restrain them. Subsequently she 
 passed through phases of suUenness, depression, and agitation, to quietude and 
 industry. The catamenia, absent on her admission, returned during her latter 
 period of convalescence. 
 
 This epoch of reconstructions is one of peril to the mind, especially 
 to those ill-trained mental constitutions in which the passions have 
 been allowed an uncontrolled expression ; and where intelligent guid- 
 ance has been denied to the instinctive desires. In fresh objects of 
 affection, in new pursuits, aims, and studies, in other forms of mental 
 culture many minds will seek and obtain relief for these perturbed 
 feelings and pent-up emotions. The anxious and intelligent mother 
 will find a sufficient object in the prospective life and well-being of the 
 offspring ; many cultured minds will find in the fields of literature a 
 sufficient relief to their pent-up energies ; whilst those who lack in 
 such facilities will perhaps bend their attention towards schemes of 
 education or charitable movements ; and the instances are not few 
 where the political s})irit of the times affords, in our day, missions for 
 the .same subjects. The peril of this perh)d is one incident to all 
 periods of reconstruction arising during emotional turmoil and pertur- 
 bation, lietlection -wants the calm essential to its orderly operation, 
 and judgment is liable to be warped and one-sided; hence, also, it is 
 
ETIOLOGY — PROGNOSIS. 401 
 
 that this age of life is one prone to bigotry, to religious fanaticism, or 
 to conduct based upon dogmatic and immature beliefs. An unusual 
 and inordinate religious zeal is, indeed, a most frequent expression of 
 this transition-period in mental life ; and tliis is of interest viewed in 
 connection with the characteristic delusions of the insanity of this age. 
 
 "NVe hear of a similar climacteric in man ; but the parallel is more 
 fanciful than strictly correct. Even its advocates who speak of 
 climacteric insanity in man, allude to it as occurring " at a later time 
 of life than in the female, . . . much more irregular and indefinite. 
 There is nothing to mark it off so clearly as the menopause" (Clouston).* 
 The period assigned for the decline of the procreative power in man 
 is 55 to G5 ; in fact, the borderland of senility and not a genuine 
 epochal transformation. As Barnes states : — " There is nothing to 
 compare with the almost sudden decay of the organs of rejDroduction 
 which marks the middle age of woman." f With a certain proportion 
 of cases the menopause in woman may, in like manner, usher-in pre- 
 mature senility; but, in all, its more or less sudden onset and the great 
 constitutional changes and local transformations wrought, frequently 
 followed by the subject taking up an entirely new lease of life, give to 
 this period a critical character wholly distinct from what we see in man. 
 
 Prog'nosis. — The ultimate issue of an ordinary uncomplicated case 
 of insanity at the climacteric may certainly be considered a favour- 
 able one ; favourable, that is, as regards the duration of the malady, 
 favourable as regards the stability of the reinstatement, and favourable 
 as contrasted with the recoverability of all cases of insanity in the 
 female when taken collectively. Even when all cases of insanity at 
 this period of life are considered, whether of recent or of remote origin, 
 complicated or otherwise, still one-half of such cases constitute absolute 
 recoveries ; and the favourable progress of the affection is indicated by 
 the fact that three-fourths of the recoveries take place within nine 
 months of the onset of the attack. 
 
 What, then, are the special features which serve to demarcate the 
 favourable from the unfavourable class 1 what are the elements which 
 enter into a favourable prognosis and the reverse 1 The hopes we can 
 give to our patient's friends of a perfect recovery will largely depend 
 upon the " ti^ne element," which plays so impoi'tant a role in determining 
 the prognosis in most forms of insanity. An early and rapid cure is, 
 as in other cases, favoured by early treatment ; and the chances of a 
 complete and speedy recovery are much strengthened if the subject 
 come under appropriate treatment within two weeks of the onset of her 
 symptoms. We would emphasise here the sjjeedi/ return to a normal 
 
 * Op. cit., p. 560. 
 
 t Clinical History of the Diseases of Women, Burues, p. 263. 
 
 26 
 
402 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 mental vigour, for it is in this particular that early treatment is so 
 desirable. The actual numerical result of recoveries coming under 
 treatment, from a week up to three months after the onset of their 
 symptoms, is about the same for all (50 to GO per cent, being recoveries); 
 but, beyond three months, fewer actual recoveries occur, and a large 
 aggregate will be relegated to the class of the chronic insane. 
 
 Will the recovery be a stable one, or will the attack subject the 
 patient to further liability 1 As a general rule it may be affirmed that 
 the more fully the affection realises the character which is regarded as 
 typical of a truly epochal form of insanity, i.e., the more fully it 
 appears to be the issue of disturbances incident to this period of life, 
 the more likely is the return to normal health to prove a secure and 
 permanent state. Hereditary predisposition will, of course, in such 
 cases produce its usual results, subjecting the victim at any period to 
 a relapse on the incidence of exciting agencies ; and the predisposing 
 influence of former seizures will also have to be considered and allowed 
 for in framing our reply to this query. An actual study of our cases of 
 insanity at the climacteric shows that some 27*7 per cent, had a family 
 predisposition to insanity ; and that 38 per cent, of the total cases had 
 suffered from a previous attack of mental derangement. Yet the 
 actual relapse after confirmed recovery from this form of insanity 
 occurred but in four instances out of the whole sei'ies of eighty-three, 
 and in three of these a predisposition to insanity was indicated by a 
 former attack in earlier life with strong hereditary taint. 
 
 Another point of importance in prognosis to recall is the mortality 
 incident to this affection. The deaths, which amount to 14-4 per cent, 
 at the West Riding Asylum, are due to intercurrent affections, in 
 which phthisis or pneumonia play the chief part ; in fact, one-half the 
 deaths occurred amongst the chronic class who had resided at the 
 asylum for a period of from two to six years. It may be stated, indeed, 
 that the insanity incident to this period is rarely, if ever, fatal in 
 itself; and the chronic remnant of this class owe their unfavourable 
 character chiefly to the exhausting influence of chronic pulmonary 
 disease, ulcerative affections of the bow^els, or the malnutrition and 
 defective blood-supply of the brain, due to an enfeebled and fatty heart. 
 Another factor in the jn'ognosis is the age of the patient. It has been 
 observed by Dr. Clouston that fewer recoveries occur after fifty years 
 of age — an opinion with wliich we concur.* 
 
 The previous habits of the patient must likewise be taken into 
 account, and especially does this apply to the use of alcoholic stimu- 
 lants, so frequently indulged in at this period of the woman's life. It 
 is a well-known fact that seci-et drinking-habits become peculiarly 
 
 * Loc. cH., p. 564. 
 
PROGNOSTIC INDICATIONS. 403 
 
 frequent at this era, a morbid craving for stimulation being engendered 
 by the depression entailed at this period of reconstruction. If this 
 vice has been contracted the malady always appears in an aggravated 
 form. The very nature of the mental disturbance, the delusional 
 melancholia often bordering upon a hypochondriasis, and always of a 
 self accusatory character, finds in this grievance a sure foundation for 
 its gloomy fears and genuine despair; these cases, as already indicated, 
 are peculiarly prone to suicidal impulse. Such subjects may exhibit 
 much outward calm, have an absent manner, a self-engrossed aspect, 
 or a suspicious furtive reticence, or betray on their features the set 
 asj>ect of despair — indications which should place us on our guard. 
 
 The question of time during which the alienation has existed, the 
 age of the patient, her hereditary predisposition to insanity, 
 and the acquired predisposition through alCOholic indulg'ence are 
 some of the chief factors which enable tis to arrive at our prognosis in 
 the case. 
 
 Very divergent views have been expressed with respect to the 
 prognosis in climacteric insanity. Thus one authority says : — • 
 
 "Climacteric insanity is far from being a hopeful form of mental derangement."* 
 Van der Kolk states — "If religious melancholy begins in the clmiacteric years, 
 then the prognosis is unfavourable;" whilst Dr. Merson says — "The history of 
 the cases I have investigated, however, shows that as regards ultimate recovery 
 the prognosis is by no means unfavourable, though an early recovery is not 
 generally to be expected, "t 
 
 Dr. Clouston gives a percentage of 57 for recoveries in the female 
 sex; I Dr. Merson's table realising 59*5 per cent., or 47 per cent, when 
 cases uncomplicated with epilepsy, general paralysis, and other brain 
 diseases were excluded. Our later statistics, it will be seen, afford us a 
 x-ecovery-rate of 48 per cent., and, therefore, justify the views 
 expressed by Dr. Merson. 
 
 What is the issue of the attack in the more unfavourable cases 1 
 It appears that about 36 per cent, form an incurable chronic residue, 
 and about 14 per cent, meet with a fatal termination, half of which 
 fatal cases also are derived from the chronic class. Yet these un- 
 fiivourable cases do not necessarily demand asylum-supervision ; in 
 fact, one-half at least become relegated to the home-circle again, and 
 are able to discharge in a fair-ly-satisfactory manner the duties of the 
 wife or mother, or compete for livelihood in their various spheres. 
 Such incomplete recoveries are instances of a permanent mental en- 
 feeblement, but are by no means subject to the recurrence of acute 
 
 * Psijchological Medicine (Drs. Bucknill and Tuke), p. 145. 
 t W(sst Riding Asylum Reports, vol. vi., p. 107. 
 t hoc. cit., p. 56.3. 
 
404 IN'SANITY AT THE CLIMACTEEIC EPOCH. 
 
 symptoms. They remain mental wrecks after the storm, the depth of 
 reduction varying much for each individual case. Quiet, orderly, in- 
 offensive, they need only the kiadly guidance of the home-circle to 
 keep them right; yet, they exhibit an unwonted apathy, an indifference 
 to former pursuits and pleasures, a lack of energy — mental and physical 
 — which was present in their old selves. At times depressed, they never 
 show active suicidal symptoms ; but exhibit a flabbiness of purpose 
 and will, which render them for lifetime the dependents upon a stronger 
 mind. 
 
 There is a remnant left, however, of these climacteric cases where 
 the issue is far different, and where some of the worst forms of incur- 
 able delusional insanity become established. Here aural hallucinations 
 largely prevail, and a sexual element often appears to enter into the 
 material of their delusions. Hours are spent at the windows listening 
 to the communications of these unseen agencies ; to w^hich passionate, 
 •wild outbursts of obscenity and abuse often succeed from the infuriated 
 victim. Such attacks of excitement largely prevail at night; and the 
 delusions based upon such sensorial anomalies lead to aggressive and 
 destructive conduct. For many years these subjects remain a prey to 
 their deluded fancies ; are usually self-opinionated, or arrogant, over- 
 bearing, defiant in demeanour, and form a section of the more noisy 
 and dangerous class in our asylum-wards. In such cases we can only 
 hope for the speedy advent of a dementia before which the painful 
 sensorial states and delusional perversions fade, while a settled calm 
 and negative state of mind take the place of former turmoil. 
 
 Treatment. — A tonic regimen is desirable in most cases of insanity 
 at this epoch of life. Open-air exercise should be enjoined ; a free 
 nutritious diet devoid of stimulants : and careful attention to the 
 2)rimce vio>. An aloetic purgative is often desirable at the onset, 
 followed by mild laxatives, of which the mineral waters are a con- 
 venient form of administration. Our experience teaches us that a 
 large proportion of cases recover without any form of medicinal treat- 
 ment ; the removal from their homes, the influence of new associations, 
 and, above all, the strict attention to dietetic treatment sufiicing to 
 ensure a cure. 
 
 There are certain cases, however, whei'e medicinal interference is 
 imperatively demanded. Ansemia must be met by the administration 
 of iron, pi'eferably in the form of the ammonio-citrate, and in combi- 
 nation with small doses of the liquor arsenicalis. Iron should not be 
 given if acute symptoms prevail either of the maniacal or melancholic 
 stamp. We should await the subsidence of these symptoms, meanwhile 
 trusting to agencies for ensuring sleep and to a liberal diet. 
 
 If there be a tendency to refuse food, we must not permit our patient 
 
TREATMENT OF CLIMACTERIC IXSAXITY. -105 
 
 to escape on tlie excuse of having partially taken her meal ; a due 
 amount of milk and eggs with beef-tea, nourishing soups, and farinaceoua* 
 food should be rigidly insisted upon ; and, if necessary to resort to 
 fcjrce, compulsoi'y feeding must be adopted. 
 
 Sleep must be secured by the adminstration of chloral, bromide of 
 potassium or paraldehyd ; of which we certainly give preference to the 
 Urst. It is rarely necessary to give larger doses than 25 or 30 gi^ains ; 
 and where from cardiac enfeeblement its use is inadmissible, paraldehyd 
 may be substituted with good results. 
 
 The indiscriminate use of sedatives in these cases is, we think, to 
 be deprecated ; and, only in the more acutely-stamped types would we 
 feel justified in the more continued w&e of sedatives. For this purpose 
 chloral in combination with bromide of potassium is the safer ti'eatment 
 to adopt; opium or morphia, henbane and conium have proved un- 
 satisfactory in our hands. The bromide given separately from the 
 chloral we have less confidence in, and the combination found most 
 desirable is 15 grains of chloral with 30 grains of bromide twice daily. 
 We by no means share in the unfavourable view expressed by some as 
 to the general inutility, or even hurtfulness, of sedative treatment in 
 the acute forms of mental ailment at this epoch ; given the means of 
 securing efiicient alimentation, such treatment is often followed by 
 the best results. 
 
 SENILE INSANITY. 
 
 Contents.— Mental Derangements Incident to Senility — Senile Mania — Senile Melan- 
 cliolia — Chronic Cerebral Atrophy — Senile Convulsions — Senile E^iilepsy — Senile 
 Dementia — Inheritance as a Factor in Senile Insanities — Exhaustive Brain-work 
 — Alcohol and Senility — Case of T. G. — Onset and Prodromata — Character of 
 the Senile Reductions — Senile Hypochondriasis (J. A.) — Senile Atrophy and 
 Thrombosis (I. B.) — Acute Senile Melancholia and Syncopal Attacks (H. D.)— 
 Partial Exaltation in Senile Insanity— Delusional Perversions of the Mono- 
 maniac and Senile Subject Contrasted — Senile Amnesia — Cases of Senile 
 Insanity (M. H. and M. I\I.) — Elimination of Urea in Chronic Cerebral Atrophy 
 and Premature Senility — A Local Manifestation of Chronic Bright's Disease. 
 
 The student is apt to mis-apply the term senile insanity, that form of 
 senile decrepitude which is but a morbid exaggeration of j^^il/siological 
 senility ; that gradual obnubilation of mind known as senile dementia is 
 apt to be taken as a tyjie of what is implied by senile insanity; and, so 
 far is he right, that it is doubtless true that a far larger proportion of 
 cases of mental impairment in senility belong to this than to any other 
 category of mental ailment. He is, however, too apt to assume that 
 all varieties of mental ailments in the aged issue in senile dementia ; 
 and that the maniacal excitement which is so frequently observed at 
 this time of life is necessarily the accompaniment or the precui'sor of 
 
406 THE INSAXITY OF THE SENILE EPOCH. 
 
 senile decay. It is, therefore, necessary to inrlicatc that this term 
 connotes a very large class of symptoms, emijracin;,' between them all 
 the varied forms of insanity usually differentiated. The pathology of old 
 age is as unique and interesting as that of infancy and adult life; and, 
 just as we are aware, that certain periods of life bestow a special 
 immunity from certain morbid aflections, so do we find old age by no 
 means an exception to this rule. That it has its own special affections 
 of the central nervous-system, as of the body at large, is also a well- 
 established fact; and that such morbid changes are characterised by a 
 special tendency towards atrophy has long been recognised. 
 
 Apart, however, from such special immunities and proclivities as 
 this period of life is apt to entail, there are other forms of mental 
 alienation common to it and to adult life which must be taken account 
 of ere a faithful picture of senile insanity can be framed. Simple 
 melancholic states, maniacal perversions, in themselves recoverable 
 forms; or more obstinate delusional perversions with, or without, 
 permanent dementia, paralytic dementia, the dementia of chronic 
 cerebral atrophy, epilepsy, and even general paralysis, may severally 
 be encountered during advanced senility in the predisposed. Yet, it 
 is none the less true that such affections, more common at other epochs 
 of life, are considerably modified by the physiological stadium, and are 
 stamped with a special impress which more or less distinguishes each 
 form of senile alienation from the psychosis of earlier periods of life. 
 
 A careful study of insanity amongst the senile admissions into our 
 asylums, and an attem2)t at a rational classification into groups accord- 
 ing to their most obvious pathological indications, will cause the 
 student much perplexity at first, owing to the extreme multiplicity of 
 symptoms which he encounters amongst such cases. He will early 
 learn, through the painful experience of a faulty diagnosis, that it is 
 easy to confound functional derangements with the earlier indications 
 of organic brain-disease; and he must be fully prepared to find his 
 prognosis stultified, unless due attention be paid to the modifying 
 influences of the senile epoch over the nature and course of the disease. 
 
 Senile Mania. — He will meet with forms of simple maniacal excite- 
 ment without any very obvious enfeeblement of the intellectual 
 faculties, in which emotional instability, incessant garrulity, and rest- 
 lessness are the only obvious disturbances recognised. Such excitement 
 may vary from one of slight degree to very acute forms; and, in the 
 latter case, may prove most persistent and most obstinate to all 
 remedial agencies. The rambling disconnected speech may pass into 
 utter incoherence, the motor restlessness become extreme, and 
 insomnia defy all our means of relief. Such cases of senile mania may 
 require long-continued and forcible feeding, and cause us much anxiety 
 
MENTAL DERANGEMENTS INCIDENT TO SENILITY. 407 
 
 lest a fatal degree of exhaustion ensue. And yet, such cases, although 
 often the precursors of permanent dementia, may completely recover 
 and leave our patients with scarcely a vestige of mental enfeeblement 
 apparent, beyond what is natural to their time of life. It is to the 
 distinction between such recoverable forms, and those intercurrent 
 attacks of mania which are frequent during progressive senile atrophy 
 of the brain, that the student Avill have his attention chiefly directed. 
 Recurrent maniacal attacks are of special frequency amongst the aged 
 iiisauo, who are prone to explosive discharges from their ill-nourished 
 and highly-unstable cerebrum ; and such recurrent seizures are notably 
 present in those senile cases who have acquired a predisposition through 
 alcoholic indulgence. 
 
 Senile Melancholia. — A second group of cases is presented in those 
 forms of simple melancholic depression to which certain predisposed 
 subjects are liable during the physiological involution of the nerve- 
 centres on the advent of senility. Depression at this epoch is always 
 of most ominous import; it may be the precursor of senile mania, it may 
 usher-in hopeless forms of senile dementia, or it may be the warning- 
 note of those serious forms of dementia which are connected with an 
 interstitial or gross cerebral change, such as occur in chronic cerebral 
 atrophy with its scleroses, or hsemorrhages, or softening from thrombi. 
 Here, again, the student will find his attention profitably directed 
 towards the diagnostic distinctions betwixt simple senile melancholia 
 as a purely functional ailment (which is a fairly recoverable form of 
 alienation), and the depression which augurs a serious structural 
 change in the nervous-centres. As we shall see later on, such forms of 
 simple melancholia, unaccompanied by any delusional state, are notably 
 characterised by their strongly-marked suicidal tendency, which appears 
 in 79 per cent, of such cases. 
 
 Chronic Cerebral Atrophy. — Passing by these simple forms of 
 aflfective insanity, we arrive at a third, and a very interesting, group of 
 cases, which, whether the symptoms be considered from the mental or 
 physical side, present evidence of a very definite pathological process — 
 we allude to chronic cerebral atrophy. This is an afiection no more 
 limited to senility than the foregoing, yet it is of special occurrence at 
 advanced age. The affective sphere of mind is also here involved, and 
 painful mental states predominate. Despondency and gloom issue at 
 limes in acute melancholic or maniacal outbursts, yet morbid depression 
 is here usually associated with enfeebled will and a special tendency to 
 instinctive, impulsive states. Chronic melancholia, with impulsive 
 propensities, is the prominent mental symptom. The disease appears 
 to project itself mainly upon the motorial sphere of mind; and the 
 diseased vascular tracts in the cerebral hemispheres are peculiarly 
 
408 THE IXSAXTTY OF THE SENTLE EPOCH. 
 
 prono to nppoar in the frontal and motor I'calms, cortical and ganglionic. 
 A group of symptoms constituted by despondency, self-absorption, 
 general intellectual torjjor, failure of memory, enfeebled volition, 
 impulsive conduct, often desperately-suicidal attempts; and, with this, 
 highly-chai-actcristic physiognomical signs, such as a pained, vacant 
 aspect, a dulled, lustreless eye, a jaundiced earthy tinge of integument, 
 tortuous radials, temporals, or brachials, a slow and lalioured utterance, 
 and an utter want of initiative — are in themselves a very suggestive 
 category. When, with such a case, we find general muscular enfeeble- 
 ment progressively advancing, a history of slight, transient strokes, a 
 very temporary loss of speech, a slight glossoplegia, facial or brachial 
 monoplegia, or slight syncopal or vertiginous attacks repeating them- 
 selves frequently, we may be pretty confident that we have to deal with 
 a case of chronic cerebral atrophy as the result of vascular disease, and 
 probably associated with considerable renal and cardiac degeneration. 
 
 Senile Convulsions. — A fourth group presents itself under the 
 form of convulsive affections. After a more or less prolonged period 
 of mania or melancholia, the persistence of which may be unexplained, 
 there will suddenly occur a partial or general convulsive seizure, with, 
 or without, loss of consciousness. The patient henceforth becomes 
 subject to more or less periodic attacks of genuine epilepsy or epilepti- 
 form convulsions. Such cases, however, are not so numerous. Out of 
 260 cases of senile female admissions but 20 cases, or 7*6 per cent, of 
 the whole, were subject to convulsive attacks, and in not more than 
 one-half this proportion did the convulsive neurosis assume such a 
 grave aspect as to be regarded as the most prominent morbid feature. 
 
 Senile Epilepsy occurring during the course of any form of mental 
 alienation is, of course, of very evil augury. It betokens, usiially, a 
 localised nutritive derangement of a grave character, due to diseased 
 vascular tracts of the cortex or ganglia at the base. 
 
 Senile Dementia. — Lastly, there is the well-known insane dotage 
 of the senile dement, in which all the mental faculties are progressively 
 affected, and in which maniacal excitement, or, less frequently, melan- 
 cholic gloom or agitation, may recur over and over again, and very 
 vivid hallucinatory and delusional conditions may prevail; yet a steady 
 decadence of mind proceeds and utter fatuity results. 
 
 With respect to the question of inheritance in senile subjects, let us 
 remember that although much depends on the organised stability of 
 the nervous-centres, we must not omit to lay due stress upon excep- 
 tional environmental conditions of life, and especially \ipon conditions 
 self-induced, or to which the organism wilfully exposes itself in 
 defiance of all physiological dictates. Whatever be the resistance of 
 ' the organism to morbid excitants, we can safely assume that the latter 
 
INCITIN-G AND PREDISPOSING AGENCIES. 409 
 
 may reach such an intensity as to break through all opposition, and 
 that inherited instability need by no means be predicted in such cases; 
 in other woi'ds, insanity may be acquired purely ab extra. "We have 
 too many instances allbrded us of the break-down of good, stable minds 
 through the stress and tension induced by surrounding conditions of 
 life, to permit us for one moment to hesitate in our acceptance of, or to 
 allow us to qualify, this statement. Sustained mental exertion may 
 be carried on under unfavourable circumstances to such a pitch as to 
 issue in complete demoralisation; undue stimulation of nervous-centres 
 already fagged by overwork, will as certainly, if persisted in, entail in 
 the issue complete disorganisation, or deterioration of the output ; it is, 
 therefore, highly necessary that we should lay full emphasis upon the 
 environmental conditions. Given a case of strong hereditary predis- 
 position, and we infer that slight exciting agencies will suffice for a 
 culmination in some morbid development. Given but a feeble predis- 
 position, and the resistance to morbid excitation rises ; so that a 
 potent cause only ah extra will induce the vicious evolution. Yet it is 
 equally true that, apart from any traceable ancestral frailty, certain 
 vicious conditions of life will of themselves induce such cerebral 
 disorder as to culminate in an attack of insanity. What do "we know 
 respecting ancestral history and the interaction of the environment in 
 cases of senile insanity 1 
 
 A predisposition was clearly ascertained in some 58 cases of senile 
 insanity out of 261 male patients, or a percentage of 22. This estimate 
 includes collateral and direct transmissions, and was limited almost 
 exclusively to the parentage and to the collateral line of brothers and 
 sisters. If direct inheritance only be taken into account, the percentage 
 would still remain as high as 15. Now this is considerably above Dr. 
 Clouston's figure (13 per cent.), and, in fact, lies midway betwixt the 
 percentage given by him* and the average heredity ascertained for 
 1810 cases of all forms of insanity alike (31-5 per cent.). Dr. Clouston 
 speaks of ancestral inheritance as "-yery uncommon" but admits that 
 such estimate includes a fallacy " that the facts about heredity were 
 further back and more forgotten in this than in any other form.''! 
 Such a qualification, undoubtedly well-based, applies equally to our 
 own statistics ; and we may with justice assume that an insane inheri- 
 tance would, if all the facts were forthcoming, be found to be pretty 
 much what is the average for all forms of insanity taken together. 
 
 But apart from the frequency of its occurrence as a factor is the 
 question of the nature of such inheritance and its intensity ; unfortun- 
 ately our data for a reliable conclusion upon these points are too scanty. 
 Dr. Clouston's assumption is that — " To have survived, therefore, the 
 
 * Op. c'lt., p. 567. i IhkL, p. 500. 
 
410 
 
 THE INSANITY OF THE SENILE EPOCH. 
 
 changes and chances, tlie crises and perils of life with intact mental func- 
 tion till after sixty, means slight neurotic heredity, or great absence of 
 exciting causes of disease."* Were we to regard the dictum tliat the 
 stronger predisposition is manifested earlier in life (open as it is to such 
 Tiumerous excejitions) we would still take exception to applying such a 
 Jaw to the cases of insanity under consideration. What are the positive 
 facts before us 1 If we take into consideration all forms of neurotic inheri- 
 tance alike, we find a percentage of 2G-4 give such histories; that in 
 several cases both father and mother were insane; that in some, several 
 members of the family were epileptic ; that in others, direct hereditary 
 insanity was traceable (associated with epilepsy and paralysis), and that 
 .suicide was not infrequent in the family. We should, therefore, 
 incline to the view that the senile insane exhibit a fairly average pre- 
 dis|)osition to insanity; and that, possibly, its late development in such 
 .subjects may depend upon the nature of the neurotic inheritance and 
 the developmental period during which it was originally acquired by 
 the ancestor ; for the law that a morbid condition tends to reappear at 
 an earlier age in the j^rogeny is not final upon this point. For us, 
 however, the more important point for recognition is that whatever 
 proclivity towards insanity there be in such subjects, due to inheri- 
 tance, there is a most powerful agency in operation in a large number 
 of such cases in the surrounding conditions of life. Undue cerebral 
 ■excitation, whether in the form of excessive mental work, and especially 
 when prolonged intellectual operations are associated with anxiety and 
 worry, or exhaustive emotional states, frequent exhaustive demands 
 upon the intellectual operations, sustained mental tension in the 
 struggle and competition for existence, will, as we well know, result in 
 utter mental and physical prostration, even in those who possess the 
 ■elasticity and resistance of manhood ; much more should we expect 
 such agencies to be operative for ill, at an age when the brain-cells 
 haA-e reached their limit of normal functional activity, when function 
 <leclines, and physiological dissolution commences, in the series of 
 downward retrogressive changes of senility. 
 
 Sucli unwise demands made on the nervous-centres during adult life 
 AVQ prone to induce premature senility, and the various mental 
 derangements to which the aged are subject ; but a still more potent 
 factor is comprised in the association with these conditions of alcoholic 
 stimulation. Excessive alcoholic indulgence lends a frightful impetus 
 to the retrograde changes of this epoch, tending to over-excitation and 
 exhaustion of the nerve-cells ; to retention of hydro-carbon in the 
 system ; to vascular paresis and disease of the arterial tunics ; to 
 universal degradation in tyjie of tissue, notably of the nerve-centres : 
 
 */6ic/., p. 566. 
 
ALCOHOL AND SENILE INSANITY, 411 
 
 we may, indeed, readily appreciate tlie evil effects of undue mental 
 exertion, backed up by alcoholic stimulation. 
 
 T. G., aged fifty-two, married, with a family of five cliildren, a ininer by occu- 
 pation. Patient was suffering from his first attack of insanity, which began a 
 month ago. He was a short, well-nourished subject, of florid complexion, con- 
 junctiva? tinged; arcus senilis M^ell marked; pupils equal and active; slight 
 iiattening of right side of face; tongue protruded straight, slightly tremulous. 
 There was excessive sensibility of the soles of the feet; when these were tickled, 
 tlie whole body was thrown into a convulsive state. He had formerly been addicted 
 to very heavy drinking, although more abstemious during the past four years. His 
 father drank to excess, and was a "bad character." His father's sister cut her 
 throat at this asylum. Patient's two sisters (twins) are at present inmates here. 
 Mother was at this time seventy-five years of age, strong and hale. No history of 
 cranial injury. 
 
 About eleven months ago, patient had noticed convulsive movements of both 
 eyeballs [nystagmus), and, subsequently, jerking movements of the head and neck. 
 He sought treatment for his eyes at the Leeds Infirmary; but, whilst there, his 
 limbs suddenly one night were thrown into convulsive movements like the head. 
 Such movements recur frequently, but have sometimes left him completely for 
 a week together; they are always increased during emotional states. He had 
 gradually lost power in his right arm and leg; and speech also had become much 
 impaired. Childish moods were then noticed; he would collect worthless rubbish, 
 and, if deprived of it, become most passionate and violent. Memory deteriorated, 
 and he began to misname his acquaintances and relatives. Great irritability was 
 apparent later on; he would violently assault little children without obvious 
 reason. 
 
 A fortnight before admission he had, for the first time, a succession of fits, in 
 which ' ' his eyes were drawn-up — he frothed much at the mouth, his mouth being 
 dra^^Ti to one side (which side unknown) ; his limbs were much jerked about, and 
 he remained for some time unconscious." Had sufi'ered lately from aural and 
 visual hallucinations; accused his wife of being unfaithful to him, and said, 
 "people make a fool of me." He had threatened his wife with violence, and had 
 said he would cut his throat. 
 
 He was emotional upon his admission, singing, weeping, and rambling alter- 
 nately. He was then obviously suffering from ataxic aphasia, with a certain 
 degree of amnesia. "Asked to pronounce a certain word, he frequently repeats the 
 first syllable before proceeding, and when the word is completed successful^, he 
 is apt to reiterate the whole Avord over and over again, or interpolate it subse- 
 quently into a sentence wholly irrelevant and foreign to it in context." 
 
 "He understands all that is said, but his replies are frequently quite incom- 
 prehensible ; memory is notably impaired, and consciousness so far affected that 
 he fails to recognise where he is, when he came, or the nature of his surromidings. 
 He shows the instantaneous obliteration of memory for any given name or date so 
 characteristic of certain alcoholics.* He still evinces distrust of his wife, and is 
 inclined to impute to her all his troubles and present physical ailments. Atten- 
 tion is commanded with fair ease. He becomes readily emotional and agitated, 
 when his breathing is accelerated, and choreic movements of head and limbs 
 supervene ; locomotion somewhat impaired by the jerkj' naovements of his limbs. " 
 
 * See case of /. F., and of M. H. L., pp. 310, 311. 
 
^12 THE INSANITY OF THE SENILE EPOCH. 
 
 Such being the history prior to and upon admission, the patient, a fortnight 
 later, had several recurrences of tlie choreic movements, became decidedly suicidal, 
 dashing himself Iiead foremost on the floor. Three months later, he had a paralytic 
 seizure sudden in onset. He fell on his knees ; was unconscious for a short time ; 
 the right side of face and riglit arm showed muscular twitchings — the eyes turned 
 to the right side, and tlie eyelids were convulsively affected. The twitching of 
 the right arm continued long after return of consciousness ; slight right hemiplegia 
 was present the following day. 
 
 For several weeks he continued very restless, in a hea\'y, stupid state, and 
 evidently much demented ; both pupils minutely contracted. The lunbs became 
 more enfeebled, and he had to be kept in bed. 
 
 A recurrence of the convulsive attacks supervened some months later, and after 
 lying for a few days in a semi-conscious state with constant twitcliings of the 
 limbs, and a high temperature, he died. 
 
 Sectio cadav. Skull-cap symmetrical, of average thickness and density ; no adhe- 
 sion of dura mater. Sinuses contained fluid blood. Arachnoid opaque over frontal 
 and parietal regions, with considerable fluid in the meshes of pia mater, which Avas 
 thick and tourjh, but strijjped freely. There were one or two doubtful patches of 
 adhesion along the marginal or first frontal gyrus. Vessels at base were very 
 atheromatous. There was great wasting of gyri in the frontal and parietal regions, 
 especially on the left side. The brain tliroiighout was softer than normal, and of 
 a dirty, rusty hue. The grey matter Avas shallow; the white matter studded 
 with very niunerous coarse vessels, showing also upon section small patches 
 of a imihish tint. No special focus of softenmg was noted. Cerebellum and basal 
 ganglia presented no change. 
 
 Whole lirain weighed 1270 grms. Left frontal lobe A^-eighed 198 grms. 
 
 Eight hemisphere ,, 555 ,, Cerebellum ,, 167 ,, 
 
 Left ,, „ 515 „ Pons „ 20 ,, 
 
 Right frontal lobe ,, 327 ,, Medulla ,, 8 „ 
 
 The heart weighed 355 grms. ; muscle pale, ill-nourished ; large patches of 
 atheroma at base of aorta; valves healthy. 
 
 Plight lung, 955 grms. ; intensely engorged throughout, but still floated, and 
 on pressure crepitated ; no tubercle or inflammatory induration. 
 
 Left hmg, 810 grms.; adherent by old fibrous bands; like the right lung, it 
 was engorged throughout. 
 
 Liver, firmly bound to diaphragm; substance firm and fibrous. 
 
 Spleen, 163 grms. ; congested and friable. 
 
 Right kidney, 140 grms. ; left kidney, ISO grms. Capsules were adherent in 
 both organs ; the surface graniilar ; the sulistance greatly wasted in cortical 
 and pyramidal jDortions ; the pelvis of the right kidney was dilated. 
 
 Of the 261 male senile cases, as many as 75 (i.e., 28-7 pci' cent.) were 
 conclusively proved to have been of intemperate habits for some years 
 prior to their attack of insanity; and there is reason for regarding this 
 percentage as far below the actual truth. Later on, we shall find that 
 alcohol gives a special direction to the morbid tendency, having a 
 preponderating influence in the production of special forms of senile 
 psychoses. Thus senile mania, melancholia, and the dementia of 
 
PEODROMATA: — SYMPTOMS AT 02ISET. 413 
 
 chronic cerebral atrophy eacli afford an alcoholic history in 40 per 
 cent. ; whilst amongst the senile dements proper, this factor appears 
 only in IG per cent. 
 
 Onset and Prodromata. — Were we to attempt to define the 
 boundary betwixt the physiological and pathological form of senility, 
 between the ordinaiy second childishness of old age, and the dementia 
 resulting from the senile atrophy of disease, we should find the task 
 a difficult if not an impossible one. No such limit exists ; the one 
 form passes by such gradations into the other, that it is, at times, 
 impossible to say that the physiological retrogression has been 
 respected, and that the symptoms imply no genuine pathological 
 change. Cases there are where the onset of senile dementia is so 
 marked, or so sudden, or so premature, that no doubt whatever can 
 be entertained that the physiological barrier has been overstepped ; 
 yet, in most instances, the atrophy of premature senility, at its onset, 
 heralds itself by very uncertain symptoms, which pass by insensible 
 gi'adations into the less equivocal character of the fully-developed 
 disease. 
 
 Amongst the prodromal signs of this affection are an uncertainty 
 and fickleness of disposition, and rajDid changes of mood. Moody 
 taciturnity alternates with fits of almost childish hilarity. The 
 patient exhibits unreasonable irritability, spasmodic passion upon 
 trivial occurrences, intolerance of contradiction or restriction, and 
 impatience of former pursuits. Dr. Anstie has drawn attention to the 
 irritable perversity of early stages.* Hebetude and lassitude are 
 frequent precursors of incipient cerebral atrophy ; but, the more 
 striking feature is the alternation of moods, emotional variability and 
 explosiveness. Headache is often a prominent symptom, and vascular 
 turgescence a notable feature ; slight exei'tion, such as ascending a hill 
 or a flight of stairs, or violent laughter, resulting in swollen contorted 
 veins and florid face. Then arise noticeable defects in the intellectual 
 operations due to occasional lajose of memory, very occasional and very 
 transient, yet anxiously noted by watchful friends. Insomnia at 
 night may alternate with diurnal hebetude, lessened activity and 
 languor. 
 
 Symptoms. — Such signs are of ominous portent in those advanced 
 in years, or whose former mode of life is known to have been favour- 
 able to premature senility. An attack of maniacal excitement may 
 now usher-in unequivocal signs of the nutritional impairment of the 
 brain; and upon its subsidence, well-marked indications of enfeebled 
 mind appear. 
 
 Similarly, much mental depression may ensue, and melancholic 
 * See Pdi/chological Medicine, Buckuill and Tuke, p. 3i2. 
 
414 THE INSANITY OF THE SENILE EPOCH. 
 
 agitation precede the more profound reductions of a later date. In 
 tlie greater number of cases, however, the transition is a gradual one, 
 from the prodromal signs indicative of failing nutrition, to those of 
 functional derangement of greater gravity, or of its complete arrest. 
 
 The failing mental powers illustrate the law of dissolution, whereby 
 the highest and last-evolved members of a series fail earliest. The 
 power of abstract thought suffers early ; complex reasoning becomes 
 a painful effort; mental processes generally become simple and more 
 automatic. Representative states are less vigorous, and association 
 of ideas enfeebled ; hence, the contrasting faculties of the mind lose 
 their former energy. The creative operations of the imaginative 
 sphere decline, and reverie usurps their place in the mental life. 
 The higher emotionaP states and moral sentiments fail to affect the 
 mental life and the conduct of the individual with the vigour of 
 former days; and, in 'fact, the possible adaptations of the organism 
 are far less complicated and its envii'onmental horizon is correspond- 
 ingly limited. This may ;dl be true, and yet memory may not be 
 greatly affected ; sooner or later, however, this faculty declines, and, 
 as has been frequently observed, the failure is chiefly as respects 
 recent events, the viore remote events of the history being recalled 
 vividly and accurately. We do not here recognise the instantaneous 
 loss of impressions referred to in alcoholic cases; it is not a feature in 
 senile insanity apart from alcoholism ; yet, that there is greatly 
 diminished impressibility in senile dementia is nevertheless true. The 
 characteristic senile memory, the diminished revivability of recent 
 impressions as compared with more organised ones, betrays itself in 
 the whole tenor of the patient's life henceforth ; he lives his child- 
 hood's days over again ; recent impressions have but a transient and 
 faint influence upon;^his ideation — or they fuse with the more vivid 
 series of older and more remote states of feeling; a dreamy reverie 
 takes the place of vigorous perceptive processes ; bygone events appear 
 transformed into existent realities, and are blended and confused with 
 the passing events of the moment. Localisation in time and space 
 will eventually be impossible, and complete incoherence of thought 
 will ensue. Although this law of dissolution is invariably exemplified 
 in senile dementia, it is remarkable that at times we are surprised to 
 find, even in cases of profound enfeeblement of memory, a transient 
 gleam of intelligence — the recognition of a series of perfectly recent 
 impressions in their natural connection — when we had supposed the 
 subject was completely oblivious to such circumstances. This seems 
 only explicable on the assumption that the law of trivial association 
 will bring together the recent impressions of the moment in relation 
 to the more deeply-organised states of the past ; and that the more 
 
NATURE OF THE SENILE REDUCTIONS. 415 
 
 deeply-organised are the states with whicli such recent impressions are- 
 associated, the more recoverable such states of consciousness are and 
 the more resistant to morbid influences. 
 
 Now follows a greater or less blunting of the special senses; deaf- 
 ness is a common symptom ; there is also slowed nervous conduction 
 and a sluggish reaction. The expreSSive faculties suffer likewise 
 with the impressive sphere ; not only is the subject less recipient 
 and impressionable^ but he is also less reactive. The intelligent 
 initiative is rarely assumed ; all actions are more instinctive, auto- 
 matic, and impulsive; speech is hesitating, slowed, and highly charac- 
 teristic — not only as the result of dementia, but also because the 
 tongue has lost its cunning and is less glib ; there is a dislike for any 
 mental effort from the outset, and eventually an utter inability for 
 sustained concentration of the mind on any one subject ; there is an 
 equal distaste for 'physical exertion. Reduced to an automaton, in, 
 every sense of the word, his habits of life are simple in the extreme ; 
 and all his feelings, thoughts, and utterances savour of sameness and 
 repetition. Of all the insane the senile dement is the one whose 
 habits of life are most stereotyped, and whose actions generally 
 and speech are least variable and, therefore, most predicable. 
 
 In the dissolution of his nervous organisation the doubly-compounded 
 rhythmic actions of an elaborate nervous mechanism appear to have 
 given place to the simpler rhythms regulating the activities of simpler 
 forms of life. The physical signs of senile decrepitude are notably 
 marked ; they are those of almost universal atrophy. Exceptional 
 cases occur where obesity prevails ; but the rule is that all the tissues, 
 viscera (except heart and kidney), and glands undergo excessive 
 atrophy, often pi'eceded by fatty degenerative change. It is scarcely 
 necessary to more than recall the thin harsh skin ; the wrinkled face ; 
 edentulous jaws; the senile arcus ; the grey hair and bald pate witli 
 its glossy atrophic integument ; the tortuous corded temporals or 
 radials ; the diminished stature and weight ; the skinny, shrunken, 
 extremities ; evident emaciation, muscular enfeeblement, and wasting ; 
 stooping attitude and tottering gait. 
 
 It must not be supposed that the mental decadence here sketched- 
 out takes place without emotional stoi-ms ; for wild gusts of excitement 
 sweep over the scene repeatedly during the progi'ess of the cerebral 
 atrophy. Such maniacal attacks are often most persistent and most 
 obstinate to treatment. In fact, the recurrent maniacal attacks of senile 
 insanity during the progress of cerebral atrophy are the least amen- 
 able to treatment of all forms of mania. The long continuance of such 
 excitement, the deprivation of sleep, and incessant restlessness, is often 
 a source of surprise to the student of insanity, who would a priori 
 
41 G THE LSSAXITY OF TUE SEXILE EPOCH. 
 
 anticipate rapid exhaustion as the natural outcome. Such cases 
 naturally cause much anxiety and trouble to their guardians, but this 
 anxiety is largely amplified by their occasional refusal of food, and 
 obstinate resistance to compulsory feeding. The maniacal outbursts 
 of these senile dements is often revolting from their degraded habits 
 and utter disregard of all decency. They are filthy in the extreme ; 
 they are also destructive, and are continually removing their clothes 
 and exposing themselves. A sexual element, also, is often a prominent 
 feature in such subjects; erotic tendencies being by no means in- 
 frequent during such maniacal attacks. Thus it is that at the onset of 
 senile insanity, ere other well-pronounced symptoms declare them- 
 selves, the subject (formerly a most moral and well-conducted man) 
 suddenly exhibits such erotic tendencies, outrages every sense of 
 decency, and brings disgrace upon himself and connections, ere it is 
 discovered that he is an iri'esponsible agent. 
 
 This objectionable tendency is one strong reason why an aged 
 parent, suifei'ing from such maniacal outbursts, should be removed 
 from the care of his family. Occasionally such outbursts of excite- 
 ment alternate with depression, and the following instance of senile 
 hypochondriasis illustrates this well : — 
 
 J. A., aged sixty -two, widower, a labourer; a man of average height and well- 
 nourished, with a bullet-shaped head, light saudy-coloured hair, and blue eyes. 
 Patient had lived a steady temperate life ; had suffered from no special illnesses — 
 *' stroke " or "fit." Had sustained no injury to the head. Family history was not 
 ascertainable. He had been wretchedly depressed for six months ; but for three 
 years preceding his admission, he had suffered from slight attacks of depression 
 alternating with excitement, and was taken charge of in the workhouse iufii'mary- 
 wards. Six mouths since, whilst in a very dejected state of mind, he sprang over 
 a bridge uito the river, but was rescued and taken to the workhouse, where he has 
 remained employing himself at useful occupations, but always depressed. After an 
 exciting religious service which he attended six weeks prior to his arrival at the 
 asylum, he became terribly dejected, and, at times, acutely melaacholic, rushing 
 about, wringing his hands, and crying out "lost, lost," and tried eventually to 
 leap from a window. He was brought to the asylum in a state of great agitation, 
 struggling -wildly, and necessitatmg restraint during the transit. The excitement 
 abated shortly afterwards ; he took a hearty meal and slept well. The next morn- 
 ing he was able to converse calmly, and gave a detailed account of his past life. 
 "For some years past he has been subject to i)eriods of 'confusion of thouglit,' and 
 failure of memory ; it comes on snddenbj, unexpeciedhj, and at such times he is 
 wholly incapacitated for work. At tunes such attacks were prolonged and accom- 
 panied by intense depression, during which he had to be placed imdcr supervision. 
 In one of these fits of despondency he attempted suicide. He beheves he is 
 'eternally lost;' but his chief trouble at this time was not so much liia soul's 
 welfare, as the idea that he cannot digest his food ; he constantly dwells upon the . 
 condition of his stomach and bowels, to which he refers many imaginary ailments." 
 His memory was but slightly impaired, being more sluggish of recall than actually 
 deflective; hia intellectual operations geucxally were torpid; his attention enfeebled. 
 
SENILE HYPOCHONDRIASIS — SENILE ATROPHY AND THROMBOSIS. 417 
 
 SO that occasional confusion of ideas occurred during conversation ; no hallucina- 
 tions existed. He had a dejected expression. The x'^pils were equal and active, 
 of normal size ; the tongue was protruded straight, and showed no ataxy or 
 tremor. No evident degeneration of the superlicial arteries was indicated, and 
 the heart was apparently healthy. 
 
 Patient at the asylum soon settled down to suitable occupations, but alwa3'S 
 wore a depressed and anxious expression ; and was eager to talk of his hypochon- 
 driacal fancies. His memory for recent events underwent notable enfeeblemcnt, 
 and his speech was slow and laboured. Suddenly he became acutely melancholic, 
 betrayed extreme agitation, labouring under the delusion that he was lost, but he 
 resumed his former state in a few days. Eighteen months after admission, it is 
 noted that "he is habitually dejected, groans at times, observes that nervous 
 debility has affected his mind ; he sleeps badly and his health is feeble." Dur- 
 ing the following year he continued more agitated, his melancholic delusions gaining 
 a tirmer hold upon him. He affirmed that " the influence is on him, and will blow 
 him to atoms;" that "his inside is flushed up to his throat;" that "there is a fire 
 within his body;" that his food has "never digested since he came here," and that 
 his "bowels are obstructed." Chloral alone afforded him relief, and was frequently 
 required to secixre sleep. Thus he remained for some years with no relief nor altera- 
 tion of his deluded state, pacing up and down the wards with woe-begone aspect, 
 groanmg, importunate upon the subject of his hypochondriacal fancies; dwelling 
 upon his "depressed spirits," "sleeplessness," and " the fire that has for twenty 
 years burned within him." He died, seven years after admission, of pulmonary 
 congestion. 
 
 Many cases of senile dementia present for some time a gradual, 
 progressive mental enfeeblement, without any notable degree of excite- 
 ment. A constant unrest, a mild depression, with very vague fears 
 and ill-defined notions of coming trouble prevail, often associated with 
 distrust and more definite suspicions of persecution. Such was the 
 following case, in which the ideas of persecution became more defined, 
 and issued in paroxysms of great agitation; and in which the progress of 
 atheromatous, vascular disease resulted in a slight transitory mono- 
 plegia from plugging of the vessels. 
 
 I. B., a widow, aged seventy-five. Lost her husband eight years ago, and lived 
 with her children until removed to the workhouse, nine weeks since, having become 
 unmanageable at home. She had been failing in mental powers for some few years. 
 . At this time she was excited and very restless, wandering about her room day and 
 night, seeking her husband, whom she believed still lived, and expressuig fears that 
 the inmates of the workhouse had designs upon her life. Her habits as regards 
 alcohol had been temperate ; there was no history of insanity or other neurosis in 
 her antecedents. Upon admission she was fairly quiet, and conversed affably. 
 Grave mental failure was apparent ; she still thought she was at the -SA-orkhouse, 
 although she had been here a week ; "came direct from her own home, where she 
 had been living with her husband and mother-in-law ; the latter is not old, and 
 she speaks of her husband as youthful; she herself is about thirty-six years of age; 
 her husband lives in Kew Leeds; she saw him a fortnight ago." "She makes vague 
 statements of ill-treatment before coming here, weeps childishly, and then as 
 suddenly becomes cliccrful and contented. She is a shrunken old woman, mucli 
 
418 THE INSANITY OF THE SENILE EPOCH. 
 
 reduced in bodily condition ; the face much wrinkled, the complexion earthy, and 
 the hair grey and scanty ; there are no teeth. The superficial arteries show no 
 marked signs of degeneration ; the jailse is 90, regular and of fair strength ; no 
 obvious morbid state of circulatory or respiratory systems appreciable ; urine 
 almost colourless ; specific gravity, 1010 ; no trace of albumeu ; no deposits." During 
 her first mouth's residence here she exhibited the usual reductions of the senile 
 dement, but no outbursts of excitement occurred. She slept soundly and took her 
 food heartily, yet she was restless, discontented, peevish, wandered about in an 
 aimless, half-vacant manner, and, when questioned, explained that her husband 
 was at work close by at a colliery, and that she sought him and her son. Her 
 habits also were inattentive ; did not recognise the nature of her surroundings ; 
 believed she was still at Clayton Workhouse. About four weeks after admission 
 she had one of the characteristic seizures to which these aged dements are subject. 
 Whilst sitting in her chair she became pale and faint, lost consciousness moment- 
 arily, and the left upper extremity was found paralysed. The patient remained in 
 a state of semi-stupor for about an hour, then recovered rapidly, and shortly 
 afterwards could walk about readily; the paralysed limb regained its usual power. 
 A month later it is noted that "she fancies her father lives here, as also that his age 
 and her own are the same. Is dirty, restless ; often weeps and cries to go home ; 
 is more feeble and wasted." Still later on she became melancholic, even acutely so ; 
 appeared in great agitation and terrified ; would cry aloud, " Are you going to pub 
 me underground? " 
 
 The following case i.s one of a more acute character ; the prevailing 
 mental state being that of melancholic depression, attaining at times a 
 degree of acute melancholia. It will be noted how the physical exam- 
 ination testifies to the general malnutrition, great emaciation, and to 
 the failure in cardiac energy and advance of atheromatous change in. 
 the peripheral blood-vessels. The most striking feature in this case is 
 the hypochondriacal state, which is not at all unusual in the acute 
 forms of senile insanity ; hideous delusions being entertained as to the 
 sinister intention of those with whom the patient is brought in contact. 
 The rapid cardiac failure often leads to alarming syncopal attacks. 
 
 H. D., aged sixty-two, and married. A somewhat tall woman of very haggard, 
 wasted aspect; the complexion sallow, and condition generally very anaemic. 
 Physical examination betrayed enfeebled cardiac energy ; the impulse exceedingly 
 weak, the sounds at base less clear and sharp than normal, but there was no 
 murmur. The temporal and radial vessels were somewhat hard and incompressible, 
 but not tortuous; pulse 96, very small aud feeble. The abdomen was shrunken 
 and hepatic dullness much diminished. Urine 1020, slightly cloudy, anibcr-coloured, 
 alkaline ; a trace of albumen ; a large deposit of mucus. The patient, on admission, 
 was very restless and maniacal— suddenly springing out of bed, knocking over the 
 buckets of water used by the scrubbers, and upsetting the patients' food, declaring 
 it to be poisoned. She made strenuous efforts to escape from her ward, refused her 
 food, asserting that her body was " full up," aud there was no room in her stomach 
 for food. After a restless night she was found vei-y melancholic, and the subject of 
 hypochondriacal delusions. Thus, she stated that for two years past debility and 
 loss of appetite had prevailed, and she had now discovered that her spine had 
 
ACUTE SENILE MELANCHOLIA. 419 
 
 grown forward so as to encroach upoa her stomach, jjreventing the entrance of food; 
 her bones had grown longer and thinner, owing to a poison in the water in which 
 she bathed herself. "She affirms that stars appear in tlie room, talks childishly, 
 and falls into a doze. Hallucinations of hearing prevail at times; she hears the 
 voices of thronging multitudes who have come to watch her. She declares 
 that the flesh has been taken off her bones by some agent introduced into her bath, 
 and that she cannot sit, stand, or walk; wishes to be hanged." Her memory was 
 enfeebled, especially respecting recent events, and a week after admission she 
 thought she was in the Women's and Children's Hospital, and had been here two 
 days. A few days later she expressed fears of being sent away, and upon being 
 questioned, admitted that she believed she was to be cut up by the butcher. Was 
 sleepless and restless, talking all night. Made such remarks as — "Don't put my 
 eyes out ; are you going to blind me? are you going to make me deaf? " Occasion- 
 ally her melancholic fears so got the better of her at night that she could not be 
 kept in association with others ; but had to be removed to a single room, and a 
 small dose of chloral administered ; cried out in terrified tones — " Don't do it to- 
 night, will you ? What are you going to do ? you have done it long since, haven't 
 you ? " Her habits were now very degraded. A month after admission she had a. 
 severe syncopal attack, remained very pale and subconscious for some time, and the 
 pidse became extremely feeble. The base of the right lung now presented signs of 
 pueumouic consolidation ; and two days later it is noted — "Pvequires feeding by 
 the funnel with every meal ; is talkative ; asks. What are you going to do with 
 me ? Ghastly pallor and emaciation are present ; she becomes partly syncopal in 
 the erect posture ; there is friction-sound at base of right lung in front ; over the 
 basal two inches of this lung posteriorly, percussion is dull, and there is high-pitched 
 bronchial breathing with sonorous rhonchi ; there is cough with purulent expecto- 
 ration. Ordered rffff^Ji grain atropine hypodermically ; is fed with milk, eggs, and 
 mutton-broth." She sank into a state of coma in a little over a month from 
 admission, and died. 
 
 As an instance of senile insanity, with the prevalence of mental 
 exaltation, the case of J/. H. (p. 424) may be usefully contrasted 
 with the above. 
 
 The mental exaltation here alluded to is one of gravest moment 
 and ominous of coming dissolution ; the genei'al exaltation, which is 
 the prevalent feature in all simple maniacal states, is but the expression 
 of a very universal disorder of function. It is the partial exaltation 
 manifested as regai-ds one or other of the most complex groups of feel- 
 ings which comprise the pesthetic or the religious sentiments, the social 
 and the domestic feelings, the sentiments of possession, of freedom, and 
 many others — the later developments of civilised man — it is this exal- 
 tation which is so ominous of coming evil. The sentiments are, as ex- 
 pressed by H. Spencer, purely re-representative feelings; a compounded 
 aggregate of numerous recollections, vague yet massive, combined 
 with a still vaguer part, a kindred feeling organically associated by 
 ancestral experience.* Such optimism is usually the knell of com- 
 mencing decay. We need not here attempt to analyse such complex 
 groups; we need only recall the foct that according to the special group 
 * Principles of Psychology, vol. ii., p. 57S. 
 
