Diseases of the Nervous System
82 Art. VII.?. ‘’ No. V.?Partial Insanity. :Author: Robert Boyd, M.D. Edin., F.R.C.P. Bond. President Medico-Psychological Association, 1870 ; Late Physician and Superintendent Somerset County Lunatic Asylum; Formerly Resident Physician St. Marylebone Infirmary, and Lecturer on Medicine.
In continuation of previous communications to the Journal the following is an analysis of the records of admissions under the above head, to the Somerset County Lunatic Asylum. These records were commenced thirty years ago, and under the original form were continually added to for upwards of twenty succeeding years. With this analysis is included an occasional cursory abstract from the annual reports of the asylum of any special references to cases of melancholia, moral insanity, etc. In all fatal cases, unless expressly prohibited, post-mortem examinations were made, as a rule, and the appearances and weight of the organs systematically entered. This system adopted of weighing, insures the inspection of each organ separately, and was following out what I had previously been accustomed to at the St. Marylebone Infirmary, and which enabled Dr Clendinning, in his Croonian lectures in 1838, to give the regular average absolute weight of the human organs for the whole of life above puberty in ounces avoirdupois, in males and females.
The average weight of the brains of the insane examined in the Somerset County Asylum was found to be one-twenty- fourth heavier than the average weight of the same above puberty in both sexes, as given by Dr Clendinning. In comparing the weights of the cerebral hemispheres, in more than half they were found to be equal; in the remainder the right was heaviest in about one-third, and the left in about two-thirds ; the average weight of the left was greatest. The difference in weight was most frequent in epileptics; some of these cases, where remarkable differences occurred, have been published in the Medico-Chirurgical Transactions, Vol. XXXIX., 1856.
In one remarkable instance, that of a male, the right hemisphere weighed only 9? ounces, the left 18^ ounces ; there was an arrest of development of the extremities on the opposite side, the left arm and leg being shorter and smaller than those on the right. There was sudden death in this case, and no mental deficiency. The case occurred in 1842. Similar cases were found showing deficiency in one cerebral hemisphere to the extent of several ounces, with short limbs, contracted joints, hemiplegia on the DISEASES OF THE NERVOUS SYSTEM. 83 opposite side of the body. The brain of one of these cases was placed in the Museum of the Royal College of Physicians. The symptoms attending helpless cases of general paralysis seemed clearly to indicate disease of the spinal cord, and led to the examination of it after death in all cases. Unmistakeable signs of inflammation were frequently found, and will be found by any one who has the opportunity and will take the trouble to examine the spinal cord in cases of general paralysis. There was usually softening of parts of the cord, or else unusual firm- ness in parts of the cord. The membranes were sometimes found inflamed and with pus on surface. Specimens of the spinal cords were sent to be microscopically examined by Mr. Gulliver, who found indications of inflammation, exudation corpuscles in all, with few exceptions; in one there was dis- integration. Mr. Queckett, Mr. Obre, and Dr Ogle were supplied with portions of diseased spinal cord from cases of general paralysis, and were of a similar opinion regarding their origin from inflammation. There is no better criterion of the amount of disease in the pulmonary organs than is to be obtained by weighing them, as in pneumonia and tubercular disease; the heart will also be frequently found to be increased to double and sometimes to almost treble the average weight. The abdominal organs will be found to vary considerably from the average weight; the stomach sometimes, more frequently the liver; the pancreas and renal capsules seldom ; the kidneys often?not unfrequently below the average ; the spleen varies very often in weight and condition, being frequently softened.
(a) Under that form of mental disorder commonly termed Melancholia, there were admitted into the Somerset. Asylum from March 1, 1848, to July 1, 1867, 600 cases?262 males and 338 females. Civil condition as to marriage: 81 males and 150 females were single, 160 males and 136 females married, and 21 males and 62 females widowed. Ages Males Females Under 20 years …. 6 6 From 20 to 30 … .44 72 ? 30 to 40 … . 52 64 ? 40 to 50 … . 53 80 ? 50 to 60 … . 49 59 ? 60 to 70 … . 49 51 ? 70 to 80 … .9 6 262 338 Causes.?Much trouble was experienced in ascertaining the history of those patients who were transferred from other asylums, or who had been for any length of time in confine- ment. The primary causes were often difficult to be assigned, were sometimes various, and in many instances quite unknown, even in cases admitted for the first time. Where hereditary predisposition existed it is here given as the cause, the only one, although there may have been a second, or proximate cause. In the same manner, previous illness has sometimes been the predisposing cause, succeeded by a second, or proxi- mate cause, which has not here been distinguished, as, for example, a fit of drinking, which frequently was the immediate cause where a predisposition existed.
Causes assigned Males Females Hereditary … . .59 79 Previous illness 53 69 Distress and poverty Domestic affliction, grief Delusions, religious Ill-usage and desertion Disappointed love Pride and jealousy Over-study, anxiety . Fright and witchcraft Injuries, accidents Intemperance Unknown causes 27 12 23 49 13 29 4 9 4 11 4 2 4 4 2 12 9 2 8 3 52 57 262 338
In the first four cases from hereditary predisposition in males, the proximate cause was in one case, grief at the loss of his situation; in a second, religious fanaticism, attended with visions ; in a third, poverty ; and in a fourth, intemperance in drink. Likewise, in the first four females, the exciting causes were poverty, grief, passion, and hysteria. In cases following protracted illness, sudden suicidal tendencies were sometimes observed.
Of all the symptoms in these cases of melancholia the suicidal tendency was the most prevalent and was reported in 22? per cent, of the males and in 25 per cent, of the females. Of the attempts made, that by strangulation was the most usual. 11 males and 25 females refused food, and required to be forcibly fed by the stomach tube. Of the males 20^ per cent, and of the females 18^ per cent, were reported as dangerous or violent, and 11^ per cent, males and 13f per cent, females were rest- less, noisy, and stubborn ; 18 per cent, males and 13^ per cent, females were in a feeble state and quiet, a tew were suspicious, strange, visited by spirits, and addicted to wander purposelessly. It may broadly be stated that nearly one-third the patients had suicidal tendencies either by actual attempts on their lives or starvation ; a third were violent, dangerous, restless, and des- tructive ; and a third had illusions of vision or hearing, strange suspicions, and in feeble health. The conduct of 8 per cent, the males and 6^ per cent, the females was orderly, and about 8 per cent, the males and 3^ per cent, the females were noted as rational in their conversation. There were employed in their various callings as tradesmen, in the garden, and on the farm, 37 per cent, of the males ; and in the laundry, the kitchen, in needlework, and assisting the attendants in the dining hall and elsewhere, 30 per cent, of the females. All patients of both sexes, not confined in the infirmaries from illness or in an excited state, had their meals in the dining-hall, and attended weekly entertainments there, as dancing, music, and theatricals. In hot weather a large tent in front of the asylum was used for the meals and for the weekly entertainments instead of the large hall.
