PATHOLOGY AND THERAPEUTICS

J. L. C. SCHROEDER VAN DER KOLK,

PROFESSOR OF PHYSIOLOGY IN THK UNIVERSITY OF UTRECHT.

TRANSLATED FROM THE GERMAN BV

FELLOW, BY EXAMINATION, OF THE ROYAL COLLEGE OF SURGEONS OF ESULAND \

SURGEON TO THE MELBOURNE HOSPITAL; SURGEUN TO THE VICTORIAN

ASYLUM AND SCHOOL FOR THE BLIND, ETC.

LONDON:
JOHN CHURCHILL & SONS, NEW BURLINGTON STREET.

TRANSLATOR'S PREFACE.

Circumstances, several years ago, led the translator to a study of the

morbid anatomy of mental insanity ; and, in the course of his reading,

he was much impressed by the originality and clearness of this

treatise of the late Professor Schroeder van der Kolk, especially

in regard to cerebral physiology and pathology. It is fortunate that

the laudable desire for knowledge of two medical students (one of

whom, Dr. F. A. Hart sen, has since so well fulfilled the duty of

editing the memoir of his honoured teacher) should have induced

Schroeder van der Kolk to take in hand the work which he had in

view, bid which, nevertheless, might else not have been accomplished.

Through the kind intervention of Professor Miquel, the English

translation appears, with the sanction of Dr. II. W. Schroeder van

der Kolk, son of the lamented author, and also with the permission of

Messrs. Vieweg, the well-known medical publishers of Brunswick.

The translator desires to express his thanks to Dr. H. W. Schroeder

van der Kolk, and to the Messrs. Vieiveg ; and he also very gratefully

acknowledges the revision of the manuscript by his distinguished

friend, Dr.F. von Mueller, C.M.G., F.R.S. The translator regrets

the delay which has occurred in publication, but trusts that those who

are, like himself, engaged in the duties of surgical practice, will make

allowance for the numerous interruptions to which, with such

avocations, a task of this kind must of necessity be subjected.

Melbourne, fune, 1869.

PRINTED BY WALKER, MAY AND CO.,

99 BOURKE STREET WEST.

The Utrecht Professor, J. L. C. Schroeder van der Kolk (the
renovator of the Dutch Institution for the Insane), whose death
took place early in May, 1862, was long occupied with the plan
of comparing together his physiological studies and his
practical experience of mental diseases in order to lay them
before the public. But as so often happens in life, he yet needed
some special inducement to enter upon the work, and the occasion
presented itself in the autumn of 1861, when two students of
medicine in Utrecht, Herr P. Templeman van der Hoeven, and
the undersigned, from the want of a psychiatric clinic at our
University, betook themselves to Schroeder van der Kolk,
with a request to be introduced under his guidance into the
domain of Mental Diseases.

He readily acceded to our request, and immediately arranged
that we should come to his study twice a week, when he would
read to us what he had elaborated for his book, and converse with
us thereupon.

We have thus seen the book arise, have recognised its
object, and we are aware of the value the author set on it, and of
how much time and trouble it had cost him.

He accomplished the undertaking with assiduous zeal, as if he
felt that his career was hastening to its end, and that he must
bestir himself to complete the crowning work of his literary
activity. Death, indeed, overtook him while engaged in this
labour, but he previously expressed his wish that the work should
be published.

My friend, Dr. H. "VV. Schroeder van der Kolk, then paid me the
compliment of entrusting to me the fulfilment of his father's wish.

On account of the haste with which the material had been
put together, alterations were repeatedly necessary, not only of
single expressions but sometimes of whole sentences, whereby
however, as little damage as possible has been done to Schroeder
van der Kolk's style. The work, indeed, was not yet entirely
finished (for example, in the paragraph on the cerebellum, I found
two empty pages, and the author manifestly intended to add
something here), indeed its therapeutical part was not even
commenced. It was possible to supply this last want by two
treatises of Schroeder van der Kolk's, of which one was pub-
lished in the Tydsehr. der Nederl, Maalschappy van Geneeskunde
(1852) and the other was found among the papers of the deceased.

Such is the origin of this work, in which the material basis of
our spiritual activity is authenticated by facts ; but, also, at the

same time, the belief in a continuation of man's existence after
dissolution of the body is guarded as his undoubted right. It
furnishes what is for many, a not at all superfluous demonstration,
that no anatomico-physiological researches whatever, can in any
way overthrow the data derived from the moral ordering of the
world, and that no danger is connected therewith, if, to the
usually calumniated materialism, its claim is accorded.

Utrecht, April, 1803.

In the translation of this posthumous work, I have permitted
myself, quite without detriment to the subject matter, to make
several slight and also some more considerable formal alterations
and abbreviations which German language and science appeared
to require, although the editor, probably from reverence,
had allowed the original to stand unaltered. To make up for
these abbreviations, I will, in this place at least, add a completion
which I extract from a letter of 21st November, 1861, the last
which I ever received from the excellent Schroeder van der Kolk.
He communicated to me that he was writing on the physiology
and pathology of the brain, and that in my treatise on micro-
cephalon he had found a further confirmation of his opinion on
the relation between the anterior and posterior lobes of the brain,
which are separated from one another by the gyrus centralis.
That view was based partly on measurements which he had prose-
cuted on the illustrations furnished by Eud. "Wagner {Treatise
on the Ti/pical Varieties of the Convolutions of the Hemispheres):�
" I took," says he, " fine letter paper on which squares were
inscribed, drew the representations through them, then counted
how many squares the lobus anterior before the gyrus centralis
A A, and how many squares the lobus posterior behind the gyrus
had, and obtained the following results :�

Gauss, Taf. v., fig. 1 .. .. 154 : 174 = 88,5 : 100

IMriehlet, Taf. v., fig. 2 .. .. 203 : 203 = 100 : 100

Philologist Hermann, Taf. v., fig. 3 .. 152 : 202 = 75 : 100

Artisan"Krebs, Taf. v., fig. 4 .. 142 : 206 = 69 : 100

Young Ourang-Utang, Taf. v., fig. 5 138 : 224 = 57 : 100

Idiot, Taf. vi., fig. 2 .. .. 260 : 504 = 53 : 100

Microcephalus .. .. .. 92 : 191 = 48 : 100

" It is understood that this gives only a relative value, and a
relative accuracy, for I measure the plane and not the arched
surface, but after all, that occurs in a tolerably equal degree in
all the measured brains. I am convinced it would lead to good
results, if comparisons were made in this way, between the brains
of persons of talent and those of less mental capacity."

Weimar, 18th May, 1863.

CHAPTER I.
PHYSIOLOGICAL ANATOMY OF THE BRAIN.

2 Development of the Brain in the Embryo compared with its

different forms in the Animal Kingdom

3 Anatomical Connection between the primary parts of the Brain

at the Base and the Hemispheres of the Great Brain

4 Different kinds of Ganglion-cells in the Brain and Spinal Cord

in general .. .. .. .. ..

5 Mode of action and connection of the Central and Peripheral

Nerve- and Brain-cells

6 Cells of the Cortical Substance

7 Action of the Cells in the Cortical Substance

8 Different Faculties in different parts of tho Hemispheres

11 Tho Circulation in tho Brain

12 Connection and Mutual Relation between the Body and Mind

13 Influence of the Body on the Mind

14 General Pathology of the Brain

15 Inflammation of the Dura Mater ..

16 Pathological Anatomy of the Brain

12
13
2]
24
29
30
39
51
60

PATHOLOGY AND THERAPEUTICS OF INSANITY.

A. Idiopathic Insanity.

2 Different Forms and Classification of Insanity

3 Symptoms of Idiopathic Insanity in general

4 Symptoms of Sympathetic Insanity in general

Acute Idiopathic Mania .. .. ..

Chronic Idiopathic Mania

Hasmatoma of the Ear

Period of Recovery .. ..

Dementia and Idiotism

B. Sympathetic Insanity.

Thysiological Explanation of Sympathetic Mania

Pathological Anatomy of Sympathetic Mania

Symptoms of Sympathetic Mania proceeding from the Colon .. 128

Therapeutics of Sympathetic Mania proceeding from the Colon 134

Melancholy proceeding from the Sexual Apparatus

Mania proceeding from the Urinary Apparatus

Mania and Chest Affections

Mania Erethica Sensilis

Effect of Nervines and Narcotics

Page 31, lines 16 and 17, for�" on account of their course through long canals,"
read�" on account of their course through bony canals."

The doctrine of insanity is indeed that part of medical science
on which may yet be heard the most varying judgments, and
which still rests on the most insecure foundation. This is not
surprising. This section of pathology has to deal with mental
disturbances where the most important pathological phenomena
display themselves almost only by the altered mode of action of
the mental faculties, whilst the state of the body is often appa-
rently not at all impaired. If asked for the connecting link
between body and mind, we might reply that we must almost
give up the hope of ever here discovering a satisfactory solution
of so deeply hidden a mystery. The difficulties which oppose
themselves to the clearing up of the concealed indications of the
Ego, are yet increased by the imperfection of our knowledge as to
the functions of different parts of the brain. For although the
brain has been most accurately investigated by anatomists, and
has been described in its minutest details, yet for a long time
Bicherand's assertion held good, that the anatomist finds himself
here in the same case as the Parisian porter, who knows, indeed,
all the streets and alleys, even to the smallest, but does not know
what happens in the houses.

"When so little was known of the functions of different parts
of the brain, it was a matter of great difficulty to arrive at an
understanding of the pathological phenomena through post-
mortem examinations of those who had suffered from mental
diseases. But only rarely have we been fortunate enough to
bring the phenomena observed during lifetime, into relation with
the often insignificant changes which the section displayed, and
to interpret the one by the other. A clearer view into this
obscure territory seemed to be excluded by the observations
repeatedly made, that very important lesions of the brain, such
as collections of matter, more or less extensive loss of substance,
and so forth, might occur, without the intellectual powers of the
affected individual sustaining damage thereby.

Just as uncertain as on the connection between mind and
brain, were we also on the relation between the rest of the body
and the mind. The most superficial observation of temperament,
period of life, and many psychical affections, speak, indeed,
plainly enough in favour of such a relation, yet, did it always
appear problematical in what way the body is enabled to exert
an influence on our mind. Although in mentally affected
patients there were found many deviations from a healthy state,

which appeared to stand in a certain relation with the disease,
for example, costiveness, or obstruction of the bowels, menstrual
disturbances, yet was it not always easy to decide what was cause
or what was effect of the disease: still less could the inconstant
pathological conditions, which are met with in the bodies of the
mentally affected, be brought into a causal connection with the
disturbances of the mental faculties.

As many pathological changes are met with in the thoracic
and abdominal organs in the bodies of the insane, the difficult
question arises, which of these alterations are only accidental or
secondary, and what others stand in more direct causal connec-
tion with the insanity ? But the somatic lesions are during life
generally so much the less observed, because most of the insane
consider themselves quite healthy, or are so accustomed to mix
up their morbid perceptions with their confused ideas, that the
physician who does not understand their manner of expressing
themselves, can often obtain only very little information.

If, then, we were so much in the dark as to the real nature of
mental diseases, it was natural that a secure foundation for thera-
peutical treatment should be wanting, and we limited ourselves
to contend merely against the symptoms which especially struck
the eye.

The most striking and most constant manifestations, then, are
disturbances of the mental capability, and of the power of thought,
with which are combined only insignificant morbid symptoms in
the rest of the body, and indeed these symptoms may be entirely
wanting. Therefore could it occur, that many physicians, holding
to the psychical manifestations, preferred to see in insanity an
injury of the mind, rather than a somatic affection which operated
by disturbing the brain and through it, the mental faculty. Upon
this assumption, the therapeutics must be limited to psychical
influences, that is to say, we must try to act on the disposition and
understanding of the insane, and endeavour by diversion or per-
suasion to give a better direction to their perverted ideas, but we
should only have recourse to remedies upon the occurrence
of an accidental corporeal indisposition, or when a threatening
symptom makes its appearance.

Other physicians, it is true, found this view too onesided;
they supposed that insanity like other diseases, has its origin in
the bodily organism and its pathological affections, and this view
gained firmer ground through the lately-acquired knowledge of
the functions of the brain, especially also through better
explanation of the pathological changes occurring in it. There-
with must also a more pharmaco-dynamic treatment of the insane
take effect, especially as people began no longer to set them in
dark corners, and like malefactors in chains and fetters, but
rather made them accessible to observation in judiciously directed
institutions, and treated them with attention and humanity. As,
however, opinions on the nature of insanity were so widely
different, and as such opposite points of view were firmly held in

explanation of the phenomena, so it resulted that the bodily
treatment must be more empirical than rational. The secure
foundation for the therapeutics of mental diseases was wanting,
and especially the young physician in this conflict of opinions
could find no support for a safe treatment.

I attribute it principally to this, that even at present, the
psychical theory and psychical therapeutics have a marked prepon-
derance in the domain of mental disease. If we compare the
different hand-books on mental diseases, not excluding the latest
which have appeared not only in Germany but also in France
and England, we shall find that very bulky sections with numerous
subdivisions have been filled with detailed theoretical consider-
ations on the multifarious affections and anomalies of the mental
faculties, while to the practical therapeutics generally only a
couple of leaves are devoted, in which we are usually limited to
general therapeutical rules. The beginner now knows not in the
concrete case, what symptoms he shall for the most part regard,
and in what manner he can most surely obtain the recovery of
his patient. But an error here may easily lead to this, that an
insane patient, who under the treatment of a physician, operating
on a secure basis, especially in the commencement of his malady,
might yet be saved, is lost for ever, and becomes a burden in the
most unhappy condition to human society.

Nevertheless, the reproach of partiality would be perfectly
well-founded, if the physician should forget entirely the psychical
management in mental diseases, such as, for example, the removal
of former hurtful circumstances, the leading away to a correct
train of thought, kind exhortations, also diversion by work and
bodily exercise. The physician is here in a better position than
with respect to many other diseases, inasmuch as two powerful
factors and means for restoration stand at his command. As
insanity, in its different forms, increases, especially through
disturbance or interruption of the regular train of thought, so
may he by amusements, by appropriate conversation, and active
treatment, draw away the mind from noxious influences, and by
helping it to a better judgment, enable it to regain its lost
dominion over the body, and to subdue the passions. In that he
will best succeed if he has previously, by carefully estimated
medical treatment, removed, or at least lessened, those disturbing
influences and pathological conditions. The maniacal patient
has lost the dominion over his passions, the melancholic is no
longer able to hold his gloomy ideas in check, and both are slaves
of their psychical affections. Both methods of treatment
must take effect together, yet must the pharmaco-dynamic lead
the way, and prepare the patient for the psychical influences.
If, with a raging maniac, we seek to quiet the cerebral irritation
by violent coercive measures, and active means of restraint,
instead of by appropriate remedies and prudent resistance, what
result can this have but a greater excitement and an augmenta-
tion of wrath ? If the insane patient, especially the melancholic,

is firmly convinced of the truth of his erroneous ideas, then all
persuasions and remonstrances through which he should be
assured of his error, only assist in strengthening his obstinacy
and suspicion, and even excite in him the belief that he is every-
where surrounded by enemies and secret foes, who only wait for
an opportunity to destroy him. Firmly convinced of the truth
of his erroneous ideas, he imagines himself easily misunderstood,
even by those on whom as dear relatives and friends he was
accustomed to bestow his confidence. Can we then wonder, if
through such ill-timed exhortations, the physician forfeits the
confidence of the patient ? We must only set ourselves in the
condition and mode of thought of the patient himself, and figure
to ourselves what we should do, if we were persuaded of the
truth of our imaginations, and all our friends suddenly opposed
us with a continual contradiction. We should believe in an
inexplicable conspiracy, a secret object, and should wish to be
freed from the opposition ; very readily would we open our ear
to a stranger who would speak with us of quite other things, and
divert our thoughts from that discovery.

It thus depends on the knowledge of men and judgment of the
physician, who must ever know how to modify the psychical
treatment according to the different conditions of the patient.

At the same time, the physician must be thoroughly familiar
with the different organic operations which may also be present
in pathologically-altered brains ;�this, an accurate knowledge of
the nervous system and of the organisation of the brain, pre-
supposes ;�and likewise an understanding of the influences
exercised on the brain through the other parts of the body. But
as the other branches of medical science are based on accurate
knowledge of the organisation and functions of the healthy
organism, so does this hold good also in the various forms of
insanity, wherein so great a part is played, both by the functions
of the brain and also by the influences of the organism exerted
on it.