420 TIIK IXSANITY OF THE SICNILK EPOCH. 
 
 we ai'e dealing with, there will he more or less of the emotional 
 or of the intellectual constituent ; that the higher the developmental 
 phase such feelings have attained, the more closely will the emotional 
 and intellectual factors be interblended, and, therefore, the less dis- 
 tinguishable inter se; and the more prepondei'ating will be the cognitivfe 
 elements. The cognitive element is the relational ; for thought is but 
 the passage from one state of consciousness to another ; it is, in itself, 
 but a, feeling, which is of insignificant duration, as compai-ed with that 
 of the states of consciousness which it connects. In the sudden transi- 
 tion from one state to another, we get a more pronounced relationship ; 
 the cognitive element becomes more emjohasised, and thought more 
 definite. Hence, the import of the fact that the relational element of 
 mind is the first to succumb to mental disease. If, as may well be 
 conceded, the change in the nerve-cell represents the physical basis of 
 conscious states, and its protoplasmic extensions represent the relational 
 nexus between cell and cell, whereby a change from one state to another 
 is rendered possible, then our statement is tantamount to affirming 
 that there is a failure in the forcing of the relational channels — that a 
 greater conscious effort is required for definite thought, and that, 
 consequently, there occurs the intensified feeling which we have already 
 alluded to as a rise in subject-consciousness, with a corresponding fall in 
 object-consciousness. This rise in the feeling element, and failure in 
 the cognitive, leads readily to a delusional state, as might be antici- 
 pated. This failure in the relational element of mind, due to some 
 physical interruption of the molecular wave which traverses the con- 
 necting links between cell and cell, may pertain almost exclusively to 
 certain of the higher evolved groups of feelings, and, so to speak, may (by 
 a species of morbid dissection) issue in their gi*adual dissolution, while 
 the other faculties remain more or less intact. The confusion of ideas, 
 the delusional perversions, the indefiniteness of thought, accompanying 
 the decay of the cognitive element, proceed pari imssu with the rise 
 in the feeling element (as exemplified in the monomania of pride, in 
 the delusional states of general paralysis, and in the monomaniacal 
 states of masturbatic insanity), and appear to indicate territorial 
 implications of mind, possibly due to vascular changes. Here the 
 question naturally arises how far this derangement is to be attributed 
 to physical change within the nerve-fibre, or how for to interference by 
 extraneous agencies, such as vasomotor changes, kc. The nervous 
 wave which pervades the labyrinth of cell and fibre-network during 
 active functionising, is normally determined thither by the act of 
 attention ; and, however we may explain this faculty (probably due to 
 the establishment of a more i-apid and vigorous circulation through 
 the active area), its operation doubtless serves to intensify the in- 
 
* DELUSIONS OP TUE SENILE AND MONOMANIACAL SUBJECT. 421 
 
 tcllcctual or cognitive element of mind, and the relations Ijetween 
 feeling and feeling become more pronounced and definite ; or, in other 
 words, thought is intensified. On the other hand, its failure not only 
 reduces the nervous wave in volume and in vigour, but the relational 
 lines cannot be forced thereby, and hence will ensue the states of mind 
 already alluded to. Failure of attention is indubitably the earliest 
 symptom in these states of partial exaltation. From this point of 
 view, the failure of attention is the primary derangement, and the 
 moi'bid result contrasts notably with that morbid entity engendered 
 ab extra. If the bodily sensations (the coensesthesis) are seriously 
 deranged; if altogether novel and obscure sensations are aroused by 
 e.g., various visceral affections, it is notable that the personality may be 
 endangered thereby, and a transformation of the ego may result. This 
 fundamental change may be induced by the 'p&^'sistent attention given to 
 these morbid feelings so aroused — feelings which embrace both the purely 
 sensuous and cognitive elements — and overbalance previously-existing 
 states, destroy the normal contrast, and become by this very faculty of 
 attention intensified, and thus a morbid group of feelings is created and 
 consolidated, which stands out in antagonism to the old self as a new ego. 
 If sensory channels become the media for the transmission inwards to 
 the sensorium of molecular Avaves of abnormal force, volume, or fre- 
 quency, they will naturally arouse the sentinel faculty of attention to 
 question their nature and relationship, and thus further aid the forcing 
 of those relational lines which consolidate the whole. We have thus the 
 possibility in the nervous mechanism of two morbid conditions arising, 
 wholly distinct in character, whereby serious intellectual derangements 
 may ensue. In old physiological parlance we may liken them to the 
 vis afronte and vis a tergo of circulatory phenomena; the former, repre- 
 sented by the faculty of attention, the latter, by the varying in-going 
 currents along the sensory nerves. When the morbid transformation 
 of the ccencestJiesis gives rise to the gradual pervading of the old by the 
 new ego {e.g., extreme egoism of puberty) — as the strengthening and 
 elaborating, and integrating process advances under the auspices of a 
 restricted attention — the definiteness of the delusional concept becomes 
 notable, and no possibility of scepticism can arise ; there is no excite- 
 ment, but great mental calm. 
 
 Hence, the essence of these forms of monomania is their con- 
 structive nature, whilst the distinctive feature of the perversions of 
 the exalted senile dement is their dissolution ; one is synthetic, the 
 other analytic and destPUCtive. Enfeeblement of the faculty of 
 attention, therefore, evokes failure of the relational element of mind. 
 Thought becomes obscured, and lessened in vigour and definiteness, 
 the faculty of association of ideas is necessarily weakened ; feelings are 
 
422 THE INSANITY OF THE SENILE EPOCH. 
 
 more crude, ill-defined, or poorly-demarcated from associated feelings ; 
 thought becomes less coherent, delusional concepts are apt to arise 
 from exaggerated feelings, and loss of the contrasting and representative 
 faculty, and excitement prevails. In the rapid reductions of general 
 paralysis we shall see how all those feelings which are based upon tho 
 instincts of conservation of the self, or of the progeny (together witli 
 the complex and consolidated groups making up the social, religious 
 and aesthetic sentiments) successively become deranged ; and how in 
 each the faculty of attention is first or earliest involved. This disease 
 reproduces, in a terribly-rapid sequence, the morbid results which more 
 gradually ensue in the decay of senile atrophy ; the relational element 
 or the nerve-cell prolongation is the earliest to succumb. 
 
 Sonile Amnesia. — We have already seen that the earliest symptom 
 apprising us of commencing decadence of mind in senility is the failure 
 of memory for recent occurrences. The latest impressions reaching the 
 sensorium may be so imperfectly registered as to be rapidly obliterated, 
 or they may fail to establish the organic connections whereby they 
 become more permanent constituents of the nervous mechanism. In 
 the nexus of processes connected with, and extending around, a nerve- 
 cell, we decipher the integration of structure u])on which its permanence 
 as a functional unit depends ; and the more free such channels of com- 
 munication become, the more fully organised is the structure, and the 
 more stable and resistant to the enci'oachments of senile dissolutions. 
 The latest requirements, however, are expressed in the structural modi- 
 fications of the highest nervous arrangements where integration of 
 structure is least advanced ; and unlike those associations which have 
 been called into activity over and over again, many thousand times, 
 they fail in that nexus of communications necessary to their stability. 
 Thus it becomes a matter of common observation that these senile sub- 
 jects are oblivious to the most ordinary events occurring in their 
 immediate presence ; they will sit down and enjoy a hearty meal, and 
 an hour after be unconscious of the fact; will meet a friend in converse, 
 and forget immediately both the occurrence and the conversation. If 
 the event be recalled, its connections with his recent experiences are 
 so frail as to end in his relegating it to his bygone histor}^ Ribot has 
 well described the process of recollection and localisation of events 
 in time. He indicates how the mind, as it were, travels back along 
 certain definite lines, not recalling the myriad of events intervening, 
 but leaping from certain prominent stations, or, as he calls them, 
 *' reference-points," until it arrives at the desired ej^och, and thus, as it 
 were, laying down a measuring-rod which defines the two points in 
 time. "Without this abridged process and the disappearance of a 
 prodigious number of terms, localisation in time would be very long 
 
SENILE AMNESIA. 423 
 
 and tedious, and restricted to very narrow limits " ; and again, '' by 
 repetition the localisation becomes immediate, instantaneous, auto- 
 matic " (pp. 52, 53). This does not accurately describe the process for 
 all, inasmuch as the process varies much with different individuals. 
 Thus, if we take into account those who " visualise " (in the sense in 
 which this term is used by Galton), we find that the mind often recurs 
 immediately to the event in qu.estion without apparent reference-points, 
 and that the greater or less vividness or faintness of the image visualised 
 tends to localise the event in time for such subjects ; or that the mind 
 travels forwards from a similar reference-point to the present, so re- 
 versing the process described by Ribot, This condition of mental, 
 historical perspective steadily declines in senile dementia ; so that 
 localisation in time becomes to many quite impossible ; present events 
 fail to impress the organisation with their wonted vigour, and bygone 
 experiences rise into undue prominence, rivalling in their more vivid 
 reproduction the more recent occurrences, and become, as it were, pro- 
 jected into the present. This is what we might anticipate, as greater 
 resistance is ofi'ered to the molecular currents of the highest nervous 
 mechanism, the tide of nervoiTS discharges must recede to the more 
 deeply-organised structures. That the latest acquisitions and powers 
 suffer earliest is also exemplified in the failure of memory for foreign 
 languages, for late intellectual operations of abstruse nature, and, in 
 fact, for all recent additions to the individual's knowledge ; the more 
 specialised knowledge always fades soonest. So proper-names are for- 
 gotten, a father may fail to recall his children by name, although he 
 recognises each individually ; or a patient, daily attended by nurse or 
 doctor for years, may be unable to recall the name of either. Sub- 
 stantives are liable to be forgotten ; as indicated by the hesitating 
 speech, and usually a dead stop at a noun. Dr. Clouston truthfully 
 portrays the typical senile speech as " a mixture of a^^hasic, amnesic, 
 and paretic symptoms." * The decay of the intellectual is followed by 
 failure of the sentient element of mind ; emotion and feeling become 
 slowly impaired, but at a much later date. Still, the patient may 
 pursue his usual course of life, and all deeply-rooted sympathies, 
 weaknesses, and prejudices may prevail in full force : the customary 
 habits of a long life maintain their ascendancy ; and though special 
 aptitudes fail, the ifiiore general are still retained. Eventually, with 
 their decline the subject is reduced to a mere vegetative state of ex- 
 istence. The whole process forcibly illustrates the law of dissolution, 
 whereby the most-specialised, most-complex, and least-organised ner- 
 vous arrangements suffer first, and the more-general, least-complex, 
 and more-organised and stable nervous-arrangements are the last to 
 
 * Op. cit., p. 568. 
 
424 THE INSANITY OF THE SENILE EPOCH. 
 
 succumb; in otlaer -words, tlie dissolution takes the course from the 
 least to the most stable arrangements. 
 
 M. H., aged seventy-six; widowed. Has had twelve children, of whom five are 
 living. A shrunken, withered-up old woman, 4 feet 10 inches in height, and 
 weighing only 99 pounds. Skin of face extremely wrinkled; slight arcus round 
 botli cornea3 ; the hair of head scanty and white. She had a demented aspect, 
 ■which, on excitement, gave way to a mischievous, or even malign expression. She 
 was well-nigh edentulous. Phj-sical examination revealed no ahnormal condition 
 beyond very enfeebled action of the heart, and a small weak pulse. One of patient's 
 daughters was insane, her antecedents' history is free from insanitj' (mother dying 
 at age of ninety-nine), epilepsy, apoplexy, or phthisis — no history of intemper- 
 ance. 
 
 It was stated that she was quite rational until she was taken a month ago to a 
 special service of the Salvation Army; she was persuaded to preach and to sing 
 there, and had never been well since. She returned excited, irrational, and quite 
 incapable of taking care of herself. She talked almost exclusively about the 
 Salvation Army, being full of delusional notions respecting their doings. Just 
 prior to admission her excitement became intense, she possessed herself of a razor, 
 and her neighbours believed she meditated suicide; she also applied a lighted stick 
 to the back of her neck, and tried to swallow some lighted chips. Upon admission 
 she was noisy, excited, clapjiiug her hands, singing and talking incessantl3^ The 
 excitement abated after a few questions had been put, and she replied with fair 
 amount of coherence. Her thoughts appeared wholly occupied by religious 
 subjects, and she especially alluded to her attendance at Salvation Army gatherings. 
 Declared she had seen both heaven and hell — the latter "all fire and l^rimstone." 
 During examination she heard voices from above, voices which spoke to her of 
 heaven, talked in a hurried, excited, and joyous strain, and mistook the identity of 
 those around her. She says she was told by the Salvation Army that the pain she 
 felt at the back of the neck would be relieved by placing burning wood there and 
 on her bosom, this she did, and also swallowed turpentine for a similar purpose. 
 The poor woman, in fact, was found by her neighbours experimenting thus : her 
 door barred against them by a chest of drawers, and she herself, excited, with a 
 flaring stick in one hand, and a razor in the other. Five days after admission, it is 
 noted, "always elated, talks much, pi'ays much, declares she has been here since 
 August, and it is now March (really January). This building is the Salvation 
 Army Barracks at ISTewcastle-upon-Tyne." Again, a few days later, "she is 
 extremely excited, gesticulating, tossing her arms about from side to side, beUeves 
 she is captain of the Salvation Army, the asylum is their barracks, and she is leading 
 them on. A few days ago she refused her dinner because it was poisoned. " Later 
 on, her nights became greatly disturbed by excitement and nois}- garrulousness ; 
 obtahied sleep only when chloral was administered. Three weeks after admission 
 she was still noisy and excited, swore and quarrelled, threatened the patients, 
 abused the nurses, asserted she had been here twentj'^-eight weeks, and had had 
 not a bit of food; last night thej' brouglit her "what they called tea, but she had 
 to cut open her throat to take the stutf out." -^ gr. hyoscyamine ordered each 
 morning. The hyoscyamine at first gave considerable relief during the day, and, 
 later on, her nights were also less disturbed by excitement ; but, her excitement 
 re-appeared, and the hyoscyamine was increased to i gr. The excitement was 
 characterised by coarse, profane language; her conduct was revolting; her aspect 
 repulsive; and speech and act became tinctured by much obscenitj'. She had 
 
ILLUSTRATIONS OF SENILE INSANITY. 425 
 
 a very simian aspect, grinned, grimaced profusely, distorting her features, gesticu- 
 lating wildl}', siui^'ing aloud, or laughing in a convulsive cackling manner. 
 
 About four months after admission the hyoscyamine was replaced by a mixture 
 containing a drachm of the tincture of Indian hemp, and 25 grains of the double 
 bromide of sodium and ammonium for each dose daily. No relief was afforded, 
 however, and the hemp was discontinued after two months' trial. 
 
 This patient still remains at the asj-lum, now twelve months since admission. 
 Her physical health is in a very precarious state ; she is excessively emaciated, 
 and every effort has to be made to maintain her bodily heat, as she is so incessantly 
 restless and disorderly ; she is very feeble on her limbs ; her habits are still 
 repulsive and dirty ; her language profane, obscene, and irrational. Still she takes 
 her food well and sleeps better, and upon the whole is less excited. The case is a 
 typical one of mania occurring in the course of senile atrophy ; the mental exalta- 
 tion is a notable feature ; the excitement loud, boisterous, unruly, and of long con- 
 tinuance night and day for weeks together. It also affords an instructive example 
 of the effects of misguided religious services upon an unstable mental organisation 
 such as our patient's. The violent attempts prompted by her delusions illustrate 
 also how the exaltation of these senile dements may often lead to suicidal actions. 
 Another phase of her insanity was the extreme obscenity of her speech and conduct, 
 also a frequent accompaniment in such cases. 
 
 The following also may be quoted as illustrative of the vivid hallu- 
 cinations and terror seen in these cases of senile melancholia during 
 the progress of atrophy, the dangerous impulsiveness to which they are 
 liable, and the great trouble they giv^ in our asylums. 
 
 M. M., aged eighty- five. A widow with two children ; of Roman Catholic per- 
 suasion. Was admitted October 13th, 18S6, under the following certificate — 
 ' ' Chatters about dead people whom she believes to be still living in an empty 
 house close by ; and one of whom she talks of marrying to-day. Believes herself 
 to be possessed of property. Rambles about in search of imaginary objects. At 
 one moment greatly distressed and crying, the next violent in speech and conduct. 
 Has to be constantly watched to prevent her damaging windows and rambling 
 from home. Threatens to kill her children and burn her house down ; attempts to 
 strike her grandchildren with a poker." She was said to have been a very steady 
 woman with no insane or epileptic inheritance ; one daughter had died of hjemop- 
 tysis, another of phthisis. It is affirmed that imtil five weeks ago she showed 
 no mental derangement. She then became excitable, disorder^, tossed food down 
 into the cellar for others to feed upon ; soon became quite intractable, and several 
 times rushed upon her daughter with a knife. Has been most destructive of 
 clothing. "She has a large dolicho-cephalic head, a very long face, which is ex- 
 tremely wrinkled and pallid, and a fatuous expression. The hair is thin and 
 white, jaws massive and prominent, few teeth remain. She is much emaciated. 
 The superficial arteries show no very decided cording; heart's action feeble. There 
 is slight pulmonary emphysema. Examination of the organs negative. " 
 
 Oct. 2lst, 1SS6. — Restless and terrified last night ; kept looking at, and pointing 
 to, the windows, and declaring that "Mahony was coming to kill her." 
 
 Od. 25th. — Very restless ; incessantly trying to get out of the ward ; asserts that 
 she is "going home to-daj'." To have a mixture of tinctura hyoscyami with the 
 double bromides of sodium and ammonium twice daily. 
 
426 PREMATURE SENILITY. 
 
 Oct. 30th. — Somewhat less restless ; seldom will stay in the day-rooms ; prefers 
 being in the corridors with the object of getting through the doors. Says her 
 ■"Cousin is drinking up there;" she "is waiting for him; the old rattle-one is 
 coming after her all the while." Cannot tell where she is. Sleeps fairly well. 
 
 Nov. St/i. — Required feeding by the funnel; is deluded, unquiet, and speaks 
 angrily against those who feed her. Talks much in unintelligible Irish brogue. 
 
 Dec. 23rd. — Asserts that " they are going to kill her ; there are some knives with 
 them there ; there they are " — pointing to the ceiling. Is very agitated and restless ; 
 <loes not sleep well, and grows weaker. 
 
 Feb. 2nd, 18S7.— Often excited and noisy; on the .30th ult. refused her dinner 
 and remarked — " I wont take a bit ; how do I know what poison I get? " At times 
 fights with those who approach her, evidently in terror lest they should harm her. 
 Is very feeble and thin ; often requires a small dose of paraldehj-d at night to 
 secure sleep. 
 
 April "ith. — Frequently distressed and weeps, and is often excited and restless, 
 searching for her "mother;" goes up to the patients, peers into their faces 
 inquisitively, and slowly satisfies herself that thej' are not her mother. Is very 
 i'eeble and very thin. 
 
 Jifay 4th. — Declares that her mother is upstairs— pointing to the ceiling ; often 
 talks to her own reflection in the mirror; habits clean; takes food well. Bromides 
 and henbane stopped. 
 
 Premature Senility.^A careful compai-ative .survey of the fore- 
 going histories, with the case of ff. 0. detailed at p. 210, will at once 
 convince us that we are dealing in both instances with two obviously- 
 distinct affections of the nervous system. In the senile form we find 
 the results of a general decline in the vital activities ; the functions of 
 nutrition, circulation, and the respiratory activities diminished. So 
 also the blood-stream is impaired in quality, diminished in quantity, 
 sluggish in its flow ; and when we turn to the verdict of morbid 
 anatomy, the blood-channels exhibit diseased tunics, narrowing of 
 their lumen, tortuosity with attendant imj^airment of their resilience 
 accompanying atheroma, — the tissue-elements universally, and the 
 brain-cells in particular, presenting fatty-change in their constituents, 
 all indications of a senile retrogressive process. 
 
 The latter form (chronic cerebral atrophy) likewise presents a notable 
 vascular change, but of a very different nature — a compensatory hyper- 
 trophy of the muscular tunic of the small vessels, especially emphasised 
 in the cerebral arterioles, and very frequently associated with advanced 
 atheroma of the large basal blood-vessels. This hypertrophic condition 
 is also found in varying degrees in the kidneys, being identical 
 with the changes described in the arterial system by Dr. George 
 Johnson, as those of chronic Bright's disease, especially of that form 
 associated with the contracted kidney. The imperfect renal function 
 is manifested in nearly all these instances of chronic brain atrophy, 
 as may be illustrated in the following table, containing the results of 
 examination of the urine in seven typical instances, followed for the 
 
ELIMINATION OF UREA IN CHRONIC BRAIN ATROPHY. 
 
 427 
 
 
 
 M 
 
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428 
 
 PREMATURE SENILITY. 
 
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 re I— I o o 71 ce cc ■-:: X c/: ic x i: ■ 
 
 ^- o CI o t^ CI — cc X r— re — X > 
 
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CHRONIC CEREBRAL ATROPHY AND BRIGUt's DISEASE. 429 
 
 contrast by a case of general paralysis (./. //.), and one of acute 
 delirious mania {T. R.). The urea was estimated in these cases by 
 means of Gerrard's ureometer, and the amount in health normal for 
 each individual was obtained by Parkes' empirical formula, having 
 regard to the sex, body-weight, quiescent, or active condition of the 
 patient. When these conditions, together with those dependent upon 
 diet are allowed for, we still find a considerable deficit in the amount 
 of urea daily eliminated. Two cases out of the seven revealed 
 albumen, and only to a slight degree. 
 
 The history of such patients points very decisively towards the 
 morbid change being expressive of a general constitutional derangement, 
 which we must identify with chronic Bright's disease, and which 
 expends its force with varying degrees of intensity — 
 
 1. Upon the minute arterioles of the kidney, productive of the small 
 contracted organ met with— 
 
 2. Upon the minute cerebral arterioles issuing in this chronic atrophy 
 of the brain— 
 
 3. Or is chiefly emphasised in the vascular apparatus of the spinal 
 cord. 
 
 In all such cases alike we have similarly-disturbed functional prodro- 
 mata with associated neuroses; in all the high-tension pulse is a 
 characteristic indication; in all a similar effect is reproduced upon the 
 heart and large blood-vessels. 
 
 If we contrast the senile pulse where atheromatous degeneration 
 prevails with that of a typical instance of chronic brain atrophy, we 
 find the former presents a tortuous artery, unduly prominent and 
 visibly mobile with each pulsation, giving a sphygmogram of exceed- 
 ingly low tension, a vertical percussion up-stroke, an almost equally 
 sudden collapse, and a frequent diminution of the dicrotic wave varying 
 with the endo-cardial and aortic conditions. There may possibly be a 
 degree of aortitis deformans, with loss of normal elasticity, associated 
 with more or less aortic regurgitation; secondary undulations during 
 diastole are usually absent. 
 
 In these cases of cerebral Bright's disease, however, the pulse is 
 small, very hard and incompressible, in fact, indicative of a high arterial 
 tension, modified more or less by a hypertrophied left ventricle; there 
 are also a well-marked percussion-impulse A'arying with the degrees of 
 hypertrophy, a well-sustained tidal and good dicrotic waves, often 
 succeeded by a slight secondary undulation during the diastolic pause 
 (arterial elasticity). In the case of extensive atheromatous disease a 
 tracing-pressure of from 30 to 60 grammes suffices, and the occlusion- 
 pressure is very low; in the pulse of the subject of chronic brain atrophy 
 the hardness is so marked that we have often to employ a pressure of 
 
430 PREMATURE SENILITY. 
 
 180 grammes, and -with a large liypertrophied heart the pressure often 
 has to be still further increased. 
 
 The obstruction in all these cases is due to the hypertrophy of the 
 tunica vucscuhiria. As was indicated years since Ijy Dr. Broadbent,* 
 the peculiar character of the spliygmogram is immediately altered by 
 the exhibition of aniyl, and also by the onset of jjyrexia. With the 
 atheromatous condition, however, the exhilntion of amyl, of alcohol, 
 and especially of alcohol subsequent to chloral, produces such paralysis 
 of the muscular tunic as often to result in a dangerous vaso-motor 
 relaxation — a condition not seen in chronic brain atrophy except with 
 the association of extensive atheroma. 
 
 As in the early stage of Bright's disease the chief symptoms are 
 those referrible to disordered digestive and assimilative functions — 
 pyrosis, eructations, gastralgia, nausea, loathing of food, or a capricious 
 appetite may long prevail and constitute the premonitory note of 
 alarm. Then follow evidences of depraved blood ; of the hydrsemia 
 associated with adventitious irritating substances which fail to be 
 eliminated ; the red-corpuscles decrease in number, and the circulatory 
 energy becomes impaired. Yet it is in the early prominence of nervous 
 symptoms that we see indicated the tendency to issue in brain disease. 
 All cases of Bright's disease exhibit more or less of these nervous 
 derangements, but such symptoms are peculiarly emphasised in the 
 cases with which we are now concerned. Headache (often hemicrania), 
 giddiness, vertiginous seizures, syncopal attacks, severe palpitation, 
 disordered sensation (special and general) are peculiarly prominent. 
 Some subjects are victims to severe forms of facial neuralgia, others 
 complain of great mental torpor with somnolence or even stupoi*. A 
 deranged state of the blood, as regards its quality and its supply to 
 the central nervous system, explains to a large extent these symptoms 
 of disordered innervation. 
 
 Just as with the renal implication of chronic Bright's disease, the 
 intensity of constitutional and local indications may bear no constant 
 relationship to each other — so in these cases the degree to which the 
 nervous-centres are involved will greatly vary for each individual case, 
 the local having no constant relationship to the constitutional. "With 
 the implication of the nervous-centres we may find associated every 
 degree of renal and hepatic degeneration and cardiac hypertrophy ; 
 but it is more usual to find the kidneys in a state of early interstitial 
 fibrosis than very extensively affected ; we usually find one organ in a 
 much more advanced state of degeneration than the other. 
 
 The special determining factor upon which depends this tendency to 
 
 * Discussion at the Royal Medical and Cliirurgical Society, Med, Times and 
 Gaz, Dec, 1S72. 
 
ALCOHOL AS AN ETIOLOGICAL FACTOR. 431 
 
 implication of the cerebrum in particular, in cases of chronic Ijrain 
 atrophy, would appear from our statistics to be alcohol; a large 
 percentage of alcoholic cases undoubtedly succumb to this affection. 
 The selective power of the brain for alcohol has probably much to do 
 with this determination of morbid activity towards the cerebral blood- 
 vessels. Eecognising in most, if not in all, such cases, the injurious 
 effect of alcohol upon the blood-plasma, we cannot too strongly insist 
 upon the importance of defining the constitutional as apart from the 
 local derangement in the earliest stages of this affection, and of at 
 once treating such conditions with the object of evading the local 
 implication. 
 
PART III.— PATHOLOGICAL SECTION. 
 
 General Contents.— ^Nlorlnd Condition of Cranial Bones— Investing Membranes — 
 Brain Substance — Histological Elements of Cortex — Forms of Tissue Dej^radation 
 — Pathological Anatomy of General Paralysis, of Epilepsy, and of Chronic 
 Alcoholism. 
 
 GENERAL PATHOLOGY AND MORBID ANATOr/IY. 
 
 Contents. — The Cranium — Dura Mater — Pia-Arachnoid — Arachnoid Htemorrhage — 
 Adherent Pia — Vascular Apparatus — Congestion — Inflammation — Softening — 
 Atrophy — Miliary Sclerosis — Colloid Degeneration — Granular Disintegration of 
 Nerve-cells — Pigmentary or Fuscous Degeneration — Developmental Arrest of 
 Xerve-cells — Vacuolation of Cell-i^rotoplasm — Vacuolation of Nucleus — Destruc- 
 tion of Intra-cortical Nerve-fibre Plexus — Tissue Degradation from Over-strain 
 — Tissue Degradation from Active Morbid Processes — Tissue Degradation from 
 Disuse — General Summary. 
 
 The CPanium. — The bones of the skull-cap present as their more 
 frequent anomalies of texture, one or other of the following con- 
 ditions : — (1) They may be thickened even to an excessive degree, 
 and yet be light in weight from the abundance of rarefied diploe. 
 
 (2) They may be increased in thickness, and heavy from general 
 increase in density throughout, and subpei-iosteal addition of bone. 
 
 (3) They may be extremely dense, but not thickened (on the contrary, 
 they may be thinner), and the surfaces eburnated and polished in aspect. 
 
 (4) They may be reduced in thickness and density, even to such a degree 
 as to become semi-diaphanous over certain regions. 
 
 The first condition (due to subjacent irritation) is sometimes 
 associated "with thickened and adherent dura mater ; subacute 
 inflammatory states, probably, explain this association of central 
 rarefaction with superficial hyperostosis. The second condition is far 
 more frequent, and sometimes leads to extremely heavy skull-caps ; it 
 may also be due to prolonged and very chronic inflammation of the 
 texture ; although in many cases it is probably the result of repeated 
 vascular engorgements, and the excess of nutritive plasma brought to 
 these parts by conditions of violent cerebral excitement, occurring 
 through a period of many years in chronic mania. The thickened 
 dense skull-cap is frequent in epileptic subjects, and in the dementia 
 
TIIK CRANIAL UONES. 43.'i 
 
 of chronic insanity.* The inner surface may exhibit protuberant 
 bosses, frequently coinciding with subjacent atrophy of brain-substance; 
 whilst the grooving of the vitreous table is converted into a deeji 
 channelling, extending almost to the cancellated structure, and 
 bridged over here and there by newly-formed bony tissue. The 
 hyperostosis is genei'ally disposed over the whole of the vertex, but 
 is almost i-nvariably most pronounced in the frontal and the occipital 
 regions, and more especially the former locality. "When, as we occasion- 
 ally find, localised hypertrophy occurs, the frontal bone is by much the 
 more frequent site of the thickening. We have records of fifty-four 
 cases of localised hyperostosis, and in thirty-one of these the frontal 
 was the site of this bony increase ; in seven cases the occipital, and in 
 six cases the parietal were the regions involved. 
 
 A not infrequent disposition, and one which carries with it con- 
 siderable interest, is the thickened state of the left frontal associated 
 with that of the right occij)ital regions. The frequency of cranial 
 hyperostosis may be gleaned from the fact, that it presents itself in 
 one-fourth up to one-third of all cases of insanity. Thus of 1,5C5 fatal 
 cases of insanity, the cranial bones were thickened in 404 instances 
 (or 25 "8 per cent.); and they were indurated, dense, and heavy in 523 
 subjects, or 334 per cent. 
 
 The diminution in the thickness and density of the cranial vault is 
 most usually seen in senile atrophy ; the process whereby such a 
 condition is induced being, in fact, similar to that universally pre- 
 vailing at this period. The facial boneS, however, are more subject 
 to this atrophic change than those of the cranial Cavity, and, in fact, 
 we may note the coexistence of the former with hypertrophic thick- 
 ening, and induration of the latter {Rokitanshj). The sutural lines 
 are usually the site of most advanced atrophy, and irregular depressions 
 or pits alongside the sagittal suture, indicate the absorption due to 
 exuberant Pacchionian bodies along this course. The vitreous table 
 is more especially involved in these senile cases, and the morbid 
 process is one of eccentric atrophy, the compact being gradually 
 replaced by cancellous tissue. Osteophytes in the form of irregular 
 superficial masses on the inner surface of the cranium, osseous spiculse, 
 plates, and small exostoses are occasionally met with ; as also a form 
 of eburnated osteoma of concentric lamellte with radiating canaliculi, 
 
 * " Hyperostosis almost always presents itself in both its forms, namely, that of 
 deposition externally upon tlie bone, and simultaneous condensation of its tissue 
 (sclerosis). In a few cases it goes on to such an extent that the skull is not only 
 (according to ladelod and Ilg) larger than natural, misshapen, and uncommonly 
 thick (9 lines to H or 2 inches), but it also acquires a weight that is almost 
 incredible."— PailAcyi, Anat., Rokitansky, vol. iii. 
 
 28 
 
434 MORBID STATES OF THE INVESTING MEMBRANES. 
 
 and devoid of blood-vessels ( Virchow, Cornil, and Itanvier). All these 
 indicate " an extinct localised inllammatory process, the products of 
 ■which here remain in an ossified form" (Griesinger). Our own* 
 observations tend (with certain qualifications) to confirm the opinion 
 long since expressed by Dr. Bucknill, that the increased thickness of 
 the cranium in insanity is not connected with cerebral atrophy, his 
 statement being — " Some of the heaviest and thickest crania "which 
 ■we have met with, have occurred in instances in which there was 
 little or no cerebral atrophy ; and the condition of the cranium where 
 thei'e is imdoubted atrophy of the brain, is not unfrequeutly one of 
 abnormal tenuity." * 
 
 Exostoses and bony spiculte are exceptionally- rare in those dying 
 insane. Dr. Bucknill states that such outgrowths were found by him 
 in but three cases out of 400 siibjects. Our own observations ■would 
 tend to render them of even less frequent occurrence ; since out of a 
 total of 2,616 fatal cases of insanity, exostoses occurred in but six 
 cases, and bony plates in the membranes in eight other cases. 
 
 Dura MateP. — This tough inelastic sac investing the brain has so 
 long been considered and described as of double constitution (that is, 
 of dura mater proper, and parietal layer of arachnoid) that it becomes 
 important to define our position respecting its nature ere we describe 
 its anomalies. Eokitansky especially insists upon the distinction — 
 " We are compelled to adopt the distinction by the substantial differ- 
 ence -which is exhibited, at least at jfirst, by morbid processes in the 
 two layers. Inflammation, for instance, attacks one of the layers 
 independently of the other, and presents differences accordingly in its 
 course, in its proneness to extend along the surface, and in the pro- 
 ducts it furnishes, which manifest the analogy between that layer 
 and serous membrane in general."' t Despite the assertion of so 
 eminent an authority, the tendency of modern anatomists has been 
 towards the contrary opinion. The epithelial layer, forming the inner 
 smooth surface of the dura mater, is now generally regarded as proper 
 to that membrane, and not, in the true sense of the word, a reflection 
 of arachnoid. One fact, which tended to emphasise the divergence of 
 opinion respecting this anatomical structure, was the frequency of the 
 formation of so-called arachnoid cystS within the cavity embraced 
 bet^ween dura and visceral arachnoid. A certain number of patho- 
 logists regarded their origin as haemorrhag"ic, pure and simple ; 
 another class viewed them as products of true inflammatory condi- 
 tions ; and the latter naturally held that ^the inner surface of dura, 
 to which they are often attached, is a true serous surface, giving rise 
 
 * Psychological Medicine, Bucknill and Tukc, 3rcl edit. , r- 5G6. 
 t "Pathological Anatomy," iSyd. Soc. 7''rciut\, vol. iii., p, 323. 
 
MORBID STATES OF TUE DUUA MATER. 435 
 
 to these inflammatory exudates. With Axel-Key, and Pictzius, we 
 would describe a visceral arachnoid only, so that the structures and 
 spaces formed between the cranial bones and the brain would bo from 
 without inwards; (a.) dura mater ; (b.) suh-dural space {formerly the 
 ^^ arachnoid sac"); (c.) arachnoid; (d.) sub-arachnoid cavity ; (e.) _^;ia 
 mater; (f.) epicerebral space. 
 
 It must be remembered that this tough fibrous membrane is firmly 
 attached to the inner surface of the cranium, as its inner periosteum ; 
 but, the attachment amounts to firm adhesion along the sutural lines, 
 and at the basal openings, foramen ovale, foramen lacerum, and 
 foramen magnum. It is supplied with blood from the various menin- 
 geal branches, and a rich supply of nerves from the fifth, twelfth, and 
 sympathetic ; in inflammatory conditions of the bone and of this 
 membrane, the inelastic nature of the dura sets up very acute pain 
 from compression of these nervous filaments (Buret). 
 
 Adhesion, to a morbid degree, betwixt this membrane and the bones 
 of the cranium is of frequent occurrence in chronic insanity ; partial 
 adhesions, indicative of bygone inflammatory change, are found in 
 some 15 per cent, of those dying insane, whilst universal strong adhe- 
 sions were established in 90 out of 1,565 fatal cases of insanity (a per- 
 centage of 5'7). The favourite site, as before stated, for partial 
 adhesions is the frontal bone, either along the course of the coronal 
 suture, or in the hollow corresponding to the external prominences of 
 the frontal bosses (10 per cent.); the next more frequent site is the 
 sagittal line and the parietal bone on either side. In a small propor- 
 tion of cases, sixteen only (1 per cent.), the chronic inflammatoiy 
 change had induced a noticeable thickening of the dura ; and in a still 
 smaller category was its appearance as to colour modified from the 
 engorgement of its small vessels (in such cases, the texture was 
 softened and infiltrated, and the subjacent bone similarly involved). 
 Morbid adhesion betwixt this membrane and the arachnoid and brain 
 is of very rare occurrence ; we have seen it in but -6 per cent, of our 
 cases ; and this we regard as another indication of the nature of the 
 epithelial lining of the dura, which seems to present no morbid 
 sympathy wiflh the true arachnoid or to be liable to adhesive inflam- 
 matoiy states. Ptokitansky has affirmed the frequency of such con- 
 nections, but we fail to verify his statement ; at all events, amongst 
 the insane community.* The adhesions are often so extensive and 
 firm that it is difficult to remove the brain without injuring the 
 organ ; hence, the skull-cap with its attached dura have to be removed 
 together. On attempting to separate it from the bones in these 
 
 * See also on this point Dr. Bucknill : Peycholo'jkal Mcdkine, Bucknill and Take, 
 p. 568. 
 
436 MORDID STATES OF THE INVESTINO MEMBRANES. 
 
 extreme forms, we fail to do so, as the membrane tears into shreds, 
 or splits up into layers, leaving irregular white glistening membranous 
 lamellfe, strongly contrasted with the rosy or deeper tinted bone 
 around. All this is, of course, indicative of the results of old-standing 
 inflammation. 
 
 Bony plates within this membrane, as a result of further change in 
 the inflammatory exudate, occurred in 8 cases out of a total of 2,616. 
 It is probable that the exostoses described on the inner surface of the 
 bones of the skull have their origin often in the membrane itself, or in 
 exudate intervening betwixt the two. In one remarkable case the 
 whole of the falx cerebri was thus ossified into a corresponding sickle- 
 shaped bony plate,* such as permanently obtains in the ornitho- 
 rhynchus ; on the other hand, a bony tentorium cerebelli, which we 
 know is normal in many mammals, we have never seen amongst the 
 insane. 
 
 The Pia Arachnoid. — A milky cloudiness of the arachnoid is seen 
 in most brains of those dying at middle age, and the opacity becomes 
 more decided with advancing years, until, in the aged, it is seen to a 
 notable degree, apart from any actual cerebral disease. It has been 
 invariably attributed by pathologists to frequent congestive conditions 
 ^chronic hyperaemia) of the membrane, to which (as Rokitansky affirms) 
 every one at an advanced age must have been occasionally subject. 
 Whatever be the explanation in the comparatively healthy brain, there 
 is no doubt that in the extreme degi'ees of this change, seen in the 
 insane, we must infer a chronic inflammatory agency. In senile 
 atrophy of the brain we see this physiological retrogression emphasised, 
 opacities and thickening of texture being often marked features here, 
 apart from any inflammatory change; the outbursts of senile mania 
 are, however, often associated with a chronic meningo-cerebribis, which 
 subsequently reveals itself in morbid adhesions betwixt the brain and 
 soft membranes. 
 
 It is peculiarly frequent in those prone to alcoholic intoxication 
 {Rokitanshy, Griesinger), and we have seen it as a constant change in 
 the brain of the sane and insane criminal class — which class is, to a 
 notorious extent, addicted to intemperance.f In the insane community 
 generally, we have found arachnoid opacity prevails to a notable degree 
 
 * "A similar structure, constituting an unique specimen of anatomical variety, 
 is exhiljited in the slvull of a female l)elonging to my collection " [Blumcnhach). 
 
 t "It may be generally considered as the result of former chronic hypenemia and 
 inflammatory stasis ; it accordingly occurs together with increase of the Pacchionian 
 granulations — which depends on analogous processes — under all circumstances 
 where habitual cerebral congestion existed during life, as in the case of drunkards, 
 who, indeed, can rarely be considered as mentally healthy." Griesinger on "Mental 
 Diseases," Syd. Soc, 1867, p. 418. 
 
MORBID STATES OP TUE PIA ARACHNOID. 437 
 
 — in nearly 50 per cent. (772 out of 1,565 cases) — and, as usual, most 
 marked along the sulci and the immediate vicinity of the blood-vessels. 
 It is usually associated with considerable thickening of the pia 
 arachnoid (the pia is abnormally thickened in fully 48 per cent, dying 
 insane), partly from fibrinous exudates which have organised, partly 
 from plastic lymph, and often from an cedematous swollen condition of 
 the conjoined soft membranes, and the trabeculae intervening betwixt 
 them in the sulci, resulting in a watery, semi-translucent, gelatinous 
 appearance, with here and there scattered patches, points, or streaks of 
 opacity. The outer surface of the ai'achnoid, covered with a delicate 
 pavement-epithelium, becomes at times perceptibly rough and granular, 
 both to the touch and to naked-eye examination; the condition 
 resembling, histologically, the granular condition of the ependyma, or 
 lining-membrane of the ventricles; it is especially prone to occur at 
 both sites in general paralysis of the insane. 
 
 The conditions above referred to of opacity v/ith thickening of the 
 pia arachnoid may be unattended with any excess of fluid in the sub- 
 arachnoid space; usually, however, in the chronic insane, great excess 
 prevails, so that the normal limpid cerebro-spinal fluid (which varies 
 considerably between 2 drachms and 2 ounces) may be very largely 
 augmented up to 8 or 10 ounces; the soft membranes are buoyed-up 
 by such accumulation, and their meshes become thickened, glutinous, and 
 water-logged. The fluid is acid in reaction, whilst the normal cerebro- 
 spinal fluid is alkaline. It must be borne in mind that this sub- 
 arachnoid cavity is continuous with the general ventricular cavities of 
 the hemisphere, with the central canal of the spinal cord, and with the 
 sub-arachnoid space; products of inflammatory activity being thus 
 capable of transmission to distant parts by the movements produced in 
 this fluid during locomotion, respiration, and circulation, all of which 
 are known to affect the cerebrum. 
 
 In connection with the arachnoid there is an important morbid 
 state, the frequency of which, in insanity, and especially certain chronic 
 forms of insanity, makes it a striking feature in our post-mortem records; 
 the condition referred to is that of false membranous productions, 
 enclosing various contents from straw-coloured serum to thin bloody 
 serum, or blood partly or completely clotted. These formations have 
 been often referred to by the inapt term of arachnoid cysts. When 
 they occur as gelatinous-looking exudates or pseudo-membranous 
 structures upon the inner surface of the dura, they have been regarded 
 as inflammatory in origin, and have been described by Virchow as 
 pachymening'itis interna, in accordance with the view of Calmeil, 
 Boyle, and others. We incline strongly to the view that the inflam- 
 matory theory of their origin cannot be supported by a tithe of evidence 
 
438 MORBID STATES OF THE INVESTING MEMBRANES. 
 
 from asylum experience; there can, we tliink, Ijo little or no doubt 
 that, in tlic case of those dying insane at least, we must claim a 
 hSBniOrrhag'ic OPig"!!! for sucli formations. Their frequency may be 
 judged of from the fact that 81 cases are recorded in 1,565 autopsies of 
 the insane, and their special frequency in that form of insanity which 
 is associated with general pai'alysis, is emphasised by the occurrence of 
 30 instances in a series of 242 general paralytics (a percentage of 12). 
 The appeai'ances presented by them vary considerably with the stage 
 at which they are found. In early stages we may find a sliglit rusty- 
 staining over a more or less localised patch of the inner surface of the 
 dura, or, perhaps, covering the whole area of one of the fossje (and 
 especially the middle fossa at the base of the skull); over this rusty- 
 stained groundwork minute droplets of blood are seen, as if besprinkled 
 by a brush, or as if the blood had oozed from the surface by a sort of 
 sweating process. The rusty-staining can be scraped off as an extremely 
 delicate and structureless pellicle. Or, again, the inner surface of the 
 dura may overspread a somewhat amber-coloured glutinous-looking 
 layer, which can be readily stripped off and appears to be a purely 
 fibrinous formation, enclosing more or less arterial blood. Such 
 structures form translucent pellicles, which, when examined, look like 
 gutta-percha tissue stretched to a delicate tenuity. The extravasation 
 is often extensive, flattening the convolutions, and inducing consider- 
 able atrophy — a simple dark clot of blood moulded to the form of the 
 arachnoid cavity occupied by it, thick at its central parts, thinning 
 out towards its margin, and covered with a delicate fibrinous layer 
 above and below; or the fibrinous -formation may be thicker, more 
 organised, and may constitute a complete sac enclosing the blood-clot. 
 E/okitansky's classical description holds good for the formations in the 
 insane. 
 
 "Its adhesion with the dura mater, too, is loose ; it partly sticks on, and partly 
 is connected with the membrane by a few small vessels. Both walls of tlie sac arc 
 usually of a brown, rusty colour, and tenacious. They may often be separated 
 into several layers which vary in thickness, but the inner of which are more thin : 
 at the margin of the sac they coalesce and form one lamina, which soon becomes 
 reduced to a thin, brown, rusty-coloured membrane, and spreading out further on 
 the cranial vault, reaches to the base, and at length terminates in a thin, rusty- 
 coloured, gauze-like film . . . within, the sac contains a more or less thick 
 fluid, of a dark and various colour, like chocolate, or plum-sauce, rust, or yeast; in 
 course of time the lympli is gradual!}' removed, the inner surface of the sac becomes 
 smooth and polished, and the contents are changed into a colourless, thin, clear, 
 serous fluid."* 
 
 "We have never observed what the same authority states is of 
 occasional occurrence, viz., the ossification or formation of bony plates 
 
 * Op. clL, p. 330, 
 
ORIGIN OF ARACHNOID IliEMORRHAGE. 
 
 439 
 
 or concretions on its outer wall next the dura. Some of the more 
 cogent reasons for regarding these formations as non-inflammatory 
 are : — 
 
 1. The cyst is readily removable, slightly (or not at all) adherent to 
 the dura mater. 
 
 2. In the majority of cases there is no evidence whatever of the 
 existence of a pachymeningitis ; («) the dura is not thickened or 
 softened, or vascular ; (&) no organic connection exists betwixt the 
 two. 
 
 3. In eai'ly stages the characters are purely those of a simple extra- 
 vasation of blood into the arachnoid cavity (subdural space). 
 
 4. There is the co-existence in this affection of a recognised vascular 
 disease and vasomotor disturbances which render liDamorrhage 
 frequent, e.g., the othsematoma or " insane ear." 
 
 In an important communication my former colleague, Dr. Robert 
 Lawson, expressed the same views as are here entertained.'" 
 
 As regards their cause and origin and general etiological relationship 
 amongst the insane, it has been pointed out by Sir J. Crichton-Browne 
 that the age of their more frequent occurrence was between 35 and 45 
 years — an important feature as distinctive between it and ordinary 
 forms of cerebral haemorrhage, which occurs more frequently at a much 
 later period of life. The same authority in an analysis of fifty-nine 
 cases of arachnoid cyst, occurring at the West Hiding Asylum, has 
 clearly established the vast preponderance of this accident in cases of 
 general paralysis, as seen in the following table 
 
 FIFTY-XINE CASES OF ARACHNOID CYST 
 
 General paralysis afibrds 
 Chronic disorganisation of brain 
 Senile atrophy 
 Epilepsy 
 
 Mania associated with chorea 
 Mania with meningitis 
 Insanity witli Bright's disease 
 Chronic mania with phthisis 
 
 29 
 16 
 
 3 
 
 59 
 
 As regaixls sex, it is recognised as occurring more frequently in men, 
 from very obvious reasons ; the most important being the greater 
 frequency of its congener, general paralysis, in the male than in the 
 female. 
 
 Our records embrace the histories of 73 additional cases since the 
 above were tabulated by Sir Crichton-Browne, and these, arranged as 
 
 * See footnote, p. 440. 
 
440 
 
 MORBID STATES OF THE IN'VESTINr, MEMBRANES. 
 
 to associated cerebral states and sex, illustrate forcibly the foregoing 
 statements : — 
 
 SEVENTY-THREE CASES OF ARACHN'OID CYST. 
 
 General paralysis afforded instances in 30 Males and 4 Females. 
 
 Chronic disorganisation of the brain 
 
 Senile atrophy 
 
 Epilepsy 
 
 Mania . 
 
 Melancholia . 
 
 Idiocy . 
 
 12 
 G 
 3 
 2 
 1 
 1 
 
 IS 
 
 Or summarising both series we have 132 instances of ai'achnoid cyst; 
 63, or 47'7 per cent., occur in general paralysis; 35, or 26-5 per cent., 
 in chronic disorganisation of the brain; 12, or 9 per cent., in senile 
 atrophy; 7, or 5-3 per cent., in epilepsy ; and 15, or 11 '3 percent., in 
 several other forms of mental ailment. 
 
 The site of haemorrhage is almost exclusively confined to the vertex 
 and lateral aspects of the cerebrum ; we have never seen it on the 
 lower aspect of the tentorium or within the cerebellar fossa of the 
 cranium ; it is also of rare occurrence in the anterior and middle fossa? 
 at the base. 
 
 The left hemisphere is more frequently the site of the haemorrhage 
 than the right, as indicated in the sixty-five more recent cases 
 extracted from our records. 
 
 SITE OF AKACHNOID II^MOREHAGE IN SIXTY-FIVE CASES. 
 
 Both hemispheres generallj' covered above 
 Left hemisphere ,, ,, ,, 
 
 Ivight hemisphere ,, ., ,, 
 
 Ilight parieto-occipital region . 
 Right frontal region .... 
 
 Anterior fossa at base .... 
 Anterior and middle fossce 
 
 2S 
 20 
 II 
 
 r> 
 
 1 
 1 
 
 2 
 
 The extravasation most probably occurs from a vessel of tlio pia 
 mater, the vessels of which in general paralysis show very special lesions 
 
 * Dr. Lawson's statement is to the following effect : — " Amongst the sane, 
 amongst drunkards, and in cases where injury has induced pachj-meningitis 
 externa, this production of arachnoid cysts by the rupture of vessels formed 
 in inflammatory products might readily occur. . . . It is evident that at 
 least the large majority of cases of hsBmatoma in the insane, originate in direct 
 rupture of vessels and extravasation into the arachnoid sac." (Brit, and For. Med. 
 Chir. Review, 1876). 
 
ADHESION OF PI A TO CORTEX. 441 
 
 forming disc of tlio most constant cliangos in this affection. The 
 diseased condition of their tunics, which we shall allude to later on, is 
 greatly aggravated by the repeated, violent, and long-continued out- 
 bursts of excitement to which such cases are subject; and the vessels 
 Avhich have undergone most change are decidedly those in the an- 
 terior regions of the brain, coinciding with the more frequent site- 
 of these arachnoid haemorrhages. The arteries coursing within the 
 sulci are, of course, better protected by the support they receive, thaa 
 the veins distributed over the exposed surface of the gyri ; at th® 
 summits of the gyri there is evidence of inflammatory activity, well 
 marked in the presence of meningeal adhesions. The Avascular net- 
 work supported by the pia at these sites is most affected by the morbid 
 changes taking place, and hence, the venules are kept in a state of 
 continuous engorgement near the site where they empty into the 
 larger veins running to the sinuses, a condition further aggravated 
 by the active arterial flow of functional excitement. Thus, in our 
 opinion, the occurrence of at least a large proportion of these forma- 
 tions is explained as due to : — • 
 
 (rt.) The initial diseased condition of the vascular tunics. 
 
 (b.) The distended condition of the venous system from atrophyj. 
 and consequent loss of support, and obstructive conditions due ta 
 inflammatory change. 
 
 (c.) The anatomical arrangement of the veins, involving them in the- 
 most pronounced inflammatory change. 
 
 We have alluded to the evidence of congestive and chronic inflam- 
 matory conditions presented in the notable opacity, with thickening of 
 the soft membranes, the presence of efi"vised lymph, and, we might add, 
 the somewhat rare condition of purulent infiltration of the membranes 
 at the vertex in certain forms of insanity. To these we must add, 
 as indubitable evidence of inflammatory activity in the cortex and its- 
 investing membranes (chronic meningo-cerebritis), the frequency of 
 morbid adhesions between these structures. Such morbid adhesions 
 occur in chronic insanity, in chronic mania, in senile mania, occasion- 
 ally in alcoholic insanity, and especially in the mental derangement 
 associated with traumatism. It is, however, in general paralysis of 
 the insane that this condition forms so important a feature as to 
 constitute the one distinctive sign indicative of this disease to the 
 }iathologist. In a small percentage of cases only is this important 
 sign absent ; but in such exceiDtional forms other indications are 
 sufiiciently expressive of the nature of the diseased process. We shall 
 describe in detail the morbid process as it occurs when dealing with 
 the special pathology of general paralysis. For the present Ave haA-e 
 to deal Avith the general features presented by such adhesions in this 
 
442 THE MOKBID DRAIN IX INSANITY. 
 
 and othei- forms of mental disease. I find from Dr. Bullen's statistical 
 compilation from our West Riding Asylum llecords, that out of 1,5G5 
 fatal cases of insanity, morbid adhesions betwixt brain-cortex and in- 
 vesting membranes had been contracted in 340 instances, or 21*7 per 
 cent, of the whole ; whereas in a former study of general paralysis, some 
 years back, we found that in 241 cases of this disease which had proved 
 fatal, ISG (or over 77'1 jier cent.) presented well-marked adhesions, 
 the remaining fifty-five (or 22-8 per cent.) being described as free from, 
 such implication. We must, however, be prepared to meet with 
 cases where it may be dubious how far we should regard the 
 connection as amounting to a morbid adhesion ; but in our statistical 
 results above recorded, we include only such instances where the 
 removal of the membranes necessitates a teariivj-away of the superficial 
 cortex. Undoubtedly, many other cases of morbid firmness of union 
 present themselves, which, therefore, escape from this category ; and 
 this was the case in many of the 22-8 per cent, in which genuine 
 adhesions were excluded. The brain of the alcoholic presents instances 
 of this morbid firmness of union; and, histologically, this is attested 
 to in the presence of the same morbid elements which are found so 
 profusely scattered thi'ough the cortex in genuine cases of adhesion ; 
 but we do not find in the alcoholic's brain, as a rule, anything more 
 than this undue firmness of union. 
 
 On attempting to strip ofi:" a portion of adherent membrane, there 
 are seen by the naked-eye numerous tough fibrous prolongations, which 
 look like enlarged blood-vessels, connecting the under-surface of the 
 pia with the cortex of the brain. W^hen forcibly removed, the upper 
 layers peel away to varying depths upon the pia, leaving an ei'oded 
 surface which presents a highly characteristic aspect. The surface 
 looks gnawed or worm-eaten along the length of the gyri with irregular 
 sinuous margins, so that it somewhat resembles the aspect pre- 
 sented by a succulent leaf which has been attacked by a caterpillar. 
 The base of the eroded (or rather, torn) surface is distinctly punctated 
 by large open orifices from which coarse vessels have been withdrawn. 
 Adhesions of some age exhibit a coarse dense fibrillar connection 
 betwixt pia and cortex ; the normally delicate retiform aspect of the 
 neuroglia is lost in the coarse fibrillation which has ensued. In earlier 
 stages the appearance is suggestive of inflammatory implication, in the 
 distinctly-pinkish appearance of the cortex, sometimes difi'used, some- 
 times limited to the areas of recent adhesions ; the pia is thickened and 
 tumid, the seat of nuclear proliferation, its vessels deeply engorged 
 and the superjacent arachnoid also thickened, opaque, and cedematous. 
 The distended vessels are coarse and tortuous, their sheaths thickened 
 hy multiplication of their cells and the traversing of their structure by 
 
MORBID VASCULARITY OF THE CORTEX. 443 
 
 wandering leucocytes. The microsco[)e reveals infiltration of the cortex 
 by large numbers of peculiar spider-like cells — oval, Hask-shaped or 
 globose — but all throwing ofl" numerous delicate fibrillar processes which 
 entwine upon the vascular walls and meander amongst the nerve- 
 elements of the cortex. Such spider-like cells are found in all recent 
 adhesions in the upper layex'S of the cortex, immediately beneath the 
 adherent pia, forming a direct connection with its under surface 
 and the vessels passing from it into the substance of the Itrain. 
 Around the vralls of the blood-vessels these elements tend especially to 
 crowd, and their ramifying extensions will, probably, by subsequent 
 contraction, seriously interfere with the permeability of these channels 
 of nutrierd supply. The prominent role assumed by these organisms in 
 general paralysis of the insane, the frequency with which they are 
 seen, and their very striking features, induced certain obseiwers to 
 regard them as pathognomonic of this disease. We had, however, 
 some years previously indicated and sketched their appearance in 
 senile atrophy of the brain {PI. :KN.,fig. 1), and had recognised their 
 existence in other morbid conditions;* in fact, they represent a 
 hypertrophied state of what in our section of the normal histology 
 of the cortex we have described as its "lymph-connective" system. 
 
 The reason why these morbid conditions are not more frequently 
 seen in senile atrophy and other pathological states of the brain is 
 that the stage in which they are formed is an early stage of the disease, 
 a stage which in most fatal cases has long since passed by; the organisms 
 have succumbed to a fatty liquefaction and so been removed from observa- 
 tion. General paralysis, however, is a comparatively rapid process of 
 dissolution, and intercurrent affections often prove fatal, and afibrd us 
 illustrations of its morbid anatomy in early stages ; hence these morbid 
 appearances are frequently met with, yet not constantly, for, at an 
 advanced stage of this affection also, the morbid cells degenerate and 
 disappear, leaving their fibrous meshworks as their sole representative. 
 In chronic alcoholism, again, such products of morbid activity pi-esent 
 themselves, frequently in great abundance, but never, in our experience, 
 to the extreme degrees met with in certain cases of senile atrophy and 
 general paralysis. In fact, it is our opinion, based upon a large number 
 of observations, that where a specially irritative process is engendered 
 in the cortex, and more especially where a large accumulation of 
 degenerative material has to be carried off from this region, or where 
 eS'ete material accumulates as the result of some obstruction to the 
 normal transit of lymph from the brain, there we are likely to meet 
 with these vast developments of " spider-cells," as they have been 
 termed. Hence in a chronic meningO-CerebritiS, attended by much 
 * Proc. noy. Soc, Ko. 182, 1S77. 
 
444 THE MORBID BRAIX IN INSANITY. 
 
 effusion into the vascular sheath, by extravasations into the brain- 
 substance, and by the varied products of inflammatory engorgement of 
 the part, this " lymph-connective system " of the neuroglia (as we have 
 ventured to term it) undergoes the functional hypertrophy here alluded 
 to, in an extreme degree. 
 