The duration of the existing attack at the time of admission varied from 5 days to 17^ years in 217 of the males and from 1 day to 19 years in 27G of the females, the average duration being nearly alike in both sexes, viz. 494 days in males and 491 days in females.
The results were in 262 males and 338 females :? Males Females Recovered . 51*6 per cent. 53*1 per cent. Not recovered 7*6 ? 7*1 ,, Died . . 25-0 ? 24*4 ? Remaining . 15*8 ? 15*4 ? 100 100 Causes of Death.?Post-mortem examinations revealed adhesions and thickening of the dura mater, meningitis, in 12 males and 9 females; arachnitis and fluid in the cerebral ventricles in 8 males and 8 females; cerebral apoplexy in 2 females; cerebritis and softening of the brain in 3 males and 3 females; fluid in spinal canal in 2 males. In the chest, pleuritis in 3 males and 3 females ; bronchitis and asthma in 1 male and 4 females; broncho-pneumonia in 2 males and 2 females; pneumonia in 2 males and 5 females ; pleuro-pneumonia in 2 males and 2 females ; pulmonary phthisis in 17 males and 22 females ; hydro-thorax in 1 male and 3 females; pericarditis in 2 males; enlarged heart in 4 males ; Bright’s kidneys in 2 males and 1 female; ulceration in gall bladder in 1 male, coats purple, thickened, the liver fatty, weight 46^ ounces ; liver enlarged in 1 female, weighing 66 ounces ; and the gall bladder distended to the size of a goose egg; in another female there were white hard cancerous tumours in the liver, the weight 43^ ounces; dysentery, enteritis, and ulceration in the intestines in 6 males and 9 females; gastritis in 2 females; dropsy in 1 male and 1 female ; pyaemia in 1 female; erysipelas in 2 males and 1 female; cachexy and starvation in 2 males and 4 females ; suicides by hanging and drowning in 4 males and 1 female, and by scalding in 1 female (555). The latter case had been 10^ years in the asylum, and worked regularly in the laundry. She was occasionally subject to outbursts of violence, when she would break windows. She had not previously displayed any suicidal tendency, but on this occasion she got into the boiler in the wash-house, and was scalded from the hips downwards.
After the first day, when she partially recovered from the shock and sickness, she took food and conversed rationally ; there was sloughing of the skin over the left hip and thigh. Death occurred in ten days after the receipt of the injury. Amongst patients of this class, so many having suicidal propensities, some of them managed to elude detection and effectually succeeded in compassing their determination of self- destruction. One female went into a room opening directly from the corridor, where there were several other persons, only closed the door, tore the hem off one of her garments, turned the bed- stead on end, and hung herself to the leg. One man strangled himself in bed by attaching his stockings to the bedstead, having first tied them round his neck, and then throwing the weight of his body over the side. Another man hanged him- self with his braces from a gas-pipe. A third was found sus- pended in a loft in the farm-yard. One man escaped, and after some time his body was found in a pond on the Mendip Hills, about three miles distant. One man concealed a knife, and ended his existence by that means.
Suicide by starvation, if the following instances may be so designated, was not uncommon. One female, remark- able for her obstinacy, refusing to go to bed, noisy at night, standing constantly, was fed daily for three months ; she was extremely emaciated, only weighing when dead 50 lbs.; her brain was unusually large, weighing 53f ounces. One man who required feeding was also in the habit of standing constantly in one position; his weight when dead was 72 lbs., and his brain 52 ounces. Another man who required to be fed, only weighed 68 lbs. when dead; he had pulmonary phthisis. In a third man fed three times a day, pulmonary tubercles were found combined with pneumonia and congestion of blood in the cerebral vessels. Two females who required to be fed died shortly after admission, one in fourteen days ; there were small tumours in the liver, size of musket bullets ; the liver weighed 35 ounces ; the spleen was unusually large, 17^ ounces; there was also pneumonia; the body weighed 92 lbs. and the brain 5(H ounces, which is much above the average weight. The other female lived nineteen days after admission; she had meningitis and a large and soft spleen. More extensive disease was found in another female, who required to be forcibly fed, and was noisy at night (680) ; upwards of five months in the asylum ; feeble; she did not require to be fed until a month before her death; body emaciated, 72 lbs.; three scrofulous tumours in right cerebral hemisphere : one on the surface at the falx, size of a pea, one on the lower surface, and the third embedded in the corpus striatum external to the central white fibres ; the lateral ventricles distended with clear fluid; en- cephalon 46 ? ounces ; psoas abscess on the right side, containing half a pint of foetid fluid.
There is one remarkable feature that has long been observed respecting suicidal cases, namely, their great frequency in some years and times compared with others ; in one year out of 122 admissions 36 were reported as having made most determined and deliberate attempts upon their lives?12 males and 24 females; 3 males had severe wounds in their throats; one of them, unable to swallow, had to be fed by means of a tube ; 7 females were reported to have made similar attempts; 6 had been rescued from drowning, 5 from hanging, 2 from strangula- tion ; others had precipitated themselves from windows, and one or more had taken poison. An old man was admitted with a wound in his neck. As he arrived at the door of the asylum, he took a razor from his pocket, and handing it to the person who brought him, observed that he would have no occasion for it there. Although depressed he was rational, the loss of blood from the wound relieved the congestion of blood from the brain, which was probably the cause of his insane attempt. Comparative Weight of the Cerebral Hemispheres in 53 Cases of Melancholia in Males and 73 in Females.?The oppo- site hemispheres were both alike in weight in 28 males and 39 females; the right hemisphere was the heaviest in 10 males and 11 females; the left hemisphere was the heaviest in 15 males and 23 females; the right cerebral hemisphere varied in weight from 14| to 25^ ounces, and in females from 11 f to 24 ounces; the left cerebral hemisphere varied in weight from 14^ to 25i ounces in males, and from llf to 24^ ounces in females; the average weight of the right cerebral hemisphere was 20*48, and the left 20*54 ounces in males, and 19*02 the right, and 19*15 ounces the left, in females, thus showing the preponderance in weight of the left cerebral hemisphere in both sexes. The en- cephalon varied in weight in the males from 35? to 58 ounces, and in the females from 21 to 55f ounces; the average weight being in males 47^- ounces, and in females ounces.
