*J I I 
 
 
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 intijeCttpofi^fttigork 
 
 College of ^fjp^iciansf anb ^urgeonsf 
 Xibrarp 
 
 *' PRE SENTED IN MEMORY OF 
 
 -^WILLIAMHENRYDRAPER 
 
 1830-1901-P.A.ND S.-1855 
 AND HIS SON 
 
 WILLL\M KINNKUTT DMPER 
 
 1S63-1926-P.AND S.-1888 
 
f 
 
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JUST READY 
 
 GORDINIER. The Gross and Minute Anatomy of the Central 
 Nervous System. By H. C. Gordinier, a.m., m.d., Professor of 
 Physiology and of the Anatomy of the Nervous System in the Albany 
 Medical College. With many full-page Plates and other Illustrations, 
 a number of which are printed in colors and the majority of which are 
 original. Large Octavo. 
 
 Handsome Cloth, ^6.00; Sheep, ^7.00; Half Russia, ^8.00, net. 
 
 SYNOPSIS OF CONTENTS. 
 
 I. The Histologic Elements of the 
 
 Nervous System. 
 II. The Spinal Cord. 
 
 III. The Medulla Oblongata. 
 
 IV. The Cerebellum. 
 V. The Mid-Brain. 
 
 VI. The Region of the Third Ventricle. 
 VII The Membranes of the Brain. 
 VIII. The Cerebrum (Forebrain or Pros- 
 encephalon). 
 
 IX. The Histology of the Cerebral 
 Cortex, Cerebrum Ovale and as- 
 sociation, Commissural and Pro- 
 jection Systems of Fibers. 
 X. The General Anatomy of Interior 
 of the Cerebral Hemispheres. 
 XI. The Circulation of the Brain. 
 XII. Localization. 
 XIII. The Embryology of the Nervous 
 System. 
 
 This is a systematic, practical treatise upon a most important subject 
 that has been in great part neglected by English writers on neurology. 
 Dr. Gordinier has devoted many years to the special study of the nervous 
 system, and has produced a most useful work that will mark an epoch in 
 the literature of medicine. 
 
 The illustrations, of which there are a large number, are chiefly from 
 the author's own preparations. They have been reproduced in the very best 
 manner, the publishers' aim being to give results that are scientifically 
 correct and at the same time pleasing to the eye. In order that certain 
 pictures may be more faithfully shown, they will be printed in colors ; this 
 will bring out the details perfectly, and enable the student to quickly 
 recognize their relative value. Those illustrations borrowed from others 
 have generally been remade, so that they will harmonize with the general 
 style adopted for the work. In some cases these have been improved upon 
 in details that the originals failed to make clear. 
 
 The typography and paper used in printing are of the best, and the 
 publishers have spared no cost to make their part correspond in perfectness 
 with the scientific worth of the text. 
 
 P. BLAKISTON'S SON & CO., Publishers, Phila. 
 
A TEXT-BOOK 
 
 MENTAL DISEASES 
 
 WITH SPECIAL REFERENCE TO 
 
 THE PATHOLOGICAL ASPECTS 
 OF INSANITY 
 
 » 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 ; EXAMINER IN MENTAL DISEASES TO 
 
 THE VICTORIA UNIVERSITY 
 
 Secont) BMtion 
 
 THOROUGHLY REVISED, ENLARGED, AND IN PART RE-WRITTEN 
 
 WITH ILLUSTRATIONS IN THE TEXT, CHARTS, AND 
 TWENTY-SIX LITHOGRAPHED PLATES 
 
 PHILADELPHIA 
 
 P. BLAKISTON'S SON & CO 
 
 IOI2 WALNUT STREET 
 1899 
 

I: 
 
 SIR JAMES CRICHTON-BROWNE, 
 
 -M.D., LL.D., F.R.SS. (LOND. AND EDIN.), 
 
 lORD chancellor's VISITOR IN LUNACY, LATE MEDICAL DIRECTOR OF THE WEST RIDING ASYLUM 
 
 AT WAKEFIELD. 
 
 3^11 BDmicatton of 
 
 THE VIGOROUS INTELLECT, COMiMANDING ELOQUENCE, AND UNTIRING ENERGY 
 
 BROUGHT TO BEAR ON THE SCIENTIFIC ASPECTS OF 
 
 PSYCHOLOGICAL MEDICINE 
 
 DURING HIS DIRECTORATE OF THE WEST RIDING ASYLUM ; 
 
 Mnb in Tkeen Appreciation ot 
 
 HIS WIDE-SPREAD SYMPATHIES AND G E >J E R O U S IMPULSES, 
 
 ^bis IKIlorf^ is De^icateJ) 
 
 BY 
 
 THE AUTHOR. 
 
PEEFACE TO THE SECOND EDITION. 
 
 Since the appearance of the First Edition of this Treatise 
 great advances have been made in our knowledge of the 
 intimate structure of the Nervous System. The new methods 
 of Golgi and his School have thrown light on many obscure 
 points in neuro-histology, and the doctrine of the neuron and 
 neuron chains has had a paramount influence upon problems 
 in nerve physiology and pathology. 
 
 It is hoped that the revision of the Anatomical Section 
 faithfully reflects the change which has come over our con- 
 ception of the nerve-cell, and that this section correctly and 
 concisely expresses the more essential facts which recent re- 
 search has established. The large number of additional plates 
 and illustrations in the text will, it is believed, be welcomed 
 in this section : most of them are from original drawings by 
 the Author. 
 
 In the Clinical Section will be found, as additional mattei' 
 a chapter on Progressive Systematised Insanity ; an account 
 of certain forms of Impulsive Insanity ; a description of the 
 reaction-time instrument ; estimation of muscular sense dis- 
 crimination in general paralysis, alcoholism, &c. ; and a separate 
 chapter on the Treatment of Insanity. Much matter considered 
 less essential has been eliminated. 
 
 In the Pathological Section, the Author has maintained his 
 views of the importance of the Scavenger-cell as a morbid 
 factor in the changes found in the brain of the insane, nor 
 does he find in recent criticism of this view any solid reason 
 for a modification of his opinion as to the role played by 
 it in insanity. 
 
 Finally, he would express his grateful appreciation of the 
 flattering reception accorded to the First Edition, and his great 
 indebtedness to his Publishers, who have spared neither expense 
 nor care in the production of the Second Edition. 
 
 West Riding Asylum, 
 Wakefield, December, 1898. ' • 
 
PPtEFACE. 
 
 Ix wj'iting 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 risum4 
 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 fully 
 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 — tlie 
 structure, nature, and autonomy of the nerve-cell. 
 
X 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. 
 
GENERAL 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 1-141 
 
 THE SPINAL CORD. 
 
 The Cerebro-Spinal Axis — The Central Grey Matter — The White MeduUated 
 Columns — Transverse Section of Cord — Substantia Gelatinosa and Vesiculai- 
 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 Latei-al Pj'ramidal 
 Tract — Posterior Median Column — Postei'O-lateral Columns — Direct Cerebellar 
 Tract — Gowers' Antero-lateral Ascending Tract — Anteiior 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 Stilling — 
 Arcuate Fasciculi — Fillet — Nucleus of Lateral Column — Inferior Olivary Bod^- 
 — Internal and Extei-nal 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 Olivarj^ — Inferior Facial Nucleus — Nuclei 
 of Acoustic Nerve — Sound-rod of Bergmann — Acoustic Striie — Facial 
 Genu — Ascending Trigeminal Root — Abducens Facialis — Superior Olivar}- 
 Body — Lemniscus or Fillet — Upper Angle of Fourtli Ventricle — Posterior 
 Longitudinal Fasciculus — Nuclei and Root-fibi'es of Trigeminal — Locu.s 
 Cceruleus — Nuclei of Oculo-Motor and Tiocldcaris — Root-tibrcs of Fourtli 
 Nerve, Pages 8-28 
 
 THE MESENCEPHALON. 
 
 Advance in Complexity — Tegmental and Crustal Tracts — Internal Caj)sulc — 
 Corpora Quadrigemina and Tiialami — Locus Niger — Knee of Capside — 
 Posterior Perforated S])aee — Basal Aspect of Mcsenceplialon — Tiunia Pontis — 
 Corpora Albieantia — Infundibuiuni and Pituitary Body — Conducting Tracts 
 
xii CONTENTS. 
 
 of Crusta— Fundamental, Mixed and Accessory Systems — Cortical Termination 
 of Tracts— Relationships to Motor Cells of Cortex— Termini of Sensory 
 Columns of Cord — Radiations of <4ratiolet — 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 Tegment and Crusta, Pages 28-41 
 
 THE THALAMENCEPHALON. "~ 
 
 External Conformation— Inner and Outer Face of Optic Thalami— Sub-thalamic 
 Body— Thalamic Peduncles— Fimbria of Fornix— Pillars of Fornix— Cortical 
 Connections of Optic Thalami — Lamina MeduUaris 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. 
 
 Configm-ation 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 Lenticiilar 
 Nucleus— The Claustmm and Insula— Globus Pallidus— Lamina Medullares 
 of Lenticular Nucleus, Pages 49-54 
 
 THE ENCEPHALON AS A WHOLE. 
 
 Comparative and Embryological — The Neural Tube in Amphioxus and in the 
 Lamprey — The Brain in Fishes and Amphibia— 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 Neiu-al Canal — Vesicles of the Fore-brain — Olfactory Lobe — 
 Foramen of Monro— Ganglia of Fore-brain— Pitiiitary Bodj^ — The Neuro- 
 enteric Canal— Vesicle of Mid-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 INIind— Histological Elements 
 of the Cortex — Nerve-cells— Minute Structure — The Cj-toplasm — Nucleus — 
 Dendrites and Thorns— Chemical Constitution— Physiological and Patho- 
 logical —Chromatolysis— Fatigue — Lesion — Conligiu-ation and Nomenclature 
 —The Neuron— Angular Cells— Granule Cell— Pyramidal Cell— Motor Cell- 
 Pyramids of Comu— Cells of Purkinje— Cells with Ascending Axons— Cells of 
 Peripheral Zone— Mitral Cells of Olfactory Bulb— Inflated or Globose Cell — 
 Spindle Cells— Nerve-fibres of Cortex— The Primitive Fibril— Non-MeduUated 
 Fibres— Axis-cylinder Process — Mediillated Nerve-fibre — Myelin Sheath — 
 Keratoid Sheath — Fromann's Lines — Lantermanu's Dissepiments — Centric 
 
CONTENTS. XI 11 
 
 and Pei-iplieric Fibres— Staining of Axis-cylinder — Arteries of the Cortex — 
 Intima — Tunica Media — Tiuiica 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 — Lj'mphatic 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 
 Lympli-connective Elements or Scavenger-cells — Vascular Process of Scaven- 
 ger-cell — iid/e of Spider- or Scavenger-cells, .... Pages 60-101 
 
 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 — Peripheral Zone — -Ascending Axons — 
 Lacunar Layer — Striate Layer — Pyramidal Layer — Polymorphic Cells — 
 Alveus — Fascia Dentata — Stratum Granulosum — Type of Olfactory Bulb — 
 Stratum Glomerulosum — Mitre Cells - Granule and Medullated Layer — The 
 Retina — Rods — Cones Plexiform Layers — Granule Layers — Spongioblasts — 
 Ganglionic Cells — Cerebellar Cortex — Peripheral Layer — Basket Cells — Cells 
 of Piirkinje — Connective Cells — Granule Layer — Moss Fibres — 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 Role, — Electrical Excita- 
 bility of Cortex —Latent Period of Stimulation and the Summation of Stimuli 
 — Conditions AiTecting P^xcitabilitj' — Functional Equivalence of Cortex — 
 Faradic Stimulation of Cortex — Extra-polar Conduction — Conduction to 
 Lower Centres — Proximity of Psycho-motor Centres, . . Pages 101-141 
 
 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 Insanit}' — Insanity at the Periods of 
 Puberty and Adolescence — At the Puerperal Period — At the Climacteric 
 Epoch — Senile Insanity — Treatment of Insanitj', . . . Pages 142-485 
 
 STATES OF DEPRESSION. 
 
 Mental Depression Defined — Decline of Object-consciousness — Rise of Subject- 
 consciousness — Muscular Element of Thought — Failure in the Relational 
 
xiv COXTENTS. 
 
 Element of Mind — Sense of Environmental Resistance — Reductions to 
 Automatic Levels — Sense of Effort — Restricted Volition — Enfeebled Repre- 
 sentativeness — Transformations of Identity — Tlie Physiological Aspect — 
 Defective Circulation — Xutritional Impairment — Explosive Xeuroses — 
 Hunger of the Brain-cell — Painful and Pleasurable Mental States — Re- 
 action-time in Melancholia — Degi-ees of Mental Depression — Clinical 
 Varieties of Melancholia — Simple Melancholia — Delusional Melancholia — 
 Hj-pochondriacal Melancholia — Melancholia Agitans — States of Mental 
 Stupor — Stupor and H}-pnotism — Acute Dementia, . . Pages 142-178 
 
 STATES OF STUPOR. 
 
 Stupor and Dementia — Etiolog}' of Stuporose States — Stupor and Hypnotism — 
 Stuporose Melancholia — Acute Primary Dementia, . . Pages 179-189 
 
 STATES OF EXALTATION. 
 
 Mania<;al Reductions — Failure of Attention — Enfeebled Synthesis — Transient 
 Delusive States — Exalted Sense of Freedom — Impulsive Conduct — Xoctumal 
 Crises — Seclusion Fosters Hallucination — Sexual Illusions — Stadium Melan- 
 cholicum — Enfeebled Imagination — Bodilj- Symptoms — Periodicity of 
 Maniacal Phenomena — Acute Delirious Mania, . . . Pages 190-204 
 
 FULMINATING PSYCHOSES. 
 
 Uniform and Partial Denudations— Defective Control — The Xeurotie and Criminal 
 Subject — Xatiu-e of Impulsive Insanity — Insane Homicidal Impulse — Exist- 
 ence of Aura — Epigastric Aura — L'ncovering 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 — Other Forms 
 of Morbid Impulse — Kleptomania — Dipsomania — Erotomania — Obsessions — 
 Imperative or Dominant Ideas — Insanity of Doiiljt — Aboulia, . Pages 205-220 
 
 STATES OF MENTAL ENFEEBLEMENT. 
 
 31ental Deprivation in Contradistinction to Developmental Ai'rest — 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 {J.O., E.T.) — Religious Monomania (J.B.) — 
 Monomania of Persecution [E.C.) — • Progi-essive Systematised Insanity 
 ( Paranoia ) — Primary Implication — Systematisat ion — Xeuro-pathic Basis — 
 Secondary Systematised States — Tj-pical Psycho-neurotic Form — Folie a 
 deux, Pages 220-235 
 
 RECURRENT INSANITY. 
 
 Definition — Establishment of Labile Equilibrium — Prevalence at Sexual Deca- 
 dence — Heredity — Influence of Neurotic Heritage and of Ancestral Intem- 
 perance — Ata\'ism — Recurrence in the Congenitally Defective Subject — Morbid 
 Excitement and the Moral Imbecile — Alternations of Excitement and Stupor — 
 Hysteria and Menstrual IiTegularity — Eroticism (A . S. , Jf.A . JI.) — Recurrence 
 
CONTENTS. XV 
 
 in Adolescence {M. C. W.) — Recurrence at the Climacteric (H.O.) — at the 
 Senile Epoch (./. ,S'. ) — in Puerperal Subjects (M . 5. )— in Traumatic Insanity 
 (B. L.) — Morbid Impulsiveness — Hallucination and Delusion (/. B.) — Prog- 
 nosis — Treatment, Pages 235-255 
 
 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 Hemiantesthesia — Champing Movements — Pre-parox3'smal Stage — 
 Pi'emonitory Stage — Special Sense Aur;e — Vasomotor and Visceral Auras — 
 The Epileptic Paroxysm — Grand and Petit Mai — Post-paroxysmal Period — 
 Post-epileptic Automatism — Case of E. C. — Status Epilepticus — Inter- 
 paroxysmal Stage — P]pileptic Hypochondriasis, Automatism and Impulsiveness 
 — Medico-legal Relationships — Impulse — Delusion — Malingering — Reg. v. 
 Taylor — Treatment of Epileptic Insanity, .... Pages 255-284 
 
 GENERAL PARALYSIS OF THE INSANE. 
 
 Prodromata — Egoism — Eaily Moral Perversion— Faihire 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 
 — .\rticulatory Impairment — Cerebral Seizures — Syncope — Epilepsy (/. F.) — 
 Unilateral Twitching (/. S.) — Epileptiform Attacks — Conjugate Deviation — 
 Case of H. P. — Apoplectiform Seizures — Monoplegise — Hemiplegia; — Muscular 
 Sense Discrimination — Apparatus for Testing Appreciation of Weight: — Re- 
 action-time — Oculo-motor Symptoms — Spastic and Paralytic Myosis — 
 Mydriasis and Amaurosis — Reflex and Associative Iridoplegia — Cycloplegic 
 Iridoplegia or Ophthalmoplegia Interna — Size of Pupils — Statistical Tables — 
 Consensual Movements — Reflex Dilatation — Associated Irido-motor States — 
 Significance of Pupillary Anomalies— Cycloplegic Forms — Spinal Symptoms — 
 Deep Reflexes — Tabetic (jrait — Incontinence and Retention — Atrophy of 
 Vesical Muscle — The Blood in (xcneral Paralysis — Clinical Croupings of 
 (reneral Paralysis, ......... Pages 285-327 
 
 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 Anajsthesia — Relapses — Case of W. W. — Homicidal Impulse (t/. S.) 
 — Chronic Alcoholism — Physiological effects of Alcohol— Evolutionary Period 
 — Mental, Sensorial, aiid Motoi'ial Sj'mptoms (./. J.^) — Anniesic Forms (,/. F.) 
 Conditions of Mental Revivability (M. It. L.) — Delusional Forms (T. S.) 
 — Instances of "Environmental Resistance" — Visceral Illusions — The Epi- 
 gastric Voice — Various Illusory States {E, A. F.) — Evolution of Psychical 
 Phenomena — The Nervous Discharge— Hallucinations as Determining Morbid 
 Ideation — Augmented Sjjecific Resistance — Sensory Anomalies — Motor 
 
XVI CONTENTS. 
 
 Enfeeblement (./. i?.) — Twitchings, Tremors, Stolidity — Reaction-time in 
 Alcoholism — Muscular Spasms and Cramps — Oculo-motor Immunity — 
 Nystagmus — Epileptiform Attacks — Hemiplegiaa ( T. P. and /. C. ) — Classifi- 
 cation, Pages 327-370 
 
 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 — 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 (^1. H.) — Amenorrhceal and Anjemic 
 States— Influence of the Environmental Factors — Percentage of Haemoglobin 
 in Cases of Stiipor — Pubescent Insanity in the Male — Sexual Divergence — 
 Symptoms of Piibescent Insanity — Modified Forms {J. M. ) — Masturbatic and 
 Uncomplicated Form of Pubescent Insanity — Etiology — The Moral Imbecile, 
 
 Pages 370-398 
 
 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 Primiparje — Condition of 
 the Blood — Diminution of Htemoglobin — Prognosis — Treatment — Insanity of 
 Pregnancy — Relatively Infrequent — Primiparte Show no Special Liability — 
 Symptoms — Recoveries, ........ Pages 398-409 
 
 INSANITY AT THE PERIOD OF LACTATION. 
 
 Risks attendant upon Lactation — Period of Uterine Involution — Period of 
 Mammary Excitation — Symptoms — Depressing Delusions — Impulsive Nature 
 (3/. W.) — Suicide(i/. Z>.) — Caseof ^. E. C. — Intensity of Maniacal Excitement 
 — Sexual Perversions — Hallucinations — Etiology — Exhaustion and the 
 Sequelae of Labour — Protracted Uterine Involution — Lactation during 
 Profound Ansemia — Hyperlactation — Qualifications of the Nursing Mother — 
 Period for Weaning — Prognosis — Treatment, .... Pages 409-424 
 
 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 Symptoms — A Subacute Delusional Melancholia — Suicidal Tendency [S. H.) — 
 Nymphomania {A. A.) — Etiology — Incidence of Insanity at dilferent ages in 
 4085 cases — Influence of the Climacteric— Tlie Psychological Transformations 
 of this Epoch — Instinctive Actions— The " Time.-eltment" in Prognosis — 
 Alcoholism and tlie Climacteric — Treatment, . . . ' . Pages 424-437 
 
 SENILE INSANITY. 
 
 Mental Derangements Incident to Senility — Senile Mania — Senile Melancholia — 
 Chronic Cerebral Atrophy — Senile Convulsions — Senile Epilepsy — Senile 
 
CONTENTS. XVII 
 
 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 (/. .4.) — Senile 
 Atrophy and Thrombosis (/. i?.)- Acute Senile Melancholia and .'>yiicopal 
 Attacks {H. 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 M. M.) — Elimination of Urea in Chronic 
 Cerebral Atrophj- and Premature Senility — A Local Manifestation of Chronic 
 Bright's Disease, ......... Pages 437-4(30 
 
 THE TREATMENT OF INSANITY. 
 
 Physiological Element in Treatment — The Moral Element — The Mental Nurse — 
 Individualised Treatment — Hospitals for the Acute Insane — Modern Revolu- 
 tion in Treatment — Rest and Exercise — Treatment of Delusion — Destructive 
 Habits — Suicidal Tendencies — Therapeutics — Rdle of the more important 
 Sedatives Employed : — Chloral — Chloralamide — Paraldehyd — Sulphonal — 
 Trional — Tetronal — Hyoscyamine — Duboisine — Opium — Cannabis Indica — 
 Conium Pages 4G0-4S5 
 
 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 486-594 
 
 GENERAL PATHOLOGY AND MORBID ANATOMY. 
 
 The Cranium-— Dura Mater — Pia-arachnoid — Arachnoid H;emorrhage — Adherent 
 Pia — Vascular Apparatus — Congestion — Inflammatio7i — Softening — Atroplijr 
 — Miliary Sclerosis — Colloid Degeneration— Granular Disintegration of Nerve- 
 cells — Pigmentary or Fuscous Degeneration— Developmental Arrest of Nerve- 
 cells — Vacuolation of Cell-j)iotoplasm — Vacuolation of Nucleus — Destruction 
 of Intra-cortical Nerve-fibre plexus — Tissue Degradation from Over-strain — 
 Tissue Degradation from Active Morbid Processes — Tissue Degradation from 
 Disuse — General Summary, ....... Pages 486-547 
 
 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 Tilt Brain and ils il/emhranes: — Early Implication of Vascular Tissues — Vital and 
 Mechanical Efiects — Effects on Lymph-connective System — Intracellular 
 Digestion — Jidle of Phagocytes, or Scavenger-cells — Character of Scavenger- 
 element — Its Vascular Process — Fuscous Degeneration of Nerve-cells — Three 
 Stages of Morbid Evolution : — InHainmator}' Engorgement — Implication of 
 Pia-arachnoid— Nuclear Proliferation of Adventitia — Paralj'sis of Arterial 
 tunics — -Diapedesis^ — Exudalitui — Htemorrhagic Transudations — Arachnoid 
 
 b 
 
xvill CONTENTS. 
 
 HEemorrhage — 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 — Change ^ in Vascular, Connective, and Nervous 
 Elements — System-implication of Lateral Columns — Secondarj' to Cortical 
 Lesions — Respects Sj'stematic 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 
 Columns — Pseudo-tabetic Forms — Ataxic Tabes — Loss of Knee-jerk— Anorexia 
 — Flashing Pains and Sensory Symptoms — Genuine Tabetic Form in General 
 Paralysis, Pages 548-675 
 
 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 575-581 
 
 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 M otor 
 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 Medullated 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 — Neiu'otic 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 Impli- 
 cation of Cord — Constitutional State that of Chi'onic Bright's Disease — 
 Exceptional Transition to General Paralysis — Significance of Arterial Changes 
 — Aflection of the Visceral System, Pages 581-594 
 
DESCRIPTION OF PLATES. 
 
 PLATE I. 
 
 Illustrative of the "Motor Type" of Cortex. Page 62. 
 
 The section taken from the extra-limbic area of rabbit's brain, near the frontal 
 pole of lienaisphere. 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 sub-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. L Olfactory root. 
 J. Corpus callosum. K. Parietal sulcus. S. Sylvian depression. T, Limbic 
 fissure. The types of cortex ai'e indicated bj' the siibjacent scheme. 
 
 PLATE n. Page 70. 
 
 Fk;. 1. Cerebellar Cortex of Young Rat. 
 
 Section in direction of lamina, showing the arrangement of cells of Purkinje, 
 and the T-shaped fibres arising fi'om the underlying graniiles. Sublimate pre- 
 paration. X 110. 
 
 Fig. 2. 
 
 Section across lamina showing arborisation of dendrites of cells of Purkinje and 
 their descending axons. Sublimate preparation. x 110. 
 
 PLATE in. Page 74. 
 
 Fig. 1. Cerebellar Cortex of Mouse. 
 Showing cells of Purkinje, granules, and moss-fibres. Sublimate preparation, 
 
 X no. 
 
 Fig. 2. Cerebellar Cortex of Max. 
 
 Showing stellate cells in neighbourliood of cells of Purkinje, distributing branches 
 upwards to the peripheral zone; section taken across lamina. Sublimate pre- 
 paration. X 110. 
 
 PLATE IV. Page 82. 
 
 Fig. 1. Cerebellar Cortex (Human). 
 
 Section in direction of lamina sliows large stellate nerve-cell near cells of 
 Purkinje; the latter are truncated; a few terminal dendrites occu])y outer half of 
 peripheral zone, tlie liorizontal fibres being derived from the granules below. 
 Sublimate preparation. ■- 110. 
 
XX DESCRIPTION OF PLATES. 
 
 Fig. 2. Olfactory Bttlb of Rat (Semi-diageam). 
 
 Arrangement of mitre-cells in relationship to their centric and peripheric dis- 
 tribution. 
 
 PLATE V. Page 92.. 
 
 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 VI. Page 100. 
 
 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 
 gyi'us of human brain. x 157. 
 
 PLATE VII. Page 104. 
 
 Fig. 1. Cerebral Cortex : Nerve-cells of Second Layer (Rat). 
 
 Showing characteristic groupings of cells : the dendrites are notably hirsute^ 
 and the terminal dendi'ites of a large nerve-cell from the subjacent layers pass, 
 upwards betwixt the two groups. Sublimate preparation, x 110. 
 
 Fig 2. Cornu Ammonis of Young Rat. 
 
 Shows pyramidal nerve-cells of Cornu and granules of fascia dentata. Sublimate 
 preparation. x 110. 
 
 PLATE VIII. Page 108. 
 
 Fig. 1. Cerebellar Cortex of Mouse. 
 
 Shows granular layer between cells of Purkinje, and tlie T-shaped fibres of 
 peripheral zone. Sublimate preparation. x 110. 
 
 Fig. 2. Cerebral Cortex of Rat. 
 
 Arrangement of stellate connective element beneath pia coA-ering peripheral 
 zone ; transitional elements are also shown interblending with the terminal 
 arborisations from nerve-cells of underlying strata. Silver-chi'ome pieparation. 
 X 110. 
 
 PLATE IX. Page 114. 
 
 Fig. 1. Cerebellar Cortex (Mouse). 
 
 . Shows basket-work around cells of Purkinje : axons from intrinsic cells of 
 pei'ipheral zone are seen contributing bj' numerous descending collaterals to this 
 
■DESCRIPTION OF PLATES. XXl 
 
 basket-work, which in the specimen is much obscured by the dense deposit of 
 sublimate. Sublimate prepaiation. x 360. 
 
 Fig. 2. Scheme of Retinal Layers ix Mammals. 
 As indicated by the more recent researches of Ramon-y-Cajal. 
 
 PLATE X. Page 116. 
 
 Fig. 1. " Sensory Cortex." 
 
 Taken from the "modified upper limbic" ty^^e in the brain of the rabbit. 
 This area is represented in the small figures on the i-abbit's brain on this plate by 
 the dotted area covei'ing the inner and mesial aspect posteriorly, internal to the 
 parietal sulcus, K. 
 
 Fk;. 2. "Modified Olfactory Type." 
 
 Taken from the posterior extremity of the lower limbic arc of the rabbit's brain. 
 The area is represented in the first of the three figures, and is lettered T, The 
 large swollen cell of the second layer is a notable feature of this cortical area. 
 X 210. 
 
 PLATE XL Page 124. 
 
 Fig. 1. Cerebral Cortex (Rat). 
 
 Arrangement of nerve-cells of cortex beneath "outer olfactory root." Silver- 
 chrome preparation. x 1 10. 
 
 Fig. 2. Cerebral Cortex of Rat. 
 
 Nerve-cells showing extremely hirsute dendrites and descending axons. Sub- 
 limate preparation. x 110. 
 
 PLATE XIL Page 132. 
 
 Section through "Motok Cortex" of Brain of Cat. 
 Specially prepared to show relationships existing between the nerve-cells and 
 the lymphatic channels and saccules of coi'tex. The connection of the pericellular 
 sacs with the blood-vessels is clearly indicated, as is also the arching of the 
 nutrient vessel around the nerve-cell. The perivascular nuclei in some cases 
 alone indicate the position of the Ij'mphatic sheath. 
 
 PLATE XIII. Page 136. 
 
 Fig. 1. Spinal (iAXGLrox-CELL ok the Frcx; (Von Lenhossek). 
 
 The nucleus shows a deep stained nucleolus, a faint linin network beset with 
 chromatin granules. The filar element is faintly represented in the cytoplasm, 
 but tlie chromophilic granules of Nissl are a notable feature, together with tlie 
 finer granular vortex licncatli the nucleus, representing the so-called coitrosonie. 
 Two small connective tissue cells appear to the left. This figure is l)orr()wed from 
 Wilson's The (Jell in DfreJopmciil and Iiiheritaiire. 
 
 Fjc. 2. CoR'I'KX OK ClORKBRUM (PiG, TWO 1)A>'S OM)). 
 
 Sublimate preparation taken from near mesial aspect of iicmisplicrc. SubUmate 
 prepai-ation. x 110. 
 
Xxii DESCRIPTIOX OF PLATES. 
 
 PLATE XIV. Page 512, 
 
 Fig. 1. DEGE>-EBATioy of Meduulated Eibees rs" Lateeal Coltthxs of Spts'Ai. 
 Coed foemikg so-calxed "Miliae.t Sclerosis," as seex ttn^der a Low- 
 power Objective. 
 
 The pale nodular stmctures are the " miliary" patches into which varicose and 
 moniliforni fibres are seen to pass ; most of such patches are multilocular, and are 
 snrroimded by deep-stained sclerosed tissue. 
 
 Fig. 2. -'Colloid" Patches resultixg from Degexeratiox of Medfll-^ted 
 Fibres of Spix-^l Cord — more Highly Magnified. 
 
 The multilocular constitution of the patch is mdicated by delicate outlines ; 
 axis-cylinders devoid of medulla are seen passing into the degenerated focus ; and 
 
 scavenger-ceU is seen thrusting its ramifying processes into the substance of the 
 colloid patch. 
 Fig. 3. "Colloid" Patch still more Highly ^vIagnified to show the 
 
 Oi:TLT>"E of ^IrLTTLOCrLAE iL\TERLA^L WITH A FiXE StEOMA OF ELASTIC 
 
 Fibres Arol-^'d. x 350. 
 
 PLATE XV. Page 516. 
 
 Degener-A-TIOX of K'erve-fibres of Lateral Columns of Spinal Cord ix 
 so-called '-'Colloid Degeneration" of these Tracts. 
 
 The axis-cylinders are seen stripped of their meduUated sheath, or surrounded 
 by moniliform medulla undergoing granular degeneration, each with a super- 
 imposed nucleus, which reaUy represents a young seavenger-ceU. At other parts 
 of the field the medulla is seen in process of segmentation, and attacked bj- 
 scavenger-cells crowded -with granular contents. 
 
 PLATE XVI. Page 520. 
 
 " Colloid Degeneration." 
 
 Portion of inferior olivary and accessory olivary bodies in a case of glosso-labio- 
 larjTigeal paralysis {T. W., p. 520), showing spheroidal products of degenerated 
 medullated fibre, and the complete immunity from morbid change presented by 
 the grey matter. x 22. 
 
 PLATE XVII. Page 5-26. 
 
 Fig. 1. "Colloid Degeneration." 
 
 Showino- 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 foeming the 
 Aecifoem Steipe of the Peeipheeal Zone of the Coetex in a Case of 
 Advanced Senile Atrophy of the Beain. 
 
 Numerous scavenger-cells are scattered amongst the degenerate fibres, and oil- 
 globules crowd upon the vessels in their vicinity. x 350. 
 
DESCRIPTION OF PLATES. xxiii 
 
 PLATE XVIII. Pageo8(J. 
 
 To Illustrate Sclerosis of Cerebellar Cortex in a Case ok 
 Ei'iLEPTic Imbecility. 
 
 A. Healthy leaflet closeh' adjoining diseased tract, showing the cells of Puikinje 
 iininvolved. 
 
 B. The sclerosed leaflets united lirmly together, the cells of Purkinje absent, 
 and the normal structiu'e completely altered. 
 
 PLATE XIX. Page 544. 
 
 To Illustrate Sclerosis of Cornu Ammonis in Epileptic Insanity. 
 
 A. Peripheral zone in gyius hippocampi. 
 
 B. Vacuolated cells beneath the above, 
 
 PLATE XX. Page 5.V2. 
 
 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 sucli a vacxiole appears to have burst through the 
 cell-protoplasm, or the latter contains numerous small vacuoles, the unaffected 
 protoplasm still staining deeply. 
 
 PLATE XXI. Page 5.56. 
 
 Extreme Degrees of 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 
 branches. Tlie retracted protoplasm and displaced nucleus are evident features. 
 X 350. 
 
 PLATE XXIL Page 560. 
 
 Fuscous Degeneration of Large Ganglionic Cells from the 
 Motor Cortex of Human Brain. 
 
 The pale patches repiesent the areas of pigmentary degeneration, the mass being 
 coarsely granular and of bright yellow tint. The unaffected pi'otoplasm is seen 
 retracted and stained by the aniline dye, and the apex of one of these cells is 
 pigmented and stunted. x 350. 
 
 PLATE XXIII. Page 568. 
 
 Fji:. 1. Fatty Degeneration and Atrophic Shrinking of the Pkkii'Heral 
 Zone (1st Layer) of Cortex in a Case of Advanced Senile Atrophy 
 of the Brain, taken from a Section of the Ascending Frontai- Con- 
 volution. 
 
 Scavenger-elements are seen profusely scattered through the upper layers, 
 invading the vascular-tracts and surrounding the nerve-cells. The latter arc 
 diminished in numbers, and a notable sclerous sluiiiking of tliesc superficial layers 
 of the cortex is evident. x 130. 
 
XXIV DESCRIPTION OF PLATES. 
 
 Fia. 2. Patty Disixtegkation of Cortex i>" a Case of Advanced Senile 
 Atrophy of the Braix. 
 
 The peripheral zone (first layer) is here delineated, the vasevdar walls as well as 
 the scavenger-cells are surrounded by collections of oil-globules and fatty dtbris. 
 X 350. 
 
 Pk;. 3. Xerve-cells from the Deeper Layers of the Cortex undergoixg 
 
 DlSIXTEGBATIOX AND REMOVAL BY THE AgEXCY OF SCAVENGER-CELLS WHICH 
 
 st'rrouxd them. 
 
 The uerve-cells are seen in difi'erent 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 
 nerve-disintegiation around them. x 350. 
 
 PLATE XXIY. Page 584. 
 
 Fig. 1. Granular DegenepvAtion of Ner^-e-cells. 
 
 Taken from the fifth layer of motor cortex in a case of chronic alcoholic insanitj'. 
 Proliferation of the perivascular nuclei as well as the pericellular elements is 
 evident, and a coarse granular degeneration of the protoplasm of the nerve-cell 
 has occurred. x 210. 
 
 Fig, 2. Invasion of Deepest or Spindle-cell L.\yer of the Cortex by" 
 Scavenger-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 180. 
 
 Fig. 3. AxErRVSMAL Dilatation of Perivascular Sac ix' a Case of 
 General Paraly'Sis. x 210. 
 
 PLATE XXV. Page 588. 
 
 Scavenger-elements in fihst layer of Cortex of Human Brain, Illus- 
 trating TILEIR MODE OF PROLIFERATION AXD PERMEATION OF THE C0RTIC.\L 
 
 Structure by' their Fibrillation. 
 
 The coarse vascular processes may readily be distinguished from the finer fibrils 
 given off bj' these organisms. x 240. 
 
 PLATE XXVI. Page 592. 
 
 Degexeratiox of Nerve-cells ix Humax" Cortex. 
 
 Taken from a section of the motor region to illu.strate the mode of connection 
 and relationships existing between the scavenger-elements of the lymph-connective 
 system and the cortical blood-vessels. The swollen granidar degenerated nerve- 
 cells are seen attacked on all hands by the scavenger-elements, x 210. 
 
DESCRIPTION OF WOODCUTS. xxv 
 
 DESCRIPTION OF CHARTS. 
 
 Chart A. Chart of recoveries in insanity of the climacteric. Page •2')2. 
 
 ,, ,, recurrent insanity. 
 
 Chart B. Chart of recoveries in insanity of pubert}- and adolescence in both sexes. 
 
 Page 396. 
 Ch.\rt C. Chart of recoveries in insanity of the puerperal and lactational j^eriods. 
 
 lacre 422. 
 
 DESCRIPTION OF WOODCUTS. 
 
 FIG. PAGE 
 
 1. Section across transitional region of medulla, showing decussation of 
 
 pyramidal tract aiid nuclei of posterior columns, . {ScJura/he), 6 
 
 2. Cross-section of medulla oblongata at the upper decussation of the 
 
 pyramidal tract, ....... {Schira/haj, . 9 
 
 3. Section of medvilla 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 ci- Stirliwj), 18 
 
 5. Section through pons on a level with the origin of the great root of 
 
 the trigeminus, ........( Wernic/ce), 22 
 
 6. Scheme of segmentation of third nerve nuclei, showing presiuned 
 
 anatomical and physiological relationships, ..... 27 
 
 7. Horizontal section through hemispheres, the right at a deeper level 
 
 than the left, ...... {Landois d Stir/imj), 30 
 
 8. Section thi'ough hemispheres (vertical transverse), passing through 
 
 plane of middle commissure, ..... {Gegenhaiir), 50 
 
 9. Cerebral cortex ; nerve-cells of second layer; higher ampliiication (rat), . 72 
 
 10. Pyramidal nerve-cell of motor cerebral cortex (hunian), ... 77 
 
 11. Cerebral cortex ; nerve-cell from deeper zone of cortex (human), . . 79 
 
 12. Cerebral cortex ; nerve-cells of second layer wth extensive lumificatiun 
 
 of axons (rat), ........... 81 
 
 13. Cerebral cortex ; spindle-cells of deepest laj'er (human), ... 81 
 
 14. Cerebi-al cortex ; granules of fascia dentata — cornu Annnonis (ral)bit). 111 
 
 15. Cerebral cortex ; nerve-cells of second layer ; descending axons, . . 127 
 
 16. Left ascending frontal and parietal convolutions seen from the side, 
 
 with tlie attached frontal gyri included in scheme of examination of 
 detached cell groups, . . . . . . . . . .129 
 
 17. Left ascending frontal and parietal gyri, with the attached frontal 
 
 convolutions as seen at vertex, to illustrate site of detached cell- 
 groups, ............ l.SO 
 
 18. Reaction-time apparatus, ......... 162 
 
 19. Scheme of segmentation of third nerve nuclei, siiowing presumed 
 
 anatomical and physiological relationships, ..... 308 
 
 20. Scheme illustrative of pupillary reactions, 318 
 
XXVI DESCRIPTION OF WOODCUTS. 
 
 FIG. PAGE 
 
 21. Mesial aspect of human brain, illustrative of the more frequent site of 
 
 localised softenings in order of precedence, ..... 506 
 
 22. Lateral aspect of human brain (right hemisphere), illustrative of the 
 
 more frequent site of localised softenings in order of precedence, . 506 
 
 23. Section across hemispheres and basal ganglia, illustrative of the site of 
 
 localised softenings, in order of precedence, ..... 507 
 
 24. Lateral aspect of left hemisphere of human brain, illustrative of the 
 
 sites of election of atrophy, in order of precedence, . . . .511 
 
 The Author would wish to acknowledge his indebtedness to the Cambridge 
 Scientific Instrument Company, the Editors of the British Medical Journal, and 
 Messrs. Macmillan for permission to utilise Figs. 18 and 20, and Plate xiii. , 
 Fig. 1. 
 
A TREATISE 
 
 MENTAL DISEASES, 
 
 PART I.— ANATOMICAL AND HISTOLOGICAL SECTION. 
 
 Contents.— The Spinal Cord— The Medulla Oblongata— The Mesencephalon— The 
 Thalamencephalon — The Prosencephalon— The Encephalon as a whole — The 
 Cerebral Cortex— Cortical Lamination. 
 
 THE SPINAL CORD. 
 
 The cerebro-spinal axis consists of a series of longitudinally disposed 
 columns of white medullated 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 diff"ei'ent 
 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 v/ell as the "bilateral symmetry" referred to, ere we describe 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 Oblong'ata, 
 and into the much larger and more important ganglionic masses at the 
 base of the cepebPUm. 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 off, 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 
 continuoiis tracts throughout the whole cerebro-spinal axis; they consti- 
 
 1 
 
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 the longest 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 
 destined. 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 a functional 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 forcibly 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 former, as the cerebral hemispheres and cere- 
 bellum, 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 
 core. We shall find this appertain to the radiating fibres received by 
 
SUBSTANTIA GELATINOSA AND VESICULAR COLUMNS. 3 
 
 the cerebFum, the cerebellum, the thalamus, quadrig-eminal 
 bodies, the geniculate, and the inferior olivary, in particuUir ; 
 
 and, in almost all alike, we shall find even to the cerebral hemi- 
 spheres, a zonular layer of medullated fibres bounding the grey 
 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 lumbar 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 
 bulbous; 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 gelatinosa 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 
 distinctly clustered, similar cells which appear as the representatives 
 of the same formation. Dr. Ross traces this formation as reaj)pearing 
 in the lower end of the medulla oblongata, where he considers it to be 
 * These cells have been spoken of as " bipolar," but this is an error, since few of 
 tlie elements fail to show several processes. 
 
^ THE SPINAL CORD. 
 
 represented by the nucleus common to the origin of the spinal acces- 
 sory, vagus, and glosso-pharyngeal 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 (Gaskell). 
 
 In the posterior horn, we find sparsely scattered cells of fusiform 
 contour and of small size (15/x), 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 projection 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 intepmedio-lateral 
 tract of Clarke : it contains a cluster of cells which higher up fuse 
 with the postero-lateral group already alluded to. 
 
 The outer margin of grey is behind this site blended in a coarse 
 meshwork with the neighbouring white medullated strands, consti- 
 tuting the so-called formatio reticularis. 
 
 The white medullated substance of the cord investing this central 
 crrey mass is roughly distinguished into an anterior, lateral, and 
 
PYRAMIDAL TRACTS. 5 
 
 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 
 emhryological research indicating their inechillated development at 
 distinct periods of life ; or again, by the facts of the AVallerian 
 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 
 Turcl:). 
 . 2. — Anterior radicular (or root) zone (also termed anterior ground 
 fibres of Flechsuj). 
 Laterally — 3. Lateral or crossed pyramidal tract. 
 ■4. Direct cerebellar tract. 
 
 5. Antero-lateral ascending tract of Gowers (also extending forwards). 
 
 6. Lateral limiting layer. 
 
 Posteriorly — 7. Postero-extemal (or postero-lateral) column [column of Burdach : 
 posterior radicidar zone : posterior ground fibres of Flechsig). 
 8. Postero-internal (or postero-median) column (column of Goll). 
 
 Direct PyPamidal Tracts. — A certain proportion of the fibres of 
 the anterior pyramids 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 
 ■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 the 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, py), the lateral tract passes down 
 in the posterior section of the lateral columns, becoming like the anterior 
 direct tract, progressively diminished in size to the lowest level of the 
 * In rare exceptions even less than half the pyramidal fibres decussate at this 
 level (Flechsig). 
 
6 THE SPIXAL CORD. 
 
 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 through the intervention of their terminal arboriza- 
 tions. The direct and crossed pyramidal tracts represent a continuous 
 connection with the cortex of the motor area of the brain, passing un- 
 interruptedly in this course through the CrUSta of the cePebral 
 
 peduncle and the internal capsule. 
 
 r.jj.aL 
 
 Fig. 1. — Section across transition region of medulla, showing decussation of 
 pyramidal tract and nuclei of posterior columns. 
 
 s.l.p. Posterior longitudinal sulcus. 
 n.g, Xucleus funiculi gracilis. 
 n.c, Xucleus funiculi cuueati. 
 5"!, Funiculus gracilis. 
 H'^, Funiculus cuneati. 
 c.e, Xeck of posterior liorn. 
 g, Head of posterior horn. 
 r.p.C.L, Posterior I'oots of first cervical 
 nerve. 
 
 X, Cell group in base of posterior cornu. 
 cc. Central canal. 
 S, Lateral column. 
 
 a and 6, Cell clusters in anterior cornu. 
 C.a, Anterior cornu. 
 pii. Pyramidal tract from lateral columns 
 
 decussating at d as they ascend. 
 f-l.a, Anterior longitudinal tissure. 
 /. r, Formatio reticularis. 
 
 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. 
 
LATERAL COLUMNS AND TRACTS. 7 
 
 PostePO-Lateral Columns cannot, like the postero-median, be 
 regarded as largely a continuo^is tract throughout the spinal cord. A 
 great 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 CUneate 
 
 nucleus. 
 
 Direct CePebellar 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 fi'ont of the crossed pyramidal and direct cere- 
 bellar tracts. The tract is regarded as a sensory tract originating 
 from root fibres of the sensory nerves decussating across the posterior 
 commissure.* Arising in the lumbar region where it lies across the 
 lateral columns on a level with the posterior commissure, it becomes 
 placed, higher up in the cord, more superficial. Here, ia transverse 
 section, it forms a comma-shaped tract, its head lying betwixt the 
 crossed pyramidal and direct cerebellar tracts, whilst its attenuated 
 tail extends along the outer border of the cord, almost as far as the 
 anterior median fissure. It can be traced up into the medulla in 
 front of the direct cerebellar tract, but where the latter unites with 
 the restiform body, its further course is not definitely ascertained. 
 Some authorities {BecJderevj, Bruce, and Tooth) suggest its termination 
 in the lateral nuclei ; others {Iladden and Sherrington) trace it into 
 the restiform tract. 
 
 Anterior Radicular Zone and Lateral Limiting: Layer.— 
 
 These may be considered together as constituting, likf many of the 
 fibres of the posterior radicular zone, a series of short commissural 
 fibres uniting the grey matter at different levels. In the case of the 
 
 * Diayno.-iis of Di'^nw^ti of the Spinal Cord, First Kd., 1879 ; and Diseases of the 
 Nervoiis System, vol. i., page 12-2 ((iowers). ■ 
 
Q THE MEDULLA OBLONGATA. 
 
 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." (Gotcers^'). 
 
 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) Burdacli's columns (in part). 
 Descending motor from cortex cerebri — 
 
 (4) Tiirck's columns. 
 
 (5) Crossed pyramidal tract. 
 Ascending sensory tracts — 
 
 (6) Goll's columns from posterior roots. 
 
 (7) Direct cerebellar from visceral tract. 
 
 (8) Anterodateral ascending from crossed sensory roots. 
 
 THE MEDULLA OBLONGATA. 
 
 A transverse section taken just below the calamUS SCriptoriuS 
 so as to reveal the central canal intact, ere it opens out on the 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 olivary reg'ion. 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 medullated fibres 
 seen in transverse section encircled by medullated loops — the Solitary 
 
 fasciculus, fasciculus rotundus or respiratory fascicle. From 
 
 this point the central grey matter inclines backwards to the middle 
 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. 
 On each side of the central canal a column of fibres enclosing an 
 
 * Loc. cit., i^. 123. 
 
eminently: teretes. . 9 
 
 elongated nucleus of nex-ve corpuscles, measuring 23 /x x 11 /x, 
 extends forwards towards the middle line ; and here, still enclosed 
 in the central gx'ey area, is a mesial compact cluster of small cells. 
 The former represents the nucleus of the emineniia or fasciculus 
 teres, which at higher levels becomes a prominent feature on the 
 floor of the ventricle. Root fibres of the 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. 
 
 Ip ^ ' /'S J^' n.c. 
 
 Fig. 2. — Cross-section of medulla oblougata at the upper decussation 
 of the pyramidal tract. 
 
 s.l.p. Posterior longitudinal sulcus. 
 H^, Funiculus gracilis. 
 a.g. Nucleus of funiculus gracilis. 
 H-, Funiculus cuoeatus. 
 n.c. Nucleus of funiculus cuneatus. 
 n.c^, External nucleus of funiculus cu- 
 neatus. 
 a.V, Ascending root of trigeminus, 
 f/, Substantia gelatinosa. 
 f.a, f.a^, f.a-, External arciform fibres. 
 F.r, Formatio reticularis. 
 n.l, Nucleus of lateral column. 
 
 u^, Accessory olive. 
 
 0, Inferior olivary body. 
 
 n.ar. Nucleus arciformis. 
 
 P>/, Pyramid. 
 
 f./.a, Anterior longitudinal fissure. 
 
 d.a, Anterior or upper decussation of 
 pyramids. 
 
 n.XII, Nucleus and root fibres of hypo- 
 glossal nerve. 
 
 c.c. Central canal. 
 
 n.XI, Nucleus of siiinal accessory. 
 
 Above the calamus 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 eminentise tCPCtes, which, 
 as we stated, formed the antero-lateral V)Oundaries of the central canal, 
 become now exposed on the surface, as the innermost column seen 
 in this lower half of the ventricle, on either side of the median 
 
lO THE MEDULLA OBLONGATA. 
 
 raphe. Formerly covered by the ala CinePea, which represents 
 the nucleus of the vagus, the fasciculi teretes pass upwards as white 
 columns, strongly contrasting with the grey of the vagus nucleus ; 
 and, as they take this course, they lie superjacent to the hypoglossal 
 nuclei. These eminences, therefore, map out the course of the hypo- 
 glossal nuclei, but must not be identified with that nerve, as they 
 belong to a wholly distinct system. Whilst the white columns of the 
 eminentife teretes become wider and more pronounced upwards, the 
 ala cinerea disappears between them and a more external eminence — 
 the acoustic tubercle — so that transverse sections exhibit on either 
 side of the median raphe from within outwards the eminenti3& 
 
 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 strlSB 
 acOUStiCSe, 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 hypog'lOSSal and the vag^O- 
 
 aecessory nuclei (fig. 3). 
 
 Having so far followed the disposition of the central grey matter,, 
 from just below the opening-up of the central canal to the level of the 
 strise medullares of the acoustic nerve, the student should now direct 
 his attention to a cross-section of meduUated fibres of a notable 
 crescentic configuration, and encircling on its outer side a coarsely 
 reticulated region largely made up of deep stained connective tissue. 
 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 g'elatinosa of the posterior cornu. The medul- 
 lated crescent is the ascending root of the fifth nerve, representing 
 
ANTERIOR AND LATERAL COLUMNS. 
 
 II 
 
 the ascent of the remaining portion of the posterior root zone of tlie 
 spinal cord. Drawing an imaginary line from the solitary fasciculus 
 outwards to this crescent — to its anterior border in the lower levels, 
 and to its posterior border in the higher level near the acoustic — we 
 map off 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 inferior olivary 
 
 „ nX' , nX' 
 iiJUl f/ /J J' 3 
 t I __.?!>^-^*^' n c 
 
 oa.TTi 
 
 fla ,,„,. p 
 
 Section'of medulla oblougata tlirough the inferior olivary bodies. 
 o.a.l. Outer accessory olive. 
 
 Fig. 3 
 ■n.t. Nucleus of fasciculus teres. 
 n.XII, Nucleus of hypoglossal nerve. 
 n.X and n.X^^ Nuclei of vagus. 
 f.s. Funiculus solitarius. 
 n.g, Nucleus of funiculus gracilis. 
 n.c, Nucleus of funiculus cuueatus. 
 n.am. Nucleus ambiguus. 
 C.i\ Restiform tract. 
 g. Substantia gelatinosa. 
 a. F, Ascending root of trigeminus (fifth 
 
 nerve), 
 i^'.r, Reticular formation of lateral column 
 a.X, Root fibres of vagus. 
 
 n.l, Nucleus of lateral columns. 
 f.a.e, External arciform fibres, 
 o, Inferior olivary body. 
 XII, Emergent root fibres of hypoglossal. 
 J), Anterior pyramid. 
 n.ar. Nucleus arciformis. 
 f.l.a. Anterior longitudinal fissure. 
 p.ol. Olivary peduncle. 
 o.a.ni, Inner accessory olive. 
 V, Anterior column. 
 r, Median raphi.'. 
 
 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 drawn to the crescentic root of the fifth nerve. 
 The inner of the two divisions corresponds to the antePiOP COlumil 
 of the cord; the outer division, to the lateral COlumns. I'he two 
 imaginary lines, so drawn, correspond to the direction taken by a 
 
12 THE MEDULLA OBLONGATA. 
 
 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 antePiOP or motOP, a latePal or 
 
 mixed system, and a postepiop or sensopy 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 tei'ritory, lies the solitary fasciculus, and the ascending 
 root fibres of the fifth nerve around the gelatinous substance of 
 Rolando. The crescentic root-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 
 PestifOPm tPact of the cerebellum. 
 
 At this level it will be apparent that large numbers of delicate 
 arched fasciculi are thrown ofi* 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- 
 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 
 opposite 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 tind 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 the divergent course assumed by the resultant 
 
RESTIFORM AND INNER DIVISION OF CEREBELLAR PEDUNCLE. I 3 
 
 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 meduUated fibres seen in cross-section, no7ie 
 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 /a, x 22 /a, 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 /x X 20 /x. 
 
 The medullated formation so constituted is an important division 
 of the medulla to recognise. It has been long known as the inneP 
 
 division of the inferior cerebellar peduncle— the restiform 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 connection 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, terminate in the grey matter of the 
 opposite olive. Nearer the calamus we find that the clavate and 
 cuneate 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 svstem 
 (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 been 
 applied, the ascending fibres being the continuation of the outermost 
 part of the anterior root zone. Two well-defined nuclei characterise 
 
14 THE MEDULLA OBLONGATA. 
 
 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 ; not traversed, as these are, by 
 dense fasciculi of arcuate fibres passing to the olivary body. The 
 former called the nucleuS of the lateral eolumn 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 nucleus. 
 
 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. 
 
 Intercalated between the lateral columns of the medulla and the 
 anterior or median, is the inferior olivary hody, extending throughout 
 the region we have been studying, but terminating at the level of the 
 lowermost fibres of the jootzs. 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- 
 verse section reveals a grey nucleus, imbedded in a medullated invest- 
 ment of longitudinal fibres — the so-called fillet or ollvary fasClCUluS. 
 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 hei*e, bordering upon this 
 opening in the capsule, is an elongated belt of grey matter, containing 
 
ACCESSORY OLIVES— MIXED LATERAL SYSTEM. i 5 
 
 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 aCCeSSOPy 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 ou ; 
 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 pons. 
 
 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 hypoglossal — but of four of 
 the mixed lateral system, viz., the spinal-accessory, vagus, glosso- 
 pjliaryngeal, 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 hypoglossal, 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 centi ic and peripheric fibres connected with 
 them. The external also lies at a posterior plane to the internal. 
 The cells are large and multicaudate, forming the most conspicuous 
 cell-groupings in the whole sectional area of the medulla : they 
 measure 60 /x x 20 /x. The centric connections of these nuclei 
 consist of certain straight fibres of the median raphe, which run back- 
 wards as far as the central gi"ey 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 Ijorder to pass obliquely outwards, are the peripheric Juscicrdi 
 — the root-Jibres of the hypoglossal. These emerge from between the 
 
 * These bodies ai'e also known as tlie "external and internal paiolivary 
 bodies." 
 
I 6 THE MEDULLA OBLOXGATA. 
 
 yjyramid 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 strice 
 medullares 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. Throughout the whole 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 arise 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 viotor 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 fasciculi 
 emerge and run hachwards parallel to the emergent root fibres of 
 this system of nerves, 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 olivary body. Much discrepancy 
 appears with respect to the descriptions given to these anterior roots 
 of orio-in of the mixed lateral system ; some authorities 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 tlie 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 inferior 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 column 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 recurrent fasciculi 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. 
 
 * Psychiatry, translated by Sachs, part i., p. 124. 
 
 1 
 
SENSORY NUCLEUS. 
 
 ^7 
 
 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 belovj the, vagal nucleus ; the latter centre can also be 
 differentiated into two groups, an external and internal nucleus, de- 
 sci'ibed 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 the main root fibres — the spinal accessory between the 
 olivary bodies and gelatinous substance ; the vagus and glosso-pharyn- 
 geal througli 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 faSClCUlus, which 
 really represents an ascending" FOOt 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 
 nerves. The posterior sensory nucleus is regarded by Dr. Hoss as 
 the representative of the VCSiculaP 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 
 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 fi'om the medulla ; this is the fifth root of origin for 
 these nerves. Another small fnsciculus has been described by Clarke 
 as passing from the faSCiCUlUS tCrCS into the vag'US. 
 
 The Upper Half. — Passing now to the upper half oi the medulla, 
 which upon its ventricular aspect is, like the lower half, triangular 
 in outline, its base being mapped out by the acoustic strijB and its 
 lateral boundaries formed by the superior cerebellar peduncles, con- 
 verging to the quadrigeminal bodies, we meet first witii two 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 
 
THE MEDULLA OBLONGATA. 
 
 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 })air, or the abducens and facial ; the sensory 
 nerve is the eighth, the aCOUStiC or auditOPy. 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, 
 
 M'xidle cerebellar 
 tieduncle. 
 
 Conariuni or pineal gland. 
 
 Hrachiani coxtjunctiviuu anticiuik. 
 
 Uracil ium conjunctivum 
 posticum. 
 
 PedimcaluB cerebri. 
 
 ad corpora quadri-^ 
 ^emina, or 
 -auperior cerebellar 
 peduncle. 
 
 id medullam oblon- 
 
 eratam, or inferior 
 
 cerebellar 
 
 peduncle. 
 
 Aecflssorias nucleus 
 
 Obex. 
 
 Clava 
 
 Funiculus cuneatus 
 (Part of restiform bodj ). 
 
 Funiculus gracilis 
 (Posterior pyramid) 
 
 Fig. 4. — Medulla oblongata and pons with neighbouring structures seen from behind : 
 schematic representation of the nuclei of origin of the several cranial nerves. 
 
 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 striae medullares (see fig. 4, 6, 7, 8). As in the loiver 
 triangular area of the grey floor below the striae, we found the nuclei 
 ot a motor (XII) and three mixed nerves (IX, X, XI) associated 
 
OLIVARY BODIES— FACIAL NUCLEUS. IQ 
 
 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 SUperiOF Olivapy 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, comjiact 
 ■columns, are now concealed beneath the most anterior fibres of the 
 middle cerebellar peduncle (pons), which enclose them between their 
 transversely disposed fasciculi, as a more superficial and a deep series 
 of fibres; whilst laterally the toPachia of the pons diverge to the 
 ■cerebellum, and farther back the restiform and internal divisions of 
 the inferior cerebellar peduncles in like manner pass to their dis- 
 tribution. On a level with the striie medullares an intermediate 
 transitional stage is apparent ; and, as we pass to higher planes, the 
 inferior olivaiy body loses its outward inclination, its long axis 
 becoming disposed autero-posteriorly and immediately behind the 
 two pyramids. Thus a lateral constriction occurs which gives the 
 niedulla here from before backwards an apparent but not absolute 
 increased depth. This antero-posterior depth appears still more 
 •exaggerated by the lower loops of the pons capping the pyramids in 
 front, which 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 
 Jifth nerve, whilst immediately posterior 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 mattep. 
 
 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 the Jifth nerve of a very notable lai'ge 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 antepiop or infepiop nucleus of the facial nepve, and from 
 
 it a somewhat wide belt of sparsely scattered fasciculi pass back to 
 ascend, as we shall see later on, as the g^enu of the facial nerve, 
 whilst the compressed nucleus of the lateral columns sends in- 
 distinctly marked fibres towards the median grey. The superior 
 olivary does not as yet present itself; in this plane we may study 
 
20 THE MEDULLA OBLONGATA. 
 
 the various nuclei of origin of the auditory nerve. Following the grey 
 matter of the floor of the ventricle outwards from the median promi- 
 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 intemaL 
 auditory nucleus is seen. Immediately outside this sensory nucleus 
 is the tessellated area characterising the inner division of the inferior 
 cerebellar peduncle ; followed still further outwards by the transverse- 
 section of the crescent-like rentiform 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 with its 
 lateral prominence, the inner peduncular tract, and tl.e restiform 
 column — are embraced superficially by a zonular investment of fibres 
 issuing from the region of the raphe; in fact, the strice medullar es,. 
 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 above enumerated, are- 
 embraced from within by the anterior auditory root, which runs 
 chiefly between the restiform tract and the ascending root of the 
 fifth, although many of its fasciculi traverse the structure of the 
 latter. The student should remark here that the fifth ascending- 
 root serves always to distinguish to him the emergent roots of the 
 facial from those of the aiiditory ; the facial lying to the inner, and 
 the auditory to the outer side of this root. 
 
 We should, therefore, regard the auditory nerve as possessing two 
 roots of origin — (1) anterior, also called the internal, deep or vesti- 
 bular root, whose peripheral destination is the semi-circular canals ;, 
 and (2) the posterior, also called the external, superficial or cochlear 
 root, which in its turn ends in the cochlea. 
 
 POSteriOP Root.— -The fibres from this source enter the anterior 
 or accessory auditory nucleus, which forms so prominent a feature as 
 it lies upon the deep root of the auditory nerve, and, as suggested by 
 Bruce, might much more justly be termed the auditOPy g'ang'lion. 
 
 From this centre they form connections with the following- 
 structures : — 
 
 (a) Through the striae acousticEe with the fopmatio reticularis. 
 (6) With external and internal acoustic nuclei of -same side, 
 (c) With the flocculus. 
 
 {d) With superior olive of the same and opposite sides by the medium of the 
 trapezoid body. 
 
 - Anterior Root. — The vestibular root, continuous with the so- 
 called ascending, root of the auditory nerve, arises in part from the 
 cuneate nucleus, in part from the large cells of the external acoustic 
 
ANTERIOR ROOT. 21 
 
 or Deiter's nucleus ; whilst a further division passes into the internal 
 or chief nucleus of the auditory ; and some fibres are traced into 
 Bechterew's nucleus. From the internal and external acoustic nuclei 
 
 the following connections are traced : — 
 
 (a) With the sixth nerve nucleus of the same side, 
 (h) With the inferior olivary of the same side. 
 ((•) With the fioceuhis of the same side. 
 
 (d) With the ojDposite formatio reticularis. 
 
 (e) With the opposite roof nuclei of the cerebellum. 
 
 (/) W^ith the opposite posterior longitudinal fasciculus and thus possibly with 
 the third nerve nucleus. 
 
 Lastly, the cuneate nucleus may bring the vestibular root into 
 ■connection with the fillet and with both restiform bodies (Bruce). 
 
 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 oi 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. 
 
 On either side of the median line at the extreme posterior end of 
 the raphe, is an oval cross-section of medulla 1^ mm. by a ^- mm. in 
 size, sharply defined and lying between the grey matter of the floor 
 and the hindmost series of arcuate fasciculi given off' fx'om 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 forwai'ds and outwards to their emergence from the medulla, 
 forming in this latter course the boundary between sensory and motor 
 divisions. In the sensory division outside this root lies, as we before 
 indicated, the ascending" trigeminal 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 
 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 
 
22 
 
 THE MEDULLA OBLONGATA. 
 
 nerve or sixth pair. The nucleus itself is the abducens-facialiSy 
 
 also termed the posterior or superior facial nucleus, or again the 
 nucleus of the sixth nerve. It is placed in communication with 
 the cerebrum by means of the fibrse rectse 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 
 
 G.f. 
 
 Fig. 5. 
 
 -Section through pons on a level with the origin of the great 
 root of the trigeminus. 
 
 G.j, Gem; of facial nerve. 
 
 VII, Root fibres of facial. 
 
 Vm, Motor nucleus of trigemiuus. 
 
 Va, Ascending root of trigeminus. 
 
 i?, Restiform tract. 
 
 M.P, Fibres of pons varolii. 
 
 •p.l.h. Posterior longitudinal fasciculus. 
 
 F.B, Reticular formation, 
 s.o, Superior olivary body. 
 F, Lemniscus or fillet. 
 Fy, Pyramids. 
 
 s.t.f,d.t.f. Superficial and deep transverse 
 fibres of the pons. 
 
 arch beneath the abducens-facialis to its inner and posterior aspect,. 
 and thence running upwards as the gemi of the facial, again bend 
 around its upper border in the graceful sweep of the emergent roots. 
 
 The Superior Olivary Body. — We have seen that this body 
 extends from the lowest border of the 2yons 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 trapC— 
 ZOideS which becomes exposed superficially in animals where the- 
 
UPPER OLIVARY BODY. 23 
 
 dimensions of the pons are greatly reduced with the diminished supply 
 of fibres i-eaching 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 doivnwards 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 motOP 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, which are connected 
 with the optic tracts, transmit stimuli thence emanating, to the 
 superior olivary bodies through the medium of the fillet, and so to the 
 oculo-motor apparatus of the sixth and third nerves. 
 
 We have already seen that the posterior columns of the cord resolve 
 themselves through the intermediation of their clavate and cuneate 
 nuclei into tlie 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 aS'ecting 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 peduncle 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 carried 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 
 
24 THE MEDULLA OBLONGATA. 
 
 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 
 antePiOP 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 either 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 suffers 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 anterior or motor column of grey matter, containing 
 nerve cells, and externally a lateral ot sensory column, such as charac- 
 terised the cranial nerve origins in the lower half of the medulla. 
 Betwixt these planes and the iipper 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 oi-igin for its motor root 
 within the motor area of the pons somewhat similar in position to the 
 nuclei of the latei'al division, which at lower levels sent fasciculi to 
 the mixed system of nerves — the so-called nucleus ambig'UUS. 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 up[)er 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 thi'oughout the whole of the medulla followed up in our 
 sections the aSCCnding" root of the trig'eminal, 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 tubercle of Rolando, 
 and so would seem to have a close connection with the caput COrnu 
 
NUCLEI OF THE OCULO-MOTOR AND TR0CHLEARI8. 
 
 -0 
 
 pOSteriOPiS. A median root is described as originating from a 
 nucleus ;it the level of emergence of the sensory root, in contiguity 
 with tiie ascending root and the motor nucleus. On the lateral 
 margin of the central grev 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 lasciculi 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, iorming the substantia ferruginea, which is seen through the 
 grey floor of the ventricle at the site named the loCUS COBPUleuS. 
 From these cells, according to Meynert, pass root fibres to the 
 opposite trigeminal root (sensory trunk), which in their course 
 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 with these latter fibres are described others 
 which 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 ])Osterior 
 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 /orirth 
 nerve. Both are believed to receive their centric fibres through tli'e 
 median raphe, those of the third nerve decussating ere they reach 
 their nucleus. 
 
 Tlie segmentation of the nucleus of the motor oculi nerve has been 
 variously described by diff'erent authorities : we follow here more 
 strictly the account given by Bruce,* which certainly accords most 
 
 *"()ii the Segmentation of the Nucleus of the Third Cranial Nerve," Alex. 
 Bruce, Pror. Roy. Soc. Ediii., 18S9. Ill n.st rat ions of I In- X<rvt Tracts, of tin Mhl 
 and Hind Brain, Alex. Brnce, 1892. 
 
26 
 
 THE MEDULLA OBLONGATA. 
 
 closely witli our own observatiohs. The whole nucleus consists of 
 seven chief segments — a central with three lateral groups on either 
 side, and of six minor segments, which we shall speak of as the 
 superior, the inferior, and the external nuclei (see fig. 6). 
 
 The central or median nucleus lies along the mesial longitudinal 
 plane behind the raphe, and consequently in the V-shaped interval 
 betwixt the two posterior longitudinal fasciculi. It is freely con- 
 nected by commissui-al fibres with the nucleus on either side of it, C. 
 
 Pupillary con- 
 tractions. 
 
 Accommodation 
 
 Associated accom- 
 modation and 
 convergence. 
 
 Spliiucter iridls. 
 
 Ciliary muscle-. 
 
 Extrinsic muscles- 
 
 of eyeball and 
 levator palpebrae. 
 
 Fig. 6.— Scheme of segmentation of third nerve nuclei showing- presumed anatomicla 
 and physiological relationships. 
 
 A, Anterior nucleus; C, Central or median nucleus; A', External nucleus of 
 Bruce; I, Inferior nucleus (segment of anterior); ,S, Superior or nucleus of 
 Darkschewitsch ; PI, Postero-internal or pale nucleus of Edinger-Westphal ; 
 PJiJ, Postero-external or posterolateral nucleus. 
 
 The anterior nuclei. On either side of the latter nucleus, and 
 resting in the hollow of the posterior longitudinal fasciculus, is an 
 important collection of nerve cells, the longest of all the oculoruiotor 
 segments, and most richly supplied with commissural fibres, coupling 
 not onl}' these two nuclei together but also connecting them with the 
 intervening or central nucleus, A. These two anterior nuclei extend 
 upwards and downwards beyond the levels of the central nucleus. 
 The upper ends of these nuclei are but very scantily supplied with 
 commissural fibres. 
 
 Postero-internal nuclei, also called the pale nuclei or nuclei of 
 Edinger-Westphal, are wedged in between the central and anterior 
 nuclei ; narrow below and increasing in bulk upwards they terminate 
 
ROOT FIBRES OF THE TROCHLEARIS. 2/ 
 
 in a characteristic club-shaped head above the level of the anterior 
 segments, PI. 
 
 Postero-external nuclei, also called the postero-lateral group, 
 lie still more external along the outer divisions of the posterior longi- 
 tudinal fasciculus, their nerve cells resembling those of the anterior 
 group, PE. 
 
 The six minor segments consist of — (a) a superior couple ; (h) an 
 inferior couple ; and (c) an external couple. 
 
 The SUpePiOP, also called the nucleus of Darkschewitsch, is placed 
 above the upper end of the postero-external nucleus, forming the 
 extreme upper limit of the motor oculi nucleus, S. Bruce states that 
 it forms the terminus for many of the fibres of the posterior commissure. 
 
 The inferior is just as clearly segmented off from the lower end of 
 the anterior nuclei, and is distinguished from the latter by the com- 
 plete absence of inter-commissural fibres, I. 
 
 The external is a group described by Bruce lying upon the outer 
 aspect of the postero-external nuclei, and of much more limited extent 
 than the latter group, E. 
 
 All these nuclei are intimately connected with the posterior-longi- 
 tudinal fasciculus on the one hand, and with the root fibres of the 
 third nerve on the other. So far as we can at present suggest the 
 function of these several nuclei we may regard it as probable that the 
 central subserve the function of accommodation ; the postero-internal 
 that of contraction of the iris ; whilst the anterior is the centre for 
 the associated act of accommodation with convergence {Bruce). 
 
 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 teg'mentum 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 severinfj 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 
 anterior medullary 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 
 * ZJi'.fca-ve.s' of the Xervou.'i Si/sfcm, vt)l. ii., p. 44. 
 
2S THE MESENCEPHALON. 
 
 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 
 peripheral side of their nuclei of origin, but invariably on their 
 proximal or centric side. 
 
 THE MESENCEPHALON. 
 
 Upon the most casual examination of the cerebro-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 uiiifovm 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 
 difierent 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— /.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 difierent 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 g-land, thalami optici, striate 
 
CRUSTA. 
 
 29 
 
 bodies, and cortex cerebri. It is important that the student 
 understand that the termination of the fibres upwards occurs in o-rev 
 masses placed at different relative levels, answering to the position of 
 the hind-brain, the mid-brain, the inter-brain, 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 mesencephalon, the hind and inner portion of the crura forms, 
 as we 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 embracing optic tractS, which 
 at this part of the base define the boundary between mesencephalon 
 behind and thalamcncephalon in front. At this point each crusta 
 ])lunges deeply into the brain, disappearing between thalamus and 
 lenticular nucleus, and passes up as a compressed medu Hated 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 correspondino- 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 sufl^ers displacement through the intrusion in mesial planes 
 of the head of the caudate nucleus, whei eby 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 
 caprsule 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 thalimus. 
 
 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 pol^ of the wedge-shaped thalami. In like manner the latter. 
 
30 
 
 THE MESENCEPHALON, 
 
 which have their bi'oad extremity hindmost, are also pressed out- 
 wards behind by the intervening quadpigceminal and g-eniculate 
 l30dies. These three important structures — the corpora quadri- 
 gemina, thalami, and caudate nuclei — which represent the three 
 
 Eeptum luciduin 
 <^lumiiae fornlcis. 
 
 Corpue Elriatuni. 
 
 Btria tenninalis. 
 
 Thalamus opticus. — 
 
 Comu antioum. 
 
 Caput nuclei caudati 
 
 ISrachium conjunc- 
 tivum anticum. 
 Pedunculus cerebri, 
 
 r ad corpora 
 quadrige- 
 mina. 
 ad niedullam 
 oblongatain, 
 
 ad pontem. 
 
 Hippocampus- 
 
 Fis 
 
 Fumculus cuneatus 
 Funiculus gracilis. 
 
 7.— Horizontal section through hemispheres, the right at a deeper 
 level than the left. 
 
 divisions of the mesencephalon, diencephalon, and partly of the 
 prosencephalon, as before indicated, rest upon and embrace the 
 tegmental and crustal divisions of the cerebral peduncle. 
 
INTERNAL CAPSULE. ->! 
 
 %J 
 
 On the other hand, the outer division of the striate body — the 
 lenticular nucleus — lias its base directed forwards and outwards 
 parallel with 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. Near 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 antePiOP 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 ])lane of the middle 
 commissure, the antei-ior 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 posterior segments (fig. 7). 
 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 foi-nix 
 cut across. 
 
 Lastly, turning our attention again to the base of the brain, we 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 
 peduncleSj 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- 
 
32 
 
 THE MESENCEPHALON. 
 
 forcement of fibres within the pons to account for the much larger 
 size which the crusta bears to the corresponding anterior pyramid of 
 the medulLi. An examination of the pyramidal tracts and crusta in a- 
 nine months' embryo giv^es us most valuable information respecting 
 the origin of the fibres found therein. In the pyi'amids 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 
 CiirsTA. 
 Inner third, 
 
 Ix Internal 
 Capsule. 
 Anterior segment, 
 
 Cortical Termini. 
 
 Mixed Tract, 
 
 Fundamental Tract, 
 
 Sensory Tract, 
 
 Third frontal gjrus 
 posteriorly. As- 
 cending frontal 
 and parietal gj-ri 
 at their lower 
 end. 
 Behind and between Posterior segment. Second frontal and 
 Accessory and ,.,„ Anterior third, middle portion of 
 
 central gj'ri. 
 Posterior segment, First frontal pos- 
 Middle third, teriorl3\ Upper 
 end of centi-al 
 gyri ; paracentral 
 andi^arietal g^Ti. 
 Do., do., Temporo - occipital 
 
 Posterior third. regions. 
 
 The aboA'c table reads as follows : — The accessor}'- tract occupies the inner third 
 of the crusta, passes up the anterior segment of internal capsule, and terminates 
 in the cortex of the third frontal and lower end of ascending frontal and parietal 
 gyri — and so for the remaining tracts. 
 
 Fundamental, 
 Middle third, 
 
 Outer fourth, 
 
CONDUCTING TRACTS OF THE CRUSTA. 
 
 33 
 
 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, ifec. 
 The tracts we have now traced have 7io connection with the basal 
 ganglia : they pass between the lenticular nucleus, thalamus, and 
 caudate nucleus uninterruptedly to their cortical termini. Thus, as we 
 have seen, the pyramidal tract extends uninterruptedly between the 
 cortex of the central g'yPi and their immediate neighbourhood, and 
 the motor cells of the anterior eornua of the 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 very complex and specialised co-ordinations, 
 the muscles being very numerous, but relatively very small in size : the 
 fundamental group which supply 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 accessory 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 central gyri 
 extend as far as the lumbar enlargement for the musculature of the 
 legs. Hence the former constitute comparatively short loops, and 
 supply many though 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 pyramidal 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, when they suddenly turn back, 
 and are distributed to the OCCipital and temporO-Sphenoidal lobes. 
 As before stated, they have no connection with the thalamus or 
 lenticular nucleus. So far for the direct sensory and motor fasciculi 
 of the crusta and internal capsule. The internal capsule, however, 
 includes several other systems of fibres, of which the following are the 
 more readily followed out : — 
 
 (a) Fibres to the cortex from the outer surface of the optic 
 thalamus. 
 
 3 
 
34 I'HE MESENCEPHALON. 
 
 (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- 
 wards ; 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 Gratiolet : 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 
 
 g-yri and the cerebellum. 
 
 (e) Fibres 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 imagine a lamella of fibres spread over the 
 broad base or outer aspect of this wedge to pass downwards beneath 
 the lenticular nucleus 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. 
 
ANSA PEDUNCULARIS. 35 
 
 Such an arrangement is represented by the external capsule and its 
 continuation at the base, where it is termed the ansa pedunculapis 
 •of Gratiolet or substantia innominata of Reil ; and a portion of 
 ■which crossing the crusta to its inner side is named the COUaP, 
 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 
 4irise from the under surface of the lenticular nucleus, from a ganglion 
 lying in this position, and from the cortex of the sylvian fissure, 
 upper and temporal margin of the insula. Tlie capsular portion of 
 the ansa has no organic connection with the base of the lenticular 
 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 claustpal 
 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 nucleus 
 — from those concentric lamellse, the laminSB medullaPes. The 
 fasciculus completely crosses the crusta pai'allel 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 paphe to the central grey substance, where 
 they terminate after decussation in the nucleus Of OPigfin 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 pOStePiOP long-itudinal fasciculus, 
 which may possibly be traced down into the spinal cord as the most 
 posterior of the fibres of the anterior column in front of the grey 
 commissure of the cord. 
 
 The third layer of the ansa arises from the sylvian foSSa :nid 
 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 infePiOP peduncle 
 
3^6 THE MESENCEPHALON. 
 
 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. 
 
 Dissection. — Place the brain with the base uppermost, ha-\"ing carefuU}' 
 removed the membranes and the large vessels. Remove ■with the blade a shallo'w 
 horizontal slice from one of the temporo-sphenoidal lobes so as to pass throiigh the 
 hook of the uncinate gyrus ; this lays bare the section of the pes hippo- 
 eampi, and the amygdaloid nucleus. Pass the handle of the scalpel 
 vertically through the medullary strands outside the pes — it enters the extremity 
 of the descending horn of the lateral ventricle. Carry an incision along the 
 floor in a somewhat curved direction, backwards and outwards, along the whole 
 length of the occipito-temporal g}Ti. This exposes the descending comu throughout 
 its extent, and the worm-like COPnu ammonis is seen descending from above 
 to terminate at the pes. The tails of the caudate and lenticulaP nuclei are 
 now seen along the roof of the cornu, and a white, glistening, narrow band of 
 
 fibres curves do^svnwards towards the amygdala— the taenia semicipculapis. 
 
 Upon raising up the inner border of the uncinate gjTus, 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 pulvinar 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 
 OlfaetOPy nerves. Dra^sving the optic ner^^es backwards we expose the deUcate, 
 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 antePiOP COmmiS- 
 SUPe, crossing from one to the other hemisphere. 
 
 Upon gently drawing apart the divergent crura cerebri in fronts 
 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 be the inner margin of a 
 dark pigmented body, of lenticular section, the substantia nigra 
 of Soemmering, which forms a distinct boundary wall betwixt the 
 crusta in front and tlie 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-brain or quadri- 
 geminal bodies. 
 
LEMNISCUS OR FILLET AND AQUEDUCT. 37 
 
 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 tlie 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 meduUated 
 lamella on either side of the crus cerebri — that from the nates being 
 deeper-placed and over-laid by that from the testes ; this downward 
 extension is called the fillet of the quadrigerainal 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 COnarium 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 
 <^uadrigeminal bodies lie immediately over the continuation of the 
 central gi'ey 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 tlie 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 tlie 
 deei)er transverse fibres be dealt with in like manner, we come down 
 uiion the most anterior layers of the tegmentum, and these, wlien 
 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 
 
35 THE MESENCEPHALON. 
 
 raphe of the pons (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 cerebellap column. Whilst 
 
 the lemniscus in this part of its course gradually encloses the several 
 other tegmental structures, including the red nucleus, the fibres given 
 off 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 trans- 
 verse fibres of the pons, and, becoming superficial, pass downwards 
 to the cerebellum as its superior peduncles. We must now follow 
 the fasciculi of the mesencephalon in transverse sections taken 
 across the upper and lower pairs of quadrigeminal bodies. 
 
 In such sections passing through the region of the nateS, five 
 structures which demand examinution 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. {h) 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, embi*acing 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 cei'ebral cortex converging 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 tlie 
 superior brachium of the nates ; and, j)'>"''Or 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 
 
RED NUCLEUS OF TEGMENTUM. 39 
 
 medulla extends downwards, presenting a similar formation for the 
 testes as for the upper 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 
 explaiiis 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 
 brachium ; whilst the inferior brachium and hence the testes have 
 likewise a connection with the inner side of the tract. Hence the 
 nates and testes are 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 tlie 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 Tegmentum 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 travex'se its structure. 
 
 In the lower planes of the mid-brain, through the testes, the 
 medullary fasciculi derived from the red nucleus, now called the 
 
40 THE MESENCEPHALON. 
 
 SUperiOF eePebellaP 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 fasciculi 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 u|)on the same side. If we adopt 
 
 Meynert's view of the projection System, the nucleus ruber 
 
 forms an internode or point of interruption between the coronal 
 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 occurs on the same side 
 as the hemispheres supplying the coronal attachments. 
 
 Posterior Longitudinal Fasciculus.— A compact column of 
 
 lai-ge 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, and that its coronal origin is from the cortex 
 of the operculum, insula, and temporal lobs ; it is traced into the 
 posterior fibres of the anterior columns of the spinal cord. 
 
 Substantia Nigra 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 (Mei/nert). 
 Fibres pass downwai'ds 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. 
 
CONNECTIONS OF TEUMENT AND CRUSTA. 4 1 
 
 We have thus traced the several 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, the quadrigeminal bodies seated upon 
 the brain stem or pedunCUlus CePebri, 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 CPUSta and tegment severed by the intervening 
 substantia nigra. The nates and testes have intimate connections 
 through their hrachia with the cerebral cortex and retina ; and below 
 tlirough 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, viz. : — 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. 7, should be made, 
 in which the relative position of the mesencephalon and epencephalon 
 are equally exposed. We here see the tA/o 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, tlien, form the chief structures constituting 
 
 the "tween-brain " or thalamencephalon. To appreciate their 
 
 mutual relationships — their centric and peripheric connections — a 
 
42 TBE THALAMEXCEPHALOX. 
 
 careful study of sections carried througii 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 ilh;stration (fig. 7) given on p. 30. 
 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 the StPia teFminaliS 
 (cornea), which is also the upper and outer boundary of the thalamen- 
 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 
 ventricle 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 
 commissux'es which cross the ventricle, and which are really deCUS- 
 
 sating" medullated tracts of the thalami. 
 
 AVhilst 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 configuration. 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 appear like the transverse-section of a 
 boat, keel downwards, in whicli 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 
 
THE THALAMIC PEDUNCLES. 43 
 
 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 
 substantia nigra being immediately beneath it ; whilst the whole 
 extent of the central cavities of the third ventricle and its grey walls 
 continuous below with the infundibulum and posterior perforated 
 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 te^mentiim 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 lamellfe, 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 infer- 
 ior). These thalamic peduncles connect its structure with the frontal 
 lobe, the sylvian fossa, temporal lobe, and gyrus fornicatus res})ec- 
 tively. Such cortical fasciculi have necessarily a lengthened course 
 to pursue, and none more so than that from the g'ypus fomi- 
 CatUS, which reaches its destination after a peculiarly complex spiral 
 course. The anterior peduncle approaches the thalamus from the 
 frontal cortex througli the strands of the anterior segment of the 
 internal capsule between lenticular and caudate nuclei, interlacing 
 here with its tibres, 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 
 
44 THE THALAMENCEPHALON. 
 
 peduncle, already alluded to as the third layer of the ansa pedun- 
 ciilaris, connected with the cortex of the temporal lobe, passes from 
 beneath the lenticular nucleus up into the thalamus, expanding also in 
 brush-like manner chiefl}^ along its internal portion, and forming the 
 inner boundary of the thalamus. It also deciissates at the middle 
 and posterior commissure to pass down as tegmental fasciculi of the 
 crus. 
 
 Both these peduncular expansions are interrupted by the nerve cells 
 in the grey intercalated layers of the thalamus ere they decussate at 
 the commissures. The SUpePiOP peduncle takes a still more com- 
 plicated course ; its centric connection is with the cortex of the 
 gyrus fornicatus — appearing first in the two fimbpice or posterior 
 pillars of the fornix arising from the cornu Ammonis ; 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 mai'gin coronal 
 radiations from the occipital and mid-regions of the hemisphere. 
 These fasciculi radiate from the upper and outer border of the thala- 
 mus to corresponding regions of the brain opposite them ; the middle 
 section spreading towards 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 with 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 sensory fibres of the 
 cord destined for the occipital and temporal lobes ; and, as we have 
 previously seen (fig. 7, 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 arcAeo? /asciCM^i towards the median line — /.e., across the long axis 
 
CORTICAL CONNECTIONS OF OPTIC THALAMUS. 45 
 
 of the thalamus ; the meduHated tracts being intercalated by the grey 
 matter common to the whole ganglion. Upon a lower level than 
 the entrance of these cortical radiations, other medulltited 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 botli 
 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 fascicidi, in passing inta 
 the hinder half of the tegmentum, run immediately across the axis of 
 the optic and COPtical Padiations just described ; and necessarily 
 form apparent concentric dissepiments in these regions. These 
 laminated dissepiments form the new meduUated 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 meduUated 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 
 ventricles, 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 towards 
 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 parallel to the direction of the 
 stria cornea, 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 
 off from the whole of its outer aspect meduUated 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 
 
46 THE THALAMENCEPHALON. 
 
 temporo-sphenoidal lobes. The greater bulk of these pass dea'ply into 
 the thalamus, and, as before said (p. 43), are crossed by the brush- 
 like fasciculi of the thalamic peduncles. The more superficial layer 
 iirst revealed upon raising the tail of the caudate, enters into the con- 
 stitution of the white capsular investment of the thalamus 
 
 (stratum ^o?^a/e), which gives to this ganglion its peculiar white hue 
 within 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 the grey matter of the third ventricle becomes apparent. This 
 capsule or stratum zonale is itself of complex formation : it receives 
 also fibres from the optic tracts, the uppermost of those which join the 
 thalamus ; so also fasciculi from the frontal lobe enter it by the anterior 
 })eduncle of the thalamus, and in like manner the most superficial 
 stratum of the ansa lenticularis ; lastly, the gyrus fornicatus sends its 
 contribution by 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 tlius 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 foiiiicatus, . . . Through pillars of fornix. 
 Retina, ..... Through uppermost thalamic connections 
 
 of optic tract. 
 
 The Pineal Body and its Connections.— Surrounding the upper 
 
 pair of the quadrigeminal bodies, immediately beneath the posterior 
 extremity 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 
 
 tures in the brain, of closely aggregated cells, varying considerably in 
 size from 5 /x to 18 ,a. 
 
 Its connection with the rest of the cerebrum is effected by means 
 of two processeSj which are directed forwards along the inner border 
 •of the thalami optici, forming a boundary between the latter and tlie 
 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 the pineal body or habenula. These 
 peduncles are distinctly ganglionic in structure, and together with the 
 pineal body are probably to be regarded, as Meynert believes, as ganglia 
 of origin for the tegtnentum,. 
 
 The connections by meduUated 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 thQ posterior longitudinal fasciculus. This rectan- 
 gular bend has gained for it the appellation of the fasciculus retFO- 
 ilexUS — 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 retroflexus 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 ^Hween 
 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 fi-ont of 
 meduUated fasciculi passing downwards from tlie i)Osterior commissure 
 and the emergent roots of the third nerve. In a section carried still 
 nearer the mesial plane, we see its course about]complete, whilst a portion 
 ■of both ascending and descending pillarsof the fornix is revealed likewise. 
 
48 THE THALAMENCEPHALON. 
 
 Posterior Commissure, — We have already traced the anterior 
 and inferior peduncles of the thalamus as far as their decussation 
 in the posterior commissure, and it would seem extremely probable 
 that the fasciculus retrqflexus undergoes partial decussation through 
 the medium of this commissure also. Near the mesial line, we can 
 readily trace 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 medullated 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 peripheric extensions from a series of gang- 
 lionic bodies, viz. : — The fasciculus retroflexus, the mass of the 
 posterior commissure, and the quadrigeminal fasciculi called the- 
 
 lemnisci or fillets of the nates and testes. 
 
 Corpora GeniCUlata. — Beneath the pulvinar of the thalamus 
 in man we see a small club-shaped body about the size of a coffee-bean,, 
 directly continuous with the optic ti-act anteriorly, and by a notable 
 border separating mesencephalon from thalam,encephalon, connected 
 with 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 
 ganglion, and hence also with the nates. An inner segment 
 of the optic tract, but much more limited in extent, passes into 
 the internal geniculate and thence to the nates also ; no fibres 
 from the optic nerve are believed to pass by this tract to the testes. 
 
 The remaining connections of the optic tract are the optic thalamus 
 (to the stratum zonale and radiating fasciculi previously described) ;. 
 and the basal optic ganglion, a small body of grey matter lying beside 
 the tuber cinereum immediately covered by the optic commissure. 
 
CONFIGURATION OF CEREBRAL HEMISPHERES. 49 
 
 The ganglia of origin of tlie optic nerves, therefore, are the upper 
 quadrigeininal, 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 (?) temporo-sphenoidal lobes. 
 
 PROSENCEPHALON OR FORE-BRAIN. 
 
 Conflg'UPation. — We have already seen that divergence 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 tracts. 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 of 
 grey substance, whose configuration 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 crus 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 
 orbital aspect of the frontal, sweeps round the fronto-parietal to the 
 tip of the temporo-sphenoidal lobe. The more flattened aspect of the 
 region of the 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 
 and in man. Although identical in the nature of their histological 
 
 4 
 
50 
 
 THE PROSENCEPHALON. 
 
 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 
 
 Fig. 8. — Section through hemispheres (vertical transverse) through 
 plane of middle commissure. 
 
 N.c, Tail of caudate nucleus. 
 
 Cx^ Corpus callosum. 
 
 F, Fornix and choroid plexus. 
 
 a. Internal capsule. 
 
 T.o, Optic thalamus. 
 
 C.?;i, Middle commissure. 
 C.e, External capsule. 
 CI, Claustrum. 
 
 1, 2, 3, Three segments of lenticular 
 nucleus. 
 
 fossa. 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 
 ganglia 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 
 cerebral envelope in their mesial position. Thus, the adult brain 
 
CAUDATE NUCLEUS. ^I 
 
 "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 
 -iinterior 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 course, 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 lucldum, 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 cortex of the frontal lobe 
 with the anterior 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 zonale). Still further back, the tail arches 
 downwards into the descending hoi-n of the ventricle, and can be 
 ti'aced upon the roof of the latter as far forwards as its anterior 
 extremity, where it terminates in a somewhat bulbous end, having 
 immediately in front of it a mass of grey matter, termed the 
 amyg'dala. It will be seen from this description that the bulbous 
 extremity of the tail extends almost as far forwards as the head of the 
 caudate nucleus, and thus describes an almost complete loop around 
 the internal capsule and thalamus, hence termed the " SUrcingle." 
 The whole course of this loop can be well demonstrated by vertical 
 longitudinal sections of the hemisphere ; whilst vertical transverse 
 sections anywhere between the amygdala and posterior end of thalamus 
 reveal the upper and lower segments of the surcingle, as isolated grey 
 masses above and below the thalamus. Each of these prosencephalic 
 
52 
 
 THE PROSENCEPHALON. 
 
 ganglia has a surface perfectly free, that is, devoid of medullated 
 attachments — and other aspects, which present the termini of centric- 
 and peripheric strands. 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 
 separated for some distance by that formation from the temporal 
 extremity or cauda of the intraventricular nucleus. Posteriorly, 
 however, they approach each other, and bridges of grey matter connect 
 them, separated by medulla. They are also separated here by the 
 centric extension (brachium) from the external geniculate body ; and, 
 finally, along the roof of the descending cornu these two temporal 
 extremities fuse together, forming the lower segment of the surcingle. 
 
 The constitution of the surcingle, therefore, is different in its upper 
 and lower arc, being pvirely an extension of the innermost nucleus 
 above ; but formed out of the fused tem])oral 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, there is the mesencephalon, the quadrigeminal bodies, each 
 throwing downward its loop-like fillet or lemniscus ; and throwing 
 upwards its centric arm in the form of the brachia. At a higher level, 
 the thalamencephalon shows us the optic thalamus astride the posterior 
 edge 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 
 tail of the caudate. Then still higher we get the arc of the caudate body 
 astride the anterior edge of the internal capsule with its long tail-like 
 loop also passing down the roof of the descending cornu in conjunction 
 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 hemisphere. For descriptive purposes it is 
 convenient to distinguish between upper or ventricular, and 
 
 lower, cornual or temporal arc of the surcingle : the caudal 
 
 extremity, the body of the caudate nucleus, and its caput directed 
 towards the base : whilst we also speak of its ventricular and 
 capsular aspects. 
 
 In like manner the lenticular nucleus has its frontal, its temporal. 
 
STRIA TERMINALIS -OLFACTORY AREA. 53 
 
 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 — COPtiCO- 
 Striate and COrticO-lentiCUlar fasciculi for the centric bundles : 
 
 pedunculo-striate and pedunculo-ventricular for the peripheric 
 
 bundles : direct pedunCUlaP 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, 
 ^nd along the upper arc of the surcingle betwixt it and the 
 thalamus, as far as the anterior end of the latter. Inferiorly it is 
 <listributed to the amyg'daloid nucleus; and by Meynert is regarded 
 as arising from the head of the caudate nucleus. Schwalbe, on the 
 other hand, regards this conclusion as dubious, and expresses the 
 opinion 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 taenia 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 in can be clearly seen to consist of a 
 superficial and deeper fasciculus at its termination, and to be con- 
 nected throughout its course with the caudate nucleus : the latter 
 arches downwai'ds 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 olfactOPy area— embraced, in fact, within the trig'Onum 
 Olfactorium. It would be hazardous to affirm that none of the 
 superficial 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- 
 missui'e from behind in such a direction as to ensure decussation, and 
 so bring the hippocampal region and caudate nucleus into crossed 
 relationship with the olfactory bulb.* We shall refer to this 
 •connection further on when dealing with the relationships of the 
 anterior commissure. 
 
 Lenticular Nucleus. — •Although in section both vertical and hori- 
 zontal, this ganglion exhibits a distinctly wedge-shaped contour, its 
 
 * See "Comparative Structure of the Brain'iii Rodents," by tlie Autlior, in 
 •the Philoao/jliical Traih-iactiowi, part ii., 1882, p. 730. 
 
54;. THE PROSENCEPHALON. 
 
 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 operation readily effected either by dissection or the brush, 
 the ganglia being held beneath water, 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 purpose of recognising their fundamental configuration. 
 
 The lenticular, then, appears 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 COPOna Padiata separates it from the 
 caudate nucleiis 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 upon 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 claustPUm, 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. 8). These three divisions are not merely 
 distinguished by their difference in colour, but are separated by well- 
 marked dissepiments called laminSB meduUaPeS, which, as thin 
 medullated partitions, descend from the internal capsule down to 
 the basal aspect of the brain, lying concentrically to the insular- 
 aspect of the ganglion : two and sometimes three such dissepiments 
 exist. The medullated fibres forming these dissepiments, and arising 
 from the internal capsule, bend inwards at different points to form 
 radial fibres, all directed towards the peduncular end of the wedge ;. 
 a certain proportion, however, completely traverse the lenticular as- 
 laminae medullares ; and, escaping at the base of the ganglion, pursue 
 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 ansa 
 lenticularis already referred 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 
 lamina, 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 BRAIN IN LOWER VERTEBRATA. 55 
 
 THE ENCEPHALON AS A WHOLE. 
 
 Comparative and EmbPyolOg"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 lowest 
 form of vertebrate animals — the amphiOXUS or lancelet, which 
 therefore 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 laHfipPey exhibits a large pyriform 
 dilatation of the neural tube, and retains for a long period this rudimen- 
 tary form, which, however, in comparison with its spinal system, bears 
 to it scarcely a higher proportionate 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 distension of the neural axis becomes very 
 early transformed by transverse 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 
 vertebrate, higher in the series, at a certain stage of its developmental 
 history. These five vesicles represent what in higher animals become 
 
 respectively the fope-brain or cepebpum, the twixt-bpain, the 
 mid-bpain, the hind-bpain, and the aftep-bpain. 
 
 These several parts in fishes and amphibia represent elements of the 
 higher vertebrate brain, which remain permanent in them, but subject 
 to most diverse modifications in structural complexity and in relative 
 preponderance of one or other segment. The fully developed brain in 
 fishes presents great variety in the relative size of the individual lobes. 
 In the first place, the early differentiation 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 series, and representing (1) the CePebpal hemi- 
 
 sphepes; (2) the optic lobes; (3) the cepebellum; (4) tiie medulla. 
 
 The two former, as seen in the brain of the perch, are disposed in 
 pairs, whilst in front of the cerebral hemispheres we see yet two small 
 bulbous swellings, from which arise the olfactory nerves, and which 
 are called, therefore, the olfactOPy gang^lia. These ganglia are 
 absent in the Shark, Skate, Whiting, (fcc, and are replaced by an 
 elongated peduncle capped at the extremity by the ganglia as in man. 
 
 The cerebral hemispheres in flsheS 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, whicli in the fish, it must be remembei'ed, represent 
 the thalamencephalon (thalamus and third ventricle) as well as the 
 
50 THE ENCEPHALON— COMPARATIVE. 
 
 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 large 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 gland, 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 hypoapla or the lobi 
 InferiOPeS, whose significance is unknown: they are peculiar to fishes. 
 From the centre projects 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 represent the chief part of their cephalic ganglia. 
 
 Behind the optic lobes comes a single tongue-like lobe— the cere- 
 bellum — 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, whilst in the more sluggish fish, it is 
 relatively small ; in osseous fishes it is usually considerably below the 
 size of the optic lobes. The last division of the brain is the medulla, 
 lying immediately behind and beneath the cerebellum, mapped off 
 from the spinal cord by its somewhat larger size, and the origin of 
 numerous important nerves. 
 
 In amphibia, the brain presents a smaller cerebellum than in 
 fishes, corresponding with their more torpid habit. 
 
 The reptilian brain differs 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, tlie cerebral hemispheres exhibit a great developmental 
 advance. They are very large, and cover more or less completely the 
 optic lobes. The cerebrum contains a distinct cavity, corresponding 
 to the lateral ventricles, and communicating with the hoUoW 
 peduncle of a small olfactory lobe in front. From the fioor 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 across the middle line. 
 
VESICLES OF THE FORE-BRAIN. 57 
 
 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 meduUapy groove, 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 medullary 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 vesicles 
 
 of the fore-brain, the mid-brain, and the hind-brain. 
 
 Vesicles of the Fore-brain. — From the first of these, a lateral 
 bulging Qn either side becomes soon apparent, and, steadily increasing, 
 is at 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 the fore-part 
 of the first cerebral vesicle become differentiated tlierefrom ; and these 
 are destined by rapid growth and development to become the most 
 important and conspicuous parts of the cranial contents. They form 
 
 the cerebral hemispheres or prosencephalon. At the second 
 
 month of intra-uterine life, they are mere insignificant ampulla?, 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-brain, or from giving origin to the optic thalami — the 
 thalamencephalon. Hence the two pairs of vesicles, tlie optic and 
 hemispheric, have their genetic origin from the tlialamencephalon, and 
 a direct connection between these structures is maintained during 
 all later stages of development. The cerebral hemispheres, as oftshoots 
 from the primary cerebral vesicle, are hollow vesicles, communicating 
 witli each other and with the cavity of their parent vesicle, the third 
 ventricle, by means of the foramen Of MonrO. As the walls of the 
 
58 THE EXCEPHALOX— EMBRYOLOGICAL. 
 
 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 that 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 gang^lia of the fore-bPain. 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 ojotic 
 thalami, connected behind by the posterior commissure, just above which 
 a small median projection forms— the pineal gland : its floor upon the 
 other hand, sends downwards a conical projection — the infundihulum, 
 
 which, later on, unites with the hypophysis Cerebri or pituitary 
 
 body, immediately over the pharynx or extreme end of the alimentary 
 canal. The funnel-shaped extension of the 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 
 cerebro-spinal system. The upper part or roof of the thalamen- 
 cephalon becomes thinned out into a mere lamella of pia mater, 
 covering the third 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 hemisphere 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 intra-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 the 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 low^er 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 
 
CRANIAL FLEXURES. 5^ 
 
 upper segment is termed from the cerebellum the hind-bpain 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, the 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 hinder 
 parts of the neural tube, so that the quadrigeminal bodies which 
 hitherto, as in animals, 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 t\\e fourth month, a slight depression appearing 
 on the outer aspect of each hemisphere midway between its anterior 
 and posterior extremity, indicates the position of the sylvian fossa ; 
 and were a horizontal section of the hemisphere carried through this- 
 depression we should find the walls of the vesicle within much thick- 
 ened at this point, the thickened mass protruding into the central 
 cavity as the rudimentary striate gang'lia. This fossa, which is 
 seen early in all mammalian brains, becomes the insula, island of 
 Reil, or central lobe, vvhilst the cortical structure, thickening 
 around it, forms a distinct fissure, the sylvian fissure, whose 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- 
 
6o THE CEREBRAL CORTEX. 
 
 •on the inner aspect of the hemisphere, mapping off the occipital from 
 the parietal lobe on its median aspect. This fissure in its descent 
 meets the hippocampal fissure at the point where 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, 
 reproducing at an early period of embryonic development, as a tran- 
 sient condition, the features permanently stamped in those of a lower 
 ^rade. The infinite degree of complexity ultimately obtained by the 
 mammal's brain is prefigured by the forms assumed in the lower classes 
 of vertebrata, and depends, for the most part, upon the preponderance 
 •of certain divisions of the encephalic mass over others, and also upon 
 the growing complexity of individual parts, either as the result of 
 increasing difterentiation of existing structures or the addition of 
 supplemental parts in the form of gangliated 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 
 <;ortex. We find the second exemplified by certain ganglionic out- 
 growths from the original brain-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 ^•arious 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 
 Oratiolet, Ecker, Turner, Broca, Huxley, who, amongst other valuable 
 results, have introduced a definite nomenclature which reduces to 
 precise terms, univei-sally intelligible, the statements of dififerent 
 workers in this department. Another field of enquiry has 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 put and answers received 
 by this method of research, and a majDping out of the complicated 
 
METHODS OF ENQUIRY. 6l 
 
 fields of the cortex into physiological territories established by Terrier^ 
 Hitzig, Horsley, and others. Another field of enquiry has received 
 but scant attention, yet it is one which an accui'ate 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 coai-ser examination of its medullated tracts by 
 the cleavage methods of Gratiolet, &c. It is but a natural a jyrioi'i 
 conclusion that difi'erentiation in cerebral /unction implies likewise a. 
 struchiral difierentiation, and that this latter is one of qualitative as 
 well as quantitative value. 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 difierentiation characteristic of those parts, and hence to be 
 helpful in the recognition of analogous regions in other orders. If it 
 can be establislied that areas, whose functional endowments are 
 familiar to us, present uniformly specialised anatomical features, we may 
 reasonably conclude that other structurally diiFerentiated areas, whose 
 functions are unknown to us at present, have each and all of them 
 diverse endowments. An attempt to delineate the homologous areas 
 of the cortex in different orders of mammalia by simple inspection 
 would (on a priori 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, which 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 COPtex cerebri, merits our most careful study, as being pre- 
 eminently the site of those deranged functions and pathological pro- 
 cesses which express themselves in mental disease. AVhatever 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 cei'sbral 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 
 
62 THE CEREBRAL CORTEX. 
 
 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 brain-stem of the peduncles and the great com- 
 missural tract of the corpus callosum pass. 
 
 The distribution of the surface into intricate convolutionaiy 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 enquiries to the convoluted brain 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 
 oi 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 Kodent, which is a 
 smooth-brained animal, take the Rat as our illustration. 
 
 HistolOg'ical Elements. — In the first place, what are the elemen- 
 tary constituents of the cortex 1 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 cortex are 
 
 (a) Nerve cells. 
 
 (6) Medullated and non-medullated nerve fibres. 
 
 (c) Connective mesh work of "neuroglia cell and fibre." 
 
 (d) Blood-vascular supply, 
 
 (e) Lymphatic supply. 
 
 {a) Nerve Cells. 
 
 Minute Structure. — The nerve cell, in contradistinction to the 
 nerve unit, or neuron, is an irregular mass of protoplasm, in a large 
 proportion of instances approaching a more or less spheroidal contour, 
 but frequently elongated, fusiform, triradiate or multipolar. Its 
 ■contour is dependent upon the site and number of its branches, and 
 thus a bipolar cell will assume a spindle form, whilst a multipolar 
 cell will partake of an amoeboid contour. Whatever the form of cell, 
 however, certain constant characteristics are displayed in all alike in 
 common with the cells of all animal tissues. The nerve cell invariably 
 
Plate 1 
 
 
 ^• 
 
 ^^ 
 
 
 
 r-J, 
 
 a. 
 
 I 
 
 • •••.*., ... .. 
 
 i* . . 
 
 '\ .1. 
 
 
 
 4 
 
 
 
 i: 
 
 I 
 
 aeax 
 
 I.'Iotor Typ e " 
 fcxtia-iiiTibic area of Rabbits Brain 
 f-rontal -pole of lie misph-ere. k 2.0 0. 
 
 Vm Extra limbic type. 
 
 I '■'"I JJppsr Urnbio iijpe.. 
 
 UnnS Modified Tipper Um.'bzc'f^pe 
 ModvfvecL olfojytory tqp& 
 Outer olfactory type 
 
 WM Irmer olfactory ti/p& 
 
 Brain of Rabbit 
 Mesial aspect basal aspect 8c Vertex 
 DistTibMtioTi of -various larca- 
 nated types of Cortex. 
 
 Bale'&JDanielsson.Ltd. Sculp 
 
NERVE CELLS— THE CYTOPLASM. 63 
 
 contains a nucleus — usually of large proportionate size compared with 
 the cell itself, and of a structure essentially differing from the cell 
 protoplasm surrounding it. Apart from morphological differences a 
 chemical distinction exists betwixt nucleus and the cell body, which is 
 of critical importance in the physiological phases through which the 
 cell passes, and to which, later on, we shall refer. The nerve cell has 
 no definite wall or membrane, such as we find in the vegetable cell, 
 although in pathological states such formed material is often to be 
 recognised ; on the other hand, the nucleus is possessed of a distinct 
 membrane which sharply demai'cates it from the suri'ounding cell 
 protoplasm, and which, in certain cells, may assume a considerable 
 density. Usually placed centrally within the cell, the nucleus may, 
 in certain moi'bid conditions, be transferred to the side or be dislocated 
 to the apical pole of the cell, as is so often seen in the pyramidal cells 
 of the cortex. 
 