 Again, in the later stages of senile degeneration, the fatty atrophy of 
 texture has advanced to so extreme a degree, usually during a very 
 prolonged course of many years, that the surface of the cortex is 
 widely severed from the membranes overlying it by the compensatory 
 accumulation of fluid ; any delicate adhesions which had been formed 
 in early stages have been softened and broken down. The membranes 
 are not thickened to the same extent as in general paralysis, where 
 they often form a dense, thick, felt-like structure which fully occupies 
 the space formed by the recession of the atrophic brain. The physical 
 conditions, therefore, as well as the more rapid course of the one 
 compared with the other, have probably much to do with the presence 
 or absence of adherent membranes. We must, however, not omit the 
 fact, that the tearing of the cortex is, to a certain extent, also due to 
 the softening of the outer layers of the cortex by the inflammatory 
 process: but this alone by no means accounts for the appearances, 
 since the condition observed on removing the membranes in a brain 
 simply softened by decomposition, or from those regions always exces- 
 sively soft, at the basal aspect of the cerebrum, in no way reproduces the 
 appearance of the eroded cortex in general paralysis. 
 
 The brain-substance, both grey and white, in fatal cases of 
 insanity is found in a very variable condition of vascularity dependent 
 frequently upon wholly-extrinsic agencies and accidental states, which 
 are completely foreign to the cerebral disturbance existing during life. 
 We must remember the peculiarities of the vascular mechanism we are 
 dealing with, which explain to a great extent the variations noticed. 
 The pia mater is a Avondrously vascular meshwork, capable of an 
 enormous degree of distension and venous engorgement, as we some- 
 times see to an astonishing extent in obstructions to the return of 
 venous blood to the heart, in cases of intra-thoracic pressure. It serves 
 the purpose of bringing into immediate contact with the surface of the 
 brain a very large amount of venous blood ; the carriers of which are 
 so disposed as to offer a direct mechanical disadvantage to the return 
 of venous blood from the cranial cavity — the current of blood in the 
 large cerebral veins being opposed to that of the current in the sinuses 
 by their oblique direction and opening into the sinuses from behind 
 forwards. Thus, whilst in the veins of the lower extremities, special 
 facilities (such as their valves) are introduced to favour the circulation 
 in its return, the intracranial veins have a direct obstruction offered 
 
MORBID VASCULARITY OF THE CORTKX. 445 
 
 to the too speedy flow towards the heart ; an obstruction which even 
 leads to a hypertrophic state of the tissues in this immediate neigh- 
 bourhood.* The venous blood in this vascular membrane and system 
 of sinuses serves the purpose of keeping up a sustained backward 
 pressure upon the cortical venules, and thus effectually provides for 
 the continued patency of the minute vessels of the cortex. It is only 
 exceptionally that this patency is interfered with to a state of complete 
 anfemia, when, of course, unconsciousness supervenes. Sleep is an 
 instance of a rhythmic interference with this condition ; and the 
 agency whereby the ansemia is produced is well illustrated in Mosso's 
 experiments with the plethysmograph, whereby he clearly shows a well- 
 marked dilatation of the peripheral vessels as the immediate prelude 
 to sleep. A similar condition of things is found at the other extremity 
 of the cerebral circulation — viz., the basilar artery. Here we find the 
 two vertebrals taken together about double the capacity of the recipient 
 basilar artery ; and as the result of this a sustained pressure of no 
 inconsiderable degree is kept up in the minute nutrient arteries passing 
 direct from it into the substance of the pons. Hence these vitally- 
 important centres are kept continuously supplied with blood, a supply 
 which will only be augmented as contraction in the distal cerebral 
 branches produces ansemia in those parts. If we keep this mechanism 
 of the venous system of the cortex in view, we at once see how 
 variable will be the vascular appearances of the brain according to the 
 mode of death ; the presence of obstruction in the heart and lungs to 
 the venous circulation, and especially obstruction in the cranial 
 sinuses, such as frequently occurs in cases of insanity. So likewise 
 the mode of opening the body for 2^ost-7)iortem examination greatly 
 modifies the appearance of the cortex and white matter, but especially 
 of the soft membranes. If the cranium be opened before the thorax, 
 the vessels will be found far more engorged than when the reverse pro- 
 cedure is adopted, whereby opportunity is afforded for draining off the 
 blood from the head through the large vessels so severed in the chest. 
 As to the results of intra-thoracic pressure, we must be prepared to 
 find engorgement of the cerebral vessels in the pia in all cases of severe 
 
 * "The common thickening of the membranes over the upper surface of the 
 brain, increasing towards the longitudinal sinus, is explicable by the mechanical 
 congestion that must be favoured there, through the current of blood from the 
 cerebral veins entering the longitudinal sinus against the course of the stream 
 within the sinus. The check so caused to the entering stream will have most 
 effect on the part of the stream that is near the vein wall, for this is weaker than 
 the current in the middle of the vein, but this parietal layer of the stream receives 
 the blood from the parts near the sinus, and hence these will feel the check more 
 than the distant parts, and will tend to be held all one's life in a state of mechanical 
 congestion of mild degree " (Lectures on Analytical Pathologij. Moxou). 
 
446 TUB MORDID BRAIN IX INSANITY. 
 
 obstruction or obliteration of the pulmonary blood-vessels — e.g., exten- 
 sive new growths in the nicdiastiniun, copious pleuritic elFusions, con- 
 striction from, various causes of the roots of the lungs, fibroid 
 induration of lung, kc. Rokitansky has alluded to the extremes we 
 occasionally meet with of this obstructive engorgement of the cerebral 
 membranes, the vessels of which he describes as forming " spirally- 
 twisted coils and intestine-like circonvolutions." * Nor is this any 
 exaggeration of what we see occasionally in asylum practice. We 
 should have said very rarely, for but three such cases have occurred in 
 our experience of considerably over two thousand inspections. Such, for 
 instance, was the case of an alcoholic subject suffering from fibroid indu- 
 ration of the lung, and in whose case capillary bronchitis supervened, 
 resulting in an extremely-stupoi'ose condition for days together. The 
 necropsy revealed an extraordinary development of varices and con- 
 torted vessels in the membranes actually concealing from view exten- 
 sive areas of the brain-surface ; whilst enormous numbers of extrava- 
 sations varying from miliary and punctiform hcemorrhages to patches 
 from a pea to a florin in extent were scattered throughout a deeply- 
 congested brain both in grey and white substance. f To a much less 
 marked degree is the engorgement recognised in obstructive throm- 
 bosis of the sinuses, for in all examples met with we have found the 
 patency of the channel diminished only to a minor extent from firm 
 organisation and shrinking of the clot. Death from pulmonary 
 gangi'ene occasionally occurs as the result of such clots, or portions 
 of such dislodged, passing by the right cavities of the heart into the 
 pulmonary vessels. The result of contraction of a limited vascular 
 area of the cortex upon neighbouring territories must, we opine 
 for the present, be a moot point ; but we cannot fail to regard it as 
 highly probable that any such limited spasm must tell in an exactly 
 reversed vascular state of neighbouring cortical and subcortical 
 tracts. The cortical nutrient branches form, as we have learnt from 
 M. Duret, an absolutely-terminal (non-anastomotic) system of vessels, 
 and (counter to the view of Heubner) the larger branches of the pia 
 also map-out individualised and but feebly inter-communicating terri- 
 tories. Hence, we have reason to infer that each terminal system is 
 the representative of a neuro-vascular autonomy ; and that limited 
 spasms of such a system, whilst raising the blood-pressure generally 
 throughout the periphery, also cause increased flow to neighbouring 
 cortical realms. How extremely delicate is the adjustment so aflected 
 is obvious from the researches of Mosso, who remarked that in the 
 
 * " Pathological Anatomj'," Sydenham Soc, vol. iv., pp. 372-3. 
 t See also a similar case reported in the Lancet for January 11, 1S79, by 
 Dr. Coupland 
 
MORBID VASCULARITY — CEREBRITIS. 447 
 
 case of his patient, when asleep, the slightest sound, such as the tick of 
 a watch, oi' a spoken word, short of awakening the sleeper, invariably 
 caused increased vascularity of the brain, with a corresponding fall 
 of blood-pressure in the arm, as registered by the plethysmography 
 Such an observation gives us a graphic illustration of what is con- 
 tinually occurring, during the normal active processes in our conscious 
 moments, as the mere result of sensory excitations alone. 
 
 A bright red blush irregularly distributed in patches is often 
 observed in the cortex of those dying insane, a rosy-tinted mottling, 
 stippled here and there with the orifices of larger vessels cut across, 
 and defining (in most cases very accurately) the limits of certain 
 independent vascular tracts or plexuses. It is more frequently an 
 accompaniment of the more acute forms of insanity, and we hesitate to 
 attach to it any further importance than as indicating the severity of 
 the late functional disturbance. Certain it is that this appearance is- 
 not necessarily correlated with any obvious structural change in the 
 part ; nevertheless, it is a witness to the storm which has swept past. 
 We have suggested elsewhere* that, "the last act of arterial contraction, 
 in which the smaller arterioles have failed to empty themselves into 
 the venous system, may in part explain this appearance," and have 
 also noted how " this blotchy red aspect of the cortex reappears very 
 fi'equently in the medulla in similar cases;" and we still regard it as 
 l^robably so explained, the failure to contract being evidence of the 
 paretic state of the vessel, whilst the effect of limited spasms would 
 from our former remarks be still more likely to issue in this blotchy 
 mottling of the cortex. The same remarks apply to the rosy vascular 
 zones which so frequently present themselves along the junction of the 
 white and grey matter. This and the fourth layer are usually the 
 sites of the rosy discoloration now alluded to ; and this coincides with 
 the results of imperfect injections of the cortex, which indicate that 
 
 the long" straight vessels and their horizontal nexus on the 
 
 confines of the grey are the most readily filled ; next, the plexus 
 around the cells of the fourth and fifth layers ; and lastly, the vascular 
 plexus in the third and the first layers respectively. We have 
 alluded to this ready filling of these straight vessels of the medulla as 
 a sort of safety-valve action for relieving the cortex from undue engorge- 
 ment. The rosy mottling of the medulla is again a frequent accom- 
 paniment of the foregoing signs where such cerebral excitement has 
 preceded death, or where epilepsy has terminated fatally in the 
 '' status ;" and in such cases it is interesting to note the comparative 
 paucity of puncta vasculosa which undoubtedly (as JSTiemeyer has 
 stated) form a most unsafe criterion to accept of congested states of the 
 * The Human Brain : Methods of Examination, p. 52, 
 
448 THE MORIUI) BRAIN' IX INSANITY. 
 
 brain.* Since, then, the appoar.ajices above detailed are occasionally 
 the sequence of uther tlian lamhid states, how are we to deal with 
 their significance as morbid signs 1 The reply is, in the presence of 
 minute extravasations, in the coarseness or evident disease of the small 
 'vessels, in the existence of much ledema of the tissues, in the altered 
 <consistence and specific gravity of the tissues; all of which afford 
 indications of value ere we resort to more minute histological 
 examination. 
 
 Increased vascularity is by no means the more frequent appearance 
 found in fatal cases of insanity — in acutely -maniacal conditions, and 
 •especially in general paralysis, it is often observed ; but, by far the 
 Jarger number of cases afford evidence of poverty of blood in the brain 
 iind general malnutrition. Thus uniform pallor prevailed as a note- 
 •worthy feature in 841 cases out of a total of 1565 autopsies, or consider- 
 .ably over one-half (53-7 per cent.). "What was stated respecting the 
 independence of vascular regions of the brain as regards both the 
 terminal arterioles and the larger areas mapped-off by the distribution 
 of three main arteries of the cerebrum, is illustrated by the anaemic 
 ^states of the cortex, even as we found it was by states of hypersemia. 
 We find conditions of patchy pallor mottling the cortex, or a uniformly 
 diffused pallor, or, not by any means infrequent in cases of melancholia, 
 .a notable pallor of the carotid arete associated with fulness of vessels 
 both of the white and grey substance in the vertebral system 
 ^posterior cerebral). By far the more extreme forms of antemia 
 met with in the insane are cases of chronic phthisis, unfortunately so 
 frequent in asylums. The pallor is a most sti'iking feature, and is due, 
 ■of course, to general bloodlessness throughout the system. So also as 
 the result of severe haemorrhage, as in the post-partum haemorrhage 
 -which may usher in puerperal insanity, this condition of blanch- 
 ing will be found present. Intracranial pressure, again, such as 
 results from sanguineous ajjoplexy, the presence of adventitious 
 growths, or excessive development of interstitial connective {neuroglia) 
 may all lead to notable anajmia by foix-ible exclusion of blood from 
 the cerebral vessels ; but, here the blanched aspect of the surface is 
 associated with so much flattening of the convolutions that the 
 conditions are at once appreciated. 
 
 Inflammation. —Acute cerebritis as a diffuse afl'ection of the 
 
 brain we have had no experience of amongst the insane; on the other 
 Land, as a localised condition due to focal lesion, it is by no means 
 uncommon, whilst a chronic meningo-cerebritis is also of very frequent 
 occurrence. To take the more acute process first, we usually find it as 
 ihe result of an emholon or thrombus of a cerebral blood-vessel, which 
 * Text-hook of Medicine, Niemcyer. 
 
INDICATIONS OF CEREBRITIS. 449 
 
 has given rise to much punctiform haemorrhage around, or to hfcmor- 
 rhagic foci in the cortex or ganglia; or, again, to the presence of new- 
 growths, such as carcinoma or tubercle, which are frequently surrounded 
 by a zone of red inflammatory softening, beyond which extends a 
 further non-inflammatory zone of simple white or yellow softening. 
 The cerebral tissue so involved is swollen, distinctly cedematous, and 
 variable in its consistence up to the extreme degrees of difiiuence ; it is 
 usually of bright pink hue, with streaky or punctated haemorrhages 
 scattered throughout its texture. 
 
 The inflamed tissue may show little or no discoloration, in fact this 
 is very frequently the case ; but in all instances we find the presence of 
 inflammatory exudates modifying the appearance and textural con- 
 tinuity of the part, presenting compound granule-cells, nuclei, leucocytes, 
 broken-down nerve-structures and pigment; whilst the specific gravity 
 will be invariably augmented by the inflammatory exudation present. 
 In the immediate neighbourhood of such inflammatory patches we often 
 find the tissue in a state of white or yellow softening, non-inflammatory 
 in character; in fact, due to interference with the nutrient supply of 
 the part, to plugging of the minute vessels, or to direct pressure of the 
 swollen cedematous tissue around the inflamed focus. There is no 
 causal connection betwixt such states of inflammatory softening and 
 insanity; they occur as accidents in the course of certain vascular 
 diseases associated with mental disease, and, therefore, it is necessary 
 to allude to them here. Far otherwise is it with the chronic inflamma- 
 tion of brain and membranes which is intimately related to the insidious 
 and fatal malady, general paralysis. In this form of chronic meningo- 
 cerebritis the inflammatory changes begin, probably, at several difierent 
 points, spreading from one convolution to another, until in many cases 
 the whole cerebral mantle is involved, with the exception of the 
 occipital gyri, which almost invariably escape implication. The 
 progress of inflammatory activity is usually most marked in the frontal 
 regions in both hemispheres, and less advanced in the parietal. The 
 cortex is much thinned in the fronto-parietal region, and of very 
 variable colour, frequently exhibiting the irregular mottled aspect 
 from pinkish discolorations or congested patches, but also quite as 
 often pale grey, or of a uniform dirty grey hue with but poorly-defined 
 lamination. The arterioles of the cortex are frequently and notably 
 coarse and engorged. The substance of the cortex is much reduced in 
 consistence, and cedematous; the whole brain is softened, and has an 
 ill-nourished look; in fact, apart from the firm inflammatory adhesion 
 of the opaque and thickened membranes, the naked-eye appearances of 
 the cortex are not unlike an extremely ill-nourished and atrophied 
 brain in old age, presenting in itself no characteristic indications of the 
 extensive inflammatory changes which it has undergone. 
 
 29 
 
450 THE MORBID BRAIN IN INSANITY. 
 
 Softening". — Out of 853 cases of insanity proving fatal, 390 afforded 
 insUmces of an increasetl consistence of brain or one of average tirin- 
 ness ; the remainder were noted as having a diminished consistence 
 throughout. The actual figures were as follows : — 
 
 Increased consistence throughout .... 98 cases. 
 
 Firm consistence ,, . , . . 110 ,, 
 
 Fair or average consistence ,, . . . . 182 ,, 
 
 Diminished consistence ,, . . . . 463 ,, 
 
 Roughly speaking, therefore, close upon one-half (or 45 7 per cent.) 
 were of normal consistence or above the usual degree of firmness — the 
 remaining 54*2 per cent, being softened, either as the result of disease 
 or of post-mortem change. As a fact, however, a state of general 
 reduced consistence, apart from any putrefactive process, prevails in a 
 large percentage of cases ; and this is accounted for by the large pro- 
 portion of cases of senile atrophy, of general paralysis, and of organic 
 brain-disease (the result of diseased arteries) which accumulate in" our 
 asylums and form so large a fraction of the fatal cases. The general 
 diminution in cerebral consistence may be due to oedema of its texture, 
 as the grey matter has notable hygrometric powers; it may be due to dis- 
 integration of structure from the fatty degeneration of senility, or from 
 extensive vascular disease restricting its nutrient supply, or it may be 
 the result of inflammatory processes. In all cases we observe that the 
 vascular system is largely involved. The oedema is first established 
 by the undue engorgement of vessels which thus relieve themselves 
 (not only in congestive and inflammatory processes, but also in the 
 atrophy resulting in the so-called hydrops ex vacuo); the fatty disinte- 
 gration of senile brain is invariably associated with, and greatly 
 furthex'ed by, diseased arterial tunics ; and, lastly, the inflammatory 
 processes, which ai-e of a chronic diffuse nature, are, we believe, in 
 themselves vascular in their origin. Hence we see bow large a section 
 of the insane show indications of defective nutrition in the central 
 nervous system, and derangements of its blood supply ; yet acute or 
 recent insanity affords few and far less pronounced signs of such 
 impairment. It is in the chronic stage of insanity that obvious 
 structural changes indicate to us the serious nature of the nutritive 
 failure. In instances of general reduction in the consistence of the 
 brain, the organ fails on removal to maintain its erect position ; it falls 
 apai't at the commissural junctions, the diverging hemispheres tending 
 by the mere effect of gravity to tear the latter asunder, especially as these 
 commissures are themselves unduly soft. The hemispheres have lost 
 their plump contour ; the convolutions may have undergone consider- 
 able atrophy, and their widely-gaping sulci may enclose much serous 
 
CEREBRAL SOFTENING. 451 
 
 fluid ; whilst the whole brain feels flahby to the touch, and devoid of 
 its normal compact aspect, as well as of the firm and resilient feel of 
 iiealthy structure. In the ventincles we often find considerable serous 
 fluid unduly distending these cavities, whose walls have a macerated 
 aspect, and are undergoing rapid solutions of continuity. The white 
 substance may have a glairy, brilliant aspect, be much softened in 
 texture, pit on pressure, whilst few or no puncta vasculosa appear, the 
 vessels being compressed by the swollen (edematous structure around ; 
 or it may, on the other hand, have a dull, lack-lustre surface, mottled 
 with difi'used congested zones, stained with hsematine, and presenting 
 numerous coarse and bristly vessels. 
 
 In extreme cases of white softening, however, the brain-substance 
 may be completely diffluent here and there, and present to the touch 
 a semi-fluctuating feel, breaking up readily upon manipulation ; its 
 central parts — the fornix, septum pellucidum, and commissure — being 
 more or less wholly disintegrated. Such localised softenings super- 
 added to the more generally diffused form above described, are due to 
 the association of plugging of the cerebral blood-vessels by thrombus or 
 embolon. The substance of the brain thus implicated may be reduced 
 to a soft, pappy, cream-like fluid ; or the almost diffluent medulla may 
 wash away in this form by the impact of a gentle stream of water. 
 Localised softenings, as the result of thrombosis or embolism, frequently 
 illustrate to us the regional autonomy of the cerebral blood-vessels by 
 invading only the district of supply of one of the principal branches of 
 the three large vessels of the cerebrum ; and thus we may have lesions 
 of one of three districts of the anterior, or of the posterior cerebral, 
 or one of the four districts of the middle cerebral, exclusively, or 
 variously associated. 
 
 In this connection undoubtedly the area of supply of the middle 
 cerelDPal is far the more frequently afi'ected ; next to this, but with 
 far less frequency, the posterior cerebral areas sufier ; and least 
 frequently of all, the areas supplied by the anteriOP Cerebral. The 
 relative implication of the various branches, or rather their territories 
 of distribution, are for the middle cerebral or Sylvian trunk as follows 
 (the more frequently implicated branches in order of precedence) : — 
 Parieto-sphenoidal, ascending frontal, ascending parietal, external and 
 inferior frontal branches. For the posterior cerebral the order of 
 precedence is — first, the occipital branch, and, far less frequently, the 
 two anterior branches to the uncinate and fusiform gyri. Again, for 
 the anterior cerebral the order of precedence in morbid implication 
 is — the middle and external frontal branch, the anterior and internal 
 frontal, and, least frequently, the posterior and internal branch. This 
 may be more clearly represented in the following tabulation — 
 
452 
 
 THE MORBID HHAltf IN INSANITY. 
 
 Anterior Cerebral. Miildle Cerebral. 
 
 Middle and internal frontal I'arieto-splienoiclal artery. 
 
 artery. Ascending frontal ,, 
 
 Anterior ., ,, ,, Ascending parietal ,, 
 
 Posterior ,, ,, ,, Kxternal and inferior frontal 
 
 Posterior Cerebral. 
 Occipital artery. 
 Anterior and posterior 
 temporal artery. 
 
 Fig. 10. — Illustrative of the more frequent site of localised soften ingsTin 
 order of precedence. 
 
 In 149 cases of localised lesions, the convolutions most frequently 
 affected, and medullated centrum would run as follows in like order of 
 precedence : — 
 
 1. Upper temporo-sphenoldal gyrus. 
 
 2. Occipital and cuneate ,, 
 
 3. Ascending frontal ,, 
 
 4. Postero-parietal ,, 
 
 5. Centrum ovale = not defining as to 
 
 anterior or middle frontal territory. 
 
 6. Annectants. 
 
 7. Angular and supramarginaL 
 
 8. Orbital. 
 
 9. Insula and operculum. 
 
 10. Fusiform and uncinate. 
 
 11. Gyrus fornicatus and quadrate. 
 
 Fig. 11. — Illustrative of the more frequent site of localised softenings in 
 order of precedence. 
 
LOCALISKD SOFTENING. 
 
 453 
 
 A further analysis of 166 cases of localised or focal softenings (due 
 either to thrombosis, embolism, or to haemorrhage) in the substance of 
 the basal ganglia, and their medullated capsules indicate the respective 
 proclivity to such lesions in the insane to be as follows : — The lej'l 
 hemisphere is in all instances of ganglionic lesion, slightly more prone 
 to implication; the intraventricular nucleus is far the more frequently 
 affected, the optic thalamus comes next in frequency, but the pro- 
 portion does not rise beyond two-thirds the latter; the extraventricular 
 or lenticular nucleus is somewhat less frequently involved than the 
 optic thalamus ; lastly, the two capsules, external and internal, are 
 far less often implicated, and of these the inner shares the greatest 
 immunity. 
 
 Fig, 12. — Illustrative of the luoic ire^uent site of localised softenings in 
 order of precedence. 
 
 Of the 166 cases of softening from which these data are obtained, 
 thirty-four were instances of hfemorrhage, and the remaining number 
 were the results of clot, usually thrombosis. The results agree, therefore, 
 
454 THE MORBID BRAIN IN INSANITY. 
 
 in every particular with those arrived at from a study of the locality 
 of cerebral lijemorrhage, for it has been shown by Andral and Durand- 
 Fardel, that the corpora striata are more frequently the site of 
 haemorrhage than the thalami ; and Charcot expresses his opinion that 
 next to the opto-striate bodies, the claustrum is the more frequent 
 site of lesion.* Whatever be the origin of the cerebral lucmorrhages 
 met with in the insane (whether the result of a periarteritis or an 
 endarteritis), this we can safely affirm, that the same systems of 
 vessels have the same relative liability to suffer in cases of softening, 
 following occlusion from thrombosis, as in cases of haimoiTliagic foci. 
 
 Atrophy. — Wasting of the grey and white meduUated structures 
 of the brain is of very frequent occurrence in insanity, but it is as a 
 sequel to the acute forms ; and, in the chronic forms of insanity, such 
 atrophy is seen to invade these structures to an extensive degree. It 
 may be general throughout the cerebral hemispheres, whilst the basal 
 ganglia and mesencephalon escape implication ; but, occasionally, the 
 whole of the intracranial ganglia are involved. On the other hand, 
 it may be localised or pa7'tial, when it may implicate any region of the 
 brain. It may be rapidly induced as the result of an inflammatory 
 process ; or it may be of extremely sloio and insidious progress ; or the 
 steady progressive dissolution implicating the whole cerebrum, which 
 distinguishes the atrophy of premature senility. The intimate structure 
 of the centi'al nervous system would indicate peculiar relationships as 
 established betwixt the individual elements which must be fully recog- 
 nised ere we clearly appreciate the significance of these various forms 
 of atrophic change. Let us take as illustration of our remarks the 
 district supplied by one of the terminal cortical arteries. Now, we 
 affirm that the autonomy of this department demands a mutual sym- 
 pathy betwixt all the constituent elements of the same ; in other words, 
 action and reaction is so established between them that any derange- 
 ment in the functional activity of the one must, of necessity, affect the 
 other. In fact, the more highly differentiated the structural parts of a 
 tissue become, the moi'e dependerd also do they mutually become. It 
 matters little for this terminal arterial territory if a distant branch 
 (however large) off the same trunk be plugged, it still maintains its 
 autonomy; but it matters veiy much if this minute branch itself be 
 obstructed. The nerve-cell is dependent upon the terminal artery for 
 a due supply of its nutrient plasma ; the artery, in its turn, is regu- 
 lated as to its calibre by the functional activity of the nerve-cell ; the 
 lymph-connective system of the neuroglia is stimulated to renewed 
 activity by the accumulating i)roducts of nerve disintegration ; the 
 
 * Localisation in Cerebral Diseases. 
 
CEREBRAL ATROPHY. 455 
 
 nervous elements depend upon this continuous removal of effete 
 material for their normal storage and discharge of energy ; and so, in 
 like manner, the connective and vascular elements are mutually de- 
 pendent. In no organ of the body is this mutual dependence of parts 
 so exquisitely elaborated as in the brain and, a fortiori, the cerebral 
 cortex. Terminal vessels exist elsewhere, as in the spleen, kidney, 
 and lung ; but the presence of the nervous element establishes a much 
 more complete mutual dependence of parts. This inter-dependence of 
 the sti'uctural elements of the cortex, due to its terminal system of 
 arteries, is of primary importance to us in correctly appreciating the 
 morbid appearances presented in insanity. Another factor, however, 
 must be invariably considered with respect to all morbid lesions of the 
 cortex, and that is the sympathy betwixt distant territories which 
 ai'e functionally associated in their activities, and structurally linked 
 together by "association" fibres. The former condition — the inter- 
 dependence of parts in terminal systems — was the direct outcome of 
 elaborate differentiation ; the latter condition of sympathy betwixt 
 distant territories is established by an equally elaborate structural 
 integration. 
 
 Keeping these facts in view, it becomes obvious that much obscurity 
 naturally overshadows many pathological processes in the cortex 
 cerebri, despite the prominence of the morbid changes presented. No 
 one element of the tissue of the cortex can suffer materially, without 
 rapidly disturbing the nutritive equilibrium consistent with the health 
 of the territory to which it is attached ; hence it often becomes a 
 question whether changes observed in the nerve-cells are evidence of 
 primary implications, or whether they are secondarily induced through 
 a disturbance in the circulation of the district, or impairment of the 
 lymphatic functions of the cortex, in a blood crasis, or other cause; or, 
 again, as in the medulla, whether a sclerosic change with atrophy of 
 nerve-tubuli is primarily pai-enchymatous (originating in the nervous 
 element), or interstitial (sj^reading from the neui'oglia to the latter). 
 There is every reason to believe that in the nervous centres both 
 parenchymatous and interstitial change may occur as the primary fact ; 
 that the nerve-cell, for instance, may be stamped with a morbid insta- 
 bility wholly independent of any ab extra agency, and this as an 
 inherited or as an acquired condition ; nor is it unreasonable to sup- 
 pose that the changes iu the nerve-cell in physiological senescence 
 are initiated apart from any nutritive anomalies and blood vascular 
 changes, being simply the expression of the expiration of its fixed term 
 of existence. 
 
 The very general atrophy of the cei'ebral cortex occurring in patho- 
 logical senescence is often, but by no means invariably, associated with 
 
456 THK Monnin rijain in insanity. 
 
 a degeneration of its nutrient vf;ssels, and wlien these vessels are 
 involved it is to a very varying degree. Yet what is invariably foiind 
 is the degeneration of the nerve-cells which, in any appreciable degree 
 of atrophy, are extensively and very notably implicated. We have 
 here, in fact, what may be regarded as a true parenchymatous 
 degeneration ; the primary change is initiated in the nerve-cell. 
 
 Other forms of atrophy, usually more limited in distribution, occur 
 as the result of over-action of nervous centres; in such cases the element 
 which chiefly assumes the morbid rdle is the connective matrix or 
 neuroglia, although the primary incitant was undoubtedly nervous. 
 Illustrations are afforded in the case of alcoholism, where repeated 
 over-stimulation of nervous elements and the waste and eflete material 
 so produced, demand from the lymph-connective system more than its 
 capabilities can accomplish; the result is a temporary hypertrophy 
 of this tissue, the multiplication of its active elements {phaijocytes) 
 followed by their fibrillation, and the eventual atrophy due to the 
 encroachments of the connective upon the nervous elements. A 
 different illustration is afforded by cases of epileptic insanity, for here 
 again over-action leads to degeneration and atrophy of nerve-cells 
 through the medium of an encroaching connective; the conditions of 
 the epileptic are, however, by no means parallel to the alcoholic, and 
 we find that, in lieu of actual atrophy of the brain-mass, there is often 
 hypertrophy and augmented density due to the inordinate growth of 
 the connective element. Instances of premature senility (or what 
 used to be called atrophia cerebri precox) are illustrative of this form 
 of atrophy from over-activity of nervous centres. Long continued or 
 oft repeated excitement induces a similar state of atrophy, as seen in 
 most fatal cases of chronic insanity. 
 
 A frequent cavise of localised shrinking of the brain-substance is the 
 destruction and cicatricial condensation of tissue in hemorrhagic foci; 
 or, again, as the result of inflammatory destruction of nervous tissue, 
 whether arising centrally or spreading inwards from the meninges. 
 Either of these affections occurring in infancy will almost certainly, 
 owing to the principle enunciated above, retard the development of 
 distant parts, so that in adult life the brain will exhibit great disparity 
 in its two hemispheres, and in different regions of the afiected 
 hemisphere. Such cases also illustrate the crossed connection betwixt 
 cerebrum and cerebellum, and between the cerebellum and the opposite 
 olivary body, such as have been indicated by Van-der-Kolk and 
 Aleynert. As illustrative of this condition, may be mentioned the case 
 of a paralytic idiot, the subject of right hemiplegia and epilepsy, who 
 died at the West Riding Asylum, and in whom there was found 
 atrophy, with sclerosis of the left cerebral hemisphere, associated with 
 
CEREBRAL ATROPHY. 
 
 457 
 
 atrophy of the right lobe of the cerebellum (Major) ; * also the case of 
 another patient at this asylum, in which a lesion of one hemisphere 
 of the cerebellum, of the nature of an old htemorrhagic cavity with 
 dense sclerous walls implicating the corpus dentatum, was associated 
 with degeneration of the olivary body of the opposite side (Dudley), f 
 
 The frequency of atrophy of the cerebral hemispheres in insanity, 
 may be conclusively shown by the post-mortem statistics afforded at the 
 West Riding Asylum. It is hereby shown that, out of a total of 1,565 
 fatal cases of all forms of insanity, as many as 1,055 (or 67'4 per cent.) 
 presented evidence of cerebral atrophy; that the wasting was general 
 throughout the hemisphere in 574 of these cases, although 261 also 
 exhibited a special implication of certain areas, and that in 481 other 
 
 Fig. 13. — Illustrative of the sites of election of atrophy in order of precedence. 
 
 cases partial or localised atrophy was observed. The fronto-parietal 
 segment of the hemispheres enjoys least immunity from the atrophy 
 incident to insanity, and we find atrophy confined to the frontal lobes 
 in a large number of cases, in fact, in the proportion of three-fourths to 
 one-fourth respectively. Of still more restricted areas the postero- 
 parietal lobule appears most prone to a localised atrophy (forty cases); 
 the central gyri ranking next to this lobule in the frequency of their 
 implication (thirty-seven cases) ; the separate frontal gyri and Sylvian 
 boundary (operculum) were thus affected in thirty-three and twenty- 
 
 * See descriptive summary with illustrations of this case by Dr. H. C. Major, 
 Jovr. Mental Sc, July, 1879. 
 
 t See report with illustrations by Dr. William Dudley, Jotir. Mental Sc, 
 July, 1886. 
 
458 TUE MOUUID IJIiAIN IN INSANITY. 
 
 nine cases respectively; then followed the temporo-sphenoidal and the 
 occipital gyri, the an<;ular being implicated in but eight cases. The 
 general results arrived at by a large series of weights of the brain in 
 the insane, excluding cases of congenital defect, teach us that the 
 lowest average weight due to atrophy is attained by instances of so- 
 called organic dementia (hajmorrhagic or ischaiuiic softenings); senile 
 atrophy of the brain follows next; whilst general paralysis ranks third 
 in order. 
 
 Miliary Sclerosis. — So frequently has the lesion, to which this 
 term is applied, been recognised as occurring in the central nervous 
 system of those dying insane, since it was first described and figured 
 by Drs. Batty Tuke and Rutherford in 1868, that we feel diflBdent in 
 suggesting a new name ; although we diflei- from those observers in 
 regarding its nature as that of genuine sclerosis or overgrowth of the 
 connective element of the nervous tissues. That the morbid change 
 hitherto recognised under this term must eventually ])e renamed we 
 are confident ; and that when its nature is fully understood its impor- 
 tance will gain for it much greater attention than it has hitherto 
 received we are equally confident ; meanwhile, we retain the name 
 whereby it has been known for the past twenty years, as the least 
 likely to mislead the student as to the change to which we refer. 
 The morbid appearance presented by this lesion has been the subject 
 of frequent examination by many observers, but little (if anything) 
 has been added to the graphic account given by its discoverers.* 
 Some, however, have gone the length of denying its ])athological 
 origin, asserting it to be a jjost-mortem change or an artificial product 
 cleverly manufactured by the histologist's reagents : amyloid, colloid 
 bodies, and "miliary sclerosis," have all in their turn been explained 
 away by some as the results of alcohol or other reagents. Unfortunately 
 for this theoi'y, however, all such changes are to be found in the 
 perfectly-fresh brain before any reagent has been applied, and it requires 
 but a short experience in the fresh preparation of nervous structures 
 amongst the insane to vindicate their pathological import. Dr. Batty 
 Tuke's description of the fully-developed lesion is as follows : — 
 
 "As a rule, the spots are unilocular, occasionally bilocular, and in rare instances 
 multilocular ; but whatever their condition m this respect is, they possess the same 
 internal characteristics. A thin section prepared in chromic acid viewed by the 
 naked eye shows a number of opaque spots irregularly distributed over the surface 
 of the white matter ; they are best seen in a tinted section, as they are not colour- 
 
 * See especially Dr. Batty Tuke's article on the " Morbid Histology of tlie 
 Brain and Spinal Cord in the Insane," Brit, and For. Medko-Chlr. Review, July, 
 1873 ; also Dr. Kesteven's paper in the Brit, and For. Medico-Chir. Review, April, 
 1869. 
 
■pinal cord formiTi^ 
 
 ^^^T^ 
 
 / .* 
 
 ^ 
 
 i -^yAb 
 
 
MILIARY SCLEROSIS. 459 
 
 able by carmine. When magnified by a low power they have a somewluit luminous 
 pearly lustre, and when magnified 2ii0 and 800 diameters linear, they are seen to 
 consist of molecular material, with a stroma of exceedingly delicate colourless 
 fibrils. They possess a well-defined outline, and the neighljouring nerve-fibres and 
 blood-vessels are pushed aside, and curve round them. In well-advanced cases the 
 plasm seems denser at the circumference of the spots than at their centre, and a 
 degree of absorption of the contiguous nerve-fibres is evident ; this solution of con- 
 tinuity is only noticeable at the point where the lateral expansion is greatest. The 
 spots are generally colourless, but in some instances they are of a yellowish-green 
 tint, which may be attributable to chromic acid. They vary much in size ; uni- 
 locular patches are -s^jjth of an inch to rJuth of an inch in diameter, the multilocular 
 from over vr^th to ^^th of an inch. As many as eleven locules have been noticed 
 in one patch, separated one from the other by fine trabecular of nervous tissue." * 
 
 The favourite sites of election for the development of these morbid 
 appearances seem to be the white matter of the cerebrum, the pons and 
 medulla, and the lateral columns of the spinal cord. In the last posi- 
 tion it can be studied to best advantage, although it is far more 
 generally met with in the medulla of the cerebral hemispheres. When 
 its occurrence is noted in the brain, we find that on holding up a 
 stained section slightly aslant to the light, numerous little bright 
 pellucid points appear scattered through the medullated structure, and 
 just perceptible to the naked eye ; they are also seen by reflected light, 
 but not by direct transmitted light. Under a low power each of these 
 brilliant points is resolved into a distinctly lobulated patch some 20 /a 
 to 50 fjj in diameter, their colourless aspect strongly contrasting with 
 the stained tissues in which they are imbedded. At first sight they 
 look like a number of unequal sized droplets of a fluid of somewhat 
 dense unctuous consistence, which have incompletely fused with each 
 other ; and which, with somewhat oblique light, stand ovit in bold 
 relief with opalescent or frosted pearly lustre. By direct light they 
 appear more translucent, and often seem like unequally lobulated 
 cavities (in some cases actually being so, the contents having fallen 
 out during the pi-eparation of the specimen). They present, moreover, 
 three suggestive features which have a direct bearing on the question 
 of their pathogenesis. 
 
 {a.) They are distinctly limited to the white meduUated. Structure 
 of the brain ; and, where they approach the grey cortex of tlie con- 
 volutions, they, in most cases, ahrujylly terminate, the naked-eye suflUces 
 to elicit this limitation. When they do invade the cortex, as very 
 rarely occurs, it is only in its lowermost zone, and then strictly along 
 the line of the large medullated radiations. 
 
 {b.) The perivascular nuclei frequently exhibit abundant proliferation 
 and granular hivmatoidin masses freely cover the shoatli of the vessel. 
 
 * Loc. cit., p. '205. 
 
460 THK MORBID RRAIN IN INSANITY. 
 
 (e.) The condition is at a certain stiige invariably associated with an 
 increase of the so-called spider-cells or Deiter's corpuscles. 
 
 If the spinal cord rather than the brain be the subject of our 
 scrutiny, we tind the lesion presents still more prominent and obtrusive 
 indications of its presence. Its demonstration is not only facilitated 
 by certain features here presented, but the essential nature of the 
 change also becomes clearly evident. On examining, by unaided 
 vision, a stained, transverse section of a spinal cord so affected, we 
 find a dark-stained area (undoubtedly sclerosic in nature) of one or 
 both lateral columns ajyjyarently riddled by numerous minute aper- 
 tures ; in reality, they are not apertures, but minute foci readily 
 transmitting light, owing to their altered tissue and resistance to all 
 staining reagents. We have here, in fact, a system-disease of the 
 cord — a lateral sclerosis with certain peculiar morbid features super- 
 added. 
 
 At the site of these apparent apertures the microscope reveals 
 colourless translucent patches, irregular in contour, usually more or 
 less lobulated, and frequently showing in their midst indications of 
 varicose medullated fibres ; reproducing in other respects the appear- 
 ances above described in the miliary patches of the brain. Around 
 such unstained areas the tissue is always condensed and most deeply 
 stained, and the nerve-elements are much wasted or completely 
 replaced by sclerosed tissue [PI. \\.,fig. 1). Far more instructive speci- 
 mens, however, are obtained from longitudinal sections through the 
 diseased columns. The morbid product is then seen to be aggregated 
 in oval or elongated elliptic patches measuring 139 /a to 186 /i in length 
 by 40 /A to 70 /A in breadth ; and in many cases the morbid material 
 has dropped out, leaving only an irregular opening, the boundaries of 
 which are fibrillated and never clean-cut or punched-out through the 
 tissues, as are certain channels of morbid origin found occasionally at 
 these sites. The appearance at once suggests to the mind the forcible 
 extravasation at numerous points of a coagulable material which has 
 driven the textural elements asunder before it ; a suggestion further 
 favoured by the almost invariable presence of a blood-vessel (often 
 of considerable magnitude) running in close proximity to, or even 
 appearing to lose itself in, the morbid focus. The morbid material is 
 seen to consist of a congeries of oval or spherical segments of delicate 
 and indistinct outline, the sole indication of which is often the gentle 
 curve of a connective fibre passing over it (^Pl. vi.. Jig. 2). Usually 
 pellucid, it may be found slightly opalescent, whilst overlying and 
 passing between its segments is an extremely fine plexus of fibrils. 
 Some of the fibres branch dichotomously, and have the appearance 
 of veritable elastic fibres ; others arise from delicate spider-cells, 
 
MILIARY SCLEROSIS. 461 
 
 ■which are numerously scattered around the confines of the diseased 
 patch {PL vi., fig. 3). Around their lobulated contour we find a 
 condensation of tissue, the nerve-fibres atrophied or absent, and 
 the sclerous tissue and blood-vessels closely packed and curving 
 round the mass. But the more important point to note is that 
 all the medullated fibres, in a line with the diseased tract, are 
 in a condition of advanced disease, and end directly in this morbid 
 focus ; extreme varicosity with segmentation of the medullated sheath 
 is apparent. These medullated fibres, as they approach the diseased 
 focus, are, in many cases, seen to be regularly moniliform, segmenta- 
 tion of the white matter of Schwann having proceeded so far that 
 spherical masses of medulla are strung upon the axis-cylinder like 
 beads upon a string ; at times the retraction of the segmented 
 portion is not so great, and an irregularly varicose aspect ensues ; 
 whilst, in other cases, large pyriform masses of medulla are seen, the 
 axis-cylinder extending like a stalk from its narrow end {PI. vii.). 
 Beside these varicose fibres lie naked axis-cylinders wholly devoid of 
 an investing medulla, and swollen beyond their natural dimensions. 
 
 The spherical masses of medulla exhibit a series of progressive 
 changes towards disintegration. The early stage is represented by 
 the simple spheroid or pear-shaped mass, perfectly clear and trans- 
 lucent, with, perhaps, a faint indication of the axis-cylinder running 
 through its centre or displaced laterally. The next stage presents a 
 slightly-frosted clouding of its interior, followed later on by the forma- 
 tion of numerous extremely minute granules within. In the third 
 stage the spheroid becomes not only full of these granules (apparently 
 fatty in nature), but its whole mass takes up a faint staining of 
 aniline or hsematoxylin dye, whereby it is distinctly contrasted 
 with the clear spheroids of an earlier stage which remain unstained 
 {PI. vii.). 
 
 In the immediate neighbourhood of these segmented medullated 
 fibres careful examination reveals a vast number of spindle-cells ; so 
 delicately pellucid are these bodies, and so faintly do they take up the 
 staining reagent, that they are readily mistaken for free nuclei, since 
 their nucleus is always deeply stained, and this error is not unfrequently 
 committed. At the height of the morbid activity, however, the nature 
 of these elements undergoes a remarkable change ; they then stain 
 well, even to their ultimate ramifications, and they apply themselves 
 so well to the task of removing disintegrative material arising from the 
 nerve-tissue that their interior soon becomes filled with the minute 
 granules which we have referred to as clouding the medullary 
 spheroids {PL vi., fig. 2, PL vii.). These lymph- connective elements 
 thrive abundantly at the expense of the nerve-tissue and enlarge 
 
462 THK MORBID BRAIN IN INSANITY. 
 
 greatly in bulk, whilst their extensive ramifications pervade its 
 structure in all directions. Along the couise of such degenerating 
 medullary fibres the bead-like segmentation often produces a clo.se 
 resemblance to a series of large cells, a resemblance which becomes 
 most striking by the occurrence of what looks like a fair-sized 
 nucleus occupying the centre of each sphere; undoubtedly they have 
 been frequently described as cells, an error not to be wondered at 
 since few reagents display well their real nature ; carmine and hsema- 
 toxylin help to falsify the appearance, but aniline blue-black with 
 bright illumination seems best adapted for exhibiting their real 
 constitution. With other dyes they might readily pass for nuclei 
 arranged along the nerve-fibre at each of its moniliform segments, 
 did we not know that the medullated fibres of the centric nervous 
 system (unlike the peripheral nerves) are devoid both of nuclei 
 and of Schwann's sheath, being, in fact, not made up of inter- 
 annular segments. Properly -prepared sections, however, show that 
 this apparent nucleus does not occupy the interior, but lies upon the 
 exterior of the sphere, and is in reality the nucleus of a young spideP- 
 Cell, surrounded by a little granular protoplasm from which delicate 
 branches radiate and clasp the spherule of myelin (PL vii.). Being 
 closely appressed to the spheroid, it looks like a protruding nucleus; and 
 the regularity with which a whole series of such moniliform enlargements 
 in a line with each other show these aggressive cells, would appear to 
 indicate a remarkable morbid affinity. It is also to be noted that where 
 these nucleated spider-cells apply themselves, the medullated spheres 
 have all undergone a granular Change and admit of staining"; 
 where the myelin-droplets remain clear, homogeneous, and unstained, 
 these nucleated cells do not present themselves. On the other hand, 
 these scavenger-cells appear abundantly in the dense sclerosic tissue 
 immediately surrounding a miliary patch. 
 
 The degenerative change which we have thus followed in the medul- 
 lated fibres of the spinal cord is recognisable as an all-important feature 
 in the white medullated strands of the cerebral convolutions in chronic 
 alcoholism, and especially in senile atrophy of the brain ; the same 
 activity of the lymph-connective system prevails in these cases, and (as 
 we shall see when treating of these affections) spider-cells accumulate 
 around the disintegrating nerve-fibre. In the cortex of the brain these 
 spider-cells are often found (during the disintegrative stages of disease) 
 to contain small masses of deeper stained material apparently derived 
 from the neighbouring nerve-cells (PL xv., Ji(/. 3). Eventually the 
 fibrillation so resulting entirely replaces the nervous tissue, so that 
 deep-stained tracts consisting of sclerous tissue only are seen here and 
 there at the more advanced sites of disease. 
 

 SccLvengtr cells 
 
 , Scgijvenger cecls 
 ff' y filled- vn.ih aranv.1 
 
 ijchre i~ 
 - tOLiion.. 
 
 Degeneration of Nerve -fi'bres of lateral 
 so-called "Colic 
 of these tracts 
 
 f S-piiLsl cord vci so-called "Colloid de^en 
 
MILIARY SCLKROSIS. 463 
 
 Thus, in the immediate neighbourhood of these patches of miliary 
 sclerosis, we find the nervous tissue in a state of papenchymatous 
 deg'eneration, which, resulting in destruction and atrophy of the 
 essential elements, becomes the site of a g'enuine SClePOSiS. What 
 relationship exists between the unstained patches of miliary sclerosis 
 and the condition of parenchymatous degeneration around ? 
 
 We have ali-eady referred to the invariable presence of a fair-sized 
 blood-vessel lying in direct contact with these patches of miliary de 
 generation. If these be closely examined we find reason for believing 
 that the coats of the vessel are involved by extension in the morbid 
 process, the coats are unduly thickened, the perivascular nuclei have 
 undergone great proliferation, the vessels are much contorted, and very 
 frequently occluded. We would suggest that the patch of miliary 
 degeneration may be directly due to this implication of a neighbouring 
 blood-vessel, by the exudation from the vessel inducing such swelling 
 of the myelin as to rupture the delicate investing albuminous sheath, 
 or possibly by a direct action upon the latter. The patch undoubtedly 
 consists of altered myelin exuded in droplets from the medullated 
 tubes and coalescing more or less completely — the axis-cylinders forced 
 aside with the neighbouring tissues, or undergoing complete solution of 
 continuity. In a large proportion there can be very little doubt that 
 disruption of the axis-cylinder occurs, judging from the appearances 
 presented by the section of the miliary spot. The skeleton framework 
 of the structure, however, still remains in the form of a delicate plexus 
 of elastic fibrils beautifully dissected-out by the process, and brou<^ht 
 into relief upon the colourless spherules of myelin ; with these there 
 becomes blended ultimately a fine stroma of fibres arising from the 
 spider-cells around. The latter condition occasionally proceeds to an 
 excessive extent in similarly degenerative foci in the cerebrum and 
 cerebellum, when we meet with isolated tufts of delicate interlacin<y 
 fibres forming dense meshworks (beautifully revealed by aniline dyes 
 in the fresh brain), which are devoid of nervous structure and of all 
 cellular elements alike. In other instances the small nodule falls out 
 during preparation, or (as Dr. Batty Tuke observes) may be picked-out 
 with the point of a knife from the hardened brain. The naked-eye 
 appearance of these formations, as they present themselves in situ in a 
 segment of the cord, is that of just perceptible points perfectly white 
 and opaque, and thus contrasted strongly with the deep chrome tint of 
 the surrounding tissue. Removed by a pin-point to a glass slide, they 
 are found to resist considerably the pressure applied to the cover »lass, 
 but upon the addition of a drop of bichromate of potash solution firm 
 pressure resolves them into tolerably large spherical bodies. Osmic 
 acid does not darken these morbid formations, but this fact mi^^ht be 
 
464 THE MORBID BRAIN IN INSANITY. 
 
 anticipated from the change induced by the chrome salts. The effect 
 of nitric acid and other reagents has been studied by Dr. Rutherford ; 
 the former renders the mass transparent, and subsequently resolves it 
 into a number of colourless bodies about the size of a blood-corpuscle, 
 apparently formed by the coalescence of droplets occasioned by the acid 
 solution of the mass. By pressure on the cover glass these bodies be- 
 come elongated and, eventually, removed entirely, leaving a delicate 
 fibrous stroma of connective in their place. Strong sulphuric acid acts 
 similarly. It will be seen from the above remarks that we regard 
 these multiple lesions not as a primary sclerosic change, but as acci- 
 dents occurring in the course of a subacute inflammatory or 
 deg'enerative Chang^e in the medullated nerve tracts ; and that 
 when (during the progress of a parenchymatous inflammation of these 
 structures) the tunics of an adjacent blood-vessel become involved, 
 there we get the rupture of these globose masses in the nerve-tubuli 
 and their coalescence in the patches of miliary deposit, which are most 
 probably altered in constitution by the inflammatory efli"usion from the 
 blood-vessel. That it is not an essential feature in the history of such 
 inflammatory activity is sufficiently evidenced by its frequent absence; 
 yet, it is our opinion that in the nervous tissues of the insane its occur- 
 rence is more frequent than is usually supposed. 
 
 It is well known how difficult of demonstration are the several 
 deo'enerative and chronic inflammatory changes which occur in the 
 medullated tracts of the brain in insanity, and how liable such changes 
 are to be overlooked. The presence of such miliary spots, therefore, 
 is one of very great interest and importance, as calling attention to the 
 morbid state of the nerve-fibres in the immediate neighbourhood.* 
 
 * The following letter from Dr. Batty Tuke, inserted here by his wish, will serve 
 
 to indicate how far he retains his former opinion with respect to the morbid change 
 
 in question : — 
 
 "Edinburgh, May 24iJL, 1889. 
 
 "Dear Dr. Bevan Lewis, 
 
 " After seeing your sections and comparing them with my own, t am 
 convinced that most of the lesions described by Prof. Rutherford and myself many 
 years ago are due, as you suggest, to myelitic changes. These clianges are, for the 
 most part, the result of the increase of the white substance of Schwann. I am 
 gratified to find that you agree with what we said as to the material importance 
 of these appearances in the morbid anatomy of chronic insanity. I am not pre- 
 pared to give up the theory that certain of the changes we described may not be 
 produced in other ways, and may not be due to degeneration of other brain 
 elements. But, as I have already said, I am with you in the main. 
 
 " After your remarks on the subject it is unnecessary for me to enter upon any 
 argument to prove that miliary sclerosis is not the result of the action of hardening 
 agents. Such position is rendered quite untenable by the simple fact that the 
 lesion is often demonstrable in fresh frozen specimens. — I am, yours sincerely, 
 
 "John Batty Turk." 
 
coi.Loui i>i':(;i;Ni';iiATioN. 465 
 
 Colloid Deg*enePation. — A very frequent lesion found in the brain 
 of the insane; is that which has been termed " colloid degeneration," a 
 term applied to the presence of minute round or oval bodies, from 
 6 //, to 12 /i in diameter, which pervade the nervous structures oc- 
 casionally in extraordinary numbers. The frequency of its occurrence 
 in the brain and spinal system of the insane, its undoubtedly morbid 
 origin, and the essential nature of the lesion indicate it as one of 
 the most important conditions for our consideration in the morbid 
 histology of insanity. 
 
 Some nine years ago we described as a frequent appearance in the 
 nervous tissues of the insane certain peculiar morbid products, which, 
 although tmdoubtedly derived from the medullated nerve-fibre, bore a 
 striking resemblance to the so-called colloid bodies,* and we ventured 
 to suggest their actual identity, but withheld any dogmatic statement 
 of the case, until further observation had assured us that the usually 
 I'eceived opinion of their constitution was fallacious. Repeated ob- 
 servations since this date fully confirm our former suggestion that 
 these morbid products have been too hastily relegated to the chapter 
 of diseases of the connective framework or neuroglia ; and assure us, 
 moreover, that the morbid bodies then described by us were identical 
 in their nature with the '•' colloid " body. The name is unfortunate, 
 since it assumes a colloid transformation of a connective cell similar to 
 what occurs in the typical colloidal transformation of the epithelia of 
 the thyroid gland, or the same change in the elements of new growths, 
 and we feel convinced that in this cellular origin of the change the 
 view is inaccurate. In size these bodies vary very considerably, from 
 6 to 12 ^ in diameter, up to 40 im — the former being the usual 
 dimensions of those found in the cerebral convolutions, the latter 
 those of the regions of large medullated fibres, such as the medulla 
 oblongata. Dr. Batty Tuke gives their diameter at o-yVo' *° Tm)~s °^ 
 an inch, but this clearly applies to the minute colloid bodies of the 
 cerebral gyri ; he also notes their variability in size, quoting certain 
 experiments of his own and Dr. M'Kendrick on the brain of pigeons, 
 in which colloid bodies were discovered of very minute size {-^xru i^ch). 
 
 As we have elsewhere stated, they vary in direct relation to the 
 varying diameter of the medullated nerve-tracts in which they are 
 found. In form these morbid bodies are spherical, ovoid, or pyriform, 
 their marginal contour in later stages becoming often crenulate. 
 They are perfectly homogeneous in structure, devoid of concentric 
 markings, colourless and pellucid, they may become slightly tinged by 
 hsematoxylin, but are wholly unafi"ected by carmine or aniline dyes, 
 
 * "Lesions of the nervous tissues in the brain of the insane," Brain, Oct., 
 1879, p. 364. 
 
 30 
 
466 TIIK MORBID HUAIX IN INSANITY. 
 
 and thoy exliibit no reaction with the iodine and sulphuric acid 
 test. 
 
 A case of bulbar paralysis occurring at the West Eiding Asylum 
 showed the lower half of the medulla to be the site of this lesion to 
 such an extent, that its sections under a low power appeared as if 
 besprinkled by thousands of minute droplets, and yet to the naked 
 eye no abnormal appearance presented itself, and the section, although 
 pale, was uniformly and faii-ly-well stained. A glance at the accom- 
 panying sketch [PI. viii.) will reveal the microscopic dimensions of 
 these bodies and their wide-spread implications. Yet it will be 
 eijually obvious how absolutely the limits of the grey matter of the 
 medulla is respected. Thus, in the olivary bodies we observe these 
 morbid formations wholly confined to its medullated core, and nowhere 
 implicating its plicated grey su.bstance, except where the latter is traversed 
 by medullated fibres ; and the same remark applies to the grey matter 
 of the floor of the fourth ventricle, and nuclei of the cranial nerves. 
 
 The following is a resume of the clinical features and pathological 
 appearances in this case : — 
 
 T. W, , aged thirty, married. He is a stone-mason, and was stated to have been 
 insane for five months upon his admission. Two years previous to this date he 
 was stated to have had a paralytic stroke. Five weeks prior to admission 
 he again had a paralytic seizure (right hemiplegia), was deprived of speech, 
 and became depressed and suicidal ; great and increasing difiiculty in degluti- 
 tion had been noted since this second paral3'tic seizure. On admission to the 
 asylum he was completely speechless, could only utter inarticulate sounds, or try 
 to explain himself by gesture and pantomime. He appreciated all that was said to 
 him, but showed considerable amnesia. When asked to write down his name he 
 took up the pencil with his left hand first, and then, transferring it to his right, 
 hesitated for some time as if tryuig to recall something, and then threw it down in 
 despair. He expressed numbers by tapping successively with his finger on the 
 table. He had been a steady man, of temperate habits. 
 