I therefore deem it necessary to prefix a consideration of the
brain and nervous system to the Pathology of Mental Diseases,
but I shall assume the rough anatomical relations to be known,
and shall no further enter upon their description.

PATHOLOGY AND THERAPEUTICS
OF MENTAL DISEASES.

PHYSIOLOGICAL ANATOMY OF THE BRAIN.

Section 1.�General Survey.

"Without doubt, to give an explanation of the functions of the
brain is among the most difficult problems of physiology. In all
times have the most acute thinkers industriously sought to
inquire into this subject. They were, however, more or less
impeded by the thick veil wherewith Nature has here concealed
her secrets.

Various means have been employed in order to clear up this
dark territory. Quite arbitrarily a sensorium commune was
assumed, in which the soul had set up its throne, whence all
impressions were conducted onwards, and by which all commands
were imparted. Descartes placed the seat of this in the pineal
gland, Vieussens in the centrum semicirculare, named after him,
even Soemmerung in one of the cavities of the brain. Later
physiologists strove for the solution of the problem through
vivisections, and Flourens (JRecherches experimentales sur les
proprietes du systeme nerveux: Paris, 1824), as well as his
successors, believed at least that this much might be concluded,
that the proper mental functions must be referred particularly
to the great brain. A deeper penetration into the hidden
laboratory of nature was herein rendered difficult by the
circumstance, that our judgment of the feelings of animals is
uncertain, and consequently the phenomena occurring after
mutilation of different parts of the brain are only obscure and
imperfect answers. One got conjectures as to the use of
different parts of the brain, and formed hypotheses out of them.

Others sought through comparative investigation of the brain
in different animals, and through comparison of the life mani-
festations (Lebens-ausserungen) connected with different brain
organisation, to arrive nearer to a solution of this question. But
inasmuch as the perceptions, or intellectual activities, of the
animals are entirely unknown, so neither in this way could the
surrounding veil be removed.

2 PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES.

Further, it was endeavoured through a comparison of clinical
observation with the accurately investigated anatomical lesions
of the brain, to obtain explanation, but likewise withoub success.
For we meet with very different pathological alterations of the
brain, where, in one case most severe and considerable symptoms
of disease preceded death, but in another case scarcely a morbid
symptom had appeared during life. Indeed we only need to
compare the long list of cases which Burdach {Structure and Life
of the Brain, third part) has put together, to become convinced
that these clinico-anatomical investigations, which also for the
most part cannot lay claim to great accuracy, rather tended to
cause obscurity and confusion, than to clear up the view as to
the functions of the brain.

Availing myself of whatever, in any of the before-mentioned
ways, has become known as reliable, or even as probable, and at
the same time drawing in the microscopical elucidations of the
minute structure of the spinal cord and the brain, and the
connection of their elements, I have trodden another path, and
have sought as far as possible to put the simplest questions to
Nature. Behind the entirely simple, Nature, indeed, often
conceals her secrets, and a search after the complicated will
probably help to confuse us, and to put us on a false track.

EMBRYONIC DEVELOPMENT OF THE BRAIN.

Section 2.�Development of the Brain in the Embryo, compared with its
different forms in the Animal Kingdom.

It is known that the embryonal brain proceeds from the same
simple forms in which we find it persistent in the lower animals,
and upon this especially rests the proposition, that a fixed type
lies at the groundwork of the vertebrate kingdom, whose develop-
ment gradually advances from the fishes up to man, so that the
different races of animals are, as it were, merely links of a great
chain.

Accordingly, we ask what parts form the first foundation of
the brain in the embryo, and in the lowest vertebrate animals,
or what parts of the brain are to be regarded as primary, and
absolutely indispensable, and what only appear later as
secondary, but which on that account are endowed with not less
important functions ?

Let us take into our hand the excellent representations of the
embryonal human brain of Tiedemann (Anatomie und Bildungs-
geschichte des Q-ehims : Niirnburg, 1816) ; we shall observe the
spinal cord bend itself under an angle, into the medulla oblongata,
and in front of the first foundation of the cerebellum are seen
the corpora quadrigemina, and also yet further forwards the optic
thalami, which but just now become covered by the indications of
the hemispheres. We find, also, the same fundamental form in
fishes, only the medulla oblongata and cerebellum are yet very
imperfect, the hereupon following corpora quadrigemina are very

DEVELOPMENT OF THE BEAIN.

large, and a prominence lying in front of these, not only gives
off the roots of the olfactory nerve, but also covers the corpora
striata and thalami, so that it is to be interpreted as the foundation
of the hemisphere.

Upon the signification and functions of these different parts
we can be in no doubt. In the fish, we see the trigeminal, the
acoustic, the vagus, which also corresponds to the glossopharyn-
geal, arise from the medulla oblongata, in a word, the nerves of
sensation, hearing, and taste. In the medulla oblongata, and
possibly even somewhat further forwards, in case a connection
with the thalamus occurs, must accordingly the seat of percep-
tion for sensation, hearing and taste be contained; there are in
fishes no other parts to which these functions can be referred.

Further forwards we see the optic nerves come off from the
corpora quadrigemina. Thus, these must be in the fish the seat
of the perception of sight, as no other parts are found which
could fulfil this purpose.

Still further forward, at the root of the olfactory nerve, must
then the perception of impressions of smell take place.

Now remain still the corpora striata, which stand in so close
relation with the pyramids, and the movement-inducing anterior
nerve roots ; they are organs of motion on which the will acts,
and through which we exercise command over the movements of
our body.

We herefrom assume that the first foundation of the brain
begins with parts through which we are brought into relation
with the external world, that is to say, with the sensory
apparatus which, at different points of the brain, bring the
impressions received from without to perception. Only later
does the apparatus appear which insures us the government over
our own bodies and voluntary motion. The first-named are,
therefore, primary parts, or as it were the groundwork, on which
the rest of the structure is brought further and further towards
perfection and complexity.

Travelling onwards in the vertebrate kingdom, we see that the
primary foundations maintain themselves, with the amphibia,
with the birds, with the different mammalia. The nerves arise
in the fish as in man, out of the very same parts ; the optic, in
all of them, proceeds from the anterior corpora quadrigemina,
the trigeminal from the medulla oblongata, and so on, and in the
lower animals as well as in man, injuries of those corpora quadri-
gemina are followed by complete blindness. Thus we come to
the conclusion that the functions of these primary parts of the
brain are identical in the whole animal kingdom. But in the
higher animals there appear in addition new and constantly more
elaborated parts, namely, the hemispheres, which, in the advanc-
ing development of the embryo, as in the higher grades of the
animal kingdom, constantly increase further backwards, and
cover the parts lying at the base of the brain. In the fishes, the
hemispheres are very small, and allow the corpora quadrigemina

4 PATHOLOGY AND THEBAPETITICS 01" MENTAL DISEASES.

to lie still quite free; in the amphibia they have already increased
in size; in the birds the corpora quadrigemina are displaced
laterally by the growth of the hemispheres, while this was not
et found in the embryo of the bird; in the mammalia, the
emispheres begin to bridge over the corpora quadrigemina, and
with a greater development posteriorly, they lie on the cere-
bellum : at length in man, they have increased so as entirely to
cover the latter.

We cannot, therefore, place the seat of the sensory perceptions
in the hemispheres, and. just as little the motor energy of the
will; for we have already observed both functions in complete
attainment in the fishes, where, however, only the first rudi-
ment of the hemispheres is bestowed. In a certain sense we
may therefore distinguish the hemispheres as secondary parts of
the brain, which are added to the primary, and stand in relation
with the organs for perception and expression of the will, but do
not themselves represent those organs.

It is also generally acknowledged that the hemispheres are
insensible, and injuries of them are not attended with perception
of pain, impressions made on them do not become sensitive
perceptions.

If we ask after the signification and the functions of these
secondary parts of the brain, those especially of the hemispheres
of the great brain, the assumption appears not too bold that the
impressions on the deeper-lying primary parts, are here further
elaborated and changed to definite ideas. It is also now universally
admitted, that the hemispheres of the great brain are the organs
of the higher intellectual faculties, and for this, as will be shown
further on, pathological anatomy furnishes quite distinct proof.

The different modes of action of the primary percipient parts
of the brain and of the hemispheres of the great brain, present
themselves very distinctly, when we consider the occurrences in
the act of vision.

For example, if I look at an object, its perception follows in
the anterior corpora quadrigemina, and that perception, dis-
regarding the peculiarities of the eyes, is the same in the fish
and in man. Whilst, if I say that object is a man, or he is a
friend whom I recognise, then have we no longer to do with an
action of the corpora quadrigemina, but with one belonging to
the cerebral hemispheres, to which the impression received
through the corpora quadrigemina was transferred for further
elaboration. This observing, recognising, judging, is a higher
function, which reaches a very different degree in man and in the
fish. If now that object vanishes, and the perception in the
corpora quadrigemina ceases, I no longer indeed see my friend,
but with that the secondary action of the hemispheres is not
yet lost; the impression, which here becomes changed into
an idea, can be called back, and I can again present to my mind
the picture of my friend with all the peculiarities which show
themselves in him.

DEVELOPMENT OF THE BEAlN. 5

Before I undertake a closer explanation of these modes of
action, for which latter, still further evidence shall he adduced,
it is especially requisite to prove, that between the deeper-lying
primary percipient parts of the brain, and the cerebral hemi-
spheres an anatomical connection really exists. In other words,
the way is to be shown (that is, the fibres) through which the
primary impressions become conveyed to the hemispheres.

Section 3.�Anatomical connection between the primary parts of the brain at
the base, and the hemispheres of the great brain.

The central nervous system consists of two kinds of substance,
of the grey and of the white or medullary substance. In the
present day, a detailed proof is scarcely necessary that the true
sources or centres of the power of the brain are to be sought in
the grey substance and its cells, while on the other hand, the
nerve fibres or nerve tubes in general, merely form conductors.
It is further acknowledged that all nerves originate in cells of
the grey substance, which cells are connected by fibres with one
another and with other groups of cells. We might, in a certain
sense, therefore, compare these nerve fibres with our telegraph
wires, and the groups of ganglion cells with our telegraph offices,
where an action is originated, and becomes conducted away
through nerve fibres to other parts.*

It is known that in those parts lying at the base of the brain
which I have just distinguished as primary, several nuclei of
grey matter occur; thus, for example, at the origin of all the
nerves of sense in the medulla oblongata, in the corpora quadri-
gemina and optic thalami; also, the corpora striata, which appear
to us to be the centre for voluntary motion, consist of grey
substance for the greater part. The cerebral hemispheres are
covered by the grey, so called cortical layer. Between these two
structures, we find masses of white medullary fibres. One may
therefore, a priori, suspect, that these white brain fibres represent
conductors, by which an effect is conveyed from one part to
another, and through which the connection between the various
groups of grey substance is established. In an inquiry into the
functions of the brain one must, therefore, necessarily take into
account the course and direction of these fibres, as also their
connection with the grey substance.

* We must not indeed view the nerve fibres as simple conductors, whose efficacy
proceeds entirely from the grey substance, for some spontaneous power also dwells
in them. According to some recent researches of Pfliiger, a muscle contracts more
strongly, when the irritation acts not too near the muscle itself, but runs through a
longer nerve-tract. A divided nerve may lose the power of answering to irritation
by muscle contraction, but may, by repose, again acquire that power, although it
is separated from its origin. Through the researches of Philipeaux and Vulpian it
was ascertained even that a divided, and after a certain time, degenerated nerve
may, after the lapse of a longer space of time, return to a normal condition, so that,
on the occurrence of irritation, it again calls forth muscular contraction, notwith-
standing it has not re-united with the trunk (Comptes Rendus, Sept. 3,1860, p.
363). This faculty, in such cases, the nerves do not receive from the ganglion cells.
The ganglion cells may, however, act as stimulant to the dormant energy in the
nerve tubes, the peculiarity of which energy is indeed still quite unknown to us.

6 PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES.

Vieussens, Vicy d'Azyr, Gall, but especially Eeil (BeiTs
Archiv. Bd., 8, 9, 11), have in earlier times accurately examined
and described the course of the brain fibres, and more lately
Arnold(Icones cerehri),~Fmil\e (Anatomie du Systerne nerveux cerebro-
spinal, 1844), and Gratiolet (Leuret et Gratiolet, Anatomie comparee
du systerne nerveux: Paris, 1857), are especially to be mentioned.

According to Foville's researches, we have to distinguish two
special fibre systems, which place the parts lying at the base of
the brain in connection with the cortical layer. The first system,
which was already more or less known to the earlier anatomists,
comprises those fibres which leave the anterior surface of
the medulla oblongata as the pyramids, pass through the pons
and the crura cerebri to the corpora striata, or, more exactly
expressed, those fibres which, as carriers or conductors of our
will, arise in the corpora striata, and pass backwards through the
parts named to the medulla oblongata and anterior columns of the
spinal cord. But on the other side, a mass of radiating fibres
proceeds from the corpora striata, rises vertically to the con-
volutions of the brain, to end in its cortical substance. These
fibres, spreading out like a fan, extend to the anterior, middle,
and posterior lobes of the brain, down to the base, running
nearly everywhere parallel to the fissura magna between the two
hemispheres, and about two centimetres distant from this fissure.
Foville reckons with these his gyri of the fourth order. Through
these fan-like fibres, arising from the corpora striata, the centres
of our voluntary motion stand in close connection with the grey
cortex of the brain.

The second system of fibres which put the centres of percep-
tion in connection with the great brain, have an entirely different
course. From the posterior surface of the medulla oblongata,
the fibres course along the inner side of the thalamus, and in
the walls of the third ventricle to the anterior perforated space
{substantia perforata antica), which is situated in front of the
optic tract, here crossing the crus cerebri, and at the side of the
chiasma. With this place the root of the olfactory nerve is in
direct connection, and the optic communicates with it, through
its soft commissure, commissura mollis. From thence, this
bundle of fibres runs in an arched direction from before back-
wards over the corpus callosum, and turns downward behind its
posterior border to the lower part of the lobe ; it is covered with
grey substance, and from it fibres are constantly given off, which
are directed towards the upper edge of the great fissure of the
brain. This convolution (by Foville called Ourlet), whose fibres
run from before to behind, but not fan-like, appears especially
destined to connect the centres of perception with the cortical
substance. To this second system also probably belongs the
layer of fibres described by Gratiolet {Anat. comparee, pi. xxvi.,
fig. 4"""""") which radiate backwards and upwards, from the
tractus opticus, where this turns from behind towards the
corpora quadrigemina and the thalamus.

CONNECTION BETWEEN VAEIOTTS PABTS OF THE BEAIN. 7

A third system of brain fibres is formed by the commissures by
which the two hemispheres of the brain are brought into
connection with one another.

From this short survey, it is clear that the centres of voluntary
motion and of sensory perception are connected with the great
brain by a double system of fibres; the one, fan-like, extends
from out of the corpora striata upwards ; the other, horse-shoe
shaped, from before to behind over the corpus callosum. It will,
therefore, be necessary to enter into a closer examination of the
elements composing these parts, and to ascertain if by that
means the obscurity which envelopes the functions of the brain
cannot in some degree be cleared up.

Section 4.�Different kinds of Ganglion-cells in the Brain and Spinal
Cord in general.

"When, in late years, the minute structure of the central
nervous system began to be subjected to a more accurate
microscopical examination, it became quite apparent that the cells
which were met with in such numbers in the grey nerve
substance, are the most important forms of the nervous system,
and that all activity proceeds from them. Thereupon it was
also found that these ganglion cells, in different places, are
distinguished from one another by size and shape. The cells in
the anterior cornua of the spinal cord, from which the motor
nerves arise, are distinguished not only by more considerable
size, but they also possess a greater number of filaments by
which they are connected partly with one another, partly with
the nerves arising from them. The cells in the posterior cornua
of the spinal cord, which appear to stand in closer relation with
sensitive nerves, are in general smaller, more oblong, and have
fewer filaments. But even yet smaller cells occur in the spinal
cord. Jacubowitsch (TJeber diefeinere Structur des Gehirns und
Ruckenmarks : Breslau, 1857) believed, therefore, that three kinds
of cells might be distinguished, namely, large motor, small
sensitive, smallest sympathetic.

I have elsewhere averred (Bau und Functionen der Medulla
Spinalis und oblongata, u.s.w., s. 129), that this division cannot
be carried out, as the cells out of which the auditorius arises are
even larger than those motor cells in the anterior cornua of the
spinal cord. In the brain, again, even greater differences occur.
In the cerebullum we find very large cells with peculiar shape
and ramification, and then, again, very small ones ; in the pons
Varolii the cells are smaller, in the substantia nigra of the crura
cerebri again, larger, and, on the contrary, very small in the
corpora striata, but mixed with some larger ones; also, in the
cortical substance of the hemispheres, especially in the surface,
one meets with layers of the most delicate cells, for the distinct
perception of which, even, very strong magnifying power is
required.