 The Cytoplasm. — The protoplasmic contents of the cell apart 
 from the nucleus is spoken of as the cytoplasm ; whilst that of the 
 nucleus is known as the karyoplasm. The cytoplasm is by no means 
 clear, homogeneous and structureless, as direct observation of the 
 fresh unstained cell would lead us to infer; but is, like the corre- 
 sponding karyoplasm, of highly complex structure. A very delicate 
 fibrillar structure pervades the whole cell, becoming continuous with 
 close set parallel fibres, which pass into the several processes given off 
 from the cell body, and to which they give a finely striated appearance. 
 As these fine strise pass into the cytoplasm from the cell processes they 
 diverge and form, according to most authorities, a sort of reticulum, or 
 delicate meshwork or sponge (spoiigioplasm) which supports peculiar 
 granules or rod-like bodies known as the chromophil granules of 
 Nissl. 
 
 The achromatic fibrillar struct\ire or cytoreticulum has been recog- 
 nised by Benda, Dogiel, Nissl, and others, in nerve cells, and has been 
 identified by them with the filar mass of Fleming. Although the 
 achromatic fibrils are traced into all the processes of the cell, the 
 granules of Nissl (or " chromatophilic " substance) do not enter 
 the axon, as was shown by Benda in 1886, whilst they extend freely 
 into the large dendrons. The "chromophilic" masses of Nissl, usually 
 I'od-like, tetrahedral, polyhedral or granular in aspect, may be disposed 
 concentrically around the nucleus, or parallel to the cell contour: 
 whilst, converging towards the dendrons, they course through the 
 latter in parallel streaks. They show a very strong^affinity for certain 
 dyes, especially the colour derivatives of di-phenylamine — such as 
 methylene blue and thionin, and so also for toluidinjblue. With the 
 former of these stains, as by Nissl's method, the granule masses are 
 deeply coloured, as are also the nucleoli, whilst the nucleus remains 
 
64 ' THE CEREBRAL CORTEX. 
 
 unaffected. Nissl has classified all nerve cells according to whether 
 the granule masses are arranged : — 
 
 (1) In a reticulated pattern or mesh work (Archyocbromic) ; 
 
 (2) In elongated spindles, streaks or knots (Stychochromie) ; 
 
 (3) Or without any apparent order or groupings (Gryochromic). 
 
 These granules are regarded as incrusting the cytoreticulum, tilling 
 up more or less its meshwork. When they are approximated by the 
 diminution or shrinking of the cell they show deeper staining, and 
 the cell is regarded as in a resting" stage (pyknomorphic); when more 
 widely diffused and the cell increased in size, it is regarded as evidence 
 of functional activity (apyknomorphic). Since the term " resting, "^ 
 however, has long been applied to the stage preceding mitosis, it 
 should be discarded here ; as also should the term " chromophilic ' as 
 applied to the granules of Nissl, since it is likely to be confounded 
 with the chromatin masses of the nucleus, with which it must not be 
 identified. 
 
 Lu<7aro * regards Nissl's granules as identical with Fleming's 
 " interfilar " mass, and, so far as cell function is concerned, as having 
 a passive role, t 
 
 The filar structure is supported by the more fluid, transparent 
 g-FOUnd-SUbstance or hyaloplasm. Reasoning from analogy we 
 should presume that this reticulated structure is itself composed, as 
 in other animal cells, of extremely minute granules — the so-called 
 "microsomes"; and that they are probably directly continuous with 
 the similar structures in the nucleus. If this be so, the nucleus 
 evidently does not lie free within the cell. 
 
 The cytoplasm of nerve cells is very frequently the site of pigment 
 granules, which, in the pyramidal cells, in physiological states inva- 
 riably assume a position at the base of the cell; but in pathological 
 states may be very widely diffused throughout the cytoplasm. 
 
 Granular proteid matter is also found here in disease, as well as 
 fatty granules — products of cell metabolism. These, together with 
 vacuoles, form the principal lifeless structures in the cytoplasm. 
 
 The nerve cell is, according to Lenhossek, not an exception to other 
 tissue cells as regards another all-important constituent of the cyto- 
 plasm : this is the so-called " centrosome " — a single or double granule 
 exceedingly minute, scarcely larger than a microsome, deeply stained 
 by certain reagents, and distinguished by its forming the centre of 
 a peculiar area of the cytoreticulum called the "attraction-sphere." 
 Usually in close contiguity to the nucleus, it forms the starting-point 
 
 * Riviata di Pathol, nerc. e. Ment., vol. i., Jan., 1896. 
 
 t " Sulle Modificazion delle Cellule nervose nei diversi Stati functionali." 
 Lo Sperimentale, vol. xlix., Aug., 1895. 
 
NUCLEUS— DENDRITES AND THORNS. 65 
 
 for all those mysterious changes which result in division of the cell 
 and x'eproduction. 
 
 Ayers has identified the centrosome in the nerve cell of the electric 
 lobe of the Torpedo, and has noted the frequent presence of two, or 
 €ven three, nuclei. He also clearly traces the division of such nerve 
 cells in the Torpedo brain — although the usual teaching has been that 
 after the third month of fo3tal life the neuroblasts no longer increase 
 in number but in size only {His), and that the appearance of axons 
 and dendrons is final for all further cell division.* 
 
 Nucleus. — As before stated, the nucleus is a constant feature of all 
 nerve cells ; usually spherical or oval in contour, sharp edged from 
 its possession of a limiting membrane, it contains within it a gTOUnd- 
 SUbstanCG or karyolymph pervaded by an extremely fine thread-like 
 reticulum — the linin reticulum, with minute granules along its course, 
 and continuous with the nucleus membrane and the cytoreticulum of 
 the cell. But, beyond this, a much coarser structure readily stained 
 by certain dyes, and which varies much both in amount and in appear, 
 ance at different periods of the cell life, is a still more prominent 
 feature. This latter material may form an irregular meshwork or 
 accumulate in large granule masses, and is peculiarly characterised by 
 staining of an intense depth with basic aniline dyes. From the latter 
 feature it is called " Chromatin," and must be carefully distinguished 
 from the " chromophilic " granules of the cytoplasm. Within the 
 nucleus is usually found a spherical body stained deeply by plasma 
 dyes, and, so, reacting like the cytoplasm : this is the so-called 
 " nucleolus." 
 
 Dendrites and Thorns. — The dendrites of the cortical nerve cells 
 are beset in most cases, if not in all, by delicate thorn-like projections, 
 each tipped with a minute bulb, which, together with the stalk, is 
 stained deep black by the silver-chrome and mercury methods of Golgi 
 ^nd Cox. They resemble the gland-bearing hairs of the vegetable 
 kingdom rather than true spines, thorns (epines), and commence where 
 the first branchings of the main dendron occur. They give the den- 
 drites a rough, hispid appearance, which at once serves to distinguish 
 the protoplasmic processes from the smooth contoured axon, the latter 
 being always devoid of such projections. These thorns or gemmules, 
 as they have also been termed, vary considerably in length at different 
 sites along the dendrite — Hill states from 1 /x to 8 or 10 /x ; the 
 " longest being found in the granules of the olfactory bulb." f 
 
 The function assigned to these thorns has been that of aff'ording 
 multiple points of contact for the nerve fibril, naked axons, and 
 terminal arborisations, which pass athwart the dendrites. On the 
 
 * Morphol. Labor. Univ. Missoiu'i, Columbia, ^March, 1896. 
 t " Note on Thorns," Brain, vol. xx., p. 1.33. 
 
66 THE CEREBRAL CORTEX. 
 
 other hand, the theory held by Hill is expressed by him in these 
 words : — " The thorn is really the cell end of an iinstainable nerve 
 filament surrounded by a film of staining cell plasm."* If this 
 position be confirmed, the whole doctrine of conduction of nervoua 
 currents by contact falls to the ground and the continuity doctrine of 
 Gerlach would, with certain modifications, be re-established. 
 
 Chemical Constitution. — The linin network of the nucleus and 
 the cytoreticulum are identical in constitution, and, as Wilson indi- 
 cates, this identity is well established by the fact that the spindles of 
 the mitotic figure in certain rare cases may arise within the nucleus, 
 as where we have an intra-nuclear centrosome. This achromatic 
 network has, of course, a chemical constitution entirely difiering from 
 the chromatic network or chromatin masses, as indicated by staining 
 reactions. The minute granules along this network stain readily with 
 acid aniline dyes, such as acid fuchsin, eosin, rubin, and Congo red ; 
 granules so reacting are termed Oxychromatin granules. On the 
 other hand, the granules and masses of chromatin are termed Basi- 
 chromatin since they stain vigorously with basic aniline dyes — viz., 
 methyl green, safiranin, Bismarck brown. The Basichromatin or 
 Chromatin of biologists is now almost definitely ascertained to be 
 identical with the Nucleins (Miescher) complex organic compounds 
 of nucleic acid and albumen, in which the proportion of nucleic acid 
 may vary very greatly. 
 
 It has been ascertained by direct experiment that mixtures of 
 nucleic acid and albumen when treated by methyl green and acid 
 fuchsin take up a green, bluish- violet, or red coloration according to 
 the amount of Nucleic acid present — the basic dye always predominating 
 with the larger amount of nucleic acid [Malfatti). The deeper staining 
 of the basichromatin, therefore, indicates the presence of larger pro- 
 portions of nucleic acid; and this seems to be indicated in certain 
 pathological states of the cell nucleus as in hydrophobia, also in 
 certain physiological phases of the cell life — as in the case with the 
 chromosomes just prior to and during mitosis, and again with the 
 nucleus of the spermatozoon, which, judging from the intensity of the 
 reaction, must be nearly pure nucleic acid. 
 
 . Nucleic acid is remarkable for the large amount of phosphorus- 
 combined with it — pure nucleic acid having over 9 per cent, of 
 phosphorus and no sulphur ; whilst the nucleins found in cell nuclei 
 vary in their amount of phosphorus from 3'2 to 9-6 per cent. In fact, 
 we have in the percentage of phosphorus the means for estimating 
 the purity of nucleic acid in basichromatin. The chromatin network 
 embraces also many granules identical with the oxychromatin granules 
 of the achromatic network ; and, since every phase of coloration 
 * " The Chrome-Silver Method," Brain, 1896 ; also loc. cit. vol., xx. 
 
CYTORETICULUM. 
 
 67 
 
 from basic to acid reaction occurs in these granules when treated with 
 differential dyes, it is believed that the chromatin is directly con- 
 vertible into oxychromatin by the loss of its greater proportion of 
 phosphorus — in other words, a lower member of the nuclein series 
 results ( WUso7i).'^- All late researches seem to point to the fact that in 
 the growth of the chromatin masses, and in the loss of their stainin*^' 
 capacity for basic dyes, we have evidence of the taking up of albu- 
 minous material and the giving up of phosphorus, and that this occurs 
 during periods of great constructive activity of the cytoplasm : whilst 
 with the diminution in size of the chromosomes and their more intense 
 staining, such synthetic metabolism is at its lowest ebb. 
 
 It is of great interest to note that the nucleins which play so 
 important a part in the economy of the nerve cell (as well, indeed as 
 in all cells of both vegetable and animal tissues) have as their decom- 
 position products the highly nitrogenised compounds called the xanthin 
 bodies — viz., adenin, guanin, xanthin, and hypoxanthin, and which, as 
 illustrated by the following table, are the direct precursors of uric acid 
 which probably represents the total result of nuclein decomposition : 
 
 Adenin, C5H5N5 
 
 Guanin, CsHsNjO 
 
 Hypoxanthin, . . . . . . C5H4lSr40 
 
 ■ Xanthin, C5H4N4O2 
 
 Uric acid, C5H4N4O3 
 
 PhysiolOg-ical and Patholog-ical. — As yet, we are far from 
 being able to give a decisive opinion upon the physiological signifi- 
 cance of the cytoreticulum and the chromatophil granules of Nissl. 
 Authorities are much at variance on this point, and the results of 
 experimental research are frequently of a conflicting nature. It may 
 not be premature, however, to give here the more important and 
 seemingly conclusive results obtained. In the first place, the granules 
 of Nissl, or so-called " Tigroids," may be regarded as representing 
 Fleming's inter-filar mass : the unstained, achromatic substance 
 corresponding to his filar maSS. In the next place, these granules 
 form no part of the conducting mechanism of the neui-on— they play a 
 more passive role. Whether they be nutritive material, as Lugaro 
 suggests, or whether (as we opine) they in some manner intensify the 
 nervous discharge along the conducting strands, they take no direct 
 part in the conveyance of the nerve impulse, which almost certainly 
 is the attribute of the achromatic or filar network (cytoreticulum). 
 Although, as it were, superadded to the true anatomical conducting 
 mechanism of the neuron, they by no means act like the lifeless bodies 
 which are so often found in the cell protoplasm generally ; on the 
 contrary, they are peculiarly sensitive in their reaction to various 
 * "The Cell in Development and Inheritance," Columbia Unir. Biol. Series, iv. 
 
68 THE CEREBRAL CORTEX. 
 
 agencies, although Lugaro would maintain that they bear a direct 
 relationship to the size of the cell rather than that they vary with its 
 functional conditions. A great mass of evidence is, however, now 
 forthcoming to show that these granules, both during certain physio- 
 logical phases of cell life and as the result of experimental irritation, 
 traumatism, or pathological change, undergo very notable and exten- 
 sive alteration. 
 
 ChPOmatolysis. — The most familiar change observed consists in a 
 peculiar diffusion of the chromophil granules, which, instead of lying 
 closely around the neighbourhood of the nucleus as in pyknomorphic 
 cells, are scattered peripherally, the granules being more widely 
 severed, whilst the nucleus is often displaced towards the periphery of 
 the cell. Occasionally, a clear zone surrounds the nucleus still 
 central in position ; or, again, the granules may be generally diffused 
 and broken down into a fine pulverulent condition, giving the 
 cytoplasm a punctuated aspect. In other instances the granules may 
 not be so much altered in form as displaced outwards, and surrounding 
 an unstained vitreous, homogeneous looking substance.* Chromato- 
 lysis may be a purely functional change — the granules may again 
 resume their former size, position, and staining reaction ; on the other 
 hand, it may be the precursor of complete loss of normal structure and 
 break down of the neuron. 
 
 Fatig'Ue. — Attempts have been made by electrical excitation of 
 the nervous system of the frog, the dog, and cat {Hodges) to ascertain 
 the effect of fatigue thus induced on the cells of the spinal ganglia; 
 and Fish has examined the nerve cells after execution of a criminal by 
 electricity, in which 1740 volts had been passed, and in which he 
 found notable vacuolation of nerve cells. In a second case, however, 
 as well as in animals killed by the electric current, he quite failed to 
 find similar changes. All such attempts are too coarse to teach us 
 anything with regard to normal physiological processes ; and the 
 appearances resulting can only be classed with pathological results, 
 such as would ensue where chemical, thermal, or mechanical irritants 
 were employed. Normal fatigue has been, however, studied in the 
 ganglia and brain of the honey bee, the sparrow, and pigeon [Hodges). 
 In such phases the nucleus lost its network or reticulated aspect, 
 decreased in size, and became crenated in contour. The cytoplasm 
 usually shrinks considerably, does not stain so readily, and loses its 
 affinity for oxygen : occasionally vacuolation occurred. The normal 
 condition was only very slowly restored after prolonged rest, five 
 hours' stimulation requiring twenty -four hours' repose for complete 
 repair. Gustav Mann describes the same results, affirms that there is 
 
 * Dr. Adolf Meyer has described several types of chromatolj-sis occurring in 
 degenerative diseases of the neuron. American J ourn. oj Tmanity, a'oI. liv., No. 2. 
 
CONFIGURATION OF THE NERVE CELL. 69 
 
 a diffusion of chi'omatin within the nucleus, and that cell, nucleus, and 
 nucleoli all alike increase in size in states of activity of the neuron. 
 The chromophil granules in the cytoplasm show slight increase during 
 functional activity, and diminution in amount and diffusion only with 
 extreme fatigue {Lugaro). 
 
 Lesion. — If by section, ligature, compression, chemical or thermal 
 irritation the axon be destroyed, beyond the changes which are well- 
 known to result in the peripheral segment and muscle to which it is 
 supplied, we find the motor cells subject to a chromatolysis, such as 
 has been already described — viz., primary increased size of cell, 
 scattering and diminution of chromophilic granules from the centre 
 outwards, wandering of the nucleus to the periphery without any 
 change in its integrity, and, eventually, a lessening of the size of the 
 cell. Such changes have been established by the observations of 
 Nissl, Marinesco, Lugaro, and v. Gehuchten within 40 hours after 
 lesion ; and repair does not set in for two or three weeks, nor is the 
 normal re-established for about three months. 
 
 In such cases no change occurs in the cytoreticulum ; the achromatic 
 constituent remains intact, whilst the complete repair undergone 
 proves that no genuine degeneration has taken place, but that the 
 process is one of simple deranged function. A much more rapid 
 chromatolysis, followed by destruction of the cell, however, occurs, in 
 the case of the spinal ganglion cells, in section of the peripheral nerves 
 {Marinesco) ; a fact explained by their severance from all trophic 
 influence. 
 
 Config'UPation. — Recent research into the general morphology 
 and intimate histological structure of the nerve cell has so far enlarged 
 the boundaries of our knowledge, that it becomes essential to start with 
 a definite terminology which includes no ambiguous terms for the com- 
 plicated apparatus presented as the modern conception of a nerve cell. 
 
 The body of the cell, including all its contents, we shall denominate 
 the cell or neurocyte ; the protoplasmic body of the cell, in contra- 
 distinction to the nucleus, may be termed the ncUPOSOme or 
 cytoplasm. If the cell is provided with protoplasmic processes, we 
 speak of the main trunk as the dendPOn, and the finer arborisations, 
 as the dendrites. If one of tliese occupy a polar position whilst the 
 others arise from the base or sides, as in the pyramidal cells of the 
 cortex, we should designate the former as apical or primapy 
 dendrons, and the others as latCPal, basal, or secondapy dendrons. 
 The dendron, be it remembered, is not an essential part of the cell, 
 since many nerve cells have no dendron. The axis-cylinder may be 
 much more conveniently termed the axon, which may be naked 
 (non-meduUated) or meduUated, and such branches as arise along 
 its course, as COUatePalS. The distal termination of an axon or 
 
70 THE CEREBRAL CORTEX. 
 
 its collaterals in a plexvts, we speak of as a terminal aPbOPisation ; 
 
 and for the whole system thus embraced, i.e., the neurocyte with its 
 axon, collaterals, terminal arborisations, and, if present, the dendritic 
 expansions, we use preferably the term neuron in the original sense 
 adopted by Waldeyer.* 
 
 The Neuron. — The nerve cell or neurocyte may vary much in 
 contour; it may be pyramidal, small or large in size, giving origin to 
 apical or primary dendron, whilst from its sides and base emerge 
 secondary dendrons as well as the aixon ; it may assume a swollen, 
 inflated, or flask-like configuration ; or may be elongated in a long 
 spindle-like element, either pole being the origin of extended jjrocesses, 
 as seen in the lowermost layer of the cerebral cortex and the claustral 
 formation. It may assume an irregular, angular, polyhedral form ; or, 
 again, may resemble a large granule, in which the nucleus is of large 
 proportionate size, and the cell protoplasm greatly limited in amount, 
 as is the case with the granule cells of the cortex cerebri, the cere- 
 bellum, and other regions of the nervous centres. It must be under- 
 stood that our description of the contour of the neurocyte and the size 
 of its individual parts, refers entirely to fresh frozen sections — the 
 deforming influence of chrome reagents, and of the silver and mer- 
 curial reagents of Golgi and Oajal being so great as to require 
 checking by examination of fresh specimens. It is not, however, upon 
 these diversities in contour that we can lay such emphasis as was 
 formerly done — but the whole neuron — cell, axon, and dendron (where 
 present) must be considered in all its diversities of form before we 
 Can relegate the unit to its proper place in a rational classification. 
 We shall, therefore, consider shortly the more important forms of 
 neuron presented to us in the cortex cerebri, cerebellum, and their 
 dependencies. The elements thus to be discussed are as follows : — 
 
 (1) Angular and sensory cells of Golgi. 
 
 (2) Granule cells (cerebrum, cerebellum, cornu, olfactory lobe, retma). 
 
 (3) Pyramidal cells of cortex and its varieties — 
 (a) Motor cell. 
 
 (/?) Pyramids of cornu. 
 (y) Cells of Piu'kinje. 
 
 (4) Cells with ascending axons. 
 
 (5) Cells of peripheral zone. 
 
 (6) Mitral cells of olfactory bulbs. 
 
 (7) Inflated and irregularly globose cell. 
 
 (8) Spindle cells. 
 
 (1) The ang'Ular cell is of very irregular contour, occasionally 
 
 approaching an oval, a pyriform, or even a fusiform outline. It quite 
 
 as frequently assumes more of a pyramidal, and still more frequently 
 
 an inverted pyramidal contour, due to a bicorned formation of its 
 
 * Deutsche med. Wochenschr., ISdl. 
 
Plate II. 
 
 Fig. I. 
 
 X 110. 
 
 Fig. 2. 
 
 X 110. 
 
 CEREBELLAR CORTEX: CELLS OF PURKINJE (HUMAN). 
 
 Bale, Sons £ Daniehson, Ltd.,Lith. 
 
ANGULAR AND GRANULE CELLS. 7 I 
 
 uppermost 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 great limbic lobe of the 
 Pig or of the Sheep. To see its more notable development, 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 clumps of these 
 irregularly-shaped nerve cells closely appressed, usually measuring 
 18 /x X 10 /x 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 
 feature, seen in these elements in the rodent, in the sheep, the pig, 
 and other mammals, is also seen in the cortex of man.* In OSIliatiC 
 rnammals, 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 recognised at 
 other levels, but it is here (gyrus hippocampi) that its richest develop- 
 ment occurs. 
 
 Amongst these angular cells are scattered globose or shot-like cells 
 — the " Cellule polygonale " of Cajal, which, as seen by the silver- 
 chromate method, and especially by the modified Cox's process, are 
 apparently identical with the sensory cells of Golgi. These cells throw 
 off numerous protoplasmic processes, which are rough and thorny, like 
 the dendrons of the pyramidal cells, and which divide and subdivide 
 as they spread outwards from the cell. Moreover, from each cell 
 arises an extremely delicate naked axis-cylinder or neuron, which 
 thi'ows off along a complicated course numerous offshoots or delicate 
 collaterals, which conjointly form a complex system of curves around 
 the cell or stretch into distant parts of the cortex, either upwards, 
 downwards, or horizontally in its peripheral zone (fig. 9). 
 
 (2) The granule cell is a small element, averaging 10 /x x 8 /x in 
 size, and many not larger than 9 /x, and with a nucleus of 4 /^ to 5 /a in 
 diameter. Slightly conical in form, with relatively large nucleus, the 
 delicate protoplasm 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 vi.). In 
 the histological study of the cortex, these two varieties of cell — the 
 ang'UlaP and the granule — are so diverse in forms, and their regional 
 
 * "The Cortical Lamination of the Motor Area of the Brain," Proc. Royal Soc, 
 No. 185. 
 
 + "The Comparative Structure of the Brain in Hodents," Fhilosojih, Trans., 
 partii., 1882, p. 709. 
 
72 
 
 THE CEREBRAL CORTEX. 
 
 ; 
 
 I 
 
 Q 
 
 f^ 
 
GRANULE CELLS. 
 
 73 
 
 distribution is so distinct, that it would be inexcusable to confuse the 
 two formations as of identical constituents. 
 
 Several varieties of granule cells exist which, by the older methods 
 of research, were not differentiated, but can now be readily dis- 
 tinguished. The more important are the granule cells of 
 
 (1) Cerebrum; (2) CerebeUum ; (3) Cornu Ammonis ; (4) Olfactory bulb; (5) 
 Retina. 
 
 By some authors it is doubted if either of the last two is correctly 
 to be claimed as a true nervous element ; both are supposed to be 
 devoid of that all-essential feature of the neuron — viz., an axon. 
 Protoj)lasmic processes certainly do exist, branching similarly to those 
 of other nervous elements ; but, in the absence of the axon, the granule 
 elements of the olfactory bulb and the spongioblasts of the retina 
 might, by some, be justifiably classed as connective structures.* 
 Those of the cerebral cortex average 10 //- by 8 /a. in size, many not 
 larger than 9 /a-, with a nucleus of 4 /a, to 5 /a, in diameter. Slightly 
 conical in form, with relatively large nucleus, the delicate protoplasm 
 extends into several extremely fine processes ; an apical process being 
 also often present. This element forms an important constituent of 
 sensory realms of the brain, and may be seen as a densely grouped 
 formation in what we have elsewhere f described as the modified upper 
 limbic type in the rodent (Plate iv., fig. 1). 
 
 The small granules of the cerebellum on the other hand, forming 
 the densely packed inner cortical layer, give origin to three or four 
 small stunted protoplasmic processes, rapidly ending by subdivision 
 amongst the neighbouring granules. The axon arising from one of 
 these same processes passes straight up into the pure grey layer, and, 
 bifurcating at right angles, each division courses in contrary directions 
 parallel to the cortical surface. Their intimate relationships we shall 
 refer to later on (Plate viii., fig. 1). 
 
 In the fascia dentata of the cornu Ammonis the granule element is 
 peculiar ; its protoplasmic processes arise wholly from the outer pole 
 of the cell to spread widely in a rich plume into the peripheral zone. 
 Its axon passes through the granule layer, and, after giving oft" 
 numerous collaterals, becomes continuous with the so-called " Moss- 
 fibres" of this region, which ramify across the dendrons of the large 
 pyramidal cells (Plate vii., fig. 2). 
 
 (3) The Pyramidal Cell. — From its uniform contour, large size, 
 very general distribution (regional), and depth of formation, this cell 
 has come to be regarded by many as pre-eminently the nerve element 
 of the cortex. 
 
 *.See " Notes on Granules," by Alex Hill, M.D., Brain, vol. xx., p. 125. 
 t " The Comparative Structure of the Brain in Rodents," Philoaoph. Trans., 
 part ii., 1882. 
 
74 THE CEREBRAL CORTEX. 
 
 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 off 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 lower end 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 denta- 
 tions caused by the processes distributed therefrom. From the summit 
 of the cell arises the apex pPOCeSS, or primary dendron, directed 
 radially to the surface of the cortex, whilst on either side from the 
 basal aspect — the secondary — fairly stout branches diverge — 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 apex process, or main dendron, passes 
 upwards towards the outermost layer of the cortex, to which it usually, 
 but not invariably, extends ; small branches arise from thickened axils 
 along its course, and, eventually, the main branch divides and sub- 
 divides into a large number of branches forming a rich plume within 
 the first cortical layer. These dendrites appear to terminate imme- 
 diately beneath the pia, or sweep horizontally beneath the latter for 
 varying distances. The most important feature revealed by the silver- 
 chrome method as regards this apex process and its dendritic plumule, 
 is the fact that the branches are apparently terminal, and are clothed 
 throughout their course by minute thorn-like appendages, each sur- 
 mounted by a minute bulb or bead-like head, in the intervals between 
 which lie the axons or axis-cylinder processes and the terminal arbor- 
 isations formed by the latter (Plate xiii., fig. 2). Cajal * terms the 
 primary dendron the tPUnk {tige) as being the earliest evolved of the 
 protoplasmic processes. These bodies, therefore, throw off three sets 
 of protoplasmic fibres : — 
 
 (a) The apical dendPOns, which are by far the most conspicuous, 
 and always radiate to the surface of the cortex ; 
 
 * See on this point — Cajal, " Sur la Structure de I'Ecorce C^r^brale," La Cellule, 
 1891, tome vii., p. 135. Also the author on " The Structure of the First Layer of 
 the Cortex," Edi7i. Med. Jouni., June, 1897. 
 
Plate 111. 
 
 X 110 
 
 Fig. I. 
 
 Fio. 2. 
 
 Bale, Sons £ Danielsson, Ltd.,Lith. 
 
MOTOR CELL. 
 
 75 
 
 (b) The large basal dendrons, running obliquely outwards and 
 downwards on both sides ; and 
 
 (c) Numerous very delicate lateral dendrons radiating from all inter- 
 vening districts of the surface into the nervous meshwork around. 
 
 These lateral protoplasmic processes give origin to numei'ous branches 
 which ramify extensively in the neighbourhood around the cell, and, 
 like those of the apical plumules, are also invested by thorny appen- 
 dages (epines). 
 
 The axon passes downwards from the lower pole of the cell, or from 
 a basal dendron here, to enter the white medulla of the corona radiata: 
 its constitution and relationships can be better relegated to our descrip- 
 tion of the first variety of the pyramidal cell, viz. — the Motor. 
 
 Each cell contains an oval nucleuS, with well-defined nucleolUS, 
 7 /x X 5 fx in size. The dimensions of the cell vary from 1 2 /i x 8 ,«,, 
 in the more superficial to 41 /^c x 23 /a- in the deeper layers. 
 
 (a) The Motor Cell. — We are alive to the exception which may be 
 taken to any such implication as the above designation conveys ; yet, 
 as it appears to us that the argument in favour of their motor endow- 
 ments has been materially strengthened by further 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 ephithet ''giant cell," being even smaller than the 
 lower cells of the 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/// in length by 55 /a in the shorter diameter ; the average dimensions 
 of a very large number in the ascending frontal convolution being 
 GO/i X 25 /x. The extremes are 30 /a. and 96 /a for length, 12 ,a and 45 ,a 
 for breadth. They contain an oval nucleus, 13-20,a 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 apex process, throwing oflf the greater number of proto- 
 plasmic 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 basal processes being usually the larger, 
 the cells tend to lengthen out in their direction and assume a more 
 or less fusiform outline. Large processes, however, given out from 
 various other points of the cell, greatly 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 slightly pyriform ; that the fusiform outline is the 
 next stage of their development; and that further modifications occur 
 
76 THE CEREBRAL CORTEX. 
 
 as other processes beyond the apical and basal extend laterally. So 
 likewise we shall see the reverse change undergone hy 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 cell is seen to consist of a 
 delicate protoplasm, which appears to be directly continuous with its 
 various processes ; nor can any trace of the fibrillated structure of 
 the cell -contents described by Max Schultze be detected unless, 
 indeed, reagents be employed. Then we obtain, as by Nissl's method 
 of staining, eridence of a complicated structure, to which we have 
 previously referred (see p. 67). 
 
 The lower pole of the cell is usually pig'mented as a normal 
 condition, just as is the case with the multipolar cells of the spinal 
 cord. A large round or oval nucleus enclosing a nucleolus is always 
 present in these cells. Each cell throws off what may be termed 
 primapy and SGCOndary protoplasmic branches — the former the 
 apical extension ; the latter including all other processes except 
 the axon, whether coarse or delicate fibres. The division usually 
 adopted by Continental writers is into centripetal (apical and 
 lateral secondary processes) and centrifugal (axis - cylinder or 
 axon). 
 
 The apex process or primary dendron, formed by the gradual 
 attenuation of the cell, passes straight up through the superjacent 
 layer of cells, throwing off in its course several collateral protoplasmic 
 processes, which usually run obliquely upwards and outwards from the 
 trunk and lose themselves in the neighbourhood around ; whilst, as in 
 the pyramidal cell above described, the main trunk, on entering the 
 peripheral zone, furnishes a rich dendritic plume to that layer, the 
 fibres of which similarly present a fine hispid appearance from minute 
 projecting spines. Since in the motor cortex these nerve elements 
 are aggregated into groups or clusters (Plate v.), these apical pro- 
 cesses, closely approximated, often run in sheaves through the more 
 superficial layers. A basal protOplasmiC pPOCeSS often arises in 
 like manner from a gradual attenuation of the opposite pole, as in 
 fusiform cells, and large lateral branches may strike out from this 
 extended pole. The basal process usually, however, continues down- 
 wards 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 termed the axon or 
 axiS-eylindeP pPOCesS. Upon this Meynert remarks — " It is the 
 more rarely seen because, being the process which enters the medulla, 
 its direction is dependent upon the angles formed by the fasciculi of 
 the latter, which by no means form a straight line with the apical 
 
MOTOR CELL. 
 
 n 
 
 Fig. 10. 
 
78 THE CEREBRAL CORTEX. 
 
 processes of the pyramid." * This obliquity of position, therefore, 
 necessitates its being cut off in sections on a plane with the radiating 
 apical processes. This statement, however, no longer remains true for 
 the neiv methods of preparation, since the wealth of structure and 
 comparative thickness of sections examined in silver-chrome prepara- 
 tions admit of the axon being readily seen in most cells (fig. 10). 
 
 The secondary or lateral processes which radiate from the cell 
 on all sides, unlike the primary, divide and subdivide almost im- 
 mediately after their origin, and interlace in the intricate webwork of 
 nerve and connective fibre around the cell. Schafier has recently 
 indicated that these secondary processes are readily distinguished 
 from the axons by Nissl's method of staining ; spindle-shaped chromo- 
 phil bodies stained by methylene blue are grouped around these 
 secondary processes, but the axon is devoid of such bodies.t 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 crossing and recrossing, hut not inosculating, with those 
 from adjacent cell territories. The termination of such branches is 
 regarded as absolutely free — i.e., no true meshwork by re-2inio7i of the 
 branches of one cell with the other is supposed to occur ; at least, such 
 is the appearance presented by sections prepared by the Golgi and Cox 
 methods of examination. 
 
 We have observed as many as eighteen main processes diverge from 
 a single cell in such sections ; in vertical sections the average nuaiber 
 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 indicate the wealth of communicating 
 branches which these " motor units " possess. 
 
 The axon, as before stated, arises directly from the gradual attenua- 
 tion of the lower pole, or it may arise indirectly from a basal dendron. 
 It passes downwards towards the medulla, throwing off at right angles 
 along this course some six to ten extremely fine collateral branches 
 (Cajal), which end in delicate terminal ramifications around. The 
 axon still maintains the same uniform dimensions, and, entering the 
 medulla, it either bends at right angles to continue its further course 
 or bifurcates into two divisions running in opposite directions. 
 
 When we come to examine what appear to be the corresponding 
 
 * The Brain of Mammals, Strieker's Handbook, p. 387. 
 f Neurologisches Centralhlatt, Dec. 15, 1893. 
 
MOTOR CELL. 
 
 79 
 
 cells in the cortex cerebri of some of the lower mammals, we find 
 certain strong points of resemblance, together with certain distinctive 
 features by which we may very readily recognise them as not human. 
 Thus in the pigf, 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 ganglionic cells in the parietal and temporo- 
 sphenoidal lobes of man. Nowhere do we find the irregular, swollen, 
 
 Fig. 11.— Cerebral cortex : nerve cell from deeper 
 zones of cortex (human). 
 
 and at times almost globose cells so frequent in the motor area of the 
 human brain."* Again, in the sheep, we 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 /x x 11 ,7,. In the 
 cat, however, these elements are plump, oval, and pyriform ; average 
 51 /x X 21 //, in size, with an occasional gigantic cell of 106 /x x 32 //, ; 
 
 * " Researches on the Comparative Structure of the Cortex Cerebri," Proc. Roy. 
 Soc., part i., 1880. 
 
3o THE CEREBRAL CORTEX. 
 
 and are grouped together in well-marked clusters. In the rodsilt 
 (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 
 prepai'ations, but still closer appear their affinities in structural 
 arran^-ements when teazed-out specimens of brain and cord are com- 
 pared. The inference that these cells are specialised elements 
 rests on this resemblance, on their exceptionally large size and 
 abrupt commencement, and the peculiar clustered groupings assumed 
 in a region which has been shown by Ferrier to possess motor 
 endowments (see p. 121). 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, 
 are connected with elements which, through the slenderness 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." t 
 
 (;3) Pyramids of Cornu. — The great pyramidal cells of the cornu 
 Ammonis in close approximation to the fimbria are peculiar in several 
 respects. From their superior or apical pole arises a very thick 
 dendron, which almost immediately breaks up into a coarse dendritic 
 arborisation — stunted, and in nowise resembling the finer dendritic 
 plumules of the pyramids of the cerebral cortex. Again, the collaterals 
 arising from the axons of these cells pursue a notably recurrent course, 
 passing by their cells to ramify eventually over the dendrites of the 
 smaller pyramidal cells of the cornu. These smaller pyramids, on the 
 other hand, more closely resemble those of the cortex cerebri; they 
 are usually pyriform or spindle-shaped, or, far less frequently, pyra- 
 midal in contour (Plate vii., fig. 2). 
 
 (7) Cells of Purkinje. — The flask-like cells of the cerebellar 
 ■cortex were never satisfactorily displayed in chrome preparations by 
 the older methods of staining with carmine, hematoxylin, lirc, the 
 
 *See the diagram of the five-layer type in Meynert's Piiichiatry, and also in 
 Sydenham Society's Trails, of his monogi-aph, fig. 234. 
 f Brain of Mammals, p. 387. 
 
NERVE CELLS WITH ASCENDING AXONS. 
 
 8l 
 
 profuse branchings into the peripheral layer were well revealed by- 
 aniline blue-black (Sankey) ; but yet their axons were revealed merely 
 by a very short projection from their base, their continuation being 
 lost in the subjacent granule layer. Moreover, the elaborate basket- 
 work found around the cell, as well as the plexus of branches from 
 underlying cells, which spread over their main dendrons, were not 
 discovered until the silver-chrome method of Golgi came to our assist-. 
 ance. By this means the cell appears as a flask-like element throwing 
 upwards one or two main dendrons, which divide and subdivide into 
 a rich dendritic arborisation as far as the pial surface ; whilst the 
 axon arising from its base passes through the granule layer and, 
 throwing off several collaterals, is eventually lost in the raedullated 
 tract of the lamina. Their relationship to the basket - work and 
 plexuses around their dendrons will be more fully described in the 
 section on the cerebellar cortex. 
 
 (4) Cells with ascending^ Axons. — Certain cells scattered through 
 the pyramidal and ganglionic layers of the cerebral cortex have been 
 
 Fig. 12. — Cerebral cortex: nerve cells of second layer with extensive; 
 ramification of axons (rat). 
 
82 THE CEREBRAL CORTEX. 
 
 lj»,tely shown by Martinotti to have the usual distribution of branches 
 reversed. As frequently spindle-shaped as triangular and throwing 
 off protoplasmic processes both ascending and descending, the axon, 
 on the other hand, arising often from a coarse apical dendron, ascends 
 to the peripheral zone. Here it breaks into two or three branches 
 which take a horizontal course, and subdivide in a very extensive 
 terminal ramification in this the lowermost region of the outer cortical 
 layer. Cajal describes a similar arrangement of certain such ascending 
 axons immediately beneath the second layer (fig. 12). 
 
 (5) Cells of the PeriphePal Zone. — These nervous elements, to 
 which great importance has lately been assigned by Cajal and others, 
 are either fusiform or stellate ; the former being bipolar and throwing 
 off from either pole a horizontally disposed protoplasmic process which 
 eventually thins off into several genuine axons, disposed parallel to 
 the surface ; whilst exceedingly delicate collaterals arise from these 
 to ramify upwards in the peripheral zone. In like manner, the 
 stellate cells are multipolar, yet their branches are disposed along 
 horizontal planes, and throw upwards collaterals in the same manner, 
 all of which have the aspect of delicate axons. Here, then, it will be 
 observed we have cells provided with no genuine dendritic expansions, 
 the protoplasmic processes being directly continuous with the axons 
 arising therefrom ; moreover, the cells never trespass beyond the 
 boundary of the cortical zone in which they lie. 
 
 (6) Mitral Cells of the Olfactory Bulb.— Another very peculiar 
 type of cell is illustrated by the so-called " mitre " cell. This element 
 is triangular, or more swollen or globose in contour, giving origin to 
 lateral ramifying processes, and to a stout dendron, which, arising 
 from its superficial aspect, passes downwards to an olfactory glomerulus, 
 and breaks up within it into a rich terminal plexus of branches. An 
 axon also arises from the deeper aspect of the cell to become continuous 
 with an olfactory nerve fibre (Plate iv., fig. 2). 
 
 (7) The Inflated or Irregularly Globose Cell.— The nerve cell 
 
 to which the epithet 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 Rodents (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 SAvollen, inflated, globose, or 
 flask-shaped, and, moreover, oi far greater size. The average dimensions 
 attained by it are 37 /i x 32 /a, with a nucleus of 13, a; some are more 
 
Plate IV. 
 
 Fig. I. 
 
 X 110. 
 
 CEREBELLAR CORTEX: STELLATE NERVE-CELL NEAR CELLS 
 OF PURKINJE (HUMAN). 
 
 Granules. 
 
 Collaterals of Axon. 
 
 ^ Descending Collateral. 
 
 Axon of Mitre Cell. 
 Mitre Cells. 
 
 Vu;. 2. 
 
 Glomeruli. 
 Olfactory Ner^'C Fibre. 
 
 X 110. 
 
 OLFACTORY BULB OF RAT: SEMI-DIAGRAM. 
 
 liaU, Sons it Danidsson, Lld.JAth. 
 
NERVE CELLS-. THE SPINDLE CELL. S^ 
 
 •elongate, measuring 46 /i x 27 fi. Hence, these elements are 7nore titan 
 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 the 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 cortex 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 apices and plexiform branching. 
 The cell throws ofl" numerous fine processes 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 
 characteristic appearance and resembles the vesicular cell, which, in the 
 medulla and spinal cord, is regarded as possessing sensoi'y endowments. 
 It appears to us that the 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. 
 
 (8) The Spindle Cell. — This undoubtedly is also a specialised 
 ■element. The cell is a narrow fusiform body, attaining the average 
 dimensions of 25 /i, x 9 /x, the largest being 32/0. x 13/j(., with an oval 
 •or fusiform nucleus 11 /x to 13/^ in length x 6,<a to 9/i in breadth.* 
 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, t Fi-equently 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 connectinfj 
 system of the brain, and since the claustrum is entirely composed of such 
 elements, the term claustpal formation has been proposed for it by 
 Meynert. These elements are peculiarly ])rone 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 brain ; this applies 
 equally to the mammalian brain in general. 
 
 * T ro.iuiactions of the Roy. Sac, 1882, part ii., pp. 714-15. 
 iOp. cit., p. 389. 
 
84 
 
 Fie 13.— Cerebral cortex : spindle cells of deepest layer (human). 
 
NERVE FIBRES: PRIMITIVE FIBRIL. 85 
 
 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 projections 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 arrest — 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 eai'ly stages in the development of the more 
 advanced forms of cortical cells, and may or may not have aflS.nities 
 to the inflated irregularly globose elements already described 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 — 
 
 (a) Nerve fibres ; 
 
 (b) Blood-vessels ; 
 
 (c) Connective matrix or neuroglia ; 
 
 (d) Lymph channels. 
 
 (a) Nerve Fibres. — As is well known, nerve fibres, central and 
 peripheral, present varied forms, corresponding to five stages of de- 
 velopment—from the ultimate fibril up to the ensheathed and medul- 
 lated fibre of the peripheral nerve trunks. The last, the most perfect 
 and complex form, does not occur in the nerve centres at all. In the 
 cortex, as well as the nervous centres generally, three forms of fibre 
 are met with — (1) The primitive fibril. (2) Naked, non-medullated 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 imlnbition of fluid ai-ound, 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. 
 
86 THE CEREBRAL CORTEX. 
 
 (2) The Naked or Non-MeduUated Fibres, the protoplasmic 
 
 processes of Deiters, form an important constituent of the cortex. 
 From what has already been stated respecting the mode of branching 
 of the nerve cells, it will be apparent that the protoplasmic extensions 
 occur in complicated meshworks throughout the cortex. The apical 
 process and lateral extensions pass by subdivision into an intricate 
 meshwork of fibrils : the basal process becomes invested lower down 
 with a protecting layer of medulla. This is the process to which, 
 properly, should be restricted the term axiS-Cy Under proCeSS ; and, 
 for all other extensions of the cell protoplasm, the term nOIl- 
 
 medullated fibre or protoplasmic process should be applied. 
 
 Since, however, recent research has demonstrated the fundamental 
 distinction betwixt the protoplasmic processes and the axis-cylinder 
 (the former being invested by spiny projections, and becoming 
 more and more attenuated as they subdivide; the latter invariably 
 smoother, and I'etaining a uniform diameter in spite of numerous 
 collaterals which emerge from it) it would be well to adopt the terms 
 of Dendron and Axon as applicable to these two. Eventually the 
 axon may terminate as a rich arborisation around other cells. Such 
 processes are very variable in size ; but, at their origin from the 
 various cells of the cortex, they range between 1 /j, and 6 /x 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 uppermost 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 authorities (Max Schultze* Landois and Stirling j) : 
 the homogeneous nature of the non-medullated fibre and axis-cylinder 
 has, on the other hand, been maintained by Kolliker,X Waldeyer,^ and 
 others. Since those who support the view of the fibrillation of the 
 axis-cylinder regard the fibre as a compound of the ultimate fibrils 
 already described, separated by a small quantity of interfibrillar sub- 
 stance, and believe them to be continuous through the ganglion cell in 
 what they desciibe as a well-marked fibrillation of its interior, the 
 question of the homogeneity or of the fibrillated constitution of the 
 axis-cylinder becomes 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 
 
 * Strieker's Human and Comparative Histology, Syd. Soc, p. 158. 
 
 t Text-Book of Human Phy.'iiology, vol. ii., p. 768. 
 
 X Geivehelehre, 5th Aufl,, 1867, p. 244. 
 
 § Zeitschrift fiir JRationeUe Medicin, Band xx., 1863. 
 
NERVE FIBRES: MEDULLATED FIBRE. 8/ 
 
 have a far difierent significance. Nor, according to some, need this 
 visible continuity of the fibrillte be demanded to establish the case — 
 more or less fusion may occur tliroughout the length of the fibre ; 
 and the splitting up into fibrilhe only be observed at the centric and 
 peripheric terminations as an indication of the fibrillar constitution of 
 the axis-cylinder and its lines of molecular disturbances. If r these 
 protoplasmic processes and axis-cylinders be submitted to the action of 
 silver nitrate in the dark, subsequent exposure shows them to be 
 marked by a peculiar transverse striation, first indicated by Fromann.* 
 Their significance is unknown. 
 
 (3) Medullated Fibre op Axis-cylinder Process.— This may 
 
 be either examined in the 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 bells found at a higher level. 
 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 a})pearance, non-medullated fibres having a 
 grey translucency. Tlie myelin is of fluid consistence, and appears 
 limited simply by a very friable, soft, protoplasmic envelope (Cornil 
 and Banvierf), 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 material, which they term the kcratoid 
 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 divei't, for the time, our attention), although 
 the axis-cylinder is continuous throughout, the medullary sheath is 
 not so, but presents at regular intervals annular constrictions named 
 Ranvier's nodes, after their discoverer. Ranvier called the indi- 
 vidual 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 COrpuSCleS — 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 
 
 * Virchow's Archiv, Band xxxi. 
 
 t Pathological Histology, vol. i., p. 3.3. Trans, by A. M. Hart. 
 
88 THE CEREBRAL CORTEX. 
 
 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 material, 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, 
 possesses, as we have already remarked, no sheath of Schwann ; it is 
 consequently devoid of the constrictions or nodes of Ranvier, has no 
 interannular segments, no nuclei along its length, nor does it exhibit 
 any signs of Ranvier's cross on treatment by silver nitrate. The 
 constitution of these centric medullated fibres, therefore, leads to a 
 TTiore perishable nature. They are far 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 
 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 compensated for, as 
 before stated, in peripheral fibres by the presence of the constrictions 
 of Ranvier. 
 
 To stain the axis-cylinder throughout its length in these centric fibres, 
 we must first displace the myelin.''^ This can be effected by prolonged 
 immersion of the section in water, and subsequent staining with 
 aniline blue-black. Twelve hours' immersion usually suffices 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 cortex downwards into the core of 
 the medulla, to which they converge in large numbers — deeply stained ; 
 and forming a striking contrast to the unstained aspect of nerve 
 
 * In the very minute medullated fibres of the cortex we have an exception to 
 this nile — the axis-cylinder staining fairly well -nnthout displacement of its 
 investing myelin sheath : a result due undoubtedly to the small calibre of the latter 
 allowing a certain amount of permeability. 
 
BLOOD-VESSELS: ARTERIES. 89 
 
 elements at this site in sections which have beea prepared in the usual 
 manner. But although such axis-cylinders present difficulties in 
 staining along their leugtli, 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 a frosted vitreous aspect, with a very slightly granular appear- 
 ance, the diameter of the fibre being from three to four times that of 
 the axis-cylinder.-'' Large medullated fibres occur at this site, in 
 section, measuring 13 /x 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— (i) Apteries.— These vessels, 
 
 as they dip into the cortex, vary in dimensions from 4 /x to 12 /x. 
 They possess the three tunics which are recognisable to the naked 
 eye in large arteries elsewhere, the tunica adventitia, 'media, and 
 intima ; but, as in these larger vessels microscopic examination 
 reveals the fact that each of these tunics is separable into several 
 differently-constituted layers, so the larger cortical blood-vessels 
 exhibit in the innermost 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 structureless membranous tube, with numerous oval nuclei, 
 well seen in carmine-stained preparations, scattered over its surface. 
 These nuclear elements are disposed longitiidinally, i.e., in the direction 
 of the vessel's length. The action of a solution of silver nitrate (^ 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 margin 
 Vjy a cementing material, which is mapped out in black lines by its 
 reduction of the silver salt. Moreover, 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 transvei-se sections of the vessel ; in the larger 
 arteries it is a distinctly fenestrated membrane, the representative 
 
 * It murt he home in mind that there exists a r^ertain definite relationship 
 betwixt diameter of axis-cylinder and medullated sheath : the larger axis-cylinder 
 always ha\ing a larger slieatli and ','('•€ vaviX. 
 
90 THE CEREBRAL CORTEX. 
 
 of Henle's fenestrated and elastic laminee, which can be stripped 
 off 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 tibre with oval or strap-shaped nuclei. Such fibres being 
 arranged transversely to the long axis of the vessel, or, rather, coiling 
 spirally around it, appear at riglit angles to the longitudinally-disposed 
 nuclei of the intima. Where this tunic is well 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 outline 
 irom the projection of these muscular fibres. In transverse sections 
 of the small arteries one or two such muscle cells surround the 
 open lumen. The muscular element does not enter largely into the 
 constitution of the cortical blood-vessels. These vessels, like those 
 of the cranial fcavity 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 
 {Sharj)ey). 
 
 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 are 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 {Eberth"'). 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 extreme 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 sheatli, 
 traverses channels in the cortical substance which form a wall limiting 
 the distension of the vessel. This limiting channel has no definite 
 endothelial lining, so far as can be discovered by the silver treatment ; 
 
 *See Strieker's Human and Comparative Histology, vol. i., p. 287, fig. 53. 
 
BLOOD-VESSELS: CAPILLARIES. 9 I 
 
 it is termed the pepivasCUlaP channel of His, and is continuous with 
 the epicerebral space between the intima pia and the outer sur- 
 face of the cortex. Traversing this perivascuhir space are 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 /x and 
 10 /A — i.e., when full of blood. The capillaries of the cortex, however, 
 are often not over 4 /x in diameter (^^^V^ inch), and are therefore of less 
 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 rami6cations do not permit the passage of the red blood- 
 corpuscle. 
 
 The only constituents of the arterial tunics, which enter into the 
 structure of the capillary, are the endothelial layCP or intima and 
 the adventitial investment. in lact, the transition from the 
 smallest artery into the larger capillary is indicated by the disappear- 
 ance of the muscular fibre cell, and the continuation of the channel as 
 an apparently homogeneous tubular membrane, with oval nuclei along 
 its course, and here and there nucleated 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: 07d)/ 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 cohmrless 
 cor[)uscles migrate. 
 
 In the smaller capillaries 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 vessel. 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 deriya- 
 
92 THE CEREBRAL CORTEX. 
 
 tives of the adventitial sheath, and are therefore always external 
 to and placed upon the fusiform nuclei. They are often the best 
 «uide to the direction of the capillary loops around the nerve cell 
 (Plate xii.). 
 
 (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 hovv they difier from the arteries, 
 and to point out the distinctive characteristics of these three divisions 
 of the vascular supply — artery, vein, and capillary. 
 
 The veins consist, then, of but three tunics — the Intima, Media, 
 and Adventitia. The tunica intima is similar to that of the artery ; 
 but the endothelial 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 than in arteries) 
 is wholly absent in the small veins of the cortex. The adventitia 
 reproduces 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 i heir tissue — the absence of the muscular and 
 elastic element leading to a loider lumen; moreover, the thin media, 
 due to the absence of muscle cells, results in a very thin-walled 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 Eberth, whose views are so much to the 
 point that we quote them here : — 
 
 ' ' Between the capillaries of the hyaloid of the Frog, isolated stellate cells occur, 
 with round nuclei and delicate protoplasm, branching off into many processes, 
 which 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 transverse!}' 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 functions of the neuroglia matrix would render structural 
 diiferentiation of this non-nervous constituent highly probable in 
 
 *" Eberth on tlie Minute Anatomy of the Capillaries,"' Strieker's Jlisioloijy, 
 vol. 1., p. 286. 
 
Platf.Y. 
 
 :» 
 
 j Ner^ye cells 
 
 of Lhird Lajen 
 
 liorzcc m.oioT cells 
 "■' ^ourfh larjer. 
 
 Moior-Cortex of Pig. 
 -f^ervf-.^^l-rncT.'.- ri 2"^^ -<'^*» 4'-"Uvers respectively >' 3 o. 
 
 YihA. 
 
 M-.--. or- Cortex of Pi^ -left KemispKere 
 
 '<>i'bilm«' its five-UiTun?«U-d type ^ ith tlvej>lests 
 
 or clusterf: r-ic cel\s. y /o 
 
 Bale &Darvielsson,Lt<3 , Sculp 
 
THE XEUR0C4LIA MATRIX. 
 
 93 
 
 different regions of the cerebro-spinal system. Tliis, we find, accords 
 ■with actual fact ; for, as a supporting, as well as embedding and 
 protective material, the requirements demanded will differ widely in 
 the white medullated 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 
 medullated fibres of the Spinal Cord will be found to possess a strong 
 binding material in the form of large-sized nucleated cells, with 
 numerous lengthened ramifying processes, together with a plexus of 
 fine fibrils (probably elastic tihre — Gerlach) ; whilst a structureless or 
 very finely granular material is found here but sparingly. Still nearer 
 the periphery of the cord, this supporting structure becomes a veritable 
 fibrillar connective sheath of great strength, with trabeculse 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 peripheral 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 neuroglia. 
 
 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 affirm that, when dealing with nerve cells 
 and their delicate extensions, the supporting material will be chiefly 
 
 the structureless or finely molecular basis-substance ; whilst as 
 
 we approach the medullated tracts, we shall find that the COnnectiV© 
 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 tlie 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 
 
94 THE CEREBRAL CORTEX. 
 
 more evident it becomes that the supposed free nuclei are invested by- 
 protoplasm, and, in fact, are likewise nucleated ceils. These two cell 
 elements differ much as regards their relationships and also their 
 ■dimensions. 
 
 (1) The smaller of the two kinds of cell vary from 6 /x to 9 ,'x in 
 diameter ; have a spheroidal nucleus, surrounded by an extremely 
 ■delicate protoplasmic investment, which, as before intimated, is 
 shrunken, often beyond recognition, in hardened specimens. The 
 nucleus is, proportionately to the cell itself, very large, and invariably 
 ■Stains of an intense depth of colour with aniline blue-black. These 
 elements appear disposed in three 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 
 Mood-vessels (capillary and arteriole). 
 
 (2) The larger cellular elements of the nexiroglia are usually 13 /^ 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 greater 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, however, 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 special afl&nity for this staining reagent, a fact, 
 which indicates very conclusively the non-nervoiis character of these 
 larger 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, 
 itenuity of branches, very faint staining, and poor differentiation are 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, undergoing excessive proliferation, and 
 betraying their morbid activity by the intensity of colouring which 
 they acquire. 
 
 If now we appeal to the silver-chrome methods of preparation, 
 the appearances are very dissimilar. Two forms of cell obtrusively 
 present themselves in both the white and grey matter of the brain ; 
 the one with a poorly defined cell body, obscured by much deposit of 
 silver, throwing off on all sides short, shaggy, protoplasmic processes, 
 
THE NEUR0C4LIA MATRIX. 95 
 
 dendritic or dichotomously dividing ; the other, a cell element, also 
 badly defined, forming a centre from which radiate outwards exceed- 
 ingly fine fibrils, often of gi-eat length, sharply defined contour, not 
 ■dividing dichotomously, nor presenting the thickened hispid aspect of 
 the processes of the first described element. These exceedingly fine 
 fibrils are characterised not only by their length, tenuity, and clean 
 contour, but also by their tendency to exhibit many sharp angular 
 bends along their course. 
 
 When the former element is more closely examined, we find the 
 invariable presence of one or more lengthened thick processes by 
 which the cell is attached to a neighbouring blood-vessel ; such pro- 
 cesses end in a sort of conical or flattened sucker-like thickening on 
 the vessel's walls. We have here, in fact, modified by the silver- 
 chrome method, the same element described as the large cellular 
 element of the neuroglia, and which, later on, we shall refer to as the 
 spider cell. The second form, or stellate cell, has by some been 
 regarded as a distinct element ; it is found more particularly in the 
 white matter of the brain, and under the pia covering the cortex. A 
 point of great significance, however, is the fact that they lie invariably 
 in close contiguity to a blood-vessel, and that in favourable prepara- 
 tions, when the dense deposits of silver are dissolving ofi", we can 
 identify them as spider or Deiter's cells, the vascular attachments 
 being clearly apparent. Between these two forms, superficially so 
 different, there exists a further transitional element readily distin- 
 guished ' in most regions of the brain and medulla, but especially 
 beneath the intima pia, and which at once indicates to us the 
 essential identity of the two former kinds of cell. 
 
 The transitional forms alluded to are strung beneath the pia, 
 attached by a vascular process to a vessel of the latter, whilst from 
 the central end of the cell, which is usually ovoid in form, a large 
 number of extremely long delicate fibrils extend into the first and 
 subjacent layers of the cortex, resembling in all respects those of the 
 stellate cell just described. These fibres, however, arise from short 
 stunted protoplasmic processes which are truly dendritic and hispid, 
 and take their origin immediately from the cell body, whilst some of 
 these fine fibrils present numerous moniliform enlargements along 
 their course. To summarise, therefore, we find three stages of 
 development presented by these elements, viz. : — 
 
 (a) Cells with short, thickened, moss-like protoplasmic processes, 
 dendritic or branching dichotomously, and possessing also thick 
 vascular attachments ; 
 
 (b) Long and exceedingly fine unbranclied fibrils radiating from an 
 obscurely marked central cell, also (under cei'tain conditions) showing 
 vascular processes ; 
 
g6 THE CEREBRAL CORTEX. 
 
 (c) Transitional forms with vascular processes, short dendritic 
 branches, from which are given oft' long delicate fibrils like those of 
 the stellate cell, and often distinctly moniliform. 
 
 As stated elsewhere, we regard all spider-cells as destined to pass 
 through the three stages — the embryonic moniliform, the fully 
 developed spider-cell or "lymph-connective" stage, and, lastly, the 
 stellate cell; whilst in normal devolution the lymph-connective or 
 spider-cell passes back into the fibre state of the stellate cell, losing 
 its active functional manifestations, and assuming, therefore, the purely 
 mechanical rtU of a support for the blood-vessels and meduUated nerve 
 fibres in its vicinity.* 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 
 ISTerve cell to the Blood and Lymph channels. 
 
 {d) Lymphatic System of the Brain.— To Obersteiner is due 
 
 the credit of first definitely indicating the existence and relationships 
 of these lymph channels.t 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 
 cases apparently based upon incomplete methods of examination. 
 This is not the place to enter on debateable ground ; but we are 
 compelled, owing to the'supreme importance of the subject as aflFecting 
 the physiology and pathology 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 sucli a manner, that the vessels when con- 
 tracted are enclosed within a channel of much greater calibre. The 
 disparity betwixt the diameter of vessel and brain-channel will be 
 affected undoubtedly by corrugating reagents ; and hence, we never 
 fail to find these channels disproportionately large in brain which has 
 been subject to extremes of hardening by chromic acid, &c, ; but 
 recession of the brain-substance may occur from many other causes 
 actinc^ 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 
 
 * "Structure of the First or Outermost Layer of the Cerebral Cortex," Edhu 
 Med. Joiirn., June, 1897. 
 
 + "t)ber einige Lymphraiime im Gehirne" [Sitzh. d. K. Akad. d. Wis-seu-sch., 
 Jan. Heft, 1870). 
 
 + " The Relationships of the Nerve Cells of the Cortex to the Lymphatic System 
 of the Brain,"' Proc. Boy. Soc, No. 182, 1877. 
 
LYMPHATIC SYSTEM OF CORTEX. 97 
 
 by the name of the perivascular channels of the brain — the peri- 
 vascular channels of His : these are not the lymph 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 the brain, and yet the epithelial elements of the epl- 
 cerebral surface are not continuous along this tubular channel. 
 
 In the next place we find, under 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 careful examination. To exhibit the true 
 relationships of these perivascular channels and pericellular sacs, let 
 us revert to the smaller cellular element described in the neuroglia 
 (p. 94). 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 adven- 
 titial tunic, and map out its course very accurately ; occasionally 
 closely applied to the perivascular channel, as before stated, or separated 
 as irregular ampullae 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 con- 
 tinuous, 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 surrounding these minute channels to their 
 ultimate ramifications ; and thus, the perivascular lymph space of the 
 adveutitia 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 cell in 
 certain states not only accumulate 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 
 
 7 
 
98 THE CEREBRAL CORTEX. 
 
 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-diflFerentiated 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 same 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- 
 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 general perivascular channels at their ultimate ramifica- 
 tions around the arterio-capillary plexuses were enlarged here aud 
 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 matrix 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, ai'e found, as already indi- 
 cated, to have a definite and constant relationship to the cortical 
 
LYMPH-CONNECTIVE SYSTEM. 
 
 99 
 
 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. 
 
 What are these fibrous prolongations 1 Careful examination of one 
 of the large neuroglia elements reveals the fact that they throw off two 
 sets of processes — (1) an enormous number of extremely delicate fibres, 
 which spread into the intervascular area around, and (2) a much 
 thicker, 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. 
 In morbid states, as we shall see, this terminal protoplasm of the 
 vascular process becomes spider-like, in its turn throwing ofi" 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 liave frequently satisfied ourselves. 
 The branched cells which we have now described have often been 
 jrecognised 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 effect the reabsorption and distribution of the eflfete 
 material 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 
 
 * Hence they are often named after liira — Deiters' cells. — Untersuchimyta liber 
 •Gehirii und Riickenmark der Menschen und der Smiyethiere, 1865. 
 
lOO THE CEREBRAL CORTEX. 
 
 of this system of spider cells, as vre shall for the future call these 
 elements of the "lymph-connective system." ■^•' !Meynert long since 
 drew attention to their frequent presence as associated ■with congestion 
 and degeneration of the lyn:phatic glands of the head and neck, and 
 we have 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.! The morbid changes undergone by this lymph-connective 
 system and the effects of its morbid activity will be more fully dealt 
 with when treating of the pathology of the cortex. 1 For the present 
 we shall summarise the above statements as follows : — The lymphatic 
 system of the brain consists — 
 
 (1) In the first place, of a distensible lymphatic sheath, loosely applied 
 around the arterioles and venules, containing numerous nucleated 
 cells in its texture — the adventitial lymph sJieath, the whole being 
 included within a non-distensible channel of the brain-substance, devoid 
 of endothelial lining— perivascular channel of His. 
 
 (2) In the second place, of a continuation of the cellular elements of 
 
 this sheath, loosely applied to the arterio-capillary plexuses, 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. 
 
 * It mav prove of interest to give here references to some few of the articles 
 bearing directly upon phagocjirosis : — " Poisonous and Defensive Albumoses," by 
 Dr. Hankin in Brit. Jled. Journ., May, 1890, p. 126. "Lectures on Phagocj"tosis 
 and Imnittnity,'" by Sims Woodhead, Lancet. Jan. and Feb., 1892. " Discussion 
 on Phagoc}i;osis and Immunity," Brit. Med. Journ., Feb. and Mar., 1892. 
 " Ptomaines and Animal Alkaloids," Brit. Med. Journ., Xov., 1892. " The 
 Spider (so-called Scavenger) Cell of the Brain," by Edwin GoodaU in Journcd 
 of Pathology, Feb., 1894. "The Spider or Phagocyte Cells of Senile Insanity, 
 General Paralysis, and Alcoholic Insanity," by Alfred Campbell, Journ. Mental 
 Sc, Oct., 1894. 
 
 t We have elsewhere alkided to the comparative significance of these elements as 
 follows : — " In man they appear ia 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 
 fimctional activity, and in vascular affections resulting in retrogressive changes 
 and a reversion to a low type of structure." — " Comparative Structure of the 
 Cortex Cerebri." Trans. Royal Soc, part i., 1880. 
 
 t See in this connection a suggestive article by Dr. Shaw on Aprosexia in 
 Children — a condition where adenoid growths (post pharj-ngeal) obstruct the flow 
 of lymph from the frontal lobe, which naturally escapes through the lymphatics 
 of the ethmoid plate. — Practitioner, July, 1S90. 
 
r'UneVJ. 
 
 
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 ,ix 
 
 ■ I »^ -A i^ r ,'■ 
 * . : ' 1 •Ny'jr^v• 
 
 •*>\; ; '' 
 
 ^ 
 
 s 
 
 L/-~-*f ^^ ,R 
 
 ;■>>- 
 
 Zarge Pyramids of lov,\ , 
 strata of Third lajc 
 
 Cranizle elements 
 in Fourfh layer. 
 
 Ganglionic cells 
 of Fifth layer. 
 
 Spindle eLeinenis 
 of Sixth layer 
 
 K|-^ 
 
 : : 6.1 "S e ns ory typ e " 
 
 „ , ^ „ l^erve elements of 3- .^'QJ, 5 - &.6*^ layers 
 
 t)ensor>^ \vpe of First AriTiectaiit Gyrus of 
 
 uuor. OvroMsn rirst Anrvectant Human Brain. 
 
 Tvn;? of hinr,;^:, Cortex. x65. xl57. 
 
 Bale iDanielsson. Ltd Sculp. 
 
RETICULATED WHITE SUBSTANCE. lOI 
 
 (3) Lastly, of a system of plasmatic cells with numei'ous prolon- 
 gations, which are always in intimate connection with the adventitial 
 lymph sheath, and which drain the areas between the vascular 
 branches : these we have termed the lymph-connective elements. 
 
 If we take a comprehensive view of the whole system — the channelled 
 vascular tracts, the saccular ampullae along the capillary tube, the 
 canalicular-like formation of the lymph-connective elements, all em- 
 bedded in a homogeneous matrix of neuroglia — we cannot but be 
 struck by the sponge-like arrangement of the cortex, and the facilities 
 so afforded for the free circulation of plasma throughout its most 
 intimate regions. 
 
 CORTICAL LAMINATION. 
 
 Having familiarised 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 laminae 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 dai'k grey layers, more opaque in aspect, and in certain 
 regions exhibiting a sharply-detined 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 bordering upon the corpus callosum, and the 
 convolution of the hippocampus, at the base, where its peculiar 
 aspect has gained for it the name of the reticulated white SUb- 
 Stance. As we shall see later 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 numbers 
 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 
 
I02 LAMINATION OF CEREBRAL CORTEX. 
 
 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 difierent 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 rudimentary 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 forward as the gyrus hippocampi or lower limbic 
 arc (figs. 1, 2, B). 
 
 Looked at from the base, we see the lower limbic arc separated from 
 the extra-limbic mass by a well-defined fissure — 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 neai- 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 very 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 
 
LAMINAR TYPES OF CORTEX. 103 
 
 or extra-limbic portion ia 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 
 mapped out by its distinctly pcde aspect as compared with the cortex 
 external to it. 
 
 The difierent regions which we have now indicated are all dis- 
 tinguished by a type of cortex peculiar to each ; and thus the upper 
 limbic arc, the lower limbic arc, the olfactory area, the extra-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 differentiation 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 eigh' 
 distinct • types of cortex, not mere fanciful distinctions based upon 
 trivial peculiarities ; but, in all cases, abrujjt 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 
 sharply drawn at the furrows intervening between these regions. In 
 higher animals, and especially in man, no such abrupt demarcation 
 occurs ; distinct transition reg'ions He 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 type. (6) Extra-limbic type. 
 
 (3) Outer olfactory type. (7) Type of cornu Ammonis. 
 
 (4) Inner olfactory type. (8) Type of olfactory bulb. 
 
 * In his earlier memoir, published in Strieker's Human and Comparative Histology, 
 as well as in his later views expressed in Psychiatry, Meynert defines but five 
 types of cortical lamination as distinctive of the brain in mammals. We find our- 
 selves unable to agree with Meynert, not only as regards his enumeration of types 
 of lamination, Init in some cases as regards his description of the specific characters 
 of individual types of cortex. 
 
lOA LAMINATION OF CEREBRAL CORTEX. 
 
 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 cornu Ammonis. 
 
 (5) Type of olfactory bulb. 
 
 In addition to these types of cortical lamination we have also to 
 consider the cerebellar cortex, and what is really an ofi'shoot of the 
 cerebral cortex — viz., the retina. 
 
 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 upper limbic arc, occupies the 
 median cortex of the hemisphere from the frontal pole to the end of 
 the sub-parietal furrow (figs. 1-3, + ); it moreover spreads beyond 
 the sagittal margin, and embraces the pointed frontal extremity of 
 the extra-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 
 areas enclosed within the last mentioned and the outer root of the 
 olfactory bulb (fig. 2, dark area). 
 
 (5) The fifth, or modified olfactory 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. 
 
 (6) 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 COrnu 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 olfactory bulb, has its distribu- 
 tion sufficiently indicated by its name (figs. 1, 2, F). 
 
Plate VII. 
 
 Fig. I. 
 
 
 X 110 
 
 Fk;. 2. 
 
 CORNU 
 CELLS 
 
 AMMCJNIS OF YOUNC; RAT. SHOWING PYRAMIDAL 
 OF CORNU, AND GRANULFS OF FASCIA DENTATA. 
 
 Bale, Sons <& Daniehson, Ltd.,LUh. 
 
UPPER LIMBIC TYPES. 
 
 105 
 
 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 represented 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 de- 
 licate subdivisions of the apical processes of nerve cells in the 
 subjacent layers. This layer 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 re- 
 semblance to the upper half of the third layer in higher animals. 
 They diff'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, ^uch 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 
 character of the large nerve cells of the motor cortex. Their apex pro- 
 cess extends right through the pyramidal series into the peripheral 
 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, 
 thepefore, is constituted by 
 
 (1) A peripheral 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 x., fig. 1), the upper limbic arc exhibits the in- 
 tercalation of a series of g'ranule CellS 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 compared with the investing protoplasm : 
 they form a belt of densely crowded elements. The cortex, therefore, 
 
I06 LAMIXATIOX OF CEREBRAL CORTEX. 
 
 of the area represented in Plate x. (figs. 3 and 5, dotted area) 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 tind 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 iirst layer of its 
 cortex ; fibres which ramify at all depths in this layer to unite with 
 the meshwork derived from the apex processes of the cells beneath. 
 Xext to this succeeds a shallow belt of irregular cells, pyramidal, 
 oval, or fusiform, small in size, each with a bifurcate apex process, 
 which immediately undergo rapid subdivision. They are arranged 
 in peculiarly appressed clumps. Then amongst them appear a few 
 large cells of pvramidal contour, which deeper down increase in num- 
 ber and form 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. 
 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 a in diameter; with these are associated 
 numerous minute granules only 5 a in diameter, like the granule 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 the peculiar 
 second layer of cells. These nervous elements are more than double 
 
TYPE OF CORNU AMMONIS. 
 
 107 
 
 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 bitid or bieorned process. This 
 belt of inflated cells is superimposed on a series of small pyramidal 
 bodies, which succeeds them (Plate x., fig. 2). A pale belt, devoid of 
 nerve cells, follows the latter, and is in turn succeeded by a seiies 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 differs 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 limljic type, and, 
 therefore, presents an exception to the rule of abrupt demarcation 
 shown by other varieties of cortex. The gradual passage of one into 
 another form we shall have reason to refer to later on ; for the present, 
 it will sufl&ce to enumerate the relative layers of this formation. 
 
 (1) Peripheral 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 cornu 
 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. 
 
 Peripheral Zone [Limiting Zone or Molecular Layer).- — This super- 
 ficial layer receives the terminal dendrites ascending from the sub- 
 jacent pyramidal cells of the fourth layer, and the terminal ramifications 
 of axons also derived from subjacent cells — ascending" axons. Apart 
 from these, however, we find, according to Cajal, certain nerve cells 
 •proper to this layer — cells of fusiform or more or less triangular form, 
 with several dendritic branchings, whilst a tine axon ramifies very 
 extensively through the whole thickness of the stratum. Meynert 
 recognised spindle-formed cells in this his " Nuclear layer." 
 
 The cells whose axons enter into the constitution of this peripheral 
 zone are the nerve cells horizontally disposed within the second layer — 
 the so-called "lacunar layer" of the cornu ; as well as the polymorphic 
 cells of the fifth layer, lying just beneath the belt of pyramidal cells. 
 
I08 LAMINATION OF CEREBRAL CORTEX. 
 
 Lacunar Layer. — This, the second layer of the cornu Ammonis, is 
 formed by 
 
 (1) Horizontally disposed meduUated fibres, the origin, of which has 
 been traced to the large size collaterals ascending from the axons of 
 the giant pyramids and ramifying across the primary dendrites of the 
 small pyi-amids, which run vertically at this level ; 
 
 (2) Terminal arborisations from collaterals ascending from the white 
 matter or alveus ; 
 
 (3) Terminal arborisations of the ascending axons of subjacent cells ; 
 
 (4) The intrinsic cells of this layer, usually triangular in form, 
 possessed of several dendrites, and an axon which terminates in an 
 arborisation horizontally distributed along this layer, losing itself, as 
 before stated, in the lower region of the peripheral zone. 
 
 Striate Layer. — This is the part characterised by its radiate appear- 
 ance due to the ascent of the dendrons of the pyramidal cells. Several 
 species of nerve cell are found in this layer, distinguished by the dis- 
 tribution of their axons. All have dendritic expansions, which are 
 distributed to the two upper layers on the one hand, and to the layer 
 of polymorphic cells on the other. All such cells give origin to axons 
 which ramify extensively ; some upwards into the two superficial 
 layers ; others horizontally within the striate layer ; and, lastly, others 
 descending to end in free arborisations around the pyramidal cells and 
 the subjacent polymorphic cells (Cajal). 
 
 Pyramidal Layer.— These nerve cells, so characteristic of the cortex 
 of the cornu Ammonis, vary much in form in different animals ; they 
 are closely appressed and often appear in several tiers one over the 
 other. More frequently oval or spindle-shaped, they, at times, assume 
 a more spherical contour; but, in all cases, whilst several protoplasmic 
 processes descend from their base, an apical dendron ascends towards 
 the peripheral zone. This latter throws ofi" several collaterals on its 
 ascent through the striate layer, and upon its arrival at the lacunar 
 layer, its primary splitting up into dendrites occurs, and a rich 
 terminal plume results, whose branches extend up to the pial surface 
 of the cortex. Like the corresponding pyramids of the cerebral cortex 
 these dendrites are covered by rough thorny projections. The axon of 
 these pyramids (long known to be continuous with the medullated 
 fibres of the alveus) descends to the white stratum below, throwing off 
 several collaterals in their course, and then, bending at right angles, 
 becomes continuous with the medulla of the alveus — many bifurcating 
 into two branches which run in opposite directions. 
 
 A very important distinction must be made between the inferior or 
 giant pyramids near the fimbria, and the superior or small-sized pyra- 
 mids beneath the alveus as regards their conformation, relationships, 
 and functional significance. The former are not only larger in size, 
 
Plate VIII. 
 
 X 110 
 
 Fig. I. 
 
 X 110 
 
 Fig. 2. 
 
 Bale, Sons & Daniehson, Ltd.,LUh. 
 
TYPE OF CORNU AMMONIS. 109 
 
 have thicker dendrons with stunted dendritic arborisations, but also 
 their axons are continuous with the fibres of the fimbria, not with 
 those of the alveus as is the case with the smaller pyramids ; at the 
 same time these axons originate the recurrent collaterals alrt^ady alluded 
 to, which pass through the lacunar layer to ramify over the primary 
 dendrites of the smaller pyramids. A further distinction is established 
 by the fact that the axons of the granules of the fascia dentata (moss 
 fibres) are brought into close velationshii)S with the dendrons of these 
 giant cells alone and not with those of the smaller cells. 
 
 Folymorjihic Cells. — The irregular and fusiform cells beneath the 
 pyramidal layer constitute the "polymorphic layer "of Cajal — the old 
 " stratum raoleculare " of Kupffer. Formerly classed as simple spindle- 
 shaped cells recent authorities describe certain notable features as 
 presented by them. They may be divided into three groups — all the 
 cells of which are dendritic — these dendrites ramifying amongst the 
 protoplasmic processes and the collaterals from the axons of the 
 pyramids. These groups are characterised as having — 
 
 (1) Ascending and recurrent axons ; 
 
 (2) Horizontal and plexiform axons ; 
 
 (3) Deep spindle cells with ramifying axons. 
 
 In the first group of ascending and recurrent axons this process 
 ascends through the radiate stratum, throwing off occasional collaterals 
 in this course, some of which pass up into the lacunar and peripheral 
 layers, whilst the main axou curves downwards again and, passing 
 into the pyramidal layer, forms a rich terminal plexus of fibres around 
 these cells. In the second group, the axon passes off' horizontally and 
 divides into numerous branches after the manner of Golgi's sensory 
 cells. From these originate collaterals, which ascend to the pyramidal 
 layer and surround its cells with a plexus of branches mingling with 
 the similar plexus from the recurrent axons. 
 
 In the third group, the cells are spindle shaped; they have long 
 been recognised in the neighbourhood of the alveus, but only recent 
 research has revealed the fact that they possess axons which ramify 
 extensively in this stratum and ascend upwards to a higher level. 
 
 Besides these three, Cajal describes a cell which gives off" an 
 ascending axon terminating by ramification in the lacunar and 
 peripheral layers, but having no recurrent branch. We need scarcely 
 include here certain cells, as Cajal does, which, together with others 
 in the stratum radiatuni, are admittedly similar in type to the pyra- 
 midal cell, and are really dislocated cells not special to these layers, 
 any more than we should speak of those cells found in the lowermost 
 stratum of the peripheral layer which are really elements dislocated 
 from the cells of the second layer of the cerebral cortex, and which 
 are also seen in the region of the fascia dentata. 
 
1 I o LAMINATION OF CEREBRAL CORTEX. 
 
 Medullated Layer or Alveus. — This deepest layer, bounded centrally 
 by the ependyma of the ventricles, is largely constituted by the axons 
 of the pyramidal cells, many of which, as before stated, bifurcate into 
 a thick and a slender process running in an opposite direction. These 
 medullated fibres throw upwards collaterals which ramify in the 
 upper layers of the cornu. 
 
 The Fascia Dentat'i. — In this region we have to distinguish three 
 layers, viz. : — 
 
 (1) Peripheral or molecular ; 
 
 (2) Granule layer or small pyramids ; 
 
 (3) Polymorphic cells. 
 
 Molecular Layer. — This, like the corresponding layer of the cortex 
 generally, and that of the cornu Ammonis formation proper, receives 
 the terminal plume of dendrites given off from the subjacent cells, and 
 which are here brought into relationships with the axons of certain 
 nerve cells peculiar to this layer. These cells are distributed in a 
 double series, superficial and deep (Cajal) ; they are ovoid, stellate, or 
 spindle-shaped — the deeper cells being the larger and more freely 
 supplied with protoplasmic processes. Both have an axon thicker in 
 the deeper cells, and ramifying to great distances in a horizontal 
 direction, but much finer in the smaller cells and far more restricted 
 in range. 
 
 Stratum Granulosum. — The elements of this layer are very small, 
 densely appressed, forming a deep stratum of minute ovoid, pyramidal 
 cells, throwing off numerous protoplasmic processes towards the 
 peripheral zone : whilst its axon, descending through the subjacent 
 layer of cells (polymorphous), gives origin here to numerous delicate 
 collaterals, which ramify amongst the polymorphic cells. Continuing 
 its course, it bends as a knotty, non-medullated fibre along the length 
 of the cornu, upon the body and dendrons of the giant pyramids. 
 These axons from the granules appear similar in all respects to the 
 so-called "moss fibres" of the cerebellum. Cajal affirms that such 
 moss fibres never trespass on the region of the alveus or the lacunar 
 layer of the cornu proper ; but are invariably confined to the giant 
 pyramids, their moss-like bunches resting in close contact with these 
 cells. It will be observed that these axons of the granules form a 
 terminal arborisation, bringing tliem into relationship with the giant 
 pyi'amids and their dendrons, just as the collaterals ascending from 
 the axons of the latter ramify over the dendrites of the smaller 
 pyramids of the cornu. 
 
 Pyramidal cells of notable character occupy the upper regions of 
 this granule zone. They have an apical process (protoplasmic), which 
 ascends to be distributed in branches to the molecular layer ; several 
 
TYPE OF CORNU AMMONIS. 
 
 Ill 
 
 protoplasmic branches given off from the base of the cell, and an axon 
 "which running horizontally immediately above the granule layer sends 
 downwards numerous collaterals to envelope the granules in a rich 
 plexus of branches. 
 
 Fig. 14. — Cerebral cortex : granules of fascia dentata — Cornu Ammonis (rabbit). 
 
 Stratum of Polymorphic Cells. — Irregularly shaped cells are seen 
 beneath the granule layer, throwing off protoplasmic processes in 
 several directions, and with an ascending axon passing upwards 
 through the granule into the molecular layer, there to bifurcate and 
 ramify in extended horizontal planes. Some of these cells are stated, 
 however, to give off an axon which runs horizontally along the summit 
 of the granule zone, taking part with the pyramidal cells in the 
 formation of the intergranular plexus already described. Cajal, 
 moreover, describes in this layer nerve cells similar to the sensitive 
 cells of Golgi ; and others with a descending axon continued into the 
 alveus. Lastly, immediately above the molecular layer of the cornu 
 proper, where it is concealed by the fascia dentata, are large fusiform 
 cells, whose axon can be followed into the alveus. 
 
 The Olfactory Bulb. — The cortex of the olfactory bulb consists 
 of a superficial and a deep fibre-tract ; the former non-medullated, 
 connecting the nervous apparatus of the Schneiderian membrane with 
 the olfactory bulb ; the latter, medullated, and connecting the bulb 
 
I I 2 LAMINATION OF CEREBRAL CORTEX. 
 
 tlirough the olfactory tract with the centric termini in the cerebral 
 cortex. These two tracts of nerve fibre are brought into relationship 
 through the medium of the intervening layers, three in number, of 
 nerve cells and fibre systems. 
 
 We have thus, from without inwards, five distinct strata : — 
 
 (1) Flexus of peripheral nerve fibres. 
 
 (2) Layer of olfactory glomeruli. 
 
 (3) Molecular layer with small nerve cells. 
 
 (4) Layer of so-called " mitre cells." 
 
 (5) Layer of granules and medullated nerve fibres. 
 
 The superficial layer of the bulb is formed by non-medullated fibres 
 which, arising from bipolar nerve cells of the Schneiderian membrane, 
 pass through the cribriform plate to form a densely woven plexus, on 
 the surface of the bulb ; the fibres eventually terminate by a free 
 arborisation in the interior of the glomeruli which form the character- 
 istic feature of the second layer of the bulb. These spheroidal bodies 
 were first observed by Leydig in the fish, and constitute Meynert's 
 "stratum glomerulosum.' Each glomerulus consists almost entirely 
 of the interlacements of the olfactory fibres derived from the super- 
 ficial layer on the one hand, and, upon the other, of those derived 
 from the cells of the fourth layer: whilst a few nuclear-like cells are 
 found within and around the glomerulus. The silver-chrome method 
 shows that the non-medullated fibres on entering the glomerulus split 
 up into arborisations of excessively flexuous, thickened and varicose 
 fibrils (Cajal), which never again emerge from the glomerulus. Here 
 thev intertwine, but do not inosculate, with a rich arborisation of 
 dendrites derived from a process of the cells of the fourth layer — the 
 so-called "mitre cell." Immediately beneath the glomerular layer is a 
 stratum of finely grani^lar material, in which are imbedded small fusi- 
 form nerve cells which throw off a coai'se protoplasmic process (dendron) 
 towards the glomerulus, in the interior of which it loses itself as 
 a dendritic arborisation. An extremely fine axon passes from the cell 
 deeply towards the granule layer of the bulb and, bending at right 
 angles, passes backwards amongst the medullated fibres of the tract. 
 
 Layer of Mitre C'eZ^i\ —Between the preceding and the deepest layer 
 of the bulb lies a stratum of cells, remarkable for their size, configura- 
 tion, and relationships. These elements are usually of large size, of 
 mitre-like form, throw off lateral processes ramifying through the 
 neiofhbouring molectilar layer, whilst, from their lower aspect descends 
 a coarse dendron, which, entering a glomerulus, breaks into a terminal 
 ramification of dendrites interlacing with the olfactory nerve fibres, as 
 already noted. From the deep aspect of the mitre cells a stout axon 
 passes upwards to the granule layer, and here, bending backwards, 
 
THE RETINA. I I 3 
 
 becomes continuous with a medullated fibre of the olfactory tract, for 
 distribution to the cerebral cortex. In this course through the granule 
 layer, the axon throws downwards several vertical collaterals, which 
 ramify in the molecular layer ( Van Gehichten and Martin). 
 
 Layer of Granules and Medullated Fibres. — This, the deepest layer 
 of the grey matter of the bulb, is of considerable thickness, and is 
 formed by granules similar in form to those of the cerebellar granule 
 layer, but separated into compact groups by the passage of fasciculi of 
 medullated fibres. According to Cajal and others they diS'er morpho- 
 logically from the granules of the rust-coloured layer of the cerebellum ; 
 these possess a distinct axis-cylinder, while those of the olfactory bulb 
 are devoid of such.* These spherical or angular cells throw off two 
 processes ; one, downwards to the mitre layer, where it ends in a 
 terminal plume in close contiguity to the lateral dendrons of the 
 mitral cells ; the other, far less conspicuous, passes inwards to ramify 
 amongst the granule groups at a deeper site. The terminal dendrites 
 of the peripheral plume are thickly beset with minute spiny projections 
 along their course, like the similar formations along the terminal 
 plumules of the pyramidal cells of the cerebral cortex. The pePiphePal 
 dendron is always present ; the central dendron may be insignificant 
 or altogether wanting {Pedro Ramon). Golgi has, moreover, described 
 large sized stellate cells sparsely scattered in the granule layer, which, 
 besides protoplasmic processes, possess an axon which (according to 
 Cajal) always ends in a rich arborisation within the molecular layer of 
 the bulb. The medullated fibres found in this deepest layer of the 
 bulb consist very largely of the axons derived from the mitre and 
 small fusiform cells ; but also embrace medullated fibres which pass 
 from the brain to the bulb (centrifugal), and end in free ramifications 
 in the granule layer. 
 
 The Retina. — ^The nerve elements of the retina consist of a super- 
 ficial layer — the well-known rods and cones ; of an outer and inner 
 granule layer, separated by outer and inner plexiform relational 
 fields ; and of an innermost layer of ganglionic cells and optic nerve 
 fibres. The rods and cones of the superficial layer are morphologically 
 continuous with the elements of the outer granule layer, but are 
 usually, for convenience, described separately. The inner granule 
 layer differs essentially from the outer not alone in the conformation 
 of its constituent elements — the granule cells, but in the presence of 
 two other nerve elements — the horizontal cells and retinal spongio- 
 blasts : whilst the outer granule layer is a comparatively simple 
 
 * This opinion, which has given rise to the doctrine of "amacrine cells," or 
 nerve cells without axis-cylinders, appears to us to be satisfactorily confuted by 
 Dr. Hill, who has discovered the axon and figured it. See "Notes on Granules," 
 by Alex Hill, Brain, vol. xx., p. 125. 
 
 8 
 
I 1 4 LA^illNATION OF CEREBRAL CORTEX. 
 
 structure — the inner is much more complex and may be subdivided 
 into three layers : — 
 
 (a) Superficial horizontal cells ; 
 
 (b) Bipolar granule cell ; 
 
 (c) Spongioblasts of the deepest stratum. 
 
 Lastly, the inner plexiform or relational field is one of very great 
 complexity, embracing, as it does, the ramifying branches of the 
 bipolar granule cells, the dendrites of the ganglionic series, and the 
 branches of the retinal spongioblasts. 
 
 RefAnal Rods. — The rods are cylindrical bodies, fine in mammals and 
 nocturnal bii'ds (in man 50 /^ to 60 'i, long by 2 ,a thick, according to 
 Max Schultze) ; but of large size in Batrachia, diurnal birds and fishes 
 (Cajal), consisting of an inner segment or body, and an outer segment 
 perfectly cylindrical and unpointed. Unlike the cones they are not 
 attached directly to the body of the granule cell of the next layer, but 
 through the medium of a peripheral process extending from the latter ; 
 so that the granule cells of the rods resemble a bipolar ganglion cell, 
 ■of which the finer or centric process extends to the outer plexiform 
 layer. Here this process ends in a small spherical swelling embraced 
 by the dendritic peripheral branch of the cells of the deeper granule 
 layer. The rod fibres are always finer than the cone fibres. 
 
 Retinal Cones. — The cone, always shorter than the rod, consists of a 
 flask-shaped body or inner segment, about 6 /i in thickness, terminated 
 in a pointed conical extremity ; and an outer segment, which is more 
 strongly refractile than the inner segment. Schultze has described a 
 longitudinal striation of the outer segment of both rods and cones in 
 fishes, amphibia, and mammals, including man ; and likewise a similar 
 striation of the inner segments in man and mammals. The body is 
 distinctly continuous with the granule cell of the cone — an ovoid body 
 with large nucleus, from which a centric process descends to the outer 
 reticulated or plexiform layer, where it ends in a conical swelling with 
 a. few lateral free fibres. In reptiles the rods are absent, the cones 
 alone being found. It is interesting to note that Krause has shown 
 that the rods and cones both persist after section of the optic nerves, 
 their appearance suggesting no degenerative change. The external 
 limiting membrane forms a natural boundary between the rods and 
 cones and their subjacent granule cells. 
 
 Outer Plexiform Layer. — In this layer the protoplasmic branchings 
 from the peripheral ends of the bipolar cells take part — some inter- 
 lacing with the termini of the centric branch of the cone cell ; others 
 receiving between them the spherical globules of the centric branch of 
 the rods. Bamifying fibres extend also into this layer from the 
 horizontal cells of the subjacent stratum. 
 
Plate IX 
 
 X 360. 
 
 Fig. I. 
 
 Layer of Rods and Cones. 
 
 External Granule Layer. 
 
 Outer Plexiform Layer. \ 
 
 Internal Granule Layer. 
 
 Internal Plexiform Layer. 
 
 Ganglion Cell Layer. 
 
 ..Fibres of Rods. 
 
 -Fibres of Cones. 
 
 -Interlacement of inner Granules ivith 
 termini of Rod and Cone Fibres. 
 
 -Bipolar Cell connected with Rods. 
 -Bipolar Cell connected 7uitk Cones. 
 SpongiobUists. 
 
 Field of Interlacement of Ganglion Cells 
 with inner Granule Elements, and 
 Spongioblasts. 
 
 Ganglion Cells of Retina. 
 jOptic Nerve Fibres. 
 
 V\r,. 2. 
 SCHEME OF RETINAL LAYERS IN MAMMALS. 
 
 Bale, Sons £ DanUlsson, Lld.,Ltlh. 
 
THE RETINA. II5 
 
 Inner Granule Layer. — Three subdivisions are described by Cajal — 
 {a) horizontal cells ; (h) bipolar granules ; (c) retinal spongioblasts. 
 The former consist of small and large horizontally disposed nerve 
 cells, of which the large-sized are the most internal ; both throw off 
 numerous protoplasmic processes and a long axon ; the axon from the 
 smaller and more superficial cell is very fine, giving origin to several 
 short ramifying collaterals. In the deeper cells this axon is much 
 larger, and terminates, after a lengthened course, in a rich arborisation 
 in connection with the spherules of the rods {Cajal). These ramifica- 
 tions add, therefore, very materially to the plexiform meshwork of the 
 third layer. The bipolar cells of this layer are fusiform in contour, 
 give off from their peripheral pole a tuft of protoplasmic branches, 
 which spread laterally into the outer plexiform layer ; whilst the fine 
 centric branch descends to different levels of the inner plexiform layer, 
 ending in a plume of free branches in close relationship to the ascend- 
 ing dendrites of the ganglionic cells. Cajal specially distinguishes 
 these bipolar cells into such as have a peripheral ascending plume of 
 branches, and those with a flattened plume : the former being dis- 
 tributed to the spherules of the rods ; the latter to the branches of the 
 cones. The terminal arborisations of the centric or descending branch 
 of these, bipolar cells meet the dendrites of the ganglionic cells at 
 different levels of the inner plexiform layer, thus dividing it into five 
 or more strata. 
 
 Retinal Spongioblasts. — These cells are remarkable in the fact that 
 they possess no axon. They are disposed in the lowermost stratum of 
 the inner granule layer, in immediate contact with the inner plexiform 
 layer and all their processes are directed centrally. Schafer doubts 
 their nervous nature.* 
 
 Inner Plexiform Layer. — We have, therefore, immediately beneath 
 the inner granule layer, a very rich relational field, in which three 
 distinct retinal elements are brought into immediate apposition, viz. : — 
 
 (a) Bipolar granule elements ; (6) Retinal spongioblasts ; 
 (c) Ganglionic cells. 
 
 This elaborate system of fibres is known as the inner plexiform layer. 
 
 Ganglionic Cells. — These cells, like those of other parts of the 
 nervous centres, vary much in size, from 15 /a to 30 /x in diameter in 
 the fresh state ; they are flask-shaped or ovoid in contour, usually 
 devoid of pigment, and possess a large nucleus with a prominent 
 nucleolus. They give origin to a peripheral and centric process — the 
 former directed into the depths of the inner plexiform layer, as a 
 dendritic arborisation, extending laterally in the horizontal plane as 
 far as one or other of the five stratifications of this layer, where they 
 
 * "The Nerve Cell considered as the Basis of Neurology," Brain, 1893, p. 138. 
 
= Il6 LAMINATION OF CEREBRAL CORTEX. 
 
 blend with the corresponding terminal fibres of the retinal spongio- 
 blasts and the bipolar granule elements. The centric process is really 
 its axon, '-which becomes continuous, as an optic nerve fibre, with the 
 deepest layer as it courses towards the optic nerve. 
 
 Oajal divides these ganglionic cells into three series : those whose 
 dendrites are restricted to one stratification only ; those distributed to 
 two or more; and those which observe no such law of stratification,. 
 but are equally distributed throughout the whole depth of this plexi- 
 form layer ("cellules unistratifiees, multistratifiees, et diffuses"). So 
 far, therefore, from the optic nerve fibres being in direct continuity 
 with the special visual elements of the retina — the rods and cones — 
 we find, according to the researches of Cajal, Van Gehuchten, and 
 others, that there are two breaks in this course : the first, betwixt the 
 dendrites of the ganglionic cells and the bipolar elements ; the next^ 
 betwixt the peripheral ofishoots of the latter and the termini of the 
 centric branches of the rods and cones respectively. This is in accord 
 with the results of physiological and pathological teaching, for we 
 know that section of the optic nerve fibres entails fatty degeneration 
 of the ganglion cells of the retina {Erause), whilst the rods and cones- 
 escape intact ; moreover, in blindness from optic nerve atrophy and in 
 glaucoma from intraocular pressure the ganglion cells suflPer in like 
 manner. 
 
 The Cerebellar Cortex — Lamination. — The cerebellar cortex may 
 be regarded as two-laminated, a superficial or external, commonly 
 termed "the molecular layer," and an internal or granule layer; 
 whilst upon the confines of both is a series of voluminous cells 
 peculiar to the cerebellar structure, termed the "cells of Purkinje." 
 The leaflets or foliola of the cerebellum are mostly disposed trans- 
 versely to the antero-posterior axis of the brain, and sections may be 
 taken either in the direction of the plane of these lamellae— z.c.^ 
 frontal sections, or across their plane antero-posteriorly — i.e., 
 sagittal sections. The microscopic appearance is very diflerent in 
 these two cases. In the antero-posterior or sagittal section, the 
 dendritic expansions of the cells of Purkinje attain their maximum 
 development and are displayed to the greatest advantage, whilst the 
 nerve cells peculiar to the superficial layer, with their neuraxons, are 
 also seen following the same plane. In frontal sections, on the other 
 hand, the cells of Purkinje are seen as it were in projile, their dendritic 
 branchings, insignificant and flattened laterally, would indicate a 
 somewhat fan-shaped conformation in the direction of the sagittal 
 plane. At the same time, we lose the characteristic branchings of the 
 nerve cells peculiar to the molecular layer, and, in lieu thereof, we see 
 a horizontal striation of this layer, due to bifurcation of the axons of 
 . the granule cells of the deeper layer, and which, being cut across in 
 
■)^ 
 
 A 
 
Plate X. 
 
 
 
 
 
 
 
 
 Fii.2. 
 
 '^V A '<^ • ^ "MoSifiea oifactoi^- type" 
 
 r/ '^^- ■• f Iiom posterior extremity of I^wex limbic 
 
 j^-«y- " Brain of Rattil xilO 
 
 Fii.l. 
 
 "SensOTy Cortex' 
 Prom tlie "Modified upper liml)ic' type 
 m Brain of Rab^iil. x 214- 
 
 CZ3 i ; 
 
 Brain of H^fb t 
 Ivlesij.l ^Tpe^t > asal aspect 
 Distritixtion of ^^a^lo.J;s 
 Tiated types cf Cort. 
 
 e iDaliieUson.ltd , Sculp 
 
THE CEREBELLAR CORTEX LAYERS. I I 7 
 
 sagittal sections, appear simply as innumerable dots scattered through- 
 out the field at this level. 
 
 Superficial Layer of Cortex. — The external layer immediately beneath 
 the pia has, in the embryo, a structure quite peculiar to itself, of 
 which, however, all trace is lost in later life ; it forms a peripheral 
 zone (not as yet encroached upon by the dendrons of the cells of 
 Purkinje) and consists, according to Cajal, of — 
 
 (1) A superficial series of granule-like cells placed vertically to the 
 surface ; 
 
 (2) A deeper layer of horizontally disposed bipolar cells lying next 
 to the molecular layer. 
 
 In the fully developed cortex, however, the elements demanding 
 attention are : — (a) The intrinsic nerve cells or elements peculiar to 
 this layer; {b) the dendrons and collaterals of the cells of Purkinje, 
 together with the nerve fibres extending from undeidying structures ; 
 (c) non-nervous or connective elements. 
 
 (a) Nerve Cells of the Superficial Layer. — These are irregular, 
 stellate, or polyhedral cells, most numerous in the deeper realm of this 
 layer, having their long axis disposed antero-posteriorly — i.e., in the 
 plane of the dendrons of the cells of Purkinje. Numerous long 
 protoplasmic processes are given off" by these cells ; but, in particular, 
 a fine and greatly elongated axon, which also courses along the plane 
 of these same dendrons. Along this course, wdiich is more or less 
 parallel to the surface of the cortex, vertical ofifshoots or collaterals 
 descend to the cells of Purkinje, and, becoming coarser near these cells, 
 split up into a terminal ramification, which forms a basket-work* 
 embracing the body of the latter as far as the commencement of its 
 axon. Contracted over the lower pole of the cell, this basket-work 
 extends brush-like a short distance along the neuraxon, where it is 
 still devoid of a medullary sheath. It is remarkable how this terminal 
 basket-work escapes staining in aniline preparations, where the cells 
 of Purkinje are yet admirably displayed. The cell with enclosing 
 basket-work is named by KoUiker a " basket cell " [Korhzellen). 
 
 Close to the pial surface of the cortex a few stellate cells, much 
 smaller, are found ; their protoplasmic processes are richly developed, 
 and the axon, which runs antero-posteriorly, ramifies extensively, but 
 its destination is imknown. 
 
 (6) Cells of Purkinje. — These flask -shaped cells, so characteristic of 
 the cerebellar cortex, throw ofi^ from their upjier or outer pole a single 
 or double dendron (in the latter case, giving the cell a somewhat 
 horned appearance), from which arises a luxuriant arborisation by 
 frequent dichotomous division as far as the surface of the cortex. 
 These dendrites neither anastomose with each other nor with the 
 * Endkoerheiiy Faserkorhe, Fa-'icrpiimtl of Kolliker. 
 
I 1 8 LAJMIXATIOX OF CEREBRAL CORTEX. 
 
 neighbouring cells ; they are strictly terminal and often turn back 
 upon themselves. The dendritic system is spread out along the 
 antero-posterior plane, and the branches are, moreover, thickly studded 
 with minute thorny processes like the corresponding projections 
 (epines) upon nerve cells in other regions {Van Gehuchten, Cajal, 
 Betzius). From the lower or internal pole of the cell descends the 
 neuraxon, which, passing through the granule layer of the cerebellum 
 (becoming medullated in this course), enters the central medullated 
 core of the lamina, probably passing out of the cerebellum to distant 
 centres. Shortly after its origin the axon throws off some two or 
 three delicate collaterals, which, passing upwards into the peripheral 
 layer, end by a terminal ramification in contact with the lower 
 dendrites of the neighbouring cells of Purkinje ; thus, according 
 to Cajal, they ensure a certain degree of functional solidarity. 
 
 Besides the structures just described the molecular layer displays in 
 frontal sections [i.e., sections taken along the course of the lamincB) a 
 distinct striation due to fibres running at all depths parallel to the 
 surface, which, on close examination, are seen to arise in all cases from 
 the T-shaped bifurcation of numerous vertical fibres passing upwards 
 into this layer from the stratum of granules below. These delicate 
 fibres, which are really the axons of the granules of the cerebellum, give 
 off no collaterals, pass horizontally through the dendritic expansions 
 of the cells of Purkinje, and thus bring the granule layer into intimate 
 connection with those arborisations. They are stated by Cajal to end 
 after a lengthened course in a free and varicose thickening near the 
 white matter of the lamina. If we refer to frontal sections as the 
 " plane of lamination," and to the sagittal sections across a lamina as 
 the "plane of arborisation," i.e., of the dendrites of Purkinje, then it 
 may be stated that the cells of Purkinje are brought into intimate 
 functional relationship along the plane of arborisation by the axons of 
 the cells of the peripheral layer, and the basket-work resulting from 
 their collaterals ; whilst they are bound in functional relationship 
 along the laminar plane by the parallel T-shaped axons arising from 
 the granules of the second layer ; and at the same time their functional 
 co-operation may be established by the recurrent collaterals arising 
 from their axons, and ramifying in the proximity of the lower dendrites 
 of the neighbouring cells of Purkinje. 
 
 A further relationship, however, is established between the cells of 
 Purkinje and certain coarse fibres ("fibres grimpantes " of Cajal) which 
 ascend from the central medulla through the granule layer, and form 
 a dense plexus upon the primary and secondary dendrites of these 
 cells, just as the nerve cells of the peripheral layer form the basket- 
 work enveloping the body of the cell. The peripheral origin of these 
 fibres is unknown. 
 
THE CEREBELLAR CORTEX LAYERS. I I 9 
 
 (c) Non-nervous or Connective Elements. — These are of two kinds : — 
 
 (1) A large irregularly shaped dendritic cell, lying in close proximity 
 to the cells of Purkinje, which throws off, in the granule layer, a 
 number of thick short processes and several long vertical branches. 
 The latter pass upwards into the peripheral layer, each fibre ending 
 immediately beneath the pia in a small triangular or conical thicken- 
 ing ; these fibres have long been known as the fibres of Bergmann. 
 
 (2) Deeper in the granule layer and extending into the medullated 
 centres are numerous stellate cells in no wise differing from the 
 stellate glia cells common to the nervous centres at large. 
 
 Granule Layer of the Cortex. — -Beneath the peripheral layer is a 
 compact stratum of small, nearly spherical nerve cells, possessing very 
 little protoplasm, and throwing off on all sides some few short pro- 
 cesses, which end in miniature arborisations around the bodies of the 
 neighbouring granules. From the cell body or one of its processes 
 arises an extremely delicate axon, which passes vertically upwards, 
 and, at varying levels in the outer zone, bifurcates into the T-shaped 
 fibres which have already been alluded to in this stratum of the cortex. 
 
 Golgi and Cajal also describe large stellate cells as occurring sparsely 
 in the granule layer, with extensive protoplasmic processes spreading 
 in all directions — often far into the peripheral layer, and with an 
 axon which, passing downwards into the granule layer, ramifies to an 
 extraordinary extent amongst these granules, ending, according to 
 Cajal, by free varicose extremities. 
 
 Moss Fibres of the Cerebellum. — In the granule layer certain notable 
 fibres, first described by Cajal as moss fibres, appear ; they ascend 
 from the medulla as coarse medullated fibres which, on entering the 
 granule layer, split up and ramify extensively among the granules, 
 presenting here and there along their course peculiar rough knotty 
 thickenings or moss-like growth, and do not extend beyond the granule 
 layer. These fibres are presumed to bring the granules of the cere- 
 bellum into relationship with distant nerve centres, and are suggested 
 as the possible central nerve termini of the cerebellar tract {Cajal). 
 
 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 envelope, 
 where it folds round the cerebral peduncle at the base — the COmu 
 
 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 region of 
 
I20 LAMINATION OF CEREBRAL CORTEX. 
 
 the hemisphere. It is these more complex forms of cortex which 
 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 
 higher animals, we find structural modifications in the cortex of this 
 region, which appear to foreshadow the 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 layer 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 rajndly in 
 depth and in loealth 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 upper 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 fissure externally. On the other hand, if we examine similarly 
 a vertical section taken through the posterior moiety of the upper 
 limbic arc (Plate vi.) 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 uninterruptedly. If we now examine vertical sections of the 
 hemisphere in the antero-posterior plane, we find that — 
 
 («) 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 
 cortex increase in richness conspicuously towards the occipital pole ; 
 
 {h) 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 foregoing 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 
 upper limbic arc are especially characterised by the preponderance of 
 
DISTRIBUTION OF THE GANGLIONIC CELL. 121 
 
 the g^ang'lioilic series, which accumulates here in rich clustered 
 groups ; towai'ds 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 
 cell att-ains like importance from its notable wealth of elements and 
 its more or less complete exclusion of the small pyramidal series; whilst 
 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 pyramidal 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.* 
 
 Regional Distribution of the Ganglionic Cell.— Attention 
 
 was first directed to the peculiarly clustered arrangement of these cells 
 in the cortex of man and the higher apes by Professor Betz,t 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 
 
 * See upon this point, Meynert, " Brain of Mammals," Syd. Soc, p. 383 ; also, 
 Brain, vol. i., p. 358. 
 
 t " Anatomischer Nachweis zweier Gehirncentra," Prof. Betz, Ctntralhlatf f. d. 
 Med. Wisseiisch. , Aug., 1884. 
 
 t It is true that Meynert would dispose of the assumed significance of these cells 
 on the ground that their large size depends on the distance which their apical 
 process has to traverse in reaching the outer laj'er, and their gradual increase iu 
 dimensions being, as he states, proportionate to this distance. The "gradual 
 increase in size" alluded to proves to us tliat Meynert lias failed to identify the 
 elements I'eferred 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 tlie 
 "modified lower limbic type" contains larger elements tlian any of its subjacent 
 layers. 
 