 Circulatorj^ respiratory, and genito-uriuary systems appeared normal. 
 
 His gait was somewhat unsteadj', but there was no inclination to one side; the 
 grip of the right hand is much diminished, and he uses his left hand in lieu of the 
 right ; no muscular wasting is apparent. The extremities are extremely cold, and 
 both the feet and hands, as well as nose and cheeks, are livid ; a similar patchy 
 lividity is seen over the whole body. He fails to whistle or spit ; cannot close 
 his mouth, but opens it widely ; saliva constantly dribbles from the mouth ; he 
 swallows fluid food only, and that with the greatest difiiculty, throwing his head 
 far back and accomplishing the act only after a prolonged effort, and then with 
 much spluttering. The tongue appears completely paralysed, lies helplessly on 
 the floor of the mouth, and cannot be protruded or laterally displaced. 
 
 Common sensibility and reflex activity appear normal and equal on both sides ; 
 perception of temperature and electric sensibility normal ; all the affected muscles 
 react energetically with feeble faradaic stimulation; all special senses appear normal. 
 The pupils are dilated, the right pupil being the larger and more sluggish. For 
 five years he remained a most anxious case for feeding, beiug in constant danger of 
 

 Accessory Uiivary bodies 
 P a r al V s i s she"wiTi^ 
 
BULBAR PARALYSIS — SIONIFICANCK OF COLLOID CHANGE. 467 
 
 choking. He had no further paralytic seizure, and died eventually of pulmonary 
 gangrene. 
 
 Summari) of Au/ojjsi/. — Bones of skull thickened and very dense ; no adhesion of 
 dura mater ; the pia-arachnoid is opaque at the vertex, thickened, tough, and 
 buoyed up by much serous fluid. In both hemispheres there is considerable atrophy 
 of the convolutions, and where this wasting is extreme the cortex, after removal 
 of the membranes, presents well-marked cauliflower [tuckering of the surface. The 
 whole brain weighed but 990 grammes. The thickened membranes stripped with 
 ease from all parts of the surface, except at certain sites where softening of the 
 cortex had occurred. The softened patches were disposed with a certain degree of 
 symmetry on both sides, thus : — 
 
 Right Hemisphere. Left Hemisphere. 
 
 Slight along lower third of ascending Lower half of ascending frontal. 
 
 frontal. Three upper annectants and bound- 
 
 Second annectant gyrus and cortex of aries of parieto-occipital sulcus. 
 
 interparietal sulcus. 
 Middle of third frontal gyrus. 
 
 The patch of softening is generally of a greyish colour, translucent, and gelatini- 
 form, its centre of bright yellow hue surrounded by a greyish translucent zone ; 
 it is pulpy and torn upon removal of the superjacent membranes. 
 
 The cauliflower puckering characterising the sites of most extreme wasting were 
 disposed in the right hemisphere along the convolution bounding the longitudinal 
 fissure, the middle of the second frontal and the angular gyrus ; in the left hemi- 
 sphere it involved the postero-parietal, the middle of the second frontal, and a 
 portion of the second temporo-sphenoidal convolution. 
 
 Respecting the other organs of the body, the only point essential to note here 
 (beyond the gangrenous condition of the lung) was the absence of any cardiac 
 disease, and the presence of granular and wasted kidneys, somewhat extreme in 
 both instances. 
 
 In the brain, also, we find these bodies encroach upon the grey 
 matter only exceptionally, and then invariably along the direction taken 
 by the large medullated tracts (the tang'ential fibres of the periphePal 
 zone more especially), and more rarely the intraCOrtical arcifOPm 
 fibres {PI- ix., figs. 1, 2). We have already alluded to the same limi- 
 tation as regulating the distribution of the " miliary" patches. 
 
 No theory of the connective origin of these morbid formations could 
 account for this peculiar restriction. Reverting to the case of bulbar 
 paralysis [PI. viii.), we find, these morbid products especially large and 
 suitable for study along the fibres of the median raphe, the emergent 
 root-fibres of the hypoglossal, and the arciform fibres near the raphe 
 posteriorly. In these positions they lie either superimposed to the 
 medullated fasciculi, or are crossed superficially by others ; but, when- 
 ever their conformation assumes an elongate outline, their long 
 diameter takes the direction of the medullated fasciculus lying 
 parallel to the fibres. In many instances they are distinctly seen 
 
468 THE MORBID BKAIN IN' INSANITY. 
 
 to be an oval swelling aloug tlie course of the medullated fibre, and 
 the axis-cylinder can be traced through the centre of the swelling; 
 in other instances a pyriforni body presents itself, the narrow end of 
 which is directly continuous with a swollen and deeply-stained axis- 
 cylinder; or, again, a subglobose body, from the two poles of which 
 the medullated axis is continued (although not traceable) within its 
 structui-e. Some of the largest examples of the elliptic form attain the 
 dimensions of 55 /«. by 37 /a. 
 
 The presence of a nucleus within these bodies has been said to occur, 
 giving, of course, much colour to the account of their cellular origin ; 
 with respect to this, we stated in the article already referred to, that 
 such bodies were always extraneous. " Occasionally a nucleus appeared 
 on the surface or border of these bodies, but it could always be regarded 
 as extraneous to the morbid formation and accidentally superimposed."* 
 Our methods of preparation now enable us to considerably extend such 
 a statement ; not only are they in all cases extraneous to the morbid 
 swelling, but they are not free nuclei ; they are really the nuclei of 
 spider-cells (which are found when carefully looked for) attached to 
 most of these so-called colloid bodies {PI. vii.). So far from being, as 
 we supposed, accidentally superimposed, they are important elements 
 in the morbid role, their significance being identical with what has 
 already been delineated in our description of '•' miliary sclerosis." 
 
 The " colloid " body is, in its early stage, perfectly translucent and 
 so minute that (unlike the miliary patch) it is not evident to the 
 naked eye under reflected light (P?. x. B.); it is likewise attached, form- 
 ing an integral part of the medullated fibre, and, hence, not removable 
 like the miliary deposit; it is, also, a single, homogeneous body showing 
 (of course) no stroma of fibrils through its structure ; but these difier- 
 ences do not, we observe, indicate a distinct pathogenesis. Given 
 certain conditions at a later stage, and the colloid bodies become 
 opalescent or granular, swell to greater proportions, burst their albu- 
 minous sheath and coalesce as free miliary products, appear multi- 
 locular and have their structure permeated by the ramifying processes 
 of scavenger spider-cells {PI. vi.. Jigs. 2, 3). 
 
 The history is the same for all parts of the cerebro-spinal axis con- 
 taining medullated fibres ; but, as before stated, the transition stages 
 are best studied where the larger medullated fibres exist in the region 
 of the pons, medulla, and lateral columns of the cord. That this 
 transition from the " colloid " to the " miliary" formations had occurred 
 in the case quoted years since by Kesteven, is to our mind conclusive. 
 In his case the section of medulla of a patient, of whom the clinical 
 history was unfortunately wanting, appeared under a low power to be 
 
 * Loc. cit., p. 366. 
 
SIGNIFICANCE OF MILIARY AND COLLOID CIIANGK. 469 
 
 full of minute cavities or perforations, which, when examined by 
 higher powers, were found, in many instances, filled with a fine 
 granular substance, similar to what we have already described as 
 found in " miliary " patches. This drawing of the morbid groupings 
 in the medulla reproduces the appearance met with in the case of 
 bulbar paralysis already alluded to {PI. viii.), with this exception, 
 that in the latter case the product of morbid activity was far more 
 profusely scattered, and the individual bodies, of course, very minute 
 (not having coalesced into miliary patches). Mr. Kesteven observes 
 in reference to his case : — 
 
 "These cavities are irregular, scattered, without evidence of order, throughout 
 the medulla oblongata referred to. They cannot be said to predominate specially 
 in any one of the elements of the organ; but if they prevail at all in any part, 
 it may perhaps be said that they are rather more numerous posteriorly than 
 anteriorly. In one section, about the level of the calamus scriptorius, I counted 
 several hundreds of these cavities." Again he adds :— " The surrounding textures 
 appear to be perfectly healthy, with entire absence of any inflammatory action ; 
 neither is there sign of disease of the blood-vessels in the surrounding tissue. The 
 morbid change is restricted to these detached points, and it is wholly a matter of 
 conjecture whether it commenced in the capillaries, or in nerve-tubes or cells."* 
 
 Whenever this lesion appears in the spinal axis, it will be found 
 advisable to study its nature in longitudinal sections and by the aid of 
 aniline dyes. 
 
 To summarise our results, we regard both the " miliary " and 
 " colloid " change as representing stages in the progress of a chronic 
 degenerative affection of the medullated fibres of the centric nervous 
 system ; an affection which is of most frequent occurrence in the brain 
 of the insane, and one of most vital import. A difference of opinion 
 may exist regarding the special nature of the affection, whether it 
 should be taken to indicate a simple degenerative change or one of 
 chronic inflammatory irritation ; and, in fact, the same question may 
 be asked concerning the changes resulting from section of a peripheral 
 nerve. In the one case, as in the other, the real origin of the affection 
 is in the severance of the fibre from its trophic cell. It is in the 
 diseased state of the cortical nerve-cells that we must seek, in most of 
 our cases of insanity, for an explanation of this degeneration of the 
 nerve-fibres ; of course, any lesion causing severance betwixt the two, 
 at any site along the fibre, will act in like manner, but the central 
 disease in the cortical cell is usually the primary fact presented to us. 
 The segmentation of myelin, occurring in this chronic affection, 
 difiers in some important particulars from what we see taking place 
 
 * See original article, "Notes of a Peculiar Form of ' Granular Degeneration ' 
 observed in a Medulla Oblongata." By W. B. Kesteven. Brii. and For. Med. 
 Chit: Rev., April, lS6t1. 
 
470 TUE MORBID BRAIN IN INSANITY. 
 
 ill degeneration from section of peripheral nerves. Thf latter is 
 apparently a more active process, and is the result of the direct morbid 
 activity of the cellular constituents of the nerve-fibre ; in its enlarged 
 and dividing nucleus, and increased development of protoplasm, we 
 recognise (as long since taught by Ranvier) the destructive agencies 
 which bring about the segmentation and eventual destruction of the 
 axis-cylinder and its medullary investment. In the more delicate 
 fibres of the brain and spinal cord, segmentation of the myelin occurs 
 more spontaneously ; and as the medulla separates into varicose 
 nodules along the length of the fibre, it becomes less susceptible to 
 staining by Pal's process, which, in the healthy fibre, stains the 
 niedullated sheath of a deep purple, leaving the axis-cylinder untouched. 
 It is then often noticed that the annular segments, although per- 
 fectly uncoloured for the greater part by this process, yet have a slight 
 coloured fringe around both poles, the intervening medullated connec- 
 tion with the adjacent varicosity being normally stained and continuous 
 with this coloured fringe. The appearance suggests an unchanged part 
 of the medulla or its albuminous sheath at this site ; possibly remains 
 of the ruptured sheath. We must not regard varicosity of the fibres 
 as conclusive of a commencing degenerative change ; but when extreme 
 varicosity of the larger medullated fibi-es is associated with their 
 tendency to take up aniline and carmine staining, when they exhibit 
 granular contents and clouding, and especially when apparently free 
 granular masses with proliferating spider-cells are seen, we may be 
 quite confident that we are dealing with a genuine degenerative 
 change; finally, the presence of "colloid" bodies or of "miliary" 
 patches assures us of the existence of the same condition. 
 
 Such extreme conditions of " colloid degeneration " (referred to by 
 Dr. Batty Tuke as of occasional occurrence in the white substance of 
 the brain, in which the section looks like " a slice of cold sago- 
 pudding ") are undoubtedly states of degenerated medullary fibres from 
 disease of their centric cells. 
 
 How far does this condition of the medullated fibre interfere with its 
 normal conductibility or excitability'? The long persistence of the 
 axis-cylinder probably permits a free conduction along the fibre for 
 some time after the latter is completely denuded of its myelin sheath; 
 and we must regard this as still possible so long as actual severance of 
 the axis be not etfected. Such severance occurs (as we have seen) in 
 the accidental accompaniment of "miliary sclerosis," and then sudden 
 interruption must occur in the conductibility of the fibre; but, apart 
 from such an occurrence the process is one of very chronic course, the 
 denudation of tlie axis-cylinder takes place very gradually, and the 
 latter eventually succumbs to the encroachment of the sclerous tissue. 
 
GRANULAR DEGENERATION OF NERVE-CELLS. 471 
 
 Granular Disintegration of Nerve-Cells. — The whole cell be- 
 comes swollen, and assumes a more spherical contour ; the cell 
 protoplasm loses its apparent homogeneity, and is clouded and 
 obscured by the formation of granules within ; the devitalised proto- 
 plasm no longer shows its affinity for the staining reagents, and 
 becomes but faintly tinted by carmine or aniline dyes ; the nucleus 
 in like manner resisting these reagents. The nucleus often retires 
 before the degenerating mass, is thrust aside, and becomes atrophied, 
 shrunken, angular or elongated ; moreover, the physiological pigment 
 of the cell (usually found in a small collection at its base) becomes 
 uniformly diffused, so that the altered granular protoplasm becomes 
 of a yellowish tinge [PL xv[.,Jlg. 1). Meanwhile the lateral processes 
 have become attenuated, and eventually dwindle down and wholly dis- 
 appear; this gives the cell a still more globose aspect. In like manner, 
 the apical process disintegrates, but the basal extension still remains, and 
 is often notably swollen and prominent; it is seen in fresh specimens to 
 be lai'gely denuded of its investing medulla. These degenerate cells 
 are mostly indistinct (from the absence of active staining), and some 
 of the larger cells of the fifth layer in the motor cortex look like the 
 ghosts of their former selves. Many of the smaller cells are found 
 simply represented as a small heap of granules retaining more or less 
 the outline of the original cell; the whole of the field around is the 
 seat of much fatty granular matter, and especially accumulated 
 around the blood-vessels. In the case of the latter we find the 
 perivascular spaces greatly enlarged, the sheath enclosing fatty 
 granules and deposits of hsematine ; the vessels are usually athero- 
 matous, and fatty disintegrating branched corpuscles are spread on 
 their exterior. The presence of much fatty matter is revealed by the 
 fact that fresh preparations treated for a few seconds only bv osmic 
 acid ('25 per cent.) tend to become greatly obscured by a minute 
 granular deposit forming over the surface of the section. The most 
 accurate description of granular degeneration is, we think, that first 
 recorded by Dr. H. C. Major, and certainly before his researches it 
 had never been shown that a primary senile atrophy of the brain-cells 
 occurred in senile dementia.* That observer also recorded similar 
 changes in the cortex of aged animals, reproducing what he found in 
 the human subject. Our further researches into the subject have 
 resulted in the following observations. The early stage of granular 
 disintegration of the cortical nerve-cells is signalised by certain 
 remarkable features in the peripheral-zone of the cortex, immediately 
 beneath the pia mater. Here the medullated fibres running parallel 
 to the surface assume an extreme degree of varicosity, and active 
 * West Biding Asylum Beporttf, vol. ii. 
 
472 THE MORBID BRAIN IN INSANITY. 
 
 degenerative changes ensue. The elements of the lymph-connective 
 system (spider-cells) proliferate and crowd around these varicose 
 fibres, which now become moniliform from segmentation of the 
 myelin, so that large globose or oval bodies unstained and connected 
 by a narrow neck constituted by the stained axis-cylinder, are seen in 
 large numbers beneath the pia {PI. ix.,Jig. 1). The bodies from being 
 perfectly colourless and homogeneous, become clouded and slightly 
 granular, and a dense proliferation of the spider-cells insinuates 
 itself between and around these degenerating fibres, their branches 
 forming a thick meshwork of fibres in this outer zone of the cortex. 
 As in this stage the spider-cells stain intensely with aniline-black, 
 we get in such specimens the contrast of numbers of colourless and 
 somewhat lustrous spheres upon a dark background of felted fibre 
 (Fl. ix., Jig. 1). This fibrous meshwork strikes down into the first 
 cortical layer some distance beyond the limit of the medullated tract. 
 This — the early — stage of granular degeneration is not so often seen, 
 we much more frequently meet with the next stage, as in subjects dying 
 from senile atrophy. It was this early stage of granular degeneration 
 in senile atrophy that we drew attention to some twelve years ago, 
 in an article on the lymphatic system of the brain;* we there sketched 
 the appearances presented in such a section, and reproduce the sketch 
 here, since it has been assumed by some that these features were 
 peculiar to general paralysis (/7. xv.,Jlg. 1) ; we would here insist that 
 all cases of senile cerebral atrophy exhibit this proliferation of s])ider- 
 cells in the earlier stage of its evolution. Not only so, but we have 
 already sufficiently indicated that we may expect to find similar 
 appearances whenever these medullated fibres are degenerating, what- 
 ever be the cause. 
 
 We see, therefore, reproduced in this layer of the cortex, in the 
 fatty or granular degeneration of the nerve-cells, the so-called colloid 
 degeneration already studied in the medulla and elsewhere. Do the 
 same sclerotic results occur which we have traced in the latter? If 
 this layer of the cortex be carefully examined (fresh sections) in the 
 more advanced stage of this degenerative aSection, we discover here 
 and there a few colloid bodies remaining ; but, in lieu of the long 
 series of large moniliform fibres, or groups of large colloid bodies, and 
 dense fibrous meshwork ai'ound, we find free nuclei undoubtedly 
 arising from the spider-cells, scattered in numbers about, and each 
 nucleus forming a centre, around which an abundance of highly 
 refractile granules collect, which are of fatty nature (PI. xv.. Jig. 2). 
 These clusters of fatt}'^ granules around the free nucleus represent the 
 disintegration of the spider-cell itself, for we often observe some of 
 * Proc. Boy. Soc, No. 182, 1877. 
 
irig/l 
 . -1 ^.^ - v^iieratioTv of jl. tu --Lii.i .^.-'j, 
 3 in first layer of Cortex wiih 
 Scaven* e^" '; ' ' - 
 .0 Alcolmiic li 
 
 
 ♦-©.v.',-,* »i^ ., '.P'i^-s^ i ^SOt"-. o? -^ i 
 
PIGMENTARY DEGENERATION OF NERVE- CELLS. 473 
 
 these elements full of glistening particles, and with their ramifying 
 processes well seen lying amongst their disintegrated congeners. 
 
 The blood-vessels also at this stage have their sheath laden with 
 fatty debris and refractile granules, like those surrounding the nuclei. 
 It can be well appreciated how, under this process of fatty liquefaction 
 and removal, this layer of the cortex becomes rapidly atrophied ; the 
 shrinking which occurs is apparent in the figure {PL xv., Jiffs. 1, 2). 
 
 Pigrnentapy or Fuscous Deg-eneration.— The deposit of pig- 
 ment in the nerve-cells of the grey matter of the brain and spinal cord 
 is a constant feature in healthy states of these centres. So far from 
 being in itself an indication of degeneration, its absence should at 
 once make us suspicious of the integrity of the cell-unit, whilst its 
 presence seems indicative, up to a certain point, of normal physio- 
 logical activity. In some way, as yet not clearly understood, the 
 presence of pigment plays an important rdle in the functional activity 
 of the nerve-cell, and we need only refer to its abundance in the organs 
 of special sense to emphasise this fact. We have seen in cases of 
 granular degeneration, such as occurs in senile atrophy of the brain, 
 that the earlier stages of decline in the functional vigour of the nerv^ 
 cell is associated with a diminution of its natural pigment. If the 
 dementia has been ushered in by evidence of long-continued and great 
 excitement, as in attacks of senile mania, then we find a notable 
 degree of pigmentation of the degenerated cell far beyond what is seen 
 in health. 
 
 Epileptic insanity and the insanity of general paralysis are of all 
 forms of mental ailment, those most prone to excessive pigmentation, 
 but all morbid states of the nerve-centres which are associated with 
 excessive and frequent engorgements of their vascular apparatus lead 
 to the production of this increase of pigment ; and thus, we find the 
 same condition of the nerve-cell in certain cerebro-spinal tracts in 
 severe chorea and even in so acute an affection as hydrophobia. To 
 class this "fuscous" state with granular degeneration is we think 
 misleading ; the latter is truly a degeneration of the cell-protoplasm 
 and may be associated, as we have just said, with increase or decrease 
 of the normal pigment ; the former is not truly a degeneration, but 
 may be associated with an accompanying retrograde change in the 
 neighbouring protoplasm, or, perhaps, may be its immedilte cause. 
 The one fact clearly established in the history of the various psychoses 
 is^ that, where excessive pigmentation of nerve-cells is found, it is a 
 witness to a bygone functional hyper-activity. 
 
 The large ganglionic cells of the cortex which are peculiarly prone 
 to this excessive pigmentation offer us the best means for its illustra- 
 tion both in normal and abnormal states. In fresh preparations 
 
474 TIIK MOHIill) HHAIN IN INSANITY. 
 
 examined straight from tin- i'lH'cziiig-iiiicrotomc, we tind at one of the 
 inferior angles, or along the basal arc of tlie cell, ;i siiiall collection of 
 golden yellow pigment, through which a number of daik, amorphous, 
 minute granules are scattered ; it appears to be surrounded on all sides 
 by protoplasm, but is quite distinct from the latter ; often it assumes a 
 somewhat crescentic form partially encircling the nucleus. In degenera- 
 ting cells, such as we have already referred to, the changes observed 
 in the various stages are as follows : — First, the whole cell becomes 
 tumid, and losing its more elliptic outline, approaches a somewhat 
 pyriform or spheroidal contour, the pigment being notably increased 
 in quantity. At the same time the cell-protoplasm stains of an intense 
 depth of colour with aniline blue-black ; so deeply tinged does it 
 become that unless subjected to the dye for an unusually short period, 
 the whole of the unpigmented protoplasm and its contained nucleus 
 becomes obscured [PI. xiv.). "With this intensity of staining of one por- 
 tion, of the cell we have the pigmented portion wholly unaffected by the 
 aniline or carmine dyes, and assuming a bright yellow or brownish- 
 yellow tinge, and a rough granular aspect. The cell becomes still more 
 globose in aspect, and its numerous radiating lateral offshoots (at first 
 coarse and deeply stained) can be traced through the pigme7ited patch up 
 to the receding protoplasm. The nucleus is deeply stained by the 
 tisual reagents (PI. xiv.). This appears to us to be the first stage of 
 functional hyper-activity, and we find, as constant associates with 
 these degenerating cells, coarse, dilated blood-vessels, together with 
 leucocytes and ha^matuidin crystals along the perivascular channels. 
 
 The retraction of the unattected protoplasm carries with it the 
 nucleus towards the apex of the cell, or draws it out eccentrically and 
 to the side ; but at times the invasion of the pigmentary change 
 appears at the summit of the cell when the nucleus and investing 
 protoplasm retreat towards the base. The nucleus itself may now 
 become pigmented in some cases, but in all it assumes eventually a 
 more or less irregular angular contour, losing the plump, oval contour 
 seen in fresh and healthy sections. At this juncture, also, tlie staining 
 of the cell by aniline becomes less evident, and, with the encroachment 
 of the ever-increasing pigmented area, faintly stained tracts or angles 
 of protoplasm may alone remain. The radiating lateral processes 
 dwindle down into extremely attenuated extensions and entirely 
 disappear, the cell being devoid of all except a basal and perhaps a 
 short apical stump ; in others, a few bristle-like projections from the 
 sides of the cell still remain, so that it has a somewdiat spiny aspect. 
 In this stage, whatever processes remain are but ^•ery faintly stained by 
 reagents, or have a granular, degenerating aspect, while the pigment 
 discoloration can often be traced far down the process from its 
 
PIflMENTARV DEOENEHATION OF XEltVK-CELLS. 475 
 
 junction with tlie cell. The jjigmentcd area appears to l^e separated 
 from the remaining protoplasm of the cell by an investing capsule of 
 more deeply-stained material, so that when the greater part of the 
 cell is involved in the change, the latter appears to possess a very 
 definite investing-wall, deeply-stained by aniline, with brownish-yellow, 
 granular pigment within {PI. xiii.). Such a sharply-defined, indurated 
 border gives the cell the appearance which has been described by 
 Meynert and Lubimoff" as a "sclerosed swelling." At this period the 
 nucleus, besides presenting an irregular contour, exhibits one or more 
 highly-refractile spots, probably of fatty nature ; it remains always the 
 centre around which any non-pigmented and unaflected protoplasm 
 which is left collects. Hence many cells in an advanced stage of 
 degeneration exhibit an eccentric nucleus surrounded by a narrow 
 zone of stained (and hence presumably still healthy) protoplasm, 
 delicate extensions of which can be traced as dark 'fibres running 
 through, the investing pigmented granular cell-mass, the whole being 
 enclosed within an irregular, distorted, dark-stained sclerous envelope. 
 We have also often observed a sharply-defined cincture separating the 
 healthier from the degenerate portion of the cell ; and it may always 
 be noted that the processes which arise from the pigmented area are 
 more degenerated than those issuing from the healthier stained 
 segment. The individual granules seen in the pigmented mass are 
 from 1 /A to 2 //. in diameter. 
 
 The last stage is that of general shrinking of the cell, which is, 
 however, preceded by a partial resolution of the bright yellow or 
 dusky pigmented granules into many highly-refractile globules, more 
 obviously fatty in nature; whilst this admixture diminishes the 
 fuscous aspect of the cell {PI. xvi.. Jig. I; PI. xviii.). In many, a still 
 more complete transformation is apparent ; the yellow tint wholly 
 goes, the cell is filled by a somewhat bright, translucent colourless 
 material, finely granular or molecular in part, and the outline of the 
 cell is so faintly mapped-out that it may be easily overlooked. These 
 shrunken cells are also found broken up into little heaps of colourless 
 or faintly-pigmented disintegrated molecules {PL xv., fig. o). 
 
 The granular pigment in the fresh sections is apparently unafiected 
 by ether, by alcohol, or by both conjointly ; nor does it undergo any 
 obvious change with caustic soda or fuming nitric acid. All such 
 pigmented collections, in cells advanced in degeneration, show a 
 decided darkening when treated with osmic acid (1 per cent.), and 
 thus reveal a certain proportion of fatty constituents; whereas the 
 pale cell, full of translucent material, shows decidedly a fatty reaction 
 when so treated. "We have already noted that the pigmented portion 
 takes up none of the usual dyes — carmine, luvmatoxylin, or aniline. 
 
476 
 
 THK MORBID HRAIN IN INSANITY. 
 
 To summarise briefly the changes thus undergone by the cell, we may 
 arrange them under three periods, thus : — 
 
 Period of over activity. — (1. ) Swelling of cell with increase of pigment. 
 
 Dark stainingof protoplasm, nucleus, and branches. 
 (2. ) Advancing degeneration, cell more globose ; jiroto- 
 plasm retracting. 
 Sclerosic investment of cell and cincture formed. 
 Period of diminished activity. — Nucleus eccentric, deformed, fatty, with narrow 
 
 encircling zone of protoplasm. 
 Processes few ; these, as well as cell-protoplasm, 
 faintly stained. 
 Period of absorption. — Fatty transformation and decoloration of cell. 
 
 Atrophy with shrinking or rupture into a heap of 
 granules. 
 
 During the progress of the fatty transformation, vacuolation of the 
 cell not infrequently occurs ; and it is from this cause that it appears 
 occasionally full of loculi, the fatty contents of which seem to have 
 dropped out or to have been absorbed, the walls or dissepiments of the 
 several loculi remaining rigid. Such cells present a very extraordinary 
 appearance {Ph. xi., xiii.), and we are ignorant as to the cause which 
 induces this transformation rather than the more usual fuscous change 
 and atrophy. 
 
 Developmental Arrest of the Nerve-Cell. — At an early phase 
 
 of its history the cortical nerve-cell of the human subject is of 
 spheroidal contour, its basal process non-medullated, and the cell 
 itself possessed of extremely few processes. Not only so, but the cells 
 are of small size, and are much more uniform in their dimensions 
 throughout the depth of the cortex than in the fully- developed and 
 adult brain. So utterly unlike are these young cells to the form 
 ultimately assumed in the fully-developed stage, that the one cannot 
 possibly be mistaken for the other. "When, therefore, this type of 
 cell prevails at a later period of life, we have unanswerable testimony 
 to its arrested development. It might, of course, be objected that 
 such primitive cell-forms, occurring in youth and adult life, were 
 products of a retrogressive process and not absolute proof of their 
 arrested development ; and this view might be supposed to be streng- 
 thened by the fact that in the granular and granulo-pigmentary 
 degenerations already described we have reproduced inflated cell- 
 forms, which at a certain stage possess characters strongly reminding 
 us of the primitive cell. 
 
 Such a conclusion is, however, inadmissible, since these degenerative 
 processes are progressive, and result in the complete disintegration of 
 the nervous elements ; since we And in these cases cells side by side in 
 
DEVELOPMENTAL ARREST OF NERVE-CELLS. 477 
 
 every stage of degenerative change ; and since, in the great majority of 
 the cells involved, special features present themselves which are not 
 afforded by the cells of stunted cerebral development to which we now 
 allude. 
 
 It appears to us that too little attention has been bestowed upon 
 this important evidence of developmental arrest; we drew attention 
 to its occurrence in certain instances of epileptic idiocy and imbecility 
 in the year 1879,* and since this period we have had frequent oppor- 
 tunity of verifying the observations then made. 
 
 The condition to which we allude we find restricted to the con- 
 vulsive neuroses ; hitherto we have failed to note its presence in 
 simple forms of COng-enital defect and deaf-mutism; all the 
 instances falling under our notice being subjects of epileptic 
 
 idiocy. 
 
 It is important to note, in the first place, that the cortical layers 
 presenting this primitive type are especially the second and the third 
 layers ; the larger ganglionic cells are usually in a state of excessive 
 pigmentation, and even present evidence of the granular degeneration 
 such as we usually meet with in epileptic insanity ; but, apart from 
 this, they do not assume the characters presented by the elements of 
 the superimposed layers, and they usually retain their normal outline. 
 
 Our first glance at the cortex in the second and third layers, throuo-h 
 a low-power objective, suggests to the mind a staining of the nuclear 
 elements only, the faint delineation of the cell escaping attention ; but 
 it soon becomes obvious on more careful search that the nerve-cells are 
 there in apparently undiminished numbers, but the majority completely- 
 unaffected by the staining reagent employed. Their appearance is 
 made obvious, in fact, by the presence of pigmented (or else colour- 
 less, but translucent and often highly-refractile) contents which com- 
 pletely Jill the cell. 
 
 We have alluded to these cells as spheroidal, and in many instances 
 such is the case; but, perhaps, the slightly-pyriform contour pre- 
 dominates. They resemble, in fact, a number of delicate, yellow, 
 pear-shaped bladders suspended by a stalk — the stalk being the faintly- 
 stained apex process, whilst, at the junction of the latter with the cell, 
 the well-stained nucleus presents itself. The only elements which 
 stain normally with the aniline dye are the large cells of the fifth 
 layer, and these (as before stated) are often degenerated. 
 
 With greater amplification the cell-contents are found to be granular 
 
 throughout— not as in the degenerative change previously described, 
 
 such as exists in senile atrophy, limited to one portion of the cell, and 
 
 contrasting strongly with the stained protoplasm elsewhere, but 
 
 * Brain, Oct., 1S79, p. 371. 
 
478 TirK MOHini) iii;Ai\ in insanity. 
 
 unifoTinhj and coarsely granular, i-esolved Ijy high jiowers into oval 
 or spherical bodies usually 2 /x to 4 /x in diameter. Such granules are 
 often highly refractile and quite colourless, but usually are pigmented 
 of a bright yellow tint. Certain cells exhibit a faint staining between 
 these granular bodies, giving it a somewhat reticulated aspect ; this 
 undou1>tedly indicates the existence of the original protoplasmic 
 groundwork of the cell unaffected by pigmentary or fatty change, 
 and, in some instances, a somewhat dark-stained border surrounds the 
 cell, forming a well-detined outline — this is, however, exceptional. 
 
 The eccentricity of the nucleus is a notable feature, its usual position 
 being at the junction of the apex-pi'ocess with the cell, but it is occa- 
 sionally appressed and flattened against the sides of the cell ; it is of 
 fair proportionate size in most cells, is deeply stained by aniline, and 
 often presents one or more refractile spots in its interior. The branches 
 radiating from these cells always stain very feebly, are very delicate 
 and attenuated, and the paucity of branches is one of the most notable 
 features of the cell ; in the greater number of instances the apex- 
 process is alone detected. Most cells show only two divergent branches 
 near the inferior pole, whilst it is rare to meet with four or five pro- 
 cesses. We may thus summarise the features presented by these 
 nerve-cells of the upper layers of the cortex : — 
 
 (a.) Spheroidal or pyriform contour of cells. 
 
 (6.) Marked eccentricity of nucleus, usually apical in position. 
 
 (c.) Coarse granular condition of contents. 
 
 (c^.) Pigmentation universal, or indications of a fatty change of 
 protoplasm. 
 
 (e.) Great paucity of branches. 
 
 (/. ) Peculiar characters far most mai'ked in cells of second and 
 third layers. 
 
 We have, therefore, in the upper cellular zones of the cortex in 
 these cases of mental defect associated with epilepsy : — 
 
 1. The primitive type of cell reproduced as regards contour and 
 branching ; 
 
 2. But stamped of a deg'CnePate type by the granulo-pigmentary 
 or fatty condition of its contents. 
 
 It would seem to us that the latter condition is not an active 
 degeneration, but rather the natural state of a degenerate type of cell, 
 as it does not proceed to the rapid disintegration of cell-structure 
 which pertains to the ordinary granular and "fuscous " degenerations 
 of later life ; and, as we have seen, it is not at any time found as a 
 partial, but as a universal, condition of the cell-structure. In epileptic 
 insanity where the epilepsy is acquired at puberty or at adult age, how- 
 ever frequent and severe the convulsive seizures, however long-standing 
 
VACUOLATION OF NKHVE-CELLS. 479 
 
 such phenomena have been, we never find reproduced the appearances 
 above detailed. However advanced the "fuscous " or granular chan^'e, 
 we find the degenerating cells, if once they have acquired their normal 
 developmental characters, show indications of the mature type to the 
 very end ; and, hence, we can in no way consider the very peculiar 
 conformation of these cells in epileptic idiocy to be the outcome of a 
 primary degeneration. We shall again allude to these stunted globose 
 cells when dealing with epileptic insanity, 
 
 VaCUOlation of Nerve-Cells.— This change consists in the ap- 
 pearance within the nerve-cell of oval or perfectly-spheroidal bodies, 
 of high refractile power quite unaffected by any staining reagent, 
 colourless but lustrous. In many cases the lustrous, refractile quality 
 may be wanting, and it is then evident that the spheroidal outline is 
 that of a genuine caviti/ or vacuole, from which the former contents 
 have been removed, or escaped by rupture ; that such rupture of the 
 cell does occur is sufficiently evident in the case of certain elements 
 where an incomplete vacuole is apparent along the border of the nerve- 
 cell, which is interrupted here by a wide opening leading into the cavity 
 of the vacuole. There may be but one such vacuole formed in the 
 cell-protoplasm, but we frequently find many such within each cell ; 
 and, in extreme cases, they crowd the interior so as to present the 
 very remarkable appearance indicated in the accompanying fio-ure, 
 where the outlines of eighteen vacuoles were seen in a single large multi- 
 polar cell. The removal of the contents of such vacuoles may be 
 effected by reagents, by the methods of preparation of the section, and, 
 as we believe, by direct absorption during life through the agency of 
 the lymph-connective system. However removed, it is evident 
 that the original cavity maintains its former contour, and is never 
 encroached upon by the protoplasm surrounding it ; and in such cases 
 where the cavity has opened up on the outer surface of the cell no 
 retraction of the protoplasm occurs, but the contour is rigidly pre- 
 served. The protoplasm surrounding the vacuoles is more or less in 
 a state of granular degeneration, faintly stained, or pigmented and 
 fuscous. This association of vacuolation and granular degeneration is 
 invariable (PL xiii.) ; yet the vacuoles are often immediately in 
 contact with unaffected protoplasm which assumes a deep-stained tint, 
 and still further aids in bringing thetu into relief Tlie nucleus of the 
 cell may be concealed from view or really absent ; usually it is con- 
 siderably displaced. The aspect of many of these degenerated cells is 
 suggestive of encapsulation, through the formation of an outer deli- 
 cate investing pellicle of devitalised protoplasm (see lower three 
 cells in PI. xiii.). The granular degeneration and the resultintr 
 vacuolation and feeble staining of nerve-cells indicate a fatty chancre 
 
480 TiiK MOinni) huain in insanity. 
 
 in the cell-protoplasm, and the separation of the fatty matter which 
 fills the vacuole can, as is now well known, be artificially induced ; 
 thus in phosp/iorus poisoniny we are aware that an acute fatty degenera- 
 tion occurs in the tissues from an increased metamorphosis of albumen, 
 but chiefly from interference with the oxidation of the tissues, and, 
 hence, the accumulation of fat within the cell. This is mainly due to 
 the destruction of the oxygen-carriers — the red blood-corpuscles — 
 induced by phosphorus* ( Voit and Bauer). This rapid splitting-up of 
 the protoplasm of the cell, and the accumulation of fat within its struc- 
 ture, is equally induced in the nerve-cells ; and the experiments of Voit 
 and Bauer have been repeated upon dogs and rabbits by Popow, Danilo, 
 Kreyssig, and Flesch, with results which indicate that phosphorus 
 and arsenic apparently induce a granular degeneration and vacuolation 
 of the ganglion cells of the spinal cord. Flesch, however, and, later 
 on, Trzebinski, have questioned the conclusions arrived at by other 
 authorities, and would assign the vacuolation to an alteration induced 
 by chrome reagents. The latter emphatically asserts that in fresh 
 preparations examined by him the change was never witnessed.t We 
 have on the contrary not only constantly met with vacuolated cells in 
 fresh frozen-sections of certain subjects of insanity, but the most ex- 
 tensive instance of this degenerative change we have seen, and 
 which we have figured in Plate xii., was treated entirely by fresh 
 methods (sections from frozen brain being stained with aniline 
 blue black). We are, therefore, assured that Flesch is certainly 
 premature in the conclusion arrived at, viz., that vacuolation is not 
 met with in nervous tissues examined fresh, but is presumably induced 
 by hardening reagents. Trzebinski's researches indicate that these 
 changes may be imitated by the use of chrome reagents in healthy 
 tissues ; but they do not prove the artificial nature of these changes 
 in diseased nervous centres, since we repeatedly meet with these 
 vacuolated cells in onv frozen- sections of brain. 
 
 The vacuolation is, as before stated, always associated with the 
 granular degeneration, although the latter may frequently be found to 
 afl^brd no instances of vacuolation. We meet, therefore, with this 
 change in the cell in senile cerebral atrophy, and it is by no means an 
 infrequent condition in the insanity of chronic alcoholism. In both 
 cases we must attribute it to the accumulation of hydrocarbon in the 
 tissues from defective oxidation, which is the invax'iable sequel to old 
 ace, and to excessive indulgence in alcohol. 
 
 Vacuolation of Nucleus. — The former condition is usually con- 
 
 * Zeitschrift filr Bioloijie, vii., Voit and Bauer. 
 
 \ Arch, fur Path. Anal. u. Physiol, u. fiir Klin. Med., Bd. cvii., H.I. or an 
 abstract of the paper by Dr. Ernest Birt in Brain. 
 

 
 ^■V x' 
 
 \ .... •: 
 
 
 A. 
 
 
 
 ■..^ 
 
 J" 
 
VACUOLATION OF NUCLEUS. 481 
 
 fined to the nerve-cell, the nucleus not necessarily being implicated in 
 like manner ; and it is a feature more common in the large ganglionic 
 cells of the spinal cord or the motor area of the cortex of the brain, 
 than in the cells of the posterior cornua, or of the superjacent layers of 
 the cortex ; at all times they are more prominent and obtrusive 
 appearances in the former positions. 
 
 The nucleus-change, however, is one peculiarly common to the 
 smaller cells of the upper layers of the cortex ; and, in fact, is often 
 limited to the second layer— the small angular cells, fringing externally 
 the small pyramidal elements of the third layer. It is exceptional 
 to find so notable and so extensive a change as that represented in PI. 
 xii. On referring to that drawing, we observe that almost every cell 
 is vacuolated ; some containing several vacuoles, and most presenting 
 unnatural, distorted outlines as the result of the change undergone. 
 It will also be observed that the nucleus is, in the univacuolated 
 cells, the primary seat of disease ; so that in many cases the whole 
 nucleus is represented by a spherical vacuole, and the cell, in lieu of 
 its dark-stained centre, shows an unstained bright spheroid surrounded 
 by the stained protoplasm of the cell. Early indications of this change 
 are revealed by a minute oily droplet in the centre of the nucleus ; 
 such droplets multiply and progressively enlarge, until, no longer 
 coalescing in the nucleus, they become free within the cell-protoplasm, 
 which is also found in a state of granular degeneration (^Pl. xii.). 
 The change as peculiarly confined to the nucleus in early stages, will 
 be more carefully considered in our section on the pathology of the 
 insanity of epilepsy, as it is in this and certain other convulsive 
 afi"ections that we meet with it as a very notable and uniform change. 
 
 It may at first appear an unnecessary refinement to distinguish 
 between the vacuolation of cell and of nucleus as we have here done ; 
 both are indications of a fatty change finally producing the self-same dis- 
 integration. It is, however, important that such a distinction be 
 drawn, since the site of lesion in both instances appears to us to 
 indicate a wholly dissimilar origin. The fatty disintegration and 
 vacuolation of the large ganglionic cells appear to be induced by 
 changes in the blood-corpuscles leading to defective oxygenation, by 
 chronic pulmonary afiections acting in the same way, by the efi'ects of 
 certain poisons (arsenic, phosphorus) or any of the many circum- 
 stances which restrict the supply of oxygen to the tissues ; the effect 
 is a general one, but those elements in the cortex naturally suffer 
 earliest and most severely whose nutrition is carried on at greatest 
 disadvantage. This is peculiarly the case with all the large-sized cells 
 of the cortex, whose bulk and greater distance from the arterial twigs 
 is inimical to rapid restoration of nutritive equilibrium, as long since 
 
 31 
 
482 TIIK MORBID BRAIN IN INSANITY. 
 
 indicated by Dr. Ro.ss.* These large cells, therefore, are the first to 
 succumb to fatty change induced by any general effect restricting 
 oxidation. 
 
 When, however, we meet with a special layer of the cortex, and 
 more especially of its smallest nerve-elements so affiected, the same 
 explanation is not valid ; we cannot imagine these minute elements 
 suffei'ing so extensively, whilst the larger escape from any wide- 
 spread defect in oxygenation. We can only here presume that the 
 change induced is indicative of an intrbisic morbid factor in tJie cell 
 itself, or of its immediate structural connections. Hence we regard 
 the changes found in senile atrophy of the brain-cell as having an 
 entirely different significance to those found in epilepsy and iu chronic 
 alcoholic insanity ; in the latter we do not look for a cause of the 
 degenerative change in the blood or vascular apparatus, but in some 
 primary condition of the nervous arrangements in themselves. 
 
 Destruction of Nerve-Fibre Plexus. — In cases of chronic 
 
 insanity, and especially where atrophy is a prominent feature in the 
 cerebral hemispheres, the fresh cortex obtained by freezing, and 
 stained by aniline blue-black, shows highly-characteristic appear- 
 ances. In healthy brain a clear differentiation of the nervous elements, 
 the cell and nerve-fibre plexus, prevails, when fresh sections are so 
 • treated ; they appear darkly-stained, and imbedded in a clear, un- 
 stained matrix, in which connective nuclei and meandering vessels 
 are less obviously defined. In the chronic atrophic diseases of the 
 cortex associated with insanity the aspect is very different. Here we 
 find much diffusiveneSS of staining, the matrix being uniformly 
 -affected by the aniline, or exhibiting a patchy mottling of a deep 
 aniline tint separated by perfectly light or faintly-tinted areas. 
 
 In consequence of this diffuse staining of the matrix, which often 
 approaches the depth of tint assumed by the nerve-cell, the differen- 
 tiation of the latter is greatly impaired ; and we have known these 
 specimens thrown aside as badly-prepared sections, the blurred and 
 indistinct elements being regarded as failures in staining rather than 
 the results of morbid change. In all advanced cases the uniform 
 diffusiveness of staining is much intensified by the degenerative 
 changes proceeding in the nerve-cell and its network of branches ; 
 but, it is important to note, that the former long survives the latter 
 as an essential though diseased element in the cortex. It is the 
 fibre-plexus formed by the radiating processes (not the primary but 
 the secondary) which are earliest implicated, and we frequently note 
 their almost entire absence from the field, whilst the degenerate cell 
 remains in various stages of decay. 
 
 * Diseases of ilte Nervous System, vol. i. 
 
DESTRUCTION OF NERVE-FIBRE PLEXUS. 483 
 
 In cases of secondary dementia, we always note the appearances 
 now detailed, especially in the anterior sections of the hemispheres ; 
 there is the great paucity of cell-processes, the patchy mottling of the 
 intercellular areas of the matrix, an increase in nuclei, and the field 
 strewn with the faintly-stained, indefinite, blurred outline of degener- 
 ating nerve-cells. The patchy mottling, on closer examination, resolves 
 itself into the fine fibrillar meshwork which originates from the 
 scavenger-elements (spider-cells), and which has replaced the non- 
 medullated meshwork intervening between the nerve-cells : but partly 
 into coarser patches resulting from the disintegrated nerve-cells, which 
 have entirely lost all semblance of their former outline, or being 
 well-defined in their lower half, become indistinct above, and fade ofi" 
 imperceptibly into the surrounding matrix; or they may have attached 
 to them a few shrunken nuclei as sole representatives of the spider- 
 cells which attacked them at an earlier stage. 
 
 The fact last alluded to is important. It must be borne in mind 
 that these destructive elements have but a transient period of exist- 
 ence, and the more actively they play the part of scavengers on the 
 neighbouring tissue, the more rapidly (we may assume) do they 
 fibrillate and lose their cellular constitution, passing in this stage 
 through a fatty transformation like the nerve-cell {PI. xv.. Jig. 2). 
 
 In advanced instances of this interstitial atrophy, we consequently 
 may find few, if any, of these characteristic organisms present them- 
 selves ; but the resulting fibrillar meshwork is always perceptible. 
 The fatty change of these tissue-elements involves considerable dis- 
 coloration by the use of osmic acid, which is requisite in the fresh 
 process of examination, and it therefore becomes imperative that 
 a very dilute solution of the reagent be employed, unless the firmness 
 of tissue permits of its being entirely dispensed with ; if the usual 
 •5 per cent, solution be employed, great obscuration of the tissue- 
 elements may result. 
 
 The delicate, unprotected processes of the intercellular nerve-plexus 
 lend themselves most readily to the ravages of the scavenger-cells ; 
 they succumb sooner than the apex-process, the cell itself, and the 
 basal axis-cylinder process, which persist latest [PL x.y.,Jig. 1). Hence, 
 as we shall find in most instances of secondary dementia, it is this 
 plexus which is earliest and most exposed to decay, and from it issues 
 that interstitial atrophy which progressively advances to the termina- 
 tion of the case ; it is a destruction of tissue which can never be 
 replaced. 
 
 A due estimate of the nerve-cell as the elementary unit of the 
 nervous mechanism is now universally recognised as essential to an 
 intelligent appreciation of the phenomena of cerebral activity, whether 
 
484 THE MOIiBID 15KAIN IN INSANITY. 
 
 from the physiological or pathological standpoint. That the absence 
 of the elaborate cell-mechanisms of the cortex, and their imagined 
 replacement by a perfectly homogeneous structureless matrix in which 
 the nerve-fibres lost themselves, would introduce into our problems in 
 the present state of physiological science, inextricable confusion, is self- 
 evident ; since the phenomena of functional differentiation would then 
 remain to us a profound mystery, and the simplest correlations of mind 
 would await an explanation. 
 
 If for these reasons only, we may safely exalt the nerve-cell to 
 a position of the very highest importance in our problems of mind. It 
 is on this account highly important that the nerve-cell of the cerebral 
 cortex should be the subject of careful study by all interested in 
 psychological medicine ; and that due attention should be paid to 
 the conditioning of its functional activities, and to the results of its 
 nutritional impairment, disease and death. 
 
 In our chapter on the histology of the cortex, we have dwelt 
 sufficiently upon this structural unit in its relationships to the sur- 
 rounding elements, to indicate the intricacy and delicate adjustment 
 established betwixt it and its physiological environment. Suspended 
 within a sac in direct connection with the lymph-channels surrounding 
 the blood-vessels — or rather its own special nutrient capillary — the 
 nerve-cell becomes liable to any influence, however trivial, disturbing 
 the blood-stream in its neighbourhood {PL v.). A quickened circulation, 
 a retarded flow, an ansemic state of cortex must influence the functional 
 activity of these centres of feeling and thought ; a vitiated quality of 
 the blood, or the presence of toxic agents introduced from without, or 
 elaborated within, the economy will all affect them in a greater or less 
 degree ; whilst the activity of the lymph-connective system in the 
 removal of the effete products of functional wear and tear, will play an 
 all-important role in the same direction. 
 
 That delicate system of lymph-COnnective elements, to which 
 we have alluded as permeating (in the normal state) the whole of the 
 cerebral mass of white and grey substance, takes a more active share 
 in the pathogenesis of mental decadence than any other : and the 
 more the question is investigated, the greater importance, we feel con- 
 vinced, will be attached to these elements in the processes of disease 
 as afiecting the nervous centres. Their physiolog'ical indications 
 are clear; they are the SCaveng'ePS Of the brain; and the evidence 
 obtainable renders it now incontrovertible that they are liable to exces- 
 sive and rapid development under certain morbid conditions affecting 
 cerebral nutrition and repair. In the normal condition of healthy 
 cerebration these elements, far from being obtrusively present, are 
 so delicate and pellucid that they often escape detection ; but that 
 
TISSUE-DEGRADATION AND OVER-STRAIN. 485 
 
 they are universally present can be readily verified by special methods 
 of examination. 
 
 Whatever leads to increased waste of cerebral neurine ; whenever 
 structural disinteg'ration is slowly proceeding either in nerve- 
 cell or fibre ; whenever accumulation of debris occurs from disease 
 of the vascular tracts, then we invariably note an augmented activity 
 registered in these SCaveng-er-elementS of the brain. That their 
 activity is in direct ratio to the functional activity of the essential 
 neurine tissue, we think there can be no doubt ; nor that with each 
 accession of the nerve-tide they are stimulated to increased activity 
 in the removal of the products of waste and the plasma effused from 
 the vessels. In healthy states, however, they never assume the hyper- 
 trophied form, the deep staining, the coarse fibrillation, the rapid 
 multiplication, and the evidence of obvious intracellular digestion, 
 which are so readily observed in pathological states {PL xvii.). 
 
 Tissue-Degradation from Over-strain.— In certain pathological 
 
 states, notably in general paralysis, we shall find that these organisms 
 play an all-important part, and are most prominent factors in the 
 morbid process; but, we desire here to draw attention to their 
 connection with certain states on the very borderland of pathology, 
 viz., instances of " over-strain," where cerebral activity has been too 
 long or too intensely encouraged, and mental tension has been associated 
 with worrying and distracting circumstances. In such cases, as aU of 
 us are aware, there is a risk of permanent damage, and most of us 
 are acquainted with instances of such. That sustained mental work 
 indulged in by the healthiest subjects, yet with disregard to physio- 
 logical laws, will reach (if persisted in) a limit where the pathological 
 barrier is passed, is undoubtedly true ; but, that the introduction of 
 the element of worry, interfering with the smooth current of 
 intellectual work, has a specially vicious influence in this direction 
 is a fact of such far-reaching consequences, that it cannot be too 
 forcibly, or too often, insisted upon. No amount of rest from mental 
 labour, no change of circumstances, nor absence of all disturbing 
 agencies will, in the cases we refer to, restore the mental faculties to 
 their former vigour ; it would seem that an actual destruction of 
 tissue has occurred as completely as if excised by the scalpel, and 
 that restitution to the former state is impossible. We believe 
 that in such instances an actual degenei-ation of cerebral-tissue 
 has been entailed, that the lymph-connective system has received 
 just such a stimulus beyond the physiological limits necessary to 
 ordinary repair, that these physiological units become pathological 
 factors, and the nervous elements themselves succumb to their 
 rapacity. 
 
486 THE MORBID BRAIN IN INSANITY. 
 
 Tissue-Deg-padation from Active Patholog'ical Processes.— 
 
 In consecutive dementia fullowing upon acute insanity, we have 
 evidence tliat what we have portrayed above occurs to a very wide 
 extent in the cortex of the cerebrum. That it occurs in a minor 
 degree in all attacks of mania and acute melancholia is also very 
 probable, judging from the almost invariable signs of instability, and 
 slight enfeeblement of potential nerve-energy in most apparent re- 
 coveries ; but for consecutive dementia the actual fact stands out as a 
 prominent and highly-significant feature, that there is very obvious 
 destruction of the nerve-fibre plexus of the coi'tex, and that the 
 intercellular elements have degraded in type to the purely connective, 
 or have undergone fatty disintegration and removal. 
 
 We regard the appearances presented by such cases (already 
 described, p. 482) as indications of the storm which overswept the 
 region, and as evidence of repeated engorgement of the cortical vessels 
 attendant upon the hyper-activity of the nerve-elements. We see in 
 such instances the coarse and tortuous blood-vessels, the frequent minute 
 extravasations and deposits of hsematoidine in their neighbourhood, 
 and other changes incideiit to bygone attacks of excitement ; but, in 
 the presence of the spider-cells and the degraded type of tissue, we 
 see an actively-destructive agency at work, which has, therefore, a 
 very different significance to the vascular changes associated therewith. 
 
 In no case of acute uncomplicated mania or melancholia, fatal in 
 early days, have we met with these organisms as pathological factors ; 
 it would seem that the normal elements play their part as tissue- 
 scavengers, with a fair promise of success up to a certain limit of time. 
 In fact, the duration of the excitement is of primary importance 
 in the elaboration of these morbid factors ; this we shall have occasion 
 to see again and again in our clinical studies of insanity, where the 
 time-element is of such great moment that it is customary to 
 assume (arbitrarily of course, for many exceptions occur) that cases of 
 mania of over twelve months' duration may be relegated to the 
 chronic class of the insane. There is, indeed, but little doubt that 
 ' beyond a certain period, varying for each individual's neurotic resist- 
 ance (whether it be within or beyond twelve months' duration of 
 mental excitement), these elements multiply and take up a pathological 
 role, preying upon the tissues whose functional integrity in health 
 they subserve. 
 
 Another factor should, however, be taken into account in this con- 
 nection, viz.. Age. The tendency in advancing age is towards a 
 multiplication or overgrowth of these elements, so that in senile 
 dementia (as we shall see) they form the natural associates of the atro- 
 phic changes which accompany the decadence of mind. This tendency 
 
TISSUE-DEGRADATION FROM DISUSE. 487 
 
 is, therefore, emphasised in all acute insanities occurring in advancing 
 years; and we may regard age as an important element in determin- 
 ing the consecutive dementia resulting from all forms of insanity. 
 
 Tissue-Deg"Padation from Disuse.— The process we have been 
 
 considering is one of genuine degradation of tissue preceded by over- 
 stimulation of cortical areas ; but, a degradation in type may also be 
 slowly induced (according to well-known physiological principles) by 
 lowered functional activity or disuSG. The atrophic changes then 
 resultant are induced through the agency of the same scavengez-- 
 elements which remove the degenerating tissues and replace them by 
 their own fibrillated stroma. We are thus inclined to explain the 
 profusion of these spider-elements in the cortex of most domesticated 
 animals, notably in the sheep and in the tame rabbit. In the former, 
 the pia is firmly attached to the surface of the brain by these elements, 
 and requires considerable force for its removal ; in the latter, sections 
 through the cortex exhibit them in great abundance in the peripheral 
 zone. Similarly they are to be noted in the cat, dog, ox, and monkey 
 in varying degrees. Sir J. Crichton-Browne has called attention to 
 the disparity in weight between the brain of certain wild and domesti- 
 cated animals, taking as a forcible illustration the reduced weight of 
 the brain of the tame, domesticated duck as contrasted with that of its 
 wild representative. The decadence from disuse of certain faculties 
 essential in the wild state is thus actually expressed in weight, and we 
 might infer that in all alike a degradation of tissue initiates such 
 atrophic changes. In man a similar change suggests itself as occur- 
 ring in those instances where a long life of unusual mental and bodily 
 activity has been suddenly interrupted by circumstances which restrict 
 within an extremely limited range his further activities; in such 
 instances, how frequently do we date the first evidence of mental 
 decadence from the cessation of the customary active life of the 
 individual. The preference to "die in harness, rather than rust" is 
 a trite saying, dictated by a full appreciation of the physiological 
 principle of the decline of faculties with their disuse. 
 
 Since then, these lymph-connective elements play so important 
 a rtle in the degenerations of cerebral tissues in mental disease, it 
 becomes an interesting question to inquire how far their pathological 
 development may reveal itself to the naked-eye examination of the 
 morbid brain 1 The presence of unnatural attachments betwixt the 
 pia-arachnoid and subjacent cortex as morbid adhesion is conclusive 
 evidence of the presence of these pathological elements ; even undue 
 firmness of connection, apart from actual adhesion, may indicate their 
 presence (as we have seen, occurs in the brain of the lower animals), 
 but their presence in the cortex already softened by an acute process, 
 
488 THE MORBID BRAIN IN INSANITY. 
 
 such as occurs in general paralysis of the insane, is accompanied by 
 the most pronounced appearances of morbid connection. 
 