PATHOLOGY AND THEEAPETTTICS OF MENTAL DISEASES.

I might, indeed, have before laid down as a general rule the
proposition enunciated in my work above-named (p. 128), that
where the nerve fibres or the grey substance are endowed with
a peculiar function, specific cells occur, which are distinguished
as well by their form and structure as by their connection with
other cells.

Through and in these cells begins the peculiar kind of action
which is communicated to the nerve fibres. Thus with the
centripetal nerves, with the olfactory, the optic, the auditory,
the nerves of taste, we find at the peripheral extremities ganglion
cells, through which the activity in these nerves becomes
excited. Very probably we have with the sensitive nerves the
same condition, in the tactile (Pacinian) corpuscles, through which
may be explained the different sensations produced by a stimulant
acting on the skin and the same stimulant affecting immediately
the nerve trunk. By the beautiful experiments of E. H.
"Weber, we know that the skin indeed distinguishes warm
and cold objects, but that only a painful sensation occurs
when a nerve trunk is excited by warm or cold objects. We
may pre-suppose the same relation in the central nervous system.
Everywhere, where cells are found, the action proceeds from
these, and where the effects are diverse, there will also the struc-
ture and composition of the cells be distinguished by peculiarities.
Microscopical examination has already thoroughly confirmed this.

Before I further set forth these diversities of the cells, I will
first treat of their mode of action, and of the action of the parts
in which they occur, so far as we are in a condition to give an
account of them. Otherwise the mere enumeration of these
diversities would be only a dry catalogue of small peculiarities, in
which it would not be easy to discover any regulated connection.

Section 5.�Mode of Action and Connection of the Central and Peripheral
Nerve- and Brain-Cells.

In order to understand the mode of action of the brain
cells, we must inquire into the functions of our organs of
sense, in which the different cells play so great a part.

However strange it may at first sight appear, we are quite
justified in stating that in the strict sense of the words, in seeing,
not the light itself, in hearing, not the sound itself, is perceived.
A short explanation will make this clear.

As is known, behind the retina of the eye lies the so-called
bacillary layer, whose rods are so placed that their axes coincide
with the rays penetrating the eye, that is to say, the direction of
the rays is in the length of the rods. In an individual rod, a
specific action is called forth by the light, and is conveyed by an
extremely delicate fibre to a nerve cell (Ecker, Icones Physiolog.,
tab. xx., fig. 12 b, c, g,f, m) ; but this stimulation of the nerve
cell brings into activity those fibres of the retina with which it
stands in connection. The nerve fibres themselves, that is

CENTRAL AND PERIPHERAL NERVE AND BRAIN CEILS.

to say, the retina, is itself as we now very well know insensible
to light, and a cone of light directed through a lens to the
place of entrance of the opticus where all the fibres of the retina
assemble is not perceived. These fibres become excited through
the nerve cells which receive the irritation from the rods. The
fibres of the retina and of the opticus carry hence the effect to
the corpora quadrigemina, where they again terminate in peculiar
cells, and here for the first time does perception of light take
place. All injuries of the anterior corpora quadrigemina, have,
therefore, blindness as a direct consequence.

When, in the dark, we press on the eye, and experience a
sensation of light or fire springing forth, there is, of course, no
light, but through the mechanical effect the retina is excited,
and it communicates that excitement to the centre, where we
perceive it as light. Consequently, we perceive not the light
itself, but a peculiar kind of operation in the cells of the retina
and the corpora quadrigemina. But we must assume that the
cells in the corpora quadrigemina stand in close connection with
the individual, so that we may properly distinguish them as
central cells, or, still better, as perception cells. Their specific
function in this case is to set in our knowledge the consciousness
of the perception of light.

With hearing the case is similar. In the cochlea the cells of
Corti* are probably destined to communicate the impressions of
sound to the cells of the auditory nerve, and it would appear
that the vibrations of sound produce just as little effect on the
nerves of hearing as the rays of light on the retina. Otherwise,
it would be difficult to explain how we are in a condition to
distinguish the different tones of a piece of music if all the tones
were conveyed simultaneously through the same nerve fibres.
The effect is now delivered to one fibre of the auditory nerve,
which fibre probably corresponds to a particular tone, and this
fibre leads to the central cells, out of which the auditory nerve
arises. The operation of these cells we now perceive as sound,
and not, peradventure, as light or as pain ; we perceive also the
specific action of these cells, and not the air vibrations themselves.
Therefore may hallucinations of hearing occur without any real
sound being in operation. That those central cells, or perception
cells, do not become immediately affected by vibrations of sound
is to be concluded from this�that destruction of the internal ear
has deafness as a consequence; for vibrations of sound are con-
veyed by all fluids and solid bodies, consequently, also, through
the skull and through the brain, and must therefore reach the
perception cells.

We find a similar disposition in the olfactory apparatus. In

* Compare Ecker's Icones Phys., tab. xvi., fig. 2,f_; g, k, k. The connection
of the Cortian cells with the auditory nerve has again lately been denied, and
especially the structure of the bird appears to oppose it, where the thicker end of
the Cortian cell is turned to the nerve fibre. Here the nerves appear to spread out
only in the skin or in the cartilage of the acoustic membrane, just as, also, according
to many statements, in the mammals the nerve remains under the lamina perforata.

10 PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES.

the upper part of the nostrils lie peculiar epithelial cells, which
appear to be connected by a fine fibre, with ganglion cells, in which
the fibres of the olfactory nerve end.* Certainly odorous
particles do not act directly on the nerve fibres, they would
scarcely be able to press so quickly through the relatively thick
epithelial cells, they rather, appear to induce a specific action in
the epithelial cells, which by means of theganglion cells, is delivered
to the fibres of the olfactory nerve. So soon as these epithelial
cells experience an injury in their power, smell is lost. Also,
only volatile matters are smelt, not, however, through fluids,
although these may be saturated with odorous material; for fluids
appear to cause an abnormal action of the epithelial cells by
inducing their imbibition and swelling. With copious secretion
of mucus in catarrh we lose smelling. Mucus and water, however,
can only with difliculty penetrate to the nerve itself; they act
much more on the epithelial cells, which appear to have for the
olfactory nerve the same signification as the bacillary layer for
the retina, or the Cortian cells for the auditory nerve.

The nerve of taste appears to end in like manner, although
anatomical proof of this has not yet been produced. Thus much
appears determined, that the fibres of the glosso-pharyngeus
terminate in small nerve cells (Eemak in Mutter's Archiv, 1852,
s. 52), and similar ones seem to be present with the finest fibres
of the lingualis. The gustatory papillae, again, seem to be
covered with Cortian cells, which end in a long fine fibre, and
cohere with the fibres of the gustatory nerve (Hxsen, De Lingum
ranince textura: Dorp, 1857, figs. 4, 5,6). A connection between
the epithelial cells and the nerve fibres, such as occurs between
the retina and its bacillary layer, and in the other organs of
sense, is therefore at least, very probable. So much is certain,
that changes of the epithelial cells in the coated tongue have a
decided influence on taste. Nor can we fairly assume that sapid
matters penetrate to the nerves themselves, and affect these
directly; for, if the latter were so completely exposed to the
action of external agents, they might much more quickly sustain
injury from salt and strongly irritating substances. Further, we
cannot well believe that these substances penetrate so quickly
through the mucous membrane and come into contact with the
nerve itself; the acids at least would be neutralised by the
saliva, and consequently could no longer act on the nerve. In
any case we are justified in the assumption, that sapid substances
are not directly perceived, that through them only a peculiar
effect is produced on the nerves of taste, which effect is carried
to the central cells in the brain, and here becomes perceived,
that is to say, in other words, the action of these central cells is

* The immediate connection of these parts (Ecker, Icones phys., tab. xviii.,
figs. 2, 3, 5,) is indeed not yet quite proved, but still is highly probable. The
representation in the dissertation of Erichsen (tie textura vera Olfactorii ejmque
ramorum: Dorp, 1867) which illustrates the connection between the nerve fibres
and epithelial cells, might well awaken distrust; and the correctness of the
observation has been also doubted by others.

CENTRAL AND PERIPHERAL NERVE AND BRAIN CELLS. 11

perceived as taste. But it is not certain whether different kinds
of cells exist here, which, on the occurrence of irritation, excite
the sensation of sour, of sweet, or of bitter.

Lastly, the same condition appears to obtain with regard to
the cutaneous sensibility. Certainly, the mode of ending of the
sensitive nerves is not perfectly known; they appear to end in
the tactile corpuscles, in which also cells filled with granular
matter occur, and which thus correspond to nerve cells. It is
true that these tactile corpuscles, first described by Wagner and
Meissner, are known almost only in the fingers and toes, and the
mode of termination of the remaining sensitive nerves is not yet
discovered. The transmission of impressions on the skin follows
in a complicated manner. The sensitive nerves appear to end in
peculiar ganglion cells in the spinal cord, from which fibres
course to the other side, and hence rise to the base of the brain,
where at or near the thalamus nervi optici the peculiar
perception follows.*

In this respect the already-related experiment of E. H. Weber
is significant, as showing that we can take cognizance of different
degrees of temperature by means of the skin, but not by placing
a warm or cold body in contact with a nerve-trunk. In the latter
case we merely experience a feeling of pain. We may from this
draw the conclusion that in the skin, and very probably by means
of the nerve cells which everywhere manifest themselves as
exciters of nervous action, a specific stimulation and mode of
action in the sensitive nerve fibres occurs, but this stimulation
becomes perceived in the centre of the nervous system as cold or
as warmth. Thus it happens that the nerves of sense always
answer through their special sensibilities, when the same stimu-
lant�e.g., the electric or galvanic�acts upon them; galvanic
irritation produces appearance of light in the eye, sensations of
sound in the ear, perception of taste in the tongue, pain or a feeling
of warmth in the skin. The stimulant in operation is one and
the same, but on the other hand the effect on the central cells is
different, and brings us the perceptions corresponding to the
different organs of sense. Thus it is that section of the opticus
is not attended with pain, but merely with a sensation of light.

It follows, from the preceding, that in reality we do not
perceive the natural phenomena themselves by which we are

* If we suppose the anterior cornua of the spinal cord, which are connected with
the motor nerves, and the posterior cornua, in which the sensitive fibres end, to be
prolonged upwards into the brain, then the anterior cornua will be represented by
the corpora striata, of whose motor relations there is no doubt, and the posterior
cornua by the thalami, which probably serve for perception of feeling. Tiirck also
maintains that with loss of perception of feeling, an injury of the thalami always
becomes apparent. An observation of Waters (Brit. Med. Jour., 4th May, 1861;
Schmidt's Jahrbiicher, 1861, No. 9, s. 294), entirely corresponds with this. A
man who had long suffered from weakness of the left arm became hemiplegic : the
speech and power of thought were not impaired, the tongue was drawn somewhat to
the left and the mouth towards the right, the right eye could not be completely
opened, the sense of touch appeared no way affected. On section, the right corpus
striatum was found quite softened, the corresponding thalamus entirely normal.
Waters concludes from this that the corpus striatum stands in relation to motion.

12 PATHOLOGY AND THERAPEUTICS OP MENTAL DISEASES.

surrounded (die uns umgebende Natur selbsi), but only the
peculiar effects of the brain cells which are called forth by
impressions from without. "What does not here (i.e., in the
brain cells) call forth an effect, is not perceived by us. Thus
may yet many things be existing in Nature of which we have no
knowledge. These cells, which from their mode of action we
may designate perception cells, stand in close relation with our
individuality or our mind, that is to say, in their active powers
they communicate immediately with our mind. They lie, how-
ever, altogether in parts which are to be found at the base of the
brain, which first arise in the embryo, and which in the fishes
constitute nearly the entire brain.

These cells are very much distinguished by size, configuration,
and richness of connecting fibres, from those cells which occur
in the spinal cord, from which the motor nerves arise, just as
also sensitive and reflex nerves end therein, and of the action of
which cells we obtain no direct perception.*

Section 6.�Cells of the Cortical Substance.

Clinical researches, vivisections, and comparative anatomy,
lead to the now generally well-acknowledged assumption that
the cortical layer of the great cerebral hemispheres stands in
close relation with the intellectual powers. On microscopical
examination of this cortical layer, for example, in vertical sections,
we see that the fibres of the medullary substance penetrate into
it in a fan-like manner, unite again into bundles, become crossed
by transverse fibres, and that numerous ganglion cells lie between
these bundles. These cells vary in magnitude, although they are
all very small, they have several minute filaments (Auslaufer),
generally three or four.f

* Pfliiger's view, which Lewis in his new Physiology has brought into so great
currency, I will not more particularly detail. An unconscious sensation (Empftn-
dung), which Lewis will yet distinguish from perception, is, in my opinion, a
nonentity. The researches on the sensory function of the spinal cord by A. Mayer,
of Mainz (Prager Viertrfjahrsschrift, 1861, 1 Bd., s. 44, bis 45; Schmidt's
Jahrbiicher, 1861, Bd. Ill, s. 278), are of especial interest in reference to this
point. According to Mayer, Pfliiger has been so far in error, since the medulla
oblongata in the frog extends much lower downwards, that is to say, as far as the
shoulder blades, and consequently on decapitation of the frog, it still remains in
connection with the spinal cord. But in it are rooted sensation and motion, as may
be observed in the development history of animals and in the brain of the fish.
Those appearances which prove the existence of sensation and voluntary motion
cease in the frog as soon as the medulla oblongata is also taken away. Therein lies
a fresh proof that the seat of voluntary motion is to be sought in the corpora striata,
and at the end of the medulla oblongata. If the true spinal marrow alone is in
existence, voluntary motion is absent, and merely reflex movements are still
observed; the animals no longer accomplish co-ordinate movements, and they
betray no sensibility. The arguments which have been adduced from the movements
of the tail in eels, salamanders, and even young cats, are not convincing. The �
movements of the cat's tail vary according to the different situations of the irritated
point. Thus Schifffound that on irritating the tip, the tail always turned away from
the irritant; on the other hand, on irritation of the root, it approached the flame.

t The course of the fibres as portrayed by Berlin (Beitrag zur Structur-lehre
der Grosshirmoindungen Erlangen, 1858), I find quite correct; on the other
hand I find there the ganglion cells too large, and also too few; for they exist in
countless multitude.

CELLB OF THE COBTICAX SUBSTANCE.

Near it also very fine cells occur, which are mostly situated on
an extremely fine fibre (JFadchen), and through it are connected
with a nerve fibre or with a larger cell.

Section 7.�Action of the Cells in the Cortical Substance.

In the cortical substance different kinds of cells lie above one
another in several rows, in which the vertically penetrating
medullary fibres appear to end, and, moreover, these cells appear
also to be connected with one another by means of fibres.

The difference in magnitude and configuration of these cells
justifies the assumption that they have also different functions.

But we have seen that, next to these primary parts at the base
of the brain, in the ascending scale of animals, as also in the
embryo, more of the great brain becomes developed, grows back-
wards, and covers those primary parts. In the same ratio with
this increase of the great brain, the mental powers also increase.
It has thus been proved that the cortical layer of the cerebrum
is closely connected, through peculiar brain fibres, with the
primary parts at the base, or with the organs of perception
and of the will. To become acquainted with the condition and
the mode of action of these cells of the grey substance, is there-
fore an important but also a difficult problem.

Proper sensitive impressions are conveyed to the perception
cells lying in the primary parts of the brain, which cells are
connected by peculiar fibres with the cortex of the brain.
Herein also may those influences become further extended, and
here may they be elaborated {yerarbeitet), somewhat in the
following manner.

When we go to bed and, for example, lie on one side, a
multitude of confused images hovers before our mind. If we are
at all excited by preceding lively company, or by any other
cause, then these images become so vivid that they prevent sleep.
Involuntarily we turn on the other side, and the images vanish,
but soon become replaced by others. After some time we lie
again on the other side, in order to be freed from the troublesome
images; this is yet again several times repeated, until at last we
sleep. This sequence of events permits of the following
explanation. As the blood exercises an exciting influence on the
whole nervous system, so does it especially on the cortical
substance which is unusually rich in capillaries. The vessels of
the brain have, as is known, thinner walls, as the muscular layer
is almost entirely absent in them, on which account also they can
exert only a weak pressure on the blood. The blood following
the laws of gravity will accumulate in the deeper-lying parts of
the grey substance, and in consequence of the greater congestion
and more copious transudation will act more powerfully on the
cells, whose natural function is therefore stimulated to activity.
But these cells do not at all excite the idea of light, or sound, or
pain; rather will the impressions received through the organs of

14 PATHOLOGY AKD THEEAFETTTICS OF MENTAL DISEASES.

sense conveyed to them (i.e., the cells of the grey substance) be
united into images and representations, and be reproduced by
renewed irritation. Therefore, if, in the circumstances specified,
we turn to the other side that involuntary activity ceases, but
the blood sinks again into the opposite hemisphere and the game
begins here anew.

