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from nofm?l omental vat?tes.. to < show I wish s?tery?' deportares three after fits of different of things: (1) that, epileptic degrees are different 'of^ dissolution^ conse 'therfc sW?rky,1 and, k<de?pt&?', '.'i d?ii?w i-')?-i ro .-':..']:.:'. >osr .y, .y- :'{ v : :-?--jj j!'?,I;.::. yif? ^different **shallows" of evolu#on q?ettfclyi <2) to try to remaining; account f6i the existence in some o? the cases of increased excitability of the ^erVOtf? arrangements of the different lower levels! <?f evolution i?ithis double I shall make usei of a remy?in^: attempt, principle stated but much more '" ' essentially long ago by Laycock, by ' ' '' explicitly 1 8$. Dickson the Roy at Oo?l?gc of FhysibidJis; that lesions AnStie, andj laterj ; D?litt?t?at by Thompson (3) negative ; 2?a,?<jh,n ' . ". of the centres cause paralysis. ' It is h?hest JACKSON, M.t>.!, F.R.:?, F.B^C.P.,; well known that^some li'?i ^?IhUGHLIN?S* ' epileptics,? afte;r their fits, are maniacal.' '' , _'n d:m?? " '?f the to Bt?ya?cian The: Condition is 'called butait should be called Loncloh'Hospital? mania," epileptic unconsciousness with mania." the condition is ^epileptic Plainly ' double a negative^ and there is a positive ; there'is Since element. ? Lecture , ': ,. 1 ?.II. the fit is over, and as 'the r?mains unconscious, there is of pati?at in this lecture, I will state what I believe to reference 1^3n.<?4e*fcal On th? physical of some of the highest necessity, side, los? of function of nervous rfccords with b? of his highest the doctritte ce?tres-r-let us say, of the highest two centres, which arrangements. ^n^lrAfr?rchy . I used -The coexisting mania the outcome of greatly to arrange them to the morpho layers. is, I contend, according Qfr&of$i$nJ. raised of the next lower level of evolution the activity of; the nervous, remaining, o.brpn cord,. medulla lggjp^ ?f visions system?spinal, third layer, which is ndrmal, for hyp?rphySiological except activity^ now arrange. that on ran anatomieojphysiological basis? gfb^velc-i.'I But now comes th? question, Why man furiously is an unconscious with- which each ?repre t??*t ?ty ;dsp'eorally m> to degree of indirectness on the loss of function active 1 of the highest two layers, is the Why; or part of it. The lowest motor' centres' e?r?^th? ant?* the third, of hyperphysiological setyts'ffte next, 'bottyjt layer in the state activity to consider this question and aWthe I must rf? for spoken of? In-order cord, methodically, tob&?l?gous1nuclei Mrn?j'o^ of the begitt by speaking paroxysm. nerves frbJn extend prior epileptic the lowest, up; higher spinal they ito^jCr^njial; An epileptic a sudden and excessive dis depends/ upon paroxysm : for the pcujar muscles, horns up to the nuclei They are- at Wcwotf or of energy, beginning in some part of the highest charge, * liberation ' ' and 'Cerebral lowest cerebellar hence lesion^ of (Mtt-ulofp?st centres; centres. a There fulminate is, in Other Words, $'' physiological from the whole flt?ft? ?(tits' dff !he parts they represent central nervous certain abnormal nutrition cells, by process), gra ^pathological , ;t!hti/ attain' an is the which cerebellar The lowest dually Very high tension-^high instability, centre? ignoring hyper system! SY^em & condition?and liberate of and most physiological suddenly centres large quantity ; , eacth repre; organised aF?rSfe ^nbst1 simple aha then re-attain The I eherg^, point gradually high'instability.of sent? h s^fli^ limited anost the, region bp'dy indirectly,, hut/yet Wi?h particularly ' to urge is, that not only do those highly unstable are The ; they ?middle motor nt??rfy ^directly representative. ce?s !pUschatge'by lines towards the parts of the body *'[downward" ? c?ttr?res are1 the convolutions motor but that also discharg? up Ferrietf's making they they by laterally region. esr^cMly*'represent, t( and overcome the resistance of healthy, and less wider cross-lines^" ( and represent complex comparatively ^j5sV. a??^orfe 'organised, nervous same collateral of the each of Stahle, rank; arrangements general rfgj?jf^,?? the body doubly indirectly ; they are re-represe?it?tiye, whieft then from the primal dis "downwards." Thus, partly discharges are of centres in. front so>ca?led convolutions T?ft ?highest rflptor .the more from the secondary of healthy charge, and much discharges as I believe, moto? I say "so-called," and have urged for region.; nervous there is an enormous towards arrangements, energy^liberation 'that the whole anterior <fi the In illustration, let us suppose that the-Navy Board? part of th? brain? is motor,1 periphery. flftl?y1 V??trs, more of cfflfeW mot?!1 each I speak in detail, of this: ih; another highest navy-centres?consists members^ twenty-four one;of lecture,. whom governs the whole of the Navy, the intermediation of motor are the. most and least organised through centres TJ^ig^?st cpinple^ middle and lowest officials. to We illustrate two' things. First, try a of of centres the highest small pai-t little destruction