David Ferrier

The Croonian Lectures on Cerebral Localisation.

LECTURE I: INTRODUCTORY. MR. PRESIDENT AND GENTLEMEN,-While highly appreciating the distinguished honour of being appointed Croonian Lecturer of the College of Physicians, I must confess to having undertaken the onerous duties of the office with considerable hesitation and trepidation, for, though the subject which I have chosen is one to which I have devoted a good deal of attention, and which, in one of its aspects, namely, The Localisation of Cerebral Disease, I have already had the honour of discussing before you as Goulstonian Lecturer, yet, considering the enormous amount of work that has been done in this department in recent years, and the nume-

The Goulstonian Lectures on the Localisation of Cerebral Disease

LECTURE I (concluded).-March I th. MM. FRANCK and Pitres* have shown that a distinct interval elapses between the excitation and the movement: an interval which, after deducting the latent periods of nervous and muscular stimulation, and the rate of transmission of neural impulse in the cord and nerves, leaves a residue of nine-two-hundredths of a second of retardation in the grey matter. If, however, the grey matter be removed, and the stimulus applied to the medullary fibres, the period of retardation diminishes to six-two-hundredths of a second. This proves, in accordance with the laws of stimulation of nerve-centres, that the grey matter intervenes, not as a conductor, but as a centre. It has likewise been proved by the experiments of Putnam, Carville and Duret, etc., and verified by Franck and Pitres, that, in order to excite movements after removal of the cortex, a stronger stimulation is necessary than that required for the cortex itself. This, on the physical conduction theory, would be, the less the resistance, the less the effect: a proposition manifestly absurd. It is, however, the property of the nerve-centres to reinforce an excitation; and such is the case with the cortical grey matter. Still more important, perhaps, than these results, is the fact that certain modifications occur in the excitability of the medullary fibres after removal of the cortex, which conclusively demonstrate that we have to deal with neurility, and not with mere electrical conductibility, as Mr. Lewes supposes. We know from Wallers researches that, when a motor nerve is divided, the excitability gradually diminishes and ultimately disappears: phenomena which proceed pari passu with progressive degeneration of the nerve from the centre towards the periphery. In a similar manner, it has been found by Albertoni and Michieli,+ con. firmed by Dupuy,

II. The functional relations of the motor roots of the brachial and lumbo-sacral plexuses

and by MM. Franck and Pitres, that, after a certain period, excitation of the medullary fibres no longer gives rise to the movements which can be caused by stimulation immediately after removal of the grey matter of the cortex. In dogs, as a rule, as Franck and Pitres have shown, the excitability totally disappears about the fourth day; and this coincides with the period at which, in consequence of the degeneration described, the motor nerves of the dog lose their excitability. By such facts, the only plausible arguments in favour of mere physical conduction of the electrical currents are shown to be absolutely without foundation; and, all other evidence apart, the direct relation of the cortical grey matter to movements is established beyond all doubt.

The Constant Occurrence of Sarcina Ventriculi (Goodsir) in the Blood of Man and the Lower Animals: With Remarks on the Nature of Sarcinous Vomiting.

The functions subserved by the plexiform arrangement of the nerves of the limbs, and the mode of distribution of the several roots of the brachial and lumbo-sacral plexuses, have been the subject of frequent speculation and of occasional experimental research; and the question is one of considerable physiological and pathological interest. A mere naked-eye examination of the mode in which the roots unite to form the larger trunks allows of an approximate determination of the possible roots of each trunk; and by more minute dissection and maceration in dissociating liquids, as has been done by W. Krause in the case of the brachial plexus (“Beiträge zur Neurologie der Oberen Extremität,” 1865), the constituent fibres of the nerve-trunks may be determined with greater precision. But it is obvious that anatomical dissection, however minute, is unable to discriminate between the sensory and motor constituents of the nerve-trunks, or to indicate their functional relations and distribution. The only possible methods by which this can be arrived at are by determ ining the effects of excitation or destruction of the individual roots of the plexus.

Experimental Researches in Cerebral Physiology and Pathology.