In this way are explained the involuntary occurrence and the
irregularity of these images and representations; and not alone
in the night-time, but also by day, when we are engaged in
conversation, such involuntary images may pass through our
minds. We find a very good sketch of them in Graubius'
excellent treatise, " De regimine mentis quod medicorim est,"
where it is said : Quam incommodum scepe est rem aliquam cogitanti,
sopitis etiam sensibis extemis, tot tamque alienas ex corpore suggeri
imagines ; quam difficile cum prosiliunt, reprimere, cavere ne continue
interveniant.*

But, we may ask, does not this theory lead to the grossest
materialism, and will not our mind through it be degraded to the
level of a mere cell life ? By no means. By that interpretation,
during which I have, as much as possible, truly followed the
course of nature, the independence of the individuality of the
mind remains, according to my opinion, in the clearest way
secured. For during the time in which those confused and
intricate images pass before our mind, we may at will, firmly
retain one of them so as further to embellish it quite according
to our liking. That proves, then, that a still higher faculty is
active in us, which can receive and perceive those impressions,
but is also at the sam , time in a state independently to interfere
and to govern the orderless mass. We have a telegraph office,
but at the same time also a telegraphist who voluntarily and inde-
pendently exerts influence. The involuntary delineation of those
images is an organic operation of the brain: we feel that the
images are presented to us, that they are not our own indi-
viduality, and. that they exist as objects outside of us. Our will,
on the contrary, belongs to our individuality, it is not product of
the body but of the mind, it is subject. The materialist will
compare us to a telegraph office without a telegraphist, to an
automaton, who only blindly acts, without order, without will,
without understanding and judgment, to an uninterrupted
dreamer who cannot perceive his own dream. Free will belongs
to the higher individuality, it is an attribute of the soul.

With these involuntary images, correspond also those which

* The question may indeed be started, whether the involuntary and confused images
which play about us, are really productions of the brain cortex, or whether they
may not perhaps originate in the retina, and be conveyed to us from this. The
following easily repeated experiment, which I have often employed, contradicts this
assumption. If, in the dark, one has such an image before oneself, let the eyes be
moved to the right or to the left, and one becomes convinced thereby that the image
does not follow the motions of the eyes, but remains immovably fixed in front.
If one then observes accurately the spot which the image in question occupies, and
places a finger upon it, one becomes satisfied that this spot is above the eyes in front
of the forehead, that is in the region of the lobi anieriores cerebri.

ACTION OF THE CELLS IN THE CORTICAL SUBSTANCE. 15

occur as signs of cerebral irritation in our confused dreams. The
state of bodily health is, therefore, of most decided influence on
the dreams. After a heavy supper, through which increased
congestion of the brain occurs, we generally dream, doubtless in
consequence of irritation of the cells in the cortical layer, in
which earlier impressions and representations become again
awakened, and now by an impulse which proceeds from the body
and not from the mind. The connection of these cells with one
another appears to be for the purpose of combining the
impressions received through the organs of sense, in order to
transform them to ideas and images for the mind, so that
inversely, the mind can again call back those impressions. These
cells are the physical elements of the faculty of recollection, and
with injury of the brain cortex in imbecility or in great age the
memory is quickly lost, that is in these cells the earlier
impressions can no longer be reproduced with similar facility.

If an unusual impression befalls the brain cortex, if it is
strongly irritated through accelerated circulation, through the
more or less pathologically altered blood in nervous fever, then
those ideas and images attain such strength, that we are no
longer able to distinguish them from those brought about by the
organs of sense, or more strictly by the perception cells, delirium
arises. Or after the copious taking of spirits, the images pass
more quickly and under stronger impressions on our mind, so
that we can no longer accurately follow them ; the thoughts are
no longer under our control, and we rave.



		31
	THE CIECTTLATIOIf IN THE BEATS'.	31
	THE CIECTTLATIOIf IN THE BEATS'.

thyreoidea inferior arises, and at the division of the carotis communis into the carotis interna and externa, the thyreoidea superior goes off. The constant doubling of the thyreoidea on each side, shows that a definite purpose is to be attained by it, and that it is not merely to secure a copious supply of blood to the thyroid gland, for the latter object would have been very simply attained, if one of the two thyreoideae had received a greater calibre. But the thyroid gland can take up much blood, and it appears to be able to expand itself powerfully, since Forneris considers that he has ascertained by measurement that in consequence of this expansion or swelling, the neck is larger during sleep and on awaking than during the day. Also in the dead body, the size, the consistence, the vascularity of this gland differ remarkably. We may then well assume that the propelled blood finds less resistance in the two extensile thyreoidea^ than in the vertebralis and in the carotis interna, which, on account of their course through long canals, can increase only slightly in diameter and not at all in length, and on that account it flows off in greater quantity towards the thyroid gland. Therefore, without prejudice to other functions which are possibly also entrusted to it, the thyroid may be regarded as a diverticulum or reservoir, by which a too-strong pressure of blood may be diverted from the brain. Moreover, the position of the origin of the thyreoide* in proximity to the vertebralis and carotis interna, yet gains in significance, as this arrangement is not limited to the mammalia. For, according to J. Simon {On the Comparative Anatomy of the Thyroid gland, xa.Ph.il. Transact., 1844, p. 295), the thyreoidea? of the bird arise exactly opposite the place where the carotid and vertebral come off, and even in amphibia and fishes these vessels stand in relation with the vessels of the brain. From this it becomes not improbable that the presence of a goitre, which receives a great deal of blood, and which may derive too powerfully from the brain, induces in cretins a weaker development of the brain, or, at least, a debilitated energy of it, although cretinism is not to be regarded as a product of the goitre, but only appears to be frequently present with it. It might also in this way be explained why individuals who are afflicted with goitre, for the most part are not very lively and active, but appear to be more phlegmatic. It may also be connected herewith, that I have sometimes, in meningitis chronica and meningitis idiopathica, found a small indurated yellow-tinged thyroid gland, because through this condition the derivation of the blood-stream from the brain would be impeded, which then led to repeated congestions, and contributed to the development of meningitis. I should at least wish this point to be regarded in future examinations. The spreading also of the vessels in the face conduces to derivation from the brain. There are not many other arteries which are so easily filled with blood, and extended, as the arteries of the face; they are everywhere surrounded by soft fat,



		35
	THE CIBCTTLATION IN THE BBAITf.	35
	THE CIBCTTLATION IN THE BBAITf.

show a violet colouring similar to the tip of the nose. Together with the other diagnostic signs of venous congestion, as it occurs, for example, in the climacteric years, or sympathetic with uterine diseases, the deeper colour of the lower eyelid acquires a decided value. Upon superficial ohservation it might appear as if the firmness of the vessels of the brain was impaired by their walls being thinner; but the walls of the vessels seem to be thinner rather for the purpose of avoiding rupture of the capillaries. For the middle muscular coat alone is almost entirely wanting ; through its contraction the blood experiences a stronger pressure, and is driven into the smaller vessels ; but on the other hand, the inner and outer coats of the vessels, afford to the latter their proper firmness and power of resistance. From absence of the muscular coat, the walls of the vessels yield more easily to the stream of blood, offering less resistance to it, and also driving the blood with less force through the capillaries which in the brain are so delicate, and receive so little support from without. The conse- quence of this is a more even, not pulsatory, stream of blood in the capillaries of the brain. For while the larger vessels which form numerous anastomoses run a considerable distance on the pia mater, although on account of their easy distensibility they readily yield to each stroke of the pulse by reception of the inflowing blood-wave, no pulsation is conveyed to the smaller vessels of the brain by them. In this, also, may be sought the significance of the rete mirabile which occurs in the skull cavity of many mammalia, namely, in the ox, sheep, and deer. But nature has taken even still further care. As is known, the pia mater covers the cerebral convolutions, and from its under surface very fine capillaries pass into the grey substance, where they inosculate freely and then pass into fine veins, which again return to the pia mater, and here unite into larger branches. Now, if the blood in the vessels of the pia mater, in order to pass into the veins must all go through the cortical layer of the convolutions, every more active determination of blood, for example, even in any violent movement must immediately manifest itself, in so easily excitable a cortical layer. But that is not the case, and indeed for this reason, that in the pia mater itself, a free communication exists between the arteries and the veins, of which I have convinced myself by means of injections.* Thus in a violent congestion, the blood for the most part, passes away over the cortical layer, without acting on this, into * The brain is to be taken out of the skull in such a manner, that at least the upper part of the dura mater together with the sinus remains attached to it. Then a small pipe is to be placed in the divided carotis or vertebralis, and ligatures are to be applied on the other arteries; likewise a canula is to be introduced into the sinus longitudinalis, just where it passes into the sinus transversus. If now we inject alternately red size into the arteries, and blue size into the veins, we may distinctly see that the red size passes directly into the veins, and that on injecting the veins the red size is again passed back into the arteries. This certainly speaks strongly in favour of a free communication; of course the brain must be taken out with the greatest possible care so as to avoid all bruising.



		43
	BELATION BETWEEN BODY AUD MIST).	43

alternating action, than with the remaining brain cells. Those cells which receive the sensory impressions, communicate to us their action, indeed, but on the other hand our mind is not able to act upon them. We see a picture by means of the light falling on our eyes, but we are not able by means of our will to call forth in the dark the same appearance; we may indeed remember the picture seen, but not with that brightness and clearness in which it actually fell on our eye. Were this possible, we should not be able to distinguish the productions of our imagination, and the real appearances from one another, and thence would incessant confusion arise. It appears to be a peculiarity of the perception cells, that they are set in activity only through the nerve fibres coming from the organs of sense, and not through our will. In this way it becomes possible that the sensory impressions are kept pure and unmixed. If the will could seize and arbitrarily call forth, for example, a photograph, then would an actually seen picture often enough become as altered and transformed, through one inwardly called forth, as the pictures of our fancy, and we should never be able to decide with certainty on our visual perceptions, as it then would always be doubtful whether our mind had not involuntarily produced some or other alteration in them. The impression must be only momentary, and it must leave no traces behind ; otherwise the seen image would remain behind after the vanishing of the object, which must lead to confusion. Thus it becomes apparent as a necessity, that an apparatus be present which conveys to us the images of actual objects pure and unaltered, yet which retains them no longer than the impression proceeding from the object remains ; but beside that, also, a second apparatus in which those impressions are collected and accumulated, only in such force that they can be distin- guished from real ones, and out of which we can again call them into appearance in order to combine them with others, and to design alterations in them. Herewith is the circumstance worthy of observation, that the proper perception cells, which convey to us the sensitive impressions, appear to be able temporarily to suspend their connection with the mind, so that the impressions are no longer perceived, as for example, in sleep. If a portion of the body is during sleep exposed to a continuous action of cold, or if a tight neckcloth exercises any pressure, there does not occur a proper perception of these influences, but impressions are effected in the cortical substance through which arise ideas and images analogous to those which do not depend upon direct sensory perceptions. Thus in sleep the perception cells do not communi- cate their impressions to the mind. In a dream, on the contrary, the connection between the cells of the brain cortex and the mind is not dissolved. If the imagination in dreams becomes still more vivid, we have somnambulism, in which the individual



		51
	INFLUENCE OF THE BODY ON THE MIND.	51
	INFLUENCE OF THE BODY ON THE MIND.

Section 13.�Influence of the Body on the Mind. After that the peculiar and specific functions of the different ganglion cells, especially in the brain cortex, as well as their connection and interchange of action with the mind, have been discussed, it must appear desirable to inquire into the somatic causes by which these cells may become excited and set in increased activity, and which thus exercise so important an influence on our mental powers. Among these causative forces, in any case the first place must be conceded to the blood. Its more or less decided arterial condition, the possible admixture of foreign substances, the rapidity of its movement, the filling of the vessels of the brain,� these are all so many important points. No part of our body is able to exercise its activity, if arterial blood does not reach it, and we may therefore well distinguish this as the life fluid. But it is admitted that no other part is so sensitive to the slightest modification of the condition of the blood, as the nervous system, especially the brain. In the lungs and in the liver venous blood in large quantity is normally found, and it may, without injury, accumulate copiously in them; but the presence of venous blood in the arteries of the brain, can, within a few minutes, lead to a fatal stasis, which was shown in an unanswerable manner by the experiments of Bichat (Sur la Vie et la Mort, 4th edit.: Paris, 1822, p. 360), which must always remain as a pattern of physiological experiments. The peculiar disposition of the fcetal circulation also speaks in favour of this, where the more arterial blood streams especially to the brain and spinal marrow, and the body generally receives pure arterial blood only after the beginning of pulmonary respiration. It stands again in connection with this, that the grey sub- stance of the brain in general, but especially the brain cortex is so rich in capillaries, especially when we compare the capillary richness of the medullary substance with it. (E. H. Ekker, OnderzoeTcingen over het haarvatenstelsel van hersenen en rugge- inerg in Nederl. Lane., 1852, p. 329.) From this rich supply of arterial blood to the brain cortex, we may draw the conclusion, that the cells of the cortex stand in active interchange with it, added to which it is also to be observed that the arteries entering the grey layer from the pia mater, have a very short course, and for the most part do not reach even to the deeper medullary substance; the consequence of this arrange- ment must be a rapid renewal of the blood. But these parts of the brain are also very sensitive if only any portion of foreign matter is mixed with the blood. In a room filled with people, in the air of which the chemist can discover scarcely any difference in the proportional composition, and whose greater content of carbonic acid with purity in other respects would have no injurious influence, we see,espeeially in sensitive women, faintings, spasms, and other phenomena occur, and for this reason, that in



	56
	56	PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES.
		PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES.

on the tormenting anguish and disquietude cannot be removed by arguments of reason; a circumstance which is generally too little regarded. As thus sorrowfulness and grief act on the intestines, and call forth in these pecular disturbances; so, again, analogous affections of the intestines and of the sympathetic, cause in a reflex manner, a gloomy ill-defined feeling of depression in the brain, breaking down of the spirit, melancholy. However, the pathological affection of the sympathetic does not always lead to melancholy; vivid impressions, phantasms, and hallucinations may also arise from this source. An interest- ing proof of this we owe to the celebrated Larrey. A soldier had been shot in the abdomen, and had on the right side a fistulous opening, which commenced two fingers' breadth from the most prominent part of the false ribs, and ran obliquely inwards and to the left. A probe in the fistula took a direction towards the transverse colon and the anterior surface of the stomach, and the touching of these deep parts with the probe immediately called forth unusual nervous symptoms. First there occurred a sensation of cold and of oppressive pain; then followed a spasmodic contraction of the whole abdomen, and a stretching of the limbs ; after this the man fell into a confused chattering, into a kind of somnambulism, and this stage one could lengthen at will if one entered into his arguments; after twenty-five or thirty minutes these incidents at last ceased, and the patient assumed again a kind of home sickness and an hypochondriacal humour which had taken possession of him without intermission since he had been wounded. Larrey thinks that the ball, probably enveloped in a portion of the shirt, had experienced a strong resistance from the abdominal wall, had then passed through the thin layers of the omentum, and struck the underlying transverse colon with violence, so that its inner vascular layer was torn ; for immediately after the first occurrence of inflammation, a severe bleeding from the intestine took place. In addition, the ball had occasioned a concussion of the coeliac ganglion, to hyperesthesia of which, Larry correctly refers the hypochondriasis and the other nervous phenomena. The direct influence of the sympathetic on the occurrence of the brain symptoms, is, in this case, distinct enough. The operation of the sympathetic, derived from the colon, which, as I shall show further on, exhibits a peculiar tendency to reflex action on the brain, I have on one occasion had an oppor- tunity of perceiving .in myself. In consequence of a powerful mental exertion, and fatiguing work, with the addition of a cold, I was attacked with a remittent fever, after, quite contrary to my habit, I had previously suffered for some days from consti- pated bowels, with a feeling of fulness of the abdomen. My physician feared the development of a nervous fever, and on that account was opposed to the employment of mild purgatives and clysters, which I wished to receive. After two days' duration of



		TRANSLATOR'S PREFACE. Circumstances, several years ago, led the translator to a study of the morbid anatomy of mental insanity ; and, in the course of his reading, he was much impressed by the originality and clearness of this treatise of the late Professor Schroeder van der Kolk, especially in regard to cerebral physiology and pathology. It is fortunate that the laudable desire for knowledge of two medical students (one of whom, Dr. F. A. Hart sen, has since so well fulfilled the duty of editing the memoir of his honoured teacher) should have induced Schroeder van der Kolk to take in hand the work which he had in view, bid which, nevertheless, might else not have been accomplished. Through the kind intervention of Professor Miquel, the English translation appears, with the sanction of Dr. II. W. Schroeder van der Kolk, son of the lamented author, and also with the permission of Messrs. Vieweg, the well-known medical publishers of Brunswick. The translator desires to express his thanks to Dr. H. W. Schroeder van der Kolk, and to the Messrs. Vieiveg ; and he also very gratefully acknowledges the revision of the manuscript by his distinguished friend, Dr.F. von Mueller, C.M.G., F.R.S. The translator regrets the delay which has occurred in publication, but trusts that those who are, like himself, engaged in the duties of surgical practice, will make allowance for the numerous interruptions to which, with such avocations, a task of this kind must of necessity be subjected. Melbourne, fune, 1869.