very produces sudden and excessive effect, whilst Of such small part pro-? obntres over again ymat . discharges represent nd^,motor ajhthe^lowes. an enormous one effect. If of the twenty centres nave represented, duces, although will be disputed indirectly, and I gotur-ther, by few. four members his duties, the whole navy administration is Very centres over up gives say 4&at the highest motor (frontal lobes) represent again,' there is compensation defe?tiVe1 throughout, what the middle motor- centres slightly by greater activity combinations, repjre ^.n^or^?prn^iex. of some of: the remaining members this is analogous to ;* there is increasing or twenty-three ' ^capitulation, greater se^^'^n destruction of a small part of the highest centres. It is notorious that so that, ultimately complexity,! motor ?he higliest ifttocapy^cf..representation, a small part of the brain?a small part of the highest be centres?may or,, in other words',, qo-ordinate, rnibv,ements of- all tfepr^entr is practically ; compensation iii the most ? any striking destroyed : without symptoms xw?> It special and complex. combination^. tj^) body to the epileptic But the case analogous fit, is when one of the perfect. the scheme of sensory centres. ( Jne, (tp. give is)n^Qj^s^ main; oonc^ insane. navy officials becomes that the highest twenty-four Then, highest Occasionally sensory (chiefly) centres?parts'!Jbehi?u swiSj^?e,^!) by issuing foolish orders to lower officials,'te also the highest downwards," discharging region?and .(cjiieJ&y),motor.centres? ?^fti^^Sje'ns?qry he produces and yet slight disturbance in the navy. of the sp-called motor But, widespread up the physical region?make parj*\ wrfr<mt his he by wrongly advising colleagues, "discharging collaterally;" and. (2) that, jus?t ,as-consciousness tytpijhtP?,consciousness; retou.,^ leads them to issue foolish orders to lower officials j leads them to ^dis so its .anatomical, person psj^chical, ba?sis; (highest oj|^i|j:4t^4^whole. of foolish the Thus, by a multiplication orders, charge downwards." person the, whole c^t^sjj^epie^ents physical?represents impressions whole is severely and universally "convulsed." The officials s o?all naVy in oldrfasliionepl parts of his body;; afc?f i^j^enf language, work more to com are centres the highest wh?, ill the tease of loss of one of their colleagues, the whole of Otates potentially organism. one becomes when Ithat loss, are compelled, survivals of the fittest pensate insane, to co states, of. cx^^iqusnies&i attend centres.repres?nt ' in his excess. to the term "Co I beg particular attention operate / t ? organism. y ?MJi?^iWP?e in excess. It is, so to Spealc, Compensation inverted ; both times insisted operation" of all nervous that the symptomatology ~v#s.everal on any scheme of Localisation. have to be carefully considered in every case there is a negative, that and that duplex; j^i$r At length we come to the condition 'the when fit is over. element.. ? shall further, illustrate this by 'epileptic ^s,^iso?f positive oc It is commonly of epileptic mania,'that it sometimes said, however, I ought to have mentioned pases pf insanity. before 4hat Dr* .in, curs in, or, rather, that it replac?s, an ordinary vears a&?> pointed paroxysm. epileptie out that, ,in insanity, there, is both ^^^f.^^i dissolution I shall shortly Further1, what element. speak of as the first depthiof who his t)r. Mortimer positive *aW^A?y^?ftn?,a Granville^ effected ^y?remaining after^-an the doctrine uses epileptic discharge Wotild, ? believe^ tie of dissoluj;ion, the terjm ? ,applied ' IvJ^ars; then- to I considered orto be part Of, ?;paroxysm* W, by most medical j^on^ and takes note of the ". exposure"' of. .the; lower layers do not accept these hypotheses dissolution . i; ; but, if they were verified, ; vthe lpwei\ Jev?ls ?f evolution ?Jl ren^ainin^J. still be exemplified,'although process. by a different '^wftl;state states, whicl^ arej^jp^tific^Jly regarded,, would ^.r^-^piJoptic ? counter-hypothesis; and leave it t? my hearers to judge Whether ^r

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2 ?[tni?si be clearly understood that ? am, not speaking 't?f ?fc?jlept?f?rma?i^u?es ; centres?se-called ' they depend: Bn (ft^harg?'beginning in ?eine part df the middle1 a!lower ?egieeibi eyohrtio?. < : >ni.;ir; niol^i^ot?i-cdt?la^s?of