 Yet, although their presence is confirmed by the morbid adhesions 
 so affected, it by no means follows that the absence of adhesion 
 necessarily excludes them from this site; in fact, these elements in 
 a state of morbid proliferation in the outer zone of the cortex may be 
 frequently seen where no suspicion of adherent membranes exists {PI. 
 XV., fig. 2). In the latter case, their appearance is usually coincident 
 with considerable fatty disinteg'Pation of tissue, these elements 
 themselves succumbing to this change, and very considerable inter- 
 stitial atrophy is apparent. 
 
 Another indication of the ravages of these scavenger-cells is afforded 
 by the various atrophic states presented by the cortex of the chronic insane 
 — of course, exclusive of such atrophy as is dependent upon obviously 
 gross lesions — apoplectic foci, softened tracts, (kc. [PI. xv.,Jig. 1). Such 
 atrophy is always attendant upon the degradation of tissue to which we 
 now refer, and its distribution maps out with tolerable accuracy the 
 areas chiefly implicated by these agencies ; and, moreover, the localisa- 
 tion of such wasted areas has an important bearing upon the history of 
 the acute attack preceding the consecutive atrophic change. It is also 
 a very noteworthy feature with respect to the degradations of tissue so 
 resulting, that the peripheral zone of the cerebral cortex is far more 
 prone to implication than deeper regions, at an early stage of the 
 process ; eventually these elements attack the deeper layers and the 
 medullary strands, but their destructive agency is chiefly exhausted 
 upon the nerve-fit)Pe plexus formed by the naked, unprotected 
 processes of the cells. The importance of this fact is at once evident 
 when taken in connection with the prevailing view as to the autonomy 
 of the cell and the significance of its ramifying processes ; the cell 
 represents the sensOPy unit of mind, and the processes whereby its 
 connection with similar units is effected represent the relational 
 element of mind, the means whereby a change from one state of 
 feeling to another is rendered possible. With the breaking-down of 
 these nerve-fibre plexuses the relational element of mind progressively 
 
 suffers, the intellectual vig-oup wanes ; whilst the pupely 
 
 sensuous element may long hold its own. 
 
 The nerve-cell itself eventually succumbs to a disintegrating process, 
 possibly secondary to the destruction of its processes ; and (as we have 
 already indicated, p. 483) relics of such cells, in all stages of dissolu- 
 tion, are to be seen scattered throughout the cortex in advanced cases 
 of consecutive dementia. The tissue-destruction is of such a nature as 
 not to lend itself to the processes of repair ; and, in the appearances 
 so presented, we must learn to recognise a. permanent mental enfeeblement. 
 
%K 
 
 O 
 
 
 
 Tr^, 
 
 M 
 
 'N 
 
PATHOLOGICAL INDICATIONS — SUMMARY. 489 
 
 From the clinical and pathological aspects of acute and chronic 
 insanity we feel justified in making the following assumptions : — 
 
 (1) Acute insanity may be regarded as a very general implication 
 of the sphere of mind, and hence of a wide-spread disturbance of the 
 cerebral cortex. 
 
 (2) Its operation is decidedly concentred upon the motOP or 
 fponto-parietal section of the hemispheres, judging from the dis- 
 position of morbid appearances and the resultant atrophy of the 
 
 secondary dementia. 
 
 (3) That in certain forms of mental derangement (the fulminating^ 
 psychoses as they may be termed) approximating to the epileptic 
 and convulsive neuroses in their character, a more local Orig'in is 
 often presumable ; and in such instances we often find sensory areas 
 peculiarly prone to implication. 
 
 (4) That even in the more universal implication of acute insanity, 
 the full force of the nerve-storm falls with unequal strength upon 
 special areas ; as indicated in the uncured wrecks of our asylum 
 chronics, whose brains exhibit a very variable and unequal distribu- 
 tion of the wasted areas. 
 
 (5) In its destructive implication of the cortex, it is the inter- 
 cellular nerve-fibre plexus (the relational element) which primarily 
 and principally sufiers. 
 
 (6) That the atrophic state induced in the consecutive forms of 
 dementia results in a greatly-diminished brain-weight, as long since 
 indicated by Sir J. Crichton-Browne.* 
 
 Let us consider these more in detail. Our studies of the pathology of 
 insanity would impress us with the important principle, that whenever 
 the nervous elements of the cortex are primarily the seat of disease 
 originating mental derangement, then the implication of the sphere of 
 mind tends always to be more generally or universally involved ; but 
 that where the nerve-changes are secondarily induced as the result of 
 vascular disease, the greater tendency is shown towards a local or 
 partial implication of that sphere. In the former case, the intimate 
 connection of the nervous system may partly explain this more general 
 implication, as it is scarcely possible for any serious affection of any 
 
 * The statement made by Sir Crichton-Browne is to this effect: — " Consecutive 
 and chronic dementia, a form or forms of mental disease, embracing so many of the 
 inmates of our lunatic hospitals, whose nervous systems have been inseparably 
 damaged by the acute storms of disease, or who have subsided quietly into the 
 depths of fatuous degeneration, is represented in Table vi. by a brain-weight only 
 a shade greater than that of organic dementia; the average for males being 1.315"3 
 grammes, and for females 1159"5 grammes." Brain, vol. ii., " On the Weight of 
 the Brain and its Component Parts in the Insane." 
 
490 THE MORBID URAIS IN INSANITY. 
 
 cortical area to be established without involving neighbouring and 
 distant territories closely associated in their functional activities, and, 
 therefore, in organic connection with each otlier ; but, in the latter 
 case, the territorial independence of the arterial supply and the ter- 
 minal nutrient twigs of the cortex impose, as is well known, a localising 
 character upon most of the nervous affections originating in vascular 
 lesion. Hence we find that, whereas in ordinary uncomplicated acute 
 insanity (acute mania or melancholia) the territorial implication is a 
 Vepy g'eneral one, although invariably expressed at certain sites 
 more than at others ; yet, that in certain insanities {e.g., that accom- 
 panying general paralysis), special sites of election are taken by the 
 diseased process, one area being affected after the other, until ultimately 
 the localising character of the ailment fades into a widespread, general 
 implication. So, again, in alcoholic insanity, the resulting dementia is 
 peculiarly apt to exhibit this partial and restricted Character 
 (especially in certain forms of amnesia to which we have previously 
 alluded) ; upon the other hand, the gradually advancing, yet universal 
 implication of mind in the decadence of senile atrophy would imply 
 not as in the former a vascular, but a primarily nerVOUS orig"in. 
 
 This tendency of primary nervous implication to share in the 
 universality, which also characterises nervous affections of hjfimic 
 origin, should not blind us to the fact already emphasised, that in the 
 widest-spread mental disturbance the morbid implication is always 
 more strongly expressed in certain directions than in others ; and that, 
 in a certain sense, we may with propriety speak not of insanity l)ut 
 of insanities, multiform in their nature, and all pointing to certain 
 definite weakened areas in the material substrata of mind. In this 
 sense we have long been accustomed to appreciate Dr. Hughlings- 
 Jackson's dicta when dealing with the reductions of insanities ; and in 
 this connection "a plea for the minute study of mania," by Sir J. 
 Crichton-Browne, is well worthy of attention.* It is in this direction 
 that we may yet hope for much enlightenment at the hands of 
 clinical observers upon the question of cerebral localisation, or, at all 
 events, for facts confirmatory of the results of experimental enquiry. 
 Dealing, however, as we do here with mental operations the alienist 
 has a field before him which extends far beyond the present limits of 
 possible physiological experimentation. 
 
 The superficial wasting of the cerebral hemispheres in insanity is far 
 more general and extreme in the fronto-parietal segment of the brain ; 
 in fact, as we have before seen, in three-fourths of all cases of cerebral 
 atrophy we find the wasting limited to this division. It is the so-called 
 motor, and intellectual, and inhibitory sections of the hemisphere j'^'f 
 
 * Brain, vol. iii. 
 
PATHOLOGICAL INDICATIONS — SUMMARY. 491 
 
 excellence which suffer most severely as the result of acute insanity and 
 its sequelae ; not the assuined sensory section. The more localised 
 wasting, on the other hand, where limited to individual gyri, exhibits 
 the same tendency to locate itself in motor areas, affecting in order 
 of frequency the centres for the (a.) lower extremities ; (b.) the upper 
 extremities; (c.) the face and tongue; whilst the separate frontal gyri 
 come in order of frequency between the two latter. Last of all come 
 the sensory areas of the temporo-sphenoidal, occipital, and angular 
 regions (fig. 13, p. 457). 
 
 A very different feature is presented by the localised softenings, 
 due, in far the greater proportion of cases, to thrombosis of the 
 cerebral vessels. Here it is distinctly seen (fig. 11, p. 452) that the 
 sensory areas of the upper temporo-sphenoidal, occipital and cuneate 
 divisions are most prone to become involved ; the motor areas of 
 the ascending frontal and postero- parietal following in their turn. 
 In mental derangements associated with (1 determined by) these 
 vascular affections, therefore, we find the most persistent hal- 
 lucinations of hearing" ; and this is a suggestive feature taken 
 in connection with the proneness to the implication of the fourth 
 
 or sphenoidal branch of the middle cerebral, and the occipital 
 
 division of the posterior cerebral arteries. Alcoholic insanity, 
 perliaps, affords us the best instances of the kind. What it is that 
 determines the more frequent implication of these arterial channels 
 than the other branches of the same trunk, we cannot at present 
 even surmise. 
 
 With respect to the question of localisation as affecting the frontal 
 division of the hemispheres, it will be occasionally found that the 
 atrophic sequelae of insanity exhibit a very notable wasting" of the 
 frontal lobes ; the atrophy to which we allude is so extreme as 
 to give this lobe a peculiar pointed aspect, reminding one strongly 
 of the cerebrum in the i^abbit as regards its general outline. We 
 have met with several instances — three especially marked cases — of 
 this extreme atrophy of the frontal lobe. Its importance depends 
 upon the constant association of a definite series of symptoms, which 
 seem to us to have a localising significance and to which we drew 
 attention in a former article on cerebral localisation.* The symptoms 
 to which we refer comprise a peculiar form of dementia, in which 
 extreme somnolence prevails, and an utter incapacity for the 
 most trivial mental effort. Unlike many dements, their attention 
 can scarcely be even momentarily aroused, and then only to be 
 followed by a lapse into the profound torpor which simulates sleep. 
 This condition of somnolence, lasting day and night, may continue 
 * Bnt. .][(',/. Jour., vol. ii., 18SS. 
 
492 THE MORIHD BRAIN IN INSANITY. 
 
 for months or even years ere a fatal termination ensues. The subject 
 is a perfect automaton, moves only when pushed along, requires 
 feeding by hand, but swallows the bolus of food when placed in his 
 mouth, and lies in bed torpid and motionless, giving utterance to no 
 articulate sound. In one case — that of an aged demented female, in 
 whom the framework, muscles and integument, testified to extreme 
 atrophy — such a condition was induced during the last two years of 
 her life ; but, at long intervals, evidence of nerve-instability was 
 forthcoming, in the sudden, unexpected outburst of frantic passion 
 in which she struggled, kicked, screamed and swore, employing a 
 very free vocabulary of abusive epithets ; the outburst would last 
 for but a minute, when the profound torpor again ensued. For 
 months prior to her death she remained bed-ridden and during the 
 ■whole of the period, except when roused for feeding, in a state of 
 apparent profound sleep. Feeding had to be pursued with care, as 
 she would often neglect swallowing the food placed in her mouth to 
 lapse into her drowsy state, from which she was roused only by 
 shaking and continuous exhortation. 
 
 In another typical case, the patient was the subject of general 
 paralysis ; in this form of disease, the symptoms now referred to and 
 the frontal atrophy associated therewith are not of very infrequent 
 occurrence ; the condition is one of long standing, and must not, of 
 course, be confounded with the temporary stupor of the congestive and 
 apoplectiform seizures incident to this disease. 
 
 That extreme atrophy of the frontal lobe may occur in congenital 
 cerebral affections without the symptoms here alluded to, is evident 
 from the case of an epileptic lad at the West Riding Asylum, whose 
 frontal gyri presented attenuation to mere riband-like folds ; and in 
 whom restlessness predominated. Yet, in his case, intelligence was 
 so far extinct, that he showed no appreciative recognition of any 
 objects around him, and could not be taught to feed or clothe himself, 
 or attend to any of his bodily wants ; he mechanically sucked every- 
 thing placed in his hands ; could just utter imperfectly his own 
 christian name. All his senses were intact. Goltz, in his removal of 
 the frontal region in dogs, noted that the senses were intact; there 
 was great irritability and restlessness ; they had a stupid, fixed 
 expression of eye ; in following a bone thrown before them they 
 apparently forgot their object and passed it by.* 
 
 Horsley and Schafer observed temporary Stupidity in monkeys, 
 from whom the prefrontal lobes had been removed ; but more to our 
 point at present are the observations of Professor Ferrier, who, upon 
 
 * PJluger\s Archiv., Bd. xxxiv. , 1884. 
 
THE BRAIN AND ITS MEMBRANES IN GENERAL PARALYSLS. 493 
 
 removal of the prefrontal region in monkeys, noted the following 
 facts — to quote his own words : — 
 
 " Instead of, as before, being actively interested in their surroundings, and 
 curiously prying into all that came within the field of their observation, they 
 remained apathetic or dull, or dozed off to sleep, responding only to the sensations 
 or impressions of the moment, or varying their listlessness with restless and pur- 
 poseless wanderings to and fro. While not absolutely demented, they had lost, 
 to all ai^pearance, the faculty of attentive and intelligent observation." * 
 
 It is impossible, upon reading this description, not to be struck by 
 the remarkable similarity presented, in the mental deterioration of 
 the patients to whom we have alluded, to the animals in whom the 
 prefrontal lobes had been removed. 
 
 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 Contents. — the Brain and its Membranes: — Early implication of Vascular Tissues — 
 Vital and Mechanical Effects — Effects on Lymph-Connective System — Intra- 
 cellular Digestion— i?o?e of Phagocytes, or Scavenger-Cells— Character of 
 Scavenger-Element— Its Vascular Process — Fuscous Degeneration of Kerve- 
 Cells — Three Stages of Morbid Evolution: — Inflammatory Engorgement— Impli- 
 cation of Pia-Arachnoid — Nuclear Proliferation on Adventitia— Paralysis of 
 Arterial Tunics — Diapedesis— Exudation — Haemorrhagic Transudations — Arach- 
 noid Hajmorrhage— Second Stage :— Hypertrophy of Lymph-Connective System 
 —Fuscous Change and Removal of Nerve-Cells — Nature of the Destructive 
 Process — Early Implication of Apex Process — Third Stage :— Fibrillation and 
 Atrophy. The Spinal Cord: — Spinal Cases in Four Groups — Evolution of Pseudo- 
 Tabetic and Spastic Paraplegic Forms — Angio-Neuroses — Pathogenesis of 
 Transient Tabetic Forms — Changes in Vascular, Connective, and Nervous Ele- 
 ments — System-Implication of Lateral Columns — Secondary to Cortical Lesions 
 — Respects Systematic Barrier— Chronic Parenchymatous Myelitis— Dependent 
 on Gradual Degeneration of Cortical Cells— Amyotrophic Form— Degeneration 
 of Cornual Elements in Cervical Associated with Descending Lateral Sclerosis 
 in Dorsi-Lumbar Regions — Combined System-Implication of Cohmins — Pseudo- 
 Tabetic Forms— Ataxic Tabes— Loss of KneeJerk— Anorexia— Flashing Pains 
 and Sensory Symptoms— Genuine Tabetic Forms in General Paralysis. 
 
 The Brain and. its MemtoraneS. — The earliest indication of morbid 
 change is certainly presented by the vasculap tiSSUeS ; turgescence 
 of the vessels of the pia, great distension and engorgement of the 
 cortical arterioles, are seen as the apparent result of an irritative 
 process in their tissues. The perivascular lymph-channels are the 
 site of a nuclear proliferation and segmentation of protoplasm, often 
 so enormous as to entirely conceal the enclosed vessel from view. 
 Certain methods of staining and preparing nerve-tissue are peculiarly 
 adapted for exhibiting this change in the early stage of general par- 
 alysis ; and it may be stated that the usual chrome methods are so 
 
 * Functions of the Brain, 2nd edit., p. 40L 
 
494 PATHOLOGICAL ANATOMY OF GENKRAL PARALYSIS. 
 
 prejudicial to the morbid texture, that those who exclusively adopt 
 them must have failed, as a natural result, to appreciate the true 
 nature of the morbid change produced, and the very serious impli- 
 cation of the vascular tracts which ensues. This development of 
 nuclei along the lymph-sheath embracing the vessel must be regarded 
 as a genuine inflammatory condition ; accompanying it, we observe 
 the usual signs of an inflammatory process, a transudation of the fluid 
 contents of the vessels into the lymph-channel and tissue beyond — 
 a diapedesis; or an escape of amoeboid leucocytes from within the vessel 
 through its coats, and collections of haematoidine crystals, frequently 
 at the angular bifurcation of the vessels or between it and the peri- 
 vascular sheath. 
 
 The results of this inflammatory process are very damaging to the 
 blood-vessel itself; changes are induced of a vital and mechanical 
 nature. Vital, in so far, that the neighbouring inflammatory state of 
 the sheath appears to paralyse the tunica muscularis of the smaller 
 arteries, and the natural elasticity of the vessel becomes also impaired ; 
 a relaxation ensuing which favours in a high degree stasis of the blood 
 current, aneurismal distensions, and, on further mechanical obstruction, 
 rupture of the vessel. Mechanical, in so far, that the uniform support 
 of the adventitial sheath is impaired or lost, or its nuclear accumu- 
 lations encroach on the lumen of the vessel and compress it ; or its 
 transudation-contents in like manner (or otherwise) prejudicially aff'ect 
 the other tunics of the vessel. At a still later period the sheath is yet 
 further damaged by the numerous branching processes of cells exti'a- 
 vascular in position, which play so important a role in the morbid 
 process, and to which we must now direct attention. 
 
 In this, the second stage, there proceeds a remarkable development 
 of the lymph-connective system of the brain. The cells, which 
 are usually described as "glia cells," or what we have in our anatomical 
 section alluded to as the "flask-shaped elements" of the neuroglia, 
 undergo a wondrous transformation, the real significance of which does 
 not appear to have been hitherto appreciated. We will first describe 
 these elements in their pathological developments ; and, subsequently, 
 allude to the important role they play in the morbid evolution of this 
 disease.* As before stated, these elements ai'e small flask-shaped cells 
 
 * Intra-cellular digestion is now an established pathological fact, and the 
 researches of MetschnikofF have extended largely the rdle of certain cellular 
 organisms in the elimination of morbid material. The term phagocyte^, which he 
 employs for those large cells active in the removal of effete material in the frog 
 and other cold-blooded animals, we have employed when referring to the spider- 
 cell ; but we prefer the term scaverKjer-cell for those fixed tissue-organisms which, 
 as we have seen, have an active physiological and pathological rOle. See 
 Metschnikoff's Original Articles, Virchoiv's Archiv., vols, xcvi., xcvii. 
 
LYMPH-CONNECTIVE SYSTEM, 495 
 
 with a comparativoly large nucleus at their greater extremity, which 
 latter staius but faintly with aniline-black, whilst the protoplasm of 
 the cell itself remains unstained, and so delicate as to be recognised 
 with difficulty in healthy states. Each has a connection by a delicate 
 process with a neighbouring blood-vessel, and, in frozen sections fresh 
 examined, exhibits several i-adiate branches so fragile, and excessively 
 delicate, as to be only seen after a keen search, since they remain 
 wholly unstained by reagents {Fl. xviii.). In the morbid change to 
 which we now allude, these flask-shaped cells enlarge very considerably 
 into great amoeboid-like masses of protoplasm, often exhibiting sub- 
 division of the nucleus ; and, what is of great import, their protoplasm 
 now stains deeply with aniline, although not so intensely as do their 
 nuclei. From this extraordinary cell of protean form radiate on all 
 sides numerous branching fibrils, forming an intricate and delicate 
 network around it as a centre, all of which branches, even to their 
 most delicate subdivisions, are readily stained by the same reac^ent. 
 These cells have been termed Deiter's cells : they are all characterised 
 by the presence of a vascular process ; but well-prepared specimens 
 show us not one, but often several, such processes distinguished by 
 their greater diameter, their deep staining, and their termination 
 in a nucleated-mass of protoplasm upon the walls of a blood-vessel 
 {PI. xviii.). The students' attention should be drawn to the fact that 
 in healthy states of the cortex these peculiar neuroglia elements may 
 be readily distinguished from the nerve-cells, apart from their contour, 
 by the fact that their nucleus alone stains faintly with aniline, whilst 
 both protoplasm of cell and nucleus of the nerve-elements stain deeply ; 
 whereas, in the diseased state to which we allude the morbid elements 
 act like nerve-cells, both nucleus and cell-protoplasm, as well as ulti- 
 mate fibrils, become deeply tinged by the dye, so that, in some cases, 
 they do not look unlike nerve- cells ; and a few may even be mistaken 
 for such, until the "vascular process" is detected. This difierent 
 reaction in the diseased state is doubtless due to the increased and 
 unnatural vitality * of these protoplasmic masses. These lymph- 
 connective elements (normally spread as free cells, except for their 
 vascular branch, throughout the neuroglia-framework of the brain) 
 multiply by nuclear division and segmentation of the cell-mass until 
 their numbers are so prodigious as to rival the densest groupings of 
 nerve-elements in the same region (PI. xvii. ; PI. xvi., fy. 2). Their 
 normal off"-shoot from the parent-vessel, or its sheath, explains their 
 more dense distribution on either side of the vascular channels ; but 
 
 * Even nerve-cells in certain diseased states stain 7norc intensely than in health 
 —e.g., early stage of fuscous degeneration— but subsequently the reaction becomes 
 progressively less intense. 
 
496 PATIlOLOr.ICAL ANATOMY OF GENERAL PARALYSIS. 
 
 they may jtermeate every tract of the cortex, from the peripheral 
 zone to the deepest layer, and are, moreover, often formed deep in 
 the medullated structure of the brain. 
 
 Whenever a branch forms a new connection with a blood-vessel, 
 at its junction with the sheath there is invariaVjly found a nucleated 
 mass of protoplasm, often undergoing subdivision, and this process is 
 specialised by its greater size and depth of staining; the other 
 processes are much finer and more delicate, take a more tortuous 
 course, and branch into numerous still finer ramifications (Fl. xviii.). 
 Co-eval with this morbid transformation, we find the nerve-cells present 
 indubitable evidence of a degenerative process (PI. xy'i., Jig. 1 ; PL xviii.). 
 The morbid condition of the cell has itself been described by some 
 authors as inflammatory in its intrinsic nature (Mierzejewski) ; Vjut, 
 when carefully studied, we wholly fail to recognise an inflammatory 
 condition, we see but the evidence of a true degeneration due to acute 
 nutritional anomalies, and fail to observe any notable difi"erence be- 
 tween the changes through which these cells pass, and those of the 
 cortex in senile atrophy, except in the greater tendency to a true 
 steatosis in the latter state ; and still less do we perceive the dis- 
 tinction from what is observed in the " fusCOUS " chang'e of the large 
 cortical cells of the epileptic's brain (PL xiv.). 
 
 Where the cortex is extensively invaded by the abundance of lymph- 
 connective cells, the nerve-cells will be found to present every stage of 
 degenerative transformation from an incipient change in molecular 
 consistence and coarseness to a broken-down residue recognised only 
 as a faintly pigmented patch, scarcely preserving its outline as a 
 cellular structure (PL xv.,Jig. 3). What is highly important for us to 
 note is the connection betwixt such cells and the neuroglia-elements 
 just described. The processes of these morbid elements apply them- 
 selves to the nerve-cells, surround and embrace them closely ; whilst 
 the latter are often overlaid by one or more of these spider-like bodies, 
 still maintaining their connection by a long straight jrrocess with a 
 distant capillary (PL xvii.). 
 
 Occasionally, the branches appear directly connected with the nerve- 
 cell, and at their junction a minute nuclear-like mass, more deeply 
 stained, is seen. Wherever we find the nerve-elements much invaded 
 by their strangely transformed congeners, there we observe advanced 
 degeneration of the cell, to describe which in detail would be to repeat 
 the description already given of pigmentary or fuscous decay (p. 473). 
 It may be stated here, however, that the apical process appears to 
 sufier at an early stage of the disease, and disappears often before the 
 cell itself is very gravely implicated. 
 
 As the nerve-cells undergo more and more serious disorganisation 
 

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STAGES OP MORBID EVOLUTION. 497 
 
 and dwindle away, so these elements of the neuroglia multiply and 
 throw out their protoplasmic extensions in all directions around, tie 
 down blood-vessels, draw the perivascular sheaths by their contraction 
 out of their normal course so that they become (as represented in the 
 figure, Fl. xviii.) pulled in this or that direction into innumerable 
 angular or funnel-like extensions by the attached processes of these 
 cells ; the vessels themselves become contorted, and drawn from their 
 normal direction. 
 
 Then a further change ensues, the cellular elements appear to reach 
 a limit to their morbid activity, and expend their remaining vitality 
 in a dense fibrillation. The protoplasm of the cell dwindles down 
 as these meshworks of fibres form around it, and the nucleus alone 
 remains as a sort of nodal point from which this fibrillated mesh 
 radiates as from a centre, its branches interlacing most intimately.*" 
 This stage of dense fibrillation and disappearance of the cell-protoplasm 
 is the third Stag'e in the morbid evolution of general paralysis. 
 
 To recapitulate, we have three well-marked steps thus defined 
 whereby we may trace the morbid implication of the cortex. 
 
 1. A stage of inflammatory change in the tunica adventitia with 
 excessive nuclear proliferation, profound changes in the vascular 
 channels, and trophic changes induced in the tissues around. 
 
 2. A stage of extraordinary development of the lymph-connective 
 system of the brain, with a parallel degeneration and disappearance 
 of nerve-elements, and the axis-cylinders of which are denuded. 
 
 3. A stage of general fibrillation with shrinking, and extreme 
 atrophy of the pax^ts involved. 
 
 We may now proceed more fully to enquire into the indications 
 afforded us by the morbid changes characterising the above stadia. 
 
 Stag'e of Inflammatory Eng-orgement. — It is in the vessels of 
 
 the 2^i<^ that lesions are earliest witnessed, and the lymphatic sheath is 
 that in which the inflammatory change originates. Here it is that, in 
 the earliest stages of the disease observed in the brain of a general 
 paralytic, the initial vascular derangements are first to be noted; and 
 cases proving fatal at an early stage, through the agency of any inter- 
 current affection, may exhibit (beyond a slight general cloudiness of the 
 arachnoid along the course of the vessels in the fronto-parietal regions, 
 and a very slight increase in the toughness of the membrane) no other 
 naked-eye evidence of disease. The membranes may be slightly more 
 difficult of removal than in health, but show no genuine adhesion to 
 the subjacent cortex. Yet sections of cortex examined microscopically 
 
 * Such isolated nodules of dense fibrillated tissue of almost microscopic dimen- 
 sions occasionally occur in the cerebellum. Their import has not to our knowledge 
 been previously recognised. 
 
 32 
 
498 PATHOLOGICAL ANATOMY OP GENERAL PARALYSIS. 
 
 nil show a notable increase in the nucleated protoplasmic cells of the 
 adventitia of the vessels of the pia, which vessels are also large, dis- 
 tended, and often tortuous; together with a general, though slight, 
 proliferation of the most superficial flask-shaped cells of the peri- 
 pheral zone of the cortex, and the vessels of the intima pise resting 
 upon it. From these cells of the pia long delicate processes are sent 
 out extending deeply down into this layer; and, in fact, simulating in 
 this early stage an appearance often found normally in the cortex of 
 certain domesticated animals (the sheep, pig, rabbit, &c.). That these 
 changes commence in the vascular supply of the pia-arachnoid, 
 gradually extend into the cortex, and eventually penetrate its deepest 
 layers, numerous examinations have established beyond doubt. 
 
 In a further-advanced stage of this disease the soft membranes 
 become far more gravely implicated. The nuclear proliferation around 
 the vessels of the pia, their distension and engorgement (from paralysis 
 of the vital contractility of the muscular coat) lead to a very free 
 exudation into the meshes of the pia. The connective trabeculse lying 
 between the intima pia and arachnoid (which are so especially loose 
 and plentiful within the sulci separating the convolutions) become 
 saturated with a fluid exudate, present a swollen and gelatiniform 
 aspect to the naked eye, streaked with opaque lines, or assume a patchy, 
 or a general and uniformly-difiused opalescence ; whilst to histological 
 examination of sections they reveal beautifully-disposed mesliworks of 
 connective fibrils, rich in cells, and permeating in every direction the 
 subarachnoid space. Into this space exude the cellular and fluid 
 products of the inflammatory sheath. This tendency to the accumula- 
 tion of exudate in the subarachnoid lymph-tissue receives a marked 
 increment at a later stage of the disease; foi', when atrophic changes 
 occur in the cortex as the result of impaired nutrition and degeneration 
 of nerve-elements, a great compensatory serosity of this region is 
 established, and the membranes become fairly water-logged. The 
 atrophy, which is the result of a genuine sclerous change in the 
 cortex, is necessarily more marked in the sulci than over the summits 
 of the gyri, the area of cortical surface involved in the one case being 
 far greater than in the other, and, in consequence thereof, the gyri 
 become narroived and attenuated — the thinning of the cortical layers 
 being the most marked feature. 
 
 The vessels in the pia lose the normal support received from the 
 opposed gyri, and, as more compensatory eff"usion occurs to fill up the 
 space left by the receding brain structure, so the natural support 
 received by their walls becomes lessened, and in the diseased state of 
 their parietes there becomes established a strong tendency to hsemor- 
 rhagic transudation, or to actual rupture and haemorrhage. Such 
 
STAGE OF INFLAMMATORY ENGORGEMENT, 499 
 
 haemorrhages may be slight and merely punctiform, and are frequently 
 observed ; or blood may be transfused into the subarachnoid space and 
 a fibrinous coagiilum form upon its meshwork ; or, as we often see, 
 a film of blood may be exuded upon the epicerebral surface, between 
 the pia and cortex ; or, lastly, the delicate and perforated arachnoid 
 may permit an extravasation on to its outer surface, so that the 
 subdural space may thus become the site of a more or less extensive 
 hemorrhage. The latter, or so-called mening"eal hsemOPPha^e, 
 may be a mere delicate film of blood, or a simple rusty staining of the 
 arachnoid surface, or a thick coagulum of blood extending over the 
 greater part of one or both hemispheres ; or a coagulum within a firm 
 fibrinous or organising investment completely encysted ; or, again, a 
 thin, but tough, glutinous or fibrinous pellicle, slightly rust^stained, 
 may be peeled ofi" the surface of the dura, forming one or other of the 
 varieties of the so-called arachnoid cysts. These encysted haemorrhages 
 (which are by no means peculiar to general paralysis, although 
 frequently associated with this disease) appear to be due, in these 
 cases at least, to an initial extravasation caused by the rupture of a 
 diseased vessel in the pia-arachnoid, and to the subsequent rupture of 
 newly-formed vessels within the organising clot. In none of these cases 
 does it appear to us to have a direct inflamviatory origin in the 
 membranes. Beyond these extravasations and infiltrations of blood, 
 which invariably occur during an advanced atrophic stage of the 
 disease, we find similar conditions established within the cortex itself 
 Here, also, the blood-vessels lose the normal support given them in 
 health by the approximation of the perivascular walls, which permit 
 of a limited, but a definitely-restricted, expansion. In atrophy of the 
 cortex, however, these channels become enormously enlarged and 
 filled also with exudate from the contained vessels ; this distension of 
 the perivascular channels favours the aneurysmal dilatations already 
 alluded to, and the eventual rupture or transudation of the contents 
 of the blood-vessels into the surrounding space and neighbouring 
 tissue. Hence we get, in all such cases, evidence of extravasated 
 blood in the form of hsematoidine crystals, which often occur in 
 aggregated heaps, especially in the neighbourhood of degenerating 
 nerve-cells. It would appear that the natural subsidence of compen- 
 satory fluid into the sulci, and the much greater recession of the 
 atrophic cortex allowed for by the special position of the walls of the 
 gyri, is unfavourable to the formation of adhesions ; for it is a fact 
 that such morbid adhesions in general paralysis are almost strictly 
 limited to the summits of the gyri, where the pia-arachnoid is in close 
 contact and does not permit of the accumulation of serosity to nearly 
 the same extent as in the sulci. As the inflammatory state of the 
 
500 PATHOLOGICAL ANATOMY OF GENEKAL PARALYSIS. 
 
 lyini)hatic sheath of the vessels extends to the deeper layers of the 
 cortex, other grave disturbances necessarily ensue ; and this leads us 
 to the second stage of the disease, which is characterised by the 
 extraordinary development of the lymph-connective system of the 
 brain. 
 
 Second Stag'e. — The implication of the perivascular lymph-channels 
 by the enormous production of protoplasmic masses on their walls, and 
 the blocking of their channels and impairment of the vascular tissues, 
 directly affect the nutrition of the nerve-cells. A granular change 
 ill their protoplasm ensues, and fusCOUS deg"eneration of theii- 
 contents leads to their ultimately breaking-down into a fine molecular 
 mass of debris. This, together with inflammatory exudates from the 
 vessels, must be removed ; but the lymph-channels are not in such a 
 condition as to ensure this removal of effete material. It is at this 
 juncture that the supplementary lymph-connective element comes into 
 play. In the normal state, maintaining its connection with the 
 vascular walls by its Deiter's process, it either, by circulation of 
 protoplasm or by contraction of the latter, removes such effete material 
 from the cortex. Now, however, these organisms rapidly increase in 
 size and numbers, forming large amoeboid masses of protoplasm, which 
 apply themselves to all the degenerative elements around, and by a 
 process of intussusception remove such particles into their interior. 
 For long, these spider-like cells, or Deiter's cells as they have been 
 termed, have been recognised by sevei'al authorities in the coi'tex of 
 the general paralytic, and veiy varying and conflicting statements 
 have been made respecting them ; by some, they were regarded as 
 metamorphosed leucocytes wandering from the blood-vessels ; by 
 others, as a simple px'oliferating connective, which by its pressure and 
 strangulation destroyed the neighbouring nerve-tissues ; others, again, 
 saw in them no special connection with general paralysis, since they 
 have been recognised in various diseased states of the brain. It is 
 true that these organisms are met with in other affections of the 
 nervous-system, but simply because they play a most important role 
 in the pathology of nervous diseases, and it is only when their real 
 functional endowments are perceived that we recognise their important 
 significance in the cortical lesions of general pai'alysis. 
 
 The failure of the usual lymphatic tracts to remove efl'ete matter 
 from the brain reacts by calling forth an increased functional activity 
 in these lymph-connective appendices in the neuroglia, a true functional 
 hypertrophy ensues, and these spider-like elements apply themselves 
 to the task. They become the "phagocytes" or scavewr/ers o/^Ae tissue; 
 live, thrive and multiply upon the degenerating protoplasmic masses 
 of nerve-cells and their extensions, and all effete material lying in 
 
STAGES OP CELL DEGENERATION AND FIBRILLATION. 501 
 
 their neighbourhood is ultimately appropriated to their use. These 
 active scavengers are also destructive of the living tissues; they affix 
 tlieir sucker-like processes to any portion of their structure, and at the 
 point of juncture we invariably see a small speck of active protoplasm 
 containing a nucleus, probably in process of subdivision. Occasionally, 
 several of these active elements are seen completely covering a large 
 nerve-cell, which is in an advanced stage of decay, or scarcely visible, 
 forming a mere pigmented molecular groundwork. They are usually 
 noted in great abundance in the deeper half of the peripheral or 
 outermost layer of the cortex, and, being unmixed with nerve-cells, are 
 here peculiarly clear and defined. At this site their destructive agency 
 makes itself felt upon the medullated nerve-fibres, which at this depth 
 run parallel to the surface of the cortex as continuations of the apical 
 processes of the cells of the lower layers. These, therefore, are the 
 first nervous structures to be involved, and the apical processes of the 
 pyramids are the first to undergo degenerative change. 
 
 Third Stag'e. — Like all actively-growing elements these also have 
 only a limited existence in this condition of morbidly-exaggerated 
 function. The cells throw out innumerable fine processes ; and as the 
 fibrillar meshworks increase so the cell-protoplasm, at whose expense 
 they appear to be formed, dwindles down and eventually disappears. 
 Hence we have here a veritable substitution of fibrillar connective 
 formed out of the effete material afforded by the atrophic nerve-tissue, 
 a genuine degradation of tissue. The process does not appear to us 
 to be at all akin to the destructive influence of a compression from 
 sclerous invasion ; but rather that the presence of the sclerous element 
 is explained by its production out of already-degenerated nerve- 
 elements. 
 
 The Spinal Cord. — The spinal symptoms associated with the cere- 
 bral disturbances of general paralysis have long been a subject of 
 intense interest to the pathologist; and much diversity of opinion 
 exists relative thereto, less so, perhaps, respecting the intrinsic naizire 
 of the morbid change, as the mode of implication of the spinal 
 tissue-elements and the initiator^/ conditions upon which the lesion 
 depends. As is well known, the spinal cord is by no means uniformly 
 implicated in all cases of general paralysis ; nor is the selected site of 
 morbid change a constant feature. A large majority of cases of 
 general paralysis pass through the various stages of the disease with- 
 out any notable spinal symptoms, apart from those due to implication 
 of the bulbar nerve-nuclei, until the latest epoch of the affection is 
 reached ; whilst in others, from the very outset the spinal symptoms 
 are the most prominent feature of the case. In other cases, again, the 
 spinal symptoms appear to bear a definite relation to the various 
 
502 PATHOLOfJlCAL ANATOMY OF <;RNEKAL PAllALYSIS. 
 
 stages of cerebral disturbance, and vary in their nature pari lyassu 
 with the latter. Thus we may be permitted to group cases usually 
 encountered into four arbitrary divisions. 
 
 (1) In the majority of cases, we have as the only evidence of spinal 
 implication, a somewhat general diminution of cutaneous sensibility, 
 associated with a sluggish or greatly-diminished knee-jerk ; alternating 
 later on with (or supplanted by) increased knee-jerk, usually as the 
 direct sequel to a convulsive or apoplectiform seizure. Later on, in 
 the disease, 2^(^'>'^tic symptoms may predominate, and contractions be 
 established ; but these follow in the wake of pronounced cerebral 
 disturbances (convulsions, &c.), and appear, in fact, to be initiated 
 thereby ; whilst the cerebral implication throughout has been all along 
 the more emphasised. 
 
 (2) Here, there is a second group comprising from the very onset 
 notable tabetic symjytoms, the cerebral often so greatly in abeyance as 
 to arouse the doubt whether we are not here engaged with a genuine 
 tabes dorsalis of local spinal origin. The disturbance of sensation, the 
 abolition of the deep reflexes, the ataxic gait, are all so prominent that 
 we are apt to attribute such symptoms to a primary implication of the 
 cord itself. And yet, in this tabetic form of general paralysis, we most 
 usually witness complete subsidence of the special spinal symptoms, 
 the tabetic gait passes oft" the knee-jerk returns, and then the full 
 development of the cei-ebral symptoms is established ; or, what is not 
 infrequent, the sensory implication of the cord becomes a motory 
 
 afiection and spastic paraplegia replaces the ansBsthesia and 
 ataxy. 
 
 (3) In yet another series of cases, the viotor sjmial anomalies are 
 from the first a most notable feature ; and symptoms indicating 
 a symmetrical descending sclerosis of the lateral columns are early 
 apparent, usually as the sequel of convulsive seizures, a mode of 
 implication which appears to us of special frequency in general 
 paralysis attecting those subjects who are addicted to alcoholic indul- 
 gence. 
 
 (4) Lastly, there are those cases where no spinal symptoms whatever 
 are noticed, the derangements being cerebral throughout (13-6 per 
 cent.). 
 
 In explaining the features comprised under these arbitrarily-con- 
 stituted groups, there has been a tendency to regard the later-evolved 
 cerebral derangements of typical general paralysis established in a 
 well-marked tabetic case, as due to an ascending change — i.e., to pro- 
 pagation by direct continuity of diseased tissue ; thus making a 
 system-disease of the spiual cord the originating factor of the subse- 
 quent cortical lesions of general paralysis. 
 

 \v.. 
 
PATHOGENESIS OF SPINAL IMPLICATION. 503 
 
 And, in like manner, the subsequent establishment of motor spinal 
 symptoms {spastic paraj)le(jia) has been regarded as a direct transference 
 of morbid implication across from sensory to motor columns of the 
 cord, or to a descending lateral sclerosis having direct continuity with 
 cortical lesions. It appears to us that there is little evidence in favour 
 of such views, which would seem to originate in too servile an atten- 
 tion to the great law enunciated by Waller. The Wallerian degener- 
 ations do account for much in the pathological reductions of general 
 paralysis; yet it appears to us to be much strained by efforts to 
 establish its role when, after repeated attempts made to trace such 
 degenerative continuity of tissue, the best observers have invariably 
 been foiled. It is a notable fact that, despite frequent and most 
 careful examinations of the spinal lesions of general paralysis, we yet 
 fail to trace the continuity of descending changes of the lateral 
 columns of the cord with the tegmental structures of the pons. 
 We are apt in paying too strict attention to the operation of this 
 important law to overlook the transfer of disease to distant parts of 
 the nervous system through implication of higher realms, not hy direct 
 continuity of diseased tissue, but through the vasomotor agency 
 operative upon nervous tracts in physiological sympathy with their 
 higher centres. 
 
 This, it would seem, is illustrated in the pathogenetic history of 
 general paralysis, wherein irritative or destructive lesions of the cortex 
 cerebri invariably produce change in the nutrition of the cord, vary- 
 ing in its site, nature, and intensity with the regions of the cortex 
 implicated. Physiological experimentation teaches us that vascular 
 tonus is dependent upon the vasomotor centre, or rather centres, 
 within the medulla ; such centres maintaining their regulative capacity 
 even upon removal of the hemispheres in animals ;* yet, it is never- 
 theless true that though thus independent of cerebral innervation, the 
 latter steps in and inhibits the activity of these centres in the medulla, 
 as seen in the electric stimulation of the cortex, and, again, in its 
 agency during certain emotional disturbances, as shown in the pallor 
 of fright and the blush of shame. So also in pathological conditions, 
 the ang"io-neurOSeS (or affections of the blood-vessels through 
 deranged nervous agency) form a class of diseases which may implicate 
 any tissue or organ in the body ; and in like manner, the vascular 
 supply of the cord and medulla may undergo derangement through the 
 disturbing influence of the higher cortical centres. We incline to 
 
 * Section of the medulla at the calamus scriptorius paralyses the greater part of 
 the vasomotor nerves of the body, and the blood-pressure, consequently, falls 
 throughout the whole arterial system. Landois, op. cit. ; see also Ferrier, Functions 
 of the Brain. Burdon-Sanderson, Handbook of the Phyaiolog. Lahorator>i. 
 
504 PATHOLOGICAL ANATOMY OF GENERAL PAUALYSIS. 
 
 regard the primary implication of the cord in general paralysis as in 
 this manner produced — as being a genuine angio-neurosis. Later on, the 
 destructive lesions in the cortex, together with the irritative process in 
 the cord and medulla, lead to a general rise in blood-pressure, as seen 
 in the sphygmographic tracings in advanced subjects (p. 429). The 
 engorgement of the blood-vessels of the posterior columns of the cord is 
 followed by transudation through their walls, and the lymphatic func- 
 tions are stimulated to increased activity. Usually the latter function 
 sufl&ces to re-establish the balance, and the tabetic symptoms at first 
 apparently subside; but occasionally they persist, and then we meet with 
 a true degenerative change in the posterior columns. The pressure of the 
 engorged vessels in the sensory tract of the cord is the essential cause 
 of the early tabetic symptoms and sensory distui-bances of many cases 
 of- general paralysis ; and in the fact that this is often a transient 
 state, not necessarily leading to destructive results in the nerAe- 
 elements, we find an explanation of the subsidence of such symptoms. 
 We must not be understood to imply that the changes in the posterior 
 columns of the cord in those cases of general paralysis characterised 
 by persistent tabetic symptoms are due to the identical lesion found 
 in typical tabes dorsalis ; we have not here an ascending sclerosis of 
 these columns, but a very distinct affection, which appears to commence 
 generally and simultaneously through large tracts of the cord ; in 
 genuine tabes we perceive extensive and extreme destruction of nerve- 
 fibres, whereas in the pseudo-tabetic general paralytic we often find 
 the nerve-fibres little (if at all) implicated. In some of the most 
 extreme cases of the disease yet observed, the nerve-fibres of the 
 posterior column were of fair size and apparently healthy. 
 
 With respect to the lateral columns of the cord, however, the case is 
 different ; a genuine sclerosis is here established, which results in 
 progressive destruction of nerve-tissue, and which (although it may 
 originate at one or several sites) spreads downwards as a descending 
 sclerosis along the physiological tracts on which it has established 
 itself. Commencing, we opine, as an angio-neurosis in a territory 
 directly in sympathy with implicated cerebral areas, it leads to much 
 more profound lesions than are found in the posterior columns of the 
 cord. 
 
 In the posterior columns of the cord the morbid appearance 
 presented must be studied in respect to the vascular, connective, and 
 nerve-elements respectively. 
 
 VaseulaP System.^ — Nearly all cases present an apparent increase 
 in the number of the vessels of the posterior columns. The appearance 
 is, however, deceptive, in that there is not an absolute numerical 
 increase in the vessels seen in transverse section, but an increase in 
 
CHANGES IN VASCULAR AND CONNECTIVE STRUCTURES. 505 
 
 their size, due to long-continued engorgement, which renders them a 
 most prominent feature in the sectional fields. Limited to certain 
 divisions, or scattered indiscriminately over the whole area of these 
 columns in aniline or hseraatoxylin preparations, they at once obtrude 
 themselves on our notice. The individual vessels, although of large 
 size, have a lumen greatly diminished by the encroachment of their 
 thickened walls ; the muscular coat of the smaller vessels is distinctly 
 hypertrophied, presenting the appearance which has been so well 
 described by Dr. Johnson in the renal vessels in chronic Bright's 
 disease. In other respects, the vessel appears free from morbid 
 change ; the lymphatic channels are not unduly distended, no pro- 
 liferation of nuclei is observed, and no other evidence of inflammatory 
 change in the vessel's tunics or exudates from its channel, such as 
 were described in the vessels of the cortex. The change appears to be 
 one of simple compensatory hypertrophy induced by the engorged 
 condition of these vessels demanding increased contraction on the part 
 of the arterial muscle to carry on the circulation of the cord. Just as 
 in the renal vessels, the muscular coat hypertrophies to overcome the 
 languid circulation of the organ, so the muscularis of the rachidian 
 arterioles increases with the engorgement of these columns, induced 
 by the changes occurring in the cerebral cortex. 
 
 The Connective System. — The stellate cells found normally 
 throughout the columns of the cord, and which are the representatives 
 of the delicate neuroglia-elements spoken of as the flask-shaped bodies 
 of the cortex cerebri, do not, in the healthy cord, form so prominent a 
 feature in transverse sections. In diseased states, however, they not 
 only enlarge, but multiply greatly, and their proliferation as " Deiter's 
 cells " is a notable feature in the columns of the cord in general 
 paralysis. In fact, these spider-like cells accumulate in vast numbers, 
 and especially along the vascular tracts, giving these regions a deeper 
 staining in aniline preparations quite appreciable to the naked eye. 
 Such tracts, consequently, look at first sight like sclerosed tissue, 
 until microscopic examination resolves them into large numbers of 
 deeply-stained spider-cells. They are by no means peculiar to general 
 paralysis, as they are found in these columns also in chronic inflam- 
 matory conditions, in all long-standing congestions of the cord, in alco- 
 holism, and in senile atrophy of the cerebro-spinal system. A genuine 
 sclerosis, such as is seen in primary tabes, we do not find ; no finely- 
 punctated connective tissue pervades these columns of the cord, so that 
 the uniformly-deep tinge of stained preparations is not so frequent 
 a feature here. The increase is simply that of the lymph-connective 
 system, apparently stimulated by the engorged condition of the vascu- 
 lar apparatus and the defective elimination dependent thereupon. 
 
506 PATHOLOGICAL ANATOMY OK r;ENKKAL PARALVSLS. 
 
 The Nervous Elements. — As above stated, those often remain 
 little or not at all implicated. No enlarged axis-cylinders are 
 observed, no swelling of the meduUated sheath, no proliferation of 
 nuclei ; nothing which can be translated into signs of inflammatory 
 implication of the nerve-fibre. The spider or " scavenger-cells " (as we 
 have termed those elements) appear powerless in their agency upon 
 medullated nerve-tubes, and it would seem that their destructive 
 agency directly affects only the \inprotected protoplasmic structures, 
 the nerve-cell, the axis-cylinder process before it attains its medullary 
 investment, or the protoplasmic bi^anches of these cells. The connec- 
 tive elements, however, eftect the degeneration of the medullated tube 
 by the pressure and encroachment of sclerous fibrillated tissvie, as seen 
 by the invasion of the finely-punctated tissue in other forms of 
 ascending sclerosis. 
 
 As to the site of the changes just considered, the postcriOP COm- 
 miSSUPal zone of the cord is a special favourite site of election. 
 Here the vascular tracts almost invariably exhibit the change 
 described, even if nowhere else observable. The COlumns of Goll 
 are likewise often implicated, whilst a third favourite site appears to 
 be the posterior radicular zone, the morbid change extending 
 from the entrance of the innermost fibres of the posterior roots into 
 the cord along their course until they enter the posterior cornu. The 
 proliferating scavenger-cells, as before stated, usually follow the course 
 of these morbidly-distended vessels, and by their depth of staining 
 map out the posterior column into a riband-like band involving one 
 or both radicular zones, or occupy the inner wedge-shaped extremity of 
 Goll's column, or form a deep-coloured belt immediately behind the 
 posterior commissure. In such cases the substantia g'elatinosa of 
 the posterior cornu is riddled throughout by similar dilated blood- 
 channels. This increased vascularity may pervade the whole of the 
 central grey matter, as well as the lateral columns. 
 
 System-Implication of Lateral Columns. — When these coluinns 
 
 are involved the indications presented are those of chronic and mild 
 congestion leading to eventual sclerosic degeneration of the tissue. In 
 fresh preparations such changes may not l)e appreciable to the naked 
 eye, and (unlike the secondai-y degenerations from focal lesion in the 
 cerebrum) they are not revealed, except to histological examination. 
 In the ordinary forms of descending lateral sclerosis consecutive to 
 desti'uctive lesions in the motor area, the degenerated columns betray 
 themselves by their greyish translucent aspect, showing through the 
 pia just as the ascending sclerosis of genuine tabes reveals itself by 
 the same peculiar pearly translucency in the posterior columns. The 
 naked-eye examination, however, may indicate its existence by the 
 
ASSOCIATED SVSTEM-DISKASKS OF THK COHD. 507 
 
 altered contour of the cord, the column implicated being often shrunken, 
 contracted, and the normal symmetry distorted. Again, section of the 
 fresh cord in the former affection (descending lateral sclerosis) exhibits 
 the degeneration to the naked eye as a greyish, brownish, or fawn tint, 
 and a translucency due to the diminution of medullated sheaths of 
 the nerve-fibres, as also to the preponderance of enlarged blood-vessels 
 and connective elements. In the lesions of these columns in general 
 paralysis these appearances are observed only where the process has 
 been unusually active; in the great majority of cases they require 
 microscopic examination of specially-hardened chrome-specimens to 
 reveal the degenerative condition. 
 
 What is observed in such sections prepared and stained by the usual 
 means is the deep tint taken up by the diseased tract; the vessels and 
 trabecular tissue and intervening connective being so far predominant 
 as to take up much more of the staining reagent than the healthy 
 tracts, where the axis-cylinder is ensheathed by its normal amount of 
 myeline; if, before staining, such sections are "cleared up" and examined 
 by transmitted light, the peculiar translucent aspect of the diseased 
 tracts also suffices to map them out accurately to the naked eye. The 
 intimate nature of the process is revealed by histological examination. 
 It is thus found that, in the posterior half of the lateral column, reach- 
 ing back to the posterior cornu, but bounded externally by a tract of 
 healthy nerve-tissue — the direct cerebellar tract — there is a dark-stained 
 area in which the nerve-elements are in a state of inflammatory 
 disintegration. The medullated fibres have lost a great part of their 
 myeline, and are notably diminished in size — their axis-cylinders, 
 however, still remaining; here and there the nerve-fibres appear larger 
 than usual, the medulla swollen — faintly tinted with the dye (an 
 indication of its necrotic stage) — and the axis-cylinder either displaced 
 laterally or entirely absent. These enlarged fibres, seen in transverse 
 sections, are but the swollen moniliform portions of the disintegrating 
 nerve-fibre divided at its lai'gest diameter. To indicate this fact, 
 longitudinal sections through the column should be made, and examined 
 in the fresh and in the mounted state. The nerve-fibres will then be 
 seen to be undergoing marked inflammatory change; a large proportion 
 may exhibit almost empty medullated sheaths, enclosing a still- 
 continuous axis-cylinder; in most cases the axis-cylinder is itself 
 izaterrupted, displaced, contoi'ted, and severed along its course; the less 
 degenerate fibres show irregular enlargements along their course, often 
 presenting a notably-moniliform asj)ect due to proliferation of tlie 
 nerve-nuclei, increase of their protoplasm, and segmentation of the 
 medulla thus induced; in fact, an active destructive process, in which 
 these nucleated masses of protoplasm forming the cellular element of 
 
508 PATHOLOGICAL ANATOMY OF r.ENEHAL PAFJALYSLS. 
 
 each segmented node of the nerve-iibro take the eliief part, a process 
 clearly enunciated by Rjinvier. If these longituflinal sections are 
 examined- in the unmounted state prior to the clearing up with oil of 
 cloves, the fibres are also seen to have freely scattered over them a 
 large quantity of compound granule-cells — another indication of the 
 inflammatory change. These gi'anule-masses are immediately lost upon 
 the use of this clearing reagent, but may be temporarily preserved by 
 mounting in glycerine. 
 
 Returning to our transverse sections of these columns, we find the 
 trabecular tissue largely increased, its radiating cells enlarged, and 
 much fine punctated fibrillar tissue (deeply-stained) intervening betwixt 
 the degenerate nerve-fibres, and following out especially the direction 
 of the vascular tracts. The vessels themselves are unduly large, and 
 very prominent in the diseased part; their walls are invariably 
 thickened, the muscular tissue, more especially, being thus increased; 
 ■whilst the smaller vessels exhibit the change more notably than the 
 larger; in many cases the lumen may be almost obliterated. The 
 lymphatic sheath may be distended, but this change is not so prominent 
 a feature as in the common form of lateral sclerosis from cerebral focal 
 disease; nor, upon the other hand, does it approach to the remarkable 
 change seen in corresponding tissues in the cortex of general paralysis. 
 The vessels themselves usually form centres from which connective tissue 
 radiates into the surrounding nervous structures placed in the axil of 
 the trabecula; the open lumen, the thick wall of the vessel, and its 
 occasionally distended sheath are prominent objects, and the radiate 
 cells around thrust out their processes into the finely-punctated 
 connective in which the nerve-fibrils are imbedded. The appearance is 
 almost suggestive, at first sight, of primary interstitial change; but this 
 can scarcely be maintained in view of the fact tliat the vessels may be 
 traced through healthy tissue (such as pass through the direct cerebellar 
 columns) into the diseased focus, and that only on their arrival in the 
 inflamed zone do they present the morbid appearances described. The 
 same statement holds good for ordinary descending sclerosis, secondary 
 to cerebral lesions; here, also, we witness the implication of the vessel 
 only upon its arrival at the site of morbid activity. Again, we do not 
 meet with the enormous nuclear proliferation upon the walls of these 
 arterioles, such as we found in the cortex; the adventitia is, as a rule, 
 devoid of any undue proliferation. It is not, however, intimated by 
 this, that a true parenchymatous neuritis may not induce such nuclear 
 proliferation by extension of the inflammation to the vascular tracts 
 and interstitial tissue; but, that, in the absence of this change, we 
 probably have positive evidence of an inflammatory extension to the 
 blood-vessel not having occurred. A still more important indication 
 
"PlaieXiV. 
 
 FigTn.erd.ed aridi shruTil-cen apex. 
 
 Piarncntecl ^ranide mass^ 
 
 ^iTimken &. displaced nucleus 
 
 \ » 
 
 _^^'<^i^-m£nied OTanular mass. 
 
 Process contimzczis ivUh 
 retracted -protoplas-f. 
 
 Tusccus de^ eTiereitioTi of large Ganglioz^ic cells 
 of Motor Cortex , lL\xiin.aTi. x350. 
 