		MELBOURNE : PRINTED BY WALKER, MAY AND CO., 99 BOURKE STREET WEST.



			PKEFACE.

		The Utrecht Professor, J. L. C. Schroeder van der Kolk (the renovator of the Dutch Institution for the Insane), whose death took place early in May, 1862, was long occupied with the plan of comparing together his physiological studies and his practical experience of mental diseases in order to lay them before the public. But as so often happens in life, he yet needed some special inducement to enter upon the work, and the occasion presented itself in the autumn of 1861, when two students of medicine in Utrecht, Herr P. Templeman van der Hoeven, and the undersigned, from the want of a psychiatric clinic at our University, betook themselves to Schroeder van der Kolk, with a request to be introduced under his guidance into the domain of Mental Diseases. He readily acceded to our request, and immediately arranged that we should come to his study twice a week, when he would read to us what he had elaborated for his book, and converse with us thereupon. We have thus seen the book arise, have recognised its object, and we are aware of the value the author set on it, and of how much time and trouble it had cost him. He accomplished the undertaking with assiduous zeal, as if he felt that his career was hastening to its end, and that he must bestir himself to complete the crowning work of his literary activity. Death, indeed, overtook him while engaged in this labour, but he previously expressed his wish that the work should be published. My friend, Dr. H. "VV. Schroeder van der Kolk, then paid me the compliment of entrusting to me the fulfilment of his father's wish. On account of the haste with which the material had been put together, alterations were repeatedly necessary, not only of single expressions but sometimes of whole sentences, whereby however, as little damage as possible has been done to Schroeder van der Kolk's style. The work, indeed, was not yet entirely finished (for example, in the paragraph on the cerebellum, I found two empty pages, and the author manifestly intended to add something here), indeed its therapeutical part was not even commenced. It was possible to supply this last want by two treatises of Schroeder van der Kolk's, of which one was pub- lished in the Tydsehr. der Nederl, Maalschappy van Geneeskunde (1852) and the other was found among the papers of the deceased. Such is the origin of this work, in which the material basis of our spiritual activity is authenticated by facts ; but, also, at the a



Vi PREFACE. same time, the belief in a continuation of man's existence after dissolution of the body is guarded as his undoubted right. It furnishes what is for many, a not at all superfluous demonstration, that no anatomico-physiological researches whatever, can in any way overthrow the data derived from the moral ordering of the world, and that no danger is connected therewith, if, to the usually calumniated materialism, its claim is accorded. De. P. A. HAETSEN. Utrecht, April, 1803. In the translation of this posthumous work, I have permitted myself, quite without detriment to the subject matter, to make several slight and also some more considerable formal alterations and abbreviations which German language and science appeared to require, although the editor, probably from reverence, had allowed the original to stand unaltered. To make up for these abbreviations, I will, in this place at least, add a completion which I extract from a letter of 21st November, 1861, the last which I ever received from the excellent Schroeder van der Kolk. He communicated to me that he was writing on the physiology and pathology of the brain, and that in my treatise on micro- cephalon he had found a further confirmation of his opinion on the relation between the anterior and posterior lobes of the brain, which are separated from one another by the gyrus centralis. That view was based partly on measurements which he had prose- cuted on the illustrations furnished by Eud. "Wagner {Treatise on the Ti/pical Varieties of the Convolutions of the Hemispheres):� " I took," says he, " fine letter paper on which squares were inscribed, drew the representations through them, then counted how many squares the lobus anterior before the gyrus centralis A A, and how many squares the lobus posterior behind the gyrus had, and obtained the following results :� Lob. Lob. ant. post. Gauss, Taf. v., fig. 1 .. .. 154 : 174 = 88,5 : 100 IMriehlet, Taf. v., fig. 2 .. .. 203 : 203 = 100 : 100 Philologist Hermann, Taf. v., fig. 3 .. 152 : 202 = 75 : 100 Artisan"Krebs, Taf. v., fig. 4 .. 142 : 206 = 69 : 100 Young Ourang-Utang, Taf. v., fig. 5 138 : 224 = 57 : 100 Idiot, Taf. vi., fig. 2 .. .. 260 : 504 = 53 : 100 Microcephalus .. .. .. 92 : 191 = 48 : 100 " It is understood that this gives only a relative value, and a relative accuracy, for I measure the plane and not the arched surface, but after all, that occurs in a tolerably equal degree in all the measured brains. I am convinced it would lead to good results, if comparisons were made in this way, between the brains of persons of talent and those of less mental capacity."

		Db. THEILE.

	Weimar, 18th May, 1863.



			INTRODUCTION.

		The doctrine of insanity is indeed that part of medical science on which may yet be heard the most varying judgments, and which still rests on the most insecure foundation. This is not surprising. This section of pathology has to deal with mental disturbances where the most important pathological phenomena display themselves almost only by the altered mode of action of the mental faculties, whilst the state of the body is often appa- rently not at all impaired. If asked for the connecting link between body and mind, we might reply that we must almost give up the hope of ever here discovering a satisfactory solution of so deeply hidden a mystery. The difficulties which oppose themselves to the clearing up of the concealed indications of the Ego, are yet increased by the imperfection of our knowledge as to the functions of different parts of the brain. For although the brain has been most accurately investigated by anatomists, and has been described in its minutest details, yet for a long time Bicherand's assertion held good, that the anatomist finds himself here in the same case as the Parisian porter, who knows, indeed, all the streets and alleys, even to the smallest, but does not know what happens in the houses. "When so little was known of the functions of different parts of the brain, it was a matter of great difficulty to arrive at an understanding of the pathological phenomena through post- mortem examinations of those who had suffered from mental diseases. But only rarely have we been fortunate enough to bring the phenomena observed during lifetime, into relation with the often insignificant changes which the section displayed, and to interpret the one by the other. A clearer view into this obscure territory seemed to be excluded by the observations repeatedly made, that very important lesions of the brain, such as collections of matter, more or less extensive loss of substance, and so forth, might occur, without the intellectual powers of the affected individual sustaining damage thereby. Just as uncertain as on the connection between mind and brain, were we also on the relation between the rest of the body and the mind. The most superficial observation of temperament, period of life, and many psychical affections, speak, indeed, plainly enough in favour of such a relation, yet, did it always appear problematical in what way the body is enabled to exert an influence on our mind. Although in mentally affected patients there were found many deviations from a healthy state,



		INTKODTTCTIOIT.
	X


which appeared to stand in a certain relation with the disease, for example, costiveness, or obstruction of the bowels, menstrual disturbances, yet was it not always easy to decide what was cause or what was effect of the disease: still less could the inconstant pathological conditions, which are met with in the bodies of the mentally affected, be brought into a causal connection with the disturbances of the mental faculties. As many pathological changes are met with in the thoracic and abdominal organs in the bodies of the insane, the difficult question arises, which of these alterations are only accidental or secondary, and what others stand in more direct causal connec- tion with the insanity ? But the somatic lesions are during life generally so much the less observed, because most of the insane consider themselves quite healthy, or are so accustomed to mix up their morbid perceptions with their confused ideas, that the physician who does not understand their manner of expressing themselves, can often obtain only very little information. If, then, we were so much in the dark as to the real nature of mental diseases, it was natural that a secure foundation for thera- peutical treatment should be wanting, and we limited ourselves to contend merely against the symptoms which especially struck the eye. The most striking and most constant manifestations, then, are disturbances of the mental capability, and of the power of thought, with which are combined only insignificant morbid symptoms in the rest of the body, and indeed these symptoms may be entirely wanting. Therefore could it occur, that many physicians, holding to the psychical manifestations, preferred to see in insanity an injury of the mind, rather than a somatic affection which operated by disturbing the brain and through it, the mental faculty. Upon this assumption, the therapeutics must be limited to psychical influences, that is to say, we must try to act on the disposition and understanding of the insane, and endeavour by diversion or per- suasion to give a better direction to their perverted ideas, but we should only have recourse to remedies upon the occurrence of an accidental corporeal indisposition, or when a threatening symptom makes its appearance. Other physicians, it is true, found this view too onesided; they supposed that insanity like other diseases, has its origin in the bodily organism and its pathological affections, and this view gained firmer ground through the lately-acquired knowledge of the functions of the brain, especially also through better explanation of the pathological changes occurring in it. There- with must also a more pharmaco-dynamic treatment of the insane take effect, especially as people began no longer to set them in dark corners, and like malefactors in chains and fetters, but rather made them accessible to observation in judiciously directed institutions, and treated them with attention and humanity. As, however, opinions on the nature of insanity were so widely different, and as such opposite points of view were firmly held in



		xi
	INTEODUCTIOlf.


explanation of the phenomena, so it resulted that the bodily treatment must be more empirical than rational. The secure foundation for the therapeutics of mental diseases was wanting, and especially the young physician in this conflict of opinions could find no support for a safe treatment. I attribute it principally to this, that even at present, the psychical theory and psychical therapeutics have a marked prepon- derance in the domain of mental disease. If we compare the different hand-books on mental diseases, not excluding the latest which have appeared not only in Germany but also in France and England, we shall find that very bulky sections with numerous subdivisions have been filled with detailed theoretical consider- ations on the multifarious affections and anomalies of the mental faculties, while to the practical therapeutics generally only a couple of leaves are devoted, in which we are usually limited to general therapeutical rules. The beginner now knows not in the concrete case, what symptoms he shall for the most part regard, and in what manner he can most surely obtain the recovery of his patient. But an error here may easily lead to this, that an insane patient, who under the treatment of a physician, operating on a secure basis, especially in the commencement of his malady, might yet be saved, is lost for ever, and becomes a burden in the most unhappy condition to human society. Nevertheless, the reproach of partiality would be perfectly well-founded, if the physician should forget entirely the psychical management in mental diseases, such as, for example, the removal of former hurtful circumstances, the leading away to a correct train of thought, kind exhortations, also diversion by work and bodily exercise. The physician is here in a better position than with respect to many other diseases, inasmuch as two powerful factors and means for restoration stand at his command. As insanity, in its different forms, increases, especially through disturbance or interruption of the regular train of thought, so may he by amusements, by appropriate conversation, and active treatment, draw away the mind from noxious influences, and by helping it to a better judgment, enable it to regain its lost dominion over the body, and to subdue the passions. In that he will best succeed if he has previously, by carefully estimated medical treatment, removed, or at least lessened, those disturbing influences and pathological conditions. The maniacal patient has lost the dominion over his passions, the melancholic is no longer able to hold his gloomy ideas in check, and both are slaves of their psychical affections. Both methods of treatment must take effect together, yet must the pharmaco-dynamic lead the way, and prepare the patient for the psychical influences. If, with a raging maniac, we seek to quiet the cerebral irritation by violent coercive measures, and active means of restraint, instead of by appropriate remedies and prudent resistance, what result can this have but a greater excitement and an augmenta- tion of wrath ? If the insane patient, especially the melancholic,



			xii introduction;

		is firmly convinced of the truth of his erroneous ideas, then all persuasions and remonstrances through which he should be assured of his error, only assist in strengthening his obstinacy and suspicion, and even excite in him the belief that he is every- where surrounded by enemies and secret foes, who only wait for an opportunity to destroy him. Firmly convinced of the truth of his erroneous ideas, he imagines himself easily misunderstood, even by those on whom as dear relatives and friends he was accustomed to bestow his confidence. Can we then wonder, if through such ill-timed exhortations, the physician forfeits the confidence of the patient ? We must only set ourselves in the condition and mode of thought of the patient himself, and figure to ourselves what we should do, if we were persuaded of the truth of our imaginations, and all our friends suddenly opposed us with a continual contradiction. We should believe in an inexplicable conspiracy, a secret object, and should wish to be freed from the opposition ; very readily would we open our ear to a stranger who would speak with us of quite other things, and divert our thoughts from that discovery. It thus depends on the knowledge of men and judgment of the physician, who must ever know how to modify the psychical treatment according to the different conditions of the patient. At the same time, the physician must be thoroughly familiar with the different organic operations which may also be present in pathologically-altered brains ;�this, an accurate knowledge of the nervous system and of the organisation of the brain, pre- supposes ;�and likewise an understanding of the influences exercised on the brain through the other parts of the body. But as the other branches of medical science are based on accurate knowledge of the organisation and functions of the healthy organism, so does this hold good also in the various forms of insanity, wherein so great a part is played, both by the functions of the brain and also by the influences of the organism exerted on it. I therefore deem it necessary to prefix a consideration of the brain and nervous system to the Pathology of Mental Diseases, but I shall assume the rough anatomical relations to be known, and shall no further enter upon their description.



			PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES.

		CHAPTEE I. PHYSIOLOGICAL ANATOMY OF THE BRAIN. Section 1.�General Survey. "Without doubt, to give an explanation of the functions of the brain is among the most difficult problems of physiology. In all times have the most acute thinkers industriously sought to inquire into this subject. They were, however, more or less impeded by the thick veil wherewith Nature has here concealed her secrets. Various means have been employed in order to clear up this dark territory. Quite arbitrarily a sensorium commune was assumed, in which the soul had set up its throne, whence all impressions were conducted onwards, and by which all commands were imparted. Descartes placed the seat of this in the pineal gland, Vieussens in the centrum semicirculare, named after him, even Soemmerung in one of the cavities of the brain. Later physiologists strove for the solution of the problem through vivisections, and Flourens (JRecherches experimentales sur les proprietes du systeme nerveux: Paris, 1824), as well as his successors, believed at least that this much might be concluded, that the proper mental functions must be referred particularly to the great brain. A deeper penetration into the hidden laboratory of nature was herein rendered difficult by the circumstance, that our judgment of the feelings of animals is uncertain, and consequently the phenomena occurring after mutilation of different parts of the brain are only obscure and imperfect answers. One got conjectures as to the use of different parts of the brain, and formed hypotheses out of them. Others sought through comparative investigation of the brain in different animals, and through comparison of the life mani- festations (Lebens-ausserungen) connected with different brain organisation, to arrive nearer to a solution of this question. But inasmuch as the perceptions, or intellectual activities, of the animals are entirely unknown, so neither in this way could the surrounding veil be removed. B



		16 PATHOLOGY AND THEEAPETTTICS OF MENTAL DISEASES. corpora quadrigemina followed undiminished, but the capability of elaborating these signs was lost, of combining them into an idea, into a word. This process appears to occur purely in the brain cortex. The man had also lost the capability of writing, so that he could no longer sign his name. No trace of paralysis could be observed in his fingers, nevertheless, he made figures on paper which resembled inverted letters, or were entirely unrecognisable. Consequently, he had not only lost the capability of combining signs or letters, but he was also deprived of the distinct idea or recollection of these signs, and upon that depended his inability to write. For when these ideas in the cortical layer failed, the man could no longer act in such a manner through his will on the corpora striata and so govern his movements that the letters or words should be properly formed on paper. In this case, the connection, throxigh the communicating fibres, of the cortical layer and the corpora striata, the organ of voluntary motion, becomes apparent. So in the fancy of the painter a distinct idea of his painting is present. This idea arises not in the corpora striata, but in the cortical layer, where the impressions appear to combine into an image whither at least are transmitted, the impressions which his will can reproduce and also bring on the paper. But the most remarkable circumstance with my tradesman was, that he could still, according to the assurance of his son, keep his ledger and reckon now as ever; unfortunately I forgot to satisfy myself on this point by some tests. This, however, is to be remembered, that there exist so called prominent talents, for example distinguished calculators who understand very little of other things. But more definitely does it lead to the belief that different parts of the cortical layer are also endowed with different functions, in support of which view further evidence shall afterwards be adduced. Quite similar observations are found in an interesting treatise by Dr. Marce {Memoire sur quelques observations de physiologie pathologique, tendant a demontrer Texistence d'unprincipe co-ordina- teur de I'e'criture et des ses rapports avec le principe co-ordinateur de la parole. ISxtrait de la Oaz. Med. de Paris, 1856). Marce gives there twelve cases which he had partly himself observed, partly collected. A man had lost his speech but could still write. When required to repeat the pronounced word tambour, he said fromage, but he wrote the word quite correctly. He transcribed the words feuille medicate accurately, but when required to pronounce them, he said feqiiicale, fenicale, fedicale. In three of the collected cases the capability of writing was also lost. In one of these three cases the memory of words failed. A pocket-handkerchief was given to him ; he did not know the name of it, and wrote down that he had forgotten the word. The word pocket-handkerchief he transcribed correctly j