The first male patient admitted to the Somerset Asylum suffered from melancholia; aged 47, married, first attack; an agricultural labourer, reported as being a well-disposed, quiet, in- dustrious man. The cause assigned was hereditary predisposi- tion and grief and distress of mind at leaving an old master with whom he had lived fifteen or sixteen years, and to whom he was greatly attached. His conduct most exemplary, conversation subdued, relating to his malady; he had an idea that he had not slept for years; propensities to wander; he left his home without any cause, and had an unusual desire, for him, to take stimulants. Pulse 90 on admission, tongue clean, appetite good, bowels regular, motion slow, expression melancholy. Since admission he has been very industrious in assisting the attendants in cleaning, collecting the dinner utensils, always willing and obliging. He complained at first of want of sleep, but he acknowledged afterwards that he had obtained a little. He wished to be allowed to return home to his family for the purpose of cultivating his garden ; his discharge on probation was granted by the visitors, as allowed by 8 and 9 Vic., c. 120, sec. 71. At the end of the time he was discharged off the books, recovered.
Another early case of admission and recovery in melancholia was the case of a marble mason (4), aged 55, married, transferred from a licensed house. There was hereditary predisposition in his case, and he had a brother and a sister insane; there were seven of the family ; his father was a mason. He was quiet, silent, moping, sat by himself, idle. This condition had existed for a year previously, came on when at work in London. General health indifferent, pulse 78, tongue coated yellow, skin harsh, appetite good, bowels rather relaxed. There was no material improvement in this case for fifteen months; his bodily health quickly improved, but he could not be induced to occupy himself in any way, until he was visited about this time by an old master of his, who said he was an excellent workman, but that he could not be kept sober. A montli afterwards he was discharged on probation, and it was found that he had obtained work at his trade in Bath, and was quite well in his mind. The third male admitted was also of the same class, a black- smith, aged 58, married ; second attack, of two years’ duration; also a transfer from the same licensed house as the preceding; the assigned cause, domestic grief, from the conduct of his wife. He was reported as being of ail amiable, obliging disposition. He had seven children; one daughter had epileptic fits. On his first attack he felt an irresistible desire to destroy himself. On the first appearance of the disorder, about thirty years before, during a thunderstorm, he said he heard a woman’s voice, a woman he had known at that time; after reading the 4th chapter of the 1st Epistle of Peter and 12th verse, he thought he was to undergo a fiery trial; conduct exemplary, memory good, conver- sation connected; had visions of spirits, principally at night; he liked to be reading his Bible, and pointing out concording passages.
His general health fairly good ; pulse 78, skin cool, appetite small; lame on left leg, owing to chronic rheumatism. When able, he assisted willingly in the kitchen; he suffered from pains and sickness occasionally. His health improved; one month after admission heweighed 157 lbs.;height,5 feet Ginclies; circumference of head, 23 inches; antero-posterior measurement from nasal and frontal depression to the occipital protuberance, 14 inches ; transverse, 11^ inches from one external auditory foramen to the other ; height of forehead, 2 inches. Eye dull, pupil sluggish, colour grey. Temperature of head, 72?; under tongue, 96?; improved, continued to assist in the kitchen, sleeps better. In the autumn he was in the infirmary for pains in his limbs ; his mind wTas much troubled ; he fancied he saw spirits and animals in his room, and on three occasions was noisy at night; he blamed the spirits for the pains in his limbs ; believed ” he was possessed of the devil, who sent them to trouble him as he troubled Job of old.” In the spring he was again in the kitchen, and in the summer he was visited by his son and daughter from London, who had not seen him for two and a-half years; they thought him improved; he was glad to see them, and he conversed with them rationally.
For four years he continued in much the same state, some- times in the kitchen, at others ill in the infirmary; weight 155 lbs. The following year (1855) his weight had increased to 179 lbs. In 1858 his limbs failed him, he could scarcely get about; he was, as usual, quiet, but still had his delusions. In 1859 and I860 there was no change in his mental or bodily state. In 1862 he was mostly confined to bed; in 1863 he had an attack of bronchitis; in 1866 he was completely bedridden in the infirmary ; and in 1868 I left him still an inmate of the asylum after a residence of twenty years and three months.
From amongst the female recoveries are shortly to be noticed the following cases:?The first (No. 28), a female, aged 23, single; first attack of six months’ duration previous to admission, owing to grief at the death of her mother : hereditary predisposition on the mother’s side; she attempted suicide by taking laudanum a fortnight before her admission; was quiet, and impressed with the idea that she would shortly die ; she had religious impressions, and was inactive, peevish and indo- lent. Pulse 96, skin hot, tongue clean, appetite good. She knocked at her door at night. After the first month her health and spirits improved, and she occupied herself with needlework ; in a fortnight afterwards she had a relapse, became sullen, and cried about home and her father ; this condition did not long continue ; she gradually improved, and six weeks afterwards bore a cheerful countenance, had grown fat, and seemed almost well enough to be discharged. At the end of another month she was entirely free from delusions, was discharged recovered, atter a stay of 177 days in the asylum.
A second case (423) was in a female, aged 21, married ; had one child; first attack of one month’s duration; ten months after her child’s birth she said her eye had offended, and she attempted to pluck it out with her fingers. Her couversation was repeating an eye for an eye, and her ideas of her lost and wicked state ; her memory bad ; her general health indifferent; pulse 84, tongue clean, skin cold, appetite bad, bowels regular. Melancholy expression, black hair, sallow complexion, grey irides. She fancies that she has injured her child and other- wise done a great deal of harm. The day after being ad- mitted she required to be fed by the stomach tube. She afterwards took food without being forced, and gradually im- proved in health. At the end of six weeks she became rational, was comparatively well in health, and was removed from the infirmary to the convalescent ward. At the end of four and a half months she was taken home by her husband, recovered. Seven years afterwards she was re-admitted, in a similar state of melancholia; very feeble, scarcely able to walk, her illness of two weeks’ duration ; she has been in very destitute circumstances. Pulse 84, skin cold, tongue clean, appetite ravenous. She gradually recovered from this attack, and at the end of three months was again discharged quite well.
The last female case of melancholia now to be noticed was one which was so remarkably characteristic of the disorder, that a drawing was made of her in the asylum by a lady. Ihe patient was Not 34, an agricultural labourer, aged 34, single ; the second attack of two weeks’ duration. She was a quiet, good-tempered woman, a Baptist, rather indolent, could neither read nor write, which was unusual, as all the preceding cases were more or less educated. The cause assigned for the present attack was grief for the death of a friend and neighbour. She fancied she had taken a false oath respecting the identity of a man who was taken up, and that the devil was coming to fetch her. Her memory was good. She was discharged from a licensed house after her first attack six years before, and had been a pensioner on the parish ever since.