PARENCHYMATOUS MYELITIS. 509 
 
 of the change being primarily a ixirenchymatous neuritis is found in the 
 tendency of the lesion to assume a genuine system-distribution; and 
 the argument holds good for these changes in the lateral columns of the 
 cord in general paralysis, just as Gowers indicates that it does for the 
 system-disease of tabes dorsalis. 
 
 Assuming, then, that the changes met with in the lateral columns of 
 the cord in general paralysis are of the nature of a parenchymatous 
 i-ather than an interstitial myelitis, and that this change tends to 
 establish a system-disease of the cord, we naturally ask how the 
 change is primarily induced. Why do the nerve-fibres take on the 
 inflammatory condition described 1 There can be little doubt that the 
 true explanation lies in the destructive and irritating lesions proceed- 
 ing in their trophic centres in the cerebrum ; for we may safely assume 
 that the cortical cells in communication with such motor fibres also 
 exert a trophic influence over them. The initiatory change, viz., the 
 increase of the nucleated protoplasts of the medullated nerve-tubuli, 
 we do know occurs as the result of its separation from its trophic 
 centre, as by section or other lesion; and we trace in the cortex 
 lesions of motor cells which indubitably should lead to the changes 
 described. It is a significant fact, also, that one of the earliest indica- 
 tions of the change is the extreme vascularity of the tract afiected, in 
 itself, possibly, the expression of the trophic disturbance. To sum- 
 marise these views : — 
 
 1. The change is induced secondarily to the cortical lesions. 
 
 2. It establishes itself after the WaUerian principle ; does not 
 overstep its systematic barrier, although it may originate simultaneously 
 at several distinct and distant parts of this tract. 
 
 3. It reproduces, in varying degrees of intensity, the character of a 
 chronic parenchymatous myelitis with notable vascular change. 
 
 4. Its intensity never approaches that of the descending myelitis 
 due to large focal lesions of the cortex, and being in its essential nature 
 
 dependent upon a gradually-advancing- deg'eneration of cortical 
 
 nerve-cells, and not a sudden or gross lesion such as the former, the 
 irritative influence on the cord is greatly mitigated. 
 
 Although, in the greater number of cases, the change found in the 
 posterior columns of the cord is limited to the vascular distension 
 above alluded to, and the abundant production of scavenger-cells ; yet, 
 in certain instances, we meet with a genuine myelitis, the site of which 
 is usually the posterior radicular zone, often extending across towards 
 the columns of Goll. Here, the nerve-tubuli have veritably undergone 
 inflammatory change ; and, as will be described more fully in the 
 lateral columns, the medullated sheath is found swollen, faintly stained, 
 the site of nuclear proliferation and disintegration of myeline. Many 
 
510 PATHOLOfJICAL ANATOMY OF OENERAL PARALYSIS. 
 
 of these enlarged tubuli show no axis-cylinder or one which is displaced 
 laterally, and the increase of connective along the vascular tracts often 
 leads to a notable diminution and distortion of these columns of the 
 cord. The ordinary grey degeneration of these columns seen in tabes 
 (lorsalis is not in these cases reproduced, hut a much more irritative 
 process, highly inflammatory in character, and closely resembling the 
 sclerosic conditions of the lateral columns with which it is often 
 associated. (PI. vi.,Jigs. 1-3; PI. vii.) 
 
 Combined System-Implication of Columns.— Do the changes 
 
 found ever resemble those of amyotrophic lateral sclerosis 1 We need 
 only refer to the case of M. J. R. (p. 278) for a typical illustration of 
 this amyotrophic sclerosis associated with general paralysis. Such 
 cases present a very rapid downward career, which is mapped-out in the 
 earlier stage by successive apoplectiform and convulsive seizures ; the 
 latter are usually unilateral, often limited to the facial muscles, and 
 unattended by loss of consciousness. As a sequel to this seizure or "fit," 
 as the friends term it, a loss of power in one or other limb is almost 
 universally found to exist; usually it is the arm that suffers most after 
 these attacks, the grasping power being greatly diminished, and the 
 subsequent changes in the muscular power and nutrition of this 
 member may be disturbed in advance of the lower extremities. 
 These paretic states at first may be very transient, or last a day 
 or more ; the locomotion continues unimpaired, the general nutrition 
 of the body may be unaffected, and exercise be taken without 
 inducing fatigue for a period of one or two years subsequent to the 
 onset of the cerebral disturbance. Then, there appear symptoms 
 which inaugurate the advent of organic changes in the cord ; the 
 locomotor powers may still be good, and considerable muscular force 
 may be exhibited, but equilibration is distinctly disturbed, and al- 
 though the patients may be able to approximate their feet in the 
 erect position, and close their eyes with but slight swaying, yet they 
 stagger considerably in attempting to walk in a straight line (heel 
 and toe). The gait gradually indicates advancing ataxy, the legs 
 are thrown out in disorderly fashion, and the tendency to come down 
 on the heel is also recognised. Yet, in lieu of decreased or abolished 
 knee-jerk, we now find either that it is normal in force and range, or 
 that it is greatly increased. At this stage also, we get ankle-clonos 
 in one or other limb as a frequent accompaniment. The tongue now 
 is protruded jerkily, and all its movements are ataxic, the lips may 
 be exceedingly tremulous, but deglutition is unimpaired. 
 
 Attacks of maniacal excitement may now precede sudden failures of 
 power in the lower extremities, and we find ankle-clonos and the knee- 
 tap reaction in excess. The arms now rapidly emaciate, and become 
 
AjMyotropiiic form. 511 
 
 correspondingly defective in muscular power ; in fact, the most marked 
 feature of the case at this period will be this extreme atrophy of the 
 upper extremities, in which the more specialised muscles are not 
 picked-out in the manner of the ordinary progressive muscular atrophy, 
 but the large muscles of the shoulder-joint, the musculature of the arm, 
 and the flexors and extensors of the forearm are chiefly involved. No 
 contractures of the arm occur, or myotatic increase, but complete 
 flaccidity, and the legs do not participate in this subacute atrophic 
 state. On the other hand, the legs show more marked sensory dis- 
 turbances, cutaneous sensibility becomes blunted, there is increased 
 swaying in the erect position, the gait may be that of an unsteady 
 jog-trot, or more notably ataxic. Exalted knee-jerk and clones may 
 still exist ; but, muscular enfeeblement now rapidly supervenes ; the 
 limbs tend to exhibit spasmodic fixation, but are more frequently 
 kept stiff and rigid by voluntary effort. The patient is now bed- 
 ridden, and at this stage is usually profoundly demented. Implication 
 of the sensory nerve-roots becomes evidenced by almost complete loss 
 of cutaneous sensibility in one or both legs, and is probably, also, 
 indicated by a sharp distressing cry often repeated, as if the poor 
 patient were the subject of sudden lightning-pains. Ataxy is also 
 now present to a very notable degree, and the knee-jerk (up till this 
 period normal, or unduly exaggerated) is completely aboHshed ; 
 plantar-reflex is also absent. By this stage the subject is in a 
 pitiable condition, helpless in limb, utterly incapable of attending 
 to the most trivial wants, exceedingly timid, and the apparent sufferer 
 from fulgurant pains; there is profound implication of the bulbar 
 nerves, deglutition being so far impaired as to make the effort both 
 painful and full of risk ; whilst softened food placed in the mouth is 
 apt to be retained as a bolus in the cheek-pouch for hours, unless care 
 be taken. The extreme emaciation of the upper extremities is also 
 attended by rapid atrophy of the facial muscles, loss of all adipose 
 tissues, and a sharpened pinched expression of the features. 
 
 Reverting now to the amyotrophic form described, we note first, 
 that the spinal appear consecutively to the cerebral derangements ; 
 and, as before stated, are almost invariably ushered-in as the direct 
 results of apoplectiform or convulsive seizures. The resulting paresis 
 is, at first, nothing more than the post-convulsive exhaustion, often 
 seen in epileptics, in whom also the myotatic increase indicated by 
 the knee-jerk and ankle-clonos is often seen ; but, eventually, the 
 inco-ordination established, apart from defect of sensation or patellar 
 reaction, indicates a morbid change in some region of the cord, other 
 than that of the posterior sensory roots, and this change is detected 
 across the columns of Goll, and partly in the 2^ost-co7)wiissural zone, the 
 
512 PATHOLOGICAL ANATOMY OF (iENKUAL PARALYSIS. 
 
 implication of wliitli undoubtedly leads to inco-ordinate action, with- 
 out further derangement of cutaneous or muscular sensibility. In 
 fact, a morbid basis is established for the muscular excitability 
 indicated by the increased knee-jerk in a finely-punctated sclerosis of 
 the lateral columns of the cord, which may be traced from the dorsal 
 cord throughout the lumbar region, but it may not be at all apparent 
 in thece rvical region. {PI. vii.) It is to the increase of this sclerosic 
 state of these columns we must attriVjute the progressive stiffening of 
 the lower limbs, and their exalted muscular irritability. Later on in 
 the history of these cases, the changes noted in the columns of Goll 
 spread obliquely outwards so as to directly involve the posterior sensory 
 root-libres, inducing thereby the notable ataxy and anaesthesia of the 
 limbs ; but still exhibiting betwixt lower and upper limbs, the contrast 
 of rigidity of the former (associated with no special wasting) and of 
 extreme atrophy, paresis and flaccidity of the latter. As regards the 
 arms, the changes found in the anterior cornua suffice to indicate 
 the cause of extreme emaciation of certain muscular groupings, and 
 their progressive enfeeblement in motor power. {PL xiii.j The 
 lesions in the multipolar cells of the cornua also, in like-manner, 
 explain the complete flaccidity of this member, for in this region the 
 lateral columns are not diseased. Charcot's view of amyotrophic 
 lateral sclerosis cannot be advanced here ; for we plainly see a 
 degenerative atrophy of the cornual elements at a plane considerably 
 higher than any change indicated in the lateral columns of the cord ; 
 the latter, in fact, is first seen in the dorsi-lumbar region, not in the 
 cervical, whereas the degeneration of the anterior cornua is first 
 seen in the cervical region. That the latter is established by a sort 
 of projection of the disease forwards from the lateral columns is, 
 therefore, here quite untenable, nor, in fact, can any relationship 
 betwixt the two be aiffirmed ; and this accords completely with what 
 we constantly see in ordinary descending lateral sclerosis from focal 
 cerebral lesion, where the lateral columns may remain for eight or 
 ten or more years profoundly implicated, with no obvious change in 
 the cornua. Evidently, then, this disease in the anterior cornua of 
 the cervical and the lateral sclerosis of lower regions of the cord are 
 independent states, mutually related only as regards a community of 
 origin higher up in the cerebral cortex. Why it is that the cornua 
 are afiected in the cervical, and the lateral columns in the dorsi- 
 lumbar cord, can probably be explained only by the special localisation 
 and depth of lesion, or degenerative change within the cerebral cortex. 
 Then, again, as regards the posterior columns of the cord ; we find 
 here the frequent vascular change observed in general paralysis, and 
 the aflections whereby the cortical lesions tend to project their 
 
PSEUDO-TABETIC EOItM. 513 
 
 influence upon subordinate regions of the spinal axis ; the vascular 
 turgescence, however, is not so great in these cases as the purely 
 neural change. {PL xvi., fig. 3.) The change is not one of connective 
 proliferation, of abundant cell-growth of scavenger-elements, or of 
 notably-enlarged vessels presenting changes in their tunics ; it is not a 
 vascular nor interstitial connection, but a purely neural change — 
 a genuine myelitis — tending to spread exclusively along the direction 
 of the sensory root-fibres, as indicated in the description above given. 
 No cases, in fact, would better indicate to us the neural origin of 
 ascending changes in general paralysis, and in certain forms of tabes. 
 
 If, as often happens, the posterior cornua be also implicated by 
 extension of this lesion to the substantia gelatinosa, we get anaesthesia 
 of the corresponding limb. 
 
 The order of evolution of the morbid changes, appear to be as 
 follows — first, the posterior median and posterior commissural zones 
 are involved, issuing in inco-ordinate gait ; next, the lesion tends to 
 spread over the whole of the posterior root-zone, and along the course 
 of its sensory fibres ; at the same time progressive degenerative 
 changes occur in the lateral columns in the dorsi-lumbar region. Ere 
 these latter changes are much advanced, amyotrophic change is 
 observed in the upper extremities, revealing the lesion located in the 
 anterior cornua, and, subsequent to this, a rapid ascending change 
 from this site implicates the bulbar nerve-nuclei, and hastens on the 
 fatal termination. 
 
 Implication of Posterior Columns (Pseudo-tabetic forms). — 
 
 We have thus, so fai-, dealt with a combined system-aflfection of the 
 cord in general paralysis, where a postero-lateral change predominates 
 in the lower region, and a polar impairment (issuiug in progressive 
 general muscular and bulbar atrophy) is emphasised in the cervical 
 regions. Let us now consider, more particularly, the cases where the 
 former exclusively exists. {See case ofH. U.,p.2^l.) A notable feature 
 in this class of cases is the predominance of sensorial derangements, not 
 as regards spinal symptoms only, but as expressed in cerebral symptoms 
 also. The mental anomalies appear specially to indicate a wide-spread 
 sensorial implication, and the maniacal perversions are characterised by 
 most vivid acute hallucinations, by very painful emotional states, often 
 culminating in attacks of the most acute melancholia. The painful 
 mental states are all associated with well-marked hysteric outbursts 
 so characteristic of this series of cases. It is only in the later stages 
 of the disease, when the dementia is fjxr advanced, that this painful 
 state of mind declines, or rather is replaced by a condition bordering 
 upon idiocy, often with much frenzied excitement. 
 
 Another prominent symptom is that of frequent convulsive attacks, 
 
 33 
 
514 PATHOLO(;lCAL ANATOMY OF GENKRAL PARALYSIS. 
 
 which are often peculiarly severe in nature, and leave wide-spread and 
 notable sequehe, physical and mental. When such a case presents 
 itself, we are struck at the onset by the marked tabetic gait, a feature 
 especially striking if the subject be in a state of excitement. The feet 
 are planted wide apart, the legs thrown out in most disorderly style, 
 and the heel brought down with disproportionate force. The inco- 
 ordination is further increased by closing the eyes, and the patient 
 cannot stand in this position without falling. Yet, muscular power is 
 in no way necessarily impaired, and the limbs will resist forcibly efforts 
 to extend them. Since, however, convulsions are very frequent in 
 such cases, we often find a considerable amount of paresis, but this 
 only of a ti-ansient nature at first ; great fatigue upon slight exertion 
 may be complained of, or the grasping power diminished, as in one of 
 our cases, to 4 kilogrammes. No permanent paralysis is detected in 
 this early stage; but the all-important fact to recognise is the complete 
 absence of muscular atrophy, and the non-implication of the cutaneous 
 and muscular nerves. Yet, simultaneously with this absence of sen- 
 sory manifestation in lower planes, we may find the sensory tract of 
 the trigeminus implicated — e.g., the herpetic eruption and trophic 
 impairment of cornea in the case of H. U. 
 
 The ataxic gait is, as usual, a more obtrusive symptom than the 
 same impairment in the movements of the hand and arm ; yet an 
 attempt to write, to button the coat, to sew, or thread a needle at once 
 makes evident the fact that the inco-ordination of the hands is as gravely 
 impaired as that of the lower extremities. If convulsions occur, they 
 are usually unilateral, or much more marked on one side than the 
 other; they generally leave behind them a hemiplegic state, often with 
 complete hemiansesthesia. The reductions from such convulsive seiz- 
 ures are often most profound and prolonged, the subjects being left for 
 days together in a state of complete stupor ; mute, requiring forcible 
 feeding and catheterism, and keeping the mouth full of saliva. Then, 
 as normal sensation is regained and muscular power returns, we may 
 have wild delirious excitement, which may be associated with desperate 
 suicidal impulses. (//. U., p. 281.) 
 
 Repeated attacks of hemiplegia with more or less complete anes- 
 thesia of the same side occur, leaving the patient speechless and 
 helpless for days, until eventually the aspect of the case is one of utter 
 imbecility. In the intervals, however, between such seizures, he may 
 still go about exhibiting notably the inco-ordinate gait, but with 
 normal, or more often with acutely-exaggerated knee-jerk. Contractions 
 of the limbs now ensue, being generally limited to the upper ex- 
 tremities, and corresponding to the side usually left paralysed after 
 convulsive seizures ; thus, in a case of right hemiplegia with hemi- 
 
PSEUDO-TABETIC FORM. 515 
 
 anaesthesia following convulsive attacks, the permanent paralysis and 
 contracture is sure to develop on this same side. Ushered-in by 
 slight initial rigidity of the extensors of the forearm and wrist (which 
 permit of wrist- and ankle-clonos upon slight flexion), the flexors soon 
 antagonise and contract the arm in the usual semiflexed and pronated 
 position. In this advanced stage there may still be no vasomotor 
 change in the limb, and no indication whatever of trophic disturbance; 
 but at a still later stage the skin of the feet may be cold and bluish, and 
 a co-existent ancesthesia may be noted in the skin of the calves, the 
 plantar reflexes, however, still remaining brisk. The lower extremities 
 may show a certain degree of clasp-knife rigidity, or spasmodic fixation, 
 but no permanent contracture ; yet, in the latest stage, the repeated 
 convulsive seizures so far exhaust the energy of the motor tract, that 
 the patient sits squatting in stooping posture, or attempts locomotion 
 on hands and knees. Deglutition may be little impaired except as the 
 immediate result of epileptiform seizures; grinding of the teeth is a 
 very frequent accompaniment. 
 
 From the first series these cases are, of course, notably distinguished 
 from the outset, by the far greater obtrusiveness of inco-ordination, 
 which, at first sight typically tabetic, is subsequently found wanting 
 in that implication of the sensory nerve-roots which would render it 
 a genuine tabetic condition. No disturbance of muscular or cutaneous 
 sensibility, however, is discoverable, except as the immediate outcome 
 of a cerebral discharge. Such cases conclusively prove that inco- 
 ordination may result from lesions in the regions of the posterior 
 columns other than the posterior root-zone; and that the posterior root- 
 fibres must be implicated to explain any existing sensory anomalies of 
 skin and muscles. We find in the cases presented by this series that 
 the postei"ior root-zone is absolutely free from disease ; and that any 
 morbid implication of the posterior columns of the cord is exclusively 
 limited to the posterior commissural zone and posterior-median columns 
 (columns of Goll), in cervical, dorsal, and lumbar divisions of the cord; 
 this implication of the columns of Goll with a perfectly healthy state 
 of the sensory root-fibres we have repeatedly recognised.* The lesion 
 observed differs also from that of the former series in being a much 
 more pronounced vascular and cellular change. The vessels of the pos- 
 terior commissural zone being notably dilated, and extending down the 
 median raphe, are accompanied by a dense crowding of scavenger-cells 
 (the abundant proliferation of which is a striking feature) presenting a 
 coarse trabecular appearance, in which thick-walled vessels with con- 
 tracted lumen are freely scattered. (PI. xvi., Jig. 3; PI. xviii.) The 
 
 * See in this connection the microscopic examination of the cord in tlie case of 
 H. U., p. 282. 
 
516 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 nerve-fibre does not itself appear implicated as in the former series, 
 and the disturbances in their oonductibility are pnjbably the result 
 of the pressure produced by this morbid cellular growth, and the 
 engorged and distended nutrient vessels of this region. The mor])id 
 change in tissue follows out very accurately the immediate confines 
 of Goll along the inner half of the wedge-shaped apex, where it 
 lies in contact with the columns of Burdach, respecting rigidly the 
 posterior root-zone, however; but, the columns are throughout their 
 inner half the site of such change, especially along the median raphe. 
 It would appear highly probable that, in those cases where inco-ordina- 
 tion, existing notably ybr a time only, has gradually declined or wholly 
 disappeared, the phenomena may be regarded as 2)'>'^ssure results which 
 have not proceeded to actual myelitis, and in which the scavenger-cells 
 have performed their depurative functions (p. 497) and have been 
 replaced by fibrillated tissue. The muscular tone in all these cases is 
 but slightly, if at all, impaired ; and the anterior cornua remain intact, 
 as evidenced by the well-nourished aspect of the muscles late on in the 
 disease ; no centric atrophy of the limbs is seen as in the former cases. 
 The general muscular debility and fatigue upon slight exertion, which 
 such cases present, are the outcome of the exhaustive convulsive seizures 
 to which they are so subject, and not of a persistent paralysis or 
 atrophic change in the muscles of the limb. The descending changes 
 in the lateral columns always appear as the sequel of the convulsive 
 seizures above alluded to, and explain the association of exaggerated 
 knee-jerk with the inco-ordinate movements of the limbs; such sclerous 
 change implicates, as before stated, the greater part of the column, 
 respecting, however, the direct cerebellar and intermedio-lateral zone, it 
 yet creeps forward as far as the postero-external group of cells in the 
 anterior cornu. The change occurring in the posterior median tracts 
 of the cord is earlier in its incidence than this lateral sclerosis, as 
 shown by the much larger development of contractures in the limb 
 after a long persistence of inco-'ordination. Then we have to consider 
 the association of the cortical implication with these spinal changes. 
 It is in such cases we get little, if any, indication of adherent 
 membranes, and the atrophic state of cortex will be chiefly located in 
 the upper parietal or postero-parietal lobule. We have elsewhere 
 indicated the association of lesions at this site with ti-emulous and 
 ataxic movements of the lower limbs,* and it appears to the 
 writer probable, that the implication of the posterior columns of 
 the cord, at the side named, has some direct originating con- 
 nection with the extreme atrophy undergone in the postero-parietal 
 lobule. 
 
 * "Localisation in Cerebral Disease," Brit. Med. Jour., vol. ii., 1883. 
 
TABES AND GENERAL PAIJALYSIS. 517 
 
 The absence of muscular atrophy, which characterised tlie former 
 series of cases, is consistent with the immunity of the anterior c<jrnua 
 from morbid change. 
 
 Waiving for a time any consideration of a presumed identity in such 
 apparently different neuroses as tahes and general paralysis, if the 
 question be put as to the frequency of association of the two aflfec- 
 tions so named, the reply would possibly be in favour of a very 
 infrequent alliance as observed in asylum practice. Nor would this 
 opinion be surprising if we remember that the most obtrusive symptoms 
 associated with tahes is one not by any means essential to the diseased 
 process which is at the root of the ailment. InCO-OPdination — so 
 prominent a feature in all marked cases of tabeS dorsalis — need not 
 be present to constitute this disease ; and, if ataxiC symptoms are 
 considered as essential features in tahes, then the incidence of such an 
 affection during the evolution of general paralysis would very justly 
 be regarded as most infrequent. 
 
 If, however, we adhere strictly to what is accepted as the patho- 
 logical definition of tahes, viz., an affection of the posterior nerve-roots 
 or the peripheral sensory nerves, and accept as its essential clinical 
 feature the abolition of knee-jerk, then we do find evidence in favour 
 of a very frequent association between these affections. 
 
 There is substantial evidence (both clinical and pathological) in 
 favour of this severance of ataxic symptoms from the truly tabetic 
 sign — loss of knee-jerk ; and the position assumed by Dr. Gowers in 
 favour of such severance appears to us unassailable. There is undoubt- 
 edly an ataxic paraplegia without the knee-tendon accompaniments of 
 tabes; there are, moreover, forms of indubitable tabes which exhibit 
 no inco-ordination. On the other hand, we have i-epeatedly verified 
 these data upon pathological grounds, and recognise lesions of a special 
 region of the posterior columns not implicating the posterior nerve- 
 roots as the essential condition associated with iuco-ordinate move- 
 ments of the limbs, the knee-jerk being normal or exaggerated ; whilst 
 implication of the posterior nerve-roots was invariably associated with 
 the abolition of that reflex phenomenon. Hence, a fallacy is likely to 
 occur in our estimate of the frequency of association of these two 
 cerebro-spinal neuroses ; just as in the ordinary form of tahes the loss 
 of the knee-jerk is a symptom which may precede the more obtrusive 
 evidence of the disease by many years, being a symptom which is apt 
 to escape detection. It is, indeed, generally revealed at an early date, 
 not from the prominence of any motor inco-ordination, but from the 
 lancinating pains with wliich it is so frequently associated. Tabes, 
 therefore, in this strict sense of the term, occurs in fully 15-9 per cent, 
 of general paralytics (see Analysis, p. 2G9), a fiiirly large proportion; 
 
518 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 and sucli cases exliibit certain features wliich justify us in separately 
 considering the class.* 
 
 It is not, however, with these more frequent forms that we are now 
 more immediately concerned, hut with the fur less frequent associa- 
 tion of ataxic tabes with general paralysis. 
 
 Implication of Posterior Columns (Ataxic Tahes).— This rare 
 
 form of disease claims our closest attention, not alone from the 
 acuteness of the neurosis, and the wide sweep of the nerve-storm over 
 the most distant regions of the nervous system, but more especially 
 from the emphatic testimony borne by its clinical history to the close 
 alliance (if not identity) of the morbid processes underlying tabes 
 dorsalis and general paralysis. 
 
 The attack is usually ushered-in by cerebral symptoms which may 
 be purely mental, and of the nature of a maniacal or melancholic out- 
 burst; or an apoplectiform or convulsive seizure may occur, such as not 
 infrequently present themselves about the onset of general paralysis. 
 When mental symptoms predominate they have usually been of an acute 
 character, tending to melancholic agitation with impulses to suicide or 
 dangerous aggressive violence. We have not observed the wild delirious 
 state seen in the ataxic paraplegia last described. If COng'GStive or 
 convulsive seizures usher in the affection, there may supervene a 
 ti-ansient hemiplegia, more or less complete ; and, probably as a sequel 
 to this, we first recognise the inco-ordinate movement of the limbs. We 
 are not in a position to state wlien the knee-jerk declines, from the fjict 
 that these subjects come before our notice for their mental infii'mity ; 
 certain it is, however, that it was lost in all the cases which presented 
 themselves ; whether such loss occurred (as is quite possible) before 
 prominent cerebral disturbances existed, or not, is a subject deserving 
 further inquixy. A notable symptom in all these tabetic general 
 paralytics is a severe frontal headache, often complained of to the 
 exclusion of all other symptoms. 
 
 The mental state is peculiar in the fact that it is wanting in the 
 redundant flow of spirits exhibited by typical paralytics, even where 
 the most grandiose notions prevail. The emotional states associated 
 with ideas of extraordinary wealth, unusual attainments, or wondrous 
 capacities for action, even if they do prevail, are tinctured by con- 
 siderable discontent, querulousness, and evidence of a general moi-al 
 decadence. The subject may be distrustful, cunning, treacherous, and 
 exhibit sullen gloom and despondency, or even harbour suicidal 
 tendencies. Dementia may not obtrude itself on our notice until the 
 cerebro-spinal affection is far advanced ; and it must be affirmed that 
 
 * The analysis, moreover, indicates, if we include cases where tlie reflex is not 
 completely abolished, the still higher proportion of 20'4 per cent. 
 
fpM^ 
 
 fS-l^SM^-^-K 
 
 Gection from tlie ascexLcLin^ frontal convolutioxL iu a case of SeTiile airop]^. 
 The proliferation of corLTiective" cells of the nxppex coxtical layers 
 IS seen iTivacLln^ tlie vascular tracts and nervous elements xlSO. 
 
 Group, of 
 <coLven 
 
 'up. of ,_ &avenqer-cell surroiaided ly bil-globxRes. 
 
 Faiiif -products accurmzlaiing 
 '■~ound SloodL-vessel 
 
 -i('^:^ 
 
 F„, '!v disiii-te 2>TaiiOTi of periplieral zone (1= layer) of Cortex 
 in a case of advanced Senile atrophy of Brain . x 350 
 
 Nerve -c^ll iieTfcid cf processes 
 
 Swollen decjeneraiino 
 Jferve-ceTL •■•., 
 
 Tibrillatina Scavenger- cells. 
 
 Scavenger elements filled -mih granules. 
 
 ■i-w-r^'^l ni.^i.rilearaiei and surrciindtd 
 ::lar debris. 
 
 TT^ i o 
 
ATAXIC TABES AND GENERAL PARALYSIS. 519 
 
 cerebral symptoms may entirely fail to manifest themselves, and the 
 patient be sent from under asylum supervision, but suffei'ing from 
 pronounced ataxy of the limbs, and other symptoms of tabes dorsalis. 
 
 The bulbar symptoms of general paralysis are not necessarily a 
 prominent feature ; the pupils may be unequal, and respond sluggishly 
 or not at all to light ; the tongue and facial muscles may be somewhat 
 tremulous, but the articulation is often clear and distinct. • 
 
 On the other hand, the spinal symptoms will be striking features in 
 the case ; the patient plants his feet in the manner of the ataxic upon 
 a wide basis of support ; when he approximates them, he sways 
 considerably and tends to fall ; if he closes his eyes he must inevit- 
 ably fall ; he fails to walk backwards, and forward progression is 
 accomplished by disorderly thrusts of the leg, first to one side and 
 then to the other, the heels coming down with a forcible stamp. If 
 he be placed upon his back, and be requested to resist extension of 
 the limbs, he exhibits considerable muscular power, and the grasp of 
 the hand may be unimpaired. On percussing the patella-tendons the 
 knee-jerk is found absent, whilst the plantar and superficial reflexes 
 may all be present. No anaesthesia or other sensory defect may 
 prevail. As in tj'^pically tabetic cases, lightning-pains may still further 
 cloud the poor victim's life, and be of so agonising a nature as to 
 render sleep futile, and necessitate frequent recourse to morphia. In 
 all cases it appeared to us that a connection could always be established 
 between the more acute cerebral and spinal exacerbations. The ataxy, 
 in such cases as we describe, is more frequently emphasised in both 
 upper and lower extremities; in uncomplicated tabes it is the legs 
 which chiefly suffer, and tlie arms may as we know escape. The 
 ataxy, however, is a symptom which varies in degree from time to 
 time, and is indubitably worse with coincident mental exacerbations ; the 
 truly tabetic symptom — abolished knee-jerk — however, is persistent, 
 never being regained. We have known an instance in which both ex- 
 tremities were thiis ataxic; notwithstanding the patient was able to 
 write a fairly intelligible letter, although with considerable painful 
 effort and exhaustion. This was the case in the subject detailed by 
 my colleague. Dr. Bullen,* where the patient, tortured by delusions 
 of persecution, spent many hours at the sacrifice of much discomfort in 
 writing down his morbid experiences and recording his accusations 
 against his imaginaiy enemies. In this case, muscular sense was so 
 far defective that he could not touch the tip of his nose with the finger, 
 when the eyes were closed, after repeated trials, nor approximate the 
 tips of the fingers of both hands. It would appear also from the 
 
 "'' "A case of Locomotor Ataxy followed by General Paralysis of the Insane. " 
 Brain, April, 1888. 
 
520 PATHOLO(iICAL ANATOMY OF (ilONKKAL PARALYSIS. 
 
 history of this case tliat th(! arms were first affected (the reverse of 
 what is usual), since sk>venly writing first drew attention to the fact 
 of manual inco-ordination. 
 
 The pains vary much in character and distribution, tljey are usually 
 sudden, sharp, and lancinating, described as like electricity passing 
 through a limb; they may be described as tearing, agonising pains of 
 momentary duration only, or as "flashings painS " as one patient 
 described them ; or, again, there may be an intense burning pain over 
 a localised spot, as the knee or foot, and occasional " g"irdle painS " 
 supervene. RhGUmatoid pains are almost always complained of, and 
 the patient will, at times, speak of a spasmodic jerk of the whole arm, 
 due (as he says) to the pain ; or from the same cause the leg may 
 suddenly give way beneath him, and he drops on his knees momen- 
 tarily powerless. Thus in Dr. Bullen's case " there was momentary 
 loss of power in right leg, with dimness of vision and confusion 
 occasionally," also " hy perse sthesia over the area of Wrisberg."* 
 Priapism and nocturnal seminal emissions occur at an early stage 
 of the affection of the cord, and sexual proclivities are engendered at 
 this period, often colouring the-, delusional concepts of the subject, his 
 conversation and bearing being suggestive of satyriasis. Impotency 
 follows, and as indicated by Dr. Gowers, usually when the cremasteric 
 and ahdomhial reflexes fail to respond to normal stimuli. Hysteric 
 symptoms often supplement the mental derangements, and a species of 
 insane or hysteric cunning is a prominent feature. In these hysteric 
 outbursts, we have seen one patient assault his wife with the most 
 cowardly and uncalled-for violence ; others, who have plotted dex- 
 terously and with cunning persistence and mendacity to damage the 
 reputation of the nurse or attendant administering to their wants ; 
 and others, who have been most foul and obscene in their language. 
 This association of hysteric states in the tabetic general paralytic 
 should be remembered, since they are apt also to simulate symptoms 
 and to deceive grossly, if too much reliance be placed upon subjective 
 indications. 
 
 Delayed conduction along the sensory strands is known to be of 
 frequent occurrence in tabetic subjects at a certain stage; this we have 
 witnessed in a tabetic general paralytic to the extent of twelve seconds, 
 which elapsed betwixt pricking the sole of the foot and the registering 
 of the sensation felt. 
 
 Gastric, laryngeal, and rectal crises have all been recognised in this 
 neurotic condition, and are so severe at times as to render the patient 
 desperately and determinedly suicidal. 
 
 Tabetic General Paralysis. — To proceed to the more frequent 
 
 * Loc. cit. 
 
gp:nuine tabetic form. 521 
 
 class of tabetic cases in general paralysis where abolished knee-jerk 
 has been detected, but where ataxy is absent or plays quite a sub- 
 ordinate part in the symptomatic role, we find that a striking feature 
 in the mental disturbance is the almost universal prevalence of melan- 
 cholic depression, the dejected, hopeless aspect of the patient notably 
 contrasting with the beaming expression of the typical paralytic. A 
 basis for such depression is usually found in a persistent and torment- 
 ing sense-hallucination, to which they are prone, and which is not 
 unusually of a sexual nature. One case long observed by us was 
 subject to the persecution of a woman's voice from the neighbourino- 
 town, which haunted him whenever he went out of doors, and which 
 prompted him to mari-y her; the hallucination co-existed even with 
 intense depression and noisy weeping. It is in these hallucinatory 
 states we find an explanation for another frequent association, that of 
 suicidal feelings which peculiarly characterise this class of cases. 
 Almost all such cases have made determined attempts to take their 
 own life by drowning, hanging, strangling, or like desperate means, 
 prior to their admission to an asylum ; and their subsequent history is 
 only too confirmatory of this dangerous impulsive tendency. As 
 dementia, however, advances, the more acute melancholy usually 
 declines and is replaced by sullen gloom varied by fitful periods of 
 cheerfulness, in which we perceive the characteristic features of 
 general paralysis — the egoistic state and optimism ; the delirious 
 agitation of the purely ataxic forms we do not observe in such 
 patients. Occasionally, but rarely, optimism may be from the onset 
 a prominent feature; there is in such a case advanced dementia. 
 Thus one subject rambled continuously upon his " thousands of 
 champagne, hundreds of thousands of cigars, and his five hundred 
 sons and daughters." The aspect of the patient corresponds to the 
 mental state ; it is usually one of gloomy dejection or querulous dis- 
 content, in which the vacuous expression of dementia is apparent; 
 
 the brow is often corrugated from the persistent frontal head- 
 ache so frequent here, and the hair is often rubbed ofi" the frontal 
 region, or off" the whole of one side of the head, by the patient's hands; 
 the skin is swarthy or earthy in tint; there is always a notable 
 degree of atonicity in the facial muscles, and, indeed, throughout 
 the musculature of the limbs. Upon the least excitement tremors 
 of the facial muscles are induced, but no twitching; the lips parti- 
 cipate in the same unsteadiness, and the tongue exhibits a fine fibrillar 
 tremor; speech is impaired, articulation being slowed, or blurred 
 and thick, or a little quivering; it is never explosive. The oculo- 
 motor symptoms characteristic of general paralysis were present in 
 all the cases observed bv us. 
 
522 PATHOLOGICAL AKATOMV OK EPILEPTIC INSANITY. 
 
 PATHOLOGY OF EPILEPSY. 
 
 Contents. — Modern View of its Nature — An Impalpable Trophic Change— Objections 
 to Methods of Examination — Change in Elements of the Second Cortical Layer 
 — Fatty Ciiange in Nuclei of Nerve-Cell — Common also to Alcoholic Insanity — 
 Vacuolation of Nucleus — Ultimate Break-down of Nerve-cell — Implication of 
 Motor-Cells- -Absence of Vascular Implication — Functional Endowments of 
 Nucleus — Resistance of Cell to Discharge — Nutritional lihythm— Significance of 
 Size of Cell and Nucleus — Primitive Type of Nerve-cell — Degraded Type of 
 Nerve-cell — Cell-couformation as indicative of a Convulsive Constitution. 
 
 The morl)icl histology of epilepsy is confessedly an obscure question 
 if we confine our attention to those seizures in which coarse brain- 
 disease and naked-eye changes are not appreciable. Only recently 
 Ave have the authority of Dr. Gowers to the effect that there is little 
 likelihood at present of our knowledge of its pathological nature 
 becoinincr more definite, and that — " The chanjces in the nerve-centres 
 are jDrobably of that fine kind which is revealed only by altered func- 
 tion, and elude the most minute research." There exists a wide- 
 spread community of opinion that the pathological anatomy of epilepsy, 
 whatever it be, is the expression of a grave nutritional disturbance of 
 cell-protoplasm, a nutritive disturbance which need not express 
 itself in palpable morbid change even to the higher powers of the 
 microscope. From this opinion, however, we must dissent ; for it 
 appears to us that a morbid appearance of the cortical cell does exist 
 of a highly-characteristic nature, when the cortex is the subject of 
 careful examination by t\\e fresh methods of research. 
 
 Nor does it appear strange that the morbid change alluded to has 
 been overlooked, since the usual methods of preparation are often the 
 least adapted for revealing it ; the chrome salts subjecting the cell to 
 very important alterations which obscure the actual state. In the first 
 place, the nervous elements of the cortex involved are the smallest 
 met with ; and, in themselves, are not the most clearly demonstrable 
 in a state of health. Again, attention is likely to be distracted by the 
 less-important changes in cells of greater magnitude, where morbid 
 appearances are more pronounced features. In the next place, the 
 tissue-staining is liable to obscure the early appearance of disease 
 unless cautiously performed, and more especially the employment of 
 osmic acid of too high a percentage, or for too prolonged an action. 
 
 The change in the cell alluded to is not peculiar to epilepsy ; it 
 occurs in other diseases, and especially alcoholic brain-disease, but 
 never to so marked a degree and limited to such special cortical areas 
 as in epileptic insanity. The nerve-elements are not the only ones to 
 present morbid implication, for the connective-element or neuroglia is, 
 as long known, invariably in excess of the normal. To describe the 
 
CHANGES IN NUCLEUS OF NERVE-CELL. 523 
 
 nerve lesion first. The small irregularly-shaped nerve-cells, occupying 
 the position of the second layer of the cortex, exhibit a degenerative 
 change which is so far peculiar that the nucleus of the cell is the 
 earliest portion affected ; the cell-protoplasm being apparently second- 
 arily involved. The centre of the nucleus is occupied by an 
 extremely-bright, highly-refractile, spherical Ijody — obviously of a /a^^y 
 nature. If the cell be stained by the aniline blue-black the morbid 
 body appears as an unstained bright, spherical bead in the centre of the 
 deep blue-black nucleus ; the cell-protoplasm around being in its place 
 differentiated by its lighter staining. In many of the surrounding 
 cells no further change may be observed ; but, closer observation shows 
 that either the refractile body has increased so as to occupy the 
 whole available space in the nucleus, the boundaries of w-hich are still 
 mapped-out by a deep-stained circle, or that two or more of such 
 bright refractile bodies present themselves within the nucleus, or that 
 the nucleus itself is no longer apparent within the cell, the highly 
 refractile body (in size and outline like the nucleus) being its presumed 
 representative {PI. xi., B.). 
 
 Although the more usual aspect presented is that of a bright 
 spherical droplet of oil, it is by no means invariably spherical, but 
 may assume a crescentic, oblong, or irregular contour. Minute as 
 these nerve-cells are, the strong contrast established betwixt the 
 bright lusti'ous centre and the deep blue-black aniline stain of the 
 surrounding nucleus, renders the change so distinct that, when once 
 the attention is directed to it, a 1-inch objective suffices to reveal it 
 readily as a wide-spread change in the series of the second cortical 
 layer of cells. It is not here assumed that cells in other layers wholly 
 escape a similar implication, but that, whilst such a nuclear change 
 may be detected here and there in the small and large pyramidal cells 
 of the succeeding layer, it is not an exceptional, but a most fi-equent, 
 or universal, change in the second layer of the cortex; often every cell 
 within a large field still retaining its nucleus, is seen flashed within by 
 this bright morbid spectrum {PL xi., B.). When the change has pro- 
 gressed so far that one-half of the nucleus is occupied by the morbid 
 substance, the former appears to have lost its selective capacity for the 
 aniline reagent, stains poorly, and is but faintly differentiated from the 
 enclosing cell ; and, as the fatty change proceeds, any remaining nuclear 
 mass presents so delicate a stippled shading that it fades ofi' into tlie 
 cell-protoplasm, and is with difficulty distinguished therefrom, or is 
 wholly lost to view. It is interesting to observe the persistence 
 shown by the nerve-cell despite the degenerative change in its nucleus, 
 and it is only later on in the stage of dissolution that the cell-proto- 
 plasm betrays evidence of degeneration. That the cells ultimately 
 
524 IWTIIOLOGICAL ANATOMY OF EPILEPTIC INSANITY. 
 
 break-down is sufficicnitly evidenced by the paucity of elements in this 
 layer contrasted with wliat is seen in the healthy brain, and by the 
 abundance of fragmentary residue left ]>y the process of disintegration 
 at this level of the cortex. 
 
 The more advanced stage of this fatty nuclear change reveals a 
 VaCUOlatGd condition of the cell, which becomes even a more striking 
 feature tlian the simple fatty change. This vacuolation is evidently 
 attributable to the bursting out from the cell of the globular bead of 
 fatty substance, leaving the cavity containing it as a very conspicuous 
 object of sharp-cut marginal contour. Usually the cell maintains its 
 original contour, whilst a large cavity occupies its centre, as large as 
 is consistent with the capacity of the cell, so that a perfectly spherical 
 outline is maintained within an angular or pyramidal boundary, the 
 merest rim of stained protoplasm (thickest where the processes emerge) 
 bounding this cortical vacuole (PL xii.). At times the escape of these 
 contents involves a large margin of the cell, rupturing and destroying 
 its lateral, or its basal, periphery ; still the remaining protoplasm else- 
 where maintains a rigid skeleton of the original cell, so that little real 
 distortion of the less-affected portion of the cell exists. The evidence 
 of morbid change in the surrounding protoplasm of the cell exists not 
 only in the rigid retention of the form of the enclosed cavity, but also 
 in the presence of pale spots indicating the degeneration of its mass, 
 which are, however, of far less lustrous aspect than the nuclear 
 contents. Scattered amongst the less-diseased cells of this layer we 
 find angular fragments of destroyed nerve-elements, or sheaves of 
 apical processes completely dissevered from any relict of cellular 
 structure. This extreme degree of change, now described as vacuola- 
 tion of the cell, may occupy the whole of the second layer of the 
 cortex; but, in certain cases, it has been found to affect every layer 
 down to the spindle-series of cells inclusive. When the larger cells are 
 the subject of this change, the cell-protoplasm presents aggregated 
 globules of morbid material, obscured by the deeper staining of 
 healthier protoplasm ; yet, pale by contrast, it gives the cell a peculiar 
 rugged mulberry-like aspect. 
 
 The large " ganglionic " cells suffer very unequally in different sub- 
 jects and at different sites. In early stages of implication they appear 
 swollen, and take up an intense staining of their protoplasm, so as to 
 obscure their contents in aniline blue-black preparations. Such cells, 
 in mounted preparations present an unusual relief, with clear-cut 
 contour, very unlike the same cell in a further advanced stage of 
 degeneration, and are much more sharply defined in this state than in 
 health (Fl. xii., deeper layer). Pigmentary degeneration of a limited 
 portion of the cell may be seen, whilst in the darkly-stained protoplasm 
 
EXTENSIVE VACUOLATION OF NUCLEI. 525 
 
 three or four paler spots are seen, somewhat refVactile and gleaming 
 through the superimposed protoplasm. Many of such large cells are 
 swollen and globose, maintain their lateral and basal processes, Ijut 
 have no apical process, or merely a stunted one attached ; they are 
 uniformly stained of a pale tint throughout, the nucleus having dis- 
 appeared. When still further degenerated these cells present a blurred 
 outline, as if from fatty liquefaction of their contents; or an extremely 
 faint ghost-like representative of the cell alone remains. 
 
 With this fatty, nuclear change and vacuolation of the cells of the 
 superficial cortical layer, we observe no associated vascular change ; 
 the vessels may be somewhat coarse, and distended more than usual, 
 but no extreme alteration is observable in the tunics of the vessel, of 
 course excepting such as may be attributable to other agencies, such as 
 the senile or alcoholic degenerations, or the complication of tubercle or 
 of syphilis. Nuclear proliferation along the adventitia is rarely seen 
 in epileptic insanity. In like manner, we do not meet with the 
 presence of sjnder-cells, which permeate the cortex and medulla where 
 vascular lesions afi'ecting the blood and lymph-channels prevail. Thus, 
 in the morbid anatomy of epileptic insanity we find a special freedom 
 from nuclear proliferation, from vascular degeneration, and from 
 hypertrophic states of the lymph-connective system, which obtrude 
 themselves in alcoholic cases and in the subjects of general pai^alysis. 
 
 Patholog'y. — The essential nature of epilepsy is that of an abnormal 
 discharge of nerve-force from the higher cerebral centres in the cortex, 
 an " occasional, sudden, rapid, and excessive discharge " {Dr. Htighlings- 
 Jackson). It matters not, for the essential character of this afliection, 
 whether the phenomena are sensorial almost exclusively or motoiial, 
 whether the sphere of mind is specially involved, or whether there is 
 the fullest development of the epileptic spasm; the essence of the 
 disease consists in this excessive local discharge.'" A nutritive irrita- 
 bility underlies the morbid activity, and invariably expresses itself in 
 some one or other morbid change recognisable in the structural 
 elements of the cortex. As we have seen in such cases of epilepsy, 
 where mental disturbance predominates and actual insanity co-exists, 
 we have a notable affection of a special series of cells, not exclusively 
 seen, however, in this disease, for it likewise prevails in other con- 
 vulsive afi'ections, such as chronic alcoholism wherein spasmodic 
 discharges of nerve-energy are frequent. 
 
 The extensive nuclear degenerations which we have described must 
 issue in the death of the cell. We know little, for certainty, as to the 
 
 * Ou the origin, essential uatiire, ami conditioning factors of the nervous dis- 
 charge, see a masterly analysis in Dr. Charles Mercier's recent work — IVie Mei'vous 
 System and the Mind. 
 
526 PATHOLOGICAL ANATOMY OF EPILEPTIC INSANITY. 
 
 functional endowments of the nucleus, but we may recognise its presence 
 in all conditions of active growth and functional life in the cell, whether 
 it be a nerve-cell or element of other tissues, including the phenomena 
 of karyokinesis. With its atrophy and disappearance we find associated 
 declining functional activity and ultimate degeneration of the cell 
 itself. We have seen elsewhere that there is much reason for re- 
 garding the cells which prevail in this layer of the cortex, as per- 
 taining to this sensory type of nerve-element, and that an organic 
 connection subsists betwixt them and the large motor elements dis- 
 tributed at a lower level ; in fact we may, perhaps, regard these 
 individual layers as constituting a highly-complex sensory-motor arc, 
 of which they are the respective poles. What is the functional 
 relationship existing between these elements ? That these presumed 
 sensory units have an inhibitory control over the subjacent elements, 
 and that, lacking such control, their discharge will be subjected to the 
 periodicity of the nutritive rhythm is very probable. The changes 
 presented by the cortical nerve-cells have long led us to regard the 
 nucleus as subserving an important role in the functional activity of 
 the cell ; that its displacements, distortion, degeneration, enfeebled 
 vitality,* and its absence are constant accompaniments of cerebral 
 disturbances characterised by loss of inhibitory control.^ 
 
 From this point of view, we have been accustomed to regard the 
 proportionate size of nucleus to nerve-cell as indicative of the inhibitory 
 controlling capacity of the cell in question — its own resistance to dis- 
 charge. Hence, these minute elements with large nuclei in the second 
 layer would possess a far higher degree of resistance to nervous discharge 
 than those of lower levels, in which the nucleus bears a far smaller 
 ratio to the surrounding cell-mass. Thus in these higher levels nerve- 
 discharge would be impeded, and the resistance and time-element charact- 
 eristic of the mental operations would come into play. Certain it is 
 that in such cases whei'e nuclear degeneration has proceeded far in this 
 layer, there is a motor and mental instability characterised especially 
 by periods of nutritional rhythm. In like manner, the cells of the 
 motor area are proportionately large, and subserve the function of 
 storage of motor energy ; but their nucleus is small in proportion 
 
 * As probably ilhistrated in its feeble staining to usual reagents. 
 
 t Nor is this supposition opposed to the results of Kussniaul and Tenner upon 
 the effects of sudden loss of large quantities of blood. Suddenly-induced anaemia 
 hy withdrawing the requisite pabulum would directly affect the nuclear centres of 
 cell-life, which are recognised as actively operative in the nutrition of the cell ; 
 the withdrawal of such pabulum would be equivalent to a total arrest of such 
 function, to the virtual paralysis resulting in the discharge of nerve-energy from 
 the cell expressed, on the mental side in loss of consciousness, and on the physical 
 side in general convulsions. 
 
THE MORBID NERVE-CELL IN EPILEPSY. 527 
 
 thereto, and their resistance to discharge consequently slight, their 
 functional equilibrium is more readily affected ; their greater mass 
 requires augmented nutritive resources to reinstate them subsequent 
 to their discharge (Ross). 
 
 It has already been indicated in discussing the etiological relation- 
 ships of epilepsy that heredity plays a prominent role, and that epilepsy, 
 direct or collateral, occurs in a large proportion of cases; with these 
 are associated ancestral intemperance, which likewise is an important 
 factor. It becomes, therefore, a question worthy of consideration 
 whether we have here to recognise in the structural modification of the 
 cell the physical basis of such hereditary transmission; is it probable 
 that the nuclear and cellular change bears the imprint of ancestral 
 vice? That the inflated spheroidal cell of epileptic idiots is a distinct 
 reversion (or, at least, an undeveloped stage) is doubtless true; not only 
 does its conformation indicate its lowered type; its degenerated proto- 
 plasm a sustained nutritional anomaly; its paucity of branches a 
 restricted relational element of cell-life; and its nuclear change in form 
 and position some vital peculiarity inconsistent with the normal 
 activity of the cell : but we also have evidence of reversion in its case, 
 in the appearance of such cells {i.e., of inflated spheroidal elements with 
 few processes) in some lower forms of life, and we have elsewhere indi- 
 cated their existence as a normal element in the cortex of the ape.* 
 We see no reason, therefore, for doubting that when such cells occur in 
 the cortex of a class who also bear the history of ancestral vices, such as 
 epilepsy and drink, that it is the expression of a reversion to a more 
 primitive type so induced. 
 
 Here, however, we must distinguish betwixt idiopathic epilepsy in 
 the adult, and those forms which are clearly due to gross central 
 change, or such cases where epilepsy is but the accidental accompani- 
 ment of developmental arrest. The onset of epilepsy in early life is 
 recognised as highly ominous to the mental well-being, and it is 
 undoubtedly an established fact that, although in adult life in 
 exceptional cases, epileptic seizures may co-exist with great intellectual 
 vigour, yet its occurrence during periods of active cerebral develop- 
 ment in infancy and youth is attended by a profound change in such 
 activities, and usually in their total arrest. This fact is often expressed 
 in such terms as to imply apparently that the "fits" — i.e., the convulsive 
 seizures themselves — are the agencies whereby the cerebral activities 
 underlying mental evolution are injuriously affected. It must, how- 
 ever, be borne in mind that the convulsive discharge in itself is not the 
 factor in the arrest, but simply betrays the nutritional impairment (in 
 itself the origin of the convulsive discharge, and, at the same time, 
 * Trans. Roy. Soc, he. cit. 
 
528 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 of arrested evolution). It is in the structural peculiarity of the cell 
 that we must learn to recognise the origin of the convulsion, and 
 of the stunted mental development which such vicious conformation 
 symbolises. 
 
 On the other hand, in forms of idiopathic epilepsy arising subsequent 
 to the attainment of adult life, the more striking feature presented to 
 our notice is the degradation of mind — its gradual obnubilation by 
 progressive dementia. Are we prepared to recognise such distinction 
 in the histological elements of the cortex? We think there can be but 
 little doubt that in the latter cases {dementia) we simply witness a 
 degenerative affection of the nerve-cell, which, apart from this, betrays 
 evidence of a full developmental constitution. In the former (epileptic 
 idiocy), however, we find an altered type of cell, a limitation of its 
 connecting meshwork, and a conformation so decided as to at once 
 indicate the distinction. Yet, underlying both forms, we still recognise 
 that disparity betwixt nucleus and protoplasm, and the displacement 
 or degeneration of the former, which to us appears to bespeak a 
 convulsive constitution. 
 
 PATHOLOGY OF CHRONIC ALCOHOLISM. 
 
 Contents. — Morbid Change iu Cerebral Vessels — Scavenger-Cells in Outer Zone of 
 Cortex — Sclerosis of Outer Zone — Amyloid Bodies beneath Pia — Implication 
 of Motor and Spindle-Cells — Significance of these Changes— Deepest Layers 
 more generally Involved — Early Vascular Implication— Aneurysmal Bulgings — 
 Atheromatous and Fatty Change — Pigmentary Degeneration of Motor Cells — 
 Scavenger-Elements in Spindle-Layer — Degeueratioa of MeduUated Nerve- 
 Fibre — Sx^inal Lesions— Vascularity — Hypertrophy of Tunica Muscularis an 
 Inconstant Feature — Eelationships to Chronic Bright's Disease — Sclerosis of 
 White Columns of Cord — Spinal Degenerations in Ty^ncal Case — Implication of 
 Clai'ke's Column — Immunity from Multiple Neuritis — Neurotic Heritage — 
 Chronic Endarteritis— Fatty and Sclerous Tendency — The Brain of the Criminal 
 Class — Exceptional Resemblance to General Paralysis — Coincidence of Grandiose 
 State and Delusions of Persecution — Inconstant Vertical Implication of Cord — 
 Constitutional State that of Chronic Bright's Disease — Exceptional Transition 
 to Genei-al Paralysis — Significance of Arterial Changes — Affection of the 
 Visceral System. 
 
 The vessels dipping into the cortex from the pia are of undue size, 
 coarse, and frequently tortuous, and their coats are in advanced stages 
 of atheromatous and fatty change. The nuclei of the adventitial sheath 
 are somewhat numerous, are freely proliferating, or their protoplasm is 
 in a state of fatty disintegration (PL xvi.. Jigs. 1, 2). Far the more 
 prominent feature, however, is the abundance of scavenger-cells which 
 pervades the upper or outermost region of the peripheral zone of the 
 cortex lying immediately beneath the pia ; these nucleated proto- 
 
Plate XV: 
 
 iall ancjizLar cells of 4^^-^ lay tr —-jk «ifV)'l ^cff^ 
 
 PefwasculaT izzzclei 
 PeTtvasciilar niiclei 
 
 Moior ISferve-cell and ,.-■ 
 its mzt-riei'd -■rescel 
 
 ■De^eneraiion of Apejc process 
 
 •:** ti 7VeT-ire -ceZZ zxncierqoiTiq 
 -»,'•;■--•?»■ — 7 7 , . -^ 
 
 •• ^^ granuLar cLe^ene-rcLZ-LOTL. 
 
 ' J)LsecLsecL OL-rie-riol&. 
 
 
 Gr an.iilaTr iegener aiioii of T>Ter"\re - cells itl fif-tli lawyer of 
 IvToioir Coi:te:K: ^^itli pirolif eTatioxL of peT#cell-u:lax &-p>eri = 
 ^asc"ulaT TLitclei in a case of Clironic Alcoliolic InsarLity. 
 
 X 210 . 
 
 SpxdeT cells p-rclxfe-raivno. 
 
 \ iDngeTieratinj Nerve- cell 
 *M.--"devoxd ofmicleizs. 
 
 )(\ 
 
 ^:^^^ 
 
 FeriYascixlar'TaxcleL crawdinc 
 -Lvpon irralls of hlood vesset. 
 
 Fii.2. 
 
 J^-olifeTaizon. of _^ 
 
 -nuclei on iii= " f] 
 '■si-foTn-L cells \1 
 
 Axieiari sirtal cliia tation of 
 PeriA^ascular sac. 
 General Paralysis. 
 X 210.. 
 
 Cftan^es in deepest or Spinile cell layer 
 of launxan Cortege. 
 Chronic Alcoliolic Insanity. 
 xl80. 
 
 T)aTiiel3S0TLik Co, sc-ilp . 
 
CHANGES IN OUTER ZONE OF CORTEX. 52& 
 
 plasmic bodies are everywhere seen, their branching processes forming 
 a dense matting which converts the outermost fourth of this cortical 
 layer into a closely-felted substance of minute meshes, the aspect of 
 which differs strikingly from that normal to this region {PL ix.,Jig. 1). 
 Whenever a blood-vessel passes downwards through the cortical layers, 
 these scavenger-cells are more numerous, following the line of vascular 
 channelling, and so dipping down into the nerve-elements of the 
 second layer. The appearance forcibly reminds one of the increase of 
 connective passing along Grlisson's capsule in a sclerosic state of the 
 liver. 
 