122 LAMINATION OF CEREBRAL CORTEX. 
 
 and the higher mammals (Pig, Sheep, Dog, Cat, Ape, and Man) assumes- 
 in separate regions of the cortex a different arrangement, which we have 
 
 termed the clustered or nested and the laminar or solitary 
 
 arrangement* — the former showing these 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 grouping 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 ar- 
 rangement being scarcely indicated, and a deep and dense formation 
 replacing the latter. As already 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 pyramids 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 Plates i. and v. 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 far 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 
 manner, thins out into a mere insignificant formation — yet always most 
 richly developed along the sagittal margin of the hemisphere. 
 
 Plate v., fig. 1, represents the arrangement 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 five-laminated cortex, with clustered cell- 
 groups, spreads over the anterior half of the upper limbic arc (which 
 
 • "Comparative Structure of Cortex Cerebri," Trans. Roy. Soc, part i., 1880. 
 Functioiis of the Brain, second edition, p. 259, fig. 78. 
 
DISTRIBUTIOX OF THE GANGLIONIC CELL. 123 
 
 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-laminaied 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 forms a distinct limit to two types of 
 lamination — peculiar to the vertex — the five- 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 structure of the cortex and 
 its deep connections, the more forcibly am I impressed with the belief 
 that the various fissures and sulci are not mere accidental productions,! 
 but have a deep significance of their own, dividing off the cortical 
 superficies into morpliologicaUy, if not physiologically, distioict organs. 
 Hitherto the fissures and sulci which I have found to be boundary 
 lines of distinct cortical realms are the followinjr : — 
 
 * 0]}. cit., p. 724. 
 
 t That is, the result of pressure merely during the development of the cranial 
 arch. 
 
124 LAMINATION OF CEREBRAL CORTEX. 
 
 "(1) The limbic fissure. (4) The superior parietal sulcus. 
 
 (2) The infra-parietal sulcus. (5) The inter-parietal 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 cortical 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 prevail. Another striking resemblance occurs in the 
 distribution of these laminar types — that characterised by the g'ranule 
 cell predominating towards the OCClpltal polC ; 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 man and that of the lower 
 mammals. 
 
 As to the divergences 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.g., 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 
 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, differ from what we 
 
Plate XL 
 
 Fig. I. 
 
 Connective Tissue Cell.^ 
 
 •.'-Dendrites thickly clothed with Geniinules. 
 
 Axon. Jrotn cells o/ louver layers with 
 tcfDiinal arl>orizatio}i. 
 
 Axons with Collaterals. 
 
 X 110 
 
 Fu;. 2. 
 
 BRAIN OF YOUNG RAT: SECOND LAYER. OF CORTEX 
 
 NERVE-CELLS, SHOWINC EXTREMELY HIRSUTE DENDRITES 
 
 AND DESCENDING AXONS. 
 
 lidU, Sons £ Danielsson, Ltd. Lith. 
 
LAMINATION OF THE MOTOR AREA. 125 
 
 have regarded as the homologous series in lower mammals, in beino- 
 restricted as a typical formation to a comparatively limited area of the 
 cortex — that of the rodent, e.g., being spread 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 man 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 groups 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, chatac- 
 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 authorities 
 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 
 five-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 convolutionary 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. 
 
 Such irregularly-disposed areas 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 limits tlie cortex 
 
126 LAMIXATIOX OF CEREBRAL CORTEX. 
 
 ■externally ; it presents all the features already described as peculiar 
 to the cortical neuroglia (see p. 94). The outer surface, upon which 
 the intima pia rests, presents numerous flattened cells, from which 
 excessively delicate processes pass downwards into this layer. These 
 •cellular elements are often found, detached from fresh sections, float- 
 ing in the medium around : they form, in fact, a kind of epithelial 
 limiting layer, extremely delicate and translucent. This first layer, 
 ■or peripheral zone, exhibits a pellucid homogeneous matrix (becoming 
 finely molecular with reagents) and three structural constituents — (a) 
 non-nervous, (b) nervous, (c) vascular. 
 
 (a) The non-nervous constitiients are not numerous, are widely dis- 
 persed, and belong to the two categories of the perivascular or 
 -adventitial elements and the elements of the lymph-connective system 
 already refer-red to (p. 94). The former measure 6 ,tt to 9 /z in diameter, 
 possess a spheroidal nucleus, stain well, and are seen disposed along 
 the course of the blood-vessels. The latter often measure 13 n, in 
 diameter, possess one and occasionally two or three nuclei, are spher- 
 oidal, flask-shaped, or irregular in contour, stain uniformly and very 
 faintly, and throw off numerous excessively delicate processes, which 
 in healthy fresh cortex can only be distinguished with difficulty. 
 
 (6) The nervous constituents embrace a series of medullated, non- 
 medullated nerve fibres, and nerve cells peculiar to this layer. 
 
 The medullated nerve fibres course along the outer division of this 
 zonular layer, in a horizontal direction, lying parallel to the pial surface 
 of the cortex ; many of these are observed to pass downwards into the 
 deeper layers of the grey matter. In certain regions, this medullated 
 tract or tangential belt, so characteristic of the first cortical layer, lies 
 .&t a somewhat deeper level near the second layer of cells. In most 
 small mammals these fibres take also an antero-posterior direction. 
 The non-medullated nerve fibres are of two kinds, viz., protoplasmic 
 processes or dendrons from the underlying cells (p. 128): and terminal 
 distribution of axons from the cells peculiar to this layer, and also 
 from those of subjacent tracts. 
 
 The nerve cells, very sparse in number, are chiefly limited to the 
 lower two-thirds of the peripheral zone. Three kinds of nerve cells 
 are described by Cajal : — the polygonal or stellate, with numerous 
 protoplasmic processes, but with one axon only, which, arising from 
 the body of the cell, ramifies very extensively in all directions in this 
 zone, terminating in fine, varicose and free fibrils ; long fusiform, 
 bipolar cells disposed antero-posteriorly, and, from either pole, giving 
 origin to an exceedingly long protoplasmic process, which along its 
 course throws off" from time to time collateral branches upwards to 
 the pial surface. The peculiar feature, however, in these cells is the 
 plurality of their axons ; each main protoplasmic branch appears con- 
 
LAMINATION OF THE MOTOR AREA. 
 
 127 
 
 tinuous with, or gives off at some distance from the cell, an axon 
 which, coursing horizontally, throws off numerous ascending collaterals, 
 ■ending in extremely delicate branches throughout a very extensive 
 region of this layer. Such axons are pi'obably medullated (Cajal). 
 Supernumerary axons arise also from the secondary protoplasmic 
 branches, usually ascending in their course. These cells, therefore, 
 exhibit the unusual feature of protoplasmic processes ending in axons. 
 
 Lastly, there are triangular elements which usually throw off three 
 main protoplasmic processes ; two of which run horizontally to the 
 surface, or course somewhat obliquely upwards ; whilst the third 
 passes downwards to bifurcate into arcuate processes, from which arise 
 two, three, or more axons probably medullated, and of extensive 
 distribution. A smaller and more rounded element is also found here, 
 which not only originates axons from its protoplasmic processes, but 
 sends off an axon from the cell body, from which numerous collaterals 
 arise and ascend to the surface. 
 
 In all these nerve cells of the peripheral zone, besides the plurality 
 of axons, their extensive rami- 
 fication, and their origin from 
 protoplasmic processes, the 
 characteristic features are the 
 great paucity of dendritic 
 branchings, the great length of 
 the dendrons, and the absence 
 of varicosities and collateral 
 spines (Cajal). 
 
 (c) The vascular elements 
 pass as long straight vessels 
 for deep distribution, and as 
 short branched and smaller 
 vessels through its structure ; 
 they call for no special re- 
 mark here. 
 
 Second Layer.— A nar- 
 row belt of very closely 
 agcjref'ated nerve cells of irre- 
 gular marginal contour, oval, 
 pyramidal, or angular, with 
 a proportionately large nu- 
 cleus, forms this stratum. The 
 cells vary much in size, and, 
 as we have previously re- 
 marked, are much more richly developed in some than in other 
 regions of the brain. They measure (fig. 15) from 11 /x to 23 /«, in length, 
 G /A to 9 ,'Jb in breadth, the nucleus being often 6 /ti in diameter. 
 
 Fig. 15. — Cerebral cortex : nerve cells of 
 second layer : descending axons. 
 
128 LAMINATION OF CEREBRAL CORTEX. 
 
 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. In the cortex at the vertex in a rat and rabbit 
 this second layer is practically absent ; although it may be traced 
 as small, scattered, appressed groupings of cells on the lateral aspects 
 of the brain. To see these cells to advantage in such brains we must 
 examine the lower arc of the limbic lobe. The same may be said 
 for the sheep ; but, in the pig, this layer is a fairly notable one 
 throughout, reaching a thickness of 138 {Jj. In the cat, dog, and man 
 the depth attained may be 279 /a. 
 
 Third Layer. — Subjacent to the above lies a deep belt of nerve 
 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 /a x 8 /a; those of the deeper regions of this layer 
 22 ih up to even 41 /a in length, and 23 /a 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. 
 
 (b) 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) Lastly, 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 
 
MOTOR-CELL GROUPINGS. 
 
 129 
 
 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 
 to the surface, a position aptly termed reclinate by Dr. Major. These 
 cells measure from 25 /a to 32 /a in length, by 9 /a to 13 /.o in breadth, 
 and exhibit a large oval nucleus. 
 
 Distribution of the Motor-cell Groups.— The specialised five- 
 
 p.— 
 
 Fig. 16.— Left ascendiug 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. R, Region of large elongate cells. 
 
 P, Fifth group of ganglionic cells. 
 
 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 "paracentral" lobule; it remains for us to indicate more 
 particularly the exact site occupied by this type. In the scheme now 
 presented, the results of an investigation into the localisation of these 
 areas in eight human brains, made in 1878 by the author in conjunction 
 
 9 
 
I30 
 
 LAMINATION OF CEREBRAL CORTEX. 
 
 with Dr. Henry Clark, are given.* The arrangement and distribution 
 were strangely uniform in all these cases (see figs. 16 and 17). 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 were grouped into several distinct areas, very clearly 
 and definitely interrupted by the transitional type of cortex. The 
 variations in the extent of such areas are no more than might be 
 anticipated from the developmental variations indicated by the 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 segments — 
 an upper, comprising two-thirds its length, into which run the 
 superior and middle frontal; and a lower, comprising the remaining 
 third, continuous with the inferior frontal in front, and with the 
 ascending parietal behind. 
 
 Taking first the upper two-thirds, we find that the upper end has 
 
 R-->. 
 
 Fig. 17.— Left ascending frontal and parietal gyri, with the attached frontal 
 convolutions, as seen at the vertex. 
 
 A-D, First group of ganglionic cells. 
 E-G, Second „ 
 H-K, Third „ 
 
 M-N, Barren area. 
 
 N-O, Fourth group of ganghonic cells. 
 
 R, Region of large elongate cells. 
 
 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 
 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 
 
 * " The Cortical Lamination of the Motor Area of the Brain," by Bevan Lewis 
 and Henry Clarke, Proc. Roy. Soc, No. 185, 1878. 
 
TRANSITION-REALMS. I^I 
 
 of two other similar groups (H-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 
 perfect and dense clusters. Such clusters occupy especially the parietal 
 aspect of the convolution, which is adjacent to the ascending parietal 
 convolution. They appear, therefore, in the cortex forming the wall 
 ■of the Rolandic 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 
 Tipper 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. 
 
 The 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 summit 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 the middle frontal (N-0).— This group, as before 
 stated, becomes continuous with that of the middle frontal ; it also 
 begins with 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 the paracentral lobule. Some enor- 
 mous cells are found in the groupings of this area. 
 
 Tpansition-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 Terrier : 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 covered by cortex transitional in its character between the 
 former and what Ave find existing in sensory realms. If, for instance, 
 the upper extremity of the ascending parietal be subjected to examina- 
 tion, we find that its interior 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. 
 
132 LAMINATION OF CEREBRAL CORTEX, 
 
 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 diminished in size, and although often arranged 
 in clustered groups, the groups are poor in elements and sparse. 
 
 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. Roughly 
 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 interpai-ietal 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 versd. As the one formation, 
 tends to die out, the other tends to increase in thickness and density. 
 
 (2) Substitutional stratification 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- 
 Vhen the angular element of the second layer develops into the large- 
 
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SIGNIFICANCE OF SIZE OF CELLS. 
 
 ^33 
 
 globose cell of this layer in the modified loweF limbic type of 
 the rat, rabbit, mole, <kc. ; or where the elements of the fifth layer in 
 the sensory cortex become changed into the larger complex cells of the 
 motor g^POUpingS. As we traverse the whole range of the cortex, 
 one or other of the above influences is at work in modifyino' 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 
 diiferent nerve cells : is it but an accident of their position in the 
 cortex as to relative depth : is it indicative merely of the age of the 
 cell : is it dependent on their specific functional connections : or upon 
 the degree of complexity attained by the nerve element ? 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 twenty 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 obviously natural to suppose that 
 the greater the distance along which a nerve cell has to transmit its 
 energy, the larger will that nerve cell probably be ; in the next place, 
 as we are dealing with the non-medullated fibre of the apex, we might 
 also assume that the loss by diffusion around may 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 
 Meynert's assumption, if we regard the dendrites as functionating 
 cdlulifugally ; but, the reverse is now accepted as the true course pur- 
 sued by the nerve current. 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 
 
 * Psychiatrisches Centralblatt, No. 6, 1878. 
 
T34 LAMINATION OF CEREBRAL CORTEX. 
 
 oriorinal memoir, '*•' we find numerous exceptions to his rule, that the 
 smaller element is always higher in the cortex, and, given a section 
 of brain examined by the fresh methods, such exceptions become very 
 numerous indeed. That the general tendency to this larger size with 
 their deeper position is maintained, we of course allow ; what we 
 dispute is the explanation afforded, which leaves out of consideration 
 the numerous exceptional small elements refei'red to. 
 
 In the next place, were this explanation held tenable for this form 
 of cortex, the formation described by us as the modified lower 
 limbic COPtex of the rodent would entirely confute such a principle, 
 since here we have a series of very large CellS, the largest by lar 
 in the whole depth, here lying quite Superficial as the second layer 
 in 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 brain, we iind 
 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 v. represent conclusively what we have 
 here stated : the outlines of the cells are represented at their respec- 
 tive levels as sketched by the camera lucida, and it is seen that 
 the upper elements measure but 18/x x 11, 'x, being quite superficial 
 in the series of small pyramids ; that the lowest of the series include 
 elements measuring but 36//, x 23 /x, although at a depth of 116 /x 
 beneath the former : whilst a little higher we find numerous cells 
 measuring 18//. x 13 /x in size— i.e., very slightly larger than those of 
 the superficial series, although 953 /i beneath them. When, however, 
 we pass from the largest pyramidal to the ganglionic cells lying only 
 209 ,a lower down, we come suddenly upon huge elements measuring 
 from 84 /x to 97 /x in length, by 36 /x to 46 /x 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 rela- 
 tion between the size of the cell and other conditions to which it is 
 exposed, which may give us the required explanation ] 
 
 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 
 * "The Brain of Mammals," Syd. Soc. Trans. 
 
SIGNIFICANCE OF SIZE OF CELLS. 
 
 in the case of the motor cortex. The medullated fibre (axon), 
 •which arises from the basal extremity of the great motor cells, 
 traverses uninterruptedly an enormous distance to reach the respec- 
 tive cell-groups which represent in the spinal cord the musculature 
 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 
 througli 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 centre for the great musculature of the limbs, as illus- 
 trated by the following table of actual measurements : — 
 
 Comparative Size 
 
 OF Brain Cells, 
 
 
 
 Average Size of 
 
 Largest Cell- 
 
 
 Ganglion Cells. 
 
 Maximum Size. ' 
 
 Left ascending frontal (upper end), . 
 
 60 m X 25 m 
 
 90 m X 45 m 
 
 Frontal gyri (areas at posterior end), . 
 
 45 /u X 20 m 
 
 69 m X 27 m 
 
 Left ascending frontal (lower end), . 
 
 35 m X 17 m 
 
 41m X 18 m 
 
 Left ascending parietal (upper end), . 
 
 66 M X 41 M 
 
 88 m X 41m 
 
 ,, ,, (middle third), 
 
 46 m X 37 m 
 
 55 m X 32 m 
 
 j> ,, (lower third), . 
 
 41 M X 24 m 
 
 ... 
 
 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"reater 
 musculature being presided over by the groups of larg-est 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 tlie deepest elements 
 are not necessarily the oldest, for some of the lowest of a series are 
 very small and very simple in their connections. The reason for this 
 was shrewdly given by Dr. Ross from observations on the develop- 
 
136 LAMINATION OF CEREBRAL CORTEX. 
 
 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 
 contiguity 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 brain 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 meshwork 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, and are brought 
 into apposition by delicate lateral 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 experimen- 
 tation by Ferrier, Hitzig, Horsley, and Beevor, and clinical investi- 
 gations, 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 
 preponderating 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 equilibrium. 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 
 quantity in one large cell. I have also suggested that small muscles, or, more 
 properly, movements which require little energy for the displacements they have 
 to effect (those of the face and of the hands in touch, for example), are represented 
 by small cells. Such movements are rapidly changing during many of the 
 
 * Diseases of the Nervous System, vol. ii., p. 26, 1881. 
 
Plate XIII. 
 
 
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 'J, i: .{.-•^V-. JVV \ 
 
 
 / 
 
 Fig. I. 
 
 Fk;, 2. 
 
 X 110. 
 
 CORTEX OF PIG'S BRAIN, TWO DAYS OLD, 
 SUBLIMATE PREPARATION. 
 
 Bale, Sons & Datiielsson, Ltd.JAth. 
 
THE NUCLEUS OF THE NERVE CELL. I 37 
 
 ■operations they serve in — writing, for example — and require repetitions of short 
 liberations of energy, and necessitate quick recuperation of the 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 granular 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 some 
 mysterious influence over the nutPitive 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 insta- 
 bility. We have long been accustomed to regard it as related more 
 definitely to the functional activity of the cell, and less directly 
 related to the nutPitiVC 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 storage and liberation of energy 
 
 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 discharge, as a 
 kind of imperium in imperio exercising a controlling influence upon 
 the perturbations which reach the cell from sensoi'y 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 running-dotvn 
 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. 
 
 * "On Temporary Paralysis after Epileptiform and Epileptic Seizures," Brain, 
 vol. iii., footnote to p. 43G. 
 
138 LAMINATION OF CEREBRAL CORTEX. 
 
 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 atforded by the very lai'ge nucleus. In the next place, we 
 have every reason for believing that this superficial belt of angular 
 cells is in direct functional connection with the subjacent cells of large 
 size, and that their morbid instability would, therefore, affect 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 slotu accumulation and storage of energy, which, when liberated, 
 would again result in a tardy re-instatement 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 sufficient 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. 
 
 — It is from these phenomena we infer that the cortical areas found to 
 be excitable are really centres, in the proper acceptation of the term. 
 Tt must be remembered that a ganglionic centrum is an elaborative 
 structure, and that stimuli applied to it meet with delay ere the result- 
 ino- response be elicited. The excitation of a centre is therefore accom- 
 panied by the time element seen in nerve stimulation in a marked 
 * Functions offJie Brain, 2nd edition, p. 223. 
 
LATENT PERIOD OF STIMULATION. 139 
 
 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 tlie first place, we find (after, of course, abstracting 
 the time required for transmission down spinal cox'd and motor nerves 
 and the latent period of the muscle) that the retardation is 0'045 of 
 a second, and in the latter place, 0'03 of a second (^Franck and Pitres). 
 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 effect of electric stimuli on motor centres, the more important 
 may be stated as follows : — 
 
 (1) In the same animal the numbeP 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 46 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. 
 Rliythm of stimulus at above 10 per second = muscular rhythm constant 
 
 and independent (Schafer and Horsley). 
 Rhythm of stimulus about 46 per second = continuous muscular contraction 
 
 [Franck and Pitres). 
 
 (4) The muscular curve of cortical stimulation is less sudden in its 
 rise and more sustained than the curve shown in subcortical stimula- 
 tion, and all voluntary muscular contractions show a similar rate of 
 undulation in the muscular curve. 
 
 Modifying" Circumstances. — The excitability of the cortical areas 
 is subject to great variation. Thus, different animals vary in the 
 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 hSBmorrhag^e greatly reduces or even abolishes, whilst 
 moderate loss of blood exalts, the excitability of these parts 
 (Munk, llitzig). Prolonged expOSUre and stimulation rapidly 
 exhaust, whilst apnoea, and the deep narCOSiS of chloroform, 
 ether, chloral, and morphia abolish it [ScJiiff), so that all animals 
 completely ansesthetised fail to reveal such excitability. So if the 
 
T40 LAMINATION OF CEREBRAL CORTEX. 
 
 cortex be in a state of inflammatory iPPitation, 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 
 tenth 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, however, 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 ChaPactCP 
 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 Electpic Stimulation of Coptex.— Professor 
 
 Ferrier gives preference to the faPadiC Stimulation of the cortex, 
 rather than the galvanic, since the first requisite is a stimulus of a 
 certain dUPation, and not the momentary effect 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. 
 
 ExtPa polaP 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 
 
PROXIMITY OF PSYCHO-MOTOR CENTRES. 141 
 
 which was stimulated. This fact, however, does not vitiate the result* 
 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 distributed as to occupy 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 Professor Terrier 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. ciL, p. 229. 
 
142 
 
 PART II.— CLINICAL SECTION. 
 
 €eneral Contents. — States of Depression — States of Exaltation— Fulminating 
 Psychoses — States of Mental Enfeebleraent — Recurrent Insanity — Ejjileptic 
 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— Rise 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 propoi'tion to what would 
 occur in the liealthy mind, then we infer that the grey cortex of the 
 brain is so far disordered as to functionate abnormally, and we speak 
 of the result as pathological depression. It is clear, therefore, that 
 our chief diiEculty 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 
 special peculiarities of temperament. We cannot apply the same rule 
 to a callous, unemotional nature as to one refined and sensitive. 
 
MENTAL DEPRESSION. 
 
 h: 
 
 In our search for adequate causes we do not confine our attention 
 to the patient's environment ; we must look for possible moral agencies, 
 sucli 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, 
 wl)ile 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 well 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 difliculty 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 l)y that failure in 
 object-consciousness which invariably inaugurates a corresj^onding 
 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 
 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 
 
 * Mental Diseases, p. 210. 
 
 t Pfiychological Medicine, Bucknill & Tuke, 3rd edit., p. 440. 
 Principles of Psychology, vol. i., p. 177. 
 
144 STATES OF DEPRESSION. 
 
 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 negative 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 pise 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 up 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 afi"ection 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 b& 
 understood as implying that the nature of these states or conditions consists in 
 inaction and weakness, or in the sup2Jression of the mental or cerebral phenomena 
 which accompany them. We have much more cause to assume that verj' violent 
 states oj 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 painful 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,' 
 
DECLINE IN OBJECT-CONSCIOUSNESS. 
 
 145 
 
 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 ippitation in the substrata of SUbject-COnsCiOUSnesS, 
 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 us is rarely if ever reached, 
 yet the 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 Objeet-COnseiOUSnesS. — 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 quali- 
 tative 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 : (b) 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 Thought.— The constant 
 
 accompaniment of depressed mental states is a diminished range of 
 perception ; and, since every perception is a complex phenomenon of 
 composite states of consciousness — if one or other of the e.ssential 
 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, 
 
 * " Mental Diseases," Syd. Soc, p. 210. 
 •J: Principles of Psychology, vol. ii., p. 459. 
 
 10 
 
146 STATES OF DEPRESSION. 
 
 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— 
 i;hose of size, position, form. A vigorous perception of these primary 
 or space attributes of body is dependent largely upon 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 afiected, 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, 
 &c., which subserves the purpose of locomotion and coarse movements. 
 The sense of muscular contractions which forms the basis of the prim- 
 ordial 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 
 contraction, 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 thought," which in the normal state is 
 of free and easy play, the rise into consciousness of its primordial 
 muscular element means efibrt, 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 
 cases of intense grief, as from a sudden mental shock, are associated 
 with a notable contraction of this sphere, and space dimensions 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" relations of bulk, configuration, and position are recognisable only by the 
 intellectual operations of the mind, and it is this intellectual element which is 
 
SENSE OF ENVIRONMENTAL RESISTANCE. 1 47 
 
 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 Spencer), 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 gPasp 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 relation element of 
 mind, therefore, external resistance must be pari passu 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 primary states of consciousness and other 
 secondary component impressions which fail to rise into consciousness, 
 or are more or less revivable or representative. 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 TCVWS- 
 CUlar origin. If, in every conception of a sphere, 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 nnd movement fails, in health, to rise into consciousness — an 
 automatic play calls up vivid representation of form and figure without 
 
148 STATES OF DEPRESSION. 
 
 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, delay occur in the production of such relational states, 
 the statical attributes of body will be perceived only after COnseiOUS 
 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 efibrt 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 effOFt 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 characterise all intellectual processes. The 
 restless movements of the intellectual eye (in the artist, poet, &c.), 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 motor element of mind which is here at fault — the relational 
 element of thought, since it is the space attributes of bodies which 
 are involved. Now, since in the appreciation of these attributes of 
 body (form, bulk, &c.) the subject is active and the object passive, it 
 results that the motor constructive element of the 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 
 consciousness by the agency of anaesthetics. To any one who has 
 been anaesthetised, and who recalls his experiences, say, with nitrous 
 
RESTRICTED VOLITION. 1 49 
 
 oxide, it mu3t be obvious how the environment crowds in upon one 
 more and more, and how the ego, or personality enslaven 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 representation in consciousness of the several 
 possible lines of action. This, in other Avords, is equivalent to saying, 
 that various feeble motor excitations are represented in consciousness, 
 a^nd 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 motOP 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 enfeeblement 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 
 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 representations 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 
 
150 STATES OF DEPRESSION. 
 
 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 Pealisation 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 resiilt 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 which 
 enables the one group to preponderate and overcome the other in 
 action. 
 
 To employ a figurative illustration — thus do we witness in the surging 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 surging 
 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 
 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/aU in object-consciousness and a rise in subject-conscious- 
 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 
 
FAILURE OF PERSONAL IDENTITY. 
 
 151 
 
 of encroachment from without. We fail to grasp the environment : 
 we do not know it, in the sense of measuring our strength against it — 
 aoid hence lue fear 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 pasSivC 
 e^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 differ- 
 ence is observable in these cases of confused identity, but the more 
 important distinction appears to exist between — 
 
 (a) Oases 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 
 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 melajicholic types of alienation, whilst the 
 former are educts of the more purely rnaniacal 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, 
 
 * See on this point especially Ribot, p. 107-110; also Griesinger's Mental 
 Diseases, p. 51 ; cf. Spencer, Sully. 
 
152 STATES OF DEPRESSION. 
 
 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, musculature, 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 con- 
 siderably, 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 compl«?tely 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 ap])reciate 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- 
 tion, but aid in the welling-up of the emotional life of the subject, and 
 it is from this latter source that falsifications Of Sense arise. 
 
 As subject-consciousness becomes more and more pronounced with 
 failure of object-consciousness, all impressions alike, received from the 
 non-ego, become the pabulum for the growth of an all-pervading 
 eg'Oism. The subject broods over his multiform and novel feelings — 
 morbid 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 out of 
 this source there now 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 
 
TRANSFORMATIONS OF IDENTITY. I 53 
 
 lieu of the old and normal relationships pre-existing. It would be a 
 fallacy to assume that the falsifications of the environment precede 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 
 begot 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 tj^e 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 immediate 
 concepts, as we may term those which are the result of pure intellectual operations, 
 unassisted by, or only associated with, emotional states, are more subordinate to 
 accurate laws of logic : the more mediate concepts, emotionally derived, are less 
 susceptible to such exactitude of classifying and grouping. Such concepts, in the 
 morbid states now under consideration, are utterly illogical, unclassifiable, frag- 
 mentary, and betray but the disjecta m,emhra 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 re-arrangement 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 transfor- 
 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 that newly-acquiPGd freedom 
 which, at this juncture, appears to dawn upon the mind of the 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- 
 
154 STATES OF DEPRESSION. 
 
 tion of a new-got freedom entirely effaces the enmity of the non-ego 
 from the mind. 
 
 Like all sudden and extensive transformations of miud, 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 old /in the character of a foreign thou, 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 Adolent 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 Pe -integration 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 
 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-energising in lower 
 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 sensa- 
 tions and ideas are conserved which are the fittest to survive : irrational 
 as may be the beliefs, inconsistent the new concepts with the actual 
 truth, still, as Hughlings-Jackson indicates, they are the best possible 
 in the patient's state of reduction. 1 
 
 * "Mental Diseases," Syd. Soc, p. 50. 
 
 t Dr. Hughlings-Jackson has repeatedly insisted upon the negative and positive 
 results of epileptic seizures. 
 
 + We are prone, by the loose phraseology of common life, to regard the subjec- 
 tive as a permanent possession — to speak of our mind as a something bej'ond the 
 simple active contents of the moment and as the accumulated psychical acti^^ty 
 of our total existence ; as if thoughts could be bottled-up permanently and 
 unchangeably. It is the material substratum of thought^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 Psychology, p. 485. 
 
THE PHYSIOLOGICAL ASPECT. 
 
 155 
 
 As the tide of intellectual life retires, so does it well-up into emotional 
 states ; but such emotional wave must have its rebound, and this is 
 expressed in the re-integration which 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, 
 in many subjects, permanent damage should ensue? 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, in- 
 definite perceptions, emotional surgings which have no obvious origin or 
 purpose, characterise a period of perturbation of the mental life, which 
 may readily lead to misdirected ejQForts 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 vesanise, it would appear to us more important to lay 
 emphasis upon the morbid processes 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 natuie as 
 to one in their mode of origin : they indicate quantitative as well 
 as qualitative variations in tlie 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. 
 
 *See on this subject the section on the "Insanities of the Period of Pubes- 
 cence." 
 
156 STATES OF DEPRESSION. 
 
 Two groups stand strongly contrasted here : the one, in which a 
 defective CerebPal 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 various qualitative variations of 
 the blood-plasma — tOXSemia, &c. — a group conveniently placed 
 between the two former. 
 
 D'Abundo has recently affirmed that the toxic and bactericidal 
 action of the defibrinated blood-serum is much increased in all forms 
 of insanity, except in mental depression, in which, on the contrary, it 
 is lessened. His experiments demonstrated the fact that some 10 c.c. 
 of serum to the kilogramme of blood kills rabbits by acute intoxica- 
 tion. It by no means follows, however, that mental symptoms due to 
 the products of auto-intoxication should bear any direct relationship 
 to the toxic effect on lower animals of the blood-serum injected. 
 The effect of certain poisons administered to rabbits upon the nerve 
 cell and its histological constituents has recently been carefully 
 studied by Nissl, very definite changes being induced in the nerve 
 cells of the spinal cord and brain by such agencies as alcohol, morphia, 
 strychnine, lead, phosphorus, and arsenic* 
 
 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 functionally 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 clearly distinguish those affections in 
 which the prominent indication is that of simple depressed circulation, 
 from a state in which the vitiated quality of the blood chiefly 
 appeals to us, and, lastly, from those grave affections in which 
 acute and chronic nutritional anomalies are the chief factors con- 
 cerned. 
 
 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 
 * Rivista Sper. di Freniatria, vol. xviii. 
 
PATHOLOGICAL DEPRESSION. 
 
 157 
 
 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 anaemia 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 pathologfical 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 
 disturbed. 
 
 Viewed from the mental aspect, the highest psychical operations are 
 first enfeebled : 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 
 world 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 
 abeyance, and the functions of organic life are all depressed. The 
 vitality of the organism as a whole, being largely dependent upon the 
 activity of the nervous centres, must necessarily suft'er when this 
 important 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 
 distract the attention — the mental pain and disquiet is intensified 
 thereby : apathy and indifference may be replaced by timidity, fright, 
 
 * 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. cit., p. 198). 
 
158 STATES OF DEPRESSION. 
 
 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 
 -v^hich 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 
 accumulating 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 dispro- 
 portionate 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 intensity. The nePVe pulse is irregular, fitful, intermittent. 
 
 This group comprises certain varieties of so-called impulsive 
 insanity — the homicidal and suicidal — the subjects of epileptic 
 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 nePVe-elementS. How does this starvation betray itself 1 
 In replying to this enquiry let us briefly refer to the physiological 
 appetites for food, &c., and parallelise them with the case in point : 
 we shall then find that all animal appetites are dependent upon two 
 essential factors : — 
 
 (a) The reception of peripheral excitations by a centric register. 
 
 (6) 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 membrane : 
 and for its alleviation the centres must receive impressions so 
 created. But excitation of the peripheral ends of the vagus, produced 
 by any mechanical contact other than by the ingestion of aliment, 
 temporarily suffices to restore the nutritive equilibrium of the nerve- 
 ceutres. The rhythmic pulse of excitations thus transmitted to the 
 centrum 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 
 depends not alone upon the transmission of the physiological stimuli. 
 
MENTAL DEPRESSION. 
 
 159 
 
 but also upon the collateral flow of blood to the part. So — as regards 
 the special senses — the abolition of the usual afferent impressions 
 begets a condition which is truly a pathological hunger. Strikingly is 
 this the case with the sense o? hearing : depression of spirits is a well- 
 marked 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 
 faculty is in its evolution — the less dependent is it in this respect upon 
 ■presentative excitations ; and thus the sense of sight, when similarly 
 affected, fails to indicate in the same notable degree a corresponding 
 depression of the emotions — idealising or centric 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 
 mec-hanisms initiating representative processes are starved out by 
 deficiency of blood, then there is begotten a corresponding 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 diffusion-currents provocative of the pleasurable emotional states 
 which always accompany healthy energising of these centi-es. Corre- 
 sponding, therefore, to the dreariness of thought in cognitive realms, 
 we have in the region of feeling such painful mental depression 
 as accords with what we should term the hung'eP 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 
 through 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 
 epi-peripheral excitatitms, as those of the special senses — i.e., whether 
 the physiological stimuli are continuously received, or have intervals 
 of some duration, or, as in the case of the heart, are equable 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 weakening 0/ that associative affinity 
 which arouses correlative centres, and Avhich is the physical basis of 
 ideal association. In like manner, the directive agency of such ex- 
 hausted centres must be enfeebled, and the blending of impressions 
 and associated states into the "serial line of thought" (Spencer) 
 
l6o STATES OF DEPRESSION. 
 
 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 Eomanes 
 aptly terms it, becomes arrestive of the higher processes of thought, 
 and this resistance in the intellectual sphere is associated with a 
 diffusion 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 under-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. Mental 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-conscious- 
 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 
 diffused 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 such 
 states as the result of under-action, the under-action is distinctly that 
 of the higher planes, whilst there is a corresponding surplus of activity 
 aroused in the subordinate planes of feeling and emotion. The so- 
 called states of over-action, again, are similar conditions more definitely 
 expressed — the over-action being that of the recipient, afferent, or im- 
 pressive sphere, with a corresponding under-action of the efferent, 
 intellectual, and expressive sphere — in fact, all grades of mental pain 
 are dependent upon OVCF-action on the impreSSiVC 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 thought and action: we likewise find painful mental 
 
THE REACTION-TIME IN MELANCHOLIA. i6l 
 
 •states associated with the surging tide of feeling vainly struggling to 
 bui'st 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 fretfulness — passing, in fact, towards states whei'e 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 pain, 
 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 vagaries 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 ojjerations are not grossly involved, that a failure 
 in the energy of cerebral reflex can be 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 struck of the 
 rapidity of reaction from less than tiventy 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. 
 
 Reaction-Time Instrument. — We have employed an instrument 
 made by the Cambridge Scientific Instrument Company and designed 
 by Mr. Galton, and have found it admirably adapted for our purpose 
 in testing the reactions in the insane. A short description of this 
 apparatus (fig. 18) may not be out of place here.* 
 
 * See description of this apparatus by the author in Hack Tnkc's Dictionary of 
 Paychological Medicine, vol. ii., Art. " Psycho-pliysical Methods," No. 3, 
 p. 1022. 
 
 11 
 
l62 
 
 STATES OF DEPRESSION. 
 
 Fig. 18. — Reaction-Time Apparatus. 
 f;^The above represents the apparatus as subsequently modified for obtaining a 
 prolonged reaction-time. It will be noted that four graduated rods take the place of 
 a single rod ; that each rod is suspended by an electro-magnet to secure silent release, 
 and that the six Bunsen cells (quart) supply the current for working the electric 
 signals, the upper series of magnets, and the electro-magnet for the clamp. The 
 simpler form of apparatus — devoid of the extra rods, battery, and foot-board — was 
 the instrument mainly used for the results given throughout this work. 
 
REACTION-TIME INSTRUMENT. 163 
 
 A square standard of pitch pine, 5 feet 10 inches in height, is fixed 
 into a solid, unyielding tripod, in which levelling screws ensure its 
 exactly vertical position. Half way down this standard a i-ectangular 
 piece of mahogany or teak is screwed at right angles to its long axis ; 
 this supports a horizontal table upon whicli rests the hand of the party 
 to be tested. To the same rectangular piece a small electro-magnet is 
 fixed, which holds in position (as an armature) a spring stirrup so 
 long as the electric circuit remains unbroken. This latter circuit 
 passes over the table to a contact breaker, so that the finger of the 
 operator, by depressing a button here, breaks the circuit, releases the 
 stirrup, which, being in its turn drawn back by a powerful spiral 
 spring, clamps the registry rod in its fall. The steel base of the 
 stirrup is fitted inside with rubber, thus forming a more effective brake. 
 
 From the summit of the standard a box- or lancewood rod is sus- 
 pended, three feet in length, and accurately graduated along its edge 
 in hundredths of a second, up to thirty divisions, the limit of its 
 complete registry being therefore three-tenths of a second. Astride 
 the summit of the registry rod rides a heavy brass plate which falls a 
 short distance with the rod, being then arrested by a diaphragm, its 
 impact causing the SOUnd signal ; or by the make and break of an 
 electric current here it starts an electric bell as the sound signal. 
 The registry rod as it hangs suspended is concealed from the subject's 
 view by a narrow projecting ledge of pine wood fitted to the standard 
 betwixt the rod and the person to be tested. In this ledge, at a con- 
 venient height for the eye, is a small vertical slit or window, and a 
 corresponding slit exists in the rod through which the light is seen ; 
 but, on the release of the rod, the window is closed by its fall, and a 
 Si^ht signal is thus afforded. 
 
 This apparatus should be as simple as possible, solid and absolutely 
 steady ; the rod should hang perfectly vertical and should not come in 
 contact witii any surface in its fall ; by arranging the levelling screws 
 in the tripod the clamping of the rod should secure it from any sliding, 
 and in its descent the rebound should be reduced to a minimum at the 
 foot, and as little clatter as possible allowed. The release of the rod 
 should be effected with absolute silence, and this is best secured by 
 suspending it to a straight bar electro-magnet by a short cylinder of 
 soft iron. The fall of the rod should be on a cushion or i)ad filled with 
 sand to deaden the resulting thud and check the rebound. The rod is 
 released by pressing a button conveniently placed behind the standard 
 out of observation, which breaks the circuit of the electro-magnet 
 suspending the rod. 
 
 The Test. — The subject sits supporting his right hand on the table, 
 his forefinger on the interrupting button of the clainp-magnet. The 
 operator silently releases the rod which gives the sound signal, and the 
 
164 
 
 STATES OF DEPRESSION. 
 
 forefinger is instantly depressed, releasing the stirrup and clamping 
 the rod. The figure on the front of the rod where clamped gives the 
 reaction-time for the SOUnd signal. 
 
 In the next place the brass weight is removed and the subject, 
 sitting as before, is directed to keep his eye on the light seen through 
 the slit in the rod. The rod is now released, the light disappears, and 
 the subject, as before, clamps the rod as rapidly as possible. The time 
 taken in the fall, as read ofi" on the edge of the graduated rod, gives 
 the total reaction-time for a sig'ht signal. 
 
 The general results, so far obtained, would indicate a decided prolon- 
 gation of the reaction-time in many forms of insanity. Simple afiective 
 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 alcoholic 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. K one of the patients tested suffered 
 from any serious degree of dementia, such as would have prevented 
 their fully entering into the interest of the trial. ^'' 
 
 In general paralysis, 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 ix Health and Disease. 
 
 Acoustic Stimulus. 
 
 Sec. 
 
 •13 
 
 •15 
 
 •16 
 
 Self, . 
 R. H., 
 T. H., 
 
 R. L., -13 
 
 D. A., •le 
 
 R. W., Simijh Melancholia, . . "29 
 
 M. L., „ „ . . . •22 
 
 S. W., Climacteric Melancholia, . 29 
 
 J. W., Hypochondriacal „ . . "23 
 
 G. A., Delusional ,, . . '20 
 
 C. K., „ „ . . •U 
 
 * See also " Reaction-time in certain Forms of Insanity," in Tuke's Dictionary 
 of Psychological Medicine, vol. ii. ; also "Reaction-time" (in same), by Prof. 
 Jastrow, with Bibliography. 
 
 Optic Stimulus. 
 Sec. 
 •16 
 •17 
 •18 
 •21 
 •21 
 •30 
 •25 
 •29 
 •24 
 •26 
 •24 
 
REACTION-TIME IN HEALTH AND DISEASE. 
 
 165 
 
 Acoustic Stimulus. 
 
 Optic Stimulus 
 
 Sec. 
 
 Sec. 
 
 0-149 
 
 0-200 
 
 
 0-151 
 
 0-2-25 
 
 
 0-180 
 
 0-188 
 
 
 0-182 
 
 0-194 
 
 
 0-128 
 
 0-175 
 
 
 0-136 
 
 0-150 
 
 
 0-1-22 
 
 0-191 
 
 
 0-120 
 
 0-193 
 
 With the above we also contrast the results given in a table by 
 
 von Kries and Auerbach, embracing the investigations of several 
 
 observers * : — 
 
 Observer. 
 
 Hirsch, 
 Hankel, 
 Donders, 
 Von Wittich, 
 Wundt, 
 Exner, 
 Auerbach, . 
 Von Kries, . 
 
 It will be apparent from the observations on healthy subjects, that 
 whereas from ^jf^ to -^-^jj of a second formed the limit of variability 
 for acoustic stimuli, and y^^ to ^Yij ^^^ visual stimuli — in the insane, 
 the former is only exceptionally below -f^jj, and the latter rises from 
 tVo ^^ TijV °^ ^ 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 sight 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 speed 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 which sensory 
 impulses pass over into motor impulses is different (Ladd). t 
 
 The prolongation of the reaction-time in cases of insanity generally, 
 would indicate a special impairment in the visual as contrasted with 
 the auditory sphere : both are often involved ; but the former often 
 suifers 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 atent 
 period of end- and centric-org'ans : and we may assume, with 
 
 nearly as much certainty, that in the deranged states met with in the 
 insane, the protraction of reaction-time found is due, either to impli- 
 cation 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 aftective insanity. 
 
 Deg'reeS of Mental Depression. — Of the innumerable combina- 
 tions of mental symptoms embraced under states of mental depression, 
 
 * Archiv. f. Anat. u. Physiol., Physiolog. Abth., 1877. 
 t Elements of Physiological Psychology, p. 477. 
 X Vide infra, under Alcoholic Insanity. 
 
1 66 STATES OF DEPRESSION. 
 
 certain forms present themselves, having many features in common of 
 sufficient 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 which the 
 emotional or affective sphere is chiefly at fault ; and of a delusional 
 melancholia, in which the intellectual or ideational sphere suffers. 
 
 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 tliis universality of implication we do not mean that all mental 
 faculties 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 derangement, 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-conscious- 
 ness invariably presents this corresponding enfeeblement : 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 which 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 
 transient functional disturbances falling far short of pathological 
 depression, we find a gloomy emotional tone associated so frequently 
 with a morbid suspicion, bordering at times upon actual delusive 
 states — inconsistent, irrational misjudgments of our fellow-men and 
 
 * These considerations sufficiently indicate the fallacies of implication to the 
 student's mind of the term partial as contrasted with generalised insanity. 
 
SIMPLE MELANCHOLIA. 
 
 167 
 
 universal distrust, 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 minor degrees of pathological reduction result in a welling-up 
 of feeling as the more obtrusive feature (simple melancholia) — deeper 
 reductions, 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 
 explanation," to use Griesinger's phi'aseology. 
 
 It will at once be apparent how this view differs from that which enunciates, as 
 its leading doctrine, an affective origin for insanity : our own view being that the 
 relational and the sentient elements of mind must be conjointly implicated, and 
 that the priority 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 delusions, including the hypochondriacal form. 
 
 (c) Melancholia agitans. 
 
 (d) Melancholia atonita, or melancholy with stupor. 
 
 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 different depths of dissohUion — serial 
 stages in the same disease. 
 
 A still lower stage of reduction is that of maniacal excitement : and 
 we mention this fact here, since it is so frequently implied that mania 
 and melancholia are distinct diseases, rather than different stages of the 
 same morbid process. 
 
 (a) 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 intel- 
 lectual disturbance — if such mental pain be abnormal in its intensity 
 and disproportionate to any exciting cause, we liave a species of simple 
 melancholia. 
 
 Here, at the outset, we must qualify the phrase, "a purelj' emotional or affective 
 insanity:" for it requires but little insight 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 scientific 
 sense, between the purely emotional and the intellectual states. When we speak 
 of emotional states, we must ever bear in mind that the term connotes more or less 
 of the intellectual element of mind — that every mental operation presupposes in 
 its very simplest form — feeling, memory, reason, volition ; or rather tliat these are 
 but different aspects of the same state. It is, therefore, onlj' in tlie greater pre- 
 
1 68 STATES OF DEPRESSION. 
 
 ponderance of the one or the other factor that we distinguish between abnormal 
 mental states. 
 
 Simple melancholia, therefore, really embraces those states of morbid 
 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 intensity and 
 obtrusiveness overshadow any slight intellectual disorder which may 
 be present. Definite delusional states, therefore, are evidently excluded 
 from our definition ; reason still asserts herself; there is no enfeeble- 
 ment of memory ; volitional control is not withdrawn. The cerebral 
 dissolutions which such states of melancholia imply tend certainly 
 towards 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, 
 although 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 indifference 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 away 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- 
 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 mental vigour. 
 
SIMPLE MELANCHOLIA. 169 
 
 It is at this period that SUicidal pPOmpting'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 tlie 
 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 : 
 they 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 business 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. 
 
 It is by no means unusual at this stage of depression for homicidal 
 actions to replace the suicidal deed. From motives of intense love for 
 her offspring — to save them from the terrible calamity which appears- 
 to await herself — the mother will occasionally sacrifice her children or 
 anyone nearest and dearest to her (^Nicholson). '■•' 
 
 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 correctly interpreted as due to 
 the subject's own indisposition, but doubts arise — distrust prevails — 
 and a SUSpiciOUS bearing" 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 happen — 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-tiiree, a married woman with a family of two children, 
 was admitted suffering from an attack of depression, which liad commenced about 
 
 * See Dr. Nicholson's remarks at the discussion of Dr. Semalaigne's Art. on the 
 "Insanity of rersecution," Journ. oj Mental Science, vol. xl,, p. 516. 
 
170 STATES OF DEPRESSION. 
 
 three weeks previously. She had an earthy complexion — the cheeks mottled with 
 dilated capillaries : her bodily condition approached the obese. No pronounced 
 cardio-vascular change was apparent, although the heart's action was somewhat 
 feeble : the genito-ixrinary 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 tliat 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 extremely 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 was constantly the subject of vague fear, and 
 frequently asked what was to become of her. No delusions were apparent : she 
 had suffered 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 explanation 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 daily, 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. 
 
 (b) 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 cause 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 several 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 anotlier state of 
 existence — to his moral being. An infinity of delusive notions, there- 
 fore, necessarily presents itself, often in such strange and contrasting 
 combinations as to be utterly unclassifiable. 
 
 Prominent, 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 
 
DELUSIONAL MELANCHOLIA. I 71 
 
 which, if the cattention be riveted thereupon, constitute the so-called 
 hypochondriacal melancholia. Then again, we meet with de- 
 lusions relative to the moral being — the victim has committed the 
 unpardonable sin, or for some, perhaps, insignificant action, his soul 
 is entirely 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, treachery. And yet again, a well-marked class of patients 
 infer demoniacal possession, witchcraft or other unseen agency 
 as accounting for their states of mental pertui'bation. 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 frequently associations 
 of irreparable alcoholic brain disease — of epileptic states — of traumatic 
 forms of brain disease, &c. In the following case, however, we find 
 such hallucinations of smell in acute insanity induced by alcohol, 
 but rapidly recovered from : — 
 
 M. A. S. , a married woman, aged forty-eight, suffering from her first attack of 
 insanity, stated to have been of ten days' duration. She had 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 inherited 
 insanity. She was of corpulent proportions, her complexion dusky, and expression 
 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 minims 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 was 
 "a woman after her to burn her," that "she saw the flames." The following 
 night six hours' sleep ensued upon the administration of 25 grains of chloral : she 
 awoke calm and ordei'ly. 
 
 At this period she was composed, attentive, and coherent, but betrayed the 
 presence of numerous delusions and recent aural liallucinations : thought slie was in 
 an asylum : came here for protection from the noise in her own house. There was 
 such shouting and calling ; if she did not aihsiuer, the.y 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 you there?" they 
 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 liis body blowni up by dynamite.) She 
 had "smelt an earthy ■smell like that of a dead body in lier house for the past few 
 weeks." When she went to tlie police for protection, "hundreds of blackguards 
 followed shouting after her." She went the same day to get water from a tap in 
 
172 STATES OF DEPRESSION. 
 
 the yard. " She Avas sure it was drugged, it dried up her mouth, which began 
 burning and swelling ; she was confident somebody wanted to stab her." As usual 
 in such cases, she absolutely repudiated anj- 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, "0 Mrs. Rustan, Mrs. Rustan, 
 Mrs. Birkett, Am y, come down here ; Im 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 house." Xone of these voices have been heard since coming 
 to the asylum. 
 
 A fortnight after her admission she exhibited but verj- gentle depression, and for 
 the first time began to question the real or imaginary nature of the voices heard. 
 Xo relapse occurred, and in less than two months 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 currents arouse, as we have seen (p. 160), none but the 
 massive feeling oi pleasurable well-being, 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 
 2}hysical in contradistinction to the phj/siological 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 from the 
 phj'sical en\'ironment are not referred thereto ; and, although the appropriate 
 reaction maj'' occur, this by no means proves that such sensations are not referred to 
 some part of the organic or physiological environment. The higher we rise, the more 
 definite becomes the reference of its O'wn series of excitations to the object-world ; 
 and this, in 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 nature as 
 embraced in 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 " sensUOUS 
 core " of the personality be implicated either by peripheral or 
 centric derangements. That the former is possible, we have confirmed 
 by numerous instances of hypochondriasis with mental derangement. 
 
HYPOCHONDRIACAL MELANCHOLIA. 
 
 17, 
 
 arising from disease of the abdominal and thoracic viscera ; that the 
 hitter occurs, is sufficiently obvious in the excitation of similar states 
 by menial agencies — the perusal of morbid and sensational books, 
 obscene pamphlets, and the association with similar ca,ses of hypo- 
 chondriasis. 
 
 The anxieties and delusions of the hypochondriacal patient may 
 have reference to any part of his bodily organisation : amongst the 
 insane, howevei", prominence is given to the tract innervated by the 
 pneumogastric 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 
 complaint. 
 
 The hypochondriacal subjects of epileptic insanity almost invariably 
 refer 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, hypochondriacal 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 Insanity). 
 
 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 intensified at ouce by the 
 introduction of the cesophageal 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 cesophagismus of hysterical 
 suVjjects. Organic stricture we have very rarely met with in such 
 subjects ; but direct compression from enlarged thyroid we have 
 frequently found, associated with 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 
 the throat, and fully persuaded that they are 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 
 
174 STATES OF DEPRESSION. 
 
 feeding, declaring that the food so introduced can do them no- 
 good. 
 
 In like manner, other subjects declare that they have no stomachy 
 and transform various dyspeptic symptoms into indications of grave 
 disease : 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 pliglit. 
 
 In other cases, the genital organs are the source of anxiety — the- 
 subject believes himself to be impotent or the subject of syphilis, 
 and no possible argument can be used to assure him that his whole 
 system is not permeated by the virus. One patient, at the West 
 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 
 a<yony. The strangest combinations of delusional notions arise out of 
 the most trivial disturbances of function — slight constipation, tlatulence,. 
 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 
 to demonstrate how his brain was gradually passing out by that 
 channel. 
 
 Patients, again, will lie in bed declaring their inability to rise 
 because they have no body or no legs : and one well-known character 
 
HYPOCHONDRIACAL MELANCHOLIA. 
 
 1/5 
 
 at Wakefield, when asked lier name, would always reply, " I have no- 
 name ; I am no-one ; I have no body, no head, no limbs ; I'm a voice ; 
 I'm an echo." 
 
 Burrows speaks of hypochondriasis as never occurring before the 
 age of twenty-five;*^ but liyiwchondriacal 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 strikino- 
 instances of the kind which I have met with, was that of a younf 
 tabetic subject, in whom cerebral disturbance supervened, and in 
 whom 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. % In like manner, we find patients who will 
 lie in bed, forcibly and continuously eructating, or obtrusively sham- 
 ming eflforts 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 startinf^s 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 
 about as if in torture. In another instance of hypochondriasis, a 
 female endeavoured, for months together, to attract notice bv 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. It is in this craving for sympathy 
 
 * Commentaries, p. 466. iOp. n'f., p. 217. 
 
 JThe case was one of interest througliout, and lias been fully detailed by my 
 colleague, Ur. F. St. John BuUen, Brain, part xli., April, 1888. 
 
176 STATES OF DEPRESSION. 
 
 and self-reference that genuine hypochondriacal insanity differs from 
 the hypochondriacal stage of delusional insanity — i.e., of the pro- 
 gressive systeniatised insanities : in the latter, as we shall see later 
 •on, the reference of the subject is invariably to the environment ; the 
 cause of all his misery is outside, and in lieu of the craving for 
 .sympathy, a hostile feeling is rapidly engendered. 
 
 Occasionally, the morbid ejjigastric 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. 
 
 Another 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 surreptitiously ; yet 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 tendejicies 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 which 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. 
 
 id) Melancholia Ag'itans. — We have referred to delusional forms 
 of melancholia as a deeper reduction than the simple affective form : 
 now such cases of delusional insanity frequently exhibit acute symp- 
 toms* — i.e., restlessness, incessant movement, insufferable anguish, and 
 * Acute in the sense of intensity, not of duration. 
 
MELANCHOLIA AGITANS. 
 
 177 
 
 every indication of an agonised state of mind — these forms of aciUe 
 melancholia are still deeper stages in reduction : they are in every 
 sense an approach to the maniacal reductions. By melancholia agitans, 
 we do not indicate this acuteness or intensity of mental pain, for the 
 actual pain is often far more superficial in character than might at first 
 sight be apparent : but we denote by this term the prevalence of a 
 THOtOP ag"itatioil, which, in like manner, approximates to the 
 maniacal states. Such forms of melancholia may he 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 death. Dr. Fleury recognises the intensity of suicidal pro- 
 clivities, as well as the unfavourable prognosis of agitated melancholia 
 occurring at the climacteric in women ; he also draws attention to the 
 frequent association of such disturbance with drinking propensities.* 
 
 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, 
 picking 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 sobbiug or ejaculations 
 sufficiently expressive of mental distress. Almost invariably the 
 delusive ideas from which she suff"ers 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 
 have occurred as a prelude to this stage of reduction, and in their 
 recall may constitute material for delusive ideas. The hypochondriacal 
 forms which we have just studied may exhibit this state of motor 
 agitation at different periods of its course. Let us take as our illustra- 
 tion of this form of mental depression the following case, where, after 
 an onset of acute melancholic reductions and grave moral perversions, 
 the patient passed into this chronic stage of melancholia agitans : — 
 
 S. A. A., aged 52, and married. The medical certificate runs as follows^ 
 ' ' Will not leave her bed, rocks herself about, moaning and repeating that she is 
 doomed to go to hell. Saj^s she can see the flames of hell before her eyes : that it 
 is of no use eating 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 you all to pieces : all my love is turned to hatred." Here, then, we 
 have a case of acute melancholia, utterly unfitted for home treatment — tortured 
 by hallucinations of the senses, and delusions based thereupon : also by impulses 
 to violence — "I could tear you all to pieces"; and grave moral perversion, as 
 indicated in her confession to her daughter — "All my love is turned to hatred." 
 
 * " Chnical Notes on agitated Melancholia in Women," by Dr. E, L. Fleury, 
 Journ. 0/ Mental Science, July, 1895, p. 548. 
 
 12 
 
178 STATES OF DEPRESSION. 
 
 These impulses, if neglected, would just as readily issue in a suicidal act. They 
 indicate extreme instability of nerve-tissue, and the explosion must occur in some 
 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. She has had considerable anxiety caused her by a drunken husband, who 
 has squandered all his means, and lost much property. A brother of the patient 
 hanged himself. 
 
 The acuteness 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 outburst — in impulses 
 towards self-destruction, &c. ; but, on the other hand, obtain continuous relief 
 in motor agitation and querulous complainings. Tliere is no pent-up energy 
 here as in the case H. T. : it seeks and obtains relief in incessant garrulity. 
 
 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 formulae from frequent repetition. 
 
 We recall one patient, the subject of chronic mania, who would 
 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 which she had 
 poisoned fifteen children with corrosive sublimate : would describe 
 how she deceived the mothers: how she "watched the little brats 
 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 burnt 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 e^ect 
 which they produce on the mind of the observer, their fondne^ss for 
 mimicry, extravagance, and distortion. 
 
STUPOR. 179 
 
 STATES OF MENTAL STUPOR. 
 
 Contents. — Stupor and Dementia — Etiology of Stuporose States — Stupor and 
 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 sus- 
 pension 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, 
 which may be suddenly Pe-initiated under an altered state of things. 
 
 As in cases of dementia, the abolition or impairment of these faculties 
 has often notable accompaniments extending over a wide range of the 
 cerebro-spinal 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 natui'e 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 are 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 
 transient 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, sufficiently indicate the torpor of the perceptive faculties ; with 
 the gradual re-instatement 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 
 
l8o STATES OF MENTAL STUPOR. 
 
 of discharged centres, and find no parallel in states of stupor where the- 
 dormant intellect is shown 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 haa 
 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;" &c., &c. 
 
 (h) Nervous discharges from tracts of unstable cortex, as in 
 epilepsy and general paralysis, lead to mental stupor through exhaus- 
 tion of the centres so discharged : much here depends as to whether 
 the centres feo discharged have few or many sensorial or psychical 
 correlatives. 
 
 (c) Other influences leading to exhaustive expenditure of force- 
 exhaustive drains from the system — e.g., phthisis — the vicious habit 
 of masturbation. 
 
 {d) Acute forms of insanity are prone to be followed by stupor. 
 
 (e) Bromism, in like manner, whilst aflfecting 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 toxsemise have a like effect. 
 
 We must carefully distinguish these forms of stupor from the 
 stupidity induced through obstruction of the nasal passages described 
 as aprosexia nasalis by Gay ; adenoid growths will here cause such 
 obstruction to the lymph flow from the cranium as to induce much 
 heaviness and stupidity, a vacant expression, a wandering gaze, a 
 thick pronunciation, an open mouth from imperfect respiration, and 
 dulness of hearing (Victor Lange).^' The removal of such growths 
 often leads to a rapid and marvellous change in the mental life. 
 
 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, Dr. Carpenter, and more recently 
 Heidenheim, Charcot, and Richer have revealed to us; and which 
 now assume a more intelligible form as the phenomena become investi- 
 * Centralblatt filr Nervenheilkunde, Marz, 1893. 
 
ETIOLOGY OF STUPOROSE STATES. l8l 
 
 gated by strict scientific methods. It appears tliat, in these 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 notable 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 which prevail in the insane exhibit 
 features which at times strongly suggest allied conditions of the 
 cerebrum to those found in the "biolOgised" 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 {Landois),j 
 and in those conditions which pre-eminently favour what are known 
 to be predisposing causes of hypnotic ana 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 subiects, induce the hypnotised state. 
 So, states of mental abstraction, where a monotonous impression or 
 idea is the sole subject of thought, and where other impressions are 
 voluntarily excluded, are conditions which pre-eminently favour states 
 of induced hypnotism and stupor. It will be of interest to mention 
 
 * The earliest symptoms of hypnotism appear as the result of stimulation of the 
 nuclei of the oculo-raotor tract in the mechiUa : there is s^Dasm of accommodation, 
 restricted accommodative range, the;5.r. approaches the 2}-p-: then stimulation of 
 the sympathetic occurs with exophthalmos, widening of palpebral fissure, dilata- 
 tion of pupil, quickened pulse and breathing. 
 
 tLandois and Stirling's Physiology, vol. ii., p. 269. 
 
152 STATES OF MENTAL STUPOR. 
 
 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. 
 
 Mental stupor approximates 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 hand, it does appear that the mind is- 
 often the subject of dominant ideas imposed through external agency, 
 and that the cataleptiform positions which the body and limbs may be 
 made to assume, can be plausibly explained on the principle of sugges- 
 tion through the rmiscular 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 his 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. 
 Closing 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 (Carpenter) ; 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, with two children ; the youngest, 
 an infant, aged nine weeks, was weaned upon the outbreak of mental sj'mptoms 
 six weeks ago. No history of inherited insanity, neuroses, drink, or other 
 vice. The labour had been natural in all particulars. On admission, she had 
 a very vacuous expression : ' ' stared round the room in a vacant manner : was 
 wholly inattentive to what was said, and very rarely spoke. When questioned 
 she usually remained silent, even though the querj' was repeated many times, 
 and efforts were made to rouse her attention ; or she i-epeated the concluding words 
 
MENTAL STUPOR SIMULATING HYPNOTISM. 1 83 
 
 of the question, or the words which she heard uttered by a neighbouring patient." 
 She was emaciated and anaemic ; her pupils widely dilated. The thoracic and 
 abdominal viscera revealed no evidence of disease to physical 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 ammonio-citrate of iron, and 5 minims of liquor strychnise 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 abundantly. 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 amenorrhoea 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 freely converse about her state of health, 
 and was eventually discharged as relieved to the care of her husband. 
 
 In such a case as the foregoing, we see the distinction between simple 
 melancholic depression and the more acute depression often associated 
 with stuporose states : whereas the gentle depression 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 expi-ession of these painful states (melancholia 
 agitans) ; 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 stupidite of French alienists. 
 
 Such patients are often completely dumb — their whole aspect that 
 of intense stupidity; 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 jjatients, who have suffered from melancholy with stupor, 
 have, upon recovery, recorded full details of their mental state : they 
 are generally labouring 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 
 
184 STATES OF MENTAL STUPOR. 
 
 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 rapid, 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 bear in mind this 
 suicidal tendency in stuporose melancholia j it is a constant danger to 
 be feared, and all the more since the apparent stupor is more that of 
 bodily activity, and one is apt to forget that the mental state is often 
 one of intensely acute and painful strain, most liable to explosive 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 stnporose melancholia of long standing : — 
 
 H. T., short of stature, slight in build, and thin, was admitted at the age 
 of twenty-six. She is a married woman, of steady, temperate, industrious habits, 
 and was suffering from her first attack of maniacal excitement, the onset of which 
 occurred a week ago. Xo predisposing or exciting cause could be ascertained for 
 her attack. 
 
 Shortly after admission she became violently excited, and apparenth' in great 
 terror and suspicion of all around. After a short remission of this excited stage, 
 she became depressed, apathetic, and torpid in appearance. 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 catamenia 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 indicative of intense self- 
 abstraction and the prevalence of some delusional idea which dominates her whole 
 life, and which now frequently issues, without any warning, in sudden, irnpidsive, 
 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 
 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, however, occasional gleams of intelligence- 
 transient recognition of her surroundings. She could not be induced to empW 
 herself ; was found one morning in a fixed attitude in the centre of the laundry 
 wash-house, and on being C[uestioned, said she was "at the Midland Station 
 awaiting the down train." She was very pale and anfemic — there was amenorrhcea. 
 She now takes iron and arsenic in mixture : subsequently altered to iron and aloes. 
 
 On June 6, 1883 — She cannot be persuaded to employ herself : still at times 
 
ACUTE DEMENTIA. 1 85 
 
 assumes fantastic, rigid, cataleptic postures, but is not now violent to herself — 
 spasmodic outbursts of temper occur, when she is aggressive and destructive. Her 
 expression now indicates a full appreciation of all that occurs around her, and 
 judging from it, an absence of mental pain. Iron with cantharides and guaiacum 
 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. 
 
 Jtdy 31. — No benefit has resulted from Faradaism : to-day a constant current, 
 from six to eight (Gaifife'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 in her habits, still idle : shows 
 signs of indecency — exposing herself, and on being reproved threatens to slap the 
 ofl&cer in the face. There is wide dilatation of the pupils ; cataleptiform positions 
 are still assumed, and long retained. 
 
 August 9. — Continued improvement : catamenia have occurred naturallj' 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 frequently. No 
 improvement occurred subsequent to that above noted, and in June, 1884, 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. 
 
 Jn other instances, however, the reductions are from the onset so 
 profound that a primary dementia occurs quite suddenly, and this 
 represents the condition usually known as typical acute dementia. 
 Acute primary dementia has been by some confounded with the 
 stuporose form of melancholia — melancholie avec stupeur : by others, 
 with simple stupor, i.e., suspension of the intellectual operations apart 
 from melancholic states, and not one of actual abolition 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, repre.sents the degree of actual 
 
 * In connection with stuporose states. Dr. Whitwell has communicated certain 
 observations 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 appeared in exlenso in the 
 Journal of Mental Science. 
 
1 86 STATES OF MENTAL STUPOR. 
 
 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 find 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 be inclined to predicate. In severe 
 cases of acute dementia no such rousing can be induced, and upon 
 restoration to more active function, the mind of the subject still fails 
 to recall much (if anything at allj that has taken place throughout the 
 attack. 
 
 The following is an interesting case of this primary dementia, 
 occurring in a young girl at the AVest Riding Asylum : — 
 
 A. J., who is now twenty-two years of age, was admitted seven years 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, apoplexy, epilepsy, and 
 phthisis. Patient had never injured her head. Quite recently it was recorded that 
 she had become silent, gloomj-, 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 beheve that she 
 appreciated either spoken or pantomimic language : a sUght inarticulate cry alone 
 escaped her. Facial conformation of low tj^e — expression heavy, torpid. She 
 showed a slight cataleptic fixity of the body and hmbs at times : the Umbs 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 was 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 behaviom: at times. 
 
 In August, 1882, it is noted :— She has become heavy, apathetic, apparently 
 demented ; is negligent in her habits, never speaks, and requires all her bodily 
 wants to be ministered to by others ; she slavers at the mouth, extremities are 
 cold and livid ; catamenia have not occurred for six weeks. Is led about readily 
 and exercised. 
 
 On the nth of September she suddenly spoke to some patients, caUing 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 1883, she had repeated attacks of stupor which were charac- 
 
ACUTE PRIMARY DEMENTIA. 187 
 
 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 
 frequently questioned upon this point. The last attack of the kind occurred on 
 the loth of May, 1885, and her mental faculties did not clear up until the 20th of 
 November, a period of six months. 
 
 In such cases, we do not find the subject prone to sudden, wild 
 outbursts of maniacal or melancholic frenzy, such as we found pre- 
 vailed in stuporose melancholia — to active and desperate attempts at 
 self-destruction, folloived by as sudden a lapse into the stuporose state. 
 The condition of mind is distinct in the two affections : in the one 
 (the melancholic) it is strained and ever prone to explosive outbursts, 
 in the other (the demented) too feeble to initiate any such attempt. 
 
 The 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 completely 
 obliterated, and the mind is a blank to the events of each attack. 
 
 The apathetic passivity of such cases also contrasts strongly 
 with tlie resistance, and often violent struggling, offered by the subject 
 of melancholia cum stupore. The blank, stupid, idiotic stare, and the 
 utterly demented expression, are likewise very different from the aspect 
 presented by the latter affection, where mental tension is very evident 
 in the pained look, which sometimes is varied by gleams of transient 
 ecstasy. Cataleptic fixation of the limbs is a frequent, but by no 
 means invariable, accompaniment 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 
 side." These are the less profound instances of reduction. 
 
 The heart is feeble, and there is great torpor of circulation— the 
 hands and feet being cold and livid to an intense degree. Such 
 
1 88 , STATES OF MENTAL STUPOR. 
 
 patients are utterly negligent in their liabits, they require feeding 
 throughout the attack, and all their wants have to be attended to by 
 others. 
 
 The follovving 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 established, 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 appearance of furunculi or carbuncle, 
 or erysipelas of the head or face. The case in point presents a parallel 
 instance. 
 
 W. S., aged nineteen, a gardener — of strong neurotic inheritance, his father 
 having had repeated attacks of insanity, and his brother being at present an inmate 
 of this asylum — was admitted on the 19th of June, 1885. Upoia 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 
 him with distressed expression, and obstinately reticent. He was a fairly nourished 
 lad — hair bro-\vn, irides greenish, 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 strength, 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 
 nightly. 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 this period he has presented a typical 
 instance of mental stupor, the former melancholic phase liaving quite passed away. 
 He sits in a slovenly stooping attitude, the head bent forwards upon the chest — the 
 legs thrust 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 the head, 
 they long remain so, and are gradually allowed to drop to his side. The whole 
 limb thus gravitates 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, thej' 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 friction, 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 
 
ACUTE PRIMARY DEMENTIA. 189 
 
 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 hsemacytometer and htemoglobinometer, gave 
 the following results : — 
 
 Red Corpuscles. Hasmoglobin. White Corpuscles. Value per Corpuscle. * 
 
 100 per hsemic unit. 68 % to 80 %• '4 per haemic unit. "68 % to "80 7o- 
 
 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 was negligent in his habits : ' ' another patient makes 
 him laugh by imitation." 
 
 This partial relief was, however, attended with loss of flesh, pallor, and debility, 
 and he continued for nearly three months in this condition, occasionally lapsing into 
 more profound stupor. At this 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, 
 bright, chatty, and it was 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 resident but a few months. The blood examined, just prior to his dis- 
 charge from the asylum, gave the following indications : — 
 
 Red Corpuscles. Hemoglobin. White Corpuscles. Value per Corpuscle. 
 
 100 per haemic unit. 90%. -28. 90%. 
 
 * Vorster has observed a frequent increase of the hremoglobin together with a 
 rise in specific gravity of the blood where conditions of venous stasis prevail, and 
 especially in melancholia and apathetic dementia. He regards a percentage of 
 hcemoglobin below 90 in the male, and below 85 in the female, to be of pathological 
 significance. — (Allgemeine Zeitschr. f. Psych., Bd. 1., Heft 3 und 4). 
 
IQO STATES OF EXALTATION. 
 
 STATES OF EXALTATION. 
 
 Contents. — Maniacal Reductions— Failure of Attention— Enfeebled Synthesis — 
 Transient Delusive States — Exalted Sense of Freedom — Impulsive Conduct — 
 Nocturnal Crises — Seclusion Fosters Hallucination — Sexual Illusions— Stadium 
 Melancholicum — Enfeebled Imagination — Bodily Symptoms — Periodicity of 
 Maniacal Phenomena — Acute Delirious Mania. 
 
 Viewed from the clinical aspect, cases of mental depression chiefly 
 impress us 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 terra 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 suppressed. We should, therefore, carefully define 
 to our minds the connotations of these respective terms — exaltation 
 -and depression ; and we shall then learn that the more arbitrary, nar- 
 row, and exclusive our definition, the less readily do we perceive that the 
 one is the converse of the other; and that the freer our definition 
 becomes, so as to embrace all mental operations within its limits, the 
 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. 
 
 Mania is far more prevalent than other forms of insanity amongst 
 the less civilised races of mankind ; thus the percentage of mania 
 amongst the Kafiir race is given at 67, and melancholia is distinctly 
 rare, and not acute (Greenlees). In reference to this interesting fact 
 Dr, Greenlees writes : — " If we consider the theories of those who 
 maintain that while mania represents a loss of the lower developed 
 strata of the mental organism, melancholia indicates an absence of 
 the higher and latest developed strata, then this prevalence of mania 
 amongst natives of low developed brain-functions goes far to prove 
 this theory."* 
 
 *" Insanity amongst the Natives of South Africa," hy T. Duncan Greenlees, 
 Journ. of Mental Science, vol. xli., p. 72. 
 
THE REDUCTIONS OF MANIA. 
 
 191 
 
 In states of mental exaltation, we also trace the same failure in 
 object consciousness, with the corresponding rise in subject conscious- 
 ness, which states of mental depression present, but how different are 
 the features of the two viewed in contrast. 
 
 Here we have in the welling-np of feeling, pleasurable emotions 
 in place of painful states ; a general sense of well-being, exuberant 
 joy, excessive hilarity, 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 gfPeateP depth — 
 the difference is one of decree. 
 
 All maniacal conditions are pre-eminently distinguished by a failure 
 of attention or of the capacity for serial thOUg'ht, and a rise of the 
 purely sensuous in place of the intellectual operations — in fact, the 
 latter are enfeebled, and the emotional elements are aroused ; and, as 
 before indicated in cases of depression, 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 
 cerebral cortex — so here in mania we must recognise an ebb of this 
 cerebral tide, corresponding to the lowered plane of psychical activity ; 
 for the activity which we I'ecognise in the excitement of lower levels 
 is one of disorderly ungoverned 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- 
 
 * Just as the sensitiveness of the retinal field declines progressively from one 
 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 press out of consciousness those obscure faint 
 excitations of the outer field of vision : so with 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. 
 
192 STATES OF EXALTATION. 
 
 tions of a far more abstract nature than is the case with that of 
 association by contiguity, and the same may be said of the latter as 
 contrasted with the process of association by accident or incongruity. 
 It is the more abstract representative processes of association by 
 SimilaPity which are first involved in maniacal reductions — the less 
 abstract presentative-representative processes not being so far involved. 
 This fact explains much of what we observe in the maniac's conduct ; 
 his perceptions 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 by 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-up of clothing and 
 bedding, in the swallowing of garbage, 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- 
 recfulated 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 
 perversions are of a very recoverable nature. As contrasted with 
 the fixed perversions of monomania, Griesinger thus alludes to 
 them : — 
 
 " 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, which certainly ought not to be regarded in an onto- 
 logical sense as ' fragments of monomania,' as phenomena of quite another aflFection 
 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 the soul-life ; 
 
TRANSIENT DELUSIVE STATES. 
 
 193 
 
 they become so confused in their hurry, and pursue each other so rapidly, that 
 they have no time to become fixed or to dwell in the mind." * 
 
 An "over-action on lower planes," as Dr. Hughlings-Jackson would 
 term the state to which we allude, characterises 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 
 movement, 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 i)re- 
 vailing mood. The exuberance of feeling usually expresses itself in 
 goodwill to all mankind — in a universal optimism, which often issues 
 in schemes of philanthropy as impracticable in their nature as they 
 are transient in their duration — in extravagant and ludicrous profiers 
 of patronage to science and arts ; or the mood may vary from this to 
 one of supreme arrogance, in like manner conjured up by the ex- 
 aggerated self- feeling ; and the subject may announce himself to be 
 some mighty personage, and assume a defiant, threatening, or savage 
 aspect. We observe that these reductions in maniacal states bring the 
 
 * Op. ciL, p. 274; see also Theodore KoUe on "Variability in Delusions" — 
 AUgemeijie Zeitachrift fur Psychiatric, Bd. xlix., Heft 1 und 2. 
 
 13 
 
194 STATES OF EXALTATION. 
 
 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. It is this instinctive level to which maniacal 
 reductions attain that characterises the features of mania as contrasted 
 with melancholia ; and, as will be stated later, the prevalent psychoses 
 of earliest childhood (prior to the evolution of higher grades of mental 
 activity) are peculiarly instinctive forms of derangement — mania, not 
 melancholia, and wholly devoid of delusional accompaniments. 
 
 Nocturnal Crises. — The insane are peculiarly liable to be affected 
 by those cyclical conditions which are recognised in the healthy in- 
 dividual, and thus the periods of waste and repair, embraced by the 
 day's labour and 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, boisterous 
 excitement, shouting, singing, incessantly chattering, replying to 
 imagined voices, restlessly wandering about, or beating the doors or 
 shutters of their room. During the day, the association with their 
 fellow-patients, application to their 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 which 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 
 slowly, and the more profound depths are not usually reached for an 
 hour, or even longer ; the reflex excitability of all the nervous centres 
 (spinal also) is reduced — the organic functions are lessened. In these 
 
NOCTURNAL CRISES: HALLUCINATIONS. 1 95 
 
 cases of nocturnal excitement, however, the effect of this periodic lapse 
 of consciousness is to call up more 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 tlie 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 later stages 
 of most cases. 
 
 Hallucinations are not infrequently referred to one side only ; but, 
 more frequently bilateral, they may alternate from side to side 
 {Toulouse); or, being quasi-bilateral, may vary in their character, 
 assuming thus, in auditory hallucinations, a hostile, threatening, 
 abusive tone on one side — a consolatory, cheering tone on the oppo- 
 site side {Magnan). These antagonistic hallucinations are of extreme 
 interest. In 39 cases of unilateral hallucinations observed by Toulouse,* 
 hearing was involved in 26, sight in 7, sight and hearing in 4, sight 
 and touch in 1, and in one other case touch was also afiected. Of the 
 26 unilateral hallucinations of hearing 23 were strictly unilateral, 
 1 case alternated from side to side, and in 2 others the bilateral anta- 
 gonistic features alluded to above were evident. It is a well-known 
 fact that unilateral hallucinations of hearing may appear in focal 
 hemispheric lesions. Thus, in an epileptic subject with right brachio- 
 facial paralysis, aphasia and lateral homonymous hemiopia, and, on 
 another occasion, associated with loss of sensibility, there was the 
 accompaniment of auditory hallucinations on the right side {Pick).\ 
 Unilateral hallucinations of hearing and, vaguely, also of sight occurred 
 
 * Gaz. d. H6p., May and June, 1892. 
 
 + Neurologisches Centralblatt, No. 11, 1892. 
 
196 STATES OF EXALTATION. 
 
 in a case of alcoholism, where Jacksonian epilepsy (with other symp- 
 toms indicating focal lesion of the right hemisphere) existed — the 
 auditory hallucinations being restricted to the left side.* 
 
 In many, the hallucinatory phenomena are recognised by the patient 
 as having no real objective origin, and yet 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 rec;;r, 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. 
 
 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 unrefreshed, 
 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 depression, 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 
 melancholieum 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 symptoms 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 
 
 * Toulouse, loc. cit. 
 
MANIACAL REDUCTIONS. 1 97 
 
 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 unexpectedly, comes a marked 
 transformation, signalising the maniacal reduction. The gloom and 
 despondency appear to be lifted off — 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, flow 
 in unlicensed freedom and in unwonted rapidity, reproducing the 
 symptoms of early alcoholic intoxication. The patient is garrulous — 
 obtrusively so : talks about his own affairs ; 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 memory fairly intact, or partially obscured, 
 upon events occurring during his maniacal attack; his attention is 
 commauded 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 renders 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 seriality of thought 
 becomes impossible. Every degree of incoherence may thus present 
 itself, from the mildest occasional rambling, to utter incoherence, 
 where speech is quite unintelligible, as in the deepest reductions 
 of typho-mania or acute delirions-mania. The 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 maniacal 
 subject is not imaginative, in the proper sense of the term; at times 
 
198 STATES OF EXALTATION. 
 
 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. Jiidgment may be perverted upon 
 certain points, but is just as frequently unaffected ; 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 
 tumult of ideas occurring with the emotional background of exaggerated 
 well-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. R. L., aged twenty-one, single, by occupation a dyer. A young man of 
 moderate height, muscular, pale, and ansemic, 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 
 maniacal excitement, shouting aloud, singing, laughing, and gesticulating franti- 
 cally. At first 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 grandiose 
 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 par- 
 ticulars. 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 
 
BODILY SYMPTOMS IN MANIA. 199 
 
 announces himself as General Gordon — at another he is Sir Garnet Wolseley, and 
 by tone and gesture assumes a military bearing. These rapidly varying delusional 
 states, 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 was 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, affirming that he believed him- 
 self, throughout the attack, to be some great personage with military functions. 
 
 The exuberant swell of feeling, and the torrent of disconnected ideas, 
 may express themselves in continuous garrulity, in noisy chattering, 
 in threatening and abusive tones, in laughter, singing, or loud shout- 
 ing, with corresponding 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. 
 
 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 
 lights up the flame afresh. These intervals of depression are in nowise 
 difierent from the melancholic states ; in fact, it is but a step from the 
 maniacal to the melancholic stage. At this instinctive level, the 
 patient instantly reacts 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 us, the rapid turn 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 — tlie great majority 
 of maniacal subjects undoubtedly exhibit marked pallor o/l/ieface — the 
 skin generally being also of yellowish tinge, unctuous feel, and foul 
 
200 STATES OF EXALTATION. 
 
 odour. The pulse is small, somewhat frequent, and the heart's sounds 
 are often muffled, 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. Clifford Allbuttf that the optiC disC iS angemic, becoming, 
 in a few days subsequent to the attack, suffused and obscure. 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 
 assuming a pinched appearance, the features are sharpened, a dark 
 areola surrounds the eyes, the eyeballs are sunken, yet restlessly 
 active and mobile. The re-instatement 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 excite- 
 ment, the body temperature is apyrexial and normal. 
 
 Periodicity. — During the course of maniacal 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 diurnal 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 " bad 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 proper 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 periodicity 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 in- 
 curred. 
 
 * Op. cit., p. 288. 
 
 t The Ophthalmoscope in Diseases of the Nervous System, Dr. AUbutt's observa- 
 tions are based upon the examination of as many as fifty-one cases of mania at the 
 West Riding Asyhim. 
 
PROGNOSIS OF MANIA. 20I 
 
 ProgTlOSiS. — Acute mania occasionally proves fatal ; the explana- 
 tion of such an untoward event is the presence of some intercurrent 
 affection such as pneumonia, the exhaustion of phthisis, or the associa- 
 tion with septicaemia, as in certain forms of puerperal mania. In fact, 
 puerperal mania occurring as the sequel to exhausting hpemorrhages — 
 ante or post partum — is a very grave affection and not unlikely to issue 
 in a fatal termination. If we exclude the mania symptomatic of 
 epilepsy, general paralysis, and alcoholic insanity, we may state that 
 simple uncomplicated acute mania is a remarkably recoverable affection.* 
 Exceptions, however, occur even in uncomplicated mania, where, from 
 the neglect of early and judicious treatment in greatly debilitated 
 subjects, death ensues. 
 
 Far more frequent than a fatal termination is the establishment of 
 chronic mania, in which a permanent mental enfeeblement results, 
 associated with recurrent attacks of excitement. Especially ominous 
 of this termination is the return of physical health and vigour, the 
 re-establishment of the nutritive functions, the tendency to enbonpoinf, 
 or actual obesity in some cases, with no corresponding improvement in 
 the mental state, but persistence of the maniacal reductions, and a 
 general mental enfeeblement. States of mental enfeeblement including 
 chronic mania, consecutive dementia, and the monomaniacal per- 
 versions represent the several modes of unfavourable termination 
 when recovery does not ensue. The mode of recovery varies much in 
 individual cases ; it ma}' be abrupt — so abrupt that in the course of 
 twenty-four hours the patient may emerge from a state of acute excite- 
 ment into one of coherence and perfect calm, with, it may be, a slight 
 confusion alone recognisable ; such terminations are not desirable, and 
 almost certainly issue in relapse which may recur over and over again 
 ere permanent recovery is ensured.! The more reliable process is a 
 steady return to former levels of mental life ; a process of gradual 
 evolution, broken, it may be, by slight reductions in which excitement 
 temporarily increased invariably leads to subsequent stages of clearer 
 consciousness — a process in itself both instructive and reassuring. 
 Savage affirms that the more prolonged the initial melancholic stage, 
 the longer is the second stage of excitement likely to be ; the longer 
 these two, the less hopeful the prognosis ; and the greater the amount 
 of excitement, the greater is the tendency for the patient to pass into a 
 condition of depi'ession afterwai-ds. 
 
 * Reference to the table of results on p. 221 will illustrate this fact, bearing in 
 mind that the percentage of deaths in acute mania (13'4) includes uncomplicated 
 as well as all complicated cases. 
 
 tSuch abrupt terminations of maniacal excitement are apt to take place on 
 the occurrence of some acute bodily affection — e.fj , pneumonia, erysipelas, the 
 appearance of carbuncles or boils — by some regarded as suggestive for a derivative 
 system of treatment. 
 
202 STATES OF EXALTATION. 
 
 Age is a factor of much importance as regards the question of 
 recovery ; the younger the subject, the more likely is he to recover. 
 We do not even, exclude the mania of adolescent insanity here — so far 
 as it relates to the female sex ; but, should the psychosis characteristic 
 of adolescent insanity occur in the male, the prognosis is far more 
 unfavourable.* So, likewise, for recurrent mania — each occurrence 
 serves but to re-establish a still greater tendency to maniacal out- 
 bursts, the attacks becoming more frequent, the intervals shorter, and 
 the enfeeblement of mind steadily progressing.! 
 
 Acute Delirious Mania. — This, the delire aigu of French 
 
 ■writers, represents the most profound maniacal reductions which 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 predisposition 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 
 smd frequency of a fatal termination. It is quite exceptional for a case 
 of acute mania to prove fatal ; in fact, unless the indi^ddual is much 
 debilitated prior to the attack — suffering from some exhausting ailment, 
 such as phthisis — or when it is the sequel of exhausting haemorrhages, 
 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 
 must be given. The tongue is dry and brown ; the lips and teeth 
 become covered with sordes ; food is often most peristently refused, 
 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 may 
 pass involuntarily, as do the stools. If intelligently-directed treatment 
 
 * See under Insanity of Puhtrty and Adolescence. t Cf. p. 250. 
 
ACUTE DELIRIOUS MANIA. 203 
 
 be not early adopted, a rapidly fatal termination ensues ; and even 
 under the most favourable circumstances, the struggle to bring the 
 patient safely through the storm is an anxious and prolonged 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 suffered from mental derangement some four 
 years ago, attributed by her friends to her son's running away from his home ; 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 very small 
 and feeble. There was extreme anaemia — 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 had 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 incolierent. 
 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 iron and quinine, his die. Two days subsequent to admis- 
 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 
 reply coherently ; compulsory feeding has still to be resorted to." The folio-wing 
 day it is stated that — "Patient was more than usually excited again last night, 
 repeatedly sprang out of bed, and jumped into the patients' beds. Slept one 
 hour after two ounces of stimulant. She remained sleepless and wild all night, 
 despite a sedative then given. Has taken her food for the first time voluntaril}'." 
 
 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 hardl}' 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 qiute 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, thiclvcned, and the swelling 
 hard and tense ; the left eye is completely closed by great ojdema of the Uds ; 
 temperature has fallen from 102' to 100', pulse 108. There is considerable 
 
204 STATES OF EXALTATION. 
 
 tumefaction of the left tonsil. Suppuration occurred in the swollen part, and dis- 
 charge took place from the external meatiis 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 Adolently assaulted his wife and threatened her life. His mental distvirbance 
 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 worked 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 Relieving-ofhcer 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 extremely 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 continuoiis snatches with 
 his hands as though to grasp imaginary objects, and lay muttering utterly inco- 
 herent gibberish. There were much tremor of the limbs, and muscular jerkings 
 generally. Patient's consciousness was so far obscured that he failed to appreciate 
 the purport of anything said or done for him. Paraldehyde (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, 
 owing to his resolute resistance and terrified state of mind. He was pale, pinched, 
 and haggard, and continually restless through the next day, requiring regular 
 catheterism, a normal amount of iirine being each time withdrawn. The following 
 night he obtained no sleep, tossing about restlessly, and muttei'ing 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 ; but 
 he died the following day from cardiac failure. 
 
PARTIAL DENUDATIONS : DEVELOPMENTAL DEFECTS. 205 
 
 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— Eelief of Mental Tension— Illustrative Cases— Suicide in Homicidal 
 Subjects— Etiology— Effect of Physiological Cycles— Epilepsy— Masked Epilejisy 
 —Alcohol and Impulsive Insanity- The Mimetic Tendency— Suicidal Impulse- 
 Kleptomania — Dipsomania— Erotomania— Imperative Obsessions. 
 
 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 so uniform 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 premature 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 the diseased 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 altogether reduced to the mental state of childhood— a ;)/ms or 
 minus quantity ever prevents an exact parallel being drawn, so that 
 we readily distinguish such anomalous reductions from the results of 
 a uniform 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 infontile 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 record of the slow 
 progressive superposition of controlling centres. Normal 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 partial denu- 
 dations — so here, in the progress of mental evolution, we meet with 
 developmental phases of a monstrous character, presenting, not the 
 
2o6 THE FULMINATING PSYCHOSES. 
 
 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 ; 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 more readily find their parallel in the various 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 effects 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. Olouston 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 hypertesthetic 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 
 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 
 degree 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 the 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. 
 
 * Op. cit., p. 311. 
 
IMPULSIVE AND MORAL INSANITY. 207 
 
 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 affections in which the chief, nay, the sole discoverable feature 
 is this failure of inhibition exhibited in ungovernable, sudden impulse, 
 and in entirely unrestrained conduct, whilst the intellectual and 
 emotional spheres remain wholly or only in part unaffected. 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 doubted the existence of pure insane im- 
 pulse apart from intellectual flaw or delusion ; and many authorities 
 of repute 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 terrible malady, and painted its distinctive 
 features in no 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 upon 
 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 an 
 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, 
 
2o8 THE FULMINATING PSYCHOSES. 
 
 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 
 consequences 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 
 dec^rees 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 into 
 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 emphasises 
 — that alternations of pure imjndsive insanity and forms y^ 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 mOtlveleSS 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 upon this fact. Suddenly, amidst, 
 it mav be, the pleasures of the family circle, or at the moment of 
 devotional exercise, to the intense horror of the subject, the morbid 
 feeling suggests itself without any obvious provocation (like a phantom 
 demon), and requires all his efforts to dispel 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 
 wronc motive to an insane impulse, influenced by accidental circum- 
 stances in w^hich the subject happens to be placed. The motiveless 
 nature of the morbid impulse is forcibly illustrated by cases in which 
 * See, on this point, Drs. Bucknill and Tuke, op. cit. , p. 268. 
 
THE EPIGASTRIC AURA AND HOMICIDAL IMPULSE. 209 
 
 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 moibid 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 aUPa 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 are 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 {Taylor ■\), 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 of 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 
 impulse. In certain other cases a definite hallucination of the special 
 senses may be the 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 Marc, seems to indicate the repression of the impulse by the 
 arresting of the aura : — 
 
 "Mr. R., a distinguished chemist and poet, of a naturally mild and sociable 
 disposition, placed himself under restraint in one of the mainon-i de santi of the 
 Faubourg St. Antoine. Tormented with an homicidal impulse, he prostrated 
 himself 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 reqiiested him to tie his thumbs togetlier with a ribbon. 
 This slight ligatiu-e was sufficient to calm the unhappy R., who subsequently 
 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 
 
 * See in this connection an instructive case of homicidal and suicidal insanity 
 recorded by Dr. Frank A. Elkins, Edin. Med. Joum., 1890. 
 t Med. Jurisprudence, vol. ii., p. 553. 
 
 14 
 
2IO THE FULMINATING PSYCHOSES. 
 
 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 up 
 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 appetite of carnivora for food, which rises to fury when 
 the flesh is scented out and begins to be tasted." + 
 
 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 suflPused, 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. 
 
 In connection with outbursts of homicidal frenzy the Amok of the 
 Malays affords instructive parallels amongst lower states of civilisa- 
 tion. Suicide amongst the Malays, it appears, is extremely rare 
 {Ellis), but the paroxysms of murderous frenzy known as " running 
 amuck," appear clearly to be associated with a sub-conscious auto- 
 matic mental state, as in genuine epileptic and alcoholic automatism, 
 the agent being left wholly oblivious to his murderous deeds, 
 "Amoks result from an idiosyncrasy or peculiar temperament com- 
 mon amongst Malays, a temperament which all who have had 
 intercourse with them must have observed, although they cannot 
 account for or thoroughly understand it. It consists in a proneness 
 to chronic disease of feeling, resulting from want of moral elasticity, 
 which leaves the mind a prey to the pain of grief, until it is filled with 
 a malignant gloom and despair, and the whole horizon of existence is 
 overcast with blackness. . . . These cases require discrimination 
 on the part of the medical jurist to prevent irresponsible persona 
 suffering the penalty of the injured law." {Dr. Oxley, quoted by 
 Gilmore Ellis.) 
 
 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 Pinel quoted in Dr. Maudsley's Responsibility in Mental Disease, 
 p. 141. 
 
 t The Senses and the Intellect, Alex. Bain, pp. 126 and 253. 
 
CASE OF REG. V. MOUNTAIN. 2 1 I 
 
 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 afforded by the accomplishment of the act, or 
 
 the dissipation of the morbid energy in other 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 d^o^^^l 
 herself, as the result of imperative feelings distinctly arising from the group of 
 organic sensations. The unfortunate subject of such ancestral frailty had alwaj's 
 been timid and unnaturally suspicious ; but no decided delusional phase had 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 agon}' 
 of mind without success for years. They were increasing in intensitj', and to 
 add 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 
 produced grave mental disturbance, characterised bj^ pei'sistent delusions of 
 persecution and errors of identity. On two occasions he suffered from genuine 
 
 * Op. cit., p. 156. 
 
2 12 THE FULMINATING PSYCHOSES. 
 
 attacks of maniacal excitement, but of transient duration only. As a natural 
 result of these intemperate habits, his former symptoms became further intensified ; 
 yet, up to the evening of the murder (except when under the influence of driak), 
 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 
 together, 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 who 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 
 often years. See a notable case recorded by Dr. Tuke.* 
 
 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 
 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 usually one of complete 
 relief from anxiety, and utter indifference to the enormity of his crime ; 
 frequently 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 
 * Psychological Medicine, 1874, p. 268. 
 
ETIOLOGY OF IMPULSIVE INSANITY. 2 I 3 
 
 the time, and bis subsequent behaviour, might almost have been 
 regarded 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 far impaired as to issue in 
 forgetfulness of the details of the homicidal act. When such is the 
 case — when any marked obscuration of memory is apparent — we may 
 presume the impulse to have been of epileptic origin, or to be the 
 outcome of alcoholic delirium. 
 
 Etiolog'y. — In all these cases of pure impulsive insanity there is, 
 we believe, a well-established basis of a neurotic heritage, and if the 
 individual's history is scrutinised with suflB,cient care, we are assured 
 that evidence of mental 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 pxierfcral period during lactation, and asso- 
 ciated with the various forms of menstrual clerangem,ent. Several 
 instances are on record where the revolutionary epoch of puberty 
 has aroused the homicidal feelings in youth, as in the case of Margaret 
 Messenger, aged thirteen years, who killed her brother and drowned 
 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 E,eg. 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 
 restrain 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 kniiwn, renders 
 * Quoted in Taylor's Medical Jurisprudence, vol. ii., p. 564. 
 
214 T-S^ FULMINATING PSYCHOSES. 
 
 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 ; 
 
 (b) In the so-called "epilepsia larvata" [Morel), 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 
 Insanity ; 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- 
 sional state, with which it has often a direct connection (see case of 
 Reg. V. Taylor, see Alcoholic Insanity); 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 
 oi E.G., see Epildptic Insanity) — 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 dui'ation, 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 
 homicidal 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 
 murderous 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 
 
ETIOLOGY OF IMPULSIVE INSANITY. 215 
 
 a semi-unconscious automatic state of mind. It is astonishing how 
 complicated may be the acts perfoi'med 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 
 without any object, but also without any accident."* 
 
 The Amok of the Malays already referred to (p. 210) is attributed, 
 most plausibly, by Gilmore Ellis to masked epilepsy — alcoholic 
 reductions being wholly out of question in view of the great aversion 
 of the whole race to alcohol, f 
 
 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 (without any motive or malice) any one 
 with 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 effects 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)|, in which a 
 mad impulse to murder prevails, may thus be induced by what is 
 usually considered by no means immoderate drinking. The symptoms, 
 however, embrace much mental confusion, and the subject 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 
 
 * Diseases of the Nervous System, vol. ii., p. 69L 
 
 t See a most instructive article with cases on " The Amok of the Malays," by 
 W. Gilmore Ellis, M.D., Singapore, Journ. oj Mental Science, July, 1893. 
 
 X Maudsley is undoubtedly correct in asserting that many cases of mania 
 transitoria are really instances of "mental epilepsy." — Op. cit., p. 230. 
 
 § On the subject of mania transitoria Maudsley 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 are some cases in which there is no 
 evidence of epilepsy in any of its forms to be found ; but it may well be doubted 
 whether a distinct insane neurosis is not always present in these cases. With 
 such a constitutional predisposition, a genuine attack of acute insanity, 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 
 perpetrated. 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 efifect of alcoholic intemperance 
 upon a person strongly predisposed to insanity, or upon one whom a former attack 
 
2l6 THE FULMINATING PSYCHOSES. 
 
 fail to note the vicious agency of imitation which was originally 
 emphasised by Esquirol, as one of the causes of this aflfection. 
 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 startling crime. 
 
 The Suicidal Impulse. — What we have said respecting the 
 homicidal impulse applies in most particulars 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 far, that 
 they, recognising the horror of their situation, and the unnatural 
 character of the morbid promptings, revolt against the perpetration 
 of the act. Like the homicide, they may implore protection, and 
 voluntarily resign themselves to asylum supervision, dreading lest 
 they may be overmastered by 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 ordinary suicidal tendency of 
 simple melancholia, where the morbid depression precedes and ex- 
 plains the negative suicidal state ; but the condition where, from the 
 first, the suicidal propensity presents itself, any depression being 
 secondary, and induced by the patient's helpless condition. The 
 climacteric epoch not unfrequently develops this impulsive form of 
 insanity just as it does homicidal states ; and a good illustrative case 
 is detailed further on in our study of the insanity prevailing at this 
 
 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 effect 
 may be produced by powerful moral causes, sexual excitement, and other 
 recognised causes of insanity." {Re-sponsihility in Mental Disease, p. 247.) 
 
THE SUICIDAL IMPULSE : KLEPTOMANIA. 2 I 7 
 
 period of life (see case of *S'. IJ.). Winslow records 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 pui'sues me, impelling me to self-destruction. My wife, 
 friends, and children observe my listlessness and perceive my despon- 
 dency, but they know nothing of the worm that is gnawing within."*' 
 The morbid impulses to which the insane are prone are as diverse 
 as are the active tendencies of the mind itself; but many manifesta- 
 tions of an instinctive character, on account of their obtrusive and 
 criminal nature, have claimed special attention, and have been exalted 
 by some authorities into distinct foi'ms of insanity ; whereas, in 
 truth, they should be merely regarded as symptoms or a group of 
 symptoms (syndPOmes) which may occur in any form of insanity, 
 and which, in particular, characterise the raeutnl alienations of the 
 
 degenerate. Such are cases of kleptomania, pypomania, dipso- 
 mania, and erotomania, or the impulse towards theft, incendiarism, 
 drunkenness, and sexual outrage. A few remarks on these so-called 
 obsessions may deserve a place here. 
 
 Kleptomania. — The essential character of this condition is, like 
 that of all morbid, instinctive acts, more or less incontrollable, despite 
 any resistance to its perpetration the subject may exert. It is not a 
 mere propensity towards thievish acts, such as characterise so many 
 forms of insanity ; but, the idea of possessing what is not rightfully 
 theirs, attended often by great anxiety and terror lest control be lost, 
 becomes in itself the originating factor which determines the theft. 
 The painful feeling preceding the crime vividly portrays the lack of 
 control and the cruel helplessness of the victim, the intensity of the 
 idea being the immediate precursor of the impulsive act. In general 
 paralysis, the early stages are often characterised by thievish pro- 
 pensities, but the nature of the act is wholly different ; the stupidity 
 and awkwardness of the deed are in themselves sufficiently indicative 
 of its being the outcome of dementia, just as are the other moral 
 lapses which appear in this disease (p. 287). In other forms of 
 dementia and imbecility, and in the confusional reductions of epileptic 
 insanity, the thievish act can usually be at once distinguished from 
 the impulses of the kleptomaniac ; yet, in epilepsy the genuine con- 
 dition may also be revealed. In the latter case, it may be an indica- 
 tion of transient reduction, in which, higher controlling centres being 
 in abeyance, the morbid propensity springs irresistibly into activity ; 
 or it may be the outcome of permanent moral lapse from the continued 
 progressive denudation of this disease. 
 
 What is all important for us to realise is the fact that just as by 
 diseased processes (epilepsy), by toxic agencies (alcohol), or again, by 
 * Obscure Diseases of the Brain, p. 260. 
 
2l8 THE FULMINATING PSYCHOSES. 
 
 functional excesses (sexual), the volitional control is so paralysed, as 
 to admit of over-action throughout the whole gamut of morbid pro- 
 pensities, so also in the degenerate organism, where inhibitory centres 
 have always been of rudimentary development, any of these pseudo- 
 moral lapses may betray themselves as genuine convulsive or impulsive 
 acts. Kleptomania has been affirmed to be a frequent accompaniment 
 of menstrual derangement and the late pregnant state. 
 
 Dipsomania. — The same features pertain to this condition ; there 
 is an all-powerful, irresistible tendency to drink, which appears after 
 a more or less mental depression, vague sense of impending evil, and 
 a general functional disturbance ; it shows a paroxysmal or inter- 
 mittent nature, and the debauch, often leading to the greatest excesses 
 in other directions, is often followed by a keen sense of shame and 
 penitence, and also by an utter indifference or distaste for stimulants 
 in the interval. Its rhythmic or paroxysmal recurrence appears to 
 indicate nutritional anomalies as the basis for the morbid syndrome, 
 and, in most cases, there is undoubted evidence forthcoming of a 
 neurotic taint. In all cases the phenomena are alike ; first, the 
 obsession or idea of drink 3 then the anguish aroused by the sense of 
 volitional impotence ; and lastly, the incontrollable impulse to drink, 
 leading often to the most immoral, degrading, and vicious conduct to 
 secure the intoxicant. In the facts that the taste for drink does not 
 first occur, that, indeed, the victim often does not care for drink for its 
 own sake, and that alcoholism does not usually lead to this disease, we 
 at once perceive the distinction from ordinary cases of drunkenness. 
 The essential features are, in short, the impotence of will before a 
 cruel obsession, the short but painful struggle to resist, the impulsive 
 outbreak, a morbid syndrome occurring in a degenerate subject whose 
 inheritance has probably revealed itself throughout life in mental 
 instability, in general want of balance, and in the features which 
 notably present themselves in all forms of the explosive psychoses. 
 
 Erotomania. — The same remarks apply almost in every particular 
 to conditions of erotomania, which embraces so-called "satyriasis" 
 and "nymphomania," terms applied to the erotic impulses occurring 
 respectively in the male and female subject. Satyriasis appears 
 occasionally after epileptic discharges, claiming on this account special 
 attention at the hands of the medico-jurist. Instances of perverted 
 sexuality, again, often include cases of true impulsive insanity, but 
 the whole subject has received such special attention from Continental 
 writers that the reader may be referred to the voluminous works of 
 Lombroso, Krafft-Ebing, Caspar, and others for further particulars. 
 
 Obsessions, Imperative or Dominant Ideas.— When any one 
 
 idea or group of ideas invade the mind automatically to the exclusion 
 of others, despite the effort of the will to suppress or eliminate the 
 
OBSESSIONS, IMPERATIVE OR DOMINANT IDEAS. 219 
 
 same, we speak of it as a dominant or imperative idea — an obsession. 
 Such obsession may alone present itself, as an isolated fact, but it is 
 usually the initial stage preceding irresistible imjndse. 
 
 The effective capacity of the will rises and falls with the resistance 
 presented to it — e.g., with the vividness of the idea to be suppressed ; 
 and we are well acquainted with conditions where the morbid vivid- 
 ness of the idea is such that the will is powerless to inhibit, although 
 exercising its normal energy. In such a case, we cannot speak of the 
 morbid syndrome of obsession and impulse as due to enfeeblement or 
 disease of the will, but rather to an. overpowering morbid tendency 
 wholly disproportionate to the normal volitional activities of the 
 subject. Obsession, or imperative ideas become, in this sense, a 
 sort of mental monstrosity, and must be clearly distinguished from 
 such phenomena as epileptic impulse, where genuine reductions have 
 removed volitional control, with the result that instinstive actions 
 spring instantly into life. 
 
 Such painful obsessions are usually found in the subjectsof a neurotic 
 heritage — ancestral epilepsy, alcoholism, insanity or crime being most 
 frequently traced. The degenerate offspring of a neuropathic stock 
 becomes still more subject to such obsessions by agencies which tend 
 to reduce the volitional control — alcoholic and sexual excesses in 
 particular:. The frequent and persistent dii-ection of the attention to 
 certain morbid ideas will also tend in the degenerate to establish such 
 obsessions, and favour their relief by the corresponding impulsive act. 
 There is little doubt but that the moi'bid and repulsive sensationalism 
 of our Assize Courts, thronged as they are by unstable and degenerate 
 individuals, largely fosters the tendency to the development of obses- 
 sions and the fulminating psychoses, through misdirected imagination. 
 
 Amongst those most generally met with are the obsessions of fear 
 and indecision. The fear may pertain to any person, place, object or 
 relationship ; the category of the things feared being limited only by 
 the possibilities of existence. This morbid dread, however, pertains 
 nearly uniformly to some definite object, and the innumerable terms 
 invented to designate these mental states illustrate forcibly the absur- 
 dity of attempting the symptomatological classification of such mental 
 manifestations. A fear of pollution by places and things ; a fear of 
 closed or open spaces ; a dread of certain animals ; of the sight of blood, 
 knives, poisons, explosives — are some of the more common, but the list 
 might be almost indefinitely extended. 
 
 The obsession of doubt again resembles that of fear, having as its 
 basis an utter distrust of self ; e.g., there may be a tendency to review 
 incessantly over and over again one's own actions ; to repeat again 
 and again numerical calculations; to interpose repeatedly an incon- 
 gruous and wholly irrelevant word or phrase in the course of conver- 
 
2 20 STATES OF MENTAL ENFEEBLEMENT. 
 
 sation ; or to enumerate over and over objects lying before his gaze. 
 One notable case known to the writer would present herself a dozen 
 times a day at a railway station, but never could persuade herself to 
 undertake the short jouruey intended; in this case complete recovery 
 was secured. 
 
 Closely allied to the foregoing are the states where there is inability 
 to rise, to walk, or to sit down (astasia, abasia), and which have been 
 closely studied by Continental writers in hysteric subjects. In these 
 conditions, the will does not fail in its inhibitory capacity, as in 
 restraining a morbid impulse, but it fails to initiate the action desired; 
 such states are known as "aboulias," or "aboulic obsessions." 
 
 STATES OF MENTAL ENFEEBLEMENT. 
 
 Contents. — Mental Deprivation in Contradistinction to Developmental Arrest — 
 Persistent Enfeeblement — Chronic Residue of Asylum Communities — Recover- 
 ability of Maniacal and Melancholic Forms — Consecutive Dementia — Delusional 
 Insanity — Genesis of Monomaniacal States — Environmental Resistance — Trans- 
 . formation Completed — Mystic Symbolism —Illustrative Cases of Delusional 
 Insanity — Monomania of Pride (J.O., E.T.) — Religious Monomania (J.B.) — 
 Monomania of Persecution — Progressive Systematised Insanity (Paranoia) — 
 Primary Implication — Systematisation — Neuropathic Basis — Secondary Syste- 
 matised States — Typical Psycho-Xeurotic Form — FoUe li deux. 
 
 Amongst states of mental enfeeblement are comprised numerous 
 widely different groups, which constitute the large bulk of our 
 a,sylum communities, and in which the mental ailment differs in its 
 mode of origin, essential nature, and the characteristic features 
 presented. The term mental " enfeeblement " is perhaps the least 
 objectionable which we may employ for the various 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— i.e., states of acquired defect, 
 
 whilst congenital and developmental arrest would be more appropri- 
 ately considered under a distinct category. Idiocy and imbecility would, 
 therefore, be excluded from this class, which would, however, comprise 
 the various forms of monomania, of chronic mania, and dementia. 
 