Three months after admission she had very much improved ; her countenance, from being the picture of melancholy, had quite changed, and become quite cheerful. Her likeness was taken a second time, to show the happy change in it, by the same lady. She went to work in the laundry, and in about six months was discharged perfectly recovered. Exactly eleven years afterwards she was re-admitted in a similar state of melancholia; had been three weeks ill, and had made an attempt to drown herself; health very bad; dejected, lying on the floor, quite incapable of exertion. After thirteen months in the asylum for this attack, she was once more discharged recovered.
Four and a-half years afterwards she was re-admitted for the third time, having arrived at the age of 63. Six months after- wards she was in a convalescent state, and was discharged home at her own request.
Two years after her last discharge she was re-admitted in a similar state as on the previous occasion. This time she was noisy at night, fancied the devil was throwing fire down her throat. By degrees she improved, and at the end of nine months she had become rational, and was discharged recovered.
(b) Moral Insanity.?There were but few which came strictly under this head amongst the class of patients admitted to the asylum, only 8 males and 3 females. Their ages were: Under 20 years, 1 female; from 20 to 30, 2 males and 1 female ; 30 to 40, 3 males and 1 female, 40 to 50, 1 male; 50 to GO, 1 male. Civil state : 5 males and 2 females were single; 3 males and 2 females married.
Causes.?Intemperance and an epileptic mother were the assigned causes in 1 male, and 1 male was paralysed and had thieving propensities ; 1 male was greedy and slovenly in his habits. Excessive pride was the cause assigned in 1 male ; in 1 male fear, in 1 male disappointment; the two last were rational; also 2 males found wandering were rational. In 2 females the desertion of their husbands was the supposed cause, and in 1 female grief at the loss of her situation; one of the females was suicidal. Results: 2 of the males and the 3 females recovered ; 3 males were discharged relieved, and 1 male not improved. The duration of the attack prior to admission varied in the males from 1 week to 8 years, and in the females from 2 weeks to 4 years.
An example of this form of mental disorder occurred in one of the early admissions to the asylum, in a male, No. 11, by trade a shoemaker, aged 26, single, transferred from a licensed house ; a first attack of thirteen months’ duration. He could read and write well, and was a member of the Church of England ; proud, self-conceited, and idle in his habits. It was reported that he had fallen in love with a clergyman’s daughter, and expected to get married. His conversation was connected, manner^ cheerful, expression cunning, black hair, grey eyes, pulse 78, tongue clean, skin cool, appetite good, had a shuffling gait, height 5’feet 7 inches, weight 135 lbs., the cir- cumference of head 22 inches, antero-posterior measurement 14 and transverse 11? inches. He was fond of reading, attended church regularly, and joined in the singing, in which he was an adept. After the first month lie was induced to work at his trade occasionally, with reluctance; he was quarrel- some. On one occasion he made his escape, and was brought back frum his father’s. He remained in the asylum for seven and a-half years, in much the same state, till towards the end, when lie suffered from pulmonary phthisis, and was taken home to his native place.
A female domestic servant, No. 20, aged 18, single, first attack, of three weeks’duration, able to read and write, a member of the Church of England, fair complexion, skin warm, pulse 100, tongue clean, good expression, conversation con- nected. Cause assigned : Unkind treatment; it was reported that she had attempted suicide. Very quiet; was employed at needlework. She remained forty-three days in the asylum, and was taken home by her sister, recovered.
(c) Delirium tremens, if it may not be considered as coming under the same head, seems to be closely allied to moral insanity. Within the period, there were admitted to the asylum 30 males and 3 females of this class. Their ages, from 20 to 30 years, 1 male ; from 30 to 40 years, 13 males and 1 female; from 40 to 50, 13 males and 1 female; from 50 to 60 years, 3 males and 1 female. Social condition? 8 males unmarried, 19 males and 2 females married, and 3 males and 1 female widowed. Suicidal attempts were made by 5 of the males ; 21 males and 2 females were reported as violent or dangerous, 2 males destructive, 1 male quarrelsome, 1 male and 1 female helpless. Of the males 14 were employed and 2 of the females. Duration of the attack prior to admis- sion varied in 30 males from 2 days to 2 years, and in 3 females from 5 days to 6 months. Results were?recoveries in 23 males and 2 females; discharged not recovered, 5 males and 1 female ; died, 2 males. One male died con- vulsed and the second one died from dropsy.
A labourer (1045), aged 36, married, five children, first attack ; duration, two months ; could neither read nor write. An hereditary predisposition to insanity, of intemperate habits, was violent, and had a quarrel with a man in a public-house ; his head was injured. He was brought to the asylum in a mori- bund state ; pulse 54, cold skin, pupils contracted, unconscious ; he was able to swallow some fluid; he died about three hours after his admission. A coroner’s inquest was held. His wife stated that ” during the last two months he complained of his head, was convulsed, and said he thought he should go out of his mind.” The body was examined seventeen hours after death. There were no external marks or bruises; it was fat and well formed; weight, 146 lbs.; length, 5 feet 8 inches. Circum- ference of head, 23 inches ; antero-posterior, 13 ; and transverse measurement 11^ inches; effusion of blood beneath the scalp, skull thick ; dura mater tense, the hemispheres protruded over the edge directly the membranes were divided; the brain was unusually pale; the left lateral ventricle was distended with fluid: some of it in cysts size of a walnut, two fluid ounces by measure, escaped. From the fornix on the right side was sus- pended a cyst, size of a pigeon’s egg, containing straw-coloured fluid, which occupied the position of the ” septum lucidum.” In the anterior and outer side of the right cerebral hemisphere was a firm pale tumour, size of a walnut; the ” corpus striatum ” on that side was unusually pale and soft, and the softening ex- tending downwards to the right crus cerebri and its junction with the pons was infiltrated with blood. The right cerebral hemisphere was 4^ ounces heavier than the left, owing partly, no doubt, to the escape of the fluid from the left side. The right ventricle was closed, the sides pressed together, and the cerebral structure denser on that side than the left. Weight of the right cerebral hemisphere, 25 ; left, 20? ounces. About 5 ounces of dark-coloured blood escaped when the spinal cord was opened; the spinal cord was unusually firm; weight 14 ounce. All the other organs natural.
Here was an extraordinary amount of cerebral disease accidentally discovered, it might be said, in a drinking man’ supposed to be only in a state of delirium tremens.
A case (446) occurred in a male, aged 35, single, a pedlar; in a state of delirium tremens, was found wandering very de- pressed and unhappy, supposed himself to be deserted by the Creator, became violent, and threatened to kill himself. After a few days’ residence in the asylum he quite recovered his senses and was discharged recovered. About a fortnight after- wards he returned to the asylum in a deranged state, said he was unable to refrain from drink, and begged to be again admitted. His application could not be entertained without a fresh order and certificates.