 This felted structure is always most dense immediately beneath the 
 pia, where it is so far condensed as to take a deeper staining of the 
 reagent quite recognisable to the naked eye. The depth of the whole 
 peripheral zone is also perceptibly diminished, the outer fourth being 
 distinctly mapped-off from the rest by its deeper tinge. We meet 
 with this development in different stages; occasionally the cellular 
 element predominates — young scavenger-cells are numerous, their fine 
 extensions being widely scattered and sparse ; in other cases the cells 
 are found of larger size, forming plump, amoeboid elements, from which 
 radiate processes pass into a fine meshwork around ; still later, the 
 protoplasmic masses have dwindled down or totally disappeared, 
 leaving simply the dense, felted, fibrous structure profusely besprinkled 
 with the still remaining nuclei {PL ix., /iff. 1). Beneath the pia, 
 betwixt it and the surface of the cortex in the so-called eincerehral 
 space, we often find a vast' quantity of amyloid bodieS, and the fact 
 that these are abundantly recognisable in fresh sections from frozen 
 brain is a sufficient refutation of the assumption that such bodies are 
 not of morbid nature, but artificial products of alcoholic reagents used 
 in preparation. Here and there along the walls of a blood-vessel a 
 little heap of proliferating nuclei is seen, from which fibrous extensions 
 pervade the cortex on all sides, giving the vessel a peculiar spinous 
 aspect. 
 
 The perivascular space is also seen distended by numerous lymphoid 
 elements, and the nuclei of the sheath are often mapped-out by a 
 linear series of oil-globules which alone remain to represent the 
 degenerated element. Critically examining the second and third 
 layers of the cortex, we find no very prominent lesion — a few of the 
 lower pyramidal cells may be degenerate — but, until we reach the fifth 
 layer of motor cells, no very obvious change is apparent in most cases 
 {PL xyl,flcj. 1). 
 
 These large cells, however, are in an advanced stage of fatty change, 
 and together with the layer of spindle-cells immediately beneath, are 
 undergoing extensive disintegration and absorption {PL xvi., fig. 2). 
 
 34 
 
■530 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 Can we explain this apparent anomaly of the escape of the superjacent 
 layers of nerve-cells, and the extensive implication of the outermost 
 and deepest layers betwixt which they lie ? A special selection of 
 certain layers by the morbid process appears to be evident here ; and 
 may be a fact of great significance. 
 
 In the first place, we must call to mind the fact, that the outermost 
 cortical layer represents the apical distribution of the large, deep- 
 seated cells which have been presumed to possess motor endowments ; 
 and that their poles, therefore, are (in the early stage of general 
 paralysis, as well as in alcoholism) affected by the sclerosic change 
 proceeding in the outer layer of the cortex, and that these cells are, 
 therefore, affected by a degenerative change ere the morbid process 
 extends deeply into the small elements of the second and third layers. 
 But simultaneously with this an invasion of cortical-elements also 
 takes place from below — i.e., from the medulla of the gyri, and this 
 morbid process spreading upwards involves both spindle and motor 
 elements successively. 
 
 The cerebral cortex presents, therefore, in such cases very notable 
 morbid change ; and one specially characterised by the greater 
 concentration of the lesion in motor realms of the hemisphere, as well 
 as by a somewhat definite restriction to certain layers of the cortex, to 
 the exclusion, more or less, of the other layers. The deepest 
 cortical layers are those more especially affected ; cases being met 
 with where the uppermost layers show no morbid indications 
 whatsoever. 
 
 The vascular, nei"vou3, and connective elements all participate in 
 the change, and it thus becomes of interest to learn which of these 
 tissues is primarily involved and, therefore, plays the more important 
 role in establishing the pathogenesis of chronic alcoholic insanity. A 
 careful study of a series of such cases would lead one to infer that the 
 vascular is the first tissue involved in the morbid evolution. The 
 long, straight vessels of the cortex are peculiarly liable to these 
 changes, and where they dip down deep into the spindle-series of cells, 
 such vessels present gross lesions of their tissues, as also of the 
 immediate neighbourhood around. 
 
 The vessels themselves are enormously and unequally distended, 
 showing numerous ampullae or aneurysmal distensions, usually fusiform 
 in character, their tunics crowded with nuclear proliferation. Care- 
 fully-prepared sections of frozen cortex often appear riddled by a large 
 number of circular holes, with sharp-cut edges, as if punched out of the 
 brain-tissue; or by long fusiform channels, the site of diseased vessels 
 which may have dropped out ; or still convey distended vessels, the 
 walls of which are mottled by atheromatous change, whilst a peculiar 
 
IMPLICATION OF NERVE-CELLS. 531 
 
 albuminoid material (unstained by aniline) fills their cavity or is 
 effused around their ruptured orifices. The nervous, as well as the 
 connective, elements of the upper three or four layers of the cortex 
 may exhibit no morbid change, but at the site of the large, so-called 
 motor cells, constituting the clustered groups of the central gyri, we 
 discover a notable degeneration. These great nerve-elements are 
 much swollen and rounded in contour, and, in lieu of their usual 
 extremely delicate protoplasm, present a rough granular aspect inter- 
 nally, which often takes an intense staining from aniline, leaving a 
 portion, however, quite unaffected by the reagent and of a coarsely 
 granular and often yellowish hue {PI. xvi., fig. 1). Such cells are 
 frequently seen deprived of their apical processes by a veritable 
 degeneration. At its connection with the cell itself this process 
 may be greatly and irregularly swollen and pigmented, beyond 
 which a sudden attenuation occurs, and, after a slightly-contorted 
 course, it disappears entirely (see several instances in PI. x.yi.,fig. 1). 
 Another appearance universally presented by these degenerate cells is 
 the abnormal, coarsely-defined boundary-wall of the cell, which, as we 
 know, does not exist as a separate constituent in the normal cell of 
 health, or, at all events, cannot be difierentiated from the protoplasmic 
 contents in fresh-prepared sections from frozen cortex. The formation 
 of this cell-wall, betwixt which and the enclosed protoplasm a mass of 
 pigment collects, the former shrinking as the latter encroaches upon the 
 cell-contents, is a constant feature in all cases of alcoholic degeneration 
 of the cortex ; it brings the cell into a peculiarly notable relief, which 
 is observed in other degenerative affections of the cortex. These large 
 degenerate cells have usually several short, stunted, and swollen 
 processes to which nuclei adhere. Three-fourths of their cavity may 
 be occupied by coarse, granular, golden pigment, and the stained 
 protoplasmic residue exhibit a few glistening refractile oil-globules, or 
 one large circular cavity (vacuole), from which such oil-globules have 
 forced their way out, the protoplasm in such a case not filling the 
 vacuum. 
 
 Down in the lowest layer of the series — the spindle-cell formation — 
 we come suddenly upon large developments of scavenger-cells, which 
 above this level were not apparent. Such elements, characterised by 
 their spider-like appearance, are scattered profusely upon the coarse 
 blood-vessels of this region (above referred to), and extend their rami- 
 fying processes in all directions around (PL xyL, fig. 2). The spindle-cells, 
 moreover, are themselves covered by heaps of nuclear proliferations 
 which often entirely conceal them from view, so that their position 
 and course are usually mapped-out and alone indicated by these little 
 nuclear accumulations. One is also struck by their greatly diminished 
 
532 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 number, and by their frequent pigmentary change where the cell- 
 contents are visible. The conclusion forced upon us by the appear- 
 ances presented is that they are undergoing rapid degeneration and 
 removal through the agency of the scavenger-corpuscles, which, as 
 previously explained, act in the capacity of "phagocytes," and devour 
 the nerve-elements. In PL :x.Yi.,Jig. 1, representing the large motor 
 cells, we observe three large elements with truncated summits under- 
 going marked degeneration. Above, there is a similar cell, in which 
 the greater part of the apical process is pigmented yellow, whilst at 
 its base a coarse vessel, crowded with a heap of nuclei, is seen. 
 Many small cells are also scattered about, covered with a rich nuclear 
 proliferation. In fig. 2, which represents the same cortex but at a 
 lower level, the spindle-cell formation is seen, sparsely scattered with 
 nuclei, but the site of a rich colony of scavenger-corpuscles. The 
 paucity of the spindle-cells, which, at this site, should be most abun- 
 dant, is well seen in contrast with a section taken from sensory realms 
 where scavenger-cells are not formed (to the right and below in fig. 2) ; 
 the cells are not pigmented, but are covered with nuclei. The basal or 
 axis-cylinder process of these large motor cells is a very persistent struc- 
 ture in most degenerative aff"ections of the nerve-cell ; and, as we have 
 seen, whilst the apical process readily breaks down and degenerates at 
 an early stage, we yet find that this axis-cylinder process jiersists. If, 
 however, the medullated nerve-fibres passing up from the medullary core 
 of the gyrus into these lower regions of the cortex be examined, a very 
 striking change is apparent. In fresh sections of healthy bi-ain these 
 fibres are not stained by the aniline method ; the medullated sheath 
 prevents the reagent gaining access to the axis-cylinder. In certain 
 degenerative conditions, however, a change occurs in the medullary 
 investment, probably of a fatty nature. The medulla is removed or 
 greatly attenuated, so that the axis is exposed and stained readily by 
 this reagent, and then it is apparent that the axis-cylinder is itself 
 greatly swollen and often irregularly fusiform. The identical appear- 
 ance is also observed in senile decay of the cortex, and here often 
 to a much more striking degree than in alcoholics. Upon the medul- 
 lated investment, where it appears, spider-cells are often seen abun- 
 dantly ramifying. The medulla of the convolutions in cases of chronic 
 alcoholism, therefore, presents very notable divergence from the normal 
 appearance, which at once arrests the attention in preparations of fresh 
 brain, stained by the aniline methods, the straight axis-cylinders being 
 prominent objects crowding the field in bundles which can be traced 
 for great distances through the medulla. 
 
 On scanning the white matter, we are also struck by the large 
 number of extremely coarse dilated vessels, which afibrd us evidence 
 
VASCULAR LESIONS — SPINAL IMPLICATION. 533 
 
 also of grave structural change. These nutrient twigs are not only 
 generally dilated, but present along their course frequent fusiform and 
 sacculated aneurysmal distensions, often of large size, the coats of which 
 are notably diseased. These aneurysmal sacs in many cases will have 
 fallen out of the section, giving rise, as described in the cortex 
 above, to clean-cut circular or fusiform openings, which are often very 
 numerous in such subjects. The sacculated dilatation is often the site 
 of a large accumulation of hsematoidine granules which crowd its 
 interior, and are scattered profusely over its surface. Occasionally the 
 vessel is seen plugged (possibly by a fatty embolus) ; the proximal 
 distended part may have ruptured, extravasated blood and hsemato- 
 idine crystals crowding the field around; or a more frequent appearance 
 (seen, in fact, universally over the field) is the distended vessel with 
 the intima in a state of atheromatous and fatty Chang'G, and the 
 nucleated element of the sheath also undergoing fatty disintegration ; 
 the walls covered with young* spideP-CellS, and bristling with their 
 processes on either side (PL x.Yi.,fig. 2). 
 
 Large patches of fatty material containing oil-globules and granules 
 are seen along the coats of the blood-vessels, in fresh-stained aniline 
 preparations. As unstained, colourless, and highly refractile spots, 
 contrasting with the healthier and stained tunics around, such patches 
 have a swollen, semi-opaque aspect. All the more degenerate nutrient 
 twigs are the site of a rich colony of scavenger-cells in their various 
 phases of development and retrogression ; such elements often look 
 like simple nuclei, until, carefully focussed, their delicate protoplasmic 
 mass and radiating processes are discerned. These scavenger-elements 
 are traced in great abundance throughovit the white matter of the 
 convolutions. 
 
 Plugged vessels, also, appear frequently ; the tissue on either side 
 being often deep-stained and sclerous in character, and the axis- 
 cylinder in the neighbourhood unduly large and ii-regularly swollen. 
 The medulla shows a patchy staining of its ground-work to low powers, 
 which on the use of higher objectives is resolved into light, unstained 
 areas having few or no nuclei, and darker stained areas of a fine- 
 punctated aspect (the result of fibrillated spider-cells), amongst which 
 are many nuclei. 
 
 Spinal Cord. — Throughout the whole extent of the spinal cord we 
 find increased vascularity or, at least, a more obtrusive presentation of 
 vessels than is normally observed here. The vessels supplying the 
 posterior columns are those most afiected, those of the anterior 
 columns least involved, whilst the lateral tracts suffer almost as 
 frequently as the posterior. These nutrient branches become pro- 
 minent objects by reason of the great increase in the thickness of 
 
534 PATHOLOGICAL ANATOMY OP ALCOHOLISM. 
 
 their walls ; a feature which is exceptionally striking with respect 
 to the smaller vessels between 4 /x and 8 /i in diameter, the open 
 lumen of such divided vessels rarely being over one-third or one- 
 fourth the whole dia^meter; but vessels measuring respectively 18 /x 
 and 36 /i across also have not infrequently a lumen of but 5 /x to 10 /i. 
 This increase in thickness is seen to be due entirely to their muscular 
 coat, which in small vessels of 8 /a, diameter will attain the thickness of 
 2 (h. The increase in the muSCUlariS encroaches much upon the 
 cavity of the vessel itself, and the non-elastic intima is conse- 
 quently thrown into a plaited form, or has a condensed deeply-stained 
 appearance mapping it off from the tunica media ; occasionally, the 
 vessel is occluded by this increase in its muscular tunic. 
 
 It is not all cases of alcoholism that exhibit this notable thickening 
 of the muscularis ; for in some we observe far less concentration of the 
 disease upon the vascular supply of the cord than upon the vessels of 
 the cerebral cortex. The following averages represent very conclu- 
 sively the dimensions of the lumen relatively to those of the arterial 
 tunics in cases where spinal symptoms were a notable feature, as con- 
 trasted with those in which no special symptoms presented them- 
 selves : — 
 
 Vessels in Chronic Alcoholic Insanity. 
 
 Presenting Spinal Symptoms. i Cases Devoid of Spinal Symptoms. 
 
 Whole Diameter of I Diameter of 
 
 Vessel. Lmnen. VesseL Lumen. 
 
 18 /u 5 m 
 
 27 /x 9 M 
 
 37 /^ 10 ^t 
 
 18 m 13 /u 
 
 27 M 23 M 
 
 32 M 19/11 
 
 The change in these vessels appears to be identical with that 
 increase of the muscularis which has now been long recognised in 
 chronic Brig'ht's disease, since its discovery by Dr. Geo. Johnston ; 
 no notable fatty change implicates the intima; the vessels do not 
 here, as elsewhere and in the brain, necessarily show atheromatous 
 degeneration ; nor does the adventitial sheath betray evidence of a 
 reactive inflammatory condition. The immediate environment of the 
 vessel shows, in most cases, a normal condition, beyond the prevalence 
 here and there of amyloid bodies in juxtaposition to the vessel. Occa- 
 sionally these bodies become very profusely scattered throughout the 
 whole extent of the white columns of the cord, more especially around 
 its periphery and following inwards the direction taken by its nutrient 
 branches. In these latter cases we find, however, indications of an 
 inflammatory change — a chronic meningitis; the pia being often greatly 
 thickened, its vessels much distended, and its meshes containinsf 
 
Plate XVII. 
 
 S-pider -cells follo-ivinq i^asciilar trad 
 
 Coarser- vascular 
 hraricKes of 
 S-pider- cell. 
 
 Spider cells with, lona 
 deliccLze fibrils. 
 
 Flexus of finer fibrils. 
 
 Scaven.ger eleiaents (Spider- cells) in p eri^plieTal zone 
 ox- 1^ layer of tlie Coxtex — IxxanaxL "braixi.. 
 
 X 240 . 
 
DISTRIBUTION OF SPINAL LK.SIONS. 535 
 
 leucocytes and inflammatory products. The connective trabeculse 
 extending from the pia into the substance of the cord are extremely 
 coarse, and a diffuse sclerosis thus originating often affects all the 
 medullated tracts of the spinal cord. Thus, the peripheral zone of the 
 cord is especially implicated ; and the sclerous tissue follows more 
 readily the course of the larger blood-vessels, so that the median raphe 
 of the posterior columns is a favourite site of this sclerous change, 
 which often extends over the whole of the columns of Goll. The 
 coarse deep-channelling by blood-vessels, and the profusion of scavenger- 
 cells, give to the posterior columns a notably morbid aspect. In a 
 typical case examined the antero-lateral columns were extensively 
 implicated ; the pia was greatly thickened ; and a patchy diffuse 
 sclerosis affected the anterior root-zone, and the lateral columns, together 
 with its direct cerebellar tract. The various segments of the cord also 
 showed much irregularity in distribution of the morbid change, and 
 the non-systematic nature of the lesion was clearly demonstrated. 
 The posterior nerve-roots, also, indicate a similar interstitial change ; 
 bundles of atrophied nerve-tubuli being seen imbedded in much deep- 
 stained connective-tissue. Atrophic changes, also, had involved the 
 cell-groupings of the anterior cornu ; and the postero-lateral group in 
 the cervical region on one side was notably affected, few cells remain- 
 ing, and these degenerated as the result of the invasive sclerosic 
 tissue. The intermedio-lateral group was (in the lower cervical) in a 
 similar state of degeneration on the side corresponding to marked 
 sclerosis of the lateral column. 
 
 The intermedio-lateral group of cells appears peculiarly prone 
 to degeneration, and other cell-groupings — e.g., the antero-lateral and 
 the internal of the anterior horn on the same side are thus in like 
 manner involved. Clarke's vesicular COlumn is likewise liable to 
 implication in these affections. Cornual changes are by no means 
 infrequent, and are of special interest here in relation to the implica- 
 tion of special cell-groupings which are apt to present themselves. 
 Thus, in the dorsal region, it is not unusual to find the cells of the 
 intermedio-lateral column of one side plump and healthy ; those of the 
 opposite side being utterly degenerated in the midst of a dense sclerous 
 tissue ; the same unilateral lesion of Clarke's vesicular column may also 
 be observed. In the former class of cases, the naked-eye appearance 
 presents no abnormality in sections across the cord, and it is only in 
 the second series, where wide tracts of connective trabecule traverse 
 the columns of medulla, that we appreciate morbid change; which is still 
 more apparent when the stained section is cleared up and examined. 
 That the posterior nerve-roots do occasionally participate in the change 
 has already been stated ; but, that the spinal changes originate in the 
 
536 PATHOLOGICAL ANATOMY OP ALCOHOLISM. 
 
 affection of the peripheral nerves is by no means probable ; they must 
 be regarded as coincident affections. Frequent as multiple neuritis is 
 amongst chronic alcoholics of the female sex, we do not recall any 
 cases occurring in alcoholic insanity. That it is occasionally met with 
 we do not doubt, although the jjercentage of insane females subject to 
 chronic alcoholism is small ; but we must bs prepared to regard cases 
 of chronic alcoholic insanity as presenting predispositions which more 
 or less modify the tendency to peripheral implication of the nervous- 
 system. Whatever ])e the explanation of this paucity of cases of 
 multiple alcoholic neuritis amongst the insane community, certain it 
 is, that alcohol in these predisposed subjects does tend to concentrate 
 its operations chiefly upon the vascular membranes, first, of the brain 
 and, next, of the spinal cord. 
 
 Patholog'y. — The pathology of alcoholic insanity is but one chapter, 
 though not the least important, in a long history of retrogressive 
 changes to which the whole organism is subjected through the 
 prolonged operation of this agent. Through the medium of the blood- 
 vascular system, alcohol, by its ready absorption and permeability, is 
 rapidly conveyed to the most distant parts of the organism, establishing 
 wide-spread constitutional disturbances; whilst through the peculiar 
 selective capacity of the nervous centres for this poison, it thereupon 
 expends its primary and most potent influence. Although in all cases 
 the nervous centres bear the chief brunt of its attack, it by no means 
 follows that the subjects of chronic alcoholism suffer in the same way. 
 In one, the gastric; in a second, the hepatic; in a third, the renal and 
 cardiac symptoms may come to the front; whilst in others, the nervous 
 centres express the special ^■irulence of the agent in their direction. 
 Undoubtedly a neurotiC heritag'S plays a foremost part in thus 
 predisposing to more exclusive determination of the morbid agency 
 upon the higher nervous centres, just as those subjects predisjiosed to 
 renal degeneration will, on the establishment of alcoholism, display the 
 usual cardio-vascular changes of chronic Bright's disease. Beyond the 
 limits of simple functional hyper-activity of the nervous centres induced 
 by frequent indulgence in alcoholic drinks, its persistent use leads to 
 organic change, first expressed in the vessel's wall by the direct 
 irritating effect of the spirit on its tissue elements. A chronic 
 inflammatory state leading to extensive atheromatous and fatty 
 degeneration of the intima is the first apparent effect, associated with 
 which we find parallel changes undergone by the adventitial sheath in 
 the increase and fatty degeneration of its elements. Fat-emboli are 
 frequently established in the smaller cortical vessels during the progress 
 of these changes, and the extensive dilatation and aneurysmal states 
 described above are probably direct results of the diminished resistance 
 
CIIHONIC ENDARTERITIS — STEATOSIS AND SCLEROSIS. 537 
 
 of the vessel, and paralysis of its muscular coat. An extensive 
 endarteritis of a most chronic and insidious chai-acter affects the 
 ultimate terminal radicals of the cortex, and, with the pre-existing 
 change in the composition of the blood, leads to the devitalisation of 
 the nervous tissues, undermining the nutritional stability of the nerve- 
 cells. The subsequent change in the interstitial tissue around, and 
 the nervous elements themselves, apparently depends much upon the 
 subject's predisposition, which seems to be the chief determining factor 
 in engendering the fatty or sclerous change which characterises these 
 two classes of alcoholic subjects. In all alike, however, we find the 
 tendency to a degradation of tissue in the replacement of the normal 
 elements by new connective growth; but in some we find a special 
 tendency to extensive fatty change in the nervous centres, so that the 
 parallel degeneration seen elsewhere, as in the fatty or the sclerosed 
 liver, seems to be also reproduced here. It is probable that the fatty 
 change is altogether a tnore acute process, and the sclerosis the result 
 of a much slower and more gradual poisoning of the tissues; the fatty 
 Chang'e, moreover, is much more liable to be induced in the case of 
 senile alcoholics. We may take it, that the changes observed in the 
 cerebral meninges as well as in the soft investment of the cord, when 
 affected, are undoubtedly indicative of a very chronic inflammatory 
 action proceeding in the vessels of the membranes, and slowly involv- 
 ing the upper cortical strata ; for thus only can we explain the frequent 
 association of membi-anes opaque and thickened, and the permeation of 
 the cortex along the vascular tracts by dense connective networks. 
 Much of the opacity of these delicate membranes is undoubtedly the 
 resulting change of years of excessive indulgence, for it is induced 
 slowly in all cases of long-continued alcoholic indulgence, apart from 
 the establishment of actual insanity; thus, in most criminals, who 
 are notoriously addicted to drinking, we discover such opaque and 
 thickened membranes, and this usually in the postero-parietal regions 
 of the brain {Henry Clarke). 
 
 Coincident with this implication of the membranes, a similar 
 change is found throughout the nutrient supply of the medullated 
 substance of the convolution, which, as before stated, leads to im- 
 portant changes in the lowermost series of nerve-cells, the spindle- 
 layer and the medullated nerve-fibres themselves at this site. It is 
 obvious, upon examining several cases, that the one site may be 
 chiefly affected to the greater or less exclusion of the other, and that, 
 thus, a sclerous change in the peripheral zone of the cortex may 
 preponderate over any morbid change at a greater depth, or that this 
 deeper implication may be the more expressed feature, the pia- 
 arachnoid being free from notable opacity and thickening. It is 
 
538 PATIIOLOOICAL AN'ATOMY OF ALCOUOLISM. 
 
 moi'e usual, however, to find both areas ail'ected, and this to a pro- 
 found degree. Certain cases of chronic alcoholism approach, as we 
 have seen, in their clinical features, the history of general paralysis ; 
 and when we come to the morlnd anatomy, we find the membranes of 
 the brain often presenting similar appearances, both as regards naked- 
 eye aspects and distribution of lesion. The vascular implication, 
 however, is far different, and cannot be readily confused. In the one 
 (alcoholism) the morbid change is centred in the atheromatous state 
 of the inner coat ; the numerous bulgings and fusiform dilatation 
 being also highly characteristic of this chronic inflammatory implica- 
 tion. The outer or adventitial investment does not show the 
 enormous nuclear proliferation which is so notable a feature in 
 general paralysis (P/. xvi., fig. 3); although in degenerated vessels 
 it will be the seat of a profusion of scavenger-cells which entangle 
 its walls in their processes. In the other (general paralysis), as 
 previously stated, the morbid change is concentrated in the adven- 
 titial sheath, and is a far more acute irritative process in the loose 
 external tunic of the vessel, which explains the more rapid implication 
 of the nervovis structures lying immediately around by direct 
 extension. It is on this limitation of the more gross change for 
 a time to the inner tunic of the hlood-vessels in chronic alcoholism, 
 that the slow (yet progressive) impairment of nutrition of the nerve- 
 centres depends, which so frequently issues in steady enfeeblement 
 of the mental faculties, akin to the advancing imbecility of senile 
 atrophy, in which similar changes of the vessel's wall occur. It is, 
 on the other hand, in the early implication and rapid spread of morbid 
 activity along the adventitial tunic of the vessels that the more acute 
 changes are induced in the nerve-cells of the cortex in the general 
 paralytic. When, however, superadded to the intravascular lesions, 
 we find sclerous tissue permeating the peripheral zone of the cortex, 
 we have an invasion of those most externally-disposed medullated 
 fibres which are also involved in general paralysis {PI. y.\.,fig. 1). It is 
 in such cases, probably, that the mental symptoms assimilate to those 
 characteristic of general paralysis. The sclerous shrinking of the 
 new connective formation around the extensions from the under- 
 lying ganglionic cells, results in a degeneration which is ultimately 
 transferred to these cells themselves, inducing the already-described 
 pigmentary and fatty degeneration preceding their absolute destruction 
 and removal ; but, this extensive atrophy of these large elements of 
 the cortex is coincident only with the most advanced fox'ms of 
 alcoholic dementia ; the earlier stage of vascular impairment, and 
 the growth of young scavenger-cells in the periphei-al zone, ere the cells 
 are themselves involved, being apparently associated with the maniacal 
 
Plate XVIII 
 
 Swollen, degeneraied 
 ITerve-ccll. 
 
 Vascular p-rocess 
 of Svider-cell 
 
 i 
 
 
 
 S-pinoTzs eoctensions Jrorr^ 
 va.scu.lccr walls. 
 
 -De gender diiTtp ITeTve.- 
 celLs o-iia-cked. hxr 
 
 3n^.i'>-~-cell€. 
 
 S-pvdLer-ce.ll v/iiK Us 
 ■va-scvcLar px.ocess. 
 
 Ariertcle. surrozzn^ded hu- 
 Spi,djer elemenis. 
 
 -Defeneration of Nerve - cells in Corterc 
 with proliferation of the Spider or Scavenger- cells. 
 Section from ftfth Cortical layer m Motor recicn. 
 
 X 210. 
 
NATURE OP THE SPINAL IMPLICATION. 539 
 
 excitement and early delusional perversions of alcoholism. It is 
 certainly a remarkable feature that in both afiections we get a 
 similar implication of the vascular channels of the pia over the 
 almost identical motor realms of the cortex ; that in both, the same 
 nervous elements are primarily involved ; and that, clinically, there 
 are presented to us so many features in common between the two 
 afiections, that it often becomes a moot point for diagnosis. This 
 peripheral implication of the cortex would appear to us to explain 
 the grandiose feeling, so frequently commingled with the delusions of 
 persecution, from which alcoholic subjects suffer ; the notions of wealth, 
 of landed possessions, of exalted social status, which we find so often 
 underlying delusions of restricted liberty, or of malign influence 
 brought to bear upon them. When, howevei', the motor cell and 
 axis-cylinder process are themselves involved, then we find the 
 characteristic delusions of persecution predominate to the exclusion 
 often of such optimistic states ; and the profound implication of the 
 " motor element " of mind may call forth ideas of restricted volitional 
 freedom and reactive capacity. In all the more characteristic phases 
 of chronic alcoholism, we never fail to identify these profound lesions 
 within the white medullated substance of the fronto-parietal lobe, 
 associated with the degeneration and breaking-up of the large " motor- 
 cells " and spindle-series. Whilst, therefore, the cortical lesions of 
 general paralysis indicate an invasion from without inwards, affecting 
 the sensory elements and apical (? sensory) poles of the motor-cells ; 
 alcoholism induces, in addition thereto, extensive vascular changes 
 from within outwards, implicating the medulla of tlie gyri, and 
 effecting a destructive degeneration of the medullated fibres. 
 
 Spinal Cord. — The morbid changes found in the spinal axis can 
 scarcely be relegated, in any typical case of alcoholism, to one of the 
 strict system-affections of the cord; they are too palpably of the nature 
 of a slowly-encroaching sclerous change encircling the cord, originating 
 in its investing membranes, and creeping inwards along the vascular 
 tracts, and especially along the posterior median raphe. There is also, 
 undoubtedly, a tendency in such cases to a frequent implication of the 
 posterior nerve-roots, by a similai-ly-disposed lesion spreading into its 
 structure from its perineural investment, inducing a change quite dis- 
 similar in nature to that of the so-called multiple neuritis, w'hich also 
 occurs in chronic alcoholism. The investing zone of sclerosis is by no 
 means uniformly advanced at all points ; more frequently we observe 
 a decided preponderance at certain definite arcs — e.g., the marginal arc 
 of the lateral column, on one or on both sides ; or the segment im- 
 mediately adjacent to the posterior nerve- roots ; or, occasionally, a 
 section of the outer margin of the anterior root-zone; and, very 
 
540 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 frequontly, the posterior median raph6, spreading thence throughout 
 the columns of Golh Whence this tendency to arise at different sites? 
 Wliat are the determining factors? Although we cannot reply to 
 these questions with full assurance at present, yet it is a fact of no 
 little significance that such lesions are, as in genei'al paralysis, dis- 
 tributed along the columns which are in anatomical connection with 
 discharging tracts at higher levels in the cerebrum ; and that, as in 
 general paralysis, we find system-degenerations established apparently 
 along columns in physiological sympathy with diseased tracts higher 
 up, yet not hy morbid continuity ; so here, also, the functional dis- 
 turbances aroused in the cortex may, probably, by inducing continuous 
 engorgement along certain spinal ti-acts, by the hyperactivity of their 
 conducting strands, determine to that region the chief morbid implica- 
 tion. The symptoms accord with this mode of implication, for we 
 first get decided evidence of a very chronic lejyto-menijigitis, which 
 precedes symptoms of ascending and descending changes secondarily 
 induced by the spread of the lesion inwards ; and, still later, we find 
 the central grey matter and special cell-groups implicated, apparently 
 by extension along the nutrient vessels, by the same lesion. That the 
 symptoms vary greatly in individual cases is not surprising, as they 
 wholly depend iipon site, and depth of imj)lication of the cord. 
 
 The lumbar cord may be the first affected, and the deranged sensory 
 and motor symptoms be limited wholly to the legs ; or, again, stiffness 
 or spasm of the neck and retraction of the head may indicate cervical 
 implication; or the dorsal region may be the site of most pronounced 
 implications ; the vertical extent of the meningeal affection may be 
 slight or universal. 
 
 The constitutional state engendered in chronic alcoholic insanity is 
 ideiitical with what forms the basis of chronic Bright's disease ; and as 
 in this affection we have a multiplicity of local expressions of the 
 morbid lesions, so, here, we find the tendency is towards a concentra- 
 tion in the nervous centres ; atrophic states of brain, or of spinal cord, 
 or of both combined, are thus induced from predominance of — 
 
 {a.) Simple fatty degeneration of their nutritive vessels and tissues. 
 
 (6.) From fatty degeneration associated with interstitial sclerosis. 
 
 (c.) From diffuse sclerous, interstitial change. 
 
 (d.) From periai'teritis and hypertrophy of the tunica muscularis. 
 
 In the periarteritis, occasionally engendered in chronic alcoholics of 
 a certain age, we probably see the pathological boundary-line over- 
 stepped betwixt simple alcoholic insanity and general paralysis of the 
 insane ; and we have resulting therefrom, in a more acute spread of 
 the cortical lesions, what might be regarded as general paralysis 
 accidentally evolved out of chronic alcoholism, or, as some would 
 
NATURK OF THE SPINAL IMPLICATION. 541 
 
 less correctly state the case, general jaaralysis caused by alcohol. 
 Alcohol has its own role to play, and a most extensive one it is ; but, 
 the tissue-changes engendered thereby are always as highly character- 
 istic as are the morbid sequences of general paralysis, and we must 
 seek to dissever from the latter disease our notions of alcohol playing 
 the part of a direct etiological factor, in the sense of originating the 
 primal tissue-changes by which this disease is characterised. 
 
 In the notable thickening of the muscular tunic of the arteries seen 
 in the spinal cord, in certain cases of alcoholic insanity, we find the 
 general symptomatology points to the depravation of the nutrient 
 fluids, to the especially-vitiated state of the blood, mal-assimilation, 
 disordered digestion, deranged excretory functions, bringing in their 
 wake the resultant changes in the arterial tunics. In such cases, as 
 we have seen, the membranes of the cord presented no notable change, 
 and no coarse sclerous bands of connective invaded the columns ; the 
 symptoms, which were those of an ataxic paraplegia of very gradual 
 accession, were explained by the great predominance of scavenger-cells 
 along the commissural end of the raphe, with morbid vascularity of 
 the posterior columns at this site, the vessels all presenting great 
 hypertrophy of their muscular tunic ; a remarkable abundance of 
 amyloid bodies was spread throughout the peripheral areas of the 
 cord, and especially the posterior columns. The lateral columns 
 exhibit a very fine punctated connective, which has induced a certain 
 degree of atrophy of the nerve-tubuli, whilst here also the character- 
 istic hypertrophied muscular vessels prevail abundantly throughout 
 all regions of the cord. Nor must we fail to call attention to the fact 
 of implication of the visceral column of the cord — the vesicular formation 
 of Clarke. A very general implication of the blood-vascular system 
 prevails ; the great vessels undergo fatty and atheromatous change ; 
 and the circulatory centre itself — the heart — being an early sufi"erer, 
 its muscle succumbs to fatty infiltration and degeneration, its cavities 
 dilate, and its vital capacity is profoundly reduced. Corresponding 
 changes appear in the large vessels at the base of the brain, which 
 become atheromatous and distorted. It is this enfeeblement of centric 
 circulatory energy, furthered by the retarded flow of blood in the 
 minute vessels, which calls forth that compensatory increase of the 
 muscular tunic of the cerebral and spinal arteries. Another factor, 
 of great moment here for evil, must not be overlooked, that is, the 
 diminished vis a fronte of cortical areas, which normally favours 
 circulation ; a failure due to the devitalisation by alcohol of the nerve- 
 tissue, and possibly the inherited enfeeblement of neui-otic descent. 
 
INDEX. 
 
 Abdueens facialis, 21, 23. 
 
 nucleus of, 19, 23. 
 Acoustic striffi, 10, 20, 21. 
 
 ,, tubercle, 10. 
 Activity, restricted central, 133. 
 Adherent pia, histology of, 442. 
 Adhesions of pia, 441. 
 Adolescence and alcoholic excess, 289. 
 
 ,, and recurrent insanity, 208. 
 
 Adolescent insanity, 334. 
 
 ,, ,, blood in, 351. 
 
 ,, ,, etiology of, .359-361. 
 
 ,, ,, evolution of, .334. 
 
 ,, ,, prognosis in, 362-364. 
 
 ,, ,, treatment of, 364. 
 
 Adventitial coat of arteries, 76, 82. 
 
 ,, ,, of capillaries, 77. 
 
 Affective insanity, 138. 
 Ala cinerea, 10. 
 
 Alcohol, efl'ects of, on animals, 306. 
 Alcoholic insanity, 288-333. 
 
 ,, ,, a convulsive neurosis, 
 
 291-.301. 
 ,, ,, acute, 297. 
 
 ,, ,, amblyopia in, 298. 
 
 ,, ,, and suicide, 292. 
 
 chronic, .303, .308. 
 ,, ,, clinical forms of, 296. 
 
 ,, ,, delu.sions in, 295, 296. 
 
 ,, ,, dyschromatopsia in, 
 
 298. 
 „ ,, evolution of, 306. 
 
 ,, ,. fatty degeneration in, 
 
 537. 
 ,, „ hallucinations in, 293. 
 
 298, 316, 320. 
 ,, ,. muscular spasm in, 
 
 328. 
 ,, ,, nature of attack, 291. 
 
 ,, ,, nystagmus in, .328. 
 
 ,, ,, pathological anatomy 
 
 of, 528-541. 
 ,, ,, jiredisposition, 291- 
 
 293. 
 ^, ,, reaction-time in, 326, 
 
 327. 
 ,, ,, relapses in, 299. 
 
 ,, ,, scavenger-cells in, 
 
 529. 
 
 I Alcoholism, amnesic fonns of, 309, 311. 
 
 ,, amj'loid bodies in, 529. 
 
 ,, arachnoid opacity in, 436. 
 
 ,, classification of, 331-333. 
 
 ,, climacteric and, 402. 
 
 ,, cortical adhesions in, 44"J. 
 
 ,, tlelusional forms of, 312. 
 
 chronic, .303, .308. 
 
 , , en V ironmental resist ance in , 
 
 315. 
 
 ,, epigastric voice in, 317. 
 
 , , epileptiform seizures in. .328. 
 
 ,, general paralysis and, 538. 
 
 ,, hypochondriasis and, 147. 
 
 ,, impulsive insanity and, 186. 
 
 ,, motor symptoms in, 322. 
 
 ,, nerve-ceUs in, 529, 5.30-532. 
 
 ,, object-consciousness in, .321. 
 
 ,, peripheral zone in, 539. 
 
 ,, senile insanity aud, 410. 
 
 ,, sensorj' troubles in, 322. 
 
 ,, sexual illusions in, 317. 
 
 ,, spinal cord in, 532-536, 539. 
 
 ,, symptoms of chronic, .308. 
 
 types of, 333. 
 
 ,, vascular affections in, 533- 
 
 535, 540. 
 
 ,, visceral illusions in, 317. 
 
 Allhutt {Dr. Clifford) on the optic disc, 
 
 171. 
 Amnesia in alcoholism, .309, 311. 
 ,, in senile insanity, 414, 422. 
 ,, (transient) in G. I*., 25.3. 
 Amphibia, brain of, 55, 57. 
 Amphioxus, ,, ~M. 
 Amygdaloid nucleus, .35, 52. 
 Amyotrophic form of (J. P., 511-513. 
 Anajmia, signs of cerebral, 130. 
 Anaesthetics, action of, 122. 
 Andral on cerebral hajmorrhage, 454. 
 Angio-neuroses in G. P., 503. 
 Angular nerve-cells, 64. 
 Ansa peduncularis, 34, .35. 
 Ape, cortex of, 97. 
 Apex-process of nerve-cells, 65, 67. 
 Apoplectiform seizures, 262. 
 Aqueduct and central grey axis, 24, .37. 
 Arachnoid, anatomical relationships of. 
 4.34. 
 
INDEX. 
 
 543 
 
 Anichuoid cysts, 4.37-441. 
 
 ,, false membranes, 437- 
 
 ,, liaimorrliage, origin of, 441. 
 
 ,, ,, statistics of, 
 
 439-440. 
 ,, opacities, 43G. 
 
 Arcuate fibres of medulla, 12. 
 Arijy/l-Iiobartson symptom in G. P., 265. 
 Arndt on nerve-cells, 63. 
 Arterial areas and softening, 451, 452, 
 491. 
 ,, loops of cortex, 82. 
 ,, supply of brain, 445. 
 Arteries in G. P. , 494. 
 
 ,, of cerebral cortex, 75. 
 Arterio-capillary plexuses, 82, 85. 
 Articulatory troubles in G. P., 258. 
 Association of ideas, failure of, 164. 
 Atavism in recurrent insanity, 204. 
 Atrophy, cerebellar, 456-458. 
 ,, cerebral, 454-458. 
 ,, ,, localised, 456-458. 
 
 ,, chronic cerebral, 407, 426. 
 ,, ,, and Bright's 
 
 disease, 429. 
 ,, ,, blood-vessels 
 
 in, 430. 
 ,, ,, pulse in, 429. 
 
 ,, ,, urea in, 427- 
 
 428. 
 ,, senile, 417-455. 
 Auditory nerve-nuclei, 19. 
 Aura, auditory, 229. 
 ,, epigastric, 181. 
 ,, epileptic, 227. 
 ,, gustatory, 230. 
 ,, homicidal impulse and, 180. 
 ,, oLfactory, 230. 
 ,, organic or visceral, 230. 
 ,, special sense, 228. 
 ,, vasomotor, 230. 
 ,, visceral, 230. 
 „ visual, 229. 
 Automatic segregation, 123, 
 Automatism, ejiileptic, 186, 234, 235, 
 239, 244. 
 ,, mania and, 123. 
 
 Axis, central grey, 1. 
 
 ,, cerebro-spinal, 1. 
 Axis-cylinder, fibrillation of, 72. 
 
 ,, process, 65, 67, 71, 72. 
 
 ,, staining of, 74. 
 
 Bain (Prof.) on animal appetites, 181. 
 Basal ganglia, connections of, 33. 
 
 ,, process of nerve-cells, 65, 66. 
 Beevor's physiological experiments, 109. 
 Berrjmaiin, sound-rod of, 21. 
 Betz, giant cells of, 66, 95, 106. 
 Birds, brain of, 57. 
 Bladder atrophy in G. P., 285. 
 „ troubles in G. P., 284. 
 Blood in acute dementia, 161, 162. 
 
 Blood in adolescent insanity, 351. 
 ,, general paralysis, 288. 
 ,, puerperal insanity, 370. 
 Blood-vessels in chronic alcoholism, 
 533-5.35. 
 ,, of cerebral cortex, 75. 
 
 Blumenbach on bony falx, 436. 
 Boll on spider-cells, 84. 
 Bowel troubles in G. P., 286. 
 Brachia of quadingeminal bodies, 37, 38. 
 Brain of man and lower mammals, 98. 
 Bright's disease and alcoholism, 540. 
 
 ,, cerebral atrophy, 
 
 429, 534 
 Broca's cerebral convolutions, 61. 
 
 ,, extra-limbus, 87. 
 Bromism, 151. 
 Buchnill [Dr. ) on mania and melancholia, 
 
 116. 
 Bulbar paralysis and colloid change, 466, 
 
 467. 
 Bullen (St. John) on cortical adhesions, 
 442. 
 ,, locomotor ataxy in 
 
 G. P., 519. 
 Burdach, columns of, 5. 
 
 ,, lamina meduUaris of, 44. 
 
 Calamus scriptorius, 8. 
 Calcarine fissure, 60. 
 Gcdmnl on pachymeningitis, 486 
 Capillaries of brain, 76. 
 Capsule, internal, 28, 33. 
 
 knee of, 28. 
 GarpeiUer [Dr.) on alcohol, 305. 
 Oarville and Buret, 113. 
 Cat, nerve-cells of, 68, 97. 
 Cataleptic fixity of lind)s, 1 60. 
 Caudate nucleus, 28, 51. 
 Central grey axis, 1. 
 Centre median of Luys, 45. 
 Cerebellar peduncle (inner), 13. 
 
 (outer), 10, 12, 13. 
 
 ,, tract (direct), 7 
 Cerebral seizures in G. P., 259. 
 Cerebritis, 448. 
 Cerebro-spinal axis, 1. 
 
 fluid, 437. 
 Charcot on cerebral hemorrhage, 454. 
 Chronic insane class, 189. 
 Circulation, defective cerebral, 129. 
 
 ,, Heuhiier and Duret on, 446. 
 
 ,, mechanism of cerebral, 445. 
 
 , , Moxon ( Dr. ) on cerebral, 445. 
 
 Clarke (Henry) on alcoholism, 537. 
 
 ,, (Lockh(irt), vesicular columns of, 
 3, IS, ,535, 541. 
 Claustral formation of Mcynert, 70. 
 Claustrum, 34, 54. 
 Climacteric, alcoholic excess at, 402. 
 
 ,, convulsive neuroses at, 184» 
 
 185. 
 
 ,, recurrent insanity 205,210, 
 
544 
 
 INOKX. 
 
 Climacteric insanity, 392-405. 
 
 ,, ,, Clouslon (Dr.) oi\, 
 
 401, 403. 
 ,, ,, delusions in, 393. 
 
 ,, ,, etiology of, 395. 
 
 ,, ,, jMemou (Dr.) on, 
 
 403. 
 ,, ,. prognosis in, 401. 
 
 ,, ,, sexual illusions 
 
 in, 404. 
 ,, ,, statistics of, 398. 
 
 ,, ,, transformations 
 
 of, 398, 399. 
 ,, ,, treatment of, 404. 
 
 Clustered cells of cortex, 96. 
 Colloid degeneration, 4(55-470. 
 
 ,, bulbar paralysis 
 
 and, 466, 467. 
 ,, histology of, 408- 
 
 470. 
 „ Kes/.eve7i on, 469. 
 
 M'Kendrick (Dr.) 
 
 on, 465. 
 Tuke (Dr. Batty) 
 on, 465. 
 Commissure, anterior, 30. 
 
 ,, posterior, 37, 48. 
 
 Compensation, functional, 113. 
 Conarium aud brachia, 37. 
 Congenital defect and relapses, 205. 
 Conjugate deviation in G. P., 262. 
 Connective cells of brain, 79, 80, 497, 505. 
 
 ,, matrix of brain, 78. 
 
 Consciousness, faint aud vivid states, 1 1 S. 
 ,, lapsed states, 120. 
 
 ,, object- and subject-, 116. 
 
 Consecutive dementia, 190. 
 Consensual movements in G. P. , 275. 
 Convulsions, senile, 408. 
 Convulsive neuroses and alcohol, 291, 
 
 ,301, 329. 
 Corii'il and Banvier on nerve-fibres, 73. 
 Cornu Ammonis, type of, 89. 
 Cornu, anterior, 4. 
 
 ,, caput and cervix, .3. 
 ,, posterior, 3, 513. 
 Corpora albicantia, 30, 44. 
 ,, genicidata, 28, 48. 
 ,, quadrigemina, 28. 
 ,, striata, 28. 
 Corpus trapezoides, 15, 23. 
 Corpuscles of nerve-fibres, 73. 
 Correspondence, variations in the, 116. 
 Cortex cerebri, 62. 
 ,, depth of, 95. 
 ,, excitability of, 111, 112. 
 ,, functional equivalence of, 113. 
 ,, histology of, 63. 
 ,, lamination of, 85. 
 Cortical adhesions, 441, 442. 
 
 ,, and alcoholism, 442. 
 
 Coupland (Dr.) on meningeal engorge- 
 ment, 446. 
 
 Craniun), morbid states of, 433. 
 Crichlon- Browne (Sir J.) on arachnoid 
 hifimorrhage, 4.39. 
 ,, biain weights, 489. 
 
 <i. P., 254. 
 ,, localisation, 490. 
 
 Critical periods of life, 128. 
 Crucial sulcus, 97. 
 Crusta, 27. 
 
 ,, passage into capsule, 31. 
 ,, system of fibres in, 31. 
 
 Danilo on phosphorus poisoning, 480. 
 Deafness, depression accompanj'ing, 132. 
 Decorative tendency in G. P., 257. 
 Decussation, anterior sensory, 24. 
 
 ,, of cerebellar peduncle, 37. 
 
 ,, of trochlear nerve, 26. 
 
 Degeneration, colloid, 465. 
 fatty, 471. 
 
 fuscous, 473, 496, .500. 
 ,, granular, 471, 530, 534. 
 
 ,, miliaiy, 458. 
 
 ,, pigmentary, 473, 496, 500, 
 
 524. 
 Degradation (tissue) from disease, 486. 
 ,, from disuse, 487. 
 
 ,, from overstrain, 
 
 4S5. 
 DeUer.'i' cells, S3. 
 
 ,, protoplasmic processes of, 71. 
 Delirious mania, 172, 176. 
 Delirium, alcoholic, 297. 
 Delusional forms of alcoholism, 312. 
 
 ,, insanity, 192. 
 
 Delusions, genesis of, 126. 
 
 , , in alcoholic insanity, 295, 296, 
 
 ,, ,, climacteric insanity, 393. 
 
 ,, ,, epileptic insanity, 245. 
 
 ,, ,, general paralysis, 255. 
 
 ,, of senile and monomaniacal, 
 
 421. 
 ,, optimistic, 295. 
 
 ,, transient, 164. 
 
 Dementia, acute primary, 157, 162, 
 ,, consecutive, 190. 
 
 ,, secondary and tissue degra- 
 
 dation, 482, 489. 
 ,, senile, 4US. 
 
 Dentate nucleus, 13. 
 Denudations, uniform and partial, 176. 
 Depression, conditions of pathological, 
 116. 
 ,, definition of, 115. 
 
 ,, degrees of, 137. 
 
 ,, reaction-time in, .327. 
 
 ,, .states of, 115, 150. 
 
 Deprivation, mental, 188. 
 Developmental arrest, 177, 188,476,479. 
 Diffusion-currents in epilepsy, 222. 
 Discharge (nerve) in alcoholic insanity, 
 320. 
 „ ,, epilepsy, 526. 
 
INDEX. 
 
 545 
 
 Dissolution in senile insanity, 414. 
 ,, planes of, 128. 
 
 Disuse (functional) and tissue-degrada- 
 tion, 487. 
 
 Divergencies in laminar type, 94. 
 
 Bonders on pupillary reactions, 276. 
 
 Dudfey {Dr. Wm. ) on cerebellar atrophy, 
 457. 
 
 Dura mater, adhesions of, 435. 
 ,, ,, bony plates in, 4.36. 
 J J ,, inflammation of, 435, 436. 
 ,, ,, morbid states of, 434-436. 
 
 Durand-Fardel on htemorrhage, 454. 
 
 Buret, researches of, 113, 114, 435, 446. 
 
 Dynamic attributes of perception, 119. 
 
 Dyschromatopsia in alcoholism, 298. 
 
 EbePth on the capillaries, 78. 
 
 ,, ,, vascular tunics, 76. 
 
 Echer on the convolutions, 60. 
 Effort, sense of conscious, 121. 
 Egoism of the general paralytic, 251. 
 ,, ,, pubescent subject, 338. 
 Elastic coat of cortical arteries, 75. 
 Electric stimulation of cortex, 113. 
 Eminentiae teretes, 9, 10. 
 Encephalon, comparative and embryo- 
 logical, 55. 
 Enfeeblement, states of mental, 188. 
 Enuresis in G. P., 286 
 Environment in monomania, 193. 
 
 ,, physical and physiological, 
 
 143. 
 ,, resistance of, 119, 121, 124, 
 
 315. 
 ,, transformations of, 126. 
 
 Epicerebral space, 76, 81. 
 Epigastric voice in alcoholism, 317. 
 Epilepsia larvata, 185, 186. 
 Epilepsy, aura in, 227. 
 
 ,, automatism of, 186, 234, 235, 
 
 239, 244. 
 ,, dreamy state of, 185, 186. 
 ,, (grand et petit mal), 231. 
 ,, nuqldings- Jackson (Br.) on, 
 
 525. 
 ,, impulsive states of, 242, 244. 
 , , interparoxysmal stage of, 239. 
 ,, natui'e of, 525. 
 ,, nucleus of nerve-cells in, 523- 
 
 525. 
 ,, pathology of, 522-528. 
 ,, piginentarv degeneration in, 
 
 524. 
 , , post-paroxysmal period, 232. 
 ,, premonitory stage of, 227. 
 ,, pre-paroxysmal jjeriod of, 226. 
 ,, senile, 408. 
 ,, sensory, 225. 
 ,, vacuolation of nuclei, 523-525. 
 Epileptic discharge, 221. 
 
 ,, hypochondi'iasis, 241. 
 ,, katatonia, 238. 
 
 Epileptic mania, 233. 
 ,, neurosis, 221. 
 ,, paroxysm, 230. 
 „ status, 2.38. 
 Epileptic insanity, 221-250. 
 ,, definition, 221. 
 ,, degrees of reduction in, 
 
 223. 
 ,, delusional states in, 245. 
 ,, diffusion-currents in, 222. 
 ,, discliarge from sensory 
 
 areas, 224. 
 ,, homicide in, 247. 
 ,, hysterical attacks of, 235. 
 ,, malingering in, 246. 
 ,, medico-legal aspects, 243. 
 ,, nascent nerve-tracks, 223. 
 ,, reaction-time in, 242. 
 ,, treatment of, 249. 
 Epileptiform attacks in alcoholism, 328. 
 „ G. P., 260, 261. 
 Equivalence, functional, 113. 
 Esquirol on the mimetic tendency, 187. 
 Ewald on the keratoid sheath, 73. 
 Exaltation, definition of, 162. 
 
 ,, impulsive states in, 166. 
 
 ,, states of mental, 162-176. 
 
 Excitability of cortex. 111, 112. 
 Explosiveness of nerve-tissue, 131. 
 Extra-limbic type of cortex, 89. 
 Extra-polar conduction, 114. 
 
 Facial nerve, genu, 20, 22. 
 
 nucleus, 19, 20. 
 Falx cerebri, Bhimenbach on, 436. 
 
 ,, ossification of, 436. 
 
 Fasciculus, posterior longitudinal, 24, 
 34, 40. 
 ,, retroflexus, 47. 
 
 ,, solitarius, 8, 11, 17. 
 
 „ teres, 9. 
 
 Feelings, tlie non-relational, 116. 
 Ferrier{Br. Dd.) on the convolutions, 61. 
 „ ,, frontal lobes, 
 
 493. 
 ,, ,, motor area, 96. 
 
 ,, physiological experi- 
 
 ments, 109, 111. 
 Fifth nerve, ascending root of, 11, 22. 
 Fillet, 15, 23, 37. 
 , , of crus, 34. 
 Fimbrite, 44. 
 Fishes, brain of, 55, 56. 
 Fissure, calcarine, 60. 
 
 ,, hippocampal, 60. 
 Flechsig, ground-fibres of, 5. 
 Flesch on phosphorus poisoning, 480. 
 Flexures, cranial, 59. 
 Fore-brain, configuration of, 49. 
 Formatio reticularis, 4, 14. 
 Fornix, pillars of, 30, 44. 
 Franck and Fiires, researches of, 112. 
 Friction, Romanes on ganglionic, 133. 
 35 
 
546 
 
 INDEX. 
 
 Fritsch and Hitzig, researches of, 111. 
 Fromann^s striatious, 72, 73. 
 Frontal lobe, functions of, 491, 49.3. 
 Fulminating psychoses, 131, 17G, 181. 
 Funiculus gracilis and cuneatus, 9, 11. 
 Fuscous degeneration, 473, 476. 
 
 Galezowski on chromatic anaesthesia, 
 
 298. 
 Gallon, reaction register of, 135. 
 Ganglia of crust and tegment, 27. 
 
 ,, olfactory, 56. 
 Ganglion, basal optic, 49. 
 Ganglionic cells of cortex, 95. 
 
 ,, layer of motor area, 101. 
 Gaskell's visceral system of nerves, 4. 
 Gelatinous substance of Rolando, 3, 11, 
 
 513. 
 General Paralysis, 250-288. 
 
 ,, amyotrophic form of, 511- 
 
 51.3. 
 ,, angio-neuroses in, 503. 
 ,, ataxic form of, 518-520. 
 ,, articulation in, 258. 
 , , atrophy of bladder in, 285. 
 ,, bladder troubles in, 284. 
 
 blood in, 288. 
 ,, bowel troubles in, 286. 
 ,, cerebral seizures in, 259. 
 ,, chronic alcoholism and, 
 
 538. 
 ,, classification of, 502. 
 ,, deep reflexes in, 278, 281. 
 ,, delusions of, 255. 
 ,, early moral perversions, 
 
 252. 
 , , early paresis in, 254. 
 , , enfeebled attention in, 253. 
 ,, epileptiform seizui'es in, 
 
 259, 261. 
 ,, facial expression in, 258. 
 ,, first stage of, 497. 
 ,, genuine tabetic form, 520. 
 ,, headache in, 521. 
 ,, membranes in, 497. 
 , , meningeal hfemorrhage, 
 
 499. 
 ,, nerve-elements of cord,507. 
 ,, oculo - motor symptoms, 
 
 263-277. 
 ,, paralytic seizures in, 262, 
 
 263. 
 , , parenchymatous myelitis, 
 
 509. 
 ,, pathological anatomy of, 
 
 493-521. 
 ,, prodromal stage of, 251. 
 ,, pseudo - tabetic form of, 
 
 513-518. 
 ,, reaction-time in, 263. 
 ,, rheumatoid pains in, 520. 
 ,, scavenger-cells in, 494-497, 
 505. 
 