It is one of the numerous merits of this classification, and therein it shows its truly scientific character, that it helps in the solution of a practical question such as the one under discussion. By bringing the bodily causes of the mental symptoms prominently before our minds, it enables us to see whether we can treat and remove them with the means at our disposal in private houses. It helps our prognosis greatly; so that we can take into account the probable duration of the severe and acute symptoms that often make home-treatment impossible if they continue long. When a case is distinctly incurable from the first, the question of sending him to a lunatic asylum is immensely simplified. Dt. Skaes Classification.-I shall briefly go over the different groups into which Dr. Skae divides insanity with reference to this question. His first group is congenital insanity, comprising idiocy and the various degrees of imbecility. This class of cases require training rather than medical treatment, and, as a general rule, are not suitable inmates of asylums. At home under the kindly care of relations, in institutions for the training of imbeciles, or in workhouses, such cases are most suitably placed. The next group, that of epileptic insanity, does most undoubtedly often require asylum-treatment, where there is a tendency to great violence and excitement after the fits. In many cases, however, this violence is very transient; and where circumstances allow suitable attendance during these times, the patients may be kept outside, and lead far happier lives than in asylums. If an epileptic, however, have become permanently irritable, with suspicions and sudden impulses to violence, then our duty is clear in the matter. The insanity of masturbation comes next; and I think every effort ought to be made to keep this class out of asylums, at first trying every means of cure before sending them there. The great hope in such cases is to get the bodily health into a thoroughly vigorous condition, and rouse the mind to interest itself in something that is healthfully stimulating. The same observations apply to hysterical insanity in the female, and to the short attacks of mania that sometimes occur at puberty (insanity of pubes. cence) in both sexes. In the case of puerperal insanity, everything depends on the intensity of the symptoms and the circumstances of the patient. In itself, this form, more than any other, tends to recovery with anything like proper treatment. Among the very rich, almost no cases of puerperal insanity need be sent to asylums ; but they must often be sent from home, under the care of proper attendants. Among the very poor, on the contrary, I believe nearly every case would get better much sooner, and more satisfactdorily, if sent to asylums. Somewhat the same remarks apply to insanity from prolonged lactation. The cure of this is a mere matter of abundance of good nourishment and stimulants, with some mild sedative to procure sleep. The insanity of pregnancy should only be sent to an asylum when the symptoms are so extremely acute that the patient cannot be managed elsewhere, or where strong suicidal tendency exists. Uterine insanity is so apt to be associated with fixed delusions of a sexual character, that most cases have, sooner or later, to be sent to asylums; and that being so, it is better they should be sent early, when treatment is of some avail. In few kinds of insanity is there such a tendency to think that nothing is wrong, and so an obstinate aversion to treatment of any sort. In an asylum, this treatment can be carried out nolens vokns. Climacteric insanity, or that occurring at the change of life, is usually a very curable affection, and its symptoms are mild in their character, so that resort to an asylum is seldom necessary. In the case of senile insanity, all must depend on the violence of the symptoms and the circumstances of the patient. Among the rich, such cases need never be sent to asylums. Among the poor, no cases are often so much benefited by asylum regimen and treatment. Phthisical insanity unfortunately needs asylumtreatment in most cases. The waywardness, dislike to relatives, irritability and fickleness that characterise it, can be better managed in an institution than in a private house. Traumatic mania, or that caused by violence, is generally best treated in an asylum. Its symptoms are apt to be violent and unmanageable out of one. Delirium tremens and alcoholism should not be sent to asylums, nor the attacks of ephemeral mania that sometimes follow a drunken bout. Dipsomaniacs should not be sent to an asylum. They should, assuredly, for their own sakes, be prevented from having stimulants; but, unquestionably, the law does not at present recognise this as a form of mental alienation that justifies deprivation of liberty. If we send such cases to asylums, we do so at our own risk; and I cannot see that it is the duty of our profession to expose itself to legal penalties in such cases. Mr. DalrymSples bill will, no doubt, in time, put matters right in this respect. General paralytic insanity, I may say, should always be sent to an asylum. It is utterly hopeless from the first, and can be far better managed in an institution with means and appliances at hand. And there is no object in delaying time when we have made our diagnosis. The patient will merely be squandering his means, and causing infinite pain and annoyance to his relatives during the time he is allowed to remain at home. In the case of acute idiopathic insanity, with a strong hereditary predisposition, if the patient be young, I believe it is of much importance to send the case to an asylum. Early treatment of the right kind may save the patient from falling into dementia, which he is likely enough to do under any circumstances. How should the existence of strong hereditary predisposition to insanity affect our view of sending a case to an asylum or keeping him at home? I think it ought to incline us to send him to the asylum, on account of the greater importance of having right treatment early and thoroughly applied in such a case. Hereditary predisposition does not denote incurability, by any means. In fact, such cases are quite as curable as others; but it does indicate a great liability to recurrence of the attack after being cured. I am not going to enter here into the question of boarding out, in suitable families, the harmlessly demented, weak-minded, and mildly incurable insane. That is a question of expediency. They are working it out in Scotland. The English lunacy law as yet makes no provision for its being carried out under the supervision necessary to its being successful; so we need not discuss it.