A second case (458) in a male, aged 34, also a pedlar; he was admitted in a state of delirium tremens, reported as dangerous to others; he was discharged, recovered, in six months after his admission. The following year he was found wander- ing about, neglecting his business and drinking. He dis- turbed the congregation at the Methodist Chapel by slapping the children about the ears, and was brought back to the asylum. He became noisy, his health declined, and after three years he was removed to the union, in a helpless and harmless state, and with symptoms of general paralysis. A female (564), aged 50, married, a mason’s wife; first attack of five days’ duration ; had been drinking; occasionally violent ; destructive to her clothing; was admitted in a state of delirium tremens; two months after admission she began to improve, and three months subsequently was discharged re- covered.
(cZ) Dementia, or Incoherence, is a form of mental disorder sometimes met with as a first attack in an acute form, but more frequently in a chronic stage, as a termination of one or other of the various forms of insanity ; hence the recoveries in this disorder are but few. Cases of mania and melancholia frequently terminate in dementia, and it is often combined with epilepsy and general paralysis.
The admissions under the head of Dementia during the twenty years amounted to 381. In this number were included 73 who were in a state of fatuity, persons in the decline of life after 70 years of age, sent for care to the Asylum, being poor. They ought not to be classed with the insane, and will be con- sidered separately. Deducting these 73 cases, there were 208; of these 93 were males, and 115 were females.
As regards their ages on admission, 1 male was 19 only ; between the ages of 20 and 30 there were 12 males and 16 females:?
Males. Females. From 30 to 40 … .20 22 ? 40 to 50 … . 16 24 ? 50 to 60 … ? 14 21 ? 60 to 70, inclusive 30 32 Their civil state as to marriage: 45 males and 56 females were unmarried; 41 males and 42 females were married; 7 males and 14 females were widowed; in 3 females not ascertained. Causes.? These were attributed to hereditary predisposition in 12 males and 15 females, or 8 per cent, in the one and 10^ per cent, in the other. In 12 males and 1 female the mental disorder followed various injuries, principally of the head ; in 13 males and 9 females it was consequent on paralysis or organic cerebral disease ; in 13 males and 14 females on previous bodily illness ; in 2 males and 12 females on domestic distress, grief, or poverty ; in 4 males and 2 females it was attributed to intem- perance ; in 1 female from love; in 1 male from overwork ; and in 1 male and 1 female from fright. In males 28 per cent, and in females 17 per cent, were from physical causes; from moral causes, 8 per cent, in males and 10 per cent, in females. Cases found wandering and transferred from other asylums amounted to 28 per cent, in males and 51 per cent, in females; and a large number of the causes were unknown. Suicidal propensities were reported in 6 males and 10 females, some of whom required to be fed forcibly.
One-fourth of both sexes were reported as being violent or dangerous to others; several were restless, and 15 males and 30 females destructive; 23 males and 34 females were feeble or helpless; and 22 males and 23 females quiet and harmless. Fuund capable and employed, 40 males and 31 females; 11 males and 25 females were wilfully idle.
The results were :? Males. Females. Eecovered ….. 3 5 Not recovered … .30 29 Died 85 80 Bemaining … . .17 32 Total …135 146
Causes of death were various, and in many instances the immediate cause was difficult to be ascertained, as many organs were found diseased in the same individual. Enumeration of the causes was as follows:?Inflammation, preternatural adhesions, thickening of the membranes covering the brain, meningitis, found in 31 males and 14 females; signs of inflammation of the brain itself, cerebritis, in 3 males and 8 females ; softening of the brain in 8 males and 8 females ; unusual firmness of brain in 1 female, and remarkable atrophy or wasting of it in 3 males; cerebral apoplexy in 6 males and 3 females; paralysis in 3 males and 2 females; and true bone found imbedded in the brain in 1 female (288), weighing grains, attached to the dura mater about the middle of the right cerebral hemisphere and an inch from the longitudinal sinus. It was sent to the College of Surgeons, to Mr. Queckett, who wrote that” the bone sent for examination is true bone, containing corpuscles and Haversian canals, like the bone of the extremities. I have never but in one instance seen such a tiling from within the cranium, and this was attached to the falx.” The cause of death was in this case pulmonary phthisis.
Inflammation of the spinal cord, myelitis, was found in 2 males and 3 females; inflammation of the lungs, pneumonia, in 24 males and 11 females; pleuro-pneumoniain 4 males and2 females; bron- chitis in 9 males and 5 females; asthma and emphysema in 6 males and 8 females ; fluid in the chest, hydrothorax, in 2 males and 4 females; pulmonary phthisis in 10 males and 7 females; influenza in 2 males; pericarditis in 1 and enlarged heart in 5 females. No. 464 was aged 66, a widow ; one year previous to admission in very bad health, demented and helpless, hemiplegia from apoplexy, unable to stand alone, had to be carried to the infirmary, where she was suddenly seized with dyspnoea eighteen weeks after admission, and died in six days. Weight of the body, 94 lbs.; length, 5 feet; circumference of head, 22; antero- posterior, 13; and transverse measurement, 13^ inches. The lateral ventricles were distended with clear fluid ; in the right corpus striatum there was a rusty-coloured stain and cicatrix, showing the union of the surfaces of brain after the absorption of the clot of blood. Some of the white central fibres of the corpus striatum had been destroyed by the clot; the hemiplegia was of the left side ; there was a rusty deposit also in the left optic thalamus the size of a split pea ; there were several rusty deposits on the surface of the hemispheres ; the cerebral arteries contained numerous atheromatous deposits, and were very gene- rally diseased; the right cerebral hemisphere weighed 17^, the left 17? ounces. There was more fluid than usual in the spinal canal, and the upper part of the spinal cord was softer than natural. In the chest there was a pint of fluid in the right pleura; the lower lobe of the right lung was compressed and tough, the bronchial lining membrane of both being red and covered with muco-purulent matter. The heart very much enlarged, and the valves thickened; weight, 15? ounces. The kidneys wasted and granular, right 2f, left ounces. Bright’s disease in 2 other females and 1 male, dropsy in 1 male and 3 females. Peritonitis in 1 male and 2 females; enteritis in 2 males and 9 females ; ulcer in stomach in 1 female, and ulcer in colon in 1. No. 399, aged 60, married, no children, feeble health, afflicted with bleeding piles for sixteen years, but recently the bleeding had been stopped. She fancied her food was poisoned, and was disinclined to eat. She was noisy at night, and was given anodynes. Six months after admission she passed clots of blood from her bowels, and for several weeks was principally con- fined to bed. When she left her bed she was still feeble. In the following summer she had a second attack, and passed a considerable quantity of blood