			ACTION OF THE CELXS IN THE COETICAL SUBSTANCE. 17

		he also produced a pocket-handkerchief when the name became known, and he could likewise write it; but after a few minutes he had again forgotten the name, and he could also no longer write it. The eleventh observation agrees with mine in this�that the patient distinguished the single letters quite well, but was no longer able to combine them into a word. He transcribed a word quite correctly, but could not write it when it was dictated to him. This patient, also, like my tradesman, could write figures very well. The patient of the seventh observation was restored. "When he could not yet write down his name from memory, not only did he write figures, but he also solved complicated arithmetical exercises, and set the figures always in their proper places. Only later did he begin to write words. In the sixth and eighth observations, also, the patients could not write letters, and only made unrecognizable characters on paper. The different intellectual faculties are thus not always simul- taneously lost: with some patients the combining of words fails ; others cannot form letters by the memory; and at the same time some of them retain perfectly the recollection of figures. Intelligent thought was unimpaired in all. "We must, therefore, with Marce, assume that these intellectual powers do not come into activity in the same parts of the brain. In that way is explained why many persons, for example, I myself, have a much better memory for numbers than for names. "We may thus regard the cells in the cortical layer as the apparatus for memory and for imagination. It quite corresponds therewith, that in brain diseases, especially when the cortical layer suffers, memory is so readily lost; and also in advanced old age, when the cells are no longer so excitable, and partly atrophy, or at any rate undergo some change. For at least in the medulla spinalis and medulla oblongata the cells are more deeply coloured and richer in pigment in old age. If they no longer answer to the influence present, and no longer provide us with the required idea of a figure, then recollection fails us. A remarkable observation of the kind was made by me in a man who had lost his recollection for most words and things, through concussion of the brain, resulting from a fall. He came into the Utrecht Institution, and could mention neither his name nor his age, nor the place of his birth; also, in speaking, he could frequently not find the words. When a cat came into his sight, he was much surprised at the extraordinary animal, the like of which he had never before seen, and he began to draw the cat with a stick on the sand. Soon afterwards he met with a chestnut tree in blossom; the beauty of the flowers, which he persisted in not having seen before, he found so remarkable that he climbed the tree, plucked a bunch of flowers, and began to C



		18 PATHOLOGY AND THEBAPETTTICS OF MEKTAL DISEASES. delineate this with a lead pencil. He was surprised that he succeeded so well, for he thought that he had never learnt to draw, and therefore believed that all men were born artists. He now wished to make all the patients with whom he came into contact draw, as, according to his opinion, they must be able to do this equally well. As his pupils were partly unwilling and indocile, he took great pains to convince them that, if they only wished, they could draw just as well as he. After some time his recollection began to improve, and many remembrances of his earlier life returned to him. He related, for the most part, at my visits, his dreams of the preceding night, and he recognised in the morning, parts of his earlier life- history in these dreams. He knew the names of many of the villages of Eriesland, of which province he was a native, among them also the name of his native village. It is true he did not yet recognise in it his early dwelling-place, but the name made an especial impression on him ; it was for him a very pretty and remarkable name, without his knowing wherefore. The next night the picture of his village returned to him in a dream, and now he related that he had dwelt in this village. It seemed to him " as if something were removed from his brain," and he was again in a position to imagine new things. This was parti- cularly repeated in his dreams, with several things, and it seemed as if, through increased congestion during sleep, and through better nutrition, the cells were returning to their activity. In a few weeks he had entirely recovered, without a trace of brain affection or of failure of memory remaining behind, and he stayed yet some time longer in the institution, as an attendant. Thus we see that, in this case, the efficacy of those organs in which ideas and images are reproduced was impaired through the concussion of the brain; with their recovery the memory returned. � * Impairment of the activity of these cells moreover, seems to occur easily. Even in quiet dreamless sleep this appears to be the case, and the cessation of their action, and of all ideas, seems to stand in close connection with the absence of con- sciousness. We may distinguish these cells through which images are reproduced as imagination cells (Vorstellungszellen). Examples are not wanting to show that, strange to say, their operation may be impaired to a greater or less degree. A young lady, through the running away of a horse, sustained a severe injury by her head being struck against a tree, and became unconscious. She recovered herself, but retained for three weeks a childish manner j she recognised me, however, quite well, and remembered perfectly my visit of the previous day. One morning she awoke as out of a dream, and was quite herself again, only she had forgotten everything which had occurred to her since being struck against the tree. She knew that she had sat in the carriage, that the horse had run away, that she had been struck on the head,



		ACTION OF THE CELLS IN THE CORTICAL SUBSTANCE. 19 while the three succeeding weeks were quite obliterated from her life. Still more remarkable are the cases where a periodical remission or disappearance of the memory seems to occur. Several years ago I was consulted in the case of a girl, twenty years of age, who, seven years previously, had recovered from a tedious illness, out of which at last, the now four-years-existing condition had arisen. In the morning after she awoke, at a certain hour, a kind of chorea appeared, in which she beat with the hands according to measure to the right and left, that continued a half- hour ; then she came to herself, but behaved quite like a child. The next day the convulsions occurred again. But, after they had ended, she behaved herself quite as a discreet maiden ; she spoke French and German well, and showed herself well read. Then, also, she knew nothing of the preceding day, but her memory corresponded only with the day but one before, or with the so-called lucid day. This went so far that, on the silly or childish day, she began to learn French again, but had only made moderate progress, while on the following day she spoke it quite fluently. I had visited her fourteen days, invariably on the so-called childish days, when she always recognised me. Then, for the first time, I came to her on a good day, and was quite a stranger to her; she could not remember ever to have seen me. This change had already occurred uninterruptedly for four years, and with such regularity that one might have set the clock by it; for the blows or strokes always returned at the same time, and were repeated in the same number. She was once affected with a tertian fever, the paroxysms of which exerted no influence on the disease. In expectation of a favourable reaction, the fever was not immediately stopped, it was postponed and fell on the bad day. The girl then knew not what was the matter with her, and conducted herself as if she had never heard of the fever. During the summer she generally went with her parents to a country house, and the bad day was chosen for the journey; when she awoke on the next day she was much astonished at the change of residence, and knew not how she had come to the present dwelling-place. In the Treatise on Obscure Diseases of the Brain, by Forbes Winslow {JEdinb. Review, 1860), a similar case is communicated, only that here a four-weekly period occurred. These cases sufficiently prove that the memory is linked to the organisation, and participates in its diseases. Only we cannot yet specify what changes in the cells of the cortical substance must take place when definite manifestations shall appear. In the above related cases of failure of memory, the higher mental faculties have sustained no disturbance, and the faculty of judgment is not weakened, only the judgment often rests upon false premisses. If the premisses are conceded, then is the conclusion perfectly correct, and we ourselves could conclude no differently, if we agreed with those premisses, t



		20 PATHOLOGY AND THEBAPETTTICS OF MENTAL DISEASES. The higher intellectual faculties are thus not connected with these cells and their action, they are utterances of the mind itself, and thereon is the logical order and regularity made conditional, in opposition to the confused ideas arising in organic disturbances. It is remarkable that all the organs of sense do not stand in the same close connection with the higher mental faculties. The most important sense we have undoubtedly in the organ of vision, through which presentations of colour and form are conveyed to us; the impressions retained become also for the most part reproduced, and we speak of pictures of thought. The nerve of sight also stands in anatomical connection with the whole hemi- spheres ; in front through the commissura mollis, laterally through the tractus opticus, turning round the crus cerebri, behind through the radiating fibres discovered by Gratiolet; but the fibres of the anterior corpora quadrigemina, radiate along the thalami to the lamina perforata antica, and spread from here through Foville's Owlet further into the great hemispheres. So multiplied a connection of the nerve with the great brain is not found with any other organ of sense. Accordingly, we do not speak of sounds of thought, or of tastes of thought, but only of ideas and pictures of thought. It is true that the nerve of hearing also stands in close connection with the great brain, and especially indeed with the upper and hinder parts of the hemispheres. On that account the nerve of hearing acts more on the feeling and disposition which these parts of the brain, as I shall later detail, especially subserve, whilst sight stands in close connection with the understanding. As the ideas of sight, so are also the ideas of hearing, repro- duced in the cortical layer. The composer writes his piece of music for the full orchestra without taking an instrument to help him, and in his imagination he hears the whole concert in such a manner that he is in a position to perceive the euphony and the harmony of the whole, and to combine in the most regular and best way, the tones of the different instruments. As is known, the great Beethoven, on account of deafness, could not hear his own compositions. Once, when after the completion of a com- position, a friend to whom he wished to display his new and to himself, pleasing work, visited him, he sat down to the pianoforte and played ; but the friend heard only confused tones, because the deaf Beethoven did not know that besides the instrument being thoroughly out of tune, many of its strings were also broken, so that only discordant sounds could be produced. Pathological alterations and irritations of those cells in the brain cortex which are in connection with the nerve of hearing, have the sometimes occurring hallucinations of hearing as a consequence. For the rest we are yet very far from knowing the places in the brain cortex where the representation- or recollection-cells of every individual organ of sense are situated.

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		FACULTIES IS DIFFEBENT FABTS OF THE HEMISPHEBES. 21 Section 8.�Different Faculties in different parts of the Hemispheres. That to all parts of the cerebral convolutions are not assigned exactly similar functions, was long ago suspected. Further, that a finely arched forehead, as a rule, indicates high intellectual endowment, was already not unknown to the Greeks, as we may conclude from their delineations of a Jupiter, Apollo, and so .forth. The strongly prominent forehead as the prerogative of man, came yet more definitely into view when Camper proposed the facial angle named after him, and pointed out its difference in Azteks, Negroes, and Europeans, likewise in children and in grown-up persons. G-all certainly acted very arbitrarily in the localisation of his organs, yet, at least, he placed the most important organs of the higher mental faculties behind the forehead. Carus (Qrundzuge einer Cranioscopie: Stuttgart, 1841. Ueber wissenschaftliche Cranioscopie in Mutter's Archiv, 1843, s. 149) distinguished three divisions of the brain which correspond to the three cranial vertebrae, and which should be found repeated in all vertebrata. The anterior portion, or the hemispheres, which essentially lie under the frontal bone, is for him the real seat of the under- standing, namely, of idea, of perception, and of the faculty of imagination: the middle portion under the parietal bones, to which also the corpora quadrigemina belong, is the especial seat of feeling and disposition ; to the posterior portion, corresponding with the posterior cranial vertebra, are volition, the faculty of desiring, reproduction of the species, attached. Certainly, I cannot entirely agree with Carus; his statements regarding the two first portions have, however, been supported more recently by many confirmations, and my own observations, to be communicated further on, stand also in accordance therewith. Carus asserts that the anterior portion of the brain, the regio intellectus, is better developed, as well in animals as in man, in proportion as the intellectual powers are prominent; he found that the fore- head in many learned and distinguished men, as Kant, Ehrenberg, Purkinje, Eetzius, Eaumer, Thorwaldsen, Schiller, Grothe, was both higher and broader. He further contended that in women the middle section of the skull is relatively more developed than the anterior, whilst in men the proportion is reversed; in that he relies upon Hamilton, who found the anterior section of the male brain larger, and appeals also to the slight development of the forehead in Negroes and uncultivated nations. We have to thank Huschke for more accurate measurements of the sexual differences of the superficies of the hemispheres {Schadel, Him, undSeele Jena, 1854). Innormalbrains,heobtained for the distance of the upper end of the central fissure from the anterior and from the posterior end of the brain� In women, 59 and 130 millimetres .. .. 31-3 : 68-7 In men, 88 and 113 millimetres .. .. 439 : 66-1 He found, moreover, when the brain was cut through vertically



		22 PATHOLOGY AND THERAPEUTICS OE MENTAL DISEASES. in front of the corpus callosum that the anterior section in men, the posterior in women was relatively more developed. The superficies of the male frontal bone reached (the mean of 32 skulls) 15,000 square millimetres, that of the female frontal bone only 13,000 square millimetres. But as besides, the female skull is absolutely smaller, he also compared the area of the frontal bone with that of the rest of the vault of the skull, so far as the hemi- spheres are covered by it, and these two values rank thus : the mean of 14 female skulls � 26'5 : 735 per cent.; the mean of 16 male skulls ==283 : 747 per cent. Further, according to Huschke's measurements, in the higher races of men a more decided difference in the skull capacity of the male and female sex occurs than in the lower races; this difference is in a great degree more remarkable in the European than in the negro. Similarly also the German race shows a high development of the frontal bone relatively to the rest of the skull vault, in comparison with the lower races whose intellectual development is less. Huschke's measurements have also brought out this remarkable result, that the skull bones, up to the fourth year have doubled in size, but that subsequently, the frontal bone increases, and in the adult is sometimes trebled in size. Betzius {Beurtheilung der Phrenologie vom Standpunkte der Anatomie in Mailer's ArcMv, 1848, s. 243) comparing the development of the human brain with the development of this organ in the animal kingdom, found that in the embryo the posterior lobe of the brain becomes latest developed, and belongs in reality to man alone, and from that he concluded that the anterior lobes of the brain must be considered the lowest, the posterior the highest. But meanwhile, if we are to conclude on other grounds that the upper and hinder part of the hemi- spheres is more especially destined for the feeling and disposition �wherein, after all, man, in comparison with animals, stands still higher than in his intellectual development�that circumstance by no means contradicts our assumption, that the anterior section of the hemispheres, lying under the frontal bone, is more especially destined for intellectual life, and that the upper and hinder part of the hemispheres is rather devoted to sentimental life. My respected friend, R. Wagner {Oottingen gelehrte Anz.,1860; Februar und Mai, und JJeber die typischen Verschiedenheiten der Windungen der Hemispharen und uber die Lehre vom Sirngewicht, u. s. w., Gottingen, 1860), has presented us with tables of the weight of the brain of persons of different degrees of intelligence, and of both sexes. Celebrated men occupy the first place in the maximum of weight of brain; yet a youth of fifteen stands very high above several learned men, and even women reach above the latter. Wagner, therefore, concludes from those weighings that the mean weight of the brain does not differ in very intelligent and in less intelligent individuals. With this result of Wagner's I can quite agree, only it appears to me that the measure of comparison laid down is not a correct



		FACULTIES 1$ DlfEEKENT PABTS OP THE HEMISPHERES. 23 one. In these weighings the different causes of death ought to be taken into consideration. In a patient who has died of typhus, in consequence of the congestion, there is surely much trans- udation in the brain, whereby its weight is raised. Further, as Huschke has pointed out, in men the anterior lobes, in women the posterior lobes, are the larger, so that notwithstanding the difference in particular parts of the brain, the total weight may be similar in two individuals, or the female brain may even be the heavier. Wagner would have attained better results if he had followed further in the road struck out by Huschke. That the anterior cerebral lobes of learned men were most rich in convolutions, stands in accordance with my observations and with my views. It is remarkable, that in the brains of two very intelligent individuals, "Wagner found very few convolutions. Unfortunately, it is not at the same time mentioned, whether their anterior lobes were not perhaps more developed. A comparison of the weight of the great brain with the cere- bellum, whose function is yet rather obscure, was undertaken by Wagner and others. No particular result was established, except this, that in women the great brain is relatively heavier in proportion to the smaller. At present, most writers agree in the view, that it must be assumed that the anterior portion of the great brain is the seat of the higher intellectual faculties. The evidences for this view are so numerous, that I regard it as one of the most certain in cerebral physiology. It is a recognised circumstance, which we see confirmed in idiots, that weakness of intellect is often associated with a low forehead. We meet, indeed, with cretins and idiots with large heads; but for the most part, collections of water are then the cause. In sound intellectual activity, forms of the skull where the forehead is strongly inclined backwards, so that the anterior cerebral lobes can only be small, are excluded.* The forms of the brain in animals also supply confirmation. Thus may be mentioned the great development of the anterior cerebral lobes in the orang-utang. which in this respect stands next to man, and also displays the greatest intellectual develop- ment among animals. It was permitted to me to examine the brain of a celebrated mathematician and natural philosopher, who was distinguished for remarkable intelligence and acuteness, and I was astonished at the number of convolutions in this brain, but which indi- vidually were not large. The same kind of conformation I afterwards saw with K. Wagner at Grottingen in the brain of the celebrated Gauss, and I have also found the like in the brains of other distinguished learned men. Quite the reverse I find in the brain of an idiot in my * Obviously the artificially-produced forms of the skull of the so-called Flat- heads in America cannot be considered a defect, but merely a dislocation; they cannot, therefore, be brought forward as counter evidence.