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tt?t? it accords'wiih take is that the sudden ahd' the?acts^ The view;! of excessive discharge in an exhaustion produces paroxysm epileptic in that nerve-tr?cts currents which have been travelled by excessive I will illustrate seizure. paroxysm. by a simple cas??an epileptiform Aman has convulsion of the left leg, followed by temporary paralysis ?fthat limb. It will be agreed upon that, in such a case, there is dis ease in some part of the cortex in the right middle region of the brain Since the event outside is (middle motor centres), say a tumour. And, it is inside is excessive obvious that the corresponding event excessive, of nerve-cells near the tumour. in order that Further, ^-discharge or "explosions" the central discharges and secondary? inside?primary " must the nerve-currents may get at" the muscles outside, developed travel a particular into the down the internal capsule route?passing lat?ral column of the cord, they will next overcome and dis opposite and ultimately, charge certain anterior horns (some lowest centres), by from nerves, get at the muscles ; there is excessive peripheral activity cortex discharging to muscles convulsed. The explanation suggested of the temporary (Todd and Alexander Robertson), post-epileptiform4 is that, after the excessive nerve of central "exercise" paralysis, fibres during the for a time remain seizure, epileptiform they exhausted. of this hypothesis seems to be given by, Confirmation ih some cases, the existence of exaggerated and foot-clonus,5 knee-jerk in the stage of the has found Beevor post-epileptiform paralysis. same after some epileptic is seizures.6 Further evidence confirmatory Franck and Pitres, for whose work I scientific experimental. highly a most have con found that after epileptiform admiration, respectful vulsions induced in dogs, the part of the cortex which had been arti remained for a time unexcitable.7 ficially discharged, The1 generalisation arrived at is that a sudden, and excessive dis or sudden and excessive of energy of part of the liberation charge, middle motor centres,- produces great activity, of followed by* exhaustion other parts secondarily the running Besides down of?loss engaged. of energy of?the cells of the "discharging lesion" there is a far wider negative state from running down of the parts dis secondarily of central nerve-fibres effected by charged j attd from the exhaustion these primary and secondary discharges. Todd and Robertson's to the highest Applying centres, hypothesis we say that after an fit there is, according to its degree of epileptic or fewer exhaustion of more in those highest severity, "layers" centres. I believe there to be also some exhaustion of middle centres, of and fibres in the lateral columns of the cord, and sometimes of some of the lowest centres. (Here is an example of compound order. ) The range of exhaustion will vary according downwards to the severity of the discharge also another factor governing ; we must bear in mind the that lower more the centre the it is, and thus range, organised that it will resist more and recuperate sooner. I neglect the impli cation of the lower centres. case to the of exhaus Now, manifestly, returning epileptic mania, tion of the highest two layers of the a purely centres being highest state cannot account for the negative state, mania.' superpositive cannot be the cause of I repeat, Nothing that, the mani something. are supposed acal actions to be the outcome of the activity, on the lower level of evolution nervous remaining?third arrange layer?of ments for over-physiological are healthy which, except ; activity, that they are manifestations of the survival of the fittest states on the level of evolution. To show more particu lower, but then highest, we must of exhaustion, larly what is meant, speak of three degrees three increasing are effected by which depths of dissolution, epileptic of different count of the corres discharges degrees of severity, taking 3 I "have been said to believe that accept the doctrine of replacement?to Tn reality, I entirely "psychoses" occur instead of ordinary epileptic paroxysms. disbelieve that doctrine ; I gave it up many years ago. I believe that all elaborate, suddenly-occurring states in epileptics, whether they are to be called mental or The very title of a paper I published, West Riding physical, follow a paroxysm. Asylum Reports, vol. v, 1875, "On Temporary Mental Disorders after Epileptic Paroxysms," shows this. ,4 A very valuable paper on Paralysis, after such seizures, has been published by Dr. ' Dutil, Revue deMedicine, March, 1883. 5? published a case of this kind in the Medical Times and Gazette, February 12th, 1881, "On a Case of Temporary Left Hemlplegia, with Foot-Clonus and Exag gerated KneerPhenomenon, after an Epileptiform Seizure, beginning in the Left Foot." : ,z 6 I have suggested that these increased "reflexes" are owing to loss of control, to over-activity of anterior horns (lowest centres) consequent on withdrawal of cerebral inhibitory influence. I now think it far more likely that there is exhaus tion not only of fibres in the lateral columns of the cord, as I suggested in the paper mentioned ; but, as Gowers has stated, of inhibitory centres in the cord it self. Westphal and Go wers have pointed out that after some epileptic paroxysms there^is temporary loss of the knee-jerk. Gowers suggests that in these cases the lumbar nuclei were exhausted ; that the exhaustion was deeper than in cases where the knee-jerk is excessive. i " Ce ph?nom?ne de l'?puisement cortical cons?cutif aux acc?s d'?pilepsie par tielle est tr?s facile ? con stater. "?MM. Fran?ois-Franck et A. Pitres, Archives de Physiologie, 15Ao?t, 1883. No. 6.