with each evacuation from her bowels, and died in a week after the attack. The body only weighed 68 pounds; length, 5 feet 3 inches; it was examined 30 hours after death. The circumference of head 21?, antero- posterior 13?, and the transverse measurement 13i inches. The skull and brain appeared natural; the right cerebral hemisphere was 19, the left 19? ounces. Spinal cord natural. Chest, a portion of the middle lobe size of a hen’s egg, in a state of pneumonia, some miliary tubercles in both lungs; heart small, 7i ounces. In the pelvis of the right kidney was a calculus the size of a marble, dark-coloured, and smooth on surface; each kidney weighed 5 ounces. The mucous membrane of the colon ulcerated throughout, and cause of death dysentery. Dysentery was the cause of death in 4 males and in 8 other females. Cancer of stomach in 1 male; cancer of liver in 1 male and in 1 female; enlargement of liver in 1 female; cancer in uterus of 1 ; and ovarian tumour in 1 (No. 300), aged 56, single, first attack, duration many years, in very bad health; has ovarian disease and oedema of legs ; her breathing short and difficult. Six months after admission she had sickness, and a month afterwards she became faint and died. The body weighed 145 pounds ; length, 5 feet 3 inches ; circumference of head 21, antero-posterior 14, transverse 10 inches. The brain unusually pale; each cerebral hemisphere weighed 19 ounces ; spinal cord was also pale. Both lungs were emphysematous, one pint of fluid in the right pleura, the right lung congested with blood ; weight, 17^ ; the left, 10 ounces; the heart, 11 ounces; thickening of the mitral valve. Abdomen filled by an immense ovarian tumour 41 inches in circumference ; there were three small lateral tumours on each side of it, and one rather behind, on the right, under the great lobe of the liver, which contained about a pint of straw- coloured fluid in a thinner membrane of sac than the others, which had thicker coats, and had each a communicating opening with the large tumour or cyst; it contained a thick, creamy fluid, was mixed with gelatinous broken-down membrane ; the contents filled a three gallon bucket, and the smaller tumours contained about half a gallon more. In a drop of the contents Mr. Gulliver distinguished by the microscope pus, bits of fibrine, serum, an excess of fatty matter, some pus-like cells ; no frag- ments of entozoa or true hydatids, and nothing like them. One male sank from erysipelas, combined with cerebritis (No. 632), aged 42, married, 8 children, a carman ; he had been taken to the union, and five days previous to his admission he stood on a hot bar of the grate in the workhouse, trying to get up the chimney; he also tried to get through the windows. There were burns on both feet, and phlegmanous erysipelas of both legs. He died a fortnight after admission. Body examined 25 hours after death; weight, 107 lbs.; length, 5 feet 7 inches; circumference of head, 22 ; anteroposterior and transverse measurements, each 14 inches. The dura mater firmly adherent to the skull and dry, the cerebrum on right side of a pinkish hue at the centrum ovale of Yicq. D’Azyr, not so on the left side, but the veins on the left side were congested with blood, and numerous bloody dots were present on the cut surfaces; the right hemisphere weighed 21, the left 22 ounces; spinal cord natural, weight 1 ounce. Slight pleuritic adhesions of the lungs, and cadaveric congestion. Heart enlarged, 15 ounces; bony deposit in the aorta near the heart. Other organs natural.
One male (48) died from a sad accident, a severe burn, aged 36, single, transferred from a licensed house, by occupation a gardener, quiet and harmless. He was always cheerful, and went out to work, but quite demented; he had been in the same state for nearly seven years in the Asylum, and was latterly in the habit of assisting the engineer at the fires and at the gas works, when he was seen rushing at the top of his speed in front of the Asylum from towards the limekiln all in a blaze ; a blanket was thrown round him, his burning clothes torn off, the only part remaining the wristbands of his shirt and his boots; his whole body was burned and face scorched ; the epidermis peeled off his legs, knees, and hands, and the nail of middle finger of left hand with it. The body was covered with cotton wadding, and some parts dredged with carbonate of magnesia. He said that in stepping across the limekiln, which was 4 feet wide at the top, his foot slipped, and it flamed up and set fire to his clothes. He was very sick and restless during the night; he only sur- vived the accident about nineteen hours. One male died of typhoid fever.
A female (No. 492), aged 68, married, was admitted in a state of dementia of five years’ duration, attributed to grief. She had a violent temper, was destructive in her habits, and in a bad state of health. She gesticulated constantly, was in the habit of lying on the floor, and had cataleptic symptoms, which in- creased in severity. She had repeated jerkings of the upper extremities, and had lost control of the lower, so that she was scarcely able to walk. Her mental faculties did not become worse. At the end of a fortnight she had opisthotonos tetanic spasms. The spine was blistered, and a solution of atropine on lint applied to the surface. The tetanic spasms were after- wards less violent, and she found less difficulty in swallow- ing ; it was afterwards found easier to teed her with the stomach tube. She died five months and three weeks after admission. Body examined fourteen hours after death; weight, 79 lbs; length, 5 feet 2 inches ; circumference of head 21, antero- posterior 12, and transverse 13 inches. The brain was rather soft, dark in colour, and there was more fluid than usual in the pia mater and in the lateral ventricles ; each cerebral hemi- sphere only weighed 14| ounces ; encephalon, 34^ ounces, about 9 ounces below the average weight. There was a”plate of bone, size of a silver 3d., on the arachnoid membrane of the spinal cord itself at this point, and the spine was curved forward in the same situation. The heart was 9| ounces, which is above the average weight; the other organs were natural. A second case (1319), in a married female, aged 30, of choraic convulsions was, after four months in the Asylum, discharged recovered.
The youngest male admitted recovered apparently for a time, and was taken home by his father after sixteen months in the Asylum; his age was 19 years, and he had been previously sixteen months in a licensed house; was occasionally violent, of filthy habits, indifferent health; chattered incoherently; under tonics, cod liver oil, and phosphate of strychnine, his health veiy much improved.
Two years and a half afterwards he was readmitted, with the premonitory symptoms of general paralysis. He was cheerful, in fair bodily condition. He gradually got worse, became rest- less and excitable, and so violent that lie had to be removed to another ward. Six months afterwards he required to be fed, and tottered in walking. In the course of a few weeks he was better; could feed himself; pulse 72, full; tongue clean ; appe- tite good; pupils irregular, right more dilated than the left.; was blistered on the nape, took bichloride of mercury. The week after sensation continued dull ; temperature, 90? in axilla, 97? between his mouth ; temperature of room, 65?. At the end of three months, in May 1868, he was improved, walking about, and remained in the Asylum.