 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, whether jirimary or con- 
 secutive in their origin. In fact, we comprise under it the incurable 
 terminations of acute insanity — the chronic insane residue which 
 
TRANSIENT AND PERSISTENT ENFEEBLEMENT. 
 
 221 
 
 remains, as wrecks remain after the storm ; also, such cases of per- 
 manent enfeeblement, as are oiot preceded by acute mental symptoms, 
 e.g., the "primary dementia" of organic disease of the brain — from 
 morbid growth, apoplectic foci, and cerebral ramollisement — and the 
 dementia of senile atrophy. Under the 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. 
 
 
 
 
 Percentage. 
 
 
 Number 
 of 
 
 Form of Mental Disease. 
 
 
 
 
 
 
 
 
 
 Cases. 
 
 
 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 
 
 9-0 
 
 12-0 
 
 46 
 
 Chronic, 
 
 
 13 
 
 36-9 
 
 50-0 
 
 237 
 
 Delusional, . 
 
 37'-0 
 
 130 
 
 18-5 
 
 31 
 
 85 
 
 Recurrent, . 
 
 57-6 
 
 82 
 
 140 
 
 20-0 
 
 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 
 
 5-8 
 
 15-6 
 
 299 
 
 Delusional, . 
 
 55-5 
 
 14-0 
 
 143 
 
 16-0 
 
 16 
 
 Recurrent, . 
 
 50-0 
 
 12-5 
 
 12-5 
 
 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 
 
 7-6 
 
 33 
 
 Organic, . 
 
 9 
 
 54-0 
 
 30-0 
 
 6-0 
 
 121 
 
 Epilepsy, 
 
 11-5 
 
 26-4 
 
 23-0 
 
 38-8 
 
 .74 
 
 General Paralysis, 
 
 
 72-9 
 
 21-6 
 
 5-4 
 
 82 
 
 Imbecility, .... 
 
 
 17-0 
 
 51-3 
 
 30-7 
 
 13 
 
 Idiocy, 
 
 
 38-4 
 
 15-3 
 
 45-9 
 
 18 
 
 Chronic Cerebral Atrophy, 
 
 
 77-7 
 
 22-0 
 
 1 
 
 1809 
 
 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, will serve to indicate whence our chronic insane 
 inmates are chiefly derived. 
 
 In the Table it will be observed that a large proportion of 
 maniacal and melancholy patients are discharged " relieved," and this 
 class comprises a number of permanently 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- 
 
22 2 STATES OF MENTAL ENFEEBLEMENT. 
 
 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 enfeeblement, result- 
 ino- 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 
 Recovered. 
 
 Died. 
 
 " Relieved." 
 
 Chronic 
 Remainder. 
 
 Maniacal forms. 
 
 . 53-2 
 
 11-9 
 
 14-0 
 
 20-6 
 
 Melancholic ,, 
 
 . 57-1 
 
 14-8 
 
 12-9 
 
 150 
 
 The more unfavourable character 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 
 such 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 enfeeblement of mind, 
 a complete change in the 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 
 
DELUSIONAL INSANITY. 
 
 223 
 
 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 emplov 
 themselves at the simplest manual labour. They will stand about for 
 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 are 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 
 difTerent 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. 
 
 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 
 presenting 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 indifi'erentism 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 
 * Op. cit., pp. 340-345. 
 
224 
 
 STATES OF MENTAL ENFEEBLEMENT. 
 
 states of monomania. Monomania as a morbid entity must be re- 
 garded as a state evolved out o/ melancholic and maniacal perversions — 
 as a special derivative of these conditions, and as one of the termina- 
 tions in chronic insanity. It can be studied to the greatest 
 advantage in association with the preceding 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 rapidity 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 
 chases 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 going on within. We speak 
 occasionally, but incorrectly, of such cases as instances of suppressed 
 mania — there is no mental tension, but complete relief in the active 
 ideational process. Monomaniacal states are essentially those where 
 the rise in subject-consciousness does not tend to escape in outward 
 action, but rather to find relief in forms of perverted ideation ; and 
 herein 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 \)siq\x fixity. They 
 rise more definitely and vaore forcibly 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 
 
MONOMANIACAL PERVERSIONS. 225 
 
 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 affections, 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 affection 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-sufficiency of the new 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 
 opposition offered to their delusive uttei-ances 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 
 symbolism 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 
 
 15 
 
2 26 STATES OF MENTAL ENFEEBLEMENT. 
 
 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 or dangerous ; 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 patient's bonnets in the workroom ; the " Saviour of 
 mankind" {J. 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 Monomania. 
 
 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 
 years of age, a well-nourished man of medium height, and free from any bodily 
 ailments. His wife had long recognised his mental failure, but maniacal excite- 
 ment had now compelled her to place him under restraint. He was at that 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 maniacal 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 difl'erently 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 
 
CASES OF MONOMANIA. 227 
 
 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 persecutions 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 mori. 
 Occasionally his letters to the medical stafi' 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, 1887. 
 " Professed Englishmen or Britons, 
 
 " 1, 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 Halifax." 
 
 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 persistently, 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 by the " working of the spirit — wliich 
 has been working 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 cheerful, affable 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 
 
2 28 STATES OF MENTAL ENFEEBLEMENT. 
 
 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 God 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 
 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 personality is, as we see, 
 completely transformed. At times she will state that she feels she is Jesus Christ, 
 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 singiug 
 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 iirst 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 the 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. States 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 the 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 improvement, but she always remained pale and aucemic. Her 
 excitement was characterised by loud, abusive, and blasphemous language to all 
 around her, and by a hostile demeanour and threats of violence to those who 
 
MONOMANIA OF PRIDE. 229 
 
 tipproached. Little or no abatement of her excitement took place vmder treatment 
 by succus conii, bromide, with Indian hemp, opium, or hyoscyamine. 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 
 ribbons, or mock diadem, and her dress decorated with coloured devices, all of 
 which 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 
 portrait of the young Prince, and speak of herself as the Empress — his mother. 
 Her 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, wliich she attributed to having been shot there by the medical ofl&cer. 
 On one occasion she was heard to utter a loud piercing shriek, and was observed, 
 transfixed with 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. 
 
 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, 
 and insists upon being addressed by her formal title ; she 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 repellant 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. 
 
 Both 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. 
 
 Progressive Systematised Insanity (Paranoia).— The clinical 
 
 features which first appear to have suggested the constitution of a 
 distinct morbid entity to which the terms " Verriicktheit," " priniare 
 
230 (STATES OF MENTAL ENFEEBLEMENT. 
 
 Verriicktheit," " Progressive Systematised Insanity " were applied 
 
 were : — 
 
 (a) A Primary Implication on 
 
 (b) A Neuropathic Basis ; 
 
 (c) A Systematised Delusional Perversion with 
 
 (d) Progressive Mental Enfeeblement and Incurability. 
 What value ought to be assigned to each of these terms in the con- 
 stitution of a nosological entity 1 Let us endeavour to weigh their 
 significance for purposes of classification. 
 
 Primary Implication. — By this term is implied a specialised 
 insanity or one not preceded by a generalised insanity, such as mania 
 or melancholia ; in other words, a primary alienation not based upon 
 an affective disorder ; an alienation gradually evolved, in which the 
 earliest symptoms may be most obscure and indefinite, but eventually 
 culminating in complete intellectual downfall. With regard to the 
 value of this feature, it may be stated that, whilst all forms of insanity 
 appear to be preceded by more or less affective disorder, the intensity 
 of such emotional disturbance varies with each case in every possible 
 dec^ree ; so that it is difficult, nay impossible, in many cases to state 
 whether the insanity was truly primary in this sense, or secondary to 
 an affective disturbance. Taking also into consideration the doubt so 
 often introduced by want of observation, or by lack of intelligence on 
 the part of the friends, we are still more inclined to assume that a 
 somewhat arbitrary value has been assigned to this feature for purposes 
 of classification. 
 
 Professors Wille and Meynert both affirm that there are not many 
 cases in which it is difficult to determine, in the early stage, whether 
 they belong to primare Verriicktheit, or to melancholia {Hack Tuke). 
 
 Since the days of Griesinger, who emphatically declared that emo- 
 tional disorder always preceded systematised insanity — that the latter 
 was always secondary — German alienists have shown a complete change 
 of front, and now subscribe largely to the opinion long held by French 
 authors as to the existence of a Primary Verriicktheit. 
 
 From what has already been stated by us as to the all-prevalent 
 feature at the onset of mental disease (p. 153) it must be inferred 
 that a disorder of feeling precedes and accompanies all forms of 
 insanity ; and that a primary implication of the intellect, strictly so 
 to speak, cannot be logically assumed to exist. In all such cases as 
 are quoted as types of primary systematised insanity we note the 
 affective disorder in early stages and throughout the disease; the 
 melancholic gloom, or other disorder of feeling, from the earliest days 
 may be mild and, as it were, drawn-out fine, yet this inobtrusive 
 character does not warrant us in asserting that the morbid syndrome 
 has not been evolved out of the moral nature. 
 
THE NEUROPATHIC BASIS. 
 
 231 
 
 Systematised Delusional Perversion.— Here again the value 
 
 of a systematised process for differential groupings appears to be open 
 to question, since systematisation is a feature prevalent in almost all 
 progressive forms of mental alienation — i.e., where emotional storms 
 are in abeyance. It is essential to the establishment of a systematised 
 insanity — to the evolution of, e.g., that extraordinary morbid develop- 
 ment we know as monomania — that the morbid process should work 
 to its destined end in an atmosphere of comparative calm ; in fact, all 
 progressive insanities, if not accompanied by much tumult or acute 
 disturbance, tend towards systematisation. At all periods of life, in 
 early youth, during adolescence, middle life, and even in senility we 
 may frequently trace this tendency to systematisation — much seems 
 to depend upon the absence of emotional turmoil. This insistence 
 upon the systematised nature of the insanity appears to us, therefore, 
 as a simple statement over again of the well-recognised fact, that in 
 all morbid reductions of the mental life the interpenetration of the 
 morbid factor is favoured by emotional calm ; that whenever a morbid 
 process involves the intellectual element of mind, it is clear, defined, 
 and more systematised — the less the perturbation of feeling and 
 emotion. This is but a primary fact in psycho-physics, and a part 
 of the natural history of insanity in its ensemble, but scarcely seems to 
 warrant the position assigned it as the essential feature of a specific 
 entity. When the psychologist tells us that the more there is of 
 feeling the less there is of cognition, and vice versd, he expresses the 
 law which is the basis of all systematised psychoses ; the greater the 
 emotional turmoil, the fewer and more unsubstantial are the possible 
 coherences established in the intellectual sphere, and, therefore, the 
 more dissoluble and transient the delusive concepts. Systematisation 
 in mental disease has, therefore, for us a far more general value, and 
 cannot thus forcibly be detached as the prevailing feature of any one 
 artificially constituted syndrome. 
 
 The Neuropathic Basis. — Here again appeal is made to a very 
 general accompaniment of insanity, not necessarily of the so-called 
 systematised groups. Its value here seems to us chiefly to depend on 
 the explanation it affords of the pathogenesis of the so-called Primary 
 Insanities, as off"ering an explanation of the gradual onset without acute 
 or generalised symptoms. Our views on this point have been given 
 uj)on a former occasion, and we shall here merely quote the opinions 
 then arrived at : — We held that there was no form of mental derange- 
 ment which had not some degree of affective disorder as its accom- 
 paniment; that a certain section of the degenerative class had arrived 
 at a level — through former parental emotional storms — at which any 
 notable affective disorder was in most instances no longer possible ; 
 that what was termed "Paranoia" was simply delusional insanity 
 
232 STATES OF MENTAL ENFEEBLEMENT. 
 
 engrafted on a degenerative or psychopathic basis ; that there were 
 reasons for believing that systematisation depends mainly upon the 
 incidence of insanity upon a psychopathic subject, and that too much 
 emphasis has been bestowed upon it as a differential feature in the 
 various forms of insanity.* 
 
 Referring to cases of criminal paranoics we have elsewhere stated 
 that it "is open to suggestion that such subjects are at the least the 
 relics of a neurotic ancestry in which the more acute storms of disease, 
 to wit — acute alcoholism, convulsive epilepsy, impulsive forms of 
 insanity, &c., have already passed over the parental stock, whilst the 
 later stages of such nervous affections betray themselves in the mental 
 enfeeblement of their progeny, f In this particular it is gratifying to 
 find our views in complete accord with those of Italian alienists. 
 
 If there be any excuse for the use of the term " paranoia " as a 
 synonym for " Verriicktheit " and as connoting a group of primary 
 systematised insanities, there certainly can be none for so-called 
 " Secondary Paranoia" which would embrace all systematised delu- 
 sional insanities evolved out of a generalised insanity — and which 
 does violence to the prime characteristics of the disease known as 
 paranoia — viz., the primary mode of onset of the psychosis. These 
 forms of delusional insanity have long been studied by English autho- 
 rities ; they have been spoken of as rare by Mendel, and, according to 
 Regis, have scarcely been studied at all in France. 1 
 
 Just as unmeaning and illogical then becomes the term ^' Acute 
 Paranoia," by which is implied a transient systematised insanity, of 
 a curable nature, and the existence of which has been denied by Tanzi 
 and Riva, Krafft-Ebing, and others. French authors have wisely 
 abstained from recognising its existence, since the usual implication 
 of the term "paranoia" would negative its possible occurrence. It 
 appears to us, therefore, that we might with far greater consistency 
 limit the term " paranoia " (if it is indeed necessary to retain it) to 
 what has been described by the Italian School as degenerative 
 
 paranoia and the primary psyeho-neurotie form, eliminating 
 
 altogether the so-called acute and secondary paranoias. 
 
 The term '•' paranoia " is ill-chosen and, etymologically, has not the 
 significance of that far better term which it tends to displace — " primare 
 Verriicktheit," or primary systematised insanity ; these latter at least 
 have the merit of defining the disease implied, whilst the former has 
 led to still greater confusion than previously existed, and appears to 
 have been introduced to avoid the awkward implication of primary 
 attached indelibly to the term " Verriicktheit " ; it has led also to the 
 
 * Brit. Med. Joum. (Meeting of Psj^chological Sec), August 20th, 1892. 
 t " The Origins of Crime" {Fortnightly Review, September, 1893). 
 X Mental Disease by Regis, translation by Bannister, p. 166. 
 
TYPICAL SYSTEMATISED INSANITY. 233 
 
 subdivision into numerous groups of questionable value of the classical 
 *' delusional insanity " of English authorities. 
 
 Our own view is in favour of substituting for these terms — 
 
 (a) Primary systematised insanity of the degenerate. 
 
 (b) Typical primary systematised insanity (i.e., psycho-neurotic) ; 
 
 yet always with the proviso that the term "primary " may not be held 
 as strictly correct or even justifiable, implying merely a proportion- 
 ately mild emotional reaction in the one case, and, in the foi-mer case, 
 that the original acute psychosis is still to be traced in the ancestry — 
 a view also accepted by the Italian school of psychiatry. 
 
 We shall describe in detail here only the typical primary systema- 
 tised insanity : — 
 
 Typical Systematised Insanity (Psycho - neurotic). — The 
 
 evolution of a typical case of progressive systematised insanity pre- 
 sents three stages of varying duration — (a) Hypochondriasis with 
 suspicion ; (6) Persecutory insanity ; (c) Transformation of the personal 
 identity. 
 
 (a) The subject in this early stage betrays a notable hypochondriasis, 
 a self-analytic tendency, in which the victim refers all his troubles to 
 some outside agency. All his feelings — bodily and mental — are sub- 
 jected to a rigid self-analytic process ; trivialities are exaggerated to 
 undue dimensions ; bodily sensations are criticised with a morbid 
 intensity; his ideas and mental faculties all appear to have undergone 
 some peculiar and mysterious change ; his environment looks altered, 
 and he reads in the gestures, looks, signs, and words of those around 
 him a special reference to himself. With this weakening of object- 
 consciousness and intensified egoism, suspicion of the environment 
 grows apace, depression and gloom supervene, reticence and brooding 
 indicate the gathering distrust and hostility to the outer world. 
 
 (b) Hallucinations, almost invariably aural, now appear upon the 
 scene ; smell, taste, tactile and general sensation may all be involved ; 
 but visual hallucinations are remarkable by their absence. The hallu- 
 cinations of hearing may be unilateral, bilateral, or antagonistic — 
 the "epigastric voice" may be heard, or his thoughts be repeated 
 audibly within his brain, and any of the varied forms of hallucinations, 
 including the sexual already described, may prevail ; in all cases they 
 suggest the malign and hostile character of his environment. Not 
 only does he find his thoughts echoed within him, but also his most 
 secret feelings are known to and reflected by those around him. Some 
 mysterious power seems to have gained access to hi.s mind, regulates 
 his mental life, enslaves his will and speech, so that he is driven to 
 think and utter ideas not his own. Electricity, galvanism, hypnotism, 
 telephonic, telepathic, and other agencies are evoked to explain these 
 
234 STATES OF MENTAL ENFEEBLEMENT. 
 
 mysterious powers exerted over him by his enemies ; and elaborate 
 sketches are often drafted which detail to his satisfaction the methods 
 whereby he is subjected to such torture. The numerous phases pre- 
 sented by the several forms of monomaniacal perversion all betray 
 the same progressive systematisation of the delusive concepts ; the 
 prevailing hostility of the environment and resultant distrust ; and, 
 finally, lead to the climax in the third stage, viz. : — 
 
 (c) A transformation of the personality which is introduced by 
 mystic and symbolic references, by the creation of unmeaning words 
 (neologisms) to express what they otherwise cannot convey ; and the 
 final apotheosis of the mind into the vagaries of ambitious insanity. 
 
 We have here described what is regarded as a typical case of 
 so-called "paranoia" or primary systematised insanity: it will be 
 apparent to all who have read the preceding chapters on Mental 
 Depression, Exaltation, and Enfeeblement that the features now pre- 
 sented are those which characterise all forms of persistent delusional 
 insanity or monomaniacal perversion. Degenerative paranoia is, 
 therefore, nothing more than delusional insanity arising in a degen- 
 erate subject, and consequently stamped with peculiarities which more 
 or less prevail in all the psychoses of the degenerate. Psycho-neurotic 
 paranoia is the typical course pursued by all delusional insanities ; 
 whether as the outcome of a generalised insanity, or whether it be not, 
 is a mere accident, and apparently of little moment as regards the 
 ultimate course and issue of the case. A systematised insanity abso- 
 lutely identical in all its stages with that just described is by no means 
 of rare occurrence as the outcome of adolescent mania ; similarly also 
 of alcoholic insanity ; both would be held to be genuine cases of 
 secondary systematised insanity — not a partial but a generalised 
 insanity. 
 
 Folie a deux. — Systematised delusional insanity is the form which, 
 far more frequently than any other, appears to give rise to so-called 
 "communicated insanity" or Folie a deux ; a condition where 
 intimate association between an insane and a sane individual leads to 
 a similar mental disturbance in the latter. The absence of acute, 
 generalised mental disturbance, the calm reasoning insanity, the 
 systematised character of the delusive beliefs, and their steady and 
 gradual evolution, all tend insidiously to produce their morbid efiects 
 upon the mind of a strongly neurotic subject, closely associated either 
 by ties of relationship or as companion with the alien. The malady 
 thus aroused is usually identical in nature, and exactly similar delu- 
 sive concepts become manifest unless such association be discontinued. 
 The ofispring of a highly neurotic stock may thus show in adult life the 
 arousal, first in the one, then in the second, third or more, of a similar 
 systematised insanity ; or a deluded husband may arouse the same 
 
PERSISTENT MENTAL INSTABILITY. 235 
 
 form of disorder in a neurotic wife, or vice versd. Where several 
 members of the same family are affected, and the malady is similar in 
 character, we must by no means conclude that they are necessarily 
 instances of Folie ci deux ; we must carefully distinguish betwixt direct 
 transmission from a neurotic stock, and the morbid effects of association 
 betwixt individual members of the family. In fact, it is only when it 
 has been clearly shown that there is a direct morbid influence of the 
 one upon the other, that intimate association has existed, and that 
 evolution of symptoms pursues the same course in both individuals, 
 we can reasonably assume a psychic infection. When individuals not 
 related hy consanguinity, but otherwise closely associated, betray a 
 similar delusional insanity, aroused upon a psychopathic basis, we may 
 regard the case as strongly suggestive of Folie ct deux ; yet, no hasty 
 conclusion should be arrived at, even here, since much may be attri- 
 butable to identical conditions of life, corresponding lines of feeling 
 and sentiment, and, especially, similar morbid or vicious habits, m 
 neurotic subjects. 
 
 That the fear of such developments is but a remote one, even in the 
 opinion of those who fully recognise the existence of this malady, is 
 sufficiently evident in the promiscuous association of the subjects 01 
 systematised insanity with all classes of the community in our large 
 asylums. Whatever plea has been advanced for segregation of different 
 classes of the insane, certainly that which has received the least 
 emphasis has been the plea for the avoidance of communicated insanity 
 through too promiscuous association. 
 
 RECURRENT INSANITY. 
 
 Contents.— Definition— EstabUshment of Labile Equilibrium— Prevalence at Sexual 
 Decadence— Heredity— Id flueuce of Neurotic] Heritage and of Ancestral lutem- 
 peraoce-Atavism— Recurrence in the Congenitally Defective Subject— Morbid 
 Excitement and the Moral Imbecile— Alternationa of Excitement and Stupor- 
 Hysteria and Menstrual Irregularity— Eroticism [A. j?.)— Recurrence in Adol- 
 escence (M. G. PT. )— Recurrence at the Climacteric (//. 0.)— at the Senile Epoch 
 {/. 8.)— in Puerperal Subjects [M. i?.)— in Traumatic Insanity (B. Z,.)— Morbid 
 Impulsiveness- Hallucination and Delusion {J. ^.)— Circular Insanity- 
 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 
 
236 PERSISTENT MENTAL INSTABILITY. 
 
 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 different 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. " Noth withstanding 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 category " (Sankey).* 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. 
 
 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 66 individuals so affected, 49 had 
 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. 
 
 * Lectures on Mental Disease, p. 179. 
 
INCIDENCE OF RECURRENT INSANITY. 
 
 237 
 
 Table of Female Recureents. 
 
 Number of 
 Attacks. 
 
 Occurring between 
 
 the Age of 
 
 Representing 
 Interval of 
 
 Number of 
 Attacks. 
 
 Occurring between 
 the Age of 
 
 Representing 
 Interval of 
 
 5 
 
 16 and 32 yrs. 
 
 16 yrs. 
 
 Several 
 
 31 and 36 yrs. 
 
 5 yrs. 
 
 3 
 
 17 „ 20 ,, 
 
 3 „ 
 
 5 
 
 32 , 
 
 > 48 „ 
 
 16 , 
 
 
 3 
 
 17 „ 21 „ 
 
 4 „ 
 
 8 
 
 32 , 
 
 , 42 „ 
 
 10 , 
 
 
 Several 
 
 18 „ 30 „ 
 
 12 „ 
 
 5 
 
 33 , 
 
 , 37 „ 
 
 4 , 
 
 
 3 
 
 19 „ 24 „ 
 
 5 „ 
 
 4 
 
 35 , 
 
 , 50 „ 
 
 15 , 
 
 
 3 
 
 20 „ 21 „ 
 
 1 ., 
 
 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 ,, 
 
 2 , 
 
 
 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 
 
 44 , 
 
 , 58 „ 
 
 14 , 
 
 
 3 
 
 30 „ 41 „ 
 
 11 „ 
 
 3 
 
 47 , 
 
 , 55 „ 
 
 8 , 
 
 
 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 
 
 30 „ 35 „ 
 
 5 ,, 
 
 3 
 
 54 , 
 
 , 56 „ 
 
 2 , 
 
 
 4 
 
 30 ,, 55 „ 
 
 25 „ 
 
 Total, 50 
 
 Persons. 
 
 193 (+Several) 
 
 Attacks. 
 
 
 
 Respective Age in Quinquennial Periods, in 164 Cases of 
 Recurrent Insanity. 
 
 Age 
 
 Males. 
 
 Females. 
 
 Up to 25 years. 
 
 10 
 
 9 
 
 » 30 „ 
 
 7 
 
 8 
 
 J > "5 J > 
 
 7 
 
 9 
 
 „ 40 „ 
 
 9 
 
 8 
 
 „ 45 „ 
 
 7 
 
 21 
 
 „ 50 „ 
 
 9 
 
 9 
 
 5j 55 ,, 
 
 5 
 
 13 
 
 „ 60 „ 
 
 4 
 
 17 
 
 „ 65 „ 
 
 3 
 
 4 
 
 » 70 „ 
 
 5 
 
 
 
 66 
 
 98 
 
238 PERSISTENT MEXTAL INSTABILITY. 
 
 "Who are the subjects most liable to this form of mental disturbance'? 
 
 They have a strongly stamped hereditary history of insanity ; 
 
 the parentage, T\'hen 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, vre 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 
 adolescents, where 20 per cent, revealed 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 -l per cent, (males 8'9, and 
 females 12'6), or over tico-thirds the proportion of cases shown by 
 adolescent forms of insanity ; and in 80 per cent, of such instances 
 of parental intemperance, the father 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 1 If we accept, 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 reasonably be assumed that the neuroses of early life — 
 chorea, hysteria, epilepsy — will be especially prone to re-assert them- 
 selves also at a similar ejjoch in the life of the offspring ; and that, 
 therefore, an epileptic father or grandfather who heca'ine ejnhptic at 
 puberty will 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 appearances as an inherited aff'ection 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 
 
INTEMPERANCE AND RECURRENT INSANITY. 239 
 
 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 recurrent 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 when no other 
 record exists. Its comparatively later development than the adolescent 
 form appears to be governed by the law of limitation by age, which 
 is enforced in most hereditary affections ; the ancestral affection 
 occurring in adult life tends to reproduce itself at the same epoch. 
 Parental intemperance declares 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 further 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. 
 
240 PERSISTENT MENTAL INSTABILITY. 
 
 Dr. Sankey, on the other hand, regards the periodicity of recurrent 
 insanity as bringing this disease into close alliance with epilepsy ; hi& 
 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 petit mal, now 
 generally classed with true epilepsy." * 
 
 Nature of the Attack. — The seizure varies as to its symptoms 
 and course with the exciting cause at woi'k, 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 
 delusions of suspicion and persecution ; or by an ordinary lypemania, 
 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 melancholic delusions. Of subjects prone to recurrent 
 seizures of mania or melancholia, the more important are cases of 
 
 Congenital mental defect. Insanity with menstrual derangement. 
 
 Adolescent insanity, Puerperal insanity. 
 
 Alcoholic insanity (acute). Climacteric insanity. 
 
 Traumatism (cranial injury). Senile insanity. 
 
 Epileptic subjects, in whom recurrent seizures are frequent, are 
 necessarily excluded here by their intrinsic importance, and will be 
 considered apart. 
 
 Recurrence in Congenitally Defective States.— Those whose 
 
 mental organisations are 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 impro- 
 bable that the passions will so readily assume the opposite extreme ; 
 but, so it is, that such extremely amiable natures will pass, upon the 
 most trivial disturbance, to a bitterness and a passionate demonstra- 
 tiveness often exhibiting an inherent cruelty and viciousness. 
 
 With lack of inhibitory "staying" power, such 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. Masturbation, especially, lays the groundwork for 
 
 * Loc. cit., p. 179. 
 
STUPOR AND HYSTERIA IN RECURRENT INSANITY. 24 1 
 
 an attack of insanity by the nutritive clianges 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 mOPal imbecilG, and 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, 
 masturbation, sexual excess, alcoholic intoxication, or undue nervous 
 excitement from moral causes, acts by occasioning a malnutrition of 
 the central nervous system, already predisposed 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 
 humour, 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 alternations of ex- 
 citement 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, reproducing, as it does, many promi- 
 nent hysteric symptoms. 
 
 The typically hysteric subject is generally the subject of menstrual 
 irregularities, as in the following case : — 
 
 A. S., aged twenty years, mill-hand, admitted Maj', 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 cliaracterised 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 amenorrhrea. In less than two years she again 
 required restraint ; the catamenia having ceased, she, about a month afterwards, 
 became restless, sleepless, and excital)le, prone to destructiveness, and very 
 indecent both in speech 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- 
 
 16 
 
242 PERSISTENT MENTAL INSTABILITY. 
 
 charged under a twelvemonth. A fourth occurrence of insanity 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 months subsequently, was pvirely maniacal in kind ; 
 there was rambling at first upon religious topics, slight or no evidence of eroticism, 
 and no added irregularity of menstrual performance — which, it was stated, 
 generally erred on the side of insufficiency. Seven months accomplished a cure. 
 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. 
 
 ReCUPPence 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 over and 
 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 proportion 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 past 
 she has been in delicate health, and is distinctly ancemic. She brings with her 
 a strong neurotic heritage ; her maternal grandmother was twice under treatment 
 at an asylum, her mental balance overthrown 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 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 upon 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, 
 
RECURRENT INSANITY IN ADOLESCENCE. 
 
 243 
 
 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 daj^s 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 noisy, 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 sufficiently staid to attend the weekly dance. Exactly a month after the 
 Jirst relapse, a second occurs, in which she again proves boisterous, violent, and 
 destructive ; her bodily healtli, however, has been progressively improving since 
 her admission. It was clearly seen that her relapses were coincident with the 
 menstrual periods ; but the occurrence of the next period was passed without any 
 mental disturbance, and she was discharged, recovered, a few weeks subsequently. 
 
 Six years later, that is, when twent3r-four years of age, this patient again became 
 an inmate of our wards. She had kept well, and regularly emploj^ed as a dyer 
 during the interval, when, iipon the 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. 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 laughs and becomes obscene and repulsive. 
 
 As on the former occasion, the excitement completely abated in a fortnight's 
 time from admission ; but only to return again in a violent form, marked by all 
 the features above depicted, and extending over a period of about two months, 
 when a gradual improvement succeeded, until complete convalescence was ensured. 
 
 ReCUFFence at the ClimacteFic. — 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 
 raenoiDause, 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 charactei'ised 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. History of paternal intemperance — an aunt 
 hung herself — ^an uncle died in a lunatic asj'lum. H. 0. liad been intemperate, 
 but had enjoyed good liealth. Of three cliildren l)orne l)y her, one died of con- 
 vulsions. The alleged cause of her present attack was domestic anxiet}', embracing 
 supposed infidelity on tlie part of her husband, and occurring at the period of the 
 climacteric. Depression of mind, lasting .some six months, culminated in an 
 
244 PERSISTENT MENTAL INSTABILITY. 
 
 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 interval had 
 been spent in Wadsley Asylum, and she had been discharged but one week when 
 depression of spirits and apprehensive fears beset her, and she developed the 
 delusion that chloroform was secretly administered to her. She admitted having 
 been addicted for years to alcohol in excess ; showed great defect of memory^ 
 with 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. 
 There was some progressive dementia and sluggishness of intellectual operations, 
 with emotional dulness and, especially, defect of memory. Nevertheless, in two 
 months' time she improved sufhciently to justify her discharge. Her recovery 
 only lasted a couple of months, though she abstained from alcohol ; she developed 
 restlessness, insomnia, melancholic fears, and delusions. When re-admitted for 
 the fourth time, she was anxious and apprehensive, but not burdened with sus- 
 picion to the same extent 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 woiuen^ 
 took their origin at the following respective ages : — 
 
 Upto20yrs.— SOyrs.— 40yrs.— SOyrs.— eOyrs.— 70yrs. Doubtful. Total. 
 Number of recurrent cases 
 
 occurring, ... 2 10 15 25 24 2 2 80 
 
 Number in which ^r.s< at- 
 tack 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 Jirst 
 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 
 
THE SENILE EPOCH. 
 
 245 
 
 influence in originating this form of insanity ; but that it is especially 
 prone to excite its recurrence in those who have already suffered 
 therefrom. 
 
 ReeuPFence 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 recurrent 
 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. Patient belonged to a higlily neurotic stock. Her 
 mother and sister were both insane ; her brother cut his throat ; and, at a subse- 
 quent period, her sister's son, becoming the subject of impulsive insanity, murdered 
 his mother in the most brutal manner, kicking her to death, and causing the most 
 terrible mutilations of her head and body. Her symptoms had shown a long 
 premonitory stage ; but four months prior to admission, she was restless, garrulous, 
 betrayed alternations of despondency and excitability, 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 
 inadequate to provoke such distress in a normal state. She had a sharp, weazened 
 aspect, with dark piercing eyes ; was emaciated and shrunken. A decided hypo- 
 chondriacal element was indicated by the prominence 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 impulsive ; her uncontrollable 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 querulously dwell iipon her 
 ailments ; at other times, her impulsiveness tended to suicidal acts. Being dis- 
 charged, " relieved," to her husband's care, she subsequently relapsed, and then 
 attempted hanging herself in a wardrobe ; but, being detected, rushed to the 
 window with intent to leap from it. She was re-admitted, 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 imperatively 
 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 re-appearance 
 at the same period in tlie off'spring. 
 
246 PERSISTENT MENTAL INSTABILITY. 
 
 Recurrence in Puerperal Cases. — A certain proportion of 
 
 women betray a tendency to maniacal perversions upon the accom- 
 plishment of each partui'ition, 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. History of paternal intemperance — a sister 
 melancholic, but did not reqiiire asylum treatment. The patient, after her fourth 
 confinement, a severe one, developed symptoms of insanity, and was removed to 
 Wadsley, where she was retained about two months. 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 convalescing from mania and 
 rapidly became quiet, industrious, and fairlj' cheerful. There was neither con- 
 tinuance of, nor return to, the homicidal tendency ; she was sent out recovered in 
 less than two months. The interval between the preceding and the following 
 attack was five years, during which time patient had two cliildren ; the last labour 
 being followed by post-partum hfemorrhage and, more remotely, bj' profuse men- 
 struation. It appeared that she soon showed mental aberration after her discharge, 
 developing suspiciovis ideas about her neighbours, and fancying that they jeered 
 at her and called her names, and it was stated that she attempted to cut lier 
 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 behaviotir, anxiety, and hj'pochondriacal 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 upon the head, or 
 to a violent blow causing temporary 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. 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 
 present mental disorder. Her forehead was deeply scarred, as the result of 
 injuries received by a fall upon the head some years previously. 
 
FREQUENCY OF MORBID IMPULSE. 247 
 
 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, effected 
 bj' a piece of cord tied roiuid 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 dimib while she was in hell — i.e., prison. At first abstracted 
 and suspicious, exhibiting many purposeless tricks of gesture and countenance, she 
 quickly became an active and industrious inmate, showing, liowever, some irra- 
 tionalit}'-, together with considei-able want of control. Although no delusions of 
 suspicion regarding those surrounding her were manifest, yet the low type of her 
 appeai'ance received confirmation in occasional outbursts of violence, without 
 adequate cause, and at all times characterised by the utmost brutality. Her 
 behaviour, however, not deserving of the license of insanity, she was, after a resi- 
 dence of three months, sent back to gaol. 
 
 In less than 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 thisstate 
 she remained for nearly a week, when she commenced gradually' to improve, 
 and ultimately settled down into a quite affable patient of industrious habits, with 
 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. — Some 31 per cent, of the 136 
 
 instances of recurrent insanity manifested suicidal tendencies, both 
 sexes being about equally subject to such promptings. The melancholic 
 forma, 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 the 
 few cases occurring below forty years of age in the female, the self- 
 destructive impulse appeai-ed 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 58 per cent. 
 
 Hence, recurrent insanity embraces a very high proportion of in- 
 dividuals dangerous to others — a fact explained, in like manner, by 
 the large number addicted to vicious habits of life, and especially 
 alcoholic excess. With respect to this morbid impulsiveness. Dr. 
 
248 PERSISTENT MENTAL INSTABILITY. 
 
 Sankey, reaffirming with M. Morel its resemblance 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 with 
 any unconsciousness, yet they seem scarcely voluntary." "^^ Amongst 
 this class are comprised many of the criminal community of low 
 mental type, often associated with 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 their 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 prompted by the utmost brutality and the most vicious 
 instincts. Beyond the trouble given by the criminal class in an 
 institution 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 associ- 
 ations were far different. This social evil is a blot upon our legislature 
 that loudly calls for redress. 
 
 Hallucinations and Delusions. — Hallucinations prevailed in 
 '2'2~i 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 alcoljolic 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, 
 twenty-eight years of age, addicted to intemperance in drink, and 
 the subject of a serious cranial injury in youth, calls himself Sir, 
 Roger Tichborne, and accuses his relatives of filling his bedroom with 
 the vapour of chloi"oform. 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 
 
 * Op. cit., p. 175. 
 
THE CRIMINAL INSANE: HALLUCINATIONS AND DELUSIONS. 249 
 
 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, 
 and often begged to be operated upon with 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. 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 workhouse, whither 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. Upon admission 
 he was depressed, heavy, and sluggish, yet sufficiently calm to give a clear account 
 of himself. He was ill nourished, with flabby muscles ; complexion sallow and 
 dirty; several deeply-incised wounds recently inflicted were observed on forehead ; 
 expression depressed and torpid. Patient gave a history of excessive drinking 
 for some j'ears 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 inactive ; 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 normal consciousness, and was shortly 
 afterwards employed for a time at work, and discharged. 
 
 The next occasion upon which we hear of him was two years following his dis- 
 charge. During the interval he had gone to America, resumed his drinking 
 habits, and was soon an inmate of the Trenton Asylum. When re-admitted liere, 
 he had developed tj^pical delusions ; declared that some clockwork was within his 
 chest -the movements were incessant, caused him great suft'ering, 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 upon 
 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 al^out whenever they choose. He became much agitated and 
 excited during this narration ; talked hurriedly and incoherently. 
 
 For two months he continued to exhibit the symptoms al)ove described, was 
 always excitable, spoke in a hurried floAV of words, but was coherent ; he proved 
 friendly in his disposition to those around iiim, took much interest in his domestic 
 employments, and was fairly cheerful. 
 
 A relapse occurred two months later ; the delusion became again more pro- 
 minent, and he rejjeatedly threatened to cut his tlu-oat. For the subjective 
 anomalies leeches were applied to the manubrium, but witliout result. Bromide 
 and cliloial were then given witli very considerable benefit ; the pain gradually 
 
25Q PERSISTENT MENTAL INSTABILITY. 
 
 subsided ; his sleep was ensured at night ; and in six weeks' time he declared 
 himself free from any morbid sensations, had lost his delusional notions, was quite 
 rational in converse, and left the asylum. 
 
 In one month later he again became an inmate, suffering from his fourth attack 
 of mania-ii-potu. The "clockwork " still drives him frantic ; he must cut open his 
 own chest and remove it, or will ' ' split open the chest of some one 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 
 feelings 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 sternvim. Threatens to take his own life unless relieved by some operation ; 
 is very excitable, garrulous, circumlocutory, irate. He took liquor opii with 
 spiritus setheris sulph. (aa mins. xv. ) twice daily. During the first fortnight he 
 derived relief from the opiate, but continiied to exhibit mild maniacal excitement. 
 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 sub- 
 stituted 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 proportion 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, appears to be maintained between the 
 rate of recovery amongst the male and the female residents ; the former 
 range as high as 71 "4 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 were 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- 
 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 
 
ALCOHOLIC RECURRENTS: PROGNOSIS. 25 I 
 
 disease is maintained. Dr. Blandford cites the case of a man of more 
 than eighty years of age, who came under his observation, whose 
 first attack happened when he was seventeen, and who had been 
 placed under supervision for recurrent attacks three-and-thirty times.'^' 
 A patient at the West Riding 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 discharged, and resumed her household duties 
 with energy and ability, manifesting no intellectual impairment or 
 emotional instability. 
 
 In another case — a married woman, addicted to heavy drinking, 
 had her first attack at the age of thirty-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 sufiered 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 tlie age of twenty-four years, when her 
 mental equilibrium was so far unsteadied that she continues, up to the 
 present time (a period of ten 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. Tliis much we ma}* conclude, that the conditions which precede the first 
 are not necessary to subsequent attacks ; that as epileptic seizures niaj' continue 
 after the ostensible cause of the first fit is removed — e.g., worms — so the disorder 
 once recurring may repeat itself, persistently remaining as a vice of the constitu- 
 tion of the individual, of which it now forms a portion " (Blandjord)f. 
 
 With this statement of Dr. Blandford we fully agree, so long as it 
 is understood that the conditions of the first attack, to which he 
 alludes, are environing, 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 fail to elicit to the full extent from the most careful enquiries 
 the magnitude and importance of inherited neurotic conditions. Yet 
 * InsaMity and it.'i Treatment, p. 71. t Op. cil., p. 7'2. 
 
252 PERSISTENT MENTAL INSTABILITr. 
 
 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 (5 1-4 per cent.). If, therefore, in 
 one-Jialf tide 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' experience at the West Riding 
 Asylum, we may construct from their histories a chart of recoveries, 
 such as is given on Chart A. 
 
 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 mouth, again to decline to the 
 level of one or two cases monthly until the thirteenth month, after 
 which the recoveries are few and distant — e.g., one at twenty months, 
 one at two years, and one at six years. 
 
 The recovery line for the men difi"ers from that of the women in 
 attaining the climax two months later; the largest proportion of cures 
 for female recurrents (seventeen) taking place during the fourth month 
 of their attack, and steadily declining to the seventh; whilst the 
 maximum of male recoveries (twenty-six) occurs 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 suS'ered from 
 several i)revious attacks, or were subjects of congenital mental defect. 
 
 CiFCulap Insanity (Folie Circulaire, Folie a Double Forme).— 
 
 This is a condition where melancholia and mania, or the reverse, follow 
 each other in invariable sequence, with or without a shorter or longer 
 interval of lucidity. Between the attacks of melancholia and mania 
 there may exist a period when the subject can be regarded as in 
 neither phase, but calm, lucid, and apparently stable ; so that there 
 may be some danger of mistaking the lucid interval as one of actual 
 recovery, rather than the transition period from one to the other 
 mental phase. 
 
 Or again, there may be no such intermission, but the depression 
 may gradually diminish, passing insensibly into excitement. 
 
 In like manner, the successive cycles of excitement and depression 
 
Chart A 
 
 dumber cf 7 
 Cases. 
 
 CHART of RECOVERIES 
 
 INSANITY AT THE CLIMACTERIC 
 
 Durationnf Attack. 4)1'. 6iv. 2m 
 
 2 13 14 15 16 19 20 2/ 4y 
 
 Jumberof CHART of RECOVERIES in RECURRENT FORMS of INSANITY.; 167 Cases.; 
 
 Cases. lOp 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 — -^ — 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \-- 
 
 --/ 
 
 
 
 \ 
 
 
 
 \ 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 / 
 
 
 \ 
 
 7 
 
 
 
 Iv 
 
 
 A 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Dura* 
 
Chart A 
 
 CHART of RECOVERIES. 
 
 INSANITY AT THE CLIMACTERIC. 
 
 = : A 
 
 n 
 
 w-/ ^nr S 
 
 H t5^^ ± 
 
 i E \/ r A 
 
 1: " I T . . .7 V ., 
 
 DaralionofAtlack. 4if 6»'. 2ot 5 4 5 6 7 8 9 10 II 12 13 14- 15 16 19 20 2j/. 4y 
 
 Number-of CHART of RECOVERIES in RECURRENT FORMS of INSANITY.(I67 Cases.) 
 
 
 
 K /r "" 
 
 ^ V4 " "" 
 
 / i 
 
 
 '^v^ t,\ ^ 
 
 M ^i te A , .^ / . 
 
 A h \£ A rw^ 
 
 V .^ ^ 
 
 pto f4»:. 6» 2» 3 4 5 6 7 8 9. 10 II 12 15 14 15 18 2/ 3/ 5^ 
 
 L 
 
 Note.- Bkir/,- 7.mc MALE Itccarrmts 37 C 
 JJi/Jfdlijie FEMALE , JOO 
 
 ANALYSIS OF RESULTS. 
 
 Recovered Relieved Died Ctironu 
 
 Male +6 14 3 4. 
 
 Female 5 9 15 8 IB 
 
CIRCULAR INSANITY. 253 
 
 may be separated by so short an interval of lucidity that the attacks 
 tliemselves appear continuous — no intermission whatever occurring. 
 We therefore recognise in the history of such cases the stage of 
 
 (a) Maniacal reductions : (c) Melancholic reductions : 
 
 (6) Transition : [d) Interparoxysmal lucidity. 
 
 In many cases the stages b and d may be entirely absent. 
 
 Should there be no interparoxysmal period the attacks of melan- 
 cholia and mania alternate constantly, establishing thus a continued 
 insanity of alternating mental phases — the tr^le Folie Circulaire of 
 many authors ; whilst, if the interparoxysmal stage be well marked, 
 we have the intermittent form of circular insanity. 
 
 The stage of depression may reproduce a^iy of the usual forms of 
 melancholia, stupor, or melancholic stupor ; in no respect is the form 
 of reduction peculiar to this disease ; in like manner, the maniacal 
 reductions may extend to any depth, issuing in the gentlest or the 
 most acute degree of excitement. In the nature of the depression 
 or excitement there is no feature which specially stamps this aflection 
 beyond the alternating character of the reductions. 
 
 Although in individual cases each attack is almost an exact counter- 
 part of that which has preceded it — and this as regards intensitij and 
 nature of symptoms, duration of each stage and of the complete cycle — 
 yet, in different subjects, great diversity is shown in all these 
 particulars. Each stage of reduction may last from a day or two 
 to several weeks or months, and the interparoxysmal period is subject 
 to the same xmcertainty. The affection is notably a chronic and 
 incurable one ; and, although in certain cases a year or more may 
 intervene betwixt the attacks, the tendency to recur soon betrays 
 itself, and very rare indeed are the instances of recovery. 
 
 Etiology. — Although classed under the heading of recurrent forms 
 of insanity, it will be seen that the family alliance is by no means so 
 close as this might at first seem to imply. The tendency to recur; 
 the reproduction of similar mental phases ; the peculiarly incurable 
 nature of the disease ; and lastly, the strong hereditary basis upon 
 which it is engrafted, might suggest this alliance. When, however, 
 we more closely study the etiology of this aifection we are at once 
 struck by much dissimilarity ; the following factors illustrate this : — 
 
 Sex. — It prevails far more frequently in woman than in man : all 
 writers alike assert the influence of sex in this direction. 
 
 Age. — Puberty and the period following, up to thirty, afford by far 
 the greater proportion of cases of Folie Circulaire. 
 
 Heredity. — Direct heredity plays an important role in its develop- 
 ment. A neurotic heritage, epilepsy, alcoholism, chorea, hysteria, and 
 insanity are the constant antecedents of this affection in the ancestry. 
 
2 54 PERSISTENT MENTAL INSTABILITY. 
 
 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 
 upon the subjects of this, than of those of any other form of insanity. 
 Alcoholic treatment 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 find 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 Reports 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 affected 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 
 inadmissible 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 prescribed. 
 
 In the circular form of insanity the general pi'inciples which guide 
 us in the treatment of mania and melancholia must also here be relied 
 upon. Attempts have been made to cut short the periodicity of this 
 affection by such remedies as quinine, digitalis, cannabis, morphia, and 
 
p:pileptic insanity. 
 
 255 
 
 the bromides. Quinine has been administered in large doses, up to 30 
 grains, but with indifferent results ; a better palliative treatment is 
 that of the tonic regimen applicable to all cases of periodical forms of 
 insanity. 
 
 EPILEPTIC INSANITY. 
 
 Contents: — Definition — Epileptic Neurosis — Immediate and Remote Results of 
 Epileptic Discharge — Diffusion-currents — Nascent Nerve-tracts — Discharge 
 from Sensory Areas — The Aura in Sensory Epilepsies— Epileptic Amaurosis, 
 Hemianopsia and Hemiansesthesia — Champing Movements — Pre-paroxysmal 
 Stage — Premonitory Stage — Special Sense Aurse — Vaso-motor and Visceral 
 Aurffi — 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. 
 
 By epileptic insanity we mean that form of mental derangement 
 in the antecedent history, oncome, and further development 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 physical side a parallel disorder 
 of mind, we speak of it as epileptic in.sanity. Ej)ilepsies may develop 
 during the course of other cei-ebral 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 afflicted, having no direct 
 connection with the primary cerebral dei-angement, 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 mental derangement of the epileptic may assume the form of 
 mariiacal 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, 
 
256 EPILEPTIC INSANITY. 
 
 dissolutions, and the persistent impairment due to a constantly 
 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 
 the mental faculties seen in epileptic dementia. Hence, in studying 
 epileptic insanity, we have to consider the acute symptoms or immedi- 
 ate after-effects of a fit, as well as the chronic impairment presented 
 during the intervening periods between the attacks. It is not, as 
 before stated, every 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 consciousness ") 
 that the mind is prone to suffer. An all-important principle which 
 the same authority has taught us to recognise is that, in these epil- 
 eptic seizures, there is a brutal expenditure of force wholly out 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 par- 
 alysed 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 nerves 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. 
 
 * See Wed Riding Asylum Reports, vol. iii., p. 331. 
 
EFFECTS OF DIFFUSED CURRENTS. 257 
 
 All this means, of course, clitFusion currents around the primary- 
 discharging centre. 
 
 If, then, all energising and discharging of motor centres be accom- 
 panied by such effects in related centres, how much greater will be the 
 effect when the motor areas are overflooded by the brutal explosiveness 
 of epileptic discharges. "VVe 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-tPaetS, 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 they 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, or, 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 " 
 {Hughlings-Jackson).'-'' In like manner may arise pure sensory epilep- 
 sies, with, or without, loss of consciousness in the full acceptation of 
 the phrase ; or a primary 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'pand 
 mal, in which the loss of consciousness is early and complete, and the 
 spread of the discharge 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 mainspring of 
 
 * Lor. cit. , p. 268. 
 
 17 
 
258 EPILEPTIC IXSAXITY. 
 
 a ^vatch, renders it impossible in most cases to distinguish any sequence 
 in the resulting spasms. It is truly a universal spasm, or, to use Dr. 
 Hughlings-Jackson's vigorous phrase, " a clotted mass of movements." 
 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 sensory 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 patient ; but — impressed only by 
 the results of the motor discharges — we must not lose sight of the fact, 
 that equally powerful discharges, of which we see no result, may pass 
 along sensory ai'eas at the period when consciousness is abolished. 
 Undoubtedly the muscular spasms are likely to attract to themselves 
 undue attention on the student's part ; and he forgets for the time 
 that still more noxious eflects are being produced in the areas of 
 mental and sensorial activity silently and concealed from his view. 
 It is, therefore, 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 aflection. 
 
 It is very obvious that amongst a large number of epileptics in our 
 asylums who suffer from mental derangement, there is very great 
 divergence in the history and progress of their affection — the pheno- 
 mena of their disease by no means present 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 are 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 tits '"') 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 speaking, no entity to be called epilepsy ; but innumerable 
 different epilepsies as there are innumerable seats of discharging 
 
SENSORY EPILEPSIES. 259 
 
 lesions. And as the first symptoms in the paroxysm is the first effect 
 of the discharge of the centre unstable, any two paroxysms beginning 
 differently will differ throughout, however little."* From all this it 
 becomes sufficiently obvious that we must not rest satisfied with a 
 mere observation of the 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 gropes about on hands and knees — 
 epileptic amaurosis is, however, an infrequent effect of this disease. 
 
 Another epileptic becomes hemiansesthetic 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 upon 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 
 jmtient 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 oid 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 tliese 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 searching apparently for some object; 
 or he may remove his coat, turn out the contents of his pocket, &c. 
 
 * Loc. cit., p. 270. 
 
26o EPILEPTIC INSANITY. 
 
 One of our patients invariably after his fit empties his pockets on the 
 table, secures his pipe, and placing it (although empty) in his mouth, 
 marches to and fro with 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, 
 therefore, 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 Ppeparoxysmal Stage.— 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 universally 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) hypochondriacal perversions, which may have 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 more frequent as a genuine aura— a. 
 psychical state, the immediate accompaniment of the commencing 
 epileptic discharge ; (5) joyous elation may precede an attack, a. 
 
THE AURA EPILEPTICA. 26 I 
 
 general state of optimism be present, often associated, however, with 
 gross egoistical sentiments; (6) confusion of ideas, diminished 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 prominent 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 Asylum almost invariably beti'ays to his 
 attendant this state of mind ; he stalks np and do^vn 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 mysterious air — " What they put in my 
 food and medicine explains everything." At times he openly accuses the doctors 
 of drugging his food and drink, and always in the stage preceding convtdsion. 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 by 
 drinking his own urine, which he has been detected doing on more than one 
 occasion, and with this avowed object in view. 
 
 2. Premonitory Stage. — 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-ca,lled warnings or aurSB. In fact, the phenomena embraced by this 
 period, the epileptic aura, are but the subjective aspects of the nervous 
 discharges in cortical centres, the initiatory 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 
 transient duration, only during the earliest period of the attack ; the 
 objective are obtrusively present, but from the eaidy failure of con- 
 sciousness have no mental correlates. Since, however, the epileptic 
 aura constitutes the earliest symptom of the acttial 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 
 phenomena of an aura may be co-extensive with all forms of sensation 
 whatsoevei-, and may even be constituted by more elaborate forms of 
 
262 EPILEPTIC INSANITY. 
 
 psychical activity. The sensation constituting an aura is, therefore,, 
 referred to any portion of the environment, including in the latter term 
 the body and its organs generally. We thus may get axtrce, of — (1) the 
 special senses ; (2) of the visceral or organic sensations ; and (3) 
 intellectual or psychical aurse. A few remarks on these sensations will 
 render the subject clearer. 
 
 (a) 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. Taste 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 capable 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 us 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 
 Sig'ht 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'ht 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 farther 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 remarks 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 with 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 
 arise momentarily and co-instantaneously throughout the organism 
 during the healthy activity of all its tissues, its muscles, bony frame- 
 work, viscera, and vascular apparatus form in their aggregate what are 
 
ORGANIC AND SPECIAL-SENSE AUR/E. 263 
 
 termed the sensations of OPg'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 bien-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 embracing 
 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 urino-genitory apparatus. 
 
 Visual Aurce. — These occasionally precede the seizure in epileptic 
 insanity, but, as pointed out years since by Sir J. Crichton-Browne, 
 aurse are not of frequent occurrence amongst this class of epileptics, f 
 When they do occur, the visual auras 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. Red and blue are the colours more 
 frequently seen in these visual aurse [Gowers). 
 
 . Auditory Warnings. — These are less frequent than the visual ; but 
 are occasionally met with in elaborate form. Dr. Ross speaks of 
 hissing, singing, or explosive noises ; of a noise in the ears, followed 
 by vocal utterances, in some cases of ordinary epilepsy. | 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. 
 Consciousness, as a rule, is in them too early lost for these phenomena 
 to occur. 
 
 Gustatory and Olfactory Aurce. — These are the least frequent forms of 
 aurse 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 
 
 * The /Se/we*' and Intel ltd , Alexander Bain — "Sensations of Organic Life." 
 t West Riding Asylum Medical Reportu, vol. iii., p. 160. 
 X Diseamn of the Nervous System, vol. ii., p. 919. 
 
264 . EPILEPTIC INSANITY. 
 
 auree. 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-^iotor 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 op Organic Aurae. — These are the more prevalent 
 sensations recognised in epilepsy, as stated by Sir J.- 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 pain in the pr^cordia, or violent 
 palpitation of the heart. A feeling, identical with the globus hystericus, 
 is also very frequently observed in epileptic insanity (Gowers). All 
 these SLUTse, it will be noted, are referrible to a centric disturbance of 
 the vagus and spinal accessory. 
 
 3. The Epileptic Paroxysm. — This paroxysm may be charac- 
 terised Vjy 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 different subjects, so no sharp line of demarcation can be drawn 
 between the two extreme limits. A not infrequent symptom of the 
 approaching attack is a non-painful contraction of the fingers of the 
 arm first aff'ected ; thus one instance, amongst several, invariably has 
 a painless flexion of the fourth and fifth fingers of the left hand with a 
 cramp-like swelling of the right sterno-mastoid muscle which warns 
 him that the fit is about to occur. These muscular cramps preced- 
 ing epileptic seizures appear very frequent prodromata amongst the 
 epileptic insane community. Classically, and for convenience of 
 
 * Loc. cit. 
 
GRAND MAL. 265 
 
 description we recognise the two forms, called respectively le g'Pand 
 
 mal and le petit mal. 
 
 {a) 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; 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 ]iale, 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 com- 
 bined 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 move- 
 ments, which eventually are large, interrupted, 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 
 
 * Professor Bechterew has given the results of experiments suggested by him to 
 Dr. Todorski, in which it is clearly proved that during epileptic seizures, arti- 
 ficially induced in animals, the tonic period is characterised by an increase of 
 blood-pressure at both central and peripheral ends of the carotids, as well as in 
 the jugular veins ; whilst, in further experiments, it was shown that the pressure 
 of the cerebro-spinal fluid always equalled that of the carotids. During tlie fit 
 there is always an increased flow of arterial blood to the brain. — Xeuroloiji-iches 
 CeiitralUatt, No. 23, 1894. 
 
266 EPILEPTIC IXSAXITY. 
 
 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. 
 
 The condition of the deep reflexes following upon these epileptic 
 seizures is of interest. Certain seizures are invariably followed by 
 exalted knee-jerk, and also well-marked ankle clones : the clones may 
 be established a fe^v minutes after the fit, or may succeed immediately 
 to the convulsion. AYe have noted this immediate establishment of 
 clonos also in cases of general paralysis, and, in one instance, in which 
 severe epileptiform convulsions preceded by a cry affected the right 
 arm only, excessive clonos existed in both ankles, but was most 
 marked on the right side, the convulsive seizures being frequent, but 
 of short duration, and followed by very prolonged unconsciousness. 
 In contrast with the above there are other instances where the knee- 
 jerk is completely lost after a severe fit, re-appearing again slowly in 
 the course of four or five minutes : in such cases clonos is not 
 observed, and the post-epileptic stupor has been prolonged and 
 profound, 
 
 ih) Petit Mai. — In these attacks there may be nothing observed 
 beyond momentary loss of consciousness and pallor of face. The 
 patient may be sitting or standing during the attack ; he does not fall. 
 He may drop what he holds in his hands, or be suddenly arrested in 
 movement, but may instantly recover himself, and act as if nothing 
 unusual had occurred. Esquirol relates the case of a lady equestrian 
 who had frequent attacks of petit mal when on horseback, yet never 
 fell off". There was momentary arrest in her conversation, the bridle 
 dropped from her hand, but, in a few seconds, she had recovered and 
 finished the sentence interrupted by the attack. Very often the face, 
 subsequent to pallor, becomes flushed (Goicers). In these slight seizures 
 there maybe slight facial spasm — the expression is momentarily ^aW/ 
 or a spasm of the hand may occur, or a more noticeable (but limited) 
 convulsion of very transient duration. 
 
 One of the preuionitory 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 vial occurring, 
 or these two forms of epilepsy may occur inditferently, now one and 
 now another, in the same subject — or attacks of grand mal interspersed 
 with the minor attack, may gradually predominate and eventually 
 whollv replace the petit vial. Thus one of our patients at the West 
 Eiding 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 
 
POST-PAROXYSMAL PERIOD. 267 
 
 was momentary loss of consciousness— the head drooped slightly, the 
 pencil slipped through his fingers, but was almost instantly regained, 
 and the sentence was 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 condition might readily have 
 been overlooked. In the case of this patient, a letter might have 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 tliose which have the greatest integration, that is to say, of the 
 substrata of consciousness " [Hughlings- Jackson).'^' 
 
 4. Post-paPOXysmal Period. — It is during this post-paroxysmal 
 period that much valuable information may be gleaned, as the mental 
 automatism then displayed is in many cases prolonged, and afibrds us 
 the opportunity of careful study. Epileptic mania of transient dura- 
 tion is a most common result of the paroxysm, but it is by no means 
 always of so fleeting a nature. Cases occur where the maniacal 
 excitement extends over many days without any further 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 {jMd mal), just as it may be the sequel to 
 the major convulsive attacks {grand mat), and a single " fit," convulsive 
 or non-convulsive, may leave the patient in this maniacal condition just 
 as frequently as a successioji 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 
 was so slight as to be scarcely, if at all, appreciable to the onlooker. 
 In like manner the major discharge, if it starts (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 suftice 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 
 
 * Loc. cit., p. 304. 
 
•268 , EPILEPTIC INSANITY. 
 
 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 last few hours of 
 the pre-paroxysmal stage. In the state of epileptic mania such delu- 
 sional perversions are very likely to re-appear, and to prompt the 
 subject to deeds of violence. There is a tendency apparent after 
 epileptic seizures in the insane, for consciousness, on its re-instatement, 
 to be occu})ied 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 E. C. in her automatic endeavour to pull out her hair (see p. 271). 
 We mention these cases more particularly because they appear to us 
 
POST-PAROXYSMAL PERIOD. 269 
 
 often to atibi'd a clue to the persistence of a delusional notion, which, 
 being present in the pve-paroxysmal stage, may rise into being in the 
 post-paroxysmal period during the reductions of this stage, and issue 
 in immediate action — i-uicidal 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. 
 
 From 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 tlie part of an able attendant, so that they are readily 
 overpowered and managed in most cases. 
 
 Again, the sexual passion may be highly evoked and erotic condi- 
 tions prevail in this post-paroxysmal stage. One of the most instructive 
 instances of this at the West Riding Asylum was the case of an 
 epileptic lad, who exhibited, as an invariable sequence to his epileptic 
 seizure, the most frantic outburst of satyriasis, immediately succeeding 
 the convulsive stage ; during this outburst, seclusion was imperative, 
 to secure his fellow-patients from indecent assaults. In the inter- 
 paroxysmal periods this patient was a well-conducted lad, devoid of 
 abnormal pruriency, and was a striking illustration of the importance 
 of recognising this condition as the outcome of epileptic reductions in 
 a certain class of subjects. 
 
 It is not, however, all cases 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 
 wall ; 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 
 
2-0 EPILEPTIC IXSAXITY. 
 
 sufiers from epileptic excitement for a fortnight subsequently. She 
 lies in bed in a huddled heap, covering her head with the bed-clothes, 
 muttering incoherently. AYlien 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 upon the cessation of the comatose stage. 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 pectiliar 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. 
 Oowers says — '•' Instead of jiresenting such automatic action, some 
 patients pass, as already mentioned, into a state of violent hysteroid 
 convulsions. 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.'" '■■ 
 
 Casf. q/ E^ C. 
 
 The most remarkable case we have met with occurred at the West Riding 
 Asylum some fourteen years ago. 
 
 It was that of a young woman aged twenty-eight, and single, who continued 
 for sixteen months under our observation, and who for the first twelve months 
 was subject to epileptic and hysteroid seizures, whilst during the latter four 
 months she was completely free from fits, and was discharged recovered. Her 
 seizures occm-red with gi-eat regularity e^-ery three weeks, and lasted from three 
 to six days — the con^-ulsive seizures occurriog both night and day. The s\-mptoms 
 of the several stages were thus distributed. 
 
 Prt-ijaroxy-invil Stage. — For some days before a seizure, restlessness, u-ritabiUt}-, 
 a pale and anxious look, depression amoxmting 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, " KiU them I kill 
 them : kiU them I " She was at this time distinctly suicidal and homicidal in 
 her impulses, and alwaj'S recognised that the "fits" were pendmg when the 
 phenomenal voice occurred. Occasionally, ^\-ithout a seizure, she now became 
 very ^■iolent and destructive, 
 
 Prtmonitory Period. — Restlessness more urgent, the " voice" more imperative, 
 then the sensations of " a clock " %vithin the head " wound up tighter and tighter," 
 when all becomes dark, and consciousness is abolished. Asked afterwards to 
 describe the "clock," she defined a circiJar sweep about 4 inches in diameter, 
 
 *0p. cit., p. 692. 
 
CASE OF HYSTERO-EPILEPSY. 27 I 
 
 and in a horizontal plane around the vortex 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 pulling out her hair. ) 
 Associated -n-ith 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 seizure ; 
 but, she often refers to the clock as it begins, crying out, "The clock," "the 
 clock," and then becomes unconscious.* 
 
 The paroxysm was invariably notable for the following features : — 
 (a) Deliberate rise of temperature and r[uickened pulse during the quarter of an 
 hour preceding the fit. 
 
 {h) Peculiar recurrence of convulsive seizure in series of threes or sixes. 
 
 (c) Extraordinary periodicity of both diiirnal and nocturnal seizures. 
 
 (d) Post-epileptic automatism replaced by hysteroid seizures occasionally ; or 
 by wild epileptic mania with determined suicidal or homicidal impulses. 
 
 The rise of temperature usually amounted to a degi'ee above normal, 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 rise in 
 tempjerature still took place, and became even more marked Avhen the fit 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 miiscles, and fit over. Three or six such 
 attacks occur in succession, the last always followed by closure of the eyes, which 
 throughout the attack had been kept open." Then after three or more minutes' 
 calm the hysteroid attach occurred ; the eyes opened suddenly, staring vacantly, 
 the head was drawn rigidly back, the body arched backwards in a position of 
 opisthotonos for about fifteen to thirty seconds ; then the head was throwTi vio- 
 lently forwards and backwards several times, and a severe struggle ensued in 
 which she had to be forcibly lestrained by several nurses to prevent hei' rushing 
 to the window or injuring herself or others. When watched (unkno^vai to herself) 
 in the padded room at night, the same attacks occur, and in the succeeding 
 hysteroid seizure her body has Vjeen tossed from end to end of the room against 
 the pads by the violence of the contortions ; her bedclothes, 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 tlie case would 
 naturally suggest a purelj^ hysterical origin for such an attack ; but that the 
 seizures were genuinely epileptic associated with sequent lij^steroid seizures, was 
 conclusively shoAvn by associated conditions which were invariably present ; these 
 were — (1) initial rise of temperature and jiulse ; (2) aura of the " clock " followed 
 
 * This case, of which the main features are given here, has been puVjlished in 
 detail in the West Ridiwj Asylum Reports, vol. vi. 
 
2/2 EPILEPTIC INSANITY. 
 
 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 epileptic attacks occurring in this subject varied from 80 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°, aiid 
 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 before the 
 fit ; but at the exact moment when the fit was expected, instead of a con\Tilsive 
 seizure, there was sudden profound sleep and a rise of about six-tenths of a degree." 
 
 Another peculiar phenomenon was noted after the conAT.ilsive seizures had 
 ceased and whilst a still childish, pettish mood prevailed, with distinct alienation, 
 the temperature taken at periods correspjonding 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, would 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 epilepsy. 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 auto- 
 matic stages. 
 
 Epileptic Katatonia. — We may here advert to cases of so-called 
 katatonia — a term intended by Kahlbaum 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 pubei'ty and adolescence, in the puerperal forms 
 of insanity, and are 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 pathological 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 extraordinaiy periodicity of the 
 attacks narrated in the last case is, of course, exceptional ; yet a well- 
 marked tendency to tlie periodic return of epileptic seizures has long 
 
STATUS EPILEPTICUS. 273 
 
 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 
 more frequent, a few seconds only intervening between each discharge, 
 so that at times they appear almost continuous, a fresh discharge being 
 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 tit 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 tixed 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 tempei-ature 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- 
 * Quoted by Ross, op. cit., p. 932. 
 
 18 
 
274 EPILEPTIC INSANITY. 
 
 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 automatisna, of a most elaborate kind, is a prominent 
 and often perilous feature in some epileptics after their fits ; its interest 
 as a medico-legal question is great. Thus we constantly observe 
 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; purloin 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 acccordance 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). 
 
 InterpaPOXysmal 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, and prior to the 
 disturbance engendered by the approach of a fresh series of fits. In 
 fact, we have to study the peculiar characters of the epileptic neurosis, 
 and the permanent mental reductions which become 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 i-espect) enables them to take up any 
 employment for which they were fitted, and carry on responsible 
 functions in various departments. Why are they, then, inmates of an 
 asylum 1 Because their epileptic seizures are preceded or followed by 
 such transient mental aberration, or by such reductions as render them 
 at tliese 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, 
 
INTERPAROXYSMAL STATE. 
 
 275 
 
 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 justice), that because a man 
 has had Jits for many years his mind must necessarily have suffered 
 permanently; although, of course, in a large number of cases, the 
 presumption is in favour of such implication. 
 
 (b) Then there are those cases of epilepsy in which 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, 
 the delusional states engendered render them, at all times, apart from 
 their paroxysmal seizures, prone to acts of desperate violence. 
 
 {d) 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 repulsive traits — more obnoxious passions ; and 
 in none does the physique undergo such a corresponding degradation 
 in type. 
 
 Amongst the sevei'al 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 
 
276 EPILEPTIC INSANITY. 
 
 exaggerated into a serious ailment, and incessant complaint is made ta 
 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 
 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 epileptic's 
 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 
 feelings 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; will 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 
 
FORENSIC ASPECTS OF EPILEPTIC INSANITY. 
 
 277 
 
 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 ai-e not to be received, except 
 with caution, 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 
 characterised, like his actions duringperiods 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 indiscriminately from a 
 large number of cases examined : — 
 
 Reactiox-time IX Epileptic Ixsaxity. 
 
 
 Acoustic Stimulus. 
 
 Optic Stimulus. 
 
 J. J. M., . 
 
 •20 of a second. 
 
 •23 of a second. 
 
 J. v., . . . 
 
 •21 
 
 •25 
 
 F. P., ... 
 
 ■18 
 
 •23 
 
 i J. D., ... 
 
 •19 
 
 •21 
 
 W. P., . . . 
 
 ■17 
 
 •19 
 
 R. H., . . . 
 
 •24 
 
 •26 
 
 A. D., ... 
 
 •28 
 
 •29 
 
 Medico-legal 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 cerebral diseases it is the one which tends to 
 engender impulsive forms 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 ? It is obvious from the foregoing considerations that 
 epileptic insanity no more presents a tiniform 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 
 
278 EPILEPTIC INSANITY. 
 
 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 wherein no mental 
 anomaly presents itself. It cannot be questioned that many epileptics 
 suffer little, if any, mental derangement prior, or subsequent, to their 
 seizures ; and, that the interparoxysmal period may 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 paribus, 
 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 proximity of an act of outrage 
 or violence to an epileptic seizure directly favours the presumption of 
 mental impairment ; and, in this connection, it must be strongly in- 
 sisted upon that the mental disturbance following upon a single 
 epileptic fit 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 
 sanel 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 
 hours, 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. 
 
IMPULSE— DELUSION. 279 
 
 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. 
 
 IneontFOllable impulse is another form of morbid activity which 
 reveals itself in the subjects of epilepsy ; like the motor explosiveness 
 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 arouse within them the 
 ancient doctrine of fatalism ; they may be terrified at their own help- 
 lessness, and implore us to impose restraint — a plea the very 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 cpnduct 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 
 motive, which, if found, he regards as evidence presumptive of the 
 volitional nature of the act, and subversive of the doctrine of its im- 
 pulsive character. He assumes that the presence of motive warrants 
 him in regarding the epileptic as fully conscious of the deed he 
 performs — 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 
 reacts 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, outrageous actions may be committed during the 
 wild mania incident to epilepsy ; in these cases, of course, no doubt 
 can arise as to the agent's utter irresponsibility. Tlie natUPO 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. 
 
28o EPILEPTIC INSANITY. 
 
 aimless, uncalculating, utterly reckless fury, which at once stamps it as 
 the work of an epileptic {Maiidsley). 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'atioil 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 early and premonitory stages of the attack ; the 
 paroxysm itself often having the effect of clearing off 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 suffers 
 notably from delusion prior to his seizures, the outcome of his 
 paroxysm should be carefully watched {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, 
 be regarded as an irresponsible agent. The depth of reduction in these 
 epileptic 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 incontroUable impulse 'i 
 
 MalingePing". — 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 be 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 stroug 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. 
 
CASE OF REG. V. TAYLOR. 28 1 
 
 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 sliould always be borne in 
 mind. The difficulty is greatly enhanced by the fact that the criminal 
 classes 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 hallucinatoi'y 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 ofcen 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 
 sufi"er 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 Eeg. 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 jwsi prior to his trial) were of this nature. The closest obser- 
 vation and repeated examination during his early imprisonment wholly 
 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 offence, 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 sti'ong 
 •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 
 
282 EPILEPTIC INSANITY. 
 
 petit 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 "i 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, handling 
 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 
 instances of hallucination, or the aura epileptica, becoming the motive 
 for action during the automatic stage is illustrated by a case where 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 sprang 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, preceded 
 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 weapon, and during this automatic stage he murdered his 
 wife. No case could more forcibly indicate the frightful 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 hromism, 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 
 DO avail ; but by far the larger number exhibit a notable reduction in 
 the frequency and severity of their fits upon their administration. The 
 
TREATMENT OF EPILEPTIC INSANITY. 283 
 
 bromides have no immediate action in checking the fits, so that a 
 somewhat prolonged treatment is necessary ere the desired etlect is 
 obtained ; hence, if the attack is threatening (owing to the severity 
 and rapid succession of the convulsions) to pass into the stattcs epilep- 
 ticus, it is of little use depending upon the bromide for cutting short 
 the attack. For this purpose we have no rival to chloral, which, 
 given in sufficiently large doses, rarely fails 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 well, first, to inject subcutaneously from -^^jj to 
 •^ of a grain of atropine if a large dose (40 to 60 grs.) 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 think, to the more frequent administration of small doses. It is 
 imperative 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 ot passing into the epileptic 
 status, and dying thus. Hence it is that in most asylums we find 
 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. 
 
 It has been stated that the percentage of hemoglobin and the 
 specific gravity of the blood occasionally increase after epileptic 
 seizures, and are constantly higher in those epileptics who have for 
 years adopted the bromide ti-eatment, than in those who have taken 
 bromides in moderation only.* 
 
 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 patient 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. 
 
 * Vorster, Oj/. cU. 
 
284 EPILEPTIC INSANITY. 
 
 On the other hand, a certain proportion of our epileptic insane have 
 a series 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 cr thrice daily, rarely fail to alleviate the 
 excitement. In the more serious delirious outburst of epileptic furor, 
 it 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 influence in epilepsy is due to this action " (Gowers). 
 
 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 
 also much maniacal excitement. Its use is also called for in all the 
 hysteroid attacks. 
 
GENERAL PARALYSIS OF THE INSANE. 285 
 
 GENERAL PARALYSIS OF THE INSANE. 
 
 Contents.— Prodromata— Egoism— Early Moral Perversion— Failure of Re-repre- 
 sentative 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 Impaimaent— Cerebral Seizures— Syncope— Epilepsy 
 (J.F.)— LTnilateral Twitching (J. S.)— Epileptiform Attacks— Conjugate Devi- 
 ation— Case of H. P.— Apoplectiform Seizures — Monoplegias — Hemiplegise— 
 Muscular Sense Discrimination — Apparatus for Testing Appreciation of 
 Weight— Reaction Time— Spastic and Paralytic Myosis — Mydriasis and Amaur- 
 osis — Reflex and Associative Iridoplegia — Statistical Tables — Consensual Move- 
 ments—Reflex Dilatation— Siguiflcance of certain Pupillary Anomalies — Spinal 
 Symptoms — Deep Reflexes — Tabetic Gait — ^Incontinence and Retention — 
 Atrophy of Vesical Muscle— The Blood in General Paralysis— Clinical Groupings 
 of 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 authorities on the subject differ 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. 
 
 General paralysis, even as a specific entity, has been called in ques- 
 tion, and its severance from other forms of chronic cortical encephalitis 
 has been regarded as an arbitrary and unjustifiable procedure. By 
 far the most able attack upon the morbid unity of this disease has 
 emanated from Dr. Reginald Farrar, and, although, we are not in 
 accord with the general thesis, we fully appreciate the vigour of 
 thought and breadth of view which characterise Dr. Farrar's article.* 
 When he is further told that no single portion of tlie 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 varied 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 cerebral 
 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 diflerent French writers of eminence, 
 the utility of which, however, is questionable, except as a matter of 
 pure convenience for purposes of description ; they do not represent 
 genuine pathological varieties. What the student should more 
 
 * " On the Clinical and Pathological Relations of General Paralysis of the 
 Insane," by Reginald Farrar, M.A., M.D., Oxon., Joum. Mental Sc, 1895. 
 
286 GENERAL PARALYSIS. 
 
 especially bear in mind is the fact that, in this affection, he is 
 dealing ^vith 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. It must be admitted, however, that this progressive 
 deterioration of the nervous mechanism from higher to lower, from 
 lower to lowest levels, is regarded by some able observers as not a satis- 
 factory statement of the case. Whilst readily admitting that the chief 
 incidence of the morbid factor is on the cortical nervous system, some 
 observers hold that the advanced, early, and extensive peripheral 
 changes (nerve and muscle) so often found, and now universally 
 admitted, bespeak something more than a mere secondary implication 
 (secondary, i.e., to the primary brain lesions) and that they closely 
 approximate (if they are not identical) to the conditions found in the 
 group of primary toxsemic Neuroses, dependent on an intrinsic toxic 
 agent {A. Campbell).'--' The progressive impairment of highly elaborated 
 motor mechanisms and the mental reductions comprise the character- 
 istic 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. 
 
 Prodromal Stage. — 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 
 o-ravest 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 afi'ective sphere of mind may issue in melan- 
 cholic gloom or despondency ; or, on the other hand, in undue elation 
 and bien-etre ; but just as often in sudden alternations of mood from 
 one extreme to the other. The general restlessness spoken of pertains 
 
 * ' ' Neuro-muscular Changes in General Paralysis,'' Journ. Mental Sc. , April, 1894. 
 
EARLY MORAL PERVERSION. 287 
 
 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 resources. 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 
 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 which 
 no adequate cause can be assigned. It will be observed that we do 
 not infer from all this a distinctly deluded 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 perversion 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 receive 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 
 wholly wanting ; and still less is that rC-reprCSentative faculty 
 intact, which enables him to contrast the act as viewed in its nature 
 with certain ethical canons. The moral lapse is, therefore, truly 
 
288 . GENERAL PARALYSIS. 
 
 signiBcant 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 
 of its accomplishment. An act of theft may be committed with open 
 effrontery, no attempt at concealment being made ; the most wanton 
 outrage on public decency — the most audacious libertinism — may be 
 committed by an individual apparently quite oblivious to a breach 
 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 effort of atten- 
 tion ; and how completely oblivious he became to the various links- 
 of the argument followed, before this disruption occurred. In this 
 
ENFEEBLED ATTENTION— TRANSIENT AMNESIA. 289 
 
 instance these sudden amnesic attacks prevailed for raany 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-iip of his 
 feelings, only relieved by a passionate flood of tears." 
 
 The transitory amnesic states are very frequent as an early 
 symptom of the disease, and almost invariably imply a serious failure 
 in attention — the faculty which, as Sir J. Crichton-Browne has insisted, 
 is earlier impaired than any other. To the same origin must be 
 attributed the forgetfulness 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 manner 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, thirt}^- 
 five, too surely indicates the ruin even now commencing " (Blandford).* 
 
 We observe, at this period, 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 j the circulation is generally sluggish ; and an 
 early symptom (one for which 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 irequent premonition is that of 
 vertiginous 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 co-exist also, or may 
 antedate the above paretic symptoms by months or even years, as 
 atiirmed by Griesinger. Another highly signiticant group of symp- 
 
 * Op. ciL, p. 200. 
 
 19 
 
290 GENERAL PARALYSIS. 
 
 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. 
 
 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 ; 
 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 efibrts 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 emotion, 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 
 are wholly different 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 given by the over- 
 clouded reason, and so the sensuous procession of impressions pass 
 
ESSENTIAL NATURE OF THE DELUSIONS. 29 I 
 
 by in everchanging kaleidoscopic hues, uniting and re-uniting in 
 fantastic combinations, conjuring up visions of immortal life, of love, 
 of beauty, of wealth, or of honour, or of all that mortal could desire. 
 Challenge him upon the absurdity of his statements and a momentary 
 irritation may occur ; but he readily wanders off into his grandiose 
 strain, asserting and re-asserting with stronger emphasis still more 
 extravagant delusions. 
 
 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 mnemonic 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 
 vicrour 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 resxilt. 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 
 right hand, and an aphasic state lasting some five minutes after 
 regaining consciousness. The following day a similar test was applied 
 to this patient ^(ntIl identical results, except that the convulsive dis- 
 charge was spread over a wider range. 
 
 We have recorded a somewhat similar case where the patient, who 
 was suffering from progressive paralysis, could not protrude his tongue 
 without inducing violent left facial spasms, the tonic twitchings being 
 associated with much vaso-motor paresis.* 
 
 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, re-asserts, and never attempts 
 
 *" Ocular Symptoms of General Paralysis," Brit. Med. Journ., April and 
 May, 1896. 
 
292 GENERAL PARALYSIS. 
 
 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 
 indefiniteness of emotional states renders their expression by language 
 difficult, 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 
 to his own satisfaction, to express by language what rises before his 
 mind, his 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 whch have 
 chiefly engrossed his mind, will usually afl'ord material for these delirious 
 conceptions ; thus, a poor labourer who through years of anxious toil 
 has struggled to support a lai'ge 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 i-esources 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 oft' 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 stuff's, 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- 
 
THE FACIAL EXPRESSION. 293 
 
 teristics are prominently developed ; the female, especially, betraying 
 much personal vanity ov 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 
 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 expression 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 efi'ort, 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. 
 
294 GENERAL PARALYSIS. 
 
 ArtiCUlatOPy Troubles. — The character of the articulation is 
 distinctive ; it is slowed, hesitating, blurred, approaching that of a 
 drunken man ; its utterance is broken, syllabic 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 tremor of the upper lip. It is 
 the labial and lingual utterance which suffers chiefly ; and, if present, 
 it is at once manifested by requesting him to repeat any alliterative 
 doggerel ; 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 word 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. Hemiplegias and monoplegise. 
 
 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 momentary prostration, he rallies and recovers his former 
 state. Such patients demand rest in bed. Attacks of petit mal 
 are occasionally mistaken for syncopal attacks, and reported as slight 
 " faints " by the nurse or friends, f 
 
 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 oi petit mal are the more usual. They are characterised by very 
 
 * See " Hemiatrophy of Tongue, with Numerous Cases," by Trevelyan, Brain, 
 vol. xiii., p. 102. 
 
 tSee "Warnings of General Paralysis of the Insane," by George H. Savage, 
 M.D., Brit. Med. Journ., April 5, 1890. 
 
LIMITED OR UNILATERAL TWITCHING. 295 
 
 transient loss of consciousness preceded by pallor, wide dilatation of 
 pupils, and perhaps a slight twitching of one side of the mouth, 
 followed by much confusion of thought, obvious in inconsistent speech 
 and conduct; or by more prolonged automatic states. 
 
 J. F. , March 21, 1881, 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 lasts 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. 
 
 2. The mouth is drawn to the right, lips twitch strongly and uncover the 
 canines. 
 
 3. Right arm flexed, with forefinger extended ; then raised and convulsively 
 jerked at shoulder ; the brow twitches violently. 
 
 4. In certain seizures the discharge spreads 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. 
 
 On the other hand, the occurrence of general paralysis as a sequence 
 to ordinary epileptic insanity is very rare, a fact which has also been 
 indicated by Savage, who states : — " It is remarkable that the epileptic 
 insane provide very few cases of general paralysis, but that general 
 paralysis follows epileptiform fits in many cases. So much is this my 
 experience, that when I hear of the onset of tits of the epileptic type 
 in a middle-aged man, I at once look for other signs of degenera- 
 tion." * 
 
 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. 
 Such twitching is often increased by handling and passive movement 
 of the limb. The limb may be fixed iii 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 proti-acted over days or even 
 weeks without interruption. The following case illustrates this fact : — 
 
 * Oi>. rit. 
 
296 GENERAL PARALYSIS. 
 
 J. S., a general paralytic, was seized with convulsive twitchings of the limbs on 
 the 25th of November, 1886. 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 clonos 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 cerebrale is rapidly produced, and is vivid 
 over all parts of the body. Both conjunctivae are injected ; both pupils show 
 mydriasis, but the left is larger, and both are fixed to a bright beam of light. 
 Bowels and bladder paralysed. Patient is greatly demented and quite mute. 
 
 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 unchanged ; the plantar reflex is greatly exaggerated and hyper-sensitive. 
 
 April 16, 1887. — 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 convulsive movements 
 in 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 degree of WOPd-blindneSS or 
 deafness presents itself. 
 
 EpileptifOPm Seizures. — Under this term are comprised general 
 convulsive seizures, or convulsive discharges from motor centres, 
 representing large associated groups of the musculature of the body 
 and limbs. Such attacks are often ushered in by premonitory twitch- 
 ings, such as those just described ; they are 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 everywhere 
 except at the starting point, usually the mouth, eye, or hand, where 
 occasional jerks are seen which may gradually die out ; or, on the 
 contrary, the preceding cycle of events may be repeated, or the renewed 
 convulsion may chiefly affect the other side."* 
 
 The onset pf 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 primary discharges occur ; the clonic stage being often 
 long protracted, 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. 
 * Treatise on General Paralysis, p. 163. 
 
VARIED CONVULSIVE AEFECTIONS. 297 
 
 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 the 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 affirmed 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 tlie cry, and 
 the mental symptoms will of course be quite different."* {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 ruuscles may be involved, the cheek flattened, and the 
 mouth drawn to the opposite side ; there may be more or less £["10880- 
 plegia, or the patient may be completely aphasic with right brachial 
 monopleg'ia ; or the leg only may be temporarily paralysed, or 
 hemiplegia may prevail. Conjugfate deviation of the head and eyes 
 is also frequent as a post-convulsive sign. 
 
 Epileptiform seizures may occur at an eai-ly period of the disease, 
 usually not until twelve months have elapsed. According to Dr. 
 Newcombe, 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 twenty-four months after the 
 commencement of the disease, whilst one only had convulsions within 
 three months of the onset, f 
 
 The immediate result of these general, wide-spread, epileptiform 
 convulsions is of far greater import as affecting the mental aspect of 
 our 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 ; sucli seizures occurring several 
 times in the course of the day and night, and lasting foi- several days together. On 
 their cessation he was left in a condition of profound imbecility, from which lie 
 never rallied. In his case, persistent and copious watery alvine evacuations 
 accompanied the convulsive attacks. 
 
 The mental deterioration following epileptiform seizures is often so 
 
 * Op. cit., p. 266 (Italics not in original). 
 
 tSee "Epileptiform seizures in general paralysis of the insane," West Riding 
 Asylum Reports, vol. v. 
 
298 GENERAL PARALYSIS. 
 
 notable as to sharply demarcate the stage of maniacal excitement and 
 delusional perversion from the last stage of hopeless dementia and 
 motor helplessness. 
 
 The epileptiform seizure is also ominous of rapid break-down ; " in 
 twenty-four out of sixty cases, death occurred within a month after an 
 attack " (JVeivcombe).* 
 
 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 with perspiration ; 
 the breathing may be heavy and laboured, the pulse rapid, and the 
 temperature quickly rises to 103° or higher. The condition is always 
 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 d.ysphag'iC symptoms, and by much increased mental enfeeblement. 
 
 Monoplegise and HemiplegiSS.— Paralysis suddenly occurring 
 without apoplectic or epileptic premonitions involving one or both 
 limbs, or complete hemiplegia, of very transient duration, is another 
 feature frequently 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 crural or a brachial monopleg-ia which may have com- 
 pletely disappeared in a few hours or days. 
 
 Muscular Sense Discrimination.— The localisation of the sense 
 
 of muscular discrimination in the so-called " motor area " of the cere- 
 bral cortex— the " kinsesthetic centres" of Bastian — appears lately to 
 have received considerable confirmation from the clinical and the 
 pathological side. We shall not attempt here to do more than to 
 " indicate that in general paralysis where the kinsesthetic centres are 
 early, and in the majority of cases most seriously, involved, the 
 muscular sense is obviously defective, and the delicate appreciation by 
 this channel often very seriously blunted. We are not aware that 
 this question has been definitely settled prior to this date, and we, 
 therefore, bring forward our results as suggesting (1) the localisation 
 of this sense, and (2) the means of accurately determining the defect 
 in this sense by measurement. 
 
 In the following cases of progressive paralysis of the insane, the 
 muscular discrimination was tested in right and left hands, with the 
 
 * Loc. cit. 
 
MUSCULAR SENSE DISCRIMINATION. 
 
 299 
 
 most careful precautions to exclude all fallacies, and all instances were 
 omitted where dementia was so advanced as to introduce a chance of 
 error. The instrument used was Galton's, a description of which is 
 given on p. 301. The figures in the tables indicate the respective indices 
 of the finest series successfully arranged : thus Q—G indicates that series 
 6, and all the coarser series up to 12, were successfully dealt with, but 
 that at series 5 the operator failed, and, therefore, series 6 repre- 
 sents the measurement of his bluntness of muscular sense appreciation. 
 
 Measurements of Muscxtlar Sense Appreciation in G.P. Lowest Registry. 
 
 Right 
 
 Kight. 
 . 3 
 . 3 
 . 3 
 . 4 
 
 E. C, . 
 
 C. A. (alcoholic excess), 
 
 J. C. (alcoholic excess), 
 
 W. G. H., . 
 
 T. B.,. 
 
 J. H., . 
 
 S. H., . 
 
 J.W.H. (extremely grandiose), 5 
 
 S. H^. (alcoholic excess), . 5 
 
 W. R., . . . .5 
 
 E.S., 6 
 
 T. C, 6 
 
 C. W. (alcoholic excess ; much 
 tremor of hands), . . 6 
 
 R. D., 6 
 
 W.B., . . . .6 
 
 W. H., . . . .7 
 W. B2., .... 7 
 J. E. (much hypochondriasis), 7 
 S. W., .... 7 
 T. L. N., . . . .8 
 
 Left. 
 
 7 
 5 
 4 
 12 
 5 
 6 
 8 
 8 
 5 
 7 
 6 
 
 6 
 
 J. S., . 
 
 J. V. B., . 
 
 J. H2., 
 
 W.G., 
 
 E. B. (alcoholic excess), . 8 
 
 E. A.A., .... 8 
 
 S. H-*., 
 
 E. B. (alcoholic excess), . 8 
 
 T. v., 9 
 
 W. B»., .... 9 
 C. S. R., . . . .9 
 T. S. (alcoholic excess), . 9 
 R. B. (alcoholic excess ; sy- 
 philis ; manual and loco- 
 motor ataxia), . . .12 
 J. M. (alcoholic excess), . 12 
 . 12 
 
 Left. 
 
 8 
 
 8 
 10 
 
 9 
 10 
 10? 
 
 8 
 
 8 
 
 9 
 
 9 
 
 9 
 12 
 
 12 
 
 12 
 8 
 
 J. H3., 
 
 T. S-.,. . . faihat\2faihat\2 
 W. R. (syphilis), ,, 12 con-ecHO 
 
 T. M., . . ,, 12 ,, 9 
 
 W. (4., . . ,, 12/cw7.san2 
 
 How far this failure of the appreciation of weight could be dis- 
 severed from loss of tactual and other sense anomalies, was put to the 
 test in several cases, with the results indicated in the following table. 
 In most of tliese we perceive that little or no impairment of cutaneous 
 sensibility existed, but, on the other hand, an acute tactual sense, and 
 a fine discrimination for temperature and painful impressions. The 
 discrimination between slight differences in temperature was tested 
 by tubes held in the palm of the hand, into which cold or warm water 
 was gradually poured to obtain the delicate shades of warmth required. 
 Tactile sensibility was tested by the ordinary sesthesiometer ; tlie 
 results with the latter instrument sufficiently attest to the absence of 
 dementia as an element explanatory of the muscular sense measure- 
 ments. For comparison with the table of measurements of the tactual 
 sense we give the normal results as stated by the best authorities. 
 
 [a) Tip of forefinger, 2-0 mm. to 2-3 mm. 
 (6) Ball of thumb, 6-5 ,, to 7-0 ,, 
 (c) Back of hand, 31-6 ,, 
 
 ('/) Back of forearm, 
 (e) Front of forearm, 
 
 45'1 nun. 
 15-0 ,, 
 
!00 
 
 GENERAL PARALYSIS. 
 
 Cases of 
 
 General 
 
 Paralysis. 
 
 Muscular Sense 
 Discrimination. 
 
 Tactual 
 Discrimination.* 
 
 Sense of 
 Temperatm-e. 
 
 E em arks. 
 
 W. B2., 
 
 Right. 
 
 7 
 
 Left. 
 6 
 
 Eight. Left. 
 (a) 2.0 mm. 5 mm. 
 {b) 12-5 „ 7-5 ,, 
 (c) 7-5 „ 10 „ 
 (rf)22-5 „ 12-5 „ 
 (e) 20 „ 12-5 ,, 
 
 Eight. Left. 
 Exquisitely 
 keen. 
 
 Excited and 
 very grandiose. 
 
 J. K, 
 
 7 
 
 7 
 
 (a) 5 ,, 5 ,, 
 {b) 9 ., 9 ,, 
 (c) 12-5 „ 10 ,, 
 (fZ)20 ,, 17-5 ,. 
 (e) 22-0 „ 22-5 ,; 
 
 Do. 
 
 Depressed and 
 h^-pochondria- 
 cal. 
 
 S. H3., 
 
 7 
 
 9 
 
 (a) 2-5 „ 2-5 ,, 
 (6) 3-5 „ 5 „ 
 (c) 6-5 ,, 9 „ 
 (d)n-o „ 22-5 ,, 
 (e) 3-5 ,, 5 ,, 
 
 Do. 
 
 Advanced G. P. 
 'with extreme 
 tremors of face 
 and limbs. 
 
 E. B., 
 
 8 
 
 10 
 
 (a) 2-5 ,, 2-5 ,, 
 (/') 7-5 ,, 10 ,, 
 (c) 10 „ 7-5 „ 
 {d) 15 „ 17-5 ,, 
 (e) 15 ,, 17'o ,, 
 
 Do. 
 
 G. P.— Alcoho- 
 lic excess. 
 
 S. H2., 
 
 5 
 
 5 
 
 (a) 3-5 ,, 2-5 ., 
 (6) 5 ., 5 „ 
 
 (c) 10 ., 5 ., 
 
 (d) 12-5 ,, 17-5 „ 
 
 (e) 15 ,, 22-5 ,, 
 
 Do. 
 
 G. P.— Alcoho- 
 lic excess. 
 
 J. H., 
 
 12 
 
 8 
 
 (a) 2-5 ., 1-5 ., 
 ib) 5 „ 2-5 „ 
 
 (c) 7o „ 10 ., 
 
 (d) 10 „ 7 „ 
 
 (e) 10 „ 12-5 ,, 
 
 Do. 
 
 G. P., with ex- 
 treme hypo- 
 chondriasis. 
 
 W.G.H., 
 
 4 
 
 12 
 
 (a) 2-5 „ 2-5 ., 
 {b) 10 „ 5 „ 
 
 (c) 12-5 „ 12-5 ,, 
 
 (d) 12*5 ,, 7"5 ,, 
 
 Do. 
 
 
 C.S.R., 
 
 9 
 
 9 
 
 (a) 2-5 „ 2-5 „ 
 
 (b) 10 „ 10 „ 
 
 (c) 15 „ 10 „ 
 
 (d) 12-5 „ 10 „ 
 
 Do. 
 
 
 R. D., 
 
 6 
 
 / 
 
 (a) 2-5 „ 2-5 „ 
 
 (b) 10 „ 7-5 „ 
 
 (c) 15 „ 12-5 ,, 
 {d) 12-5 „ 17-5 „ 
 
 Do. 
 
 
 C. A., 
 
 3 
 
 5 
 
 (a) 2-5 ,. 2-5 „ 
 
 (b) 10 „ 7-5 „ 
 
 (c) 15 ,, 15 ,, 
 
 (d) 15 „ 12-5 „ 
 
 Do. 
 
 G. P. , with his- 
 tory of alcoho- 
 lic excess. 
 
 T. M., 
 
 fails 12 
 
 succeeds with 9 
 
 (a) 2-5 „ 2-5 „ 
 
 (b) 6-5 „ 9 „ 
 (r) 7'5 ,, 7'5 ,, 
 
 Do. 
 
 Extreme tremor 
 of both hands. 
 
 * The above figures for tactual discrimination express in Millimetre-^ the minimum 
 distance at which tw"o points of the compass are distinguishable. 
 
APPARATUS FOR TESTING APPRECIATION OF WEIGHT. 
 
 301 
 
 These results clearly imply for all the cases of general paralysis 
 examined, a keen sense of slight differences of temperature ; but slight 
 or no impairment of tactile sensibility, with indeed much exaltation of 
 the latter at certain sites — e.g., at the back of the hand ; and, on the 
 other hand, distinct impairment of muscular discrimination. 
 
 It is, therefore, interesting to note that in certain other cases of 
 insanity a similar failure prevails, and where we have every reason to 
 believe similar regions of the cortex are involved. We refer to cases 
 of adolescent insanity complicated with masturbatic habits, and to 
 certain cases of alcoholism and epilepsy. The following measurements 
 may suffice to illustrate these facts : — 
 
 Muscular Sexse Impairment in Adolescent, Alcoholic, and 
 Epileptic Insanity. 
 
 
 Muscular 
 Discrimin 
 
 Sense 
 ation. 
 
 Remarks. 
 
 
 Right. 
 
 Left. 
 
 
 
 G. H., 
 
 9 
 
 9 
 
 Alcoholism : much tremor. 
 
 
 W. S. W., 
 
 9 
 
 9 
 
 Do. 
 
 
 J. J., 
 
 8 
 
 9 
 
 Alcoholic dementia. 
 
 
 W. W., 
 
 8 
 
 9 
 
 Hypochondriacal melancholia : alcoholism. 
 
 
 B. D., 
 
 6 
 
 8 
 
 Alcoholism : impulsive insanity. 
 
 
 J. \l., 
 
 6 
 
 9 
 
 Alcoholism : delusional insanit}^ 
 
 
 w. w., 
 
 7 
 
 7 
 
 Alcoholism : chronic brain atrophy. 
 
 
 D. F., 
 
 6 
 
 6 
 
 Alcoholism : delusions of suspicion. 
 
 
 J. W. T., 
 
 4 
 
 4 
 
 Alcoholism : delusional insanity. 
 
 
 S. B., 
 
 9 
 
 9 
 
 Adolescent insanity : masturbation. 
 
 
 F. D., 
 
 12 
 
 8 
 
 Do. do. 
 
 
 T. S. B., 
 
 7 
 
 7 
 
 Do. do. 
 
 
 J. B. S., 
 
 7 
 
 7 
 
 Do. do. 
 
 
 W. H. B., 
 
 5 
 
 4 
 
 Epilepsy : masturbation. 
 
 
 M. C, 
 
 12 
 
 5 
 
 Right spastic hemiplegia and epileptiform con- | 
 
 
 
 
 viilsions. 
 
 
 G. S., 
 
 4 
 
 5 
 
 Old right hemiplegia with early aphasia : epilepti- | 
 
 
 
 
 form seizures. 
 
 
 G.E.O., 
 
 5 
 
 5 
 
 Typical epileptic insanit}'. 
 
 
 Apparatus for Testing- Appreciation of Weig-ht.— The iu- 
 
 strument employed for the foregoing observations was made by the 
 Cambridge Scientific Instrument Company, and is described by Francis 
 Galton in the Journal of the Anthropological Institute, for May, 1883. 
 
 It consists of a box holding ten grooved trays readily movable, each 
 tray supporting three cylindrical weights, all of which are exactly 
 alike in size and appearance, differing only in weight. The difference 
 in weight between each consecutive pair in a series varies with each 
 tray, the difference being marked on the tray. Commencing with a 
 weight of 1000 grains, a difference of 1 per cent, or 10 grains is the 
 minimum increment adopted ; and multiples of this in each series give 
 us a gradually advancing differential from 10 grains up to 120 grains in 
 the tenth tray. Thus, where W = 1000 grains, and the value of r = 1 -01^ 
 
302 
 
 GENERAL PARALYSIS. 
 
 Tray No. 2 has weights Wr" Wr^ Wr^ 
 
 3 
 
 Wr^Wr^ WrW 
 
 4 
 
 Wr^ Wr" Wri* 
 
 •5 
 
 Wr^Wr" Wr" 
 
 6 
 
 WrOWr« Wri2 
 
 ,1 7 , 
 
 WrOWr^ Wr" 
 
 8 
 
 Wr^Wr^Wris 
 
 9 
 
 WrOWrS Wri« 
 
 10 
 
 Wr* Wri4 -wr24 
 
 12 
 
 Wro Wri2 "Wr^^ 
 
 Upon the base of each weight the index of the power of r is 
 engraved, and these figures occur also on the side of the tray so as to 
 escape the attention of the person operated upon. 
 
 Commencing with a tray where the difference is coarse we gradually 
 work up to the series requiring more delicate appreciation — requesting 
 the person to take the weights between the thumb and forefinger and 
 arrange them in the order of their respective weights. The last series 
 correctly arranged gives the minimum 'differential capacity of the sub- 
 ject. The index of the power of r which occurs on each tray, multi- 
 plied by 10 gives us in grains the differential weight appreciated : 
 thus tray 6 gives us a series of three weights differing from each other 
 by 60 grains — i.e., 1000, 1060, 1120 — whilst tray 9 differs by 90 grains 
 -^i.e., 1000, 1090, 1180, &c. 
 
 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. 
 
 Maniacal, rjarrulou-^, egoistic, 
 Suhacute mania, grandiose, noisy, and obtrusive, 
 Calm, subdued, demented, .... 
 Wild, maniacal, incoherent, extravagant optimism 
 Subacute mania, grandiose, and egoistic, , 
 Tremulous with excitement, optitnistic, notable paresis, 
 Calm, notable bidbar paralysis, much optimism, 
 Ccdm, dull, heavy, demented, . , 
 Heavy and demented, depressed, much paresis, 
 Depressed, obsc2ire egoism, sluggish. 
 Mania, garrulous, obtrusively egoistic. 
 Cheerful, calm, slight dementia, no optimism, 
 Heavy, demented, ..... 
 
 T. 
 
 P., . 
 
 W 
 
 .W.,. 
 
 J. 
 
 M., . 
 
 W 
 
 . L., . 
 
 J. 
 
 R., . 
 
 T. 
 
 S., . 
 
 R. 
 
 c, . 
 
 S. 
 
 M., . 
 
 J. 
 
 N., . 
 
 c. 
 
 P., . 
 
 w 
 
 . R., . 
 
 T. 
 
 R., . 
 
 F. 
 
 L., . 
 
 Acoustic 
 
 Stimulus. 
 
 Sec. 
 
 Optic 
 
 Stimulus 
 
 Sec. 
 
 •16 
 
 •25 
 
 •17 
 
 •24 
 
 •17 
 
 •24 
 
 •18 
 
 •18 
 
 •18 
 
 •21 
 
 s, -18 
 
 •27 
 
 •19 
 
 •23 
 
 •19 
 
 •24 
 
 •20 
 
 •27 
 
 •21 
 
 •27 
 
 "22 
 
 •23 
 
 •24 
 
 •30 
 
 •25 
 
 •27 
 
PARALYSIS OF INTRA-OCULAR MUSCULATURE. 303 
 
 Oculo-motOF Symptoms. — The eye-symptoms in general paralysis 
 form a highly characteristic and significant group. Both the extrinsic 
 and intrinsic muscles suffer; but, whilst the former present derange- 
 ments in exceptional cases only, the latter or intrinsic muscles of the 
 eyeball exhibit deranged innervation, in some way or other, in almost 
 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 affections. The 
 pupil may be small, or of moderate size, as the result of paralysis of its 
 dilator or circular fibres ; this is called paralytic myosiS, and may 
 be due to a destructive lesion in the cilio-spinal regions of the cord ; 
 in this case the pupils no longer dilate with atropine. It is a rare 
 aff'ection, but has been recorded by Baerwinkel in sclerosis of the 
 medulla oblongata.! 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 prepared 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 of 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 pupil may be (one or both) irregular in contour ; may be 
 
 * It must be understood that the remarks in this chapter apply exchisively to 
 those persistent or gradually progressive impairments of tlie oculo-niotor adjust- 
 ments, wlioUy irrespective of those variations in the size of tlie pujjil wliicli may 
 occur from day to day, and whicli include an hicoiiNtant factor, such as cortical 
 discharges, &c., or other source of transient stimulus. 
 
 t Journ. Mental Science, 1878. 
 
304 
 
 GENERAL PARALYSIS. 
 
 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 spastic 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 lig-ht-reflex without a similar impli- 
 cation of the accommodative movements of the iris is called peflex 
 iridopleg'ia, or the Argyll-Robertson symptom, which is one of great 
 sio-nificance 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 iPidopleg"ia. 
 
 Finally, accommodation itself may be impaired or lost in one or in 
 both eyes from paralysis of the ciliary muscle (tensor choroidese), and, 
 if this be associated with paralysis of the sphincter iridis to light and 
 to convergence, and of the dilating mechanism of the pupil, we may 
 speak of the condition as one of cyclopleg'ic ipidoplegia, or use 
 
 Mr. Hutchinson's term, ophthalmopleg'ia interna. 
 
 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." f 
 
 * Quoted by Donders, " Accommodation and Refraction of the Eye," St/d. Soc, 
 p. 573. 
 
 t Donders, loc. cit., p. 574. 
 
PARALYSIS OF INTRA-OCULAR MUSCULATURE. 305 
 
 The more frequent motor derangements met with may thus be 
 summarised : — 
 
 Consensual paralysis. (1) Loss of consensual movements. 
 
 Partial reflex iridoplegia. (2) Loss of light reflex. 
 
 (3) Loss of skin-reflex or of reflex dilatation. 
 Complete reflex iridoplegia. (4) Both the above conjoined. 
 Associative iridoplegia. (5) Loss of contraction ixpon convergence only. 
 
 Complete iridoplegia. (6) All the above conjoined. 
 
 Cycloplegic iridoplegia. (7) Loss of accommodation superadded. 
 
 As to the relative frequency with which these derangements to the 
 irido-muscular apparatus occurs, we usually find as an early sign 
 a slight, perhaps scarcely appreciable, inequality of the pupils, the 
 sizes of which are otherwise not abnormal, accompanied by a little 
 sluggish delay on 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, 
 utei-ine pain, &c. 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 under 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 pupil 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 tliroughout the illumination of the retina. One eye 
 succumbs to this reflex iridoplegia 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 
 
 20 
 
3o6 
 
 GENERAL PARALYSIS. 
 
 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 paralysis, 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. When testing the response to shading he should not rest 
 satisfied with the effect produced by covering one eye only, but should 
 note the much greater range of dilatation obtained when both are 
 shaded. He should also, when testing the light reflex, be careful to 
 exchide accommodative efforts. As the small pupil in the early days 
 of general paralysis becomes gradually larger with advancing reflex 
 iridoplegia, it affords us evidence of a deeper implication of the 
 nuclei in one half of the pons, as well as of the cerebral hemisphere of the 
 same side ; for it has constantly occurred to the writer to observe that 
 when unilateral convulsions or paralysis occur in the early stages of 
 general paralysis, the dilated pupil is on the side of the discharging or 
 paralysing lesion.* It appears to us unquestionable that the oculo- 
 motor disturbances, which we have above alluded to, are greater on 
 the side of the more deeply-implicated hemisphere. 
 
 The pi?i/iearf pupil may persist to the end, and yet present no im- 
 pairment of the associated movements on accommodation, as in the 
 followinsr cases : — 
 
 
 Size of Pupils. 
 
 Reaction to 
 Light. 
 
 Sympathetic 
 Reflex. 
 
 Consensual 
 Reflex. 
 
 Accommodation. 
 
 D. R., 
 S. A. L., 
 
 r-— - millimetres. 
 1-5 
 
 ,-^ millimetres. 
 1*5 
 
 Immobile. 
 Immobile. 
 