		24 PATHOLOGY AND THEBAPEITTICS OF MENTAL DISEASES. collection. All the convolutions of the anterior lobes of the brain even to the anterior central convolution are only slightly developed and are present in small number, whilst the gyri lying behind that central convolution are large and otherwise normal. But I find the most convincing proof in pathological condi- tions. As the result of my many years' continued and accurate examinations, of which further on I shall adduce several, I can state that in proper intellectual insanity (bei eigentlicher Verstan- desverwirrung), invariably the cortical layer under the frontal bone appeared more deeply coloured, was more firmly adherent to the pia mater, or was softened. On the other hand, in melancholy, where anxious agitation and sensation of heat and pressure occur, and where the emotion more than the intellect suffers, pathological changes are found rather in the convolutions of the upper and hinder lobes. Thus we come to the conclusion that the cells in the cortical layer of the upper and hinder lobe have a different action from those of the anterior lobe; the former bring about emotional feelings. Whether there may be different classes or divisions of these cells, it is not possible to decide at present. If we compare the representations of the cortical layer of the anterior and upper part of the brain by Berlin, (Beitrdge zur Structur-lehre der Grossliirmoindungen, 1858) and Stephany (Beitrdge zur Histologie der BZimrinde), with the structure of the cornu ammonis in which, according to Kupffer (Be ComuAmmonis textura: Dorpati, 1860), we must suppose only one convolution of the lower lobe of the brain, we perceive such a difference in the disposition of the cortical substance, that from this alone we must conclude the existence of a different activity. Pathological observations also supply corroborative evidence for this view. In animals also, as I have found in the dog and rabbit, a different texture of the grey substance in the anterior and posterior lobes of the brain is seen. In the rabbit's anterior lobe are seen bundles of fibres, with cells lying between them, which are mostly tripolar ; in the hinder lobe, where the roots of the olfactory nerve turn in, a texture is noticed which corresponds with that of the human cornu ammonis, namely, a regular row of stalked cells, which, like organ pipes, stand close to one another. In the anterior lobe the cells measure 0.166 to 0.168 mm., but the nuclei 0.102 mm.; in the hinder lobe there are single larger cells of 0.216 mm., with nuclei from 0.140 to 0.152 mm., but the stalked cells are smaller and have a diameter of only 0.126 to 0.140 mm. Section 9.� Vivisections. The results of my examinations laid down in the former paragraphs are confirmed by vivisections. I will not enter into a detailed statement of what different authors have concluded from their vivisections, but will rather limit myself to that which Schiff (Lehrluch der Physiologie, 1 Theil.) communicates as results of



		25
	VIVISECTIONS.


his investigations, although I cannot agree in all his conclusions. According to the unanimous testimony of authors, animals, after removal of the great brain, fall into a lethargic, or rather passive, condition. They still perceive impressions, but the proper active perfecting or elaboration of the same is wanting. The pupil contracts under the influence of light; in a bright light animals also close their eyes; in some cases even a move- ment of the head followed the to-and-fro movements of a flame. Even the taste is not entirely abolished, for if a solution of colocynth is applied to the tongue, the animals move the latter, distort the lips, open and shut the beak. With regard to smelling, nothing can be discovered, but the nasal mucous membrane is still sensitive to vapour of ammonia. Concerning the hearing, sudden detonations have no influence on the animals, and just as little the cry of birds of prey by which they were before so much terrified, and even a laying down and erecting of the ears no longer occurs. According to Schiff, that originates in the circumstance that all reflex movements {Beflexe) called forth by the sense of hearing become defined more or less by other ideas through a so-called judgment. Schiff believes, however, that the animals still hear, because the operation does not at ali injure the nerve of hearing, and the animals still see, although the optic nerve is far more easily damaged in the operation. Many things speak in a decisive manner for the presence of sensibility in the skin. Thus birds cleanse their feathers if they are annoyed with vermin. But we miss, however, the external signs of great uneasiness and painful sensations so soon as we are not mislead by the cries of the animals and the reflex movements. The impressions are passively received, without inducing permanent ideas or recollections, and without influencing either the reflection or the judgment. From all this, it is sufficiently evident that the proper seat of perception is not to be sought in the hemispheres of the great brain, but in parts at the base of the brain, where the nerve centres are contained. On the excision of the hemispheres of the great brain, Schiff also communicates the following:�A marmot and a cat try to escape when one has put colocynth on their tongues, and they resist if one tries to repeat the experiment. After cutting out the hemispheres, however, they no longer attempt to escape, and they offer no very great resistance to a repetition of the experiment. Schiff explains this by the prevented reflex move- ments. The proper ground, however, of this different conduct is to be found simply in this, that the animals are deprived of recollection. "We see, therefore, that impressions on the proper perception cells, that is, on the centres of the sensory nerves, are not permanent, else a confusion of the impressions following one another, or a blending of them must occur. These impressions do not last beyond the excitement which reaches the perception cells from the organ of sense. In those cells of the great brain, on the contrary, where the impressions become combined into



		26 PATHOLO&Y AND THEBAPEtfTICS OF MENTAL DISEASES. ideas and images, the impressions are persistent, and can also be easily again called forth, that is so to say, these cells are the material basis of the memory. The animals deprived of their great hemispheres also still see, as we may assume from their movements in stronger illumination; nevertheless, like blind animals they strike repeatedly against mechanical impediments without being able to evade them. For- getting the impression, they are no longer in a condition to modify their bodily movements according to definite ideas ; the capability of recognising the impediment, and the necessary combination to avoid it, is, with the faculty of ideation, taken away from them. They are passively susceptible without re-acting, they no longer understand or comprehend. Thus may an animal starve to death with food in its mouth or beak, because it no longer swallows until the food reaches the fauces, where it then calls forth the involuntary reflex movements of swallowing. If the hemispheres are removed in layers, the movements called forth by sensitive impressions become weaker and weaker in degree, the deeper the section goes, and the more brain mass is taken away. But already in Blourens (BechercTies experimentales, etc. : Par., 1824, p. 98) the correct observation is found, that this diminution does not proceed from a single organ, but rather that all the organs of sense sustain a blunting in a similar degree, or in other words the activity of the higher organs or of the cycle of ideation vanishes. The loss of blood in the operation, and the disturbance of the circulation, may in the first place also impair the yet uninjured parts. If the operative interference has not been too severe, then may the sensory functions gradually more and more return. After extirpation of only one hemisphere, Schiff saw no alteration or weakening of the animal movements occur. If the operation was executed with caution, the animals conducted themselves just like other animals which had sustained a considerable loss of blood. But we may conclude from this that the will still exercises its influence on the corpora striata which I have previously indicated as the seat of the motory volition, and also that the memory is not lost. Indeed, there are also cases known where, in the human subject, one hemisphere was found entirely destroyed without the intellectual power being lost. Very remarkable are those experiments relating to the corpora striata. SchifF removes the hemispheres in a rabbit so that the corpora striata lie bare, and then he removes the latter also with great care, without touching sensitive fibres and without causing pain. The animal now remains sitting quietly, as if it had not suffered anything, and displays no impulse to run away. It sits there in its own accustomed posture, a proof that it is able to maintain its equilibrium. If one now carefully seizes a hind foot and extends it, the animal allows this limb to remain, and does not draw it forward again. If one now stretches out the other hind foot, so



		27
	VIYISECTIOU'S.	27

that its belly comes to lie on the ground, the animal remains in this position, as if it were paralyzed. One may also displace the fore feet laterally, so that the animal lies upon its thorax, and it is here quite unimportant whether the feet have a symmetrical position or not. Now one may again bring back the feet into their natural position, and they support afresh the posterior part of the body. But an animal with paralysed limbs would fall down. The rabbit is become as it were cataleptic. If one now applies at any spot a stronger pressure, then the animal rises up suddenly, stretches its head and ears upwards, and executes at first slow regular jumps. Certainly in an apparently exhausted animal only weak movements could be expected ; but with every jump the strength appears to increase, the movements become constantly quicker, and if there is only space the animal rushes forwards in blind irrepressible haste until at last it strikes on some impediment, and on a sudden remains standing. Instead of assuming the sitting posture however, with its limbs drawn up, it remains immovable in that position in which it was placed by the collision, namely, the hinder limbs extended or half raised, and the nose opposed to the impediment. It is surprising what great distances an animal can traverse with constantly increasing speed, provided it meets with no obstacle. When once springing, it goes so fast that no man can follow it. An explanation of this remarkable phenomenon is not difficult. In all these movements the real will is excluded; they follow passively as in a leathern doll (ledernen Puppe), as soon as the moving apparatus is once set going. If the animal once begins to jump, it can no more bring its movements to a termination by the influence of the will, but is circumstanced like a running down clockwork. Schiff now raises the important but difficult question, "What is the seat and action of that power ? If he took away other parts of the brain lying further backwards, then the above mentioned phenomena did not occur. But a removal of the corpora striata was not indispensable, for the same result became apparent on section of the fibres which pass, radiating from the anterior and outer edge of the corpora striata, into the hemispheres, that is to say, the so-called corona radiata through which the connection between the hemispheres and the corpora striata is brought about. On this ground Schiff regards the corpora striata as the beginning of the hemispheres. According to this explanation the corpora striata would not be the apparatus for movement, and Schiff directly supports the assumption that they have nothing to do with movements. Thus much is certain, that if after their removal such rapid movements can still occur, the proper centrum motorium must be behind the corpora striata, where the crura cerebri enter into the thalami.* R. Wagner {G'dtt. gel. Am.,* Feb., 1860, s. 58) seeks the centrum motorium in the substantia nigra of the crura cerebri; however, I have scruples against this assumption. Injuries of the corpus striatum have for certain, paralysis as a consequence, and if softening of the substantia nigra occurs, then the fibres coming from the corpora striata also suffer at the same time.



		28 PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES. Hitherto, I have always been of the opinion that our will acts directly on the corpora striata, and not merely through the hemispheres. This assumption is founded chiefly on the con- sideration that, as I have had opportunity to observe myself, tubercles, apoplectic effusions, and destructive processes between the corpora striata and the cortical layer are not always followed by paralysis, which on the other hand seems never to be absent in extravasations into the corpora striata. Moreover, how the will is able also to act from the hemispheres on the corpora striata I have already explained above, and have referred to the example of the painter who brings on the paper the picture designed in his imagination. I have never been able to conceal from myself that there are difficulties in assuming that our will acts simultaneously on two different points, namely, in the cortical layer, and in the corpora striata. I may, however, in reference to this, refer to the circumstance that the perception of light certainly follows in the corpora quadrigemina, inasmuch as the removal of the hemispheres appears not to be followed by complete blindness, whilst the taste at least is certainly quite lost after that operation. That no function is assigned to the corpora striata, which appear early in the embryos of all vertebrata, and are never absent, is impossible to suppose, as is expressed in the proposition of Schiff, which runs thus: these parts of the brain have no peculiar attributes and in a physiological point of view, they cannot be separated from the hemispheres. If the will acted from the hemispheres on the corpora striata it would be very difficult to comprehend why the removal of one hemisphere is not followed by paralysis of the opposite side of the body. Mourens {Becherch.es exper., p. 29) sometimes per- ceived after this operation a weakening, which, however, soon disappeared. But Schiff ascribes this only to incidental causes, which may act in a disturbing way for a certain space of time ; for if the extirpation of only one hemisphere is executed with caution, in rabbits, dogs, cats, marmots, then only such weakness occurs, as will generally be observed after loss of blood, and it very soon passes off. A pigeon, both of whose hemispheres have been extirpated, flies if it is thrown in the air, maintains its equi- librium in its course, and if it is laid on its back, stands up. From this we perceive that the will is not completely lost, but still acts in the corpora striata. It was already prominently stated in the report of the commission appointed on Plourens's experiments, that Flourens had by no means proved the complete loss of perception in consequence of extirpation of the hemi- spheres, although perception is not manifested, and the memory is wanting. This is also proved by the experiments which Longet {Traite de physiologie, 1850, t. 2, p. 240) undertook in reference to this point. He brought a pigeon, whose hemispheres had been extirpated, into the dark. If he approached quickly with a bright light, then the iris contracted, and even the opening



		20
	TITISECTIOSTS.


of the eyelids became smaller; indeed, when he moved a lighted candle round in a circle, at such a distance from the animal that the heat could not affect it, it made corresponding revolutions with its head. If, when its eyes were shut as was generally the case, a pistol was fired, then it opened its eyes, raised its head, stretched its neck, and relapsed again into sleep. He also observed that kittens whose hemispheres had been removed, made movements with their jaws and tongue, after the intro- duction of colocynth, just like other animals who wished to get rid of a nauseous taste. The above-mentioned Commission on Flouren's Eesearches also denoted the cerebral hemispheres as the receptaculum in which perceptions attain their completion, where sensuous feelings assume definite form, leave impressions behind them, and by that, supply substantial material for the judgment: an apprehension which entirely agrees with my own. I may, therefore, assume that vivisections completely confirm those conclusions to which I have been led on quite different grounds ; the cerebral hemispheres are not the primary organs for perception; rather in them the sensitive impressions are collected into ideas and images. It is also in agreement with this that after extensive destruction of the cortical layer by inflammation or by atrophy, the phenomena of stupidity and dementia occur without the perception of sensitive impressions being lost, provided only that their centres have not sustained injury. Section 10.�The Cerebellum. Of all parts of the brain, in my opinion the cerebellum opposes the greatest difficulties in regard to the discovery of function. Hourens, Hertwig, and others have observed that injuries of the hemispheres of the small brain, or even removal of it, exercise the most important influence on the movements of the body, which indeed are not suppressed, but whose full domination appears to fail. On that account, the co-ordination of move- ments was attributed to the cerebellum. Against this view is the circumstance that a frog whose great and small brain have been removed, still jumps and executes regular movements when one of his feet is irritated. E. Wagner (Gott. gel. Am., 1860, No. 4, s. 36), from his examinations arrives at the conclusion that the cerebellum is a purely motor apparatus of the brain, which has absolutely nothing to do with the perception of sensitive impressions, or the forma- tion of ideas, and which is likewise not, or only very distantly, connected with the organic functions. It appears to him that the cerebellum although exercising some influence on the regulation of the symmetrical movements, especially the movements of walking, yet cannot be regarded directly as the regulator of the bodily movements. Man, as well as animals, after considerable



		30 PATHOLO&Y AND THEBAPEtTTICS OF MENTAL DISEASES. injuries of the cerebellum, can still move the single limbs, but they have not the trunk and the posterior limbs well under their control. According to Schiff, the same symptoms follow injury of the cerebellum, as those which we perceive after injury of the fibres, radiating from it, e.g., of the pons Varolii. If the injury does not occur symmetrically on both sides, there arises an unequal attitude of the vertebral column, and consequently irregular movements begin. Lastly, he nevertheless pronounces that the functions of the cerebellum are still entirely unknown. That the cerebellum is especially destined to secure the equilibrium of the two sides of the body, or at least to bring the latter into closer combination, we may well conclude from the course of the fibres. The pons Varolii stands in the closest connection with the pyramids, which, however, appear to serve exclusively for movements of the limbs. Behind or above the pyramids lie the different centres of the sensitive and motor nerves, and near them the accessory ganglia of the olivary as well as the restiform bodies, which represent another system of fibres radiating from the cerebellum. These pass over into the arciform fibres, which reciprocally connect the parts lying behind the bridge. A third double tract of fibres, the crura cerebelli ad corpora quadrigemina, courses laterally along the so-called hood, and, according to Stilling, these fibres decussate in the crura cerebri. Now whether these fibres, as "Wagner thinks {Qbtt. gel. Anz., 1860, Jan., s. 35), serve to convey impressions from the great brain to the cerebellum, or whether centripetal and centrifugal fibres occur in all the crura, this appears to me most probable, that the bilateral movements are controlled by the cerebellum, and, indeed, in a reflex manner. Section 11.�The Circulation in the Brain. In order to be able rightly to understand the lesions of the brain occurring in mental diseases, it is necessary to keep in mind the relation of the circulation to the vitality of the brain. For it is evident enough that an unequally strong pressure of the blood, the more arterial or venous condition of the blood, as well as other modifications of it, cannot remain without important influence on the brain. Daily experience teaches us that violent congestion of blood may interrupt the functions of the brain, and speedily lead to a fatal termination. Let us now look at the means and precautions by which a violent congestion of blood may be moderated or prevented. If, through increased activity of the heart, the blood is more powerfully and under greater pressure driven into the aorta, it runs off, for the most part and quickest, through those vessels in which a less resistance and counter pressure have to be overcome. But if we look at the branchings of the great vessels, it is certainly very remarkable that close to the vertebralis the