of three'degrees shallows of evOl?^n.'!F?*8t?Depttb. decreasing is defect of 'consciousness significant of dissolution otfthe* topmost the rise of a certain kind ef ideation significant of in^ layer along-with creased activity of the second layers is roughly The double condition ? to ordinary Second analogous sleep -with dreaming. There!*/ ctepthi ;so-called loss of consciousness, ?significant of dissolutf onof the topm?sta?rd ; or less elaborateness'(One-i actions of more ;second layers, along with ' > ? is postepileptic of which unconsciousness with matoia} example rsigni* 'ficant of > of the third layer. increased activity The double condition is analogous to sleep with somnambulism. is coma,- sigJ Third.?There > ; of the first, second, and third layers, witli which, nificant of dissolution there is persistence such as' only of "vital" seemingly, operations,' and circulation, of the of activity of retention respiration significant fourth layer. The double condition to deep slumber, is. analogous to' So-called dreamless sleep. is that in each Case tl>^ ' It will be seen that the opinion expressed lower level of evolution then highest level?is of scv?ae. remaining?th? centres. it is in the first depth. As* part of the highest Manifestly to the second, it may be asserted that the lower level of evolution is4 , These made centres. and after them ; the, centres, up of the middle of course, but are, I think, put in' activity lowest, are in activity, of remains in thoi What I believe the that |by highest. -is third the then level evolution of lower, depth highest, in the highest do not this but undertake to defend centres, to be insisted One is that in each of these opinion. thing upon and' that there is a positive, and' often & degrees there is a negative, 'We must beware element. of the ordinary nomencla superpositive, ture ; (post) epileptie r?ania is named after the positive element only ; coma is named after the negative element only. Nega (post) epileptic there are increasing loss so-called tively, degrees from defect, through of consciousness, to coma, signifying three increasing of disso-? depths lution ; positively, there are decreasing from ideation degrees through to mere vital operations, elaborate actions tnree signifying increasingly shallow evolution levels on of Later shall state a I remaining. serious qualification. then remarked on. The ideation or [The first depth was "dreamy state" was usually called an intellectual aura, and was by most physi-' cians considered to be part of the paroxysm. Was* attention Particular to the frequent occurrence drawn of the "dreamy or with state," after movements of chewing,'or and sometimes of spitting? tasting, to imply-an believed excitation of central movements, gustatory'ele > :' -/ ments.] Second Depth.?There has been a stronger which has discharge, effected deeper exhaustion. there is no ideation',' at least none Now, on recovery; is remembered but there aie actions. There are really or subdepths of the second depth, and no doubt of "the first subdegrees and third depths, of dissolution; and there ar? several correspondingly of diminishing levels of evolution. As to the second subdegrees ' depth, there are, symptomatically, actions of different degrees, of elaborate such from and as actions that of a fisher ness, highly special complex after an epileptic fit, at dinner, man, unconscious out occurring pulling a line from a reel, untying a knot, a out hook from his pocket, taking and it it all this down to baiting affixing (doing pantomimically), if they deserve that name, as such actions, on. the floor. sprawling were then of an elaborate actions [Details very given by epileptic when unconscious after a fit; the case of the fisherman above spoken serve for illustration.] ;of will, however, Here was a second depth of dissolution, in which we say, speaking that there was exhaustion of the highest two layers of the loosely, to his loss of centres, consciousness? patient's highest answering in other words, to his being ;'lost to his answering, surroundings" that he was in the So much for (his not knowing dining-room, etc.). the negative We element. lower recognise, too,"the positive element, level of evolution third of which he remaining, layer, from activity acted en rapport with other surroundings?acted as if he were on the river's bank. No is does not account for explanation adequate which the two diametrically not only for his elements, opposite ceasing to do but also his for to do that. it in another way, this, beginning Putting that patient's state differed from his previous normal postepileptic state by a minus and also by a plus ; after the fit, he was a different in the same skin ; or, as the person, although is, the popular phrase "was not himself." There was too. little of him postepileptic patient in one way, and too much of him in another way. Not only in cases called epileptic mania, but in all degrees of actions?from postepileptic such elaborate actions as those of the fisherman down to sprawling on the floor?the two diametrically elements opposite have, on any ade-' ,quate hypothesis, for. to be accounted some additional I must now make and general remarks on evolution dissolution.