 Immobile. 
 Immobile. 
 
 Immobile. 
 
 Slight in 
 left only. 
 
 Normal and 
 active. 
 
 Brisk. 
 
 In estimating the significance of these oculo-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 the upper quadrigeminal arc — i.e., by the nates, its brachia, the external 
 geniculate, and the pulvinar 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 Terrier. 
 
 (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 
 
 * See Article by Author in West Riding Asylum Reports, vol. vi. 
 
PUPILLARY ANOMALIES. 307 
 
 that, in the dog, division of one tract does not affect the reflex contraction of the 
 constrictor iridis. Knoll indicates that in the rabbit (Avith 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 pulviiiar, 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 behind the optic commissure will vary 
 with the animal ; and so lesions of the tract or of the quadrigeminal body of one 
 side will issue in varying results. Thus Baumgarten * 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 the 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 aff'ecting the tracts and the quadrigeminal 
 structures with the pulvinar alluded to above. 
 
 In like manner, destruction of these ganglia also issues in degenerative changes 
 in both optic nerves, especially that opposite the lesion. Such degenerations are 
 limited to this arc, and do not travel centrally 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 viydriasis, 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 pwpil, from above 
 
 2 millimetres to 3 millimetres for the moderate-sized jnipil, and all above 
 
 3 millimetres as large dilated pupils, we get the following proportions: — 
 
 Small contracted pupil, .... 4 cases. 
 
 Moderate-sized, . . . . . . 13 ,, 
 
 Dilated, 27 ,, 
 
 44 „ 
 In about half the cases — i.e., in twenty-one — one or both pupils measured 
 
 4 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. 309-313). In the Summary, the upper 
 
 * Central-blatt. J. d. Med. Wissenschajt, 1883. (Quoted by Ferrier.) 
 
3o8 
 
 GENERAL PARALYSIS. 
 
 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 reactions are alike for both 
 eyes. 
 
 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. 
 We have endeavoured to show elsewhere that an important dis- 
 tinction must be made between early and late inequality of pupils in 
 general paralysis, or, rather, between the inequality not associated 
 with impairment of the pupillary reflexes, and those cases where 
 unequal pupils manifest also the absence of reaction to light and to 
 other stimuli.^-' The former, or earlier, sign is an indication of the 
 cortical lesions established ; whilst the latter, or defective iridal 
 reaction, is due to advancing lesions of spinal and bulbar arrangements. 
 
 Pupillary con- 
 tractions. 
 
 ■Accommodation. 
 
 Associated accom- 
 modation and 
 convergence. 
 
 Sphincter iridis. 
 
 - Cilin ry muscl*. 
 
 Extrinsic muscles 
 
 of eyeball and 
 levator palpebrae. 
 
 rig. 19. — Scheme of segmentation of third nerve nuclei showing presumed anatomical 
 and physiological relationships. 
 
 A, Anterior nucleus ; C, Central or median nucleus ; E, External nucleus of 
 Bruce; /, Inferior nucleus (segment of anterior); S, Superior or nucleus of 
 Darkschewitsch ; PI, Postero-internal or pale nucleus of Edinger-Westphal ; 
 PE, Postero-external or postero-lateral nucleus. 
 
 * " Remarks on Ocular Symptoms of General Paralysis of the Insane, with 
 special reference to its Clinical Groupings," Brit. Med. Journ., April and May, 
 1896. 
 
ANALYSIS OF OCULAR DERANGEMENT. 
 
 309 
 
 o 
 
 rt 
 > 
 
 : 05 
 
 
 
 ^_, 
 
 
 (M 
 
 "M 
 
 10 
 
 ^ 
 
 CO 
 
 -* 
 
 
 
 GO 
 
 c^i : 
 
 
 
 
 
 
 
 
 ^ ,^ ^O 
 
 
 J2 
 
 SJD r; 
 
 CO 72 
 
 
 
 U) 
 
 
 &fi 
 
 iO 
 
 
 ft 
 
 W 
 
 ^ tJ 
 
 m :z; 
 
 05 ^ 
 
 bD 'Q 
 
 >^ ^ 
 
 > pq 
 
 » CD 
 
 5 
 
 —(CM .-H 
 
 .^ -H 00 
 
 ft 
 
 ^ ^ ^ \ -nn 
 
 
 Ph 
 
 PQ 
 
 le 
 
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 -: rt .^ 
 
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 ft H 
 
 w 
 
 bO •« E^ 
 Ph hJ f^ 
 
310 
 
 OCULO-MOTOR ANOMALIES. 
 Summary of Ocdxo-Motor a^d Associated Anomalies ix 
 
 
 Size 
 
 in 
 
 mm. 
 
 Light-Keflex. 
 
 Tocal Illumination. 
 
 Consensual. 
 
 Reflex 
 DUatation. 
 
 Associated 
 Movem ent. 
 
 J. W. M., 
 
 4? 
 
 3 
 
 Almost fixed. 
 Slight contn. 
 
 Slight contn. 
 
 Normal. 
 
 Fixed. 
 
 Normal. 
 
 J. 0. 0., 
 
 3 
 
 4 
 
 Slight. 
 Xormal. 
 
 Slight. 
 Normal. 
 
 95 
 
 " 
 
 " 
 
 M. P., . 
 
 2| 
 4 
 
 Normal. 
 
 Normal. 
 
 !) 
 
 " 
 
 )9 
 
 A. S., . 
 
 34 
 
 4i 
 
 »» 
 
 99 
 
 Sluggish. 
 
 9) 
 
 Sluggish. 
 
 J. D., . 
 
 
 Sluggish. 
 
 Slight, then oscillates. 
 2dy dilatation. 
 
 Normal. 
 
 Normal. 
 
 Normal. 
 
 M. B., . 
 
 3 
 3 
 
 Normal. 
 
 Normal. 
 
 „ 
 
 Fixed. 
 
 
 L. B., . 
 
 3i 
 
 2i 
 
 „ 
 
 Normal for both. 
 2^7 dilatation. 
 
 J) 
 
 Normal. 
 
 
 F. S., . 
 
 4 
 4 
 
 „ 
 
 Normal. 
 
 9) 
 
 Normal. 
 
 Sluggish. 
 
 
 K. T., . 
 
 3i 
 3 
 
 >j 
 
 99 
 
 Normal. 
 Dilates. 
 
 Sluggish. 
 
 
 S. S., . 
 
 •2 
 
 2 
 
 >> 
 
 99 
 
 Normal. 
 
 Normal. 
 
 
 J. P., . 
 
 3i 
 
 3i 
 
 " 
 
 99 
 
 " 
 
 Fixed. 
 
 
 J. w., . 
 
 3 
 3 
 
 Sluggish. 
 
 Normal, then oscillates 
 2<ly dilatation. 
 
 .. 
 
 Normal. 
 
 Normal. 
 Sluggish. 
 
 J. L., . 
 
 24 
 3 
 
 Sluggish and of 
 limited range. 
 
 Normal biit of 
 limited range. 
 
 9. 
 
 Slight. 
 
 Normal. 
 
 KS., . 
 
 24 
 
 24 
 
 Fixed. 
 Slight. 
 
 Slight. 
 Normal. 
 
 )) 
 
 Normal. 
 
 99 
 
 A. H., . 
 S. A. L., 
 
 2 
 
 3 
 1-5 
 
 1-0 
 
 If 
 
 14 
 
 Fixed. 
 
 Fixed. 
 Sluggish. 
 
 Fixed. 
 
 Fixed. 
 Slight. 
 Fixed. 
 Slight. 
 
 Fixed. 
 
 SUght. 
 
 Fixed. 
 
 Fixed. 
 
 Slight. 
 
 Normal. 
 
 D. R., . 
 
 " 
 
 99 
 
 Fixed. 
 
 " 
 
 9J 
 
 J. W., . 
 
 If 
 
 If 
 
 " 
 
 Fixed or of extremely 
 limited range. 
 
 " 
 
 " 
 
 Extremelj' 
 sluggish 
 
 and 
 limited. 
 
 G, B., . 
 
 2i 
 
 
 Fixed. 
 
 99 
 
 ,, 
 
 Normal. 
 
 T. W. H., 
 
 2f 
 3 
 
 „ 
 
 ,, 
 
 99 
 
 9) 
 
 19 
 
 J. C, . 
 
 
 
 24 
 
 24 
 
 >> 
 
 99 
 
 9) 
 
 " 
 
 99 
 
OCULOMOTOR ANOMALIES. 
 FoETY-FouR Cases of General Paralysis. 
 
 311 
 
 Accom- 
 modation. 
 
 J. I and 1 
 
 J- 22 Sn. 24 
 
 '^- 22 ^''- 22 
 
 ^•2lS°-23 
 J. No. 4 
 
 J. No. 4 
 
 J.No.2Sn. 
 ?dil. 
 
 J A 
 
 ^•28 
 
 27 
 
 Visual Acuity. 
 
 Sn.| 
 
 Sn. 
 
 Sn. 
 
 Sn. ^ Sn. 
 
 Sn. I Sn. 
 o 
 
 J.No.SSn. 
 
 25 
 
 Sn. 
 
 34 
 
 J. 1 Sn. 
 
 Sn. 
 
 |6 
 30 
 
 J.No.lSn. 
 
 20 
 
 J. 
 
 20 
 
 s-io 
 
 Sn. 
 
 Sn. 
 
 Sn. 
 Sn. 
 Sn. 
 
 Sn. 
 
 10 
 6^ 
 12 
 
 6^ 
 
 10 
 
 30 
 j6 
 10 
 
 10 
 
 Sn. 
 
 Sn.| 
 5 
 
 S"- 10- 
 
 Sn. 
 
 on. - 
 
 D 
 
 Sn. 
 
 30 
 
 Colour 
 Sense. 
 
 Normal. 
 
 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. 
 
 Patella- 
 Reflex. 
 
 Normal. 
 Exag. 
 
 Slightly 
 Exag. 
 
 Sluggish. 
 Normal. 
 
 Sluggish. 
 
 Almost 
 absent. 
 
 Exag. 
 
 Normal. 
 Absent. 
 
 Sluggish. 
 Normal. 
 
 Exag. 
 Normal. 
 
 SI. exag. 
 
 Slight. 
 Absent. 
 
 Absent. 
 
 Plantar- 
 Reflex. 
 
 Normal. 
 
 Sluggish. 
 
 >» 
 Normal. 
 
 Absent. 
 Exag. 
 
 >> 
 Normal. 
 
 Exag. 
 Absent. 
 
 Exag. 
 Normal. 
 
 Normal 
 Sluggish. 
 
 Normal. 
 
 Gait, &c. 
 
 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 tottermg. 
 
 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 right side. 
 
 Brisk. 
 
 Stiff. 
 
 Stiff. 
 
312 
 
 OCULO-MOTOR ANOMALIES. 
 
 
 Size 
 
 in 
 
 mm. 
 
 Light-Reflex. 
 
 Focal Illumination. 
 
 Consensual. 
 
 Reflex 
 Dilatation. 
 
 Associated 
 Movement. 
 
 J. H. W., 
 
 OS 
 
 2i 
 
 Fixed. 
 
 Fixed. 
 
 Slight. 
 Fixed. 
 
 Fixed. 
 
 Normal. 
 
 B. K., . 
 
 3^ 
 
 " 
 
 )5 
 
 Fixed. 
 
 
 Fixed. 
 
 W. M., . 
 
 3 
 3 
 
 J) 
 
 ,, 
 
 >> 
 
 
 » 
 
 C. J. C.,. 
 
 44 
 
 )5 
 
 „ 
 
 " 
 
 
 Fixed. 
 Normal. 
 
 J. J. 
 
 4 
 
 jj 
 
 >J 
 
 ,, 
 
 
 Sluggish, 
 
 J. H., . 
 
 4 
 3 
 
 )> 
 
 J5 
 
 >, 
 
 
 Fixed. 
 
 Normal. 
 
 J. L„ . 
 
 H 
 H 
 
 )) 
 
 ,, 
 
 )» 
 
 
 Fixed. 
 
 J. C. C, . 
 
 -^2 
 
 H 
 
 6 
 
 5> 
 
 " 
 
 5) 
 
 
 >j 
 
 J. M., . 
 
 7 
 5 
 
 ,, 
 
 ,, 
 
 „ 
 
 
 >) 
 
 J. A., . 
 
 34 
 
 4| 
 
 Slight, 2dy dilatation. 
 Fixed. 
 
 >5 
 
 J> 
 
 
 ?dil. 
 
 E. B., . 
 
 ■21 
 If 
 
 Fixed. 
 Slight, 2<iy dilatation. 
 
 Fixed. 
 Slight, 2dy dilatation. 
 
 » 
 
 
 Normal. 
 
 J. H., . 
 
 34 
 
 34 
 
 Sluggish. 
 
 Sluggish. 
 2<iy dilatation. 
 
 Slight. 
 
 Normal. 
 Slight. 
 
 " 
 
 A. S., . 
 
 4 
 4 
 
 Normal. 
 Sluggish. 
 
 Normal. 
 Sluggish, 2<iy dilatation. 
 
 Fixed. 
 
 Fixed. 
 
 :> 
 
 J. T., . 
 
 4 
 
 Sluggish and of 
 limited range. 
 
 Sluggish. 
 Sluggish. 
 
 „ 
 
 Fixed. 
 
 Sluggish. 
 
 » 
 
 T. T., . 
 
 4 
 4 
 
 Sluggish and of 
 limited range. 
 
 Normal. 
 Sluggish. 
 
 Sluggish. 
 
 Slight. 
 
 " 
 
 C. G., . 
 
 6 
 
 6 
 
 Sluggish. 
 
 Normal with 
 2dy dilatation. 
 
 5) 
 
 Sluggish. 
 Fixed. 
 
 Sluggish. 
 
 J. M., . 
 
 •2i 
 2 
 
 Slight with 
 2^7 dilatation. 
 
 Slight with 
 2dy dilatation. 
 
 Fixed. 
 
 Fixed. 
 
 Normal. 
 
 J. B., . 
 
 
 JS 
 
 Normal with 
 2'ly dilatation. 
 
 ,, 
 
 )j 
 
 >' 
 
 W. T. S., 
 
 44 
 
 4i 
 
 Sluggish. 
 Sluggish. 
 
 Normal 
 Sluggish, 2<ly dilatation. 
 
 Normal, 
 Sluggish. 
 
 Sluggish. 
 
 Normal. 
 Sluggish. 
 
 W. S., . 
 
 Sluggish. 
 
 Normal, then oscillates 
 with 2dy dilatation. 
 
 Sluggish. 
 
 Sluggish. 
 Fixed. 
 
 Normal. 
 
 H. M., . 
 
 3 
 
 23 
 
 Sluggish. 
 Fixed. 
 
 Normal, 
 Fixed. 
 
 Normal. 
 Fixed. 
 
 Fixed. 
 
 Slight. 
 Fixed. 
 
 B. H., . 
 
 4 
 3 
 
 Slight. 
 
 Slight. 
 
 Slight. 
 
 ») 
 
 Normal. 
 
 J. B., . 
 
 44 
 44 
 
 Slight with 
 2fly dilatation. 
 
 Slight, 2dy dilatation. 
 Normal, 2'ly dilatation. 
 
 )> 
 
 I 
 
 " 
 
 Note. — The upper figure of the fraction in col. 2 and corresponding line indicate in each case the size 
 
 same features in the le/l eye. In all other 
 

 
 uuu 
 
 LU-MUTOl 
 
 < ANOMA 
 
 LIES. 313 
 
 Accom- 
 modation. 
 
 Visual Acuity. 
 
 Colour 
 
 Sense. 
 
 1 
 1 
 
 Piitella- 
 Keflex. 
 
 Plantar- 
 Reflex. 
 
 Gait, &c. 
 
 -k 
 
 s„.2 
 
 Normal. 
 
 Normal. 
 
 Sluggish. 
 
 Stiff, broad basis, heels down first. 
 
 9 
 
 Sn. 2^ Sn. J 
 
 Sn. 50 only 
 
 s„.|s„.4 
 
 " 
 
 Exag. 
 
 " 
 
 Legs drop, left hemiplegia = contrac- 
 ture of left arm, cannot stand un- 
 supported. 
 
 )) 
 
 ? 
 
 Normal. 
 
 Brisk. 
 
 •> 
 
 s„.l 
 
 )> 
 
 Normal. 
 
 Exag. 
 
 Absent. 
 
 Leans to left side, 
 
 J. No. 1 Sn. -5 
 
 s„.| 
 
 Normal 
 but gr. = ? 
 
 " 
 
 Normal. 
 
 Stiff. 
 
 J..^Sn.-|_ 
 2o 2o 
 
 Sn. g^ Sn. g 
 
 Normal. 
 
 Absent. 
 
 Exag. 
 
 Brisk. 
 
 9 
 
 9 
 
 c, 6 
 Sn.g 
 
 Normal 
 but y. = ? 
 
 Exag. 
 clonos. 
 
 Sluggish. 
 
 Quick, elastic. Both lenses opales- 
 cent. 
 
 9 
 
 Normal. 
 
 Almost nil. 
 
 Normal. 
 
 Brisk. 
 
 J. No. 2 
 
 9 
 
 9 
 9 
 
 Normal 
 
 but gr. 
 
 = yellow. 
 
 9 
 
 Normal. 
 
 Exag. 
 
 Absent. 
 
 Exag. 
 
 Sluggish. 
 Normal. 
 Slight. 
 
 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- 
 poi'ted. 
 
 Stiff 
 
 ? dilatn. 
 
 9 
 
 9 
 
 Normal. 
 
 Sluggish. 
 
 Heavy, tottering. 
 
 Sn. - 
 ? dilatn. 
 Sn. -^-^- 
 
 -4 
 
 9 
 
 -4 
 
 Normal 
 
 but gr. 
 
 = crimson. 
 
 9 
 
 Sluggish. 
 Normal. 
 
 Exag. 
 
 Exag. 
 Sluggish. 
 
 Stoopijig, bent, unsteady, insecure. 
 
 Left eye strongly convergent when 
 eyes are directed to right. 
 
 Normal. 
 
 Absent, 
 
 Normal. 
 
 Brisk. 
 
 1 
 
 
 Normal 
 but gr. 
 = piice. 
 
 Normal. 
 
 5) 
 
 Brisk. 
 
 •'• B 
 
 Normal. 
 
 Exag. 
 
 '> 
 
 Brisk. 
 
 •'• Si 
 
 --.^ 
 
 )) 
 
 Exag. 
 Absent. 
 
 Sluggish. 
 Normal. 
 
 Right leg dragged; right arm con- 
 tracted; feeble grasp. 
 
 J. No. 1 
 
 S..^ 
 
 >> 
 
 A})sent. 
 
 Exag. 
 
 Brisk. 
 
 J. No. A 
 
 ^"4 
 
 ,, 
 
 Sluggi.'^li. 
 
 Normal. 
 
 Bri.sk, springy. 
 
 9 
 
 9 
 
 9 
 
 9 
 
 9 
 
 Stooping, shuflBing, most insecure. 
 
 J. A 
 
 •42 
 
 .s„.|s„.| 
 
 Normal. 
 
 Exag. 
 
 Normal. 
 
 Stiff. 
 
 9 
 
 9 
 
 ? 
 
 " 
 
 Sluggish. 
 
 Cannot walk or stand. 
 
 of pupillary aperture, and iridal reactions of the 
 cases the reactions are alike for both eyes. 
 
 right eye: the lower figure and line refer to the 
 
314 GENERAL PARALYSIS. 
 
 Light-reflex, — Referring to our table of actual figures, it is found 
 that over 36 per cent, have both pupils perfectly immobile and fixed 
 to the stimulus of light, and that half as many — 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 illumination 
 of the eye by a convex lens, and with a strong light — as many as 34 
 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 illum.ination of the retina. This ten- 
 dency to dilate during stimulation by light appears to me to be the 
 earliest augury of coming paralysis. 
 
 Consensual Movements. — When one eye is alternately shaded 
 and exposed, the accommodation being relaxed, we observe that both 
 pupils dilate and then contract. We speak of this reaction in the eye 
 not shaded as the COnsenSUal FCflex (dilatation or contraction) ; and 
 of the reaction in the eye alternately shaded and exposed, as the 
 direct lig'h.t Peflex. As to the course taken by the stimulus for 
 these consensual movements, it is a well-known fact that lesions of one 
 optic tract, resulting in homonymous hemianopsia, do not aflect the 
 consensual reaction [Knoll, Bechterew, Baumgarten, Erb) ; and it 
 follows from this that the stimuli pass back not along the crossed 
 fibres of the chiasma alone, but also by the alternative route of direct 
 fibres of the optic tract (see diagram, p. 318). In testing the consen- 
 sual and direct reaction it is well to bear in mind that the consensual 
 and direct refiex dilatations are equal in normal eyes ; hence the 
 shaded and exposed eye will exhibit equally dilated pupils, since the 
 covered eye lessens the contraction of the exposed eye to just the 
 same degree as the exposure of the latter diminishes the dilatation of 
 the former. It is on this account that we should test the energy of 
 dilatation by shading both eyes (p. 305). 
 
 These reactions were abolished ia 43 per cent, of the total cases, and 
 were almost invariably absent where the light-reflex was absent in 
 botJi, pupils. A considerable numV>er, 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 exception. 
 
REFLEX IRIDOPLEGIA. 
 
 315 
 
 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). — Every acoustic, tactile, painful or 
 electric stimulus will entail a dilated pupil, and the excitation of the 
 skin by pricking, pinching, or by electric brush, is the usual method 
 adopted for judging of the integrity of this reflex dilatation. It must 
 be remembered that actual sensation need not follow upon this stimu- 
 lation and its resulting dilatation ; thus, stimulation of the anaesthetic 
 skin of the hemianagsthetic subject will induce pupillary dilatation 
 just as readily as can be done in cases of coma and sleep. 
 
 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 available sensory 
 surface alike fails to produce response in such cases ; and, it is of 
 interest to note, that iinilateral 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, 
 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-motor 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-Motor States.— The associated movements of 
 contraction and dilatation of the pupil dui'ing the act of accommodation 
 and eftbrts of convergence are afiected 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 [F. Ft. ; 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 efibrts.* So far from associative 
 iridoplegia {i.e., loss of pupillary contraction upon convergence) being 
 the invariable sequence to the Argyll-Robertson pupil, the fact seems 
 
 * It has been conclusively shown by Dondcrs, as well as \)y Do Ruiter and 
 Cramer, that the associated contraction of tlie pupil occurs with the act of accom- 
 modation, when there is no increased convergence of the visual line, and also with 
 the latter when there is no change in accommodation. Loc. cit., p. 574. 
 
3l6 GENERAL PARALYSIS. 
 
 to be that this latter symptom remains almost invariably persistent up 
 to the fatal issue; whilst loss of accommodative movements (associative 
 iridoplegia), when present, is found from the first. The fact that 
 failure of response to light, on convergence, and on shading runs 
 usually on to failure of accommodation also (cycloplegia), is explained 
 by Mr. Hutchinson as possibly due in tabetic subjects to implication 
 of the ciliary ganglion, which forms a cross way for all the nerve-fibres 
 affected.* But we are of opinion that in progressive paralysis the site 
 of the lesion is more often nucleai', the degeneration involving the 
 segments of the motor-oculi nucleus and some as yet unascertained 
 connection of this nucleus with the vaso-motor.f 
 
 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 failure in this respect. 
 
 Thirdly, that the smaller pupil is the one in which light-reflex 
 is most impaired 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 rigid 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 pujnllce, 
 its iris can still be affected by stimulation of the opposite eye, through 
 the crossed opto-geniculate tract. 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 affected, the right would be 
 fixed to both influences. The six cases afforded by our series confirm 
 these views in every respect. 
 
 It thus appears that there are two links betwixt the quadri- 
 geminal centres and the cortex, on the one hand, and the periphery 
 on the other. An upper cortical and 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 
 
 * " On Paralysis of the Internal Muscles of the Eye" (Ophthahnoplegia Interna), 
 Medico-Chir. Trans., vol, xi,, p. 216. 
 
 t For a further discussion on this point see article by author, loc. cit. 
 
REFLEX IRIDOPLEGIA. 
 
 2>n 
 
 of secondary changes backwards to the quadrigeminal regions (Obs. 4, 
 p. 306), but not beyond this limit ; lesions of the upper or cortical 
 link cause degenerations, which spread both centrally and peripberi- 
 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 fields {equatorial or hovionymous hemiopia), the irido- 
 motor reflexes being involved only when the lesion is on the peripheral 
 side of the chiasma. Since, however, 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 iridal 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, &c., leads also to disturbances of irido-motor 
 reaction. The individual nuclei, defined by Henson and Voelcker as 
 extending in front of the aqueduct, may, however, be picked out by 
 morbid processes ; and, in this case, the iridal reactions suffer without 
 any necessary implication of vision, a condition frequently seen in the 
 early stages of general paralysis. 
 
 Significance of Certain Pupillary Anomalies.— The true sign 
 
 of a paralysis of the cervical sympathetic trunk, or its centre in the 
 cord, is not so much a small pupil, as the failure to dilate upon shading 
 th-e eye. Mr. Jonathan Hutchinson has shown that cases of such 
 sympathetic paralysis occasionally occur with a moderate-sized pupil.*" 
 
 It is customary, however, to regard the myosis of tabetic cases as 
 due to implication of the posterior columns of the spinal coi'd ; whilst 
 the failure to contract with light, the associated contraction on conver- 
 gence being retained, is explained by implication of Meynert's fibres 
 connecting the optic fibres with the motor oculi nucleus (see Fig. 20). 
 
 Now, if it be recalled that this partial reflex iridoplegia is 
 frequently unilateral, we see at once the difficulty of admitting this 
 explanation as correct. Bilateral implication of Meynert's fibi-es 
 would certainly lead to double reflex iridoplegia; but, since the third 
 nerve nuclei are regarded as tied together by commissural fibres, 
 implication of one side could not possibly affect the reaction to light of 
 either pu])il. Latterly, I have been accustomed to explain away this 
 
 * " Notes on the Symptom Significance of Different States of the Pupil," Brain, 
 vol. i., p. 11. 
 
GENERAL PARALYSIS. 
 
 difficulty by suggesting a hypothetical tract of fibres to exist (see 
 Fig. 20), connecting the third nerve nuclei with the dilator centre of 
 the sympathetic in the medulla. In fact, we may regard every retinal 
 stimulation by light as also inldhitiyig the dilating centre in the 
 
 Chiasmi. 
 
 / ilyotic of Third. 
 
 Motor Oculi Nucleus , 
 fur Ciliary Muscle -^■^ 
 accoauj 
 
 Mej-nert's Fibre* 
 
 Optic Tract 
 
 Motor Oculi Nucleus 
 1 lor Constrictor Pa- 
 I fillae. 
 
 i H.ii-pothetical connee- 
 ' ~ tion between Moter 
 
 ,' Oculi i Sympatlietic. 
 
 "v Dilator Centre In 
 Medulla. 
 
 Cerrlcal Sympathetic. 
 
 CiUo-Spinal Region 0/ Cord 
 
 Posterior Root* 
 
 Poeterlor Roots. 
 
 Posterior Roote. 
 
 Fig. 20. 
 medulla (through these hypothetical fibres — see diagram), these fibres 
 being the tract whereby the sympathetic is influenced by differential 
 light stimuli alone, all other stimuli, as from the cutaneous surfaces, 
 passing through the usual course in the posterior columns of the cord 
 direct to the dilator centre in the medulla. 
 
TABETIC SYMPTOMS IN GENERAL PARALYSIS. 
 
 319 
 
 Shading the eye, therefore, lessens the inhibitory effect of retinal 
 stimuli, and the dilator centre strongly functionates; division of these 
 hypothetical fibres would issue in a failure to dilate on shading, with, 
 probably, a moderate-sized pupil, whilst cutaneous and other forms of 
 sensory stimuli still effect pupillary dilatation ; extensive disease of 
 the sensory columns of the cord would impair or destroy pupillary 
 dilatation to cutaneous stimuli, yet not to shading ; whilst disease of the 
 dilator centre in the medulla, or the cilio-spinal region of the cord, 
 would abolish dilatation of the pupil for all these forms of sensory 
 stimulation, and induce a myosis from the unrestrained activity of the 
 motor oculi nucleus. 
 
 In tabetic forms of general paralysis the oculi motor anomalies 
 almost invariably precede the tabetic sign of abolished knee-jerk, and 
 the pupils failing to dilate on shading or cutaneous stimulation, a 
 paralytic myosis (moderate) eventually passes into a genuine 
 spastic myosis (1 to '2-o mm.), from the irritation of a disease process 
 advancing upon the constrictor nucleus. 
 
 Cyclopleg'iC Forms. — A special series of cases of general paralysis 
 exhibit from early days a large-sized pupil, the site of an associative 
 iridoplegia, which passes eventually into the Cyclopleg^ic form — i.e., 
 not only do the pupils fail to respond to light and on convergence, but 
 paralysis of accommodation also prevails. Vision is unimpaired for 
 distance, but plus glasses ( + 2 up to + 5 D) are required for close 
 work ; such ciliary paralysis is always bilateral. The pupils are 
 affected not only through their motor OCUll supply, but the sympa- 
 thetic is also at fault, since no dilatation follows upon shading or 
 sensory stimulation. Hence we have here the triple symptom of 
 paralysis of the accommodative, the constrictor, and the dilator 
 mechanism of the eye, and, as is indicated by Mr. Hutchinson, the 
 ciliary ganglion is the only site, as far as exact anatomical knowledge 
 extends, where the fibres for the tensor choroidese, sphincter iridis, 
 and sympathetic supply are closely associated, and could thus be 
 injured by a single lesion. 
 
 It is, however, difiicult to account for the slowly progressive nature 
 of the paralysis, and the constancy of the bilateral implication, upon 
 this assumption, and it at first appears rather to favour the view that 
 the lesion is a slowly progressive degeneration afi'ecting the several 
 nuclei of the motor oculi, which, as clearly shown by Bruce and others, 
 is very notably segmented. We regard it as probable that if, with the 
 symptoms of cycloplegic iridoplegia, there is still response to sensory 
 stimulation of the skin, but not to shading, the lesion is a nuclear 
 degeneration of the third nerve ; but if the reaction is abolished both 
 for cutaneous stimulation and for shading, the lesion affects the ciliary 
 ganglion- The remaining features characterising this group of pro- 
 
320 GENERAL PARALYSIS. 
 
 gressive paralysis are : — (1) the absence of notable spinal symptoms ; 
 (2) the profound implication of speech (" drunken speech ") ; (3) the 
 rapid course terminating in epileptiform convulsions and profound 
 reductions; and (4) its frequent association with constitutional syphilis. 
 Spinal Symptoms. — In a large proportion of subjects of general 
 paralysis the failure in the vigour and co-ordination of the greater 
 musculatures comes on very gradually and insidiously ; the lower 
 extremities remain unaffected to any appreciable extent for even two 
 or three years 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 
 a sudden paralytic seizure may occur, rendering the patient temporarily 
 helpless 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 morbid signs, may be gleaned from an analysis of the 
 forty -four cases before referred to. In six cases only (or 13-6 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 affection, and the general results may 
 be thus tabulated : — 
 
 Deep Reflexes. 
 Ejiee-jerk normal on both sides in 6 cases (13-6 per cent. 
 
 ,, exaggerated 
 
 absent 
 
 very shiggish 
 absent 07i one side 
 nearly absent 
 
 6 , 
 
 , (36-3 
 
 7 , 
 
 , (15-9 
 
 4 , 
 
 , ( 9 
 
 3 , 
 
 , ( 6-8 
 
 1 , 
 
 , ( 2-2 
 
 4 , 
 
 , ( 9 
 
 3 „ { 6-8 
 
 15 or 
 34 per cent. 
 
 ,, doubtful 
 
 Increased Knee-jerk.— The exaggerated knee-jerk, it will be 
 observed, is the more frequent phenomenon ; it may be a purely 
 functional disturbance, transient in duration, induced by nervous 
 discharge from the cerebral cortex, and hence by removal of its 
 
TABETIC SYMPTOMS IN GENERAL PARALYSIS. 32 I 
 
 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 paralysis ; on the other 
 hand, it may be a sign of organic disease of the spinal cord, and have 
 as its accompaniments the usual motor enfeeblement and muscular 
 contractions of descending sclerosis. 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, with full muscular vigour of limbs, exaggerated deep refiexes, and 
 pronounced irido-m,otor paralysis.^' 
 
 The latter association — i.e., of increased knee-jerk with structural 
 disease of cord, is exemplified in cases J. M., J. B., R. S., B. K., and 
 may be instructively associated with the ocular troubles as follows! : 
 
 Case— J. M.— Right arm and both legs paralysed and contracted; knee-jerk notably 
 exaggerated in both ; marked ocular paralysis. 
 „ J. B.— Right arm paralysed and rigid ; right leg drags ; knee-jerk notably 
 exaggerated in right ; marked ocular paralysis. 
 R. S.— Right hemiplegia 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, several (three) of the cases of hemiplegia, with early 
 commencing changes in the cord, were found associated with disturbed 
 reflexes and marked intra-ocular paralysis. 
 
 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 impairment. 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, yet all present serious oculo-motor 
 paralysis; whilst of the remaining five, the gait is noted as being 
 stifi" 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 
 reaction of the knee-jerk. Just, therefore, as we may find the associa- 
 tion of an elastic, easy gait, or of a spastic or paretic gait, with 
 exalted deep reflexes and advanced iutra-ocular paralysis : so, on the 
 other hand, we may encounter the association of a normal gait, or of a 
 * As regards transient ankle-clonos in cases of general paralysis see p. 23L 
 + See "Degrees of Knee-jerk classified," by Leonard J. Kidd, Lancet, March 
 1895, p. SOL 
 
 21 
 
32 2 GENERAL PARALYSIS. 
 
 paretic or tabetic gait, with an abolition of the deep reflexes, and like 
 irido-motor troubles. The tabetic gfait, 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. " Locomotor ataxy may be 
 associated with other forms of insanity, and may in no great degree 
 affect the duration of life ; but in some other cases ataxy appears and 
 is not complicated by mental disorder for several years, when other 
 signs of nervous degeneration appear and general paralysis becomes 
 manifest " (Savage). 
 
 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 incOlltilienee, 
 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 
 urethrce, 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 
 the alkaline urine so engendered, the cystitis having a neuropathic 
 origin not infrequently in changes within the cord and spinal nerves. 
 
 Retention far more frequently is an indication of paPalysiS of the 
 bladder ; it is, then, usually accompanied by 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 wet 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 urethrce. Such 
 section withdraws the inhibitory control of the cerebrum, thus increas- 
 ing the reflex activity of the sphincter (Landois*'). All such cases 
 
 * Op. cit., p. 653. 
 
PARALYSES FROM SPINAL IMPLICATIONS. 323 
 
 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 undergoes con- 
 siderable fatty degeneration, as the immediate result of spinal disease 
 — a genuine tropho-neurosis. Nor is this very surprising when we 
 l«arn fi'om the results of autopsy in general paralysis how extensive 
 are the trophic disturbances which other organs, and especially the 
 muscular, undergo. In this degeneration the muscular coat of the 
 bladder especially suffers, and the organ may be ruptured by a slight 
 distending force when aided by such accidents as a fall or a blow, or 
 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 subject to engage our attention.*' 
 
 A similar condition of the bladder often prevails in advanced cases 
 of tabes, and, as indicated by Dr. Buzzard, may even form the most 
 prominent symptoms and, like gastric crisis, 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 
 surgeon is consulted are examples of tabes, with the bladder trouble 
 predominating." f Apart from any well-marked spinal paralysis, 
 retention frequently occurs as the result of simple inattention, the 
 accompaniment of profound dementia, with which there is often 
 associated a diminished reflex-excitability of the bladder, the organic 
 reflexes corresponding to the general impairment of the superficial 
 •spinal reflexes. There is not only the diminished excitation 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 
 
 * A well- trained medieal 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 tiie warder's 
 report, and by actual examination of the abdomen. Even under the strictest 
 supervision an accident may still occur at times, as in the case of degenerated 
 muscular wall of the bladder. It is, however, quite inexcusable for any such 
 patient, known to be suffering from paralytic enuresis, to escape examination 
 night and morning. 
 
 + " On little-recognised phases of Tabes Dorsalis " in Diseases of the NervoiLS 
 Sij-item. Dr. Buzzard, 1882, p. 274. 
 
324 GENERAL PARALYSIS. 
 
 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. 
 Whilst 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) on the sphincter urethrse or its motor centre- 
 in the cord, so intensifying the reflex contraction ; (b) on an inhibitory 
 centre in the cord above the reflex apparatus, which antagonises the 
 latter and allows the sphincter to relax.* 
 
 The necessity for continuous care and change of bed-clothing in these- 
 wet cases is emphasised by the otherwise certain occurrence of bed- 
 sore 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, 'papular eruptions over the back, 
 the crroin, 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 paPalysiS of the anal 
 sphincter, which results in such frequent incontinence of the bowel ; 
 the condition, of course, is at once recognised on introducing 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 urethrEe, the 
 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 defalcation, by bringing the excrementitious mass down 
 into the rectum. AVhen 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 defsecation is in 
 everv way similar to that of micturition, it being really a peflex 
 spinal act durinrj a voluntary inhibition of the sjMticter. 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 contraction of the 
 sphincter ; a centre in the cerebrum for the inhibition of the latter. 
 De<^enerative changes in the lumbar cord occasionally give rise to 
 * Landois and Stirling, op. cit., p. 6o4. 
 
HEMOGLOBIN IN THE BLOOD IN GENERAL PARALYSIS. 325 
 
 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 application 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 diarrhoea, 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, affecting 
 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, t 
 
 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 peristalsis. 
 
 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 126 
 per hcemic unit, the higher register pertaining to cases where maniacal 
 excitement prevailed. ISTo 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 hsemoglobin 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. Tlie accompanying table gives the 
 results obtained in fifteen cases of general paralysis at difi'erent periods 
 of the disease : — 
 
 * " Clinical Notes on Conditions incidental to Insanity," by Robert Lawson and 
 W. Be van Le\vis. No. 1, Wt-'st Ridin<j Asylum Reports, vol. vi. 
 
 t Ophthalmople(jia Exttrna with Tabes Dor salts (Dr. Buzzard, p. 200). See also 
 case described by the same writer in Diseases of y^ervous System, p. 218. 
 
326 GENERAL PARALYSIS. 
 
 Amount of HiEMOGLOBix in the Blood in General Paralysis. 
 
 
 
 1 
 
 Red 
 
 ■\Miite 
 
 Value per 
 
 
 
 Hsemoglobin. 
 
 Corpuscles. 
 
 Corpuscles. 
 
 Corpuscle. 
 
 
 
 Per cent. 
 
 Per hfemic unit. 
 
 Perhsemic unit. 
 
 
 T. G. 
 
 (July 24, '87), 
 
 70 
 
 125 
 
 •40 
 
 •56 
 
 jj 
 
 (Aug. 2, „ ), 
 
 72 
 
 126 
 
 -40 
 
 •57 
 
 W. W. 
 
 (Aug. 5, „ ), 
 
 70 
 
 124-6 
 
 -13 
 
 •56 
 
 )) 
 
 (Nov. 8, ,, ), 
 
 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 1 
 
 •65 
 
 J) 
 
 (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 
 
 R. R. 
 
 (Aug. 4), „ ), 
 
 62 
 
 81-8 
 
 •50 1 
 
 •76 
 
 jj 
 
 (Sept. 29, „ ), 
 
 70 
 
 96-2 
 
 •32 
 
 •72 
 
 C. W. 
 
 (Nov. 5, „ ), 
 
 64 
 
 79 
 
 •20 
 
 •81 
 
 J. w. 
 
 (Dec. 16, „ ), 
 
 70 
 
 78-4 
 
 •22 . 
 
 •89 
 
 G. H. 
 
 (July i7, „ ), 
 
 68 
 
 81-8 
 
 •20 ' 
 
 •83 
 
 T. H. 
 
 (Oct. 9, „ ), 
 
 
 77-2 
 
 •25 
 
 
 B. W. 
 
 (Nov. 8, „ ), 
 
 64 
 
 
 •10 
 
 
 In the cases of R. R., J. B. S., J. A., as of several others not noted 
 in the above list, the blood flowed with great sluggishness, rendering 
 its collection by the usual means extremely difficult. In such cases 
 the surface was cold and very pallid, the vessels being undoubtedly in 
 a state of spasm, and instantaneous coagulation was prone to occur, 
 ere the blood could be withdrawn by the pipette; no inflammatory 
 complication existed in these subjects. Similar cases of extremely 
 slow oozing blood exhibited, on the other hand, abnormal delay in 
 coagulation. 
 
 Clinical Groupings of General Paralysis. — We Lave elsewhere'^' 
 
 endeavoured to analyse the more constant association of symptoms 
 which characterise certain well-defined groups of this disease ; and 
 although we cannot here enter into a detailed account of such, we 
 shall place before the reader a scheme of clinical groupings in which, 
 as it appears to us, all forms of general paralysis may be comprised. 
 Five clinical groups may thus be defined, according to the predo- 
 minance of cerebral, bulbar, or spinal symptoms, the early or late 
 onset of either, and the course pursued ; they are as follows : — 
 
 Group 1. 
 
 Paralytic mydriasis ; a partial reflex iridoplegia (liglit). 
 
 Increased myotatic irritability. 
 
 Excessive facial tremor and speech troubles. 
 
 Great optimism with profound dementia. 
 
 * Op. cit. 
 
ALCOHOL AND THE ADOLESCENT PERIOD. 327 
 
 Group 2. 
 Mydriasis with associated iridoplegia rapidly passing into the cycloplegiC 
 
 form — an early symptom. 
 Frequent myotatic excess, but no contractures. 
 Late speech troubles. 
 
 Acute excitement with frequent convulsions. 
 Very rapidly fatal course (preponderance of syphilitic historj'). 
 
 Group 3. 
 Spastic myosis ; a complete reflex iridoplegia. 
 Absent or greatly impaired knee-jerk. 
 
 Failure of equilibration ; locomotor ataxy, defective sensibility. 
 Very defective articulation. 
 Much optimism and excitement. 
 
 Group If. 
 Late eye symptoms : paralytic mydriasis, a partial reflex iridoplegia (for light 
 
 only). 
 Ataxic paraplegia confined to lower extremities (arms do not participate). 
 Great facial ataxy with extreme troubles of speech. 
 Epileptiform seizures ushering in pronounced mental enfeeblement. 
 
 Group 5. 
 No oculo-motor symptoms beyond occasional ineqiiality. 
 No contractures, but notable myotatic excess. 
 No disturbance of equilibration, locomotion, or sensation. 
 Speech troubles not pronounced. 
 Epileptiform seizures very rare, hut from tht first progressive deepening dementia. 
 
 ALCOHOLIC INSANITY. 
 
 Contents.— Alcoholism and Age— Susceptibility at Certain Developmental Phases- 
 Adolescent Period (F. S.)— Prevalence of Impulse— lufluence of Sex, Heredity, 
 Epilepsy, Cranial Injury, Ancestral Intemperance— Anomalies of Systemic and 
 Visceral Sensation— Aural Hallucinations (J. Ji.)-Delusions of Suspicion- 
 Optimistic Delusions— Clinical Forms of Alcoholism— Mania a Potu— Amblyopia 
 Cutaneous Anaesthesias-Relapses— Case of W.W.— Homicidal Impnlse (G.S.)— 
 Chronic Alcoholism— Physiological Effects of Alcohol- Evolutionary Period- 
 Mental, Sensorial, and Motorial Symptoms (J. Ji.)— Amnesic Forms (J. F)— 
 Conditions of Mental Revivability— 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 DeterminingMorbid Ideation— Augmented 
 Specitic Resistance— Sensory Anomalies- Motor Enfeeblement (J. R.)— Twitch- 
 ings, Tremors, Stohdity — Reaction-Time in Alcoholism — Muscular Spasms 
 and Cramps — Oculo-motor Immnnity — Nystagmus — Epileptiform Attacks— 
 Hemiplegia (T. P. and J. C.)— Classification. 
 
 Alcohol is a fertile source of nervous disease, and its implication of 
 the nervous centres is so general and far-reaching, that the resultant 
 symptoms are of most protean nature ; no poison, except the virus 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 
 
328 ALCOHOLIC INSANITY. 
 
 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 affections, 
 it will be well to glance generally at the insanity induced by alcoholic 
 indulgence ; and for this purpose we have inquired into the history 
 and antecedents of 464 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 the different forms 
 of alcoholic neurosis 1 
 
 Agfe. — 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 
 of drink, and the time required 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 utility, 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 
 disease ; 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 tliat 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 ielt 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- 
 
ALCOHOL AND THE ADOLESCENT PERIOD. 329 
 
 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 nowadays 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 
 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 eifects 
 of alcoholic excess as inducing reductions in the intellectual sphere, 
 and only later on, as jjrofoundly 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. y., aged twenty-five, widower, and a warehouseman. When admitted he had 
 been insane for six weeks ; had been very wild, rambling in speech ; called liimself 
 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 
 tM^o 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 hecome his, 
 ere long ; is possessed of enormous wealth." His manner is ahrupt, but lie is 
 inclined to be friendly and jovial ; expression flushed and excited ; pupils widely 
 dilated, but equal and of normal reaction ; tongue shows notable and extensive 
 fine fibrillar tremor, no ataxic jerks ; articulation is unimpaired ; the reflexes are 
 normal ; cutaneous sensibility is unimpaired. Patient is muscular and well 
 nourished. Examination of otlier systems proved negative. 
 
 In a fortnight lie was considerably calmer ; the same hien-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 
 
330 ALCOHOLIC INSANITY. 
 
 mood, from abrupt rudeness to jovial humour, he maintained 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 masturbation so repulsively shameless 
 and open that the liquor epispasticus was applied locally, and chloral with bromide 
 of potassium given internally with only temporarily good results. These habits 
 kept up persistently seemed to account for the slow progress made in his case, 
 for he remained twelve months in the asylum ere the excitement abated ; even 
 then for several months he exhibited an imbecile aspect, laughed immoderately 
 without cause, was restless, imtidy, senseless or irrelevant in his observations, 
 and given also to insane gesticulation and grimace. 
 
 Twenty months elapsed ere he was discharged recovered. 
 
 We must, as before hinted, make due allowance for this age as one 
 offering peculiar inducements to heavy drinking ; and for the fact that 
 a certain period, even for those specially predisposed, must elapse ere 
 alcoholic excess results in actual mental alienation ; but, when all 
 such factors are allowed for, we 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 are 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 affections. 
 
 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 Jbrms 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 vice. 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.* 
 
 * See in connection with the question of alcoholism as a factor in the production 
 of epilepsy, an elaborate and instructive article, "Heredity and Crime in Epileptic 
 Criminals," by Henry Clarke, Brain, vol. ii., p. 491. 
 
PREVALENCE OF IMPULSIVE STATES. 33 I 
 
 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 depression prevailed in 28-7 
 per cent. ; 42 cases were attended with delusional perversion, 28 were 
 simple melancholic forms, while 12 (or 34 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 first important fact taught us by a 
 glance over our statistics is the essentially i'm2ndsive nature of the 
 affection ; it is in all its phases a COnVUlsive neUPOSiS. Whether 
 excitement prevails, and the disordered propensities exhibit sudden, 
 explosive impulses ; or whether depression, with its frequent accom- 
 paniment 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 
 with depression — the all-important feature to be borne in mind is 
 this prevailing convulsion of conduct. The maniacal forms exhibit 
 such impulsiveness, not so much 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 i-eturned as 
 dangerously impulsive towards 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 ad- 
 vanced 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 
 
332 ALCOHOLIC INSANITY. 
 
 to be in the quinquennial periods immediately preceding and following 
 the age of forty. 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- 
 five to sixty years of age. We may, therefore, 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 afford 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 inhePitanCG cannot be stated to have 
 any very definite influence in either direction ; excitement does, 
 however, predominate in hereditary insanity ; but the proportionate 
 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 SCX, it is noted that melancholic states are to 
 maniacal proj)ortionately 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 large proportion 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, heredity, 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 percent.) 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 illusory and 
 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 
 
HALLUCINATIONS AND DELUSIONS. 335 
 
 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 — electricity ,^ 
 magnetism, mesmerism, witchcraft, 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, (fee, 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 sup{)OseU to be 
 produced by individuals known to the 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. Ji., 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 play upon him," and he heard the voices of his late 
 ofl&cers, 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 
 whisthng of gas over his head, which, he says, affects him so as " to snip a word 
 in two," just as he utters it, and ijonfounds the meaning of what he says — it also 
 afi"ects 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 pain) 
 at his epigastrium, twitches up his chest, but does not affect airas or hands. His 
 speech is hesitating, and he often, in explanation, uses the statement that, " They 
 rule my speech, and tell me what I have to say at times." Has noticed foul 
 odours, which he knew were unnatural, and caused by " the electric machine ; " 
 they prevent him from sleeping. These malevolent agents are treacherously 
 pursuing him wherever he goes ; he knows not wlij' — he cannot rid himself of 
 them, although he has " offered 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 verj' intemperate 
 habits since the age of eighteen, but had never suffered from delirium tremeyis ; 
 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. 
 
ALCOHOLIC INSANITY. 
 
 JEsihesiometer gives the following measurements of comparative sensibility :— 
 
 Tip of forefinger, 
 
 ,, thumb, 
 Ball of thumb, 
 Centre of palm. 
 Wrist, dorsal. 
 Wrist, volar. 
 Forearm, dorsal, 
 Forearm, volar, . 
 
 Right Side. 
 •05 of an inch. 
 •05 
 
 •8 
 
 •4 
 
 •9 
 
 1-7 
 
 2^3 
 
 1^9 
 
 Left Side. 
 •05 of an inch. 
 10 
 4 
 4 
 •3 
 4 
 7 
 
 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 equilibration is undisturbed, he balances well with eyes closed ; 
 stands on tiptoe, and can walk "heel and toe" along a straight line; plantar 
 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 suffered 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. 
 
 Cases 
 Delusions of Persecutions — 
 
 (a) By poisoning, ....... 24 
 
 (6) By magnetic and unseen, mysterious, agencies, 25 
 
 (c) By various other means beyond the above, . 82 
 
 Delusions affecting the moral being, . . . .29 
 
 Delusions of grandeur and of wealth, . . ,48 
 
 208 100 
 
 Frequency 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 
 
 Percentage of whole 
 (omitting decimals). 
 
 12 
 12 
 39 
 14 
 23 
 
DELUSIONS OF SUSPICION, ETC. 335 
 
 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 intensity of 
 the false belief, and their grossly exaggerated character, 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, are checked by the malignity of his former friends and 
 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 con- 
 trasted with the other forms of delusion of persecution, 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 
 himself .the " Son of God, and the Father of all nations ; " another de- 
 clares he holds the sun and moon in his hands, and regulates the move- 
 ments 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 matri- 
 monial 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 persecution comprise, as we have before stated, 
 nearly 63 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 pieces and 
 boiled," or divided limb from limb, and "their buried 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 
 
336 ALCOHOLIC INSANITY. 
 
 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 ; pre- 
 mising, 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 dui'ation — a more purely functional 
 derangement, due to the presence of the poison in the system ; and 
 that by the latter we refer to the more remote effects of the poison in 
 altering structure, through modifying the nutrition of the cerebro- 
 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 compi'ise mania 
 a potu, or the acute alcoholic delirium of Magnan, and delirium tremens, 
 or " febrile " delirium tremens of Magnan. 
 
 Mania a potu {acute alcoholic delirium ; delirium ehriosum). — Our 
 patient usually comes before 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 pro- 
 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, tkc, an exciting cause is afforded sufficiently potent to 
 
 * For a clinical study of the persecutory delusions prevalent in various forms of 
 insanity, see "Insanity of Persecution," by Rent^ Semelaigne, Jourii. Mental Sc, 
 vol. xL, p. 500. 
 
• MANIA A POTU. 337 
 
 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 invariably accompanied by characteristic illusions and hallu- 
 cinations ; in fact, the most notable feature of the delirium is the 
 predominance presented by such sensorial disturbance. In typical 
 delirium tremens motor symptoms are as prominent a feature as the 
 sensorial; whilst in the more chronic forms of alcoholism, 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 nature, 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 
 chronicity. The variable, fleeting nature of the sense-disturbances in 
 alcoholics has been long recognised {Lasegue, Magnan). The forms 
 thus conjured-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 Latvson). As under the influence of hyoscyamine, 
 pleasurable or painful visions troop before the mind's eye incessantly ; 
 yet the general mood in acute alcoholism is always painful, and tlie 
 visions, however fascinating in character, beget distrust and suspicion. 
 Much more frequently are these false impressions of a most painful, 
 terrifying nature ; and hideous, loathsome forms surround the victim. 
 Snakes, tigers, furious dogs are seen or heard, and the attendant 
 is transformed by the 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 amblyopia — vision is clouded, and the visual activity 
 diminished; and, with the amblyopia, there is also occasionally con- 
 joined a diiiicult perception of colours (dyschro7natopsia). It has been 
 shown by M. Galezowski that the chromatic anaesthesia 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 olfactoiy and gustatory ; 
 
 22 
 
338 ALCOHOLIC INSANITY. 
 
 the palate is in all cases more or less affected, and the anaesthetic con- 
 dition of the upper lip is an early symptom familiar to all who indulge 
 boo freely in alcoholic drinks. Similar ansesthesias, hypersesthesias, 
 and perverted states of general cutaneous sensibility have likewise 
 been appealed to as explanatory of the many forms of illusion pertain- 
 ing to the surface of the body from which alcoholics suffer. That 
 these sensorial expansions do become affected 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 off " of the fine edge," which all mental faculties alike suffer 
 from as the result of alcoholic reductions. 
 
 Relapses. — Alcoholic excess, long ere structural change can be 
 predicted in the 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 relapsing character is especially seen during the 
 ]jrogress 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. 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 disappointment. It 
 is all-important for us 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 stereotyped aspect. What- 
 ever be the centres of the brain which are more prone to disturbance 
 through the agency of alcohol — when once their nutritive equilibrium 
 is upset seriously by this agency — these centres are j^rone to suffer 
 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 February, 1S85. 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 
 
SENSORIAL TROUBLES IN ALCOHOLISM. 339 
 
 intemperance. Fi'om that time lie woi'ked 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 au}^ information 
 regarding his subjective state ; but, according to the certificate, he had avowed the 
 delusions that ' ' there were devils inside him, and that a man had 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 
 it at the time ; was fearful of sleeping at night. Rapid convalescence supervened, 
 delusions and hallucinations disappeared, and the patient was discharged six weeks 
 after entry. 
 
 Here then, we find, after nine months' abstinence, the recurrence 
 of acute melancholia apparently attributable 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 others have noted in other cases, here also the hallucina- 
 tions gradually lose their definiteness, a confused voice replacing the 
 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 strengthening impressions of 
 objective 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 presentative feelings 
 force themselves into being. In a case of mania a potu* (W.H.) 
 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 upon the re-instatement of wakeiul consciousness. 
 This state is not unfamiliar in normal health ; and a case is known to 
 the writer, where for some time after apparently complete wakefulness, 
 the subject saw distinctly what he conceived to be his own corpse 
 * See on this point, Majuan — Transl. by Dr. (ireenfield, p. 50. 
 
340 ALCOHOLIC INSANITY. 
 
 lying in a cofl&n 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 previously anaemic 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 dreams and frag- 
 mentary detached illusory states are thus intermingled with the 
 realities of waking hours ; the whole history of the case during its 
 acute 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 hemiplegic type of paralysis agitans, the writer well recalls- 
 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 
 affected centres were sufficiently energised to permit of their inter- 
 mittent discharge. 
 
 In the case of W. R. 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 appeai'ances ; 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 is 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 full play. At all times liable to dangerous 
 impulsiveness, the acute alcoholic is a fortiori vsxoyq prone to exhibit 
 such impulses at night ; and especially, when roused from slumber, at 
 the moment of waking, 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 thq medical officer at the night- visit to his bedside ; and who 
 confessed subsequently that eacli night he had imagined his visitant to 
 be under the form of Satan, and planned this means of attack upon 
 
IMPULSIVE VIOLENCE. 34 T 
 
 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 
 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 torture. 
 
 G. S., aged forty-seven, married, a woollen spinner bj'^ occupation. For two 
 months prior to admission he 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 beeavise he was "to be taken away and 
 deserved hanging." Wife stated that for years he had been an excessively sottish 
 di'inker, but less intemperate for the past six months. Brother was insane. 
 Patient was a fairly nourislied, muscular individual, well built, with a heavy, 
 stupid expression, sluggish in all his movements, his whole bearing indicative of 
 great apathy. He was very illiterate ; was reticent, wilful, and refused food 
 upon admission. There was no oculo-motor paralysis ; tongue was protruded 
 straight and steadily — it was covered with foul epitheha ; heart's action feeble, 
 no murmur. Abdominal viscera apparently free from all but slight functional 
 derangenlent. 
 
 During his first week's residence, when sleeping under observation, he suddenly 
 sprang out of bed, threw liimself upon a patient next to him without any pro- 
 vocation, and nearly strangled liim ; he was removed to a single room where he 
 was discovered mutilating liimself, having succeeded in inflicting a deep incision 
 with liis finger nails around the penis. 
 
 Up to this period lie had been taking morphia ; hyoscyamine (^ gr. Merck's 
 Extract) was now ordered. A month after admission it is noted — "Much quieter, 
 but still has a hang-dog look, as if much afraid of something or somebody ; " 
 and, a few days later, he became greatly excited and suspicious, attacking his 
 night-attendants and fellow-patients. Chloral (grs. xxx) ordered night and 
 morning. 
 
 Muscular enfeeblement, especially oj the lower 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 habits. 
 
 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 
 subsequfitl}' supervened, necessitating very cautious feeding. He remained help- 
 less, bedridden, and extremely demented, dying somewhat suddenly six montlis 
 after admission. 
 
 The case of 7. B. (p. 249), is a typical one of mania a pota passing 
 into chronic alcoholism in a subject predisposed to insanity, and inherit- 
 ing the results of paternal intemperance. Prior to his visit to America, 
 his seizures were of the nature of acute alcoholism; but, iipon his return 
 
342 ALCOHOLIC INSANITY. 
 
 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 
 Symptoms as the result of too tree an indulgence in intoxicating liquors, 
 has been for centuries recognised by the profession. Even in classic 
 times, we find occasional allusion to such states {Seneca). 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 Eoman 
 Empire. Nearer our times, Lettsom has clearly demonstrated the 
 sensory and motor troubles induced by long-continued alcoholic indul- 
 gence ; 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 spii-it by all 
 classes of the population (and especially of a most impure and 
 pernicious spirit, distilled from diseased potatoes, wliich formed the 
 
CHRONIC ALCOHOLISM. 343 
 
 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 
 deleterious 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. 
 
 Yan-der-Kolk f dealt with alcoholism as he met with it in Holland ; 
 and later (1876), Magnan J has done for France, in his elaborate 
 treatise on alcoholism, what Huss did for Sweden ; and in our own 
 country, Drs. Carpenter, § Marcet, || Anstie,1I Wilks,** and Parker, 
 have, amongst many others, 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. Perby,tt 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 inciter to morbid change. 
 
 It is unnecessary here to do more than very briefly allude to the 
 injurious effects 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 injui'ious effects of 
 drunkenness upon all the tissues of the organism. The chronic 
 gastric catarrh ; the hasmorrhagic mucous membrane ; the inter- 
 stitial changes in the liver and kidney ; 1. 1 the atheromatous condition 
 
 * Alcohoiis7nu.s Chronicus. Dr. M. Huss, Stockholm, 184:9-51. 
 
 t Influence of Strong Drinhs on the Human Body, by J. L. C. Schneider 
 Van-der-Kolk. Utrecht, 1853. 
 
 X Alcoholimi. Dr. V. Magnan. Translated by Dr. (Jreenfield, 1S76. 
 
 § Use and Abuse oj Alcoholic Liquors inHealth anclDisease. W. B. Carpenter, 1850. 
 II Chronic Alcoholic Intoxication. Dr. Marcet, 1862. 
 
 ^ Stimulants and Narcotics. Dr. Anstie. Macmillan, 1864. 
 
 ** Alcoholic Paralysis. Dr. Wilks. Lancet , \'^12. 
 
 \\ An ExpeHmental Enquiry concerninr/ the presence of Alcohol in (he Ventricles 
 of the Brain. 1839. 
 
 iJl^The frequency of its action on the kidney has been denied by Dr. Dickinson 
 and Dr. Anstie. Medical Times and Gazette, November, 1872. 
 
344 
 
 ALCOHOLIC INSANITY. 
 
 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 f 
 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 afiinity " of 
 nervous tissue for alcohol. 1 
 
 4. Clianges of a profound significance are induced in the blood 
 itself at an early period, laying the foundation for the various tissue- 
 changes which ensue, and which directly affect the well-being of the 
 nervous centres by the immediate functional disturbances which are 
 induced through the agency of the nutritive pabulum of the blood. 
 Such changes are the devitalisation of the red corpuscles leading to 
 impaired teration ; 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 
 
 * D^i role de V Alcohol et des Anesthetiques dans VOrganisme. Paris, 1860. 
 t Bichromate of potash, 1 grain ; sulphuric acid, 10 grains. 
 
 t See "Selective Capacity of Nervous Tissues for Alcohol,"' by Dr. Alex. 
 Robertson, Glasgow Medical Joiirn., 18S6. 
 
EVOLUTIONARY PERIOD OF ALCOHOLISM. 345 
 
 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 abnorm:\l 
 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 depends upon the kind 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 depends 
 also upon tlie 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.y^ Those specially predisposed to the rapid incidence of 
 delirium upon drinking are readily recognised. We are all acquainted 
 with friends in whom a single glass or two of wine will produce 
 striking degrees of nervous instability ; just as we recognise others in 
 whom habitude, idiosyncrasy, or other cause permits a continuous and 
 heavy indulgence in alcoholic drinks with but little obvious effect. 
 It is astonishing 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-drinker from the working-classes of Sweden, is thus given by 
 Dr. Huss : — 
 
 ' ' He rises at five 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 brand}' 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, anotlier 
 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 ouncea of spirit. iSuch 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 
 
 * " Patients specially predisposed, who, when suffering from alcoholic delirium, 
 have frequent relapses, and a convalescence often interrupted by delirious ideas, 
 assuming more or less the form of partial delusion."' Loc. cit., p. 03. 
 
346 ALCOHOLIC LN'SAXITY. 
 
 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 interesting 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 correct 
 statement. Females undoubtedly enjoy a remarkable immunity from 
 the disease, as they likewise do from general paralysis • 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 
 M. T. is a well-marked instance of this affection in women. 
 
 Lastly, as regards age. The statistics of Magnus Huss fix the fiftlt 
 decade as comprising the larger number of cases, and the fourth decade, 
 as presenting a smaller proportion, his figures are as follows : — - 
 20 to 30 years of age, ...... li eases. 
 
 30 ,, 40 
 ■iO ,, .50 
 50 ,, 60 
 60 „ 65 
 
 M 
 
 57 
 
 23 
 
 1 
 
 139 
 
 In estimating the value of this table it must be borne in mind that 
 allowance must be 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 more narrowed and selfish in his desires, his 
 altruistic sentiments rapidly declining. The imaginative faculties are 
 
 * "An inquiry into the influence of the abuse of alcohol as a predisposing cause 
 of disease."' By W. Mavcet. Brit, and For. Medko-Chir. Bev., 1862, Xos. 57-58. 
 
SYMPTOMS OF CHRONIC ALCOHOLISM. 347 
 
 early affected, the higher emotional states are warped, and the whole 
 moral nature undergoes 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 instinctive appetites '' (llag^iait).* 
 Aural hallucinations are (as in the acute form) still present, and are 
 now no longer transitory phenomena, but often of such persistence as 
 to constitute the chief mental symptom in the earlier stage of chronic 
 alcoholism ; the victim to such sensory disturbances suffers terribly, 
 and not infrequently is driven to acts of desperate violence 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, declaring 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 
 him. Old associates are especially accused by the patient of thus 
 torturing him ; thus J. j\PG. constantly heard the voice of a disreput- 
 able girl with whom 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 douiiuant 
 interest of the moment." f This is but an indication of the change 
 wrought 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 unnatural crimes ; 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 chronic 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. 
 
 " Op. cit., p. 15G. t Op. riu, p. 34. 
 
348 ALCOHOLIC INSANITY. 
 
 1. Amnesic Forms. — 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 structural 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- 
 tiveness up to a complete, and almost immediate, abolition of the 
 latest impression. A patient so affected forgets names, dates, and 
 order of sequence, to an almost incredible 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 recognise their enfeeble- 
 ment and often strive to the utmost to overcome the difficulty, such 
 efforts eventually prove successful, and are suggestive indications as 
 to the nature of the lesion. 
 
 .J. F., aged thirty-one, a dyer's labourer; admitted in January, 1887. For 
 four montlis prior to admission, he had been strange in manner, restless, and of 
 vagrant habits. He was known to be of intemperate habits, but no satisfactory 
 history could be obtained. Upon admission he was free from excitement and 
 delusion ; his intellectual operations were enfeebled, but this 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?" "/ doiiH know." What is the present month?" 
 " Don't know for certain; November, cus near as I can tell." " How long have you 
 been here ? " Don't remember sleeping more than one night here." "You gave me 
 the same reply yesterday ! " Did I? I don't remember; if so, I supjjose I have slept 
 here longer." He was now told that the day was Monday, 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, 1886; October, or 
 November, I don't know fairly." 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 rarely retained them beyond one minute; and 
 if any trivial question were put meanwhile, he became immediately oblivious to the 
 preceding impi'ession. 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 repeatedly. 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 sesthesiometer. The dynamometer registers for the right hand 28 kilos, 
 pressure, and 23 kilos, for the left hand. After a residence of three months, he 
 still affirmed that he had oi;ly slept two or three nights at the asylum. Eventu- 
 
AMNESIC TROUBLES IN ALCOHOLISM. 
 
 )49 
 
 ally, this patient gi-adually improved, and a few months later he was 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 vigour of circulation and nervous energy. 
 
 3. The organisation of such impressions in the establishment of 
 
 associated sense-impressions. 
 
 4. The vigour of the faculty of attention. 
 
 5. The element of time. 
 
 Now in the case with which we are dealing, the irdensity of the pre- 
 vious impression appears to be of minor importance, but the vicrour 
 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 proved by the retarded response made to sensoi-y stimuli^ 
 visual or auditory ; and this we have more reason to attribute to delay 
 in the sensory arc than 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 resultino' 
 in a diminution of the effective 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 forcing of new nervous 
 tfacts 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 an impression 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 impressions which might otherwise occur. 
 
 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 J. F. it will be noted that any name 
 
350 
 
 ALCOHOLIC INSANITY. 
 
 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, 
 in 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 or 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 discharge 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 afford 
 still more tangible basis for the fostering of a gloomy, suspicious, 
 distrustful nature. 
 
 We have seen how morbid sensations may be fostered and enoi'mously 
 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 
 which they may be based are distorted to an extraordinary degree. 
 Here, again (as indicated elsewhere), with the decline of object- 
 
 consciousness, there is a corresponding" rise of subject-con- 
 
NATURE OF THE DELUSIONAL PERVERSION. 
 
 151 
 
 SCiousneSS, and the conception is formed of a hostile and aggressive 
 environment. 
 
 T. S., aged fifty-six, married, commercial clerk, admitted in Januar}-, 1873, 
 suffering from his first attack of insanity, of fourteen months' duration. He was 
 somewhat above the middle height, stout, muscular, and well-nourished ; of some- 
 what swarthy complexion ; hair black, turning grej' ; 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 him ; at times, the whistling and the voice 
 are heard in the air above, and even now the voice is heard distinctly taunting him 
 from outside the window — " Thou'st made a nice job of thyself, T. S., b}' getting 
 in here." He feels impelled to accuse himself of extraordinary' crimes, such as 
 murder, poisoning, and a robbery of £50,000, "although he knows it is not true." 
 The w^histling 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 son'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 emploj^ed 
 during the first few months of his residence here ; but, when left to his own 
 resources, he invariably occupied himself in writing out length j^ 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. 
 
 The persistency of these delusions is evidenced by the follo^^•ing 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 husVjand, who resides forty miles south of London, is the 
 inventor 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 
 all are fixed at Leeds or Wortley (but I believe at the last-named place). Five or 
 six persons whom I know by their voices (but there are many others I don't know) 
 can see and hear all that transpires in the district (and to my own knowledge) 
 within a radius of thirty miles, from Wortley ; they can also tell (after having 
 applied the electro-magnet to his head) what an}' 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 ma}' be througli a material fluid — 
 call it electric, call it odic, ca/f it mhat you will, which has the power of traversing 
 space, and passing obstacles, so that the material effect is communicated one to 
 another. No man or woman's life is safe that they have anj' 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, bj' the inventor's 
 infernal machines, by him, his, and my first wife's relatives, and others who have 
 
352 
 
 ALCOHOLIC INSANITY. 
 
 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 
 way in the disposal of all I have, say about £1,500, which I have 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. — I 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 will 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 iixed. 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 with." . . . 
 (here follow abusive and obscene epithets). Don't imagine I am insane because I 
 write this from a lunatic asylum. — 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 considerable quantity of marking ink. 
 
 No words could adequately describe the terrible mental torture to which 
 this poor man was doomed, and although, at times (through the administration of 
 opiates, cheerful society or emploj'ment, and conversation to distract his mind), 
 his symptoms were somewhat alleviated — the evening invariably found him suffer- 
 ing, with redoubled force, from his invisible persecutors. Like most cases of this 
 category, he 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 probabilities of mesmerism, electro-biology, vntchcraft, odyle, electricity^, 
 and macrnetism 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 had for the first time heard, and which 
 he convincingly and triumphantl^'^regarded as the solution to the whole mystery 
 of his case.— Cases 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 
 
CASE OF T. s. 353 
 
 made to speak the thoughts of others.'^ One patient (./. 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 
 environmental agency ; the noxious cliaracter of which is inversely 
 ])roportioned 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 tlie 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 which 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 suVjject of his delusions, and never volunteered 
 any reference to them unless repeatedly prompted. 
 
 These cases of delusional insanity 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 these 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 wlien 
 the delusions (although often associated with aural hallucinations or 
 hallucinatory states of otlier 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 
 
 23 
 
354 
 
 ALCOHOLIC INSANITY. 
 
 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 more prominently or exclusively affected. 
 
 In the primarily sensorial forms we find aUPal hallucinations 
 preponderate ; and although other senses (move often those of taste, 
 smell, and general sensation) may be likewise disturbed, in most 
 cases the auditory distui-bance is the only anomaly complained of. 
 The phenomena observed may embrace every possible combination of 
 articulate or inarticulate sounds. If 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 
 him as they flitted to and fro ; another was addressed by the crows 
 as they flew past him ; but, the voice was the voice of human beings 
 whom 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 viscePal 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'astPiC voice, in which a sensation felt at the epigastrium is 
 oftea 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 with 
 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 SCXUal feelings 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, 
 * " On Bilatei'al Hallucinations," vide Magnan, Archiv. de Neurologic, Nov., 1883. 
 
VISCERAL ILLUSIONS. 355 
 
 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 affect, 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 
 position, and in which are mapped out the course of the " electric 
 fluid," and the structures which are supposed by him to be concealed 
 within tlie 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 maledictor-y comments dedicated to his persecutors. 
 The effusion throughout was couched in the most obscene and revolt- 
 ing lahguage obtrusively exposed ; in his calmer moments, no one 
 could be more decorous and punctilious in his behaviour or conversa- 
 tion. The case of J. M'-Q. 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 'aUX.y, married, printer by occupation ; a tall, powerfully-built, 
 muscular man, somewhat prematurely aged, with a suspicious, furtive look, a 
 dusk}', 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 thei'e 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 liad 
 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 Bradford could hear all that he said ; certain perforations in tlie 
 wainscotting he asserted were telephones ; the bed he lies upon is electrified, and 
 he even now feels the ciurent passing tlirougli liim. At his own home a telephune 
 wire ran beneath the floor of liis room, and upon placing the legs of his chaii" 
 parallel with this wire, he could himself feel the electric current ; people in 
 adjacent houses constantly spoke audibly through tlie walls of his liouse ; tliey 
 
356 ALCOHOLIC INSANITY. 
 
 ■were in intrigue with his wife, whose fidelity he distrusted. He found that sh» 
 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 ; h& 
 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. 
 Tlie 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 interlocutor would but spend half-an-hour with him, he would 
 also be convinced ; heard his niece this morning, and his daughter's voice last 
 night. He made a most violent attack upon an attendant later on. 
 
 Nov. 11. — "They galvanise all the chairs, and the current goes through me 
 strongly." 
 
 Dec. 7-^Remarked to an attendant who opened his door this morning, " Now 
 or never ! " and followed him closely, it is not certain with what intentions. 
 
 Ja7i. 19. — "Hears attendants in the rooms overhead making a buzzing noise 
 and talking ; '' but does not hear what thej^ say. 
 
 Feb. 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 produced 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 miu'der them all. 
 
 His subseqiient 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 prosti-ate upon waking in 
 the morning. The unseen fluid enters his ears, and afiects his brain ; 
 but his malignant enemies always keep " prudently at a distance." 
 
CASE OF CHRONIC ALCOHOLISM. 357 
 
 A very special form of delusion, already alluded to and illustrated 
 becon^es elaborated in such cases as that of J. B. Here the resistance 
 met with by the organism appears chiefly to affect 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 brain ; which ruUs 
 fm houghts and dictates his very rUterances. In such cases, where (as 
 in tliat o J.B)uo 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 
 m varying degrees affected in this class of cases, and delusional 
 concepts evolved out of the resistance which is engendered by such 
 lailure. " 
 
 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 important 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. With 
 this object, let us study the nature and effects of the sensorial distur- 
 bances. Ihe hallucinatory phenomena are, as we know, presumed to 
 be due to certain abnormal discharges from the sensory areas of the 
 cortex. 
 
 Nature of the Discharg-e.-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 statJ 
 of extremely unstable equilibrium-a state of sensory hypera^sthesia 
 prevails. When such unstable centres discharge themselves, one or 
 more of several results may occur. In the first place, as indicated by 
 -Ur. Hughlings-Jackson, the discharging centre exhausts itself— is for 
 the time being (in the case of the sensory area), less impressionable- 
 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 ; 
 
 {b) It may diffuse 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 
 
358 ALCOHOLIC INSANITY. 
 
 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. 
 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 which follow the hypersesthetic 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 subject-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 difi"use 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 gi'eat 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 object-consciousness ; 
 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 dischai'ges from these sensory areas eventually break 
 through this barrier of resistance, but only in certain determinate 
 
SENSORIAL AND MOTORIAL DISTURBANCES. 359 
 
 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 on 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 tlie intellectual operations become pervaded by such 
 agencies, and strong contrasting feelings and ideas arise, overbalancing 
 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-jyervious 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- 
 sesthesia are often noted, as in the wrist of the patient (./. J''.), 
 where tactile sensibility is greatly exalted ; the site is also equally one 
 of hyperalgjfisia. The variety of hyperalgfesia, 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 polycesthesia, 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. 
 
360 'ALCOHOLIC INSANITY. 
 
 wrenched off 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. An impairment of muscular sense discrimination can readily 
 be shown to exist in alcoholic insanity ; but, for the results of actual 
 measurements of such impairment we must refer to the chapter on 
 general paralysis (p. 298). 
 
 Motor Symptoms. — The group of symptoms described under the 
 head of sensorial anomalies, though highly characteristic of chronic 
 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 self-same 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 viode 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 moi'e particularly at this phase, 
 and upon which we do not think sufficient emphasis has been 
 placed, is this : the morbid process due to alcoholism evolved in 
 sensory areas ever tends to be translated into the motor realms of tlie 
 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 translation in physico-mental terms— the 
 delusional distortions being often nothing more than mere symbols 
 of motor enfeeblement which may not be so obtrusive a symptom 
 to the observer. 
 
CASE OF J. R. 361 
 
 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 collier}', 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 sun, moon, and 
 stars. His sister stated that patient's father was a notorious drunkard, 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 
 healthy and temperate. Patient began 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 by 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 asylum he was excited, incoherent, incessantly 
 garrulous, restless, and irrational ; " has the sun and moon — half 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. Tliere was no defect of articulation ; no 
 muscular tremor ; was of spare habit, weighing 126 lbs. ; height, 5 ft. 7 ins. 
 Tlioracic and abdominal systems appeared normal. 
 
 Some four months later he still continues maniacal ; grotesc[ue, 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." 
 
 He was re-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 weie equal and active ; deep reflexes normal. 
 
 Dec. 2. — Has become very suddenly feeble, totters much in his gait, and is inclined 
 to "double-up ;" is still maniacal, but mutters more to himself; tongue somewhat 
 brown. 
 
 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 arc blistered ; both feet are of icy coldness, 
 and are kept somewhat rigid, but there is no genuine contracture ; both 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 twitcliing and corruga- 
 tion of brow-muscles, and also of facial muscles generally ; frequent 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, inco- 
 herent, jocular, and mischievous. 
 
362 ALCOHOLIC INSANITY. 
 
 In this connection, thei'efore, 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 paresiS — 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 
 dimimition 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, when it appears as a rapid and fine 
 oscillation of the fingers and hand. A still more important sign, how- 
 ever, is that of muscular tzvitching, varying from the twanging of indivi- 
 dual 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 folpe- 
 brarum (as in emotional expression). We have on a former occasion 
 referred to the much more frequent implication of the brow muscles as 
 associated with disorders of attention,* 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-mastoidei, as in the patient, J. J ., who attributed 
 the movement to electric currents applied by the medical officers. 
 * See Brit. Med. Journ., Aug. 20, 1892, p. 409. 
 
MOTOR ENFEEBLEMENT— REACTION-TIME. 363 
 
 When the facial muscles ai"e 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 fUPFOWing'S of the muscles of the brow 
 are often obvious, due to irregular contractions or paralysis of the 
 antagonistic groups. An increased reaction-time is a notable feature 
 in alcoholic insanity, and although in a large percentage of cases 
 examined the response to acoustic as well as optic stimuli showed this 
 retardation, the delay was more uniformly present in the latter than 
 the former. Taking the average range of acoustic reaction-time as 
 -^jfjj to J^j of a second, and of optic reaction-time as —^ to ^jf^ of a 
 second, in normal subjects, as given by the several authorities already 
 quoted (p. 165), we find, on reference to the following table, tl)at out 
 of the twenty-six cases of chronic alcoholism, twenty exceed this maxi- 
 mum for acoustic stimuli, and out of twenty-four cases examined, 
 twenty-two exceed the maximum for optic stimuli. 
 
 Reaction-Time ix Alcoholic Insanity. 
 
 Much mascular trtmor, ..... 
 Chronic alcohol imn, delusions ofpersecvtion, 
 Chronic rxlcolioli>sm, delusional insanity, riolent, 
 Danf/erous, homicidal, delusions of persecution, 
 C/tronic cdcoholism, demented, morbus Brightii, 
 Sliy/t/ mania, lialhicinations, su^jjicious, tremulous, 
 Chronic alcoholism, hallucinations and delusions 
 
 of suspicion , ...... 
 
 Chronic alcoholism, hypochondriasis, suspicion. 
 Chronic alcoholism, hallucinations, delusions of 
 
 persecution, ...... "20 '20 
 
 G. A., . . Chronic alcoholism, delusions oj persecution, 
 
 violent, -20 'I'li 
 
 G. 
 
 H., . . 
 
 J. 
 
 M., . . 
 
 H. 
 
 W., . 
 
 H 
 
 G., . . 
 
 W 
 
 . W., . 
 
 J- 
 
 C, . . 
 
 E. 
 
 L., . . 
 
 R. 
 
 B., . . 
 
 J. 
 
 .P., . . 
 
 Acoustic 
 
 Stini\ilus. 
 
 iieu. 
 
 St 
 
 Optic 
 iimilus 
 Sec. 
 
 •14 
 
 
 •23 
 
 ■15 
 
 
 •21 
 
 •17 
 
 
 •2(i 
 
 •18 
 
 
 •21 
 
 •IS 
 
 
 •2-) 
 
 •, -IS 
 •I'.l 
 
 
 •25 
 •25 
 
 •1!) 
 
 
 •21) 
 
'M 
 
 ALCOHOLIC INSANITY. 
 
 Reaction-Time in Alcoholic Insanity — Continued. 
 
 Extreme depression, imicidal, susjjicious, . 
 Mania a potu, excited, voluble, 
 Tabetic, deluded, treacherous, homicidal, . 
 Chronic alcoholism, hallucinations, suspicious, . 
 Delusions q/ persecution, grim, treacherous, 
 homicidal, ..... i 
 
 Apathetic, slight mental enfeehlement, amnesic, . 
 Chronic alcoholism, delusions of persecution, 
 Chronic alcoholism, maniacal, wild, boisterous, , 
 Chronic alcoholism, notable amnesia, 
 Advanced dementia, delusions, depression, 
 Dementia, much enfeeblement of memory, apathy. 
 Calm, inohtrusive and demented. 
 Suspicious, deluded, hostile, treacherous. 
 Degraded, maniacal, vicious, repulsive, 
 Calm, demented, amnesic, deluded, . 
 Chronic alcoholism, demented, degraded. 
 
 Acoustic 
 Stimulus. 
 
 Sec. 
 
 Optic 
 
 Stimulus 
 
 Sec. 
 
 •21 
 
 •24 
 
 •21 
 
 •25 
 
 •21 
 
 •25 
 
 •21 
 
 (Blind) 
 
 •2'2 
 
 •23 
 
 •22 
 
 ■25 
 
 •22 
 
 •27 
 
 •22 
 
 •29 
 
 •22 
 
 •29 
 
 •23 
 
 •24 
 
 •23 
 
 •27 
 
 •24 
 
 •27 
 
 •24 
 
 •25 
 
 •24 
 
 30 
 
 •27 
 
 •30 
 
 •30 
 
 9 
 
 J. M., . 
 G. M., . 
 W. S.,. 
 P. T., . 
 J. .P., . 
 
 M. H. L., 
 J. G., . 
 J. .p., . 
 J. F., . 
 J. R., . 
 J. W., . 
 A. K., . 
 J. T., . 
 J. B., . 
 J. K., . 
 T. C, , 
 
 The above may be usefully compared with the results obtained from 
 subjects of ordinary forms of depression and exaltation. 
 
 We have stated elsewhere that the delayed reaction-time obtained 
 in mental disease may be due to the implication of the sensory end 
 organ, or to the central link betwixt sensory and motor adjustments ; 
 and that in alcoholic insanity it was probably the peripheral end organ 
 which suffered. We must not, however, lose sight of the notable 
 enfeeblement of attention so largely betrayed in the mental operations 
 of alcoholic subjects. Even in normal subjects we have noted a well- 
 marked increase in reaction-time after alcohol, although the subjects 
 operated upon thouglit their reaction was quickened — a result in 
 complete accord with Exner's observations where the I'eaction-time 
 was reduced by this agency from •lO of a second to '29 of a second.* 
 The effect of a diminished attention due to the distraction of a too rapid 
 process is here probably the chief agency at fault ; we must make due 
 allowance for this failure in chronic alcoholism. 
 
 Reaction-Time in Depression and Exaltation. 
 
 Acoustic 
 
 Stimulus. 
 
 Sec. 
 
 Optic 
 
 Stimulus. 
 
 Sec. 
 
 J. H. B., . Simple melancholia, 
 
 
 
 •13 
 
 •20 
 
 C. K. , . . Hypochondriacal melancholia, . 
 
 
 •14 
 
 •24 
 
 C. P., . . Delusional 
 
 
 
 ■18 
 
 •21 
 
 S. S., . . Chronic ' 
 
 ,)' 
 
 
 •IS 
 
 •18 
 
 E. H., . . Simple 
 
 
 
 •18 
 
 •18 
 
 E. D... . . „ 
 
 
 
 •21 
 
 •28 
 
 J. M. , . . Hypochondriacal 
 
 
 
 •21 
 
 •20 
 
 * Hermann's Handb. d. 
 
 Physiol., vol. ii 
 
 ;La 
 
 dd, op. cit., p. 497. 
 
 
MUSCULAR SPASMS AND CRAMPS. 
 
 365 
 
 Reaction-Time in Depression and Exaltation- 
 
 J. H., . 
 
 Hypochondriacal melancholia, 
 
 J. E., . 
 
 Simple ,, 
 
 G. H., . 
 
 ,, 
 
 
 G. P., . 
 
 Chronic 
 
 
 J. W.,. 
 
 Hypochondnacal 
 
 
 T. E., . 
 
 Chronic 
 
 
 R. W., 
 
 Simple 
 
 
 S. W., . 
 
 Climacteric 
 
 
 W. T., . 
 
 Acute mania, . 
 
 W. W., 
 
 ,,,,.,. 
 
 W. H., 
 
 Simple suhacute mania, . 
 
 M. R.,. 
 
 )> )i 
 
 W.M'C, 
 
 Acute mania, . 
 
 
 -Continued. 
 
 
 Acoustic 
 Stimulus. 
 
 Sec. 
 
 Optic 
 Stimulus. 
 
 Sec. 
 
 •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 
 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 relatively so increased by a fall in the energy of the centre. A 
 continuous contraction is thereby rendered impossible from want of a. 
 suflSciently rapid 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. 
 
366 ALCOHOLIC INSANITY. 
 
 as in the allied aflection — 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 ./. TF., continuous 
 movement of the eyeballs occurred in a horizonal 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. It has been con- 
 clusively shown that as regards the criminal, at least, epilepsy is a 
 most frequent sequel in the offspring of paternal alcoholism. " In 
 connection with this point, and also as showing the great tendency of 
 alcoholism to produce early convulsions in the offspring, it may be 
 mentioned that the average age for the commencement of the fits, for 
 those epileptics who have a direct hereditary history of drink, is less 
 by 4"5 years than for those whose parents are returned as sober." ''•■ 
 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 of such attacks present themselves, but do not 
 issue in convulsion or paralysis ; a slight dizziness or actual vertigo, 
 accompanied by syncopal attacks, or a mere tendency to faint, may be 
 noted] or there may be pallor of face, associated wdth cold perspiration, 
 Avhile the patient sinks exhausted into a chair, but may rapidly recover, 
 complaining 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 affection. 
 
 T. P., aged sixtj'-two, widower, a shoemaker by trade, a man of moderate 
 height, well-nourished, but bald at vertex wath 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, biit 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 
 
 * Henry Clarke, M.D., op. clt., p. .506. 
 
CONVULSIVE ATTACKS— CASE OF T. P, 367 
 
 months prior to his admission at the asyhim, 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 halki- 
 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 lie was restless, emotional, bursting into 
 tears whenever interrogated ; there was profound dementia. He was quite 
 oblivious to his recent history, and did not know whether he had been days, 
 months, or j'ears at the asj^um ; 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 
 unintelligible. In general appearance he was decidedly sottish. 
 
 Sliortly after admission, he liad 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, shorth^ 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 aflfected. During the succeeding three or four months, he had 
 frequent ' recurrence of such conviilsive seizures, with precisely the same motor 
 distribution as in the former attack, and chloral in all cases rapidlj' arrested the 
 convulsions. About three years after admission 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 and very pale; 
 slight adhesions of the cha^a mater. In frontal-parietal lobes of lirain there is con- 
 siderable wasting, most marked in the left hemisphere, and peculiarh' so in the 
 ascending parietal convolution and the boundaries 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 rediioed ; 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 ; tlie 
 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 elsewliere and the 
 cerebellum presented nothing abnormal. Whole brain weighs 1,234 grammes. 
 
 Pvight hemisphere, . .516 grms. Left hemisphere, . .515 grms. 
 
 Riglit 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 l^y 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, tqugh capsule, and 
 containing clear fluid. Spleen, 85 grms. ; also firmly adherent to stomacli ; its 
 
368 • ALCOHOLIC INSANITY. 
 
 substance congested, soft and dark. Right kidney, 163 grms.; capsule thin, strips 
 from a smooth, pale surface, revealing numerous shallcn- scars ; both cortical and 
 medullary portions are much rediiced — 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 I inch in diameter by a huge hydro-nephrosis — 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 
 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. Hyperassthetic. 
 
 2. Parah-tic or Paretic. 5. The Convvilsive. 
 
 3. Aniesthetic. 6. Epileptic. 
 
 Mao^nan, whilst justly criticising this division as not a genuine 
 clinical group, specially calls attention to one form — the hemian- 
 jesthetic type — which, from clinical and pathological considerations, 
 he deems worthy of this dignity. 
 
 J. C, aged sixty, a widower, employed at his trade as cm-rier 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 ^-iolent, and she had to seek assistance from 
 the Union authorities, who foimd liim incoherent and wildly excited. He was 
 said to have lived a temperate life ; to have had no con\nilsion, stroke, or cranial 
 injury ; and to have exhibited failure of memory only quite recently. All these 
 statements, however, were received with reserve, o-wing 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 Relie^^ng Officer 
 found him noisy, incessantly talking in an incoherent strain, violent to all around, 
 and kicking his furniture downstairs, declaring he was mo^-ing his home. He had 
 slept but little for nearly a week. 
 
 He was a short, thick-set individual, 5 feet 3 inches high, and ^^•eighing over 
 10 stones ; of florid complexion, with dilated malar capillaries ; bald at vertex, with 
 grey tonsure. His locomotor system appeared imaffected, and his grasping power 
 was good ; his speech betrayed no defect. His bodj- generallj' 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 eventa 
 it was wholly at fault ; he was utterly inappreciative of the nature of his sur- 
 
CONVULSIVE ATTACKS— CASE OF J. C. 369 
 
 roundings and present condition ; attention could only be commanded with 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 dailj' ; the phj'siological 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 
 notable degree of dementia. No further maniacal outburst occurred, and he was 
 relegated to the class of indolent, harmless, and helpless patients. A large 
 haematoma auris now developed — it was believed as the result of a fall on the floor. 
 Eighteen months after admission, he appears to have had a paralytic seizure affect- 
 ing both limbs on the left side, in which common sensation was somewhat blunted 
 and the superficial 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 slightl}' 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 this period he was suliject 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. 
 
 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 
 pronounced 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 leature, whilst 
 
 * Op. cit., p. 158. 
 
 24 
 
370 THE INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 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; (b) 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. 
 
 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 — Actiuisitiveness and Mimetic Characters of Childliood 
 — Imitative 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.)— Ameuorrhceal and Anaemic 
 States— Influence of the Environmental Factors— Percentage of Haemoglobin in 
 Cases of Stupor — Pubescent Insanity in the Male — Sexual Divergence- 
 Symptoms of Pubescent Insanity— Modified Forms (J. M.)— Masturbatic and 
 Uncomplicated Form of Pubescent Insanity— Etiology— The Moral Imbecile. 
 
 The Physiological and Psycholog-ical 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 
 
THE PUBESCENT EPOCH. 
 
 \n 
 
 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 chords in the male, with a corresponding 
 lowering of the voice an octave or more; an increased compass o°f 
 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 galactophorous 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 
 maturity. But it is well-established that sexual maturity— that is, the capacity 
 for hearing 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 0-225 
 
 0-65 
 
 3-40 
 
 8-30 
 
 15-95 
 
 19-02 
 
 24-17 
 
 12-47 
 
 9-82 
 
 3-45 
 
 1-77 
 
 0-225 
 
 015 
 
 » „ 005 
 
 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 
 
 „ 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 Ahortim, p. 46. 
 
372 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 sexual maturity, and through the period of adolescence. The small percentage of 
 3 "4 who show themseh^es 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 sj^stem also undergoes a profound change. 
 
 The period of adolescence, however, may be regarded as extending 
 from puberty to the age of twenty-oue 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 
 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- 
 g'ence. 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 gTOWth and develop- 
 ment, which is intimately connected with the law of reproduction " 
 {G. II. Leicesj). Tissue metabolism, therefore, is by no means a 
 constant for different periods of life. The epoch we are considering 
 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 tirst year 
 of its liie [Landois and Stirling %) ; and from Quetelet's researches it is- 
 seen that the first three years (and especially the first year) are 
 
 * Thus Spiegelberg affirms that, "So long as the body has to provide for its owti 
 development, and consequently requires a large amount of formative material, it 
 has no energy to spare for jjropagating 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-hook of 
 Midwifery, New Syd. Soc, vol. i., p. 59.) 
 
 t Life of Goethe, p. 355. t Op. ciL, p. 528. 
 
ANTAGONISM OF GROWTH AND DEVELOPMENT. 
 
 0/0 
 
 periods of wondrously active growth, the increase in stature being as 
 follows : — 
 
 First year, a gi'owth of . 20 centimetres. 
 
 Second ,, ,, . 10 ,, 
 
 Third ,, ,, . 7 
 
 Fifth to sixteenth year, ,, . 5 J ,, per annum. 
 
 Twenty-fifth to thirtieth year, . 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, token 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 
 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 G 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." t 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 extracted 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 suj)reme 
 pleasure of the organism ; yet, such activity is still chiefly tenta- 
 
 • Clinical Medicine, Syd. Soc, vol. v., p. 82. t Cyclical Changes, p. 286. 
 
374 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 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 
 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." — Word-sivorth. 
 
 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 affected 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. Oorrelatively, 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 cerebral 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- 
 assurance and orig'inating' 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 COnstPUCtiVG 
 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 
 
PUBESCENT INSANITY IN THE FEMALE. 375 
 
 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 eg'Oisni 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, 
 as that exaltation and excitement, the symptoms of an acute cerebral 
 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 perversions 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 Jlames ; motJier dead and home 
 ruined ; has murdered some one and is pursued by policemen ; is to be 
 burnt alive ; men concealed in her tuardrobe ; fellow-palients try to 
 
 * Or to be exact — delusions were present in 52 per cent, males, and 493 per 
 cent, females ; hallucinations prevailed in 25 per cent, of either sex. 
 
376 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 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 
 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 moliraen will be 
 associated with greater or less cerebral excitation ; hence at these 
 periods relapses are apt to occur (J/. C. TT., p. 242). 
 
 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. ISTot 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 lias 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 relapses occurring 
 one, two, three, four, and five times, and even more frequently, before recovery or 
 dementia finally takes place, may be taken to be especialty 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- 
 
 * hoc. cit., p. 551. 
 
STUPOR AND COINCIDENT MENSTRUAL DERANGEMENT. '^'J'J 
 
 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, nnruly 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- 
 plexion, muscular, but extremely pale and antemic. 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 asjdum, 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 jealousj- 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 bj^ the window. During the whole of tliis 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 tlierewith. 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 ecstasj' 
 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 ansemia, which accounted for the persistent amenorrhcea from which 
 she suff'ered. 
 
 The tendency to stupOP is especially marked in those cases where 
 there is well-pronounced menstPUal dePangfement, 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 
 prevails, amounting at times to fatuity ; the expression is stupid and 
 
 * In such instances of stupor associated witli menstrual derangement, changes of 
 undoubted moment occur in the constitution of the blood. The red corpuscles are 
 seldom diminisiied in number to any notable extent, but their htemoglobin is in all 
 cases alike reduced in amount. In some we find tlie corpuscular value })el()w lialf 
 the normal, as in the case of C. W. (p. 381!), wliere it is represented at -45, or that 
 of R. W. J. at -44. The amount of haemoglobin, as given by the several cases at 
 page .38(), 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 p. 38(1), the 
 percentage of htenioglobin 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 il/. A. M., the 
 haemoglobin registered as low as 20 per cent. 
 
378 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 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 anaemic, a htemic bruit may be heard over the 
 aortic valves, or the hruit-de-diable over the subclavian. Such symp- 
 toms are almost invariably associated with suppressed menses, and 
 frequently the vicious habit of masturbation prevails. Stupor, how- 
 ever, is not a necessary accompaniment of these jnenstrual derange- 
 ments with ])ronounced vaso-motor troubles. Subjects present them- 
 selves suffering from suppression of catamenia, with excessive lividity 
 and coldness of the hands, who are not stuporose, but excited, flippant, 
 and erotic. The vaso-motor centres for the limbs are in juxtaposition 
 to the cortical motor centres of the extremities, according to Eulenberg 
 and Landois, their fibres passing apparently through the posterior 
 limb of the internal capsule, and it is therefore to this site we must 
 assign most probably the irritation resulting in the. coldness and 
 lividity seen in the limbs of these subjects. 
 
 M. A. H., aged nineteen, single, a young girl of delicate physique, very thin 
 and reduced, pale and exceedingly anisemic, 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 nervous temperament. 
 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. When brought to the asylum, 
 her bloodless aspect was very notable, and her physical prostration great ; she 
 stared vacantly around, quite inappreciative of her position and relationships, 
 occasionally 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 wine, 
 milk and eggs, with extract of beef, were given freely. Ammonio-citrate of iron 
 ordered twice daily and 30 grains of chloral v hen required at night (chloral, 
 however, was required but seldom, as she soon obtained sleep without its aid). 
 During the whole of tlie succeeding month, patient's state was one of extreme 
 mental torpor and apathy ; she usually sat in a half-bent posture, utterly slovenljs 
 and negligent in her habits ; saliva dribbling from her mouth ; her expression 
 vacant, fatuovis ; 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. Tliis condition of acute dementia 
 continued for twelve months. Her bodily 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 amenorrhcva 
 was associated therewith. With this progressive phj'sical improvement there now 
 appeared a gradual advance to more normal states of consciousness ; hut not until 
 
ETIOLOGY. 379 
 
 seventeen months had elapsed did she begin to speak rationally, and about this time 
 the catamenia appeared. She became 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 recover}' 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 jjarallel in the explosive 
 condition of the nervous centres in higher ])lanes 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 exemplified in the high- 
 tide of infantile growth ; the ebb of growing youth ; the renewed 
 flow at puberty and adolescence ; and the final arrest at the maturity 
 of manhood. Along this curve of simple vegetative growth apjiear 
 the pulsations of ancestral influence. Those epochs of new develop- 
 ments, or the points when difierentiations 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. 
 
380 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 puberty, adolescence, are such epochs. They are characterised 
 especially by the tendency to reproduce ancestPal 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 the 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 Acadeniie des Sciences, that many special surgical affections 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 epiphysal osteitis, epiphysal exostosis, subungual exostosis of great toe, and 
 fibrous naso-pharyngeal polypi will usiially defy permanent cure until the twenty- 
 fifth or twenty-sixth year is reached, and temporising, therefore, is often called for 
 until adult age is attained, t 
 
 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, &c. The nervous system must necessarily sympathise 
 with such conditions, and hence parental vices, and weaknesses — 
 insanity, epilepsy, chorea — may be developed with greater frequency 
 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 10-6 per cent, 
 afforded a history of ancestral epilepsy ; and 9 "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 evolution of these forms 
 
 * Descent of Man, chap. viii. Variation of Animals and Plants under Domesti- 
 cation, vol. ii., 1868. 
 
 + See Med. Times and Gaz., April, 1872. 
 
ANCESTRAL INFLUENCE. 
 
 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 divert^ence 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 percent.; 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 followin"- 
 instructive Table reveals : — 
 
 Cases of Insanity. 
 
 Hereditary 
 Insanity. 
 
 Parental 
 Epilepsy. 
 
 Parental 
 Apoplexy. 
 
 Parental 
 Intemperance. 
 
 3,470 of both -sexes, . 
 1,810 females, 
 1,660 males, 
 
 75 adolescent females, 
 
 29-5 
 31-5 
 27-2 
 40-0 
 
 3-68 
 3-37 
 
 10 -e 
 
 .s-57 
 5-35 
 
 9-3 
 
 16-0 
 
 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 
 one chiefly occupied with the active growth of the organism as a 
 whole : and it is only towards the later period (when this activity of 
 growth, subsiding, allows tlie 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 
 relationsliips), 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 awe 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 
 * Descent of Man, p. 232. 
 
382 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 up to the age of fifteen ; -whilst nine cases occurred in each of the two 
 following years. The age of nineteen and tioenty 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 tits the woman for the duties of wife and mother. 
 
 Ovarian Derang'ementS. — Tt is important that we here fully 
 understand the relationship borne by deranged states of the sexual 
 orp-ans to the mental anomalies under consideration. Often is the 
 question asked in cases of insanity, accompanied by amenorrlioeal 
 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 1 If, however, we regard this period as a 
 great cyclical developmental stage, in which the unfolding of the 
 generative system goes on, pari passu, 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; nor, 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- 
 privation 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. 
 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 amenorrhcea, we should grievously err by 
 perhaps taking one indication of a wide-spread developmental arrest of 
 ovario-uterine evolution as the catise of a mental storm, which in itself 
 is often but a symptom of associated arrest in the development of 
 the central nervous system. 
 
OVARIAN DERANGEMENTS. 383 
 
 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 neui'osis 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 about the house, shouting wildly, 
 whistling, or reading in 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 replj' to qiaestions, wilful, and covered her face with the bedclothes. 
 Her consciousness was greatly impaired ; she failed to recognise the natiire of her 
 surroundings, and evidentlj^ 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 daily. Fortunately, her nights were passed in quiet sleep, and her appetite 
 was not defective. In less than a week there was decided improvement, all acute 
 excitement 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 ; in a fort- 
 night from admission she was actively at work in the needle-room ; and left the 
 asylum, recovered, three months after admission. 
 
 It has been already stated that insanity occurs in a rapidly-increas- 
 ing ratio from the age of fifteen to twenty, the three last vears 
 eaibracing 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 tlie 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 
 
;84 
 
 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 Insanity at Pubeett and Adolescence, with Co-incident Menstrual 
 Derangement or Notable An-emia. 
 
 Case. 
 
 Age. 
 
 Menstrual Condition. 
 
 Remarks. 
 
 1 
 
 19 
 
 Amenorrhoea for four mouths. 
 
 
 2 
 
 18 
 
 of late. [tack. 
 
 
 3 
 
 20 
 
 ,, for eight months throughout at- 
 
 
 4 
 
 16 
 
 ,, for eight mouths after admission. 
 
 Great mental stupor. 
 
 5 
 
 20 
 
 ,, throughout attack. 
 
 
 6 
 
 20 
 
 ,, for six mouths. 
 
 Fair bodily condition. 
 
 7 
 8 
 9 
 
 14 
 18 
 19 
 
 ,, throughout attack. 
 
 Stout, approaching obese. 
 
 ,, for five months prior to admission 
 
 Fair bodily condition. 
 
 
 
 and persistent up to discharge. 
 
 
 10 
 
 19 
 
 ,, for six mouths prior to admission; 
 
 Pallid, feeble ; wide, dilated 
 
 
 
 not re-established up to four 
 
 pupils. 
 
 
 
 months later. 
 
 
 11 
 
 18 
 
 ,, for five months after admission. 
 
 Very pale and anaemic. 
 
 12 
 
 16 
 
 ,, persistent up to discharge. 
 
 
 13 
 
 19 
 
 )5 M ■' 
 
 
 14 
 
 20 
 
 )i ,. 
 
 
 15 
 
 19 
 
 „ for four months preceding and three 
 months following admission. 
 
 Pupils widely dilated. 
 
 16 
 
 19 
 
 ,, for seven months after admission. 
 
 ,, ,, ,, 
 
 17 
 
 20 
 
 ,, ])ersisteut throughout attack. 
 
 
 18 
 
 17 
 
 ,, of late, but precocious puberty. 
 
 Thin, pallid and reduced ; pupils 
 
 widely dilated. 
 
 19 
 
 20 
 
 ,, for six months after admission. 
 
 Very pale, ansemic ; shows much 
 torpor. 
 
 20 
 
 20 
 
 J! >> 
 
 Very pale and anemic. 
 
 21 
 
 20 
 
 5' •' 
 
 
 22 
 
 19 
 
 ,, for eighteen months upon admis- 
 
 Pale and very feeble ; livid ex- 
 
 
 
 sion. 
 
 tremities ; "acute dementia." 
 
 2"3 
 
 20 
 
 ,, for ten months prior to admission. 
 
 Paleandansemic; cold livid hands. 
 
 24 
 
 16 
 
 ,, forfourmouths prior to admission, 
 persistent throughout attack. 
 
 
 25 
 
 17 
 
 ,, history of hysteria for two years. 
 
 Phthisical. 
 
 26 
 
 19 
 
 ,, persists for three months after 
 
 Pupils widely dilated ; feeble 
 
 
 
 admission. 
 
 health. 
 
 27 
 
 18 
 
 ,, for three mouths prior to and four 
 mouths subsequent to admission. 
 
 Pale and ansemic. 
 
 28 
 
 20 
 
 ,, for three mouths after admission. 
 
 Wide, dilated pupils. 
 
 29 
 
 18 
 
 ,, for five mouths before admission, 
 and persistent up to discharge. 
 
 Extremely thin and reduced. 
 
 SO 
 
 20 
 
 „ for six months after admission. 
 
 Pupils widely dilated. 
 
 31 
 
 20 
 
 Menstruation irregular. 
 
 
 32 
 
 15 
 
 
 Very spare and pallid ; hjemic 
 bruit ; v\idely-dilated pupils ; 
 much stupor. 
 
 33 
 
 16 
 
 
 Very ansemic ; hremic bruit. 
 
 34 
 
 18 
 
 ,, ,, for many months. 
 
 Pale and chlorotic. 
 
 35 
 
 20 
 
 ,j 
 
 
 36 
 
 19 
 
 „ ,, and scanty. 
 
 Profound waxy pallor. 
 
 37 
 
 16 
 
 
 Widely-dilated pupils. 
 
 38 
 
 17 
 
 ,, ,, for a short period. 
 
 
 39 
 
 16 
 
 ,, regular. 
 
 Very pallid, weakly ; great stupor. 
 
 40 
 
 18 
 
 Amenorrhcea for months prior to, and ir- 
 
 Very pale and ansemic ; developed 
 
 
 
 regularity subsequeut to admission. 
 
 spinal disease. 
 
 41 
 
 19 
 
 Suppression or irregularity tliroughout at- 
 tack. 
 Menstruation becoming for the first time 
 
 Very pale and ansemic. 
 
 42 
 
 17 
 
 
 
 
 established. 
 
 
 43 
 
 18 
 
 Menstruation iirst established ten months 
 prior to admission was suppressed or 
 irregular throughout attack. 
 
 Extreme ansemic pallor. 
 
 44 
 
 17 
 
 Deferred ]iuberty. 
 
 
 45 
 
 19 
 
 Deferred puberty ; catamenia established 
 seven weeks after admission (recovery). 
 
 Greatly reduced. 
 
 46 
 
 17 
 
 Deferred puberty; catamenia not established. 
 
 Stout and well-nourished. 
 
INSANITY ASSOCIATED WITH AMENORRHCEA. 385 
 
 in whom menstrual derangement or notable antemia 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 molimen, when the germ is pi-oduced 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 amenorrhoeal, dys- 
 menorrhceal, &c., 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 
 periods 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 pro- 
 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. 
 
 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 
 surroundings, a vicious educational role, or by unhealthy occupations, 
 which, while they undermine the physique or check its healthy expan- 
 sion, often afibrd no food for the mental life, but dwarf i* '~ture and 
 cramp its unfolding energies. The periods of puberty and adolescence 
 are peculiarly prone to sufi'er 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-corpuscles in such subjects : — 
 
 25 
 
386 
 
 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 Amount of Haemoglobin in Blood of Adolescent Subjects (Male and Female). 
 
 Profoundly Stuporoie. 
 
 
 1 
 
 1 
 
 
 ^1 
 
 B ft 
 >8 
 
 Besiakks. 
 
 
 
 
 Per 
 
 Per 
 
 
 
 
 
 Per 
 
 heemie 
 
 hsemic 
 
 
 
 
 
 cent. 
 
 unit. 
 
 unit. 
 
 
 
 c. w., 
 
 . Oct. 1, '87, 
 
 58 
 
 94-2 
 
 -20 
 
 •61 
 
 Complete relapse into stupor. 
 
 
 Nov. 2, '87, 
 
 60 
 
 133-8 
 
 -04 
 
 •45 
 
 Stupor of seven daj^s' duration ; 
 catamenia scanty foiu'teen 
 days ago ; second time since 
 admission; face lieavj^ anaemic, 
 lips blanched, pupils normal, 
 headache. 
 