		32 PATHOLOGY. AND THEBAPEIJTICS OF MENTAL DISEASES. and on that account the coats of the vessels have no powerful support from without. Thence it occurs that the cheeks, and indeed the whole face so easily assumes an increased colour, e.g., in powerful and sudden emotions, especially also from high degrees of temperature. If the vessels of the brain could be as easily filled, we should have to fear an apoplexy from every rather active exertion. But the carotis externa thus leads the strong pressure of blood outwards, because the carotis cerebralis in the closed cavity of the skull cannot equally well expand, and on that account opposes a more powerful resistance to the pressure of blood. Therefore, from diffused redness of the face, we may not always conclude that there is congestion of the brain, although the latter is frequently associated with the former.* Similar conditions occur with the vertebrales. These arise from the subclavian, and with strong pressure of blood the stream can be derived from the vertebrales towards the arm. For this reason may hand-baths, placing a bandage round the arm, or even the finger, stop bleeding from the nose; this I have many times experienced with the best effect, and in earlier years was accustomed to verify on myself. The resistance against a strong blood-pressure is still more increased by the brain and spinal cord being inclosed in bony cavities, which are capable of no extension, and, under ordinary circumstances, must always contain the same mass of solid or fluid contents, as no elastic structure occurs in them. Hence it has been assumed, that generally no increased quantity of blood can proceed to the brain, as the latter is not capable of compres- sion. But in apoplexies we often find large quantities of extravasated blood, f Therefore, the liquor cerebro-spinalis can afford room for a larger quantity of blood, whilst it escapes out of the cavity of the skull into the more lax and movable sac of the dura mater spinalis, which in the natural condition appears not to be very full and tense. For if we carefully open the vertebral canal, so that the dura mater is not injured, the sac may be inflated to a larger size. Tor although the skull cavity is not thoroughly unalterable, the blood vessels have yet a stronger support from it, and it opposes a stronger resistance to too great filling with blood. But a certain scope was indispensable, as every exercise * The researches of Sucquet (Schmidt's JaJirb.. 1862, No. 1, s. 20) correspond with this. He has demonstrated, in addition to the proper capillaries, also larger communicating branches between the arteries and veins, and indeed in the hand and elbow, in the foot and knee ; even in the face, in the skin of the lips, nose, eyelids, eyebrows; of the ears, in the mucous membrane of the cartilages and septum of the nose. He correctly claims for these anastomoses a derivative purpose, as in strong arterial pressure the blood will be carried on more quickly through them towards the veins. In old age these communicating branches increase in number and size. t I possess a preparation where the blood is extravasated in so great quantity between the dura mater and the skull that the coagulated mass of blood, on opening the skull, was bigger than the fist, and had pressed the hemisphere quite flat. The blood was freshly coagulated, its extravasation had occurred but recently, and with great rapidity, so that death must have been immediate.



			THE CIECTJ1ATI0N IK THE BEAIN. 33

		of power, consequently also activity of the brain, demands a more active circulation and increased change of material, on which account a powerful and continuous mental exertion occasions phenomena of congestion, and at last induces the feeling of heaviness, dulness, and fatigue. Long ago, Kellie (Ueber den Tod durch Kalte und iiber Con- gestionen des Oehirns in Fr. Nasse, Sammlung zur Kenntniss der Qehirn und Ruckenmarks-krankheiten, 1 Heft, 1837), and Dieckenhoff (De remediorum quorundam vi sanguinem cerebro et meningibus contentum diminuendi: Bonn) busied themselves with experiments on this subject. Kellie claims the discovery that on account of closure of the skull, the blood is retained in its cavity, and therefore, after a fatal haemorrhage, the brain does not appear so bloodless as the other parts of the body. But, on the other hand, if through preliminary trephining, he permitted the entrance of air into the cavity of the skull, then he found the brain also bloodless. Dieckenhoff, however, could not corroborate this statement, and I have myself found the brain quite pale and bloodless in rapidly fatal haemorrhages. Nevertheless, it appears to me that Kellie's assumption is not entirely to be rejected. For the most part we find the brain of the slaughtered sheep not quite bloodless. But if the vessels of the brain become emptied through haemorrhage, the space must be filled by something else, and, according to Kellie, it is by serous exudation. We may, however, assume that in a rapidly fatal haemorrhage the serous fluid runs from the spinal canal into the skull cavity, and supplies the place of the diverted blood. The space forming in the spinal canal, must then be balanced by filling and distension of the wide venae spinales, which veins communicate with the venae cephalicse, and stand in reciprocal relation. Nevertheless, the blood will be retained, if not completely, yet longer in the brain than in any other organ.* In lessened blood pressure, after copious loss of blood, a more active exudation of serum may easily occur, and this well explains the recognised observation, that obstructions of blood operate so deleteriously in the insane, especially in melancholic patients. If serum is once exuded, it opposes a more active circulation, the brain remains, therefore, longer anaemic, and softening of the brain and imbecility may be induced by the exuded serum. This happens in such cases frequently enough after venesection. If the vessels of the brain have become distended in conse- quence of a strong pressure of blood, as is often the case in * In post mortem examinations, when the existence of brain congestion becomes a question, we must bear in mind the suction power exerted on the blood. The brain and brain fluids contract on cooling of the body, and the blood in the veins, which still remains fluid several hours after death, is partly driven back to the brain in order to fill the space formed through its shrinking. Nasse {Vntersuchungen zur Phys. u Pathol., Bd. 1, s. 387) has already pointed this out. Thence also may it arise that the blood in the veins of the brain is mostly not coagulated, because the fibrine remains behind, and only the fluid blood returns into the cavity of the skull; therefore, in sections, the filling of the vessels of the brain gives no accurate measure of their condition during life, i)



		34 PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES. chronic insanity, there are yet other ways of passing off, for the superabundant blood. If the blood in the skull cavity is under a stronger pressure than in the face, it has an outlet through the art. ophthalmica; andjthe nose,and, through the frontalis,the supra- orbital region, acquire a deeper colour. If the congestion has a more chronic course, as in many cases of acute mania, then only the tip of the nose is more deeply coloured, even to bluish. But the same also occurs in melancholic patients. Hence we also observe in confirmed tipplers, in whom for the most part habitual brain congestion exists, so generally a red or bluish swollen nose. As the ophthalmica, through the ethmoidalis anterior extends along the septum narium as far as the tip of the nose, and likewise the skin of the nose externally is in connection with twigs of the ophthalmica and angularis, we may easily com- prehend how it is that the ophthalmica is diagnostically so significant, if the blood sustains a stronger pressure in the cavity of the skull and partly flows off through the ophthalmica. On the other hand, we have in the colour of the sclerotica, an* entirely uncertain sign. Its vessels appear, in cerebral irritation, sometimes to contract under the influence of the nervi ciliares ; at least I have myself observed the sclerotica still white in very intense cerebral congestion of several days' duration, and in apoplexies. We therefore assume that bleeding from the nose is a favourable event in congestions of the brain. If it does not occur of itself we apply a leech in the nose, from which I have several times seen the best result.* The vertebrales before they enter the cavity of the skull give off muscular branches which communicate with the auriculares posteriores. I ascribe it to this, that children, as I have many times observed, shortly before an attack of convulsions have the ears quite reddened; indeed this appearance may occur when there is merely great tendency to convulsions. In some maniacal patients the nose is coloured, and in others the ears, which I explain in this way�that in the first, the congestion occupies rather the anterior portions of the brain, in the latter rather the posterior portions. Thus, also, it may be explained why in congestions, repeated cuppings in the neck act favourably; in recent cases of epilepsy especially I have obtained very happy results from this practice. If the flowing off of blood through the veins is impeded, as, for example, in asthma, then the sinuses of the skull are filled, so that the vena ophthalmica cannot easily empty itself into them. The external veins must receive its blood, and an enlargement of the veins of the sclerotic takes place (on which the ciliary nerves exert a weaker influence), through which the sclerotic acquires a brownish appearance; and the eyelids, especially the lower one, * To explain this relation, I have frequently injected the ophthalmica alone in the skull cavity. The forehead, the tip of the nose, and the cheek were coloured thereby.



		36 PATHOLOGY AND THEKAPEUTICS OF MENTAL DISEASES. the veins ; the storm, as it were, sweeps away over us without our perceiving it. However, the effect of such a congestion always makes itself known. Suppose a good friend, in rapid course, panting and heated, were to reach us. If now a complicated question, a difficult calculation were laid before him, he would reply that he must first rest himself somewhat, that he was not at the moment sufficiently composed to think over so important a question. The cells in the cortical substance are at the moment in a con- dition of too great excitement, the ideas and images chase one another, and are not under control; deeper reflection requires a previous calming of the circulation. If the rapidity and strength of the circulation increase still more, as sometimes in fever, then delirium may be reached ; the involuntary ideas and images gain in strength, so that they are no longer to be distinguished from real impressions. Further, regard is due to the sinus dura matris, which are capable of no distension. If by impeded respiration, the outflow of blood from the jugular veins into the chest is hindered, the accumulation of blood in the skull nevertheless meets a resistance, on the one side, from the closure of the skull itself, on the other side, because the sinuses cannot extend; by means of the numerous anastomoses between the v^renae spinales and the azygos, the blood can then collect more in the abdomen.* I will also mention that the brain floats in the liquor cerebro spinalis almost as in a bath, so that, according to the researches of Toltz {Prager Vierteljalirsschr., 1855, iv. s. 99), it presses on the base of the skull with only one-fiftieth of its weight. We must here remember that the arteries, which on account of their power of expansion can endure a greater pressure, all lie on the base of the skull, but the easily compressed veins are collected on the surface of the hemispheres, and have their position mostly in furrows between the cerebral convolutions, so that they are not compressed by turgidity of the brain, and consequently the flow of blood back from the brain remains as free as possible. Moreover, between the branches of the arteries, as well as between the veins, numerous anastomoses are everywhere found, and with increased flow of blood, no violent congestion of the brain can occur, because the pressure is divided equally on all the arteries and veins. Without this disposition a stronger flow of blood, through one of the cerebral arteries, would immediately have as a * If one propels blue injection size upwards through the jugulares, one sees it pass easily from the inferior vena cava into the heart, because the wide Plexus venosi spinales anastomose with the venoe lumbales, and through them are connected with the inferior vena cava. An interesting experiment of Toltz (Gaz. med. de Paris, 1853, No. 10, u. Prager Vierteljahrsschrift, 1855, iv., s. 99), supplies a further proof that the blood, when a strong pressure is acting within the skull easily makes its way outwards. He tied the jugulares internee and externte, then laid bare the sac of the dura mater at the end of the spinal cord, and inserted J a canula, through which he syringed water into the sac of the arachnoid. 'From this, the previously corpse pale face immediately acquired a bluish colour, and the veins above the ligature were rilled,



			THE ClfiCtTLATlON IN THE BItAllf. &7

		consequence a stronger congestion in a particular section of the brain, through which dangerous extravasations of blood would easily arise. Now, also, when from any cause the flow of blood is cut off at one place, the blood may pass through lateral branches, so that the circulation still continues. Nevertheless we see in embolism of the vessels of the brain, that such an obstruction may be very deleterious, as soon as it extends over a rather large region. Through all these harmoniously combining causes it becomes possible that the brain with its vessels, notwithstanding the delicate structure of the latter, is in a position to sustain a considerable pressure. We see this in difficult parturitions, in asthma, in hooping-cough, in epilepsy, where the small vessels in the loose tissue of the eyelids, which arise from the ophthalmica coming out of the skull, burst in consequence of the great congestion of blood, without any extravasation occurring in the brain itself. Of great significance, also, are the observations on the circulation during sleep, which we owe to Arthur H. Durham {Schmidt's Jahrhb., 1861, Nr. 4., s., 13). The opinion was general that in sleep a larger quantity of blood is accumulated in the brain, and that augmented venous congestion in reality caused the coming on of sleep. The increasing sleepiness in great plethora appeared to be in favour of that view, similarly the accumulation of blood in the brain in coma, the occurrence of sleep after an epileptic attack, where evidently congestion is present, and not less the state of unconsciousness in apoplectic effusions, or in capillary Injection of the vessels of the brain. This much, however, seems to follow fromDurham's inquiries,that we must clearly distinguish tranquil sleep from coma and from sopor. A portion of the vault of the skull was removed from a dog with the trephine, and then the underlying dura mater excised ; the uncovered part of the brain appeared inclined to press into the opening, the large veins on the surface were somewhat distended, the smaller vessels of the pia mater appeared to be full of dark blood, and no decided difference of colour between arteries and veins could be perceived. Such was especially the appearance and condition during the action of chloroform. After the action of the chloroform had ceased the animal fell into a comparatively natural and sound sleep; thereupon the surface of the brain became pale, and sank rather below the level of the bone, the veins were no longer distended, little vessels having an arterial colour could be distinguished, and many which before swelled with dark blood could no longer be recognised. When after some time the animal was awakened, a weak red colour appeared to spread over the surface of the brain, and the latter again pressed into the opening in the bone. The more active the dog was, the more the pia mater became injected, and the more turgid was the reddened brain; everywhere vessels, which during sleep were not visible, showed themselves, and arteries and veins could be accurately recognised by their different colour. The



		38 PATHOLOGY AND THEBAPEtJTICS OF MENTAL DISEASES. animal was now fed, and then again sank into quiet sleep; the blood vessels again became narrower, and the surface of the brain pale as before. The difference in these appearances was the more firmly established as two animals under opposite conditions were observed. Lastly, the state of the vessels was examined with a strongly magnifying lens, and, indeed, under weak microscopical power. The trials were several times repeated with exactly similar results. Dogs were found to be more suitable than rabbits. A different atmospheric pressure could not come into consideration in these experiments, for this was the same both in the sleeping and waking state, likewise the appearances did not alter when accurately fitted glass plates were set in the opening of the skull. The explanation of the phenomena Durham finds in this, that during sleep, vascular action and congestion towards the brain exist in a less degree. In the waking state, and when the brain is in activity, it receives more blood which also moves more rapidly through the vessels, and the brain substance is more oxydised; for the functional activity of the brain demands a greater consumption of oxygen, and this vis a fronte occasions a richer supply of arterial blood, enlargement of the capillaries, and increased change of matter. The increased rapidity of the circulation causes a more copious supply of oxygen, and probably also a more active taking up of the products of decomposition into the blood. For, according to Durham's experiments, if fluids are allowed to stream through a rabbit's intestine, which lies in a surrounding fluid, the quicker the stream is the less will transude outwards through the wall of the intestine. Now, during sleep, the vis a fronte diminishes ; on account of their elasticity the vessels contract more and the nutritive circulation is predominant; fewer blood cells circulate, and the slowness with which the blood flows favours the escape of nutritive plasma. The immediate cause of temporary suspension of cerebral activity cannot be a failure of active material, or that this is exhausted by oxydation; for the already fatigued brain may be brought to renewed activity through suitable stimulation. Durham finds this cause in the products of decomposition, and appeals to the observation that the brain substance of an animal just killed has a neutral or even a slightly alkaline reaction, but shortly after influence of the atmosphere is, on the contrary, acid. Still Heynsius, before Durham, found that the quite fresh brain of the sheep or of the ox, had an acid rather than an alkaline reaction ; this was confirmed by Funke, who, at the same time, ascertained that in increased activity of the brain an acid reaction, and in inactivity of the brain, an alkaline reaction is present. Heynsius (Nederl. Tydschr, v. Geneesk, 1859, p. 651) has further demonstrated that the diffusion or exosmosis of albumen is impeded by acid, and is promoted by alkali. Thus, if after long activity, in consequence of oxydation, acid has accumulated in