 General Paralysis, second stage of, 500. 
 , , self - decorative tendency 
 
 in, 257. 
 , , sexual perversions in, 257. 
 ,, spinal cord in, 501-521. 
 ,, ,, symptoms in, 277, 
 
 501. 
 ,, syncopal attacks in, 259. 
 ,, tabetic gait in, 281. 
 ,, thii'd stage of, 501. 
 ,, transient amnesia in, 253. 
 ,, vascular implication in, 
 
 504. 
 ,, vasomotor derangement, 
 254. 
 Geniculate bodies, 28, 38. 
 Gestation, insanity during, 374-376. 
 Giant cells of Bctz, 66, 106. 
 
 ,, cortex, 95. 
 
 Globose cells, 69. 
 Globus pallidus, 54, 55. 
 Glosso-pharyngeal origin, 17. 
 Golgi on sender- cells, 84. 
 Gall's columns, 5, 506. 
 Gowers, ascending sensory tract of, 5. 
 ,, on epileptic automatism, 186. 
 Granular disintegration, 471-473. 
 Granule cell, 64, 94. 
 Gratioltt on the convolutions, 61. 
 ,, olfactory area of, 53, 91. 
 ,, optic radiations of, 33, 44. 
 Griesinger on araclinoid opacities, 435. 
 ,, cerebral irritation, 117. 
 
 ,, chronic dementia, 191. 
 
 Groupings, significance of cell-, 106. 
 
 Haemoglobin in G. P. diminished, 288. 
 
 ,, puerperal insanity, 370. 
 
 Hffimorrhage, Andral and Charcot on, 
 
 454. 
 
 „ arachnoid, 437-441, 499. 
 
 ,, Crichton- Browne (6'ir) on, 
 
 439. 
 ,, Laivson {Dr. Robert) on, 
 
 440. 
 ,, Rokitanshj on, 438. 
 
 Hallucination in alcoholic insanity, 293, 
 298, 316, 320. 
 ,, in lactational period, 382. 
 
 ,, iu recurrentinsanity,215. 
 
 ,, in seclusion, 167. 
 
 Hemiplegic seizures in G. P. , 263. 
 Heredity and senility, 408. 
 
 ,, iu recurrent insanity, 203, 204. 
 Heubner on cerebral circulation, 446. 
 Hippocampal fissure, 60. 
 His, perivascular canals of, 76, 81. 
 Hitzig, localisations of, 61. 
 
 ,, physiological experiments of, 109, 
 111. 
 Homicidal impulse, 179. 
 ,, insanitj-, 184. 
 
 Homicide and epilepsy, 247. 
 
INDEX. 
 
 547 
 
 Horn (anterior), motor cells of, 4. 
 
 ,, (posterior), sensory cells of, 3, 513, 
 Horned cells of cortex, G8. 
 Horskij {Victor), localisations of, 61. 
 
 ,, on the frontal lobes, 
 
 492. 
 ,, physiological experi- 
 
 ments of, 109, 112. 
 Hughlhigs-Jachson (Dr.) on the nerve- 
 cells, &c., 109, 222, 223, 525. 
 Hunger of the nerve-cell, 131. 
 Huss (Magnus) on chronic alcoholism, 
 304. 
 „ on classification of alco- 
 
 holism, 331. 
 ,, on Swedish dram- 
 
 drinkers, 307. 
 Huxley on the convolutions, 61. 
 Hypnotism and stupor, 152-154. 
 Hypoaria, 56. 
 Hypochondriacal melancholia, 143. 
 
 ,, ,, at puberty, 
 
 146. 
 ,, ,, delusions of, 
 
 144-147. 
 ,, ,, morbid crav- 
 
 ings of, 147. 
 „ ,, suicide in, 
 
 147. 
 ,, cesophagismus, 144. 
 
 Hypochondriasis, epileptic, 241. 
 
 ,, senile, 417. 
 
 Hypoglossal nuclei, 16. 
 Hypophysis cerebri, 58. 
 Hysteroid attacks in epilepsy, 235. 
 
 Identity, failure of, 124. 
 Idiocy, nerve- cells in, 70. 
 Illegitimacy and puerperal insanity, 369. 
 Illiisions (sexual) in alcoholic insanity, 
 
 317. 
 Imaginative faculties in mania, 169. 
 Imitativeness of youth, 337. 
 Impulse and alcoholic excess, 186. 
 
 „ ,, insanity, 291, 301. 
 
 ,, and dreamy state of epilepsy, 
 
 185. 
 ,, homicidal, 179. 
 ,, ,, aura in, 180. 
 
 , , , , masked epilepsy, 1 85. 
 
 ,', insane, 178, 179. 
 Impulsive features in epileptic insanity, 
 242, 244. 
 ,, ,, mania, 166. 
 
 ,, ,, recurrent insanity, 
 
 214. 
 ,, insanity, 131. 
 Incidence of insanity as to age, 397. 
 Incoherence of mania, 169. 
 Incontinence in G. P., 284. 
 Inflammation of brain, 448. 
 Inflated cells, 69. 
 Infundibulum, 50. 
 
 Inhibition, 110, 111, 526. 
 
 Insects, cephalic ganglion of, 56. 
 
 Insula, .30, 54, 60. 
 
 Intemperance and recurrent insanity, 
 
 204, 216. 
 Interannular segments, 73. 
 Intercalated layers, 105. 
 Intermedio-lateral tract, 4, 535. 
 Intima of capillaries, 77. 
 
 ,, cortical arteries, 75. 
 Intracellular digestion, 494. 
 Iridoplegia, associative, 265. 
 ,, reflex, 265. 
 
 Kahlbaum on katatonia, 238. 
 Katatonia, epileptic, 238. 
 Keratoid sheath, 73. 
 Kesteven on colloid degeneration, 469. 
 
 ,, miliarj^ sclerosis, 458. 
 
 Knee-jerk in G. P. (aljolished), 280. 
 
 ,, ,, (increased), 278. 
 
 Kolliker oh nerve-])rocesses, 72. 
 Kreyssig on phosphorus poisoning, 480. 
 Kries and Auerhach on reaction-time, 136. 
 Kuhne on the keratoid sheath, 73. 
 Kupffer's stratum moleculare, 92. 
 
 ,, ,, reticulare, 92. 
 
 Labile equilibrium, 201. 
 Lactation, insanity during, 376. 
 „ physiology of, 386. 
 
 ,, risks of, 376. 
 
 Lactational insanity, delusions of, 377. 
 „ ,, etiology of, 384. 
 
 ,, ,, hallucinations, 382. 
 
 ,, ,, prognosis, 389. 
 
 , , , , sexual perversions, 
 
 382. 
 ,, ,, suicide, 379. 
 
 ,, ,, symptoms, 377. 
 
 ,, ,, treatment, 391. 
 
 Lacunar laj'er of cornu Ammonis, 92. 
 Lamina meduUaris of Burdach, 45. 
 Laminae medullares, 54. 
 Laminar arrangement of cells, 96. 
 ,, types of cortex, 88, 105. 
 Lamination of cornu Ammonis, 89, 92. 
 ,, cortex, 85. 
 
 ,, extra-limbus, 89, 91. 
 
 limbic (upper), 88, 89. 
 ,, ,, (modified upper), 
 
 88, 90. 
 ,, motor area, 99-101. 
 
 olfactory bulb, 89, 93. 
 ,, type (inner), 88, 
 91. 
 ,, ), ,) (modified), 
 
 89,91,105. 
 „ ,, „ (outer), 88, 
 
 90. 
 Lamprey, 55. 
 
 Landois on nerve-processes, 72. 
 Landois and Stirling on growth, 336. 
 
548 
 
 INDEX. 
 
 Lantermann on nerve-til)rcs, 73. 
 Latent period, Ladd (Prof.) on, 130. 
 
 ,, ,, of stimulation, 111, 136. 
 
 Lateral mixed-system, 12, 17. 
 
 „ ,, sensory nucleus 
 
 of, 17. 
 Lawson (Dr. Robert) on arachnoid cysts, 
 
 438. 
 Lemniscus, 23, 37, 38. 
 Lenticular nucleus, 28, 49, 54. 
 Lewes (G. //.), antagonism of growth 
 
 and development, 336. 
 Limbic arc of rabbit's brain, 86. 
 „ ,, type of upper, 88, 89. 
 ,, lobe, 6-1. 
 
 ,, type, modified upper, 88, 90. 
 Localisation of function, 61. 
 Locomotor ataxia in G. P., 518. 
 Locus cceruleus, 25. 
 
 ,, niger, 30. 
 Luys'' centre median, 45, 63. 
 Lymph-connective system, 83, 484. 
 
 ,, ,, in senile atrophy, 
 
 44.3, 484, 488. 
 Lymphatic system of brain, 80. 
 Lyra, 44. 
 
 Magnan on alcoholism, 304, 308, 309, 
 
 333. 
 Major (Dr. H. C.) on cerebellar atrophy, 
 457. 
 J, granular degenera- 
 
 tion, 457, 471. 
 Malingering in epilepsy, 246. 
 Mania, acute delirious, 172, 176. 
 ,, bodily symptoms in, 171. 
 ,, epileptic, 233. 
 ,, onset of, 168. 
 ,, periodicity of, 172. 
 ,, a potu, 297. 
 ,, senile, 406. 
 ,, symptoms of, 170-171. 
 ,, tempei-ature in, 172-173. 
 ,, transitoria, 187. 
 Marc on homicidal impulse, 181. 
 Marcet (Dr.) on alcoholic diseases, 307. 
 Mas'mrj (Evxlolf) on alcohol, 305. 
 Masturbation and insanity, 355, 358,360. 
 Maudsley (Dr.) on mania transitoria, 187. 
 Medico-legal aspects of epilepsy, 187. 
 Medulla oblongata, 8. 
 
 ,, columns of, 12, 20. 
 
 Medullary groove, 57. 
 ,, laminae, 34. 
 
 MeduUated interannular segments, 73. 
 
 ,, nerve-fibre, 72. 
 
 Melancholia, affective, 137, 138, 
 J, agitans, 147. 
 
 ,, clinical groups of, 138, 142. 
 
 delusional, 138, 141. 
 ,, hypochondriacal, 143. 
 
 senile, 407, 418. 
 ,, stu]iorose, 155. 
 
 Melancholic stadium, 108. 
 Menstrual derangement imd convulsive 
 neuroses, 184. 
 ,, and recurrent in- 
 
 sanity, 207. 
 ,, and stupor, 341, 
 
 346, 349. 
 Mercier (Dr. Chas.) on the nervous 
 
 system, 525. 
 Mer.tun (Dr.) on climacteric insanity, 
 
 398, 403. 
 Mesencephalon, 27. 
 
 Metsckn'ikoff on intracellular digestion, 
 494. 
 ,, phagocytes, 494. 
 
 Meynert on cerebellar atrophy, 456. 
 ,, cortical lamination, 88. 
 
 ,, depth of cortex, 95. 
 
 ,, nerve-cells, 63, 67, 68, 70. 
 
 Mimetic tendency, Esquirol on, 187. 
 Molecular stratum of Kupffer, 92. 
 Monomania, cases of, 194, 200. 
 ,, delinition of, 192. 
 
 ,, environmental resistance 
 
 in, 193. 
 ,, genesis of, 192. 
 
 ,, mystic symbolism in, 194. 
 
 ,, perverted ideation in, 193. 
 
 Monoplegic seizures in G. P., 263. 
 Monro, foramen of, 58. 
 Moral perversion in G. P. , 253. 
 Mosso on cerebral circulation, 446. 
 Motor area of cortex, 99. 
 
 ,, cell-groupings, 102, 104. 
 ,, cells, 66, 101. 
 
 ,, enfeeblenient in alcoholism, 323. 
 Moxon (Dr. W.) on the cerebral veins, 
 
 445. 
 Muscular coat of arteries, 75, 53.3. 
 
 ,, element of mind, 118, 121. 
 Mydriasis, paralytic, 264. 
 Myelitis, parenchymatous, 509. 
 Myosis, paralytic, 264. 
 ,, spastic, 264. 
 
 Nates, structure of, 38. 
 Negative states of mind, 1 1 7. 
 Nerve-cells, 63-70. 
 
 ,, angular, 64. 
 
 ,. comparative size of, 108. 
 
 ,, developmental arrest, 475- 
 
 479. 
 
 ,, granule, 64. 
 
 , , Iluqhlings-Jachion (Dr. ) on, 
 
 i09. 
 
 ,, inflated or globose, 69. 
 
 ,, motor, 66. 
 
 ,, nucleus of, 109-111. 
 
 ,, primitive and degenerate 
 
 type, 478, 527. 
 
 ,, pyramidal, 65. 
 
 ,, Boss (Dr.) on, 527. 
 
 ,, significance of form, 527. 
 
INDEX. 
 
 549 
 
 Nerve-cells, significance of size, 107. 
 
 ,, spindle-shaped, 70. 
 
 Nerve-discharges in alcoholism, 320. 
 Nerve-fibres, 71-75. 
 
 ,, corjniscles of, 73. 
 
 ,, destruction of, 482. 
 
 „ naked, 71. 
 
 Nerve-tracts, forcing of nascent, 223. 
 Nested cells of cortex, 96, 102. 
 Neural canal, 57. 
 Neuro-enteric canal, 58. 
 Neuroglia cells, 79, 80. 
 
 ,, matrix, 78. 
 Niemeyer on puncta vasculosa, 448. 
 Nocturnal crises, 166. 
 Notochord, 59. 
 
 Nuclear lamina of Ammon's horn, 92. 
 Nucleus, acoustic (anterior), 21. 
 
 ,, ,, (external), 21. 
 
 ,, ,, (internal), 20. 
 
 „ ambiguus, 25. 
 
 ,, amygdaloid, 52. 
 
 ,, caudatus, 28, 51. 
 clavate, 7, 8, 12, 14. 
 cuneate, 7, 8, 12, 14. 
 
 ,, dentate (cerebellum), 13. 
 facial, 20, 23. 
 
 ,, hypoglossal, 10, 12, 16. 
 
 „ of lateral columns, 14, 17, 20. 
 
 ,, lenticularis, 30, 49, 54. 
 
 ,, of nerve-cells, 109, 111. 
 
 ,, of oculo-motor, 26. 
 
 ,, ruber of tegmentum, 26, 37, 
 39. 
 
 ,, sacral (Stilling), 4. 
 
 „ tecti, 13, 23. 
 
 ,, trigeminal (motor), 25. 
 
 ,, troclilearis, 26. 
 
 ,, vacuolation of, 523. 
 
 ,, vago- accessory, 10, 12. 
 Nursing mother, qualifications of, 389. 
 Nutritive impairment, acute, 129, 130. 
 Nystagmus in alcoholism, 328. 
 
 ObersteineP on the lymphatics, 80. 
 Object-consciousness, failure of, 116, 118, 
 
 137, 321. 
 Oculo-motor nucleus, 26. 
 
 symptoms in G. P., 263-277. 
 ffisophagismus in hypochondriasis, 144. 
 Ogston {Dr. ) on alcohol, 305. 
 Olfactory area, 53, 91. 
 
 bulb (type), 89. 
 ,, cortex (type), 88, 89. 
 Olivary body (accessory), 15. 
 ,, ,, (inferior), 14, 20. 
 
 ,, ,, (superior), 19, 23. 
 
 ,, fasciculus, 15. 
 Optic disc in mania (Dr. Allbutt), 171. 
 ,, ganglion (basal), 49. 
 ,, nerve (origin), 49. 
 , radiations of Gratiolet, 33, 44. 
 Optimism m alcoholic insanity, 295. 
 
 Orfila on alcoholic poisoning, 305. 
 Ovarian derangement at pubescence, 
 
 346, .349. 
 Over-strain and tissue-degradation, 485. 
 
 Paehymening-itiS (externa), 435, 4,36. 
 
 ,, (interna), 437. 
 
 Pain and pleasure, genesis of, 133, 134. 
 
 ,, in G. P., 520, .521. 
 Paretic states in alcoliolism, 325. 
 Parietal sulcus, primary, 87. 
 Pathology of chronic alcoholism, 528- 
 541. 
 ,, epileptic insanity, 522-528. 
 
 ,, general paralysis, 493-521. 
 
 ,, insanity, 489-492. 
 
 ,, secondary dementia, 482- 
 
 488. 
 Peduncles of pineal gland, 42, 47. 
 ,, of thalamus, 35, 51. 
 ,, superior cerebellar, 37, 39. 
 Peduncular sensory tract, 32, 33, 34. 
 Perception, statical and dynamic attri- 
 butes of, 119. 
 Percy [Dr.) on alcoholic stimuli, 305. 
 Pericellular sacs, 81. 
 Periodicity of maniacal reductions, 172, 
 Perivascular cells, 82. 
 
 ,, channels, 76, 81. 
 
 Personality, double, 125. 
 
 ,, transformations of, 124, 127. 
 Perversions, monomaniacal, 193. 
 Pia-arachnoid, adhesions of, 441. 
 
 ,, alcoholic excess, 436. 
 
 ,, morbid states of, 436. 
 
 ,, opacities and thickening 
 
 of, 436. 
 Pig, nerve-cells of, 68, 70, 96. 
 Pigmentary degeneration, 473-476. 
 Pineal body, 37, 47. 
 Pitres, researches of, 112. 
 Pituitary body, 30, 58. 
 Pneumogastric in hypochondriacal mel- 
 ancholia, 144. 
 Pons Varolii, 19. 
 
 ,, brachia of, 19. 
 
 Popow on phosphorus poisoning, 480. 
 Positive states of mind, 117. 
 Posterior perforated space, 30. 
 Pregnancy, insanity during, 374-376. 
 Premature senility, 426. 
 Primary processes of cells, 67, 71. 
 Prunitive nerve-fibrils, 71- 
 Prognosis in pubescent insanity, 362-364. 
 ,, puerperal ,, 371, 
 
 recurrent ,, 214-220. 
 Protoplasmic processes, 66, 71. 
 Pseudo-tabetic G. P., 513-518. 
 Psycho-motor centres, contiguity of, 
 
 114. 
 Puberty, egoism of, 338. 
 
 ,, initiative tendency in, 338. 
 ,, Smith (Dr. Edward) on, 337. 
 
550 
 
 INDEX. 
 
 Pubescent epoch and convulsiveneuroses, 
 184. 
 ,, ,, and insanity, 212, 334. 
 
 ,, ,, cvolutidn of, 334. 
 
 , , } , ill ^he female, 335. 
 
 „ in the male, 3r)2-.354. 
 ,, insanity, ancestral influence 
 
 in, 344,- 345. 
 ,, ,, and ansemia, .342. 
 
 „ etiology of, 343, 359-.361. 
 ,, ,, iu the female, 339. 
 
 ,, ,, in the male, 354. 
 
 ,, ,, masturbation in, 355, 
 
 358, 360. 
 ,, ,, ovarian derangement in, 
 
 346-349. 
 ,, ,, prognosis in, 362-364. 
 
 ,, ,, stupor in, 341. 
 
 ,, ,, treatment of, 364. 
 
 Puerperal insanity, blood in, 370. 
 
 ,, ,, etiology of, 367-370. 
 
 ,, ,, illegitimacy and, 369. 
 
 , , , , intensity of excitement, 
 
 365. 
 ,, ,, prognosis, 371. 
 
 ,, ,, sexual element, 365. 
 
 ,, ,, suicide in, 367. 
 
 ,, ,, treatment of, 373. 
 
 ,, period and insanity, 365. 
 Pulvinar, 42. 
 
 Pupils in general paralysis, 263-277. 
 Pyramidal tracts (crossed), 6. 
 J, (direct), 5. 
 
 ,, (in crusta), 32. 
 
 Quadrig-eminal bodies, 28, 36. 
 
 Quetelet on growth, 336. 
 
 Rabbit, nerve-cells of, 68. 
 
 , , topography of brain of, 86. 
 Pvadiations of Gratiokt, 33. 
 Ranvier, nodes of, 73. 
 Peat, nerve-cells of, 68. 
 Reaction-time in alcoholic insanity, 135, 
 326, 327. 
 ,, epileptic insanity, 242. 
 
 ,, exaltation and depression, 
 
 327. 
 ,, generalparalysis, 135, 263. 
 
 ,, healtli aud disease, 135. 
 
 ,, Krits and Auerhacli on, 
 
 1.36. 
 ,, melancholia, 134, 1.35, .327. 
 
 Reconstructive period of climacteric, 
 
 400. 
 Recoverability of mania and melancholia, 
 
 190. 
 Recurrent insanity, 201-220. 
 
 ,, adolescent subjects 
 
 and, 208. 
 „ age and, 210. 
 
 ,, alcoholic excess and, 
 
 204, 216. 
 
 Recurrent insanity, atavism and, 204. 
 
 ,, climacteric subjects 
 
 and, 205, 210. 
 ,, congenital defect 
 
 and, 206. 
 ,, definition of, 201. 
 
 , , farinaceous dietary 
 
 and, 220. 
 ,, hallucinations in, 
 
 215. 
 ,, heredity and, 203. 
 
 ,, incidence of attack, 
 
 202. 
 ,, menstrual irregular- 
 
 ities and, 207. 
 , , morbid impulse and, 
 
 214. 
 ,, nature of attack, 
 
 205, 206. 
 , , neurotic heritage in, 
 
 2U3, 204. 
 ,, prognosis in, 217- 
 
 220. 
 , , puerperal subjects 
 
 and, 211. 
 Sankey{Dr.)on,20l. 
 ,, senile epoch and, 
 
 211. 
 ,, stuporose states in, 
 
 2U7. 
 ,, traumatism and, 
 
 213. 
 ,, treatment of, 220. 
 
 Reductions, epileptic, 223, 240. 
 ,, melancholic, 138. 
 
 ,, senile, 414, 419. 
 
 Reflexes (deep) in G. P., 278. 
 Regional distribution of nerve-cells, 95. 
 lieid on climacteric insanity, 398. 
 Reil, island of, 30. 
 
 ,, substantia innominata of, 34. 
 Pie-iutegration, 127. 
 Relation, definition of, 120. 
 Relational element of mind, decline of, 
 
 120. 
 Representativeness, enfeebled, 118. 
 ,, vigour of, 123. 
 
 Reptiles, brain of, 57. 
 Resistance, sense of, 119, 120. 
 Restiform columns, 10, 12. 
 Pvestriction of the will, 120, 315. 
 Retention in G. P., 284. 
 Reticular formation, 4, 14. 
 Reticulated stratum of Kupffer, 92. 
 
 ,, white substance, 86. 
 
 Revivability of impressions, 310. 
 Rhythm, nutritional, 1.32. 
 Rodents, brain of, 63, 86. 
 Bokilansl')/ on arachnoid opacities, 436. 
 , , on engorged membranes, 446. 
 
 Rolando, fissure of, 60. 
 
 „ tubercle of, 25. 
 Romanes on "ganglionic friction," 133. 
 
INBEX. 
 
 551 
 
 Roof-nuclei of Stilling, 13, 23. 
 Root-zones of cord, 8. 
 Boss {Br.) on the lateral cell-groups, 14. 
 ,, ,, ,, mixed system, 4. 
 
 nerve-cells, 482, 527. 
 
 Sankey (Dp.) on recurrent insanity, 
 201. 
 
 Scavenger-cells and chronic alcoholism, 
 529-533. 
 fibrillation of, 83, 497. 
 ,, general paralysis and, 
 
 494-505. 
 ,, miliary sclerosis and, 
 
 462. . 
 ,, nerve-fibre plexus and, 
 
 483-488. 
 ,, senile atrophy and, 443. 
 
 ,, spinal cord and, 505. 
 
 (S'cAa/er's researches, 112, 492. 
 Sclerosis, miliary, 458. 
 
 histology of , 460-464. 
 ,, scavenger-cells in, 462. 
 
 Seclusion and hallucination, 167. 
 Secondary processes of cells, 67, 71. 
 Senile amnesia, 414, 422. 
 ,, atrophy, 417. 
 ,, convulsions, 408. 
 ,, dementia, 408. 
 ,, epilepsy, 408. 
 ,, hypochondriasis, 417. 
 ,, mania, 406. 
 ,, melancholia, 407. 
 Senile epoch, changes of, 405. 
 
 ,, recurrent insanity and, 211, 
 Senile insanity, adhesions in, 444. 
 „ amnesia of, 414, 422. 
 
 ,, alcohol and, 410. 
 
 ,, atrophy and, 417. 
 
 ,, delusions and, 421. 
 
 ,, onset and prodromata, 413. 
 
 ,, reductions of, 414, 419. 
 
 ,, scavenger-cells in, 443. 
 
 ,, sexual perversions in, 416. 
 
 Senility, premature, 410, 426, 456. 
 Sensory areas in epileptic insanity, 224. 
 ,, cells of posterior horn, 4. 
 ,, columns, termination of, 32. 
 ,, nerves of skin, 144. 
 ,, troubles in alcoholism, 321. 
 Seriality of thought, disturbed, 118. 
 Sexual divergence, 336, 352. 
 ,, element in puerperal insanity, 
 
 365. 
 ,, illusions in alcohohsm, 317. 
 ,, perversions of G. P., 257. 
 ,, 5, of lactational cases, 
 
 382. 
 Sheath of Sclnoann, 73. 
 Sheep, nerve-cells of, 68, 96. 
 Skae {Dr. ) on climacteric insanity, 398. 
 Smith (Dr. Edward) on puberty, 337. 
 Softening, cerebral, 450. 
 
 Softening, localised, 452, 453,'491. 
 Solitary arrangement of cells,";^94, 96. 
 
 ,, fasciculus, 8, 17. 
 Sound-rod oi Bn-ymann, 21. 
 Spasmodic states in alcoholism, 328. 
 Spencer (Herbert), automatic segrega- 
 tion, 123. 
 ,, faint and vivid states, 118. 
 ,, relational and non - rela- 
 tional feelings, 116. 
 ,, variations in the corre- 
 spondence, 116. 
 Spider-cells, 83. 
 
 in G. P., 494. 
 
 ,, in senile atrophy, 443. 
 
 Spiegelherg on growth and development, 
 
 336. 
 Spinal-accessory, origin of, 17. 
 Spinal cord, alcoholism (chronic) and, 
 539. 
 ,, amyotrophic implication, 
 
 511-513. 
 ,, anterior radicular zone, 8. 
 
 ,, antero-lateral columns, 7. 
 
 ,, bilateral symmetry of, 2. 
 
 ,, cell-groupings of, 4. 
 
 ,, combined system-disease 
 
 of, 510. 
 , , commissural tracts of, 8. 
 
 , , direct cerebellar tract of, 7. 
 
 inG. P., 501-521. 
 ,, intermedio-lateral tract of, 
 
 4. 
 ,, medullated columns of, 5. 
 
 ,, posterior columns of, 24, 
 
 513, 524. 
 ,, pyramidal tracts of, 5, 6, 
 
 506. 
 Spinal symptoms in G. P., 277. 
 Spindle-cells of cortex, 70. 
 Statical attributes of perception, 119. 
 Status epilepticus, 238. 
 Stcqjliany on nerve-cells, 63. 
 Stigmata, 77. 
 
 Stimulation (electric) of cortex, 113. 
 Stomata, 77. 
 
 Stratum gelatinosum, 93. 
 ,, glomerulosum, 93. 
 ,, granulosum, 93. 
 ,, reticulare, 92. 
 ,, zonale, .15, 35, 46, 51. 
 Striaj acoustica?, 10, 20, 21. 
 
 ,, terminales, 53. 
 Striate layer of cornu Ammonis, 92. 
 Stui)or, blood in, 350. 
 ,, causes of, 151. 
 ,, hj'pnotism and, 152-154. 
 ,, recurrent insanity and, 207. 
 ,, melancholia with, 155-157. 
 „ states of, 150-162. 
 Style of pineal peduncle, 47. 
 Subject-consciousness, rise of, 116. 
 Subjective in lower organisms, 143. 
 
652 
 
 INDEX. 
 
 Substantia ferniginea, 25. 
 
 ,, gelatinosa, 3, 513. 
 
 ,, iiuioininata, 34. 
 
 „ nigra {Soemmering), 36, 40. 
 
 Subthalamic body, 42. 
 Suicidal impulse, 187. 
 Suicidal promptings, 140, 147. 
 Suicide in alcoholic insanity, 292. 
 
 ,, hypochondriasis, 147. 
 
 ,, puerperal insanity, 367. 
 
 Sulci, significance of, 97. 
 Surcingle, 52. 
 
 Suspicion, genesis of, 124, 140. 
 Sweden, excessive alcoholism in, 307. 
 Syhnan aqueduct, 37. 
 
 ,, fissure, 60. 
 Symbolism, mystic, 194. 
 Syncopal attaciis in G. P., 259. 
 System-diseases of the cord, 506. 
 
 Tabetic gait in G. p., 281. 
 Taenia pontis, 30. 
 
 ,, semicircularis, 53. 
 Tegmentum, 27, 37. 
 Temperature in mania, 172, 173. 
 Thalamencephalon, 41. 
 Thalamic capsule, 46. 
 
 „ connections with hemispheres, 
 
 46. 
 „ fasciculi (direct and decussat- 
 
 ing), 45._ 
 ,, peduncle (inferior), 35. 
 ,, tubercle, 43. 
 Thalamus opticus, 28, 42. 
 Thought, muscular element of, 119. 
 Tilt on climacteric insanity, 398. 
 Toxtemia, 129. 
 
 Transitional forms of cortex, 88, 104, 105. 
 Traumatism and recurrent insanity, 213. 
 Treatment of epilepsy, 249. 
 Trifacial, ascending root of, 11, 22, 25. 
 Trigeminal, descending root of, 25. 
 ,, median root of, 25. 
 
 ,, motor nucleus of, 25. 
 
 Trigonum olfactorium, 53. 
 Trochlear nerve, nucleus of, 26. 
 
 ,, root-fibres of, 26. 
 
 Trousseau on growth, 336. 
 
 Tubercle of thalamus (anterior), 42, 46. 
 Tuke (Dr. Batly) on colloid degenera- 
 tion, 465. 
 ,, miliary sclerosis, 
 
 458, 464. 
 Tithe (Dr. Hack) on homicidal impulse, 
 
 180, 183. 
 Tunica adventitia, 76, 78. 
 ,, media, 75, 78. 
 ,, muscularis, 75, 78. 
 Tiirck, columns of, 5. 
 Turner (Prof.) on the convolutions, 61. 
 Types of cortical lamination, 88. 
 ,, divergence in, 94. 
 ,, five- and six-laminated, 97. 
 Typho-mania, 173. 
 
 Uterine involution and insanity, 376. 
 
 VaeUOlation of nerve-cell, 479-480. 
 
 of nucleus, 480-482, 523- 
 525. 
 ,, in phosphorus poisoning, 
 
 480. 
 Vagus, origin of, 17, 18. 
 Vascular implication in alcoholism, 533. 
 ,, process of scavenger- cells, 83. 
 Vascularity of cortex in insanity, 444, 
 
 447. 
 Veins of cortex, 77. 
 Velum, anterior medullary, 24. 
 Venous engorgement of membranes, 446. 
 Ventricle, iloor of fourth, 24. 
 Vesicles, cerebi-al, 57. 
 
 ,, optic, 58. 
 Vesicular columns of Clarke, 3, 18. 
 Vicq cVAzyr's bundles, 44. 
 Virchoiu on pachymeningitis, 437. 
 Visceral columns of Lockhart Clarke, 3, 
 18, 535, 541. 
 ,, illusions in alcoholism, 293, 317. 
 ,, nerve-nuclei of Gaskell, 4. 
 Volition, i-estriction of, 120, 122. 
 
 Waldeyer on nerve-processes, 78. 
 Wi7i.-ilow (Dr. Forbes) on suicide, 188. 
 
 Youth, mimetic tendency of, 307. 
 
 THE END. 
 
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A NEW TEXT-BOOK JUST PUBLISHED. 
 
 DISEASES OF THE SKIN. 
 
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 Gerald F. Yeo, m.d., f.r.c.s., Professor of Physiology in King's College, London. 321 Illustra- 
 tions and a Glossary. 758 pages. Cloth, 33.00; Leather, $3.50 
 
 RICHTER'S ORGANIC CHEMISTRY. By Prof. Victor von Richter, University of Breslau. 
 Authorized translation. First American, from the Fourth German Edition. By Edgar F. Smith, m.d., 
 PH.D., Translator of Richter's Inorganic Chemistry; Prof, of Chemistry in Wittenberg College, .Spring- 
 field, Ohio; formerly in the Laboratories of the University of Pennsylvania; Member of the Chemical 
 Societies of Berlin and Paris, of the Academy of Natural Sciences of Philadelphia, etc. Illustrated. 
 710 pages. Cloth, $300; Leather, 33-50 
 
 GOODHARTAND STARR, DISEASES OF CHILDREN. Second Edition. By J. F.Goidhart, 
 M.D., Physician to the Evelina Hospital for Children; Assistant Physician to Guy's Hospiial, London. 
 Sec nd American from third English Edition. Revised and Edited by Louis Starr, m.d., Clinical 
 Pro^'essor of Diseases of Children in the Hospital of the Univer.sity of Pennsylvania, and Physician to the 
 Children's Hospital, Phila. With many new Prescriptions and Directions for making Artificial Human 
 Milk, for the Artificial Dige.stion of Milk, etc. 760 pages. Cloth, ;^3. 00; Leather, ^3.50 
 
 From The New York Medical Record. 
 
 " As it is said of some men, so it might be said of some books, that they are ' born to greatness.' This new volume ha.«, 
 
 we believe, a mission, particularly in the hands of the young members of the profession. In these days of prolixity in medical 
 
 literature, it is refreshing to meet with an author who know> both what to say and when he has said it." 
 
 WARING'S PRACTICAL THERAPEUTICS. Fourth Edition. A Manual of Practical Thera- 
 peutics, considered with reference to Articles of the Materia Medica. Containing, also, an Index of 
 Diseases, with a list of Medicines applicable as Remedies, and a full Index of the Medicines and 
 Preparations noticed in the work. By Edward John Waring, m.d., f.r.c.p., f.l.s., etc. 4th 
 Edition. Rewritten and Revised. Edited by Dudley W. Buxton, m.d , Asst. to the Prof, of Medicine 
 at University College Hospital; Member of the Royal College of Physicians of London. 666 pages. 
 
 Cloth, $3.00; Leather, $3.50 
 
 From The Kansas Citv Medical Record. 
 
 ■'As a work of reference it excels, on account of the several complete indexes added to this edition. It was deservedly 
 
 popular in former editions, and will be more so in the one before us, on account of the careful arrangement of the subjects." 
 
 REESE'S M EDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition. By John J. 
 Reese, MD., Professor of Medical Jurisprudence and Toxicology in the University of Pennsvlvania ; late 
 Presdent of the Medical Jurisprudence Society of Philadelphia; Physician to St. Joseph's Hospital; 
 Member of the Colleee of Physicians of Phila.; Corresp inding Member of the New York Medico Le^al 
 Society, etc. 2d Edition. Revised and Enlarged. 654 pages. Cloth, $300; Leather, ;?3. 50 
 
 THE MOST PRACTICAL SERIES OF TEXT-BOOKS- 
 
JUST PUBLISHED. THIRD EDITION. 
 
 HUMAN PHYSIOLOGY. 
 
 By LANDOIS AND STIRLING. 
 
 With 692 Illustrations. 
 
 THIRD AMERICAN, FROM THE SIXTH GERMAN EDITION. 
 
 A Text-Book of Human Physiology, including Histology and Microscopical Anatomy, 
 with special reference to the requirements of Practical Medicine. - By 
 Dr. L. Landois, Professor of Physiology and Director of the Physiological Institute, 
 University of Greifswald. Translated from the Fifth German Edition, with addi- 
 tions by Wm. Stirling, m.d., scd., Brackenbury, Professor of Physiology and 
 Histology in Owen's College and Victoria University, Manchester; Examiner in 
 the Honors' School of Science, University of Oxford, England. Third Edition, 
 revised and enlarged. 692 Illustrations. 
 "A BRIDGE BETWEEN PHYSIOLOGY AND PRACTICAL MEDICINE." 
 
 One Volume. Royal Octavo. Cloth, $6.50 ; Leather, $7.50. 
 
 From the Prefaces to the English Edition. 
 The fact that Prof. Landois' book has passed through four large editions in the original since 1880, and 
 that in barely six months' time a second edition of the English has been called for, shows that in some 
 special way it has met a want. The characteristic which has thus commended the work will be found 
 mainly to lie in its eminent practicability; and it is this consideration which has induced me to undertake the 
 task of putting it into English. Landois' work, in fact, forms a Bridge between Physiology and the Practice, 
 of Medicine. It never loses sight of the fact that the student of today is the practicing physician of 
 to-morrow. In the same way, the work offers to the busy physician in practice a ready means of refreshing 
 his memory on the theoretical aspects of Medicine. He can pass backward from the examination of patho- 
 logical phenomena to the normal processes, and, in the study of these, find new indications and new lights 
 for the appreciation and treatment of the cases under consideration. With this object in view, all the 
 methods of investigation which may, to advantage, be used by the practitioner, are carefully and fully 
 described. Many additions, and about one hundred illustrations, have been introduced into this second 
 English edition, and the whole work carefully revised. 
 
 PRESS NOTICES. 
 
 " Most effectivsly aids the busy physician to trace from morbid phenomena back the course of divergence from 
 healthy physical operations, and to gather in this way new lights and novel indications for the comprehension and treatment 
 ot the maladies with which he is called upon to cope." — American Journal nf Medical Sciences. 
 
 " I know of no book which is its equal in the applications to the needs of clinical medicine." — Pro/. Harrison Allen, lati 
 Professor of I'hysiology , University of Pennsylvania. 
 
 " We have no hesitation in saying that this is the work to which the Practitioner will turn whenever he desires light 
 thrown upon the phenomena of a complicated or important case." — Edinburgh Medical Journal. 
 
 " So great are the advantages offered by Prof. Landois' '1'ext- Book, from the exhaustive and eminently practical 
 manner in which the subject is treated, that it has passed through four large editions in the same number of years. . . . 
 Dr. Stirling's annotations have materially added to the value of the work. Admirably adapted for the Practitioner. . . . 
 With this Text-book at command, no Student could fail in his examination." — The Lancet. 
 
 "One of the most practical works on Physiology ever written, forming a ' bridge ' between Physiology and Practical 
 Medicine. . . . Its chief merits are its completeness and conciseness. . . . The additions by the Editor are able and judicious. 
 . . . Excellently clear, attractive and succinct." — British Medical Journal. 
 
 "The great subjects dealt with are treated in an admirably clear, terse, and happily illustrated manner." — Practitioner. 
 
 " Unquestionably the most admirable exposition of the relations of Human Physiology to Practical Medicine ever laid 
 before English readers " — Students' Journal. 
 
 " As a work of reference, Landois and Stirling's Treatise ought to take the foremost place among the text- 
 books in the English language. The wood-cuts are noticeable for their number and beauty." — Glnsgo^v Medical Journal. 
 
 " Landois' Physiology is, without question, the best text-book on the subject that has ever been written." 
 — New York Medical Record. , 
 
 "■ The chapter on the Brain and Spinal Cord will be a irost valuable one for the general reader, the translator's notes adding 
 not a little to its importance. The sections on Sight and Hearnig are exhaustive. . . . The Chemistry of the Urine is thoroughly 
 considered. ... In its present form, the value of the original has been greatly increased. . . . The text is smooth, accurate, 
 and unusually fiee from Germanisms ; in fact, it is good English." — Neiu York Medical Journal. 
 
 " It is not for the physiological student alone that Prof. Landois' book possesses great value, for it has been addressed 
 TO THE practitioner OF MEDICINE as well, who will find here a direct application of physiological to pathological processes." 
 Medical Bulletin. 
 
 P. BLAKISTON, SON & CO., Publishers, 1012 Walnut St., Philadelphia. 
 
JUST READY. A TEXT-BOOK OF 
 
 DISEASES OF THE EYE. 
 
 BY DR. EDOUARD MEYER, 
 
 ProJ. ,i V&cole Pratique de la Faculte de Medecine de Paris; Chevalier of the Legion of Honor, etc, 
 
 AUTHORIZED TRANSLATION BY 
 
 FREELAND FERGUS, M. B., Assistant Surgeon, Glasgow Eye Infirmary. 
 
 COLORED PLATES PRINTED UNDER THE DIRECTION OF 
 
 DR. RICHARD LIEBREICH, M. R. C. S., Author of the "Atlas of Ophthalmoscopy." 
 
 WITH COLORED PLATES AND 267 ENGRAVINGS ON WOOD. 
 
 Octavo. 650 Pages. Cloth, $4.50 ; Leather, $5.50. 
 
 Synopsis of Contents. — Diagnosis and Treatment of Ocular Affections. Diseases of the Conjunc- 
 tiva. Diseases of the Cornea and Sclerotic. Iris — Ciliary Body — Choroid. Glaucoma. Diseases of the 
 Optic Nerve and Retina. Amblyopia and Amaurosis. Diseases of the Vitreous Body. Diseases of the 
 Crystalline Lens. Refraction and Accommodation. The Muscles of the Eye. Diseases of the Eyelids. 
 Diseases of the Lachrymal Passages. Diseases of the Orbit. Table of Dioptries. Index. 
 
 Forming a complete systematic Manual of Ophthalmology. The translating 
 
 and editing have been done with the assistance 
 l^x^ of the author. The illustrations, which will be 
 
 W^ found of great help in diagnosis, have been care- 
 fully engraved ; the colored plates, being re- 
 duced from Liebreich's Atlas of Ophthalmology 
 and printed under the direction of Di. Liebreich, 
 are accurate and faithful representations of their 
 subjects. 
 
 Treatment and Diagnosis receive full share 
 
 Fig. 27.-pTTryqium. of attention. Refraction and accommodation 
 
 (Attention is called to the help in diagnosis of a occupy a section of ovcr sixty pagcs, being 
 
 cut of this character. It is followed by three en- handled in a practical, concisc way that will 
 
 gravings showing the operation for Pterygium.) , • i /- • 11 1 1 1 • 
 
 commend itself specially to students and physi- 
 cians who have given the subject but little attention. The chapters describing the 
 subject of general diagnosis and the proper instruments to be used, are thorough 
 and well illustrated. 
 
 Dr. Swan M. Burnett, reviewing the book in The Archives 0/ Ophthabnology^ says : " The cause of its popularity is not 
 fiar to seek. It is clear, concise, conservative and eminently practical." 
 
 This book has gone through three French and four German Editions, 
 has been translated into Italian, Spanish, Polish, Russian, Japanese — 
 this, the English Edition, making the eighth language in which it has 
 been published. 
 
JUST READY. 
 
 THE SEVENTH REVISED AND ENLARGED EDITION 
 
 OF 
 
 ROBERTS' PRACTICE. 
 
 THE THEORY AND PRACTICE OF MEDICINE. By Fred. 
 T. Roberts, m.d., f.r.c.p., Professor of Materia Medica and Therapeu- 
 tics at University Hospital, Physician to Unive~s-.*v College Hospital, etc. 
 Seventh Edition. Revised and Enlarged. One vo.jme, 8vo., with nu- 
 merous Illustrations. Cloth Binding, ;^5.5o; Leather, ;^6.5o 
 
 The present edition has been fully revised throughout, and in some parts rewritten or re- 
 arranged. While an endeavor has been made to bring every subject up to date in all its aspects, 
 special attention has been given to the questions of treatment, with the view of bringing into 
 notice important therapeutic agents or methods which have been recently introduced. 
 
 The unexceptional large and rapid sale of this book, and the universal commendation it has 
 received from the profession, seems to be a sufficient guarantee of its merit as a Text-book. The 
 publishers are in receipt of numerous letters from professors in the medical schools, speaking 
 favorably of it, and below they give a few extracts from the medical press, American and 
 English, attesting its superiority and value to both student and practitioner. The present edi- 
 tion has been thoroughly revised and much of it re- written. 
 
 " The best Text-book for students in the English language. We know of no work in the 
 English language, or in any other, which competes with this one." — Edinburgh Medical Journal. 
 
 " Dr. Roberts' book is admirably fitted to supply the want of a good Handbook, so much 
 felt by every medical student." — Student' s Journal and Hospital Gazette. 
 
 "^'i here are great excellencies in this book, which will make it a favorite with the student." 
 — Richmond and Louisville Journal. 
 
 " We heartily recommend it to students, teachers, and practitioners." — Boston Medical and 
 Surgical Joitrnal. 
 
 " It is unsurpassed by any work that has fallen into our hands as a compendium for students." 
 The Clinic. 
 
 " We particularly commend it to students about to enter upon the practice of their profession." 
 — St. Loziis Medical and Surgical Journal. 
 
 " If there is a book in the whole of medical literature in which so much is said in so few 
 words, it has never come within our reach." — Chicago Aledical Journal. 
 
 BY THE SAME AUTHOR. 
 NOTES ON MATERIA MEDICA AND PHARMACY. 
 
 ESPECIALLY ARRANGED FOR THE USE OF STUDENTS. 
 
 16mo, Cloth, $2.00. 
 
 For sale by all Booksellers ; or will be sent by mail, postpaid, on receipt of price 
 by the Publishers, 
 
 P. Blakiston, Son & Co., 1012 Walnut Street, Philadelphia. 
 
"IT STANDS WITHOUT AN EQUAL AS THE MOST COMPLETE WORK ON PRACTICE IN 
 THE ENGLISH LANGUAGE."— A'ct** Vork Medical Journal. 
 
 FAGGE'S PRACTICE OF MEDICINE, 
 
 Two Large Royal Octavo Volumes. Containing over 1900 Pages. 
 PRICE, HANDSOMELY BOUND IN CLOTH, S8.00. 
 
 The Principles and Practice of Medicine. 
 
 Bv CHARLES HILTON FAGGE, M.D., F.R.C.P.. F.R.M.C.S., 
 
 Examiner in Medicine, University of London ; Physician to, and Lecturer on Pathology in, Guy s Hospital; 
 Senior Physician to Evelina Hospital for Sick Children, etc. 
 
 EDITED AND ARRANGED FOR THE PRESS 
 
 By p. H. Pye-Smith, M.D., F.R.C.P., 
 
 Lecturer on Medicine in Guy's Hospital, London, etc., 
 
 WITH A SECTION ON CUTANEOUS AFFECTIONS, BY THE EDITOR, A CHAPTER ON CAR- 
 DIAC DISEASES, BY SaMUEL WiLKES, M. D., F. R. S., AND TWO INDEXES, ONE OF 
 AUTHORS AND ONE OF SUBJECTS, BY ROBERT EdMUND CaRRINGTON. 
 
 Two Volumes. Royal Octavo. 1900 Pages. 
 
 Price in Cloth, $8.00. Full Leather, $10.00. Half Morocco, $12.00. Half Eussia, $12.00. 
 
 It is based on laborious researches into the pathological and clinical records of 
 Guy's Hospital, London, during the twenty years in which the author has held office 
 there as Medical Registrar, as Pathologist, and as Physician. Familiar beyond most, 
 if not all, of his contemporaries, with modern medical literature, a diliger/. reader of 
 French and German periodicals. Dr. Fagge, with his remarkably retentive memory and 
 methodical habits, was able to bring to his work of collection and criticism almost 
 unequaled opportunities of extensive experience in the wards and dead house. The 
 result is that which will probably be admitted to be a fuller, more original, and more 
 elaborate text-book on medicine than has yet appeared. It is the first of importance 
 emanating from Guy's Hospital, and the only two-volume work on the Practice of 
 Medicine that has been issued for a number of years. Several subjects, such as 
 Syphilis, that are usually omitted or but slightly spoken of in a general work of this 
 character, receive full attention. 
 
 Dr. Walter Moxon, one of Dr. Fagge's contemporaries, and a great personal 
 friend, writes of him, in a recent number of the London Lancet : — 
 
 " Fagge was, to my mind, the type of true medical greatness. I believe he was capable of any kind of 
 excellence. His greatness as a physician became evident lo observers of character very soon after his brilliant 
 student career had placed him on the staff of Guy's Hospital: he did not merely group already known facts, 
 but he found new facts. Former volumes of Guy's Hospital Reports contain ample and most valuable proof of 
 his greatness as a physician. His power of observation was sustained by immense memory, and brought into 
 action by vivid and constant suggestiveness of intelligence. He was a physician by grace of nature, and being 
 gifted with a quickness of perception, a genius for clinical facts and a patience in observation, he was at once 
 recognized as a successful practitioner and a leading figure in the hospital and among the profession. 
 
NEW AND REVISED EDITIONS. 
 
 ? OUIZ-COMPENDS ? 
 
 A SERIES OF PRACTICAL MANUALS FOR THE PHYSICIAN AND STUDENT. 
 
 Compiled in accordance with the latest teachings of prominent lecturers and the 
 
 most popular Text-books. 
 
 They form a most complete, practical and exhaustive set of manuals, containing information 
 nowhere else collected in such a condensed, practical shape. Thoroughly up to the times in 
 csz'.j respect, containing many new prescriptions and formula, and over two hundred and thirty 
 illustrations, many of which have been drawn and engraved specially for this series. The 
 authors have had large experience as quiz-masters and attaches of colleges, with exceptional 
 opportunities for notmg the most recent advances and methods. The arrangement of the suli- 
 jects, illustrations, types, etc., are all of the most approved form, and the size of the books is 
 such that they may be easily carried in the pocket. They are constantly being revised, so as to 
 include the latest and best teachings, and can be used by students of any college of medicine, 
 dentistry or pharmacy. 
 
 Bound in Cloth, each $i.oo. Interleaved, for the Addition of Notes, $1.25. 
 
 No. I. Human Anatomy. Fourth Edition, including Viscer.-\1 Anatomy, formerly 
 published separately. Over 100 Illustrations. By Samuel O. L. Potter, m.a., m.d , 
 late A. A. Surgeon U. S. Army. Professor of Practice, Cooper Med. College, San Francisco. 
 
 Nos. 2 and 3. Practice of Medicine. Fourth Edition. By Daniel E. Hughes, m.d., 
 Demonstrator of Clinical Medicine in Jefferson Med. College, Phila. In two parts. 
 
 Part I. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, 
 Biliary Passages, Liver, Kidneys, etc. (including Tests lor Urine), General Diseases, etc. 
 
 Part II. — Diseases of the Respiratory System (including Physical Diagnosis), Circulatory System and Ner- 
 vous System ; Diseases of the Blood, etc. 
 
 *-if* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the 
 Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and includmg 
 a number of prescriptions hitherto unpublished. 
 
 No. 4. Physiology, including Embryology. Fifth Edition. By Albert P. Brubaker, 
 M.D., Prof, of Physiology. Peiin'a College of Dental Surgery : Demonstrator of Physiology 
 in Jefferson Med. College, Phila. Revised, Enlarged and Illustrated. 
 
 No. 5. Obstetrics. Illustrated. Fourth Edition. For Physicians and Students. By 
 Henry G. Landis, m.d., Prof, of Obstetrics and Diseases of Women, in Starling Medical 
 College, Columbus. Revised Edition. New Illustrations. 
 
 No. 6. Materia Medica, Therapeutics and Prescription Writing. Fifth Revised 
 
 Edition. With especial Relcrcnce to the Physiological Action of Diugs, and a complete 
 article on Prescription Writing. Based on the Last Revision (Sixth) of the U. S. Pharma- 
 copoeia, and including many ur.ofticiiial remedies. By Samuel (). L. Potter, m.a., m.d., 
 late A. A. Surg. U. S. Army ; Prof, of Practice, Cooper Med. College, San Francisco. 5th 
 Edition. Improved and Enlarged, with Index. 
 
 No. 7. Gynaecology. A Compend of Diseases of Women. By He.vry Morris, m.d., 
 Demonstrator of Obstetrics, Jefferson Medical 0>llege, Philadelphia. In Press. 
 
 No. 8. Diseases of the Eye and Refraction, including Treatment and Surgery. By L. 
 Webster Fox, m.d., Chief Clinical Assistant Opthalmological Dept., Jefferson Medical 
 College, etc., and Geo. M. Gould, a.b. 71 Illustrations, 39 Formuliie. 2d Edition. 
 
 No. 9. Surgery. Illustrated. Third Edition. Including Fractures, Wounds, Disloca- 
 tions, Sprains, Amputations and other operations; Inflammation, Suppuration, Ulcers, 
 Syphdis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and 
 other Surgical Diseases. By Orville Horwitz, a.m., m.d.. Demonstrator of Surgery, 
 Jcfierson Medical College. Third Edition. Revised and Enlarged. 77 Formula; and 91 
 lllustraiions. 
 
 No. 10. Chemistry. Inorganic and Organic. For Medical and Dental Students. By Henry 
 Leffmann. m.d., Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. 2d Ed. 
 
 No. II. Fnarmacy. Based upon " Remington's Text Book of Pharmacy." By F. E. 
 St''WART, m.d., ph.g., Quiz-Master at Philadelphia College of Pharmacy. Secon 
 
 Bound in Cloth, each $1.00. Interleaved, for the Addition of Notes, $1.25. 
 
 8^" These books are constantly revised to keep up with the latest teachings and discoveries-. 
 
PUBLISHED ANNUALLY. 
 
 1890. 
 
 NOW READY. 39th YEAR. 
 
 f HE P HYSICIAN 'S Y lSlTlNG J ^IST. 
 
 (LINDSAY & BLAKISTON'S.) 
 
 CONTENTS. 
 
 AuMANAC for 1890 and 1891, 
 
 Table op Sic.ns to be used in keeping accounts. 
 
 Marshall Hall's Rkauy Method in Asphyxia. 
 
 Poisons and Astidotks, revised for 1890. 
 
 The Metric ok Krench Decimal System of 
 Weights and Measures. 
 
 Dose Table, revised and rewritten for 1890, by He 
 BART Amory Hare, m d , Demonstrator of Thera- 
 peutics, University of Pennsylvania. 
 
 List of New Remedies for 1890, by same autlior. 
 
 Aids TO Diagnosis and Treatment of Diseases op 
 the Eye, Dr. L. Webster Fox, Clinical Asst. Eye 
 Depi , Jefferson Medical College Hospital, and G. 
 M. Gould, m.d. 
 
 Diagram Showing Eruption of Milk Teeth, Dr. 
 Louis Starr, Prof of Diseases of Children, Univer- 
 sity Hospital, Philadelphia. 
 
 PosoLOGicAL Table, Meadows. 
 
 Disinfectants and Disinfecting. 
 
 ExaminatI">n op Urine, Dr. J. V alahv. iaseii u/on 
 Tyson's " Practical Examination of Urine." 6ih 
 Edition. 
 
 Incompatibility, Dr. S. O. L. Potter. 
 
 A New Complete Table for Calculating thb 
 Period of Utero-Gestation. 
 
 Syi.ve-ster's Method for Artificial Respiration. 
 Illustrated. 
 
 Diagram of the Chest. 
 
 Blank Leaves, suitably ruled, for Visiting Lists, 
 Monthly Memoranda, Addresses of Patients and 
 others ; Adilresses of Nurses, their references, etc. ; 
 Accounts asked for; Memoranda of Wants ; Obstet- 
 ric and Vaccination Engagements; Record of Births 
 and Deaths ; Cash Account, etc. 
 
 REGULAR EDITION. 
 
 For 25 Patients weekly. 
 50 
 
 75 
 
 TOO " " 
 
 50 
 
 For 25 Patients weekly. 
 50 
 
 2 Vols. 
 2 Vols. 
 
 J Jan. to June] 
 '^ ;.j 
 
 July to Dec. 
 Jan. to June 
 July to Dec. 
 
 Tucks, pockets and Pencil, |l.oo 
 
 1.25 
 
 1.50 
 
 " " " 2.00 
 
 " " " 2.50 
 
 INTERLEAVED EDITION. 
 
 Interleaved, tucks and Pencil, 
 
 50 
 
 2 Vols. 
 
 I Jan. to June ] 
 ( July to Dec. J 
 
 3.00 
 
 1.25 
 1.50 
 
 3.00 
 
 PERPETUAL EDITION, without Dates. 
 No. 1. Containing space for over 1300 names, with blank page opposite each 
 
 Visiting List page. Bound in Red Leather cover, with pocket and Pencil, $1.25 
 No. 2. Containing space for 2600 names, with blank page opposite each 
 
 Visiting List page. Bound like No. i, with Pocket and Pencil, .... 1.50 
 
 MONTHLY EDITION, without Dates. 
 
 No. 1. Bound without Flap or Pencil 75 
 
 No. 2, " with Tucks, Pencil, etc i.oo 
 
 These lists, without dates, can be commenced at any time, and used until full, 
 and are particularly useful to young physicians unable to estimate the number of 
 patients they may have during the first years of Practice, and to physicians in locali- 
 ties where epidemics occur frequently. In the Monthly Edition the patient's name 
 has to be entered but once each month. 
 
 " For completeness, compactness, and simplicity of arrangement it is excelled by none in the market." — ..V. y 
 Medical Record. 
 
 "The book is convenient in form, not too bulky, and in every respect the very best Visiting List published.' 
 — Canada Medical und Surgical Journal. 
 
 " After all the trials made, there are none superior to it." — Gaillard's Medical Journal. 
 
 " The most popular Visiting List extant." — Bujjfalo Medical and Surgical Journal. 
 
 " We have used it for years, and do not hesitate to pronounce it equal, if not superior, to any." — Southern 
 Clinic. 
 
 This is not a complicated system of keeping accounts, but a plain, systematic 
 record which, with the least expenditure of time and trouble, keeps an accurate and 
 concise list of daily visits, engagements, etc. 
 
, >