A female (590), aged 22, single, first attack, duration 2i years; hereditary predisposition on both sides ; violent, wild, excited. She was confined to bed for several weeks with a gangrenous ulcer in the left leg, which got better under charcoal and linseed-meal poultices, and bark and opium taken inwardly. Her general health improved, but her mental condition did not alter. She was often noisy at night, addicted to swearing and shouting, and occasionally to tearing her clothes and breaking windows. She had a shower-bath, after which she slept quietly; and the shower-bath, continued for about three minutes, agreed with her so well that it was used about twice a week. She walked better; she used to walk formerly on her toes, and sometimes she herself asked for a bath. At the end of thirteen years she remained, in much the same state, an inmate of the Asylum. A female (263), aged 33, married, transferred from a licensed house, two years ill, said to have been paralysed ; motion per- fect ; silent, disposed to laugh ; in good health ; weight, 159? lbs.; quiet and harmless. Three years after admission she was in- duced to occupy herself at needlework. Two years afterwards there was a decided improvement; she rapidly got better, and was discharged recovered.
The duration of the disorder at the time of admission varied in the males from 4 days to 37 years, and in the females from 1 week to 28 years.
The comparative weight of the cerebral hemispheres in cases of dementia in 46 males gave an average of 20*05 for the right and 20*2 ounces for the left; and in 53 females 18 for the right and 18*1 ounces for the left. The cerebral hemispheres were of equal weight in 22 males and in 24 females. The right was the heaviest in 9 males and 11 females ; and the left was the heaviest in 15 males and 18 females. The smallest hemispheres in the males were in a shoemaker (1184), aged 21, two years ill, when his right leg became paralysed ; small head, circumference 21 ; antero-posterior 12, and transverse 10 inches ; body emaciated, 72 lbs.; length, 5 feet 3 inches ; dura mater strongly adherent to the skull; more fluid than usual in the ventricles ; left cere- bral hemisphere smaller than the right and 1 ounce lighter, 13^ ounces; the encephalon, 33 ounces; pneumonia and gangrene of right lung. The lightest encephalon in the females (566) was 31 ounces; cerebral hemispheres were equal in weight, each 13 ounces. The heaviest, and the one in which there was the greatest difference between the cerebral hemispheres, was in a male (775), aged 30, single ; second attack, hereditary predisposition ; first attack, 8 years previous; he died from typhoid fever ; weight, 158 lbs.; length, 6 feet; circumference of head, 23; antero- posterior and transverse measurements, each 14 inches ; brain and membranes appeared natural, only a small amount of fluid in the lateral ventricles; right cerebral hemisphere 23, left 25 ounces ; the encephalon, 55i ounces. The largest female ence- phalon weighed 52 ounces (738), aged 35, first attack, 7 years’ duration; died suddenly, fainted ; weight of the body, 97 lbs.; length, 5 feet 3 inches; head large, skull unusually thick, opacity of the arachnoid ; the lateral ventricles much distended with fluid; the brain firm; the right cerebral hemisphere 23?, the left 23 ounces; the mitral valve of the heart thickened ; weight, 7| ounces; the other organs natural.
The average weight of the left cerebral hemisphere was greater than that of the right in the preceding cases, the difference being about the tenth of an ounce, in both sexes, in dementia.
(e) Fatuity, dotage, or second childhood, some authors have stated to be commonly observed in females after 70, and in males after 75 years of age. Individuals, however, vary greatly in this respect; in some dotage has been observed at an earlier, and in others at a much later time of life. Of the 73 cases admitted to the Somerset County Asylum after 70 years of age, coming under the head of Dementia, 50 only were registered as cases of senile fatuity, notwithstanding all the 73, for the for the sake of convenience, have been placed under the head of Fatuity. At this late period of existence the physical as well as the mental powers rapidly decline, emaciation takes place, the cerebral membranes become thickened and opaque, the brain is diminished in size, firmer, and tougher; all the other organs partake of the general decay, and the senses gradually become blunted.
The two following rather remarkable cases were admitted to the Asylum in the last stage of human existence: a male aged 96, and a female reported to be 90.
The male (861) aged 96, married, seven children, a basket- maker by trade; first attack, one day excited. He attempted to commit suicide in consequence of the removal of his wife to the workhouse; he was married to his third wife. General health good, considering his age; he was deaf and feeble, and was placed in the infirmary, were he remained quiet and harm- less. He occasionally occupied himself in repairing baskets. In the winter, after a residence of ten months, he had an attack of bronchitis and died. The body was examined 15 hours after death; weight, 124 lbs.; length, 5 feet 4 inches; circum- ference 22, antero-posterior 13^, and transverse measurement 14 inches. The dura mater very strongly adherent to the skull; more fluid than natural in the lateral ventricles; brain firm, right cerebral hemisphere weighed 19, the left 18f ounces, cerebellum 5, enceplialon 44 ounces, about 3 ounces under the average. The spinal cord natural. The left side of the chest contained a considerable quantity of fluid, which compressed the lung; redness of the lining membrane of bronchial tubes in both lungs. Heart large, 12 inches, valves natural. Other organs healthy. Cause of death, hydrothorax, bronchitis, and chronic meningitis.
Female (1459); her daughter-in-law stated her age to be 90; a widow; had two sons; first attack of eight months’ duration ; in a feeble state of health, incoherent, using threatening language; memory lost, expression vacant, noisy at night. Three months after admission she was very ill, confined to bed in infirmary, and died five weeks afterwards from natural decay.
Autopsy twelve hours after death. Weight of the body, 78 Ids.; length, 5 feet; circumference of head 21, denuded of scalp 20? inches; antero-posterior 12, denuded 1H; transverse measurement 10^, denuded 10 inches. The brain unusually pale; there was more fluid than natural in the cerebral ven- tricles; each hemisphere weighed 16^ ounces, and the ence- phalon 38?, nearly 5 ounces under the average. The spinal cord natural, weight 1 ounce. Chest: no pleuritic adhesions, lungs emphysematous; the right weighed 7, the left 6 ounces; heart, 7 ounces. Abdominal organs natural.
The ages of the others were, between 70 and 80, 30 males and 20 females; and from 80 to 90 years, 11 males and 10 females.
Civil state : 1 male and 5 females were single, 21 males and 10 females were married, and 20 males widowers and 16 females widows.