III. A record of experiments illustrative of the symptomatology and degenerations following lesions of the cerebellum and its peduncles and related structures in monkeys

left without aids to diagnosis beyond these which I have yet mentioned. The case which I have supposed is of the worst description as regards diagnosis. In actual practice you will find not merely the seven cardinal symptoms uponwhich we havedwelt so long, but otherminororsecondary symptoms, which, though subjecttogreat variations, often furnishvaluable corroborative testimony. These I can only name. They include delusions of every dye-aphasia, altered affections, sudden impulses, morbid appetites, ptosis, muscular twitchings or rigidity, staggering gait, glandular enlargements, vomiting, interrupted circulation, and menstrual irregularities. These, or some of these, may complicate, but more often simplify, diagnosis, which is again facilitated by the absence of other symptoms distinctive of other organic diseases, and by considerations as to the age, history, and habits of the person affected. To show you how contingent are interlaced with necessary symptoms, I shall briefly describe a case to you. Maria S., a widow, 54 years of age, was received into this asylum on the 4th May, i869. She had then been out of health for some years, never having altogether shaken off the grief occasioned by her husbands death, until the close of i868, when she became silly and childish, and suffered from a fit, and horrible pains in her head. In the spring following, she had several fits and attacks of transient excitement. She also, by imperceptible degrees, lost the use of her left side; and in consequence of this, as she persisted in moving about, suffered several falls. When brought here, she was a pale, sallow, anoemic-looking woman-so thin, as to be described in the case-book as a living skeleton. She was in a fatuous state. Though garrulous and anxious to talk, especially about her own illness, no reliable information could be got from her, as her memory was utterly fallacious. She could not recall her husbands Christian name, and was oblivious as to all measurements of time, and names of days, seasons, and places. She was often unable to find the word which she wanted, and seemed to introduce into the sentence for which that word was required any other word that occurred to her at random. Her expression was careworn, and also singular, as she had exophthalmos and blindness of the right eye, and ptosis of the right eyelid. The pupil of the left eye was much contracted, and its margin was irregular. The mouth was drawn to the left; and the tongue, when put out, pointed to the left. The sensibility of the right side of the face was much diminished. There was almost complete loss of power in the left arm and leg ; there was partial loss ,of power, with tremor, in the right arm and leg; there was a systolic murmur at the base of the heart, and a thick white fur on the tongue. During her brief sojourn in the asylum, Maria S. became more and more fatuous; her appetite for food being at some times voracious, and at other times altogether absent, so that she had to be fed. The paralysis of the right side increased, uncontrollable vomiting and diarrhoea came on, coma supervened, and then came death on the i5th June. At the necropsy, the brain was found flattened and compressed, and at its base was a cancerous tumour. This took origin in the right temporosphenoidal lobe, and extended inwards, being divided by a neck into two parts, each about the size of a small walnut; an outer part, fibrous, containing cysts and fluid contents; and an inner part, soft and pulpy, and of a pink colour, variegated by deep red blotches, and with a delicate fibrous matrix. The outer part was embedded in the temporosphenoidal lobe, and the inner lay in a sort of excavation, which had been formed by the absorption of portions of the body of the sphenoid bone, the orbital plate, and the pituitary body, and by displacement of the posterior, orbital, and surrounding gyri. It compressed the roots ,of the right olfactory nerve, the right optic tract and nerve, and the right fifth nerve. The prognosis in cerebral cancer, when it is diagnosed, is of course as gloomy as can be: nothing but death, speedy death, can be predicted. It is not, perhaps, utopian to hope that, with the progress of therapeutics, some means may be discovered of resolving or controlling malignant growths. Distinguished and sober-minded surgeons have entertained that hope. At present, however, we must be content with smoothing the pathway to the grave, and with retarding, if that may be, the passage of our patient along that miserable thorny road. If the nature and position of the tumour could be satisfactorily made out during life, its growth might perchance be slackened or arrested by frequent faradisation ; change of climate might also be beneficial. It is curious that, while in tubercle that remedy has been, and is, most fashionable and successful, in cancer it should never have received a fair trial ; and yet cancer appears to be highly susceptible to the influence of climate. Abounding in Europe, it is rare in Egypt, Algiers, Senegal, and Arabia: even in England its distribution is partial, as Mr. Haviland has conclusively proved. Hlaunting low lying grounds through which large rivers, prone to overflow their banks, descend to the sea, it eschews dry and elevated districts. Surely the progress and propagation of cancer -might be sometimes checked by a resort to those climates which art least favourable to its growth. One of the great objects in cancer of the brain, as in cancer of any other part, is to relieve pain; and that, after all, is best accomplished by the employment of opium, or some of its preparations or alkaloids. The hypodermic injection of morphia is an inestimable boon; nepenthe is a benefactor-it can at least confer an euthanasia. Cannabis Indica acts well; and so, under certain circumstances, do chlorodyne, chloral, and chloroform-the latter being, of course, used with extreme caution. When convulsions occur, bromide of potassium, in combination with tincture of sumbul, is beneficial; and, when delirium and excitement have to be combated, ergot may be had recourse to, or alcohol freely administered, for the delirium is sometimes the expression of exhaustion.