5, 1884

of evolution The doctrine implies the passage from the most organised to the least organised, or, in other terms, from the most general we say that there is a to the most special. Roughly, gradual "adding on" of the more and more special, a continual adding on of new organ isations. But this "adding on" is at the same time a "keeping down." The higher nervous out of the lower evolved arrangements evolved out of a nation keep down those lower, just as a government controls as well as directs that nation. If this be the process of evo '' a taking of dissolution is not only lution, then the reverse process " " off" o? the higher, but is at the very same time a of the letting go If the governing lower. body of this country were destroyed suddenly, we should have two causes for lamentation: of 1, The loss of services eminent men of the now uncontrolled ; and 2, the anarchy people. The loss of the governing in our pa body answers to the dissolution tient (the exhaustion of the two highest layers of his highest centres) ; no answers the anarchy to the of the next longer controlled activity lower level of evolution (third layer). Another the general involved way of stating (Anstie's principle is in epileptic mania that the and in the other principle), over-activity cases mentioned, on is not caused, but is permitted across the ; cutting the heart is not caused to go faster, but is permitted pneumogastric, to go faster. In other words, the lower level of evolution is not into activity," So we see that exhaustion but is "let go." of "goaded nervous the highest to negative layers?answers arrangements?two affection of consciousness at the same ; and this exhaustion being, from the next lower level of evolution? time, a removal of control third layer?it "let go." springs into activity?is We stay to remark on some differences in the two depths. One is that, in the first, the ideation them is re great difference between or of course we should know about it. From the membered, nothing is remembered. But it comes second, as in somnambulism, nothing to be a question of importance, and of more practical importance or not in the second at first glance, than, appears, whether depth " in spite of the expression is some ideation, there loss of conscious some nervous That there is activity of ness." of the arrangements of the third layer, is, I submit, quite centres, we are supposing highest is this: states The of "Do consciousness attend certain. question or not ? There will be two views on this matter. that activity Let me return to the case of the fisherman, who pantomimically pulled out a line from the reel, etc., when "unconscious" after an attack. Had that man, who, on recovery, remembered of his doings, nothing the nervous activities which any states of consciousness attending were producing actions ? One view would his elaborate be that the fact tnat the patient remembered nothing was proof that there were no mental states. Another view would be that the very elaborateness of the, operation states of consciousness. We implied some co-existing must Those who take the carry each view to its logical conclusion. first view?nearly all medical men, I believe?must say that the patient was a mere machine no consciousness, he was a mere ; that, having automaton. I beg that it may be borne in mind that, otherwise stated, this view is that elaborate and universal movements may occur a trace of consciousness. On the second view, without it would be a an man was admitted the that he machine, automaton, imperfect nervous of the lost his ; but it would parts having highest machinery that some of consciousness be asserted attended activities degree on of the nervous level the lower of re evolution arrangements as of two Each these views has we soon shall consequences, maining. see. a severest it is over, ; when $hird Depth. ?Supposing discharge on his back, has the patient lies motionless no is comatose, seemingly " movements "vital such as the respiratory and movements, excepting the circulatory. so far very much neglected the distinction between mental Having arid nervous states, I must now have special regard to it, the reason for which will soon appear. The current of the post-epi explanation is, that he does not move, because leptic comatose patient's immobility a I submit, is he is unconscious. This, metaphysical explanation. We want, realistic is in scientific matters, explanations. My belief is that the postepileptic The paralysis. immobility objection which has been made to this statement is that, as a mere matter of fact, there If anyone means nor any is no paralysis. that there is no hemiplegia, other local paralysis, I entirely agree with him. What I contend for The facts are not is, that there is some universally spread paralysis. in dispute of their interpretation. All are agreed ; it is a question comatose that the postepileptic does not move uncon when patient scious ; ail that I dispute because he is un is, that he does not move conscious. No man was ever unconscious without there being at the same time some physical in at least the highest change arrangements of his highest centres. I contend more that it is to put the realistic