 
 Dec. 1, '87, 
 
 72 
 
 107-8 
 
 -10 
 
 -67 
 
 Cheerful and active at convales- 
 centhome; amenorrhcea; gums 
 ruddy and anasmia decidedly 
 lessened. 
 
 
 Jan. 11, '88, 
 
 90 
 
 115 
 
 -10 
 
 •78 
 
 During menstrual period ; cata- 
 menia normal ; lively, chatty, 
 jocular ; blood coagulates 
 rather too readily. 
 
 L. E. S., 
 
 Nov. 4, '87, 
 
 70 
 
 107-2 
 
 •20 
 
 •64 
 
 Great stupor ; widely -dilated 
 pupils. 
 
 E. H., 
 
 Sep. 28, '87, 
 
 58 
 
 84-2 
 
 •40 
 
 •70 
 
 ^lelancholic ; profound pallor. 
 
 
 Oct. 8, '87, 
 
 50 
 
 66 
 
 -22 
 
 -75 
 
 ,, ,, 
 
 
 Nov. 4, '87, 
 
 58 
 
 95-8 
 
 •25 
 
 •61 
 
 Cheei-ful and lively. 
 
 M. A. P. 
 
 Nov. 15, '87, 
 
 74 
 
 93-6 
 
 •28 
 
 •79 
 
 Intense melancholia (lactational) 
 compulsory feeding. 
 
 H. S. L., 
 
 Nov. 2, '87, 
 
 78 
 
 102-8 
 
 •22 
 
 •76 
 
 Considerable stupor and hea\'i- 
 ness ; yet works and smiles 
 when addressed ; pupils large; 
 no catalepsy ; fair colour. 
 
 w. s., 
 
 Julv 25, '88, 
 
 68 
 
 100 
 
 •4 
 
 -68 
 
 Case of profound stupor of sev- 
 
 
 .Jufy 26, '88, 
 
 70 
 
 100 
 
 •25 
 
 -70 
 
 eral years' duration ('85, '89) 
 
 
 Aug. 2, '88, 
 
 74 
 
 75 
 
 •25 
 
 •98 
 
 reported at page 188. 
 
 
 Aug. 3, '88, 
 
 68 
 
 100 
 
 •40 
 
 •68 
 
 
 
 Aug. 12, '89, 
 
 90 
 
 100 
 
 •285 
 
 •90 
 
 
 R. W. J. 
 
 , Aug. 10, '89, 
 
 55 
 
 124 
 
 •18 
 
 •44 
 
 Quite mute, yet far less stupor 
 than on adjnission ; no resist- 
 ance, but shrinks, expression — 
 calm repose. 
 
 E. H., 
 
 . July 29, '87, 
 
 78 
 
 97-2 
 
 •60 
 
 •80 
 
 
 T. T., 
 
 . Aug. 3, '87, 
 
 68 
 
 95 
 
 •40 
 
 •71 
 
 ^Slelancholj' with stupor. 
 
 
 Sept. 28, '87, 
 
 72 
 
 85 
 
 •20 
 
 •84 
 
 Hysteric outbursts occasional ; 
 impulsive, treacherous. 
 
 T. M., 
 
 . July 25, '87, 
 
 60 
 
 115 
 
 •60 
 
 •52 
 
 Stupor ; mastiu'bates. 
 
 
 July 26, '87, 
 
 68 
 
 126 
 
 •08 
 
 •54 
 
 Stupor persistent. 
 
 
 Aug. 2, '87, 
 
 62 
 
 105 
 
 •40 
 
 •59 
 
 Less torpid. 
 
 
 Sept. 28, '87, 
 
 55 
 
 82 
 
 •25 
 
 •67 
 
 Cheerj' and much improved ; far 
 less torpid. 
 
 M. B., 
 
 . Oct. 1, '87, 
 
 72 
 
 118-6 
 
 •18 
 
 -61 
 
 Relapse of hystero-epilepsy, 
 fortnightlj' scanty menstrua- 
 tion, consideralile pain. 
 
 
 Nov. 15, '87, 
 
 72 
 
 84-2 
 
 •22 
 
 -85 
 
 Catamenia present, much more 
 cheer}^ and communicative. 
 
 W. R., 
 
 . Mar. 4, '88, 
 
 70 
 
 73-4 
 
 •53 
 
 •95 
 
 Melancholy : profound stupor. 
 
 For the condition of the muscular sense see remarks under General Paralysis (p. 298). 
 
SEXUAL DIVERGENCE. 387 
 
 In tlte Male Sex. 
 
 Sexual DivePgence. — 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 obtrusive 
 than in the girl. The female chiefly exhibits the recipiency of her 
 nature at this epoch, the male its pPOJectlvity in a life of action; 
 the former is the receptive organism, as the latter is the effective and 
 distributive 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 
 diff'erentiation 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, ou 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-x-eliance 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 selfishness ; and this holds good even with savages. . . . 
 Woman, owing to her maternal instincts, displays 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 deliglits 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." t 
 
 These considerations would in themselves suffice to indicate the 
 divergence in type of mental ailment to which the two sexes are 
 exposed at this period of life. Whilst the female shows a prepon- 
 derating eS'ect on the afective sphere of mind, the adolescent youth 
 
 * The correlation of these coincident developments is seen in the fact, tliat if man 
 be emasculated, the sexual ciiaracteristics never appear (Darwin, op. a'/., p. .").")7). 
 t Descent of Man, chap. xix. 
 
388 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 betrays 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, hi& 
 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 natui'al 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 afliative emotional states, the newly-awakened instincts, the 
 flood of new impressions, and the sense of widely-expanding faculties, 
 constitute a physiological stage 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 
 off the overflowing mental energy in a healthy channel ; but of 
 all faults, 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 factl 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 
 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- 
 
 * "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 tlie 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-five. 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 gentlexuen do then attain their 
 maximum of detestabilitj'. Such gawks are tliej', and foolish peacocks, and yet 
 such vulturous hunger for self-indulgence, so obstinate, obstreperous, and vain- 
 lorious ; in all senses so froward and so forward." — Sartor Resartus, "Getting 
 der way." 
 
SYMPTOMS OF PUBESCENT INSANITY. 389 
 
 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 characteristics 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-married women at different 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. 329). The extravagant nature of their 
 delusions, already alluded to when dealing with the hysteric features 
 of the female adolescent (p. 376), is peculiarly striking also in the male 
 subject ; the intensity of feeling reveals itself often in short, curt 
 aphorisms, in tlie tendency to antithesis ; in the gestures, pantomime, 
 pose, speech and its contents, may be recognised, more than in 
 any other species of mental derangement, what we would elect to term 
 the true staccato type of insanity. 
 
 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 
 
390 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 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 
 more and more involved, until utter fatuity and paralysis result ; yet 
 in the early 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 
 were present."* And again : — " The physical appearance of the males 
 was 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 : — 
 
 (a) 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 
 occurrence 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 
 * Lechirea oh Mental Diseases, p. 552. 
 
MODIFIED FORMS— CASE OF J. M. 391 
 
 twenty-one years of age,"'-' and the remainder subsequently ; or, to be 
 exact, 142 occurred before twenty-one, and 135 afterwards and up 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 the 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 aural hallucinations), sudden ferocious violence, indecent 
 assaults upon the other sex, and even suicidal acts of determined 
 character, attempts at rape, strangling, drowning; these are not unusual 
 features in the masturbatic adolescent. The type is by no means always 
 that characteristic of the ordinary sane masturbator, for, though the 
 physical symptoms of cerebrospinal 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 
 anaemic aspect, the dark areola around the eyes, tlie dilated pupil 
 and the general atony exhibited in feeble heart and languid circula- 
 tion, enfeebled motor power and disturbed co-ordination, the ainuesic 
 states, occipital headache (Spitzka), the vague unreasonable alarm, 
 eccentric dislikes fostered, and unfounded suspicions, soon attract 
 our attention. 
 
 J. M., aged nineteen, labourer; admitted June, 1882. 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 thougli conscious after some time of its prejudicial efi'ects, was unable to discon- 
 tinue its indulgence. During the four j'ears 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 bj' 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, i)t- a succes-f/id attempt to emwiculate 
 Idmself. Immediately on its performance he had two convulsive seizures, not, 
 however, recurring. A short period of mental improvement followed, and then 
 he became worse than ever. Three years before this occurrence he had had a 
 fall from a hayloft upon his head. 
 
 * From the age of thirteen to that of seventeen there were 40 cases of insanity 
 out of a total of .3,000. 
 
392 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 When admitted, he was tearfnl and much depressed, but communicative. His 
 object in castration was "to prevent the possibility of masturbation," but the 
 object attained, he was overcome by fear of having "cut himself off from God, 
 and lost his soul." This belief he maintained during his residence, but became 
 nevertheless more slightly oppressed by it, less gloomy and despondent, and de- 
 cidedly improved in some points, inasmuch as he employed himself actively, and 
 showed sociability. Was sent to home-care at the expiration of fourteen weeks. 
 
 Without attempting any refined analysis of the multifarious groups 
 which might be comprised under the head of insanities at adolescence, 
 still less attempting 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 
 period of life, and to the modifying influence of vicious habits of life, 
 e.g., masturbation and drink; intercurrent affections, such as phthisis; 
 or defective states of the blood, as in antemia. And first, let us draw 
 the distinction clearly between the forms of insanity arising during 
 adolescence, and those subject to the modifying effects of masturbation. 
 
 In drawing such a distinction we must keep in mind the fact that 
 the vice is so frequent that a pure uncomplicated 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 
 insanity of any standing, even if the subject were not previously 
 addicted 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 energy and power, enviable dis- 
 tinctions and rank, a general feeling of hien 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 masturbator. 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 ; 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 
 
MODIFIED FORMS. 393 
 
 vice are absent in the uncomplicated form. The recoverability, 
 again, of insanity at adolescence is very gre it ; the prognosis in 
 insanity modified by onanism is very grave ; in fact, the majority 
 of unfavoui'able 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 
 sliyness and reserve at first, but later on, obtrusive and unseemly 
 {F. S., p. 329). 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 bigotry 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 ot 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 
 want of spontaneity, lack oPenei-gy 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 frequently 
 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-spread exhaustion of the cerebro-spinal centres. Such 
 symptoms are — the anaemic 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 incoordinate 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 afiiative 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 witli 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 effeminate self-engrossment, 
 
394 INSANITY Of puberty and adolescence. 
 
 and delusions based on the sexual instincts, indications of sexual 
 perversions 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 overthrow 
 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 necessary to the well-being of the subject. How often it fails 
 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 
 
PROGNOSIS AND RECOVERY-RATE. 
 
 395 
 
 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 puberty, 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 
 afiection is itself coloured. Masturbation as a sym,2)tom of disease, is, of 
 course, prevalent in insanity at all periods 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 more 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 
 being successively engendered as the sexual instincts came to the fore. 
 There are few physicians who do not meet with numerous 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. 
 
 Prog'nosis. — Of all types of insanity that occurring at the puerperal 
 period is one of the most recoverable (80 per cent.), yet the recovex'y- 
 rate is nearly as high for the insanity incidental to adolescence ; in the 
 female sex tlie 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 nearly 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 already stated) depression is often largely present, the 
 prognosis is far less favouraV^le, 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 AcUiIescent Adolescent 
 
 Cases. Females. Males. 
 
 Recovery-rate per cent. , . . 80-0 73 -3 58 '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 : — 
 
 * See also on this subject Dr. Hack Tuko. I'si/cJioio<iica/ Medicine: Art., 
 "Pubescent In.sanity."' 
 
396 INSANITY OF PUBERTY AND ADOLESCENCE. 
 
 Recovered. 
 
 Relieved, 
 
 73-3 
 
 7-6 
 
 58 -4 
 
 14-4 
 
 R,emained 
 as Chronic. 
 
 Died. 
 
 Female adolescents jDer cent. , . 73*3 7'6 13'5 5"4 
 
 Male adolescents ,, . o8-4 14-4 17-3 97 
 
 The unfavourable cases form 26*5 per cent, of the total number of 
 cases in females, and 414 in males. 
 
 We have already alluded to the actual recoverability of this form of 
 insanity in its relationship to sex ; it will also repay us to observe 
 more particularly the duration of the attack up to cure in both sexes ; 
 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 
 increment of cures — viz., seventeen, fourteen, and twenty-five respec- 
 tively ; so that the summit of the curve is reached at the fifth month,* 
 hy tvhich period nearly one-half of the total number oj cases have recovered. 
 Then a sudden drop midway occurs for each month from the sixth to the 
 ninth inclusive — i.e., from ten to twelve casesforeach month respectively. 
 From this time up to twenty months the monthly curve 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 diff'ers considerably from the 
 foregoing, being less abruptly broken, being more uniform and sus- 
 tained in the early half of the period of recoverability,! 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, reproduces 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- 
 
 * It must be remembered that the period dealt with in tliese charts is that be- 
 tween actual on-'iet of insamty 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. 
 
Numbep of 
 Cases 
 
 20 
 
 CHART of RECOVERIES m FEMALES 
 PUBERTY & ADOLESCENCE. 
 
 Chart B 
 
 Recov* Reliev^ Died. Rem 
 135 14 10 : 
 
 73-3% 7-6^0 5-4% \1 
 
 Duration of Attack Aw 6 IV 2/7 3 4 5 6 7 8 9 10 II 12 13 14- 15 20 2y 3y. Ay 6y 9/ 
 
 CHART of RECOVERIES m MALES. 
 
 umber of 25 
 
 
 
 
 
 
 r-a'^ 
 
 
 
 
 
 
 
 
 
 
 V^ L. 
 
 IN Ij 
 
 u. 
 
 
 
 Cases. 
 
 24 
 23 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 22 
 21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 20 
 19 
 
 
 
 
 
 
 ( 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 18 
 17 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 16 
 15 
 
 
 
 
 /^ 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 13 
 
 
 
 
 j 
 
 J5I 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 12 
 
 
 
 / 
 
 
 
 
 
 ^,. 
 
 
 A' 
 
 
 
 
 
 
 
 
 
 
 
 Recov'^ Relieved Died Remaini 
 
 162 40 27 48 
 
 584°o 144% 9 7°o 17 3' 
 
CHART of RECOVERIES in FEMALES. 
 PUBERTY & ADOLESCENCE. 
 
 Chart B 
 
 Rttov^ ReliEV^ Died Remains 
 135 14 10 25 
 73-3"^ 7-6Ji. 5-45t I3-5;S 
 
 Duration ofAttack 4* Giv ^<i 3 4 5 6 7 8 9 10 II 12 13 14 15 20 ly 3y. iy iy 9y 
 
 CHART of RECOVERIES in MALES. 
 . PUBERTY & ADOLESCENCE. 
 
 \.' 
 
 A 
 
 CurationuiAjtatk 4* 6w 2/b 3 4 5 6 7 8 9 10 ll 12 13 14 15 20 7y iy t 
 
 Rbcov' M\eiei. 
 
 162 40 
 584% I44°i 
 
 Died. Remaining. 
 
 27 48 
 
 9-7?i 17-3% 
 
TREATMENT OF ADOLESCENT INSANITY. 397 
 
 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 favourable 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 
 characterised by excitement, but the type of insanity then prevalent 
 is distinctly a more recoverable form ; the recoveries in the earlier 
 contrasting with those in the later period, as ninety-one to seventy-one. 
 In other words, if we group together the partial recoveries, the fatal 
 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 iorms. 
 
 TreatmGnt. — The simpler forms of hysteric excitement occurring at 
 this period 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 
 sufiice to effect 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 
 prolonged insomnia persists for several nights together, in spite of the 
 above 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 pur[)ose is to 
 be strongly deprecated. 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 anajmia, our subject 
 having succumbed to the developmental wave ; the nutritive and 
 assimilative capacities having been overtaxed by the exaggerated de- 
 mands of the growing organism. Here a strictly-hygienic regimen 
 should be carefully and persistently enforced, such as outdoor exercise 
 
398 INSANITY AT THE PUERPERAL PERIOD. 
 
 and the spinal douclie or sponge-bath. Iron, especially the carbonate, 
 should be given in pill or mixture. It is well to vary the form of 
 iron, occasionally administering it in the form of iron and aloes pill; 
 or as the ammonia-citrate ; or as the sulphate of iron in combination 
 Avith 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. 
 
 INSANITY AT THE PUERPERAL PERIOD. 
 
 Contents. — Symvitoms— Predominance of Mauia — Intensity of the Morbid Process — 
 Obtrusive Sexual Element — Hallucinations — Delusions of Suspicion — Prevalence 
 of Suicidal Feelings — Etiology — Susceptibility of the Puerperal Period — Illegiti- 
 macy and Puerperal Insanity — Frequency in Primiparge — Condition of the 
 Blood — Diminution of Hasmoglobin — Prognosis — Treatment — Insanity of 
 Pregnancy — Relatively Infrequent— Primiparte show no Special 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 suiTers from early insomnia, becomes restless, 
 tidgetty, unnaturally garrulous ; 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 disturbing dreams, from which 
 she starts up in bed x-ambling 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 4-5 or 66 per cent, suffered from mania, 
 whilst states of depression prevailed in 23 patients or 3.3-8 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. 
 
HALLUCINATIONS— DELUSIONS OF SUSPICION. 399 
 
 The mental affection, then, at this stage is essentially an acUte 
 maniacal state, in which there is intense excitement, great incoherence, 
 continuoxis garrulity, and a dangerous explosiveness, which may issue in 
 most desperate impulsive conduct ; there is, moreover, a special pro- 
 clivity to indulgence in obscene language, indecent exposures of the 
 person, and genuine nymphomaniacal states ; or the deep-rooted erotic 
 feelings may, partially controlled, reveal themselves in the sudden 
 gestures, or sensual 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 
 ^.arly puerperal period with features which 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, f 
 
 Delusions. — Quite 63-2 per cent, showed obvious delusions of very 
 varied character, 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 features, the food beino- 
 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 nio'ht 
 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 t)ie evil one. This delusion that the soul is lost was 
 as frequent as in forms of insanity of a more melancholic type, occurring 
 later on during lactation ; in fact, religious 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 : — 
 
 * See also on this point Dr. Sankej-'s Ler/nres on. liisimity, pp. 12s, 1!)5. 
 t Vide Lcclure-'i on Menial Disease, p. 507. 
 
400 
 
 INSANITY AT THE PUERPERAL PERIOD. 
 
 Faces besmeared with blood peep through the windows ; spirits hover around ; 
 angels and devils surround the bed ; the patient's deceased mother confronts her, 
 and mystei'ious lights flit about the room ; voices are heard ; the form of the e^■il one 
 appears ; or they shout aloud to imaginarj' voices ; sounds are heard, interpreted 
 as conspirators beneath the building ; or a voice within prompts her to suicide. 
 
 From these considerations it will be obvious that the general tone 
 of feeling is that of distrust and suspicion, implicating her conjugal 
 relationships, 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 relationship 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 impressions. 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, 
 Mania, with delusions, . 
 Simple mania. 
 Simple melancholia. 
 Acute melancholia, 
 Melancholy, with stupor, 
 
 13 
 
 8 
 1 
 1 
 
 68 
 
 EtiolOg*y. — It would be indeed strange if, at a period 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 
 hereditarily predisposed to insanity, must necessarily incur imminent 
 
 * The term "puerperal mania" is arbitrarily assigned to the mental derange- 
 ment occurring during the^'r*^ six iveeks of the puerperal state ; involution of the 
 uterus being usually not complete for three months. 
 
ETIOLOGY. 40 r 
 
 risks at this crisis of their history. As Burrows says : — " Gestatioa 
 itself is a source of excitation in most women, and sometimes provokes 
 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 hsemorrhage. 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 di'avvn 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 birtli, in misery and secrecy, 
 to bastard children ; a condition of mind, which it is to be feared, 
 often prompts eitlier infanticide or suicide." | 
 
 Again, subsequent to labour, we have tlie whole uterine surface 
 exposing the system to the perils of hsemorrhage by imperfect 
 contraction, to retention of excretory products, to the absorption of 
 
 * Commentaries, p. 3G3. 
 
 t The urajmic element in the causation of puerperal eclampsia has been called 
 in question ; see, however, the very apposite remarks by Dr. Gowers in his 
 Disea.ie.H of the Nervotis System, vol. ii., p. 716. 
 
 X Burrows' Commentaries, p. 364. 
 
 2G 
 
402 INSANITY AT THE PUERPERAL PERIOD. 
 
 septic agencies, metritis, phlebitis, and its attendant evils.* Later, 
 still, come the evils due to imperfect depurative processes, requisite 
 for 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 disintegration found copiously 
 in the lochia, and probably as the fatty elements in the urine, 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 
 extreme 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 eclampsic 
 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. J 
 
 Illegitimacy. — I have already drawn attention to Esquirol's state- 
 ment of the prevalence of insanity amongst those who have borne 
 illegitimate children; it has also been shown by Dr. Olouston 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 born in legitimate wedlock, whilst in five only 
 were the patients unmarried women. Now the proportion of single to 
 married patients in the total admissions of 1810 cases was 35 per cent, 
 to 50 per cent, respectively ; hence the proportion of 10 per cent, of 
 single women who suffered from puerperal insanity is exceptionally 
 low.§ 
 
 *See "Clinical Illustrations of Puerperal Insanity," by Dr. Campbell Clark, 
 Lancet, vol. ii., 1883. 
 
 t Burrows, o^v. cU., p. 366. 
 
 J There is, likewise, a temporary delirium sometimes accompanying difficult 
 labours, in the fever on the secretion of milk, or the inflammation of the breasts. 
 Burrows, ih., p. 364. 
 
 § Dr. Macleod estimates the frequency of illegitimacy as a factor at IT? per 
 cent. — Address on Puerperal Insanity, 1886. 
 
THE BLOOD IN PUERPERAL INSANITY. 
 
 403 
 
 Frequent in Primiparae.— Frequent child-bearing has apparently 
 no connection with the development of insanity ; of the sixty-ei^ht 
 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 families ranging between five and nine, 22 per cent, were also 
 represented. 
 
 Second attacks occurred in eiglit cases, of whom two were primiparse, 
 and the remaining six had families ranging from two to nine. No 
 case had suff'ered from a third seizure. 
 
 The Blood in Puerperal Insanity.— Tested by the hsemoglobino- 
 
 meter the amount of haemoglobin was found below the normal, as 
 indicated by the series of observations recorded in the following 
 table : — In the case of Ji. 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 of 
 the tabulated series {M. A. M.) in which profound anaemia had resulted 
 from post-parium haemorrhage, gave upon one occasion as low a per- 
 centage as 20, rising subsequently to 32 per cent. Both specific 
 gravity of the blood and the amount of haemoglobin have been lately 
 stated to be lowered in states of mental excitement, generally with 
 much muscular activity (Vorster). 
 
 Amount of HyEMOGLOBix in the Blood in the Subjects of Puerperal Insanity. 
 
 
 
 
 d 
 
 cles. 
 emic 
 t. 
 
 m " 
 
 h3 p^ 
 
 a) " 
 
 eg 
 
 
 
 
 nl 
 
 ^i»5 
 
 ^mi 
 
 
 Remarks. 
 
 
 
 8f^ 
 
 0.0 
 
 OP-i 
 
 00 
 
 >3 
 
 
 M. A. M 
 
 , (Oct. 1, '87), 
 
 20 
 
 53-6 
 
 •25 
 
 •35 
 
 Extreme Wcaxy pallor; blood yej7/2)aZc, watery, 
 and instantly separates into serum on 
 withdrawal ; contains many minute cells 
 
 ,, 
 
 (Oct. 4, '87), 
 
 28 
 
 41-4 
 
 •06 
 
 •68 
 
 like nuclei and ill-formed corpuscles. 
 Minute fat globules in the blood and many 
 
 ,, 
 
 (Oct. 8, '87), 
 
 24 
 
 40-8 
 
 •12 
 
 •60 
 
 ill-formed corpuscles. 
 Still many minute nuclear bodies; blood 
 
 " 
 
 (Nov. 6, '87), 
 
 32 
 
 71-6 
 
 •16 
 
 •45 
 
 pale but has more consistence. 
 Red discs all contain minute glistening 
 nuclear bodies ; some tend to form dumb- 
 bell shapes and readily split up. Wild 
 
 M. A. P. 
 
 (Nov. 15, '87), 
 
 74 
 
 93-6 
 
 •28 
 
 •79 
 
 excitement. for some daiispast. 
 Profound melancholia; waxy pallor of face ; 
 compulsory feediuL; rcciuisite. JIany 
 minute corpuscles in the blood, some of 
 dumb-bell form ; larger corpuscles mea- 
 sure G to S/i ; smaller measure 6 a*. 
 
 H. S. L., 
 
 (Nov. 2, '87), 
 
 78 
 
 102-8 
 
 •22 
 
 •76 
 
 Considerable torpor of movement; nmch 
 stupor but no cataleptic iibenomcna; 
 
 C. C, . 
 
 . 
 
 
 
 
 
 pupilsdilated; betrays butslight ainemia. 
 
 (Dec. 2, '87), 
 
 60 
 
 80-6 
 
 •24 
 
 •75 
 
 Medium size corpuscles {bu.); a few small 
 
 
 
 
 
 
 
 miclei (2/*); white corpuscles measure 
 
 8 a. 
 
 R. W. .T. 
 
 (Aug. 10, '89), 
 
 5o 
 
 124 
 
 •18 
 
 •44 
 
404 INSANITY AT THE PUERPERAL PERIOD. 
 
 The corpuscular richness (numerical) in the uncomplicated cases came 
 near that of normal blood,*' being 80-6 to 124 per hfemic unit — 
 i.e., from 4,030,000 up to 6,200,000 corpuscles per cubic millimetre; 
 but, the corpuscular value estimated in haemoglobin 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 M. A. AL, however, the numerical corpuscular richness, 
 commencing at 2,680,000, fell to 2,040,000, and eventually rose to 3| 
 million corpuscles per millimetre cube ; the corpuscular value at one^ 
 time being 'SS rose to "68 and subsequently fell to "GO and even '45 — 
 the latter coincident with a wild maniacal outburst. 
 
 Prognosis. — 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 percentage of 80. 
 The mortality was S-o 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 
 recoveries rise gradually to an aggregate of thirty-seven ; dui'ing the 
 following two months, but fi.ve 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 favourably 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 percent, 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 
 ot their insanity. In an admirable summary by Dr. Macleod of a 
 large number of cases of puerperal insanity collected from English and 
 Scotch asylums, the recovery-rate is given at 77 3 per cent, of the 
 total. His statement is as follows : — " Of 814 cases of puerperal 
 insanity, 620 recovered, or 77-3 per cent. Of these 814 cases, 74 died 
 from all causes, giving a mortality rate of 9 per cent." f 
 
 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 
 
 * Assuming normal blood to be correctlj' computed at 5,000,000 per cubic 
 millimetre. 
 •i Loc. cit. 
 
PROGNOSIS— PROTRACTED RECOVERIES, 
 
 405 
 
 these patients had inherited strong neurotic tendencies ; thus, the 
 family records of these twenty-four (early) recoveries testify to the 
 following facts : — 
 
 ilother paralysed, .... 
 
 Brother insane, ..... 
 Mother insane, . . . . \ 
 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, ....... 
 
 Recovery in 2^ months. 
 5 
 
 2i 
 
 5i 
 2 
 
 1 
 4 
 
 Even direct inheritance does not, therefore, seem so strongly to affect 
 the recovery-rate in such cases when placed at an early date under 
 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 been 
 deferred, and the patient kept under their friends' supervision for a 
 period ranging from two weeks to several months. 
 
 ■ Case. 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 10 
 11 
 12 
 13 
 14 
 15 
 16 
 17 
 18 
 19 
 20 
 21 
 22 
 23 
 24 
 25 
 
 Onset prior to 
 Asylum Treatment. 
 
 
 
 Recovered. 
 
 Age 
 
 4 weeks 7 
 
 months 
 
 26 
 
 2 ,, (brother insane) . 
 
 7 
 
 
 36 
 
 2 ,, .... 
 
 7 
 
 
 
 22 
 
 3 „ 
 
 
 
 
 n 
 
 
 
 25 
 
 4 „ 
 
 
 
 
 9 
 
 
 
 24 
 
 3 „ 
 
 
 
 
 9 
 
 91 
 
 
 
 24 
 25 
 
 6 months 
 
 
 
 
 93 
 
 
 
 48 
 
 7 ,, 
 
 
 
 
 9 
 
 
 
 38 
 
 2 
 
 
 
 
 9 
 
 
 
 21 
 
 3 !' 
 
 
 
 
 10 
 
 
 
 24 
 
 3 ,, 
 
 
 
 
 11 
 
 
 
 27 
 
 2 „ 
 
 
 
 
 m 
 
 
 
 25 
 
 3 weeks 
 
 
 
 
 12 
 
 
 
 29 
 
 9 
 
 
 
 
 13^ 
 
 
 
 22 
 
 3 months 
 
 
 
 
 14 
 
 
 
 27 
 
 2 „ 
 
 V 
 
 
 
 
 2 
 2i 
 
 years 
 
 27 
 24 
 
 7 weeks 
 
 
 
 
 6| 
 
 months 
 
 25 
 
 7 „ 
 
 
 
 
 H 
 
 
 22 
 
 9 ,, (paternal heredity) 
 
 H 
 
 
 26 
 
 2 „ ( ,, „ ) 
 
 H 
 
 
 28 
 
 4 months .... 
 
 6 
 
 
 28 
 
 1 ,, . . . . 
 
 6 
 
 
 24 
 
 25 „ 
 
 
 
 
 H 
 
 
 
 25 
 
 Equally instructive is it to note, that the failures amongst those who 
 
4o6 
 
 INSANITY AT THE PUERPERAL PERIOD. 
 
 were but pai-tially 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 : — 
 
 Mortality. 
 
 Date and Cause of Death. 
 
 in 11 months ; of tubercle, 
 in 6| years ; of phthisis, 
 in 1^ 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 ; acute cerebritis (father 
 and mother insane). 
 10 days, . . 22 . in 4 years ; of phthisis. 
 
 Duration of Attack 
 
 Age of 
 
 on Admission. 
 
 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 
 
 
 Discharged "Relieved." 
 
 Duration of Attack 
 
 Age of 
 
 Date of Discliarge. 
 
 on Admission. 
 
 Patient. 
 
 
 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). 
 
 Several months. 
 
 32 
 
 8i months. 
 
 
 Remaining " 
 
 Chronic Insane." 
 
 8 weeks, 
 
 34 
 
 7 years ; still an inmate. 
 
 6 „ 
 
 26 
 
 7 , , , , strong heredity 
 
 8 months, 
 
 39 
 
 1 year and 8 months. 
 
 1 week, 
 
 30 
 
 4 years. 
 
 1 » 
 
 28 
 
 5 „ 
 
 In conclusion, then, it may be stated that the insanity occurring at 
 the puerperal period is one of most aCUte character, yet most favour- 
 able 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 
 
 (6) 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 
 
PROGNOSTIC INDICATIONS— TREATMENT. 407 
 
 recovery if ensured will probably be prolonged, yet the risks oi partial 
 recovery only will be strengthened. 
 
 Tpeatment. — Our first enquiries should be directed towards the 
 genito-iirinary 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 laboui'. 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 iisually 
 the rule. The condition of the blood would appear to indicate the 
 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. Paraldehyde has 
 been given with considerable success, and is certainly more eflacacious 
 than sulphonal ; but, of the three, we give the preference to chloral. 
 Later on, with abatement of maniacal symptoms, it will be well to 
 administer pliosphatic 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 
 strychnise, 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 during the 
 progress of the case, and by their aid it is possible to ensure sleejj in 
 many cases without resorting to the employment of sedatives. Macleod 
 wisely insists upon the re-establishment of menstruation during con- 
 valescence as an important element in treatment. " No case can be 
 
40S INSANITY AT THE GESTATION PERIOD. 
 
 considered as cured till the menstruation is regular; aloes and iron 
 pills, ergot and warm hip-baths are indicated. I have found potassium 
 permanganate pills most useful in this respect." 
 
 Insanity of Pregnancy. — insanity during the period of gestation 
 is remarkable for the infrequency of its occurrence ; upon this point 
 all authorities are agreed. Our statistics in large 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 parturition, 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 occurinng during 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 months of pregnancy — the 
 morbid cravings, the emotional and moral perversions — that they are 
 reo'arded 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 Riding Asylum would indi- 
 cate that insanity at this period is by no means more prevalent amongst 
 primiparce, 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 more 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 
 dreads that some imaginary evil is about to befall her ; she becomes 
 suspicious, and often exhil)its want of confidence in her husband and 
 relatives. All the cases which required removal to the asylum 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 
 
INSANITY AT THE PERIOD OF LACTATION. 409 
 
 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 efforts 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 beyond the third month of 
 gestation, and two cases aluae left the asylum i-ecovered before their 
 confinement. The proportion of " recoveries " amounted to o4-5 per 
 cent., whilst two others left, after a ])rolonged residence, sufficiently 
 relieved for home treatment; two, however, died — one from puerperal 
 fever, and the other of chronic phthisis. 
 
 With respect to the origin of the mental derangement we can pre- 
 dicate but little from the scanty figures at our disposal nnd the history 
 of the few instances afforded us. It was ascertained, however, that 
 strong hereditary predisposition prevailed in 36 per cent. ; that two other 
 cases subsequently died oi general paralysis ; and that three others, 
 although affording no history of ancestral insanity, were considered 
 to be of congenitfdly-di'fective mental organisation. 
 
 INSANITY AT THE PERIOD OF LACTATION. 
 
 Contents. — Risks Attendant upon Lactation— Period of Uterine luvohitiou— Period 
 of Mammary Excitation— Symptoms— Depressing Delusions— Impulsive Nature 
 (M. W.) — Suicide (M. D.) — Intensity of Maniacal Excitement — Sexual Perver- 
 sions — Hallucinations— Etiology -Exhaustion and the Se(|uel;e of Labour — Pro- 
 tracted LTterine Involution — Lactation during Profound Anaemia— Hyperlacta- 
 tion — Qualiticatiou 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. Tlie 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 morbid imjietus towards insanity is 
 greatly strengthened. Undoubtedly, the factor peculiar to this period 
 of lactation, to which are attributable in part tlie mental reductions, 
 vary with tlie pliysiological changes incident to this period. Thus, 
 in the early period of lactation, the immodiate effects of gestation 
 
4IO INSANITY AT THE PERIOD OF LACTATION. 
 
 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 
 apparatus 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 parturient 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 
 period, variously assigned by different 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 Smith f quotes two 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 rdle. 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, iu 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 voices issue in the 
 morbid 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. 
 
 * Diseases of Women, p. 469. t Manual of Obstetrics, p. 92. 
 
PREDOMINANCE OF MANIA WITH DELUSIONS. 4 II 
 
 The onset 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, gestui-es, 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. 
 
 The delusional notions vary from time to time, and periods of 
 exaltation alternate with mental pain, rising even to the pitch of acute 
 melancholia. Such subjects usually come under our notice in asylums, 
 looking exceedingly pallid irom anaemia, reduced, thin, and jaded from 
 continued sleeplessness and excitement. In this stage of excitement 
 they are often dangerously impulsive, and require most careful 
 watching. Thus, one of our patients, who had suckled her infant up 
 to the twelfth month, although 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 children. Patient in- 
 herited insanity from the mother, who was an inmate of this asylum twenty 3'ears 
 ago after confinement. The patient was confined twelve months prior to admission, 
 and had brouglit tlie infant up at tlie breast until four months since, when depres- 
 sion first supervened : her health began to fail, restlessness, low spirits, suicidal 
 feelings, and the delusions that her soul was lost, that the devil was in her house, 
 and that all her 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, frequentl}' felt tempted to injure herself, had lost all 
 control, and (unless closely observed) would certainly have destroj'ed herself. Had 
 found her memory much impaired of late, and this had troubled her greatly ; slie 
 had also taken a deep-rooted dislike to her home, Ijccause she fancied that a friend 
 who lived opposite was constantly watching her. Admitted that she believed he?' 
 soul to he lost, and felt given-ri,p to def^pair. The cataraenia had been regular and 
 normal for some months. Cod-liver oil emulsion ordered, and a mixture containing 
 10 min. of liq. opii, and aromatic sulphuric acid three times dail3^ 
 
 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 sufficiently to employ herself in 
 household occupations within two months of her admission to tliu asylum. Then 
 came a relapse with sudden suicidal imitntse, and it is noted, Novemlier 2n(l — "This 
 morning, when employed in the chief female officer's bedroom, she was caught in 
 the act of suspendiwj herself to the hed-post hy the blind-cord." 
 
4 "I 2 INSANITY AT THE PERIOD OF LACTATION. 
 
 She was again placed under opium treatment, whicli 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, flighty, erratic, and given to silly 
 laughter; reduced in health, and anaemic, with a hsemic 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 barely 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. 
 
 M. D. , aged thii'ty-two, married, and the mother of three children, showed her 
 first symptoms of mental alienation four weeks prior to admission. Four months 
 before this date she gave birth to twins, and had suckled both up to the present time. 
 The history testilies 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 history was defective, but an aunt is stated to have died in an asylum. 
 
 On admission (Oct. 18th) she was low, despondent, and emotional ; querulous 
 and discontented. She conversed readily upon the siibject 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 impul'iea to kill her children, but denied this fact to the doctor. She 
 now regards this artiiice as a great sin for which she cannot be forgiven. 
 
 Nou. Int. — Is most determinedly suicidal, and 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. 
 
 Noo. 21th. — To-day attempted to swallow a needle, whicli became impacted in 
 the pharynx, and was removed with some difficulty. 
 
 Noo. 2Qth. — It was discovered by the appearance of swelling and stiffness of 
 the neck, that she had also on the 27th inserted a darning-needle tliere ; she was 
 questioned on the point, and admitted the act. There was no mark in the skin, 
 but 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. 
 
 Dec. I'ith. — After slight improvement has again become desperately suicidal; 
 
SUICIDAL AND IMPULSIVE TENDENCIES. 
 
 41. 
 
 tries to choke lierself by anything she can lay hands upon, and constantly seeks 
 to obtain needles by stealth, 
 
 Dec. 16<A. — This morning a sharp projection like the head of a needle was felt 
 beneath the skin on tlie right side of the neck, about the middle of the sterno- 
 mastoid. An unsuccessful 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 and 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 rajjidl}- succumbed to 
 the attack, and died on the 14tli of January. A jjoiit-'inorttm examination ex- 
 hibited a localised peritonitis, the coils of small intestine being matted together by 
 a considerable amount of lymph and purulent material : the large bowel had 
 escaped implication. Slight ulcerative points, with patches of intense congestion, 
 were revealed along the jejunum and duodenum, behind which was a purulent 
 collection in which a needle \\ inch long lay embedded. Three other needles Avere 
 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 was a piece of charred 
 wood, 83 inches in length by about 1 in thickness. 
 
 A similarly enfeebled, exsanguine, nursing mother, reduced by seven 
 former pregnancies and nursings during the period often years — the first 
 accompanied by puerperal convulsions, and each subsequent puerperum 
 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 throwing 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.* 
 
 The character of the maniacal state is especially one of intensity. 
 It is essentially an acute mania with or without hallucinations ; but^ 
 yet, 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 fiherperal form is peculiarly ])rone to 
 wild, impulsive, indiscriminate conduct, as the outcome of very extreme 
 reductions ; it is peculiarly a convulsive affection, as in epileptic furor; 
 but such profound 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 thii'ty-one, married twelve months ago, and delivered of her first child 
 three months before her admission. Tlie labour had been natural, but her healtli, 
 previoiisly reduced, had become progressively worse, and she had l)een wholly 
 incapa))le 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 
 
 * The suicidal propenmty was witnessed in 31 '8 per cent, of our cases; impuhive 
 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. 
 
414 INSANITY AT THE PERIOD OF LACTATION. 
 
 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 li\'ing 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 utterly 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. Abundant strong nourisliment, 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 delirious mania, quite 
 incoherent, and extremely prostrate, the tongue dry and coated, the lips covered 
 with sordes. She then became somewhat calmer, and in six days was able to sit 
 up in the day-room, being fairly quiet and manageable. It was not until six 
 months had elapsed from her admission that the catamenia were re-established, 
 after which the patient's mental symptoms (which consisted of very slight excite- 
 ment, suspicion, and unreasonable irritability) passed off entirely, and in a few 
 weeks she left recovered. 
 
 The 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 affirmed) 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 
 
FORMS OF MENTAL DERANGEMENT ASSUMED. 
 
 415 
 
 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 prompts 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 '6 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 puerj^eral 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. 
 
 The vivid nature of such creations, the enfeebled frame of the patient, 
 the complete loss of self-assurance, 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 
 — ansels — 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 from which our sixty- 
 six cases suffered, we find them, as contrasted with the puerperal 
 cases, distributed as follows : — 
 
 Forms of Mental Ailment. 
 
 lactational. 
 
 Puerperal 
 
 Simple mania, ...... 
 
 6 
 
 7 
 
 Acute ,, 
 
 . 18 
 
 31 
 
 Acute delirious mania, .... 
 
 1 
 
 .... 
 
 Mania with prominent delusions, . 
 
 . 11 
 
 7 
 
 Recurrent mania, ..... 
 
 3 
 
 
 Dementia with excitement, 
 
 1 
 
 ... 
 
 Simple melancholia, .... 
 
 3 
 
 S 
 
 Acute ,, .... 
 
 3 
 
 1 
 
 Melancholia with prominent delusions, , 
 
 . 17 
 
 14 
 
 Melancholy with stupor, 
 
 , 
 
 * 1 
 
 General paralysis, 
 
 2 
 
 
 Congenital mental defect, 
 
 1 
 
 
 
 66 
 
 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. 
 
41 6 INSANITY AT THE PERIOD OF LACTATION. 
 
 Excitement in the Early Months. — The more acute forms of 
 
 excitement prevail within the Jirst three months following parturition ; 
 and the delusions of persecution and associated gloom and despondency 
 of melancholia, predominate where mental symptoms first betrayed 
 themselves six months or m,ore 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 depres- 
 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 
 factors which may operate as exciting causes of the attack ; we are not 
 dealing in the majority of our cases with a simjjle agency, such as 
 hyperlactation ; we have to consider not only the peculiar mental 
 temperament and physique of the nursing mother, but also the series 
 of 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 suckliug 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. Sevioxis 2^ost -part um haemorrhage, or the flooding 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. 
 
 6. Hj^Derlactation. 
 
 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 dei'angement, 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. Primipara, labour very protracted and severe. 
 „ 2. Instrumental delivery, severe post-partum htemorrhage. 
 ,, 3. Protracted labour, profuse hiemorrhage. 
 ,, 4. Instrumental deliveiy, profuse flooding, phlegmasia. 
 ., 5. Very severe po>.^^jar?!t?« haemorrhage. 
 
PROTRACTED INVOLUTION— EXHAUSTION. 4 1 7 
 
 Case 6. Severe flooding during gestation, menorrhagia at all catamenial periods, 
 profound anaemia. 
 ,, 7. Menori'hagia at all monthly periods ; profound anfemia. 
 
 In the foregoing series, it will be observed, one case alone was that 
 of a priniiparous subject ; and, in fact, insanity during lactation is 
 infrequent after first confinements. In the insanity occurring at, or 
 shortly following, labour {jnierperal insanity), primiparse play a far 
 more important part ; 32 "S per cent, of such cases being first confine- 
 ments. The insanity occui'ring during lactation presents us with but 
 16-6 per cent, as primiparous subjects.* 
 
 Uterine Involution. — We have strong reasons for suspecting that 
 defective uterine 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 
 approximates 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 
 period. It is by no means uncommon to find mothers suckling their 
 infants seA^eral 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 cliild, 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 impoi-tance, as an etiological factor, of 
 such vicious persistence despite failing vigour, progressive anaemia, and 
 even well-marked mental disturbance. 
 
 Case. 
 
 1. Suckled infant nine months, and for two or three weeks indubitabh* insane. 
 
 2. ,, infant seven months, and for several weeks had been failing in health 
 
 and ailing mentally. 
 
 3. ,, several other infants, as well as her own, during the year. 
 
 4. ,, infant nine months, whilst extremel}' delicate and in feeble health. 
 
 5. , , child for four years, and had always indulged in prolonged lactation. 
 
 6. ,, infant four months, although for j-ears depressed. 
 
 7. ,, infant fifteen months, last three months during alienation. 
 
 • First labours, 16 "6 per cent. Third labours, 22 1 per cent. 
 
 Second ,, 1.3 '6 ,, Fourth ,, 19-6 ,, 
 
 27 
 
41 8 INSANITY AT THE PERIOD OF LACTATION. 
 
 Case. 
 
 8. Siickled infant eleven months, yet peculiar and deranged throughout the 
 
 whole period of lactation. 
 
 9. , , infant nine months, yet for three months distinctly deranged in mind. 
 
 10. , , infant ten months ; several ursemic conviilsions three months after 
 
 confinement. 
 
 11. ,, infant four months, yet has been insane for two years. 
 
 12. ,, infant ten months ; in very feeble health and deranged of late. 
 
 1.3. ,, infant, whilst becoming for four months past steadily and progres- 
 sively enfeebled and blanched from ansemia. 
 
 14. ,, infant nine months and a-half, although for three months deranged. 
 
 15. ,, infant nine months, yet depressed for years. 
 
 16. ,, twins four months, yet for one month deranged in mind. 
 
 Injudicious nursing, therefore, plays 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 anaemia, whether 
 induced by hyperlactation, by copious haemorrhages, 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 wdth 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 
 hydrocarbons 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 pi'otein-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 
 
 * Thus we are told that the cattle exposed to cold and miich muscular exertion 
 in Switzerland yield a very small quantity of butter, but an unusually large pro- 
 portion of cheese. — Carpenter's Physiology, p. 613. 
 
QUALIFICATIONS OF THE NURSING MOTHER. 419 
 
 ^lrea 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 profoundly 
 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 
 from the albuminous constituents of the blood is occasioned and ansemia 
 results. In the nursing-mother an accumulation of storage-fat appears 
 to occur, reminding one of the condition of hybernating animals, in 
 which, during a prolonged winter's sleep, the entire absence of food 
 requii'es (despite the cessation of activity and the extremely lowered 
 respiratory and heat processes) a large storage of fat to supply the slow, 
 though continuous, waste. So in the nurse, the waste occurring through 
 the mammary 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 marked 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 prepared for her arduous functions, and it is a 
 notable fact that, in a very large proportion of cases of insanity occur- 
 ring duidng lactation, this symptom of ominous significance is recorded. 
 It should always be accepted as a note of wai'ning in those Avho 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 prolonged 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 otliers 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 puei-perum, or, maybe, haemorrhage before or during labour, 
 suckles her infant with injudicious frequency, sacrifices her rest 
 night after night, and probably takes insuflicient or unsuitable 
 nourishment. The constant drain from her system and loss of rest 
 
42 O INSANITY AT THE PERIOD OF LACTATION. 
 
 engender aneemic 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 
 aid in the formation of the fatty principles required.! In this way,, 
 as in all cases where a similar drain upon the system occurs 
 (leucorrhoea, diarrhoea, profuse suppuration), anaemia 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 efficient 
 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 off"spring from misguided maternal instincts, and often 
 with the object of deferring a subsequent conception ; the hydrajmio 
 state of the blood results in a slow and sluggish circulation, and in 
 the splenic pulp, and especially the portal circulation of the liver, i 
 as in the marrow of bone, such sluggish flow favours the destructive 
 hsemolytic 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 
 
 * It must be remembered that only part of the fat is derived from the food 
 directly ; the rest is a product of a splitting-up of proteids in tissue metabolism 
 (Landois and Stirling's Human Physiology, p. 518). 
 
 -t" Then, also, we 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 continiies comparatively stable ; yet, in certain 
 pathological states, the organic albumen becoming verj' unstable may undergo 
 rapid disintegration, as in fevers, &c. (Stirling, op. cit., vol. i., p. 506.) 
 
 J The liver is regarded as one of the chief sites of haemolysis "because bile- 
 pigments are formed from haemoglobin, 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. ^2 I 
 
 incomparably less than the fat, muscles, and even bones (see V. Voit's 
 experiments quoted by Landois, p. 5U), 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 ex{)re'^sed 
 with no uncertain cry. 
 
 What is the proper time for tveaning ? The period is, of course, a 
 most variable and uncertain time; each individual case must be 
 judged upon its own merits, and in considering, as we are compelled 
 to do, the interests of both parties, the mother and offspring, the 
 question necessarily becomes peculiarly trying and delicate, ow^ng 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 nur^e 
 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 efi-ort 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 prolonged 
 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 where we 
 deal with a healthy nurse— viz., that the period of lactation be ex- 
 tended in most cases over the period of evolution of the canine teeth. 
 
 "My rule, provided there be no serious oljstacles to surmount, otlier 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 difhcult process than the evolution 
 of the nicisors or first molars. My rule, therefore, is to wait, irrespective of age, 
 till the infant has sixteen teeth." * 
 
 * Trousneau, op. cit., vol. iv., p. 163. 
 
42 2 INSANITY AT THE PERIOD OF LACTATION. 
 
 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 angemia 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 
 earlier the symptoms of mental alienation occur, the more favourable 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 80 per cent, is to 65-6 per cent. The percentage 
 of recoveries for the whole number of female cases of insanity was 44'6, 
 so that the percentage of 6o-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 affects 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 : — 
 
 Total. 
 From 15 to 20 1 (at 19) ... ... ... 1 
 
 13 
 
 21 
 
 20 
 
 9 
 
 1 
 
 43 7 9 6 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 
 
 Age. 
 
 Recovered. 
 
 Relieved. 
 
 Died. 
 
 Remained 
 Chrouic. 
 
 L-om 15 to 20 
 
 1 
 
 (at 19) 
 
 
 
 
 „ 20 to 25 
 
 9 
 
 
 2 
 
 2 
 
 
 „ 25 to 30 
 
 15 
 
 
 3 
 
 1 
 
 2 
 
 ,, 30 to 35 
 
 13 
 
 
 1 
 
 3 
 
 3 
 
 „ 35 to 40 
 
 5 
 
 
 1 
 
 2 
 
 1 
 
 „ 40 to 45 
 
 
 
 
 1((?. 
 
 P.) ... 
 
Chart C 
 
 CHART of RECOVERIES m 70 PUERPERAL & 67 LACTATION CASES. 
 
 q 
 
 
 
 
 
 
 
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 8 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 X j^ 
 
 
 
 
 
 
 
 
 
 
 
 
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 /.. 
 
 
 
 
 
 
 
 
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 Upto 
 
 4w. 6w. 2/*i7^. 3 4-567 
 
 9 10 II 12 13 14 17 2^^. 
 
 Note.- T?/^^;^ Z i^^- indk<ifes Uie Puerperal 
 
 JJoUMLine . . LACTATIONAL FORMS. 
 
 ANALYSIS OF RESULTS. 
 
 Recovered Relieved Died Chronic 
 
 Puerperal 56or80% 4op5-7% 6or8-5°/o 4or57% 
 
 Lactational 44or65-6°/o 6or9°/o 8orl2°/o 9opI3-4% 
 
 BAct & SOA^S A OAAf/£LSS0N: 
 
PROGNOSIS— TREATMENT. 423 
 
 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 appear, 
 at first sight, that youth is favoured as regards greater immunity from 
 such afiectious ; in the attack being more acute, and hence more 
 favourable ; and in the ultimate issue in recovery. This 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 
 37,560 who are from twenty to twenty-five years of age; this represents 
 a ratio of 3-246 to 1. Taking, therefore, into consideration this fact, 
 that the number of married women in the "West Riding between the 
 ages of twenty-five and thirty-five is more than trijjle 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 unfavour- 
 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 afffictions, 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, two 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, nuiy 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— depression 
 
424 INSAXITY AT THE CLIMACTERIC EPOCH. 
 
 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 
 alone, or, better still, in combination with euonymin. Shower-baths, 
 cold spinal douches, and open-air exercise are 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 
 subcutaneously, or the liquor opii, will 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 Dehisioual Melancholia— Suicidal Tendency 
 (S. H. )— Xympbomania (A. A.)— Etiology— Incidence of Insanity at different 
 ages in 4085 cases— Influence of the Climacteric— The Psychological Trans- 
 formations of this Epoch— Instinctive Actions— The " Time-element" 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 symptoms 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 subacute delusional melancholia being far the more 
 frequent form ; yet maniacal states are by no means unfrequent, and 
 outbursts of excitement, alternating with depression, 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 
 
 *Thus Dr. Skae characterised the alienation occurring at this period of life as : — 
 ' ' A monomania of fear, despondency, remorse, hopelessness, passing occasionally 
 into dementia," 
 
SYMPTOMS— DELUSIONS— DESPONDENCY. 425 
 
 occur ia about the same proportion of cases, 27 per cent, of the whole 
 series being subject to such anomalies ; whilst evidence of the impli- 
 cation of other special senses was very rarely obtained. Intellectual 
 perversions soon ensue, sometimes evolved out of the sensorial dis- 
 turbances, often independent of such states, but invariably intensified 
 by hallucinatory and illusional phenomena when present. Delusional 
 states were recognised in 73 per cent., and out of a total of sixt^^-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 helL 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 J;his ailment accuses herself of the most heinous crimes, 
 and dreads the pux\suit of human or spiritual beings who thirst for her 
 life's blood ; but, at times, a case presents a somewhat different 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 declared 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 
 pi'omptings, 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 occasion- 
 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 ])00r 
 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 
 
426 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 similar perverted sensorial states. Especially have we learnt to dread 
 the impulsiveness of depression at the climacteric when associated with 
 the tendency to drink heavily.* The 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 married woman, in comfortable circumstances at home, 
 was admitted suffering from severe mental depression. She was a strong, muscular 
 subject of medium height, but somewhat pale and anjemic ; had a family of three 
 children living ; and was last confined, some eighteen months ago, of a still-born 
 child. Her habits of life were 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 
 suff'ocate herself, and also to cut her throat. Had expressed no delusion, and did 
 not suffer from hallucination. 
 
 No cardiac or arterial disease was apparent ; the respiratory and alimentary 
 systems were normal. The urine was 1020 specific gravity, faintly 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 anything 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 qiierulously 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 re-admission 
 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 incontrollable 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. 
 Amenorrhoea has existed for eight months." Under similar treatment she pro- 
 gressed during the first month so far as to be cheerful, active, industrious, and, 
 according to her own statement, had suflered from no return of morbid impulse. 
 She had, however, a somewhat careless, flippant manner, which was unsatisfactor}- 
 as indicating a reduction in the moral sense not natural to her. About this time 
 she again became somewhat querulous, importunate about returning home, and 
 there was slight hypochondriasis. This culminated in her abstracting from a 
 cupboard a quart bottle of spirits, locking herself in the bathroom of an officer's 
 house, and deliberately swallowing the whole of the contents of tlie bottle. She 
 was discovered in time to rescue her, and on her recovery from her semi-comatose 
 
 * See also Fleury, Journ. Mental Science, July, 1895, p. 551. 
 
IMPULSIVE STATES. 427 
 
 state she avowed that she had taken the spii'its with suicidal intent. Again she 
 became more cheery, less hypochondriacal, active, and useful, and in six weeks 
 time she Avas tried once more in an associated dormitor}-, where she slept with 
 fiftj^ other patients. She protested her freedom from impulses ever since 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 
 ligatui'e was tightly secured, the bed-clothing perfectly undisturbed, and the 
 sheet drawn over the face to secure her from the observation of the patients sleep- 
 ing beside her — sufilcient evidence of the desperate determination which had 
 initiated the act. 
 
 Contrasted with the case of S. H. we may take that of A. A., in 
 which maniacal perversions of a prominent nymphomaniacal nature 
 prevail. 
 
 A. A., aged fortj'-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 Avas in a state of subacute excitement upon her admission, 
 and was dangerously aggressive ; she expressed the delusion that she was Queen, 
 that her husband 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 hsemic 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. Eor some weeks after admission the excitement abated suificiently 
 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 ^hom 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. "She now betrays 
 a strongly erotic condition evidenced by expression and gesture and lascivious re- 
 marks ; when less under self-control this tendencj' gives vent to repulsive 
 and obscene language. She has deA^eloped 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 conversation, 
 betrays the same agitated manner, and is subject to periodic attacks of wild 
 nymphomaniacal excitement as formerl}^ 
 
 EtiolOg'y. — In endeavouring to estimate statistically the influence 
 of the climacteric involution upon the development of forms of mental 
 alienation prevailing at this epoch, we naturally lirst question ourselves 
 as to the relative frequency of insanity at this and other periods of 
 life. Were we to take promiscuously an aggregate of cases becoming 
 insane at different ages over an extended series of years, we should 
 become early convinced that the question, far from being a simple 
 one, as it might at first be regarded, was really a very complicated 
 problem to unravel. 
 
42 8 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 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. 429, 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 otiier grounds 
 — the encroachment of environmental agencies. The wealthy 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 community, 
 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 married, 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 which had not originated at this epoch of life ; and 
 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 4*4 upon the total admissions. The 
 
INCIDENCE OF INSANITY OF 4,085 CASES. 
 
 429 
 
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430 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 astonishing disparity in estimates upon this point by different writers 
 is seen in the following table : — 
 
 Classed as Climacteric Insanity. 
 
 „ .„ „ n SkaesEdin- Clouston's Edin- Mpr^ion''; West l^evan Lewis' 
 
 Reids Han well bui-oh Roval burch Hoval ^lerson s vv est West Riding 
 
 Statistics of 703 Tilt's Statistics, ^^^^^^^fl ' Asylumf ^o'^'f (tfll'''"' Asylum, 
 
 ■Cases of Insanity. 558'Cases. 1,549 Cases. i.uoi ^.ases. i,s08 Cases. 
 
 1-1% 3 to 4% iri7„ 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 "■lean from Dr. Mer son'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 the chief, element in the causation of the mental disorder, though 
 it may be afhrmed 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. Merson'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- 
 plex terms of the whole organism ; that the cerebrum itself is but a 
 vast assemblage of such highly-complex representative realms; and 
 that in the higher realms such nervous mechanisms as form the 
 physical 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 
 
 * Psychological Medicine, Drs. Bucknill and Tuke, .3rd edit., p. 360. 
 
 t " Climacteric Period in Relation to Insanity," W.E.A. Reports, vol. vi., 1876. 
 
ETIOLOGICAL FACTORS. 
 
 431 
 
 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 
 thatwide-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 
 paramount 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, 
 find their nervous representatives in the fundamental tracts of the 
 nervous system, and draw largely upon that system during their life of 
 functional activity. Pei-iodic 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 sensorium 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 tPansformatlon, more or less, of the eg"0, 
 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 aflfected by the 
 resultant transformations undergone, such periods being eminently 
 periods of nerve instability. 
 
 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 disturbance of the nervous-centres — headache, 
 vertigo, faintness, " heat-fiushes," emotional waves, phases of moral 
 perversity, irritability, querulous impatience, even intellectual disturb- 
 ance (especially of memory and of attention) prevail ; and, wanting the 
 relief afforded by the depurative process 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, purposeless waves of feeling, abortive yearn- 
 ings, redundant, vague, uncontrolled desires, and misdirected energy. 
 
432 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 That great reservoir of nerve-force, which had for its object the pro- 
 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-in a period of reconstructions. 
 
 J. F. , aged forty-one, single ; admitted January, 1880. Patient's father was very 
 intemperate ; her mother and brother had been inmates of this asylum. 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 fairty calm attention and apprehensiveness was 
 constantly interrupted by outbursts of furious excitement and violence. An insane 
 self-congratulation in her power of occasioning terror by her actions, seemed 
 possibly of influence in the production of her paroxysms of passion. 
 
 For three months she was liable to these dangerous impidses, of which she was 
 aware, and expressed her grief at being unable to restrain them. Subsequently she 
 passed through phases of sidlenness, 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 sufiicient 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 spirit of the times affords, in our day, missions for 
 the same subjects. The peril of this period is one incident to all 
 periods of reconstruction arising during emotional turmoil and pertur- 
 bation. Reflection wants the calm essential to its orderly operation, 
 and judgment is liable to be warped and one-sided ; hence, also, it is 
 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 this is of interest viewed in 
 connection with the characteristic delusions of the insanity of this age. 
 
 We 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. 
 
ETIOLOGY— PROGNOSIS. 
 
 433 
 
 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 65 ; 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 reproduction 
 which marks the middle age of women." + With a certain proportion 
 of cases the menopause in women 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? The hopes we can 
 give to our patient's friends of a perfect recovery will largely depend 
 upon the "time element," which plays so important 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 speedy return to a normal 
 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 60 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 
 
 * Op. cit., p. 500. 
 
 t Clinical Hklory of the Diseases of Women, Barnes, p. 263. 
 
 28 
 
434 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 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 series 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 afiections of the bowels, or the malnutrition and 
 defective blood-supply of the brain, due to an enfeebled and fatty heart. 
 Another factor in the prognosis is the age of the patient. It has been 
 observed by Dr. Olouston that fewer recoveries occur after fifty years 
 of age — an opinion with which 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 secret drinking habits become peculiarly 
 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 
 aspect of despair — indications which should place us on our guard. 
 
 * Loc. cit.y p. 564. 
 
PROGNOSTIC INDICATIONS. 
 
 435 
 
 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 indulgence are 
 •some of the chief factors which enable us 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 climacteric years, 
 then the prognosis is unfavourable;" whilst Dr. Merson sa3'S — "The history of 
 the cases I have investigated, however, shows that as regards ultimate recovery 
 the prognosis is by no means unfavourable, though an earl}^ recovery is not 
 generally to be expected, "t 
 
 Dr. Clouston gives a percentage of 57 for recoveries in the female 
 sex; j 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, afibrd us a 
 recovery-rate of 48 per cent., and, therefore, justify the views ex- 
 pressed 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- 
 favourable 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 fairly-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 
 ■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 kindly 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 
 
 * Pfiijchohgical Medicine (Drs. Bucknill and Tuke), p. 14.5, 
 fWesl Ridinij A^rjlum Report's, vol. vi., p. 107. 
 XLoc. cit., p. 563. 
 
436 INSANITY AT THE CLIMACTERIC EPOCH. 
 
 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 which 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 ta 
 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- 
 2yrimce vice. An aloetic purgative is often desirable at the onsets 
 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 sufficing to 
 ensure a cure. 
 
 There are certain cases, however, where medicinal interference is 
 imperatively demanded. Anaemia must be met by the administration 
 of iron, preferably 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 
 to escape on the excuse of having partially taken her meal ; a due 
 amount of milk and eggs with beef-tea, nourishing soups, and farinaceous 
 food should be rigidly insisted upon ; and, if necessary to resort to 
 force, compulsory feeding must be adopted. 
 
 Sleep must be secured l)y the administration of chloral, bromide of 
 potassium or paraldehyd ; of which we certainly give preference to the 
 first. It is rarely necessary to give larger doses than 25 or 30 grains ; 
 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 use of sedatives. For this purpose 
 chloi-al in combination with bromide of potassium is the safer treatment 
 
SENILE INSANITY. 
 
 437 
 
 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 efiBcient alimentation, such treatment is often followed by 
 the best results. 
 
 SENILE INSANITY. 
 
 Contents. ^Mental Derangements Incident to Senility — Senile Mania— Senile Melan- 
 cholia— Chronic Cerebral Atrophy— Senile Convulsions — Senile Epilepsy — 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— Case of Senile Insanity 
 (M. M.)— 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 physiological 
 senility ; that gradual obnubilation of mind known as senile dementia is 
 apt to be taken as a type of what is implied by senile insanity ; and, so 
 far is he right, that it is doubtless true 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 precursor of 
 senile decay. It is therefore, necessary to indicate that this term 
 connotes a very large class of symptoms, embracing 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 moi'bid affections, 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 atropluj 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 
 
438 THE INSANITY OF THE SENILE EPOCH. 
 
 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 attempt 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 
 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 will have his attention chiefly directed. 
 Recurrent maniacal attacks are of special frequency amongst the aged 
 insane, 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 
 
MENTAL DERANGEMENTS INCIDENT TO SENILITY. 439 
 
 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 htemorrhages, 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 nerve-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 
 affective 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 affection 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 
 times 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 
 prone to appear in the frontal and motor realms, cortical and ganglionic. 
 A group of symptoms constituted by despondency, self-absorption, 
 general intellectual torpor, failure of memory, enfeebled volition, 
 impulsive conduct, often desperately-suicidal attempts; and, with this, 
 highly-characteristic 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 laVjoured utterance, 
 and an utter want of initiative — are in themselves a very suggestive 
 category. When, with such a case, we find general muscular enteeble- 
 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. 
 
440 THE INSAXITY OF THE SENILE EPOCH. 
 
 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, usuallv, 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 pi'ogressivelv 
 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 steadv 
 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 upon 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 
 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 words, insanity may be acquired purely ab extra. We have 
 too many instances afforded 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 
 
INCITING AND PREDISPOSING AGENCIES. 441 
 
 potent cause only ab 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 % 
 
 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 '■'very 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 
 changes and chances, the crises and perils of life with intact mental func- 
 tion till after sixty, means slight neui'otic heredity, or great absence of 
 exciting causes of disease."! Were we to regard the dictum that the 
 stronger predisposition is manifested earlier in Hie (open as it is to such 
 numerous e^tceptions) we would still take exception to applying such a 
 law to the cases of insanity under consideration. What are the positive 
 facts before us? If we take into consideration all forms of neurotic inheri- 
 tance alike, we find a percentage of 26-4 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 hereditaiy 
 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 in.sane exhibit a fairly average pre- 
 disposition to insanity; and that, possibly, its late development in such 
 subjects may depend upon the nature of the neurotic inheritance and 
 the developmental period d\iring which it was originally acquired by 
 the ancestor ; for the law that a morbid condition tends to reappear at 
 * Op. cit., p. 567. ilbid., p. 566. Xi^id., p. 566. 
 
442 THE INSANITY OF THE SENILE EPOCH. 
 
 an earlier age in the progeny 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 
 have reached their limit of normal functional activity, when function 
 declines, and physiological dissolution commences, in the series of 
 downward retrogressive changes of senility. 
 
 Such unwise demands made on the nervous-centres during adult life 
 are prone to induce premature senility, and the various mental de- 
 rangements 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 nei-ve-cells ; to retention of hydro-carbon in the 
 system ; to vascular paresis and disease of the arterial tunics ; to 
 universal degradation in type of tissue, notably of the nerve-centres : 
 we may, indeed, readily appreciate the evil effects of undue mental 
 exertion backed up by alcoholic stimulation. 
 
 T. G., aged fifty-two, married, with a family of five children, a miner by occu- 
 pation. Patient was suff'ering from his first attack of insanity, which began a 
 month ago. He was a short, well-nourished subject, of florid complexion, con- 
 junctivse tinged ; arcus senilus well marked ; pupils equal and active ; slight 
 flattening of right side of face ; tongue protruded straight, slightly tremulous. 
 There was excessive sensibility of the soles of the feet ; when these were tickled, 
 the whole body was thro^vn into a convulsive state. He had formerly been addicted 
 to very heavy drinking, although more abstemious during the past four j'ears. His 
 father di-ank 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. 
 iSIother 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 [nyitagmxiis), and, subsequently, jerking movements of the head and neck. 
 He sought treatment for his eyes at the Leeds Infirmary ; but, whilst there, his 
 limbs siiddenlj' one night were thrown into convulsive movements hke 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 
 
ALCOHOL AND SP^NILE INSANITY. 443 
 
 impaired. Childish moods were then noticed ; he would collect worthless rubbisli, 
 and, if deprived of it, become most passionate and violent. Memory deteriorated, 
 and he began to misname his acquaintances and relatives, trreat irritabilitj- 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 ej-es were drawn-up — he frothed much at the mouth, his mouth being 
 drawn to one side (which side unknown) ; his limbs were much jerked about, and 
 he remained for some time unconscious." Had suffered 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 woi-d, he frequently repeats tlie 
 first syllable before proceeding, and -when the word is completed successfullj', he 
 is apt to reiterate the whole word 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 surroundings. 
 He shows the instantaneo-m 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 liis troubles and present physical ailments. Atten- 
 tion is commanded with fair ease. He becomes readily emotional and agitated, 
 ■when his breathing is accelei'ated, and choreic movements of head and limbs 
 supervene ; locomotion somewhat impaired by the jerky movements of his limbs." 
 
 Such being the history prior to and upon admission, the patient, a fortnight 
 later, had several recurrences of the choreic movements, became decidedly suicidal, 
 dashing himself head 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 right arm showed muscular twitchings — the eyes turned 
 to the right side, and the eyelids were convulsively affected. The twitching of 
 the right arm continued long after return of consciousness ; slight right hemiplegia 
 was present the following da}'. 
 
 For several weeks he continued very restless, in a heav}', stupid state, and 
 evidently much demented ; both pupils minutely conti-acted. The limbs 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 twitchings of tlie 
 limbs, and a high temi)erature, he died. 
 
 Sectio cadar. Skull-cap sj'mmetrical, of average tliickness and density ; no adhe- 
 sion of dura mater. Sinuses contained fluid blood. Arachnoid opaque over frontal 
 and parietal regions, with (■()nsidcra1)le fluid in tiie meshes of pia mater, which was 
 thick 3i,nd toiKjh, but si ri})}i<(l 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, 
 eHpecially on the left aide. The brain throughout Avas softer tlian normal, aiul of 
 a dirty, rusty hue. The gi-ey matter was shallow ; the wliite matter studded 
 with very numerous coarse vessels, showing also upon suction small patches 
 
 * See case of ■/. /'., p. 348. 
 
444 
 
 THE INSANITY OF THE SENILE EPOCH. 
 
 of a pinkish tint. No special focus of softening was noted. Cerebellum and basal 
 ganglia presented no change. 
 
 Whole brain weighed 1270 grms. Left frontal lobe weighed 198 grms. 
 
 Right 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. 
 
 Right hing, 955 grms. ; intensely engorged throughout, but still floated, and 
 on pressure crepitated ; no tubercle or inflammatory induration. 
 
 Left lung, 810 grms. ; adherent by old fibrous bands; lika 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, 180 grms. Capsules were adherent in 
 both organs ; the surface granular ; the substance greatly wasted in cortical 
 and pyramidal portions ; the pelvis of the right kidney was dilated. 
 
 Of the 261 male senile cases, as many as 75 (i.e., 28-7 per 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 
 chronic cerebral atrophy each afl'ord an alcoholic history in 40 per 
 cent.; whilst amongst the senile dements propex', this factor appears 
 only in 16 per cent. 
 
 Onset and Prodromata. — Were we to attempt to define the 
 boundary betwixt the physiological and pathological form of senility, 
 between the ordinary second childishness of old age, and the dementia 
 resulting from the senile atrophy of disease, we should find the task 
 a difiicult 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 
 gradations 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 rapid changes of mood. Moody 
 taciturnity alternates with fits of almost childish hilarity. The 
 
PRODROMATA-SYMPTOMS AT ONSET. 
 
 445 
 
 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 exertion, 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 lapse 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 foi'mer 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 
 bi'ain ; and upon its subsidence, well-marked indications of enfeebled 
 mind appear. 
 
 Similarly, much mental depression may ensue, and melancholic 
 agitation precede the more profound reductions of a later date. In 
 the 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 emotional 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 environmental horizon is correspond, 
 ingly limited. This may all 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 cliiefly as respects 
 recent events, the more 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 
 * See P syvholoijkal Medicine, Bucknill and Tuke, p. 342, 
 
446 THE INSANITY OF THE SENILE EPOCH. 
 
 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 ; byegone 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 remai-kable 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 
 deeply -organised are the states with which 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 expreSSiVG 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 
 imental 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 jjhysical exertion. Reduced to an automaton, in 
 every sense of the word, his habits of life are simple in the extreme j 
 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 
 
NATURE OF THE SENILE REDUCTIONS. 
 
 447 
 
 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 preceded 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 with 
 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 storms ; for wild gusts of excitement 
 sweep over the scene repeatedly during the progress 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 
 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 irresponsible agent. 
 
 This objectionable tendency is one strong reason whv an a^ed 
 parent, sufi'ering 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, witli a bullet-shaped head, light sandy-coloured hair, and blue eyes. 
 Patient had lived a steady, temperate Hfe ; had suffered from no special illnesses— 
 " stroke " or "fit." Had sustained no injury to the head. Family history was not 
 
448 
 
 THE INSANITY OF THE SENILE EPOCH. 
 
 ascertainable. He had been \\Tetchedly 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 infirmary- 
 wards. Six months since, whilst in a very dejected state of mind, he sprang over 
 a bridge into the river, but was rescued and taken to the workhouse, where he has 
 remained employing himself at useful occupations, but alu-ays dep7-essed. 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 melancholic, 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 necessitating 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. 
 " Eor some years past he has been subject to periods of 'confusion of thought," and 
 failure of memory ; it comes on S'udclenly, unexpectedly, and at such times he is 
 wholly incapacitated for work. At times such attacks were prolonged and accom- 
 panied by intense depression, during which he had to be placed under super^-ision. 
 In one of these fits of despondency he attempted suicide. He believes he is 
 ' eternally lost ; ' but his chief trouble at this time was not so much his 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 aihnents." 
 His memory was but slightly impaired, being more sluggish of recall than actually 
 defective ; his intellectual operations generally were torpid; his attention enfeebled, 
 so that occasional confusion of ideas occurred during conversation ; no hallucina- 
 tions existed. He had a dejected expression. The pupils were equal and active, 
 of normal size ; the tongue was protruded straight, and showed no ataxy or 
 tremor. No evident degeneration of the superficial arteries was indicated, and 
 the heart was apparently healthy. 
 
 Chloral alone afforded him relief, and was frequently required to secure sleep. 
 Thus he remained for some j'ears with no relief nor alteration of his deluded state, 
 pacing up and down the wards %^-ith woe-begone aspect, groaning, importunate 
 upon the subject of his hj-pochondriacal 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. 
 
 3Ianv cases of senile dementia present for some time a gradual, 
 prot^ressive 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 ^^-iclow, 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 expressing fears that 
 the inmates of the workhouse had designs upon her life. Her habits as regards 
 
ACUTE SENILE MELANCHOLIA. 449 
 
 alcohol had been temperate ; there was no historj- of insanity or other neurosis in 
 her antecedents. Upon admission she was fairly fjuiet, and conversed affably-. 
 Grave mental failure was apparent ; she still thought she was at the workhouse, 
 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 thirtj'-six years of age; 
 her liusbaufl lives in New Leeds ; she saw him a fortnight ago. " ' ' She makes vague 
 statements of ill-treatment before coming here, weeps childishlj', and then as 
 suddenly becomes cheerful and contented. She is a shrunken old woman, much 
 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 pulse 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 albumen ; no deposits." During 
 her first month'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, j'et 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 Claj'ton 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 extremitj^ 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 " slie fancies her father lives here, as also that his age 
 and her own are the same. Is dirtj% restless ; often weeps and cries to go home ; 
 is more feeble and wasted." Still later on she became melancholic, even acutelj' so ; 
 appeared in great agitation and terrified ; would cry aloud, ' ' Are you going to put 
 me underground ? " 
 
 The following case is 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 verj' haggard, 
 wasted aspect ; the complexion sallow, and condition generallj' very amemic. 
 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 and feeble. The abdomen was shrunken 
 and hepatic dulness much diminislied. Urine 1020, slightly cloud}-, amber-coloured, 
 alkaline ; a trace of albumen ; a large deposit of mucus. The patient on admission, 
 
 29 
 
450 THE IKSANITY OF THE SENILE EPOCH. 
 
 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," and there was no room in her stomach 
 for food. After a restless night she was found very 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 
 grown forward so as to encroach upon her stomach, preventing 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 the room, talks childishly, 
 and falls into a doze. Made such remarks as — "Don't put my eyes out ; are you 
 going to blind me ? are you going to make me deaf ?" Occasionally 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 very degraded. A month after admission she had a sei-ere syncopal 
 attach, remained very pale and subconscious for some time, and the pulse became 
 extremely feeble. She died of pneumonia shortly after this date. 
 
 When mental exaltation prevails it is a symptom of gravest moment 
 and ominous of coming dissolution ; the general 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 regards one or other of the most complex groups of feel- 
 ings which comprise the aasthetic 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 fact that according to the special group 
 we are dealing with, there will be 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 preponderating will be the cognitive 
 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 compared 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 emphasised, and thought more 
 
 * Principles oj Psychology, vol. ii., p. 578. 
 
DELUSIONS OF THE SENILE AND MONOMANIACAL SUBJECT. 45 I 
 
 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 afl&rming 
 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 sicbject-consciotisness, with a corresponding fall in 
 object-consciousness. This rise in the feeling element, and failure in 
 the cognitive, leads readily to a delusional atate, 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 gradual 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 2yari jmssu 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 far to interference by 
 extraneous agencies, such as vasomotor changes, &c. 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 rapid and vigorous circulation through 
 the active area), its operation doubtless serves to intensify the in- 
 tellectual or cognitive element of mind, and the relations between 
 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 
 morbid result contrasts notably with that morbid entity engendered 
 ah extra. If the bodily sensations (the coentesthesis) are seriously 
 deranged ; if altogether novel and obscure sensations are aroused by 
 e.g., various visceral afifections, it is notable that the personality may be 
 
452 THE IXSAXITY OF THE SENILE EPOCH. 
 
 endangered thereby, and a transformation of the ego may result. This 
 fundamental change may be induced by the 2)S'>'sistent attention given to 
 tliese 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 waves 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 a f route 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 ccencesthesis 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 destructive. 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 
 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 have seen how all those feelings which are based upon the 
 instincts of conservation of the self, or of the progeny (together with 
 the complex and consolidated groups making up the social, religious 
 and festhetic 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. 
 
SENILE AMNESIA. 453 
 
 Senile 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 
 became 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 upon 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 encroachments 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 history. Ribot has 
 well described the process of recollection and localisation of events 
 in titne. 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 epoch, 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 
 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 difi'erent 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 question 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 ii7ne becomes to many quite impossible ; present events 
 
454 THE INSANITY OF THE SENILE EPOCH. 
 
 fail to impress the organisation with their wonted vigoui', 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 offered to the molecular currents of the highest nervous 
 mechanism, the tide of nervous 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 aphasic, 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 more 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 
 succumb; in other words, the dissolution takes the course from the 
 least to the most stable arrangements. 
 
 The following 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 give in our asylums. 
 
 M. M., aged eighty-five. A widow with two children ; of Roman Catholic per- 
 suasion. Was admitted October 13th, 1886, imder 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 marrj'ing to-daj-. Believes herself 
 to be possessed of property. Rambles about in search of imaginarj- objects. At 
 one moment greatl}- distressed and crj-ing, 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 
 
 * Op. cit., p. 568. 
 
PREMATURE SENILITY. 455 
 
 strike her grand-children with a poker." She was said to have been a very steady 
 woman, with no insane or epileptic inheritance; one daughter had died of htemop- 
 tysis, another of phthisis. It is affirmed that until five weeks ago she showed 
 no mental derangement. She then became excitable, disorderly, 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, 1886. — Restless and terrified last night ; kept looking at, and pointing 
 to, the windows, and declaring that "Mahony was coming to kill her." 
 
 Oct. 25th. — Very restless ; incessantly trying to get out of the ward; asserts that 
 she is ''going home to-day." To have a mixture of tinctura hyoscyami with the 
 double bromides of sodium and ammonium twice daily. 
 
 ^ov. Sth. — 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; thei-e are some knives with 
 them there ; there they are" — pointing to the ceiling. Is very agitated and restless; 
 does not sleep well, and grows weaker. 
 
 Feb. 2nd, 1887. — Often excited and noisy ; on the 30th ult. refused her dinner 
 and remarked — "I won't 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 paraldehyd at night to 
 secure sleep. 
 
 Premature Senility. — A careful comparative survey of the fore- 
 going histories, w^ith the case of H. 0. detailed at p. 243, 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, cii'culation, 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 exliibit diseased tunics, narrowing of 
 their lumen, tortuosity with attendant impairment 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 
 
456 
 
 PREMATURE SENILITY, 
 
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ELIMINATION OF UREA IN CHRONIC BRAIN ATROPHY. 457 
 
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458 PREMATURE SENILITY. 
 
 associated with the contracted kidney. The imperfect renal function 
 is manifested in nearly all these instances of clironic brain atrophy, 
 as may be illustrated in the foregoing table, containing the results of 
 examination of the urine in seven typical instances, followed for the 
 contrast by a case of general paralysis {J. JJ.}, and one of acute 
 delirious mania {T. i?.). 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 varying with the degrees of 
 hypertrophy, a well-sustained tidal and good dicrotic wave, often 
 succeeded by a slight secondary undulation during the diastolic pause 
 (arterial elasticity). In the case of extensive atheromatous disease a 
 
CHRONIC CEREBRAL ATROPHY AND BRIGHT'S DISEASE. 459 
 
 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 
 180 grammes, and with a large hypertrophied heart the pressure often 
 has to be still further increased. 
 
 The obstruction in all these cases is due to the hypertrophy of the 
 tunica muscularis. As was indicated years since by Dr. Broadbent,*- 
 the peculiar character of the sphygmogram is immediately altered by 
 the exhibition of amyl, and also by the onset of pyrexia. With the 
 atheromatous condition, however, the exhibition 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 Bi-ight'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 stupor. 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 inter- 
 stitial fibrosis than very extensively affected ; we usually find one 
 
 * Discussion at the Royal Medical and Chirurgical Socit-ty, ^f('(l. Times and 
 6az., Dec, 1872. 
 
460 THE TREATMENT OF INSANITY. 
 
 organ in a much more advanced state of degeneration than the 
 other. 
 
 The special determining factor upon which depends this tendency to 
 implication of the cerebrum in particular, in cases of chronic brain 
 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. Recognising 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. 
 
 THE TREATMENT OF INSANITY. 
 
 Contents.— Physiological Element in Treatment— The Moral Element— The Mental 
 Nnrse— Individualised Treatment— Hospitals for the Acute Insane — Modern 
 Revolution in Treatment— Rest and Exercise— Treatment of Delusion ; Destruc- 
 tive Habits ; Suicidal Tendencies— Therapeutics — Role of the more Imijortant 
 Sedatives Employed — Chloral — Chloralamide — Paraldehyd — Sulphonal — 
 Trional and Tetronal— Hyoscyamine— Duboisine — Opium — Cannabis Indica — 
 Couium. 
 
 The treatment of insanity naturally resolves itself into {a) Physio- 
 logical or Hygienic ; (6) Moral ; and (c) Therapeutic Measures. 
 
 It is necessary that we appreciate the implication of these terms, 
 just as we must recognise that a strict classification under these 
 headings cannot be always logically claimed for any special line of 
 treatment adopted ; thus, the physiological often includes a moral 
 element, the moral often has a notably physiological opei'ation, whilst 
 the therapeutic again has, under certain conditions, an equally strong 
 moral effect. 
 
 The Physiological Element in Treatment.— By these measures 
 
 we seek either to convey the organism into a more suitable environ- 
 ment, or so to modify the existing environment as to reduce to a 
 minimum the friction established betwixt the two; in other words, to 
 favour, by the removal of certain ascertained inimical factors, the 
 healthy and normal adaptation of the organism to its environment. In 
 every sense humanitarian principles guide us here, and the law of the 
 survival of the fittest is recognised, only to be opposed and combatted 
 by the full force of modern altruistic measures. 
 
 All sources of irritation to the organism, where detected, must be 
 removed, whether these be physical, mental, or both conjoined. 
 
THE MORAL ELEMENT IN TREATMENT. 461 
 
 Exhausting occupations, mental strain, especially with worry and 
 coincident anxiety, irregular habits of life, and local associations which 
 are recognised as tending to foster a feeling of antagonism to the 
 environment; all these should be met and com batted, and this, as is 
 well known, can, in by far the larger number of cases, only be ensured 
 by the i*emoval of the patiejit to fresh surroundings, by placing him 
 where the conditions of life are simpler, and where hygienic con- 
 siderations are stringently kept in view. 
 
 Just as we strive to remove all sources of irritation, so we endeavour 
 to eliminate such noxious agencies as by self indulgence, or by the 
 influence of injudicious friends, have entered into the vicious circle of 
 his life — alcoholic indulgence, the morphia, chloral, or cocaine habit, 
 sexual excess, morbid excitement of any character, solitary habits, and 
 morbid introspection. Wherever the organism is exposed to peril, as 
 in suicidal conditions, extreme violence, absolute refusal of food, lone 
 continued and complete sleeplessness, the physiological factor in treat- 
 ment plays a conspicuous role, since the removal of the patient to an 
 asylum or hospital is then almost invariably demanded, if only to 
 secure the full moral and therapeutic effect of treatment. 
 
 The Moral Element in Treatment. — By moral treatment we 
 
 refer exclusively to the direct effect of mind upon mind, whether this 
 be of t^he nature of a soothing, calmative influence, or of judicious 
 repressive measures adopted towards any vicious or dangerous ten- 
 dencies upon the part of the patient ; in other words, the psychical 
 environment is so modified as to induce a healthy response, and 
 encourage normal adaptation. The physician here largely depends 
 upon the nurse ; the constant companionship of a suitable attendant 
 is the sheet-anchor of success. Here it is, also, that a strong contrast 
 can be drawn between the usual hospital and mental nurse. We must 
 admit that the intelligent, responsive, and successful mental nurse has 
 a far more complicated sphere of labour to engage in than the nurse 
 in the medical and stxrgical wards of a hospital. 
 
 {a) The Mental Nurse. — It is not so generally recognised by those 
 who interest themselves in the furtherance of nursing schemes, that, 
 whilst the hospital nurse is usually incapable of taking charge of 
 mental cases from lack of experience in so special a department, the 
 asylum nurse, on the other hand, if well trained, is fitted for hospital 
 work, whilst her experience in mental nursing makes her a most 
 invaluable adjunct to the usual stafi'.* The nurse who can enter 
 
 * There is a sad lack of the co-operative spirit betwixt these two classes of 
 Institutions, strange as it may appear, and, perhaps, not the least important 
 obstacle to a reform in this direction lies in the absolutely untrutliful suggestion 
 so freely indulged in by those who should know better — viz., that the asylum nurse 
 is a raw recruit untrained for hospital work and not certificated. The establishment 
 
462 THE TREATMENT OF INSANITY. 
 
 most closely into the mind of her patient, who can probe her feelings 
 with instinctive readiness, and adapt her resources to the varying 
 moods presented, is, indeed, a valuable auxiliary to the medical atten- 
 dant. A quiet, calm, gentle demeanour, free from the least flurry, a 
 constant cheerfulness and brightness unruffled by any of her patient's 
 vagaries, an absolutely even temper, great patience and forbearance, 
 are indispensable requisites. The nurse should be self-possessed, but 
 not self-assertive ; should exhibit a firmness united with gentleness 
 and the quiet self-reliance begot alone of a ripe experience, and a com- 
 plete faith in the virtue and efficacy of patience conjoined with 
 sympathy. A watchfulness ever wary, yet inobtrusive ; a studious 
 regard to all her patient's susceptibilities — nervousness, irritability, 
 moroseness, despondency — meeting evei-y varying phase with its 
 suitable corrective. This is a function demanding the highest social 
 •qualifications a nurse could be required to exhibit, and, as might be 
 expected, the woman in this capacity is far more successful than the 
 male attendant. These, then, are some of the qualifications demanded 
 of a good mental nurse, and if such be required of a nurse in charge of 
 a single case, how much more complicated becomes her role when 
 placed in charge of a large ward, where she also has to encounter and 
 control the actions and interactions between a number of patients all 
 -varying more or less in the special treatment applicable to each case 1 
 It is in this capacity that her tact and address will be best displayed, 
 as she has not only to keep a watchful supervision over her patient's 
 welfare, but also to control and train a subordinate staff" of nurses, and 
 to strive by her influence to spread a spirit of loyalty and discipline 
 amongst the junior nurses. 
 
 The conscientious discharge of such functions entails a heavy burden 
 of responsibility, demands a healthy physique to stand the strain, and 
 involves upon those responsible for the employment of such nurses 
 the duty of providing them with adequate rest, recreation, and well- 
 regulated and substantial dietary. 
 
 {b) Individualised Treatment. — The whole aim of moral treatment is 
 that of individualising the subject to the fullest possible extent ; each 
 case must be treated upon its own merits, to obtain the best results ; each 
 patient must receive as much attention as the physician and nurse can 
 bestow. Here it is that a great stumbling-block presents itself to the 
 alienist in charge of our large asylums, where the vast accumulation of 
 the chronic insane paralyse his best eff'orts. The large proportion of 
 
 by the Medico-Psychological Association of examinations for certificates in mental 
 nursing, and the ambulance and nursing classes held now in all British asjdums, is 
 of coiirse a sufficient refutation to this most unjust aspersion. That the public 
 and the profession fully appreciate the higher functions of the mental nurse is 
 indicated by tlie higher scale asked for her services and so readily granted. 
 
THERAPEUTIC MEASURES. 463 
 
 the chronic and incurable class in our asylums require no such elaborate 
 system as is provided necessarily for the minority — the recent and 
 acute. Attempts have been made to obtaining redress for this con- 
 dition of things at the hands of the Union authorities, it being 
 suggested that large numbers of the incurable and harmless might, 
 with wisdom, be relegated to the large union infirmaries, which, if 
 somewhat better officered, might, at a much reduced rate, support the 
 great bulk of the chronic residue. The attempt has, however, not met 
 with encouragement, and it is more than probable that our Councils 
 will eventually solve the question by building asylums upon more 
 economical principles for this class of the insane ; and by erecting 
 hospitals for the acute and recent in connection with each large county 
 asylum ; this appears to be the more rational solution to the problem. 
 The hospital should be built upon the most approved scientific prin- 
 ciples, and should embrace an administrative block capable of meeting 
 the fullest demands of modern treatment. It should afford facilities 
 in the form of laboratories for scientific research at the hands of the 
 medical staff; and should aim at being a centi'e for the teaching of 
 psychiatric medicine, since our asylums alone embrace the material for 
 such studies. Into this hospital should be received all incoming cases 
 of insanity, those recognised as chronic and incurable being at once 
 drafted off to the larger institution, and those alone retained here who 
 present hopes of final recovery or such relief as is compatible with 
 discharse to their homes. No distractions would thus occur to the 
 medical and nursing staff by the multitudinous and importunate 
 demands of the chronic class, which, at present, so largely enslave 
 their attention and limit their utility for the real work of asylum life. 
 All who have had any practical acquaintance with the insane must 
 recall cases where the difficulty of segregating, so as to remove certain 
 acute cases from the influence of irritating chronic patients, retarded 
 recovery ; and where thf> want of more individualised attention 
 appeared answerable for the gradual drifting of such cases into 
 secondary dementia ; nor is it a rare occasion to see a notable change 
 for the better effected in such cases when transferred to other wards, 
 where the sources of annoyance were fewer, and where the nurse was 
 able to afford more continuous attention, or was better adapted for her 
 duties. 
 
 Therapeutic Measures. — During the past quarter of a century 
 the treatment of insanity by therapeutic measures has undergone a 
 complete i-evolution. Three decades ago antiphlogistic theories still 
 maintained their ascendancy over certain minds, and depletion by 
 bleeding, either lancet or leech, active purgation, ])owerful drugs, 
 especially the tartai'ated antimony, were all in vogue. Excited 
 patients wei'e often kept for days together on the verge of narcosis. 
 
464 THE TREATMENT OF INSANITY. 
 
 croton oil and tartarated antimonial ointments were vigorously rubbed 
 into the scalp, and this was considered an heroic and consistent mode 
 of treatment. All this is now altered ; not so much, perhaps, by the 
 demonstration of the inutility or even actively injurious results of 
 these procedures, as by our growing acquaintance with the structure 
 and functions of the nervous system, its physiological chemistry and 
 pathology. And thus, as with the death of all old systems, a healthy 
 scepticism of such treatment arose, not by any critical exposure of its 
 vicious nature, but by the general advance in various departments of 
 knowledge. 
 
 The reaction against such heroic measures had, as its fundamental 
 conception, the nature of insanity as a reduction both in physical and 
 in mental vigour ; and, as a necessary corollary, the employment of 
 means to build u]) an exhausted nervous system, and above all things 
 to avoid lowering the vital energies of the fabric. Yet, as in all such 
 reactions, the sceptical spirit often appears to have carried some of its 
 votaries too far, their faith in all medicaments being so violated that 
 they are even prepared to affirm that all alike are useless. On the 
 other hand, old systems and habits of thought die hard, and, even now, 
 we have faint revivals of these old-fashioned views afforded us, if not 
 to so serious a degree, at least to an extent that is often open to 
 censure ; thus we still hear rest in bed strongly deprecated for cases 
 of excitement, although it is almost universally admitted by the most 
 experienced as a powerful agent for the reduction of excitement and 
 the renovation of the nervous system. And thus we find at the 
 present time extreme views held still by a few, the more rational line 
 of treatment lying, as is usual, in the golden mean. 
 
 Hest and Exercise. — A very large proportion of the patients con- 
 signed to our asylums in the early days of treatment imperatively 
 demand rest in every form in which it can be enjoined. To place a 
 recent case of acute excitement amongst a number of others similarly 
 noisy and boisterous would be the height of absurdity and thoughtless- 
 ness ; just as it would be to insist upon the attendance at a dance^ 
 theatrical entertainment, or concert of a patient plunged into the 
 abject misery of melancholia. For all recent cases rest in bed is one of 
 our best adjuvants to treatment; the sleeplessness, the irritation of 
 removal to an asylum, and the various unfavourable circumstances to 
 which the patient has been exposed call for immediate rest, soothing 
 influences, quiet and even a darkened room. All recent oases of an 
 acute character are wisely retained in bed for at least two days after 
 admission ; we invariably, if practicable, make a careful examination 
 into the mental and bodily condition on the second day. All cases 
 sufficiently conscious are thus brought to feel that they are exposed to 
 a rational system of treatment. It is then decided whether further 
 
REST AND EXERCISE. 465 
 
 rest in bed through the day be desirable or not, and, to a large extent, 
 the reply depends upon the patient's physical condition. In a large 
 number it will be found advisable to keep them in bed for at least a 
 part of the day for some little time ; and to encourage meanwhile the 
 reparative processes which have probably been much neglected prior 
 to their arrival. Debilitated and senile subjects, maniacal or melan- 
 cholic, refusing food persistently will thus often imperatively demand 
 rest in bed throughout the day ; and so the turbulence of acute excite- 
 ment in exhausted subjects is far better treated in the quiet of a side 
 room than exposed to the irritation of other cases in a day-room. In 
 such cases, to enjoin out-door exercise indiscriminately might occasion 
 much harm and would certainly prejudice the recovery unfavourably. 
 
 In the large Berlin State asylums this line of treatment is followed ; 
 and especially at Dalldorf, which, to our mind, reflects the most 
 advanced and rational aspects of modern psychiatric medicine in 
 Germany, it was pleasing to note the genuine hospital character of the 
 treatment adopted. Dr. Koenig of that institution kindly favoured 
 us with his views on rest as an agent employed by himself and other 
 alienists in the early days of mental disease. He informs us that all 
 recent cases are kept in bed after admission for twenty-four hours at 
 least with the object of calming excitement, impressing the patient 
 with the hospital nature of the treatment adopted. On the second 
 day, some are allowed to leave their bed ; others are kept at rest 
 therein for weeks or even months unless they resent the treatment, 
 when it is modified in accordance with their wishes. Dr. Koenig 
 insists upon the necessity of adequate out-door exercise where this can 
 be borne ; but he by no means intends to indicate its indiscriminate 
 application to all cases of excitement ; his plea is one of moderation, 
 and he strongly repudiates extremes in either method of treatment. 
 We agree with him that it is often of service to take certain cases of 
 recent excitement out for an hour's walk, subsequently allowing them 
 to return to bed rather than to remain up among their fellow patients. 
 
 It is, we think, quite wrong to adopt any absolute rule for the 
 exercise and rest of recent cases ; each case must be treated on its own 
 merits, and the individualised treatment nowhere indicates its value 
 so empliatically as in its application to the exercise, recreation, em- 
 ployment, and rest afforded to recent cases of insanity. 
 
 That the surplus energy of the maniac should be carried off by 
 severe muscular exercise is a doctrine which, in recent cases at least, 
 may be carried to a very dangerous extent. In fact, the explosiveness 
 of recent mania and melancholia, as due to cortical instability, and the 
 withdrawal of higher control indicates a demand for the conservation of 
 energy so as to lead it off by channels directly subservient to the use 
 of the organism ; and by quiet, by nourishing food, tonic regimen, and 
 
 30 
 
466 THE TREATMENT OF INSANITY. 
 
 complete physiological rest to improve the nerve tone and central 
 stability. 
 
 Another fallacy which is introduced by extreme views upon exercise 
 in recent insanity is that the boisterousness, noise, and strugglings of 
 the acute maniac serve so far to demoralise the orderly discipline of a 
 ward and the domestic comfort of the inmates, that the resort to 
 sedatives is likely to be adopted, where, otherwise, they would not be 
 given ; in this case, the sedative becomes a form of chemical restraint 
 and is much to be deprecated ; infinitely preferable is it that the 
 patient should be isolated under such conditions, than that we should 
 be driven in recent cases to employ sedatives for such a purpose. 
 
 A diificulty also arises from the accumulation in our wards of the 
 excited chronic class, some of whom are at times utterly unfit for 
 associating with the recent and acute inmate. According to some 
 extremists, these patients, hopelessly insane as they are, should be 
 kept in association with others, however excited and noisy or violent 
 they may be, rather than be isolated for their prolonged paroxysms of 
 excitement. To this doctrine we can never subscribe ; fully recog- 
 nising as we do the vicious nature of isolation carried to an undue 
 extent, we must distinguish between the hopelessly incurable and the 
 recent case ; and we assert that the injury thus inflicted upon recent 
 cases by the irritation of such associates is incalculably greater than 
 that arising from any temporary isolation of the chronic class during 
 their most protracted outbursts of mania. 
 
 Amongst chronic cases, it is true, excitement may often be met by 
 employment and vigorous exercise ; but, even here, we must differ- 
 entiate between those who suffer and those who do not suff'er from 
 physical disability, from cardiac aff'ections, or serious cardio-vascular 
 degenerations so frequent amongst these cases. 
 
 Delusions. — It is a .fully recognised principle that delusive beliefs 
 and utterances are never to be met with directly adverse criticism, 
 and on no account is the physician or the nurse to oppose them by 
 hostile argument, but rather to ignore their existence, or at most to 
 refuse quietly but firmly to admit the delusive statements made. 
 The attention of melancholic patients tend to be far too engrossed by 
 their delusive beliefs and hallucinations to permit us to further 
 emphasise these states by encouraging discussion on the subject. 
 The primary object of the nurse should be to divert the attention from 
 all such themes, and to employ the energies in directions least likely 
 to foster self-engrossment, and least apt to recall morbid associations. 
 
 In this way we often find that association with other patients does 
 far more benefit than the isolation necessitated by a single charge. 
 The thoughtful nurse will encourage all that tends to distract the 
 attention from any painful theme by directly encouraging a healthy 
 
DESTRUCTIVE HABITS. 467 
 
 interest in their fellow patients, their assistance being sought for 
 wherever it can be legitimately accoi-ded. To the social nexus estab- 
 lished in this way under the comparatively novel circumstances of 
 asylum life in our wards, is to be attributed much of the improvement 
 which occurs in cases of melancholic depression and delusional perver- 
 sion. In eliciting the delusions of the insane for clinical purposes, it 
 is, therefore, wise to forego frequent discussion on the subject, and 
 these remai'ks apply especially to such delusions as tend to become 
 fixed, and those which show an early tendency towards systematisa- 
 tion — e.g., adolescent insanity, the melancholic delusions of the climac- 
 teric period, and those of alcoholic insanity. 
 
 In the former, solitary and vicious habits must especially be pre- 
 vented, and wherever possible, association both night and day is to be 
 strictly enjoined with the object of correcting or suppressing such 
 habits, which lead most certainly to hallucinatory conditions with all 
 their persistency and far-reaching consequences. 
 
 If, however, we recognise the primary systematised form of 
 insanity as the evolved psychosis, it matters little whether the 
 delusions be the subject theme of conversation or not, the delu- 
 sional perversion will steadily, but surely, progress to a hopeless 
 termination. 
 
 Destructive Habits. — Destructiveness in the insane may be the out- 
 come of JDure wanton mischief, a love of annoying others, or the act of 
 a passionate outburst, such as is so frequently seen in the epileptic or 
 congenital imbecile ; on the other hand, it is very often the outcome 
 of maniacal reductions, indicating the outflow of superabundant energy, 
 and so, likewise, is the restless excitement of dementia, whether senile 
 or paralytic ; lastly, it may be the result of sudden incontrollable 
 impulse after epileptic and alcoholic reductions, and especially in the 
 insanity of early childhood. Thus the dementia of general paralysis 
 is frequently accompanied by the destruction of clothing and bedding 
 during paroxysms of excitement ; epileptie furor, following upon 
 epileptic seizures, is often accompanied by extreme destructiveness 
 and other dangerous symptoms of a purely impulsive nature. As 
 illustrative of the destructive impulse may be quoted the case of an 
 adult male, a criminal lunatic, who would, ever and anon, be found in 
 his cell stark naked, with all his clothing torn to shreds at his feet. 
 On being questioned as to his motive, with a silly half-vacant smile he 
 would reply, "I don't know; I suppose I must have done it." He 
 was soon found to have had an attack of petit mal, and, subsequently 
 to his removal to an asylum, he would, without any apparent cause, 
 suddenly turn round and strike anyone near him full in the face. 
 When admonished, he would affirni with a complacent smile that he 
 could not help doing so. His condition remained uncorrected after 
 
468 THE TREATMENT OF INSANITY. 
 
 several months' treatment, both moral and therapeutic, and was purely 
 the outcome of the epileptic neurosis. 
 
 The incorrigible destructiveness of chronic mania is also a source of 
 much annoyance and outlay in our large asylums. 
 
 When we are dealing with mischievous and passionate outbursts, 
 moral treatment is a powerful adjunct; the threat to suspend all 
 indulgencies will alone suffice in many cases to arrest such tendencies. 
 The change to another ward, with the moral effect of new companions, 
 may effect the same result, and the isolation in bed with none but 
 indestructible clothing will prove sufficiently deterrent in other cases. 
 In the destructive tendencies of maniacal excitement on the other hand, 
 moral means are of little avail. The constant presence of the nurse, 
 her firm and repeated interference with such habits may be of avail in 
 some cases, but in the majority it is found absolutely essential to 
 supply the patient with strong indestructible dress material and 
 bedding, including well-padded ticking rugs, whilst the clothing must 
 be so secured as not to be readily removed or loosened by the patient. 
 Locked boots are also essential for these cases occasionally. The 
 impulsive forms of destructiveness such as occur in epilepsy and 
 alcoholism will likewise derive but little benefit from moral treatment; 
 extreme vigilance will have to be exercised, whilst the treatment 
 proper to the convulsive neuroses is being furthered. 
 
 A form of destructiveness, found not unfrequently in melancholic 
 states, and also in certain cases of dementia, is that of pulling out the 
 hair from the head till patches absolutely bare are found, or the whole 
 scalp is left bald. Some patients will pluck out hair by hair, and, if 
 not carefully watched, will swallow such ; large accummulations have 
 thus occurred in the stomach or intestinal tract. Idiots will occa- 
 sionally do this ; and we recall such a case where it was carried on so 
 stealthily at long intervals that a large mass of hair, agglutinated by 
 mucus, became impacted at the pyloi'ic orifice of the stomach, and led 
 to a fatal result.* In such cases we have no better resource, upon the 
 failure of moral suasion, than to adopt restraint, which is here fully 
 justifiable. 
 
 In chronic melancholia, again, we often find the querulous dis- 
 content express itself in such destructiveness ; the picking out of 
 threads, the tearing up of seams in the clothing, or the ripping open 
 of the bedclothes. Here much can be done by the soothing influence 
 of the nurse, who will endeavour at the same time to repress such 
 habits by distracting the attention into other directions. When the 
 
 *A similar case is recorded fully by Dr. Cobbold. The patient was an epileptic 
 diot, and the difficulties of detection, diagnosis, and tlie post-mortem conditions 
 were almost identical with our own case. Journal Mental Science, April, 1886, 
 p. 52. 
 
SUICIDAL TENDENCY. 469 
 
 symptom is the outcome of the abnormal flow of energy, as in most 
 cases of excitement, active muscular exercise out of doors, under the 
 charge of one or two nurses, will do much to arrest the tendency ; 
 excitement will thereby be often much allayed, and on the return of 
 the patient to the quiet of her room, a refreshing sleep may result. 
 
 Suicidal Tendency. — This tendency manifests itself in such varied 
 forms, and the means sought for the accomplishment of the act are so 
 diverse, that it is not to be wondered at that our efforts are thwarted 
 at times, despite the facilities which a large asylum usually commands 
 for the observation and control of the subject. The negative feeling 
 prompting to suicide need be by no means profound ; in fact, it may 
 only occasionally assert itself as a sort of slight intensification of the 
 prevailing depression ; or the subject may affirm that, when the 
 feeling arises, he has not the nerve to accomplish the act. It may be 
 constantly present and carefully concealed from the medical attendant, 
 or it may prove only too evident in tlie fixed, hopeless and painful 
 expression, and the furtive glance, and the incessant restlessness, 
 which are only too well recognised by the experienced observer. It 
 may display itself by determined and constant plotting to accomplish 
 its object, with critical periods of desperate efforts ; or, again, it may 
 prove purely convulsive and paroxysmal in nature, following upon an 
 epileptic seizure, or during the " horrors " of delirium tremens. It 
 jnay assert itself in long-continued refusal of food, violent resistance 
 to forcible feeding, kept up, it may be, for weeks and months together, 
 and often with attempts at inducing regurgitation after forcible feed- 
 ing. It will be readily admitted that under these varied phases the 
 treatment must be adapted to the individual case. It might be 
 thought that, in the majority of cases of determined suicidal tendency, 
 moral influences would prove of little avail. As a fact, however, this 
 is not the case, and experience teaches us how wonderfully beneficial 
 may be the influence emanating from a cheerful, sympathetic, firm, 
 and efficient nurse. The rapid change which often takes place in 
 these melancholic patients, when removed from inimical influences to 
 the care of a nurse endued with tact and discrimination, is one of the 
 most surprising and satisfactory experiences of asylum treatment. 
 
 It has been stated by Morselli, and noted by others, that certain 
 classes of tlie population adopt almost invariably the same suicidal 
 methods. It is so also in our insane community ; certain individuals 
 always choose by preference the same methods for accomplishing the 
 deed ; hence it becomes essential to learn, as far as possible, the 
 former tendencies of our case, and for the nurse to observe carefully 
 what are the special morbid proclivities of her charge, In all cases 
 alike, it will be well to remove at once all possible sources of peril- 
 ed., scissors, knives, needles, cord, matches, vtc. ; it may be necessary 
 
470 THE TREATMENT OF INSANITY. 
 
 to remove false teeth, and in desperate cases to cut the hair short, or 
 remove anything that may be used as a ligature. The windows must 
 be secured, so that no danger from precipitation need be feared ; the 
 open fire-places may need a guard, but the constant presence of the 
 nurse must be chiefly relied upon to secure the patient from the risk 
 of her impulses. It should always be remembered by the nurse that 
 her sympathy may be misdirected by constant reference to her 
 patient's painful mental states ; as in delusional states, the depression 
 must be.^more or less ignored, combatted by a constant cheerfulness, 
 every effort being made to induce an initiative on the part of the 
 patient. We have thus found good results accrue by affording such 
 subjects^the means of inviting and entertaining patients from other 
 wards, and playing the role of hostess for the nonce ; any such device 
 for distracting the attention from the prevailing egoism must prove 
 beneficial, and every sign of a returning initiative may be welcomed 
 as of good omen. Despite the close observation thus enjoined, it 
 must|invariably be the rule that the restriction of individual liberty 
 should be as inobtrusive as is compatible with safety ; and as soon as 
 good reason is afforded us for assuming that the suicidal feeling has 
 lost its hold, we should not neglect to indicate to our charge our 
 returning confidence. Unnecessary restrictions too long prolonged 
 are injurious, in so far that they both irritate and tend to destroy 
 the growing self-respect and assurance. With respect to entertain- 
 ments carried out on an extensive sale, our experience is not 
 altogether favourable ; for the chronic residents of a large asylum 
 the frequent dances, concerts, theatrical entertainments may serve 
 well to relieve the tedium vitce ; but as an auxiliary in the treatment 
 of acute insanity, such means must play a very secondary part in the 
 furtherance of our cures. If their role here be considered fairly, we 
 should avow that in many cases of depression they are decidedly 
 injurious when indiscriminately employed ; that they often impose 
 more suffering upon the subject ; and that, in most instances, they are 
 more beneficial in the later stages, when returning interest in their 
 surroundings indicates that convalescence has set in. We are strongly 
 of opinion that we cannot too carefully individualise and select our 
 subjects when the question of entertainment comes to the fore. In 
 like manner, the wise physician will very carefully consider the 
 advisability of permitting attendance on religious sei-vices, and 
 cautiously note their effect when they are permitted. 
 