The Lumleian Lectures ON TABES DORSALIS

This paper is the detailed record of the symptoms, temporary and permanent, following total and partial extirpation of the cerebellum, and section of its peduncles, and the degenerations so induced; and includes the effects of destruction of the tubercles on the posterior surface of the medulla oblongata, and the degenerations resulting therefrom, together with some observations on the central relations of the 5th cranial nerve. The paper is illustrated by photographs taken direct from the microscopical sections. Special reference is made to the similar researches of Luciani and Marchi. The most noteworthy features of complete extirpation of the cerebellum were the extraordinary disturbances of station and locomotion, and the long-continued and apparently persistent unsteadiness of the trunk and limbs on muscular effort.

KING'S COLLEGE HOSPITAL REMOVAL FUND.

LECTURE I.* MR. PRESIDENT AND GENTLJAMEN,-The choice of a subject must always, I imagine, be a matter of difficulty to the One who has the honour of being appointed to deliver the Lumleian Lectures. Having been invited to open a discussion on tabes at the forthcomning International Medical Congress, it appeared to me that I might with advantage to myself, and I hope not without profit to you, take as. the basis of my lectures some questions relating to the nature and pathology of tabes which are likely to be lebated by the neurologists assembled in Lisbon. Tabes seems to be of perennial interest at neurological and medical congresses. Nor is this much to be wondered at, considering the vast field which it covers, and the variety of questions which it raises. The literature of tabes is enormous, and the treatises and memoirs relating to it litexally count by thousands. It will be my endeavour in these lectures to present to

An experimental research upon cerebro-cortical afferent and efferent tracts

The main object of the removal is more fully to carry out the idea of the Charity by transferring it from a district largely denuded of its poorer inhabitants to one in which there is a dense population urgently in need of hospital accommodation. By the removal this urgent need, which has long existed in South London, will be met, without the addition of another large general hospital to those at present existing, most of which already have a constant struggle in meeting their necessary expenditure. The Governors when sanctioning the present course authorised the | joint committee appointed by the Council of Kings College and the Committee of Management of the Hospital to act for them in all matters appertaining to the removal. In accepting this authority the committee are fully conscious of the great responsibility they have taken upon themselves, and they are determined to jealously guard the traditions of the Charity, and the many benefac-

Septicæmia and the Catheter

The primary object of the research has been to elucidate by the aid of destructive lesions, and the study of the consecutive degenerations, the tracts by which impressions of general and special sensibility are conveyed to the cortex of the brain. For this purpose, the cortical area, supposed to be the sensory centre under consideration, was extirpated; and, secondly, the nerve, tract or primary ganglionic structure connected therewith was divided or destroyed. In this way strands of degeneration w^ere induced, in due course, of cortical afferent or efferent nature, revealed by the osmium-bichromate method of Marchi.