to the negative down in his ! patient's immobility physical change nervous to the physical?than to the centres?to attribute the physical state. In other words, mental I give a realistic correlative negative one. in place of a metaphysical I put this question, "If explanation were all, why as should not the patient move loss of consciousness well as ever ?" This question will not seem in the least degree strange to the majority of medical men, out, they posi for, as I have pointed assert that an epileptic maniac who manifests universal and tively no movements elaborate consciousness. has exceedingly sets of facts. Let us look at two comparable If a man does not move his of that limb, everybody declares that limb to leg after a convulsion be paralysed. But if a man, after an epileptic fit, which involves the does not move any of his limbs, his condition whole of his body, is is given that the patient not called paralytic does ; the explanation not move because he is unconscious. with this view, one Consistently ought to say that the man who does not move his leg after an epilepti over sees this explana form seizure, has lost volition it. Everybody tion to be purely verbal ; but the explanation, which is identically the same in effect, that the man does not move because he is unconscious, a a does not jar on anybody's mind familiar it has ; being expression, of realism, but I contend that it is not realistic appearance deceptive a greater at all. Let us consider from another range of cases it seems to me to be because point of view ; I dwell upon this matter to establish that negative states of the highest of vast importance or widely centres produce some universal ol the distributed paralysis I admit that part of the paralytic condition may be owing to body. of elements of lower centres. exhaustion a After the patient declares (le petit nial), slight" attack of epilepsy knocked etc. to be The explana himself up," unfit for anything," is given in popular tion of this condition the patient is language, said to be weak ; but if the very same patient has an exceedingly severe fit, and if after it he does not move any way (except for "vital" then his is movements), immobility explained metaphysically. of one leg after an epilepti In the simple case instanced of paralysis to be paralysed. is declared form seizure, the patient So that of the is given first a popular I would is ; but, ask, what explanation " " nervous discharge weakness after an excessive but paralysis ? Of is but I the second a metaphysical contend that ; explanation given should not move if loss of conscious there is no reason why a patient ness were all ; it is not all. Of the third only is a thoroughly realistic that local immobility Are we to believe after a given. explanation is paralysis, and that universal after a local convulsion immobility a meta is not paralysis, but that it demands universal convulsion ? Besides, that the loss of conscious supposing explanation physical ness does explain the immobility in post-epileptic coma, will it also and the foot-clonus the exaggerated described knee-jerks by explain to Beevor, than this, according Beevor ? More there is, after some of the two eyes. lateral deviation Does attacks, transitory epileptic for this deviation ? Is it not decisive account loss of consciousness as the eyes deviate evidence of at least some paralysis, from especially in the prior paroxysm turned ? the side to which they were strongly cer in postepileptiform would such deviation paralysis, Occurring an some after tainly be said to imply epileptic paralysis. Occurring some paralysis. I shall speak of it again in fit, it surely also means some recent to next when my lecture, by Ferrier referring experiments on the frontal lobes, which I call the highest motor and Gerald Yeo, centres. that the universal It may be said, "Your supposition immobility is discrepant after a severe discharge is paralysis, with your explanation and mania. If unconsciousness of the second degree of postepileptic of three layers is causative of some universal you say that exhaustion in post-epileptic admit that in the post coma, you must paralysis of two layers also entails if less, exhaustion some, epileptic mania are bound to say that the epileptic mania has some You paralysis. at the very same time he is in a state of universal although paralysis, I do not endorse the absurdity universal Of course, that a activity." man is perfectly paralysed all over, and that at the same time he is in movement all over. is, that in post-epileptic My contention simply all over the body, of paralysis mania there is some degree or, more some of all and that at the loss of movements parts, precisely, and over development is persistence of some very same time there of all parts. To show that this is not an extrava other movements out that loss of movements of the whole of a I would gance, point of some other movements of the whole of that part, with persistence common Take the case of imperfect thing. part, is an exceedingly or after an epileptiform of an arm in ordinary hemiplegia, paralysis " To say that the arm is "weak is misleading. The patient seizure. of the whole of the limb, and yet retains has lost some movements of the whole of the limb. Often enough there \ some other movements

April 6, 1884.]