The results were, that 81 per cent, of males and 68 per cent, of females died; 14 per cent, males and 26 per cent, females were after a time removed to their homes or to the workhouses to end their days ; and 5 per cent, males and 6 per cent, females remained in the Asylum. The causes of death were : from inflammation of the cerebrum, meningitis, in 4 males and in 1 female ; from effusion of blood, cerebral apoplexy, in 15 males and 8 females, in combination with which there was frequently grave disease of the lungs, a cerebral tumour in 1 male, cerebritis in 4 males and 6 females; much fluid in the ventricles in 4 males and 5 females ; pneumonia in 10 males and 2 females; pleura-pneumonia in 1 male, and broncho-pneumo- nia in 2 females; hydrothorax in 1 male and 2 females; bron- chitis or asthma in 9 males and 4 females; enteritis in 1 male and 8 females ; dysentery in 1 female; cancer of the stomach in 1 male, an ulcer size of half-a-crown at the cardiac end, no symptom of it during life, appetite good ; cancer of the liver in 1 male. With respect to the cerebral hemispheres, they were of equal weight in 15 males and 6 females; the right prepon- derated in 8 males and 6 females, and the left in 9 males and 9 females. The right hemisphere varied in weight in 32 males from 16? to 24^ ounces, and the left from 16 to 23 ounces. In 21 females the right hemisphere varied in weight from 14^ to 21 ounces, and the left from 15 to 21 ounces. The average weight of the right cerebral hemisphere was in the males 19*57, and of the left 19*69 ounces. The average weight of the right cerebral hemisphere was in the females 17*40, and of the left 17*46 ounces. Thus we find the preponderance of weight, in the left cerebral hemisphere, still existing at this most advanced period of life.
Note on Genekal Paralysis of tiie Insane. In the number of the Journal of Psychological Medicine, for April 1877, there is an able review of the works of three French writers on General Paralysis.
It is there stated that one of those writers, ” M. Magnan, claims priority in having determined the centre, or it may be one of many centres, of that disorganising process which is in- dicated by the symptoms of general paralysis, which penetrates throughout all parts of the encephalon, and produces those secondary pathological appearances which have previously been identified as the cause of the disorders of mobility and sensi- bility which follow.”
” These microscopic features, as well as those conspicuous to the naked eye, may appear first in the brain and its appendages, and afterwards in the medulla ; or they may appear first in the medulla and afterwards in the brain; and they may appear simultaneously in both organs ; or, in other words, the progress may be upwards or downwards along these nervous tracts. Ac- cording to priority in the development of these pathological conditions are observed perversions of mind, of mobility, of sensibility. Should the brain be originally attacked, the psy- chical signs predominate, or are exclusively manifested ; should the medulla be the primary seat of the disease, muscidar pain, tremor, in fact, ataxic symptoms, spreading gradually to the lips and tongue, disturbance of the visceral organs correspon- ding to the portions of the spinal column involved, precede alienation and greatly augment the difficulties in diagnosis; and, lastly, when the whole cerebro-spinal axis participates at once in the degeneration, the characteristic indications of general paralysis will appear simultaneously, or in rapid succession.” The appearances described by M. Magnan fully coincide with my own observations, and it will be found that I have, in my reports from time to time, described the naked eye and microscopic appearances of the cord, and likewise the granula- tions on the membranes in the lateral and fourth ventricles, which latter, as M. Magnan’s reviewer truly states, have been found in numerous cases other than those of general paralysis. I take this opportunity of claiming priority in the discovery of the pathological changes in this disease, to substantiate which I here briefly recapitulate some of my observations made upwards of thirty years ago, and confirmed by the examination from time to time of the bodies of nearly 160 patients who died whilst under my care in the Somerset County Asylum.
In the first report of the Somerset County Lunatic Asylum, for 1848, it is stated that fatal cases of general paralysis or palsy were found on examination to be accompanied by, and probably dependent on, softening and other results of inflamma- tion of the spinal marrow, and frequently of the ventricles and membranes of the base of the brain. Subsequent examinations have confirmed this statement, and these will be found in the obituary in the second report, of the following year 1849. The attention of pathologists is called to this important subject, no reference being found to it in any English writer. Although so little seems to be known respecting the morbid anatomy of general paralysis, so fatal a disease of the insane, it results, from my observations, that there is no affection of the nervous centres occurring in insanity which presents such well marked and constant morbid changes, and these are seated chiefly in the spinal cord, although the brain or its membranes are commonly implicated. These changes are chiefly-inflam- mation of the cord itself or its membranes (meningo-myelitis), thickening and preternatural adhesions of the arachnoid, soften- ing induration, enlargement or atrophy of the spinal cord itself. In the brain, thickening of the arachnoid, with fluid at the base of the skull, and in the ventricles and spinal canal, gelatinous fluid beneath the arachnoid (166 m.) concealing the gyrse, and a roughness from crystals, as if minute particles of sand were sprinkled on the floor of the 4th, and sometimes to a slighter extent also in the lateral ventricles.
It may further be observed that general paralysis or palsy sometimes precedes the mental derangement. This would occur where the spinal cord first became diseased, and disease after- wards attacked the brain ; such cases, originating in the spinal cord, are most likely to be checked if detected early. The application of warmth to the spine caused manifestations of pain in some patients when percussion failed to do so. General paralysis is, however, mostly preceded by some form of insanity, and is commonly the forerunner of a speedy and fatal termina- tion, unless a more precise knowledge of its true nature should lead to a corresponding improvement in its treatment. The acute cases of palsy, or those in which the disease was of short duration and death ensued quickly, were distinguished by softening of the spinal cord, and in one case by enlargement of it. In the last of the eases in the obituary of 1849, the symptoms of palsy only existed four or five weeks, death occurred rather suddenly after a convulsive fit; there was softening of the cord, and a considerable quantity of fluid in the cerebral ventricles and spinal canal. Many cases of sudden death have, I believe, been wrongly attributed to what has been termed serous apoplexy, where fluid has been found in the lateral ventricles?a very- frequent occurrence in the aged?and in which the fatal event, if the spinal cord had been carefully examined, would have been found to have been caused from softening in it. The chronic cases of palsy, those in which the fatal termination did not occur for several months, were distinguished by induration, sometimes by atrophy of the spinal cord, and by the thickening of its membranes.
Besides the cases of general paralysis there will be found in the obituary of 1849 cases of paralysis dependent on old injury, or disease of the brain different from the disease already pointed out, and distinguished by rigid muscular contractions in some of the limbs, with more or less loss of motion, and in one loss of speech and power of swallowing; these symptoms were the result of cerebral apoplexy and injury to the structure of the brain itself; the spinal cord was in a healthy state.?From the ” Second Annual Eeport of the Somerset County Asylum.”
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