 Treatment of Depression. — The diet should be nutritious and un- 
 stimulating ; alcohol is unnecessary in most cases of mental disease, 
 and positively injurious in explosive states and in epileptic insanity 
 in particular. In all forms where diminished control results in 
 morbid impulse, of the nature of obsessions, alcohol is practically 
 
TREATMENT OF DEPRESSION. 47 1 
 
 contra-indicated. It is of value where cardiac energy is greatly 
 impaired and exhaustion imminent, as e.g., in persistent refusal of 
 food, but even here it should be given in graduated doses according 
 to the reaction of each individual case; it is of value where depressant 
 drugs, such as chloral, have to be administered despite a failing heart 
 and impaired circulation. In long continued melancholic agitation, 
 with sleeplessness and emaciation, its use is often imperatively de- 
 manded ; in such cases, no one can dissent from Lauder Brunton's 
 view that it is a food in a certain sense ; it economises the proteid 
 metabolism. With the same object in view, we should insist on a 
 due supply of carbohydrates in the food, as tending to restrict proteid 
 transformation. In simple cases of melancholia, where there is little 
 tendency to tissue waste, our attention will be chieily directed to 
 maintaining the appetite, relieving torpor of liver and bowel, and 
 ensuring that the digestive and assimilative functions be duly per- 
 formed ; whilst we add to the dietary such elements as are 
 obviously indicated by the patient's condition, such as iron, arsenic, 
 the compound phosphates, cod-liver oil emulsion, and malt ex- 
 tracts. 
 
 It is worse than useless to give our subject a surplus of nitrogenous 
 food over and above his capacity for assimilating it ; we dare not 
 violate physiological rules so far, otherwise we load the bowel with 
 decomposing food and add to our patient's misery. In fact, by so 
 doing we disorder nutrition at its fountain head, and render auto- 
 intoxication a very serious probability. An abundant milk supply 
 should be our staple article of diet ; fish, meat, eggs should be given 
 liberally, with a varied vegetable diet at regular intervals and with 
 discretion. Where resistance to food occurs, compulsory feeding 
 must be enjoined, but only after every effort has been made by tact 
 and kindly persuasion to induce the patient to take food voluntarily. 
 Obstinate refusal must be met with determination and vigour ; three 
 meals a day should be given forcibly, and, in very exhausted states, a 
 lourth feed may with advantage be given late at night. It is by no 
 means unusual for deluded subjects to receive willingly from the 
 medical attendant or night nurse what the day attendant failed to 
 administer ; and, occasionally, a patient will take by stealth what she 
 obstinately refuses when offered to her. The question of removal 
 from home of mild forms of depression will depend chiefly upon the 
 social circumstances of the family ; if the means are forthcoming, a 
 private nurse may be engaged with advantage, but, even then, associa- 
 tion with the friends is not admissible. This is one reason why 
 residence away from home or travelling in single charge is often 
 essential. Even with suicidal tendencies, single charge, under a 
 thoroughly competent nurse, is not negatived. 
 
472 THE TREATMEXT OF IXSAXITY. 
 
 Depression at Puberty. — Hysterical symptoms in pubescent girls 
 often assume a suicidal feature ; usually the feeling is obtrusively 
 emphasised; there is a morbid plea for sympathy which is by no 
 means necessarily genuine ; removal to an asylum under these circum- 
 stances would often be felt as a lasting disgrace, and extreme delicacy 
 must dictate to the medical attendant the proper course to pursue. 
 Travelling in single charge or residence away from friends may be 
 enjoined here with advantage; but. it will at once be seen that the 
 poorer class cannot afford the cost which this implies, and must fall 
 back upon asylum treatment as the only resource. In such cases, the 
 tact and ability of the nurse will be tried to the uttermost. 
 
 Neurasthenia and Depression. — In the case of certain neurasthenic 
 subjects, the ordinary social obligations and conventionalities of life 
 become not only burdensome, but a source of constantly increasing 
 irritation ; it is eminently unwise to insist upon these functions under 
 such circumstances ; much harm may be done thereby, and great risk 
 run. The relatives will often strive to induce the siifFerer to over- 
 come his scruples by insisting upon attendance at religious services, 
 public amusements, or even by the performance of public functions, 
 despite the fact that he regards it in the light of mental torture; such 
 a stoical doctrine is, to say the least, irrational. A wise attendant 
 will at once remove all such sources of annoyance, will lead the mind 
 into other and more congenial channels of thought and action, and, 
 only when returning health demonstrates increasing self-assurance, 
 will it be wise to suggest a return to former conditions of life ; even 
 then the suggestion should be so framed as to appear to be the 
 patient's own desire. 
 
 JJelanchoIy with Stupor. — Apart from the general principles of 
 treatment above noted, these cases will derive much advantage from 
 the administration of baths — electric, shower, and spinal douche ; 
 whilst masso-therapeutics, shampooing, with the application of the 
 constant current to the scalp may be conjoined with advantage. These 
 cases, of course, demand great care and watchfulness to secure a due 
 amount of nourishment being taken, and to ensure the regular action 
 of the bowel and the emptying of the bladder. 
 
 In all cases of depression we endeavour, if possible, to secure 
 natural sleep before resorting to sedatives ; but delay is dangerous in 
 acute melancholia, and the symptoms are grave from the outset ; 
 the persistent refusal of food, the absolute insomnia, and acute 
 depression, entail such rapid wasting and exhaustion that we cannot 
 be too jjrompt in securing sleep even at the cost of sedative treatment. 
 Food must be given regularly, and, if necessary, with force; and, as 
 in the case of acute delirious mania, the patient must be treated from 
 the tirst as an invalid in a perilous condition. The removal of all 
 
EXCITEMENT OF GENERAL PARALYSIS. 
 
 473 
 
 sources of irritation, absolute quiet, a darkened room, free ventilation 
 of the sick room, a cool equable temperature, cleanliness, order, a 
 quiet, firm, and cheerful demeanour on the part of the nurse, will all 
 tend to influence the patient's mind, and to induce the natural repose 
 required. 
 
 The depression occurring at the climacteric and during lactation, if 
 of a mild character, may often be treated at home, or away from home 
 with a suitable nurse; should suicidal promptings be strong, however, 
 removal to an asylum will be most judicious. 
 
 Treatment of Excitement. — Most cases of excitement are still more 
 unsuitable for home nursin-r than is the ^ase with depression; mild 
 hysterical foruis and very early outbreaks of senile insanity, as also 
 puerperal and gestational forms, should all have the benefit of home 
 treatment when this can be conjoined Avith good nursing and safety. 
 The dangerous impulsiveness of puerperal subjects render them the 
 more anxious class to deal with in this way ; yet it is peculiarly desir- 
 able that a trial should be made ere resorting to the severe procedure 
 of asylum supervision. 
 
 Pubescent and Adolescent Insanity. — It is wise to resort to early 
 removal from home in these subjects; apart from the necessity of 
 breaking through associations, which often tend towards fostering 
 systematised delusions, we have to shield the patient from the results 
 of his own vicious habits, and from the dangerous impulsiveness to 
 which he exposes himself and his friends. In this form exercise and 
 employment are of vast importance, as is the case with all recurrent 
 seizures of youthful subjects; they aid in warding off self-contempla- 
 tion, brooding and morbid feeling, the nursing of delusional notions, 
 and the ill effects of hallucinatory states. Order, discipline, and 
 regularity of employment do much for these cases; whilst a nutritive 
 unstimulating diet, cold shower baths, and open air exercise are potent 
 adjuvants to treatment. Perhaps in no cases is isolation so vicious as 
 it is here ; it is equalled only by association with the chronic insane, 
 which is enforced by our modern methods of overcrowding and defec- 
 tive classification. Mimicry is rampant in these subjects; hence, the 
 sooner they are brought to employ their energies in useful out-door 
 employment which distracts their attention, the better. Amusements, 
 social gatherings, games of chance and skill, and athletic sports should 
 all be encouraged in these subjects, who otherwise spend their exist- 
 ence in isolation from their fellows and in morbid brooding. 
 
 Excitement of General Paralysis. — We can only deal with such cases 
 satisfactorily with the complete armamentarium of an asylum at our 
 command. The padded room is often required to obviate self-injury 
 from l)lind and aimless violence, and to secure them from the injuries 
 which manual interference would so often entail. In advanced cases 
 
474 
 
 THE TREATMENT OF INSANITY. 
 
 — noisy, struggling, degraded — the single room is an absolute neces- 
 sity, as is also the bed upon the floor to obviate falls. Wherever 
 noisy excitement is not so great a featiire, we may resort to observa- 
 tion night and day with benefit. Great precautions must invariably 
 be taken to avoid fractures of the ribs and other bones, which are 
 preternaturally brittle in this disease, and often in a state of extreme 
 osteo-porosis. It is scarcely necessary again to call attention to the 
 danger of bed-sores in these subjects, to the risk of overlooking a 
 distended and paralysed bladder, or to the treatment of destructive 
 habits so prevalent in this disease ; the principles already enunciated 
 should be strictly followed out here (see Destructive Habits). 
 
 Senile Excitement. — Much that has been said as to general paralysis 
 applies to these cases ; we have here to deal with frenzied excitement 
 at times, associated with great debility, often with serious cardio- 
 vascular afiections, renal degeneration, and all its accompaniments. 
 Only in very mild and early cases can we hope for success from treat- 
 ment at home; the padded room, the single room, or constant observa- 
 tion, and the frequent attention of the medical attendant are impera- 
 tively called for in all serious cases. For the insomnia of senile mania, 
 chloralamide and paialdehyd may be given with benefit ; the latter 
 preferably where digestive troubles are prevalent (see Treatment, p. 477). 
 
 In the later stages of senile decrepitude where excitement has been 
 replaced by mere restlessness, or apathetic dementia, ordinary prin- 
 ciples must guide our treatment, and, above all, is it important to 
 give a due amount of rest, and to intervene occasionally where alco- 
 holic stimulation seems desirable. 
 
 Alcoholic Excitement. — In the acute non-febrile form — mania-a-potu, 
 or acute alcoholic delirium — the cunning, treacherous, impulsive 
 violence, the delusions of suspicion and yjersecution, are the features 
 ever to be borne in mind, and they must be treated on the general 
 principles already enunciated (see Delusions, &c., ante). The excite- 
 ment and insomnia are best met by chloral, which is also our sheet- 
 anchor in the treatment of the febrile form of alcoholism or delirium 
 tremens. Duboisine has been given with success, but trional always 
 fails ; nor can we trust to cannabis for good results, nor yet to hyoscya- 
 mine, which relieves the excitement of chronic alcoholism (see Treat- 
 ment, p. 480). 
 
 Therapeutic Measures. — The treatment of insanity by drugs, 
 electricity, hydrotherapeutics, and other measures rests as yet upon 
 an unsatisfactory basis, in so far as it is to a great extent palliative 
 only, and, at the same time, empirical. Our remedies are very largely 
 applied to the treatment of mere symptoms, or we endeavour to 
 establish nutritive equilibrium ; or, again, we attempt the removal of 
 such disordered functions in other organs than the brain as may be 
 
THERAPEUTIC MEASURES. 475 
 
 1 
 
 regarded either as the direct outcome of centric disturbance, or even 
 as the possible exciting cause of the mental dei'angement itself 
 
 It is too early as yet to base our treatment (as many have done) 
 upon an assumed connection of mental derangements with various 
 visceral disturbances ; and though the latter afford indications for 
 treatment, we are far from recognising this principle as the basis for 
 a scientific treatment of the insanities. As we learn more of the 
 agencies which affect tissue metabolism ; when we can follow more 
 clearly the products of such activity — constructive or destructive — or, 
 when we awake from our ignorance of the toxines which pathogenic 
 organisms may develop in the system, we shall be nearing a time of 
 rational therapeutics. Physiological chemistry must therefore lead 
 the way towards this wished-for consummation. 
 
 AVe shall not attempt here to do more than merely indicate the role 
 of the more potent remedies used in the treatment of insanity, the 
 greater number of which are, of course, sedatives and hypnotics. An 
 attempt to treat of the applications of electricity, baths, massage, kc, 
 would unduly extend the space at our command, and we, therefore, 
 proceed to enumerate the chief remedies employed for the treatment of 
 insomnia, excitement, and depression arising in the course of mental 
 disease. 
 
 Chloral Hydrate. — The role of chloral in insanity is chiefly limited 
 to the treatment of sleeplessness in acute insanity, delirium tremens, 
 general paralysis, and the furor and convulsive seizures of epileptic 
 insanity. Its continued use in acute maniacal attacks is to be depre- 
 cated as highly prejudicial to ultimate recovery, but in acute melan- 
 cholic cases it has proved most serviceable. 
 
 As a hypnotic we, of course, possess in it a most valued agent, and 
 in all convulsive cases of excitement, such as alcoholic, epileptic, and 
 the excitement of general paralysis, we find it invaluable. In senile 
 cases, however, its role is far more limited, especially with well- 
 marked arterial degenei-ation and cardiac debility. In these latter 
 instances it should never be given unshielded by a sympathetic 
 stimulant, such as atropine or alcohol. Given in these cases with 
 stimulants, however, it is apt to produce severe headache next day, 
 although the powerful odour of the breath indicates that rapid 
 elimination is induced. In all cases whei-e we recognise cardiac 
 debility, difl'usible stimulants should be combined ; but it is wise 
 to discard its use for other hypnotics where there is arterial degenera- 
 tion, valvular disease, and a tendency to renal degeneration. Un- 
 doubtedly, it is of value in melancholia, not for continuous use but 
 for the insomnia, especially if the latter results from aural hallucina- 
 tions, and where these prompt to desperate suicidal attempts. In the 
 agitated form of melancholia we have seen much benefit accrue from 
 
476 THE TREATMENT OF INSANITY. 
 
 its use when combined with bromides and administered thus two or 
 three times a day, of course, in moderate dose. Here refusal of food 
 will often present itself, and forcible alimentation may be required in 
 addition. On the other hand, it is useless in delusional forms of 
 melancholia where the delusion prompts to the forced abstinence ; and 
 in acute mania, except that dependent upon general paralysis, alcoholic 
 insanity, and epilepsy, we should reject chloral, except as a hypnotic 
 for occasional use. 
 
 We have already alluded to its use in the gentle excitement of G. P., 
 with evidence of much cerebral excitation and grinding of teeth ; here 
 very small doses are most valuable. The rubbing off of the hair, the 
 boring of the head into the pillow, the heated scalp and flushed face, 
 and the tossing of the head to and fro, often accompanied by a sharp 
 cry, all seem to us to indicate its use. In like manner it may be given 
 in the restlessness of choreic insanity with undoubted benefit. 
 
 Its use as a hypnotic is also fully justified in chronic alcoholism 
 where delusions of persecution and acutely painful auditory hallucina- 
 tions render sleep impossible. In delirium tremens it is certainly our 
 sheet anchor. It is far preferable to opium, and should be given in a 
 full dose so as to obtain a long and refreshing sleep. Over and over 
 again have we seen the best results ensue from this treatment ; the 
 patient awaking from his slumber a new creature, rational, confident, 
 free from hallucinatory states, and practically in his right mind. In 
 fact, feeding and chloral are the chief agencies to be dependent upon. 
 The great loss of heat after chloral administration should always 
 be borne in mind; unless care be enjoined to prevent exposure, 
 pneumonia is very apt to supervene in debilitated subjects; and it 
 should specially be enjoined upon the nurse that all patients taking 
 chloral at night must receive extra attention in the way of clothing 
 when out-door exercising during the ensuing twenty-four hours. 
 
 The extreme value of this drug in epilepsy during the furor, or for 
 averting convulsions, or for the treatment of the epileptic status has 
 ali'eady received attention at our hands (see Epileptic Insanity), and it 
 remains only to observe that chloi'al will check the convulsions, wholly 
 or in part, according to the dose administered ; a small dose will 
 simply modify the discharge in its spread and intensity, where a 
 stronger dose would entirely arrest the convulsion. A prolonged Jwat 
 discharge has also been observed by us as the result of the convulsive 
 seizure being arrested — a sort of substitution of thermal for motor 
 phenomena. 
 
 Chloralamide. — -This is undoubtedly a most valuable hypnotic, free 
 from the unpleasant taste of paraldehyd, and from the disagreeable 
 tainting of the breath entailed by the latter. It is fairly prompt in 
 action, in this respect being superior to sulphonal {Gordon), but less 
 
THERAPEUTIC MEASURES. 477 
 
 so than chloral, usually in forty minutes to an hour. Very rarely are 
 unpleasant after-effects experienced, and certainly no digestive or 
 gastro-intestinal derangement ; nor is there any lowering of body 
 temperature. Chloralamide does not affect peripheral sensibility ; it 
 diminishes reflex action, but does not depress cardiac, respiratory, or 
 cerebral centres, nor is the blood-pressure notably lowered [Gordon). 
 As an analgesic it is of little or no service. 
 
 This druo- is of most service where chloral would be given were it 
 not contra-indicated by cardiac or vascular lesions, where valvular or 
 myocardial degeneration, or where renal disease with more or less 
 vascular atheroma intervenes ; here this drug may be given safely, and 
 often with the result of procuring a calm, deep, and refreshing sleep. 
 In the insomnia of melancholia generally, we have found it most 
 useful, but its value is also great in the wakefulness of alcoholic 
 insanity and general paralysis. It has by some been also lauded for 
 all forms of acute maniacal excitement. In senile insomnia its value 
 is undoubted. Either sul phonal, trional, or chloralamide may be given 
 in lieu of paraldehyd or chloral, in cases where laryngeal phthisis or 
 inflammatory conditions of the throat or stomach preclude the use of 
 the latter. It may best be given in similar doses to chloral in an 
 alcoholic stimulant in which it readily dissolves, but must never be 
 combined with alkalies or in hot solutions, as it readily decomposes 
 under these condition*. 
 
 Parcddeliyd. — Prompt in action, even more so than chloral, this 
 drug is a valuable hypnotic, producing in from five to twenty minutes 
 a calm, peaceful sleep, sometimes, however, preceded by slight excite- 
 ment. Unpleasant eftects, such as drowsiness, nausea, headache, rarely 
 occur. It has been shown by Gordon* that even in minute doses it 
 aids the peptone forming power of pepsine, always accelerating the 
 digestion of fibrin, whilst this process is notably retarded by chloral- 
 amide, sulphonal, and urethane. It, therefore, may be given with 
 more confidence than the latter during the period of food digestion, 
 It has been affirmed that the hsemoglobin is reduced by this drug,, 
 metlisemoglobin being produced; but this statement has been called 
 in question by Hayem. Like sulphonal and urethane it diminishes 
 peripheral sensibility ; slows, but strengthens, the heart's action ; and 
 does not depress the respiratory centre. It is, therefore, far better 
 adapted for cases of insanity complicated by organic diseases of the 
 heart and vascular degeneration than chloral, which should be avoided 
 here. It has, moreover, a powerful diuretic effect and has no poisonous 
 action on the tissues. 
 
 For the insomnia of senile mania, either it or chloralamide may be 
 given with great hope of success, and with no fear of disagreeable after 
 * Brit. Med. Joum., July 18, 1891. 
 
478 THE TREATMENT OF INSANITY. 
 
 effects. Its analgesic effect is so trifling that no reliance can be placed 
 upon it unless combined, as it then may be, with morphia. In simple 
 maniacal states it is a most valuable hypnotic, but not so useful as 
 chloral either in the mania attending general paralysis or epilepsy ; 
 and, despite the statements of certain authorities, we have found it far 
 less useful in acute alcoholism than chloral hydrate. It can be 
 administered at times advantageously jjer rectum. The great objection 
 to this drug is its pungent taste and the exceedingly disagreeable and 
 persistent odour of the breath, retained often over twenty-four hours, 
 a,nd similarly occasioned when the drug is administered by rectum. 
 
 Disulphones. — Among this group we have at least one most reliable 
 hypnotic. With respect to the individual merits of the three, sulphonal, 
 trional, and tetronal, the latter has failed to realise the theoretical 
 expectation that, having four ethyl groups to the molecule, its hypnotic 
 value would be far greater than the two former ; despite the contrary 
 view of Raraoni, clinical experience is generally adverse to this a jmori 
 dictum. Tetronal, however, is a good sedative {Scliaefer, Boettiger), but 
 is as little adapted as trional as an analgesic, or in cases where the 
 psychical and motor exitement are very severe. 
 
 We do not hesitate to regard trional as far the safer and best 
 hypnotic of the group for cases of mental derangement ; it is more 
 readily decomposed in the system and more rapidly eliminated than 
 sulphonal ; hence its action is more rapid (twenty minutes to an hour) 
 and effective, and its effects less prolonged ; the sleep is deep, dream- 
 less, and refreshing (six to eight hours or longer); not attended by the 
 early irregular respiratory rhythm seen when sulphonal or chloral 
 have been given, nor does it entail, like these, weariness, lassitude, 
 confusion, and dreamy states. Lastly, cumulative action has not been 
 observed, and only three or four cases are quoted (even these open to 
 doubt) where hsematoporphyrin has appeared in the urine ; nor has 
 any evidence been forthcoming to prove that the drug exerts any ill 
 effects on the bodily organs. 
 
 As a hypnotic we certainly have no safer remedy than trional in 
 most cases of sleeplessness from melancholic depression, either with or 
 without hallucinations, in neurasthenia and in epileptic wakefulness. 
 In CTeneral paralysis it is less useful than chloral ; and in alcoholic 
 delirium it almost invariably fails {Koster, Boettiger). We must 
 always bear in mind the fact that where neuralgic and painful 
 affections generally prevail trional is not the hypnotic to be given; or, 
 if it be for any special reason chosen, it should be combined with 
 morphia or some other analgesic. Owing to the fact that its beneficial 
 effect seems to extend to the next evening — a natural sleep being 
 usually obtained — some authorities {Krafft-Ehing, &c.) recommend it 
 to be given on alternate nights, or it may be varied, with benefit, by 
 
THERAPEUTIC MEASURES. 479 
 
 other hypnotics, sulphonal, paraldehyd, chloral, or chloralamide ; we 
 regard this as an important feature in treatment. 
 
 As to its more continued use, the most important role is, we think, 
 that advocated by Collatz * of giving small doses, say, 7 grains in 
 combination with opium in simple melancholia ; in this way most 
 valuable sedative results have ensued. Impulsive forms of insanity 
 are less benefited by it than by chloral or hyoscyamine, nor does it 
 act satisfactorily in the excitement of general paralysis. One great 
 feature is that no injurious action results in cases of cardiac debility, 
 or valvular aifection with failing compensation ; here, where we dare 
 not give chloral with impunity, we administer sulphonal or trional 
 with absolute confidence. Weir Mitchell has extended its role to 
 epilepsy ; it appears to arrest the fits when bromide is for a time 
 contra-indicated, or when temporary suspension during bromism is 
 called for. In like manner it has been found useful in the restlessness 
 of severe chorea associated with insanity. 
 
 The maximum dose of the drug should be considered to be 25 grains, 
 but 15 grains is usually effectual ; it should be administered in warm 
 milk or other fluid, or in warm spirits; and, should the effect be 
 unusually delayed, it may with advantage be given a short time before 
 retiring to rest. It is also important to note that it is equally effectual 
 when given ^;e?' rectum. 
 
 Hyoscyamine. — This powerful alkaloid, which is isomeric with 
 hyoscine and atropine, has been found of far greater service than the 
 last in the treatment of insanity. It was investigated and extensively 
 employed by the late Dr. Robert Lawson, and his essay upon the 
 physiological effects on the lower animals and man still remains the 
 most reliable and classic contribution to the subject.! He used it in 
 the form of Merck's amorphous extract, given either by the mouth or 
 subcutaneously. It, as well as hyoscine, has been employed very 
 extensively since this date, both in England and on the Continent, 
 and our views as to its efficacy are now fairly clear. 
 
 In moderate doses there is a primary lowering of the pulse-rate, 
 followed, subsequently, by a greatly increased rapidity which is long 
 maintained ; but if very small doses be given, the depressive effect 
 alone is witnessed and no stimulation occurs. If, on the other hand, 
 large doses be administered, immediate stimulation of the heart's 
 action takes place with no primary depression {Lawson). The physio- 
 lo'ncal results of a moderate dose are — well-marked mydriasis in from 
 three to five minutes, reaching its maximum in twenty minutes, and 
 slowly subsiding, it may be, for several successive days. The rise of 
 the pulse-rate is associated with a lowered respiratory rhythm, and a 
 
 * Berl. Klin. Woch., Oct., 1893. 
 
 t West Biding Aiylum Medical Reports, vol. v., 1875. 
 
480 THE TREATMENT OF INSANITY. 
 
 fall in body temperature. The mouth and fauces become dry at an 
 early stage, the secretions generally, with the exception of the renal, 
 are diminished ; as regards the latter, there is more or less diuresis. 
 Giddiness and drowsiness are apt to prevail, and sleep is prone to be 
 restless and disturbed. Mild excitement supervenes, attended with 
 rather vivid hallucinations of sight and hearing, and great motor 
 impairment affects the limbs. Speech is somewhat thick and char- 
 acterised by rambling incoherence. 
 
 Hyoscyamine has proved beneficial in reducing the excitement of 
 simple and recurrent forms of mania, and also the maniacal excitement 
 associated with epilepsy. It has been stated to have acted well in 
 reducing the number of fits in the epileptic status ; but in view of the 
 undoubted efficacy of chloral here, it is scarcely admissible for this 
 purpose, and our experience would be distinctly adverse to its employ- 
 ment. In chronic alcoholism it has been found useful, and in delusional 
 insanity not of an acute type it has been much lauded {Latvson). 
 Certain symptoms of insanity are well treated by this alkaloid, and the 
 greatest benefit has accrued from its administration in cases of incessant 
 garrulity or logorrhoea, in the restlessness of senile mania, and in 
 destructive tendencies, whether voluntary or incontrollable. The 
 disadvantage of the drug, which should always be borne in mind, is 
 the tendency to cause much dryness of mouth and throat, and to 
 impair appetite when given in single large doses; hence it is unsuitable 
 where forcible feeding is necessary, or where loss of appetite and 
 gastric disturbance prevail. It is, however, claimed for this alkaloid 
 that continued use is not attended by these unsatisfactory results. 
 Again, it should not be given where vascular disease is suspected, 
 especially where extensive atheroma exists. Two cases of haematemesis 
 appeared to be very clearly traceable to its administration under these 
 conditions. It must not be forgotten that its long-continued use 
 involves serious loss of body-weight. 
 
 So also in melancholia, it is decidedly objectionable, and has always 
 failed here in our hands. Whilst, therefore, its use is mostly restricted 
 to maniacal conditions, it is in the milder and sub-acute forms of 
 mania that it is of chief value ; in very acute excitement it is contra- 
 indicated and a fortiori in the form of acute delirious mania. As a. 
 hypnotic its action is far more powerful than atropine, but the alkaloid 
 hyoscine, which is stated to have five times the power of hyoscyamine 
 (Martindale),* is more suitable for this purpose in doses of from y-^^ 
 to _i- of a grain. The advantage claimed for hyoscine is the freedom 
 from after effects, and especially the absence of constipation incurred 
 (Ringer and Sainsbury)A Hyoscyamine is of great value for its moral 
 
 * Brit. Med. Journ., vol. ii., 18SS, p. 736. 
 
 t Dictionary oj PsycJiological Medicine, Hack Tuke, vol. ii., p. 1142. 
 
THERAPEUTIC MEASURES. 
 
 481 
 
 effect as an agent in the treatment of the criminal type of insanity ; 
 this was long since maintained by Lawson, and our further experience 
 of the drug certainly emphasises this opinion. Whether this result 
 ensues from the moral effect wholly is open to question; certain it is 
 that most impulsive forms of insanity of this class are benefited by 
 hyoscyamine, and the consciousness of the motor impotence induced 
 may well play the chief factor towards the favourable issue. 
 
 Savage regards Merck's extractive as a useful form of restraint in 
 violent and dangerous cases, "especially those that are very homicidal, 
 and those that, seeoiing to have lost common sensibility, dash them- 
 selves about and run serious risk of injuring themselves." * 
 
 Diiboisine, said to be identical with hyoscine, has been brought 
 forward as a powerful sedative in conditions of maniacal excitement. 
 Some authorities give the sulphate by injection in doses as large as 1 
 to 2 milligrammes twice daily ; but it is more prudent to limit the 
 dose to 1 milligramme = -001 gramme, to commence at 2 decimilli- 
 grammes = -0002, and rarely exceed -0008 gramme. When large 
 doses, such as -001 to -002 gramme, have been given, loss of appetite, 
 vomiting, and emaciation have ensued {Mongeri, (fee). 
 
 After subcutaneous injection of duboisine, mydriasis rapidly ensues, 
 the pulse rate is lowered, motor enfeeblement occurs, and a profound 
 sleep of several hours usually follows in suitable cases. 
 
 It has been given as a sedative in acute mania, chronic mania, acute 
 alcoholism, and general paralysis with favourable results; but Mendel 
 asserts that the drug acts by removing all restlessness, and not as a 
 direct soporific, and hence, whilst it is useless in melancholia, paranoia, 
 &c., it is very valuable in excitement with much motor restlessness, 
 unless the latter be due to hallucinations or delusions, f Mendel 
 administers it in doses of from 5 to 8 decimilligrammes. Duboisine 
 has also been given with the best results in hystero-epilepsy by 
 Albertoni and Belmondo, and also in paralysis agitans. 
 
 Our own experience is not in favour of its use as a substitute for 
 hyoscine ; the latter, or the hyoscyamine extract of Merck, is, in our 
 opinion, of greater value and more extended application. 
 
 Opium.— Our experience of the treatment of insanity by opium and 
 its several alkaloids demands from us the expression of unqualified 
 approval. Granting tliat the cases be carefully selected, we know no 
 drug in the pharmacopteia which is more directly valuable for the cure 
 of certain forms of depression. A fairly large exj)erience has now 
 indicated to us that opium — and opium alone — has any powerfully 
 curative influence over such melancholic reductions as are attended by 
 notable restlessness, mental disquiet, anxious fears, and depressing 
 
 * "Hyoscyamine and it.s Uses," Journ. Mental Sc, July, 1879, p. 18.3. 
 f Neiir. Central., February, 1893. 
 
 31 
 
482 THE TREATMENT OF INSANITY. 
 
 delusions. As a soporific, excejit where pain intervenes, we rarely or 
 never employ opium; we have far more valued remedies at our disposal. 
 Its rdle^ however, apart from its analgesic properties, is that of con- 
 tinuous administration in slowly increasing doses for the relief of painful 
 mental depression, though not for the depression characterised solely 
 by anergic and stuporose states. In these cases, then, of simple 
 melancholia, with much motor restlessness, opium or morphia will not 
 only relieve the depression, but will also often result in no disturbance 
 of stomach or bowel ; the appetite will often improve, and the bowels 
 remain free from constipation. The opinion that if given for any 
 length of time it invariably does harm by its effects on assimilation, as 
 stated by Ringer and Sainsbury, *' is directly contradicted by the 
 results of our experience in the treatment of depression, which, at all 
 events, should be excepted from the verdict. Owing to its effects on 
 the urinary secretion, many withhold its administration when albu- 
 minuria exists, and would strictly prohibit its use in confirmed renal 
 disease. We, however, fully subscribe to the opinion of the last-named 
 writers, that the dangers accruing from its use in these morbid con- 
 ditions have been much overstated. 
 
 On the other hand, in cases of maniacal excitement we find opium 
 nearly always inadmissible; it usually adds to the excitement, impairs 
 the appetite, deranges peristalsis; why its employment here is followed 
 by such totally different results we know not, but, as a matter of 
 clinical experience, such certainly appears to us an established fact. 
 
 In former days opium was given far more frequently as a soporific, 
 but even then it was taught that where excitement prevailed and 
 evidence of " cerebral congestion " was forthcoming it was contra- 
 indicated. At the present time we should wholly discard opium for 
 this purpose and fall back upon one or other of the more recent and 
 reliable hypnotics. We prefer giving the drug in the form of the 
 liquor opii sedativus, which is best tolerated by its admixture with an 
 equal amount of sulphuric ether, commencing with doses of 10 to 15 
 minims twice daily, increasing the dose to 20, 25, and 30 minims three 
 times daily, and rarely, if ever, exceeding 40 minims for a dose. 
 Bearing in mind the idiosyncrasies of advanced age we may safely 
 administer, in this manner, a maximum of 30 minims three times a 
 day, or an equivalent of 12 grains of solid opium. The tolerance 
 established for this drug is remarkable in states of mental depression, 
 and when, eventually, improvement in the symptoms supervenes, it is 
 strange to note how little tendency to habit is engendered and how 
 well the subject stands the immediate withdrawal of the customary 
 sedative. In fact, we can by no means reason from its operation in 
 the sane to its effects upon the insane mind. Should it tend to 
 * Tuke's Diet. Pnychol. Med., vol. ii., Art. "Sedatives." 
 
THERAPEUTIC MEASURES. 483 
 
 impairment of appetite, furred tongue, nausea, or constipation we may 
 with advantage substitute morphia subcutaneously, but we shall 
 obtain less of the stimulant effect of opium by this course. The 
 hypodermic administration of morphia is useful when the patient 
 refuses medicine by the mouth, and its prompt operation is one great 
 advantage in its favour. We should not, of course, think of giving 
 opium when there is marked derangement of tlie digestive organs 
 means should be adopted for restoring the tone and functional efficiency 
 of the digestive tract before commencing a course of opiates ; the 
 hepatic functions especially call for attention in this connection, and 
 it may be necessary to wash out the stomach, to administer a mercurial 
 purge, to give naphthaline, beta-naphthol, salicylate of bismuth, or 
 other intestinal disinfectant ere more special treatment be ado})ted. 
 It may be laid down as a rule that in all cases where forcible feeding 
 is required opium treatment should be postponed. 
 
 There are two affections where we should never attempt opium or 
 its alkaloids ; we refer to acute delirious mania and to general 
 paralysis. In the former, the adynamic symptoms are almost certain 
 to be increased to an alarming extent if opiates be given ; nor is even 
 a single dose as a hypnotic to be given here so long as we have such 
 reliable agents as chloral and the disulphones. In both tlie climacteric 
 and senile forms of melancholia. Savage speaks favourably of morphia 
 in conjunction with other agencies.* 
 
 Cannabis Indica. — Indian hemp has had a very extensive trial in 
 the treatment of insanity, and is undoubtedly a valuable sedative, free 
 from many of the objections attached to other remedies of this class. 
 In full doses the drug causes great exhilaration and a condition of 
 reverie with a train of mental and nervous phenomena of a most 
 pleasurable nature ; vivid hallucinations prevail, and the gay and 
 pleasurable state may appi'oach to a stage of ecstasy. Wood gives a 
 lively description of his personal experiences after taking the drug. 
 The above noted symptoms were followed by numbness, by " spells " 
 of partial unconsciousness to his surroundings, time was prolonged 
 indefinitely — seconds seemed hours, distance was exaggerated, and a 
 horrible sense of impending death supervened. Antagonism between 
 his feelings and will was noted, passing into unutterable despair.f 
 Many of these phenomena are experienced during the inhalation of 
 nitrous oxide gas; the prolongation of time, the exaggeration of sounds, 
 the feeling of utter helplessness and despair will be familiar to many 
 who have experienced the effects of this gas. The antagonism referred 
 to by Wood is in this case referred to an outside factor inimical to the 
 personality rather than of the nature of dual consciousness. The drug 
 
 * Iiisanity and Allied Neuroses, by Geo. H. Savage, p. 200. 
 + Treatise ou Therapeutics, Art. "Cannabis." 
 
484 THE TREATMENT OF INSANITY. 
 
 has a powerful diuretic effect, and this has been suggested as playing 
 an important part in the avoidance of bromism when cannabis and 
 bromide salts are given in combination. The breathing and circula- 
 tion are but slightly affected, and, although the symptoms of intoxica- 
 tion are so alarming to the patient, the administration of the drug can 
 scarcely be regarded as attended by any real danger ( Wood). 
 
 A great disadvantage attached to this remedy, as also to conium, 
 is the great variation in strength of different specimens, and the con- 
 sequent uncertainty of their action ; some specimens are quite inert. 
 Dr. Blandford found the extract vary immensely in efficiency.* 
 
 With respect to the therapeutics of this drug we have found it of 
 extreme value both as sedative and hypnotic in cases of maniacal 
 excitement ; but we have always administered it for this purpose in 
 combination with bromide of potassium (30 grains of the latter to 
 1 drachm of the tincture). Its role seems chiefly to be that of reducing 
 the excitement of chronic mania, more especially such cases as present 
 hostile, vindictive, and homicidal violence ; the drug appears in every 
 sense a deterrent, without inducing unpleasant and painful feelings, 
 and where the latter exist as the outcome of persecutory delusions a 
 calmative influence is distinctly manifest. We are of opinion that the 
 antagonism occurring in acute intoxication by the drug is mildly 
 represented in the continuous administration of the smaller doses in 
 insanity, and that a feeling of timidity and distrust of their own 
 powers is often engendered and leads to a healthier and more rational 
 adaptation in conduct. The class of patients to which we now refer 
 derive benefit from a long course of the " green mixture " as we term 
 the combination of bromide and hemp ; the appetite improves, the 
 body-weight is maintained, even if there be early loss, muscular tone 
 is not impaired, at the same time excitement abates, sleep is more- 
 uniform and complete, and the bodily functions are not disturbed. In 
 other forms of excitement, such as the restlessness of senile insomnia, 
 it is also advocated, and even for the sleeplessness of general paralysis 
 [Br, Russell Reynolds). We cannot say that we have confirmed this 
 latter statement, but are quite convinced that its use, as Dr. Reynolds 
 states, in cases of acute mania and alcoholic delirium is at least 
 restricted, if not absolutely contra-indicated. On one point most 
 authorities appear agreed; it is injurious in cases of melancholic 
 depression, especially if given in continued doses. 
 
 In epileptic mania, cannabis in combination with bromide is of the 
 greatest value, and, in fact, in the whole list of the explosive neuroses 
 this combination is most suitable. It also finds its rdle in the excite- 
 ment and vicious turbulence of imbecility ; still more so when the 
 subject is an epileptic. It will be seen from what preceded that, like 
 • Insanity and its Treatment, 4th edit. , p. 440. 
 
THERAPEUTIC MEASURES. 485 
 
 hyoscyamine, we find cannabis most serviceable in chronic and incur- 
 able forms of insanity, and that to a certain extent it is interchanf^e- 
 able with the former in the treatment of these forms of disease. 
 
 It is well known that cannabis in the form of hashisch is the cause 
 assigned for a large proportion of the insanity of the asylums in India 
 and elsewhere; thus at the Cairo Lunatic Asylum Dr. Sand with found 
 that out of a population of 226 males and 62 females, there were as 
 many as 23 recent cases under treatment for hashisch, and 150 other 
 chronic dements whose insanity was traced to the same cause.* 
 
 It is of interest also to note that Dr. Sandwith alludes to the ever 
 increasing timidity 0/ those accustomed to its continuous use, and which 
 may partly explain the moral influence which this drug certainly 
 exerts in subjects of chi'onic mania. 
 
 Conium. — This drug was formerly used far more extensively than it 
 is at present, and its disuse probably is accounted for on the same 
 grounds which led to its discontinuance by ourselves, viz., its extra- 
 ordinary variability in physiological operation, and the absolute 
 uncertainty of numerous samples of the drug vended. Frequently the 
 preparations were quite inert, no trace of the usual physiological 
 effects being presented when large doses were administered. 
 
 This uncertainty of operation has proved fatal to its retention as a 
 depresso-motor for cases of insanity, in view of the far readier and 
 more certain effect of other agents which may now be employed. Its 
 physiological action is slowly established even under large doses ; the 
 pupils dilate, vision may be disturbed from paralysis of accommodation, 
 some giddiness may be experienced, but the most marked symptom is 
 great languor and muscular debility, arising from paralysis not of the 
 trunks of the motor nerves so much as of the motor end-plates. The 
 influence on the circulation is trivial, the pulse, at first depressed, 
 becomes somewhat quickened. The sensory nerves are not affected by 
 medicinal doses; if lethal doses are given, tingling, numbness, and 
 formication have been complained of. 
 
 We have found this drug of value in simple mania, and in no other 
 form of mental disturbance. When a trustworthy sample has been 
 secured it certainly diminished the restless activity of the subject, 
 had a powerful calmative influence over the excitement, and fostered 
 the tendency to sleep. We have always administered this drug in the 
 form of succus conii, and in doses of two to six drachms two or three 
 times a day. The alkaloid has also been given subcutaneously and 
 apparently with much success by some. We have, personally, no 
 experience of its administration in this form. 
 
 * Joum. Mental Sc, vol. xxxiv., p. 482. 
 
486 
 
 PART III.— PATHOLOGICAL SECTION. 
 
 General Contents. — Morbid Condition of Cranial Bones— Investing Membranes — 
 Brain Substance— Histological Elements of Cortex — Forms of Tissue Degradation 
 — Pathological Anatomy of General Paralysis, of Epilepsy, and of Chronic 
 Alcoholism. 
 
 GENERAL PATHOLOGY AND MORBID ANATOMY. 
 
 Contents.— 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 — 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 Cranium. — 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 subperiosteal 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 ; SUbaCUt© 
 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 
 
THE CRANIAL BONES. 487 
 
 of chronic insanity.* The inner surface may exhibit protuberant 
 bosses, frequently coinciding with subjacent atrophy of brain-sub- 
 stance ; whilst the grooving of the vitreous table is converted into a 
 deep channelling, extending almost to the cancellated structure, and 
 bridged over here and there by newly-formed bony tissue. The 
 hyperostosis is generally disposed over the whole of the vertex, but 
 is almost invariably 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 occipital 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 1,565 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 33-4 per cent. 
 
 The diminution in the thickness and density of the cranial vault is 
 most usually seen in senile atPOphy ; 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 co-existence of the former with hypertrophic thick- 
 ening, and induration of the latter (^Rokitanshy). 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 moi'e 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 lamellee with radiating canaliculi, 
 and devoid of blood-vessels ( Virchow, Gornil and Ranvier). All these 
 
 * " Hyperostosis almost always presents itself in both its forms, namely, that of 
 deposition externally upon the 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 uncommonlj- 
 thick (9 lines to 1^ or 2 inches), but it also act^uires a weight tliat is ahuost 
 incredible.'" — Pathol. Anal., liokitansky, vol. iii. 
 
488 MORBID STATES OF THE INVESTING MEMBRANES. 
 
 indicate "an extinct localised inflammatory 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 tlie 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 
 there is undoubted atrophy of the brain, is not unfrequently one of 
 abnormal tenuity."* 
 
 Exostoses and bony spiculse are exceptionally rare in those dying 
 insane. Dr. Bucknill states that such outgrowths were found by him 
 in but three cases out of 400 subjects. Our own observations would 
 tend to render them of even less frequent occurrence ; since out of a 
 total of 261(3 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 ])Osition 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 first, by morbid processes in the 
 two layers. Inflammation, for instance, attacks one of the layers 
 independently of the other, and presents difierences 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." f 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 aPachnoid CystS within the cavity embraced 
 between dura and visceral arachnoid. A certain number of patho- 
 logists regarded their origin as hSBmOPPhagiC, pure and simple ; 
 another class viewed them as products of true inflamitiatOPy 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 
 to these inflammatory exudates. With Axel-Key, and Retzius, we 
 would describe a visceral arachnoid only, so that the structures and 
 
 * Psychological Medicine, Bucknill and Tuke, 3rd edit., p. 566. 
 t "Pathological Anatomy," Syd, Soc. Trans., vol. iii., p. 323. 
 
MORBID STATES OF THE DURA. MATER. 489 
 
 spaces formed between the cranial bones and the brain would be from 
 without inwards — (a) dura mxater ; (b) sub-dural space {formerly the 
 " arachnoid sac " ) ; (c) arachnoid ; (d) sub-arachnoid cavity ; (e) pia 
 mater ; (/) epicerebral space. 
 
 It must be remembered that this tough tibrous 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 nei'vous filaments (Buret). 
 
 Adhesion, to a morbid degree, betwixt this membranes 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 sti'ong 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 moi'e 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 inflammatory 
 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 with the true arachnoid or to be liable to adhesive inflam- 
 matory states. Rokitansky has aflirraed 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 ditficult to remove the brain without injuring the 
 organ ; hence, the skull-cap with its attacl>ed dura have to be removed 
 together. On attempting to separate it from the bones in these 
 ■extreme forms, we fail to do so, as the membrane tears into shreds 
 or splits up into layers, leaving irregular white glistening membranous 
 lamellae, strongly contrasted with the rosy or deeper-tinted bone 
 
 * See also on this point Dr. Bucknill: PnyrJiological ^fedicinl:, Buckiiill and Take, 
 p. 568. 
 
490 MORBID STATES OF THE INVESTING MEMBRANES. 
 
 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 2616. 
 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 hypersemia) 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 degrees 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-cerebritis, which 
 subsequently reveals itself in morbid adhesions betwixt the brain and 
 soft membranes. 
 
 It is peculiarly frequent in those prone to alcoholic intoxication 
 (^Rokitansky, Griesinyer), 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. | In the insane community 
 generally, we have found arachnoid opacity prevails to a notable degree 
 ■ — 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. 
 
 * "A similar structure, constituting an unique specimen of anatomical variety, 
 is exhibited in the skull of a female belonging to my collection" [Bhivienbach) . 
 
 tFor the histological changes of the pia-arachnoid evoking the milky opacity 
 seen in insanity, cf. article hy Dr. Robertson, Jour it. iVJeiifal Sc, Oct., 1895. 
 
 J " It may be generally considered as the result of former chronic hyperaemia and 
 inflammatory stasis ; it according!}' 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' health}'. " Griesinger on 
 "Mental Diseases," Syd. Soc, 1867, p. 418. 
 
MORBID STATES OF THE PIA ARACHNOID. 49 1 
 
 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 oedematous swollen condition of 
 the conjoined soft membranes, and the trabeculee 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 arachnoid, 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 genei'al paralysis of the insane.'" 
 
 The conditions above referred to of opacity with 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 miist be borne in mind that this sub- 
 arachnoid cavity is continuous witli 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 aft'ect 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 7nortem 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 cj'sts. 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 
 from asylum experience ; there can, we think, be little or no doubt 
 
 * See " Degenerative Lesions of the Arterial System," by Cecil F, Beadles, 
 Journ. Mental Sc, Jan., ISQ"), p. 45. 
 
492 MORBID STATES OF THE INVESTING MEMBRANES. 
 
 that, in the case of tliose dyiug insane at least, we must claim a 
 hSBmOPPhag'iC OPig"!!! for such 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 paralysis, is emphasised by the occurrence of 
 30 instances in a series of 242 general paralytics (a percentage of 12). 
 The appearances presented by them vary considerably with the stage 
 at which they are found. In early stages we may find a slight 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 fossae (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 oflfas 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. 
 JElokitansky'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 the sac are 
 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 lymph is gradually removed, the inner surface of the sac becomes 
 smooth and polished, and the contents are changed into a colourless, thin, clear, 
 serous fluid." t 
 
 We have never observed what the same authority states is of 
 occasional occurrence — viz., the ossification or formation of bony plates 
 
 * See " The Pathology of Sub-dural Membranes," by Ford Robertson, Journ. 
 Mental Sc, vol. iv., July, 1896. 
 fOp. ciL, p. .330. 
 
ORIGIN OF ARACHNOID HAEMORRHAGE. 
 
 493 
 
 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 ; (a) the dura is not thickened or 
 softened, or vascular ; (b) no organic connection exists betwixt the 
 two. 
 
 3. In early 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 haemorrhage fre- 
 quent — 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 
 yeai-s — 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 fitty-nine 
 cases of arachnoid cyst, occurring at the West Riding Asylum, has 
 clearly established the vast preponderance of this accident in cases of 
 general paralysis, as seen in the following table : — 
 
 FIFTY-NINE CASES OF ARACHNOID CYST. 
 
 General paralysis affords 
 Chronic disorganisation of brain 
 
 
 
 29 
 16 
 
 Senile atrophy 
 
 Epilepsy .... 
 
 Mania associated with chorea 
 
 
 
 4 
 3 
 2 
 
 Mania with meningitis 
 
 
 
 2 
 
 Insanity with Bright's disease 
 Chronic mania with phthisis 
 
 
 
 2 
 
 1 
 
 59 
 
 As regards sex, it is recognised as occurring more frequently in men,, 
 from very obvious reasons ; the most important being the greater 
 
 * Dr. Lawson's statement is to the following effect: — "Amongst the sane, 
 amongst drunkards, and in cases where injiiry has induced pachymeningitis 
 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 hiematoma in the insane, originate in direct 
 rupture of vessels and extravasation into the arachnoid sac." {Brit, and For. 
 Med, Chir. Review, 1876.) 
 
494 
 
 MORBID STATES OF THE INVESTING MEMBRANES. 
 
 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 Crichton-Browne, and these, arranged as 
 to associated cerebral states and sex, illustrate forcibly the foregoing 
 statements : — 
 
 SEVENTY-THREE CASES OF ARACHNOID CYST. 
 
 General paralysis afforded instances in 30 Males and 4 Females. 
 
 Chronic disorganisation of the brain 
 
 „ 1'-^ 
 
 „ 7 
 
 Senile atrophy 
 
 Epilepsy .... 
 
 Mania .... 
 
 Melancholia 
 
 „ 6 
 
 „ 3 
 
 2 
 
 „ 1 
 
 2 
 
 ,, 1 
 
 2 
 
 „ 2 
 
 Idiocy 
 
 ,. 1 
 
 
 55 
 
 18 
 
 On summarising both series we have 132 instances of arachnoid 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 per cent., in 
 several other forms of mental ailment. 
 
 The site of haemorrhage is almost exclusively confined to the vertex 
 and lateral aspects ot 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 fossse 
 at the base. 
 
 The left hemisphere is more frequently the site of the hsemorrhage 
 than the right, as indicated in the sixty-five more recent cases 
 ■extracted from our records. 
 
 SITE OF ARACHNOID HEMORRHAGE IN SIXTY 
 
 Both hemispheres generally covered above 
 Left hemisphere ,, ,, ,, 
 
 Right hemisphere ,, ,, ,, 
 
 Right parieto-occipital region 
 Right frontal region 
 Anterior fossa at base 
 Anterior and middle fossEe . 
 
 •FIVE CASES. 
 
 28 
 20 
 11 
 2 
 1 
 1 
 2 
 
 65 
 
 The extravasation most probably occurs from a vessel of the pia 
 mater, the vessels of which in general paralysis show very special lesions 
 forming one of the most constant changes in this aflfection. Tlie 
 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 
 which have undergone most change are decidedly those in the an- 
 
ADHESION OF PIA TO CORTEX. 495 
 
 terior regions of the brain, coinciding with the more frequent site 
 of these arachnoid hfemorrhages. The arteries coursing within the 
 sulci are, of course, better protected by the support they receive, than 
 the veins distributed over the exposed surface of the gyri ; at the 
 summits of the gyri there is evidence of inflammatory activity, well 
 marked in the presence of meningeal adhesions. The vascular 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 : — 
 
 {a) The initial diseased condition of the vascular tunics. 
 
 (6) The distended condition of the venous system from atrophy, 
 and consequent loss of support, and obstructive conditions due to 
 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 thickeniiig of 
 the soft membranes, the presence of effused 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 
 pathologist. In a sinall jiercuntage of cases only is this important 
 sign absent ; but in such exceptional 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 we have 
 to deal with the general leatures presented by such adhesions in this 
 and other forms of mental disease. I find from Dr. BuUen's statistical 
 compilation from our West Riding Asylum Records, that out of 1,565 
 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 
 
496 THE MORBID BRAIN IN INSANITY. 
 
 fatal, 186 (or over 77-1 per 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 tearing awaij 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 through the cortex in genuine cases of adhesion ; 
 but we do not find in the alcoholic's brain, as a rule, anything move 
 than this undue firmness of union. 
 
 On attempting to strip off" 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. When forcibly removed, the upper 
 layers peel away to varying depths upon the pia, leaving an eroded 
 surface which presents a highly characteristic aspect. The surface 
 looks gnawed or worm-eaten along the length of the gyri with irregular 
 sinuois 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 diffused, 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 oedematous. 
 The distended vessels are coarse and tortuous, their sheaths thickened 
 by multiplication of their cells and the traversing of their structure by 
 wandering leucocytes. The microscope reveals infiltration of the cortex 
 by large numbers of i)eculiar spider-like cells — oval, flask-shaped or 
 fdobose — but all throwing off" numei-ous 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 layers of the cortex, immediately beneath the 
 adherent pia, forming a direct connection with its under surface 
 
MORBID VASCULARITY OF THE CORTEX. 497 
 
 and the vessels passing from it into the substance of the brain. 
 Around the walls 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 nutrient 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 observers 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 (PL xxiii., Jiff. 1), and had recognised 
 their existence in other morbid conditions ; *'" in fact, they repre- 
 sent 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 whicli 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 afford 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 mesh works as their sole representative. 
 In chronic alcoholism, again, such products of morbid activity present 
 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 
 effete 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-CerebPitiS, attended by much 
 effusion into the vascular slieath, 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 
 
 *Froc. Roy. Soc, No. 182, 1877. 
 
 tSee in this connection "The Morbid Changes of the Aged Insane," l)y Alfred 
 W. Campbell, M.D., Journ, Mental Sc, Oct., 1894, p. 64.5, in which an attempt 
 is made to distinguish the typical senile spider cell from that of general paralj'sis 
 and of alcoholic insanity. 
 
 32 
 
498 THE MORBID BRAIN IN INSANITY. 
 
 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 excessively soft, at the basal aspect of the cerebrum, in 
 no way reproduces the appearance of the eroded cortex in general 
 paralysis. 
 
 The bPain-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 wondrously 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 pui'pose of bringing into immediate contact with the surface of the 
 brain a very lai'ge amount of venous blood j 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 dii-ect obstruction offered 
 to the too speedy flow towai'ds the heart; an obstruction which even 
 leads to a hypertrophic state of the tissues in this immediate neigh- 
 
MORBID VASCULARITY OF THE CORTEX. 499 
 
 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 
 an;emia, when, of course, unconsciousness supervenes. Sleejj is an 
 instance of a rhythmic interference with this condition ; and the 
 agency whereby the antemia 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 i-esult 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 anjemia 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 bi'ain 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 post-mortem examination greatly 
 modifies the appearance of the cortex and white mattei*, 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 thi-ough 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 
 obstruction or obliteration of the pulmonaiy blood-vessels — e.g., ex- 
 tensive new growths in the mediastinum, copious pleuritic eftusions, 
 constriction from various causes of the roots of the lungs, fibroid 
 
 * "The common thickening of the membranes over the upper surface of tlie 
 brain, increasing towards the longitudinal sinus, is explicable by tlie mechanical 
 congestion that must be favoured there, through the current of l)lood from the 
 cerebral veins entering the longitudinal sinus against the course of tlie stream 
 within the siiuis. The check so caused to the entering stream will have most 
 effect on the part of the stream tiuit 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 lience these will feel the check more 
 than the distant parts, and will tend to be held all one's life in a state of meclianical 
 . congestion of mild degree " [Lecture.^ on Analytical Palholo<iy. Moxou). 
 
500 THE MORBID BRAIN IN INSANITY. 
 
 induration of lung, &c. Eokitansky 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-stuporose 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 haemorrhages 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 
 gangrene 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 affected 
 is obvious from the researches of Mosso, who remarked that in the 
 case of his patient, when asleep, the slightest sound, such as the tick of 
 a watch, or 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 
 
 * " Pathological Anatomy," Sydenham Soc, vol. iv., pp. 372-3. 
 t See also a similar case reported in the Lancet for January 11, 1879, by 
 Dr. Coupland. 
 
MORBID VASCULARITY— CEREBRITIS. 50 1 
 
 Such an obsei-vation 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 tliose 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 
 frequently in the medulla in similar cases;" and we still regai-d it as 
 probably 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 Niemeyer has 
 stated) form a most unsafe criterion to accept of congested states of the 
 brain, f Since, then, the appearances above detailed are occasionally 
 the sequence of otlier than morbid states, how are we to deal with 
 their significance as morbid signs 1 The reply is, in the presence of 
 rjiinute extravasations, in the coarseness or evident disease of the small 
 
 * The Human Brain : MelhofU of Examiiiution, p. 52, 
 t Text-book of Mtdicine, Niemeyer. 
 
502 THE MORBID BRAIN IN INSANITY. 
 
 vessels, in the existence of much oedema 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 
 larger number of cases afford evidence of poverty of blood in the brain 
 and 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 hyperpemia. 
 We find conditions of patchy pallor mottling the cortex, or a uniformly 
 diffused pallor, or, not by any means infrequent in cases oi melancholia, 
 a notable pallor of the carotid areas 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 anaemia 
 met with in the insane are cases of chronic phthisis, unfortunately so 
 frequent in asylums. The pallor is a most striking feature, and is due, 
 of course, to general bloodlessness throughout the system. So also as 
 the result of severe haemorrhage, as in the post-partuvi haemorrhage 
 which may usher in puerperal insanity, this condition of blanching 
 will be found present. Intracranial pressure, again, such as results 
 from sanguineous apoplexy, the. presence of adventitious growths, 
 or excessive development of interstitial connective {neuroglia^ may all 
 lead to notable anaemia by forcible exclusion of blood from the cere- 
 bral 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 affection of the 
 
 brain we have had no experience of amongst the insane • on the other 
 hand, 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 iis^ 
 the result of an embolon or thrombus of a cerebral blood-vessel, which 
 has given rise to much punctiform haemorrhage around, or to haemor- 
 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 
 
INDICATIONS OF CEREBRITIS. 503 
 
 variable in its consistence up to the extreme degree of diffluence ; it is 
 usually of bright pink hue, with streaky or punctated hemorrhages 
 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 oedematous 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 different 
 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-detined 
 lamination. The arterioles of the cortex are frequently and notably 
 coarse and engorged. The substance of the cortex is much reduced in 
 consistence, and oedematous ; 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, tlu^ naked-eye appear- 
 ances 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. 
 
 Softening". — Out of 853 cases of insanity proving fatal, .'590 
 aff"orded instances of an increased consistence of brain or one 
 of average firmness ; the remainder were noted as having a 
 diminished consistence throughout. The actual figures were as 
 follows : — 
 
504 THE MORBID BRAIN IN INSANITY. 
 
 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 pai*alysis, 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 resti-icting 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 
 furthered by, diseased arterial tunics ; and, lastly, the inflammatory 
 processes, which are of a chronic diff'use nature, are, we believe, in 
 themselves vascular in their origin. Hence we see how 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 
 apart at the commissural junctions, the diverging hemispheres tending 
 by the mere eff'ect of gravity to tear the latter asunder, especially as these 
 commissures are themselves unduly soft. The hemispheres have lost 
 their plum]) contour ; the convolutions may have undergone consider- 
 able atrophy, and their widely-gaping sulci may enclose much serous 
 fluid ; whilst the whole brain feels flabby to the touch, and devoid of 
 its normal compact aspect, as well as of the firm and resilient feel of 
 healthy structure. In the ventricles 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 
 
CEREBRAL SOFTENING. 505 
 
 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 diffused congested zones, stained with hpematine, 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 interior, 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 
 cerebral is far the more frequently affected ; next to this, but with 
 far less frequency, the posterior cerebral areas suffer ; and least 
 frequently of all, the areas supplied by the anterior 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 postei'ior and internal branch. This 
 may be more clearly represented in the following tabulation — 
 
 Anterior Cerebral. Miiklle Cerebral. Posterior Cerebral. 
 
 Middle and internalfrontal Parieto-sphenoidal artery Occipital artery. 
 
 artery. Ascending frontal ,, Anterior and posterior 
 
 Anterior ,, ,, ,, Ascending parietal ,, temporal artery. 
 
 Posterior ,, ,, ,, E.xternal and inferior frontal ,, 
 
5o6 
 
 THE MORBID BRAIN IN INSANITY. 
 
 Fig. 21. — Illustrative of the more frequent site of localised softenings in 
 order of precedence. 
 
 In 149 cases of localised lesions, the convolutions most frequentlv 
 affected, and medullated centrum would run as follows in like order of 
 precedence : — 
 
 1. Upper teniporo-sphenoidal gyrus. 
 
 2. Occipital and cimeate ,, 
 
 3. Ascending frontal ,, 
 
 4. Postero-parietal ,, 
 
 5. Centrum ovale = not defining as to 
 
 anterior or middle frontal territorv. 
 
 6. Annectants. 
 
 7. Angular and supramarginal. 
 
 8. Orbital. 
 
 9. Insula and operculum. 
 
 10. Fusiform and uncinate. 
 
 11. Gp'us fornicatus and quadrate 
 
 Fig. 22. — Illustrative of the more frequent site of localised softenings in 
 order of precedence^ 
 
 A further analysis of 166 cases of localised or focal softenings (due 
 either to thrombosis, embolism, or to hsemorrhage) in the substance of 
 the basal ganglia, and their medullated capsules indicate the respective 
 
LOCALISED SOFTENING. 
 
 507 
 
 proclivity to such lesions in the insane to be as follows : — The left 
 hemisphere is in all instances of ganglionic lesion, slightly more prone 
 to implication; the intraventricular nucleus is far the more frequently 
 affected, the oj)tic thalamus comes next in frequency, but the propor- 
 tion does not rise beyond two-thirds the latter ; the extra ventricular 
 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. '23. — Ilhistrixtive of the more frequent site of localised aofteniiigs in 
 order of precedence. 
 
 Of the 166 cases of softening from which these data are obtained, 
 thirty-four were instances of hiemorrhage, and the remaining number 
 were the results of clot, usually thrombosis. The results agree, there-, 
 fore, in every particular with those arrived at from a study of the 
 locality of cerebral hieniorrhage, for it has been shown by Andral and 
 Durand-Fardel, that tiie corpora striata are more frequently the site of 
 haemorrhage than the tlialami ; and Charcot expresses his opinion that 
 
508 THE MORBID BRAIN IN INSANITY. 
 
 next to the opto-striate bodies, the claustrum is the more frequent 
 site of lesion.* Whatever be the origin of the cerebral hsemorrhages 
 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 thi'ombosis, as in cases of hsemorrhagic foci. 
 
 Atrophy. — Wasting of the grey and white medullated 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 paritaZ, 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 slow and insidious progress ; or the 
 steady progressive dissolution implicating the whole cerebrum, which 
 distinguishes the atrophy of premature senility. The intimate structure 
 of the central 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 corcical 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 woi"ds, 
 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 more dependent 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 very 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 products of nerve disintegration ; the 
 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, 
 * Localisatioivi in Cerebral Diseases. 
 
CEREBRAL ATROPHY. 
 
 509 
 
 and lung ; but the presence of the nervous element establishes a much 
 more complete mutual dependence of parts. This inter-dependence of 
 the structural elements of the cortex, due to its terminal system of 
 arteries, is of primary importance to us in correctly appreciating the 
 morbid appearances ])resented 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 
 are 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 primary parenchymatous (oinginating in the nervous 
 element), or interstitial (spreading from the neuroglia 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 in 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 cerebral cortex occurring in patho- 
 logical sequence is often, but by no means invariably, associated with 
 a degeneration of its nutrient vessels, and wdien these vessels are 
 involved it is to a very varying degree. Yet what is invariably found 
 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 paren- 
 chymatous degeneration ; the jirimary change is initiated in the 
 nerve-cell. 
 
5IO THE MORBID BRAIN IN INSANITY. 
 
 Other foi-ms 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 role 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 effete material 
 so produced, demand from the lymph-connective system more than its 
 capabilities can accomplish; tne result is a temporary hypertrophy 
 •of this tissue, the multiplication of its active elements {phagocytes) 
 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 nrrvous centres. Long continued or 
 oft repeated excitement inducea a similar state of atrophy, as seen in 
 most fatal cases of chronic insanity. 
 
 A frequent cause of localised shrinking of the brain-substance is the 
 destruction and cicati'icial condensation of tissue in hsemorrhagic 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 affected 
 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 
 Meynert. 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 
 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 hsemorrhagic cavity with 
 dense sclerous walls implicating the corpus dentatum, was asso- 
 
 * See descriptive summary with illustrations of this case by Dr. H. C. Major, 
 Journ. Mental Sc, Jul}', 1879. 
 
CEREBRAL ATROPHY. 
 
 511 
 
 •ciated with degeneration of the olivary body of the opposite side 
 {Dudley).^^- 
 
 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. 24.— 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 thi-ee-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) wei-e thus affected in thirty-three and twenty- 
 nine cases respectively; then followed the temporo-sphenoidal and the 
 occipital gyri, the angular 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 tliat the 
 lowest average weight due to atrophy is attained by instances of so- 
 
 * See report with illustrations by Dr. William Dudley, Journ, Mental Sc, July, 
 1886 ; see also paper on "Atrophy and Sclerosis of the Cerebellum," by C. Hubert 
 Bond, Journ. Mental. Sc, July, 1895. 
 
512 THE MORBID BRAIN IN INSANITY. 
 
 called organic dementia (hfemorrhagic or ischsemic softenings); senile 
 atrophy of the brain follows next;, whilst general pax'alysis ranks third 
 in order. 
 
 MiliaPy 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 diffident in 
 suggesting a new name ; although we differ 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 be renamed we 
 are confident; and that when its nature is fully understood its im- 
 portance 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 thirty 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 pathological 
 origin, asserting it to be a post-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. Unfortun- 
 ately for this theory, 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 Avhatever their condition in 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- 
 able by carmine. When magnified by a low power they have a somewhat luminous 
 pearly lustre, and when magnified 250 and 800 diameters Unear, they are seen to 
 'consist of molecular material, with a stroma of exceedingly delicate colourless 
 fibrils. They possess a well-defined outline, and the neighbouring 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 
 
 * See especially Dr. Batty Tuke's article on the " Morbid Histology of the Brain 
 and Spinal Cord in the Insane," Bnt. and For. Medico-Chir. Beview, July, 1873 ; 
 also Dr. Kesteven's paper in the Brit, and For. Medico-Chir. Beview, April, 1869. 
 
Plate XT/ 
 
 ' ' If ' K( ' I'lwfe /- ^°^'^<^°se Sc moniliforin fibres 
 
 }l%;Wk^%MF '/passing intd'Miliani -patch." 
 
 Z)aTk sclerosed 
 
 Fio.l . 
 
 b 
 DeoeneratioTL of meciijiiateci fi^'ire m lateral colTinms 
 of Spinal cord formiiio so-called 'Miliary Sclerosis" 
 as seen under lo"w po->/*Aer objective. 
 
 Aj:i£ cylinders 
 termtnatLTig in -patch.. 
 
 Centre cf Colloid -patch 
 ■' shemng delicate mul 
 tiloculaTou.tlin.es." 
 
 Spider- element . 
 
 witkftTie ramifying processes 
 
 Colloid pakh Tesxiltm^ from 
 
 De<i>eneTation of TOedullated 
 
 fibres of cord . 
 
 "Colloid patch more highly Tnagmfied 
 
 shewing outline of muUilocular -raatenal 
 
 ^fine stroiTia of elastic fibre . x 350. 
 
 Bale*:DaTiiel.';.'»oti Ltd .>c\jlp 
 
MILIARY SCLEROSIS. 
 
 513 
 
 spots are generally colourless, but in some instances thej- are of a yello^vish-green 
 tint, which may be attributable to chromic acid. They vary much in size ; uni- 
 locular patches are ^^th of an inch to y^ath of an inch in diameter, the multilocular 
 from over vrj-jjth to ^j^th of an inch. As many as eleven locules have been noticed 
 in one patch, separated one from the other by tine 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. AVhen 
 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 lobuJated patch some 20 //. 
 to 50 /x in diameter, their colourless aspect strongly contrastini;; 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 out 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 preparation 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 medullated Structure 
 of the brain ; and, where they approach the grey cortex of the con- 
 volutions, they, in most cases, abruptly termhtate, tlie naked-eye suflices 
 to elicit this limitation. When they do invade the cortex, as very 
 rarely occurs, it is only in its lowermost zone, and then strictlv along 
 the line of the large medullated radiations. 
 
 (6) The perivascular nuclei frequently exhibit abundant proliferation, 
 and granular hsematoidin masses freely cover the sheath of the vessel. 
 
 (c) The condition is at a certain stage 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 find 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 9, spinal cord so afiected, we 
 
 * Loc. cit., p. 205. 
 
 33 
 
514 THE MORBID BRAIN IN INSANITY. 
 
 find a dark-stained area (undoubtedly sclerosic in nature) of one or 
 both lateral columns apparently 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 ; repi'oducing 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 (^PL xiv., 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 /i to 186 /i in length 
 by 40 /A to 70 //- 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 piinched-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 
 extravasations at numerous points of a coagulable material which has 
 driven the textui'al 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 xiv., fig. 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 
 which are numerously scattered around the confines of the diseased 
 patch (PI. xiv., 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 
 
MILIARY SCLEROSIS. 5 I 5 
 
 focus, are, in many cases, seen to be regularly luoniliform, 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. xv.). 
 Beside these varicose fibres lie naked axis-cylinders wholly devoid of 
 an investing medulla, and swollen beyond their natural dimensions. 
 
 The spheincal 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 
 {PL XV.). 
 
 In the immediate neighbourhood of these segmented medullated 
 fibres careful examination reveals a vast number of spider-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 xiv., fig. 2, PL xv.). These lymph-connective elements 
 thrive abundantly at the expense of the nerve-tissue and enlarge 
 greatly in bulk, whilst their extensive ramifications pervade its 
 structure in all directions. Along the course of such degenerating 
 medullary fibres the bead-like segmentation often produces a close 
 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 hfema- 
 toxylin help to falsify the appearance, but aniline blue-black with 
 -bright illumination seems best adapted for exhibiting their real 
 
5l6 THE MORBID BRAIN IN INSANITY. 
 
 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 spider- 
 cell, surrounded by a little granular protoplasm from which delicate 
 branches radiate and clasp the spherule of myelin (PL xv.). 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 afiinity. 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 disintegratins; 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 {PI. xxiii., Jig. 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. 
 
 Thus, in the immediate neighbourhood of these patches of miliary 
 sclerosis, we find the nervous tissue in a state of parenchymatous 
 deg'eneration, which, resulting in destruction and atrophy of the 
 essential elements, becomes the site of a g'enuine SClerOSiS. What 
 relationship exists between the unstained patches of miliary sclerosis 
 and the condition of parenchymatous degeneration around 1 
 
 We have already 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 
 
Plate XV; 
 
 Axis cylinders stripped 
 of Medulla . 
 
 Monilijorm. Medulla undergoing /| |\ \ 
 granular defeneration. '"' ^m 
 
 Sca^^engeT cells aiiacking 
 degeneraziTio tiihizlx. 
 
 Granular degencra iic r. jj (^^ 
 of segmented Medulla 
 
 ecbch with a superimp csed ' "{^gw ifj^. ] r-' 
 
 njLcleus (Spider-cell) . i/^/v'-v k' 
 
 Small artery ' 
 
 enger cells 
 fitted, y/ith Qranides. 
 
 J Mcdullated. fibre in process 
 cf seq-meniaiiori . 
 
 Defeneration of Nerve -fibres of lateral colunms ■ 
 
 of Spina] cord in so-called ''Colloid de^^eneraiion." 
 
 of tliese tracts .- 
 
 B«>le A-Dartielsson.Ltd , Sculp 
 
MILIARY SCLEROSIS. 517 
 
 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 swelliiig 
 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 
 <!0utinuity. 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 sti'ucture, however, still remains in the form of a delicate plexus 
 of elastic fibrils beautifully dissected-out by the process, and brought 
 into relief upon the colourless spherules of myelin ; with these there 
 becomes blended ultimately a fine stroma of fibres arising from the 
 S|)ider-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 interlacing 
 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 tliat 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 glass, 
 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 might be 
 anticipated from tlie change induced by the chrome salts. The efi'ect 
 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 
 
5t8 the morbid brain in insanity. 
 
 ■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 effusion 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 
 degenerative 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.*-' 
 
 Colloid DegfenePation. — 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 /x to 12 //. 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 undotibtedly derived from, the medidlated nerve-fibre, bore a 
 
 * 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, Maij 24:fh, 1889. 
 
 "Dear Dr. Bevax Lewis, 
 
 " After seeing your sections and comparing them with my o^^u, I 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 changes 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 unnecessaiy 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, j-ours sincereh', 
 
 "JoHX Batty Ttke." 
 
COLLOID DEGENERATION. 5 19 
 
 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 
 received 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 iJy in diameter, up to 40 /^ — 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 0^0 ^° ttoo ^^ 
 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 {-^-^j^ inch). 
 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 
 hfematoxylin, but are wholly unaffected by carmine or aniline dyes, 
 and they exhibit no reaction with the iodine and sulphui'ic acid test. 
 
 A case of bulbar paralysis occurring at the West Riding 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 fairly-well stained. A glance at the accom- 
 panying sketch {PI. xvi.) will reveal the microscopic dimensions of 
 these bodies and their wide-spread implications. Yet it will be 
 equally obvious how absolutely the limits of the grey matter of the 
 medulla is respected. Thus, in the olivary Vjodies we observe these 
 morbid formations wholly confined to its medullated core, and nowhere 
 implicating its plicated grey substance, except where the latter in traversed 
 
 * "Lesions of the nervous tissues in the hi-ain of the insane," Bi-ain, Oct., 
 1S79, p. 364. 
 
520 THE MORBID BRAIN IN INSANITY. 
 
 hy 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 difficulty in degluti- 
 tion had been noted since this second paralytic 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 trying 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. 
 
 Circulatory, respiratory, and genito-urinary systems appeared normal. 
 
 His gait was somewhat unsteady, 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 moiith, but opens it widely ; saliva constantly dribbles from the mouth ; he 
 swallows fluid food only, and that with the greatest difficulty, throwing his head 
 far back and accomplishing the act only after a prolonged effort, and then with 
 much spluttering. The tongue appears completelj' 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 f aradaic 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, being in constant danger of 
 choking. He had no further paralytic seizure, and died eventually of pulmonary 
 gangrene. 
 
 Summary of A utop.sy.— 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 puckering of the surface. The 
 whole brain weighed about 900 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 aries of parieto-occipital sulcus. 
 
 of inter-parietal sulcus. 
 Middle of third frontal gyrus. 
 
\ 
 
 
 
 r-^o o OO 
 
 
 >i^:^ 
 
 Portion of Inferior Olivary &Accessory. Olivary "bodies, 
 in a case of Bulb ar Paralysis shewinA 
 "Colloid Defeneration'. X ^ £. '^ 
 
 BaleScL'aivi-.lsson Ltd.Scu> 
 
BULBAR PARALYSIS— SIGNIFICANCE OF COLLOID CHANGE. 52 I 
 
 The patch of softening is generally of a greyish colour, translucent, and gela- 
 tiniform, 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 was 
 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 
 hy the large medullated tracts (the tangential fibres of the peripheral 
 zone more especially), and more rarely the intraCOrtical arciform 
 fibres {PI- xvii., Jigs. 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. xvi.), 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 raj)he 
 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 to 
 be an oval swelling along the course of the medullated fibre, and the 
 axis-cylinder can be traced through the centre of the swelling; in other 
 instances a pyriform 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 medul- 
 lated axis is continued (although not traceable) within its structure. 
 Some of the largest examples of the elliptic form attain the dimensions 
 of 55 /A 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 Vie regarded 
 as extraneous to the morbid formation and accidentally superimposed."* 
 Our metliods of preparation now enable us to considerably extend such 
 a statement; not only are they in all cases extraneous to the morbid 
 
 * Loc fit., p. 36ti. 
 
522 THE MORBID BRAIN IN INSANITY. 
 
 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. xv.). 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 {PI. xviii. ^.); 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 difi^er- 
 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. x.\Y.,figs. 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 
 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 {PL xvi.), 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 l)e 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 
 
SIGNIFICANCE OF MILIARY AND COLLOID CHANGE. 523 
 
 of conjecture whether it commenced in tlie capiUaries, 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, 
 dift'ers in some important particulars from what we see taking place 
 in degeneration from section of peripheral nerves. The 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 
 medullated sheath of a deep purple, leaving the axis-cylinder untouched. 
 It is then often noticed that the annular segments, although perfectly 
 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 
 
 * See original article, "Notes of a Peculiar Form of 'Granular Degeneration" 
 observed in a Medulla Oblongata." By W. B. Kesteven. Brit, ami For. Miil. 
 Chir. Rec, April, 1801). 
 
524 THE MORBID BRAIN IN INSANITY. 
 
 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 fibres 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 aff'ected. 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 the axis cylinder takes place very gradually, and the 
 latter eventually succumbs to the encroachment of the sclerous tissue. 
 
 Granular Disinteg'ration 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 Avithin ; the devitalised proto- 
 plasm no longer shows its afiinity 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 difi'ased, so that the altered granular protoplasm becomes 
 of a yellowish tinge {PI. xxiy., fig. 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 largely 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 
 
GRANULAR DEdENERATION OF NERVE-CELLS. 525 
 
 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 hrematine ; the vessels a)-e 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 by 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 ati'ophy of the brain-cells 
 occurred in senile dementia.* That observer also recorded similar 
 chnnges 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 
 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. xvii., fig. 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. xvii.. 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 earlg stage of granular degeneration 
 in senile atrophy that we drew attention to some twelve years ago, 
 
 * West Bidiny Asylum Reports, vol. ii. 
 
526 THE MORBID BRAIN IN INSANITY. 
 
 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 {PI. xxiii., Jig. 1); we would here insist that 
 all cases of senile cerebral atrophy exhibit this proliferation of spider- 
 cells in the earlier stages of its evolution. Xot only so, but we have 
 already sufficiently indicated that we may expect to find similar 
 appearances whenever these medullated iibres are degenerating, what- 
 ever he 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 affection, 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 mesh work around, we tind 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 {PL xxiii., ^g-, 2). 
 These clusters of fatty granules around the free nucleus represent 
 the disintegration of the spider-cell itself, for we often observe 
 some of these elements full of glistening particles, and with their 
 ramifying processes well seen lying amongst their disintegrated con- 
 geners. 
 
 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 {PI. xxiii., figs. 1, 2). 
 
 In considering the source of the fat we are met at the outset of our 
 ■enquiry by Cohnheim's assertion that it is exceedingly improbable 
 that lecithin could be converted in the organism into iat. Xow, we 
 are aware that nucleo-albumins, albumins, and lecithins (perhaps also 
 nucleo-lecithins) are found in the cytoplasm, and the medullated sheath 
 ■of nerve fibres ; and if we find, as by Marchi's method, the degenera- 
 tion of this proteid matter, and a replacement by fatty granules, we 
 must infer that the latter either arose from the proteid, or ai'e intro- 
 duced ab extra. Miescher has shown that in the growth of the ova in 
 Rhine salmon the wasting of muscular substance and the f\\t of the 
 muscles, in other words, the splitting up of so much proteid tnatter 
 issues in the large amount of nuclein and lecithin required for this 
 * Proc. Roy. Soc, No. 182, 1877. 
 
Sclerous 
 tissue. 
 
 Small vessel in section. 
 
 Plate X\/l 
 
 Colloid bodies arranged 
 in. linear series. 
 
 Pli.l. 
 
 "Colloid" defeneration of me dull ate d arciform 
 filores in first layer of Cortex witli active 
 Scavenger cells. 
 Chronic Alcoholic Insanity, x 350. 
 
 Deep stained scle^ 
 
 TOILS ielt crowded 
 
 with products of 
 
 degenerated me ' 
 
 didlated fibres. 
 
 Scavenger- elements 
 fihriaating . 
 
 Branching Scavenger cells 
 amonq Colloid bodies. 
 
 Colloid traTLsformaiion 
 of medullated fibres . 
 
 Fatty transformation of medullated 
 fibres (latest sixL^e.) 
 
 
 ■Fri 
 
 
 >^~ 
 
 ^ 
 
 
 *.« 
 
 
 ■-.■.'.•:: Vessels with Trails 
 •^^3 C)'^°^'^^d with oil globules. 
 
 Fio.2. 
 
 "Colloid'^ defeneration of medullated nerve fibre 
 forming the arciform stripe m first layer of Cortex. 
 Advanced Senile Atrophy of Brain. x 350. 
 
 Bale <StDa-rae]sson,Ltd . Sculp 
 
PIGMENTARY DEGENERATION OF NERVE-CELLS. 527 
 
 physiolosjical phase. Hence nuclein and lecithin do arise synthetically 
 loithin the body by the splitting up of the proteid molecule.* 
 
 When, again, Hofmann showed that the eggs of Musca vomitoria 
 could grow upon blood, and obtain all the requirements for the 
 resulting grub from the proteid and cholestearin of the blood cor- 
 puscles, the same lesson was enforced, f 
 
 The immediate source of this fatty transfer may be referred to three 
 categories : — 
 
 (a) Failure in the oxygen capacity of the nerve-cell ; less oxygen is 
 absorbed. 
 
 (6) Reduced oxygen value of the red blood corpuscles, such as we 
 know to be the case in senility when the vital energies are at a 
 low ebb. 
 
 (c) Interference with the blood supply — both from arterial degenera- 
 tion and want of centric and circulatory energy. 
 
 We can only here presume that the cell nucleus plays a most 
 important role, since the vital activity of the nuclear chromosomes 
 appears to be the chief agency in the synthetic metabolism of the cell ; 
 and in the fact that the nucleus stains so faintly in these cases of senile 
 degeneration, we see that a change has occurred in the chromatin which 
 necessarily must be expressed in an altered nutrition of the cytoplasm. 
 Instructive in this connection also is the fact that fatty degeneration 
 ensues on the administr-ation of arsenic, antimony, mineral acids, carbon 
 monoxide and phosphorus, all of which restrict the supply of oxygen. 
 
 Pigmentary or Fuscous Degeneration. — 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 role 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 nerve- 
 cell is associated with a ditninution 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. 
 
 * See also evidence adduced by INIott in AUbutt's System of Medicine, Art, 
 "Nutrition," vol. i., p. 188. 
 
 t Quoted by Bunge, Physiol. Chem. 
 
528 THE MORBID BRAIN IN INSANITY. 
 
 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 immediate 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. Schafer* says : — " It 
 seems to me that it {i.e., pigment) is usually to be interpreted as a 
 sign of activity rather than of decadence. For there is no doubt that 
 in other organs the presence of pigment in cells is accompanied by 
 marked protoplasmic activity, which may be both chemical and 
 physical. I need only mention in this connection the hepatic cells, 
 the pigment cells in the skin of the frog, and the hexagonal cells 
 which form the outermost layers of the retina of the eye." 
 
 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 
 examined straight from the freezing-microtome, we find at one of the 
 inferior angles, or along the basal arc of the cell, a small collection of 
 golden yellow pigment, through which a number of dark, 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 {PL xxii.). 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- 
 
 * " The Nerve-cell Considered as the Basis of Neurology," Brain, 1893, p. 136. 
 
PIGMENTARY DEGENERATION OF NERVE-CELLS. 529 
 
 yellow tinge, and a rough granular aspect. The cell becomes still more 
 o-lobose in aspect, and its numerous radiating lateral offshoots (at first 
 coarse and deeply stained) can be traced through the jngmented patch up 
 to the receding protoplasm. The nucleus is deeply stained by the 
 usual reagents {PL xxii.). 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 hjematoidin crystals along the perivascular channels. 
 
 The retraction of the unaffected 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, the 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 somewhat spiny aspect. 
 In this stage, whatever processes remain are but very faintly stained by 
 reagents, or have a granular, degenerating aspect, while the pigment 
 discoloration can often be traced far down the process from its 
 junction with the cell. The pigmented area appears to be 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. xxi.). 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 unaffected 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 
 
 34 
 
530 THE MORBID BRAIN IN INSANITY. 
 
 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 /^ to 2 /a- 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 (P/. xxiv.,^^. 1 ; PI. xxvi.). 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 xxiii.,^^. 3). 
 
 The behaviour of the chromophil granules has been noted and admir- 
 ably figured by Meyer. In the earlier and intermediate stages these 
 granules, greatly reduced in size, give to the swollen cell a finely-punc- 
 tated aspect, the dissolution of the granules giving place to pigment.* 
 
 The granular pigment in the fresh sections is apparently iinaffected 
 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, hsematoxylin, or aniline. 
 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 staining of protoplasm, nucleus, and branches. 
 (2) Advancing degeneration, cell more globose ; proto- 
 X3lasm retracting. 
 Sclerosic investment of cell and cinture 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. 
 
 * "Types of Changes in the Giant Cells of Paracentral Lobule," by Adolph 
 Meyer, American Journ. of Insanity, vol. liv., No. 2. 
 
DEVELOPMENTAL ARREST OF NERVE-CELLS, 531 
 
 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 [PI. xix., xxi.), 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 through- 
 out 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 tyj)e 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 develop- 
 ment ; and this view might be supposed to be strengthened 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 find in these cases cells side by side in 
 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 congenital defect and deaf-mutism; all the 
 instances falling under our notice being subjects of epileptic 
 
 idiocy, 
 
 * Brain, Oct., 1879, p. 371. 
 
532 
 
 THE MORBID BRAIN IN INSANITY. 
 
 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, through 
 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 com'pletely 
 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 fill 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 
 uniformly^ and coarsely granular, resolved by high powers 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 them a somewhat reticulated aspect ; this- 
 undoubtedly indicates the existence of the original protoplasmic 
 groundwork of the cell unafi'ected by pigmentary or fatty change, 
 and, in some instances, a somewhat dark-stained border surrounds the 
 cell, forming a well-defined outline — this is, however, exceptional. 
 
 The eccentricity of the nucleus is a notable feature, its usual position 
 being at the junction of the apex-process 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 
 
VACUOLATION OF NERVE-CELLS. 533 
 
 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 
 jierve-cells of the upper layers of the cortex : — 
 . (a) Spheroidal or pyriform contour of cells. 
 
 (b) Marked eccentricity of nucleus, usually apical in position. 
 
 (c) Ci arse gi-anular condition of contents. 
 
 (d) Pigmentation universal, or indications of a fatty change of 
 protoplasm. 
 
 (e) Great paucity of branches. 
 
 (/) Peculiar characters far most marked 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-enerate 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 
 such phenomena have been, we never find reproduced the appearances 
 above detailed. However advanced the "fuscous" or granular change, 
 we find the degenerating cells, if once they have acquired their normal 
 developmental characters, show indications of the mature type to tlie 
 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 jtower 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 cavity 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- 
 
534 
 
 THE MORBID BRAIN IX IXSAXITY. 
 
 cell, ■\vhicli 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 figure^ 
 where the outlines of eighteen vacuoles were seen in a single large 
 multipolar 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- 
 invai'iable {PI. xxi.) ; yet the vacuoles are often imvfiediately in 
 contact with unaffected protoplasm which assumes a deep-stained tint^ 
 and still further aids in bringing them into relief. The 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 
 delicate investing pellicle of devitalised protoplasm (see lower three 
 cells in PI. xxi.). The granular degeneration and the resulting 
 vacuolation and feeble staining of nerve-cells indicate a fatty change 
 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 2yhosphorus j)oisoning we are aware that an acute fatty degenei'a- 
 tion occurs in the tissues from an increased metamorphosis of albumen, 
 but chiefiy from interference with the oxidation of the tissues, and,, 
 hence, the accumulation of fat wfithin 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 Yoit 
 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 
 
 * Zeitschrijt Jiir Biologic, vii., Voit and Bauer. 
 
VACUOLATION OF NUCLEUS. 535 
 
 preparations examined by him the change was never witnessed.* We 
 have on the contrary not only constantly met with vacuolated cells in 
 fresh frozen-sections of certain subjects of insanity, but the most 
 extensive instance of this degenerative change we have seen, and 
 which we have figured in Plate xxi., 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 o\xv frozen-sections of brain, f 
 
 The vacuolation is, as before stated, always associated with the 
 granular degeneration, although the latter may frequently be found 
 to afford 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 invariable accompaniment 
 of old age, and to excessive indulgence in alcohol. 
 
 Vacuolation of Nucleus. — The former condition is usually con- 
 fined to the nerve-cell, the nucleus not necessai'ily 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 peculiai-ly 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. 
 XX. On referring to that drawing, we observe that almost every cell 
 is vacuolated; some containing several vacuoles, and most presenting 
 
 * Arch, fur Path. Anat. u. Physiol u. fur Klin. Mtd., Ud. cvii., H.l. or an 
 abstract of the paper by Dr. Eruext Birt in Brain. 
 
 tSee " Remarks on a case of phosphorus poisoning, witli special reference to 
 the mental symptoms during life, and the pathological appearances in the Brain 
 Cortex after death," by F. A. Elkins and J. Middlcmass, Brit. Med. Joirru., 
 Dec, 1891; also "Vacuolation and I'liospiiorus Poisoning," by Dr. l\Iacplier^;on, 
 Lancet, May, 1S92. 
 
 t " Vacuolation of Nerve Cells and .Septic Infection,'" Jom-n. of Patholo[)y, 
 Feb., 1894. 
 
536 THE MORBID BRAIN IN INSANITY. 
 
 unnatural, distorted outlines as the result of tlie change undergone. 
 It will also be observed that the nucleus is. in the univacuolated 
 cells, the ppimapy seat of disease; so that in many cases the whole 
 nucl»-us 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 [PI. xx.). 
 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, since it is in this and certain other convulsive 
 affections 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 
 disintegration. 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 affections acting in the same way, by the effects 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 artei-ial twigs 
 is inimical to rapid restoration of nutritive equilibrium, as long since 
 indicated by Dr. Ross.* 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 affected, the same 
 explanation is not valid; we cannot imagine these minute elements 
 suffering 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 intrinsic morbid factor in the 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 in chronic 
 alcoholic insanity ; in the latter we do not look for a cause of the 
 * Diseases of the Xercous System, vol. i. 
 
Plate XVIII. 
 
 
 
 -■ r 
 
 ■S^' 
 
 
 •; •* 
 
 '- 
 
 
 ::.\: , , 
 
 - ,?• . 
 
 • .' 
 
 '■■*hii^# 
 
 B 
 
 Sclerosic implication of Cerebellar Cortex, 
 in a case of Epilepsy. 
 
 A. ReaUlay leaflet closely adjoimn* diseased tract. 
 
 B. Sclerosed leaflets united firmly together. 
 
 Bale &X)anielsson.Ltd. Sculp. 
 
DESTRUCTION OF NERVE-FIBRE PLEXUS. 537 
 
 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 diflerentiation 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 chi'onic atrophic diseases of the 
 cortex associated with insanity the aspect is very different. Here we 
 find much difFusiveneSS of staining, the mati'ix 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. 
 
 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-pi'ocesses, 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 exaTnination, resolves 
 itself into the fine fibrillar meshwork whicli originates from tlie 
 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 
 
 * Consult on tliis point tlie following recent articles : — " Vacuolation of nerve- 
 cell nuclei in the cortex in two cases of cerebral concussion," by J. Macplierson, 
 M.D., Lancet, May, 1892 ; " Vacuolation of nuclei in Myx<L'denia," Dr. Wliitwell, 
 Brit. Med. Jonra., vol. 1., 1892 ; " Vacuolation of uerve-cell nuclei," by Dr. Skae, 
 Brit. Med. Jouni., May, 1894, and l)y Dr. Wynne, Brit. Med. Joxru., June, 1894. 
 
538 THE MORBID BRAIN IN INSANITY. 
 
 have entirely lost all semblance of their former outline, or being 
 well-defined in their lower half, become indistinct above, and fade oflT 
 imperceptibly into the surrounding mati'ix; 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 {PL :s.xii.,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 fi.brillar 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 {PI. xxiii., 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 
 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-fibi'es 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 simi)lest correlations of mind 
 would await an exjdanation. 
 
 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 
 
DESTRUCTION OF NERVE-FIBRE PLEXUS. 539 
 
 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 deatli. 
 
 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 {PI. xii.). A quickened circula- 
 tion, a retarded flow, an anaemic 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 affecting the nervous centres. Their physiolog'ical indications 
 are clear ; they are the SCaveng'erS 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 
 they are universally present can be readily verified by special methods 
 of examination. 
 
 Whatever leads to increased waste of cerebral neurine ; whenever 
 structural disintegration is slowly proceeding either in nerve-cell 
 or fibre ; whenever accumulation of debris occurs from disease of 
 the vascular tracts, then we invariablv note an augmented activity 
 registered in these SCaveng"er-elementS of tlie 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 eff"used from 
 the vessels. In healthy states, however, they never assume the hyper- 
 
540 THE MORBID BRAIN IN INSANITY. 
 
 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 xxv.). 
 
 Tissue-Degradation fpom 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 all of 
 us are aware, there is a risk of permanent damag'e, 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 influeoice 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 degeneration 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 physio- 
 logical units become pathological factors, and the nervous elements 
 themselves succumb to their rapacity. 
 
 Tissue-Deg"radation from Active Patholog-ical Processes. — 
 
 In consecutive dementia following upon acute insanity, we have 
 evidence that 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-enei'gy 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 
 desti'uction of the nerve-tiljre plexus of the cortex, 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. 537) as indications of the storm which overswept the 
 
TISSUE-DEGRADATION FROM DISUSE. 541 
 
 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 hiematoidine in their neighbourhood, 
 and other changes incident to bygone attacks of excitement ; but in 
 the presence of the spider-cells and the degraded type of issue, 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 uncoviplicattd 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 
 rdle, preying upon the tissues whose functional integrity in health 
 they subserve. 
 
 Another factor should, however, be taken into account in this con- 
 nection — viz., Ag'e. 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 
 is, therefore, emphasised in all acute insanities occurring in advancing 
 years ; and we may regard age as an important element in determining 
 the consecutive dementia resulting from all forms of insanity. 
 
 Tissue-Degradation 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 
 lowei-ed functional activity or disuse. The ati-ophic changes then 
 resultant are induced through the agency of the same scavenger- 
 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 tlie tame rabbit. In the former, 
 the pia is hrmly attached to the surface of the brain by these elements, 
 and requires considerable force for its removal ; in the latter, sections 
 
542 THE MORBID BKAIN IN INSANITY. 
 
 through the cortex exhibit them in great abundance in the peripheral 
 ^one. 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 role in the degenerations of cerebral tissues in mental disease, it 
 becomes an interesting question to enquire how far their pathological 
 development may reveal itself to the naked-eye examination of the 
 morbid brain % 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, 
 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. 
 xxiii., fig. 2). In the latter case, their appearance is usually coincident 
 with considerable fatty disintegration of tissue, these elements 
 themselves succumbing to this change, and very considerable inter- 
 stitial atrophy is apparent. 
 
 Another indication of the ravages of tliese scavenger-cells is aftbrded 
 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, &c. {PL xxiii., fig. 1 ). Such 
 atrophy is always attendant upon the degradation of tissue to which we 
 
PATHOLOGICAL INDICATIONS— SUMMARY. 543 
 
 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 nePVe-fibre 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 sensOry unit ol 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-flbre plexuses the relational element of mind progressively 
 
 suffers, the intellectual vigour wanes ; whilst the purely 
 
 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. 537) 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, 2)ervianent mental enfeeblement. 
 
 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 motor or 
 frontO-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 origfin is 
 often presumable; and in such instances we often find sensory areas 
 peculiarly prone to implication. 
 
 (4r) 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 
 
544 THE MORBID BRAIX IN INSANITY. 
 
 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- 
 eellulaP nerve-flbre plexus (the relational element) which primarily 
 and principally suffers. 
 
 (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 irrvmarily 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 
 cortical area to be established without involving neighbouring and 
 distant territories closely associated in their functional activities, and, 
 therefore, in organic connection with each other ; 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 localishig 
 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 
 very general one, although invariably expressed at certain sites 
 more than at others ; yet, that in certain insanities (e.g., that accom- 
 panying general paralysis), special slteS 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 origin. 
 
 * The statement made by Crichton-Bro\viie 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 irreparably 
 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 1315-3 
 grammes, and for females 1159-5 grammes." Brain, vol. ii., " On the Weight of 
 the Brain and its Component Parts in the Insane." 
 
Plate XiX 
 
 
 mH 
 
 
 ^•^'. 
 
 .>^ 
 
 A. 
 
 Sclerosis of Cornu AmTRonis in Epileptic insanif,y 
 A-Pexiplxeral zone in Gyrus hippocampi. 
 B . Vacuolated cells beneath tTie alcove 
 
 B.»!eA.DAmlsl:if.oli IfcJ Scillr 
 
PATHOLOGICAL INDICATIONS— SUMMARY. 545 
 
 This tendency of primary nervous implication to share in the 
 universality, which also characterises nervous affections of hsemic 
 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 but 
 of insanities, multiform in their nature, and all pointing to certain 
 definite weakened areas in the material substrata of mind. In tliis 
 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 contix'matory 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 par 
 excellence which suflTer most severely as the result of acute insanity and 
 its sequelae ; not the assumed 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. 24, p. 511). 
 
 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. 22, p. 506) 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 (? determined by) these vascular 
 affections, therefore, we find the most persistent hallucinations 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 
 
 * Brain, vol. iii. 
 
 35 
 
546 THE MORBID BRAIN IN INSANITY. 
 
 CerebPal arteries. Alcoholic insanity, perhaps, 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 sequelse 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 rabbit 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 SOmno- 
 lenee 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 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 toi-pid and 
 motionless, giving uttei-ance 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 lovg intervals, 
 evidence of nerve-instability was forthcoming in the sudden, un- 
 expected outburst of frantic passion, in which she struggled, kicked, 
 screamed, and swore, employing a very free vocabulary of abusive 
 epithets; the outburst would last but for 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 swallow- 
 ing the food placed in her mouth to lapse into her drowsy state, 
 from which she was i-oused only by shaking and continuous exhor- 
 tation. 
 
 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 
 
 * Brit. Med. Jour., vol. ii., 1883. 
 
PATHOLOGICAL INDICATIONS-SUMMARY. 547 
 
 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 iar 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 pi'esent are the observations of Professor Ferrier, who, upon 
 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 prj'ing 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 appearance, the facidty of attentive and intelligent observation." t 
 
 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. 
 
 * Pfliiger's Archiv., Bd. xxxiv., 1884. 
 
 i Functions of fha Brain, 2nd edit., p. -iOL 
 
548 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 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— iid^e of Phagocytes, or Scavenger-Cells — Character of 
 Scavenger-Element— Its Vascular Process — Fuscous Degeneration of Nerve- 
 Cells — Three Stages of Morbid Evolution: — Inflammatory Engorgement — Impli- 
 cation of Pia Arachnoid — Nuclear Proliferation on Adventitia — Paralysis of 
 Arterial Tunics — Diapedesis— Exudation — Htemorrhagic Transudations— Arach- 
 noid Haemorrhage — Second Stage: — Hypertrophy of Lymph-Connective System 
 — Fuscous Change and Removal of Nerve-Cells— Nature of tlie Destructive 
 Process — Early Implication of Apex Process — Third Stage : — Fibrillation and 
 Atrophy. The Sxtinal Cord: — Spinal Cases in Four Groups — Evolution of Pseudo- 
 Tabetic and Spastic Paraplegic Forms Pathogenises 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 Lateral Sclerosis in Dorsi- 
 Lumbar Regions — Combined System-Implication of Columns — Pseudo-Tabetic 
 Forms— Ataxic Tabes — Loss of Knee- Jerk — Anorexia — Flashing Pains and 
 Sensory Symptoms — Genuine Tabetic Forms in General Paralysis. 
 
 The Brain and its Membranes. — The earliest indication of morbid 
 change is certainly presented by the vaSCUlar 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 
 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 hsematoidine 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 
 
LYMPH-CONNECTIVE SYSTEM. 549 
 
 nature. Vital, in so far, that the neighbouring inflammatory state of 
 tlie 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 affect 
 the other tunics of the vessel. At a still later period the sheath is yet 
 further damaged by the numerous branching processes of cells extra- 
 vascular in position, which play so important a role in the morbid 
 process, and to which we must now direct attention. 
 
 In this, tlie 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 are small flask-shaped cells 
 with a comparatively large nucleus at their greater extremity, which 
 latter stains but faintly with aniline-black, whilst the protoplasm of 
 the cell itself remains unstained, and so delicate as to be recognised 
 with diflSculty in healthy states. Each has a connection by a delicate 
 process with a neighbouring blood-vessel, and, in frozen sections fresh 
 •examined, exhibits several radiate branches so fragile, and excessively 
 ■delicate, as to be only seen after a keen search, since they remain 
 wholly unstained by reagents {PL xxvi.). 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 
 
 * Intra-cellular digestion is now an established pathological fact, and the 
 researches of Jletschnikoff have extended largely the r6le of certain celhilar 
 organisms in the elimination of morbid material. The term pha(joci/tes, whioli he 
 employs for those large cells active in the removal of effete material in the frotr 
 and other cold-blooded animals, we have employed when referring to the spider- 
 cell ; but we prefer the term scacencjer-cell for those fixed tissue-organisms wliich, 
 as we have seen, have an active physiological and patliological rdle. See 
 J/e^sc/miA'o//'*- Original Articles, Virchows Arrhir., vols, xcvi., xcvii. 
 
550 
 
 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 most delicate subdivisions, are readily stained by the same reagent. 
 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 
 (^Pl. xxvi.). The student's 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 protoplasrii of cell omd 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 different 
 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. xxv. ; PI. xxiY.,fff. 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 
 they may permeate every tract of the cortex, from the peripheral 
 zone to the deepest layer, and are, moreover, often formed deep in 
 the meduUated structure of the brain. 
 
 Whenever a branch forms a new connection with a blood-vessel, 
 at its junction with the sheath there is invariably 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 [PL xxvi.). 
 Co-eval with this morbid transformation, we find the nerve-cells present 
 indubitable evidence of a degenerative process{P/. xxiv,,^'^. 1 ; PI. xxvi.). 
 The morbid condition of the cell has itself been described by some 
 authors as inflammatory in its intrinsic nature (Mierzejeivski) ; but,, 
 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 diflerence be- 
 
 * Even nerve-cells in certain diseased states stain )nore intensely than in health 
 — e.g., early stage of fuscous degeneration — but subsequently the reaction becomes 
 progressively less intense. 
 
LYMPH-CONNECTIVE SYSTEM. 55 I 
 
 tween the changes through which these cells pass, and those of the 
 cortex in senile atrophy, except in the greater tendency to a tPUe 
 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 
 coi'tical cells of the epileptic's brain [Fl. xxii.). 
 
 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 (PI. y.^\\\.,fig. 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 process with a 
 distant capillary (PI. xxv.). 
 
 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. 527)- 
 It may be stated here, however, that the apical process appears to 
 suffer 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 
 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, PI. xxvi.) 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 tibrillated mesh 
 radiates as from a centre, its branches interlacing most intimately.'" 
 
 * Such isolated nodules of dense fihrillated tissue of almost microscopic dimen- 
 sions occasionally occur in the cerebellum. Tlieir import has not to our knowledge 
 been previously recognised. 
 
552 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 This stage of dense fibrillation and disappearance of the cell-protoplasm 
 is the third stag's 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, the axis-cylinders of which are denuded. 
 
 3. A stage of general fibrillation with shrinking, and extreme 
 atrophy of the parts involved. 
 
 We may now proceed more fully to enquire into the indications 
 aff'orded us by the morbid changes characterising the above stadia. 
 
 Stage of Inflammatory Eng-orgement.— It is in the vessels of 
 
 the pia 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 frontoparietal 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 
 all show a notable increase in the nucleated protoplasmic ceils 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 pia 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 prolifei-ation 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 trabeculfe lying 
 between the intima pia and arachnoid (which are so especially loose 
 
Plate XX. 
 
 One Jorqe 'Vacuole occTcpvLnq cell. 
 
 d e d witk 
 
 E^ctreme Vacuole 
 
 4 ■ hA^- 
 
 ^ 
 
 -A- 
 
 ^ ^. 
 
 -^ 
 
 r J'. 
 
 is: 
 
 
 
 
 : >-4^ 
 
 ^ 
 
 f*C ^# 
 
 
 ?? 
 
 U^ 
 
 V 
 
 A 
 
 .rifh .■nuc'^e'v. 
 
 of ^K ;r1 
 
 Bale iDanielssan. Ltd ,Sc-ulp 
 
STAGE OF INFLAMMATORY ENGORGEMENT. 553 
 
 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-diffused opalescence ; whilst to histological 
 examination of sections they reveal beautifully-disposed meshworks 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 accumu- 
 lation of exudate in the subarachnoid lymph-tissue receives a marked 
 increment at a later stage of the disease ; for, 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 narrowed 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 effusion occurs to All 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 hsemorrhage. Such 
 haemorrhages may be slight and merely punctiform, and are frequently 
 observed ; or blood may be transfused into the subarachnoid space and 
 a fibrinous coagulum 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 
 haemorrhage. The latter, or so-called mening*eal haemOPPhag'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 ott' 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 
 
554 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 newly-formed vessels within the organising clot. In none of these cases 
 does it appear to us to have a direct inflammatory origin in the 
 membranes. Beyond these extravasations and infiltrations of blood, 
 which invariably occur during an advanced atrophic stage of the 
 disease, we iind 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 aneurismal 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 
 lymphatic 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's. — 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 
 in their protoplasm ensues, and fuSCOUS deg'enePation of their 
 contents l^ads 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 l^rge amoeboid masses of protoplasm, which 
 
STAGES OF CELL DEGENERATION AND FIBRILLATION. 555 
 
 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 several authorities in the cortex of 
 the general paralytic, and very 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 proliferating 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 paralysis. 
 
 The failure of the usual lymphatic tracts to remove effete 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 scavengers of the tissue: 
 live, thrive, and multiply upon the degenerating protoplasmic masses- 
 of nerve-cells and their extensions, and all effete material lying in 
 their neighbourhood is ultimately appropriated to their use. These 
 active scavengers are also destructive of the living tissues ; they atSx 
 their 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. These, therefore, are 
 the first nervous structures to be involved, and the apical processes 
 of the pyramids are also amongst the first to undergo degenerative 
 change. 
 
 Third Stag's. — 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. 
 
556 PATHOLOaiCAL ANATOMY OF GENERAL PARALYSIS. 
 
 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 
 cerebral 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 nature 
 of the morbid change as the mode of implication of the spinal tissue- 
 elements and the initiatory conditions upon which the lesion depends. 
 As is well known, the spinal cord is by no means uniformly im- 
 plicated 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 symptom.s 
 are the most prominent feature of the case. In other cases, again, the 
 spinal symptoms appear to bear a definite relation to the various 
 stages of cerebral disturbance, and vary in their nature pari passu 
 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, paretic 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 symptoms, 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 off, the knee-jerk returns, and then the full 
 
Plate XXI. 
 
 Vacuoles c'rowdiTici ivie^jcr of nerve-cell. 
 