is loss of some of the most "delicate at the same movements, with, to the retention of many movements. "coarser" Unable time, or to the patient his shirt, button may be able to grasp strongly, a some cases strike In further there is, if possible, heavy blow. An arm is demonstration. all over, paralysed partially permanently loss of some movements of the whole of th? limb ; and yet that other movements of the whole of the limb remain is emphasised by the occurrence of severe convulsion of it, which is nothing other than a sudden excessive of the movements development remaining. Any of localisation has to account for this. In chorea adequate doctrine we find persisting over same movements of with the paralysis, parts ; what has been called loss or defect of voluntary in this co-ordination disease is indirect evidence of some paralysis disorder ; the involuntary of co-ordination is owing to over activity of movements left. I contend that there is no difficulty whatever in conceiving, what ever difficulty there may be in believing, of the that the exhaustion defect of consciousness is layer, first depth, which highest " implies, of a slight degree of paralysis causative out thin all over the "spread that exhaustion of two layers, second (called body "weakness"); which loss of consciousness is paralysis depth, implies, spread out more over all the from the "thickly" body, notwithstandirg that, third raised activity the other movements of of all parts of the layer, excess be in the and that in post-epileptic ; body may great immobility coma is paralysis still all over the body. spread more thickly are sensorimotor Since I say (1) that the highest centres ; (2) that of consciousness affections of parts conditions negative imply negative of the highest centres ; and (3) that there is some defect of conscious THREE CASES OF PLEURAL EFFUSION WITH VERY ness in every case of insanity, I ought to hold the opinion that, FEW SUBJECTIVE SYMPTOMS. in every case of insanity, there is some degree, of however slight, or widely universal or motor, or both. distributed Oxford. By W. M. BEAUMONT, paralysis?sensory, M.R.C.S., So I do. That I could not demonstrate its existence in many cases, I are come under my notice, I should expect there to be the least degree admit. have recently of regative affec The following cases, which tion of consciousness, and correspondingly the least paralysis, in cases of interest from the fact that in each the patient was unaware that there In neither was of insanity the accompanying where was was with the chest. serious element the matter very positive anything that is, on the physical was very to lie on the sound side was con and inability there any dyspnoea, elaborate, side, when the dissolution shallow and the level of evolution In cases remaining was very high. spicuous by its absence. of dementia, the patient's to his and one who, prima be put down J. D., woman, might hysterical "lethargy" aged 42, a nervous, state?a mental to exaggerate I should call would have been expected negative every little ache and metaphysical explanation. facie, a feeling dementia the chronic analogue of what acutely and epigastrium, is post-epileptic of pains in the abdomen coma, pain, complained severe to the lethargy to the negative or less and attribute not sufficiently condition of more of spirits, although of malaise and depression her of the patient's mental She had been continuously confine her to bed. centres, state, nursing highest implied by his negative occupied and call the lethargy paralysis. There was neither husband through a long, and finally fatal illness. is indirectly in some cases of insanity nor cough ; she ate well, and could sleep when admitted lying Paralysis (when its pain in the chest existence might be denied directly) in the assertions on either side. that there is loss of facial as a I skodaic found of matter of tremor the limbs of the On chest, routine, expression, articulation, difficulty examining of some paralysis), evidence that resonance below the left clavicle as far as the second rib; below and shambling (indirect gait. Taking but one of these, surely loss of expression to the There was also -dul either of base. loss the dulness absolute (flatness) extending implies most or continuous there was facial movements, ness in the axillary and infra-axillary special or "delicate" Posteriorly, regions. develop " " or both. ment of them (rigidity), area as low as the is no abstraction resonance There in the left interscapular expression high-pitched we know to be lost. What of any healthy person's and infrascapular is from in the infraspinous conduct sixth rib ; dulness regions, taking as I have enumerated his movements. Such symptoms are just those curve first pointed out by Dr. Ellis.1 There was the italic/-shaped I should expect from chronic negative there was lesions of parts of the highest and in one spot at the left base posteriorly gophony, motor centres. cases of general was exist in many but The heart's tubular They imperceptible, paresis, which impulse breathing. Crichton Browne in persuading has shown to be owing especially to disease I had great extend in the epigastrium. difficulty apparently from the front backwards in the brain, from highest motor at the sixth to treatment. centres her to submit On aspirating ing interspace ounces of clear towards middle. in the infra-axillary I drew off thirty-four region, for the "serious Now I serum. The following blood-coloured qualification" spoke of. has to be met. been not had There was W. robust, very difficulty, H., 12, an errand-boy, taking the case of the fisherman, aged so-called a of from working. and Iqss consciousness, deep dissolution, yet implying although he had never been laid up in bed, nor prevented a very his very elaborate doings had been level of remain the which evolution in left of He occasional side, implied high pains complained I hold that in post-epileptic but states there are local dissolutions, the last twelve months. felt during ing. Night-sweats supervened, that the post-epileptic is in, or preponderates exhaustion He had been under medical there was no cough nor haemoptysis. meaning in, one cerebral there is a low level of evolu for debility. treatment Thus, whilst hemisphere. tion in the highest centres of one half of the brain, there is a perfect somewhat under the chest was found to be flattened On examination, or very on the left If so, the discrepancy and there was very little respiratory motion the clavicles, high level in those of the opposite half. measured of the chest at the nipple-level The semicircumference side. disappears. the assertion illustrated The breath was that all elaborate half an inch more on the left than on the right side. [The lecturer then variously in cases of insanity states of every kind were the There was skodaic resonance under the left clavkle down (positive) mental very foetid. nervous outcome of activities of healthy on the lower The percussion-note over wards to the second rib, and dulness below. arrangements level of evolution He was duller and the believed that the patient in the upper half, than normal the manubrium remaining. suffering saw rats, mice, from delirium nervous tremens to the ensiform of in then dulness etc., by agency cartilage. intensity deepened areas was which the pathological and supraspinous had spared ; he did not in thesuprascapular the dulness process arrangements " " I Posteriorly, a believe that a patient nor heard voices that (words spoken), 1 " Clinical Lectures On Cases of Pleuritic Effusion," by Dr. R. Douglas Powell man framed the delusion melancholic that he was going to hell, during (Medical Times and Gazette, 1882). In connection with this, it" is curious to notice the activity of nervous elements touched the line of dulness that such a careful observer as Professor Frerichs states that process. by any pathological He thought in that in Anstie's the not of hydatids of the liver is at a lower level close to the vertebral column and the lay principle explanation, only "this does not he hold good with is in the than it sternum axilla, "but," continues, these positive mental but of the necessarily " Clinical symptoms, co-existing Treatise on Diseases of the Liver," by P. T. Frerichs, pleuritic effusions." also]. negative mental symptoms Transactions of theSydenham Society, Vol. ii, p. 247. See also Dr. Stephen Ward He then spoke of the several factors in cases of insanity. On Some Affections of the liver, 1872, p. 55. (1) There

are different depths of dissolution, both of uniform and loeal dissolu illustrated' centres. This has just been tions of the highest by eases no doubt be illustrated of local dissolutions, and might by a parallel cases from those with cases of insanity?by series of chronic very if the duplex down to cases of dementia, symptom* complex delusions, dissolu were The of noted. each (2) person undergoing'the atology or unintelligent. intelligent tion, young or old, educated or uneducated, that the was rate at effected. lie believed dissolution The which (3) on the more the greater was the activity rapidly control was removed, the in illustration, lower level of evolution remaining?contrasting, dissolu who had undergone of the epileptic maniac, furious delirium or so, with of the senile dement, who the quiescence tion in a minute some thousand times more had undergone dissolution (Simi slowly. of external cases of epilepsy.) influence (4) The larly for different of of the induction and local bodily states. circumstances Examples very elaborate states of the highest centres (in the lower level of evolution were given excitations by all writers by simple peripheral remaining) on dreams. The lower level of evolution, then, in hyperphysiological to it. a stimuli to simple irradiation allowed wider coming activity, " of part of not necessarily voices" might imply any disease Hearing That sounds or words. with concerned par any centres especially reduced in a patient be determined, ticular mental abnormality might state in or local, by some morbid to a lower level of evolution, uniform the ear or auditory nerve, or in its nucleus acting on the lower level of evolution remaining.]

BMJ Publishing Group

The Croonian Lectures On Evolution And Dissolution Of The Nervous System Author(s): J. Hughlings Jackson Reviewed work(s): Source: The British Medical Journal, Vol. 1, No. 1214 (Apr. 5, 1884), pp. 660-663 Published by: BMJ Publishing Group Stable URL: . Accessed: 26/05/2012 10:02
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