 Eeirari^Kg jjrcioplasvi of cell. 
 
 Vcuiirjlatr.cn &. graradar 
 i^.egenc'atioii.. 
 
 Diru/rr:<^,/ 
 
 .Celt .'.wo Lien ..• 
 TA^itl-i hriqlit iraniliiccTii ccidents 
 
 V 
 
 ^rll .swollen, indi.n'o.tad 
 :';d de-void of hranches. 
 
 Mulii'p olar ganglionic cells 
 •jrLdsrioirv^ sxtrerae decrees of vaciioleitiorL-. 
 
 fronv anterior Corn-j: of Spin-sl Cord. 
 
 -In a Cc->se of General Paralysis x 350 
 
 iSale&JJaraelsson l.ta c.-.;u.D 
 
PATHOGENESIS OF SPINAL IMPLICATION. 557 
 
 development of the cerebral symptoms is established ; or, what is not 
 infrequent, the sensory implication of the cord becomes a motory 
 
 affection, and spastic paraplegia replaces the ansesthesia and 
 ataxy. 
 
 (3) In yet another series of cases the motor spinal 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 tlie sequel of convulsive seizures, a mode of 
 implication which appears to us of special frequency in general 
 paralysis affecting 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 spinal cord the originating factor of the subse- 
 quent cortical lesions of general paralysis. 
 
 And, in like manner, the subsequent establishment of motor spinal 
 symptoms [spastic paraplegia) has been regarded as a direct transference 
 of morbid implication aci'oss 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 by direct 
 continuity of diseased tissue, but through the vasomotor agency 
 operative upon nervous tracts in physiological sympathy with their 
 higher centres. 
 
 VasCUlaP System. — Nearly all cases present an apparent increase 
 in the number of the vessels of the posterior columns. The appearance 
 
558 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 is, however, deceptive, in that there is not an absolute numerical 
 increase in the vessels seen in transverse section, but an increase in 
 their size, due to long-continued engorgement, which rendei's 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 hsematoxylin preparations, they at once obti-ude 
 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 tlie 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 chi'onic 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 prepai-ations 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 
 
ASSOCIATED SYSTEM-DISEASES OF THE CORD. 559 
 
 vascular apparatus and the defective elimination dependent there- 
 upon. 
 
 The Nervous Elements. — As above stated, these often remain 
 little or not at all implicated. No enlarged axis-cylinders are 
 observed, no swelling of the medullated sheath, no proliferation of 
 nuclei; nothing which can be translated into signs of inilammatory 
 implication of the nerve-fibre. The spider or " scavenyer-cells" (as we 
 have termed those elements) appear povverless in their agency upon 
 medullated nerve-tubes, and ic would seem that their destructive 
 agency directly affects only the unprotected protoplasmic structures, 
 the nerve-cell, the axis-cylinder process before it attains its medullary 
 investment, or the |)rotoplasniic branches of these cells. The connec- 
 tive elements, however, effect the degeneration of the medullated tube 
 by the pressure and encroachment of sclerous fibrillated tissue, 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 posteriOP com- 
 missural 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 GoU 
 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 tlie 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 gfelatinosa 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 columns 
 
 are involved, the indications presented ai-e those of chronic and mild 
 congestion leading to eventual sclerosic degeneration of the tissue. In 
 fresh preparations such changes may not be appreciable to the naked 
 eye, and (unlike the secondary 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 
 destructive 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 th.e posterior columns. The 
 
560 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 naked-eye examination, however, may indicate its existence by the 
 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 afiection (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 deej) 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 latei'al 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 nioniliform portions of the disintegrating 
 nerve-fibre divided at its largest 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 
 interrupted, displaced, contorted, and severed along its course ; the 
 less degenerate fibres show irregular enlargements along their course, 
 often presenting a notably-moniliform aspect due to proliferation of 
 the 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 
 
Plate XXII 
 
 :zr. k clispl 
 
 tptacic: rnzcLer.i, 
 
 ■Fxqrn.eriisd qi^a-mjlaT Tf.o.^s. 
 
 Frocess contimzcus Tvit'\ 
 retracted -prcrtqplasrr. 
 
 Piarnenisd g ram.de rrLass.j.>'^' 
 
 r-ixScous cLe c eii.£ratioai of large GaTLglior^i eye ells 
 of Motor Cortex li-xiaan x550. 
 
 Bale AiDani elsson , Ltd. Sculp . 
 
ASSOCIATED SYSTP^M- DISEASES OF THE CORD. 56 I 
 
 each segmented node of the nerve-fibre take the chief part, a process 
 clearly enn&ciated by Ranvier. If these longitudinal 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 granule-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 lai-gely 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 smallei- 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 con- 
 nective in which the nerve-fibrils are embedded. The appearance is 
 almost suggestive, at first sight, of primary interstitial change; but this 
 can scarcely be maintained in view of the fact that 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 
 of the change being primarily a parenchymatoiis neuritis is found in the 
 
 36 
 
562 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 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 
 rather 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 \ve 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 affected, in 
 itself, possibly, the expression of the trophic disturbance. To sum- 
 marise these views : — 
 
 1. The change is induced seCOndaPily to the cortical lesions. 
 
 2. It establishes itself after the WallePian 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 g^radually-advancingf degeneration of cortical 
 
 nerve-cells, and not a sudden or gross lesion such as the former, the 
 irritative influence on the cord is greatly mitigated. The changes 
 found in the peripheral nervous system, their vascular tracts, and the 
 muscular system have been well described by Dr. Alfred Campbell. f 
 In his article will be found an exposition of the view of a primary 
 ■toxic origin for these peripheral changes (as opposed to the view now 
 propounded) given in a masterly manner and with good illustrations. 
 Dr. Campbell found extensive changes in the vagi (as did Colella),J in 
 
 * See in this connection ' ' Ansemia as a Cause of Degenerative Changes in the 
 Columns of the Spinal Cord," Report in Lancet, March 30, 1895. Also "Destruc- 
 tion of Central Grey Matter in Rabbits on Compression of Aorta " [Ehrlich and 
 Brieger) 
 
 tOjo. cit. t Aniiali di Neurologia, 1891, pp. 115 to 200. 
 
COMBINED SYSTEM-IMPLICATION OF COLUMNS. 563 
 
 the phrenic, the mixed spinal nerves and their peripheral terminations, 
 the small blood-vessels of the nerve sheath (as did Goodall and Rux- 
 ton),* and, to a less degree, the spinal nerve roots, the cranial nerves 
 and their nuclei of origin ( Wigglesworth, Mickle, and others). 
 
 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 tnyelitis, 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 
 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 
 dorsalis is not in these cases reproduced, but 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. xiv., figs. 1-3 ; PL xv.). 
 
 Combined System-Implication of Columns.— Do the changes 
 
 found ever resemble those of amyotrophic lateral sclerosis? 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 
 univei'sally found to exist ; usually it is the arm that suflers 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 
 * Brain, 1892, p. 241. 
 
564 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 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 tliis stage also, we get ankle-clonoa 
 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 
 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 ai*e chiefly involved. No 
 contractures of the arm occur, or myotatic increase, but complete 
 flaccidity, and the legs do not participate in this sub-acute 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 clonos may 
 still exist ; but, muscular enfeeblement now rapidly supervenes ; the 
 limbs tend to exhibit spasmodic fixation, but are more frequently 
 kept stifi" and rigid by voluntary efibrt. 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 lighlning-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 abolished ; 
 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 sufierer 
 from fulgurant pains ; there is profound implication of the bulbar 
 nerves, deglutition being so far impaired as to make the efibrt 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. 
 
AMYOTROPHIC FORM. 565' 
 
 that the spinal appear consecutively to the cerebral derangements ; 
 and, as before stated, are almost invariably \ishered-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 
 incoordination established, apart from defect of sensation or patellar 
 reaction, indicates a morbid change in some region of the cord, other 
 thaii that of the posterior sensory roots, and this change is detected 
 across the columns of Goll, and partly in the post-co7nmis sural zone, the 
 implication of which 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 the cervical region. [PI. xv. ) It is to the increase of this sclerosic 
 state of these columns we must attribute the progressive stiffening of 
 the lower limbs, and their exalted muscular irritability. Later on in 
 the history of these cases, the changes noticed in the columns of Goll 
 spread obliquely outwards so as to directly involve the posterior sensory 
 root-fibres, 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 sufiice to indicate 
 the cause of extreme emaciation of certain muscular groupings, and 
 their progressive enfeeblement in motor power. (PI. xxi.) 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 tlie 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 aflBrmed ; 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 
 
566 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 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 affected 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 cliange 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 affections whereby the cortical lesions tend to project their 
 influence upon subordinate regions of the spinal axis ; the vascular 
 turgescence, however, is not so great in these cases as the purely 
 neural change. [PI. xxiv.jjig. 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, appears 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 mucli 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). — 
 
 "VVe have thus, so far, dealt with a combined system-atfection of the 
 cord in general paralysis, where a postero-lateral change predominates 
 in the lower region, and a polar impairment (issuing 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. A notable feature in this class of cases is 
 the predominance of sensorial derangements, not as regai'ds 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 
 
PSEUDO-TABETIC FORM. 567 
 
 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 far advanced, that 
 this painful state of mind declines, or rather is replaced by a 
 condition bordering upon idiocy, often with much frenzied excite- 
 ment. 
 
 Another prominent symptom is that of frequent convulsive attacks, 
 which are often peculiarly severe in nature, and leave wide-spread and 
 notable sequelae, 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 transient 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., herpetic eruptions and trophic impair- 
 ment of cornea. 
 
 The ataxic gait is, as usual, a more obtrusive symptom than the 
 same impairment in the movements in 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. 
 
 Repeated attacks of hemiplegia with more or less complete anaes- 
 
568 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 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 raore often with acutely-exaggerated knee-jerTf,. Contractions 
 of the limbs now ensue, generally limited to the upper extremi- 
 ties, and corresponding to the side usually left paralysed after 
 convulsive seizures; thus, in a case of right hemiplegia withhemi- 
 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 ilexion), 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 
 at 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 posterior 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.* Tlie lesion 
 
 * See in this connection the microscopic examination of the cord in the case of 
 .ff.C/.,p. 282. 
 
Plate XXIII. 
 
 ^g- 
 
 Section from the ascexicliri^ .. convolu-tioTL iu a case of Senile airopky. 
 
 The proliferation of cOTLiLective "V .f the XLpp ex • cortical layers 
 
 ;in.(i TiervoTis ' eleiaents x 180. 
 
 is.seeix invadirLg the vascular 
 
 GroioD 
 
 °J 
 
 o„ , ■ -' -n '■ pcavenqeT-cell surroztnded Ttlt oil-glolides 
 
 ocavenoer ceLLs.\ A ; j -i 
 
 ^ 
 
 K^^^ 
 
 
 FattY prcdiTcis accznn.ido.hnq 
 aroiznA. 3\ood.--v-esseZ. 
 
 
 
 ??/' 
 
 Fii.S,, 
 
 Fatty disinte oxaiioT!. of p eripliexal zoxie (^l—la-yer) of Cortex 
 in a case of advanced Senile acroplry" of BraiTi . x550. 
 
 Nc^'ire-ceTL dLevbid. of pnocesses \ 
 
 Syrollen degeneraiin^ 
 Merve-cell ■•■.. 
 
 1: ibritlaiinq ScaveTWer- cells. 
 
 Scavenqer elements filled -with qramdes_ 
 
 JIoTYe-cell diointegr-cded and surrcnnded 
 by ^raniclar debris. 
 
 Fig. 3. 
 
 Drsintegratin^ ISfeTve-cells of Cortex surrounded Ijv Scavenger- cells. 
 
PSEUDO-TABETIC FORM. 569' 
 
 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 strikiug feature) presenting a 
 coarse trabecular appearance, in which thick-walled vessels with con- 
 tracted lumen are freely scattered. [PL xxiv., fig. 3; PL xxvi.) The 
 nerve-fibre does not itself appear implicated as in the former series, 
 and the disturbances in its conductibility are probably the result 
 of the pressure produced by this morbid cellular growth, and the 
 engorged and distended nutrient vessels of this region. The morbid 
 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 pressure results which 
 have not j^roceeded 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 inter medio-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 tlie 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 tremulous and 
 
570 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 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. 
 
 The absence of muscular atrophy, which characterised the former 
 series of cases, is consistent with the immunity of the anterior cornua 
 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 affec- 
 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 symp- 
 tom associated with tahes is one by no means essential to the diseased 
 process which is at the root of the ailment. InCO-Ordination — so- 
 prominent a feature in all marked cases of tabeS dOPSaliS — need not 
 be present to constitute this disease ; and, if ataxic symptoms are 
 considered as essential features in tabes, 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 afiections. 
 
 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 ivithout the knee-tendon accompaniments of 
 tabes ; there are, moreover, forms of indubitable tabes which exhibit 
 no inCO-OPdination. On the other hand, we have repeatedly 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 inco-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 retiex phenomenon. Hence, a fallacy is likely ta 
 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 
 * " Localisation in Cerebral Disease,"' Brit. Mtd. Jonrn., vol. ii., 1883. 
 
ATAXIC TABES AND GENERAL PARALYSIS. 57 1 
 
 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 which 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. 320), a fairly large proportion ; 
 and such cases exhibit certain features which justify us in separately 
 considering the class.* 
 
 It is not, however, with these more frequent forms that we are now 
 more immediately concerned, but with the far less frequent associa- 
 tion of ata.cic tabes with general paralysis. 
 
 Implication of Posterior Columns (Ataxic Tabes). — This rare 
 form of disease claims our closest attention, not alone from the 
 acuteuess of the neuroses, 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 taben 
 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 tnental symptotns 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 tlie ataxic paraplegia last described. If COngestiVG or 
 convulsive seizures usher in the atiection, there may supervene a 
 transient 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 when the knee-jerk declines, from the fact 
 that these subjects come before our notice for their mental infirmity ; 
 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 deserA-ing 
 further inquiry. A notable symptom in all these tabetic general 
 paralytics is a severe fi-ontal 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 
 Avith 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 moral 
 
 * The analysis, moreover, indicates, if we include cases where tiie retiex is not 
 completely abolislied, the still liigher proportion of 20*4 per cent. 
 
572 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 decadence. The subject may be distrustful, cunning, tx'eaclierouS; 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; audit must be affirmed that 
 cerebral symptoms may entirely fail to manifest themselves, and the 
 patient be sent from under asylum supervision, but suffering 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 antesthesia or other sensory defect may 
 prevail As in typically 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 the 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 
 extremities were thus 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 imaginary enemies. In this case muscular sense was so 
 
 * "A case of Locomotor Ataxy followed by General Paralysis of the Insane."' 
 Brain, April, 1888. 
 
GENUINE TABETIC FORM. 
 
 573 
 
 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 
 history of this case that the arms were Jlrst afiiected (the reverse of 
 what is usual), since slovenly writing first drew attention to the fact 
 of manual inco-ordination. 
 
 The pains vary much in character and distribution; they are usually 
 Budden, sharp, and lancinating, described as like electricity/ passing 
 through a limb ; they may be described as tearing, agonising pains of 
 momentar}^ duration only, or as " flashing 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. Rheumatoid 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 " hyperesthesia 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 abdominal 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 
 
 * Loc. cit. 
 
574 PATHOLOGICAL ANATOMY OF GENERAL PARALYSIS. 
 
 ■desperately and determinedly suicidal. In connection with such crises 
 Campbell's statement is of great interest — " In all my cases the pneu- 
 mogastric nerves were extensively and sti-ikingly diseased, more so 
 than any of the peripheral nerves, and decidedly more than any 
 cranial nerve. My observations in this connection entirely agree 
 with those recently made by Colella (Joe. cit.), and, in my opinion, it 
 is impossible to attach too much importance to the remarkable singling 
 out of the vagi for such extreme degenerations in this disease."* 
 
 Tabetic General Paralysis. — To proceed to the more frequent 
 •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 neighbouring 
 town, which haunted him whenever he went out of doors, and which 
 prompted him to marry 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 fPOntal head- 
 ache so frequent here, and the hair is often rubbed off tlie frontal 
 region, or off the whole of one side of the head, by the patient's hands ; 
 
 * Loc. cit., p. 188, 
 
PATHOLOaV OF EPILEPSY. 575 
 
 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 by us. 
 
 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 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. 
 
 The morbid 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. Upon this point 
 we have the authority of Dr. Gowers to the effect that there is little 
 likelihood at present of our knowledge of its pathological nature 
 becoming more definite, and that — " The changes in the nerve-centres 
 are probably 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 distUPbanCG 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 moibid appearance of the cortical cell does exist 
 of a highly-characteristic nature, when the cortex is the subject of 
 careful examination by the 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 
 
5/6 PATHOLOGICAL ANATOMY OF EPILEPTIC INSANITY. 
 
 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 
 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 body — obviously o^ a. fatty 
 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 which 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. xix., 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 
 brio'ht lustrous 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 pyi'amidal cells 
 of the succeeding layer, it is not an exceptional, but a most frequent, 
 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 {PI. xix., B). When the change has pro- 
 gressed so far that one-half of the nucleus is occupied by the morbid 
 
EXTENSIVE VACUOLATION OF NUCLEI. 577 
 
 substance, the former appears to have lost its selective capacity for the 
 aniline i*eagent, stains poorly, and is bnt faintly differentiated from the 
 enclosing cell ; and, as the fatty change proceeds, any remaining nuclear 
 mass presents such a delicate stippled shading that it fades off into the 
 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 
 bi'eak-down is sufficiently evidenced by the paucity of elements in this 
 layer contrasted with what is seen in the healthy brain, and by the 
 abundance of fragmentary residue left by the process of disintegration 
 at this level of the cortex. 
 
 The more advanced stage of this fatty nuclear change reveals a 
 vacuolated condition of the cell, which becomes even a more striking 
 feature than 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 {PI. xx.). 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 poi-tion 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- 
 
 37 
 
5 78 PATHOLOGICAL ANATOMY OF EPILEPTIC INSANITY. 
 
 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 {PI. xx., deeper layer). Pigmentary degeneration of a limited 
 portion of the cell may be seen, whilst in the darkly-stained protoplasm 
 three or four paler spots are seen, somewhat refractile and gleaming 
 through the superimposed protoplasm. Many of such large cells are 
 swollen and globose, maintain their lateral and basal processes, but 
 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 affecting the blood and lymph-channels prev^ail. 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 paralysis. 
 
 PatholOg'y. — The essential nature of epilepsy is that of an abnormal 
 discharge of nerve-force from the liigher cerebral centres in the cortex, 
 an "occasional, sudden, rapid, and excessive discharge" {Dr. Hughlings- 
 Jackson). It matters not, for the essential character of this affection, 
 whether the phenomena are sensorial almost exclusively or motorial, 
 whether the sphere of mind is specially involved, or whether there is 
 the fullest development of the epileptic spasm ; the essence of tlie 
 disease consists in this excessive loccd 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, 
 
 * On the origin, essential nature, and conditioning factors of the nervous dis- 
 charge see a masterly analysis in Dr. Chailes Mercier's woi'k — 7'Ae Nerronj< 
 System and the Mind, 
 
THE MORBID NERVE-CELL IN EPILEPSY. 579 
 
 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 affections, such as chronic alcoholism whei'ein 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 
 functional endowments of the nucleus, but we may recognise its presence 
 in all conditions of active growth and functional life in the cell, whether 
 dt 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 the se7isory type of nerve-element, and that a functional 
 connection subsists betwixt them and the large motor elements dis- 
 tributed at a lower level; in fact we may, pei'haps, 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 1 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 ai'e constant accompaniments of cerebral 
 disturbances characterised by loss of inhibitor ij control, j 
 
 From this point of view, we have been accustomed to regard the 
 proportionate size of nucleus to nerve-cell as indicative of the inliibitory 
 •controlling capacity of the cell in question— its otan resistance to dis- 
 cfuirge. 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-elnnent charac- 
 
 * As proliably illustrated in its feeble staining to usual reagents. 
 
 t Nor is this supposition opposed to the results of Kussmaul and Tenner upon 
 the effects of sudden loss of large quantities of blood. Suddenly-induced ana'Uiia 
 by withdrawing the requisite pabulum would directl}' att'ect the nuclear centres of 
 -cell-life, which ai'e recognised as active!}' operative in the nutrition of the cell ; 
 the withdrawal of such pabulum would be ctpiivalent to a total arrest of such 
 function, to the virtual paral3sis resulting in the discharge of nerve-energy from 
 the cell expressed, on the mental side in loss of consciousness, and on the pliysical 
 side in general convulsions. 
 
580 PATHOLOGICAL ANATOMY OF EPILEPTIC INSANITY. 
 
 teristic of the mental operations would come into play. Certain it is 
 that in such cases where 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 n;otor energy ; but their nucleus is small in proportion 
 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- 
 ship 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, they are 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 
 * Trans. Roy. Soc, loc. cit. 
 
PATHOLOGY OF CHRONIC ALCOHOLISM. 58 1 
 
 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, 
 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 confirmation 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 Changes 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 Medullated 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 Endai'teritis- 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 General Paralysis— Significance of Arterial Changes — Affection of the 
 Visceral System. 
 
 'rhe vessels dipping into the cortex from the pia are of undue size, 
 coarse, frequently tortuous, and tlieir 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 
 
582 PATH0L0C4ICAL ANATOMY OF ALCOHOLISM. 
 
 in a state of fatty disintegration {PL x^\\.,fiys. 1, 2.) Far tiie more 
 prominent feature, however, is the abundance of scavenger-cells wliich 
 pervade the upper or outermost region of the peripheral zone of the 
 cortex lying immediately beneath the pia ; these nucleated proto- 
 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 xvii., Jig. 1). 
 Wherever 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 Glisson'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 staiuing 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 xvii., Jig. 1). Beneath the pia, 
 betwixt it and the surface of the cortex in the so-called epicerebral 
 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 sufiicient 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 xxiv.,^^. 1). 
 
IMPLICATION OF NERVE-CELLS. 583 
 
 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 {PI. xxiv., Jig. 2), 
 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 tlie 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 cerebi'al 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 
 COPtical layers are those more especially afiected ; cases being met 
 with where the uppermost layers show no morbid indications 
 whatsoever. 
 
 The vascular, nervous, 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 
 
584 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 which may have dropped out; or still convey distended vessels, the . 
 walls of which are mottled by atheromatous change, whilst a peculiar 
 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 {PL xxiv., 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 PL xx.iv.,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 differentiated 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 tilling the 
 vacuum. 
 
 Down in the lowest layer of the series — the spindle-cell formation — 
 we come suddenly upon large developments of scavenger- eel Is, 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 ramify- 
 ing processes in all directions around (J^l. yixiv., fig. 2). The spindle-cells, 
 moreover, are themselves covered by heaps of nucleaP pPOlifePations 
 which often entirely conceal them from view, so that their position 
 and course are usually mapped-out and alone indicated by these little 
 
r: 
 
 anqiiLu 
 
 nci 
 
 V^ 
 
 h e7'T:vas cicl a.y mcclei. 
 t'erivascuLar riuciex. 
 
 t^ 
 
 
 I \-oen pro I i nr 
 
 J^ er-^e ' celL zuide-rqoinc 
 qranulaT cLe q sne-r^ci^ ' . r 
 
 4^ ^'%^'^'m^L DisecLsecl. a.i^{r-r{ol& 
 
 Motor Nerve -cell and 
 ; Is TLiit-rierd 'vessel. 
 
 'C>r .jiui'lar <iH y ei\ei: a L] o il of" Mer-v<=j - cells itl fifili layer of 
 T'/l (jH C/i- Cf;Tl:x-"x '^/vitln. px' clil e^- atTon of ]-) exi c ellnjl ar &-peTi = 
 
 S'pi(J.er- cells p-rolvfcra-tTrio. 
 
 V*?*^^!;***-^- '/•• 
 
 .^ /Degenerating Nerve- cell 
 M- --''devoid ofmicleus. 
 
 .;=T*^^~~?i'~~V^^'^ T^'olxferaii on o-f 
 
 f" i V l\i ["ii JL- ^''""^^s^' on fu- 
 
 J\ />^ .''sifcTrtt ceils 
 
 \ 
 
 uLar nuclei. CToi/irdiT/q 
 a^' 'vralls of 'blood, -vessel. 
 
 r 
 
 ■ ' ' ' - .'j 
 
 ;) ' .. in deepest qt Spindle ceil layer 
 
 of TiumaA Corte-x-. 
 Chronic Alctjholic Insanity. 
 
 
 Fic.3. 
 
 o 
 Aneurisinal dilatation of 
 Perivascular sac 
 GeaeTal P6\ralysis 
 X 210. 
 
 Bal'; tDaJiieiaaon Ltd ,Srt:lp 
 
IMPLICATION OF NERVE-CELLS. 585 
 
 nuclear accumulations. One is also struck by their greatly diminished 
 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 PI. xx\.\'.,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 spimlle-CL-ll 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 of 
 axis-cylinder process of these large motor cells is a very persistent struc- 
 ture in most degenerative affections 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 persists. 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 brain 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 jireparations 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 alford us evidence 
 
586 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 also of grave structural change. These nutrient twigs are not only 
 generally dilated, but present along their course frequent fusiform and 
 sacculated aneurismal distensions, often of large size, the coats of which 
 are notably diseased. These aneurismal 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 
 numei'ous in such subjects. The sacculated dilatation is often the site 
 of a large accumulation of h^matoidine 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, extra vasated blood and hfemato- 
 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 Change, and the 
 nucleated element of the sheath also undergoing fatty disintegration ; 
 the walls covered with young^ Spider-Cells, and bristling with their 
 processes on either side {PI. xxiv.,Jig. 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 throughout 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 irregularly 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 affected, those of the anterior 
 columns least involved, whilst the lateral tracts sufter almost as 
 frequently as the posterior. These nutrient branches become pro- 
 minent objects by reason of the great increase in the thickness of 
 their walls — a feature which is exceptionally striking with respect to 
 
 
DISTRIBUTION OF SPINAL LESIONS. 587 
 
 the smaller vessels between 4 fi, and 8 ;x, in diameter, tlie open lumen 
 of such divided vessels rarely being over one-third or one-fourth the 
 whole diameter; but vessels measuring, respectively, 18 /i and 36 ^ 
 across also have not infrequently a lumen of but 5 //- to 10 /a,. This 
 increase in thickness is seen to be due entirely to their muscular coat, 
 which in small vessels of 8 /z diameter will attain the thickness of 2 /a. 
 The increase in the muSCUlaPiS encroaches much upon the cavity of 
 the vessel itself, and the non-elastic intinia is consequently thrown 
 into a plaited form, or has a condensed deeply-stained appearance 
 map])ing 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 jiresented them- 
 selves : — 
 
 Vessels in Chronic Alcoholic Insanity. 
 
 Presenting Spinal Symptoms. Cases Devoid of Spinal Symptoms. 
 
 Whole Diameter of t „ Diameter of .. 
 
 Vessel. ^""^«"- Vessel. ^"™''"- 
 
 18 M 5 M 18 m 13 m 
 
 27 M 9 m I 27 M 23 ^ 
 
 37 M 10 u ;V2 M 19 M 
 
 The change in these vessels appears to be identical with that 
 increase of the muscularis which has now been long recognised in 
 chronic Bright'S disease, since its discovery by Dr. Geo. Johnston; 
 no notable fatty cliange 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 
 vessels shows, in most cases, a normal condition, beyond the prevalence 
 here and there of amyloid bodies in juxtapo.-ition 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 hitter cases we find, however, indications of an 
 inflammatory change — a chronic meningitis; tlie pia being often greatly 
 thickened, its vessels mucli distended, and its meshes containing 
 leucocytes and inflammatory products. The connective trabecuhe 
 extending from the pia into the substance of the cord are extremely 
 coarse, and a diffuse SClerOSis thus originating often aflects all the 
 
588 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 medullated tracts of the spinal cord. Thus, the peripheral zone of the 
 cord is es^^eciallj implicated ; and the sclerosic 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 Gloll. 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. 
 Tlie posterior nerve-roots, also, indicate a similar interstitial change; 
 bundles of atrophied nerve-tubuli being seen embedded 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, iew cells remain- 
 ing, and these degenerated as the result of the inva.sive 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 gfroup of cells appears peculiarly prone 
 to degeneration, and other cell-groupings^e.^r., 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 trabeculfe 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 
 affection of the peripheral nerves is by no means ])robable ; they must 
 be regarded as coincident affections. Fi'equent 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 
 
PI ate. XXV 
 
 Spider -cells foltownio -rascular tract. 
 
 
 iS'yjzc/eT- cells with J cnq 
 deCiccLia fibrils 
 
 oarser vo.S'':izLa.r 
 hranches of 
 Spider- ceTL. 
 
 Scavenger elements (S-pid-^ 
 or i ■"''r layer of ''' 
 
 leral zone 
 
 Bale ScDaTii elsFoix Ltd. S-; i . 
 
PATHOLOGY— CHRONIC ENDARTERITIS. 589 
 
 we do not doubt, although the percentage of insane females subject to 
 chronic alcoholism is small ; but we must be prepared to regard cases 
 of chronic alcoholic insanity as presenting predispositions which more 
 or less 711 odify the tendency to peripheral implication of the nervous- 
 system. Whatever be the explanation of this paucity of cases of 
 multiple alcoholic neuritis amongst the insane community, certain it 
 is that alcohol in tliese predisposed subjects does tend to concentrate 
 its operations chiefly upon the vascular membranes, first, of the brain 
 and, next, of the spinal cord. 
 
 Pathologfy. — 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 sufi"er in the same way. 
 In one, the gasti'ic ; 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 virulence of the agent in their direction. 
 Undoubtedly a neUPOtiC heritage plays a foremost part in thus 
 predisposing to more exclusive determination of the morbid agency 
 upon the higher nervous centres, just as those subjects predisposed ta 
 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 eftect 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 eff'ect, 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 aneurismal states 
 described above are probably direct results of the diminished resist- 
 ance of the vessel, and paralysis of its muscular coat. An extensive 
 endarteritis of a most chronic and insidious character aflects 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- 
 
590 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 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 more 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 VCPy 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 membranes 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, apai't 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 througliout 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 sjnndle- 
 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 pei'ipheral 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 
 more usual, however, to find both areas affected, 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 morbid 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. 
 
STEATOSIS AND SCLEROSIS. 59 I 
 
 liowever, is far ditferent, aud 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 {PL xxix., Jig. 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 nervous 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 blood-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 ireneral 
 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. xxiii., 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 destruc- 
 tion and removal; but, this extensive atrophy of these large elements 
 of tlie cortex is coincident only with the most advanced forms of 
 alcoholic dementia ; the earlier stage of vascular impairment, and the 
 growth of young scavenger-cells in the peripheral zone, ere the cells are 
 themselves involved, being apparently associated with the maniacal 
 excitement and early delusional perversions of alcoholism. It is 
 certainly a remarkable feature that in both affections 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 
 affections, that it often becomes a moot point for diagnosis. This 
 
592 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 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, however, 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 
 w^ithin the white medullated substance of the fronto-parietal lobe, 
 associated with the degeneration and breaking-up of the large " motn^-- 
 cells " and spindle-series. Whilst, therefore, the cortical lesions of 
 general paralysis indicate an invasion from without inwards, affecting 
 the sensory elements and a])ical (? sensory) poles of the motor-cells, 
 alcoholism induces, in addition thereto, extensive vascular changes 
 from within outwards, implicating the medulla of the gyri, and 
 effecting a destructive degeneration of the medullated fibres. 
 
 Spinal COPd. — 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 similarly-dis})Osed 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, which 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.^., 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 fre- 
 quentlv, the posterior median raphe, spreading thence throughout the 
 columns of Goll. Whence this tendency to arise at different sites '? 
 What 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 general paralysis, dis- 
 tributed along the columns which are in anatoQiical connection with 
 discharging tracts at higher levels in tlie cerebrum ; and that, as in 
 general paralysis, we find system-degenerations established apparently 
 
Plate XX'\/I 
 
 
 A 
 
 Syvoller^ cLe<^enera.iea. /4d^ 
 
 Nerve.- cell 
 
 
 Y^ascular -process 
 of Spider -cell. 
 
 
 J V{J\'\I)egeriera,tirLg N^e-- 
 c&JZs a,iia.ck,ed, b 
 Spider- celZa. 
 
 S'-pT^d-er-ce-il -wj,ih, zis 
 , -vo-ScizlcLr process: 
 
 / ^^» \ ArierCoLe. siLrrou.rL.iJ.scL bv 
 
 Spider elerixerits. 
 
 Degeneration of Kerve - cells in Cortex 
 with proliferalion cf fhe Spider or Scavenger- cells. 
 Section from fiftK Cortical layer in Motor region. 
 
 X 210. 
 
 Bale fcDaraelsson.Lid . •'iculp 
 
NATURE OF THE SPINAL IMPLICATION. 593 
 
 along columns in physiological sympathy with diseased tracts higher 
 lip, yet not hij morbid continuity ; so here, also, the functional dis- 
 turbances aroused in the cortex may, probably, by inducing continuous 
 engorgement along certain spinal tracts, 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 lepto-meningitis, 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 upon site and dejyth of implication of the cord. 
 
 The lumbar coi'd may be the first afiected, and the deranged sensory 
 and motor syroptoms 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 pi'onounced 
 implications ; the vertical extent of the meningeal affection may be 
 slight or universal. 
 
 The constitutional state engendered in chronic alcoholic insanity is 
 identical 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 concentration 
 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 periarteritis 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 
 less correctly state the case, general paralysis 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 
 
 38 
 
594 
 
 PATHOLOGICAL ANATOMY OF ALCOHOLISM. 
 
 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 abvmdantly 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 Olai'ke. 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 siifFerer, 
 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 neurotic descent. 
 
595 
 
 INDEX. 
 
 Abdueens facialis, 21, 22. 
 
 ,, nucleus of, IS, 22. 
 
 Aboulias, 220. 
 
 Accommodation, centre for, 27. 
 Achromatine, 63 
 Acoustic strife, 10, 20, 
 ,, tubercle, 10. 
 Adherent pia, histology of, 496. 
 Adhesions of pia, 495. 
 Adolescence and alcoholic excess, 381. 
 
 „ and recurrent insanity, 238. 
 
 Adolescent insanity, 334. 
 
 ,, ,, blood in, 351. 
 
 „ ,, etiology of, 394. 
 
 „ ,, evolution of, 370. 
 
 „ ,, muscularsensein, 301. 
 
 ,, ,, prognosis in, 395. 
 
 ,, ' ,, staccato type of, 389. 
 ,, ,, stupor in, 377. 
 
 ,, ,, treatment of, .364. 
 
 „ ,, vaso- motor disturb- 
 
 ances, 378. 
 Adventitial coat of arteries, 90, .97. 
 
 ,, ,, capillaries, 91. 
 
 Affective insanity, 166. 
 Ala cinerea, 10. 
 Albertoni and Belmondo on duboisine, 
 
 481. 
 Alcohol, effect on animals, 306. 
 
 ,, ,, on reaction - time, 164, 
 
 363, 365. 
 Alcoholic insanity, 327, 370. 
 
 ,, >> 3- convulsive neurosis, 
 
 331, 341. 
 ,, ,, acute, 336. 
 
 ,, ,, amblj^opia in, 337. 
 
 ,, ,, and suicide, 331. 
 
 ,, ,, chronic, 342, 346. 
 
 ,, ,, clinical forms of, 336. 
 
 ,, ,, delusions in, 334, 335. 
 
 ,, ,, dyschromatopsiain,337. 
 
 ,, ,, evolution of, 345, 357. 
 
 ,, ,, fatty degeneration in, 
 
 586. 
 ,, ,, hallucinations in, 347, 
 
 352, 354, 358. 
 ,, ,, muscular spasm in, 365. 
 
 „ ,, natureofattack,331,357. 
 
 ,, ,, nystagmus in, .366. 
 
 Alcoholic insanity, patliological anatomy 
 of, 581, 594. 
 
 ,, ,, predisposition, 330, 332. 
 
 ,, ,, reaction-time in, 363, 
 
 364. 
 
 ,, ,, relapses in, 338. 
 
 ,, ,, scavenger-cells in, 582, 
 
 585. 
 Alcoholism, amnesic forms of, 348, 349. 
 
 ,, amyloid bodies in, 582. 
 
 ,, arachnoid opacity in, 590. 
 
 ,, classification of, 368, 370. 
 
 ,, climacteric and, 402. 
 
 ,, cortical adhesions in, 496. 
 
 , , delusional forms of, 334, 335. 
 
 ,, chronic, 342, 346. 
 
 ,, environmental resistance in, 
 
 350. 
 
 ,, epigastric voice in, 354. 
 
 , , epileptiform seizures in, 365. 
 
 ,, and epilepsy, 366. 
 
 ,, and epilepsy, hyoscyamine 
 
 in, 480. 
 
 ,, general paralysis and, 590. 
 
 ,, hypochondriasis and, 176. 
 
 ,, impulsive insanity and, 215. 
 
 ,, motor sjauptoms in, 360,362, 
 
 ,, muscular sense in, 301. 
 
 ,, nerve-ceils in, 583, 585. 
 
 ,, object-consciousness in, 350. 
 
 ,, peripheral zone in, 582. 
 
 ,, senile insanity and, 442,444. 
 
 , , sensory troubles in, 359. 
 
 ,, sexual illusions in, 355. 
 
 ,, spinal cord in, 592-594. 
 
 ,, symptoms of chronic, 346. 
 
 ,, types of, 368. 
 
 ,, vascular affections in, 591- 
 
 594. 
 
 ,, visceral illusions in, 332. 
 
 AllhnU (Prof.) on the optic disc, 200. 
 Alveus, 110. 
 
 Amenorrhoea and stupor, 377. 
 Amnesia in alcoliolism, 34S, 349. 
 ,, in senile insanity, 453. 
 ,, (transient) in (l."P., 289. 
 Araock (anuick) of tlie Malays, 210, 215. 
 Amphibia, brain of, 55, 56. 
 Ampliioxus, ,, 5.1. 
 
596 
 
 INDEX. 
 
 Amygdaloid nucleus, 36, 53. 
 Amyotrophic form of G. P., 564, 566. 
 Anaemia, signs of cerebral, 159. 
 Anaesthetics, action of, 148. 
 Andral on cerebral haemorrhage, 507. 
 Angular nerve-cells, 70. 
 Ansa pedunciilaris, 34, 35. 
 Aorta, compression of, 562. 
 Ape, cortex of, 123. 
 Apex-process of nerve-cells, 96. 
 Apoplectiform seizures, 298. 
 Apparatus, reaction-time, 161, 164. 
 Aprosexia and lymph obstruction, 100. 
 
 ,, Victor Lange on, 180. 
 
 Apncea, effect on cortex, 139. 
 Aqueduct and central grey axis, 24, 37. 
 Arachnoid, anatomical relationships of, 
 488. 
 ,, cysts, 491, 495. 
 
 ,, false membranes, 491. 
 
 , , hfemorrhage, origin of, 495. 
 
 ,, ,, statistics of, 
 
 493, 494. 
 ,, opacities, 490, 491. 
 
 Arborizations, terminal, 70. 
 Arcuate fibres of medulla, 12. 
 Argyll- Robertson, symptom in G.P., 304. 
 Arterial areas and softenings, 505-508. 
 ;, loops of cortex, 38. 
 ,, supply of brain, 498-502. 
 Arteries in G. P. , 557. 
 
 ,, of cerebral cortex, 89. 
 Arterio-capillary plexuses, 98, 100. 
 Articulatory troubles in G. P. , 294. 
 Association of ideas, failure in, 192. 
 Ataxia in general paralysis, 556. 
 Atavism in recurrent insanity, 239. 
 Atrophy, cerebellar, 510. 
 ,, cerebral, 508-512. 
 ,, ,, localised, 510-512. 
 
 ,, chronic cerebral, 439-455. 
 ,, ,, and BrigMs 
 
 disease, 459. 
 , , , , blood - vessels 
 
 in, 459. 
 „ ,, pulse in, 458. 
 
 ,, ,, urea in, 456, 
 
 458. 
 ,, senile, 440. 
 Attraction-sphere, 64. 
 Auditory nerve, cerebellar connections 
 of, 21. 
 , , cochlear root of, 20. 
 
 ,, Deifer's nucleus of, 20. 
 
 vestibiilar root of, 20. 
 
 An 
 Au 
 
 ditory nerve-niiclei, 20. 
 
 ra, auditory, 263. 
 
 , epigastric, 209. 
 
 , epileptic, 261. 
 
 , gustatory, 263. 
 
 , homicidal impulse and, 208. 
 
 , olfactory, 263. 
 
 , organic or. visceral, 264. 
 
 Aura, special sense, 262. 
 
 ,, vasomotor, 264. 
 
 ,, visceral, 264. 
 
 ,, visual, 263. 
 Automatic segregation, 150. 
 Automatism, epileptic, 274, 277, 279. 
 
 ,, mania and, 193, 194. 
 
 Ayers on centrosome, 65. 
 Axis, central grey, 1. 
 
 ,, cerebro-spinal, 1. 
 Axis-cylinder, fibrillation of, 86. 
 ,, process, 69, 75, 76. 
 
 ,, staining of, 78. 
 
 Axons, 69, 75, 78. 
 
 ,, plurality of, 126, 127. 
 
 ,, recurrent, 109. 
 
 Baetepieidal power of blood ininsanity,. 
 
 156. 
 Bain [Prof.) on animal appetites, 210. 
 Basal ganglia, connections of, 33, 34. 
 
 ,, process of nerve-cells, 75, 78. 
 Basket-work and basket-cells, 117- 
 Basichromatin, 66. 
 Batrachia, retinal rods in, 114. 
 Bauer and Voit on phosphorus poison- 
 ing, 534. 
 Beadles on A-asci^lar degeneration, 491. 
 Bechterei'j (Prof.) on blood pressure in 
 epilepsy, 265. 
 , , on consensual reaction 
 
 of pupils, 314. 
 Beevor^s physiological experiments, 136.- 
 Benda on the cj^oreticulum, 63. 
 Betz, giant cells of, 75, 129, 133. 
 Birds, brain of, 56. 
 
 ,, retinal rods of, 114. 
 Bladder atrophy in G. P. , 323. 
 
 troubles in G. P., 322-324. 
 Blandford [Dr. ) on Indian hemp, 484. 
 
 ,, on recurrent insanity, 251. 
 
 Blood in acute dementia, 1 89. 
 ,, adolescent insanity, 386. 
 ,, general paralysis, 525, 526. 
 ,, insanity, toxic effect of, 156. 
 ,, puerperal insanity, 403. 
 Blood-vessels in chronic alcoholism, 591- 
 594. 
 , , of cerebral cortex, 89. 
 
 Blumenhach on bony falx, 490. 
 Boll on spider-cells, 99. 
 Boettiger on trional, 478. 
 Bond on sclerosis of cerebellum, 511. 
 Bowel troubles in G. P., 324, 325. 
 Brachia of quadrigeminal bodies, 38, 39. 
 Brain of man and lower mammals, 124. 
 Brighfs disease and alcoholism, 593. 
 
 ,, and cerebral atrophy^ 
 
 458, 459, 587. 
 Brora s cerebral convolutions, 60. 
 
 ,, extra-limbus, 102. 
 Bromism, 180. 
 
INDEX. 
 
 597 
 
 Bruce [Ahx.) on motor oculi nucleus, 
 25, 26. 
 ,, on auditory nerve, 21. 
 
 Buchiill (Dr.) on mania and melancholia, 
 
 143. 
 Bulbar paralj'sis and colloid change, 
 
 519, 520. 
 BuUen {St. John) on cortical adhesions, 
 495. 
 ,, on locomotor ataxy in 
 
 a. P., 572. 
 Burdach, columns of, 5. 
 
 ,, lamina medullar is of, 35. 
 
 Caja.1, ascending axons of, 109. 
 ,, fibres grimpantes, lis. 
 ,, moss fibres, 119. 
 ,, on cells of retina, 115. 
 ,, on sensory cells, 71. 
 ,, on the retina, 116. 
 Calamus scriptorius, 8. 
 Calcarine fissure, 60. 
 Calmeil on pachymeningitis, 491. 
 Cainpljell [Alfred], neuro - muscular 
 changes in G. P. , 
 286, 576. 
 ,, morbid changes in 
 
 senility, 497. 
 ,, spider cells, 100. 
 
 Camiabis indica as a sedative, 484. 
 
 Wood on, 483. 
 Capillaries of brain, 98. 
 Capsule, internal, 29, 33. 
 
 knee of, 29. 
 Carpenter (Dr. ) on alcohol, 343, 344. 
 Carville and Duret, 140. 
 Cat, nerve-cells of, 79, 123. 
 Cataleptic fixity of limbs, 187. 
 Caudate nucleus, 29, 51. 
 Cells, archyochromic, 64. 
 ,, ascending axons, 109. 
 ,, chemistry of, 66. 
 ,•, conduction in, 67. 
 ,. configuration, 69. 
 ,, fatigue of, 68. 
 ,, metabolism of, 66, 67. 
 ,, mitral of olfactory, 112. 
 ,, physiology and pathology of, 67. 
 ,, pyramidal (of cornu), 80, 108. 
 ,, sensory of Golijt, 71. 
 ,, spider or scavenger, 100,554-556. 
 ,, stellate, 95. 
 ,, stychochromic, 64. 
 ,, transitional, of neuroglia, 95. 
 Central grey axis, 1. 
 Centre median of Luys, 45. 
 Centrosome, 64. 
 
 Cerebellum, atrophy and sclerosis of, 
 511. 
 ,, basket-cells of, 117. 
 
 ,, connective cells of, 119. 
 
 ,, cortex of, 116 
 
 ,, fibres grimpantes of, 118. 
 
 Cerebellum, granules of, 119. 
 ,, moss fibres of, 119. 
 
 ,, superficial layer of, 117. 
 
 Cerebellar peduncle (inner), 13. 
 
 ,, ,, (outer), 11, 12, 13. 
 
 ., tract (dii'cct), 7. 
 
 Cerebral seizures in G.P., 294. 
 Cerebritis, 502. 
 Cerebro-spinal axis, 1. 
 
 fluid, 491. 
 Charcot on cerebral haemorrhage, 507. 
 Childhood, insanity of, 208. 
 Chloral hydrate in insomnia, 475. 
 Chloralamide in insomnia, 476. 
 
 ,, effects on digestion, 477. 
 
 Chromatin of nucleus, 66. 
 
 ,, nature of, 66, 67. 
 
 Chromatolysis, 68. 
 Chromophil bodies in nerve-cells, 68. 
 
 ,, Meyer on changes in, 
 
 530. 
 Chronic insane class, 221. 
 Circular insanity, 252. 
 Ciliary muscle, centre for, 27. 
 Circulation, defective cerebral, 156. 
 
 , , Heuhner and Dtiret on, 500. 
 
 ,, mechanism of cerebral, 498, 
 
 499. 
 ,, Moxon (Dr.) on cerebral, 
 
 499. 
 Clarke (Henry) on alcoholism, 330, 366, 
 590. 
 ,, (Lockhart) vesicular columns of, 
 3, 17, 588, 594. 
 Claustral formation of Meynert, 83. 
 Claustrum, 35, 54. 
 Climacteric, alcoholic excess at, 434. 
 
 ,, convulsive neuroses at, 213. 
 
 ,, recurrent insanity, 248, 247. 
 
 ,, treatment during, 436. 
 
 Climacteric insanity, 424, 437. 
 
 ,, Cloitston (Dr. ) on, 430, 
 
 434, 435. 
 ,, delusions in, 425. 
 
 „ etiology of, 427. 
 
 .1/er.sm (Z>r.) on, 430. 
 ,, prognosis in, 433. 
 
 ,, sexual illusions in, 427. 
 
 ,, statistics of, 430. 
 
 , , transformations of, 
 
 430-4.32. 
 , , treatment of, 404. 
 
 Clinical groupings of G. P., .326. 
 Clouston (Dr.) on climacteric insanity, 
 433, 434. 
 ,, on pubescent insanity, 
 
 376. 
 ,, on senile speech, 454. 
 
 ,, predisposition in senile 
 
 insanity, 441. 
 Clustered cells of cortex, 75, 122, 133. 
 Collaterals, axons of, 109. 
 ,, recurrent, 109, 
 
598 
 
 INDEX. 
 
 Collatz on trional, 479. 
 Colloid degeneration, 518-524. 
 
 ,, biilbar paralysis and, 
 
 519-521. 
 ,, histology of, 521-524. 
 
 ,, Kesteven on, 522, 
 
 523. 
 ,, M^Kendrich on, 519. 
 
 Tuke {Batty) on, bis. 
 Commissure, anterior, 37. 
 
 ,, posterior, 37, 48. 
 
 Compensation, functional, 140. 
 Conariiim and brachia, 37. 
 Congenital defect and relapses, 240. 
 Conjugate deviation in G. P., 297. 
 Cones in retina, 114. 
 Conium in insanity, 485. 
 Connective cells of brain, 94, 95, 551, 
 558._ 
 ,, matrix of brain, 93. 
 
 Consciousness, faint and vivid states of, 
 145. 
 ,, lapsed states of, 120. 
 
 ,, object and subject, 143. 
 
 Consecutive dementia, 222. 
 Consensual movements in G. P., 314. 
 
 ,, of iris, 314. 
 
 Convvilsions, senile, 440. 
 Convulsive neurosis and alcohol, 331, 
 
 340, 366. 
 Cornil and Ranvier on nerve fibres, 87. 
 Cornu Ammonis, granules of, 110. 
 ,, lacunar layer of, 108, 
 
 ,, peripheral zone of, 107. 
 
 • ,, polymorphic cells of, 109. 
 
 ,, pyramidal cells of, 80, 
 
 108. 
 ,, striate layer of, 108. 
 
 ,, structiire of, 107. 
 
 ,, type of, 107. 
 
 Cornu, anterior, 4. 
 
 ,, caput and cervix, 3. 
 ,. posterior, 3. 
 Corpora albicantia, 31, 44. 
 ,, geniculata, 30, 31, 48. 
 ,, quadrigemina, 28. 
 ,, striata, 28. 
 Corpus trapezoides, 15, 23. 
 Corpuscles of nerve fibres, 87. 
 Correspondence, variations in the, 143. 
 Cortex cerebri, 60. 
 „ depth of, 121. 
 
 excitability of, 138, 139. 
 ,, functional equivalence of, 140. 
 ,, histology of, 62-135. 
 ,, lamination of, 101-119. 
 Cortical adhesions, 548, 551. 
 
 ,, ,, and alcoholism, 496. 
 
 Coupland (Dr.) on meningeal engorge- 
 ment, 500. 
 Cramps preceding epileptic seizures, 
 
 264. 
 Cranium, morbid states of, 486-488. 
 
 Crichton- Broivne (Sir J.) on arachnoid 
 haemorrhage, 
 493. 
 ,, ,, on brain 
 
 weights, 544. 
 onG.P.,289. 
 ,, ,, on localisa- 
 
 tion, 545. 
 Crises, gastric, laryngeal, and rectal, 
 
 573, 574. 
 Critical periods of life, 155. 
 Crucial sulcus, 123. 
 Crusta, 28. 
 
 ,, passage into capsule, 32. 
 ,, system of fibres in, 32. 
 Cycloplegia in general paralysis, 319. 
 Cytoplasm, 63. 
 Cytoreticulum, 63. 
 
 D'AbundO on the blood in insanity, 
 
 156. 
 Danilo on phosphorus poisoning, 534. 
 Deafness, depression accompanying, 159'. 
 Decorative tendency in G. P. , 292. 
 Decussation, anterior sensory, 23. 
 
 , , of cerebellar peduncle, .38. 
 
 ,, of trochlear nerve, 25. 
 
 Degeneration, colloid, 518-524. 
 fatty, 524. 
 ,, fuscous, 527-531. 
 
 ,, granular, 524-527. 
 
 ,, miliary, 512-518. 
 
 ,, pigmentary, 527-531, 576. 
 
 Degradation (tissue) from disease, 540. 
 ,, ,, from disuse, 541. 
 
 ,, ,, from overstrain, 
 
 540. 
 Deiters' cells, 98, 99. 
 
 ,, protoplasmic processes of, 86. 
 Delirious mania, 202. 
 Delirium, alcoholic, 336. 
 Delusional forms of alcoholism, 350. 
 
 „ insanity, 223, 233. 
 
 Delusions, genesis of, 152, 224. 
 
 ,, in alcoholic insanity, 334, 
 
 335. 
 ,, in climacteric insanity, 425. 
 
 ,, in epileptic insanity, 280. 
 
 ,, in general paralj'sis, 290, 292. 
 
 ,, senile and monomanical, 450. 
 
 ,, optimistic, 334. 
 
 ,, transient, 193, 290, 291. 
 
 ,, treatment of, 466. 
 
 Dementia, acute primary, 185. 
 ,, consecutive, 222. 
 
 ,, secondaryand tissue degrada- 
 
 tion, 543, 544. 
 ,, senile, 440. 
 
 Dendrites of nerve-cells, 65. 
 Dendritic plumules of cortex, 74, 76. 
 Dendrons of pyramidal nerve-cells, 74,76. 
 
 ,, primary and secondary', 76. 
 Dentate nucleus, 13. 
 
INDEX. 
 
 599 
 
 Denudations, unifoi'm and partial, 205. 
 Depression, conditions of pathological, 
 143. 
 ,, definition, 142. 
 
 ,, degrees of, 165. 
 
 ,, reaction-time in, 864, 865. 
 
 states of, 142, 178. 
 ,, treatment of acute, 470. 
 
 ,. ,, climacteric, 
 
 473. 
 ,, ,, lactational, 
 
 473. 
 ,, ,, neurasthenic, 
 
 472. 
 ,, ,, pubescent,472. 
 
 ,, ,, stuporose,472. 
 
 Depiivation, mental, 220. 
 Destructive habits, 467. 
 Developmental arrest, 205, 220, 581. 
 Diffusion currents in epilepsy, 257. 
 Dipsomania, 218. 
 
 Discharge (nerve) in alcoholic insanity, 
 357. 
 ,, ,, epilepsy, 579. 
 
 Dissolution in senile insanity, 447. 
 
 ,, planes of, 154, 155. 
 
 Disulphonesandh«matoporphyrine,479. 
 Disuse (functional) and tissue degrada- 
 tion, 541. 
 Divergence in laminar type, 103. 
 Dogiel on the cytoreticulum, 63. 
 Dominant ideas, 218. 
 Donders oil pupillary reactions, 276. 
 Duboisine as a sedative, 481. 
 Dudley (Dr.) on cerebellar atrophy, 510. 
 Dura mater, adhesions of, 489. 
 ,, bony plates in, 490. 
 
 ,, inflammation of, 488-490. 
 
 morbid states of, 488-490. 
 Durand- Fardel on haemori'hage, 507. 
 Duret, researches of, 140, 489, 500. 
 Dynamic attributes of perception, 145. 
 Dyschromatopsia in alcoholism, 337. 
 
 Eberth on the capillaries, 92. 
 
 ,, ,, vascular tunics, 90. 
 Echer on the convolutions, 60. 
 Effort, sense of conscious, 148. 
 Egoism of the geneial paralytic, 287. 
 ,, ,, pubescent subject, 375. 
 
 Ehrlich and Brie<jer on compression of 
 
 aorta, 562. 
 Erb on consensual reaction, 814. 
 Elastic coat of cortical arteries, 89. 
 Electric stimulation of cortex, 140. 
 Elkiiifi on phosphorus poisoning, 583. 
 
 ,, on suicidal and homicidal in- 
 sanity, 209. 
 EU'in (Dr. Giknore) on Malavan amock, 
 
 210, 215. 
 Eminentia' teretes, 9, 10. 
 Encephalon, comparative and enil)ryo- 
 
 logical, 55, (JO. 
 
 Enfeeblement, states of mental, 220. 
 Enuresis in G. P. , 323. 
 Environment in monomania, 225. 
 
 , , physical and physiological, 
 
 170. 
 ,, resistance of, 146, 148, 150, 
 
 225, 350. 
 ,, ti'ansformations of, 152, 
 
 153. 
 Epicerebral space, 91, 97. 
 Epigastric voice, 317. 
 Epilepsia larvata, 214, 215. 
 Epileps}', aura in, 227. 
 
 ,, automatism of, 269, 274, 279. 
 
 ,, alcoholic heredity in, 366. 
 
 , , blood pressure in, 265. 
 
 ,, deep reflexes in, 266. 
 
 ,, dreamy states in, 214, 215. 
 
 ,, (grand et petit mal), 231. 
 
 ,, hsemoglobin and specific 
 
 gravity in, 288. 
 ,, hyoscyamine in, 480. 
 ,, impidsive states of, 279. 
 , , interparoxysmal stage of, 274. 
 ,, muscular sense in, 301. 
 ,, nature of, 525. 
 ,, nucleus of nerve-cells in, 576, 
 
 579. 
 , , pathology of, 575. 
 ,, pigmentary degeneration in, 
 
 578. 
 , , post - paroxysmal period of, 
 
 260. 
 ,, post-paroxysmal erotism in, 
 
 269. 
 ,, premonitory stage of, 261. 
 ,, pre-paroxysmal stage of, 260. 
 ,, senile, 440. 
 ,, sensorj', 258. 
 ,, trional in, 478. 
 ,, vacuolation of nuclei, 535-537. 
 Epileptic discharge, 256. 
 
 ,, ,, clonos after, 266. 
 
 ,, ,, muscular cramps pre- 
 
 ceding, 264. 
 ,, ,, thievish propensities, 
 
 274. 
 ,, hj'pochondriasis, 275. 
 ,, katatonia, 272. 
 ,, mania, 267, 268. 
 ,, neurosis, 255. 
 ,, paroxysm, 264. 
 ,, status, 272-274. 
 Epileptic insanity, 255-284. 
 
 definition, 255. 
 degrees of reduction in, 
 
 257. 
 delusional states in,280. 
 diffusion currents in, 
 
 257. 
 discharge from sensory 
 
 areas, 258. 
 homicide in, 280. 
 
6oo 
 
 INDEX. 
 
 Epileptic insanity, hysterical attacks of, 
 270. 
 , , malingering in, 280. 
 
 ,, medico-legal aspects in, 
 
 277. 
 , , nascent nerve-tracts,257. 
 
 ,, reaction-time in, 277. 
 
 ,, treatment of, 282. 
 
 Epileptiform attacks in alcoholism, 365. 
 
 G. P., 296. 
 Esquirol on the mimetic tendency, 216. 
 Equivalence, functional, 140. 
 Etiology of circular insanity, 253. 
 Ewald on the keratoid sheath, 87. 
 Exaltation, definition of, 190. 
 
 ,, impulsive states in, 197- 
 
 ,, states of mental, 190-294. 
 
 Excitability of cortex, 138, 139. 
 Exner on reaction-time after alcohol, 364. 
 Explosiveness of nerve-tissue, 158, 159, 
 
 210, 395. 
 Extra-limbic type of cortex, 104. 
 Extra-polar conduction, 140. 
 
 Facial nerve, genu, 21, 22. 
 
 ,, nucleus, 18, 19. 
 
 Falx cerebri, Blumenbach on, 490. 
 
 ,, ossification of, 490. 
 
 Farrar {Dr. R. ) on general paralysis, 285. 
 Fasciculus, posterior longitudinal, 24, 
 35, 40. 
 ,, retroflexus, 47. 
 
 ,, solitarius, 8, 11, 17. 
 
 ,, teres, 9. 
 
 Fatigue, eilects on nerve-cells, 68. 
 Fatty degeneration, sources of, 473, 526. 
 ,, Cohnhtim on, 526. 
 
 „ Mott on, 473, 527. 
 
 Feelings, non-relational, 143. 
 Ferrier (Prof. ) on the convolutions, 60. 
 ,, ,, frontal lobe, 547. 
 
 ,, ,, motor area, 122. 
 
 ,, ,, physiological ex- 
 
 periments, 136, 
 141. 
 Fifth nerve, ascending root of, 11, 22. 
 Fillet, 14, 23, 37. 
 ,, of crus, 35. 
 Fimbria, 44. 
 
 ,, giant-cells near, 108. 
 Fishes, brain of, 55, 56. 
 
 ,, retinal rods in, 114. 
 Fissure, calcarine, 60. 
 
 ,, hippocampal, 60. 
 Flechsig, ground-fibres of, 5. 
 Flesch on phosphorus poisoning, 534. 
 Flemming, filar mass of, 64. 
 
 ,, interfilar mass of, 60. 
 
 Flexures, cranial, 59. 
 Fleury (Dr. ) on agitated melancholia, 177. 
 ,, insanityat climacteric, 426. 
 
 Folie a deux, 252. 
 Folic circulaire, 252. 
 
 Fore-brain, configuration of, 534. 
 
 Formatio reticularis, 4, 15. 
 
 Fornix, pillars of, 31, 44. 
 
 Frank and Pitres, researches of, 139. 
 
 Friction, Romanes on ganglionic, 160. 
 
 Fritsch and Hitzig, researches of, 138. 
 
 Fromann's striations, 88. 
 
 Frontal lobe, function of, 546, 547. 
 
 Fulminating psychoses, 205-220. 
 
 andamock, 210, 215. 
 Funiculus gracilis and cuneatus, 8, 11. 
 Fuscous degeneration, 527-531. 
 
 GalezOWSki on chromatic ansesthesia, 
 337. 
 
 Gallon, reaction-time register, 161-164. 
 Ganglia of crust and tegment, 28. 
 
 ,, olfactory, 56. 
 Ganglion, basal optic, 49. 
 Ganglionic cells of coi'tex, 121. 
 ,, ,, retina, 115. 
 
 ,, layer of motor area, 125. 
 
 Gaskell's visceral system of nerves, 4. 
 Gehuehlen on chromatolysis, 69. 
 
 ,, on axons of mitre-cells, 112. 
 
 Gelatinous substance oiRolando, 3,11, 566. 
 Gemmules on cells of Purhinje, 118. 
 General paralysis, 285-387. 
 
 ,, amyotrophic form of, 564- 
 566. 
 
 ,, ai-ticulation in, 294. 
 
 ,, ataxic form of, 571. 
 
 ,, ,, gait in, 556. 
 
 ,, atrophy of bladder in, 323. 
 bladder troubles in, 322-324. 
 
 ,, blood in, 325, 326. 
 
 ,, bowel troubles in, 324, 325. 
 
 ,, cerebral seizures in, 294. 
 
 ,, chronic alcoholism and, 591. 
 
 ,, classification of, 556. 
 
 ,, crises in, 564, 572, 573. 
 
 ,, cycloplegic forms of, 319. 
 
 ,, clinical groupings of, 326. 
 
 ,, deep reflexes in, 320. 
 
 „ delusions of, 290, 292. 
 
 ,, early moral perversions, 287. 
 
 ,, early paresis in, 289. 
 
 ,, enfeebled attention in, 288. 
 
 ,, epileptiform seizures in, 
 294, 296. 
 
 ,, facial expression in, 293. 
 
 ,, first stage of, 548. 
 
 ,, genuine tabetic form, 574. 
 
 ,, headache in, 574. 
 
 ,, kleptomania, 288. 
 
 ,, membranes in, 548. 
 
 , , meningeal haemorrhage, 553. 
 
 ,, muscular sense, 298. 
 
 ,, myosis, 303, 317. 
 
 ,, nerve-elements of cord, 50. 
 
 ,, oculo-motor svmptoms, 303- 
 320. / 
 
 ,, j)aralytic seizures in, 298. 
 
INDEX. 
 
 601 
 
 Oeneral paralysis, parenchj'matous 
 myelitis, 562. 
 ,, pathological anatomy of, 
 
 548-575. 
 ,, prodromal stage of, '2i6. 
 ,, pseudo-tabetic form of, 566- 
 
 570. 
 ,, reaction-time in, 302. 
 ,, rheumatoid pains in, 573. 
 ,, scavenger-cells in, 549-551, 
 
 555. 
 ,, second stage of, 190, 554. 
 , , self -decorative tendency in, 
 
 292. 
 ,, sexual perversions in, 293. 
 ,, spinal cord in, 556-575, 
 ,, ,, symptoms in, 320. 
 
 ,, syncopal attacks in, 294. 
 ,, tabetic gait in, 322. 
 ,, tactile sense, 300. 
 ,, third stage of, 555. 
 ,, transient amnesia of, 289. 
 ,, toxins in, 286. 
 ,, treatment of, 473. 
 ,, vascular implication in, 
 
 557. 
 ,, vasomotor derangement, 
 289. 
 CTeniculate bodies, 30, 31, 38, 39. 
 Gestation, insanit}' during, 408, 409. 
 Giant-cells of Befz, 121. 
 Globose cells, 82. 
 Globus pfillidus, 54. 
 Glosso-pharyngeal origin, 17. 
 Golgi, sensory cells of, 71. 
 ,, on spider-cells, 99. 
 ,, on stellate cells of cerebellum, 
 119. 
 Goodall on scavenger-cells, 100. 
 Gordon on paraldehyde, 477. 
 Goictvi, alternation of symptoms in 
 tabes, .556. 
 . ,, ascending sensory tract of, 5. 
 
 ,, on epileptic automatism, 215. 
 
 Granular disintegration, .524-527. 
 Granules, basichromatin, 66. 
 ,, chromophile, 69. 
 ,, ,, iyMyaro on, 64, 69. 
 
 ,, oxychromatin, 66. 
 ,, (iViW.s), staining of, 63, 64. 
 Granule-cell of cerebellum, 73, 119. 
 
 ,, of cerebral cortex, 71, 73. 
 
 „ of olfactory bulb, 73, 113. 
 
 ,, of retina, 73, 115. 
 
 Granule-layer of retina, 115. 
 Gralioht on the convolutions, 60. 
 ,, olfactory' area of, 53, 102. 
 ,, optic radiations of, 34, 45. 
 Orttnlees (T. Duncan), infrequency of 
 
 melancholia in Kaffirs, 190. 
 G ri<'jiin<itr on arachnoid opacities, 490. 
 ,, on cerebral irritation, 144. 
 
 ,, on chronic dementia, 223. 
 
 Groupings, significance of cell-, 133. 
 
 Habits, destructive, 467. 
 Ha?matoporphyrin and sulphonal, 479. 
 Hemoglobin in acute dementia, 189. 
 
 ,, in adolescent insanity, 386. 
 
 ,, in epileptic dementia, 161, 
 
 249. 
 in G. P. diminished, .325, 
 326. 
 ,, in puerperal insanity, 403. 
 
 Hasmorrhage, Andral and Charcot on, 
 507. 
 ,, arachnoid. 491-495. 
 
 ,, Crichto7i- Browne (Sir J.) 
 
 on, 493. 
 ,, efi'ects on cortex, 139. 
 
 ,, Lawson [Dr. Robert) on, 
 
 493. 
 ,, Rokitansky on, 492. 
 
 Hallucination in alcoholic insanity, 332, 
 347, 354, 358. 
 ,, in lactational period, 415. 
 
 ,, in recurrent insanity, 
 
 248. 
 ,, in seclusion, 167. 
 
 ,, unilateral, 195. 
 
 ,, with focal lesion, 195. 
 
 Hemiplegic seizures in G. P., 366. 
 Hemp (cannabis) in insanity, 483. 
 Hereditj' and senility, 440. 
 
 ,, in recurrent insanity, 238. 
 ITeubner on cerebral circulation, 500. 
 Hill (Dr. Alex) on amacrine cells, 113. 
 ,, on dendritic thorns, 
 
 65. 
 ,, on granules, 73. 
 
 Hippocampal fissure, 60. 
 His, perivascular canals of, 97, 100. 
 Hitzig, localisations of, 61. 
 
 ,, physiological experiments of, 
 136, 139. 
 Hodges on fatigue of nerve-cell, 68. 
 Hofman on proteid transformation, 527. 
 Homicidal impulse, 208, 213. 
 
 ,, impulse and melancholia, 
 
 212. 
 ,, insanity, 212. 
 
 Homicide and epileps}', 280. 
 Horn (anterior), motor cells of, 4. 
 
 ,, (posterior), sensory cells of, 4, 
 566. 
 Horned cells of cortex, 79. 
 Horsley (Victor), localisations of, 61. 
 
 ,, on the frontal lobes, 
 
 547. 
 ,, physiological experi- 
 
 ments of, 1,36, 139. 
 Hughlings-Jachfon {Dr.) on the nerve- 
 cells, 136, 138, 2,56, 257. 
 Hunger of the nerve-cell, 159. 
 .ffw.s-s (Magnus) on chronic alcoholism, 
 343. 
 
602 
 
 INDEX. 
 
 Huss [Jilagmis) on classification of alco- 
 holism, 368. 
 ,, on Swedish dram 
 
 drinkers, 345. 
 Hutchinson {Jonathan) on cycloplegia, 
 
 316, 319. 
 Huxley on the convolutions, 61. 
 Hyaloplasm, 64. 
 Hydrophobia, nerve-cells of, 
 Hyoscyamine in insanity, 479. 
 
 ,, Laicson on, 337, 479. 
 
 ,, Binger and Sainsbury on, 
 
 480. 
 ,, Savage on, 481. 
 
 Hj'pnotics, use of, in insanity', 475-485. 
 Hypnotism and stiipor, 180-182. 
 Hypoaria, 56. 
 Hypochondriacal melancholia, 172. 
 
 ,, ,, at pixberty, 
 
 146. 
 ,, ,, delusions of, 
 
 174. 
 ,, ,, morbid crav- 
 
 ingsof, 176. 
 ,, ,, suicide in. 
 
 176. 
 ,, cesoxDhagismus, 173. 
 
 Hj'pochondriasis, epileptic, 275. 
 
 ,, senile, 447. 
 
 H;^'poglossal nuclei, 15. 
 Hj'pophysis cerebri, 58. 
 Hysteroid attacks in epileps}-, 270. 
 
 Identity, failure of, 151. 
 Idiotcy, nerA'e-cells of, 85. 
 Illegitimacy and puerperal insanitj', 402. 
 Illusions(sexual) in alcoholic insanity,355. 
 Imaginative faculties in mania, 198. 
 Imitativeness of youth, 373, 374. 
 Imperative ideas, 218. 
 Impulse and alcoholic excess, 215. 
 ,, ,, insanity, 331. 
 
 ,, dreamy states of epilepsy, 
 
 214. 
 ,, homicidal, 179. 
 ,, ,, aura in, 209. 
 
 ,, ,, masked epilepsv, 
 
 214. 
 ,, insane, 207, 208. 
 Impulsive features in epileptic insanitj-, 
 277, 279. 
 ,, ,, in mania. 194. 
 
 , , , , in recurrent insanity, 
 
 247. 
 ,, forms of insanitj', 205. 
 insanity, 213-218. 
 Incidence of insanity as to age, 429. 
 Incoherence of mania, 197. 
 Incontinence in G. P., 322-324. 
 Inflammation of the brain, 502. 
 Inflated cells, 82. 
 Infundibulum, 31, 58. 
 Inhibition, 137, 138, 579. 
 
 Insanity, adolescent and pubescent 
 (treatment), 473. 
 ,, circular, 252. 
 
 ,, ,, etiolog}' of, 253. 
 
 ,, ,, treatment of, 254. 
 
 ,, commiinicated, 234. 
 
 ,, forms of impulsive, 205, 217. 
 
 , , of double form, 252. 
 
 of doubt, 219. 
 ,, partial or generalised, 230. 
 
 Insomnia, treatment of, 475, et seq. 
 Insula, 31, 54, 59. 
 Intemperance and recurrent insanity, 
 
 238. 
 Interannular segments, 87. 
 Intercalated layers, 120. 
 Intercurrent aiiections, effects of, 188. 
 Intermedio-lateral tract, 4, 588. 
 Intima of capillaries, 91. 
 
 ,, of cortical arteries, 89. 
 Intracellular digestion, 549. 
 Iridoplegia, associative, 304. 
 
 ,, cycloplegic, 305, 316, 319. 
 
 reflex, 304. 
 ,, ,, and associative, 315. 
 
 KaffiP races, melancholia infrequent in, 
 190. 
 
 Kahlhaum on katatonia, 272. 
 
 Karj'oplasm, 63. 
 
 Katatonia, epileptic, 272. 
 
 Keratoid sheath, 87. 
 
 Kesteven on colloid degeneration, 522, 
 523. 
 ,, on miliary sclerosis, 512. 
 
 Kleptomania, 217. 
 
 Knee-jerk in G. P. (abolished), 321, 
 ,, (increased), 320. 
 
 Knoll on consensual reaction, 314, 
 
 KolJe ( Theodore) variability in delusions, 
 193. 
 
 Kolliktr on basket-cells, 117. 
 ,, on nerve-processes, 86. 
 
 Ko^ter on trional in G. P. and alco- 
 holism, 478. 
 
 Krafft-Ebing on trional in insanity, 478. 
 
 Krause on the retina, 116. 
 
 Kre.yssig on phosphoi'us poisoning, 5.34. 
 
 Kries and Auerbach on reaction-time, 
 165. 
 
 Ktihne on the keratoid sheath, 87. 
 
 Kupffer's stratum moleculare, 107. 
 ,, reticulare, 107, 
 
 Labile equilibrium, 236. 
 Lactation, insanity during, 409. 
 ,, physiologv of, 419. 
 
 risks of, 409. 
 ,, treatment of depression in, 
 
 423. 
 Lactational insanit}', delusions of, 411. 
 ,, etiology of, 416, 
 
 hallucinations, 415. 
 
INDEX. 
 
 60 • 
 
 Lactational insanity, prognosis, 422. 
 
 ,, sexual pervei'sions, 
 
 414. 
 ,, suicide, 412. 
 
 ,, symptoms, 410. 
 
 ,, treatment, 42.3. 
 
 Lacunar layer of cornu Ammonis, 108. 
 Ladd on reaction-time, 165. 
 Laminae medullares, 54. 
 Lamina medullaris of Burdnch, 45. 
 Laminar arrangement of cells, 122. 
 ,, tj'pes of cortex, 103, 132. 
 Lamination of cornu Ammonis, 107-111. 
 ,. of cortex, 101. 
 
 ,, of extra-limbus, 104, 107. 
 
 ,, of upper limbic, 104, 105. 
 
 ,. of modified upper limbic, 
 
 104, 105. 
 ,, of motor area, 125-129, 
 
 of olfactory bulb, 104, 111. 
 „ type (inner), 
 104, 106. 
 ,, ,, ,, (modified), 
 
 104, 106. 
 ,, ,, ,, (outer), 
 
 104, 106. 
 Lamprey, 55. 
 
 Landois on cortical vaso-motor centres, 
 378. 
 ,, on nerve-processes, 86. 
 LandoU and Siirlhig on grow'th, 372. 
 Lange (Df. Victor) on aprosexia, ISO. 
 Lantermann on nerve-fibres, 88. 
 Latent period, Ladd [Prof.) on, 165. 
 
 ,, of stimulation, 138, 165. 
 
 Lateral mixed-system, 12, 16. 
 
 , , sensorj^ nucleus of, 16. 
 
 Laicson {Dr. Robert) on arachnoid cysts, 
 493. 
 ,, on hyoscyamine, 
 
 3.37, 479. 
 Lecithin as a source of fat, 526. 
 
 ,, and fat, Miescher and Hofman 
 on, 526, 527. 
 Lemniscus, 23, 37, 39. 
 Lesion, effects on nerve-cell contents, 69. 
 Lenticular nucleus, 26, 49, 54. 
 Lewes ( G. H.) antagonism of growth and 
 
 development, 37'i. 
 Limbic arc of rabbit's brain, 102. 
 
 ,, type of upper, 104, 105. 
 Limbic lobe, 102. 
 
 ,, type, modified upper, 104, 105. 
 Localisation of function, 61. 
 Locomotor ataxia in G. P., 571. 
 Locus c'eruleus, 25. 
 
 ,, niger, 31. 
 Lugaro on Xi-ssl'-i graniUes, 69. 
 Linin network, 65. 
 Lvy^s centre median, 45. 
 Lymph-connective system, 96, 534. 
 
 ,, ,, in senile atroph}-, 
 
 497, 534, 542. 
 
 Lj'mph obstruction and aprosexia, 100. 
 Lymphatic system of brain, 96-101. 
 Lyra, 44. 
 
 Maeleod on piierperal insanity, 402. 
 Macpherson on vacuolated nuclei in 
 
 concussion, 537. 
 Malfatti on nucleic acid, 66. 
 Magnan on alcoholism, 339, 343, 345, 
 368. 
 ,, on antagonistic hallucinations, 
 195. 
 Major (Dr. H. C.) on cerebellar atrophy, 
 510. 
 ,, on granular degenera- 
 
 tion, 525. 
 Malays, temperament of, 210. 
 Malingering in epilepsj'^, 280. 
 ,, insanity, 281. 
 
 Mania, acute delirious, 202. 
 „ bodily symptoms in, 199. 
 ,, contrasted with melancholia, 
 190. 
 epileptic, 267, 268. 
 ,, instinctive level of, 193, 194. 
 ,, onset of, 196. 
 ,, opium in, 482. 
 „ periodicity of, 200. 
 ,, prognosis in, 201. 
 ,, a potu, 336. 
 ,, recovery in, 201. 
 
 senile, 438. 
 ,, sj-mptoms of, 196-199. 
 ,, temperature in, 200. 
 ,, transitoria, 215. 
 Marc on homicidal impulse, 209. 
 Marcet {Dr. ) on alcoholic diseases, 346. 
 Martinotti on ascending axons, 82. 
 Marinesco on traumatism of cells, 69. 
 Masing {RudolJ) on alcohol, 344. 
 Masturbation and insanity, 391, 395. 
 Maudsley {Dr. ) on mania transitoria, 
 
 214, 215. 
 Medico-legal aspects of insanity, 277- 
 Medulla oblongata, 8. 
 
 ,, columns of, 11, 20. 
 
 Medullary groove, 57. 
 ,, lamina?, 55. 
 
 Medullated inter-annular segments, 87. 
 
 ,, nerve-fibre, 87. 
 
 Melancholia, affective, 166. 
 ,, agitans, 176. 
 
 ,, clinical grou])s of, 167. 
 
 ,, dehisional, 170. 
 
 ,, homicide in, 212. 
 
 ,, liypocliondriacal, 172. 
 
 ,, oj)ium in, 4S1. 
 
 senile, 438, 449. 
 ,, stuporose, 184. 
 
 Melancholic stadium, 196. 
 Mendet on duboisine, 481. 
 jMenstrual derangement and convulsive 
 neuroses, 213. 
 
6o4 
 
 INDEX. 
 
 Menstrual derangement and recurrent 
 insanity, 241. 
 , , and stupor, 377, 385. 
 
 Mercier {Dr. Chas.) on the nervous 
 
 system, 578. 
 Merson [Dr.) on climacteric insanity, 
 
 430, 435. 
 Mesencephalon, 28. 
 
 Metschnikof on intra-cellular digestion, 
 549. 
 ,, phagocytes, 549. 
 
 Meyer on chromophil granules, 530. 
 Meynert on cerebellar atrophy, 510. 
 ,, on cortical lamination, 104. 
 ,, on depth of cortex, 121. 
 ,, on nerve-cells, 74, 76, 80, 83. 
 Microsomes, 64. 
 Middlemost (and Elkins) on phosphorus 
 
 poisoning, 535. 
 Miescher's observations on growth of 
 
 ova, 526. 
 Mickle on epileptiform seizures, 296. 
 Mimetic tendency, Esqtdrol on, 216. 
 Mitchell ( W^eir) on trional, 479. 
 Mitre-cells, axons of, 112. 
 
 ,, of olfactory bulb, 1 12. 
 
 Meynert on axons, 76. 
 3Iongeri on duboisine, 481. 
 Monomania, cases of, 226-229. 
 ,, definition of, 223. 
 ,, environmental resistance, 225. 
 ,, genesis of, 224. 
 ,, mystic sj^mbolism in, 225. 
 ,, perverted ideation in. 224. 
 Monoplegic seizures in G.P., 287. 
 Monro, foramen of, 57. 
 Moral perversion in G.P. , 287. 
 Moss-fibres of cerebellum, 119. 
 
 ,, of cornu, 110. 
 
 Mosso on cerebral circulation, 500. 
 Morphia in insanity, 482, 483. 
 Motor area of cortex, 125-129. 
 ,, cell-groupings, 129-132. 
 „ cells, 75-80. 
 
 ,, enfeeblement in alcoholism, 360. 
 Motor oculi, nucleus of, 25, 26. 
 Mott (Dr.) on origin of fat from lecithin, 
 
 526. 
 Moxon (Dr.) on the cerebral veins, 499. 
 Muscular coat of arteries, 90, 591. 
 ,, element of mind, 145, 148. 
 ,, sense, apparatus for testing, 
 
 301, 302. 
 ,, ,, discrimination, 298. 
 
 ,, ,, measurement of, 299-301. 
 
 Mydriasis, paralytic, 303. 
 Myelitis, parenchymatous, 562. 
 Myosis, pai'alytic, 303. 
 
 ,, significance of, 303, 317. 
 ,, spastic, 303. 
 Munk, effects of haemorrhage, 139. 
 
 Nates, structure of, 38. 
 
 Negative states of mind, 144. 
 Nerve-cells, 62, 65-85. 
 ,, angular, 70. 
 ,, comparative size of, 135. 
 ,, classification of, 70. 
 ,, developmental arrest of, 531. 
 ,, effects of poisons on, 156. 
 ,, granule, 71. 
 ,, Hughlings- Jackson (Dr.) on, 
 
 257. 
 ,, inflated or globose, 82. 
 ,, motor, 75. 
 „ nucleus of, 65, 109-111. 
 , , primitive and degenerate type 
 
 of, 533, 579. 
 ,, pyramidal, 73. 
 
 A:o.9s(Z)r.) on, 580. 
 ,, sensory (of Golgi), 71. 
 ,, significance of form, 580. 
 ,, ,, size, 107. 
 
 ,, spindle-shaped, S3. 
 Nerve-discharges in alcoholism, 357- 
 Nerve-fibres, 85-89. 
 
 ,, corpuscles of, 87. 
 
 ,, destruction of, 537. 
 
 ,, naked, 86. 
 
 Nerve-tracts, forcing of nascent, 257. 
 Narcosis, effects on cortex, 139. 
 Nested-cells of cortex, 75, 129, 133. 
 Neural canal, 57. 
 Neuro-enteric canal, 58. 
 Neuroglia cells, 93-96. 
 ,, matrix, 92. 
 
 ,, scavenger-cells of, 98-101,555. 
 ,, stellate-cell of, 95. 
 ,, transitional cells of, 95. 
 Neuron, 70. 
 Neurosome, 69. 
 
 Nicolson ( Dr. ) on the homicidal act, 169. 
 Niemeyer on puncta vasculosa, 448. 
 Nissl on classification of nerve-cells, 64. 
 ,, on the cytoreticulum, 63. 
 , , on effects of poisons on nerve-cells, 
 156. 
 Nocturnal crises, 194. 
 Notochord, 59. 
 
 Nuclear lamina of Amnion's horn, 107. 
 Nucleus, acoustic (anterior), 21. 
 ,, (external), 21. 
 (internal), 20. 
 ambiguus, 24. 
 amygdaloid, 52. 
 caudatus, 29, 51. 
 chromatin of, 65. 
 clavate, 6, 8, 12, 13. 
 cuneate, 6, 8, 12, 13. 
 dentate (cerebellum), 13. 
 displacement of, 63, 68, 69. 
 facial, 19, 22. 
 hypoglossal, 10, 12, 16. 
 of lateral columns, 14, 17, 20. 
 lenticularis, 31, 49, 54. 
 linin network of, 65. 
 
INDEX. 
 
 605 
 
 Nucleus, morphology of, 65. 
 
 of nerve-cells, 55, 109-111. 
 
 ,, oculo-motor, 26. 
 
 ,, ruber of tegmentum, 27, 39, 47. 
 
 ,, sacral {stiiLmrj), 4. 
 tecti, 13, 23. 
 
 ,, trigeminal (motor), 24. 
 
 ,, trochlearis, 27. 
 
 ,, vacuolation of, 535. 
 
 ,, vago-accessory, 10, 12. 
 Nucleins, 66. 
 
 ,, and xantbin products, 67. 
 Nurse, the mental, 461. 
 Nursing mother, qualifications of, 417- 
 
 422. 
 Nutritive impairment, acute, 156. 
 Nystagmus in alcoholism, 366, 
 
 ObeFSteineP on the lymphatics, 96. 
 Object -consciousness, failure of, 143, 
 
 144, 157. 
 Obsessions, 218. 
 Ociilo-motor nucleus, 26. 
 
 ,, mechanism, diagram of. 
 
 318. 
 ,, signs in tabetic G. P., 319. 
 
 ,, symptoms in G. P., 303- 
 
 320. 
 CEsophagismus in hj'pochondriasis, 173. 
 Ogstoh (Dr. ) on alcohol, 343. 
 Olfactory area, 53, 102. 
 
 bulb (type), 104, 111. 
 ,, cortex (type), 106. 
 ,, lamination, 112. 
 Ophthalmoplegia interna, .304, 316. 
 Opium in treatment of insanity, 481. 
 Olivary bodj' (accessory), 14. 
 ,, (inferior), 14, 19. 
 
 (superior), 19, 22. 
 Olivary fasciculus, 14. 
 Optic disc in mania (Prof. Allhutt), 200. 
 ,, ganglion (basal), 49. 
 ,, nerve (origin), 49. 
 ,, radiations of Gratiolet, 34, 45. 
 Optimism in alcoholic insanity, 295. 
 Orfila on alcoholic poisoning, 344. 
 Ovarian dei'angement at pubescence, 
 
 3S2-3S4. 
 Overstrain and tissue-degradation, 540. 
 Oxley (Dr.) on amock of Malays, 210. 
 Oxychromatin, 66. 
 
 Pachymeningitis (externa), 489. 
 
 ,, (interna), 491. 
 
 Pain and pleasure, genesis of, 160, 161. 
 
 in (t. P., 573, 574. 
 Paraldehyde, effects on digestion, 477. 
 ,, Gordon on, 477. 
 
 ,, in the insomnia of insan- 
 
 ity, 477. 
 Paranoia (see Syntematined insaniti/, pro- 
 gressive), 229. 
 Paretic states in alcoiiolism, 36G. 
 
 Parietal sulcus, primary, 102. 
 Pathology of chronic alcoholism, 581- 
 594. 
 ,, of epileptic insanity, 575- 
 
 581. 
 ,, of general paratysis, 548- 
 
 575. 
 ,, of insanity, 543-547. 
 
 ,, of secondary dementia, 537- 
 
 543. 
 Peduncles of pineal gland, 42, 47. 
 ,, of thalamus, 35, 51. 
 
 ,, superior cerebellar, 37, 39. 
 
 Peduncular sensorj^ tract, 32, 33, 34. 
 Perception, statical and dynamic attri- 
 butes of, 146. 
 Percy (Dr.) on alcoholic stimuli, 344. 
 Pericellular sacs, 97. 
 Periodicity of maniacal reductions, 200. 
 Peripheral zone, cells of, 126, 127. 
 Perivascular cells, 97. 
 
 ,, channels, 97, 100. 
 
 Personality, double, 151. 
 
 ,, transformations of, 150- 
 
 154. 
 Perversions, monomaniacal, 224. 
 Phagocytes, 84. 
 Phagocytosis, reference to authorities, 
 
 100. 
 Phosphorus poisoning and fatty degen- 
 eration, 534, 535. 
 ,, and jmcleins, 66. 
 
 Pia-arachnoid, adhesions of, 495. 
 
 ,, alcoholic excess, 496. 
 
 ,, morbid states of, 490- 
 
 492. 
 „ opacities and thicken- 
 
 ings of, 490. 
 „ Robertson on, 490, 492. 
 
 Pick (Pro/.) on unilateral hallucinations, 
 
 195. 
 Pig, cortex of, 79, 122. 
 
 ,, nerve-cells of, 79, 85, 122. 
 Pigmentary degeneration, 527-531. 
 Pigmentation, Schdfer on, 528. 
 Pineal body, 37, 47. 
 Pitres, researches of, 139. 
 Pituitary body, 31, 58. 
 Pneumogastric in hjqiochondriacal 
 
 melancholia, 173. 
 Poisons, elfects on nerve-cells, 129. 
 Polygonal cells of Cajal, 71. 
 Pons Varolii, 19. 
 
 ,, brachia of, 19. 
 
 Popow on phosphorus poisoning, 534. 
 Positive states of mind, 144. 
 Posterior perforated space, 31. 
 Pregnancy, insanity during, 408, 409. 
 Premature senility, 455-460. 
 Primary processes of cells, 74, 76, 78. 
 Primitive nerve-fibrils, 85. 
 Prognosis in acute mania, 201. 
 
 ,, in adolescent insanity, 395. 
 
6o6 
 
 INDEX. 
 
 Prognosis in pubescent insanity, 395. 
 i^^-,, in puerperal ,, 404. 
 
 ,, in recurrent ,, 250. 
 
 Protoplasmic processes, 86. 
 Pseudo-tabetic G. P., 566-570. 
 Psycho-motor centres, contiguity of, 
 
 141. 
 Puberty, egoism of, 374. 
 
 ,, imitative tendency of, 374. 
 „. Smith (Dr. Edward) on, 373. 
 Pubescent epoch and convulsive neiu'oses, 
 394. 
 ,, . ,, evolution of, 370. 
 „ ,, and insanity, 240-242, 
 
 .370. 
 ,, ,, in the female, 335. 
 
 ,, ,, in the male, 387. 
 
 , , insanity, ancestral influence in, 
 
 380, 381. 
 ,, ,, and anaemia, 384. 
 
 ,, ,, etiology of, 379, 394. 
 
 ,, ,, Gloustoii on, 376, 390, 
 
 399. 
 ,, ,, in the female, 375. 
 
 „ ,, in the male, 389, 
 
 ,, ,, masturbation in, 391, 
 
 393, 395. 
 ,, ,, ovarian derangements 
 
 in, 382-384. 
 ,, ,, pi'ognosis in, 395. 
 
 „ stupor in, 377, 384, 386. 
 ,, ,, treatment of, 397. 
 
 ,, ,, A^aso- motor derange- 
 
 ments in, 378. 
 Piierperal insanity, blood in, 403. 
 
 ,, etiology of, 400-403. 
 
 ,, ,, illegitimacy and, 
 
 402. 
 ,, ,, intensity of excite- 
 
 ment, 399. 
 ,, and kleptomania, 
 
 218. 
 ,, ,, MacLeod on, 402. 
 
 ,, ,, prognosis in, 404. 
 
 ,, ,, sexual element, 399. 
 
 ,, ,, suicide in, 401). 
 
 ,, ,, treatment of, 407. 
 
 ,, period and insanity, 401, 402. 
 Pulvinar, 42. 
 
 Pupillary anomalies, significance of, 
 317. 
 ,, contraction, centre for, 308. 
 
 Pupils, Argyll- Robertson sign, 304. 
 ,, consensual reaction of, 314. 
 ,, in general paralysis, 303-320. 
 „ inequality of, 303, 305, 308. 
 ,, reflex dilatation of, 315. 
 Purkinje, cells of, 117. 
 
 ,, axons of cells of, 118. 
 
 ,, functional solidarity of cells 
 
 of, 118. 
 ,, relationships of cells of, 118. 
 Pyknomorphic stage, 64. 
 
 Pyramidal cells, 73. 
 
 ,, axons of, 75, 76, 78. 
 
 ,, of cornu, 80. 
 
 ,, pigment of, 76. 
 layer of cornu, 80. 
 tracts (crossed), 5. 
 
 ,, (direct), 5. 
 
 ,, (in crusta), 32. 
 
 QuadPigeminal bodies, 28, 38. 
 
 Quetelet on growth, 372. 
 
 Rabbit, nerve-cells of, 80. 
 
 ,, topography of brain, 102. 
 Radiations of Gratiolet, 34. 
 Banvier, nodes of, 87. 
 Rat, nerve-cells of, 80. 
 Reaction-time in alcoholic insanity, 363, 
 364. 
 ,, in epileptic insanity, 277. 
 
 ,, in exaltation and depres- 
 
 sion, 364, 365. 
 ,, in general paralysis, 302. 
 
 ,, in health and disease, 164. 
 
 ,, Kries and Auerhach on, 
 
 165. 
 ,, in melancholia, 161, 364, 
 
 365. 
 ,, apparatus for testing, 
 
 161-164. 
 Reconstructive period of climacteric, 431 . 
 Recoverabilityof maniaand melancholia, 
 
 222. 
 Recoveries abrupt in mania, 172. 
 Rectal crises in G. P., 573. 
 Recurrent insanity, 201-220. 
 
 ,, ,, adolescent subjects 
 
 and, 242. 
 ,, ,, age and, 245. 
 
 ,, ,, alcoholic excess and, 
 
 238. 
 ,, ,, atavism and, 239. 
 
 ,, ,, Blandford on, 251. 
 
 ,, ,, climacteric subjects 
 
 and, 243. 
 ,, ,, congenital defect 
 
 and, 240. 
 ,, ,, definition of, 235. 
 
 ,, ,, farinaceous dietary 
 
 and, 254. 
 ,, ,, hallucinations in, 
 
 248. 
 ,, ,, heredity and, 238. 
 
 ,, ,, incidence of attack, 
 
 238. 
 ,, ,, menstrual irregular- 
 
 ities and, 241. 
 ,, ,, morbid impulse and, 
 
 247. 
 ,, ,, nature of attack, 
 
 240. 
 ,, ,, neurotic heritage in, 
 
 238, 239. 
 
INDEX. 
 
 607 
 
 ReciuTeut insanity, prognosis in, 250. 
 ,, ,, puerperal subjects 
 
 and, -246. 
 ,, ,, Sankey (Dr.) on, 
 
 236. 
 ,, ,, senile epoch and, 
 
 245. 
 ,, ,, stuporose states in, 
 
 241. 
 ,, ,, traumatism and, 
 
 246. 
 ,, ,, treatment of, 254. 
 
 Reductions, ejjileptic, 257, 275. 
 ,, maniacal, 190. 
 
 ,, melancholic, 138. 
 
 ,, senile, 447. 
 
 Reflexes (deep) in G. P., 320. 
 
 ,, in epilepsy, 266. 
 Regional distribution of nerve-cells, 121. 
 Heid on climacteric insanity, 430. 
 ReU, island of, 31. 
 
 ,, substantia innominata, 35. 
 Re-integration, 154. 
 Relation, definition of, 146. 
 Relational element of mind, 146. 
 Representativeness, enfeebled, 145. 
 ,, vigour of, 150. 
 
 Reptiles, brain of, 56. 
 
 ,, retina of, 114. 
 Resistance, sense of, 147, 148. 
 Restiform columns, 10, 12. 
 Restriction of the will, 149, 352. 
 Retina, cones of, 114. 
 
 ,, ganglionic cells of, 115. 
 ,, granule layer of, 115. 
 ,, plexiform layer of, 114, 115. 
 ,, rods of, 114. 
 „ spongioblasts of, 115. 
 Retinal cones of reptiles, 114. 
 ,, rods of Batrachia, 114. 
 ,, ,, of birds and fishes, 114. 
 
 Retention in G. P., 322-.324. 
 Reticular formation, 4, 13. 
 Reticulated stratum of Kupjfer, 107. 
 
 ,, white substance, 101. 
 
 Re^ivability of impressions, 349, 
 Rhythm, nutritional, 137. 
 Ringer (and Sainsbury) on hyoscyamine, 
 
 480. 
 Robertson (Dr. W. F.) on opacity of pia- 
 
 arachnoid, 490, 492. 
 Rodents, brain of, 68, 102. 
 Rokltansky on arachnoid opacities, 490. 
 ,, on engorged membranes, 500. 
 Rolando, fissure of, 59. 
 
 ,, tubercle of, 24. 
 Romanes on "ganglionic friction," 160. 
 Roof-nuclei of Stillinq, 13, 23. 
 Root- zones of cord, 8, 
 Ross (Dr.) on the lateral cell-groups, 
 14. 
 , , on tlie lateral mixed system, 
 
 3. 
 
 Ross (Dr.) on the nerve-cells, 580. 
 Ruxton (Dr.) on the blood-vessels of 
 G. P., 563. 
 
 Sankey (Dp.) on recurrent insanity, 235. 
 Satj'riasis and epilepsy, 269. 
 Sava/e (Dr.) on ataxic symptoms in 
 G. P., 322. 
 ,, on epileptic seizures in 
 
 G. P., 295. 
 ,, on prognosis in mania, 
 
 201. 
 Scavenger-cells, 100, 554-556. 
 
 ,, CampbeU on 100. 
 
 ,, Goodall on, 100. 
 
 ,, and chronic alcoholism, 
 
 582-585. 
 ,, fibrillation of, 
 
 ,, general paralysis and, 
 
 549-551, 555. 
 ,, miliary sclerosis and, 
 
 516. 
 ,, nerve-fibre plexus and, 
 
 5.37-541. 
 , , senile atrophy and, 497. 
 
 ,, spinal cord and, 558. 
 
 Schdfer (Prof.) on pigment in nerve- 
 cells, 528. 
 ,, on spongioblasts, 115. 
 
 ,, researches of, 139, 547. 
 
 Schijf, effects of narcosis, 1.39. 
 Sclerosis of cerebellum, 510. 
 ,, histology of, 514-518. 
 ,, miliary, 458. 
 ,, scavenger-cells in, 516. 
 Seclusion and hallucination, 195. 
 Secondaiy processes of cells, 78. 
 Sedatives in insanity, 475. 
 Segmentation of third cranial nerve, 
 
 25-28. 
 Senile amnesia, 453. 
 ,, atrophy, 449. 
 ,, convulsions, 408. 
 ,, dementia, 440. 
 ,, epilepsy, 440. 
 ,, hypochondriasis, 449. 
 ,, mania, 438. 
 ,, melancholia, 438. 
 Senile epoch, changes of, 437. 
 
 ,, recurrent insanity and, 245. 
 
 Senile insanity, adhesions in, 497. 
 ,, amnesia of, 453. 
 
 ,, alcohol and, 442. 
 
 ,, atrophy ami, 499. 
 
 ,, delusions and, 450. 
 
 ,, onset and prodroniata, 
 
 444. 
 ,, reductions of, 447. 
 
 ,, .scavenger-cells in, 497- 
 
 ,, sexual perversions in, 
 
 447. 
 , , treatment of excitement, 
 
 474. 
 
6o8 
 
 INDEX. 
 
 Senility, premature, 455-460. 
 Sensory areas in epileptic insanity, 258. 
 ,, cells of Golgi, 71. 
 ,, ,, of posterior horn, 4. 
 
 ,, columns, termination of, 32. 
 ,, nerves of skin, 173. 
 ,, troubles in alcoholism, 359. 
 SeriaUty of thought, disturbed, 145. 
 Sexual divergence, 372, 387. 
 
 ,, element in puerperal insanity, 
 
 399. 
 ,, illusions in alcoholism, 355. 
 ,, perversions of G. P., 293. 
 , , , , of lactational cases, 414. 
 
 Shaiv ( Dr. E. ) on aprosexia, 100. 
 Sheath of Schwann, 87. 
 Sheep, cortex of, 87. 
 
 „ nerve-cells of, 80, 122. 
 Shae {Dr.) on climacteric insanitj% 430. 
 ,, on vacuolation of nuclei, 538. 
 
 Smith [Dr. Edivard) on piiberty, 373. 
 Softening, cerebral, 503. 
 
 ,, localised, 505-507, 544 
 
 Solitary arrangement of cells, 122. 
 
 ,, fasciculus, 8, 17. 
 Spasmodic states in alcoholism, 365. 
 Spastic m^'^osis in tabetic G. P., 303, 317. 
 Speech, Ciouston on senile, 454. 
 Spencer (Herbert), automatic segrega- 
 tion, 150. 
 , , faint and vivid states, 
 
 145. 
 ,, relational and non-re- 
 
 lational feelings, 143. 
 , , variations in the corre- 
 
 spondence, 143. 
 Spermatozoon, nucleic acid in, 66. 
 Sphincter iridis, centre for, 308, 318. 
 Spider-cells, 98, 99. 
 
 in G. P., 549-551, 555. 
 ,, in senile atrophy, 497. 
 
 Spiegelberg on growth and development, 
 
 372. 
 Spinal -accessory, origin of, 17. 
 Spinal cord, alcoholism (chronic) and, 
 592-594. 
 ,, amj'otrophic implication, 
 
 564-566. 
 anterior radicular zone, 7. 
 antero-lateral columns, 7. 
 bilateral symmetry of, 1. 
 cell-groupings of, 4. 
 combined system-diseases 
 
 of, 563. 
 commissural tracts of, 8. 
 direct cerebellar tract of, 7. 
 in G. P., 556-575. 
 intermedio-lateral tract of, 
 
 4. 
 medullated coli;mns of, 5. 
 posterior columns of, 23. 
 pyramidal tracts of, 5, 6. 
 Spinal symptoms of G. P., 320. 
 
 Spindle-cells of cortex, 83. 
 Spongioblasts of retina, 115. 
 Staccato type of insanity, 389. 
 Statical attributes of perception, 140. 
 Statvis epilepticiis, 272-274. 
 Stigmata, 91. 
 
 Stimulation (electric) of cortex, 138, 140. 
 Stomata, 91. 
 
 Stratum gelatinosum, 112. 
 ,, glomerulosum, 112. 
 ,, granulosum, 112, 113. 
 ,, reticulare, 108. 
 ,, zonale, 15, 36, 46, 51. 
 Strife acoustics?, 10, 20. 
 
 ,, terminales, 53. 
 Striate layer of cornu Ammonis, 108. 
 Stupor, blood in, 189, 385. 
 ,, causes of, 180. 
 ,, hj'pnotism and, 180, 182. 
 ,, melancholia with, 183, 185. 
 ,, recurrent insanity and, 241. 
 
 states of, 179-189. 
 ,, with amenorrhcea, 385. 
 Stychochromic cells, 64. 
 Style of pineal peduncle, 47. 
 Subject-consciousness, rise of, 144. 
 Subjective in lower organisms, 172. 
 Substantia ferruginea, 25. 
 ,, gelatinosa, 3, 566. 
 
 ,, innominata, 35. 
 
 ,, nigra [Soemmering), 36, 40. 
 
 Subthalamic bod3% 43. 
 Suicidal impulse, 216. 
 
 ,, promptings, 169, 176. 
 ,, ,, treatment of, 469. 
 
 Suicide in alcoholic insanity, 3.31. 
 ,, in hypochondriasis, 176. 
 , , puerperal insanity, 400. 
 Sulci, significance of, 123. 
 Surcingle, 51. 
 Summation of stimuli, 139. 
 Sulphonal effects on digestion, 477. 
 
 ,, in insanity, 478. 
 Suspicion, genesis of, 169. 
 Sweden, excessive alcoholism in, 343. 
 Sjdvian aqueduct, 37. 
 
 ,, fissure, 59. 
 Symbolism, mystic, 225. 
 Syncopal attacks in G.P., 294. 
 System-diseases of the cord, 563. 
 Systematized insanity (^progressive), 229. 
 
 Tabes, alternation of symjitoms in, 556. 
 Tabetic gait in G.P., .322. 
 Tactile sense in general paralysis, 300. 
 Tajnia pontis, 31. 
 
 ,, semicircularis, 53. 
 Tegmentum, 28, 37. 
 Temperature in mania, 200. 
 Tetronal in insanity, 478. 
 Thalamencephalon, 41. 
 Thalamic capsule, 46. 
 
 ,, connections witli hemisphere, 46. 
 
INDEX. 
 
 609 
 
 Thalamic fasciculi (direct and decussat- 
 ing), 45. 
 ,, peduncle (inferior), 34, 43. 
 ,, tubercle, 42, 44. 
 Thalamus opticus, 28, 41. 
 Therapeutics, 474. 
 
 Third cranial nerve, nuclei of, 25-28. 
 Thorns or gemmules, 118. 
 
 ,, Hill (Alex) on, 60. 
 
 Thought, muscular element of, 145-148. 
 Tilt on climacteric insanity, 430. 
 Torpedo, centrosome in nerve-cells of, 
 
 64, 65, 
 Toulouse on unilateral hallucinations, 
 
 195. 
 Toxaemia, 156. 
 
 Toxic power of blood in insanity, 156. 
 Toxins in general paralysis, 286. 
 Transitional forms of cortex, 131. 
 Traumatism and recurrent insanity, 246. 
 Treatment of alcoholic excitement, 474. 
 ,, of depression and its forms, 
 
 470-473. 
 ,, of epilepsy, 282. 
 
 , , of excitement and its various 
 
 forms, 470-474. 
 ,, of excitement in G.P., 473. 
 
 ,, of insanity, 460. 
 
 ,, of senile excitement, 474. 
 
 ,, of suicidal tendencies, 469. 
 
 ,, moral element in, 461. 
 
 , , . physiological element in, 460. 
 ,, therapeutic element in, 463. 
 
 Trifacial, ascending root of, 11, 21, 24. 
 Trigeminal, descending root of, 25. 
 ,, median root of, 25. 
 
 „ motor nucleus of, 24. 
 
 Trigonum olfactorium, 53. 
 Trional in insanity, 478. 
 Trochlear nerve, nucleus of, 25. 
 
 ,, ,, root-fibres of, 27. 
 
 I'rovssean on growth, 373. 
 Trzebinski on phosphorus poisoning, 534, 
 
 535. 
 Tubercle of thalamus (anterior), 42, 46. 
 Tuke (Dr. Battij) on colloid degenera- 
 tion, 518. 
 ,, ,, on miliary sclerosis, 
 
 512, 517. 
 Tuke (Dr. Hack) on homicidal impulse, 
 
 208, 212. 
 Tunica adventitia, 90, 92. 
 „ media, 90, 92. 
 ,, muscularis, 90, 92. 
 Tiirck, columns of, 5. 
 
 Turner (Prof.) on the convolutions, 60. 
 Types, divergence in, 119-121, 123. 
 
 ,, five- and six-laminated, 123-125. 
 
 ,, of cortical lamination, 103, 
 Typho-mania, 202. 
 
 Urethane, 477. 
 
 Uric acid and nucleins, 67. 
 
 Uterine involution and insanitj-, 409. 
 
 VaeUOlation in phosphorus poisoning, 
 534. 
 
 ., of nuclei in concussion, 
 
 537, 
 ,, of nucleus, 535-537. 
 
 ,, of nerve-cells, 533-535. 
 
 Vagus, origin of, 16, 17. 
 Vascular degeneration, Beadlea on, 491 
 ,, implication in alcoholism, 591- 
 
 594. 
 ,, process of scavenger-cell, 554- 
 556. 
 Vascularity of cortex in insanity, 498- 
 
 502. 
 Vaso-motor disorders in puberty, 378. 
 Veins of cortex, 92. 
 Velum, anterior medullary, 24. 
 Venous engorgement of membranes, 499. 
 Ventricle, floor of fourth, 23. 
 Vesicles, cerebral, 57, 58. 
 
 ,, optic, 57. 
 Vesicular columns of Clarke, 3, 17. 
 Vicq d'Azj/r^f bundles, 44. 
 Virchow on pachymeningitis, 491. 
 Visceral columns of Lockhart Clarke, 3, 
 17, 588, 594. 
 , , illusions in alcoholism, 332, .352. 
 , , nerve-nuclei of Gaskell, 4. 
 Voit and Bauer on phosphorus poison- 
 ing, 534, 535. 
 Volition, restriction of, 149, 150. 
 Vornter on amount of haemoglobin, 189, 
 403. 
 ,, on specific gravity of blood in 
 insanity, 189, 403. 
 
 WaldeyeP on nerve-processes, 86. 
 
 ,, neuron of, 70. 
 
 Whitwell on vacuolation, 537. 
 Wilson on nuclein, 67. 
 Winsloxo (Dr. Forbes) on suicide, 217. 
 Wood on cannabis indica, 483. 
 Wynne on vacuolation, 537. 
 
 Youth, mimetic tendency of, 374. 
 
 THK END. 
 
 BELL ANI> BAIN, LrMITBD, PRINTERS, GLASGOW. 
 
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